'Care left undone' during nursing shifts: associations with workload and perceived quality of care

Factors influencing the missed nursing care in patients from a private hospital

Objective:

to determine the factors that influence the missed nursing care in hospitalized patients.

Methods:

descriptive correlational study developed at a private hospital in Mexico. To identify the missed nursing care and related factors, the MISSCARE survey was used, which measures the care missed and associated factors. The care missed and the factors were grouped in global and dimension rates. For the analysis, descriptive statistics, Spearman’s correlation and simple linear regression were used. Approval for the study was obtained from the ethics committee.

Results:

the participants were 71 nurses from emergency, intensive care and inpatient services. The global missed care index corresponded to M=7.45 (SD=10.74); the highest missed care index was found in the dimension basic care interventions (M=13.02, SD=17.60). The main factor contributing to the care missed was human resources (M=56.13, SD=21.38). The factors related to the care missed were human resources (r_s=0.408, p<0.001) and communication (r_s=0.418, p<0.001).

Conclusions:

the nursing care missed is mainly due to the human resource factor; these study findings will permit the strengthening of nursing care continuity.

Factors Related to School Nurse Workload

Recognizing the need for a school nurse workload model based on more than the number of students in a caseload, the National Association of School Nurses issued recommendations related to measuring school nurse workload. Next, a workforce acuity task force (WATF) was charged with identifying the steps needed to further the recommendations. As a first step, the WATF focused on identifying existing literature and practices related to school nurse workload. The purpose of this article is to synthesize and categorize the factors that were identified, delineate sources for collecting and retrieving these factors, and make recommendations for clinicians and researchers interested in developing instruments to measure school nurse workload.

‘You just can’t do it all’: a secondary analysis of nurses' perceptions of teamwork, staffing and workload

The purpose of this study was to re-examine data to explore connections between nurses’ perceptions of teamwork, staffing and workload, focusing on salient aspects and connections, from the nurses’ perspective. Insufficient staffing levels and imbalanced workload distributions are prominent challenges in contemporary healthcare which can cause increased incident reports, medical errors and lower patient satisfaction. Using a novel form of secondary analysis – an original qualitative analysis followed by a quantification of the qualitative data, we found themes of teamwork, staffing and workload were interrelated in the data. When facing workload challenges created by understaffing, participants directly attributed their units’ ability to meet the needs of patient care to levels of teamwork on the unit. We suggest that teamwork in healthcare needs targeted organisational support. In other words, healthcare organisations must systematically approach and monitor the status of nursing teamwork, e.g. implement programmes to develop it as needed, particularly when faced with staffing and workload challenges. Healthcare leaders can learn from and the healthcare delivery workplace can be shaped by listening to teamwork perceptions of nurses.

A qualitative formative evaluation of a patient-centred patient safety intervention delivered in collaboration with hospital volunteers

Background

Evidence suggests that patients can meaningfully feed back to healthcare providers about the safety of their care. The PRASE (Patient Reporting and Action for a Safe Environment) intervention provides a way to systematically collect feedback from patients to support service improvement. The intervention is being implemented in acute care settings with patient feedback collected by hospital volunteers for the first time.

Objective

To undertake a formative evaluation which explores the feasibility and acceptability of the PRASE intervention delivered in collaboration with hospital volunteers from the perspectives of key stakeholders.

Design

A qualitative evaluation design was adopted across two acute NHS trusts in the UK between July 2014 and November 2015. We conducted five focus groups with hospital volunteers (n=15), voluntary services and patient experience staff (n=3) and semi‐structured interviews with ward staff (n=5). Data were interpreted using framework analysis.

Results

All stakeholders were positive about the PRASE intervention as a way to support service improvement, and the benefits of involving volunteers. Volunteers felt adequate training and support would be essential for retention. Staff concentrated on the infrastructure needed for implementation and raised concerns around sustainability. Findings were fed back to the implementation team to support revisions to the intervention moving into the subsequent summative evaluation phase.

Conclusion

Although there are concerns regarding sustainability in practice, the PRASE intervention delivered in collaboration with hospital volunteers is a promising approach to collect patient feedback for service improvement.

Missed Nursing Care in Pediatrics

OBJECTIVES

A growing literature suggests that missed nursing care is common in hospitals and may contribute to poor patient outcomes. There has been scant empirical evidence in pediatric populations. Our objectives were to describe the frequency and patterns of missed nursing care in inpatient pediatric settings and to determine whether missed nursing care is associated with unfavorable work environments and high nurse workloads.

METHODS

A cross-sectional study using registered nurse survey data from 2006 to 2008 was conducted. Data from 2187 NICU, PICU, and general pediatric nurses in 223 hospitals in 4 US states were analyzed. For 12 nursing activities, nurses reported about necessary activities that were not done on their last shift because of time constraints. Nurses reported their patient assignment and rated their work environment.

RESULTS

More than half of pediatric nurses had missed care on their previous shift. On average, pediatric nurses missed 1.5 necessary care activities. Missed care was more common in poor versus better work environments (1.9 vs 1.2; P < .01). For 9 of 12 nursing activities, the prevalence of missed care was significantly higher in the poor environments (P < .05). In regression models that controlled for nurse, nursing unit, and hospital characteristics, the odds that a nurse missed care were 40% lower in better environments and increased by 70% for each additional patient.

