A cross-hospital exploration of nurses' experiences with horizontal violence

AIM

To explore nurses' experiences of horizontal violence (HV) in three diverse non-affiliated organisations within a single city in the USA.

BACKGROUND

Horizontal violence, also called workplace bullying or lateral violence, is a long-standing nursing issue.

METHOD

Content analysis was used to analyse open-format textual responses from 126 registered nurses.

RESULTS

A powerful collective story emerged from nurses' shared experiences with HV, describing the characters and the setting in which HV and its consequences exist. Nurses' depictions of HV were consistent despite the different organisational structures of their workplaces suggesting that hospital type is not the explanation for HV, rather the culture of acute care nursing. Nurses want change and asked for tactics to resolve HV within their institutions; some provided specific solutions.

CONCLUSION

Nurse managers must continue to address HV by using a variety of known tactics, as well as adopting new evidence-based interventions as they are identified. The anti-bullying message should be disseminated through professional nursing organisations as well as in local health-care establishments.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers need to be the culture champions who hold individuals accountable for HV and foster professionalism through their leadership.

The effectiveness of computer system tools on potentially inappropriate medications ordered at discharge for adults older than 65 years of age: a systematic review

BACKGROUND

Prescribing potentially inappropriate medications to the elderly leads to adverse health outcomes. The use of computer systems decision making tools has been shown to decrease the incidence of prescribing potentially inappropriate medications for the elderly; however, these results are often dependent upon other variables, such as provider compliance.

OBJECTIVE

To examine and synthesize the best available evidence related to the effect of computer systems clinical decision making tools on frequency of ordering potentially inappropriate medications at discharge and related unplanned emergency room visits or hospital readmissions in community dwelling patients older than 65 years of age.

INCLUSION CRITERIA

Adults older than 65 years of age prescribed potentially inappropriate medications.Types of interventions Electronic or computer based clinical decision making supplement or support related to prescribing of potentially inappropriate medications.The outcome measures were frequency of ordering potentially inappropriate medications (PIMs) for patients at discharge, unexpected hospital readmission rate and unexpected emergency room visits of patients who were discharged on PIMs.Randomised control trials and quasi-experimental studies.

SEARCH STRATEGY

The search strategy aimed to find both published and unpublished studies in the English language from January 2003 through July 2011. A search of PubMED, CINAHL, Health Source Nursing/Academic Edition, MasterFILE Premier, Scopus, DARE, Academic Search Premier, Scirus, Embase was conducted.

METHODOLOGICAL QUALITY

Studies were critically evaluated by two independent reviewers using standardised critical appraisal instruments from the Joanna Briggs Institute.

DATA COLLECTION

Data were extracted using the standardised data extraction instruments from the Joanna Briggs Institute.

DATA SYNTHESIS

Results from quantitative papers were pooled in statistical meta-analysis as appropriate using JBI-MAStARI. Where statistical pooling was not possible, the findings are presented in narrative form.

RESULTS

A total of five articles, four randomised control studies and one quasi-experimental study were included. One study demonstrated that a computerised alert tool along with collaboration of the health care providers resulted in a statistically significant (p=0.002) decrease in ordering of PIMs as well as improved medication safety in patients older than 65 years of age. Similarly, a randomised controlled study demonstrated that computerised physician order entry with decision support significantly (p=0.02) reduced prescribing of PIMs for seniors (odds ratio=0.55, 95% CI=0.34 - 0.89). Another study demonstrated that computer-based access to complete drug profiles and alerts reduced the rate of initiation of potentially inappropriate prescriptions by 18% (RR=0.82, 95% CI=0.69-0.98). Yet another study demonstrated that implementation of age specific alerts decreases prescription writing of PIMs from 21.9 prescriptions to 16.8 per 10,000 patients; p value < 0.01. One study demonstrated that age specific alerts reduced prescribing of PIMs from 150.2 to 137.2 prescriptions per 10,000 patients; the p value = 0.75 was not statistically significant. Results from two trials were pooled for meta-analysis, with summary RR = 0.82, and 95%CI (0.76 - 0.88). No studies were found that specifically addressed unexpected hospital readmission or unexpected visits to the emergency room of patients who were discharged on PIMs.

