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For over a decade, the Department of Veterans Affairs (VA) has used the Bereaved Family Survey (BFS) to measure the quality of end-of-life (EOL) care in VA inpatient settings. In 2019, VA developed a revised version of the BFS to evaluate the quality of EOL care for Veterans who received hospice services in VA-contracted community nursing homes (CNHs).The purpose of this analysis was to evaluate the psychometric properties and factor structure of the BFS-CNH.The BFS-CNH was administered to the next-of-kin of Veterans who died in a VA-contracted CNH with hospice care between October 2019 and April 2020. Exploratory factor analysis (EFA) was used with the 10 core items of the BFS-CNH that were derived from the inpatient BFS to evaluate whether the BFS-CNH exhibited a similar factor structure to the inpatient version. Cronbach's alpha was used to assess internal consistency/reliability of the identified factors and linear regression models were used to evaluate construct validity of the identified BFS-CNH factor scores and individual items.The EFA revealed a three-dimension solution that corresponded to factors on the inpatient BFS, including Care and Communication, Emotional and Spiritual Support and Death Benefits. Cronbach's alpha coefficients for all three factors indicated acceptable internal consistency.Our findings provide support for use of the BFS-CNH to evaluate the quality of EOL care provided to Veterans in CNHs and lay the foundation for future comparisons of BFS ratings between VA inpatient and CNH settings.

Patient experiences should be considered by healthcare systems when implementing care practices to improve quality of end-of-life care. Families and caregivers of recent in-patient decedents may be best positioned to recommend practices for quality improvement.To identify actionable practices that bereaved families highlight as contributing to high quality end-of-life care.We conducted qualitative content analysis of narrative responses to the Bereaved Family Surveys Veterans Health Administration inpatient decedents. Out of 5964 completed surveys in 2017, 4604 (77%) contained at least one word in response to the open-ended questions. For feasibility, 1500/4604 responses were randomly selected for analysis. An additional 300 randomly selected responses were analyzed to confirm saturation.Over 23% percent (355/1500) of the initially analyzed narrative responses contained actionable practices. By synthesizing narrative responses to the BFS in a national healthcare system, we identified 98 actionable practices reported by the bereaved families that have potential for implementation in QI efforts. Specifically, we identified 67 end-of-life practices and 31 practices in patient-centered care domains of physical environment, food, staffing, coordination, technology and transportation. The 67 cluster into domains including respectful care and communication, emotional and spiritual support, death benefits, symptom management. Sorting these practices by target levels for organizational change illuminated opportunities for implementation.Narrative responses from bereaved family members can yield approaches for systematic quality improvement. These approaches can serve as a menu in diverse contexts looking for approaches to improve patient quality of death in in-patient settings.

Palliative care consultations (PCCs) are associated with reduced physical and psychological symptoms that are related to suicide risk. Little is known, however, about the association between PCCs and death from suicide among patients at high risk of short-term mortality.To examine the association between the number of PCCs and documentation of suicide in a cohort of Veterans at high risk of short-term mortality, before and after accounting for Veterans' sociodemographic characteristics and clinical conditions.An observational cohort study was conducted using linked Veterans Affairs clinical and administrative databases for 580,620 decedents with high risk of one-year mortality. Logistic regression models were used to examine the association between number of PCCs and documentation of suicide.Higher percentages of Veterans who died by suicide were diagnosed with chronic pulmonary disease as well as mental health/substance use conditions compared with Veterans who died from other causes. In adjusted models, one PCC in the 90 days prior to death was significantly associated with a 71% decrease in the odds of suicide (OR = 0.29, 95% CI = 0.23-0.37, P0.001) and two or more PCCs were associated with a 78% decrease (OR = 0.22, 95% CI = 0.15-0.33, P0.001). Associated "number needed to be exposed" estimates suggest that 421 Veterans in this population would need to receive at least one PCC to prevent one suicide.While acknowledging the importance of specialized mental health care in reducing suicide among high-risk patients, interventions delivered in the context of PCCs may also play a role.