CONCLUSIONS

Nurses in inpatient pediatric care settings that care for fewer patients each and practice in a professionally supportive work environment miss care less often, increasing quality of patient care.

[Evaluation of care conditions in intensive care units : Results of an online questionnaire of critical care nurses]

In the following article, selected results of a descriptive study on personnel staffing and patients' care in intensive care units in Germany are presented and discussed. The main focus is laid on comparing features of personnel staffing with indicators of job satisfaction and patients' care. The study is based on an online questionnaire of critical care nurses run in 2017. The article represents the data of 2233 included German critical care nurses. The main results are the following: a low nurse patient ratio (≥1:3) in intensive care units has the tendency to cause higher risks in patients' care and shows lower job satisfaction than nurses with higher nurse-patient ratio (≤1:2).

Hospital Magnet® Designation and Missed Nursing Care in Neonatal Intensive Care Units

Missed nursing care is an emerging measure of front-line nursing care effectiveness in neonatal intensive care units (NICUs). Given Magnet® hospitals' reputations for nursing care quality, missed care comparisons with non-Magnet® hospitals may yield insights about how Magnet® designation influences patient outcomes. The purpose of this secondary analysis was to evaluate the relationship between hospital Magnet® designation and 1) the occurrence of nurse-reported missed care and 2) reasons for missed nursing care between NICU nurses employed in Magnet® and non-Magnet® hospitals. A random sample of certified neonatal intensive care unit nurses was invited to participate in a cross-sectional survey in 2012; data were analyzed from nurses who provided direct patient care (n=230). Logistic regression was used to model relationships between Magnet® designation and reports of the occurrence of and reasons for missed care while controlling for nurse and shift characteristics. There was no relationship between Magnet® designation and missed care occurrence for 34 of 35 types of care. Nurses in Magnet® hospitals were significantly less likely to report tensions and communication breakdowns with other staff, lack of familiarity with policies/procedures, and lack of back-up support from team members as reasons for missed care. Missed nursing care in NICUs occurs regardless of hospital Magnet® recognition. However, nurses' reasons for missed care systematically differ in Magnet® and non-Magnet® hospitals and these differences merit further exploration.

Assessment of the nursing care product (APROCENF): a reliability and construct validity study

Objectives

to verify the reliability and construct validity estimates of the "Assessment of nursing care product" scale (APROCENF) and its applicability.

Methods

this validation study included a sample of 40 (inter-rater reliability) and 172 (construct validity) assessments performed by nurses at the end of the work shift at nine inpatient services of a teaching hospital in the Brazilian Southeast. The data were collected between February and September/2014 with interruptions. Cronbach's alpha and Spearman's correlation coefficients were calculated, as well as the intraclass correlation and the weighted kappa index (inter-rater reliability). Exploratory factor analysis was used with principal component extraction and varimax rotation (construct validity).

Results

the internal consistency revealed an alpha coefficient of 0.85, item-item correlation ranging between 0.13 and 0.61 and item-total correlation between 0.43 and 0.69. Inter-rater equivalence was obtained and all items evidenced significant factor loadings.

Conclusion

this research evidenced the reliability and construct validity of the scale to assess the nursing care product. Its application in nursing practice permits identifying improvements needed in the production process, contributing to management and care decisions.

Correlates and predictors of missed nursing care in hospitals

AIMS AND OBJECTIVES

To identify the contribution of hospital, unit, staff characteristics, staffing adequacy and teamwork to missed nursing care in Iceland hospitals.

BACKGROUND

A recently identified quality indicator for nursing care and patient safety is missed nursing care defined as any standard, required nursing care omitted or significantly delayed, indicating an error of omission. Former studies point to contributing factors to missed nursing care regarding hospital, unit and staff characteristics, perceptions of staffing adequacy as well as nursing teamwork, displayed in the Missed Nursing Care Model.

DESIGN

This was a quantitative cross-sectional survey study.

METHODS

The samples were all registered nurses and practical nurses (n = 864) working on 27 medical, surgical and intensive care inpatient units in eight hospitals throughout Iceland. Response rate was 69·3%. Data were collected in March-April 2012 using the combined MISSCARE Survey-Icelandic and the Nursing Teamwork Survey-Icelandic. Descriptive, correlational and regression statistics were used for data analysis.

RESULTS

Missed nursing care was significantly related to hospital and unit type, participants' age and role and their perception of adequate staffing and level of teamwork. The multiple regression testing of Model 1 indicated unit type, role, age and staffing adequacy to predict 16% of the variance in missed nursing care. Controlling for unit type, role, age and perceptions of staffing adequacy, the multiple regression testing of Model 2 showed that nursing teamwork predicted an additional 14% of the variance in missed nursing care.

CONCLUSIONS

The results shed light on the correlates and predictors of missed nursing care in hospitals. This study gives direction as to the development of strategies for decreasing missed nursing care, including ensuring appropriate staffing levels and enhanced teamwork.

RELEVANCE TO CLINICAL PRACTICE

By identifying contributing factors to missed nursing care, appropriate interventions can be developed and tested.

