Nurses’ Perception of Nurses’ Perception of StaffingStaffingand Resource Adequacy: and Resource Adequacy: Does Does Job Design Make a Job Design Make a Difference?Difference?Kamisha Hamilton Escoto, PhDKamisha Hamilton Escoto, PhD

University of MinnesotaUniversity of Minnesota

Ben-Tzion Karsh, PhD (University of Wisconsin-Ben-Tzion Karsh, PhD (University of Wisconsin-Madison)Madison)Matthew Scanlon, MD (Children’s Hospital of Matthew Scanlon, MD (Children’s Hospital of Wisconsin)Wisconsin)Neal Patel, MD (Vanderbilt Children’s Hospital)Neal Patel, MD (Vanderbilt Children’s Hospital)Theresa Shalaby, RN (Vanderbilt Children’s Theresa Shalaby, RN (Vanderbilt Children’s Hospital)Hospital)Kathleen Murkowski, CRT (Children’s Hospital of Kathleen Murkowski, CRT (Children’s Hospital of Wisconsin)Wisconsin)Rainu Kaushal, MD, MPH (Brigham and Women’s Rainu Kaushal, MD, MPH (Brigham and Women’s Hospital)Hospital)Judy Arnold, RN (Vanderbilt Children’s Hospital)Judy Arnold, RN (Vanderbilt Children’s Hospital)

BackgroundBackground

Consequences of nurse staffing levels Consequences of nurse staffing levels (Aiken et al., 2002; Lang et al., 2004, Mark et al., 2004)(Aiken et al., 2002; Lang et al., 2004, Mark et al., 2004)

Patient outcomes: inpatient mortality, Patient outcomes: inpatient mortality, failure to rescuefailure to rescue

Nurse outcomes: burnout, dissatisfactionNurse outcomes: burnout, dissatisfaction Hospital: length of stayHospital: length of stay

Trends in nurse staffing Trends in nurse staffing (Bond et al., 2000; (Bond et al., 2000;

Buerhaus & Staiger, 1999) Buerhaus & Staiger, 1999) not necessarily not necessarily aligned with perception of staffing aligned with perception of staffing levels levels (Aiken et al., 2000)(Aiken et al., 2000)

Why is Why is perceptionperception of of adequate staffing adequate staffing

important?important? Staffing perceptions associated with…Staffing perceptions associated with…

Job satisfaction, organizational and Job satisfaction, organizational and professional commitmentprofessional commitment (DeGroot et al.., 1998)(DeGroot et al.., 1998)

Lower perception of quality of care at the Lower perception of quality of care at the hospital level, quality of nursing care on the hospital level, quality of nursing care on the last shiftlast shift (McCusker et al., 2004),(McCusker et al., 2004), and perception of and perception of own ability to provide quality careown ability to provide quality care (Escoto & Karsh, (Escoto & Karsh, 2006; Williams, 1998)2006; Williams, 1998)

Nurse safety outcomesNurse safety outcomes (e.g., needlestick (e.g., needlestick injuries) injuries) (Clarke et al., 2002)(Clarke et al., 2002)

Despite importance of staffing Despite importance of staffing perceptions there has been little perceptions there has been little exploration of its predictors in the exploration of its predictors in the literatureliterature (e.g., Mark, 2004)(e.g., Mark, 2004)

Staff/resource adequacy (SRA)

Task controlResource controlSkill discretion

Social supportNurse-physician

relationsFeedback

Job Demands

What are the predictors of What are the predictors of perception of staffing/resource perception of staffing/resource

adequacy?adequacy?Model based on the literature (Kramer & Schmalenberg,

2002; Kramer et al., 2004) and Demand-Control-Support theory of job design (Karasek, 1979; Johnson & Hall, 1988)

MethodsMethods Analysis of data from a larger study of Analysis of data from a larger study of

working conditions, outcomes, and working conditions, outcomes, and technology with pediatric nursestechnology with pediatric nurses

Design: Cross-sectional, survey designDesign: Cross-sectional, survey design Sample:Sample:

Free-standing, academic pediatric hospital Free-standing, academic pediatric hospital with 222 beds and 9 inpatient unitswith 222 beds and 9 inpatient units

Staff nurses employed in 3 unitsStaff nurses employed in 3 units Pediatric Intensive Care Unit Pediatric Intensive Care Unit Medical/Surgical Medical/Surgical Hematology-Oncology-Transplant Hematology-Oncology-Transplant

Statistical AnalysisStatistical Analysis Data preparation for regression analysesData preparation for regression analyses

Factor analysis Factor analysis Reliability (Cronbach’s Reliability (Cronbach’s ))

Descriptive statistics & Bivariate Descriptive statistics & Bivariate correlationcorrelation

Two regression modelsTwo regression models Block 1. DemographicsBlock 1. Demographics Block 2. Job demandsBlock 2. Job demands Block 3. Control VariablesBlock 3. Control Variables Block 4. Support VariablesBlock 4. Support Variables Block 5. Interactions Block 5. Interactions

