BACKGROUND:Nurse retention and wellbeing have reached alarmingly low levels in recent years and health systems globally are searching for large-scale systemic solutions to reduce nurse burnout, improve wellbeing, and increase job satisfaction and retention while simultaneously enhancing patient care quality and safety. OBJECTIVE:To evaluate whether a minimum nurse staffing policy intervention in Queensland Australia improved nurse wellbeing, intentions to leave employment, and patient safety. METHODS:This is a quasi-experimental intervention study in which we compared nurse outcomes, patient safety measures, quality of care indicators, and operational failures among 27 hospitals subject to a minimum nurse staffing policy (i.e. intervention hospitals) and 41 hospitals not subject to the policy (i.e. comparison hospitals) at two points in time: prior to implementation of the policy (i.e. baseline) and two years after implementation (i.e. post-implementation). Percentages of nurses with unfavorable outcomes and unfavorable ratings of quality of care and patient safety are reported for intervention and comparison hospitals at baseline and post-implementation of the staffing policy. Fixed effects logistic regression models evaluated the interaction between the intervention effect and the post-implementation period to report the impact of the staffing policy on outcomes. RESULTS:The minimum nurse staffing policy intervention was associated with improvements in staffing, nurse wellbeing and job outcomes, and quality of care and patient safety in the intervention hospitals. Nurses in intervention hospitals had 24 % lower odds of high burnout (OR 0.76, 95 % CI 0.61-0.94, p < 0.05) and 27 % lower odds of job dissatisfaction (OR 0.73, 95 % CI 0.59-0.91, p < 0.01) at post-implementation relative to the baseline; no statistically significant differences in these outcomes were found among comparison hospitals. Job dissatisfaction with workload, professional development, autonomy at work, and work schedule all declined significantly in intervention hospitals and worsened over time in comparison hospitals. Nurse work environment scores improved in the intervention hospitals and worsened in the comparison hospitals. Quality of care, patient safety, and operational failures markedly improved in the intervention hospitals and generally worsened in the comparison hospitals. CONCLUSIONS:The quasi-experimental study design gives policymakers and hospital administrators strong confidence that minimum nurse staffing policy interventions can result in more favorable work environments for nurses, better job outcomes including lower nurse burnout and job dissatisfaction, and improvements in quality of care and safety for patients.

BACKGROUND:Descriptive studies have documented high hospital nurse burnout and turnover but there are few, if any, large-scale evaluations of organizational interventions to improve clinician retention. The Magnet model is an organizational hospital intervention associated with better clinician and patient outcomes but there is insufficient evidence as to whether the Magnet model based on structural empowerment of clinicians results in better outcomes or rewards hospitals with good work environments, and whether the Magnet model can be implemented at scale outside the United States. OBJECTIVE:To evaluate whether Magnet4Europe-a multiyear organizational intervention of European hospitals-could be implemented and would result in improvements in nurse well-being, care quality, and patient safety. DESIGN:Quasi-experimental longitudinal evaluation of 56 European intervention hospitals in 6 countries. Hospital-level implementation of the intervention measured by changes (from baseline to follow-up) in 77 Magnet model intervention targets. Outcome measures (eg, nurse burnout, intent to leave, quality of care, patient safety) were derived from surveys of nurses (4546 nurses at baseline; 3171 at follow-up). FINDINGS:Hospitals that implemented intervention targets during the study period observed reductions in nurse burnout, nurses' intentions to leave their jobs, and unfavorable care quality. Each 10-percentage-point increase in intervention target implementation was associated with 2.7%-point reduction in nurses who intend to leave (β -2.66; 95% CI: -4.74, -0.58, P <0.05). Hospitals which implemented more than 25% of intervention targets observed 6.3%-point reduction in nurse burnout, 7.6%-point reduction in intent to leave, 6.4%-point reduction in unfavorable care quality, and 3.7%-point reduction in unfavorable patient safety. Improvements in hospital percentages of nurses reporting staffing adequacy were associated with reductions in burnout, intentions to leave, unfavorable care quality, and patient safety. CONCLUSION:Successful implementation of Magnet4Europe demonstrates promise for international adoption at scale of Magnet as an organizational intervention for improving clinician well-being, care quality, and patient safety.

