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Effect of Changes in Hospital Nursing Resources on Improvements in Patient Safety and Quality of Care

A Panel Study

Sloane, Douglas M., PhD*; Smith, Herbert L., PhD†,‡; McHugh, Matthew D., PhD, JD, MPH, RN; Aiken, Linda H., PhD, RN

doi: 10.1097/MLR.0000000000001002
Original Articles

Background: Evidence shows hospitals with better nursing resources have better outcomes but few studies have shown that outcomes change over time within hospitals as nursing resources change.

Objectives: To determine whether changes in nursing resources over time within hospitals are related to changes in quality of care and patient safety.

Research Design: Multilevel logistic response models, using data from a panel of 737 hospitals in which cross-sections of nurse informants surveyed in 2006 and 2016, were used to simultaneously estimate longitudinal and cross-sectional associations between nursing resources, quality of care, and patient safety.

Measures: Nursing resources included hospital-level measures of work environments, nurse staffing, and nurse education. Care quality was measured by overall rating of care quality, confidence in patients managing care after discharge, confidence in management resolving patient care problems; patient safety was measured by patient safety grade, concern with mistakes, and freedom to question authority.

Results: After taking into account cross-sectional differences between hospitals, differences among nurses within hospitals, and potential confounding variables, changes within hospitals in nursing resources were associated with significant changes in quality of care and patient safety. Improvements in work environment of 1 SD decrease odds of unfavorable quality care and patient safety by factors ranging from 0.82 to 0.97.

Conclusions: Improvements within hospitals in work environments, nurse staffing, and educational composition of nurses coincide with improvements in quality of care and patient safety. Cross-sectional results closely approximate longitudinal panel results.

*Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing

Department of Sociology, Population Studies Center

Center for Health Outcomes and Policy Research, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA

Supported by the National Institute of Nursing Research (NINR) (R01NR014855, Aiken). Conclusions are the authors’ own and do not necessarily reflect the opinion of NINR.

The authors declare no conflict of interest.

Reprints: Matthew D. McHugh, PhD, JD, MPH, RN, Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, 418 Curie Boulevard, Philadelphia, PA 19104-4217. E-mail:

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