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all requirements in PDF files and photosThere is PDF files with questions must be solved, and other question in the photo and all must be solved correctly.word counts depends on each questions.similarity must be less than 5\%Turintin report is needed photo_2020_05_20_16_44_54.jpg lower_medicare_mortality_nursing_research_assignment_part_2.pdf nursing_research_assignment_part_2_for_academic_year_2019_2020.pdf Unformatted Attachment Preview Lower Medicare Mortality among a Set of Hospitals Known for Good Nursing Care Author(s): Linda H. Aiken, Herbert L. Smith and Eileen T. Lake Source: Medical Care, Vol. 32, No. 8 (Aug., 1994), pp. 771-787 Published by: Lippincott Williams & Wilkins Stable URL: http://www.jstor.org/stable/3766652 Accessed: 27-06-2016 09:54 UTC Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at http://about.jstor.org/terms JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org. Lippincott Williams & Wilkins is collaborating with JSTOR to digitize, preserve and extend access to Medical Care This content downloaded from 153.104.6.4 on Mon, 27 Jun 2016 09:54:08 UTC All use subject to http://about.jstor.org/terms MEDICAL CARE Volume 32, Number 8, pp 771-787 ? 1994, J.B. Lippincott Company Lower Medicare Mortality Among a Set of Hospitals Known for Good Nursing Care LINDA H. AIKEN, PHD*, HERBERT L. SMITHt, PHD, AND EILEEN T. LAKE, MPPf The objective of this study is to investigate whether hospitals known to be good places to practice nursing have lower Medicare mortality than hospitals that are otherwise similar with respect to a variety of non-nursing organizational characteristics. Research to date on determinants of hospital mortality has not focused on the organization of nursing. We capitalize on the existence of a set of studies of 39 hospitals that, for reasons other than patient outcomes, have been singled out as hospitals known for good nursing care. We match these magnet hospitals with 195 control hospitals, selected from all nonmagnet U.S. hospitals with over 100 Medicare discharges, using a multi- variate matched sampling procedure that controls for hospital characteristics. Medicare mortality rates of magnet versus control hospitals are compared us- ing variance components models, which pool information on the five matches per magnet hospital, and adjust for differences in patient composition as measured by predicted mortality. The magnet hospitals observed mortality rates are 7.7\% lower (9 fewer deaths per 1,000 Medicare discharges) than the matched control hospitals (P = .011). After adjusting for differences in predicted mortality, the magnet hospitals have a 4.6\% lower mortality rate (P = .026 [95\% confidence interval 0.9 to 9.4 fewer deaths per 1,000]). The same factors that lead hospitals to be identified as effective from the standpoint of the organization of nursing care are associated with lower mortality among Medicare patients. Key words: nursing care; Medicare; mortality rates. (Med Care 1994;32:771-787) In this study we find that magnet hospitals, are conducive to better patient care), have hospitals that embody a set of organizational lower mortality than matched hospitals, attributes that nurses find desirable (and that which are similar along other organizational dimensions, but that are not known as set- * From the Center for Health Services and Policy Research, School of Nursing and Department of Sociology and Population Studies Center, Philadelphia, Pennsylva- tings that place a high institutional priority on nia. t From the Department of Sociology and Population Studies Center, University of Pennsylvania, Philadelphia, Pennsylvania. t From the Center for Health Services and Policy Research, University of Pennsylvania, Philadelphia, Pennsyl- vania. This research was supported by grants from The Baxter Foundation and from the National Institute of Nursing Research (R01 NR 02280), NIH. Address for correspondence: Linda H. Aiken, PHD, Center for Health Services and Policy Research, School of Nursing Philadelphia, PA 19104-6096. nursing. Those familiar with the inner workings of hospitals will not be surprised there is a relationship between the practice of nursing and the mortality experience of hospital patients.1-3 The connection between nursing and mortality rates dates as far back as the reforms in British hospitals made under Florence Nightingale during the Crimean War.4 Nurses are the only professional caregivers in hospitals who are at the bedside of hospital patients around the clock. What nurses do-or do not do (or in some circum- 771 This content downloaded from 153.104.6.4 on Mon, 27 Jun 2016 09:54:08 UTC All use subject to http://about.jstor.org/terms MEDICAL CARE AIKEN ET AL. stances are not allowed to do)-is directly and institutional culture, ranging from unit- related to a variety of patient outcomes, including in-hospital deaths.5 American phy- level specialization (e.g., dedicated AIDS units) to