Newly Licensed RN Retention: Hospital and Nurse Characteristics.

OBJECTIVES: The aims of this study were to examine the relationship between 1-year retention of newly licensed RNs (NLRNs) employed in hospitals and personal and hospital characteristics, and determine which characteristics had the most influence. METHODS: A secondary analysis of data collected in a study of transition to practice was used to describe the retention of 1464 NLRNs employed by 97 hospitals in 3 states. Hospitals varied in size, location (urban and rural), Magnet® designation, and university affiliation. The NLRNs also varied in education, age, race, gender, and experience. RESULTS: The overall retention rate at 1 year was 83%. Retention of NLRNs was higher in urban areas and in Magnet hospitals. The only personal characteristic that affected retention was age, with younger nurses more likely to stay. CONCLUSION: Hospital characteristics had a larger effect on NLRN retention than personal characteristics. Hospitals in rural areas have a particular challenge in retaining NLRNs.

Voluntary Medication Error Reporting by ED Nurses: Examining the Association With Work Environment and Social Capital.

INTRODUCTION: Medication errors are one of the most frequently occurring errors in health care settings. The complexity of the ED work environment places patients at risk for medication errors. Most hospitals rely on nurses' voluntary medication error reporting, but these errors are under-reported. The purpose of this study was to examine the relationship among work environment (nurse manager leadership style and safety climate), social capital (warmth and belonging relationships and organizational trust), and nurses' willingness to report medication errors. METHODS: A cross-sectional descriptive design using a questionnaire with a convenience sample of emergency nurses was used. Data were analyzed using descriptive, correlation, Mann-Whitney U, and Kruskal-Wallis statistics. RESULTS: A total of 71 emergency nurses were included in the study. Emergency nurses' willingness to report errors decreased as the nurses' years of experience increased (r = -0.25, P = .03). Their willingness to report errors increased when they received more feedback about errors (r = 0.25, P = .03) and when their managers used a transactional leadership style (r = 0.28, P = .01). DISCUSSION: ED nurse managers can modify their leadership style to encourage error reporting. Timely feedback after an error report is particularly important. Engaging experienced nurses to understand error root causes could increase voluntary error reporting.

Differences in Innovative Behavior Among Hospital-Based Registered Nurses.

BACKGROUND: The 2010 Institute of Medicine report, 'The Future of Nursing: Leading Change, Advancing Health', advocated for nurses to innovate in their practice, research, and education. However, little is known about the innovative behavior of registered nurses or whether there are differences in innovative behavior among registered nurses. OBJECTIVE: The purpose of this article is to describe the innovative behavior of hospital-based registered nurses and understand the differences in innovative behavior when registered nurses are categorized into various demographic groups. METHODS: A survey of 251 hospital-based registered nurses from 9 hospitals in California was administered to assess demographic characteristics and innovative behavior, measured through Scott and Bruce's Individual Innovative Behavior Scale. RESULTS: Hospital-based registered nurses, on average, reported moderate levels of innovative behavior. There were statistically significant differences in innovative behavior when registered nurses were categorized according to specialty certification, role, level of education, hospital size, and hospital innovativeness. CONCLUSIONS: To support innovative behavior, organizations should provide opportunities for specialty certification and increasing levels of education.

Comparison of Unit-Level Patient Turnover Measures in Acute Care Hospital Settings.

High patient turnover is a critical factor increasing nursing workload. Despite the growing number of studies on patient turnover, no consensus about how to measure turnover has been achieved. This study was designed to assess the correlation among patient turnover measures commonly used in recent studies and to examine the degree of agreement among the measures for classifying units with different levels of patient turnover. Using unit-level data collected for this study from 292 units in 88 hospitals participating in the National Database of Nursing Quality Indicators®, we compared four patient turnover measures: the inverse of length of stay (1/LOS), admissions, discharges, and transfers per daily census (ADTC), ADTC with short-stay adjustment, and the number of ADTs and short-stay patients divided by the total number of treated patients, or Unit Activity Index (UAI). We assessed the measures' agreement on turnover quartile classifications, using percent agreement and Cohen's kappa statistic (weighted and unweighted). Pearson correlation coefficients also were calculated. ADTC with or without adjustment for short-stay patients had high correlations and substantial agreement with the measure of 1/LOS (κ = .62 to .91; r = .90 to .95). The UAI measure required data less commonly collected by participating hospital units and showed only moderate correlations and fair agreement with the other measures (κ = .23 to .39; r = .41 to .45). The UAI may not be comparable and interchangeable with other patient turnover measures when data are obtained from multiple units and hospitals. © 2016 Wiley Periodicals, Inc.

