Effect of an Age-Stratified Working Environment and Hospital Characteristics on Nurse Turnover

Hospital and unit characteristics associated with nursing turnover include skill mix but not staffing level: An observational cross-sectional study

Background and aimNurse staffing levels are associated with patient mortality, but little is known regarding the association between nurse turnover rate and patient mortality. This study investigated the combined effect of the bed-to-nurse ratio and the nurse turnover rate on in-hospital mortality in patients admitted to Korean acute care hospitals using national administrative data.MethodsThis study analyzed data from the National Health Insurance Service (NHIS) on 459,113 admitted patients and 111,342 employed nurses in 403 hospitals in South Korea from January to December 2016. Differences in in-hospital mortality and nurse turnover among hospital characteristics, including the bed-to-nurse ratio, were explored using the chi-square test. Multilevel, multivariate GEE logistic regression analyses were used to examine the combined effect of the bed-to-nurse ratio and the nurse turnover rate on in-hospital mortality.ResultsDuring the study period, 13,675 (3.0%) patients died during hospitalization, and 13,349 (12.0%) nurses left their jobs. The risk of death among patients admitted to hospitals with a bed-to-nurse ratio of < 2.5 and a nurse turnover rate of ≥ 12% was lower than among patients admitted to hospitals with a bed-to-nurse ratio of ≥ 4.5 and a nurse turnover rate of ≥ 12% (odds ratio [OR] = 0.63; 95% confidence interval [CI], 0.48–0.82). The risk of in-hospital mortality decreased further when the nurse turnover rate was < 12% (OR = 0.59; 95% CI, 0.44–0.79).ConclusionThe bed-to-nurse ratio and nurse turnover rate were jointly associated with patient mortality. When hospitals with a low bed-to-nurse ratio also experienced high nurse turnover, the risk of in-hospital mortality was even greater. The finding of this study will help health policy makers to better understand the importance of both nursing staffing levels and nurse turnover rates. It is necessary to create a comprehensive improvement plan that integrates policies aiming to improve nurse staffing levels and reduce turnover rates into a single strategy.

본 연구는 병원에 근무하는 간호사의 이직률과 병원의 구조적 특성 간 관련성을 확인하기 위하여 시행하였다. 자료는 한국보건산업진흥원에서 매년 조사하는 병원경영분석자료를 이용하였으며, 2008년에 전국에서 자기기입식으로 입력한 병원은 247개였다. 2008년 우리나라 간호사의 평균 이직률은 32.0%(공공병원 15.5%; ...

To describe key elements of a set of hospital prenatal substance exposure protocols, and to relate variations in protocol content to the state legislative environment and hospital characteristics. Nurse managers and hospital administrators with responsibility for perinatal care were asked to provide their hospital's prenatal substance exposure protocol. Using a structured coding form, two independent coders read and abstracted information from the 87 protocols received. Hospital and patient characteristics and the state's legal environment were cross-tabulated. Only half of coded protocols included an implementation date; 37% lacked any goal or statement of purpose. Most covered the key components of prenatal substance exposure management, such as precipitants and guidelines for toxicology screening, but failed to present their contents clearly. Only a few discussed whether specific maternal consent is required for a maternal or a newborn toxicology screen. Protocols from states that had made some legislative response to prenatal substance exposure were more likely to provide reporting guidelines and a discussion of consent for a toxicology screen for mothers and newborns. Protocols were more likely to be found in larger hospitals and were more detailed in hospitals serving more affluent and less minority patient populations. More attention needs to be devoted to the development of prenatal substance exposure protocols, as their lack of clarity precludes most from meeting protocol development goals, such as encouraging standardized care. Associations between hospital characteristics, state legislative environment and protocol features suggest that legislative mandates could shape their development and features.

In 2012, the Centers for Medicare and Medicaid Services (CMS) initiated the Medicare Shared Savings Program (MSSP) and Pioneer Accountable Care Organization (ACO) programs. Organizations in the MSSP model shared cost savings they generated with CMS, and those in the Pioneer program shared both savings and losses. It is largely unknown what hospital and environmental characteristics are associated with the development of CMS ACOs with one- or two-sided risk models. The aim of this study was to assess the organizational and environmental characteristics associated with hospital participation in the MSSP and Pioneer ACOs. Hospitals participating in CMS ACO programs were identified using primary and secondary data. The ACO hospital sample was linked with the American Hospital Association, Health Information and Management System Society, and other data sets. Multinomial probit models were estimated that distinguished organizational and environmental factors associated with hospital participation in the MSSP and Pioneer ACOs. Hospital participation in both CMS ACO programs was associated with prior experience with risk-based payments and care management programs, advanced health information technology, and location in higher-income and more competitive areas. Whereas various health system types were associated with hospital participation in the MSSP, centralized health systems, higher numbers of physicians in tightly integrated physician-organizational arrangements, and location in areas with greater supply of primary care physicians were associated with Pioneer ACOs. Favorable hospital characteristics were, in the aggregate, more important than favorable environmental factors for MSSP participation. MSSP ACOs may look for broader organizational capabilities from participating hospitals that may be reflective of a wide range of providers participating in diverse markets. Pioneer ACOs may rely on specific hospital and environmental characteristics to achieve quality and spending targets set for two-sided contracts. Hospital and ACO leaders can use our results to identify hospitals with certain characteristics favorable to their participation in either one- or two-sided ACOs.