BACKGROUND: Bereaved family members of racial/ethnic minority Veterans are less likely than families of White Veterans to provide favorable overall ratings of end-of-life (EOL) care quality; however, the underlying mechanisms for these differences have not been explored. The objective of this study was to examine whether a set of EOL care process measures mediated the association between Veteran race/ethnicity and bereaved families’ overall rating of the quality of EOL care in VA medical centers (VAMCs). METHODS: A retrospective, cross-sectional analysis of linked Bereaved Family Survey (BFS), administrative and clinical data was conducted. The sample included 17,911 Veterans (mean age: 73.7; SD: 11.6) who died on an acute or intensive care unit across 121 VAMCs between October 2010 and September 2015. Mediation analyses were used to assess whether five care processes (potentially burdensome transitions, high-intensity EOL treatment, and the BFS factors of Care and Communication, Emotional and Spiritual Support, and Death Benefits) significantly affected the association between Veteran race/ethnicity and a poor/fair BFS overall rating. RESULTS: Potentially burdensome transitions, high-intensity EOL treatment, and the three BFS factors of Care and Communication, Emotional and Spiritual Support, and Death Benefits did not substantially mediate the relationship between Veteran race/ethnicity and poor/fair overall ratings of quality of EOL care by bereaved family members. CONCLUSIONS: The reasons underlying poorer ratings of quality of EOL care among bereaved family members of racial/ethnic minority Veterans remain largely unexplained. More research on identifying potential mechanisms, including experiences of racism, and the unique EOL care needs of racial and ethnic minority Veterans and their families is warranted.

BACKGROUND The Department of Veterans Affairs (VA)'s home-based primary care (HBPC) program provides coordinated, interdisciplinary care to seriously ill and disabled veterans, but few evaluations have considered end-of-life (EOL) care in this population. The aim of this study was to describe veterans' use of community-based hospice services while enrolled in HBPC and their associations with bereaved families' perceptions of care. METHODS This study was a retrospective analysis of electronic medical record and bereaved family survey (BFS) data for veterans who died while enrolled in VA's HBPC program between October 2013 and September 2019. Seven regional VA networks called Veteran Integrated Service Networks participated in BFS data collection. The final sample included 3967 veterans who were receiving HBPC services at the time of death and whose next-of-kin completed a BFS. The primary outcome was the BFS global rating of care received in the last 30 days of life. Adjusted proportions for all BFS outcomes were examined and compared between those who received community-based hospice services and those who did not. RESULTS Overall, 52.6% of BFS respondents reported that the care received by HBPC-enrolled veterans in the last 30 days of life was excellent using the BFS global rating. Among families of HBPC-enrolled veterans who received community-based hospice services, the BFS global rating was roughly eight percentage points higher than those who did not (55.7 vs. 47.0%, p

Background Electronic health record (EHR) usability issues represent an emerging threat to the wellbeing of nurses and patients; however, few large studies have examined these relationships. Objective To examine associations between EHR usability and nurse job (burnout, job dissatisfaction, and intention to leave) and surgical patient (inpatient mortality and 30-day readmission) outcomes. Methods A cross-sectional analysis of linked American Hospital Association, state patient discharge, and nurse survey data was conducted. The sample included 343 hospitals, 1,281,848 surgical patients, and 12,004 nurses. Logistic regression models were used to assess relationships between EHR usability and outcomes, before and after accounting for EHR adoption level (comprehensive vs. basic or less) and other confounders. Results In fully adjusted models, nurses who worked in hospitals with poorer EHR usability had significantly higher odds of burnout [odds ratio (OR), 1.41; 95% confidence interval (CI), 1.21-1.64], job dissatisfaction (OR, 1.61; 95% CI, 1.37-1.90) and intention to leave (OR, 1.31; 95% CI, 1.09-1.58) compared with nurses working in hospitals with better usability. Surgical patients treated in hospitals with poorer EHR usability had significantly higher odds of inpatient mortality (OR, 1.21; 95% CI, 1.09-1.35) and 30-day readmission (OR, 1.06; 95% CI, 1.01-1.12) compared with patients in hospitals with better usability. Comprehensive EHR adoption was associated with higher odds of nurse burnout (OR, 1.14; 95% CI, 1.01-1.28). Conclusion Employing EHR systems with suboptimal usability was associated with higher odds of adverse nurse job outcomes and surgical patient mortality and readmission. EHR usability may be more important to nurse job and patient outcomes than comprehensive EHR adoption.

