Nursing care left undone in psychiatric hospitals and its association with nurse staffing: A cross-sectional multi-centre study in Switzerland

INTRODUCTION

Nursing care left undone occurs when nurses omit activities because of resource shortfalls. Higher levels of nursing care left undone are associated with worse nurse staffing and organizational factors. Plentiful evidence from acute, long-term and community care supports such associations; however, mental healthcare settings are under-studied.

AIM

The aim of the study was to describe nursing care left undone's frequency in mental health inpatient settings and explore its association with nurse staffing levels.

METHOD

As part of the multi-centre cross-sectional MatchRN Psychiatry study, data were collected by questionnaire from 114 units in 13 Swiss psychiatric hospitals. Nursing care left undone was analysed describing frequencies descriptively and used linear mixed models to assess its association with staffing.

RESULTS

Data from 994 nurses were analysed. The most commonly omitted activities were evaluating nursing processes (30.5%), formulating nursing diagnoses (27.4%) and defining care objectives (22.7%). Nursing care left undone was higher in units with low staffing levels.

DISCUSSION

As in somatic care settings, in psychiatric hospitals, 'indirect' care activities are most commonly omitted.

IMPLICATIONS FOR PRACTICE

This study highlights factors affecting the frequency of nursing care left undone, including staffing levels and perceived leadership. The findings emphasize the importance of nurse managers taking action to improve work environment factors.

Setting new priorities for nursing research: The updated Swiss Nursing Research Agenda-a systematic, participative approach

AIM

To identify current key areas for nursing research in Switzerland, we revised the Swiss Research Agenda for Nursing (SRAN) initially published in 2008.

BACKGROUND

By developing a research agenda, nursing researchers internationally prioritize and cluster relevant topics within the research community. The process should be collaborative and systematic to provide credible information for decisionmakers in health care research, policy, and practice.

SOURCES OF EVIDENCE

After a participative, systematic, and critical evaluation within and outside of the Swiss Association for Nursing Science, the updated SRAN 2019-2029 defines four research priorities (new models of care, nursing care interventions, work and care environment, and quality of care and patient safety) and four transversal themes (organization of research, research methodologies, research in health care policy and public health perspectives).

CONCLUSION

Adding to other national nursing research agendas, the categories are organized in a framework of key research priorities and transversal themes. They relate to the importance of global and local foci of research as well as challenges in health care services and policy systems. The agenda is an important prerequisite for enhancing the influence of nursing research in Switzerland and provides guidance for the next decade.

IMPLICATIONS FOR NURSING PRACTICE

The revised agenda ensures that research projects target key knowledge gaps and the discipline's core questions in respective countries.

IMPLICATIONS FOR HEALTH POLICY

Nursing research should inform and influence health policy on all institutional and political levels. Therefore, the integration of public health perspectives in research is one of the most important new aspects of SRAN 2019-2029.

Work-schedule management in psychiatric hospitals and its associations with nurses' emotional exhaustion and intention to leave: A cross-sectional multicenter study

BACKGROUND

Managing nurses' work schedules in hospitals is challenging because employer needs, like shift changes at short notice and overtime, may conflict with nurses' desires for a predictable and stable schedule. Nurses should have a certain degree of control over their work schedules, and their supervisors should support their needs in scheduling. How perceived control over work schedules, perceived support from supervisors in scheduling, shift changes at short notice, and overtime affect nurses' emotional exhaustion and intentions to leave has not been studied.

OBJECTIVES

The aims are (1) to describe perceived control, perceived supervisor support, shift changes at short notice, and overtime among nurses in psychiatric hospitals; (2) to assess the variation of these four factors between units at psychiatric hospitals; and (3) to investigate the association between these factors with nurses' emotional exhaustion and intentions to leave.

DESIGN

Cross-sectional survey study.

SETTING(S)

Swiss psychiatric hospitals with 24-hour services.

PARTICIPANTS

Registered nurses (N = 994) from 114 adult-inpatient units.

METHODS

To describe perceived control, perceived supervisor support, shift changes at short notice, and overtime among nurses, we calculated frequencies, percentages, means, and standard deviations of their responses to the survey. To assess the variation between units, we computed intraclass correlations for the four factors. We constructed random-effects models accounting for the clustering of nurses in units for emotional exhaustion and intentions to leave separately.

RESULTS

Perception of work-schedule control was 3.32 (SD 1.39, range 0-5); perception of supervisor work-schedule support was 3.28 (SD 1.14, range 0-4). On average, 9 % of the nurses had to take over a shift at short notice at least three times per month, and 40 % worked at least 15 minute overtime on their most recent shift. Intraclass correlation for all four factors was higher than 0.05. Emotional exhaustion was significantly associated with supervisor support and overtime, and leaving intentions were significantly associated with perceived control, supervisor support and overtime.

CONCLUSION

Perceived control, perceived supervisor support, shift changes at short notice, and overtime are promising factors for interventions to prevent nurses' emotional exhaustion and allay their intentions to leave. Unit managers should provide nurses with increased predictability and influence on their work schedules. This could reduce early career endings and early retirement and counteract nurse shortages.

Implementation fidelity of a multifactorial in-hospital fall prevention program and its association with unit systems factors: a single center, cross-sectional study

BACKGROUND

Falls are a common, costly global public health burden. In hospitals, multifactorial fall prevention programs have proved effective in reducing falls' incidence; however, translating those programs accurately into daily clinical practice remains challenging. This study's aim was to identify ward-level system factors associated with implementation fidelity to a multifactorial fall prevention program (StuPA) targeting hospitalized adult patients in an acute care setting.

METHODS

This retrospective cross-sectional study used administrative data on 11,827 patients admitted between July and December 2019 to 19 acute care wards at the University Hospital Basel, Switzerland, as well as data on the StuPA implementation evaluation survey conducted in April 2019. Data were analysed using descriptive statistics, Pearson's coefficients and linear regression modelling for variables of interest.

RESULTS

The patient sample had an average age of 68 years and a median length of stay of 8.4 (IQR: 2.1) days. The mean care dependency score was 35.4 points (ePA-AC scale: from 10 points (totally dependent) to 40 points (totally independent)); the mean number of transfers per patient -(e.g., change of room, admission, discharge) was 2.6 (range: 2.4- 2.8). Overall, 336 patients (2.8%) experienced at least one fall, resulting in a rate of 5.1 falls per 1'000 patient days. The median inter-ward StuPA implementation fidelity was 80.6% (range: 63.9-91.7%). We found the mean number of inpatient transfers during hospitalisation and the mean ward-level patient care dependency to be statistically significant predictors of StuPA implementation fidelity.

CONCLUSION

Wards with higher care dependency and patient transfer levels showed higher implementation fidelity to the fall prevention program. Therefore, we assume that patients with the highest fall prevention needs received greater exposure to the program. For the StuPA fall prevention program, our results suggest a need for implementation strategies contextually adapted to the specific characteristics of the target wards and patients.

