A validation study of the high acuity readmission risk pediatric screen (HARRPS) tool©: Predicting readmission risk within the pediatric population.

BACKGROUND: The initial research study of the High Acuity Readmission Risk Pediatric Screen (HARRPS) Tool © focused on using retrospective data to apply weighted values to the questions within the tool, identify overall risk score, and attribute risk categories (low, moderate, high risk) to the overall risk score. This study focused on validating the data from the initial study, as well as cross examining the need to include admission diagnosis within the tool. METHOD: Study was a single-centered, retrospective chart review study using a different subset of patients from the initial study. Pediatric patients with thirty-day readmissions were compared to pediatric patients without a thirty-day readmission over a twelve-month period. Utilized same statistical software and methodology from initial study to identify if readmission risk probability could be replicated with a different population. RESULTS: The initial study performed in 2018 demonstrated a c-statistic score/ area under the curve (AUC) of 0.68 [95% CI: 0.67, 0.69]. In addition, the initial study demonstrated as risk score increases, the probability of readmission gradually increased until a patient had a risk score of seven or greater, at which point readmission risk plateaued. This resulted in low, moderate, and high readmission risk categories. The current study performed using data from 2019 demonstrated an improved c-statistic score / AUC of 0.83 [95% CI: 0.80, 0.87] with admission diagnosis included, and a c-statistic score / AUC of 0.80 [95% CI: 0.76, 0.83] without the admission diagnosis included. The analysis of overall risk score demonstrated a substantial difference in how to interpret final readmission risk scores. Both the initial study and validation study were consistent in demonstrating a risk score of three or less was associated with low readmission risk. However, in the validation study, there was no substantial difference between moderate or high risk, leading to updating the tool from 3 risk categories into 2 risk categories of low risk and at risk of readmission. CONCLUSION: Based on the finding from the validation study, the admission diagnosis was removed from the HARRPS Tool© as the difference in c-statistic score was nominal, and the risk categories were changed from three categories (low, moderate, high risk) to two categories of low risk (score 0-2) and at risk of readmission for a score of 3+. The ability of the HARRPS Tool© to predict readmission risk preforms best with a c-statistic = 0.80, outperforming the following tools: LACE (0.65), LACE -SDH (0.67), LACE + (0.61), Epic's readmission risk model (0.69), and SQLAPE ® (0.71) (Ryan, et al., 2021; Hwang, et al., 2021).

Newly Licensed Nurse Perceived Incivility: A Valid and Reliable Assessment Tool.

OBJECTIVE: To test the instrument, Nursing Student Perception of Civil and Uncivil Behaviors (NSPCUB) in newly licensed nurses' (NLNs') to create a credible measure of NLNs' perceptions of civil/uncivil behaviors by RNs. BACKGROUND: Uncivil behaviors in the workplace result in poor morale, absenteeism, and turnover. When targeted toward NLNs, the outcome of these behaviors can affect not only a job but a future career. METHODS: A convenience sample of NLNs from 3 cohorts completed the modified NSPCUB-NLN 12-item survey. Exploratory factor analysis and reliability statistics were conducted. Concurrent validity was evaluated. RESULTS: Exploratory factor analysis identified passive and active incivility subscales with high reliability (overall Cronbach's α = 0.917). Participants expressing positive experiences scored higher than those with negative experiences (P < 0.0001), supporting instrument validity. CONCLUSIONS: This study demonstrated that the NSPCUB-NLN is a valid and reliable instrument for use with NLNs. This will assist nurse leaders in evaluating unit cultures for incivility, guiding interventions for a healthy work environment.

Feeding Therapy Treatments for Infants With Unilateral Vocal Cord Paresis.

IMPORTANCE: No evidence-based treatment protocol currently exists for infants with vocal cord paresis (VCP). OBJECTIVE: To assess the impact of feeding position on feeding success among infants with unilateral VCP and examine other variables that may be associated with feeding success. DESIGN: Retrospective descriptive study. SETTING: Midwestern pediatric hospital serving rural and urban populations. PARTICIPANTS: Sixty-seven infants age <1 yr diagnosed with unilateral VCP by otolaryngologist while inpatient. OUTCOMES AND MEASURES: Bottle or breastfeeding without the use of a thickening agent at discharge and without readmission for feeding difficulties ≤3 mo of discharge was considered feeding success. RESULTS: Chart review was completed for 67 infants with unilateral VCP. Infants fed in side lying were more likely to feed without use of a thickened liquid than infants fed in upright (70% vs. 17%; p = .01). Infants who had patent ductus arteriosus (PDA) ligation and infants who were premature were more likely to need thickener and to be readmitted for feeding difficulties. CONCLUSIONS AND RELEVANCE: Further study is required to investigate the use of side-lying position versus upright position for feeding infants with VCP. Using the side-lying position allowed more infants to feed without thickener agents, and patient characteristics, including history of PDA ligation and prematurity, correlated with the need for thickened liquids and readmission. Consensus on the safety and efficacy of thickening breast milk is limited, so this information may allow more infants to breastfeed or drink expressed breast milk safely by bottle. It also provides medical providers information that can possibly prevent readmissions. What This Article Adds: The results of this study can inform occupational therapy feeding practice through use of the side-lying position, as well as being aware of patient characteristics that are correlated with increased feeding difficulties.