PURPOSE: Several studies have identified differences in end-of-life (EOL) care between urban and rural areas, yet little is known about potential differences in care processes or family evaluations of care. The purpose of this study is to examine the relationship between rurality of residence and quality of EOL care within the Veterans Affairs healthcare system. METHODS: This study was a retrospective, cross-sectional analysis of 126,475 veterans who died from October 2009 through September 2016 in inpatient settings across 151 facilities. Using unadjusted and adjusted logistic regression, we compared quality of EOL care between urban and rural veterans using family evaluations of care and four quality of care indicators for receipt of (1) palliative care consult (2) a chaplain visit (3) death in an inpatient hospice unit, and (4) bereavement support. FINDINGS: Veterans from rural areas had lower odds of dying in an inpatient hospice unit compared to veterans from urban areas, before and after adjustment (large rural OR 0.73, 95% CI: 0.70–0.77; P < .001, small rural OR 0.81, 95% CI: 0.77–0.86; P < .001, isolated rural OR 0.87, 95% CI: 0.81–0.93; P < .001). Differences in comparisons of other quality of care indicators were small and of mixed significance. No significant differences were found in family ratings of care in fully adjusted models. CONCLUSION: Receipt of some EOL quality indicators differed with urban-rural residence for some comparisons. However, family ratings of care did not. Our findings call for further investigation into unmeasured individual characteristics and facility processes related to rurality.

Background Despite evidence suggesting higher quality and safer care in hospitals with comprehensive electronic health record (EHR) systems, factors related to advanced system usability remain largely unknown, particularly among nurses. Little empirical research has examined sociotechnical factors, such as the work environment, that may shape the relationship between advanced EHR adoption and quality of care. Objective The objective of this study was to examine the independent and joint effects of comprehensive EHR adoption and the hospital work environment on nurse reports of EHR usability and nurse-reported quality of care and safety. Methods This study was a secondary analysis of nurse and hospital survey data. Unadjusted and adjusted logistic regression models were used to assess the relationship between EHR adoption level, work environment, and a set of EHR usability and quality/safety outcomes. The sample included 12,377 nurses working in 353 hospitals. Results In fully adjusted models, comprehensive EHR adoption was associated with lower odds of nurses reporting poor usability outcomes, such as dissatisfaction with the system (odds ratio [OR]: 0.75; 95% confidence interval [CI]: 0.61–0.92). The work environment was associated with all usability outcomes with nurses in better environments being less likely to report negatively. Comprehensive EHRs (OR: 0.83; 95% CI: 0.71–0.96) and better work environments (OR: 0.47; 95% CI: 0.42–0.52) were associated with lower odds of nurses reporting fair/poor quality of care, while poor patient safety grade was associated with the work environment (OR: 0.50; 95% CI: 0.46–0.54), but not EHR adoption level. Conclusion Our findings suggest that adoption of a comprehensive EHR is associated with more positive usability ratings and higher quality of care. We also found that—independent of EHR adoption level—the hospital work environment plays a significant role in how nurses evaluate EHR usability and whether EHRs have their intended effects on improving quality and safety of care.

