BACKGROUND/RATIONALE:
Recent, large-scale studies have examined the relationship between nurse staffing practices and patient outcomes such as mortality and medical complications. Results suggest a strong relationship between the number and skill mix of nurses in hospital inpatient units and outcomes for hospitalized patients. For Veterans Health Administration (VHA) hospitals, there is little information on the relationship between nurse staffing and nursing care processes, or the effect of staffing structures on patient outcomes.

OBJECTIVE(S):
This study examines associations between nurse staffing, work environment, nursing care processes, nursing outcomes and nurse-sensitive patient outcomes in VHA hospitals.

METHODS:
This project is an observational cross-sectional study of nursing work environments combined with retrospective nurse staffing and patient data extraction from VA national administrative databases. Between February-May 2003, we surveyed nursing staff with clinical nursing duties at 125 VHA hospitals using a survey instrument adapted from the International Hospital Outcomes Consortium (IHOC) study of nurses in 5 countries. We used VA cost accounting data to measure nursing hours per patient day (HPPD) and skill mix at the unit level for the same period. Patient outcomes from previous studies include mortality conditional on complications, potentially nurse-sensitive outcomes, and (for surgical patients only) failure-to-rescue; this study also includes patient satisfaction data and surgical outcomes from VA national databases. All patient outcomes analyses are conducted at the patient level, including nursing unit and facility level variables. For analysis of conditional mortality, we stratified by ICU and non-ICU admitting unit and estimated the model in two steps, first predicting patient probability of experiencing a major complication, then probability of death conditional on experiencing a complication, controlling for probability of complication.

FINDINGS/RESULTS:
A total of 11,338 nursing personnel responded to the survey, an overall 26.4% response rate. Return rate is not significantly associated with perceptions of quality of care or job satisfaction, and results are consistent with satisfaction scores from federal hospital nurses in the 2000 National Sample Survey of Registered Nurses and the 2001 VA All Employee Survey. Compared to results reported by the IHOC study of nurses from 5 countries, VHA has fewer RNs under 30 than all other samples; fewer VHA RNs reported plans to leave their jobs in the next year than RNs in Pennsylvania, Scotland and England; and VHA RNs reported less job dissatisfaction than RNs in Pennsylvania but more dissatisfaction than RNs in other countries. VHA RNs reported the quality of care provided on their unit was excellent: 40% compared to 12-36% for IHOC samples. Non-VHA RNs in Pennsylvania reported higher nurse to patient ratios overall than VHA RNs; 59% of VHA RNs reported responsibility for 4 or fewer patients on their last shift compared with 17% of Pennsylvania RNs.

We included 24,190 VHA patients first admitted to an ICU and 102,192 patients first admitted to an acute medical/surgical unit in the primary analysis of associations between nurse staffing and conditional mortality (probability of death after experiencing a complication). Overall, 4.2% of these patients experienced one of five serious complications, but predicted probabilities of complications differed between the two unit types. The predicted probability of complication increased the risk of death very significantly in both ICU and acute patients. In medical/surgical units, the marginal effect of RN hours per patient day was significant, but non-RN HPPD were not. The reverse was true for ICUs, where non-RN HPPD was significant at p = 0.05. Nurse staffing structures (HPPD and skill mix) appear to have a greater effect in non-intensive care units where there is greater variation in both RN and non-RN HPPD.

IMPACT:
This is the first large-scale study of nursing factors and patient outcomes using unit level rather than facility level data and is the first opportunity to explore differences among ICU and acute medical/surgical settings.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Back AL, Li YF, Sales AE. Impact of palliative care case management on resource use by patients dying of cancer at a Veterans Affairs medical center. Journal of palliative medicine. 2005 Feb 1; 8(1):26-35. [view]
2. Li YF, Lake ET, Sales AE, Sharp ND, Greiner GT, Lowy E, Liu CF, Mitchell PH, Sochalski JA. Measuring nurses' practice environments with the revised nursing work index: evidence from registered nurses in the veterans health administration. Research in nursing & health. 2007 Feb 1; 30(1):31-44. [view]
3. Sharp ND, Greiner GT, Li YF, Mitchell PH, Sochalski JA, Cournoyer PR, Sales AE. Nurse executive and staff nurse perceptions of the effects of reorganization in Veterans Health Administration hospitals. The Journal of nursing administration. 2006 Oct 1; 36(10):471-8. [view]
4. Sales AE, Sharp ND, Li YF, Greiner GT, Lowy E, Mitchell P, Sochalski JA, Cournoyer P. Nurse staffing and patient outcomes in Veterans Affairs hospitals. The Journal of nursing administration. 2005 Oct 1; 35(10):459-66. [view]
5. Sales A, Sharp N, Li YF, Lowy E, Greiner G, Liu CF, Alt-White A, Rick C, Sochalski J, Mitchell PH, Rosenthal G, Stetler C, Cournoyer P, Needleman J. The association between nursing factors and patient mortality in the Veterans Health Administration: the view from the nursing unit level. Medical care. 2008 Sep 1; 46(9):938-45. [view]

