Effects of Hospital Care Environment on Patient Mortality and Nurse Outcomes - Literature review Example

Critique: “Effects of Hospital Care Environment on Patient Mortality and Nurse Outcomes” Impact of Hospital Care Environment Goes Here Institutional Affiliation Goes Here Introduction The hospital environment is one of the major factors which influence the delivery of healthcare facilities to the patient and those responsible for the delivery of such facilities. Adequate staffing and the level of their qualification are the two contributing factors which are known and recognized to impact the overall quality of hospital administration. Aiken L.H., et al (2008), in this study tried to explore the role played by the hospital care environment on patient outcome as well nursing practice, exclusively. The authors have stated their objective at the outset, by directing the aim of their inquiry towards the single factor of environment, eliminating the contribution of other known factors both by their approach of analysis and mode of research. The sentence that most clearly approximates the problem statement as well as the purpose of this study is at the beginning of the second paragraph in the introductory section of the article and states that, “The purpose of this article was to empirically examine whether better hospital nurse care environments are associated with lower patient mortality and better nurse outcomes independently of nurse staffing and the education of the registered nurse (RN) workforce in hospitals.” The authors have been very precise in the statement of their objective and have built upon the need for this study by showing that evaluation for the specific criteria (hospital environment) has nor been done as yet. According to them staffing patterns as well education levels of nurses have been evaluated in past research and there exists a lacuna in this evaluation due to the lack of data on the impact of hospital environment. The study has been based on the research conducted in magnet hospitals which according to the authors was consist in the demonstration of links between better care environments and superior nurse and patient outcomes. The authors have highlighted the skepticism expressed by some stakeholders about the net significance of nurse practice environments on patient outcomes when patient-to-nurse staffing ratios were taken into account. The authors feel that such doubts need to be cleared in order to guide the leaders in nursing to make better decisions to improve nurse retention and patient outcomes, thereby necessitating the need for this study. In this study, a large number of hospital environments (168) in the state of Pennsylvania were evaluated for impact on the delivery of healthcare, both in terms of patient mortality and nurse experience. The authors claim that better care environments are definitely associated with lower patient mortality, as well as the facilitation of better nursing services and job satisfaction, at the conclusion of the study. The authors have built their hypothesis on the basis of a well recognized fact that the Practice Environment Scale of the Nursing Work Index (PES-NWI) is accepted as a measure for the National Quality Forum’s standard, for measuring hospital care environments and its association with patient outcomes. On this basis they have prepared a methodical approach to the issue by preparing a survey pattern which none of the hospitals selected for the study could ignore, due to its inclusive sampling design, thereby strengthening the case for generalization of the results. The concepts have been well defined by selecting and categorizing the hospitals into three broad categories, the nursing staff according to their level of education, area of operations and the type of the three identified categories of hospitals they were working in and the patients based on the severity or the expected outcome of their conditions. The categorization of all the three factors- nurses, patients and hospital environments into specified groups or blocks was done after thorough incorporation of strict, well defined criteria. All key characteristics of a concept i.e. parsimony, utility, clarity/clear boundaries and ability of being observable, were adequately taken care of. This was ensured by the collection of survey data in a consistent manner over a prolonged interval of time. The hospitals selected represented a large population size in one of the larger states, Pennsylvania and included 80% of the adult care hospitals which had a minimum of 40 nursing staff, reporting more than 100 cases of surgical discharges of the type shortlisted and defined for the study and satisfied the structural characteristics according to the American Hospital association as well as the Pennsylvania Health Care Cost Containment Council. The nurses who participated in the study and answered the questionnaire were selected randomly and represented 50% of the total population of working nurses in the state of Pennsylvania. 52% of the participating nurses completed the survey, which according to the authors compared favorably with other surveys of this nature in the past, which translated into better extrapolation of the results towards revealing the national trend. Patient outcome data was collected from a large number (232,342) of patients who represented the population due to the common factor of pre identified general surgical procedures, although their age varied from 20 to 85 years. The data was collected for a fairly long stretch of time which spanned a period of 19 months. The hospital structural characteristics were defined on the basis of national and state survey data and they were characterized by the number of total beds in the hospital, the level of education of the hospital staff and the degree of medical specialties available at the premises. Nurse: patient ratio was taken into consideration along with the educational composition of the nursing workforce. Patient care environments were measured according to PES-NW1 by selecting and analyzing only three sub scales which did not overlap with direct staffing and nurse education. These were the ‘nursing foundations for quality of care’, ‘ability, leadership and support qualities of nurse manager’ and ‘collegial nurse-physician relations’. According to authors all these subscales have good psychometric properties thereby leading to appropriate inputs for analysis of pertinent data obtained, which was well directed towards the purpose of this study. Based on the evaluation of these sub scales, the hospital environments were divided into the ‘poor’, ‘better’ and ‘mixed’ categories in terms of the care environment. The nurses’ perception of the quality of care was assessed on the basis of six surveys which evaluated job satisfaction, burnout and the intent to leave the job in the subsequent year. A 9-item emotional exhaustion sub-scale (Maslach Burnout Inventory) was employed for this purpose. Opinion questions about quality care for the nurses were included in the questionnaire. Patient outcomes and characteristics were evaluated by dividing them into two classes – ‘patients dying within 30 days’ of admission and ‘patients with complications dying within 30 days’. Board certification status of the operating surgeons was taken into consideration for evaluating the surgical outcomes. The