The Influence of Appropriate Staffing and Healthy Work Environments on Patient and Nurse Outcomes

The untold emotional toll of navigating the health system: the journey of patients in/from India, living with serious and/or chronic conditions

Patient journey mapping, a novel method to visualize all the interactions a patient might have with the health system, is increasingly being adopted by the healthcare industry to identify challenges patients face, with the goal of improving health outcomes. However, patient journey maps are often used internally within pharma companies and are not published widely. Here, I conducted in-depth interviews with eight Indian patients/caregivers dealing with chronic and/or serious conditions; seven of the interviewees were living in India and spoke entirely from the perspective of the Indian health system, whereas one spoke from his experience of living in India, Ireland, and the UK. Using insights from these interviews, drawing on my own experience as a patient living with a rare disease and multiple comorbidities, and seeking feedback from several international patient advocates and industry professionals, I constructed a detailed map visualizing the collective journey of patients with serious/chronic conditions. Apart from showing the different stages in the patient journey, the map visualizes the associated stress levels, pain points (issues leading to a negative experience), emotions, and information-seeking behavior. One key insight that emerges is that along with a range of highly variable emotions patients experience, stress is a consistent factor throughout the patient journey. In many cases, the stress is caused or exacerbated by factors that can be avoided, such as long wait times, procedural hassles, inadequate or inaccurate information, and lack of empathy in interactions with healthcare professionals. The frustrations patients experience stem from a mix of underlying practical/tangible and emotional/aspirational needs. I have discussed these needs at length and provided suggestions for changes that could be implemented in the health system to meet these needs better. While my analysis presented here is generally framed from the context of the Indian health system, and some points discussed might have nuances in other health systems, the themes and insights provided are relevant to all patients and their journey, anywhere in the world. Pharmaceutical industry professionals, healthcare providers, and policymakers may benefit from these insights and may apply them to make strategic decisions and changes in their approach, with the goal of improving patient experience and health outcomes globally.

Peroxynitrite-Triggered Carbon Monoxide Donor Improves Ischemic Stroke Outcome by Inhibiting Neuronal Apoptosis and Ferroptosis

Cerebral ischemia-reperfusion injury produces excessive reactive oxygen and nitrogen species, including superoxide, nitric oxide, and peroxynitrite (ONOO-). We recently developed a new ONOO--triggered metal-free carbon monoxide donor (PCOD585), exhibiting a notable neuroprotective outcome on the rat middle cerebral artery occlusion model and rendering an exciting intervention opportunity toward ischemia-induced brain injuries. However, its therapeutic mechanism still needs to be addressed. In the pharmacological study, we found PCOD585 inhibited neuronal Bcl2/Bax/caspase-3 apoptosis pathway in the peri-infarcted area of stroke by scavenging ONOO-. ONOO- scavenging further led to decreased Acyl-CoA synthetase long-chain family member 4 and increased glutathione peroxidase 4, to minimize lipoperoxidation. Additionally, the carbon monoxide release upon the ONOO- reaction with PCOD585 further inhibited the neuronal Iron-dependent ferroptosis associated with ischemia-reperfusion. Such a synergistic neuroprotective mechanism of PCOD585 yields as potent a neuroprotective effect as Edaravone. Additionally, PCOD585 penetrates the blood-brain barrier and reduces the degradation of zonula occludens-1 by inhibiting matrix metalloproteinase-9, thereby protecting the integrity of the blood-brain barrier. Our study provides a new perspective for developing multi-functional compounds to treat ischemic stroke.

"Unaware and Unprepared": Experiences of Critical Care Nurses Providing End-of-Life Care; A Qualitative Study

Modern health care delivery incorporates technology to prolong life for those with serious illnesses. As technology continues to advance, the critical care nurses' role particularly at the end of life (EOL) continues to evolve, requiring higher levels of care. This contributes to an already complex environment for nurses to practice. The aim of this study was to explore the experiences of critical care nurses in providing care for patients at EOL. This qualitative descriptive study describes the experience of 216 critical care nurses across the United States. Content analysis illuminated 5 themes: We Can't Fix Everyone, Task-Oriented Nursing, A Profession of Broken Individuals, Unaware and Unprepared, and A Hand to Hold. Study findings provide a unique perspective of critical care nurses and the health care delivery for patients and families at EOL. This study supports the imperative of creating and sustaining healthy work environments and palliative care education as essentials for critical care nurses who care for patients at EOL.

