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Linking RN Workgroup Job Satisfaction to Pressure Ulcers Among Older Adults on Acute Care Hospital Units

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Linking RN Workgroup JobSatisfaction to Pressure UlcersAmong Older Adults onAcute Care Hospital Units

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Research in Nursing & Health, 2013, 36, 181–190

Linking RN Workgroup Job Satisfaction to Pressure Ulcers Among Older Adults on Acute Care Hospital Units
JiSun Choi,1* Sandra Bergquist-Beringer,1** Vincent S. Staggs2y

1

National Database of Nursing Quality Indicators, University of Kansas School of Nursing, 3901 Rainbow Blvd, MS 3060, Kansas City, KS 2 Department of Biostatistics, University of Kansas Medical Center, Kansas City, KS Accepted 3 January 2013

Abstract: We examined the relationship between registered nurse (RN) workgroup job satisfaction and hospital-acquired pressure ulcers (HAPUs) among older adults on six types of acute care units. Randomintercept logistic regression analyses were performed using 2009 unit-level data from the National Database of Nursing Quality Indicators1 (NDNQI1) and the NDNQI RN Survey. Overall, RN workgroup job satisfaction was negatively associated with HAPU rates, although the relationship varied by unit type. RN workgroup satisfaction was significantly associated with HAPU rates on critical care, medical, and rehabilitation units. No significant association was found on step-down, surgical, and medical-surgical units. Findings provide evidence that higher RN workgroup job satisfaction is related to lower HAPU rates among older adult patients in acute care hospitals. ß 2013 Wiley Periodicals, Inc. Res Nurs Health
36:181–190, 2013

Keywords: RN job satisfaction; nurse-sensitive quality indicator; hospital-acquired pressure ulcers

With ongoing fiscal constraints and increased regulatory scrutiny over hospitalacquired conditions in US acute care hospitals, health care executives and providers are increasingly challenged to keep patients safe. Pressure ulcers are a serious patient safety issue because most are considered reasonably preventable through evidence-based care. Moreover, in 2008, the Centers for Medicare and Medicaid

Services (CMS) stopped reimbursing hospitals for the extra cost of treating hospital-acquired stages III and IV pressure ulcers (CMS, 2008). Preventing pressure ulcer occurrence is now a high priority among acute care facilities. Pressure ulcer prevention requires interdisciplinary team effort and organizational support, but nurses are central to this effort as they provide direct 24-hour patient care, including

Conflict of interest: nothing to declare. This study was conducted under a contract with the American Nurses Association. The authors thank Dr. Nancy Dunton for helpful comments on this manuscript. Correspondence to JiSun Choi *Senior Research Associate. **Associate Professor. y Research Assistant Professor. Published online 13 February 2013 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/nur.21531

ß 2013 Wiley Periodicals, Inc.