Comparison of Nurse Staffing Measurements in Staffing-Outcomes Research.

BACKGROUND: Investigators have used a variety of operational definitions of nursing hours of care in measuring nurse staffing for health services research. However, little is known about which approach is best for nurse staffing measurement. OBJECTIVE: To examine whether various nursing hours measures yield different model estimations when predicting patient outcomes and to determine the best method to measure nurse staffing based on the model estimations. DATA SOURCES/SETTING: We analyzed data from the University HealthSystem Consortium for 2005. The sample comprised 208 hospital-quarter observations from 54 hospitals, representing information on 971 adult-care units and about 1 million inpatient discharges. METHODS: We compared regression models using different combinations of staffing measures based on productive/nonproductive and direct-care/indirect-care hours. Akaike Information Criterion and Bayesian Information Criterion were used in the assessment of staffing measure performance. RESULTS: The models that included the staffing measure calculated from productive hours by direct-care providers were best, in general. However, the Akaike Information Criterion and Bayesian Information Criterion differences between models were small, indicating that distinguishing nonproductive and indirect-care hours from productive direct-care hours does not substantially affect the approximation of the relationship between nurse staffing and patient outcomes. CONCLUSIONS: This study is the first to explicitly evaluate various measures of nurse staffing. Productive hours by direct-care providers are the strongest measure related to patient outcomes and thus should be preferred in research on nurse staffing and patient outcomes.

Preceptor Support in Hospital Transition to Practice Programs.

OBJECTIVE: The aim of this study was to describe newly licensed RN (NLRN) preceptorships and the effects on competency and retention. BACKGROUND: Preceptors are widely used, but little is known about the benefit from the perspective of the NLRN or about the models of the relationships. The National Council of State Boards of Nursing added questions about the preceptor experience in a study of transition-to-practice programs. METHODS: Hospitals were coded as having high or low preceptor support in regard to scheduling NLRN on the same shifts as their preceptors, assignment sharing, and preceptor release time and a low number of preceptors per preceptee. RESULTS: Half of the 82 hospitals were classified as high, and half as low preceptor support. NLRNs and their preceptors in high-support hospitals evaluated the preceptor experience and NLRN competence higher. In addition, NLRN retention was higher in the high-support hospitals. CONCLUSIONS: To improve NLRN competence and retention, preceptors should have adequate time with each NLRN, share shift and patient assignments, and have few preceptees assigned to each preceptor concurrently.

Job satisfaction and horizontal violence in hospital staff registered nurses: the mediating role of peer relationships.

AIMS AND OBJECTIVES: To describe the association between horizontal violence and job satisfaction in hospital staff registered nurses and the degree to which peer relationships mediates the relationship. Additionally, the association between nurse and work characteristics and job satisfaction were determined. BACKGROUND: Horizontal violence is a major predictor of nurses' job satisfaction. Yet, not enough is known about the relationship between these variables. Job satisfaction is an important variable to study because it is a predictor of patient care quality and safety internationally. Peer relationships, a job satisfier for nurses, was identified as a potential mediator in the association between horizontal violence and job satisfaction. DESIGN: Cross-sectional mediational model testing. METHODS: An anonymous four-part survey of a random sample of 175 hospital staff registered nurses working in California provided the data. Data about horizontal violence, peer relationships, job satisfaction, and nurse and work characteristics were collected between March-August 2010. RESULTS: A statistically significant negative relationship was found between horizontal violence and peer relationships, job satisfaction and a statistically significant positive relationship was found between peer relationships and job satisfaction. Peer relationships mediated the association between horizontal violence and job satisfaction. Job satisfaction was reported as higher by nurses who worked in teaching hospitals. There were no statistically significant differences in job satisfaction based on gender, ethnicity, basic registered nurse education, highest degree held, size of hospital or clinical area. CONCLUSIONS: The results suggest that peer relationships can attenuate the negative relationship between horizontal violence and job satisfaction. This adds to the extant literature on the relationship between horizontal violence and job satisfaction. RELEVANCE TO CLINICAL PRACTICE: The findings highlight peer relationships as an important factor when considering effective interventions that foster hospital staff registered nurses' job satisfaction in the presence of horizontal violence.

