Nurses' working conditions: implications for infectious disease.Staffing patterns and nurses' working conditions are risk factors for healthcare-associated infections as well as occupational injuries and infections. Staffing shortages, especially of nurses, have been identified as one of the major factors expected to constrain hospitals' ability to deal with future outbreaks of emerging infections. These problems are compounded by a global nursing shortage. Understanding and improving nurses' working conditions can potentially decrease the incidence of many infectious diseases infectious diseases: see communicable diseases. . Relevant research is reviewed, and policy options are discussed. ********** The Institute of Medicine's report, To Err is Human "To Err is Human: Building a Safer Health System" is a groundbreaking report issued in 2000 by the U.S. Institute of Medicine which resulted in an increased awareness of U.S. medical errors. The push for patient safety that followed its release currently continues. , which spotlighted the problem of patient safety, reported that tens of thousands of Americans die each year as a result of human error in the delivery of health care (1). Authors of a more recent Institute of Medicine report, Keeping Patients Safe, Transforming the Work Environment of Nurses, concluded that nursing is inseparably linked to patient safety and emphasized that poor working conditions for nurses and inadequate nurse staffing levels increase the risk for errors (2). Nurse working conditions are related to patients' risk of healthcare-associated infections and occupational injuries and infections among staff (3). We discuss the nurse workforce, review research examining nursing as it relates to infectious disease Infectious disease A pathological condition spread among biological species. Infectious diseases, although varied in their effects, are always associated with viruses, bacteria, fungi, protozoa, multicellular parasites and aberrant proteins known as prions. , identify gaps in the literature, and discuss potential policy options. Although our focus is on the nursing workforce in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. , international trends and comparisons are also discussed. The Nursing Workforce Nearly 3 million registered nurses (RNs) work in the United States. Ninety-five percent of these nurses are women, as are most of the 700,000 licensed practical nurses li·censed practical nurse n. Abbr. LPN A nurse who has completed a practical nursing program and is licensed by a state to provide routine patient care under the direction of a registered nurse or a physician. and >2 million unlicensed nurse assistants. Internationally, occupational distributions are similar. More than 1 million RNs work in hospitals, which makes nursing the largest hospital workforce. In 60% of U.S. hospitals, vacancy rates for RNs have increased since 1999; 14% of hospitals now report a severe nurse shortage (i.e., >20% of positions vacant). The American Hospital Association American Hospital Association (AHA), n.pr a nonprofit national organization of individuals, institutions, and organizations engaged in direct patient care. The association works to promote the improvement of health care services. has reported that hospitals have up to 168,000 vacant positions; 126,000 (75%) of the available positions in these hospitals are for RNs (4). The current nursing shortage is related to an aging workforce, problems with retaining licensed personnel, and difficulty recruiting young people into the nursing workforce. The demand for RNs is projected to grow by 22% by 2008, and unless market corrections Market correction A relatively short-term drop in stock market prices, generally viewed as bringing overpriced stocks back to a level closer to companies' actual values. are made, the nursing shortage may reach 800,000 vacant positions by 2020 (5). Recent reports document that the nursing shortage is a severe and growing global problem (4). Historically, the turnover rate among nurses is more than double that for other professionals of comparable education and sex (6). Recent estimates in U.S. hospitals of RN turnover and intention to quit have ranged from 17% to 36% (6,7), figures that compare to an overall turnover rate of 2.2% for those employed in health services health services Managed care The benefits covered under a health contract and social services social services Noun, pl welfare services provided by local authorities or a state agency for people with particular social needs social services npl → servicios mpl sociales and 1.2% for those employed in educational services. In an investigation of the effects of various nurse working conditions in intensive care units, researchers found >17% of RNs indicated their intentions to quit within 1 year (P.W. Stone, unpub, data). This finding was disconcerting dis·con·cert tr.v. dis·con·cert·ed, dis·con·cert·ing, dis·con·certs 1. To upset the self-possession of; ruffle. See Synonyms at embarrass. 