By Debra Wood, RN, contributor
January 11, 2013 - Good nursing work environments and better nurse staffing can lower the odds of patient readmissions, according to new research from the University of Pennsylvania School of Nursing.
Matthew D. McHugh, PhD, JD, MPH, RN, found a link between nurse–patient staffing ratios and nurse work environment and hospital readmissions.
“Staffing and work environment were consistent across three conditions--heart failure, myocardial infarction and pneumonia,” said Matthew D. McHugh, PhD, JD, MPH, RN, assistant professor of nursing at the Center for Health Outcomes and Policy Research at the University of Pennsylvania in Philadelphia and a Robert Wood Johnson Foundation nurse faculty scholar. For staffing, “each additional patient per nurse was associated with a 6 percent to 9 percent increase in the odds of readmission, depending on the condition.”
Penn researchers examined data from more than 200,000 nurses and 412 hospitals in California, Pennsylvania and New Jersey and found the likelihood of readmission within 30 days among Medicare patients age 65 or older with heart failure, acute myocardial infarction and pneumonia was 7 percent, 6 percent and 10 percent lower, respectively, when the patients were treated in hospitals with good nursing work environments.
McHugh said he was not surprised at the findings, since prior research has shown good outcomes with better nursing work environments and manageable workloads for nurses.
“It makes perfect sense, because many of the interventions, things like discharge planning, patient education, monitoring for complications and a disease-specific focus … are the bread and butter of what nurses do on a day-to-day basis,” McHugh said. “When nurses are overwhelmed with a workload that’s unmanageable, when there is not enough staff or they don’t work in an environment that supports their ability to do their work well, don’t have good relation with physicians or don’t have support from managers, they are not able to do those core functions well. Those things then would translate into higher readmission rates.”
Lee Norman, MD, said discharge planning takes time and requires a team approach.
Lee Norman, MD, senior vice president and chief medical officer for The University of Kansas Hospital in Kansas City, said it made sense that lower nurse–patient ratios and better environments could lead to fewer readmissions, because the better prepared patients are, the better they will do.
“The best way for people to be prepared to leave the hospital is to spend an adequate amount of time over time [on education] and do more than hand them an instruction sheet as they walk out the door,” Norman said. “So many things go into the preparation of patients to return to their homes.”
Those at higher risk for readmissions, typically, have comorbidites, making the discharge planning more complicated, and preparing them takes time, he said.
Kel Pults, RN, MSN, a consultant with RGP Healthcare in Minneapolis, said that’s where nursing environments come in--nurses who are overworked due to understaffing often do not have the time to properly prepare patients to care for themselves.
Kel Pults, RN, MSN, said overworked nurses do not have time to adequately prepare patients for discharge.
“If they are overworked and understaffed, they do not have the time to spend with patients and do sufficient education around the disease process, and studies show that’s part of the reason patients come back to the hospital,” Pults said. “That’s a main function of nurses: education of patients. Physicians are getting more involved.”
Pults said reducing readmissions requires a hospital-wide, enterprise effort that starts at admission and goes well past discharge.
Norman recommended an integrative approach, with physicians, nurses and other members of the team working together, all part of a supportive culture like the one the University of Kansas Hospital has fostered for the past 12 years.
“Discharge planning starts at the moment of admission,” Norman said. “It requires really listening to the patient.”
The Penn-surveyed nurses knew whether their patients were well equipped to manage on their own after discharge. Fifty-six percent of nurses employed in hospitals staffed with less than four patients per nurse on average and 59 percent of nurses working in hospitals with good work environments reported being confident their patients knew how to care for themselves, compared with 48 percent of nurses working in hospitals with a patient-to-nurse ratio of 6:1 or greater, and 45 percent of nurses toiling in facilities with poor work environments.
“Nurses are pretty good barometers of those sort of things and tend to reflect fairly accurately quality of care,” McHugh said.
Additionally, in a good work environment, nurses are more likely to speak up when they expect a patient is not ready for discharge, and physicians will thank them for their insight, Norman said. It’s part of a culture of safety and mutual respect.
“If they are not ready to go, they shouldn’t go home,” Norman said. “It starts with a management philosophy of ‘Put the patient first.’”
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