Healthcare providers' perceived acceptability of a warning signs intervention for rural hospital-to-home transitional care: A cross-sectional study

INTRODUCTION

There is a pressing need for transitional care that prepares rural dwelling medical patients to identify and respond to the signs of worsening health conditions. An evidence-based warning signs intervention has the potential to address this need. While the intervention is predominantly delivered by nurses, other healthcare providers may be required to deliver it in rural communities where human health resources are typically limited. Understanding the perspectives of other healthcare providers likely to be involved in delivering the intervention is a necessary first step to avert consequences of low acceptability, such as poor intervention implementation, uptake, and effectiveness. This study examined and compared nurses' and other healthcare providers' perceived acceptability of an evidence-based warning signs intervention proposed for rural transitional care.

METHODS

A cross-sectional design was used. The convenience sample included 45 nurses and 32 other healthcare providers (e.g., physical and occupational therapists, physicians) who self-identified as delivering transitional care to patients in rural Ontario, Canada. In an online survey, participants were presented with a description of the warning signs intervention and completed established measures of intervention acceptability. The measures captured 10 intervention acceptability attributes (effectiveness, appropriateness, risk, convenience, relevance, applicability, usefulness, frequency of current use, likelihood of future use, and confidence in ability to deliver the intervention). Ratings ≥ 2 indicated acceptability. Data analysis included descriptive statistics, independent samples t-tests, as well as effect sizes to quantify the magnitude of any differences in acceptability ratings between nurses and other healthcare providers.

RESULTS

Nurses and other healthcare providers rated all intervention attributes > 2, except the attributes of convenience and frequency of current use. Differences between the two groups were found for only three attributes: nurses' ratings were significantly higher than other healthcare providers on perceived applicability, frequency of current use, and the likelihood of future use of the intervention (all p's < .007; effect sizes .58 - .68, respectively).

DISCUSSION

The results indicate that both participant groups had positive perspectives of the intervention on most of the attributes and suggest that initiatives to enhance the convenience of the intervention's implementation are warranted to support its widespread adoption in rural transitional care. However, the results also suggest that other healthcare providers may be less receptive to the intervention in practice. Future research is needed to explore and mitigate the possible reasons for low ratings on perceived convenience and frequency of current use of the intervention, as well as the between group differences on perceived applicability, frequency of current use, and the likelihood of future use of the intervention.

CONCLUSIONS

The intervention represents a tenable option for rural transitional care in Ontario, Canada, and possibly other jurisdictions emphasizing transitional care.

Master clinical teachers and personalised learning

Clinical history taking and physical examination are two of the most important competencies of physicians. In addition to informing diagnoses, these activities build rapport and establish relationships between caregivers and patients. Despite this, emphasis on the assessment of bedside clinical skills is declining. To prepare our students for clinical work, we began a clinical competency, personalised teaching programme in which students perform a history and physical examination in front of a master clinical teacher (MCT) approximately every 2 weeks throughout their core clerkship year. The MCT works with the student in a clinical encounter, providing personalised bedside instruction on all features of being a clinician including bedside manner, history-taking skills, physical examination skills, and clinical reasoning. The MCT then provides an assessment of student's competency development and gives feedback to the student about what they do well and where they have opportunities for growth. Assessment data are collected and tracked longitudinally across the clerkship phase to ensure that each student is progressing developmentally. With over 6000 observations of student performance, we are able to discern competency development and growth over time. We can identify if a student is not improving as expected during their clerkship phase and intervene by providing extra practice and training. This core clerkship teaching programme has been well received by both students and instructors and has led us to pilot this approach during the post-clerkship phase of our medical training.

Standardized Nursing Diagnoses in a Surgical Hospital Setting: A Retrospective Study Based on Electronic Health Data

Introduction

In electronic health records (EHRs), standardized nursing terminologies (SNTs), such as nursing diagnoses (NDs), are needed to demonstrate the impact of nursing care on patient outcomes. Unfortunately, the use of NDs is not common in clinical practice, especially in surgical settings, and is rarely included in EHRs.

Objectives

The aim of the study was to describe the prevalence and trend of NDs in a hospital surgical setting by also analyzing the relationship between NDs and hospital outcomes.

Methods

A retrospective study was conducted. All adult inpatients consecutively admitted to one of the 15 surgical inpatient units of an Italian university hospital across 1 year were included. Data, including the Professional Assessment Instrument and the Hospital Discharge Register, were collected retrospectively from the hospital's EHRs.

