Providing feedback following Leadership WalkRounds is associated with better patient safety culture, higher employee engagement and lower burnout

BACKGROUND

There is a poorly understood relationship between Leadership WalkRounds (WR) and domains such as safety culture, employee engagement, burnout and work-life balance.

METHODS

This cross-sectional survey study evaluated associations between receiving feedback about actions taken as a result of WR and healthcare worker assessments of patient safety culture, employee engagement, burnout and work-life balance, across 829 work settings.

RESULTS

16 797 of 23 853 administered surveys were returned (70.4%). 5497 (32.7% of total) reported that they had participated in WR, and 4074 (24.3%) reported that they participated in WR with feedback. Work settings reporting more WR with feedback had substantially higher safety culture domain scores (first vs fourth quartile Cohen's d range: 0.34-0.84; % increase range: 15-27) and significantly higher engagement scores for four of its six domains (first vs fourth quartile Cohen's d range: 0.02-0.76; % increase range: 0.48-0.70).

CONCLUSION

This WR study of patient safety and organisational outcomes tested relationships with a comprehensive set of safety culture and engagement metrics in the largest sample of hospitals and respondents to date. Beyond measuring simply whether WRs occur, we examine WR with feedback, as WR being done well. We suggest that when WRs are conducted, acted on, and the results are fed back to those involved, the work setting is a better place to deliver and receive care as assessed across a broad range of metrics, including teamwork, safety, leadership, growth opportunities, participation in decision-making and the emotional exhaustion component of burnout. Whether WR with feedback is a manifestation of better norms, or a cause of these norms, is unknown, but the link is demonstrably potent.

A qualitative analysis of the Three Good Things intervention in healthcare workers

BACKGROUND

Intensive care unit (ICU) personnel have an elevated prevalence of job-related burn-out and post-traumatic stress disorder, which can ultimately impact patient care. To strengthen healthcare workers' skills to deal with stressful events, it is important to focus not only on minimising suffering but also on increasing happiness, as this entails many more benefits than simply feeling good. Thus, the purpose of this study was to explore the content of the 'good things' reported by healthcare workers participating in the 'Three Good Things' intervention.

METHODS

In a tertiary care medical centre, a sample of 89 neonatal ICU (NICU) healthcare professionals registered for the online intervention. Of these, 32 individuals eventually participated fully in the 14-day online Three Good Things intervention survey. Daily emails reminded participants to reflect on and respond to the questions: "What are the three things that went well today?" and "What was your role in bringing them about?" To analyse their responses, we applied a thematic analysis, which was guided by our theoretical understanding of resilience.

RESULTS

Involving more than 1300 statements, the Three Good Things responses of the 32 study participants, including registered nurses, physicians and neonatal nurse practitioners, led to the identification of three main themes: (1) having a good day at work; (2) having supportive relationships and (3) making meaningful use of self-determined time.

CONCLUSIONS

The findings show the personal and professional relevance of supportive relationships strengthened by clear communication and common activities that foster positive emotions. The Three Good Things exercise acknowledges the importance of self-care in healthcare workers and appears to promote well-being, which might ultimately strengthen resilience.

Are nursing home care workers' health and presenteeism associated with implicit rationing of care? A cross-sectional multi-site study

To explore associations between care workers' health and implicit rationing of care. Diverse studies have linked impaired health to reduced work performance - a factor measured through omission of required tasks. This cross-sectional study gathered data from 3239 care workers in 162 Swiss nursing homes. Data were analyzed via a linear logistic regression model using general estimating equations. Overall, rationing of care occurred "never" to "seldom." Rationing of activities of daily living was positively associated with care workers' joint pain (β 0.04, CI 0.001-0.07), emotional exhaustion (β 0.11, CI 0.07-0.15), and presenteeism (β 0.05, CI 0.004-0.09). Rationing of caring, rehabilitation, and monitoring was positively associated with care workers' joint pain (β 0.05, CI 0.01-0.09) and emotional exhaustion (β 0.2, CI 1.16-0.24). Care workers health complaints are strongly associated with rationing of tasks directly related to resident care.

How hospital leaders contribute to patient safety through the development of trust

OBJECTIVE

The aim of this study was to explore the associations between hospital management support for patient safety, registered nurses' trust in hospital management, and their overall perception of patient safety, considering aspects of safety communication as possible mediating variables.

BACKGROUND

Limited research exists regarding how key elements of a patient safety culture, that is, leadership, safety communication, and trust, are interrelated.

METHODS

This study used cross-sectional nurse survey data from 1,633 registered nurses working in 35 acute care hospitals participating in the Swiss arm of the RN4CAST (Nurse Forecasting in Europe) study.

RESULTS

A path analysis revealed that the indirect associations between "management support for patient safety" and "overall perception of patient safety" were more prominent than the direct association.

