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Background: The nurse work environment is theorized to influence the quality of nursing care, nurse job outcomes, and patient outcomes., Objective: The aim of this meta-analysis was to evaluate quantitatively the association of the work environment with job and health outcomes., Research Design: Relevant studies published through September 2018 were identified. Inclusion criteria were use of a nationally endorsed work environment measure and reporting of odds ratios (ORs) and 95% confidence intervals from regression models of 4 outcome classes: nurse job outcomes, safety and quality ratings, patient outcomes, and patient satisfaction. Pooled ORs and confidence intervals were estimated for each outcome using fixed or random effects models., Subjects: Of 308 articles reviewed, 40 met inclusion criteria. After excluding 23 due to sample overlap or too few observations to meta-analyze, a set of 17 articles, comprising 21 independent samples, was analyzed. Cumulatively, these articles reported data from 2677 hospitals, 141 nursing units, 165,024 nurses, and 1,368,420 patients, in 22 countries., Measures: Practice Environment Scale of the Nursing Work Index, a National Quality Forum nursing care performance standard., Results: Consistent, significant associations between the work environment and all outcome classes were identified. Better work environments were associated with lower odds of negative nurse outcomes (average OR of 0.71), poor safety or quality ratings (average OR of 0.65), and negative patient outcomes (average OR of 0.93), but higher odds of patient satisfaction (OR of 1.16)., Conclusions: The nurse work environment warrants attention to promote health care quality, safety, and patient and clinician well-being.

In this study, we examined the influence of professional network characteristics, available professional support, and perceived support quality on intent to stay among for-profit nursing home (NH) directors of nursing (DON). We hypothesized that the receipt of high quality professional support would be associated with DON intent to stay. DONs have a critical mandate to provide leadership that influences their facilities' work climate and care quality. Yet, they often struggle to manage overwhelming responsibilities and are left feeling alienated, frustrated, and intent on leaving their jobs. Professional support, accessed via professional networks, may help DONs combat frustration and mitigate turnover that threatens NH care quality. Using a descriptive survey design, we electronically surveyed all DONs employed by a single for-profit NH corporation to collect data pertaining to their professional networks, receipt of professional support, perceptions regarding support quality, and intentions to stay in their positions. One-hundred-ninety-five DONs (65%) responded, with 133 (44%) completing every survey component. We employed social network analysis methods to construct datasets linking descriptors of DON respondents with attribute information about 1,164 network members. Statistical analyses (ANOVAs, point biserial correlations, and binomial logistic regression) yielded several findings supporting our hypothesis: (i) DONs' professional networks closely resembled the teams in which they worked daily; (ii) DONs relied on this core network of individuals to provide task support primarily; (iii) DON-nursing home administrator relationships were most important; and (iv) perceptions of support quality and support from nursing home administrators were the strongest predictors of DON intent to stay., (© 2019 Wiley Periodicals, Inc.)

Background: Parental presence in the neonatal intensive care unit (NICU) is essential for families to participate in infant care and prepare them to transition from hospital to home. Nurses are the principal caregivers in the NICU. The nurse work environment may influence whether parents spend time with their hospitalized infants., Purpose: To examine the relationship between the NICU work environment and parental presence in the NICU using a national data set., Methods: We conducted a cross-sectional, observational study of a national sample of 104 NICUs, where 6060 nurses reported on 15,233 infants cared for. Secondary analysis was used to examine associations between the Practice Environment Scale of the Nursing Work Index (PES-NWI) (subscale items and with a composite measure) and the proportion of parents who were present during the nurses' shift., Results: Parents of 60% (SD = 9.7%) of infants were present during the nurses' shift. The PES-NWI composite score and 2 domains-Nurse Participation in Hospital Affairs and Manager Leadership and Support-were significant predictors of parental presence. A 1 SD higher score in the composite or either subscale was associated with 2.5% more parents being present., Implications for Practice: Parental presence in the NICU is significantly associated with better nurse work environments. NICU practices may be enhanced through enhanced leadership and professional opportunities for nurse managers and staff., Implications for Research: Future work may benefit from qualitative work with parents to illuminate their experiences with nursing leaders and nurse-led interventions in the NICU and design and testing of interventions to improve the NICU work environment.

Objectives: To describe the variation across neonatal intensive care units (NICUs) in missed nursing care in disproportionately black and non-black-serving hospitals. To analyze the nursing factors associated with missing nursing care., Data Sources/study Setting: Survey of random samples of licensed nurses in four large U.S. states., Study Design: This was a retrospective, secondary analysis of 1,037 staff nurses in 134 NICUs classified into three groups based on their percent of infants of black race. Measures included the average patient load, individual nurses' patient loads, professional nursing characteristics, nurse work environment, and nursing care missed on the last shift., Data Collection: Survey data from a Multi-State Nursing Care and Patient Safety Study were analyzed (39 percent response rate)., Principal Findings: The patient-to-nurse ratio was significantly higher in high-black hospitals. Nurses in high-black NICUs missed nearly 50 percent more nursing care than in low-black NICUs. Lower nurse staffing (an additional patient per nurse) significantly increased the odds of missed care, while better practice environments decreased the odds., Conclusions: Nurses in high-black NICUs face inadequate staffing. They are more likely to miss required nursing care. Improving staffing and workloads may improve the quality of care for the infants born in high-black hospitals., (© Health Research and Educational Trust.)