CONCLUSIONS

Reduction in prescribing of potentially inappropriate medications occurs when clinical decision making computer support tools, such as drug specific alerts, are available to providers.Computer systems clinical decision making tools have potential for reducing numbers of potentially inappropriate medications prescribed for the community based population older than 65 years of age.Future research should continue to explore the effects of computerized clinical decision making tools on prescription writing habits of practitioners for the elderly population. In addition, documentation of unplanned ER visits and unplanned readmission rates needs to be correlated with the use of potentially inappropriate medications.

A qualitative systematic review of internal and external influences on shared decision-making in all health care settings

REVIEW QUESTION/OBJECTIVE

The objective of this review is to identify and synthesize the best available evidence related to the meaningfulness of internal and external influences on shared-decision making for adult patients and health care providers in all health care settings.The specific questions to be answered are: BACKGROUND: Patient-centered care is emphasized in today's healthcare arena. This emphasis is seen in the works of the International Alliance of Patients' Organizations (IAOP) who describe patient-centered healthcare as care that is aimed at addressing the needs and preferences of patients. The IAOP presents five principles which are foundational to the achievement of patient-centered healthcare: respect, choice, policy, access and support, as well as information. These five principles are further described as:Within the description of these five principles the idea of shared decision-making is clearly evident.The concept of shared decision-making began to appear in the literature in the 1990s. It is defined as a "process jointly shared by patients and their health care provider. It aims at helping patients play an active role in decisions concerning their health, which is the ultimate goal of patient-centered care." The details of the shared decision-making process are complex and consist of a series of steps including:Three overall representative decision-making models are noted in contemporary literature. These three models include: paternalistic, informed decision-making, and shared decision-making. The paternalistic model is an autocratic style of decision-making where the healthcare provider carries out the care from the perspective of knowing what is best for the patient and therefore makes all decisions. The informed decision-making model takes place as the information needed to make decisions is conveyed to the patient and the patient makes the decisions without the healthcare provider involvement. Finally, the shared decision-making model is representative of a sharing and a negotiation towards treatment decisions. Thus, these models represent a range with patient non-participation at one end of the continuum to informed decision making or a high level of patient power at the other end. Several shared decision-making models focus on the process of shared decision-making previously noted. A discussion of several process models follows below.Charles et al. depicts a process model of shared decision-making that identifies key characteristics that must be in evidence. The patient shares in the responsibility with the healthcare provider in this model. The key characteristics included:This model illustrates that there must be at least two individuals participating, however, family and friends may be involved in a variety of roles such as the collector of information, the interpreter of this information, coach, advisor, negotiator, and caretaker. This model also depicts the need to take steps to participate in the shared decision-making process. To take steps means that there is an agreement between and among all involved that shared decision-making is necessary and preferred. Research about patient preferences, however, offers divergent views. The link between patient preferences for shared decision-making and the actuality of shared decision-making in practice is not strong. Research concerning patients and patient preferences on shared decision-making points to variations depending on age, education, socio-economic status, culture, and diagnosis. Healthcare providers may also hold preferences for shared decision-making; however, research in this area is not as comprehensive as is patient focused research. Elwyn et al. explored the views of general practice providers on involving patients in decisions. Both positive and negative views were identified ranging from receptive, noting potential benefits, to concern for the unrealistic nature of participation and sharing in the decision-making process. An example of this potential difficulty, from a healthcare provider perspective, is identifying the potential conflict that may develop when a patient's preference is different from clinical practice guidelines. This is further exemplified in healthcare encounters when a situation may not yield itself to a clear answer but rather lies in a grey area. These situations are challenging for healthcare providers.The notion of information sharing as a prerequisite to shared decision-making offers insight into another process. The healthcare provider must provide the patient the information that they need to know and understand in order to even consider and participate in the shared decision-making process. This information may include the disease, potential treatments, consequences of those treatments, and any alternatives, which may include the decision to do nothing. Without knowing this information the patient will not be able to participate in the shared decision-making process. The complexity of this step is realized if one considers what the healthcare provider needs to know in order to first assess what the patient knows and does not know, the readiness of the patient to participate in this educational process and learn