2. because this national U.S. sample of 2,324 RNs was highly qualified; their average experience in health care was 15.6 years (SD = 9.20), and their average tenure in their current position was 8.0 years (SD = 7.50). Of those intending to leave, 72% expressed poor working conditions as the reason. In an American Hospital Association-sponsored study, researchers estimated the cost of replacing one RN to be $30,000-$64,000 (4). To cover patient census fluctuations and unplanned absences and to fill vacant positions caused by this nursing shortage, many healthcare facilities have increased nurses' patient loads or expanded the use of nonpermanent staff, such as float pool and agency nurses (4). Concerns have been voiced that reliance on agency nursing services elevates hospital costs, increases the fragmentation of health care, and discourages longer term proactive solutions to staffing shortages that would improve the morale of the permanent staff as well as the quality of patient care services (8). Extended work shifts and overtime for nurses have also escalated; however, nurses report making more errors when working shifts >12 hours, working overtime, or working >40 hours per week (9). To increase the overall supply of nurses, many countries are increasingly relying on international recruitment and migration (10). The percentage of foreign-trained nurses in the United States is 4%, compared to 8% in the United Kingdom and 23% in New Zealand New Zealand (zē`lənd), island country (2005 est. pop. 4,035,000), 104,454 sq mi (270,534 sq km), in the S Pacific Ocean, over 1,000 mi (1,600 km) SE of Australia. The capital is Wellington; the largest city and leading port is Auckland. (11). However, the actual number of foreign-trained nurses in the United States is 90,000, which compares to 42,000 in the United Kingdom (12). In 2002, for the first time more foreign-trained nurses (n = 16,155) were newly registered in Britain than were those who had been educated within the country (n = 14,538). Many concerns exist about clinical competencies, cultural sensitivity, and ethics of the practice of importing nurses (13). While international recruitment can be a solution in one country, it can create additional shortages in others. Nursing and Healthcare-associated Infections A recent evidence-based practice report sponsored by the Agency for Healthcare Quality and Research concluded that a relationship exists between lower levels of nurse staffing and higher incidence of adverse patient outcomes (14). Nurses' working conditions have been associated with medication errors medication error Malpractice An error in the type of medication administered or dosage. See Adverse effect, Error. and falls, increased deaths, and spread of infection (15-30) (Table). RN staffing levels have been associated with the spread of disease during outbreaks (17,22,23,25,28). However, increasing nurse-to-patient ratios alone is not adequate; more complex staffing issues appear to be at work. Many studies have found that the times of higher ratios of "pool staff" (i.e., nursing staff who were members of the hospital pool service or agency nurses) to "regular staff" (i.e., nurses permanently assigned to the unit) were independently associated with healthcare-associated infections (16,17,21,27). The skill mix of the staff, that is, the ratio of RNs to total nursing personnel (RNs plus nurses' aides), is also related to healthcare-associated infections; increased RN skill mix decreases the incidence of healthcare-associated infections (20,29,30). In a recent comprehensive review of the literature, the authors concluded that evidence of the relationship between nurses' working environment and patient safety outcomes, including healthcare-associated infections is growing. They also concluded that stability, skill mix, and experience of the nurse workforce in specific settings are emerging as important factors in that relationship (31). Nurses' Work and Occupational Exposure to Infectious Disease All healthcare workers face a wide range of hazards on the job, including blood and body fluid exposure as well as musculoskeletal musculoskeletal /mus·cu·lo·skel·e·tal/ (-skel´e-t'l) pertaining to or comprising the skeleton and muscles. mus·cu·lo·skel·e·tal adj. Relating to or involving the muscles and the skeleton. injuries related to ergonomic ergonomic - Concerning ergonomics or exhibitting good ergonimics. hazards from lifting and repetitive tasks; nursing personnel often experience these hazards most frequently (32). In 2001, U.S. hospitals reported 293,600 nonfatal occupational injuries and illnesses among their personnel. Among the eight private U.S. industries with [greater than or equal to] 100,000 injuries and illnesses annually, the number of cases of nonfatal injury or illness in hospitals is the second highest; and the incidence rate of injuries and illnesses per 100 fulltime workers employed in nursing and personal care facilities is 13.5; by contrast, the national average is 1.8. In 2001, nursing aides and orderlies reported the highest number of occupational injuries that resulted in days away from work of any service industry (70,300); RNs had the second highest number (24,400) (33). Work-acquired infectious diseases are among the risks all healthcare workers face; and bloodborne pathogens figure prominently among these. Occupational exposure to blood and body fluids is well documented among healthcare workers. Annual exposure prevalence rates range from <10% to 44%, depending on the occupational subgroup (34). Every year, approximately 600,000-800,000 occupational needlestick injuries occur in the United States (34). In a study of 60 U.S. hospitals in a 4-year period, nurses were the most likely to experience a blood or body fluid exposure (Figure) (34). Most exposures involve percutaneous percutaneous /per·cu·ta·ne·ous/ (per?ku-ta´ne-us) performed through the skin. per·cu·ta·ne·ous adj. Passed, done, or effected through the unbroken skin. injuries (e.g., needlesticks), although mucocutaneous mucocutaneous /mu·co·cu·ta·ne·ous/ (-ku-ta´ne-us) pertaining to or affecting the mucous membrane and the