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The Effects of Changes in the Hospital Nursing Workforce and Practice Environment on the Outcomes of Surgical Oncology Patients: a Two-Stage Panel Study

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The Effects of Changes in the Hospital Nursing Workforce and Practice Environment on the Outcomes of Surgical Oncology Patients: a Two-Stage Panel Study University of Pennsylvania ScholarlyCommons Publicly Accessible Penn Dissertations 2014 The Effects of Changes in the Hospital Nursing Workforce and Practice Environment on the Outcomes of Surgical Oncology Patients: A Two-Stage Panel Study Jill Marie Vanak University of Pennsylvania, [email protected] Follow this and additional works at: https://repository.upenn.edu/edissertations Part of the Health and Medical Administration Commons, and the Nursing Commons Recommended Citation Vanak, Jill Marie, "The Effects of Changes in the Hospital Nursing Workforce and Practice Environment on the Outcomes of Surgical Oncology Patients: A Two-Stage Panel Study" (2014). Publicly Accessible Penn Dissertations. 1480. https://repository.upenn.edu/edissertations/1480 This paper is posted at ScholarlyCommons. https://repository.upenn.edu/edissertations/1480 For more information, please contact [email protected]. The Effects of Changes in the Hospital Nursing Workforce and Practice Environment on the Outcomes of Surgical Oncology Patients: A Two-Stage Panel Study Abstract ABSTRACT THE EFFECTS OF CHANGES IN THE HOSPITAL NURSING WORKFORCE AND PRACTICE ENVIRONMENT ON THE OUTCOMES OF SURGICAL ONCOLOGY PATIENTS: A TWO-STAGE PANEL STUDY Jill M. Vanak Eileen T. Lake Prior research has documented that a better educated nursing workforce, higher nurse staffing vle els, and better nurse practice environments are significantly associated with improved quality of care and lower patient mortality in multiple patient populations. Most prior research has used cross-sectional data to analyze associations between variables at a single time point. Little research has addressed whether changes in hospital nursing characteristics over time are associated with changes in outcomes. This two- stage panel study, in which cross-sectional samples of patients and nurses in acute care hospitals in Pennsylvania were compared at two time points, provides evidence of the relationship between changes in hospital nursing characteristics and patient outcomes. The objective of this study was to examine the effects of changes in hospital-level proportion of baccalaureate-prepared nurses, nurse staffing, and the nurse acticepr environment on changes in rates of failure-to-rescue and 30-day mortality in a surgical oncologic patient population between two points in time. The study was a two-stage panel designed secondary analysis that examined the effect of changes between 1999 and 2006 in nursing characteristics in 135 hospitals on changes in risk-adjusted mortality and failure-to-rescue of 29, 356 adult oncology patients admitted for primary surgical intervention for the purposes of disease management. The study combined information about nursing characteristics from nurse surveys with patient characteristics and outcomes derived from a state cancer registry and hospital discharge abstracts and hospital characteristics drawn from administrative databases. Multivariate regression modeling was employed to jointly assess the effect of changes in the organization of nursing within an institution on outcomes, controlling for both patient and hospital characteristics. The overall mean percentage of nurses with a baccalaureate degree across hospitals did not change significantly between 1999 and 2006. The mean number of patients per nurse across all hospitals was 5.81 in 1999 and 5.76 in 2006, a non-significant change, with the astv majority of hospitals decreasing or increasing the average number of patients per nurse by less than one patient. Nurse-reported practice environment scores increased significantly during the study period. A number of hospitals had increases in level of nurse education, nurse staffing, andating r of the practice environment over the period, while many others had decreases. Some of the changes in both directions were sizable. Improvement in nurse staffing was associated witheductions r in failure-to-rescue and mortality rates. The addition of one patient to the nurse's average workload resulted in an average increase of 4.34 deaths for every 1,000 patients. For the subset of patients with complications, the addition of one patient to the nurse's average workload resulted in an average increase of 13.47 deaths for every 1,000 patients. When controlling for patient characteristics, with every 10% increase in the proportion of nurses with a baccalaureate degree, hospitals had an average reduction of 5.07 deaths for every 1,000 patients. This association was not significant in models that controlled for hospital characteristics. Investments in hospital