Research Team
Principal Investigator
- Professor Peter Davis, Christchurch School of Medicine and Health Sciences
Co-investigators
- Suzanne Gower [Christchurch School of Medicine and Health Sciences]
- Patrick Graham [Christchurch School of Medicine and Health Sciences]
- Dr Mary Finlayson [School of Health Sciences, Massey University (Albany)]
- Dr Robin Gauld [Department of Preventive and Social Medicine, Dunedin School of Medicine]
- Andrew Sporle [Christchurch School of Medicine and Health Sciences]
Background
This research will examine patient outcomes and nurse staffing in New Zealand's secondary and tertiary hospitals across the period 1988-1999, during which two distinct waves of hospital restructuring took place in New Zealand, one following the State Sector Act (1988) and the other the Health and Disability Services Act (1993).
Aims
To trace changes in severity-adjusted hospital patient outcomes, including inpatient, 30-day and 60-day post-discharge mortality, readmission rates and failure-to-rescue rates.To determine the relative effects of nurse staffing (nurse-patient ratios, nursing skill mix, total FTEs per 1000 patient days, change in staffing over time) on severity-adjusted patient outcomes and selected nurse outcomes (burnout, needle-stick injuries) controlling for explanatory variables. To determine the extent to which organisational attributes that affect nursing practice mediate the effects of nurse staffing on patient outcomes, and whether better patient outcomes in New Zealand hospitals are associated with organisational attributes common to magnet hospitals in the United States.
Method
The National Minimum Dataset (NMDS), routinely collected by the New Zealand Health Information Service (NZHIS), will be used to establish patient outcome measures for the period 1988-1999 including length of stay, inpatient, 30-day and 60-day post-discharge mortality, readmission rates, and failure-to-rescue rates. All outcome measures will be adjusted for both hospital and patient characteristics.
Information held by hospitals and statutory agencies will be used to calculate over time traditional measures of the nursing workforce, including nurse-patient ratios and nursing skill mix. The Clinical Environment index survey instrument will be administered to all staff employed as nurses in the study hospitals. This will indicate hospitals' organisational attributes at a single point in time. Information on changes in each hospital will be collected, using existing documentation and interviews.
Significance and Relevance
New Zealand's health sector reforms have arguably gone further and faster than those in other countries similarly compelled to contain spending on health care. Because hospital care accounts for a large proportion of health spending, hospital restructuring has been a large part of those reforms.
Hospital restructuring has implications for a number of groups, including those seeking hospital care as patients and those within the health care workforce, the largest group of which are nurses. For patients, changes in the hospital sector have resulted in shorter stays in hospital, more day stay admissions and ambulatory procedures, and longer waiting times. As a result, patients are likely to show higher levels of acuity and severity when they are in hospital. Thus, while nurses are required to care for patients in need of higher levels of care, hospital restructuring has also changed the way in which their work is organised and managed, the numbers and skill mix of those employed, and the work they are expected to undertake.
Research indicates that patient outcomes are linked to nurse-patient ratios and nurse skill mix. Hospitals in which the organisation of nursing promotes a high level of nurse autonomy, nurse control over the patient care environment, and good relationships between nurses and doctors, have better patient outcomes.
This project will determine if, where these "magnet hospital" features exist in New Zealand, patient outcomes are similarly improved. It will also determine if the implementation of hospital restructuring, varying as it did between institutions, is reflected in patient outcomes. Both sets of findings will have value in future policy making, providing evidence of best practice in maximising patient outcomes.
Publications
Finlayson MP, Gower SE. Hospital restructuring: identifying the impact on patients and nurses. Nursing Praxis in New Zealand 18(1) 27-35, 2002.
Gower S, Finlayson M, Turnbull J. Hospital restructuring: the impact on nursing. In R. Gould (ed.), Continuity amid Chaos. Health care management and delivery in New Zealand. University of Otago Press, Dunedin, pp 123-136, 2003.
Hossain M, Graham PJ, Gower S, Davis P. Hierarchical Bayesian generalised linear models with time dependent clustering: Assessing the effect of health sector reform on patient outcomes in New Zealand. Health Services and Outcomes Research Methodology 4:169-186, 2003.