The Impact of Heavy Perceived Nurse Workloads on Patient and Nurse Outcomes

This study investigated the relationships between seven workload factors and patient and nurse outcomes. (1) Background: Health systems researchers are beginning to address nurses’ workload demands at different unit, job and task levels; and the types of administrative interventions needed for specific workload demands. (2) Methods: This was a cross-sectional correlational study of 472 acute care nurses from British Columbia, Canada. The workload factors included nurse reports of unit-level RN staffing levels and patient acuity and patient dependency; job-level nurse perceptions of heavy workloads, nursing tasks left undone and compromised standards; and task-level interruptions to work flow. Patient outcomes were nurse-reported frequencies of medication errors, patient falls and urinary tract infections; and nurse outcomes were emotional exhaustion and job satisfaction. (3) Results: Job-level perceptions of heavy workloads and task-level interruptions had significant direct effects on patient and nurse outcomes. Tasks left undone mediated the relationships between heavy workloads and nurse and patient outcomes; and between interruptions and nurse and patient outcomes. Compromised professional nursing standards mediated the relationships between heavy workloads and nurse outcomes; and between interruptions and nurse outcomes. (4) Conclusion: Administrators should work collaboratively with nurses to identify work environment strategies that ameliorate workload demands at different levels.

Making a difference for children and families: an appreciative inquiry of health visitor values and why they start and stay in post

The study aimed to develop an understanding of health visitor recruitment and retention by examining what existing staff and new recruits wanted from their job, their professional aspirations and what would encourage them to start and stay in employment. Following a period of steady decline in numbers, the health visitor workforce in England has recently been invested in and expanded to deliver universal child public health. To capitalise on this large investment, managers need an understanding of factors influencing workforce retention and continuing recruitment of health visitors. The study was designed using an interpretive approach and involved students (n = 17) and qualified health visitors (n = 22) from the north and south of England. Appreciative inquiry (AI) exercises were used as methods of data collection during 2012. During AI exercises students and health visitors wrote about 'a practice experience you have felt excited and motivated by and briefly describe the factors that contributed to this'. Participants were invited to discuss their written accounts of practice with a peer during an audio-recorded sharing session. Participants gave consent for written accounts and transcribed recordings to be used as study data, which was examined using framework analysis. In exploring personal meanings of health visiting, participants spoke about the common aspiration to make a difference to children and families. To achieve this, they expected their job to allow them to: connect with families; work with others; use their knowledge, skills and experience; use professional autonomy. The study offers new insights into health visitors' aspirations, showing consistency with conceptual explanations of optimal professional practice. Psychological contract theory illustrates connections between professional aspirations and work commitment. Managers can use these findings as part of workforce recruitment and retention strategies and for building on the health visitor commitment to making a difference to children and families.

Oral Health Care Guidelines, Training, and Resources among Stroke Care Providers

During a stroke, the mouth tends to become an unhealthy place and may give rise to various life-threatening conditions. To this end, there have been repeated calls to incorporate oral hygiene guidelines and practices for hospitalized stroke patients to prevent aspiration pneumonia and improve patients' oral health. The objective of the study was to determine health care providers' practices of oral health care among patients hospitalized after an occurrence of stroke and to determine health care providers' background and work environment effect on these practices. A cross-sectional study was conducted among stroke care providers in 13 public hospitals in Malaysia. The questionnaires distributed were self-administered, where nursing staff provided details of their oral health care practices for stroke patients. Information on the background of health care providers and work environment was also collected. Overall, a total of 780 responses from the registered nurses were obtained. Almost half of the respondents (48.1%) reported that they recommended toothbrushing twice or more per day to stroke patients. Two-thirds (64.7%) reported that they performed daily mouthwashing on their patient, while less than half (38.8%) reported daily oral hygiene assistance. Result of the analysis revealed that oral hygiene practices were significantly associated with having working wards ( P < 0.05), level of qualification ( P < 0.05), having oral health care guidelines ( P < 0.001), specific resources ( P < 0.05), and attending previous training in oral care ( P < 0.001). Provision of oral hygiene practices for hospitalized stroke patients is important. A lack of oral health care guidelines, support from dental professionals, specific resources, training, and assistance in daily oral care for patients is evident and detrimental to oral hygiene practices. The current findings have significant implications for new initiatives to support health care providers, particularly the registered nurses performing oral health care for hospitalized stroke patients. Knowledge Transfer Statement: This study may provide a basis of information for improving the delivery of oral health care to stroke patients. Enhancement in the training and improvement in the existing guidelines and resources is pivotal for the provision of better oral health care for the potential benefits to these patients, including their improved quality of life and disease prevention.

Impact of teamwork on missed care in four Australian hospitals

AIMS AND OBJECTIVES

Investigate effects of teamwork on missed nursing care across a healthcare network in Australia.

BACKGROUND

Missed care is universally used as an indicator of quality nursing care, however, little is known about mitigating effects of teamwork on these events.

DESIGN

A descriptive exploratory study.

METHODS

Missed Care and Team Work surveys were completed by 334 nurses. Using Stata software, nursing staff demographic information and components of missed care and teamwork were compared across the healthcare network. Statistical tests were performed to identify predicting factors for missed care.

