Nurses' experience of handoffs on four Canadian medical and surgical units: A shared accountability for knowing and safeguarding the patient.

AIMS: To explore nurses' experience and describe how they manage various contextual factors affecting the nurse-to-nurse handoff at change of shift. DESIGN: Qualitative descriptive study. METHODS: A convenience sample of 51 nurses from four medical and surgical care units at a university-affiliated hospital in Montreal, Canada, participated in one of the 19 focus group interviews from November 2017 to January 2018. Data were analysed through a continuous and iterative process of thematic analysis. RESULTS: Analysis of the data generated a core theme of 'sharing accountability for knowing and safeguarding the patient' that is achieved through actions related to nurses' role in the exchange. Specifically, the outgoing nurse takes actions to ensure continuity of care when letting go, and the incoming nurse takes actions to provide seamless care when taking over. In both roles, nurses navigate each handoff juncture by mutually adjusting, ensuring attentiveness, managing judgements, keeping on track, and venting and debriefing. Handoff is also shaped by contextual conditions related to handoff norms and practices, the nursing environment, individual nurse attributes and patient characteristics. CONCLUSIONS: This study generated a conceptualization of nurses' roles and experience that details the relationship among the elements and conditions that shape nurse-to-nurse handoffs. IMPACT: Nursing handoff involves the communication of patient information and relational behaviours that support the exchange. Although many factors are known to influence handoffs, little was known about nurses' experience of dealing with these at the point of care. This study contributed a comprehensive conceptualization of nursing handoff that could be useful in identifying areas for quality improvement and guiding future educational efforts.

Top priorities for the next decade of nursing health services research.

BACKGROUND: The U.S. health care system faces increasing pressures for reform. The importance of nurses in addressing health care delivery challenges cannot be overstated. PURPOSE: To present a Nursing Health Services Research (NHSR) agenda for the 2020s. METHOD: A meeting of an interdisciplinary group of 38 health services researchers to discuss five key challenges facing health care delivery (behavioral health, primary care, maternal/neonatal outcomes, the aging population, health care spending) and identify the most pressing and feasible research questions for NHSR in the coming decade. FINDINGS: Guided by a list of inputs affecting health care delivery (health information technology, workforce, delivery systems, payment, social determinants of health), meeting participants identified 5 to 6 research questions for each challenge. Also, eight cross-cutting themes illuminating the opportunities and barriers facing NHSR emerged. DISCUSSION: The Agenda can act as a foundation for new NHSR - which is more important than ever - in the 2020s.

Nursing handoffs and clinical judgments regarding patient risk of deterioration: A mixed-methods study.

AIMS AND OBJECTIVES: To explore how change-of-shift handoffs relate to nurses' clinical judgments regarding patient risk of deterioration. BACKGROUND: The transfer of responsibility for patients' care comes with an exchange of information about their condition during change-of-shift handoff. However, it is unclear how this exchange affects nurses' clinical judgments regarding patient risk of deterioration. DESIGN: A sequential explanatory mixed-methods study reported according to the STROBE and COREQ guidelines. METHODS: Over four months, 62 nurses from one surgical and two medical units at a single Canadian hospital recorded their handoffs at change of shift. After each handoff, the two nurses involved each rated the patient's risk of experiencing cardiac arrest or being transferred to an intensive care unit in the next 24 hr separately. The information shared in handoffs was subjected to content analysis; code frequencies were contrasted per nurses' ratings of patient risk to identify characteristics of information that facilitated or hindered nurses' agreement. RESULTS: Out of 444 recorded handoffs, there were 125 in which at least one nurse judged that a patient was at risk of deterioration; nurses agreed in 32 cases (25.6%) and disagreed in 93 (74.4%). These handoffs generally included information on abnormal vital signs, breathing problems, chest pain, alteration of mental status or neurological symptoms. However, the quantity and seriousness of clinical cues, recent transfers from intensive care units, pain without a clear cause, signs of delirium and nurses' knowledge of patient were found to affect nurses' agreement. CONCLUSIONS: Nurses exchanged more information regarding known indicators of deterioration in handoffs when they judged that patients were at risk. Disagreements most often involved incoming nurses rating patient risk as higher. RELEVANCE TO CLINICAL PRACTICE: This study suggests a need to sensitise nurses to the impact of certain cues at report on their colleagues' subsequent clinical judgments. Low levels of agreement between nurses underscore the importance of exchanging impressions regarding the likely evolution of a patient's situation to promote continuity of care.