Addressing Patient Safety Hazards Using Critical Incident Reporting in Hospitals: A Systematic Review

INTRODUCTION

Critical incident reporting systems (CIRS) are in use worldwide. They are designed to improve patient care by detecting and analyzing critical and adverse patient events and by taking corrective actions to prevent reoccurrence. Critical incident reporting systems have recently been criticized for their lack of effectiveness in achieving actual patient safety improvements. However, no overview yet exists of the reported incidents' characteristics, their communication within institutions, or actions taken either to correct them or to prevent their recurrence. Our main goals were to systematically describe the reported CIRS events and to assess the actions taken and their learning effects. In this systematic review of studies based on CIRS data, we analyzed the main types of critical incidents (CIs), the severity of their consequences, their contributing factors, and any reported corrective actions.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we queried MEDLINE, Embase, CINAHL, and Scopus for publications on hospital-based CIRS. We classified the consequences of the incidents according to the National Coordinating Council for Medication Error Reporting and Prevention index, the contributing factors according to the Yorkshire Contributory Factors Framework and the Human Factors Classification Framework, and all corrective actions taken according to an action hierarchy model on intervention strengths.

RESULTS

We reviewed 41 studies, which covered 479,483 CI reports from 212 hospitals in 17 countries. The most frequent type of incident was medication related (28.8%); the most frequent contributing factor was labeled "active failure" within health care provision (26.1%). Of all professions, nurses submitted the largest percentage (83.7%) of CI reports. Actions taken to prevent future CIs were described in 15 studies (36.6%). Overall, the analyzed studies varied considerably regarding methodology and focus.

CONCLUSIONS

This review of studies from hospital-based CIRS provides an overview of reported CIs' contributing factors, characteristics, and consequences, as well as of the actions taken to prevent their recurrence. Because only 1 in 3 studies reported on corrective actions within the healthcare facilities, more emphasis on such actions and learnings from CIRS is required. However, incomplete or fragmented reporting and communication cycles may additionally limit the potential value of CIRS. To make a CIRS a useful tool for improving patient safety, the focus must be put on its strength of providing new qualitative insights in unknown hazards and also on the development of tools to facilitate nomenclature and management CIRS events, including corrective actions in a more standardized manner.

The effect of time-varying capacity utilization on 14-day in-hospital mortality: a retrospective longitudinal study in Swiss general hospitals

BACKGROUND

High bed-occupancy (capacity utilization) rates are commonly thought to increase in-hospital mortality; however, little evidence supports a causal relationship between the two. This observational study aimed to assess three time-varying covariates-capacity utilization, patient turnover and clinical complexity level- and to estimate causal effect of time-varying high capacity utilization on 14 day in-hospital mortality.

METHODS

This retrospective population-based analysis was based on routine administrative data (n = 1,152,506 inpatient cases) of 102 Swiss general hospitals. Considering the longitudinal nature of the problem from available literature and expert knowledge, we represented the underlying data generating mechanism as a directed acyclic graph. To adjust for patient turnover and patient clinical complexity levels as time-varying confounders, we fitted a marginal structure model (MSM) that used inverse probability of treatment weights (IPTWs) for high and low capacity utilization. We also adjusted for patient age and sex, weekdays-vs-weekend, comorbidity weight, and hospital type.

RESULTS

For each participating hospital, our analyses evaluated the ≥85th percentile as a threshold for high capacity utilization for the higher risk of mortality. The mean bed-occupancy threshold was 83.1% (SD 8.6) across hospitals and ranged from 42.1 to 95.9% between hospitals. For each additional day of exposure to high capacity utilization, our MSM incorporating IPTWs showed a 2% increase in the odds of 14-day in-hospital mortality (OR 1.02, 95% CI: 1.01 to 1.03).

CONCLUSIONS

Exposure to high capacity utilization increases the mortality risk of inpatients. Accurate monitoring of capacity utilization and flexible human resource planning are key strategies for hospitals to lower the exposure to high capacity utilization.

Variation in detected adverse events using trigger tools: A systematic review and meta-analysis

Background

Adverse event (AE) detection is a major patient safety priority. However, despite extensive research on AEs, reported incidence rates vary widely.

Objective

This study aimed: (1) to synthesize available evidence on AE incidence in acute care inpatient settings using Trigger Tool methodology; and (2) to explore whether study characteristics and study quality explain variations in reported AE incidence.

Design

Systematic review and meta-analysis.

Methods

To identify relevant studies, we queried PubMed, EMBASE, CINAHL, Cochrane Library and three journals in the patient safety field (last update search 25.05.2022). Eligible publications fulfilled the following criteria: adult inpatient samples; acute care hospital settings; Trigger Tool methodology; focus on specialty of internal medicine, surgery or oncology; published in English, French, German, Italian or Spanish. Systematic reviews and studies addressing adverse drug events or exclusively deceased patients were excluded. Risk of bias was assessed using an adapted version of the Quality Assessment Tool for Diagnostic Accuracy Studies 2. Our main outcome of interest was AEs per 100 admissions. We assessed nine study characteristics plus study quality as potential sources of variation using random regression models. We received no funding and did not register this review.

Results

Screening 6,685 publications yielded 54 eligible studies covering 194,470 admissions. The cumulative AE incidence was 30.0 per 100 admissions (95% CI 23.9–37.5; I² = 99.7%) and between study heterogeneity was high with a prediction interval of 5.4–164.7. Overall studies’ risk of bias and applicability-related concerns were rated as low. Eight out of nine methodological study characteristics did explain some variation of reported AE rates, such as patient age and type of hospital. Also, study quality did explain variation.

Conclusion

Estimates of AE studies using trigger tool methodology vary while explaining variation is seriously hampered by the low standards of reporting such as the timeframe of AE detection. Specific reporting guidelines for studies using retrospective medical record review methodology are necessary to strengthen the current evidence base and to help explain between study variation.

Occurrence of No-Harm Incidents and Adverse Events in Hospitalized Patients with Ischemic Stroke or TIA: A Cohort Study Using Trigger Tool Methodology

Adverse events (AEs)—healthcare caused events leading to patient harm or even death—are common in healthcare. Although it is a frequently investigated topic, systematic knowledge on this phenomenon in stroke patients is limited. To determine cumulative incidence of no-harm incidents and AEs, including their severity and preventability, a cohort study using trigger tool methodology for retrospective record review was designed. The study was carried out in a stroke center at a university hospital in the German speaking part of Switzerland. Electronic records from 150 randomly selected patient admissions for transient ischemic attack (TIA) or ischemic stroke, with or without acute recanalization therapy, were used. In total, 170 events (108 AEs and 62 no-harm incidents) were identified, affecting 83 patients (55.3%; 95% CI 47 to 63.4), corresponding to an event rate of 113 events/100 admissions or 142 events/1000 patient days. The three most frequent AEs were ischemic strokes (n = 12, 7.1%), urinary tract infections (n = 11, 6.5%) and phlebitis (n = 10, 5.9%). The most frequent no-harm incidents were medication events (n = 37, 21.8%). Preventability ranged from 12.5% for allergic reactions to 100% for medication events and pressure ulcers. Most of the events found (142; 83.5%; 95% CI 76.9 to 88.6) occurred throughout the whole stroke care. The remaining 28 events (16.5%; 95% CI 11.4 to 23.1) were detected during stroke care but were related to care outside the stroke pathway. Trigger tool methodology allows detection of AEs and no-harm incidents, showing a frequent occurrence of both event types in stroke and TIA patients. Further investigations into events’ relationships with organizational systems and processes will be needed, first to achieve a better understanding of these events’ underlying mechanisms and risk factors, then to determine efforts needed to improve patient safety.