independent variables in this study can be enumerated as the hospital categorization according to size, the number of staff and the nurse: patient ratio, total number of surgical cases in the particular hospitals and educational status of the hospital staff. The dependent variables will be the questionnaire compliance, responses according to literacy level, age/sex of the patients, existence of chronic/preexisting conditions and the type of surgical cases in a hospital during the duration of the study. The theoretical framework for this study is built up well by the authors. They have cited literature which provides evidence for a better patient outcome when staffing and education of the healthcare staff have exerted positive influence on patient outcomes. The connection of the two factors with the hospital care environment is suggestive of an additive effect but has been unexplored according to the authors. They have built upon this idea to initiate this study in an effort to get an analysis whether this factor has a positive influence on patient outcome or not. The literature review is quite comprehensive and the majorities of the sources are primary in nature and come from reputed journals. The authors have built upon the established facts of a correlation established between better outcomes and better nursing practices and better educational levels of the nursing staff as established by previous studies. The consistency of results obtained in a large number of previous studies done at magnet hospitals on the benefits of a better care environment towards patient outcomes serves as an impetus to further investigations of this nature. Better practice environments and implementation of new organizational strategies have been shown to have a beneficial effect on patient outcomes in a variety of situations in previous work. All literature cited by the authors is current and incorporates the latest data obtained from studies conducted at diverse locations. Standards of evaluation and frameworks for the study have been prepared according to established norms as shown in the cited literature. The study design is comprehensive and takes all variables into consideration for the collection of data. The majority of hospitals in Pennsylvania State were taken into consideration to get a fair evaluation of the criteria under investigation. It was ensured that the staffing pattern was commensurate with the requirements of the study and satisfied the minimum criteria. The frequency as well as the nature of surgical discharges was taken into consideration with the minimum standard set at 100 cases in a hospital. The selection also included the structural criteria standards for the selected hospitals, ability of the nursing staff to respond to the questionnaires and the type of patients to be evaluated. The study design was most appropriate for this level of inquiry as it satisfied more than the minimal level of statistical criteria. Most of the extraneous variables were well controlled as strict criteria were employed to standardize the possible responses according to similarity of inputs obtained form the three categorizations of institutions under investigation. The nurse: patient ratio, education level of nursing staff, age and sex of nurses as well as patients were some of the variables which were kept up to strictly defined criteria. As this study was based on questionnaires and evaluation of readily available classified data from responsible health authorities like the American Hospital Association and Pennsylvania State, there was no scope or potential for any harm to the patients as well as participating nursing staff. The study protocol was duly approved by the institutional review board of the University of Pennsylvania, but there is no mention of an informed consent of the participants as the paper mentions just that the random sample nursing staff was provided questionnaires at their homes. Probably as the patients under review had no implications on the procedure they had to undergo and the data obtained did not impinge on their health status in any way, their consent was deemed unnecessary. Data was obtained in the form of questionnaires provided to the nurses and the responses obtained were well within the confidence limits. Maslach Burnout Inventory standardized tool was used which was consistent with published norms for health professionals in the Maslach Burnout Inventory manual. 133 variables were controlled which were predictive of mortality and failure to rescue in the data set which included age, sex, transfer of patients from other hospitals, 48 dummy variables that indicated the surgery type and 28 dummy variables that indicated the absence or presence of chronic preexisting conditions as classified by the International Classification of Diseases were used. Reliability of instruments was ensured by giving examples of previous studies of this nature and the confidence level of data interpretation. The data collection method ranged from ordinal to interval/ration as it involved calculation of means and median values for hospital level practice environment subscales to evaluate the environments by categorizing them into better, mixed or poor care environments. A normal distribution pattern was used to evaluate the nurse characteristics, outcomes, reports of adverse effects and assessment of patient care quality. Odds ratios were calculated for comparing the hospital care environments with staffing patterns and the nurse outcomes according to their particular place of employment. Patient outcome was evaluated in a similar pattern by calculating the odds ratios. The study was successful in demonstrating that surgical mortality rates were 60% higher in poorly staffed hospitals with the poorest patient care environments, than in hospitals with better care environments in the sample, the best nurse staffing levels, and the most highly educated nurses. The study demonstrates that improving nurse staffing, education, and the care environment contribute independently to better patient outcomes. From obtained figures the authors estimated that the actual number of patient deaths that could be averted annually by improved care environments, nurse staffing, and nurse education can be as high as 40,000 patients per year, which is a significant figure. The authors have however desisted from jumping to conclusions and have suggested further reinforcement of facts by further studies as this type of studies were based on cross-sectional data. The study is comprehensive in structure and statistically significant interpretations have been obtained which indicate a better patient outcome and nurses’ performance when the hospital environment is improved. The only weakness could be that such analysis may not be true for all hospital settings where motivational factors, dedication to work and skill of the health professionals may contribute in a significant manner. A hospital lacking in staff with these characteristics is likely to yield erroneous data for such generalized interpretations. The authors have related their findings to administration as well as education. References Aiken Linda, Clarke Sean P., Sloane Douglas M., Lake Eileen T. and Cheney Timothy, (2008), Effects of Hospital Care Environment on Patient Mortality and Nurse Outcomes, JONA Volume 38, Number 5, pp 223-229. Read More