Evidence Based Standards For Measuring Nurse Staffing and Performance

Evidence-based Standards for Measuring Nurse
Staffing and Performance

Project # RC1 0621 06
Report for the
Canadian Health Services Research Foundation
December, 2003
Revised and Resubmitted, September, 2004
Prepared by
Linda OBrien-Pallas, RN, PhD
Donna Thomson, RN, MBA
Linda McGillis Hall, RN, PhD
George Pink, PhD
Mickey Kerr, PhD
Sping Wang, PhD
Xiaoqiang Li, PhD
Raquel Meyer, RN, PhD Student
Acknowledgements
The investigators wish to thank the Canadian Health Services Research Foundation, the Ontario
Hospital Association Change Foundation, the nursing effectiveness, utilization, and outcomes
research unit of the faculty of nursing at the University of Toronto, and the contributing hospitals
for the financial support that made this research project possible.
The advisory committee members are acknowledged for their guidance in the development of the
data collection tools and for their assistance in interpreting the results and their input on the
feasibility of collecting significant data elements on an ongoing basis.
Dr. Judith Shamian Health Canada
Kathleen MacMillan Health Canada
Jill Strachan Canadian Institute for Health Information
Barbara McGill and Nancy Savage Atlantic Health Sciences Corporation
Jane Moser University Health Network
David McNeil Sudbury Regional Hospital
Margaret Keatings Hamilton Health Sciences
Heather Sherrard Ottawa Heart Institute
Carol Wong London Health Sciences Centre
Lucille Auffrey Canadian Nurses Association
Sue Williams Ontario Joint Provincial Nursing Committee
Beverly Tedford New Brunswick Department of Health and Wellness
Sue Matthews Ontario Ministry of Health and Long-Term Care
Hospital and site co-ordinators and data collectors are recognized for their efforts to collect
comprehensive and accurate data about their organization, patients, and nurses in order to
support this project. Staff and patients at participating hospitals are thanked for their willingness
to participate in this study by completing surveys. Health records departments are thanked for
providing patient-specific diagnoses and outcomes.
Hospitals and Site Co-ordinators:
Sudbury Regional Hospital: Claire Gignac
London Health Sciences Centre: Nancy Hilborn
University Health Network: Elke Ruthig
Hamilton Health Sciences: Bernice King
Atlantic Health Sciences Corporation: Trevor Fotheringham
Ottawa Heart Institute: Judith Sellick
A special thank you is given to project co-ordinators Shirliana Bruce and Min Zhang and
research assistant Irene Cheung.
Evidence-based Staffing
Key Implications for Decision Makers

Variations in nursing productivity/utilization and staffing patterns are frequently observed
between, as well as within, hospitals. Decision makers are challenged to maximize
productivity/utilization and minimize staffing costs, while ensuring the quality of care.
Recommendations from this study inform decision-making on these important issues within
hospital cardiac and cardiovascular units.
Nursing unit productivity/utilization levels should target 85 percent, plus or minus five
percent. Levels higher than this lead to higher costs, poorer patient care, and poorer nurse
outcomes.
Maximum productivity/utilization is 93 percent (because seven percent of the shift is

made up of paid, mandatory breaks). Units where nurses frequently work at or beyond
maximum productivity/utilization must urgently reduce productivity/utilization and
implement acceptable standards.
Productivity/Utilization targets can be met by enhancing nurse autonomy, reducing

emotional exhaustion, and having enough staff to cope with rapidly changing patient
conditions.
Overall costs are reduced when experienced nurses are retained. Retention is more likely
when there is job security, when nurses can work to their full scope of practice, and when
productivity/utilization levels are below 83 percent.
Retention strategies must address the physical and mental health of nurses, balancing the
efforts and rewards associated with work, nurse autonomy, full scope of practice,
managerial relationships, innovative work schedules, hiring more nurses into full-time
permanent positions, and reasonable nurse-to-patient ratios based on targeted
productivity/utilization standards. These will minimize the effect of persistently high job
demands and reduce absenteeism and the use of overtime.
Investment is needed for infrastructure to collect data that will monitor and improve care
delivery processes and measurement of performance outcomes. Data that should be
routinely captured, but are not yet, include valid workload measurement; environmental
complexity; patient nursing diagnoses and OMAHA ratings of knowledge, behaviour,
and status; nurse and patient SF-12 health status; nurse to patient ratios; and
productivity/utilization.
ii
Executive Summary
Policy makers and hospital administrators are seeking evidence to support nursing staffing
decisions that includes both the volume and mix of nurses required to provide efficient and effective
care. The principal objective of this study was to examine the interrelationships between variables
thought to influence patient, nurse, and system outcomes. The results provide quality, evidence-based
standards for adjusted ranges of nursing productivity/utilization and for staffing levels for patients
receiving cardiac and cardiovascular nursing care.
Although hospitals have little control over patient severity and complexity, organizations can
manage nurse characteristics, system characteristics and behaviours, and environmental factors that
influence patient, nurse, and system outcomes. Numerous findings provide important evidence to
guide policy and management decisions related to the deployment and use of nursing personnel.
These findings suggest that organizations can implement many strategies to improve the cost and
quality of care.
In the past, actions to minimize expenses have focused on reducing the cost of inputs, the
number of nurses, and the skill level. The findings of this study suggest that to actually reduce the
cost and improve the quality of patient care, organizations will benefit from 1) hiring experienced,
full-time, baccalaureate-prepared nurses; 2) staffing enough nurses to meet workload demands; and
3) creating work environments that foster nurses mental and physical health, safety, security, and
satisfaction. The evidence supports the need for a significant change in the way organizations view
costs and suggests that the emphasis on cost of inputs should shift to the cost of outputs and the
quality of care.
The study found nursing productivity/utilization should be kept at 85 percent, plus or minus
five percent. When rates rise above 80%, costs increase and quality of care decreases. Patient health
is more likely to be improved at discharge if productivity/utilization levels are below 80 percent and
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if patients are cared for by nurses who work less overtime. When productivity/utilization levels are
kept below 80 percent, nurses are more likely to be satisfied with their jobs and absenteeism is
reduced, and nurses are less likely to want to leave their jobs when productivity/utilization is less
than 83 percent.
Costs are lower when hospitals maintain productivity/utilization levels below 90% and
implement strategies to improve nurse health and incentives to retain experienced nurses. Autonomy
can be enhanced by balancing the number of patients assigned to each nurse and each nursing unit,
and emotional exhaustion is less likely when nurses are satisfied, mentally and physically healthy,
and feel that they receive appropriate rewards for their efforts. Nurses are more likely to be
physically healthy when there are good relationships with the physicians on the unit, and these
relationships tend to improve when nurses autonomy and decision-making abilities are respected.
Aggression- and violence-free workplaces are key to enabling nurses to do their nursing
interventions on time. There also needs to be enough nursing staff to deal with the rapidly changing
conditions in hospitalized patients, so that nurses have enough time to complete patient care.
Patient care is improved when units are staffed with degree-prepared nurses and when nurses
can work to their full scope of practice. This not only improves job satisfaction, but nurses are also
less likely to leave their jobs.
Patients health behaviour improves when nurses have a satisfying work environment, secure
employment, and when unit productivity/utilization does not exceed 88 percent. Enhanced nurse
autonomy, full-time employment, and fewer shift changes are shown to improve patients knowledge
about their conditions when they are discharged.
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Table of Contents
Acknowledgements.......................................................................................................................... i
Key Implications for Decision Makers ........................................................................................... ii
Executive Summary ....................................................................................................................... iii
I. Context......................................................................................................................................... 7
II. Implications................................................................................................................................ 8
System Implications.................................................................................................................... 9
Patient Implications .................................................................................................................. 13
Nursing Implications................................................................................................................. 13
III. Approach................................................................................................................................. 15
IV. Results..................................................................................................................................... 18
Descriptives............................................................................................................................... 18
Research Question 1. ................................................................................................................ 21
Intermediate System Outputs..........................................................................................21
Patient Outcomes............................................................................................................22
Nurse Outcomes..............................................................................................................24
System Outcomes............................................................................................................27
V. Additional Resources ............................................................................................................... 32
VI. Further Research..................................................................................................................... 32
VII. References ............................................................................................................................. 32
Appendices
A.
Annotated Bibliography...............................................................................................35
B.
Patient Care Delivery Model.......................................................................................84
C.
Tables.............................................................................................................................85
D.
Instruments, Psychometric Properties, and Variables at Individual and Unit

Levels............................................................................................................................117
E.
Data Collection Forms................................................................................................124
F.
Methods........................................................................................................................162
G.
Descriptive Analyses...................................................................................................168
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I. Context
Nurse staffing is closely linked to patient outcomes and system effectiveness. A greater
understanding of the causes and outcomes of hospital nurse staffing is essential to meet
increasing demands for both cost and quality accountability in healthcare. Recent Canadian
reports highlight the urgent need to identify methods for valid measurement of nursing workload
and productivity/utilization, and to understand their relationship with patient, nurse, and system
outcomes,1,2,3,4 a need further underscored by the current and predicted nursing workforce
shortages.2,5
Policy makers and hospital administrators are seeking evidence to support nursing staffing
decisions that includes both the volume and mix of nurses required to provide efficient and
effective care. Prior studies have provided insight into some of the factors contributing to the
need for nurses and the effect of different staffing approaches on patients, providers, and systems
(Appendix A). Recent evidence suggests that adding one patient to each nurses caseload in
acute-care hospitals is associated with increases in 30-day mortality (seven percent), failure-torescue (seven percent), nurse burnout (23 percent), and job dissatisfaction (15 percent).6 Another
study demonstrated that an increase of one hour of overtime per week increases the odds of a
work-related injury by 70 percent.7 Part-time and casual employment can also negatively impact
continuity of care and the nurses ability to influence clinical and work related decisions.8 A
review of relevant studies is presented in Appendix A.
The principal objective of this study was to examine the interrelationships between variables
thought to influence patient, nurse, and system outcomes, in order to provide quality evidencebased standards for adjusted ranges of nursing productivity/utilization and for staffing levels for
patients receiving cardiac and cardiovascular nursing care. This evidence will help policy makers
develop mechanisms and policies to measure the need for nursing service in light of appropriate
staffing and productivity/utilization standards. By examining specific cardiac and cardiology
diagnoses, as well as nurse and nursing work indicators within hospital cardiac and
cardiovascular unit settings, this research study examined four questions:
1. To what extent do patient, nurse, and system characteristics and behaviours, and
environmental complexity measures, explain variation in nursing worked hours and
patient, nurse, and system outcomes, such as length of stay?
2. To what extent is there agreement between the estimates generated by a gold standard for
measuring nursing resource needs (PRN workload methodology) and the worked hours of
care per patient, and how does variance affect patient and nurse outcomes?
3. At what nurse-patient ratio and with what proportion of registered nurse worked hours
are productivity/utilization and patient and nurse outcomes improved, after controlling
for the influence of patient, nurse, organizational, and environmental factors?
4. Which data elements, in addition to those routinely collected within administrative
databases, are critical for routine data collection in Canada? To what extent do policy and
administrative decision makers support the feasibility of routine data collection?
II. Implications
Numerous findings provide important evidence to guide policy and management decisions
related to the deployment and use of nursing personnel. Although hospitals have little control
over patient severity and complexity, organizations can manage nurse characteristics, system
characteristics and behaviours, and environmental factors that influence patient, nurse, and
system outcomes. The implications of this study are directed at those latter factors, which are
amenable to policy and management intervention.
System Implications
1. Results of this study suggest a target of 85 percent (plus or minus five percent) unit
productivity/utilization on a daily basis. Sustained productivity/utilization outside this range
will result in higher costs and poorer quality of care. Rationale: Different levels of unit
productivity/utilization are associated with different outcomes as summarized in Table 1.
Although the goal is to maximize nurse activity, at productivity/utilization levels above 80
percent, negative outcomes emerge because there arent enough nurses to meet demands. The
maximum work capacity of any employee is 93 percent, because seven percent is allocated to
paid breaks during which time no work is contractually expected. At 93 percent, nurses are
working flat out with no flexibility to meet unanticipated demands or rapidly changing
patient acuity. This study demonstrates that significant benefits, both fiscal and human, can
be achieved by moderating productivity/utilization levels within a range of 85 percent, plus
or minus five percent. It must be noted however, the suggested range may not be applicable
to specialty units with variable patient flow demands, such as emergency and labour and
delivery departments.
Depending on performance goals, organizations may wish to target specific unit
productivity/utilization values in Table 1. These values are cumulative in nature, such that, if
a unit works at a 92 percent productivity/utilization level, not only will lengths of stay be
longer, but all of the other negative outcomes that occur with productivity/utilization values
below 92 percent will apply.
Table 1. Productivity/Utilization Levels and Associated Outcomes

Productivity/Utilization
Levels (%)
> 91
> 90
> 88
> 85
> 83
> 80
Outcomes
Longer length of stay
Higher costs per resource intensity weight
Less improvement in patient behaviour scores at discharge
Higher nurse autonomy
Deteriorated nurse relationships with physicians
Higher intention to leave among nurses
More nurse absenteeism
Less improvement in patient physical health at discharge
Less nurse job satisfaction
Although the Canadian Institute for Health Information defines productivity/utilization as

workload over worked hours,9 this neither accounts for the quality and outcomes of care
delivered, nor the impact of length of stay on total cost. This definition is not a measure of
productivity/utilization as an output, but rather a measure of use as a process. Workload
over worked hours actually measures use of nursing resources and thus evaluates an
organizations ability to operate to meet patient care standards and needs.
2. Unit productivity/utilization levels below 90 percent, strategies to address nurse health, and
incentives to retain experienced nurses who are expert in their field should lower resource
intensity weight costs (the cost of providing services to groups of people with different
characteristics). Rationale: Lower costs per resource intensity weight are associated with
higher physical health scores for nurses, expert clinical practice, reduced length of stay, and
unit productivity/utilization levels below 90 percent.
3. Attendance at pre-operative clinics as a routine process for surgical patients, adequate
staffing to prevent medical problems, and unit productivity/utilization levels below 91
percent are recommended. Rationale: Shorter-than-expected length of stay is 185 percent
10
more likely when patients attend pre-operative clinics and 57 percent less likely when
patients suffer medical problems as a consequence of their treatment.
4. Maintaining unit productivity/utilization levels below 90 percent and recognizing the effect
of complex and numerous nursing diagnoses will optimize the actual worked hours per
patient. Rationale: Increases in actual worked hours per patient are associated with increases
in nursing worked hours and with higher numbers of nursing diagnoses. Actual patient care
hours decline as unit productivity/utilization exceeds 90 percent and with increases in the
proportion of both full-time nurses and average clinical expertise on the unit.
5. Efforts should be made to prevent adverse events to reduce overall costs. Rationale: Patients
who suffer medical consequences are 319 percent more likely to be referred to homecare, and
for each additional hour of care given, the patient is 13 percent more likely to suffer a
medical consequence.
6. Staffing should be sufficient to account for the rapidly changing conditions in hospitalized
patients so that all key nursing interventions can be done. Rationale: Patient interventions are
more likely to be left undone when there are more unanticipated changes in patient acuity or
when nurses experience violence. The likelihood of patient interventions not being completed
increases by 260 percent for nurses at risk of feeling their efforts are not properly rewarded.
7. Providing innovative programs to create aggression-free work environments will enable
nurses to complete key nursing interventions on time. Rationale: Delays in interventions are
more likely when nurses on the unit experience violence, but they are 27 percent less likely
for every 10 percent increase in degree-prepared nurses on the unit.
8. Efforts to improve the job satisfaction of nurses will lead to better ratings of quality of
nursing care. Rationale: Nurse ratings of good/excellent quality of nursing care are 606
11
percent more likely when nurses rate the quality of patient care over the past year as
improved and 159 percent more likely when nurses are satisfied.
9. Staffing units with degree-prepared nurses and ensuring that nurses can provide the quality
nursing care that they deem appropriate will improve nurse perceptions of patient care
quality over the last year. Rationale: Ratings of improved quality of patient care over the past
year are 915 percent more likely when nurses report good/excellent quality of nursing care
and are 40 percent more likely for every 10 percent increase in degree-prepared nurses on the
unit.
10. Unit productivity/utilization levels should be kept below 80 percent, and work environments
should be assessed to determine why there is higher absenteeism among full-time nurses.
Rationale: Absenteeism is reduced when unit productivity/utilization remains below 80
percent. Full-time nurses are 152 percent more likely to be absent than those who work parttime or casually. Nurses who are physically healthy are five percent less likely to be absent.
11. Job security and allowing nurses with degrees to work to their full scope of practice will
prevent nurses from leaving. Rationale: Intent to leave is 197 percent more likely among
nurses who are concerned about job security and 101 percent more likely among degreeprepared nurses. As unit productivity/utilization exceeds 83 percent, intent to leave increases.
However, intent to leave is 97 percent less likely for every 10 percent increase in proportion
of nurse ratings of improved quality of nursing care on unit, 58 percent less likely when
nurses are satisfied, and 51 percent less likely when nurses work full-time.
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Patient Implications
12. Reducing overtime hours and unit productivity/utilization levels below 80 percent will
improve patients physical status at discharge. Rationale: Improvements in patient SF-12
physical scores at discharge are 45 percent less likely when productivity/utilization exceeds
80 percent and seven percent less likely for each additional hour of nurse overtime.
13. Creating satisfying work environments, offering secure employment, and ensuring unit
productivity/utilization does not exceed 88 percent enhances changes in patient behaviours
related to nursing diagnoses. Rationale: Patient behaviour scores are more likely to decrease
when unit productivity/utilization exceeds 88 percent. Improvements in patient behaviour
scores at discharge are 176 percent more likely when nurses are satisfied but 53 percent less
likely when nurses were forced to change units within the past year or anticipate forced
changes in units in the next year.
14. Employing more nurses in full-time positions, facilitating autonomy, and reducing the
frequency of shift changes improves patients knowledge about their conditions at discharge.
Rationale: Improved patient knowledge scores at discharge are 74 percent more likely for
every 10 percent increase in nurses worked hours on the unit and 24 percent more likely for
every 10 percent increase in full-time nurses on the unit. Patient knowledge scores are 44
percent less likely to improve for every 10 percent increase in nurses on the unit with more
than one shift change during the past two weeks.
Nursing Implications
15. Ensuring sufficient numbers of nurses who are physically healthy and continuity of care
providers, as well as facilitating autonomy and decision-making will improve nursephysician relationships. Rationale: Improved nurse-physician relationships are associated
13
with higher proportions of physically healthy nurses and increases in nurses hours worked
on the unit. Deterioration in nurse-physician relationships is associated with unit
productivity/utilization beyond 85 percent.
16. Finding balance between the number of patients assigned to a nurse, the rate of occupancy on
the unit, and unit productivity/utilization is recommended to enhance autonomy. Rationale:
Lower nurse autonomy is associated with higher unit occupancy rates, nurses experiencing
effort and reward imbalance, more degree-prepared nurses, and greater nurse clinical
expertise. Higher nurse autonomy is associated with unit productivity/utilization greater than
85 percent, nurse satisfaction, and higher nurse-patient ratios.
17. Hiring degree-prepared nurses, increasing average hours per patient, promoting autonomy,
ensuring good quality nursing care, and maintaining unit productivity/utilization levels below
80 percent are recommended to improve nurse job satisfaction. Rationale: Higher nurse job
satisfaction is 301 percent more likely when nurses rate the quality of nursing care as good or
better, and 10 percent more likely for every hour increase in the average worked hours on the
unit. Improved job satisfaction is also 56 percent more likely for every 10 percent increase of
nurses with degree preparation and 24 percent more likely for each one point increase in
ratings of nurse autonomy. Higher job satisfaction is 57 percent less likely when unit
productivity/utilization levels exceed 80 percent.
18. Environmental scanning for factors that cause full-time nurses to be more emotionally
exhausted is recommended. Rationale: Emotional exhaustion is 242 percent more likely
when nurses experience effort and reward imbalance and 179 percent more likely when
nurses work full-time. However, emotional exhaustion is 66 percent less likely when nurses
are satisfied, 10 percent less likely with every one point increase in mental health scores, and
14
four percent less likely with every one point increase in physical health scores. For every 10
percent increase in satisfied nurses on the unit, nurses are 32 percent less likely to suffer from
emotional exhaustion.
19. Improving nurse-physician relationships at the unit level, balancing the demands placed on
nurses and the rewards they receive for their work, and enhancing job satisfaction will
improve nurses physical health. Rationale: Nurses are 49 percent less likely to be physically
healthy when they experience an effort and reward imbalance and 41 percent less likely to be
physically healthy when they are emotionally exhausted. However, as relationships between
nurses and physicians improve, nurses are more likely to be physically healthy.
III. Approach
This study, which comprised cross-sectional and longitudinal components, included the
cardiac and cardiovascular care units of six hospitals in Ontario and New Brunswick. The Patient
Care Delivery System Model10 was adapted for this study (Appendix B). This model emphasizes
that characteristics of patients, nurses, and the system, as well as system behaviours, interact with
communication and co-ordination, environmental complexity, and care delivery activities to
produce system outputs (intermediate outputs include unit productivity/utilization and daily
hours of care per patient; overall outputs include patient, nurse, and system outcomes) and
provide feedback for the entire system.
Ethical approval was received from the University of Toronto and from hospital sites. Patient
and nurse consent was obtained on site. Eight hospitals met the inclusion criteria (high volumes
of patients in the cardiac case mix groups of interest). The first six hospitals approached agreed
to participate. Each hospitals chief nursing officer or designate joined the studys advisory
15
committee and became a local investigator to oversee hospital ethics approval, hiring of project
staff, and data quality at the site.
On participating units, data for study patients, all nurses, and the unit itself were collected on
each patient for each day of stay. Data were collected from patients and nurses directly as well as
from administrative sources. The key variables and data sources are summarized in Table 1
(Appendix C). A detailed summary of each measure and its related psychometric properties
appears in Appendix D, and data collection forms are presented in Appendix E. In addition to
this unit-level data, nurses completed a survey package questionnaire that addressed issues like
burnout, the balance between work efforts and rewards, nurse-physician relationships, autonomy,
and health. Nurses provided input into the PRN workload measurements, identification of
nursing diagnoses, and ratings of patient knowledge, behaviour, and status.
Data were collected between February and December 2002. Data collection periods averaged
six months at each site to maximize the number of patients assessed, but the target of 145
patients for all specified case mix groups was not achieved. Inter-rater reliability on the
application of all measures remained at 90 percent during orientation and throughout the study.
Of 1,107 surveys provided to nurses at all six sites, 727 were returned (66 percent response
rate). In total, 1,230 patients housed in 24 nursing units from the six hospitals were included in
the full study, accounting for 8,113 patient days of data.
Decision makers were involved in developing the proposal and reviewed all data collection
forms and methods prior to implementation. They also reviewed drafts of the descriptive data for
the studys final report. They made recommendations on additional data elements that should be
routinely collected and assisted in the overall interpretation of the studys findings.
16
The findings will be published in peer reviewed and trade journals to target different
audiences. The report, fact sheets, and a video will be sent to hospital executives, nongovernment bodies which influence health policy, and each ministry of health in Canada.
Analysis Techniques: Data were analysed using SPSS version 11 and MLwin beta version
2.0. Initially, the distribution and transformation of variables was conducted. Descriptive
statistics were compiled, and subscale scores and alpha reliabilities for the various research tools
used were generated. Basic comparisons between hospitals or units were made using analysis of
variance (ANOVA). Where applicable, the Pearson Product Moment Correlation was used to
explore interrelationships between variables.
Hierarchical linear modeling is useful for understanding relationships in multilevel
structures. Since data in this study were collected at both the hospital unit level and at the
individual nurse and patient level, a multilevel approach to the analysis was proposed as a way to
better account for the possible clustering of effects within hospitals. That is, questionnaire
responses from nurses within hospitals were likely to be affected by things that are fixed for all
employees in that organization, such as the size and type of the organization. The advantage of
hierarchical linear modeling methods is that they can account for this clustering or grouping of
variation in scores on questionnaire measures within a given organization. Without accounting
for the possible clustering of effects within hospitals, the conclusions of the study could be
invalid, since other statistical measures assume that no such clustering occurs.
For multilevel modeling, most variables were dichotomized and hierarchical logistic
regressions were completed. Only unit productivity/utilization, worked hours per patient, cost per
resource intensity weight, nurse-physician relationship, violence, and autonomy were kept as
numeric variables. Worked hours per patient and cost per resource intensity weight were
17
logarithm transformed due to their highly skewed distributions. The order of entry of variables
into the statistical modeling process was consistent with the theoretical framework at two levels.
The first level included individual nurse and patient variables, while the second unit level
included system characteristics and behaviours and throughput factors. Some of the nurse
questionnaire measures were also aggregated to the unit level as a measurement of unit
atmosphere or morale. Multicollinearity among independent variables was examined, but none of
the variables was very strongly associated with any other. To determine whether or not variables
were associated with outcomes, individual variables were sequentially added to statistical models
and the properties of each newly expanded model were compared to the previous one to see if
the new variable was of any importance (see Appendix F).
IV. Results
Descriptives
Descriptive results pertaining directly to the implications outlined above are presented
here. More detailed results and tables are presented in Appendix G.
Patient Characteristics: For 1,230 patients in the study, the mean age was 63.5 years,
and 66.7 percent were male. The most common cardiac case mix group was percutaneous
transluminal coronary angioplast. Of the surgical patients, one-third (33 percent) attended a preoperative clinic and more than half (57.5 percent) received post-operative education. About one
in 10 (10.9 percent) was referred to homecare. On a scale of 1 to 5, OMAHA knowledge,
behaviour, and status scores regarding nursing diagnoses averaged 3.4, 4, and 3.3 respectively,
upon admission or identification of new nursing diagnoses. At admission, 87 percent and 49.2
percent of patients scored below the standardized American norms for physical and mental
health, respectively.
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Nurse Characteristic: Of 727 nurses who completed the survey, most (93.9 percent) were
female, registered nurses (96.6 percent), with a mean age of 40.6 years. More than 42 percent of
nurses held a bachelor or higher degree. On average, 59.8 percent of nurses were employed fulltime, with 97.8 percent indicating permanent employment. Almost 40 percent of nurses rated
their approach to care delivery as expert, rather than novice.
System Characteristics and Behaviour: On an average day, nurses on each nursing unit
admitted 6.1 and discharged 6.1 patients per 24 hour period. Overall, 64.3 percent of nurses
reported significant increases in employer expectations for overtime in the last year and actual
increases in overtime worked per week: zero to one hour (45.1 percent), two to four hours (32.2
percent), and greater than four hours (22.7 percent). Of the overtime reported, 26.7 percent was
unpaid and 22.8 percent was involuntary. Eight percent of nurses experienced a forced change in
their work unit in the previous year, and 15.1 percent anticipated such a change in the upcoming
year. Nurses continue to perform tasks that could be delegated to non-nursing personnel,
including ancillary services (83.5 percent), venipunctures (64.8 percent), housekeeping (55.1
percent), delivering trays (55.1 percent), and starting intravenous sites (51 percent).
Intermediate System Output: Unit productivity/utilization was determined by dividing
unit workload by total worked hours on the unit. The maximum capacity of any employee is 93
percent, because seven percent is allocated to paid breaks when no work is contractually
expected. At 93 percent, nurses are working flat out with no flexibility to meet unanticipated
demands or rapidly changing patient acuity. On 46 percent of the days, units worked beyond the
ceiling value of 93 percent, and on 61.5 percent of the days units worked beyond 85 percent.
Patient Outcomes: Few medical consequences were reported, although variation existed
among hospitals. Medical consequences included falls with injury (0.7 percent), medication
19
errors with consequences (1.6 percent), death (0.4 percent), and complications such as urinary
tract infections (1.5 percent), pneumonia (1.3 percent), wound infections (1.4 percent), bed sores
(0.4 percent), and thrombosis (0.2 percent). Between admission and discharge, patients scores
for SF-12 physical health status improved (41.1 percent) nearly as often as they declined (44.9
percent). A similar pattern was noted for patients mental health status (42.3 percent improving
and 44.9 percent deteriorating). For physical and mental health status scores, 12.8 percent of
patients showed no change. Overall, general improvement of patients was evidenced through
mean changes in OMAHA knowledge (0.43), behaviour (0.25), and status (0.79) scores between
admission and discharge (or appearance and resolution of new nursing diagnoses).
Nurse Outcomes: On average, nurses scored 22.7 for emotional exhaustion, six for
depersonalization, and 12.2 for personal accomplishment using Maslachs Burnout Inventory.
Almost 30 percent of nurses were at risk for emotional burnout. Additionally, 18 percent of
nurses said their work efforts exceeded work rewards. On average, 17.7 percent of nurses were
dissatisfied with work, primarily due to inadequate opportunities to interact with management
(45.5 percent).
Of the nurse survey respondents, 34.8 percent and 49.2 percent scored below the
standardized American norms for physical and mental health, respectively. During the two weeks
preceding the survey, 32.4 percent of nurses changed their shift time more than once. During the
week preceding the survey, nurses experienced emotional abuse (24.9 percent), threat of assault
(13.6 percent), and physical assault (10.2 percent) while at work. The main sources of this
workplace abuse were patients (31.1 percent), other nurses (21.5 percent), physicians (15.8
percent), and families (10.7 percent).
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System Outcomes: Nurse ratings of quality of care and omission or delay of patient
interventions comprised the measures of quality of care. Of 714 responses, 13.4 percent of nurses
rated the nursing care quality on the last shift as fair/poor, while 41.9 percent said patient care
quality had deteriorated over the last year. When faced with insufficient time, nurses generally
omitted nursing (as opposed to physician-dependent) interventions. The most frequently omitted
interventions included care planning (48.2 percent), comforting/talking (38.6 percent), back/skin
care (31.4 percent), oral hygiene (28.7 percent), patient/family teaching (23.3 percent), and
documentation (22.6 percent). Delayed interventions included vital signs/medications/dressings
(37.3 percent), mobilization/turns (30.5 percent), call bell response (25.9 percent), and PRN pain
medications (16.6 percent). In total, nurses reported missing 1,768 work episodes in the last year,
with each episode averaging 2.42 shifts. Although 16.4 percent of nurses were never absent,
frequency of missed episodes ranged from one to two (42.9 percent), three to four (25.2 percent),
and greater than four (15.5 percent). Reasons for absenteeism were reported as physical health
(71.4 percent), mental health (5.4 percent), injury (4.8 percent), and other (18.4 percent).Almost
five percent of nurses planned to leave their job in the next year. Only 5.6 percent of nurses
expected to have difficulty in securing a new job if they wanted one.
Research Question 1.
To what extent do patient, nurse, system characteristics and behaviours, and environmental
complexity measures explain variation in nursing worked hours and patient, nurse, and system
outcomes, such as length of stay?
Intermediate System Outputs
Unit productivity/utilization: As indicated earlier, at 93 percent productivity/utilization,
nurses are working at maximum capacity, and high rates of productivity/utilization on the unit
21
directly influence patient outcomes. This analysis identifies the variables associated with higher
and lower productivity/utilization at the unit level. Higher productivity/utilization levels were
more likely when there were more nursing worked hours on the unit, higher nurse-to-patient
ratios, higher nurse autonomy, and when nurses required more time to complete the work as
specified by the patient care plan. Productivity/Utilization was more likely to be lower when
units were specialized (such as units that only service patients with cardiology conditions) and
where a higher proportion of nurses on the unit were emotionally exhausted or mentally healthy.
When nurses are emotionally exhausted they may not be able to work at the same level of
productivity/utilization than when they are not. Nurses who are mentally healthy may be inclined
to say no to unrealistic work expectations.
Actual Worked Hours per Patient: The actual worked hours per patient were likely to
increase with a higher proportion of nursing worked hours on the unit and when patients had
more nursing diagnoses. Increases in worked hours per patient were associated with increases in
unit productivity/utilization up to the cut-off point of 90 percent. Units with more clinical
expertise or with a higher proportion of full-time nurses were more likely to provide fewer hours
of patient care.
Patient Outcomes
Tables 2 to 19 (Appendix C) display the variables modeled in relation to patient health and
safety outcomes.
Medical Consequences: Since there were so few medical consequences of any one type, all
types of consequences were summed into one category. In this analysis, the factors associated
with the presence or absence of any medical consequences during a patients stay were
examined. As patients experienced greater numbers of nursing diagnoses, reflecting more
22
complex nursing needs, they were more likely to suffer medical consequences. Medical
consequences were 53 percent more likely for each additional nursing diagnosis. In contrast,
patients with better mental health at admission were less likely to have medical consequences.
Patients who experienced medical consequences were more likely to require greater actual
worked hours of nursing care during their stay and 319 percent more likely to be referred to
homecare for follow-up after discharge, resulting in additional expense to the health system.
OMAHA Knowledge, Behaviour, and Status at Discharge. Helping patients understand the
cause and course of their conditions is seen to improve the overall health of patients. A ceiling
effect was observed among the OMAHA knowledge, behaviour, and status scores, in that
patients with higher scores at admission were less likely to demonstrate improvements in these
scores at discharge (because there was less room for improvement). Improved patient knowledge
scores at discharge were 74 percent more likely for every 10 percent increase in nursing worked
hours on the unit and 24 percent more likely for every 10 percent increase in full-time nurses on
the unit. When patients were cared for by nurses who reported higher autonomy in their jobs,
they were more likely to show increases in knowledge about their condition at discharge.
However, patient knowledge was 44 percent less likely to improve for every 10 percent increase
in the proportion of nurses who had at least one shift change in the last two weeks.
Helping patients understand which behaviours they need to change in order to improve their
health status is another important role function of the nurse. When cared for by nurses who were
very satisfied with their work, patients were 176 percent more likely to demonstrate
improvements in their behaviour scores at discharge. Conversely, patients cared for by nurses
with concerns about job security were 53 percent less likely to demonstrate improved behaviour
23
scores at discharge. Productivity/Utilization levels below 88.2 percent were associated with
increased possibility of improvements in patients behaviour scores at discharge.
SF-12 Health Status at Discharge: As with the OMAHA scores, patients with higher
physical and mental health scores at admission were less likely to see improvements in these
scores at discharge. Improvement in patients physical health status at discharge was less likely
for patients with higher resource intensity weights and for patients with more nursing diagnosis.
These two factors reflect the medical acuity and nursing complexity of patients needs for
nursing care. Patient physical health scores were 45 percent less likely to improve when unit
productivity/utilization exceeded 80 percent and were seven percent less likely to improve for
each additional hour of nurse overtime. However, patients who scored higher in physical health
status at admission were more likely to have improvements in mental health status at discharge.
Patients who stayed longer in hospital were less likely to show improvements in mental health
status scores at discharge. More hours of care were likely to be used if patient mental health was
not improved at discharge.
Nurse Outcomes
Although improving patient outcomes and reducing the risk of medical consequences are
goals of healthcare, achievement of these goals may sometimes occur at the expense of nurse
health and safety. In order to retain and recruit nurses senior and experienced nurses in
particular understanding which factors influence nurse outcomes is pivotal. Ten nurse
outcome variables derived from the literature were subsequently used in this analysis. Tables 10
to 19 (Appendix C) display the variables modeled in relation to nurse outcomes.
Emotional Exhaustion: Physically and mentally healthy nurses were less likely to experience
emotional exhaustion (burnout). The likelihood of emotional exhaustion increased by 242
24
percent when nurses were at risk of an effort and reward imbalance and by 179 percent when
nurses worked full-time. Nurses were 32 percent less likely to suffer high emotional exhaustion
for every 10 percent increase in the proportion of satisfied nurses on units.
Autonomy: Nurses reported higher autonomy in practice when they reported stronger
relationships with physicians, were more satisfied with their job, or said the quality of patient
care improved over the last year. Autonomy was also higher when patients had attended a preoperative clinic and when the nurse-patient ratio was high. As unit productivity/utilization
exceeded 85 percent, nurses reported more autonomy, possibly since nurses have to make
decisions on their own under such circumstances. However, lower autonomy scores were
reported by degree-prepared nurses and by nurses who rated themselves as expert clinicians,
perhaps due to organizational constraints imposed on their practice. When occupancy is high on
the unit or when nurses were at risk of an effort and reward imbalance, autonomy was likely to
be lower.
Job Satisfaction: Nurses who were at risk for emotional exhaustion were 71 percent less
likely to be satisfied with their jobs, and when unit productivity/utilization levels were higher
than 80 percent, nursing staff were 57 percent less likely to be satisfied. Nurse satisfaction was
301 percent more likely when nurses rated the nursing care given on the last shift as
good/excellent and 56 percent more likely among degree-prepared nurses. As the average hours
available for care on the unit increased and when nurses autonomy increased, so did nurses
satisfaction.
Nurse-Physician Relationships: On units with higher proportions of physically healthy nurses
and of nursing worked hours, nurses were more likely to have better relationships with
physicians. Nurses who perceived their practice to be more autonomous and those who rated the
25
quality of nursing care on the last shift as good/excellent were also more likely to have better
relationships with physicians. However, nurse-physician relationships tended to deteriorate when
there was a higher proportion of nurses with frequent shift changes on the unit and as nurses took
on more patients in their daily assignment or care for patients with more nursing diagnoses.
Deteriorated relationships were also more likely as unit productivity/utilization levels exceeded
85 percent.
SF-12 Health Status: Higher physical health status scores were 59 percent less likely for
female nurses; 49 percent less likely when nurses were at risk for an effort and reward
imbalance; and 41 percent less likely for nurses at risk of emotional exhaustion. In contrast,
nurses were more likely to be physically healthy when stronger nurse-physician relationships
were reported on the unit and as the average worked hours available for care on the unit
decreased. The likelihood of being physically healthy increased by 58 percent when nurses were
satisfied with their job, and decreased by 28 percent for every 10 percent increase in nursing
worked hours probably because increased nursing hours came from the same nurses worked on
the unit rather than from new hired nurses.
Female nurses were 52 percent less likely to be mentally healthy than male nurses, and older
nurses reported better mental health. Nurses with one point increases in their physical health
scores were four percent less likely to be mentally healthy. Nurses were less likely to be mentally
healthy when they were at risk of emotional exhaustion and as the average worked hours on the
unit increased. The likelihood of being mentally healthy increased by 74 percent when nurses
were satisfied with their current job and decreased by 79 percent when nurses were at risk of
emotional exhaustion.
26
System Outcomes
Tables 20 to 29 (Appendix C) display the variables modeled in relation to system outcomes.
Length of Stay: Patients in units where the productivity/utilization of the unit exceeded 91
percent were more likely to have longer-than-expected lengths of stay. Patients with more
nursing diagnoses and with higher resource intensity weights, reflecting greater medical acuity,
were also more likely to have longer lengths of stay. Shorter-than-expected lengths of stay were
two percent and 185 percent more likely for patients whose physical health status scores were
one point higher at admission and for those who attended a pre-operative clinic, respectively.
Shorter-than-expected length of stay was 57 percent less likely when patients experienced
medical consequences and 13 percent less likely for each additional nursing diagnosis.
Interventions Not Done or Delayed: Older, experienced nurses were less likely to have
interventions not completed at the end of their shift. The likelihood of interventions not being
completed increased by 260 percent when nurses were at risk for an effort-reward imbalance.
The more often patients had unanticipated changes in acuity, the more often interventions were
left undone. The more frequently violence was experienced by individual nurses and the higher
the medical complexity (as indicated by the resource intensity weight), the more likely
interventions were not completed. The greater the number of nursing diagnoses, the less likely
interventions were not completed. The likelihood of interventions being left undone was reduced
as units hired nurses with more clinical expertise and reduced for units that increased average
overtime. Interventions not completed were 12 percent less likely with every one point increase
in the ratings of nurse autonomy. The more nurses re-sequenced their activities in response to
demands from others, the less often interventions were left undone.
27
Delayed interventions were 74 percent more likely when nurses worked full-time, 87 percent
more likely when nurses had concerns about job security, and 123 percent more likely when
nurses were at risk of an effort and reward imbalance. Interventions were 27% less likely to be
delayed for every 10% increase in the proportion of degree-prepared nurses on the unit. More
complex patients with increasing numbers of nursing diagnoses were less likely to experience
delays in receiving interventions. However, when individual nurses experienced violence or
where the average level of violence was high on a unit, interventions were more likely to be
delayed. Interventions were 71 percent more likely to be delayed for every 10 percent increase in
absenteeism at the unit level.
Quality of Patient Care Over the Past Year: When nurses rated themselves as expert
clinicians, they were less likely to rate the quality of patient care on the unit as improved.
Likewise, when interventions were delayed, nurses were 46 percent less likely to report
improvements in the quality of patient care. The likelihood of improved nurse ratings of patient
care increased by 915 percent when nurses rated the quality of nursing care given on the unit as
good/excellent (as opposed to fair/poor) and when nurse autonomy was higher. Improved quality
of patient care was 41 percent less likely with every 10 percent increase in nursing worked hours
on the unit but 40 percent more likely with every 10 percent increase in degree-prepared nurses
on the unit.
Quality of Nursing Care on the Last Shift: Good or excellent ratings by nurses of the quality
of nursing care on the last shift were 606 percent more likely when individual nurses rated the
quality of patient care as improved over the last year; 159 percent more likely when nurses were
satisfied; and more likely when nurses rated themselves as clinical experts. Nurses reports of
strong nurse-physician relationships were also associated with good/excellent ratings of nursing
28
care on the last shift. However, nurses who changed shifts at least once during the past two
weeks were 50 percent less likely to rate the quality of nursing care as good/excellent. Likewise
when a 10 percent increase in the proportion of ratings of quality of nursing care at the unit level
were good/excellent, individual nurses on the unit were 93 percent more likely to rate individual
scores of quality of nursing care as good/excellent. However, for units with higher ratings of
nurse-physician relationships on average, individual nurses were less likely to rate nursing care
as good/excellent.
Absenteeism: Full-time nurses were 152 percent more likely than part-time and casual nurses
to miss work. Nurses who scored one point higher in physical health status scores were five
percent less likely to miss work. When unit productivity/utilization was below 79.7 percent,
nurses tended to have fewer days absent.
Intent to Leave: Degree-prepared nurses were 101 percent more likely to leave as compared
to diploma-prepared nurses. Nurses who reported job instability were 197 percent more likely to
report intentions of leaving than those who did not. Satisfied nurses were 58 percent less likely to
intend to leave. Full-time nurses were 51 percent less likely to leave than part-time or casual
nurses. When productivity/utilization was below 82.8 percent on the unit, nurses were less likely
to leave.
Cost Per Resource Intensity Weight: Patients who were admitted with higher mental health
status scores and with a higher number of nursing diagnoses were more likely to have higher
costs per resource intensity weight, as were patients who attended pre-operative and postoperative education. Lower costs per resource intensity weight were more likely when care was
provided in part in step-down units, when nurses rated themselves as clinical experts, and with
emergency admissions, higher nurse-patient ratios, and higher physical health status scores
29
among nurses. As length of stay increased and as unit productivity/utilization exceeded 90

percent, so did the cost per resource intensity weight.
Research Question 2
To what extent is there agreement between the estimates generated by a gold standard for
measuring nursing resource needs (PRN workload methodology) and the worked hours per
patient, and how does variance affect the patient and nurse outcomes?
Table 30 (Appendix C) reveals that only two significant variables were found when
examining the PRN estimates and actual worked hours. When actual worked hours were less
than PRN predicted hours, nurses were more likely to leave in the next year and
productivity/utilization was more likely to be high.
Research Question 3
At what nurse-patient ratio and with what proportion of nursing worked hours are
productivity/utilization and patient and nurse outcomes improved, after controlling for the
influence of patient, nurse, organizational, and environmental factors?
As shown in Table 31 (Appendix C), when a nurse was assigned more patients, the
relationship with physicians deteriorated and autonomy increased. When more patients were
assigned to a nurse, unit productivity/utilization increased and cost per resource intensity weight
decreased. For every additional worked hour per patient, the odds of medical consequences
increased by 13 percent, and the odds of improvement in patient mental health at discharge
decreased by six percent. For every additional hour increase in the average worked hours on the
unit, the likelihood of nurses being satisfied with the current job increased by 10 percent, but
their odds of being physically and mentally health declined by 10 percent and seven percent
respectively. For every 10 percent increase in the proportion of nursing worked hours the odds of
30
patients having improved knowledge scores increased by 74 percent, but nurses were 28 percent
less likely to be physically healthy, were 41 percent less likely to rate the quality of patient care
as improved.
Given that the maximum productivity/utilization for any unit should not exceed 93 percent,
productivity/utilization levels range from 79.7 percent for absenteeism to 91.4 percent for
shorter-than-expected length of stay. These findings highlight the difficulties nurses face in this
study, where almost 50 percent of the nursing units worked over productivity/utilization levels of
93 percent.
Research Question 4
Which data elements, in addition to those routinely collected within administrative databases,
are critical for routine data collection in Canada? To what extent do policy and administrative
decision makers support the feasibility of routine data collection?
Discussion with our policy and practice decision-making partners identified that:
1. nurse SF-12 physical and mental health status, emotional exhaustion, autonomy, effort and
reward imbalance, and quality of nurse-physician relationships should be monitored annually
in the new National Nursing Health Survey;
2. unit workload data should be checked for reliability and validity at least annually, and these
data, in combination with worked hours, should be tracked regularly by nursing unit
managers to determine if actual values exceed those recommended in this study. The
Environmental Complexity Scale should be completed on each shift by nurses.
Productivity/Utilization and environmental complexity should become quality indicators
used by the Canadian Council of Health Services Accreditation to monitor healthy
workplaces; and
31
3. nursing diagnoses and OMAHA tool ratings should be used daily in practice. Automated care
planning systems that are easy to access and use are recommended. These are important
indicators of patient goal achievement.
V. Additional Resources
The reader is referred to the works of Aiken et al, OBrien-Pallas et al, and Shamian and
OBrien-Pallas et al as referenced in Appendix A.
VI. Further Research
1. Develop and validate a shorter version of the effort and reward imbalance scale.
2. Conduct studies to examine the influencing factors and nature of short- and long-term
illnesses among nurses. Evaluate strategies (such as access to fitness centers, improved hot
meals in the hospital, and mandatory breaks) that may enhance the health of nurses.
3. Replicate this study on other patient populations to determine if the productivity/utilization
cut-off points hold.
4. Explore experienced nurses perceptions of quality and develop measures of quality that can
be evaluated yearly at the nursing unit level.
VII. References
1. Canadian Nursing Advisory Committee. (2002).Our health, our future: Creating quality
workplaces for Canadian nurses. Toronto, ON: Author.
2. OBrien-Pallas, L. L., Thomson, D., Alksnis, C., Luba, M., Pagniello, A., Ray, K. et al
(2003). Stepping to success and sustainability: An analysis of Ontarios nursing workforce.
Toronto, ON: Nursing Effectiveness, Utilization, and Outcomes Research Unit.
3. Canadian Council for Health Service Accreditation (2002). Recognition guidelines for 2003:
Specific issues and related criteria. Ottawa, ON: Author.
4. Baumann, A., O'Brien-Pallas, L., Armstrong-Stassen, M., Blythe, J., Bourbonnais, R.
Cameron, S. et al. (2001). Commitment and care: The benefits of a healthy workplace for
32
nurse, their patients and the system a policy synthesis. Ottawa, ON: Canadian Health
Service Research Foundation.
5. OBrien-Pallas, L. L., Alksnis, C., Wang, S., Birch, S., & Tomblin Murphy, G. (2003). Bring
the future into focus: Projecting RN retirement in Canada. Toronto, ON: Canadian Institute
for Health Information.
6. Aiken, L., Clarke, S., Sloane, D., Sochalski, J., & Silber, J. (2002). Hospital nurse staffing
and patient mortality, nurse burnout, and job satisfaction. JAMA: The Journal of American
Medical Association, 288(16), 1987-1993.
7. Shamian, J., OBrien-Pallas, L., Kerr, M., Koehoorn, M., Thomson, D., & Alksnis, C.
(2001). Effects of job strain, hospital organizational factors and individual characteristics on
work-related disability among nurses. Toronto, ON: Ontario Workplace Safety and Insurance
Board.
8. Grinspun, D. (2003). Part-time and casual nursing work: The perils of healthcare
restructuring. International Journal of Sociology and Social Policy, 23(8/9), 54-70.
9. Canadian Institute for Health Information. (1999). MIS guidelines for Canadian healthcare
facilities. Ottawa, ON: Author.
10. OBrien-Pallas, L., Giovannetti, P., Peereboom, E., & Marton, C. (1995). Case costing and
nursing workload: Past, present and future [Working Paper 95-1]. Hamilton, ON: Quality of
Nursing Worklife Research Unit.
33
Appendix A. Annotated Bibliography

