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There is a severe global shortage of midwives, and the situation worsens when qualified professionals leave their jobs because of inadequate working conditions. Hospitals have increasing difficulties in filling vacancies for midwives. In the case of Germany, midwives tend to give up birth assistance after an average of seven years working in delivery rooms, which are usually led by physicians. We aim to provide concrete recommendations on encouraging qualified professionals to work in maternity wards by examining the job preferences of midwives who currently do not provide such services. These insights shall help policy makers and hospital managers to fill vacancies more quickly and provide adequate care to more women. Discrete choice experiment. Online survey promoted through email and social media to midwives in Germany. 415 midwives participated; we examine the subgroup of 241 midwives who do not offer birth assistance. We obtain individual parameter estimates through a multinominal logit analysis with hierarchical Bayes estimation techniques, calculate importance weights, and simulate uptake probabilities of different hypothetical job offers that include birth assistance. Participants want to provide birth assistance but fiercely reject doing so under physicians' supervision. With a 15 % increase in income, however, 16 % would accept this least preferred setting. Forty-four percent, however, would choose to offer birth assistance if they could work in a midwife-led unit. An additional increase in income of 5 % (15 %) could even lead to uptake probabilities of 67 % (77 %). There is a common understanding that midwife-led care is a safe and effective option for healthy women. Policy makers are advised to further extend their initial support for such units to fill vacancies quicker and enable comprehensive healthcare for more childbearing women. Midwife-led units help counter shortages: Midwives want to provide birth assistance but reject doing so under physicians' supervision. [ABSTRACT FROM AUTHOR]

Patient safety is threatened when early signs of clinical deterioration are missed or not acted upon. This research began as a clinical–academic partnership established around a shared concern of nursing physical assessment practices on general wards and delayed recognition of clinical deterioration. The outcome was the development of a complex intervention facilitated at the ward level for proactive nursing surveillance. The evidence-based nursing core assessment (ENCORE) trial was a pragmatic cluster-randomised controlled trial. We hypothesised that ward intervention would reduce the incidence of patient rescue events (medical emergency team activations) and serious adverse events. We randomised 29 general wards in a 1:2 allocation, across 5 Australian hospitals to intervention (n = 10) and usual care wards (n = 19). Skilled facilitation over 12 months enabled practitioner-led, ward-level practice change for proactive nursing surveillance. The primary outcome was the rate of medical emergency team activations and secondary outcomes were unplanned intensive care unit admissions, on-ward resuscitations, and unexpected deaths. Outcomes were prospectively collected for 6 months following the initial 6 months of implementation. Analysis was at the patient level using generalised linear mixed models to account for clustering by ward. We analysed 29,385 patient admissions to intervention (n = 11,792) and control (n = 17,593) wards. Adjusted models for overall effects suggested the intervention increased the rate of medical emergency team activations (adjusted incidence rate ratio 1.314; 95 % confidence interval 0.975, 1.773), although the confidence interval was compatible with a marginal decrease to a substantial increase in rate. Confidence intervals for secondary outcomes included a range of plausible effects from benefit to harm. However, considerable heterogeneity was observed in intervention effects by patient comorbidity. Among patients with few comorbid conditions in the intervention arm there was a lower medical emergency team activation rate and decreased odds of unexpected death. Among patients with multimorbidity in the intervention arm there were higher rates of medical emergency team activation and intensive care unit admissions. Trial outcomes have refined our assumptions about the impact of the ENCORE intervention. The intervention appears to have protective effects for patients with low complexity where frontline teams can respond locally. It also appears to have redistributed medical emergency team activations and unplanned intensive care unit admissions, mobilising higher rates of rescue for patients with multimorbidity. ACTRN12618001903279 (Date of registration: 22/11/2018; First participant recruited: 01/02/2019). [ABSTRACT FROM AUTHOR]

Depressive symptoms are common in patients with cancer and more prevalent in Chinese patients. The Center for Epidemiologic Studies Depression Scale is one of the most widely used self-report scales to assess depressive symptoms in both community and hospitalized samples. A revised Center for Epidemiologic Studies Depression Scale has been created, but the evidence on psychometric properties is limited. To develop the Chinese version of the scale, and to examine the cross-cultural validity, structural validity, construct validity, internal consistency, test-retest reliability, measurement error, responsiveness, and floor/ceiling effect of the scale among patients with cancer according to the recommendation in the consensus-based standards for the selection of health status measurement instruments checklist. A cross-sectional survey design with 33 participants (approximately 10%) completing the follow-up survey for evaluating the test-retest reliability. Randomly selected eight wards of an oncology hospital in China. Of the 595 patients we approached in the randomly selected eight wards, 310 gave their informed consent and completed the survey. The Chinese version of the Center for Epidemiologic Studies Depression Scale-Revised was developed by four researchers (two translators and two reviewers) who were proficient in both English and Chinese. Participants completed the scale and the depression module of the Patient Health Questionnaire. Principal components analyses, Spearman's correlation, the Mann-Whitney U test, Cronbach's alpha, and the intraclass correlation coefficient were used. The cross-culture validity was excellent based on the consensus-based standards for the selection of the health status measurement instruments checklist. A two-factor structure was determined: somatic symptoms and affective-cognitive symptoms. The sufficient construct validity was supported by that the score of the Center for Epidemiologic Studies Depression Scale-Revised was strongly correlated with the depression module of the Patient Health Questionnaire score (rho = 0.73, p < 0.001) and patients who had received chemotherapy (p = 0.002)/radiotherapy (p = 0.035) reported higher scores of depression than those who have not. The Cronbach's alphas of the total scale and subscales ranged from 0.82–0.88. The test-retest reliability was sufficient (intraclass correlation coefficient = 0.73–0.81, all p < 0.001) for total scale and subscales. The smallest detectable change was 2.98 and the responsiveness was adequate, with no floor/ceiling effect. This study supports the Chinese version of the Center for Epidemiologic Studies Depression Scale-Revised as a valid and reliable measurement of depressive symptoms in patients with cancer. [ABSTRACT FROM AUTHOR]

The implementation of early warning scoring systems and medical emergency teams that aim to reduce failure to rescue in general wards is only effective if frontline nurses can recognize and act on clinical deterioration in a timely manner. While much of the research to date has primarily focused on registered nurses as recognizers of clinical deterioration, little research has sought to explore the role of enrolled nurses in recognizing clinical deterioration and to provide a big picture of how enrolled and registered nurses recognize clinical deterioration in general ward patients. To conduct an exploration of the experiences of enrolled and registered nurses in recognizing clinically deteriorating patients in general wards. A qualitative, descriptive design. General wards at a 1,000-bed acute general hospital in Singapore. A purposive sample of 22 enrolled and registered nurses who had at least 6 months of nursing experience and who were working in the general wards. Individual semi-structured interviews were conducted between October 2016 and February 2017. Interviews were transcribed verbatim and analyzed using thematic analysis. Four salient themes emerged from the data analysis. The first, 'Having a sense of knowing', illustrates how knowing a patient and past experiences facilitated the early recognition of clinical deterioration before the patient turned haemodynamically unstable. The second, 'Patient assessment practices', depicts the physical assessment skills that nurses used to detect clinical deterioration. The third, 'Delegation of routine patient care and assessment to enrolled nurses', demonstrates that nursing activities were delegated to enrolled nurses with lesser directional and supervisory aspects that "delegation" implies, which can potentially compromise patient safety. The fourth, 'Missing the big picture', identifies overwhelming workload and fixation on specific parameters of a patient as reasons for both enrolled and registered nurses missing the big picture of the patient's deterioration. This study provides a snapshot of the recognition of clinical deterioration among enrolled and registered nurses in general wards. Our findings illuminate the need to support the roles of enrolled and registered nurses, with an emphasis on patient assessment and strengthening collaborative practices among nurses, to improve early recognition and timely treatment of clinically deteriorating ward patients. [ABSTRACT FROM AUTHOR]

Physical restraint is a coercive intervention used to prevent individuals from harming themselves or others. However, serious adverse effects have been reported. Minimising the use of restraint requires a multimodal approach to target both organisational and individual factors. The 'Six Core Strategies' developed in America, underpinned by prevention and trauma informed principles, is one such approach. An adapted version of the Six Core Strategies was developed and its impact upon physical restraint usage in mental health Trusts in the United Kingdom evaluated. This became known as 'REsTRAIN YOURSELF. The hypothesis was that restraint would be reduced by 40% on the implementation wards over a six-month period. A non-randomised controlled trial design was employed. Fourteen, adult, mental health wards from seven mental health hospitals in the North West of England took part in the study. Two acute care wards were targeted from all eligible acute wards within each site in negotiation with each Trust. The intervention wards (total n = 144 beds, mean = 20.1 beds per ward) and control wards (total n = 147 beds, mean = 21.0 beds per ward) were primarily mixed gender but included single sex wards also (2 female-only and 1 male-only in each group). All wards offered pharmacological and psychosocial interventions over short admission durations (circa 15 days) for patients with a mixture of enduring mental health problems. As part of a pre and post-test method, physical restraint figures were collected using prospective, routine hospital records before and 6 months after the intervention. Restraint rates on seven wards receiving the REsTRAIN YOURSELF intervention were compared with those on seven control wards over three study phases (baseline, implementation and adoption). In total, 1680 restraint incidents were logged over the study period. The restraint rate was significantly lower on the intervention wards in the adoption phase (6.62 events/1000 bed-days, 95% CI 5.53–7.72) compared to the baseline phase (9.38, 95% CI 8.19–10.55). Across all implementation wards there was an average reduction of restraint by 22%, with some wards showing a reduction of 60% and others less so (8%). The association between ward type and study phase was statistically significant. In conclusion, it is possible that reductions in the use of physical restraint are achievable using a model such as the Six Core Strategies. This approach can be adapted for global settings and changes can be sustained over time with continued support. [ABSTRACT FROM AUTHOR]

Abstract Background and objectives The complex health problems of older persons require that health professionals closely work together, in particular when an acute decline necessitates admission at an acute geriatric unit. These working conditions may cause additional stress in staff. This study aims to identify the relation between interprofessional teamwork, the quality of care and turnover intention in acute geriatric units. Design, setting, participants and methods Perceptions of interprofessional teamwork, quality of care and turnover intention among team members of 55 acute geriatric units were measured using validated questionnaires. A multilevel linear regression model was built for quality of care and logistic regression for turnover intention, with random intercept for acute geriatric unit. Results The overall response rate was 60%. Of the 890 respondents, 71% were nursing professionals, 20% allied health professionals, 5% physicians, and 4% administrative staff. Twenty-three percent reported poor to fair quality of care in their unit; 19% was not sure that patients or families had been given enough means to organise care after discharge. Fifteen percent reported turnover intention (18%, 8%, 9% and 11% among nursing professionals, allied health professionals, physicians and administrative workers respectively, p = 0.005). Higher perceived interprofessional teamwork was related to higher quality of care (estimated coefficient 0.05, p < 0.001) and lower turnover intention in nursing professionals only (estimated OR 0.94, p < 0.001). Conclusion Creating a care environment of good interprofessional teamwork can help acute geriatric units to retain nursing professionals in the job and achieve higher quality of care. [ABSTRACT FROM AUTHOR]