Background/objective The COVID-19 pandemic has resulted in rapid changes to end-of-life care for hospitalized older adults and their families, including visitation restrictions. We examined bereaved families' perceptions of the quality of end-of-life communication among Veterans, families and staff in Veterans Affairs (VA) medical centers during the COVID-19 pandemic. Design Qualitative descriptive study using data from a survey of bereaved family members of Veterans administered from March-June 2020. Data were analyzed using qualitative content analysis. Setting VA medical centers with the highest numbers of COVID-19 cases during the study period. Participants Next-of-kin of 328 Veterans who died in one of 37 VA medical centers' acute care, intensive care, nursing home, or hospice units. Measurements Open-ended survey questions (response rate = 37%) about family member's perceptions of: (1) communication with the healthcare team about the patient, (2) communication with the patient, and (3) use of remote communication technologies. Results Bereaved family members identified contextual factors perceived to impact communication quality including: allowing family at the bedside when death is imminent, fears that the patient died alone, and overall perceptions of VA care. Characteristics of perceived high-quality communication included staff availability for remote communication and being kept informed of the patient's condition and plan of care. Low-quality communication with staff was perceived to result from limited access to staff, insufficient updates regarding the patient's condition, and when the family member was not consulted about care decision-making. Communication quality with the patient was facilitated or impeded by the availability and use of video-enabled remote technologies. Conclusion Communication between patients, families, and healthcare teams at the end of life remains critically important during times of limited in-person visitation. Families report that low-quality communication causes profound distress that can affect the quality of dying and bereavement. Innovative strategies are needed to ensure that high-quality communication occurs despite pandemic-related visitation restrictions.

Context We reviewed the Veterans Health Administration Bereaved Family Survey's open-ended responses to understand end-of-life (EOL) care best practices for Vietnam and pre-Vietnam Veterans. Objectives To identify 1) recommendations for improved EOL care enhancements for older Veterans, 2) a model of best practices in EOL care for Veterans, and 3) any relevant differences in best practices between Vietnam and prior war eras. Methods We examined five years of Bereaved Family Survey data (n = 2784), collected between 2013 and 2017, from bereaved family members of Veterans focusing on 2 open-ended questions: 1) Is there anything else you would like to share about the Veteran's care during his last month of life? 2) Is there anything else you would like to share about how the care could have been improved for the Veteran? Applied thematic analysis identified successes and challenges in the experience of the bereaved of Vietnam and pre-Vietnam era Veterans. Results Regardless of war era and death venue, a patient-centered approach to EOL care with readily available staff who could 1) provide ongoing support, comfort, honor, and validation; 2) routinely adjust to the patient's changing needs; 3) and provide clear, honest, timely, compassionate communication was important to the bereaved. Consideration of the uniqueness of Vietnam Veterans is beneficial. Conclusions Patient-centered EOL care should include assigning a point of contact that follows the patient, educates the family on expectations, ensures the patient's changing needs are met, ensures the family has appropriate support, and communicates updates to the family throughout the patient's care continuum.

Surveys of bereaved family members are increasingly being used to evaluate end-of-life (EOL) care and to measure organizational performance in EOL care quality. The Bereaved Family Survey (BFS) is used to monitor EOL care quality and benchmark performance in the Veterans Affairs (VA) health-care system. The objective of this study was to develop a case-mix adjustment model for the BFS and to examine changes in facility-level scores following adjustment, in order to provide fair comparisons across facilities. We conducted a cross-sectional secondary analysis of medical record and survey data from veterans and their family members across 146 VA medical centers. Following adjustment using model-based propensity weighting, the mean change in the BFS-Performance Measure score across facilities was −0.6 with a range of −2.6 to 0.6. Fifty-five (38%) facilities changed within ±0.5 percentage points of their unadjusted score. On average, facilities that benefited most from adjustment cared for patients with greater comorbidity burden and were located in urban areas in the Northwest and Midwestern regions of the country. Case-mix adjustment results in minor changes to facility-level BFS scores but allows for fairer comparisons of EOL care quality. Case-mix adjustment of the BFS positions this National Quality Forum–endorsed measure for use in public reporting and internal quality dashboards for VA leadership and may inform the development and refinement of case-mix adjustment models for other surveys of bereaved family members.

