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Operational failures, defined as the inability of the work system to reliably provide information, services, and supplies needed when, where, and to who, are a pervasive problem in U.S. hospitals that disrupt nurses' ability to provide safe and effective care.We examined the relationship between operational failures, patient satisfaction, nurse-reported quality and safety, and nurse job outcomes (e.g., burnout and job satisfaction) and whether differences in hospital work environments explained the relationship.We conducted a cross-sectional analysis using population-based survey data from 11,709 registered nurses in 415 hospitals who participated in the RN4CAST-US nurse survey (2015-2016) and the 2016 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The RN4CAST-US nurse survey focused on hospital quality and safety, job outcomes, and hospital work environments. The HCAHPS survey collected publicly reported patient data on their satisfaction with their care. Operational failures were evaluated using an eight-item composite measure that assessed missing supplies, orders, medication, missing/wrong patient diet, electronic documentation problems, insufficient staff, and time spent on workarounds and nonnursing tasks. Multilevel regression models were used to test the hypothesized relationships.Operational failures were associated with low patient satisfaction scores, poor quality and safety outcomes, and poor nurse job outcomes, and those associations were partly accounted for by hospital work environments.Operational failures prevent high-quality care and positive patient and nurse outcomes. Operational failures and the hospital work environment should be targeted simultaneously to maximize quality improvement efforts. Hospital leadership should work with frontline staff to identify and target the sources of operational failures in nursing units. Improvements to hospital work environments may reduce the occurrence of operational failures.

ImportanceA surgical consultation is a critical first step in the care of patients with emergency general surgery conditions. It is unknown if Black Medicare patients and White Medicare patients receive surgical consultations at similar rates when they are admitted from the emergency department.ObjectiveTo determine whether Black Medicare patients have similar rates of surgical consultations when compared with White Medicare patients after being admitted from the emergency department with an emergency general surgery condition.Design, Setting, and ParticipantsThis was a retrospective cohort study that took place at US hospitals with an emergency department and used a computational generalization of inverse propensity score weight to create patient populations with similar covariate distributions. Participants were Medicare patients age 65.5 years or older admitted from the emergency department for an emergency general surgery condition between July 1, 2015, and June 30, 2018. The analysis was performed during February 2022. Patients were classified into 1 of 5 emergency general surgery condition categories based on principal diagnosis codes: colorectal, general abdominal, hepatopancreatobiliary, intestinal obstruction, and upper gastrointestinal.ExposuresBlack vs White race.Main Outcomes and MeasuresReceipt of a surgical consultation after admission from the emergency department with an emergency general surgery condition.ResultsA total of 1 686 940 patients were included in the study. Of those included, 214 788 patients were Black (12.7%) and 1 472 152 patients were White (87.3%). After standardizing for medical and diagnostic imaging covariates, Black patients had 14% lower odds of receiving a surgical consultation (odds ratio [OR], 0.86; 95% CI, 0.85-0.87) with a risk difference of −3.17 (95% CI, −3.41 to −2.92). After standardizing for socioeconomic covariates, Black patients remained at an 11% lower odds of receiving a surgical consultation compared with similar White patients (OR, 0.89; 95% CI, 0.88-0.90) with a risk difference of −2.49 (95% CI, −2.75 to −2.23). Additionally, when restricting the analysis to Black patients and White patients who were treated in the same hospitals, Black patients had 8% lower odds of receiving a surgical consultation when compared with White patients (OR, 0.92; 95% CI, 0.90-0.93) with a risk difference of −1.82 (95% CI, −2.18 to −1.46).Conclusions and RelevanceIn this study, Black Medicare patients had lower odds of receiving a surgical consultation after being admitted from the emergency department with an emergency general surgery condition when compared with similar White Medicare patients. These disparities in consultation rates cannot be fully attributed to medical comorbidities, insurance status, socioeconomic factors, or individual hospital-level effects.

With the growth of vertical integration among physician practices (i.e., hospital–physician integration), there have been many studies of its effects on health care treatments and spending. It is unknown if integration shapes provider configurations, especially against the backdrop of increasing employment of nurse practitioners (NPs) and physician assistants (PAs) across specialties. Using a longitudinal panel of 144,289 practices (2008-2015), we examined the association of vertical integration with NP and PA employment. We find positive associations between vertical integration and newly employing NPs and PAs within physician practices; however, the relationships differ by practice specialty type as well as timing of vertical integration. Supplementary analyses offer supporting evidence for coinciding enhancements to practice productivity, diversification, and provider task allocation. Our results suggest that vertical integration may promote interdisciplinary provider configurations, which has the potential to improve care delivery efficiency.

BACKGROUND: Racial minorities are disproportionately affected by stroke, with Black patients experiencing worse post-stroke outcomes than White patients. A modifiable aspect of acute stroke care delivery not yet examined is whether disparities in stroke outcomes are related to hospital nurse staffing levels. OBJECTIVES: To determine whether 7- and 30-day readmission disparities between Black and White patients were associated with nurse staffing levels. METHODS: We conducted a secondary analysis of 542 hospitals in four states. Risk-adjusted, logistic regression models were used to determine the association of nurse staffing with 7-day and 30-day all-cause readmissions for Black and White ischemic stroke patients. RESULTS: Our sample included 98,150 ischemic stroke patients (87% White, 13% Black). Thirty-day readmission rates were 10.4% (12.7% for Black, 10.0% for White patients). In models accounting for hospital and patient characteristics, the odds of 30-day readmissions were higher for Black than White patients. A significant interaction was found between race and nurse staffing, with Black patients experiencing higher odds of 30-day and 7-day readmissions for each additional patient cared for by a nurse. In the best-staffed hospitals (< 3 patients per nurse), Black and White stroke patients’ disparities were no longer significant. DISCUSSION: Disparities in readmissions between Black and White stroke patients may be linked to the level of nurse staffing in the hospitals where they receive care. Tailoring nurse staffing levels to meet the needs of Black ischemic stroke patients represents a promising intervention to address systemic inequities linked to readmission disparities among minority stroke patients.

