Nurses' reports on hospital care in five countries

The current nursing shortage, high hospital nurse job dissatisfaction, and reports of uneven quality of hospital care are not uniquely American phenomena. This paper presents reports from 43,000 nurses from more than 700 hospitals in the United States, Canada, England, Scotland, and Germany in 1998-1999. Nurses in countries with distinctly different health care systems report similar shortcomings in their work environments and the quality of hospital care. While the competence of and relation between nurses and physicians appear satisfactory, core problems in work design and workforce management threaten the provision of care. Resolving these issues, which are amenable to managerial intervention, is essential to preserving patient safety and care of consistently high quality.     

Implications of the California Nurse Staffing Mandate for Other States

Objectives. To determine whether nurse staffing in California hospitals, where state‐mandated minimum nurse‐to‐patient ratios are in effect, differs from two states without legislation and whether those differences are associated with nurse and patient outcomes. Data Sources. Primary survey data from 22,336 hospital staff nurses in California, Pennsylvania, and New Jersey in 2006 and state hospital discharge databases. Study Design. Nurse workloads are compared across the three states and we examine how nurse and patient outcomes, including patient mortality and failure‐to‐rescue, are affected by the differences in nurse workloads across the hospitals in these states. Principal Findings. California hospital nurses cared for one less patient on average than nurses in the other states and two fewer patients on medical and surgical units. Lower ratios are associated with significantly lower mortality. When nurses' workloads were in line with California‐mandated ratios in all three states, nurses' burnout and job dissatisfaction were lower, and nurses reported consistently better quality of care. Conclusions. Hospital nurse staffing ratios mandated in California are associated with lower mortality and nurse outcomes predictive of better nurse retention in California and in other states where they occur.     

"The nurse satisfaction,service quality and nurse retention chain": implications for management of recruitment and retention

This paper presents the findings of a qualitative study, based on interviews with over 130 nurses and midwives in four London Trust hospitals on: the main factors influencing nurse satisfaction and retention; empirical support for the robustness of a conceptual framework or model "the nurse satisfaction, service quality and nurse retention chain"; and some managerial considerations for recruitment and retention. The three main factors influencing job satisfaction were patients, the inherent characteristics of nursing and the nursing team; the two main sources of job dissatisfaction were staff shortages and poor management and amongst nurse retention strategies improving working conditions was more important than increased pay. For recruitment, as well as retention, improving the image and reputation of nursing along with improvements in work-life balance were pre-requisites for meeting the challenging target of an additional 20,000 nurses on the wards by 2004.     

Strengthening hospital nursing

Hospitals, nurses, the media, Congress, and the private sector are increasingly concerned about shortages of registered nurses (RNs) and the impact on safety and quality of patient care. Findings from a growing number of studies provide evidence of a relationship between hospital nurse staffing and adverse outcomes experienced by medical and surgical patients. These findings have policy implications for strengthening the nursing profession, monitoring the quality of hospital care associated with nursing, and improving the relationship between hospitals and the nursing profession.     

Hospital restructuring and the work of registered nurses

American hospitals have undergone three waves of organizational restructuring in the past two decades. These changes have had direct effects on a key set of employees--nurses. A review of the relevant literature to identify the ways in which hospital restructuring affects the work of registered nurses focuses on three important structural characteristics of nursing work: nurses' work roles, workload, and control of work. The review concludes that the impact of restructuring on each of the characteristics affects nurses' satisfaction with their work and may also affect the quality of patient care. While much of the policy debate around restructuring focuses on the extent to which reductions in nurse staffing levels affects quality of care, it is important to examine not only changes in nurse staffing levels, but changes in the work performed by registered nurses, as well.     

