Relationship between transition shock in novice emergency room nurses, quality of nursing care, and adverse patient events: The mediating role of emotional exhaustion

BACKGROUND

Transition shock, experienced during the first two years of employment, has been attributed to decreased clinical performance and an overall decrease in work productivity among newly graduated nurses, as well as compromised patient safety outcomes. This study tested the intermediary effect of emotional exhaustion on the association between transition shock in novice emergency room (ER) nurses, adverse patient events, and nursing care quality.

METHODS

A descriptive study was carried out involving 303 novice ER nurses from various emergency units in five different hospitals in Central Philippines, utilizing four standardized scales. Mediation testing was performed using Hayes' PROCESS macro in SPSS (Model 4).

RESULTS

Transition shock in novice ER nurses was associated with an increased incidence of adverse patient events (β = 0.3897, p = 0.0005) and poorer nursing care quality (β = -0.2146, p = 0.0021). Furthermore, emotional exhaustion partially mediated the association between transition shock and the two patient-related outcomes: adverse patient events (β = 0.0477, 95 % CI = 0.0078-0.0997) and nursing care quality (β = -0.0142, 95 % CI = -0.0412 to -0.0095).

CONCLUSIONS

Transition shock in novice ER nurses contributed to heightened emotional exhaustion, which subsequently led to an increased incidence of adverse patient events and a decline in the quality of nursing care.

Does competition support integrated care to improve quality?

Introduction

This work investigates the compatibility of integrated care and competition in China and analyses the impact of integrated care on regional care quality (DeptQ) within a competitive framework.

Method

The study was built on multivariate correspondence analysis and a two-way fixed-effects model. The data were collected from Xiamen's Big Data Application Open Platform and represent nine specialised departments that regularly performed inter-institutional referrals between 2016 and 2019.

Results

First, care quality for referred patients (ReferQ) and the relative scale of referred patients (ReferScale) and competition have an antagonistic but not completely mutually exclusive relationship. Second, ReferQ and competition both have a significant effect on DeptQ, but only when competition is weak can ReferQ and competition act synergistically on DeptQ. When competition is fierce, competition will weaken the impact of ReferQ on DeptQ.

Conclusion

Changes in the intensity of integrated care and competition ultimately affect care quality.

Emergency room nurses' caring ability and its relationship with patient safety outcomes: A cross-sectional study

INTRODUCTION

Nurse caring ability plays a crucial role in providing quality care and ensuring patient safety. However, further research is warranted to understand the specific impact of caring ability on patient safety in the emergency department.

AIM

This study has two-fold purposes: (a) to examine the association between nurses' demographic characteristics and their perceptions of their caring ability, and (b) to explore the relationship between nurses' caring ability and nursing care quality, as well as its impact on adverse patient events and missed care.

METHODS

This cross-sectional study included a convenience sample of emergency room nurses working in select hospitals in the Philippines. Descriptive statistics and regression analyses were performed to analyze the data.

RESULTS

A total of 164 out of the 200 emergency nurses invited responded to the survey. The mean score for the caring ability inventory was 67.89 out of 80. Nurses' demographic characteristics, including job status (working part-time) and hospital size (working in small and medium-sized hospitals), were associated with higher levels of caring ability. Higher levels of nurses' caring ability were associated with better nursing care quality (β = 0.259, p <.001), a reduction in adverse events (β = -0.169, p <.05), and a decrease in instances of missed care (β = -0.158, p <.01).

CONCLUSION

This study emphasizes the significance of nurses' characteristics in influencing nurse caring abilities. Additionally, the results underscore the importance of nurse caring ability in the emergency department and its association with nursing care quality and patient safety outcomes. Organizational strategies directed toward promoting and enhancing nurse caring ability in the emergency department can have positive implications for nursing practice, including improved nursing care quality, reduced adverse events, and decreased instances of missed care.

A day in the life of a home care worker in England: A human factors systems perspective

The delivery of home care in England is explored with respect to (a) the work system (b) the barriers that challenge worker performance, and most importantly (c) whether these barriers impact the quality and safety of the care received by older adults. Data were collected using surveys and interviews with home care workers (n = 11). The analysis used two validated Human Factors and Ergonomics (HFE) models to map the data which identified three key performance barriers; (1) time factors, (2) organisational practices, and (3) job design. Adaptive behaviour was identified as being routine to manage time barriers, which resulted in trade-offs between care outcomes (delivery), quality and safety standards and work-related quality of life. The findings make an important contribution to the limited research literature on home care work by highlighting the opportunity for an HFE systems perspective to provide a novel approach for both understanding home care and building better home care systems.

Outcomes of ST elevation myocardial infarction in patients with cancer: a nationwide study

AIMS

To assess processes of care and clinical outcomes in cancer patients with ST elevation myocardial infarction (STEMI) according to cancer type.

METHODS AND RESULTS

This is a national population-based study of patients admitted with STEMI in the UK between January 2005 and March 2019. Data were obtained from the National Heart Attack Myocardial Infarction National Audit Project (MINAP) registry and the Hospital Episode Statistics registry. We identified 353 448 STEMI-indexed admissions between 2005 and 2019. Of those, 8581 (2.4%) had active cancer. Prostate cancer (29% of STEMI patients with cancer) was the most common cancer followed by haematologic malignancies (14%) and lung cancer (13%). Cancer patients were less likely to receive invasive coronary revascularization (60.0% vs. 71.6%, P < 0.001] and had higher in-hospital death [odd ratio (OR) 1.39, 95% confidence interval (CI) 1.25-1.54] and bleeding (OR 1.23, 95% CI 1.03-1.46). Cancer patients had higher mortality at 30 days (HR 2.39, 95% CI 2.19-2.62) and 1 year (HR 3.73, 95% CI 3.58-3.89). Lung cancer was the cancer associated with the highest risk of death in the hospital (OR 1.75, 95% CI 1.39-2.22) and at 1 year (OR 8.08, 95% CI 7.44-8.78). Colon cancer (OR 1.98, 95% CI 1.24-3.14) was the main cancer associated with major bleeding. All common cancer types were associated with higher mortality at 1 year. Cardiovascular death (62%) was the main cause of death in the first 30 days, while cancer (52%) was the main cause of death within 1 year.

CONCLUSION

STEMI patients with cancer have a higher risk of short- and long-term mortality, particularly lung cancer. Colon cancer is the main cancer associated with major bleeding. Cardiovascular disease was the main cause of death in the first month, whereas cancer was the main cause of death within 1 year.

Guideline-concordant use of cognitive behavioral therapy for insomnia in the Veterans Health Administration

OBJECTIVE

To characterize guideline-concordant use of cognitive behavioral therapy for insomnia vs. sleep medications among Veterans Health Administration patients.

METHODS

Cognitive behavioral therapy for insomnia was identified from the text of psychotherapy notes within the Veterans Health Administration's electronic medical record. Patients that received first-line cognitive behavioral therapy for insomnia (ie, no prior insomnia treatment) were compared to those who first received a sleep medication in fiscal year 2021.

RESULTS

Among 5,519,016 patients, first-line cognitive behavioral therapy for insomnia was received by 9313 (0.2%) whereas 225,618 (4.1%) were newly prescribed a sleep medication without prior cognitive behavioral therapy for insomnia. Patients over 60 years old and those with substance use disorders were less likely to receive first-line cognitive behavioral therapy for insomnia compared to other patients.

CONCLUSIONS

Adherence to practice guidelines to provide cognitive behavioral therapy for insomnia as first-line treatment for insomnia disorder remains a challenge, highlighting the need to better integrate effective implementation strategies within therapist training programs. Targeted strategies may be needed for older patients or those with substance use disorders.

Exploring the relationship between compassion, the practice environment, and quality of care as perceived by paediatric nurses

PURPOSE

To (1) explore associations between paediatric nurses' perceptions of their own compassion, the practice environment, and quality of care, and (2) identify factors that influence perceived quality of care.

DESIGN AND METHODS

Cross-sectional survey of paediatric nurses (n = 113) from a hospital network in Melbourne, Australia. The survey included the Compassion Scale, Practice Environment Scale of the Nurse Work Index (PES-NWI), a single quality of care item, and demographic items. Hierarchical regression was used to explore factors that predicted perceived care quality.

RESULTS

There were moderate positive correlations between perceived care quality and both compassion (rho = 0.36, p < .001) and practice environment (i.e., total PES-NWI: rho = 0.45, p < .001). There were significant differences in perceived care quality based on nurses' work area (i.e., critical care vs medical/surgical wards). The final hierarchical regression analysis included compassion (Step 2) and four of five PES-NWI subscales (Step 3), controlling for work area (Step 1). The model was statistically significant and explained 44% of variance in perceived quality; compassion and PES-NWI subscale 2 (Nursing foundations for quality of care) were statistically significant predictors.

CONCLUSIONS

Paediatric nurses' perceptions of quality were influenced by their own compassion for others and elements of the practice environment, particularly nursing foundations for care quality, which is characterised by a clear nursing philosophy and model of care, with programs and processes to support practice.

PRACTICE IMPLICATIONS

The findings offer insights into potentially modifiable individual and workplace factors that contribute to paediatric nurses' perceptions of care quality.

Toxic leadership and its relationship with outcomes on the nursing workforce and patient safety: a systematic review

PURPOSE

This study aims to appraise and synthesize evidence examining the effects of toxic leadership on the nursing workforce and patient safety outcomes.

