Common predictors of nurse-reported quality of care and patient safety.

BACKGROUND: In the era of the Patient Protection and Affordable Care Act, quality of care and patient safety in health care have never been more visible to patients or providers. Registered nurses (nurses) are key players not only in providing direct patient care but also in evaluating the quality and safety of care provided to patients and families. PURPOSE: We had the opportunity to study a unique cohort of nurses to understand more about the common predictors of nurse-reported quality of care and patient safety across acute care settings. APPROACH: We analyzed cross-sectional survey data that were collected in 2015 from 731 nurses, as part of a national 10-year panel study of nurses. Variables selected for inclusion in regression analyses were chosen based on the Systems Engineering Initiative for Patient Safety model, which is composed of work system or structure, process, and outcomes. RESULTS: Our findings indicate that factors from three components of the Systems Engineering Initiative for Patient Safety model-Work System (person, environment, and organization) are predictive of quality of care and patient safety as reported by nurses. The main results from our multiple linear and logistic regression models suggest that significant predictors common to both quality and safety were job satisfaction and organizational constraints. In addition, unit type and procedural justice were associated with patient safety, whereas better nurse-physician relations were associated with quality of care. CONCLUSION: Increasing nurses' job satisfaction and reducing organizational constraints may be areas to focus on to improve quality of care and patient safety. PRACTICAL IMPLICATIONS: Our results provide direction for hospitals and nurse managers as to how to allocate finite resources to achieve improvements in quality of care and patient safety alike.

Diversity and education of the nursing workforce 2006-2016.

BACKGROUND: The Institute of Medicine (IOM) report, The Future of Nursing, included recommendations to increase nurse diversity, the percent of nurses obtaining a bachelor's degree, and inter-professional education. PURPOSE: The purpose of this paper is to report the progress toward achievement of these recommendations. METHODS: We used a longitudinal, multi-state data from four cohorts of nurses newly licensed in 2004 to 2005, 2007 to 2008, 2010 to 2011, and 2014 to 2015 to examine and compare the trends. FINDING: The percentage of males who became licensed increased, from 8.8% in 2004 to 2005 cohort to 13.6% in the 2014 to 2015 cohort. The percentage of white-non-Hispanic nurses who were licensed decreased from 78.9% in 2007 to 2008 to 73.8% in 2014 to 2015. These differences primarily reflect an increase in white-Hispanic nurses. More nurses are obtaining a bachelor's degree as their first professional degree, from 36.6% in 2004 to 2005 cohort to 48.5% in 2014 to 2015 cohort. About 40% of the 2014 to 2015 cohort reported that they learned to work in inter-professional teams. Collegial nurse-physician relations had an upward positive trajectory over time increasing almost 7%. DISCUSSION: The diversity and education of new nurses have increased, but are short of meeting the IOM recommendations.

Impact of transformational leadership on nurse work outcomes.

AIMS: To examine the effect of transformational leadership on early career nurses' intent to stay, job satisfaction and organizational commitment. BACKGROUND: Lack of leadership support is one of the top reasons staff nurses leave. Current studies reported mixed results about the impact of transformational leadership on key nurse outcomes. However, little is known whether leadership directly or indirectly affects satisfaction, organizational commitment and intent to stay. DESIGN: This study was a cross-sectional study of nurses who had been licensed for 7·5-8·5 years which was part of a 10-year longitudinal panel design. METHODS: The analytic sample was 1037 nationally representative newly licensed Registered Nurses. Data were collected from January-March 2013. We used a probit model to model the relationship between transformational leadership and intent to stay, organizational commitment and job satisfaction. RESULTS: Transformational leadership did not have a significant impact on intent to stay and job satisfaction, but significantly associated with organizational commitment. Organizational commitment, job satisfaction, mentor support, promotional opportunities and age were positively associated with intent to stay, while ethnicity, non-local job opportunities and work settings were negatively associated with intent to stay. CONCLUSIONS: Transformational leadership had no direct relationship with intent to stay and job satisfaction and had a small direct positive effect on organizational commitment. Transformational leadership has potential to slow attrition and retain nurses by creating a positive work environment that supports nurses. Any improvement in job satisfaction and organizational commitment would positively increase the change in probability for intent to stay.

Educational gaps and solutions for early-career nurse managers' education and participation in quality improvement.

