Highlights • The interrelationship between the concepts patient empowerment, patient participation and patient-centeredness is clarified. • Patient empowerment is a meta-paradigm. • Patient ...participation is a strategy to achieve patient-centered care. • A patient-centered approach leads to patient empowerment. • The application of the concepts might lead to a better quality of care and a better quality of life.
Summary Background Austerity measures and health-system redesign to minimise hospital expenditures risk adversely affecting patient outcomes. The RN4CAST study was designed to inform decision making ...about nursing, one of the largest components of hospital operating expenses. We aimed to assess whether differences in patient to nurse ratios and nurses' educational qualifications in nine of the 12 RN4CAST countries with similar patient discharge data were associated with variation in hospital mortality after common surgical procedures. Methods For this observational study, we obtained discharge data for 422 730 patients aged 50 years or older who underwent common surgeries in 300 hospitals in nine European countries. Administrative data were coded with a standard protocol (variants of the ninth or tenth versions of the International Classification of Diseases) to estimate 30 day in-hospital mortality by use of risk adjustment measures including age, sex, admission type, 43 dummy variables suggesting surgery type, and 17 dummy variables suggesting comorbidities present at admission. Surveys of 26 516 nurses practising in study hospitals were used to measure nurse staffing and nurse education. We used generalised estimating equations to assess the effects of nursing factors on the likelihood of surgical patients dying within 30 days of admission, before and after adjusting for other hospital and patient characteristics. Findings An increase in a nurses' workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7% (odds ratio 1·068, 95% CI 1·031–1·106), and every 10% increase in bachelor's degree nurses was associated with a decrease in this likelihood by 7% (0·929, 0·886–0·973). These associations imply that patients in hospitals in which 60% of nurses had bachelor's degrees and nurses cared for an average of six patients would have almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor's degrees and nurses cared for an average of eight patients. Interpretation Nurse staffing cuts to save money might adversely affect patient outcomes. An increased emphasis on bachelor's education for nurses could reduce preventable hospital deaths. Funding European Union's Seventh Framework Programme, National Institute of Nursing Research, National Institutes of Health, the Norwegian Nurses Organisation and the Norwegian Knowledge Centre for the Health Services, Swedish Association of Health Professionals, the regional agreement on medical training and clinical research between Stockholm County Council and Karolinska Institutet, Committee for Health and Caring Sciences and Strategic Research Program in Care Sciences at Karolinska Institutet, Spanish Ministry of Science and Innovation.
Variation in post-operative mortality rates has been associated with differences in registered nurse staffing levels. When nurse staffing levels are lower there is also a higher incidence of ...necessary but missed nursing care. Missed nursing care may be a significant predictor of patient mortality following surgery.
Examine if missed nursing care mediates the observed association between nurse staffing levels and mortality.
Data from the RN4CAST study (2009–2011) combined routinely collected data on 422,730 surgical patients from 300 general acute hospitals in 9 countries, with survey data from 26,516 registered nurses, to examine associations between nurses’ staffing, missed care and 30-day in-patient mortality. Staffing and missed care measures were derived from the nurse survey. A generalized estimation approach was used to examine the relationship between first staffing, and then missed care, on mortality. Bayesian methods were used to test for mediation.
Nurse staffing and missed nursing care were significantly associated with 30-day case-mix adjusted mortality. An increase in a nurse’s workload by one patient and a 10% increase in the percent of missed nursing care were associated with a 7% (OR 1.068, 95% CI 1.031–1.106) and 16% (OR 1.159 95% CI 1.039–1.294) increase in the odds of a patient dying within 30days of admission respectively. Mediation analysis shows an association between nurse staffing and missed care and a subsequent association between missed care and mortality.
Missed nursing care, which is highly related to nurse staffing, is associated with increased odds of patients dying in hospital following common surgical procedures. The analyses support the hypothesis that missed nursing care mediates the relationship between registered nurse staffing and risk of patient mortality. Measuring missed care may provide an ‘early warning’ indicator of higher risk for poor patient outcomes.
Cost containment pressures underscore the need to better understand how nursing resources can be optimally configured.
To obtain a snapshot of European nurses’ assessments of their hospital work ...environments and quality of care in order to identify promising strategies to retain nurses in hospital practice and to avoid quality of care erosions related to cost containment.
Cross sectional surveys of 33,659 hospital medical–surgical nurses in 12 European countries.
Surveyed nurses provided care in 488 hospitals in Belgium, England, Finland, Germany, Greece, Ireland, the Netherlands, Norway, Poland, Spain, Sweden, and Switzerland.
All nurses were surveyed from medical-surgical units 30 or more hospitals from geographically representative samples of hospitals in each country, except for Ireland and Norway, where all hospitals were selected, and Sweden, where nearly all hospitals were included by sampling all medical–surgical nurses who were members of the Swedish Nursing Association.