skin. mu·co·cu·ta·ne·ous adj. Of or relating to the skin and a mucous membrane. (e.g., spray or splashes to the eyes or mouth) and direct contact of infected blood with nonintact skin are also routes of exposure. These potential infections, like healthcare-associated infections, also appear to be tied to nurses' working conditions. In a cross-sectional study cross-sectional study n. See synchronic study. cross-sectional study, n the scientific method for the analysis of data gathered from two or more samples at one point in time. of >1,500 nurses employed on 40 units in 20 hospitals, poor organizational climate The concept of organizational climate has been assessed by various authors, of which many of them published their own definition of organizational climate. Organizational climate, however, proves to be hard to define. and high workloads were associated with 50% to 200% increases in the likelihood of needlestick injuries and near-misses among hospital nurses (3). Emerging infectious diseases An emerging infectious disease (EID) is an infectious disease whose incidence has increased in the past 20 years and threatens to increase in the near future. EIDs include diseases caused by a newly identified microorganism or newly identified strain of a known microorganism (e.g. and outbreaks of recognized contagious illnesses have highlighted other concerns about the safety of healthcare workers. For example, much of the worldwide severe acute respiratory syndrome Severe Acute Respiratory Syndrome (SARS) Definition Severe acute respiratory syndrome (SARS) is the first emergent and highly transmissible viral disease to appear during the twenty-first century. (SARS) outbreak was hospital-based, and healthcare workers made up a large proportion of cases, accounting for 37% to 63% of suspected SARS patients in highly affected countries (35). In many countries, nurses were the largest single group affected by SARS (36). During the Toronto outbreak, patient care activities commonly conducted by critical care nurses, such as manipulating oxygen masks and suctioning suctioning removal of material through the use of negative pressure, as in suctioning an operative wound during and after surgery to remove exudates. infected patients, were significantly associated with SARS infection (37). In the event of an influenza pandemic
respiratory disease, respiratory disorder adult respiratory distress syndrome, ARDS, wet lung, white lung - acute lung injury characterized by coughing and rales; inflammation of the (38). These threats to safety of the nurse and other essential healthcare workers are of concern for many reasons. First, a trained, qualified healthcare workforce is necessary to respond and care for the public in the event of an outbreak. Staffing issues and hospital organization problems are believed to have complicated the containment of the SARS crisis in Toronto. Staffing shortages, especially of nurses, have been identified as one of the major factors expected to constrain hospitals' ability to deal with possible future threats (4). Without adequate numbers of trained hospital employees to implement effective infection control procedures, such as hand hygiene and proper isolation procedures, emergency departments and hospital wards can easily become the venues where the spread of epidemics occurs. Second, the perception of unsafe working conditions both for the patient and the worker may actually hinder recruitment and retention of qualified staff. In a American Nurses Association American Nurses Association, n.pr professional organization of registered nurses created to encourage high standards in nursing care, pro-mote nursing as a profession, and lobby Congress for issues of concern to nurses. survey of RNs (N = 7,353), 88% of respondents reported health and safety concerns related to work, 75% felt the quality of nursing care had declined in their work setting in the past 2 years, and 92% of those respondents related these concerns to inadequate staffing. Furthermore, >70% of respondents indicated concerns about the acute and chronic effects of work stress and overwork overwork the condition produced by working a draft animal or working dog, an eventing or endurance horse too hard. See also exhaustion. , concerns about a disabling dis·a·ble tr.v. dis·a·bled, dis·a·bling, dis·a·bles 1. To deprive of capability or effectiveness, especially to impair the physical abilities of. 2. Law To render legally disqualified. back injury (60%), and fear of contracting HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. or hepatitis from a needlestick injury (45%). Nurses reported that these health and safety concerns influence their decision to continue working in the field of nursing and the kind of nursing work they choose to perform. Because of these concerns, nearly 55% of the nurses surveyed would not recommend the nursing profession as a career for their children or friends. Although the results of this survey may not be generalizable gen·er·al·ize v. gen·er·al·ized, gen·er·al·iz·ing, gen·er·al·iz·es v.tr. 1. a. To reduce to a general form, class, or law. b. To render indefinite or unspecific. 