Table of Contents
1.
Patient Characteristics
35
2.
Nurse Characteristics
38
3.
System Characteristics and Behaviours
40
4.
Throughputs
60
5.
Patient Outcomes
62
6.
Nurse Outcomes
65
7.
System Outcomes
74
8.
Glossary
76
9.
References
76
34
1.
Discharge planning model

for elders hospitalized
with heart failure.
Predicting resource
utilization in patients with
unstable angina.
Impact of a first
myocardial infarction on
self-perceived health
status.
Perceived learning needs

of patients with coronary
artery disease.
2. Bull, Hansen,
Gross (2000)
3. Calvin, Klein,
Vanden Berg,
, Meyer,
RamirezMorgen,
Parrillo
(1998)
4. Crilley, Farrer
(2001)
5. Czar, Engler
(1997)
Focus
Decision latitude,
psychological demand,
job strain, & coronary
heart disease.
Authors/Year
1. Alterman,
Shekelle,
Vernon,
Burau (1994)
465 patients
admitted for
unstable angina
to a tertiary care
university-based
medical centre,
prospective
evaluation.
165 patients
were surveyed 2
years after a first
myocardial
infarction
Convenience
sample of 28
men admitted
with angina or
myocardial
Sample
Annual examine
of 1,683 men
employed at
Hawthorne
Works for 25
years.
158 elder/
caregiver dyads,
before-and-after
non-equivalent
control group.
Patient learning
needs,
demographics,
occupation
Patient
demographics,
occupation
Patient
demographics,
education,
continuity of
care, patient
teaching,
medical
diagnosis.
Patient
demographics,
medical
diagnosis.
Inputs
Occupation,
medical
diagnosis.
Throughputs
SF-12 patient
health status
Length of stay,
costs of care,
complications
Patients
perceived health
status, costs of
care
Outputs
35
Patients having their first myocardial infarction

have significantly lower levels of self-perceived
health status after 2 years than control subjects.
Health status is associated with persistent
cardiac symptoms & lack of employment.
No significant difference in learning needs
between hospitalization & subsequent clinic
visits. Most important learning needs were
symptom recognition, cardiac
anatomy/physiology, & medications.
Predictive model of risk of major complications

can be used to analyze cost of care, resource
utilization, & outcomes. Resource utilization
increases as the probability of risk for cardiac
complications increases (ex: highest risk group
had 75% higher costs than the lowest risk
group).
Findings
Contrary to the hypothesis, those with highest
decision latitude had lowest coronary heart
disease death rates (risk of 6.8, with average
risk being 7.8). No association between
coronary heart disease & psychological
demand.
Elders who received new model of discharge
planning felt more prepared to manage care
(t=4.30), felt in better health (t=2.0) & spent
fewer days in hospital when readmitted.
Facilitated elder & caregiver participation in
planning.
Impact of work
organization
(psychological demand,
work control, & social
support) on
cardiovascular disease
mortality.
Variable affecting length

of stay.
Relationship between
7. Johnson,
Stewart, Hall,
Fredlund,
Theorell
(1996)
8. Marchette,
Holloman
(1986)
9. Shi (1996)
Psychosocial factors in
the development &
prognosis of coronary
heart disease.
Focus
6. Hemingway,
Marmot
(1999)
Authors/Year
12,517 Swedish
men 25-74
currently or
previously
employed.
Random sample
from entire
Swedish
population, 80%
response rate.
500 patients
discharged from
an acute care
hospital.
Stratified
random sampling
of 100 patients
with 5 most
common
diagnostic
categories.
274,311 patient
Sample
infarction to a
California
universityaffiliated
medical centre.
Patient
Medical
diagnosis, patient
demographics,
patient education
given.
Patient
occupation,
social support,
patient
demographics
education.
Social supports,
occupation,
medical
diagnosis.
Inputs
Throughputs
Length of stay
Length of stay
Patient mortality
Outputs
36
Direct relationships between longer length of
For every area of discharge planning the nurse

carried out (nutrition, medication, etc.), there
was a decrease of 0.8 days of hospitalization (2
days for CVA patients). Strong relationship
between timing of planning & length of stay
(for every day that the planning was postponed,
there was an increase of 0.8 days of
hospitalization).
Findings
No correlation between learning needs & age,
occupation, smoking or marital status. Most
important learning needs are those that affect
survival. A self-administered questionnaire can
be used to determine patients perceived
learning needs so education can focus on areas
most important to the patient.
Strong correlations between depression/ anxiety
& development of coronary heart disease
(11/11 studies). Traits such as type A/ hostility
(6/14 studies), work organization (6/10 studies)
& social support (5/8 studies) also have
moderate correlations with coronary heart
disease.
Workers with low work control had a higher
risk for cardiovascular mortality (after 5 year
exposure, relative risk of mortality is 1.46 for
low control vs. 1 .00 for high control). No
significant associations between physical job
demand, work social support, job hazards, &
cardiovascular mortality.
Turning points of
recovery from cardiac
surgery in an intensive
care unit.
Impact of high effort, low

reward conditions in the
workplace on
cardiovascular health.
Impact of stressful work
on ischemic heart disease.
10. Shih, Chu,

Yu, Hu,
Huang,
(1997)
11. Siegrist
(1996)
Psychosocial factors in
14. Steptoe
Predictors of hospital
outcomes.
13. Silber,
Rosenbaum,
Ross (1995)
12. Siegrist,
Peter, Junger,
Cremer,
Seidel (1990)
Focus
patient & hospital
characteristics on length
of stay.
Authors/Year
73,174 patient
admissions to
137 hospitals.
Data from
national surveys.
Recruited 416
middle-aged
blue-collar men
from steel &
metal plants in
West Germany
for prospective
study, followed
over 6.5 years.
Sample
records & 484
hospitals,
random sampling
of hospitals &
discharges.
Convenience
sample of 30
adults who had
undergone
cardiac surgery
in 1of 3 general
hospitals in
northern Taiwan.
Staffing ratios,
medical
diagnosis, patient
demographics,
hospital size,
Occupation,
Patient
demographics,
occupation
Medical
diagnosis
Inputs
demographics,
hospital size,
medical
diagnosis, social
support.
Patient
demographics.
Throughputs
Effort & reward
Adverse
occurrences.
37
Those with fewer social supports were at
Turning points included events, nursing actions,

& time. Components of turning points were
preceding conditions, markers, &
consequences. Turning point experiences
included none (7%), both (57%) or one of
positive (33%) & negative (3%) outcomes. May
sensitize nurses to detect more quickly patients
turning point experiences. Nurses may educate
patients before surgery based on turning point
knowledge.
Variables indicating high effort & low reward
(money, esteem, status) predict cardiovascular
events. These conditions at work must be
considered a risk for cardiovascular health.
Status inconsistency (regression
coefficient=1.48), job insecurity (1.23), work
pressure (1.24) & need for control (1.51)
predicted ischemic heart disease occurrence.
Reducing burden of high workload &
increasing reward & security could reduce
ischemic heart disease risk. Individual
prevention could be directed at coping with
work demands & strengthening regenerative
potential.
Nearly all of predictable variation in outcomes
is from differing patient characteristics, not
hospital or staffing ones.
Admission to or
discharge from
intensive care
unit., post-op
complications.
Effort-reward
imbalance,
health status.
Findings
stay & older age, non-married status, being
female, being African American, & having
insurance. Fewer hospital beds correlated with
shorter length of stay tables omitted).
Outputs
2.
Focus
the cause of coronary
heart disease.
Highlights issues
from Canadian
Health Services
Research
Foundations report
on healthy
workplaces for
nurses.
16. Coutts (2001)
Focus
Describe nurses'
health status,
examine trends in
injury compensation
claims, & determine
factors contributing
to high-injury claim
rates.
Authors, Year
15. Bruce, Sale,
Shamian,
O'Brien-Pallas,
Thomson
(2002).
Authors/Year
(1999)
Sample
121 nurses from
10 acute care
hospitals with
high & low
nurse-injury
compensation
claim rates.
Interviews with 5
chief executive
officers, 10 chief
nursing officers,
&9
Occupational
Health &
Security Officers
Sample
Nurse
absenteeism
Inputs
Nurse
demographics,
workload,
staffing.
Inputs
social support,
medical
diagnosis
Work
environment
Throughputs
Organizational
work
environment.
Throughputs
Nurse job
satisfaction,
violence, nurses
health.
Outputs
Absenteeism,
nurse injury.
Outputs
imbalance
38
When nurses are more independent & have

more say in patient treatment, they find jobs
more satisfying. There is a direct relationship
between hours of overtime & sick time.
Fatigue, too much to do & temporary staffing
lead to nurses getting hurt. Good working
conditions for nurses should be a standard for
hospital accreditation.
Findings
Nurses in both high-claim & low-claim
hospitals identified physical work environment,
claims process, & staffing as factors related to
different injury claim rates among hospitals.
Workload is a contributing factor to high-injury
rates among nurses.
Findings
increased risk for cardiovascular death. Other
risk factors: stressful work conditions, cynically
hostile attitude.
Comparison of lowback pain in female

nurses & other
employed women.
Associations between
self-rated
psychosocial
conditions &
characteristics of
musculoskeletal
symptoms, signs, &
syndromes.
Summary report from

Institute of Medicine
about adequacy of
nursing in hospitals
18. Josephson,
Vingard,
MUSICNorrtalje Study
Group (1998)
19. Toomingas,
Theorell,
Michelsen,
Nordemar
(1997)
20. Wunderlich,
Sloan, Davis
(1996)
Focus
Musculoskeletal
symptoms & job
strain in nurses.
Authors, Year
17. Josephson,
Lagerstrom,
Hagberg, Hjelm
(1997)
Sample
285 nurses at a
county hospital.
Repeated crosssectional surveys
given to all
personnel on
wards with
patients
requiring daily
care (e.g.
transfers).
Random sample
of 333 women
with back pain &
733 women in
control group (81
and 188
respectively
were employed
in nursing).
358 men &
women from
various
occupations (83
male furniture
movers, 89
female medical
secretaries; 96
men & 90
women of
working
population).
Work
environment.
Psychosocial
work conditions
(demands, social
support, decision
latitude)
Nursing ratios,
professional
status, proportion
of nurse worked
Conflicting
demands, job
strain.
Throughputs
Nurse
demographics
Inputs
Nurses health,
patient
outcomes,
violence.
Symptoms,
signs, &
syndromes of
musculoskeletal
origin.
Low-back
problems
Outputs
Nurses health
status.
39
Increase in acuity in hospitals means that RNs

may need more education. Ancillary nursing
personnel should have documented evidence of
competency. Nurses have high rates of work-
Strong associations between poor psychosocial

conditions (especially low support & high
demands) & musculoskeletal disorders
(especially central body region). Most
prevalence ratios were above 1.0 meaning
mostly positive associations between
unfavourable conditions & pain.
Female nursing personnel had no increased risk

of low-back pain compared with other
employed women. Combinations of physical &
psychosocial factors are associated with high
risk. Physical load is more significant in
nursing than psychosocial factors in relation to
low-back pain
Findings
Job strain is a risk factor for musculoskeletal
symptoms & the risk is higher when combined
with perceived physical exertion (RR=1.5-2.1).
Increased job strain may be associated with
staff cuts, reorganization, & new requirements.
3.
Focus
& nursing homes.
Examine effects of
nurse staffing &
organizational
support for nursing
care on nurses'
dissatisfaction with
their jobs, nurse
burnout, & nurse
reports of quality
patient care in
22. Aiken, Clarke,

Sloane, (2002).
Focus
Mortality rates in
hospitals with higher
proportion of RN
staff to total staff
Authors, Year
21. Aiken, Smith,
Lake (1994)
System Characteristics and Behaviours
Authors, Year
10,319 nurses
working in
medical &
surgical units in
303 international
hospitals
Unit of analysis
is hospital
Sample
39 magnet
hospitals
matched with
195 control
hospitals in U.S.
Sample
Workload,
proportion of nurse
worked hours,
organizational
support.
Inputs
Hospital size &
organization,
staffing ratios.
Inputs
hours, staffing
levels.
Throughputs
Throughputs
Nurse burnout,
job satisfaction,
nurses
perceived quality
of care.
Outputs
Mortality rates
Outputs
40
Findings
Observed mortality rates for magnet hospitals
are 7.7% lower (9 fewer deaths per 1,000
Medicare discharges; p=0.011). After adjusting
for predicted mortality, magnet hospital rates
were 4.6% lower (p=0.026, CI 95%; 0.9 to 0.4
fewer deaths per 1,000).
Magnet hospitals had significantly higher RN:
total nursing personnel ratios & slightly higher
nurse: patient ratios
Skill mix & nurse: patient ratios do not explain
the mortality effect or the variability in effects
across hospitals. Authors propose that mortality
effect derives from greater status, autonomy &
control afforded nurses in magnet hospitals; not
simply an issue of credentials & number of
nurses.
Organizational/managerial support for nursing
had a pronounced effect on nurse dissatisfaction
& burnout. Organizational support for nursing
& nurse staffing were directly related to nurseassessed quality of care. Nurse reports of low
quality care were three times as likely in
hospitals with low staffing & support for
nurses, compared to hospitals with high staffing
& support.
Findings
related injury & back injuries were related to
staffing issues. Violence towards healthcare
workers is increasing.
Nurse staffing &

patient occurrences.
Relationship among
incidence rates of 6
adverse pt. outcomes,
the hours of care
26. Blegen,
Vaughn (1998)
27. Blegen,
Goode, Reed,
(1998).
Hospital ownership,
performance, &
outcomes.
Focus
hospitals.
Determine
association between
patient-to-nurse ratio
& patient mortality,
failure among
surgical patients, &
factors related to
nurse retention.
Literature review of
various methods of
nurse staffing level
measurement.
25. Baker,
Messmer,
Gyurko,
Domagala,
Franklin, Eads,
Harshman,
Layne (2000)
24. Arthur, James

(1994)
23. Aiken, Clarke,

Sloane,
Sochalski,
Silber (2002).
Authors, Year
42 inpatient units
in an 880-bed
university
hospital.
39 units in 11
hospitals.
6,097 hospitals
in the U.S.
210 adult general

hospitals; 10,184
staff nurses
randomly
surveyed;
232,342 patients
discharged.
Sample
Patient acuity:
(unique Patient
Classification
System; levels
Staffing mix, type

of unit.
Patient
demographics,
nursing
interventions,
patient
dependency, and
proportion of nurse
worked hours.
Hospital ownership
type (public,
private-for profit,
private non-profit),
performance
Nurse
demographics,
professional status,
medical diagnosis,
patient
demographics,
hospital size.
Inputs
Organizational
work
environment.
Workload
measurement.
Throughputs
Adverse events,
morbidity,
mortality, patient
satisfaction,
nurse
satisfaction,
costs,
productivity.
Patient
complications
(med errors,
falls),
cardiopulmonary
arrests.
Patient
outcomes:
medication
errors per 10,000
Staffing ratios,
length of stay.
Nurse job
satisfaction,
burnout, patient
mortality, costs,
and
complications.
Outputs
41
Higher proportion of RNs resulted in fewer

patient complications (med errors/dose R2=0.576, falls R2=-0.456) but the relationship is
not linear. Units with RN proportion >85% had
higher med errors (may be heightened
vigilance, sicker patients with more meds).
Controlling for average patient acuity adjusted
at unit level, RN proportion was inversely
related to the unit rates of medication errors,
decubiti, & patient complaints. Total hours of
Various approaches to nurse demand methods:

consensus (intuitive, consultative method), topdown management (staffing norms, staffing
formulae), & bottom-up management (nursing
interventions, patient dependency). Debates
surrounding these methods include:
comparability vs. local suitability, control,
efficiency, effectiveness, & philosophy of care.
Hospital ownership has an impact on hospital
performance in relation to system operations:
costs, prices, & financial management
practices; & personal issues. Association
between hospital ownership & adverse events
consistently supported.
In hospitals with high patient-to-nurse ratios,

surgical patients experience higher riskadjusted 30-day mortality & failure-to-rescue
rates (odds ratio 1.07), & nurses are more likely
to experience burnout & job dissatisfaction
(odds ratio for dissatisfaction is 1.15).
Findings
Synopsis of ANA
study on relationship
between staffing &
patient outcomes.
Mandatory minimum
nurse staffing levels
in hospitals
28. Brown (2001)
29. Buerhaus
(1997)
Focus
provided by all
nursing personnel &
the proportion of
those care hours
given by RNs.
Authors, Year
Nearly 13
million patients
in 1500 hospitals
from 9 states
Fiscal year 1993.
21,783
discharges &
198,962 patient
days of care
provided by
1074 FTE
nursing staff
members, 832 of
those FTEs were
RNs.
Sample
Proportion of nurse
worked hours,
nurse-to-patient
ratio
Nurse staffing: All

Hours (monthly
hours of care
patient per day by
RNs, LPNs,
NAs/patient days
on unit); RN Hours
(hours of direct RN
patient care/patient
days); RN
proportion (RN
hours patient per
day/All Hours)
Proportion of nurse
worked hours,
medical diagnosis.
Inputs
range between 1
and 7 most
acute/most care)
Throughputs
Costs of care,
clinical
outcomes
Staffing ratios,
patient
complications &
outcomes, length
of stay
Outputs
doses (nurse selfreport), falls,
decubiti, urinary
& respiratory
infections,
patient
complaints per
1,000 patient
days & mortality
rates per 1,000
patient days.
42
Several patient outcomes were significantly

related to staffing (length of stay, pneumonia,
post-op infections, ulcers, urinary tact
infections). Cost savings in reductions of staff
& mix may not be real savings when
complications & increased length of stay are
considered.
Staffing regulations (if imposed) would force
employers to ignore dynamic interactions of
economic, technology, capital & labour supply
variables. There would be significant costs
associated with enforcing the regulation which
would outweigh the benefits.
When the proportion of RNs in the staff mix

was greater than 87.5%, adverse outcomes also
increased.
A larger proportion of care delivery by RNs

was associated with a decrease in adverse pt
outcomes up to a level of 87.5% of RN staffing.
Findings
care from all nursing personnel were associated
directly with complaints, decubiti, & mortality;
however total hours of care were highly
correlated with acuity.
Using case mix group

to predict workload.
33. Campbell,
Taylor,
Callaghan,
Shuldham
Reasons for the CNA

backed nurse-topatient ratios.
31. California
Nurses
Association.
(2001)
32. Callaghan,
Cartwright,
ORourke,
Davies (2003)
infant to staff ratios
in first three days of
life on the survival to
hospital discharge
Focus
changes in patientnurse ratios resulting
from hospital
restructuring &
nursing staff
satisfaction,
psychological health,
& perceptions of
hospital functioning.
Authors, Year
30. Burke (2003)
798 patients &

30 nurses from
one ward.
Retrospective
Jan. 1996 Dec.

1999
692 very low

birth weight
infants in an
Australian
intensive care
unit
1st wave Nov.

1996. 2nd wave
Nov. 1999.
Sample
Self-report
survey of 744
hospital-based
nursing
survivors.
Staffing: number of
nurses working per
shift, maximum
number of infants
per shift
Patient
demographics,
admission type,
case mix group.
Infant
characteristics:
dependency
(infant:nurse ratios:
intensive 1:1, high
1:2, medium 1:3, &
recovery 1:5), birth
history, admission
& physiological
data
Hospital: size
Medical diagnosis
Nurse: experience,
employment status,
education,
demographics
Inputs
Patient-nurse ratio:
current & changes
since restructuring
began
Workload
Throughputs
Costs of care,
length of stay.
Survival to
hospital
discharge,
adjusted for
initial risk (using
Clinical Risk
Index for Babies)
& for unit
workload (infant
dependency
scores)
Outputs
Work outcomes,
work
experiences:
extent of
restructuring,
perceived
workload, job
security,
psychological
health, hospital
effectiveness:
Staffing ratios
43
Regression analysis showed that there was no

relationship between resources used & nursing
clinical hours; however, there was a good
relationship between the number of patients &
Overall hospital mortality rate of 12% (80 out

of 692 infants).
Odds of mortality, adjusted for initial risk &
unit workload improved by 82% when an
infant:staff ratio of greater than 1.71 occurred.
Strong ratios will help reduce the nursing

shortage. They must be determined in
accordance to individual patient care needs.
Findings
53% of nurses reported an increased patientnurse ratio. Increased ratios associated with less
job satisfaction & job security, greater intention
to quit & more restructuring initiatives, poorer
psychological (but not physical) health, & less
effective hospital functioning.
Cost associated with

absenteeism,
overtime, &
involuntary part-time
employment.
Effect of nurse
staffing levels on
adverse events.
34. Canadian
Labour &
Business Centre
(2002).
35. Clark (2002)
Focus
Authors, Year
(1997)
Data from 799

hospitals in 11
states.
201 bed hospital

in Ottawa.
Sample
data from
hospital pt.
administration
system.
Proportion of nurse
worked hours.
Nurse
demographics.
Inputs
Throughputs
Patient
complications &
outcomes, length
of stay, staffing
ratios.
Costs of care,
absenteeism, use
of agency nurses,
turnover.
Outputs
44
Findings
resources used. Average lengths of stay for case
mix groups were greater than predicted. For
cystic fibrosis patients (representative of
specialist nursing), case mix group accounted
for only 18% of variation in nursing time
required. Case mix group has shown to be a
poor predictor of nursing requirement.
Overtime hours have increased dramatically
over past 3 years. Agency costs represent 34 %
of overtime costs. There are estimates that 2530% of absenteeism is related to stress &
injury. Additional full-time equivalents would
reduce costs.
Higher proportion of RNs resulted in better
care. No association between lower rates of
outcomes & number of hours of care by LPNs
or nurses aides.
Measuring nursing
costs using nursing
workload.
Effect of nurse
staffing issues on
nurse communication
& patient outcomes.
Impact of workplace
health on quality of
care.
37. Cockerill,
OBrien-Pallas,
Bolley, Pink
(1993)
38. Doran,
McGillis Hall,
Sidani,
OBrien-Pallas,
Donner, Baker,
Pink (2001)
39.Eisenberg,
Bowman, Foster
(2001)
Focus
Organizational
climate, staffing, &
safety equipment
Authors, Year
36. Clarke,
Rockett, Sloane,
Aiken (2002)
1116 nurses from

19 urban
teaching
hospitals.
Stratified
random sample,
97% response
rate.
256 patient
records from 4
units in a large
teaching
hospital.
Sample
1998 survey data
for 2287 medical
surgical unit
nurses in 22 US
hospitals (20
were magnet
hospitals). 1998
survey of
management,
infection control,
purchasing
officials re:
equipment
selection &
procurement
Staffing ratios,
proportion of nurse
worked hours,
patient
demographics, case
mix groups, nurse
education,
experience.
Staffing mix, ratios
Inputs
Self-report
compliance with
universal
precautions &
perceived risk Nurse
characteristics.
Protective
Equipment.
Nurse staffing:
patients cared for
on last shift
worked; hospitallevel measure
averaging patient
loads,
organizational
climate (R-NWI)
Case mix group
Work
environment
Workload
(GRASP, NISS,
Medicus, PRN)
Throughputs
Costs of care,
quality of care
Patient health
status.
Costs of care.
Outputs
- Needlestick
injuries & nearmisses: selfreport
occurrence,
frequency in past
month & past
year,
circumstances,
reporting
45
Environment, organization, staffing, & culture

influence quality of care via their effect on the
healthy workplace. Adequate number of staff,
There were significant differences among

systems in estimates of care for patients.
Nursing costs per case differ significantly
depending solely on workload measurement
system used (as much as 30% difference in cost
for same patient).
Higher mix of RNs improved communication &
led to beneficial patient outcomes. Nursepatient ratio (r=0.138) & proportion of
regulated staff (r=0.155) positively affected
nurse communication. Effective communication
among nurses led to better patient health
outcomes (r=0.175).
Findings
- Average day shift workload ranged from 3.6
to 8.7 patients per nurse (n = 22)
- In n=5, average day shift workload of more
than 6 patients (heaviest workload)
- nurses with heaviest workload were 50%
more likely to report an injury & 40% more
likely to report a near-miss in the preceding
month
Factors that influence

turnover & absence
of nurses, the
relationship between
absence & turnover.
Nurses views of
workload & work
overload.
40. Gauci Borda,

Norman (1997)
41. Gaudine
(2000)
Focus
Authors, Year
31 staff nurses
from 9 different
units of a
hospital in
central Canada,
volunteer
sampling.
17 studies on
relationship
between job
satisfaction,
intent to
stay/leave &
actual turnover.
Sample
Nurse
demographics,
experience, and
patient acuity.
Nurse job
satisfaction, system
organizational
factors.
Inputs
Simultaneous
demands,
unanticipated
events,
interruptions,
noise level.
Throughputs
Nurses feelings
of workload &
overload.
Nurse
absenteeism,
turnover.
Outputs
46
Findings
appropriate blend of skills & proper equipment
enable work. Heavy workloads inhibit staff
from participating in research. Enhancing
workers health & satisfaction may improve
patient outcomes.
Job satisfaction influences absence & intent to
stay. Intent to stay in current employment
influences turnover. Intent to stay is most
strongly associated with job satisfaction. Pay &
opportunity for alternative employment also
influence intent to stay, which is supported by
two studies. Absence is positively related to
turnover (absence increased before turnover) &
negatively related to intent to stay. Kinship
responsibility is directly related to intent to
stay.
Meanings that nurses attributed to workload
include volume, simultaneous demands,
demands on self, qualitative overload,
anticipation, responsibility, interdependence,
non-work roles & exhaustion. The meanings of
work overload include simultaneous demands,
qualitative work overload, heavy load, &
responsibility. These meanings include more
dimensions than current measures of workload.
Implementation of a
nursing partnership
model.
Effects of variables
on nursing workload.
Factors that affect

patient mortality
rates.
43. Grillo-Peck,
Risner (1995)
44. Halloran
(1985)
45. Hartz,
Krakauer,
Kuhn, Young,
Focus
Impact of hospital
restructuring on
nurses.
Authors, Year
42. Greenglass,
Burke (2001)
2560 patient
records & 141
nursing staff
members from a
279-bed acute
care, community
hospital. This
included all
patients admitted
& discharged
over a 4 month
period.
3100 hospitals in
the United
States. Data from
Sample
1363 nurses
employed in
hospitals
undergoing
restructuring.
Random
selection from
union
membership,
35% response
rate.
156 patients
from a
neuroscience
unit in an 800bed not-forprofit hospital in
Ohio.
Patient
demographics,
medical diagnosis,
Patient mortality.
Costs of care,
nursing
workload.
Nursing diagnoses,
medical diagnoses
(DRG), patient
demographics.
Outputs
Perceived quality
of care, job
satisfaction,
working
conditions.
Patient length of
stay,
complications
(infections,
falls), medication
errors.
Throughputs
Proportion of nurse
worked hours, care
delivery system,
medical diagnosis,
patient
demographics, and
continuity of care.
Inputs
Nurse education,
demographics,
hospital size.
47
Higher mortality rates were associated with forprofit (121/1000 patients vs. average of
116/1000) & public hospitals (120/1000) &
Findings
Restructuring had a negative effect on staff
(97.9% of respondents agree) & working
conditions (94%). It has compromised the
quality of care & reduced nurses ability to
provide services for patients. During hospital
restructuring workload was the most significant
& consistent predictor of distress in nurses, as
manifested in lower job satisfaction,
professional efficacy, & job security. Greater
workload also contributed to depression,
cynicism, & anxiety.
A nursing partnership model which included a
decrease in RNs & a primary nursing model
was implemented. RNs were partnered with a
patient care technician & assisted by service
associates. This allowed for continuity of care.
Patient complications showed a downward
trend after the implementation & length of stay
decreased. RNs were able to spend less time in
non-professional tasks.
Variations in nursing workload were better
explained by nursing condition than by medical
condition or patient demographics (75% of the
sum of the squared regression coefficient is
associated with nursing diagnosis & 25 % is
associated with medical diagnosis). There was a
strong positive relationship between workload
& length of stay in hospital (correlation
coefficient=0.774). Of demographic
characteristics, only age is associated with
variations in workload (r=0.198).
Pilot project for

implementing LPNs
to maintain quality
during staffing
shortages.
Influencing factors
on mortality in
intensive care units.
Adequacy of nurse
staffing.
47. Kenney.
(2001)
48. Knaus, Draper,

Wagner,
Zimmerman
(1986)
49. Kobs. (1997)
Optimal nurse
staffing levels in long
term care.
Focus
46. Hendrix,
Foreman (2001)
Authors, Year
Jacobsen, Gay,
Muenz, Katzoff,
Bailey, Rimm
(1989)
5,030 patients in
intensive care
units in 13
tertiary care
hospitals.
Hospitals were
self selected &
patients were
convenience
sampled.
Sample
the Healthcare
Financing
Administration
& the American
Hospital
Association
annual survey.
Over 12,000
federally
certified skilled
& intermediate
nursing homes in
the United States
(data from
1994).
Proportion of nurse
worked hours.
Patient
demographics,
admission type,
medical diagnosis.
Staffing mix,
ratios.
Proportion of nurse
worked hours,
nursing ratios.
Inputs
hospital size,
proportion of nurse
worked hours,
nurse ratios.
Workload.
Throughputs
Patient
complications,
Nurses health,
costs of care,
patient
satisfaction,
complications
(falls, med
errors), nurse
satisfaction
Patient
complications &
outcomes.
Cost of care,
costs of injury,
patient outcomes
(decubitus
ulcers), public
burden.
Outputs
48
There is a positive correlation between shorter

length of stay & higher staffing levels. As RN
Degree of coordination of intensive care

positively influences its effectiveness.
Interaction & communication between
physicians & nurses affect patient mortality.
There is an optimal level of nurse staffing that

minimizes decubitus ulcers in nursing homes.
The presence of RNs (superior skills; =-1.659)
& nurses aides (lower wage; =-7.334))
reduces costs associated with ulcer care while
the presence of LPNs (=4.544) increases the
cost of ulcer care. Nursing homes should
increase the number of RNs & NAs.
There were no changes in quality of care
(number of treatment/procedure errors & falls
remained stable) or staff satisfaction with the
addition of LPNs. LPNs were delegated to tasks
by RNs who were still responsible for several
patients.
Findings
osteopathic hospitals (129/1000). The
characteristics most closely linked with
mortality are related to training of medical staff
(e.g. higher percentage of RNs = lower
mortality). Higher occupancy rate was
associated with lower mortality rate.
Impact of staffing &

work organization on
patient outcomes &
healthcare workers.
nurse staffing &
adverse events.
Evaluation of a
model for analyzing
hospital mortality
rates.
Characteristics of
magnet hospitals.
Characteristics of
magnet hospitals.
50. Kovner (2001)
51. Kovner,
Gergen (1998)
52. Krakauer,
Bailey, Skellan,
Stewart, Hartz,
Kuhn, Rimm
(1992)
53. Kramer,
Schmalenberg.
(1988) Part 1.
54. Kramer,
Schmalenberg
(1988) Part 2.
Focus
Authors, Year
16 magnet
hospitals.
589 acute-care
hospitals in 10
states, data from
a 20% stratified
probability
sample to
approximate US
hospitals.
42,773 patients
from 84
hospitals.
Random
sampling of
discharges &
hospitals from
strata.
16 magnet
hospitals.
Sample
Hospital size,
staffing ratios,
nurse education,
experience.
Hospital size,
staffing ratios,
nurse education,
experience.
Proportion of nurse
worked hours,
hospital size.
Nurse staffing
(FTE RNs working
patient per day).
Nurses education,
staffing ratios.
Inputs
Throughputs
Nurse turnover.
Nurse turnover.
Patient
complications.
Patient mortality,
medication error
rates, postoperative
infections.
Outputs
length of stay,
staffing ratios.
Nurses health,
patient
complications.
49
Magnet hospitals are successful in recruiting &

retaining nurses during periods of shortage.
Fluidity & informality allows for
communication & exchange of information.
Staff nurses were allowed time for research,
publication & special projects. There is support
for continuing education & encouragement of
autonomy & entrepreneurship.
Magnet hospitals have characteristics similar to
well run companies. They deal with nursing
shortage by altering organizational conditions
to eliminate internal shortage. Leaders are
Hospitals with higher proportion of RNs had

lower adjusted mortality rates (difference of
2.1-3.6%).
Findings
staffing increased, patient complications
decreased.
Inverse relationship between mortality &
number of RNs. Inverse relationship between
complications & number of RNs. There are
high rates of illness & injury among healthcare
personnel.
Inverse relationships between FTE RNs per
adjusted inpatient day & urinary tact infections
(-636.96, p<.001), pneumonia (-159.41,
p<.001), thrombosis (-33.22, p<.01), pulmonary
compromise (-59.69, p<.05) after major
surgery.
57. Maxwell
(2002).
Organization of
intensive care units &
the influence on
patient outcomes.
55. Kutsogiannis,
Hague, Triska,
Johnston,
Noseworthy
(2001)
56. Manitoba
Nursing
Strategy (2003).
The Manitoba
Nursing Strategy
(MNS) is a report
released by the
Manitoba
government to
address the concerns
raised by nurses &
other stakeholders
within the healthcare
system.
Factors needed to
create high-quality
care environments.
Focus
Authors, Year
Sample
System
organization,
workload, nurse
job control.
Care delivery
system.
Inputs
Work
environment.
Work
environment &
organization.
Throughputs
Nurse health, job

satisfaction,
patient
outcomes.
Costs of care,
patient
complications,
length of stay.
Outputs
50
Job design, job rewards, organizational change,

& job security can have major employee health
implications. Role stressors & job insecurity
influence the work environment. Workload,
work pace, & work scheduling are important
work environment issues facing health-care
workers. Positive health outcomes for nurses
are associated with high job control & a balance
of job demands with sufficient resources.
Hospitals with positive work environments
have better staff recruitment & retention, &
patient outcomes.
Findings
highly visible & accessible. Magnet hospitals
value quality, autonomy, informal
communication, innovation, education, respect,
excellence, & bringing out the best in each
individual.
Important factors in organization include
communication, leadership, & interdisciplinary
politics. Better standardized practices &
coordination were related to better outcomes
(lower mortality & morbidity).
MNS includes:
1. Increase the supply of nurses
2. Improve access to staff development for
nurses.
3.
3. Improve the utilization of nurses.
4. Improve working conditions.
5. Increase nurses' opportunities to provide
input into decision-making.
The Demonstration
Critical Care Unit:
organizational &
clinical outcomes.
E7ffects of
organizational
variables in care
delivery systems on
adverse outcomes.
59. Mitchell,
Armstrong,
Simpson, Lentz
(1989)
60. Mitchell,
Shortell, (1997)
Focus
Reports on staff mix
& work status of
nurses in adult
medical, surgical, &
obstetrical units in
Ontario's teaching
hospitals.
Authors, Year
58. McGillis Hall,
Irvine Doran,
Baker, Pink,
Sidani, O'BrienPallas, Donner
(2002).
Sample
19 teaching
hospitals, 2,046
patients, 1,116
nurses, 74 unit
managers.
Random
sampling was
used.
42 nurses, 68
physicians, 192
patient
admissions.
Patients
representative of
units population
except for drug
overdose or short
stay.
81 research
papers.
Organizational
variables in care
delivery systems.
Inputs
Nurse
demographics,
experience,
employment status,
care delivery
system, proportion
of nurse worked
hours.
Hospital size &
type, nurse
demographics,
admission type,
patient
demographics,
medical diagnosis.
Throughputs
Patient
morbidity,
mortality, &
adverse effects.
Costs of care,
nurse job
satisfaction, &
burnout, patient
complications,
length of stay.
Outputs
51
Some support that nursing surveillance, quality

of working environment & interactions with
other professionals are related to lower
mortality & complications. Patient variables
have a greater impact than organizational
variables. Adverse events are more closely
related to organizational factors than is
mortality.
Findings
There is a need for developing appropriate
levels of knowledge & skill for complex
inpatients cared for in medical/surgical &
obstetrical units. The proportions of RNs within
the individual unit staffing models remained
relatively high (60-89%). More than one third
of the nursing staff were employed on a parttime or casual basis.
Positive organizational & clinical outcomes
exist with valued aspects of organizational
environment (high nurse-physician
collaboration, highly rated nursing
performance, positive organizational climate)
as compared with historical comparison
samples.
Determine
equivalence of
workload estimates
of 5 patient
classification
methods (NISS,
GRASP, Medicus,
PRN 76 & PRN 80)
Presents a meta-
62. OBrienPallas,
Cockerill, Leatt
(1992)
63. OBrien-
Focus
Examine the relation
between the amount
of care provided by
nurses at the hospital
& patients' outcomes.
Authors, Year
61. Needleman,
Buerhaus,
Mattke, Stewart,
Zelevinsky
(2002)
206 patients
from a large
urban teaching
hospital,
purposive
sampling in
selected units
(critical care
unit, intensive
care unit, etc.).
14 nursing units
Sample
1997 admin data
for 799 hospital
in 11 US states
(discharges:
5,075,969
medical &
1,104,659
surgical patients;
accounted for
26% of 1997
discharges from
non-federal US
hospitals). Unit
of analysis was
hospital.
Nursing
Case mix group

classification
Inputs
Inpatient staffing
levels patient per
day adjusted for
inpatient vs.
outpatient bias;
differences
between hospitals
level of nursing
care per DRG; risk
adjustment for
patient
characteristics; &
hospital
characteristics
(number of hospital
beds, teaching
status, state, &
metropolitan/nonmetropolitan).
Presence of new
Throughputs
Amount of direct
Program cost
forecasting
Outputs
Length of stay,
post-operative
complications,
adverse events,
mortality. Failure
to rescue defined
as: death from
pneumonia,
shock or cardiac
arrest, upper GI
bleeding, sepsis,
or deep venous
thrombosis
p.1715
52
Multifactorial intensity & complexity of care
Findings
- Mean hours of nursing care per patient-day
was 11.4; of which, 7.8, 1.2 & 2.4 provided by
RNs, LPNs, & nursing aides respectively. Mean
proportion of total hours of RN care was 68%
& of nursing aides care was 21%.
- Among medical patients, a higher proportion
of RN hours of care patient per day & greater
absolute number of RN hours of care per day
associated with shorter length of stay (p=0.01 &
p<0.001), lower rates of urinary tact infection (
p<0.001 & p=0.003) & lower rates of upper GI
bleeding (p=0.03 & p=0.007). Higher
proportion of RN hours associated with lower
rates of pneumonia (p=0.001), shock or cardiac
arrest (p=0.007), & failure to rescue (p=0.05).
- Among surgical patients, higher proportion of
RN care associated with lower rates of urinary
tact infection (p=0.04). Greater number of
hours of RN care patient per day associated
with lower rates of failure to rescue (p=0.008).
- No association found between RN staffing
levels & rate of in-hospital mortality. No
association found between increased staffing by
LPN or nursing aides & rate of adverse
outcomes.
Clinically significant differences in hours of
care estimates found by each system but a high
correlation between the systems suggests that
calibration could be used to compare data
(alphas < 0.0001).
Variables that affect

nursing utilization in
a home visiting
nursing service.
Economic impact of
staffing decisions
64. OBrienPallas, Doran,

