Outcomes of Nurse Working Conditions in Intensive Care Units

1. Outcomes of Nurse Working Conditions in Intensive Care Units Presented at: AHRQ�s Patient Safety Conference, June 6th, 2005 Washington DC The Research Team: Patricia W. Stone, Andrew Dick, Teresa Horan, Elaine Larson, Cathy Mooney-Kane, Diane Pastor and Jack Zwanziger ps2024@columbia.edu AHRQ R01 HS013114

2. Purpose Estimate the effect of OC factors on ICU nurses� intention to leave Estimate OC and other working condition variables on patient safety outcomes in ICUs Healthcare acquire infections (HAI)

3. Design-Analytic Approach National study Cross sectional analysis Logistic Regression Intention to Leave (ITL) Probit Healthcare Associated Infections (HAI)

5. Sampling Hospitals invited to enroll CDC�s National Nosocomial Infections Surveillance (NNIS) system Association of Professionals of Infection Control list serve Eligible Adult ICUs Use NNIS definitions and surveillance techniques 500 patient days per year Critical care nurses surveyed All RNs employed in enrolled ICU Anonymous survey identifiable to ICU where distributed

6. Survey Measures Organizational climate (OC) Perceived Nursing Work Environment (PNWE) (Choi et al., 2004) 7 subscales (participatory governance, supervision, adequate staffing/resources, professional practice, collaboration, training, scheduling) Demographic questions 8 items including gender, age, education and experience Behavioral intention to leave (ITL) 1 item, �Do you intend to leave your position in the coming year?�

7. ICU Level Data ICU type Wages Adjusted by MSA Workload Proportion overtime Nurse to patient ratios NIW based on patient diagnoses

8. Patient Level Variables Severity of Risk Previous year admissions Based on groupings using DCG Patient age Medicare claims linked to infection control data Healthcare Acquired Infections (HAI) CDC definitions from NNIS

9. Results 2,324 nurse respondents (41% response rate) 76,931 patients 68 hospitals 110 ICUs

10. Nurse Demographics n percent* Gender Female 2086 89.5 Male 234 10.0 Education ASN/Diploma 963 41.3 BSN or higher 1341 57.6 Employment Status Full-time 1797 77.1 Part-time 339 14.5 Float 173 7.4 * Percents do not equal 100 due to missing data

11. Nurse Demographics Mean Standard Deviation Age 39.5 9.8 Healthcare Exp. 15.7 9.3 ICU Exp. 10.3 8.4 Tenure 8.0 7.5

12. Hospitals Characteristics Bed size = 299 35% 300-399 13% = 400 52% Teaching status Teaching 74%

13. Patient Characteristics 75% Male Average age 76.6 years (6.7) 49.84% Medical/Surgical ICUs Overall 2.9% HAI rate

14. Organizational Climate Factors and Intention to Leave Factor Odds Ratio (95% CI) Participatory governance 0.54* (.41, .72) Supervisor 0.74* (.55, .98) Adequate staffing/resources 1.10 (.83, 1.5) Professional practice 0.80 (.53, 1.2) Collaboration 1.23 (.91, 1.7) Training 0.63* (.46, .85) Scheduling 0.83 (.65, 1.1)

15. Predictors of HAI* Variable Coefficient p value Gender 0.15 0.005 Age (75 to 79 vs. to 65-74) 0.14 0.003 Hx Cancer -0.29 0.005 Hx GI 0.46 <0.001 Hx Cardiac Arrest 0.31 0.001 Hx CV 0.25 0.010 Hx Transplant 0.51 0.013 ICU type (CV vs Med/Surg) -035 <0.001 Proportion of RN overtime 2.34 0.033 Mean OC -0.72 0.012

16. Summary Participatory Governance, Supervisor and Training of other nurses are related to ITL Overtime use is positively related to patient�s risk of HAI Organizational Climate is inversely related to patient�s risk of HAI Intention to leave and staffing ratios were not related to risk of HAI

17. HAI:Important Patient Safety Issue 2 million cases annually 500,000 occur in ICUs NI have risen over the last 30 years Estimated to cost hospitals $5.9 billion per year

18. Next Steps Use other measures of patient safety measures found in Medicare claims Mortality Disposition at discharge Develop models with components of OC (not just composite measure).

19. Quote of the Day! �Culture (climate) eats strategy for lunch everyday!�

20. Thanks and stay tuned�.