Psychiatric boarding incidence, duration, and associated factors in United States emergency departments.

INTRODUCTION: Boarding, especially among psychiatric patients, has been characterized as a significant cause of ED crowding, but no quantitative analysis has described boarding nationally. This study determines the incidence, duration, and factors associated with ED boarding in the United States. METHODS: 2008 National Hospital Ambulatory Medical Care Survey ED data were stratified by visit type (psychiatric vs. non-psychiatric), boarding status, and patient and hospital characteristics. Boarding was defined as a visit with an ED length of stay >6 hours, and boarding time as ED length of stay minus 6 hours. Pearson's chi-square tests describe hospital and patient characteristics stratified by boarding status. Multilevel multivariable logistic and linear regressions determine associations with boarding and boarding time. RESULTS: While 11% of all ED patients boarded, 21.5% of all psychiatric ED patients boarded. Boarding was also more prolonged for psychiatric ED patients. Controlling for confounders, odds of boarding for psychiatric patients were 4.78 (2.63-8.66) times higher than non-psychiatric, and psychiatric patients boarded 2.78 (1.91-3.64) hours longer than non-psychiatric. DISCUSSION: US EDs experienced high proportions and durations of boarding with psychiatric patients disproportionately affected. Additional research concerning mental health care services and legislation may be required to address ED psychiatric patient boarding.

The effects of cognitive impairment on nursing home residents' emergency department visits and hospitalizations.

BACKGROUND: Little is known about the relationship of cognitive impairment (CI) in nursing home (NH) residents and their use of emergency department (ED) and subsequent hospital services. METHODS: We analyzed 2006 Medicare claims and resident assessment data for 112,412 Medicare beneficiaries aged >65 years residing in US nursing facilities. We estimated the effect of resident characteristics and severity of CI on rates of total ED visits per year, then estimated the odds of hospitalization after ED evaluation. RESULTS: Mild CI predicted higher rates of ED visits relative to no CI, and ED visit rates decreased as severity of CI increased. In unadjusted models, mild CI and very severe CI predicted higher odds of hospitalization after ED evaluation; however, after adjusting for other factors, severity of CI was not significant. CONCLUSIONS: Higher rates of ED visits among those with mild CI may represent a unique marker in the presentation of acute illness and warrant further investigation.

Validity and reliability on three European language versions of the Safety Organizing Scale.

BACKGROUND: The Safety Organizing Scale (SOS) offers a reliable snapshot of nurses' engagement in unit-level safety behaviors in hospitals. As no comparable questionnaire exists in German, French and Italian, we explored the psychometric properties of SOS translations into each of those languages. DESIGN AND METHODS: The psychometric properties of the nine-item SOS were tested according to American Educational Research Association guidelines. SUBJECTS AND SETTING: Between October 2009 and June 2010, 1633 registered medical and/or surgical nurses in 35 Swiss hospitals completed translated SOS questionnaires. RESULTS: For each translation, psychometric evaluation revealed evidence based on content (scale-content validity index >0.89), response patterns (e.g. average of missing values across all items = 0.80%), internal structure (e.g. comparative fit indices >0.90, root mean square error of approximation <0.08) and reliability (Cronbach's alpha >0.79). We differentiated the scale regarding one related concept (implicit rationing of nursing care). Higher SOS scores correlated with supportive leadership and lower nurse-reported medication errors, but not with nurse-reported patient falls. CONCLUSIONS: The SOS offers a valuable measurement of engagement in safety practices that might influence patient outcomes. Initial evidence regarding the validity and reliability of the translated versions supports their use in German, French and Italian. Concurrent validity will require confirmation via further analysis using more reliable outcome measures (e.g. mortality rates). The translated versions' predictive validity needs to be established in prospective studies.

