Electronic Medical Records, Nurse Staffing, and Nurse-Sensitive Patient Outcomes: Evidence from California Hospitals, 1998�C2007

Objective

To estimate the effects of electronic medical records (EMR) implementation on medical-surgical acute unit costs, length of stay, nurse staffing levels, nursing skill mix, nurse cost per hour, and nurse-sensitive patient outcomes.

Data Sources

Data on EMR implementation came from the 1998–2007 HIMSS Analytics Databases. Data on nurse staffing and patient outcomes came from the 1998–2007 Annual Financial Disclosure Reports and Patient Discharge Databases of the California Office of Statewide Health Planning and Development (OSHPD).

Methods

Longitudinal analysis of an unbalanced panel of 326 short-term, general acute care hospitals in California. Marginal effects estimated using fixed effects (within-hospital) OLS regression.

Principal Findings

EMR implementation was associated with 6–10 percent higher cost per discharge in medical-surgical acute units. EMR stage 2 increased registered nurse hours per patient day by 15–26 percent and reduced licensed vocational nurse cost per hour by 2–4 percent. EMR stage 3 was associated with 3–4 percent lower rates of in-hospital mortality for conditions.

Conclusions

Our results suggest that advanced EMR applications may increase hospital costs and nurse staffing levels, as well as increase complications and decrease mortality for some conditions. Contrary to expectation, we found no support for the proposition that EMR reduced length of stay or decreased the demand for nurses.     

Hospital Use of Agency‐Employed Supplemental Nurses and Patient Mortality and Failure to Rescue

Objective

To determine the association between the use of agency-employed supplemental registered nurses (SRNs) to staff hospitals and patient mortality and failure to rescue (FTR).

Data Sources

Primary survey data from 40,356 registered nurses in 665 hospitals in four states in 2006 were linked with American Hospital Association and inpatient mortality data from state agencies for approximately 1.3 million patients.

Study Design

Logistic regression models were used to examine the association between SRN use and 30-day in-hospital mortality and FTR, controlling for patient and hospital characteristics, nurse staffing, the proportion of nurses with bachelor''s degrees, and quality of the work environment.

Principal Findings

Before controlling for multiple nurse characteristics of hospitals, higher proportions of agency-employed SRNs in hospitals appeared to be associated with higher mortality (OR = 1.06) and FTR (OR = 1.05). Hospitals with higher proportions of SRNs have poorer work environments, however, and the significant relationships between SRNs and mortality outcomes were rendered insignificant when work environments were taken into account.

Conclusions

Higher use of SRNs does not appear to have deleterious consequences for patient mortality and may alleviate nurse staffing problems that could produce higher mortality.     

Nurses' workload and its relation with physiological stress reactions

OBJECTIVE:

to analyze the relation between the workload and the physiological stress reactions among nurses working at a hospital service.

METHODS:

cross-sectional, correlational, quantitative study, involving 95 nurses, in 2011 and 2012. Spearman''s bivariate Correlation Test was used.

RESULTS:

most subjects are female, between 23 and 61 years old and working between 21 and 78 hours per week. The most frequent physiological reactions were back pain, fatigue/exhaustion, stiff neck and stomach acidity, with 46.3% of the subjects presenting low and 42.1% moderate physiological stress responses. No correlation was found between the workload and the physiological stress responses.

CONCLUSION:

although most of the nurses work more than 36 hours/week, physiologically, they do not present high reaction levels in response to stress. These workers deal with conflicts in the vertical and horizontal relations between professionals, family members and patients. In that sense, taking care of professionals who offer health services can be a fundamental strategy, as good user care mainly depends on healthy teams.     

Do Medicaid Wage Pass‐through Payments Increase Nursing Home Staffing?

Objective

To assess the impact of state Medicaid wage pass-through policy on direct-care staffing levels in U.S. nursing homes.

Data Sources

Online Survey Certification and Reporting (OSCAR) data, and state Medicaid nursing home reimbursement policies over the period 1996–2004.

Study Design

A fixed-effects panel model with two-step feasible-generalized least squares estimates is used to examine the effect of pass-through adoption on direct-care staff hours per resident day (HPRD) in nursing homes.

Data Collection/Extraction Methods

A panel data file tracking annual OSCAR surveys per facility over the study period is linked with annual information on state Medicaid wage pass-through and related policies.

