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BACKGROUND: Hospitals are resurrecting the outdated "team nursing" model of staffing that substitutes lower-wage staff for registered nurses (RNs). OBJECTIVES: To evaluate whether reducing the proportion of RNs to total nursing staff in hospitals is in the best interest of patients, hospitals, and payers. RESEARCH DESIGN: Cross-sectional, retrospective. SUBJECTS: In all, 6,559,704 Medicare patients in 2676 general acute-care US hospitals in 2019. MEASURES: Patient outcomes: in-hospital and 30-day mortality, 30-day readmission, length of stay, and patient satisfaction. Avoidable Medicare costs associated with readmissions and cost savings to hospitals associated with shorter stays are projected. RESULTS: A 10 percentage-point reduction in RNs was associated with 7% higher odds of in-hospital death, 1% higher odds of readmission, 2% increase in expected days, and lower patient satisfaction. We estimate a 10 percentage-point reduction in RNs would result in 10,947 avoidable deaths annually and 5207 avoidable readmissions, which translates into roughly $68.5 million in additional Medicare costs. Hospitals would forgo nearly $3 billion in cost savings annually because of patients requiring longer stays. CONCLUSIONS: Reducing the proportion of RNs in hospitals, even when total nursing personnel hours are kept the same, is likely to result in significant avoidable patient deaths, readmissions, longer lengths of stay, and decreased patient satisfaction, in addition to excess Medicare costs and forgone cost savings to hospitals. Estimates represent only a 10 percentage-point dilution in skill mix; however, the team nursing model includes much larger reductions of 40-50 percentage-points-the human and economic consequences of which could be substantial.
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Tiempo de Internación , Medicare , Personal de Enfermería en Hospital , Readmisión del Paciente , Admisión y Programación de Personal , Humanos , Personal de Enfermería en Hospital/economía , Personal de Enfermería en Hospital/provisión & distribución , Estudios Transversales , Estudios Retrospectivos , Admisión y Programación de Personal/estadística & datos numéricos , Estados Unidos , Medicare/economía , Medicare/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Masculino , Femenino , Satisfacción del Paciente , Mortalidad Hospitalaria , AncianoRESUMEN
BACKGROUND: During the Covid-19 pandemic, Covid-19 mortality varied depending on the hospital where patients were admitted, but it is unknown what aspects of hospitals were important for mitigating preventable deaths. OBJECTIVE: To determine whether hospital differences in pre-pandemic and during pandemic nursing resources-average patient-to-registered nurse (RN) staffing ratios, proportion of bachelor-qualified RNs, nurse work environments, Magnet recognition-explain differences in risk-adjusted Covid-19 mortality; and to estimate how many deaths may have been prevented if nurses were better resourced prior to and during the pandemic. METHODS: This is a cross-sectional study of 87,936 Medicare beneficiaries (65-99â¯years old) hospitalized with Covid-19 and discharged (or died) between April 1 and December 31, 2020, in 237 general acute care hospitals in New York and Illinois. Measures of hospital nursing resources (i.e. patient-to-RN staffing ratios, proportion of bachelor-qualified RNs, nurse work environments, Magnet recognition) in the pre-pandemic period (December 2019 to February 2020) and during (April to June 2021) were used to predict in-hospital and 30-day mortality using adjusted logistic regression models. RESULTS: The mean age of patients was 78â¯years (8.6 SD); 51â¯% were male (nâ¯=â¯44,998). 23â¯% of patients admitted to the hospital with Covid-19 died during the hospitalization (nâ¯=â¯20,243); 31.5â¯% died within 30-days of admission (nâ¯=â¯27,719). Patients admitted with Covid-19 to hospitals with better nursing resources pre-pandemic and during the pandemic were statistically significantly less likely to die. For example, each additional patient in the average nurses' workload pre-pandemic was associated with 20â¯% higher odds of in-hospital mortality (OR 1.20, 95â¯% CI [1.12-1.28], pâ¯<â¯0.001) and 15â¯% higher odds of 30-day mortality (OR 1.15, 95â¯% CI [1.09-1.21], pâ¯<â¯0.001). Hospitals with greater proportions of BSN-qualified RNs, better quality nurse work environments, and Magnet recognition offered similar protective benefits to patients during the pandemic. If all hospitals in the study had superior nursing resources prior to or during the pandemic, models estimate many thousands of deaths among patients hospitalized with Covid-19 could have been avoided. CONCLUSIONS: Patients with Covid-19 admitted to hospitals with adequate numbers of RNs caring for patients, a workforce rich in BSN-qualified RNs, and high-quality nurse work environments (both prior to and during the Covid-19 pandemic) were more likely to survive the hospitalization. Bolstering these hospital nursing resources during ordinary times is necessary to ensure better patient outcomes and emergency-preparedness of hospitals for future public health emergencies.
