Short answer: yes, improving nurses’ work environment can even save lives. Surgical patients in hospitals with better nurse work environments were less likely to be admitted to an intensive care unit (ICU) and less likely to die, according to an analysis of nearly 270,000 patient records.
“Intensive Care Unit Utilization Following Major Surgery and the Nurse Work Environment” is the first study to directly link the nurse work environment to ICU use. Its findings suggest that efforts to improve the work environment for nurses may reduce ICU utilization and avoid risks associated with ICU admissions. The article is published in AACN Advanced Critical Care.
The researchers examined a large sample of Medicare beneficiaries undergoing general, orthopedic or vascular surgical procedures between January 2006 and October 2007. The cross-sectional study included 269,764 adult surgical patients in 453 hospitals.
They found that surgical patients in hospitals with good nurse work environments had 16% lower odds of ICU admission, 12% lower odds of in-hospital mortality, and 11% lower odds of dying within 30 days of hospital admission than patients in hospitals with mixed or poor nurse work environments. When they examined the joint outcome of either ICU admission or death within 30 days of hospital admission, they found 15% lower odds for either event for patients in hospitals with good nurse work environments.
Patients in the best nurse work environments had the lowest occurrence of ICU admission or 30-day mortality.
Co-author Anna Krupp, PhD, MSHP, RN, is an assistant professor, the University of Iowa College of Nursing. The research was conducted during her post-doctoral fellowship in health services and outcomes research at the University of Pennsylvania School of Nursing in the Center for Health Outcomes and Policy Research (CHOPR), where she was a National Clinician Scholar. Other co-authors are Karen Lasater, PhD, RN, FAAN, and Matthew McHugh, PhD, MPH, JD, RN, CRNP, from CHOPR and Penn’s Leonard Davis Institute of Health Economics.
“A key difference between ICUs and lower acuity units is the staffing ratio of patients to nurses.”
“Hospitals with better nurse work environments may be better equipped to provide complex patient care in a lower acuity setting without compromising a patient’s odds of mortality,” Krupp said. “A key difference between ICUs and lower acuity units is the staffing ratio of patients to nurses. In the context of the COVID-19 pandemic, our findings suggest that a limiting factor in a hospital’s capacity to respond to the COVID-19 surges of critically ill patients is likely related to the quality of the nurse work environments prior to the pandemic. Fewer additional ICU beds may have been needed if hospitals had good nurse work environments prior to the pandemic, with enough nurses to safely care for patients in lower acuity settings.”
The research team used data from three sources: the Medicare Provider Analysis and Review, hospital characteristics from an American Hospital Association annual survey, and the RN4CAST survey of approximately 34,000 registered nurses at hospitals in California, Florida, New Jersey, and Pennsylvania. Hospitals were assigned unique individual identifiers to link them across the sources.
The nurse work environment was measured using the 31-item Practice Environment Scale of the Nursing Work Index, which is endorsed by the National Quality Forum. Hospitals were then categorized as good (top 25%), poor (bottom 25%) or mixed, which were the 50% between the high and low scales.
Patients in the best nurse work environments had the lowest occurrence of ICU admission or 30-day mortality. Patients in hospitals with poor nurse work environments had the highest occurrence.
Surgical patients in hospitals with good versus poor nurse work environments had 29% lower odds of being admitted to an ICU, 23% lower odds of in-hospital mortality, 21% lower odds of 30-day mortality, and 28% lower odds of being admitted to an ICU or experience 30-day mortality.
Admission to an ICU varied significantly by surgical group, with vascular surgical patients having the highest use of ICUs (47.4%), followed by general (18.2%) and orthopedic (5.9%).
Hospital characteristics, such as number of beds, teaching status, and technology capabilities, varied significantly. The analysis revealed that those with the best nurse work environments were nonteaching hospitals with more than 250 beds.