Zero Harm During Transition in Care From the Emergency Department to Medical/Surgical Units.

BACKGROUND: Health care-related errors are the third leading cause of death in the United States. When evidence-based processes are applied, harm related to health care errors can reach zero. PURPOSE: The purpose was to achieve zero preventable harm to patients during transitions in care from the emergency department (ED) to medical/surgical (Med/Surg) areas. METHODS: A performance improvement process was used to drive the evidence-based design to eliminate harm in transitions from the ED to Med/Surg units. Once initial design was complete, small tests of change were deployed until zero harm was achieved. RESULTS: Zero harm during transitions from the ED to Med/Surg areas was achieved. The use of formal performance improvement systems, tools, and evidence-based practices allows organizations to achieve and sustain zero harm during these transitions in care. CONCLUSION: This transitions project met multiple objectives. In addition, throughput efficiencies were realized.

A comparative analysis of work-family conflict among staff, managerial, and executive nurses.

BACKGROUND: Nurses frequently are caught between the demands of work and family. While studies have explored this issue among staff nurses, none have compared nurse leaders to staff nurses. This study compares work-family conflict (WFC) and family-work conflict (FWC) among staff, managerial, and executive nurses. METHODS: In this survey design, 20% of registered nurses were randomly sampled across Florida with a 9% response rate. Survey questions included personal, professional, and work environment characteristics and perceptions of WFC/FWC. Analyses of variance tested the differences between- and within-group scores for WFC/FWC for staff, managerial, and executive nurses. Ordinary Least Squares regressions tested the relationships between personal, professional and work environment measures, focusing on the three different nursing roles, and WFC/FWC scores. FINDINGS: Nurses experienced more WFC than FWC. Staff nurses experienced significantly less WFC than nurse managers and nurse executives (analysis of variance mean difference -0.881 and -2.693, respectively). Nonwhite nurses experienced more WFC and FWC than white nurses. Longer shift length predicted greater WFC. FWC was lower with paid leave for childbirth. DISCUSSION: Higher WFC among nurse managers and executives may discourage nurses from taking on or staying in leadership roles. Efforts must be taken to decrease WFC/FWC among nurses in these roles.

The Incidence of Workplace Bullying and Related Environmental Factors Among Nurse Managers.

OBJECTIVE: The purpose of the study was to explore relationships between authentic leadership style, global social power, job demand, job control, and workplace bullying of nurse managers in acute care settings across the United States. BACKGROUND: Consequences of workplace bullying are linked to intent to leave, turnover, and harmful emotional and physical effects. METHODS: An explorative, descriptive, cross-sectional design using an online survey was utilized. RESULTS: Thirty-five percent of nurse managers reported being a target of workplace bullying with severity levels ranging from occasional to severe. Executive nurse leaders were identified as the primary perpetrator with the downward direction recognized as most prominent. CONCLUSIONS: Nurse managers are recipients of workplace bullying emanating from executive nurse leaders, clinical nurses, and their nurse manager peers.

Leading in the Healthcare Vortex.

The 2016 International Nursing Administration Research Conference, Leading in a Healthcare Vortex, was held in Orlando, Florida. The program drew 116 attendees with representation from Canada and Brazil. Participants from practice, education, and research discussed leadership in our turbulent healthcare climate, which are highlighted in this column. The conference was dedicated to the memory of Dr Heather S. Laschinger in recognition of her distinguished research legacy of empowering nursing work environments and mentorship of prominent nursing administration researchers.

Incivility, retention and new graduate nurses: an integrated review of the literature.

AIM: To evaluate the influence of incivility on the new graduate nurse transition experience. BACKGROUND: Incivility in the work environment is a major source of dissatisfaction and new graduate nurses are especially vulnerable. Incivility contributes to the high levels of turnover associated within the first 2 years of new graduate nurse employment. EVALUATION: An integrated review of the literature was conducted using MEDLINE-EBSCOhost, PsycInfo and CINAHL databases. Relevant articles were reviewed for appropriateness related to inclusion/exclusion criteria and for quality using established criteria. Sixteen studies were included in the final analysis. KEY ISSUES: Themes that emerged included workplace incivility, nurse residency programmes, mentoring through preceptors and empowerment/work environment. Findings indicated that incivility in the workplace was a significant predictor of low job satisfaction in new graduate nurses transitioning into practice. CONCLUSIONS: While graduate nurse transition programmes are associated with improved satisfaction and retention, they appear to address incivility by acculturating new graduate nurses to the experience of incivility. There is little evidence that the culture of incivility has been addressed. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers have the responsibility to be aware of the prevalence of incivility, assess for its occurrence, and implement strategies which eliminate workplace incivility and tolerance for uncivil behaviours.

Expectations of millennial nurse graduates transitioning into practice.