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The Practice Environment Scale of the Nursing Work Index (PES-NWI) has been utilized for two decades globally to measure nurse work environments. Its 31 items in five domains present a substantial respondent burden, threatening survey response rates. The purpose of this study was to derive and validate a short form: the PES-5. We conducted a cross-sectional, secondary analysis of survey data from nurses in 760 hospitals in six U.S. states in 2016 or 2019. One representative item per subscale was selected by highest item-to-subscale R2 from the original PES-NWI publication. Five psychometric properties of the PES-5 were evaluated. The reproduced structure of the full form was confirmed in the 2016 data by the highest R2 for the selected items. The unidimensional structure of the PES-5 was confirmed through confirmatory factor analysis. The correlation between the composite values of the 28-item and 5-item versions was 0.94. The Cronbach's alpha reliability of the PES-5 was >0.80. The intraclass correlation coefficient (ICC 1, k), which evaluates the stability of aggregated values when data are clustered, i.e., nurses are nested within hospitals, was >0.80 in both datasets, demonstrating satisfactory aggregate properties. Construct validity was supported by the selected items being ranked highly in their respective subscales by an expert panel. Criterion validity was supported by an analysis of variance of the PES-5 mean value across responses to a single-item work environment measure. Similar patterns of relationships with other key variables were identified by statistically significant odds ratios in regression models predicting patient mortality from the PES-5. The classification accuracy of the PES-5 was high, with 88% of hospitals classified identically by both versions. The PES-5 shows promise for measurement of nurses' work environments while maximizing response rate by reducing participant burden.
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Psicometría , Lugar de Trabajo , Humanos , Estudios Transversales , Femenino , Encuestas y Cuestionarios/normas , Reproducibilidad de los Resultados , Masculino , Lugar de Trabajo/psicología , Adulto , Estados Unidos , Persona de Mediana Edad , Personal de Enfermería en Hospital/estadística & datos numéricos , Personal de Enfermería en Hospital/psicología , Satisfacción en el TrabajoRESUMEN
Language barriers significantly affect communication between patients and health care staff and are associated with receipt of lower-quality care. Registered nurses are well positioned members of the health care team to reduce and eliminate disparities for patients with limited English proficiency (LEP). Current evidence recommends nurses use interpreters or translation devices to overcome language barriers; however, these recommendations fail to recognize that structural system-level factors, such as unsupportive work environments and poor nurse-to-patient staffing ratios, reduce nurses' ability to implement these recommendations. The Quality Health Outcomes Model (QHOM) is a useful framework for understanding relationships between hospital systems, the delivery of care interventions, and patient outcomes. The goal of this manuscript is to use the QHOM and existing empirical evidence to present a new perspective on the long-standing clinical challenge of reducing language-related health outcome disparities by considering the context in which nurses deliver patient care.
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Disparidades en Atención de Salud , Dominio Limitado del Inglés , Humanos , Personal de Enfermería en Hospital , Hospitalización/estadística & datos numéricos , Barreras de Comunicación , Calidad de la Atención de Salud , Traducción , Evaluación de Resultado en la Atención de SaludRESUMEN
OBJECTIVES: To determine the well-being of physicians and nurses in hospital practice in Europe, and to identify interventions that hold promise for reducing adverse clinician outcomes and improving patient safety. DESIGN: Baseline cross-sectional survey of 2187 physicians and 6643 nurses practicing in 64 hospitals in six European countries participating in the EU-funded Magnet4Europe intervention to improve clinicians' well-being. SETTING: Acute general hospitals with 150 or more beds in six European countries: Belgium, England, Germany, Ireland, Sweden and Norway. PARTICIPANTS: Physicians and nurses with direct patient contact working in adult medical and surgical inpatient units, including intensive care and emergency departments. MAIN OUTCOME MEASURES: Burnout, job dissatisfaction, physical and mental health, intent to leave job, quality of care and patient safety and interventions clinicians believe would improve their well-being. RESULTS: Poor work/life balance (57% physicians, 40% nurses), intent to leave (29% physicians, 33% nurses) and high burnout (25% physicians, 26% nurses) were prevalent. Rates varied by hospitals within countries and between countries. Better work environments and staffing were associated with lower percentages of clinicians reporting unfavourable health indicators, quality of care and patient safety. The effect of a 1 IQR improvement in work environments was associated with 7.2% fewer physicians and 5.3% fewer nurses reporting high burnout, and 14.2% fewer physicians and 8.6% fewer nurses giving their hospital an unfavourable rating of quality of care. Improving nurse staffing levels (79% nurses) and reducing bureaucracy and red tape (44% physicians) were interventions clinicians reported would be most effective in improving their own well-being, whereas individual mental health interventions were less frequently prioritised. CONCLUSIONS: Burnout, mental health morbidities, job dissatisfaction and concerns about patient safety and care quality are prevalent among European hospital physicians and nurses. Interventions to improve hospital work environments and staffing are more important to clinicians than mental health interventions to improve personal resilience.
