The multicenter impacts of an emergency physician lead on departmental flow and provider experiences.

INTRODUCTION: Emergency department (ED) flow impacts patient safety, quality of care and ED provider satisfaction. Throughput interventions have been shown to improve flow, yet few studies have reported the impact of ED physician leadership roles on patient flow and provider experiences. The study objective was to evaluate the impacts of the emergency physician lead role on ED flow metrics and provider experiences. METHODS: Quantitative data about patient flow metrics were collected from ED information systems in two tertiary hospital EDs and analyzed to compare ED length of stay, EMS hallway length of stay, physician initial assessment time, 72-h readmission and left without being seen rates three months before and following emergency physician lead role implementation. ED flow metrics for adult patients at each site were analyzed independently using descriptive and inferential statistics, t tests and multivariable regression analysis. Qualitative data were collected via surveys from ED providers (physicians, nurses, and EMS) about their experiences working with the emergency physician leads and analyzed for themes about emergency physician leads impact. RESULTS: The number of ED visits was relatively stable pre-post at the Peter Lougheed Centre (Lougheed) but increased pre-post at the Foothills Medical Centre (Foothills). Post-intervention at Lougheed median ED length of stay decreased by 18 min (p < 0.001) and at Foothills ED length of stay increased by 8 min (p < 0.001). EMS length of stay at Lougheed decreased by 20 min (p < 0.001), and at Foothills length of stay increased by 17 min (p < 0.001). Themes in provider feedback were that emergency physician leads (1) facilitated patient flow, (2) impacted provider workload, and (3) supported patient flow and safety with early assessments, treatments and investigations. CONCLUSION: In this study, the emergency physician lead impacted ED flow metrics variably at different sites, but important learnings from provider experiences can guide future emergency physician lead implementation.

RéSUMé: INTRODUCTION: Le flux des services d'urgence a une incidence sur la sécurité des patients, la qualité des soins et la satisfaction des fournisseurs de services d'urgence. Il a été démontré que les interventions de débit améliorent le flux, mais peu d'études ont rapporté l'impact des rôles de leadership des médecins des urgences sur le flux des patients et les expériences des prestataires. L'objectif de l'étude était d'évaluer l'impact du rôle du médecin chef des urgences sur les paramètres de flux des urgences et les expériences des prestataires. MéTHODES: Les données quantitatives sur les paramètres du flux des patients ont été recueillies à partir des systèmes d'information des urgences de deux hôpitaux tertiaires et analysées afin de comparer la durée du séjour aux urgences, la durée du séjour dans le couloir des SMU, le temps d'évaluation initiale par le médecin, les réadmissions dans les 72 heures et les taux de sortie sans consultation trois mois avant et après la mise en œuvre du rôle de chef des urgences. Les paramètres de débit des urgences pour les patients adultes de chaque site ont été analysés indépendamment à l'aide de statistiques descriptives et inférentielles, de tests t et d'une analyse de régression multivariable. Les données qualitatives ont été recueillies par le biais d'enquêtes auprès de fournisseurs de services d'urgence (médecins, infirmières et services médicaux d'urgence) sur leur expérience de travail avec les médecins chefs des services d'urgence et analysées pour en dégager les thèmes concernant l'impact des médecins chefs des services d'urgence. RéSULTATS: Le nombre de visites aux urgences était relativement stable avant et après au Peter Lougheed Centre (Lougheed), mais a augmenté avant et après au Foothills Medical Center (Foothills). Après l'intervention, la durée médiane du séjour aux urgences de Lougheed a diminué de 18 minutes (p < 0.001) et celle des urgences de Foothills a augmenté de 8 minutes (p < 0.001). La durée du séjour en SMU a diminué de 20 minutes à Lougheed (p < 0.001), et a augmenté de 17 minutes à Foothills (p < 0.001). Les thèmes abordés dans les commentaires des fournisseurs étaient les suivants : les responsables des urgences (1) facilitaient le flux des patients, (2) avaient un impact sur la charge de travail des fournisseurs et (3) favorisaient le flux et la sécurité des patients grâce à des évaluations, des traitements et des examens précoces. CONCLUSION: Dans cette étude, le médecin chef des urgences a eu un impact variable sur les paramètres de débit des urgences dans les différents sites, mais les enseignements importants tirés des expériences des fournisseurs peuvent guider la mise en œuvre future du médecin chef des urgences.

Public health nurse perceptions of evolving work and how work is managed: A qualitative study.

