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Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PARutgers, School of Nursing, The State University of New Jersey, Newark, NJ
Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PASchool of Nursing, University of Washington, Seattle, WA
American Nurses Credentialing Center Pathway to Excellence Program holds promise for improved home care.
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Patient care is better when home care agencies empower and equip nurses.
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Nurse retention in home care is likely better when work environments are good.
Abstract
Background
Unlike the Magnet Recognition Program, the newer Pathway to Excellence Program designed to improve work environments in a broader range of organizations has not yet been the focus of substantial research.
Purpose
The purpose of the study was to examine the association of Pathway to Excellence Program Standards with better patient care quality and workforce outcomes in home care.
Method
Cross-sectional survey of registered nurses yielded informants from 871 home care agencies in the United States. Variables representing each of the 12 Pathway Standards were entered into logistic regression models to determine associations with better patient care and nurse workforce outcomes.
Discussion
All Pathway Standards are strongly and significantly associated with better patient care and better workforce outcomes. Home care agencies with better-rated professional work environments consistently had better patient care and nurse workforce outcomes.
Conclusions
This study validates the Pathway to Excellence Standards as important to patient care quality and nursing workforce outcomes in home care.
Although there is substantial research suggesting the attainment and maintenance of Magnet Recognition is an intervention associated with better work environments and better patient and nurse outcomes in hospitals, similar research on the newer Pathway to Excellence Program is lacking, especially related to nonhospital settings. The objective of this study was to validate whether Pathway to Excellence Program Standards are associated with better patient care quality and workforce outcomes in home care. If so, the Pathway Program may become, as in the case of Magnet Recognition, a blueprint for an intervention to improve home care organizations as well as a means to recognize those with nursing excellence (
Over three decades of research has established that the Magnet Recognition program is successful in identifying institutions with nursing excellence and that the Magnet Journey itself is an intervention to develop nursing excellence (
Launched in 2009, the Pathway to Excellence Program requires health care organizations to meet 12 Standards for workplace excellence (Figure 1). Each Pathway Standard consists of detailed criteria that indicate the presence of good nurse work environments (
). The Pathway Program recognizes health care organizations in all settings that create positive work environments where nurses can excel in their practice and patient care. The Pathway to Excellence Program framework “provides a valuable infrastructure for transforming cultures in any settings where nurses work, regardless of the location and size (
).” The Pathway Program is meant to enable a wider range of organizations, such as home care organizations, to qualify for Recognition and to be helped on the journey of improved work environments and better care outcomes.
There is an absence of evidence at present to determine whether the Pathway Program can identify organizations with excellent nursing and whether the Standards that are the core of the Program have promise as an intervention to move smaller organizations toward nursing excellence. Currently, no home care agency is recognized by either Pathway or Magnet (
). No studies have shown a relationship between the work environment in home care and patient-care quality in terms of nursing care that is provided. Additionally, there is no empirical research on whether Pathway Standards are related to good patient care and outcomes in a home care organization context.
Methods
This study utilizes an observational, cross-sectional study design to examine the association between the Pathway Standards and (a) indicators of patient care quality and (b) nursing workforce outcomes in home care. Nurse survey data, collected by the Center for Health Outcomes and Policy Research at the University of Pennsylvania, contain information on the nurse work environment, nurse satisfaction and burnout, nurse demographics, and patient care quality indicators (
Following a review of the literature, questions on the nurse survey were mapped to each Standard, with most items drawn from items on the Practice Environment Scale of the Nursing Work Index (
). Graduate and undergraduate research assistants independently mapped items to the Standards, referring to the expanded definitions and elements of performance in the ANCC manual (
). Authors with home care work experience jointly made final decisions regarding mapping of items to Standards. Each item was scored on a scale from 1 to 4: 1 = strongly disagree, 2 = disagree, 3 = agree, or 4 = strongly agree. The internal consistency of each set of Pathway Standard items was evaluated using Cronbach's alpha statistic. Higher mean Pathway Standard composite scores indicate better nurse work environments.
Nurses' individual ratings of Pathway Standards were coded 1 (lowest quartile), 2 (middle quartiles), and 3 (top quartile), and the logistic regression models used to estimate outcomes impose linear constraints on their effects. Thus, the odds ratios (ORs) indicate both the difference between the top and middle quartiles and between the middle and lowest quartiles of hospitals, with respect to Standards. The difference between the top and bottom quartile would equal the OR squared (OR2). All models were adjusted to account for clustering of nurses within agencies, as well as differences in nurse age, nurse education, state, and employment in a Medicare certified agency.
