Stimpfel AW, Sloane DM, Aiken LH. The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction. Health Aff (Millwood). 2012;31(11). Technical Appendix METHODS--Design and Data Nurse Survey In the Multi-State Nursing Care and Patient Safety Study, nurse survey data were collected in 2005-2008 from nearly 100,000 nurses in California, Pennsylvania, New Jersey, and Florida using state licensure lists as sampling frames. The survey was fairly wide ranging and included questions about among many other things the nurses shift length, work environment, staffing, burnout, job satisfaction, intentions to leave and characteristics of scheduling. Mailed surveys were sent directly to the homes of nurses, who represented random samples of 40% of all nurses licensed in California and Pennsylvania, 50% of all nurses licensed in New Jersey, and 25% of all licensed nurses in Florida. The different sampling fractions in the different states were driven by funding constraints. We used a modified Dillman approach with postcard reminders and a second mailing of questionnaires to nonrespondents. 1 The nurses surveyed included nurses working in all settings, in and out of direct patient care, and nurses who had chosen to maintain their licenses but not work as nurses, and some nurses who were unemployed.
The response rate was 39%. Response rates in large surveys have been decreasing for many years and a higher response rate may not always provide unbiased samples. 2,3 To determine the degree to which our sample was biased on the variables of proximal interest, we drew a random sample of nurses from the non-responders to the original survey from Pennsylvania (n=650) and California (n=650). Additional efforts were employed to avoid non-response from the smaller sample (e.g. phone calls, priority mail, and cash incentives) and as a result we achieved a 91% response rate in the sample of non-respondents. There were a few demographic differences between respondents and the original non-respondents, however, there was no evidence that the two samples differed with respect to nurses reports of burnout, job dissatisfaction, or other relevant variables in our study. 4 Due to the large number of respondents and the lack of evidence of response bias, we are confident in the reliability and validity of the findings from the survey. Additional Detail for Measures Burnout. Burnout was measured by the Emotional Exhaustion subscale of the Maslach Burnout Inventory that sums nine items, each measured by a seven-point ordinal scale, to assess nurses feelings of job-related emotional exhaustion. 5 Nurses were classified as being burned out if their score on the Emotional
Exhaustion subscale was higher than the published average greater than or equal to 27 for health care workers. 6 Job Satisfaction. Job satisfaction was measured on a fourpoint ordinal scale with responses ranging from very satisfied to very dissatisfied. For analysis purposes, job satisfaction was dichotomized to compare nurses who reported being either a little or very dissatisfied with nurses who reported being very or moderately satisfied. Intent to leave. Intent to leave was measured using a yes/no response to the question, Do you plan to be with your current employer one year from now? Unit specialty. A dichotomous variable was created from the nurse survey to categorize nurses working in intensive care units versus general care units. This was done in order to adjust for the differential influence that hospitals with more intensive care settings, resulting in better staffing ratios, would have on these models. The Practice Environment Scale of the Nursing Work Index. The instrument consists of five subscales related to (1) nurse participation in hospital affairs; (2) nursing foundations for quality of care; (3) nurse manager ability, leadership, and support of nurses; (4) staffing and resource adequacy; and (5) collegial nurse physician relations. As in previous research 7, the staffing and resource adequacy subscale (Staffing and
Resource Adequacy) was omitted because of its high correlation with our nurse staffing measure. For each hospital, we calculated subscale measures by averaging the values of all items in the subscale for all the nurses in the hospital. We then created a categorical summary measure for each hospital that has demonstrated good predictive validity where hospitals above the median on 3 or 4 subscales were classified as having good work environments; hospitals above the median on 1 or 2 subscales were classified as having mixed work environments; and hospitals above the median on zero subscales were classified as having poor work environments. Hospital Controls. Additional variables were derived from the nurse survey and American Hospital Association Annual Survey data to serve as control variables in the predictive models. Hospital characteristics were obtained from the American Hospital Association Annual Survey and included hospital size, teaching status, ownership, and core based statistical area, a measure of population density. These variables were included in the regression models to adjust for hospital factors that were related to the voluntary participation in the Hospital Consumer Assessment of Healthcare Providers and Systems survey during the study period prior to participation. Additional Detail for Analysis
For the descriptive analyses, frequencies, including numbers and percentages, were calculated for the major outcomes of interest. We used bivariate generalized estimating equation (GEE) models to assess the relationship between shift length and the three nurse outcomes. Next, multivariate generalized estimating equation (GEE) methods were used to reassess these relationships after controlling for potential confounds. The models we used account for the clustering of the nurses within hospitals 8 and produce robust standard error estimates that adjust for the correlations among clustered observations. Parameter estimates were transformed to odds ratios for ease of interpretation. The second part of the analysis entailed hospital-level regression modeling of patient satisfaction, and included all acute care hospitals in California, Florida, New Jersey and Pennsylvania for which we had nurse survey data and that reported Hospital Consumer Assessment of Healthcare Providers and Systems survey data to the Centers for Medicare and Medicaid Services. The final hospital sample for the regression models was 396. Specifically, ordinary least squares regression models were used to estimate the effect of nurse shift length on patient satisfaction. We first estimated bivariate models for each of the ten Hospital Consumer Assessment of Healthcare Providers and Systems survey outcomes and then estimated
multivariate models for the same outcomes that accounted for nurse age, hospital state, core-based statistical area, bed size, ownership, teaching status, practice environment, and nurse-to-patient ratio. Statistical significance was set at the.05 level using two-tailed tests for all analyses. References 1. Dillman DA. Mail and Internet Surveys the Tailored Design Method. New York: John Wiley & Sons; 2000. 2. Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveys published in medical journals. J Clin Epidemiol. 1997;50(10):1129-1136. PMID: 9368521. 3. Johnson TP, Wislar JS. Response rates and nonresponse errors in surveys. JAMA : the journal of the American Medical Association. 2012;307(17):1805-1806. 4. Smith HL. A double sample to minimize bias due to nonresponse in a mail survey In: Ruiz-Gazen A, Guilbert P, Haziza D, Tille Y, eds. Paris: Dunod; 2008:334-335-339. 5. Maslach C, Jackson SE. The measurement of experienced burnout. Journal of Organizational Behaviour. 1981;2:99-100-113. 6. Maslach C, Jackson SE. Maslach Burnout Inventory Manual. 2nd ed. Palo Alto, CA: Consulting Psychologists Press; 1986.
