Nurse Work Environment and Hospital-Onset Clostridioides difficile Infection

Background:

Clostridioides difficile is the leading cause of hospital-onset diarrhea, with reports of 235,700 cases annually and attributed medical costs of nearly $22,000 within 5 years of diagnosis.1,2 Since 2015, when the Centers for Medicare and Medicaid Services (CMS) added C. difficile infection (CDI) metrics into the Hospital Inpatient Quality Reporting Program, most hospitals have demonstrated a reduction in CDI rates.1,3,4 However, exposure to antibiotics and colonization of infected patients continue to contribute to the development and spread of CDI, posing a considerable burden to the US health care system.2,5

Nurses are integral in implementing CDI prevention and control practices in the acute care setting. Nurses represent the largest number of health care professionals working in hospitals where they work in close proximity to patients, and regularly interact with physicians and other professionals at the bedside in the delivery and monitoring of patient care. It is nurses who implement the bundle of practices to prevent and control the spread of hospital-onset CDI, which includes prompt and appropriate diagnostic testing of unformed stool, prompt initiations of contact precautions among patients with CDI, exceptional hand hygiene, and the potential to influence best environmental disinfection or antibiotic stewardship.6–8 However, these practices are complex, challenging, and time-consuming for nurses as they often face challenges in communication regarding isolation orders and diagnostic tests, discordant perceptions with physicians regarding CDI risk factors that prompt testing, as well as a pressured workflow to don and doff personal protective equipment appropriately.6,8–10 It is hypothesized that a supportive clinical work environment would reduce these barriers and facilitate consistent adherence to best practices in infection prevention.

In this study, we explore how aspects of the nurse work environment are related to hospital-onset CDI. The work environment of nurses has been identified as an important, modifiable set of organizational features that impact patient outcomes.11–15 The work environment comprises multiple dimensions, including the extent to which the managers and supervisory staff support nurses and their practice, nurses participate in hospital and nursing committees and contribute to hospital policy decisions, nurses and physicians collaborate and have good working relationships with each other, and hospitals have enough nursing staff to provide quality patient care. These organizational features have been shown to be associated with various positive patient outcomes, including lowered mortality,12,16–19 failure to rescue,18,19 readmission,14 adverse patient events and complications,13,18 and nurse-rated quality of care.20 However, to our knowledge, prior research has not yet examined how nurses and the work environment impact hospital-onset CDI.

We focus on the work environment of nursing care because it is where nursing work interplays with the social and political contexts of the organization. The nurse work environment is characterized as a set of organizational features that facilitate or constrain nursing behavior and practice.21 Studying the work environment aids in our understanding of how organizations can promote frontline staff behavior change and how staff behavior can give rise to organizational change and uptake of new practices,22,23 such as those relating to CDI prevention and control. When management supports and responds to issues identified by bedside nurses and when nurses are involved in hospital affairs, nurses are more likely to think critically about their work and make suggestions about improving practices.24,25 In addition, when frontline staff can work effectively in an interdisciplinary team of professionals and mobilize resource resources quickly, they are able to contribute to a better quality of care.26,27

In this study, we examine reports from frontline nurses to determine whether there is an association between aspects of the nurse work environment and hospital-onset CDI. Based on a Donabedian framework—which states that structures affect processes, which in turn affect outcomes28—we posit that aspects of the nurse work environments, such as human and material resources and structures for frontline nurse participation in hospital affairs, affect processes for CDI prevention and control that are carried out by frontline clinicians such as nurses, which in turn affect hospital-onset CDI.

METHODS

RESULTS

Table ​Table11 shows the hospital and nurse characteristics. Seventy percent of the hospitals in our sample had 200+ beds, 77% were nonprofit, and 92% provided oncology services. Only 4% of hospitals were rural referral centers. On average, nurses reported high satisfaction with their career in nursing (mean=1.49, on a 1–4 scale where 1=very satisfied) and having worked nearly 20 years as a nurse. More than 60% of the nurses reported having a BSN or higher degree. We found that 53% of the study hospitals had an SIR for hospital-onset CDI greater than the national average SIR (more infections observed than predicted); the remaining 47% were below the benchmark (fewer than average infections observed).

As shown in Table ​Table2,2, the average nurse-reported scores were somewhat variable across subscales. The average score for Managerial Ability, Leadership, and Support was 2.76; Nurse Participation in Hospital Affairs was 2.71; Collegial Physician-Nurse Relationships was 3.05; and Staffing and Resource Adequacy was 2.54. The mean subscale scores of the PES-NWI were fairly similar for hospitals in adjacent quartiles, such as between Q4 and Q3, or Q3 and Q2 (ie, <1 SD for each subscale overall), though the difference between hospitals in the highest versus lowest quartiles (Q4 vs. Q1) was quite dramatic (roughly 2.5 SDs in all cases).

Table ​Table33 shows the results from our regression analyses. The odds of hospitals having higher than average SIRs were significantly lower and less than half as great (odds ratios ranged from 0.35 to 0.45) in hospitals in the highest quartile than in hospitals in the lowest quartile for all 4 nurse work environment subscales we considered (managerial support, nurse participation in hospital affairs, physician-nurse relations, and staffing and resource adequacy). The composite scale comprised of all 4 subscales was also significantly associated with hospital-onset CDI.