Missed nursing care is a significant threat to quality patient care. Promoting collective efficacy within nurse work environments could decrease missed care. The purpose was to understand how missed care is associated with nurse work environments and collective efficacy of hospital staff nurses. A cross-sectional, convenience sample was obtained through online surveys from registered nurses working at five southwestern U.S. hospitals. Descriptive, correlational, regression, and path analyses were conducted ( N = 233). The percentage of nurses who reported that at least one care activity was missed frequently or always was 94%. Mouth care (36.0% of nurses) and ambulation (35.3%) were missed frequently or always. Nurse work environments and collective efficacy were moderately, positively correlated. Nurse work environments and collective efficacy were associated with less missed care (χ 2 = 10.714, p = .0054). Fostering collective efficacy in the nurse work environment could reduce missed care and improve patient outcomes.

Aim: To determine whether nurse coworker incivility is associated with the nurse work environment, defined as organisational characteristics that promote nurse autonomy., Background: Workplace incivility can negatively affect nurses, hospitals and patients. Plentiful evidence documents that nurses working in better nurse work environments have improved job and health outcomes. There is minimal knowledge about how nurse coworker incivility relates to the United States nurse work environment., Methods: Quantitative, cross-sectional. Data were collected through online surveys of registered nurses in a southwestern United States health system. The survey content included the National Quality Forum-endorsed Practice Environment Scale of the Nursing Work Index and the Workplace Incivility Scale. Data analyses were descriptive and correlational., Results: Mean levels of incivility were low in this sample of 233 staff nurses. Incivility occurred 'sporadically' (mean = 0.58; range 0.00-5.29). The nurse work environment was rated highly (mean = 3.10; range of 1.00-4.00). The nurse work environment was significantly inversely associated with coworker incivility. The nurse manager qualities were the principal factor of the nurse work environment associated with incivility., Conclusions: Supportive nurse managers reduce coworker incivility., Implications for Nursing Management: Nurse managers can shape nurse work environments to prevent nurse incivility., (© 2017 John Wiley & Sons Ltd.)

Infants in drug withdrawal have complex physiological and behavioral states, requiring intensive nursing care. The study objectives were to describe acuity, parental needs, and nurse workload of infants in drug withdrawal compared with other infants. The design was cross-sectional and involved secondary nurse survey data from 6045 staff nurses from a national sample of 104 neonatal intensive care units. Nurses reported the care of 15 233 infants, 361 (2.4%) of whom were in drug withdrawal. Three-fourths of hospitals had at least 1 infant in drug withdrawal. In these hospitals, the mean number of infants in drug withdrawal was 4.7. Infant acuity was significantly higher among infants in drug withdrawal. Parents of infants in drug withdrawal required significantly more care to address complex social situations (51% vs 12%). The number of infants assigned to nurses with at least 1 infant in withdrawal (mean = 2.69) was significantly higher than typical (mean = 2.51). Given infant acuity and parental needs, policies legislating patient-to-nurse ratios should permit professional discretion on the number of patients to assign nurses caring for infants in drug withdrawal. Managers and charge nurses should consider the demands of caring for infants in drug withdrawal in assignment decisions and provide support and education.

