Unfinished nursing care in intensive care units and the mediating role of the association between nurse working environment, and quality of care and nurses' wellbeing

OBJECTIVES

Unfinished care refers to the situation in which nurses are forced to delay or omit necessary nursing care. The objectives was: 1) to measure the prevalence of unfinished nursing care in intensive care units during the COVID-19 pandemic; 2) to examine whether unfinished nursing care has a mediating role in the relationship between nurse working environment and nurse-perceived quality of care and risk of burnout among nurses.

DESIGN

A national cross-sectional survey.

SETTING

Seventy-five intensive care units in Belgium (December 2021 to February 2022).

MAIN OUTCOME MEASURES

The Practice Environment Scale of the Nursing Work Index was used to measure the work environment. The perception of quality and safety of care was evaluated via a Likert-type scale. The risk of burnout was assessed using the Maslach Burnout Inventory scale.

RESULTS

A total of 2,183 nurse responses were included (response rate of 47.8%). Seventy-six percent of nurses reported at least one unfinished nursing care activity during their last shift. The staffing and resource adequacy subdimension of the Practice Environment Scale of the Nursing Work Index had the strongest correlation with unfinished nursing care. An increase in unfinished nursing care led to significantly lower perceived quality and safety of care and an increase in high risk of burnout. Unfinished nursing care appears to be a mediating factor for the association between staffing and resource adequacy and the quality and safety of care perceived by nurses and risk of burnout.

CONCLUSIONS

Unfinished nursing care, which is highly related to staffing and resource adequacy, is associated with increased odds of nurses being at risk of burnout and reporting a lower level of perceived quality of care.

IMPLICATIONS FOR CLINICAL PRACTICE

The monitoring of unfinished nursing care in the intensive care unit is an important early indicator of problems related to adequate staffing levels, the well-being of nurses, and the perceived quality of care.

Physician and nurse well-being, patient safety and recommendations for interventions: cross-sectional survey in hospitals in six European countries

OBJECTIVES

To determine the well-being of physicians and nurses in hospital practice in Europe, and to identify interventions that hold promise for reducing adverse clinician outcomes and improving patient safety.

DESIGN

Baseline cross-sectional survey of 2187 physicians and 6643 nurses practicing in 64 hospitals in six European countries participating in the EU-funded Magnet4Europe intervention to improve clinicians' well-being.

SETTING

Acute general hospitals with 150 or more beds in six European countries: Belgium, England, Germany, Ireland, Sweden and Norway.

PARTICIPANTS

Physicians and nurses with direct patient contact working in adult medical and surgical inpatient units, including intensive care and emergency departments.

MAIN OUTCOME MEASURES

Burnout, job dissatisfaction, physical and mental health, intent to leave job, quality of care and patient safety and interventions clinicians believe would improve their well-being.

RESULTS

Poor work/life balance (57% physicians, 40% nurses), intent to leave (29% physicians, 33% nurses) and high burnout (25% physicians, 26% nurses) were prevalent. Rates varied by hospitals within countries and between countries. Better work environments and staffing were associated with lower percentages of clinicians reporting unfavourable health indicators, quality of care and patient safety. The effect of a 1 IQR improvement in work environments was associated with 7.2% fewer physicians and 5.3% fewer nurses reporting high burnout, and 14.2% fewer physicians and 8.6% fewer nurses giving their hospital an unfavourable rating of quality of care. Improving nurse staffing levels (79% nurses) and reducing bureaucracy and red tape (44% physicians) were interventions clinicians reported would be most effective in improving their own well-being, whereas individual mental health interventions were less frequently prioritised.

CONCLUSIONS

Burnout, mental health morbidities, job dissatisfaction and concerns about patient safety and care quality are prevalent among European hospital physicians and nurses. Interventions to improve hospital work environments and staffing are more important to clinicians than mental health interventions to improve personal resilience.

Engaging leadership and nurse well-being: the role of the work environment and work motivation-a cross-sectional study

BACKGROUND

Healthcare literature suggests that leadership behavior has a profound impact on nurse work-related well-being. Yet, more research is needed to better conceptualize, measure, and analyse the concepts of leadership and well-being, and to understand the psychological mechanisms underlying this association. Combining Self-Determination and Job Demands-Resources theory, this study aims to investigate the association between engaging leadership and burnout and work engagement among nurses by focusing on two explanatory mechanisms: perceived job characteristics (job demands and resources) and intrinsic motivation.

METHODS

A cross-sectional survey of 1117 direct care nurses (response rate = 25%) from 13 general acute care hospitals in Belgium. Validated instruments were used to measure nurses' perceptions of engaging leadership, burnout, work engagement, intrinsic motivation and job demands and job resources. Structural equation modeling was performed to test the hypothesised model which assumed a serial mediation of job characteristics and intrinsic motivation in the relationship of engaging leadership with nurse work-related well-being.

RESULTS

Confirmatory factor analysis indicated a good fit of the measurement model. The findings offer support for the hypothesized model, indicating that engaging leadership is linked to enhanced well-being, as reflected in increased work engagement, and reduced burnout. The results further showed that this association is mediated by nurses' perceptions of job resources and intrinsic motivation. Notably, while job demands mediated the relationship between EL and nurses' well-being, the relationship became unsignificant when including intrinsic motivation as second mediator.

CONCLUSIONS

Engaging leaders foster a favourable work environment for nursing staff which is not only beneficial for their work motivation but also for their work-related well-being. Engaging leadership and job resources are modifiable aspects of healthcare organisations. Interventions aimed at developing engaging leadership behaviours among nursing leaders and building job resources will help healthcare organisations to create favourable working conditions for their nurses.

TRIAL REGISTRATION

The study described herein is funded under the European Union's Horizon 2020 Research and Innovation programme from 2020 to 2023 (Grant Agreement 848031). The protocol of Magnet4Europe is registered in the ISRCTN registry (ISRCTN10196901).

What makes nurses flourish at work? How the perceived clinical work environment relates to nurse motivation and well-being: A cross-sectional study

BACKGROUND

Literature shows that the work environment is a main determinant of nurses' well-being and psychological strain; yet, the (psychological) mechanisms underlying this relationship remain understudied.

OBJECTIVE

This study explored the underlying (psychological) mechanisms (why) and boundary conditions (when) by which characteristics present in the clinical work environment influence nurses' well-being. We investigated the mediating role of intrinsic motivation in the relationship of job demands and job resources with burnout vs. work engagement. In addition, we examined if job resources strengthen the relationship of job demands with intrinsic motivation and burnout.

DESIGN

A cross-sectional survey study.

SETTING(S)

General acute care hospitals in Belgium (n = 14).

PARTICIPANTS

Direct care nurses (n = 1729).

METHODS

Data were collected by means of online questionnaires between October 2020 and July 2021. Study variables included burnout, work engagement, intrinsic motivation and a set of different job demands (workload, role conflicts, emotional demands, red tape) and job resources (performance feedback, autonomy, skill use, opportunity for growth, and value congruence). All variables were obtained using self-report measures. The central hypotheses were tested using structural equation modeling.

RESULTS

Job resources appeared to be a crucial factor for nurses' health showing positive associations with work motivation (β = 0.513) and work engagement (β = 0.462) and negative associations with burnout (β = -0.216). Job demands remained an essential factor that harms psychological health and is associated with increased burnout (β = 0.489). Our results confirmed that intrinsic motivation mediated the relationship of job resources with work engagement (β = 0.170) and burnout (β = -0.135). In addition, job resources moderated the relationship of job demands with burnout (β = -0.039). Against our expectations, we found no associations between job demands and intrinsic motivation or a moderation effect of job resources on the respective relationship.

CONCLUSIONS

A highly demanding work environment can be a source of significant stress which may put nurses' health at severe risk. Nurses who perceive sufficient job resources such as feedback, autonomy and opportunities for growth and development, are likely to feel intrinsically motivated at work. In addition, it will foster their work engagement and prevent them from burning out, particularly when job demands are high.

REGISTRATION

The study described herein is funded under the European Union's Horizon 2020 Research and Innovation program from 2020 to 2023 (Grant Agreement 848031). The protocol of Magnet4Europe is registered in the ISRCTN registry (ISRCTN10196901).