Murray,
Cockerill,
Sidani, LaurieShaw,
LochhassGerlach (2001)
65. OBrienPallas,
Thomson,
Alksnis, Bruce
Focus
paradigm for
examining nursing
work & resource use.
Authors, Year
Pallas, Irvine,
Peereboom,
Murray (1997)
Ontario acute
care hospitals
Clients were unit

of analysis.
38 RNs, 11
RPNs; 751
clients receiving
home healthcare
(6,840 visits or
7% of agency
caseload during
study period);
convenience
sample.
Sample
in a 489 bed
pediatric tertiary
care, urban,
hospital, crosssectional sample.
Hospital
Characteristics:
earned (paid) hours
patient per day (for
Agency:
geographic
location, visit type,
caseload,
proportion of nurse
worked hours &
continuity of care.
Nurse: education,
experience,
professional status.
Agency: total
visits.
Nurse: perceived
adequacy of care
time.
Patient health
status, OMAHA
scores
(knowledge,
behaviour, and
status).
Agency: visit
time
Client:
demographics,
nursing & medical
diagnoses,
OMAHA scores,
SF-36 health status,
time on program
Environmental
Complexity:
competing
demands/nurse
safety,
unanticipated
case complexity,
formal
information
exchange, voice
mail, travel,
unanticipated
admissions.
Outputs
care required
(PRN 80), costs
of care.
Throughputs
staff, relief staff,
unanticipated
events.
Inputs
complexity
(NANDA),
medical complexity
case mix groups
(CMGsTM),
medical severity
(length of stay).
53
Overall, Client Care Delivery Model explained

35.6% (R2 = .33) of the variation in number of
visits. Visits performed by degree-prepared
nurses resulted in fewer total visits & improved
RN perceptions of visit adequacy. Greater time
per visit, higher scores for formal information
exchange & continuity of care by the primary
nurse were associated with fewer visits. A
medical diagnosis of neoplasm, greater number
of nurses visiting client, palliative & long
duration visits types, & increasing use of voice
mail were associated with increased number of
visits.
Between 1994 and 1998, inpatient cases
dropped by 184,766 while outpatient cases
increased by 144, 603. Data suggest that an
increase in the overall resources used by
Findings
model examines costs, nursing work &
variability in resource use across patients &
environments. Relationships observed between
4 key variables & workload: patients nursing
condition (positive linear relationship with # of
diagnoses), medical condition (most have
coefficients of variation > 0.5), caregiver
characteristics & the environment.
Overall, Client Care Delivery Model explained
47% (R2 = .46) of the variation in average visit
time. Medical & nursing diagnoses explained
14.7% of variation in average visit length.
Specifically, mental health diagnoses
contributed to longer but not necessarily more
visits. Unanticipated case complexity &
unanticipated admissions were positively
associated with greater average visit time,
explaining 20.5% of the variation.
Factors that affect

staffing needs.
Focus
66. Pinkerton,
Rivers (2001)
Authors, Year
(2001)
Sample
Nurse education,
experience, use of
relief staff,
workload,
proportion of nurse
worked hours
Patient
Characteristics:
relative intensity
weights,
complexity of
inpatient hospital
cases (1994/95
1998/99);
Inputs
RN, RPN, & UCP
combined), RN
survey of
absenteeism &
overtime, staffing,
compensation,
workload data &
productivity
Frequency &
complexity of
changes.
Throughputs
Burnout.
Outputs
54
Overtime costs almost perfectly correlated

(r=.928, p>.01) with sick time costs. Hours
patient per day were related to both overtime
costs (r=.439, p<.01) & sick time costs (r= .488,
p<.01) suggesting that as hours of care patient
per day increased, so did the overtime that
nurses were asked to work & the incidence of
missed shifts due to illness.
Important variables include unit cohesiveness,
chaos factors, communication, organizational
skills of nurses, support staff availability, &
number of float staff.
In 1998/99 alone, $171 million spent on

overtime hours (approx. 2,250 FTEs); of which,
$57 million on overtime pay premiums. $19
million spent on nursing agency personnel &
$39 million spent on sick time (approx. 765
FTEs).
Findings
hospitalized patients in recent years even
though the number of hospitalized cases & the
average length of stay have decreased.
Complexity levels have tended to increase for
all age groups in each year between 1994 and
1998, while the overall number of nurses
working in hospital settings ahs decreased.
Impact of nurse
staffing levels & skill
mix on patient
outcomes
Whether
organizational,
administrative, &
practice factors
differentiate among
hospitals & patient
care units as to
registered nurse
68. Prescott
(1993)
69. Prescott
(1986)
Focus
RN staffing levels &
patient outcomes.
Authors, Year
67. Potter, Barr,
McSweeney,
Sledge (2003)
Data collected in
1981 & 1982
1044 staff nurses

working on 90
patient care units
in 15 hospitals.
Unit of analysis
was inpatient
unit. Adjusted
for float
percentage &
acuity.
Sample
All acute
inpatient care
units (n=32) of
one hospital.
2000.022001.01.
Staff-patient ratios
33 predictor
variables.
Unit vacancy rates,

voluntary turnover,
stability.
Patient
characteristics:
acuity (vendorbased patient
classification tool).
Proportion of nurse
worked hours,
staffing levels.
Inputs
8 hour day shift
nurse staffing
converted to direct
nursing care daily
hours per patient
for all nursing
personnel per
month; average:
number of hours of
nursing care per
patient daily on day
shift; percentage
of RN & UAP
direct care hours;
float percentage;
total patient care
hours.
Throughputs
Patient mortality,
quality, and costs
of care.
Outputs
Patient
outcomes: falls
per 1000 patient
days, medication
errors per 1,000
patient days,
self-reported
symptom
management
(VAS), self-care
& health status
(National Center
for Health
Statistics Health
Interview
Survey) & postdischarge patient
satisfaction.
55
High vacancy rates associated with 7 variables

including high staff-patient ratios on evening
shift & perceived inadequacy of working
conditions.
High percentage of RNs is associated with

lower than expected mortality rates (13
studies), length of stay, costs, complications.
Salary savings of declining skill mix may be
offset by productivity declines.
Model explained 52% of variability in vacancy
rates, 56% of variability in stability rates, &
42% of variability in relative turnover.
Findings
Percentage of RN hours negatively correlated
with patients perception of pain & positively
correlated with patients perceptions of selfcare ability & health status, as well as
satisfaction post-discharge.
Staffing intensity &

costs of care.
Review of literature
on characteristics &
impact of healthy
work organizations
Characteristics of
acute care hospitals
that report RN
shortages when
widespread shortage
exists & when
widespread shortage
is no longer evident.
Understanding the
70. Robertson,
Dowd, Hassan
(1997)
71. Sainfort,
Karsh, Booske,
Smith (2001)
72. Seago, Ash,

Spetz, Coffman,
Grumbach
(2001)
73. Seybolt (1986)
Focus
vacancy, stability, &
turnover rates.
Authors, Year
647 females RNs
All acute-care
hospitals in
United States,
secondary data
from national
survey.
196 acute care

hospitals in
California from
AHA annual
survey.
Sample
Career stage, work-
Staffing levels
(shortages), patient
demographics,
nurse education,
care delivery
system.
Hospital size, care

delivery system,
staffing
Proportion of
Nurse worked
hours
Inputs
at organizational
level.
Work
environment
Throughputs
Nurse turnover
Nurse health
status, patient
complications,
job satisfaction,
burnout
Costs of care,
Staffing ratios.
Outputs
56
High turnover associated with 7 variables

including low staff-patient ratios on night shift
& perceived inadequacy of working conditions.
Negative association between some staffing
levels & costs of care (r=-0.04 to r=-0.36).
Higher respiratory care technician staffing
intensity is related to lower costs per episode of
care (r=-0.36). Positive relationship between
RN staffing intensity & costs of care (may be
due to use of high skill mix strategy) r=0.08.
There are limits of skill-specific staffing
intensity below which costs of care are actually
increased. Understaffing increases costs &
reduces quality.
Creates a model & research agenda for
healthcare quality improvement & patient
safety. Organizational factors & working
conditions affect employee health &
productivity.
Location in South, high percentage of nonwhite county residents, high percentage of
patients with Medicare as payer, higher patient
acuity & use of team nursing care delivery
predicted hospitals reporting shortages both
when there was & when there was not a
widespread shortage. Wage is not a significant
predictor of shortages. RN workforce policy
needs to place emphasis on distribution relative
to overall supply.
Turnover intentions of employees at different
High stability associated with 7 variables

including increased staff-patient ratios &
perceived inadequacy of working conditions.
Findings
Hospital & patient

characteristics that
predict mortality after
surgery.
Quality of care, nurse

staffing & patient
outcomes.
Impact of hospital
restructuring on
patient outcomes
74. Silber,
Williams,
Krakauer,
Schwartz (1992)
75. Sochalski
(2001)
76. Sovie, Jawad

(2001)
Focus
causes of premature
nurse turnover in
order to retain nurses.
Authors, Year
2831 patients
undergoing
cholecystectomy
& 3141 patients
undergoing
transurethral
prostatectomy.
Random
selection, from 7
states.
13,200 medicalsurgical RNs
from acute care
hospitals in
Pennsylvania.
Random sample
from state board
database, 52%
response rate.
1997 & 1998
fiscal year data
from 29 U.S.
university
teaching
hospitals (with >
300 acute
operating beds)
from 8 of 9 U.S.
census regions; 1
inpatient acute
adult medical
Sample
at a large West
Coast hospital
Structure:
MECON-PEERx
Operations
Benchmarking
Database Reports
(FTE for each type
of nursing
personnel;
proportion of nurse
worked hours;
hours worked per
patient daily for
Nurse
demographics,
education,
proportion of nurse
worked hours
Inputs
role design (job,
interactions,
organizational
policies)
Patient
characteristics,
number of hospital
beds, staff ratios
Process:
Management
Practices &
Organizational
Processes
Questionnaire &
Quality of
Employment
Survey subscale
on autonomy &
decision-making
Work
environment,
workload
Throughputs
Outcome:
Patient outcomes
(annual fall rates,
nosocomial
pressure ulcers,
urinary tact
infections,
patient
satisfaction with
various surveys)
Job satisfaction,
burnout, patient
complications
Adverse patient
outcomes,
mortality
Outputs
intentions
57
- RNs fewer in number with an increase in

unlicensed assistive personnel.
- increased RN hours worked patient per day
associated with lower fall rates (F=11.73,
p=0.002) & higher patient satisfaction with pain
management (F=15.05, p=0.0007)
- increased worked hours patient per day by all
staff associated with lower rates of urinary tract
infections.
Medical/surgical RNs had lowest scores on

quality of care (compared to other types of
units), had a higher number of tasks left undone
at the end of shift & are experiencing
significant levels of burnout. Higher workloads
were associated with lower quality (r=-0.24).
41% of nurses were moderately or very
dissatisfied with their job.
Adverse occurrences associated primarily with

patient characteristics. Failure to rescue
associated more with hospital characteristics
than patient characteristics (higher relative
risk). Understanding reasons behind variations
in mortality should be used to upgrade quality
of care.
Findings
career stages are affected by differing work-role
design factors.
The relationship of
nursing requirements
& workload measures
& hospital mortality
in the intensive care
unit.
78. TarnowMordi, Hau,

Warden,
Shearer (2000)
Implementation of a
Standard Staffing
Index to allocate
nursing staff.
Focus
77. Strickland,
Neely (1995)
Authors, Year
One adult
intensive care
unit in the UK.
All admissions
(n=1050)
between 1992 &
1995 that met
criteria for
adjustment of
mortality risk by
the APACHE II
equation (Acute
Physiology &
Chronic Health
Evaluation)
9000-bed
academic
medical centre in
Texas.
Units of analysis:
hospital nursing
dept (incl.
intensive care
units); medical
units;
surgical units
Sample
unit & surgical
unit per hospital;
- Patient predicted
risk of mortality
(APACHE II
equation which
uses information
from the 1st 24h
after admission).
intensive care unit
workload:
occupancy (highest
number of beds
occupied each shift
& peak occupancy
as the highest
occupancy per shift
during patient
stay), total
Inputs
RN, unlicensed
staff, LPN, clerks,
managers; labour
costs per discharge;
restructuring
assessment tool; &
interview)
- nurse
demographics &
satisfaction
(Individual Nurse
Questionnaire)
Staffing mix,
patient acuity
Throughputs
Mortality rates
Costs of care,
productivity,
staffing ratios
Outputs
58
Two measures of intensive care unit workload

most strongly associated with adjusted
mortality (excluding total unit nursing care
requirements) were peak occupancy & the ratio
of occupied to appropriately staffed beds.
Patients exposed to high intensive care unit

workload were more likely to die (odds ratio 31 [1.9-5.0]) than those exposed to lower
workload, both before & after adjustment for
risk by the APACHE II equation.
New system determined nursing productivity

quickly & efficiently & specific patient need
were determined through regular & thorough
evaluations. One person was responsible for
staffing on each unit. The SSI allowed for an
efficient & accurate utilization of nursing
personnel.
Unadjusted mortality was greater for patients
exposed to high versus moderate overall
intensive care unit workload (odds ratio 4-0 [26-6.2] (p. 187).
Findings
Reasons for nursing

turnover.
Determine the
relationships between
nursing staffing &
specific nursesensitive outcomes.
80. Weisman,
Alexander,
Chase (1981)
81. Whitman,
Yookyang,
Davidson, Wolf,
Wang (2002)
nursing turnover.
Focus
79. Wai, Bame,

Robinson
(1998)
Authors, Year
1259 full-time
RNs in two large
hospitals. Entire
population was
targeted, 98%
response rate.
Observational
data from 95
patient care units
across 10 acute
care hospitals in
eastern US.
Sample
Nurse professional
status, staffing
hours, patient days
per unit, worked
hours patient per
day (WHPPD)
Nurse
demographics.
Inputs
Intensive care unit
nursing
requirement-UK
Intensive Care
Society
recommendation,
ratio of occupied to
appropriately
staffed beds
Nurse
demographics,
education,
professional status,
hospital size.
Structural
hospital or unit
variations.
Workload
Throughputs
Medical errors,
fall rates,
infections, ulcer
rates.
Job satisfaction
Costs of care, job

satisfaction.
Outputs
59
Significant inverse relationships present

between staffing & falls in cardiac intensive
care (r=-0.53), medication errors in cardiac &
non-cardiac intensive care unit (r=-0.55 and 0.65 respectively) & restraint rates in medicalsurgical units (r=-0.48). No statistically
significant relationships were found between
the outcomes of central line infection rates &
pressure ulcer rates & WHPPD across specialty
units. An inverse relationship between WHPPD
& falls was present in cardiac intermediate care
(r=-0.53). The impact of staffing on outcomes
Older staff, minorities, those with higher

income, emotional support, or longer tenure had
lower turnover. Factors leading to turnover
include job satisfaction & tension,
organizational commitment, job possibilities &
supervisor behaviour.
Majority resigned due to job dissatisfaction
(57.1% and 72.5%). Personal factors have little
effect on turnover process. Reasons for
resigning include work pressures due to
understaffing & number or scheduling of work
hours. Low pay was least frequently cited as the
reason (less than 2%).
Findings
Use of aggregate data (total) intensive care unit
nursing care requirements) may explain the
association between high intensive care unit
nursing requirement & mortality, potentially
because more seriously ill pts are more likely to
die.
4.
One-Stop Recovery:
a fast-track program
for cardiac surgical
patients.
Implementation of a
step-down unit to
decrease intensive
care unit length of
83. Brown (2000)
84. Cady, Mattes,

Burton (1995)
Focus
Study of
environmental
uncertainty.
Focus
Authors, Year
82. Allred,
Michel, Arford,
Carter, Veitch,
Dring, Beason,
Hiott, Finch
(1994)
Throughputs
Authors, Year
Teaching
hospital with 220
adult beds, 27%
are intensive care
Sample
113 RNs from a
tertiary care
medical centre in
south-eastern
United States.
Stratified
random
sampling, 66%
response rate.
Sample
Patient
demographics,
medical
diagnosis, patient
Nurse ratios,
patient teaching,
and medical
diagnosis.
Inputs
Nurses
experience.
Inputs
Nursing
workload
Throughputs
Work
environment,
unanticipated
events,
environmental
uncertainty.
Throughputs
Length of stay in
intensive care
unit. ,
readmissions to
Length of stay in
intensive care
unit & step-down
units, costs of
care, patient
complications
Outputs
Outputs
60
Fast-track programs improve patient comfort,

enhance quality of care, & reduce costs.
Barriers include physician reluctance, limited
resources, lack of communication, & patient &
family anxiety. One-stop Recovery offers
continuity of staff, limits multiple inpatient
transfers, increases flexibility in human &
institutional resources, reduces intensive care
unit readmissions, & enhances patient comfort
& family support. Patient care is provided in
one location by consistent staff throughout the
recovery.
Time spent in intensive care unit decreased
significantly for those admitted to step down
unit 1.99 days instead of 3.35). Length of stay
did not differ for those in a step down unit.
Findings
No difference between nurses work status or
experience & response patterns after chi-square
analysis. Increase in environments complexity
(r=0.49), changeability (r=0.34) &
unpredictability (r=0.56) lead to increased
environmental uncertainty.
Findings
is highly variable across specialty units, but
when present, the relationships are inversely
related with lower staffing levels resulting in
higher rates of all outcomes.
Service-line concept
& patient-centered
care in a cardiac
setting.
Nursing productivity
& quality in the wake
of cost cutting.
Nurse case
management from the
87. Duffy,
Lemieux (1995)
88. Helt, Jelinek

(1988)
89. Lamb, Stempel

(1994)
Strategic planning
methodology for
nursing care.
86. Drenkard
(2001)
Focus
Reducing costs &

length of stay &
improving efficiency
& quality of care in
cardiac surgery.
stay.
85. Cohn,
Rosborough,
Fernandez
(1997)
Authors, Year
16 patients who
had worked with
Eight million
patient days from
Medicus
National
Database in US.
Multidisciplinary
healthcare team
at Brigham &
Womens
hospital.
Sample
unit. Comparable
institutions
provided
information for
comparison.
Continuity of
care.
Hospital size,
workload,
proportion of
nurse worked
hours.
Continuity of
care.
Care delivery
system.
Medical
diagnosis.
Inputs
acuity,
proportion of
nurse worked
hours, nursing
ratios.
Throughputs
Patient
complications,
Perceived quality
of care, length of
stay, costs of
care.
Costs of care,
productivity.
Outputs
intensive care
unit. , nurse job
satisfaction,
patient
complications,
costs of care.
Length of stay,
costs of care
61
Multidisciplinary group met weekly to discuss

problems with cardiac surgical services. Care
Coordination Team monitors clinical pathways
& recommends ways to improve services.
Results include higher volume of surgery,
decreased length of stay (by about 15%),
decreased costs, & increased patient satisfaction
(to 95%).
The methodology uses a transformational
leadership assessment tool, quality planning
methods & large group interventions to engage
nurses in implementation of strategies. Six
driving strategies for nursing were determined:
leadership, practice, culture, learning, and
research & role clarity.
A horizontal, multidisciplinary environment
with a performance-based model is described.
Employee roles are broadened to focus on the
entire process of care with all disciplines
working together.
Even in face of staffing reductions, productivity
(decrease in ratio of nursing hours to workload)
& quality (based on specific objectives) have
improved. While acuity increased, length of
stay had decreased. Increased percentage of
RNs leads to increased productivity, only half
of which is lost due to higher costs.
The study explored patients perspective of
working with a nurse case manager. Patients
Findings
Quality of care remained excellent & costs
were decreased for patient in the step down
unit.
5.
Focus
patients perspective:
the insider-expert.
Staffing
characteristics &
patient satisfaction in
home healthcare.
measures of home
care resource
consumption &
patient outcome
measures.
91. Dansky,
Brannon,
Wangsness,
(1994)
92. Fortinsky,
Madigan
(1997).
Focus
Nurses effects on
patient outcomes.
Authors, Year
90. Brooten,
Naylor (1995)
Patient Outcomes
Authors, Year
13 not-for-profit
home health
agencies in
Pennsylvania &
Ohio.
N = 201 adult
medical/surgical
home care
patients who
began new
episodes of home
care from 10
medicarecertified home
care agencies in
Ohio.
Sample
Sample
a nurse case
manager during
hospitalization,
ranging in age
from 66-100.
Patient
characteristics:
the 29 item
OASIS
assessment
(demographics,
clinical &
functional health
status, illness &
rehab prognosis
& amt. of family
& other informal
support recd by
Nurse education
& experience,
agency size.
Inputs
Proportion of
nurse worked
hours.
Inputs
Throughputs
Throughputs
Patient
outcomes:
discharge status;
change in
clinical &
functional health
status measures
between
admission &
discharge.
Outputs
Patient
complications &
outcomes,
staffing ratios,
costs of care.
Patient
satisfaction
Outputs
health status.
62
Patients who were admitted to home care from

hospitals & who received home care for longer
No significant differences were noted in the use

of home care resources between patients who
improved & those whose health status declined
during the episode of home care.
Findings
Most important issues include types of patient
outcomes that should be measured & the
amount & type of nursing needed in a given
environment, for specific patient groups & in
order to affect outcomes.
Higher numbers of full-time staff or of BNSprepared RNs predicted higher patient
satisfaction. Size of agency had no impact on
satisfaction. Agencies with medium benefits
had the highest patient satisfaction.
Patients whose episodes ended with discharge
at home vs. hospitalization had similar total
visit numbers & costs but those discharged to
hospitals utilized the home care resources over
less time.
Findings
described the process of nurses becoming their
insider-expert. This consists of three phases:
bonding, working & changing. Relationship
with a nurse insider-expert enabled patients to
improve health outcomes, have fewer
hospitalizations, & better quality of life.

client outcomes with
a home visiting
nursing service.
94. OBrienPallas, Doran,

Murray,
Cockerill,
Sidani, LaurieShaw,
LochhassGerlach (2002)
Effects of staffing on
infection rates.
Focus
93. Lancaster
(1997)
Authors, Year
38 RNs, 11
RPNs, 751
clients receiving
home healthcare,
convenience
sample.
Sample
Agency:
Nurse:
demographics,
education,
experience,
professional
status
Client:
demographics,
nursing &
medical
diagnosis,
OMAHA scores,
SF-36 health
status, time on
program
Resource
consumption:
total # of home
visits by all
disciplines;
disciplinespecific cost
information;
length of stay;
service intensity
(# of visits per
day)
Inputs
pts at home)
Throughputs
Patient health
status, OMAHA
(knowledge,
behaviour,
status)
Patient
complications,
staffing ratios.
Outputs
63
Increased patient-to-nurse ratios place severe

time constraints on nurses. This has been shown
to result in increased infection rates with central
venous catheters.
Clients with degree-prepared nurses had better
OMAHA scores (1.8 times better odds of
improved knowledge and 2.2 times better odds
of improved behaviour). Clinical, provider,
organizational & environmental factors affect
outcomes. Medical & nursing diagnoses explain
much of variation in outcomes. Environmental
complexity was negatively associated with
client outcomes.
Findings
than the 62-day study period used the greatest
number of resources.
The relationship
between nature-ofthe-task aspects of
organization design,
structural aspects of
organization design
& organizational
effectiveness
(operationalized as
outcome resident
functional ability).
96. Rohrer,
Momany,
Chang (1993).
Relationships
between hospital
variables & patient
outcomes.
Focus
95. Proctor,
Yarcheski,
Oriscello (1996)
Authors, Year
872 nursing
home residents
& 10 nursing
homes.
68 patients
diagnosed with
MI from a large
urban medical
centre.
Sample
Organizational
design included
3 structural
measuresjob
assignment,
hierarchy,
closeness of
supervision & 2
nature-of-task
measurespace
of operations &
workload.
Inputs
geographic
location, visit
type, caseload,
proportion of
nurse worked
hours &
continuity of
care
Patient
demographics
Throughputs
Resident
outcomes: The 7item physical
function scale
included bladder
incontinence,
bowel
incontinence,
bathing, eating,
mobility
(walking or
wheeling),
dressing, &
transferring.
Patient judgment
of quality of
care.
Outputs
64
Significant correlations between nursing care &

patient outcome post-MI (0.40) as well as
hospital environment & pt. outcome post-MI
(0.28). Nursing care accounted for 16 % of
variance in pt. outcomes. Pt. level of education
was related to outcome (0.41).
Only job assignment & hierarchy (structural
variables) were related to improved physical
function. In general, assuming a stable pace of
operations & workload, non-specific job
assignment & less hierarchy were related to
better physical function. A consistent workload
effect was demonstrated in that fewer heavy
care residents resulted in better resident
physical functioning.
Findings
6.
Complication rate as
a measure of quality
of care in coronary
artery bypass graft
surgery.
98. Silber,
Rosenbaum,
Schwartz, Ross,
Williams (1995)
Focus
Effects of individual
& organizational
characteristics on job
satisfaction.
Authors, Year
99. Adams, Bond
(2000)
Nurse Outcomes
Focus
Workload &
environmental factors
in medication errors.
Authors, Year
97. Roseman,
Booker (1995)
Sample
834 nurses from
England. Data
collected via
postal survey,
hospitals chosen
were stratified to
include all health
regions, response
rate 57%.
16,673 patients
who underwent
coronary artery
bypass graft
surgery (CABG)
at 57 hospitals in
1991, data from
American
Hospital
Association
annual survey.
Sample
All med errors in
a 5 year period
from a 140 bed
hospital in
Alaska.
Inputs
Nurse
demographics.
Patient
demographics,
hospital size,
nursing ratios,
medical
diagnosis.
Inputs
Throughputs
Organizational
characteristics.
Throughputs
Work
environment,
workload.
Outputs
Job satisfaction.
Patient mortality,
complication, &
failure to rescue
rates.
Outputs
Med errors.
65
Findings
There were no correlations with job satisfaction
& nurses age or level of education. Some
correlations were found between job
satisfaction & cohesion of nursing team (0.51),
staff organization including staffing &
workload (0.46), level of professional practice
(0.46) & collaboration with medical staff
(0.41). Most important factors in job
satisfaction were social & professional
Findings
Errors were positively associated with number
of shifts worked by temporary staff & with
patient days but negatively associated with
overtime shifts (use of experienced nurses). A
seasonal pattern of errors emerged: errors
corresponded with the level of darkness that
occurred 2 months earlier (i.e. Winter darkness
correlated with increased med errors in early
spring).
Many hospitals with higher quality of care had
higher complication rates but lower mortality
rates (ex: facilities with an MRI had 38%
increase in complications). Hospital rankings
based on complication rates give different
information than those based on mortality rates.
Complication rates should not be used to judge
hospital quality of care until more is known
about the difference.
Describe how nurse

staffing changed
relative to hospital
restructuring (case
mix of patients
receiving care), &
examine changes in
nursing practice
environments.
Investigates
associations between
experiences of work
stress among nurses.
101. Aiken, Clarke,

Sloane (2000)
103. Baumann,
Giovannetti,
OBrien-Pallas,
Mallette, Deber,
Blythe,
Hibberd,
DiCenso (2001)
Nurses perceptions
affected by job
change experiences.
Burnout in AIDS care

nurses.
100. Aiken, Sloane

(1997)
102. Baker, Kilmer,

Synergist,
Shuffle, (2000)
Focus
Authors, Year
1662 nurses from

two large
teaching
hospitals. The
entire population
was surveyed,
50.7% response
rate.
204 female
nurses from a
university
hospital in
Germany.
1998 survey of
more than 2,000
nurses in 22
hospitals; 1996
surveys from
chief executive
officers at 646
hospitals.
820 RNs &

LPNs on AIDS
units. All nurses
on selected units
were surveyed
with an 86%
response rate.
Sample
Nurse
demographics.
Proportion of
nurse worked
hours, workload,
continuity of
care, nurse work
index.
Care delivery
system, nurse
education &
experience
Inputs
Work
environment,
workload.
Organizational
restructuring.
Work
environment &
organization.
Throughputs
Perceived quality
of care.
Burnout, effort
& reward
imbalance,
Mortality, patient
satisfaction.
Burnout, job
satisfaction,
nurse health,
patient
complications.
Outputs
66
Effort & reward imbalance was predictive of

emotional exhaustion (F=35.33) &
depersonalization (F=8.97), both dimensions of
burnout. Nurses feelings of personal
accomplishment were lowest among those with
a mismatch between demands and rewards.
Burnout is observed more often among younger
nurses.
All nurses were negatively affected by hospital
restructuring. Nurses reported that work
environments had deteriorated in the previous
year with heavier workloads, greater patient
acuity & more workplace injuries. Nurses
perceived a decline in quality of care. Those
who experienced job change (involuntary
reallocation) were more dissatisfied, less
confident, more concerned about patient
Findings
relationships with nursing & other colleagues.
Nurses in dedicated AIDS units were less
emotionally exhausted than in scattered bed
units. The organizational attributes associated
with lower burnout are also related to safer
work environment, greater satisfaction with
care & lower mortality. Organizational support
accounts for 5% variance in emotional
exhaustion. Nurse well-being is enhanced by
autonomy & control over work.
Nurse control over the practice environment
explains variations in patient satisfaction. Better
organizational support was associated with
lower emotional exhaustion. The higher the
staffing level, the lower the death rate (r=-0.49).

nurses job
satisfaction.
The psychological
effects of nurses
work environments.
A follow-up of
magnet hospitals 15
years after their
designation to see
how restructuring has
affected the status.
Effects of hospital
restructuring on
nurses.
104. Blegen (1993)
105. Bourbonnais,
Comeau,
Vezina, Dion
(1998)
106. Buchan (1999)
107. Burke,
Greenglass
(2000)
Focus
Authors, Year
1362 nurses in
Ontario. Random
selection from a
nurses' union,
35% response
rate.
1891 nurses from

six acute care
hospitals in
Quebec,
voluntary
recruitment.
Mostly bedside
nurses working
full time.
10 magnet
hospitals & 5
ANCC hospitals
Meta-analysis of
48 studies &
15,048 subjects.
Sample
Administration,
professional
practice &
development
factors (staffing,
care delivery
models,
proportion of
nurse worked
hours)
Nurse
demographics,
experience,
education, &
professional
status.
Nurse
demographics,
experience
Nurse
demographics,
experience.
Inputs
Workload, work
environment.
Work
environment.
Throughputs
Nurses
emotional &
physical health,
burnout.
Cost of care
Nurse burnout,
psychological
distress, job
strain, social
support at work.
Nurse job
satisfaction,
burnout.
Outputs
67
Full time & part time nurses experienced

hospital restructuring & downsizing in similar
ways. FT nurses had poorer health, were more
emotionally exhausted (mean=3.6/6 vs. PT
mean=3.0/6) & were more likely to be absent
(mean=3.2/4 vs. PT mean=2.5/4). Restructuring
was associated with less work satisfaction &
poorer well-being.
Due to reorganization, some hospitals no longer

exhibit characteristics of magnetism. It is not
the magnet hospital label that is important,
but the concepts of quality care, effective staff
deployment & job satisfaction. There is a need
for monitoring & re-accreditation to maintain a
live register of magnet hospitals.
Findings
welfare, & less committed.
Job satisfaction most strongly associated with
stress & organizational commitment. Other
factors included communication with
supervisor, autonomy, recognition,
routinization, communication with peers,
fairness, & control. Low correlations with age,
yrs of experience, education, &
professionalism.
High psychological demands & low decision
latitude is associated with psychological
distress (adjusted odds ratio of 2.34) &
emotional exhaustion (OR=5.77). Social
support at work altered mental health but not
job strain.
Strategies for nurse

retention: preceptors,
mentors, & sponsors.
Effects of workplace
attributes on nurses
satisfaction & quality
of care.
Effects of healthcare
109. Carey,
Campbell
(1994)
110. Clarke,
Laschinger,
Giovannetti,
Shamian,
Thomson,
Tourangeau,
(2001)
111. Davison,
Focus
Job satisfaction,
propensity to leave &
burnout in RNs &
RN assistants.
Authors, Year
108. Cameron,
Horsburgh,
ArmstrongStassen (1994)
143 staff nurses

from two large
teaching
hospitals in
Atlanta. Random
sample selection
with 44% and
36% response
rate from
respective
hospitals.
17,965 RNs in
392 hospitals
from Alberta,
Ontario &
British
Columbia.
Representative
samples were
drawn from
Ontario &
British Columbia
while all RNs in
Alberta were
sampled.
Response rate
was 49-57%.
Longitudinal
Sample
623 RNs & 231
RN assistants
from 3
community
hospitals.
Nurse
Hinshaw &
Nurse burnout,
job satisfaction,
perceived quality
of care, patient
adverse events
(falls, med
errors).
Work
environment.
Nurse
demographics,
experience.
Outputs
Nurses job
satisfaction,
burnout.
Job satisfaction
Throughputs
Work
environment
Nurse education,
experience.
Inputs
Nurse
demographics
68
Perceived high workload (Price & Mueller
Strongest predictors of nurses emotional

exhaustion & satisfaction with jobs are having
control over work environment, having
sufficient resources & effective nursing
leadership. Nurse-assessed quality was
significantly correlated with occurrence of
adverse events (r=-0.145for falls to -0.454 for
wrong med). Hospitals with good physiciannurse collaboration & strong nursing leadership
have less burnout & lower turnover intentions.
Leadership & nurses length of experience on
the unit were predictive of intent to leave
current job.
Findings
Nurses were only moderately satisfied with
their jobs (mean scores are lower than other
employees). RNs with more experience had
higher job satisfaction & less burnout. RNs in
psychiatric settings were least satisfied. Greater
satisfaction & less burnout when a fit was
demonstrated between person & environment
(tables omitted)
No causal relationship between mentors & job
satisfaction (R2 for factors = 0.01-0.08). Nurses
leave b/c of dissatisfaction rather than needs for
recognition, accomplishment, or self-worth.
Environments where management supports
interpersonal relationships have higher levels of
satisfaction & less turnover.
Hospitals can have

various types of
ethical climates.
Managers may be
able to enhance
nurses satisfaction
by altering this
climate.
Patient & nurse

satisfaction within
different care
delivery models &
organizational
structures.
113. Joseph,
Deshpande
(1997)
114. Kangas, Kee,

McKee-Waddle
(1999)
Factors contributing
to burnout & life
satisfaction in nurses.
Focus
reforms on job
satisfaction &
voluntary turnover
among hospital
nurses
112. Demerouti,
Bakker,
Nachreiner,
Schaufeli
(2000)
Authors, Year
Folcarelli,
Crawford,
Duprat,
Clifford
(1997)
144 nurses from

large non-profit
hospital.
Average subject
was 40 year old
married female
who has worked
at hospital for 9
years. 50%
response rate.
102 nurses &
102 patients
from 3 different
hospitals (2
traditional, 1
shared
governance).
Systematic
random sampling
109 nurses from

one hospital &
two nursing
homes in
Germany,
response rate
59%.
Sample
survey of 685
nurses from one
hospital between
1993 and 1994
Proportion of
nurse worked
hours, care
delivery models
(primary nursing,
team nursing,
case
management),
continuity of
Ethical climate
shared
perception of
how issues
should be
addressed &
what is ethically
correct
Nursing
demographics,
experience.
Inputs
demographics,
wage, clinical
advancement
level,
termination
status, work
conditions
Workload.
Throughputs
Nurse job
satisfaction
Job satisfaction
of nurses (with
pay, promotion,
coworkers,
supervisors,
work itself)
Outputs
Atwoods Nurse
Job Satisfaction
Scale; Price &
Muellers Model
of Turnover;
Perlin &
Schoolers
Personal Mastery
Scale
Burnout.
69
Age & occupational tenure showed a positive

relationship with exhaustion. Age was
significantly, negatively related to life
satisfaction. Job demands have a strong positive
effect on exhaustion while job resources have a
strong negative effect on disengagement. Job
demands & job resources correlate negatively
with each other (-0.61).
Professional, instrumental (protect own
interests), independence (decide for oneself
whats right) climates had no impact on job
satisfaction. Caring (whats best for everyone)
climate influence pay, supervisor, & overall
satisfaction. Rules (strict with policies) climate
had positive impact on overall satisfaction.
Efficiency (must control costs) climate had
negative impact on satisfaction with
supervisors.
No difference in nurse job satisfaction between
types of care delivery models. Somewhat
higher patient satisfaction for those within the
primary care delivery model (not significant).
Supportive environment (=-0.709) & working
in a specialized unit (=-0.305) increase nurse
job satisfaction.
Findings
overload subscale) was an important
determinant of low job satisfaction. Insufficient
time to complete the job predicted turnover.
Nurse recruitment &

retention.
Job satisfaction &

retention of nurses in
magnet & nonmagnet hospitals.
Impact of values on
nurses satisfaction &
perceived
productivity.
115. Kovner, C.,

Hendrickson,
G., Knickman,
J., Finkler, S.
(1994)
116. Kramer &

Schmalenberg
(1990)
117. Kramer,
Hafner (1989)
Focus
Authors, Year
2336 staff nurses

in 24 hospitals.
A 1/3 sample,
proportionate by
regions of the
country, of the
magnet hospitals
Sample
used. Inclusion
criteria included
6mos experience
& type of unit.
37 hospitals, 858
RNs on 68 pilot
units & 335 RNs
on comparison
units. Pilot units
were selfselected;
comparison units
were chosen by
evaluators to be
similar to pilot
units.
1800 nurses in
magnet & nonmagnet hospitals
across United
States.
Image &
valuation of
nurses how
they see
themselves &
how others see
them;
Inputs
care, patient
demographics
Work
environment.
Throughputs
Job satisfaction,
including
organizational
structure,
professional
practice,
management
style, quality of
leadership,
professional
development;
also overall job
satisfaction.
Nurses job
satisfaction,
perceived quality
of care.
Nurse
satisfaction
Outputs
70
Inverse correlation between value congruence

& nurse job satisfaction, quality of care (for
staff nurse-top manager dyad, correlation
between value congruence & satisfaction
ranged from 0.074-0.377). Staff nurses reported
fewer factors as important to satisfaction &
quality of care than did other members of
Magnet hospitals have higher degree of

satisfaction & better staffing situations than
non-magnet. Positive correlation between
hospital image of nursing & adequacy of
staffing.
Pilot project to improve recruitment &

retention. All of the innovations enhanced
satisfaction. Nurses ranked pay as most
important factor, followed by autonomy &
professional status. Education initiatives,
reorganization, & new technology enhanced
satisfaction. With each change, there was an
initial dissatisfaction.
Findings
Impact of workplace
empowerment &
organizational trust
on nurses work
satisfaction.
Impact of nurse
burnout on patient
satisfaction.
119. Laschinger,
Finegan,
Shamian (2001)
120. Leiter, Harvie,

Frizzell (1998)
Effects of teamwork
on staff perception of
empowerment & job
satisfaction.
Focus
118. Kutzscher,
Sabiston,
Laschinger,
Nish (1997).
Authors, Year
Sample
was drawn,
random sampling
of nurses.
210 staff who
participated on
multidisciplinary
teams & a
random sample
of 185 staff
(response rate
52%) who did
not.
412 staff nurses
from Ontario.
Random
selection from
professional
registry list,
equal sampling
of males &
females.
711 nurses &
605 patients
from sixteen
hospital units.
Volunteers
completed the
nurse surveys &
patients were
randomly
sampled.
Nurse & patient
demographics.
Nurse
demographics,
professional
status.
Inputs
Work
environment
Work
environment
Throughputs
Nurse burnout,
meaningfulness
of work, patient
outcomes, &
satisfaction.
Nurses job
satisfaction
Job satisfaction.
Outputs
71
Patients perceptions of quality were correlated

with nurses relationships with work (more
meaning, less exhaustion=higher perception of
quality). Patients were more satisfied on units
where nurses found the work meaningful &
were less satisfied on units where nurses were
exhausted or rated high on cynicism (Spearman
rank order correlations). No correlations
between professional efficacy & patient
satisfaction.
Staff nurse empowerment impacts on their trust

in management & their job satisfaction.
Fostering environments that enhance
empowerment will have positive effects on
members & effectiveness. Access to
information (correlation=0.49) & support (0.46)
are strongly related to trust in management.
Feedback & guidance are also related to trust.
Findings
nursing. Important factors include role clarity,
role evolvement, role distance, responsiveness
from management, autonomy.
Perceptions of work empowerment were higher
for staff who were on teams (t=5.04). The staff
on teams was slightly more satisfied but the
difference was not significant.
Variables influencing
nurses values.
The effect of nurse

managers
management styles
on staff nurse job
satisfaction.
Job satisfaction
among recent
graduates.
Management style &
122. McNeeseSmith, Crook

(2003)
123. Moss, Rowles

(1997)
124. Munro (1983)
125. Nakata, Saylor
Focus
Impact of nursing
staff mix models &
organizational change
strategies.
Authors, Year
121. McGillis Hall,
Doran, Baker,
Pink, Sidani,
OBrien-Pallas,
Donner (2001)
329 recent
nursing
graduates.
Design was a
stratified, twostage probability
sample of high
school grads in
US (2% in
nursing).
102 RNs &
Sample
2046 patients,
1116 nurses, 63
unit managers,
50 senior
executives from
19 teaching
hospitals across
Ontario.
412 RNs from 3
Los Angeles
hospitals.
Hospitals were
selected for
convenience,
nurses were
randomly
sampled.
623 nurses in 3
Midwestern
hospitals
Management
styles
(exploitive/
authoritative,
benevolent/
authoritative,
consultative,
participative).
Nurse education
Nurse
demographics,
education
Inputs
Proportion of
nurse worked
hours, medical
diagnosis (case
mix group)
Work
Throughputs
Job satisfaction.
Job satisfaction
Job satisfaction
Nurse job
satisfaction
Outputs
Med errors,
infections, nurse
job satisfaction,
perceived quality
of care.
Positive correlation between perceived
72
Education background did not affect job

satisfaction. Achievement, responsibility (33%
of variance), advancement, growth (2.2% of
variance), & work itself (5.5% of variance) are
related to satisfaction. Administrators need to
appeal to nurses needs for challenges &
opportunities to grow.
By using appropriate management styles, staff

nurse job satisfaction may be improved. Job
satisfaction improved as the style approached
participative management.
Highest rated value was good supervisory

relations. If managers support nurses in
attaining values in work setting, retention may
be improved. Correlations between supervisory
relations & security (r=0.59) & security &
achievement (r=0.60) were noted. Negative
correlation with economic values & job
satisfaction (r=-0.14).
Findings
Nursing leadership has positive influence on
nurses job satisfaction (t=4.88). Lower
complexity of patients corresponds with high
job satisfaction (t=-3.17). Units with lower
proportion of RNs to RPNs had more med
errors & wound infections.
Factors that affect

nurses job
satisfaction.
cost-effective nurse
staffing
127. Roedel,
Nystrom (1998)
128. Shullanberger
(2000)
To determine the
extent to which RNs
have seen specific
changes in their work
environments since
the task force
recommendations
were released.
Focus
nurse satisfaction.
126. RNAO (2002)
Authors, Year
(1994)
135 RNs from a