Background Across hospitals, there is wide variation in ICU utilization after surgery. However, it is unknown whether and to what extent the nurse work environment is associated with a patient’s odds of admission to an intensive care unit. Purpose To estimate the relationship between hospitals’ nurse work environment and a patient’s likelihood of ICU admission and mortality following surgery. Methods A cross-sectional study of 269 764 adult surgical patients in 453 hospitals was conducted. Logistic regression models were used to estimate the effects of the work environment on the odds of patients’ admission to the intensive care unit and mortality. Results Patients in hospitals with good work environments had 16% lower odds of intensive care unit admission and 15% lower odds of mortality or intensive care unit admission than patients in hospitals with mixed or poor environments. Conclusions Patients in hospitals with better nurse work environments were less likely to be admitted to an intensive care unit and less likely to die. Hospitals with better nurse work environments may be better equipped to provide postoperative patient care on lower acuity units.

Multivariate matching has two goals (i) to construct treated and control groups that have similar distributions of observed covariates, and (ii) to produce matched pairs or sets that are homogeneou...

BACKGROUND Evidence indicates hospitals with better registered nurse (RN) staffing have better patient outcomes. Whether involving more nurse practitioners (NPs) in inpatient care produces better outcomes is largely unknown. OBJECTIVE The objective of this study was to determine whether the presence of more NPs produces better inpatient outcomes net of RN staffing. RESEARCH DESIGN This was a 2015-2016 cross-sectional data on 579 hospitals linked from: (1) RN4CAST-US nurse surveys; (2) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient surveys; (3) surgical patient discharge abstracts; (4) Medicare Spending per Beneficiary (MSPB) reports; (5) American Hospital Association (AHA) Annual Survey. Hospitals were grouped according to their NP/beds ratios [

Unrest in Chile over inequalities has underscored the need to improve public hospitals. Nursing has been overlooked as a solution to quality and access concerns, and nurse staffing is poor by international standards. Using Chile's new diagnosis-related groups system and surveys of nurses and patients, we provide information to policy makers on feasibility, net costs, and estimated improved outcomes associated with increasing nursing resources in public hospitals.For this multilevel cross-sectional study, we used data from surveys of hospital nurses to measure staffing and work environments in public and private Chilean adult high-complexity hospitals, which were linked with patient satisfaction survey and discharge data from the national diagnosis-related groups database for inpatients. All adult patients on medical and surgical units whose conditions permitted and who had been hospitalised for more than 48 h were invited to participate in the patient experience survey until 50 responses were obtained in each hospital. We estimated associations between nurse staffing and work environment quality with inpatient 30-day mortality, 30-day readmission, length of stay (LOS), patient experience, and care quality using multilevel random-effects logistic regression models and zero-truncated negative binomial regression models, with clustering of patients within hospitals.We collected and analysed surveys of 1652 hospital nurses from 40 hospitals (34 public and six private), satisfaction surveys of 2013 patients, and discharge data for 761 948 inpatients. Nurse staffing was significantly related to all outcomes, including mortality, after adjusting for patient characteristics, and the work environment was related to patient experience and nurses' quality assessments. Each patient added to nurses' workloads increased mortality (odds ratio 1·04, 95% CI 1·01-1·07, p0·01), readmissions (1·02, 1·01-1·03, p0·01), and LOS (incident rate ratio 1·04, 95% CI 1·01-1·06, p0·05). Nurse workloads across hospitals varied from six to 24 patients per nurse. Patients in hospitals with 18 patients per nurse, compared with those in hospitals with eight patients per nurse, had 41% higher odds of dying, 20% higher odds of being readmitted, 41% higher odds of staying longer, and 68% lower odds of rating their hospital highly. We estimated that savings from reduced readmissions and shorter stays would exceed the costs of adding nurses by US$1·2 million and $5·4 million if the additional nurses resulted in average workloads of 12 or ten patients per nurse, respectively.Improved hospital nurse staffing in Chile was associated with lower inpatient mortality, higher patient satisfaction, fewer readmissions, and shorter hospital stays, suggesting that greater investments in nurses could return higher quality of care and greater value.Sigma Theta Tau International, University of Pennsylvania Global Engagement Fund, University of Pennsylvania School of Nursing's Center for Health Outcomes, and Policy Research and Population Research Center.For the Spanish translation of the abstract see Supplementary Materials section.

Qualifying comorbidity sets (QCS) are tools used to identify multimorbid patients at increased surgical risk. It is unknown how the QCS framework for multimorbidity affects surgical risk in different racial groups.This retrospective cohort study included Medicare patients age ≥65.5 who underwent an emergency general surgery operation from 2015 to 2018. Our exposure was race and multimorbidity, included in our model as an interaction term. The primary outcome of the study was 30-day mortality. Secondary outcomes included routine discharge, 30-day readmission, length of stay, and complications.In total, 163,148 patients who underwent and operation were included in this study. Of these, 13,852 (8.5%, p 0.001) were Black, and 149,296 (91.5%, p 0.001) were White. Black multimorbid patients had no significant differences in 30-day mortality, routine discharge or 30-day readmission when compared to White multimorbid patients after risk-adjustment. Black multimorbid patients had significantly lower odds of complications (OR 0.89, p = 0.014) compared to White multimorbid patients.Our study of universally insured patients highlights the critical role of pre-operative health status and its association with surgical outcomes.

To determine the effect of operative versus nonoperative management of emergency general surgery conditions on short-term and long-term outcomes.Many emergency general surgery conditions can be managed either operatively or nonoperatively, but high-quality evidence to guide management decisions is scarce.We included 507,677 Medicare patients treated for an emergency general surgery condition between July 1, 2015, and June 30, 2018. Operative management was compared with nonoperative management using a preference-based instrumental variable analysis and near-far matching to minimize selection bias and unmeasured confounding. Outcomes were mortality, complications, and readmissions.For hepatopancreaticobiliary conditions, operative management was associated with lower risk of mortality at 30 days [-2.6% (95% confidence interval: -4.0, -1.3)], 90 days [-4.7% (-6.50, -2.8)], and 180 days [-6.4% (-8.5, -4.2)]. Among 56,582 intestinal obstruction patients, operative management was associated with a higher risk of inpatient mortality [2.8% (0.7, 4.9)] but no significant difference thereafter. For upper gastrointestinal conditions, operative management was associated with a 9.7% higher risk of in-hospital mortality (6.4, 13.1), which increased over time. There was a 6.9% higher risk of inpatient mortality (3.6, 10.2) with operative management for colorectal conditions, which increased over time. For general abdominal conditions, operative management was associated with 12.2% increased risk of inpatient mortality (8.7, 15.8). This effect was attenuated at 30 days [8.5% (3.8, 13.2)] and nonsignificant thereafter.The effect of operative emergency general surgery management varied across conditions and over time. For colorectal and upper gastrointestinal conditions, outcomes are superior with nonoperative management, whereas surgery is favored for patients with hepatopancreaticobiliary conditions. For obstructions and general abdominal conditions, results were equivalent overall. These findings may support patients, clinicians, and families making these challenging decisions.