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Agotamiento Profesional , Personal de Enfermería en Hospital , Adulto , Humanos , Estudios Transversales , Seguridad del Paciente , Personal de Enfermería en Hospital/psicología , Agotamiento Profesional/epidemiología , Europa (Continente) , Hospitales Generales , Pacientes Internos , Satisfacción en el Trabajo , Encuestas y CuestionariosRESUMEN
The dementia population has higher rates of mortality during hospital stays than those without dementia. The aim of this study is to examine the relationship between ownership status (i.e. for-profit vs. not-for-profit) and nursing resources (i.e. nurse work environment, nurse-to-patient staffing, and nurse education) on 30-day mortality among post-surgical older adults with dementia. A cross-sectional analysis of linked American Hospital Association, Medicare claims, and nurse survey data was conducted using multi-level logistic regression models. We examined these models to assess the relationship between ownership status and 30-day mortality after adjusting patient and hospital characteristics. We also analyzed the relationship between the hospital ownership status and the 30-day mortality, after considering the three nursing resources. Older adults with dementia who received care in hospitals with not-for-profit status were less likely to die within 30 days of admission following surgery compared to those treated in hospitals with for-profit hospital status (i.e. odds ratio 0.82, 95% confidence interval 0.73-0.92, p = <.001). In addition, the odds ratios estimating the association between ownership and mortality were similar across the different models of the three nursing resources with and without those controls (i.e. 0.88 vs. 0.83 vs. 0.82). Surgical patients with dementia had better outcomes when cared for in not-for-profit hospitals, particularly with greater levels of nurse education and nurse staffing. The relationship between profit status and mortality was partly explained by the lower levels of nurse staffing and education in for-profit vs. not-for-profit hospitals.
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BACKGROUND: Despite decreases in readmissions among Medicare beneficiaries after the implementation of the Hospital Readmissions Reduction Program, older adults living with multiple chronic conditions (MCCs) continue to experience higher readmission rates. Few strategies leverage nursing to identify patients at risk for readmission. OBJECTIVES: Examine the effect of nurse assessments of discharge readiness on 30-day readmissions. RESEARCH DESIGN: Cross-sectional study linking 3 secondary data sources (ie, nurse survey, hospital survey, and Medicare claims data) representing 424 hospitals. SUBJECTS: A total of 188,806 Medicare surgical patients with MCCs. MEASURES: Discharge readiness was derived from the 2016 RN4CAST-US survey. Medicare claims data was used to determine the MCC count. The outcome was 30-day readmissions across the MCC count. RESULTS: The average discharge readiness score was 0.45 (range=0-0.86) indicating that, in the average hospital, <50% of nurses were confident their patient or caregiver could manage their care after discharge. Nearly 8% of patients were readmitted within 30 days of discharge; the highest rates of readmissions were among individuals with ≥5 MCCs (4293, 13.50%). For each 10% increase in the proportion of nurses in a hospital who were confident in their patients' discharge readiness, the odds of 30-day readmission decreased by 2% (95% CI: 0.96-1.00; P =0.028) for patients with 2-4 MCCs and 3% (95% CI: 0.94-0.99; P =0.015) for patients with ≥5 MCCs, relative to patients with 0-1 MCCs. CONCLUSIONS: Nurse assessments of discharge readiness may be a useful signal for hospitals to reduce readmissions and examine factors interfering with discharge processes.