Retrospective Chart Review: Readmission Prediction Ability of the High Acuity Readmission Risk Pediatric Screen (HARRPS) Tool.

BACKGROUND: Nurse Case Managers utilize adult based readmission risk tools upon admission to identify readmission risk. An evidence-based pediatric readmission tool could not be identified to replicate in the pediatric space, therefore the High Acuity Readmission Risk Pediatric Screen (HARRPS) Tool was developed to fill this gap. The research aim was to develop a risk score algorithm that accurately predicts pediatric readmissions and provide a predictive validation of the HARRPS Tool. METHOD: This was a single-centered, retrospective chart review study which compared pediatric patients with thirty-day readmissions to those without thirty-day readmissions over a twelve-month period. Sample size ratio of 1:2 was determined via power analysis with an overall sample size of 5371. Each category from the HARRPS Tool was appropriately weighted based upon data from this study to then produce an overall, patient-level risk score, which was summed [allowable range: 0, 14] across all components. Cross validation was used to ascertain the readmission risk predictability. RESULTS: Of the 5306 patients included in the final analysis, 1343 (25.3%) had a thirty-day readmission. Out of nine risk components analyzed, eight were consistent with the literature review findings. Patients with a score of seven or higher had a 54.9% predicted probability of a thirty-day readmission, compared to 13.6% for patients with a risk score of zero. The c-statistic score of the HARRPS Tool was determined to be 0.68 [95% CI, 0.67, 0.69]. Overall, the HARRPS Tool was favorable and provides initial credibility of the tool's predictive power for the general pediatric population.

Quality of Sleep in a Pediatric Hospital: A Descriptive Study Based on an Assessment of Interruptions, Perceptions, and the Environment.

OBJECTIVE: To investigate the amount and type of hospitalized children's nighttime sleep interruptions, perceptions, and efficiency. BACKGROUND: Sleep in hospitals is notoriously poor and impedes healing. Pediatric studies have been limited including breadth of diagnoses, age, or measures. METHODS: Actigraphy, sleep surveys, and nursing diaries were used to describe sleep on 2 nursing units along with environmental assessments. RESULTS: Ninety-five children from 1 month to 17 years with multiple diagnoses participated. The median number of awakenings was 2.7 per night. The median for the longest uninterrupted episode of sleep was 5.5 hours. Children need 8 to 17 hours of daily sleep, while this sample had a median of 7.5 hours of night sleep. Sensors showed talk as the predominant noise, whereas surveys showed alarms and vital signs awakened patients. CONCLUSIONS: Children are not getting essential, minimally interrupted sleep in hospitals. Disseminating results will increase awareness and accelerate environmental changes.

Incivility Toward Nursing Students in Clinical Rotations: Measuring the Incidence and Testing Interventions.

OBJECTIVE: The purpose of this study was to measure nursing student perceptions of incivility in the clinical learning environment and test interventions that improve these perceptions. The secondary aim was to further test the reliability of the Nursing Student Perception of Civil and Uncivil Behaviors (NSPCUB) tool. BACKGROUND: Incidence of incivility in nursing is well documented in the literature; however, there are few evidence-based interventions to combat this phenomenon. METHODS: NSPCUB was administered to 314 nursing students. Data were used to develop hospital-wide and unit-specific interventions. After implementation of the interventions, the survey was administered to 410 students. RESULTS: There was a statistically significant mean increase for 7 of the 12 survey items, hospital-wide, and the findings reenforced NSPCUB as a highly reliable tool. CONCLUSIONS: This instrument can be used by nurse executives to measure perceptions of incivility, identify areas for improvement, and implement interventions.

SIRA+P: Development and Testing.

