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.

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.

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.

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.

Pain and Anxiety in Rural Acute Coronary Syndrome Patients Awaiting Diagnostic Cardiac Catheterization.

CONTEXT: In rural areas of Canada, people with acute coronary syndromes (ACS) can wait up to 32 hours for transfer for diagnostic cardiac catheterization (CATH). While awaiting CATH, it is critical that pain and anxiety management be optimal to preserve myocardial muscle and minimize the risk of further deterioration. OBJECTIVES: The aim of this study was to examine the relationship between clinical management, cardiac pain intensity, and state anxiety for rural ACS patients awaiting diagnostic CATH. METHODS: In a prospective, descriptive-correlational repeated-measures design involving 121 ACS rural patients, we examined the associations of analgesic and nitroglycerin administration with cardiac pain intensity (numeric rating scale) and state anxiety (Spielberger State Anxiety Inventory) and also nurses' pain knowledge and attitudes (Toronto Pain Management Inventory-ACS Version and Knowledge and Attitudes Survey Regarding Pain) using linear mixed models. RESULTS: The mean age of patients was 67.6 ± 13, 50% were men, and 60% had unstable angina and the remainder had non-ST-elevated myocardial infarction. During follow-up, cardiac pain intensity scores remained in the mild range from 1.1 ± 2.2 to 2.4 ± 2.7. State anxiety ranged from 44.0 ± 7.2 to 46.2 ± 6.6. Cumulative analgesic dose was associated with a reduction in cardiac pain by 1.0 points (numeric rating scale, 0-10) (t108 = -2.5; SE, -0.25; confidence interval, -0.45 to -0.06; P = .013). Analgesic administration was not associated with state anxiety. Over the course of follow-up, ACS patients reported consistently high anxiety scores. CONCLUSIONS: Whereas cardiac pain declines in most patients in the early hours after admission, many patients experience a persistent anxious state up to 8 hours later, which suggest that development and testing of protocols for anxiety reduction may be needed. More urgently, the development and examination of a treatment intervention, early on in the ACS trajectory, are warranted that targets pain and anxiety for those for whom immediate angioplasty is not possible and who continue to experience cardiac pain and persistent high levels of anxiety. Moreover, a larger prognostic study is required to determine whether high levels of anxiety in rural ACS patients are predictive of major adverse cardiac events.

Patients in the radiology department may be at increased risk of developing critical instability.

The purpose of this study was to calculate the event rate for in-patients in the Radiology Department (RD) developing instability leading to calls for Medical Emergency Team assistance (MET-RD) compared to general ward (MET-W) patients. A retrospective comparison was done of MET-RD and MET-W calls in 2009 in a U.S. tertiary hospital with a well-established MET system. MET-RD and MET-W event rates represented as MET calls/hour/1000 admissions, adjusted for length of stay (LOS); rates also calculated for RD modalities. There were 31,320 hospital ward admissions had 1,230 MET-W, and among 149,569 radiology admissions there were 56 MET-RD. When adjusted for LOS, the MET-RD event rate was 2 times higher than the MET-W rate (0.48 vs. 0.24 events/hour/1000 admissions). Event rates differed by procedure: computed tomography (CT) had 38% of MET-RDs (event rate 0.89); magnetic resonance imaging (MRI) accounted for 27% (event rate 1.56). Nuclear medicine had 1% of RD admissions but these patients accounted for 5% of MET-RD (event rate 1.53). Interventional radiology (IR) had 6% of RD admissions but 16% of MET-RD (event rate 0.61). While general x-ray comprised 63% of RD admissions, only 11% of MET-RD involved their care (event rate 0.09). In conclusion, the overall MET-RD event rate was twice the MET-W event rate; CT, MRI and IR rates were 3.7-6.5 times higher than on wards. RD patients are at increased risk for a MET call compared to ward patients when the time at risk is considered. Increased surveillance of RD patients is warranted.

Organizational climate and hospital nurses' caring practices: a mixed-methods study.

Organizational climate in healthcare settings influences patient outcomes, but its effect on nursing care delivery remains poorly understood. In this mixed-methods study, nurse surveys (N = 292) were combined with a qualitative case study of 15 direct-care registered nurses (RNs), nursing personnel, and managers. Organizational climate explained 11% of the variation in RNs' reported frequency of caring practices. Qualitative data suggested that caring practices were affected by the interplay of organizational climate dimensions with patients and nurses characteristics. Workload intensity and role ambiguity led RNs to leave many caring practices to practical nurses and assistive personnel. Systemic interventions are needed to improve organizational climate and to support RNs' involvement in a full range of caring practices.