Importance:Physician burnout and retention problems are threatening workforce stability and patient care. Objective:To compare physician well-being in multiple European countries and the US to inform physician well-being interventions and evaluate whether modifiable aspects of hospital care environments are associated with physician job outcomes. Design, Setting, and Participants:This cross-sectional study was conducted at 49 hospitals in 6 European countries (Belgium, England, Germany, Ireland, Sweden, and Norway) and 56 US hospitals. European data from physicians and nurses were collected in 2023; US data were collected in 2021. Data were analyzed from February through August 2025. Exposures:Three explanatory variables were measured at the hospital level: nurse staffing adequacy, clinical care environment, and physician and nurse teamwork. Main Outcomes and Measures:Primary outcomes include individual-level measures of physician well-being and job outcomes (eg, high burnout, job dissatisfaction, intention to leave employer, and willingness to recommend employer). Results:Among a total of 21 396 physicians and nurses, 1149 European physicians (mean [SD] age, 41.3 [10.6] years; 536 female [46.5%] and 609 male [52.9%]) and 5334 US physicians (mean [SD] age, 44.5 [11.8] years; 1861 female [34.9%] and 2373 male [44.5%]) reported on their well-being and 3044 European nurses and 11 869 US nurses reported on hospital care environments. Poor well-being was common among hospital physicians in the US and Europe; for example, 324 of 1083 physicians in Europe with responses to the question (29.9%) and 1178 of 4959 physicians with responses to the question (23.8%) intended to leave their job within a year. Improvements in nurse staffing adequacy, clinical care environments, and clinician teamwork were associated with favorable physician job outcomes in the US and Europe. For example, among US hospitals, a 10% increase in favorable care environments was associated with lower odds of physicians intending to leave (odds ratio [OR], 0.78; 95% CI, 0.68-0.90), not recommending their hospital (OR, 0.75; 95% CI, 0.61-0.92), experiencing high burnout (OR, 0.90; 95% CI, 0.83-0.98), and having job dissatisfaction (OR, 0.81; 95% CI, 0.69-0.95). Among European hospitals, a 10% increase in hospital-level reports of nurse staffing adequacy was associated with lower odds of physicians intending to leave (OR, 0.80; 95% CI, 0.71-0.91), not recommending their hospital (OR, 0.73; 95% CI, 0.61-0.88), reporting high burnout (OR, 0.88; 95% CI, 0.78-0.99), and reporting job dissatisfaction (OR, 0.85; 95% CI, 0.73-0.98). Conclusions and Relevance:In this study, improved hospital nurse work environments were associated with more favorable physician outcomes, and modifiable features of the hospital environment, including having adequate numbers of direct care nurses and strong physician and nurse teamwork, were associated with greater physician well-being. These findings may inform the development and implementation of evidence-based interventions to improve physician well-being and retention.

Introduction The increasing burden of mental distress reported by healthcare professionals is a matter of serious concern and there is a growing recognition of the role of the workplace in creating this problem. Magnet hospitals, a model shown to attract and retain staff in US research, creates positive work environments that aim to support the well-being of healthcare professionals.Methods and analysis Magnet4Europe is a cluster randomised controlled trial, with wait list controls, designed to evaluate the effects of organisational redesign, based on the Magnet model, on nurses’ and physicians’ well-being in general acute care hospitals, using a multicomponent implementation strategy. The study will be conducted in more than 60 general acute care hospitals in Belgium, England, Germany, Ireland, Norway and Sweden. The primary outcome is burnout among nurses and physicians, assessed in longitudinal surveys of nurses and physicians at participating hospitals. Additional data will be collected from them on perceived work environments, patient safety and patient quality of care and will be triangulated with data from medical records, including case mix-adjusted in-hospital mortality. The process of implementation will be evaluated using qualitative data from focus group and key informant interviews.Ethics and dissemination This study was approved by the Ethics Committee Research UZ/KU Leuven, Belgium; additionally, ethics approval is obtained in all other participating countries either through a central or decentral authority. Findings will be disseminated at conferences, through peer-reviewed manuscripts and via social media.Trial registration number ISRCTN10196901.