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Afecciones Crónicas Múltiples , Alta del Paciente , Humanos , Anciano , Estados Unidos , Readmisión del Paciente , Estudios Transversales , Medicare , Estudios RetrospectivosRESUMEN
INTRODUCTION: This study determined the relationship between the emergency nurse work environment and emergency department patient left without being seen rates and lengths of stay. METHODS: Cross-sectional analysis of 215 New York and Illinois emergency departments. The work environment (abbreviated Practice Environment Scale of the Nursing Work Index) was measured by emergency nurses in the 2021 RN4CAST-NY/IL survey and linked with outcomes from Hospital Compare. Regression models estimated the relationship between the nurse work environment and emergency department patient left without being seen rates, median length of stay (in minutes), and median behavioral health patient length of stay. Model coefficients were used to estimate expected additional care minutes gained if emergency department work environments improved. RESULTS: "Mixed" work environments had the longest median overall length of stay (3.4 hours) and the highest median left without being seen rates (2.2%), while "poor" work environments had the longest median length of stay for behavioral health patients (6 hours). Improving the emergency department work environment from poor to mixed (and mixed to better) was associated with a 13-minute reduction in overall length of stay (P ≤ .05), a 33-minute reduction in behavioral health length of stay (P ≤ .01), and a 19% reduction in left without being seen rates (P ≤ .01). We estimated 11,824 to 41,071 additional patients could be seen in emergency departments associated with work environment improvements from "poor" to "better," depending on annual patient volumes. DISCUSSION: Hospital administrators should consider investing in nurse work environments as a foundation to improve timely outcomes.
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Enfermería de Urgencia , Servicio de Urgencia en Hospital , Tiempo de Internación , Humanos , Illinois , Servicio de Urgencia en Hospital/estadística & datos numéricos , New York , Estudios Transversales , Tiempo de Internación/estadística & datos numéricos , Personal de Enfermería en Hospital/estadística & datos numéricos , Lugar de Trabajo/psicología , Femenino , Masculino , Adulto , Encuestas y Cuestionarios , Condiciones de TrabajoRESUMEN
BACKGROUND: Readmissions following hospitalization for common surgical procedures are prevalent among older adults and are disproportionally experienced by Hispanic patients. One potential explanation for these disparities is that Hispanic patients may receive care in hospitals with lower-quality nursing care. OBJECTIVES: The objective of this study was to evaluate the relationship between the hospital-level work environment of nurses and hospital readmissions among older Hispanic patients. METHODS: Using linked data sources from 2014 to 2016, we conducted a cross-sectional analysis of 522 hospitals and 732,035 general, orthopedic, and vascular surgical patients (80,978 Hispanic patients and 651,057 non-Hispanic White patients) in four states. Multivariable logistic regression models were employed to determine the relationship between the work environment and older Hispanic patient readmissions at multiple time periods (7, 30, and 90 days). RESULTS: In final adjusted models that included an interaction between work environment and ethnicity, an increase in the quality of the work environment resulted in a decrease in the odds of readmission that was greater for older Hispanic surgical patients at all time periods. Specifically, an increase in three of the five work environment subscales (Nurse Participation in Hospital Affairs, Nursing Foundations for Quality of Care, and Staffing and Resource Adequacy) was associated with a reduction in the odds of readmission that was greater for Hispanic patients than their non-Hispanic White counterparts. DISCUSSION: System-level investments in the work environment may reduce Hispanic patient readmission disparities. This study's findings may be used to inform the development of targeted interventions to prevent hospital readmissions for Hispanic patients.
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Personal de Enfermería en Hospital , Readmisión del Paciente , Humanos , Estados Unidos , Anciano , Estudios Transversales , Hospitales , Condiciones de TrabajoRESUMEN
Objective: To determine the association between emergency nurses' work environments and patient care quality and safety, and nurse burnout, intent to leave, and job dissatisfaction. Methods: Cross-sectional study of 221 hospitals in New York and Illinois informed by surveys from 746 emergency nurses and 6932 inpatient nurses with linked data on hospital characteristics from American Hospital Association Annual Hospital Survey. The RN4CAST-NY/IL study surveyed all registered nurses in New York and Illinois between April and June 2021 about patient safety, care quality, burnout, intent to leave, and job dissatisfaction and aggregated their responses to specific hospitals where they practiced. Work environment quality was measured using the abbreviated Practice Environment Scale of the Nursing Work Index. Generalized estimating equations were used to determine the relationship between emergency nurses' work environments on patient care and nurse job outcomes. Results: A total of 58% of emergency nurses reported high burnout, 39% reported job dissatisfaction, and 27% indicated intent to leave their job in the next year. Nurses in hospitals with good (vs mixed) or mixed (vs poor) emergency work environments were less likely to report unfavorable patient care quality and hospital safety grades, and were less likely to experience high burnout, job dissatisfaction, and intentions to leave the job, by factors ranging from odds ratio (OR) 0.21 (95% confidence interval [CI], 0.16-0.29) to OR 0.46 (95% CI, 0.34-0.61). Conclusions: Given the complex and high stakes nature of emergency nursing care, leaders should place a high priority on organizational solutions targeting improved nurse staffing and work environments to advance better patient and clinician outcomes.