2. to all nursing personnel because of the nonprobability sampling Sampling is the use of a subset of the population to represent the whole population. Probability sampling, or random sampling, is a sampling technique in which the probability of getting any particular sample may be calculated. method and inclusion of only RNs, the results suggest that concern over safety may be contributing to hospital personnel shortages and hindering recruitment efforts. Dissatisfaction, burnout Burnout Depletion of a tax shelter's benefits. In the context of mortgage backed securities it refers to the percentage of the pool that has prepaid their mortgage. , and concerns about quality of care are reportedly common among hospital nurses in five other industrialized in·dus·tri·al·ize v. in·dus·tri·al·ized, in·dus·tri·al·iz·ing, in·dus·tri·al·iz·es v.tr. 1. To develop industry in (a country or society, for example). 2. countries (39). Gaps in Current Knowledge Barring unprecedented growth in the nursing workforce or unforeseen new forces in health care that intervene to reduce burden of care in society, the numbers of nurses will not keep pace with the demand for services. In the coming decades, we face the prospect of fewer professionals and more unlicensed workers in the healthcare workforce. Decisions will have to be made about how hospitals will safely adapt to this situation. At this time, little evidence exists on what constitutes a safe and efficient labor force mix. Therefore, the general impact of nurse working conditions needs to be examined. First, longitudinal studies longitudinal studies, n.pl the epidemiologic studies that record data from a respresentative sample at repeated intervals over an extended span of time rather than at a single or limited number over a short period. that track change in infection rates and other untoward incidents over time, under different working conditions, and with different staffing models are essential. Second, researchers need to study how the actual care received by patients varies under different staffing conditions at the bedside so that a better understanding of the impact of work environments at the point of care can be gained. Finally, since costs of care increase when patients have adverse outcomes (40) and nurses' working conditions affect outcomes, better working conditions could arguably ar·gu·a·ble adj. 1. Open to argument: an arguable question, still unresolved. 2. That can be argued plausibly; defensible in argument: three arguable points of law. save the healthcare system money. However, the cost-benefit ratio Cost-benefit ratio The net present value of an investment divided by the investment's initial cost. Also called the profitability index. is not known and economic analyses, which include costs related to training, recruitment, and retention, need to be conducted. Implications for Policy Policy solutions for nurse staffing fall into two general categories: 1) incentives and funding for various parties to increase the supply of nurses and 2) employer and hospital regulatory approaches. Although scholarships, loan forgiveness schemes, and funding of new nursing school student slots may be helpful, these policies are unlikely to overcome the long-standing, complex nature of the difficulties in recruiting sufficient newcomers to the nursing profession and then retaining a qualified workforce. In the United States, regulatory approaches by the states have included prohibiting mandatory overtime for nurses (nine states with regulations), holding hospitals accountable for developing and implementing valid staffing plans (seven states), and setting minimum staffing ratios (one state). Regulating minimum nurse-patient ratios has received much attention, despite critiques from the hospital industry that insufficient data exist to credibly set minimum safe staffing levels. California was the first state to implement hospitalwide minimum nurse-patient ratios. The effects of this regulation need to be carefully examined. Although nursing services are positively correlated with patient outcomes, controversy exists over what constitutes an optimal staffing ratio, and little empirical evidence is available on which to base these decisions. Staffing levels for bedside nurses are not the only critical resource involved in decreasing risks for healthcare-associated infections, occupational injuries, and infections. Also important is determining the critical mass of infection control and occupational health professionals needed for surveillance, identification of departures from sound practices, and ongoing education of healthcare workers. Policies aimed at ensuring the availability of training programs on all aspects of patient and worker safety are needed, as is the availability of appropriate supplies to prevent unnecessary infections among patients and nurses. Conclusions Nursing is a predominately female occupation in which the working conditions are often poor. Such conditions contribute to recruitment and retention problems. Together with demographic changes, the result is a shortage of qualified nurses. Mounting evidence demonstrates that the lack of an adequate supply of qualified nurses is a global public safety issue that may require a multipronged mul·ti·pronged adj. 1. Having many prongs. 2. Involving several different directions, aspects, or elements: a multipronged attack; a multipronged tax bill. policy approach. Monitoring and improving the working conditions of nurses are likely to improve the quality of health care by decreasing the incidence of many infectious diseases, assisting in retaining qualified nurses, and encouraging men and women to enter the profession. Further research is needed to understand how best to protect the patient as well as the healthcare worker. Changes in the workforce will have implications for infectious disease, infection control, and occupational health professionals with a need for much more thorough training of nonprofessionals in critical practices.