DESIGN/METHODOLOGY/APPROACH

This is a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. Five electronic databases (SCOPUS, PubMed, Web of Science, CINAHL and Psych INFO) were searched to identify relevant articles. Two independent researchers conducted the data extraction and appraisal. A content analysis was used to identify toxic leadership outcomes.

FINDINGS

The initial literature search identified 376 articles, 16 of which were deemed relevant to the final review. Results of the content analysis identified 31 outcomes, which were clustered into five themes: satisfaction with work; relationship with organization; psychological state and well-being; productivity and performance; and patient safety outcomes. Seven mediators between toxic leadership and five outcomes were identified in the included studies.

PRACTICAL IMPLICATIONS

Organizational strategies to improve outcomes in the nursing workforce should involve measures to build and develop positive leadership and prevent toxic behaviors among nurse managers through theory-driven strategies, human resource management efforts and relevant policy.

ORIGINALITY/VALUE

The review findings have provided modest evidence suggesting that working under a leader who exhibits toxic behaviors may have adverse consequences in the nursing workforce; however, more research examining if this leadership style influences patient safety and care outcomes is warranted.

Systemic anticancer treatment in the Netherlands: Few hospitals treat many patients, many hospitals treat few patients

INTRODUCTION

The correlation between patient volume and clinical outcomes is well known for various oncological treatments, especially in the surgical field. The current level of centralisation of systemic treatment of (hemato-)oncology indications in Dutch hospitals is unknown.

OBJECTIVES

The aim of this study was to gain insight in patient volumes per hospital of patients treated with systemic anticancer treatment in the Netherlands.

METHODS

National claims data (Vektis) of all 73 Dutch hospitals that provide systemic anticancer medication in the Netherlands for the time period 2019 were used. The distribution of volumes of patients treated with anticancer medication for 38 different haematological or oncological indications was analysed. Hospitals were categorized into academic/specialised, general, and top clinical. Two volume cut off points (10 and 30 patients) were used to identify hospitals treating relatively few patients with anticancer medication. Four indications were investigated in more detail.

RESULTS

A wide distribution in patient volumes within hospitals was observed. Top clinical hospitals generally treated the most patients per hospital, followed by general and academic/specialised oncology hospitals. The volume cut off points showed that in 19 indications (50%) the majority (>50%) of all hospitals treated less than 10 patients and in 25 indications (66%) the majority of all hospitals treated less than 30 patients with anticancer medication. Four case studies demonstrated that relatively few hospitals treat many patients while many hospitals treat few patients with anticancer medication.

CONCLUSION

In the majority of oncology indications, a large proportion of Dutch hospitals treat small numbers of unique patients with anticancer medication. The high level of fragmentation gives ground for further exploration and discussion on how the organisation of care can support optimization of the efficiency and quality of care. Professional groups, policy makers, patients, and healthcare insurers should consider per indication whether centralisation is warranted.

Prognosis, characteristics, and provision of care for patients with the unspecified heart failure electronic health record phenotype: a population-based linked cohort study of 95262 individuals

Background

Whether the accuracy of the phenotype ascribed to patients in electronic health records (EHRs) is associated with variation in prognosis and care provision is unknown. We investigated this for heart failure (HF, characterised as HF with preserved ejection fraction [HFpEF], HF with reduced ejection fraction [HFrEF] and unspecified HF).

Methods

We included individuals aged 16 years and older with a new diagnosis of HF between January 2, 1998 and February 28, 2022 from linked primary and secondary care records in the Clinical Practice Research Datalink in England. We investigated the provision of guideline-recommended diagnostic investigations and pharmacological treatments. The primary outcome was a composite of HF hospitalisation or all-cause death, and secondary outcomes were time to HF hospitalisation, all-cause death and death from cardiovascular causes. We used Kaplan-Meier curves and log rank tests to compare survival across HF phenotypes and adjusted for potential confounders in Cox proportional hazards regression analyses.

Findings

Of a cohort of 95,262 individuals, 1271 (1.3%) were recorded as having HFpEF, 10,793 (11.3%) as HFrEF and 83,198 (87.3%) as unspecified HF. Individuals recorded as unspecified HF were older with a higher prevalence of dementia. Unspecified HF, compared to patients with a recorded HF phenotype, were less likely to receive specialist assessment, echocardiography or natriuretic peptide testing in the peri-diagnostic period, or receive angiotensin-converting enzyme inhibitors, beta blockers or mineralocorticoid receptor antagonists up to 12 months after diagnosis (risk ratios compared to HFrEF, 0.64, 95% CI 0.63-0.64; 0.59, 0.58-0.60; 0.57, 0.55-0.59; respectively) and had significantly worse outcomes (adjusted hazard ratios compared to HFrEF, HF hospitalisation and death 1.66, 95% CI 1.59-1.74; all-cause mortality 2.00, 1.90-2.10; cardiovascular death 1.77, 1.65-1.90).

Interpretation

Our findings suggested that absence of specification of HF phenotype in routine EHRs is inversely associated with clinical investigations, treatments and survival, representing an actionable target to mitigate prognostic and health resource burden.

Funding

Japan Research Foundation for Healthy Aging and British Heart Foundation.

Palliative care utilization across health sectors for patients with gynecologic malignancies in Ontario, Canada from 2006 to 2018

OBJECTIVE

Early palliative care (PC) is associated with improved patient quality of life, less aggressive end-of-life care, and prolonged survival. We evaluated patterns of PC delivery in gynecologic oncology.

METHODS

We conducted a population-based, retrospective cohort study of gynecologic cancer decedents in Ontario from 2006 to 2018 using linked administrative health care data.

RESULTS

The cohort included 16,237 decedents; 51.1% died of ovarian cancer, 30.3% uterine cancer, 12.1% cervical cancer, and 6.5% vulvar/vaginal cancers. Palliative care was most often delivered in the hospital inpatient setting in 81%, and 53% received specialist PC. PC was first received during hospital admission in 53%, and by outpatient physician care in only 23%. Palliative care was initiated a median 193 days prior to death, with the lowest two quintiles initiating care ≤70 days before death. The average user of PC resources (third quintile) received 68 days of PC. While cumulative use of community PC gradually increased over the final year of life, institutional palliative care use exponentially rose from 12 weeks until death. On multivariable analyses, predictors of initiating palliative care during a hospital admission included age ≥70 years at death, ≤3 month cancer survival, having cervical or uterine cancer, not having a primary care provider, or being in the lowest 3 income quintiles.

CONCLUSION

Most palliative care is initiated and delivered during hospital admission, and is initiated late in a significant proportion. Strategies to increase access to anticipatory and integrated palliative care may improve the quality of the disease course and the end of life.

Factors that shape recurrent miscarriage care experiences: findings from a national survey

BACKGROUND

Learning what matters to women/couples with recurrent miscarriage (RM) is essential to inform service improvement efforts and future RM care practices. Previous national and international surveys have examined inpatient stays, maternity care, and care experiences around pregnancy loss, but there is little focus on RM care. We aimed to explore the experiences of women and men who have received RM care and identify patient-centred care items linked to overall RM care experience.

METHODS

Between September and November 2021, we invited people who had experienced two or more consecutive first trimester miscarriages and received care for RM in Ireland in the ten-year period prior to participate in a cross-sectional web-based national survey. The survey was purposefully designed and administered via Qualtrics. It included questions on sociodemographics, pregnancy and pregnancy loss history, investigation and treatment for RM, overall RM care experience, and patient-centred care items at various stages of the RM care pathway such as respect for patients' preferences, information and support, the environment, and involvement of partners/family. We analysed data using Stata.

RESULTS

We included 139 participants (97% women, n = 135) in our analysis. Of the 135 women, 79% were aged 35-44 years (n = 106), 24% rated their overall RM care experience as poor (n = 32), 36% said the care they received was much worse than expected (n = 48), and 60% stated health care professionals in different places did not work well together (n = 81). Women were more likely to rate a good care experience if they had a healthcare professional to talk to about their worries/fears for RM investigations (RRR 6.11 [95% CI: 1.41-26.41]), received a treatment plan (n = 70) (RRR 3.71 [95% CI: 1.28-10.71]), and received answers they could understand in a subsequent pregnancy (n = 97) (RRR 8 [95% CI: 0.95-67.13]).

CONCLUSIONS

While overall experience of RM care was poor, we identified areas that could potentially improve people's RM care experiences - which have international relevance - such as information provision, supportive care, communication between healthcare professionals and people with RM, and care coordination between healthcare professionals across care settings.

How are witnessed workplace bullying and bystander roles related to perceived care quality, work engagement, and turnover intentions in the healthcare sector? A longitudinal study

BACKGROUND

Workplace bullying is widespread in the healthcare sector and the negative effects are well known. However, less attention has been paid to bystanders who witness bullying in the workplace. Bystanders can affect the bullying process by engaging in active, passive, or destructive behaviors. There is a need to study work-related and organizational consequences of witnessing bullying and bystander behaviors.

OBJECTIVE

The aim was to explore how witnessed workplace bullying and bystander behaviors are associated with work-related and organizational consequences, such as perceived quality of care, work engagement, and turnover intentions, among healthcare workers over time.

DESIGN

Longitudinal design. An online questionnaire was administered twice over the course of six months.