the information, as well as, the individual learning styles of the patient taking into consideration the patient's ideas, values, beliefs, education, culture, literacy, and age. Depending on the results of this assessment the health care provider then must communicate the information to the patient. This is also a complex process that must take into consideration the relationship, comfort level, and trust between the healthcare provider and the patient.Finally, the treatment decision is reached between both the healthcare provider and the patient. Charles et al. portrays shared decision-making as a process with the end product, the shared decision, as the outcome. This outcome may be a decision as to the agreement of a treatment decision, no agreement reached as to a treatment decision, and disagreement as to a treatment decision. Negotiation is a part of the process as the "test of a shared decision (as distinct from the decision-making process) is if both parties agree on the treatment option."Towle and Godolphin developed a process model that further exemplifies the role of the healthcare provider and the patient in the shared decision-making process as mutual partners with mutual responsibilities. The capacity to engage in this shared decision-making rests, therefore, on competencies including knowledge, skills, and abilities for both the healthcare provider and the patient. This mutual partnership and the corresponding competencies are presented for both the healthcare provider and the patient in this model. The competencies noted for the healthcare provider for shared decision making include:Patient competencies include:This model illustrates the shared decision-making process with emphasis on the role of the healthcare provider and the patient very similar to the prior model. This model, however, gives greater emphasis to the process of the co-participation of the healthcare provider and the patient. The co-participation depicts a mutual partnership with mutual responsibilities that can be seen as "reciprocal relationships of dialogue." For this to take place the relationship between and among the participants of the shared decision-making process is important along with other internal and external influences such as communication, trust, mutual respect, honesty, time, continuity, and commitment. Cultural, social, and age group differences; evidence; and team and family are considered within this model.Elwyn et al. presents yet another model that depicts the shared decision-making process; however, this model offers a view where the healthcare provider holds greater responsibility in this process. In this particular model the process focuses on the healthcare provider and the essential skills needed to engage the patient in shard decisions. The competencies outlined in this model include:The healthcare provider must demonstrate knowledge, competencies, and skills as a communicator. The skills for communication competency require the healthcare provider to be able to elicit the patient's thoughts and input regarding treatment management throughout the consultation. The healthcare provider must also demonstrate competencies in assessment skills beyond physical assessment that includes the ability to assess the patient's perceptions and readiness to participate. In addition, the healthcare provider must be able to assess the patient's readiness to learn the information that the patient needs to know in order to fully engage in the shared decision-making process, assess what the patient already knows, what the patient does not know, and whether or not the information that the patient knows is accurate. Once this assessment is completed the healthcare provider then must draw on his/her knowledge, competencies, and skills necessary to teach the patient what the patient needs to know to be informed. This facilitates the notion of the tailor-made information noted previously. The healthcare provider also requires competencies in how to check and evaluate the entire process to ensure that the patient does understand and accept with comfort not only the plan being negotiated but the entire process of sharing in decision-making. In addition to the above, there are further competencies such as competence in working with groups and teams, competencies in terms of cultural knowledge, competencies with regard to negotiation skills, as well as, competencies when faced with ethical challenges.Shared decision-making has been associated with autonomy, empowerment, and effectiveness and efficiency. Both patients and health care providers have noted improvement in relationships and improved interactions when shared decision-making is in evidence. Along with this improved relationship and interaction enhanced compliance is noted. Additional research points to patient satisfaction and enhanced quality of life. There is some evidence to suggest that shared decision-making does facilitate positive health outcomes.In today's healthcare environment there is greater emphasis on patient-centered care that exemplifies patient engagement, participation, partnership, and shared decision-making. Given the shift from the more autocratic delivery of care to the shared approach there is a need to more fully understand the what of shared decision-making as well as how shared decision-making takes place along with what internal and external influences may encourage, support, and facilitate the shared decision-making process. These influences are intervening variables that may be of significance for the successful development of practice-based strategies that may foster shared decision-making in practice. The purpose of this qualitative systematic review is to identify internal and external influences on shared decision-making in all health care settings.A preliminary search of the Joanna Briggs Library of Systematic Reviews, MEDLINE, CINAHL, and PROSPERO did not identify any previously conducted qualitative systematic reviews on the meaningfulness of internal and external influences on shared decision-making.

