Search

Purpose: Home health care is one of the fastest growing health care sectors in the United States. However, little is known of differences in trends in quality performance between rural and urban home health agencies over time. This study aimed to examine disparities in quality performance between rural and urban home health agencies between 2014 and 2018. Methods: This is a cohort study using 2014‐2018 national Home Health Compare data and Providers of Service Profile data, including 7,908 home health agencies, of which 1,537 were rural agencies. Quality performance measures included timely initiation of care, hospitalization, and emergency department (ED) visits. Two‐level hierarchical regression models were used to identify rural‐urban differences in these quality indicators over time when controlling organizational characteristics. Findings: Rural agencies were less likely to be for‐profit and accredited, and more likely to be hospital‐based, serve both Medicare and Medicaid beneficiaries, and have hospice programs. Rural agencies consistently outperformed on timely initiation of care over time, and urban agencies consistently outperformed on hospitalization and ED visits over time. These gaps between rural and urban agencies were steady over time except the gap in hospitalization, which slightly narrowed over time (Coef. = 0.11, P =.001 for urban and year interaction term). Conclusions: Significant differences exist in quality of care between rural and urban home health agencies and such differences have not been significantly narrowed over time. To reduce rural‐urban disparities, policy makers should take into account unique challenges faced by urban and rural agencies when making policy decisions. [ABSTRACT FROM AUTHOR]

Internationally educated nurses (IENs) are an important part of the U.S. nursing workforce. Optimizing their transition-to-practice (TTP) experiences in the United States is crucial for ensuring high-quality patient and IENs' outcomes. The purpose of this integrative review is to analyze and synthesize the current evidence surrounding IEN TTP experiences in the United States from 2000 to 2018 to inform improvements in TTP. Eighteen studies were included. TTP was defined through IENs' description of facilitators and barriers of the transition process and presented in seven themes. Two themes were facilitators: support from family and nursing colleagues, and perceptions of self-efficacy. The remaining five themes were barriers: (a) the stigma associated with educational preparation, (b) communication and language, (c) differences in culture, (d) differences in nursing practice, and (e) legal issues. Findings are important for improving TTP programs. Further research focusing on the outcomes of transition programs is needed to inform policymaking surrounding IEN recruitment and retention. [ABSTRACT FROM AUTHOR]

Employing internationally educated nurses (IENs) to address the nursing workforce shortage is common in many countries, including the United States. This study examined the relationship between unit utilization of IENs and collaboration in U.S. hospitals. Results indicated more IENs on a unit did not significantly affect the collaboration among nurses and between nurses and physicians. The presence of IENs significantly influenced unit nursing characteristics, such as education attainment and unit tenure. [ABSTRACT FROM AUTHOR]

Purpose: To examine which characteristics of the practice environment were associated with missed nursing care in U.S. acute care hospital units. Design: A descriptive, correlational study used secondary analysis of the 2015 National Database of Nursing Quality Indicators® Registered Nurse (RN) Survey data. Subscales of the Practice Environment Scale of the Nursing Work Index were used to measure practice environment characteristics. The sample included 1,583 units in 371 hospitals, containing survey responses from 31,650 RNs. Methods: Multilevel logistic regression was performed to estimate the effects of the practice environment characteristics on missed care, controlling for hospital and unit characteristics. Results: About 84.1% of unit RNs reported missing at least one of the 15 necessary care activities. Good environment units had 63.3% significantly lower odds of having RNs miss care activities than poor environment units. Units had 81.5% lower odds of having RNs miss any necessary activities with 1 point increase of the staffing and resource adequacy score; 21.9% lower odds for 1 point increase in the nurse–physician relations score; and approximately 2.1 times higher odds with 1 point increase in the nurse participation in hospital affairs score. Conclusions: Good environments were significantly associated with lower levels of missed care. The impact on missed care differed by the characteristics of the practice environment. Clinical Relevance: Hospital and nursing administrators should maintain good practice environments for nurses to reduce missed care activities and thus potentially improve patient outcomes. Specifically, their efforts should be targeted on improving staffing and resource adequacy and nurse–physician relations and on reducing workloads on hospital affairs. [ABSTRACT FROM AUTHOR]