Baccalaureate education in nursing and patient outcomes.

OBJECTIVES: The aim of this study was to examine the effects of registered nurse (RN) education by determining whether nurse-sensitive patient outcomes were better in hospitals with a higher proportion of RNs with baccalaureate degrees. BACKGROUND: The Future of Nursing report recommends increasing the percentage of RNs with baccalaureate degrees from 50% to 80% by 2020. Research has linked RN education levels to hospital mortality rates but not with other nurse-sensitive outcomes. METHODS: This was a cross-sectional study that, with the use of data from 21 University HealthSystem Consortium hospitals, analyzed the association between RN education and patient outcomes (risk-adjusted patient safety and quality of care indicators), controlling for nurse staffing and hospital characteristics. RESULTS: Hospitals with a higher percentage of RNs with baccalaureate or higher degrees had lower congestive heart failure mortality, decubitus ulcers, failure to rescue, and postoperative deep vein thrombosis or pulmonary embolism and shorter length of stay. CONCLUSION: The recommendation of the Future of Nursing report to increase RN education levels is supported by these findings.

High rate of unemployment after liver transplantation: analysis of the United Network for Organ Sharing database.

The goal of liver transplantation (LT) is to maximize the length and quality of a patient's life and facilitate his or her return to full productivity. The aims of this study were (1) to use the United Network for Organ Sharing (UNOS) data set to determine the proportions of recipients who were employed and unemployed within 24 months after LT between 2002 and 2008 and (2) to examine the factors associated with a return to employment. UNOS data that were collected since the adoption of the Model for End-Stage Liver Disease scoring system on February 27, 2002 were analyzed. There were 21,942 transplant recipients who met the inclusion criteria. The employment status of the recipients was analyzed within a 60-day window at the following times after transplantation: 6, 12, and 24 months. Approximately one-quarter of the LT recipients (5360 or 24.4%) were employed within 24 months after transplantation, and the remaining recipients had not returned to work. The demographic variables that were independently associated with posttransplant employment included an age of 18 to 40 years, male sex, a college degree, Caucasian race, and pretransplant employment. Patients with alcoholic liver disease had a significantly lower rate of employment than patients with other etiologies of liver disease. The recipients who were employed after transplantation had significantly better functional status than those who were not employed. In conclusion, the employment rate after LT is low, with only one-quarter of LT recipients employed. New national and individual transplant program policies are needed to assess the root causes of unemployment in recipients who wish to work after LT.

Patient turnover and the relationship between nurse staffing and patient outcomes.

High patient turnover (patient throughput generated by admissions, discharges, and transfers) contributes to increased demands and resources for care. We examined how the relationship between registered nurse (RN) staffing and failure-to-rescue (FTR) varied with patient turnover levels by analyzing quarterly data from the University HealthSystem Consortium. The data included 42 hospitals, representing 759 nursing units and about 1 million inpatients. Higher RN staffing was associated with lower FTR. When patient turnover increased from 48.6% to 60.7% on nonintensive units (non-ICUs), the beneficial effect of non-ICU RN staffing on FTR was reduced by 11.5%. RN staffing should be adjusted according to patient turnover because turnover increases patient care demand beyond that presented by patient count, and outcomes may be adversely affected.

Nurse staffing effects on patient outcomes: safety-net and non-safety-net hospitals.

