An Analysis of Variance in Nursing-Sensitive Patient Safety Indicators Related to Magnet Status, Nurse Staffing, and Other Hospital Characteristics

Abstract

The purpose of this research was to identify if there was a significant difference in the risk-adjusted rates for a subset of five of the Agency for Healthcare Research and Quality’s (AHRQ) Patient Safety Indicators (PSIs) in relation to ANCC’s Magnet® designation in U.S. hospitals. This exploratory, cross-sectional study involved the analysis of organizational characteristics, including magnet status, nurse staffing, bed size (categorical and number of operated beds), and other organizational characteristics in relation to 5 of 20 of AHRQ’s PSIs. The five PSIs were selected based on previous research findings that showed associations between nurse staffing and complications of care. Data from AHRQ’s Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) for Calendar Year (CY) 2006 were combined with CY 2006 American Hospital Association (AHA) data, and hospitals with ANCC Magnet® designation were identified. The study used descriptive statistics, comparison of means, and a multivariate analysis of covariance (MANCOVA) to answer five research questions in relation to the differences is ANCC Magnet® hospitals versus non-magnet hospitals. The research questions addressed the following: (a) describing the differences in organizational characteristics, (b) identifying the risk-adjusted PSI rates, (c) determining nurse staffing differences, (d) identifying the relationships between organizational characteristics and the five selected PSIs, and (e) determining if there was a difference in the risk-adjusted PSI rates while controlling for nurse staffing and bed size. Findings included the following: (a) preventable adverse event rates were not lower in magnet hospitals; (b) nurse staffing was better in magnet hospitals; and (c) magnet status was not associated with preventable PSIs, while controlling for RN staffing and bed size. Significant findings included the following: (a) nurse staff hours per adjusted patient day (APD), (t = 2.513, df = 1001, p = .012) and RN hours per APD (t = 4.132, df = 1001, p < .000) were significantly higher in magnet than non-magnet hospitals; (b) magnet hospitals had a significantly higher rate of postoperative deep vein thrombosis (DVT) / pulmonary embolus (PE), (t = 2.44, df = 914, p = .015); and (c) magnet hospitals had a significantly lower rate of death among surgical inpatients (t = -2.05, df = 64.15, p = .044). The MANCOVA analysis indicated that magnet and non- magnet hospital groups did not significantly differ on the combined variable created from the five PSIs considered to be sensitive to nurse staffing (p = .383, tested at p < .05), while controlling for RN staffing and number of operated beds. The multivariate analysis revealed a significant relationship between the combined variable created from the selected PSIs in relation to the covariates of RN hours per APD (p = .001, tested at p < .05) and number of operated beds (p < .000, tested at p < .05). The univariate analysis indicated that the covariates had a significant relationship with four of the selected PSIs and included: (a) number of operated beds with the PSIs of decubitus ulcer, postoperative respiratory failure, and postoperative DVT/PE; and (b) RN hours per APD with the PSI of death among surgical inpatients. The study findings were limited by the size of the magnet group (n = 43) and by using administrative and AHA data, which are not validated by medical record review. Generalizability of the findings may be limited, and studies with a larger magnet sample need to be conducted. Further research is needed to reveal organizational characteristics and care delivery processes that contribute to safety and quality outcomes. Preventable adverse events can cause unnecessary harm to patients, waste resources, and increase operational cost and charges to payers, and are an increasing concern to nurse and hospital administrators related to reimbursement changes for the Centers for Medicare and Medicaid Services (CMS) “never events”. Chief nurse executives (CNEs) need evidence-based strategies that optimize quality outcomes in relation to resources expended for staffing plans, skill mix, capital expenditures, and other resource allocation decisions. In the future, designation as an ANCC Magnet® facility needs to ensure that evidence related to better patient outcomes exists, similar to the many years of evidence relating magnet designation to better work environments and nurses’ satisfaction.