Abstract Introduction As the electronic health record becomes more sophisticated, commensurate advances in cost accounting have risen as a top priority for hospital leaders. This study explored: 1) the average time to complete common nursing tasks documented in the electronic health record, 2) nursing-related tasks that remain undocumented, 3) the association between observation data and actual nursing documentation, and 4) considerations for model development and report design to be used for activity based cost accounting in nursing. Methods This was an observational study completed on acute care inpatient nursing units at a large academic medical center. During a five-week period, 63 nurses from 25 units were observed for over 250 h. Results Nearly 60% of the observed nursing activities did not fit into categories readily available in, and easily abstracted from, the electronic health record. The undocumented activities accounted for over half of the observation tasks and equated to nearly 130 h, in which over 40 h were spent on the activity of documentation/charting itself. Furthermore, nearly 36 h were spent on communication, followed by 13.5 h on monitoring/surveillance, two critical tasks in nursing which cannot be overlooked. Conclusions Using the electronic health record for cost accounting in nursing is a novel approach. In addition to the electronic health record, supplementary sources of data must be included to accurately capture nursing work and associated costs. Findings and lessons learned from this study will be used to guide future work and develop a model that determines the cost of nursing care and improved value in hospitalized patients. [ABSTRACT FROM AUTHOR]

Background Bedside handover is the delivery of the nurse-to-nurse shift handover at the patient’s bedside. The method is increasingly used in nursing, but the evidence concerning the implementation process and compliance to the method is limited. Objectives To determine the compliance with a structured bedside handover protocol following ISBARR and if there were differences in compliance between wards. Design A multicentred observational study with unannounced and non-participatory observations (n = 638) one month after the implementation of a structured bedside handover protocol. Settings and participants Observations of individual patient handovers between nurses from the morning shift and the afternoon shift in 12 nursing wards in seven hospitals in Flanders, Belgium. Methods A tailored and structured bedside handover protocol following ISBARR was developed, and nurses were trained accordingly. One month after implementation, a minimum of 50 observations were performed with a checklist, in each participating ward. To enhance reliability, 20% of the observations were conducted by two researchers, and inter-rater agreement was calculated. Data were analysed using descriptive statistics, one-way ANOVAs and multilevel analysis. Results Average compliance rates to the structured content protocol during bedside handovers were high (83.63%; SD 11.44%), and length of stay, the type of ward and the nursing care model were influencing contextual factors. Items that were most often omitted included identification of the patient (46.27%), the introduction of nurses (36.51%), hand hygiene (35.89%), actively involving the patient (34.44%), and using the call light (21.37%). Items concerning the exchange of clinical information (e.g., test results, reason for admittance, diagnoses) were omitted less (8.09%–1.45%). Absence of the patients (27.29%) and staffing issues (26.70%) accounted for more than half of the non-executed bedside handovers. On average, a bedside handover took 146 s per patient. Conclusions When the bedside handover was delivered, compliance to the structured content was high, indicating that the execution of a bedside handover is a feasible step for nurses. The compliance rate was influenced by the patient’s length of stay, the nursing care model and the type of ward, but their influence was limited. Future implementation projects on bedside handover should focus sufficiently on standard hospital procedures and patient involvement. According to the nurses, there was however a high number of situations where bedside handovers could not be delivered, perhaps indicating a reluctance in practice to use bedside handovers. [ABSTRACT FROM AUTHOR]

Background Keeping long-term care nurses employed is necessary to sustain the current and future demand for high-quality long-term care services. Understanding the factors relating to intention to stay among long-term care nurses is limited by the scarcity of studies in long-term care settings, lack of investigation of multiple factors, and the weakness of existing explanatory models. Objective To identify the factors associated with long-term care nurses’ intention to stay in their current workplace. Design A cross-sectional questionnaire survey. Setting Two hundred and fifty-seven hospitals with long-term care wards across Japan. Participants A total of 3128 staff nurses and 257 nurse managers from the long-term care wards of the participating hospitals. Method The questionnaire assessed nurses’ intention to continue working in the current workplace as well as potential related factors, including individual factors (demographic data, reason for choosing current workplace, burnout, work engagement, somatic symptom burden) and unit factors (unit size, nurse-manager-related data, patients’ medical acuity, average number of overtime hours, recreational activities, social support, perceived quality of care process, educational opportunities, feeling of loneliness, and ability to request days off). Multilevel logistic regression analysis was used to determine which variables best explained nurses’ intention to stay in their workplace. Results Only 40.1% of the respondents reported wanting to continue working at their current workplace. The regression analysis revealed that long-term care nurses’ intention to stay was positively associated with nurses’ age (odds ratio [95% confidence interval]: 1.02 [1.01–1.03]), work engagement (1.24 [1.14–1.35]), getting appropriate support from nurse managers (2.78 [1.60–4.82]), perceived quality of care process (1.04 [1.01–1.06]), educational opportunities (1.06 [1.0–1.13]), and various specific reasons for choosing their workplace (e.g., a good workplace atmosphere, being interested in gerontological nursing, and a high salary). By contrast, intention to stay was negatively associated with emotional exhaustion (0.93 [0.91–0.95]) and depersonalization (0.91 [0.89–0.93]). Intention to stay was associated with neither nurses’ qualifications nor patient medical acuity. Conclusion Reason for choosing the workplace, work engagement, getting support from the nurse manager, and perceived quality of care process are significant predictors of long-term care nurses’ intention to stay in the workplace. Promoting such nurses’ work engagement, provision of high-quality care, and access to educational opportunities might augment long-term care nurses’ intention to stay. [ABSTRACT FROM AUTHOR]

Background Nurse staffing level is an important factor on nursing sensitive outcome. The relationships of nurse staffing level with nursing sensitive outcomes such as mortality, upper gastrointestinal bleeding and pressure ulcer have been explored in the United States, Canada, Australia, and New Zealand. Lower level of hospital nurse staffing seems associated with more adverse outcomes, especially mortality. However, there is insufficient evidence of the nurse staffing level-outcome relationship in other indicators. Objectives This study was conducted to describe the status and prove the relationships of nurse staffing level with nursing sensitive outcome indicators for adult medical and surgical inpatients in Korea. Patient and hospital characteristics as covariates on nurse sensitive outcome were also explored. Design This was a retrospective observational study. Setting The study setting was all 46 tertiary hospitals in Korea. Participants We selected all anonymized patients aged 19 years or older and admitted at tertiary hospitals for two years (2013–2014) using electronic reimbursement claims data. Method Multiple logistic regression was used to examine relationships of nurse staffing level (accounted for full-time registered nurses in general ward only) with Nursing-sensitive outcomes (NSOs) adjusted for patient and hospital characteristics. NSOs included urinary tract infection, upper gastrointestinal tract bleeding, deep vein thrombosis, hospital-acquired pneumonia, pressure ulcer, sepsis, shock/cardiac arrest, CNS complication, in-hospital death, wound infection, physiologic/metabolic derangement and pulmonary failure. Results The total number of patients in 46 tertiary hospitals in Korea for two years was 3,665,307. Among these, number of patients who had at least one nursing-sensitive outcome was 338,369 (9.23%). The significant relationships of nurse staffing level with six nursing-sensitive outcome rates (urinary tract infection, upper gastrointestinal tract bleeding, hospital-acquired pneumonia, shock/cardiac arrest, in-hospital death, and wound infection) were shown. These six nursing-sensitive outcomes showed an increasing trend as nurse staffing level degraded even after adjusting for patient and hospital characteristics. When the nursing-sensitive outcomes between those of group 1 (bed-to-nurse ratio < 2:1) and group 3 (between 2.5:1 and 3:1) were compared, the adjusted incidence rate of shock/cardiac arrest showed the highest difference (1.06%). Conclusion We demonstrated strong evidence for the relationships of nurse staffing level with six nursing-sensitive outcomes. We can use this study to improve nursing quality and to inform patients of the nursing quality of hospitals so they can choose hospitals with better nursing quality. The nurse staffing level should be optimized for better outcomes. [ABSTRACT FROM AUTHOR]

Early warning scores based on vital signs are used in hospitals to estimate patient deterioration and to initiate an adequate and timely response when necessary. These scores show acceptable performance in predicting patient outcomes. However, they tend to generate many false positives leading to an increased workload in clinical practice. Additionally, nurses feel a tension between the application of an early warning score and their own clinical judgement. Nurse intuition is often included as an extra call criterion next to an early warning score. It is therefore important to investigate its predictive value. The aim of this study was to develop and validate a Nurse Intuition Patient Deterioration Scale (NIPDS). The NIPDS was developed using the latest evidence after which relevant items were selected by an expert panel. The scale was tested in a prospective observational study in 2 surgical and 2 medical wards in a Belgian hospital. Data were collected from December 1st, 2019 until March 31st, 2020. A NIPDS registration was done at each patient admission and whenever the attending nurse felt worried. The studied outcomes were urgent physician assistance call, resuscitation team call, patient death, and unplanned transfer to intensive/medium care. Psychometric analyses and scale optimisation were carried out using Rasch modelling techniques. Finally, the scale's accuracy and an optimal threshold were determined. The scale item content validity index is 0.88 indicating that the selected items should be included in the instrument according to the expert panel. Item-total score correlation coefficients range between 0.573 (item 9 – pain) and 0.874 (item 6 – behaviour). The Person Separation Index is 0.814 indicating satisfactory discriminatory power. An overall fit of the NIPDS data to the Rasch model was confirmed. Rasch modelling showed that the item 'pain' signalled misfit. Furthermore, the person-item map showed disordered items which were corrected in the final model. The AUROC to predict an event within 24 h after registration was 0.957 (95% CI 0.932–0.982; p < 0.001) indicating excellent model performance. The results showed that the NIPDS is a valid and accurate instrument to predict events in surgical and medical patients. It showed better performance compared to an existing score estimating nurse intuition. In practice, the NIPDS could be used by nurses to estimate clinical deterioration in addition to an early warning score. It remains unclear if the combination of NIPDS with an early warning score could reduce workload without losing accuracy and this should be explored in future research. Newly developed nurse intuition scale, which uses clinical cues to estimate deterioration in hospitalised patients, is brief and performs well in predicting physician assistance, resuscitation team calls, patient death and unplanned transfer to intensive or medium care. [ABSTRACT FROM AUTHOR]