OBJECTIVES: To describe the development of a new skin risk assessment scale called Skin Injury Risk Assessment and Prevention (SIRA+P) and to establish initial reliability and validity of the scale among patients ranging in age from birth, including pre-term, to adulthood, regardless of age or acuity of illness. STUDY DESIGN: The single-site study was a retrospective chart review to evaluate the measurement properties of SIRA+P. Charts of 385 patients of all ages and in all units (including the neonatal and pediatric intensive care units) of a free-standing children's hospital were included. Concurrent validity was assessed with scales having previously established reliability and validity. For subjects <30days of age, the comparison scale was the Neonatal Skin Risk Assessment Scale (NSRAS); for subjects 31days through 17years, the Braden Q Scale (Braden Q) was used; and for subjects 18years and older, the Braden Scale (Braden) was used. Interrater reliability was examined using Intraclass Correlation Coefficients (ICC). Concurrent validity procedures compared SIRA+P with NSRAS, Braden Q, and Braden using Pearson Correlation Coefficients. RESULTS: Interrater reliability for SIRA+P was very high (0.878). SIRA+P strongly correlated with the NSRAS (0.725), the Braden Q (-0.634), and the Braden (-0.778). CONCLUSION: SIRA+P is designed to be used within the EHR and includes nursing decision support to guide pressure injury prevention interventions for specific skin integrity risks. SIRA+P has good interrater reliability, is valid across all age groups and accounts for device-related pressure.

Improving Immunization Rates at an Urban Charter School.

A midwestern children's hospital operates a school-based clinic in an urban charter school. The clinic provides the expertise and knowledge of an advanced practice registered nurse (APRN) and offers a structure permitting care coordination and continuity. The APRN created a systematic process for immunization record maintenance. This process identifies students needing recommended vaccines for their age group and provides opportunities for students to update their record or receive immunizations. This initiative demonstrated that improved vaccination compliance can be sustained through systematic methods to identify immunization gaps and support the administration of necessary vaccines.

Development of an Instrument to Measure Civil and Uncivil Behaviors in the Hospital Clinical Environment: Implications for Nurse Leaders.

OBJECTIVE: The purpose of this study is to develop a valid and reliable instrument to measure nursing students' (NSs') perceptions of civil and uncivil behaviors displayed by direct care nurses in the hospital clinical environment. BACKGROUND: Incivility in nursing has been well documented. However, little is known about perceptions of incivility by NSs in the hospital clinical environment and its effects on NSs' transition to professional practice. METHODS: A 13-item instrument was developed using literature, faculty feedback, and a semistructured focus group. The instrument was administered to convenience samples of NSs at a Midwest, Magnet-designated pediatric hospital (N = 496). RESULTS: Findings indicated high reliability and validity of the instrument, with a Cronbach's α of .930. CONCLUSIONS: This study has produced a valid and reliable survey instrument to measure the perception of civil and noncivil behaviors on the part of clinical nurses as rated by NSs in hospital clinical settings. The use of this instrument will be beneficial to nurse executives in measuring these perceptions in their clinical settings.

The clinical scene investigator academy: the power of staff nurses improving patient and organizational outcomes.

Nurses are in a key position to have an impact on the national quality agenda. However, many lack the quality and safety methods to lead this work. The Clinical Scene Investigator Academy provided 23 nurses from 7 regional hospitals with the knowledge and support necessary to implement nurse-led quality improvement projects. Not only did each Clinical Scene Investigator project improve patient and/or staff outcomes but 3 such projects also had a significant economic impact.

Development and testing of an organizational job satisfaction tool: increasing precision for strategic improvements.

OBJECTIVE: This article describes the development and testing of a new instrument that measures organizational job satisfaction (OJS). BACKGROUND: Nurse satisfaction includes 2 different types of satisfaction: OJS and professional work satisfaction. To obtain valid results, each type must be measured correctly. METHODS: A metasynthesis of OJS was conducted from 3 sources: nurse satisfaction instruments, attributes present in recruitment advertisements, and nursing comments from a national survey. A cross-walk of these sources provided 17 consistent OJS satisfiers. A survey of 10,000 nurses identified the importance of these satisfiers. RESULTS: Cronbach α for the scale was .85. The satisfiers were grouped into 3 categories: universally important, moderately important, and unimportant. CONCLUSIONS: A synthesis from 3 sources, including identification of important satisfiers, provides validity for the OJS scale. The scale is a reliable and valid tool used to assess and evaluate strategies to improve the nurses' work environment.

Developing and testing a clinical information system evaluation tool: prioritizing modifications through end-user input.

OBJECTIVE: The objectives were to develop and validate the Information System Evaluation Tool (ISET), use feedback to modify the institution's clinical information system (CIS), and determine the modifications' success. BACKGROUND: The ability of a CIS to increase patient safety and care quality is dependent on its systems and processes. A survey was needed to provide the specificity necessary to make meaningful system improvements. METHODS: The ISET was pilot tested and revised before being administered before implementation of the CIS. It was administered at 2 times after implementation. The ISET was revised after analysis of the results, and comparisons were made between the times. RESULTS: The ISET is a valid and reliable instrument. Perceptions of the CIS initially decreased, but had significantly improved by 16 months after implementation. CONCLUSIONS: End-users must be convinced that the CIS supports their practice and improves care for adoption to be successful. The ISET measures these perceptions and highlights areas for improvement.

