Linda H Aiken’s research while affiliated with University of Pennsylvania and other places

Background: Emergency medicine is a highly interdisciplinary field, and emergency nurses and physicians have high rates of burnout compared to other specialties. National and international agencies prioritize investments in systems-based solutions to improve clinicians' work environments. The objective of this study was to determine whether emergency department (ED) clinicians agree on the quality of work environments, and whether their agreement is associated with job outcomes, patient safety, and quality of care. Methods: This cross-sectional study used data from 1,604 ED nurses (n = 1,190) and physicians (n = 414) who completed the 2021 US Clinician Wellbeing Study in 47 Magnet hospitals. A K-means algorithm classified hospitals into 'profiles' based on nurse and physician agreement on work environment assessments. Hospital-level linear regression models determined the relationship between hospital profiles and clinician job and patient outcomes. Results: The overall clinician sample (n = 1,604) was on average 39.4 years of age (SD = 11.2), 72.3% female, with 8.3 years of experience (SD = 7.9), 77.7% White, and 93.6% non-Hispanic. Two hospital profiles indicated clinician agreement: "Agree, Unfavorable Environment" (n = 10 hospitals), and "Agree, Favorable Environment" (n = 15); the third profile indicated disagreement: "Disagree, Less Favorable Environment among Nurses" (n = 22). There were no hospital profiles with physicians rating their work environment less favorably than nurses. Compared to the "Agree, Favorable Environment" hospitals, the "Agree, Unfavorable Environment" and "Disagree, Less Favorable among Nurses" hospitals were associated with higher burnout (e.g., β = 25.8%, 95% CI 11.6, 40.1, p <.001 and β = 15.4, 95% CI 3.7, 27.2, p <.001, respectively), job dissatisfaction, and intent to leave; and unfavorable patient care quality and unfavorable patient safety grades (e.g., β = 29.1%, 95% CI 18.4, 39.8, p <.001 and β = 11.9%, 95% CI 3.0, 20.8, p <.01, respectively). Conclusions: In this cross-sectional study, emergency nurses and physicians in almost half of study hospitals disagreed on the quality of the work environment, suggesting that two essential collaborators in high-stakes care do not agree on deficiencies in ED work environments. Sustainable systems-based solutions to improve ED work environments involve bridging these disparate workplace experiences.

Aim Evaluate the relationship between hospital nursing resources and outcomes among patients with chronic wounds. Design Cross‐sectional observational. Methods Hospital‐level predictors included the nurse work environment, proportion of Bachelor of Science ( BSN )‐prepared nurses, and skill mix (i.e., registered nurses [ RN ] as proportion of nursing personnel). Outcomes included in‐hospital and 30‐day mortality, discharging to a higher level of care and length of stay. Individual‐level nurse data were aggregated to create hospital‐level measures of nursing resources. We utilised multi‐level modelling with nurses nested within hospitals and outcomes at the patient level. Data Three datasets from 2021: RN4CAST‐New York/Illinois survey, Medicare Provider Analysis and Review claims and American Hospital Association Annual Survey. Results The sample included 34,113 patients with chronic wounds in 215 hospitals in New York and Illinois. In adjusted models, a 1 standard deviation improvement in the work environment was associated with 12% lower odds of in‐hospital mortality, 8% lower odds of discharging to a higher level of care and a shorter length of stay by a factor of 0.96. A 10% increase in BSN composition was associated with 8% reduced odds of in‐hospital mortality and 6% reduced odds of 30‐day mortality. A 10% increase in skill mix was associated with 12% lower odds of in‐hospital mortality and a shorter length of stay by a factor of 0.91. Conclusion Improved nursing resources are associated with better outcomes among patients with chronic wounds. Implications Nurses manage the care of patients with chronic wounds; thus, hospital investment in nursing resources is imperative for good outcomes. Impact Modifiable hospital nursing resources are associated with outcomes among patients with chronic wounds, a complex population. Reporting STROBE.

OBJECTIVE To determine modifiable organizational factors associated with advanced practice RN (APRN) burnout in Magnet ® -designated hospitals to guide organizational interventions to improve APRN well-being and retention. METHODS Cross-sectional study of work environments of 50 US Magnet hospitals and the associated well-being of 21 855 of their clinicians (APRNs, physician assistants, physicians [MDs], RNs). RESULTS Overall, 37% of APRNs experienced high burnout compared with 34% of MDs ( P < 0.05) and 49% of RNs ( P < 0.001); additionally, 32% of APRNs intended to leave their jobs. APRN burnout was significantly lower in organizations that minimized chaotic working conditions, provided APRNs more control over their workloads, involved APRNs in shared governance, improved clinician and management relations, and improved interprofessional teamwork. CONCLUSIONS Well-being and retention of APRNs in Magnet hospitals require their greater engagement in organization processes and systems that improve work environments.

