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ABSTRACT: Aims and objectives. To investigate the circumstances of nursing care eight hours before serious adverse events (=SAE's) on medical and surgical nursing units with subsequent in-hospital mortality in order to identify the extent to which these SAE's were potentially preventable. Background. The prevention of SAE 's in acute care is coming under increasing scrutiny, while the role nursing care plays in the prevention of acute critical deterioration of patients is unclear. Methods. Retrospective review of patient records of 63 SAE's in a Belgian teaching hospital where death was the final outcome following a cardiac arrest team call or unplanned ICU admission from an acute care unit. Data from chart reviews were combined with data regarding working conditions on the nursing unit at the time of the events and experts' opinions regarding the preventability of the outcomes. Finally, a pilot survey of staff nurses about their experiences with deteriorating patients and knowledge of vital signs and call criteria was conducted independently of the chart abstractions and case reviews. Results. Experts were almost five times more likely to designate a case as potentially preventable when a cardiac arrest team call was the terminal event and were 40% less likely to designate a case as potentially preventable when more observations were documented in patient records. Survey results revealed that nurses were often unaware that their patients were deteriorating before the crisis. Nurses also reported threshold levels for concern for abnormal vital signs that suggested they would call for assistance relatively late in clinical crises. Conclusion. Renewed attention to accurate recording, documentation and interpretation of vital signs in hospital nursing practice appears needed. Relevance to clinical practice. Timely detection of deteriorating patients to assist staff to improve their outcomes appears to be jeopardised by a number of practices and factors and merits deeper study.
Journal of Clinical Nursing 07/2012; · 1.12 Impact Factor
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ABSTRACT: To explore the relationship between inpatient mortality and implicit rationing of nursing care, the quality of nurse work environments and the patient-to-nurse staffing ratio in Swiss acute care hospitals.
Cross-sectional correlational design.
Eight Swiss acute care hospitals examined in a survey-based study and 71 comparison institutions.
A total of 165 862 discharge abstracts from patients treated in the 8 RICH Nursing Study (the Rationing of Nursing Care in Switzerland Study) hospitals and 760 608 discharge abstracts from patients treated in 71 Swiss acute care hospitals offering similar services and maintaining comparable patient volumes to the RICH Nursing hospitals.
The dependent variable was inpatient mortality. Logistic regression models were used to estimate the effects of the independent hospital-level measures.
Patients treated in the hospital with the highest rationing level were 51% more likely to die than those in peer institutions (adjusted OR: 1.51, 95% CI: 1.34-1.70). Patients treated in the study hospitals with higher nurse work environment quality ratings had a significantly lower likelihood of death (adjusted OR: 0.80, 95% CI: 0.67-0.97) and those treated in the hospital with the highest measured patient-to-nurse ratio (10:1) had a 37% higher risk of death (adjusted OR: 1.37, 95% CI: 1.24-1.52) than those in comparison institutions.
Measures of rationing may reflect care conditions that place hospital patients at risk of negative outcomes and thus deserve attention in future hospital outcomes research studies.
International Journal for Quality in Health Care 03/2012; 24(3):230-8. · 1.96 Impact Factor
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Evidence-based nursing 09/2011; 14(4):122-3.
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ABSTRACT: To examine attitudes towards research and perceived barriers and facilitators of research utilisation in clinical practice in a broad cross-section of Spanish nurses.
Nurses' attitudes towards research are critical in determining whether study findings are used to improve practice.
Cross-sectional comparative survey in Hospitals, Primary Care Centres and University-affiliated schools of nursing.
Surveys were completed by 917 nurses: 69 who received funding from the Spanish national agency (1998-2004) and a nationally representative sample of 848 nurses who did not have the same research experience (the Comparison group). Two instruments (BARRIERS and Attitudes towards nursing research) were translated and culturally adapted for use in Spain. A descriptive analysis of demographic and practice characteristics was performed. Total scale scores, as well as subscale scores, were computed and compared across the two groups using one-way analysis of variance (anova) and multivariate analysis of variance (manova) with post hoc tests. Pearson product-moment correlation coefficients were computed between the total tool scores and subscales measuring barriers and attitudes in both groups.
The investigators differed from other nurses on several demographic and work characteristics (more males, older age and more likely to work a fixed day shift schedule). On the whole, investigators showed more favourable attitudes but perceived several elements as posing greater barriers to research utilisation than the Comparison groups. Across all respondents, issues related to the quality of research were rated as the greatest barriers to research utilisation, followed by organisational barriers, barriers involving the communication of findings and finally, those related to nurses' values, awareness and skills.
