Rationing of Nursing Care and Its Relationship with Nurse Staffing and Patient Outcomes: The Mediation Effect Tested by Structural Equation Modeling
Abstract
:1. Introduction
2. Methods
Study Participants
3. Measures
3.1. Patient Outcomes
3.2. Nurse Staffing
3.3. RONC
3.4. Controlling Variables
3.5. Statistical Analysis
- When controlling for organizational, nurse, and patient characteristics, the lower the nurse staffing level is, the higher score RONC will be.
- When controlling for organizational, nurse, and patient characteristics, the lower the nurse staffing level is, the higher score of nurse-reported quality assessments and patient adverse events, and patient-reported dissatisfaction will be.
- When controlling for organizational, nurse, and patient characteristics, the effects of nurse staffing on patient outcomes were indirect, which were mediated by RONC.
- When controlling for organizational, nurse, and patient characteristics, the higher the score of nurses-reported quality assessments and patient adverse events lead to higher score of patient-reported dissatisfaction.
4. Results
5. Discussion
6. Conclusions and Implications
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
References
- Schubert, M.; Glass, T.R.; Clarke, S.P.; Aiken, L.H.; Schaffert-Witvliet, B.; Sloane, D.M.; De Geest, S. Rationing of nursing care and its relationship to patient outcomes: The Swiss extension of the International Hospital Outcomes Study. Int. J. Qual. Health Care 2008, 20, 227–237. [Google Scholar] [CrossRef] [PubMed]
- Aiken, L.H.; Sloane, D.M.; Cimiotti, J.P.; Clarke, S.P.; Flynn, L.; Seago, J.A.; Spetz, J.; Smith, H.L. Implications of the California Nurse Staffing Mandate for Other States. Health Serv. 2010, 45, 904–921. [Google Scholar] [CrossRef] [Green Version]
- West, E.; Barron, D.N.; Reeves, R. Overcoming the barriers to patient-centered care: Time, tools and training. J. Clin. Nurs. 2005, 14, 435–443. [Google Scholar] [CrossRef] [PubMed]
- Ausserhofer, D.; Schubert, M.; Desmedt, M.; Blegen, M.A.; De Geest, S.; Schwendimann, S. The association of patient safety climate and nurse-related organizational factors with selected patient outcomes: A cross-sectional survey. Int. J. Nurs. Stud. 2012, 50, 240–252. [Google Scholar] [CrossRef] [PubMed]
- Schubert, M.; Clarke, S.P.; Glass, T.R.; Schaffert-Witvliet, B.; De Geest, S. Identifying thresholds for relationships between impacts of rationing of nursing care and nurse- and patient-reported outcomes in Swiss hospitals: A correlational study. Int. J. Nurs. Stud. 2009, 46, 884–893. [Google Scholar] [CrossRef]
- Aiken, L.H.; Clarke, S.P.; Sloane, D.M. Hospital staffing, organization, and quality of care: Cross-national findings. Int. J. Qual. Health Care 2002, 14, 5–13. [Google Scholar] [CrossRef]
- Papastavrou, E.; Andreou, P.; Vryonides, S. The hidden ethical element of nursing care rationing. Nurs. Ethics 2014, 21, 583–593. [Google Scholar] [CrossRef]
- Vryonides, S.; Papastavrou, E.; Charalambous, A.; Andreou, P.; Merkouris, A. The ethical dimension of nursing care rationing: A thematic synthesis of qualitative studies. Nurs. Ethics 2014, 22, 881–900. [Google Scholar] [CrossRef] [PubMed]
- Kalisch, B.J. Missed nursing care: A qualitative study. J. Nurs. Care Qual. 2006, 21, 306–313. [Google Scholar] [CrossRef] [PubMed]
- Kalisch, B.J.; Landstrom, G.; Williams, R.A. Missed nursing care: Errors of omission. Nurs. Ethics 2009, 57, 3–9. [Google Scholar] [CrossRef]
- Schubert, M.; Glass, T.R.; Clarke, S.P.; Schaffert-Witvliet, B.; De Geest, S. Validation of the Basel Extent of Rationing of Nursing Care Instrument. Nurs. Res. 2007, 56, 416–424. [Google Scholar] [CrossRef] [Green Version]
- Kalisch, B.J.; Tschannen, D.; Lee, K.H. Missed Nursing Care, Staffing, and Patient Falls. J. Nurs. Care Qual. 2012, 27, 6–12. [Google Scholar] [CrossRef]
- Schubert, M.; Clarke, S.P.; Aiken, L.H.; De Geest, S. Associations between rationing of nursing care and inpatient mortality in Swiss hospitals. Int. J. Qual. Health Care 2012, 24, 230–238. [Google Scholar] [CrossRef] [Green Version]