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OBJECTIVES: Conducting health services research relies on consistent diagnosis code documentation; however, it is unknown if consistent documentation in claims data occurs among patients with sickle cell disease (SCD) and/or trait (SCT). The objective of this study was to examine the consistency of International Classification of Diseases (ICD) code documentation for SCD/SCT and identify coding discrepancies between patients' hospitalizations. PATIENTS: A total of 80 031 hospitalization records across 528 hospitals belonging to 15 380 unique patients who had at least 1 documentation of SCD/SCT and 2 or more hospitalizations during the study period (April 2015-December 2016). METHODS: Secondary analysis of patient discharge abstracts in California, Florida, New Jersey, and Pennsylvania. ICD 9 and ICD 10 codes identified patients with SCD/SCT. Variations in documentation consistency across hospitals were examined. RESULTS: Only 51% of patients were consistently documented. There were statistically significant differences in whether a patient was or was not consistently documented based on: age, race/ethnicity, sex, insurer, and disease type. Twenty-five percent of hospitalization records were not consistently documented with an SCD code. Hospitalization records, for patients not consistently documented (49%), often included primary admitting diagnoses for conditions associated with SCD. Few hospitals (18%) were above average in consistently documenting SCD/SCT. CONCLUSIONS: Not consistent documentation for SCD/SCT occurs with variation among patients and across disease type and hospitals. These findings signal to researchers the importance of thoroughly identifying all hospitalizations when studying populations with chronic disease. Without accurate documentation, research relying on claims data may produce inaccurate findings.
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Anemia de Células Falciformes , Clasificación Internacional de Enfermedades , Humanos , Anemia de Células Falciformes/terapia , Hospitalización , Hospitales , Alta del PacienteRESUMEN
INTRODUCTION: Many countries in Europe are facing a shortage of nurses and seek effective recruitment and retention strategies. The nursing workforce is increasingly diverse in its educational background, ranging from 3-year vocational training (diploma) to bachelor and master educated nurses. This study analyses recruitment and retention strategies for academically educated nurses (minimum bachelor), including intention to leave, job satisfaction and work engagement compared with diploma nurses in innovative German hospitals; it explores recruitment and retention challenges and opportunities, and identifies lessons on recruitment and retention taking an international perspective. METHODS AND ANALYSIS: The study will apply a convergent mixed-methods design, including qualitative and quantitative methods. The qualitative study will include semistructured interviews among hospital managers, nurses, students and stakeholders in Germany. In addition, expert interviews will be conducted internationally in countries with a higher proportion of bachelor/master nurses in hospitals. The quantitative, cross-sectional study will consist of a survey among professional nurses (bachelor/master, diploma nurses) in German hospitals. Study settings are hospitals with a higher-than-average proportion of bachelor nurses or relevant recruitment, work environment or retention strategies in place. Analyses will be conducted in several phases, first in parallel, then combined via triangulation: the parallel analysis technique will analyse the qualitative and quantitative data separately via content analyses (interviews) and descriptive, bivariate and multivariate analyses (survey). Subsequently, data sources will be collectively analysed via a triangulation matrix focusing on developing thematic exploratory clusters at three systemic levels: microlevel, mesolevel and macrolevel. The analyses will be relevant for generating lessons for clinical nursing, management and policy in Germany and internationally. ETHICS AND DISSEMINATION: Ethics approval was obtained by the Charité Ethics Committee.Several dissemination channels will be used, including publications and presentations, for the scientific community, nursing management, clinical nurses and the wider public in Germany and internationally.
