Primary Care Nurse Practitioner Wage Differences by Employment Setting.

BACKGROUND: Previous studies reported that primary care nurse practitioners working in primary care settings may earn less than those working in specialty care settings. However, few studies have examined why such wage difference exists. PURPOSE: This study used human capital theory to determine the degree to which the wage differences between dingsPCNPs working in primary care versus specialty care settings is driven by the differences in PCNPs' characteristics. Feasible generalized least squares regression was used to examine the wage differences for PCNPs working in primary care and specialty care settings. METHODS: A cross-sectional, secondary data analysis was conducted using the restricted file of 2012 National Sample Survey of Nurse Practitioners. FINDINGS: Oaxaca-Blinder decomposition technique was used to explore the factors contributing to wage differences.The results suggested that hourly wages of PCNPs working in primary care settings were, on average, 7.1% lower than PCNPs working in specialty care settings, holding PCNPs' socio-demographic, human capital, and employment characteristics constant. Approximately 4% of this wage difference was explained by PCNPs' characteristics; but 96% of these differences were due to unexplained factors. DISCUSSION: A large, unexplained wage difference exists between PCNPs working in primary care and specialty care settings.

Relationships Between Nurse Staffing and Patients' Experiences, and the Mediating Effects of Missed Nursing Care.

PURPOSE: The aims of this study were to examine the relationships between nurse staffing and patients' experiences, and to determine the mediating effects of patient-reported missed care on the relationship between nurse staffing and patients' experiences. DESIGN: The study included 362 nurses and 208 patients from 23 nursing units of six hospitals in South Korea. METHODS: Nurse staffing was measured by patient-to-nurse ratios and by nurse- and patient-perceived staffing adequacy. Patients' experiences included adverse events, communication with nurses, and overall hospital rating. Patient-reported missed care was measured using the MISSCARE Survey-Patient with three domains: communication, basic care, and timely response. FINDINGS: Lower nurse-perceived staffing adequacy was associated with more patient-reported missed communication. Lower patient-perceived staffing adequacy was associated with more missed care and adverse events, and a lower likelihood of experiencing good communication with nurses and of giving a high overall rating to the hospital. Patient-reported missed care mediated the relationship between nurse staffing and patients' experiences. CONCLUSIONS: Nurse staffing adequacy, particularly as perceived by patients, was significantly associated with patient-reported missed communication and basic care, as well as patients' experiences. CLINICAL RELEVANCE: Appropriate nurse staffing is required to reduce missed care and to improve patients' experiences.

Hospital Magnet® Designation and Missed Nursing Care in Neonatal Intensive Care Units.

Missed nursing care is an emerging measure of front-line nursing care effectiveness in neonatal intensive care units (NICUs). Given Magnet® hospitals' reputations for nursing care quality, missed care comparisons with non-Magnet® hospitals may yield insights about how Magnet® designation influences patient outcomes. The purpose of this secondary analysis was to evaluate the relationship between hospital Magnet® designation and 1) the occurrence of nurse-reported missed care and 2) reasons for missed nursing care between NICU nurses employed in Magnet® and non-Magnet® hospitals. A random sample of certified neonatal intensive care unit nurses was invited to participate in a cross-sectional survey in 2012; data were analyzed from nurses who provided direct patient care (n=230). Logistic regression was used to model relationships between Magnet® designation and reports of the occurrence of and reasons for missed care while controlling for nurse and shift characteristics. There was no relationship between Magnet® designation and missed care occurrence for 34 of 35 types of care. Nurses in Magnet® hospitals were significantly less likely to report tensions and communication breakdowns with other staff, lack of familiarity with policies/procedures, and lack of back-up support from team members as reasons for missed care. Missed nursing care in NICUs occurs regardless of hospital Magnet® recognition. However, nurses' reasons for missed care systematically differ in Magnet® and non-Magnet® hospitals and these differences merit further exploration.

The relationship between work complexity and nurses' participation in decision making in hospitals.