SETTING(S)

Employees in the healthcare sector in Sweden, such as physicians, nurses, and assistant nurses, responded to the questionnaire.

PARTICIPANTS

1144 participants provided longitudinal data.

METHODS

Structural equation modeling was used to explore the associations between witnessed bullying, bystander behavior, work-related and organizational factors over time.

RESULTS

Witnessed workplace bullying (B = -0.18, 95 % CI [-0.23 to -0.12]) and the bystander outsider role (B = -0.24, 95 % CI [-0.29 to -0.19]) were statistically significantly related to a decrease in perceived quality of care. Work engagement was statistically significantly predicted by all three bystander roles over time; positively by the defender role (B = 0.11, 95 % CI [0.05-0.17]), and negatively by the outsider role (B = -0.23, 95 % CI [-0.29 to -0.16]), and the assistant role (B = -0.32, 95 % CI [-0.41 to -0.24]). The outsider role (B = 0.12, 95 % CI [0.02-0.22]), the assistant role (B = 0.17, 95 % CI [0.03-0.30]), and witnessed workplace bullying (B = 0.18, 95 % CI [0.08-0.29]), all positively predicted increased turnover intentions at a subsequent time point.

CONCLUSIONS

In addition to the direct negative impact workplace bullying has on those targeted by it, witnessing bullying and taking different bystander roles can have work-related and organizational consequences by influencing perceived care quality, employees' work engagement, and their intention to leave the organization.

Choosing wisely recommendations regarding the top five list of procedures to avoid in the treatment of viral hepatitis: A position statement from the Brazilian Society of Hepatology endorsed by the Latin American Association for the Study of the liver

INTRODUCTION AND OBJECTIVES

The Choosing Wisely (CW) initiative aims to improve daily practice supported by evidence concerning unnecessary medical tests, procedures, and treatments. This philosophy is essential in managing viral hepatitis (VH), which primary care physicians increasingly carry out. It is also essential to achieving disease elimination. Thus, the aim of our study was to propose evidence-based CW recommendations in VH.

MATERIALS AND METHODS

The Brazilian Society of Hepatology (SBH) formed a panel of experts in VH who selected evidence-based CW recommendations, which were subsequently scrutinized and ranked by all members of SBH using a web-based approach.

RESULTS

Five recommendations were chosen in order of importance: 1) do not order anti-HCV testing after achieving sustained virological response; 2) do not request serial HCV viral load to evaluate HCV progression, 3) do not add ribavirin to direct-acting antivirals in non-cirrhotic, naïve HCV patients; 4) do not screen for hepatocellular carcinoma in HCV patients with none to moderate fibrosis (≤ F2); 5) do not request anti-HBs after HBV vaccination, except for children born to HBV-infected mothers, hemodialysis patients, healthcare professionals, people who have had sexual contact with chronic HBV carriers, HIV-positive persons and immunocompromised individuals (hematopoietic stem-cell transplant recipients or persons receiving chemotherapy).

CONCLUSIONS

CW recommendations may help general practitioners adopt a more rational and cost-effective approach in managing patients with VH in Brazil and Latin America, leading to lesser waste or harm to patients.

The Predictors of Clinical Competence among Hospital Nurses: A Cross-Sectional Study in Hamadan, West Iran

Background

Nurses' clinical competence (CC) is critical in providing high-quality and safe nursing care. Assessment of nurses' CC and its predictors is a key step to improve their CC and the quality of their services. The aim of this study was to determine the predictors of CC among hospital nurses in Iran.

Methods

This analytical cross-sectional study was conducted from September 2020 to May 2021. Participants were purposively selected from four university hospitals in Hamadan, west of Iran. A demographic questionnaire and the 73-item Nurse Competence Scale were used for data collection. A total of 300 questionnaires were distributed and 270 questionnaires (response rate: 90%) were completed and returned to the researcher. Data were analyzed using the SPSS software (v. 16.0) and the one-way analysis of variance, the independent-sample t, the Mann-Whitney U, and the Kruskal-Wallis tests, the Pearson and the Spearman correlation analyses, and the linear regression analysis.

Results

The mean score of CC was 40.28±8.6 (in the possible range of 0-100) and the highest and the lowest dimensional mean scores were for the situation management (56.13±11) and the ensuring quality (25.3±8.1) dimensions, respectively. The mean score of CC had significant relationship with age, work experience, and ward of working and these variables significantly predicted 77% of the variance of CC (adjusted R = 0.778, P<0.05).

Conclusions

According to the results of this study, age, work experience and ward of working weresignificant predictors of CC in hospital nurses. Nursing managers should employ strategies such as reducing nurses' workload, improving their employment status, and providing them with quality in-service education in order to improve their CC and the quality of their services.

Inpatient care provider perspectives on the development and implementation of an addiction medicine consultation service in a small urban setting

BACKGROUND

To evaluate provider perspectives on the development and implementation of an inpatient Addiction Medicine Consult Service, including their awareness of the service, its perceived role in the continuum of care, and changes over time in their perceptions of care quality for inpatients with substance use disorders.

METHODS

Repeated cross-sectional survey of hospital-based physicians, nurses and social workers performed at service launch (April-June, 2017) and 4 years later (March-June, 2021).

RESULTS

Providers had generally positive perceptions of the service and its impact on care quality, but encountered significant barriers at both time points in meeting patient needs (related to high patient complexity and difficulty connecting patients with community services post-discharge). Relative to physicians and social workers, nurses were less likely to be familiar with the service or see it as beneficial.

CONCLUSIONS

Findings indicate that the service fills a gap that existed previously in the local system of care; however, numerous opportunities exist to further strengthen the system beyond the hospital setting to promote longer-term health among people who use substances. For nurses in particular, outreach, education, and other resources (e.g., dedicated nursing role support, nurse liaison) are warranted to ensure that nurses feel supported and confident caring for this patient population.

High quality care following orthopaedic injury in Zambia: A qualitative, patient-centred study

BACKGROUND

Injuries are a significant cause of mortality and morbidity, particular in low- and middle-income countries (LMICs). While there is a focus on increasing injury care capacity, less attention is given to assessing, improving, and understanding the quality of care provided, especially from a patient perspective. This study therefore aims to understand what patients from a Zambian orthopaedic ward believe good quality care to be, to identify its key components, and contribute to better understanding what patients believe local healthcare priorities could be.

METHODS

Patients admitted to the orthopaedic ward of a Zambian tertiary care hospital were invited to take part in-depth face-to-face interviews. Interviews were continued until thematic saturation was achieved. Interviews were recorded and transcribed. Analysis was done using an inductive grounded theory approach.

RESULTS

Of 13 patients approached, 12 consented to take part. Analysis of the themes from the transcripts led to the emergence of four core categories of quality care which are important to the patient: i) restoring the patient to normality (category: 'restoring normality'), ii) establishing trust between patients and providers ('trusting the provider'), iii) respecting the patient and allowing them to maintain autonomy ('autonomy and respect') iv) finding ways for patients to enjoy their time in the hospital ('enjoying life'). From these results, a patient perspective theory of quality care emerged. This theory posits the idea that high-quality care in this context needs to fulfil these four core categories. Additionally, these core categories were ranked on significance and priority.

CONCLUSION

The hierarchy of core categories could help to identify areas to improve care quality in this setting. Not only has this study helped to determine local priorities for achieving high-quality care but can encourage others to test injured patient perceptions of care quality in comparable settings.

A comparison of end-of-life care patterns between older patients with both cancer and Alzheimer's disease and related dementias versus those with only cancer

INTRODUCTION

Aggressive end-of-life (EOL) care that is not aligned with the preferences of persons with cancer has negative impacts on their quality of life. Alzheimer's disease and related dementias (ADRD) could potentially complicate EOL care planning among persons with cancer. Little is known about the aggressive EOL care patterns among Medicare beneficiaries with both cancer and ADRD.

MATERIALS AND METHODS

A matched retrospective cohort was created using the 2004 to 2016 Surveillance, Epidemiology, End Results-Medicare (SEER-Medicare) data differentiated by beneficiaries' ADRD status. Beneficiaries with breast, lung, colorectal, or prostate cancer who died between January 1, 2005 and December 31, 2016, were included. Six existing domains of aggressive EOL care and one overall indicator were derived. The major predictor was having ADRD comorbidity; other covariates included sex, marital status, census tract poverty indicator, race/ethnicity, metro status, geographic location, Charlson Comorbidity Index (CCI), survival time, cancer site, and histology stage. Multivariable logistic regression models were deployed to estimate the odds of receiving aggressive EOL care.

RESULTS

The study sample was 135,380 people after the one-to-one propensity score matching. The prevalence of aggressive EOL care utilization was slightly lower in beneficiaries with both cancer and ADRD when compared to beneficiaries with cancer only (54% vs. 58%, p < 0.0001). Beneficiaries with both cancer and ADRD were less likely to receive aggressive EOL care (AOR: 0.88, 95% CI: 0.86, 0.90) versus beneficiaries with cancer only. From the multivariable logistic regression model, certain beneficiaries' characteristics were associated with higher odds of receiving aggressive EOL care, such as: beneficiaries belonging to a racial/ethnic minority, a shorter survival time, and a higher CCI score.

DISCUSSION

The combined presence of ADRD and cancer was associated with lower odds of receiving aggressive EOL care compared to the presence of only cancer; however, the prevalence difference between the cohorts was not huge. Future studies could conduct in-depth evaluations of the ADRD's influence on the EOL care utilization.

