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A 36-Hospital Time and Motion Study: How Do Medical-Surgical Nurses Spend Their Time?
Abstract and Figures
Context: Nurses are the primary hospital caregivers. Increasing the efficiency and effectiveness of nursing care is essential to hospital function and the delivery of safe patient care.Objective: We undertook a time and motion study to document how nurses spend their time. The goal was to identify drivers of inefficiency in nursing work processes and nursing unit design.Design: Nurses from 36 medical-surgical units were invited to participate in research protocols designed to assess how nurses spend their time, nurse location and movement, and nurse physiologic response.Main Outcome Measures: Nurses' time was divided into categories of activities (nursing practice, unit-related functions, nonclinical activities, and waste) and locations (patient room, nurse station, on-unit, off-unit). Total distance traveled and energy expenditure were assessed. Distance traveled was evaluated across types of unit design.Results: A total of 767 nurses participated. More than three-quarters of all reported time was devoted to nursing practice. Three subcategories accounted for most of nursing practice time: documentation (35.3%; 147.5 minutes), medication administration (17.2%; 72 minutes), and care coordination (20.6%; 86 minutes). Patient care activities accounted for 19.3% (81 minutes) of nursing practice time, and only 7.2% (31 minutes) of nursing practice time was considered to be used for patient assessment and reading of vital signs.Conclusion: The time and motion study identified three main targets for improving the efficiency of nursing care: documentation, medication administration, and care coordination. Changes in technology, work processes, and unit organization and design may allow for substantial improvements in the use of nurses' time and the safe delivery of care.
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... Reducing unnecessary movement of nurses to optimize nurses' movement is essential. Literature has shown that the nurses who consumed more time in walking spent less time at the patients' bedsides (Trites et al. 1970;Ulrich et al. 2004;Hendrich et al. 2008). Hendrich, Chow, Skierczynski, and Lu (2008) found that nurses walked an average of 3.0 to 5.5 km in the day shift; while for the night shift nurse, the average walking distance varied between 2 and 5 km. ...
... Literature has shown that the nurses who consumed more time in walking spent less time at the patients' bedsides (Trites et al. 1970;Ulrich et al. 2004;Hendrich et al. 2008). Hendrich, Chow, Skierczynski, and Lu (2008) found that nurses walked an average of 3.0 to 5.5 km in the day shift; while for the night shift nurse, the average walking distance varied between 2 and 5 km. Nurses' walking distance can be as much as 10 km during a shift (Pati et al. 2012). ...
... Grasshopper plug-in, 'PedSim' is used for modeling pedestrian walking behavior in Rhino space. The pedestrian walking behavior is defined by a series of Grasshopper components, setting agent target points, vision properties, target force etc. 'PedSim' is based on the social force model (Helbing and Molnar 1995) with the collision avoidance model. Agents choose the shortest route, avoid collisions with other objects by analyzing the current environment, and move to the target points. ...
This study investigates the nursing unit design for care quality and efficient operation, evaluating visibility and walking distance of nurses in the different form of layout. Sufficient visibility from nurses' station to patient rooms and corridors can increase nurses' care abilities to understand the needs and movements of patients. The workload and time caused by nurse's walking can be diverted to patient care. Isovist analysis and agent-based simulation are experimented to investigate the effects of spatial layout on visibility and nurses' accessibility to patients. In the isovist analysis, the nurses' station facing patient rooms were more effective in nurse-to-patient visibility. In the nurse's walking trail analysis, uneven walking distance of each nurse appeared due to the asymmetric patient room layout centering the nurses' station and heavy room allocation plan. Understanding the potential impacts of design parameters enables designers to predict possible behaviors in each design alternative and to make effective and efficient design decisions for the occupants. This study underlines the role of the physical environment in the delivery of patient care and nurse's well-being. It presents an evaluation framework integrating syntactic analysis and agent-based simulation to predict the effect of the spatial layouts on the hospital activities.
... This report estimated that as many as 98,000 individuals in the United States die each year as a result of preventable medical errors-many of which are attributable to operational failures (Institute of Medicine, 2000)-and the inability of the work system to reliably provide information, services, and supplies needed when, where, and to who (Tucker, 2004). Twenty years later, operational failures (Hendrich et al., 2008;Tucker, 2004;Tucker et al., 2014;Tucker & Spear, 2006) and preventable medical harm related to operational failures (Bates & Singh, 2018) remain a pervasive problem in U.S. hospitals. On average, nurses encounter an operational failure once every 37 minutes (Tucker et al., 2014). ...