OBJECTIVE: The aim of this study is to examine the relationship between work complexity and nurses' participation in decision making in hospital nursing units. BACKGROUND: Increasing nurses' participation in decision making has been used as a way to manage work complexity; however, the work of nurses in acute care hospitals has become highly complex, and strategies used to manage this complexity have not been fully explored. METHODS: The relationship between work complexity and nurse participation in decision making was examined using data from the Outcomes Research in Nursing Administration project. The sample included 3,718 RNs in 278 medical-surgical units in 143 hospitals. RESULTS: When work complexity increased, nurses' participation in decision making decreased. CONCLUSIONS: When nurses have limited input into decision making, the information available to the care team may be incomplete. Barriers to nurses' participation in decision making should be explored and interventions developed so that nurses may be full participants in decision making affecting both patients and the work environment.

A descriptive study of nurse-reported missed care in neonatal intensive care units.

AIMS: The aims of this study are to describe: (1) the frequency of nurse-reported missed care in neonatal intensive care units; and (2) nurses' reports of factors contributing to missed care on their last shift worked. BACKGROUND: Missed nursing care, or necessary care that is not delivered, is increasingly cited as a contributor to adverse patient outcomes. Previous studies highlight the frequency of missed nursing care in adult settings; the occurrence of missed nursing care in neonatal intensive care units is unknown. DESIGN: A descriptive analysis of neonatal nurses' self-reports of missed care using data collected through a cross-sectional web-based survey. METHODS: A random sample of certified neonatal intensive care nurses in seven states was invited to participate in the survey in April 2012. Data were collected from nurses who provide direct patient care in a neonatal intensive care unit (n = 230). Descriptive statistics constituted the primary analytic approach. RESULTS: Nurses reported missing a range of patient care activities on their last shift worked. Nurses most frequently missed rounds, oral care for ventilated infants, educating and involving parents in care and oral feedings. Hand hygiene, safety and physical assessment and medication administration were missed least often. The most common reasons for missed care included frequent interruptions, urgent patient situations and an unexpected rise in patient volume and/or acuity on the unit. CONCLUSION: We find that basic nursing care in the neonatal intensive care unit is missed and that system factors may contribute to missed care in this setting.

A research protocol for testing relationships between nurse workload, missed nursing care and neonatal outcomes: the neonatal nursing care quality study.

AIM: We describe an innovative research protocol to test the role of missed nursing care as a mediator of the association between nurse workload and patient outcomes in the neonatal intensive care unit. BACKGROUND: Increases in nurses' workloads are associated with adverse patient outcomes in neonatal intensive care settings. Missed nursing care is a frequently hypothesized explanation for the association between workload and outcomes. Few studies to date have tested missed care as a variable that mediates the workload-outcomes relationship. DESIGN: We use a longitudinal, observational study design. METHODS: We will recruit approximately 125 nurses (80% of target population) providing direct patient care in one neonatal intensive care unit. Four, 6-week data collection cycles occur over 1 year. At the end of every shift, nurses report on their workloads and the frequency with which specific patient care activities were missed for each infant cared for during the shift. Infant-specific nurse reports of missed care are linked to shift-level infant outcomes data extracted from the electronic health record. Funding for the study began in July 2012; Research Ethics Committee approval was granted in December 2012. DISCUSSION: Missed care may explain the effects of nurse workload on patient outcomes. This research will generate preliminary evidence regarding the causal relationships among nurses' workloads, missed care and infant outcomes that we will confirm in a future multi-site study.

Geographic mobility of Korean new graduate nurses from their first to subsequent jobs and metropolitan-nonmetropolitan differences in their job satisfaction.

BACKGROUND: Nurses are known to migrate from rural to urban areas, which may cause geographic imbalances in the workforce. PURPOSE: The aim of this study was to compare new graduate nurse retention based on the type of geographic area (capital, metropolitan, and nonmetropolitan) of their first job and their job satisfaction by geographic location. METHODS: The sample included 533 nursing graduates working full-time as registered nurses in hospitals or clinics. Survival analysis was conducted to compare nurse retention in three geographic locations. RESULTS: Survival curves for nurses in capital and nonmetropolitan areas were significantly different. The 1-, 2-, and 3-year survival probabilities of nurses in the capital were .923, .881, and .872, respectively, whereas those in nonmetropolitan areas were .887, .776, and .672, respectively. Nurses in nonmetropolitan areas were more dissatisfied with pay (odd ratio [OR] = 1.820, p = .009), fringe benefits (OR =1.893, p = .015), employment security (OR =2.640, p = .033), and personal growth (OR =1.626, p = .045) than those in the capital. CONCLUSIONS: Nurses employed in nonmetropolitan areas were more mobile and less satisfied with their jobs than those in the capital.