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skin and pressure ulcer risk assessment and prevention interventions. Hospital nurse job satisfaction has been theoretically linked to better quality of patient care, based on findings that nurses perceived high-quality patient care to be a major influence on their job satisfaction (B. Hayes, Bonner, & Pryor, 2010; Utriainen & ¨ s, 2009). Further, nurses who believed Kynga they provided high-quality care to patients were very satisfied with their careers (Perry, 2005). Yet, little empirical evidence was found to support a relationship between nurse job satisfaction and better patient outcomes or between registered nurse (RN) job satisfaction and hospital-acquired pressure ulcer (HAPU) rates in acute care hospitals. Therefore, we examined the relationship between RN workgroup job satisfaction and HAPU rates among hospitalized older adults on critical care, stepdown, medical, surgical, combined medicalsurgical, and rehabilitation units where RNs provide daily care to patients and serious safety risks may occur. Pressure Ulcers and Job Satisfaction A pressure ulcer is defined by the National Pressure Ulcer Advisory Panel and the European Pressure Ulcer Advisory Panel and (NPUAPEPUAP, 2009) as a ‘‘localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear.’’ Pressure ulcers cause pain (Pieper, Langemo, & Cuddigan, 2009), and are associated with prolonged hospital length of stay (Graves, Birrell, & Whitby, 2005) and increased healthcare costs (Russo, Steiner, & Spector, 2008). Older adults are at high risk for pressure ulcer development during hospitalization (Baumgarten et al., 2006), given the potential for prolonged immobility and likely presence of other comorbid conditions. Considering the growing number of older adult patients in acute care hospitals, it is important to understand patient safety issues in this population. The literature includes a myriad of studies on pressure ulcers among hospitalized adult patients. Major areas of investigation include the identification of patient risk factors for pressure ulcers, the development and validation of pressure ulcer risk assessment scales, and the evaluation of pressure ulcer prevention programs. Although the critical role of RNs in improving patient care quality and safety
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outcomes has long been recognized (Institute of Medicine [IOM], 2003, 2010), relatively few researchers have investigated whether nursing factors such as job satisfaction, nurse staffing, and education are related to pressure ulcers in acute care hospitals (Dunton, Gajewski, Klaus, & Pierson, 2007; Lake & Cheung, 2006). Job satisfaction is integral to nursing practice and significant to health care system outcomes, including nurse and patient outcomes (B. Hayes et al., 2010). Hospital nurses’ job satisfaction repeatedly has been found to be related to their retention (L. J. Hayes et al., 2006), which has raised the question of whether RN job satisfaction affects patient outcomes. Nevertheless, few studies have been conducted to examine the relationship between nurses’ job satisfaction and patient clinical outcomes. In a recent study, the effect of nurse job satisfaction on patient satisfaction was examined at the hospital level (McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011). Results from this multi-state study indicated that RN job satisfaction was significantly associated with patient satisfaction with hospitals. Specifically, patient satisfaction was found to be lower in acute care hospitals with a higher percentage of RNs who reported that they were dissatisfied with their work. Furthermore, nurse job satisfaction varies by hospital unit type. In one study, researchers examined unit-level RN job satisfaction (i.e., RN workgroup job satisfaction) among 10 unit types in 206 US acute care hospitals, and found that RN workgroup job satisfaction varied across different types of units (Boyle, Miller, Gajewski, Hart, & Dunton, 2006). RN workgroups in pediatric, rehabilitation, and outpatient units had the highest level of satisfaction, whereas those in surgical services and emergency departments had the lowest satisfaction. No studies were found, however, in which researchers examined the relationship between RN job satisfaction and patient outcomes at the unit level while accounting for differences in RN workgroup job satisfaction across various unit types. Therefore, more studies are needed to better understand the relationship between RN workgroup job satisfaction and patient outcomes by unit type. Conceptual Model of the Study The study was guided by Donabedian’s framework of quality (1966) that incorporates three

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components of care quality (structure, process, and outcome). In this conceptual framework, the structures of care affect the processes of care, which in turn affect the outcomes of care. For this study, we modified the hypothesized relationships among these three elements of quality to examine the direct relationship between the process of care (RN workgroup job satisfaction) and the outcomes of care (HAPU rates), adjusting for the structures of care (unit and hospital characteristics). Unit and hospital characteristics were considered confounders of the true relationship between RN workgroup job satisfaction and HAPUs and were controlled for in our data analysis. Unit characteristics included in the model represent other nursing factors (nurse staffing, RN education level, and RN unit tenure) shown in previous research to be related to unit-level HAPU rates (Dunton et al., 2007). Although a large body of literature has demonstrated a link between better staffing levels (e.g., higher RN hours per patient day) and positive patient outcomes, such as lower mortality rates, shorter length of stay, and lower fall rates (Kane, Shamliyan, Mueller, Duval, & Wilt, 2007; Unruh, 2008), evidence to support the relationship between staffing levels and pressure ulcers is inconclusive (Lake & Cheung, 2006). In a recent study using unit-level data (Dunton et al., 2007), the observed relationship between nurse staffing and HAPUs was in an unexpected direction; units with higher total nursing hours per patient day reported higher HAPU rates. Among other nursing factors examined in this study (RN education level and RN experience), lower HAPU rates were significantly associated with a higher percentage of RNs with more than 10 years of experience in nursing. Hospital characteristics in this study included Magnet status, teaching status, and bed size. Teaching status and bed size are traditional hospital characteristics examined in patient outcomes research. Magnet status was also included because better patient outcomes, such as lower fall rates, were found in Magnet hospitals compared with non-Magnet hospitals in previous studies (Dunton et al., 2007; Lake, Shang, Klaus, & Dunton, 2010). We hypothesized that RN workgroup job satisfaction was inversely related to the rate of HAPUs among older adults on acute care units when structural characteristics were controlled. We also hypothesized that the relationship between RN workgroup job satisfaction and
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pressure ulcer rates would be different across unit types.