Table. Summary of studies on nurse staffing and healthcare-associated
infections (a)
Investigator Sample Findings
Outbreak investigations
Anderson et al. (17) 36-bed neonatal ICU; During MRSA outbreak,
8 cases 42% staff untrained,
up to 62% from
outside facility
Archibald et al. (28) 1 pediatric ICU; Decrease 2 infections/
43 patients 1,000 patient days for
each unit increase in
RN h: patient-day
ratio (b)
Fridkin et al. (25) 230-bed VA center; Patient-nurse ratio
170 patients increased during BSI
outbreak (c)
Harbarth et al. (22) 15-bed neonatal ICU; Enterobacter cloacae
8 cases outbreak terminated
after decrease
workload
Vicca (23) 1 adult unit; MRSA (b) cases
50 cases associated with
increase workload,
decrease RN-patient
ratio
Prospective studies
Alonso-Echanove et 8 ICUs; Float RNs >60% central
al. (16) 4,535 patients venous catheter days
increased risk for
BSI (d)
Haley et al. (26) 85-bed neonatal ICU; MRSA infections
76 infants increased within
1 month of worsening
workload (c)
Robert et al. (21) 20-bed surgical ICU; BSI associated with
28 cases lower regular
nurse-patient and
higher pooled
staff-patient
ratios (b)
Retrospective studies
Amaravadi et al. (19) 32 hospitals; Night nurse-patient
353 patients ratio <1:2 associated
with pneumonia (c)
and BSI (c)
Arnow et al. (27) 1 burn unit; New cases MRSA (b)
147 patients paralleled number of
overtime h and number
of shifts by outside
staff
Knauf et al. (30) 502 hospitals Pneumonia, (c)
postoperative
infection, (c) UTI (c)
associated with low
RN h and skill mix
Kovner et al. (15) 530-570 hospitals; Increase nurse h per
10 states adjusted patient day
associated with
decreased
pneumonia (c)
Kovner & Gergen (24) 589 hospitals; Increase RN FTEs
1,993 patients associated with
decreased UTI (b)
and pneumonia (b)
Lichtig et al. (20) 1,575 hospitals Pneumonia, (b)
postoperative
infection, (b) UTI
(b) associated with
low RN skill mix
Needleman et al. (29) 799 hospitals; Higher proportion RN
6,180,628 patients h, higher RN h per
day resulted in
decreased UTI (b)
Stegenga et al. (18) 44-bed pediatric <10.5 nurse h per
unit; 2,929 patient day resulted
admissions in increased
gastrointestinal
infections (c)
(a) HAI, healthcare-associated infections; RN, registered nurse;
MRSA, methicillin-resistant Staphylococcus aureus; BSI, bloodstream
infection; UTI, urinary tract infection; VA, Veterans Administration;
ICU, intensive care unit; FTE, full-time equivalent.
(b) Significant at [less than or equal to] 0.005.
(c) Significant at [less than or equal to] 0.05.
(d) Significant at 0.01.
