Date of Award

Spring 2019

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Department

Nursing

First Advisor

Weiss, Marianne E.

Second Advisor

Yakusheva, Olga

Third Advisor

Bobay, Kathleen L.

Abstract

Background: Promoting continuity of nursing care has the potential to increase patient readiness for discharge, which has been associated with fewer readmissions and emergency department (ED) visits. The few studies that have examined nursing continuity during acute care hospitalizations did not focus on discharge or post-discharge outcomes.Objectives: The aim of this research study was to examine the association of continuity in nurse assignment to patients prior to hospital discharge with return to hospital (readmission and ED/Observation visits), including exploration of the mediating pathway through patient readiness for discharge and moderation effects of unit environment and unit nurse characteristics.Methods: In a sample of 18,203 adult, medical-surgical patients from 33 Magnet hospitals participating in a randomized clinical trial evaluating implementation of discharge readiness assessments, regression analysis with simultaneous equation modeling was used to evaluate the impact of nurse continuity on readmissions and ED/Observation visits within 30 days after hospital discharge and the mediating pathway through discharge readiness measured by patient self-report and nurse assessments. Moderating effects of unit environment and nursing characteristics were examined across quartiles of unit environment (nurse staffing hours per patient day) and unit nurse characteristics (education and experience). Analyses were adjusted for patient characteristics, hospital fixed effects, and clustering at the hospital level.Results: Continuous nurse assignment on the last 2 days of hospitalization was observed in 6,441 (35.4%) patient discharges and was associated with a 0.85 absolute percentage point (95% CI [-0.0166, -0.0004], p<0.05) reduction (7.8% relative reduction) in readmissions. There was no significant association with ED/Observation visits. Sensitivity analysis revealed a stronger effect in patients with higher Elixhauser Comorbidity Indexes. Readiness for discharge was not a mediator of the effect of continuity on return to hospital. Unit characteristics were not associated with nursing continuity. No moderation effect was evident for unit environment and nurse characteristics. Discussion: Continuity of nurse assignment on the last 2 days of hospitalization can reduce readmissions. Staffing for continuity may benefit patients and health care systems, with greater benefits for high comorbidity patients. Nurse continuity should be a priority consideration in assigning acute care nurses to augment readmission reduction efforts.

Available for download on Friday, May 28, 2021

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