Background: There are two largely distinct research literatures on the association of the nurse work environment and the safety climate on patient outcomes., Objective: To determine whether hospital safety climate and work environment make comparable or distinct contributions to patient mortality., Design: Cross-sectional secondary analysis of linked datasets of Registered Nurse survey responses, adult acute care discharge records, and hospital characteristics., Setting: Acute care hospitals in California, Florida, New Jersey, and Pennsylvania., Participants: The sample included 600 hospitals linked to 27,009 nurse survey respondents and 852,974 surgical patients., Methods: Nurse survey data included assessments of the nurse work environment and hospital safety climate. The outcome of interest was in-hospital mortality. Data analyses included descriptive statistics and multivariate random intercept logistic regression., Results: In a fully adjusted model, a one standard deviation increase in work environment score was associated with an 8.1% decrease in the odds of mortality (OR 0.919, p<0.001). A one-standard deviation increase in safety climate score was similarly associated with a 7.7% decrease in the odds of mortality (OR 0.923, p<0.001). However, when work environment and safety climate were modeled together, the effect of the work environment remained significant, while safety climate became a non-significant predictor of mortality odds (OR 0.940, p=0.035 vs. OR 0.971, p=0.316)., Conclusions: We found that safety climate perception is not predictive of patient mortality beyond the effect of the nurse work environment. To advance hospital safety and quality and improve patient outcomes, organizational interventions should be directed toward improving nurse work environments., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objectives: A growing literature suggests that missed nursing care is common in hospitals and may contribute to poor patient outcomes. There has been scant empirical evidence in pediatric populations. Our objectives were to describe the frequency and patterns of missed nursing care in inpatient pediatric settings and to determine whether missed nursing care is associated with unfavorable work environments and high nurse workloads., Methods: A cross-sectional study using registered nurse survey data from 2006 to 2008 was conducted. Data from 2187 NICU, PICU, and general pediatric nurses in 223 hospitals in 4 US states were analyzed. For 12 nursing activities, nurses reported about necessary activities that were not done on their last shift because of time constraints. Nurses reported their patient assignment and rated their work environment., Results: More than half of pediatric nurses had missed care on their previous shift. On average, pediatric nurses missed 1.5 necessary care activities. Missed care was more common in poor versus better work environments (1.9 vs 1.2; P < .01). For 9 of 12 nursing activities, the prevalence of missed care was significantly higher in the poor environments ( P < .05). In regression models that controlled for nurse, nursing unit, and hospital characteristics, the odds that a nurse missed care were 40% lower in better environments and increased by 70% for each additional patient., Conclusions: Nurses in inpatient pediatric care settings that care for fewer patients each and practice in a professionally supportive work environment miss care less often, increasing quality of patient care., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Background: As nurses are the principal care provider in the hospital setting, the completion or omission of nursing care is likely to have a sizable impact on the patient care experience. However, this relationship has not been explored empirically., Aim: To describe the prevalence and patterns of missed nursing care and explore their relationship to the patient care experience., Methods: This cross-sectional study used secondary nurse and patient survey data from 409 adult non-federal acute care US hospitals in four states. Descriptive statistics were calculated and linear regression models were conducted at the hospital level. Regression models included controls for hospital structural characteristics., Results: In an average hospital, nurses missed 2.7 of 12 required care activities per shift. Three-fourths (73.4%) of nurses reported missing at least one activity on their last shift. This percentage ranged from 25 to 100 across hospitals. Nurses most commonly reported not being able to comfort or talk with patients (47.6%) and plan care (38.5%). 6 out of 10 patients rated hospitals highly. This proportion ranged from 33% to 90% across hospitals. At hospitals where nurses missed more care (1 SD higher=0.74 items), 2.2% fewer patients rated the hospital highly (p<0.001); a coefficient equivalent to a one-quarter SD change., Conclusions: Missed nursing care is common in US hospitals and varies widely. Most patients rate their hospital care experience highly, but this also varies widely across hospitals. Patients have poorer care experiences in hospitals where more nurses miss required nursing care. Supporting nurses' ability to complete required care may optimise the patient care experience. As hospitals face changing reimbursement landscapes, ensuring adequate nursing resources should be a top priority., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Context: Nurses are principal caregivers in the neonatal intensive care unit and support mothers to establish and sustain a supply of human milk for their infants. Whether an infant receives essential nutrition and immunological protection provided in human milk at discharge is an issue of health care quality in this setting., Objectives: To examine the association of the neonatal intensive care unit work environment, staffing levels, level of nurse education, lactation consultant availability, and nurse-reported breastfeeding support with very low birth weight infant receipt of human milk at discharge., Design and Setting: Cross sectional analysis combining nurse survey data with infant discharge data., Participants: A national sample of neonatal intensive care units (N=97), nurses (N=5614) and very low birth weight infants (N=6997)., Methods: Sequential multivariate linear regression models were estimated at the unit level between the dependent variable (rate of very low birth weight infants discharged on "any human milk") and the independent variables (nurse work environment, nurse staffing, nursing staff education and experience, lactation consultant availability, and nurse-reported breastfeeding support)., Results: The majority of very low birth weight infants (52%) were discharged on formula only. Fewer infants (42%) received human milk mixed with fortifier or formula. Only 6% of infants were discharged on exclusive human milk. A 1 SD increase (0.25) in the Practice Environment Scale of the Nursing Work Index composite score was associated with a four percentage point increase in the fraction of infants discharged on human milk (p<0.05). A 1 SD increase (0.15) in the fraction of nurses with a bachelor's degree in nursing was associated with a three percentage point increase in the fraction infants discharged on human milk (p<0.05). The acuity-adjusted staffing ratio was marginally associated with the rate of human milk at discharge (p=.056). A 1 SD increase (7%) in the fraction of infants who received breastfeeding support was associated with an eight percentage point increase in the fraction of infants discharged on human milk (p<0.001)., Conclusions: Neonatal intensive care units with better work environments, better educated nurses, and more infants who receive breastfeeding support by nurses have higher rates of very low birth weight infants discharged home on human milk. Investments by nurse administrators to improve work environments and support educational preparation of nursing staff may ensure that the most vulnerable infants have the best nutrition at the point of discharge., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

The objective of this study was to investigate the associations between the neonatal intensive care unit (NICU) work environment, quality of care, safety, and patient outcomes. A secondary analysis was conducted of responses of 1247 NICU staff nurses in 171 hospitals to a large nurse survey. Better work environments were associated with lower odds of nurses reporting poor quality, safety, and outcomes. Improving the work environment may be a promising strategy to achieve safer settings for at-risk newborns.