Turnover of new graduate nurses in their first job using survival analysis.

PURPOSE: To examine factors related to turnover of new graduate nurses in their first job. DESIGN: Data were obtained from a 3-year panel survey (2006-2008) of the Graduates Occupational Mobility Survey that followed-up college graduates in South Korea. The sample consisted of 351 new graduates whose first job was as a full-time registered nurse in a hospital. METHODS: Survival analysis was conducted to estimate survival curves and related factors, including individual and family, nursing education, hospital, and job dissatisfaction (overall and 10 specific job aspects). FINDINGS: The estimated probabilities of staying in their first job for 1, 2, and 3 years were 0.823, 0.666, and 0.537, respectively. Nurses reporting overall job dissatisfaction had significantly lower survival probabilities than those who reported themselves to be either neutral or satisfied. Nurses were more likely to leave if they were married or worked in small (vs. large), nonmetropolitan, and nonunionized hospitals. Dissatisfaction with interpersonal relationships, work content, and physical work environment was associated with a significant increase in the hazards of leaving the first job. CONCLUSIONS: Hospital characteristics as well as job satisfaction were significantly associated with new graduates' turnover. CLINICAL RELEVANCE: The high turnover of new graduates could be reduced by improving their job satisfaction, especially with interpersonal relationships, work content, and the physical work environment.

Quality and strength of patient safety climate on medical-surgical units.

BACKGROUND: Describing the safety climate in hospitals is an important first step in creating work environments where safety is a priority. Yet, little is known about the patient safety climate on medical-surgical units. PURPOSES: Study purposes were to describe quality and strength of the patient safety climate on medical-surgical units and explore hospital and unit characteristics associated with this climate. METHODOLOGY: Data came from a larger organizational study to investigate hospital and unit characteristics associated with organizational, nurse, and patient outcomes. The sample for this study was 3,689 RNs on 286 medical-surgical units in 146 hospitals. FINDINGS: Nursing workgroup and managerial commitment to safety were the two most strongly positive attributes of the patient safety climate. However, issues surrounding the balance between job duties and safety compliance and nurses' reluctance to reveal errors continue to be problematic. Nurses in Magnet hospitals were more likely to communicate about errors and participate in error-related problem solving. Nurses on smaller units and units with lower work complexity reported greater safety compliance and were more likely to communicate about and reveal errors. Nurses on smaller units also reported greater commitment to patient safety and participation in error-related problem solving. PRACTICE IMPLICATIONS: Nursing workgroup commitment to safety is a valuable resource that can be leveraged to promote a sense of personal responsibility for and shared ownership of patient safety. Managers can capitalize on this commitment by promoting a work environment in which control over nursing practice and active participation in unit decisions are encouraged and by developing channels of communication that increase staff nurse involvement in identifying patient safety issues, prioritizing unit-level safety goals, and resolving day-to-day operational problems the have the potential to jeopardize patient safety.

Demographic diversity, value congruence, and workplace outcomes in acute care.

Nursing scholars and healthcare administrators often assume that a more diverse nursing workforce will lead to better patient and nurse outcomes, but this assumption has not been subject to rigorous empirical testing. In a study of nursing units in acute care hospitals, the influence of age, gender, education, race/ethnicity, and perceived value diversity on nurse job satisfaction, nurse intent to stay, and patient satisfaction were examined. Support was found for a negative relationship between perceived value diversity and all outcomes and for a negative relationship between education diversity and intent to stay. Additionally, positive relationships were found between race/ethnicity diversity and nurse job satisfaction as well as between age diversity and intent to stay. From a practice perspective, the findings suggest that implementing retention, recruitment, and management practices that foster a strong shared value system among nurses may lead to better workplace outcomes.

Effects of learning climate and registered nurse staffing on medication errors.