Characteristics of stroke units and stroke teams in Spain in 2018. Pre2Ictus project

INTRODUCTION

The aim of this work is to describe the characteristics of stroke units and stroke teams in Spain.

METHODS

We performed a cross-sectional study based on an ad-hoc questionnaire designed by 5 experts and addressed to neurologists leading stroke units/teams that had been operational for ≥ 1 year.

RESULTS

The survey was completed by 43 stroke units (61% of units in Spain) and 14 stroke teams. A mean (standard deviation) of 4 (3) neurologists were assigned to each stroke unit/team; 98% of stroke units (and 38% of stroke teams) have an on-call neurologist available 24 hours a day, 98% of units (79% of stroke teams) included specialised nurses, 86% of units (71% of stroke teams) included a social worker, and 81% of units (71% of stroke teams) included a rehabilitation physician. Most stroke units (80%) had 4--6 beds with continuous non-invasive monitoring. The mean number of unmonitored beds was 14 (8) for stroke units and 12 (7) for stroke teams. The mean duration of non-invasive monitoring was 3 (1) days. All stroke units and 86% of stroke teams had intravenous thrombolysis available, and 81% of stroke units and 21% of stroke teams were able to perform mechanical thrombectomy, whereas the remaining centres had referral pathways in place. Telestroke systems were in place at 44% of stroke units, providing support to a mean of 4 (3) centres. Activity is recorded in clinical registries by 77% of stroke units and 50% of stroke teams, but less than 75% of data is completed in 25% of cases.

CONCLUSIONS

Most stroke units/teams comply with the current recommendations. The systematic use of clinical registries should be improved to further improve patient care.

Assessment of Health Service Quality Through Electronic Health Record - A Scoping Review

The World Health Organization defines, that high quality health services should be effective, safe, people-centered, timely, equitable, integrated, and effective. This requires systematic quality assessment. The aim of this scoping review was to explore how electronic health records (EHRs) have been used to assess quality of health services using the WHO criteria. A total of 4247 records were obtained whereof 8 studies were included in the review. Research showed that EHRs were used to evaluate safety, performance and care processes. EHRs were regarded as an applicable real-world data source, highlighting the importance of consistency and standardised terminologies. Use of EHR data is limited to its representation of the real world and current evaluation systems have limited quality criteria, diverse definitions and they use only structured data. Future research should explore possibilities of natural language processing methods and include narrative EHR information for a more a comprehensive view of service quality assessment.

Developing guideline-based key performance indicators for recurrent miscarriage care: lessons from a multi-stage consensus process with a diverse stakeholder group

BACKGROUND

Standardised care pathways tailored to women/couples who experience recurrent miscarriage are needed; however, clinical practice is inconsistent and poorly organised. In this paper, we outline our processes and experiences of developing guideline-based key performance indicators (KPIs) for recurrent miscarriage care with a diverse stakeholder group which will be used to evaluate national services. To date, such exercises have generally only involved clinicians, with the need for greater stakeholder involvement highlighted.

METHODS

Our study involved six stages: (i) identification and synthesis of recommendations for recurrent miscarriage care through a systematic review of clinical practice guidelines; (ii) a two-round modified e-Delphi survey with stakeholders to develop consensus on recommendations and outcomes; (iii) four virtual meetings to develop this consensus further; (iv) development of a list of candidate KPIs; (v) survey to achieve consensus on the final suite of KPIs and a (vi) virtual meeting to agree on the final set of KPIs. Through participatory methods, participants provided feedback on the process of KPI development.

RESULTS

From an initial list of 373 recommendations and 14 outcomes, 110 indicators were prioritised for inclusion in the final suite of KPIs: (i) structure of care (n = 20); (ii) counselling and supportive care (n = 7); (iii) investigations (n = 30); treatment (n = 34); outcomes (n = 19). Participants' feedback on the process comprised three main themes: accessibility, richness in diversity, streamlining the development process.

CONCLUSIONS

It is important and feasible to develop guideline-based KPIs with a diverse stakeholder group. One hundred and ten KPIs were prioritised for inclusion in a suite of guideline-based KPIs for recurrent miscarriage care. Insights into our experiences may help others undertaking similar projects, particularly those undertaken in the absence of a clinical guideline and/or involving a range of stakeholders.

Effect of exergaming on wellbeing of residents in a nursing home: a single blinded intervention study

Introduction

To improve the quality of life in nursing homes, meaningful activities and social contact are indispensable. Exergames can play a role addressing these needs.

Methods

In a randomized single blinded controlled intervention study, we investigated the effect of playing exergames on general wellbeing, fun and on social interaction.

Results

Thirty-five residents participated: 18 residents took part in the intervention group and 17 in the control group. The median mental wellbeing score of the intervention group increased from 42/50 to 45. The median sleep score of the intervention increased from 23/30 to 28. The median pain score of the intervention group improved from 18/20 to 20. The median score on subjective cognition increased from 24/30 to 26 while the mean scores on the objective assessment decreased from 1.8/2 to 1.7. Coaches gave an average fun score of 8.9/10 and an average intensity of exercise score of 11.6/20. Residents and coaches appreciated the social contact. Coaches reported a high feasibility (average of 4.1/5) but a low accessibility and a high intensity of supervision.

Conclusions

Exergaming is a feasible and pleasant complement to the usual activities with a positive impact on wellbeing, sleep, pain, and perceived cognition. Future research should focus on vulnerable groups and aim to develop a study in an implementation design.

How clinicians manage routinely low supplies of personal protective equipment

BACKGROUND

Recommended personal protective equipment (PPE) is routinely limited or unavailable in low-income countries, but there is limited research as to how clinicians adapt to that scarcity, despite the implications for patients and workers.

METHODS

This is a qualitative secondary analysis of case study data collected in Liberia in 2019. Data from the parent study were included in this analysis if it addressed availability and use of PPE in the clinical setting. Conventional content analysis was used on data including: field notes documenting nurse practice, semi-structured interview transcripts, and photographs.

RESULTS

Data from the majority of participants (32/37) and all facilities (12/12) in the parent studies were included. Eighty-three percent of facilities reported limited PPE. Five management strategies for coping with limited PPE supplies were observed, reported, or both: rationing PPE, self-purchasing PPE, asking patients to purchase PPE, substituting PPE, and working without PPE. Approaches to rationing PPE included using PPE only for symptomatic patients or not performing physical exams. Substitutions for PPE were based on supply availability.

CONCLUSIONS

Strategies developed by clinicians to manage low PPE likely have negative consequences for both workers and patients; further research into the topic is important, as is better PPE provision in low-income countries.

Quality Metrics in Hand Surgery: A Systematic Review

PURPOSE

The enactment of the Patient Protection and Affordable Care Act in 2010 placed an emphasis on measuring the quality of care. However, the issue of how best to measure quality remains in question. Although some surgical specialties frequently rely on quality measures such as the mortality rate, measuring quality in hand surgery necessitates the use of metrics beyond this traditional scope. A review was performed of the potential quality metrics used in the hand surgery literature published after the Affordable Care Act was enacted, to identify current trends in quality measurement and guide efforts to improve the quality of care in hand surgery.

METHODS

We searched the PubMed and EMBASE databases to identify original research articles within hand surgery to assess how care is being measured. Data extracted from the articles included study characteristics, quality metrics, and the domain(s) of quality.

RESULTS

A total of 7,308 articles were identified, and 63 prospective and retrospective articles were included in the analysis. The most common quality measure reported in the hand surgery literature was an outcome measure (100%) and the least common was a structure measure (30.2%). The most common metrics were pain (44.4%) and patient-reported measures (41.3%). Effectiveness (42.9%) was the most frequently assessed domain of quality, whereas efficiency (3.2%) was the least studied.

CONCLUSIONS

We identified quality measures used in contemporary hand surgery literature and found a substantial variation in the representation of quality metrics. Structure and process measures can be leveraged to provide a more holistic assessment of the quality of care in hand surgery.

CLINICAL RELEVANCE

Although outcome measurements are critical to understanding effectiveness, structure and process measures should be considered and reported as necessary, because these metrics may influence treatment outcomes and the development of quality measures.

The association between perceived hospital ethical climate and self-evaluated care quality for COVID-19 patients: the mediating role of ethical sensitivity among Chinese anti-pandemic nurses

Background

The COVID-19 pandemic called for a new ethical climate in the designated hospitals and imposed challenges on care quality for anti-pandemic nurses. Less was known about whether hospital ethical climate and nurses’ ethical sensitivity were associated with care quality. This study examined the association between the perceived hospital ethical climate and self-evaluated quality of care for COVID-19 patients among anti-pandemic nurses, and explored the mediating role of ethical sensitivity in this relationship.

Methods

A cross-sectional study was conducted through an online survey. A total of 399 anti-pandemic nurses from ten designated hospitals in three provinces of China were recruited to fill out an online survey. Multiple linear regression analysis and a bootstrap test were used to examine the relationships between ethical climate, ethical sensitivity and care quality.

