Association of Catheter Associated Urinary Tract Infection with the Practice Environment at the Unit Level
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1 Association of Catheter Associated Urinary Tract Infection with the Practice Environment at the Unit Level Nancy Ballard, PhD, RN, NEA-BC Dissertation University of Kansas
2 Disclosures Authors Nancy Ballard, PhD, RN Byron Gajewski, PhD Shin Hye Park, PhD, RN Peggy Miller, PhD, RN Marjorie J. Bott, PhD, RN No financial disclosures No conflict of interests to declare
3 Background Patient Outcomes Importance in Acute Care Financial Impact in the USA Centers for Medicare & Medicaid Reimbursement Public Reporting Hospital Acquired Conditions (HAC) Falls with Injury Pressure Ulcers Nosocomial Infections
4 Nosocomial Infections Five Preventable Ventilator Associated Pneumonia VAP Surgical Site Infection (SSI) Clostridium Difficile Infection (CDI) Central Line Bloodstream Infection (CLBSI) Catheter Associated Urinary Tract Infection (CAUTI) Estimated Cost in USA $9.8 billion (95%CI, $8.3-$11.5 billion) in 2012 dollars* *Zimlichman et al. (2013)
5 Catheter Associated Urinary Tract Inf. (CAUTI) Most frequent nosocomial infection 13,000 deaths associated with UTI (CDC, 2010) 75% of UTIs- associated with a urinary catheter (CDC, n.d.) 17% of bacteremias have a urinary source Prevention supported by: Decreased use Standardized care Association between nurse staffing and UTI (Aiken, Sloane, & Wu, 2012)
6 Practice Environment & Outcomes 1983 Original Study, Magnet Hospitals (McClure & Hinshaw Eds., 2002) Identified characteristics of good practice environments Nurse-to-patient staffing level major factor in prevention of HACs (Multiple investigators) Practice environment affects outcomes associated with staffing levels (Aiken et al., 2011)
7 Practice Environment & Outcomes Healthy work environment Important to nurse satisfaction Patient outcomes Magnet vs non-magnet hospitals (Aiken & Colleagues, 2000; Kramer & Colleagues, 2011) Leiter & Laschinger (2006) Posited Nurse Worklife Model Practice Environment associated w/burnout & personal accomplishment
8 Gap in the Literature Studies to date of NWLM: Aggregated Individual-level nurse survey data Nurse perception of adverse patient outcomes Other studies of outcomes related to the practice environment: Hospital-level using administrative data Hospital-level adverse event rates Gap: Evaluation of the association of unit level measures of practice environment with measured clinical outcomes.
9 Design Correlational path analysis: Structural Equation Modelling (SEM) NWLM of Job Enjoyment fit to the data Secondary Analysis National Database for Nursing Quality Indicators (NDNQI) 2012 RN Satisfaction Survey Data Reporting Practice Environment Scale (PES) and Job Enjoyment Scale (JES) Unit types: medical, surgical, combined medical-surgical
10 Measures Job Enjoyment Scale (JES) Seven item scale Likert-type responses from strongly disagree (1) to strongly agree (6) (α =.97) Practice Environment Scales (PES) Five Subscales (α =.87-90) 3-10 items Likert-type responses, strongly disagree (1) to strongly agree (4)
11 Measures ( cont d) CAUTI ( USA-National Healthcare Safety Network definition) Raw data from 2012 were annualized to calculate rates Rate - Total number of reported CAUTIs /total number of catheter days x 1000.