The neonatal intensive care unit (NICU) is a setting with high nurse-to-patient ratios. Little is known about the factors that determine nurse workload and assignment. The goals of this study were to (1) develop a measure of NICU infant acuity; (2) describe the acuity distribution of NICU infants; (3) describe the nurse/infant ratio at each acuity level, and examine the factors other than acuity, including nurse qualifications and the availability of physicians and other providers, that determined staffing ratios; and (4) explore whether nurse qualifications were related to the acuity of assigned infants. In a two-stage cohort study, data were collected in 104 NICUs in 2008 by nurse survey (6,038 nurses and 15,191 infants assigned to them) and administrators reported on unit-level staffing of non-nurse providers; in a subset of 70 NICUs in 2009-2010, census data were collected on four selected shifts (3,871 nurses and 9,276 infants assigned to them). Most NICU infants (62%) were low-acuity (Levels 1 and 2); 12% of infants were high-acuity (Levels 4 and 5). The nurse-to-infant ratio ranged from 0.33 for the lowest-acuity infants to 0.95 for the highest-acuity infants. The staffing ratio was significantly related to the acuity of assigned infants but not to nurse education, experience, certification, or availability of other providers. There was a significant but small difference in the percentage of high-acuity (Levels 4 and 5) infants assigned to nurses with specialty certification (15% vs. 12% for nurses without certification). These staffing patterns may not optimize patient outcomes in this highly intensive pediatric care setting., (© 2015 Wiley Periodicals, Inc.)

Objective: To determine if hospital-level disparities in very low birth weight (VLBW) infant outcomes are explained by poorer hospital nursing characteristics., Data Sources: Nurse survey and VLBW infant registry data., Study Design: Retrospective study of 8,252 VLBW infants in 98 Vermont Oxford Network hospital neonatal intensive care units (NICUs) nationally. NICUs were classified into three groups based on their percent of infants of black race. Two nurse-sensitive perinatal quality standards were studied: nosocomial infection and breast milk., Data Collection: Primary nurse survey (N = 5,773, 77 percent response rate)., Principal Findings: VLBW infants born in high-black concentration hospitals had higher rates of infection and discharge without breast milk than VLBW infants born in low-black concentration hospitals. Nurse understaffing was higher and practice environments were worse in high-black as compared to low-black hospitals. NICU nursing features accounted for one-third to one-half of the hospital-level health disparities., Conclusions: Poorer nursing characteristics contribute to disparities in VLBW infant outcomes in two nurse-sensitive perinatal quality standards. Improvements in nursing have potential to improve the quality of care for seven out of ten black VLBW infants who are born in high-black hospitals in this country., (© Health Research and Educational Trust.)

Background: An important goal of home health care is to assist patients to remain in community living arrangements. Yet home care often fails to prevent hospitalizations and to facilitate discharges to community living, thus putting patients at risk of additional health challenges and increasing care costs., Objectives: To determine the relationship between home health agency work environments and agency-level rates of acute hospitalization and discharges to community living., Methods and Design: Analysis of linked Center for Medicare and Medicaid Services Home Health Compare data and nurse survey data from 118 home health agencies. Robust regression models were used to estimate the effect of work environment ratings on between-agency variation in rates of acute hospitalization and community discharge., Results: Home health agencies with good work environments had lower rates of acute hospitalizations and higher rates of patient discharges to community living arrangements compared with home health agencies with poor work environments., Conclusion: Improved work environments in home health agencies hold promise for optimizing patient outcomes and reducing use of expensive hospital and institutional care.