Results

The sample included 5,027 surgical inpatients. There was a mean of 6.3 ± 4.3 NDs per patient. The average distribution of NDs showed a stable trend throughout the year. The most representative NANDA-I ND domain was safety/protection. The total number of NDs on admission was significantly higher for patient whose length of stay was longer. A statistically significant correlation was observed between the number of NDs on admission and the number of intra-hospital patient transfers. Additionally, the mean number of NDs on admission was higher for patients who were later transferred to an intensive care unit compared to those who were not transferred.

Conclusion

NDs represent the key to understanding the contribution of nurses in the surgical setting. NDs collected upon admission can represent a prognostic factor related to the hospital's key outcomes.

Developing a simulation tool to quantify biomechanical load and quality of care in nursing

Nursing is a high musculoskeletal disorder (MSD) risk job with high workload demands. This study combines Digital Human Modelling (DHM) and Discrete Event Simulation (DES) to address the need for tools to better manage MSD risk. This novel approach quantifies physical-workload, work-performance, and quality-of-care, in response to varying geographical patient-bed assignments, patient-acuity levels, and nurse-patient ratios. Lumbar loads for 86 care-delivery tasks in an acute care hospital unit were used as inputs in a DES model of the care-delivery process, creating a shift-long time trace of the biomechanical load. Peak L4/L5 compression and moment were 3574 N and 111.58 Nm, respectively. This study reports trade-offs in all three experiments: (i) increasing geographical patient-bed assignment distance decreased L4/L5 compression (8.8%); (ii) increased patient-acuity decreased L4/L5 moment (4%); (iii) Increased nurse-patient ratio decreased L4/L5 compression (10%) and moment (17%). However, in all experiments, Quality of care indicators deteriorated (20, 19, and 29%, respectively). Practitioner Summary: This research has the potential to support decision-makers by developing a simulation tool that quantifies the impact of varying operational and design-policies in terms of biomechanical-load and quality of care. The demonstrator-model reports: as geographical patient-bed distance, patient-acuity levels, and nurse-patient ratios increase, biomechanical-load reduces, and quality of care deteriorates.

Healthcare consumers' and professionals' perceived acceptability of evidence-based interventions for rural transitional care

BACKGROUND

There is a pressing need for high quality hospital-to-home transitional care in rural communities. Four evidence-based interventions (discharge planning, treatments, warning signs, and physical activity) have the potential to improve rural transitional care. However, there is limited understanding of how the perceptions of healthcare consumers and professionals compare on the acceptability of the interventions. Convergent views on intervention acceptability support implementation, whereas divergent views highlight areas requiring reconciliation prior to implementation.

AIMS

This study compared the acceptability of four evidence-based interventions proposed for rural transitional care, as perceived by healthcare consumers and professionals.

METHODS

A cross-sectional, comparative design was used. The convenience sample included 36 healthcare consumers (20 patients and 16 family caregivers) who had experienced a hospital-to-home transition in the past month and 30 healthcare professionals (29 registered nurses and one nurse practitioner) who provided transitional care in rural Ontario, Canada. Participants were presented with descriptions of the four interventions and completed an established intervention acceptability measure. Presentation of the four intervention descriptions and respective acceptability measures was randomized to control for possible order effects. The perceived overall acceptability of the interventions and their attributes (i.e., effectiveness, appropriateness, risk, and convenience) were compared using independent samples t-tests.

RESULTS

Consumer ratings were consistently higher across all four interventions in terms of overall acceptability as well as effectiveness, appropriateness, and convenience (all p's < .01; effect sizes 0.70-1.13). No significant between-group differences in perceived risk were found.

LINKING EVIDENCE TO ACTION

Contextual and methodological differences may account for variability in ratings, but further research is needed to explore these propositions. The results support future qualitative inquiry targeting professionals to better understand their perspectives on the effectiveness, appropriateness, and convenience of the four interventions.

Transfer of patients in hospital units: impacts on nursing workload

OBJECTIVE

To measure the average time spent by the nursing team in transferring patients; to compare the activities observed during the performance of this intervention with those described by the Nursing Interventions Classification and to investigate the intensity of its influence on the workload.

METHOD

Observational study using timekeeping software conducted in two hospitals in the northwest region of the State of São Paulo. 200 patient transfers were monitored by the team using two validated instruments.

RESULTS

The average time spent by nurses on transfers ranged from 9.3 (standard deviation = 3.5) to 12.2 (standard deviation = 2.5) minutes and by assistants/ technicians between 7.1 (standard deviation = 2,8) and 11.0 (standard deviation = 2.2) minutes. 63 transfers made by nurses and 87 by assistants/technicians were considered qualified (>70% of the score). The team expended 19.3 to 29% of the working day time in this intervention.