Background: The Magnet hospital is a recognition system in the US having a low turnover and high retention of nurses and providing a high quality of patient care. We sought to examine the effect of characteristics of the work environment of Magnet hospitals on nurses’ job satisfaction using multi-level analysis in hospitals in Japan. Methods: We distributed anonymous self-administered questionnaires in August 2011 to all nurses via the directors of the nursing departments of four private hospitals. The response rate of nurses was 91%; 373 completed questionnaires in 21 wards were used for analysis. The questionnaire items addressed basic attributes and employment characteristics, the Japanese version of the Practice Environment Scale of the Nursing Work Index (PES-NWI) for assessing characteristics of the work environment of Magnet hospitals, and a job satisfaction scale. We conducted multi-level analysis to examine effects of the PES-NWI sub-scales at both the individual and ward levels on nurses’ job satisfaction. Results: Results of the multi-level analysis for nurses’ job satisfaction showed that a full model which included the sub-scales of the PES-NWI at both the individual and ward levels was the most appropriate model. Additionally, coefficients of ward-level values showing significant relationships with job satisfaction were greater than those of individual-level values. At the individual level, all sub-scales of the PES-NWI except for “nurse participation in hospital affairs” showed positive relationships with nurses’ job satisfaction, while at the ward level “nurse participation in hospital affairs” showed a significant positive relationship, and “nurse manager ability, leadership, and support of nurses” showed a significant negative relationship, with nurses’ job satisfaction. Conclusion: These findings suggest that while characteristics of the work environment of Magnet hospitals are important predictors, factors relating to cultural differences, such as decentralized department structures, might influence nurses’ job satisfaction at the ward level.

Nurses’ reports of staffing adequacy and surgical site infections: A cross-sectional multi-centre study

To assess turnover intention among experienced nurses and explore the effects of work environment, job characteristics and work engagement on turnover intention. The nursing shortage is an urgent concern in China. A high turnover rate of experienced nurses could have serious effects on the quality of care, costs and the efficiency of hospitals. It is crucial to explore the predictors of turnover intention and develop strategies tailored to experienced nurses. A descriptive, cross-sectional survey design. A total of 778 experienced nurses from seven hospitals was surveyed on their work engagement, job characteristics, work environment and turnover intention in March-May 2017. Structural equationmodelling was used to test a theoretical model and the hypotheses. The results showed that 35.9% of experienced nurses had high-level turnover intention. The final model explained 50% of the variance in experienced nurses' turnover intention and demonstrated that: (1) work environment was positively associated with higher work engagement and lower turnover intention and work engagement partially mediated the relationship between work environment and turnover intention; and (2) job characteristics were positively related to higher work engagement and lower turnover intention and work engagement fully mediated the relationship between job characteristics and turnover intention. The study confirms the intrinsic and extrinsic motivators on work engagement posited by job demands-resources model. Theory-driven strategies to improve work environment, enhance job characteristics and promote wok engagement are needed to address the nursing shortage and high turnover intention among experienced nurses.

Purchasing human services through contracts with private providers has become an increasingly common practice over the past 20 years. Using data from a national survey of psychiatric inpatient facilities, this paper examines the extent to which psychiatric units in privately controlled general hospitals and private psychiatric specialty hospitals (N = 611) participate in contractual arrangements to provide services to governmental bodies. It also examines how the likelihood of such a practice is affected by hospital characteristics (general or specialty, for profit or nonprofit) and features of hospitals' environments, including the competitiveness of the market for psychiatric inpatient care and the population's need for services in the hospital's county. The findings indicate that nonprofit psychiatric specialty hospitals were more likely than other types of hospitals to enter into such contracts, and that forces such as local competition and need for services were not predictors of such involvement. Contracting was shown to have a significant impact on the level of referrals a hospital accepted, but these levels were also affected by competition and need. Among hospitals with public contracts, referral acceptance from public agencies was unaffected by these factors, but they did have a significant effect on referral acceptance by hospitals without public contracts. These data suggest that public agencies contracting for services with private hospitals may represent a means by which "public sector" patients may gain access to private providers. Further, this mechanism may impose sufficient structure and regulation on the acceptance of such patients that many concerns of hospital administrators regarding patients who are costly and difficult to treat and discharge can be allayed.

