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American Journal of Infection Control (2016) -

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American Journal of Infection Control American Journal of

Infection Control

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Brief report

The critical care nurse work environment, physician stang, and risk
for ventilator-associated pneumonia
Deena Kelly Costa PhD, RN a,*, James J. Yang PhD b, Milisa Manojlovich PhD, RN, CCRN a
a Department of Systems, Populations, and Leadership, School of Nursing, University of Michigan, Ann Arbor, MI
b School of Nursing, University of Michigan, Ann Arbor, MI

Key Words: We examined the relationship between intensivist physician stang, nurse work environment, and
Critical care stang ventilator-associated pneumonia (VAP) in 25 intensive care units. We found a signicant interaction between
Health care-associated infections the nurse work environment, intensivist physician stang, and VAP. Future work may need to focus on
Health care delivery
fostering organizational collaboration between nursing and medicine to leverage skills of both clinician
Collaboration
groups to reduce risk for VAP in critically ill patients.
2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier
Inc. All rights reserved.

Ventilator-associated pneumonia (VAP) is the most common
health care-associated infection (HAI) in intensive care unit (ICU)
patients.1 Interventions to minimize VAP, such as protocols,2 are de-
livered by nurses and often require physician involvement. The nurse
work environment and ICU physician stang model are modi-
able characteristics that may improve nurses and physicians ability
to deliver preventive VAP care. However, virtually no studies have
examined how the nurse work environment and intensivist phy-
sician stang model together may minimize VAP. The purpose of
this study was to examine the effects of the nurse work environ-
ment and ICU physician stang model on VAP rates.
METHODS
ICU physician stang model6 was dichotomized as represent-
ing a closed ICU model (specially trained physicians manage care)
or an open ICU (any physician manages care).
We derived unit-level VAP rates using data from all patients in
each ICU (calculated as the number of VAP cases divided by the
number of ventilator days in the ICU).3
We a priori identied select variables as potential confound-
ers: nurse stang (registered nursing hours per patient day),7 nurse
education (proportion of nurses with a bachelors degree in nursing
or higher),5 hospital size (small, medium, or large),8 ICU type (general,
medical, or surgical),8 capacity utilization (calculated as the ICU unit
occupancy rate over the average ICU length of stay9), and severity
of illness (average Acute Physiology and Chronic Health Evalua-
tion [APACHE] score).3

This was a secondary analysis of cross-sectional nurse survey data

from 25 ICUs in Michigan (2005-2006). Details of the survey meth-
odology were previously reported.3 All data were summarized and
analyzed at the unit level.
The 2 explanatory variables were the nurse work environment
and ICU physician stang model. We measured the nurse work en-
vironment using the Practice Environment Scale-Nursing Work
Index.4 We calculated a unit-level composite Practice Environ-
ment Scale-Nursing Work Index score representing the work
environment in each ICU.5
* Address correspondence to: Deena Kelly Costa, PhD, RN, School of Nursing,
University of Michigan, 400 N Ingalls St #4351, Ann Arbor, MI 48109.
E-mail address: dkcosta@umich.edu (D.K. Costa).
The Blue Cross Blue Shield Foundation of Michigan provided funding for the parent
study to this work in 2004-2006 (grant #785.RFP, PI: Manojlovich).
Conicts of Interest: None to report.
Statistical analysis
We used Poisson regression to model the relationship between
the explanatory variables and VAP rates, assessing the marginal and
joint effects of the nurse work environment and ICU physician staff-
ing on VAP. We also tested the interaction between nurse work
environment and ICU physician stang model on VAP. Given our
small sample size, we used the lasso method to select potential con-
founders to include in the regression model.10 Selected variables were
unit type, hospital size, APACHE score, capacity utilization, and nurse
education. See online supplement Appendix S1 for additional details
regarding the lasso method.
We used R statistical software (R Foundation for Statistical Com-
puting, Vienna, Austria) and its package (glmnet) for the lasso method
and Stata version 13.0 (StataCorp, College Station, TX) for descrip-
tive and regression analyses. We displayed the results of our

0196-6553/ 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2016.03.028
 ARTICLE IN PRESS
2 D.K. Costa et al. / American Journal of Infection Control (2016) -

interaction analysis graphically, using the margins command in Stata. deviation above the mean is signicantly associated with lower rates
We set signicance at P < .05. Our study was determined as not regu- of VAP. Conversely, in closed ICUs, increasing the nurse work en-
lated by the University of Michigan Institutional Review Board vironment 1 standard deviation above the mean is signicantly
(HUM00104864). associated with higher rates of VAP.