P.W.S.'s work was supported by AHRQ AHRQ, n.pr See Agency for Healthcare Research and Quality. , R01 HS13114. Dr. Stone is an assistant professor at Columbia University Columbia University, mainly in New York City; founded 1754 as King's College by grant of King George II; first college in New York City, fifth oldest in the United States; one of the eight Ivy League institutions. School of Nursing. Her research interests include the assessment of cost and quality outcomes related to nursing care delivery. Figure. Blood and body fluids' exposure by personnel category. Nurses 44% Physicians 29% Technicians 13% Housekeeping 3% Others 11% Source: National Institute for Occupational Safety and Health (34). Note: Table made from pie chart. References (1.) Institute of Medicine. To err is human: building a safer health system. Washington: National Academy Press; 2000. (2.) Institute of Medicine. 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Mentioned in: Allergic Bronchopulmonary Aspergillosis, Hospital-Acquired Infections, Pseudomonas Infections risk in a pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children. pe·di·at·ric adj. Of or relating to pediatrics. cardiac intensive care unit. Pediatr Infect Dis J. 1997;16:1045-8. (29.) Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med. 2002;346:1715-22. (30.) Knauf RA, Lichtig LK, Risen-McCoy R, Singer AD, Wozniak L. Implementing nursing's report card: a study of RN staffing, length of stay and patient outcomes. Washington: American Nurses Association; 1997. (31.) Jackson M, Chairello L, Gaynes RP, Gerberding JL. Nurse staffing and health care-associated infections: proceedings from a working group meeting. Am J Infect Control. 2002;30:199-206. (32.) Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. . Worker health chartbook, 2000. Cincinnati (OH): US Department of Health and Human Services, Public Health Service; 2000. (33.) U.S. Bureau of Labor Statistics Bureau of Labor Statistics (BLS) A research agency of the U.S. Department of Labor; it compiles statistics on hours of work, average hourly earnings, employment and unemployment, consumer prices and many other variables. . Lost-worktime injuries and illnesses: characteristics and resulting days away from work. Washington: The Bureau; 2003. (34.) Occupational outlook handbook, 2002-2003 edition. Washington: U.S. Department of Labor, Bureau of Labor Statistics; 1999. (35.) Varia var·i·a n. A miscellany, especially of literary works. [Latin, from neuter pl. of varius, various.] M, Wilson S, Sarwal S, McGeer A, Gournis E, Galanis E, et al. Investigation of a nosocomial outbreak of severe acute respiratory syndrome (SARS) in Toronto, Canada. CMAJ CMAJ Canadian Medical Association Journal . 2003;169:285-92. (36.) Booth CM, Boone RH, Tomlison G, Detsky AS. Clinical features and short-term outcomes of 144 patients with SARS in the greater Toronto area The Greater Toronto Area (widely abbreviated as the GTA) is the most populous metropolitan area in Canada. The GTA is a provincial planning area with a population of 5,555,912 at the 2006 Canadian Census. . JAMA JAMA abbr. Journal of the American Medical Association . 2003;289:2801-9. (37.) Loeb M, McGeer A, Henry B, Ofner M, Rose D, Hylwka T. SARS among critical care nurses, Toronto. Emerg Infect Dis. 2004;10:251-5. (38.) Moisiuk SE, Robson D, Klass LK, Kliewer G, Wasyliuk W, Davi M, et al. Outbreak of parainfluenza virus parainfluenza virus n. Any of five types of viruses of the genus Paramyxovirus that are associated with various respiratory infections, especially in children. type 3 in an intermediate care neonatal nursery. Pediatr Infect Dis J. 1998;17:49-53. (39.) Aiken LH, Clarke SP, Sloane DM. Hospital staffing, organization, and quality of care: Cross-national findings. Nurs Outlook. 2002;50:187-94. (40.) Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization hospitalization /hos·pi·tal·iza·tion/ (hos?pi-t'l-i-za´shun) 1. the placing of a patient in a hospital for treatment. 2. the term of confinement in a hospital. . JAMA. 2003;290:1868-74. Address for correspondence: Patricia W. Stone, Columbia University, School of Nursing, 617 W. 168th Street, New York New York, state, United States New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of , NY 10032, USA; fax: 212-305-6937; email: Ps2024@columbia.edu Patricia W. Stone, * Sean P
Sean Paul Joseph (born May 7, 1979) known by his stage name Sean P (formerly Sean Paul), is an American rapper and one half (with J-Bo) of the group YoungBloodZ. . Clarke, ([dagger]) Jeannie Cimiotti, * and Rosaly Correa-de-Araujo ([double dagger double dagger n. A reference mark (  ) used in printing and writing. Also called diesis.Noun 1. ]) * Columbia University School of Nursing, New York, New York, USA; ([dagger]) University of Pennsylvania (body, education) University of Pennsylvania - The home of ENIAC and Machiavelli. http://upenn.edu/. Address: Philadelphia, PA, USA. School of Nursing, Philadelphia, Pennsylvania, USA; and ([double dagger]) Agency for Healthcare Research and Quality, Rockville, Maryland Rockville is the county seat of Montgomery County, Maryland, United States. According to the 2006 census update, the city had a total population of 59,114, making it the second largest city in Maryland. , USA |
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