Abstract Background Collaboration among healthcare providers has been considered a promising strategy for improving care quality and patient outcomes. Despite mounting evidence demonstrating the impact of collaboration on outcomes of healthcare providers, there is little empirical evidence on the relationship between collaboration and patient safety outcomes, particularly at the patient care unit level. Objectives The purpose of this study is to identify the extent to which interdisciplinary collaboration between nurses and physicians and intradisciplinary collaboration among nurses on patient care units are associated with patient safety outcomes. Methods This is a cross-sectional study using nurse survey data and patient safety indicators data from U.S. acute care hospital units. Collaboration at the unit level was measured by two 6-item scales: nurse-nurse interaction scale and nurse-physician interaction scale. Patient outcome measures included hospital-acquired pressure ulcers (HAPUs) and patient falls. The unit of analysis was the patient care unit, and the final sample included 900 units of 5 adult unit types in 160 hospitals in the U.S. Multilevel logistic and Poisson regressions were used to estimate the relationship between collaboration and patient outcomes. All models were controlled for hospital and unit characteristics, and clustering of units within hospitals was considered. Results On average, units had 26 patients with HAPUs per 1000 patients and 3 patient falls per 1000 patient days. Critical care units had the highest HAPU rate (50/1000 patients) and the lowest fall rate (1/1000 patient days). A one-unit increase in the nurse-nurse interaction scale score led to 31% decrease in the odds of having a HAPU (OR, 0.69; 95% CI, 0.56–0.82) and 8% lower patient fall rate (IRR, 0.92; 95% CI, 0.87–0.98) on a nursing unit. A one-unit increase in the nurse-physician interaction scale score was associated with 19% decrease in the odds of having a HAPU (OR, 0.81; 95% CI, 0.68–0.97) and 13% lower fall rates (IRR, 0.87; 95% CI, 0.82–0.93) on a unit. Conclusions Both nurse-physician collaboration and nurse-nurse collaboration were significantly associated with patient safety outcomes. Findings from this study suggest that improving collaboration among healthcare providers should be considered as an important strategy for promoting patient safety and both interdisciplinary and intradisciplinary collaboration are critical for achieving better patient outcomes. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The aim of this study was to examine the impact of nurse shift patterns on nurses' collaboration with nurses and physicians in US acute care hospital units. BACKGROUND: Collaboration between nurses and other healthcare providers is critical for ensuring quality patient care. Nurses perform collaboration during their shift work; thus, nurse shift patterns may influence collaboration. However, there is a dearth of empirical evidence of the relationship between nurse shift patterns and collaboration of nurses with other healthcare providers. METHODS: This is a cross-sectional study using data from 957 units in 168 acute care hospitals. Measures of collaboration include nurse-nurse collaboration and nurse-physician collaboration. Measures of shift patterns included shift length and overtime. Multilevel linear regressions were conducted at the unit level, controlling unit and hospital characteristics. RESULTS: Overtime (more nurses working overtime or longer overtime hours) was associated with lower collaboration at the unit level; however, shift length was not. CONCLUSIONS: Working overtime may negatively influence nurses' collaboration with other healthcare providers. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To examine the trends in baccalaureate (bachelor of science in nursing)–prepared registered nurses (BSN RNs) in U.S. acute care hospital units and to project the growth in the number of BSN RNs by 2020. Design: This is a longitudinal study using the Registered Nurse Education Indicators data (2004–2013) from the National Database of Nursing Quality Indicators. Methods: The level of BSN RNs in each unit was operationalized as the proportion of nurses holding a baccalaureate degree or higher among all the nurses in a unit. Our sample included 12,194 unit‐years from 2,126 units of six cohorts in 377 U.S. acute care hospitals. A hierarchical linear regression model was used to examine the trends in BSN RNs and to project future growth in the number of BSN RNs when controlling for hospital and unit characteristics and considering repeated measures in units over time and clustering of units within hospitals. Results: The proportion of BSN RNs in U.S. acute care hospital units increased from 44% in 2004 to 57% in 2013 (a 30% increase); when combining all cohorts, this rate increased from 44% in 2009 to 51% in 2013. On average, the proportion of BSN RNs in a unit increased by 1.3% annually before 2010 and by 1.9% each year from 2010 on. The percentage of units having at least 80% of their nurses with a baccalaureate degree or higher increased from 3% in 2009 to 7% in 2013. Based on the current trends, 64% of the nurses working in a hospital unit will have a baccalaureate degree by 2020, and 22% of the units will reach the 80% goal by 2020. Conclusions: There was a significant increase in the proportion of BSN RNs in U.S. acute care hospital units over the past decade, particularly after 2010. However, given the current trends, it is unlikely that the goal of 80% nurses with a baccalaureate degree will be achieved by 2020. Clinical Relevance: The U.S. nursing workforce is under educational transformation in order to meet the increasing healthcare needs. To help accelerate this transformation, further advocacy, commitment, and investment are needed from all healthcare stakeholders (e.g., policymakers, executives and managers of healthcare facilities, nursing schools, etc.). [ABSTRACT FROM AUTHOR]

