Does State-Level Nurse Practitioner Scope-of-Practice Policy Affect Access to Care?

There is heated debate surrounding policy reform granting full state-level nurse practitioner (NP) scope of practice (SOP) in all U.S. states. NP SOP policy is argued to impact access to care; however, a synthesis of empirical studies assessing this relationship has yet to be performed. Our study fills this critical gap by systematically reviewing studies that examine this relationship. We apply Aday and Andersen's Access Framework to operationalize access to care. We also use this framework to map components of access to care that may relate to NP SOP through concepts identified in this review. Our findings suggest that full state-level NP SOP policy is associated with increases in various components of access to care, but additional work is needed to evaluate causality and underlying mechanisms behind this policy's effect on access. This work is necessary to align research, practice, and policy efforts surrounding NP SOP with healthcare accessibility.

Association of Nurse Workload With Missed Nursing Care in the Neonatal Intensive Care Unit.

Importance: Quality improvement initiatives demonstrate the contribution of reliable nursing care to gains in clinical and safety outcomes in neonatal intensive care units (NICUs); when core care is missed, outcomes can worsen. Objective: To evaluate the association of NICU nurse workload with missed nursing care. Design, Setting, and Participants: A prospective design was used to evaluate associations between shift-level workload of individual nurses and missed care for assigned infants from March 1, 2013, through January 31, 2014, at a 52-bed level IV NICU in a Midwestern academic medical center. A convenience sample of registered nurses who provided direct patient care and completed unit orientation were enrolled. Nurses reported care during each shift for individual infants whose clinical data were extracted from the electronic health record. Data were analyzed from January 1, 2015, through August 13, 2018. Exposures: Workload was assessed each shift with objective measures (infant-to-nurse staffing ratio and infant acuity scores) and a subjective measure (the National Aeronautics and Space Administration Task Load Index [NASA-TLX]). Main Outcomes and Measures: Missed nursing care was measured by self-report of omission of 11 essential care practices. Cross-classified, multilevel logistic regression models were used to estimate associations of workload with missed care. Results: A total of 136 nurses provided reports of shift-level workload and missed nursing care for 418 infants during 332 shifts of 12 hours each. When workload variables were modeled independently, 7 of 12 models demonstrated a significant worsening association of increased infant-to-nurse ratio with odds of missed care (eg, nurses caring for ≥3 infants were 2.51 times more likely to report missing any care during the shift [95% credible interval, 1.81-3.47]), and all 12 models demonstrated a significant worsening association of increased NASA-TLX subjective workload ratings with odds of missed care (eg, each 5-point increase in a nurse's NASA-TLX rating during a shift was associated with a 34% increase in the likelihood of missing a nursing assessment for his or her assigned infant[s] during the same shift [95% credible interval, 1.30-1.39]). When modeling all workload variables jointly, only 4 of 12 models demonstrated significant association of staffing ratios with odds of missed care, whereas the association with NASA-TLX ratings remained significant in all models. Few associations of acuity scores were observed across modeling strategies. Conclusions and Relevance: The workload of NICU nurses is significantly associated with missed nursing care, and subjective workload ratings are particularly important. Subjective workload represents an important aspect of nurse workload that remains largely unmeasured despite high potential for intervention.

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.

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.

Survey of North Carolina hospital policies regarding visitor use of personal protective equipment for entering the rooms of patients under isolation precautions.

OBJECTIVE: To explore the range of hospital policies for visitor use of personal protective equipment (PPE) when entering the room of patients under isolation precautions. DESIGN: Survey using an online questionnaire. SETTING: Acute care hospitals registered in the North Carolina Statewide Program for Infection Control and Epidemiology (SPICE). METHODS: A total of 136 North Carolina hospitals were invited to participate in an online survey. The survey questionnaire was developed, reviewed, and pilot tested, and then it was distributed through SPICE listserv registered e-mail addresses. The survey was conducted from February 6 to March 30, 2012. RESULTS: Among 93 respondent hospitals (response rate, 68.4%), 82 acute care hospitals (60.3%) were included in the analyses. Substantial variation was observed with regard to hospital policies for visitor PPE use when visiting patients under isolation precautions. A total of 71% of hospitals had a hospital visitor policy, and 96% of respondents agreed that hospitals should have a visitor policy. Only 14% of hospitals monitored visitor compliance with PPE. Reported compliance rates varied from "very low" to 97%. Many hospitals (28%) reported difficulties related to visitor compliance with isolation precautions, including hostility and refusal to comply. CONCLUSIONS: Our study results illuminated hospital policy variations for visitor isolation precautions. Reported problems with hospital visitor policies (eg, different policies across departments or facilities) suggest the need for standard guidelines and for enhanced public awareness about the importance of visitor compliance with isolation precautions.

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.

Using minimum nurse staffing regulations to measure the relationship between nursing and hospital quality of care.

This study tests whether changes in licensed nurse staffing led to changes in patient safety, using the natural experiment of 2004 California implementation of minimum staffing ratios. We calculated counts of six patient safety outcomes from California Patient Discharge Data from 2000 through 2006, using the Agency for Healthcare Research and Quality Patient Safety Indicators (PSI) software. For patients experiencing nonmortality-related PSIs, we measured mean lengths of stay. We estimated difference-in-difference equations of changes in PSIs using Poisson models and calculated the marginal impact of nurse staffing on outcomes from fixed-effect Poisson regressions. Licensed nurse staffing increased in the postregulation period, except for hospitals in the highest quartile of preregulation staffing. Growth in registered nurse staffing was associated with improvement for only one PSI and reduced length of stay for one PSI. Higher registered nurse staffing per patient day had a limited impact on adverse events in California hospitals.

