1. Nurses Perception of Staffing and Resource Adequacy: Does Job Design Make a Difference? Kamisha Hamilton Escoto, PhD University of Minnesota Ben-Tzion Karsh, PhD (University of Wisconsin-Madison) Matthew Scanlon, MD (Childrens Hospital of Wisconsin) Neal Patel, MD (Vanderbilt Childrens Hospital) Theresa Shalaby, RN (Vanderbilt Childrens Hospital) Kathleen Murkowski, CRT (Childrens Hospital of Wisconsin) Rainu Kaushal, MD, MPH (Brigham and Womens Hospital) Judy Arnold, RN (Vanderbilt Childrens Hospital)

2. Background Consequences of nurse staffing levels (Aiken et al., 2002; Lang et al., 2004, Mark et al., 2004) Consequences of nurse staffing levels (Aiken et al., 2002; Lang et al., 2004, Mark et al., 2004) Patient outcomes: inpatient mortality, failure to rescue Patient outcomes: inpatient mortality, failure to rescue Nurse outcomes: burnout, dissatisfaction Nurse outcomes: burnout, dissatisfaction Hospital: length of stay Hospital: length of stay Trends in nurse staffing (Bond et al., 2000; Buerhaus & Staiger, 1999) not necessarily aligned with perception of staffing levels (Aiken et al., 2000) Trends in nurse staffing (Bond et al., 2000; Buerhaus & Staiger, 1999) not necessarily aligned with perception of staffing levels (Aiken et al., 2000)

3. Why is perception of adequate staffing important? Staffing perceptions associated with… Staffing perceptions associated with… Job satisfaction, organizational and professional commitment (DeGroot et al.., 1998) Job satisfaction, organizational and professional commitment (DeGroot et al.., 1998) Lower perception of quality of care at the hospital level, quality of nursing care on the last shift (McCusker et al., 2004), and perception of own ability to provide quality care (Escoto & Karsh, 2006; Williams, 1998) Lower perception of quality of care at the hospital level, quality of nursing care on the last shift (McCusker et al., 2004), and perception of own ability to provide quality care (Escoto & Karsh, 2006; Williams, 1998) Nurse safety outcomes (e.g., needlestick injuries) (Clarke et al., 2002) Nurse safety outcomes (e.g., needlestick injuries) (Clarke et al., 2002) Despite importance of staffing perceptions there has been little exploration of its predictors in the literature (e.g., Mark, 2004) Despite importance of staffing perceptions there has been little exploration of its predictors in the literature (e.g., Mark, 2004)

4. Staff/resource adequacy (SRA) Task control Resource control Skill discretion Social support Nurse-physician relations Feedback Job Demands What are the predictors of perception of staffing/resource adequacy? Model based on the literature ( Kramer & Schmalenberg, 2002; Kramer et al., 2004) and Demand-Control-Support theory of job design ( Karasek, 1979; Johnson & Hall, 1988)

5. Methods Analysis of data from a larger study of working conditions, outcomes, and technology with pediatric nurses Analysis of data from a larger study of working conditions, outcomes, and technology with pediatric nurses Design: Cross-sectional, survey design Design: Cross-sectional, survey design Sample: Sample: Free-standing, academic pediatric hospital with 222 beds and 9 inpatient units Free-standing, academic pediatric hospital with 222 beds and 9 inpatient units Staff nurses employed in 3 units Staff nurses employed in 3 units Pediatric Intensive Care Unit Pediatric Intensive Care Unit Medical/Surgical Medical/Surgical Hematology-Oncology-Transplant Hematology-Oncology-Transplant

6. Statistical Analysis Data preparation for regression analyses Data preparation for regression analyses Factor analysis Factor analysis Reliability (Cronbachs ) Reliability (Cronbachs ) Descriptive statistics & Bivariate correlation Descriptive statistics & Bivariate correlation Two regression models Two regression models Block 1. Demographics Block 1. Demographics Block 2. Job demands Block 2. Job demands Block 3. Control Variables Block 3. Control Variables Block 4. Support Variables Block 4. Support Variables Block 5. Interactions Block 5. Interactions Model 1: Control variables x Job demands Model 1: Control variables x Job demands Model 2: Support variables x Job demands Model 2: Support variables x Job demands

