Celsea Tibbitt

Purpose: Moral distress is a pervasive challenge in nursing and has been associated with burnout, job dissatisfaction, and turnover. Although Magnet Recognition has been associated with more favorable nursing practice environments and nurse outcomes, little is known about the association between Magnet status and nurses' experiences of moral distress or the role of leadership responsiveness in this association. This study examined whether management responsiveness to patient care concerns accounted for part of the association between hospital Magnet status and nurse moral distress. Design: This was a cross‐sectional observational study. Methods: Data from the 2024 Penn Nurses4All Survey and the 2023 American Hospital Association Annual Survey were linked. The analytic sample included 18,678 direct care nurses from 1829 hospitals across 10 US states. The dependent variable was nurse moral distress, the independent variable was hospital Magnet status, and the mediator was nurse‐reported management responsiveness to patient care concerns. A 2‐1‐1 multilevel mediation model using multilevel structural equation modeling was estimated to distinguish within‐ and between‐hospital associations while accounting for the clustering of nurses within hospitals. Models adjusted for nurse‐ and hospital‐level characteristics. Results: Nurses in Magnet hospitals reported lower levels of moral distress and more favorable assessments of management responsiveness than nurses in non‐Magnet hospitals. At the between‐hospital level, Magnet status was associated with higher management responsiveness (unstandardized coefficient b = 0.18, 95% CI = 0.15 to 0.21, p < 0.001), and higher management responsiveness was associated with lower moral distress ( b = −0.31, 95% CI = −0.39 to −0.23, p < 0.001). Greater management responsiveness was also associated with lower moral distress at the within‐hospital level ( b = −0.34, 95% CI = −0.35 to −0.33, p < 0.001). The direct between‐hospital association between Magnet status and moral distress remained statistically significant after accounting for management responsiveness ( b = −0.05, 95% CI = −0.08 to −0.01, p = 0.011). The between‐hospital indirect association between Magnet status and moral distress involving management responsiveness was statistically significant ( b = −0.06, Monte Carlo 95% CI = −0.08 to −0.04, p < 0.001). Similar findings were observed using administrative responsiveness to nurse concerns. Conclusions: Nurses working in Magnet hospitals reported lower levels of moral distress and more favorable assessments of management responsiveness than nurses working in non‐Magnet hospitals. Management responsiveness statistically accounted for part of the observed between‐hospital association between Magnet status and moral distress. Clinical Relevance: Leadership responsiveness to nurses' patient care concerns may represent an important and potentially modifiable organizational factor associated with moral distress. Organizational strategies to strengthen management responsiveness and nurses' ability to raise patient care concerns warrant further evaluation as approaches to supporting nurse well‐being.

Background: Communication failures in inpatient maternity care are one of the leading causes of preventable maternal mortality. Most maternal mortality occurs during the postpartum period after hospital discharge. Nurses provide most direct inpatient maternity care and are responsible for postpartum discharge teaching, which is a critical moment for communicating about the care plan, concerns, warning signs, and follow-up plans to the patient, who will likely not be seen by a health care practitioner for 6 weeks, if at all. Objective: The purpose of this study is to develop a deeper understanding of communication practices between nurses and first-time mothers during postpartum discharge teaching, including what supports or hinders the transfer of critical information and recommendations for improvement from the nurses and patients themselves. A secondary objective is to assess the acceptability, feasibility, and appropriateness of video-reflexive ethnography (VRE) as an intervention to improve care quality and processes. Methods: We are using a health equity–informed mixed methods study design to develop a deeper understanding of communication practices between nurses and patients during postpartum discharge teaching for first-time mothers, including determinants for optimal communication and recommendations for improvement. Qualitative data will come from VRE, which will take place in 3 rounds: round 1 comprises video recording of actual postpartum discharge teaching, round 2 comprises independent review of the recording by both nurses and mothers, and round 3 comprises group reflexivity sessions with nurse participants. The planned analyses include a qualitative descriptive analysis of the video recordings and qualitative content analyses of the transcripts of the independent review and group reflexivity sessions. Quantitative data will come from a survey of nurse respondents regarding the feasibility, acceptability, and appropriateness of using VRE to reflect on and improve their practice. Survey results and reflections on VRE from round 3 will be integrated into a joint display. Results: This project was funded in 2023 and approved by the Institutional Review Board of the University of Pennsylvania on December 6, 2023. Data collection will take place from 2024 to 2025. Results are expected to be published in 2026. Conclusions: Our work aims to engage with nurses and first-time mothers to identify opportunities to improve postpartum discharge teaching and communication. Secondarily, we plan to find out whether study participants find VRE feasible, acceptable, and appropriate for improving the quality of care and health care communication. International Registered Report Identifier (IRRID): DERR1-10.2196/72139