As a sensitivity analysis, we used Hospital Compare’s categorization as an additional outcome variable.32 Hospital Compare standardizes SIR and computes a 95% CI, wherein if a given hospital’s upper bound of the CI is <1, then the hospital’s performance is better than the national benchmark. Thus, this additional outcome variable was coded as 1 if a hospital’s upper CI was ≤1 (an undesirable outcome) and coded as 0 if the hospital’s upper CI was <1 (a desirable outcome). Table A3 in the Online Appendix (Supplemental Digital Content 1, http://links.lww.com/MLR/C643) shows the results. These results are similar to those shown in Table ​Table33 in terms of the direction of the coefficients, but they are not statistically significant, except for collegial physician-nurse relations.

DISCUSSION

To our knowledge, this study is the first to explore the association between the nurse work environment and hospital-onset CDI. Our findings show that all four aspects of the nursing work environment that we examined—managerial support, nurse participation in hospital affairs, collegial physician-nurse relationship, and staffing and resource adequacy—were each, and as a composite measure, associated with a decrease in the odds of having an SIR higher than the national SIR, which implied having a fewer number of infections than predicted, or a desirable outcome.34

Prior research has found that nurses face barriers such as nurse understaffing,36 frequent operational errors,35 lack of accurate and timely communication, and frequently changing policies related to CDI prevention and control.6,8–10 Our findings suggest that supportive nurse managers and supervisors and nurses’ involvement in organizational governance may serve to mitigate those barriers and contribute to lowering hospital-onset CDI in acute care hospitals. Our findings also indicate that collegial relationships between physicians and nurses as well as nurse staffing and resource adequacy, which are aspects that have been established as being important to patient safety and quality,26,27 play an important role in preventing and controlling CDI. It is possible that when physicians and nurses have good working relationships, they are able to resolve discordant perceptions regarding CDI risk factors that prompt testing. Future work should also examine the role of effective working relationships among pharmacists, microbiologists, environmental service workers, and other support staff. Compliance with certain CDI prevention and control practices, such as environmental disinfection and antibiotic stewardship, require communication and coordination between multiple professional groups.

Prior studies on CDI prevention and control practices have mostly focused on identifying and describing practices that aim to reduce CDI,6–8,42 but not as much on the role of nurses. The relationship between the nurse work environment and hospital-onset CDI detected in this study highlights the critical role that bedside nurses may play in preventing and controlling hospital-onset CDI. It is likely that nurses, who work closely with patients and other support staff, facilitate the implementation of CDI prevention and control practices, which are continually evolving, multifactorial, and complex.6–8 An environment that supports collegial relationships among staff will most likely result in improved daily sporicidal cleaning, a cost-effective infection control measure to prevent CDI.42 Investing in the nurse work environment may help hospitals to prioritize these interventions and disseminate related information, as supportive work environments enable nurses to identify opportunities for improvement in daily cleaning or encourage colleagues to be diligent about hand hygiene. Thus, when developing infection prevention and control practices, policymakers and hospital administrators should consider the roles that nurses can play in scaling and disseminating those practices.

Our findings have practical implications. Our results highlight the importance of nurse managers’ leadership and support. We find that the odds of being below the national benchmark (ie, fewer infections) is substantially lower when manager ability, leadership, and support are perceived favorably by bedside nurses. With respect to prioritizing quality and motivating adherence to protocols, prior literature on leadership suggests that leader behaviors are crucial, as staff attends to their actions.11,43 Proven leadership behaviors for promoting the importance of infection prevention and control practices include creating strategic goals with milestones, fostering coordination, and communicating periodically about the implemented protocols.43,44 Moreover, we found that differences in the extent to which managers listen and respond to issues raised by bedside nurses and nurse participation in organizational affairs were associated with variation in hospital-onset CDI. This 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 and to explore interventions focusing on improving aspects of the work environment for frontline staff.

Improving the work environment is not as costly as hiring additional staff, but still comes with its own challenges, as it entails developing managerial effectiveness and distributing authority for governance and decision-making to those closest to patients. Establishing a favorable, positive nurse work environment is an important basis for the American Nurses Credentialing Center’s Magnet Recognition Program, which has been demonstrated to result in improved work environments and better patient outcomes.45 Hospitals may find the guide to achieving Magnet designation helpful when trying to enhance the work environment and address the challenges of culture change.46

Our study had a few limitations. First, our data were cross-sectional from only four states and as such, our findings might not be generalizable to nurses and hospitals in other states. However, the 4 states included are exceptionally large and represent a large percentage of the nurses nationwide. Second, CDI data are subject to variations in diagnostic testing practices. Still, the CDC risk-adjustment methods do adjust somewhat for different laboratory testing protocols that have different sensitivity and specificity for detecting infections. Third, our data were limited to 2016 when the nurse survey was administered. That year was the second year in which hospitals were incentivized to reduce CDI risks through participation in Hospital Inpatient Quality Reporting Program. The associations uncovered in this study may or may not be present today. In particular, further investigations are warranted to determine the impact of the COVID-19 pandemic on CDI. Early reports suggest that during the pandemic interdisciplinary teamwork and extensive efforts in infection control have resulted in a decrease in CDI.47–49 However, if these efforts to control CDI are sustainable has yet to be seen.

A supportive nurse work environment including adequate nurse staffing and resources is a key condition for reducing hospital-onset infections. Because a significant share of hospitals has deficient work environments that continue to hamper infection prevention, a promising strategy to lower hospital-onset CDI and other infections is a serious and sustained commitment by the hospital industry and its leaders to significantly improve hospital nurse work environments.

Supplementary Material

ACKNOWLEDGMENTS

Footnotes

REFERENCES