Sean Clarke

Abstract

Aims and objectives: To explore how change-of-shift handoffs relate to nurses' clinical judgments regarding patient risk of deterioration. Background: The transfer of responsibility for patients' care comes with an exchange of information about their condition during change-of-shift handoff. However, it is unclear how this exchange affects nurses' clinical judgments regarding patient risk of deterioration. Design: A sequential explanatory mixed-methods study reported according to the STROBE and COREQ guidelines. Methods: Over four months, 62 nurses from one surgical and two medical units at a single Canadian hospital recorded their handoffs at change of shift. After each handoff, the two nurses involved each rated the patient's risk of experiencing cardiac arrest or being transferred to an intensive care unit in the next 24 hr separately. The information shared in handoffs was subjected to content analysis; code frequencies were contrasted per nurses' ratings of patient risk to identify characteristics of information that facilitated or hindered nurses' agreement. Results: Out of 444 recorded handoffs, there were 125 in which at least one nurse judged that a patient was at risk of deterioration; nurses agreed in 32 cases (25.6%) and disagreed in 93 (74.4%). These handoffs generally included information on abnormal vital signs, breathing problems, chest pain, alteration of mental status or neurological symptoms. However, the quantity and seriousness of clinical cues, recent transfers from intensive care units, pain without a clear cause, signs of delirium and nurses' knowledge of patient were found to affect nurses' agreement. Conclusions: Nurses exchanged more information regarding known indicators of deterioration in handoffs when they judged that patients were at risk. Disagreements most often involved incoming nurses rating patient risk as higher. Relevance to clinical practice: This study suggests a need to sensitise nurses to the impact of certain cues at report on their colleagues' subsequent clinical judgments. Low levels of agreement between nurses underscore the importance of exchanging impressions regarding the likely evolution of a patient's situation to promote continuity of care.

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Context: State scope of practice (SoP) laws impose significant restrictions on the services that a nurse practitioner (NP) may provide in some states, yet evidence about SoP limitations on the quality of primary care is very limited. Method: This study uses six different classifications of state regulations and bivariate and multivariate analyses to compare beneficiaries attributed to primary care nurse practitioners and primary care physicians in 2013 testing two hypotheses: (1) chronic disease management, cancer screening, preventable hospitalizations, and adverse outcomes of care provided by primary care nurse practitioners are better in reduced and restricted practice states compared to states without restrictions and (2) by decreasing access to care, SoP restrictions negatively affect the quality of primary care. Findings: Results show a lack of consistent association between quality of primary care provided by NPs and state SoP restrictions. Conclusion: State regulations restricting NP SoP do not improve the quality of care.

Abstract

Simulation followed by debriefing is increasingly common in clinical nursing education. Yet, limited studies have compared approaches to debriefing—the portion of simulations where participants re-examine and make sense of their experience. In this study, 120 baccalaureate nursing students in Quebec were randomized to receive one of two types of debriefing (self-assessment with Plus-Delta vs. guided reflection using a structured tool with REsPoND) after each of four simulations (a hemorrhage scenario, two sepsis scenarios, and a trauma simulation) during which their situation awareness was measured as a proxy for their clinical judgment. Unexpectedly, situation awareness scores showed little to no consistency across students or simulations and no clear improvements over time were noted, which rendered the comparison of the debriefing approaches across scenarios problematic. However, when comparing the two iterations of the sepsis scenario, students who participated in a reflective debriefing showed greater improvement in their recognition of abnormalities in patient vital signs and level of consciousness than students whose debriefing involved self-assessment.

Abstract

Background: The portability and multiple functionalities of mobile devices make them well suited for collecting field data for naturalistic research, which is often beset with complexities in recruitment and logistics. This paper describes the implementation of a research protocol using mobile devices to study nurses' exchanges of patient information at change of shift. Methods: Nurses from three medical and surgical units of an acute care teaching hospital in Montreal, Canada, were invited to participate. On 10 selected days, participants were asked to record their handoffs using mobile devices and to complete paper questionnaires regarding these exchanges. Nurse acceptance of mobile devices was assessed using a 30-item technology acceptance questionnaire and focus group interviews. The principal feasibility indicator was whether or not 80 complete handoffs could be collected on each unit. Results: From October to December 2017, 63 of 108 eligible nurses completed the study. Results suggest that the use of mobile devices was acceptable to nurses, who felt that the devices were easy to use but did not improve their job performance. The principal feasibility criterion was met, with complete data collected for 176, 84, and 170 of the eligible handoffs on each unit (81% of eligible handoffs). The research protocol was acceptable to nurses, who felt the study's demands did not interfere with their clinical work. Conclusions: The research protocol involving mobile devices was feasible and acceptable to nurses. Nurses felt the research protocol, including the use of mobile devices, required minimal investment of time and effort. This suggests that their decision to participate in research involving mobile devices was based on their perception that the study protocol and the use of the device would not be demanding. Further work is needed to determine if studies involving more sophisticated and possibly more demanding technology would be equally feasible and acceptable to nurses.

