Newly Licensed RN Retention: Hospital and Nurse Characteristics.

OBJECTIVES: The aims of this study were to examine the relationship between 1-year retention of newly licensed RNs (NLRNs) employed in hospitals and personal and hospital characteristics, and determine which characteristics had the most influence. METHODS: A secondary analysis of data collected in a study of transition to practice was used to describe the retention of 1464 NLRNs employed by 97 hospitals in 3 states. Hospitals varied in size, location (urban and rural), Magnet® designation, and university affiliation. The NLRNs also varied in education, age, race, gender, and experience. RESULTS: The overall retention rate at 1 year was 83%. Retention of NLRNs was higher in urban areas and in Magnet hospitals. The only personal characteristic that affected retention was age, with younger nurses more likely to stay. CONCLUSION: Hospital characteristics had a larger effect on NLRN retention than personal characteristics. Hospitals in rural areas have a particular challenge in retaining NLRNs.

Voluntary Medication Error Reporting by ED Nurses: Examining the Association With Work Environment and Social Capital.

INTRODUCTION: Medication errors are one of the most frequently occurring errors in health care settings. The complexity of the ED work environment places patients at risk for medication errors. Most hospitals rely on nurses' voluntary medication error reporting, but these errors are under-reported. The purpose of this study was to examine the relationship among work environment (nurse manager leadership style and safety climate), social capital (warmth and belonging relationships and organizational trust), and nurses' willingness to report medication errors. METHODS: A cross-sectional descriptive design using a questionnaire with a convenience sample of emergency nurses was used. Data were analyzed using descriptive, correlation, Mann-Whitney U, and Kruskal-Wallis statistics. RESULTS: A total of 71 emergency nurses were included in the study. Emergency nurses' willingness to report errors decreased as the nurses' years of experience increased (r = -0.25, P = .03). Their willingness to report errors increased when they received more feedback about errors (r = 0.25, P = .03) and when their managers used a transactional leadership style (r = 0.28, P = .01). DISCUSSION: ED nurse managers can modify their leadership style to encourage error reporting. Timely feedback after an error report is particularly important. Engaging experienced nurses to understand error root causes could increase voluntary error reporting.

Comparison of Unit-Level Patient Turnover Measures in Acute Care Hospital Settings.

High patient turnover is a critical factor increasing nursing workload. Despite the growing number of studies on patient turnover, no consensus about how to measure turnover has been achieved. This study was designed to assess the correlation among patient turnover measures commonly used in recent studies and to examine the degree of agreement among the measures for classifying units with different levels of patient turnover. Using unit-level data collected for this study from 292 units in 88 hospitals participating in the National Database of Nursing Quality Indicators®, we compared four patient turnover measures: the inverse of length of stay (1/LOS), admissions, discharges, and transfers per daily census (ADTC), ADTC with short-stay adjustment, and the number of ADTs and short-stay patients divided by the total number of treated patients, or Unit Activity Index (UAI). We assessed the measures' agreement on turnover quartile classifications, using percent agreement and Cohen's kappa statistic (weighted and unweighted). Pearson correlation coefficients also were calculated. ADTC with or without adjustment for short-stay patients had high correlations and substantial agreement with the measure of 1/LOS (κ = .62 to .91; r = .90 to .95). The UAI measure required data less commonly collected by participating hospital units and showed only moderate correlations and fair agreement with the other measures (κ = .23 to .39; r = .41 to .45). The UAI may not be comparable and interchangeable with other patient turnover measures when data are obtained from multiple units and hospitals. © 2016 Wiley Periodicals, Inc.

Differences in Innovative Behavior Among Hospital-Based Registered Nurses.