the implementation of hospitalwide professional nursing practice models, sicians typically combine office and hospital- based practice, and therefore observe their hospitalized patients only periodically. Nurses are physiciansprimary source of information about changes in their patients conditions. Nurses often must act in the absence of the physician when timely intervention is required.6 As hospital care has become increasingly complex, the exercise of professional judgment by nurses is ever more important in preventing adverse and sometimes catastrophic events.7 The modem hospital has been described as having two lines of authority, medicine and administration.8 Nurses have traditionally been subordinate to both, even though they have the most direct knowledge and under- standing of patient care requirements by virtue of their constant contact with pa- do indeed result in more autonomy, control, and status for nurses.* We conjecture that hospitals that facilitate professional autonomy, control over practice, and compara- tively good relations between nurses and physicians will be ones in which nurses are able to exercise their professional judgment on a more routine basis, with positive implications for the quality and outcomes of pa- tient care. In this paper we show that a group of hos- pitals characterized by nurses as being good places to work also achieved better patient outcomes as reflected by lower mortality. Although we cannot document the entire causal chain by which nurses affect mortality, we do review studies showing that the hospitals in contemporary hospitals as the glue that which nurses prefer to work have distinct organizational features. The study provides new evidence that these features are more profes- keeps the highly specialized, often frag- sional autonomy, greater control over the mented system of hospital care together. The potential for using nursing to improve patient outcomes is apparent in the multihospital study practice environment, and better relationships with physicians. We were able to demonstrate that the superior mortality experience in the study hospitals cannot be attributed to either differential patient characteristics or other or- tients. Lewis Thomas9 has described nurses in of variation in intensive care death rates, by Knaus and associates,10 in which patterns of communication between nurses and physicians were the single most significant factor associated with excess mortality-more important, for example, than whether the unit had a medical director, or whether it was in a ganizational features not related to nursing, but previously shown to be associated with differential hospital mortality. The proportion of physicians who are board certified, whether the hospital is a teaching facility, type of own- teaching hospital. Yet contemporary hospital ership, financial status, are examples of such nursing practice is most often characterized by findings. a lack of professional autonomy, poor control over the practice setting, and inadequate provisions for routine communication with physi- Review of Previous Studies cians about crucial clinical decisions. All of these compromise the ability of nurses to exercise their professional judgment on behalf of the well-being of their patients.8 The degree to which hospitals empower nurses to use their professional nursing skills in a timely manner during in-patient hospital care varies. Certain forms of hospital organization The literature on the organization of hospital nursing and variation in hospital mortality have developed independently of one *Aiken LH, Smith HL. Effects of specialization on the status and autonomy of nurses: Results from a natural ex- periment in hospital AIDS care. Paper presented at the American Sociological Association, Miami, FL, August 1993. 772 This content downloaded from 153.104.6.4 on Mon, 27 Jun 2016 09:54:08 UTC All use subject to http://about.jstor.org/terms Vol. 32, No. 8 MEDICARE MORTALITY AND GOOD NURSING CARE another for the most part. Research on the organization of nursing care primarily has been motivated by debates over the causes and potential solutions to hospital nursing shortages. The focus has been on determining how hospital work environments could be restructured to make them more desirable places for professional nurses to practice.11-8 The dominant outcome variables studied have been nurse satisfaction, job turnover, and hospital nurse vacancy rates. Far less attention has been given to the relationship between nursing or- hospitals.32 The ambiguity of both findings and interpretation can also be found concerning other postulated or observed correlates of mortality, including ownership, size, financial status, and urban vs. rural location.29-34,37 The nursing variable in multivariate hospital mortality studies, usually registered nurse (RN) to patient ratios or RNs as a percentage of total nursing personnel, is usually found to be a significant correlate of mortality. Little