A recent study assessing the relationship between nursing specialty certification rates and surgical site infections (SSI) provides an innovative option for future research exploring relationships between nursing and hospital procedures and medical and/or surgical adverse events. Published in the July/August issue of the Journal of Nursing Administration (JONA), the peer-reviewed journal for nursing managers and executives, the research was conducted by representatives from the University of Kansas Medical Center, the National Database of Nursing Quality Indicators (NDNQI), the Competency & Credentialing Institute (CCI) and the University of Wyoming. It was sponsored through a grant from CCI.
The study examined data from 69 hospitals, 346 units and 6,585 registered nurses (RNs) participating in the National Database of Nursing Quality Indicators (NDNQI), as well as the Centers for Disease Control National Healthcare Safety Network (NHSN) SSI data on 22,188 patients who underwent colon (COLO) and abdominal hysterectomy (HYST) procedures. The study found higher American Society of Anesthesiologist (ASA) scores, longer surgical procedure time, and contaminated or dirty wounds were associated with higher SSI occurrence.
"This study represents the first time researchers have had the opportunity to review extensive amounts of data for nursing outcomes by combining a large, nursing-focused database (NDNQI) with a large national database of patient outcomes (NHSN) and paves the way for future models of study down the road," said Emily Cramer, Ph.D., research assistant professor, University of Kansas Medical Center and study researcher. "Having access to this level of detail into care settings, procedures, nursing education and certification, surgical details, patient wound characteristics, and more allows us to have a unique understanding of what is truly impactful and essential when it comes to what surgical nurses require to ensure successful patient care."
The study authors utilized a "structure-process-outcome" framework utilized by Tavlov & colleagues, finding that structures and processes of care influenced care outcome. Effects of structure--provider (nurse), patient, and system (hospital) characteristics--were examined on the outcome of SSI. Utilizing this framework allowed researchers to control for other structural characteristics that might affect SSI occurrence, including: 1) system characteristics, such as Magnet ® status, ownership, and teaching status; 2) provider characteristics, such as nursing education and years on the unit; and 3) patient characteristics of ASA score and wound class. (See Figure 1. SSI study structure, process and outcome variables.)
The study also found 40 percent lower odds for SSIs among hospitals with Magnet® designation after adjusting for other hospital characteristics, patient/procedure characteristics, certification rates, and RN covariates.
"These findings reinforce the already well-known and well-researched benefits of Magnet® status within a hospital system," said James Stobinski, PhD, RN, CNOR, CSSM, CEO, CCI, and study author. "Whether for recruiting top talent, maintaining a superior level of patient care and safety, or fostering a collaborative environment, the benefits of obtaining Magnet hospital status provides returns on investment and ample opportunity for nursing and hospital staff growth. The results of this study remind us of the intrinsic benefits of Magnet status to hospital staff and patients alike."
Moving forward, the researchers hope to explore further the relevance of Needleman's recently proposed Expanded Conceptual Model for Credentialing in Nursing. Needleman's expanded theory adds three intervening pathways between structure and outcomes (i.e. "invisible architecture") such as organizational and unit climate, culture and leadership, including how specialty-certified nurses provide secondary benefits to those not in their care, creating multiple associations and causal pathways that affect outcomes.
"The two large national databases contained multiple levels of data, so we have access to an overwhelming amount of information, but the datasets lacked information about organizational invisible architecture that may hinder or enhance nursing autonomy and patient success," said Diane K. Boyle, Ph.D., RN, FAAN, Professor at the Whitney School of Nursing, University of Wyoming and study author. "To build upon the findings of this study, we would next hope to explore the concept of nursing autonomy within Needleman's theoretical framework in a given setting and its benefits to nurses amongst co-workers, with other medical staff, with patients, and within the larger hospital setting."
The study was a secondary analysis of 2014 data from the NHSN and the NDNQI annual RN survey, including more than 285,000 nurses on more than 16,000 units, spanning perioperative, surgical intensive care (SICU) and medical-surgical intensive care (MSICU), in nearly 850 hospitals. Participating NDNQI hospitals were required to submit 2014 SSI data to NHSN, resulting in 72 hospitals submitting 2014 NHSN SSI data on COCO and HYST surgical procedures to NDNQI.
The analysis was restricted to hospitals with eligible perioperative units, adult SICU, MSICU, surgical units, and M/S units, as well as hospitals where at least one perioperative unit and at least one SICU, MSICU, surgical, or M/S unit participated in the survey. To complete the NDNQI survey, RNs must have been employed on the unit for at least three months and spent fifty percent or more of their time in direct patient care.