... In response to operational failures, healthcare professionals, such as nurses and physicians, often engage in workaroundsan intentional effort to create the desired result despite the obstacle (Halbesleben et al., 2010;Tucker et al., 2014) and circumvent safety protocols in order to complete necessary work (Hendrich et al., 2008;Tucker, 2004;Tucker et al., 2014;Tucker & Spear, 2006). When a nurse encounters an operational failure, they are faced with the decision of whether to perform a workaround. ...
... This decision may be influenced by several factors, including the sheer burden of operational failures in their respective care setting. Research has documented that, on average, nurses spend 10% of their time engaging in workarounds to address operational failures (Hendrich et al., 2008;Tucker, 2004). Although workarounds can solve the immediate problem, they also enable failures to reoccur if no attempt is made to address problems systematically. ...
Background:
Operational failures, defined as inability of the work system to reliably provide information, services, and supplies needed when, where, and to who, are a pervasive problem in U.S. hospitals that disrupt nurses' ability to provide safe and effective care.
Objectives:
We examined the relationship between operational failures, patient satisfaction, nurse-reported quality and safety, and nurse job outcomes (e.g., burnout, job satisfaction) and whether differences in hospital work environments explained the relationship.
Methods:
We conducted a cross-sectional analysis using population-based survey data from 11,709 RNs in 415 hospitals who participated in the RN4CAST-US nurse survey (2015-2016) and the 2016 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The RN4CAST-US nurse survey focused on hospital quality and safety, job outcomes, and hospital work environments. The HCAHPS survey collected publicly reported patient data on their satisfaction with their care. Operational failures were evaluated using an 8-item composite measure that assessed missing supplies, orders, medication, missing/wrong patient diet, electronic documentation problems, insufficient staff, and time spent on workarounds and nonnursing tasks. Multilevel regression models were used to test the hypothesized relationships.
Results:
Operational failures were associated with low patient satisfaction scores, poor quality and safety outcomes, poor nurse job outcomes, and those associations were partly accounted for by hospital work environments.
Discussion:
Operational failures prevent high-quality care and positive patient and nurse outcomes. Operational failures and the hospital work environment should be targeted simultaneously to maximize quality improvement efforts. Hospital leadership should work with frontline staff to identify and target the sources of operational failures in nursing units. Improvements to hospital work environments may reduce the occurrence of operational failures.
... For further research, the authors recommend other interest perspectives beyond the scope of this study. The subsequent research should include how the hospital healthcare professionals (nurse, pharmacist, laboratory technologist, sonographer, etc.) at each station spend their time and energy (movement) delivering their services to the patients, as Hendrich A, et al. (2008) [8] have been studying. And the amount of care needed by surgical patients and trends over time as the study by van Oostveen CJ, et al, (2013) [9,10]. ...
... For further research, the authors recommend other interest perspectives beyond the scope of this study. The subsequent research should include how the hospital healthcare professionals (nurse, pharmacist, laboratory technologist, sonographer, etc.) at each station spend their time and energy (movement) delivering their services to the patients, as Hendrich A, et al. (2008) [8] have been studying. And the amount of care needed by surgical patients and trends over time as the study by van Oostveen CJ, et al, (2013) [9,10]. ...
This study was the experience of direct and continuous observation of a physical checkup task among three hospitals in Thailand, using a time-keeping device (a digital stopwatch or a cellular-phone timer) to record the time taken to accomplish the tasks from a patient's perspective. The main objective was to identify problems in the operational work process, explore the steps of the medical transactions, and solve them by proposing a more efficient work process for each hospital. The improvement was executed by combining some specific and typical steps to eliminate the bottlenecks and rearranging the physical layout of each hospital to reduce the time utilized and distance traveled by the patients. At each hospital, the research team will provide appropriate recommendations to remove the obstacles made at the end of the three months of the study. Earlier, the hospital marketing staff confirmed that with time freed up from our research, they could develop a robust campaign to attract additional checkup patients to fill up the expanded capacity, resulting in additional revenues. With the ensuing nine-month implementation of our action plans, the ended results at all the three hospitals enhanced the performance of the check-up/wellness programs and significant benefits of time-and-motion savings, leading to eventual patient satisfaction and revenue generation. Website: https://he01.tci-thaijo.org/index.php/JMedGlob/ How to cite this article: Manawanitjarern W, Ngaopaiboon P, Vallibhakara SA, Tomtitchong P. A Time-and-Motion Study to increase the efficiency among service levels of various scaled hospitals in Thailand: A Case Study.