Results

Nurses reported mean scores of 4.43 ± 0.577 (out of 5) for hospital ethical climate, 45.00 ± 7.085 (out of 54) for ethical sensitivity, and 5.35 ± 0.661 (out of 6) for self-evaluated care quality. After controlling for covariates, perceived hospital ethical climate was positively associated with self-evaluated care quality (direct effect = 0.710, 95% confidence interval [CI] 0.628, 0.792), and was partly mediated by ethical sensitivity (indirect effect = 0.078, 95% confidence interval [CI] 0.002, 0.145).

Conclusions

Chinese nurses who cared for COVID-19 patients perceived high levels of hospital ethical climate, ethical sensitivity, and self-evaluated care quality. Positive perceptions of hospital ethical climate were both directly associated with a higher level of self-evaluated care quality and indirectly associated, through the mediation effect of ethical sensitivity among anti-pandemic nurses.

Urban, Low-Income, African American Parents' Experiences and Expectations of Well-Child Care

PURPOSE

Well-child care is the foundation of pediatric health promotion and disease prevention. Primary care quality is lower for low-income and African American children compared to white children, and social determinants have an increasingly acknowledged impact on child health. Ensuring that high-quality well-child care fulfills its potential to mitigate the negative effects of social determinants on African American children is imperative. This study provides an understanding of urban, low-income, African American well-child care experiences and expectations.

DESIGN AND METHODS

A qualitative, focus group method was used. A purposive, volunteer sample of low-income, African American parents with children birth to age five was recruited from St. Louis and Milwaukee. Focus groups were held in convenient, community sites. Data was audio-digitally recorded. Transcribed data were coded and analyzed through inductive content analysis.

RESULTS

Thirty-five caregivers, 86% females, participated in four focus groups. Categories (and sub-categories) identified include: Community factors (We want better schools, It's getting more rough where I live); Sources of parenting advice (Google it, Call your parent, Older remedies); System challenges (Cost, Frequent new faces, Politics); Challenges with providers (Couldn't help me, Missed something important, Treated differently, Are you really listening?); Anticipatory guidance (Breastfeeding, Discipline, Vaccines, Development); and What parents desire (Know them, trust).

CONCLUSIONS

This study reveals the contexts that give rise to health care disparities and provides insight into parent's healthcare behaviors.

PRACTICE IMPLICATIONS

Results offer providers guidance in providing well-child care for this population to improve pediatric care quality and child health.

Urban, Low-Income, African American Well-Child Care: Comparison of Parent and Healthcare Provider Experiences and Expectations

OBJECTIVES

Urban, low-income, African American children and parents report lower quality primary care and face negative social determinants of health. High-quality well-child care is critical for this population. The purpose of this qualitative study was to compare and contrast parent and health care provider experiences of well-child care for urban, low-income, African American families to better understand the complex factors involved in care quality and health outcomes.

METHODS

Two data sets were analyzed using conventional content analysis, parent focus group data, and provider interviews. After analysis, results were sorted into similar categories, and convergence coding was completed to identify areas of agreement, partial agreement, dissonance, and silence.

RESULTS

Thirty-five parents took part in four focus groups, and nine providers were interviewed. Following convergence coding, five categories and 31 subcategories were identified. The five categories included: social determinants of health, sources of advice and support, challenges with the healthcare system, parent-provider relationships, and anticipatory guidance topics.

CONCLUSIONS FOR PRACTICE

Triangulation demonstrated convergence between parents and providers understanding of the concepts and functions of well-child care, however the prominence and meaning varied within each category and sub-category. The variance in agreement, areas of silence, and dissonance shed light on why the population reports lower overall quality primary care.

[Senior-friendly hospital: The hospital of the 21st century]

The current health system must be revolutionized to meet the specific and real requirements of the largest population attended, older adults, and tailor the hospital to their needs, not the other way round. This is the goal of Hospital Universitario Infanta Leonor: senior-friendly hospital. The project was established as a business process management system integrated into the management's hospital map. Four subprocesses were defined, as were all activities and tasks to be performed. The subprocesses are health care (delirium and functional decline prevention and the identification of frail older patients), training, the environment and its structures, and patient and family involvement. The leadership corresponds to the geriatricians who coordinate a multidisciplinary team of the project's referents. Actions must be scientific, evidence-based, rigorous, and evaluable, and they should be audited. The final aim is to change established mentalities, routines, and habits to convert the hospital to a friendlier place for older adults.

Relationship between staff thriving, through engagement and research activity, and hospital-related outcome measures: A retrospective cross-sectional study

INTRODUCTION AND OBJECTIVES

Both the standardised hospital mortality index (SHMI) and Care Quality Commission (CQC) ratings are used by the National Health Service (NHS) to monitor performance in English hospitals. We assessed if staff thriving, the concept of vitality and learning at work, through application of the surrogate measures engagement and research activity is associated with more favourable hospital performance outcomes.

METHODS

This concerned a retrospective cross-sectional study using data for 129 English NHS hospital Trusts from the year 2019. Outcome measures were SHMI (linear regression, unstandardised coefficient beta) and CQC (binary logistic regression, odds ratio [OR]), whereas the independent variables considered were hospital location, degree of patient deprivation, research activity (drawn from National Institute for Health Research records and controlled for hospital size), and staff engagement scores (based on three survey questions corresponding to validated engagement factors).

RESULTS

Staff engagement accounted for over half of the 13% variance R² for the whole model related to improved CQC rating (OR 13.75, p-value 0.002). Increased research activity was associated with a lower SHMI score (unstandardized beta -0.024, p-value 0.007, R² 5% for each point change in research activity quotient), but independently from the higher SHMI seen for Northern hospital Trusts (beta 0.063, p-value 0.003, R² 11.6%). The degree of patient deprivation did not influence SHMI or CQC outcomes in the regression models.

CONCLUSION

Increased staff thriving exhibits a modest, yet significantly, association with improved hospital performance; this was observed despite an underlying regional dichotomy in mortality rates.

The association between physician staff numbers and mortality in English hospitals

BACKGROUND

Physician medical specialties place specific demands on medical staff. Often patients have multiple co-morbidities, frailty is common, and mortality rates are higher than other specialties such as surgery. The key intervention for patients admitted under physician subspecialties is the care provided on the ward. The current evidence base to inform staffing in physician medical specialty wards is limited. The aim of this analysis is to investigate the association between medical staffing levels within physician medical specialties and mortality.

METHODS

This study is a cross-sectional analysis of national data, which is aggregated at provider level. Medical beds per senior, middle grade and junior physicians employed in physician medical specialties were calculated from national employment records for acute hospitals in England, in 2017. Outcome measures included unadjusted mortality rate and Summary Hospital-level Mortality Indicator (SHMI) in physician medical specialties. Both Raw mortality and SHMI include deaths during admission or within 30 days following discharge. Linear regression models were constructed for each medical staffing grade for unadjusted mortality, SHMI and SHMI adjusted for local provider factors.

FINDINGS

The mean number of medical beds per senior, middle grade and junior physicians were 7.3(SD 2.5), 19.7(11.5), 10.1(3.1) respectively. Lower bed numbers per medical staff grade were associated with lower than expected mortality by SHMI; senior(Coefficient 0.012(95%CI:0.005-0.018),p = 0.001), middle grade(0.002(0.0002-0.005),p = 0.032) and junior(0.008(0.002-0.015),p = 0.014). Hospital providers were more likely to achieve a better than expected mortality (SHMI<1) if  beds per physician were lower than; 5.3, 14.6 and 9.0 for senior, middle grade and junior doctors respectively.

INTERPRETATION

Acute hospital providers with fewer beds per medical staff of all grades are associated with lower than expected mortality.

FUNDING

No external funding is associated with this analysis.

Outcome measures used in the smartphone applications for the management of low back pain: a systematic scoping review

PURPOSE

Smartphone applications (SPApps) have become a key tool for the self-management of low back pain (LBP). However, the scientific evidence behind the outcome measures used in SPApps for LBP is never investigated before. Therefore, this systematic review firstly assess the quality of the free SPApps for LBP, secondly examines the outcome measures used and thirdly evaluates the outcome measures against the International Classification of Functioning, Disability and Health (ICF) core set classifications for LBP.

METHODS

A systematic scoping review was conducted in the iTunes and Google Play™ on-line stores for LBP SPApps which are free to download. These searches were conducted using keywords suggested by the Cochrane Back and Neck Group. SPApps were screened and downloaded to assess the quality using the Mobile App Rating Scale (MARS). SPApps using outcome measures were reviewed separately to evaluate whether their outcome measures represented any of the ICF components for LBP.

RESULTS

The overall quality of the apps has a mean MARS score of 2.5/5. Out of 74 apps reviewed, only four apps had outcome measures that could be linked to ICF components for LBP. Two of the four categories comprising the LBP core set were well represented.

CONCLUSION

The overall quality of the SPApps for LBP is low. Only very few SPApps offer outcome measures to monitor their effectiveness in the management of LBP. There is very limited evidence to show that the outcome measures used in the apps represents all the four core sets of LBP criteria set by ICF.

Pediatric emergency care: Associations between process factors and outcomes - Children's and parents' views combined with register data

BACKGROUND

Care quality in hospital units can be assessed based on three elements: structure, process, and outcomes. Relationships between elements are particularly important but have largely been unexplored.

PURPOSE

The purpose of the study was to investigate the relationships between factors of the emergency care process, length of stay, and care outcomes (i.e. care quality and patient satisfaction).

METHODS

Medical and administrative registry data from children's visits were combined with cross-sectional survey data and analyzed using descriptive methods, median test, and linear regression. Eighty-nine child-parent pairs from four emergency departments participated.