RESULTS

The most commonly reported components of missed care were as follows: ambulation three times per day (43·3%), turning patient every two hours (29%) and mouth care (27·7%). The commonest reasons mentioned for missed care were as follows: inadequate labour resources (range 69·8-52·7%), followed by material resources (range 59·3-33·3%) and communication (range 39·3-27·2%). There were significant differences in missed care scores across units. Using the mean scores in regression correlation matrix, the negative relationship of missed care and teamwork was supported (r = -0·34, p < 0·001). Controlling for occupation of the staff member and staff characteristics in multiple regression models, teamwork alone accounted for about 9% of missed nursing care.

CONCLUSION

Similar to previous international research findings, our results showed nursing teamwork significantly impacted on missed nursing care. Teamwork may be a mitigating factor to address missed care and future research is needed.

RELEVANCE TO CLINICAL PRACTICE

These results may provide administrators, educators and clinicians with information to develop practices and policies to improve patient care internationally.

Independent risk factors for the development of skin erosion due to incontinence (incontinence-associated dermatitis category 2) in nursing home residents: results from a multivariate binary regression analysis

The aim of this study was to identify characteristics independently associated with a higher risk of developing skin damage because of incontinence [incontinence-associated dermatitis (IAD) category 2] in nursing home residents. As part of a larger randomised controlled trial, IAD incidence was monitored for 1 month in a sample of 381 incontinent residents using a validated IAD Severity Categorisation Tool. Data on demographical, physical, functional and psychological characteristics were collected. The overall IAD incidence (category 1-2) was 30·0%, and 6% of the participants developed skin damage (IAD category 2). Residents who developed IAD category 2 were less mobile [odds ratio (OR) 2·72, 95% confidence interval (CI) 1·06-6·94], had more friction and shear issues (OR 2·54; 95% CI 1·02-6·33) and had more erythema due to incontinence (OR 3·02; 95% CI 1·04-8·73) before IAD category 2 occurrence. Care providers should give full attention to risk factors to both detect residents at risk for IAD development and to start prevention in time.

Nursing care documentation practice: The unfinished task of nursing care in the University of Gondar Hospital

INTRODUCTION

Even though nursing care documentation is an important part of nursing practice, it is commonly left undone. The objective of this study was to assess nursing care documentation practice and the associated factors among nurses who are working at the University of Gondar Hospital.

METHODS

An institution-based cross-sectional study was conducted among 220 nurses working at the University of Gondar Hospital inpatient wards from March 20 to April 30, 2014. Data were collected using a structured and pre-tested self-administered questionnaire. Data were entered into Epi Info version 7 and analyzed with SPSS version 20. Descriptive statistics, bivariate, and multivariate logistic regression analyses were carried out.

RESULTS

Two hundred and six nurses returned the questionnaire. Good nursing care documentation practice among nurses was 37.4%. A low nurse-to-patient ratio AOR = 2.15 (95%CI [1.155, 4.020]), in-service training on standard nursing process AOR = 2.6 (95%CI[1.326, 5.052]), good knowledge AOR = 2.156(95% CI [1.092, 4.254]), and good attitude toward nursing care documentation AOR = 2.22 (95% CI [1.105, 4.471] were significantly associated with nursing care documentation practice.

CONCLUSION

Most of the nursing care provided remains undocumented. Nurse-to-patient ratio, in-service training, knowledge, and attitude of nurses toward nursing care documentation were factors associated with nursing care documentation practice.

Nursing care missed in patients at risk of or having pressure ulcers

Objective:

to determine the nursing care missed as perceived by the nursing staff and its relation with the nursing care missed identified in the assessment of patients at risk of or having pressur ulcers.

Method:

descriptive correlation study. The participants were 161 nurses and 483 patients from a public hospital. The MISSCARE survey was used in combination with a Nursing Care Assessment Form for Patients at Risk of or having pressure ulcers. For the analysis, descriptive and inferential statistics were used.

Results:

the nursing staff indicated greater omission in skin care (38.5%), position change (31.1%) and the registration of risk factors for the development of pressure ulcers (33.5%). The nursing care missed identified in the assessment related to the use of pressure relief on bony prominences and drainage tubes interfering in the patient's movements (both with 58.6%) and the use of pneumatic mattresses (57.6%).

Conclusion:

a high percentage of nursing care missed was found according to the staff's perception. Nevertheless, the assessment of the nursing care missed was much higher. No significant relation was found between both. Therefore, it is a priority to reflect on the importance of objective patient assessments.

The person-centred care of older people with cognitive impairment in acute care (POPAC) scale - psychometric evaluation

AIM

To test the reliability and validity of the Person-centred care of Older People with cognitive impairment in Acute Care scale to determine nurses' perceptions of person-centred care.

BACKGROUND

One-third of older adults admitted to hospital are at risk of serious hospital-acquired complications such as falls, infections and pressure injuries because of cognitive impairment. These risks can be reduced through person-centred practices. The Person-centred care of Older People with cognitive impairment in Acute Care scale is a self-report staff instrument to explore the extent to which person-centred practices are undertaken; however psychometric testing is limited.

METHODS

A cross-sectional sample of acute care nurses (n = 240) in Queensland, Australia completing self-report questionnaires. Psychometric analyses of item performance, reliability and validity were conducted.

