Human capital in the nursing workforce and its impact on patient outcomes
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Human Capital in the Nursing Workforce and Its Impact on Patient Outcomes. Ciaran S. Phibbs, Ph.D. June 2, 2007. Research Team. Investigators Ann Bartel Patricia Stone Nancy Beaulieu Programmers and Research Assistants Lakshmi Ananath Cecilia Machado Susan Schmitt Andrea Shane.

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Human capital in the nursing workforce and its impact on patient outcomes

Human Capital in the Nursing Workforce and Its Impact on Patient Outcomes

Ciaran S. Phibbs, Ph.D.

June 2, 2007


Research team
Research Team Patient Outcomes

  • Investigators

  • Ann Bartel

  • Patricia Stone

  • Nancy Beaulieu

  • Programmers and Research Assistants

  • Lakshmi Ananath

  • Cecilia Machado

  • Susan Schmitt

  • Andrea Shane

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Background
Background Patient Outcomes

  • Relationship between hospital nurse staffing and quality of care is a significant concern for health services researchers, health services providers and policymakers.

  • Prior research has found evidence showing negative correlation between adverse patient outcomes and nurse staffing levels, but this literature has numerous limitations.

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What our paper contributes
What Our Paper Contributes Patient Outcomes

  • Unit-level data

  • Monthly observations

  • Longitudinal 4 years.

  • Data from a single organization (VA).

  • Adds role played by human capital and relational capital in the nursing workforce

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Hypotheses we test
Hypotheses We Test Patient Outcomes

  • RNs with more general human capital (education, experience) deliver higher quality nursing care

  • RNs with more firm-specific human capital (job tenure) deliver higher quality nursing care

  • Relational capital (stability of nursing team) contributes to higher quality care because stable teams are better at sharing tacit knowledge and facilitating coordination.

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Nurse staffing data
Nurse Staffing Data Patient Outcomes

  • DSS, VA’s implementation of TSI, a comprehensive hospital activity based accounting system.

  • Inpatient nursing labor tracked at the unit level.

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Nurse staffing data1
Nurse Staffing Data Patient Outcomes

  • Monthly extract that reports the number of hours, for each type of nursing labor, including:

    • RNs

    • LVNs

    • Aides

    • Advanced practice nurses

    • Others

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Nurse staffing data2
Nurse Staffing Data Patient Outcomes

  • Hours worked and costs reported separately for “regular” hours, overtime, and vacation/sick/holiday hours. Thus, we can track nursing labor by the actual hours worked, not the hours nurses were paid.

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Human capital data
Human Capital Data Patient Outcomes

  • We extracted human capital and other nursing characteristics from the VA payroll data (PAID). These data contain a wealth of information, including VA tenure, education, and age.

  • PAID also reports hours of overtime and shift premiums (track off-shift labor).

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Human capital data1
Human Capital Data Patient Outcomes

  • DSS tracks where people work to allocate costs.

  • DSS made a special extract for us that summarized, by PAID codes, how all nursing labor was allocated across units, for each facility.

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Patient data
Patient Data Patient Outcomes

  • Unlike most discharge abstracts, VA has a “bedsection” file, with one record for each bedsection stay, which are defined by the treating specialty of the physician. ICUs are separate bedsections.

    • Thus, most, but not all, unit stays have a corresponding bedsection record.

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Empirical model
Empirical Model Patient Outcomes

  • PSIit = α1(RN Hrs PPD)it + α2(RN Hrs PPD2 )it +

  • α3 HCit + α4 Non-RN Hours PPDit + α5DRGit + α6AGEit + α7 LOSit + α8Dischargesit +

  • Year + λi + εit

  • HC is measured by percentage of RN hours provided by RNs with at least a B.S. degree, RN age (“experience”), RN tenure, and percentage of RN hours provided by part-time RNs.

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Summary statistics
Summary Statistics Patient Outcomes

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2006 average rate of failure to rescue by icu bed section
2006 average rate of failure to rescue, by ICU bed section Patient Outcomes

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2006 average rate of infection by icu bed section
2006 average rate of infection, by ICU bed section Patient Outcomes

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Preliminary findings
Preliminary Findings Patient Outcomes

  • General human capital (education) is negatively correlated with the rate of infections due to medical care

  • Specific human capital (job tenure) is negatively correlated with the rate of infections due to medical care and rate of failure to rescue. The former correlation holds even controlling for nursing-unit fixed effects.

  • Data are only for intensive-care units and results are likely to be a lower bound on effects for more diverse units.

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Summary of ols results human capital variables
Summary of OLS Results: Human Capital Variables Patient Outcomes

  • General human capital (education) is negatively correlated with the rate of infections

  • Specific human capital (tenure) is negatively correlated with the rate of infections. A one standard deviation increase in RN tenure is associated with a 19% decrease in rate of infections

  • Specific human capital (tenure) and failure to rescue are negatively correlated (though less robust). A one standard deviation increase in RN tenure is associated with a 4% decrease in failure to rescue rate.

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Summary of ols results other variables
Summary of OLS Results: Other Variables Patient Outcomes

  • RN staffing has a negative but diminishing effect on infection rate, and is negatively correlated with failure to rescue rate

  • Non-RN hours has no effect

  • Very low patient volume is associated with higher failure to rescue rate

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Summary of fixed effects results
Summary of Fixed Effects Results Patient Outcomes

  • RN tenure negatively correlated with rate of infections and the measured impact is more than twice as large as the OLS effect.

  • RN tenure is insignificant in failure to rescue equation.

  • RN education is insignificant in both equations.

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Plans for future work
Plans for Future Work Patient Outcomes

  • Expand sample to include all acute-care units

  • Control for prior experience of RNs

  • Control for union membership

  • Study other measures of health care quality such as 30-day mortality rate, re-admission rates and patient-assessed quality of care

  • Add more information about human capital, especially for off-shifts

  • Add information from RN satisfaction survey

  • Construct measures of team stability to study relational capital

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Patient data1
Patient Data Patient Outcomes

  • 88% of the acute bedsection records link to only 1 IPD stay.

    • 437,465 acute hospitalizations in FY 06

    • 54,323 had more than 1 IPD stay mapped to the same bedsection stay

      • 94% of these had 2 IPDs

      • 5.7% had 3 IPDs

      • 0.3% had 4 or 5 IPDs

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Correlations
Correlations Patient Outcomes

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Rate of infections ols regressions
Rate of Infections, OLS Regressions Patient Outcomes

Notes: N=2866 in columns (1) through (4). N=2821 in column 5. All regressions include dummy variables

for quartiles of the number of discharges and year dummy variables.

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Failure to rescue rate ols regressions
Failure to Rescue Rate, OLS Regressions Patient Outcomes

Notes: N=2673 in columns (1) through (4); N=2631 in column (5). All regressions include dummy variables for quartiles of discharges and dummy variables for years.

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Rate of infections fixed effects
Rate of Infections Fixed Effects Patient Outcomes

Notes: N=2866 in columns (1) through (4). N=2821 in column (5). All regressions include dummy variables for quartiles of discharges and dummy variables for years.l

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Failure to rescue rate fixed effects
Failure to Rescue Rate, Fixed Effects Patient Outcomes

Notes: N=2673 in columns (1) through (4). N=2631 in column (5). All regressions include dummy variables for quartiles of discharges and dummy variables for years.

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