substantive or analytic consideration is given to this association, which is variously interpreted as representing the effect of clinical ganization and patient outcomes. Conversely, the large literature on variations in mortality across hospitals19-24 has skill level29,30 or service intensity.31 concentrated on methodological issues and the Magnet Hositals association between the institutional and or- ganizational characteristics of hospitals and their in-patient mortality. The methodological Hospitals do differ from one another in their quality of nursing care. This is an impor- focus of the research primarily is on how to tant dimension of a hospitals reputation.23 separate components of variation due to severity of illness and other characteristics of patients, from manipulable dimensions of hospi- Rather than undertaking a large, detailed, na- tal organization. Development of measures to stage severity of illness has advanced considerably; measures of organizational dimensions have lagged by comparison.10,25,26 When institutional attributes or charac- teristics are the focus of hospital mortality studies, a large number of organizational cor- relates are examined, which sometimes in- cludes nursing.1927-32 Board certification of physicians has been found uniformly to be as- sociated with better quality of hospital care and lower mortality.2830,32-35 The teaching status of hospitals is another variable of fre- quent interest. The referral patterns characteristic of such hospitals may result in a more severely ill patient population and higher mortality than at nonteaching hospitals.36 Conversely, teaching hospital status may denote a better qualified staff, greater technologi- cal sophistication, etc., and thus be expected to yield better outcomes.2837 As would be ex- tional study of the mortality experience of hospitals known for good nursing care, we are capitalizing on the existence of a set of studies of several dozen hospitals that have been singled out as hospitals known for good nursing care for reasons other than the study of patient outcomes. Among experts on nursing, there is general agreement on the attributes of a good nursing service.15,38,39 In the early 1980s, the American Academy of Nursing (AAN) set about the task of identifying a set of hospitals with reputations as being good places in which to practice nursing.15 These hospitals were not identified by low mortality rate, nor were they selected according to any overt organizational features. Rather, the intent of the original study was to demonstrate that hospitals differed from one another with respect to their attractiveness to nurses, and that attractive hospitals were better able to maintain low rates of nursing turn- over and vacancy, which led to their eventual designation as magnet hospitals. The magnet hospitals were identified in pected from such competing hypotheses, findings are inconsistent across studies, some docu- the original study as follows:15 six AAN hos- menting more adverse outcomes, some less and some showing no differences at teaching pital nursing experts in each of eight regions of the country who were selected to nominate 773 This content downloaded from 153.104.6.4 on Mon, 27 Jun 2016 09:54:08 UTC All use subject to http://about.jstor.org/terms MEDICAL CARE AIKEN ET AL. 6 to 10 hospitals that met the following three criteria: 1) nurses consider the hospital a good place to practice nursing; 2) the hospital has the ability to recruit and retain professional nurses, as evidenced by a relatively low turn- over rate; and 3) the hospital is located in an area where it will have competition for staff from other institutions and agencies. A total of 165 hospitals were nominated; 155 agreed to participate in the study. Each participating hospital provided information on a range of nursing-related issues including nurse vacancy, turnover, and absentee rates; the ratio of inexperienced to experienced nurses; use of supplemental staffing agencies; nurse staffing policies; educational preparation of nurses in leadership positions; and the predominant mode of nurse organization on the units (i.e., primary, team, functional, or other). Hospitals were then ranked according to evidence of be- ing able to attract and retain professional nurses and to create an environment condu- cive to good nursing care. The top-ranked 41 institutions were subjected to a subsequent round of data collection involving interviews with staff nurses and directors of nursing. the magnet hospitals include all hospitals that might meet the original specified criteria. However, the selection process appears to have been sufficiently stringent as to lead us to expect that the 41 magnet hospitals would share some common characteristics with respect to nursing that would differentiate them from the vast majority of American hospitals. The nurses practicing in the designated magnet hospitals cited the following organizational attributes as important