Principal Findings

Among the states introducing wage pass-through over the study period, the policy is associated with between 3.0 and 4.0 percent net increases in certified nurse aide (CNA) HPRD in the years following adoption. No discernable pass-through effect is observed on either registered nurse or licensed practical nurse HPRD.

Conclusions

State Medicaid wage pass-through programs offer a potentially effective policy tool to boost direct-care CNA staffing in nursing homes, at least in the short term.     

Peer Reviewed: Work Time and 11-Year Progression of Carotid Atherosclerosis in Middle-Aged Finnish Men

Introduction

Studies of the relationship between work time and health have been inconclusive. Consequently, we sought to examine the effect of work time on progression of atherosclerosis.

Methods

This prospective study of 621 middle-aged Finnish men evaluated effects of baseline and repeat measures of work time on 11-year progression of ultrasonographically assessed carotid intima-media thickness (IMT) and interactions with cardiovascular disease. Multiple linear regression models adjusted for 21 biological, behavioral, and psychosocial risk factors.

Results

Working 3 (minimum), 5 (medium), or 7 (maximum) days per week at baseline was associated with 23%, 31%, and 40% 11-year increases in IMT, respectively. The relative change ratio (RCR) at maximum vs minimum was 1.14 for baseline days worked per week and 1.10 for hours worked per year of follow-up. Significant interactions existed between cardiovascular disease and work time. Men with ischemic heart disease (IHD) who worked the maximum of 14.5 hours per day experienced a 69% increase in IMT compared with a 29% increase in men without IHD. The RCR ratio for IHD (RCR_IHD/RCR_{no IHD}) was 1.44 for hours per day. Similarly, the RCR ratio for baseline carotid artery stenosis was 1.29 for hours per day and 1.22 for hours per year.

Conclusion

Increases in work time are positively associated with progression of carotid atherosclerosis in middle-aged men, especially in those with preexisting cardiovascular disease. Our findings are consistent with the hemodynamic theory of atherosclerosis.     

Nurse overtime, working conditions, and the presence of mandatory nurse overtime regulations

Although more states have regulated mandatory nurse overtime, limited research has examined the impact of these regulations on the actual time nurses work and their working conditions. The purpose of this study was to compare nurse overtime and working conditions between states with and states without regulations limiting mandatory nurse overtime. Data were collected from registered nurses working in hospitals located in states with and without mandatory nurse overtime regulations; the final sample consisted of 219 nurses. No difference was found in overtime worked between nurses who worked in states with regulations or without. Those nurses working in states with regulations cared for more patients per shift and experienced more chronic nursing shortages on their nursing units than those working in states without regulation. Continuous efforts are needed to improve the implementation of regulations to reduce nurse mandatory overtime and long work hours.     

Peer Reviewed: Changes in Local School Policies and Practices in Washington State After an Unfunded Physical Activity and Nutrition Mandate

Introduction

Policies and practices in schools may create environments that encourage and reinforce healthy behaviors and are thus a means for stemming the rising rates of childhood obesity. We assessed the effect of a 2005 statewide school physical activity and nutrition mandate on policies and practices in middle and high schools in Washington State.

Methods

We used 2002, 2004, and 2006 statewide School Health Profiles survey data from Washington, with Oregon as a comparison group, to create longitudinal linear regression models to describe changes in relevant school policies after the Washington statewide mandate. Policy area composite measures were generated by principal component factor analysis from survey questions about multiple binary measure policy and practice.

Results

Relative to expected trends without the mandate, we found significant percentage-point increases in various policies, including restricted access to competitive foods in middle and high schools (increased by 18.8-20.0 percentage points); school food practices (increased by 10.4 percentage points in middle schools); and eliminating exemptions from physical education (PE) for sports (16.6 percentage-point increase for middle schools), exemptions from PE for community activities (12.8 and 14.4 percentage-point increases for middle and high schools, respectively) and exemptions from PE for academics (18.1 percentage-point increase for middle schools).

Conclusion

Our results suggest that a statewide mandate had a modest effect on increasing physical activity and nutrition policies and practices in schools. Government policy is potentially an effective tool for addressing the childhood obesity epidemic through improvements in school physical activity and nutrition environments.     

Work patterns and fatigue-related risk among junior doctors

Background

To reduce fatigue‐related risk among junior doctors, recent initiatives in Europe and the USA have introduced limits on work hours. However, research in other industries has highlighted that other aspects of work patterns are important in generating fatigue, in addition to total work hours. The Australian Medical Association (AMA) has proposed a more comprehensive fatigue risk management approach.