TWEETABLE ABSTRACT

Providing nurses with sufficient resources will not only increase their motivation and engagement at work but also reduce their feelings of burnout.

Exploring unfinished nursing care among nursing students: a discussion paper

BACKGROUND

In line with the impetus traceable among the nursing staff, studies regarding the perception of Unfinished Care among students have increased in recent years as also recommended by some policy documents in the consideration that, as future members of the staff, they are expected to raise concerns about failures in the standards of care. However, no discussion of their methodological requirements has been provided to date. The aim of this study is to debate Unfinished Care explorations among nursing students and developing recommendations.

METHODS

A Rapid Review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, followed by a scientific discussion based on empirical evidence that emerged from the review combined with expert knowledge. Medline, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus databases were searched up to May 2022.

RESULTS

In the last five years, seven studies have been conducted by researchers affiliated at the university level, involving from 18 to 737 undergraduate students across Europe. By critically analysing their key aspects, there are derived some recommendations in conducting investigations in this field as, (a) the hidden meaning of Unfinished Care investigations among students by also deciding which concept is mostly appropriate to investigate; (b) the need of establishing alliances with the clinical settings in order to involve them in such explorations; (c) more complex research methods capable of exploring this issue among students by promoting learning outcomes and not only a simple data collection; and (e) the influences of these explorations on students' wellbeing, as well as on ethical implications and that regarding the relationship between the healthcare services and the universities.

CONCLUSION

Policymakers consider students to be key informants of the quality of nursing care issues witnessed during their clinical placements. The related emerging line of research is intriguing because of the underlying methodological, ethical and system complexities that need to be addressed according to some considerations.

Recruiting and retaining bachelor qualified nurses in German hospitals (BSN4Hospital): protocol of a mixed-methods design

INTRODUCTION

Many countries in Europe are facing a shortage of nurses and seek effective recruitment and retention strategies. The nursing workforce is increasingly diverse in its educational background, ranging from 3-year vocational training (diploma) to bachelor and master educated nurses. This study analyses recruitment and retention strategies for academically educated nurses (minimum bachelor), including intention to leave, job satisfaction and work engagement compared with diploma nurses in innovative German hospitals; it explores recruitment and retention challenges and opportunities, and identifies lessons on recruitment and retention taking an international perspective.

METHODS AND ANALYSIS

The study will apply a convergent mixed-methods design, including qualitative and quantitative methods. The qualitative study will include semistructured interviews among hospital managers, nurses, students and stakeholders in Germany. In addition, expert interviews will be conducted internationally in countries with a higher proportion of bachelor/master nurses in hospitals. The quantitative, cross-sectional study will consist of a survey among professional nurses (bachelor/master, diploma nurses) in German hospitals. Study settings are hospitals with a higher-than-average proportion of bachelor nurses or relevant recruitment, work environment or retention strategies in place. Analyses will be conducted in several phases, first in parallel, then combined via triangulation: the parallel analysis technique will analyse the qualitative and quantitative data separately via content analyses (interviews) and descriptive, bivariate and multivariate analyses (survey). Subsequently, data sources will be collectively analysed via a triangulation matrix focusing on developing thematic exploratory clusters at three systemic levels: microlevel, mesolevel and macrolevel. The analyses will be relevant for generating lessons for clinical nursing, management and policy in Germany and internationally.

ETHICS AND DISSEMINATION

Ethics approval was obtained by the Charité Ethics Committee.Several dissemination channels will be used, including publications and presentations, for the scientific community, nursing management, clinical nurses and the wider public in Germany and internationally.

How nurses' job characteristics affect their self-assessed work environment in hospitals- Slovenian use of the practice environment scale of the nursing work index

BACKGROUND

Nurses' work environment influences nursing practice. Inappropriate working conditions are the result of underdeveloped workplace infrastructure, poor work organisation, inadequate education, and inappropriate staffing norms. The aim of this study was to describe and examine the predictors that affect nurses' work environment using the Practice Environment Scale of the Nursing Work Index (PES-NWI).

METHODS

The validation of the PES-NWI was made. Nurse-reported job characteristics were used as independent variables. The sample included 1,010 nurses from adult surgical and medical units at 10 Slovenian hospitals. The Nurse Forecasting (RN4CAST) protocol was used. Permission to conduct the study was obtained from the National Medical Ethics Committee.

RESULTS

The PES-NWI mean (2.64) was low, as were job and career satisfaction at 2.96 and 2.89, respectively. The PES-NWI can be explained in 48% with 'Opportunities for advancement', 'Educational opportunities', 'Satisfaction with current job', 'Professional status', 'Study leave', and 'Level of education'. A three-factor solution of PES-NWI yielded eight distinct variables.

CONCLUSIONS

The obtained average on the Nursing Work Index was one of the lowest among previously conducted surveys. Nurses should be recognized as equals in the healthcare workforce who need to be empowered to develop the profession and have career development opportunities. Inter-professional relations and equal involvement of nurses in hospital affairs are also very important.

TRIAL REGISTRATION

This is a non-intervention study - retrospectively registered.

Improving hospital nurse staffing during the pandemic: Implementation of the 2019 Fund for Health Care Staff in Belgium

Chronic hospital nurse understaffing is a pre-existing condition of the COVID-19 pandemic. With nurses on the frontline against the pandemic, safe nurse staffing in hospitals is high on the political agenda of the responsible ministers of Health. This paper presents a recent Belgian policy reform to improve nurse staffing levels. Although the reform was initiated before the pandemic, its roll-out took place from 2020 onwards. Through a substantial increase of the hospital budget, policy makers envisaged to improve patient-to-nurse ratios. Yet, this ambition was considerably toned down during the implementation. Due to a shortage of nurses in the labour market, hospital associations successfully lobbied to allocate part of the budget to hire non-nursing staff. Moreover, other healthcare settings claimed their share of the pie. Elements of international best-practice examples such as ward managers supernumerary to the team and increasing the transparency on staffing decisions were adopted. Other measures, such as mandated patient-to-nurse ratios, nurse staffing committees, or the monitoring or public reporting of ratios, were not retained. Additional measures were taken to safeguard that bedside staffing levels would improve, such as the requirement to demonstrate a net increase in staff to obtain additional budget, staffing plan's approval by local work councils and recommendation to base staff allocation on patient acuity measures. This policy process makes clear that the engagement of budgets is only a first step towards safe staffing levels, which needs to be embedded in a comprehensive policy plan. Future evaluation of bedside nurse staffing levels and nurse wellbeing is needed to conclude about the effectiveness of these measures and the intended and unintended effects they provoked.

A workplace organisational intervention to improve hospital nurses' and physicians' mental health: study protocol for the Magnet4Europe wait list cluster randomised controlled trial

INTRODUCTION

The increasing burden of mental distress reported by healthcare professionals is a matter of serious concern and there is a growing recognition of the role of the workplace in creating this problem. Magnet hospitals, a model shown to attract and retain staff in US research, creates positive work environments that aim to support the well-being of healthcare professionals.

METHODS AND ANALYSIS

Magnet4Europe is a cluster randomised controlled trial, with wait list controls, designed to evaluate the effects of organisational redesign, based on the Magnet model, on nurses' and physicians' well-being in general acute care hospitals, using a multicomponent implementation strategy. The study will be conducted in more than 60 general acute care hospitals in Belgium, England, Germany, Ireland, Norway and Sweden. The primary outcome is burnout among nurses and physicians, assessed in longitudinal surveys of nurses and physicians at participating hospitals. Additional data will be collected from them on perceived work environments, patient safety and patient quality of care and will be triangulated with data from medical records, including case mix-adjusted in-hospital mortality. The process of implementation will be evaluated using qualitative data from focus group and key informant interviews.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee Research UZ/KU Leuven, Belgium; additionally, ethics approval is obtained in all other participating countries either through a central or decentral authority. Findings will be disseminated at conferences, through peer-reviewed manuscripts and via social media.

TRIAL REGISTRATION NUMBER

ISRCTN10196901.