7. McHugh MD, Kutney-Lee A, Cimiotti JP, Sloane DM, Aiken LH. Nurses' widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Aff (Millwood). 2011;30(2):202-210. PMID: 21289340. 8. Hanley JA, Negassa A, Edwardes MD, Forrester JE. Statistical analysis of correlated data using generalized estimating equations: An orientation. Am J Epidemiol. 2003;157(4):364-375. PMID: 12578807.
Supplemental Exhibit 3 Full specifications of regression models to correspond with results discussing the relationship between nurses' shift length and nurse outcomes: burnout, job dissatisfaction and intention to leave Unadjusted Adjusted Dependent variable Covariates Estimate SE 95% CI p value Estimate 95% CI SE p value Burnout 10-11 hour shift 1.71 0.073 1.48 1.97 <.0001 1.58 0.08 1.35 1.84 <.0001 12-13 hour shift 1.13 0.04 1.04 1.22 0.003 1.11 0.04 1.02 1.20 0.0126 > 13 hour shift 2.85 0.073 2.47 3.28 <.0001 2.70 0.08 2.32 3.15 <.0001 31-40 years old 0.95 0.05 0.86 1.05 0.2838 41-50 years old 1.01 0.05 0.91 1.12 0.8782 51-60 years old 0.94 0.06 0.84 1.05 0.2738 61 years old 0.57 0.09 0.48 0.69 <.0001 Male 1.16 0.06 1.02 1.31 0.0228 ICU 0.76 0.04 0.70 0.81 <.0001 Nurse staffing 1.06 0.02 1.02 1.09 0.0005 Mixed practice environment 0.82 0.04 0.75 0.89 <.0001 Good practice environment 0.59 0.05 0.53 0.65 <.0001 101-250 beds 1.14 0.09 0.96 1.36 0.1372 251 Beds 1.06 0.09 0.89 1.26 0.5197 Minor teaching 1.03 0.04 0.95 1.12 0.4289 Major teaching 1.18 0.06 1.04 1.34 0.0096 Technology 1.06 0.04 0.98 1.16 0.1556 Note. Number of observations=19,462; number of events (burnout)=6,763
Job dissatisfaction 10-11 hour shift 1.72 0.083 1.47 2.02 <.0001 1.67 0.09 1.40 1.99 <.0001 12-13 hour shift 1.1 0.046 1 1.2 0.042 1.12 0.04 1.03 1.22 0.01 > 13 hour shift 2.42 0.076 2.09 2.81 <.0001 2.38 0.08 2.04 2.79 <.0001 31-40 years old 1.12 0.06 1.00 1.24 0.05 41-50 years old 1.29 0.06 1.15 1.44 <.0001 51-60 years old 1.28 0.06 1.15 1.44 <.0001 61 years old 0.90 0.09 0.75 1.08 0.27 Male 1.04 0.07 0.91 1.19 0.57 ICU 0.91 0.04 0.83 0.99 0.03 Nurse staffing 1.08 0.02 1.05 1.12 <.0001 Mixed practice environment 0.69 0.05 0.62 0.76 <.0001 Good practice environment 0.45 0.06 0.40 0.50 <.0001 101-250 beds 0.92 0.09 0.76 1.10 0.34 251 Beds 0.84 0.10 0.70 1.02 0.08 Minor teaching 1.09 0.05 0.99 1.20 0.07 Major teaching 1.11 0.08 0.94 1.30 0.23 Technology 1.06 0.05 0.96 1.17 0.25 Note. Number of observations=19,274; number of events (dissatisfied)=5,082 Intention to leave 10-11 hour shift 1.49 0.109 1.21 1.85 0.0002 1.55 0.12 1.24 1.95 0.0001 12-13 hour shift 1.53 0.056 1.37 1.71 <.0001 1.45 0.06 1.30 1.63 <.0001 > 13 hour shift 2.79 0.093 2.32 3.35 <.0001 2.57 0.10 2.10 3.15 <.0001 31-40 years old 0.65 0.07 0.57 0.75 <.0001 41-50 years old 0.47 0.07 0.41 0.54 <.0001 51-60 years old 0.39 0.08 0.34 0.45 <.0001 61 years old 0.88 0.10 0.72 1.06 0.1712
Male 1.36 0.08 1.17 1.59 <.0001 ICU 0.92 0.05 0.83 1.01 0.0755 Nurse staffing 1.03 0.02 0.99 1.08 0.1788 Mixed practice environment 0.72 0.06 0.64 0.81 <.0001 Good practice environment 0.56 0.07 0.49 0.64 <.0001 101-250 beds 0.87 0.12 0.68 1.10 0.2472 251 Beds 0.77 0.13 0.60 0.99 0.0383 Minor teaching 1.01 0.06 0.91 1.13 0.8172 Major teaching 0.92 0.09 0.77 1.08 0.3055 Technology 1.17 0.06 1.03 1.32 0.0182 Note. Number of observations=19,503; number of events (intent to leave)=2,846 The reference groups include: 8-9 hour shift category, 30 year old, female, non-icu, poor practice environment, <100 beds, non-teaching hospitals, and low technology.