Context The COVID-19 pandemic resulted in visitation restrictions across most health care settings, necessitating the use of remote communication to facilitate communication among families, patients and health care teams. Objective To examine the impact of remote communication on families’ evaluation of end-of-life care during the COVID-19 pandemic. Methods Retrospective, cross-sectional, mixed methods study using data from an after-death survey administered from March 17–June 30, 2020. The primary outcome was the next of kin's global assessment of care during the Veteran's last month of life. Results Data were obtained from the next-of-kin of 328 Veterans who died in an inpatient unit (i.e., acute care, intensive care, nursing home, hospice units) in one of 37 VA medical centers with the highest numbers of COVID-19 cases. The adjusted percentage of bereaved families reporting excellent overall end-of-life care was statistically significantly higher among those reporting Very Effective remote communication compared to those reporting that remote communication was Mostly, Somewhat, or Not at All Effective (69.5% vs. 35.7%). Similar differences were observed in evaluations of remote communication effectiveness with the health care team. Overall, 81.3% of family members who offered positive comments about communication with either the Veteran or the health care team reported excellent overall end-of-life care vs. 28.4% who made negative comments. Conclusions Effective remote communication with the patient and the health care team was associated with significantly better ratings of the overall experience of end-of-life care by bereaved family members. Our findings offer timely insights into the importance of remote communication strategies.

Few studies have examined comprehensively racial/ethnic variations in quality of end-of-life care. Examine end-of-life care quality received by Veterans and their families, comparing racial/ethnic minorities to nonminorities. This is a retrospective, cross-sectional analysis of chart review and survey data. Nearly all deaths in 145 Veterans Affairs Medical Centers nationally (n=94,697) in addition to Bereaved Family Survey (BFS) data (n=51,859) from October 2009 to September 2014. Outcomes included 15 BFS items and 4 indicators of high-quality end-of-life care, including receipt of a palliative care consult, chaplain visit, bereavement contact, and death in hospice/palliative care unit. Veteran race/ethnicity was measured via chart review and defined as non-Hispanic white, non-Hispanic black, Hispanic, or other. In adjusted models, no differences were observed by race/ethnicity in receipt of a palliative care consult or death in a hospice unit. Although black Veterans were less likely than white Veterans to receive a chaplain visit, Hispanic Veterans were more likely than white Veterans to receive a chaplain visit and to receive a bereavement contact. Less favorable outcomes for racial/ethnic minorities were noted on several BFS items. In comparison with family members of white Veterans, families of minority Veterans were less likely to report excellent overall care, and this difference was largest for black Veterans (48% vs. 62%). Bereaved family members of minority Veterans generally rate the quality of end-of-life care less favorably than those of white Veterans. Family perceptions are critical to the evaluation of equity and quality of end-of-life care.

Background In federal response to the aging population of Vietnam-era Veterans, Congress directed the Department of Veterans Affairs (VA) to create a pilot program to identify and develop best practices for improving hospice care for this population. A first step in VA's response was to identify whether the end-of-life (EOL) care needs and outcomes of Vietnam-era Veterans differed from previous generations. Methods Using medical records and bereaved family surveys, we examined clinical characteristics, healthcare utilization, and EOL quality indicators for Vietnam-era Veterans who died in VA inpatient settings between fiscal year 2013-2017. Contemporaneous comparisons were made with World War II/Korean War-era Veterans. Results Compared to prior generations, higher percentages of Vietnam-era Veterans had mental health/substance use diagnoses and disability. Similar percentages of family members in both groups reported that overall EOL care was excellent; however, post-traumatic stress disorder management ratings by families of Vietnam-era Veterans were significantly lower. Conclusions Although current VA EOL practices are largely meeting the needs of Vietnam-era Veterans, greater focus on mental health comorbidity, including post-traumatic stress disorder, Agent Orange-related conditions, and ensuring access to quality EOL care in the community is warranted. Implications Policymakers and healthcare professionals should anticipate more physical and mental health comorbidities among Veterans at EOL as Vietnam-era Veterans continue to age. Findings are being used to inform the development of standardized EOL care protocols and training programs for non-VA healthcare providers that are tailored to the needs of this population.