BackgroundThere are known clinical benefits associated with investments in nursing. Less is known about their value.AimsTo compare surgical patient outcomes and costs in hospitals with better versus worse nursing resources and to determine if value differs across these hospitals for patients with different mortality risks.MethodsRetrospective matched-cohort design of patient outcomes at hospitals with better versus worse nursing resources, defined by patient-to-nurse ratios, skill mix, proportions of bachelors-degree nurses and nurse work environments. The sample included 62 715 pairs of surgical patients in 76 better nursing resourced hospitals and 230 worse nursing resourced hospitals from 2013 to 2015. Patients were exactly matched on principal procedures and their hospital’s size category, teaching and technology status, and were closely matched on comorbidities and other risk factors.ResultsPatients in hospitals with better nursing resources had lower 30-day mortality: 2.7% vs 3.1% (p<0.001), lower failure-to-rescue: 5.4% vs 6.2% (p<0.001), lower readmissions: 12.6% vs 13.5% (p<0.001), shorter lengths of stay: 4.70 days vs 4.76 days (p<0.001), more intensive care unit admissions: 17.2% vs 15.4% (p<0.001) and marginally higher nurse-adjusted costs (which account for the costs of better nursing resources): $20 096 vs $19 358 (p<0.001), as compared with patients in worse nursing resourced hospitals. The nurse-adjusted cost associated with a 1% improvement in mortality at better nursing hospitals was $2035. Patients with the highest mortality risk realised the greatest value from nursing resources.ConclusionHospitals with better nursing resources provided better clinical outcomes for surgical patients at a small additional cost. Generally, the sicker the patient, the greater the value at better nursing resourced hospitals.

Background Unrest in Chile over inequalities has underscored the need to improve public hospitals. Nursing has been overlooked as a solution to quality and access concerns, and nurse staffing is poor by international standards. Using Chile's new diagnosis-related groups system and surveys of nurses and patients, we provide information to policy makers on feasibility, net costs, and estimated improved outcomes associated with increasing nursing resources in public hospitals. Methods For this multilevel cross-sectional study, we used data from surveys of hospital nurses to measure staffing and work environments in public and private Chilean adult high-complexity hospitals, which were linked with patient satisfaction survey and discharge data from the national diagnosis-related groups database for inpatients. All adult patients on medical and surgical units whose conditions permitted and who had been hospitalised for more than 48 h were invited to participate in the patient experience survey until 50 responses were obtained in each hospital. We estimated associations between nurse staffing and work environment quality with inpatient 30-day mortality, 30-day readmission, length of stay (LOS), patient experience, and care quality using multilevel random-effects logistic regression models and zero-truncated negative binomial regression models, with clustering of patients within hospitals. Findings We collected and analysed surveys of 1652 hospital nurses from 40 hospitals (34 public and six private), satisfaction surveys of 2013 patients, and discharge data for 761 948 inpatients. Nurse staffing was significantly related to all outcomes, including mortality, after adjusting for patient characteristics, and the work environment was related to patient experience and nurses' quality assessments. Each patient added to nurses' workloads increased mortality (odds ratio 1middot04, 95% CI 1middot01-1middot07, p<0middot01), readmissions (1middot02, 1middot01-1middot03, p<0middot01), and LOS (incident rate ratio 1middot04, 95% CI 1middot01-1middot06, p<0middot05). Nurse workloads across hospitals varied from six to 24 patients per nurse. Patients in hospitals with 18 patients per nurse, compared with those in hospitals with eight patients per nurse, had 41% higher odds of dying, 20% higher odds of being readmitted, 41% higher odds of staying longer, and 68% lower odds of rating their hospital highly. We estimated that savings from reduced readmissions and shorter stays would exceed the costs of adding nurses by US$1middot2 million and $5middot4 million if the additional nurses resulted in average workloads of 12 or ten patients per nurse, respectively. Interpretation Improved hospital nurse staffing in Chile was associated with lower inpatient mortality, higher patient satisfaction, fewer readmissions, and shorter hospital stays, suggesting that greater investments in nurses could return higher quality of care and greater value.

