Objective: A growing body of research suggests that organizational factors in hospitals affect a range of patient outcomes, from satisfaction with care to inpatient mortality, as well as important nurse outcomes such as job satisfaction, burnout, and intent to resign. Driven by growing interest in safety in health care, particular attention is now being paid to the role of organizational factors in errors and accidents in hospitals. Our team at the University of Pennsylvania has studied sharps injuries in hospitals for some time and has examined clinician and organizational factors influencing their occurrence. Sharps injuries are of interest not only as an important occupational health issue for nurses, but also because they may serve as a proxy for important safety and quality problems in hospitals. In prior studies using datasets on nurses in 20 hospitals in 1991 and 22 hospitals in 1998, we found that nurses working on nursing units or in hospitals characterized by poor working climates (defined broadly) were at significantly higher risk of sustaining needlestick injuries. The purpose of the present study is to determine whether this finding persists when specific aspects of nurses’ work environments are investigated in a much larger pool of nurses and hospitals across 4 jurisdictions in North America. Design: Cross-sectional surveys conducted by member sites of the International Hospital Outcomes Research Consortium. Population, Sample, Setting, Years: Probability samples of licensed RNs working as hospital staff nurses in Pennsylvania, Ontario, Alberta, and British Columbia drawn using licensure/registration rolls in each jurisdiction in 1998-1999. Hospitals from which at least 10 nurses returned questionnaires were selected in order to ensure reliability of the organizational measures. The analytic sample consisted of 27,810 nurses working in 473 hospitals. Variables: The major outcome variable was retrospectively-reported sharps injuries within the previous year (assessed using a series of previously-validated questions). Hospital investment in standards of care was measured using a newly-developed subscale of the Nursing Work Index—Revised (Aiken & Patrician, 2000) addressing hospital investments in the quality of nursing care. In each hospital, the proportion of nurses agreeing that orientation and preceptorship programs for newly-hired nurses, active quality assurance program, an active inservice and/or continuing education program, and high standards of care promulgated by the administration were present was calculated. The number of these features (maximum of 5) that at least 70% of the nurses agreed were present in the institution was determined. Control variables included nurse clinical specialty, hours worked by each nurse in the previous year (a proxy for exposure) and availability of safety equipment for injections and venipuncture. Methods: Measures were drawn from anonymous mail-in questionnaires linked at the hospital level. Using robust logistic regression models with employing hospital as the clustering variable, the risk of sharps injuries for nurses from hospitals with no features, one or more features, and all of the organizational features of interest were computed, before and after controls for background variables. Findings: Overall, 12.4% of the nurses reported one or more sharps injuries in the preceding year. A clear impact of investments in standards of care was found such that nurses in hospitals with fewer of the features reported more sharps injuries. For instance, 7.9% of nurses in hospitals with all five elements reported injuries, as compared with 16.6% of nurses in hospitals with none. After adjusting for hospital and nurse characteristics, the risk of sustaining at least one injury remained twice as high in nurses from hospitals with the fewest as compared with the most features [adjusted Odds Ratio, 95% CI: 1.89 (1.34, 2.66)]. Conclusions: Investments in developing and maintaining high standards of care are an important predictor of sharps injuries among staff nurses in general hospitals in North America. Implications: Allocation of resources in hospital nursing has important consequences for safety. Future research on safety in health care should focus on specific quality initiatives and professional development programs as well as staffing and organizational culture. While possibly expedient in the short term, cuts in staff orientation and education and quality assurance efforts should be done with great caution, given the human and financial costs of preventable errors and accidents.
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