Substantial evidence indicates that patient outcomes are more favourable in hospitals with better nurse staffing. One policy designed to achieve better staffing is minimum nurse-to-patient ratio mandates, but such policies have rarely been implemented or evaluated. In 2016, Queensland (Australia) implemented minimum nurse-to-patient ratios in selected hospitals. We aimed to assess the effects of this policy on staffing levels and patient outcomes and whether both were associated.For this prospective panel study, we compared Queensland hospitals subject to the ratio policy (27 intervention hospitals) and those that discharged similar patients but were not subject to ratios (28 comparison hospitals) at two timepoints: before implementation of ratios (baseline) and 2 years after implementation (post-implementation). We used standardised Queensland Hospital Admitted Patient Data, linked with death records, to obtain data on patient characteristics and outcomes (30-day mortality, 7-day readmissions, and length of stay [LOS]) for medical-surgical patients and survey data from 17 010 medical-surgical nurses in the study hospitals before and after policy implementation. Survey data from nurses were used to measure nurse staffing and, after linking with standardised patient data, to estimate the differential change in outcomes between patients in intervention and comparison hospitals, and determine whether nurse staffing changes were related to it.We included 231 902 patients (142 986 in intervention hospitals and 88 916 in comparison hospitals) assessed at baseline (2016) and 257 253 patients (160 167 in intervention hospitals and 97 086 in comparison hospitals) assessed in the post-implementation period (2018). After implementation, mortality rates were not significantly higher than at baseline in comparison hospitals (adjusted odds ratio [OR] 1·07, 95% CI 0·97-1·17, p=0·18), but were significantly lower than at baseline in intervention hospitals (0·89, 0·84-0·95, p=0·0003). From baseline to post-implementation, readmissions increased in comparison hospitals (1·06, 1·01-1·12, p=0·015), but not in intervention hospitals (1·00, 0·95-1·04, p=0·92). Although LOS decreased in both groups post-implementation, the reduction was more pronounced in intervention hospitals than in comparison hospitals (adjusted incident rate ratio [IRR] 0·95, 95% CI 0·92-0·99, p=0·010). Staffing changed in hospitals from baseline to post-implementation: of the 36 hospitals with reliable staffing measures, 30 (83%) had more than 4·5 patients per nurse at baseline, with the number decreasing to 21 (58%) post-implementation. The majority of change was at intervention hospitals, and staffing improvements by one patient per nurse produced reductions in mortality (OR 0·93, 95% CI 0·86-0·99, p=0·045), readmissions (0·93, 0·89-0·97, p0·0001), and LOS (IRR 0·97, 0·94-0·99, p=0·035). In addition to producing better outcomes, the costs avoided due to fewer readmissions and shorter LOS were more than twice the cost of the additional nurse staffing.Minimum nurse-to-patient ratio policies are a feasible approach to improve nurse staffing and patient outcomes with good return on investment.Queensland Health, National Institutes of Health, National Institute of Nursing Research.

ObjectivesEvaluate whether hospital factors, including nurse resources, explain racial differences in Medicare black and white patient surgical outcomes and whether disparities changed over time.DesignRetrospective tapered-match.Setting571 hospitals at two time points (Early Era 2003–2005; Recent Era 2013–2015).Participants6752 black patients and three sets of 6752 white controls selected from 107 001 potential controls (Early Era). 4964 black patients and three sets of 4964 white controls selected from 74 108 potential controls (Recent Era).InterventionsBlack patients were matched to white controls on demographics (age, sex, state and year of procedure), procedure (demographics variables plus 136 International Classification of Diseases (ICD)-9 principal procedure codes) and presentation (demographics and procedure variables plus 34 comorbidities, a mortality risk score, a propensity score for being black, emergency admission, transfer status, predicted procedure time).Outcomes30-day and 1-year mortality.ResultsBefore matching, black patients had more comorbidities, higher risk of mortality despite being younger and underwent procedures at different percentages than white patients. Whites in the demographics match had lower mortality at 30 days (5.6% vs 6.7% Early Era; 5.4% vs 5.7% Recent Era) and 1-year (15.5% vs 21.5% Early Era; 12.3% vs 15.9% Recent Era). Black–white 1-year mortality differences were equivalent after matching patients with respect to presentation, procedure and demographic factors. Black–white 30-day mortality differences were equivalent after matching on procedure and demographic factors. Racial disparities in outcomes remained unchanged between the two time periods spanning 10 years. All patients in hospitals with better nurse resources had lower odds of 30-day (OR 0.60, 95% CI 0.46 to 0.78, pConclusionsSurvival disparities among black and white patients are largely explained by differences in demographic, procedure and presentation factors. Better nurse resources (eg, staffing, work environment) were associated with lower mortality for all patients.

Background The Safe Staffing for Quality Care Act under consideration in the New York (NY) state assembly would require hospitals to staff enough nurses to safely care for patients. The impact of regulated minimum patient-to-nurse staffing ratios in acute care hospitals in NY is unknown. Objectives To examine variation in patient-to-nurse staffing in NY hospitals and its association with adverse outcomes (ie, mortality and avoidable costs). Research design Cross-sectional data on nurse staffing in 116 acute care general hospitals in NY are linked with Medicare claims data. Subjects A total of 417,861 Medicare medical and surgical patients. Measures Patient-to-nurse staffing is the primary predictor variable. Outcomes include in-hospital mortality, length of stay, 30-day readmission, and estimated costs using Medicare-specific cost-to-charge ratios. Results Hospital staffing ranged from 4.3 to 10.5 patients per nurse (P/N), and averaged 6.3 P/N. After adjusting for potential confounders each additional patient per nurse, for surgical and medical patients, respectively, was associated with higher odds of in-hospital mortality [odds ratio (OR)=1.13, P=0.0262; OR=1.13, P=0.0019], longer lengths of stay (incidence rate ratio=1.09, P=0.0008; incidence rate ratio=1.05, P=0.0023), and higher odds of 30-day readmission (OR=1.08, P=0.0002; OR=1.06, P=0.0003). Were hospitals staffed at the 4:1 P/N ratio proposed in the legislation, we conservatively estimated 4370 lives saved and $720 million saved over the 2-year study period in shorter lengths of stay and avoided readmissions. Conclusions Patient-to-nurse staffing varies substantially across NY hospitals and higher ratios adversely affect patients. Our estimates of potential lives and costs saved substantially underestimate potential benefits of improved hospital nurse staffing.