Background Nursing resources, such as staffing ratios and skill mix, vary across hospitals. Better nursing resources have been linked to better patient outcomes but are assumed to increase costs. The value of investments in nursing resources, in terms of clinical benefits relative to costs, is unclear. Objective To determine whether there are differential clinical outcomes, costs, and value among medical patients at hospitals characterized by better or worse nursing resources. Design Matched cohort study of patients in 306 acute care hospitals. Patients A total of 74,045 matched pairs of fee-for-service Medicare beneficiaries admitted for common medical conditions (25,446 sepsis pairs; 16,332 congestive heart failure pairs; 12,811 pneumonia pairs; 10,598 stroke pairs; 8858 acute myocardial infarction pairs). Patients were also matched on hospital size, technology, and teaching status. Main Measures Better ( n = 76) and worse ( n = 230) nursing resourced hospitals were defined by patient-to-nurse ratios, skill mix, proportions of bachelors-degree nurses, and nurse work environments. Outcomes included 30-day mortality, readmission, and resource utilization-based costs. Key Results Patients in hospitals with better nursing resources had significantly lower 30-day mortality (16.1% vs 17.1%, p < 0.0001) and fewer readmissions (32.3% vs 33.6%, p < 0.0001) yet costs were not significantly different ($18,848 vs 18,671, p = 0.133). The greatest outcomes and cost advantage of better nursing resourced hospitals were in patients with sepsis who had lower mortality (25.3% vs 27.6%, p < 0.0001). Overall, patients with the highest risk of mortality on admission experienced the greatest reductions in mortality and readmission from better nursing at no difference in cost. Conclusions Medicare beneficiaries with common medical conditions admitted to hospitals with better nursing resources experienced more favorable outcomes at almost no difference in cost.

What a lovely paper!I use a number of the topics and points raised by Hill (1965) to reconsider aspects of the notion of causation in research in the social sciences and especially in sociology, the field with which I am most familiar.One could do more.The paper's intellectual concision and economy of expression are laudable.Each time I read it, I generate a new set of marginal comments.I first read the paper many years ago.But why?The topical ambit is restricted: association or causation in epidemiology-occupational medicine in particular.It is very English in that it features chimney sweeps, although there is nothing Mary Poppins-y about them: These poor men were dying from scrotal cancer at a rate that was extraordinarily high relative to such deaths among other workers.This implicated as causes of their cancers the tars and oils characteristic of their trade (Hill 1965, p. 295).I am a sociologist, not an epidemiologist; have not studied scrotal cancer or any of the other diseases and physical conditions discussed by Hill (1965); and until late in life had never been to England.I would only have known of the paper via Holland (1986, pp.956-957), where it figures among the canonical disciplinary treatments of causation related to Rubin's (1974) model for causal inference.At that time I did not pick up much from it, because I was reading it with a whiggish cast of mind, as if it were evident that the diffuse treatments of causation in the past were noble-but-incomplete efforts on route to the precision of the present.Now I wonder, especially where the social sciences are concerned.The mental discipline imposed by the potential outcomes framework (Rubin 2005) is very powerful.When I was first exposed to it (Holland 1986;Rosenbaum 1984), it was as though the scales fell from my eyes.I used this framework to first think (Smith 1990), then re-think (Smith 2013) all manner of studies in sociology, demography, criminology, and social epidemiology.Developments in causal thinking in the social sciences have been tremendous (e.g., Morgan 2013).But as I read Hill (1965) in retrospect, I think I see some threads of my own re-thinking of the situation, which is an admix of professional, scientific, and intellectual critique.In brief, and without nuance: We have harnessed ourselves to a "game" in which the objective is to make a world of interconnected, purposive actors bound in historical time and changing social structures look something like a randomized experiment.This feeds into a reductionist, individualist view of social science-and of the world we live in.Causes become embodied in the subjects on whom we make measurements and do causal calculations.Researchers claim priority for the importance of causal analysis because of its