7. Characteristics of the nursing sample CharacteristicN (%) UnitPediatric Intensive Care Unit (PICU)65 (54.2%) Medical/Surgical32 (26.7%) Hematology-Oncology-Transplant23 (19.2%) Age18-29 years40 (33.3%) 30-39 years38 (31.7%) 40-49 years30 (25.0%) 50 years and older12 (10.0%) EducationBachelors degree100 (83.3%) Graduate degree11 (9.2%) Associates degree or Diploma9 (7.5%) Racial backgroundWhite115 (95.8%) Non-white5 (4.2%) GenderFemale117 (97.5%) Male3 (2.5%) Experience11.6 years (Range 3 mo – 36 years) N=120, Response rate = 59.1%

8. Results - Descriptive Statistics Scale (# items)MeanSDRange Cronbach Job demands (3)4.440.802.3 - 6.00.65 Task control (4)3.431.101.25 – 6.00.77 Resource control (2)2.341.280.0 – 6.00.92 Skill discretion (1)3.801.291.0 - 6.0- Social support (4)4.180.930.67 – 6.00.72 Nurse-physician relations (3)4.071.022.0 – 6.00.89 Feedback (3)3.591.091.0 - 6.00.79 Staffing/resource adequacy (4)3.490.841.0 – 5.00.84 Response scale for all variables ranged from 0 (not at all) – 6 (a great deal)

9. Regression of SRA on job design variables, N=120 Source R2R2R2R2 R 2 change PBeta Demands --Job demands (D) 0.1700.131<0.001-0.443** Control --Task control (TC) --Resource control (RC) --Skill discretion (SD) 0.3460.176<0.0010.0200.0770.116* Support --Social support --Nurse-physician relations --Feedback0.5010.155<0.0010.0940.267**0.141* Job demands x control --TC x D --RC x D --SD x D *p<0.05; **p<0.01. Beta values are from the final regression equation; [F(17, 102)=7.944, p<0.001] Model is adjusted for unit, gender, ethnicity, education and years of nursing experience. Not significant

10. Source R2R2R2R2 R 2 change PBeta Demands --Job Demands (D)0.1700.131<0.001-0.437** Control --Task control --Resource control --Skill discretion 0.3460.176<0.0010.0100.0600.142** Support --Social support (SS) --Nurse-physician relations (NP) --Feedback (F) 0.5010.155<0.0010.0740.266**0.153** Job demands x support --SS x D --NP x D --F x D 0.5220.0210.056-0.220*0.0820.116 * p<0.05; **p<0.01. Beta values are from the final regression equation [F(17, 102)=8.656, p<0.001] Model is adjusted for unit, gender, ethnicity, education and years of nursing experience. Regression of SRA on job design variables, N=120

11. Interaction – Job demands & Social support

12. Conclusions Improving conditions of work as important as determining optimal levels of nurse staffing Improving conditions of work as important as determining optimal levels of nurse staffing Interventions supporting freedom to be creative, feedback mechanisms, and collaboration between nurses and physicians are essential Interventions supporting freedom to be creative, feedback mechanisms, and collaboration between nurses and physicians are essential Social support may help alleviate burden on nurses, but at high demand levels may be counterproductive Social support may help alleviate burden on nurses, but at high demand levels may be counterproductive Limitations Limitations Cross-sectional design Cross-sectional design Scale measurement (job control variables) Scale measurement (job control variables) External validity External validity

