Work satisfaction among California registered nurses: a longitudinal comparative analysis

California's minimum nurse-to-patient staffing ratio law, the nation's first, was implemented in 2004. This study had two aims: (a) to evaluate the effect of the nurse-to-patient ratios law on nurse job satisfaction in order to advance the debate over the merits of nurse staffing law, and (b) to compare California nurses who were satisfied against those who were not, in order to facilitate the development targeted retention interventions based on empirical evidence. The sample's overall job satisfaction increased significantly as the years passed, suggesting the nurse-to-patient ratios law was associated with improvements in nurse satisfaction. Satisfied RNs were more likely to have a balanced and financially secure life that included a partner, children living at home, higher hourly wages, and higher income from sources other than a nursing job. Nurses working in direct patient care positions remained dissatisfied in larger proportions than those working in other types of positions, even after the nurse-to-patient ratios were implemented. More nurses are satisfied today than before the ratios; nevertheless, far too many nurses (18.5%) have job satisfaction scores that are neutral or worse.     

Value-added care: a paradigm shift in patient care delivery

Spiraling costs in health care have placed hospitals in a constant state of transition. As a result, nursing practice is now influenced by numerous factors and has remained in a continuous state of flux. Multiple changes within the last 2 decades in nurse/patient ratio and blend of front-line nurses are examples of this transition. To reframe the nursing practice into an economic equation that captures the cost, quality, and service, a paradigm shift in thinking is needed in order to assess work redesign. Nursing productivity must be evaluated in terms of value-added care, a vision that goes beyond direct care activities and includes team collaboration, physician rounding, increased RN-to-aide communication, and patient centeredness; all of which are crucial to the nurse's role and the patient's well-being. The science of appropriating staffing depends on assessment and implementation of systematic changes best illustrated through a "systems theory" framework. A throughput transformation is required to create process changes with input elements (number of front-line nurses) in order to increase time spent in value-added care and to decrease waste activities with an improvement in efficiency, quality, and service. The purpose of this pilot study was two-fold: (a) to gain an understanding of how much time RNs spent in value-added care, and (b) whether increasing the combined level of RNs and unlicensed assistive personnel increased the amount of time spent in value-added care compared to time spent in necessary tasks and waste.     

Factors influencing work productivity and intent to stay in nursing

The researchers document the individual and workplace characteristics associated with decreased work productivity and intent to stay in nursing for nurses employed in direct patient care in the hospital setting. Factors associated with decreased work productivity were age, total years worked as a RN, quality of care provided, job stress score, having had a job injury, and having a health problem. Nurse leaders must place additional efforts on changes needed to improve the hospital workplace environment to decrease job stress, improve RNs' ability to provide quality care, and to assure the health and safety of nurses. Reducing job stress and providing adequate staffing so quality of care can be provided will enhance job satisfaction which will also encourage RNs to stay at the bedside. Improved work environments may delay older RNs' retirement from the workforce.     

Nurse staffing decisions: an integrative review of the literature

The author exhaustively explores the current literature and attempts to summarize the current thinking on how to best decide on the most cost-effective nurse staffing requirements. Between 1984 and 1994 FTE nursing employees decreased by 7.3%, causing some researchers to seek ways to explore the relationship between staffing levels, staff and patient satisfaction and outcomes of care. Satisfaction among staff nurses working in a self-scheduling environment was determined largely by the individual's ability to negotiate for the desired days and shifts and by the nurse manager's ability to stand back from the process and let the staff collaboratively work it out. Work structure related studies seemed to find that 12-hour shifts were reported to be "less fatiguing" than traditional 8-hour shifts. Staffing studies found that rural hospitals still used 0.27 more RNs per occupied bed than urban hospitals and that the presence of a unit secretary was associated with a decreased use of RNs.     