Model 1: Control variables x Job demandsModel 1: Control variables x Job demands Model 2: Support variables x Job demandsModel 2: Support variables x Job demands

Characteristics of the nursing Characteristics of the nursing samplesample

Characteristic N (%)

Unit Pediatric Intensive Care Unit (PICU)

65 (54.2%)

Medical/Surgical 32 (26.7%)

Hematology-Oncology-Transplant

23 (19.2%)

Age 18-29 years 40 (33.3%)

30-39 years 38 (31.7%)

40-49 years 30 (25.0%)

50 years and older 12 (10.0%)

Education Bachelor’s degree 100 (83.3%)

Graduate degree 11 (9.2%)

Associate’s degree or Diploma 9 (7.5%)

Racial background White 115 (95.8%)

Non-white 5 (4.2%)

Gender Female 117 (97.5%)

Male 3 (2.5%)

Experience 11.6 years (Range 3 mo – 36 years)N=120, Response rate =

59.1%

Results - Descriptive Results - Descriptive StatisticsStatistics

Scale (# items) Mean

SD Range Cronbach

Job demands (3) 4.44 0.80 2.3 - 6.0 0.65

Task control (4) 3.43 1.10 1.25 – 6.0 0.77

Resource control (2) 2.34 1.28 0.0 – 6.0 0.92

Skill discretion (1) 3.80 1.29 1.0 - 6.0 -

Social support (4) 4.18 0.93 0.67 – 6.0 0.72

Nurse-physician relations (3)

4.07 1.02 2.0 – 6.0 0.89

Feedback (3) 3.59 1.09 1.0 - 6.0 0.79

Staffing/resource adequacy (4)

3.49 0.84 1.0 – 5.0 0.84

Response scale for all variables ranged from “0” (not at all) – “6” (a great deal)

Regression of SRA on job design variables, Regression of SRA on job design variables, N=120N=120

SourceSource RR22 RR22 changechange

PP BetaBeta

DemandsDemands

--Job demands (D)--Job demands (D)0.1700.170 0.1310.131 <0.001<0.001

-0.443**-0.443**

ControlControl

----Task control (TC)Task control (TC)

--Resource control --Resource control (RC)(RC)

--Skill discretion (SD)--Skill discretion (SD)

0.3460.346 0.1760.176 <0.001<0.001

0.0200.020

0.0770.077

0.116*0.116*

SupportSupport

--Social support--Social support

--Nurse-physician --Nurse-physician relationsrelations

--Feedback--Feedback

0.5010.501 0.1550.155 <0.001<0.001

0.0940.094

0.267**0.267**

0.141*0.141*

Job demands x control Job demands x control

--TC x D--TC x D

--RC x D--RC x D

--SD x D--SD x D*p<0.05; **p<0.01 . Beta values are from the final regression equation; [F(17, 102)=7.944, p<0.001] Model is adjusted for unit, gender, ethnicity, education and years of nursing experience.

Not significant

SourceSource RR22 RR22 changechange

PP BetaBeta

DemandsDemands--Job Demands (D)

0.1700.170 0.1310.131 <0.001<0.001

-0.437**-0.437**

ControlControl

----Task control Task control

--Resource control--Resource control

--Skill discretion--Skill discretion

0.3460.346 0.1760.176 <0.001<0.001

0.0100.010

0.0600.060

0.142**0.142**

SupportSupport

--Social support (SS)--Social support (SS)

--Nurse-physician --Nurse-physician relations (NP)relations (NP)

--Feedback (F)--Feedback (F)

0.5010.501 0.1550.155 <0.001<0.001

0.0740.074

0.266**0.266**

0.153**0.153**

Job demands x Job demands x supportsupport

--SS x D--SS x D

--NP x D--NP x D

--F x D--F x D

0.5220.522 0.0210.021 0.0560.056

-0.220*-0.220*

0.0820.082

0.1160.116*p<0.05; **p<0.01. Beta values are from the final regression equation [F(17, 102)=8.656, p<0.001] Model is adjusted for unit, gender, ethnicity, education and years of nursing experience.

Regression of SRA on job design Regression of SRA on job design variables, N=120variables, N=120

Interaction – Job demands & Interaction – Job demands & Social supportSocial support

ConclusionsConclusions Improving conditions of work as important as Improving conditions of work as important as

determining optimal levels of nurse staffingdetermining optimal levels of nurse staffing Interventions supporting freedom to be Interventions supporting freedom to be

creative, feedback mechanisms, and creative, feedback mechanisms, and collaboration between nurses and physicians collaboration between nurses and physicians are essentialare essential

Social support may help alleviate burden on Social support may help alleviate burden on nurses, but at high demand levels may be nurses, but at high demand levels may be counterproductivecounterproductive

LimitationsLimitations Cross-sectional designCross-sectional design Scale measurement (job control variables)Scale measurement (job control variables) External validityExternal validity

AcknowledgmentsAcknowledgments This research was supported by AHRQ-1 R01 This research was supported by AHRQ-1 R01

