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

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

Acuity-adjusted Staffing, Nurse Practice Environments and NICU Outcomes

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

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

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.

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

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

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.

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

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.

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

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

The Effects of Nursing on NICU Patient Outcomes

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

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 www.nicunursingsurvey.com

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

NINR Study…Data Entry Website

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

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

Recruiting and Staffing for Clinical Nursing Expertise

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

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

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