200-bed
community
hospital, selfselection, all
female
respondents.
Sample
LPNs from an
acute care
hospital in
California. All
staff in selected
units was
surveyed with a
43% response
rate.
Surveys given to
RNAO members
& non-member
RNs,
RNs age 23-67
yrs. Convenience
sample, 549
responses.
Proportion of
nurse worked
hours
Nurses
education.
Nurse
demographics,
employment
status, sector of
employment,
position,
workload,
proportion of
nurse worked
hours
Inputs
Workload
Work
environment.
Work
environment.
Throughputs
environment.
Costs of care,
nurse
satisfaction.
Nurse job
satisfaction.
Nurse job
satisfaction.
Outputs
73
Nurse satisfaction has positive relationship with

self-scheduling. Optimal skill mix of 85% RNs.
Nurses remunerative value is more than what
can be measured by workload.
Respondents are not experiencing a high degree

of control through flexibility of the work
schedules. Professional satisfaction was rated
highly. RNs indicate no change in opportunities
to participate in decision-making that
influences patient care. When nurses have
satisfactory workloads & continuity of patient
assignment, their overall job satisfaction
improves. Consistency in patient assignment is
linked to nurses' perceptions of improved
organizational commitment to nursing.
Nurses ranked co-worker satisfaction as the
highest satisfaction score. Less task identity,
autonomy or feedback is related to lower job
satisfaction. Skill variety & task significance
tend to be unrelated to most facets of job
satisfaction.
Findings
management style & staff nurse job satisfaction
(r=0.48). The closer the management style to
participative group management, the higher the
satisfaction. Nurses would like to be more
involved in decision-making & setting of unit
goals. Autonomy & authority are sources of job
satisfaction while poor communication leads to
dissatisfaction.
7.
nurse job satisfaction
& inpatient
satisfaction.
Overtime & what

nurses can do when
faced with mandatory
or faced overtime.
131. Tzeng,
Ketefian (2002)
132. Vernarec
(2000).
Authors, Year
Focus

nurses job
satisfaction.
130. Tonges,
Rothstein,
Carter (1998)
System Outcomes
Focus
Impact of leadership
behaviours on nurses
emotional
exhaustion.
Authors, Year
129. Stordeur,
Dhoore,
Vandenberghe
(2001)
Sample
Sample
625 ward nurses
from a university
hospital. 39.2%
response rate but
demographics of
sample similar to
nursing
population.
222 staff nurses
in acute care
hospitals. All
nurses meeting
the selection
criteria were
surveyed.
59 patients &
103 nurses from
six units in a
Taiwan teaching
hospital. Cluster
sampling
technique.
Inputs
Patient teaching,
continuity of
care, patient
demographics,
nurse
demographics,
experience
Continuity of
care, nurse
demographics,
experience.
Inputs
Work stressors
(physical,
psychological,
social
environments) &
leadership
behaviours
Throughputs
Work
environment
Throughputs
Work
environment
Outputs
Nurse health,
burnout.
Nurse job
satisfaction,
length of stay
Nurses job
satisfaction,
burnout.
Outputs
Emotional
exhaustion
component of
burnout
Findings
74
Nurses who work overtime are also under the

stress of competing job & family
responsibilities, their own health, & their
patients' safety.
Nurses job satisfaction is correlated with

inpatient satisfaction factors: explanation of
care (r=0.765), pain management (r=0.866) as
well as the nurses general happiness (r=0.891).
Nurses general happiness positively
contributed to patient satisfaction.
Aspects of job important to satisfaction include

continuity of care, autonomy, individual
accountability, & performance feedback.
Findings
Work stressors explained 22% of emotional
exhaustion whereas leadership dimensions
explained 9%. Stress from physical (=0.28) &
social (=0.17) environment, role ambiguity
(=0.17), active management-by-exception
leadership (=0.13) significantly associated
with emotional exhaustion.
Length of stay in
intensive care unit
after coronary artery
bypass graft.
The association
between nurses job
strain & sick leave.
Implementing global
bundled payments on
Hospital costs of
coronary artery
bypass grafting.
outcomes related to
nursing.
133. Anderson,
Higgins,
Rozmus (1999)
134. Bourbonnais,
Mondor Myrto
(2001)
135. Liu,
Subramanian,
Cromwell
(2001)
136. Pierce (1997)
Focus
Authors, Year
1793 nurses from

six acute care
hospitals in
Quebec,
voluntary
recruitment.
Patients
undergoing
bypass surgery at
three hospitals
(in Atlanta, Ann
Arbor and
Boston).
152 patients in a
large teaching
hospital in
Tennessee, 81%
male, 19%
female.
Sample
Care delivery
system, staff
mix, size of
hospital, nurses
education, use of
agency
personnel.
Patient
demographics,
admission type,
medical
diagnosis.
Nurse
demographics,
experience
Patient
demographics,
medical
diagnosis.
Inputs
Throughputs
Length of stay in
intensive care
unit & step-down
units, patient
mortality, costs
of care, post-op
complications.
Nurse burnout,
job strain, social
support at work,
short term &
certified sick
leaves.
Costs of care
(direct variable
costs e.g. nurses
wages),
postoperative
complications,
length of stay.
Nurse
satisfaction,
costs of care,
patient
complications.
Outputs
75
Short term sick leaves were associated with job

strain (incidence-density ratio = 1.20) & low
social support (IDR=1.26). Certified sick leaves
were significantly associated with low social
support (IDR=1.27 for all diagnoses &
IDR=1.78 for mental health diagnoses).
All hospitals had significant reductions in total
direct variable costs, many coming from
reduced nursing costs (e.g. decreased length of
stay). Payment method aligns physician &
hospital incentives. Improvements in
efficiencies were made without diminishing
quality of care.
Clinical nursing studies and studies of care
delivery systems should be integrated.
Increased nursing care, better prepared staff,
more consistency among caregivers and
leadership correlate with lower mortality.
Intensive care unit length of stay was shorter

when ambulation was initiated sooner (t=-2.68).
Shorter hospitalization for patients who stayed
in intensive care unit 1 day than those staying 2
days (t=-1.46; not significant).
Findings
8.
9.
Glossary
BNS Bachelor of Nursing Science
LPN Licensed Practical Nurse
RPN Registered Practical Nurse
RN Registered Nurse
WHPPD worked hours per patient day

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Appendix B. Patient Care Delivery Model
INPUTS
Patient Care Delivery Model

(OBrien-Pallas et al., 2003)
Demographics
Significant other support
Medical diagnoses
Nursing diagnoses
OMAHA knowledge, behaviour,
status
Admission type
Pre-operative clinic
Education booked post-op/post
discharge
SF-12 health status
Demographics
Professional status
Employment status
Education
Clinical expertise
Experience
THROUGHPUTS
Interventions
Patient
Care
Delivery
System in
Cardiac &
Cardiovascular
Units
Perceived Work
Environment
INTERMEDIATE
OUTPUTS
Worked hours
Productivity/
Utilization
OUPUTS
Patient Outcomes
Medical consequences
OMAHA knowledge, behaviour,
status
SF-12 health status
Resource intensity weight
Mortality
Nurse Outcomes
Burnout
Effort & reward imbalance
Autonomy & control
Job satisfaction
Relationships with MDs
SF-12 health status
Violence at work
Geographic location
Hospital size
Unit size, type, patient mix
Occupancy
System Behaviours
Workload
Nurse-to-patient ratios
Proportion of RN worked hours
Continuity of care/shift change
Unit instability
Overtime
Use of agency & relief staff
# of units nurse works on
Non-nursing tasks
System Outcomes
Environmental Complexity
Factors
Resequencing of work in
response to others
Unanticipated delays due to
changes in patient acuity
Characteristics & composition
of caregiving team
Length of stay
Cost per resource intensity
weight
Quality of patient care
Quality of nursing care
Interventions delayed
Interventions not done
Absenteeism
Intent to leave
Feedback
84
Appendix C. Tables
Table 1. Key Variables and Data Sources ......................................................................................................86
Table 2. Estimates for Patient Outcomes from the Hierarchical Linear Models .................................87
Table 3. Odds Ratios for Patient Outcomes from the Hierarchical Linear Models ............................88
Table 4: Hierarchical Logistic Regression for Medical Consequences Developed During Hospital
Stay .......................................................................................................................................................89
Table 5: Hierarchical Logistic Regression for Improvement in Patients Physical Health ..............90
Table 6: Hierarchical Logistic Regression for Improvement in Patients Mental Health ................91
Table 7: Hierarchical Logistic Regression for Patients Knowledge Improvement at
Discharge/Diagnoses Resolved ....................................................................................................92
Table 8: Hierarchical Logistic Regression for Patients Behaviour Improvement at
Table 9: Hierarchical Logistic Regression for Patients Status Improvement at
Table 10. Estimates for Nurse Outcomes in the Hierarchical Linear Models ......................................95
Table 11. Odds Ratios for Nurse Outcomes in the Hierarchical Linear Models .................................96
Table 12: Hierarchical Linear Regression for Nurse-Physician Relationship .....................................97
Table 13: Hierarchical Linear Regression for Autonomy ..........................................................................98
Table 14: Hierarchical Logistic Regression for Job Satisfaction .............................................................99
Table 15: Hierarchical Logistic Regression for Emotional Exhaustion...............................................100
Table 16: Hierarchical Linear Regression for Nurses Physical Health ..............................................101
Table 17: Hierarchical Linear Regression for Nurses Mental Health .................................................102
Table 18. Estimates for System Outcomes from the Hierarchical Linear Models............................103
Table 19. Odds Ratios for System Outcomes in the Hierarchical Linear Models ............................104
Table 20: Hierarchical Logistic Regression for Patients with Shorter Than Expected Length of
Stay .....................................................................................................................................................105
Table 21: Hierarchical Logistic Regression for Interventions Not Done ............................................106
Table 22: Hierarchical Logistic Regression for Interventions Delayed ...............................................107
Table 23: Hierarchical Logistic Regression for Quality of Nursing Care ...........................................108
Table 24: Hierarchical Logistic Regression for Quality of Patient Care .............................................109
Table 25: Hierarchical Logistic Regression for Absenteeism ................................................................110
Table 26: Hierarchical Logistic Regression for Intent to Leave ............................................................111
Table 27: Hierarchical Linear Regression for Productivity/Utilization ...............................................112
Table 28: Hierarchical Linear Regression for Cost per Resource Intensity Weight (Log Scale) .113
Table 29: Hierarchical Linear Regression for Worked Hours per Patient (Log Scale) ...114
Table 30: Hierarchical Linear Models for Patient, Nurse, and System Outcomes on Congruence
Between PRN Hours and Actual Worked Hours per Patient.............................................115
Table 31: Summary Table of the Effect of Nursing Hours, Proportion of RN Worked Hours,
Nurse-Patient Ratio, and Productivity/Utilization on Patient, Nurse and System
Outcomes, in Odds Ratio, Coefficient, and Cut point .........................................................116
85
Table 1. Key Variables and Data Sources

Measure
SF-12 Health Status
Survey (physical and
mental health status)
When Administered
Method/Source
Admission or in pre-op clinic
Patient self-report
NANDA Nursing
Diagnoses and OMAHA
Problem Rating Scale
Admission
Discharge
Discharge
Data collector from patient

chart/kardex and nurse
Daily to identify new or

resolved diagnoses
Patient Data Form
Once over patient stay

chart/kardex/interview
PRN Workload Tool
Daily

chart/kardex, unit workload
tool, and nurse
Case Mix Group
After discharge
Electronic file submitted by

Heath Records Department
Resource Intensity
Weight
After discharge
Electronic file submitted by

Heath Records Department
Nurse Survey
Once at beginning of data

collection
Nurse self-report
Daily Unit Staffing Form
Daily
Data collector from unit

assignment sheet and ward
clerk
Environmental
Complexity Scale
Daily
Nurses
86
Table 2. Estimates for Patient Outcomes from the Hierarchical Linear

Models
Predictor
Medical
Conseq.
Patient Level
Pre-Operative Clinics
Referral for Homecare
Medical Consequences
Resource Intensity Weight
Number of Nursing Diagnoses
Physical Health at Admission
Mental Health at Admission
Knowledge at Admission
Behaviour at Admission
Status at Admission
Worked Hours per Patient
Length of Stay
Nurse Level
Education (ref: Diploma)
Overtime Hours
Unit Instability
Interventions Not done
Interventions Delayed
Autonomy
Physical Health
Mental Health
Satisfaction with Current Job (ref: Dissatisfied)
Nurse-Patient Ratio
Unit Level
Proportion of RN Worked Hours
Productivity/Utilization (Quadratic)
Productivity/Utilization (beyond 88%)
Proportion of Full-time Employment
Proportion of Nurses Reporting Shift Changes
Physical
Health
Mental
Health
Omaha
Knowledge
Omaha
Behaviour
Omaha
Status
0.08
0.06
0.01
0.00
0.05
0.08
0.01
0.00
1.43 *
0.02
0.43 *
-0.01
-0.03 *
-0.10 *
-0.12 *
-0.13 *
0.00
-0.01
-0.06
0.01 *
-0.09 *
0.01
0.05
0.01
0.00
-1.33 *
-2.14 *
0.13 *
0.03
0.00
0.01
-0.06 *
-0.04 *
0.04
0.01
0.12
-0.02
0.11
-0.08 *
0.05
0.04
-0.29
0.02
-0.97
1.08
0.08
-0.02
0.27
-0.10
0.03
-0.02
-0.01
-0.01
0.01
0.01
-0.47
0.10
0.17 *
-0.02
-0.01
0.25
0.05
-0.14
0.11
3.72
-0.94
0.53
5.55 *
7.40 *
-1.48 *
0.00
0.00
-0.02
-0.01
-0.08
-0.03
-0.75 *
0.03
-0.01
0.10
0.02
-0.27
-0.42
-0.01
-0.01
1.02 *
-0.03
-0.02
0.02
0.16
0.42
17.83 *
-10.11 *
2.06
4.94 *
-1.49 *
-0.80 *
-0.60 *
-0.67
0.30
2.13 *
-5.75 *
* for p-value at 0.05 or less

Notes: (1) All patient outcome variables were dichotomized and modeled in hierarchical logistic regressions. For medical
consequences, 1 = development of complications, falls with injury, or death; for physical and mental health, 1 = improved at
discharge; for Omaha knowledge, behaviour, and status, 1 = improvement at discharge or diagnoses resolved. (2) The
productivity/utilization cut point is 88.2% for Omaha behaviour.
87
Table 3. Odds Ratios for Patient Outcomes from the Hierarchical Linear
Models
Predictor
Medical
Conseq.
Patient Level
Pre-Operative Clinics
4.19
1.02
1.53
0.99
0.97
Status at Admission
1.13
Length of Stay
1.03
Nurse Level
1.13
Overtime Hours
0.98
Unit Instability
Interventions Not Done
0.38
2.94
Autonomy
Physical Health
1.03
Mental Health
0.98
Nurse-Patient Ratio
1.28
Unit Level
1.45
0.51
Physical
Health
Mental
Health
Omaha
Knowledge
Omaha
Behaviour
Omaha
Status
*
*
0.90 *
0.89 *
0.88 *
1.00
0.99
0.94
1.01 *
0.92 *
1.01
1.05
1.01
1.00
0.26 *
1.08
1.07
1.01
1.00
1.05
1.08
1.01
1.00
0.12 *
*
0.23 *
1.00
1.00
1.00
1.01
0.94 *
0.96 *
1.04
1.01
0.98
0.99
1.11
0.93 *
1.05
1.04
0.75
1.02
1.10
1.02
1.08
0.98
1.32
0.91
1.00
0.99
1.01
1.01
0.62
1.11
1.19 *
0.98
0.99
0.92
0.97
0.47 *
1.03
0.99
0.98
1.02
1.05
0.87
1.11
0.99
0.99
2.76 *
0.97
0.91
1.05
1.74 *
n/a *
1.04
n/a *
n/a *
1.23
n/a *
0.76
0.66
1.17
n/a *
n/a *
0.55 *
1.35
1.24 *
0.56 *

Notes: (1) All patient outcome variables were dichotomized and modeled in hierarchical logistic regressions. For medical
consequences, 1 = falls with injury, medication errors, death, or development of complications; for physical and mental health, 1 =
Improved at discharge; for Omaha knowledge, behaviour and status, 1 = improvement at discharge or diagnoses resolved. (2) The
productivity/utilization cut point is 88.2% for Omaha behaviour. (3) The odds ratios for proportion of RN worked hours, proportion of
full-time employment and proportion of nurses reporting shift changes are based on a 10% increase. (4) Odds ratio for quadratic
transformation of productivity/utilization is not reported.
88
Table 4: Hierarchical Logistic Regression for Medical

Consequences Developed During Hospital Stay
Predictor
Beta
SE
Odds
Ratio
Patient Level
Length of Stay
1.43
0.02
0.43
-0.01
-0.03
0.13
0.03
0.36
0.06
0.08
0.01
0.01
0.05
0.02
4.19
1.02
1.53
0.99
0.97
1.13
1.03
Nurse Level
Overtime Hours
Physical Health
Mental Health
Nurse-Patient Ratio
0.12
-0.02
-0.97
1.08
0.03
-0.02
0.25
0.63
0.07
0.70
0.64
0.04
0.03
0.23
1.13
0.98
0.38
2.94
1.03
0.98
1.28
Unit Level
3.72
-0.67
2.59
0.53
1.45
0.51
*
*
*
*
* p-value at 0.05 or less

Notes: (1) For measurements of predictor and outcome variables, see Appendix F. (2)
Odds ratio for proportion of RN worked hours is based on a 10% increase.
89
Table 5: Hierarchical Logistic Regression for Improvement in

Patients Physical Health
Predictor
Beta
SE
Odds
Ratio
Patient Level
-0.10
0.04
0.90
-0.12
0.04
0.89
-0.13
0.01
0.88
0.00
0.01
1.00
0.00
0.02
1.00
Length of Stay
0.01
0.01
1.01
Nurse Level
0.11
0.25
1.11
Overtime Hours
-0.08
0.04
0.93
0.08
0.40
1.08
-0.02
0.33
0.98
Physical Health
-0.01
0.02
1.00
Mental Health
-0.01
0.01
0.99
Nurse-Patient Ratio
0.05
0.08
1.05
Unit Level
-0.94
1.15
0.91
-0.60
0.26
0.55
Notes: (1) For measurements of predictor and outcome variables, see Appendix F. (2) Odds
ratio for proportion of RN worked hours is based on a 10% increase.
*
*
*
90
Table 6: Hierarchical Logistic Regression for Improvement in

Patients Mental Health
Predictor
Beta
SE
Odds
Ratio
Patient Level
Length of Stay
-0.01
-0.06
0.01
-0.09
-0.06
-0.04
0.04
0.04
0.01
0.01
0.03
0.02
0.99
0.94
1.01
0.92
0.94
0.96
0.05
0.04
0.27
-0.10
0.01
0.01
-0.14
0.24
0.03
0.34
0.29
0.01
0.01
0.08
1.05
1.04
1.32
0.91
1.01
1.01
0.87
0.53
0.30
1.08
0.27
1.05
1.35
Nurse Level
Overtime Hours
Physical Health
Mental Health
Nurse-Patient Ratio
Unit Level
*
*
*
*

91
Table 7: Hierarchical Logistic Regression for Patients

Knowledge Improvement at Discharge/Diagnoses Resolved
Predictor
Beta
SE
Odds
Ratio
Patient Level
Length of Stay
Nurse Level
Overtime Hours
Autonomy
Physical Health
Mental Health
Nurse-Patient Ratio
0.01
0.05
0.01
0.00
-1.33
0.04
0.01
0.04
0.04
0.01
0.01
0.13
0.02
0.02
1.01
1.05
1.01
1.00
0.26
1.04
1.01
-0.29
0.02
-0.47
0.10
0.17
-0.02
-0.01
0.11
0.25
0.03
0.35
0.30
0.04
0.02
0.01
0.08
0.75
1.02
0.62
1.11
1.19
0.98
0.99
1.11
Unit Level
Proportion of Full-Time Employment
5.55
7.40
-1.49
2.13
-5.75
1.36
1.16
0.32
0.61
0.82
1.74
n/a
n/a
1.24
0.56
*
*
*
*
*

ratios for proportion of RN worked hours, proportion of full-time employment, and
proportion of nurses reporting shift changes are based on a 10% increase.
92
Table 8: Hierarchical Logistic Regression for Patients

Behaviour Improvement at Discharge/Diagnoses Resolved
Predictor
Beta
SE
Odds
Ratio
Patient Level
Length of Stay
Nurse Level
Overtime Hours
Unit Instability
Physical Health
Mental Health
Nurse-Patient Ratio
0.08
0.06
0.01
0.00
-2.14
-0.02
-0.01
0.05
0.04
0.01
0.01
0.18
0.04
0.02
1.08
1.07
1.01
1.00
0.12
0.98
0.99
-0.08
-0.03
-0.75
0.03
-0.01
-0.01
-0.01
1.02
-0.03
0.28
0.04
0.33
0.36
0.35
0.02
0.01
0.27
0.08
0.92
0.97
0.47
1.03
0.99
0.99
0.99
2.76
0.97
Unit Level
0.42
17.83
-10.11
1.53
1.41
0.99
1.04
n/a
n/a
*
*

Odds ratio for proportion of RN worked hours is based on a 10% increase. (3)
productivity/utilization cut point is 88.2%.
93
Table 9: Hierarchical Logistic Regression for Patients Status

Improvement at Discharge/Diagnoses Resolved
Predictor
Patient Level
Status at Admission
Length of Stay
Nurse Level
Overtime Hours
Physical Health
Mental Health
Nurse-patient Ratio
Unit Level
Beta
SE
Odds
Ratio
0.05
0.08
0.01
0.00
-1.48
0.00
0.00
0.05
0.05
0.01
0.01
0.18
0.03
0.02
1.05
1.08
1.01
1.00
0.23
1.00
1.00
0.10
0.02
-0.27
-0.42
-0.02
0.02
0.16
0.29
0.04
0.39
0.33
0.02
0.01
0.09
1.10
1.02
0.76
0.66
0.98
1.02
1.17
2.06
4.94
-0.80
1.26
1.16
0.39
1.23
n/a
n/a
*
*

94
Table 10. Estimates for Nurse Outcomes in the Hierarchical Linear Models
Predictor
N-P
relationship
Autotonomy
Satisfaction
Emotional
Exhaust'n
Physical
Health
Mental
Health
Nurse Level
Gender (ref: Male)
Age
Full-time Employment (ref: PT/Casual)
Over Time Hours
Clinical Expertise
Unit Instability
Shift Change
Effort and Reward Imbalance
Emotional Exhaustion
Autonomy
Nurse-physician Relationship
Absenteeism
Physical Health
Mental Health
Improved Quality of Patient Care (ref: Deteriorated)
Good Quality of Nursing Care (ref: Poor)
Nurse-patient Ratio
0.16
0.16
-0.44 *
0.03
0.01
-0.33 *
-0.03
-0.01
-0.33
-0.10
-0.89 *
-0.07
0.30 *
0.29
0.59 *
-0.37 *
0.62 *
-0.36
0.02
0.02
1.04 *
0.67 *
0.28
0.67 *
0.02
-0.10 *
0.83 *
0.04
-0.05
-0.02
2.89 *
-0.40 *
-2.07 *
0.02
1.69
1.58 *
-0.01
0.01
0.44 *
0.12
-0.02
0.09
-0.31
0.01
-0.13
0.01
-0.49
-1.23 *
0.21 *
0.06
0.02
0.02
0.37
1.39 *
0.31
-0.02
0.00
-0.90 *
-0.01
0.02
-0.11
0.02
0.14
-0.22
-0.26
-0.10
0.37
-0.67 *
-0.53 *
0.05
-0.10
-0.04 *
-0.11 *
-1.09 *
0.28
-0.57
0.49
-0.02 *
0.46 *
0.13
-0.24
-0.38
0.55 *
0.14
0.00
-0.29
-0.10 *
-3.28 *
-0.20
-0.07 *
-1.37
-0.16
-0.03
0.11
1.03 *
0.01
0.21
0.03
-0.12
1.23 *
-0.74 *
0.03 *
-0.21
-0.03
0.02
0.08
-0.27
-0.05
-0.05
-0.14
-0.51
-1.56 *
0.04
0.05
-0.04 *
Patient Level
Proportion of Patients Attended Pre-operative Clinics
Average Resource Intensity Weight
Average Number of Nursing Diagnoses
0.05
-0.10
0.05
-0.07
Unit Level
Unit Occupancy
Average Worked Hours
Average Age of Nurses
Proportion of Emotionally Exhausted Nurses
Average Nurse-physician Relationship
Proportion of Physically Healthy Nurses
Proportion of Satisfied Nurses
0.10 *
0.78
0.08
1.63
-0.53
-0.85 *
-0.15 *
-2.08 *
-0.43
0.88 *
4.62 *
-3.88 *
Notes: (1) Except for nurse-physician relationship and autonomy, all nurse outcomes were dichotomized and modelled in hierarchial
logistic regression. For satisfaction, 1 = satisfied with current job; for emotional exhaustion, 1 = at risk; for physical and mental health,
1 =healthier than average of female population.
95
Table 11. Odds Ratios for Nurse Outcomes in the Hierarchical Linear
Models
Predictor
N-P
relationship
Autotonomy
Satisfaction
Emotional
Exhaust'n
Physical
Health
Mental
Health
Nurse Level
Gender (ref: Male)
Age
Over Time Hours
Clinical Expertise
Unit Instability
Shift Change
Autonomy
Absenteeism
Physical Health
Mental Health
Nurse-patient Ratio
n/a
n/a
n/a *
n/a
n/a
n/a *
n/a
n/a
n/a
n/a
n/a *
n/a
n/a *
n/a
n/a *
n/a *
n/a *
n/a
n/a
n/a
n/a *
n/a *
n/a
n/a *
n/a
n/a *
n/a *
n/a
n/a
n/a
n/a *
n/a *
n/a *
n/a
n/a
n/a *
n/a
n/a
0.98
1.00
0.41 *
0.99
1.02
0.90
1.02
1.15
0.80
0.77
0.90
1.45
0.51 *
0.59 *
1.06
0.91
1.45
4.01 *
1.36
0.96 *
0.90 *
0.34 *
1.32
0.56
1.64
0.98 *
1.58 *
1.14
0.79
0.69
1.74 *
1.15
1.00
0.75
1.05
0.90
1.05
0.93
1.10 *
1.08
1.08
1.18
0.59
0.90 *
0.72 *
0.82
0.93 *
0.87
0.85
1.56 *
1.12
0.98
1.09
0.73
1.01
0.88
1.01
0.61
0.29 *
1.24 *
1.06
1.02
1.02
0.97
1.12
2.79 *
1.01
1.24
1.03
0.89
3.42 *
0.48 *
1.03 *
0.81
0.97
1.02
1.09
0.76
0.96
0.95
0.87
0.60
0.21 *
1.04
1.06
0.96 *
Patient Level
Unit Level
Unit Occupancy
0.43 *
0.86 *
n/a *
0.65
2.40 *
n/a *
0.68 *
Notes: (1) Except for nurse-physician relationship and autonomy, all nurse outcomes were dichotomized and modelled in hierarchial
logistic regression. For satisfaction, 1 = satisfied with current job; for emotional exhaustion, 1 = at risk; for physical and mental
health, 1 =healthier than average of female population. (2) The odds ratio for proportion of RN worked hours, proportion of nurses
with BScN or above, proportion of nurses reporting shift changes, proportion of emotionally exhaused nurses, proportion of
physically healthy nurses, proportion of satisfied nurses, proportion of nurses rating good nurse care quality are based on a 10%
increase.
96
Table 12: Hierarchical Linear Regression for Nurse-Physician

Relationship
Predictor
Beta
SE
Odds
Ratio
Nurse Level
Full-Time Employment (ref: PT/Casual)
Autonomy
Physical Health
Mental Health
0.16
0.16
0.30
-0.01
0.01
0.29
0.59
0.14
0.14
0.03
0.01
0.01
0.15
0.22
n/a
n/a
n/a
n/a
n/a
n/a
n/a
0.02
-0.10
-0.37
0.02
0.05
0.18
n/a
n/a
n/a
*
*
-0.02
2.89
-0.40
-2.08
4.62
0.03
1.39
0.20
0.78
1.01
n/a
n/a
n/a
n/a
n/a
*
*
*
*
Patient Level
Nurse-Patient Ratio
Unit Level

Note: For measurements of predictor and outcome variables, see Appendix F.
97
Table 13: Hierarchical Linear Regression for Autonomy

Predictor
Beta
SE
Odds
Ratio
-0.44
0.03
0.01
-0.33
-0.03
-0.01
-0.33
-0.10
-0.89
-0.07
0.62
-0.36
0.02
0.02
1.04
0.67
0.28
0.67
0.20
0.22
0.02
0.16
0.25
0.20
0.26
0.23
0.29
0.26
0.06
0.25
0.01
0.01
0.22
0.23
0.32
0.24
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
0.83
0.04
-0.05
0.37
0.03
0.07
n/a
n/a
n/a
-2.07
0.02
1.69
1.58
1.03
0.04
2.01
0.29
n/a
n/a
n/a
n/a
Nurse Level
Overtime Hours
Clinical Expertise
Unit Instability
Shift Change
Nurse-Physician Relationship
Absenteeism
Physical Health
Mental Health
Nurse-Patient Ratio
*
*
*
*
*
Patient Level
Unit Level
Unit Occupancy

Note: For measurements of predictor and outcome variables, see Appendix F.
98
Table 14: Hierarchical Logistic Regression for Job

Satisfaction
Predictor
Beta
SE
Odds
Ratio
0.44
0.12
-0.02
0.09
-0.31
0.01
-0.13
0.01
-0.49
-1.23
0.21
0.06
0.02
0.02
0.37
1.39
0.31
0.22
0.23
0.02
0.19
0.27
0.22
0.27
0.25
0.39
0.30
0.05
0.07
0.01
0.01
0.25
0.46
0.29
1.56
1.12
0.98
1.09
0.73
1.01
0.88
1.01
0.61
0.29
1.24
1.06
1.02
1.02
1.45
4.01
1.36
0.05
-0.10
0.04
0.08
1.05
0.90
0.10
0.78
-0.85
0.04
1.99
0.32
1.10
1.08
0.43
Nurse Level
Overtime Hours
Clinical Expertise
Unit Instability
Shift Change
Autonomy
Physical Health
Mental Health
Nurse-Patient Ratio
*
*
Patient Level
Unit Level
*
*

99
Table 15: Hierarchical Logistic Regression for Emotional

Exhaustion
Predictor
Beta
SE
Odds
Ratio
-0.03
0.11
1.03
0.01
0.21
0.03
-0.12
1.23
-0.02
0.00
-0.04
-0.11
-1.09
0.28
-0.57
0.49
0.02
0.26
0.28
0.03
0.22
0.27
0.34
0.33
0.05
0.08
0.02
0.01
0.31
0.29
0.40
0.33
0.97
1.12
2.79
1.01
1.24
1.03
0.89
3.42
0.98
1.00
0.96
0.90
0.34
1.32
0.56
1.64
0.05
-0.07
0.05
0.10
1.05
0.93
0.08
1.63
-0.53
-3.88
0.06
2.36
0.35
1.37
1.08
1.18
0.59
0.68
Nurse Level
Age
Overtime Hours
Clinical Expertise
Shift Change
Autonomy
Physical Health
Mental Health
Nurse-Patient Ratio
*
*
*
Patient Level
Unit Level
ratios for proportion of RN worked hours and proportion of satisfied nurses are based on a
10% increase.
100
Table 16: Hierarchical Linear Regression for Nurses Physical

Health
Predictor
Beta
SE
Odds
Ratio
-0.90
-0.01
0.02
-0.11
0.02
0.14
-0.22
-0.26
-0.10
0.37
-0.67
-0.53
0.05
-0.10
-0.02
0.46
0.13
-0.24
-0.38
0.42
0.01
0.18
0.18
0.02
0.15
0.21
0.17
0.23
0.20
0.25
0.23
0.04
0.05
0.01
0.20
0.20
0.28
0.21
0.41
0.99
1.02
0.90
1.02
1.15
0.80
0.77
0.90
1.45
0.51
0.59
1.06
0.91
0.98
1.58
1.14
0.79
0.69
-0.10
-3.28
-0.20
-0.15
0.88
0.04
1.20
0.21
0.04
0.17
0.90
0.72
0.82
0.86
2.40
*
*
Nurse Level
Gender (ref: Male)
Age
Overtime Hours
Clinical Expertise
Unit Instability
Shift Change
Autonomy
Mental Health
Nurse-Patient Ratio
*
*
*
*
Unit Level
Average Nurse-Physician Relationship
*
*

101
Table 17: Hierarchical Linear Regression for Nurses Mental

Health
Predictor
Beta
SE
Odds
Ratio
-0.74
0.03
-0.21
-0.03
0.02
0.08
-0.27
-0.05
-0.05
-0.14
-0.51
-1.56
0.04
0.05
-0.04
0.55
0.14
0.00
-0.29
0.38
0.01
0.18
0.18
0.02
0.16
0.23
0.18
0.23
0.20
0.28
0.23
0.04
0.05
0.01
0.20
0.20
0.28
0.23
0.48
1.03
0.81
0.97
1.02
1.09
0.76
0.96
0.95
0.87
0.60
0.21
1.04
1.06
0.96
1.74
1.15
1.00
0.75
*
*
-0.07
-1.37
-0.16
-0.43
0.03
1.25
0.23
0.88
0.93
0.87
0.85
0.65
Nurse Level
Gender (ref: Male)
Age
Overtime Hours
Clinical Expertise
Unit Instability
Shift Change
Autonomy
Physical Health
Nurse-Patient Ratio
*
*
Unit Level

ratios for proportion of RN worked hours and proportion of emotionally exhausted nurses are
based on a 10% increase.
102
Table 18. Estimates for System Outcomes from the Hierarchical Linear
Models
Predictor
LOS
Not
Done
Delay
-0.04 *
-0.02
0.32
-0.06
-0.01
0.48
0.09 *
0.11
0.06
-0.48
0.82 *
0.55 *
0.03
-0.09
0.63 *
-0.13
0.43 *
1.28 *
-0.12
-0.13 *
-0.14
-0.04
-0.02
-0.01
-0.17
0.80 *
0.01
-0.07
0.06
0.37
0.01
-0.02
-0.21
0.43
-1.44 *
2.97 *
0.50
Quality of
Nursing Care
Quality of
Patient Care
Absenteeism
Leave
Productivity/
Utilization
Cost per
RIW
Worked
hours
0.003
0.047
0.015
-0.001
0.004
-0.163 *
-0.002
0.069
-0.025
-0.012
0.018
0.001
0.001
-0.011 *
0.000
-0.001
0.000
0.045 *
-0.110 *
-0.010
Nurse Level
Age
Dependent Children (ref: No)
Work on Multiple Units
Over Time Hours
Clinical Expertise
Unit Instability
Shift Change
Prevalence of Violence
Autonomy
Intent to Leave
Physical Health
Mental Health
Nurse-patient Ratio
Re-sequencing of Work
Unanticipated Changes in Patient Acuity
More Time Needed
-0.03
-0.10
0.17
-0.02
0.02
-0.17
0.00
-0.49
0.48
0.02
0.58 *
-0.04
-0.69 *
0.15
0.29
-0.17
-0.02
-0.84 *
0.23
0.33
-0.59
-0.11
0.33
-0.61
0.07
0.22 *
-0.25
-0.62 *
-0.44
0.30
0.16 *
0.03
0.00
0.01
0.95 *
1.95 *
0.01
0.01
0.33
-0.69
2.32 *
-0.54
-0.02
0.56
-0.06
0.00
-0.03
0.70 *
0.93 *
0.01
-0.20
0.27
0.31
-0.72 *
-0.01
0.13
1.09 *
0.42
-0.03
-0.04
-0.08
0.11
-0.35
0.37
-0.08
0.07
-0.05 *
-0.02
0.01
-0.50
0.54
0.38
0.02
-0.01
-0.87 *
-0.35
0.09
-0.08
0.024
0.000
0.007 *
0.001 *
Patient Level
Proportion of Patients Employed Full-time
Pre-operative Clinics
Post-operative/-discharge Education
Emergency Admission (ref: Elective)
Length of Stay
1.10 *
1.05 *
0.241 *
0.128 *
-0.85 *
-0.153 *
-0.31 *
-0.14 *
0.02 *
0.01
0.01
0.11 *
-0.22 *
0.01
-0.23 *
0.000
-0.003
0.030 *
0.001
0.006 *
0.507 *
0.000
0.006 *
0.000
0.000
-0.001
Unit Level
Pure Cardiology (ref: Mix)
Step Down Unit (ref: Other Types of Units)
Proportion of Nurses with BScN or Above
Average Overtime Hours
Average Clinical Expertise
Prevalence of Violence at Unit
Proportion of Nurses Reporting Sick Leave
Proportion of Mentally Healthy Nurses
Proportion of Nurses Rating Good Nursing Care Quality
-0.196 *
-2.262 *
0.49
8.72 *
-4.77 *
-0.01
0.56
0.07
-1.40
-0.12
-1.66
-0.05
-5.22 *
-0.38
-0.24
-3.21 *
-0.25
-0.11
3.34 *
0.06
-0.01
-0.25
-1.24
-10.32 * -12.71 *
6.47 *
7.68 *
0.532 *
0.090
-10.557 *
5.901 *
0.597 *
11.872 *
-6.619 *
-0.297 *
-0.29 *
-2.77 *
-0.260 *
2.10 *
-0.557 *
-0.75 *
5.35 *
-0.445 *
6.57 *
-3.62 *
Notes: (1) Length of stay, tasks not done or delayed, quality of nursing care and quality of patient care were dichotomized and modeled in hierarchical logistic regressions. For length of
stay, 1 = hospital stay shorter than expected; for not done, 1 = at least one task not done on last shift; for delay, 1 = at least one task delayed on last shift; quality of nursing care, 1 =
excellent/good; for quality of patient care, 1 = improved; for absenteeism, 1 = more than one occasion in past year; for leave, 1 = intent to leave within next year. (2) The
productivity/utilization cut points are 91.4% for LOS, 79.7% for absenteeism, 82.8% for intent to leave, 89.5% for cost per RIW and 89.7% for worked hours.
103
Table 19. Odds Ratios for System Outcomes in the Hierarchical Linear
Models
Predictor
LOS
Not
Done
Delay
0.96 *
0.98
1.37
0.94
0.99
1.62
1.09 *
1.12
1.06
0.62
2.27 *
1.74 *
1.03
0.92
1.87 *
0.88
1.53 *
3.60 *
0.89
0.88 *
0.87
0.96
0.98
0.99
0.85
2.23 *
1.01
0.93
1.06
1.45
1.01
0.98
0.81
Quality of
Nursing Care
Quality of
Patient Care
Absenteeism
Leave
Productivity/
Utilization
Cost per
RIW
Worked
hours
n/a
n/a
n/a
n/a
n/a
n/a *
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a *
n/a
n/a
n/a
n/a *
n/a *
n/a
Nurse Level
Age
Over Time Hours
Clinical Expertise
Unit Instability
Shift Change
Autonomy
Intent to leave
Physical Health
Mental Health
Nurse-patient Ratio
More Time Needed
0.97
0.91
1.18
0.98
1.02
0.85
1.53
0.24 *
19.47 *
1.65
1.00
0.61
1.62
1.02
1.79 *
0.97
0.50 *
1.16
1.33
0.84
0.98
0.43 *
1.26
1.39
0.98
1.75
0.94
1.00
0.97
2.01 *
2.52 *
1.01
0.82
1.31
1.37
0.49 *
1.00
1.14
2.97 *
1.52
0.56
0.90
1.40
0.54
1.08
1.25 *
0.78
0.54 *
0.64
1.35
1.17 *
1.03
0.97
0.96
0.92
1.12
0.70
1.45
0.92
1.08
1.00
1.01
2.59 *
7.06 *
1.01
1.01
1.39
0.95 *
0.98
1.01
0.60
1.72
1.47
1.02
0.99
0.42 *
0.71
1.10
0.92
0.50
10.15 *
0.59
n/a *
n/a *
Patient Level
Proportion of Patients Employed Full-time
Length of Stay
3.00 *
2.85 *
n/a *
n/a *
0.43 *
n/a *
0.74 *
0.87 *
1.02 *
1.01
1.01
1.12 *
0.80 *
1.01
0.80 *
n/a
n/a
n/a *
n/a
n/a *
n/a
n/a *
n/a
n/a
n/a *
n/a
Unit Level
n/a *
n/a *
1.05
n/a *
n/a *
0.99
1.06
1.07
0.87
0.89
0.85
0.95
0.59 *
0.69
0.78
0.73 *
0.78
0.89
1.40 *
1.07
0.97
n/a *
n/a *
0.99
0.88
n/a *
n/a *
n/a *
n/a
n/a *
n/a *
n/a *
n/a *
n/a *
n/a *
0.75 *
0.06 *
n/a *
8.14 *
n/a *
0.47 *
1.71 *
n/a *
1.93 *
0.03 *
Notes: (1) Length of stay, tasks not done or delayed, quality of nursing care and quality of patient care were dichotomized and modeled in hierarchical logistic regressions. For length
of stay, 1 = hospital stay shorter than expected; for not done, 1 = at least one task not done on last shift; for delay, 1 = at least one task delayed on last shift; for quality of nursing
care, 1 = excellent/good; for quality of patient care, 1 = improved; for absenteeism, 1 = more than one occasion in past year; for leave, 1 = intent to leave within next year. (2) The
productivity/utilization cut points are 91.4% for LOS, 79.7% for absenteeism, 82.8% for intent to leave, 89.5% for cost per RIW, and 89.7% for worked hours. (3) The odds ratios for
proportion of RN worked hours, proportion of nurses with BScN or above, proportion of nurses reporting sick leave and proportion of nurses rating good nursing care quality are
based on a 10% increase. (4) Odds ratio for quadratic transformation of productivity/utilization is not reported.
104
Table 20: Hierarchical Logistic Regression for Patients with

Shorter Than Expected Length of Stay
Predictor
Beta
SE
Odds
Ratio
Patient Level
Nurse Level
Overtime Hours
Physical Health
Mental Health
Nurse-Patient Ratio
1.05
-0.85
-0.31
-0.14
0.02
0.01
0.01
0.26
0.31
0.04
0.04
0.01
0.01
0.03
2.85
0.43
0.74
0.87
1.02
1.01
1.01
0.32
-0.03
-0.10
0.17
-0.02
0.02
-0.17
0.29
0.04
0.36
0.29
0.02
0.02
0.10
1.37
0.97
0.91
1.18
0.98
1.02
0.85
Unit Level
0.49
8.72
-4.77
1.78
2.10
1.34
1.05
n/a
n/a
*
*
*
*
*
*
*

Odds ratio for proportion of RN worked hours is based on a 10% increase. (3)
Productivity/utilization cut point is 91.4%.
105
Table 21: Hierarchical Logistic Regression for Interventions

Not Done
Predictor
Beta
SE
Odds
Ratio
-0.044
-0.061
0.480
0.085
0.109
0.058
-0.477
0.821
1.281
-0.115
-0.126
-0.143
-0.040
-0.020
-0.009
-0.168
0.428
-1.443
2.969
0.017
0.246
0.260
0.025
0.210
0.318
0.254
0.219
0.557
0.347
0.051
0.077
0.384
0.016
0.015
0.263
0.481
0.445
0.574
0.96
0.94
1.62
1.09
1.12
1.06
0.62
2.27
3.60
0.89
0.88
0.87
0.96
0.98
0.99
0.85
1.53
0.24
19.47
1.099
0.113
-0.218
0.399
0.038
0.085
3.00
1.12
0.80
-0.011
0.557
-0.376
-0.292
-2.771
0.067
2.510
0.403
0.139
0.937
0.99
1.06
0.69
0.75
0.06
Nurse Level
Age
Overtime Hours
Clinical Expertise
Unit Instability
Shift Change
Autonomy
Intent to Leave
Physical Health
Mental Health
Nurse-Patient Ratio
*
*
*
*
*
Patient Level
Proportion of Patients Employed Full-Time
*
*
Unit Level
*
*