... In the current study, physicians and nurses did not differ in their concerns about patient safety, contradicting similar studies 3,14,16 . Though current participating nurses had fewer concerns than doctors and kept silent more often, they reported higher speaking rates; these seemingly contrasting results could be attributed to nurses being the primary hospital caregivers, thereby spending more time with patients and encountering more incidents 17,18 . Furthermore, since nurses are considered the symbol of warmth and compassion 19 , they need to perceive their profession and themselves positively 20 . ...
ABSTRACT
OBJECTIVE: To assess the safety climate among and between health practitioners in Saudi Arabia by identifying speaking up behavior and speaking up about the related climate.
METHODOLOGY: A cross-sectional study was conducted among 135 physicians and 434 nurses in Saudi public hospitals using the Speaking Up about Patient Safety Questionnaire to assess various speaking up dimensions. Study questionnaires were completed from May to June 2019. The research purpose and confidentiality and anonymity assurance were provided at the beginning of the questionnaire. The individuals' participation was regarded as informed consent.
RESULTS: a total of 569 physicians and nurses participated. Both professions perceived concerns regarding patient safety, and nurses kept silent more yet reported a higher likelihood of speaking up than physicians. Psychological protection for speaking up was equal for both professions, but nurses reported the environment as encouraging, and physicians were more resigned.
CONCLUSION: The findings of this study support further investment into research to design interventions and improve patient safety by enhancing speaking up behavior and speaking up climate through recognizing and eliminating the barriers in healthcare settings. Despite ongoing improvement efforts, the current findings highlighted that safety is yet to be fully established.
Keywords: Speaking up behaviour, Speaking up climate, Patient Safety, Safety climate, Saudi Arabia, Healthcare practitioners.
... The efficient use of their time is critical in providing effective nursing services which can affect the quality of the given health care services. However increased nurse workload and the growing nursing workforce shortage have negative impact on the amount of nursing time available for care activities (Hendrich et al., 2008;Tamiselvi & Regunath 2013). Therefore nurses must identify effective TM approaches to increase their professional productivity as an administrator or caregiver and also personal satisfaction in their life. ...
Time management is an essential skill for the employees who work in a busy health settings. This was descriptive study and the aim of this study is to determine the importance paid for time management in nursing. in Turkey. Data was collected by searching “Ulakbim National Databases and Turkish Medline and 22 studies out of 365 were included in the assessment.. While studies which determine time usage show that nurses do not use their time efficiently, studies which measure time management skill, time management skill of nurses or students is at medium-high level. In order to clarify this contradiction, much more studies should be carried out and apart from descriptive studies factors which effect use of time in working environment should be analyzed. This study shows that the issue of time management in nursing is not analyzed as a privileged issue in Turkey and there has not been study that would evaluate time management of nurses.Keywords: Nurse, student, time management, work sampling
Background
The use of assistive robotic systems in care is intended to relieve nursing staff. Differentiated and literature-based findings on current application possibilities, technological developments and empirical findings are necessary to enable a goal-oriented and participatory development of assistive robotic systems of care. The aim of this review was to identify assistive robotic systems and their areas of application in nursing settings. Furthermore, an overview of existing social and nursing science findings from the research field of assistive robotic systems will be described.
Methods
A systematic literature search was performed based on the JBI scoping review methodology. During the period from May to August 2020, the databases MEDLINE via PubMed, CINAHL, Cochrane Library, Web of Science, and IEEE Xplore Digital Library were searched. In order to reflect current developments and evidence in the present literature work, a supplementary search with these same requirements was conducted in January 2022.
Results
The 47 included publications are divided into 15 studies, 23 technical articles and nine opinion-based articles (text-opinion). A total of 39 different assistive robotic systems were identified. There were 55% in the testing phase and 29% of the systems in the development phase. Assistive robotic systems can be divided into six fields of application: Information and patient data processing, assistance with activities of daily living, fetch and bring activities, telepresence and communication, monitoring, safety and navigation, and complex assistance systems. The description of the study findings is divided into "integration of technology and impact on practice" and "attitude and acceptance of elderly people towards assistive robotic systems".
Conclusion
The results of the research show that the use of assistive robotic systems in care mainly take place in the context of development and testing phases. In addition to usability and acceptance issues, implementation factors must be integrated into theory-driven research projects.