Cost effectiveness of a medical vigilance system to reduce patient falls

Patient falls are a serious problem in hospitals, resulting in substantial morbidity, mortality, length of stay, and costs. The results of a small trial of a patient vigilance system in a post-neurosurgery unit of a large acute care hospital are reported. The system includes two components: (a) passive sensor array placed under the patient in a hospital bed, and (b) a bedside unit that connects to the nurse call system already in place at the hospital. This trial demonstrated the overall effectiveness of the vigilance system in reducing the rate of patient falls. The cost-effectiveness analysis found that use of this system was associated with somewhat higher measured costs. It is likely that the system was cost-saving, due to unmeasured costs.     

The implications of nurse staffing information: the real value of reporting nursing data

There is a dearth of information about the relationship between the patient care contributions of nursing and its financial contributions to an organization. As consumers and legislators are becoming more aware of the ramifications of nurse staffing issues, and as they endeavor to address them with legislative solutions, the decision on how best to develop optimal staffing strategies may soon be taken away from nursing leaders. To maintain control of this important issue and develop solutions that will help highlight the economic and patient care contributions of nurses, a thorough understanding of the problem, and a new commitment are needed from nursing leaders to take charge of the issue. To relate nursing care to patient outcomes, meaningful data on the nursing care provided is needed in addition to data on the nursing needs of patients. Staffing and performance monitoring tools should be used to effectively plan, implement, and control financial and operating resources as well as measure the economic value of the nursing profession's contribution to the cost and benefits of patient care.     

Registered nurses: the impact of wages on labour force participation and hours worked – are wages an effective mechanism for addressing RN shortages with evidence from 1960 to 2008?

Registered nurses (RNs) are critical producers and coordinators of patient care in acute and non-acute settings (Needleman et al. 2011). The Affordable Care Act coupled with an ageing population, are increasing demand for health care and, in turn, RNs. Numbering 3 million, RNs comprise the largest professional occupation in health care. Therefore, the labour force participation and hours worked are of keen interest to stakeholders and policymakers. Rising demand may exacerbate nursing shortages and have important effects on costs. We estimate the impact of wages on participation and hours worked as a possible policy tool to increase nursing supply. In 2008, the RN wage had a positive and significant effect on participation and a small positive but only marginally significant effect on hours worked given participation. The latter elasticity for married females (single females) was 0.11 (0.33). Therefore, the elasticity of hours worked with respect to the nurse wage is and unlikely to have an important effect on the participation rates or hours worked of currently trained female RNs. Consequently, wage increases are unlikely to be an effective policy to increase the labour supply among the currently licensed RNs and will not relieve any short-term nursing shortage.     

Why are shortages of hospital RNs concentrated in specialty care units?

This article is the first in a series examining the interplay between the aging of the nurse workforce and other factors driving the growing nursing shortage that are already affecting some specialty areas. Nearly 60% of the current RN workforce is over 40 years of age; and the percentage of RNs under age 30 has fallen by nearly 40% since 1980. The total number of FTE RNs is projected to shrink after 2010, likely resulting in shortages of RNs "when the large baby-boom generation of RNs starts to retire." Because ICUs have historically attracted younger RNs, the rapid decline in the number of RNs in the workforce under age 30 plays a large role in explaining the development of shortages in the ICU. The growing difficulties staffing operating rooms and other peri-operative services is seen as related to the aging work force as more diploma prepared nurses have been attracted to this specialty because they had educational exposure to this area.     

Patients' perceptions of nurse staffing, nursing care, adverse events, and overall satisfaction with the hospital experience

Noticeably absent in the discussions surrounding nurse staffing and adverse events is the patients' perspective, except for their satisfaction with various aspects of their hospitalization experience. The results of a study undertaken to test a theoretical model of patients' perceptions of nurse staffing, the nursing care they receive, self-reported adverse events, and overall satisfaction with the hospital experience are presented. Perception of nurse staffing only weakly predicted the number of adverse events reported by patients, but was a strong predictor of the perception of nursing care received, and the perception of nursing care received was the only significant predictor of overall satisfaction with the hospital experience.     