Development and Implementation of an e-Trigger Tool for Adverse Drug Events in a Swiss University Hospital

PURPOSE

The purpose of the study was to develop and implement an institution-specific trigger tool based on the Institute for Healthcare Improvement medication module trigger tool (IHI MMTT) in order to detect and monitor ADEs.

METHODS

We performed an investigator-driven, single-center study using retrospective and prospective patient data to develop ("development phase") and implement ("implementation phase") an efficient, institution-specific trigger tool based on the IHI MMTT. Complete medical data from 1008 patients hospitalized in 2018 were used in the development phase. ADEs were identified by chart review. The performance of two versions of the tool was assessed by comparing their sensitivities and specificities. Tool A employed only digitally extracted triggers ("e-trigger-tool") while Tool B employed an additional manually extracted trigger. The superior tool - taking efficiency into account - was applied prospectively to 19-22 randomly chosen charts per month for 26 months during the implementation phase.

RESULTS

In the development phase, 189 (19%) patients had ≥1 ADE (total 277 ADEs). The time needed to identify these ADEs was 15 minutes/chart. A total of 203 patients had ≥1 trigger (total 273 triggers - Tool B). The sensitivities and specificities of Tools A and B were 0.41 and 0.86, and 0.43 and 0.86, respectively. Tool A was more time-efficient than Tool B (4 vs 9 minutes/chart) and was therefore used in the implementation phase. During the 26-month implementation phase, 22 patients experienced trigger-identified ADEs and 529 did not. The median number of ADEs per 1000 patient days was 6 (range 0-13). Patients with at least one ADE had a mean hospital stay of 22.3 ± 19.7 days, compared to 8.0 ± 7.6 days for those without an ADE (p = 2.7×10-14).

CONCLUSION

We developed and implemented an e-trigger tool that was specific and moderately sensitive, gave consistent results and required minimal resources.

Critical incident reporting over time: a retrospective, descriptive analysis of 5493 cases

PURPOSE

As recommended by the WHO and many national healthcare authorities, health care institutions of most industrialised countries have employed a critical incident reporting system (CIRS). However, little is known about differences in critical incidents across clinical specialties, the use of CIRSs amongst different professional groups, the types, severity and risk of reoccurrence of critical incidents, their contributing factors and the preventive actions taken in response.

METHODS

In this retrospective, descriptive study we critically reviewed all reports filed in the CIRS of our institution between 2013 and 2019 and analysed characteristics over time.

RESULTS

Of the 5493 analysed incidents, the main types were related to medications (32.8%), clinical procedures (32.6%) or behaviour of employees (23.3%). Only 21.6% of reports were made by physicians, 51.3% were rated at least "high risk". Major contributing factors were personal factors (44.0%), lack of training and knowledge (43.7%) and communication errors (36.1%). Most actions taken to prevent similar events aimed at improving communications (23.6%); in 46.3% no actions whatsoever were taken. Longitudinal analysis revealed that reporting increased in internal medicine and obstetrics but collapsed in laboratory medicine / microbiology. Steady increases in medication-type incidents as well as lack of training and knowledge as contributing factors were observed.

CONCLUSION

This study revealed that the efferent loop (feedback, preventive actions taken) was the weakest part of the CIRS in our institution, indicating that no learning may have resulted from a large number of reports. In particular, the actions taken appeared to not adequately address the major contributing factors. This highlights that special attention must be paid to the efferent loop of a CIRS to fulfil the purpose of such a reporting system and ultimately to improve patient safety.

A Transactional "Second-Victim" Model-Experiences of Affected Healthcare Professionals in Acute-Somatic Inpatient Settings: A Qualitative Metasynthesis

BACKGROUND

"Second victims" are healthcare professionals traumatized by involvement in significant adverse events. Associated burdens, e.g., guilt, can impair professional performance, thereby endangering patient safety. To date, however, a model of second victims' experiences toward a deeper understanding of qualitative studies is missing. Therefore, we aimed to identify, describe, and interpret these experiences in acute-somatic inpatient settings.

METHODS

This qualitative metasynthesis reflects a systematic literature search of PubMed, CINAHL, and PsycINFO, extended by hand searches and expert consultations. Two researchers independently evaluated qualitative studies in German and English, assessing study quality via internationally approved criteria. Results were analyzed inductively and aggregated quantitatively.

RESULTS

Based on 19 qualitative studies (explorative-descriptive: n = 13; grounded theory: n = 3; phenomenology: n = 3), a model of second-victim experience was drafted. This depicts a multistage developmental process: in appraising their situation, second victims focus on their involvement in an adverse event, and they become traumatized. To restore their integrity, they attempt to understand the event and to act accordingly; however, their reactions are commonly emotional and issue focused. Outcomes include leaving the profession, surviving, or thriving. This development process is alternately modulated by safety culture and healthcare professionals.

CONCLUSIONS

For the first time, this model works systematically from the second-victim perspective based on qualitative studies. Based on our findings, we recommend integrating second victims' experiences into safety culture and root-cause analyses. Our transactional model of second-victim experience provides a foundation for strategies to maintain and improve patient safety.

Changes in Safety and Teamwork Climate After Adding Structured Observations to Patient Safety WalkRounds

BACKGROUND

Patient safety is essential for the reliable delivery of health care. One way to positively influence patient safety is to improve the safety and teamwork climate of a clinical area. Research shows that patient safety WalkRounds (WRs) are an appropriate and common method to improve safety culture. The aim of this study was to combine WRs with observations of specific patient safety dimensions and to measure the safety and teamwork climate.

METHODS

In this observational study, WRs took place in eight work settings across a 770-bed university hospital in Switzerland. During rounds, health care workers (HCWs) were observed in relation to defined patient safety dimensions. In addition, HCWs were surveyed using safety and teamwork climate scales before the initial WRs and six to nine months later, and implementation of planned improvement actions following the WRs was evaluated.

RESULTS

During WRs, 810 activities of HCWs were observed, of which 85.4% met the requirements for safe care. Safety and teamwork climate did not change significantly after nine months. A total of 36 action plan items were planned to address safety deficits that surfaced during WRs, but only 40.7% of the action items had been implemented after nine months.