Contradicting fears, California's nurse-to-patient mandate did not reduce the skill level of the nursing workforce in hospitals

When California passed a law in 1999 establishing minimum nurse-to-patient staffing ratios for hospitals, it was feared that hospitals might respond by disproportionately hiring lower-skill licensed vocational nurses. This article examines nurse staffing ratios for California hospitals for the period 1997-2008. It compares staffing levels to those in similar hospitals in the United States. We found that California's mandate did not reduce the nurse workforce skill level as feared. Instead, California hospitals on average followed the trend of hospitals nationally by increasing their nursing skill mix, and they primarily used more highly skilled registered nurses to meet the staffing mandate. In addition, we found that the staffing mandate resulted in roughly an additional half-hour of nursing per adjusted patient day beyond what would have been expected in the absence of the policy. Policy makers in other states can look to California's experience when considering similar approaches to improving patient care.     

Nurses' widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care

Job dissatisfaction among nurses contributes to costly labor disputes, turnover, and risk to patients. Examining survey data from 95,499 nurses, we found much higher job dissatisfaction and burnout among nurses who were directly caring for patients in hospitals and nursing homes than among nurses working in other jobs or settings, such as the pharmaceutical industry. Strikingly, nurses are particularly dissatisfied with their health benefits, which highlights the need for a benefits review to make nurses' benefits more comparable to those of other white-collar employees. Patient satisfaction levels are lower in hospitals with more nurses who are dissatisfied or burned out-a finding that signals problems with quality of care. Improving nurses' working conditions may improve both nurses' and patients' satisfaction as well as the quality of care.     

Hospital nurse practice environments and outcomes for surgical oncology patients

Objective. To examine the effect of nursing practice environments on outcomes of hospitalized cancer patients undergoing surgery.
Data Sources. Secondary analysis of cancer registry, inpatient claims, administrative and nurse survey data collected in Pennsylvania for 1998–1999.
Study Design. Nurse staffing (patient to nurse ratio), educational preparation (proportion of nurses holding at least a bachelor's degree), and the practice environment (Practice Environment Scale of the Nursing Work Index) were calculated from a survey of nurses and aggregated to the hospital level. Logistic regression models predicted the odds of 30-day mortality, complications, and failure to rescue (death following a complication).
Principal Findings. Unadjusted death, complication, and failure to rescue rates were 3.4, 35.7, and 9.3 percent, respectively. Nurse staffing and educational preparation of registered nurses were significantly associated with patient outcomes. After adjusting for patient and hospital characteristics, patients in hospitals with poor nurse practice environments had significantly increased odds of death (odds ratio, 1.37; 95 percent confidence interval, 1.07–1.76) and of failure to rescue (odds ratio, 1.48; 95 percent confidence interval, 1.07–2.03). Receipt of care in National Cancer Institute-designated cancer centers significantly decreased the odds of death, which can be explained partly by better nurse practice environments.
Conclusions. This study is one of the first to examine the predictive validity of the National Quality Forum's endorsed measure of the nurse practice environment. Improvements in the quality of nurse practice environments could reduce adverse outcomes for hospitalized surgical oncology patients.     

The relationship between hospital unit culture and nurses' quality of work life

Turnover rates for hospital nurses have been increasing in recent years, which is partially a result of increasing pressure on nurses from higher productivity expectations in a managed care environment. Improving nurse retention is a difficult challenge to managers since the bureaucratic cultural norm of hospitals, with its hierarchical structures, rules, and regulations, and heavy emphasis on measurement of outcomes and costs, may not be the culture most conducive to enhancing nurses' job satisfaction and commitment. Accordingly, this study investigates the relationships between unit organizational culture and several important job-related variables for nurse retention in the labor and delivery units of seven hospitals. Data analysis shows that unit organizational culture does affect nurses' quality of work life factors and that human relations cultural values are positively related to organizational commitment, job involvement, empowerment, and job satisfaction, and negatively related to intent to turnover. These findings suggest that although increasing recruitment of nurses and improved compensation and benefits strategies may offset hospital nurse shortages in the short term, improving quality of work life may be a more practical and long-term approach to improving hospital nurse retention.     

