Nurse productivity: using evidence to enhance nurses' use of time

The UK is experiencing a nursing shortage, making it challenging to maintain the staffing levels required to deliver effective patient care. One way of enhancing the care delivered by the existing workforce could be to optimise nurse productivity; however, previous efforts to do this have been largely ineffective, due in part to a focus on the processes of care delivery rather than the nursing activities within these processes. In this article, the author explores the concept of nurse productivity and suggests that enhancing productivity requires the identification of nursing activities and consideration of how these may be undertaken in a more time-efficient manner - or removed altogether. The author discusses two such activities: intentional (hourly) rounding, and fixed-time manual vital signs for patients on general wards. The author also considers the potential of using automatic continuous remote monitoring on general hospital wards to free up nurses' time for other care activities.

Strengthening Healthy Work Environment Outcomes Via Interprofessional Direct Care Champion Roles

OBJECTIVE

To provide an organization-wide, systematic approach to creating and sustaining healthy work environments (HWEs) through frontline interprofessional staff education and coaching engagement.

BACKGROUND

HWE has been an overarching concept in the organization's nursing professional practice model since 2014; however, few practice settings routinely translated survey findings to improve the work environment's health via local interprofessional direct care team members.

METHODS

The program used a participatory approach where HWE champions committed to participate in centralized professional development activities and local quality improvement initiatives to bolster the health of area work environments.

RESULTS

Fifty-one champions representing 44 practice settings participated in the professional development program. Mean HWE scores for all standards increased from year 1 to 2, with 15 practice settings seeing categorical improvement. Meaningful recognition and true collaboration were the standards most often targeted for improvement.

CONCLUSION

The HWE champion role appears to be a promising strategy for engaging frontline interprofessional staff in the assessment and implementation of initiatives to improve the health of work environments.

Leadership in Nursing Excellence: The Magnet Recognition® Journey Experiences in Europe

Improving work conditions and the provision of high-quality care and patient safety is an issue in European hospitals. Inspired by a US program for nursing excellence, Magnet Recognition, a Belgian hospital shared their experiences by organizing a summer school in 2019 with nurses of 21 hospitals from 9 countries. This article explains the hospital's research program, the link between the journey and the content of the summer school, lessons learned, and the extent to which participants of European hospitals were interested in nursing excellence and Magnet designation.

Near-miss analysis in a large hospital in southern Brazil: A 5-year retrospective study

BACKGROUND

Near-miss analysis is an effective method for preventing serious adverse events, including never events such as wrong-site surgery.

OBJECTIVE

To analyze all near-miss incidents reported in a large general hospital in southern Brazil between January 2013 and August 2017.

METHOD

We performed a descriptive retrospective study of near-miss incidents recorded in the hospital's electronic reporting system in a large non-profit hospital (497 beds). The results are expressed as absolute (n) and relative frequencies (%). Pearson's chi-square test, Fisher's exact test (Monte Carlo simulation) and linear regression were used.

RESULTS

A total of 12,939 near-miss incidents were recorded during the study period, with linear growth in the number of reports. Near-miss incidents were most frequent for medication, followed by processes unspecified in the International Classification for Patient Safety framework, followed by information control (patient chart and fluid balance data), followed by venous/vascular puncture. The highest prevalence of reports was observed in inpatient wards, in adult, pediatric, and neonatal intensive care units, and in the surgical center/post-anesthesia care unit. Pharmacists and nursing personnel recorded most of the reports during the day shift.

CONCLUSION

The most frequent categories of near-miss incidents were medication processes, other institutional protocols, information control issues, and venous/vascular puncture. The significant number of reported near-miss incidents reflects good adherence to the reporting system.

A mixed methods study to evaluate the effects of a teamwork enhancement and quality improvement initiative on nurses' work environment

AIMS

To test the effect of a teamwork enhancement and quality improvement program named 'Nurturing Effective Teams and Continuous Quality Improvement' on nurses' work environments in the hospital setting.