BACKGROUND: The 2010 Institute of Medicine report, 'The Future of Nursing: Leading Change, Advancing Health', advocated for nurses to innovate in their practice, research, and education. However, little is known about the innovative behavior of registered nurses or whether there are differences in innovative behavior among registered nurses. OBJECTIVE: The purpose of this article is to describe the innovative behavior of hospital-based registered nurses and understand the differences in innovative behavior when registered nurses are categorized into various demographic groups. METHODS: A survey of 251 hospital-based registered nurses from 9 hospitals in California was administered to assess demographic characteristics and innovative behavior, measured through Scott and Bruce's Individual Innovative Behavior Scale. RESULTS: Hospital-based registered nurses, on average, reported moderate levels of innovative behavior. There were statistically significant differences in innovative behavior when registered nurses were categorized according to specialty certification, role, level of education, hospital size, and hospital innovativeness. CONCLUSIONS: To support innovative behavior, organizations should provide opportunities for specialty certification and increasing levels of education.

Preceptor Support in Hospital Transition to Practice Programs.

OBJECTIVE: The aim of this study was to describe newly licensed RN (NLRN) preceptorships and the effects on competency and retention. BACKGROUND: Preceptors are widely used, but little is known about the benefit from the perspective of the NLRN or about the models of the relationships. The National Council of State Boards of Nursing added questions about the preceptor experience in a study of transition-to-practice programs. METHODS: Hospitals were coded as having high or low preceptor support in regard to scheduling NLRN on the same shifts as their preceptors, assignment sharing, and preceptor release time and a low number of preceptors per preceptee. RESULTS: Half of the 82 hospitals were classified as high, and half as low preceptor support. NLRNs and their preceptors in high-support hospitals evaluated the preceptor experience and NLRN competence higher. In addition, NLRN retention was higher in the high-support hospitals. CONCLUSIONS: To improve NLRN competence and retention, preceptors should have adequate time with each NLRN, share shift and patient assignments, and have few preceptees assigned to each preceptor concurrently.

Influence of Institutional Guidelines on Oral Hygiene Practices in Intensive Care Units.

BACKGROUND: Maintaining oral hygiene is a key component of preventing ventilator-associated pneumonia; however, practices are inconsistent. OBJECTIVES: To explore how characteristics of institutional guidelines for oral hygiene influence nurses' oral hygiene practices and perceptions of that practice. METHODS: Oral hygiene section of a larger survey study on prevention of ventilator-associated pneumonia. Critical care nurses at 8 hospitals in Northern California that had more than 1000 ventilator days in 2009 were recruited to participate in the survey. Twenty-one questions addressed oral hygiene practices and practice perceptions. Descriptive statistics, analysis of variance, and Spearman correlations were used for analyses. RESULTS: A total of 576 critical care nurses (45% response rate) responded to the survey. Three types of institutional oral hygiene guidelines existed: nursing policy, order set, and information bulletin. Nursing policy provided the most detail about the oral hygiene care; however, adherence, awareness, and priority level were higher with order sets (P < .05). The content and method of disseminating these guidelines varied, and nursing practices were affected by these differences. Nurses assessed the oral cavity and used oral swabs more often when those practices were included in institutional guidelines. CONCLUSIONS: The content and dissemination method of institutional guidelines on oral hygiene do influence the oral hygiene practices of critical care nurses. Future studies examining how institutional guidelines could best be incorporated into routine workflow are needed.

Job satisfaction and horizontal violence in hospital staff registered nurses: the mediating role of peer relationships.

AIMS AND OBJECTIVES: To describe the association between horizontal violence and job satisfaction in hospital staff registered nurses and the degree to which peer relationships mediates the relationship. Additionally, the association between nurse and work characteristics and job satisfaction were determined. BACKGROUND: Horizontal violence is a major predictor of nurses' job satisfaction. Yet, not enough is known about the relationship between these variables. Job satisfaction is an important variable to study because it is a predictor of patient care quality and safety internationally. Peer relationships, a job satisfier for nurses, was identified as a potential mediator in the association between horizontal violence and job satisfaction. DESIGN: Cross-sectional mediational model testing. METHODS: An anonymous four-part survey of a random sample of 175 hospital staff registered nurses working in California provided the data. Data about horizontal violence, peer relationships, job satisfaction, and nurse and work characteristics were collected between March-August 2010. RESULTS: A statistically significant negative relationship was found between horizontal violence and peer relationships, job satisfaction and a statistically significant positive relationship was found between peer relationships and job satisfaction. Peer relationships mediated the association between horizontal violence and job satisfaction. Job satisfaction was reported as higher by nurses who worked in teaching hospitals. There were no statistically significant differences in job satisfaction based on gender, ethnicity, basic registered nurse education, highest degree held, size of hospital or clinical area. CONCLUSIONS: The results suggest that peer relationships can attenuate the negative relationship between horizontal violence and job satisfaction. This adds to the extant literature on the relationship between horizontal violence and job satisfaction. RELEVANCE TO CLINICAL PRACTICE: The findings highlight peer relationships as an important factor when considering effective interventions that foster hospital staff registered nurses' job satisfaction in the presence of horizontal violence.