Introduction The complexity of modern burn care requires an integrated team of clinicians working together to achieve the best possible outcome for each survivor. Nurses are central to many aspects of a burn survivor’s care including physiologic monitoring, fluid resuscitation, pain management, infection prevention, complex wound care, and rehabilitation. Previous research suggests that hospital nursing resources such as staffing, education, and the quality of the work environment relate to overall patient mortality, but the relationship between those resources and burn mortality has not been previously examined. Due to their unique and complex care needs, burn patients are likely highly sensitive to nursing resources. Methods This study examined whether patient-to-nurse ratios, nurse education, and features of the clinical work environment are associated with burn patient in-hospital mortality. A multivariable regression model using a linked, cross-sectional claims database of 14,064 adult (&amp;gt;18 yrs.) burn patients admitted to 653 hospitals was employed. Mortality was risk-adjusted for age, burn size, the presence of mechanical ventilation, co-morbidities, and hospital characteristics such as burn patient volume, technological capabilities, and teaching status. Nursing resources were independently reported by 29,586 bedside nurses working in the study hospitals. The work environment was assessed using the National Quality Forum-endorsed Practice Environment Scale. Nursing resources differ in the high vs. low-volume hospitals, so the final model includes an interaction term for each nursing resource and hospital burn patient volume. Results In the risk-adjusted main-effects model, the patient’s age, burn size, presence of mechanical ventilation, comorbidities, and hospital burn patient volume were all significantly associated with in-hospital mortality. The full model including interaction terms suggests that in high burn patient volume hospitals (&amp;gt;100 patients / yr.) each additional patient added to a nurse’s workload is associated with 30% higher odds of mortality (p&amp;lt; 0.05, 95% CI [1.02, 1.94]), and improvements in the nurse work environment are associated with 28% lower odds of mortality (p&amp;lt; 0.05, 95%CI [0.07, 0.99]). Conclusions Nurse staffing and the nurse work environment significantly relate to burn patient mortality in high-volume burn hospitals where the most complex burn patients often receive care. Applicability of Research to Practice Nursing resources are critical to the survival of the most complex burn patients, and are a significant, yet previously unmeasured variable in the evaluation of burn outcomes. To promote optimal recovery for burn survivors, attention to nurse staffing and the work environment is warranted. Future evaluations of burn patient outcomes should account for hospital nursing resources.

Aims: We assessed the levels of airborne bacteria, Gram-negative bacteria (GNB), and fungi in six hospital lobbies, and investigated the environmental and hospital characteristics that affected the airborne microorganism levels. Methods: An Andersen single-stage sampler equipped with appropriate nutrition plate agar was used to collect the samples. The three types of microorganisms were repeatedly collected at a fixed location in each hospital (assumed to be representative of the entire hospital lobby) from 08:00 through 24:00, with a sampling time of less than 5 min. Temperature and relative humidity were simultaneously monitored. Results: Multiple regression analysis was used to identify the major factors affecting microorganism levels. The average levels of bacteria (7.2 × 102 CFU/m3), GNB (1.7 × 10 CFU/m3), and fungi (7.7 × 10 CFU/m3) indicated that all hospital lobbies were generally contaminated. Season was the only factor that significantly affected the levels of all microorganisms (p < 0.0001), where contamination was the highest during the summer, significantly higher than during the winter. Other significant factors varied by microorganism, as follows: airborne bacteria (number of people in the lobby, sampling time), GNB (scale of hospital), and fungi (humidity and air temperature). Conclusions: Hospital lobby air was generally contaminated with microorganisms, including bacteria, GNB, and fungi. Environmental factors that may significantly influence the airborne concentrations of these agents should be managed to minimize airborne levels.