OBJECTIVE: The objective of this study was to examine early-career frontline nurse managers' (FLNMs') reported educational preparedness and participation in quality improvement (QI). BACKGROUND: Frontline nurse managers are vitally important for leading QI. However, it is not well known if they have adequate knowledge and skills to lead this important function. METHODS: We examined cross-sectional survey data from 42 FLNMs using descriptive statistics. RESULTS: About 30% of FLNMs reported being very prepared across 12 measured QI skills by schools or employers and 35% reported participating in a specific clinical effort to improve patient care on their unit more than once a month. More than 50% reported having good organizational support for QI, but only about 30% reported being rewarded for their contributions to QI. CONCLUSION: Our study highlights opportunities for development in QI for FLNMs and offers some solutions for nurse executives that can bridge the educational gaps.

Use of temporary nursing staff and nosocomial infections in intensive care units.

AIMS AND OBJECTIVES: To examine the nature and prevalence of the use of temporary nursing staff in intensive care units and relationships between the use of temporary nursing staff and the occurrence of nosocomial infections (central line-associated blood stream infections and ventilator-associated pneumonia). BACKGROUND: Hiring temporary nurses raises controversial issues with respect to nurse staffing, care processes and patient outcomes, yet empirical findings regarding the use of temporary nurses are mixed. Whether adverse patient outcomes in intensive care units are related to the use of temporary nursing staff remains unexamined. DESIGN: A retrospective longitudinal design was used. METHODS: Data were collected monthly from 12 intensive care units at six hospitals; 144 ICU-month data points were used for the analysis. Chi-square, anova and logit regression models were used to examine the research questions. RESULTS: The intensive care units used higher levels of temporary nursing staff, but the use of temporary nursing staff was not significantly associated with nosocomial infections. Nurses' perceptions regarding staffing and resource adequacy were significantly associated with nosocomial infections. CONCLUSIONS: No evidence was found to link the use of temporary nursing staff and nosocomial infections. Instead, nurses' perceptions of staffing adequacy were related to nosocomial infections. RELEVANCE TO CLINICAL PRACTICE: Given the greater use of temporary nursing staff in intensive care units, nurse managers in intensive care units need to monitor the levels of temporary nurse staffing and develop a systematic approach for hospitals to assist in these nurses' adjustment, which can reduce the burden of both temporary and permanent intensive care unit nurses. In addition to quantitative measures of nurse staffing, nurses' perceptions regarding staffing adequacy can be used to measure nurse staffing in relation to adverse patient outcomes.

Exploring direct and indirect influences of physical work environment on job satisfaction for early-career registered nurses employed in hospitals.

We explored direct and indirect influences of physical work environment on job satisfaction in a nationally representative sample of 1,141 early-career registered nurses. In the fully specified model, physical work environment had a non-significant direct effect on job satisfaction. The path analysis used to test multiple indirect effects showed that physical work environment had a positive indirect effect (p < .05) on job satisfaction through ten variables: negative affectivity, variety, workgroup cohesion, nurse-physician relations, quantitative workload, organizational constraints, distributive justice, promotional opportunity, local and non-local job opportunities. The findings make important contributions to the understanding of the relationship between physical work environment and job satisfaction. The results can inform health care leaders' insight about how physical work environment influences nurses' job satisfaction.

Analysis of nurse staffing and patient outcomes using comprehensive nurse staffing characteristics in acute care nursing units.

Associations between comprehensive nurse staffing characteristics and patient falls and pressure ulcers were examined using negative binomial regression modeling with hospital- and time-fixed effects. A convenience sample was collected from 35 nursing units in 3 hospitals. Rates of patient falls and injury falls were found to be greater with higher temporary registered nurse staffing levels but decreased with greater levels of licensed practical nursing care hours per patient day. Pressure ulcers were not related to any staffing characteristics.

Intersection of migration and turnover theories-What can we learn?