Conference Presentations

1. Lowy E, Sales AE, Li YF, Sharp ND, Greiner GT. Association between Nurse Staffing and Education and Inpatient Mortality in VHA. Paper presented at: Sigma Theta Tau International Honor Society of Nursing Annual Convention; 2006 Jul 1; Montréal, Canada. [view]
2. Sales A, Greiner G, Sharp N, Li Y, Lowy E, Liu C, Sochalski J, Mitchell P, Needleman J. Association Between Nurse Staffing and Education and Inpatient Mortality in VHA. Poster session presented at: VA HSR&D National Meeting; 2006 Feb 15; Arlington, VA. [view]
3. Liu CF, Sales AE, Li YF, Greiner GT, Sharp ND, Lowy E. Association Between Nurse Staffing and Length of Stay in VHA. Poster session presented at: AcademyHealth Annual Research Meeting; 2006 Jun 26; Seattle, WA. [view]
4. Lowy E, Sales AE, Li YF, Sharp ND, Greiner GT. Association of Nurse Staffing with Surgical Patient Mortality in VHA Acute Care Units. Poster session presented at: AcademyHealth Annual Research Meeting; 2006 Jun 26; Seattle, WA. [view]
5. Sales A, Li YF, Greiner GT, Lowy E, Liu CF. Association of Unit-level Perceptions of Work Environment with Patient Mortality in VHA Acute Care Units. Poster session presented at: AcademyHealth Annual Research Meeting; 2006 Jun 26; Seattle, WA. [view]
6. Liu CF, Li YF, Sharp N, Maciejewski ML, Sales A, Needleman J. Nurse Staffing and Direct Inpatient Care Costs. Poster session presented at: VA Nursing Leadership Annual Conference; 2008 Apr 12; Seattle, WA. [view]
7. Liu CF, Li YF, Sharp N, Lowy E, Maciejewski M, Sales A. Nurse Staffing and Direct Inpatient Care Costs. Paper presented at: AcademyHealth Annual Research Meeting; 2008 Jun 8; Washington, DC. [view]
8. Sales AE. Nurse staffing and skill mix and association with cost in the Veterans Health Administration. Paper presented at: American Society of Health Economists Biennial Conference; 2006 Jun 4; Madison, WI. [view]
9. Greiner G, Sharp N, Li Y, Lowy E, Almenoff P, Sales A. Organizational Factors and ICU Patient Outcomes in VHA. Poster session presented at: VA HSR&D National Meeting; 2006 Feb 15; Arlington, VA. [view]
10. Li YF, Liu CF, Sharp N, Sales A. The association between costs and nurses' perception of practice environment in acute inpatient care. Poster session presented at: AcademyHealth Annual Research Meeting; 2008 Jun 9; Washington, DC. [view]
11. Sales AE, Li YF, Liu CF. The association between costs and nurses' perception of practice environment in acute inpatient nursing. Poster session presented at: American Society of Health Economists Biennial Conference; 2008 Jun 23; Durham, NC. [view]
12. Li YF, Liu CF, Sales A. The association between costs and nurses' perception of practice environment in acute inpatient nursing. Poster session presented at: VA Nursing Leadership Annual Conference; 2008 Apr 12; Seattle, WA. [view]
13. Greiner GT, Sharp N, Lowy E, Almenoff P, Sales A. The Association Between Nursing and Other Inpatient Organizational Factors and Inpatient Mortality for Patients Experiencing an ICU Stay During Their Hospitalization in a VA. Poster session presented at: AcademyHealth Annual Research Meeting; 2006 Jun 26; Seattle, WA. [view]
14. Li YF, Sales AE, Sharp ND, Greiner GT, Liu CF, Needleman J. The association between nursing factors and patient mortality in the Veterans Health Administration: the view from the nursing unit level. Poster session presented at: VA Nursing Leadership Annual Conference; 2008 Apr 12; Seattle, WA. [view]
15. Li YF, Liu CF, Sharp ND, Lowy E, Maciejewski ML, Sales AE, Needleman J. The Associations of Nurse, Patient and Organizational Characteristics with Nursing Workload. Poster session presented at: VA HSR&D National Meeting; 2008 Feb 13; Baltimore, MD. [view]
16. Li YF, Sharp N, Liu CF, Sales A. The associations of nurse, patient and organizational characteristics with nursing workload. Poster session presented at: AcademyHealth Annual Research Meeting; 2008 Jun 9; Washington, DC. [view]
17. Liu CF. The Relationship between Line Authority for Nurse Staffing - Patient Care Costs. Paper presented at: AcademyHealth Annual Research Meeting; 2007 Jun 4; Orlando, FL. [view]
18. Liu CF. The Relationship between Line Authority for Nurse Staffing and Patient Care Costs. Paper presented at: International Health Economics Association Biennial World Congress on Health Economics; 2007 Jul 9; Copenhagen, Denmark. [view]
19. Sharp N, Liu CF, Li YF, Lowy E, Sales A, Maciejewski M, Needleman J. The Relationship between Line Authority for Nurse Staffing and Patient Care Costs in VA. Poster session presented at: VA Nursing Leadership Annual Conference; 2008 Apr 12; Seattle, WA. [view]
20. Li YF, Sharp ND, Greiner GT, Lowy E, Liu CF, Sales AE. The Relationship between Patient Satisfaction and Inpatient Nursing Care. Poster session presented at: AcademyHealth Annual Research Meeting; 2006 Jun 26; Seattle, WA. [view]

DRA: Health Systems
DRE: Epidemiology
Keywords: Nursing, Patient outcomes, Staffing
MeSH Terms: none