Crime rates have dropped substantially in the United States, but incarceration rates have remained high. The standard explanation for the lasting trend in incarceration is that the policy choices from the 1980s and 1990s were part of a secular increase in punitiveness that has kept rates of incarceration high. Our study highlights a heretofore overlooked perspective: that the crime-punishment wave in the 1980s and 1990s created cohort differences in incarceration over the life course that changed the level of incarceration even decades after the wave. With individual-level longitudinal sentencing data from 1972 to 2016 in North Carolina, we show that cohort effects-the lingering impacts of having reached young adulthood at particular times in the history of crime and punishment-are at least as large (and likely much larger) than annual variation in incarceration rates attributable to period-specific events and proclivities. The birth cohorts that reach prime age of crime during the 1980s and 1990s crime-punishment wave have elevated rates of incarceration throughout their observed life course. The key mechanism for their elevated incarceration rates decades after the crime-punishment wave is the accumulation of extended criminal history under a sentencing structure that systematically escalates punishment for those with priors.

BACKGROUND:Rigorous measurement of organizational performance requires large, unbiased samples to allow inferences to the population. Studies of organizations, including hospitals, often rely on voluntary surveys subject to nonresponse bias. For example, hospital administrators with concerns about performance are more likely to opt-out of surveys about organizational quality and safety, which is problematic for generating inferences.OBJECTIVE:The objective of this study was to describe a novel approach to obtaining a representative sample of organizations using individuals nested within organizations, and demonstrate how resurveying nonrespondents can allay concerns about bias from low response rates at the individual-level.METHODS:We review and analyze common ways of surveying hospitals. We describe the approach and results of a double-sampling technique of surveying nurses as informants about hospital quality and performance. Finally, we provide recommendations for sampling and survey methods to increase response rates and evaluate whether and to what extent bias exists.RESULTS:The survey of nurses yielded data on over 95% of hospitals in the sampling frame. Although the nurse response rate was 26%, comparisons of nurses' responses in the main survey and those of resurveyed nonrespondents, which yielded nearly a 90% response rate, revealed no statistically significant differences at the nurse-level, suggesting no evidence of nonresponse bias.CONCLUSIONS:Surveying organizations via random sampling of front-line providers can avoid the self-selection issues caused by directly sampling organizations. Response rates are commonly misinterpreted as a measure of representativeness; however, findings from the double-sampling approach show how low response rates merely increase the potential for nonresponse bias but do not confirm it.

Background: Evidence shows hospitals with better nursing resources have better outcomes but few studies have shown that outcomes change over time within hospitals as nursing resources change. Objectives: To determine whether changes in nursing resources over time within hospitals are related to changes in quality of care and patient safety. Research Design: Multilevel logistic response models, using data from a panel of 737 hospitals in which cross-sections of nurse informants surveyed in 2006 and 2016, were used to simultaneously estimate longitudinal and cross-sectional associations between nursing resources, quality of care, and patient safety. Measures: Nursing resources included hospital-level measures of work environments, nurse staffing, and nurse education. Care quality was measured by overall rating of care quality, confidence in patients managing care after discharge, confidence in management resolving patient care problems; patient safety was measured by patient safety grade, concern with mistakes, and freedom to question authority. Results: After taking into account cross-sectional differences between hospitals, differences among nurses within hospitals, and potential confounding variables, changes within hospitals in nursing resources were associated with significant changes in quality of care and patient safety. Improvements in work environment of 1 SD decrease odds of unfavorable quality care and patient safety by factors ranging from 0.82 to 0.97. Conclusions: Improvements within hospitals in work environments, nurse staffing, and educational composition of nurses coincide with improvements in quality of care and patient safety. Cross-sectional results closely approximate longitudinal panel results.

This article provides a demographic exposition of the changes in the U.S prison population during the period of mass incarceration that began in the late twentieth century. By drawing on data from the Survey of Inmates in State Correctional Facilities (1974-2004) for inmates 17-72 years of age (N = 336), we show that the age distribution shifted upward dramatically: Only 16 percent of the state prison population was 40 years old or older in 1974; by 2004, this percentage had doubled to 33 percent with the median age of prisoners rising from 27 to 34 years old. By using an estimable function approach, we find that the change in the age distribution of the prison population is primarily a cohort effect that is driven by the enhanced penal careers of the cohorts who hit young adulthoodthe prime age of both crime and incarcerationwhen substance use was at its peak. Period-specific factors (e.g., proclivity for punishment and incidence of offense) do matter, but they seem to play out more across the life cycles of persons most affected in young adulthood (cohort effects) than across all age groups at one point in time (period effects).

