Study Shows Link Between Nurses’ Work Environment, Hospital-Onset C. Diff

Serious and sustained commitments to improving nurse work environments in hospitals could help lower hospital-onset Clostridioides difficile infection (CDI), according to findings published in Medical Care.

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CDI is the leading cause of hospital-onset diarrhea and is associated with increased lengths of stay and mortality. Although some hospitals have successfully reduced the burden of CDI, many still struggle to reduce hospital-onset CDI. Because of their close proximity to patients, nurses are essential resources in efforts to prevent hospital-onset CDI.

Nurses represent the largest number of health care professionals working in hospitals, and they regularly interact with nearly all other clinicians in the health system environment. Importantly, nurses implement practices to prevent and control the spread of hospital-onset CDI, including prompt and appropriate diagnostic testing, prompt initiations of contact precautions, hand hygiene, and the potential to influence best environmental disinfection or antibiotic stewardship.

In the new study, investigators explored how aspects of the nurse work environment are related to hospital-onset CDI. The work environment includes multiple dimensions, including the extent to which managers and supervisory staff support nurses and their practice, participation in hospital and nursing committees, and contributions to hospital policy decisions. Nurses also collaborate with physicians and others.

These organizational features have been shown to be associated with various positive patient outcomes, including lowered mortality, failure to rescue, readmission, adverse patient events and complications, and nurse-rated quality of care. However, the investigators noted that prior research has not examined how nurses and their work environment impact hospital-onset CDI.

In the study, 353 hospitals were included with a total of 15,982 nurses. Seventy percent of the hospitals had more than 200 beds, 77% were nonprofit, and 92% provided oncology services. Only 4% were rural referral centers.

On average, nurses reported high satisfaction with their career in nursing and having worked nearly 20 years in the field. More than 60% of the nurses reported having a BSN or higher degree.

According to the study, 53% of the study hospitals had a standardized infection ratio (SIR) for hospital-onset CDI greater than the national average, signaling that more infections were observed than predicted. The remaining 47% of hospitals were below the benchmark.

The investigators found that all 4 aspects of the nursing work environment that were examined—managerial support, nurse participation in hospital affairs, collegial physician–nurse relationships, and staffing and resource adequacy—were each associated with a decrease in the odds of having an SIR higher than the national SIR. The odds of hospitals having higher than average SIRs were significantly lower and less than half as great in hospitals in the highest quartile for all 4 nurse work environment subscales, compared with hospitals in the lowest quartile.

Notably, nurses face well-known barriers, such as understaffing, frequent operational errors, lack of accurate and timely communication, and frequently changing policies related to CDI prevention and control. The authors said their findings suggest that supportive nurse managers and supervisors, as well as nurses’ involvement in organizational governance, may serve to mitigate those barriers and help lower hospital-onset CDI in acute care hospitals.

Earlier studies on CDI prevention and control practices have predominantly focused on identifying and describing practices that aim to reduce CDI and have not focused as heavily on the role of nurses. The findings from this study highlight the critical role that bedside nurses may play in this issue and could have practical implications.

For example, proven leadership behaviors for promoting infection prevention and control practices include creating strategic goals with milestones, fostering coordination, and communicating periodically about the implemented protocols. Moreover, the study provides a basis for further research to examine additional aspects of the work environment that may contribute to lowering hospital-onset CDI and other infections.

Reference

Jung OS, Auken LH, Sloane DM, Fridkin SK, Li Y, Kang YJ, et al. Nurse Work Environment and Hospital-Onset Clostridioides difficile Infection. Medical Care. 61(6):360-365. doi:10.1097/MLR.0000000000001854