In this difficult economy, hospitals are facing challenges of reduced reimbursement and new healthcare regulations. Attention will be focused on reducing patient readmissions because of the impact of the Affordable Care Act. Under the Affordable Care Act, the Centers for Medicare and Medicaid will reduce payments to hospitals with higher than expected readmission rates.
A study by McHugh, in Medical Care (2013), reviewed the relationship between hospital nursing and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia. The method analyzed data from a cross-sectional survey, conducted from 2005 to 2006, of nurses in California, Pennsylvania, and New Jersey. The sample included 20,585 nurse participants from 210 hospitals in California, 134 in Pennsylvania and 68 in New Jersey.
The nurse work environment was measured by using the Practice Environment Scale of the Revised Nursing Work Index. In it the nurses state the degree to which the practice setting incorporates various organizational features. The index consists of five sub-scales:
- Staffing and resource adequacy
- Nurse participation in hospital affairs
- Nurse manager ability
- Leadership and support
- Nurse-physician relation
The identified 30-day readmissions were based on validated Risk-Standardized Readmission Measures from the Centers for Medicare and Medicaid Services. Investigators looked at readmission rates for heart failure, acute myocardial infarction, and pneumonia patients. They adjusted the analysis for a variety of hospital related co-variates including size, teaching status, non-profit or for-profit status, and volume of patients.
Although this study was based on readmission rates for cardiac and pneumonia patients, this could also be true for the cancer patient population as well. How many times have we evaluated the safety of our own cancer patients as the workload increases?
Results: Each additional patient in a nurse's workload was associated with a 7 percent increase in the odds of readmission for patients with heart failure, a 9 percent increase for patients with acute myocardial infarction, and a 6 percent increase for pneumonia patients.
Implications: Clearly, good work environments and adequate staffing ratios allow nurses to provide better care for their patients during their hospitalization and continually prepare them for a safe discharge. The Nursing Organizations Alliance (2004), a coalition of major nursing organizations throughout the United States, issued a joint position statement that identified the following key elements that support the development of healthful practice and work environments.
Although much work has been done to identify what needs to happen in practice environments, achievement of these key elements has proved challenging in today's turbulent healthcare environment.
Registered nurses can be the necessary change agents. Strategies may include:
- Discuss the results of this study at a staff meeting with the unit manager and explore with staff ideas to improve the work environment.
- Work with physician colleagues for support with hospital administration to enhance unit staffing.
- Learn more about ANA Magnet standards and its positive effects on the work environment (i.e. success of shared governance and quality councils)
- Participate in your nursing professional organization to educate the consumer about staffing levels and the impact on patient outcomes. Lobby for safe staffing level legislation.
Registered nurses are in a perfect position to utilize the results of this study and similar ones to help improve our work environment. The above strategies can reduce cost associated with unnecessary readmissions and ultimately improve the quality of care. Let's respond to this call for action.
How would you rate your own work environment? Do you feel that your cancer patients are at risk for readmission due to a less than adequate work environment?
- McHugh, M. (2013) Hospital Nursing and 30- Day Readmission Among Medicare
Patients With Heart Failure, Acute Myocardial Infarction, and Pneumonia.
Medical Care. Volume 51. Issue1. p 52-59. doi: 10.1097/. MLR.obo13e3e3182763284
- Nurses Organization Alliance. (2004). Principles and elements of a healthy practice /
Work Environment. www .aone.org /pdf/PrinciplesandElementsHealthfulWork