106
Table 22: Hierarchical Logistic Regression for Interventions

Delayed
Predictor
Beta
SE
Odds
Ratio
0.01
-0.23
0.03
0.08
1.01
0.80
-0.02
-0.01
0.55
0.03
-0.09
0.63
-0.13
0.43
0.80
0.01
-0.07
0.06
0.37
0.01
-0.02
-0.21
0.50
0.01
0.22
0.22
0.02
0.19
0.28
0.22
0.17
0.37
0.29
0.04
0.07
0.32
0.01
0.01
0.23
0.32
0.98
0.99
1.74
1.03
0.92
1.87
0.88
1.53
2.23
1.01
0.93
1.06
1.45
1.01
0.98
0.81
1.65
0.07
-1.40
-0.24
-3.21
2.10
5.35
0.05
2.20
0.30
1.00
0.81
1.63
1.07
0.87
0.78
0.73
8.14
1.71
Patient Level
Nurse Level
Age
Overtime Hours
Clinical Expertise
Unit Instability
Shift Change
Autonomy
Intent to Leave
Physical Health
Mental Health
Nurse-Patient Ratio
*
*
*
Unit Level
*
*
*

ratios for proportion of RN worked hours, proportion of nurses with BScN or above, and
proportion of nurses reporting sick leave are based on a 10% increase.
107
Table 23: Hierarchical Logistic Regression for Quality of

Nursing Care
Predictor
Beta
SE
Odds
Ratio
Nurse Level
Overtime Hours
Clinical Expertise
Unit Instability
Shift Change
Autonomy
Physical Health
Mental Health
Nurse-Patient Ratio
0.00
-0.49
0.48
0.02
0.58
-0.04
-0.69
-0.59
-0.11
0.33
-0.61
0.07
0.22
0.00
0.01
0.95
1.95
-0.69
0.29
0.30
0.30
0.02
0.22
0.35
0.30
0.48
0.36
0.35
0.34
0.06
0.09
0.02
0.02
0.40
0.36
0.45
1.00
0.61
1.62
1.02
1.79
0.97
0.50
0.56
0.90
1.40
0.54
1.08
1.25
1.00
1.01
2.59
7.06
0.50
Unit Level
-0.12
0.07
0.89
-1.66
2.63
0.85
-0.25
0.35
0.78
Average Nurse-Physician Relationship
-0.75
0.23
0.47
Proportion of Nurses Rating Good Nursing Care
6.57
1.62
1.93
Quality
ratios for proportion of RN worked hours and proportion of nurses rating good nursing care
quality are based on a 10% increase.
*
*
*
*
*
*
108
Table 24: Hierarchical Logistic Regression for Quality of Patient

Care
Predictor
Beta
SE
Odds
Ratio
Nurse Level
Overtime Hours
Clinical Expertise
Unit Instability
Shift Change
Autonomy
Physical Health
Mental Health
Good Quality of Nursing Care (ref: Deteriorated)
Nurse-Patient Ratio
0.15
0.29
-0.17
-0.02
-0.84
0.23
0.33
-0.25
-0.62
-0.44
0.30
0.16
0.03
0.01
0.01
0.33
2.32
-0.54
0.20
0.22
0.21
0.02
0.18
0.27
0.20
0.26
0.23
0.29
0.26
0.04
0.06
0.01
0.01
0.23
0.38
0.41
1.16
1.33
0.84
0.98
0.43
1.26
1.39
0.78
0.54
0.64
1.35
1.17
1.03
1.01
1.01
1.39
10.15
0.59
Unit Level
-0.05
-5.22
-0.11
3.34
0.06
1.33
0.47
1.64
0.95
0.59
0.89
1.40
*
*

ratios for proportion of RN worked hours and proportion of nurses with BScN or above are
based on a 10% increase.
109
Table 25: Hierarchical Logistic Regression for Absenteeism

Predictor
Beta
SE
Odds
Ratio
-0.02
0.56
-0.06
0.93
0.01
-0.20
0.27
0.31
-0.03
-0.04
-0.08
0.11
-0.05
-0.02
0.01
-0.50
0.54
0.38
0.02
0.45
0.24
0.24
0.02
0.22
0.30
0.24
0.37
0.33
0.05
0.07
0.02
0.01
0.27
0.28
0.38
0.29
0.98
1.75
0.94
2.52
1.01
0.82
1.31
1.37
0.97
0.96
0.92
1.12
0.95
0.98
1.01
0.60
1.72
1.47
0.06
-0.25
-10.32
6.47
0.05
1.84
4.96
2.87
1.07
0.97
n/a
n/a
Nurse Level
Age
Overtime Hours
Clinical Expertise
Unit Instability
Shift Change
Autonomy
Physical Health
Mental Health
Nurse-Patient Ratio
Unit Level
*
*

ratio for proportion of RN worked hours is based on a 10% increase. (3)
110
Table 26: Hierarchical Logistic Regression for Intent to Leave

Predictor
Beta
SE
Odds
Ratio
0.00
-0.03
0.70
-0.72
-0.01
0.13
1.09
0.42
-0.35
0.37
-0.08
0.07
0.02
-0.01
-0.87
-0.35
0.09
-0.08
0.02
0.37
0.23
0.24
0.02
0.19
0.25
0.24
0.31
0.28
0.05
0.07
0.01
0.01
0.29
0.26
0.34
0.36
1.00
0.97
2.01
0.49
1.00
1.14
2.97
1.52
0.70
1.45
0.92
1.08
1.02
0.99
0.42
0.71
1.10
0.92
-0.01
-1.24
-12.71
7.68
-3.62
0.06
1.97
5.00
3.00
1.14
0.99
0.88
n/a
n/a
0.03
Nurse Level
Age
Overtime Hours
Clinical Expertise
Unit Instability
Shift Change
Autonomy
Physical Health
Mental Health
Nurse-Patient Ratio
*
*
Unit Level
*
*
*
ratios for proportion of RN worked hours and proportion of nurses rating good nursing care
quality are based on a 10% increase. (3) Productivity/utilization cut point is 82.8%.
111
Table 27: Hierarchical Linear Regression for

Predictor
Odds
Ratio
Beta
SE
Patient Level
0.000
-0.003
0.003
0.005
n/a
n/a
Nurse Level
Overtime Hours
Autonomy
Physical Health
Mental Health
Nurse-Patient Ratio
More Time Needed
0.003
-0.001
0.024
0.000
0.007
0.001
0.001
0.045
0.001
0.018
0.001
0.024
0.020
0.003
0.001
0.001
0.007
0.000
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Unit Level
-0.196
0.532
-0.557
-0.445
0.041
0.123
0.140
0.170
n/a
n/a
n/a
n/a
*
*
*
*
*
*

Notes: (1) For measurements of predictor and outcome variables, see Appendix F.
112
Table 28: Hierarchical Linear Regression for Cost per

Resource Intensity Weight (Log Scale)
Predictor
Odds
Ratio
Beta
SE
Patient Level
Length of Stay
0.241
0.128
-0.153
0.030
0.001
0.006
0.507
0.056
0.043
0.044
0.011
0.002
0.002
0.029
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Nurse Level
Overtime Hours
Clinical Expertise
Physical Health
Nurse-Patient Ratio
More Time Needed
0.047
0.004
-0.163
0.069
-0.025
-0.011
-0.110
0.000
0.068
0.009
0.052
0.086
0.076
0.004
0.027
0.004
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Unit Level
-2.262
0.090
-10.557
5.901
0.681
0.558
0.514
0.290
n/a
n/a
n/a
n/a
*
*
*
*
*
*
*
*
*
*
*

113
Table 29: Hierarchical Linear Regression for Worked Hours

per Patient (Log Scale)
Predictor
Odds
Ratio
Beta
SE
Patient Level
Length of Stay
0.000
0.006
0.000
0.000
-0.001
0.002
0.002
0.000
0.000
0.015
n/a
n/a
n/a
n/a
n/a
Nurse Level
Overtime Hours
Physical Health
Mental Health
Nurse-Patient Ratio
0.015
-0.002
-0.012
0.018
-0.001
0.000
-0.010
0.015
0.002
0.020
0.017
0.001
0.001
0.005
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Unit Level
Proportion of Full-Time Employment
0.597
11.872
-6.619
-0.297
-0.260
0.180
0.353
0.189
0.075
0.043
n/a
n/a
n/a
n/a
n/a
*
*
*
*
*

114
Table 30: Hierarchical Linear Models for Patient, Nurse, and System
Outcomes on Congruence Between PRN Hours and Actual Worked
Hours per Patient
Coefficient
SE
p-value
OR
Patient Outcome
Physical Health Improvement
Mental Health Improvement
Omaha Knowledge Improvement
Omaha Behaviour Improvement
Omaha Status Improvement
-0.0026
-0.0045
0.0006
-0.0055
-0.0007
0.0024
0.0022
0.0043
0.0044
0.0041
0.0042
0.0037
0.2209
0.2927
0.8930
0.1779
0.8687
0.5102
1.00
1.00
1.00
0.99
1.00
1.00
Nurse Outcome
Autonomy
Satisfaction
Mentally Healthy
Physically Healthy
0.1476
0.0205
-0.0024
-0.0006
0.0008
0.0022
0.0108
0.1747
0.0028
0.0025
0.0027
0.0026
0.1721
0.2405
0.3908
0.8247
0.7751
0.4016
n/a
n/a
1.00
1.00
1.00
1.00
System Outcome
LOS Shorter than Expected LOS
Improved Rating for Quality of Patient Care
Good Rating for Quality of Nursing Care
Absenteeism
Intent to Leave
Cost per Resource Intensity Weight
0.0018
0.0004
0.0047
-0.0041
-0.0002
-0.0016
0.0055
-0.0093
0.0040
0.0024
0.0027
0.0026
0.0019
0.0023
0.0020
0.0080
0.6546
0.8766
0.0847
0.1247
0.9076
0.4864
0.0067
0.2433
1.00
1.00
1.00
1.00
1.00
1.00
1.01
n/a
0.0117
0.0025
0.0000
*
*
n/a

Note: (1) For measurements of outcome variables, see Appendix F. (2) The predictor is the PRN hours
less the worked hours per patient.
115
Table 31: Summary Table of the Effect of Nursing Hours, Proportion of

RN Worked Hours, Nurse-Patient Ratio, and Productivity/Utilization on
Patient, Nurse and System Outcomes, in Odds Ratio, Coefficient, and
Cut point
Odds ratio
Patient outcome
Physical Health
Mental Health
OMAHA Knowledge
OMAHA Behaviour
OMAHA Status
Nurse outcome
Satisfaction
Physical Health
Mental Health
System outcome
Length of Stay
Quality of Patient Care
Quality of Nursing Care
Absenteeism
Intent to Leave
Coefficient
Nurse outcome
Relationship with
Physician
Autonomy
System outcome
Cost per RIW
NursePatient
Ratio
Worked
Hours
Proportion of RN
Worked Hours
(10% Increase)
Productivity/
Utilization
(Cut point)
ns
ns
ns
ns
ns
ns
1.13a
ns
0.94a
ns
ns
ns
ns
ns
ns
1.74
ns
ns
ns
80.0%
ns
n/a
88.2%
n/a
ns
ns
ns
ns
1.10b
ns
0.90b
0.93b
ns
ns
0.72
ns
80.0%
ns
ns
ns
ns
ns
ns
ns
Ns
ns
ns
ns
ns
ns
ns
Ns
ns
ns
ns
ns
ns
0.59
Ns
ns
ns
91.4%
ns
ns
ns
ns
79.7%
82.8%
NursePatient
Ratio
Average
Worked
Hours
Proportion of RN
Worked Hours
(10% Increase)
Productivity/
Utilization
(Cut point)
-0.37
0.67
ns
ns
0.29
ns
85%
85%
0.05
-0.11
ns
n/a
n/a
n/a
0.05
ns
0.60
n/a
89.5%
89.7%
a. Worked hours per patient. b. Average worked hours on unit. Notes: (1) Only significant predictors are presented for
odds ratios and cut points. (2) "ns" stands for not significant. Predictors with ns have no impact on the outcome variables.
(3) "n/a" stands for not applicable. (4) Cost per RIW and worked hours were modeled in logarithm scale, therefore by
transforming back to the original scale, a 10% increase in proportion of RN worked hours would lead to an exponential
increase of 0.60 (or 1.06 times) in the worked hours per patient which is a 6% increase in worked hours per patient.
116
Appendix D. Instruments, Psychometric Properties, and Variables

at Individual and Unit Levels
Measure
Description and Psychometric Properties

Inputs
Patient Characteristics:
These variables were collected from the patients kardex and chart.
The actual values of these variables were used at the individual
level of analysis.
Nursing diagnoses identify the conditions in patients that create the
demand for nursing services. Content validity of the taxonomy of
nursing diagnoses is inferred from the judgment and agreement of
nurse experts meetings held bi-annually for several years1. The
number of different nursing diagnoses the patient had over the
hospital stay was used as an independent variable at the individual
level.
Patient medical condition was measured by the Case Mix Groups
Patient Input
Medical Diagnoses
(CMGs) TM developed by the Canadian Institute for Health
Information). The CMG methodology has been refined a number
of times over the last several years to improve the content validity
of the measure. The Resource Intensity Weight (RIW) assigned to
an individual CMG was used in the analysis at the individual level.
The average RIW was used where aggregation was applied.
Patient Input and Output Each nursing diagnosis selected is evaluated on three dimensions
OMAHA Problem Rating (knowledge, behaviour, and status) on a 5-point Likert scale at two
Scale2
points in time: at admission or when a new health problem is
identified (Time 1), and when the health problem is resolved or at
discharge (Time 2)2. Knowledge involves what a client knows and
understands about a specific health-related problem. Behaviour
involves what a client does - the clients practices, performances,
and skills. Status involves what a client is and how the clients
conditions or circumstances improve, remain stable, or
deteriorate2. While this rating scale has been used primarily in the
community setting, the actual measurement scale is non sectorial
in nature and appropriate for use in the hospital environment. In a
previous study, the inter-rater reliability for both nursing diagnoses
and the OMAHA outcomes rating scale was maintained at 91%
among nurse participants. The admission score ratings for
knowledge, behaviour, and status were each entered as an
independent variable in the analysis. When used as a dependent
variable each variable was dichotomized as improved over hospital
stay or as having no change or deteriorated over hospital stay.
Patient Inputs
-age, sex, significant
other support
Patient Input
NANDA Form: Nursing
Diagnoses1
117
Measure
Patient Input/Output,
Outcomes Measure;
Nurse Survey Outcome
Measure;
Medical Outcomes Study
Short Form 12 measure
of health status3
The Medical Outcomes Study SF-123 is a 12-item scale

measuring 8 health domains: physical functioning, vitality, role
functioning, physical problems, social functioning, bodily pain,
mental health, and general health perceptions 4, 5, 6, 7. The SF12
has demonstrated excellent psychometric properties and is
currently the most widely used generic measure of health status,
having been employed in hundreds of studies across a broad
spectrum of disease states5. When treated as a dependent variable,
both physical health and mental health scores were dichotomized
into healthy and not healthy using the average score for the US
population as the cut point. When treated as a unit level
independent variable, the proportion of nurses on the unit with
physical and mental health scores over US population norm was
used.
Nurse Characteristics:
Nurse Survey
-age, sex, professional
designation, education,
years of experience (this
unit, this hospital,
nursing in general), usual
shift rotation, usual
number of units worked,
etc.
These data were collected in the nurse survey. Each survey was
assigned a code number which was known to the investigators
only in order to link nurse characteristics to specific patient
assignments. The variables created at the individual level were
age, gender, number of occasions absent and number of shifts
missed, professional designation, level of education, employment
status, work on multiple units, clinical expertise, voluntary and
involuntary overtime worked, job stability, prevalence of violence,
frequency of shift change, planning to leave in the next 12 months
intervention not completed on a shift and interventions delayed on
a shift. Unit level variables created include proportions of: nurses
on unit with a bachelors degree or higher, nurses reporting shift
changes, nurses who work on more than one unit, nurses
experiencing job insecurity, intending to leave in the next twelve
months, nurses with interventions not completed or delayed, nurses
absent from the unit daily, and full time positions on the unit. Unit
level variables also included the mean age of nurses, mean years of
experience, mean ratings of clinical expertise, prevalence of
violence on the unit and average overtime hours.
System Characteristics:
Hospital Profile and Unit
Profile
Number of beds in the unit, unit type (In Patient Unit, Critical Care
Unit, Step Down Unit, and Day Surgery Unit), patient composition
(pure cardiac or mix), and care delivery system were collected
from the nurse manager for each unit. These data were used as
independent variables at the unit level.
118
Measure
System Behaviours:
System behaviours
Workload
PRN8
The nurse/patient ratio, the daily number of nursing personnel,

daily patient census, admission and discharges, actual use of
agency and relief staff were collected from the nurse manager or
charge nurse on a daily basis. As a measure of continuity, average
number of nurses per day over a patients hospital stay was used as
an independent variable in the models. The actual worked hours
per patient was estimated by total work hours divided by the
number of patients at midnight census at unit on daily basis. The
proportion of worked hours contributed by Registered Nurses was
calculated. Number of patients per unit bed was computed as a
measure of unit occupancy. The daily data were aggregated to
either unit or individual level by taking the average in order to
model their effect on outcome variables. The difference between
PRN workload hours from actual worked hours per patient was
computed in order to answer research question 2. When the actual
worked hours at patient level was used as a dependent variable, a
logarithm transformation was applied to assume normality.
This instrument lists 214 indicators or interventions that nurses
complete on behalf of patients during a 24-hour period. Each
indicator has a standard given point value which reflects the time
involved to complete interventions for patients; each point
represents five minutes8. A higher point value indicates greater
amounts of nursing care required. The PRN methodology has had
extensive testing and has gone through several iterations since it
was first developed in 1972. Content validity was established by
nurse experts during a series of meetings held over this time. In
1978, Chagnon, Audette, Lebrun, and Tilquin9 established the
construct and predictive validity of the tool. Work measurement
studies demonstrated that the time estimates predicted by the tool
corresponded to the degree of work actually done. In this study the
PRN estimates served as the gold standard for care required.
In this study, every patient was rated every day using the PRN
form in order to determine the direct care and time associated with
direct care activities. The method proposed by Tilquin in1980,
which is still in used today was used to determine total hours of
care per patients (Charles Tilquin, personal communications,
October, 2003).
119
Measure
Workload
GRASP/Medicus

GRASP or MEDICUS hours were collected daily for study
patients and for the unit as a whole, including non-study patients
as well. GRASP captures workload using a standard time
methodology. Each site develops a list of tasks based on the
activities they perform, and times are assigned to each of these
tasks. The times are based on time and/or frequency or are
established by staff nurse consensus. These times reflect the
average time to complete the task, by an average nurse, on an
average day, for an average patient in the individual facility. This
reflects the physical and organizational characteristics of the
individual facility. The MEDICUS system captures workload by
multiplying a pre-set relative value per level of care by the target
hours per unit of workload.
Throughputs
Environmental
Complexity10
Environmental complexity measures the push and pull that nurses

experience in providing care to individual patients at the standard
outlined in the nursing care plan. Factor analysis in a number of
preliminary studies has revealed that the Environmental
Complexity measure taps three main domains: unanticipated
delays and re-sequencing of work in response to others,
unanticipated delays due to changes in patient acuity, and
characteristics and composition of the caregiver10. Factor analysis
was completed for this study and again the same three factors
emerged. The alpha reliabilities were 0.81, 0.84, and 0.84
respectively.
Intermediate System Outputs:
Worked hours,
productivity/utilization
Worked hours were collected from the retrospective application of

the workload measurement system used at the hospital. The daily
unit productivity/utilization for each unit was computed by
examining the workload of patients on the unit divided by worked
hours. In the analysis of productivity/utilization, linear and
quadratic terms were first tried to test the bell or U shape of the
effect of productivity/utilization. If the bell or U shape was not
supported by data, piecewise linear was tried next. If piecewise
linear is significant, it means that the direction at a certain cut
point will change. If both strategies failed, dichotomized
productivity/utilization at various cut points was tried and the one
shown significance was used in the final model. If all these failed,
dichotomized productivity/utilization at 85% was tested.
120
Measure

Outputs
Patient Outcomes:
Patient Outcome
Measure
Medical Outcomes Study
Short Form 12 measure
of health status3
The Patient Data Form
collected information
about specific patients
over their stay.
The psychometric properties of these measures are explained

above. Patient SF-12 physical and mental health status was
measured at admission and discharge. Patients individual
admission scores were used as independent variables in many of
the models. When treated as a dependent variable, improvement at
discharge or no improvement at discharge was used for both
physical health and mental health scores.
Patient medical consequences data were gathered from the
patients chart on an ongoing basis, including deep or shallow
post-operative wound infections, fall with injury, medication
errors, urinary tract infections, bedsores, pneumonia were tracked
on this form as well as death, transfers back to ICU and whether
the patient was re-admitted with the same diagnoses within three
months. Patient mortality was obtained from medical records.
Since there were numerous medical consequences with very small
frequencies, medical consequences including falls with injury,
medication errors, death, and complications such as urinary tract
infections, pneumonia, wound infections, bed sores, and
thrombosis were summed for each patient and that value was used
in the analysis. Data were collected about type of admission,
presence of a family doctor, attendance at pre-operative clinics,
bookings for post-operative or post-discharge education, referrals
to home care and support in the home. These variables were used
as patient-level independent variables in the analysis.
Nurse Outcomes:
Measure
Maslach Burnout
Inventory10
The Maslach10 Burnout Inventory has 25 items and measures 3

dimensions: emotional exhaustion (alpha = 0.90, test-retest
reliability = 0.82), depersonalization (alpha = 0.79, test-retest
reliability = 0 .60) and personal accomplishment (alpha = 0.71, test
retest reliability = 0 .80). All coefficients were significant at pvalue < 0.001. This measure has been used in numerous studies
and has proven robust over time. In the current study, only the
emotional exhaustion scores for nurses at the individual level and
for the proportion of nurses with high levels of emotional
exhaustion at the unit level were entered.
121
Measure
Measure
Siegrists Effort and
Reward Imbalance11
Nurse Survey Process

Variables
Revised Nursing Work
Index (Autonomy
Control over Practice,
Nurse-MD Relations)12

The 17-item Effort and Reward Imbalance scale identifies the
imbalance between high effort spent and low reward received at
work, and is assumed to be particularly stressful as this imbalance
violates core expectations about reciprocity and adequate exchange
in a crucial area of social life.11 This measure has been used
extensively over the past ten years in many work settings to
measure the effect of an imbalance on the physical and mental
health of workers and more recently in the nursing population.
Combined variable odds ratios are reported as 8.241 and 95%
confidence interval. At the individual level we entered the score
for nurses, and the proportion of nurses at risk of effort and reward
imbalance was used at the unit level.
The Nursing Work Index, first developed by Kramer and Hafner12
has been used extensively in the US over the past ten years in
research related to magnet hospitals, which are hospitals that are
known to attract and retain nurses13,14,15,16 and to have better
patient outcomes17. Work attributes that have been demonstrated
as important to nurses include autonomy (7 items), control over the
work environment (18 items) and nurse-physician relations (2
items). In the Aiken et al. (1994) mortality study using ANOVA,
the mean difference in observed mortality between magnet and
non-magnet hospitals was significantly different ( p = .01).
Laschinger & colleagues recomputed the factor analysis on the
scale and identified a 5 factor solution. The five factors were
autonomy, control over practice, nurse physician relations,
leadership, and resources. The alpha reliabilities of each of these
new subscales were 0.69, 0.74, 0.83, 0.80, and 0.80 respectively.
At the individual level, the scores on each of these subscales were
entered into the model, while at the unit level the mean unit score
for each variable was entered into the models.
System Outcomes:
System Outcomes
-length of stay
System Outcomes
-cost per case
These data were retrieved from medical records. The expected

length of stay was derived from CIHIs inpatient database. The
actual length of stay or its logarithm transformation was used as an
independent variable at the individual level. When used as a
dependent variable, it was dichotomized as shorter than expected
length of stay versus the same as, or longer than, the expected
length of stay.
The actual cost per equivalent weighted case by hospital was
extracted from the Ontario Case Costing Data Base and
multiplying it by the RIW for each patient. The out of province
hospital was not used in this analysis. Logarithm transformation
was applied to assume normality when it was modeled as a
dependent variable.
122
References
1. Kim, M. J., McFarland, G.K., & McLane, A. M. (1991). Pocket guide to nursing diagnoses
(4th edition). St. Louis, MO: Mosby.
2. Martin, K. S., & Scheet, N. J. (1992). The OMAHA system: Application for community health
nursing. Philadelphia, PA: WB Saunders.
3. Ware, Jr., J. E, Kosinski, M., & Keller, A. D. (2002). SF-12: How to score the SF-12
physical and mental health summary scales (4th Ed.). Lincoln, RI: QualityMetric
Incorporated.
4. McHorney, C. A., Ware, Jr., J. E., Rogers, W., & Raczek, A. E. (1992). The validity and
relative precision of MOS Short and Long Term Status Scales and Dartmouth COOP.
Medical Care, 30, 253-265.
5. Ware, Jr., J.E., & Sherbourne, C.D. (1992). The MOS 36-Item short form health survey (SF36): Conceptual framework and item selection. Medical Care, 30, 473-483.
6. Ware, Jr., J. E., Snow, K., Kosinski, M., & Gandek, B. (1993). SF-36 Health survey manual
and interpretation guide. Boston: The Health Institute.
7. Wu, A. W. (1991). A health status questionnaire using 30 items from the medical outcomes
study: Preliminary validation in persons with early HIV infection. Medical Care, 29, 786.
8. Tilquin, C., Carle, J., Saulnier, D., Lambert, P., & Collaborators. (1981). PRN 80: Measuring
the level of nursing care required. Equipe de Recherche Oprationnelle en Sant, Institut
National de Systmatique Applique, Universit de Montral: Montral, QC.
9. Chagnon, M., Audette, L. M., Lebrun, L., & Tilquin, C. (1978). Validation of a patient
classification through evaluation of the nursing staff degree of occupation. Medical Care,
16(6), 465-475.
10. OBrien-Pallas, L. L., Irvine, D., Peereboom, E., & Murray, M. (1997). Measuring nursing
workload: Understanding variability. Nursing Economics, 15(4), 172-182.
11. Maslach, C., & Jackson, S. E. (1982). Burnout in health professions: A social psychological
analysis. In G. S. Snaders & J. Suls (Eds.), Social psychology of health and illness (pp.
227-251). Hillsdale: Lawrence Erlbaum Associates.
12. Siegrist, J. (1996). Adverse health effects of high-effort/low rewards conditions. Journal of
Occupational Health Psychology, 1(1), 27-41.
13. Kramer, M., & Hafner, L. P. (1989). Shared values: Impact on staff nurse satisfaction and
perceived productivity. Nursing Research, 38, 172-177.
14. McClure, M. L., Poulin, M. A., Sovie, M. D., & Wandelt, M. A. (1982). Magnet hospitals:
Attraction and retention of professional nurses. Kansas City: American Academy of
Nurses.
15. Kutzscher, L. I. T., Sabiston, J. A., Laschinger-Spence, H. K., & Nish, M. (1997). The effects
of teamwork on staff perception and empowerment and job satisfaction. Healthcare
Management Forum, 10(2), 12-17.
16. Kramer, M., & Schmalenberg, C. (1988). Magnet hospitals: Institutions of excellence, Parts I
& II. Journal of Nursing Administration, 18(1), 13-24.
17. Kramer. M., & Schmalenberg, C. (1990). Job satisfaction and retention: Insights for the 90s,
Parts I and II. Nursing, 21, 2-7 & 9-13.
18. Aiken, L., Smith, H., & Lake, E.T. (1994). Lower Medicare mortality among a set of
hospitals known for good nursing care. Medical Care, 32(8), 771-787.
123
Appendix E. Data Collection Forms

Nursing Diagnoses (NANDA).................................................................................................... 125
OMAHA Problem Rating Scale.................................................................................................. 126
NANDA and OMAHA Summary Sheet..................................................................................... 128
The SF-12 Health Survey ........................................................................................................ 129
SF-12 Health Survey (French Version) ...................................................................................... 131
Nurse Survey............................................................................................................................... 134
Hospital Profile ........................................................................................................................... 140
Unit/Program Profile................................................................................................................... 141
Daily Unit Staffing Form ............................................................................................................ 143
Daily Environmental Complexity Scale ..................................................................................... 148
PRN 80........................................................................................................................................ 151
PRN Daily Workload and Grasp Patient Care Hours ................................................................. 153
Patient Data Form ....................................................................................................................... 154
Maslach=s Burnout Inventory...................................................................................................... 156
Effort-Reward Imbalance............................................................................................................ 158
Nursing Work Index ................................................................................................................... 159
124
Hospital: ______________Unit: ______________Patient: _________________

Hospital Day: __________Date: ______________Data collector: __________
Evidence-based Standards for Measuring Nurse Staffing and Performance
Nursing Diagnoses (NANDA)

Please circle all numbers representing the patients problems that require nursing care.
1. Activity intolerance
2. Activity intolerance, high
risk
3. Adjustment, impaired
4. Anxiety
5. Aspiration, high risk for
6. Body image disturbance
7. Body temperature, altered,
high risk for
8. Bowel incontinence
9. Breathing pattern, ineffective
10. Cardiac output, decreased
11. Communication, impaired
verbal
12. Constipation
13. Constipation, colonic
14. Constipation, perceived
15. Coping, defensive
16. Coping, family: potential for
growth
17. Coping, ineffective family:
compromised
18. Coping, ineffective family:
disabling
19. Coping, ineffective
individual
20. Decisional conflict
21. Denial, ineffective
22. Diarrhea
23. Disuse syndrome, high risk
for
24. Diversional activity deficit
25. Dysreflexia
26. Family processes, altered

27. Fatigue
28. Fear
29. Fluid volume, deficit (1)
30. Fluid volume deficit (2)
31. Fluid volume, high risk for
32. Fluid volume excess
33. Gas exchange impaired
34. Health maintenance, altered
35. Health-seeking behaviours
36. Hopelessness
37. Incontinence, functional
38. Incontinence, reflex
39. Incontinence, stress
40. Incontinence, total
41. Incontinence, urge
42. Infection, high risk for
43. Injury, high risk for
44. Knowledge deficit
45. Management of therapeutic
regimen (individuals),
ineffective
46. Mobility, impaired physical
47. Non-compliance
48. Nutrition, altered: less than body
requirements
49. Nutrition, altered: more than
body requirements
50. Nutrition altered: high risk for
more than body requirements
51. Oral mucous membrane, altered
52. Pain
53. Pain, chronic
54. Peripheral neurovascular

dysfunction, high risk for
55. Post-trauma response
56. Powerlessness
57. Role performance,
altered
58. Self-care deficit,
bathing/hygiene
59. Self-care deficit,
dressing/grooming
60. Self-care deficit, feeding
61. Self-care deficit, toileting
62. Self-esteem disturbance
63. Self-esteem, chronic low
64. Self-esteem, situational
low
65. Sensory/perceptual
alteration
66. Social interaction,
impaired
67. Social isolation
68. Spiritual distress
69. Swallowing, impaired
70. Thought processes,
altered
71. Tissue integrity, impaired
72. Tissue perfusion, altered
73. Trauma, high risk for
74. Unilateral neglect
75. Urinary elimination,
altered
76. Urinary retention
77. Ventilation, inability to
sustain spontaneous
78. Ventilatory, weaning
process, dysfunctional
125
OMAHA Problem Rating Scale

For each patient, complete at time of:
<
admission (A)
<
discharge (D)
<
new nursing diagnoses after admission (N)
<
resolution of nursing diagnoses during care (R)
Hospital
Day
Nursing
Diagnosis
Time
Knowledge
Ability of the patient
to remember and
interpret information
Behaviour
Observable responses,
actions or activities of
the patient fitting the
occasion or purpose
Status
Condition of the patient
in relation to objective
and subjective defining
characteristics
enter:
A
D
N
R
1-No knowledge
2-Minimal knowledge
3-Basic knowledge
4-Adequate knowledge
5-Superior knowledge
1-Never appropriate
2-Rarely appropriate
3-Inconsistently appropriate
4-Usually appropriate
5-Consistently appropriate
1-Extreme signs/symptoms
2-Severe signs/symptoms
3-Moderate signs/symptoms
4-Minimal signs/symptoms
5-No signs/symptoms
126
Hospital
Day
Nursing
Diagnosis
Time
Knowledge
Ability of the patient
to remember and
interpret information
1
Behaviour
Observable responses,
actions or activities of
the patient fitting the
occasion or purpose
1
2
3
4
5
Status
Condition of the patient
in relation to objective
and subjective defining
characteristics
1
2
3
4
5
127
NANDA and OMAHA Summary Sheet

Date
Unit NANDA Diagnoses Time OMAHA Ratings

Code
A D Knowledge
Behaviour
N R
NRU Use
Only
Status
128
The SF-12 Health Survey

Your Health in General
1. In general, would you say your health is:
Excellent
Very good
Good
Fair
Poor
{1
{2
{3
{4
{5
2. The following questions are about activities you might do during a typical day.
Does your health now limit you in these activities? If so, how much?
a) Moderate activities, such as moving

a table, pushing a vacuum cleaner,
bowling, or playing golf
b) Climbing several flights of stairs
Yes,
limited
a lot
Yes,
limited
a little
No, not
limited
at all
{1
{2
{3
{1
{2
{3
3. During the past week, have you had any of the following problems with your
work or other regular daily activities as a result of your physical health?
Yes
No
a) Accomplished less than you would like
{1
{2
b) Were limited in the kind of work or other activities
{1
{2
4. During the past week, have you had any of the following problems with your
work or other regular daily activities as a result of any emotional problems
(such as feeling depressed or anxious)?
Yes
No
a) Accomplished less than you would like
{1
{2
b) Did work or other activities less carefully than usual
{1
{2
129
5. During the past week, how much did pain interfere with your normal work
(including both work outside the home and housework)?
Not at all
A little bit
Moderately
Quite a bit
Extremely
{1
{2
{3
{4
{5
6. These questions are about how you feel and how things have been with you during
the past week. For each question, please give the one answer that comes closest to
the way you have been feeling. How much of the time during the past week...
A good
All of Most bit of Some A little None
the of the
the
of the of the of the
time time
time
time
time
time
a) have you felt calm and
peaceful?
{1
{2
{3
{4
{5
{6
b) did you have a lot of

energy?
{1
{2
{3
{4
{5
{6
c) have you felt

downhearted and blue?
{1
{2
{3
{4
{5
{6
7. During the past week, how much of the time has your physical health or emotional
problems interfered with your social activities (like visiting friends, relatives, etc.)?
All of the
time
{1
Most of the
time
Some of the
time
A little of the
time
None of the
time
{2
{3
{4
{5
THANK YOU FOR COMPLETING THIS QUESTIONNAIRE!
130
SF-12 Health Survey (French Version)

QUESTIONNAIRE SUR L'TAT DE SANT - SF-12
DIRECTIVES: Les questions qui suivent portent sur votre sant, telle que vous la
percevez. Vos rponses permettront de suivre l'volution de votre tat de sant et de
savoir dans quelle mesure vous pouvez accomplir vos activits courantes.
Veuillez rpondre toutes les questions en cochant une case. En cas de doute,
rpondez de votre mieux.
1.
En gnral, diriez-vous que votre sant est:
Excellente
Trs bonne
Bonne
Passable
Mauvaise
2. Les questions suivantes portent sur les activits que vous pourriez avoir faire au
cours d'une journe normale. Votre tat de sant actuel vous limite-t-il dans ces
activits? Si oui, dans quelle mesure?
Mon tat Mon tat Mon tat
de sant de sant de sant
me limite
me
ne me
beaucoup limite un limite pas
peu
du tout
a)
Dans les activits modres comme dplacer

une table, passer l'aspirateur, jouer aux
quilles ou au golf
b)
Pour monter plusieurs tages pied
Copyright 1994 Health Assessment Lab.

All rights reserved.
(SF-12 French (Canadian) Standard Version 1.0)
131
3. Au cours de la dernire semaine, avez-vous eu l'une ou l'autre des difficults

suivantes au travail ou dans vos autres activits quotidiennes cause de votre tat de
sant physique?
OUI
a)
Avez-vous accompli moins de choses que

vous l'auriez voulu?
b)
Avez-vous t limit(e) dans la nature de vos

tches ou de vos autres activits?
NON
4. Au cours de la dernire semaine, avez-vous eu l'une ou l'autre des difficults

suivantes au travail ou dans vos autres activits quotidiennes cause de l'tat de votre
moral (comme le fait de vous sentir dprim(e) ou anxieux(se))?
OUI
NON
a)
Avez-vous accompli moins de choses que vous

l'auriez voulu?
b)
Avez-vous fait votre travail ou vos autres activits avec

moins de soin qu' l'habitude?
5.
Au cours de la dernire semaine, dans quelle mesure la douleur a-t-elle nui vos
activits habituelles (au travail comme la maison)?
Pas du tout
Un peu
Moyennement
Beaucoup
normment

132
6. Ces questions portent sur de la dernire semaine. Pour chacune des questions
suivantes, donnez la rponse qui s'approche le plus de la faon dont vous vous tes
senti(e). Au cours de la dernire semaine, combien de fois:
Tout le
temps
La
plupart Souvent Quelquefois
du
temps
Rarement
Jamais
a) Vous tes-vous senti(e)

calme et serein(e)?
b) Avez-vous eu
beaucoup d'nergie?
c) Vous tes-vous senti(e)
triste et abattu(e)?
7.
Au cours de la dernire semaine, combien de fois votre tat physique ou

moral a-t-il nui vos activits sociales (comme visiter des amis, des
parents, etc.)?
Tout le temps
La plupart du
temps
Parfois
Rarement
Jamais

133
Nurse Survey
Please circle the number of the appropriate response to each question or, where indicated, fill in the
blanks.
A.
Questions About Your Work Life
A1
What is your current employment status at this

hospital?
Full time................................
Part time...............................
Casual....................................
1
2
3
A2
Is your employment:
Permanent.............................
Temporary.............................
1
2
A3
Is this the unit you normally work on?
Yes.........................................
No.........................................
1
2
A4
What is your job title?
RN.........................................
RPN.......................................
Other (specify):___________
1
2
3
A5
How many years have you worked:

a) as an RN/RPN
b) as an RN/RPN at your present hospital
c) as an RN/RPN on your current unit
d) as a casual worker
_____ years _____ months

A6
Is your immediate supervisor a nurse?

If No, please specify the profession of your supervisor.
Yes.........................................
No (specify):______________
A7
In the past year, how many hours per week did you
work, on average:
a) in this hospital for paid work?
b) for any other paid work?
_______ hours per week

In the past year, how many hours per week, on average,

did you work on units other than the one to which you
are usually assigned? (that is, the one where you work
the most hours):
In the past year, how many hours a week, on average,

did you work in this hospital the following types of
overtime?
a) Voluntary Paid
b) Voluntary Unpaid
c) Involuntary Paid
d) Involuntary Unpaid

A8
A9
134
1
2
A10
In the past year, has the amount of overtime required

of you:
Increased................................
Remained the same...............
Decreased..............................
Not applicable........................
1
2
3
4
A11
In the past 2 weeks, how often did you change shifts?

(e.g., from days to evenings, evenings to nights, nights
to days, etc.)
None........................................
Once........................................
Twice.......................................
Other (specify):____________
1
2
3
4
A12
In the past year, have you been required to permanently

change nursing units due to restructuring/reorganization?
Yes.........................................
No..........................................
1
2
A13
In the next year, do you anticipate having to

permanently change nursing units due to
restructuring/reorganization?
Yes.....................................
No......................................
1
2
B. Questions About Your Job Satisfaction

How satisfied are you with the following aspects of your current job?
Very
Dissatisfied
Very
Satisfied
B1
Opportunities for social contact at work
B2
Opportunities for social contact with your colleagues after work
B3
Opportunities to interact with management/administration
B4
Your amount of responsibility
B5
B6
On the whole, how satisfied are you with your present job?
1
Independent of your present job, how satisfied are you with being 1
a nurse?
2
2
3
3
4
4
5
5
B7
Thinking about the next 12 months, how likely is it

that you will lose your job?
Very Likely...................................
Fairly Likely..................................
Not too likely................................
Not at all likely.............................
1
2
3
4
B8
Do you plan to leave your present nursing job?
Yes, within the next 6 months.......

Yes, within the next year...............
No plans within the year...............
1
2
3
B9
If you were looking for another job, how easy or

difficult do you think it would be for you to find
an acceptable job in nursing?
Very easy................................
Fairly easy...............................
Fairly difficult...........................
Very difficult...........................
1
2
3
4
135
C.
Questions About You
C1
What is your gender?
Female...................................................
Male......................................................
C2
What is your age?
_______ years
C3
Do you have any dependent children/others

living with you?
a) children
b) other dependents
1
2
Yes, how many children_____________

No.........................................................
Yes, how many other dependents______
No.........................................................
1
2
1
2
C4
What is your highest Nursing educational

credential?
RPN Diploma.........................................
RN Diploma...........................................
BScN....................................................
MScN....................................................
PhD Nursing..........................................
Post RN Certificate Cardiac....................
Post RN Certificate Other (specify):
_______________________________
1
2
3
4
5
6
7
C5
What is your highest Non-nursing educational

credential?
Diploma.................................................
Baccalaureate........................................
Masters.................................................
PhD.......................................................
Other (specify):___________________
Not applicable........................................
1
2
3
4
5
6
C6
In the past year:

a) On how many occasions (episodes) have you
missed work due to illness/disability?
b) How many shifts have been missed due to
illness/disability?
C7
In the past year, what is the most common

reason you missed work? (Choose one only)
_________ # occasions
_________ # shifts
Physical illness.......................................
Mental health day...................................
Injury (work related)...............................
Family illness/crisis/
commitment.............
Unable to get requested day off..............
Other (specify):___________________
136
1
2
3
4
5
6
C8
How often are you selected to be a preceptor for

another nurse?
Never....................................................
Rarely...................................................
Occasionally...........................................
Frequently..............................................
1
2
3
4
C9
How often do nurses come to you for clinical

judgment on a difficult clinical problem?
Never....................................................
Rarely...................................................
Occasionally...........................................
Frequently..............................................
1
2
3
4
C10
The following descriptions are intended to

represent levels of skill and ability in nursing
roles and functions. Which one of the following
would you say best describes the way in which
you practice on your unit?
I am a nurse who...
(circle only one response)
1) ...relies primarily on standards of care,
unit procedures and physicians= and
nurses= orders to guide patient care
2) ...has increased clinical understanding,
technical and organizational skills and is
able to anticipate the likely course of
events
3) ...perceives the patient situation as a
whole and responds appropriately as
conditions change
4) ...is good at recognizing unexpected
clinical responses and often provides an
early warning of patient changes
D.
1
2
3
4
Questions About Violence

In the last 5 shifts you worked, have you experienced
any of the following while carrying out your
responsibilities as a nurse:
D1
a) Physical assault
b) If yes, indicate source of physical assault
Yes.....................................
No.......................................
Source of physical assault:
Patient.................................
Family/visitor........................
Physician.............................
Nursing co-worker...............
Other, specify:___________
1
2
1
2
3
4
5
137
D2
a) Threat of assault
b) If yes, indicate source of threat of assault
D3
a) Emotional abuse
b) If yes, indicate source of emotional abuse
Yes.....................................
No.......................................
Source of threat of assault:
Patient.................................
Family/visitor........................
Physician.............................
1
2
Yes.....................................
No.......................................
Source of emotional abuse:
Patient.................................
Family/visitor........................
Physician.............................
1
2
1
2
3
4
5
1
2
3
4
5
E.
Questions About Your Perceptions of Quality of Care
E1
Overall, in the past year, would you say the quality of patient care
in your unit has:
Improved................
Remained the same.
Deteriorated...........
1
2
3
E2
How would you describe the quality of nursing care delivered on your
last shift?
Excellent................
Good......................
Fair........................
Poor.......................
1
2
3
4
E3
Which of the following tasks did you perform during your last shift?
1) Delivering/retrieving trays
2) Ordering, coordinating or performing ancillary services (e.g.,
physical therapy, ordering labs)
3) Starting IVs
4) Arranging discharge referrals and arranging transportation
(including nursing homes)
5) Performing ECGs
6) Routine phlebotomy (venipunctures)
7) Transporting patients (including to nursing homes)
8) Housekeeping duties (e.g., cleaning patient rooms)
Circle all that apply

1
2
3
4
5
6
7
8
138
E4
E5
Which of the following situations occurred on your last shift due

to time pressures?
1) Routine vital signs, medications or dressings not done
2) Routine vital signs, medications or dressings not on time
3) Routine mobilization or turns not done
4) Routine mobilization or turns not done on time
5) Delay in administering PRN pain medications
6) Delay in responding to patient bell
Which of the following tasks were necessary but left undone

during your last shift because you lacked the time to complete them?
1) Routine teaching for patients and families
2) Prepare patient and family for discharge
3) Comforting/talking with patients
4) Adequately documenting nursing care
5) Back rubs and skin care
6) Oral hygiene
7) Develop or update nursing care plan
1
2
3
4
5
6
1
2
3
4
5
6
7
139
Hospital _________
Date ________________________
Hospital Profile
Interview Questions
1
What is the title of the nurse responsible

for Operating Decisions?
What is the title of the nurse responsible

for Standards of Practice?
If the hospital is structured by Programs,

is there any central control of nurse
staffing decisions?
Who determines the volume and skill

mix for nursing?
Does your hospital have:

a) Student nurses
b) Student physicians
c) Residents
Where are inpatient cardiovascular and

cardiology services provided in your
hospital?
List the names and designations of
nursing units.
How long do patients routinely stay in

ICU?
Does your hospital have a formal

preoperative process prior to elective
cardiovascular surgery?
Yes..........................................................
No............................................................
If yes, please provide a description and
indicate the proportion of annual
cardiovascular patient surgical volume
that attend________________________
1
2
Does your hospital have any policies for

violence/abuse against nurses?
Yes, please provide copies......................