Acute Coronary Syndrome Pain and Anxiety in a Rural Emergency Department: Patient and Nurse Perspectives.

Rural patients can wait up to 32 hours for transfer to cardiac catheterization (CATH) for events related to acute coronary syndrome (ACS). Pain arising from myocardial ischemia can be severe and anxiety-provoking. Pain management during this time should be optimized in order to preserve vulnerable myocardial muscle. This qualitative focus group study solicited the perspectives of ACS patients and emergency staff nurses on the rural patient experience of cardiac pain and anxiety and priorities and barriers to optimal assessment and management of ACS pain. Patients described ACS pain as moderate to severe, with pain in the chest, arms, back, shoulders, and jaw. Pain was well assessed and managed upon arrival in the emergency department but anxiety was not routinely assessed or treated. Barriers identified were poor management of patients with different acuity levels, high patient volumes, and assumptions regarding patients' communication about pain. Research related to ACS pain and anxiety management in the rural context is recommended.

Les patients atteints d'un syndrome coronarien aigu (SCA) en milieu rural peuvent attendre jusqu'à 32 heures avant d'être transférés pour un cathétérisme cardiaque (CATH). La douleur associée à une ischémie myocardique peut être aiguë et provoquer de l'anxiété. La gestion de cette douleur devrait être optimisée afin de protéger le muscle myocardique, qui est en situation de vulnérabilité. Cette étude qualitative menée auprès d'un groupe cible visait à solliciter le point de vue de patients atteints d'un SCA et du personnel infirmier d'un service d'urgence en milieu rural concernant l'anxiété et la douleur cardiaque ressenties par les patients et concernant les priorités à adopter et les obstacles à surmonter pour une évaluation et une gestion optimales de la douleur liée à un SCA. Les patients ont décrit la douleur liée à un SAC comme étant légère ou aiguë et ont indiqué qu'elle se situait dans la poitrine, les bras, le dos, les épaules et les mâchoires. Selon les participants à l'étude, la douleur est évaluée et gérée adéquatement au moment de l'arrivée des patients au service d'urgence, mais l'anxiété, quant à elle, n'est pas évaluée ou traitée de façon systématique. Les obstacles mentionnés sont une mauvaise gestion des patients présentant des degrés de gravité différents, un volume important de patients et une tendance du personnel soignant à entretenir des a priori relativement à la communication par les patients de leur douleur. L'étude recommande que des recherches soient menées sur la gestion de la douleur et de l'anxiété liées au SCA en milieu rural.

Excellence and evidence in staffing: a data-driven model for excellence in staffing (2nd edition).

The Patient Protection and Affordable Care Act (PPACA, 2010) and the Institute of Medicine's (IOM, 2011) Future of Nursing report have prompted changes in the U.S. health care system. This has also stimulated a new direction of thinking for the profession of nursing. New payment and priority structures, where value is placed ahead of volume in care, will start to define our health system in new and unknown ways for years. One thing we all know for sure: we cannot afford the same inefficient models and systems of care of yesterday any longer. The Data-Driven Model for Excellence in Staffing was created as the organizing framework to lead the development of best practices for nurse staffing across the continuum through research and innovation. Regardless of the setting, nurses must integrate multiple concepts with the value of professional nursing to create new care and staffing models. Traditional models demonstrate that nurses are a commodity. If the profession is to make any significant changes in nurse staffing, it is through the articulation of the value of our professional practice within the overall health care environment. This position paper is organized around the concepts from the Data-Driven Model for Excellence in Staffing. The main concepts are: Core Concept 1: Users and Patients of Health Care, Core Concept 2: Providers of Health Care, Core Concept 3: Environment of Care, Core Concept 4: Delivery of Care, Core Concept 5: Quality, Safety, and Outcomes of Care. This position paper provides a comprehensive view of those concepts and components, why those concepts and components are important in this new era of nurse staffing, and a 3-year challenge that will push the nursing profession forward in all settings across the care continuum. There are decades of research supporting various changes to nurse staffing. Yet little has been done to move that research into practice and operations. While the primary goal of this position paper is to generate research and innovative thinking about nurse staffing across all health care settings, a second goal is to stimulate additional publications. This includes a goal of at least 20 articles in Nursing Economic$ on best practices in staffing and care models from across the continuum over the next 3 years.