Comparison of Nurse Staffing Measurements in Staffing-Outcomes Research.

BACKGROUND: Investigators have used a variety of operational definitions of nursing hours of care in measuring nurse staffing for health services research. However, little is known about which approach is best for nurse staffing measurement. OBJECTIVE: To examine whether various nursing hours measures yield different model estimations when predicting patient outcomes and to determine the best method to measure nurse staffing based on the model estimations. DATA SOURCES/SETTING: We analyzed data from the University HealthSystem Consortium for 2005. The sample comprised 208 hospital-quarter observations from 54 hospitals, representing information on 971 adult-care units and about 1 million inpatient discharges. METHODS: We compared regression models using different combinations of staffing measures based on productive/nonproductive and direct-care/indirect-care hours. Akaike Information Criterion and Bayesian Information Criterion were used in the assessment of staffing measure performance. RESULTS: The models that included the staffing measure calculated from productive hours by direct-care providers were best, in general. However, the Akaike Information Criterion and Bayesian Information Criterion differences between models were small, indicating that distinguishing nonproductive and indirect-care hours from productive direct-care hours does not substantially affect the approximation of the relationship between nurse staffing and patient outcomes. CONCLUSIONS: This study is the first to explicitly evaluate various measures of nurse staffing. Productive hours by direct-care providers are the strongest measure related to patient outcomes and thus should be preferred in research on nurse staffing and patient outcomes.

Handoffs and Patient Safety: Grasping the Story and Painting a Full Picture.

Effective handoff communication is critical for patient safety. Research is needed to understand how information processes occurring intra-shift impact handoff effectiveness. The purpose of this qualitative study was to examine medical-surgical nurses' (n = 21) perspectives about processes that promote and hinder patient safety intra-shift and during handoff. Results indicated that offgoing nurses' ability to grasp the story intra-shift was essential to convey the full picture during handoff. When oncoming nurses understood the picture being conveyed at the handoff, nurses jointly painted a full picture. Arriving and leaving the handoff with this level of information promoted patient safety. However, intra-shift disruptions often impeded nurses in their processes to grasp the story thus posing risks to patient safety. Improvement efforts need to target the different processes involved in grasping the story and painting a full picture. Future research needs to examine handoff practices and outcomes on units with good and poor practice environments.

Psychiatric boarding incidence, duration, and associated factors in United States emergency departments.

INTRODUCTION: Boarding, especially among psychiatric patients, has been characterized as a significant cause of ED crowding, but no quantitative analysis has described boarding nationally. This study determines the incidence, duration, and factors associated with ED boarding in the United States. METHODS: 2008 National Hospital Ambulatory Medical Care Survey ED data were stratified by visit type (psychiatric vs. non-psychiatric), boarding status, and patient and hospital characteristics. Boarding was defined as a visit with an ED length of stay >6 hours, and boarding time as ED length of stay minus 6 hours. Pearson's chi-square tests describe hospital and patient characteristics stratified by boarding status. Multilevel multivariable logistic and linear regressions determine associations with boarding and boarding time. RESULTS: While 11% of all ED patients boarded, 21.5% of all psychiatric ED patients boarded. Boarding was also more prolonged for psychiatric ED patients. Controlling for confounders, odds of boarding for psychiatric patients were 4.78 (2.63-8.66) times higher than non-psychiatric, and psychiatric patients boarded 2.78 (1.91-3.64) hours longer than non-psychiatric. DISCUSSION: US EDs experienced high proportions and durations of boarding with psychiatric patients disproportionately affected. Additional research concerning mental health care services and legislation may be required to address ED psychiatric patient boarding.