Supplemental Exhibit 4 Full specifications of Regression models to correspond with results discussing the relationship between nurses' shift length and patient satisfaction using the HCAHPS, 2006-2007. Hospital proportion of shifts above 13 hours Unadjusted Adjusted Dependent variable Covariates Estimate SE p value Estimate SE p value Do not recommend hospital Greater than 13 hours 0.16798 0.0364 <.0001 0.07988 0.0387 0.0396 Bed size -0.35668 0.3472 0.305 Age 1.64848 0.6831 0.0163 Core based statistical area -1.18953 0.328 0.0003 Ownership 2.78125 0.4096 <.0001 Teaching status 0.51123 0.3134 0.1037 Hospital state 0.13181 0.2023 0.5151 Nurse staffing 0.1111 0.1563 0.4776 Practice environment -1.12577 0.2529 <.0001 Note: Unadjusted model R 2 =.0514, F(1, 395)= 21.35, p<.0001; Adjusted model R 2 =.2885, F(9, 358)=16.13 p<.0001 RN communication Greater than 13 hours 0.14086 0.0315 <.0001 0.09922 0.0348 0.0046 Bed size -0.0098 0.3122 0.975 Age 1.09099 0.6142 0.0765 Core based statistical area -1.22928 0.2949 <.0001 Ownership 2.16446 0.3683 <.0001 Teaching status 0.55691 0.2818 0.0489
Hospital state -0.09816 0.1819 0.5898 Nurse staffing 0.02537 0.1405 0.8568 Practice environment -0.80319 0.2274 0.0005 Note: Unadjusted model R2 =.0482, F(1, 395)= 19.94, p<.0001; Adjusted model R2 =.2348, F(9, 358)=12.21 p<.0001 Quiet at night sometimes or never Greater than 13 hours -0.08904 0.0508 0.0805 0.06167 0.0574 0.2836 Bed size 0.836 0.5156 0.1058 Age 1.2036 1.0142 0.2361 Core based statistical area -0.3791 0.487 0.4368 Ownership 2.42935 0.6082 <.0001 Teaching status 0.41138 0.4653 0.3772 Hospital state -1.88448 0.3004 <.0001 Nurse staffing 0.0787 0.232 0.7347 Practice environment -0.83255 0.3755 0.0272 Note: Unadjusted model R2 =.0077, F(1, 395)= 3.07, p=.0805; Adjusted model R2 =.17, F(9, 358)=8.15 p<.0001 Pain controlled sometimes or never Greater than 13 hours 0.14334 0.0298 <.0001 0.09397 0.0338 0.0057 Bed size -0.0355 0.3036 0.907 Age 0.72501 0.5972 0.2255 Core based statistical area -1.10514 0.2868 0.0001 Ownership 1.65868 0.3581 <.0001 Teaching status 0.48974 0.274 0.0747 Hospital state 0.07134 0.1769 0.6869 Nurse staffing -0.02095 0.1366 0.8782 Practice environment -0.73305 0.2211 0.001 Note: Unadjusted model R2 =.0554, F(1, 395)= 23.12, p<.0001; Adjusted model R2 =.1987, F(9, 358)=9.86 p<.0001
Physician communication Greater than 13 hours 0.07429 0.0198 0.0002 0.03124 0.023 0.176 Bed size 0.16856 0.2069 0.4157 Age 0.19925 0.4069 0.6247 Core based statistical area -0.24583 0.1954 0.2092 Ownership 1.16845 0.244 <.0001 Teaching status 0.25724 0.1867 0.1691 Hospital state 0.09856 0.1205 0.414 Nurse staffing 0.00256 0.0931 0.9781 Practice environment -0.32288 0.1507 0.0328 Note: Unadjusted model R2 =.0344, F(1, 395)= 14.05, p=.0002; Adjusted model R2 =.1339, F(9, 358)=6.15 p<.0001 Low rating of hospital Greater than 13 hours 0.2408 0.0481 <.0001 0.11999 0.0522 0.0221 Bed size -0.1794 0.4688 0.7021 Age 2.0648 0.9221 0.0258 Core based statistical area -0.88734 0.4428 0.0458 Ownership 3.24293 0.553 <.0001 Teaching status 0.55821 0.423 0.1878 Hospital state 0.21453 0.2731 0.4326 Nurse staffing 0.22791 0.211 0.2807 Practice environment -1.5887 0.3414 <.0001 Note: Unadjusted model R2 =.0575, F(1, 395)= 25.08, p<.0001; Adjusted model R2 =.2661, F(9, 358)=14.42 p<.0001 Help when needed sometimes or never Greater than 13 hours 0.23641 0.0516 <.0001 0.21359 0.0572 0.0002 Bed size 0.51709 0.5133 0.3145 Age 1.13069 1.0098 0.2636