BACKGROUND: Despite increasing recognition of the significance of learning from errors, little is known about how learning climate contributes to error reduction. OBJECTIVES: The purpose of this study was to investigate whether learning climate moderates the relationship between error-producing conditions and medication errors. METHODS: A cross-sectional descriptive study was done using data from 279 nursing units in 146 randomly selected hospitals in the United States. Error-producing conditions included work environment factors (work dynamics and nurse mix), team factors (communication with physicians and nurses' expertise), personal factors (nurses' education and experience), patient factors (age, health status, and previous hospitalization), and medication-related support services. Poisson models with random effects were used with the nursing unit as the unit of analysis. RESULTS: A significant negative relationship was found between learning climate and medication errors. It also moderated the relationship between nurse mix and medication errors: When learning climate was negative, having more registered nurses was associated with fewer medication errors. However, no relationship was found between nurse mix and medication errors at either positive or average levels of learning climate. Learning climate did not moderate the relationship between work dynamics and medication errors. DISCUSSION: The way nurse mix affects medication errors depends on the level of learning climate. Nursing units with fewer registered nurses and frequent medication errors should examine their learning climate. Future research should be focused on the role of learning climate as related to the relationships between nurse mix and medication errors.

Adjusting for patient acuity in measurement of nurse staffing: two approaches.

BACKGROUND: Researchers who examine the relationship between nurse staffing and quality of care frequently rely on the Medicare case mix index to adjust for patient acuity, even though it was developed originally based on medical diagnoses and may not accurately reflect patients' needs for nursing care. OBJECTIVES: The aim of this study was to examine the differences between unadjusted measures of nurse staffing (registered nurses per 1,000 adjusted patient days) and case mix adjusted nurse staffing and nurse staffing adjusted with nursing intensity weights, which were developed to reflect patients' needs for nursing care. METHOD: Secondary data were used from 579 hospitals in 13 states from 2000 to 2006. Included were three measures of nurse staffing and hospital characteristics including ownership, geographic location, teaching status, hospital size, and percent Medicare inpatient days. RESULTS: Measures of nurse staffing differed in important ways. The differences between the measures were related systematically to ownership, geographic location, teaching status, hospital size, and percentage Medicare inpatient days. DISCUSSION: Without an accurate method to incorporate acuity into measurement of nurse staffing, research on the relationship between staffing and quality of care will not reach the full potential to inform practice.

Effects of learning climate and registered nurse staffing on medication errors.

BACKGROUND: Despite increasing recognition of the significance of learning from errors, little is known about how learning climate contributes to error reduction. OBJECTIVES: The purpose of this study was to investigate whether learning climate moderates the relationship between error-producing conditions and medication errors. METHODS: A cross-sectional descriptive study was done using data from 279 nursing units in 146 randomly selected hospitals in the United States. Error-producing conditions included work environment factors (work dynamics and nurse mix), team factors (communication with physicians and nurses' expertise), personal factors (nurses' education and experience), patient factors (age, health status, and previous hospitalization), and medication-related support services. Poisson models with random effects were used with the nursing unit as the unit of analysis. RESULTS: A significant negative relationship was found between learning climate and medication errors. It also moderated the relationship between nurse mix and medication errors: When learning climate was negative, having more registered nurses was associated with fewer medication errors. However, no relationship was found between nurse mix and medication errors at either positive or average levels of learning climate. Learning climate did not moderate the relationship between work dynamics and medication errors. DISCUSSION: The way nurse mix affects medication errors depends on the level of learning climate. Nursing units with fewer registered nurses and frequent medication errors should examine their learning climate. Future research should be focused on the role of learning climate as related to the relationships between nurse mix and medication errors.

Differences in intensive care unit work environments among and within hospitals using subscales and a composite measure of the Revised Nursing Work Index.

