Addressing the nursing work environment to promote patient safety

TOPIC

The nursing work environment has a critical impact on patient safety. Yet confusion on the specific roles and competencies of nurses, staff ratio issues, and lack of nurse empowerment create weaknesses that result in safety risks.

PURPOSE

These interrelated issues must be addressed systemically to impact the nursing care system.

DISCUSSION

Educational reform focusing upon standardized, higher level nursing education using a military model, appropriate staff ratio laws derived from the outcomes literature, and recurrent training incorporating policy-making powers can result in nurse empowerment and improved patient safety.

CONCLUSION

Improving the nursing environment requires a broad approach to benefit patient safety. By treating the work environment as a complex system, approaches can result in greater nurse professionalism, empowerment, and patient safety.

Perceptions of safety culture vary across the intensive care units of a single institution*

OBJECTIVE

To determine whether safety culture factors varied across the intensive care units (ICUs) of a single hospital, between nurses and physicians, and to explore ICU nursing directors' perceptions of their personnel's attitudes.

DESIGN

Cross-sectional surveys using the Safety Attitudes Questionnaire-ICU version, a validated, aviation industry-based safety culture survey instrument. It assesses culture across six factors: teamwork climate, perceptions of management, safety climate, stress recognition, job satisfaction, and work environment.

SETTING

Four ICUs in one tertiary care hospital.

SUBJECTS

All ICU personnel.

MEASUREMENTS AND MAIN RESULTS

We conducted the survey from January 1 to April 1, 2003, and achieved a 70.2% response rate (318 of 453). We calculated safety culture factor mean and percent-positive scores (percentage of respondents with a mean score of > or =75 on a 0-100 scale for which 100 is best) for each ICU. We compared mean ICU scores by ANOVA and percent-positive scores by chi-square. Mean and percent-positive scores by job category were modeled using a generalized estimating equations approach and compared using Wald statistics. We asked ICU nursing directors to estimate their personnel's mean scores and generated ratios of their estimates to the actual scores.Overall, factor scores were low to moderate across all factors (range across ICUs: 43.4-74.9 mean scores, 8.6-69.4 percent positive). Mean and percent-positive scores differed significantly (p < .0083, Bonferroni correction) across ICUs, except for stress recognition, which was uniformly low. Compared with physicians, nurses had significantly lower mean working conditions and perceptions of management scores. ICU nursing directors tended to overestimate their personnel's attitudes. This was greatest for teamwork, for which all director estimates exceeded actual scores, with a mean overestimate of 16%.

CONCLUSIONS

Significant safety culture variation exists across ICUs of a single hospital. ICU nursing directors tend to overestimate their personnel's attitudes, particularly for teamwork. Culture assessments based on institutional level analysis or director opinion may be flawed.

Healthy work environment standards: is your unit up to par?

Every RN should be able to work in a safe and healthy environment. Certainly, much of the foundation for such an environment rests with an organization's leadership. But it takes the commitment of every RN to make it happen 24/7. If you did a mini-assessment on your current work environment using the questions above and found it wanting, you have choices to make. First, do you stay silent or do you move the issue forward and seek change? Second, if you advocate for and try to drive change and it doesn't work, do you stay or do you go? Healthy work environments for nurses will only become the norm if nurses refuse to settle for less.

Situated cognition and cognitive apprenticeship: a model for teaching and learning clinical skills in a technologically rich and authentic learning environment

The acquisition of a range of diverse clinical skills is a central feature of the pre-registration nursing curriculum. Prior to exposure to clinical practice, it is essential that learners have the opportunity to practise and develop such skills in a safe and controlled environment under the direction and supervision of clinical experts. However, the competing demands of the HE nursing curriculum coupled with an increased number of learners have resulted in a reduced emphasis on traditional apprenticeship learning. This paper presents an alternative model for clinical skills teaching that draws upon the principles of cognitive apprenticeship [Collins, A., Brown, J.S., Newman, S., 1989. Cognitive Apprenticeship: teaching the crafts of reading, writing and mathematics. In: Resnick, L.B. (Ed.) Knowing. Learning and Instruction: Essays in Honor of Robert Glaser. Lawrence Erlbaum Associates, New Jersey, pp. 453-494] and situated cognition within a technologically rich and authentic learning environment. It will show how high quality DVD materials illustrating clinical skills performed by expert practitioners have been produced and used in conjunction with CCTV and digital recording technologies to support learning within a pedagogic framework appropriate to skills acquisition. It is argued that this model not only better prepares the student for the time they will spend in the practice setting, but also lays the foundation for the development of a clinically competent practitioner with the requisite physical and cognitive skills who is fit for purpose [UKCC, 1999. Fitness for Practice: The UKCC Commission for Nursing and Midwifery Education. United Kingdom Central Council for Nursing Midwifery and Health Visiting, London].