Quality of Primary Care Provided to Medicare Beneficiaries by Nurse Practitioners and Physicians.

OBJECTIVE: To examine differences in the quality of care provided by primary care nurse practitioners (PCNPs), primary care physicians (PCMDs), or both clinicians. DATA SOURCES: Medicare part A and part B claims during 2012-2013. STUDY DESIGN: Retrospective cohort design using standard risk-adjustment methodologies and propensity score weighting assessing 16 claims-based quality measures grouped into 4 domains of primary care: chronic disease management, preventable hospitalizations, adverse outcomes, and cancer screening. EXTRACTION METHODS: Continuously enrolled aged, disabled, and dual eligible beneficiaries who received at least 25% of their primary care services from a random sample of PCMDs, PCNPs, or both clinicians. PRINCIPAL FINDINGS: Beneficiaries attributed to PCNPs had lower hospital admissions, readmissions, inappropriate emergency department use, and low-value imaging for low back pain. Beneficiaries attributed to PCMDs were more likely than those attributed to PCNPs to receive chronic disease management and cancer screenings. Quality of care for beneficiaries jointly attributed to both clinicians generally scored in the middle of the PCNP and PCMD attributed beneficiaries with the exception of cancer screening. CONCLUSIONS: The quality of primary care varies by clinician type, with different strengths for PCNPs and PCMDs. These comparative advantages should be considered when determining how to organize primary care to Medicare beneficiaries.

Scope of Nursing Practice in a Tertiary Pediatric Setting: Associations With Nurse and Job Characteristics and Job Satisfaction.

PURPOSE: While professional nursing, like other health professions, has a recognized educational base and a legal scope of practice that is remarkably consistent across societies, there are important variations even within the same institution or organization in the extent to which professional nurses engage in the full range of activities for which they are qualified. There has been limited study of enacted (actual) scope of nursing practice (ESOP) or of its impacts on nurse job outcomes, such as job satisfaction. The aim of this study is to measure ESOP, as well as its predictors and impact on job satisfaction, in a specialty university-affiliated tertiary referral center in one of the few remaining jurisdictions outside the United States that continue to educate registered nurses at multiple educational levels. METHODS: This was a correlational cross-sectional design using structural equation modeling. Self-administered questionnaires were completed by 301 registered nurses holding permanent positions in specific clinical areas for 6 months or longer in a pediatric hospital in the province of Quebec, Canada. FINDINGS: ESOP or actual scope of practice was low-on average, nurses applied the range of skills within their theoretical scopes of practice only occasionally or "less than frequently" in their daily work (3.21 out of a possible 6 points). ESOP was strongly related to decision latitude (ß = 0.319; p  = .012), role ambiguity (ß = 0.297; p  = .011), and role overload (ß  =  0.201; p  = .012). The personal characteristics that exerted the greatest direct influence on ESOP were education level (ß  =  0.128; p  = .015) and growth need strength (ß  =  0.151; p  = .008). Results also showed that ESOP exerts a direct positive influence on nurses' job satisfaction (ß  =  0.118; p  = .006). Structural equation modeling analyses revealed a good fit of the data to the hypothesized conceptual model (χ²/df ratio index =  1.68, root mean square error of approximation  =  0.049, confirmatory fit index  =  0.985). CONCLUSIONS: Specific aspects of nurses' jobs are closely related to ESOP. ESOP is limited by certain job and personal characteristics and appears to affect nurses' job satisfaction. CLINICAL RELEVANCE: Results suggest that ESOP might be improved by adjusting nursing job characteristics and practice environments and that expanding ESOP increases nurse job satisfaction and may improve other health system outcomes as well.

Adding unregulated nursing support workers to ward staffing: Exploration of a natural experiment.