RESULTS

Item analysis revealed independent items. One item was removed due to negatively associating with the scale, improving total Cronbach's alpha from 0.76 to 0.84. The three original factors were maintained with regrouping of items. Confirmatory factor analysis confirmed the revised model.

CONCLUSIONS

The revised Person-centred care of Older People with cognitive impairment in Acute Care scale had satisfactory psychometric properties when used as a total scale.

IMPLICATIONS FOR NURSING MANAGEMENT

Scale brevity and simplicity together with rigorous development and testing indicates that the revised Person-centred care of Older People with cognitive impairment in Acute Care may be useful for quality improvement programmes into the care of older people in hospitals.

Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care

OBJECTIVES

To determine the association of hospital nursing skill mix with patient mortality, patient ratings of their care and indicators of quality of care.

DESIGN

Cross-sectional patient discharge data, hospital characteristics and nurse and patient survey data were merged and analysed using generalised estimating equations (GEE) and logistic regression models.

SETTING

Adult acute care hospitals in Belgium, England, Finland, Ireland, Spain and Switzerland.

PARTICIPANTS

Survey data were collected from 13 077 nurses in 243 hospitals, and 18 828 patients in 182 of the same hospitals in the six countries. Discharge data were obtained for 275 519 surgical patients in 188 of these hospitals.

MAIN OUTCOME MEASURES

Patient mortality, patient ratings of care, care quality, patient safety, adverse events and nurse burnout and job dissatisfaction.

RESULTS

Richer nurse skill mix (eg, every 10-point increase in the percentage of professional nurses among all nursing personnel) was associated with lower odds of mortality (OR=0.89), lower odds of low hospital ratings from patients (OR=0.90) and lower odds of reports of poor quality (OR=0.89), poor safety grades (OR=0.85) and other poor outcomes (0.80<OR<0.93), after adjusting for patient and hospital factors. Each 10 percentage point reduction in the proportion of professional nurses is associated with an 11% increase in the odds of death. In our hospital sample, there were an average of six caregivers for every 25 patients, four of whom were professional nurses. Substituting one nurse assistant for a professional nurse for every 25 patients is associated with a 21% increase in the odds of dying.

CONCLUSIONS

A bedside care workforce with a greater proportion of professional nurses is associated with better outcomes for patients and nurses. Reducing nursing skill mix by adding nursing associates and other categories of assistive nursing personnel without professional nurse qualifications may contribute to preventable deaths, erode quality and safety of hospital care and contribute to hospital nurse shortages.

Changes in turnover and vacancy rates of care workers in England from 2008 to 2010: panel analysis of national workforce data

The combination of growing demand for long-term care and higher expectations of care staff needs to be set in the context of long-standing concerns about the sustainability of recruitment and retention of front-line staff in the United Kingdom. Organisational and work environment factors are associated with vacancy levels and turnover rates. The aim of the current analysis was to investigate changes in turnover and vacancy rates over time experienced by a sample of social care employers in England. Taking a follow-up approach offers potentially more accurate estimates of changes in turnover and vacancy rates, and enables the identification of any different organisational characteristics which may be linked to reductions in these elements over time. The study constructed a panel of 2964 care providers (employers) using 18 separate data sets from the National Minimum Data Set for Social Care during 2008-2010. The findings indicate slight reductions in vacancy rates but the presence of enduring, high turnover rates among direct care workers over the study period. However, the experience of individual employers varied, with home-care providers experiencing significantly higher turnover rates than other parts of the sector. These findings raise questions around the quality and motivations of new recruits and methods of reducing specific vacancy levels. At a time of increased emphasis on care at home, it is worthwhile examining why care homes appear to have greater stability of staff and fewer vacancies than home-care agencies.

Managers' use of nursing workforce planning and deployment technologies: protocol for a realist synthesis of implementation and impact

INTRODUCTION

Nursing staffing levels in hospitals appear to be associated with improved patient outcomes. National guidance indicates that the triangulation of information from workforce planning and deployment technologies (WPTs; eg, the Safer Nursing Care Tool) and 'local knowledge' is important for managers to achieve appropriate staffing levels for better patient outcomes. Although WPTs provide managers with predictive information about future staffing requirements, ensuring patient safety and quality care also requires the consideration of information from other sources in real time. Yet little attention has been given to how to support managers to implement WPTs in practice. Given this lack of understanding, this evidence synthesis is designed to address the research question: managers' use of WPTs and their impacts on nurse staffing and patient care: what works, for whom, how and in what circumstances?

METHODS AND ANALYSIS

To explain how WPTs may work and in what contexts, we will conduct a realist evidence synthesis through sourcing relevant evidence, and consulting with stakeholders about the impacts of WPTs on health and relevant public service fields. The review will be in 4 phases over 18 months. Phase 1: we will construct an initial theoretical framework that provides plausible explanations of what works about WPTs. Phase 2: evidence retrieval, review and synthesis guided by the theoretical framework; phase 3: testing and refining of programme theories, to determine their relevance; phase 4: formulating actionable recommendations about how WPTs should be implemented in clinical practice.