CONCLUSION

WRs with structured in-person observations identified safe care practices and deficits in patient safety. Improvement action plans to address safety deficits were not fully implemented nine months later, and there were no significant changes in the safety and teamwork climate at that time.

Variation of Daily Care Demand in Swiss General Hospitals: Longitudinal Study on Capacity Utilization, Patient Turnover and Clinical Complexity Levels

Background

Variations in hospitals’ care demand relies not only on the patient volume but also on the disease severity. Understanding both daily severity and patient volume in hospitals could help to identify hospital pressure zones to improve hospital-capacity planning and policy-making.

Objective

This longitudinal study explored daily care demand dynamics in Swiss general hospitals for 3 measures: (1) capacity utilization, (2) patient turnover, and (3) patient clinical complexity level.

Methods

A retrospective population-based analysis was conducted with 1 year of routine data of 1.2 million inpatients from 102 Swiss general hospitals. Capacity utilization was measured as a percentage of the daily maximum number of inpatients. Patient turnover was measured as a percentage of the daily sum of admissions and discharges per hospital. Patient clinical complexity level was measured as the average daily patient disease severity per hospital from the clinical complexity algorithm.

Results

There was a pronounced variability of care demand in Swiss general hospitals. Among hospitals, the average daily capacity utilization ranged from 57.8% (95% CI 57.3-58.4) to 87.7% (95% CI 87.3-88.0), patient turnover ranged from 22.5% (95% CI 22.1-22.8) to 34.5% (95% CI 34.3-34.7), and the mean patient clinical complexity level ranged from 1.26 (95% CI 1.25-1.27) to 2.06 (95% CI 2.05-2.07). Moreover, both within and between hospitals, all 3 measures varied distinctly between days of the year, between days of the week, between weekdays and weekends, and between seasons.

Conclusions

While admissions and discharges drive capacity utilization and patient turnover variation, disease severity of each patient drives patient clinical complexity level. Monitoring—and, if possible, anticipating—daily care demand fluctuations is key to managing hospital pressure zones. This study provides a pathway for identifying patients’ daily exposure to strained hospital systems for a time-varying causal model.

Matching Registered Nurse Services With Changing Care Demands in Psychiatric Hospitals: Protocol for a Multicenter Observational Study (MatchRN Psychiatry Study)

BACKGROUND

The quality of care is often poorly assessed in mental health settings, and accurate evaluation requires the monitoring and comparison of not only the outcomes but also the structures and processes. The resulting data allow hospital administrators to compare their patient outcome data against those reported nationally. As Swiss psychiatric hospitals are planned and coordinated at the cantonal level, they vary considerably. In addition, nursing care structures and processes, such as nurse staffing, are only reported and aggregated at the national level, whereas nurse outcomes, such as job satisfaction or intention to leave, have yet to be assessed in Swiss psychiatric hospitals. Because they lack these key figures, psychiatric hospitals' quality of care cannot be reasonably described.

OBJECTIVE

This study's purpose is to describe health care quality by exploring hospital structures such as nurse staffing and the work environment; processes such as the rationing of care; nurse outcomes, including job satisfaction and work-life balance; and patients' symptom burden.

METHODS

MatchRN Psychiatry is a multicenter observational study of Swiss psychiatric hospitals. The sample for this study included approximately 1300 nurses from 113 units of 13 psychiatric hospitals in Switzerland's German-speaking region. In addition, routine patient assessment data from each participating hospital were included. The nurse survey consisted of 164 items covering three dimensions-work environment, patient safety climate, and the rationing of care. The unit-level questionnaire included 57 items, including the number of beds, number of nurses, and nurses' education levels. Routine patient data included items such as main diagnosis, the number and duration of freedom-restrictive measures, and symptom burden at admission and discharge. Data were collected between September 2019 and June 2021. The data will be analyzed descriptively by using multilevel regression linear mixed models and generalized linear mixed models to explore associations between variables of interest.

RESULTS

The response rate from the nurse survey was 71.49% (1209/1691). All data are currently being checked for consistency and plausibility. The MatchRN Psychiatry study is funded by the participating psychiatric hospitals and the Swiss Psychiatric Nursing Leaders Association (Vereinigung Pflegekader Psychiatrie Schweiz).

CONCLUSIONS

For the first time, the MatchRN Psychiatry study will systematically evaluate the quality of care in psychiatric hospitals in Switzerland in terms of organizational structures, processes, and patient and nurse outcomes. The participating psychiatric hospitals will benefit from findings that are relevant to the future planning of nurse staffing. The findings of this study will contribute to improvement strategies for nurses' work environments and patient experiences in Swiss psychiatric hospitals.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/26700.

Effect of barcode technology on medication preparation safety: a quasi-experimental study

BACKGROUND

Medication errors are a common problem in hospitals and a major driver of adverse patient outcomes. Barcode verification technology is a promising strategy to help ensure safe medication preparation practices.

OBJECTIVES

The objectives of this study were (i) to assess the effects of a barcode-assisted medication preparation and administration system regarding the rate of medication preparation errors and (ii) to compare the time spent on medication preparation tasks by medical staff.

METHODS

A quasi-experimental study with a pre-post design was conducted, from August 2017 to July 2018, in two mixed medical/surgical units of a tertiary teaching hospital. The primary aim was to assess the effects of a barcode-based electronically assisted medication preparation and administration system linked to the hospital's electronic medication administration record regarding the rate of medication preparation errors and time-based staff performance. Data were collected using direct observation. Adjusted and unadjusted logistic models were used for error frequencies and linear regression models for time performance.

RESULTS

5932 instances of medication selection and dosing during 79 medication preparation procedures were observed. The overall medication preparation error incidence decreased from 9.9% at baseline to 4.5% at post-intervention, corresponding to a relative risk reduction of 54.5% (P < 0.001). However, the adjusted effect by registered nurses (RNs) and nurses' work experience of total medication preparation errors showed only borderline significance (odds ratio [OR] 0.64, P = 0.051). For adjusted error-specific analyses, significant error reductions were found in wrong medication errors (OR 0.38, P < 0.010) and wrong dosage errors (OR 0.12, P = 0.004). Wrong patient, wrong form and ambiguous dispenser errors did not occur at post-intervention. Errors of omission (OR 1.53, P = 0.17), additional doses (OR 0.63, P = 0.64) and wrong dispenser boxes (OR 0.51, P = 0.11) did not change significantly. The time necessary to prepare medications for a 24-h period also decreased significantly-from 30.2 min to 17.2 min (beta = -6.5, P = 0.047), while mean preparation time per individual medication dose fell from 24.3 s to 15.1 s (beta = -5.0, P = 0.002).

CONCLUSION

Use of the new barcode technology significantly reduced the rate of some medication preparation errors in our sample. Moreover, the time necessary for medication preparation, both per 24-h period and per single-medication dose, was significantly reduced.