Purpose To identify how organizational nursing factors at different structural levels (i.e., unit-level work environment and hospital Magnet status) are associated with hospital-acquired pressure ulcers (HAPUs) in U.S. acute care hospitals. Design A cross-sectional observational study used data from the National Database of Nursing Quality Indicators®. Responses from 33,845 registered nurses (RNs) were used to measure unit work environments. The unit of analysis was the nursing unit, and there were 1,381 units in 373 hospitals in the United States. Methods Unit work environment was measured by the Practice Environment Scale of Nurse Working Index (PES-NWI). Multilevel logistic regressions were used to estimate the effects of unit work environment and hospital Magnet status on HAPUs. All models were controlled for hospital and unit characteristics when considering clustering of units within hospitals. Results Magnet hospital units had 21% lower odds of having an HAPU than non-Magnet hospital units (95% confidence interval [CI], 0.64-0.98). With one unit increase of the PES-NWI score, units had 29% lower odds of having an HAPU (95% CI, 0.55-0.91). When including both hospital Magnet status and unit work environment in the model, hospital Magnet status no longer had a significant effect on HAPUs (odds ratio [OR] = 0.82; 95% CI, 0.66-1.02), whereas the significant effect of unit work environment persisted (OR = 0.73; 95% CI, 0.56-0.93). Conclusions Both hospital and unit environments were significantly associated with HAPUs, and the unit-level work environment can be more influential in reducing HAPUs. Clinical Relevance Investment in the nurse work environments at both the hospital level and unit level has the potential to reduce HAPUs; and additional to hospital-level initiatives (e.g., Magnet recognition program), efforts targeting on-unit work environments deserve more attention. [ABSTRACT FROM AUTHOR]

In home health care, language barriers are understudied. Language barriers between patients and providers are known to affect a variety of patient outcomes. How a patient's language preference influences hospital readmission risk from home health care has yet to be determined. To determine if home care patients' language preference is associated with their risk for hospital readmission from home health care within 30 days of hospital discharge. Retrospective cross-sectional study of hospital readmissions from an urban home health care agency's administrative records and the national electronic home health care record for the United States, captured between 2010 and 2015. New York City, New York, USA. The dataset comprised 90,221 post-hospitalization patients and 6.5 million home health care visits. First, a Chi-square test was used to determine if there were significant differences in crude readmission rates based on language group. Inverse probability of treatment weighting was used to adjust for significant differences in known hospital readmission risk factors between to examine all-cause hospital readmission during a home health care stay. The final matched sample included 87,561 patients with a language preference of English, Spanish, Russian, Chinese, or Korean. English-speaking patients were considered the comparison group to the non-English speaking patients. A Marginal Structural Model was applied to estimate the impact of non-English language preference against English language preference on rehospitalization. The results of the marginal structural model were expressed as an odds ratio of likelihood of readmission to the hospital from home health care. Home health patients with a non-English language preference had a higher hospital readmission risk than English-speaking patients. Crude readmission rate for the limited English proficiency patients was 20.4% (95% CI, 19.9–21.0%) overall compared to 18.5% (95% CI, 18.7–19.2%) for English speakers (p < 0.001). Being a non-English-speaking patient was associated with an odds ratio of 1.011 (95% CI, 1.004–1.018) in increased hospital readmission rates from home health care (p = 0.001). There were also statistically significant differences in readmission rate by language group (p < 0.001), with Korean speakers having the lowest rate and Spanish speakers having the highest, when compared to English speakers. People with a non-English language preference have a higher readmission rate from home health care. Hospital and home healthcare agencies may need specialized care coordination services to reduce readmission risk for these patients. Tweetable abstract: A new US-based study finds that home care patients with language barriers are at higher risk for hospital readmission. [ABSTRACT FROM AUTHOR]