Background Access to care is often a challenge for Medicaid beneficiaries due to low practice participation. As demand increases, practices will likely look for ways to see Medicaid patients while keeping costs low. Employing nurse practitioners (NPs) and physician assistants (PAs) is one low-cost and effective means to achieve this. However, there are no longitudinal studies examining the relationship between practice Medicaid acceptance and NP/PA employment. Purpose The purpose of this study was to examine the association of practice Medicaid acceptance with NP/PA employment over time. Methods Using SK&A data (2009-2015), we constructed a panel of 102,453 unique physician practices to assess for changes in Medicaid acceptance after newly employing NPs and PAs. We employed practice-level fixed effects linear regressions. Results Our results showed that, among practices employing both NPs and PAs, there was a roughly 2% increase in the likelihood of Medicaid participation over time. When stratifying our sample by practice size and specialty, the positive correlation localized to small primary care and medical practices. When both NPs and PAs were present, small primary care practices had a 3.3% increase and small medical practices had a 6.9% increase in the likelihood of accepting Medicaid. Conclusion NP and PA employment was positively associated with increases in Medicaid participation. Practice implications As more individuals gain coverage under Medicaid, organizations will need to decide how to adapt to greater patient demand. Our results suggest that hiring NPs and PAs may be a potential lower cost strategy to accommodate new Medicaid patients.

Background Racial disparities in survival among patients who had an in-hospital cardiac arrest (IHCA) have been linked to hospital-level factors. Objectives To determine whether nurse staffing is associated with survival disparities after IHCA. Research design Cross-sectional data from (1) the American Heart Association's Get With the Guidelines-Resuscitation database; (2) the University of Pennsylvania Multi-State Nursing Care and Patient Safety Survey; and (3) The American Hospital Association annual survey. Risk-adjusted logistic regression models, which took account of the hospital and patient characteristics, were used to determine the association of nurse staffing and survival to discharge for black and white patients. Subjects A total of 14,132 adult patients aged 18 and older between 2004 and 2010 in 75 hospitals in 4 states. Results In models that accounted for hospital and patient characteristics, the odds of survival to discharge was lower for black patients than white patients [odds ratio (OR)=0.70; 95% confidence interval (CI), 0.61-0.82]. A significant interaction was found between race and medical-surgical nurse staffing for survival to discharge, such that each additional patient per nurse lowered the odds of survival for black patients (OR=0.92; 95% CI, 0.87-0.97) more than white patients (OR=0.97; 95% CI, 0.93-1.00). Conclusions Our findings suggest that disparities in IHCA survival between black and white patients may be linked to the level of medical-surgical nurse staffing in the hospitals in which they receive care and that the benefit of being admitted to hospitals with better staffing may be especially pronounced for black patients.

BACKGROUND: Research demonstrates that increased self-efficacy can help family caregivers of older adults with Alzheimer’s and other types of cognitive impairment experience lower burden and depressive symptom severity. AIMS: The purpose of this concept analysis is to address fundamental gaps in the understanding of self-efficacy in family caregivers of older adults with cognitive impairment, including updating the 26-year-old concept analysis with a contemporary definition. METHODS: This study utilizes Walker and Avant’s (2019) concept analysis method, an eight-step iterative process that helps to clarify ambiguous concepts. A literature review was conducted from July 1993 through March 2019 using PubMed/MED-LINE, Scopus, CINAHL, and Embase. Inclusion criteria encompassed peer-reviewed research articles and review articles that included family caregivers of older adults with cognitive impairment. RESULTS: Eight defining attributes of this concept are identified. The revised definition of self-efficacy in this population is a family caregiver’s confidence in their ability to: manage behaviors and other caregiving stresses, control upsetting thoughts, acquire medical information, manage medical issues, obtain self-care, access community supports, assist with activities of daily living and other care, and maintain a good relationship with a relative, friend, or neighbor of an older adult with cognitive impairment. CONCLUSION: This paper utilizes over a quarter-century of research to build on the original analysis by Mowat and Spence Laschinger (1994) and update the concept’s definition. This analysis should provide researchers with a clearer understanding of this concept and a renewed emphasis on the importance of targeting interventions to improve self-efficacy in this vulnerable caregiving population.

The complexity of modern burn care requires an integrated team of specialty providers working together to achieve the best possible outcome for each burn survivor. Nurses are central to many aspects of a burn survivor’s care, including physiologic monitoring, fluid resuscitation, pain management, infection prevention, complex wound care, and rehabilitation. Research suggests that in general, hospital nursing resources, defined as nurse staffing and the quality of the work environment, relate to patient mortality. Still, the relationship between those resources and burn mortality has not been previously examined. This study used a multivariable risk-adjusted regression model and a linked, cross-sectional claims database of more than 14,000 adults (≥18 years) thermal burn patients admitted to 653 hospitals to evaluate these relationships. Hospital nursing resources were independently reported by more than 29,000 bedside nurses working in the study hospitals. In the high burn patient-volume hospitals (≥100/y) that care for the most severe burn injuries, each additional patient added to a nurse’s workload is associated with 30% higher odds of mortality (P < .05, 95% CI: 1.02–1.94), and improving the work environment is associated with 28% lower odds of death (P < .05, 95% CI: 0.07–0.99). Nursing resources are vital in the care of burn patients and are a critical, yet previously omitted, variable in the evaluation of burn outcomes. Attention to nurse staffing and improvement to the nurse work environment is warranted to promote optimal recovery for burn survivors. Given the influence of nursing on mortality, future research evaluating burn patient outcomes should account for nursing resources.

Background Evidence suggests that Magnet and non-Magnet hospitals differ with respect to quality of care. Purpose Our study examined registered nurse (RN) staffing over time in Magnet and non-Magnet hospitals using unit-level, publicly available data in New Jersey. Methods A secondary analysis of longitudinal RN staffing data was conducted using mandated, publicly reported data of 64 hospitals representing 12 nursing specialties across 8 years (2008-2015). Staffing ratios were trended over time to compare RN staffing changes in Magnet and non-Magnet hospitals. Results Staffing was comparable in Magnet and non-Magnet hospitals for 9 of 12 specialties. On average, from 2008 until 2015, RN staffing slightly increased, with a greater percent increase in Magnet hospitals (6.9%) than in non-Magnet hospitals (4.7%). Conclusions Over 8 years in New Jersey, RN staffing improved in Magnet and non-Magnet hospitals. Although there was a slight increase for Magnet hospitals, there was no meaningful difference in staffing for all 12 specialties.