CONCLUSION

The transfer of patients has an impact on the workload of the team and needs to be considered in the measurement of nursing activities for the calculation and distribution of personnel to improve the quality and continuity of care.

Time and quality of admissions: nursing workload

OBJECTIVES

to measure the average time spent by the nursing staff during patient admission and investigate their compliance with the activities described by the Nursing Interventions Classification; evaluate the degree of interference in the workload of the team.

METHODS

observational with time measurement through software. We followed 199 admissions made by the nursing staff in seven units, using two validated instruments. Total scores ≥ 70% and 50% validated the process.

RESULTS

the average time of nurses ranged from 5.5 (standard deviation = 2.3) to 13 (standard deviation = 1.1) minutes; and the auxiliary / technician, between 4.7 (standard deviation = 2.1) and 6.8 (standard deviation = 2.0) minutes (p ≤ 0.01). We qualified six admissions made by nurses and 33 by assistants/technicians. The intervention spent 16.3% to 31.5% of the working hours of the team.

CONCLUSIONS

admission impacts nursing workload and needs to be considered both in the measurement of activities and in the sizing of the nursing staff.

Critical Care in the Military Health System: A 24-h Point Prevalence Study

Background

Healthcare expenditures are a significant economic cost with critical care services constituting one of its largest components. The Military Health System (MHS) is the largest, global healthcare system of its kind. In this project, we sought to describe critical care services and the patients who receive them in the MHS.

Methods

We surveyed 26 military treatment facilities (MTFs) representing 38 critical care services or intensive care units (ICUs). MTFs with multiple ICUs and critical care services responded to the survey as services (e.g., surgical or medical ICU service), whereas MTFs with only one ICU responded as a unit and gave information about all types of patients (i.e., medical and surgical). Our survey was divided into an administrative portion and a 24-h point prevalence survey of patients and patient care. The administrative portion is reported separately in this journal. The 24-h point prevalence survey collected information about all patients present in, admitted to, or discharged from participating services/units during the same 24-h period in December 2014. The survey was anonymous and protected health information was not collected.

Findings

Sixteen MTFs (69%) and 27 ICU services/units (71%) returned the point prevalence survey. MTFs with >200 beds (n = 3, 22%) were categorized as "high capacity centers" (HCCs) whereas those with ≤200 beds (n = 13, 78%) were characterized as low capacity centers (LCCs). Two MTFs (one HCC and one LCC) returned only administrative data. The remaining 16 MTFs reported data about 151 patients. In all, 100 (67%) of the patients were at three HCCs during this study period. One HCC accounted for 39% (59 patients) of all patient care during this study. Most patients were cared for in mixed medical/surgical ICUs (34.4%), followed by medical (21.2%), surgical (18.5%), trauma (11.9%), cardiac (7.9%), and burn (6.0%) ICUs. The most common medical indication for admission was cardiac followed by general medical. The most common surgical indications for admission were trauma, other, and cardiothoracic surgery. The average APACHE II score of all patients across both LCCs and HCCs was 11 ± 8.1 (8 ± 7.8 vs. 13 ± 7.7 p = 0.008). The lower acuity of patients in this study is reflected in a high turnover rate, low rate of arterial and central line placements (33%), and low rates of life support (all types, 30%; mechanical ventilation only, 21.2%; noninvasive mechanic ventilation only, 7.9%; and vasoactive medications, 6.6%). Thirty-five (23.2%) patients within the study were affected by a total of 57 complications. The three most common complications experienced were acute kidney injury, bleeding, and sepsis.

Discussion

This is the first detailed report about MHS critical care services and the patients receiving care. It describes a low acuity ICU patient population, concentrated at larger MTFs. This study highlights the need for the establishment of a system that allows for the continuous collection of high priority information about clinical care in the MHS in order to facilitate implementation of standardized protocols and process improvements.

Evidence on Nurse Staffing Ratios and Patient Outcomes in a Low-Income Country: Implications for Future Research and Practice

BACKGROUND

Conclusive evidence on the effect of nurse staffing ratios on nurse-sensitive outcomes (NSOs) has not yet been achieved worldwide.

AIMS

To describe the relationship between nurse staffing and NSOs at a Magnet designated, university hospital a low-income country.

METHODS

A 48-month prospective study assessed the relationship between nurse staffing and six patient outcomes or NSOs in medical-surgical units and critical care units (CCUs). Nurse staffing was measured by nursing hours per patient day (NHPPD) and skill mix, whereas NSOs were total falls and injury falls per 1,000 patient days, percent of surveyed patients with hospital-acquired pressure injuries (HAPI), catheter-associated urinary tract infections, ventilator-associated pneumonia, and central line-associated bloodstream infections (CLABSI) per 1,000 central line days.