BACKGROUND: The international migration of nurses has become a major issue in the international health and workforce policy circles, but analyses are not based on a comprehensive theory. PURPOSE: The purpose of this article was to compare the concepts of an integrated nursing turnover theory with the concepts of one international migration framework. METHODS: An integrated turnover theory is compared with a frequently used migration framework using examples of each. DISCUSSION: Migration concepts relate well to turnover concepts, but the relative importance and strength of various concepts may differ. For example, identification, development, and measurement of the concept of national commitment, if it exists, is parallel to organizational commitment and may be fruitful in understanding the processes that lead to nurse migration. CONCLUSIONS: The turnover theory provides a framework for examining migration concepts and considering how these concepts could relate to each other in a future theory of migration. Ultimately, a better understanding of the relationships and strengths of these concepts could lead to more effective policy.

What does nurse turnover rate mean and what is the rate?

Registered nurse turnover is an important indicator of the nurse job market. Despite its wide use as a measure for health-care system analysis, there is a lack of consistency in the definition of turnover. Some definitions include any nurse leaving an organization; others may include involuntary and voluntary leaving. These inconsistent definitions also result in various turnover rates. The RN Work Project is a 10-year panel study of new nurses. Data were collected from the new nurses, rather than from a specific organization. About 17.5% of new nurses leave their first job within 1 year of starting their jobs. Consistent and accurate measurement of turnover is an important step in addressing organizational work environments and policies about the nursing workforce.

Verbal abuse from nurse colleagues and work environment of early career registered nurses.

PURPOSE: This study examined relationships between verbal abuse from nurse colleagues and demographic characteristics, work attributes, and work attitudes of early career registered nurses (RNs). DESIGN AND METHODS: Data are from the fourth wave of a national panel survey of early career RNs begun in 2006. The final analytic sample included 1,407 RNs. Descriptive statistics were used to describe the sample, analysis of variance to compare means, and chi square to compare categorical variables. FINDINGS: RNs reporting higher levels of verbal abuse from nurse colleagues were more likely to be unmarried, work in a hospital setting, or work in a non-magnet hospital. They also had lower job satisfaction, and less organizational commitment, autonomy, and intent to stay. Lastly, they perceived their work environments unfavorably. CONCLUSIONS: Data support the hypothesis that early career RNs are vulnerable to the effects of verbal abuse from nurse colleagues. Although more verbal abuse is seen in environments with unfavorable working conditions, and RNs working in such environments tend to have less favorable work attitudes, one cannot assume causality. It is unclear if poor working conditions create an environment where verbal abuse is tolerated or if verbal abuse creates an unfavorable work environment. CLINICAL RELEVANCE: There is a need to develop and test evidence-based interventions to deal with the problems inherent with verbal abuse from nurse colleagues.

Work environment factors other than staffing associated with nurses' ratings of patient care quality.

BACKGROUND: The impact of registered nurse (RN) staffing on patient care quality has been extensively studied. Identifying additional modifiable work environment factors linked to patient care quality is critical as the projected shortage of approximately 250,000 RNs over the next 15 years will limit institutions' ability to rely on RN staffing alone to ensure high-quality care. PURPOSE: We examined the association between RNs' ratings of patient care quality and several novel work environment factors adjusting for the effects of two staffing variables: reported patient-to-RN ratios and ratings of staffing adequacy. METHODOLOGY: We used a cross-sectional, correlational design and a mailed survey to collect data in 2009 from a national sample of RNs (n = 1,439) in the United States. A multivariate logistic regression was used to analyze the data. FINDINGS: Workgroup cohesion, nurse-physician relations, procedural justice, organizational constraints, and physical work environment were associated with RNs' ratings of quality, adjusting for staffing. Furthermore, employment in a Magnet hospital and job satisfaction were positively related to ratings of quality, whereas supervisory support was not. PRACTICE IMPLICATIONS: Our evidence demonstrates the importance of considering RN work environment factors other than staffing when planning improvements in patient care quality. Health care managers can use the results of our study to strategically allocate resources toward work environment factors that have the potential to improve quality of care.

Early-career registered nurses' participation in hospital quality improvement activities.

We surveyed 2 cohorts of early-career registered nurses from 15 states in the US, 2 years apart, to compare their reported participation in hospital quality improvement (QI) activities. We anticipated differences between the 2 cohorts because of the growth of several initiatives for engaging nurses in QI. There were no differences between the 2 cohorts across 14 measured activities, except for their reported use of appropriate strategies to improve hand-washing compliance to reduce nosocomial infection rates.

Positive work environments of early-career registered nurses and the correlation with physician verbal abuse.