Aims and objectives To assess the nursing practice environments and nurse job-related outcomes in two types of hospitals in Saudi Arabia. Background The nursing shortage is a challenging problem in Saudi hospitals. Studies have shown that poor practice environments and high patient-to-nurse ratios are associated with poor nurse job outcomes (i.e. job dissatisfaction, burnout and intention to leave) and that can lead to nurse turnover and compound the nursing shortage. However, little research has been conducted on this topic in Saudi Arabia. Design A cross-sectional design. A model that links the nursing practice environment and patient-to-nurse ratio to nurse job outcomes was tested through a path analysis of survey data. Methods A sample of 404 nurses from public and military hospitals in Saudi Arabia completed a survey that included the Practice Environment Scale of the Nursing Work Index, the Maslach Burnout Inventory and questions related to job dissatisfaction and intention to leave the job. A model of nurse turnover was used to test the relationships among study variables. This study was carried out in accordance with the STROBE checklist for cross-sectional studies. Results The nursing practice environment and nurse job outcomes were better in military hospital compared with public hospital. Overall, 53% of participants had high burnout, 39% were dissatisfied, and 26% intended to leave their jobs. The path analysis showed that the nursing practice environment and patient-to-nurse ratio were predictors of burnout and job dissatisfaction, which in turn lead to intention to leave. The tested model had good fit and explained the direct and indirect effects of study variables. Conclusion Poor nursing practice environments and high patient-to-nurse ratios contribute to poor nurse job outcomes in Saudi hospitals. Relevance to clinical practice Nurse leaders can focus on enhancing practice environments and reducing patient-to-nurse ratios as retention strategies to improve nurse job outcomes.

Background/objectives New or worsened disabilities in functional, cognitive, or mental health following an intensive care unit (ICU) stay are referred to as post-intensive care syndrome (PICS). PICS has not been described in older adults receiving home care. Our aim was to examine the relationship between length of ICU stay and PICS among older adults receiving home care. We expected that patients in the ICU for 3 days or longer would demonstrate significantly more disability in all three domains on follow-up than those not in the ICU. A secondary aim was to identify patient characteristics increasing the odds of disability. Design Retrospective cohort study. Setting Hospitalization for sepsis in the United States. Participants A total of 21 520 Medicare patients receiving home care and reassessed a median of 1 day (interquartile range 1-2 d) after hospital discharge. Measurements PICS was defined as a decline or worsening in one or more of 16 indicators tested before and after hospitalization using OASIS (Home Health Outcome and Assessment Information Set) and Medicare claims data. Results The sample was predominantly female and white. All had sepsis, and most (81.8%) had severe sepsis. In adjusted models, an ICU stay of 3 days or longer, compared with no ICU stay, increased the odds of physical disability. Overall, the declines were modest and found in specific activities of daily living (16% for feeding and lower body dressing to 26% for oral medicine management). No changes were identified in cognition or mental health. Significant determinants of new or worsened physical disabilities were sepsis severity, older age, depression, frailty, and dementia. Conclusion Older adults receiving home care who develop sepsis and are in an ICU for 3 days or longer are likely to develop new or worsened physical disabilities. Whether these disabilities remain after the early postdischarge phase requires further study. J Am Geriatr Soc 67:520-526, 2019.