Overview on the target population and methods used in care pathway projects: A narrative review

BACKGROUND

There is evidence that the efficiency and effectiveness of care processes can be improved in all countries. Care pathways (CPs) are proposed as a method to improve the quality of care by reducing variation. During the last decades, CPs have been intensively used in practice. The objective of this study is to examine the study designs for investigating CPs, for which pathologies CPs are used and what the reported indicators to measure the impact of CPs are.

METHODS

A narrative review of the literature published from 2015 to 2019 was performed.

RESULTS

We identified 286 studies, of which 207 evaluated the impact of CPs, 33 were review articles, 29 studies described the development of a CP, 12 were study protocols and 5 opinion papers. The most frequently reported study design for studying the impact of a CP is pre-posttest (n = 82), followed by cross-sectional studies (n = 50). Oncology, cardiovascular disease and abdominal surgery are the domains with the highest numbers of studies evaluating the impact of CPs. Financial (n = 86), process (n = 76) and clinical indicators (n = 74) are the most frequently reported indicators while service (n = 12) and team indicators (n = 6) are less reported.

CONCLUSIONS

Based on the relative low number of identified studies compared with the number of CP projects in organisations, we conclude that the CP knowledge is not only found in the literature. We, therefore, argue that (inter)national scientific societies should not only focus on searching and spreading evidence on the content of care but also enhance their knowledge sharing initiatives on the organisation of care processes.

A 15-Year Follow-up Retrospective Study on 959 Spine Surgeries: What Can We Learn From Real-world Data?

STUDY DESIGN

This was a retrospective study.

OBJECTIVE

The aim of this study was to investigate the patient flow and need for additional surgery after first-time lower back surgery. Next, we analyzed the patients who developed chronic low back pain (LBP) and were treated with spinal cord stimulation.

SUMMARY OF BACKGROUND DATA

LBP has a lifetime prevalence of 84% and imposes a high economic burden. Treatment is focused on preventing chronic pain. Research has shown the efficacy of treatment options. However, less is known about who benefits the most from which therapy and when they should be positioned in the treatment algorithm.

METHODS

In this retrospective study, data of all patients who underwent first-time surgery from 2000 to 2004 were included. After 10-15 years, patients were contacted about their quality of life (QoL) (EuroQoL-5 Dimension) and life and heath perception (EuroQoL Visual Analogue Scale).

RESULTS

In all, 959 patients underwent surgery at the lower back area. Follow-up time ranged from 13 to 17 years; 225 patients (23.5%) underwent a second surgery. In total, 20 patients (2.1%) developed chronic neuropathic back pain and received spinal cord stimulation therapy. Ten years postsurgery, 438 (45.7%) patients completed the QoL and LBP questionnaires. The health-related QoL and health situation were significantly lower in patients with multiple surgeries ( P <0.001).

CONCLUSIONS

The study results indicate that large data sets, with multiple outcome measurements and long-term follow-up are necessary to improve our knowledge and to optimize the therapeutic pathway. In that way, we might learn how to select a patient for the right treatment or treatments at the right moment and shorten the circulation in our health care system.

Challenges and opportunities in health care and nursing management research in times of COVID-19 outbreak

Aim

To reflect upon the concrete implications of the COVID‐19 outbreak regarding ongoing health service and nursing management research (NMR) and to identify possible research priorities for the current and post‐pandemic era.

Background

Health service research and the nursing management research debate have received little attention to date, despite their relevance in responding to the increased demand of care during the COVID‐19 outbreak.

Methods

A critical analysis on experiences was performed while leading international‐funded studies at different degrees of complexity and targets, involving nurse managers, nurses, care processes and health care services in the last year.

Results

Ongoing research projects have been profoundly affected by the COVID‐19 outbreak in their aims, methods, management processes, feasibility and outcomes.

Conclusions

The COVID‐19 outbreak is an unprecedented stress test for the health care sector and for the nursing services. Its onset and persistence have rendered more easily to see what prevails in terms of effectiveness and what fails in our health care services.

Implications for Nursing Management

Nurse managers have lived and are still living through this crisis, given their omnipresence in the health care systems. Therefore, setting NMR priorities and working together to imagine and design the post‐COVID‐19 era is essential.

A mixed methods multiple case study to evaluate the implementation of a care pathway for colorectal cancer surgery using extended normalization process theory

BACKGROUND

Specific factors that facilitate or prevent the implementation of enhanced recovery protocols for colorectal cancer surgery have been described in previous qualitative studies. This study aims to perform a concurrent qualitative and quantitative evaluation of factors associated with successful implementation of a care pathway (CP) for patients undergoing surgery for colorectal cancer.

METHODS

This comparative mixed methods multiple case study was based on a sample of 10 hospitals in 4 European countries that implemented a specific CP and performed pre- and post-implementation measurements. In-depth post-implementation interviews were conducted with healthcare professionals who were directly involved. Primary outcomes included protocol adherence and improvement rate. Secondary outcomes included length of stay (LOS) and self-rated protocol adherence. The hospitals were ranked based on these quantitative findings, and those with the highest and lowest scores were included in this study. Qualitative data were summarized on a per-case basis using extended Normalization Process Theory (eNPT) as theoretical framework. The data were then combined and analyzed using joint display methodology.

RESULTS

Data from 381 patients and 30 healthcare professionals were included. Mean protocol adherence rate increased from 56 to 62% and mean LOS decreased by 2.1 days. Both measures varied greatly between hospitals. The two highest-ranking hospitals and the three lowest-ranking hospitals were included as cases. Factors which could explain the differences in pre- and post-implementation performance included the degree to which the CP was integrated into daily practice, the level of experience and support for CP methodology provided to the improvement team, the intrinsic motivation of the team, shared goals and the degree of management support, alignment of CP development and hospital strategy, and participation of relevant disciplines, most notably, physicians.

CONCLUSIONS

Overall improvement was achieved but was highly variable among the 5 hospitals evaluated. Specific factors involved in the implementation process that may be contributing to these differences were conceptualized using eNPT. Multidisciplinary teams intending to implement a CP should invest in shared goals and teamwork and focus on integration of the CP into daily processes. Support from hospital management directed specifically at quality improvement including audit may likewise facilitate the implementation process.

TRIAL REGISTRATION

NCT02965794 . US National Library of Medicine, ClinicalTrials.gov . Registered 4 August 2014.

Qualitative Evaluation of the Implementation of a Care Pathway for Colorectal Cancer Surgery

Colorectal cancer care can be standardized by using enhanced recovery protocols. However, adherence to these protocols varies. Using Medical Research Council (MRC) guidance on process evaluations, we examined the experience of health care professionals in the implementation of a care pathway for colorectal surgery, by describing the intervention, context, implementation, mechanisms, and outcomes. Based on data from semi-structured interviews, we divided respondents into two groups: those who perceived positive outcomes of the implementation and those who perceived no effect. Respondents who perceived positive outcomes reported clinical leadership, use of feedback, positive effects of standardization, and teamwork as factors contributing to positive perceived outcomes. Respondents who perceived no effect reported a lack of organizational support, as well as challenging collaboration and standardization as mechanisms potentially explaining the poorer perception of outcomes. Multiple implementation activities were used, focusing on competence, behavior, or workplace. Our findings suggest that feedback is an important implementation activity.

Effect of an intervention on the congruence of nurses' and patients' perceptions of patient-centred care: A pre-test post-test study

AIMS AND OBJECTIVES

To evaluate measurement invariance of the Individualized Care Scale (ICS) across patients and nurses, and assess the degree of congruence in nurses' and patients' perceptions on patient-centredness and the impact of an intervention there on.

METHODS

A pre-post intervention study design with an expert by experience intervention was conducted in 2016 to 2017. Nurses (n = 138) and patients (n = 199) of two hospital departments in Belgium were surveyed. Patient-centredness was measured using the ICS (ICS-Nurse and ICS-Patient). Measurement invariance was evaluated by conducting multiple-group confirmatory factor analysis. Unpaired t tests and difference in difference analysis were used to evaluate the degree of congruence in nurses' and patients' perceptions on patient-centredness and assess pre-post changes in nurses' and patients' scores, respectively. SQUIRE guidelines were followed to report the study.