Very similar profiles of perceptions and attitudes regarding research were found in these samples of Spanish nurses relative to those from other countries in earlier reports. Nurses who had experience conducting research demonstrated more favourable research-related attitudes and perceived barriers differently than those without such experience.
Understanding different organisational and experience perspectives is important to identify challenges and opportunities to ensure research utilisation in clinical practice.
Journal of Clinical Nursing 07/2011; 20(13-14):1936-47. · 1.12 Impact Factor
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ABSTRACT: Delirium affects approximately 20% to 25% of patients undergoing cardiac surgery and is particularly common in older adults. This article reviews the etiology and risk factors for delirium associated with cardiac surgery in older adults. Delirium screening, prevention, and treatment strategies, including both pharmacological and nonpharmacological therapies, are presented. Interventions appropriate in both the intensive care unit and
Journal of Gerontological Nursing 11/2010; 36(11):34-45. · 0.78 Impact Factor
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ABSTRACT: Delirium affects approximately 20% to 25% of patients undergoing cardiac surgery and is particularly common in older adults. This article reviews the etiology and risk factors for delirium associated with cardiac surgery in older adults. Delirium screening, prevention, and treatment strategies, including both pharmacological and nonpharamcological therapies, are presented. Interventions appropriate in both the intensive care unit and ward settings after cardiac surgery are outlined.
Journal of Gerontological Nursing 10/2010; · 0.78 Impact Factor
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ABSTRACT: To determine whether nurse staffing in California hospitals, where state-mandated minimum nurse-to-patient ratios are in effect, differs from two states without legislation and whether those differences are associated with nurse and patient outcomes.
Primary survey data from 22,336 hospital staff nurses in California, Pennsylvania, and New Jersey in 2006 and state hospital discharge databases.
Nurse workloads are compared across the three states and we examine how nurse and patient outcomes, including patient mortality and failure-to-rescue, are affected by the differences in nurse workloads across the hospitals in these states.
California hospital nurses cared for one less patient on average than nurses in the other states and two fewer patients on medical and surgical units. Lower ratios are associated with significantly lower mortality. When nurses' workloads were in line with California-mandated ratios in all three states, nurses' burnout and job dissatisfaction were lower, and nurses reported consistently better quality of care.
Hospital nurse staffing ratios mandated in California are associated with lower mortality and nurse outcomes predictive of better nurse retention in California and in other states where they occur.
Health Services Research 08/2010; 45(4):904-21. · 2.16 Impact Factor
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ABSTRACT: We explored the relationship between nurse burnout and ratings of quality of care in 53,846 nurses from six countries. In this secondary analysis, we used data from the International Hospital Outcomes Study; data were collected from 1998 to 2005. The Maslach Burnout Inventory and a single-item reflecting nurse-rated quality of care were used in multiple logistic regression modeling to investigate the association between nurse burnout and nurse-rated quality of care. Across countries, higher levels of burnout were associated with lower ratings of the quality of care independent of nurses' ratings of practice environments. These findings suggest that reducing nurse burnout may be an effective strategy for improving nurse-rated quality of care in hospitals.
Research in Nursing & Health 08/2010; 33(4):288-98. · 1.71 Impact Factor
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The American journal of nursing 05/2010; 110(5):11. · 0.69 Impact Factor
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ABSTRACT: We studied the relationship between registered nurses' extended work duration with adverse events and errors, including needlestick injuries, work-related injuries, patient falls with injury, nosocomial infections, and medication errors.
Using bivariate and multivariate logistic regression, this secondary analysis of 11,516 registered nurses examined nurse characteristics, work hours, and adverse events and errors.
All of the adverse event and error variables were significantly related to working more than 40 hours in the average week. Medication errors and needlestick injuries had the strongest and most consistent relationships with the work hour and voluntary overtime variables.
This study confirms prior findings that increased work hours raise the likelihood of adverse events and errors in healthcare, and further found the same relationship with voluntary overtime.
Legislation has focused on mandatory overtime; however, this study demonstrated that voluntary overtime could also negatively impact nurse and patient safety.
Journal of safety research 04/2010; 41(2):153-62. · 1.34 Impact Factor
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International journal of nursing studies 08/2009; 46(7):875-8. · 1.91 Impact Factor
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ABSTRACT: Studies have linked nurse staffing levels (number and skill mix) to several nurse-sensitive patient outcomes. However, evidence from European countries has been limited.