DESIGN

Mixed-method study with quasi-experimental controlled trial and focus group interviews.

METHODS

Twelve units from two Philippine tertiary government hospitals will be matched and allocated to have 72 nurses receiving the teamwork enhancement and quality improvement program, or no intervention. The program focuses on enhancing the nurse autonomy, leadership and management support, teamwork, and workload management, delivered in two phases: (a) teamwork enhancement training using team strategies and tools to enhance the performance and patient safety; and (b) implementation of quality improvement projects using the model for improvement to identify priority unit issues and change ideas and tested using the Plan-Do-Study-Act cycle. The 6-month implementation includes two trainings and seven mentoring sessions with a quality improvement facilitator. Primary outcome is the nurses' work environment and secondary outcomes are job satisfaction, burnout risk, turnover intention, and perceived quality of care provided measured at the nurse-level using self-administered survey and measured at 0, 3, and 6 months. Focus group interviews will be conducted among 14-16 nurse subjects to explore their experience during the program, while other stakeholders will be interviewed to reflect the program effects. Generalized equation modelling will be used to identify the program effects on the quantitative outcomes and content analysis will be used for qualitative data.

DISCUSSION

Establishing measures to improve the nurses' work environments can be used to address poor nurse outcomes in high workload and low-resource settings.

IMPACT

A favourable nurse work environment is the cornerstone to sustainable nursing workforce and positive outcomes. This study will provide explicit evidence to inform the effect of a structured evidence-based protocol in improving nurses' work environment given resource-limited context.

TRIAL REGISTRATION

China Clinical Trial Registration Center (CciCTR), Registration number ChiCTR1900021754 (March 8, 2019).

New Burnout Evaluation Model Based on the Brief Burnout Questionnaire: Psychometric Properties for Nursing

Health care personnel are considered one of the worker sectors most exposed to heavier workloads and work stress. One of the consequences associated with the exposure to chronic stress is the development of burnout syndrome. Given that evaluating this syndrome requires addressing the context in which they are to be used, the purpose of this work was to analyze the psychometric properties and structure of the Burnout Brief Questionnaire (CBB), and to propose a more suitable version for its application to health professionals, and more specifically nurses. The final study sample was made up of 1236 working nursing professionals. An exploratory factorial analysis was carried out and a new model was proposed through a confirmatory factorial analysis. Thus, validation of the CBB questionnaire for nursing health care personnel showed an adequate discrimination of the items and a high internal consistency of the scale. With respect to the factorial analysis, four factors were extracted from the revised model. Specifically, these new factors, called job dissatisfaction, social climate, personal impact, and motivational abandonment, showed an adequate index of adjustment. Thus, the Brief Burnout Questionnaire Revised for nursing staff has favorable psychometric properties, and this model can be applied to all health care professionals.

Staff empowerment and engagement in a magnet® recognized and joint commission international accredited academic centre in Belgium: a cross-sectional survey

Background

A substantial number of studies linked aspects of a balanced, healthy and supportive nurse practice environment with quality and patient safety. To what extent balanced work characteristics such as social capital, decision latitude and workload are relevant for all staff engaged in patient care including healthcare and medical staff in a Magnet Recognized and Joint Commission International accredited academic centre is unclear. The study aim is to investigate associations between work characteristics such as social capital, decision latitude and workload, work engagement and feelings of burnout as explanatory variables and job satisfaction, turnover intentions and perceived quality of care as dependent variables in a study population of nursing, healthcare and medical staff taken in account generation differences.

Methods

Hierarchical regression analysis estimated strength of associations with demographic characteristics (block-1), professional category (block-2), work characteristics (block-3) and work engagement or burnout dimensions (block-4) as explanatory variables of job satisfaction and turnover intention and quality of care as outcome variables.