RESULTS

The shortest length of stay had children at the lowest triage level (p < 0.001) Children with more diagnostic tests (p < 0.001) and more procedures (p < 0.001) performed had the longest length of stay. In linear regression analysis (f = 6.626, df = 6, p = 0.001, R² = 0.214), the satisfaction of child-parent pairs was associated with performance of more tests and procedures, higher triage levels, and child streaming onto the pediatrician care track.

CONCLUSIONS

Care process factors affect length of children's stay in emergency departments and could predict children's and parents' satisfaction with, and evaluations of, care quality.

Characteristics of stroke units and stroke teams in Spain in 2018. Pre2Ictus project

INTRODUCTION

The aim of this work is to describe the characteristics of stroke units and stroke teams in Spain.

METHOD

We performed a cross-sectional study based on an ad hoc questionnaire designed by 5 experts and addressed to neurologists leading stroke units/teams that had been operational for ≥ 1 year.

RESULTS

The survey was completed by 43 stroke units (61% of units in Spain) and 14 stroke teams. The mean (SD) number of neurologists assigned to each unit/team is 4±3. 98% of stroke units (and 38% of stroke teams) have a neurologist on-call available 24hours, 365 days. 98% of stroke units (79% of stroke teams) have specialised nurse, 95% of units (71% of stroke teams) auxiliary personnel, 86% of units (71% of stroke teams) social worker, 81% of stroke units (71% of stroke teams) have a rehabilitation physician and 81% of stroke units (86% of stroke teams) a physiotherapist. Most stroke units (80%) have 4-6 beds with continuous non-invasive monitoring. The mean number of unmonitored beds is 14 (8) for stroke units and 12 (7) for stroke teams. The mean duration of non-invasive monitoring is 3 (1) days. All stroke units and 86% of stroke teams have intravenous thrombolysis available, and 81% of stroke units and 21% of stroke teams are able to perform mechanical thrombectomy, whereas the remaining centres have referral pathways in place. Telestroke systems are available at 44% of stroke units, providing support to a mean of 4 (3) centres. Activity is recorded in clinical registries by 77% of stroke units and 50% of stroke teams, but less than 75% of data is completed in 25% of cases.

CONCLUSIONS

Most stroke units/teams comply with the current recommendations. The systematic use of clinical registries should be improved to further improve patient care.

Data quality predicts care quality: findings from a national clinical audit

BACKGROUND

Missing clinical outcome data are a common occurrence in longitudinal studies. Data quality in clinical audit is a particular cause for concern. The relationship between departmental levels of missing clinical outcome data and care quality is not known. We hypothesise that completeness of key outcome data in a national audit predicts departmental performance.

METHODS

The National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis (NCAREIA) collected data on care of patients with suspected rheumatoid arthritis (RA) from early 2014 to late 2015. This observational cohort study collected data on patient demographics, departmental variables, service quality measures including time to treatment, and the key RA clinical outcome measure, disease activity at baseline, and 3 months follow-up. A mixed effects model was conducted to identify departments with high/low proportions of missing baseline disease activity data with the results plotted on a caterpillar graph. A mixed effects model was conducted to assess if missing baseline disease activity predicted prompt treatment.

RESULTS

Six thousand two hundred five patients with complete treatment time data and a diagnosis of RA were recruited from 136 departments. 34.3% had missing disease activity at baseline. Mixed effects modelling identified 13 departments with high levels of missing disease activity, with a cluster observed in the Northwest of England. Missing baseline disease activity was associated with not commencing treatment promptly in an adjusted mix effects model, odds ratio 0.50 (95% CI 0.41 to 0.61, p < 0.0001).

CONCLUSIONS

We have shown that poor engagement in a national audit program correlates with the quality of care provided. Our findings support the use of data completeness as an additional service quality indicator.

The effects of cast-related training for nurses on the quality of cast care: A quasi-experimental study

INTRODUCTION

Quality cast application and care is among the nursing skills which require competence, knowledge, and expertise. This study aimed to assess the effects of cast-related training for nurses on the quality of pre-, intra- and post-casting care.

METHODS

This quasi-experimental study was conducted in 2018 in two phases: before and after a cast-related training for nurses involved in cast application and care. In the first phase, 94 patients with a cast were assessed for pre- intra- and post-casting care quality. In the second phase, after the training program, the same number of new patients were assessed. Study data were collected using a 57-item checklist with items on; patient preparation, cast application, and post-casting care including patient education. Descriptive statistics, Fisher's exact, and independent-samples t-tests were used to analyze the data.

RESULTS

The mean pre-casting care score significantly increased from 1.39 ± 0.16 at baseline to 1.69 ± 0.32 after the intervention (P = 0.001). The mean intra-casting care score increased from 1.42 ± 0.31 at baseline to 1.52 ± 0.17 after the intervention (P = 0.014). However, the study intervention did not improve the mean post-casting care score.

CONCLUSION

This training program improved the quality of pre- and intra-casting care, but did not improve the post-casting care and care measures related to patient education. Therefore, regular in-service training programs for nurses are recommended to improve their knowledge, skills, and performance in cast- pplication and care.

Stroke treatment outcomes in hospitals with and without Stroke Units

INTRODUCTION

Organisational capacity in terms of resources and care circuits to shorten response times in new stroke cases is key to obtaining positive outcomes. This study compares therapeutic approaches and treatment outcomes between traditional care centres (with stroke teams and no stroke unit) and centres with stroke units.

METHODS

We conducted a prospective, quasi-experimental study (without randomisation of the units analysed) to draw comparisons between 2 centres with stroke units and 4 centres providing traditional care through the neurology department, analysing a selection of agreed indicators for monitoring quality of stroke care. A total of 225 patients participated in the study. In addition, self-administered questionnaires were used to collect patients' evaluations of the service and healthcare received.

RESULTS

Centres with stroke units showed shorter response times after symptom onset, both in the time taken to arrive at the centre and in the time elapsed from patient's arrival at the hospital to diagnostic imaging. Hospitals with stroke units had greater capacity to respond through the application of intravenous thrombolysis than centres delivering traditional neurological care.

CONCLUSION

Centres with stroke units showed a better fit to the reference standards for stroke response time, as calculated in the Quick study, than centres providing traditional care through the neurology department.

A Rasch analysis of the Person-Centred Climate Questionnaire - staff version

Background

Person-centred care is the bedrock of modern dementia services, yet the evidence-base to support its implementation is not firmly established. Research is hindered by a need for more robust measurement instruments. The 14-item Person-Centred Climate Questionnaire - Staff version (PCQ-S) is one of the most established scales and has promising measurement properties. However, its construction under classical test theory methods leaves question marks over its rigour and the need for evaluation under more modern testing procedures.

Methods

The PCQ-S was self-completed by nurses and other care staff working across nursing homes in 35 Swedish municipalities in 2013/14. A Rasch analysis was undertaken in RUMM2030 using a partial credit model suited to the Likert-type items. Three subscales of the PCQ-S were evaluated against common thresholds for overall fit to the Rasch model; ordering of category thresholds; unidimensionality; local dependency; targeting; and Differential Item Functioning. Three subscales were evaluated separately as unidimensional models and then combined as subtests into a single measure. Due to large number of respondents (n = 4381), two random sub-samples were drawn, with a satisfactory model established in the first (‘evaluation’) and confirmed in the second (‘validation’). Final item locations and a table converting raw scores to Rasch-transformed values were created using the full sample.

Results

All three subscales had disordered thresholds for some items, which were resolved by collapsing categories. The three subscales fit the assumptions of the Rasch model after the removal of two items, except for subscale 3, where there was evidence of local dependence between two items. By forming subtests, the 3 subscales were combined into a single Rasch model which had satisfactory fit statistics. The Rasch form of the instrument (PCQ-S-R) had an adequate but modest Person Separation Index (< 0.80) and some evidence of mistargeting due to a low number of ‘difficult-to-endorse’ items.

Conclusions

The PCQ-S-R has 12 items and can be used as a unidimensional scale with interval level properties, using the nomogram presented within this paper. The scale is reliable but has some inefficiencies due to too few high-end thresholds inhibiting discrimination amongst populations who already perceive that person-centred care is very good in their environment.

Greek hospital environments

PURPOSE

The purpose of this paper is three-fold: first, to assess nurse satisfaction levels with working environment (known as favourability) in five Greek public hospitals using the practice environment scale (PES); second, to compare perceptions among nurses employed in surgical and medical departments; and third, to examine relationships between perceptions and nurse educational level and experience.

DESIGN/METHODOLOGY/APPROACH

In total, 532 nurses from five major public hospitals in Greece completed the PES. Descriptive statistics, t-tests and Spearman correlations were employed to analyse the data.

FINDINGS

Nurses perceived their work settings as unfavourable in all five hospitals, with collegial nurse-physician relations emerging as the only positive factor. Compared to medical wards, surgical departments emerged as slightly more positive working environments. Work department notwithstanding, in some cases, education and experience levels affected their perceptions on management, poor care quality, limited nurse involvement in hospital affairs and nursing shortage.

PRACTICAL IMPLICATIONS

Hospital managers do not provide sufficient support for Greek nurses in their working environments.