- Aiken, L.H.; Clarke, S.P.; Sloane, D.M.; Sochalski, J.A.; Busse, R.; Clarke, H.; Giovannetti, P.; Hunt, J.; Rafferty, A.M.; Shamian, J. Nurses’ Reports on Hospital Care in Five Countries. Health Aff. 2001, 20, 43–53. [Google Scholar] [CrossRef]
- Zhu, X.-W.; You, L.-M.; Fang, J.-B.; Hou, S.-X.; Lu, M.-M.; Lv, A.-L.; Ma, W.-G.; Wang, H.-H.; Wu, Z.-J.; Zhang, L.-F.; et al. Nurse Staffing Levels Make a Difference on Patient Outcomes: A Multisite Study in Chinese Hospitals. J. Nurs. Sch. 2012, 44, 266–273. [Google Scholar] [CrossRef] [PubMed]
- Liu, J.; You, L.; Zheng, J.; Ross, A.M.; Liu, K. Effects of work environment on quality of care in ICUs: A multisite survey in China. J. Nurs. Care. Qual. 2016, 31, 1–8. [Google Scholar] [CrossRef]
- Liu, X.; Zheng, J.; Liu, K.; Baggs, J.G.; Liu, J.; Wu, Y.; You, L. Hospital nursing organizational factors, nursing care left undone, and nurse burnout as predictors of patient safety: A structural equation modeling. Int. J. Nurs. Stud. 2018, 86, 82–89. [Google Scholar] [CrossRef] [PubMed]
- Wu, S.; Li, H.; Yang, S.; Zhu, W.; Wang, X.-R. The mediating and moderating role of personal strain and coping resource in the relationship between work stressor and quality of life among Chinese nurses. Int. Arch. Occup. Environ. Health 2012, 85, 35–43. [Google Scholar] [CrossRef]
- You, L.; Aiken, L.H.; Sloane, D.M.; Liu, k.; He, G.; Hu, Y.; Jiang, X.; Li, X.; Li, X.; Liu, H.; et al. Hospital nursing, care quality, and patient satisfaction: Cross-sectional surveys of nurses and patients in hospitals in China and Europe. Int. J. Nurs. Stud. 2012, 50, 154–161. [Google Scholar] [CrossRef]
- Patrician, P.A.; Shang, J.; Lake, E.T. Organizational Determinants of Work Outcomes and Quality Care Ratings Among Army Medical Department Registered Nurses. Nurs. Health 2010, 33, 99–110. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Lehrman, W.G.; Elliott, M.N.; Goldstein, E.; Beckett, M.K.; Klein, D.J.; Giordano, L.A. Characteristics of hospitaos demonstrating superior performance in patient experience and clinical process measures of care. Med. Care Res. Rev. 2010, 67, 38–55. [Google Scholar] [CrossRef]
- Jha, A.K.; Orav, E.J.; Zheng, J.; Epstein, A.L. Patients’ perception of hospital care in the United States. N. Engl. J. Med. 2008, 359, 1921–1931. [Google Scholar] [CrossRef]
- Asberg, K.K.; Bowers, C.; Renk, K.; McKinney, C. A structural equation modeling approach to the study of stress and psychological adjustment in emerging adults. Child. Psychiatry Hum. Dev. 2008, 39, 481–501. [Google Scholar] [CrossRef]
- Hair, J.; Anderson, R.; Tatharn, R.; Black, W.C. Multivariate Data Analysis with Reading; Macmillan Publishing: New York, NY, USA, 1992. [Google Scholar]
- McHugh, M.D.; Rochman, M.F.; Sloane, D.M.; Berg, B.A.; Mancini, M.E.; Nadkarni, V.M.; Merchant, M.A.; Aiken, L.H.; American Heart Association’s Get With The Guidelines-Resuscitation Investigators. Better nurse staffing and nurse work environments associated with increased survival on in-hospital cardiac arrest patients. Med. Care 2016, 54, 74–80. [Google Scholar] [CrossRef] [PubMed]
- Schubett, M.; Ausserhofer, D.; Desmedt, M.; Schwendimann, S.; Lesaffre, E.; Li, B.; De Geest, S. Levels and correlates of implicit rationing of nursing care in Swiss acute care hospitals—A cross sectional study. Int. J. Nurs. Stud. 2013, 50, 230–239. [Google Scholar] [CrossRef]
- Donabedian, A.; Li, Y. Explorations in Quality Assessment and Monitoring; Beijing University Medical Press & Beijing University Press: Beijing, China, 2007. (in Chinese) [Google Scholar]
- Weinberg, A.D.; Lesesne, A.J.; Richards, C.L.; Pals, J.K. Quality care indicators and staffing levels in a nursing facility subacute unit. J. Am. Med. Direct. Assoc. 2002, 3, 1–4. [Google Scholar] [CrossRef]
- Covinsky, K.E.; Martin, G.E.; Beyth, R.J.; Justice, A.C.; Sehgal, A.R.; Landefeld, C.S. The Relationship Between Clinical Assessments of Nutritional Status and Adverse Outcomes in Older Hospitalized Medical Patients. J. Am. Geriatr. Soc. 1999, 47, 532–538. [Google Scholar] [CrossRef]