Sample
Nurse survey data were derived from large random samples of RNs in California, New Jersey, and Pennsylvania who were mailed surveys. The RN licensing boards in each state provided the sampling frame for the nurse survey, and the overall response rate was 39%. A follow-up nonresponse survey that achieved a 94% response rate revealed no response bias between respondents and nonrespondents (
A double sample to minimize bias due to non-response in a mail survey.
in: Ruiz-Gazen A. Guilbert P. Haziza D. Tillé Y. Survey methods: Applications to longitudinal studies, to health, to electoral studies and to studies in developing countries. Dunod,
Paris, France2008: 334-339
). The nurses provided the name of their employer (home care agency) and information on patient care quality and characteristics of their professional work environment; details of the nurse survey are described elsewhere (
). This study was completed under University of Pennsylvania IRB approval #176400.
Patient Care Quality and Workforce Outcomes
Patient Care Quality Outcomes
Patient care outcomes included nurse-reported quality of patient transitions across care settings and nurses' ability to complete essential nursing care. For example, nurses were asked how often their patients “fall between the cracks” when transferred between settings. Quality of patient care included nurse-reported essential but missed care due to resource constraints including a lack of time to: (a) comfort/talk with patients and their family, (b) teach patients and caregivers about their health, including self-management of their illness and proper use of medications, and (c) coordinate care, including communication with other health team members and community supports and services.
Nursing Workforce Outcomes
Nurse outcomes included job dissatisfaction, burnout, and intent to leave their job during the next year. Burnout was measured using the nine-item emotional exhaustion subscale of the Maslach Burnout Inventory (
). Scores of 27 or above were considered indicative of high burnout, consistent with published norms for health professionals in the Maslach Burnout Inventory manual (
). Job dissatisfaction was measured on a four-point scale and dichotomized so that nurses who reported being either “a little” or “very” dissatisfied were characterized as “dissatisfied”. Intent to leave employer was equated with nurses who answered “yes” when asked if they intended to leave their current employer within 1 year. Descriptive statistics were used to summarize home care nurses' demographic characteristics including level of education.
Findings
Home Care Nurse Sample
A total of 3,486 registered nurses responded who identified their primary work setting as home care and also identified their employer enabling the aggregation of nurses by home care agency. The mean age was nearly 51 years old (SD = 9.69), the majority of respondents were female, and 44% held a baccalaureate degree. Additional descriptive characteristics of the nurse sample are displayed in Table 1.
Table 1Nurse Characteristics (N = 3,486)
Characteristics
n
%
Age (mean, SD)
50.6
9.7
Male
108
3.2
Race (n = 3,295)
White
2,947
89.5
Asian/Pacific Islander
153
4.6
Black/African-American
108
3.3
American Indian
5
0.2
Mixed race
31
0.9
Other race
51
1.5
Hispanic (overlaps with race) (n = 3,318)
90
2.7
Highest level of nursing education (n = 3,145)
RN diploma
819
26.0
Associate degree
944
30.0
Baccalaureate degree
1,139
36.2
Master degree
241
7.7
Doctoral degree
2
0.1
State
California
990
28.4
New Jersey
1,182
33.9
Pennsylvania
1,314
37.7
Reported employment in Medicare-certified HHA
2,176
63.6
In proprietary (for-profit) Medicare-certified agency
Completed surveys were received from nurses in 871 different home care agencies or distinct branches of large agencies. The home care agencies in our sample included 151 hospice specialty programs, 31 pediatric specialty agencies, and 18 infusion specialty agencies. Over half of all the agencies (n = 462) were Medicare certified, and of these nearly half were private, for-profit agencies (n = 207). Compared with the national profile of the home health and hospice industry for the same time period, our sample contains a larger fraction of not-for-profit agencies (29% vs. 18%) (
In our sample, Cronbach's alphas for the Pathway Standards subscales ranged from 0.65 to 0.87. Taking into consideration that many of the Standards were measured with three items or less, Cronbach's alpha coefficients above 0.60 may be interpreted as acceptable (
). The lowest alphas obtained were for the Standards “Equitable Compensation Is Provided” (α = 0.65) and “A Balanced Lifestyle Is Encouraged” (α = 0.69). As a whole, the Pathway Standards exhibited a good level of reliability and Cronbach's alphas of the overall scale are presented in Table 2. Additionally, for our sample of home care nurses the Cronbach's alpha of the measure of burnout (nine-item emotional exhaustion subscale of the Maslach Burnout Inventory) was very strong (α = 0.92).