Effectiveness of patient-caregiver dyad discharge interventions on hospital readmissions of elderly patients with community acquired pneumonia: a systematic review

BACKGROUND

The aim of discharge planning is to reduce unplanned readmission to the hospital and improve coordination of care. As the global population ages, including family caregivers in discharge planning maybe an effective strategy to improve patient outcomes and quality of care. In the United States, hospital readmission following discharge for community acquired pneumonia is a process measure utilized to evaluate discharge planning outcomes.

OBJECTIVES

The objective of this systematic review was to identify the effect of patient-caregiver dyad discharge learning need interventions on unexpected readmissions within thirty days of elderly patients (65 years or older) with community acquired pneumonia.

METHODS

A systematic review of English language studies published and unpublished after 1991on patient and caregiver learning needs related to discharge education and unplanned hospital readmission. Studies including patients aged 65 and older experiencing discharge from a hospital setting, were the primary focus.A comprehensive search of electronic databases was performed for the period of 1991-2010 to find relevant studies. A three-stage search processwas used consisting of an initial database search, scanning of reference lists, citation searching of key papers, contact with authors via the Internet and through personal communication, keyword searching of the World Wide Web. Four authors independently undertook quality assessment and data analysis using the standardized critical appraisal and data extraction tool from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument. Data were summarized by use of narrative methods.

MAIN RESULTS

Five studies were pertinent to the review. Direct comparisons of the studies are limited due to different methods and subject participants. We found statistically significant results that caregiver education interventions impact positively on decreasing unplanned readmissions. Two randomized control trials and one quasi-experimental study were identified that addressed a multidisciplinary discharge education intervention which included caregivers of elderly pneumonia patients. Multidisciplinary care transition intervention was associated with fewer readmissions in thirty days (odds ratio = 0.55; 95% CI 0.32-0.94; odds ratio = 0.56; 95% CI 0.24-1.31; odds ratio= 0.41; 95% CI 0.28-0.75). One case control study and one quasi experimental study identified lack of documented patient or family education as independently associated with unplanned readmissions within thirty days in elderly patient populations that included chronic lung disease (odds ratio = 2.3; 95% CI = 1.2-4.5: odds ratio= 0.52; 95% CI = 0.28-0.96).Wherein, the first of these studies calculated the rate of readmission when caregiver education is omitted whilst the second calculated readmission when an educational intervention is included. However, whilst improved readmission rates with caregiver education was unlikely due to chance, due to the difficulties in isolating caregiver education as a direct intervention, issues of homogeneity limit the generalizability of this review.

CONCLUSIONS

This review highlights the dearth of information on the caregiver's need for specific information on discharge and the need for future research.There is little evidence that education interventions aimed at caregivers are uniformly effective in decreasing pneumonia readmission rates. The evidence suggests that a structured education intervention that includes caregivers probably brings about a small reduction in unexpected readmissions within thirty days for elderly patients with community acquired pneumonia. The specific caregiver learning needs assessment remains variable and uncertain.Research has been aimed at implementation of community acquired pneumonia guidelines to improve mortality and unexpected readmissions within thirty days. However, quality of discharge teaching, a key component of coordinated care, is a strong predictor of readiness for discharge and readmission rates. There is a need for quality randomized studies evaluations of the outcomes specific to patient-caregiver dyad discharge interventions.

The integration of constructed wetlands into a treatment system for airport runoff

A new surface runoff treatment system has been designed for London Heathrow Airport, which incorporates separate floating constructed wetlands or reedbeds and sub-surface flow constructed wetlands as major pollutant removal systems. The primary requirement of the newly developed treatment system is to control the concentrations of glycols following their use as de-icers and anti-icers within the airport. The ability of reedbeds to contribute to this treatment role was fully tested through pilot scale, on-site experiments over a 2 year period. The average reductions in runoff BOD concentrations achieved by pilot scale surface flow and sub-surface flow reedbeds were 30.9% and 32.9%, respectively. The corresponding average glycol removal efficiencies were 54.2% and 78.3%, following shock dosing inputs. These treatment performances are used to predict the required full scale constructed wetland surface areas needed to attain the desired effluent water quality. The treatment system also incorporates aeration, storage and, combined with reedbed technology, has been designed to reduce a mixed inlet BOD concentration of 240 mg/l to less than 40 mg/l for water temperatures varying between 6 degrees C and 20 degrees C.