Presentation on theme: "Nursing Characteristics that Affect Patient Outcomes"— Presentation transcript:
1Nursing Characteristics that Affect Patient Outcomes Shana GreenEileen Lake, Robyn CheungCenter for Health Outcomes, Policy and Research (CHOPR)
2SUMR GoalsLearn about the theory and research linking nursing to qualityAssist with collection of quantitative data in multisite hospital studyLearn the sections of a research manuscript and assist to prepare different sectionsLearn to prepare/write a proposalDevelop a presentation of study findings for a research meeting
3Acuity-adjusted Staffing, Nurse Practice Environments and NICU Outcomes
4Acuity-adjusted Staffing… Purpose To examine whether acuity-adjusted nurse staffing and environments contribute to variation in VLBW infant outcomes in NICUs.
5Adjusted- acuity Staffing… Methods Observational study with data collected by web survey6400 nurses in 104 NICUs from the Vermont Oxford Network (VON)8490 infants from VON database
6Acuity- adjusted Staffing… Measures Nurse StaffingAn estimate of the average of patient needs on a particular unitsNo standardized method of selecting nurse staffing levelsAcuityAverage severity of illness of inpatient populationDetermines amount of care patient needsNo standardized methods for determining the acuity of infants in NICUAcuity WeightsDaily proportion of a nurses required to take care for an infant in an acuity category.
7Acuity- adjusted Staffing…Results On average, a nurse cared for two infants, but this varied by infant acuity.Infant acuityInfants in acuity levels 1, 2, and 3 comprise the largest proportion of infants.Acuity levelNurse/patient ratioContinuing care 10.34Intermediate care 20.38Intensive care 30.49Multi- system support 40.66Complex critical care 50.95
8Acuity- adjusted Staffing…Results Nurse Qualifications56% BSN19% neonatal specialist74% ≥5 years in NICUProfessional Practice EnvironmentExceptional hospital sample~5,000 hospitals523 hospitals104 hospitals
9Acuity- adjusted Staffing…Results OutcomesA lower staffing level is associated with higher proportions of BSNs and NICU-experienced nursesStaffing and BSN proportion are associated with mortalityNICU experience is associated with SIVHA more professional practice environment is associated with lower odds of infection.VLBW infants in magnet hospitals had lower odds of mortality.
10Nursing Unit Organization and Very Low Birth Weight Infant Outcomes in Neonatal Intensive Care Units Eileen Lake, PhD, RN, FAAN, University of PennsylvaniaJeannette Rogowski, PhD, University of Medicine and Dentistry of New JerseyJeffrey Horbar, MD, University of VermontDouglas Staiger, PhD, Dartmouth CollegeMichael Kenny, MS, University of VermontThelma Patrick, RN, PhD, The Ohio State UniversityRobyn Cheung, RN, PhD, University of PennsylvaniaVLBW infants are high-risk patients closely monitored through life support measures and intensive interventions in NICUsNursing care may provide an opportunity to improve outcomes; since unexplained variations exist.BackgroundStaffingOn average, a nurse cared for two infants, but this varied by infant acuity (Table 1 and Fig. 1).Infant acuityInfants in acuity levels 1, 2, and 3 comprise the largest proportion of infants. (Fig. 2).Nurse Qualifications56% BSN; 19% neonatal specialist; 74% ≥5 years of nursing experience.Professional Practice EnvironmentExceptional hospital sample: 33% magnet certification based on exemplary nursing standards, compared to VON (19%) and hospitals nationally (6%).OutcomesAverage infant outcomes-- mortality, 11%; nosocomial infection, 17%; severe intraventricular hemorrhage (SIVH), 7%; and chronic lung disease, 26%.Analyses of VON: significantly lower likelihood of death (OR = .86, p = .05) for VLBW infants in magnet hospitals and marginally significant lower likelihood of infection and SIVH. Better professional practice environment appears to be associated with a lower likelihood of infection.ResultsFigure 1. Observed/ expected acuity-adjusted staffing levels for study hospitals.Nurse staffing and environment explains a small amount of the variation in VLBW infant outcomes across NICUsWhile magnet hospitals achieve better infant outcomes, the preponderance of magnet hospitals in the sample cohort makes it hard to differentiate which aspects of these hospitals are influential.ConclusionsOur research findings support evidence-based management decisions to improve the quality of NICU care by:informing managers about staffing ratios and staff qualifications andidentifying the features of practice environments that are most influential for infant outcomes.Policy ImplicationsTo examine whether acuity-adjusted nurse staffing and environments contribute to variation in VLBW infant outcomes in NICUs.ObjectiveFigure 1Figure 2. Percent distribution by infant acuity across 104 NICUs.Study Design, Sample and MethodsTable 1. Nurse to patient ratios by acuity level.Acuity levelNurse/patient ratioContinuing care 10.34Intermediate care 20.38Intensive care 30.49Multi- system support 40.66Complex critical care 50.95Observational study with data collected by web survey6400 nurses in 104 NICUs from the Vermont Oxford Network (VON), an international quality improvement collaborative for neonatal care8490 infants from VON databaseAnalyzed outcomes in random-effects logit models; controlled for patient demographic and birth characteristics.Table 1Figure 2
11Acuity- adjusted Staffing…Next Steps PurposeTo adjust for hospital characteristics (523 VON hospitals) that have an impact on NICU patient outcomesTo find the effect of nursing on NICU patient outcomes.
12Acuity- adjusted Staffing…Next Steps AHA DataDatabase of over 6,000 hospitalsVariablesMNAMEMLOCSTATEMLOCCITYNICBDMapp8Teaching hospital?CNTRLOwnership status?ADJADCCensus of patientsFTERNFull time or equivalent RN
13Acuity- adjusted Staffing…Next Steps Reduce AHA databaseRemove hospitals without NICBD (value 0)Delete non VON hospitalsCompare hospname to mnameEnter magnet status
15NINR Study… Purpose NINR Study Quarterly data collection for nurses and infants in a single shiftExplore staffing patterns across seasonsExplore nursing as a resource to reduce cross-hospital disparities in mortality
16NINR… Site Coordinator Responsibility Secure IRB approvalComply with documentation requirementsCollect and submit statistics on the composition of the nursing unit staff, layout, medical and non-medical personnel staffingCollect infant data from staff nursesEnter data on
17NINR… Site Management Documentation Data Entry Website Pilot Study Secure IRB approvalmodification 3Conflict of InterestPHS (42 CFR Part 50; Subpart F)Responsibility of Applicants for Promoting Objectivity in Research for Which PHS Funding Is SoughtFinancial DisclosureCITI CertificationHuman subjects trainingData Entry WebsitePilot Study
19NINR Study… Progress Pilot Study First Data Collection Protocol Nine SitesJune 15, 2009First Data Collection55 of 77 Sites Collected DataJuly 15, 2009 at 2pmData includes nurse and patient status from 7am to 2pm
20NINR Study… Next Steps Complete first quarter data collection Report staffing level and infant acuity to hospitals in studyComplete remaining 3 quarters of data collectionAnalysis
21Recruiting and Staffing for Clinical Nursing Expertise
22Manuscript Tasks Associated with Manuscript Response to Reviewers Literature ReviewTableAPA Format
23Manuscript Literature Review Expertise View of Expertise Experience Domain specific knowledgeComplex reflexive thinkingIntuitionView of ExpertisePeer nominatedNew measures
24Manuscript Literature Review Cultivation of Expertise Mentorship (Field 2004)Continuing education (Ericsson et. al. 2007)Practice environment (Foley et. al. 2009)CompetitiveDemands excellenceFosters autonomy, practice control and relationship with physicians