Path Analysis: Interrelationships Between Nurse Manager Competencies, Practice Environment Perceptions, and Frontline Nurses' Intent to Stay.

OBJECTIVE: To examine the correlation between nurse manager (NM) competencies, work environment (Practice Environment Scale of the Nursing Work Index [PES-NWI]), and frontline nurses' intent to stay; the direct effect of NM competency on frontline nurses' intent to stay; and the indirect effect of NM competency on frontline nurses' intent to stay, mediated by PES-NWI. BACKGROUND: PES-NWI and NMs' competency can impact frontline nurses' intent to stay. METHODS: Cross-sectional study with secondary analysis of NM Competency and NDNQI® (National Database of Nursing Quality Indicators®) RN Survey data with path analysis for effects of the model's variables. RESULTS: Positive, weak correlations between NM competencies and frontline nurses' practice environments were found; NM competencies and frontline nurses' intent to stay were not correlated. Paths were NM competency/PES-NWI (ß = 0.20, P = 0.001) and PES-NWI/intent to stay (ß = 0.55, P < 0.001); NM competency/intent to stay was not significant. Indirect effect of NM competency on frontline nurses' intent to stay was mediated through PES-NWI (ß = 0.11, P = 0.002; 95% confidence interval, 0.05-0.17). CONCLUSIONS: Investing in NMs' competency can help create supportive work environments and frontline nurses' intent to stay.

Evidence on Fall and Injurious Fall Prevention Interventions in Acute Care Hospitals.

Falls and injurious falls are a major safety concern for patient care in acute care hospitals. Inpatient falls and injurious falls can cause extra financial burden to patients, families, and healthcare facilities. This article provides clinical implications and recommendations for adult inpatient fall and injurious fall prevention through a brief review of factors associated with falls and injurious falls and current fall prevention practices in acute care hospitals.

Practice Environment Characteristics Associated With Missed Nursing Care.

PURPOSE: To examine which characteristics of the practice environment were associated with missed nursing care in U.S. acute care hospital units. DESIGN: A descriptive, correlational study used secondary analysis of the 2015 National Database of Nursing Quality Indicators® Registered Nurse (RN) Survey data. Subscales of the Practice Environment Scale of the Nursing Work Index were used to measure practice environment characteristics. The sample included 1,583 units in 371 hospitals, containing survey responses from 31,650 RNs. METHODS: Multilevel logistic regression was performed to estimate the effects of the practice environment characteristics on missed care, controlling for hospital and unit characteristics. RESULTS: About 84.1% of unit RNs reported missing at least one of the 15 necessary care activities. Good environment units had 63.3% significantly lower odds of having RNs miss care activities than poor environment units. Units had 81.5% lower odds of having RNs miss any necessary activities with 1 point increase of the staffing and resource adequacy score; 21.9% lower odds for 1 point increase in the nurse-physician relations score; and approximately 2.1 times higher odds with 1 point increase in the nurse participation in hospital affairs score. CONCLUSIONS: Good environments were significantly associated with lower levels of missed care. The impact on missed care differed by the characteristics of the practice environment. CLINICAL RELEVANCE: Hospital and nursing administrators should maintain good practice environments for nurses to reduce missed care activities and thus potentially improve patient outcomes. Specifically, their efforts should be targeted on improving staffing and resource adequacy and nurse-physician relations and on reducing workloads on hospital affairs.

Characteristics of the Nursing Practice Environment Associated With Lower Unit-Level RN Turnover.

OBJECTIVE: The aim of this study is to examine characteristics of the nursing practice environment associated with lower RN turnover. BACKGROUND: Identifying characteristics of the practice environment that contribute to lower RN turnover is important for meeting the national quality strategy priority of reducing healthcare costs. METHODS: Data from 1002 adult care units in 162 National Database of Nursing Quality Indicators participating hospitals were analyzed using multivariate linear regression. The Practice Environment Scale of the Nursing Work Index was used to measure practice environment characteristics. RN turnover was measured at the unit level. RESULTS: Nursing units with higher overall ratings of the nursing practice environment had lower rates of RN turnover. Units with higher RN perceived staffing and resource adequacy experienced significantly lower RN turnover. CONCLUSIONS: Unit managers and hospital administrators should consider RN perception of staffing and resource adequacy and the overall practice environment when developing targeted strategies for decreasing RN turnover.

Multilevel Factors Associated With Injurious Falls in Acute Care Hospitals.

Using National Database of Nursing Quality Indicators data from July 2013 to June 2014, this correlational study examined the associations of injurious falls among all patient falls with multilevel factors in hospitals. The sample included all falls recorded in adult medical, surgical, combined medical-surgical, and step-down units (N = 2299) in participating hospitals (N = 488). Hierarchical negative binominal regression analyses were performed. Results revealed hospital and unit organizational factors associated with inpatient injurious falls.

