Validity of using a work habits scale for the daily evaluation of nurse anesthetists' clinical performance while controlling for the leniencies of the rating anesthesiologists

Patient and Operational Factors Do Not Substantively Affect the Annual Departmental Quality of Anesthesiologists' Clinical Supervision and Nurse Anesthetists' Work Habits

INTRODUCTION

Although safety climate, teamwork, and other non-technical skills in operating rooms probably influence clinical outcomes, direct associations have not been shown, at least partially due to sample size considerations. We report data from a retrospective cohort of anesthesia evaluations that can simplify the design of prospective observational studies in this area. Associations between non-technical skills in anesthesia, specifically anesthesiologists' quality of clinical supervision and nurse anesthetists' work habits, and patient and operational factors were examined.

METHODS

Eight fiscal years of evaluations and surgical cases from one hospital were included. Clinical supervision by anesthesiologists was evaluated daily using a nine-item scale. Work habits of nurse anesthetists were evaluated daily using a six-item scale. The dependent variables for both groups of staff were binary, whether all items were given the maximum score or not. Associations were tested with patient and operational variables for the entire day.

RESULTS

There were 40,718 evaluations of faculty anesthesiologists by trainees, 53,772 evaluations of nurse anesthetists by anesthesiologists, and 296,449 cases that raters and ratees started together. Cohen's d values were small (≤0.10) for all independent variables, suggesting a lack of any clinically meaningful association between patient and operational factors and evaluations given the maximum scores. For supervision quality, the day's count of orthopedic cases was a significant predictor of scores (P = 0.0011). However, the resulting absolute marginal change in the percentage of supervision scores equal to the maximum was only 0.8% (99% confidence interval: 0.2% to 1.4%), i.e., too small to be of clinical or managerial importance. Neurosurgical cases may have been a significant predictor of work habits (P = 0.0054). However, the resulting marginal change in the percentage of work habits scores equal to the maximum, an increase of 0.8% (99% confidence interval: 0.1% to 1.6%), which was again too small to be important.

CONCLUSIONS

When evaluating the effect of assigning anesthesiologists and nurse anesthetists with different clinical performance quality on clinical outcomes, supervision quality and work habits scores may be included as independent variables without concern that their effects are confounded by association with the patient or case characteristics. Clinical supervision and work habits are measures of non-technical skills. Hence, these findings suggest that non-technical performance can be judged by observing the typical small sample size of cases. Then, associations can be tested with administrative data for a far greater number of patients because there is unlikely to be a confounding association between patient and case characteristics and the clinicians' non-technical performance.

Lack of Benefit of Adjusting Adaptively Daily Invitations for the Evaluation of the Quality of Anesthesiologists' Supervision and Nurse Anesthetists' Work Habits

Introduction Whenever a department implements the evaluation of professionals, a reasonable operational goal is to request as few evaluations as possible. In anesthesiology, evaluations of anesthesiologists (by trainees) and nurse anesthetists (by anesthesiologists) with valid and psychometrically reliable scales have been made by requesting daily evaluations of the ratee's performance on the immediately preceding day. However, some trainees or nurse anesthetists are paired with the same anesthesiologist for multiple days of the same week. Multiple evaluations from the same rater during a given week may contribute little incremental information versus one evaluation from that rater for the week. We address whether daily evaluation requests could be adjusted adaptively to be made once per week, hopefully substantively reducing the number of evaluation requests. Methods Every day since 1 July 2013 at the studied department, anesthesia residents and fellows have been requested by email to evaluate anesthesiologists' quality of supervision provided during the preceding day using the De Oliveira Filho supervision scale. Every day since 29 March 2015, the anesthesiologists have been requested by email to evaluate the work habits of the nurse anesthetists during the preceding day. Both types of evaluations were made for interactions throughout the workday together, not for individual cases. The criterion for an electronic request to be sent is that the pair worked together for at least one hour that day. The current study was performed using evaluations of anesthesiologists' supervision and nurse anesthetists' work habits through 30 June 2023. Results If every evaluation request were completed by trainees on the same day it was requested, trainees would have received 13.5% fewer requests to evaluate anesthesiologists (9367/69,420), the maximum possible reduction. If anesthesiologists were to do the same for their evaluations of nurse anesthetists, the maximum possible reduction would be 7.1% fewer requests (4794/67,274). However, because most evaluations were completed after the day of the request (71%, 96,451/136,694), there would be fewer requests only if the evaluation were completed before or on the day of the next pairing. Consequently, in actual practice, there would have been only 2.4% fewer evaluation requests to trainees and 1.5% fewer to anesthesiologists, both decreases being significantly less than 5% (both adjusted P <0.0001). Among the trainees' evaluations of faculty anesthesiologists, there were 1.4% with very low scores, specifically, a mean score of less than three out of four (708/41,778). Using Bernoulli cumulative sum (CUSUM) among successive evaluations, 72 flags were raised over the 10 years. Among those, there were 36% with more than one rater giving an exceptionally low score during the same week (26/72). There were 97% (70/72) with at least one rater contributing more than one score to the recent cumulative sum. Conclusion Conceptually, evaluation requests could be skipped if a rater has already evaluated the ratee that week during an earlier day working together. Our results show that the opportunity for reductions in evaluation requests is significantly less than 5%. There may also be impaired monitoring for the detection of sudden major decreases in ratee performance. Thus, the simpler strategy of requesting evaluations daily after working together is warranted.