BACKGROUND: Verbal abuse in the workplace is experienced by registered nurses (RNs) worldwide; physicians are one of the main sources of verbal abuse. PURPOSE: To examine the relationship between levels of physician verbal abuse of early-career RNs and demographics, work attributes, and perceived work environment. METHOD: Fourth wave of a mailed national panel survey of early career RNs begun in 2006. DISCUSSION: RNs' perception of verbal abuse by physicians was significantly associated with poor workgroup cohesion, lower supervisory and mentor support, greater quantitative workload, organizational constraints, and nurse-colleague verbal abuse, as well as RNs' lower job satisfaction, organizational commitment, and intent to stay. CONCLUSION: RNs working in unfavorable work environments experience more physician abuse and have less favorable work attitudes. Causality is unclear: do poor working conditions create an environment in which physicians are more likely to be abusive, or does verbal abuse by physicians create an unfavorable work environment?

A multi-state assessment of employer-sponsored quality improvement education for early-career registered nurses.

BACKGROUND: Increasing participation of registered nurses (RNs) in quality improvement (QI) is a promising strategy to close the health care quality chasm. For RNs to participate effectively in hospital QI, they must have adequate QI knowledge and skills. METHODS: This descriptive study assessed employer-sponsored QI education and RNs' preparedness across a wide range of QI steps and processes. RNs from 15 U.S. states who were employed in hospitals and were initially licensed to practice in 2007 to 2008 were surveyed. RESULTS: Fewer than one third of respondents reported being very prepared across all measured QI topics. More than half reported receiving zero hours of training in these same topics in the last year. Lack of educational offerings on the topic was the top reason respondents gave for not obtaining QI training. CONCLUSION: The QI education offered by employers to RNs could be substantially improved. Nurse educators play a critical role in making these improvements.

Predictors of actual turnover in a national sample of newly licensed registered nurses employed in hospitals.

AIM: This paper is a report of a study of factors that affect turnover of newly licensed registered nurses in United States hospitals. BACKGROUND: There is a large body of research related to nursing retention; however, there is little information specific to newly licensed registered nurse turnover. Incidence rates of turnover among new nurses are unknown because most turnover data are not from nationally representative samples of nurses. METHOD: This study used a longitudinal panel design to obtain data from 1653 registered nurses who were recently licensed by examination for the first time. We mailed surveys to a nationally representative sample of hospital registered nurses 1 year apart. The analytic sample consisted of 1653 nurses who responded to both survey mailings in January of 2006 and 2007. RESULTS: Full-time employment and more sprains and strains (including back injuries) result in more turnover. Higher intent to stay and hours of voluntary overtime and more than one job for pay reduces turnover. When we omitted intent to stay from the probit model, less job satisfaction and organizational commitment led to more turnover, confirming their importance to turnover. Magnet Recognition Award(®) hospitals and several other work attributes had no effect on turnover. CONCLUSION: Turnover problems are complex, which means that there is no one solution to decreasing turnover. Multiple points of intervention exist. One specific approach that may improve turnover rates is hospital policies that reduce strains and sprains.

Work environment factors other than staffing associated with nurses' ratings of patient care quality.

BACKGROUND: The impact of registered nurse (RN) staffing on patient care quality has been extensively studied. Identifying additional modifiable work environment factors linked to patient care quality is critical as the projected shortage of approximately 250,000 RNs over the next 15 years will limit institutions' ability to rely on RN staffing alone to ensure high-quality care. PURPOSE: We examined the association between RNs' ratings of patient care quality and several novel work environment factors adjusting for the effects of two staffing variables: reported patient-to-RN ratios and ratings of staffing adequacy. METHODOLOGY: We used a cross-sectional, correlational design and a mailed survey to collect data in 2009 from a national sample of RNs (n = 1,439) in the United States. A multivariate logistic regression was used to analyze the data. FINDINGS: Work group cohesion, nurse-physician relations, procedural justice, organizational constraints, and physical work environment were associated with RNs' ratings of quality, adjusting for staffing. Furthermore, employment in a Magnet hospital and job satisfaction were positively related to ratings of quality, whereas supervisory support was not. PRACTICE IMPLICATIONS: Our evidence demonstrates the importance of considering RN work environment factors other than staffing when planning improvements in patient care quality. Health care managers can use the results of our study to strategically allocate resources toward work environment factors that have the potential to improve quality of care.