This study examines the association between nurse staffing levels (i.e. acuity-adjusted Nursing Hours per Patient Day, the proportion of registered nurses with a Bachelor's degree) and 10 different patient outcomes potentially sensitive to nursing care. DESIGN-SETTING-PARTICIPANTS: Cross-sectional analyses of linked data from the Belgian Nursing Minimum Dataset (general acute care and intensive care nursing units: n=1403) and Belgian Hospital Discharge Dataset (general, orthopedic and vascular surgery patients: n=260,923) of the year 2003 from all acute hospitals (n=115).
Logistic regression analyses, estimated by using a Generalized Estimation Equation Model, were used to study the association between nurse staffing and patient outcomes.
The mean acuity-adjusted Nursing Hours per Patient Day in Belgian hospitals was 2.62 (S.D.=0.29). The variability in patient outcome rates between hospitals is considerable. The inter-quartile ranges for the 10 patient outcomes go from 0.35 for Deep Venous Thrombosis to 3.77 for failure-to-rescue. No significant association was found between the acuity-adjusted Nursing Hours per Patient Day, proportion of registered nurses with a Bachelor's degree and the selected patient outcomes.
The absence of associations between hospital-level nurse staffing measures and patient outcomes should not be inferred as implying that nurse staffing does not have an impact on patient outcomes in Belgian hospitals. To better understand the dynamics of the nurse staffing and patient outcomes relationship in acute hospitals, further analyses (i.e. nursing unit level analyses) of these and other outcomes are recommended, in addition to inclusion of other study variables, including data about nursing practice environments in hospitals.
International journal of nursing studies 07/2009; 46(7):928-39. · 1.91 Impact Factor
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Sean P Clarke
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ABSTRACT: Conducting research on nurse staffing and outcomes is very challenging, and the application of staffing-outcomes research in practice is both fraught with controversy and vitally important for the safety of our patients and the future of the profession. As I stand back and think about being involved in staffing-outcomes research for nearly a decade and sharing many of my thoughts about this rapidly growing literature in reviews and commentaries in print, certain metaphors for trends in this field come to mind. I won't claim originality for the insights that follow or attempt to thoroughly trace the genealogy of the stories and metaphors here, but offer them to provide what I hope is a fresh perspective to material that I and many of my colleagues have visited and revisited on numerous occasions.
Journal of Nursing Management 04/2009; 17(2):151-4. · 1.18 Impact Factor
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ABSTRACT: In light of evidence linking registered nurse (RN) staffing levels to patient outcomes in chronic hemodialysis facilities, U.S. government regulations have set minimum RN staffing requirements during dialysis. Consequently, facility administrators are focused on decreasing nurse attrition in this crucial practice setting. This study used a cross-sectional, correlational design to investigate the effects of workload, practice environment, and care processes on burnout among nurses in U.S. chronic hemodialysis centers and to determine the association between burnout and nurses' intentions to leave their jobs. Findings indicate that predictors were associated with an increased likelihood of nurse burnout and that nurses experiencing burnout were more likely to be planning to leave their jobs. Findings have important implications for retention of nurses, enhancement of patient safety, and adherence to new federal staffing requirements in chronic hemodialysis units.
Western Journal of Nursing Research 04/2009; 31(5):569-82. · 1.19 Impact Factor
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ABSTRACT: In most multicenter studies that examine the relationship between nurse staffing and patient safety, nurse-staffing levels are measured per hospital. This can obscure relationships between staffing and outcomes at the unit level and lead to invalid inferences.
In the present study, we examined the association between nurse-staffing levels in nursing units that treat postoperative cardiac surgery patients and the in-hospital mortality of these patients. DESIGN-SETTING-PARTICIPANTS: We illustrated our approach by using administrative databases (Year 2003) representing all Belgian cardiac centers (n=28), which included data from 58 intensive care and 75 general nursing units and 9054 patients.
We used multilevel logistic regression models and controlled for differences in patient characteristics, nursing care intensity, and cardiac procedural volume.
Increased nurse staffing in postoperative general nursing units was significantly associated with decreased mortality. Nurse staffing in postoperative intensive care units was not significantly associated with in-hospital mortality possibly due to lack of variation in ICU staffing across hospitals.
This study, together with the international body of evidence, suggests that nurse staffing is one of several variables influencing patient safety. These findings further suggest the need to study the impact of nurse-staffing levels on in-hospital mortality using nursing-unit-level specific data.
International journal of nursing studies 03/2009; 46(6):796-803. · 1.91 Impact Factor
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ABSTRACT: In the Rationing of Nursing Care in Switzerland Study, implicit rationing of care was the only factor consistently significantly associated with all six studied patient outcomes. These results highlight the importance of rationing as a new system factor regarding patient safety and quality of care. Since at least some rationing of care appears inevitable, it is important to identify the thresholds of its influences in order to minimize its negative effects on patient outcomes.