BACKGROUND: Nurse staffing has been linked to hospital patient outcomes; however, previous results were inconsistent because of variations in measures of staffing and were only rarely specific to types of patient care units. OBJECTIVE: To determine the relationship between nurse staffing in general and intensive care units and patient outcomes and determine whether safety net status affects this relationship. RESEARCH DESIGN: A cross-sectional design used data from hospitals belonging to the University HealthSystem Consortium. SUBJECTS: Data were available for approximately 1.1 million adult patient discharges and staffing for 872 patient care units from 54 hospitals. MEASURES: Total hours of nursing care [Registered Nurses (RNs), Licensed Practical Nurses, and assistants] determined per inpatient day (TotHPD) and RN skill mix were the measures of staffing; Agency for Healthcare Research and Quality risk-adjusted safety and quality indicators were the outcome measures. RESULTS: TotHPD in general units was associated with lower rates of congestive heart failure mortality (P<0.05), failure to rescue (P<0.10), infections (P<0.01), and prolonged length of stay (P<0.01). RN skill mix in general units was associated with reduced failure to rescue (P<0.01) and infections (P<0.05). TotHPD in intensive care units was associated with fewer infections (P<0.05) and decubitus ulcers (P<0.10). RN skill mix was associated with fewer cases of sepsis (P<0.01) and failure to rescue (P<0.05). Safety-net status was associated with higher rates of congestive heart failure mortality, decubitus ulcers, and failure to rescue. CONCLUSIONS: Higher nurse staffing protected patients from poor outcomes; however, hospital safety-net status introduced complexities in this relationship.

Comparison of patient outcomes in Magnet® and non-Magnet hospitals.

OBJECTIVE: : This study compared patient outcomes and staffing in Magnet® and non-Magnet hospitals. BACKGROUND: : The pursuit of Magnet designation is a highly regarded program for improving staff and patient outcomes. Research has confirmed that Magnet hospitals provide positive work environments for nurses. Research related to patient outcomes in Magnet hospitals is scarce, and results vary. METHODS: : The University Health Systems Consortium provided the clinical and operational databases for the study. Using bivariate and multivariate analyses, a comparison of patient outcomes and nurse staffing in general units and ICUs of Magnet and non-Magnet hospitals was studied. OUTCOMES: : Non-Magnet hospitals had better patient outcomes than Magnet hospitals. Magnet hospitals had slightly better outcomes for pressure ulcers, but infections, postoperative sepsis, and postoperative metabolic derangement outcomes were worse in Magnet hospitals. Magnet hospitals also had lower staffing numbers. CONCLUSIONS: : Magnet hospitals in this study had less total staff and a lower RN skill mix compared with non-Magnet hospitals, which contributed to the outcomes.

Staffing changes before and after mandated nurse-to-patient ratios in California's hospitals.

California is the first state to mandate specific nurse-to-patient ratios in general acute care hospitals. These ratios went into effect January 1, 2004 and apply "at all times". Little is known about the changes in staffing that occurred subsequent to the implementation of this legislation. This study identifies and describes changes in nurse and non-nursing staffing that may have occurred as a result of the enactment of these nurse-to-patient ratios. The results of this study indicate that most hospitals made upward adjustments in their RN and registry nurse staff but decreases in support staff and other non-nurse staff were not evident. These findings suggest that these mandated ratios had the desired effect of increasing the number of nurses caring for acutely ill patients.

Competence and certification of registered nurses and safety of patients in intensive care units.

BACKGROUND: Adverse events that place patients at risk for harm are common in intensive care units. Clinicians' level of knowledge and judgment appear to play a role in the prevention, mitigation, and creation of adverse advents. Research suggests a possible association between nurses' specialty certification and clinical expertise. The relationship between specialty certification and clinical competence of registered nurses and safety of patients is a relatively new area of inquiry in nursing. OBJECTIVE: To explore the relationship between the proportion of certified staff nurses in a unit and risk of harm to patients. METHODS: Hierarchical linear modeling was used in a secondary data analysis of 48 intensive care units from a random sample of 29 hospitals to examine the relationships between unit certification rates, organizational nursing characteristics(magnet status, staffing, education, and experience), and rates of medication administration errors, falls, skin breakdown,and 3 types of nosocomial infections. Medicare case mix index was used to adjust for patient risk. RESULTS: Unit proportion of certified staff registered nurses was inversely related to rate of falls, and total hours of nursing care was positively related to medication administration errors. The mean number of years of experience of registered nurses in the unit was inversely related to frequency of urinary tract infections; however, the small sample size requires that caution be exercised when interpreting results. CONCLUSIONS: Specialty certification and competence of registered nurses are related to patients' safety. Further research on this relationship is needed.

