INQRI Advisor to Lead Study on Nurses’ Impact

A new survey of more than 250,000 registered nurses (RNs) will help to generate evidence about how nurses impact the outcomes of their patients, according to a Nurse.com article. INQRI Research Manager and National Advisory Committee Member Linda Aiken will lead the survey of RNs and Nurse Practitioners holding active licenses in California, Florida, New Jersey, and Pennsylvania.
 
Aiken is the director of the University of Pennsylvania, School of Nursing’s Center for Health Outcomes and Policy Research (CHOPR). The National Institute of Nursing Research provided a $2.9 million grant to CHOPR for the survey, which is titled Panel Study of Effects of Changes in Nursing on Patient Outcomes. RWJF, the National Council of State Boards of Nursing, the Hillman Foundation, and the Boettner Center also provided funding.

“Our study will examine organizational-level changes over time in nurse inputs in education, staffing, skill mix, and work environment between 1999, 2006 and 2015,” Aiken said in a statement on CHOPR’s website. “The great strength of this project is that in creating a panel of organizational observations, we can see where change has occurred and why.”

Washington Post Tackles Nurse Staffing Minimums, Quotes INQRI Experts

A recent Washington Post article analyzing the impact of nurse staffing minimums provides insight from two INQRI advisors.

 “There’s plenty of evidence that there’s a shortage of nursing care, and it’s not solved by anything to do with the hospital supply,”  Linda Aiken, INQRI research manager and National Advisory Committee member, tells the Washington Post. “All the shortage of care at the bedside has to do with how much hospitals want to pay nurses, and whether they want to use their resources on something else.”

Aiken’s recent research, published in the Lancet in February 2014, found that patients are more likely to die after common surgical procedures when they are cared for in hospitals with heavier nurse workloads and fewer nurses with bachelor's degrees. The study found that every extra patient increased the chance of surgical patients dying within 30 days of admission by 7 percent.

A California law requiring mandatory minimum nurse staffing has shown benefit for nurses, with studies showing that patient loads and rates of occupational injury decreased in the state, while job satisfaction among nurses increased. The Post reports, however, that there is conflicting evidence as to whether legislating mandatory minimum staffing improves patient outcomes. Lori Melichar, a labor economist for RWJF and program officer for INQRI, tells the Post that the question is complicated. “And when you layer on ‘Is this policy going to be effective,’ as a researcher and an economist, I can’t make that determination,” she says.

An INQRI-funded study on the impact of nursing staffing on hospital performance revealed that increasing the number of registered nurse (RN) hours per patient day increased the quality of patient care. The study looked in particular at patients who were being treated for acute myocardial infarction, pneumonia or heart failure.) For all three conditions, increasing the number of RN hours increased the quality of care. This did not hold true for increasing the number of licensed practical nurse or nursing assistant hours.

The study's authors—Gestur Davidson, Ira Moscovice, and Kathy Belk—posited that RNs are involved in and directly affect procedures, practices and processes that directly influence patient outcomes. This was the first study into how nurse staffing affects hospital performance on quality metrics used in the Premier Hospital Quality Demonstration project. It is reviewed in a 2013 research brief on the RWJF website.

Study Links RN Perception of Work Environment to Rates of Infection

Healthcare-associated infections (HAIs) are less likely to occur in favorable critical care work environments, according to a study of more than 3,200 nurses, Nurse.com reports. The principal investigators for the study were INQRI NAC member Linda H. Aiken and INQRI researcher Eileen Lake.

HAIs cost the health care system billions of dollars each year, according to background information for the study, which was published in the November issue of the American Journal of Critical Care. The study found nurses working in favorable critical care environments were 36 to 41 percent less likely than nurses in poor work environments to report that urinary tract infections, ventilator-associated pneumonia, and central line-associated bloodstream infections occurred more than once a month. The study also finds that critical care nurses are well-positioned to reduce the prevalence and prevention of HAIs in critically ill patients.

An INQRI team led by Eileen Lake and Jeannette Rogowski demonstrated the impact of nurse staffing and the professional practice environment in preventing infection among infants in neonatal intensive care units (NICUs). Their findings show that babies in units where nurses have less support and limited professional practice are at higher risk of developing infections. Higher levels of NICU experience are associated with better infant outcomes.

Nursing Economic$ Journal Feature: Leading Nurse Researcher Cites Importance of Transparency in Nurse Staffing Ratios

The September-October 2013 issue of Nursing Economic$ journal features the first in an insightful interview series with Linda H. Aiken PhD, FAAN, FRCN, RN, a member of the INQRI National Advisory Committee and a Research Manager supporting the Future of Nursing: Campaign for Action.

“The Impact of Research on Staffing: an Interview with Linda Aiken” covers numerous areas of nurse staffing, including the viability of public reporting as an alternative to legislatively-mandated nurse staffing ratios.

“If we had more transparent information on what staffing levels are at hospitals, consumers and nurses could exercise more informed choices in selecting a hospital for care or employment,” Aiken told NursingEconomic$. “Also, easily accessible information on staffing would expose hospitals with particularly poor staffing to increased public and professional scrutiny which would be expected to motivate improvements.”

Aiken also praises the 2013 Safe Nurse Staffing Act, introduced in Congress in April 2013, which proposes public reporting of nurse staffing on the Centers for Medicare & Medicaid Services Hospital Compare website.

Other topics covered in the interview include: variations of nurse staffing ratios across the country; inadequate staffing at minority hospitals; the impact of healthcare reform on nurse staffing; and addressing work environment issues. The second part of Aiken’s interview will be featured in the November/December 2013 issue of Nursing Economic$.