Methods Data Source This study had a cross-sectional, correlational design. Unit-level data from 2009 on pressure ulcers among older adult patients (age 65 and over) and hospital characteristics (bed size, teaching status, and Magnet status) were extracted from the National Database of Nursing Quality Indicators1 (NDNQI1). These data were linked with 2009 NDNQI annual RN Survey data that included RN job satisfaction, RN education level, and RN unit tenure. The NDNQI was established in 1998 by the American Nurses Association (ANA) to provide hospitals with unit-level data on nursing-sensitive quality indicators that reflect the structure, process, and outcomes of nursing care for patient safety and quality improvement purposes (Montalvo, 2007). NDNQI is an accepted nursing registry that meets CMS’s reporting requirement for participation in a clinical database registry for nursing-sensitive care (ANA, 2010). Participating hospitals submit data to the NDNQI either monthly or quarterly, depending on the indicator. Participation is voluntary. NDNQI has grown steadily over time from 35 hospitals to over 1,900 hospitals across the US as of December 2012. The NDNQI is the largest national nursing quality measurement program and provides unit-level performance reports that incorporate national, state, and regional comparison data on 18 nursing-sensitive quality indicators, such as nurse staffing, patient falls, pressure ulcers, and infections. Such unit-level benchmarking data are used by nursing administrators and managers to evaluate nursing performance on patient care units, identify under-performing units, develop unit-specific quality improvement activities, and achieve Magnet recognition. The NDNQI also conducts an annual RN Survey to gather information on RN work attitudes (e.g., job satisfaction) and workforce characteristics (e.g., education and unit tenure) from RNs employed in participating NDNQI hospitals. To be eligible for the Survey, RNs must spend 50% or more of their time providing direct patient care and have been employed on their current unit for at least 3 months. In 2009,