Increasingly, patients with limited English proficiency are accessing home health care services in the United States. Few studies have examined how language barriers influence provider role implementation or workload in the home health care setting. To explore home health care professionals' perspectives about how workload changes from managing language barriers influence quality and safety in home health care. A qualitative secondary data analysis using a summative content analysis approach was used to analyze existing semi-structured interview data. A large urban home health care agency located on the East Coast of the United States. Thirty five home health care providers [31 registered nurses, 3 physical therapists, 1 occupational therapist]. A total of 142 discrete incidents emerged from the analysis. Overall, home health care providers experienced distinct shifts in how they implemented their roles that added to their workload and time spent with Limited English Proficiency patients and family members. Providers were concerned about interpretation accuracy and perceived it as potentially posing risks to patient safety. Changes in work patterns, therefore, sought to maximize patient safety. Home health care providers decision-making about how they adapt practice when faced with a language barrier is a sequence of actions based on awareness of the patient's language preference and if they spoke another language. Subsequent choices showed proactive behaviors to manage increased workload shaped by their perceived risk of the threats posed by the quality of interpreter services. Future research should develop quantitative models examining differences in workload when caring for limited English proficiency versus English speaking patients as well as the relationship between visit length and patient outcomes to determine optimal quality models. [ABSTRACT FROM AUTHOR]

An increasing body of evidence highlights the importance of an individual's place of residence on their health and functional outcomes. This study is based on Outcome and Assessment Information Set data to assess the differences in emergency department visits among Medicare home health care patients by patients' residence location (rural/urban status and neighborhood socioeconomic status). Compared to urban patients, a disproportionately higher proportion of rural patients lived in more or most disadvantaged neighborhoods (83.9% vs. 41.3%). Using linear probability regression models, patients in rural areas (coefficient = .02, p < .001) and disadvantaged neighborhoods (less disadvantaged: coefficient = .02, p < .001; more disadvantaged: coefficient = .034, p < .001; most disadvantaged: coefficient = .042, p < .001) were more likely to experience emergency department visits. Policymakers should consider utilizing area-based target interventions to mitigate gaps in home health care. Also, given that the majority of rural patients reside in disadvantaged neighborhoods, neighborhood characteristics should be considered in addressing rural-urban disparities and improving home health care., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: Home health care serves millions of Americans who are "Aging in Place," including the rapidly growing population of Medicare Advantage (MA) enrollees. This study systematically reviewed extant evidence illustrating home health care (HHC) services to MA enrollees., Methods: A comprehensive literature search was conducted in 6 electronic databases to identify eligible studies, which resulted in 386 articles. Following 2 rounds of screening, 30 eligible articles were identified. Each study was also assessed independently for study quality using a validated quality assessment checklist., Results: Of the 30 studies, nearly half (n=13) were recently published between January 1, 2017 - January 6, 2022. Among various issues related to HHC to MA enrollees examined, which were often compared with Traditional Medicare (TM) enrollees, the 2 most studied issues were HHC use rate (including access) and care dosage/intensity. Inconsistencies were common in findings across reviewed studies, with slight variations in the level of inconsistency by studied outcomes. Several critical issues, such as heterogeneity of MA plans, influence of MA-specific features, and program response to policy and quality improvement initiatives, were only examined by 1 or 2 studies. The depth and scope of scientific investigation were also limited by the scale and details available in MA data in addition to other methodological limits., Conclusions: Wild variations and conflicting findings on HHC to MA beneficiaries exist across studies. More research with rigorous designs and robust MA encounter data is warranted to determine home health care for MA enrollees and the relevant outcomes., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

While home health agencies (HHAs) can seek accreditation to recognize their quality of service, it is unknown whether agencies with accreditation perform better in providing care than those without accreditation. Using 5-year data from national data sources, the aims of this study were: 1) to depict characteristics of HHAs with and without accreditation; and 2) to examine the relationship between accreditation status and HHA performance on quality-of-care metrics. This study analyzed 7,697 agencies in the US and found that 1) agencies that were for-profit, urban, not-hospital-affiliated, single-branch, Medicare enrolled only, and without hospice program were more likely to have accreditation; and 2) overall, accredited agencies performed better on the three commonly used quality indicators, timely initiation of care, hospitalization, and emergency department visit, though not all the observed differences were substantial in absolute value. Our results provide unique empirical information to agencies considering seeking accreditation.