We use CDC microdata on cause of death and CPS data on populations by age to create suicide rates for five-year age groups at five-year intervals, further cross-classified by race/ethnicity, education, and marital status. We examine the suicide history 1990-2010 of U.S. birth cohorts, net of age and cohort linear trends. These de-trended cohort deviations follow familiar patterns: most pronounced in the Baby Boom, least pronounced during the Baby Bust, they illustrate the so-called Easterlin effect. Suicide rates for women show similar patterns as suicide patterns for men. We show persistence of those effects net of micro factors (especially education and marriage) implicated in suicide behavior and correlated at the macro level with relative cohort size. Analysis of suicide patterns over time for highand low-educated men and women shows that white men with low education face a sharp increase, significantly above the linear time trends, in suicide rates among cohorts born between 1955 and 1970. This bump is mostly unrelated to secular trends of increasing average educational attainment rates, at least if no interaction between age and cohort is involved in the explanation. No obvious pattern related to cohort size is found for African-American highand low-educated men, which makes sense given the very different historical dynamics for this minority sub-population.

IMPORTANCE The literature suggests that hospitals with better nursing work environments provide better quality of care. Less is known about value (cost vs quality). OBJECTIVES To test whether hospitals with better nursing work environments displayed better value than those with worse nursing environments and to determine patient risk groups associated with the greatest value. DESIGN, SETTING, AND PARTICIPANTS A retrospective matched-cohort design, comparing the outcomes and cost of patients at focal hospitals recognized nationally as having good nurse working environments and nurse-to-bed ratios of 1 or greater with patients at control group hospitals without such recognition and with nurse-to-bed ratios less than 1. This study included 25 752 elderly Medicare general surgery patients treated at focal hospitals and 62 882 patients treated at control hospitals during 2004-2006 in Illinois, New York, and Texas. The study was conducted between January 1, 2004, and November 30, 2006; this analysis was conducted from April to August 2015. EXPOSURES Focal vs control hospitals (better vs worse nursing environment). MAIN OUTCOMES AND MEASURES Thirty-day mortality and costs reflecting resource utilization. RESULTS This study was conducted at 35 focal hospitals (mean nurse-to-bed ratio, 1.51) and 293 control hospitals (mean nurse-to-bed ratio, 0.69). Focal hospitals were larger and more teaching and technology intensive than control hospitals. Thirty-day mortality in focal hospitals was 4.8% vs 5.8% in control hospitals (P < .001), while the cost per patient was similar: the focal-control was -$163 (95% CI = -$542 to $215; P = .40), suggesting better value in the focal group. For the focal vs control hospitals, the greatest mortality benefit (17.3% vs 19.9%; P < .001) occurred in patients in the highest risk quintile, with a nonsignificant cost difference of $941 per patient ($53 701 vs $52 760; P = .25). The greatest difference in value between focal and control hospitals appeared in patients in the second-highest risk quintile, with mortality of 4.2% vs 5.8% (P < .001), with a nonsignificant cost difference of -$862 ($33 513 vs $34 375; P = .12). CONCLUSIONS AND RELEVANCE Hospitals with better nursing environments and above-average staffing levels were associated with better value (lower mortality with similar costs) compared with hospitals without nursing environment recognition and with below-average staffing, especially for higher-risk patients. These results do not suggest that improving any specific hospital's nursing environment will necessarily improve its value, but they do show that patients undergoing general surgery at hospitals with better nursing environments generally receive care of higher value.

This study integrates previously isolated findings of nursing outcomes research into an explanatory framework in which care left undone and nurse education levels are of key importance. A moderated mediation analysis of survey data from 11,549 patients and 10,733 nurses in 217 hospitals in eight European countries shows that patient care experience is better in hospitals with better nurse staffing and a more favorable work environment in which less clinical care is left undone. Clinical care left undone is a mediator in this relationship. Clinical care is left undone less frequently in hospitals with better nurse staffing and more favorable nurse work environments, and in which nurses work less overtime and are more experienced. Higher proportions of nurses with a bachelor's degree reduce the effect of worse nurse staffing on more clinical care left undone.