Objectives

To evaluate the work patterns of New Zealand junior doctors based on the AMA approach, examining relationships between different aspects of work and fatigue‐related outcomes.

Methods

An anonymous questionnaire mailed to all house officers and registrars dealt with demographics, work patterns, sleepiness, fatigue‐related clinical errors, and support for coping with work demands. Each participant was assigned a total fatigue risk score combining 10 aspects of work patterns and sleep in the preceding week.

Results

The response rate was 63% (1366 questionnaires from doctors working ⩾40 hours a week). On fatigue measures, 30% of participants scored as excessively sleepy (Epworth Sleepiness Score >10), 24% reported falling asleep driving home since becoming a doctor, 66% had felt close to falling asleep at the wheel in the past 12 months, and 42% recalled a fatigue‐related clinical error in the past 6 months. Night work and schedule instability were independently associated with more fatigue measures than was total hours worked, after controlling for demographic factors, The total risk score was a significant independent risk factor for all fatigue measures, in a dose‐dependent manner (all p<0.01). Regular access to adequate supervision at work reduced the risk of fatigue on all measures.

Conclusions

To reduce fatigue‐related risk among junior doctors, account must be taken of factors in addition to total hours of work and duration of rest breaks. The AMA fatigue risk assessment model offers a useful example of a more comprehensive approach.     

Napping during the night shift and recovery after work among hospital nurses

OBJECTIVE:

To analyze the association between the length of napping during the night shift and the recovery after work among nurses.

METHOD:

Cross-sectional epidemiological study involving 1940 nurses from 18 public hospitals in the City of Rio de Janeiro. A multidimensional and self-applied questionnaire was used with information about health, sociodemographic and occupational characteristics, health-related behaviors and housework. Multiple logistic regression was applied to identify the association, adjusted for confounding variables.

RESULTS:

The gross analyses showed 44%, 127% and 66% higher chances of a high level of recovery after work for nurses who sleep up to two hours, between 2.1 and 3 hours and 3.1 hours or more, respectively, when compared to the nurses who do not sleep. After adjusting for confounding variables, the association only continues significant for the group that sleeps 2.1 to 3 hours during the night shift (OR=1.79; 95%CI=1.33-2.41).

CONCLUSION:

The association between the length of napping and the high level of recovery after work, confirmed in the present results, can be included in the studies that aim to support more appropriate policies aimed at improving the workers'' work, life and health conditions, not only in nursing, but night-shift workers in general.     

Occupational health policies and practices related to tuberculosis in health care workers in KwaZulu-Natal,South Africa

Setting:

Three district hospitals in KwaZulu-Natal, South Africa, with specialized drug-resistant tuberculosis (TB) wards.

Objective:

To increase understanding of the implementation of occupational health (OH) and infection control (IC) guidelines for the prevention and control of TB among health care workers (HCWs).

Design:

An operational cross-sectional study conducted between July and September 2011, consisting of interviews with OH and IC nurses and chart review of OH medical records.

Results:

Although general national and provincial OH policies are in place, no specific OH policies exist for hospital settings. Two of three hospitals had a full-time OH nurse and all had a full-time IC nurse. All hospitals offered TB symptom screening; however, only 19% of HCWs were screened in 2010. TB incidence among HCWs was 1958 per 100 000 population in 2010. All hospitals offered HIV counseling and testing; however, only 22% of staff were tested across sites. Two hospitals offered isoniazid preventive therapy to HIV-positive staff and reassigned these staff to low TB risk areas.

Conclusions:

While OH policies and procedures are in place, implementation of these policies and procedures is inconsistent. This potentially places HCWs at risk of acquiring TB. These findings support the need for strengthening OH and IC services to prevent TB.     

Pain,health perception and sleep: impact on the quality of life of firefighters/rescue professionals

Objective:

to evaluate the quality of life of firefighters and rescue professionals, and characterize their socio-demographic, health, work and lifestyle profile.

Methods:

cross-sectional study that used a socio-demographic, lifestyle, health, work data questionnaire and the WHOQOL-BREF quality of life aspects, in Fire Department bases, Civil Air Patrol Group of the Military Police and Rescue Group of Emergency Services.