RESULTS

There was no evidence of measurement non-invariance. Nurses perceived the individuality of care more positively than patients both before and after the implementation of the intervention. Pre-post changes in nurses' and patients' scores were not statistically significant.

CONCLUSION

There is a significant gap between the perceptions of nurses and patients regarding the support and provision of individual care: nurses consider provided care as more individualized than patients do. To orient nurses' perspectives more towards their patients' perspective, multicomponent interventions are needed. Researchers and hospital managers may use the ICS to evaluate interventions that have the ability to close the gap in nurses' and patients' perceptions of patient-centredness. Embedding experts by experience in the professionals' team has the potential to foster patient-centredness but needs to focus on patients and nurses equally.

Measurement tools used to assess unfinished nursing care: A systematic review of psychometric properties

BACKGROUND

Different tools have been developed and validated to measure unfinished nursing care. However, no systematic review of the psychometric properties has been performed describing the quality of the methods used to estimate their validity.

AIMS

(a) To identify tools measuring unfinished nursing care that have undergone validation processes; (b) to evaluate critically the quality of the methods used in ascertaining their psychometric properties; and (c) to compare the estimated psychometric properties of these tools.

DESIGN

A systematic review of the psychometric properties also evaluating their methodological quality was performed by following the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) guideline for systematic reviews.

DATA SOURCES

The databases Medline, the Cumulative Index to Nursing and Allied Health Literature, PubMed, Google and Google Scholar were searched up to 30 June 2018.

REVIEW METHODS

Data extraction was performed following the predetermined eligibility criteria. Eight properties and their methodological quality were assessed using the COnsensus-based Standards for the selection of health Measurement INstruments criteria.

RESULTS

A total of 20 studies reported validation data regarding three family of tools: the Missed Care Survey (MISSCARE), the Basal Extent of Rationing of Nursing Care (BERNCA) and the Task Undone scale (TU-7). The most estimated psychometric properties across studies were internal consistency, followed by structural validity, content validity, and cross-cultural validity. The less evaluated psychometric properties were reliability, hypothesis testing and convergent and criterion validity.

CONCLUSION

The psychometric properties of the investigated tools showed a more than acceptable quality, as did the methodologies used to estimate these properties.

IMPACT

The MISSCARE survey is the most widely used tool validated across countries to date. Evaluating the concurrent reliability of the tools available is strongly recommended to assess their effectiveness in measuring the same phenomenon.

Evaluating Large-Scale Integrated Care Projects: The Development of a Protocol for a Mixed Methods Realist Evaluation Study in Belgium

BACKGROUND

The twelve Integrated Care Program pilot projects (ICPs) created by the government plan 'Integrated Care for Better Health' aim to achieve four outcome types (the Quadruple Aim) for people with chronic diseases in Belgium: improved population health, improved patient and provider experiences and improved cost efficiency. The aim of this article is to present the development of a mixed methods realist evaluation of this large-scale, whole system change programme.

METHODS

A scientific team was commissioned to co-design and implement an evaluation protocol in close collaboration with the government, the ICPs and several other involved stakeholders.

RESULTS

A protocol for a mixed methods realist evaluation was developed to gain insights into the mechanisms that foster successful results in ICPs. The qualitative evaluation proposed will be based on the document analysis of yearly ICP progress reports, selected case studies and focus group interviews with stakeholders. Processes and outcomes of all the projects will be monitored using indicators based on administrative data on population health and the quality and costs of care. A yearly survey will be organized to collect data on patient-reported outcomes and experiences and on provider-reported measures of inter-professional collaboration and proper wellbeing. Using both quantitative and qualitative data, we will develop theories about the mechanisms and the associated contextual factors that lead to integrated care and the Quadruple Aim outcomes.

DISCUSSION

The objective of this study is to deliver policy recommendations on strategies and best practices to improve care integration in Belgium and to implement a sustainable monitoring system that serves both policy makers and the stakeholders within the ICPs. Some challenges due to the large scale of the project and the multiple stakeholders involved may impede the successful implementation of this proposal.

Are data on missed nursing care useful for nursing leaders? The RN4CAST@IT cross-sectional study

AIM

To describe nurses' reported missed nursing care activities among hospitalized adult patients medical and surgical wards and explore gaps in service provision.

BACKGROUND

In 2015, Italy replicated the RN4CAST study, which heralded the exposition of missed care as an international phenomenon. In Italy, nurse-patient workload is high, with high levels of burnout and dissatisfaction reported, all factors associated with missed care.

METHODS

A cross-sectional study (n = 3,590) was conducted using the 13-item online Task Left Undone Tool aimed at collecting data on missed nursing care.

RESULTS

The frequency of omission of activities ranged between 7% and 50%. There were significant differences between morning, afternoon and night shifts and the various clinical settings. Oral care was the most frequently missed care activity.

CONCLUSIONS

This study takes step forward in identifying and reducing missed care on medical and surgical wards, both in Italy and also internationally, which needs to take into account the specific organisational characteristics of each setting.

IMPLICATIONS FOR NURSING MANAGEMENT

Although more essential activities are missed less frequently, much is known about the relational deficits such as information giving, education, communication and discharge advice, which managers ought to spearhead through local initiatives to improve these practices.

Safe nurse staffing policies for hospitals in England, Ireland, California, Victoria and Queensland: A discussion paper

OBJECTIVE

The association between higher registered nurses (RN) staffing (educational level and number) and better patient and nurse outcomes is well-documented. This discussion paper aims to provide an overview of safe staffing policies in various high-income countries to identify reform trends in response to recurring nurse workforce challenges.

METHODS

Based on a scan of the literature five cases were selected: England (UK), Ireland, California (USA), Victoria and Queensland (Australia). Information was gathered via a review of the grey and peer-reviewed literature. Country experts were consulted for additional information and to review country reports.

RESULTS

The focus of safe staffing policies varies: increasing transparency about staffing decisions (England), matching actual and required staffing levels based on patient acuity measurement (Ireland), mandated patient-to-nurse ratios at the level of the nurse (California) or the ward (Victoria, Queensland). Calibration of the number of patients by the number of nurses varies across cases. Nevertheless, positive effects on the nursing workforce (increased bedside staffing) and staff well-being (increased job satisfaction) have been consistently documented. The impact on patient outcomes is promising but less well evidenced.

CONCLUSION

Countries will have to set safe staffing policies to tackle challenges such as the ageing population and workforce shortages. Various approaches may prove effective, but need to be accompanied by a comprehensive policy that enhances bedside nurse staffing in an evidence-based, objective and transparent way.

Better hospital context increases success of care pathway implementation on achieving greater teamwork: a multicenter study on STEMI care

OBJECTIVE

To evaluate whether hospital context influences the effect of care pathway implementation on teamwork processes and output in STEMI care.

DESIGN

A multicenter pre-post intervention study.

SETTING

Eleven acute hospitals.

PARTICIPANTS

Cardiologists-in-chief, nurse managers, quality staff, quality managers and program managers reported on hospital context. Teamwork was rated by professional groups (medical doctors, nurses, allied health professionals, other) in the following departments: emergency room, catheterization lab, coronary care unit, cardiology ward and rehabilitation.

INTERVENTION

Care pathway covering in-hospital care from emergency services to rehabilitation.

MAIN OUTCOME MEASURES

Hospital context was measured by the five dimensions of the Model for Understanding Success in Quality: microsystem, quality improvement team, quality improvement support, high-level organization, external environment. Teamwork process measures reflected teamwork between professional groups within departments and teamwork between departments. Teamwork output was measured through the level of organized care. Two-level regression analysis accounted for clustering of respondents within hospitals and assessed the influence of hospital context on the impact of care pathway implementation on teamwork.

RESULTS

Care pathway implementation significantly improved teamwork processes both between professional groups (P < 0.001) and between departments (P < 0.001). Teamwork output also improved (P < 0.001). The effect of care pathway implementation on teamwork was more pronounced when the quality improvement team and quality improvement support and capacity were more positively reported on.

CONCLUSIONS

Hospitals can leverage the effect of quality improvement interventions such as care pathways by evaluating and improving aspects of hospital context.

