ContextGrowing evidence suggests that nurse staffing affects the quality of
care in hospitals, but little is known about whether the educational composition
of registered nurses (RNs) in hospitals is related to patient outcomes.ObjectiveTo examine whether the proportion of hospital RNs educated at the baccalaureate
level or higher is associated with risk-adjusted mortality and failure to
rescue (deaths in surgical patients with serious complications).Design, Setting, and PopulationCross-sectional analyses of outcomes data for 232 342 general,
orthopedic, and vascular surgery patients discharged from 168 nonfederal adult
general Pennsylvania hospitals between April 1, 1998, and November 30, 1999,
linked to administrative and survey data providing information on educational
composition, staffing, and other characteristics.Main Outcome MeasuresRisk-adjusted patient mortality and failure to rescue within 30 days
of admission associated with nurse educational level.ResultsThe proportion of hospital RNs holding a bachelor's degree or higher
ranged from 0% to 77% across the hospitals. After adjusting for patient characteristics
and hospital structural characteristics (size, teaching status, level of technology),
as well as for nurse staffing, nurse experience, and whether the patient's
surgeon was board certified, a 10% increase in the proportion of nurses holding
a bachelor's degree was associated with a 5% decrease in both the likelihood
of patients dying within 30 days of admission and the odds of failure to rescue
(odds ratio, 0.95; 95% confidence interval, 0.91-0.99 in both cases).ConclusionIn hospitals with higher proportions of nurses educated at the baccalaureate
level or higher, surgical patients experienced lower mortality and failure-to-rescue
rates.

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Educational levels of hospital nurses and surgical patient mortality.

Background: Interruptions have been implicated as a cause of clinical errors, yet, to our knowledge, no empirical studies of this relationship exist. We tested the hypothesis that interruptions during medication administration increase errors. Methods: We performed an observational study of nurses preparing and administering medications in 6 wards at 2 major teaching hospitals in Sydney, Australia. Procedural failures and interruptions were recorded during direct observation. Clinical errors were identified by comparing observational data with patients’ medication charts. A volunteer sample of 98 nurses (representing a participation rate of 82%) were observed preparing and administering 4271 medications to 720 patients over 505 hours from September 2006 through March 2008. Associations between procedural failures (10 indicators; eg, aseptic technique) and clinical errors (12 indicators; eg, wrong dose) and interruptions, and between interruptions and potential severity of failures and errors, were the main outcome measures. Results: Each interruption was associated with a 12.1% increase in procedural failures and a 12.7% increase in clinical errors. The association between interruptions and clinical errors was independent of hospital and nurse characteristics. Interruptions occurred in 53.1% of administrations (95% confidence interval [CI], 51.6%-54.6%). Of total drug administrations, 74.4% (n=3177) had at least 1 procedural failure (95% CI, 73.1%-75.7%). Administrations with no interruptions (n=2005) had a procedural failure rate of 69.6% (n =1 395; 95% CI, 67.6%-71.6%), which increased to 84.6% (n=148; 95% CI, 79.2%-89.9%) with 3 interruptions. Overall, 25.0% (n=1067; 95% CI, 23.7%26.3%) of administrations had at least 1 clinical error. Those with no interruptions had a rate of 25.3% (n=507; 95% CI, 23.4%-27.2%), whereas those with 3 interruptions had a rate of 38.9% (n=68; 95% CI, 31.6%-46.1%). Nurse experience provided no protection against making a clinical error and was associated with higher procedural failure rates. Error severity increased with interruption frequency. Without interruption, the estimated risk of a major error was 2.3%; with 4 interruptions this risk doubled to 4.7% (95% CI, 2.9%-7.4%; P.001). Conclusion: Among nurses at 2 hospitals, the occurrence and frequency of interruptions were significantly associated with the incidence of procedural failures and clinical errors.

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Association of Interruptions With an Increased Risk and Severity of Medication Administration Errors

Background A report by the Institute of Medicine suggests that changing the culture of health care organizations may improve patient safety. Research in this area, however, is modest and inconclusive. Because culture powerfully affects providers, and providers are a key determinant of care quality, the MEMO study (Minimizing Error, Maximizing Outcome) introduces a new model explaining how physician work attitudes may mediate the relationship between culture and patient safety. Research questions (1) Which cultural conditions affect physician stress, dissatisfaction, and burnout? and (2) Do stressed, dissatisfied, and burned out physicians deliver poorer quality care? Methods A conceptual model incorporating the research questions was analyzed via structural equation modeling using a sample of 426 primary care physicians participating in MEMO. Findings Culture, overall, played a lesser role than hypothesized. However, a cultural emphasis on quality played a key role in both quality outcomes. Further, we found that stressed, burned out, and dissatisfied physicians do report a greater likelihood of making errors and more frequent instance of suboptimal patient care. Practice implications Creating and sustaining a cultural emphasis on quality is not an easy task, but is worthwhile for patients, physicians, and health care organizations. Further, having clinicians who are satisfied and not burned out or stressed contributes substantially to the delivery of quality care.

The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study.

Background:System approaches, such as improving working conditions, have been advocated to improve patient safety. However, the independent effect of many working condition variables on patient outcomes is unknown.Objective:To examine effects of a comprehensive set of working conditions on elderly p

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Nurse working conditions and patient safety outcomes

Nurses have been found to experience higher levels of stress-related burnout compared to other health care professionals. Despite studies showing that both job satisfaction and burnout are effects of exposure to stressful working environments, leading to poor health among nurses, little is known about the causal nature and direction of these relationships. The aim of this systematic review is to identify published research that has formally investigated relationships between these variables. Six databases (including CINAHL, COCHRANE, EMBASE, MEDLINE, PROQUEST and PsyINFO) were searched for combinations of keywords, a manual search was conducted and an independent reviewer was asked to cross validate all the electronically identified articles. Of the eighty five articles that were identified from these databases, twenty one articles were excluded based on exclusion criteria; hence, a total of seventy articles were included in the study sample. The majority of identified studies exploring two and three way relationships (n = 63) were conducted in developed countries. Existing research includes predominantly cross-sectional studies (n = 68) with only a few longitudinal studies (n = 2); hence, the evidence base for causality is still very limited. Despite minimal availability of research concerning the small number of studies to investigate the relationships between work-related stress, burnout, job satisfaction and the general health of nurses, this review has identified some contradictory evidence for the role of job satisfaction. This emphasizes the need for further research towards understanding causality.

https://www.mdpi.com/1660-4601/10/6/2214/pdf

DH Hickam

Papers

The Effect of Health Care Working Conditions on Patient Safety: Summary