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Enfermeras y Enfermeros , Personal de Enfermería , Humanos , Estudios Transversales , Empleo , HospitalesRESUMEN
BACKGROUND: Primary care structural capabilities (i.e., electronic health records, care coordination, community integration, and reminder systems) can address the multiple needs of persons living with dementia (PLWD). OBJECTIVES: This study describes structural capabilities in primary care practices where nurse practitioners (NPs) provide care to PLWD and compares the presence of structural capabilities in practices with a high and low volume of PLWD. METHODS: We conducted a secondary analysis of cross-sectional data from 293 NPs in 259 practices in California. Logistic regression models were used to determine the association between the volume of PLWD and the presence of structural capabilities. RESULTS: NPs reported that 96% of practices had electronic health records, 61% had community integration, 55% had reminder systems and 35% had care coordination capabilities. Practices with a high volume of PLWD were less likely to have community integration compared to practices with a low volume of PLWD. CONCLUSION: Many PLWD-serving practices do not have the essential infrastructure for providing optimal dementia care. Practice managers should focus on implementing the essential structural capabilities to address the complex needs of PLWD. IMPLICATIONS FOR PRACTICE: Clinicians and practice administrations can use the findings of this study to improve the delivery of care in practices that provide care to PLWD.
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Demencia , Enfermeras Practicantes , Humanos , Estudios Transversales , Atención Primaria de Salud , CuidadoresRESUMEN
INTRODUCTION: Many emergency general surgery (EGS) conditions can be managed both operatively or nonoperatively; however, it is unknown whether the decision to operate affects Black and White patients differentially. METHODS: We identified a nationwide cohort of Black and White Medicare beneficiaries, hospitalized for common EGS conditions from July 2015 to June 2018. Using near-far matching to adjust for measurable confounding and an instrumental variable analysis to control for selection bias associated with treatment assignment, we compare outcomes of operative and nonoperative management in a stratified population of Black and White patients. Outcomes included in-hospital mortality, 30-day mortality, nonroutine discharge, and 30-day readmissions. An interaction test based on a t test was used to determine the conditional effects of operative versus nonoperative management between Black and White patients. RESULTS: A total of 556,087 patients met inclusion criteria, of which 59,519 (10.7%) were Black and 496,568 (89.3%) were White. Overall, 165,932 (29.8%) patients had an operation and 390,155 (70.2%) were managed nonoperatively. Significant outcome differences were seen between operative and nonoperative management for some conditions; however, no significant differences were seen for the conditional effect of race on outcomes. CONCLUSIONS: The decision to manage an EGS patient operatively versus nonoperatively has varying effects on surgical outcomes. These effects vary by EGS condition. There were no significant conditional effects of race on the outcomes of operative versus nonoperative management among universally insured older adults hospitalized with EGS conditions.
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Urgencias Médicas , Cirugía General , Medicare , Anciano , Humanos , Readmisión del Paciente , Estudios Retrospectivos , Estados Unidos , Negro o Afroamericano , Blanco , Grupos RacialesRESUMEN
Importance: Disruptions in the hospital clinical workforce threaten quality and safety of care and retention of health professionals. It is important to understand which interventions would be well received by clinicians to address the factors associated with turnover. Objectives: To determine well-being and turnover rates of physicians and nurses in hospital practice, and to identify actionable factors associated with adverse clinician outcomes, patient safety, and clinicians' preferences for interventions. Design, Setting, and Participants: This was a cross-sectional multicenter survey study conducted in 2021 with 21â¯050 physicians and nurses at 60 nationally distributed US Magnet hospitals. Respondents described their mental health and well-being, associations between modifiable work environment factors and physician and nurse burnout, mental health, hospital staff turnover, and patient safety. Data were analyzed from February 21, 2022, to March 28, 2023. Main Outcomes and Measures: Clinician outcomes (burnout, job dissatisfaction, intent to leave, turnover), well-being (depression, anxiety, work-life balance, health), patient safety, resources and work environment adequacy, and clinicians' preferences for interventions to improve their well-being. Results: The study sample comprised responses from 15â¯738 nurses (mean [SD] age, 38.4 [11.7] years; 10â¯887 (69%) women; 8404 [53%] White individuals) practicing in 60 hospitals, and 5312 physicians (mean [SD] age, 44.7 [12.0] years; 2362 [45%] men; 2768 [52%] White individuals) practicing in 53 of the same hospitals, with an average of 100 physicians and 262 nurses per hospital and an overall clinician response rate of 26%. High burnout was common among hospital physicians (32%) and nurses (47%). Nurse burnout was associated with higher turnover of both nurses and physicians. Many physicians (12%) and nurses (26%) rated their hospitals unfavorably on patient safety, reported having too few nurses (28% and 54%, respectively), reported having a poor work environment (20% and 34%, respectively), and lacked confidence in management (42% and 46%, respectively). Fewer than 10% of clinicians described their workplace as joyful. Both physicians and nurses rated management interventions to improve care delivery as more important to their mental health and well-being than interventions directed at improving clinicians' mental health. Improving nurse staffing was ranked highest among interventions (87% of nurses and 45% of physicians). Conclusions and Relevance: This cross-sectional survey study of physicians and nurses practicing in US Magnet hospitals found that hospitals characterized as having too few nurses and unfavorable work environments had higher rates of clinician burnout, turnover, and unfavorable patient safety ratings. Clinicians wanted action by management to address insufficient nurse staffing, insufficient clinician control over workload, and poor work environments; they were less interested in wellness programs and resilience training.