AIMS AND OBJECTIVES: To explore the impact of an initiative to add unregulated nursing support workers to wards in acute care hospitals. BACKGROUND: Adding nursing support workers to existing nurse staffing may be one solution to reduce nursing workloads and improve outcomes. However, the effects of this addition on nurse, patient and system outcomes are not well documented. In one state of Australia, a trial deployment of nursing support workers to wards across the public health system provided opportunity for the exploration of their impact in a natural, real-world, environment. DESIGN: Cross-sectional study. METHODS: A sample of five wards where nursing support workers had been added matched to a group of five wards where there were no nursing support workers. Data were collected via patient survey (n = 141) and nurse survey (n = 154). Analysis was comparative with regression models constructed for the different ward types. RESULTS: Nursing leadership, staffing and resources, and nurse experience were linked to outcomes on both ward types. Instability was a significant predictor of reduced quality of care and increased turnover intention on wards where support workers were added. CONCLUSION: Adding nursing support workers to ward staffing did not lead to improvements in patient care. Findings suggest that staffing a nursing ward is a complex activity and that a simple approach to staffing is unlikely to be successful. Future research should explore the process of implementation and the conditions under which this strategy is likely to be successful. RELEVANCE TO CLINICAL PRACTICE: Ward-level factors are key in making appropriate staffing and skill mix choices to limit instability and to consequently avoid negative patient, staff and system outcomes. Consideration of the ward context, alongside effective delegation processes and integration into the care team are imperative when adding nursing support workers.

Effect of transformational leadership on job satisfaction and patient safety outcomes.

BACKGROUND: Improving patient safety within health care organizations requires effective leadership at all levels. PURPOSE: The objective of this study was to investigate the effects of nurse managers' transformational leadership behaviors on job satisfaction and patient safety outcomes. METHODS: A random sample of acute care nurses in Ontario (N = 378) completed the crosssectional survey. Hypothesized model was tested using structural equation modeling. FINDING: The model fit the data acceptably. Transformational leadership had a strong positive influence on workplace empowerment, which in turn increased nurses' job satisfaction and decreased the frequency of adverse patient outcomes. Subsequently, job satisfaction was related to lower adverse events. CONCLUSION: The findings provide support for managers' use of transformational leadership behaviors as a useful strategy in creating workplace conditions that promote better safety outcomes for patients and nurses.

The quality of primary care provided by nurse practitioners to vulnerable Medicare beneficiaries.

BACKGROUND: Studies suggest nurse practitioners are heavily represented among primary care providers for vulnerable Medicare beneficiaries. PURPOSE: The purpose of this study was to compare quality indicators among three groups of vulnerable beneficiaries managed by MDs and nurse practitioners (NPs). METHODS: The methods include retrospective cohort design examining 2012 and 2013 Medicare claims for three beneficiary groups: (a) initially qualified for the program due to disability, (b) dually eligible for Medicare and Medicaid, and (c) both disabled and dually eligible. Validated quality indicators in four domains were analyzed. DISCUSSION: Gaps in outcomes suggest better performance for primary care nurse practitioners (PCNPs) in preventable hospitalizations and adverse outcomes. Outcome gaps suggesting better performance for primary care physicians in chronic disease management were diminished for beneficiaries who were both disabled and dually eligible suggesting improved performance for PCNPs within this subpopulation. CONCLUSION: These findings add new evidence indicating the quality of primary care provided to vulnerable Medicare beneficiaries by PCNPs is generally consistent with clinical guidelines and the less intensive use of costly health care services.

Education and Role Title as Predictors of Enacted (Actual) Scope of Practice in Generalist Nurses in a Pediatric Academic Health Sciences Center.