AIM: To examine variations in nurses' perceptions of their work environments among hospitals and intensive care units, and to compare analytic findings from using subscales and a composite measure of the Revised Nursing Work Index at the hospital and intensive care unit levels. BACKGROUND: A positive relationship has been found between the nurse work environment and outcomes for patients and nurses. Nurses' perceptions of their work environments have been analysed using different analytic approaches. METHODS: A survey was conducted in August-October 2007 that included 817 staff nurses in 39 adult intensive care units of 15 hospitals in South Korea. Seven subscales of the Revised Nursing Work Index were identified from an exploratory factor analysis. The subscales and composite (mean of the seven subscales) for each hospital and intensive care unit were analysed using multilevel regression analyses and classified as good, moderate or poor environments. RESULTS: Considerable variations in the subscales were found among both hospitals and intensive care units. On the composite measure, 2 hospitals were rated as good, 10 moderate and 3 poor; 9 intensive care units were ranked as good, 24 moderate and 6 poor. Even intensive care units within hospitals exhibited variations in the subscales and composite. Most hospitals and intensive care units had mixed (i.e., good, moderate, poor) environments across the seven subscales and thus, subscales were not always congruent with the composite. CONCLUSION: Heterogeneity of the subscales and the composite measure, and the differences among intensive care units within hospitals imply that use of different analytic approaches may reveal different findings and perspectives of nurse work environments.

The nurse's medication day.

The medication administration stage of the medication-use process is especially vulnerable to error because errors are least likely to be caught before reaching the patient. Medication administration, however, remains poorly understood. In this article we describe medication administration as observed in an ethnographic study conducted on one medical unit and one surgical unit. A central finding was that medication administration entailed a complex mixture of varied and often competing demands that temporally structured the nurses' entire workday. Articulation work was evident in time management strategies nurses used to handle demands from institutional policies, technical devices, patients, the physical environment, and the medications themselves. The average number of doses of medication per patient was more than double the number policy groups have indicated. Medication administration is not simply the giving of drugs, nor does it have clearly defined temporal boundaries. Because of its inseparability from other nurses' work, medication administration inherently entails interruption, thereby calling into question the current emphasis on reducing interruptions as a tactic to decrease medication errors.

Internationally educated nurse hiring: geographic distribution, community, and hospital characteristics.

As the largest importer of internationally educated nurses (IENs), the United States is considered to be the epicenter of global nurse migration. The purposes of this study were to examine the geographic distribution of IEN hiring and determine associations between community and hospital characteristics and IEN hiring. More community characteristics than hospital characteristics were strongly associated with IEN hiring which suggest perceived community needs and receptivity to lENs could be an important consideration in hospital administrators' decisions to hire IENs. These findings suggest that as the U.S. population ages and becomes increasingly diverse, the demand for IENs is likely to grow. Nurse leaders and faculty may face challenges with regard to the ethical recruitment of IENs from low-income countries, incorporation of IENs into U.S. health care organizations, and continued development of a diverse U.S.-educated nursing workforce. This study expands understanding of the demand side of IEN employment in U.S. hospitals by providing the first in-depth examination of the community and hospital factors related to hospitals' IEN hiring.

Supporting the implementation of guidelines to prevent mother-to-child-transmission of HIV in Malawi: a multi-case study.

BACKGROUND: High HIV infection and fertility rates contributed to over 12,000 children acquiring HIV from their mothers in 2011 in Malawi. To prevent mother-to-child transmission of HIV, Malawi adopted the Option B+ guidelines, and for three years, the University of North Carolina (UNC) Project provided support to strengthen guideline implementation in 134 health centres. Little is known about how implementation support strategies are delivered in low resource countries or contextual factors that may influence their delivery. The limited descriptions of support strategies and salient contextual factors limits efforts to replicate, target, and further refine strategies. Guided by the Interactive Systems Framework for Dissemination and Implementation, this study describes factors influencing implementation of support strategies and how they impacted health center staff capacity to implement Option B+ in Malawi. METHODS: A qualitative multi-case study design was applied. Data were collected through site visits to 4 heath centres (2 low- and 2-high performing centres). We interviewed 18 support providers and recipients between October 2014 and October 2015. Data were analysed using content, thematic, and cross-case analysis. RESULTS: Four categories of strategies were used to support Option B+ guidelines implementation: training, technical assistance (TA), tools, and resources. All heath-centres implemented Option B+ guidelines for care provided between the antenatal and labor and delivery periods. Gaps in Option B+ implementation occurred during community activities and during post-delivery care, including gaps in testing of children to ascertain their HIV status at 6 weeks, 12 months, and 24 months. Salient contextual factors included staffing shortages, transportation challenges, limited space and infrastructure, limited stocks of HIV testing kits, and large patient populations. CONCLUSIONS: Understanding factors that influence implementation support strategies and delivery of the Option B+ guidelines, such as availability of staff and other materials/drug resources, is critical to designing effective implementation support for low resource settings.