Adapting the Healthy Work Environment Assessment Tool for French-Canadian Intensive Care Nurses

BACKGROUND

Self-administered instruments are used to measure components of work environments that cannot be measured directly. The Healthy Work Environment Assessment Tool (HWEAT) of the American Association of Critical-Care Nurses is a promising instrument. However, it is available only in English and Japanese, precluding its use in other populations and cross-national comparisons.

OBJECTIVES

To describe the Canadian French translation and cross-cultural adaptation of the HWEAT (F-HWEAT) and to explore its factor structure and psychometric properties.

METHODS

Cross-cultural adaptation of the HWEAT and collection of evidence of validity via an electronic cross-sectional survey.

RESULTS

A total of 564 intensive care unit nurses participated in the validation study. Confirmatory factor analysis supported the presence of a single overarching factor measured by the F-HWEAT. The Cronbach α for the instrument was 0.89 (95% CI, 0.88-0.91). The mean and median interitem correlations were both 0.32, and item-partial total correlations ranged from 0.33 to 0.64. The overall F-HWEAT score indicated that nurses believed their work environment needed improvements. Moderate positive correlations were found between the overall F-HWEAT score and nurses' perceptions of care quality (r = 0.45 [95% CI, 0.38-0.51]) and safety (r = 0.48 [95% CI, 0.40-0.55]).

CONCLUSION

The results support the use of the F-HWEAT in French-speaking populations. Using the F-HWEAT will help elucidate areas needing improvement and expand global dialogues about healthy critical care work environments. With this information, nurse leaders and researchers can develop and implement modern strategies to improve the work conditions of intensive care unit nurses.

Fewer Patients per Nurse Does Not Offset Increased Nurse Stress Related to Treatment Uncertainty and Mortality in the Neonatal Intensive Care Unit

BACKGROUND

Many inpatient healthcare institutions' nurse staffing plans systematically assign fewer patients to nurses when patient acuity is high, but the impact of this strategy on components of nurse stress has not been thoroughly investigated.

PURPOSE

To examine the relationship between nurse-to-patient ratio assigned based on NICU patient acuity with the Nurse Stress Scale (NSS) subscales Death and Dying, Conflict with Physicians, Inadequate Preparation, Lack of Support, Conflict with Other Nurses, Work Load, and Uncertainty Concerning Treatment.

METHODS

A survey including the NSS tool items, demographic questions, and a question about nurse-to-patient ratio during the shift was administered. Cronbach's α, linear regression, and Spearman's correlation were used for data analysis.

RESULTS

Analysis of the 72 participating NICU nurses' survey responses showed fewer patients per nurse during the shift was negatively correlated with stress related to Death and Dying ( P < .001) and Uncertainty Concerning Treatment ( P = .002) subscale scores. This inverse relationship remained significant after controlling for education and years of experience.

IMPLICATIONS FOR PRACTICE

The observed higher stress can be inferred to be due to high patient acuity since fewer patients are assigned to nurses caring for high-acuity patients. Improvements in communication to nurses about patients' medical condition, treatment rationale, and information that should be conveyed to the family could reduce nurse stress from treatment uncertainty. Targeted education and counseling could help nurses cope with stress due to patient deaths.

IMPLICATIONS FOR RESEARCH

Interventions to reduce stress related to treatment uncertainty and death of patients among NICU nurses caring for high-acuity infants should be developed and evaluated.

Nursing Work Environment Staffing Councils: An Alternative to Mandatory Regulated Staffing Ratios

OBJECTIVE

The aim of this study was to examine the self-reported perceptions of the healthy work environment (HWE) of nurses who are members of Nursing Workplace Environment and Staffing Councils (NWESCs).

BACKGROUND

In a statewide initiative, NWESCs were established at hospitals throughout the state of New Jersey as an alternative to nurse staffing ratio laws and to provide clinical nurses a voice in determining resources needed for patient care and support an HWE.