- Aiken, L.H.; Sloane, D.M.; Ball, J.; Bruyneel, L.; Rafferty, A.M.; Griffiths, P. Patient satisfaction with hospital careand nurses in England: An observational study. BMJ Open 2018, 8. [Google Scholar] [CrossRef]
- Wang, J.; Wang, X.; Jiang, F. Structural Equation Model: Method and Application; Higher Education Press: Beijing, China, 2011. (In Chinses) [Google Scholar]
Nurse | n (%) | Patient | n (%) |
---|---|---|---|
Age (year) (Mean (SD)) | 29.42 (7.07) | Age (year) (Mean (SD)) | 54.24 (17.65) |
Working years as a nurse (Mean (SD)) | 8.73 (7.65) | Length of stay (Mean (SD)) | 14.83 (18.56) |
Gender | Gender | ||
Female | 7612 (99.50) | Female | 2422 (45.25) |
Male | 38 (0.50) | Male | 2930 (54.75) |
Initial education | Education | ||
Secondary diploma | 4961 (64.29) | No schooling or primary | 1569 (29.29) |
Advanced diploma | 2374 (30.76) | Junior middle school | 1492 (27.85) |
BSN degree | 382 (4.95) | Senior middle school | 1231 (22.98) |
Highest education | College or higher | 1065 (19.88) | |
Secondary diploma | 1418 (18.41) | Self-rated health | |
Advanced diploma | 4720 (61.28) | Good to excellent | 2787 (52.10) |
BSN degree or higher | 1564 (20.31) | Fair or poor | 2562 (47.90) |
Item | n | % |
---|---|---|
RONC (Mean (SD)) | 3.31 | 2.43 |
Response of “yes” of the 12 items in RONC a | ||
Comfort/talk with patients | 4911 | 63.88 |
Teach/counsel patients and family | 4281 | 55.68 |
Adequate patient surveillance | 2713 | 35.30 |
Prepare patients and families for discharge | 2691 | 35.00 |
Coordinating patient care | 2321 | 30.25 |
Develop or update nursing care pans | 1806 | 23.49 |
Skin care | 1682 | 21.88 |
Pain management | 1629 | 21.19 |
Adequately document nursing care | 1334 | 17.35 |
Oral hygiene | 936 | 12.17 |
Treatments and procedures | 575 | 7.48 |
Administer medications on time | 538 | 7.00 |
Variables | n (%) |
---|---|
Nurse staffing (n = 599) | |
0.11–<0.40 | 413 (68.95) |
0.40–<0.5 | 94 (15.69) |
0.50–<0.6 | 46 (7.68) |
0.60–1.40 | 46 (7.68) |
Nurse-reported quality assessments | |
Quality of care as fair or poor (n = 7735) | 2351 (30.39) |
Not confident about patients’ self-care ability on discharge (n = 7736) | 3384 (43.74) |
Patient safety culture as poor or failing (n = 7493) | 261 (3.48) |
Nurse-reported patient adverse events as “once a month or less” or more frequently | |
Wrong medication (n = 7684) | 337 (4.39) |
Pressure ulcers (n = 7661) | 319 (4.16) |
Falls with injury (n = 7624) | 175 (2.30) |
Physical restraints (n = 7614) | 1274 (16.73) |
Surgical site infections (n = 7516) | 504 (6.71) |
Urinary tract infections (n = 7563) | 655 (8.66) |
Patient-reported dissatisfaction | |
Not definitely recommend this hospital to friends and family (“probably yes”, “probably no” and “definitely no”) (n = 5371) | 2513 (46.79) |
© 2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Share and Cite
Zhu, X.; Zheng, J.; Liu, K.; You, L. Rationing of Nursing Care and Its Relationship with Nurse Staffing and Patient Outcomes: The Mediation Effect Tested by Structural Equation Modeling. Int. J. Environ. Res. Public Health 2019, 16, 1672. https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph16101672
Zhu X, Zheng J, Liu K, You L. Rationing of Nursing Care and Its Relationship with Nurse Staffing and Patient Outcomes: The Mediation Effect Tested by Structural Equation Modeling. International Journal of Environmental Research and Public Health. 2019; 16(10):1672. https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph16101672
Chicago/Turabian StyleZhu, Xiaowen, Jing Zheng, Ke Liu, and Liming You. 2019. "Rationing of Nursing Care and Its Relationship with Nurse Staffing and Patient Outcomes: The Mediation Effect Tested by Structural Equation Modeling" International Journal of Environmental Research and Public Health 16, no. 10: 1672. https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph16101672