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Agotamiento Profesional , Personal de Enfermería en Hospital , Médicos , Masculino , Humanos , Femenino , Adulto , Seguridad del Paciente , Estudios Transversales , Personal de Enfermería en Hospital/psicología , Satisfacción en el Trabajo , Agotamiento Profesional/prevención & control , Hospitales , Personal de HospitalRESUMEN
OBJECTIVES: Evaluate whether hospital factors, including nurse resources, explain racial differences in Medicare black and white patient surgical outcomes and whether disparities changed over time. DESIGN: Retrospective tapered-match. SETTING: 571 hospitals at two time points (Early Era 2003-2005; Recent Era 2013-2015). PARTICIPANTS: 6752 black patients and three sets of 6752 white controls selected from 107 001 potential controls (Early Era). 4964 black patients and three sets of 4964 white controls selected from 74 108 potential controls (Recent Era). INTERVENTIONS: Black patients were matched to white controls on demographics (age, sex, state and year of procedure), procedure (demographics variables plus 136 International Classification of Diseases (ICD)-9 principal procedure codes) and presentation (demographics and procedure variables plus 34 comorbidities, a mortality risk score, a propensity score for being black, emergency admission, transfer status, predicted procedure time). OUTCOMES: 30-day and 1-year mortality. RESULTS: Before matching, black patients had more comorbidities, higher risk of mortality despite being younger and underwent procedures at different percentages than white patients. Whites in the demographics match had lower mortality at 30 days (5.6% vs 6.7% Early Era; 5.4% vs 5.7% Recent Era) and 1-year (15.5% vs 21.5% Early Era; 12.3% vs 15.9% Recent Era). Black-white 1-year mortality differences were equivalent after matching patients with respect to presentation, procedure and demographic factors. Black-white 30-day mortality differences were equivalent after matching on procedure and demographic factors. Racial disparities in outcomes remained unchanged between the two time periods spanning 10 years. All patients in hospitals with better nurse resources had lower odds of 30-day (OR 0.60, 95% CI 0.46 to 0.78, p<0.010) and 1-year mortality (OR 0.77, 95% CI 0.65 to 0.92, p<0.010) even after accounting for other hospital factors. CONCLUSIONS: Survival disparities among black and white patients are largely explained by differences in demographic, procedure and presentation factors. Better nurse resources (eg, staffing, work environment) were associated with lower mortality for all patients.
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Negro o Afroamericano , Medicare , Humanos , Anciano , Estados Unidos/epidemiología , Estudios Retrospectivos , Hospitales , Disparidades en Atención de Salud , BlancoRESUMEN
INTRODUCTION: Electronic health record (EHR) usability, defined as the extent to which the system can be used to complete tasks, can influence patient outcomes. The aim of this study is to assess the relationship between EHR usability and postsurgical outcomes of older adults with dementia including 30-day readmission, 30-day mortality, and length of stay (LOS). METHODS: A cross-sectional analysis of linked American Hospital Association, Medicare claims data, and nurse survey data was conducted using logistic regression and negative binominal models. RESULTS: The dementia population who received care in hospitals with better EHR usability were less likely to die within 30 days of their admission following surgery compared to hospitals with poorer EHR usability (OR: 0.79, 95% CI: 0.68-0.91, p = 0.001). EHR usability was not associated with readmission or LOS. DISCUSSION: Better nurse reported EHR usability has the potential to reduce mortality rates among older adults with dementia in hospitals.