Results

The study confirmed and extended previous study findings demonstrating positive impact on staff’ job outcomes and assessed quality of care by balanced work characteristics such as social capital, decision latitude and workload in nursing staff (N = 864), healthcare staff (N = 131) and medical staff (N = 241). Generational characteristics and professional category were associated with turnover intentions and less favorable assessed quality of care, respectively. Explained variances of studied models ranged from 14.4 to 45.7%.

Conclusion

Engaging and committing staff to promote excellent patient outcomes in daily interdisciplinary practice works through clear frameworks, methods and resources supported by governance and policy structure that makes outcomes visible and accountable.

Discursive practice - lean thinking, nurses' responsibilities and the cost to care

PURPOSE

The purpose of this paper is to explore the literature regarding work intensification that is being experienced by nurses, to examine the effects this is having on their capacity to complete care. The authors contend that nurses' inability to provide all the care patients require, has negative implications on their professional responsibility.

DESIGN/METHODOLOGY/APPROACH

The authors used institutional ethnography to review the discourse in the literature. This approach supports inquiry through the review of text in order to uncover activities that remain institutionally accepted but unquestioned and hidden.

FINDINGS

What the authors found was that the quality and risk management forms an important part of lean thinking, with the organisational culture influencing outcomes; however, the professional cost to nurses has not been fully explored.

RESEARCH LIMITATIONS/IMPLICATIONS

The text uncovered inconsistency between what organisations accepted as successful cost savings, and what nurses were experiencing in their attempts to achieve the care in the face of reduced time and human resources. Nurses' attempts at completing care were done at the risk of their own professional accountability.

PRACTICAL IMPLICATIONS

Nurses are working in lean and stressful environments and are struggling to complete care within reduced resource allocations. This leads to care rationing, which negatively impacts on nurses' professional practice, and quality of care provision.

ORIGINALITY/VALUE

This approach is a departure from the standard qualitative review because the focus is on the textual relationships between what is being advocated by organisations directing cost reduction and what is actioned by the nurses working at the coalface. The discordant standpoints between these two juxtapositions are identified.

The impact of environmental and demographic factors on nursing job satisfaction

Objective

This study aims to evaluate all aspects of job satisfaction in registered nurses working in different hospitals in Shiraz, Iran.

Methods

This cross-sectional study was performed during February to August 2015 in Shiraz, Iran. It comprised of 371 registered nurses working in government and private hospitals using multi-stage cluster sampling. Job satisfaction was evaluated using 5 items of the Job Descriptive Index (JDI) consisting of 63 questions developed by Smith, Kendall, and Hulin (1969). Statistical tests including independent sample t test and one-way analysis of variance (ANOVA) were used in order to identify the relation between job satisfaction, and demographic features and work environment. Data were analyzed by SPSS version 15.0, using descriptive statistics, independent-samples t-test, and ANOVA.

Results

Our findings showed no relationship between demographic variables and job satisfaction. However, a significant association was observed between environmental aspects such as work rotation (fixed versus rotating) nurse’s status (staff vs. supervisors), type of hospitals (governmental vs. private) and work (p<0.01), promotion (p<0.02) and pay (p<0.01) items respectively; however, type of hospital was deemed exempt regarding promotion. Also regarding the number of shifts per week, nurses with more than eight shifts present a lower mean score of satisfaction about pay significantly (p=0.03).

Conclusion

The results concerning younger nurses have different types of satisfaction based on several environmental factors. Nurses’ policy makers must pay more attention to nurses’ satisfaction and focus on reducing the various inequalities.

Understanding how nurses ration care

Purpose

The purpose of this paper is to explore how nurses make decisions to ration care or leave it undone within a clinical environment that is controlled by systems level cost containment. The authors wanted to find out what professional, personal and organisational factors contribute to that decision-making process. This work follows previous international research that explored missed nursing care using Kalisch and Williams’ MISSCARE survey.

Design/methodology/approach

The authors drew on the care elements used by Kalisch and Williams, asking nurses to tell us how they decided what care to leave out, the conduits for which could include delaying care during a shift, delegating care to another health professional on the same shift, handing care over to staff on the next shift or leaving care undone.