The impact of nursing on patient and organizational outcomes

The impact of nursing on patient and organizational outcomes has received significant attention from researchers in the past 10 years. Although some research has been based on a theoretical framework, to date, there has not been one, consistent framework that can guide this research. In addition, the frameworks that have been used do not identify nursing as the pivotal concept in the model. The purpose of this article is to identify a framework to guide such research with an emphasis on nursing as the essential concept. Unit culture, nurse staffing, staffing mix, and other variables do not have a direct effect on outcomes. It is only through these variables' influence on the delivery of nursing care that outcomes are affected.

Palliative care delivery in the NICU: what barriers do neonatal nurses face?

Despite the existence of a universal protocol in palliative care for dying babies and their families, provision of this type of care remains ad hoc in contemporary neonatal settings. Influential bodies such as the American Academy of Pediatrics and the World Health Organization support palliative care to this patient population, so why are such measures not universally adopted? Are there barriers that prevent neonatal nurses from delivering this type of care? A search of the literature reveals that such barriers may be significant and that they have the potential to prevent dying babies from receiving the care they deserve. The goal of this literature review is to identify these barriers to providing palliative care in neonatal nursing. Results of the research have been used to determine item content for a survey to conceptualize and address these barriers.

Mentorship: increasing retention probabilities

Retaining nurses is a significant workforce issue. Experienced nurses in particular are getting harder to retain within hospitals and the discipline at large. One solution to boost retention is to give serious attention to professional socialization activities through contemporary nurse mentorship experiences. The authors contend that contemporary mentoring programmes, targeting developmental quality of life issues of the expert nurse, would appreciably benefit retention programmes within the hospital environment.

Health professionals' perspectives of providing care to people with dementia in the acute setting: Toward better practice

This article reports an interpretative research project about the care of patients with dementia admitted to the acute setting with a non-dementia-related illness. Open-ended interviews were conducted with 25 medical, nursing, and other health care professionals drawn from 3 metropolitan teaching hospitals in Australia. Qualitative data analysis generated 5 major themes relating to the built environment and organizational "system" as determinants of practice, the influence of key players, current dementia care management, and ideal dementia care management. Results showed acute care hospitals are not the best place for people with dementia and can negatively influence health outcomes such as functional independence and quality of life. Participants reported attempts to provide best practice but experienced major constraints stemming largely from environmental, sociocultural, and economic issues. Recommendations include the delivery of acute services in tandem with dementia services and a whole organization shift in thinking away from what conveniently suits the institution to thinking that is person-centered and dementia-friendly. With support from executive-level management, nurses can play a leading role in the implementation of practice change.

Managing mental illness in the dialysis treatment environment: a team approach

Outpatient chronic hemodialysis facilities often serve large populations of patients in an open and sometimes fast-paced environment. Any sizeable group of people will contain a sample of mental illnesses -and the end-stage renal disease diagnosis can be accompanied by co-occurring or comorbid mental illness. Thus, it is important for professional teams to be able to effectively manage related issues arising in the dialysis clinic. Guided by Medicare mandates, dialysis clinics all employ a masters level social worker to respond to the myriad psychosocial needs of this population; MSWs are trained to recognize the signs and symptoms of mental illnesses, and can help guide the team response.

Closeness, chaos and crisis: the attractions of working in acute mental health care

This paper makes a case for the attractiveness of acute mental health inpatient nursing (acute nursing) and argues that an altered perception of this work is essential if we are to provide the most acutely mentally ill and vulnerable people with a stable and expert nursing workforce. The discussion draws on an ethnographic study conducted in an inner-city psychiatric unit in England and the advantages of this method for understanding nursing work are described. Within our findings, we set out two overarching themes: the contextual realities of the contemporary acute ward and features of attraction that encourage nurses to work in the acute care setting. The former includes nurses' responsibility for the total ward environment and the latter the 'comfort of closeness' and 'surviving and thriving in chaos and crisis'. In conclusion, we argue that despite the unpopularity of the acute inpatient mental health environment, the highly sophisticated skills employed by acute nurses actually ensure the promotion of health for the majority of service users.