We sought to evaluate if better work environments or staffing were associated with improvements in care quality, patient safety, and nurse outcomes across hospitals caring for different proportions of patients who are economically disadvantaged. Few actionable approaches for hospitals with quality and resource deficits exist. One solution may be to invest in the nurse work environment and staffing. This cross-sectional study utilized secondary data from 23,629 registered nurses in 503 hospitals from a four-state survey collected in 2005–2008. Each 10% increase in the proportion of patients who are economically disadvantaged was associated with 27% and 22% decreased odds of rating unit-level care quality as excellent and giving an “A” safety grade, respectively. Each 10% increase was also associated with 9%, 25%, and 11% increased odds of job dissatisfaction, intent to leave, and burnout, respectively. The work environment had the largest association with each outcome. Accounting for the nurse work environment lessened or eliminated the negative outcomes experienced at hospitals serving high proportions of patients who are economically disadvantaged. Leaders at hospitals serving high proportions of patients who are economically disadvantaged, as well as state and federal policymakers, should work to improve quality, safety, and nurse outcomes by strengthening nurse work environments. Improving work environments highlights the role of nursing in the health care system, and policies focused on work environments are needed to improve the experiences of patients and nurses, especially at hospitals that care for many patients who are economically disadvantaged.

The shortage of nursing care in U.S. hospitals has become a national concern.The purpose of this manuscript was to determine whether hospital nursing care shortages are primarily due to the pandemic and thus likely to subside or due to hospital nurse understaffing and poor working conditions that predated it.This study used a repeated cross-sectional design before and during the pandemic of 151,335 registered nurses in New York and Illinois, and a subset of 40,674 staff nurses employed in 357 hospitals.No evidence was found that large numbers of nurses left health care or hospital practice in the first 18 months of the pandemic. Nurses working in hospitals with better nurse staffing and more favorable work environments prior to the pandemic reported significantly better outcomes during the pandemic.Policies that prevent chronic hospital nurse understaffing have the greatest potential to stabilize the hospital nurse workforce at levels supporting good care and clinician wellbeing.

Background Electronic health record (EHR) usability issues represent an emerging threat to the wellbeing of nurses and patients; however, few large studies have examined these relationships. Objective To examine associations between EHR usability and nurse job (burnout, job dissatisfaction, and intention to leave) and surgical patient (inpatient mortality and 30-day readmission) outcomes. Methods A cross-sectional analysis of linked American Hospital Association, state patient discharge, and nurse survey data was conducted. The sample included 343 hospitals, 1,281,848 surgical patients, and 12,004 nurses. Logistic regression models were used to assess relationships between EHR usability and outcomes, before and after accounting for EHR adoption level (comprehensive vs. basic or less) and other confounders. Results In fully adjusted models, nurses who worked in hospitals with poorer EHR usability had significantly higher odds of burnout [odds ratio (OR), 1.41; 95% confidence interval (CI), 1.21-1.64], job dissatisfaction (OR, 1.61; 95% CI, 1.37-1.90) and intention to leave (OR, 1.31; 95% CI, 1.09-1.58) compared with nurses working in hospitals with better usability. Surgical patients treated in hospitals with poorer EHR usability had significantly higher odds of inpatient mortality (OR, 1.21; 95% CI, 1.09-1.35) and 30-day readmission (OR, 1.06; 95% CI, 1.01-1.12) compared with patients in hospitals with better usability. Comprehensive EHR adoption was associated with higher odds of nurse burnout (OR, 1.14; 95% CI, 1.01-1.28). Conclusion Employing EHR systems with suboptimal usability was associated with higher odds of adverse nurse job outcomes and surgical patient mortality and readmission. EHR usability may be more important to nurse job and patient outcomes than comprehensive EHR adoption.

This study uses data from two cross-sections in time (2006, 2016) to determine whether changes over time in hospital employment of bachelor's of science in nursing (BSN) nurses is associated with changes in patient outcomes. Data sources include nurse survey data, American Hospital Association Annual Survey data, and patient administrative claims data from state agencies in California, Florida, New Jersey, and Pennsylvania. The study sample included general surgical patients aged 18-99 years admitted to one of the 519 study hospitals. Multilevel logistic regression and truncated negative binomial models were used to estimate the cross-sectional and longitudinal effects of the proportion of hospital BSN nurses on patient outcomes (i.e., in-hospital mortality, 7- and 30-day readmissions, length of stay). Between 2006 and 2016, the average proportion of BSN nurses in hospitals increased from 41% to 56%. Patients in hospitals that increased their proportion of BSN nurses over time had significantly reduced odds of risk-adjusted mortality (odds ratio [OR]: 0.95, 95% confidence interval [CI]: 0.92-0.98), 7-day readmission (OR: 0.96, 95% CI: 0.94-0.99) and 30-day readmission (OR: 0.98, 95% CI: 0.95-1.00), and shorter lengths of stay (incident rate ratio [IRR]: 0.98, 95% CI: 0.97-0.99). Longitudinal findings of an association between increased proportions of BSN nurses and improvements in patient outcomes corroborate previous cross-sectional research, suggesting that a better educated nurse workforce may add value to hospitals and patients.

An understudied aspect of the opioid crisis with implications for nursing is care of hospitalized surgical patients with chronic opioid use. Care needs of these patients are not well understood. This systematic review identified salient care needs and explored the role of nursing in meeting these needs.

BACKGROUND: Rigorous measurement of organizational performance requires large, unbiased samples to allow inferences to the population. Studies of organizations, including hospitals, often rely on voluntary surveys subject to nonresponse bias. For example, hospital administrators with concerns about performance are more likely to opt-out of surveys about organizational quality and safety, which is problematic for generating inferences. OBJECTIVE: The objective of this study was to describe a novel approach to obtaining a representative sample of organizations using individuals nested within organizations, and demonstrate how resurveying nonrespondents can allay concerns about bias from low response rates at the individual-level. METHODS: We review and analyze common ways of surveying hospitals. We describe the approach and results of a double-sampling technique of surveying nurses as informants about hospital quality and performance. Finally, we provide recommendations for sampling and survey methods to increase response rates and evaluate whether and to what extent bias exists. RESULTS: The survey of nurses yielded data on over 95% of hospitals in the sampling frame. Although the nurse response rate was 26%, comparisons of nurses’ responses in the main survey and those of resurveyed nonrespondents, which yielded nearly a 90% response rate, revealed no statistically significant differences at the nurse-level, suggesting no evidence of nonresponse bias. CONCLUSIONS: Surveying organizations via random sampling of front-line providers can avoid the self-selection issues caused by directly sampling organizations. Response rates are commonly misinterpreted as a measure of representativeness; however, findings from the double-sampling approach show how low response rates merely increase the potential for nonresponse bias but do not confirm it.