Objective The aim of the study is to introduce an innovative use of bar code medication administration (BCMA) data, medication pass analysis, that allows for the examination of nurse staffing and workload using data generated during regular nursing workflow.
Methods Using 1 year (October 1, 2014–September 30, 2015) of BCMA data for 11 acute care units in one Veterans Affairs Medical Center, we determined the peak time for scheduled medications and included medications scheduled for and administered within 2 hours of that time in analyses. We established for each staff member their daily peak-time medication pass characteristics (number of patients, number of peak-time scheduled medications, duration, start time), generated unit-level descriptive statistics, examined staffing trends, and estimated linear mixed-effects models of duration and start time.
Results As the most frequent (39.7%) scheduled medication time, 9:00 was the peak-time medication pass; 98.3% of patients (87.3% of patient-days) had a 9:00 medication. Use of nursing roles and number of patients per staff varied across units and over time. Number of patients, number of medications, and unit-level factors explained significant variability in registered nurse (RN) medication pass duration (conditional R2 = 0.237; marginal R2 = 0.199; intraclass correlation = 0.05). On average, an RN and a licensed practical nurse (LPN) with four patients, each with six medications, would be expected to take 70 and 74 minutes, respectively, to complete the medication pass. On a unit with median 10 patients per LPN, the median duration (127 minutes) represents untimely medication administration on more than half of staff days. With each additional patient assigned to a nurse, average start time was earlier by 4.2 minutes for RNs and 1.4 minutes for LPNs.
Conclusion Medication pass analysis of BCMA data can provide health systems a means for assessing variations in staffing, workload, and nursing practice using data generated during routine patient care activities.
Background
The physical job demands of hospital nurses are known to be very high. Although many studies have measured the physical activities of nurses subjectively using questionnaires, it remains necessary to quantify and measure nurses’ physical activity at work using objective indicators. This study was conducted to address this gap in the literature by analyzing nurses’ physical activity using both objective measurements and subjective perceptions. The number of steps, distance traveled, and actual work hours were measured during work, and the influence of related factors was analyzed.
Methods
Using a cross-sectional design, survey and activity tracking data were collected from nurses who worked in three shifts in two tertiary hospitals located in the capital region of South Korea. The participants comprised 117 nurses working in four different units (medical ward, surgical ward, intensive care unit, emergency room), and data from 351 shifts were used in the final analysis. Between-group differences in the main variables were analyzed using the t-test, the Mann–Whitney test, analysis of variance, or the Kruskal–Wallis test, as appropriate. The relationships were examined through multiple linear regression analysis.
Results
The average number of steps and distance traveled were greatest for nurses working in the emergency room, followed by the intensive care unit, surgical ward, and medical ward (in descending order). Younger nurses and those with shorter unit experience tended to have the greatest number of steps and distance traveled.
Conclusion
Using activity trackers, this study derived physical activity measures such as number of steps and distance traveled, enabling an objective examination of physical activity during shifts. Nurses’ level of physical activity differed depending on the type of nursing unit, nurses’ age, and unit experience. These results suggest the need for support programs that are specific to the job demands of specific nursing units.
Objectives
This time-motion study explored the amount of time clinicians spent on wound assessments in a real-world environment using wound assessment digital application utilizing Artificial Intelligence (AI) vs. manual methods. The study also aimed at comparing the proportion of captured quality wound images on the first attempt by the assessment method.
Methods
Clinicians practicing at Valley Wound Center who agreed to join the study were asked to record the time needed to complete wound assessment activities for patients with active wounds referred for a routine evaluation on the follow-up days at the clinic. Assessment activities included: labelling wounds, capturing images, measuring wounds, calculating surface areas, and transferring data into the patient’s record.
Results
A total of 91 patients with 115 wounds were assessed. The average time to capture and access wound image with the AI digital tool was significantly faster than a standard digital camera with an average of 62 seconds (P<0.001). The digital application was significantly faster by 77% at accurately measuring and calculating the wound surface area with an average of 45.05 seconds (P<0.001). Overall, the average time to complete a wound assessment using Swift was significantly faster by 79%. Using the AI application, the staff completed all steps in about half of the time (54%) normally spent on manual wound evaluation activities. Moreover, acquiring acceptable wound image was significantly more likely to be achieved the first time using the digital tool than the manual methods (92.2% vs. 75.7%, P<0.004).
Conclusions
Using the digital assessment tool saved significant time for clinicians in assessing wounds. It also successfully captured quality wound images at the first attempt.
