Date of Award

2014

Degree Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Graduate Group

Nursing

First Advisor

Matthew D. McHugh

Abstract

Health disparities are exacerbated by low quality care at hospitals serving economically disadvantaged patients. The organizational resources available to nurses, including appropriate levels of nurse staffing and a positive practice environment, are strongly associated with care quality, as well as nurse and patient outcomes. However, little is known about the influence of differences in organizational resources for nurses as an explanatory factor for the disparities in quality of care observed between hospitals that disproportionately serve economically disadvantaged and those that do not. To address this gap, we conducted a secondary analysis linked data from payers, hospitals, neighborhoods, nurses and patients to evaluate whether differences in nurse work environments and nurse staffing levels accounted for the hospital-level quality of care disparities based on the level of economic disadvantage of the population served by the hospital. Using a national sample of 3,782 hospitals, commonly-utilized hospital classification measures were compared, to determine which measure best represented the economic disadvantage of hospital patient populations. Using a measure reflecting the proportion of patients from high-poverty ZIP codes, nursing resources and nurse and patient outcomes were examined at a subset of hospitals in 4 states.

Lower levels of nursing resources in hospitals serving the economically disadvantaged were associated with poorer outcomes for patients, including lower levels of quality, safety and satisfaction, as well as poorer outcomes for nurses, including higher levels of job dissatisfaction, burnout and intention to leave. Compared to low-poverty hospitals, nurses at high-poverty hospitals reported less favorable nurse work environments (mean score: 2.62 vs. 2.77, p<0.000) and staffing levels (patients per nurse: 5.34 vs. 4.92, p=0.002) and were more likely to report dissatisfaction (28.2% vs. 24.4% respondents, p=0.033), intention to leave (19.8% vs. 14.7% respondents, p=0.001) and emotional exhaustion (35.8% vs. 31.7% respondents, p=0.027). In models adjusted for hospital characteristics, the percentage of nurses reporting "excellent" quality care and "grade A" safety decreased by 6% and 4.4% respectively for every 10% increase in the proportion of patients in poverty. The percentage of patients rating the hospital "9" or "10" and "definitely recommend[ing]" the hospital decreased by 1.7% and 3.1% respectively. In linear regression models adjusting for differences in nurse staffing, education and work environment, the magnitude of these effects decreased by 40-100%. This study confirms that hospitals serving a high proportion of economically disadvantaged patients have including higher levels of job dissatisfaction, burnout and intention to leave for nurses and lower levels of quality, safety and satisfaction for patients. With an explicit focus on organizational resources and the utilization of a unique dataset, this study offers an actionable solution--investment in improvement of the nurse work environment and hiring of additional nurses--which may improve hospital-based health disparities.

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