Background Needlestick and sharps injuries are prevalent work-related injuries among nurses. Safety devices prevent only one-quarter of related injuries. More studies of modifiable risk factors are needed. Objectives To examine whether long work hours and chronic insomnia are associated with needlestick and sharps injuries among hospital nurses in Taiwan. Design Cross-sectional survey. Settings/participants This analysis included 19,386 full-time bedside nurses working in 104 hospitals across Taiwan. Methods Participants filled out an anonymous questionnaire from July to September 2014. Chronic insomnia, needlestick injuries, and sharps injuries during the past year were each measured by a yes/no question. Multivariate logistic regression models were applied to examine the effects of long work hours and chronic insomnia on needlestick and sharps injuries, given with control for sex, marital status, educational level, age, years of practice, work unit, and hospital level in the model. Results More than 70% of study nurses worked long hours during the previous week (>50 h: 27.5%; 41–50 h: 43.2%), and 15.5% of nurses reported chronic insomnia. The percentage of sharps injuries (38.8%) was higher than that for needlestick injuries (22.4%) during the previous year among nurses. After adjusting for potential confounders, logistic regression yielded significant results showing that those who worked 41 to 50 h per week, >50 h per week, and had chronic insomnia were 1.17 times (95% C.I. = 1.04–1.32), 1.51 times (95% C.I. = 1.32–1.72), and 1.45 times (95% C.I. = 1.25–1.68) more likely to experience needlestick injuries, and 1.29 times (95% C.I. = 1.17–1.42), 1.37 times (95% C.I. = 1.23–1.53), and 1.56 times (95% C.I. = 1.37–1.77) more likely to experience sharps injuries, respectively, than those who worked fewer hours and did not have insomnia. Conclusions This nationwide nurse survey showed that high rates of needlestick and sharps injuries persist in hospital nurses in Taiwan. The common problems of long work hours and chronic insomnia increase the risk of these injuries. We suggest that hospital managers follow regulations on work hours and optimize shift schedules for nurses to decrease related injuries. [ABSTRACT FROM AUTHOR]

Background There is a need to improve understanding of role stress and how it affects nurses’ wellbeing, burnout and health; and hence the quality and safety of patients’ care, organizational outcomes and costs. The focus is on shift charge nurses in hospitals who are accountable during a specific shift for the patients’ care and staff functioning in accordance with hospital and unit policy. Objective To compare perceptions of stress and its intensity among hospital shift charge nurses amongst three countries: Israel, USA (state of Ohio) and Thailand. Design A cross-sectional study was performed across three countries, focusing on a convenience sample of 2616 hospital shift charge nurses recruited from 23 general hospitals. Methods A validated shift Charge Nurse Stress Questionnaire was used to assess impacts of four factors: patient & family complaints, lack of resources, responsibility burden and professional conflict. Descriptive statistics were used to describe demographic and professional characteristics of the participants. Chi square and the Fisher Exact Test were performed to test for demographic differences amongst the three samples. Parametric and non-parametric tests were used to compare mean stress levels amongst the study samples. Results The mean stress level for the total sample was 2.84 (±0.71) on a Likert scale of 1–5, implying moderate stress levels. Significant differences in stress levels were found among countries, with Thai nurses scoring the highest and Israeli nurses the lowest. Similar perceptions of stress intensity were found for all countries, with the factors “responsibility burden” and “lack of resources” considered the most stressful. Israeli and American nurses perceived similar situations as stressful and different from those perceived by Thai nurses. The findings can be partially explained by demographic, professional and cultural differences. Conclusions Similarities along with differences were found in the nature and levels of stress experienced across the studied countries. A prerequisite educational program should be mandatory for nurses prior to their nomination as shift charge nurses. Programs should be tailored to address the stress experienced by shift charge nurses. Ongoing mentorship and workshops are recommended to develop and maintain leadership abilities to cope with role stress. Future research should explore internationally the unique nature and stress of the shift charge nurse’s role and replicate this study by using the Charge Nurse Stress Questionnaire in other countries. Further international comparative studies are recommended to evaluate stress perceptions of nurses in other roles and in different practice areas. [ABSTRACT FROM AUTHOR]

Objectives The aim of this study was to assess the impact of adding assistants in nursing to acute care hospital ward nurse staffing on adverse patient outcomes using administrative health data. Design Logistic regression modelling was used with linked administrative health data to examine the association between seven adverse patient outcomes and use of assistants in nursing utilising a pre-test/post-test design. Outcomes included were in-hospital 30-day mortality, failure to rescue, urinary tract infection, pressure injury, pneumonia, sepsis and falls with injury. Setting Eleven acute care metropolitan hospitals in Western Australia. Sample Patients were retained in the dataset if they spent any time on a medical, surgical or rehabilitation ward during their admission and excluded if they only spent time on other ward types, as the outcomes used in this study are only validated for these patient populations. There were 256,302 patient records in the total sample with 125,762 in the pre-test period (2006–2007) and 130,540 in the post-test period (2009–2010). Results The results showed three significant increases in observed to expected adverse outcomes on the assistant in nursing wards (failure to rescue, urinary tract infection, falls with injury), with one significant decrease (mortality). On the non-assistant in nursing wards there was one significant decrease (pneumonia) in the observed to expected adverse outcomes and one significant increase (falls with injury). Post-test analysis showed that spending time on assistant in nursing wards was a significant predictor for urinary tract infection and pneumonia. For every 10% of extra time patients spent on assistant in nursing wards they had a 1% increase in the odds of developing a urinary tract infection and a 2% increase in the odds of developing pneumonia. Conclusion The results suggest that the introduction of assistants in nursing into ward staffing in an additive role should be done under a protocol which clearly defines their role, scope of practice, and working relationship with registered nurses, and the impact on patient care should be monitored. [ABSTRACT FROM AUTHOR]

Background Providing high quality nursing care for patients with malignancies is complex and driven by many factors. Many of the associations between nursing care quality, trust, health status and individualized care remain obscure. Objective To empirically test a model of association linking hospitalized cancer patients’ health status, nursing care quality, perceived individuality in care and trust in nurses. Design A cross-sectional, exploratory and correlational study design was used. Settings This multi-site study was conducted in cancer care clinics, in-patient wards of five tertiary care hospitals in Cyprus, Finland, Greece and Sweden. Sample Out of 876 hospitalized patients with a confirmed histopathological diagnosis of cancer approached to participate in the study in consecutive order, 599 (response rate 68%) agreed to participate and the data from 590 were used for path analysis. Methods Data were collected in 2012–2013 with the Individualized Care Scale-Patient (ICS-Patient), the Oncology Patients’ Perceptions of Quality Nursing Care Scale (OPPQNCS), the Euro-Qol (EQ-5D-3L) and the Trust in Nurses Scale. Data were analysed statistically using descriptive and inferential statistics. Mplus version 7.11 was used to determine the best Trust model with path analysis. Results Although the model fit indices suggested that the hypothesized model did not perfectly to the data, a slightly modified model which includes the reciprocal path between individualized care and nursing care quality demonstrated a good fit. Conclusion A model of trust in nurses was developed. Health status, individualized care, and nursing care quality were found to be associated with trust. The model highlights the complexity of caring for cancer patients. Trust in nurses is influenced by the provision of individualized care. Generating and promoting trust requires interventions, which promote nursing care quality, individuality and patients’ health status. [ABSTRACT FROM AUTHOR]

Background Patient classification systems have been developed to manage workloads by estimating the need for nursing resources through the identification and quantification of individual patients’ care needs. There is in use a diverse variety of patient classification systems. Most of them lack validity and reliability testing and evidence of the relationship to nursing outcomes. Objective Predictive validity of the RAFAELA system was tested by examining whether hospital mortality can be predicted by the optimality of nursing workload. Methods In this cross-sectional retrospective observational study, monthly mortality statistics and reports of daily registrations from the RAFAELA system were gathered from 34 inpatient units of two acute care hospitals in 2012 and 2013 ( n = 732). The association of hospital mortality with the chosen predictors (hospital, average daily patient to nurse ratio, average daily nursing workload and average daily workload optimality) was examined by negative binomial regression analyses. Results Compared to the incidence rate of death in the months of overstaffing when average daily nursing workload was below the optimal level, the incidence rate was nearly fivefold when average daily nursing workload was at the optimal level (IRR 4.79, 95% CI 1.57–14.67, p = 0.006) and 13-fold in the months of understaffing when average daily nursing workload was above the optimal level (IRR 12.97, 95% CI 2.86–58.88, p = 0.001). Conclusions Hospital mortality can be predicted by the RAFAELA system. This study rendered additional confirmation for the predictive validity of this patient classification system. In future, larger studies with a wider variety of nurse sensitive outcomes and multiple risk adjustments are needed. Future research should also focus on other important criteria for an adequate nursing workforce management tool such as simplicity, efficiency and acceptability. [ABSTRACT FROM AUTHOR]

Background Nursing turnover is a major issue for health care managers, notably during the global nursing workforce shortage. Despite the often hierarchical structure of the data used in nursing studies, few studies have investigated the impact of the work environment on intention to leave using multilevel techniques. Also, differences between intentions to leave the current workplace or to leave the profession entirely have rarely been studied. Objective The aim of the current study was to investigate how aspects of the nurse practice environment and satisfaction with work schedule flexibility measured at different organisational levels influenced the intention to leave the profession or the workplace due to dissatisfaction. Design Multilevel models were fitted using survey data from the RN4CAST project, which has a multi-country, multilevel, cross-sectional design. The data analysed here are based on a sample of 23,076 registered nurses from 2020 units in 384 hospitals in 10 European countries (overall response rate: 59.4%). Four levels were available for analyses: country, hospital, unit, and individual registered nurse. Practice environment and satisfaction with schedule flexibility were aggregated and studied at the unit level. Gender, experience as registered nurse, full vs. part-time work, as well as individual deviance from unit mean in practice environment and satisfaction with work schedule flexibility, were included at the individual level. Both intention to leave the profession and the hospital due to dissatisfaction were studied. Results Regarding intention to leave current workplace, there is variability at both country (6.9%) and unit (6.9%) level. However, for intention to leave the profession we found less variability at the country (4.6%) and unit level (3.9%). Intention to leave the workplace was strongly related to unit level variables. Additionally, individual characteristics and deviance from unit mean regarding practice environment and satisfaction with schedule flexibility were related to both outcomes. Major limitations of the study are its cross-sectional design and the fact that only turnover intention due to dissatisfaction was studied. Conclusions We conclude that measures aiming to improve the practice environment and schedule flexibility would be a promising approach towards increased retention of registered nurses in both their current workplaces and the nursing profession as a whole and thus a way to counteract the nursing shortage across European countries. [ABSTRACT FROM AUTHOR]

Aims To describe a surveillance approach for monitoring the effect of improvement initiatives on hospital-acquired pressure injuries and findings arising from that surveillance. Methods Random sampling of patients on the same day of each successive month from a campus of child and adult hospitals using a standard audit tool to identify presence of hospital-acquired pressure injury. Where multiple pressure injuries were present, the most severe grade injury contributed to prevalence. Statistical process control charts were used to monitor monthly performance and Maximum Likelihood Estimation to determine timing of step change. Results 8274 patients were assessed over 3 years from an eligible population of 32,259 hospitalised patients. 517 patients had hospital-acquired pressure injuries giving an overall prevalence of 6.2% (95% CI 5.7–6.8%). Annual prevalence was 8.4% (95% CI 7.4–9.5%) in the first year, falling to 5.6% (95% CI 4.7–6.4%) in the second year and 4.8% (95% CI 4.0–5.6%) in the third year. A step change was signalled with mean prevalence up to July 2013 being 7.9% (95% CI 7.1–8.8%) and mean prevalence thereafter 4.8% (95% CI 4.2–5.4%). Hospital-acquired pressure injuries were found in all age ranges, but were more frequent in children up to 14 years (17.4%) and those aged 75 years or older (38.7%). Conclusion Monthly random sampling of patients within clinical units can be used to monitor performance improvement. This approach represents a rational alternative to cross-sectional prevalence surveys especially if the focus is on performance improvement. [ABSTRACT FROM AUTHOR]

