Nursing Characteristics that Affect Patient Outcomes

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Nursing Characteristics that Affect Patient
Outcomes

• Shana Green
• Eileen Lake, Robyn Cheung
• Center for Health Outcomes, Policy and Research
  (CHOPR)

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SUMR Goals

• Learn about the theory and research linking
  nursing to quality
• Assist with collection of quantitative data in
  multisite hospital study
• Learn the sections of a research manuscript and
  assist to prepare different sections
• Learn to prepare/write a proposal
• Develop a presentation of study findings for a
  research meeting

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Acuity-adjusted Staffing Purpose

• To examine whether acuity-adjusted nurse staffing
  and environments contribute to variation in VLBW
  infant outcomes in NICUs.

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Adjusted- acuity Staffing Methods

• Observational study with data collected by web
  survey
• 6400 nurses in 104 NICUs from the Vermont Oxford
  Network (VON)
• 8490 infants from VON database

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Acuity- adjusted Staffing Measures

• Nurse Staffing
• An estimate of the average of patient needs on a
  particular units
• No standardized method of selecting nurse
  staffing levels
• Acuity
• Average severity of illness of inpatient
  population
• Determines amount of care patient needs
• No standardized methods for determining the
  acuity of infants in NICU
• Acuity Weights
• Daily proportion of a nurses required to take
  care for an infant in an acuity category.

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Acuity- adjusted StaffingResults

• Staffing
• On average, a nurse cared for two infants, but
  this varied by infant acuity.
• Infant acuity
• Infants in acuity levels 1, 2, and 3 comprise the
  largest proportion of infants.

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Acuity- adjusted StaffingResults

• Nurse Qualifications
• 56 BSN
• 19 neonatal specialist
• 74 5 years in NICU
• Professional Practice Environment
• Exceptional hospital sample

104 hospitals
5,000 hospitals
523 hospitals
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Acuity- adjusted StaffingResults

• Outcomes
• A lower staffing level is associated with higher
  proportions of BSNs and NICU-experienced nurses
• Staffing and BSN proportion are associated with
  mortality
• NICU experience is associated with SIVH
• A more professional practice environment is
  associated with lower odds of infection.
• VLBW infants in magnet hospitals had lower odds
  of mortality.

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Nursing Unit Organization and Very Low Birth
Weight Infant Outcomes in Neonatal Intensive Care
Units
Eileen Lake, PhD, RN, FAAN, University of
Pennsylvania Jeannette Rogowski, PhD, University
of Medicine and Dentistry of New Jersey Jeffrey
Horbar, MD, University of Vermont Douglas
Staiger, PhD, Dartmouth College
Michael Kenny, MS, University of Vermont Thelma
Patrick, RN, PhD, The Ohio State University Robyn
Cheung, RN, PhD, University of Pennsylvania
Figure 1. Observed/ expected acuity-adjusted
staffing levels for study hospitals.
Figure 1
Figure 2. Percent distribution by infant acuity
across 104 NICUs.
Study Design, Sample and Methods
Table 1. Nurse to patient ratios by acuity level.

• Observational study with data collected by web
  survey
• 6400 nurses in 104 NICUs from the Vermont Oxford
  Network (VON), an international quality
  improvement collaborative for neonatal care
• 8490 infants from VON database
• Analyzed outcomes in random-effects logit models
  controlled for patient demographic and birth
  characteristics.

Table 1
Figure 2
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Acuity- adjusted StaffingNext Steps

• Purpose
• To adjust for hospital characteristics (523 VON
  hospitals) that have an impact on NICU patient
  outcomes
• To find the effect of nursing on NICU patient
  outcomes.

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Acuity- adjusted StaffingNext Steps

• AHA Data
• Database of over 6,000 hospitals
• Variables
• MNAME
• MLOCSTATE
• MLOCCITY
• NICBD
• Mapp8
• Teaching hospital?
• CNTRL
• Ownership status?
• ADJADC
• Census of patients
• FTERN
• Full time or equivalent RN

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Acuity- adjusted StaffingNext Steps

• Reduce AHA database
• Remove hospitals without NICBD (value 0)
• Delete non VON hospitals
• Compare hospname to mname
• Enter magnet status

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• The Effects of Nursing on NICU Patient Outcomes

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NINR Study Purpose

• NINR Study
• Quarterly data collection for nurses and infants
  in a single shift
• Explore staffing patterns across seasons
• Explore nursing as a resource to reduce
  cross-hospital disparities in mortality

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NINR Site Coordinator Responsibility

• Secure IRB approval
• Comply with documentation requirements
• Collect and submit statistics on the composition
  of the nursing unit staff, layout, medical and
  non-medical personnel staffing
• Collect infant data from staff nurses
• Enter data on www.nicunursingsurvey.com

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NINR Site Management

• Documentation
• Secure IRB approval
• modification 3
• Conflict of Interest
• PHS (42 CFR Part 50 Subpart F)
• Responsibility of Applicants for Promoting
  Objectivity in Research for Which PHS Funding Is
  Sought
• Financial Disclosure
• CITI Certification
• Human subjects training
• Data Entry Website
• Pilot Study

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NINR StudyData Entry Website
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NINR Study Progress

• Pilot Study
• Protocol
• Nine Sites
• June 15, 2009
• First Data Collection
• 55 of 77 Sites Collected Data
• July 15, 2009 at 2pm
• Data includes nurse and patient status from 7am
  to 2pm

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NINR Study Next Steps

• Complete first quarter data collection
• Report staffing level and infant acuity to
  hospitals in study
• Complete remaining 3 quarters of data collection
• Analysis

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• Recruiting and Staffing for Clinical Nursing
  Expertise

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Manuscript

• Tasks Associated with Manuscript
• Response to Reviewers
• Literature Review
• Table
• APA Format

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Manuscript

• Literature Review
• Expertise
• Experience
• Domain specific knowledge
• Complex reflexive thinking
• Intuition
• View of Expertise
• Peer nominated
• New measures

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Manuscript

• Literature Review
• Cultivation of Expertise
• Mentorship (Field 2004)
• Continuing education (Ericsson et. al. 2007)
• Practice environment (Foley et. al. 2009)
• Competitive
• Demands excellence
• Fosters autonomy, practice control and
  relationship with physicians

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These precious patients are the smallest and
most vulnerable they will ever be during their
lifetimes
the neonatal nurse is the eyes, ears, support
of not only the baby but the entire family.