Purpose: The provision of breastfeeding support in the neonatal intensive care unit (NICU) may assist a mother to develop a milk supply for the NICU infant. Human milk offers unique benefits and its provision unique challenges in this highly vulnerable population. The provision of breastfeeding support in this setting has not been studied in a large, multihospital study. We describe the frequency of breastfeeding support provided by nurses and examined relationships between NICU nursing characteristics, the availability of a lactation consultant (LC), and breastfeeding support., Subjects and Design: This was a secondary analysis of 2008 survey data from 6060 registered nurses in 104 NICUs nationally. Nurse managers provided data on LCs. These NICUs were members of the Vermont Oxford Network, a voluntary quality and safety collaborative., Methods: Nurses reported on the infants (n = 15,233) they cared for on their last shift, including whether breastfeeding support was provided to parents. Breastfeeding support was measured as a percentage of infants on the unit. The denominator was all infants assigned to all nurse respondents on that NICU. The numerator was the number of infants that nurses reported providing breastfeeding support. Nurses also completed the Practice Environment Scale of the Nursing Work Index (PES-NWI), a nationally endorsed nursing care performance measure. The NICU nursing characteristics include the percentages of nurses with a BSN or higher degree and with 5 or more years of NICU experience, an acuity-adjusted staffing ratio, and PES-NWI subscale scores. Lactation consultant availability was measured as any/none and in full-time equivalent positions per 10 beds., Results: The parents of 14% of infants received breastfeeding support from the nurse. Half of the NICUs had an LC. Multiple regression analysis showed a significant relationship between 2 measures of nurse staffing and breastfeeding support. A 1 SD higher acuity-adjusted staffing ratio was associated with a 2% increase in infants provided breastfeeding support. A 1 SD higher score on the Staffing and Resource Adequacy PES-NWI subscale was associated with a 2% increase in infants provided breastfeeding support. There was no association between other NICU nursing characteristics or LCs and nurse-provided breastfeeding support., Conclusions: Nurses provide breastfeeding support around the clock. On a typical shift, about 1 in 7 NICU infants receives breastfeeding support from a nurse. Lactation consultants are not routinely available in NICUs, and their presence does not influence whether nurses provide breastfeeding support. Better nurse staffing fosters nurse provision of breastfeeding support.

Background: Critically ill patients are susceptible to health care-associated infections because of their illnesses and the need for intravenous access and invasive monitoring. The critical care work environment may influence the likelihood of infection in these patients., Objective: To determine whether or not the critical care nurse work environment is predictive of nurse-reported health care-associated infections., Methods: A retrospective, cross-sectional design was used with linked nurse and hospital survey data. Nurses assessed the critical care work environment and provided the frequencies of ventilator-associated pneumonias, urinary tract infections, and infections associated with central catheters. Logistic regression models were used to determine if critical care work environments were predictive of nurse-reported frequent health care-associated infections, with controls for nurse and hospital characteristics. Results The final sample consisted of 3217 critical care nurses in 320 hospitals. Compared with nurses working in poor work environments, nurses working in better work environments were 36% to 41% less likely to report that health care-associated infections occurred frequently., Conclusion: Health care-associated infections are less likely in favorable critical care work environments. These findings, based on the largest sample of critical care nurses to date, substantiate efforts to focus on the quality of the work environment as a way to minimize the frequency of health care-associated infections.

Importance: There are substantial shortfalls in nurse staffing in US neonatal intensive care units (NICUs) relative to national guidelines. These are associated with higher rates of nosocomial infections among infants with very low birth weights., Objective: To study the adequacy of NICU nurse staffing in the United States using national guidelines and analyze its association with infant outcomes., Design: Retrospective cohort study. Data for 2008 were collected by web survey of staff nurses. Data for 2009 were collected for 4 shifts in 4 calendar quarters (3 in 2009 and 1 in 2010)., Setting: Sixty-seven US NICUs from the Vermont Oxford Network, a national voluntary network of hospital NICUs., Participants: All inborn very low-birth-weight (VLBW) infants, with a NICU stay of at least 3 days, discharged from the NICUs in 2008 (n = 5771) and 2009 (n = 5630). All staff-registered nurses with infant assignments., Exposures: We measured nurse understaffing relative to acuity-based guidelines using 2008 survey data (4046 nurses and 10 394 infant assignments) and data for 4 complete shifts (3645 nurses and 8804 infant assignments) in 2009-2010., Main Outcomes and Measures: An infection in blood or cerebrospinal fluid culture occurring more than 3 days after birth among VLBW inborn infants. The hypothesis was formulated prior to data collection., Results: Hospitals understaffed 31% of their NICU infants and 68% of high-acuity infants relative to guidelines. To meet minimum staffing guidelines on average would require an additional 0.11 of a nurse per infant overall and 0.34 of a nurse per high-acuity infant. Very low-birth-weight infant infection rates were 16.4% in 2008 and 13.9% in 2009. A 1 standard deviation-higher understaffing level (SD, 0.11 in 2008 and 0.08 in 2009) was associated with adjusted odds ratios of 1.39 (95% CI, 1.19-1.62; P < .001) in 2008 and 1.40 (95% CI, 1.19-1.65; P < .001) in 2009., Conclusions and Relevance: Substantial NICU nurse understaffing relative to national guidelines is widespread. Understaffing is associated with an increased risk for VLBW nosocomial infection. Hospital administrators and NICU managers should assess their staffing decisions to devote needed nursing care to critically ill infants.