The health-care environment on a locked psychiatric ward: an ethnographic study

Recent changes in psychiatric hospital care involving a reduction in the number of beds and time spent in hospital motivated the study of conditions of inpatient care on such wards. An ethnographic study of a locked, acute psychiatric ward in a department of psychiatry was performed with the aim of describing the health-care environment in such a ward. The ward admitted patients on both a voluntarily and involuntarily basis. Data were collected by means of 3.5 months of participant observations. The results showed a health-care environment that was overshadowed by control. Staff were in control but they also lacked control; they attempted to master the situation in line with organizational demands and they sometimes failed. At the same time, the staff tried to share the responsibility of caring for patients and next of kin. Patients were controlled by staff; they were the underdogs and dependent on staff for their care and the freedom to leave the ward. Patients tried to make themselves heard and reacted to the control by developing counter-strategies. What this study adds to earlier research is patients' pressure on staff and sometimes quite an open struggle for more control, which may be an expression for an unacceptable imbalance in power between patients and staff.

Children's experiences of hospitalization

This article reports on children's experiences of hospitalization. Data were collected via semi-structured interviews with 11 children aged between seven and 14 years from four paediatric units in England. The children identified a range of fears and concerns, which included: separation from parents and family; unfamiliar environment; investigations and treatments; and loss of self-determination. The children's loss of self-determination over personal needs exacerbated their fears and concerns. It needs to be recognized that compliance with hospital routines is a variable, which influences children's reaction to hospitalization. The findings clearly indicate that children need adequate information tailored to their needs, that their views are sought in the planning and delivery of their care and that hospital environments need to be made more child-centred. Interventions designed to reduce children's stress during hospitalization are not only likely to decrease their stress at the time, but also likely to influence how future experiences are appraised and managed.

Magnet hospital characteristics and northern Canadian nurses' job satisfaction

Retention of health professionals is a serious problem in northern and rural Canada. Magnet hospital factors are known to increase job satisfaction, which contributes to retention. The purpose of this paper is to examine the extent to which magnet hospital characteristics (management support, nurse-doctor and nurse-manager relationships, professional autonomy and responsibility) contribute to northwestern Canadian hospital nurses' job satisfaction. Participants were 123 nurses from 13 hospitals in western Canada. They completed a survey and structured interview that provided data on their attitudes and perspectives about their hospital jobs. We found that some magnet hospital characteristics apply in northern and rural western Canadian hospitals. Our findings indicate that management support and nurse-manager relations are important to nurses' job satisfaction, but participants' views of management were fairly negative, an issue that management needs to address. Nurses' ability to work professionally and autonomously is also important to their satisfaction. There are indications that nursing supervisory skill sets need to be upgraded in some instances.

Organisational climate as a cause of job dissatisfaction among nursing staff in selected hospitals within the Mpumalanga Province

This article focuses on a study conducted with the purpose of exploring and describing the organisational climate as a cause of job dissatisfaction among nursing staff in selected hospitals within the Mpumalanga Province. The major objectives were to determine what organisational climate encompasses; ascertain which factors related to organisational climate can cause dissatisfaction among nurses; determine whether there is a difference in the way nursing management and the nursing staff perceive the existing organisational climate; and make recommendations for health service managers to improve the organisational climate in order to facilitate greater job satisfaction among the nursing staff. A quantitative approach with an exploratory and descriptive design encompassing the survey method was used. A questionnaire was applied as the data collection instrument and was distributed to 140 respondents. The results indicated that the nursing management and the nursing staff were content with the intrinsic factors of their jobs, but were dissatisfied with the extrinsic factors of the organisational climate. The outcome of this research affirms that there are extrinsic factors within the organisational climate that affect the nursing management and the nursing staff adversely. Recommendations were made to promote job satisfaction in selected public hospitals within the Mpumalanga province.

Hospital workplace experiences of registered nurses that have contributed to their resignation in the Durban metropolitan area

TITLE

Hospital workplace experiences of registered nurses that have contributed to their resignation in the Durban Metropolitan Area.

AIM

The purpose of this research was to explore and describe the hospital workplace experiences that had contributed to the resignations of Registered Nurses in the Durban Metropolitan Area.

METHODOLOGY

The broad perspective governing this research is qualitative in nature. The researcher employed a phenomenological approach specifically because the researcher was interested in identifying, describing and understanding the subjective experiences of individual nurses at the two Private and two Provincial health care institutions selected to participate in the study - in respect of their decision (s) to resign from their employment, and/or to leave the nursing profession. Two semistructured interviews were conducted with each participant by the researcher. The researcher applied the principle of theoretical saturation and a total of fifteen participants were interviewed and thirty interviews were conducted. Experiential themes and subthemes in the data were identified by a process of meaning condensation, and the data were managed by means of a qualitative software package - NVIVO (QSR - NUD*IST).

