Nursing Characteristics that Affect Patient Outcomes

1. Nursing Characteristics that Affect Patient Outcomes Shana Green Eileen Lake, Robyn Cheung Center for Health Outcomes, Policy and Research (CHOPR)

2. SUMR Goals Learn about the theory and research linking nursing to quality Assist with collection of quantitative data in multisite hospital study Learn the sections of a research manuscript and assist to prepare different sections Learn to prepare/write a proposal Develop a presentation of study findings for a research meeting

4. To examine whether acuity-adjusted nurse staffing and environments contribute to variation in VLBW infant outcomes in NICUs. Acuity-adjusted Staffing… Purpose

5. Observational study with data collected by web survey 6400 nurses in 104 NICUs from the Vermont Oxford Network (VON) 8490 infants from VON database Adjusted- acuity Staffing… Methods

6. Acuity- adjusted Staffing… Measures • Nurse Staffing • An estimate of the average of patient needs on a particular units • No standardized method of selecting nurse staffing levels • Acuity • Average severity of illness of inpatient population • Determines amount of care patient needs • No standardized methods for determining the acuity of infants in NICU • Acuity Weights • Daily proportion of a nurses required to take care for an infant in an acuity category.

7. Staffing On average, a nurse cared for two infants, but this varied by infant acuity. Infant acuity Infants in acuity levels 1, 2, and 3 comprise the largest proportion of infants. Acuity- adjusted Staffing…Results

8. Nurse Qualifications 56% BSN 19% neonatal specialist 74% ≥5 years in NICU Professional Practice Environment Exceptional hospital sample Acuity- adjusted Staffing…Results 104 hospitals ~5,000 hospitals 523 hospitals

9. Acuity- adjusted Staffing…Results • Outcomes • A lower staffing level is associated with higher proportions of BSNs and NICU-experienced nurses • Staffing and BSN proportion are associated with mortality • NICU experience is associated with SIVH • A more professional practice environment is associated with lower odds of infection. • VLBW infants in magnet hospitals had lower odds of mortality.

10. Results Conclusions • Nurse staffing and environment explains a small amount of the variation in VLBW infant outcomes across NICUs • While magnet hospitals achieve better infant outcomes, the preponderance of magnet hospitals in the sample cohort makes it hard to differentiate which aspects of these hospitals are influential. • Staffing • On average, a nurse cared for two infants, but this varied by infant acuity (Table 1 and Fig. 1). Infant acuity • Infants in acuity levels 1, 2, and 3 comprise the largest proportion of infants. (Fig. 2). • Nurse Qualifications • 56% BSN; 19% neonatal specialist; 74% ≥5 years of nursing experience. • Professional Practice Environment • Exceptional hospital sample: 33% magnet certification based on exemplary nursing standards, compared to VON (19%) and hospitals nationally (6%). • Outcomes • Average infant outcomes-- mortality, 11%; nosocomial infection, 17%; severe intraventricular hemorrhage (SIVH), 7%; and chronic lung disease, 26%. • Analyses of VON: significantly lower likelihood of death (OR = .86, p = .05) for VLBW infants in magnet hospitals and marginally significant lower likelihood of infection and SIVH. Better professional practice environment appears to be associated with a lower likelihood of infection. Background • VLBW infants are high-risk patients closely monitored through life support measures and intensive interventions in NICUs • Nursing care may provide an opportunity to improve outcomes; since unexplained variations exist. Policy Implications • Our research findings support evidence-based management decisions to improve the quality of NICU care by: • informing managers about staffing ratios and staff qualifications and • identifying the features of practice environments that are most influential for infant outcomes. Objective • To examine whether acuity-adjusted nurse staffing and environments contribute to variation in VLBW infant outcomes in NICUs. Nursing Unit Organization and Very Low Birth Weight Infant Outcomes in Neonatal Intensive Care Units Eileen Lake, PhD, RN, FAAN, University of Pennsylvania Jeannette Rogowski, PhD, University of Medicine and Dentistry of New Jersey Jeffrey Horbar, MD, University of Vermont Douglas Staiger, PhD, Dartmouth College Michael Kenny, MS, University of Vermont Thelma Patrick, RN, PhD, The Ohio State University Robyn Cheung, RN, PhD, University of Pennsylvania Figure 1. Observed/ expected acuity-adjusted staffing levels for study hospitals. Figure 1 Figure 2. Percent distribution by infant acuity across 104 NICUs. Study Design, Sample and Methods Table 1. Nurse to patient ratios by acuity level. • Observational study with data collected by web survey • 6400 nurses in 104 NICUs from the Vermont Oxford Network (VON), an international quality improvement collaborative for neonatal care • 8490 infants from VON database • Analyzed outcomes in random-effects logit models; controlled for patient demographic and birth characteristics. Table 1 Figure 2

11. Acuity- adjusted Staffing…Next Steps • Purpose • To adjust for hospital characteristics (523 VON hospitals) that have an impact on NICU patient outcomes • To find the effect of nursing on NICU patient outcomes.

12. Acuity- adjusted Staffing…Next Steps • AHA Data • Database of over 6,000 hospitals • Variables • MNAME • MLOCSTATE • MLOCCITY • NICBD • Mapp8 • Teaching hospital? • CNTRL • Ownership status? • ADJADC • Census of patients • FTERN • Full time or equivalent RN

13. Acuity- adjusted Staffing…Next Steps • Reduce AHA database • Remove hospitals without NICBD (value 0) • Delete non VON hospitals • Compare hospname to mname • Enter magnet status

14. The Effects of Nursing on NICU Patient Outcomes

15. NINR Study… Purpose • NINR Study • Quarterly data collection for nurses and infants in a single shift • Explore staffing patterns across seasons • Explore nursing as a resource to reduce cross-hospital disparities in mortality

16. NINR… Site Coordinator Responsibility • Secure IRB approval • Comply with documentation requirements • Collect and submit statistics on the composition of the nursing unit staff, layout, medical and non-medical personnel staffing • Collect infant data from staff nurses • Enter data on www.nicunursingsurvey.com

17. NINR… Site Management • Documentation • Secure IRB approval • modification 3 • Conflict of Interest • PHS (42 CFR Part 50; Subpart F) • Responsibility of Applicants for Promoting Objectivity in Research for Which PHS Funding Is Sought • Financial Disclosure • CITI Certification • Human subjects training • Data Entry Website • Pilot Study

18. NINR Study…Data Entry Website

19. NINR Study… Progress • Pilot Study • Protocol • Nine Sites • June 15, 2009 • First Data Collection • 55 of 77 Sites Collected Data • July 15, 2009 at 2pm • Data includes nurse and patient status from 7am to 2pm

20. NINR Study… Next Steps • Complete first quarter data collection • Report staffing level and infant acuity to hospitals in study • Complete remaining 3 quarters of data collection • Analysis

21. Recruiting and Staffing for Clinical Nursing Expertise

22. Tasks Associated with Manuscript Response to Reviewers Literature Review Table APA Format Manuscript

23. Literature Review Expertise Experience Domain specific knowledge Complex reflexive thinking Intuition View of Expertise Peer nominated New measures Manuscript

24. Manuscript • Literature Review • Cultivation of Expertise • Mentorship (Field 2004) • Continuing education (Ericsson et. al. 2007) • Practice environment (Foley et. al. 2009) • Competitive • Demands excellence • Fosters autonomy, practice control and relationship with physicians

25. “These precious patients are the smallest and most vulnerable they will ever be during their lifetimes…” “…the neonatal nurse is the eyes, ears, support of not only the baby but the entire family.”