In this study we describe nurse–physician teamwork, estimate its association with surgical patient outcomes (30-day mortality and failure-to-rescue), and determine whether these relationships depend upon other modifiable hospital nursing characteristics (nurse staffing and education levels) known to be associated with patient outcomes. This cross-sectional analysis included linked data from 29,391 nurses representing 665 acute care hospitals and 1,321,904 adult patients who underwent a general surgical, vascular, or orthopedic procedure. Surgical patients cared for in hospitals with better nurse–physician teamwork had significantly lower odds of 30-day mortality (odds ratio [OR] = 0.95) and failure-to-rescue (OR = 0.95). In addition, the odds of death and failure-to-rescue were lower for patients in hospitals with both higher nurse–physician teamwork and more favorable patient-to-nurse staffing ratios. Similar trends were observed related to nursing education levels. Improving interprofessional teamwork is one strategy to improve patient outcomes with the added importance of also considering additional features of their nursing workforce.

BACKGROUND Magnet hospitals are recognized for nursing excellence and high-value patient outcomes, yet little is known about which and when hospitals pursue Magnet recognition. Concurrently, hospital systems are becoming a more prominent feature of the U.S. health care landscape. PURPOSE The aim of the study was to examine Magnet adoption among hospital systems over time. APPROACH Using American Hospital Association surveys (1998-2012), we characterized the proportion of Magnet hospitals belonging to systems. We used hospital level fixed-effects regressions to capture changes in a given system hospital's Magnet status over time in relation to a variety of conditions, including prior Magnet adoption by system affiliates and nonaffiliates in local and geographically distant markets and whether these relationships varied by degree of system centralization. RESULTS The proportion of Magnet hospitals belonging to a system is increasing. Prior Magnet adoption by a hospital within the local market was associated with an increased likelihood of a given system hospital becoming Magnet, but the effect was larger if there was prior adoption by affiliates (7.4% higher likelihood) versus nonaffiliates (2.7% higher likelihood). Prior adoption by affiliates and nonaffiliates in geographically distant markets had a lesser effect. Hospitals belonging to centralized systems were more reactive to Magnet adoption of nonaffiliate hospitals as compared with those in decentralized systems. CONCLUSIONS Hospital systems take an organizational perspective toward Magnet adoption, whereby more system affiliates achieve Magnet recognition over time. PRACTICE IMPLICATIONS The findings are relevant to health care and nursing administrators and policymakers interested in the diffusion of an empirically supported organizational innovation associated with quality outcomes, particularly in a time of increasing hospital consolidation and system expansion. We identify factors associated with Magnet adoption across system hospitals and demonstrate the importance of considering diffusion of organizational innovations in relation to system centralization. We suggest that decentralized system hospitals may be missing potential benefits of such organizational innovations.

Objective The aim of this study was to determine whether there are modifiable characteristics of nurses and hospitals associated with nurse specialty certification. Background Hospitals, nurses, and patients benefit from nurse specialty certification, but little actionable evidence guides administrators seeking higher hospital certification rates. Methods This is a cross-sectional, secondary data analysis of 20 454 nurses in 471 hospitals across 4 states. Results Rates of certified nurses varied significantly across hospitals. Higher odds of certification were associated with Magnet® recognition and better hospital work environments at the facility level, and with BSN education, unit type (most notably, oncology), older age, more years of experience, and full-time employment at the individual nurse level. Conclusion Two strategies that hold promise for increasing nurse specialty certification are improving hospital work environments and preferentially hiring BSN nurses.

Despite concerted research and clinical efforts, sepsis remains a common, costly, and often fatal occurrence. Little evidence exists for the relationship between institutional nursing resources and the incidence and outcomes of sepsis after surgery. The objective of this study was to examine whether hospital nursing resource quality is associated with postsurgical sepsis incidence and survival. This cross-sectional, secondary data analysis used registered nurses’ reports on hospital nursing resources—staffing, education, and work environment—and multivariate logistic regressions to model their association with risk-adjusted postsurgical sepsis and mortality in 568 hospitals across four states. Better work environment quality was associated with lower odds of sepsis. While the likelihood of death among septic patients was nearly seven times that of non-septic patients, better nursing resources were associated with reduced mortality for all patients. Whereas the preponderance of sepsis research has focused on clinical interventions to prevent and treat sepsis, this study describes organizational characteristics hospital administrators may modify through organizational change targeting nurse staffing, education, and work environments to improve patient outcomes.

Background: Burnout remains a persistent issue affecting nurses across the US health system. Limited evidence exists about the direct impact of nurse burnout on patient outcomes. This study explores the relationship between nurse burnout and mortality, failure to rescue, and length of stay, while also considering the effect of a good work environment. Methods: Cross sectional data from nurses and hospitals were used in conjunction with patient claims data. Multivariate logistic regression was used to study the relationship between nurse burnout, patient outcomes, the work environment, and Magnet status. Results: Higher odds of patient mortality, failure to rescue, and prolonged length of stay were found in hospitals that had, on average, higher nurse burnout scores. Good work environments were found to attenuate the relationship between nurse burnout and mortality, failure to rescue, and length of stay. Magnet status, another indicator of a good work environment, was found to attenuate the relationship between nurse burnout and mortality and failure to rescue. Conclusions: Improving the work environment remains a solution for hospitals looking to concurrently improve nurse burnout and patient outcomes. Administrators may look to the Magnet recognition program as a blueprint to better support nurses in providing safe, high quality care.