Objective: The aims of this study were to describe the shift lengths of pediatric nurses and to measure the association of shift length with nurse job outcomes, nurse-reported patient outcomes, and nurse-assessed safety and quality of care in hospitals., Background: Long work hours have been linked with poor patient outcomes in adult patient populations, but little is known about the relationship in pediatric settings., Methods: A secondary analysis of cross-sectional nurse survey data was conducted. Our analysis focused on 3710 registered nurses who worked in 342 acute care hospitals that treated children., Results: Most pediatric nurses worked 12-hour shifts, especially in intensive care settings. Nurses who worked extended shifts of more than 13 hours reported worse job outcomes and lower quality and safety for patients compared with nurses who worked 8-hour shifts., Conclusions: Allocating resources to nursing to improve working hours may be a productive strategy for administrators to improve the health and well-being of pediatric patients and nurses.

Despite a decade's worth of effort, patient safety has improved slowly, in part because of the limited evidence base for the development and widespread dissemination of successful patient safety practices. The Agency for Healthcare Research and Quality sponsored an international group of experts in patient safety and evaluation methods to develop criteria to improve the design, evaluation, and reporting of practice research in patient safety. This article reports the findings and recommendations of this group, which include greater use of theory and logic models, more detailed descriptions of interventions and their implementation, enhanced explanation of desired and unintended outcomes, and better description and measurement of context and of how context influences interventions. Using these criteria and measuring and reporting contexts will improve the science of patient safety.

The relationships between hospital Magnet® status, nursing unit staffing, and patient falls were examined in a cross-sectional study using 2004 National Database of Nursing Quality Indicators (NDNQI®) data from 5,388 units in 108 Magnet and 528 non-Magnet hospitals. In multivariate models, the fall rate was 5% lower in Magnet than non-Magnet hospitals. An additional registered nurse (RN) hour per patient day was associated with a 3% lower fall rate in ICUs. An additional licensed practical nurse (LPN) or nursing assistant (NA) hour was associated with a 2-4% higher fall rate in non-ICUs. Patient safety may be improved by creating environments consistent with Magnet hospital standards., (© 2010 Wiley Periodicals, Inc. Res Nurs Health 33:413-425, 2010.)

Clinical nursing expertise is central to quality patient care. Research on factors that contribute to expertise has focused largely on individual nurse characteristics to the exclusion of contextual factors. To address this, we examined effects of hospital contextual factors and individual nurse education and experience on clinical nursing expertise in a cross-sectional analysis of data from 8,611 registered nurses. In a generalized ordered logistic regression analysis, the composition of the hospital staff, particularly the proportion of nurses with at least a bachelor of science in nursing degree, was associated with significantly greater odds of a nurse reporting a more advanced expertise level. Our findings suggest that, controlling for individual characteristics, the hospital context significantly influences clinical nursing expertise., (2010 Wiley Periodicals, Inc.)

Aim: To examine the association between nurses' reports of unmet nursing care needs and their reports of patients' receipt of the wrong medication or dose, nosocomial infections and patient falls with injury in hospitals., Background: Because nursing activities are often difficult to measure, and data are typically not collected by health care organisations, there are few studies that have addressed the association between nursing activities and patient outcomes., Design: Secondary analysis of cross-sectional data collected in 1999 from 10,184 staff nurses and 168 acute care hospitals in the US., Methods: Multivariate linear regression models estimated the effect of unmet nursing care needs on adverse events given the influence of patient factors and the care environment., Results: The proportion of necessary nursing care left undone ranged from 26% for preparing patients and families for discharge to as high as 74% for developing or updating nursing care plans. A majority of nurses reported that patients received the wrong medication or dose, acquired nosocomial infections, or had a fall with injury infrequently. However, nurses who reported that these adverse events occurred frequently varied considerably [i.e. medication errors (15%), patient falls with injury (20%), nosocomial infection (31%)]. After adjusting for patient factors and the care environment, there remained a significant association between unmet nursing care needs and each adverse event., Conclusion: The findings suggest that attention to optimising patient care delivery could result in a reduction in the occurrence of adverse events in hospitals., Relevance to Clinical Practice: The occurrence of adverse events may be mitigated when nurses complete care activities that require them to spend time with their patients. Hospitals should engage staff nurses in the creation of policies that influence human resources management to enhance their awareness of the care environment and patient care delivery.

Objective: The objective of this study was to analyze the net effects of nurse practice environments on nurse and patient outcomes after accounting for nurse staffing and education., Background: Staffing and education have well-documented associations with patient outcomes, but evidence on the effect of care environments on outcomes has been more limited., Methods: Data from 10,184 nurses and 232,342 surgical patients in 168 Pennsylvania hospitals were analyzed. Care environments were measured using the practice environment scales of the Nursing Work Index. Outcomes included nurse job satisfaction, burnout, intent to leave, and reports of quality of care, as well as mortality and failure to rescue in patients., Results: Nurses reported more positive job experiences and fewer concerns with care quality, and patients had significantly lower risks of death and failure to rescue in hospitals with better care environments., Conclusion: Care environment elements must be optimized alongside nurse staffing and education to achieve high quality of care.

