Throughput and nurses' workloads: Influences on nurse and patient outcomes

Patient turnover, or throughput, through nursing units can significantly impact the workloads of nurses. However, very few staffing measures account for patient throughput, thus underestimating nurses' workloads. Research has shown that when nurse staffing is more favorable, patient and nurse outcomes are more favorable. What is not known, and what this study examined, was how adjusting nurse staffing measures for patient throughput influenced the relationship between staffing and patient and nurse outcomes while also accounting for the nurse work environment, which also has significant relationships with patient and nurse outcomes. This study was a secondary analysis of hospital administrative data, patient discharge data, and nurse survey data in four states. Nurse survey data from more than 25,000 nurses were merged with administrative data from nearly 600 hospitals to study nurse outcomes, which included burnout, job dissatisfaction, and intent to leave. These data were then merged with patient discharge data from over 1.6 million surgical patients to study patient outcomes, which included 30-day mortality and failure to rescue. The novel nurse survey data provided information on hospital system-related factors, such as staffing, throughput, and the nurse work environment. Three measures of throughput-adjusted staffing were described, developed, and compared to unadjusted staffing measures as well as acuity-adjusted staffing and patient length of stayadjusted staffing. Contrary to the hypotheses, the adjusted staffing measures did not have stronger relationships with patient or nurse outcomes compared to unadjusted staffing measures. The nurse work environment was a significant predictor of both patient and nurse outcomes. Patients treated in hospitals with the most favorable nurse work environments had about 14% lower odds of death and 16% lower odds of failure to rescue compared to patients treated in hospitals with the least favorable work environments. Compared to nurses working in hospitals with the least favorable work environments, nurses in hospitals with mixed work environments were about 30% less likely to be burned out, 40% less likely to report job dissatisfaction, and 38% less likely to intend to leave their jobs. These differences were even more pronounced for nurses working in hospitals with the best work environments. Compared to nurses working in hospitals with the least favorable work environments, nurses in hospitals with the best work environments were about 46% less likely to be burned out, 60% less likely to report job dissatisfaction, and 55% less likely to intend to leave their jobs. The work environment also moderated the influence of staffing on both patient and nurse outcomes. This study was the largest study of throughput and nurse workloads to date and the first to explore throughput in relation to nurse outcomes. Although throughput-adjusted staffing did not provide significantly more information than unadjusted staffing in relation to patient and nurse outcomes, further research is needed to explore how throughput influences nurse workloads across different nursing units or work environments. Improvements in nurse work environments are promising approaches to improve both patient and nurse outcomes in hospitals. Degree Type Dissertation Degree Name Doctor of Philosophy (PhD) This dissertation is available at ScholarlyCommons: http://repository.upenn. edu/edissertations/914 Graduate Group Nursing First Advisor Ann Kutney-Lee