优质护理服务示范工程对护士工作压力与职业倦怠的影响

目的 探讨开展“优质护理服务示范工程”活动对护士工作压力与职业倦怠的影响.方法 将参加“示范工程”的3个病区60名护士为试验组,其他选择未参加“示范工程”的3个病区42名护士为对照组,两组均采用护士工作压力量表和工作倦怠量表.结果 试验组护士在护理专业及工作方面的问题、患者护理方面问题工作压力明显低于对照组护士.两组护士在护理专业、时间分配、工作环境、患者护理,以及工作压力源总分方面有统计学差异（P＜0.01）,但在管理方面得分无统计学差异（P＞0.05）;试验组护士在情绪耗竭、倦怠和成就感低落方面明显高于对照组,差异有统计学意义（P＜0.01）.结论 “示范工程”和护士工作压力源与职业倦怠存在相关性.     

A longitudinal examination of hospital registered nurse staffing and quality of care

OBJECTIVE: To evaluate previous research findings of the relationship between nurse staffing and quality of care by examining the effects of change in registered nurse staffing on change in quality of care. DATA SOURCES/STUDY SETTING: Secondary data from the American Hospital Association (AHA)(nurse staffing, hospital characteristics), InterStudy and Area Resource Files (ARF) (market characteristics), Centers for Medicare and Medicaid Services (CMS) (financial performance), and Healthcare Cost and Utilization Project (HCUP) (quality measures-in-hospital mortality ratio and the complication ratios for decubitus ulcers, pneumonia, and urinary tract infection, which were risk-adjusted using the Medstat disease staging algorithm). STUDY DESIGN: Data from a longitudinal cohort of 422 hospitals were analyzed from 1990-1995 to examine the relationships between nurse staffing and quality of care. DATA COLLECTION/EXTRACTION METHODS: A generalized method of moments estimator for dynamic panel data was used to analyze the data. Principal Findings. Increasing registered nurse staffing had a diminishing marginal effect on reducing mortality ratio, but had no consistent effect on any of the complications. Selected hospital characteristics, market characteristics, and financial performance had other independent effects on quality measures. CONCLUSIONS: The findings provide limited support for the prevailing notion that improving registered nurse (RN) staffing unconditionally improves quality of care.     

Rationing of nursing care and its relationship to patient outcomes: the Swiss extension of the International Hospital Outcomes Study.

OBJECTIVE: To explore the association between implicit rationing of nursing care and selected patient outcomes in Swiss hospitals, adjusting for major organizational variables, including the quality of the nurse practice environment and the level of nurse staffing. Rationing was measured using the newly developed Basel Extent of Rationing of Nursing Care (BERNCA) instrument. Additional data were collected using an adapted version of the International Hospital Outcomes Study questionnaire. DESIGN: Multi-hospital cross-sectional surveys of patients and nurses. SETTING: Eight Swiss acute care hospitals PARTICIPANTS: Nurses (1338) and patients (779) on 118 medical, surgical and gynecological units. MAIN OUTCOME MEASURES: Patient satisfaction, nurse-reported medication errors, patient falls, nosocomial infections, pressure ulcers and critical incidents involving patients over the previous year. RESULTS: Generally, nurses reported rarely having omitted any of the 20 nursing tasks listed in the BERNCA over their last 7 working days. However, despite relatively low levels, implicit rationing of nursing care was a significant predictor of all six patient outcomes studied. Although the adequacy of nursing resources was a significant predictor for most of the patient outcomes in unadjusted models, it was not an independent predictor in the adjusted models. Low nursing resource adequacy ratings were a significant predictor for five of the six patient outcomes in the unadjusted models, but not in the adjusted ones. CONCLUSION: As a system factor in acute general hospitals, implicit rationing of nursing care is an important new predictor of patient outcomes and merits further study.     