[Safety-II in daily clinical practice]

BACKGROUND

Providing patient safety is a central matter in health care requiring complex treatment processes containing many risks. In hospital care, adverse events and patient harm occur frequently. In this context, the safety sciences investigate causes and contributing factors of such events as well as improvement measures. With Safety-I and Safety-II, two complementary approaches come into play. While Safety-I aims to minimize adverse events, the Safety-II approach focuses on understanding the system as a whole whose normal operations can result in both desired and adverse events. With the implementation of the Critical Incident Report System (CIRS), the Safety-I approach (with a focus on errors and correction of negative consequences for patient safety) has become an integral part of the university hospital chosen for this study. The subject matter of this study is to determine if and how the Safety-II approach (focussing on normal operation and the understanding of positive effects for patient safety) is already in use and what measurements can support its integration in daily clinical practice.

METHOD

Through observation, the structures of daily feedback meetings (huddles) from six different hospital departments have been gathered to determine if they can be considered as potential starting points for the implementation of the Safety-II approach. The following expert interviews (n=7) discussed four potentials of the Safety-II approach using the Resilient Assessment Grid (RAG). Finally, a focus group discussed which measurements are central for the integration of the Safety-II approach in daily clinical practice.

RESULTS

The study shows that department teams partially follow the Safety-II approach. During team huddles, positive experiences are already exchanged. The expert interviews revealed that the RAG potentials respond, learn and anticipate have already been realized satisfactorily while the potential monitor fell behind. The focus groups regard the Safety-II approach more as a matter of corporate culture and less as a paradigm shift which is needed to be integrated into day-to-day business.

DISCUSSION

Successfully establishing the Safety-II approach requires a focus not just on unwanted occurrences. It is also necessary to focus on the often not directly apparent desired occurrences, which ensure patient safety, and to systematically reflect on them in order to contribute to the development of the organizational culture. Having a better understanding of how the system of daily clinical practice with all its subsystems works will make it possible to proactively counteract unwanted occurrences, for example through regular feedback sessions and debriefings, and to increase patient safety.

Comparing Charlson and Elixhauser comorbidity indices with different weightings to predict in-hospital mortality: an analysis of national inpatient data

Background

Understanding how comorbidity measures contribute to patient mortality is essential both to describe patient health status and to adjust for risks and potential confounding. The Charlson and Elixhauser comorbidity indices are well-established for risk adjustment and mortality prediction. Still, a different set of comorbidity weights might improve the prediction of in-hospital mortality. The present study, therefore, aimed to derive a set of new Swiss Elixhauser comorbidity weightings, to validate and compare them against those of the Charlson and Elixhauser-based van Walraven weights in an adult in-patient population-based cohort of general hospitals.

Methods

Retrospective analysis was conducted with routine data of 102 Swiss general hospitals (2012–2017) for 6.09 million inpatient cases. To derive the Swiss weightings for the Elixhauser comorbidity index, we randomly halved the inpatient data and validated the results of part 1 alongside the established weighting systems in part 2, to predict in-hospital mortality. Charlson and van Walraven weights were applied to Charlson and Elixhauser comorbidity indices. Derivation and validation of weightings were conducted with generalized additive models adjusted for age, gender and hospital types.

Results

Overall, the Elixhauser indices, c-statistic with Swiss weights (0.867, 95% CI, 0.865–0.868) and van Walraven’s weights (0.863, 95% CI, 0.862–0.864) had substantial advantage over Charlson’s weights (0.850, 95% CI, 0.849–0.851) and in the derivation and validation groups. The net reclassification improvement of new Swiss weights improved the predictive performance by 1.6% on the Elixhauser-van Walraven and 4.9% on the Charlson weights.

Conclusions

All weightings confirmed previous results with the national dataset. The new Swiss weightings model improved slightly the prediction of in-hospital mortality in Swiss hospitals. The newly derive weights support patient population-based analysis of in-hospital mortality and seek country or specific cohort-based weightings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05999-5.

[Safety Walk Rounds - Clinical unit visits with a focus on patient safety]

Safety Walk Rounds - Clinical unit visits with a focus on patient safety Abstract. Background: Safety Walk Rounds are a promising strategy to promote the safety culture and optimising patient safety. The purpose of this study was to explore patient safety attributes in various clinical areas including recommendations for improvement and leadership support. Methods: Safety Walk Rounds were conducted by the chief patient safety officer based on a structured questions format to open patient safety dialogues with clinicians at the ward level. Field notes were utilized for thematic analyses and topic categorization. Results: A total of 187 clinicians (64 % nursing staff, 19 % physicians, 17 % other health care professionals) participated on the Safety Walk Rounds. The discussion findings are presented in five categories: Events & circumstances (potentially) harmful for patients; safety culture; need for local action, as well as the need for leadership support to provide safe care. Conclusion and outlook: Safety Walk Rounds across the hospitals' clinical areas delivered insight into patient safety issues and safety culture with its caregiver's engagement to provide safe care as well as action points for future improvement including leadership support.

The German version of the high-performance work systems questionnaire (HPWS-G) in the context of patient safety: a validation study in a Swiss university hospital

BACKGROUND

High performance work systems (HPWSs) are successful work systems in the context of safety climate and patient safety. The 10-item HPWS questionnaire is a validated instrument developed to assess existing HPWS structures in hospitals. The objectives of this cross-sectional study were to translate the English HPWS questionnaire into German (HPWS-G), to rate its content validity, and to examine its psychometric properties.

METHODS

Content validity was examined by a panel of 12 physicians and nurses, and I-CVI and S-CVI calculated. For internal consistency, Cronbach's α and item-scale correlations were determined. Construct validity was measured via confirmatory factor analysis. A convenience sample of 782 nurses and physicians in a University hospital setting in Switzerland's German-speaking region was surveyed. Four inclusion criteria were applied: working in intensive care, emergency department or operating room; having daily patient contact; having worked in the current clinical area for more than three months; and more than 40% employment.

RESULTS

A total of 281 questionnaires were completed (response rate: 35.9%). Overall, the 10-item HPWS-G questionnaire showed good content validity (I-CVI = .83-1; S-CVI = .86) and internal consistency (Cronbach's α = .853). HPWS-G scores correlated significantly with safety climate (rs = .657, p < .01) and teamwork climate (rs = .615, p < .01). The proposed 1-factor model was accepted considering results of applied minimum rank factor analysis; a confirmatory factor analysis indicated an acceptable to good model fit (GFI = .968; CFI = .902; RMSEA = .043).

CONCLUSIONS

The HPWS-G showed good psychometric properties. In clinical practice it can be used to assess HPWS practices and for intra- and inter-hospital benchmarking. Some minor adaptions to the wording could be made as well as reassessing the psychometric properties at other clinical sites.