Core based statistical area -2.47646 0.4849 <.0001 Ownership 2.67914 0.6056 <.0001 Teaching status 0.51662 0.4633 0.2655 Hospital state -0.57181 0.2991 0.0567 Nurse staffing 0.20415 0.231 0.3775 Practice environment -1.27077 0.3739 0.0008 Note: Unadjusted model R2 =.0505, F(1, 395)= 20.97, p<.0001; Adjusted model R2 =.2245, F(9, 358)=11.52 p<.0001 Explain medications sometimes or never Greater than 13 hours 0.24134 0.0488 <.0001 0.11445 0.0525 0.0299 Bed size 0.48453 0.4714 0.3047 Age 1.74876 0.9274 0.0601 Core based statistical area -1.94696 0.4453 <.0001 Ownership 3.68604 0.5561 <.0001 Teaching status 0.02126 0.4255 0.9602 Hospital state -0.02984 0.2746 0.9135 Nurse staffing 0.49944 0.2122 0.0191 Practice environment -1.28182 0.3434 0.0002 Note: Unadjusted model R2 =.0585, F(1, 395)= 24.49, p<.0001; Adjusted model R2 =.2864, F(9, 358)=15.97 p<.0001 Clean room sometimes or never Greater than 13 hours 0.14907 0.0376 <.0001 0.07905 0.0423 0.0626 Bed size 0.51907 0.3799 0.1727 Age 0.63494 0.7474 0.3961 Core based statistical area -1.26201 0.3589 0.0005 Ownership 2.3318 0.4482 <.0001 Teaching status 0.58908 0.3429 0.0867 Hospital state 0.24355 0.2213 0.2719 Nurse staffing -0.07569 0.171 0.6583
Practice environment -0.7244 0.2767 0.0092 Note: Unadjusted model R2 =.0384, F(1, 395)= 15.73, p<.0001; Adjusted model R2 =.1968, F(9, 358)=9.75 p<.0001 Discharge information Greater than 13 hours 0.0881 0.0399 0.0278 0.04523 0.0436 0.0299 Bed size 0.05716 0.3911 0.3047 Age 1.22193 0.7694 0.0601 Core based statistical area -2.26121 0.3695 <.0001 Ownership 1.03115 0.4614 <.0001 Teaching status 0.06532 0.353 0.9602 Hospital state -0.36787 0.2279 0.9135 Nurse staffing 0.53087 0.176 0.0191 Practice environment -1.23955 0.2849 0.0002 Note: Unadjusted model R2 =.0122, F(1, 395)= 4.88, p=.0278; Adjusted model R2 =.2097, F(9, 358)=10.44 p<.0001 Hospital proportion of shifts 12-13 hours Unadjusted Adjusted Dependent variable Covariates Estimate SE p value Estimate SE p value Do not recommend hospital 12-13 hour shifts 0.02458 0.0076 0.0014 0.01469 0.0072 0.0433 Bed size -0.43766 0.3494 0.2111 Age 1.59636 0.6807 0.0196 Core based statistical area -1.20302 0.3277 0.0003 Ownership 2.76533 0.4106 <.0001 Teaching status 0.44161 0.311 0.1565
Hospital state 0.28569 0.1854 0.1242 Nurse staffing 0.09269 0.1566 0.5543 Practice environment -1.16574 0.2524 <.0001 Note: Unadjusted model R 2 =.0256, F(1, 395)= 10.34, p=.0014; Adjusted model R 2 =.2882, F(9, 358)=16.1 p<.0001 RN communication 12-13 hour shifts 0.02655 0.0066 0.001 0.02044 0.0065 0.0018 Bed size -0.12186 0.3133 0.6976 Age 1.04354 0.6105 0.0883 Core based statistical area -1.24071 0.2939 <.0001 Ownership 2.12974 0.3683 <.0001 Teaching status 0.47223 0.2789 0.0913 Hospital state 0.09087 0.1663 0.585 Nurse staffing -0.00044985 0.1405 0.9974 Practice environment -0.85371 0.2264 0.0002 Note: Unadjusted model R2 =.0398, F(1, 395)= 16.33, p<.0001; Adjusted model R2 =.2358, F(9, 358)=12.46 p<.0001 Quiet at night sometimes or never 12-13 hour shifts -0.01117 0.0106 0.291-0.01531 0.0107 0.155 Bed size 0.91283 0.518 0.0789 Age 0.9535 1.0093 0.3455 Core based statistical area -0.45411 0.4858 0.3506 Ownership 2.59848 0.6088 <.0001 Teaching status 0.33571 0.4611 0.467 Hospital state -1.74005 0.2748 <.0001 Nurse staffing 0.10041 0.2322 0.6657 Practice environment -0.85277 0.3743 0.0233 Note: Unadjusted model R2 =.0003, F(1, 395)= 1.12, p=.291; Adjusted model R2 =.172, F(9, 358)=8.27 p<.0001