EHRs provide an opportunity to conduct research on underrepresented oncology populations with mental health and substance use disorders. However, a lack of data quality may introduce unintended bias into EHR data. The objective of this article is describe our analysis of data quality within automated comorbidity lists commonly found in EHRs. Investigators conducted a retrospective chart review of 395 oncology patients from a safety-net integrated healthcare system. Statistical analysis included κ coefficients and a condition logistic regression. Subjects were racially and ethnically diverse and predominantly used Medicaid insurance. Weak κ coefficients ( κ = 0.2-0.39, P < .01) were noted for drug and alcohol use disorders indicating deficiencies in comorbidity documentation within the automated comorbidity list. Further, conditional logistic regression analyses revealed deficiencies in comorbidity documentation in patients with drug use disorders (odds ratio, 11.03; 95% confidence interval, 2.71-44.9; P = .01) and psychoses (odds ratio, 0.04; confidence interval, 0.02-0.10; P < .01). Findings suggest deficiencies in automatic comorbidity lists as compared with a review of provider narrative notes when identifying comorbidities. As healthcare systems increasingly use EHR data in clinical studies and decision making, the quality of healthcare delivery and clinical research may be affected by discrepancies in the documentation of comorbidities., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Patients in home health care (HHC), a rapidly growing healthcare sector, are at high risk for infections. This study aimed to identify risk factors for infections among HHC patients using the Outcome and Assessment Information Set (OASIS) data. We used a 5% random sample of the 2013 national OASIS data. Infections were identified if records indicated that patients were hospitalized or received emergency care for one of three types of infections (respiratory, wound site, and urinary tract infection). Multivariate logistic regression models were used to identify risk factors for each individual infection type. The final analysis included 128,163 patients from 8,255 HHC agencies nationwide. Approximately 3.2% of the patients developed infections during their HHC stay that led to hospitalization or emergency care treatment. We found that associations between demographics and infection risk are specific to the type of infection. In general, a history of multiple hospitalizations in past 6 months, comorbidity, having a severe condition at HHC admission, and impaired physical functioning increased HHC patients' risk of infections. We also identified that HHC patients with caregivers who needed training in providing medical procedure or treatment are at higher risk for wound-site infections. Our findings suggest that patients with underlying medical conditions and limited physical function status are more likely to develop infection. The caregiver's lack of training in providing needed care at home also places HHC patients at high risk for infection. Education for patients and caregivers should be tailored based on their health literacy level to ensure complete understanding., (© 2020 Wiley Periodicals LLC.)