Nurse staffing and quality of care with direct measurement of inpatient staffing.

BACKGROUND: Studies of the impact of registered nurse (RN) staffing on hospital quality of care for hospital inpatients often rely on data sources that do not distinguish inpatient from outpatient staffing, thus requiring imputation of staffing level. As a result, estimates of the impact of staffing on quality may be biased. OBJECTIVE: To estimate the impact of changes in RN staffing on changes in quality of care with direct measurement of staffing levels. RESEARCH DESIGN: Longitudinal regression analysis of California general acute care hospitals where inpatient staffing is measured directly. SUBJECTS: Estimation sample reflects outcomes for 11,945,276 adult inpatients at 283 hospitals from 1996 to 2001. MEASURES: Patient outcomes are in-hospital mortality ratio and surgical failure-to-rescue ratio after nurse-sensitive complications with risk adjustment through calculation of the expected number of adverse outcomes using the Medstat disease staging algorithm. Staffing levels were measured as the number of full-time equivalent nurses per 1000 inpatient days. RESULTS: Estimates suggest that changes in RN staffing were associated with reductions in mortality and failure to rescue. At 2.97 RN full-time equivalents per 1000 inpatient days, a 1-unit increase in staffing was associated with a 0.043 decrease in the mortality ratio (P < 0.05), and the estimated effect was smaller at hospitals with higher staffing levels. Estimates for failure to rescue ratio were statistically significant only at higher staffing levels. CONCLUSIONS: Results are compared with those from similar studies, including studies using imputation of inpatient staffing, and are found to be consistent with attenuation bias induced by imputation.

Impact of nursing unit turnover on patient outcomes in hospitals.

PURPOSE: The aim of this study was to examine how nursing unit turnover affects key workgroup processes and how these processes mediate the impact of nursing turnover on patient outcomes. METHODS: A secondary data analysis was used to test the hypothesized model. This study used registered nurse and patient data from 268 nursing units at 141 hospitals collected as part of the Outcomes Research in Nursing Administration (ORNA II) project. Nursing units provided monthly nursing unit turnover rates for 6 consecutive months, and registered nurses completed questionnaires measuring workgroup processes (group cohesion, relational coordination, and workgroup learning). Patient outcome measures included unit-level average length of patient stay, patient falls, medication errors, and patient satisfaction scores. RESULTS: Nursing units with moderate levels of turnover were likely to have lower levels of workgroup learning compared to those with no turnover (p<.01). Nursing units with low levels of turnover were likely to have fewer patient falls than nursing units with no turnover (p<.05). Additionally, workgroup cohesion and relational coordination had a positive impact on patient satisfaction (p<.01), and increased workgroup learning led to fewer occurrences of severe medication errors (p<.05). CONCLUSIONS: The findings of this study provide specific information on the operational impact of turnover so as to better design, fund, and implement appropriate intervention strategies to prevent registered nurse exit from nursing units. Further investigation is needed to assess the turnover-outcomes relationship as well as the mediating effect of workgroup processes on this relationship. CLINICAL RELEVANCE: Managing nursing unit turnover within appropriate levels at the nursing unit is critical to delivering high-quality patient care.

Nurse staffing and post-surgical complications using the present on admission indicator.

We evaluated the relationship between registered nurse (RN) staffing and six post-surgical complications: pneumonia, septicemia, urinary tract infections, thrombophlebitis, fluid overload, and decubitus ulcers, in a dataset that contained the present on admission (POA) indicator. We analyzed a longitudinal panel of 283 acute care hospitals in California from 1996 to 2001. Using an adaptation of the Quality Health Outcomes Model, we found no statistically significant relationships between RN staffing and the complications. In addition, the signs of the relationships were opposite to those expected. That is, as staffing increased, so did some of the complications. We discuss potential reasons for these anomalous results, including the possibility that increases in RN staffing may result in earlier detection of complications. Other explanations include issues with risk adjustment, the lack of nurse level variables in the model, and issues with the POA indicator itself.