Objective: To examine the effect of nursing practice environments on outcomes of hospitalized cancer patients undergoing surgery., Data Sources: Secondary analysis of cancer registry, inpatient claims, administrative and nurse survey data collected in Pennsylvania for 1998-1999., Study Design: Nurse staffing (patient to nurse ratio), educational preparation (proportion of nurses holding at least a bachelor's degree), and the practice environment (Practice Environment Scale of the Nursing Work Index) were calculated from a survey of nurses and aggregated to the hospital level. Logistic regression models predicted the odds of 30-day mortality, complications, and failure to rescue (death following a complication)., Principal Findings: Unadjusted death, complication, and failure to rescue rates were 3.4, 35.7, and 9.3 percent, respectively. Nurse staffing and educational preparation of registered nurses were significantly associated with patient outcomes. After adjusting for patient and hospital characteristics, patients in hospitals with poor nurse practice environments had significantly increased odds of death (odds ratio, 1.37; 95 percent confidence interval, 1.07-1.76) and of failure to rescue (odds ratio, 1.48; 95 percent confidence interval, 1.07-2.03). Receipt of care in National Cancer Institute-designated cancer centers significantly decreased the odds of death, which can be explained partly by better nurse practice environments., Conclusions: This study is one of the first to examine the predictive validity of the National Quality Forum's endorsed measure of the nurse practice environment. Improvements in the quality of nurse practice environments could reduce adverse outcomes for hospitalized surgical oncology patients.

Improvements in nurses' practice environments are essential to retain nurses and keep patients safe. The pace of improvements can accelerate if evidence is translated clearly for researchers, managers, and policymakers. This article evaluates the utility of published multidimensional instruments to measure the nursing practice environment. The assessment criteria are theoretical relevance, ease of use, and dissemination. This article also synthesizes the research that has used these instruments. Seven instruments and 54 studies are evaluated. The Practice Environment Scale of the Nursing Work Index (PES-NWI) is proposed as the most useful instrument. Its content, length, and dissemination best satisfy the set of criteria. Researchers should use the PES-NWI to generate consistent and comparable evidence; expand the content to reflect all conceptual domains; develop a short form; test the instrument in different care settings; expand the evidence of the practice environment's influence on patient outcomes; and test interventions for practice environment improvements.

Research has demonstrated an association between more nurses and more qualified nursing staff in hospitals and better patient outcomes. Patient falls and pressure ulcers have been advanced as nursing-sensitive outcomes. This article evaluates the state of the science linking nurse staffing to falls and pressure ulcers. Studies that employed multivariate analysis to discern the effect of nurse staffing on patient falls and pressure ulcers in hospitals were evaluated. Eleven studies that met inclusion criteria were contrasted on their data sources and measures, data analysis, risk adjustment, and results. The evidence of an effect of nursing hours or skill mix on patient falls and pressure ulcers is equivocal. Substantial differences in research methods across studies may account for the mixed findings. Two study types were identified based on the level at which nurse staffing was measured, hospital or nursing unit, which exhibited systematic differences in measures and methods. Improvements in measurement and methods are suggested.

Background: Multilevel models were designed to analyze data generated from a nested structure (e.g., nurses within hospitals) because conventional linear regression models underestimate standard errors and, in turn, overestimate test statistics., Objectives: To introduce 2 types of multilevel models, the random intercept model and the random coefficient model, to describe the correlation among observations within a cluster, and to demonstrate how to identify the superior model., Method: The conceptual and mathematical bases for the 2 multilevel model types are presented. Intraclass correlation is defined and assessment of model fit is detailed. An empirical example is presented in which average work hours per week and burnout are analyzed using data from 4,320 staff nurses clustered in 19 hospitals., Results: Average work hours were positively associated with nurse burnout. The multilevel models corrected the problem of underestimated standard errors in conventional linear regression models. Graphs displaying the hospital-level differences illustrated the 2 multilevel model types. Although the multilevel models corrected the underestimation of standard errors, the results did not differ substantively for the conventional or the 2 multilevel models. The intraclass correlation coefficient was .044, indicating that the extent of shared variance among nurses in a hospital was low. The random intercept model fit the data better than did the random coefficient model., Conclusions: Multilevel models provide a more accurate and comprehensive description of relationships in clustered data than do conventional models, by correcting underestimated standard errors, by estimating components of variance at several levels, and by estimating cluster-specific intercepts and slopes.