Percentages are provided for each of the nurse and hospital characteristics reported.
There was wide variation across countries in the percentages of hospital nurses that were bachelor's prepared (range 0–100%), in patient to nurse average workloads (3.7–10.2) and skill mix (54–82% nurses). More than one in five nurses (11–56%) were dissatisfied with their jobs in most countries, and dissatisfaction was pronounced with respect to wages, educational opportunities and opportunities for advancement. Sizable percentages (19–49%) of nurses intended to leave their jobs, though the percentage that thought it would be easy to find another job varied greatly across countries (16–77%). Nurse concerns with workforce management and adequate resources were widespread. While most nurses did not give their hospitals poor grades on patient safety, many doubted that safety was a management priority. Nurses reported that important nursing tasks were often left undone because of lack of time, and indicated that adverse events were not uncommon.
Nurse shortages can be expected when national economies improve unless hospital work environments improve. Wide variation in nurse staffing and skill mix suggests a lack of evidence-based decision making. Additional research is warranted on the impact of these variations in nurse resources on patient outcomes.
Aim
To reflect upon the concrete implications of the COVID‐19 outbreak regarding ongoing health service and nursing management research (NMR) and to identify possible research priorities for the ...current and post‐pandemic era.
Background
Health service research and the nursing management research debate have received little attention to date, despite their relevance in responding to the increased demand of care during the COVID‐19 outbreak.
Methods
A critical analysis on experiences was performed while leading international‐funded studies at different degrees of complexity and targets, involving nurse managers, nurses, care processes and health care services in the last year.
Results
Ongoing research projects have been profoundly affected by the COVID‐19 outbreak in their aims, methods, management processes, feasibility and outcomes.
Conclusions
The COVID‐19 outbreak is an unprecedented stress test for the health care sector and for the nursing services. Its onset and persistence have rendered more easily to see what prevails in terms of effectiveness and what fails in our health care services.
Implications for Nursing Management
Nurse managers have lived and are still living through this crisis, given their omnipresence in the health care systems. Therefore, setting NMR priorities and working together to imagine and design the post‐COVID‐19 era is essential.
Aim
The aim of this study was to explore the association between the quality of the work environment, job characteristics, demographic characteristics and a pathway of job satisfaction, emotional ...exhaustion and turnover intention among nurses in emergency departments and perform subgroup analyses.
Background
Turnover intention among nurses is high. Multiple causes have been described, mostly in large studies of nurses working on general wards, often without considering complementarity of conceptual models and showing scant interest in the consistency of associations across subgroups of nurses.
Design
Cross‐sectional multicentre survey.
Method
Convenience sample of 294 nurses in 11 Belgian emergency departments during 2014–2015. Indirect effects in the form of mediation and serial mediation were estimated to assess the association between work environment (Magnet model), job characteristics (Job Demand Control Support model) and turnover intention via job satisfaction and emotional exhaustion. Consistency of these indirect effects across subgroups of nurses was examined using moderated mediation analysis (conditional indirect effects).
Results
Several Magnet and Job Demand Control Support dimensions were related to turnover intention, either via job dissatisfaction (mediation) or via job satisfaction and emotional exhaustion (serial mediation). In the case of social support from supervisor, these indirect effects were only significant for female nurses, among whom turnover intention was higher. Last, nurses with more years of experience were less likely to indicate turnover intention.
Conclusion
To maximize prevention of turnover intention at emergency departments, interventions could target early career nurses, work environment and job characteristics. Female nurses in particular may also benefit from improved social support from their supervisor.
Pay-for-performance (P4P) is one of the primary tools used to support healthcare delivery reform. Substantial heterogeneity exists in the development and implementation of P4P in health care and its ...effects. This paper summarizes evidence, obtained from studies published between January 1990 and July 2009, concerning P4P effects, as well as evidence on the impact of design choices and contextual mediators on these effects. Effect domains include clinical effectiveness, access and equity, coordination and continuity, patient-centeredness, and cost-effectiveness.
The systematic review made use of electronic database searching, reference screening, forward citation tracking and expert consultation. The following databases were searched: Cochrane Library, EconLit, Embase, Medline, PsychINFO, and Web of Science. Studies that evaluate P4P effects in primary care or acute hospital care medicine were included. Papers concerning other target groups or settings, having no empirical evaluation design or not complying with the P4P definition were excluded. According to study design nine validated quality appraisal tools and reporting statements were applied. Data were extracted and summarized into evidence tables independently by two reviewers.