Nurse Staffing Levels: Impact of Organizational Characteristics and Registered Nurse Supply

Objective. To assess the impact of nurse supply in the geographic areas surrounding hospitals on staffing levels in hospital units, while taking into account other factors that influence nurse staffing.
Data Sources. Data regarding 279 patient care units, in 47 randomly selected community hospitals located in 11 clusters in the United States, were obtained directly from the hospitals from the U.S. Census report, National Council of State Boards of Nursing, and The Centers for Medicare and Medicaid Services.
Study Design. Cross-sectional analyses with linear mixed modeling to control for nesting of units in hospitals were conducted. For each patient care unit, the hours of care per patient day from registered nurses (RNs), LPNs, nursing assistants, and the skill-mix levels were calculated. These measures of staffing were then regressed on type of unit (intensive care, medical/surgical, telemetry/stepdown), unit size, hospital complexity, and RN supply.
Principal Findings. RN hours per patient day and RN skill mix were positively related to intensity of patient care, hospital complexity, and the supply of RNs in the geographic area surrounding the hospital. LPN hours, and licensed skill mix were predicted less reliably but appear to be used as substitutes for RNs. Overtime hours increased in areas with a lower RN supply. Vacancy and turnover rates and the use of contract nurses were not affected by nurse supply.
Conclusions. This study is the first to show that hospital RN staffing levels on both intensive care and nonintensive care units decrease as the supply of RNs in the surrounding geographic area decreases. We also show that LPN hours rise in areas where RN supply is lower. Further research to describe the quality of hospital care in relation to the supply of nurses in the area is needed.     

Nurse residency program: an effective tool for recruitment and retention

In the present health care climate, the critical nursing shortage is detrimentally affecting staffing ratios in hospitals throughout the State of California. The purpose of this newly developed nurse residency program is to have a positive affect on recruitment and retention of new graduate nurses. By providing the opportunity for nursing residents to gain "real world" experience in an acute care setting, this program supports the student nurses in their development as confident and competent practitioners. The result of this program will be manifested in increasing numbers of new graduate nurses remaining with the facilities that have residency programs. The program also leads to increased self-confidence, increased competence, and greater professional socialization, which will thereby, lead to increased quality of patient care, increased job satisfaction, decreased turnover rates, and decreased hospital costs for recruitment and retention.     

Rationing of nursing care and nurse–patient outcomes: a systematic review of quantitative studies

Bedside rationing in nursing care refers to withholding or failure to carry out certain aspects of care because of limited resources such as time, staffing or skill mix. The absence of previous systematic reviews on nursing care rationing leads to a gap of synthesized knowledge on the factors and processes related to rationing and the potential negative consequences on both patients and nurses. The aim of this study was to gain an in‐depth understanding of the factors and processes related to nursing care rationing. Selected papers were methodologically assessed based on their design, sampling, measurement and statistical analysis. Seventeen quantitative studies were reviewed, and findings were categorized into four themes: elements of nursing care being rationed, causes of rationing, nurse outcomes and patient outcomes. Results revealed that communication with patients and families, patient ambulation, and mouth care were common elements of rationed care. Nurse–patient workload and communication barriers were reported as potential causes of rationing. Patient‐related outcomes included patient falls, nosocomial infections and low patient satisfaction levels. Nurse‐related outcomes included low job and occupational satisfaction. In addition, rationing appears to be an important organizational variable linked with patient safety and quality of care. This review increases understanding of what is actually occurring at the point of care delivery so that managers will be able to improve processes that lead to high quality of care and better patient and nurse outcomes. Copyright © 2013 John Wiley & Sons, Ltd.     

Effects of hospital staffing and organizational climate on needlestick injuries to nurses

OBJECTIVES: This study determined the effects of nurse staffing and nursing organization on the likelihood of needlestick injuries in hospital nurses. METHODS: We analyzed retrospective data from 732 and prospective data from 960 nurses on needlestick exposures and near misses over different 1-month periods in 1990 and 1991. Staffing levels and survey data about working climate and risk factors for needlestick injuries were collected on 40 units in 20 hospitals. RESULTS: Nurses from units with low staffing and poor organizational climates were generally twice as likely as nurses on well-staffed and better-organized units to report risk factors, needlestick injuries, and near misses. CONCLUSIONS: Staffing and organizational climate influence hospital nurses' likelihood of sustaining needlestick injuries. Remedying problems with understaffing, inadequate administrative support, and poor morale could reduce needlestick injuries.     