13. Acknowledgments This research was supported by AHRQ-1 R01 HS013610 (Bar Coding and Employee and Patient Safety) This research was supported by AHRQ-1 R01 HS013610 (Bar Coding and Employee and Patient Safety) Bar Coding and Employee and Patient Safety Research Team Bar Coding and Employee and Patient Safety Research Team Dr. Ben-Tzion Karsh (University of Wisconsin, Madison) Dr. Ben-Tzion Karsh (University of Wisconsin, Madison) Samuel Alper (University of Wisconsin, Madison) Samuel Alper (University of Wisconsin, Madison) Judy Arnold (Vanderbilt Childrens Hospital) Judy Arnold (Vanderbilt Childrens Hospital) Dr. Patricia Brennan (University of Wisconsin, Madison) Dr. Patricia Brennan (University of Wisconsin, Madison) Dr. Roger Brown (University of Wisconsin, Madison) Dr. Roger Brown (University of Wisconsin, Madison) Richard Holden (University of Wisconsin, Madison) Richard Holden (University of Wisconsin, Madison) Dr. Rainu Kaushal (Brigham and Women's Hospital) Dr. Rainu Kaushal (Brigham and Women's Hospital) Kathy Murkowski (Childrens Hospital of Wisconsin) Kathy Murkowski (Childrens Hospital of Wisconsin) Dr. Neal Patel (Vanderbilt Childrens Hospital) Dr. Neal Patel (Vanderbilt Childrens Hospital) Dr. Matt Scanlon (Childrens Hospital of Wisconsin) Dr. Matt Scanlon (Childrens Hospital of Wisconsin) Kathleen Skibinski (University of Wisconsin-Madison) Kathleen Skibinski (University of Wisconsin-Madison)

14. Questions?

15. Variables CATEGORYVARIABLEITEMS BASED ON… DemandsJob demandsKarasek, 1979 ControlTask controlMcLaney & Hurrell, 1988 Resource controlMcLaney & Hurrell, 1988 Skill DiscretionKarasek, 1979 SupportSocial supportCaplan et al., 1975 Nurse-physician relationsAiken & Patrician, 2000 FeedbackSims et al., 1976 Dependent variable Staff/resource adequacy (SRA) Aiken & Patrician, 2000 Response scale for all variables ranged from 0 (not at all) – 6 (a great deal)

16. Staffing/resource adequacy To what extent is there enough staff to get the work done? To what extent is there enough staff to get the work done? To what extent are there enough nurses on staff to provide quality patient care? To what extent are there enough nurses on staff to provide quality patient care? To what extent is there enough time and opportunity to discuss patient care problems with other nurses? To what extent is there enough time and opportunity to discuss patient care problems with other nurses? To what extent are there adequate support services to allow you to spend time with your patients? To what extent are there adequate support services to allow you to spend time with your patients?

17. Nurse-phys relations How much teamwork exists between nurses and physicians? How much teamwork exists between nurses and physicians? How much collaboration exists between nurses and physicians? How much collaboration exists between nurses and physicians? To what extent do nurses and physicians have good working relationships? To what extent do nurses and physicians have good working relationships?

18. Task control How much influence do you have over the variety of tasks you perform? How much influence do you have over the variety of tasks you perform? How much influence do you have over the order in which you perform tasks at work? How much influence do you have over the order in which you perform tasks at work? How much influence do you have over the amount of work you do? How much influence do you have over the amount of work you do? How much influence do you have over the pace of your workthat is, how fast or slow you work? How much influence do you have over the pace of your workthat is, how fast or slow you work?

19. Resource control How much influence do you have over the availability of supplies and equipment you need to do your work? How much influence do you have over the availability of supplies and equipment you need to do your work? How much influence do you have over the availability of materials you need to do your work? How much influence do you have over the availability of materials you need to do your work?

20. Social support How much do other people at work go out of their way to make your life easier? How much do other people at work go out of their way to make your life easier? How easy is it to talk with other people at work? How easy is it to talk with other people at work? How much can you rely on other people at work when things get tough at work? How much can you rely on other people at work when things get tough at work? How much are other people at work willing to listen to your personal problems? How much are other people at work willing to listen to your personal problems?

21. Job demands To what extent does your job require you to work hard? To what extent does your job require you to work hard? To what extent does your job require a great deal to be done? To what extent does your job require a great deal to be done? To what extent do you feel there is not enough time for you to finish your work? To what extent do you feel there is not enough time for you to finish your work?

22. Skill discretion To what extent does your job require creativity? To what extent does your job require creativity?

23. Feedback To what extent do you find out how well you are doing on the job as you are working? To what extent do you find out how well you are doing on the job as you are working? To what extent do you have the opportunity to find out how well you are doing on your job? To what extent do you have the opportunity to find out how well you are doing on your job? To what extent do you know if you are performing your job well or poorly? To what extent do you know if you are performing your job well or poorly?