BackgroundReadmission rate is considered an indicator of the mental health care quality. Previous studies have examined a number of factors that are likely to influence readmission. The main objective of this systematic review is to identify the studied pre-discharge variables and describe their relevance to readmission among psychiatric patients.MethodsStudies on the association between pre-discharge variables and readmission after discharge with a main psychiatric diagnosis were searched in the bibliographic databases Ovid Medline, PsycINFO, ProQuest Health Management and OpenGrey. Relevant publications published between January 1990 and June 2014 were included. For each variable, the number of papers that considered it as a predictor of readmission and that found a significant association was recorded, together with the association direction and whether it was found respectively in bivariate and in multivariate analyses.ResultsOf the 734 articles identified in the search, 58 papers were included in this review, mainly from the USA and concerning patients with severe mental disorders. Analysed variables were classified according to the following categories: patients’ demographic, social and economic characteristics; patients’ clinical characteristics; patients’ clinical history; patients’ attitude and perception; environmental, social and hospital characteristics; and admission and discharge characteristics. The most consistently significant predictor of readmission was previous hospitalisations. Many socio-demographic variables resulted as influencing readmission, but the results were not always homogeneous. Among other patients’ clinical characteristics, diagnosis and measures of functional status were the most often used variables. Among admission characteristics, length of stay was the main factor studied; however, the results were not very consistent. Other relevant aspects resulted associated with readmission, including the presence of social support, but they have been considered only in few papers. Results of quality assessment are also reported in the review. The majority of papers were not representative of the general psychiatric population discharged from an inpatient service. Almost all studies used multivariate analytical methods, i.e., confounders were controlled for, but only around 60% adjusted for previous hospitalisation, the variable most consistently considered associated to readmission in the literature.ConclusionsThe results contribute to increase knowledge on pre-discharge factors that could be considered by researchers as well as by clinicians to predict and prevent readmissions of psychiatric patients. Associations are not always straightforward and interactions between factors have to be considered.Electronic supplementary materialThe online version of this article (doi:10.1186/s12888-016-1114-0) contains supplementary material, which is available to authorized users.

Using a national data base of urban hospitals, the effect of ownership (government, nonprofit, and for-profit) on the technical efficiency of hospitals was examined. Efficiency scores were computed using a method called data envelopment analysis. Controlling for environmental and hospital characteristics, for-profit hospitals were found somewhat less frequently and government hospitals consistently more frequently in the efficient category. When examining highly inefficient hospitals as a percentage of those receiving inefficient scores, for-profit hospitals appeared to be highly inefficient relative to the other ownership forms. Government and nonprofit hospitals were somewhat indistinguishable from one another regarding their percentages of highly inefficient scores. For-profit hospitals also tended to use supply and capital asset (hospital size) inputs less efficiently, and service and labor inputs more efficiently than hospitals in the other ownership categories.

Although recent literature has explored the relationship between various environmental market characteristics and the adoption of electronic health records (EHRs) among general, acute care hospitals, no such research currently exists for specialty hospitals, including those providing cancer care. The aim of the study was to examine the relationship between market characteristics and the adoption of EHRs among Commission on Cancer (CoC)-accredited hospitals. Secondary data on EHR adoption combined with hospital and environmental market characteristics were analyzed using logistic regression. Using the resource dependence theory, we examined how measures of munificence, complexity, and dynamism are related to the adoption of EHRs among CoC-accredited hospitals and, separately, hospitals not CoC-accredited. In a sample of 2,670 hospitals, 141 (0.05%) were academic-based CoC-accredited hospitals and 562 (21%) were community-based CoC-accredited hospitals. Measures of munificence such as cancer incidence rates (OR = 0.99, CI [0.99, 1.00], p = .020) and percentage population aged 65+ (OR = 0.99, CI [0.99, 1.00], p = .001) were negatively associated with basic EHR adoption, whereas urban location was positively associated with comprehensive EHR adoption (OR = 3.07, CI [0.89, 10.61], p = .076) for community-based CoC-accredited hospitals. Measures of complexity such as hospitals in areas with less competition were less likely to adopt a basic EHR (OR = 0.33, CI [0.19, 0.96], p = .005), whereas Medicare Managed Care penetration was positively associated with comprehensive EHR adoption (OR = 1.02, CI [1.00, 1.05], p = .070) among community-based CoC-accredited hospitals. Lastly, dynamism, measured as population change, was negatively associated with the adoption of comprehensive EHRs (OR = 0.99, CI [0.99, 1.00], p = .070) among academic-based CoC-accredited hospitals. A greater understanding of the environment's relationship to health information technology adoption in cancer hospitals will help stakeholders in these institutions make informed strategic decisions about information technology investments guided by their facilities' respective environmental factors. The results of this study may also be useful to hospital chief information officers and chief executive officers seeking to either improve their quality of care or achieve and maintain accreditation in providing cancer care.

To develop a taxonomy of governing board roles in U.S. hospitals. 2005 AHA Hospital Governance Survey, 2004 AHA Annual Survey of Hospitals, and Area Resource File. A governing board taxonomy was developed using cluster analysis. Results were validated and reviewed by industry experts. Differences in hospital and environmental characteristics across clusters were examined. One-thousand three-hundred thirty-four hospitals with complete information on the study variables were included in the analysis. Five distinct clusters of hospital governing boards were identified. Statistical tests showed that the five clusters had high internal reliability and high internal validity. Statistically significant differences in hospital and environmental conditions were found among clusters. The developed taxonomy provides policy makers, health care executives, and researchers a useful way to describe and understand hospital governing board roles. The taxonomy may also facilitate valid and systematic assessment of governance performance. Further, the taxonomy could be used as a framework for governing boards themselves to identify areas for improvement and direction for change.