Background High profile safety failures have demonstrated that recognising early warning signs of clinical and physiological deterioration can prevent or reduce harm resulting from serious adverse events. Early warning scoring systems are now routinely used in many places to detect and escalate deteriorating patients. Timely and accurate vital signs monitoring are critical for ensuring patient safety through providing data for early warning scoring systems, but little is known about current monitoring practices. Objective To establish a profile of nurses’ vital signs monitoring practices, related dialogue, and adherence to health service protocol in New South Wales, Australia. Methods Direct observations of nurses’ working practices were conducted in two wards. The observations focused on times of the day when vital signs were generally measured. Patient interactions were recorded if occurring any time during the observation periods. Participants ( n = 42) included nursing staff on one chronic disease medical and one acute surgical ward in a large urban teaching hospital in New South Wales. Results We observed 441 patient interactions. Measurement of vital signs occurred in 52% of interactions. The minimum five vital signs measures required by New South Wales Health policy were taken in only 6–21% of instances of vital signs monitoring. Vital signs were documented immediately on 93% of vitals-taking occasions and documented according to the policy in the patient's chart on 89% of these occasions. Nurse–patient interactions were initiated for the purpose of taking vital signs in 49% of interactions, with nurse–patient discourse observed during 88% of all interactions. Nurse–patient dialogue led to additional care being provided to patients in 12% of interactions. Conclusion The selection of appropriate vital signs measured and responses to these appears to rely on nurses’ clinical judgement or time availability rather than on policy-mandated frequency. The prevalence of incomplete sets of vital signs may limit identification of deteriorating patients. The findings from this study present an important baseline profile against which to evaluate the impact of introducing continuous monitoring approaches on current hospital practice. [ABSTRACT FROM AUTHOR]

Background and objectives Interdisciplinary geriatric consultation teams are implemented in the acute hospital setting in several high-income countries to provide comprehensive geriatric assessment for the increasing numbers of older patients with a geriatric profile hospitalized on non-geriatric units. Given the inconclusive evidence on this care model's effectiveness to improve patient outcomes, health care policy and practice oriented recommendations to redesign the structure and process of care provided by interdisciplinary geriatric consultation teams are needed. A scoping review was conducted to explore the structure and processes of interdisciplinary geriatric consultation teams in an international context. As nurses are considered key members of these teams, their roles and responsibilities were specifically explored. Design The revised scoping methodology framework of Arksey and O’Malley was applied. Data sources An electronic database search in Ovid MEDLINE, CINAHL and EMBASE and a hand search were performed for the identification of descriptive and experimental studies published in English, French or Dutch until April 2014. Review methods Thematic reporting with descriptive statistics was performed and study findings were validated through interdisciplinary expert meetings. Results Forty-six papers reporting on 25 distinct interdisciplinary geriatric consultation teams in eight countries across three continents were included. Eight of the 12 teams (67%) reporting on their composition, stated that nurses and physicians were the main core members with head counts varying from 1 to 4 members per profession. In 80% of these teams nurses were required to have completed training in geriatrics. Advanced practice nurses were integrated in eleven out of fourteen interdisciplinary geriatric consultation teams from the USA. Only 32% of teams used formal screening to identify patients most likely to benefit from their intervention, using heterogeneous screening methods, and scarcely providing information on the responsibilities of nurses. Nurses were involved in the medical, functional, psychological and social assessment of patients in 68% of teams, either in a leading role or in collaboration with other professions. Responsibilities of interdisciplinary geriatric consultation teams’ nurses regarding in-hospital follow-up or transitional care at hospital discharge were infrequently specified (16% of teams). Conclusions This scoping review identified that the structure and processes of care provided to geriatric patients by interdisciplinary geriatric consultation teams are highly heterogeneous. Despite nurses being key team members, only limited information on their specific roles and responsibilities was identified. More research in this area is required in order to inform health care policy and to formulate practice oriented recommendations to redesign the interdisciplinary geriatric consultation team care model aiming to improve its effectiveness. [ABSTRACT FROM AUTHOR]

Background Social capital can be an important resource to facilitate the needed improvements in quality of care and efficiency in hospitals. Objectives To assess the importance of social capital (recognition, vertical trust, horizontal trust and reciprocity) for job satisfaction, work engagement and engagement in clinical improvements. Design A prospective cohort design was used. Settings Intensive care units and emergency, surgical and medical units at five Swedish hospitals with ongoing development of their processes of care. Participants Healthcare professionals (physicians, registered nurses, assistant nurses) at five Swedish midsize hospitals. Methods The participants answered a questionnaire at two occasions, NN = 1602 at baseline and NN = 1548 at one-year follow-up. Mean hospital response rate was 53% at baseline and 59% at follow-up. Univariate, multivariate and logistic regression analyses were performed, and the prospective analysis was based on 477 respondents. Results Social capital was associated with healthcare professionals’ general work engagement and job satisfaction. Analysis showed positive associations between all measured aspects of social capital and engagement in clinical improvements of patient safety and quality of care. The prospective analysis showed that increased social capital predicted increased job satisfaction, work engagement and engagement in clinical improvements of patient safety. Conclusion Social capital is strongly related to job satisfaction and active engagement with clinical improvements. The findings contribute to a deeper knowledge of social capital as a predictive factor that influences patient safety and health among healthcare staff. [ABSTRACT FROM AUTHOR]

Objectives: The purposes of this review of unfinished care were to: (1) compare conceptual definitions and frameworks associated with unfinished care and related synonyms (i.e. missed care, implicitly rationed care; and care left undone); (2) compare and contrast approaches to instrumentation; (3) describe prevalence and patterns; (4) identify antecedents and outcomes; and (5) describe mitigating interventions. Methods: A literature search in CINAHL and MEDLINE identified 1828 articles; 54 met inclusion criteria. Search terms included: implicit ration*, miss* care, ration* care, task* undone, and unfinish*care. Analysis was performed in three phases: initial screening and sorting, comprehensive review for data extraction (first author), and confirmatory review to validate groupings, major themes, and interpretations (second author). Results: Reviewed literature included 42 quantitative reports; 7 qualitative reports; 1 mixed method report; and 4 scientific reviews. With one exception, quantitative studies involved observational cross-sectional survey designs. A total of 22 primary samples were identified; 5 involved systematic sampling. The response rate was >60% in over half of the samples. Unfinished care was measured with 14 self-report instruments. Most nursing personnel (55-98%) reported leaving at least 1 task undone. Estimates increased with survey length, recall period, scope of response referent, and scope of resource scarcity considered. Patterns of unfinished care were consistent with the subordination of teaching and emotional support activities to those related to physiologic needs and organizational audits. Predictors of unfinished care included perceived team interactions, adequacy of resources, safety climate, and nurse staffing. Unfinished care is a predictor of: decreased nurse-reported care quality, decreased patient satisfaction; increased adverse events; increased turnover; decreased job and occupational satisfaction; and increased intent to leave. Discussion & conclusions: Unfinished care is a significant problem in acute care hospitals internationally. Prioritization strategies of nurses leave patients vulnerable to unmet educational, emotional, and psychological needs. Key limitations of the science include the threat of common method/source bias, a lack of transparency regarding the use of combined samples and secondary analysis, inconsistency in the reporting format for unfinished care prevalence, and a paucity of intervention studies. [ABSTRACT FROM AUTHOR]

Background: Patient participation is a way for patients to engage in their nursing care. In view of the possible link between patient participation and safety, there is a need for an updated review to assess patient participation in nursing care. Objectives: To investigate patients' and nurses' perceptions of and behaviours towards patient participation in nursing care in the context of hospital medical wards. Design: Integrative review. Data sources: Three search strategies were employed in August 2013; a computerised database search of Cumulative Index of Nursing and Allied Health Literature, Cochrane Library, Medline and PsychINFO; reference lists were hand-searched; and forward citation searching was executed. Review methods: After reviewing the studies, extracting study data and completing summary tables the methodological quality was assessed using the Mixed-Methods Assessment Tool by two reviewers. Reviewers met then to discuss discrepancies as well as the overall strengths and limitations of the studies. Discrepancies were overcome through consensus or a third reviewer adjudicated the issue. Within and across study analysis and synthesis of the findings sections was undertaken using thematic synthesis. Results: Eight studies met inclusion criteria. Four themes were identified - enacting participation, challenges to participation, promoting participation and types of participation. Most studies included were conducted in Europe. The majority of studies used qualitative methodologies, with all studies sampling patients; nurses were included in three studies. Data were largely collected using self-reported perceptions; two studies included observational data. Methodological issues included a lack of reflexivity, unvalidated data collection tools, sampling issues and low response rates. Conclusions: On medical wards, patients and nurses desire, perceive or enact patient participation passively. Challenging factors for patient participation include patients' willingness, nurses' approach and confusion around expectations and roles. Information-sharing was identified as an activity that promotes patient participation, suggesting nurses encourage active communication with patients in practice. Involving patients in assessment and care planning may also enhance patient participation. For education, enhancing nurses' understanding of the attributes of patient participation, as well as patient-centred care approaches may be beneficial for medical ward nurses. From here, researchers need to examine ways to overcome the barriers to patient participation; further nurse participants and observational data is required on medical wards. [ABSTRACT FROM AUTHOR]

Background: Previous research studies have found that the better the quality of practice environments in hospitals, the better the outcomes for nurses and patients. Practice environment may influence nurses' ability to individualize care but the detailed relationship between individualized care and the professional practice environment has not been investigated widely. Some evidence exists about the association of practice environments with the level of individualization of nursing care, but this evidence is based on single national studies. Objectives: The aim of this study was to determine whether nurses' views of their professional practice environment associate with their views of the level of care individualization in seven countries. Design: This study had an international, multisite, prospective, cross-sectional, exploratory survey design. Settings: The study involved acute orthopedic and trauma surgical inpatient wards (n = 91) in acute care hospitals (n = 34) in seven countries, Cyprus, Finland, Greece, the State of Kansas, USA, Portugal, Sweden, and Turkey. Participants: Nurses (n= 1163), registered or licensed practical, working in direct patient care, in orthopedic and trauma inpatient units in acute care hospitals in seven countries participated in the study. Methods: Self-administered questionnaires, including two instruments, the Revised Professional Practice Environment and the Individualized Care Scale-Nurse (Individualized Care Scale-Nurse A and B) were used for data collection. Data were analyzed statistically using descriptive statistics, simultaneous multiple regression analysis, and generalized linear model. Results: Two regression models were applied to assess the predictive validity of the Revised Professional Practice Environment on the Individualized Care Scale-Nurse-A and B. The results showed that elements of the professional practice environment were associated with care individualization. Internal work motivation, cultural sensitivity, control over practice, teamwork, and staff relationship with physicians were predictors of support (Individualized Care Scale-A) for and the delivery (Individualized Care Scale-B) of individualized care. Conclusions: The results of this study provide evidence that environment aspect could explain variations in care individualization. These findings support the assertion that individualized care needs to be understood in a broader context than the immediate nurse-patient relationship and that careful development of the care environment may be an effective way to improve care quality and outcomes. [ABSTRACT FROM AUTHOR]

