Hospital registered nurse shortages: environmental, patient, and institutional predictors.

OBJECTIVE: To examine the characteristics of acute-care hospitals that report registered nurse shortages when a widespread shortage exists and when a widespread shortage is no longer evident. DATA SOURCE: Secondary data from the American Hospital Association's Nursing Personnel Survey from 1990 and 1992 were used. The study population was all acute-care hospitals in the United States. STUDY DESIGN: Outcome variables included whether a hospital experienced a shortage in 1990, when many hospitals reported a nursing shortage, or whether a hospital reported a shortage in both 1990 and 1992. Predictor variables included environmental, patient, and institutional characteristics. Associations between predictor and outcome variables were investigated using probit analyses. PRINCIPAL FINDINGS: Location in the South, a high percentage of nonwhite county residents, a high percentage of patients with Medicaid or Medicare as payer, a higher patient acuity, and use of team or functional nursing care delivery consistently predicted hospitals reporting shortages both when there was a widespread shortage and when there was no widespread shortage. CONCLUSIONS: Although some characteristics under the direct control of hospitals, such as nursing care delivery model, are associated with their reporting a shortage of nurses, shortage is also strongly associated with broader population characteristics such as minority communities and a public insurance payer mix. Awareness of these broader factors may help inform policies to improve the distribution of nurse supply.

Alcohol, head injury, and pulmonary complications.

The purpose of this study was to determine the difference in rates of pulmonary complications (e.g., aspiration, pneumonia) in head-injured patients with and without concomitant alcohol intoxication. The records of 98 consecutive patients admitted over a 1-year period to a Level I Trauma Center were reviewed. The patients were grouped into three subsets: acutely intoxicated (n = 26), acutely intoxicated with a diagnosis of chronic alcoholism (n = 14), and non-intoxicated (n = 58). Alcohol intoxication was defined as a blood alcohol level (BAL) > or = 0.08 mg/dl. Admission BALs and Glasgow Coma Scale (GCS) scores were tabulated at admission. Frequency of arterial blood gas (ABG) measurements, need for an artificial airway/mechanical ventilation, and length of stay (LOS) were analyzed by using one-way analysis of variance. Intergroup differences in breath sounds were compared by using the nonparametric Kruskall-Wallis technique. We found no statistical difference between groups in terms of pulmonary sequelae despite the remarkably high BALs observed in the study groups. Similarly, there was no statistically greater LOS in the groups with alcohol intoxication than in alcohol-free cohorts. Despite a great deal of BAL science research to support our hypothesis, we failed to demonstrate a significantly higher rate of pulmonary problems in inebriated individuals with head injuries. We found that our strict exclusion criteria (no concomitant chest, abdominal, or pelvic trauma) limited the sample to only those patients without significant intracranial bleeding, whereas most complications in blood alcohol neuroscience research have been associated with much larger mass lesions (e.g., epidural or subdural hematomas). In addition, we found the characterizations of patients as chronically alcoholic were cumbersome and inaccurate in many cases. Future research should allow for a greater range of concomitant injuries that might suggest a positive or negative relationship to acute intoxication.

Errors in data on hospital ownership.

In recent years, there has been increased public concern about changes in hospital ownership and consolidation in the hospital market. Numerous studies have examined the relationship between hospital ownership and prices, costs, organization, service mix, access to care and quality of care. However, the data on which these studies are based are often incomplete and inaccurate. In this paper, we examine several sources of data employed by researchers examining hospital ownership and discuss the degree of inaccuracy we found in each source. Substantial primary data collection is necessary to accurately account for changes in ownership and system affiliation.

Measuring shortages of hospital nurses: how do you know a hospital with a nursing shortage when you see one?

Lack of clarity in definitions of shortages of hospital registered nurses may cause problems for effective policy making, particularly if different measures for identifying a nurse shortage lead to different conclusions about which hospitals and regions are experiencing a shortage. The authors compared different methods of identifying hospitals and regions with a shortage of registered nurses, including both relatively subjective measures (e.g., a hospital administrator's report of a nurse shortage) and more objective measures (e.g., number of registered nurses per inpatient year). Associations were strongest between self-reported shortage status and nursing vacancy rates and weaker for self-reported shortage status and registered nurses per inpatient year and overall regional supply of nurses. Different definitions of nursing shortage are not equally reliable in discriminating between hospitals and regions with and without nursing shortages. When faced with reports sounding an alarm about a hospital nursing shortage, policy makers should carefully consider the definition of shortage being used.

Registered nurses, unlicensed assistive personnel, and organizational culture in hospitals.

OBJECTIVE: This study investigated "thinking and behavioral" styles that are used to measure the concept of organizational culture among registered nurses (RNs) and unlicensed assistive personnel (UAPs) in acute care hospitals. BACKGROUND: The Organizational Culture Inventory has been used in numerous industries, including hospitals, to describe aspects of organizational culture in order to better understand and manage change. Evidence shows that nursing unit and hospital culture tends to be "constructive" but little evidence indicates whether workers in different job categories influence the culture differently. METHOD: This survey was conducted in five tertiary care hospitals on the west coast of the United States. The design is cross-sectional and analytic. A convenience sample was recruited from staff members working at least 20 hours per week in the adult medical-surgical and specialty nursing units. Analyses include descriptive statistics and multiple regression. RESULTS: Staff members of color, regardless of position, scored higher on the thinking and behavioral styles of approval, avoidance, and competitiveness. Unlicensed assistive personnel, regardless of race or ethnicity, scored higher on the thinking and behavioral styles dependence and opposition. CONCLUSION: Nurse administrators and managers should be aware of how the addition of unlicensed assistive personnel or people of color can change the culture of the nursing unit or hospital. Explicit management strategies may be necessary to promote employee behaviors that are desirable for patient care and for the organization.