Background Hospitals are resurrecting the outdated “team nursing” model of staffing that substitutes lower-wage staff for registered nurses (RNs). Objectives To evaluate whether reducing the proportion of RNs to total nursing staff in hospitals is in the best interest of patients, hospitals, and payers. Research Design Cross-sectional, retrospective. Subjects In all, 6,559,704 Medicare patients in 2676 general acute-care US hospitals in 2019. Measures Patient outcomes: in-hospital and 30-day mortality, 30-day readmission, length of stay, and patient satisfaction. Avoidable Medicare costs associated with readmissions and cost savings to hospitals associated with shorter stays are projected. Results A 10 percentage-point reduction in RNs was associated with 7% higher odds of in-hospital death, 1% higher odds of readmission, 2% increase in expected days, and lower patient satisfaction. We estimate a 10 percentage-point reduction in RNs would result in 10,947 avoidable deaths annually and 5207 avoidable readmissions, which translates into roughly $68.5 million in additional Medicare costs. Hospitals would forgo nearly$3 billion in cost savings annually because of patients requiring longer stays. Conclusions Reducing the proportion of RNs in hospitals, even when total nursing personnel hours are kept the same, is likely to result in significant avoidable patient deaths, readmissions, longer lengths of stay, and decreased patient satisfaction, in addition to excess Medicare costs and forgone cost savings to hospitals. Estimates represent only a 10 percentage-point dilution in skill mix; however, the team nursing model includes much larger reductions of 40–50 percentage-points — the human and economic consequences of which could be substantial.

Aim To examine if and how selected German hospitals use nurse‐sensitive clinical indicators and perspectives on national/international benchmarking. Design Qualitative study. Methods In 2020, 18 expert interviews were conducted with key informants from five purposively selected hospitals, being the first in Germany implementing Magnet® or Pathway®. Interviews were analyzed using content analysis with deductive‐inductive coding. The study followed the COREQ guideline. Results Three major themes emerged: first, limited pre‐existence of and necessity for nurse‐sensitive data. Although most interviewees reported data collection for hospital‐acquired pressure ulcers and falls with injuries, implementation varied and interviewees highlighted the necessity to develop additional nurse‐sensitive indicators for the German context. Second, the theme creating an enabling data environment comprised building clinicians' acceptance, establishing a data culture, and reducing workload by using electronic health records. Third, challenges and opportunities in establishing benchmarking were identified but most interviewees called for a national or European benchmarking system. Conclusion The need for further development of nurse‐sensitive clinical indicators and its implementation in practice was highlighted. Several actions were suggested at hospital level to establish an enabling data environment in clinical care, including a nationwide or European benchmarking system. Implications for the Profession and Patient Care Involving nurses in data collection, comparison and benchmarking of nurse‐sensitive indicators and their use in practice can improve quality of patient care. Impact Nurse‐sensitive indicators were rarely collected, and a need for action was identified. The study results show research needs on nurse‐sensitive indicators for Germany and Europe. Measures were identified to create an enabling data environment in hospitals. An initiative was started in Germany to establish a nurse‐sensitive benchmarking capacity. Patient or Public Contribution Clinical practitioners and nurse/clinical managers were interviewed.

The Practice Environment Scale of the Nursing Work Index (PES‐NWI) has been utilized for two decades globally to measure nurse work environments. Its 31 items in five domains present a substantial respondent burden, threatening survey response rates. The purpose of this study was to derive and validate a short form: the PES‐5. We conducted a cross‐sectional, secondary analysis of survey data from nurses in 760 hospitals in six U.S. states in 2016 or 2019. One representative item per subscale was selected by highest item‐to‐subscale R² from the original PES‐NWI publication. Five psychometric properties of the PES‐5 were evaluated. The reproduced structure of the full form was confirmed in the 2016 data by the highest R² for the selected items. The unidimensional structure of the PES‐5 was confirmed through confirmatory factor analysis. The correlation between the composite values of the 28‐item and 5‐item versions was 0.94. The Cronbach's alpha reliability of the PES‐5 was >0.80. The intraclass correlation coefficient (ICC 1, k), which evaluates the stability of aggregated values when data are clustered, i.e., nurses are nested within hospitals, was >0.80 in both datasets, demonstrating satisfactory aggregate properties. Construct validity was supported by the selected items being ranked highly in their respective subscales by an expert panel. Criterion validity was supported by an analysis of variance of the PES‐5 mean value across responses to a single‐item work environment measure. Similar patterns of relationships with other key variables were identified by statistically significant odds ratios in regression models predicting patient mortality from the PES‐5. The classification accuracy of the PES‐5 was high, with 88% of hospitals classified identically by both versions. The PES‐5 shows promise for measurement of nurses’ work environments while maximizing response rate by reducing participant burden.