METHODS

This quantitative descriptive study presents the results of the Healthy Workplace Environment Assessment Tool (HWEAT) and open-ended questions about NWESCs among a sample of 352 nurses.

RESULTS

Three years after NWESC implementation, all HWEAT standard mean scores increased and were rated higher than the American Association of Critical-Care Nurses benchmark. There were statistically significant differences in clinical nurses' perceptions of an HWE compared with nurse leaders. Respondents also shared their NWESC's best practices and challenges. Responses to questions identified NWESC best practices and challenges.

CONCLUSION

This study offers insight into the improvement in nurses' perceptions of the HWE after the introduction of a statewide NWESCs. Structures such as the NWESCs may provide an alternative to mandated staffing ratios.

Exploring Meditation Profiles and Predictors in Nursing Students

Background: Nursing students face unique academic and clinical workloads linked to increased stress. Previous studies indicate formal and informal mindfulness meditation provide stress-reducing benefits. This practice aligns with holistic nursing core values of self-care and self-reflection; little is known about meditation practice in nursing students. Objectives: Our study aimed to describe meditation practice and predictors in pre-licensure nursing students. Design: Cross-sectional, multi-site. Methods: Qualtrics surveys queried individual demographics, personal meditation and exercise habits, and indicators of wellbeing. Results: Of 417 participants, 65% (n  =  271) reported at least one type of meditation practice. Prayer/spiritual activities were most prevalent (almost 70%), followed by breathing exercises (41%). Meditators reported good or excellent self-rated health status or engaged in exercise (p < .05). Meditators also reported more self-compassion, happiness, and satisfaction with life, and perceived less stress than non-meditators (p < .05). Of all factors studied, only engaging in exercise significantly predicted practicing meditation (OR = 2.05, 95%CI 1.10-3.82). Conclusion: Nursing students who engage in meditation report signs of health and well-being and utilize holistic methods such as prayer and breathing. The intrinsic motivation to engage in healthy habits such as exercise may also help students engage in mindfulness meditation and is an important finding for nursing educators.

The influence of nurse manager competency on practice environment, missed nursing care, and patient care quality: A cross-sectional study of nurse managers in U.S. hospitals

AIMS

Identify and examine drivers of nurse manager competency and high-quality practice environments.

BACKGROUND

Nurse managers are a key predictor of positive professional practice environments which are, in turn, associated with nurse, patient, and organizational outcomes. However, little work has examined the factors that contribute to nurse manager competency.

METHODS

Nurse managers completed online surveys which were matched to unit-level aggregate data of their subordinate direct care nurses' responses on the National Database of Nursing Quality Indicators. This resulted in a final sample of 541 nurse managers across 47 U.S. hospitals. Multilevel path analysis was utilized to assess a model of the antecedents and consequences of nurse manager competency.

RESULTS

Nurse manager competency and practice environments were predictive of missed nursing care and nurse-reported quality of care. Nurse manager experience was found to have twice the effect on competency as advanced education.

CONCLUSIONS

Nurse manager competency and its downstream effects are achieved through nurse manager experience and advanced education.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse manager competency yields better practice environments and nursing care. Considering the influence of experience, careful attention should be paid to the competency development process of more novice nurse managers.

Development and Testing of the Quality Improvement Self-efficacy Inventory

Quality improvement is paramount for patient safety. Leading change for quality improvement requires nurses with knowledge and skills beyond the clinical management of patients. In this study, staff nurses working in hospitals throughout Alabama were asked via an online survey to rate their quality improvement knowledge and skills using the new 10-item Quality Improvement Self-Efficacy Inventory (QISEI) and their perceptions of the nursing work environment using the Practice Environment Scale of the Nursing Work Index. Nurses (N = 886) rated the basic quality improvement items higher than the more advanced items. Several nurse characteristics and the nursing work environment were associated with nurses' ratings of their quality improvement knowledge and skills. Educators and administrators in health care organizations can use QISEI to gauge their nurses' knowledge and skills and then develop continuous professional development opportunities aimed at improving quality and safety competencies.

Implementing AACN's Healthy Work Environment Framework in an Intensive Care Unit

BACKGROUND

Bedside nurse turnover in the United States is 15.9%, representing a national challenge that has been attributed to poor work environments. Healthy work environments are associated with improved nurse satisfaction and retention as well as positive patient outcomes; unhealthy work environments have the opposite effects.

