Misfortune at Birth

This blog post originally appeared on the RWJF Human Capital Blog.

 

Eileen Lake, PhD, RN, FAAN, and Jeannette Rogowski, PhD, are co-principal investigators of a study, supported by the Robert Wood Johnson Foundation (RWJF) Interdisciplinary Nursing Quality Research Initiative, that generated evidence linking nurse staffing and work environments to infant outcomes in a national sample of neonatal intensive care units.* A new documentary, “Surviving Year One,” examines infant mortality in Rochester, N.Y. and nationwide. It is being shown on PBS and World Channel stations (check local listings). Read more about it on the RWJF Culture of Health Blog here and here.



Are some premature babies simply born in the wrong place? Premature babies are fragile at birth and most infant deaths in this country are due to prematurity.  It is well established that blacks have poorer health than whites in our country, but the origin of these disparities is still a mystery.  It’s possible that the hospital in which a child is born may tell us why certain population groups have poorer health.

A new study by University of Pennsylvania and Rutgers investigators that I led shows that seven out of ten black infants with very low birth weights (less than 3.2 lbs.) in the United States have the simple misfortune of being born in inferior hospitals. What makes these hospitals inferior?  A big component is lower nurse staffing ratios and work environments that are less supportive of excellent nursing practice than other hospitals.  Our study, which was funded by the RWJF Interdisciplinary Nursing Quality Research Initiative, indicates that the hospitals in which infants are born can affect their health all their lives. 

A Brighter Future

What can be done to make these hospitals better?  A first step would be to include nurses in decisions at all levels of the hospital, as recommended by the Institute of Medicine to position nursing to lead change and advance health. Laws in seven states require hospitals to have staff nurses participate in developing plans for safe staffing levels on all units.

Another solution would be to require hospitals to publicly report their neonatal unit staffing levels or work environment ratings (which are determined from a standard survey of nurses about features of their job, such as whether there is teamwork between nurses and doctors) so that pregnant women can make informed decisions about birth options in their communities. Five states require staffing levels to be displayed on nursing units.  Colorado already publicly reports work environment ratings on all hospitals with more than 100 beds.

It would also be a good idea to require the use of a patient acuity tool in staffing plans. We developed a five-level acuity tool for critically ill babies that is ready for use.  Our research using this acuity tool revealed substantial understaffing in neonatal intensive care nursing units was related to higher infection rates.

Previously, there was very little research evidence about the role of nurses in improving outcomes for premature babies, despite nurses being the main caregivers for infants in hospitals.  Our work filled in these gaps. We showed that in hospitals recognized for excellent nursing standards, premature infants have lower rates of death, infection, and severe brain hemorrhage. These standards include the active participation of nurses in hospital policies and decision making.

Among the premature infants who are fortunate enough to survive, the birth hospital is where they receive their first nutrition. Nurses are the principal caregivers and assist new mothers in developing supplies of breast milk, which the U.S. Surgeon General recommends for all newborns. Breast milk is particularly beneficial for premature infants because their immune systems are not completely developed, and it provides both nutrition and immunity protection. In hospitals where disproportionately more black infants are born, 47 percent more infants were discharged without receiving breast milk than in hospitals where the proportion was low. Nurses also play a great role in supporting and guiding mothers through breast-feeding. They commit a large amount of time to instructing and encouraging breast-feeding mothers, but if a neonatal intensive care unit (NICU) is understaffed, nurses have less time to devote to these activities. This in turn may affect infants’ access to breast milk.

Premature newborns often require life-saving interventions and central venous catheters.  Especially in a unit as nurse-intensive as a NICU, nurses play a significant role in preventing infection. They must remember to carefully use sterile techniques while performing procedures and be diligent about detecting early signs of infection. Although these tasks are crucial, they can also be time consuming. They may also be unintentionally overlooked in an understaffed unit. In hospitals where disproportionately more black infants are born, infections were 29 percent more frequent.

Improving Quality

These two perinatal care standards, breast milk and infection prevention, build a foundation for an infant’s lifelong health. Infections can affect neurological development and growth during childhood. In addition, the optimal nutrition provided by breast milk has a lasting impact on a person’s health. Breast-feeding is particularly important for premature infants because it reduces the chance an infant will develop a potentially fatal condition known as necrotizing enterocolitis, in which part of the bowel dies.  The study showed that one-third to one-half of the poorer health outcomes suffered by these premature infants were related to a lack of nursing resources.