A master of nursing science curriculum revision for the 21st century - a progress report

BACKGROUND

Preparing a 21^st century nursing workforce demands future-oriented curricula that address the population's evolving health care needs. With their advanced clinical skill sets and broad scope of practice, Advanced Practice Nurses strengthen healthcare systems by providing expert care, especially to people who are older and/or have chronic diseases. Bearing this in mind, we revised our established Master of Nursing Science curriculum at the University of Basel, Switzerland.

METHODS

Guided by the Advanced Nursing Practice framework, interprofessional guidelines, fundamental reports on the future of health care and the Bologna declaration, the reform process included three interrelated phases: preparation (work packages (WPs): curriculum analysis, alumni survey), revision (WPs: program accreditation, learning outcomes), and regulations (WPs: legal requirements, program launch).

RESULTS

The redesigned MScN curriculum offers two specializations: ANP and research. It was implemented in the 2014 fall semester.

CONCLUSIONS

This curriculum reform's strategic approach and step-by-step processes demonstrate how, beginning with a solid conceptual basis, congruent logical steps allowed development of a program that prepares nurses for new professional roles within innovative models of care.

[Content validity of a culturally adapted checklist for self-assessment of critical incident reporting system audit teams in a Swiss university hospital]

BACKGROUND

Critical Incident Reporting Systems (CIRS) support the analysis of critical incidents and foster quality improvement in healthcare. The analysis of CIRS reports by designated CIRS teams enable organizational learning. To maintain a constructive work flow CIRS teams should be able to self-assess their work. We adapted the checklist used by the Dutch Healthcare Inspectorate to judge the quality of sentinel event analysis reports provided by hospitals.

METHOD

The 26 items of the Dutch checklist were translated into German and culturally adapted to be used in a Swiss university hospital. Relevance and comprehensibility were rated by experts applying the Content Validity Index on item level (I-CVI) and on the checklist level (S-CVI). Five CIRS team members tested the usefulness of the revised checklist and provided feedback which we used to further revise the checklist.

RESULTS

Comprehensibility of the 19 items ranged from 58.3 % to 100 %, and the I-CVI ranged between 0.17 and 1.0. The S-CVI achieved a good 0.80. For reasons of clarity we modified, deleted and added items. CIRS team members regarded this further adapted 15-item checklist to be of limited utility.

DISCUSSION

The adapted checklist for self-assessment of the CIRS teams' work flow received good ratings for content validity but its usefulness for CIRS teams was found to be limited. The checklist may benefit from further development.

Adherence to the WHO surgical safety checklist: an observational study in a Swiss academic center

Background

The World Health Organization (WHO) Surgical Safety Checklist is used globally to ensure patient safety during surgery. Two years after its implementation in the University Hospital Basel's operating rooms, adherence to the protocol was evaluated.

Methods

This mixed method observational study took place in the surgical department of the University Hospital of Basel, Switzerland from April to August 2017. Data collection was via individual structured interviews with selected OR team members regarding checklist adherence and on-site non-participant observations of Team Time Out and Team Sign Out sequences in the OR. Data were subjected to thematic analysis and descriptive statistics compiled.

Results

Comprehensive local expert interviews indicated that individual, procedural and contextual variables influenced the application of the checklist. Facilitating factors included well-informed specialists who advocated the use of the Checklist, as well as teams focused on the checklist's intended process and on its content. In contrast, factors such as staff insecurity, a generally negative attitude towards the checklist, a lack of teamwork, and hesitance to complete the checklist, hindered its implementation.The checklist's application was evaluated in 104 on-site observations comprising of 72 Team Time Out (TTO) and 32 Team Sign Out (TSO) sections. Adherence to the protocol ranged between 96 and 100% in TTO and 22% in TSO respectively. Lack of implementation of the TSO was mainly due to the absence of one of the key OR team members, who were busy with other tasks or no longer present in the operating room.

Conclusion

The study illustrates factors, which foster and hinder consistent application of the WHO surgical safety checklist namely individual, procedural and contextual. It also demonstrates that the TTO was consistently and correctly applied, while the unavailability of key OR team members at sign-out time was the most common reason for omission or incomplete use of the TSO.

The occurrence, types, consequences and preventability of in-hospital adverse events - a scoping review

Background

Adverse events (AEs) seriously affect patient safety and quality of care, and remain a pressing global issue.

This study had three objectives: (1) to describe the proportions of patients affected by in-hospital AEs; (2) to explore the types and consequences of observed AEs; and (3) to estimate the preventability of in-hospital AEs.

Methods

We applied a scoping review method and concluded a comprehensive literature search in PubMed and CINAHL in May 2017 and in February 2018. Our target was retrospective medical record review studies applying the Harvard method–or similar methods using screening criteria–conducted in acute care hospital settings on adult patients (≥18 years).

Results

We included a total of 25 studies conducted in 27 countries across six continents. Overall, a median of 10% patients were affected by at least one AE (range: 2.9–21.9%), with a median of 7.3% (range: 0.6–30%) of AEs being fatal. Between 34.3 and 83% of AEs were considered preventable (median: 51.2%). The three most common types of AEs reported in the included studies were operative/surgical related, medication or drug/fluid related, and healthcare-associated infections.

Conclusions

Evidence regarding the occurrence of AEs confirms earlier estimates that a tenth of inpatient stays include adverse events, half of which are preventable. However, the incidence of in-hospital AEs varied considerably across studies, indicating methodological and contextual variations regarding this type of retrospective chart review across health care systems. For the future, automated methods for identifying AE using electronic health records have the potential to overcome various methodological issues and biases related to retrospective medical record review studies and to provide accurate data on their occurrence.

Trigger Tool-Based Automated Adverse Event Detection in Electronic Health Records: Systematic Review

BACKGROUND

Adverse events in health care entail substantial burdens to health care systems, institutions, and patients. Retrospective trigger tools are often manually applied to detect AEs, although automated approaches using electronic health records may offer real-time adverse event detection, allowing timely corrective interventions.

OBJECTIVE

The aim of this systematic review was to describe current study methods and challenges regarding the use of automatic trigger tool-based adverse event detection methods in electronic health records. In addition, we aimed to appraise the applied studies' designs and to synthesize estimates of adverse event prevalence and diagnostic test accuracy of automatic detection methods using manual trigger tool as a reference standard.

METHODS

PubMed, EMBASE, CINAHL, and the Cochrane Library were queried. We included observational studies, applying trigger tools in acute care settings, and excluded studies using nonhospital and outpatient settings. Eligible articles were divided into diagnostic test accuracy studies and prevalence studies. We derived the study prevalence and estimates for the positive predictive value. We assessed bias risks and applicability concerns using Quality Assessment tool for Diagnostic Accuracy Studies-2 (QUADAS-2) for diagnostic test accuracy studies and an in-house developed tool for prevalence studies.