Job Satisfaction Among Hospital Nurses: Facility Size and Location Comparisons

Despite recent declines in turnover and vacancy rates, maintaining a stable nursing staff continues to be critical to the effective operation of American hospitals. Job satisfaction is a pivotal element in nurse retention, and organizational theory suggests that some of the factors that influence job satisfaction vary by facility size. This is a study of job satisfaction among a sample of 731 nurses providing direct patient care in 22 hospitals. The sample includes approximately equal numbers of nurses employed in very small rural hospitals (1-49 beds), medium sized facilities located in small towns (50-99 beds), and larger metropolitan institutions (> 100 beds). Differences by hospital size were observed in overall job satisfaction and in five sub-dimensions of that concept (i.e., professional status, task requirements, pay, organizational policies, and autonomy). With the exception of pay, the results indicated that nurses employed in the very small rural hospitals were more satisfied with their jobs. Differences by hospital size were also observed in the personal characteristics of the nurses, several specific aspects of their job, and in their perceptions of job mobility. A set of four hierarchically nested ordinary least squares regression models indicated that job-specific characteristics were the most powerful predictors of job satisfaction.     

Satisfaction for health care employees: a quest for the Holy Grail?

This article proposes that, across industries, too much has been made of the importance of job satisfaction and its impact on organizational effectiveness. In addition, so much attention has been directed toward satisfaction that many health care employees, particularly nurses, now expect job satisfaction from their employers as an entitlement. In nursing, feelings about job satisfaction may, in fact, be exacerbated by the idealism which leads the young person entering the field to expect to be in a "helping profession" where workers almost automatically encounter the satisfaction that comes from giving the help which the patient desperately needs. Faced with the realities of long hours, grueling and often menial tasks, and sometimes churlish patients and physicians, the young nurse may, in fact, enter a period of deep dissatisfaction and of questioning nursing as a career choice. This situation is not unique to nurses. Many health care professionals face equally dissatisfying aspects of their jobs. Our focus is primarily on reducing job dissatisfaction, rather than improving job satisfaction, through practical solutions for those charged with attracting and retaining health care employees during tight labor markets.     

Incorporating nurse absenteeism into staffing with demand uncertainty

Increased nurse-to-patient ratios are associated negatively with increased costs and positively with improved patient care and reduced nurse burnout rates. Thus, it is critical from a cost, patient safety, and nurse satisfaction perspective that nurses be utilized efficiently and effectively. To address this, we propose a stochastic programming formulation for nurse staffing that accounts for variability in the patient census and nurse absenteeism, day-to-day correlations among the patient census levels, and costs associated with three different classes of nursing personnel: unit, pool, and temporary nurses. The decisions to be made include: how many unit nurses to employ, how large a pool of cross-trained nurses to maintain, how to allocate the pool nurses on a daily basis, and how many temporary nurses to utilize daily. A genetic algorithm is developed to solve the resulting model. Preliminary results using data from a large university hospital suggest that the proposed model can save a four-unit pool hundreds of thousands of dollars annually as opposed to the crude heuristics the hospital currently employs.     

护理人员职业倦怠与组织承诺、工作满意度的关系研究

目的研究职业倦怠与组织承诺、工作满意度的关系。方法采用整群随机抽样的方法,选取黑龙江省3家三级甲等公立医院660护理人员进行职业倦怠、组织承诺、工作满意度问卷调查。结果 (1)护理人员组织承诺、工作满意度和职业倦怠的平均分依次为(3.87±0.62)分、(3.24±0.71)分、(3.12±0.58)分,(2)工作满意度、组织承诺与职业倦怠分别为低度负相关关系,(3)福利待遇、规范承诺、排班、年龄、专业发展机会、婚姻状况、学历、家庭和工作平衡对职业倦怠的联合解释量为19.9%。结论护理人员组织承诺好工作满意度处于较高水平,职业倦怠比较严重,组织承诺、工作满意度对护理人员职业倦怠有负向预测作用。