Background: Quality improvement (QI) Programmes, like the Productive Ward: Releasing-time-to-care initiative, aim to 'engage' and 'empower' ward teams to actively participate, innovate and lead quality improvement at the front line. However, little is known about the relationship and impact that QI work has on the 'engagement' of the clinical teams who participate and vice-versa. Objective: This paper explores and examines the impact of a large-scale QI programme, the Productive Ward, on the 'work engagement' of the nurses and ward teams involved. Design/methods: Using the Utrecht Work Engagement Scale (UWES), we surveyed, measured and analysed work engagement in a representative test group of hospital-based ward teams who had recently commenced the latest phase of the national 'Productive Ward' initiative in Ireland and compared them to a control group of similar size and matched (as far as ispossible) on variables such as ward size, employment grade and clinical specialty area. Results: 338 individual datasets were recorded, n = 180 (53.6%) from the Productive Ward group, and n = 158 (46.4%) from the control group; the overall response rate was 67%, and did not differ significantly between the Productive Ward and control groups. The work engagement mean score (±standard deviation) in the Productive group was 4.33 (±0.88), and 4.07 (± 1.06) in the control group, representing a modest but statistically significant between-group difference (p = 0.013, independent samples t-test). Similarly modest differences were observed in all three dimensions of the work engagement construct. Employment grade and the clinical specialty area were also significantly related to the work engagement score (p < 0.001, general linear model) and (for the most part), to its components, with both clerical and nurse manager grades, and the elderly specialist areas, exhibiting substantially higher scores. Conclusions: The findings demonstrate how QI activities, like those integral to the Productive Ward programme, appear to positively impact on the work engagement (the vigour, absorption and dedication) of ward-based teams. The use and suitability of the UWES as an appropriate measure of 'engagement' in QI interventions was confirmed. The engagement of nurses and front-line clinical teams is a major component of creating, developing and sustaining a culture of improvement. [ABSTRACT FROM AUTHOR]

Background: Recruitment and retention strategies have emphasized the importance of positive work environments that support professional nursing practice for sustaining the nursing workforce. Unit leadership that creates empowering workplace conditions plays a key role in establishing supportive practice environments that increase work effective- ness, and, ultimately, improves job satisfaction. Objectives: To test a multi-level model examining the effect of both contextual and individual factors on individual nurse job satisfaction. At the unit level, structural empowerment and support for professional nursing practice (organizational resources) were hypothesized to be predictors of unit level effectiveness. At the individual level, core self-evaluation, and psychological empowerment (intrapersonal resources) weremodeled as predictors of nurse job satisfaction one year later. Cross-level unit effects on individual nurses' job satisfaction were also examined. Design: This study employed a longitudinal survey design with 545 staff nurses from 49 hospital units in Ontario, Canada. Participants completed a survey at two points in time (response rate of 40%) with standardized measures of the major study variables in the hypothesized model. Multilevel structural equation modeling was used to test the model. Results: Nurses shared perceptions of structural empowerment on their units indirectly influenced their shared perceptions of unit effectiveness (Level 2) through perceived unit support for professional nursing practice, which in turn, had a significant positive direct effect on unit effectiveness (Level 2). Unit effectiveness was also strongly related to individual nurse job satisfaction one year later. At Level 1, higher core self-evaluation had a direct and indirect effect on job satisfaction through increased psychological empowerment. Conclusions: The results suggest that nurses' job satisfaction is influenced by a combination of individual and contextual factors demonstrating utility in considering both sources of nurses' satisfaction with their work in creating effective nursing work environments. [ABSTRACT FROM AUTHOR]

Background: The hospital nursing practice environment has been found to be crucial for better nurse and patient outcomes. Yet little is known about the professional nursing practice environment at the unit level where nurses provide 24-hour bedside care to patients. Objectives: To examine differences in nursing practice environments among 11 unit types (critical care, step-down, medical, surgical, combined medical--surgical, obstetric, neonatal, pediatric, psychiatric, perioperative, and emergency) and by Magnet status overall, as well as four specific aspects of the practice environment. Design: Cross-sectional study. Settings: 5322 nursing units in 519 US acute care hospitals. Methods: The nursing practice environment was measured by the Practice Environment Scale of the Nursing Work Index. The Practice Environment Scale of the Nursing Work Index mean composite and four subscale scores were computed at the unit level. Two statistical approaches (one-way analysis of covariance and multivariate analysis of covariance analysis) were employed with a Tukey-Kramer post hoc test. Results: In general, the nursing practice environment was favorable in all unit types. There were significant differences in the nursing practice environment among the 11 unit types and by Magnet status. Pediatric units had the most favorable practice environment and medical--surgical units had the least favorable. A consistent finding across all unit types except neonatal units was that the staffing and resource adequacy subscale scored the lowest compared with all other Practice Environment Scale of the Nursing Work Index subscales (nursing foundations for quality of care, nurse manager ability, leadership, and support, and nurse--physician relations). Unit nursing practice environments were more favorable in Magnet than non-Magnet hospitals. Conclusions: Findings indicate that there are significant variations in unit nursing practice environments among 11 unit types and by hospital Magnet status. Both hospital-level and unit-specific strategies should be considered to achieve an excellent nursing practice environment in all hospital units. [ABSTRACT FROM AUTHOR]

Background: Various staffing measures have been used in examining the relationship between nurse staffing and patient outcomes. Little research has been conducted to compare these measures based on their explanatory power as predictors of nursing- sensitive outcomes. In this study, both administrative and nurse-reported measures were examined. Administrative measures included registered nurse (RN) skill mix and three versions of nursing hours per patient day (HPPD); nurse-reported measures included RN-reported number of assigned patients and RN-perceived staffing adequacy. Objectives: To examine correlations among six nurse staffing measures and to compare their explanatory power in relation to unit-acquired pressure ulcers (UAPUs). Design: Descriptive, correlational study. Settings: 2397 nursing units in 409 U.S. acute care hospitals. Methods: Random-intercept logistic regression analyses were performed using 2011 data from a national database. Relationships between nurse staffing measures and UAPU occurrences were examined in eight models, each with one or more staffing measures as predictors. Characteristics of nursing units (RN workgroup education level and RN workgroup unit tenure) and hospitals (size, teaching status, and Magnet status) were included as control variables. Results: Two versions of HPPD (total nursing HPPD and RN HPPD) and RN skill mix were significantly correlated with RN-reported number of assigned patients (r range = -0.87 to -0.75). These staffing measures had weaker correlations with RN-perceived staffing adequacy (r range = 0.16 to 0.23). Of the six staffing variables, only RN-perceived staffing adequacy and RN skill mix were significantly associated with UAPU odds, the former being the better predictor. Conclusions: Although RN-perceived staffing adequacy was not highly correlated with administrative measures of HPPD and RN skill mix, it was the strongest predictor of UAPU occurrences. RN-perceived staffing adequacy can serve as a more appropriate measure of staffing for nursing-sensitive outcomes research than administrative measures, as it reflects relevant aspects of staffing and involves an implicit adjustment for patient acuity. [ABSTRACT FROM AUTHOR]

Background: Urinary incontinence (UI) affects between 40 and 60% of people in hospital after stroke, but is often poorly managed in stroke units. Objectives: To inform an exploratory trial by three methods: identifying the organisational context for embedding the SVP; exploring health professionals' views around embedding the SVP and measuring presence/absence of UI and frequency of UI episodes at baseline and six weeks post-stroke. Design: A mixed methods single case study included analysis of organisational context using interviews with clinical leaders analysed with soft systems methodology, a process evaluation using interviews with staff delivering the intervention and analysed with Normalisation Process Theory, and outcome evaluation using data from patients receiving the SVP and analysed using descriptive statistics. Setting: An 18 bed acute stroke unit in a large Foundation Trust (a 'not for profit' privately controlled entity not accountable to the UK Department of Health) serving a population of 370,000. Participants: Health professionals and clinical leaders with a role in either delivering the SVP or linking with it in any capacity were recruited following informed consent. Patients were recruited meeting the following inclusion criteria: aged 18 or over with a diagnosis of stroke; urinary incontinence (UI) as defined by the International Continence Society; conscious; medically stable as judged by the clinical team and with incontinence classified as stress, urge, mixed or 'functional'. All patients admitted to the unit during the intervention period were screened for eligibility; informed consent to collect baseline and outcome data was sought from all eligible patients. Results: Organisational context: 18 health professionals took part in four group interviews. Findings suggest an environment not conducive to therapeutic continence management and a focus on containment of UI. Embedding the SVP into practice: 21 nursing staff took part in six group interviews. Initial confusion gave way to embedding of processes facilitated by new routines and procedures. Patient outcome: 43 patients were recruited; 28 of these commenced the SVP. Of these, 6/28 (21%) were continent at six weeks post-stroke or discharge. Conclusion: It was possible to embed the SVP into practice despite an organisational context not conducive to therapeutic continence care. Recommendations are made for introducing the SVP in a trial context. [ABSTRACT FROM AUTHOR]

Background: Around half of people aged over 70 years admitted as an emergency to general hospital have dementia, delirium or both. Dissatisfaction is often expressed about the quality of hospital care. A Medical and Mental Health Unit was developed to provide best practice care to cognitively impaired older patients. The Unit was evaluated by randomised controlled trial compared to standard care wards. Part of this evaluation involved structured non-participant observations of a random subample of participants and the recording of field notes. Objectives: The aim of this paper is to compare and contrast the behaviours of staff and patients on the Medical and Mental Health Unit and standard care wards and to provide a narrative account that helps to explain the link between structure, process and reported outcomes. Design: Field notes were analysed using the constant comparison method. Setting: A large hospital within the East Midlands region of the United Kingdom. Participants: Patient participants were aged over 65, and identified by Admissions Unit physicians as being 'confused'. Most patients had delirium or dementia. Results: Sixty observations (360 h) were made between March and December 2011. Cognitively impaired older patients had high physical and psychological needs, and were cared for in environments which were crowded, noisy and lacked privacy. Staff mostly prioritised physical over psychological needs. Person-centred care on the Medical and Mental Health Unit was mostly delivered during activity sessions or meal times by activities coordinators. Patients on this unit were able to walk around more freely than on other wards. Mental health needs were addressed more often on the Medical and Mental Health Unit than on standard care wards but most staff time was still taken up delivering physical care. More patients called out repetitively on the Unit and staff were not always able to meet the high needs of these patients. Conclusion: Care provided on the Medical and Mental Health Unit was distinctly different from standard care wards. Improvements were worthwhile, but care remained challenging and consistent good practice was difficult to maintain. Disruptive vocalisation may have been provoked by concentrating cognitively impaired patients on one ward. [ABSTRACT FROM AUTHOR]