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over 271,000 RNs participated in the survey, with a response rate of 65.2%. Sample The final analytical sample included 3,329 adult care units from 561 NDNQI hospitals. To be eligible for the study, units must have submitted 2009 data on both nurse staffing and pressure ulcers to the NDNQI and participated in the 2009 NDNQI RN survey. We included units that had at least 9 months of data on nurse staffing and at least three quarters of data on pressure ulcers. Only patients age 65 and older were included, as these patients are at higher pressure ulcer risk. Additionally, in order to insure that RNs participating in the RN survey were representative of their RN workgroups, only units with at least five responses and at least a 50% response rate were included in analysis. Measures Quarterly NDNQI data on pressure ulcers were collected at each member hospital by trained staff who visually inspected the skin of patients on each participating unit during a crosssectional survey that was performed on a single designated day. A HAPU was defined as a pressure ulcer of any category/stage (category/stage I to IV, unstageable or suspected deep tissue injury) that developed after admission to the hospital. Previous studies on the reliability of the NDNQI pressure ulcer indicator showed that nurses had moderate to substantial reliability in pressure ulcer staging and, importantly, could accurately differentiate pressure ulcers from other ulcerous wounds (Bergquist-Beringer, Dunton, Gajewski, & Klaus, 2011; Hart, Bergquist, Gajewski, & Dunton, 2006). For this study, an annualized measure of HAPUs among older adult patients was employed. An analytic file of quarterly data on HAPUs was compiled for the year 2009. The total number of older adult patients with a HAPU was computed for each unit and for the year. The annualized HAPU rate for each unit was calculated by dividing the total number of older adult patients with a HAPU during 2009 by the total number of older adult patients surveyed for a HAPU during 2009. The annual NDNQI RN Survey includes a measure of RN workgroup job satisfaction using the NDNQI-adapted Job Enjoyment (JE) scale
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(Taunton et al., 2004). The 7-item JE scale is unique, as the items were adapted to shift the focus from the satisfaction of the individual RN to that of the RNs working in each unit (RN workgroup). An example item is ‘‘nurses with whom I work would say that they are fairly well satisfied with their job.’’ The response option is a 6-point Likert type scale: 1 (strongly disagree) to 6 (strongly agree), with higher scores indicating higher RN workgroup job satisfaction. For this study, the mean JE score for each RN was computed, and these were then averaged across the RNs in each unit to obtain a unit-level score. Psychometric evaluations have established the reliability and validity of the JE scale at both the individual and unit levels (Boyle et al., 2006; Taunton et al., 2004). In the current study, the reliability of the JE scale was evaluated by calculating two intraclass correlation coefficients: ICC(1) and ICC(2). The ICC(1), an index of inter-rater reliability, was 0.20, indicating adequate within-group agreement to aggregate data at the unit level (James, 1982). The ICC(2), an estimate of the mean rater reliability, was 0.86, indicating substantial unit-level reliability (Shrout, 1998). Other explanatory variables considered in the analysis were nursing unit characteristics (nurse staffing, RN education level, and RN unit tenure) and hospital characteristics (bed size, teaching status, and Magnet status). Unit nurse staffing was measured as nursing care hours per patient day (HPPD) and included RN HPPD, licensed practical nurse (LPN) HPPD, and unlicensed assistive personnel (UAP) HPPD. Nursing care hours as defined by NDNQI (2012) are ‘‘the number of productive hours worked by nursing staff (RNs, LPNs, and UAPs) assigned to the unit who have direct patient care responsibilities for >50% of their shift.’’ Nursing staff assigned to the unit included staff employed by the facilities and contracted/agency staff. To compute the RN HPPD, LPN HPPD, and UAP HPPD, nursing care hours provided by RNs, LPNs, and UAPs were divided by the total number of patient days (defined as 24 hours beginning the day of admission and excluding the day of discharge). All three measures were calculated because RN workload may be influenced by the number of LPNs and UAPs in a unit, which may ultimately affect patient outcomes. Because nursing care hours and total number of patient days are reported to NDNQI monthly, all three measures were calculated as an average of the monthly

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HPPD for the year 2009. RN education level was measured as the percentage of RNs on the unit with a bachelor’s degree or higher. RN unit tenure, defined as the length of time an RN has worked on the current unit, was computed as the average tenure (in years) of the RNs on the unit. Hospital bed size, defined as the number of staffed beds, was dichotomized in our analysis (less than 300 beds ¼ 0 vs. 300 beds or greater ¼ 1). Hospital teaching status (teaching hospital ¼ 1 vs. non-teaching hospital ¼ 0) and Magnet status (Magnet ¼ 1 vs. nonMagnet ¼ 0) were also treated as dichotomous explanatory variables. Analysis Descriptive statistics were used to summarize hospital characteristics and study variables (e.g., unit nurse staffing, RN workgroup job satisfaction, and HAPU rates). Random-intercept logistic regression analyses were performed to examine the relationship between RN workgroup job satisfaction and HAPUs among older adult patients at the unit level. The outcome variable, the number of older adult patients with a HAPU among the number of older patients surveyed for a HAPU on each unit, was nonnormally distributed. In addition, the data used for this study were hierarchical (i.e., units were nested within hospitals). Thus, generalized linear mixed modeling was the most appropriate statistical method (Hedeker, Everitt, & Howell, 2005). The number of older adult patients with a HAPU was modeled with a negative binomial distribution. The number of older adult patients assessed for a HAPU was included in the model as an exposure variable so that the dependent variable being modeled was the HAPU rate (the number of patients with a HAPU divided by the number of patients assessed). We included a random hospital intercept in the model to account for clustering of units within hospitals. RN workgroup job satisfaction was the primary predictor of interest, while accounting for the unit (nurse staffing, RN education level, and RN unit tenure) and hospital (bed size, teaching status, and Magnet status) characteristics. First, the model was tested with data from all sample units combined. In this model, unit type was included as a categorical predictor to control for unit differences in patient acuity levels. We then fit the model separately for each of the six unit types (critical care, step-down, medical,
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Table 1. Characteristics of Sample Hospitals and All NDNQI Member Hospitals in 2009 Sample All NDNQI Hospitals, Hospitals, N ¼ 561 (%) N ¼ 1,485 (%) 48.2 51.8 28.9 71.1 63.8 36.2 47.3 52.7 24.0 76.0 72.1 27.9