Pain controlled sometimes or never 12-13 hour shifts 0.01732 0.0063 0.0063 0.0094 0.0064 0.1416 Bed size -0.08954 0.3077 0.7712 Age 0.60162 0.5996 0.3164 Core based statistical area -1.14011 0.2886 <.0001 Ownership 1.69361 0.3617 <.0001 Teaching status 0.40135 0.2739 0.1437 Hospital state 0.25995 0.1633 0.1122 Nurse staffing -0.03198 0.1379 0.8168 Practice environment -0.77693 0.2224 0.0005 Note: Unadjusted model R2 =.0188, F(1, 395)= 7.55, p<.0063; Adjusted model R2 =.1863, F(9, 358)=9.11 p<.0001 Physician communication 12-13 hour shifts 0.01951 0.0041 <.0001 0.01631 0.0042 0.0001 Bed size 0.08163 0.2044 0.6899 Age 0.26207 0.3984 0.511 Core based statistical area -0.22549 0.1918 0.2404 Ownership 1.09029 0.2403 <.0001 Teaching status 0.2387 0.182 0.1905 Hospital state 0.14859 0.1085 0.1716 Nurse staffing -0.01889 0.0916 0.8368 Practice environment -0.34273 0.1477 0.0209 Note: Unadjusted model R2 =.0552, F(1, 395)= 23.03, p<.0001; Adjusted model R2 =.164, F(9, 358)=7.8 p<.0001 Low rating of hospital 12-13 hour shifts 0.02146 0.0102 0.0366 0.00859 0.0098 0.3834 Bed size -0.23055 0.4745 0.6273 Age 1.88034 0.9246 0.0427
Core based statistical area -0.94028 0.445 0.0353 Ownership 3.3108 0.5577 <.0001 Teaching status 0.44254 0.4224 0.2955 Hospital state 0.45866 0.2518 0.0693 Nurse staffing 0.21843 0.2127 0.3051 Practice environment -1.64337 0.3429 <.0001 Note: Unadjusted model R2 =.011, F(1, 395)= 4.4, p=.0366; Adjusted model R2 =.2568, F(9, 358)=13.75 p<.0001 Help when needed sometimes or never 12-13 hour shifts 0.04041 0.0108 0.0002 0.02627 0.0108 0.0157 Bed size 0.36858 0.5221 0.4806 Age 0.8889 1.0173 0.3828 Core based statistical area -2.54404 0.4897 <.0001 Ownership 2.72513 0.6136 <.0001 Teaching status 0.31976 0.4647 0.4919 Hospital state -0.14782 0.277 0.5939 Nurse staffing 0.17247 0.234 0.4616 Practice environment -1.37246 0.3772 0.0003 Note: Unadjusted model R2 =.0343, F(1, 395)= 14, p=0002; Adjusted model R2 =.2074, F(9, 358)=10.41 p<.0001 Explain medications sometimes or never 12-13 hour shifts 0.03732 0.0103 0.0003 0.021 0.0098 0.0334 Bed size 0.36874 0.4743 0.4374 Age 1.67372 0.9243 0.071 Core based statistical area -1.96639 0.4449 <.0001 Ownership 3.66355 0.5575 <.0001 Teaching status -0.07854 0.4222 0.8525 Hospital state 0.1907 0.2517 0.4491 Nurse staffing 0.47312 0.2126 0.0267
Practice environment -1.33908 0.3427 0.0001 Note: Unadjusted model R2 =.0325, F(1, 395)= 13.25, p=.0003; Adjusted model R2 =.2861, F(9, 358)=15.94 p<.0001 Clean room sometimes or never 12-13 hour shifts 0.04221 0.0077 <.0001 0.0337 0.0078 <.0001 Bed size 0.3387 0.3743 0.3661 Age 0.73431 0.7294 0.3147 Core based statistical area -1.22889 0.3511 0.0005 Ownership 2.18556 0.44 <.0001 Teaching status 0.53594 0.3332 0.1086 Hospital state 0.37741 0.1986 0.0582 Nurse staffing -0.11974 0.1678 0.4759 Practice environment -0.77161 0.2705 0.0046 Note: Unadjusted model R2 =.0715, F(1, 395)= 30.36, p<.0001; Adjusted model R2 =.2296, F(9, 358)=11.85 p<.0001 Discharge information 12-13 hour shifts 0.03908 0.0081 <.0001 0.03244 0.008 <.0001 Bed size -0.11484 0.3853 0.7658 Age 1.38239 0.7507 0.0664 Core based statistical area -2.21036 0.3614 <.0001 Ownership 0.8579 0.4529 0.059 Teaching status 0.04573 0.343 0.894 Hospital state -0.30393 0.2044 0.138 Nurse staffing 0.48793 0.1727 0.005 Practice environment -1.27181 0.2784 <.0001 Note: Unadjusted model R2 =.0559, F(1, 395)= 23.34, p<.0001; Adjusted model R2 =.2405, F(9, 358)=12.6 p<.0001