Table 2Mean Composite Scores and Internal Consistency of Each Pathway Standard Variable
Source: The 12 Standards are from American Nurses Credentialing Center (ANCC) Pathway to Excellence Program. The items are mostly drawn from the PES-NWI (
As shown in Table 3, half of the 12 Pathway to Excellence Standards are strongly and significantly associated with better patient care in terms of safe care transitions and nurses' completion of necessary nursing care including comforting, talking with, and teaching patients and families, as well as completing care coordination (p ≤ .001). Of the remaining Standards, five were strongly and significantly associated with at least half of the patient care quality outcomes. The only Standard that was not strongly associated with patient care outcomes was “Equitable compensation is provided,” which was measured with a single item. The results for the first two Pathway Standards are discussed here as examples, with full results in Table 3.
Table 3Odds Ratios Indicating the Relationship Between Pathway Standards and Patient Care Quality and Workforce Outcomes in Home Care
Standards
Odds Ratios Indicating the Relationship Between Pathway Standards and Outcomes
Unsafe Care Transitions
Lack Time to Talk With Patients
Lack Time to Teach Patients
Lack Time to Coordinate Care
Dissatisfied With Job
High Emotional Burnout
Plans to Leave Employer
1. Nurses control the practice of nursing
0.66***
0.66***
0.68***
0.63***
0.56***
0.66***
0.57***
2. The work environment is safe and healthy
0.62***
0.65***
0.66***
0.58***
0.55***
0.51***
0.60***
3. Systems are in place to address patient care and practice concerns
0.63***
0.61***
0.67***
0.64***
0.54***
0.54***
0.64***
4. Orientation prepares nurses for the work environment
0.66***
0.74***
0.77***
0.79***
0.62***
0.70***
0.57***
5. The CNO is qualified and participates in all levels of the organization
0.68***
0.73***
0.77***
0.70***
0.54***
0.65***
0.62***
6. Professional development is provided and utilized
0.84**
0.85*
0.75***
0.84*
0.67***
0.83***
0.57***
7. Equitable compensation is provided
0.82**
0.88*
0.85*
0.95
0.68***
0.86**
0.67***
8. Nurses are recognized for achievements
0.65***
0.72***
0.78***
0.70***
0.53***
0.63***
0.55***
9. A balanced lifestyle is encouraged
0.71***
0.62***
0.75***
0.64***
0.67***
0.59***
0.79***
10. Collaborative interdisciplinary relationships are valued and supported
0.80***
0.89
0.90
0.72***
0.78***
0.80***
0.75***
11. Nurse managers are competent and accountable
0.70***
0.84*
0.82**
0.73
0.58***
0.71***
0.60***
12. A quality program and evidence-based practice are utilized
0.80***
0.85*
0.81**
0.79***
0.63***
0.78***
0.62***
Note. CNO, Chief Nursing Officer.
Logistic regression models are adjusted for state, nurse age, if nurse BSN prepared, and if agency is Medicare certified. Outcomes are significant at * = p ≤ .05, ** = p ≤ .01, *** = p ≤ .001. All models account for clustering of nurses within home care agencies.
Nurses who worked in home care agencies rated most highly for giving nurses' control over the practice of nursing (top quartile) were less than half as likely (OR = 0.662 = 0.44) to report patients falling between cracks in the system during transitions, such as when a patient is discharged from hospital to home. Similarly, nurses who rated their control over the practice of nursing the best (top quartile) were less than half as likely as those in the bottom quartile, to report that they lacked time to talk with, teach patients, and coordinate their care.
A similarly strong predictor of patient care outcomes among the indicators of Pathway Standards was nurses' ratings of their work environment as safe and healthy. Nurses who reported the safest and healthiest work environments (top quartile) were only two-fifths as likely (0.622 = 0.38) to report unsafe care transitions as nurses in the least safe and healthy (bottom quartile) work environments. The ORs in the table also indicate that nurses who reported the safest and healthiest work environments (top quartile) were less than half as likely (0.652 = 0.42) as nurses in the least safe and healthy (bottom quartile) work environments to say they lacked time to coordinate patients' care, less than half as likely (0.662 = 0.44) to report they lacked time to comfort and talk with patients and families, and were one-third as likely (0.582 = 0.34) to report they lacked time to teach patients and families. Table 3 also shows that the differences in outcomes are substantial not only between the best and the worst environments but also between the best and the middle categories.