CONCLUSION

Our findings confirm that safety communication plays a partially mediating role between "management support for patient safety" and nursing professionals' assessments of patient safety. This suggests that hospital leader-unit exchanges might improve patient safety.

Methodological considerations when translating "burnout"

No study has systematically examined how researchers address cross-cultural adaptation of burnout. We conducted an integrative review to examine how researchers had adapted the instruments to the different contexts. We reviewed the Content Validity Indexing scores for the Maslach Burnout Inventory-Human Services Survey from the 12-country comparative nursing workforce study, RN4CAST. In the integrative review, multiple issues related to translation were found in existing studies. In the cross-cultural instrument analysis, 7 out of 22 items on the instrument received an extremely low kappa score. Investigators may need to employ more rigorous cross-cultural adaptation methods when attempting to measure burnout.

Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study

BACKGROUND

Austerity measures and health-system redesign to minimise hospital expenditures risk adversely affecting patient outcomes. The RN4CAST study was designed to inform decision making about nursing, one of the largest components of hospital operating expenses. We aimed to assess whether differences in patient to nurse ratios and nurses' educational qualifications in nine of the 12 RN4CAST countries with similar patient discharge data were associated with variation in hospital mortality after common surgical procedures.

METHODS

For this observational study, we obtained discharge data for 422,730 patients aged 50 years or older who underwent common surgeries in 300 hospitals in nine European countries. Administrative data were coded with a standard protocol (variants of the ninth or tenth versions of the International Classification of Diseases) to estimate 30 day in-hospital mortality by use of risk adjustment measures including age, sex, admission type, 43 dummy variables suggesting surgery type, and 17 dummy variables suggesting comorbidities present at admission. Surveys of 26,516 nurses practising in study hospitals were used to measure nurse staffing and nurse education. We used generalised estimating equations to assess the effects of nursing factors on the likelihood of surgical patients dying within 30 days of admission, before and after adjusting for other hospital and patient characteristics.

FINDINGS

An increase in a nurses' workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7% (odds ratio 1·068, 95% CI 1·031-1·106), and every 10% increase in bachelor's degree nurses was associated with a decrease in this likelihood by 7% (0·929, 0·886-0·973). These associations imply that patients in hospitals in which 60% of nurses had bachelor's degrees and nurses cared for an average of six patients would have almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor's degrees and nurses cared for an average of eight patients.

INTERPRETATION

Nurse staffing cuts to save money might adversely affect patient outcomes. An increased emphasis on bachelor's education for nurses could reduce preventable hospital deaths.

FUNDING

European Union's Seventh Framework Programme, National Institute of Nursing Research, National Institutes of Health, the Norwegian Nurses Organisation and the Norwegian Knowledge Centre for the Health Services, Swedish Association of Health Professionals, the regional agreement on medical training and clinical research between Stockholm County Council and Karolinska Institutet, Committee for Health and Caring Sciences and Strategic Research Program in Care Sciences at Karolinska Institutet, Spanish Ministry of Science and Innovation.

A multi-method study on the quality of the nurse work environment in acute-care hospitals: positioning Switzerland in the Magnet hospital research

BACKGROUND

Magnet hospitals share nurse work environment characteristics associated with superior patient, nurse and financial outcomes. In Switzerland, however, it is uncertain how nurses appraise their work environments.

OBJECTIVES

To describe the quality of the nurse work environment in 35 Swiss acute care hospitals and to benchmark findings based on international Magnet hospital research.

METHOD

This study used two data sources: (1) the Swiss arm of the RN4CAST study; and (2) a structured literature review. Hospitals were categorised based on Magnet and non-Magnet data. Our outcome variable of interest was the quality of nurse work environment measured with the Practice Environment Scale of the Nurse Work Index (PES-NWI).

RESULTS

We reviewed 13 American, Canadian, and Australian studies of acute-care hospitals. Three provided Magnet hospitals' nurse work environment data, and all included non-Magnet hospitals' data. Swiss hospitals' evaluations on nurse work environment quality varied widely, but 25% achieved scores indicating "Magnet nurse work environments". Swiss hospitals' average "Nursing manager ability" subscale scores fulfilled Magnet hospital criteria, although "Nurse participation in hospital affairs" and "Nursing staffing and resource adequacy" scores neared non-Magnet levels.

CONCLUSION

On average, our results indicated high quality nurse work environments in Swiss hospitals. Implementing Magnet model organisational principles might be a valuable approach for Swiss acute-care hospitals to both improve mixed and unfavourable nurse work environments and to improve nurse and patient outcomes. National benchmarking of nurse work environments and other nurse-sensitive indicators may facilitate evaluating the impact of current developments in Swiss healthcare.

Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States

OBJECTIVE

To determine whether hospitals with a good organisation of care (such as improved nurse staffing and work environments) can affect patient care and nurse workforce stability in European countries.