OBJECTIVES

To implement the American Association of Critical-Care Nurses (AACN) healthy work environment (HWE) framework in an intensive care unit and to evaluate staff satisfaction, turnover, and tenure 2 years later.

METHODS

A pre-post study design was used to evaluate implementation of the HWE framework in an intensive care unit in a large academic medical facility. Interventions for each of the 6 HWE standards were performed. The AACN HWE assessment survey was used to measure skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership in 2017 and in 2019.

RESULTS

Nurse cohorts (n = 165 in 2017; n = 176 in 2019) had a mean age of 31 (median, 27; range, 23-63) years, were predominantly female (76%), and had a mean of 5 (median, 3) years of intensive care unit nursing experience. Statistically significant improvements were found in all standards except the skilled communication and overall measures. Registered nurse turnover remained stable and tenure increased by 79 days in this 2-year period.

CONCLUSIONS

Findings from this study suggest that interventions addressing the HWE standards are associated with improved staff satisfaction, turnover, and average tenure, further demonstrating the value of the HWE framework in improving retention.

Trends in Strategic Napping in Surgical Residents by Gender, Postgraduate Year, Work Schedule, and Clinical Rotation

OBJECTIVE

To identify surgical resident and clinical rotation attributes which predict on-shift napping through objectively measured sleep patterns and work schedules over a 2-month period.

DESIGN

In a cross-sectional study, participants provided schedules, completed the Epworth Sleepiness Scale (ESS), and wore sleep-tracking devices (Zulu watch) continuously for 8 weeks. Multiple linear regression predicted percent days with on-shift napping from resident and rotation characteristics.

SETTING

Greater Washington, DC area hospitals.

PARTICIPANTS

Twenty-two (n = 22) surgical residents rotating in at least 1 of 5 different clinical rotation categories.

RESULTS

Residents slept 6 hours within a 24-hour period (370 ± 129 minutes) with normal sleep efficiency (sleep efficiency (SE): 87.13% ± 7.55%). Resident ESS scores indicated excessive daytime sleepiness (11.64 ± 4.03). Ninety-five percent (n = 21) of residents napped on-shift. Residents napped on-shift approximately 32% of their working days and were most likely to nap when working between 23:00 and 05:00 hours. Earlier shift start times predicted less on-shift napping (B = -0.08, SE = 0.04, β = -2.40, t = -2.09, p = 0.05) while working more night shifts (B = 1.55, SE = 0.44, β = 4.12, t = 3.52, p = 0.003) and shifts over 24 hours (B = 1.45, SE = 0.55, β = 1.96, t = 2.63, p = 0.01) predicted more frequent on-shift napping.

CONCLUSIONS

Residents are taking advantage of opportunities to nap on-shift. Working at night seems to drive on-shift napping. However, residents still exhibit insufficient sleep and daytime sleepiness which could reduce competency and represent a safety risk to themselves and/or patients. These findings will help inform intervention strategies which are tailored to surgical residents using a biomathematical model of fatigue.

Factors That Influence Nurse Staffing Levels in Acute Care Hospital Settings

PURPOSE

To identify which patient and hospital characteristics are related to nurse staffing levels in acute care hospital settings.

DESIGN

A cross-sectional design was used for this study.

METHODS

The sample comprised 1,004 patients across 10 hospitals in the Andalucian Health Care System (southern Spain) in 2015. The sampling was carried out in a stratified, consecutive manner on the basis of (a) hospital size by geographical location, (b) type of hospital unit, and (c) patients' sex and age group. Random criteria were used to select patients based on their user identification in the electronic health record system. The variables were grouped into two categories, patient and hospital characteristics. Multilevel linear regression models (MLMs) with random intercepts were used. Two models were fitted: the first was the null model, which contained no explanatory variables except the intercepts (fixed and random), and the second (explanatory) model included selected independent variables. Independent variables were allowed to enter the explanatory model if their univariate association with the nurse staffing level in the MLM was significant at p < .05.