Labor and delivery nurse staffing as a cost-effective safety intervention.

Numerous studies have identified a relationship between staffing levels and nurse-sensitive outcomes for medical and surgical patients, but little has been published on the impact of nurse-sensitive outcomes for the childbearing family and even less that examines the relationship of intrapartum staffing on adverse perinatal outcomes. Using a derivation of Donabedian's classic structure, process, and outcomes framework, a model is proposed, which would allow obstetrical primary care providers and administrators alike the opportunity to examine the influence of nurse staffing on adverse obstetrical events, including unanticipated cesarean birth in low-risk women or newborn intensive care unit admissions. It is recognized that hospitals carry a significant burden in the prevention of adverse outcomes that range from nurse staffing levels to the internal process and infrastructure of the hospital setting. Patient outcomes are a direct result not only of the patient's health status and characteristics (eg, socioeconomic position and ethnicity), but also of interactions with the healthcare delivery system. As such, the opportunity to examine hospital characteristics (structure and processes) that may be detrimental to safe patient outcomes is of paramount importance in providing optimal outcomes for childbearing women and their families.

Competence and certification of registered nurses and safety of patients in intensive care units.

BACKGROUND: Adverse events that place patients at risk for harm are common in intensive care units. Clinicians' level of knowledge and judgment appear to play a role in the prevention, mitigation, and creation of adverse advents. Research suggests a possible association between nurses' specialty certification and clinical expertise. The relationship between specialty certification and clinical competence of registered nurses and safety of patients is a relatively new area of inquiry in nursing. OBJECTIVE: To explore the relationship between the proportion of certified staff nurses in a unit and risk of harm to patients. METHODS: Hierarchical linear modeling was used in a secondary data analysis of 48 intensive care units from a random sample of 29 hospitals to examine the relationships between unit certification rates, organizational nursing characteristics (magnet status, staffing, education, and experience), and rates of medication administration errors, falls, skin breakdown, and 3 types of nosocomial infections. Medicare case mix index was used to adjust for patient risk. RESULTS: Unit proportion of certified staff registered nurses was inversely related to rate of falls, and total hours of nursing care was positively related to medication administration errors. The mean number of years of experience of registered nurses in the unit was inversely related to frequency of urinary tract infections; however, the small sample size requires that caution be exercised when interpreting results. CONCLUSIONS: Specialty certification and competence of registered nurses are related to patients' safety. Further research on this relationship is needed.

Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy.

BACKGROUND: Seven hospitals from the San Francisco Bay Area participated in an 18-month-long Integrated Nurse Leadership Program, which was designed to improve the reliability of medication administration by developing and deploying nurse leadership and process improvement skills on one medical/surgical inpatient unit. METHODS: Each hospital formed a nurse-led project team that worked on six safety processes to improve the accuracy of medication administration: Compare medication to the medication administration record, keep medication labeled from preparation to administration, check two forms of patient identification, explain drug to patient (if applicable), chart immediately after administration, and protect process from distractions and interruptions. RESULTS: For the six hospitals included in the analysis, the accuracy of medication administration (as measured by the percent of correct doses administered) improved from 85% in the baseline period to 92% six months after the intervention and 96% 18 months after the intervention. The sum of the six safety processes completed also improved significantly, from 4.8 on a 0-6 scale at baseline to 5.6 at 6 months to 5.75 at 18 months. DISCUSSION: This study suggests that frontline nurses and other hospital-based staff, if given the training, resources, and authority, are well positioned to improve patient care and safety processes on hospital patient units. Frontline clinicians have the unique opportunity to see what is and is not working in the direct provision of patient care. To address the sustainability of the program's changes after the official project ended, each team was required to develop a sustainability plan entailing monitoring of progress, actions to ensure the improvements are built into the organizational infrastructure, and staff's interaction with leaders to ensure that the work could continue.