RESULTS

A total of 11 studies met all criteria: 2 concerned diagnostic test accuracy and 9 prevalence. We judged several studies to be at high bias risks for their automated detection method, definition of outcomes, and type of statistical analyses. Across all the 11 studies, adverse event prevalence ranged from 0% to 17.9%, with a median of 0.8%. The positive predictive value of all triggers to detect adverse events ranged from 0% to 100% across studies, with a median of 40%. Some triggers had wide ranging positive predictive value values: (1) in 6 studies, hypoglycemia had a positive predictive value ranging from 15.8% to 60%; (2) in 5 studies, naloxone had a positive predictive value ranging from 20% to 91%; (3) in 4 studies, flumazenil had a positive predictive value ranging from 38.9% to 83.3%; and (4) in 4 studies, protamine had a positive predictive value ranging from 0% to 60%. We were unable to determine the adverse event prevalence, positive predictive value, preventability, and severity in 40.4%, 10.5%, 71.1%, and 68.4% of the studies, respectively. These studies did not report the overall number of records analyzed, triggers, or adverse events; or the studies did not conduct the analysis.

CONCLUSIONS

We observed broad interstudy variation in reported adverse event prevalence and positive predictive value. The lack of sufficiently described methods led to difficulties regarding interpretation. To improve quality, we see the need for a set of recommendations to endorse optimal use of research designs and adequate reporting of future adverse event detection studies.

Factors Associated With Care Workers' Intention to Leave Employment in Nursing Homes: A Secondary Data Analysis of the Swiss Nursing Homes Human Resources Project

The emerging care personnel shortage in Swiss nursing homes is aggravated by high turnover rates. As intention to leave is a predictor of turnover, awareness of its associated factors is essential. This study applied a secondary data analysis to evaluate the prevalence and variability of 3,984 nursing home care workers' intention to leave. Work environment factors and care worker outcomes were tested via multiple regression analysis. Although 56% of care workers reported intention to leave, prevalences varied widely between facilities. Overall, intention to leave showed strong inverse relationships with supportive leadership and affective organizational commitment and weaker positive relationships with stress due to workload, emotional exhaustion, and care worker health problems. The strong direct relationship of nursing home care workers' intention to leave with affective organizational commitment and perceptions of leadership quality suggest that multilevel interventions to improve these factors might reduce intention to leave.

Factors associated with high job satisfaction among care workers in Swiss nursing homes - a cross sectional survey study

Background

While the relationship between nurses’ job satisfaction and their work in hospital environments is well known, it remains unclear, which factors are most influential in the nursing home setting. The purpose of this study was to describe job satisfaction among care workers in Swiss nursing homes and to examine its associations with work environment factors, work stressors, and health issues.

Methods

This cross-sectional study used data from a representative national sample of 162 Swiss nursing homes including 4,145 care workers from all educational levels (registered nurses, licensed practical nurses, nursing assistants and aides). Care worker-reported job satisfaction was measured with a single item. Explanatory variables were assessed with established scales, as e.g. the Practice Environment Scale – Nursing Work Index. Generalized Estimating Equation (GEE) models were used to examine factors related to job satisfaction.

Results

Overall, 36.2 % of respondents reported high satisfaction with their workplace, while another 50.4 % were rather satisfied. Factors significantly associated with high job satisfaction were supportive leadership (OR = 3.76), better teamwork and resident safety climate (OR = 2.60), a resonant nursing home administrator (OR = 2.30), adequate staffing resources (OR = 1.40), fewer workplace conflicts (OR = .61), less sense of depletion after work (OR = .88), and fewer physical health problems (OR = .91).

Conclusions

The quality of nursing home leadership–at both the unit supervisor and the executive administrator level–was strongly associated with care workers’ job satisfaction. Therefore, recruitment strategies addressing specific profiles for nursing home leaders are needed, followed by ongoing leadership training. Future studies should examine the effects of interventions designed to improve nursing home leadership and work environments on outcomes both for care staff and for residents.

Evidence on the validity and reliability of the German, French and Italian nursing home version of the Basel Extent of Rationing of Nursing Care instrument

AIM

To develop and test psychometrically the Basel Extent of Rationing of Nursing Care for Nursing Homes instrument, providing initial evidence on the validity and reliability of the German, French and Italian-language versions.

BACKGROUND

In the hospital setting, implicit rationing of nursing care is defined as the withholding of nursing activities due to lack of resources, such as staffing or time. No instrument existed to measure this concept in nursing homes.

DESIGN

Cross-sectional study.

METHODS

We developed the instrument in three phases: (1) adaption and translation; (2) content validity testing; and (3) initial validity and reliability testing. For phase 3, we analysed survey data from 4748 care workers collected between May 2012-April 2013 from a randomly selected sample of 162 nursing homes in the German-, French- and Italian-speaking regions of Switzerland to provide evidence from response processes (e.g. missing), internal structure (exploratory factor analysis), inter-item inconsistencies (e.g. Cronbach's alpha) and interscorer differences (e.g. within-group agreement).

RESULTS

Exploratory factor analysis revealed a four-factor structure with good fit statistics. Rationing of nursing care was structured in four domains: (1) activities of daily living; (2) caring, rehabilitation and monitoring; (3) documentation; and (4) social care. Items of the social care subscale showed lower content validity and more missing values than items of other subscales.

CONCLUSION

First evidence indicates that the new instrument can be recommended for research and practice to measure implicit rationing of nursing care in nursing homes. Further refinements of single items are needed.

Framework for Evaluating the Impact of Advanced Practice Nursing Roles

PURPOSE

To address the gap in evidence-based information required to support the development of advanced practice nursing (APN) roles in Switzerland, stakeholders identified the need for guidance to generate strategic evaluation data. This article describes an evaluation framework developed to inform decisions about the effective utilization of APN roles across the country.

APPROACH

A participatory approach was used by an international group of stakeholders. Published literature and an evidenced-based framework for introducing APN roles were analyzed and applied to define the purpose, target audiences, and essential elements of the evaluation framework. Through subsequent meetings and review by an expert panel, the framework was developed and refined.

FINDINGS

A framework to evaluate different types of APN roles as they evolve to meet dynamic population health, practice setting, and health system needs was created. It includes a matrix of key concepts to guide evaluations across three stages of APN role development: introduction, implementation, and long-term sustainability. For each stage, evaluation objectives and questions examining APN role structures, processes, and outcomes from different perspectives (e.g., patients, providers, managers, policy-makers) were identified.

CONCLUSIONS

A practical, robust framework based on well-established evaluation concepts and current understanding of APN roles can be used to conduct systematic evaluations.

CLINICAL RELEVANCE

The evaluation framework is sufficiently generic to allow application in developed countries globally, both for evaluation as well as research purposes.

Absenteeism and Presenteeism among Care Workers in Swiss Nursing Homes and Their Association with Psychosocial Work Environment: A Multi-Site Cross-Sectional Study

BACKGROUND

Worker productivity is central to the success of organizations such as healthcare institutions. However, both absenteeism and presenteeism impair that productivity. While various hospital studies have examined the prevalence of presenteeism and absenteeism and its associated factors among care workers, evidence from nursing home settings is scarce.