FINDINGS

The resignations of registered nurses in the Durban Metropolitan Area were found to be linked to their respective hospital workplace experiences. These experiences related to their physical working conditions and environment and included the following: unsupportive management structures, autocratic and dehumanizing management styles, negative stereotypy of nurses and the nursing profession, lack of autonomy in the workplace, professional jealousies and fractures within the profession, sub-optimal physical working conditions and shortage of staff, equipment and lack of appropriate surgical supplies, concerns regarding occupational safety e.g. the increasing exposure of health care personnel to HIV and AIDS; lack of opportunities for promotion or continuing one's professional education, the experience of workplace violence--predominantly in the form of verbal and psychological abuse, inaccurate systems of performance assessment (Joint Performance Management, Reports, Personal Profile systems)--compounded by favouritism and racism; and inadequate remuneration.

CONCLUSION

In terms of the findings of this study, the participants' lived experiences in terms of their respective hospital workplace experiences indicated that neither the maintenance factors nor the motivator factors were optimally represented, experienced or enjoyed in their respective workplaces. In terms of Herzberg's Motivator-Maintenance theory, the registered nurses who participated in this study may be described as being 'not satisfied' and 'dissatisfied' with their hospital workplace experiences, physical conditions and environment. A number of recommendations pertaining to strategies for the retention of registered nurses were made for the consideration of both Provincial and Private health care authorities, hospital management structures and the nursing profession respectively. Recommendations for further nursing research were also made.

Nurse work environments and occupational safety in intensive care units

Using data collected from 39 intensive care units (ICUs) in 23 hospitals across the United States, the purpose of this study was to examine hospital structural characteristics, nurse characteristics, and nurses' working conditions' impact on occupational safety outcomes. ICU with more positive organizational climates had lower rates of occupational injuries and blood and body fluid exposures (p < .05). Similarly, ICUs in hospitals that had attained magnet accreditation had lower rates of negative occupational health incidents (p < .05). Hospital profitability was inversely related to rates of blood and body fluid exposure (p < .05). Monitoring nurses' working conditions and improving the organizational climate of hospitals is likely to improve the safety of the employee and the profitability of the hospital through improved system outcomes (such as lower turnover of the employees) as well as improve the quality of patient care delivered.

An Iranian perspective on patients' rights

The aim of this phenomenological research study carried out in Iran was to capture the meaning of patients' rights from the lived experiences of patients and their companions. To achieve this, 12 semistructured interviews were conducted during 2005 in a teaching hospital in Tehran with patients and/or their companions. In addition, extensive field notes were compiled during the interviews. The data were analyzed using Benner's thematic analysis. The themes captured were classified into three main categories, with certain themes identified within each category. The categories were: (1) the concept of patients' rights; (2) barriers to patients' rights; and (3) facilitators of patients' rights. The distinctive themes within each of the categories were identified as: (1a) receiving real care, (1b) focus on the patient, and (1c) equality and accessibility; (2a) dissatisfaction with caregivers, and (2b) specific work environment limitations; (3a) the patient's companion, (3b) a responsible system, and (3c) the public's awareness of rights. Although certain themes identified closely resemble those identified in international patients' bills of rights, the current study focused on themes that are particularly relevant to the Iranian sociocultural context.

Nurses' perception of single-occupancy versus multioccupancy rooms in acute care environments: an exploratory comparative assessment

Health care design professionals, planners, and administrators cite the advantages of private patient rooms, including reduction of hospital-acquired infections, reduction of patient stress levels, and facilitation of nurses' and health care workers' efficiency [e.g., Ulrich, R. (2003). Creating a healing environment with evidence-based design. Paper presented at the American Institute of Architects, Academy of Architecture for Health virtual seminar-Healing environments; Ulrich, R., Quan, X., Zimring, C., Joseph, A., & Choudhary, R. (2004). The role of the physical environment in the hospital of the 21st century: A once-in-a-lifetime-opportunity. ]. A review of the literature revealed that operating costs are reduced in single-patient rooms compared with multioccupancy rooms due to reduction in transfer cost, higher bed occupancy rates, and reduction in labor cost. In addition, single rooms can positively impact patients' hospital experience through increased privacy, better interaction between family and staff, and reduced noise and anxiety. This pilot study focused on nurses' perception of the advantages and disadvantages of single-occupancy versus multioccupancy patient rooms in medical-surgical units in four hospitals in the northwest. A majority of respondents in the four hospitals favored single rooms over double-occupancy rooms for the majority of the 15 categories, including the following: appropriateness for patient examination, interaction with or accommodation of family members, and lower probability of dietary mix-ups. Future studies need to carefully examine the objective measures of patient care variables (e.g., incidents of medication errors, opportunities for surveillance), patient outcomes (e.g., recovery rate, falls), and implications of room occupancy on operating costs.