Characteristics Teaching status Teaching hospital Non-teaching hospital Magnet status Magnet hospital Non-Magnet hospital Staffed bed size Less than 300 beds 300 beds or greater

surgical, combined medical-surgical, and rehabilitation). All data analyses were performed using Stata version 11. Results Sample Characteristics As shown in Table 1, almost half of sample hospitals were teaching hospitals. About one-third of sample hospitals were Magnet hospitals, and about one-third had more than 300 staffed beds. The proportions of Magnet hospitals and large hospitals with more than 300 staffed beds were higher in the sample than across all NDNQI member hospitals in 2009. The sample of units included 729 critical care units, 527 step-down units, 615 medical units, 473 surgical units, 821 combined medical-surgical units, and 164 rehabilitation units. In our sample units, the average age of the 126,032 older adult patients assessed for pressure ulcers was 77 years old, and more than half of these were female (54.9%). The average age of the 77,826 RN survey respondents in the sample units was 38.4, and the average tenure on the unit was 5 years. More than half of the survey respondents (54.5%) had a bachelor’s or higher degree in nursing.

Description of Staffing, Satisfaction, and Hospital-Acquired Pressure Ulcer Rates Descriptive statistics for nurse staffing, RN workgroup job satisfaction, and HAPU rates are presented in Table 2. Overall, most nursing

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Table 2. Nurse Staffing, Registered Nurse (RN) Workgroup Job Satisfaction, and Hospital-Acquired Pressure Ulcers Among Older Adults by Unit Type RN HPPD, M (SD) 15.12 (2.30) 7.65 (1.89) 5.78 (1.39) 5.98 (1.35) 5.77 (1.46) 4.64 (1.21) LPN HPPD, M (SD) .07 (.29) .24 (.52) .35 (.62) .36 (.62) .41 (.68) .69 (.85) UAP HPPD, M (SD) 1.60 (1.21) 2.44 (1.10) 2.48 (.81) 2.43 (.79) 2.50 (.93) 2.90 (1.17) RN Workgroup Job Satisfaction, M (SD) 3.80 (.47) 3.73 (.51) 3.74 (.49) 3.76 (.47) 3.68 (.48) 4.02 (.47) HAPU Ratea, % 9.05 6.14 4.59 4.00 3.85 5.03

Unit Type Critical care Step-down Medical Surgical Med-Surg Rehab

N 729 527 615 473 821 164

RN, registered nurse; LPN, licensed practical nurse; UAP, unlicensed assistive personnel; HPPD, hours per patient day; HAPU, hospital-acquired pressure ulcers; Med-Surg, Combined medical-surgical; Rehab, rehabilitation. Notes. Data source: 2009 NDNQI1 database. a HAPU rate ¼ (the number of older adult patients with a HAPU during 2009/the number of older adult patients surveyed for pressure ulcers during 2009) Â 100.

hours were provided by RNs, followed by UAPs and LPNs. RN HPPD ranged from 4.64 HPPD for rehabilitation to 15.12 HPPD for critical care units. RN workgroup job satisfaction was moderate across all unit types, ranging from an average of 3.68 for combined medical-surgical units to 4.02 for rehabilitation units. The average HAPU rate across all unit types was 5.4%. Annualized HAPU rates were highest on critical care units (9.1%) and lowest on combined medical-surgical units (3.9%).