Abstract

Aims and objectives: To explore the impact of an initiative to add unregulated nursing support workers to wards in acute care hospitals. Background: Adding nursing support workers to existing nurse staffing may be one solution to reduce nursing workloads and improve outcomes. However, the effects of this addition on nurse, patient and system outcomes are not well documented. In one state of Australia, a trial deployment of nursing support workers to wards across the public health system provided opportunity for the exploration of their impact in a natural, real-world, environment. Design: Cross-sectional study. Methods: A sample of five wards where nursing support workers had been added matched to a group of five wards where there were no nursing support workers. Data were collected via patient survey (n = 141) and nurse survey (n = 154). Analysis was comparative with regression models constructed for the different ward types. Results: Nursing leadership, staffing and resources, and nurse experience were linked to outcomes on both ward types. Instability was a significant predictor of reduced quality of care and increased turnover intention on wards where support workers were added. Conclusion: Adding nursing support workers to ward staffing did not lead to improvements in patient care. Findings suggest that staffing a nursing ward is a complex activity and that a simple approach to staffing is unlikely to be successful. Future research should explore the process of implementation and the conditions under which this strategy is likely to be successful. Relevance to clinical practice: Ward-level factors are key in making appropriate staffing and skill mix choices to limit instability and to consequently avoid negative patient, staff and system outcomes. Consideration of the ward context, alongside effective delegation processes and integration into the care team are imperative when adding nursing support workers.

Abstract

In this chapter, the intuitive link between balanced, healthy, and supportive psychosocial work environments and a variety of vitally important patient, nurse, and organizational outcomes is discussed with reference to a number of clearly defined and well-researched concepts. Among the essential concepts that ground the rest of the book is the notion of a bundle of factors that provide a context for nurses' work and are known collectively as the practice environment. Landmark studies that focused specifically on nurses' experiences of their work environments in exemplary hospitals examined so-called Magnet hospitals, leading to a framework that describes the practice environment and its linkage with professional well-being, occupational stress, and quality of practice and productivity. Many ideas and models have obvious connections to the notion of practice environment such as Job Demand- Control-Support model, worklife dimensions and burnout, concepts related to burnout such as compassion fatigue, and work engagement as a mirror image concept of burnout, as well as notions of empowerment and authentic leadership. These concepts have been chosen for discussion here based on critical masses of evidence pointing to their usefulness in healthcare management and specifically in the management of nursing services. Together all of these concepts and supporting research and scholarship speak to a common point: intentional leadership approaches, grounded in a comprehensive understanding of nurses' psychosocial experiences of their work, are essential to nurses' abilities to respond to complex patients' needs in rapidly changing healthcare contexts and socioeconomic conditions.

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Background: Improving patient safety within health care organizations requires effective leadership at all levels. Purpose: The objective of this study was to investigate the effects of nurse managers’ transformational leadership behaviors on job satisfaction and patient safety outcomes. Methods: A random sample of acute care nurses in Ontario (N = 378) completed the crosssectional survey. Hypothesized model was tested using structural equation modeling. Finding: The model fit the data acceptably. Transformational leadership had a strong positive influence on workplace empowerment, which in turn increased nurses’ job satisfaction and decreased the frequency of adverse patient outcomes. Subsequently, job satisfaction was related to lower adverse events. Conclusion: The findings provide support for managers’ use of transformational leadership behaviors as a useful strategy in creating workplace conditions that promote better safety outcomes for patients and nurses.

Abstract

The concepts at the heart of this book originated more than 35 years ago and stemmed from repeated observations of a single troublesome phenomenon: cyclical nurse shortages in hospitals. Inquiries to deal with nurse workforce problems occurred alongside growing research findings suggesting that clinical nurses and other professionals were at risk of mutating from enthusiastic workers engaged with their clients to becoming emotionally drained, cynical, and insecure-the phenomenon known as burnout. The journey of this research field-reflected in the progression of the chapters in this book-has led to a variety of studies attempting to address both phenomena by focusing on the organizational contexts of nursing practice. Each of the chapters in this book offers findings and insights that we have synthesized into four recommendations for future steps in practice and another four recommendations for future steps in research. Connecting all of these recommendations is an emphasis on continuous improvement and change processes embedded in the organizational context of nursing practice, the need to draw on relevant empirical research, and the imperative for research and practice in this field to guide and inspire each other.

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