1. Nursing Characteristics that Affect Patient Outcomes
Shana Green
Eileen Lake, Robyn Cheung
Center for Health Outcomes, Policy and Research (CHOPR)

2. SUMR Goals
Learn about the theory and research linking nursing to quality
Assist with collection of quantitative data in multisite hospital study
Learn the sections of a research manuscript and assist to prepare different sections
Learn to prepare/write a proposal
Develop a presentation of study findings for a research meeting

3. Acuity-adjusted Staffing, Nurse Practice Environments and NICU Outcomes

4. Acuity-adjusted Staffing… Purpose
To examine whether acuity-adjusted nurse staffing and environments contribute to variation in VLBW infant outcomes in NICUs.

5. Adjusted- acuity Staffing… Methods
Observational study with data collected by web survey
6400 nurses in 104 NICUs from the Vermont Oxford Network (VON)
8490 infants from VON database

6. Acuity- adjusted Staffing… Measures
Nurse Staffing
An estimate of the average of patient needs on a particular units
No standardized method of selecting nurse staffing levels
Acuity
Average severity of illness of inpatient population
Determines amount of care patient needs
No standardized methods for determining the acuity of infants in NICU
Acuity Weights
Daily proportion of a nurses required to take care for an infant in an acuity category.

7. Acuity- adjusted Staffing…Results
On average, a nurse cared for two infants, but this varied by infant acuity.
Infant acuity
Infants in acuity levels 1, 2, and 3 comprise the largest proportion of infants.
Acuity level
Nurse/
patient ratio
Continuing care 1
0.34
Intermediate care 2
0.38
Intensive care 3
0.49
Multi- system support 4
0.66
Complex critical care 5
0.95

8. Acuity- adjusted Staffing…Results
Nurse Qualifications
56% BSN
19% neonatal specialist
74% ≥5 years in NICU
Professional Practice Environment
Exceptional hospital sample
~5,000 hospitals
523 hospitals
104 hospitals

9. Acuity- adjusted Staffing…Results
Outcomes
A lower staffing level is associated with higher proportions of BSNs and NICU-experienced nurses
Staffing and BSN proportion are associated with mortality
NICU experience is associated with SIVH
A more professional practice environment is associated with lower odds of infection.
VLBW infants in magnet hospitals had lower odds of mortality.

10. Nursing Unit Organization and Very Low Birth Weight Infant Outcomes in Neonatal Intensive Care Units
Eileen Lake, PhD, RN, FAAN, University of Pennsylvania
Jeannette Rogowski, PhD, University of Medicine and Dentistry of New Jersey
Jeffrey Horbar, MD, University of Vermont
Douglas Staiger, PhD, Dartmouth College
Michael Kenny, MS, University of Vermont
Thelma Patrick, RN, PhD, The Ohio State University
Robyn Cheung, RN, PhD, University of Pennsylvania
VLBW infants are high-risk patients closely monitored through life support measures and intensive interventions in NICUs
Nursing care may provide an opportunity to improve outcomes; since unexplained variations exist.
Background
Staffing
On average, a nurse cared for two infants, but this varied by infant acuity (Table 1 and Fig. 1).
Infant acuity
Infants in acuity levels 1, 2, and 3 comprise the largest proportion of infants. (Fig. 2).
Nurse Qualifications
56% BSN; 19% neonatal specialist; 74% ≥5 years of nursing experience.
Professional Practice Environment
Exceptional hospital sample: 33% magnet certification based on exemplary nursing standards, compared to VON (19%) and hospitals nationally (6%).
Outcomes
Average 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.
Results
Figure 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 NICUs
While 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.
Conclusions
Our research findings support evidence-based management decisions to improve the quality of NICU care by:
informing managers about staffing ratios and staff qualifications and
identifying the features of practice environments that are most influential for infant outcomes.
Policy Implications
To examine whether acuity-adjusted nurse staffing and environments contribute to variation in VLBW infant outcomes in NICUs.
Objective
Figure 1
Figure 2. Percent distribution by infant acuity across 104 NICUs.
Study Design, Sample and Methods
Table 1. Nurse to patient ratios by acuity level.
Acuity level
Nurse/
patient ratio
Continuing care 1
0.34
Intermediate care 2
0.38
Intensive care 3
0.49
Multi- system support 4
0.66
Complex critical care 5
0.95
Observational study with data collected by web survey
6400 nurses in 104 NICUs from the Vermont Oxford Network (VON), an international quality improvement collaborative for neonatal care
8490 infants from VON database
Analyzed outcomes in random-effects logit models; controlled for patient demographic and birth characteristics.
Table 1
Figure 2

11. Acuity- adjusted Staffing…Next Steps
Purpose
To adjust for hospital characteristics (523 VON hospitals) that have an impact on NICU patient outcomes
To find the effect of nursing on NICU patient outcomes.

12. Acuity- adjusted Staffing…Next Steps
AHA Data
Database of over 6,000 hospitals
Variables
MNAME
MLOCSTATE
MLOCCITY
NICBD
Mapp8
Teaching hospital?
CNTRL
Ownership status?
ADJADC
Census of patients
FTERN
Full time or equivalent RN

13. Acuity- adjusted Staffing…Next Steps
Reduce AHA database
Remove hospitals without NICBD (value 0)
Delete non VON hospitals
Compare hospname to mname
Enter magnet status

14. The Effects of Nursing on NICU Patient Outcomes

15. NINR Study… Purpose NINR Study
Quarterly data collection for nurses and infants in a single shift
Explore staffing patterns across seasons
Explore nursing as a resource to reduce cross-hospital disparities in mortality

16. NINR… Site Coordinator Responsibility
Secure IRB approval
Comply with documentation requirements
Collect and submit statistics on the composition of the nursing unit staff, layout, medical and non-medical personnel staffing
Collect infant data from staff nurses
Enter data on

17. NINR… Site Management Documentation Data Entry Website Pilot Study
Secure IRB approval
modification 3
Conflict of Interest
PHS (42 CFR Part 50; Subpart F)
Responsibility of Applicants for Promoting Objectivity in Research for Which PHS Funding Is Sought
Financial Disclosure
CITI Certification
Human subjects training
Data Entry Website
Pilot Study

18. NINR Study…Data Entry Website

19. NINR Study… Progress Pilot Study First Data Collection Protocol
Nine Sites
June 15, 2009
First Data Collection
55 of 77 Sites Collected Data
July 15, 2009 at 2pm
Data includes nurse and patient status from 7am to 2pm

20. NINR Study… Next Steps Complete first quarter data collection
Report staffing level and infant acuity to hospitals in study
Complete remaining 3 quarters of data collection
Analysis

21. Recruiting and Staffing for Clinical Nursing Expertise

22. Manuscript Tasks Associated with Manuscript Response to Reviewers
Literature Review
Table
APA Format

23. Manuscript Literature Review Expertise View of Expertise Experience
Domain specific knowledge
Complex reflexive thinking
Intuition
View of Expertise
Peer nominated
New measures

24. Manuscript Literature Review Cultivation of Expertise
Mentorship (Field 2004)
Continuing education (Ericsson et. al. 2007)
Practice environment (Foley et. al. 2009)
Competitive
Demands excellence
Fosters autonomy, practice control and relationship with physicians