OBJECTIVE

To explore care workers' self-reported absenteeism and presenteeism in relation to nursing homes' psychosocial work environment factors.

METHODS

We performed a cross-sectional study utilizing survey data of 3,176 professional care workers in 162 Swiss nursing homes collected between May 2012 and April 2013. A generalized estimating equation ordinal logistic regression model was used to explore associations between psychosocial work environment factors (leadership, staffing resources, work stressors, affective organizational commitment, collaboration with colleagues and supervisors, support from other personnel, job satisfaction, job autonomy) and self-reported absenteeism and presenteeism.

RESULTS

Absenteeism and presenteeism were observed in 15.6 and 32.9% of care workers, respectively. While absenteeism showed no relationship with the work environment, low presenteeism correlated with high leadership ratings (odds ratio [OR] 1.22, 95% confidence interval [CI] 1.01-1.48) and adequate staffing resources (OR 1.18, 95% CI 1.02-1.38).

CONCLUSION

Self-reported presenteeism is more common than absenteeism in Swiss nursing homes, and leadership and staffing resource adequacy are significantly associated with presenteeism, but not with absenteeism.

Nurses' accuracy and self-perceived ability using the Emergency Severity Index triage tool: a cross-sectional study in four Swiss hospitals

Background

The Emergency Severity Index (ESI) is an English language emergency department patient triage tool. After translation, it has been adapted for use to triage patients in growing numbers of emergency departments in non-English-speaking countries. Few reports of the proficiency of triage nurses to score an ESI exist. We sought to determine accuracy, inter-rater reliability, and subjective confidence of triage nurses at four hospitals to determine an ESI from standardized ESI scenarios.

Methods

Triage nurses assigned an ESI score to each of 30 standard ESI (ESI Implementation Handbook Version 4) translated teaching case scenarios. Accuracy and Inter-rater reliability (Krippendorff’s alpha) of the ESI scoring was measured. Nurses’ subjective confidence applying the ESI algorithm was obtained by a Likert scale.

Results

Sixty-nine nurses from four EDs participated in the study. They scored 59.6 % of the case scenarios correctly. Inter-rater reliability was 0.78 (Krippendorff’s alpha). Most (54/69, 78 %) felt confident in their ability to apply the ESI.

Conclusions

Low accuracy of ESI score assignment was observed when nurses scored an ESI for 30 standard written case scenarios, translated into nurses’ native language, despite a good inter-rater reliability and high nurse confidence in their ability to apply the ESI. Although feasible, using standard written case scenarios to determine ESI triage scoring effectiveness may not be the optimum means to rate nurses’ triage skills.

How to identify and recruit nurses to a survey 14 and 24 years after graduation in a context of scarce data: lessons learnt from the 2012 nurses at work pilot study on nurses' career paths

BACKGROUND

Nursing workforce data are scarce in Switzerland, with no active national registry of nurses. The worldwide nursing shortage is also affecting Switzerland, so that evidence-based results of the nurses at work project on career paths and retention are needed as part of the health care system stewardship; nurses at work is a retrospective cohort study of nurses who graduated in Swiss nursing schools in the last 30 years. Results of the pilot study are presented here (process and feasibility). The objectives are (1) to determine the size and structure of the potential target population by approaching two test-cohorts of nursing graduates (1988 and 1998); (2) to test methods of identifying and reaching them 14 and 24 years after graduation; (3) to compute participation rates, and identify recruitment and participation biases.

METHODS

Graduates' names were retrieved from 26 Swiss nursing schools: 488 nurses from the 1988 cohort and 597 from 1998 were invited to complete a web-based questionnaire. Initial updated addresses (n = 278, seed sample) were found using the Swiss Nursing Association member file. In addition, a snowball method was applied for recruitment, where directly-contacted respondents provided additional names of graduate mates or sent them the invitation. The study was further advertized through the main employers, study partners, and a press release.

RESULTS

Participation rate was 26.5% (n = 287), higher for the older cohort of 1988 (29.7%, n = 145) than for 1998 (15.6%, n = 93). Additional nurses (n = 363) not belonging to the test cohorts also answered. All schools were represented among respondents. Only 18 respondents (6%) worked outside nursing or not at all. Among respondents, 94% would 'probably' or 'maybe' agree to participate in the main study.

CONCLUSION

The pilot study demonstrated that targeted nurses could be identified and approached. There is an overwhelming interest in the project from them and from policymakers. Recommendations to increase nurses' participation rate for nurses at work include: (1) to open nurses at work recruitment to all nurses in Switzerland, while recreating cohorts post-hoc for relevant analysis; (2) to define a comprehensive communication strategy with special attention to graduate nurses who are harder to reach.

[Quality and general practice development in Swiss acute hospitals as a result of study results - a follow-up survey of nursing directors of RN4CAST hospitals]

In the RN4CAST (Nurse forecasting in Europe) study all 35 participating Swiss hospitals received a study report, which allowed them to anonymously compare findings in relation to structure, process and outcome variables. Thus, this benchmarking allowed the hospitals to identify potentials for improvement and to plan counter measures for developing the quality of their practice environment. We surveyed the RN4CAST hospitals 18 months after submitting the study report and asked chief nursing officers if the results of the RN4CAST study report had been discussed and analysed within their hospitals and if the results had led to any quality improvement or practice development projects. Out of 35 questionnaires 30 were returned (response rate = 85 %). The study report was discussed and analysed in 27 hospitals (90 %), whereby the quality (n = 27) and the usefulness (n = 22) were rated as good or very good. Less then half of the hospitals (41 %) discussed the results with the hospital units. The study report stimulated practice development and quality improvement efforts in view of the nurses' work environment (n = 20) and safety culture/climate (n = 16). Replicating the RN4CAST study in the participating hospital would allow evaluating changes on the measured variables, e. g., due to this quality improvement and practice development projects.

Exposure to Leadership WalkRounds in neonatal intensive care units is associated with a better patient safety culture and less caregiver burnout

BACKGROUND

Leadership WalkRounds (WR) are widely used in healthcare organisations to improve patient safety. The relationship between WR and caregiver assessments of patient safety culture, and healthcare worker burnout is unknown.

METHODS

This cross-sectional survey study evaluated the association between receiving feedback about actions taken as a result of WR and healthcare worker assessments of patient safety culture and burnout across 44 neonatal intensive care units (NICUs) actively participating in a structured delivery room management quality improvement initiative.

RESULTS

Of 3294 administered surveys, 2073 were returned for an overall response rate of 62.9%. More WR feedback was associated with better safety culture results and lower burnout rates in the NICUs. Participation in WR and receiving feedback about WR were less common in NICUs than in a benchmarking comparison of adult clinical areas.

CONCLUSIONS

WR are linked to patient safety and burnout. In NICUs, where they occurred more often, the workplace appears to be a better place to deliver and to receive care.