Effects of implementing a care pathway for colorectal cancer surgery in ten European hospitals: an international multicenter pre-post-test study

Adherence to evidence-based recommendations is variable and generally low. This is also followed in colorectal surgery, despite the availability of the ERAS^® protocol. The aim of the study was to evaluate the effect of implementing a care pathway for perioperative care in colorectal cancer surgery on outcomes and protocol adherence. So, we performed an international pre-test-post-test multicenter study, performed in ten hospitals in four European countries. The measures used included length of stay, morbidity and mortality, and documentation and adherence on intervention and patient level. Unadjusted pre-test-post-test differences were analyzed following an analysis adjusted for patient-mix variables. Importance-performance analysis was used to map the relationship between importance and performance of individual interventions. In total, 381 patients were included. Length of stay decreased from 12.6 to 10.7 days (p = 0.0230). Time to normal diet and walking also decreased significantly. Protocol adherence improved from 56 to 62% (p < 0.00001). Adherence to individual interventions remained highly variable. Importance-performance analysis showed 30 interventions were scored as important, of which 19 had an adherence < 70%, showing priorities for improvement. Across hospitals, change in protocol adherence ranged from a 13% decrease to a 22% increase. Implementing a care pathway for colorectal cancer surgery reduced length of stay, time to normal diet and walking. Documentation and protocol adherence improved after implementing the care pathway. However, not in all participating hospitals protocol adherence improved. Only in 25% of patients, protocol adherence of ≥ 70% was achieved, suggesting a large group is at risk for underuse. Importance-performance analysis showed which interventions are important, but have low adherence, prioritizing improvement efforts.

The Care Process Organization Triangle: A Framework to Better Understand how Clinical Pathways Work

Clinical pathways, also known as care pathways or integrated care pathways, are used worldwide to make care processes transparent and organize care around patient needs. Although this is in international use, it is still unclear why pathways sometimes work and sometimes do not. To better understand how pathways work, there is a growing need for paradigms or organizing concepts. Different quality and health-care management gurus have developed frameworks to better understand how certain processes or methods work. This paper will provide an overview of several frameworks and integrate them into Donabedian's Structure–Process–Outcome configuration. In view of this configuration, the care process organization triangle was developed. In this paper, we will describe the three cornerstones of this triangle by integrating the literature on clinical pathways. The care process organization triangle is only one model, but as Deming described it: ‘Some models can be quite useful’.

Impact of care pathway implementation on interprofessional teamwork: An international cluster randomized controlled trial

This study evaluates whether the implementation of an in-hospital care pathway (CP) improves interprofessional teamwork across countries and tests whether improved communications ("relational coordination") is the mechanism of action. A hospital-based cluster randomized controlled trial in Ireland, Belgium, Italy, and Portugal was performed. Fifty-six interprofessional teams caring for patients admitted with an exacerbation of chronic obstructive pulmonary disease or for patients with a proximal femur fracture were included and randomly assigned to an intervention group (31 teams and 567 team members), where a CP was implemented, and a control group (25 teams and 417 team members) representing usual care. Multilevel regression and mediation analysis were applied. First, although no significant effect was found on our primary outcome relational coordination, our CP significantly improved several team inputs, team processes (team climate for innovation) and team output (the level of organized care, level of competence) indicators. Second, our team process indicator of team climate for innovation partially mediated the association between CP implementation and team output indicator of better level of organized care. In conclusion, a CP sets in motion various mechanisms that improve some but not all aspects of interprofessional teamwork. Relational coordination does not appear to be the mechanism by which team outputs are enhanced.

Reinterpreting the nursing record for an electronic context

BACKGROUND

This article seeks to facilitate the re-imagining of nursing records purposefully within an electronic context. It questions existing approaches to nursing documentation, critically examines existing nursing record systems and identifies new requirements.

METHODS

A comprehensive literature review was conducted to identify themes, that might meaningfully contribute to a new approach to nursing record systems development, around four key interrelated areas - standards, decision making, abstraction and summarization, and documenting. Studies were analyzed using narrative synthesis to provide a critical analysis of the current 'state of the art', and recommendations for the future.

RESULTS

Included studies collectively described aspects of current best practice, both in terms of nursing record systems themselves, and how nurses and other health professionals contribute to and engage with those systems. A number of cross-cutting themes identified more novel approaches taken by nurses to systems development: going back to basics in determining purpose; firming up informatics foundations; nuancing or tailoring to suit different requirements; and engagement, involvement and participation.

CONCLUSION

There is a paucity of research that specifically focuses on the nature of the electronic nursing record and its impact on patient care processes and outcomes. In addition to further research in these areas, there is a need: to reinterpret nurses as knowledge workers rather than as 'data collectors'; to agree on the application in practice of appropriate standards and terminologies; and to work together with system developers to change the ways in which data are captured and care is documented.

Implications of a wide-scale educational intervention to engage nurses in evidence-based practice: The Italian RN4CAST experience

BACKGROUND

In Italy, there are still many barriers to the development of a culture of evidence-based practice (EBP) and nurses' knowledge of EBP is lacking. Additionally, in Italy there are still very few advanced practice registered nurses to significantly contribute to the development of EBP.

AIM

This aims to identify the implications of a wide-scale nursing education intervention to engage clinical nurses in EBP through the Italian RN4CAST study.

METHODS

A qualitative study based on a thematic analysis. A total of 800 clinical nurses actively participated in nine training sessions across Italy. At the end of each training session written feedback data were collected and then underwent thematic analysis.

RESULTS

All participants were strongly motivated to engage in EBP thanks to their involvement in the RN4CAST project. With regard to the implications of EBP, the thematic analysis produced the following themes: Professional identity; Quality of care; Perceptions of patients and nurses; Research impact; and Organization.

CONCLUSIONS

The involvement of a large number of clinical nurses in a research project raised their awareness about the advantages of engaging in EBP, and how evidence can be used to raise motivation to change current practice policies.

Care pathways are complex interventions in complex systems: New European Pathway Association framework

Care pathway implementation is characterised by a dual complexity. A care pathway itself represents a complex intervention with multiple interacting and interdependent intervention components and outcomes. The organisations in which care pathways are being implemented represent complex systems that need to be directed at change through an in-depth understanding of their external and internal context in which they are functioning in. This study sets out a new evidence-based and pragmatic framework that unpacks how intervention mechanisms, intervention fidelity and care context are converge and represent interacting processes that determine success or failure of the care pathway. We recommend researchers looking to increase the effectiveness of care pathway implementation and accelerate improvement of desired outcomes to adopt this framework from inception to implementation of the intervention.

Physicians' attitudes toward end-of-life decisions in amyotrophic lateral sclerosis

OBJECTIVE

This study aims (1) to assess physicians' attitudes toward different palliative end-of-life (EOL) practices in amyotrophic lateral sclerosis (ALS) care, including forgoing artificial nutrition and hydration (FANH), continuous sedation until death (CSD), and withdrawing invasive ventilation (WIV), and toward physician-assisted dying (PAD) including physician-assisted suicide and euthanasia and (2) to explore variables influencing these attitudes.

METHODS

We used two clinical vignettes depicting ALS patients in different stages of their disease progression to assess the influence of suffering (physical/psycho-existential) on attitudes toward WIV and the influence of suffering and prognosis (short-term/long-term) on attitudes toward FANH, CSD, and PAD.

RESULTS

50 physicians from European ALS centers and neurological departments completed our survey. Short-term prognosis had a positive impact on attitudes toward offering FANH (p = 0.014) and CSD (p = 0.048) as well as on attitudes toward performing CSD (p = 0.036) and euthanasia (p = 0.023). Predominantly psycho-existential suffering was associated with a more favorable attitude toward WIV but influenced attitudes toward performing CSD negatively. Regression analysis showed that religiosity was associated with more reluctant attitudes toward palliative EOL practices and PAD, whereas training in palliative care was associated with more favorable attitudes toward palliative EOL practices only.

CONCLUSION

ALS physicians seem to acknowledge psycho-existential suffering as a highly acceptable motive for WIV but not CSD. Physicians appear to be comfortable with responding to the patient's requests, but more reluctant to assume a proactive role in the decision-making process. Palliative care training may support ALS physicians in these challenging situations.