Nurse Performance Metrics: A Scoping Review

OBJECTIVE

The purposes of this scoping review are: 1) to identify instances in the literature that describe measuring individual nurse performance and 2) characterize those metrics.

BACKGROUND

The impact of nurses on patient outcomes has been demonstrated at the unit or hospital level, with nurses measured in aggregate. There is an opportunity to evaluate individual nurse performance by creating metrics that capture it.

METHODS

A scoping review based on the framework published by the Joanna Briggs Institute was performed.

RESULTS

Researchers identified 12 articles. Three themes were trended: the emerging nature of these metrics in the literature, variability in their applications, and performance implications.

CONCLUSIONS

Individual nurse performance metrics is an emerging body of research with variability in the types of metrics developed. There is an opportunity for future researchers to work with nurse leaders and staff nurses to optimize these metrics and to use them to support nursing practice and patient care.

Effect of Insufficient Interaction on the Evaluation of Anesthesiologists’ Quality of Clinical Supervision by Anesthesiology Residents and Fellows

Introduction

In this study, we tested whether raters’ (residents and fellows) decisions to evaluate (or not) critical care anesthesiologists were significantly associated with clinical interactions documented from electronic health record progress notes and whether that influenced the reliability of supervision scores. We used the de Oliveira Filho clinical supervision scale for the evaluation of faculty anesthesiologists. Email requests were sent to raters who worked one hour or longer with the anesthesiologist the preceding day in an operating room. In contrast, potential raters were requested to evaluate all critical care anesthesiologists scheduled in intensive care units during the preceding week.

Methods

Over 7.6 years, raters (N=172) received a total of 7764 requests to evaluate 21 critical care anesthesiologists. Each rater received a median/mode of three evaluation requests, one per anesthesiologist on service that week. In this retrospective cohort study, we related responses (2970 selections of “insufficient interaction” to evaluate the faculty, and 3127 completed supervision scores) to progress notes (N=25,469) electronically co-signed by the rater and anesthesiologist combination during that week.

Results

Raters with few jointly signed notes were more likely to select insufficient interaction for evaluation (P < 0.0001): 62% when no joint notes versus 1% with at least 20 joint notes during the week. Still, rater-anesthesiologist combinations with no co-authored notes accounted not only for most (78%) of the evaluation requests but also most (56%) of the completed evaluations (both P < 0.0001). Among rater and anesthesiologist combinations with each anesthesiologist receiving evaluations from multiple (at least nine) raters and each rater evaluating multiple anesthesiologists, most (72%) rater-anesthesiologist combinations were among raters who had no co-authored notes with the anesthesiologist (P < 0.0001).

Conclusions

Regular use of the supervision scale should be practiced with raters who were selected not only from their scheduled clinical site but also using electronic health record data verifying joint workload with the anesthesiologist.

Association between leniency of anesthesiologists when evaluating certified registered nurse anesthetists and when evaluating didactic lectures

Daily evaluations of certified registered nurse anesthetists' (CRNAs') work habits by anesthesiologists should be adjusted for rater leniency. The current study tested the hypothesis that there is a pairwise association by rater between leniencies of evaluations of CRNAs' daily work habits and of didactic lectures. The historical cohorts were anesthesiologists' evaluations over 53 months of CRNAs' daily work habits and 65 months of didactic lectures by visiting professors and faculty. The binary endpoints were the Likert scale scores for all 6 and 10 items, respectively, equaling the maximums of 5 for all items, or not. Mixed effects logistic regression estimated the odds of each ratee performing above or below average adjusted for rater leniency. Bivariate errors in variables least squares linear regression estimated the association between the leniency of the anesthesiologists' evaluations of work habits and didactic lectures. There were 29/107 (27%) raters who were more severe in their evaluations of CRNAs' work habits than other anesthesiologists (two-sided P < 0.01); 34/107 (32%) raters were more lenient. When evaluating lectures, 3/81 (4%) raters were more severe and 8/81 (10%) more lenient. Among the 67 anesthesiologists rating both, leniency (or severity) for work habits was not associated with that for lectures (P = 0.90, unitless slope between logits 0.02, 95% confidence interval -0.34 to 0.30). Rater leniency is of large magnitude when making daily clinical evaluations, even when using a valid and psychometrically reliable instrument. Rater leniency was context dependent, not solely a reflection of raters' personality or rating style.