No............................................................
1
2
10
Does your hospital have advanced

practice nurses for cardiovascular and/or
Yes, provide copies of their role.............
Yes..........................................................
No............................................................
Circle all that apply:

a
b
c
No............................................................
cardiology services?
11
Does your hospital have any policies for

sheath removal?
1
2
2
Yes, please provide copies......................
No............................................................
140
Hospital _________
Date ________________________
Unit/Program Profile
1
Does your unit use Critical Pathways or

Clinical Guidelines for common
cardiovascular and cardiology diagnoses?
Yes, please provide copies................

No.......................................................
1
2
Does your unit use standard nursing care

plans for common cardiovascular and
cardiology diagnoses?
Yes, please provide copies................

No.......................................................
1
2
In your unit, do your policies and

procedures for cardiovascular and
cardiology patients allow nurses, during
an emergency situation, to:
a) Initiate an IV
b) Defibrillate
c) Initiate thrombolytic agents
d) Initiate oxygen
Circle all that apply:
Is there a formal pre-op program for your

patients?
Yes......................................................
No.......................................................
Provide a description of program
goals, length of program, the services
provided and the criteria for inclusion
What is the post discharge follow-up

procedure for patients?
Describe and provide an estimate of

the percentage of patients that would
be involved
Do you have a nurse educator:

a) For the unit:
b) For the program:
Do you have any outpatient activity on this

unit?
What are the average daily hours of

housekeeping support for this unit?
a
b
c
d
1
2
a)Yes, indicate #FTEs___________

No.......................................................
b)Yes, indicate #FTEs___________
No.......................................................
1
2
1
2
Yes, please provide details...............

No.......................................................
1
2
141
Hospital _________
Are there any current issues related to the

physical environment that we should be aware
of?
10
Determining turnover rate:
Date ________________________
a) How many positions have been

posted in the past year? ___________
b) How many positions have been
budgeted for in the past year? ______
11
Determining vacancy rate:
a) How many days have been vacant in

the past year? ______
b) How many budgeted FTEs in the
past year? ______
12
Do you have access to the following allied

health professionals and are they dedicated
to the unit?
a) Physiotherapists
b) Occupational Therapists
c) Social Workers
d) Nutritionists/Dieticians
e) Other(s):__________________________
Circle only per discipline:

a) Access: Yes.................................
No.................................
Dedicated: Yes................................
No..................................
#FTEs dedicated to unit_________
b) Access: Yes.................................
No.................................
Dedicated: Yes.................................
No.................................
#FTEs dedicated to unit_________
c) Access: Yes................................
No.................................
Dedicated: Yes.................................
No.................................
#FTEs dedicated to unit__________
d) Access: Yes..............................
No.................................
Dedicated: Yes.................................
No.................................
e) Access: Yes...............................
No...............................
Dedicated: Yes................................
No.................................
142
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2

Patient Census by Shift
Shifts
# of Patients
# Admissions or
Transfers In
# Discharges or
Transfers Out
# RPNs/RNAs
FT
PT
Casual
# other (UCPs)
FT
PT
Casual
days: 0730-1530
evenings: 1530-1930
evenings: 1930-2330
nights: 2330-0730
other:
Number of Staff Working on Unit
Shifts
# RNs
FT
PT
Casual
days: 0730-1530
evenings: 1530-1930
evenings: 1930-2330
nights: 2330-0730
other:
Number of Agency Staff
Shifts
# of Agency Nurses
# of Agency Non-Nurses (e.g., Sitters)
days: 0730-1530
evenings: 1530-1930
evenings: 1930-2330
nights: 2330-0730
other:
Number of Overtime Hours
143
Hospital _________
Shifts
Date ________________________
# RNs
FT
PT
Casual
# RPNs/RNAs
FT
PT
Casual
# other (UCPs)
FT
PT
Casual
days: 0730-1530
evenings: 1530-1930
evenings: 1930-2330
nights: 2330-0730
other:
Number of Staff Absent from Unit Due to Illness

Shifts
# RNs
FT
PT
Casual
# RPNs/RNAs
FT
PT
Casual
# other (UCPs)
FT
PT
Casual
days: 0730-1530
evenings: 1530-1930
evenings: 1930-2330
nights: 2330-0730
other:
Number of Staff Absent from Unit Due to Reasons Other than Illness
Shifts
# RNs
FT
PT
#RPNs/RNAs
# other (UCPs)
Casual FT
PT
Casual FT
PT
Casual
days: 0730-1530
evenings: 1530-1930
evenings: 1930-2330
nights: 2330-0730
other:
144
Hospital _________
Date ________________________
Number of Staff who Floated To Unit

Shifts
# RNs
FT
PT
#RPNs/RNAs
# other (UCPs)
Casual FT
PT
Casual FT
PT
Casual
days: 0730-1530
evenings: 1530-1930
evenings: 1930-2330
nights: 2330-0730
other:
Number of Staff who Floated From Unit

Shifts
# RNs
FT
PT
#RPNs/RNAs
# other (UCPs)
Casual FT
PT
Casual FT
PT
Casual
days: 0730-1530
evenings: 1530-1930
evenings: 1930-2330
nights: 2330-0730
other:
Number of Staff on Orientation (either formal or on-the-job training)

Shifts
# RNs
FT
PT
#RPNs/RNAs
# other (UCPs)
Casual FT
PT
Casual FT
PT
Casual
days: 0730-1530
evenings: 1530-1930
evenings: 1930-2330
nights: 2330-0730
other:
145
Hospital _________
Date ________________________
Number of Patient Falls or Medication Errors

Shifts
Patient Falls
Medication Errors
days: 0730-1530
evenings: 1530-1930
evenings: 1930-2330
nights: 2330-0730
other:
Unit Workload Data

Patient Care Workload:
GRASP Patient Care Hours or Medicus Patient Type
________________________________________
Non-patient Care Workload:
GRASP Non-patient Care Hours or Medicus Non-patient care workload ________________________
146
Hospital _________
Date ________________________
Number of Patients Assigned to RNs at Beginning of Day Shifts

RN Code
FT
PT
Casual
147
Hospital _________
Date ________________________
Daily Environmental Complexity Scale

For the following, please rate how each item influenced your ability to provide required
care for patient(s) on this shift. Please reflect on the workload you anticipated prior to
starting your shift and decide the nature of the influence of each item. Did the item increase
anticipated workload, decrease anticipated workload or have no influence on anticipated
workload? (i=increased work, d=decreased work, or s=same as usual/no change). Then,
rate the extent of the items influence on a scale of 1 to 5 (1=low influence, 3=medium
influence, 5=high influence).
Students wanted access to charts, equipment & supplies
High
Low
Medium
Same as usual/
No change
Students on the unit today required supervision and

assistance
Decreased
workload
Increased
workload
Circle your responses. For those items not applicable to this shift please leave blank.
Students:
Staffing:
3
Scheduled unit staff absent this shift (includes UM, RNs,

RNAs, LVNs, clerical and assistive staff)
Nursing Team Functioning:

4
Staff unable to pull together to complete unit work
Assignment:
5
Rushing to get work done
Unanticipated Communication with

Doctors:
6
More than the usual calls to doctors this shift
Clarifying doctors' orders
Unanticipated Delays:
8
Doctors not answering pages
Multiple delays experienced on the unit
Medication, supplies and narcotic keys missing
10
148
Hospital _________
11
Language barrier with family and/or patient
Date ________________________
i
Unexpected Change in Patient

Condition:
12
Agitated, confused, or restless patient(s)
13
Unanticipated increase in patient acuity
16
Extra charting and paperwork
17
Greater demand for routine patient teaching
18
Greater demand for psychosocial support for patient
19
Greater demand for psychosocial support for family
High
Medium
Low
Same as usual/
No change
Extra vital signs
Decreased
workload
15
Stat blood work
14
Increased
workload
Unanticipated Time Consuming

Interventions for Patient and Family:
Unanticipated and Time Consuming NonPatient Care Activities:

20
Completing work of others (e.g. dietary, clerical staff,

housekeeping, nursing administration)
21
Interruptions (e.g., called back to desk, phone) that

influences time with patients and family
22
Participating in nursing research
23
24
25
Please add and rate any other

information regarding events that
significantly influenced your ability to
provide required care on this shift:
Copyright L. OBrien-Pallas
149
Hospital _________
Date ________________________
Please rate the time available to deliver

care on THIS SHIFT compared to the
last five shifts you have worked.
CIRCLE ONLY ONE RESPONSE:
26
Less time than usual

About the same amount of time as usual
More time than usual
Approximately how much more time do

you feel you need to give the type of
care stated in the nursing care plan or
your assessment of patients needs to
day? CIRCLE ONLY ONE RESPONSE:
27
No more time needed

< 15 minutes
15-30 minutes
31-45 minutes
46-60 minutes
>60 minutes
Copyright L. OBrien-Pallas
150
Hospital __________
Unit __________
Patient __________
PRN 80
151
Hospital __________
Unit __________
Patient __________
152
Hospital __________
Unit __________
Patient __________
PRN Daily Workload and Grasp Patient Care Hours

Date
Unit
Nurse
Code
Respiration
Feeding
Elimination
Hygiene
Communication
Treatment
Diagnostic
153
GRASP
PCH
Hospital __________
Unit __________
Patient __________
Patient Data Form

Please circle the number of the appropriate response to each question or, where indicated, fill in the
blanks.
Date of admission
dd/mm/yy _______________________
Date of discharge/transfer/death
dd/mm/yy _______________________
Admission diagnosis
Other concurrent diagnosis
Sex
Male.......................................................
Female...................................................
Age
__________years
Occupation
Highest level of education:
Less than high school diploma.............

High school diploma............................
Trade certificate/college/some university
University degree.................................
1
2
3
4
Does the patient have a potential

caregiver at home?
Yes.............................................................
No...............................................................
1
2
10
Does patient have a family physician?
Yes............................................................
No..............................................................
1
2
11
Actual length of stay in ICU:
_______ hours
12
Actual length of stay in hospital:
_______ hours
13
Has the patient been transferred back to

ICU?
Yes, number of hours in

ICU___________
No...............................................................
1
2
14
Did patient attend pre-operative clinic?
Yes.............................................................
No...............................................................
1
2
154
1
2
Hospital __________
Unit __________
Patient __________
15
Is patient booked for post-operative/postdischarge education?
Yes.........................................................
No..........................................................
1
2
16
Did patient spend time in step-down unit?
Yes, number of hours in SDU_______
1
2
No........................................................
17
Did patient have any falls:

a) Resulting in injury:
b) Not resulting in injury:
18
Did the patient develop any of the

following:
a) urinary tract infection
b) pneumonia
c) superficial incisional surgical site
infection
d) deep incisional surgical site infection
e) bedsores
f) thrombosis
a)Yes, specify injury_______________

No.....................................................
b)
Yes.....................................................
No......................................................
1
2
1
2

a
b
c
d
e
f
19
Did patient get a referral for home care?
Yes.........................................................
No..........................................................
1
2
20
Was this a planned admission?
Yes.........................................................
No..........................................................
1
2
21
Was the patient hospitalized for the same

condition in the past 3 months?
Yes.........................................................
No..........................................................
1
2
22
Were there any nurse medication errors

with this patient?
Yes, with patient consequences,

specify________________________
Yes, without patient consequences
No medication errors
1
2
3
155
Maslach=s Burnout Inventory

This section contains statements of JOB-RELATED FEELINGS. If you have never had this
feeling, circle the A0@ (zero) after the statement. Otherwise, indicate how often you feel like
this by circling the number (from1 to 6) that best describes how frequently you feel that
way.
How Often?
Never
A few
times a
year or
less
Once a
month
or less
A few
times a
month
Once
a
week
A few
times a
week
Every
day
I feel emotionally drained from my work
I feel used up at the end of the workday.
I feel fatigued when I get up in the morning and have to

face another day on the job.
I can easily understand how my patients feel about things.
I feel I treat some patients as if they were impersonal

objects.
Working with people all day is really a strain for me.
I deal very effectively with the problems of my patients.
I feel burned-out from my work.
I feel I=m positively influencing other people=s lives.
10
I=ve become more callous toward people since I took this

job.
11
I worry that this job is hardening me emotionally.
12
I feel very energetic.
13
I feel frustrated by my job.
14
I feel I=m working too hard on my job.
15
I don=t really care what happens to some patients.
16
Working directly with people puts too much stress on me.
17
I can easily create a relaxed atmosphere with my patients.
18
I accomplish many worthwhile things in this job.
156
Never
A few
times a
year or
less
Once a
month
or less
A few
times a
month
Once
a
week
A few
times a
week
Every
day
19
I feel exhilarated after working closely with my patients.
20
I feel like I=m at the end of my rope.
21
In my work, I deal with emotional problems very calmly.
22
I feel patients blame me for some of their problems.
157
Effort-Reward Imbalance
For each of the following statements, please indicate first whether you agree or disagree with it.
If there is an arrow behind your answer please also indicate how much you are generally
distressed by this situation. Thank you for answering all statements.
I am very distressed
I am distressed
I am somewhat distressed
I am not at all distressed
1. I have constant time pressure due to a heavy work load.
2. I have many interruptions and disturbances in my job.
3. I have a lot of responsibility in my job.
4. I am often pressured to work overtime
5. My job is physically demanding.
6. Over the past few years, my job has become more and
more demanding.
7. I receive the respect I deserve from my superiors.
8. I receive the respect I deserve from my colleagues.
9. I experience adequate support in difficult situations.
10. I am treated unfairly at work.
11. My job promotion prospects are poor.
12. I have experienced or I expect to experience an
undesirable change in my work situation.
13. My job security is poor.
14. My current occupational position adequately
reflects my education and training.
15. Considering all my efforts and achievements, I
receive the respect and prestige I deserve at work.
16. Considering all my efforts and achievements, my work
prospects are adequate.
17. Considering all my efforts and achievements, my salary
/income is adequate.
disagree
agree
disagree
agree
disagree
agree
disagree
agree
disagree
agree
disagree
agree
disagree
agree
disagree
agree
disagree
agree
disagree
agree
disagree
agree
disagree
agree
disagree
agree
disagree
agree
disagree
agree
disagree
agree
disagree
agree
4
3
2
1
1
1
2
2
3
3
4
4
1
1
2
2
3
3
4
4
158
Nursing Work Index

For each item in this section, please indicate the extent to which you agree that the
following items ARE PRESENT IN YOUR CURRENT JOB. Indicate your degree of
agreement by circling the appropriate number.
The following are present in your current job . . .
Strongly
Agree
Somewhat
Agree
Somewhat
Disagree
Strongly
Disagree
Adequate support services allow me to spend time with

my patients.
Physicians and nurses have good working relationships.
A good orientation program for newly employed nurses.
A supervisory staff that is supportive of the nurses.
A satisfactory salary.
Nursing controls its own practice.
Active staff development or continuing education

programs for nurses.
Career development/clinical ladder opportunity.
Opportunity for staff nurses to participate in policy

decisions.
10
Support for new and innovative ideas about patient

care.
11
Enough time and opportunity to discuss patient care

problems with other nurses.
12
Enough registered nurses on staff to provide quality

patient care.
13
A nurse manager or immediate supervisor who is a good

manager and leader.
14
A senior nursing administrator who is highly visible and

accessible to staff.
15
Flexible or modified work schedules are available.
16
Enough staff to get work done.
17
Freedom to make important patient care and work

decisions.
18
Praise and recognition for a job well done.
159
19
The opportunity for staff nurses to consult with clinical

nurse specialists or expert nurse clinicians/educators.
20
Good working relationships with other hospital

departments or programs.
21
Not being placed in a position of having to do things

that are against my nursing judgement.
22
High standards of nursing care are expected by the

administration.
23
A senior nursing administrator equal in power and

authority to other top level hospital executives.
24
A lot of team work between nurses and physicians.
25
Physicians give high quality medical care.
26
Opportunities for advancement.
27
Nursing staff are supported in pursuing degrees in

nursing.
28
A clear philosophy of nursing that pervades the patient

care environment.
29
Nurses actively participate in efforts to control costs.
30
Working with nurses who are clinically competent.
31
The nursing staff participates in selecting new

equipment.
32
A nurse manager or supervisor who backs up the

nursing staff in decision-making, even if the conflict is
with a physician.
33
Administration that listens and responds to employee

concerns.
34
An active quality assurance program.
35
Staff nurses are involved in the internal governance of

the hospital (e.g., practice and policy committees).
36
Collaboration between nurses and physicians.
37
A preceptor program for newly hired RNs.
38
Nursing care is based on a nursing rather than a

medical model.
39
Staff nurses have the opportunity to serve on hospital

and nursing committees.
160
40
The contributions that nurses make to patient care are

publicly acknowledged.
41
Nurse managers consult with staff on daily problems

and procedures.
42
A work environment that is pleasant, attractive, and

comfortable.
43
Opportunity to work on a highly specialized patient care

unit.
44
Written up-to-date nursing care plans for all patients.
45
Patient care assignments that foster continuity of care

(i.e., the same nurse cares for the patient from one day
to the next).
46
Staff nurses do not have to float from their designated

unit.
47
Staff nurse actively participate in developing their own

working schedule (i.e., what days they work, days off,
etc.).
48
Each patient care unit determines its own policies and

procedures.
49
Working with experienced nurses who Aknow@ the

hospital nurses.
161
Appendix F. Methods
Methods
Methods: Multilevel Modeling and MLwin ............................................................................... 163
Multilevel structures ............................................................................................................... 163
Variables ................................................................................................................................. 165
MLwin ..................................................................................................................................... 167
List of Tables
Table 1: Unit Characteristics Aggregated from Individual Nurse Level.................................... 164
Table 2: Dichotomy of Outcome Variables ................................................................................ 165
162
Methods: Multilevel Modeling and MLwin

Health science research often concerns problems that have a hierarchical structure, for example,
when patients are nested within units, and units are nested within hospitals. In multilevel
analysis, data structure of this nature is viewed as a multistage sample from a hierarchical
population. By focusing on the level of hierarchy in the population, multilevel modeling enables
researchers to understand where and how effects are occurring. It provides better estimates in
answering simple questions for which single-level analyses were once used and in addition,
allows more complex questions to be addressed. For example, how the effect of unit
characteristics might affect the patients outcome? Or more specifically, patients spent more time
in a unit with more full-time nurses would more likely result in a sooner discharge than in other
units.
Failing to recognize the existence of clustering will generally imply standard errors of regression
coefficients for higher level variables to be underestimated, which also leads to a higher
probability of type I error. For example, if standard errors were underestimated, it might be
inferred that there was a real difference between a teaching hospital and a non-teaching hospital,
which in fact could not be claimed due to the lack in number of hospitals included in the study.
Multilevel structures
Three sets of outcome variables, patient, nurse and system outcomes, were modeled in this study.
In order to model patient and nurse outcomes, a three-level data structure was originally
considered. Level 1 is the individual level, i.e., patient level for patient outcome or nurse level
for nurse outcomes. Level 2 is unit and level 3 is hospital. Since there were a small number of
hospitals (only 6) recruited in the study, any difference among hospitals would not be detected
due to the limited sample size at hospital level. Thus, the hospital level was removed, and only
unit level, individual patient and nurse levels were modeled. The removal of hospital level meant
that the effect of the hospital level variables was not investigated on patient, nurse, and system
outcomes, such as teaching hospital status, hospital size, etc.
To study the effect of nurses characteristics and measures on patient outcomes and because one
or more nurses may have cared for a patient during their hospital stay, information from all those
nurses was aggregated to patient level as well as attached to each patient as patient level
variables. Similarly, for those nurses who may have cared for multiple patients, information from
those patients, during the study period, was aggregated as well as attached to each nurse as nurse
level variables. Note that averaging or proportion was used in the aggregation of variables.
Missing values were imputed using either regression imputation, cell mean imputation, or mean
of nearby points (for daily data).
Since patients have changed their units during their hospital stay, the proportion of days in the
unit out of their total length of stay was assigned as weights to each unit they ever stay. For nurse
outcomes, the unit indicated in the nurse survey form was used in the analyses. In total, there are
163
24 units at unit level for either patient, nurse or system outcomes. There are 1198 patients in
patient outcome models and there are 727 nurses for most of the nurse outcome models. For
those nurse outcomes where patient characteristics have immediate impact on, only 555 direct
care nurses, during the study period, were included in the models.
To answer part of research question 1 and 3, daily productivity/utilization measurements were
modeled in a multilevel framework as well. Level 1 is date and Level 2 is the unit. Again,
hospital was not included as a level as it was excluded for other outcome models. The nurse and
patient characteristics and measurements were aggregated by date and unit such that the impact
of patient and nurse variables on the productivity/utilization at unit level can be studied.
As a measurement of unit atmosphere or morale at unit, some of individual nurse measurements
were aggregated to unit level as unit measurements. Most of them were proportions, such as
proportion of full time nurses, proportion of satisfied nurses in the unit. Others were based on
average within the unit, for example, nurse age on average. The following variables at unit level,
Table 1, have been constructed and considered in models, though not necessary included in the
final models.
Table 1: Unit Characteristics Aggregated from Individual Nurse Level
Unit Characteristics Aggregated from Individual Nurse Level
Proportion of Nurses Work On Multiple Units
Proportion of Nurses Reporting Job Instability
Proportion of Nurses with Interventions Not Done
Proportion of Nurses with Interventions Delayed
Proportion of Nurses with Risk at Effort and Reward Imbalance
Average Nurse Autonomy
Proportion of Nurses Intending to Leave Current Job
Proportion of Nurses Rating Good Patient Care Quality
164
Variables
Most of outcome variables were dichotomized and multilevel logistic regressions were used to
model the effects of predictors. How each variable was constructed or dichotomized is shown in
Table 2. Only productivity/utilization, averaged nursing hours, cost per RIW, autonomy and
nurse-physical relationship were treated as continuous variables. Logarithm transformation was
applied to averaged nursing hours and cost per RIW to assume the normality. Length of stay was
also logarithm transformed as a control variable when nursing hours and cost were modeled.
Only those measurements to answer research questions and predictors relevant conceptually or
theoretically to the outcome variables were included in the models. Other predictors will be
included in the final models if they are significantly associated with outcome variables.
Table 2: Dichotomy of Outcome Variables
Predictor and Dependent
Variable
Patient variables
Medical consequences
Length of stay
Patients physical health
Patients mental health
Omaha knowledge
Omaha behaviour
Omaha status
Actual worked hours per
patient
Cost per RIW
Nurse variables
Education
Clinical Expertise
Unit Instability
Shift Change
Measurement
Yes to any of the following: fall with injury, medication errors, death, or
complications such as UTI, pneumonia, superficial surgical site infection, deep
surgical site infection, bedsores, and thrombosis; dichotomized as yes vs. no.
Measured by the difference score between length of stay from medical record and
expected length of stay from CIHI inpatient data for Ontario; dichotomized as
shorter than expected length of stay vs. others
Measured with SF-12 scale at admission and discharge; Improved at discharge vs.
others
Measured with SF-12 scale at admission and discharge; Improved at discharge vs.
others
Increased at discharge or diagnosis resolved vs. others
Improved at discharge or diagnosis resolved vs. others
Improved at discharge or diagnosis resolved vs. others
Total nursing hours divided by midnight census
RIW*actual cost per equivalent weighted case
Highest nursing educational credential; dichotomized as BScN or above vs.
diploma
Work on more than one units vs. one
Average scores on 4-point scale on being a preceptor for another nurse, providing
clinical advice, level on expertise
Reporting any of the following: Forced to change unit in past year, anticipate
forced change of units in next year or expect to lose job within the next year;
dichotomized as yes vs. no
Reporting more than one shift change in the past 2 weeks vs. none
Reporting any of the following: physical assault, threat assault, or emotional
abuse; dichotomized as yes vs. no.
165
Predictor and Dependent

Variable
Effort and Reward
Imbalance
Autonomy
Nurse-Physician
Relationship
Absenteeism
Intent to Leave
Physical Health
Mental Health
Satisfaction with Current
Job
Improved Quality of
Patient Care
Good Quality of Nursing
Care
Measurement
Reporting interventions not done on the last shift for the following interventions:
vital sign/medications/dressings, mobilization/turns, patient/family teaching,
discharge prep, comforting/talking with patients, documenting nursing care, back
rubs/skin care, oral hygiene, or care plan; dichotomized as one or more
interventions not done vs. none
Reporting interventions delayed on the last shift for the following: vital
signs/medications/dressings, mobilization/turns, response to patient bell, or PRN
pain medication; dichotomized as one or more interventions delayed vs. none
Dichotomized as at risk of effort and reward imbalance (> 1) vs. not at risk ( 1)
Sum score of nine 7-point scale item; dichotomized as at risk (score > 27) vs. not
at risk (score 27)
Sum score of six autonomy items from NWI; the higher the score, the more
autonomy nurses feel about work.
Sum score of three nurse-physician relationship items from NWI; the higher the
score, the more positive nurses feel about the nurse-physician relationship.
Number of occasions missing work due to illness and disability; dichotomized as
one or more sick leaves vs. none
Plan to leave within the next year vs. no
Physical health, measured with SF-12
Mental health, measured with SF-12
Average score of 5-point scale on social contact at work, social contact after work,
opportunities to interact with management, amount of responsibility, satisfaction
with present Job, and satisfaction with a being a nurse; dichotomized as
satisfied/very satisfied vs. dissatisfied/very dissatisfied.
Quality of patient care in the unit in the past year; dichotomized as improvement
vs. others
Quality of nursing care in the last shift; dichotomized as excellent/good vs.
fair/poor
Environmental Complexity Scale

Re-sequencing of work in response to others
Unanticipated Changes in
Unanticipated changes in patient condition, unanticipated time consuming
Patient Acuity
interventions for patient and family, and so on.
Composition &
Supervision and assistance of student nurses
Characteristics of Care
Team
More Time Needed
Amount of more time needed to give the type of care stated in the nursing care
plan
Unit variables
Unit Occupancy
Proportion of RN worked
hours
Average worked hours
Productivity/utilization
Measured by midnight census divided by beds on unit

Proportion of nursing hours contributed by RNs in the unit
Average worked hours provided to patients on unit
Unit workload divided by total worked hours on unit
166
MLwin
MLwin beta version 2.0 was used to analyze the data. In MLwin, the hierarchical structure of the
data is identified by variables which label the units at each level1. These are known as level or
unit identifiers and must be declared when a model is being set up in the equations window or
estimate tables. The data were sorted according to the data hierarchy to ensure MLwin
functioned properly. The order of entry of variables was consistent with the theoretical
framework at two levels. The level 1 variables were first entered and tested, then moved to the
second level.
RIGLS/IGLS estimation was used to generate coefficients and their standard errors. In the case
of estimation failure from RIGLS/IGLS estimation, MCMC methods were used to continue the
estimation.
The -2 log likelihood value was used to make comparisons among different models. The test of
significance for individual variables was conducted by using the intervals and tests facility in
MLwin.
Reference
1. Rasbash, J., Browne, W. Goldstein, H., et al. (2000). A users guide to MLWIN. Multilevel
Models Project [Computer software and manual], Institute of Education, University of
London.
167
Appendix G. Descriptive Analyses

List of Tables .............................................................................................................................. 169
Descriptive Analyses .................................................................................................................. 171
1. System Characteristics ..................................................................................................................... 171
2. Patient Characteristics ..................................................................................................................... 173
2.1 Patient Demographics ...............................................................................................................................173
2.2 Medical Diagnoses....................................................................................................................................176
2.3 Nursing Diagnoses and OMAHA Scores at Admission............................................................................177
2.4 Health Status at Admission .......................................................................................................................178
3. Nurse Characteristics ....................................................................................................................... 180

3.1 Nurse Demographics.................................................................................................................................180
3.2 Professional and Employment Status........................................................................................................181
3.3 Education and Clinical Expertise ..............................................................................................................181
3.4 Experience ................................................................................................................................................182
4. System Behaviours............................................................................................................................ 184

4.1 Workload ..................................................................................................................................................184
4.2 Workload Variation by Patient Medical Diagnosis...................................................................................186
4.3 Overtime and Continuity of Care/Shift Change and Unit Instability ........................................................188
4.4 Non-Nursing Tasks ...................................................................................................................................190
5. Intermediate System Outputs ............................................................................................................ 190

5.1 Worked Hours...........................................................................................................................................190
5.2 Productivity/Utilization.............................................................................................................................193
6. Environmental Complexity ............................................................................................................... 195

7. Patient Outcomes.............................................................................................................................. 197
7.1 Medical Consequences..............................................................................................................................197
7.2 OMAHA Scores at Discharge and Change from Admission ....................................................................198
7.3 Health Status at Discharge and Change from Admission .........................................................................198
8. Nurse Outcomes................................................................................................................................ 199

8.1 Burnout and Effort & Reward Imbalance .................................................................................................199
8.2 Autonomy and Control .............................................................................................................................201
8.3 Job Satisfaction .........................................................................................................................................201
8.4 Health Status .............................................................................................................................................202
8.5 Violence at Work ......................................................................................................................................203
9. System Outcomes .............................................................................................................................. 204

9.1 Quality of Care..........................................................................................................................................204
9.2 Absenteeism..............................................................................................................................................205
9.3 Intent to Leave ..........................................................................................................................................206
References................................................................................................................................................. 207
168
List of Tables
Table 1: Hospital Characteristics............................................................................................... 171
Table 2: Unit Characteristics ..................................................................................................... 172
Table 3: Aspects of Care Process Percent of Patients Reporting Yes to Items in the Table, by
Hospital..................................................................................................................... 173
Table 4: Percent of Surgical Patients who Attended Pre-op Clinic and Post-op Education, by
Hospital..................................................................................................................... 173
Table 5: Patient Demographics, by Hospital ............................................................................. 174
Table 6: Patient Age, by Gender and Hospital........................................................................... 174
Table 7: Percent Distribution of Patient Occupation, by Category, by Hospital....................... 175
Table 8: Patient Employment Status Percent Distribution by Hospital .................................. 175
Table 9: Patient Educational Status Percent Distribution by Hospital................................... 175
Table 10: Percent Distribution of the Number of CMGs, by Hospital ....................................... 176
Table 11: Mean of Number of Nursing Diagnoses, by Unit Type .............................................. 177
Table 12: OMAHA Scores at Time 1 (Admission and Appearance of New Diagnosis), by Hospital
................................................................................................................................... 178
Table 13: Patient Health Status at Admission, by Hospital........................................................ 179
Table 14: Patient Health Status at Admission, Percent Less than US Norm, by Hospital......... 179
Table 15: Patient Health Status at Discharge, by Hospital........................................................ 180
Table 16: Patient Health Status at Discharge, Percent Less than US Norm, by Hospital......... 180
Table 17: Nurse Demographics, by Hospital ............................................................................. 181
Table 18: Nurse Employment Status, by Hospital ...................................................................... 181
Table 19: Nurse Education and Expertise, by Hospital ............................................................. 182
Table 20: Nurse Experience, N and Percent of Total Respondents, by Hospital ....................... 182
Table 21: Mean (SD) of PRN Workload (in Minutes) by Category, by Hospital ....................... 185
Table 22: PRN Workload Category as Percent of Total PRN Workload, by Hospital .............. 185
Table 23: Comparison of PRN to GRASP/Medicus Workload (in Hours), by Hospital ............ 186
Table 24: Percent Distribution of Work (in Minutes) by Workload Category, by CMG Type... 187
Table 25: Percent of Nurses Reporting Overtime in Average Hours per Week, by Hospital..... 188
Table 26: Percent Change of Nurse Overtime Hours in the Past Year, by Unit Type ............... 188
Table 27: Percent of Overtime Unpaid or Involuntary, if Working Overtime, by Hospital ....... 189
Table 28: Continuity of Care and Amount of Change, by Hospital ........................................... 189
Table 29: Percent of Nurses Reporting Performing Non-Nursing Tasks for Items in the Table, by
Hospital..................................................................................................................... 190
Table 30: Actual Staffing Hours, by Unit, by Day...................................................................... 191
Table 31: Percent of Actual Staffing, by Unit, by Day ............................................................... 192
Table 32: Daily Patient Census, Admissions, and Discharges, by Unit..................................... 193
Table 33: Number of Days When Unit GRASP/Medicus is Greater than 85% and 93% of Total
Nurse Hours, by Unit ................................................................................................ 194
Table 34: Percent of Nurses Reporting Average Hours Worked Per Week in the Past Year, by
Hospital..................................................................................................................... 195
Table 35: Mean of Three Subscales from ECS, by Hospital....................................................... 196
Table 36: Percent of Nurses Reporting Additional Time Needed to Provide Quality of Care, by
Hospital Unit............................................................................................................. 196
169
Table 37: Medical Consequences Percent Reporting Yes to the Items in the Table, by Hospital
................................................................................................................................... 197
Table 38: OMAHA Scores at Time 2 (Resolution of Diagnosis or at Discharge), by Hospital . 198
Table 39: Differences in OMAHA Scores Between Time 1 and Time 2, by Hospital................. 198
Table 40: Change in Patient Physical Health Status (SF-12) from Admission to Discharge .... 199
Table 41: Change in Patient Mental Health Status (SF-12) from Admission to Discharge....... 199
Table 42: Burnout Mean Scores of MBI Subscales, by Hospital............................................. 200
Table 43: Burnout Percent of Nurses at Risk for Emotional Exhaustion and ERI, by Hospital
................................................................................................................................... 200
Table 44: Nurse Work Index Subscales, by Hospital.................................................................. 201
Table 45: Job Satisfaction Percent of Nurses Dissatisfied, by Hospital ................................. 202
Table 46: Nurse Health Status, by Hospital ............................................................................... 202
Table 47: Nurse Health Status, Percent of SF-12 Scores Less than US Norm for Females, by
Hospital..................................................................................................................... 203
Table 48: Prevalence of Violence Percent of Nurses Reporting Yes to the Items in the Table, by
Hospital..................................................................................................................... 203
Table 49: Source of Emotional Abuse, by Hospital.................................................................... 204
Table 50: Quality Issues Percent of Nurses Reporting Yes to Items in the Table, by Hospital205
Table 51: Absenteeism Percent of Episodes Absent and Mean Shifts per Episode in the Past
Year, by Hospital ...................................................................................................... 206
Table 52: Absenteeism Most Common Reason to Miss Work in the Past Year, by Hospital .. 206
Table 53: Intent to Leave Percent of Nurses Reporting Yes to the Items in the Table, by
Hospital..................................................................................................................... 206
170
Descriptive Analyses
The results of descriptive analyses are presented at hospital or unit level. Hospital names are
suppressed to ensure confidentiality. All comparisons between hospitals and units are merely
crude rate comparisons that do not take into account differences in characteristics of patients,
nurses, or organizations.
1. System Characteristics
Tables 1 and 2 outline the profiles of six hospitals and 24 nursing cardiac and cardiovascular
units. Six characteristics describe the hospitals. The total number of inpatient beds denotes the
overall size of individual hospitals. Hospital 6 had the largest number of beds whereas Hospital 5
had the smallest. Four of the six hospitals were teaching hospitals. The survey period varied at
each site because the volume of eligible patients in each hospital influenced the number of study
days. Each hospital had a target of 200 patients. Due to staffing problems, Hospitals 1 - 5 agreed
to extend their data collection period to ensure that a sufficient number of patients were included
in the analysis. Hospital 6, however, was not able to participate fully and thus had fewer patients
completing the survey form and finished the study in a much shorter period of time than the
other hospitals. The ability to capture patient level data was limited in some organizations due to
the length of time required each day to collect staff data from non computerized systems.
Table 1: Hospital Characteristics
Hospital
Number of Beds
Teaching
Survey Patients
Number of Study Days
Patient Midnight Census
Number of Units
1
567
N
189
136
14
3
2
778
Y
243
121
23
3
3
507
N
259
114
33
2
4
777
Y
195
184
19
5
5
121
Y
285
136
18
6
6
1060
Y
59
64
13
5
Total
3243
n/a
1230
755
19
24
Note: Y=Yes, teaching hospital; N=No, non-teaching hospital; n/a=Not applicable

Number of Beds=Total inpatient beds
Surveyed Patients=Number of patients who completed Patient Data Form
Patient Midnight Census=Average number of patients in surveyed units
Hospitals in the sample provided cardiac and cardiology nursing care using a variety of
organizational structures. Surgical patients generally received a portion of their care in a critical
care unit (CCU) but pre- and post-operative care was provided on an inpatient (IP) unit. In some
organizations (hospitals 1 and 6), step-down units (SDU) were used in addition to the CCU.
Some patients also received care in a CCU or SDU but many patients did not use critical care
services.
The structure and organization of health delivery can affect patient, nurse, and system outcomes.
For example, attendance at pre admission or post operative education may have an effect on the
resources required during the hospital stay and on the overall length of stay.
171
Table 2: Unit Characteristics

Hospital
1
2
3
4
Unit Name
Unit
Type
Pure
Cardiology*
Coronary care unit

Step-down unit
Cardiac post-surgery/pre-op
Intensive care unit
Coronary care unit
Combined Cardiology/Cardiovascular
Critical care area
Combined Cardiology/Cardiovascular
6 Eaton South + 6 NU
Cardiovascular intensive care units (2)
Interventional short stay unit
Inpatient cardiology
Interventional cardiology unit
Cardiac surgical unit/Recovery
Coronary Care unit
Cardiovascular
Cardiology/surgical
Cardiology
Coronary Care units (3)
Cardiology
Cardiology Step-down
CCU
SDU
IP
CCU
CCU
IP
CCU
IP
IP
CCU
DS
IP
DS
CCU
CCU
IP
IP
IP
CCU
IP
SDU
Y
Y
Y
N
Y
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Number
of Beds
12
18
27
19
11
40
15
48
56
19
29
26
17
16
6
28
27
33
38
32
32
Number of
Study
Patients
39
48
102
7
134
102
36
223
19
40
66
70
35
9
2
38
79
122
51
7
1
Note: CCU = Critical Care Unit

DS = Day Surgery
IP = Inpatient
SDU = Step-Down Unit
*Pure cardiology = units that provide care exclusively for cardiac and cardiovascular patients as opposed to patients
with other medical or surgical conditions.
Tables 3 and 4 show various aspects of the care process in planned admission, pre-op and postop clinics, referrals to home care, time in SDU, and transfer to ICU. On average, almost half of
survey patients reported that their admission was a planned readmission. More than one-fifth
(22%) of the patients attended a pre-op clinic and more than half (53%) had post-admission
education. About one in ten patients (10.9%) were referred to home care. There were 11.3% of
patients who spent time in a SDU. Only 2% of the patients were transferred back to ICU.
Hospital 5 had the largest proportion of patients with planned admission (65.4%), which was
almost six times that of Hospital 6 (11.9%). Hospital 1 had more surgical patients attending preoperation clinics than all other hospitals, while Hospital 3 provided post-admission education for
more cardiac and cardiovascular patients than any of the other hospitals. Hospital 2 referred
37.7% of patients to home care which was higher than other hospitals (4.3-7.7%). Hospitals 1
and 6 had a relatively larger proportion of patients spending time in SDU. Few if any patients
were transferred back to ICU in Hospitals 2, 5, and 6.
172
Table 3: Aspects of Care Process Percent of Patients Reporting Yes to Items in the Table, by
Hospital
Hospital
Number of cases
Planned admission
Referred to home care
Spent time in SDU
Transferred back to ICU
1
189
35.4
4.3
28.0
3.7
2
243
32.2
37.7
6.2
0.4
3
259
38.2
6.5
7.6
3.1
4
195
56.3
6.6
10.0
3.6
5
285
65.4
7.1
0.5
0.7
6
59
11.9
7.7
28.3
0.0
Total
1230
44.5
10.9
11.3
2.0
Note: Due to missing values in each category the denominators to generate percentages are slightly different from N.
Table 4: Percent of Surgical Patients who Attended Pre-op Clinic and Post-op Education, by
Hospital
Hospital
Number of cases
Attended pre-op clinic
Post-op education
1
66
59.1
65.2
2
69
13.0
10.1
3
82
31.7
72.0
4
78
48.7
70.5
5
129
20.9
63.6
6
16
37.5
43.8
Total
440
33.0
57.5
Note: Due to missing values in each category the denominators to generate percentages are slightly different from N.
2. Patient Characteristics
Patient characteristics were captured from a variety of data sources.
1) Patients provided information about themselves and their care process in a survey.
2) Each hospitals Health Records Department provided health records data that included
medical diagnosis at discharge, resource intensity weight, length of stay, admission type,
etc.
3) Patients completed a SF-12 Health Survey indicating their functional status at the time of
admission and discharge.
4) Data collectors collected nursing diagnoses (NANDA) and ratings of patient OMAHA
knowledge, behaviour, and status concerning each nursing diagnosis from the chart,
Kardex, and in consultation with the nurse.
In total, 1,230 patients were entered into the study.
2.1 Patient Demographics
As shown in Tables 5 and 6, the average age of patients was 63.5 years and two-thirds were male
(66.7%). Hospital 2 had the largest proportion of females, and Hospitals 1 and 6 had female
proportions well below the average.
Hospitals 2 and 3 had high proportions (40.2 and 40.0% respectively) of patients over the age of
70, whereas Hospital 4 has the highest proportion (24.6%) of patients under the age of 50.
Patients at Hospitals 2 and 3 were less likely to have a caregiver at home. This may be explained
by the higher average age of patients at these sites. On average, over 95% of patients had a
family doctor.
173
Table 5: Patient Demographics, by Hospital

Hospital
Total
Number of patients
189
243
259
195
285
59
1230
% Male
% Female
% Age >=70
% Age < 50
% Caregiver at home
% Family Physician
74.1
25.9
30.7
14.8
87.3
94.7
60.1
39.9
40.2
11.9
79.1
95.9
63.3
36.7
40.0
13.8
75.9
93.1
70.8
29.2
29.2
24.6
85.1
93.8
66.7
33.7
37.0
14.2
84.2
98.6
74.6
25.4
33.9
11.9
83.1
91.5
66.7
33.3
35.9
15.3
82.0
95.2
Note: The denominators used to generate percentages for each demographic may be slightly different from the
number of patients presented in the table.
Table 6: Patient Age, by Gender and Hospital