Context The Bereaved Family Survey (BFS) is used to evaluate the quality of end-of-life (EOL) care in Veterans Affairs inpatient settings. The BFS consists of a global Performance Measure (BFS-PM) and three factors that relate to specific aspects of EOL care. Objective The purpose of this study was to identify empirically based target scores on each BFS factor that are most strongly related to a rating of “excellent” on the BFS-PM. Methods We conducted a cross-sectional analysis of BFS and Veteran clinical data from January 2012 to January 2016. Logistic regression models were constructed for each potential cut point on the three BFS factors and accounted for facility case-mix and nonresponse bias. Model fit was assessed primarily using the Liu Index, Bayesian Information Criterion (BIC), and classification accuracy values. Results Our analytic sample included 40,180 Veterans whose next-of-kin completed a BFS. The mean BFS response rate across study years was 58%. A score of 14 or higher on the Respectful Care and Communication factor (range 0–15) had the lowest BIC (121355) and highest percent correctly classified (81.2%). The Emotional and Spiritual Support factor (range 0–9) had an optimal score of 8 or higher (BIC = 133685; % correctly classified = 77.1%). An optimal cut point on the Benefits factor was not identified. Conclusion The identification of data-driven targets makes BFS factor scores more useful to clinicians and administrators focused on improving quality of EOL care in their facilities. Our results lend support for prioritizing quality improvement efforts related to respectful care and communication.

In federal response to the aging population of Vietnam-era Veterans, Congress directed the Department of Veterans Affairs (VA) to create a pilot program to identify and develop best practices for improving hospice care for this population. A first step in VA’s response was to identify whether the end-of-life (EOL) care needs and outcomes of Vietnam-era Veterans differed from previous generations. Using medical records and bereaved family surveys, we examined clinical characteristics, healthcare utilization, and EOL quality indicators for Vietnam-era Veterans who died in VA inpatient settings between 2013-17. Contemporaneous comparisons were made with World War II/Korean War-era Veterans. Compared to prior generations, higher percentages of Vietnam-era Veterans had mental health/substance use diagnoses and disability. Similar percentages of family members in both groups reported that overall EOL care was excellent; however, post-traumatic stress disorder management ratings by families of Vietnam-era Veterans were significantly lower. Although current VA EOL practices are largely meeting the needs of Vietnam-era Veterans, greater focus on mental health comorbidity, including post-traumatic stress disorder, Agent Orange-related conditions, and ensuring access to quality EOL care in the community is warranted. Policymakers and healthcare professionals should anticipate more physical and mental health comorbidities among Veterans at EOL as Vietnam-era Veterans continue to age. Findings are being used to inform the development of standardized EOL care protocols and training programs for non-VA healthcare providers that are tailored to the needs of this population.

The objective of this study was to investigate the associations between the neonatal intensive care unit (NICU) work environment, quality of care, safety, and patient outcomes. A secondary analysis was conducted of responses of 1247 NICU staff nurses in 171 hospitals to a large nurse survey. Better work environments were associated with lower odds of nurses reporting poor quality, safety, and outcomes. Improving the work environment may be a promising strategy to achieve safer settings for at-risk newborns.

Research has documented an association between Magnet hospitals and better outcomes for nurses and patients. However, little longitudinal evidence exists to support a causal link between Magnet recognition and outcomes.To compare changes over time in surgical patient outcomes, nurse-reported quality, and nurse outcomes in a sample of hospitals that attained Magnet recognition between 1999 and 2007 with hospitals that remained non-Magnet.Retrospective, 2-stage panel design using 4 secondary data sources.One hundred thirty-six Pennsylvania hospitals (11 emerging Magnets and 125 non-Magnets).American Nurses Credentialing Center Magnet recognition; risk-adjusted rates of surgical 30-day mortality and failure-to-rescue, nurse-reported quality measures, and nurse outcomes; the Practice Environment Scale of the Nursing Work Index.Fixed-effects difference models were used to compare changes in outcomes between emerging Magnet hospitals and hospitals that remained non-Magnet.Emerging Magnet hospitals demonstrated markedly greater improvements in their work environments than other hospitals. On average, the changes in 30-day surgical mortality and failure-to-rescue rates over the study period were more pronounced in emerging Magnet hospitals than in non-Magnet hospitals, by 2.4 fewer deaths per 1000 patients (P0.01) and 6.1 fewer deaths per 1000 patients (P=0.02), respectively. Similar differences in the changes for emerging Magnet hospitals and non-Magnet hospitals were observed in nurse-reported quality of care and nurse outcomes.In general, Magnet recognition is associated with significant improvements over time in the quality of the work environment, and in patient and nurse outcomes that exceed those of non-Magnet hospitals.