DESIGN

Cross sectional surveys of patients and nurses.

SETTING

Nurses were surveyed in general acute care hospitals (488 in 12 European countries; 617 in the United States); patients were surveyed in 210 European hospitals and 430 US hospitals.

PARTICIPANTS

33 659 nurses and 11 318 patients in Europe; 27 509 nurses and more than 120 000 patients in the US.

MAIN OUTCOME MEASURES

Nurse outcomes (hospital staffing, work environments, burnout, dissatisfaction, intention to leave job in the next year, patient safety, quality of care), patient outcomes (satisfaction overall and with nursing care, willingness to recommend hospitals).

RESULTS

The percentage of nurses reporting poor or fair quality of patient care varied substantially by country (from 11% (Ireland) to 47% (Greece)), as did rates for nurses who gave their hospital a poor or failing safety grade (4% (Switzerland) to 18% (Poland)). We found high rates of nurse burnout (10% (Netherlands) to 78% (Greece)), job dissatisfaction (11% (Netherlands) to 56% (Greece)), and intention to leave (14% (US) to 49% (Finland, Greece)). Patients' high ratings of their hospitals also varied considerably (35% (Spain) to 61% (Finland, Ireland)), as did rates of patients willing to recommend their hospital (53% (Greece) to 78% (Switzerland)). Improved work environments and reduced ratios of patients to nurses were associated with increased care quality and patient satisfaction. In European hospitals, after adjusting for hospital and nurse characteristics, nurses with better work environments were half as likely to report poor or fair care quality (adjusted odds ratio 0.56, 95% confidence interval 0.51 to 0.61) and give their hospitals poor or failing grades on patient safety (0.50, 0.44 to 0.56). Each additional patient per nurse increased the odds of nurses reporting poor or fair quality care (1.11, 1.07 to 1.15) and poor or failing safety grades (1.10, 1.05 to 1.16). Patients in hospitals with better work environments were more likely to rate their hospital highly (1.16, 1.03 to 1.32) and recommend their hospitals (1.20, 1.05 to 1.37), whereas those with higher ratios of patients to nurses were less likely to rate them highly (0.94, 0.91 to 0.97) or recommend them (0.95, 0.91 to 0.98). Results were similar in the US. Nurses and patients agreed on which hospitals provided good care and could be recommended.

CONCLUSIONS

Deficits in hospital care quality were common in all countries. Improvement of hospital work environments might be a relatively low cost strategy to improve safety and quality in hospital care and to increase patient satisfaction.

Nurse-reported patient safety climate in Swiss hospitals: a descriptive-explorative substudy of the Swiss RN4CAST study

QUESTIONS UNDER STUDY

Measuring the patient safety climate in the organisation of healthcare can help to identify problematic issues with a view to improving patient safety. We aimed (1) to describe the nurse-reported engagement in safety behaviours, (2) to describe the prevailing nurse-reported patient safety climate of general medical, surgical and mixed medical-surgical units in Swiss acute-care hospitals and (3) to explore differences between hospital type, unit type and language regions.

METHODS

This substudy utilised data from the nurse survey (N = 1,633) of the multicentre-cross sectional RN4CAST study. Patient safety climate was measured with the 9-item Safety Organizing Scale (SOS) which captured registered nurses' engagement in safety behaviours and practices at the unit level.

RESULTS

A total of 35 Swiss hospitals participated in the study. Of the 120 eligible units included in the analysis, only on 33 units (27.5%) did at least 60% of the nurses report a positive patient safety climate. A majority of nurses (51.2-63.4%, n = 1,564) reported that they were "consistently engaged" in only three of the nine measured patient safety behaviours. Our multilevel regression analyses revealed both significant between-unit and between-hospital variability. From our three variables of interest (hospital type, unit type and language regions) only language regions was consistently related to nurse-reported patient safety climate. Nurses in the German-speaking region reported a more positive patient safety climate than nurses in the French- and Italian-speaking language regions.

CONCLUSIONS

The findings of this study suggest a need to improve the patient safety climate on many units in Swiss hospitals. Leaders in hospitals should strengthen the patient safety climate at unit level by implementing methods, such as root cause analysis or patient safety leadership walk rounds, to improve individual and team skills and redesign work processes. The impact of these efforts should be measured by periodically assessing the patient safety climate with the SOS.