AIM: To explore public health nurse (PHN) perspectives of their evolving work and how public health nurse work is managed in a Canadian health region. BACKGROUND: Professional and public health organisations describe public health nurse practice roles as population-focused work. Health care management directs public health nurse work to achieve specific goals. METHODS: In this qualitative study, data were collected during focus groups with 42 public health nurse participants in one health region. Focus group data were analysed for meanings and themes. RESULTS: Public health nurses perceived increasing immunizations and limited resources for public health nurse work meant that population-focused care for the public was rationed or missing. Participants perceived the health care organisation directed, managed and assigned public health nurse specialist work; however, public health nurses managed their client-focused practice with knowledge, reasoning and support from colleagues. CONCLUSIONS: Evolving visible public health nurse work was managed by health organisational management directives to increase immunizations and disease control. Public health nurses managed their evolving visible and invisible work supported by their knowledge, practice values and public health nurse colleagues. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing management must lead and communicate the vision supporting better health, better population-focused care and health outcomes to public health nurse and stakeholders, while reviewing resources needed to optimize public health nursing and improve population health.

Nurses' clinical reasoning practices that support safe medication administration: An integrative review of the literature.

AIMS AND OBJECTIVES: To review the current literature about nurses' clinical reasoning practices that support safe medication administration. BACKGROUND: The literature about medication administration frequently focuses on avoiding medication errors. Nurses' clinical reasoning used during medication administration to maintain medication safety receives less attention in the literature. As healthcare professionals, nurses work closely with patients, assessing and intervening to promote mediation safety prior to, during and after medication administration. They also provide discharge teaching about using medication safely. Nurses' clinical reasoning and practices that support medication safety are often invisible when the focus is medication errors avoidance. DESIGN: An integrative literature review was guided by Whittemore and Knafl's (Journal of Advanced Nursing, 5, 2005 and 546) five-stage review of the 11 articles that met review criteria. This review is modelled after Gaffney et al.'s (Journal of Clinical Nursing, 25, 2016 and 906) integrative review on medical error recovery. METHODS: Health databases were accessed and systematically searched for research reporting nurses' clinical reasoning practices that supported safe medication administration. The level and quality of evidence of the included research articles were assessed using The Johns Hopkins Nursing Evidence-Based Practice Rating Scale©. RESULTS: Nurses have a central role in safe medication administration, including but not limited to risk awareness about the potential for medication errors. Nurses assess patients and their medication and use knowledge and clinical reasoning to administer medication safely. Results indicated nurses' use of clinical reasoning to maintain safe medication administration was inadequately articulated in 10 of 11 studies reviewed. CONCLUSION: Nurses are primarily responsible for safe medication administration. Nurses draw from their foundational knowledge of patient conditions and organisational processes and use clinical reasoning that supports safe medication practice. There was minimal evidence clearly articulating nurses' clinical reasoning used to support medication safety. RELEVANCE TO CLINICAL PRACTICE: This review focused on finding evidence of nurses' clinical reasoning that supported safe medication administration.

Nurse retention strategies: advice from experienced registered nurses.

PURPOSE: The purpose of the paper is to explore the insights of experienced nurses regarding initiatives they believe would effectively retain nurses like themselves in the nursing profession. DESIGN/METHODOLOGY/APPROACH: As part of a qualitative investigation into the perceptions of nurses regarding issues affecting their profession, experienced nurses were asked to describe what retention strategies they would recommend to policy-makers. A total of 16 semi-structured interviews were conducted with long-term nurses in a health region in western Canada. FINDINGS: The paper found that seven retention strategies were commonly mentioned by the participants. The qualitative mode of inquiry allowed the nurses to convey the context, attitudes and feelings behind their recommendations. RESEARCH LIMITATIONS/IMPLICATIONS: The work environments and accompanying retention policies experienced by nurses vary widely according to the specific employment context As is typical with qualitative research, the findings of this study cannot be considered as generalizable to all nurses in all health care settings. PRACTICAL IMPLICATIONS: The results of this paper provide a deeper understanding of the attitudes, emotions and contextual issues behind the nurse retention strategies seen as most appropriate by the target audience of long-term nurses. ORIGINALITY/VALUE: While there is much literature advocating the implementation of nurse retention strategies, very little evidence has been presented from a qualitative lens. It is necessary to directly listen to the voices of those impacted by policies in order to better appreciate how such policies are perceived from a bottom-up perspective.