Comparison of Reasons for Nurse Turnover in Magnet® and Non-Magnet Hospitals.

OBJECTIVE: The aim of this study is to compare rates and reasons for registered nurse (RN) turnover by Magnet® status. BACKGROUND: Although lower RN turnover rates in Magnet hospitals have been documented well in the literature, little is known about specific separation reasons for RN turnover and whether the reasons differ between Magnet and non-Magnet hospitals. METHODS: This descriptive, correlational study analyzed unit-level 2013 National Database of Nursing Quality Indicators® turnover data (2,958 units; 497 hospitals). Poisson regression and Wilcoxon-Mann-Whitney test were used. RESULTS: Registered nurse turnover due to environment-related reasons was higher on units in non-Magnet hospitals than units in Magnet hospitals. Units in non-Magnet hospitals had 4.684 times higher turnover rates due to staffing/workload and 1.439 times higher rates due to work schedules than did units in Magnet hospitals. CONCLUSIONS: Nursing administrators in both Magnet and non-Magnet hospitals need to continually strive to improve unit work environments, particularly staffing and workload conditions and work scheduling.

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.

Hospital Magnet Status, Unit Work Environment, and Pressure Ulcers.

PURPOSE: To identify how organizational nursing factors at different structural levels (i.e., unit-level work environment and hospital Magnet status) are associated with hospital-acquired pressure ulcers (HAPUs) in U.S. acute care hospitals. DESIGN: A cross-sectional observational study used data from the National Database of Nursing Quality Indicators®. Responses from 33,845 registered nurses (RNs) were used to measure unit work environments. The unit of analysis was the nursing unit, and there were 1,381 units in 373 hospitals in the United States. METHODS: Unit work environment was measured by the Practice Environment Scale of Nurse Working Index (PES-NWI). Multilevel logistic regressions were used to estimate the effects of unit work environment and hospital Magnet status on HAPUs. All models were controlled for hospital and unit characteristics when considering clustering of units within hospitals. RESULTS: Magnet hospital units had 21% lower odds of having an HAPU than non-Magnet hospital units (95% confidence interval [CI], 0.64-0.98). With one unit increase of the PES-NWI score, units had 29% lower odds of having an HAPU (95% CI, 0.55-0.91). When including both hospital Magnet status and unit work environment in the model, hospital Magnet status no longer had a significant effect on HAPUs (odds ratio [OR] = 0.82; 95% CI, 0.66-1.02), whereas the significant effect of unit work environment persisted (OR = 0.73; 95% CI, 0.56-0.93). CONCLUSIONS: Both hospital and unit environments were significantly associated with HAPUs, and the unit-level work environment can be more influential in reducing HAPUs. CLINICAL RELEVANCE: Investment in the nurse work environments at both the hospital level and unit level has the potential to reduce HAPUs; and additional to hospital-level initiatives (e.g., Magnet recognition program), efforts targeting on-unit work environments deserve more attention.

How hospitals view unit-level nurse turnover data collection: analysis of a hospital survey.

OBJECTIVE: The objectives of this study were to examine the quality of unit-level nurse turnover data collection among the National Database of Nursing Quality Indicators hospitals and to identify the burdens of collecting such data. BACKGROUND: Tracking and managing nurse turnover at the unit level are critical for administrators who determine managerial strategies. Little is known about the quality of and burdens of unit-level turnover data collection. METHODS: Surveys from 178 hospitals were analyzed descriptively. RESULTS: Most hospitals strongly agreed or agreed with the quality of unit-level turnover data collection. Hospitals identified the burdens of additional time and resources needed for unit-level turnover data collection and the difficulty of obtaining specific reasons for turnover. CONCLUSIONS: Collecting unit-level nurse turnover data can be important and useful for administrators to improve nurse retention, workforce stability, and quality of care. We suggest that the advantages of unit-level nurse turnover data and reports can overcome the identified burdens.

Higher numbers of nurses and consultants improve survival rates for critically ill patients.

Implications for practice and research: The number of nurses, as well as doctors, working in intensive care units (ICUs) is associated with patient mortality. Patients at high risk of death are more vulnerable if they are admitted to ICUs with lower nurse staffing, while higher unit workload in ICUs is associated with higher patient mortality. Future research would be aided by the establishment of standardised national electronic databases.

Validity and Reliability of a Newly Developed Instrument to Measure Nursing Workarounds During Medication Administration.