ObjectivesSepsis is a serious inflammatory response to infection with a high death rate. Timely and effective treatment may improve sepsis outcomes resulting in mandatory sepsis care protocol adherence reporting. How the impact of patient-to-nurse staffing compares to sepsis protocol compliance and patient outcomes is not well understood. This study aimed to determine the association between hospital sepsis protocol compliance, patient-to-nurse staffing ratios and patient outcomes.DesignA cross-sectional study examining hospital nurse staffing, sepsis protocol compliance and sepsis patient outcomes, using linked data from nurse (2015–2016, 2020) and hospital (2017) surveys, and Centers for Medicare and Medicaid Services Hospital Compare (2017) and corresponding MedPAR patient claims.Setting537 hospitals across six US states (California, Florida, Pennsylvania, New York, Illinois and New Jersey).Participants252 699 Medicare inpatients with sepsis present on admission.MeasuresThe explanatory variables are nurse staffing and SEP-1 compliance. Outcomes are mortality (within 30 and 60 days of index admission), readmissions (within 7, 30, and 60 days of discharge), admission to the intensive care unit (ICU) and lengths of stay (LOS).ResultsSepsis protocol compliance and nurse staffing vary widely across hospitals. Each additional patient per nurse was associated with increased odds of 30-day and 60-day mortality (9% (OR 1.09, 95% CI 1.05 to 1.13) and 10% (1.10, 95% CI 1.07 to 1.14)), 7-day, 30-day and 60-day readmission (8% (OR 1.08, 95% CI 1.05 to 1.11, pConclusionsOutcomes are more strongly associated with improved nurse staffing than with increased compliance with sepsis protocols.

Background Despite nurses’ responsibilities in recognition and treatment of sepsis, little evidence documents whether patient-to-nurse staffing ratios are associated with clinical outcomes for patients with sepsis. Methods Using linked data sources from 2017 including MEDPAR patient claims, Hospital Compare, American Hospital Association, and a large survey of nurses, we estimate the effect of hospital patient-to-nurse staffing ratios and adherence to the Early Management Bundle for patients with Severe Sepsis/Septic Shock SEP-1 sepsis bundles on patients’ odds of in-hospital and 60-day mortality, readmission, and length of stay. Logistic regression is used to estimate mortality and readmission, while zero-truncated negative binomial models are used for length of stay. Results Each additional patient per nurse is associated with 12% higher odds of in-hospital mortality, 7% higher odds of 60-day mortality, 7% higher odds of 60-day readmission, and longer lengths of stay, even after accounting for patient and hospital covariates including hospital adherence to SEP-1 bundles. Adherence to SEP-1 bundles is associated with lower in-hospital mortality and shorter lengths of stay; however, the effects are markedly smaller than those observed for staffing. Discussion Improving hospital nurse staffing over and above implementing sepsis bundles holds promise for significant improvements in sepsis patient outcomes.

IntroductionEfforts to enact nurse staffing legislation often lack timely, local evidence about how specific policies could directly impact the public’s health. Despite numerous studies indicating better staffing is associated with more favourable patient outcomes, only one US state (California) sets patient-to-nurse staffing standards. To inform staffing legislation actively under consideration in two other US states (New York, Illinois), we sought to determine whether staffing varies across hospitals and the consequences for patient outcomes. Coincidentally, data collection occurred just prior to the COVID-19 outbreak; thus, these data also provide a real-time example of the public health implications of chronic hospital nurse understaffing.MethodsSurvey data from nurses and patients in 254 hospitals in New York and Illinois between December 2019 and February 2020 document associations of nurse staffing with care quality, patient experiences and nurse burnout.ResultsMean staffing in medical-surgical units varied from 3.3 to 9.7 patients per nurse, with the worst mean staffing in New York City. Over half the nurses in both states experienced high burnout. Half gave their hospitals unfavourable safety grades and two-thirds would not definitely recommend their hospitals. One-third of patients rated their hospitals less than excellent and would not definitely recommend it to others. After adjusting for confounding factors, each additional patient per nurse increased odds of nurses and per cent of patients giving unfavourable reports; ORs ranged from 1.15 to 1.52 for nurses on medical-surgical units and from 1.32 to 3.63 for nurses on intensive care units.ConclusionsHospital nurses were burned out and working in understaffed conditions in the weeks prior to the first wave of COVID-19 cases, posing risks to the public’s health. Such risks could be addressed by safe nurse staffing policies currently under consideration.

Background Nursing resources, such as staffing ratios and skill mix, vary across hospitals. Better nursing resources have been linked to better patient outcomes but are assumed to increase costs. The value of investments in nursing resources, in terms of clinical benefits relative to costs, is unclear. Objective To determine whether there are differential clinical outcomes, costs, and value among medical patients at hospitals characterized by better or worse nursing resources. Design Matched cohort study of patients in 306 acute care hospitals. Patients A total of 74,045 matched pairs of fee-for-service Medicare beneficiaries admitted for common medical conditions (25,446 sepsis pairs; 16,332 congestive heart failure pairs; 12,811 pneumonia pairs; 10,598 stroke pairs; 8858 acute myocardial infarction pairs). Patients were also matched on hospital size, technology, and teaching status. Main Measures Better (n = 76) and worse (n = 230) nursing resourced hospitals were defined by patient-to-nurse ratios, skill mix, proportions of bachelors-degree nurses, and nurse work environments. Outcomes included 30-day mortality, readmission, and resource utilization-based costs. Key Results Patients in hospitals with better nursing resources had significantly lower 30-day mortality (16.1% vs 17.1%, p

BackgroundThere are known clinical benefits associated with investments in nursing. Less is known about their value.AimsTo compare surgical patient outcomes and costs in hospitals with better versus worse nursing resources and to determine if value differs across these hospitals for patients with different mortality risks.MethodsRetrospective matched-cohort design of patient outcomes at hospitals with better versus worse nursing resources, defined by patient-to-nurse ratios, skill mix, proportions of bachelors-degree nurses and nurse work environments. The sample included 62 715 pairs of surgical patients in 76 better nursing resourced hospitals and 230 worse nursing resourced hospitals from 2013 to 2015. Patients were exactly matched on principal procedures and their hospital’s size category, teaching and technology status, and were closely matched on comorbidities and other risk factors.ResultsPatients in hospitals with better nursing resources had lower 30-day mortality: 2.7% vs 3.1% (pConclusionHospitals with better nursing resources provided better clinical outcomes for surgical patients at a small additional cost. Generally, the sicker the patient, the greater the value at better nursing resourced hospitals.

Extensive evidence supports the association between increased nurse staffing and improved quality of patient care. Public reporting or public disclosure of nurse staffing patterns aims to incentivize hospitals to improve staffing by making comparison data available for consumers as well as nurses and hospital administrators. Currently, eight states in the United States publicly report and disclose information on nurse staffing levels to the public. We review the available public reporting mechanisms by systematically categorizing and comparing states that report nurse staffing. We also discuss the implications for future state and federal policy with regard to publicly reporting or disclosing nurse staffing.