RESULTS

The odds for total falls, injury falls, HAPI, and CLABSI in the medical-surgical units were higher with lower NHPPD ratios, OR = 4.67, p = .000; OR = 4.33, p = .001; OR = 3.77, p = .004 and OR = 2.61, p = .006, respectively. For the CCUs, lower rates of NHPPD increased the odds for total falls, OR = 6.25, p = .0007, HAPIs OR = 3.91, p = .001 and CLABSI, OR = 4.78, p = .000. Skill mix was associated with total falls, OR = 2.40, p = .005 and HAPIs OR = 2.07, p = .03 in the medical-surgical units but had no effect in any NSOs in the CCUs.

LINKING EVIDENCE TO ACTION

Higher rates of nurses per patient were effective in improving some NSOs but not others. Skill mix had no effect on any of the six NSOs in the CCUs. As such, the results remain inconclusive as the benefits of the higher nurse to patient ratios in this low-income country warranting further multisite studies in different settings and countries.

Determinants of occupational injury for US home health aides reporting one or more work-related injuries

OBJECTIVES

Home health aides (HHAs) work in a high-risk industry and experience high rates of work-related injury that have been significantly associated with reduction in workers and organisational productivity, quality and performance. The main objective of the study was to examine how worker environment and ergonomic factors affect HHA risk for reporting occupational injuries.

METHOD

We used cross-sectional analysis of data from the 2007 National Home Health and Hospice Aide Survey (NHHAS). The study sample consisted of a nationally represented sample of home health aides (n=3.377) with a 76.6% response rate. We used two scales ¹ : a Work Environment Scale and ² an Ergonomic Scale. Univariate and bivariate analyses were conducted to describe HHA work-related injury across individual, job and organisational factors. To measure scale reliability, Cronbach's alphas were calculated. Multivariable logistic regression was used to determine predictors of reported occupational injury.

RESULTS

In terms of Work Environment Scale, the injury risk was decreased in HHAs who did not consistently care for the same patients (OR=0.96, 95% CI: 0.53 to 1.73). In terms of Ergonomic Scale, the injury risk was decreased only in HHAs who reported not needing any other devices for job safety (OR=0.30, 95% (CI): 0.15 to 0.61). No other Work Environment or Ergonomic Scale factors were associated with HHAs' risk of injury.

CONCLUSION

This study has great implications on a subcategory of the workforce that has a limited amount of published work and studies, as of today, as well as an anticipated large demand for them.

Patient Turnover: A Concept Analysis

Patient turnover influences the quality and safety of patient care. However, variations in the conceptual underpinnings of patient turnover limit the understanding of the phenomenon. A concept analysis was completed to clarify the role of patient turnover in relation to outcomes in the acute care hospital setting. The defining attributes, antecedents, consequences, and empirical referents of patient turnover were proposed. Nursing leaders should account for patient turnover in workload and staffing calculations. Further research is needed to clarify the influence of patient turnover on the quality and safety of nursing care using a unified understanding of the phenomenon.

Comparison of Unit-Level Patient Turnover Measures in Acute Care Hospital Settings

High patient turnover is a critical factor increasing nursing workload. Despite the growing number of studies on patient turnover, no consensus about how to measure turnover has been achieved. This study was designed to assess the correlation among patient turnover measures commonly used in recent studies and to examine the degree of agreement among the measures for classifying units with different levels of patient turnover. Using unit-level data collected for this study from 292 units in 88 hospitals participating in the National Database of Nursing Quality Indicators®, we compared four patient turnover measures: the inverse of length of stay (1/LOS), admissions, discharges, and transfers per daily census (ADTC), ADTC with short-stay adjustment, and the number of ADTs and short-stay patients divided by the total number of treated patients, or Unit Activity Index (UAI). We assessed the measures' agreement on turnover quartile classifications, using percent agreement and Cohen's kappa statistic (weighted and unweighted). Pearson correlation coefficients also were calculated. ADTC with or without adjustment for short-stay patients had high correlations and substantial agreement with the measure of 1/LOS (κ = .62 to .91; r = .90 to .95). The UAI measure required data less commonly collected by participating hospital units and showed only moderate correlations and fair agreement with the other measures (κ = .23 to .39; r = .41 to .45). The UAI may not be comparable and interchangeable with other patient turnover measures when data are obtained from multiple units and hospitals. © 2016 Wiley Periodicals, Inc.