Hospital staff registered nurses' perception of horizontal violence, peer relationships, and the quality and safety of patient care.

OBJECTIVE: To test hypotheses from a horizontal violence and quality and safety of patient care model: horizontal violence (negative behavior among peers) is inversely related to peer relations, quality of care and it is positively related to errors and adverse events. Additionally, the association between horizontal violence, peer relations, quality of care, errors and adverse events, and nurse and work characteristics were determined. PARTICIPANTS: A random sample (n= 175) of hospital staff Registered Nurses working in California. METHODS: Nurses participated via survey. Bivariate and multivariate analyses tested the study hypotheses. RESULTS: Hypotheses were supported. Horizontal violence was inversely related to peer relations and quality of care, and positively related to errors and adverse events. Including peer relations in the analyses altered the relationship between horizontal violence and quality of care but not between horizontal violence, errors and adverse events. Nurse and hospital characteristics were not related to other variables. Clinical area contributed significantly in predicting the quality of care, errors and adverse events but not peer relationships. CONCLUSIONS: Horizontal violence affects peer relationships and the quality and safety of patient care as perceived by participating nurses. Supportive peer relationships are important to mitigate the impact of horizontal violence on quality of care.

The effects of cognitive impairment on nursing home residents' emergency department visits and hospitalizations.

BACKGROUND: Little is known about the relationship of cognitive impairment (CI) in nursing home (NH) residents and their use of emergency department (ED) and subsequent hospital services. METHODS: We analyzed 2006 Medicare claims and resident assessment data for 112,412 Medicare beneficiaries aged >65 years residing in US nursing facilities. We estimated the effect of resident characteristics and severity of CI on rates of total ED visits per year, then estimated the odds of hospitalization after ED evaluation. RESULTS: Mild CI predicted higher rates of ED visits relative to no CI, and ED visit rates decreased as severity of CI increased. In unadjusted models, mild CI and very severe CI predicted higher odds of hospitalization after ED evaluation; however, after adjusting for other factors, severity of CI was not significant. CONCLUSIONS: Higher rates of ED visits among those with mild CI may represent a unique marker in the presentation of acute illness and warrant further investigation.

Adherence to institution-specific ventilator-associated pneumonia prevention guidelines.

BACKGROUND: Various institution-specific guidelines have been developed to prevent ventilator-associated pneumonia. However, the availability of guidelines does not ensure adherence to recommended strategies. OBJECTIVE: To identify factors that influence adherence to guidelines for prevention of ventilator-associated pneumonia, with a focus on oral hygiene, head-of-bed elevation, and spontaneous breathing trials. METHODS: A cross-sectional descriptive study of critical care nurses at 8 hospitals in Northern California was conducted. A survey was created to gather information on possible facilitators of and barriers to adherence to institution-specific guidelines for preventing ventilator-associated pneumonia. User factors, guideline qualities, and contextual factors were explored and tested for possible relationships. RESULTS: A total of 576 critical care nurses participated in the survey. Each hospital had unique guidelines for preventing ventilator-associated pneumonia. In general, nurses had positive attitudes and reported adhering to the guidelines always or most of the time. Factors associated with adherence differed according to the intervention implemented. The score on the user attitude scale was the strongest and most consistent predictor of adherence across interventions (odds ratio, 3.49-4.75). Time availability (odds ratio, 1.54) and the level of prioritization (odds ratio, 1.86) were also significant predictors. CONCLUSION: The most consistent facilitator of adherence to guidelines for prevention of ventilator-associated pneumonia was nurses' positive attitude toward the guidelines.

The relationship between hospital systems load and patient harm.