In-hospital mortality after serious adverse events on medical and surgical nursing units: a mixed methods study.

AIMS AND OBJECTIVES: To investigate the circumstances of nursing care eight hours before serious adverse events (=SAE's) on medical and surgical nursing units with subsequent in-hospital mortality in order to identify the extent to which these SAE's were potentially preventable. BACKGROUND: The prevention of SAE 's in acute care is coming under increasing scrutiny, while the role nursing care plays in the prevention of acute critical deterioration of patients is unclear. METHODS: Retrospective review of patient records of 63 SAE's in a Belgian teaching hospital where death was the final outcome following a cardiac arrest team call or unplanned ICU admission from an acute care unit. Data from chart reviews were combined with data regarding working conditions on the nursing unit at the time of the events and experts' opinions regarding the preventability of the outcomes. Finally, a pilot survey of staff nurses about their experiences with deteriorating patients and knowledge of vital signs and call criteria was conducted independently of the chart abstractions and case reviews. RESULTS: Experts were almost five times more likely to designate a case as potentially preventable when a cardiac arrest team call was the terminal event and were 40% less likely to designate a case as potentially preventable when more observations were documented in patient records. Survey results revealed that nurses were often unaware that their patients were deteriorating before the crisis. Nurses also reported threshold levels for concern for abnormal vital signs that suggested they would call for assistance relatively late in clinical crises. CONCLUSION: Renewed attention to accurate recording, documentation and interpretation of vital signs in hospital nursing practice appears needed. RELEVANCE TO CLINICAL PRACTICE: Timely detection of deteriorating patients to assist staff to improve their outcomes appears to be jeopardised by a number of practices and factors and merits deeper study.

Practice-academia collaboration in nursing: contexts and future directions.

At a time of profound challenges in health care delivery and professional education characterized by imperatives to improve quality, responsiveness to client needs and efficient use of existing resources, the relationship between nursing education and service is in deep need of reinforcement and rethinking. Important directions for the future include attending to the complementary roles of academia and service in ensuring patient- and family-centered care, building reciprocity in the relationship between clinical agencies and universities, clarifying the intersecting roles of clinical agencies in the generation of various types of research and scholarship, engaging nurses and trainees at all roles within the profession in local- and higher-level health policy, and reinventing joint roles between service and academia.

Associations between rationing of nursing care and inpatient mortality in Swiss hospitals.

OBJECTIVE: To explore the relationship between inpatient mortality and implicit rationing of nursing care, the quality of nurse work environments and the patient-to-nurse staffing ratio in Swiss acute care hospitals. DESIGN: Cross-sectional correlational design. SETTING: Eight Swiss acute care hospitals examined in a survey-based study and 71 comparison institutions. PARTICIPANTS: A total of 165 862 discharge abstracts from patients treated in the 8 RICH Nursing Study (the Rationing of Nursing Care in Switzerland Study) hospitals and 760 608 discharge abstracts from patients treated in 71 Swiss acute care hospitals offering similar services and maintaining comparable patient volumes to the RICH Nursing hospitals. MAIN OUTCOME MEASURES: The dependent variable was inpatient mortality. Logistic regression models were used to estimate the effects of the independent hospital-level measures. RESULTS: Patients treated in the hospital with the highest rationing level were 51% more likely to die than those in peer institutions (adjusted OR: 1.51, 95% CI: 1.34-1.70). Patients treated in the study hospitals with higher nurse work environment quality ratings had a significantly lower likelihood of death (adjusted OR: 0.80, 95% CI: 0.67-0.97) and those treated in the hospital with the highest measured patient-to-nurse ratio (10:1) had a 37% higher risk of death (adjusted OR: 1.37, 95% CI: 1.24-1.52) than those in comparison institutions. CONCLUSIONS: Measures of rationing may reflect care conditions that place hospital patients at risk of negative outcomes and thus deserve attention in future hospital outcomes research studies.

Spanish nurses' attitudes towards research and perceived barriers and facilitators of research utilisation: a comparative survey of nurses with and without experience as principal investigators.