Background: The specific job demands of working in a hospital may place nurses at elevated risk for developing distress, anxiety and depression. Screening followed by referral to early interventions may reduce the incidence of these health problems and promote work functioning. Objective: To evaluate the comparative cost-effectiveness of two strategies to promote work functioning among nurses by reducing symptoms of mental health complaints. Three conditions were compared: the control condition consisted of online screening for mental health problems without feedback about the screening results. The occupational physician condition consisted of screening, feedback and referral to the occupational physician for screen-positive nurses. The third condition included screening, feedback, and referral to e-mental health. Design: The study was designed as an economic evaluation alongside a pragmatic cluster randomised controlled trial with randomisation at hospital-ward level. Setting and participants: The study included 617 nurses in one academic medical centre in the Netherlands. Methods: Treatment response was defined as an improvement on the Nurses Work Functioning Questionnaire of at least 40% between baseline and follow-up. Total per-participant costs encompassed intervention costs, direct medical and non-medical costs, and indirect costs stemming from lost productivity due to absenteeism and presenteeism. All costs were indexed for the year 2011. Results: At 6 months follow-up, significant improvement in work functioning occurred in 20%, 24% and 16% of the participating nurses in the control condition, the occupational physician condition and the e-mental health condition, respectively. In these conditions the total average annualised costs were €1752, €1266 and €1375 per nurse. The median incremental cost-effectiveness ratio for the occupational physician condition versus the control condition was dominant, suggesting cost savings of €5049 per treatment responder. The incremental cost-effectiveness ratio for the e-mental health condition versus the control condition was estimated at €4054 (added costs) per treatment responder. Sensitivity analyses attested to the robustness of these findings. [ABSTRACT FROM AUTHOR]

Background: Patient safety culture is an important factor in the effort to reduce adverse events in the hospital and improve patient safety. A few studies have shown the relationship between patient safety culture and adverse events, yet no such research has been reported in China. Objectives: This study aimed to describe nurses' perception of patient safety culture and frequencies of adverse events, and examine the relationship between them. Design: This study was a descriptive, correlated study. Setting and participants: We selected 28 inpatient units and emergency departments in 7 level-3 general hospitals from 5 districts in Guangzhou, China, and we surveyed 463 nurses. Methods: The Hospital Survey on Patient Safety Culture was used to measure nurses' perception of patient safety culture, and the frequencies of adverse events which happened frequently in hospital were estimated by nurses. We used multiple logistic regression models to examine the relationship between patient safety culture scores and estimated frequencies of each type of adverse event. Results: The Positive Response Rates of 12 dimensions of the Hospital Survey on Patient Safety Culture varied from 23.6% to 89.7%. There were 47.8-75.6% nurses who estimated that these adverse events had happened in the past year. After controlling for all nurse related factors, a higher mean score of ''Organizational Learning-Continuous Improve- ment'' was significantly related to lower the occurrence of pressure ulcers (OR = 0.249), prolonged physical restraint (OR = 0.406), and complaints (OR = 0.369); a higher mean score of ''Frequency of Event Reporting'' was significantly related to lower the occurrence of medicine errors (OR = 0.699) and pressure ulcers (OR = 0.639). Conclusions: The results confirmed the hypothesis that an improvement in patient safety culture was related to a decrease in the occurrence of adverse events. [ABSTRACT FROM AUTHOR]

Aim: To investigate the impact of nurse practice environment factors, nurse work characteristics, and burnout on nurse reported job outcomes, quality of care, and patient adverse events variables at the nursing unit level. Background: Nurse practice environment studies show growing insights and knowledge about determining factors for nurse workforce stability, quality of care, and patient safety. Until now, international studies have primarily focused on variability at the hospital level; however, insights at the nursing unit level can reveal key factors in the nurse practice environment. Design: A cross-sectional design with a survey. Method: In a cross-sectional survey, a sample of 1108 nurses assigned to 96 nursing units completed a structured questionnaire composed of various validated instruments measuring nurse practice environment factors, nurse work characteristics, burnout, nurse reported job outcomes, quality of care, and patient adverse events. Associations between the variables were examined using multilevel modelling techniques. Results: Various unit-level associations (simple models) were identified between nurse practice environment factors, nurse work characteristics, burnout dimensions, and nurse reported outcome variables. Multiple multilevel models showed various independent variables such as nursing management at the unit level, social capital, emotional exhaustion, and depersonalization as important predictors of nurse reported outcome [ABSTRACT FROM AUTHOR]

Background: Informal caregivers play an important role in hospital-at-home schemes. However they may increase their burden, especially chronic diseases, like COPD. In the absence of clear differences in effectiveness and cost-effectiveness between hospital-at- home and usual hospital care, informal caregiver preferences play an important role. This study investigated informal caregiver strain, satisfaction and preferences for place of treatment with a community-based hospital-at-homes scheme for COPD exacerbations. Method: The study was part of a larger randomised controlled trial. By randomisation, patients were allocated to usual hospital care or hospital-at-home, which included discharge at day 4 of admission, followed by home treatment with homes visits by community nurses until day 7 of treatment. Patients allocated to usual hospital care received care as usual in the hospital and were discharged at day 7. Patients were asked if they had an informal caregiver and who this was. Patients and their caregivers were followed for 90 days. Informal caregiver strain was assessed with the caregiver strain index. Satisfaction and preference were assessed using questionnaires. All measurements were performed at the end of the 7-day treatment and the end of the 90-days follow-up. Findings: Of the 139 patients, 124 had an informal caregiver, of whom three-quarter was the patients' spouse. There was no significant difference in caregiver strain between hospital-at-home and usual hospital care at both time points (mean difference at T + 4 days 0.47 95% CI 0.96 to 1.91, p = 0.514; mean difference at T + 90 days 0.36 95% CI 1.85 to 1.35, p = 0.634). At the end of the 7-day treatment, 33% (N = 15) of caregivers of patients allocated to hospital treatment and 71% (N = 37) of caregivers of patients allocated to home treatment preferred home treatment, if they could choose. Caregivers were satisfied with the treatment the patient received within hospital-at-home. Conclusion: There were no differences in caregiver strain between the community-based hospital-at-home scheme and usual hospital care. Most caregivers were satisfied with the treatment. In addition to other outcomes, our results support the wider implementation of hospital-at-home for COPD exacerbations. [ABSTRACT FROM AUTHOR]

Background: Systematically targeting modifiable risk factors for delirium may reduce its incidence. However, research interventions have not become part of routine clinical practice. Particular approaches to the education of clinical staff may improve their practice and patient outcomes. Objectives: To evaluate the effectiveness of a multifaceted educational program in preventing delirium in hospitalised older patients and improving staff practice, knowledge and confidence. Design: A before and after study. Setting: A 22-bed general medical ward of a district hospital in Sydney, Australia. Participants: Patients were aged 65 years and over and not delirious upon admission. Of 568 eligible patients, 129 were recruited pre-intervention (3 withdrew initial consent) and 129 patients post-intervention. Methods: Prior to the intervention, in order to establish a baseline, patients were assessed early after admission and again at discharge. The intervention was a one-hour lecture on delirium focusing on prevention for medical and nursing staff followed by weekly interactive tutorials with delirium resource staff and ward modifications. Following the initial education session, data were gathered in a second group of medical ward patients at the same time-points to ascertain the effectiveness of the intervention. Pre and postintervention data were analysed to determine change in staff objective knowledge and self-ratings of confidence and clinical practice in relation to delirium. The main outcome measures were incident delirium and change in staff practice, confidence and knowledge. Results: The mean age of patients was 81. The pre and post-intervention groups were comparable, aside from greater co morbidity in the pre-intervention group (F(1, 253) = 9.20, p = 0.003). Post-intervention there was a significant reduction in incident delirium (19% vs. 10.1%, X2 = 4.14, p = 0.042), and improved function on discharge (mean improvement 5.3 points, p < 0.001, SD 13.31, 95% CI -7.61 to -2.97). Staff objective knowledge of delirium improved post-intervention and their confidence assessing and managing delirious patients. Staff addressed more risk factors for delirium postintervention (8.1 vs. 9.8, F(1, 253) = 73.44, p < 0.001). Conclusions: A low-cost educational intervention reduced the incidence of delirium and improved function in older medical patients and staff knowledge and practice addressing risk factors for delirium. The program is readily transferable to other settings, but requires replication due to limitations of the before and after design. [ABSTRACT FROM AUTHOR]

Background: Disturbed sleep pattern is a common symptom after head trauma and its prevalence in acute traumatic brain injury (TBI) is less discussed. Sleep has a profound impact on cognitive function recovery and the mediating effect of disturbed sleep on cognitive function recovery has not been examined after acute TBI. Objectives: To identify the prevalence of disturbed sleep in mild, moderate, and severe acute TBI patients, and to determine the mediating effects of sleep on the relationship between brain injury severity and the recovery of cognitive function. Design: A prospective study design. Setting: Neurosurgical wards in a medical center in northern Taiwan. Participants: Fifty-two acute TBI patients between the ages of 18 and 65 years who had received a diagnosis of TBI for the first time, and were admitted to the neurosurgical ward. Method: The severity of brain injury was initially determined using the Glasgow Coma Scale. Each patient wore an actigraphy instrument on a non-paralytic or non-dominated limb for 7 consecutive days. A 7-day sleep diary was used to facilitate data analysis. Cognitive function was assessed on the first and seventh day after admission based on the Rancho Los Amigos Levels of Cognitive Functioning. Results: The mild (n = 35), moderate (n = 7) and severe (n = 10) TBI patients exhibited poorer sleep efficiency, and longer total sleep time (TST) and waking time after sleep onset, compared with the normative values for the sleep-related variables (P < .05 for all). The severe and moderate TBI patients had longer daytime TST than the mild TBI patients (P < .001), and the severe TBI patients had longer 24-h TST than the mild TBI patients (P = .001). The relationship between the severity of brain injury and the recovery of cognition function was mediated by daytime TST (t = -2.65, P = .004). Conclusions: Poor sleep efficiency, prolonged periods of daytime sleep, and a high prevalence of hypersomnia are common symptoms in acute TBI patients. The duration of daytime sleep mediates the relationship between the severity of brain injury and the recovery of cognition function. [ABSTRACT FROM AUTHOR]

Background: Ensuring the safety of hospitalized patients remains a major challenge for healthcare systems, and nursing services are at the center of hospital care. Yet our knowledge about safety of nursing care is quite limited. In fact, most earlier studies examined one, or at most two, indicators, thus presenting an incomplete picture of safety at an institutional or broader level. Furthermore, methodologies have differed from one study to another, making benchmarking difficult. Objectives: The aim of this study was to describe the frequencies of six adverse events widely considered in the literature to be nursing-sensitive outcomes and to estimate the degree to which these events could be attributed to nursing care. Method: Cross-sectional review of charts of 2699 patients hospitalized on 22 medical units in 11 hospitals in Quebec, Canada. The events included: pressure sores, falls, medication administration errors, pneumonias, urinary infections, and inappropriate use of restraints. Experienced nurse reviewers abstracted patients' charts based on a grid developed for the study. Results: Patient-level risk for at least one of these six adverse events was 15.3%, ranging from 9% to 28% across units. Of the 412 patients who experienced an event, 30% experienced two or more, for a total of 568 events. The risk of experiencing an adverse event with consequences was 6.2%, with a unit-level range from 3.2% to 13.5%. Abstractors concluded that 76.8% of the events were attributable to nursing care. Conclusion: While the measurement approach adopted here has limitations stemming from reliance on review of documentation, it provided a practical means of assessing several nursing-sensitive adverse events simultaneously. Given that patient safety issues are so complex, tracking their prevalence and impact is important, as is finding means of evaluating progress in reducing them. [ABSTRACT FROM AUTHOR]