ORIGINALITY/VALUE

The authors attempted to evaluate nursing practice environments in Greek hospitals, viewed from nurse perspectives. The authors identified insufficient support for nurses' working in these hospitals.

[Quality reporting in long-term care facilities-information requirements, search strategies, and information sources for persons in need of care and their family members]

Persons in need of care and their family members should be able to realistically assess and compare the quality of care services. Recent legislation therefore states that the current procedure to assess and present care quality has to be developed further. While quality measurements can be informed by the literature, knowledge on suitable formats for presenting quality information that is suitable for care-receiving persons and their families is highly fragmentary.The "Development of quality reporting in long-term care" project, a cooperation between the Charité, the federal association of the AOK (AOK-Bundesverband), and the Center for Quality in Care (ZQP), provides the current findings on the information requirements of persons in need of care and their family members when choosing a care facility. Aspects related to nursing staff have a particularly high relevance, e. g. respectful behavior of the personnel, well-trained caregivers, sufficient staff density, seldom changes in the personnel of the institution, and thoroughly conducted care that is adjusted to individual needs. These criteria have been given the highest relevance by persons in need of care as well as their family members.The findings hint at the necessity to provide comprehensive and detailed information about the staffing of care facilities in the future: for example, on the staff ratio and qualifications. Apart from that, comprehensive knowledge on formats to present information is urgently needed - taking into account the needs of care-dependent persons and their families and how information can be optimally processed.

Analysis of the quality of seasonal malaria chemoprevention provided by community health Workers in Boulsa health district, Burkina Faso

Background

Since 2014, the Burkina Faso government has made Seasonal Malaria Chemoprevention (SMC) a priority in its strategic plan to fight against malaria among children aged from 3 to 59 months. Very few studies have examined the care provided by community health workers in the framework of this strategy. The purpose of this study was to evaluate the level of quality of care provided by the latter.

Methods

This was a mixed study. The quantitative component consisted of a non-participant observation of community health workers during the administration of care. The qualitative component consisted of one-on-one interviews with community health workers, child caregivers and head nurses. Five dimensions (organizational accessibility, interpersonal relationship, technical competence, safety of care and satisfaction of child caregivers) adapted from the Donabedian quality of care model were used to assess the quality level of care. The Corlien et al. Health Systems Research Program Implementation Scale was used to establish quality scores for each of the five dimensions. The study sites were the health centers located in the administrative centers of the 4 communes of the health district of Boulsa. The data were collected during the first cycle of the 2017 SMC campaign.

Results

A total of 14 active pairs (28 CHWs) were observed and 40 in-depth interviews with community health workers, Head nurses in duty and community leaders were conducted. The results show that community health workers worked in pairs. They had all received SMC training and possessed equipment to do their job. The dimensions of organizational accessibility and satisfaction of the caregivers were rated as good. The dimensions of interpersonal relationship and technical competence were judged to be of an acceptable score. Safety of care was judged to be of a low-level score. The overall quality of care was considered acceptable.

Conclusion

The results of this study have shown that despite the difficulties faced by community health workers, they manage to deliver acceptable quality of care. Their use would be an asset for SMC in particular and for the health system in general.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4299-3) contains supplementary material, which is available to authorized users.

Assessing Key Stakeholders' Knowledge, Needs, and Preferences for Head and Neck Cancer Survivorship Care Plans

Cancer survivorship care plans (SCPs) are endorsed to support quality care for cancer survivors, but uptake is slow. We assessed knowledge, needs, and preferences for SCP content and delivery from a wide variety of stakeholders. We focused SCP content for head and neck cancer as it is a disease prone to long-term side effects requiring management from multiple providers. We conducted telephone-based, qualitative interviews. We purposively sampled head and neck cancer survivors (n = 4), primary care physicians in the community (n = 5), and providers affiliated with a large academic medical center (n = 5) who treat head and neck cancer, cancer specialists (n = 6), and nurse practitioners/supportive care staff (n = 5). Interviews were recorded, transcribed, and analyzed using direct content analysis. Few participants reported personal experience with SCPs, but most supported the concept. Several key themes emerged: (1) perceived ambiguity regarding roles and responsibilities for SCPs, (2) a need to tailor the content and language based on the intended recipient, (3) documentation process should be as automated and streamlined as possible, (4) concerns about using the SCP to coordinate with outside providers, and (5) that SCPs would have added value as a "living document." We also report SCP-related issues that are unique to serving patients diagnosed with head and neck cancer. Effort is needed to tailor SCPs for different recipients and optimize their potential for successful implementation, impact on care outcomes, and sustainability. Many cancer survivors may not receive a SCP as part of routine care. Survivors could engage their health care team by requesting a SCP.

Improvement in Quality of Care for Patients with Type 2 Diabetes in Hungary Between 2008 and 2016: Results from Two Population-Based Representative Surveys

INTRODUCTION

Due to the increasing trends of recent decades, diabetes prevalence has reached a frequency of 1/11 adults worldwide. However, this disadvantageous trend has not been accompanied by worsened outcome indicators; better short-term (e.g., HbA1c levels) and long-term [e.g., all-cause mortality among type 2 diabetes mellitus (T2DM) patients] outcomes can be observed globally. We aimed to describe changes in the effectiveness of type 2 diabetes mellitus care between 2008 and 2016 based on outcome indicators.

METHODS

The study is a secondary analysis of data from two previously performed surveys. Both surveys were conducted in the framework of the General Practitioners' Morbidity Sentinel Stations Program (GPMSSP), which maintains a nationally representative registry of T2DM patients.

RESULTS

The largest improvement was observed in achieving fasting blood glucose and HbA1c target values [OR = 0.67, 95% confidence interval (CI), 0.56-0.80 and OR = 0.58; 95% CI, 0.48-0.70, respectively]. Moderate improvement was detected by reaching body mass index (BMI), diastolic blood pressure and total cholesterol target values (OR = 0.78, 95% CI, 0.65-0.93; OR = 0.78, 95% CI, 0.65-0.94 and OR = 0.76, 95% CI, 0.63-0.92, respectively).

CONCLUSION

Our study demonstrated that if standardized indicators are investigated in population-based samples, the effectiveness of T2DM care can be monitored by ad hoc surveys. The systematic application of this approach completed with the detailed documentation of the applied therapies could demonstrate the public health impact of certain modifications in T2DM care. An overall improvement in metabolic control (glycaemic control, lipid status and obesity) was observed, which was not accompanied by improved therapeutic target achievement for systolic blood pressure.

Practice Environment Characteristics Associated With Missed Nursing Care

PURPOSE

To examine which characteristics of the practice environment were associated with missed nursing care in U.S. acute care hospital units.

DESIGN

A descriptive, correlational study used secondary analysis of the 2015 National Database of Nursing Quality Indicators^® Registered Nurse (RN) Survey data. Subscales of the Practice Environment Scale of the Nursing Work Index were used to measure practice environment characteristics. The sample included 1,583 units in 371 hospitals, containing survey responses from 31,650 RNs.

METHODS

Multilevel logistic regression was performed to estimate the effects of the practice environment characteristics on missed care, controlling for hospital and unit characteristics.

RESULTS

About 84.1% of unit RNs reported missing at least one of the 15 necessary care activities. Good environment units had 63.3% significantly lower odds of having RNs miss care activities than poor environment units. Units had 81.5% lower odds of having RNs miss any necessary activities with 1 point increase of the staffing and resource adequacy score; 21.9% lower odds for 1 point increase in the nurse-physician relations score; and approximately 2.1 times higher odds with 1 point increase in the nurse participation in hospital affairs score.

CONCLUSIONS

Good environments were significantly associated with lower levels of missed care. The impact on missed care differed by the characteristics of the practice environment.

CLINICAL RELEVANCE

Hospital and nursing administrators should maintain good practice environments for nurses to reduce missed care activities and thus potentially improve patient outcomes. Specifically, their efforts should be targeted on improving staffing and resource adequacy and nurse-physician relations and on reducing workloads on hospital affairs.

Patient prioritization for pharmaceutical care in hospital: A systematic review of assessment tools

BACKGROUND

Clinical pharmacy services improve patient safety, outcomes, and care quality; however, UK clinical pharmacy services face limited resources, insufficient capacity, and patients who present with increasingly complex medication regimes and morbidities. These indicate a need for the prioritization of pharmacy services. Several prioritization tools have been developed; however, there has been no comprehensive review of such tools to date.

OBJECTIVE

A systematic review was conducted to provide a structured overview and description of existing assessment tools with a focus on study quality, themes, tool validity, risk factors, and high-risk drug classes.

METHODS

Systematic searches for English-language publications (from 1990 to September 2017) were conducted in Embase, Medline, Scopus, International Pharmaceutical Abstracts, and Web of Science. Papers in the inpatient setting and in which the tool users were pharmacists or pharmacy technicians were included. Data on each study (e.g. aim and design) and the structure of tools (e.g. risk factors) from each included study were extracted by 2 independent reviewers. A descriptive analysis was conducted to summarize these tools along with a thematic analysis of study findings. The quality of each paper was assessed using the Hawker method.

RESULTS

Nineteen studies involving 17 risk assessment tools were included. Most tools were developed in Europe (76.5%) and published in the last 5 years (82%). Most tools (88%) were designed to identify patients at greatest risk of adverse drug reactions, adverse drug events, or medication errors and to guide appropriate pharmaceutical care. Ten out of 17 tools (59%) were validated. None showed a measurable impact on prescription errors or adverse drug events. Keys themes identified from the studies were the positive impact of risk assessment tools on both patient care and provision of pharmacy services as well as the limitations of risk assessment tools.