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Demencia , Registros Electrónicos de Salud , Humanos , Anciano , Estados Unidos , Estudios Transversales , Medicare , Readmisión del Paciente , Demencia/cirugíaRESUMEN
BACKGROUND: The shortage of nursing care in US hospitals has become a national concern. PURPOSE: The purpose of this manuscript was to determine whether hospital nursing care shortages are primarily due to the pandemic and thus likely to subside or due to hospital nurse understaffing and poor working conditions that predated it. METHODS: This study used a repeated cross-sectional design before and during the pandemic of 151,335 registered nurses in New York and Illinois, and a subset of 40,674 staff nurses employed in 357 hospitals. FINDINGS: No evidence was found that large numbers of nurses left health care or hospital practice in the first 18 months of the pandemic. Nurses working in hospitals with better nurse staffing and more favorable work environments prior to the pandemic reported significantly better outcomes during the pandemic. DISCUSSION: Policies that prevent chronic hospital nurse understaffing have the greatest potential to stabilize the hospital nurse workforce at levels supporting good care and clinician wellbeing.
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COVID-19 , Enfermeras y Enfermeros , Personal de Enfermería en Hospital , Humanos , Calidad de la Atención de Salud , Estudios Transversales , Pandemias , Admisión y Programación de PersonalRESUMEN
BACKGROUND: Qualifying comorbidity sets (QCS) are tools used to identify multimorbid patients at increased surgical risk. It is unknown how the QCS framework for multimorbidity affects surgical risk in different racial groups. METHODS: This retrospective cohort study included Medicare patients age ≥65.5 who underwent an emergency general surgery operation from 2015 to 2018. Our exposure was race and multimorbidity, included in our model as an interaction term. The primary outcome of the study was 30-day mortality. Secondary outcomes included routine discharge, 30-day readmission, length of stay, and complications. RESULTS: In total, 163,148 patients who underwent and operation were included in this study. Of these, 13,852 (8.5%, p < 0.001) were Black, and 149,296 (91.5%, p < 0.001) were White. Black multimorbid patients had no significant differences in 30-day mortality, routine discharge or 30-day readmission when compared to White multimorbid patients after risk-adjustment. Black multimorbid patients had significantly lower odds of complications (OR 0.89, p = 0.014) compared to White multimorbid patients. CONCLUSIONS: Our study of universally insured patients highlights the critical role of pre-operative health status and its association with surgical outcomes.
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Medicare , Multimorbilidad , Humanos , Anciano , Estados Unidos/epidemiología , Estudios Retrospectivos , Grupos Raciales , Readmisión del Paciente , Disparidades en Atención de SaludRESUMEN
OBJECTIVE: To determine the effect of operative versus nonoperative management of emergency general surgery conditions on short-term and long-term outcomes. BACKGROUND: Many emergency general surgery conditions can be managed either operatively or nonoperatively, but high-quality evidence to guide management decisions is scarce. METHODS: We included 507,677 Medicare patients treated for an emergency general surgery condition between July 1, 2015, and June 30, 2018. Operative management was compared with nonoperative management using a preference-based instrumental variable analysis and near-far matching to minimize selection bias and unmeasured confounding. Outcomes were mortality, complications, and readmissions. RESULTS: For hepatopancreaticobiliary conditions, operative management was associated with lower risk of mortality at 30 days [-2.6% (95% confidence interval: -4.0, -1.3)], 90 days [-4.7% (-6.50, -2.8)], and 180 days [-6.4% (-8.5, -4.2)]. Among 56,582 intestinal obstruction patients, operative management was associated with a higher risk of inpatient mortality [2.8% (0.7, 4.9)] but no significant difference thereafter. For upper gastrointestinal conditions, operative management was associated with a 9.7% higher risk of in-hospital mortality (6.4, 13.1), which increased over time. There was a 6.9% higher risk of inpatient mortality (3.6, 10.2) with operative management for colorectal conditions, which increased over time. For general abdominal conditions, operative management was associated with 12.2% increased risk of inpatient mortality (8.7, 15.8). This effect was attenuated at 30 days [8.5% (3.8, 13.2)] and nonsignificant thereafter. CONCLUSIONS: The effect of operative emergency general surgery management varied across conditions and over time. For colorectal and upper gastrointestinal conditions, outcomes are superior with nonoperative management, whereas surgery is favored for patients with hepatopancreaticobiliary conditions. For obstructions and general abdominal conditions, results were equivalent overall. These findings may support patients, clinicians, and families making these challenging decisions.