Meeting the challenges for gerontological nursing in Europe: The European Nursing Academy for Care of Older persons (ENACO)

In order to support the urgent need for proactive and targeted investments in care for older persons a group of geriatric nurse specialists from different European countries convened in Leuven (Belgium) in November 2002 to launch the European Nursing Academy for Care of Older persons (ENACO). The mission of ENACO is to enhance outcomes of older persons and their caregivers through strengthening gerontological clinical nursing care, education, research and health policy within an interdisciplinary context. Specific objectives of ENACO are: 1) providing up-to-date education and training by "teaching the teachers". More specifically, the target groups are master's prepared nurses specialized in gerontology who can contribute and guide the development of gerontological/geriatric nursing care in their own country; 2) developing a core curriculum for basic gerontological nursing education in Europe and; 3) developing an European network of gerontological nursing expertise. More specifically, a web page providing opportunities for interactive communication as well as a mentoring program will be developed for nurses interested in the deepening and fine-tuning of their professional experience in care for older persons. The fact that care for older persons is high on the European agenda, the collaboration with the European Academy for Medicine of Ageing (EAMA), and other professional organizations in Europe and other parts of the world, are promising elements in the development of ENACO.

[Prevention of falls in acute hospital care. Review of the literature]

Patient falls frequently occur in institutions of health care. Various occurrencies may cause patient falls; and sometimes have grave consequences for the people involved, affecting their quality of life. Falls often result in longer stays in hospital and/or in rehabilitation institutions. Hence patient security and prevention of falls become a quality factor for the health care professionals. The literature search on the subject of fall prevention in acute care from a nursing perspective encompasses the years 1988-1998 (MEDLINE, EMBASE). 21 articles were thoroughly examined. The prevention strategies are essentially based on risk assessment (guess of fall danger), intervention (preventive care measures) systematic reporting of the incidents of falls and their consequences. Introduction of the preventing programs and measures resulted in a considerable reduction of patient falls. The preventive measures focussed on reducing the risks of falling in everyday clinical life by increasing attention and presence of the staff caring for patients. The methods used were descriptive or exploratory. Despite plausible reports, connections between preventive measures and a reduced number of patient falls were not scientifically proven. Further investigations to the effectiveness of caring measures concerning fall prevention in acute care of experimental or quasi-experimental design are needed.

[Frequency and circumstances of falls in acute care hospitals: a pilot study]

Falls among (elderly) patients are common in institutional settings. Falls may lead to fright, pain, slight or severe injuries, they may increase the duration of the hospital stay, patient discomfort and affect the quality of life. We conducted a prospective study to evaluate the incidence of patient falls in a public hospital (300 beds) in the city of Zurich and to test a fall report form to assess patients after the event. 372 falls were reported during the 12 month evaluation period from 1996 to 1997 (6.7 falls per 1000 patient days) in 9 wards with 184 beds for patients requiring both acute care and/or longer term geriatric rehabilitation. 207 (56%) of the falls remained without detectable consequences, 6 (1.6%) of the patients suffered from serious (fracture), and 89 (24%) from slight injuries (contusions, abrasions, lacerations). Most of the falls (286) happened unattended in the patient rooms, 162 (44%) of the patients have been found disoriented, and only 60 (16%) were able to ambulate independently (without using a device or personal assistance). Almost 50% (182) of the falls occurred within ten days after admission. No peaks during the day in the time of falling were seen. The hospital management recommended the use of an official incident reporting from (fall-protocol) for all units since January 1998. The development of a hospital-wide fall prevention program is being prepared.

Effect of norepinephrine on ketogenesis, fatty acid oxidation, and esterification in isolated rat hepatocytes

Recent studies in man demonstrated a marked ketogenic effect of increased plasma norepinephrine concentrations as observed in diabetic ketoacidosis. Since this effect may have been due either to increased substrate supply for ketogenesis (lipolysis) or to direct hepatic activation of ketogenesis, the latter mechanism was examined in isolated rat hepatocytes. Incubation of hepatocytes with norepinephrine (10(-7) to 10(-4) M) resulted in a dose-dependent increase in conversion of the long-chain fatty acid [1-14C]palmitate into ketone bodies and CO2. Norepinephrine decreased [1-14C]palmitate conversion into triglycerides without affecting fatty acid uptake. Norepinephrine enhanced ketogenesis from [1-14C]palmitate in a physiologic range of fatty acid concentrations (0.5-2.5 mM), but failed to affect fatty acid esterification to phospholipids or mono- and diglycerides. In contrast to long-chain fatty acids, oxidation of the medium-chain fatty acid [1-14C]octanoate to ketone bodies was not enhanced by norepinephrine, whereas CO2 production increased. The effect of norepinephrine on [1-14C]fatty acid oxidation was blocked by the alpha 1 receptor blocker prazosin. The results demonstrate that norepinephrine diverts long-chain fatty acids into the pathways of oxidation and ketogenesis away from esterification, suggesting enhanced carnitine-dependent mitochondrial fatty acid uptake. The studies using octanoate indicated that norepinephrine also enhanced fatty acid oxidation by increasing the flux of acetyl-CoA through the Krebs cycle. The data suggest that stress-associated sympathetic activation and norepinephrine discharge, as observed in diabetic ketoacidosis, result in direct activation of ketogenesis in the liver.