Hospital proportion of shifts 10-11 hours Unadjusted Adjusted Dependent variable Covariates Estimate SE p value Estimate SE p value Do not recommend hospital 10-11 hour shifts -0.13542 0.0504 0.0075-0.11832 0.0478 0.0138 Bed size -0.42043 0.3472 0.2267 Age 1.49388 0.6765 0.0279 Core based statistical area -1.17939 0.3272 0.0004 Ownership 2.70631 0.4116 <.0001 Teaching status 0.40423 0.3102 0.1934 Hospital state 0.3457 0.1857 0.0634 Nurse staffing 0.09737 0.156 0.5329 Practice environment -1.20968 0.2525 <.0001 Note: Unadjusted model R 2 =.018, F(1, 395)= 7.23, p=.0075; Adjusted model R 2 =.2921, F(9, 358)=16.41 p<.0001 RN communication 10-11 hour shifts -0.15844 0.0433 0.0003-0.13946 0.043 0.0013 Bed size -0.0852 0.312 0.7849 Age 0.89812 0.6079 0.1404 Core based statistical area -1.22044 0.294 <.0001 Ownership 2.08147 0.3698 <.0001 Teaching status 0.4256 0.2788 0.1277 Hospital state 0.16461 0.1668 0.3245 Nurse staffing 0.00929 0.1402 0.9472 Practice environment -0.90425 0.2269 <.0001
Note: Unadjusted model R2 =.0329, F(1, 395)= 13.39, p=.0003; Adjusted model R2 =.2398, F(9, 358)=12.55 p<.0001 Quiet at night sometimes or never 10-11 hour shifts -0.21115 0.0687 0.0022-0.10773 0.0711 0.1304 Bed size 0.77854 0.516 0.1322 Age 1.08607 1.0054 0.2808 Core based statistical area -0.36307 0.4863 0.4558 Ownership 2.34949 0.6117 0.0001 Teaching status 0.32526 0.4611 0.481 Hospital state -1.71299 0.2759 <.0001 Nurse staffing 0.06601 0.2318 0.776 Practice environment -0.90422 0.3753 0.0165 Note: Unadjusted model R2 =.0234, F(1, 395)= 9.46, p=.0022; Adjusted model R2 =.1727, F(9, 358)=8.3 p<.0001 Pain controlled sometimes or never 10-11 hour shifts -0.10633 0.0414 0.0106-0.08908 0.0421 0.035 Bed size -0.08525 0.3057 0.7805 Age 0.53754 0.5956 0.3674 Core based statistical area -1.1183 0.2881 0.0001 Ownership 1.63788 0.3624 <.0001 Teaching status 0.37457 0.2731 0.1711 Hospital state 0.30353 0.1635 0.0641 Nurse staffing -0.03069 0.1373 0.8233 Practice environment -0.81067 0.2223 0.0003 Note: Unadjusted model R2 =.0164, F(1, 395)= 6.59, p=.0106; Adjusted model R2 =.1915, F(9, 358)=9.42 p<.0001 Physician communication 12-13 hour shifts -0.09367 0.0271 0.0006-0.08992 0.0282 0.0016 Bed size 0.12165 0.205 0.5533
Age 0.14365 0.3995 0.7194 Core based statistical area -0.22001 0.1932 0.2556 Ownership 1.08048 0.243 <.0001 Teaching status 0.20605 0.1832 0.2614 Hospital state 0.19915 0.1096 0.0701 Nurse staffing -0.00839 0.0921 0.9275 Practice environment -0.37407 0.1491 0.0126 Note: Unadjusted model R2 =.0295, F(1, 395)= 11.98, p=.0006; Adjusted model R2 =.1534, F(9, 358)=7.21 p<.0001 Low rating of hospital 10-11 hour shifts -0.12185 0.0673 0.0708-0.12168 0.0649 0.0615 Bed size -0.24692 0.471 0.6004 Age 1.82631 0.9178 0.0474 Core based statistical area -0.90017 0.4439 0.0433 Ownership 3.20571 0.5584 <.0001 Teaching status 0.40945 0.4209 0.3313 Hospital state 0.51409 0.2519 0.042 Nurse staffing 0.21446 0.2116 0.3116 Practice environment -1.69115 0.3426 <.0001 Note: Unadjusted model R2 =.0083, F(1, 395)= 3.28, p=.0708; Adjusted model R2 =.2625, F(9, 358)=14.16 p<.0001 Help when needed sometimes or never 10-11 hour shifts -0.19533 0.0715 0.0066-0.12701 0.0719 0.0783 Bed size 0.44202 0.5222 0.3979 Age 0.69616 1.0176 0.4943 Core based statistical area -2.54415 0.4922 <.0001 Ownership 2.7333 0.6191 <.0001 Teaching status 0.27099 0.4667 0.5618 Hospital state -0.07331 0.2793 0.7931