Evaluation of a hospital work redesign: patient-focused care.

The 1990s have seen a frenzy of work redesign in acute care hospitals/health systems. Much of the redesign work in acute care hospitals has centered on changing how nurses organize and deliver care to patients. But have we really determined that redesigning nursing care delivery does what we want? The author describes the introduction of patient-focused care at one tertiary care university teaching hospital and answers the following question: Is there a change in provider or patient outcomes when the nursing care delivery system is changed from primary/total patient care to patient-focused care?

Factors influencing stay in the postanesthesia care unit: a prospective analysis.

STUDY OBJECTIVE: To identify indicators of prolonged length of stay (LOS) in the postanesthesia care unit (PACU) and to test the following hypotheses: (1) that patient age, pain medication administration at the time of PACU admission, length of surgery, and cardiovascular, pulmonary, and pain responses postoperatively predict prolonged PACU LOS and (2) that cardiovascular and pulmonary symptoms preoperatively predict cardiovascular and pulmonary symptoms postoperatively. DESIGN: Prospective, observational analysis. SETTING: PACU of a university teaching hospital. PATIENTS: 1,067 patients scheduled for surgery with general anesthesia between February and September 1996, 18 years of age or older. MEASUREMENT AND MAIN RESULTS: 11.2% of the variation in prolonged PACU LOS can be predicted by age, pain medication at the time of PACU admission, and postoperative cardiovascular, pulmonary, and pain symptoms. A significant number of patients who did not report a prior history experienced postoperative cardiovascular and pulmonary symptoms. CONCLUSION: Patient history and postoperative symptoms predict only a small percentage of prolonged PACU stays. Organizational factors may be a more important predictor of prolonged PACU stay. Additionally, assessment of cardiovascular and pulmonary history needs refinement to improve prediction of patient responses postoperatively.

Five pitfalls of work redesign in acute care.

During work redesign in nursing units, five common pitfalls can emerge: moving too fast, failing to involve major stakeholders, discounting bargaining unit contracts, separating training classes and not defining desired outcomes. Suggestions on how to avoid these problems are given.

Job strain among registered nurses and other hospital workers.

OBJECTIVE: The authors describe factors associated with job strain for various job titles in the acute care hospital using the Karasek Job Strain Model, discuss the reliability and validity of the Job Content Questionnaire, and discuss use of the model to enhance the work environment. BACKGROUND: The Karasek Job Strain Model has been used to describe many occupations in the United States and other countries. Some research indicates that occupations that arouse stress hormones are those in which employees have little job control or must complete psychologically demanding tasks, such as those under time pressure, and these positions can be describe as high-strain jobs. METHOD: This descriptive correlational study was conducted at five tertiary care hospitals on the West Coast. A purposive volunteer sample of staff members working at least 20 hours per week in the adult medical-surgical and specialty nursing units was recruited. RESULTS: Mean scores for each of the nursing units and the overall mean scores for the staff in the initial analysis fell into the Active Work quadrant of the Karasek Job Strain Model. When nursing job titles were analyzed, registered nurses had significantly higher Decision Latitude scores than did nurse assistants (P < 0.001) and clerical staff (P < 0.001), but there were no significant differences for Psychological Demands. CONCLUSIONS: Working with nurse assistants to appropriately increase decision latitude related to their work has the potential to enhance the work environment by reducing job strain and improving staff health and morale.

Organizational culture in hospitals: issues in measurement.

It is still not clear that organizational culture in hospitals is linked to patient or provider outcomes. However, measurement of organizational culture in nursing units within hospitals and for entire hospitals is common. Two instruments frequently used to measure hospital culture or work group culture within hospitals are the Organizational Culture Inventory (OCI) (Cooke & Lafferty, 1987) and the Nursing Unit Cultural Assessment Tool (NUCAT-2) (Coeling & Simms, 1993a). The purpose of this paper is to review selected empirical studies of organizational and work group culture in hospitals and critique these two measurement instruments. The paper discusses the issues of unit of analysis/aggregation bias and sample size when using these two instruments. It was concluded that OCI has been widely used in many types of organizations and has substantial data supporting the reliability and validity. However, the instrument does not always capture variation in nursing units. The NUCAT-2 has less reliability and validity data but researchers have reported wide variation among units. Individual items can be selected for use from the NUCAT-2 and it is less expensive to use than the OCI.

Culture of troubled work groups.

Managing the troubled or conflicted work group can occupy a great deal of a manager's time and energy. One hundred fifteen nurse managers and administrators responded to a descriptive survey exploring the characteristics of the culture of troubled or conflicted work groups. Those managers and administrators also described numerous successful strategies that they had used in managing these work groups.

Work group culture, stress, and hostility. Correlations with organizational outcomes.

Understanding your organizational culture is necessary if you are to be successful in making and surviving the necessary changes in current environments. Although organizational culture frequently has been studied in the business community, there are fewer studies of organizational or work group culture in hospital settings at the nursing unit level. The existing studies have emphasized the need to understand the individual work group culture before successfully implementing innovation and educational programs, or hiring and orienting new employees on nursing units. This descriptive, correlational study describes the relationships among work group culture, work-place stress, and hostility and nursing unit outcomes, specifically absenteeism and turnover. Implications of the findings include the idea that increasing decision latitude in workers may positively impact absenteeism.

A three tier competency program.

One of the complex problems facing nurse administrators and staff development educators is providing a mechanism to ensure competency of the nursing staff in specialty areas of practice. At the Santa Clara Valley Medical Center in San Jose, California, a staff nurse devised a program to solve this problem. One of the benefits of the program was to increase nurse retention and decrease turnover in a busy urban hospital.