Background
Pressure on emergency departments (EDs) from increased attendance for minor injuries has been recognised in the United Kingdom. Radiographer-led discharge (RLD) has potential for improving efficiency, through radiographers trained to discharge patients or refer them for treatment at the point of image assessment. This review aims to scope all RLD literature and identify research assessing the merits of RLD and requirements to enable implementation.
Methods
We conducted a scoping review of studies relating to RLD of emergency care patients requiring projection radiography of minor musculoskeletal (MSK) injuries. MEDLINE, Embase and CINAHL, relevant radiography journals and grey literature were searched. Articles were reviewed and the full texts of selected studies were screened against eligibility criteria. The data were extracted, collated and a narrative synthesis completed.
Results
Seven studies with varying study designs were included in the review. The small number of studies was possibly due to a generally low research uptake in radiography. The main outcome for four studies was reduced length of stay in ED, with recall and re-attendance to ED a primary outcome in one study and secondary outcome for two other studies. The potential for increased efficiency in the minor MSK pathway patient pathway and capacity for ED staff was recognised. Radiographers identified a concern regarding the risk of litigation and incentive of increased salary when considering RLD. The studies were broadly radiographer focussed, despite RLD spanning ED and Radiology.
Conclusion
There were a low number of RLD active radiographers, likely to be motivated individuals. However, RLD has potential for generalisability with protocol variations evident, all producing similar positive outcomes. Understanding radiography and ED culture could clarify facilitators for RLD to be utilised more sustainably into the future. Cost effectiveness studies, action research within ED, and cluster randomised controlled trial with process evaluation are needed to fully understand the potential for RLD.
The cost effectiveness of RLD may provide financial support for training radiographers and increasing their salary, with potential future benefit of reduction in workload within ED. RLD implementation would require an inter-professional approach achieved by understanding ED staff and patient perspectives and ensuring these views are central to RLD implementation.
Objectives: To survey operating theatre and intensive care unit staff about attitudes concerning error, stress, and teamwork and to compare these attitudes with those of airline cockpit crew. Design: Cross sectional surveys. Setting: Urban teaching and non-teaching hospitals in the United States, Israel, Germany, Switzerland, and Italy. Major airlines around the world. Participants: 1033 doctors, nurses, fellows, and residents working in operating theatres and intensive care units and over 30 000 cockpit crew members (captains, first officers, and second officers). Main outcome measures: Perceptions of error, stress, and teamwork. Results: Pilots were least likely to deny the effects of fatigue on performance (26% v 70% of consultant surgeons and 47% of consultant anaesthetists). Most pilots (97%) and intensive care staff (94%) rejected steep hierarchies (in which senior team members are not open to input from junior members), but only 55% of consultant surgeons rejected such hierarchies. High levels of teamwork with consultant surgeons were reported by 73% of surgical residents, 64% of consultant surgeons, 39% of anaesthesia consultants, 28% of surgical nurses, 25% of anaesthetic nurses, and 10% of anaesthetic residents. Only a third of staff reported that errors are handled appropriately at their hospital. A third of intensive care staff did not acknowledge that they make errors. Over half of intensive care staff reported that they find it difficult to discuss mistakes. Conclusions: Medical staff reported that error is important but difficult to discuss and not handled well in their hospital. Barriers to discussing error are more important since medical staff seem to deny the effect of stress and fatigue on performance. Further problems include differing perceptions of teamwork among team members and reluctance of senior theatre staff to accept input from junior members.
To survey operating theatre and intensive care unit staff about attitudes concerning error, stress, and teamwork and to compare these attitudes with those of airline cockpit crew.
: Cross sectional surveys.
: Urban teaching and non-teaching hospitals in the United States, Israel, Germany, Switzerland, and Italy. Major airlines around the world.
: 1033 doctors, nurses, fellows, and residents working in operating theatres and intensive care units and over 30 000 cockpit crew members (captains, first officers, and second officers).
: Perceptions of error, stress, and teamwork.
: Pilots were least likely to deny the effects of fatigue on performance (26% v 70% of consultant surgeons and 47% of consultant anaesthetists). Most pilots (97%) and intensive care staff (94%) rejected steep hierarchies (in which senior team members are not open to input from junior members), but only 55% of consultant surgeons rejected such hierarchies. High levels of teamwork with consultant surgeons were reported by 73% of surgical residents, 64% of consultant surgeons, 39% of anaesthesia consultants, 28% of surgical nurses, 25% of anaesthetic nurses, and 10% of anaesthetic residents. Only a third of staff reported that errors are handled appropriately at their hospital. A third of intensive care staff did not acknowledge that they make errors. Over half of intensive care staff reported that they find it difficult to discuss mistakes.