ETHICS AND DISSEMINATION

Ethical approval has been gained from the study's institutional sponsors. Ethical review from the National Health Service (NHS) is not required; however research and development permissions will be obtained. Findings will be disseminated through stakeholder engagement and knowledge mobilisation activities. The synthesis will develop an explanatory programme theory of the implementation and impact of nursing WPTs, and practical guidance for nurse managers.

TRIAL REGISTRATION NUMBER

CRD42016038132.

Quantity and quality of interaction between staff and older patients in UK hospital wards: A descriptive study

Background

The quality of staff-patient interactions underpins the overall quality of patient experience and can affect other important outcomes. However no studies have been identified that comprehensively explore both the quality and quantity of interactions in general hospital settings.

Aims & objectives

To quantify and characterise the quality of staff-patient interactions and to identify factors associated with negative interaction ratings.

Setting

Data were gathered at two acute English NHS hospitals between March and April 2015. Six wards for adult patients participated including medicine for older people (n = 4), urology (n = 1) and orthopaedics (n = 1).

Methods

Eligible patients on participating wards were randomly selected for observation. Staff-patient interactions were observed using the Quality of Interactions Schedule. 120 h of care were observed with each 2 h observation session determined from a balanced random schedule (Monday-Friday, 08:00-22:00 h). Multilevel logistic regression models were used to determine factors associated with negative interactions.

Results

1554 interactions involving 133 patients were observed. The median length of interaction was 36 s with a mean of 6 interactions per patient per hour. Seventy three percent of interactions were categorized as positive, 17% neutral and 10% negative. Forty percent of patients had at least one negative interaction (95% confidence interval 32% to 49%). Interactions initiated by the patient (adjusted Odds Ratio [OR] 5.30), one way communication (adjusted OR 10.70), involving two or more staff (adjusted OR 5.86 for 2 staff, 6.46 for 3+ staff), having a higher total number of interactions (adjusted OR 1.09 per unit increase), and specific types of interaction content were associated with increased odds of negative interaction (p < 0.05). In the full multivariable model there was no significant association with staff characteristics, skill mix or staffing levels. Patient agitation at the outset of interaction was associated with increased odds of negative interaction in a reduced model. There was no significant association with gender, age or cognitive impairment. There was substantially more variation at ward level (variance component 1.76) and observation session level (3.49) than at patient level (0.09).

Conclusion

These findings present a unique insight into the quality and quantity of staff-patient interactions in acute care. While a high proportion of interactions were positive, findings indicate that there is scope for improvement. Future research should focus on further exploring factors associated with negative interactions, such as workload and ward culture.

Strategies for Enhancing “Person Knowledge” in an Older People Care Setting

This article presents findings from a study about compassionate care—the development of person knowledge in a medical ward caring for older people. Appreciative inquiry, an approach to research that focuses on discovering what works well and implementing strategies to help these aspects happen most of the time, was used. Staff, patients, and families participated in this study, which used a range of methods to generate data including interviews and observations. Immersion/crystallization was used to analyze these data using a reflexive and continuous approach to extracting and validating data. Findings uncovered that knowledge of the person and ways of promoting this were key dimensions of compassionate caring. The attributes of “caring conversations” emerged through the analysis process, which we suggest are crucial to developing person knowledge. The political and public focus on compassionate care makes it opportune to raise discussion around this form of knowledge in academic and practice debates.

Nurse Staffing Levels and Patient-Reported Missed Nursing Care

A total of 729 inpatients were surveyed using the MISSCARE Survey-Patient. Missed timeliness, patient reports of the time it took for them to receive care from nursing staff, was negatively associated with total nursing staff hours of care per patient-day (r = -0.09, P = .015), registered nurse (RN) hours per patient-day (r = -0.14, P = .0002), and RN skill mix (r = -0.13, P = .0004). RN skill mix was also a predictor of missed timeliness (P = .01).

Unmet Nursing Care Linked to Rehospitalizations Among Older Black AMI Patients: A Cross-Sectional Study of US Hospitals

BACKGROUND

Recent studies suggest that nurses may be unable to complete all aspects of necessary care due to a lack of time. Research is needed to determine whether unmet nursing care contributes to disparities in readmissions for vulnerable populations.

OBJECTIVES

To examine differences in the relationship between nursing care left undone and acute myocardial infarction readmissions among older black patients compared with older white patients.

RESEARCH DESIGN

Cross-sectional analysis of multiple datasets, including: 2006 to 2007 administrative discharge data, a survey of registered nurses, and the American Hospital Association Annual Survey. Risk-adjusted logistic regression models were used to estimate the association between care left undone and 30-day readmission. Interactions were used to examine the moderating effect of care left undone on readmission by race.

RESULTS

The sample included 69,065 patients in 253 hospitals in California, New Jersey, and Pennsylvania. Older black patients were 18% more likely to experience a readmission after adjusting for patient and hospital characteristics and more likely to be in hospitals where nursing care was often left undone. Black patients were more likely to be readmitted when nurses were unable to talk/comfort patients [odds ratio (OR), 1.09; 95% confidence interval (CI), 1.01-1.19], complete documentation (OR, 1.16; 95% CI, 1.01-1.32), or administer medications in a timely manner (OR, 1.26; 95% CI, 1.09-1.46).