OBJECTIVES: The objective of this study was to describe the relationship between patient harm due to health-care errors and the stresses on the hospital systems that occur because of the patients in need of care. METHODS: Two California hospitals each provided 1 year of data to study the relationship between patient harm and Hospital Systems Load. This observational study used 2 metrics, Hospital Systems Load and patient harm. Hospital Systems Load was a composite measure consisting of the areas in the hospital most sensitive to intensity of service developed using factor analysis and clinical judgment to select the components. Patient harm was assessed using a weighted measure of all hospital incidents occurring during a single day and another controlling for census. Analyses were performed separately for each hospital, and each was broken up into weekdays and weekends. These 8 conditions were compared using a Pearson's r and a trend analysis. RESULTS: Patient harm trended upward as the Hospital Systems Load increased. Six of the 8 analyses were statistically significant. CONCLUSIONS: The results of this analysis are highly suggestive of a relationship between Hospital Systems Load and patient harm.

The effects of RN staffing hours on nursing home quality: a two-stage model.

OBJECTIVES/BACKGROUND: Based on structure-process-outcome approach, this study examined the association of registered nurse (RN) staffing hours and five quality indicators, including two process measures (catheter use and antipsychotic drug use) and three outcome measures (pressure ulcers, urinary tract infections, and weight loss). SETTING/PARTICIPANTS: We used data on resident assessments, RN staffing, organizational characteristics, and market factors to examine the quality of 195 nursing homes operating in a rural state of United States - Colorado. DESIGN/METHODS: Two-stage least squares regression models were performed to address the endogenous relationships between RN staffing and the outcome-related quality indicators, and ordinary least squares regression was used for the process-related ones. This analysis focused on the relationship of RN staffing to nursing home quality indicators, controlling for organizational characteristics, resources, resident casemix, and market factors with clustering to control for geographical differences. RESULTS: Higher RN hours were associated with fewer pressure ulcers, but RN hours were not related to the other quality indicators. CONCLUSIONS: The study finding shows the importance of understanding the role of 'nurse staffing' under nursing home care, as well as the significance of associated/contextual factors with nursing home quality even in a small rural state.

Managerial span of control: a pilot study comparing departmental complexity and number of direct reports.

Nurse managers play pivotal roles in hospitals. However, restructuring has resulted in nurse managers having wider span of control and reduced visibility. The purpose of this pilot study was to compare two methods of measuring span of control: departmental complexity and number of direct reports. Forty-one nurse managers across nine hospitals completed The Ottawa Hospital Clinical Manager Span of Control Tool (TOH-SOC) and a demographic survey. A moderate positive relationship between number of direct reports and departmental complexity score was identified (r=.49, p=<.01). Intensive care departments were more likely to be classified differently, using departmental complexity compared to number of direct reports (54%). TOH-SOC is a reliable instrument (Cronbach's alpha = .838). Using departmental complexity rather than direct reports may more accurately reflect the full scope of nurse managers' responsibility.

Validity and reliability on three European language versions of the Safety Organizing Scale.

BACKGROUND: The Safety Organizing Scale (SOS) offers a reliable snapshot of nurses' engagement in unit-level safety behaviors in hospitals. As no comparable questionnaire exists in German, French and Italian, we explored the psychometric properties of SOS translations into each of those languages. DESIGN AND METHODS: The psychometric properties of the nine-item SOS were tested according to American Educational Research Association guidelines. SUBJECTS AND SETTING: Between October 2009 and June 2010, 1633 registered medical and/or surgical nurses in 35 Swiss hospitals completed translated SOS questionnaires. RESULTS: For each translation, psychometric evaluation revealed evidence based on content (scale-content validity index >0.89), response patterns (e.g. average of missing values across all items = 0.80%), internal structure (e.g. comparative fit indices >0.90, root mean square error of approximation <0.08) and reliability (Cronbach's alpha >0.79). We differentiated the scale regarding one related concept (implicit rationing of nursing care). Higher SOS scores correlated with supportive leadership and lower nurse-reported medication errors, but not with nurse-reported patient falls. CONCLUSIONS: The SOS offers a valuable measurement of engagement in safety practices that might influence patient outcomes. Initial evidence regarding the validity and reliability of the translated versions supports their use in German, French and Italian. Concurrent validity will require confirmation via further analysis using more reliable outcome measures (e.g. mortality rates). The translated versions' predictive validity needs to be established in prospective studies.

Baccalaureate education in nursing and patient outcomes.