Nurse staffing 0.19166 0.2346 0.4146 Practice environment -1.41543 0.3799 0.0002 Note: Unadjusted model R2 =.0186, F(1, 395)= 7.47, p=0066; Adjusted model R2 =.2013, F(9, 358)=10.02 p<.0001 Explain medications sometimes or never 10-11 hour shifts -0.14757 0.0681 0.0307-0.11152 0.0652 0.0883 Bed size 0.42241 0.4738 0.3732 Age 1.52076 0.9231 0.1004 Core based statistical area -1.96147 0.4465 <.0001 Ownership 3.65664 0.5616 <.0001 Teaching status -0.11966 0.4233 0.7776 Hospital state 0.25414 0.2533 0.3165 Nurse staffing 0.48719 0.2129 0.0227 Practice environment -1.37763 0.3446 <.0001 Note: Unadjusted model R2 =.0118, F(1, 395)= 4.7, p=.0307; Adjusted model R2 =.2828, F(9, 358)=15.69 p<.0001 Clean room sometimes or never 10-11 hour shifts -0.20952 0.0511-0.2022-0.16559 0.052 0.0016 Bed size 0.43156 0.3774 0.2536 Age 0.48736 0.7354 0.5079 Core based statistical area -1.22769 0.3557 0.0006 Ownership 2.19246 0.4474 <.0001 Teaching status 0.47282 0.3372 0.1618 Hospital state 0.47403 0.2018 0.0194 Nurse staffing -0.09547 0.1696 0.5738 Practice environment -0.82785 0.2745 0.0027 Note: Unadjusted model R2 =.0409, F(1, 395)= 16.8, p<.0001; Adjusted model R2 =.2113, F(9, 358)=10.66 p<.0001
Discharge information 10-11 hour shifts -0.23021 0.0534 <.0001-0.19789 0.0531 0.0002 Bed size -0.04486 0.3853 0.9074 Age 1.14901 0.7507 0.1268 Core based statistical area -2.18993 0.3631 <.0001 Ownership 0.81278 0.4567 0.076 Teaching status -0.02326 0.3443 0.9462 Hospital state -0.196 0.206 0.3421 Nurse staffing 0.50637 0.1731 0.0037 Practice environment -1.34215 0.2802 <.0001 Note: Unadjusted model R2 =.045, F(1, 395)= 18.57, p<.0001; Adjusted model R2 =.2353, F(9, 358)=12.24 p<.0001 Hospital proportion of shifts 8-9 hours Unadjusted Adjusted Dependent variable Covariates Estimate SE p value Estimate SE p value Do not recommend hospital 8-9 hour shifts -0.02933 0.0078 0.0002-0.01564 0.0077 0.0424 Bed size -0.43059 0.349 0.218 Age 1.61437 0.6815 0.0184 Core based statistical area -1.20469 0.3276 0.0003 Ownership 2.76753 0.4105 <.0001 Teaching status 0.4619 0.3113 0.1388 Hospital state 0.24253 0.1874 0.1963 Nurse staffing 0.09487 0.1565 0.5448 Practice environment -1.15293 0.2524 <.0001 Note: Unadjusted model R 2 =.0343, F(1, 395)= 14.01, p=.0002; Adjusted model R 2 =.2883, F(9, 358)=16.11 p<.0001
RN communication 8-9 hour shifts -0.02899 0.0068 <.0001-0.02179 0.0069 0.0017 Bed size -0.11216 0.3129 0.7203 Age 1.06885 0.6111 0.0812 Core based statistical area -1.24298 0.2938 <.0001 Ownership 2.13262 0.3681 <.0001 Teaching status 0.50054 0.2792 0.0738 Hospital state 0.0307 0.168 0.8551 Nurse staffing 0.00255 0.1404 0.9855 Practice environment -0.83588 0.2264 0.0003 Note: Unadjusted model R2 =.0447, F(1, 395)= 18.44, p<.0001; Adjusted model R2 =.2387, F(9, 358)=12.48 p<.0001 Quiet at night sometimes or never 8-9 hour shifts 0.0226 0.0108 0.0377 0.01794 0.0114 0.1157 Bed size 0.91282 0.5171 0.0784 Age 0.92064 1.0098 0.3626 Core based statistical area -0.45594 0.4855 0.3483 Ownership 2.60651 0.6082 <.0001 Teaching status 0.31115 0.4613 0.5004 Hospital state -1.68903 0.2776 <.0001 Nurse staffing 0.1 0.232 0.6666 Practice environment -0.86685 0.3741 0.021 Note: Unadjusted model R2 =.0109, F(1, 395)= 4.35, p=.0377; Adjusted model R2 =.1731, F(9, 358)=8.33 p<.0001 Pain controlled sometimes or never 8-9 hour shifts -0.02123 0.0065 0.0011-0.01115 0.0068 0.1 Bed size -0.0901 0.3072 0.7694 Age 0.62288 0.5998 0.2998