Employing Substantial Numbers of Foreign Educated Nurses in U.S. Hospitals Raises Risks of Poor Patient Outcomes

New Study Shows More Deaths in U.S. Hospitals That Have Higher Percentages of Nurses Educated Abroad

For over 60 years, U.S. hospitals have employed non-US-educated nurses during nurse shortages to supplement their workforce.  Although recruitment of nurses from abroad is cyclical, many foreign-educated nurses that come to the U.S. in times of shortages end up staying.  Thus their presence in the U.S. nurse workforce is long-lasting.

Little is known about the impact of foreign educated nurses on quality of hospital care in the U.S.  The majority of foreign-educated nurses in the U.S. are from countries with transitional economies, such as the Philippines, where the health care system is substantially different from that of the U.S. Unlike requirements for foreign trained physicians who practice in the U.S., nurses are not required to complete any educational program in the U.S. if they pass the licensure exam, English speaking and comprehension exams, and provide evidence that their education is “equivalent” to that required of U.S. nurses.  However, nurses from countries with transitional economies have RN licensure exam pass rates significantly lower than that of US nursing school graduates and often take the exam multiple times.

While the demand for foreign educated nurses is low at this time, improvements in the national economy and increased demand for nurses resulting from expanded health insurance coverage from the Affordable Care Act may trigger a new cycle of hospital nurse recruitment from abroad.  Thus knowing more about the potential implications of importing foreign educated nurses now is important in nursing workforce planning for the future.

Researchers from the University of Pennsylvania’s (Penn’s) Center for Health Outcomes and Policy Research in the School of Nursing in collaboration with the University of Florida’s College of Nursing in Gainesville undertook a study to determine whether U.S. hospital employment of non-US-educated nurses is associated with higher mortality after common surgical procedures, and if so, under what circumstances. They found that in hospitals in which patient-to-nurse ratios were average (five patients per nurse) or worse, mortality and failure to rescue patients with complications is significantly higher when 25 percent or more nurses were educated outside the U.S.

The study, “Utilization of non-US educated nurses in US hospitals: implications for hospital mortality,” was published in June 2013 in the International Journal for Quality in Health Care. The study was funded by the National Institute of Nursing and RWJF.

This study of 665 hospitals directed by Penn’s Center for Health Outcomes and Policy Research is one of the largest ever undertaken of the potential quality of care impact of utilization of non-US educated nurses in US hospitals.  The senior author of the paper is University of Pennsylvania professor and director of the School of Nursing’s Center for Health Outcomes and Policy Research and Leonard Davis Institute of Health Economics senior fellow, Linda H Aiken, RN, PhD, FAAN.  Co-authors include Donna Neff, RN, PhD, Associate Professor, University of Florida College of Nursing, Jeannie Cimiotti, RN, PhD, FAAN, formerly from Penn and now Associate Professor at Rutgers University College of Nursing and Director of the New Jersey Collaborating Center for Nursing, and Douglas M. Sloane, PhD, Adjunct Professor of Nursing at Penn.

The study concludes that employing substantial numbers of non-US-educated nurses in U.S. hospitals is associated with significantly higher risk-adjusted 30 day from admission mortality and failure to rescue patients who experience complications after common general, orthopedic, and vascular surgery. Only when nurse staffing in hospitals is better than average, as when nurses care for four or fewer patients each, do we find no effect of foreign educated nurses on mortality. Only 37 percent of hospitals in the study had staffing ratios of four patients per nurse or less.  The effect of having more than 25 percent non-US-educated nurses becomes increasingly deleterious as patient-to-nurse ratios increased beyond 5:1. Thus, in practical terms, high proportions of non-US-educated nurses are a potential risk factor for excess mortality.

Recruiting nurses from countries with greater burdens of illness and fewer nurses than the U.S. has been criticized in terms of its potential adverse effect on global health.  This study suggests that it is not in the public’s interest in the U.S. to rely extensively on foreign educated nurses.

The findings suggest that the US should be largely reliant on its own domestic supply of nurses to prevent future nursing shortages which would require better national nurse workforce planning and policy intervention to balance domestic nurse supply and likely future demands for nurses.         

New Human Capital Blog Post Regarding the Shortage of Primary Care Providers

A recent issue of the New England Journal of Medicine features two examples of policy analysis focused on the implications of expanding nurse practitioners' scope of practice relative to primary care, as well as an editorial addressing the same. Dr. Linda H. Aiken, a member of the INQRI National Advisory Committee and a Research Manager supporting the Future of Nursing: Campaign for Action, discusses these pieces in a new blog post on RWJF's Human Capital blog.

Click here to read Dr. Aiken's post and share your comments.

More Evidence that Supplemental Nurses Provide High Quality Care

The supplemental nursing workforce is crucial to keep hospitals adequately staffed in states suffering from a nursing shortage and at hospitals that have gaps in staffing due to nurse turnover. A new study by Linda Aiken, who serves on the National Advisory Committee for INQRI and has conducted several studies into outcomes of nursing care, shows that any hesitation hospital executives may have about using "travel nurses" is unfounded.

An article on ADVANCE for Nurses reports on the results of Aiken's recent study examining patient outcomes when they are cared for in hospitals that have a substantial number of agency nurses. The study included more than 1.3 million patients and 40,000 nurses in more than 600 hospital and found no evidence negative outcomes associated with care provided by supplemental nurses.

The article also reports on a study conducted at the Columbia School f Nursing that suggests that supplemental nurses' image may suffer because they often work in hospitals with poor work environments. The study's authors suggest that hospitals with poor work environments would have more trouble recruiting and retaining permanent nurses and rely heavily on agency nurses.

Aiken's study underscores the findings of an INQRI research team led by Ying Xue and Deborah Freund which determined that supplemental nurses had no negative impact on patient or nurse outcomes. They also found that supplemental nurses tend to have the same amount of experience as permanent RNs.