Nurse Workforce Outcomes
All 12 Pathway to Excellence Standards are strongly and significantly associated with better self-reported outcomes for nurses in terms of higher job satisfaction, lower burnout, and greater intent to remain with their employer (p < .001). Again, we describe here in detail the results for the first two Pathway Standards as examples, with full results in Table 3.
Compared with nurses who rated their control over the practice of nursing the lowest (bottom quartile), the nurses who reported the most control over the practice of nursing (top quartile) were one-third time as likely (OR = 0.562 = 0.31) to be dissatisfied with their job. Similarly, nurses who rated their control over the practice of nursing the highest (top quartile) were one-third as likely (OR = 0.572 = 0.32) to indicate that they intended to leave their employer as nurses who reported the least control over the practice of nursing (bottom quartile).
The strongest predictor of nurse job satisfaction, burnout, and intent to leave their job was nurses' ratings of their work environment as safe and healthy. Here too, by squaring the coefficients in Table 3, we find that nurses who reported the least safe and healthy work environments (bottom quartile) were 36% as likely to intend to leave their employers compared with nurses who rated their work environments as the most safe and healthy (top quartile). Nurses who reported the most safe and healthy work environments (top quartile) were 30% as likely to be dissatisfied with their job than nurses in poor (bottom quartile) work environments. Nurses' reports of emotional exhaustion (burnout) had a similar pattern, with nurses who worked in agencies rated as the least safe and healthy (bottom quartile) being one-fourth as likely to report burnout compared with nurses in the best (top quartile) work environments.
Limitations
Limitations of our study include its cross-sectional design, which limits causal inferences. As home care agencies begin to undertake the Pathway journey and are designated, research will be needed to confirm a causal relationship. Additionally, the subscales representing each Standard were developed retrospectively and should be refined prior to use for other purposes.
Discussion
Our findings are a validation of association between the Pathway to Excellence Program's core Standards with better patient care quality and workforce outcomes in home care. All 12 Pathway Standards are associated with nurse workforce outcomes including job satisfaction, burnout, and intent to leave current job. The only Pathway Standard not associated with patient care was nurse compensation, and it was important to nurse outcomes. The Pathway Standards all relate to creating supportive professional work environments. Thus our study adds to the evidence base that good work environments created by health agencies are very important to providing high quality of home care and retaining home care nurses.
Our findings suggest that the Pathway to Nursing Excellence Program will likely be successful in identifying home health agencies with excellent nursing care, as has been shown to the true for the Magnet Recognition program. Also, as is true for Magnet, the application process for Pathway recognition requiring evidence that the core Standards are met may be an intervention that helps improve work environments and outcomes of home care agencies. Our results suggest that even home care agencies with average work environments, as well as those with poor work environments, could potentially provide more effective care and be more successful in retaining nurses if they make a priority of achieving the Pathway Standards. Thus, the pursuit of Pathway credentialing holds promise for recognizing nursing excellence in home care organizations and as a blueprint for moving more home care organizations into the highest levels of patient care excellence.
Conclusions
The 30-year history of the Magnet Recognition Program and later the Pathway to Excellence Program has focused on creating health care environments that attract and retain well-qualified nurses who are supported to provide high-quality patient care. Although these programs have focused to date mostly on hospitals, our findings suggest that achieving work environment excellence in home care agencies may yield comparable benefits for patient care and nurse retention. This study provides the best evidence to date that patient care is better when home care agencies create positive practice environments. The Pathway Standards provide a clear and relevant path for home care agencies to achieve patient care excellence while maximally retaining an experienced and hard to replace nursing workforce.
Acknowledgments
This study was supported by the National Institutes of Health (T32NR007104, R01NR014855); the Agency for Healthcare Research and Quality (R00HS022406); the Robert Wood Johnson Foundation (grant 053071 to Linda Flynn); the American Nurses Foundation/Margretta Madden Styles Credentialing Research Grant; the John A. Hartford Foundation; and the Rita and Alex Hillman Foundation. Contributions: Douglas Sloane: statistical consultation; Timothy Cheney and Evan Wu: data management; and Breanna Baraff, Carly Rubin, and David Tran: research assistants.
References
Aiken L.H.
Extending the Magnet concept to developing and transition countries: Journey to excellence.
A double sample to minimize bias due to non-response in a mail survey.
in: Ruiz-Gazen A. Guilbert P. Haziza D. Tillé Y. Survey methods: Applications to longitudinal studies, to health, to electoral studies and to studies in developing countries. Dunod,
Paris, France2008: 334-339 ([in French])
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