Core based statistical area -1.13871 0.2884 <.0001 Ownership 1.6879 0.3613 <.0001 Teaching status 0.41669 0.274 0.1292 Hospital state 0.22816 0.1649 0.1674 Nurse staffing -0.03187 0.1378 0.8172 Practice environment -0.76823 0.2222 0.0006 Note: Unadjusted model R2 =.0266, F(1, 395)= 10.79, p=.0011; Adjusted model R2 =.1875, F(9, 358)=9.18 p<.0001 Physician communication 8-9 hour shifts -0.02104 0.0042 <.0001-0.01656 0.0045 0.0003 Bed size 0.09307 0.2046 0.6494 Age 0.2752 0.3995 0.4913 Core based statistical area -0.2291 0.1921 0.2337 Ownership 1.09777 0.2406 <.0001 Teaching status 0.25957 0.1825 0.1558 Hospital state 0.10361 0.1098 0.3461 Nurse staffing -0.01556 0.0918 0.8655 Practice environment -0.32887 0.148 0.0269 Note: Unadjusted model R2 =.0605, F(1, 395)= 25.38, p<.0001; Adjusted model R2 =.1612, F(9, 358)=7.46 p<.0001 Low rating of hospital 8-9 hour shifts -0.02962 0.0105 0.005-0.01013 0.0104 0.332 Bed size -0.23082 0.4739 0.6265 Age 1.89931 0.9254 0.0408 Core based statistical area -0.93912 0.4449 0.0355 Ownership 3.30591 0.5574 <.0001 Teaching status 0.45644 0.4227 0.281 Hospital state 0.42981 0.2544 0.092 Nurse staffing 0.2186 0.2126 0.3044
Practice environment -1.63544 0.3428 <.0001 Note: Unadjusted model R2 =.0198, F(1, 395)= 7.97, p=.005; Adjusted model R2 =.2572, F(9, 358)=13.77 p<.0001 Help when needed sometimes or never 8-9 hour shifts -0.04582 0.0111 <.0001-0.03228 0.0114 0.0051 Bed size 0.36201 0.52 0.4868 Age 0.95794 1.0156 0.3462 Core based statistical area -2.5377 0.4882 <.0001 Ownership 2.70213 0.6117 <.0001 Teaching status 0.36497 0.4639 0.432 Hospital state -0.24081 0.2792 0.389 Nurse staffing 0.17152 0.2333 0.4626 Practice environment -1.34764 0.3762 0.0004 Note: Unadjusted model R2 =.0416, F(1, 395)= 17.1, p<.0001; Adjusted model R2 =.2118, F(9, 358)=10.69 p<.0001 Explain medications sometimes or never 8-9 hour shifts -0.04514 0.0105 <.0001-0.02393 0.0104 0.0222 Bed size 0.37185 0.4734 0.4326 Age 1.71289 0.9244 0.0647 Core based statistical area -1.96538 0.4444 <.0001 Ownership 3.65687 0.5568 <.0001 Teaching status -0.04627 0.4223 0.9128 Hospital state 0.12323 0.2541 0.628 Nurse staffing 0.47448 0.2123 0.0261 Practice environment -1.32007 0.3424 0.0001 Note: Unadjusted model R2 =.0449, F(1, 395)= 18.5, p<.0001; Adjusted model R2 =.2875, F(9, 358)=16.05 p<.0001
Clean room sometimes or never 8-9 hour shifts -0.04447 0.0079 <.0001-0.03525 0.0082 <.0001 Bed size 0.35772 0.3742 0.3397 Age 0.77027 0.7307 0.2925 Core based statistical area -1.2341 0.3513 0.0005 Ownership 2.19454 0.4401 <.0001 Teaching status 0.58121 0.3338 0.0825 Hospital state 0.28067 0.2009 0.1632 Nurse staffing -0.11403 0.1678 0.4973 Practice environment -0.7425 0.2707 0.0064 Note: Unadjusted model R2 =.0749, F(1, 395)= 31.88, p<.0001; Adjusted model R2 =.2285, F(9, 358)=11.78 p<.0001 Discharge information 8-9 hour shifts -0.03699 0.0084 <.0001-0.03062 0.0085 0.0004 Bed size -0.08177 0.3867 0.8326 Age 1.3887 0.7552 0.0668 Core based statistical area -2.22256 0.363 <.0001 Ownership 0.88725 0.4548 0.0519 Teaching status 0.08245 0.345 0.8112 Hospital state -0.38492 0.2076 0.0646 Nurse staffing 0.49716 0.1735 0.0044 Practice environment -1.24526 0.2797 <.0001 Note: Unadjusted model R2 =.0472, F(1, 395)= 19.53, p<.0001; Adjusted model R2 =.2333, F(9, 358)=12.1 p<.0001