To describe the levels of implicit rationing of nursing care in a sample of Swiss acute care hospitals and to identify clinically meaningful thresholds of rationing.
Descriptive cross-sectional multi-center study.
Five Swiss-German and three Swiss-French acute care hospitals.
1338 nurses and 779 patients.
Implicit rationing of nursing care was measured using the newly developed Basel Extent of Rationing of Nursing Care (BERNCA) instrument. Other variables were measured using survey items from the International Hospital Outcomes Study battery. Data were summarized using appropriate descriptive measures, and logistic regression models were used to define a clinically meaningful rationing threshold level.
For the studied patient outcomes, identified rationing threshold levels varied from 0.5 (i.e., between 0 ('never') and 1 ('rarely') to 2 ('sometimes')). Three of the identified patient outcomes (nosocomial infections, pressure ulcers, and patient satisfaction) were particularly sensitive to rationing, showing negative consequences anywhere it was consistently reported (i.e., average BERNCA scores of 0.5 or above). In other cases, increases in negative outcomes were first observed from the level of 1 (average ratings of rarely).
Rationing scores generated using the BERNCA instrument provide a clinically meaningful method for tracking the correlates of low resources or difficulties in resource allocation on patient outcomes. Thresholds identified here provide parameters for administrators to respond to whenever rationing reports exceed the determined level of '0.5' or '1'. Since even very low levels of rationing had negative consequences on three of the six studied outcomes, it is advisable to treat consistent evidence of any rationing as a significant threat to patient safety and quality of care.
International journal of nursing studies 01/2009; 46(7):884-93. · 1.91 Impact Factor
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ABSTRACT: To describe the origins, design and outcomes of an international hospital outcomes collaboration focused on nursing issues.
Across countries with different cultures and histories, nursing and healthcare leaders face similar issues with respect to workforce supply, quality and safety of care and financial constraints. Until researchers began using common research protocols to investigate structure, and outcomes variables in hospital nursing across countries, studying the aspects of work environments most important to patients and nurses in large numbers of hospitals was very difficult, if not impossible.
Review/essay.
The international collaborations discussed in this article led by the University of Pennsylvania have found remarkable similarities in the experiences of hospital nurses across countries in terms of positive and negative aspects of their work, sizeable differences across hospitals within countries in working conditions and investments in high-quality practice environments, and consistent evidence of connections between modifiable features of nurses' work environments and both patient well-being and factors influencing workforce stability.
International research collaborations allow benchmarking of countries and facilities within countries on work environment factors that are important to the provision of high quality nursing care. Results of this ongoing research initiative have helped strengthen the case that optimal management of practice environments for nurses in hospitals and other settings are a key strategy for optimising patient outcomes.
Journal of Clinical Nursing 01/2009; 17(24):3317-23. · 1.12 Impact Factor
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Sean P Clarke
The Pennsylvania nurse 01/2009; 63(4):8-9.
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ABSTRACT: To explore the association between implicit rationing of nursing care and selected patient outcomes in Swiss hospitals, adjusting for major organizational variables, including the quality of the nurse practice environment and the level of nurse staffing. Rationing was measured using the newly developed Basel Extent of Rationing of Nursing Care (BERNCA) instrument. Additional data were collected using an adapted version of the International Hospital Outcomes Study questionnaire.
Multi-hospital cross-sectional surveys of patients and nurses.
Eight Swiss acute care hospitals
Nurses (1338) and patients (779) on 118 medical, surgical and gynecological units.
Patient satisfaction, nurse-reported medication errors, patient falls, nosocomial infections, pressure ulcers and critical incidents involving patients over the previous year.
Generally, nurses reported rarely having omitted any of the 20 nursing tasks listed in the BERNCA over their last 7 working days. However, despite relatively low levels, implicit rationing of nursing care was a significant predictor of all six patient outcomes studied. Although the adequacy of nursing resources was a significant predictor for most of the patient outcomes in unadjusted models, it was not an independent predictor in the adjusted models. Low nursing resource adequacy ratings were a significant predictor for five of the six patient outcomes in the unadjusted models, but not in the adjusted ones.
As a system factor in acute general hospitals, implicit rationing of nursing care is an important new predictor of patient outcomes and merits further study.
International Journal for Quality in Health Care 08/2008; 20(4):227-37. · 1.96 Impact Factor
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ABSTRACT: Whether it's already touching your facility or its impact is still to come, this crisis will test your skills as a manager. Understanding what's driving the shortage and what's predicted will help you choose the best strategies for addressing its causes and dealing with its consequences.
Nursing Management (Springhouse) 04/2008; 39(3):22-7; quiz 28.