Introduction Threats to quality and patient safety may exist when necessary nursing care is omitted. Empirical research is needed to determine how missed nursing care is associated with patient outcomes. Aim The aim of this study was to examine the relationship between missed nursing care and hospital readmissions. Methods Cross-sectional examination, using three linked data sources—(1) nurse survey, (2) patient discharge data from three states (California, New Jersey and Pennsylvania) and (3) administrative hospital data— from 2005 to 2006. We explored the incidence of 30-day readmission for 160 930 patients with heart failure in 419 acute care hospitals in the USA. Logistic regression was used to assess the effect of missed care on the odds of readmission, adjusting for patient and hospital characteristics. Results The most frequently missed nursing care activities across all hospitals in our sample included talking to and comforting patients (42.0%), developing and updating care plans (35.8%) and educating patients and families (31.5%). For 4 of the 10 studied care activities, each 10 percentage-point increase in the number of nurses reporting having missed the activity was associated with an increase in the odds of readmission by 2–8% after adjusting for patient and hospital characteristics. However, missed nursing care was no longer a significant predictor of readmission once adjusting for the nurse work environment, except in the case of the delivery of treatments and procedures (OR 1.08, 95% CI 1.02 to 1.14). Conclusions Missed care is an independent predictor of heart failure readmissions. However, once adjusting for the quality of the nurse work environment, this relationship is attenuated. Improvements in nurses’ working conditions may be one strategy to reduce care omissions and improve patient outcomes.

The objectives of this study were to examine differences in nurse engagement in shared governance across hospitals and to determine the relationship between nurse engagement and patient and nurse outcomes.There is little empirical evidence examining the relationship between shared governance and patient outcomes.A secondary analysis of linked cross-sectional data was conducted using nurse, hospital, and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey data.Engagement varied widely across hospitals. In hospitals with greater levels of engagement, nurses were significantly less likely to report unfavorable job outcomes and poor ratings of quality and safety. Higher levels of nurse engagement were associated with higher HCAHPS scores.A professional practice environment that incorporates shared governance may serve as a valuable intervention for organizations to promote optimal patient and nurse outcomes.

Two components of the Magnet Recognition Program® are exemplary professional practice and the generation of new knowledge through research and clinical innovation. Within Magnet® institutions, exemplary professional practice is evidenced by collaboration. Hospitals and schools of nursing can develop collaborative relationships to promote a culture of inquiry in clinical care and generate research to advance nursing practice and nursing science. The authors describe a collaborative model between clinical nurses and an academic nursing research center that promotes involvement of clinical nurses in research.

Objectives To provide a critical analysis of current approaches to the care of older adults with cancer, outline priority areas for geriatric oncology program development, and recommend strategies for improvement. Data Sources Published articles and reports between 1999 and 2015. Conclusion Providing an interdisciplinary model that incorporates a holistic geriatric assessment will ensure the delivery of patient-centered care that is responsive to the comprehensive needs of older patients. Implications for Nursing Practice Nursing administrators and leaders have both an opportunity and responsibility to shape the future of geriatric oncology. Preparations include workforce development and the creation of programs that are designed to meet the complex needs of this population.