Factors associated with the provision of hospice care for children.

CONTEXT: Children at the end of life often lack access to hospice care at home or in a dedicated facility. The factors that may influence whether or not hospices provide pediatric care are relatively unknown. OBJECTIVES: The purpose of this study was to understand the institutional and resource factors associated with provision of pediatric hospice care. METHODS: This study used a retrospective, longitudinal design. The main data source was the 2002 to 2008 California State Hospice Utilization Data Files. The sample size was 311 hospices or 1368 hospice observations over seven years. Drawing on institutional and resource dependence theory, this study used generalized estimating equations to examine the institutional and resource factors associated with provision of pediatric hospice care. Interaction terms were included to assess the moderating effect of resource factors on the relationship between institutional factors and provision of care. RESULTS: Membership in professional groups increased the probability (19%) of offering hospice services for children. Small- (-22%) and medium-sized (-11%) hospices were less likely to provide care for children. The probability of providing pediatric hospice care diminished (-23%) when competition increased in the prior year. Additionally, small size attenuated the accreditation-provision relationship and medium size magnified the membership-provision relationship. CONCLUSION: Professional membership may promote conformity to industry standards of pediatric care and remove the unknowns of providing hospice care for children. Hospices, especially medium-sized hospices, interested in developing or expanding care for children may benefit by identifying a pediatric champion to join a professional group.

California's minimum nurse staffing legislation: results from a natural experiment.

OBJECTIVE: To determine whether, following implementation of California's minimum nurse staffing legislation, changes in acuity-adjusted nurse staffing and quality of care in California hospitals outpaced similar changes in hospitals in comparison states without such regulations. DATA SOURCES/STUDY SETTING: Data from the American Hospital Association Annual Survey of Hospitals, the California Office of Statewide Health Planning and Development, the Hospital Cost Report Information System, and the Agency for Healthcare Research and Quality's Health Care Cost and Utilization Project's State Inpatient Databases from 2000 to 2006. STUDY DESIGN: We grouped hospitals into quartiles based on their preregulation staffing levels and used a difference-in-difference approach to compare changes in staffing and in quality of care in California hospitals to changes over the same time period in hospitals in 12 comparison states without minimum staffing legislation. DATA COLLECTION/EXTRACTION METHODS: We merged data from the above data sources to obtain measures of nurse staffing and quality of care. We used Agency for Healthcare Research and Quality's Patient Safety Indicators to measure quality. PRINCIPAL FINDINGS: With few exceptions, California hospitals increased nurse staffing levels over time significantly more than did comparison state hospitals. Failure to rescue decreased significantly more in some California hospitals, and infections due to medical care increased significantly more in some California hospitals than in comparison state hospitals. There were no statistically significant changes in either respiratory failure or postoperative sepsis. CONCLUSIONS: Following implementation of California's minimum nurse staffing legislation, nurse staffing in California increased significantly more than it did in comparison states' hospitals, but the extent of the increases depended upon preregulation staffing levels; there were mixed effects on quality.

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.

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.

Geographical imbalances: migration patterns of new graduate nurses and factors related to working in non-metropolitan hospitals.

PURPOSE: To examine geographical imbalances by analyzing new graduate nurses' migration patterns among regions where they grew up, attended nursing school, and had their first employment and to identify factors related to working in non-metropolitan areas. METHODS: The sample consisted of 507 new graduates working in hospitals as full-time registered nurses in South Korea. Migration patterns were categorized into 5 patterns based on sequential transitions of "geographic origin-nursing school-hospital." Multiple logistic regression analysis was conducted to identify factors associated with working in non-metropolitan hospitals. RESULTS: Nurses who grew up, graduated, and worked in the same region accounted for the greatest proportion (54%). Sixty-five percent had their first employment in the region where they graduated. Nurses tended to move from poor to rich regions and from non-metropolitan to metropolitan areas. Working in non-metropolitan hospitals was related to older age, the father having completed less than 4 years of college education, non-metropolitan origin, non-capital city school graduation, and a diploma (vs. baccalaureate) degree. CONCLUSION: Admitting students with rural backgrounds, increasing rural nursing school admission capacities, and providing service-requiring scholarships, particularly for students from low-income families, are recommended to address geographical imbalances.

Minimum nurse staffing legislation and the financial performance of California hospitals.

OBJECTIVE: To estimate the effect of minimum nurse staffing ratios on California acute care hospitals' financial performance. DATA SOURCES/STUDY SETTING: Secondary data from Medicare cost reports, the American Hospital Association's (AHA) Annual Survey, and the California Office of Statewide Health Planning and Development (OSHPD) are combined from 2000 to 2006 for 203 hospitals in California and 407 hospitals in 12 comparison states. STUDY DESIGN: The study employs a difference-in-difference analytical approach. Hospitals are grouped into quartiles based on pre-regulation nurse staffing levels in adult medical-surgical and pediatric units (quartile 1=lowest staffing). Differences in operating margin, operating expenses per day, and inpatient operating expenses per discharge for California hospitals within a staffing quartile during the period of regulation are compared to differences at hospitals in comparison states during the same period. DATA COLLECTION/EXTRACTION METHODS: Hospital data from Medicare cost reports are merged with nurse staffing measures obtained from AHA and from OSPHD. PRINCIPAL FINDINGS: Relative to hospitals in comparison states, operating margins declined significantly for California hospitals in quartiles 2 and 3. Operating expenses increased significantly in quartiles 1, 2, and 3. CONCLUSIONS: Implementation of minimum nurse staffing legislation in California put substantial financial pressure on some hospitals.

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.

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.