Background and Purpose: According to patient safety literature, workarounds are used when processes are not clear and may not match the intended workflows. There is no available quantitative instrument to measure the type and frequency of workarounds when nurses administer medications. The purpose of this study was to assess the psychometric properties of a newly developed instrument that measured the type and frequency of workarounds when nurses administer medications to patients. Methods: Items for the newly developed instrument were derived based on the concept analysis of workarounds, and the psychometric evaluation included content validity, face validity, item analysis, dimensionality, reliability, and construct validity testing. The instrument was administered to registered nurses in an acute care hospital in Northern Virginia. Results: Psychometric evaluation of the newly developed instrument demonstrated adequate content and face validity. Based on exploratory factor analysis using principal axis factoring of the 18 items, 12 items were retained comprising three subscales: (a) defining characteristics, (b) type of workarounds, and (c) frequency of workarounds. Cronbach's alpha ranged from .83 to .92 for the three subscales. As hypothesized, convergent validity was supported by Spearman Rho correlations ranging from .27 to .47 among the Halbesleben, Rathert, and Bennett total and two subscales. Divergent validity was supported with Spearman Rho correlations ranging from -.09 to .15 with two other Halbesleben, Rathert, and Bennett subscales. Conclusions: The findings provided beginning evidence for the reliability and validity of the newly developed Savage Barcode-Assisted Medication Administration Workarounds Tool comprised of three subscales-defining characteristics, types of workarounds, and frequencies of workarounds.

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.

PSYCHOMETRIC PROPERTIES OF THE NURSE MANAGER COMPETENCY INSTRUMENT FOR RESEARCH.

Background and Purpose: Competent nurse managers (NM) are essential to create safe and healthy work environments and support frontline nurses. Measuring NM competence with a valid and reliable instrument is critical in research. We assessed the psychometric properties of the Nurse Manager Competency Instrument for Research (NMCIR). Methods: Item analysis, internal consistency analysis, and confirmatory factor analysis were performed with a sample of 594 NMs. Results: The NMCIR showed high internal consistency. The 26 items were loaded on ten factors with a good overall fit, supporting the hypothesized factor structure. However, the findings showed poor discriminant validity. Conclusion: The NMCIR demonstrates sound psychometric properties for use in studies of NM competence. Further evaluation of the NMCIR is recommended to improve discriminant validity.

The microbiota in feces of domestic pigeons in Seoul, Korea.

In Korea, feral pigeons pose significant public health risks because they carry various zoonotic pathogens. Human population density is a significant factor in zoonotic disease events. Seoul is one of the largest cities by population density among developed countries and where most of the homeless population in Korea exists. We designed this study to compare the microbiota of pigeon feces by regional characteristics and the presence of homeless individuals. Therefore, this study used 16S rRNA amplicon sequencing to detect possible pathogenic microbes and assess the current risk of zoonosis in Seoul, South Korea. Pigeon fecal samples (n = 144) obtained from 19 public sites (86 and 58 fecal samples from regions in and outside Seoul, respectively) were examined. Potentially pathogenic bacteria were also detected in the fecal samples; Campylobacter spp. was found in 19 samples from 13 regions, Listeriaceae was found in seven samples, and Chlamydia spp. was found in three samples from two regions. Principal coordinates analysis and permutational multivariate analysis of variance revealed a significant difference in bacterial composition between the regions in Seoul (n = 86) and outside Seoul (n = 58) and between the regions with (n = 81) and without (n = 63) homeless individuals. Overall, this study identified various potentially pathogenic microorganisms in pigeon feces at public sites in South Korea. Moreover, this study demonstrates that the microbial composition was influenced by regional characteristics and homelessness. Taken together, this study provides important information for public health strategic planning and disease control.

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.

Versatile Mitogenic and Differentiation-Inducible Layer Formation by Underwater Adhesive Polypeptides.

Artificial materials have no biological functions, but they are important for medical devices such as artificial organs and matrices for regenerative medicine. In this study, mitogenic and differentiation-inducible materials are devised via the simple coating of polypeptides, which contain the sequence of epidermal growth factor or insulin-like growth factor with a key amino acid (3,4-dihydroxyphenylalanine) of underwater adhesive proteins. The adhesive polypeptides prepared via solid-phase synthesis form layers on various substrates involving organic and inorganic materials to provide biological surfaces. Through the direct activation of cognate receptors on interactive surfaces, the materials enable increased cell growth and differentiation compared to that achieved by soluble growth factors. This superior growth and differentiation are attributed to the long-lasting signal transduction (triggered by the bound growth factors), which do not cause receptor internalization and subsequent downregulation.

Relationship between Hospital Characteristics and Value-Based Program Measure Performance: A Literature Review.

Determining if the Centers for Medicare and Medicaid's value-based programs accurately represent the quality of care provided by acute-care hospitals is critical. We performed an integrative literature review to summarize research articles examining hospital characteristics associated with overall performance on the value-based program measures. The literature review was conducted by searching the PubMed and CINAHL databases. The initial search returned 18 relevant articles, 12 of which met all inclusion criteria. The emergent hospital characteristics that heavily influenced value-based program performance included size, safety-net status, geographical location, and teaching status. This review determined that many factors largely outside of acute-care hospitals' control create observed differences in value-based program performance. Additional factors such as a hospital's patient populations, socioeconomic status, and level of acuity may need to be considered prior to assigning financial penalties to under-performing hospitals.