Hormonal medication in medically assisted reproduction: a systematic review of assessments from patients

Several hormonal fertility medications have comparable effectiveness. A literature review was conducted into patients' assessments regarding seven medication characteristics including 'side effects' and 'ease of use'. Medline, CINAHL and PsycINFO were searched for female fertility patients' written assessments of a hormonal medication. The tools used were appraised and common (i.e. ≥10%) unpleasant consequences were distinguished from rare ones. The 35 eligible studies did not rely on valid and reliable tools and did not provide patient assessments regarding all seven medication characteristics for any of the globally used medications. Evidence on medications for oocyte triggering was absent and for induction of pituitary quiescence it was scarce. Regarding medications for ovarian stimulation and luteal support, evidence on general side effects (mostly headache), local side effects (mostly pain), 'interference with home life' and 'impact on psychological wellbeing' was found. Evidence on 'ease of use' and 'required education' was only identified for medication for ovarian stimulation. Evidence on 'interference with work life' and 'compliance worry' was absent. This review calls for randomized controlled trials questioning patients with valid and reliable tools. In the meantime, this review's summary of the best available evidence can be integrated in decision aids facilitating personalized and informed medication choices.

Care Pathway Effect on In-Hospital Care for ST-Elevation Myocardial Infarction

OBJECTIVES

To study the care pathway effect on the percentage of patients with ST-elevation myocardial infarction -(STEMI) receiving timely coronary reperfusion and the percentage of STEMI patients receiving optimal secondary prevention.

METHODS

A care pathway was implemented by the Collaborative Model for Achieving Breakthrough Improvement. One pre-intervention and 2 post-intervention audits included all adult STEMI patients admitted within 24 h after onset and eligible for reperfusion. Adjusted (hospital random intercepts and controls for transfer and out-of-office admission) differences in composite outcomes were analyzed by a multilevel logistic regression.

RESULTS

Significant improvements in intervals between the first medical contact (FMC) to percutaneous coronary intervention (PCI) and between the door to PCI were shown between post-intervention audit II and post-intervention audit I. Secondary prevention significantly deteriorated at post-intervention audit I but improved significantly between both post-intervention audits. Six out of nine outcomes were significantly poorer in the case of transfer. The interval from FMC to PCI was significantly poorer for patients admitted during out-of-office hours.

CONCLUSIONS

After care pathway implementation, composite outcomes improved for in-hospital STEMI care. Collaborative efforts exploited heterogeneity in performance between hospitals. Iterative and incremental care pathway implementation maximized performance improvement.

Minimal impact of a care pathway for geriatric hip fracture patients

BACKGROUND

Adherence to guidelines for patients with proximal femur fracture is suboptimal.

OBJECTIVE

To evaluate the effect of a care pathway for the in-hospital management of older geriatric hip fracture patients on adherence to guidelines and patient outcomes.

DESIGN

The European Quality of Care Pathways study is a cluster randomized controlled trial.

SETTING

26 hospitals in Belgium, Italy and Portugal.

SUBJECTS

Older adults with a proximal femur fracture (n = 514 patients) were included.

METHODS

Hospitals treating older adults (>65) with a proximal femur fracture were randomly assigned to an intervention group, i.e. implementation of a care pathway, or control group, i.e. usual care. Thirteen patient outcomes and 24 process indicators regarding in-hospital management, as well as three not-recommended care activities were measured. Adjusted and unadjusted regression analyses were conducted using intention-to-treat procedures.

RESULTS

In the intervention group 301 patients in 15 hospitals were included, and in the control group 213 patients in 11 hospitals. Sixty-five percent of the patients were older than 80 years. The implementation of this care pathway had no significant impact on the thirteen patient outcomes. The preoperative management improved significantly. Eighteen of 24 process indicators improved, but only two improved significantly. Only for a few teams a geriatrician was an integral member of the treatment team.

DISCUSSION

Implementation of a care pathway improved compliance to evidence, but no significant effect on patient outcomes was found. The impact of the collaboration between surgeons and geriatricians on adherence to guidelines and patient outcomes should be studied.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00962910.

Similarities and differences in the associations between patient safety culture dimensions and self-reported outcomes in two different cultural settings: a national cross-sectional study in Palestinian and Belgian hospitals

OBJECTIVES

To investigate the relationships between patient safety culture (PSC) dimensions and PSC self-reported outcomes across different cultures and to gain insights in cultural differences regarding PSC.

DESIGN

Observational, cross-sectional study.

SETTING

Ninety Belgian hospitals and 13 Palestinian hospitals.

PARTICIPANTS

A total of 2836 healthcare professionals matched for profession, tenure and working hours.

PRIMARY AND SECONDARY OUTCOME MEASURES

The validated versions of the Belgian and Palestinian Hospital Survey on Patient Safety Culture were used. An exploratory factor analysis was conducted. Reliability was tested using Cronbach's alpha (α). In this study, we examined the specific predictive value of the PSC dimensions and its self-reported outcome measures across different cultures and countries. Hierarchical regression and bivariate analyses were performed.

RESULTS

Eight PSC dimensions and four PSC self-reported outcomes were distinguished in both countries. Cronbach's α was α≥0.60. Significant correlations were found between PSC dimensions and its self-reported outcome (p value range <0.05 to <0.001). Hierarchical regression analyses showed overall perception of safety was highly predicted by hospital management support in Palestine (β=0.16, p<0.001) and staffing in Belgium (β=0.24, p<0.001). The frequency of events was largely predicted by feedback and communication in both countries (Palestine: β=0.24, p<0.001; Belgium: β=0.35, p<0.001). Overall grade for patient safety was predicted by organisational learning in Palestine (β=0.19, p<0.001) and staffing in Belgium (β=0.19, p<0.001). Number of events reported was predicted by staffing in Palestine (β=-0.20, p<0.001) and feedback and communication in Belgium (β=0.11, p<0.01).

CONCLUSION

To promote patient safety in Palestine and Belgium, staffing and communication regarding errors should be improved in both countries. Initiatives to improve hospital management support and establish constructive learning systems would be especially beneficial for patient safety in Palestine. Future research should address the association between safety culture and hard patient safety measures such as patient outcomes.

A call for action to establish a research agenda for building a future health workforce in Europe

The importance of a sustainable health workforce is increasingly recognised. However, the building of a future health workforce that is responsive to diverse population needs and demographic and economic change remains insufficiently understood. There is a compelling argument to be made for a comprehensive research agenda to address the questions. With a focus on Europe and taking a health systems approach, we introduce an agenda linked to the 'Health Workforce Research' section of the European Public Health Association. Six major objectives for health workforce policy were identified: (1) to develop frameworks that align health systems/governance and health workforce policy/planning, (2) to explore the effects of changing skill mixes and competencies across sectors and occupational groups, (3) to map how education and health workforce governance can be better integrated, (4) to analyse the impact of health workforce mobility on health systems, (5) to optimise the use of international/EU, national and regional health workforce data and monitoring and (6) to build capacity for policy implementation. This article highlights critical knowledge gaps that currently hamper the opportunities of effectively responding to these challenges and advising policy-makers in different health systems. Closing these knowledge gaps is therefore an important step towards future health workforce governance and policy implementation. There is an urgent need for building health workforce research as an independent, interdisciplinary and multi-professional field. This requires dedicated research funding, new academic education programmes, comparative methodology and knowledge transfer and leadership that can help countries to build a people-centred health workforce.

Prevalence and use of clinical pathways in 23 countries – an international survey by the European Pathway Association

Objectives

To give an overview on the use and prevalence of clinical pathways.

Design

Cross-sectional descriptive study.

Study participants

European Pathway Association (E-P-A) contact persons in 23 countries.

Results

Clinical pathways, also known as critical pathways or integrated care pathways, have been used in health care for 20 years. Although clinical pathways are well established, little information exists on their use and dissemination around the world. The E-P-A has performed their first international survey on the use and dissemination of clinical pathways in 23 countries. At present, pathways are used with a minority of patients, mainly in acute hospital trusts. Our survey showed that clinical pathways were predominantly viewed as a multidisciplinary tool to improve the quality and efficiency of evidence-based care. Pathways were also used as a communication tool between professionals to manage and standardize outcome-oriented care.