Background: A structurally fluent workforce is essential to demonstrate structural competency—the ability to recognize and address how social, political, and economic structures affect health. Such a workforce understands the role of external factors and social determinants in health inequities. Evidence shows that minority patients receive better care from a diverse workforce. The racial composition of hospital nurses and its correlation to patients remains unreported. Objective: The aim of this study was to evaluate patient–nurse racial concordance at the hospital level in a large geographically representative hospital sample. Methods: A cross-sectional descriptive study design was employed using the 2015 Annual Registered Nurse Survey of the National Database of Nursing Quality Indicators and 2019 Medicare patient data. Concordance was measured by subtracting the hospital nurse percentage from the patient percentage. We defined Black-serving hospital (BSH) status by classifying hospitals into categories (25/50/25) by low, medium, and high representation of Black patients. Descriptive and correlation statistics were calculated on nurse and patient race and their concordance at the hospital and BSH levels. Results: Among 574 hospitals, the proportion of Black nurses was significantly lower than that of Black patients, with considerable variation across hospitals. The representation of Black nurses and patients was strongly associated with hospitals that served more Black patients and generally employed more Black nurses. When grouped into low, medium, and high BSHs, the percentage of Black nurses differed considerably across the categories. High BSH had the greatest discordance. Discussion: Although Black nurses and Black patients are often clustered in the same hospitals, there are relatively few Black nurses in hospitals where Black patients primarily receive care. This study underscores the urgent need for healthcare institutions and policymakers to prioritize building structural competency and diversifying the nursing workforce, particularly in hospitals serving higher Black patient populations. Future research is warranted on whether patient–nurse racial concordance or a nursing workforce more reflective of the patient population it serves reduces disparities.

Background: In hospitals that serve disproportionately patients of Black race, here termed Black-serving hospitals (BSH), nurse staffing is worse, mortality rates are higher, and nursing-sensitive indicators may be worse than in other hospitals, but this evidence has not been compiled. Objective: The study objective was to examine whether nursing-sensitive indicators, which measure changes in patient health status directly affected by nursing care, differ in hospitals where Black patients predominantly access their care, as compared to other hospitals. Methods: To fulfill the objective, a cross-sectional design using publicly available 2019 to 2022 Hospital Compare, 2019 Medicare Provider Analysis and Review (MEDPAR), and case mix index (CMI) file databases were used. Four nursing-sensitive indicators were evaluated: pressure ulcer, postoperative sepsis, perioperative pulmonary embolus/deep vein thrombosis, and death rate among surgical inpatients with serious treatable complications (“failure to rescue”) in hospitals classified into high, medium, and low BSHs according to the percentage of patients of Black race in the MEDPAR data. Mean outcome differences across BSH categories were assessed through analyses of variance and regression models, which controlled for hospital CMI. Results: The 3,101 hospitals were predominantly urban nonteaching hospitals in metropolitan areas. Although 12% of hospitals had Magnet designation, BSHs were disproportionately Magnet (14%). The outcome rates were 0.59 for pressure ulcers, 3.38 for perioperative pulmonary embolus/deep vein thrombosis, 143.58 for failure to rescue, and 4.12 for sepsis. Rates were significantly higher for pressure ulcers, perioperative pulmonary embolus/deep vein thrombosis, and sepsis in high BSHs. The mean failure to rescue rate was similar across low-to-high BSHs and did not show significant differences. These results were unchanged in models adjusting for CMI. Discussion: The evidence suggests that several nursing-sensitive indicators are worse in high BSHs. Research linking nursing-sensitive indicators to nursing resources such as staffing is needed to explicate the mechanism underlying these findings. Poorer nursing-sensitive indicators in combination with poorer nurse staffing in high BSHs presents a priority for policy and management intervention.

BACKGROUND Communication failures in inpatient maternity care are one of the leading causes of preventable maternal mortality. Most maternal mortality occurs during the postpartum period after hospital discharge. Nurses provide most direct inpatient maternity care and are responsible for postpartum discharge teaching, which is a critical moment for communicating about the care plan, concerns, warning signs, and follow-up plans to the patient, who will likely not be seen by a health care practitioner for 6 weeks, if at all. OBJECTIVE The purpose of this study is to develop a deeper understanding of communication practices between nurses and first-time mothers during postpartum discharge teaching, including what supports or hinders the transfer of critical information and recommendations for improvement from the nurses and patients themselves. A secondary objective is to assess the acceptability, feasibility, and appropriateness of video-reflexive ethnography (VRE) as an intervention to improve care quality and processes. METHODS We are using a health equity–informed mixed methods study design to develop a deeper understanding of communication practices between nurses and patients during postpartum discharge teaching for first-time mothers, including determinants for optimal communication and recommendations for improvement. Qualitative data will come from VRE, which will take place in 3 rounds: round 1 comprises video recording of actual postpartum discharge teaching, round 2 comprises independent review of the recording by both nurses and mothers, and round 3 comprises group reflexivity sessions with nurse participants. The planned analyses include a qualitative descriptive analysis of the video recordings and qualitative content analyses of the transcripts of the independent review and group reflexivity sessions. Quantitative data will come from a survey of nurse respondents regarding the feasibility, acceptability, and appropriateness of using VRE to reflect on and improve their practice. Survey results and reflections on VRE from round 3 will be integrated into a joint display. RESULTS This project was funded in 2023 and approved by the Institutional Review Board of the University of Pennsylvania on December 6, 2023. Data collection will take place from 2024 to 2025. Results are expected to be published in 2026. CONCLUSIONS Our work aims to engage with nurses and first-time mothers to identify opportunities to improve postpartum discharge teaching and communication. Secondarily, we plan to find out whether study participants find VRE feasible, acceptable, and appropriate for improving the quality of care and health care communication. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/72139