Hosp
1
2
3
4
5
6
Total
N
140
146
164
138
189
44
821
Male
Mean
62.0
63.9
63.4
60.1
62.5
61.5
62.4
SD
11.64
11.71
12.66
13.68
12.58
11.24
12.44
N
49
97
95
57
96
15
409
Female
Mean
64.8
68.1
65.8
59.0
66.6
70.1
65.6
SD
13.30
13.37
11.81
16.51
14.08
11.70
13.85
N
189
243
259
195
285
59
1230
Total
Mean
62.8
65.6
64.2
59.8
63.9
63.7
63.5
SD
12.12
12.54
12.39
14.53
13.22
11.86
13.01
Patient occupation was originally collected as an open-ended question. Occupations were

subsequently classified into 14 categories according to work environments, knowledge, skill, and
level of control1 As seen in Table 7, the occupational distribution of patients varied greatly by
hospital. Hospitals 4, 5 and 6 had higher proportions of patients reporting a professional
occupation, whereas Hospital 1 had mostly service, outdoor physical, and professional
occupations. Hospital 3 had a large proportion of housewives and patients with outdoor physical
occupations. In contrast, Hospital 2 had an overall even distribution across all occupation
categories.
174
Table 7: Percent Distribution of Patient Occupation, by Category, by Hospital

Hospital
Number of Cases
Self-employed
Professional
Outdoor Physical*
Healthcare Provider
Government
Housewife
Clerical
Management
Retail/Sales
Factory
Trades
Business
Service
Not working
Total
176
5.7
10.8
10.8
5.1
2.8
8.0
0.6
8.5
3.4
9.1
5.1
4.5
23.3
2.3
152
0.7
8.6
16.4
3.9
3.9
8.6
6.6
6.6
5.3
7.9
5.3
3.9
11.2
11.2
220
6.4
8.6
15.0
1.8
2.3
18.6
0.9
5.9
5.5
6.4
3.2
6.4
12.7
6.4
153
5.2
26.8
3.9
2.6
0.7
7.8
5.2
5.2
3.3
8.5
3.3
3.9
16.3
7.2
276
4.7
17.8
4.7
6.5
7.2
5.8
6.2
13.4
4.3
7.2
1.8
6.5
12.3
1.4
57
3.5
19.3
1.8
3.5
0.0
8.8
3.5
10.5
7.0
14.0
12.3
3.5
10.5
1.8
1034
4.6
14.7
9.4
4.2
3.6
9.8
3.9
8.6
4.5
8.0
4.0
5.2
14.6
4.9
*Mostly farmers for Hospital 2 and miners for Hospital 3 in the outdoor physical occupation.
More than 60% of patients from Hospitals 1 and 5 were employed, but merely one-third of
patients in Hospitals 2 and 3 were working at the time of the survey. Hospital 3 also had the
largest proportion (20.0%) of patients not employed (Table 8). The not-employed group consists
of housewives, disabled persons, and students. Hospital 2 had primarily retired patients (53.1%)
as patients in Hospital 2 were much older than patients in other hospitals. In contrast, less than
one-third of patients in Hospitals 1 and 5 fell into the retired group.
Table 8: Patient Employment Status Percent Distribution by Hospital
Hospital
Employed
Not employed
Retired
Number of cases
Total
60.8
34.4
34.9
47.2
65.8
52.6
48.9
9.5
12.5
20.0
11.4
6.1
7.0
11.7
29.6
189
53.1
224
45.1
255
41.5
193
28.1
278
40.4
57
39.4
1196
Note: Not employed includes not working and housewives categories in Table 7.
Table 9 shows the educational status of the patients. The education level was lower in Hospitals
1 and 3, with less than one third reporting more than high school education. This may reflect the
higher proportion of service and outdoor workers in Hospital 1 and the high proportion of
housewives in Hospital 3.
Table 9: Patient Educational Status Percent Distribution by Hospital
Hospital
More than
high school
Number of cases
Total
28.2
53.5
30.6
45.0
51.3
41.4
41.9
177
185
258
188
281
58
1147
175
2.2 Medical Diagnoses

Table 10 shows the percent distribution of CMGs by hospital and the dominant CMG group in
each hospital is bolded. As can be seen, Percutaneous Transluminal Coronary Angioplasty
without Cardiac Catheterization accounts for the largest proportion for Hospitals 3, 4 and 5
whereas Cardiac Catheterization without Specified Cardiac Condition accounts for the largest
proportion in Hospital 1, Percutaneous Transluminal Coronary Angioplasty with Complicated
Cardiac Condition has the largest percentage for Hospital 6, and Major Cardio Procedure no
Pump no Catheterization is the dominant CMG group for patients in Hospital 2.
Table 10: Percent Distribution of the Number of CMGs, by Hospital
CMG
1
PTCA WO CARD CATH
PERM PACE IMPL WO SPEC CARD C
C BYPASS W PUMP WO CARD CATH
PTCA W CARD COMP
C VALVE REP W PUMP WO CARDIAC
CARD CATH NO SPEC CARD COND
C BYPASS W PUMP W CARD CATH
MAJ CARDIO PR NO PUMP NO CATH
ARRTHYMIA
HEART FAILURE
AMI NO CARD CATH NO SPEC COND
OTHER CIRCULATORY DIAGNOSIS
CHEST PAIN
CARDIAC CATH W SECIFIED CARD
UNS ANGINA W CATH NO SPEC CON
AMI WITH CARD CATH NO SP COND
PERM PACEMAKER/SPEC CARD COND
AMI WO CARD C W CHF
UNSTABLE ANGINA WO CATH WO SP
UNS ANGINA W CATH NO CRD COND
CARDIAC CATH WITH VENT TACH
CRD VLV REP W PUMP W CRD CATH
AMI W CARD CATH W & WO ANGINA
SYNCOPE AND COLLAPSE
ANGINA PECTORIS
AMI NO CARD CATH W VENT TACH
AMI W CAD CATH WITH CHF
CAR CATH W CHF
CARD CATH W VENTR TACH
MAJOR CARDIO THORA PROCE WO P
OTHER CARDIOTORACIC PROC W PU
PROCEDURE CANCELLED MNRH
ATHEROSCLEROSIS MNRH
EXTNSIVE UNREL OR PROCESUDRE
PERRIPHERAL VASCULAR DISEASE
RENAL FAILURE NO DIALYSIS
UNS ANGINA W CATH W SPEC COND
Total
15.3
6.3
11.1
4.2
10.6
19.6
5.3
0.0
4.2
2.6
2.1
0.0
1.6
2.1
1.1
0.0
0.5
1.1
0.5
2.6
0.0
1.1
0.0
0.5
0.0
0.0
0.5
0.5
1.6
1.1
0.5
1.6
0.5
0.5
0.5
0.0
0.0
189
2
1.6
5.3
6.6
9.9
2.9
0.4
11.1
13.6
4.9
3.7
4.9
4.9
1.2
4.5
3.7
4.1
2.1
3.3
3.7
0.0
1.6
0.4
1.6
0.8
1.2
0.8
0.4
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.4
243
Hospital
3
4
15.4
27.2
11.6
18.5
9.7
5.1
8.9
4.6
6.9
4.6
0.0
2.1
2.7
3.6
4.2
4.1
6.6
4.1
4.6
1.5
4.2
1.0
5.0
4.1
8.9
0.0
0.4
2.6
1.9
1.0
1.2
2.1
0.4
3.1
1.2
1.0
1.9
0.5
1.2
0.0
0.8
1.5
0.4
0.5
0.8
0.5
0.4
0.0
0.4
0.0
0.4
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
259
182
Total
5
13.0
12.6
13.0
8.1
9.1
10.9
5.6
1.8
3.2
3.2
1.4
1.8
2.1
2.1
1.4
1.1
2.8
0.4
0.4
2.1
0.4
2.1
0.4
0.4
0.0
0.0
0.0
0.4
0.0
0.0
0.4
0.0
0.0
0.0
0.0
0.4
0.0
285
6
5.1
8.5
0.0
22.0
8.5
0.0
5.1
5.1
5.1
3.4
10.2
1.7
3.4
0.0
1.7
3.4
1.7
3.4
0.0
0.0
1.7
0.0
1.7
1.7
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
55
13.5
10.7
8.9
8.1
6.9
5.9
5.7
4.9
4.6
3.3
3.2
3.2
3.0
2.2
1.9
1.8
1.8
1.5
1.4
1.1
0.9
0.9
0.7
0.5
0.3
0.2
0.2
0.2
0.2
0.2
0.2
0.2
0.1
0.1
0.1
0.1
0.1
1213
Note: Data are sorted by the percent in the Total column.
176
2.3 Nursing Diagnoses and OMAHA Scores at Admission

Nursing diagnosis is a clinical judgment about an individual or family response to an actual or
potential health problem or life process. Nursing diagnoses provide the basis for selecting
nursing interventions to achieve outcomes for which nurses are responsible. Nursing diagnoses
were recorded from admission until discharge.
Table 11 shows that the number of nursing diagnoses averaged nearly five (SD=2.6) across all
units. The highest mean number of diagnoses was observed in Hospital 5s CCU (8.44). The
lowest average numbers of nursing diagnoses were observed in the DS unit in Hospital 4 (2.58),
the DS unit in Hospital 5 (3.42), and IP unit in Hospital 3 (3.47). (Note that only 1,189 patients
were included due to missing nursing diagnoses for some patients.)
It should be noted that patients could change units during their hospital stay. Because patients
may be admitted to one unit and discharged from another, the number of patients admitted to a
unit may be different from the number of patients discharged from that unit.
Table 11: Mean of Number of Nursing Diagnoses, by Unit Type
Unit at
Discharge
Hospital 1
Hospital 2
Hospital 3
Hospital 4
Hospital 5
Hospital 6
CCU
IP
SDU
CCU
IP
CCU
IP
CCU
DS
IP
CCU
DS
IP
CCU
IP
SDU
Total
# of Patients Grouped
by Unit at Discharge
20
110
59
105
132
18
214
17
59
115
9
53
219
45
11
2
1189
Total Number of Diagnoses

Mean
SD
5.55
2.31
6.80
3.36
5.19
2.07
6.48
3.06
4.78
2.50
4.44
1.89
3.47
1.51
5.12
3.55
1.63
2.58
4.46
1.96
3.28
8.44
3.42
1.71
4.34
2.41
5.27
1.51
4.36
.81
6.50
.71
2.60
4.68
OMAHA Problem Scales for Outcomes is an evaluation tool developed by the Omaha Visiting
Nurse Association2. The tool measures clinical progress of patients in relation to specific
problems or nursing diagnoses at two points in time: at admission or when a new health problem
was identified (time 1), and when the health problem was resolved or at discharge (time 2). The
three essential dimensions, knowledge, behaviour, and status, are each rated on a 5-point Likert
scale ranging from very negative to very positive. A mean score was computed for each person
on each dimension and then averaged for the sample. Data about OMAHA at time 1 are
presented in Table 12. The data for OMAHA at time 2 and difference scores are presented under
section 7.2 in Patient Outcomes.
177
Table 12 shows that for all survey patients at time 1, the mean scores were 3.4 (SD=0.75) for
knowledge, 4.0 (SD=0.58) for behaviour, and 3.3 (SD=0.62) for status. Patients from Hospital 4
had the highest ratings across all three dimensions.
Table 12: OMAHA Scores at Time 1 (Admission and Appearance of New Diagnosis), by
Hospital
Hospital
1
2
3
4
5
6
Total
N
188
237
232
192
282
58
1189
Knowledge
Mean
SD
2.9
0.41
3.5
0.75
3.0
0.52
0.54
3.8
0.80
3.8
2.6
0.67
3.4
0.75
Behaviour
Mean
SD
3.8
0.38
4.0
0.46
3.6
0.54
0.52
4.3
4.2
0.63
0.49
4.3
4.0
0.58
Status
Mean
3.0
3.6
3.0
3.8
2.9
3.5
3.3
SD
0.26
0.43
0.63
0.47
0.55
0.57
0.62
Note: Measured on a 5-point Likert scale for Knowledge (1=No knowledge and 5=Superior knowledge), Behaviour
(1=Never appropriate in behaviour and 5=Consistently appropriate in behaviour), and Status (1=Extreme symptoms
and 5=No symptoms).
2.4 Health Status at Admission

The SF-12 is a widely used measure of general health. The questions tap eight health concepts
that are reported in two categories: physical and mental health. The eight categories are physical
functioning, role physical, bodily pain, general health, energy/fatigue, social functioning, role
emotional, and mental health.
Although the SF-12 is not quite as reliable and comprehensive as the SF-36, the results of the
two measurement tools are highly correlated (r=0.95). Confidence intervals are largely
determined by sample size; with large samples, the results will be almost the same regardless of
the tool used3.
Table 13 shows the two SF-12 subscales measured at admission at the interval level. The mean
physical health score of 35.2 (SD=11.2) ranged from, 11.0 to 64.8. The mean mental health score
of 48.2 (SD=11.0) ranged from 15.6 to 70.3. The least physically and mentally healthy patients
were found in Hospitals 5 and 1 respectively.
178
Table 13: Patient Health Status at Admission, by Hospital

Hospital
1
2
3
4
5
6
Total
186
207
256
191
277
59
1176
Physical Health Scale

Mean
35.7
35.6
34.1
37.4
33.4
37.6
35.2
SD
10.3
11.9
10.2
12.1
11.1
11.5
11.2
Range
13.7-63.0
11.2-63.4
14.2-60.1
11.9-62.4
11.0-64.8
16.8-60.6
11.0-64.8
Mental Health Scale

Mean
46.9
48.1
47.4
49.6
48.8
49.3
48.2
SD
10.7
10.8
12.0
10.5
10.5
11.7
11.0
Range
18.4-67.2
20.4-68.6
16.9-69.0
19.1-70.3
15.6-66.9
16.8-66.2
15.6-70.3
These two SF-12 subscales can be dichotomized using US norms for the general population as
the cut-point. Dichotomized data are presented in Table 14. Nearly nine in ten patients (87.0%)
were below the US population norm in physical health upon admission. About half (49.2%) of
patients had mental health scores below the US population norm. The percentage of patients that
scored below the norm for physical and mental functional status varied across hospitals (2=14.8
and 15.2 respectively, df=5, p<0.05). Generally, patients in Hospital 3 were the least physically
and mentally healthy, on average.
Table 14: Patient Health Status at Admission, Percent Less than US Norm, by Hospital
Hospital
1
2
3
4
5
6
Total
% Not
Physically Healthy
88.7
82.6
91.0
82.2
89.1
84.7
87.0
% Not
Mentally Healthy
53.2
47.3
50.8
47.1
49.3
42.4
49.2
N
186
207
256
191
276
59
1176
US Norm3
Physically not healthy: < 50.12
Mentally not healthy: < 50.04
Tables 15 and 16 display two SF-12 subscale scores measured at discharge at the interval and
dichotomous levels. Patients in Hospitals 2 and 5 tended to be the least physically healthy at
discharge while patients in Hospitals 1 and 5 had the lowest average mental health scores at
discharge. In contrast, the highest average physical and mental health scores for patients were
observed in Hospitals 6 and 4 respectively.
The comparison of changes in patient functional status from admission to discharge at the
individual level will be presented in section 7.2.
179
Table 15: Patient Health Status at Discharge, by Hospital

Hospital
1
2
3
4
5
6
Total
163
185
250
155
249
39
1041

Mean
34.7
31.2
35.3
36.0
32.8
36.1
34.0
SD
9.3
8.7
9.7
10.0
9.4
11.0
9.6
Range
14.0-58.4
15.2-56.6
14.2-56.8
16.4-60.8
12.1-56.8
18.2-59.4
12.1-60.8
Mental Health Scale

Mean
46.0
48.0
48.9
50.7
47.3
48.2
48.1
SD
10.0
9.6
11.7
10.7
11.0
12.9
10.9
Range
25.4-66.3
20.6-65.9
17.3-69.0
23.7-68.4
17.5-69.8
15.6-65.1
15.6-69.8
Table 16: Patient Health Status at Discharge, Percent Less than US Norm, by Hospital
Hospital
1
2
3
4
5
6
Total
% Not
Physically Healthy
94.5
95.7
90.0
89.0
95.2
84.6
92.6
% Not
Mentally Healthy
60.7
54.6
47.6
42.6
55.4
43.6
51.9
N
163
185
250
155
249
39
1041
US Norm3
Physically not healthy: PHYSICAL HEALTH SCALE < 50.12
Mentally not healthy: Mental Health Scale < 50.04
3. Nurse Characteristics
The nursing information was collected from the Nurse Survey, and all the data are based on self
report. The Nurse Survey was a very comprehensive survey, covering mental and physical
health, job satisfaction, workload and violence during work using many reliable measures such
as functional status of health (SF-12), Maslach Burnout Inventory (MBI), Revised Nursing Work
Index (R-NWI), and Effort/Reward Imbalance (ERI). A total of 727 nurses participated in the
study.
3.1 Nurse Demographics
Table 17 demonstrates the gender and age distributions for nurses in each of the participating
hospitals. The vast majority of nurses completing the survey were female (93.9%), which is
consistent with the female to male ratio of the Canadian nursing workforce4. Only Hospital 1
reported a slightly higher proportion of males than the other sites. This site also reported the
highest proportion of nurses less than 30 years of age and the lowest number over the age of 50.
Hospitals 3 and 4 had higher proportions of nurses who were less than 30 than the remaining
three hospitals but significantly less then Hospital 1. Unlike Ontarios profile5, some of these
organizations have more nurses under 30 than over 50.
180
Table 17: Nurse Demographics, by Hospital

Hospital
Gender
% Female
Number of Cases
Age
% < 30
% > 50
Number of Cases
Total
87.9
58
94.6
186
93.2
74
94.2
86
95.7
210
92.9
112
93.9
726
23.2
5.4
56
7.7
12.1
182
13.9
11.1
72
14.3
11.9
84
7.8
9.8
205
6.5
17.6
108
10.2
11.6
707
3.2 Professional and Employment Status

Table 18 shows the percentages of nurse respondents who were employed full-time, employed
on a permanent basis, and were Registered Nurses. The proportion of full-time nurses varied
from 54.3% to 70.9%, with three of the hospital under 60% and three over 65%. Most nurses
worked in permanent positions (97.8% on average), with the exception of Hospital 1 (89.8%).
The percentage of full-time and/or permanent employees may have been inflated because fulltime and/or permanent nurses were more likely to participate in the survey. In terms of nursing
composition, respondents were comprised of Registered Nurses (96.6%), Registered Practical
Nurses (0.8%), and charge nurses and other personal care workers such as orderlies, Registered
Nurse Technicians, clinical leaders, and healthcare aids (2.5%). All respondents from Hospital 2
were Registered Nurses and the respondents from Hospital 3 were all in permanent positions.
Table 18: Nurse Employment Status, by Hospital
Hospital
Number of Cases
% FT
% Permanent
% RN
1
59
67.8
89.8
91.4
2
186
54.3
98.9
100.0
3
74
67.6
100.0
93.2
4
86
70.9
98.8
95.1
5
210
56.2
97.1
98.6
6
112
58.0
99.1
93.6
Total
727
59.8
97.8
96.6
3.3 Education and Clinical Expertise

Table 19 gives a breakdown of the educational background of the nurses and their level of
expertise, as measured by how often peers sought their advice, how often they filled the role of
preceptor, and to what degree individuals possessed clinical expertise. The percentage of nurses
with BScN and higher degree preparation varied across hospitals, ranging from 29.3% to 61.6%.
Despite educational levels, a higher proportion of nurses in Hospital 6 acted as preceptors and
45.0% were frequently asked for clinical advice and considered themselves to be expert
clinicians. Nurses at Hospital 1 reported the lowest levels of confidence in their clinical ability
and fewer nurses were asked by their peers for clinical advice. Some of the variation in preceptor
reporting may be due to variations in the number of student nurses at these hospitals or rate of
staff nurse turnover. If turnover rates were high, larger number of staff nurses might be
preceptors regardless of their knowledge or skill level.
181
Table 19: Nurse Education and Expertise, by Hospital

Hospital
N
Education - % with BScN and
higher
1
59
2
186
3
74
4
86
5
210
6
112
Total
727
29.3
34.9
40.5
61.6
50.5
32.1
42.3
7.0
10.2
14.9
14.1
9.1
22.3
12.4
Clinical advice - % Frequent
32.8
40.3
59.5
43.0
46.2
45.0
44.4
Expert - % Recognized
expected clinical responses
19.0
39.7
35.7
36.5
45.9
45.0
39.8
Preceptor - % Frequent
3.4 Experience
Table 20: Nurse Experience, N and Percent of Total Respondents, by Hospital
Hospital
1
Yrs as a nurse
Yrs in hospital
Yrs on unit
Yrs as a nurse
Yrs in hospital
Yrs on unit
Yrs as a nurse
Yrs in hospital
Yrs on unit
Yrs as a nurse
Yrs in hospital
Yrs on unit
Yrs as a nurse
Yrs in hospital
< 1 yr
0
0.0%
1
2.2%
6
14.3%
0
0.0%
3
2.1%
7
5.3%
0
0.0%
1
2.2%
1
2.3%
2
2.4%
1
1.6%
1
1.8%
0
0.0%
2
1.4%
1- 5 yrs
13
23.2%
19
42.2%
22
52.4%
13
7.1%
37
26.2%
50
38.2%
8
11.1%
12
26.1%
24
54.5%
19
22.9%
25
41.0%
35
63.6%
22
10.6%
39
27.1%
6 -10 yrs
12
21.4%
8
17.8%
7
16.7%
23
12.5%
13
9.2%
19
14.5%
8
11.1%
4
8.7%
4
9.1%
14
16.9%
7
11.5%
4
7.3%
17
8.2%
16
11.1%
11-15 yrs
14
25.0%
9
20.0%
6
14.3%
40
21.7%
45
31.9%
34
26.0%
21
29.2%
18
39.1%
9
20.5%
10
12.0%
15
24.6%
11
20.0%
49
23.7%
41
28.5%
> 15 yrs
17
30.4%
8
17.8%
1
2.4%
108
58.7%
43
30.5%
21
16.0%
35
48.6%
11
23.9%
6
13.6%
38
45.8%
13
21.3%
4
7.3%
119
57.5%
46
31.9%
Total
56
100%
45
100%
42
100%
184
100%
141
100%
131
100%
72
100%
46
100%
44
100%
83
100%
61
100%
55
100%
207
100%
144
100%
182
Hospital
Yrs on unit
6
Yrs as a nurse
Yrs in hospital
Yrs on unit
Total
Yrs as a nurse
Yrs in hospital
Yrs on unit
< 1 yr
6
4.3%
2
1.9%
3
4.6%
5
8.3%
4
0.6%
11
2.2%
26
5.5%
1- 5 yrs
71
50.4%
6
5.7%
11
16.9%
23
38.3%
81
11.4%
143
28.5%
225
47.6%
6 -10 yrs
22
15.6%
12
11.3%
7
10.8%
11
18.3%
86
12.1%
55
11.0%
67
14.2%
11-15 yrs
26
18.4%
25
23.6%
21
32.3%
14
23.3%
159
22.5%
149
29.7%
100
21.1%
> 15 yrs
16
11.3%
61
57.5%
23
35.4%
7
11.7%
378
53.4%
144
28.7%
55
11.6%
Total
141
100%
106
100%
65
100%
60
100%
708
100%
502
100%
473
100%
Table 20 compares overall nursing experience of the nurses, their experience within the same
institution and within the same unit.
Hospital 1 nurses reported the least experience in all three categories. In all six hospitals, 53.4%
of nurses reported more than 15 years of nursing experience. Years as a nurse varied more than
years in hospital or years on the nursing unit. Nurses with greater than 15 years experience
reported less years on unit than nurses with fewer years of experience. This may reflect hospital
restructuring activities in recent years. However, Hospital 1 nurses worked the shortest time on
unit compared to any of the other hospitals which may explain lower levels of expertise as
reported in Table 19.
Age and experience were highly correlated. The correlation coefficients between age and years
worked as RN/RPN, years worked as RN/RPN at the current hospital and years worked as
RN/RPN at current unit were 0.83, 0.61 and 0.45 respectively (p<0.001).
Years worked as RN/RPN was highly associated with all three expert statuses: acting as a
preceptor (F=5.27, p<0.05), providing clinical advice (F=39.75, p <0.001), and acting as a
clinical expert (F=35.73, p <0.001).
A nurse with more years experience as RN/RPN at the current hospital was more likely to be
asked for clinical advice (F=23.65, p<0.001) or act as a clinical expert (F=8.51, p <0.01).
However, greater years of experience in current hospital were not significantly related to acting
as a preceptor.
A similar association was found between years on current unit and expert status. A nurse with
more years as RN/RPN on his/her current unit was more likely to be asked for clinical advice
(F=12.94, p<0.001) or act as a clinical expert (F=42.97, p <0.001). However, more years on
current unit was not significantly related to role as a preceptor.
Higher education was positively associated with expert status. This association was only
statistically significant nurses responded that other nurses sought their clinical judgment
183
(2=4.26, p<0.05). The associations between education and the status of providing clinical advice
or acting as a clinical expert were significant at the 0.1 level.
4. System Behaviours
4.1 Workload
Workload data (measured by PRN 806) were collected for each study patient on each study day
by the site data collectors. The PRN tool measures the volume of nursing work in minutes by
selecting the tasks that need to be completed for that day. Each task is assigned a value based on
studies completed by the PRN system in numerous facilities. Workload values are presented on
the measurement tool in five minute increments. This value reflects the average time to complete
the task, by an average nurse, on an average day, for an average patient. This methodology is
referred to as an average time methodology. The PRN tool does not directly capture the
workload associated with activities that are not patient specific, however, the PRN value can be
adjusted to account for indirect patient care. The PRN 80 values for indirect care time provided
by Tilquin were included to determine the total hours of care patients required in the next 24
hour period (Tilquin, personal communications, August, 2003). Patient care workload for each
study patient was also recorded from the unit workload tool. Hospital 2 used MEDICUS while
all other study hospitals used GRASP. Both workload tools measure nursing hours including
direct and indirect services related to patients. These values were compared to the PRN workload
value adjusted for indirect patient care.
In this study, GRASP or MEDICUS hours were collected daily for study patients and for the unit
as a whole, including non-study patients as well. The GRASP methodology captures workload
using a standard time methodology. Each site develops a list of tasks based on the activities
they perform, and times are assigned to each of these tasks. The times are based on time and/or
frequency or are established by staff nurse consensus. These times reflect the average time to
complete the task, by an average nurse, on an average day, for an average patient in the
individual facility. This reflects the physical and organizational characteristics of the individual
facility. The MEDICUS system captures workload by multiplying a pre-set relative value per
level of care by the target hours per unit of workload.
Table 21 shows PRN patient care time (in minutes) by workload category. Total workload for
each day is the sum of seven categories of activity including respiration, feeding and hydration,
elimination, hygiene and comfort, communication, treatment, and diagnostic procedures. The
average total PRN value for six hospitals was 274.5 minutes, or about 4.5 hours, for each patient
day, with wide variations (SD=227.1). In descending order, average minutes for PRN activities
are as follows: diagnostic procedures (109.0), treatment (48.6), hygiene and comfort (42.6),
communication (32.4), respiration (16.6), feeding and hydration (15.1), and elimination (10.2).
Hospital 1 averaged the most PRN minutes in total by category, except for diagnostic
procedures. Hospital 3 averaged the fewest PRN in total and tended to rank low across
categories.
184
Table 21: Mean (SD) of PRN Workload (in Minutes) by Category, by Hospital
Hospital
Resp.
Feed. &
Elim.
Hyg. &
Hyd.
Comfort
42.3
21.2
16.6
66.6
1
(48.4)
(8.7)
(12.5)
(39.5)
15.3
17.5
12.2
62.0
2
(17.2)
(12.2)
(12.2)
(39.4)
9.6
13.0
6.5
26.3
3
(15.0)
(9.1)
(10.1)
(28.2)
9.3
14.4
8.6
30.0
4
(15.8)
(9.7)
(11.0)
(31.0)
15.0
12.2
8.2
31.4
5
(25.3)
(7.5)
(12.0)
(26.1)
11.8
10.9
10.2
32.5
6
(24.6)
(8.6)
(11.8)
(26.9)
16.6
15.1
10.2
42.6
Total
(27.2)
(10.2)
(12.1)
(36.8)
Note: Overall means based on daily patient data.
Comm.
66.7
(18.8)
14.1
(11.2)
31.8
(21.9)
38.0
(14.1)
28.9
(11.6)
39.2
(13.8)
32.4
(21.9)
Treatment
58.5
(40.1)
42.9
(43.2)
46.3
(50.1)
53.4
(37.2)
48.5
(51.8)
43.1
(32.6)
48.6
(45.4)
Diag.
Proc.
132.4
(89.2)
154.9
(156.4)
49.9
(95.6)
96.4
(139.7)
90.3
(149.3)
171.1
(143.8)
109.0
(140.0)
Total
404.2
(179.6)
318.9
(238.3)
183.5
(179.8)
249.7
(213.2)
234.6
(239.2)
318.3
(201.2)
274.5
(227.1)
Table 22 shows the total PRN minutes accounted for by each workload category. Diagnostic
procedures comprised almost one-third (31.1%) of the total PRN minutes, followed by treatment
and communication as the second and third highest proportions. Activities related to respiration,
feeding and hydration, and elimination accounted for the smallest proportion, less than five
percent, of total PRN patient care. Large amounts of variation were observed across hospitals.
Hospitals 6 and 2 had the highest proportion of diagnostic procedures, whereas Hospital 3 has
the smallest proportion. The proportion of treatment time was much higher in Hospitals 3 and 4
(23.9%) than in other hospitals (14.5%-20.7%). Hygiene and comfort in Hospital 2 was much
higher (23.0%) than in other hospitals (10.4%-16.4%). The proportion of time spent in
communication with patients was extremely low in Hospital 2 (6.7% vs. 17.3%-23.6% for other
hospitals).
Table 22: PRN Workload Category as Percent of Total PRN Workload, by Hospital
Hospital
Resp.
Feed. &
Elim.
Hyg. &
Comm.
Hyd.
Comfort
1
5.7
15.8
19.4
8.8
4.0
2
3.9
8.2
6.7
4.0
23.0
3
4.3
3.1
15.0
10.4
23.6
4
2.8
7.7
3.5
11.9
21.7
5
4.7
8.3
3.3
15.0
19.9
6
2.7
4.6
2.8
10.4
16.7
Total
4.6
8.0
3.6
16.4
17.3
Note: Differences by hospital are statistically significant at p<0.000
Treatment
14.5
13.8
23.9
23.9
20.7
14.9
19.0
Diag.
Proc.
31.7
40.4
19.8
28.7
28.2
48.1
31.1
Total
100.0
100.0
100.0
100.0
100.0
100.0
100.0
Table 23 demonstrates the gap between patient care time PRN and patient workload measured in
GRASP or MEDICUS across hospitals. The PRN scores in the last column of Table 21 were
adjusted for indirect care time using the method developed by Charles Tilquin. Workload
measured by GRASP or MEDICUS was on average 1.6 hours greater than workload measured
by PRN. Hospital 2, which used MEDICUS, showed the largest workload value (10.77 hours)
among all hospitals. With a mean PRN value of 6.78 hours, Hospital 2 had the largest
discrepancy (3.99 hours) with PRN. The discrepancy is also large for Hospital 4 (2.09 hours).
185
Hospital 1 was high in both GRASP and PRN scores, with only a small discrepancy (0.63 hours).
The GRASP values, which were generally higher than PRN, were lower for Hospital 3 (-0.56
hours).
Table 23: Comparison of PRN to GRASP/Medicus Workload (in Hours), by Hospital
Hospital
WL(GM)
N
Mean
SD
PRN
Mean
SD
WL(GM)-PRN
N
Mean
SD
1
2
3
4
5
6
Total
1094
9.29
5.49
1038
8.65
3.50
1038
0.63
4.83
2029
7.06
2018
6.78
4.68
2018
3.99
4.33
10.77
1422
3.50
3.12
1421
4.06
3.49
1421
-0.56
2.43
1295
7.52
5.40
1280
5.44
4.19
1280
2.09
3.85
1939
6.20
5.47
1932
5.09
4.70
1932
1.12
3.31
334
7.13
3.94
308
6.99
4.11
308
0.23
3.90
8113
7.54
6.08
7997
5.92
4.48
7997
1.60
4.12
Note: (1) WL(GM) stands for workload measured by GRASP (for Hospitals 1, 3, 4, 5, 6) or MEDICUS (for Hospital
2). (2) Based on overall means using daily patient data.
4.2 Workload Variation by Patient Medical Diagnosis

The variation in the distribution of work across various sites may be due to variations in the mix
of patients at each site. Table 24 presents the distribution of work by Case Mix Groups (CMG) in
descending order of average PRN workload in minutes.
This analysis shows that PRN workload varies significantly by CMG. The workload for CMG
Extensive Unrelated Operating Room Procedure and CMG group Major Cardio-thoracic
Procedures Without Pump was nearly 10 hours (>588.8 minutes), the highest among all CMGs,
and six times the size of workload for Cardiac Catheterization with Congestive Heart Failure
(1.5 hours or 90 minutes). Table 24 also showed that not all CMGs had the same percentage
distribution of workload category as total workload. For example, diagnosis procedures had a
much higher percentage for CMG Acute Myocardial Infarction with Cardiac Catheterization
with Congestive Heart Failure than for others CMG subgroups.
186
14
38
22
747
704
13
848
993
22
3
171
158
168
5
3
505
78
264
579
13
19
228
545
13
324
53
206
70
8
281
250
189
90
133
124
21
2
7904
EXTNSIVE UNREL OR PROCESUDRE

MAJOR CARDIO THORA PROCE WO P
OTHER CARDIOTORACIC PROC W PU
C VALVE REPLACE W PUMP WO CAR
MAJ CARDIO PR NO PUMP NO CATH
AMI W CAD CATH W CHF
C BYPASS W PUMP W CARD CATH
C BYPASS W PUMP WO CARD CATH
CAD CATH W VENTR FIB
ATHEROSCLEROSIS MNRH
CAR VALVE REPL W PUMP W CARD
AMI WO CARD C W CHF
AMI W CARD CATH NO SPEC COND
PROCEDURE CANCELLED MNRH
PERRIPHERAL VASCULAR DISEASE
PTCA W CARD COMP
UNSTABLE ANGINA WO CATH WO SP
AMI NO CARD CATH NO SPEC COND
PTCA WO CARD CATH
UNS ANGINA W CATH W SPEC COND
AMI NO CARD CATH W VENT TACH
CARD CATH WO SPECIFIED CONDITI
PERM PACE IMPL WO SPEC CARD C
ANGINA PECTORIS
HEART FAILURE
AMI W CARD CATH WITH ANGINA
PERM PACEMAKER IMPLANT W
UNS ANGINA W CATH NO CRD COND
CARDIAC CATH W CHF
ARRYTHMIA
OTHER CIRCULATORY DIAGNOSIS
CARDIAC CATH W SECIFIED CARD
CARDIAC CATH WITH VENT TACH
UNSTABLE ANGINA W CARD CATH W
CHEST PAIN
SYNCOPE AND COLLAPSE
RENAL FAILURE NO DIALYSIS
Total
596.1
588.8
411.4
389.9
361.1
351.5
344.4
341
313
310
307.1
273.1
272.6
259
256.7
247.4
234.7
229.7
212
209.2
207.6
205.7
200.1
191.5
191.3
186.9
184.3
176.4
176.3
174.4
169
166.1
160.7
158.1
138.8
130
97.5
274
Average
Total
Workload
17.35
7.35
15.10
8.57
4.72
4.28
5.57
6.97
4.94
2.10
6.91
4.82
2.89
6.16
5.88
3.55
3.12
2.48
1.94
1.92
3.17
2.63
2.12
4.15
4.63
1.79
2.37
4.14
5.86
3.31
3.45
2.39
1.32
3.52
3.15
8.60
0.00
4.60
Resp
4.06
4.71
4.79
5.74
7.04
5.94
6.72
6.52
6.41
5.29
6.86
8.26
8.39
3.41
9.80
8.47
9.38
9.70
9.03
8.08
9.69
9.78
8.65
8.22
10.62
9.70
8.61
10.08
7.03
9.49
10.43
9.92
10.64
10.40
11.47
9.40
12.04
8.06
Feed &
Hyd
2.23
2.99
2.30
3.48
3.32
4.36
3.00
3.32
4.44
1.22
4.34
6.23
3.53
0.00
10.49
3.49
3.93
6.20
3.15
2.79
3.46
3.07
4.17
5.36
4.85
3.99
2.92
2.59
0.71
2.73
5.00
3.50
1.91
2.32
1.64
0.72
0.00
3.55
Elim.
21.11
18.08
14.92
15.57
19.10
17.97
17.15
15.88
17.68
11.61
17.13
20.57
15.48
9.51
17.23
14.66
17.60
22.32
12.38
18.25
19.43
13.52
14.38
19.88
19.00
17.67
15.47
14.69
18.93
15.14
20.21
18.07
17.20
18.85
14.74
14.26
12.04
16.48
Hyg &
Comfort
12.33
13.40
16.62
15.64
11.35
12.14
14.19
17.13
19.87
31.53
14.47
13.12
15.79
30.49
19.97
17.63
14.98
13.29
22.28
5.76
15.49
28.11
22.28
13.21
18.06
18.55
18.22
23.02
24.58
20.72
16.89
17.50
18.54
16.55
26.01
19.50
29.17
17.30
Comm.
17.44
15.42
17.38
21.50
19.13
11.17
18.85
21.94
11.39
19.07
20.00
15.53
15.95
27.08
10.56
17.77
14.71
14.75
20.93
10.40
15.67
16.67
20.40
12.84
17.57
15.70
19.35
21.35
11.35
15.62
17.52
18.52
15.52
19.93
16.70
13.43
6.02
18.99
Treatm
ent
Percentage Distribution of Workload
187
Note: (1) Based on patient daily entry data for 1,198 patients. (2) Data are sorted by Average Total Workload.
N*
CMG
Table 24: Percent Distribution of Work (in Minutes) by Workload Category, by CMG Type
25.48
38.05
28.88
29.42
35.35
44.15
34.64
28.25
35.28
29.18
30.29
31.46
37.97
23.34
26.07
34.43
36.26
31.39
30.37
52.79
33.08
26.22
28.10
36.34
24.95
32.60
33.06
24.12
31.54
33.00
26.52
30.10
34.87
28.43
26.29
34.08
40.74
31.02
Diag.
Proc.
4.3 Overtime and Continuity of Care/Shift Change and Unit Instability

Table 25 shows the worked overtime hours in three categories by hospital (on average, 7% of the
nurses worked more than 40 hours per week in their own hospital; see Table 34). Close to half of
the nurses (45.1%) in all the hospitals reported either no overtime or less than one hour overtime
per week. Another 32.2% worked 1-4 hours of overtime per week. The rest of the nurses (22.7%)
worked greater than four hours overtime per week. Within the latter category, the highest and
lowest proportions were achieved by Hospitals 6 (38.5%) and 4 (16.7%).
Table 25: Percent of Nurses Reporting Overtime in Average Hours per Week, by Hospital
Hospital
1
2
3
4
5
6
Total
0-1
1-4
>4
52
153
64
72
184
96
621
36.5
47.7
37.5
51.4
47.8
40.6
45.1
32.7
33.3
45.3
31.9
32.6
20.8
32.2
30.8
19.0
17.2
16.7
19.6
38.5
22.7
Table 26 presents the percent change in overtime in the past year by unit type. Nurses were asked
whether the amount of overtime required had increased, remained the same, or decreased in the
past year. For most nurses (64.3%), overtime work increased. The CCU in Hospital 4 reported
the highest proportion of no change in overtime hours. Nurses in Hospitals 4 and 5 more
frequently reported decreases in overtime in the past year than the nurses in the other institutions.
Table 26: Percent Change of Nurse Overtime Hours in the Past Year, by Unit Type
Unit Type
Hospital 1
N
CCU
IP
SDU
CCU
IP
CCU
IP
CCU
DS
IP
CCU
DS
IP
CCU
IP
SDU
Increased
Remained Same
28
64.3
32.1
18
72.2
22.2
3
0.0
100.0
Hospital 2
97
62.9
36.1
37
89.2
10.8
Hospital 3
31
54.8
38.7
35
68.6
28.6
Hospital 4
27
18.5
63.0
5
80.0
20.0
23
39.1
47.8
Hospital 5
52
38.5
40.4
29
69.0
27.6
70
54.3
41.4
Hospital 6
58
75.9
24.1
11
63.6
27.3
15
60.0
40.0
Total
539
64.3
32.1
Note: Significance test is not available because of small N in some of the cells.
Decreased
3.6
5.6
0.0
1.0
0.0
6.5
2.9
18.5
0.0
13.0
21.2
3.4
4.3
0.0
9.1
0.0
3.6
The DS unit in Hospital 4 also had a very low number of nurses reporting an increase in levels of
overtime while the other units in the same hospital had high numbers reporting a decrease (Table
188
26). These nurses were more likely (51.4%) to report an average of less than one hour of
overtime as compared to other hospitals (Table 25).
Table 27 contrasts the prevalence of unpaid overtime and involuntary overtime. Unpaid overtime
includes both voluntary and involuntary; involuntary includes both paid and unpaid overtime.
Hospital 4 reported the highest percentage of unpaid overtime but below average involuntary
overtime. Overtime may not by itself be a contributing factor to high stress levels, but rather the
involuntary nature of overtime in some organizations may lead to high levels of stress. Some
nurses choose to work overtime and therefore overtime may not be a source of stress. However,
we hypothesize that when overtime is involuntary in nature it may serve as a source of stress.
Table 27: Percent of Overtime Unpaid or Involuntary, if Working Overtime, by Hospital
Hospital
1
2
3
4
5
6
Total
% Unpaid
37
84
46
37
114
65
383
% Involuntary
13.0
28.6
36.1
42.1
25.7
18.6
26.7
27.7
25.6
29.3
21.3
18.4
20.5
22.8
Continuity of care was operationalized as the proportion of shift changes more frequent than
once in the last two weeks as well as the proportion of nurses forced to change units in the past
year and of those who anticipated forced changes in their unit in the coming year (Table 28).
Nurses in Hospital 5 experienced higher levels of forced change in the last year, but Hospital 1
had the highest percentage anticipating a change in the next year. The nurses in Hospital 5 also
reported the highest number of shift changes per week. Nurses who were forced to change unit in
the past year had a higher nurse-patient ratio than nurses not experiencing a forced unit change
(F=12.7, p<0.001). The proportion of shift changes and anticipation of forced changes in unit
was associated with emotional exhaustion (measured by Maslachs Burnout Inventory). Those
who anticipated forced change of unit were more likely to rank high on the emotional exhaustion
index (thus not healthy) than those who did not anticipated forced change of unit (F=8.7,
p<0.01).
Table 28: Continuity of Care and Amount of Change, by Hospital
Hospital
% More than 1 shift change
in the past 2 weeks
N
% Forced to change nursing
units in the past year
N
% Anticipating forced change
of unit
N
Total
36.2
58
36.3
182
17.6
74
30.2
86
41.3
206
18.5
108
32.4
714
10.3
58
8.7
184
0.0
74
2.4
85
13.8
210
4.5
111
8.0
722
24.6
57
14.1
184
6.8
73
7.1
85
20.8
207
17.0
112
15.7
718
189
4.4 Non-Nursing Tasks