OBJECTIVE: The aim of this study is to document the enacted (actual) scope of practice (SOP) of nurses in pediatric settings in relation to education level and position. BACKGROUND: Baccalaureate-prepared staff nurses routinely carry out only a fraction of the activities essential for quality of care and patient safety they have been educated for. A direct care nurse clinician role exists for nurses with bachelor's degrees in Quebec, Canada. METHOD: Survey of 301 nurses in a pediatric university hospital in Quebec was conducted. RESULTS: Enacted (actual) SOP for baccalaureate-educated nurses was significantly broader than that of nurses with junior college diplomas and nurse clinicians (baccalaureate-educated) carried out complex activities more frequently. CONCLUSION: The creation of job titling and role descriptions that reflect the upper range of nursing competencies could be an important tool for promoting broadened SOP for baccalaureate nurses.

A protocol to assess the impact of adding nursing support workers to ward staffing.

AIM: To assess the impact of adding nursing support workers to ward staffing. BACKGROUND: Nurses' capacity to provide safe care is compromised by increased workloads and nursing shortages. Use of unregulated workers is an alternative to increasing the number of regulated nurses. The impact of adding nursing support workers on patient, nurse and system outcomes has not been systematically evaluated. DESIGN: A mixed longitudinal and cross-sectional design using administrative data sets and prospective data from a sample of wards. METHODS: Payroll data will identify wards on which unregulated staff work. To assess the impact on nursing-sensitive outcomes, retrospective analysis of morbidity and mortality data of all patients admitted to Western Australia hospitals for over 24 hours across 4 years will be undertaken. For the cross-sectional study, a sample of 20 pairs of matched wards will be selected: 10 with unregulated workers added and 10 where they have not. From this sample the impact on patients will be assessed using the Patient Evaluation of Emotional Care during Hospitalisation survey. The impact on nurses will be assessed by a nurse survey used extensively which includes variables such as job satisfaction and intention to leave. The impact on system outcomes will be explored using work sampling of staff activities and the Practice Environment Scale. Interviews will determine nurses' experience of working with nursing support workers. DISCUSSION: The study aims to provide evidence about the impact of adding nursing support workers to ward staffing for patients, staff and the work environment.

Rationing of nursing care interventions and its association with nurse-reported outcomes in the neonatal intensive care unit: a cross-sectional survey.

BACKGROUND: Evidence internationally suggests that staffing constraints and non-supportive work environments result in the rationing of nursing interventions (that is, limiting or omitting interventions for particular patients), which in turn may influence patient outcomes. In the neonatal intensive care unit (NICU), preliminary studies have found that discharge preparation and infant comfort care are among the most frequently rationed nursing interventions. However, it is unknown if the rationing of discharge preparation is related to lower perceptions of parent and infant readiness for NICU discharge, and if reports of increased rationing of infant comfort care are related to lower levels of perceived neonatal pain control. The purpose of this study was to assess these relationships. METHODS: In late 2014, a cross-sectional survey was mailed to 285 Registered Nurses (RNs) working in one of 7 NICUs in the province of Quebec (Canada). The survey contained validated measures of care rationing, parent and infant readiness for discharge, and pain control, as well as items measuring RNs' characteristics. Multivariate regression was used to examine the association between care rationing, readiness for discharge and pain control, while adjusting for RNs' characteristics and clustering within NICUs. RESULTS: Overall, 125 RNs completed the survey; a 44.0 % response rate. Among the respondents, 28.0 and 40.0 % reported rationing discharge preparation and infant comfort care "often" or "very often", respectively. Additionally, 15.2 % of respondents felt parents and infants were underprepared for NICU discharge, and 54.4 % felt that pain was not well managed on their unit. In multivariate analyses, the rationing of discharge preparation was negatively related to RNs' perceptions of parent and infant readiness for discharge, while reports of rationing of parental support and teaching and infant comfort care were associated with less favourable perceptions of neonatal pain control. CONCLUSIONS: The rationing of nursing interventions appears to influence parent and infant readiness for discharge, as well as pain control in NICUs. Future investigations, in neonatal nursing care as well as in other nursing specialties, should address objectively measured patient outcomes (such as objective pain assessments and post-discharge outcomes assessed through administrative data).

Optimizing full scope of practice for nurse practitioners in primary care: A proposed conceptual model.