Results:

ninety professionals participated in this study - 71 firefighters, 9 nurses, 7 doctors and 3 flight crew members. The average age of the group was 36.4 ± 7.8 years; they worked about 63.7 hours per week; 20.2% reported pain in the last week and 72.7% had body mass index above 25 kg/m2. The average of the WHOQOL-BREF domains was: physical (74.6), psychological (75.2), social (76.5) and environmental (58.7). Significant association was found (Mann-Whitney test and Spearman correlation) between the WHOQOL-BREF domains and pain in the past six months, in the last week, health perception, job satisfaction, hours of sleep, domestic tasks and study.

Conclusion:

the main factors related to quality of life were presence of pain, health perception, sleep and domestic activity.     

Nurse-perceived Patient Adverse Events and Nursing Practice Environment

Objectives:

To evaluate the occurrence of patient adverse events in Korean hospitals as perceived by nurses and examine the correlation between patient adverse events with the nurse practice environment at nurse and hospital level.

Methods:

In total, 3096 nurses working in 60 general inpatient hospital units were included. A two-level logistic regression analysis was performed.

Results:

At the hospital level, patient adverse events included patient falls (60.5%), nosocomial infections (51.7%), pressure sores (42.6%) and medication errors (33.3%). Among the hospital-level explanatory variables associated with the nursing practice environment, ‘physician- nurse relationship’ correlated with medication errors while ‘education for improving quality of care’ affected patient falls.

Conclusions:

The doctor-nurse relationship and access to education that can improve the quality of care at the hospital level may help decrease the occurrence of patient adverse events.     

Nurse-Perceived Patient Adverse Events depend on Nursing Workload

Objectives

The purpose of this study was to investigate the correlation between nursing workload and nurse-perceived patient adverse events.

Methods

A total of 1,816 nurses working in general inpatient units of 23 tertiary general hospitals in South Korea were surveyed, and collected data were analyzed through multilevel logistic regression analysis.

Results

Among variables related to nursing workload, the non-nursing task experience had an influence on all four types of patient adverse events. Nurses with non-nursing tasks experienced patient adverse events—falls [odds ratio (OR) = 1.31], nosocomial infections (OR = 1.23), pressure sores (OR = 1.16), and medication errors (OR = 1.23)—more often than occasionally. In addition, when the bed to nurse ratio was higher, nurses experienced cases of pressure sores more often (OR = 1.35). By contrast, nurses who said the nursing workforce is sufficient were less likely than others to experience cases of pressure sores (OR = 0.78). Hospitals with a relatively high proportion of nurses who perceived the nursing workforce to be sufficient showed a low rate of medication error (OR = 0.28).

Conclusion

The study suggested that the high level of nursing workload in South Korea increases the possibility of patient adverse events.     

Occupational risk factors for low back pain among drivers of three-wheelers in Sri Lanka

Background:

Approximately 5% of all households in Sri Lanka operate a three-wheeler as their primary source of income. However, very little is known about the occupational health risks associated with driving these vehicles.

Objectives:

The aim of this study was to assess occupational risk factors, including the number of hours worked associated with the 4-week prevalence of low back pain (LBP) among drivers of three-wheelers.

Methods:

Questionnaires were administered to 200 full-time drivers of three-wheelers from the Galle District in Sri Lanka. Occupational, psychological, socio-demographic, lifestyle, and anthropometric variables were collected. Univariate and multivariate analysis were used to investigate the correlation between occupational risk factors of the prevalence of LBP.

Results:

15.5% of respondents reported experiencing LBP in the previous 4 months. Univariate analysis revealed that the number of hours worked per week, feeling pressure to compete with other drivers, and perceived stress scale scores were significantly associated with the 4-week prevalence of LBP. Multivariate analysis found that the number of hours worked per week and engine type were significantly associated with LBP.

Conclusions:

LBP is common among drivers of three-wheelers in Sri Lanka. Long work hours and two-stroke engines were significantly associated with LBP. Results from this study point towards a role for educational, behavioral health, and policy interventions to help prevent and reduce LBP among these drivers.     

Managing Patients With Heart Failure: A Qualitative Study of Multidisciplinary Teams With Specialist Heart Failure Nurses

PURPOSE

The purpose of this study was to explore the perceptions and experiences of health care clinicians working in multidisciplinary teams that include specialist heart failure nurses when caring for the management of heart failure patients.

METHODS

We used a qualitative in-depth interview study nested in a broader ethnographic study of unplanned admissions in heart failure patients (HoldFAST). We interviewed 24 clinicians across primary, secondary, and community care in 3 locations in the Midlands, South Central, and South West of England.