Conclusions

There is a future for the use of clinical pathways, but there is a need for international benchmarking and knowledge sharing with regard to their development, implementation and evaluation.

Patient experiences with care across various types of mental health care: Questionnaire development, measurement invariance, and patients' reports

To describe the development, validation, and findings of a patient experience questionnaire across 7 types of residential and ambulatory mental health care services. Thirty-five items were hypothesized to cover information, participation, therapeutic relationship, personalized care, organization and collaboration, safety, patient rights, outcomes of care, and discharge preparation and after-care. Also included were 2 overall rating items (scoring and recommending the organization). This Dutch questionnaire was applied in 79 organizations in Belgium (N patients = 5,168). Exploratory structural equation modelling was conducted on a random split-half sample to examine dimensionality. Confirmatory factor analysis and multiple group confirmatory factor analyses were conducted on the holdout sample to confirm dimensionality and assess measurement invariance across type of service and patient characteristics. Multilevel logistic regression models linking subscale top box scores to overall rating items were used to assess criterion validity. The hypothesized dimensionality was partly confirmed, and configural and scalar invariance were demonstrated across types of organizations and patient characteristics. Subscale scores were significantly associated with overall ratings. Process evaluation showed that participating organizations strongly support continued use of this questionnaire. This validated patient experience questionnaire supports comparison across organizations from different types of services to improve the quality of mental health care.

Teamwork and Adherence to Recommendations Explain the Effect of a Care Pathway on Reduced 30-day Readmission for Patients with a COPD Exacerbation

This study aimed to increase our understanding of processes that underlie the effect of care pathway implementation on reduced 30-day readmission rate. Adherence to evidence-based recommendations, teamwork and burnout have previously been identified as potential mechanisms in this association. We conducted a secondary data analysis of 257 patients admitted with chronic obstructive pulmonary disease exacerbation and 284 team members caring for these patients in 19 Belgian, Italian and Portuguese hospitals. Clinical measures included 30-day readmission and adherence to a specific set of five care activities. Teamwork measures included team climate for innovation, level of organized care and burnout (emotional exhaustion, level of competence and mental detachment). Care pathway implementation was significantly associated with better adherence and reduced 30-day readmission. Better adherence and higher level of competence were also related to reduced 30-day readmission. Only better adherence fully mediated the association between care pathway implementation and reduced 30-day readmission. Better team climate for innovation and level of organized care, although both improved after care pathway implementation, did not show any explanatory mechanisms in the association between care pathway implementation and reduced 30-day readmission. Implementation of a care pathway had an impact on clinical and team indicators. To reduce 30-day readmission rates, in the development and implementation of a care pathway, hospitals should measure adherence to evidence-based recommendations during the whole process, as this can give information regarding the success of implementation.

Managing in-hospital quality improvement: An importance-performance analysis to set priorities for ST-elevation myocardial infarction care

BACKGROUND

A focus on specific priorities increases the success rate of quality improvement efforts for broad and complex-care processes. Importance-performance analysis presents a possible approach to set priorities around which to design and implement effective quality improvement initiatives. Persistent variation in hospital performance makes ST-elevation myocardial infarction care relevant to consider for importance-performance analysis.

AIMS

The purpose of this study was to identify quality improvement priorities in ST-elevation myocardial infarction care.

METHODS

Importance and performance levels of ST-elevation myocardial infarction key interventions were combined in an importance-performance analysis. Content validity indexes on 23 ST-elevation myocardial infarction key interventions of a multidisciplinary RAND Delphi Survey defined importance levels. Structured review of 300 patient records in 15 acute hospitals determined performance levels. The significance of between-hospital variation was determined by a Kruskal-Wallis test. A performance heat-map allowed for hospital-specific priority setting.

RESULTS

Seven key interventions were each rated as an overall improvement priority. Priority key interventions related to risk assessment, timely reperfusion by percutaneous coronary intervention and secondary prevention. Between-hospital performance varied significantly for the majority of key interventions. The type and number of priorities varied strongly across hospitals.

CONCLUSIONS

Guideline adherence in ST-elevation myocardial infarction care is low and improvement priorities vary between hospitals. Importance-performance analysis helps clinicians and management in demarcation of the nature, number and order of improvement priorities. By offering a tailored improvement focus, this methodology makes improvement efforts more specific and achievable.

Effectiveness of discharge interventions from hospital to home on hospital readmissions: a systematic review

BACKGROUND

Many discharge interventions are developed to reduce unplanned hospital readmissions, but it is unclear which interventions are more effective.

OBJECTIVES

The objective of this review was to identify discharge interventions from hospital to home that reduce hospital readmissions within three months and to understand their effect on secondary outcome measures.

INCLUSION CRITERIA

Participants were adults (18 years or older) discharged from a medical or surgical ward.The included interventions had to be designed to ease the care transition from hospital to home or to prevent problems after hospital discharge.This review considered only randomized controlled trials.The primary outcome measure was hospital readmission within three months after discharge. Secondary outcomes included patient satisfaction, return to emergency departments and mortality.

SEARCH STRATEGY

Studies in English between January 1990 and July 2014 were considered for inclusion. The databases searched were PubMed, Web of Science, Embase and CINAHL.

METHODOLOGICAL QUALITY

Methodological validity was assessed by two reviewers prior to inclusion using the standardized critical appraisal instruments from the Joanna Briggs Institute.

DATA EXTRACTION

Quantitative data were independently extracted by the two reviewers using the standardized data extraction tool from the Joanna Briggs Institute.

DATA SYNTHESIS

Meta-analysis was performed by using a random effect model; data were pooled using Mantel-Haenszel methods. For subgroups analysis only papers with critical appraisal score of seven or more were selected.

RESULTS

Meta-analysis was performed on 47 studies. The overall relative risk for hospital readmission was 0.77 [95% CI, 0.70-0.84] (p<0.00001). The relative risk for return to the emergency department was 0.75 [95% CI, 0.55-1.01] (p=0.06) and for mortality 0.70 [95% CI, 0.48-1.01] (p=0.06). Patient satisfaction improved in favor of the intervention group in five out of the six studies evaluating patient satisfaction.Exploratory subgroup analysis found that interventions starting during hospital stay and continuing after discharge were more effective in reducing readmissions compared to interventions starting after discharge (between subgroup difference p=0.01). Multicomponent interventions were not more effective compared to single component interventions (between subgroup difference p=0.54). Interventions oriented towards patient empowerment were more effective compared to all other interventions (between subgroup difference p=0.02).

CONCLUSIONS

Interventions designed to improve the care transition from hospital to home are effective in reducing hospital readmission. These interventions preferably start in the hospital and continue after discharge rather than starting after discharge. Enhancing patient empowerment is a key factor in reducing hospital readmissions.Interventions to reduce hospital readmissions should start during hospital stay and continue in the community (grade A recommendation). This requires financial systems to support and facilitate collaboration between hospitals and home care.Interventions that support patient empowerment are more effective in reducing hospital readmissions (grade B recommendation). To promote patient empowerment caregivers must be trained to increase patients' capacity to self-care.Future research should focus on interventions that improve patient empowerment and the effects of discharge interventions after more than three months.

Development of a model care pathway for adults undergoing colorectal cancer surgery: Evidence-based key interventions and indicators

RATIONALE, AIMS, AND OBJECTIVES

During the last decades, perioperative care for patients with colorectal cancer has shifted towards more standardized care, so-called "enhanced recovery after surgery." Those programs aim to optimize interventions in perioperative care to decrease the rate of postoperative complications, improve patients' recovery, and shorten hospital stay. The purpose of this literature review is to identify, summarize, and operationalize the clinical content of both key interventions and clinical indicators to develop an evidence-based model pathway for surgical patients with colorectal cancer.

METHODS

A systematic search in 3 databases was conducted to identify key interventions (KIs) and indicators to measure the effect of implementation of care pathways. The KIs from the enhanced recovery after surgery protocol were listed and used as framework to identify and match KIs used in the included studies. The Clinical Pathway Compass was used to categorize the indicators.