BACKGROUND: Nurse practitioners (NPs), if utilized to their optimal potential, could play a key role in meeting the growing demand for primary care. PURPOSE: The purpose of this study was to propose a comprehensive model for maximizing NP contributions to primary care which includes the factors affecting NP care and patient outcomes and explains their interrelated impact. METHOD: We synthesized the results of the published literature to develop a model, which emphasizes NP scope of practice regulations, institutional policies, NP practice environment, and NP workforce outcomes as determinants of NP care and patient outcomes. DISCUSSION: Our model provides a framework to help explain how variations in scope of practice regulations at the state-level and institutional policies within organizations directly and indirectly influence the practice environment of NPs, NP workforce outcomes, and patient care and outcomes. CONCLUSION: Aligning policy change, organizational innovations, and future research are critical to NP optimal utilization and patient care and outcomes.

Risk Factors and Best Practices for the Prevention of Post-Cardiac Surgery Surgical Site Infections in a Tertiary Care Centre.

BACKGROUND: Post-cardiac surgery surgical site infections (SSIs) pose devastating consequences in terms of morbidity and mortality to patients. OBJECTIVE: To examine current risk factors and best practice perioperative care for prevention of SSI following cardiac surgery through the lens of the demographic/clinical characteristics of patients who developed post-cardiac surgery SSIs at a major tertiary care institution, and to identify where documentation is lacking and could be improved to better serve clinical practice. METHODS: A literature review on post-cardiac surgery SSI prevention and risk factors was performed. These risk factors were examined through a retrospective chart review of the population of patients who developed SSIs during the study period. RESULTS: The study population was characterized by a high prevalence of riskfactors including age, diabetes, obesity, operative time, blood glucose control, surgical re-exploration, blood transfusions, and emergency context, as well as differences from best practice guidelines such as preoperative showering. Compared to other populations in the literature, several ofthese risk factors were more prevalent at the study site than in the other comparable populations. CONCLUSION: The patient population had a relatively high prevalence of riskfactors, and the care received by these patients varied in some ways from best practices. Using best practice guidelines, known risk factors, and the data specific to the institution can provide insightsfor analysis and practice improvement efforts in the form of identifying at-risk patients, improving adherence to best practice guidelines, targeting areas to focus care efforts, and improving clincal documentation.

Live attenuated simian immunodeficiency virus vaccination confers superinfection resistance against macrophage-tropic and neurovirulent wild-type SIV challenge.

Vaccination with live attenuated simian immunodeficiency virus (SIV) in non-human primate species provides a means of characterizing the protective processes of retroviral superinfection and may lead to novel advances of human immunodeficiency virus (HIV)/AIDS vaccine design. The minimally attenuated SIVmacC8 vaccine has been demonstrated to elicit early potent protection against pathogenic rechallenge with genetically diverse viral isolates in cynomolgus macaques (Macaca fascicularis). In this study, we have characterized further the biological breadth of this vaccine protection by assessing the ability of both the nef-disrupted SIVmacC8 and its nef-intact counterpart SIVmacJ5 viruses to prevent superinfection with the macrophage/neurotropic SIVmac239/17E-Fr (SIVmac17E-Fr) isolate. Inoculation with either SIVmacC8 or SIVmacJ5 and subsequent detailed characterization of the viral replication kinetics revealed a wide range of virus-host outcomes. Both nef-disrupted and nef-intact immunizing viruses were able to prevent establishment of SIVmac17E-Fr in peripheral blood and secondary lymphoid tissues. Differences in virus kinetics, indicative of an active process, identified uncontrolled replication in one macaque which although able to prevent SIVmac17E-Fr superinfection led to extensive neuropathological complications. The ability to prevent a biologically heterologous, CD4-independent/CCR5+ viral isolate and the macrophage-tropic SIVmac316 strain from establishing infection supports the hypothesis that direct target cell blocking is unlikely to be a central feature of live lentivirus vaccination. These data provide further evidence to demonstrate that inoculation of a live retroviral vaccine can deliver broad spectrum protection against both macrophage-tropic as well as lymphocytotropic viruses. These data add to our knowledge of live attenuated SIV vaccines but further highlight potential safety concerns of vaccinating with a live retrovirus.