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

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Publications (374)


Fig. 1 K-means clusters identifying hospital profiles of clinician work environment agreement. Note. Green values indicate "Agree, Favorable Environment"; Red values indicate "Disagree, Less Favorable for Nurses"; Black values indicate "Agree, Unfavorable Environment" using the proportion of clinicians rating their work environment as "poor or fair" from the Clinician WellBeing Study of emergency nurses and physicians
Hospital-level linear regression models determining the relationship between hospital profiles and clinician job and patient care quality and safety outcomes
Association of emergency department nurse and physician work environment agreement on clinician job and patient outcomes
  • Article
  • Full-text available

May 2025

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9 Reads

BMC Health Services Research

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Anish K. Agarwal

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Daniela Golinelli

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JJ Whade

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.

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The Impact of Nursing Resources on Chronic Wound Management: A Cross-Sectional Analysis

April 2025

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7 Reads

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.


Comparing Average Percentages of Clinician Burnout and Well-being Between APRNs and PAs, and Between MDs, APPs, and RNs Within APPs Between Clinicians APRNs PAs MDs APPs RNs
Comparing APRN Demographic and Work Characteristics by Level of Burnout Characteristics All APRNs High Burnout (38% [n = 516]) Low Burnout (62% [n = 844]) P
Comparing APRN Work Environments and Related Factors by Level of Burnout
Advanced Practice Registered Nurse Burnout in Magnet Hospitals: Opportunities for Organizational Intervention

March 2025

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29 Reads

JONA The Journal of Nursing Administration

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.





Patient Outcomes and Characteristics
Proportion of RNs in the Total Nursing Staff and Other Hospital Characteristics in 2676 Study Hospitals Proportion of RNs in the Total Nursing Staff
Hospital HCAHPS Star Ratings in 2676 Study Hospitals
Effect of a 10 Percentage-Point Reduction in RNs to Total Nursing Staff on Patient Outcomes and Odds of Losing a HCAHPS Star Rating
Alternative Models of Nurse Staffing May Be Dangerous in High-Stakes Hospital Care

June 2024

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151 Reads

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10 Citations

Medical Care

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 68.5millioninadditionalMedicarecosts.Hospitalswouldforgonearly68.5 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.



Nurse‐sensitive quality and benchmarking in hospitals striving for Magnet® or Pathway® designation: A qualitative study

May 2024

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121 Reads

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1 Citation

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.


Scatterplot of the 28‐item and 5‐item PES‐NWI composite scores in the 2016 hospital sample. PES‐NWI, Practice Environment Scale of the Nursing Work Index.
Validation of a short form of the practice environment scale of the nursing work index: The PES‐5

April 2024

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84 Reads

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15 Citations

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.


Citations (81)


... 5 Similar findings have been observed in Chile 6 ; and studies in the USA also demonstrate substantial hospital cost savings due to better patient outcomes. [7][8][9][10] In sum, mounting evidence from various jurisdictions with both privately and publicly funded healthcare systems concludes that hospital investments to staff more nurses at the bedside generate cost savings to hospitals (which can be reinvested into nursing) via greater efficiencies in care delivery and better clinical outcomes. 11 The evidence to date has largely confirmed the hypothesis that hospitals can 'spend more, to save more', however, 'spending more' is often an unappealing option in an already high-cost industry where institutions tend to operate with Editorial tightly constrained budgets. ...

Reference:

Eliminating hospital nurse understaffing is a cost-effective patient safety intervention
The effect of registered nurse staffing and skill mix on length of stay and hospital costs
  • Citing Article
  • January 2025

Nursing Outlook

... A recent study reported a direct relationship between how well hospitals were staffed with nurses and their number of patient deaths from COVID-19. 4 As well, turnover is estimated to cost a hospital between US$11 000 and US$90 000 per bedside nurse, 5 and the adverse consequences of the nursing shortage continue to grow. ...

Hospital nurse staffing variation and Covid-19 deaths: A cross-sectional study
  • Citing Article
  • June 2024

International Journal of Nursing Studies

... These findings from Europe are supported by a study from the United States where a 10 percentage-point reduction in registered nurses was associated with a 7% higher odds of in-hospital death, 1% higher odds of readmission, and lower patient satisfaction. 9 Another study, from Australia, found that increasing the proportion of time that patients spent on wards where nursing assistants were employed increased the odds of urinary tract infections and pneumonia among patients. 10 Meanwhile, a systematic review that included studies from the United States, China, and Australia-as well as Belgium and the United Kingdom, concluded that policies that lead to a reduction in the proportion of registered nurses in nursing teams could produce worse outcomes at increased costs and there is no evidence that such approaches are cost-effective. ...