RESULTS

Fifteen studies were included. The number of KI used in the study protocols ranged from 9 to 20. In total, 33 KIs were identified. Little information was available concerning the implementation of and compliance to the protocol. Length of stay and complication rate are the most common used indicators (used in 15/15 and 14/15 of the studies), followed by 21 other measures. All but one of the included studies reported a reduction in length of stay.

CONCLUSION

There is a considerable variation in both number of KIs and indicators as well as operationalization of key interventions, for surgical patients with colorectal cancer documented in literature. Therefore, we summarized the input from different studies and developed an evidence-based model pathway, which can serve as a basis for a local/regional care pathway team to build their own pathway.

Key interventions and quality indicators for quality improvement of STEMI care: a RAND Delphi survey

OBJECTIVE

Identification, selection and validation of key interventions and quality indicators for improvement of in hospital quality of care for ST-elevated myocardial infarction (STEMI) patients.

METHODS AND RESULTS

A structured literature review was followed by a RAND Delphi Survey. A purposively selected multidisciplinary expert panel of cardiologists, nurse managers and quality managers selected and validated key interventions and quality indicators prior for quality improvement for STEMI. First, 34 experts (76% response rate) individually assessed the appropriateness of items to quality improvement on a nine point Likert scale. Twenty-seven key interventions, 16 quality indicators at patient level and 27 quality indicators at STEMI care programme level were selected. Eighteen additional items were suggested. Experts received personal feedback, benchmarking their score with group results (response rate, mean, median and content validity index). Consequently, 32 experts (71% response rate) openly discussed items with an item-content validity index above 75%. By consensus, the expert panel validated a final set of 25 key interventions, 13 quality indicators at patient level and 20 quality indicators at care programme level prior for improvement of in hospital care for STEMI.

CONCLUSIONS

A structured literature review and multidisciplinary expertise was combined to validate a set of key interventions and quality indicators prior for improvement of care for STEMI. The results allow researchers and hospital staff to evaluate and support quality improvement interventions in a large cohort within the context of a health care system.

Variation in care for surgical patients with colorectal cancer: protocol adherence in 12 European hospitals

PURPOSE

Surgical care for patients with colorectal cancer has become increasingly standardized. The Enhanced Recovery After Surgery (ERAS) protocol is a widely accepted structured care method to improve postoperative outcomes of patients after surgery. Despite growing evidence of effectiveness, adherence to the protocol remains challenging in practice. This study was designed to assess the adherence rate in daily practice and examine the relationship between the importance of interventions and adherence rate.

METHODS

This international observational, cross-sectional multicenter study was performed in 12 hospitals in four European countries. Patients were included from January 1, 2014. Data was retrospectively collected from the patient record by the local study coordinator.

RESULTS

A total of 230 patients were included in the study. Protocol adherence was analyzed for both the individual interventions and on patient level. The interventions with the highest adherence were antibiotic prophylaxis (95%), thromboprophylaxis (87%), and measuring body weight at admission (87%). Interventions with the lowest adherence were early mobilization-walking and sitting (9 and 6%, respectively). The adherence ranged between 16 and 75%, with an average of 44%.

CONCLUSION

Our results show that the average protocol adherence in clinical practice is 44%. The variation on patient and hospital level is considerable. Only in one patient the adherence rate was >70%. In total, 30% of patients received 50% or more of the key interventions. A solid implementation strategy seems to be needed to improve the uptake of the ERAS pathway. The importance-performance matrix can help in prioritizing the areas for improvement.

Post-operative mortality, missed care and nurse staffing in nine countries: A cross-sectional study

Background

Variation in post-operative mortality rates has been associated with differences in registered nurse staffing levels. When nurse staffing levels are lower there is also a higher incidence of necessary but missed nursing care. Missed nursing care may be a significant predictor of patient mortality following surgery.

Aim

Examine if missed nursing care mediates the observed association between nurse staffing levels and mortality.

Method

Data from the RN4CAST study (2009–2011) combined routinely collected data on 422,730 surgical patients from 300 general acute hospitals in 9 countries, with survey data from 26,516 registered nurses, to examine associations between nurses’ staffing, missed care and 30-day in-patient mortality. Staffing and missed care measures were derived from the nurse survey. A generalized estimation approach was used to examine the relationship between first staffing, and then missed care, on mortality. Bayesian methods were used to test for mediation.

Results

Nurse staffing and missed nursing care were significantly associated with 30-day case-mix adjusted mortality. An increase in a nurse’s workload by one patient and a 10% increase in the percent of missed nursing care were associated with a 7% (OR 1.068, 95% CI 1.031–1.106) and 16% (OR 1.159 95% CI 1.039–1.294) increase in the odds of a patient dying within 30 days of admission respectively. Mediation analysis shows an association between nurse staffing and missed care and a subsequent association between missed care and mortality.

Conclusion

Missed nursing care, which is highly related to nurse staffing, is associated with increased odds of patients dying in hospital following common surgical procedures. The analyses support the hypothesis that missed nursing care mediates the relationship between registered nurse staffing and risk of patient mortality. Measuring missed care may provide an ‘early warning’ indicator of higher risk for poor patient outcomes.

Better organized care via care pathways: A multicenter study

An increased need for efficiency and effectiveness in today’s healthcare system urges professionals to improve the organization of care. Care pathways are an important tool to achieve this. The overall aim of this study was to analyze if care pathways lead to better organization of care processes. For this, the Care Process Self-Evaluation tool (CPSET) was used to evaluate how healthcare professionals perceive the organization of care processes. Based on information from 2692 health care professionals gathered between November 2007 and October 2011 we audited 261 care processes in 108 organizations. Multilevel analysis was used to compare care processes without and with care pathways and analyze if care pathways led to better organization of care processes. A significant difference between care processes with and without care pathways was found. A care pathway in use led to significant better scores on the overall CPSET scale (p<0.001) and its subscales, “coordination of care” (p<0.001) and “follow-up of care” (p<0.001). Physicians had the highest score on the overall CPSET scale and the five subscales. Care processes organized by care pathways had a 2.6 times higher probability that the care process was well-organized. In around 75% of the cases a care pathway led to better organized care processes. Care processes supported by care pathways were better organized, but not all care pathways were well-organized. Managers can use care pathways to make healthcare professionals more aware of their role in the organization of the care process.

Evolving Role of the Nursing Informatics Specialist

The scope of nursing informatics practice has been evolving over the course of the last 5 decades, expanding to address the needs of health care organizations and in response to the evolution of technology. In parallel, the educational preparation of nursing informatics specialists has become more formalized and shaped by the requisite competencies of the role. In this chapter, the authors describe the evolution of nursing informatics roles, scope and focus of practice, and anticipated role responsibilities and opportunities for the future. Further, implications and considerations for the future are presented.

An International Study of Adherence to Guidelines for Patients Hospitalised with a COPD Exacerbation

Guideline adherence rates for the treatment of chronic obstructive pulmonary disease (COPD) exacerbation are low. The aim of this study is to perform an importance-performance analysis as an approach for prioritisation of interventions by linking guidelines adherence rates to expert consensus rates for the in-hospital management of COPD exacerbation. We illustrate the relevance of such approach by describing variation in guideline adherence across indicators and hospitals. A secondary data analysis of patients with an acute COPD exacerbation admitted to Belgian, Italian and Portuguese hospitals was performed. Twenty-one process indicators were used to describe adherence to guidelines from patient record reviews. Expert consensus on the importance for follow-up of these 21 indicators was derived from a previous Delphi study. Three of the twenty-one indicators had high level of expert consensus and a high level of adherence. Eleven of the twenty-one indicators had high level of expert consensus but a low level of adherence. For none of the 378 patients included in this study were all process indicators adhered to, patients received 41.0% of the recommended care on average, and only 34.1% of the patients received 50% or more of the care they should receive. There was also a large variation within and between hospitals regarding the care received. This study confirms the findings of previous studies, indicating that COPD exacerbations are largely undertreated. Importance-performance analysis provides a decision-making tool for prioritising indicators. All hospitals in this study would benefit from having in place a quality framework for systematic follow-up of these indicators.