State mandatory overtime regulations and newly licensed nurses' mandatory and voluntary overtime and total work hours.

Nurse overtime has been used to handle normal variations in patient census and to control chronic understaffing. By 2010, 16 states had regulations to limit nurse overtime. We examined mandatory overtime regulations and their association with mandatory and voluntary overtime and total hours worked by newly licensed registered nurses (NLRNs). For this secondary data analysis, we used a panel survey of NLRNs; the final dataset consisted of 1,706 NLRNs. Nurses working in states that instituted overtime regulations after 2003 or in states that restricted any type of mandatory overtime had a lower probability of experiencing mandatory overtime than those nurses working in states without regulations. Nurses who worked in states with mandatory overtime regulations reported fewer total hours worked per week. The findings of this study provided insight into how mandatory overtime regulations were related to nurse mandatory and voluntary overtime and the total number of hours worked. Future research should investigate institutions' compliance with regulations and the impact of regulations on nurse and patient outcomes.

New nurses' views of quality improvement education.

BACKGROUND: Quality improvement (QI) is a focus of hospital managers and policymakers. The role of registered nurses (RNs) in QI in hospitals is vital because most hospital-based RNs provide direct care to patients. QI skills are necessary to identify gaps between current care and best practice and to design, implement, test, and evaluate changes and are essential for R.N.s to participate effectively in QI. Newly licensed registered nurses' (new nurses') positions as direct caregivers could have an impact on QI if nurses lack sufficient knowledge, concepts, and tools required for QI. METHODS: Data came from the 436 respondents (69.4% response rate) to a 2008 eight-page mailed survey to participants in a nationally representative panel survey of new nurses who graduated between August 1, 2004, and July 31, 2005. RESULTS: Overall, 159 (38.6%) of new nurses thought that they were "poorly" or "very poorly" prepared about or had never heard of" QI. Their perceptions of preparation varied widely by the specific topic. Baccalaureate (B.S.) graduates reported significantly higher levels of preparation than associate degree (A.D.) graduates in evidence-based practice; assessing gaps in practice, teamwork, and collaboration; and many of the research-type skills such as data collection, analysis, measurement, and measuring resulting changes. DISCUSSION: Registered-nurse educational programs need to improve education about and application of QI concepts and to consider focusing QI content into a separate course to have some confidence that faculty will teach it. Despite the strong focus on QI in hospitals, new nurses do not see the connection between QI education and successfully performing their hospital jobs. Both nursing programs and hospitals should help new nurses make the connection.

Generational differences among newly licensed registered nurses.

Responses of 2369 newly licensed registered nurses from 3 generational cohorts-Baby Boomers, Generation X, and Generation Y-were studied to identify differences in their characteristics, work-related experiences, and attitudes. These responses revealed significant differences among generations in: job satisfaction, organizational commitment, work motivation, work-to-family conflict, family-to-work conflict, distributive justice, promotional opportunities, supervisory support, mentor support, procedural justice, and perceptions of local job opportunities. Health organizations and their leaders need to anticipate intergenerational differences among newly licensed nurses and should provide for supportive working environments that recognize those differences. Orientation and residency programs for newly licensed nurses should be tailored to the varying needs of different generations. Future research should focus on evaluating the effectiveness of orientation and residency programs with regard to different generations so that these programs can be tailored to meet the varying needs of newly licensed nurses at the start of their careers.

What newly licensed registered nurses have to say about their first experiences.

To understand factors that promote retention of Newly Licensed Registered Nurses (NLRNs) and those that contribute to turnover, a survey of a national sample of NLRNs was conducted. This article describes the content analysis of 612 NLRN comments about their work life. Using Krippendorff's technique, 5 themes were discovered. Colliding expectations describes conflicts between nurses' personal view of nursing and their lived experience. The need for speed describes the pressure related to a variety of temporal issues. You want too much expresses the pressure and stress NLRNs feel personally and professionally. How dare you describes unacceptable communication patterns between providers. Change is on the horizon suggests optimism for the future as NLRNs speak of transforming the systems where care is provided. This content analysis reveals that the working environment where NLRNs begin their career is in need of reform. Suggestions are offered from the nurses themselves.