Objectives: The rapidly changing organizational context within which health care is delivered is altering provider-patient relations and processes of clinical decision-making, with significant implications for patient outcomes. Yet definitive research on such effects is lacking. The authors seek to underscore the contribution of organizational research to studies of clinical outcomes and demonstrates several approaches to further such efforts., Methods: The authors present a theoretical framework of the operant mechanisms linking organizational attributes and patient outcomes. They use case examples from their ongoing research on hospitals to illustrate strategies for measuring these mechanisms and for overcoming some of the feasibility issues inherent in organizational research., Results: Several methodological issues are explored: (1) exploiting "targets of opportunity" and "natural experiments" is a promising strategy for studying patient outcomes related to organizational reform; (2) indices of organizational traits, constructed from individual survey responses, can illuminate the operant mechanisms by which structure affects outcomes; and (3) secondary data sources and innovative statistical matching procedures provide a feasible strategy for constructing study comparison groups. Extending the organizational outcomes research strategy to new areas of inquiry offers an opportunity to enhance our understanding of how nursing organization affects outcomes., Conclusions: Improving the effectiveness of medical care in a health-care system undergoing fundamental restructuring requires greater understanding of how organizational context affects clinical outcomes. A higher priority should be placed on organizational outcomes research by researchers and funding agencies.

Objectives: This study sought to determine whether there were differences in acquired immunodeficiency syndrome (AIDS) patients' satisfaction with inpatient nursing care on dedicated AIDS units compared with conventional, multidiagnosis medical units., Methods: Interview data were collected from more than 600 consecutive AIDS admissions in 40 patient care units in 20 hospitals in 11 high AIDS incidence cities. Ten hospitals with dedicated AIDS units were matched with comparable hospitals treating AIDS patients on multidiagnosis medical units. AIDS patients' satisfaction with nursing care on dedicated AIDS units was compared with AIDS patients' satisfaction with care on scattered-bed units in the same hospital and with AIDS patients' satisfaction on scattered-bed units in different, matched hospitals without dedicated units. Interhospital differences that were not controlled by design were controlled statistically, as were differences in patient characteristics and illness severity., Results: Acquired immunodeficiency syndrome patients receiving care on dedicated AIDS units were significantly more satisfied with their nursing care. In hospitals with units of both types, dedicated AIDS units had a higher proportion of white patients, men, and homosexuals, whereas scattered-bed units had more minority patients and intravenous drug users. Controlling for these factors as well as for differences in illness severity and interhospital differences in patient satisfaction did not diminish the positive AIDS unit effect on patient satisfaction., Conclusions: Dedicated AIDS units achieve higher levels of satisfaction among patients with AIDS than general medical units. There is no evidence that patients feel isolated or stigmatized on dedicated AIDS units compared with patients on general units, and many patients have a clear preference for dedicated units.

Chile is a country with a relatively low prevalence of HIV infection, where successful prevention has the potential to change the future course of the epidemic. A controversial national prevention strategy based upon public education has emerged in response to characterizations of the epidemic as well-dispersed with a growing involvement of heterosexuals. This characterization is not consistent with the observed facts. There is a comparatively well-organized health care system in Santiago that is doing a good job of detecting HIV infection and already has in place the elements of a targeted intervention scheme. Chile should place priority on the use of the existing health care infrastructure for implementing both the traditional public health interventions for sexually transmitted diseases (contact tracing and partner notification) and the AIDS-necessitated strategy of focused counseling and education.

The objective of this study is to investigate whether hospitals known to be good places to practice nursing have lower Medicare mortality than hospitals that are otherwise similar with respect to a variety of non-nursing organizational characteristics. Research to date on determinants of hospital mortality has not focused on the organization of nursing. We capitalize on the existence of a set of studies of 39 hospitals that, for reasons other than patient outcomes, have been singled out as hospitals known for good nursing care. We match these "magnet" hospitals with 195 control hospitals, selected from all nonmagnet U.S. hospitals with over 100 Medicare discharges, using a multivariate matched sampling procedure that controls for hospital characteristics. Medicare mortality rates of magnet versus control hospitals are compared using variance components models, which pool information on the five matches per magnet hospital, and adjust for differences in patient composition as measured by predicted mortality. The magnet hospitals' observed mortality rates are 7.7% lower (9 fewer deaths per 1,000 Medicare discharges) than the matched control hospitals (P = .011). After adjusting for differences in predicted mortality, the magnet hospitals have a 4.6% lower mortality rate (P = .026 [95% confidence interval 0.9 to 9.4 fewer deaths per 1,000]). The same factors that lead hospitals to be identified as effective from the standpoint of the organization of nursing care are associated with lower mortality among Medicare patients.

This exploratory study examined whether outcomes of care for HIV-infected patients are related to whether the patient's primary provider is a physician (MD) or a nurse practitioner (NP). Functional status, symptom occurrence, self management, health service use and patients' assessment of their care were evaluated for 87 HIV-infected patients in a teaching hospital outpatient setting. NP patients were three times as likely to report their health status as only fair or poor (odds-ratio = 3.06, p = .028), and reported significantly more unpleasant symptoms over a four-week period. Despite being in poorer health than patients cared for by physicians, NP patients functioned at comparable levels and used no more health care services than MD patients. NP patients reported 45 percent fewer problems with their care (p = 0.003). Findings suggest that more extensive use of nurse practitioners could safely enhance access to care for persons with HIV-related illnesses.