Can nurses reduce readmissions?

If their work environment is good

How can you make sure that your nurses make a difference to the outcomes of your patients? According to a study in the January issue of Medical Care1, all it takes is a good patient/nurse ratio and good leadership.

Matthew McHugh, PhD, JD, MPH, RN, and his colleagues looked at the outcomes of heart failure patients in three states and the staffing ratios, educational level of the nurses, and the work environment, and found that improving staffing levels and the work environment make the most difference in preventing 30-day readmissions among that patient base.

Work environment was evaluated based on a National Quality Forum-endorsed Practice Environment Scale of the Revised Nursing Work Index, which includes elements such as physician-nurse relations, nursing leadership support, and participation in hospital affairs.

“There is a lot of focus on readmissions now, since hospitals are on the hook for them,” McHugh says. “And more than the financial impact, they aren’t a good outcome, particularly not for older adults. Finding ways to keep them out of the hospital is an important goal.” Since patients are in the hospital for 24-hour access to nursing care, it figures that nurses matter to outcomes. But beyond throwing more nurses at the problem, what can they do?

It turns out there is more than staffing to the solution — although nurse-to-patient ratios are also important, he says. There are several elements that make for a good work environment: resource adequacy — or having enough stuff to do your job; nursing participation in hospital affairs — meaning a flatter, less hierarchical structure; support from nurse leadership and the ability of nurse managers; having policies and practices in place that support decision-making at the bedside; and the educational level of the nurses, with more BSN nurses being better.

McHugh says if you put hospitals into three buckets — those that do poorly, those that are average, and those that do well on those elements of a good work environment — you can control for a variety of other factors such as severity of illness, size of hospital, and still be able to predict which hospitals will have the worse readmission rates.

He suggests that hospitals take great care to look at the quarterly practice environment scale survey results on a unit-by-unit level. There are 31 items on the survey, and if you aren’t doing well on some of them, it’s a good place to start — not just because it will make your hospital a better place to work, but because patient outcomes improve along with morale.

It’s good to add more nurses, too, he says, noting that it is “hard to find an example of really good staffing and really bad outcomes. But staffing levels are conditional on work environment. At lower levels, if you add people, but don’t improve work environment issues, you won’t overcome that work environment’s downward pull.”


1. McHugh MD. Hospital nursing and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia. MedCare. 2013 Jan;51(1):52-9. doi: 10.1097/MLR.0b013e3182763284.


For more information on this topic, contact Matthew D. McHugh PhD, JD, MPH, RN, FAAN, Assistant Professor of Nursing, Robert Wood Johnson Foundation Nurse Faculty Scholar, Center for Health Outcomes & Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA. Telephone: (215) 746-0205.