Background: The present shortage of registered nurses (RNs) in many European countries is expected to continue and worsen, which poses a substantial threat to the maintenance of healthcare in this region. Work-family conflict is a known risk factor for turnover and sickness absence. Objective: This paper empirically examines whether the nurse practice environment is associated with experienced work-family conflict. Design: A multilevel model was fit with the individual RN at the 1st, and the hospital department at the 2nd level using cross-sectional RN survey data from the Swedish part of RN4CAST, an EU 7th framework project. The data analyzed here is based on a national sample of 8356 female and 592 male RNs from 369 hospital departments. Results: We found that 6% of the variability in work-family conflict experienced by RNs was at the department level. Organizational level factors significantly accounted for most of the variability at this level with two of the work practice environment factors examined, staffing adequacy and nurse involvement in hospital affairs, significantly related to work- family conflict. Due to the design of the study, factors on ward and work group levels could not be analyzed, but are likely to account for additional variance which in the present analysis appears to be on the individual level, with private life factors likely explaining another major part. Conclusion: These results suggest that higher level organizational factors in health care have a significant impact on the risk of work-family conflict among RNs through their impact on the nurse practice environment. Lower level organizational factors should be investigated in future studies using hierarchical multilevel sampling. [ABSTRACT FROM AUTHOR]

Background: High standards of quality and patient safety in hospital wards cannot be achieved without the active role of the nursing leaders that manage these units. Previous studies tended to focus on the leadership behaviours of nurses in relation to staff job satisfaction and other organizational outcomes. Less is known about the leadership skills of senior charge nurses that are effective for ensuring safety for patients and staff in their wards. Objectives: The aim of the two studies was to identify the leadership behaviours of senior charge nurses that are (a) typically used and, (b) that relate to safety outcomes. Methods: In study one, semi-structured interviews were conducted with 15 senior charge nurses at an acute NHS hospital. Transcribed interviews were coded using Yukl's Managerial Practices Survey (MPS) framework. In study two, self ratings of leadership (using the MPS) from 15 senior charge nurses (SCN) and upward ratings from 82 staff nurses reporting to them were used to investigate associations between SCNs' leadership behaviours and worker and patient-related safety outcomes. Results: The interviews in study one demonstrated the relevance of the MPS leadership framework for nurses at hospital ward level. The SCNs mainly engaged in relations- oriented (n = 370, 49%), and task-oriented (n = 342, 45%) behaviours, with fewer changeoriented (n = 25, 3%), and lead by example behaviours (n = 26, 3%). In demanding situations, more task-oriented behaviours were reported. In study two, staff nurses' ratings of their SCNs' behaviours (Monitoring and Recognizing) were related to staff compliance with rules and patient injuries (medium severity), while the self ratings of SCNs indicated that Supporting behaviours were linked to lower infection rates and Envisioning change behaviours were linked to lower infection and other safety indicators for both patients and staff. Conclusion: This study provides preliminary data on the usability of a standard leadership taxonomy (Yukl et al., 2002), and the related MPS questionnaire, on a nursing sample. The findings indicate the relevance of several leadership behaviours of SCNs for ensuring a safer ward environment and contribute to the evidence base for their leadership skills training. [ABSTRACT FROM AUTHOR]

Background: Nurses' clinical judgement plays a vital role in pressure ulcer risk assessment, but evidence is lacking which patient characteristics are important for nurses' perception of patients' risk exposure. Objectives: To explore which patient characteristics nurses employ when assessing pressure ulcer risk without use of a risk assessment scale. Design: Mixed methods design triangulating observational data from the control group of a quasi-experimental trial and data from semi-structured interviews with nurses. Setting: Two traumatological wards at a university hospital. Participants: Quantitative data: A consecutive sample of 106 patients matching the eligibility criteria (age≥18 years, no pressure ulcers category ≥2 at admission and ≥5 days expected length of stay). Qualitative data: A purposive sample of 16 nurses. Methods: Quantitative data: Predictor variables for pressure ulcer risk were measured by study assistants at the bedside each second day. Concurrently, nurses documented their clinical judgement on patients' pressure ulcer risk by means of a 4-step global judgement scale. Bivariate correlations between predictor variables and nurses' risk estimates were established. Qualitative data: In interviews, nurses were asked to assess fictitious patients' pressure ulcer risk and to justify their risk estimates. Patient characteristics perceived as relevant for nurses' judements were thematically clustered. Triangulation: Firstly, predictors of nurses' risk estimates identified in bivariate analysis were cross-mapped with interview findings. Secondly, three models to predict nurses' risk estimates underwent multiple linear regression analysis. Results: Nurses consider multiple patient characteristics for pressure ulcer risk assess- ment, but regard some conditions more important than others. Triangulation showed that these are measures reflecting patients' exposure to pressure or overall care dependency. Qualitative data furthermore indicate that nurses are likely to trade off risk-enhancing conditions against conditions perceived to be protective. Here, patients' mental capabilities like willingness to engage in one owns care seem to be particularly important. Due to missing information on these variables in the quantitative data, they could not be incorporated into triangulation. [ABSTRACT FROM AUTHOR]

Background: Internationally, nursing professionals are coming under increasing pressure to highlight the contribution they make to health care and patient outcomes. Despite this, difficulties exist in the provision of quality information aimed at describing nursing work in sufficient detail. The Irish Minimum Data Set for General Nursing is a new nursing data collection system aimed at highlighting the contribution of nursing to patient care. Objectives: The objectives of this study were to investigate the construct validity and internal reliability of the Irish Nursing Minimum Data Set for General Nursing and to assess its usefulness in measuring the mediating effects of nursing interventions on patient well-being for a group of short stay medical and surgical patients. Design: This was a quantitative study using a repeated measures design. Setting: Participants sampled came from both general surgery and general medicine wards in 6 hospitals throughout the Republic of Ireland. Participants: Nurses took on the role of data collectors. Nurses participating in the study were qualified, registered nurses engaged in direct patient care. Because the unit of analysis for this study was the patient day, patient numbers were considered in estimations of sample size requirements. A total of 337 usable Nursing Minimum Data Set booklets were collected. Methods: The construct validity of the tool was established using exploratory factor analysis with a Promax rotation and Maximum Likelihood extraction. Internal reliability was established using the Cronbach's Alpha coefficient. Path analysis was used to assess the mediating effects of nursing interventions on patient well-being. Results: The results of the exploratory factor analysis and path analysis met the criteria for an appropriate model fit. All Cronbach Alpha scores were above .7. Conclusion: The overall findings of the study inferred that the Irish Nursing Minimum Data for General Nursing possessed construct validity and internal reliability. The study results also inferred the potential of the tool in the investigation of the impact of nursing on patient well-being. As such, this new tool demonstrated potential to be used in the provision of quality information to inform policy in relation to the organisation of nursing care. More research is needed to further establish its use in the assessment of patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Attention in the ward should shift from preventing medication administration errors to managing them. Nevertheless, little is known in regard with the practices nursing wards apply to learn from medication administration errors as a means of limiting them. Aims: To test the effectiveness of four types of learning practices, namely, non-integrated, integrated, supervisory and patchy learning practices in limiting medication administration errors. Methods: Data were collected from a convenient sample of 4 hospitals in Israel by multiple methods (observations and self-report questionnaires) at two time points. The sample included 76 wards (360 nurses). Medication administration error was defined as any deviation from prescribed medication processes and measured by a validated structured observation sheet. Wards' use of medication administration technologies, location of the medication station, and workload were observed; learning practices and demographics were measured by validated questionnaires. Findings: Results of the mixed linear model analysis indicated that the use of technology and quiet location of the medication cabinet were significantly associated with reduced medication administration errors (estimate = .03, p < .05 and estimate = -.17, p < .01 correspondently), while workload was significantly linked to inflated medication administration errors (estimate = .04, p < .05). Of the learning practices, supervisory learning was the only practice significantly linked to reduced medication administration errors (estimate = -.04, p < .05). Integrated and patchy learning were significantly linked to higher levels of medication administration errors (estimate = -.03, p < .05 and estimate = -.04, p < .01 correspondently). Non-integrated learning was not associated with it (p > .05). Conclusions: How wards manage errors might have implications for medication administration errors beyond the effects of typical individual, organizational and technology risk factors. Head nurse can facilitate learning from errors by ''management by walking around'' and monitoring nurses' medication administration behaviors. [ABSTRACT FROM AUTHOR]

Background: An important role of the registered nurse is to identify patient deterioration by monitoring the patient condition and vital signs. Increasingly, this is supplemented with continuous electrocardiographic (ECG) monitoring. Continuous monitoring is inefficient in identifying deterioration because of the high number of false and nuisance alarms. Lack of strong evidence or formal guidelines for the care of patients receiving ECG monitoring has led clinicians to rely too heavily on this technology without consideration of its limitations. The nursing workload associated with alarm management remains unexamined. Objective: To describe nurses' routine practices related to continuous ECG monitoring, frequency and types of alarms, their associated nursing interventions, and the impact on the patient's plan of care. Methods: Design. Prospective, descriptive, observational study. Setting and participants. Between January 2011 and March 2011 we observed nine Registered Nurses providing care for patients receiving continuous ECG monitoring in non-critical care areas. The PI and two research assistants observed each nurse for two 3-h observation periods and recorded data on a researcher designed observation tool. At the end of each observation period, the observers printed the alarm events as recorded by the central monitoring computer. Results: Nurses responded to 46.8% of all alarms. During the observation period, there were no dysrhythmia adverse events. One patient had a change in condition requiring transfer to a higher level of care. A range of nursing interventions occurred in response to alarms. Conclusion: Nurses routine practices related to monitoring continue to reveal gaps in practice related to alarm management. Observations of practice also revealed the difficulties and complexities of managing alarm systems and the range of nursing interventions associated with managing alarms. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this study was to synthesize qualitative studies of how adolescents and young adults with chronic diseases experience the transition from paediatric to adult hospital care. Design: The review is designed as a qualitative metasynthesis and is following Sandelowski and Barroso's guidelines for synthesizing qualitative research. Data sources: Literature searches were conducted in the databases PubMed, Ovid, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), ISI Web of Science, and Nordic and German databases covering the period from 1999 to November 2010. In addition, forward citation snowball searching was conducted in the databases Ovid, CINAHL, ISI Web of Science, Scopus and Google Scholar. Review methods: Of the 1143 records screened, 18 studies were included. Inclusion criteria were qualitative studies in English, German or Nordic languages on adolescents' and young adults' transition experiences when transferring from paediatric to adult care. There was no age limit, provided the focus was on the actual transfer process and participants had a chronic somatic disease. The studies were appraised as suitable for inclusion using a published appraisal tool. Data were analyzed into metasummaries and a metasynthesis according to established guidelines for synthesis of qualitative research. Results: Four themes illustrating experiences of loss of familiar surroundings and relationships combined with insecurity and a feeling of being unprepared for what was ahead were identified: facing changes in significant relationships, moving from a familiar to an unknown ward culture, being prepared for transfer and achieving responsibility. Conclusions: Young adults' transition experiences seem to be comparable across diagnoses. Feelings of not belonging and of being redundant during the transfer process are striking. Health care professionals' appreciation of young adults' need to be acknowledged and valued as competent collaborators in their own transfer is crucial, and may protect them from additional health problems during a vulnerable phase. Further research including participants across various cultures and health care systems is needed. [ABSTRACT FROM AUTHOR]

