The quality of hospital work environments and missed nursing care is linked to heart failure readmissions: a cross-sectional study of US hospitals

Abstract

Introduction Threats to quality and patient safety may exist when necessary nursing care is omitted. Empirical research is needed to determine how missed nursing care is associated with patient outcomes. Aim The aim of this study was to examine the relationship between missed nursing care and hospital readmissions. Methods Cross-sectional examination, using three linked data sources—(1) nurse survey, (2) patient discharge data from three states (California, New Jersey and Pennsylvania) and (3) administrative hospital data— from 2005 to 2006. We explored the incidence of 30-day readmission for 160 930 patients with heart failure in 419 acute care hospitals in the USA. Logistic regression was used to assess the effect of missed care on the odds of readmission, adjusting for patient and hospital characteristics. Results The most frequently missed nursing care activities across all hospitals in our sample included talking to and comforting patients (42.0%), developing and updating care plans (35.8%) and educating patients and families (31.5%). For 4 of the 10 studied care activities, each 10 percentage-point increase in the number of nurses reporting having missed the activity was associated with an increase in the odds of readmission by 2–8% after adjusting for patient and hospital characteristics. However, missed nursing care was no longer a significant predictor of readmission once adjusting for the nurse work environment, except in the case of the delivery of treatments and procedures (OR 1.08, 95% CI 1.02 to 1.14). Conclusions Missed care is an independent predictor of heart failure readmissions. However, once adjusting for the quality of the nurse work environment, this relationship is attenuated. Improvements in nurses’ working conditions may be one strategy to reduce care omissions and improve patient outcomes.

Nurse staffing matters: now what?

“…The results reported by Brooks Carthon et al 1 are intriguing and in that they point to new directions for a voluminous but to a great extent stagnant literature. However, assuming that patients with heart failure are necessarily the first group that we should target for changes in care coordination may lead to considerable difficulty, replicating these findings with higher quality prospective studies.…”

“…In addition to the general methodological concerns noted earlier, an additional note of caution is warranted about inferences from the work reported by Brooks Carthon et al 1 Focusing on readmissions for patients with heart failure has the merit of obvious policy relevance, as hospitals face penalties if they cannot reduce readmissions among these patients. However, a substantial proportion of hospitalised patients with heart failure are in fact at the end of their lives, with relatively little possibility of staying out of the hospital, particularly when alternative services for high-quality end of life care are not readily available to them 23.…”

“…Brooks Carthon and colleagues1 assess the relationship between the quality of hospital work environments for registered nurses and ‘missed care’ reported by nurses. Similar to other authors, they define missed care as care that nurses regarded as necessary but left undone due to a lack of time 2–4.…”

“…Similar to other authors, they define missed care as care that nurses regarded as necessary but left undone due to a lack of time 2–4. Brooks Carthon and colleagues1 also explore the relationship between both of these variables and hospital readmissions for heart failure. Their analysis represents an important step in moving beyond the literature describing relationships between nurse staffing and patient outcomes 5–7…”

“…For patients with heart failure in the large sample of hospitals included in their secondary analysis, Brooks Carthon et al 1 find that nurses’ self-report of missing important elements of care correlates with readmissions in this group of ill, vulnerable patients. For 4 of the 10 nursing activities they studied, each 10-percentage-point increase in the number of nurses reporting having missed the activity was associated with an increase in the odds of readmission by 2%–8% after adjusting for patient and hospital characteristics.…”