Alternative Models of Nurse Staffing May Be Dangerous in High-Stakes Hospital Care

Medical Care

... To demonstrate the intricate relationships between nursing interventions, staffing levels, and favourable patient outcomes, intensive care units (ICUs) have been using nurse-sensitive quality indicators. Patient outcomes influenced by nursing care, either directly or indirectly, are referred to as nursing-sensitive quality indicators (NSQIs) (Maier et al., 2024). Most a hospital's financial resources are allocated to care in intensive care units (ICUs), which accounts for many health care costs. ...

Nurse‐sensitive quality and benchmarking in hospitals striving for Magnet® or Pathway® designation: A qualitative study

... One notable limitation of this study is the sample size, which may be insufficient for robust psychometric evaluations of the Slovak translation of the PES-NWI. As highlighted by Lake et al. (2024), a sample size of at least 320 is recommended for comprehensive reliability assessments of a 31-item instrument like the PES-NWI. While the reported Cronbach's alpha of 0.920 indicates excellent internal consistency, future studies with larger sample sizes are essential for validating these findings and enhancing generalizability. ...

Validation of a short form of the practice environment scale of the nursing work index: The PES‐5

... Studies have shown that burnout and poor mental health in HCWs has increased since prior to the pandemic [2] and may lead to an increase in staff turnover [3][4][5]. Identifying and addressing factors that influence burnout in healthcare settings is a priority for the United States Surgeon General [6] and working to prevent and address burnout and turnover in HCWs is especially important, as burnout and turnover may also impact the quality of care provided to patients and lead to billions of dollars in cost to an already stressed healthcare system [7][8][9]. ...

Nurses' intention to leave, nurse workload and in-hospital patient mortality in Italy: A descriptive and regression study
  • Citing Article
  • March 2024

Health Policy

... These programs, which integrate wellness strategies, stress screening and the promotion of emotional awareness, have demonstrated a favorable cost-benefit ratio, with a positive impact on occupational health. (20,21,22,23,24) Multi-component workplace health promotion programmes have also shown promising results, with examples such as the Magnet4Europe project (22) and the MENTUPP study, (23) which adopt approaches focused on institutional culture, leadership training and organizational development. These programs aim not only to reduce presenteeism, but also to create healthier and more productive working environments. ...

Physician and nurse well-being, patient safety and recommendations for interventions: cross-sectional survey in hospitals in six European countries

... Despite the collaborative nature of the ED, the policies, strategies, and operational work flows to guide clinical care delivery and the cultivation of safe work environments in this setting are often siloed within medicine or nursing [13,14]. Research siloed by clinician group may impede progress in advancing safe, high-quality care in the ED and ensuring that hospitals can recruit and retain clinicians in this setting [2,15,16]. ...

The association of the emergency department work environment on patient care and nurse job outcomes

Journal of the American College of Emergency Physicians Open

... This structure allows students to first acquire foundational nursing skills in the BN curriculum before progressing to the MN program, where they can specialize in management, research and education roles [4]. Further advanced nursing education in Croatia could be achieved through postgraduate special or doctoral studies. ...

Recruiting and retaining bachelor qualified nurses in German hospitals (BSN4Hospital): protocol of a mixed-methods design

... For example, in the United States insufficient lactation space, rigid schedules preventing lactation relief, and persistent stigma about breastfeeding as a nurse mother remain common despite federal protections (e.g., Providing Urgent Maternal Protections (PUMP) for Nursing Mothers Act and Section 4207 of the Affordable Care Act) (Barraza et al. 2020; Thompson et al. 2024). In the fast-paced environment of critical care, where time and privacy are scarce, these barriers intensify both physical discomfort and emotional strain (Bae 2021;Turnbach et al. 2024). Addressing these obstacles is essential for gender equity, the health of nurses and their infants, and for sustaining a resilient critical care workforce (Burns et al. 2022;Johnson et al. 2025). ...

Emergency Nurses’ Well-Being in Magnet Hospitals and Recommendations for Improvements in Work Environments: A Multicenter Cross-Sectional Observational Study
  • Citing Article
  • July 2023

Journal of Emergency Nursing