CONCLUSIONS

Unmet nursing care is associated with readmissions for older black patients following acute myocardial infarction. Investment in nursing resources to improve the delivery of nursing care may decrease disparities in readmission.

Changes to nurses' practice environment over time

AIMS

To examine changes in the nursing practice environment, retention-related factors, unit stability and patient care tasks delayed or left undone, over two periods between 2004 and 2013.

BACKGROUND

Positive nurse practice environments have been linked to nurse retention and care quality outcomes.

METHODS

The collection of the Practice Environment Scale of the Nursing Work Index, job satisfaction, intent to leave, unit instability and tasks delayed or not done at six acute-care hospitals across three Australian states, in two waves between 2004 and 2013; results from the two waves are compared.

RESULTS

On average, practice environment scores declined slightly; nurses reported a greater difficulty in finding another nursing position, lower intent to leave their current job and greater instability in their current position. Rates of delayed tasks increased over the period, whereas rates of tasks left undone have decreased over the period.

CONCLUSIONS

The decline in nurses' perceptions of the quality of the practice environment is disappointing, particularly given the protracted workforce shortages that have persisted. Significant organisational restructuring and turnover of nurse executives may have contributed to this decline.

IMPLICATION FOR NURSING MANAGEMENT

Managers need to apply existing evidence to improve nurse practice environments and manage instability.

Conducting experimental research in marginalised populations: clinical and methodological implications from a mixed-methods randomised controlled trial in Kenya

Experimental studies to test interventions for people living with HIV in low- and middle-income countries are essential to ensure appropriate and effective clinical care. The implications of study participation on outcome data in such populations have been discussed theoretically, but rarely empirically examined. We aimed to explore the effects of participating in a randomised controlled trial conducted in an HIV clinic in Mombasa, Kenya. We report qualitative data from the Treatment Outcomes in Palliative Care trial, which evaluated the impact of a nurse-led palliative care intervention for HIV positive adults on antiretroviral therapy compared to standard care. Participants in both arms attended five monthly quantitative data collection appointments. Post-trial exit, 10 control and 20 intervention patients participated in semi-structured qualitative interviews, analysed using thematic analysis. We found benefit attributed to the compassion of the research team, social support, communication, completion of patient reported outcome measures (PROMs) and material support (transport reimbursement). Being treated with compassion and receiving social support enabled participants to build positive relationships with the research team, which improved mental health and well-being. Open and non-judgmental communication made participants feel accepted. Participants described how repeated completion of the PROMs was a prompt for reflection, through which they began to help themselves and self-care. Participant reimbursements relieved financial hardship and enabled them to fulfil their social responsibilities, enhancing self-worth. These findings emphasise the importance of compassion, support and effective communication in the clinical encounter, particularly in stigmatised and isolated populations, and the potential of the integration of simple PROMs to improve patient outcomes. Participation in research has unexpected positive benefits for participants, which should be taken into account when designing research in similar populations. Researchers should be aware of the effects of financial reimbursement and contact with researchers in isolated and impoverished communities.

Registered nurse, healthcare support worker, medical staffing levels and mortality in English hospital trusts: a cross-sectional study

OBJECTIVES

To examine associations between mortality and registered nurse (RN) staffing in English hospital trusts taking account of medical and healthcare support worker (HCSW) staffing.

SETTING

Secondary care provided in acute hospital National Health Service (NHS) trusts in England.

PARTICIPANTS

Two data sets are examined: Administrative data from 137 NHS acute hospital trusts (staffing measured as beds per staff member). A cross-sectional survey of 2917 registered nurses in a subsample of 31 trusts (measured patients per ward nurse).

OUTCOME MEASURE

Risk-adjusted mortality rates for adult patients (administrative data).

RESULTS

For medical admissions, higher mortality was associated with more occupied beds per RN (RR 1.22, 95% CI 1.04 to 1.43, p=0.02) and per doctor (RR 1.10, 95% CI 1.05 to 1.15, p <0.01) employed by the trust whereas, lower HCSW staffing was associated with lower mortality (RR 0.95, 95% CI 0.91 to 1.00, p=0.04). In multivariable models the relationship was statistically significant for doctors (RR 1.08, 95% CI 1.02 to 1.15, p=0.02) and HCSWs (RR 0.93, 95% CI 0.89 to 0.98, p<01) but not RNs (RR 1.14, 95% CI 0.95 to 1.38, p=0.17). Trusts with an average of ≤ 6 patients per RN in medical wards had a 20% lower mortality rate compared to trusts with >10 patients per nurse (RR 0.80, 95% CI 0.76 to 0.85, p<0.01). The relationship remained significant in the multivariable model (RR 0.89, 95% CI 0.83 to 0.95, p<0.01). Results for surgical wards/admissions followed a similar pattern but with fewer significant results.

CONCLUSIONS

Ward-based RN staffing is significantly associated with reduced mortality for medical patients. There is little evidence for beneficial associations with HCSW staffing. Higher doctor staffing levels is associated with reduced mortality. The estimated association between RN staffing and mortality changes when medical and HCSW staffing is considered and depending on whether ward or trust wide staffing levels are considered.