Factors associated with increased hospital costs in patients treated with lipid-based amphotericin B for empirical therapy

Summary

Lipid-based amphotericin B agents have been studied in a number of clinical settings and patient populations, most notably as empirical therapy for patients at-risk for systemic fungal infection and for patients with documented invasive disease. In clinical practice, lipid-based therapies have been considered second- or even third-line therapy due to concerns about costs. However, few analyses have been conducted to determine those factors associated with empirical antifungal therapy and lipid-based agents that are most likely to influence hospital costs and length of stay.

The purpose of this analysis is to determine which demographic, treatment, and clinical outcome factors contribute to increased hospital costs and length of stay in patients treated empirically with a lipid-based amphotericin B agent.

A retrospective analysis of 89 patients enrolled in the clinical study was performed to assess hospital costs and length of stay following the start of empirical antifungal therapy. Bivariate and multivariate regressions were performed to identify variables most likely to affect hospital costs and length of stay.

Allogeneic bone marrow transplant (BMT) status, days of treatment, doubling of baseline creatinine, and dialysis were found to be predictive both of increased hospital costs and length of stay. Length of stay and number of concomitant nephrotoxic agents also were found to affect hospital costs.

Overall, risk factors and clinical outcomes associated with nephrotoxicity increased hospital costs and length of stay in patients treated empirically with lipid-based antifungal agents. Renal dialysis also increased hospital cost significantly. For empirical antifungal therapy, providers should consider both patient-specific risk factors and product-specific outcomes in selecting an appropriate agent.     

Predicting nurses' organizational and professional identification: the effect of nursing roles, professional autonomy, and supportive communication

Recruiting and retaining qualified nursing staff is of growing importance to today's hospital and nurse leaders. Findings from a survey completed by 190 RNs at a major teaching hospital revealed that nursing roles, professional autonomy, and supportive communication were differentially related to the nurses' organizational and professional identification. Professional autonomy was by far the strongest predictor of nurse identification, followed by manager and co-worker support. Co-worker support and traditional nursing roles predicted nurse professional identification, but neither traditional nor collaborative roles predicted nurses' identification with their organization. Communication strategies intended to help executives retain qualified nursing staff are presented.     

Minimum nurse staffing ratios for nursing homes

The authors explored minimum nurse staffing ratios for nursing homes using production function simulations. Minimum levels of registered nurse hours per resident day were 0.31, 1.83, and 3.3 at 50%, 75%, and 90% levels of quality respectively. These results suggest that efficiency-oriented minimum nurse staffing points exist, and could be used to inform policymakers and nursing home administrators on better resource allocation and health care delivery.     

Information technology, nurse staffing, and patient needs

As health care organizations increasingly adopt health information technology, time-sensitive data that track patients' requirements for nursing care and nurses' responsiveness to these needs might be available to support evidence-based nurse staffing decisions. care information technologies available in hospitals and on nursing units may provide valuable sources of information that can be translated into usable data. In this study, the usefulness of electronic data obtained from a nurse tracking call light system as a source of information for quality measurement was explored. The findings point to what might be under-utilization of existing health information technology to track patients' needs and nurses' responsiveness, patient census, and patient movements. The authors recommend health information technology be used less as support for other organizational systems and more as an administrative resource that can allow nurse executives to be more actively engaged within and across nursing environments.     

Evidence-based staffing: potential roles for informatics

Over the last 15 years, evidence has been accumulating relating higher levels of nurse staffing in both quantity and experience to lower rates of adverse patient outcomes. Consequently, to promote quality patient outcomes efficiently, making staffing decisions based in evidence is of increasing importance. However, there is still limited data to help decide how to effectively allocate scarce nurse resources in practice. Existing principles, frameworks, and guidelines provide a foundation for nurse staffing decisions but face poor adoption. To determine optimal nurse staffing practices and provide evidence-based recommendations for policy, and integration into operations, comprehensive data are necessary. Information technology can assist nurse staffing decisions. Four informatics processes that may support evidence-based nurse staffing are described: (a) Data acquisition from multiple data sources, (b) Representation of data in a way it can be re-used for multiple purposes, (c) Sophisticated data processing and mining, and (d) Presentation of data in standardized and user-configurable ways.     