12 Practice Environment Scale Variable Definition # Items α PES-Collegial RN-MD Relations Presence of collaborative working relationship (RN-MD Collaboration) 3.87 PES-Nurse Participation in Hospital Affairs PES-Staffing and resource adequacy Policy development and decisions about practice (Policy Involvement) Staffing level is adequate to provide the care needed (Staffing Adequacy)
13 PES-Nurse manager ability, leadership, and support PES-Nursing Foundations for Quality Care PES ( cont d) Nursing manger viewed as a leader who provides strong support (Strong Leadership) Nursing practice is supported by high standards, professional nursing philosophy, education, expectation of competency, and measurement of quality (Nursing Model of Care)
14 Job Enjoyment Scale Items (1-6 Scale) Stem: Nurses with whom I work would say that they: 1. Are fairly well satisfied with their jobs. 2. Would not consider taking another job 3.* Have to force themselves to come to work much of the time. 4. Are enthusiastic about their work almost every day. 5. Like their jobs better than the average worker does. 6.* Feel that each day on their job will never end. 7. Find real enjoyment in their work. *Reverse scored so that a higher score = higher Job Enjoyment
15 Data Analysis Descriptive statistics & ANOVA (SPSS version 18) SEM correlational path analysis Mplus Software version 7 to test the hypothesized a priori NWLM-JE Incremental fit indices Comparative Fit Index (CFI) - Acceptable range: >.90 Root Mean Square Error of Approximation (RMSEA) - Acceptable range: <.08 Standardized Root Mean Square Residual (SRMR) <.08 (Hooper, Couglan & Mullen, 2008)
16 National Database for Nursing Quality Indicators 2012 RN Satisfaction Data and Quality Outcomes data Study Aim Confirm structure of the modified NWLM of Job Enjoyment from previous study of unit level 2011 data set Evaluate the relationship of elements of the nurse practice environment with CAUTI
17 Study Assumptions Unit level data with at least 40% response rate accurately reflect the score for the unit (Kramer et al., 2009) CAUTI rates sufficient to determine the pathways for association of the NWLM-JE with CAUTI rate at the unit level.
18 Hypothesized Nurse Worklife Model of Job Enjoyment & CAUTI rates Nurse Manager Ability, Leadership & Support Collegial RN-MD Relationships Practice Staffing & Resource Adequacy Key: CAUTI = Catheter Acquired Urinary Tract Infection; ---- Paths added to original NWLM from 2011 Study All paths to JES (+) association Participation in Hospital Affairs Nursing Foundation for Quality Care Job Enjoyment Scale (JES) (-) CAUTI Rates
19 Results: Hospital & Unit Type Characteristics (N=1,106) Bed Size % Unit Types % < Medical Surgical Medical- Surgical * 20.1 Teaching Status & Magnet Status 40.5 Academic Medical Center* 19.4 Teaching 34.5 Non-teaching 46.0 Magnet Status 45.0 % RN Characteristics Range % M % Female White BSN or higher Certification *ANOVA indicated a significant difference on CAUTI rate for Academic Medical Center status & Hospital bed size > 500
20 Results: PES subscales moderately to highly correlated (r =.53 to.88); reliabilities range =.94 to.97 CFA for subscales-cfi = with the exception of Participation in Hospital Affairs (CFI =.85) Job Enjoyment Scale similar across all unit types [M = 3.71 (SD=.58) to 3.78 (SD=.58)]
21 Results (cont d) CAUTI Rate Medical M = 1.91 (SD=2.7) Surgical M = 1.54 (SD=2.1) Medical-Surgical M = 1.91 (SD=2.5) Model Fit Indices: CFI =.995 RMSEA= 0.04 (95% CI = ) SRMR=0.02
22 PES-Nurse Manager Ability, Leadership & Support.60 c.53 c PES-Collegial RN-MD Relationships.32 c PES-Participation in Hospital Affairs.21 c.23 c.26 c Results of Modified NWLM with CAUTI Rates PES-Staffing & Resource Adequacy.32 c.20 c.08 b.66 c PES-Nursing.08 b Foundation for Quality Care.63 c Key: PES = Practice Environment Scale; CAUTI = Catheter Associated Urinary Tract Infection Job Enjoyment Scale = control variable Academic Medical Ctr.13 c -.08 b CAUTI Rates.07 b Coefficients depicted in the model are standardized; a p <.05; b p<.01; c p<.001 Bed Size > 500
23 Associated Impact on CAUTI Rate 1 point Change in Job Enjoyment associated with change in CAUTI Rate of.08, p=<.01
24 Significance Modified NWLM of Job Enjoyment paths from previous study supported Significant negative association of CAUTI rate with Practice Environment through Job Enjoyment at the unit level Positive association of academic medical centers and hospitals with > 500 beds Impact of the practice environment on CAUTI aligns with work at the hospital level by Aiken Pervasive impact of nurse manager in NWLM aligns research on importance of first-line nurse leadership
25 Limitations: Sample may not be representative of hospital populations across the U.S. Under representation of rural & smaller hospitals Higher proportion of Magnet designated hospitals in the NDNQI database. Units with poor practice environments may be under represented due to lack of a 40% response rate. Cross-sectional data limits inference of causality
26 Strengths Large national sample from all census divisions Well-defined valid and reliable measures for variables Measured clinical outcome
27 Questions?
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