RESULTS

Two hierarchical levels were established to control variance (patients and hospital). The model variables explained 63.4% of the variance at level 1 (patients) and 71.8% at level 2 (hospital). Statistically significant factors were the type of hospital unit (p = .002), shift (p < .001), and season (p < .001). None of the variables associated with patient characteristics obtained statistical significance in the model.

CONCLUSIONS

Nurse staffing levels were associated with hospital characteristics rather than patient characteristics.

CLINICAL RELEVANCE

This study provides evidence about factors that impact on nurse staffing levels in the settings studied. Further studies should determine the influence of patient characteristics in determining optimal nurse staffing levels.

Perceptions of Authentic Nurse Leadership and Work Environment and the Pandemic Impact for Nurse Leaders and Clinical Nurses

OBJECTIVE

The aim of this study was to determine the pandemic impact on the relationship between nurses' perception of the authentic nurse leadership (ANL) of their manager and their perception of the work environment.

BACKGROUND

Both ANL and healthy work environment (HWE) contribute to staff and patient outcomes. Our 1st study of these 2 variables revealed a positive relationship. Will this be upheld in a pandemic year?

METHODS

More than 5000 nurses from a national sample participated in a cross-sectional, correlational, descriptive study using the Authentic Nurse Leadership Questionnaire, the Critical Elements of a Healthy Work Environment Scale, and a pandemic impact on practice question.

RESULTS

Overall, nurses perceived ANL and HWE were present despite a high level of pandemic impact; however, when clinical nurses were separated from managers/directors, HWE was not present for frontline nurses. The moderate correlation of ANL and HWE was replicated in this larger study.

CONCLUSIONS

This is the 2nd study of the positive relationship between ANL and HWE using these models, supporting ANL as an essential standard of a HWE. ANL was present for clinical nurses in a pandemic year signaling that nurse leaders rose to meet frontline leadership needs. HWE was present overall, but not for clinical nurses. Leadership is essential to work environments and outcomes especially in times of crisis and significant change.

Nurse perspectives in the emergency department: The synergy tool in workload management and work engagement

AIM

To explore emergency nurses' perceptions of how a nurse-driven patient needs assessment tool, the synergy tool, influenced their workload management.

BACKGROUND

Quadruple Aim, particularly the fourth aim of improved staff work experiences, served as the conceptual framework to engage nurses in a participatory action research project. This project took place between 2017 and 2020 in two tertiary care emergency departments in one large Canadian city.

METHOD

This study employed a qualitative descriptive component, focus group interviews and nurse comments on two open-ended survey questions.

RESULTS

Use of the synergy tool heightened nurses' awareness of patients' holistic care needs. Nurses also stated how patient needs assessment data helped them identify unsafe workloads.

CONCLUSIONS

The synergy tool, adapted for emergency department use by nurses, was a means to engage and empower nurses. Patient needs assessment data from the tool identified staffing gaps, resulting in additional nursing staff for both emergency departments.

IMPLICATIONS FOR NURSING MANAGEMENT

A focus on patient needs assessment can be an effective way to address nurses' workload concerns.

Predictors and priority of caring behaviours in intensive care units

BACKGROUND

There is an increasing number of studies addressing nurses' perception of caring behaviours; however, on the issue of quality of care, it is important to understand why nurses focus more on certain elements of caring than others, and this needs to investigate influencing factors on, priorities, and predictors of caring behaviours.

AIMS

The main goal of this study was to determine the predictors and priorities of nurses' caring behaviours in intensive care units to improve the quality of care and patient outcomes.

METHODS

This is a cross-sectional survey of nurses working in adult and pediatric ICUs in Iran. The participants were 470 ICU nurses from eight hospitals in Iran. Data were collected over 6 months in 2018 using the Persian version of "Caring Assessment Report Evaluation Q-Care"; "Determinants of Nurse Caring Behaviors"; and a demographic data form.

RESULTS

By broad descriptive and analytical analysis, thirteen items were recognized as predictors of caring behaviours. The most important individual predictors reported as "interest in the nursing profession," "moral obligation," and "job experience," respectively. The most important perceived nursing behaviours were, respectively, subscales of "accessible," "monitors/follow-through" and "explains/facilitates."

