Outcomes of Hospital Reform in Alberta in Comparison to Other Canadian Provinces, the United States and the United Kingdom (IHOS)

Start/End Dates: 1998 - 2001

Investigators: Phyllis Giovannetti (PI), Marilyn Wood, Donna Smith, Konrad Fassbender, Carole A. Estabrooks

Funder: Alberta Heritage Foundation for Medical Research (AHFMR)

Grant Amount: $300,000

Background: This study was part of the International Survey of Hospital Staffing and Organization on Patient Outcomes. The goal of the larger study is to examine the link between hospital characteristics, such as staffing, work environment, organizational attributes, and patient outcomes including mortality, morbidity, length-of-stay, and failure-to-rescue. The seven-site study, headed by a team of researchers at the University of Pennsylvania, utilizes the differences in approach to hospital restructuring undertaken in the United States, England, Scotland, Germany, and Canada. In addition to the Alberta survey, Canada was represented by site studies in Ontario and British Columbia.

Description: The aim of the project was to determine if the hospital restructuring of the mid-90's had an impact on patient and nurse outcomes.

The purpose of this study was to examine the relationship between hospital organization and patient outcomes in two ways.

  1. One component uses the survey data collected from Alberta nurses to measure indirectly the organizational attributes of the respective hospitals.

  2. A second component links the survey data to patient outcomes collected from provincial administrative records including mortality, morbidity, and failure-to-rescue (a measure of complications arising from a lack of diligent patient monitoring).

Summary: The objective of this study was to  assess the relative effects and importance of nurse education and skill mix, continuity of care and quality of work environment, in predicting 30-day mortality after adjusting for institutional factors and individual patients characteristics. A cross-sectional analysis of outcome data for 18,142 patients discharged from 49 acute care hospitals in Alberta, for diagnoses of acute myocardial infarction (AMI), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), pneumonia or stroke, between April 1, 1998 and March 31, 1999. Mortality data were linked to patient demographic and comorbidity factors, institutional characteristics, and hospital nursing characteristics derived from a survey of all registered nurses working in acute care hospitals.

Patient comorbidities and age explained 44.2% of the variance in 30-day mortality. After adjustment for patient comorbidities and demographic factors, and the size, teaching and urban status of the study hospitals in a fixed effect model, the odds ratios (95% confidence interval) of the significant hospital nursing characteristics which predict 30-day mortality were: 0.81 (0.68-0.96) for higher level of nurse education level, 0.83 (0.73-0.96) for richer nurse skill-mix, 1.26 (1.09-1.47) for higher proportion of casual or temporary positions, and 0.74 (0.60-0.91) for greater nurse – physician relationships. The institutional and hospital nursing characteristics explained an additional 36.9%.

The products of this research program are:

Technical Report:


  • Estabrooks, C.A., Midodzi, W., Cummings, G., Ricker, K.L., & Giovannetti, P. (2005). The Impact of hospital nursing characteristics on 30-day mortality. Nursing Research, 54(2), 74-84

  • Hesketh, K., Duncan, S., Estabrooks, C.A., Reimer, M., Hyndman, K., Acorn, S., & Giovannetti, P. (2003). Workplace violence in Alberta and British Columbia hospitals. Health Policy, 63(3), 311 - 321

  • Estabrooks, C.A., Tourangeau, A., Humphrey, C.K., Hesketh, K., Giovannetti, P., Clarke, H., Acorn, A., Wong, J., Thomson, D., & Shamian, J. (2002). Measuring the hospital practice environment: A Canadian Context. Research in Nursing & Health, 25(4), 256-268

  • Duncan, S.M., Hyndman, K., Estabrooks, C.A., Hesketh, K., Humphrey, C.K., Wong, J.S., Acorn, S., & Giovannetti, G. (2001). Nurses’ experience of violence in Alberta and British Columbia hospitals. Canadian Journal of Nursing Research, 32(4), 57-78

  • Sochalski, J., Estabrooks, C.A., & Humphrey, C.K. (1999). Nurse staffing and patient outcomes: Evolution of an international study. Canadian Journal of Nursing Research, 31, 69–88

Book Chapters:

  • Estabrooks, C. A. (2003). The emotional and interpersonal dimensions of health care and their impact on organizational and clinical outcomes: Building an integrative, action-oriented research agenda. In L. Dubé, G. Ferland, & D. S. Moskowitz (Editors), Emotional & Interpersonal Dimensions of Health Services. Montreal: McGill-Queen's University Press (pp. 45-55)

Non-Refereed Publications:

  • Estabrooks, C.A., Duncan, S.M., Hyndman, K, Hesketh, K., Humphrey, C.K., Wong, J.S., Reimer, M.A., Acorn, S., & Giovannetti, P. (2000). Nurses experience of violence. [letter] Canadian Nurse, 96(9), 6

  • Duncan, S., Estabrooks, C.A., & Reimer, M. (2000). High Rates of Workplace Violence Against Nurses: Findings of the Alberta Nurse Survey (Preliminary Research Report). United Nurses of Alberta New Bulletin, 24(4), 6–7

  • Duncan, S., Estabrooks, C.A., & Reimer, M. (2000). High Rates of Workplace Violence Against Nurses: Findings of the Alberta Nurse Survey (Preliminary Research Report). Alberta RN, 56(2), 13–15