Despite the nurses reports of poor quality nursing care and the high percentage of nurses
reporting that essential nursing tasks are not being completed or are delayed, nurses continue to
report a high volume of tasks that could be delegated to non-nursing personnel. Table 29 shows
how likely a nurse is to perform these tasks.
Among eight non-nursing tasks listed in Table 29, nurses more likely reported ancillary
service, venipunctures, housekeeping, delivering trays, and starting IVs. Each hospital
varied in which tasks were more likely to be performed by the nurse. Hospital 1 had the largest
proportion of nurses who reported delivering trays, venipunctures, and performing ECGs.
Hospital 2 was more likely to mention transporting patients than the others. Hospital 3 had the
largest proportion reporting housekeeping and arranging transportation. Hospital 5 was most
likely to report starting IVs. Hospital 6 had the largest proportion reporting ancillary service.
Table 29: Percent of Nurses Reporting Performing Non-Nursing Tasks for Items in the Table,
by Hospital
Non nursing tasks
Number of Cases
Ancillary service
Venipunctures
Delivering trays
Housekeeping
Starting IVs
Performing ECGs
Transporting patients
Arranging
transportation
Total
58
87.9
82.8
72.4
63.8
67.2
51.7
22.4
184
82.6
72.3
34.2
44.6
17.4
15.8
42.4
73
90.4
11.0
54.8
87.7
63.0
9.6
24.7
86
89.5
64.0
51.2
47.7
62.8
37.2
20.9
210
74.3
73.8
65.2
64.3
71.0
50.0
26.2
111
91.0
62.2
64.9
35.1
43.2
48.6
36.0
722
83.5
64.8
55.1
55.1
51.0
35.6
30.7
32.8
27.2
38.4
30.2
23.3
31.5
28.7
Note: Non-nursing tasks are sorted by percent in the Total column
5. Intermediate System Outputs

Staffing information was collected by the site data collectors for each day of the study and for
each nursing unit. Data were collected by shift, by skill level, and by employment status. Data
about unit staffing, patient census, and unit daily workload are displayed in Tables 30-34.
5.1 Worked Hours
Table 30 shows that the actual staffing hours varied from hospital to hospital and from unit to
unit. In general, CCUs had a higher average daily worked hours and workload with the highest
for CCU in Hospital 3 (329.3) and lowest (88.0) for the DS unit in Hospital 4. The IP unit in
Hospital 4 averaged the highest number of agency worked hours (23.9). In contrast, Hospital 3
used no agency worked hours. The SDU in Hospital 6 averaged the highest number of overtime
hours (6.7) and absent hours (27.4).
190
Table 30: Actual Staffing Hours, by Unit, by Day

Unit Type
Worked
Hours All
Staff
Agency
Worked
Hours
Overtime
Hours
Absent
Hours
All GRASP
Workload
Mean
N
Mean
N
Mean
N
Mean
N
Mean
(A)
(B)
(C)
(D)
(E)
Hospital 1 CCU
87 146.4
87
3.2
87
4.4
87
14.7
79
148.1
IP
117 160.2
117
3.5
117
1.4
117
8.4
103
149.6
SDU
87 104.9
87
0.0
87
1.3
87
5.4
81
101.1
CCU
227 298.4
227
0.9
227
0.3
228
12.7
228
Hospital 2
300.8
IP
122 206.0
122
5.2
122
0.8
122
9.1
122
213.5
108 329.3
108
0.0
108
0.4
108
9.9
107
299.1
Hospital 3 CCU
IP
112 264.5
112
0.0
112
5.4
112
5.6
112
200.7
Hospital 4 CCU
219 284.4
219
0.1
219
0.4
219
9.4
217
252.4
DS
109
88.0
109
0.1
110
0.1
109
4.8
107
77.2
IP
220 249.1
220
220
0.6
220
9.2
217
272.3
23.9
200 203.5
200
0.1
200
2.7
200
7.4
200
171.9
Hospital 5 CCU
DS
101 134.5
101
0.1
101
1.4
101
6.9
100
115.1
IP
229 143.4
228
2.3
228
0.7
229
6.3
226
141.0
142 141.9
142
1.5
142
4.7
142
13.9
140
90.1
Hospital 6 CCU
IP
62 136.2
62
1.7
62
3.6
62
13.2
60
88.6
SDU
19 222.9
18
7.6
18
18
19
107.1
6.7
27.4
Total
2161 206.1
2159
3.6
2160
1.6
2161
9.2 2118
190.9
Note: (1) N is the number of unit days. (2) Letters A, B, C, D, and E will be used in the following table. (3) GRASP
hours are MEDICUS hours for Hospital 2. (3) Agency worked hours includes hours worked by agency nurses and/or
agency non-nursing staff (e.g., sitters).
The hospital workload measure, agency worked hours, overtime worked hours, and absent hours
as a percent (or ratio) of total worked hours are displayed in Table 31. The hospital workload
measure averaged 92.6% of total worked hours across all units and hospitals. Of 16 hospital
units, four had ratios over 100% and three had ratios over 93%. Hospital 6 has the lowest ratio
for all unit types (less than 65%). Units in Hospital 6, on the other hand, reported more overtime
hours and absent hours than other units. Agency hours comprised 9.6% of worked hours on
Hospital 4s IP unit as compared to 3.4% or less for other units.
191
Table 31: Percent of Actual Staffing, by Unit, by Day

Unit Type
Hospital 1
WL(GM)/WH
(E/A)
Agency/WH
(B/A)
Overtime/WH
(C/A)
Absent/WH
(D/A)
CCU
IP
SDU
CCU
IP
CCU
IP
CCU
DS
IP
CCU
DS
IP
CCU
IP
SDU
101.2
2.2
3.0
10.0
93.4
2.2
0.9
5.2
96.4
0.0
1.2
5.1
Hospital 2
100.8
0.3
0.1
4.3
103.6
2.5
0.4
4.4
Hospital 3
90.8
0.0
0.1
3.0
75.9
0.0
2.0
2.1
Hospital 4
88.7
0.0
0.1
3.3
87.7
0.1
0.1
5.5
0.2
3.7
109.3
9.6
Hospital 5
84.5
0.0
1.3
3.6
85.6
0.1
1.0
5.1
98.3
1.6
0.5
4.4
Hospital 6
63.5
1.1
9.8
3.3
65.1
1.2
2.6
9.7
48.0
3.4
3.0
12.3
Total
92.6
1.7
0.8
4.5
Notes: (1) WH denotes worked hours. (2) See Table 30 for designations of A-E. (3) Agency worked hours includes
hours worked by agency nurses and/or agency non-nursing staff (e.g., sitters).
As shown in Table 32, the overall daily averages per unit were 19.8 patients on census, 6.1
admissions, and 6.1 discharges. Patient census, daily admission, and daily discharge, however,
varied greatly by unit type and by hospital. For all hospitals, IP units averaged the most patients,
ranging from 15.5 to 49.7 patients per day, and the most admissions and discharges, except in the
case of DS units. The IP unit in Hospital 3 averaged the highest number of patients, admissions,
and discharges per day. The IP unit for Hospital 2 also tended to average a higher number of
patients. The lowest and highest mean censuses were found in Hospitals 1 and 3 respectively.
192
Table 32: Daily Patient Census, Admissions, and Discharges, by Unit

Unit Type
Hospital 1
Hospital 2
Hospital 3
Hospital 4
Hospital 5
Hospital 6
Midnight Census
N
Mean
CCU
IP
SDU
CCU
IP
CCU
IP
CCU
DS
IP
CCU
DS
IP
CCU
IP
SDU
Total
87
117
87
228
122
108
112
219
117
221
200
101
228
142
62
19
2170
10.0
17.0
15.1
15.5
37.8
16.2
49.7
10.4
8.3
34.5
9.0
12.6
28.1
10.3
15.5
29.5
19.8
Daily Admissions
N
Mean
87
117
87
228
122
108
111
219
109
221
200
101
228
142
62
19
2161
2.7
6.3
3.7
4.5
9.3
6.6
15.6
3.4
7.0
6.5
2.8
7.6
6.5
4.0
13.0
5.3
6.1
Daily Discharges
N
Mean
87
117
87
228
122
108
112
219
117
221
200
101
229
142
62
19
2171
2.7
6.4
3.6
4.6
9.0
6.6
15.2
3.4
7.8
6.7
2.7
7.4
6.4
4.0
12.9
5.3
6.1
5.2 Productivity/Utilization
Nursing unit productivity/utilization is measured as the ratio of GRASP/Medicus workload hours
to worked hours. The maximum work capacity of any employee is 93%. Seven percent of
worked hours are allocated to paid breaks during which time no workload is contractually
expected. At 93% nurses are working flat out with no flexibility to meet unanticipated demands
or rapidly changing patient acuity. This study hypothesized that a value of 85% is an appropriate
productivity/utilization level to ensure high quality cost effective care.
As shown in Table 33, in a large proportion of units, nurses were working beyond 93%
productivity/utilization levels. On 61.5% of the study days, productivity/utilization levels were
higher than 85%. Generally, IP units had higher productivity/utilization levels than CCUs, SDUs,
and DS units. This finding is not unexpected since these units must staff differently to monitor
patients. The productivity/utilization levels were lowest in Hospital 6. On 46.5% of the study
days, productivity/utilization levels were higher than 93%. CCUs in Hospitals 1, 3, and 6 as well
as IP units in Hospitals 2, 4, and 5 were most frequently above 93% productivity/utilization
levels within their respective organizations.
193
Table 33: Number of Days When Unit GRASP/Medicus is Greater than 85% and 93% of Total
Nurse Hours, by Unit
Unit Type
Hospital 1
Number of Days
Reported
% Days with WL(GM)

> 85% of
Total Nursing Hours
% Days with WL(GM)

> 93% of
Total Nursing Hours
CCU
IP
SDU
CCU
IP
CCU
IP
CCU
DS
IP
CCU
DS
IP
CCU
IP
SDU
79
79.7
62.0
103
63.1
49.5
81
67.9
58.0
Hospital 2
225
60.0
51.1
121
99.2
90.1
Hospital 3
107
60.7
48.6
112
29.5
11.6
Hospital 4
216
67.1
35.2
99
48.5
34.3
216
96.8
88.0
Hospital 5
199
41.2
21.6
100
51.0
37.0
226
86.7
63.7
Hospital 6
140
13.6
9.3
60
10.0
8.3
19
5.3
0.0
Total
2103
61.5
46.5
Note: (1) WL(GM) stands for workload measured as GRASP (in Hospital 1, 3, 4, 5, 6) or Medicus (in Hospital 2).
(2) Differences by unit are statistically significant (2=744.9, df=23, p<0.01)
Table 34 displays worked hours of nurses in the study hospital and in other employment. Nearly
two thirds of surveyed nurses worked between 31 to 40 hours a week in the past year, which is
typical of full-time employee work time. One quarter of surveyed nurses reported working hours
between 21 and 30 hours. On average, only 3.8% of nurses worked less than 20 hours a week. In
addition, 7% of nurses averaged over 40 worked hours per week. Nearly one in four nurses
(22.5%) reported paid work outside the study hospital.
Hospital 1 had the highest proportion of nurses working full-time (71.9%), whereas the
proportion of nurses working part-time (i.e., less than 30 work hours per week) was highest in
Hospital 2 (35.8%) and 5 (38.0%). Hospital 2 also had a relatively high proportion of nurses
(8.4%) working less than 20 hours weekly in the study hospital.
Nurses in Hospitals 3 and 4 are vulnerable to strenuous work conditions: nearly one in nine
(11.8%) nurses in Hospital 3, and one in six (15.9%) nurses in Hospital 4 worked the most
overtime. In addition, nurses in Hospital 4 were most likely to hold paid employment outside the
study hospital. Some of this variation may be due to the available supply of employment
opportunities in individual locations.
194
Table 34: Percent of Nurses Reporting Average Hours Worked Per Week in the Past Year, by
Hospital
Hospital
In this Hospital
N
1
2
3
4
5
6
Total
57
179
69
85
208
107
705
< 20
hrs
1.8
8.4
1.4
2.4
4.8
1.9
3.8
Other Employment
21-30 hrs
31-40 hrs
19.3
27.4
24.6
16.5
33.2
24.3
26.4
71.9
59.8
58.0
69.4
57.7
67.3
62.3
> 40
hrs
7.0
4.5
15.9
11.8
4.3
6.5
7.0
> 10 hrs
15
60
21
20
44
26
186
6.7
21.6
28.5
35.0
27.2
11.4
22.5
6. Environmental Complexity
The Environmental Complexity Scale (ECS) captures nurses ratings of how daily unit factors
influence their ability to provide required care for patients. Twenty-two ECS items were
administered daily to all nurses working day shift on participating study units. Missing data were
imputed using individual and unit means. Three subscales were constructed to capture different
dimensions of nurses work complexity: (1) Re-Sequencing of Work in Response to Others; (2)
Unanticipated Changes in Patient Acuity; and, (3) Composition and Characteristics of the Care
Team which considers students, staffing, and nurse team functioning. The values range between
0 and 10.
As shown in Table 35, the means for the three subscales (resequence, change, team) were 6.1
(SD=0.88), 6.5 (SD=1.04), and 5.7 (SD=1.06), respectively, for all study hospitals. The
differences by unit for all subscales are statistically significant at p<0.001, but there are no clear
patterns by hospital or by unit type.
195
Table 35: Mean of Three Subscales from ECS, by Hospital

Unit Type
Hospital 1
N*
CCU
IP
SDU
CCU
IP
CCU
IP
CCU
DS
IP
CCU
DS
IP
CCU
IP
SDU
519
765
355
Hospital 2
2574
1035
Hospital 3
438
627
Hospital 4
531
102
242
Hospital 5
1673
621
1732
Hospital 6
827
384
202
Total
12627
*N=Number of day entries by nurses.
Resequence
Mean
SD
5.9
6.0
5.5
5.6
5.8
6.1
6.3
5.7
5.9
6.1
6.8
6.6
6.4
6.3
6.3
6.1
6.1
0.75
1.32
0.65
0.72
0.74
0.97
0.92
0.92
1.04
0.81
0.52
0.74
0.76
0.66
0.49
0.73
0.88
Change
Mean
SD
6.6
6.5
6.3
6.2
6.2
6.7
6.8
6.7
6.0
6.9
6.7
6.6
6.5
6.7
6.8
6.6
6.5
1.17
1.46
1.13
0.98
0.98
1.26
1.17
1.18
0.98
1.05
0.77
1.01
0.94
0.80
0.68
1.05
1.04
Team
Mean
SD
5.8
6.1
5.5
5.5
5.3
5.3
5.8
5.6
5.3
6.3
5.7
5.9
5.3
6.6
6.7
6.4
5.7
1.14
1.64
0.93
0.99
0.76
0.81
1.28
1.58
0.49
1.02
0.46
0.38
0.73
1.09
1.01
1.42
1.06
On average, 42.9% nurses on study units needed more time on their shift to provide the level of
patient care specified in the nursing care plan. These results are presented by hospital unit in
Table 36.
Table 36: Percent of Nurses Reporting Additional Time Needed to Provide Quality of Care, by
Hospital Unit
Unit Type
N*
Hospital 1
CCU
475
IP
702
SDU
304
Hospital 2
CCU
1976
IP
889
Hospital 3
CCU
393
IP
553
Hospital 4
CCU
478
DS
96
IP
217
Hospital 5
CCU
1655
DS
612
IP
1677
Hospital 6
CCU
576
IP
250
SDU
175
Total
11028
*N=Number of day entries by nurses.
no more
time
needed
31.6
28.5
30.3
60.7
46.2
49.6
25.7
55.9
33.3
27.6
85.1
78.4
71.8
51.9
51.6
13.7
57.1
% <15
min.
11.2
15.8
5.3
5.1
8.8
7.9
14.1
5.0
11.5
3.7
0.8
1.1
2.1
3.3
6.8
11.4
5.6
% 15-30
min.
18.5
27.4
28.6
12.9
20.4
16.0
27.5
12.8
34.4
21.2
6.3
8.3
11.6
16.3
20.0
27.4
15.4
% 31-45
min.
13.9
14.1
13.8
7.9
11.9
8.9
14.6
8.4
7.3
17.1
3.3
5.9
4.9
13.0
12.8
21.7
8.9
% 46-60
min.
13.9
7.0
9.2
6.1
5.6
9.2
9.2
9.0
5.2
14.7
3.3
3.9
5.2
8.3
5.6
12.6
6.6
% >60
min.
10.9
7.3
12.8
7.3
7.1
8.4
8.9
9.0
8.3
15.7
1.2
2.3
4.4
7.1
3.2
13.1
6.3
196
7. Patient Outcomes
Patient outcomes in this section include medical consequences (from the Patient Data Form) and
patient health status change (from the Patient SF-12 Health Status Survey).
7.1 Medical Consequences
Data on medical consequences were collected by data collection staff via health records, who
recorded the number of negative events and medical complications patients experienced during
their hospital stay. Negative events included an unexpected return to the Intensive Care Unit
(ICU), a fall with injury, a readmission within three months, and a recorded complication in the
health record. Medical complications tracked included urinary tract infection, pneumonia, deep
or superficial surgical wound infection, bedsore, and thrombosis. As shown in Table 37, medical
consequences were rare for all six hospitals, although these tended to be somewhat higher for
Hospitals 4 and 2 than for other hospitals. Hospital 4 had the highest incidences of medical
complications. No hospitals reported medical errors with patient consequences except for
Hospital 1 (one case reported). Nearly one-third (32%) of patients have been hospitalized for the
same condition in the past 3 months. The readmission rate is the highest in Hospital 1 (39%) and
lowest in Hospital 6 (12%), where the nurses had low workload to worked hours ratio. In
addition, Hospital 1 reported higher incidences in returned to ICU post-op than other hospitals.
Table 37: Medical Consequences Percent Reporting Yes to the Items in the Table, by
Hospital
Hospital
Number of cases
1
189
2
243
3
259
4
195
5
285
6
59
Total
1230
Returned to ICU post-op
3.7
0.4
3.1
3.6
0.7
0.0
2.0
Falls with Injury
0.0
0.8
0.8
0.0
1.4
0.0
0.7
Urinary tract Infection
1.1
2.5
0.0
3.6
1.1
0.0
1.5
Pneumonia
2.1
2.1
0.4
2.6
0.4
0.0
1.3
Wound Infection
0.0
3.3
0.8
2.1
0.7
1.7
1.4
Bedsores
0.0
0.4
0.4
1.5
0.0
0.0
0.4
Thrombosis
0.0
0.0
0.0
1.0
0.0
0.0
0.2
0.5
0.0
0.0
0.0
0.0
0.0
0.0
1.6
1.6
1.2
6.0
0.4
1.9
1.6
38.6
36.7
29.3
31.7
30.6
12.3
32.0
Medication Errors with

consequences
Admitted in past week
with same diagnosis
Hospitalized for the
same condition in the
past 3 months
197
7.2 OMAHA Scores at Discharge and Change from Admission

Patient OMAHA scores at admission (or appearance of new diagnosis) were presented earlier in
Table 12. Table 38 shows the mean OMAHA scores at time 2. For all study patients, the means
were 3.8 (SD=0.67) for knowledge, 4.2 (SD=0.52) for behaviour, and 4.1 (SD=0.62) for status.
Patients from Hospital 2 had the highest scores across all three dimensions. Patients from
Hospital 1 ranked low for all dimensions at time 2, probably due to low scores at admission.
Table 38: OMAHA Scores at Time 2 (Resolution of Diagnosis or at Discharge), by Hospital
Hospital
1
2
3
4
5
6
Total
N
188
237
232
192
282
58
1189
Knowledge
Mean
SD
3.6
0.55
0.72
4.1
3.8
0.39
4.0
0.45
3.9
0.75
2.8
0.63
3.8
0.67
Behaviour
Mean
SD
3.9
0.37
0.47
4.5
4.1
0.39
4.4
0.49
4.3
0.61
4.3
0.45
4.2
0.52
Status
Mean
3.8
4.3
4.2
4.3
3.9
3.6
4.1
SD
0.57
0.53
0.56
0.48
0.69
0.63
0.62
Table 39 shows the mean change scores for each hospital for knowledge, behaviour, and status
between time 1 (at admission or appearance of new diagnosis) and time 2 (at discharge or
resolution of diagnosis).
Table 39: Differences in OMAHA Scores Between Time 1 and Time 2, by Hospital
Hospital
1
2
3
4
5
6
Total
N
188
237
232
192
282
58
1189
Knowledge
Mean
SD
0.63
0.59
0.58
0.57
0.55
0.79
0.25
0.41
0.07
0.29
0.14
0.26
0.43
0.55
Behaviour
Mean
SD
0.16
0.35
0.45
0.42
0.50
0.48
0.13
0.46
0.08
0.34
0.07
0.23
0.25
0.44
Status
Mean
0.77
0.68
1.16
0.42
0.98
0.12
0.79
SD
0.59
0.53
0.67
0.52
0.77
0.33
0.68
7.3 Health Status at Discharge and Change from Admission

Patient physical and mental functional status at admission was presented earlier in Tables 13 and
14. Tables 40 and 41 show the changes in patient functional status from admission to discharge.
As can be seen, more than 40% of patients had improved physical and mental health at discharge
(41% for physical health and 42% for mental health) and about 45% of patients had physical and
mental scores at discharge lower than at admission. For patients who reported an improvement in
health, Hospital 1 had the highest change score among all hospitals (9.39 for physical health and
10.81 for mental health). For patients who had a decrease in the score, Hospital 3 had the
smallest change (-7.37 for physical health and -4.53 for mental health).
198
Table 40: Change in Patient Physical Health Status (SF-12) from Admission to Discharge
Hospital
Increased
N
1
2
3
4
5
6
All hospitals
Percent
Mean (SD)
64
53
116
64
102
15
414
Decreased
N
9.39 (7.72)
6.19 (5.72)
7.06 (5.71)
8.41 (7.48)
7.63 (6.87)
7.13 (5.32)
7.66 (6.65)
Mean (SD)
83
96
71
81
116
18
465
41.1%
-9.57 (7.99)
-10.69 (9.00)
-7.37 (7.22)
-10.05 (8.14)
-8.77 (7.17)
-7.44 (6.24)
-9.27 (7.91)
46.1%
No Change
N
15
12
62
6
28
6
129
12.8%
Table 41: Change in Patient Mental Health Status (SF-12) from Admission to Discharge
Hospital
Increased
N
1
2
3
4
5
6
All hospitals
Percent
Mean (SD)
61
68
112
77
90
18
426
10.81 (9.82)
8.78 (8.77)
6.31 (7.09)
8.70 (5.90)
7.20 (7.01)
5.66 (3.72)
7.94 (7.64)
Decreased
N
Mean (SD)
86
81
75
68
128
15
453
42.3%
-8.81 (6.78)
-8.27 (6.75)
-4.53 (5.41)
-7.66 (6.33)
-8.93 (7.65)
-10.60 (8.25)
-7.93 (6.97)
44.9%
No Change
N
15
12
62
6
28
6
129
12.8%
8. Nurse Outcomes
This section presents results related to nurse burnout, job satisfaction, absenteeism, and intent to
leave.
8.1 Burnout and Effort & Reward Imbalance
Maslachs Burnout Inventory (MBI) and the Effort-Reward Imbalance (ERI) questionnaire were
included in the Nurse Survey to measure burnout. The MBI is a 22-item scale with three
subscales: emotional exhaustion (EE), depersonalization (DP) and personal accomplishment
(PA). A seven point categorical scale ranging from never, a few times a year or less to
everyday is used to examine nurses feelings about their work and patients. Items are split
amongst the EE (9 items), DP (5 items), and PA (8 items) subscales. Table 42 displays the means
and standard deviations. The highest MBI subscale scores amongst Hospitals 3, 1, and 5 were
associated with the three highest proportions of nurses who ranked below the US norms for
mental health for females (Table 48).
Table 42 shows nurses who worked at Hospital 3 averaged the worst job-related feelings of
emotional exhaustion, while those at Hospital 1 scored highest on depersonalization aspects. The
199
nurses who worked at Hospital 5 were least likely to claim that they had personal
accomplishments.
Table 42: Burnout Mean Scores of MBI Subscales, by Hospital
Hospital
N
1
2
3
4
5
6
Total
58
171
71
82
199
108
689
EE
Mean
25.0
20.8
26.3
20.6
23.1
23.3
22.7
SD
12.1
9.6
10.8
10.2
10.2
10.5
10.5
N
58
173
74
79
205
108
697
DP
Mean
7.6
5.5
7.1
4.6
5.9
6.0
6.0
SD
6.4
5.3
5.6
4.4
5.1
4.9
5.2
N
56
163
70
82
205
101
677
PA
Mean
10.9
12.2
12.5
10.8
13.3
11.6
12.2
SD
7.0
7.1
5.9
5.8
7.0
6.8
6.8
Note: EE=Emotional Exhaustion Index

DP=Depersonalization Index
PA=Personal Accomplishment Index
Difference by hospital is statistically significant at p<0.05 for all three subscales.
The Effort-Reward Imbalance (ERI) scale, a 17-item scale that measures the balance between
nurses efforts and their rewards, was also used to assess burnout. The ERI uses a four point
scale to measure the extent of stress, from I am not at all distressed to I am very distressed.
The greater the ERI score, the greater the individuals distress. To determine which proportions
of nurses were at risk for ERI or MBI emotional exhaustion, the ERI and MBI (EE) variables
were dichotomized. The ERI already has values of 0 or 1, while the MBI (EE) was dichotomized
using values greater than 27 as per instrument guidelines. The proportion of nurses at risk is
displayed in Table 43. Nurses in Hospital 3 were most at risk for emotional exhaustion (43.7%
vs. 22.2%-36.2%). These results are consistent with the MBI EE scores in Table 42, as well as
the mental health data in Table 48 where Hospital 3 had the largest proportion of nurses whose
mental health was below the US population norm. Nurses in Hospital 3 were also more likely to
feel imbalances in effort and reward than nurses in other hospitals (25.8% vs. 10%-22%).
Table 43: Burnout Percent of Nurses at Risk for Emotional Exhaustion and ERI, by
Hospital
Hospital
1
2
3
4
5
6
Total
N
58
171
71
82
199
108
689
% at Risk for
MBI_EE
36.2
22.2
43.7
25.6
29.6
33.3
29.9
N
50
141
62
70
166
88
577
% at Risk for
ERI
22.0
17.7
25.8
10.0
16.3
20.5
18
Note: ERI=Effort-Reward Imbalance (>1, at risk)

MBI_EE=Maslachs Burnout Inventory-Emotional Exhaustion (>27, at risk)
Difference by hospital is not significant (2=6.8, df=5, p>.05)
200
8.2 Autonomy and Control

Table 44 shows the subscale response from the Revised Nursing Work Index (R-NWI). The
NWI measures nurses job satisfaction and perception of quality of care. For each of the 41 items
in the survey, the nurses responded on a 4-point forced choice Likert scale, with choice ranging
from 1=strongly disagree to 4=strongly agree. No neutral response options are provided. Five
subscales were created and listed by hospital. Higher scores reflect better working conditions and
job satisfaction.
Hospital 4 showed the best scores for all five subscales: autonomy, control over patient care,
nurse-physician (NP) relationship, leadership, and resources available.
Table 44: Nurse Work Index Subscales, by Hospital
Hospital
1
Autonomy
N
Mean
(SD)
55
Control
N
Mean
(SD)
NP Relation
N
Mean
(SD)
Leadership
N
Mean
(SD)
16.2
58
17.0
59
7.4
52
28.2
(3.28)
(3.31)
(2.15)
(5.54)
2
173
16.4
181
18.5
182
8.6
167
30.1
(2.83)
(3.71)
(1.76)
(5.72)
3
69
15.2
73
18.1
73
8.1
69
28.7
(3.23)
(3.80)
(2.01)
(5.32)
4
81
83
85
79
20.6
9.2
32.7
17.6
(3.06)
(4.22)
(1.86)
(6.26)
5
203
15.6
204
19.0
208
8.1
201
27.5
(3.11)
(3.98)
(1.99)
(5.65)
6
101
14.7
108
17.5
110
8.4
104
26.2
(3.18)
(3.42)
(1.92)
(6.26)
Total
682
15.9
707
18.6
717
8.4
672
28.8
(3.18)
(3.81)
(1.97)
(6.09)
Note: Difference by hospital is statistically different at p<0.002 for all nurse work indices.
Resource
N
Mean
(SD)
58
184
73
84
206
108
713
9.7
(1.44)
10.2
(1.37)
9.5
(1.57)
10.4
(1.74)
10.0
(1.51)
9.9
(1.34)
10.0
(1.49)
8.3 Job Satisfaction

Table 45 shows the percent of dissatisfied nurses for each hospital. On average, 17.0% of the
nurses were dissatisfied with their current jobs. Variation in dissatisfaction in present job across
hospitals was minimal with the exceptions of Hospitals 1 (28.9%) and 4 (9.3%). Satisfaction
with current job was only moderately correlated with satisfaction of being a nurse (r=0.474,
p<0.001).
In five hospitals, 37.6-49.0% of the nurses were dissatisfied with their opportunities to interact
with management. The one notable exception was Hospital 6 with over 63% of nurses reporting
this issue. In four of the six hospitals only 15.3-22.7% of nurses were dissatisfied with the
amount of responsibility. Hospitals 1 and 3 reported notably higher scores at 43.9% and 42.3%
respectively.
In five hospitals, 11.0-15.1% of nurses were dissatisfied with opportunities for social contact at
work and 19.2-27.9% with opportunities for social contact after work. The one exception was
Hospital 2 where nurses appeared more satisfied with social opportunities.
201
Table 45: Job Satisfaction Percent of Nurses Dissatisfied, by Hospital

Hospital
Opportunities to
interact w/ Mgmt
Amount of
Responsibility
Social Contact after work
Satisfaction - present
job
40.4
37.9
40.8
37.6
49.0
63.6
45.5
43.9
18.7
42.3
15.3
19.8
22.7
23.6
26.3
16.6
19.2
27.9
20.2
22.0
20.9
28.6
14.1
19.7
9.3
18.2
18.2
17.0
Satisfaction - nurse
21.1
9.2
21.9
10.5
20.2
13.6
15.4
Social Contact work
12.3
4.9
13.9
15.1
11.0
13.6
10.7
57
181
73
86
208
109
714
Number of Cases
Total
Note: (1) Items are sorted by percent in the Total column. (2) Number of valid responses varied slightly from item to
item.
8.4 Health Status

Table 47 shows the physical and mental health levels for nurses in each of the hospitals as
measured by the SF-12. The average physical health score for nurses was 50.1, slightly above the
US norm for females in the general population (49.11). However, the average mental health
score (47.3) was below the US female norm (49.42). Hospital 4 had the highest mean physical
health scores (53.0), and Hospital 6 had a slightly better mean mental health score than those of
others hospitals (48.2).
Since the SF-12 questionnaire was completed by both patients and nurses, comparisons are
possible. The overall average mental health score for nurses (47.3) was lower than the average
scores for patients, either at admission (48.2) or discharge (48.1) as noted in Tables 13 and 15.
Table 46: Nurse Health Status, by Hospital
Hospital
1
2
3
4
5
6
Total
58
178
73
80
204
106
699

Mean
SD
Range
50.7
8.9
15.3-62.2
50.3
8.7
17.6-65.2
48.9
10.2
21.6-64.7
5.3
36.9-56.0
53.0
49.1
8.6
22.6-65.4
50.2
8.1
18.9-64.6
50.1
8.5
15.3-65.4
Mental Health Scale

Mean
SD
Range
45.1
12.2
23.7-63.9
48.1
10.0
16.3-64.1
45.9
10.5
18.9-63.8
47.9
9.9
18.7-62.1
47.1
10.5
17.4-62.6
10.4
20.7-63.8
48.2
47.3
10.4
16.3-64.1
Table 48 gives the proportion of nurses in each hospital that scored below the norm for females
in the general US population, and thus was not considered healthy. Only 34.8% of nurses scored
below the population norm, indicating that, in general, nurses are physically healthier than the
general US female population. Nearly half of nurses (49.2%) were categorized as not mentally
202
healthy, which was comparable to the categorization of patients at admission (49.2%) and
discharge (51.9%) as noted in Tables 14 and 16.
Table 47: Nurse Health Status, Percent of SF-12 Scores Less than US Norm for Females, by
Hospital
Hospital
1
2
3
4
5
6
Total
% Not
Physically Healthy
% Not
Mentally Healthy
31.0
34.3
38.4
20.0
39.7
36.8
34.8
53.4
46.1
54.8
47.5
52.0
44.3
49.2
58
178
73
80
204
106
699
Norm for Female3

Physically not healthy: Physical Health Scale < 49.11
Mentally not healthy: Mental Health Scale < 49.42
8.5 Violence at Work

Table 49 presents the prevalence of violence and abuse towards nurses. Among 720 nurses
completing the survey, 24.9% experienced emotional abuse, 13.6% experienced the threat of
assault, and 10.2% experienced physical assault. Hospital 6 reported the highest proportion of
emotional abuse and threats of assault. Hospital 1 reported the highest percentage of physical
assaults. The smallest proportion of nurses who reported emotional abuse and threats of assault
were in Hospital 4.
More than 97% of physical assault or threats of assault were from patients (data not shown).
Table 48: Prevalence of Violence Percent of Nurses Reporting Yes to the Items in the Table,
by Hospital
Hospital
Physical Assault
Threats of Assault
Emotional Abuse
Number of cases
1
3.4
8.5
25.4
59
2
10.8
15.7
17.4
184
3
11.0
13.9
27.4
73
4
2.4
5.9
25.9
85
5
13.8
13.9
26.8
209
6
11.8
18.2
30.9
110
Total
10.2
13.6
24.9
720
Note: Statistically significant for physical assault (2=12.1, df=5, p<0.05), but not for threat assault or emotional
abuse.
The sources of emotional abuse varied as evidenced in Table 50. The major source of emotional
abuse was from patients (31.1%), followed by abuse from other nurses (21.5%), and then from
physicians or patients families.
203
Table 49: Source of Emotional Abuse, by Hospital

Hospital
Patient
Family
MD
Nurse
Any two combined
Any three combined
Any four combined
Number of cases
1
33.3
0.0
0.0
26.7
33.3
6.7
0.0
15
2
28.1
12.5
12.5
28.1
12.5
3.1
3.1
32
3
26.3
15.8
26.3
10.5
15.8
5.3
0.0
19
4
22.7
13.6
13.6
36.4
13.6
0.0
0.0
22
5
33.9
10.7
19.6
17.7
7.1
7.1
3.6
56
6
36.4
9.1
15.2
15.2
18.2
3.0
0.0
32
Total
31.1
10.7
15.8
21.5
14.1
4.5
1.7
176
9. System Outcomes
9.1 Quality of Care
Table 53 presents the quality of care and likelihood that tasks are delayed or accomplished.
Quality of nursing care is shown as the percent of nurses reporting fair/poor care delivered to
patients; quality of patient care is shown as the percent of nurses reporting quality of care
deteriorated.
Hospital 1 reports an overall high level of tasks not done or delayed whereas Hospital 4 tends to
report low levels in almost all categories. When faced with a shortage of time, different decisions
appear to be made about which tasks can be left undone or delayed. Nurses are more likely to
complete tasks that are ordered by physicians such as vital signs, medication, and dressings.
We hypothesize that delayed actions can also have negative consequences in terms of patient
clinical outcomes, patient satisfaction, and system costs.
204
Table 50: Quality Issues Percent of Nurses Reporting Yes to Items in the Table, by Hospital
Hospital
Quality of Care
Number of Cases
Nursing Care: Fair/Poor
Care Delivered
Patient Care: Quality of Care
Deteriorated
Not Done
Number of Cases
Care Plan*
Comforting/Talking
Back/Skin Care
Oral Hygiene
Pt/Family Teaching
Documentation
Mobilization/Turns
Discharge Prep
VS/Meds/Dressings
Mean # Tasks Not Done
Delayed
Number of Cases
VS/Meds/Dressings
Mobilization/Turns
Call bell Response
PRN pain meds
# Tasks Delayed
Total
56
182
73
85
209
109
714
31.0
10.9
20.5
10.6
8.1
15.5
13.4
58.9
40.1
61.6
15.3
39.7
47.7
41.9
58
84.6
62.1
43.1
60.3
46.6
42.1
19.0
25.9
6.9
3.19
184
64.9
34.8
27.2
41.8
18.6
31.5
13.0
13.7
5.4
1.97
73
57.6
45.2
31.5
31.5
26.0
28.8
13.7
12.3
2.7
2.35
86
37.6
25.6
23.3
12.8
18.6
15.1
9.3
7.0
3.5
1.52
210
42.9
35.7
32.9
17.1
20.0
11.4
6.2
10.5
1.0
1.78
111
51.8
44.1
36.0
22.5
27.0
20.7
27.0
4.5
7.2
2.38
722
48.2
38.6
31.4
28.7
23.3
22.6
13.3
11.4
4.0
2.06
58
51.7
17.2
53.4
37.9
1.58
184
40.8
40.2
20.7
13.9
1.14
73
47.9
35.6
30.1
31.5
1.43
86
24.4
20.9
19.8
14.0
.79
210
28.6
27.1
25.2
9.0
.90
111
43.2
31.5
23.4
17.1
1.14
722
37.3
30.5
25.9
16.6
1.09
*For care plan, the valid number of cases is low for Hospitals 1 (N=13), 2 (N=37) and 3 (N=59).
Note: Items are sorted by percent in the Total column
9.1 Absenteeism
The Nurse Survey asked: In the past year: a) On how many occasions (episodes) have you
missed work due to illness/disability? b) How many shifts have been missed due to
illness/disability?
Table 51 shows that the total number of missed work episodes from the six survey hospitals was
1,768. Individual nurses missed from 1 to 56 episodes (data not shown). Of the 683 nurses who
reported missed occasions in the past year, 42.9% missed 1-2 episodes, 25.2% missed 3-4
episodes, and 15.5% missed more than four episodes. Another 16% indicated nil work episodes
missed.
Once the number of episodes was grouped into four categories, the pattern of distribution varied
amongst hospitals. Hospitals 6, 2, 3, and 1 had the largest proportions in order of ascending
categories from 0 episodes to >4 episodes.
On average, Hospital 6 averaged the highest missed shifts per episode (3.71; SD=7.7) shifts.
205
Table 51: Absenteeism Percent of Episodes Absent and Mean Shifts per Episode in the Past
Year, by Hospital
Hospital
1
2
3
4
5
6
Total
Total #
episodes
226
382
172
252
513
225
1768
%0
episodes
% 1-2
episodes
% 3-4
episodes
%>4
episodes
57
174
71
81
193
107
683
8.8
14.4
19.7
18.5
14.5
23.4
16.4
31.6
53.4
32.4
45.7
41.5
39.3
42.9
24.6
24.1
35.2
22.2
22.8
27.1
25.2
35.1
8.0
12.7
13.6
21.2
10.3
15.5
N
49
145
56
57
162
78
547
Mean (SD)
shifts/episode
1.61 (0.90)
2.47 (4.58)
2.31 (2.77)
1.39 (0.61)
2.41 (5.32)
3.71 (7.70)
2.42 (4.85)
Table 52 presents the common reasons for nurse absenteeism. The primary reason was physical
illness (71.4%). Other reasons were mental health days and injury. Nurses at Hospitals 2 and 3
indicated physical illness most frequently, while Hospital 1 nurses tended to report mental health
day, injury, and other.
Table 52: Absenteeism Most Common Reason to Miss Work in the Past Year, by Hospital
Hospital
1
2
3
4
5
6
Total
N
56
167
63
73
194
94
647
% Physical
illness
50.0
77.8
77.8
72.6
73.2
63.8
71.4
% Mental
health day
12.5
5.4
4.8
4.1
4.1
5.3
5.4
% Injury
% Other
8.9
4.8
3.2
2.7
4.1
6.4
4.8
28.6
12.0
14.3
20.5
18.6
24.5
18.4
9.2 Intent to Leave

Table 46 shows the percent of nurses who expected to lose their job or intended to leave within
the next 6 months. Hospital 1 nurses not only reported the highest levels of dissatisfaction with
their current job (Table 45), but also the highest levels of intent to leave. Surprisingly, nurses in
this hospital were most likely to expect difficulties in finding a new job. Hospital 5 had the
highest percent of nurses expecting to lose their jobs, while not a single nurse in Hospital 1
expected to lose theirs in the next 12 months.
Table 53: Intent to Leave Percent of Nurses Reporting Yes to the Items in the Table, by
Hospital
Hospital
Number of Cases
Expect to lose job
Plan to Leave 6 months
Difficult finding job
1
58
0
10.3
14.0
2
186
1.6
3.8
1.6
3
74
2.7
6.8
2.8
4
86
3.5
3.5
2.3
5
207
12.1
5.3
10.6
6
110
5.5
3.6
3.6
Total
721
5.4
5.0
5.7
206
References
1. Karasek, R. & Theorell, T. (1990). Healthy Work: Stress, Productivity, and the Reconstruction
of Working Life. New York: Basic Books, Inc., Publishers.
2. Martin, K. S., & Scheet, N. J. (1992). The OMAHA System: Application for Community Health
Nursing. Philadelphia, PA: WB Saunders.
3. Ware, J., Kosinski, M. & Keller, S. (2002). SF-12: How to Score the SF-12 Physical and
Mental Health Summary Scales. Fourth Edition, QualityMetric Incorporated, Lincoln,
Rhode Island, and Health Assessment Lab, Boston, Massachusetts.
4. Canadian Institute for Health Information. (2003). Workforce Trends of Registered Nurses in
Canada, 2002. Ottawa, ON: Author.
5. OBrien-Pallas, L., Thomson, D., Alksnis, C., Luba, M., Pagniello, A., Ray, K. L., & Meyer,
R. (2003). Stepping to Success and Sustainability: An Analysis of Ontario's Nursing
Workforce. Toronto, ON: Nursing Effectiveness, Utilization, and Outcomes Research
Unit, University of Toronto.
6. Chagnon, M., Audette, L. M., Lebrun, L., & Tilquin, C. (1978). Validation of a patient
classification through evaluation of the nursing staff degree of occupation. Medical Care,
16(6), 465-475.
207

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Evidence Based Standards For Measuring Nurse Staffing and Performance

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Evidence-based Standards for Measuring Nurse

Staffing and Performance

Key Implications for Decision Makers

Maximum productivity/utilization is 93 percent (because seven percent of the shift is

Productivity/Utilization targets can be met by enhancing nurse autonomy, reducing

Patient Care Delivery Model.......................................................................................84

Instruments, Psychometric Properties, and Variables at Individual and Unit

Data Collection Forms................................................................................................124

Table 1. Productivity/Utilization Levels and Associated Outcomes

Although the Canadian Institute for Health Information defines productivity/utilization as

among nurses. As length of stay increased and as unit productivity/utilization exceeded 90

Appendix A. Annotated Bibliography

System Characteristics and Behaviours

Discharge planning model

Perceived learning needs

Patients having their first myocardial infarction

Predictive model of risk of major complications

Variable affecting length

Direct relationships between longer length of

For every area of discharge planning the nurse

Impact of high effort, low

10. Shih, Chu,

Effort & reward

Those with fewer social supports were at

Turning points included events, nursing actions,

16. Coutts (2001)

When nurses are more independent & have

Comparison of lowback pain in female

Summary report from

Increase in acuity in hospitals means that RNs

Strong associations between poor psychosocial

Female nursing personnel had no increased risk

22. Aiken, Clarke,

System Characteristics and Behaviours

Nurse staffing &

24. Arthur, James

23. Aiken, Clarke,

210 adult general

Staffing mix, type

Higher proportion of RNs resulted in fewer

Various approaches to nurse demand methods:

In hospitals with high patient-to-nurse ratios,

28. Brown (2001)

Fiscal year 1993.

Nurse staffing: All

Several patient outcomes were significantly

When the proportion of RNs in the staff mix

A larger proportion of care delivery by RNs

Using case mix group

Reasons for the CNA

798 patients &

Jan. 1996 Dec.

692 very low

1st wave Nov.

Regression analysis showed that there was no

Overall hospital mortality rate of 12% (80 out

Strong ratios will help reduce the nursing

Cost associated with

35. Clark (2002)