CONCLUSIONS

Current assessment tools are heterogeneous in their content, targeting diverse patient groups and clinical settings making generalization difficult. However, an underlying theme of all studies was that tools appear to achieve their aim in directing pharmaceutical care to where it is needed most which might provide reassurance and incentive for greater adoption and development of tools across clinical pharmacy services. However, further research is required to measure objectively the impact of tools on patient outcomes and on workforce efficiency so that comparisons can be made between tools.

A multicriteria resource allocation model for the redesign of services following birth

BACKGROUND

Many healthcare services are under considerable pressure to reduce costs while improving quality. This is particularly true in the United Kingdom's National Health Service where postnatal care is sometimes viewed as having a low priority. There is much debate about the service's redesign and the reallocation of resources, both along care pathways and between groups of mothers and babies with different needs. The aim of this study was to develop a decision support tool that would encourage a systemic approach to service redesign and that could assess the various quality and financial implications of service change options making the consequent trade-offs explicit. The paper describes the development process and an initial implementation as a preliminary exploration of the possible merits of this approach.

METHODS

Other studies have suggested that combining multicriteria decision analysis with programme budgeting and marginal analysis might offer a suitable basis for resource allocation decisions in healthcare systems. The Postnatal care Resource Allocation Model incorporated this approach in a decision support tool to analyse the consequences of varying design parameters, notably staff contacts and time, on the various quality domains and costs. The initial phase of the study focussed on mapping postnatal care, involving interviews and workshops with a variety of stakeholders. This was supplemented with a literature review and the resultant knowledge base was encoded in the decision support tool. The model was then tested with various stakeholders before being used in an NHS Trust in England.

RESULTS

The model provides practical support, helping staff explore options and articulate their proposals for the redesign of postnatal care. The integration of cost and quality domains facilitates trade-offs, allowing staff to explore the benefits of reallocating resources between hospital and community-based care, and different patient-categories.

CONCLUSIONS

The main benefits of the model include its structure for assembling the key data, sharing evidence amongst multi-professional teams and encouraging constructive, systemic debate. Although the model was developed in the context of the routine maternity services for mothers and babies in the days following birth it could be adapted for use in other health care services.

The state of the science of nurse work environments in the United States: A systematic review

A healthy nurse work environment is a workplace that is safe, empowering, and satisfying. Many research studies were conducted on nurse work environments in the last decade; however, it lacks an overview of these research studies. The purpose of this review is to identify, evaluate, and summarize the major foci of studies about nurse work environments in the United States published between January 2005 and December 2017 and provide strategies to improve nurse work environments. Databases searched included MEDLINE via PubMed, CINAHL, PsycINFO, Nursing and Allied Health, and the Cochrane Library. The literature search followed the PRISMA guideline. Fifty-four articles were reviewed. Five major themes emerged: 1) Impacts of healthy work environments on nurses' outcomes such as psychological health, emotional strains, job satisfaction, and retention; 2) Associations between healthy work environments and nurse interpersonal relationships at workplaces, job performance, and productivity; 3) Effects of healthy work environments on patient care quality; 4) Influences of healthy work environments on hospital accidental safety; and 5) Relationships between nurse leadership and healthy work environments. This review shows that nurses, as frontline patient care providers, are the foundation for patient safety and care quality. Promoting nurse empowerment, engagement, and interpersonal relationships at work is rudimental to achieve a healthy work environment and quality patient care. Healthier work environments lead to more satisfied nurses who will result in better job performance and higher quality of patient care, which will subsequently improve healthcare organizations' financial viability. Fostering a healthy work environment is a continuous effort.

Effects of Individual Nurse and Hospital Characteristics on Patient Adverse Events and Quality of Care: A Multilevel Analysis

PURPOSE

This study aimed to investigate effects of individual nurse and hospital characteristics on patient adverse events and quality of care using a multilevel approach.

DESIGN

This is a secondary analysis of a combination of nurse survey data (N = 1,053 nurses) and facility data (N = 63 hospitals) in Canada.

METHODS

Multilevel ordinal logistic regression was employed to examine effects of individual nurse and hospital characteristics on patient adverse events. Multilevel linear regressions were used to investigate effects of individual nurse and hospital characteristics on quality of care.

FINDINGS

Organizational safety culture was associated with patient adverse events and quality of care. Controlling for effects of nurse and hospital characteristics, nurses in hospitals with a stronger safety culture were 64% less likely to report administration of wrong medication, time, or dose; 58% less likely to report patient falls with injury; and 60% less likely to report urinary tract infections; and were more likely to report higher levels of quality of care. Additionally, the effects of individual-level baccalaureate education and years of experience on quality of care differed across hospitals, and hospital-level nurse education interacted with individual-level baccalaureate education.

CONCLUSIONS

This study makes significant contributions to existing knowledge regarding the positive effect of organizational safety culture on patient adverse events and quality of care.

CLINICAL RELEVANCE

Healthcare organizations should strive to improve their safety culture by creating environments where healthcare providers trust each other, work collaboratively, and share accountability for patient safety and care quality.

Is organizational justice climate at the workplace associated with individual-level quality of care and organizational affective commitment? A multi-level, cross-sectional study on dentistry in Sweden

Purpose

The aim of this study is to investigate whether organizational justice climate at the workplace level is associated with individual staff members’ perceptions of care quality and affective commitment to the workplace.

Methods

The study adopts a cross-sectional multi-level design. Data were collected using an electronic survey and a response rate of 75% was obtained. Organizational justice climate and affective commitment to the workplace were measured by items from Copenhagen Psychosocial Questionnaire and quality of care by three self-developed items. Non-managerial staff working at dental clinics with at least five respondents (n = 900 from 68 units) was included in analyses. A set of Level-2 random intercept models were built to predict individual-level organizational affective commitment and perceived quality of care from unit-level organizational justice climate, controlling for potential confounding by group size, gender, age, and occupation.

Results

The results of the empty model showed substantial between-unit variation for both affective commitment (ICC-1 = 0.17) and quality of care (ICC-1 = 0.12). The overall results showed that the shared perception of organizational justice climate at the clinical unit level was significantly associated with perceived quality of care and affective commitment to the organization (p < 0.001).

Conclusions

Organizational justice climate at work unit level explained all variation in affective commitment among dental clinics and was associated with both the individual staff members’ affective commitment and perceived quality of care. These findings suggest a potential for that addressing organizational justice climate may be a way to promote quality of care and enhancing affective commitment. However, longitudinal studies are needed to support causality in the examined relationships. Intervention research is also recommended to probe the effectiveness of actions increasing unit-level organizational justice climate and test their impact on quality of care and affective commitment.

Nursing home care quality: a cluster analysis

Purpose The purpose of this paper is to explore potential differences in how nursing home residents rate care quality and to explore cluster characteristics. Design/methodology/approach A cross-sectional design was used, with one questionnaire including questions from quality from patients' perspective and Big Five personality traits, together with questions related to socio-demographic aspects and health condition. Residents ( n=103) from four Norwegian nursing homes participated (74.1 per cent response rate). Hierarchical cluster analysis identified clusters with respect to care quality perceptions. χ² tests and one-way between-groups ANOVA were performed to characterise the clusters ( p<0.05). Findings Two clusters were identified; Cluster 1 residents (28.2 per cent) had the best care quality perceptions and Cluster 2 (67.0 per cent) had the worst perceptions. The clusters were statistically significant and characterised by personal-related conditions: gender, psychological well-being, preferences, admission, satisfaction with staying in the nursing home, emotional stability and agreeableness, and by external objective care conditions: healthcare personnel and registered nurses. Research limitations/implications Residents assessed as having no cognitive impairments were included, thus excluding the largest group. By choosing questionnaire design and structured interviews, the number able to participate may increase. Practical implications Findings may provide healthcare personnel and managers with increased knowledge on which to develop strategies to improve specific care quality perceptions. Originality/value Cluster analysis can be an effective tool for differentiating between nursing homes residents' care quality perceptions.

Information technology-enabled team-based, patient-centered care: The example of depression screening and management in cancer care

The existing healthcare delivery systems across the world need to be redesigned to ensure high-quality care is delivered to all patients. This redesign needs to ensure care is knowledge-based, patient-centered and systems-minded. The rapid advances in the capabilities of information and communication technology and its recent rapid adoption in healthcare delivery have ensured this technology will play a vital role in the redesign of the healthcare delivery system. This commentary highlights promising new developments in health information technology (IT) that can support patient engagement and self-management as well as team-based, patient-centered care. Collaborative care is an effective approach to screen and treat depression in cancer patients and it is a good example of the benefits of team-based and patient-centered care. However, this approach was developed prior to the widespread adoption and use of health IT. We provide examples to illustrate how health IT can improve prevention and treatment of depression in cancer patients. We found several knowledge gaps that limit our ability to realize the full potential of health IT in the context of cancer and comorbid depression care. These gaps need to be filled to improve patient engagement; enhance the reach and effectiveness of collaborative care and web-based programs to prevent and treat depression in cancer patients. We also identify knowledge gaps in health IT design and implementation. Filling these gaps will help shape policies that enable clinical teams to deliver high-quality cancer care globally.