Evaluation of Technical Efficiency of Nursing Care in U.S. Critical Care Units

Purpose: This study aimed to explore relative technical efficiency of nursing care in U.S. critical care units and determine the effects of organizational and environmental factors on efficiency in providing quality of nursing care. Methods: This study was a cross-sectional, nursing unit-level secondary data analysis. Adult critical care units were included in the sample if they participated in the 2014 National Database of Nursing Quality Indicators. Data were obtained from this database and the Centers for Medicare and Medicaid Services. Data envelopment analysis was used to estimate technical efficiency for each critical care unit. Multilevel modeling was then employed for the hierarchically structured data to determine the effects of organizational and environmental factors on technical efficiency. Results: The overall efficiency score of the critical care units in the sample was 0.581, and only 6 units were technically efficient. For nursing unit-level organizational factors, proportions of registered nurses with a bachelor’s degree and a specialty nursing certification were significantly correlated with technical efficiency, but no correlation was found with the proportion having a master’s or higher degree. In addition, nurse-to-patient ratio showed the strongest positive correlation with technical efficiency. For hospital-level organizational factors, units in non-Magnet and small bed size hospitals had higher technical efficiency scores than those in Magnet hospitals and medium or large bed size hospitals. Medicare case mix index was not significantly related to technical efficiency. Regarding environmental factors, although county-level variations in explaining technical efficiency were identified, neither Medicare Advantage penetration nor hospital competition significantly affected technical efficiency. Conclusions: The results suggest that various organizational factors had significant impacts on technical efficiency. However, Medicare Advantage penetration and hospital competition in a market did not create pressure for critical care units to become more efficient by reducing their inputs. Further studies are needed to identify other county-level factors that do predict nursing unit-level technical efficiency. The study findings can be translated into management strategies at various levels by administrators and policy makers to avoid excessive costs associated with nurse staffing and adverse patient outcomes while maintaining effective critical care services.