Efficacy of the nurse ethicist in reducing moral distress: what can the NHS learn from the USA?

Having first been introduced to nursing 30 years ago, 'moral distress' is not a new concept. Despite this, original research exploring moral distress has been largely absent from nursing literature produced in the UK, yet it has received increasing interest in the USA. Nurse researchers there have sought to explore, measure and understand moral distress. They are now beginning to develop and test ways in which the effects of moral distress can be reduced. The author of this article travelled to various institutions on the east coast of the USA to meet nurses leading the field of research into moral distress. This is the first of two interrelated articles that seek to explore the concept of moral distress. Drawing on both the author's experiences while in the USA and current literature, moral distress will be defined, its known effects described, and ways that nurses can mitigate its effects at a personal level discussed.

Multi-Tiered Observation and Response Charts: Prevalence and Incidence of Triggers, Modifications and Calls, to Acutely Deteriorating Adult Patients

BACKGROUND

Observation charts are the primary tool for recording patient vital signs. They have a critical role in documenting triggers for a multi-tiered escalation response to the deteriorating patient. The objectives of this study were to ascertain the prevalence and incidence of triggers, trigger modifications and escalation response (Call) amongst general medical and surgical inpatients following the introduction of an observation and response chart (ORC).

METHODS

Prospective (prevalence), over two 24-hour periods, and retrospective (incidence), over entire hospital stay, observational study of documented patient observations intended to trigger one of three escalation responses, being a MER-Medical Emergency Response [highest tier], MDT-Multidisciplinary Team [admitting team], or Nurse-senior ward nurse [lowest tier] response amongst adult general medical and surgical patients.

RESULTS

PREVALENCE

416 patients, 321 (77.2%) being medical admissions, median age 76 years (IQR 62, 85) and 95 (22.8%) Not for Resuscitation (NFR). Overall, 193 (46.4%) patients had a Trigger, being 17 (4.1%) MER, 45 (10.8%) MDT and 178 (42.8%) Nurse triggers. 60 (14.4%) patients had a Call, and 72 (17.3%) a modified Trigger.

INCIDENCE

206 patients, of similar age, of whom 166 (80.5%) had a Trigger, 122 (59.2%) a Call, and 91 (44.2%) a modified Trigger. PREVALENCE and incidence of failure to Call was 33.2% and 68% of patients, respectively, particular for Nurse Triggers (26.7% and 62.1%, respectively). The number of Modifications, Calls, and failure to Call, correlated with the number of Triggers (0.912 [p<0.01], 0.631 [p<0.01], 0.988 [p<0.01]).

CONCLUSION

Within a multi-tiered response system for the detection and response to the deteriorating patient Triggers, their Modifications and failure to Call are common, particularly within the lower tiers of escalation. The number of Triggers and their Modifications may erode the structure, compliance, and potential efficacy of structured observation and response charts within a multi-tiered response system.

Patient satisfaction and non-UK educated nurses: a cross-sectional observational study of English National Health Service Hospitals

OBJECTIVES

To examine whether patient satisfaction with nursing care in National Health Service (NHS) hospitals in England is associated with the proportion of non-UK educated nurses providing care.

DESIGN

Cross-sectional analysis using data from the 2010 NHS Adult Inpatient Survey merged with data from nurse and hospital administrator surveys. Logistic regression models with corrections for clustering were used to determine whether the proportions of non-UK educated nurses were significantly related to patient satisfaction before and after taking account of other hospital, nursing and patient characteristics.

SETTING

31 English NHS trusts.

PARTICIPANTS

12,506 patients 16 years of age and older with at least one overnight stay that completed a satisfaction survey; 2962 bedside care nurses who completed a nurse survey; and 31 NHS trusts.

MAIN OUTCOME MEASURE

Patient satisfaction.

RESULTS

The percentage of non-UK educated nurses providing bedside hospital care, which ranged from 1% to 52% of nurses, was significantly associated with patient satisfaction. After controlling for potential confounding factors, each 10-point increase in the percentage of non-UK educated nurses diminished the odds of patients reporting good or excellent care by 12% (OR=0.88), and decreased the odds of patients agreeing that they always had confidence and trust in nurses by 13% (OR=0.87). Other indicators of patient satisfaction also revealed lower satisfaction in hospitals with higher percentages of non-UK educated nurses.

CONCLUSIONS

Use of non-UK educated nurses in English NHS hospitals is associated with lower patient satisfaction. Importing nurses from abroad to substitute for domestically educated nurses may negatively impact quality of care.

The medication process, workload and patient safety in inpatient units

Objective To conduct a survey of critical points in the medication process, its repercussions on the demands made on the nursing team and risks related to patient safety. Method This was a qualitative descriptive study that adopted an ecological-restorative approach. The data were collected through focus groups and photographs. Participants consisted of nurses and nursing technicians. Results Three categories emerged from the thematic analysis: challenges related to the process of prescribing and dispensing medication; medication administration with relation to work shift organization; and the use of new technologies to reduce medication errors. The results indicated that the medication process plays a central role in organizing nursing care, being that these professionals represent the last barrier for detecting medication prescription and administration errors. Conclusion By identifying vulnerabilities in the medication administration phase, the use of technology can help ensure patient safety.