OBJECTIVES: The aim of this study was to examine the effects of registered nurse (RN) education by determining whether nurse-sensitive patient outcomes were better in hospitals with a higher proportion of RNs with baccalaureate degrees. BACKGROUND: The Future of Nursing report recommends increasing the percentage of RNs with baccalaureate degrees from 50% to 80% by 2020. Research has linked RN education levels to hospital mortality rates but not with other nurse-sensitive outcomes. METHODS: This was a cross-sectional study that, with the use of data from 21 University HealthSystem Consortium hospitals, analyzed the association between RN education and patient outcomes (risk-adjusted patient safety and quality of care indicators), controlling for nurse staffing and hospital characteristics. RESULTS: Hospitals with a higher percentage of RNs with baccalaureate or higher degrees had lower congestive heart failure mortality, decubitus ulcers, failure to rescue, and postoperative deep vein thrombosis or pulmonary embolism and shorter length of stay. CONCLUSION: The recommendation of the Future of Nursing report to increase RN education levels is supported by these findings.

The association of patient safety climate and nurse-related organizational factors with selected patient outcomes: a cross-sectional survey.

BACKGROUND: Patient safety climate (PSC) is an important work environment factor determining patient safety and quality of care in healthcare organizations. Few studies have investigated the relationship between PSC and patient outcomes, considering possible confounding effects of other nurse-related organizational factors. OBJECTIVE: The purpose of this study was to explore the relationship between PSC and patient outcomes in Swiss acute care hospitals, adjusting for major organizational variables. METHODS: This is a sub-study of the Swiss arm of the multicenter-cross sectional RN4CAST (Nurse Forecasting: Human Resources Planning in Nursing) study. We utilized data from 1630 registered nurses (RNs) working in 132 surgical, medical and mixed surgical-medical units within 35 Swiss acute care hospitals. PSC was measured with the 9-item Safety Organizing Scale. Other organizational variables measured with established instruments included the quality of the nurse practice environment, implicit rationing of nursing care, nurse staffing, and skill mix levels. We performed multilevel multivariate logistic regression to explore relationships between seven patient outcomes (nurse-reported medication errors, pressure ulcers, patient falls, urinary tract infection, bloodstream infection, pneumonia; and patient satisfaction) and PSC. RESULTS: In none of our regression models was PSC a significant predictor for any of the seven patient outcomes. From our nurse-related organizational variables, the most robust predictor was implicit rationing of nursing care. After controlling for major organizational variables and hierarchical data structure, higher levels of implicit rationing of nursing care resulted in significant decrease in the odds of patient satisfaction (OR=0.276, 95%CI=0.113-0.675) and significant increase in the odds of nurse reported medication errors (OR=2.513, 95%CI=1.118-5.653), bloodstream infections (OR=3.011, 95%CI=1.429-6.347), and pneumonia (OR=2.672, 95%CI=1.117-6.395). CONCLUSIONS: We failed to confirm our hypotheses that PSC is related to improved patient outcomes, which we need to re-test with more reliable outcome measures, such as 30-day patient mortality. Based on our findings, general medical/surgical units should monitor the rationing of nursing care levels which may help to detect imbalances in the "work system", such as inadequate nurse staffing or skill mix levels to meet patients' needs.

Horizontal violence among hospital staff nurses related to oppressed self or oppressed group.

Horizontal violence among nurses is recognized as a major problem in hospitals; however, the origins and effects on patient care have not been studied. This study described the incidence of horizontal violence among hospital staff RNs and tested 2 hypotheses about the social origins of this behavior. A random sample of 175 hospital staff RNs drawn from the California Board of Registered Nursing's mailing list was surveyed. Horizontal violence was reported by 21.1% (n = 37) of participating nurses. Hypotheses were supported. Findings suggested (a) a positive relationship between beliefs consistent with an oppressed self and horizontal violence (r = .434, P < .05) and (b) a positive relationship between beliefs consistent with those of an oppressed group and horizontal violence (r = .453, P < .05). A change in the oppressive social structure of hospitals may be needed to truly address horizontal violence in the best interest of the quality and safety of patient care.