Findings

The findings suggest that nurses do not readily consider their accountability when deciding what care to leave or delay, instead their priorities focus on the patient and the organisation, the outcomes for which are frequently achieved by completing work after a shift.

Originality/value

The actions of nurses implicitly rationing care is largely hidden from view, the consequences for which potentially have far reaching effects to the nurses and the patients. This paper raised awareness to hidden issues facing nurses within a cycle of implicitly rationing care, caught between wanting to provide care to their patients, meeting the organisation’s directives and ensuring professional safety. Rethinking how care is measured to reflect its unpredictable nature is essential.

Reported implementation lessons from a national quality improvement initiative; Productive Ward: Releasing Time to Care™. A qualitative, ward-based team perspective

AIM

To explore the experiences of participants involved in the implementation of the Productive Ward: Releasing Time to Care™ initiative in Ireland, identifying key implementation lessons.

BACKGROUND

A large-scale quality improvement programme Productive Ward: Releasing Time to Care™ was introduced nationwide into Ireland in 2011. We captured accounts from ward-based teams in an implementation phase during 2013-14 to explore their experiences.

METHODS

Semi-structured, in-depth interviews with a purposive sample of 24 members of ward-based teams from nine sites involved in the second national phase of the initiative were conducted. Interviews were analysed and coded under themes, using a seven-stage iterative process.

RESULTS

The predominant theme identified was associated with the implementation and management of the initiative and included: project management; training; preparation; information and communication; and participant's negative experiences. The most prominent challenge reported related to other competing clinical priorities.

CONCLUSIONS

Despite the structured approach of Productive Ward: Releasing Time to Care™, it appears that overstretched and busy clinical environments struggle to provide the right climate and context for ward-based teams to engage and interact actively with quality improvement tools, methods and activities.

IMPLICATIONS FOR NURSING MANAGEMENT

Findings highlight five key aspects of implementation and management that will help facilitate successful adoption of large-scale, ward-based quality improvement programmes such as Productive Ward: Releasing Time to Care™. Utilising pre-existing implementation or quality frameworks to assess each ward/unit for 'readiness' prior to commencing a quality improvement intervention such as Productive Ward: Releasing Time to Care™ should be considered.

Nonlinear Analysis to Detect if Excellent Nursing Work Environments Have Highest Well-Being

PURPOSE

To detect potentially nonlinear associations between nurses' work environment and nurse staffing on the one hand and nurse burnout on the other hand.

DESIGN

A cross-sectional multicountry study for which data collection using a survey of 33,731 registered nurses in 12 European countries took place during 2009 to 2010.

METHODS

A semiparametric latent variable model that describes both linear and potentially nonlinear associations between burnout (Maslach Burnout Inventory: emotional exhaustion, depersonalization, personal accomplishment) and work environment (Practice Environment Scale of the Nursing Work Index: managerial support for nursing, doctor-nurse collegial relations, promotion of care quality) and staffing (patient-to-nurse ratio).

FINDINGS

Similar conclusions are reached from linear and nonlinear models estimating the association between work environment and burnout. For staffing, an increase in the patient-to-nurse ratio is associated with an increase in emotional exhaustion. At about 15 patients per nurse, no further increase in emotional exhaustion is seen.

CONCLUSIONS

Absence of evidence for diminishing returns of improving work environments suggests that continuous improvement and achieving excellence in nurse work environments pays off strongly in terms of lower nurse-reported burnout rates. Nurse staffing policy would benefit from a larger number of studies that identify specific minimum as well as maximum thresholds at which inputs affect nurse and patient outcomes.

CLINICAL RELEVANCE

Nurse burnout is omnipresent and has previously been shown to be related to worse patient outcomes. Additional increments in characteristics of excellent work environments, up to the highest possible standard, correspond to lower nurse burnout.