One hundred twenty-eight evaluation studies provide a large body of evidence -to be interpreted with caution- concerning the effects of P4P on clinical effectiveness and equity of care. However, less evidence on the impact on coordination, continuity, patient-centeredness and cost-effectiveness was found. P4P effects can be judged to be encouraging or disappointing, depending on the primary mission of the P4P program: supporting minimal quality standards and/or boosting quality improvement. Moreover, the effects of P4P interventions varied according to design choices and characteristics of the context in which it was introduced.Future P4P programs should (1) select and define P4P targets on the basis of baseline room for improvement, (2) make use of process and (intermediary) outcome indicators as target measures, (3) involve stakeholders and communicate information about the programs thoroughly and directly, (4) implement a uniform P4P design across payers, (5) focus on both quality improvement and achievement, and (6) distribute incentives to the individual and/or team level.
P4P programs result in the full spectrum of possible effects for specific targets, from absent or negligible to strongly beneficial. Based on the evidence the review has provided further indications on how effect findings are likely to relate to P4P design choices and context. The provided best practice hypotheses should be tested in future research.
The safety and quality of patient care are basic guidelines in finding new and improved solutions in nursing. Important and influential factors shape the nurses' work environment in hospitals.
With ...the study, we intended to investigate whether the perception of nurses' work environment is related to the safety culture and the quality of patient care and whether it differs according to nurses' level of education.
The study with a quantitative research method was conducted at the six clinical departments of the University Medical Centre, Ljubljana in 2019. We used a survey questionnaire from the European survey Nurse forecasting in Europe (RN4CAST).
270 nurses were included in the study. The response rate was 54%. The study confirmed that there is a correlation between the assessment of the nurses' work environment and the general assessment of patient safety (r = 0.36; p <0.001), the general assessment of the quality of nursing care (r = 0.32; p <0.001), the confidence in patient self-care at discharge (r = 0.29; p <0.001) and the quality of patient care in the previous year (r = 0.27; p = 0.001). The results showed frequent verbal abuse of nurses, in 44.9% by patients and their relatives and in 35.4% by staff. Graduate nurses rated the work environment more negatively than healthcare technicians (p = 0.003).
We confirmed the correlation between the assessment of nurses' work environment and patient safety and the quality of health care, and that employees' education influences the assessment and perception of the work environment.
Care pathways are often said to promote interprofessional teamwork. As no systematic review on pathway effectiveness has ever focused on how care pathways promote teamwork, the objective of this ...review was to study this relationship. We performed an extensive search of electronic databases and identified 26 relevant studies. In our analysis of these studies we identified 20 team indicators and found that care pathways positively affected 17 of these indicators. Most frequently positive effects were found on staff knowledge, interprofessional documentation, team communication and team relations. However, the level of evidence was rather low. We found Level II evidence for improved interprofessional documentation. We also found Level II evidence for increased workload; improved actual versus planned team size; and improved continuity of care. The studies most frequently mentioned the need for a multidisciplinary approach and educational training sessions in order for pathways to be successful. The systematic review revealed that care pathways have the potential to support interprofessional teams in enhancing teamwork. Necessary conditions are a context that supports teamwork and including appropriate active pathway components that can mediate an effect on team processes. To achieve this, each care pathway requires a clearly defined team approach customized to the individual teams’ needs.
► This review enhances understanding on how and in what circumstances care pathways work. ► Most frequently found effects were improved team knowledge, interprofessional documentation, communication and relations. ► A supportive context that puts care processes and teams in the frontline of concern, needs to be pursued. ► Teams involved in care pathways need to be trained to improve team processes and manage team conflicts appropriately. ► To be successful, each care pathway requires a clearly defined team approach, customized to the individual teams’ needs.
ObjectiveTo examine individual, situational and organisational aspects that influence psychological impact and recovery of a patient safety incident on physicians, nurses and ...midwives.DesignCross-sectional, retrospective surveys of physicians, midwives and nurses.Setting33 Belgian hospitals.Participants913 clinicians (186 physicians, 682 nurses, 45 midwives) involved in a patient safety incident.Main outcome measuresThe Impact of Event Scale was used to retrospectively measure psychological impact of the safety incident at the time of the event and compare it with psychological impact at the time of the survey.ResultsIndividual, situational as well as organisational aspects influenced psychological impact and recovery of a patient safety incident. Psychological impact is higher when the degree of harm for the patient is more severe, when healthcare professionals feel responsible for the incident and among female healthcare professionals. Impact of degree of harm differed across clinicians. Psychological impact is lower among more optimistic professionals. Overall, impact decreased significantly over time. This effect was more pronounced for women and for those who feel responsible for the incident. The longer ago the incident took place, the stronger impact had decreased. Also, higher psychological impact is related with the use of a more active coping and planning coping strategy, and is unrelated to support seeking coping strategies. Rendered support and a support culture reduce psychological impact, whereas a blame culture increases psychological impact. No associations were found with job experience and resilience of the health professional, the presence of a second victim support team or guideline and working in a learning culture.ConclusionsHealthcare organisations should anticipate on providing their staff appropriate and timely support structures that are tailored to the healthcare professional involved in the incident and to the specific situation of the incident.
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