Most importantly, if safe staffing helps to improve nurses’ resources in the NICU, the outcomes of those seven of ten black very low birth weight infants may be improved.  Health as a newborn builds a foundation for a healthier life.

*Lake is the Jessie M. Scott Term Chair in Nursing and Health Policy at the University of Pennsylvania School of Nursing and associate director of the Center for Health Outcomes & Policy Research. She leads a program of research on the contributions of the nurse's work environment and clinical nursing expertise to patient outcomes. She has developed an instrument to measure the work environment that is endorsed by the National Quality Forum as a nursing care performance standard that is used internationally.

Rogowski is the University Professor in Health Economics at the Rutgers School of Public Health. For more than two decades, her research has focused on access to care, quality and treatment costs for infants with very low birth weights. Rogowski has served as a member of the Institute of Medicine Committee on Understanding Premature Birth and Assuring Healthy Outcomes and is currently a member of the National Advisory Committee for the RWJF Investigator Awards in Health Policy Research.

Staffing Issues a Factor in Higher Weekend Hospitalization Mortality Rates

Patients hospitalized on weekends are at a 15 percent higher risk of dying due to issues related to nurse and physician staffing and training, according to a new report. Researchers concluded that “low staffing levels of nurses and physicians significantly impact mortality.” Mortality rates were also higher among patients admitted to the hospital on weekends in hospitals with less experienced staff, such as resident trainees.

The study, which is currently available in provisional form, was conducted by researchers from Tufts Medical Center in Boston who examined data on more than 48 million patients admitted to hospitals for non-elective reasons from January 1, 2003-December 31, 2008.

Researchers found that the overall odds of mortality were higher for patients in hospitals with fewer nurses and staff physicians. Hospitals with more nurses or physicians per hospital bed had a 10 percent lower rate of mortality after a weekend admission. Mortality in hospitals with the highest number of resident trainees was 17 percent higher following a weekend admission, compared with hospitals with no resident trainees.

An INQRI study, “The Effect of Off-peak Hospital Environments on Nurses' Work: an Institutional Ethnography” also revealed the negative impact of weekend and evening admissions on mortality rates. The INQRI study showed that nurses’ “off-peak” work environments play a significant role in the increased patient mortality.

In off-peak environments, nurses have less access to support, work with less supervision, and have strained communication with on-call health care providers, the study found. Researchers identified ways in which nurse administrators can mitigate the possible reasons for these disparities:

• Being conscious of the fact that the majority of hours nurses work are “off-peak” and ensuring that institutions’ efforts and programs include peak and “off-peak” times;
• Knowing that implementing a solution for a problem that occurs during peak hours may unintentionally create a problem for those nurses who work “off-peak” and involving nurses from every shift in planning and evaluating work processes;
• Collecting performance data in a way that allows for comparing that data across days of the week and times (both peak and “off-peak”), rather than aggregating data over 24 hours or over an entire week; and
• Proactively addressing nurse-physician relations in the hospital.

The INQRI grantees were Patti Hamilton and Gretchen Gemeinhardt.

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.         

Better Nurse Staffing, Education and Work Environment Contribute to Magnet Hospitals' Patient Outcomes

A new study in Medical Care, conducted by Matthew McHugh, an RWJF Nurse Faculty Scholar, finds that the lower mortality rates at Magnet Hospitals are achieved in part because of investments in nursing. This study reflects many of the findings of INQRI studies into the impact of nurse staffing, work environment and education on quality of patient care.

McHugh and his colleagues compared investment in nursing and patient outcomes at Magnet and non-Magnet hospitals in California, Florida, Pennsylvania and New Jersey. They found significant differences in nursing at Magnet hospitals, including better work environments, higher nurse-to-patient staffing ratios, and higher proportions of nursing with bachelor's degrees and specialty certification. Magnet hospitals also had better patient outcomes, including lower "failure to rescue" and mortality rates. They also reported that the Magnet application process may also play a role in promoting higher quality care.

A summary of the study is on Science Codex.