nursing features including increasing the proportion of baccalaureate-prepared nurses and lowering patient-to-nurse ratios within hospitals may contribute to improvement in outcomes of surgical oncology patients. Degree Type Dissertation Degree Name Doctor of Philosophy (PhD) Graduate Group Nursing First Advisor Eileen T. Lake Keywords education, nursing, oncology, practice environment, staffing, surgical Subject Categories Health and Medical Administration | Medicine and Health Sciences | Nursing This dissertation is available at ScholarlyCommons: https://repository.upenn.edu/edissertations/1480 THE EFFECTS OF CHANGES IN THE HOSPITAL NURSING WORKFORCE AND PRACTICE ENVIRONMENT ON THE OUTCOMES OF SURGICAL ONCOLOGY PATIENTS: A TWO-STAGE PANEL STUDY Jill Marie Vanak A DISSERTATION in Nursing Presented to the Faculties of the University of Pennsylvania in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy 2014 Supervisor of Dissertation ______________________________ Eileen T. Lake, PhD, RN, FAAN Associate Professor of Nursing Graduate Group-Chairperson _________________________ Barbara J. Riegel, DNSc, RN, FAAN, FAHA Professor of Nursing Dissertation Committee Ann Kutney-Lee, PhD, RN Assistant Professor of Nursing Salimah Meghani, PhD, MBE, RN, FAAN Associate Professor of Nursing Kelly Wiltse-Nicely, PhD, MSN, CRNA Assistant Professor of Nurse Anesthesia Dedication To my parents Your love is like the North Star, you guide me when I’m lost. In a changing world, you are my constant. ii Acknowledgement I acknowledge, with gratitude, my debt to my dissertation chair and advisor, Dr. Eileen Lake. Your constant presence, guidance, and support have led to intellectual development and personal growth. When I thought I could not, you knew I could. I would like to express my gratitude to Dr. Linda Aiken. Thank you for providing me with a fellowship, and the opportunity to learn. I would like to express my gratitude to Dr. Ann Kutney-Lee for her mentorship, support, and guidance in developing this research. Thank you for providing the foundation for my research, in more ways than one. You never let me veer from the study of oncology, and for that, I am grateful. Thank you to my committee members, Dr. Eileen Lake, Dr. Ann Kutney-Lee, Dr. Kelly Wiltse-Nicely, Dr. Salimah Meghani, Dr. Rosemary Polomano, and Dr. Sarah Kagan, for your feedback, support, and mentorship. Thank you to the faculty, administrative staff, pre-doctoral and post-doctoral fellows at the Center for Health Outcomes and Policy Research who provided inspiration, support, and scholarship throughout my years. A special thank you and acknowledgement to Tim Cheney and Jesse Chittams for their guidance in all things statistical. Without you, this work would not have been possible. You are two of the finest teachers I have had. Thank you for having patience. Thank you to my parents for their constant love and support. You are my North Star. Thank you to my family, who always provide much needed perspective, laughter, and love. To Nick-who taught me to live by the words: Stop. Smile. Breathe. Life is Beautiful. At last, you came along. A thank you to my fellow doctoral students, past and present, especially Lisa Quinn, Amy Witkoski Stimpfel and Deena Kelly, for their guidance, support, and iii camaraderie. To the nurses, physicians, and staff at Memorial Sloan Kettering Cancer Center who supported my schooling and this endeavor, especially Dr. Dennis Graham, Dr. Nancy Kline, and Dr. David Rice, thank you for your encouragement and your wisdom. Nancy, you inspired me to return to school, you inspired me to find a place at the table, you inspired me to have a voice, you inspired me to excel. You continue to inspire me. Thank you all for your guidance, mentorship, and support. iv ABSTRACT THE EFFECTS OF CHANGES IN THE HOSPITAL NURSING WORKFORCE AND PRACTICE ENVIRONMENT ON THE OUTCOMES OF SURGICAL ONCOLOGY PATIENTS: A TWO-STAGE PANEL STUDY Jill M. Vanak Eileen T. Lake Prior research has documented that a better educated nursing workforce, higher nurse staffing levels, and better nurse practice environments are significantly associated with improved quality of care and lower patient mortality in multiple patient populations. Most prior research has used cross-sectional data to analyze associations between variables at a single time point. Little research has addressed whether changes in hospital nursing characteristics over time are associated with changes in outcomes. This two-stage panel study, in which cross- sectional samples of patients and nurses in acute care hospitals in Pennsylvania were compared at two time points, provides evidence of the relationship between changes in hospital nursing characteristics and patient outcomes. The objective of this study was to examine the effects of changes in hospital-level proportion of baccalaureate-prepared nurses, nurse staffing, and the nurse practice environment on changes
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