Predictors of Hospital-Acquired Pressure Ulcers Among Older Adult Patients The results of the random-intercept logistic regression models for HAPUs among older adult patients are presented in Table 3. In the model with all sample units, RN workgroup job satisfaction was significantly and inversely associated with the likelihood of HAPU while controlling for the other explanatory variables. For critical care, medical, and

Table 3. Odds Ratios for Hospital-Acquired Pressure Ulcers Among Older Adults in Random-Intercept Logistic Regression Models All Sample Units Critical Step-Down Medical Surgical Med-Surg Rehab (n ¼ 3,329) (n ¼ 729) (n ¼ 527) (n ¼ 615) (n ¼ 473) (n ¼ 821) (n ¼ 164) .98ÃÃ 1.05Ã 1.14Ã 1.02 1.00 .97Ã .81Ã 1.27Ã 1.05 Referent .69Ã .57ÃÃ .55ÃÃ .51ÃÃ .67Ã .97ÃÃ 1.03 1.00 1.02 1.00 .98 .87 1.37ÃÃ 1.14 1.00 1.07Ã 1.19 .95 1.00 .97Ã .76Ã 1.42Ã 1.00 .98Ã .98 1.13 .97 1.00 .97 .64ÃÃ 1.27 .92 .99 .99 .96 1.02 1.00 .98 .81 1.19 1.02 .99 .97 1.02 1.00 1.00 .98 .86 1.15 1.01 .97Ã .97 .98 1.05 1.00 .96 .87 1.01 .74

Variable RN workgroup job satisfaction RN HPPD LPN HPPD UAP HPPD RN education level RN unit tenure Magnet Bed size Teaching Unit type Critical Step-down Medical Surgical Med-Surg Rehab

Notes. RN, registered nurse; LPN, licensed practical nurse; UAP, unlicensed assistive personnel; HPPD, hours per patient day; Med-Surg, Combined medical-surgical; Rehab, rehabilitation. Ã p < .05. ÃÃ p < .001.