RESULTS

Within a framework of the role and contribution of the heart failure specialist nurse, our study identified 2 thematic areas that the clinicians agreed still represent particular challenges when working with heart failure patients. The first was communication with patients, in particular explaining the diagnosis and helping patients to understand the condition. The participants recognized that such communication was most effective when they had a long-term relationship with patients and families and that the specialist nurse played an important part in achieving this relationship. The second was communication within the team. Multidisciplinary input was especially needed because of the complexity of many patients and issues around medications, and the participants believed the specialist nurse may facilitate team communication.

CONCLUSIONS

The study highlights the role of specialist heart failure nurses in delivering education tailored to patients and facilitating better liaison among all clinicians, particularly when dealing with the management of comorbidities and drug regimens. The way in which specialist nurses were able to be caseworkers for their patients was perceived as a method of ensuring coordination and continuity of care.     

Associations of perceived work strain with nicotine dependence in a community sample

Background

Little is known about work strain and smoking, and even less about work strain and nicotine dependence.

Aim

To investigate the relations of perceived work strain with nicotine dependence among an adult general population sample.

Method

Cross sectional survey with a probability sample of residents of a northern German area with 4075 participants, aged 18–64 years (participation rate 70.2%). The current study is based on 2549 participants who were working 15 or more hours per week. Face to face at‐home computer aided interviews (World Health Organization Composite International Diagnostic Interview) were carried out. Work strain, defined as high work demand and low work control, was assessed with a questionnaire. Nicotine dependence was diagnosed according to the Diagnostic and Statistical Manual (DSM‐IV) of the American Psychiatric Association. In addition, the Fagerström Test for Nicotine Dependence (FTND) was used.

Results

Subjects with work strain had an odds ratio of 1.6 (95% CI 1.2 to 2.3) for nicotine dependence compared to those who had no work strain. In a general linear model, higher work strain was associated with a stronger relation between work demand and work control and the FTND. The findings were adjusted for alcohol use disorders, occupational status, age, and sex.

Conclusion

Perceived work strain is related to nicotine dependence in this general adult population.     

Gynecologic pain related to occupational stress among female factory workers in Tianjin,China

Background:

Dysmenorrhea, dyspareunia, and non-cyclic pelvic pain are health concerns for factory workers in China and may be increased by occupational stress.

Objectives:

To estimate the prevalence and demographic and occupational factors associated with three types of gynecologic pain among female factory workers in Tianjin.

Methods:

The study included 651 female workers from three factories in Tianjin, China. Logistic regression models were estimated to determine associations between occupational stress and gynecologic pain.

Results:

Occupational stress including high job strain, exhaustion, and stress related to working conditions was a risk factor for gynecologic pain. High job strain and poor job security were associated with an increased risk for dysmenorrhea. Compulsory overtime and exhaustion were associated with increased non-cyclic pelvic pain. Working overtime and exhaustion were associated with increased dyspareunia.

Conclusions:

As China’s population of female factory workers grows, research on the reproductive health of this population is essential.     

Concurrent and Lagged Effects of Registered Nurse Turnover and Staffing on Unit‐Acquired Pressure Ulcers

Objective

We examined the concurrent and lagged effects of registered nurse (RN) turnover on unit-acquired pressure ulcer rates and whether RN staffing mediated the effects.

Data Sources/Setting

Quarterly unit-level data were obtained from the National Database of Nursing Quality Indicators for 2008 to 2010. A total of 10,935 unit-quarter observations (2,294 units, 465 hospitals) were analyzed.

Methods

This longitudinal study used multilevel regressions and tested time-lagged effects of study variables on outcomes.

Findings

The lagged effect of RN turnover on unit-acquired pressure ulcers was significant, while there was no concurrent effect. For every 10 percentage-point increase in RN turnover in a quarter, the odds of a patient having a pressure ulcer increased by 4 percent in the next quarter. Higher RN turnover in a quarter was associated with lower RN staffing in the current and subsequent quarters. Higher RN staffing was associated with lower pressure ulcer rates, but it did not mediate the relationship between turnover and pressure ulcers.

Conclusions

We suggest that RN turnover is an important factor that affects pressure ulcer rates and RN staffing needed for high-quality patient care. Given the high RN turnover rates, hospital and nursing administrators should prepare for its negative effect on patient outcomes.