Widespread reports of declining levels of quality of care and patient safety in hospitals, an escalation in calls for legislation mandating minimum nurse staffing ratios, and growing levels of nurse burnout and a looming nursing shortage have focused attention on the working conditions that nurses face and their implications for patient outcomes. This article reports on the preliminary results of an international study on how nurse staffing levels and the nursing practice environment affect the quality of care and patient outcomes in hospitals. Surveys of staff nurses working in acute care hospitals in Pennsylvania reveal that one out of every five staff nurses reported the quality of care on their unit as fair or poor. Workload played a role in these quality assessments, but it was the consequences of workload, such as the reports of unfinished nursing at the end of the last shift and the frequency of adverse events among patients, that played a much more prominent role.
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References
1.
Agency for Healthcare Research and Quality . (2000). Research Activities, July 2000, no. 239.
2.
Aiken, L. H. , Lake, E. T., Sochalski, J., & Sloane, D. M. (1997). Design of an outcomes study of the organization of hospital AIDS care. Research in the Sociology of Health Care, 14, 3-26.
3.
Aiken, L. H. , & Patrician, P. A. (2000). Measuring organizational traits of hospitals: the Revised Nursing Work Index. Nursing Research, 49(3), 146-153.
4.
Aiken, L. H. , Sloane, D. M., & Klocinski, J. L. (1997). Hospital nurses’ occupational exposure to blood: Prospective, retrospective, and institutional reports. American Journal of Public Health, 87(1), 103-107.
5.
Aiken, L. H. , Sloane, D. M., Lake, E. T., Sochalski, J., & Weber, A. L. (1999). Organization and outcomes of inpatient AIDS care. Medical Care, 37(8), 760-772.
6.
al-Haider, A. S. , & Wan, T. T. (1991). Modeling organizational determinants of hospital mortality. Health Services Research, 26(3), 303-323.
7.
American Nurses Association . (1996). Nursing quality indicators definitions and implications. Washington, DC: American Nurses Publishing.
8.
American Nurses Association . (2000). Nurse staffing and patient outcomes in the inpatient hospital setting. Washington, DC: American Nurses Publishing.
9.
Bernreuter, M. E. , & Cardona, M. S. (1997). Survey and critique of studies related to unlicenced assistive personnel from 1975 to 1997, part 1. Journal of Nursing Administration, 27(6), 24-29.
10.
Blegen, M. A. , Goode, C. J., & Reed L. (1998). Nurse staffing and patient outcomes. Nursing Research, 47(1), 43-50.
11.
Blegen, M. A. , & Vaughn, T. (1998). A multisite study of nurse staffing and patient occurrences. Nursing Economics, 16(4), 196-203.
12.
Brannon, R. L. (1996). Restructuring hospital nursing: reversing the trend toward a professional workforce. International Journal of Health Services, 26, 643-654.
13.
Buerhaus, P. I. , & Needleman, J. (2000). Policy implications for research on nurse staffing and quality of patient care. Policy, Politics, & Nursing Practice, 1(1), 5-15.
14.
Czaplinski, C. , & Diers, D. (1998). The effect of staff nursing on length of stay and mortality. Medical Care, 36(12), 1626-1638.
15.
Dillman, D. A. (1978). Mail and telephone surveys: The total design method. New York: John Wiley.
16.
Ginsburg, P. (1999). Tracking health care costs: Long-predicted upturn appears (Issue Brief No. 23). Washington, DC: Center for Studying Health System Change.
17.
Hall, L. M. (1998). Policy implications when changing staff mix. Nursing Economics, 16(6), 291-297, 312.
18.
Hartz, A. J. , Krakauer, H., Kuhn, E. M., Young, M., Jacobsen, S. J., Gay, G., Muenz, L., Katzoff, M., Bailey, R. C., & Rimm, A. A. (1989). Hospital characteristics and mortality rates. New England Journal of Medicine, 321(25), 1720-1725.
19.
Institute of Medicine . (1999). To err is human: Building a safer health system. Washington, DC: National Academy Press.
20.
Kaiser Family Foundation and Harvard School of Public Health . (1999). 1999 survey of physicians and nurses [Online]. Available: http://www.kff.org
21.
Kovner, C. T. , & Gergen, P. J. (1998). Nurse staffing levels and adverse events following surgery in U.S. hospitals. Image, 30(4), 315-321.
22.
Kramer, M. , & Hafner, L. (1989). Shared values: Impact on staff nurse job satisfaction and perceived productivity. Nursing Research, 38(3), 172-177.