The use of nurse practitioners (NPs) in primary care is one way to address growing patient demand and improve care delivery. However, little is known about trends in NP presence in primary care practices, or about how state policies such as scope-of-practice laws and expansion of eligibility for Medicaid may encourage or inhibit the use of NPs. We found increasing NP presence in both rural and nonrural primary care practices in the period 2008–16. At the end of the period, NPs constituted 25.2 percent of providers in rural and 23.0 percent in nonrural practices, compared to 17.6 percent and 15.9 percent, respectively, in 2008. States with full scope-of-practice laws had the highest NP presence, but the fastest growth occurred in states with reduced and restricted scopes of practice. State Medicaid expansion status was not associated with greater NP presence. Overall, primary care practices are embracing interdisciplinary provider configurations, and including NPs as providers can strengthen health care delivery.

Objectives To investigate whether care in a hospital with more nurses holding at least a Bachelor of Science in Nursing (BSN) degree is associated with lower mortality for individuals with Alzheimer's disease and related dementias (ADRD) undergoing surgery ADRD. Design Cross‐sectional data from 2006–07 Medicare claims were linked with the Multi‐State Nursing Care and Patient Safety Survey of nurses in 4 states. Setting Adult, nonfederal, acute care hospitals in California, Florida, New Jersey, and Pennsylvania (N=531). Participants Medicare beneficiaries aged 65 and older with and without ADRD undergoing general, orthopedic, or vascular surgery (N=353,333; ADRD, n=46,163; no ADRD, n=307,170). Measurements Thirty‐day mortality and failure to rescue (death after a complication). Results Controlling for hospital, procedure, and individual characteristics, each 10% increase in the proportion of BSN nurses was associated with 4% lower odds of death (odds ratio (OR)=0.96, 95% confidence interval (CI)=0.93–0.98) for individuals without ADRD, but 10% lower odds of death (OR=0.90, 95% CI=0.87–0.94) for those with ADRD. Each 10% increase in the proportion of nurses holding a BSN degree or higher was associated with 5% lower odds of failure to rescue (OR=0.95, 95% CI=0.92–0.98) for individuals without ADRD but 10% lower odds of failure to rescue (OR=0.90, 95% CI=0.87–0.94) for those with ADRD. Conclusion Individuals undergoing surgery who have coexisting ADRD are more likely to die within 30 days of admission and die after a complication than those without ADRD. Having more BSN nurses in the hospital improves the odds of good outcomes for all individuals and has a much greater effect in individuals with ADRD.

ObjectiveTo evaluate variation in Illinois hospital nurse staffing ratios and to determine whether higher nurse workloads are associated with mortality and length of stay for patients, and cost outcomes for hospitals.DesignCross-sectional analysis of multiple data sources including a 2020 survey of nurses linked to patient outcomes data.Setting: 87 acute care hospitals in Illinois.Participants210 493 Medicare patients, 65 years and older, who were hospitalised in a study hospital. 1391 registered nurses employed in direct patient care on a medical–surgical unit in a study hospital.Main outcome measuresPrimary outcomes were 30-day mortality and length of stay. Deaths avoided and cost savings to hospitals were predicted based on results from regression estimates if hospitals were to have staffed at a 4:1 ratio during the study period. Cost savings were computed from reductions in lengths of stay using cost-to-charge ratios.ResultsPatient-to-nurse staffing ratios on medical-surgical units ranged from 4.2 to 7.6 (mean=5.4; SD=0.7). After adjusting for hospital and patient characteristics, the odds of 30-day mortality for each patient increased by 16% for each additional patient in the average nurse’s workload (95% CI 1.04 to 1.28; p=0.006). The odds of staying in the hospital a day longer at all intervals increased by 5% for each additional patient in the nurse’s workload (95% CI 1.00 to 1.09, p=0.041). If study hospitals staffed at a 4:1 ratio during the 1-year study period, more than 1595 deaths would have been avoided and hospitals would have collectively saved over $117 million.ConclusionsPatient-to-nurse staffing ratios vary considerably across Illinois hospitals. If nurses in Illinois hospital medical–surgical units cared for no more than four patients each, thousands of deaths could be avoided, and patients would experience shorter lengths of stay, resulting in cost-savings for hospitals.

Introduction For over half a century, hospitals in the United States have actively recruited foreign-educated nurses (FENs) in response to nurse shortages in hospitals and nursing homes. Little attention has been paid to the quality of care in the United States related to employment of FENs. Aims The purpose of this retrospective study was to determine whether employment of FENs in U.S. hospitals is associated with patient care experience. Method This study used cross-sectional data from three sources in 425 hospitals in four large states to evaluate the relationship between patient perceptions of care and hospital employment of FENs. The study linked data from publicly reported patient experience of care surveys, nurse surveys, and administrative data using unique hospital identifiers common across the data sets. Results Patient-reported care experience was found to be more negative in hospitals employing more FENs, after controls for other possible explanations. Each 10% increase in FENs was associated with a decrease in the percentage of patients who would recommend their hospital and a decrease in the percentage of patients giving favorable reports on five nursing-specific aspects of patient experience. Conclusions The results of this study suggest that employment of substantial numbers of nurses educated outside the United States may have implications for quality of care. The findings suggest that research on the outcomes of transition programs for FENs would be useful to inform regulatory policies.

Care quality continues to be a focal point within US health care. One quality innovation is the Magnet recognition program for hospitals, which is a nurse-driven initiative emphasizing care and patient-safety improvements. To date, Magnet hospitals have been associated with better outcomes, but their distribution is highly uneven. Relatedly, little research has characterized what factors drive Magnet adoption (eg, competitive pressure from other hospitals).To examine if hospitals respond to more competing hospitals becoming Magnets by also becoming Magnet institutions.We use longitudinal data from the American Hospital Association, 1997-2012, and estimate hospital-level fixed-effect regressions to capture the association between Magnet adoption among competitors and a hospital's own likelihood of becoming a Magnet. We also explore heterogeneity in the relationships according to a hospital's standing within its market.Having more competitors become Magnets strongly predicts that a given hospital seeks Magnet recognition; yet, a hospital's market position and prevailing competition levels are moderating influences.A large literature links Magnet hospitals with better outcomes for patients and nurses, and more recent evidence suggests a business case for becoming a Magnet. We find evidence that hospitals seem motivated by competitive pressure, which suggests economic considerations in the decision to invest in costly care improvements.