Nursing resources affect hospital patient experience ratings, report finds

The nursing work environment, nurse education, and staffing levels are independent factors affecting hospital scores on a key measure of patient-centered care—with significant implications for reimbursements, reports a study in Medical Care.

"Our results provide evidence-based guidance about which modifiable aspects of hospital nursing are likely to improve patient experience ratings," says Kathleen E. Fitzpatrick Rosenbaum, Ph.D., RN, CCRN, of Yale University.

The researchers analyzed Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores for 540 hospitals in four states (California, Florida, New Jersey, and Pennsylvania) for the year 2016. Developed by the US Centers for Medicare & Medicaid Services, the HCAHPS survey assesses patient experiences of hospital care, with the goal of determining the extent of patient-centered care.

Because patient experience ratings affect Medicare reimbursement levels, "hospital executives are motivated to identify levers for improving HCAHPS scores," the researchers write. However, there is "minimal evidence" about what organizational strategies hospitals can follow to improve their HCAHPS ratings. Research has shown that organizational resources related to nursing care are associated with better patient outcomes.

Using data on a wide range of hospital characteristics, the study focused on the relationships between HCAHPS ratings and four categories of hospital nursing resources:

• Education—percentage of nurses with a bachelor's degree or higher
• Skill mix—proportion of registered nurses to total nursing staff
• Staffing—patient-to-nurse ratio
• Work environment—nurse ratings of the quality of their work environment

'Evidence-based guidance' on nursing resources to improve patient experience

The average "top box" (overall) HCAHPS rating was 68%. Scores ranged from about 76% for hospitals in the highest HCAHPS category to 60% in the lowest category. Large, non-teaching hospitals with high technology capabilities tended to have the highest HCAHPS scores.

After adjustment for hospital characteristics, the factor most strongly related to HCAHPS ratings was work environment. For each standard deviation increase in work environment score, hospitals were more than twice as likely (odds ratio 2.42) to be in a higher patient experience performance category.

Nurse education and staffing showed significant but weaker associations with HCAHPS scores, while nursing skill mix was not a significant factor. Within the work environment category, staff development/continuing education and nurse participation in hospital affairs seemed to have the greatest impact on HCAHPS scores.

"Our findings enhance three decades of evidence generated by the Center for Health Outcomes and Policy Research at the University of Pennsylvania, where the research was conducted, revealing the potential to improve patient outcomes by providing optimal settings for professional nurses," remarks senior author Eileen Lake, Ph.D., RN.

"Improving nursing resources is a strategic organizational intervention likely to improve HCAHPS ratings," the researchers write. While work environment is the single most important factor, previous studies suggest that taking steps to improve nurse staffing and work environment together "may have a synergistic effect on achieving higher patient experience ratings."

Dr. Rosenbaum and co-authors conclude, "Our findings offer a signal to hospital executives that improving the work environment, staffing, and nurse education may be wise investments toward achieving 'top-box' patient experience levels."