23.
Lee, J. L. , Chang, B. L., Pearson, M. L., Kahn, K. L., & Rubenstein, L. V. (1999). Does what nurses do affect clinical outcomes for hospitalized patients? A review of the literature. Health Services Research, 34(5), 1011-1032.
24.
Levit, K. , Cowan, C., Lazenby, H., Sensenig, A., McDonnell, P., Stiller, J., & Martin, A. (2000). Health spending in 1998: Signals of change. Health Affairs, 19(1), 124-132.
25.
Maslach, C. , & Jackson, S. E. (1982). Burnout in health professions: A social psychological analysis. In G. S. Snaders & J. Suls (Eds.), Social psychology of health and illness (pp. 227-251). Hillsdale, NJ: Lawrence Erlbaum Associates.
26.
Maslach, C. , Jackson, S. E., Leiter, M. P. (1997). Maslach Burnout Inventory: Third edition. In C. P. Zalaquett & R. J. Wood (Eds.), Evaluating stress: A book of resources (pp. 191-218). Lanham, MD: Scarecrow Press.
27.
McKee, M. , Aiken, L. H., Rafferty, A. M., Sochalski, J. (1998). Organisational change and quality of health care: An evolving international agenda. Quality of Health Care, 7(1), 37-41.
28.
Mitchell, P. H. , Armstrong, S., Simpson, T. F., & Lentz, M. (1989). American Association of Critical-Care Nurses Demonstration Project: Profile of excellence in critical care nursing. Heart & Lung, 18(3), 219-237.
29.
Pearson, M. L. , Lee, J. L., Chang, B. L., Elliott, H, M., Kahn, K. L., & Rubenstein, L. V. (2000). Structured implicit review: A new method for monitoring nursing care quality. Medical Care, 38 (11), 1074-1091,.
30.
Shindul-Rothschild, J. , Berry, D., & Long-Middleton, E. (1996). Where have all the nurses gone? Final results of our patient care survey. American Journal of Nursing, 96(11), 24-39.
31.
Shindul-Rothschild, J. , & Duffy, M. (1996). The impact of restructuring and work design on nursing practice and patient care. Best Practices and Benchmarking in Health Care, 1(6), 271-282.
32.
Shortell, S. M. , & Hughes, E. F. (1988). The effects of regulation, competition, and ownership on mortality rates among hospital inpatients. New England Journal of Medicine, 318(17), 1100-1107.
33.
Siehoff, A. M. (1998). Impact of unlicenced assistive personnel on patient satisfaction: An integrative review of the literature. Journal of Nursing Care Quality, 13(2), 1-10.
34.
Sochalski, J. , & Aiken, L. H. (1999). Accounting for variation in hospital outcomes: A cross-national study. Health Affairs, 18(2), 256-259.
35.
Sochalski, J. , Aiken, L. H., & Fagin, C. M. (1997). Hospital restructuring in the United States, Canada, and Western Europe: An outcomes research agenda. Medical Care, 35 (Suppl. 10), OS13-OS25.
36.
Sochalski, J. , Estabrooks, C. A., & Humphrey, C. K. (1999). Nurse staffing and patient outcomes: Evolution of an international study. Canadian Journal of Nursing Research, 31(3), 69-88.
37.
van Servellen, G. , & Schultz, M. A. (1999). Demystifying the influence of hospital characteristics on inpatient mortality rates. Journal of Nursing Administration, 29(4), 39-47.
38.
Walston, S. L. , Burns, L. R., & Kimberly, J. R. (2000). Does reengineering really work? An examination of the context and outcomes of hospital reengineering initiatives. Health Services Research, 34(6), 1363-1388.
39.
Walston, S. L. , & Kimberly, J. R. (1997). Reengineering hospitals: Experience and analysis from the field. Hospital and Health Services Administration, 42(2), 143-163.
40.
White, K. L. (1997). Hospital restructuring in North America and Europe. Medical Care, 35(Suppl. 10), OS7-OS12.
41.
Wunderlich, G. S. , Sloan, F. A., & Davis, C. K. (Eds.) (1996). Nursing staff in hospitals and nursing homes: Is it adequate?Washington, DC: National Academy Press.
42.
Young, G. J. , Charns, M. P., Desai, K., Khuri, S. F., Forbes, M. G., Henderson, W., & Daly, J. (1998). Patterns of coordination and clinical outcomes: A study of surgical outcomes. Health Services Research, 33(5), 1211-1236.