in making their hospitals good places to work:15,40-43 1) the importance and status of nurses in the organization as reflected in the formal organizational structure of nursing and its relationship to the organization of the hospital, i.e., a flat organization of the nursing department with few supervisors, and a chief nurse executive with a strong position in the bureaucratic hier- archy of the hospital; 2) nurse autonomy to make clinical decisions within their areas of competence, and to control their own practice; 3) control over the practice environment, in- cluding decentralized decision-making at the unit level, adequate staffing, a limit to the pro- These were the hospitals that ultimately came portion of nurses who were new graduates, and established mechanisms to facilitate communi- to be designated as magnet hospitals. The in-patient mortality rates of the hos- ganization of nurses clinical responsibilities at pitals were not considered. At that time com- the unit level to promote accountability and parative, standardized hospital rates probably were not available to either institutions or the AAN panelists. Moreover, important as they may be in the aggregate, the magni- cation between nurses and physicians; 4) or- continuity of care, e.g., primary nursing, and less use of floatingof nurses to equalize staff- ing across units; and 5) an established culture tude of mortality differences that exist signifying nursings importance in the overall mission of the institution, as reflected in sala- among hospitals is comparatively small, and ried practice (compared to hourly wages), insti- difficult for even a well-qualified observer to tutional investment in nurses continuing education, and supervisory personnel who support nursesdecision-making responsibilities. discern at the scene, especially when measured against a backdrop of stochastic fluctuation over time. When we subsequently compare the mortality rates of magnet hospitals with nonmagnet hospitals, we are reasonably confident that the distinction between hospital types pertains to features of the organization of nursing, and is not in itself, another measure of hospital mortality. The process by which these hospitals were selected does not necessarily guarantee that The original study of these hospitals was conducted in 1982.15 A follow-up study was conducted in a geographically stratified subsample of the magnet hospitals in 1986,40,41 and again in 1989.42,43 At each point, the magnet hospitals were found to have maintained their ability to attract and recruit nurses, and to have retained the organizational features found in the initial study. 774 This content downloaded from 153.104.6.4 on Mon, 27 Jun 2016 09:54:08 UTC All use subject to http://about.jstor.org/terms Vol. 32, No. 8 MEDICARE MORTALITY AND GOOD NURSING CARE The organizational dimensions found to by greater nurse autonomy and control, and be common among the magnet hospitals are better relations with physicians, can be found tality in the few previous studies on the nurses concerning the presence of various job similar to those associated with lower mor- topic, i.e., decentralized decision-making at the nursing unit level, ward specialization, standardization of nursing procedures, qualifications of nurses, and good relations with physicians.10,27,34 What is not clear from these earlier studies is how or why these particular organizational dimensions of hospitals would be likely to affect what nurses do. Our contention is that they result in enhanced intra-organizational status for nurses that provides a level of professional autonomy and control that enables nurses to put into action what they know and can do for patients. We viewed the magnet hospitals, which are clearly at one end of the scale on which the organization of nursing can be evaluated, as representing an opportunity to test whether there is any payoff in in Table 1, which summarizes the reports of characteristics at 25 hospitals, including 17 magnet hospitals, from two different studies. The first study is by Kramer and Hafner,40 and involves a geographically stratified sub-sample of 16 of the original 41 magnet hospitals. Kra- mer generously provided to us a unit-record data tape from this study, without which the following comparison would have been impossible. The second study is by the present authors (see footnote, page 772), and involves a geographically stratified set of hospitals selected originally to serve as controls in a study of hospitals with specialized AIDS units. Coincidentally, it also includes two magnet hospitals from the original AAN study,l5 one of which is among the 16 magnet hospitals studied by Kramer and Hafner.40 In both studies, nurses at these hospitals terms of reduced hospital mortality. were asked to evaluate a battery of items (the Nursing Work Index). Each nurse was asked to Enhanced Autonomy, Control, and Status in indicate, for each item, th ... Purchase answer to see full attachment