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rehabilitation units, the odds of HAPU occurrence were 2–3% lower for each 1-unit increase in RN workgroup job satisfaction. For step-down, surgical, combined medicalsurgical units, no significant relationship between RN workgroup job satisfaction and HAPUs was found. Of the unit characteristics (RN HPPD, LPN HPPD, UAP HPPD, RN education level, and RN unit tenure), only RN unit tenure was significantly related to the HAPU rate in the expected direction, and only in step-down units. In the model with all sample units, the odds of HAPU occurrence decreased by 3% for each 1-year increase in the unit tenure of RNs. RN HPPD and LPN HPPD were also significantly related to HAPU rates in this model, but the relationships were in the opposite direction of what was expected. For each additional RN HPPD and additional LPN HPPD, the odds of HAPU occurrence increased by 5% and 14%, respectively. These relationships were attenuated to non-significance in the models for specific unit types, except for in step-down units, where only RN HPPD remained positively associated with the HAPU rate. Magnet status and bed size were significantly related to HAPUs. In the model with all units, the odds of HAPU occurrence were 19% lower in Magnet hospitals compared to nonMagnet hospitals, and 27% higher in hospitals with 300 or more beds compared to hospitals with <300 beds. However, these associations were not consistent across unit type. Magnet status remained significantly associated with the HAPU rate in the step-down and medical unit models, and bed size remained significantly associated with the HAPU rate only in the critical care and step-down unit models. Discussion This study was conducted to examine the relationship between RN workgroup job satisfaction and HAPU rates among hospitalized older adults on six acute care unit types. The reported average HAPU rate across six unit types included in the study was 5.4%, which was slightly higher than the overall rate of 5.0% among acute care facilities in the US reported in the 2009 International Pressure Ulcer Prevalence (IPUP) survey (VanGilder, Amlung, Harrison, & Meyer, 2009). The difference in study findings is likely due to sampling variations; the IPUP survey included adult patients of all ages from a
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wide range of units that encompassed psychiatric units and emergency departments, whereas this study included older adults from in-patient acute care units. HAPU rates in our study were highest on critical care units (9.1%), followed by stepdown units (6.1%), rehabilitation units (5.0%), medical units (4.6%), surgical units (4.0%), and combined medical-surgical units (3.9%). These findings were also similar to those from the 2009 IPUP survey (VanGilder et al., 2009), where HAPU rates were highest in critical care units (9.9%) and lowest on surgical and combined medical-surgical units (4.3%). Older adult patients are more likely to suffer from chronic diseases and mobility impairments that compound conditions requiring admission to the critical care unit and place them at higher risk for pressure ulcer development during hospitalization than patients on other unit types. Findings indicate the need for more effective pressure ulcer prevention to reduce the occurrence of these wounds among older adult patients in critical care units. RN workgroups included in our study reported moderate job satisfaction overall, which is consistent with findings from a previous study on RN workgroup job satisfaction among 10 unit types in US acute care hospitals (Boyle et al., 2006). Findings from our study support the hypothesis that higher RN workgroup job satisfaction is significantly related to lower HAPU rates among older adults on acute hospital care units and also show that the association between RN job satisfaction and HAPU rates may vary by unit type. Higher job satisfaction among RN workgroups was significantly associated with lower HAPU rates among older adults on critical care, medical, and rehabilitation units, but no significant relationship was found in step-down, surgical, and medicalsurgical units. It should be noted that effects were small, with statistical significance being attributable in part to the large sample size. Further research controlling for individual patient risk factors may provide more precise assessment of the relationship between job satisfaction and HAPU rates and its variation by unit type. In a meta-analysis of job satisfaction studies, Judge, Thoresen, Bono, and Patton (2001) found that job satisfaction was moderately and positively related to job performance. This finding suggests that the relationship between RN workgroup satisfaction and HAPU rates may be mediated by unit-level RN job performance. Each nursing unit has its own culture and