Despite the rapid increase in the number of persons with dementia (PWD) receiving home health care (HHC), little is known of HHC services patterns to PWD of varied backgrounds, including language preference other than English. Analyzing data of 12,043 PWD from an urban home health agency, we found on average PWD received 2.48 skilled visits or 1.88-hour skilled care and 5.81 aide visits or 24.13-hour aide care weekly. Approximately 63% of the skilled visits were from nurses. More non-English preferred PWD received aide visits, compared to English preferred PWD (44% vs. 36%). The type and intensity of HHC services were associated with language preference; when stratified by insurance, non-English preference was still significantly associated with more HHC aide care. Our study indicated that HHC services (both type and amount) varied by language preference and insurance type as an indicator of access disparities was a significant contributor to the observed differences., Competing Interests: Declaration of Competing Interest None., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Nursing unit is the micro-organization in the hospital health care system in which integrated patient care is provided. Nursing units of different types serve patients with distinct care goals, clinical tasks, and social structures and norms. However, empirical evidence is sparse on unit type differences in quality of care and its relation with nurse work environment. Nurse work environment has been found as an important nursing factor predicting nurse and patient outcomes., Objectives: To examine the unit type differences in nurse-reported quality of care, and to identify the association between unit work environment and quality of care by unit types., Methods: This is a cross-sectional study using nurse survey data (2012) from US hospitals nationwide. The nurse survey collected data on quality of care, nurse work environment, and other work related information from staff nurses working in units of various types. Unit types were systematically classified across hospitals. The unit of analysis was the nursing unit, and the final sample included 7677 units of 14 unit types from 577 hospitals in 49 states in the US. Multilevel regressions were used to assess the relationship between nurse work environment and quality of care across and by unit types., Results: On average, units had 58% of the nurses reporting excellent quality of care and 40% of the nurses reporting improved quality of care over the past year. Unit quality of care varied by unit types, from 43% of the nurses in adult medical units to 73% of the nurses in interventional units rating overall quality of care on unit as excellent, and from 35% of the nurses in adult critical care units to 44% of the nurses in adult medical units and medical-surgical combined units reporting improved quality of care. Estimates from regressions indicated that better unit work environments were associated with higher quality of care when controlling various hospital and unit covariates; and this association persisted among units of different types., Conclusions: Unit type differences exist in the overall quality of care as well as achievement in improving quality of care. The low rates of nurses reporting improvement in the quality of nursing care to patients suggest that further interventions focusing at the unit-level are needed for achieving high care quality. Findings from our study also suggest that improving nurse work environments can be an effective strategy to improve quality of care., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: The objective of this study is to identify the effects of unit collaboration and nursing leadership on nurse outcomes and quality of care., Background: Along with the current healthcare reform, collaboration of care providers and nursing leadership has been underscored; however, empirical evidence of the impact on outcomes and quality of care has been limited., Methods: Data from 29742 nurses in 1228 units of 200 acute care hospitals in 41 states were analyzed using multilevel linear regressions. Collaboration (nurse-nurse collaboration and nurse-physician collaboration) and nursing leadership were measured at the unit level. Outcomes included nurse job satisfaction, intent to leave, and nurse-reported quality of care., Results: Nurses reported lower intent to leave, higher job satisfaction, and better quality of care in units with better collaboration and stronger nursing leadership., Conclusion: Creating a care environment of strong collaboration among care providers and nursing leadership can help hospitals maintain a competitive nursing workforce supporting high quality of care.

Background: Growing scrutiny of readmissions has placed hospitals at the center of readmission prevention. Little is known, however, about hospital nursing—a critical organizational component of hospital service system—in relation to readmissions., Objectives: To determine the relationships between hospital nursing factors—nurse work environment, nurse staffing, and nurse education—and 30-day readmissions among Medicare patients undergoing general, orthopedic, and vascular surgery., Method and Design: We linked Medicare patient discharge data, multistate nurse survey data, and American Hospital Association Annual Survey data. Our sample included 220,914 Medicare surgical patients and 25,082 nurses from 528 hospitals in 4 states (California, Florida, New Jersey, and Pennsylvania). Risk-adjusted robust logistic regressions were used for analyses., Results: The average 30-day readmission rate was 10% in our sample (general surgery: 11%; orthopedic surgery: 8%; vascular surgery: 12%). Readmission rates varied widely across surgical procedures and could be as high as 26% (upper limb and toe amputation for circulatory system disorders). Each additional patient per nurse increased the odds of readmission by 3% (OR=1.03; 95% CI, 1.00-1.05). Patients cared in hospitals with better nurse work environments had lower odds of readmission (OR=0.97; 95% CI, 0.95-0.99). Administrative support to nursing practice (OR=0.96; 95% CI, 0.94-0.99) and nurse-physician relations (OR=0.97; 95% CI, 0.95-0.99) were 2 main attributes of the work environment that were associated with readmissions., Conclusions: Better nurse staffing and work environment were significantly associated with 30-day readmission, and can be considered as system-level interventions to reduce readmissions and associated financial penalties.

Research has shown that hospitals with better nurse staffing and work environments have better nurse outcomes-less burnout, job dissatisfaction, and intention to leave the job. Many studies, however, have not accounted for wage effects, which may confound findings. By using a secondary analysis with cross-sectional administrative data and a four-state survey of nurses, we investigated how wage, work environment, and staffing were associated with nurse outcomes. Logistic regression models, with and without wage, were used to estimate the effects of work environment and staffing on burnout, job dissatisfaction, and intent to leave. We discovered that wage was associated with job dissatisfaction and intent to leave but had little influence on burnout, while work environment and average patient-to-nurse ratio still have considerable effects on nurse outcomes. Wage is important for good nurse outcomes, but it does not diminish the significant influence of work environment and staffing on nurse outcomes., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)