AIMS AND OBJECTIVE: To examine attitudes towards research and perceived barriers and facilitators of research utilisation in clinical practice in a broad cross-section of Spanish nurses. BACKGROUND: Nurses' attitudes towards research are critical in determining whether study findings are used to improve practice. DESIGN: Cross-sectional comparative survey in Hospitals, Primary Care Centres and University-affiliated schools of nursing. METHODS: Surveys were completed by 917 nurses: 69 who received funding from the Spanish national agency (1998-2004) and a nationally representative sample of 848 nurses who did not have the same research experience (the Comparison group). Two instruments (BARRIERS and Attitudes towards nursing research) were translated and culturally adapted for use in Spain. A descriptive analysis of demographic and practice characteristics was performed. Total scale scores, as well as subscale scores, were computed and compared across the two groups using one-way analysis of variance (anova) and multivariate analysis of variance (manova) with post hoc tests. Pearson product-moment correlation coefficients were computed between the total tool scores and subscales measuring barriers and attitudes in both groups. RESULTS: The investigators differed from other nurses on several demographic and work characteristics (more males, older age and more likely to work a fixed day shift schedule). On the whole, investigators showed more favourable attitudes but perceived several elements as posing greater barriers to research utilisation than the Comparison groups. Across all respondents, issues related to the quality of research were rated as the greatest barriers to research utilisation, followed by organisational barriers, barriers involving the communication of findings and finally, those related to nurses' values, awareness and skills. CONCLUSIONS: Very similar profiles of perceptions and attitudes regarding research were found in these samples of Spanish nurses relative to those from other countries in earlier reports. Nurses who had experience conducting research demonstrated more favourable research-related attitudes and perceived barriers differently than those without such experience. RELEVANCE TO CLINICAL PRACTICE: Understanding different organisational and experience perspectives is important to identify challenges and opportunities to ensure research utilisation in clinical practice.

Nurses' work environments, care rationing, job outcomes, and quality of care on neonatal units.

AIM: This paper is a report of a study of the relationship between work environment characteristics and neonatal intensive care unit nurses' perceptions of care rationing, job outcomes, and quality of care. BACKGROUND: International evidence suggests that attention to work environments might improve nurse recruitment and retention, and the quality of care. However, comparatively little attention has been given to neonatal care, a specialty where patient and nurse outcomes are potentially quite sensitive to problems with staffing and work environments. METHODS: Over a 6-month period in 2007-2008, a questionnaire containing measures of work environment characteristics, nursing care rationing, job satisfaction, burnout and quality of care was distributed to 553 nurses in all neonatal intensive care units in the province of Quebec (Canada). RESULTS: A total of 339 nurses (61.3%) completed questionnaires. Overall, 18.6% were dissatisfied with their job, 35.7% showed high emotional exhaustion, and 19.2% rated the quality of care on their unit as fair or poor. Care activities most frequently rationed because of insufficient time were discharge planning, parental support and teaching, and comfort care. In multivariate analyses, higher work environment ratings were related to lower likelihood of reporting rationing and burnout, and better ratings of quality of care and job satisfaction. CONCLUSION: Additional research on the determinants of nurse outcomes, the quality of patient care, and the impact of rationing of nursing care on patient outcomes in neonatal intensive care units is required. The Neonatal Extent of Work Rationing Instrument appears to be a useful tool for monitoring the extent of rationing of nursing care in neonatal units.

Nurse burnout and quality of care: cross-national investigation in six countries.

We explored the relationship between nurse burnout and ratings of quality of care in 53,846 nurses from six countries. In this secondary analysis, we used data from the International Hospital Outcomes Study; data were collected from 1998 to 2005. The Maslach Burnout Inventory and a single-item reflecting nurse-rated quality of care were used in multiple logistic regression modeling to investigate the association between nurse burnout and nurse-rated quality of care. Across countries, higher levels of burnout were associated with lower ratings of the quality of care independent of nurses' ratings of practice environments. These findings suggest that reducing nurse burnout may be an effective strategy for improving nurse-rated quality of care in hospitals.

Delirium in older cardiac surgery patients: directions for practice.

Delirium affects approximately 20% to 25% of patients undergoing cardiac surgery and is particularly common in older adults. This article reviews the etiology and risk factors for delirium associated with cardiac surgery in older adults. Delirium screening, prevention, and treatment strategies, including both pharmacological and nonpharmacological therapies, are presented. Interventions appropriate in both the intensive care unit and