CONCLUSION

The results provide insight into new and context-specific predictors of nurses' caring behaviours. These findings suggest that nursing managers, besides selecting skilful staff for ICUs, may consider employing those of higher "interest in the nursing profession"; "moral obligation"; and "job experience." They, also, need to be aware that organizational culture, climate, and values have a great impact on the caring behaviours of nurses. This could help them to handle the complex issue of improving the quality of care more efficiently.

Nurse-Sensitive Quality Metrics to Benchmark in Pediatric Cardiovascular Care

BACKGROUND

Associations between the quality of nursing care and patient outcomes have been demonstrated globally. However, translation and application of this evidence to robust measurement in pediatric specialty nursing care has been limited.

OBJECTIVES

To test the feasibility and performance of nurse-sensitive measures in pediatric cardiovascular programs.

METHODS

Ten nurse-sensitive measures targeting nursing workforce, care process, and patient outcomes were implemented, and measurement data were collected for 6 months across 9 children's hospitals in the Consortium of Congenital Cardiac Care-Measurement of Nursing Practice (C4-MNP). Participating sites evaluated the feasibility of collecting data and the usability of the data.

RESULTS

Variations in nursing workforce characteristics were reported across sites, including proportion of registered nurses with 0 to 2 years of experience, nursing education, and nursing certification. Clinical measurement data on weight gain in infants who have undergone cardiac surgery, unplanned transfer to the cardiac intensive care unit, and pain management highlighted opportunities for improvement in care processes. Overall, each measure received a score of 75% or greater in feasibility and usability.

CONCLUSIONS

Collaborative evaluation of measurement performance, feasibility, and usability provided important information for continued refinement of the measures, development of systems to support data collection, and selection of benchmarks across C4-MNP. Results supported the development of target benchmarks for C4-MNP sites to compare performance, share best practices for improving the quality of pediatric cardiovascular nursing care, and inform nurse staffing models.

Nursing Workload, Knowledge about Pain, and Their Relation to Pain Records

PURPOSE

To study the relationship between frequency of pain assessment and nursing workload, and also to analyze the frequency of pain assessment and its relation to knowledge and attitudes toward pain on nursing professionals in intensive care unit.

METHODS

An ambispective study was conducted in a Spanish tertiary-level intensive care unit between October 2017 and April 2018. For measurement of workload, the Nursing Activities Score scale was used, and for measurement of pain knowledge, the Knowledge and Attitudes Survey Regarding Pain was used.

RESULTS

There were 1,207 measurements among 41 nurses and 1,838 among 317 patients. The average nursing workload was high (70.97 points). We found statistically significant positive association between nursing workload and the frequency of assessment (p < .001), as well as frequency of assessment and patients with communicative capacity (p = .008).

CONCLUSIONS

Nursing workload affects the registration and assessment of patients' pain, resulting in a greater number of records as the workload performed by nurses increases. It is necessary to study in greater depth how the severity of pain, gender of the patients, and workload of nurses influence pain registration and assessment.

A hermeneutic-phenomenological study of paediatric intensive care unit nurses' professional identity following hospital redesign: Lessons learned for managers

AIM

To provide insights for health care managers by exploring paediatric intensive care unit nurses' lived experience of professional identity in the context of organisational change.

BACKGROUND

While professional identity improves retention of nurses and provision of quality care, outcomes of importance for managers, organisational change perturbs this identity.

METHOD

The study used a hermeneutic-phenomenological design. Data were collected via individual interviews, photographs, participant observation and document review. A purposive sampling strategy was used to recruit paediatric intensive care unit nurses (n = 15) in a large Canadian paediatric hospital.

RESULTS

Nurses' critical care identity eroded in this organisation due to the interplay between hospital redesign and new eligibility criteria for patient admissions.

CONCLUSION

Interactions between multiple projects and the unit context, as well as nursing professional identity, need to be considered early on during project planning. This study fills an important gap in research concerning the management challenges brought about by the intersection of multiple changes.

IMPLICATIONS FOR NURSING MANAGEMENT

The results from this study bring to light three important lessons for nurse managers: 1) the specific unit context should be evaluated before a project is initiated; 2) the physical environment needs to be considered when determining staffing requirements; and 3) identity transitions need to be managed.