HS013610 (Bar Coding and Employee and Patient HS013610 (Bar Coding and Employee and Patient Safety)Safety)

Bar Coding and Employee and Patient Safety Bar Coding and Employee and Patient Safety Research TeamResearch Team Dr. Ben-Tzion Karsh (University of Wisconsin, Madison)Dr. Ben-Tzion Karsh (University of Wisconsin, Madison) Samuel Alper (University of Wisconsin, Madison)Samuel Alper (University of Wisconsin, Madison) Judy Arnold (Vanderbilt Children’s Hospital)Judy Arnold (Vanderbilt Children’s Hospital) Dr. Patricia Brennan (University of Wisconsin, Madison)Dr. Patricia Brennan (University of Wisconsin, Madison) Dr. Roger Brown (University of Wisconsin, Madison)Dr. Roger Brown (University of Wisconsin, Madison) Richard Holden (University of Wisconsin, Madison)Richard Holden (University of Wisconsin, Madison) Dr. Rainu Kaushal (Brigham and Women's Hospital)Dr. Rainu Kaushal (Brigham and Women's Hospital) Kathy Murkowski (Children’s Hospital of Wisconsin)Kathy Murkowski (Children’s Hospital of Wisconsin) Dr. Neal Patel (Vanderbilt Children’s Hospital)Dr. Neal Patel (Vanderbilt Children’s Hospital) Dr. Matt Scanlon (Children’s Hospital of Wisconsin)Dr. Matt Scanlon (Children’s Hospital of Wisconsin) Kathleen Skibinski (University of Wisconsin-Madison)Kathleen Skibinski (University of Wisconsin-Madison)

Questions?Questions?

VariablesVariables

CATEGORY

VARIABLE ITEMS BASED ON…

Demands Job demands Karasek, 1979

Control Task control McLaney & Hurrell, 1988

Resource control McLaney & Hurrell, 1988

Skill Discretion Karasek, 1979

Support Social support Caplan et al., 1975

Nurse-physician relations

Aiken & Patrician, 2000

Feedback Sims et al., 1976

Dependent variable

Staff/resource adequacy (SRA)

Aiken & Patrician, 2000Response scale for all variables ranged from “0” (not at all) – “6” (a great deal)

Staffing/resource Staffing/resource adequacyadequacy

To what extent is there enough staff to get To what extent is there enough staff to get the work done?the work done?

To what extent are there enough nurses To what extent are there enough nurses on staff to provide quality patient care?on staff to provide quality patient care?

To what extent is there enough time and To what extent is there enough time and opportunity to discuss patient care opportunity to discuss patient care problems with other nurses?problems with other nurses?

To what extent are there adequate To what extent are there adequate support services to allow you to spend support services to allow you to spend time with your patients?time with your patients?

Nurse-phys relationsNurse-phys relations

How much teamwork exists between How much teamwork exists between nurses and physicians?nurses and physicians?

How much collaboration exists How much collaboration exists between nurses and physicians?between nurses and physicians?

To what extent do nurses and To what extent do nurses and physicians have good working physicians have good working relationships? relationships?

Task controlTask control

How much influence do you have over How much influence do you have over the variety of tasks you perform?the variety of tasks you perform?

How much influence do you have over How much influence do you have over the order in which you perform tasks the order in which you perform tasks at work?at work?

How much influence do you have over How much influence do you have over the amount of work you do?the amount of work you do?

How much influence do you have over How much influence do you have over the pace of your work—that is, how the pace of your work—that is, how fast or slow you work?fast or slow you work?

Resource controlResource control

How much influence do you have How much influence do you have over the availability of supplies and over the availability of supplies and equipment you need to do your equipment you need to do your work?work?

How much influence do you have How much influence do you have over the availability of materials you over the availability of materials you need to do your work?need to do your work?

Social supportSocial support

How much do other people at work go out How much do other people at work go out of their way to make your life easier?of their way to make your life easier?

How easy is it to talk with other people at How easy is it to talk with other people at work?work?

How much can you rely on other people How much can you rely on other people at work when things get tough at work?at work when things get tough at work?

How much are other people at work How much are other people at work willing to listen to your personal willing to listen to your personal problems?problems?

Job demandsJob demands

To what extent does your job require To what extent does your job require you to work hard?you to work hard?

To what extent does your job require To what extent does your job require a great deal to be done?a great deal to be done?

To what extent do you feel there is To what extent do you feel there is not enough time for you to finish not enough time for you to finish your work?your work?

Skill discretionSkill discretion

• To what extent does your job To what extent does your job require creativity?require creativity?

FeedbackFeedback

To what extent do you find out how To what extent do you find out how well you are doing on the job as you well you are doing on the job as you are working?are working?

To what extent do you have the To what extent do you have the opportunity to find out how well you opportunity to find out how well you are doing on your job?are doing on your job?

To what extent do you know if you To what extent do you know if you are performing your job well or are performing your job well or poorly?poorly?