Background: Absenteeism and turnover among healthcare workers have a significant impact on overall healthcare system performance. The literature captures variables from different levels of measurement and analysis as being associated with attendance behavior among nurses. Yet, it remains unclear how variables from different contextual levels interact to impact nurses' attendance behaviors. Objectives: The purpose of this review is to develop an integrative multilevel framework that optimizes our understanding of absenteeism and turnover among nurses in hospital settings. Methods: We therefore systematically examine English-only studies retrieved from two major databases, PubMed and CINAHL Plus and published between January, 2007 and January, 2013 (inclusive). Findings: Our review led to the identification of 7619 articles out of which 41 matched the inclusion criteria. The analysis yielded a total of 91 antecedent variables and 12 outcome variables for turnover, and 29 antecedent variables and 9 outcome variables for absenteeism. The various manifested variables were analyzed using content analysis and grouped into 11 categories, and further into five main factors: Job, Organization, Individual, National and inTerpersonal (JOINT). Thus, we propose the JOINT multilevel conceptual model for investigating absenteeism and turnover among nurses. Conclusions: The JOINT model can be adapted by researchers for fitting their hypothesized multilevel relationships. It can also be used by nursing managers as a lens for holistically managing nurses' attendance behaviors. [ABSTRACT FROM AUTHOR]

Background: Hip surgery is associated with the risk of postoperative urinary retention. To avoid urinary retention hip surgery patients undergo urinary catheterisation. Urinary catheterisation, however, is associated with increased risk for urinary tract infection (UTI). At present, there is limited evidence for whether intermittent or indwelling urinary catheterisation is the preferred choice for short-term bladder drainage in patients undergoing hip surgery. Objectives: The aim of the study was to investigate differences between intermittent and indwelling urinary catheterisation in hip surgery patients in relation to nosocomial UTI and cost-effectiveness. Design: Randomised controlled trial with cost-effectiveness analysis. Setting: The study was carried out at an orthopaedic department at a Swedish University Hospital. Methods: One hundred and seventy hip surgery patients (patients with fractures or with osteoarthritis) were randomly allocated to either intermittent or indwelling urinary catheterisation. Data collection took place at four time points: during stay in hospital, at discharge and at 4 weeks and 4 months after discharge. Results: Eighteen patients contracted nosocomial UTIs, 8 in the intermittent catheterisation group and 10 in the indwelling catheterisation group (absolute difference 2.4%, 95% CI -6.9-11.6%) The patients in the intermittent catheterisation group were more often catheterised (p<0.001) and required more bladder scans (p<0.001) but regained normal bladder function sooner than the patients in the indwelling catheterisation group (p<0.001). Fourteen percent of the patients in the intermittent group did not need any catheterisation. Cost-effectiveness was similar between the indwelling and intermittent urinary catheterisation methods. Conclusions: Both indwelling and intermittent methods could be appropriate in clinical practice. Both methods have advantages and disadvantages but by not using routine indwelling catheterisation, unnecessary catheterisations might be avoided in this patient group. [ABSTRACT FROM AUTHOR]

Background: The nurses' ability to document patient's status, problems and progress is an important issue in patients' safety. Nursing terminologies are intended to support nursing practice but as any other clinical tool, they should be evaluated to assure quality and warrant effective written communication among clinicians. Objectives: This study was aimed to evaluate the usability of the diagnosis axis of an interface terminology by assessing its completeness and the frequency of use of its concepts. Design: Observational, longitudinal, multicentre study. Setting: A total of 8 hospitals representing 162 acute medical-surgical, obstetric and mental health nursing wards, step-down units and home in-patient units were included. Participants: Overall, 246,400 electronic care plans were studied; 53.5% from male patients; 14.6% paediatrics and 33.7% from patients elder than 70 years old. Most were admitted due to cardiocirculatory, respiratory, digestive or musculoskeletal conditions (50.5%), other acute medical or surgical disorders (29.8%) and obstetrics (19.3%). Methods: The main outcome measures were: the use of nursing diagnoses from the interface terminology evaluated and their accumulated frequency, analysed over a 3-year retrospective review of the electronic nursing care plans. The analysis of data included descriptive statistics with a confidence level of 95% for confidence intervals. Results: Most of the diagnostic concepts from the interface terminology were used (92.3%) by nurses to illustrate patients' problems in the electronic care plans. Their frequency of use widely varied, from some very frequent diagnoses like Risk for haemorrhage (51.4%; CI 95%: 51.25-51.65) or Acute pain (49.6%; CI: 49.49-49.88) to others used only in exceptional cases like Faecal impaction or Extravasation. The first nursing diagnosis related to family or caregiver emerges in the 32nd place of the ranking. Conclusions: Results for outcome measures oriented that the diagnosis axis of this interface terminology meets the usability criterion of completeness when assessing for the use of its concepts in the acute care setting. [ABSTRACT FROM AUTHOR]

Aim: To explore the mechanisms through which nurse practice environment dimensions are associated with job outcomes and nurse-assessed quality of care. Mediating variables tested included nurse work characteristics of workload, social capital, decision latitude, as well as burnout dimensions of emotional exhaustion, depersonalization, and personal accomplishment. Background: Acute care hospitals face daily challenges to their efforts to achieve nurse workforce stability, safety, and quality of care. A body of knowledge shows a favourably rated nurse practice environment as an important condition for better nurse and patient outcome variables; however, further research initiatives are imperative for a clear understanding to support and guide the practice community. Design: Cross-sectional survey. Method: Grounded on previous empirical findings, a structural equation model designed with valid measurement instruments was tested. The study population was registered acute care nurses (N = 1201) in two independent hospitals and one hospital group with six hospitals in Belgium. Results: Nurse practice environment dimensions predicted job outcome variables and nurse ratings of quality of care. Analyses were consistent with features of nurses' work characteristics including perceived workload, decision latitude, and social capital, as well as three dimension of burnout playing mediating roles between nurse practice environment and outcomes. A revised model adjusted using various fit measures explained 52% and 47% of job outcomes and nurse-assessed quality of care, respectively. Conclusion: The study refines understanding of the relationship between aspects of nursing practice in order to achieve favourable nursing outcomes and offers important concepts for managers to track in their daily work. The findings of this study indicate that it is important for clinicians and leaders to consider how nurses are involved in decision- making about care processes and tracking outcomes of care and whether they are able to work with physicians, superiors, peers, and subordinates in a trusting environment based on shared values. The involvement of nurse managers at the unit level is especially critical because of associations with nurse work characteristics such as decision latitude and social capital and outcome variables. Further practice and research initiatives to support nurses' involvement in decision-making process and interdisciplinary teamwork are recommended. [ABSTRACT FROM AUTHOR]

Background: Physical restraints are contrary to patients' autonomy and freedom. Their justification for controlling psychomotor agitation and risk of falling is being questioned more and more often. Physical restraints are associated with many negative outcomes. The German law is explicit, allowing physical restraints in nursing only as an exception. Data on the use of physical restraints in acute hospitals in Germany are sparse. Objectives: To investigate the prevalence of physical restraints and characteristics associated with physical restraint use in acute hospitals. Design: Cross-sectional study. Participants and setting: 1276 patients (mean age 65 years, 45% women, 50% surgical) on 61 wards (n = 47 general; n = 14 intensive care) in four acute care hospitals in North Rhine- Westphalia, Germany. Methods: One investigator visited each hospital ward at three randomly allocated time slots on randomly selected days within a period of three months. A total of 3434 direct observations on physical restraint status were collected. The study period lasted from October 2008 to March 2009. For analysis, one time slot per patient room was randomly chosen in order to avoid repeated analysis of the same patient. Results: The prevalence of patients with at least one physical restraint was 11.8% (95%CI 7.8-15.7). The measures used most often were full bed rails (9.8%, 95%CI 6.5-13.1). There was pronounced prevalence variation throughout the wards (general wards: 0.0-31.3%; intensive care: 0.0-90.0%). The prevalence of physical restraints between hospitals ranged from 6.2 to 16.6%, the overall association with hospital was non-significant. Multivariate regression analysis revealed statistically significant characteristics for physical restraint use: age 80-99 years versus 18-54 years (adjusted odds ratio 4.34, 95%CI 2.18-8.64), feeding tube (2.70, 1.40-5.22), indwelling urinary catheter (6.52, 3.75-11.34), and staying in intensive care unit (3.39, 1.29-8.92). Sharing a multi-bed room (0.55, 0.35-0.89) and in situ central venous line were inversely associated (0.44, 0.19-0.98). Conclusions: Physical restraints are apparently standard care in German acute hospitals. However, variation between wards indicates that hospital care with only few physical restraints is feasible. Respecting patients' dignity and integrity warrants intervention programmes aimed at decreasing practice variation towards a general reduction of physical restraints in acute hospitals in Germany. [ABSTRACT FROM AUTHOR]

Background: Few, if any, studies have compared the health issues of nurses working in different hospital settings. The objective of this study was to compare the health status and work-related health hazards among nurses working in different hospital units in Taiwan. Methods: This study was a cross-sectional survey. The study participants were 21,095 fulltime employees with a professional background in nursing, working at 100 hospitals across Taiwan. The study participants responded to a structured questionnaire from May to July, 2011. Results: After adjustment for age, sex, educational level, accredited hospital level, and certification as a health promoting hospital, nurses who worked in administration and in outpatient clinics reported better overall health than nurses who worked in operating rooms/delivery rooms, and these nurses reported better overall health than nurses who worked in emergency rooms/intensive care units and general wards. Depressed mood followed the same trend. Nurses who worked in the operating rooms/delivery rooms, wards, and emergency rooms/intensive care units were at higher risk for occupational incidents than nurses who worked in outpatient clinics and administration. The most prevalent health hazards among nurses were low back pain, sprained/strained muscles, cuts, and verbal or sexual harassment/violence. Conclusions: Nurses who worked in emergency rooms/intensive care units and in wards had worse health and more depressed moods than nurses in other hospital units. Work related health hazards were common and varied among nurses working in different hospital units. Worksite-based health promotion programs should take these differences into consideration to tailor wellness programs for nurses working in different hospital settings. [ABSTRACT FROM AUTHOR]