Medical staff reported that error is important but difficult to discuss and not handled well in their hospital. Barriers to discussing error are more important since medical staff seem to deny the effect of stress and fatigue on performance. Further problems include differing perceptions of teamwork among team members and reluctance of senior theatre staff to accept input from junior members.
The organizational context in which nurses practice is important in explaining variation in patient outcomes, but research has been hampered by the absence of instruments to measure organizational attributes empirically.
To report on the development and utility of the Revised Nursing Work Index (NWI-R) in measuring characteristics of professional nursing practice environments.
The NWI-R was used in a national acquired immunodeficiency syndrome (AIDS) care study. The sample consisted of 40 units in 20 hospitals. Of these 20 hospitals, 10 provided AIDS care in both dedicated AIDS units and general medical units, thus introducing to the design an element of internal control. The remaining 10 hospitals were selected through a matching procedure. Three of the matched control hospitals were magnet hospitals. Nurses were recruited into the study if they worked at least 16 hours per week on the study unit. The nurses completed the NWI-R in addition to other measures.
A response rate of 86% was attained. Response rates per unit ranged from 73% to 100%. Cronbach's alpha was 0.96 for the entire NWI-R, with aggregated subscale alphas of 0.84 to 0.91. Validity of the NWI-R was demonstrated by the origin of the instrument, its ability to differentiate nurses who worked within a professional practice environment from those who did not, and its ability to explain differences in nurse burnout.
The NWI-R has been found to capture organizational attributes that characterize professional nursing practice environments.
Operational failures in healthcare can hinder employees, potentially decreasing both productivity and quality of care. At the same time, regulatory agencies, industry experts, and consumers increasingly demand that health care organizations learn from prior failures to prevent recurrence. Building on the notion that learning from operational failures requires an accurate understanding of their nature, this paper reports on an in-depth study of operational failures encountered by hospital nurses. Data analysis suggests that in this context (1) most operational failures stem from breakdowns in the supply of materials and information across organizational boundaries and (2) employees quickly compensate for most failures. We propose that these two conditions—lack of control of processes that create failures and the ease with which employees restore functioning—make it difficult for organizations to recognize these incidents as learning opportunities, and if they do, to capitalize on the opportunity. This has an important implication for efforts to generate organizational learning and improvement from employees’ experiences with failures. Highly interdependent front-line workers do not control organizational processes responsible for the majority of failures they encounter and have a difficult task convincing powerful associates that these obstacles warrant solution efforts, making it likely operational failures will persist.
Nurses spend an average of only 31% of their time with patients. The authors determined how nurses spend their time and suggest three ways to reduce time spent on non-essential nursing functions: delegation of some tasks to support personnel, greater use of pharmacy personnel in a decentralized setting, and greater use of computers. Together these changes may both decrease demand for nurses' time and enable professional nurses to focus their energy on tasks that require professional expertise.
The objective of this study is to investigate whether hospitals known to be good places to practice nursing have lower Medicare mortality than hospitals that are otherwise similar with respect to a variety of non-nursing organizational characteristics. Research to date on determinants of hospital mortality has not focused on the organization of nursing. We capitalize on the existence of a set of studies of 39 hospitals that, for reasons other than patient outcomes, have been singled out as hospitals known for good nursing care. We match these "magnet" hospitals with 195 control hospitals, selected from all nonmagnet U.S. hospitals with over 100 Medicare discharges, using a multivariate matched sampling procedure that controls for hospital characteristics. Medicare mortality rates of magnet versus control hospitals are compared using variance components models, which pool information on the five matches per magnet hospital, and adjust for differences in patient composition as measured by predicted mortality. The magnet hospitals' observed mortality rates are 7.7% lower (9 fewer deaths per 1,000 Medicare discharges) than the matched control hospitals (P = .011). After adjusting for differences in predicted mortality, the magnet hospitals have a 4.6% lower mortality rate (P = .026 [95% confidence interval 0.9 to 9.4 fewer deaths per 1,000]). The same factors that lead hospitals to be identified as effective from the standpoint of the organization of nursing care are associated with lower mortality among Medicare patients.
We all know the changes in our health care system have been substantial and far-reaching. But what effects are downsizing, restructuring, and the use of unlicensed personnel having on the quality of patient care you deliver and on your work life? More than 7,000 survey respondents gave us their answers.