Context Better hospital nurse staffing, more educated nurses, and improved nurse work environments have been shown to be associated with lower hospital mortality. Little is known about whether and under what conditions each type of investment works better to improve outcomes. Objective To determine the conditions under which the impact of hospital nurse staffing, nurse education, and work environment are associated with patient outcomes. Design, Setting, and Participants Outcomes of 665 hospitals in four large states were studied through linked data from hospital discharge abstracts for 1,262,120 general, orthopedic, and vascular surgery patients, a random sample of 39,038 hospital staff nurses, and American Hospital Association data. Main outcome measures 30-day inpatient mortality and failure-to-rescue. Results The effect of decreasing workloads by one patient/nurse on deaths and failure-to-rescue is virtually nil in hospitals with poor work environments, but decreases the odds on both deaths and failures in hospitals with average environments by 4%, and in hospitals with the best environments by 9 and 10% respectively. The effect of 10% more BSN nurses decreases the odds on both outcomes in all hospitals, regardless of their work environment, by roughly 4%. Conclusions While the positive effect of increasing percentages of BSN nurses is consistent across all hospitals, lowering the patient-to-nurse ratios markedly improves patient outcomes in hospitals with good work environments, slightly improves them in hospitals with average environments, and has no effect in hospitals with poor environments.

Job dissatisfaction among nurses contributes to costly labor disputes, turnover, and risk to patients. Examining survey data from 95,499 nurses, we found much higher job dissatisfaction and burnout among nurses who were directly caring for patients in hospitals and nursing homes than among nurses working in other jobs or settings, such as the pharmaceutical industry. Strikingly, nurses are particularly dissatisfied with their health benefits, which highlights the need for a benefits review to make nurses’ benefits more comparable to those of other white-collar employees. Patient satisfaction levels are lower in hospitals with more nurses who are dissatisfied or burned out—a finding that signals problems with quality of care. Improving nurses’ working conditions may improve both nurses’ and patients’ satisfaction as well as the quality of care.

Background Each year, nearly 7 million hospitalized patients acquire infections while being treated for other conditions. Nurse staffing has been implicated in the spread of infection within hospitals, yet little evidence is available to explain this association. Methods We linked nurse survey data to the Pennsylvania Health Care Cost Containment Council report on hospital infections and the American Hospital Association Annual Survey. We examined urinary tract and surgical site infection, the most prevalent infections reported and those likely to be acquired on any unit within a hospital. Linear regression was used to estimate the effect of nurse and hospital characteristics on health care–associated infections. Results There was a significant association between patient-to-nurse ratio and urinary tract infection (0.86; P = .02) and surgical site infection (0.93; P = .04). In a multivariate model controlling for patient severity and nurse and hospital characteristics, only nurse burnout remained significantly associated with urinary tract infection (0.82; P = .03) and surgical site infection (1.56; P < .01) infection. Hospitals in which burnout was reduced by 30% had a total of 6,239 fewer infections, for an annual cost saving of up to $68 million. Conclusions We provide a plausible explanation for the association between nurse staffing and health care–associated infections. Reducing burnout in registered nurses is a promising strategy to help control infections in acute care facilities.

Patient satisfaction is receiving greater attention as a result of the rise in pay-for-performance (P4P) and the public release of data from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. This paper examines the relationship between nursing and patient satisfaction across 430 hospitals. The nurse work environment was significantly related to all HCAHPS patient satisfaction measures. Additionally, patient-to-nurse workloads were significantly associated with patients’ ratings and recommendation of the hospital to others, and with their satisfaction with the receipt of discharge information. Improving nurses’ work environments, including nurse staffing, may improve the patient experience and quality of care.

Objectives. To determine whether nurse staffing in California hospitals, where state-mandated minimum nurse-to-patient ratios are in effect, differs from two states without legislation and whether those differences are associated with nurse and patient outcomes. Data Sources. Primary survey data from 22,336 hospital staff nurses in California, Pennsylvania, and New Jersey in 2006 and state hospital discharge databases. Study Design. Nurse workloads are compared across the three states and we examine how nurse and patient outcomes, including patient mortality and failure-to-rescue, are affected by the differences in nurse workloads across the hospitals in these states. Principal Findings. California hospital nurses cared for one less patient on average than nurses in the other states and two fewer patients on medical and surgical units. Lower ratios are associated with significantly lower mortality. When nurses' workloads were in line with California-mandated ratios in all three states, nurses' burnout and job dissatisfaction were lower, and nurses reported consistently better quality of care. Conclusions. Hospital nurse staffing ratios mandated in California are associated with lower mortality and nurse outcomes predictive of better nurse retention in California and in other states where they occur.

Background Research has documented an association between Magnet hospitals and better outcomes for nurses and patients. However, little longitudinal evidence exists to support a causal link between Magnet recognition and outcomes. Objective To compare changes over time in surgical patient outcomes, nurse-reported quality, and nurse outcomes in a sample of hospitals that attained Magnet recognition between 1999 and 2007 with hospitals that remained non-Magnet. Research Design Retrospective, two-stage panel design using four secondary data sources. Subjects 136 Pennsylvania hospitals (11 “emerging” Magnets and 125 non-Magnets) Measures American Nurses Credentialing Center Magnet recognition; risk-adjusted rates of surgical 30-day mortality and failure-to-rescue, nurse-reported quality measures, and nurse outcomes; the Practice Environment Scale of the Nursing Work Index Methods Fixed effects difference models were used to compare changes in outcomes between emerging Magnet hospitals and hospitals that remained non-Magnet. Results Emerging Magnet hospitals demonstrated markedly greater improvements in their work environments than other hospitals. On average, the changes in 30-day surgical mortality and failure-to-rescue rates over the study period were more pronounced in emerging Magnet hospitals than in non-Magnet hospitals, by 2.4 fewer deaths per 1000 patients (p<.01) and 6.1 fewer deaths per 1000 patients (p=0.02), respectively. Similar differences in the changes for emerging Magnet hospitals and non-Magnet hospitals were observed in nurse-reported quality of care and nurse outcomes. Conclusions In general, Magnet recognition is associated with significant improvements over time in the quality of the work environment, and in patient and nurse outcomes that exceed those of non-Magnet hospitals.

Key Points Question What were the most recent US national estimates of nurse burnout and associated factors that may put nurses at risk for burnout? Findings This secondary analysis of cross-sectional survey data from more than 3.9 million US registered nurses found that among nurses who reported leaving their current employment (9.5% of sample), 31.5% reported leaving because of burnout in 2018. The hospital setting and working more than 20 hours per week were associated with greater odds of burnout. Meaning With increasing demands placed on frontline nurses during the coronavirus disease 2019 pandemic, these findings suggest an urgent need for solutions to address burnout among nurses.

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