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dynamics that may be pivotal in implementing unit-specific quality improvement initiatives. Satisfied RN workgroups may be more likely to make efforts to reduce HAPU rates on their units, which would ultimately affect pressure ulcer outcomes. Further research is needed to understand how RN workgroup job satisfaction affects HAPU rates through unit-based quality improvement efforts, as well as to see whether RN workgroup job satisfaction is a proxy for RNs’ attitudes towards quality improvement initiatives at the unit level. In this study, longer RN tenure on the current unit was found to be related to lower HAPU rates among older adult patients across sampled units, although this significant relationship remained only for step-down units when examined by unit type. Similarly, Dunton et al. (2007) found that units with a higher percentage of RNs with more than 10 years of experience in nursing had fewer HAPUs, suggesting that experienced nurses are important to the provision of high-quality care. Dunton et al. (2007) also found that more total nursing hours per patient day were associated with more HAPUs. This is consistent with our findings of a positive association between nurse staffing and HAPU rates among older adults on step down units. It is possible that there was inadequate control for differences among units in patient acuity levels. For example, step-down units with more RN HPPD may have sicker, older adult patients at higher risk of pressure ulcers than those with fewer RN HPPD, leading to an apparent positive association between RN HPPD and the HAPU rate. Another possible explanation is potential confounding of RN skill mix and years of experience on a unit. Units with more RN HPPD may have a higher proportion of less experienced RNs, such as new graduate nurses and agency nurses. Although further investigation on the possible moderating effect of other nursing workforce factors (e.g., RN unit tenure and RN educational level) on the relationship between nurse staffing and patient outcomes is needed to clarify this issue, our findings demonstrate the importance of both the quantity and quality of nurse staffing for meeting the care needs of the patient on each nursing unit and thereby reducing HAPU rates. Finally, we found that HAPUs are less likely to occur in Magnet-recognized hospitals, although this relationship remained significant only for step-down and medical units. The Magnet1 recognition program, designed by the
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American Nurses Credentialing Center (ANCC), is a mechanism for recognizing hospitals that create and sustain an excellent work environment for nurses to provide professional nursing practice to patients. Researchers have shown that ANCC Magnet-recognized hospitals have better nurse and patient outcomes, including higher RN job satisfaction and lower mortality rates (Drenkard, 2010; Kelly, McHugh, & Aiken, 2011; Schmalenberg & Kramer, 2008). However, most of these analyses were conducted at the hospital level. It is important to examine the effect of hospital Magnet status on patient outcomes at the unit level, as nurse staffing, education, unit tenure, and other factors may differ across unit type. In our sample, Magnet status was the strongest predictor of HAPU rates among older adults, stronger than RN job satisfaction. Further research is needed to validate this finding and explore the mechanism by which the Magnet recognition program reduces HAPU rates. Limitations Although we used unit-level data of a large and national sample of hospitals from the NDNQI database, the results from this study may not be generalizable to all US acute facilities, as the sampled hospitals were voluntary participants in NDNQI. Larger and not-for-profit hospitals tend to be over-represented among NDNQI member hospitals compared with all US hospitals (Dunton et al., 2007; Lake et al., 2010). In addition our subsample consisted only of units that submitted data on both pressure ulcers and nurse staffing to NDNQI during 2009 and participated in the RN survey that year. We were unique in analyzing unit-level data to examine the relationship between RN job satisfaction and HAPU rates. Ideally, unitor patient-level data on patient acuity level and on risk factors, such as gender, body mass index, risk assessment score, nutritional status, and length of stay, would be taken into account in the analysis, but those data were not available for our analysis. To provide some control for unit differences in patient characteristics, we included unit type in our analysis as a proxy for patient acuity level and also tested the models separately by unit type. However, this approach may not adequately have adjusted for patient risk factors for HAPU development. Other nursing factors that might be related to pressure ulcer occurrence, such as the level of nurse

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knowledge and attitude toward pressure ulcer prevention, were not included in the analysis. Future studies are needed to explore the relationship between RN job satisfaction and HAPU rates while employing adequate risk adjustment methods that include patient-level risk factors, nursing unit factors, and hospital characteristics. Last, HAPUs in our study included a pressure ulcer of any category/stage (category/stage I to IV, unstageable or suspected deep tissue injury) as defined by NPUAP (NPUAP-EPUAP, 2009). Some researchers have excluded stage I pressure ulcers due to reported variability of identification (Dahlstrom et al., 2011), but we did not limit subgroups of pressure ulcers to stage II and higher because NDNQI data on pressure ulcer identification and staging have been found reliable (Bergquist-Beringer et al., 2011). However, further research in which pressure ulcers are modeled by stage may provide additional information on the relationship between RN job satisfaction and HAPU rates. Conclusion Our research team was the first to examine a link between RN workgroup job satisfaction and HAPU rates among older adults on six types of acute care units. The finding that RN workgroup job satisfaction was significantly associated with the rate of HAPUs among older adults provides empirical evidence to support the relationship between RN job satisfaction and better patient care outcomes. The lower HAPU rate in Magnet than non-Magnet hospitals also adds to the limited evidence that Magnet-recognized hospitals have better patient outcomes on selected nursing unit types (Dunton et al., 2007; Lake et al., 2010). Importantly, our findings demonstrate the advantage of unit-level analysis, which allowed us to capture variations in the relationships among study variables across unit types. The results from this analytical approach might guide the development of strategies to facilitate RN workgroups’ capability to deliver high-quality patient care on units where serious safety risks occur. References
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