The impact of nursing on patient and organizational outcomes

The impact of nursing on patient and organizational outcomes has received significant attention from researchers in the past 10 years. Although some research has been based on a theoretical framework, to date, there has not been one, consistent framework that can guide this research. In addition, the frameworks that have been used do not identify nursing as the pivotal concept in the model. The purpose of this article is to identify a framework to guide such research with an emphasis on nursing as the essential concept. Unit culture, nurse staffing, staffing mix, and other variables do not have a direct effect on outcomes. It is only through these variables' influence on the delivery of nursing care that outcomes are affected.     

Comparing variations in labor costs for two vs. one full-time nurse manager

Labor costs for two versus one full-time nurse manager were compared. Results revealed reductions in nursing costs per patient day. These results suggest that innovative models may hold promise as organizations struggle to retain nurses and decrease costs.     

Linking nursing workload and performance indicators in ambulatory care

More and more ambulatory care organizations are using nursing report cards to monitor and evaluate the quality and effectiveness of nursing care in the ambulatory setting. Nurse staffing levels is usually one of the items included in a nursing report card and the one most scrutinized by ambulatory care administrators. One strategy employed by the nursing leadership at the South Texas Veterans Healthcare System to justify nurse staffing levels is linking administrative staffing monitors with nurse-sensitive outcomes via workload and performance indicators. Through this approach, nurse leaders are able to justify nurse staffing level changes, needed technology changes, process improvements, and/or workflow needs to administrators with positive results and support.     

The potential imposition of wage controls on nurses: a threat to nurses, patients, and hospitals

When there are shortages of RNs, hospitals and health care organizations in competitive nurse labor markets respond by increasing wages: some hospitals will respond faster and some will offer higher wages than others. The wage increase brings about two important short and long-run outcomes that, together, will increase the supply of RNs in the labor market. Because wage controls prevent the flexibility of wages to adjust, they can cause a shortage to develop when the demand for RNs is increasing (as in the 1970s), and wage controls will lengthen the duration of a shortage once it has begun. The impacts of prolonged RN shortages are multifaceted and destructive to nurses, patients, and hospitals. Looking ahead over the next 15 years when the demand for RNs is expected to grow by roughly 3% per year and the supply of RNs by much less than that, a new nursing shortage is projected to develop and reach a deficit of 285,000 RNs by 2020. The worst thing that could happen to the nursing profession would be to impose wage controls on nurses as this would prevent the needed short and long-run labor supply responses from developing and thereby eliminate the shortage.     

How does the Price Regulation Policy Impact on Patient–Nurse Ratios and the Length of Hospital Stays in Japanese Hospitals?

This study examines how the 2000 and 2006 revisions of the fee‐for‐service system have affected patient–nurse ratios and the average length of hospital stays in Japan. The empirical results show that hospitals are quite responsive to changes in price policy. The fee revisions have certainly achieved the policy objectives of reducing patient–nurse ratios and the length of hospital stays. As a result, hospitals have responded by greatly increasing the number of expensive beds for acute care. However, this was not exactly predicted by the Japanese government, which has aimed to reallocate health‐care resources, such as beds, to subacute or long‐term care.     

A longitudinal cost analysis of primary and team nursing

Cost findings from a 4-year (1984-1989) externally funded, empirical study, comparing primary and team nursing on medical units in a tertiary care teaching hospital, demonstrates that primary nursing is less costly than team nursing. An average savings of 6.5% was realized for the duration of the study. Three factors are identified as being responsible for the difference on a cost per patient per day basis. Overall, cost analysis per DRG from primary nursing suggests cost differences related to high DRG volume and average length-of-stay. An administrative review of the study's implications highlights the relevancy of these findings in relationship to nurse retention and cost savings.