RESULTS
DISCUSSION
Sample summary statistics and details about our methods are
To our knowledge, this was the rst comprehensive assess-
in online supplement Appendix S1.
ment of how the critical care nurse work environment and ICU
The marginal and joint effects of the nurse work environment
physician stang model together may inuence VAP. We found a
and ICU physician stang are displayed in Table 1. The incident rate
signicant interaction effect between the nurse work environ-
ratios of the interaction results are displayed in Table 1. We found
ment, ICU physician stang model, and VAP.
a signicant interaction between the nurse work environment and
Our results suggest that the effect of the work environment and
ICU stang model on VAP (P = .003). Figure 1 graphically displays
ICU physician stang model on VAP may depend on each other.
the results, demonstrating that the effect of the nurse work envi-
Better work environments for nurses may have a positive effect in
ronment on VAP depends on the ICU physician stang model. In
minimizing VAP risk in the absence of intensivist physicians (open
open ICUs, increasing the nurse work environment 1 standard
ICU physician stang model) but a negative effect, increasing risk
of VAP, in the other ICU physician stang model (closed ICUs).
Our results raise awareness of the need to recognize the
Table 1 multiprofessional contribution to HAIs. Organization-level inter-
Poisson regression models estimating the effect of the nurse work environment and
ventions to minimize HAIs must emphasize the multiprofessional
closed intensive care unit (ICU) physician stang model* on rate of ventilator as-
sociated pneumonia (n = 25) context to be able to achieve meaningful improvement. Historical-
ly, at the organization level, examination of ICU characteristics that
Adjusted for unit-level
may affect outcomes has occurred in siloseach discipline (eg,
Unadjusted IRR characteristics IRR
(95% CI), P value (95% CI), P value nursing and medicine) focusing on its respective contribution to
Marginal
patient care in isolation.3,6 Yet our ndings suggest that we may need
Work environment 6.02 (1.75-20.7), P = .004 5.76 (1.29-25.6), P = .02 to emphasize modiable characteristics of ICU nursing and medi-
Closed ICU model 2.99 (1.32-6.73), P = .008 0.60 (0.26-1.40), P = .24 cine together, integrating the contribution of both disciplines to
Joint outcomes.
Work environment 5.11 (1.32-19.83), P = .02 5.79 (1.33-25.17), P = .02
Our study does have limitations. Our sample came exclusively
Closed ICU model 2.68 (1.10-6.57), P = .03 0.59 (0.25-1.38), P = .22
Interaction from southeastern Michigan, so generalizability may be limited. This
Work environment 1.63 (1.09-2.45), P = .02 1.94 (1.25-3.03), P = .003 is a secondary analysis of data that were collected 10 years ago;
closed ICU model however, we know of no other source of data available to examine
Work environment 0.87 (10.64-1.17), P = .36 0.76 (0.55-1.07), P = .12 the nurse work environment, ICU physician stang, and VAP. Our
Closed ICU model 2.94 (1.20-7.20), P = .02 0.64 (0.32-1.29), P = .21
sample size of 25 ICUs limited the precision of our estimates because
CI, condence interval; IRR, incident rate ratio. our condence intervals are wide. Only 4 ICUs were open, limit-
*Models control for unit type, hospital size, Acute Physiology and Chronic Health
ing our conclusions. Although we controlled for severity of illness,
Evaluation score, capacity utilization, and nurse education at the unit-level.

For the interaction, we standardized the nurse work environment so that it is in- it was an average APACHE score for each ICU, which may not suf-
terpreted as one standard deviation change. ciently assess severity.
25
20 15
VAP rates
10 5
0

-2 -1 0 1 2
Nurse work environment, standardized

open ICU closed ICU

Fig 1. Margins plot estimating the effect of the nurse work environment~ on ventilator-associated pneumonia (VAP) rates in open versus closed intensive care units (ICUs).
The nurse work environment is standardized so that 1 unit change is interpreted as 1 standard deviation change. Open ICU is dened as an ICU where any physician can
manage a patients care compared with a closed ICU model, which is dened as an ICU where only specially trained physicians can manage a patients care.
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D.K. Costa et al. / American Journal of Infection Control (2016) -
CONCLUSIONS
This is among the rst studies to examine ICU physician staff-
ing, the nurse work environment, and VAP, and we found a positive
interaction between the nurse work environment and ICU physi-
cian stang on VAP. We contend that future work should examine
how to foster organizational collaboration between ICU nursing and
medicine to leverage the strengths of each discipline to minimize
VAP in critically ill patient populations.
APPENDIX: SUPPLEMENTARY MATERIAL
Supplementary data to this article can be found online at
doi:10.1016/j.ajic.2016.03.028.
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