Nurse-driven programs to improve patient outcomes: transforming care at the bedside, integrated nurse leadership program, and the clinical scene investigator academy.

As the national quality agenda continues to be a key driver in healthcare, more programs are being developed to teach staff nurses how to lead quality change projects. Nurses are in a unique position to do this work; however, they may lack project management and leadership skills to do so. The authors provide a content analysis that compares and contrasts 3 such programs.

Shift work and hospital employees: A descriptive multi-site study.

BACKGROUND: Hospitals staff with 12-hour and other shift work patterns to account for daily and seasonal workload requirements. Research in healthcare and industries requiring shift work suggests there may be negative health consequences to the workers related to fatigue and other factors. Due to the 24/7 nature of healthcare, it is important to understand the impact of shift work on employees. OBJECTIVES: The objectives of this study were to investigate how shift work impacts satisfaction with time for social and home activities, based on the Social and Domestic Survey, and chronic fatigue. In addition, an exploration of drowsy driving was undertaken. DESIGN AND SETTING: This study was a multi-site, descriptive survey study, conducted in 4 acute care hospitals in one metropolitan area in the central United States. PARTICIPANTS: Participants included healthcare workers in five 24/7 departments: nursing, respiratory therapy, laboratory, radiology and pharmacy. METHODS: Measures included demographics, work characteristics, and scales including the: Social and Domestic Survey, Circadian Type Inventory, and Chronic Fatigue Scale along with data regarding drowsy driving and automobile accidents/near misses. Data were analyzed using descriptive statistics for sample characteristics. An exploratory factor analysis was conducted on the Social and Domestic Survey. Group differences were tested using Mann-Whitney U tests and regression analyses. RESULTS: The sample included 1563 subjects (24% RR). The mean age was 40 years. Nursing comprised 77% of the sample, 88% were female, 85% were in a direct patient care role, 67% worked day shift, and 49% worked 12-hour shifts. Pay was important for working night shift, but home life was important for day shift. Night shift (p<0.001) and 12-hour shift workers (p<0.001) had higher chronic fatigue. However, after controlling for other factors, working night shift remained a significant predictor of chronic fatigue and lower satisfaction with time for daily tasks and family/social life, whereas working 12-hour shifts predicted higher satisfaction with daily tasks and periodic life activities. Thirty-five percent of workers reported altering their driving behavior at least half the time due to drowsy driving and 19% had an automobile accident or near miss due to drowsy driving. CONCLUSIONS: Findings suggest that night and long shifts can have negative effects on fatigue, family, and social life. Drowsy driving and accidents/near misses frequently occur due to drowsy driving. Leaders should continue to study the 24/7 work environment and test measures to improve the safety of shift workers.

Planning and creating a new bi-state nursing workforce center through unique partnerships.

Multiple strategies are needed to address the complex issues related to the nursing shortage. It is not enough to focus on increasing the number of students in the pipeline unless this is met with complimentary work to improve the professional practice environments of nursing staff. In addition, nurse-driven improvement projects that address specific patient and organizational outcomes will elevate the role of nurses from trusted professional to quality agents. The authors describe a partnership that has launched a new type of workforce center with core missions to create work environment improvements and point-of-care change led by staff nurses.

Driving Organizational Change From the Bedside: The AACN Clinical Scene Investigator Academy.

BACKGROUND: Staff nurses are pivotal in leading change related to quality improvement efforts, although many lack skills to steer change from the bedside. The American Association of Critical-Care Nurses (AACN) staff nurse leadership program, Clinical Scene Investigator (CSI) Academy, teaches and empowers staff nurses in leadership skills and change concepts to translate evidence into practice affecting patient outcomes. OBJECTIVES: To describe the curriculum of the AACN CSI Academy that provides staff nurses with the leadership skills required to create unit-based change projects that positively impact patient/family outcomes. METHODS: The curriculum of the Academy included leadership topics, communication, change concepts, quality improvement methods, project management, and data management and analysis. Each team of participants collected project data to show improvements in patient care. The program evaluation used many data sources to assess the program effectiveness, relating to the professional growth of the participant nurses. The participants assessed project patient outcomes, sustainability, and spread. RESULTS: The first cohort of CSI participants included 164 direct care nurses from 42 hospitals in 6 cities. They rated the Academy highly in the program evaluation, and they reported that the Academy contributed to their professional development. The individual hospital quality improvement projects resulted in positive patient and estimated fiscal outcomes that were generally sustained 1 year after the program. CONCLUSION: With the skills, tools, and support obtained from participation in the CSI Academy, staff nurses can make substantial contributions to their organizations in clinical and possibly fiscal outcomes.