AIMS: Identified as Millennials, nurses born after 1980 are anticipated to redefine the employer-employee relationship as one based on the employee's wants and needs. The purpose of this study is to portray the expectations of Millennial student nurses immediately before graduation. Understanding these expectations may provide insight for leaders who are responsible for crafting a successful transition experience. Successful transition and decreased turnover are important elements of cost management for the nursing enterprise. METHODS/SUBJECTS: A qualitative descriptive design was used to collect data from 14 students enrolled in a traditional BSN academic nursing program approximately 2 months prior to graduation. Upon completion of private, confidential semistructured interviews, data were transcribed, coded, and analyzed. Demographic data were compiled and interview data summarized according to identified themes. RESULTS/CONCLUSIONS: Three overarching themes emerged: the expectation that transition would be stressful, the expectation that there would be a safety net of support, and the expectation to be valued and respected as a professional. Revealing was the expectation of supportive relationships and a collaborative approach to patient care. Failure to meet those expectations may result in turnover as Millennials seek opportunities that meet their expectations.

Nurses' self-concept and perceived quality of care: a narrative analysis.

The perceptions of staff nurses on factors affecting patient care quality and safety have received little attention in the literature. Narrative analysis of comments provided by 106 staff nurses working in a medical-surgical setting revealed that nurses experienced contradictions and unmet expectations related to their professional role. The consequence was feelings of powerlessness, isolation, and low self-esteem, which affected nurses' perceived ability to provide quality patient care and ensure patient safety. This perceived inability to act in a professionally autonomous manner on behalf of patients, in turn, influenced nurses' professional self-concept. Recommendations are offered to enhance nurses' professional self-concept through staff development and policy changes.

Factor Structure of the Denyes Self Care Practice Instrument (DSCPI-90).

This study evaluates the factor structure and concurrent validity of a measure of self-care, the Denyes Self Care Practice Instrument (DSCPI-90), when used with adults. Three hundred eight participants complete the 18-item DSCPI-90 and a measure of general health status. Data are examined using descriptive statistics, exploratory factor analysis, and correlation. An efficient 12-item, two-factor model is identified. Reducing the number of items from 18 to 12 does not have an untoward effect on either scale reliability or the amount of variance explained. Correlations with a measure of health status are modest, lending validity to the construct of self-care as being distinct from, yet related to, health status. It is concluded that the 12-item version of the DSCPI is reliable and valid when used with adults.

The importance of mental health to the experience of job strain: an evidence-guided approach to improve retention.

AIMS: The purpose of this study was to evaluate the causal relationships between job strain, the practice environment and the use of coping skills in order to assist in the prediction of nurses who are at risk for voluntary turnover and identify potential intervention strategies. BACKGROUND: Analysis of the US nurse workforce indicates that it will be necessary to identify new strategies that will promote a healthy workforce and retain nurses in the workplace. METHODS: Exploratory cross-sectional survey of 1235 staff nurses resulted in 308 usable surveys (25%). Data were analysed using multivariate statistical techniques (SEM). RESULTS: It was determined that diminished mental health status as a component of job strain was predictive of propensity to leave as was a diminished assessment of the professional practice environment. Mental health was favourably influenced by coping behaviour. CONCLUSIONS: Evidence-based strategies which support mental health and reinforce the positive role of coping as a mediating factor may aid in nurse retention efforts. IMPLICATIONS FOR NURSING MANAGEMENT: This study expands the literature by offering a theoretically supported model to evaluate the response of individuals to the experience of job strain in the work environment. The model demonstrated that the health consequences of job strain are modified through the use of active coping behaviour, and that those nurses with elevated self-assessed health had a lower propensity to leave. As active coping may be taught, the model suggests a means to identify those at risk and support manager intervention.

Teach-Back Method: Using a Nursing Education Intervention to Improve Discharge Instructions on an Adult Oncology Unit.

BACKGROUND: Transitions from acute clinical care to the outpatient setting can be daunting. Clear explanations of discharge instructions from nurses and assessment of the patient's understanding can have a positive impact. OBJECTIVES: The purpose of this study was to assess the effect of an education intervention on nurses' use of the teach-back method, as well as the effects on patient satisfaction at discharge. METHODS: The setting was a 20-bed adult oncology unit. Nurses' understanding of the teach-back method pre- and posteducation intervention was assessed using the Conviction and Confidence Scale. The effect of the intervention on patient satisfaction was assessed using the Press Ganey survey three months before and after teach-back education. FINDINGS: The results of this study indicated that nurses were more confident in their ability to use the teach-back method and integrated many teach-back competencies into clinical practice. Although few follow-up surveys were received, longer-term data indicated continued improvement in patient satisfaction and understanding of discharge instructions.

Can proactive rapid response team rounding improve surveillance and reduce unplanned escalations in care? A controlled before and after study.

BACKGROUND: Unplanned escalations manifest as a breakdown of hospital care attributable to clinician error through missed or delayed identification of physiological instability, ineffective treatment, or iatrogenic harm. OBJECTIVES: To examine the impact of an Early Warning Score-based proactive rapid response team model on the frequency of unplanned intra-hospital escalations in care compared with a rapid response team model based on staff nurse identification of vital sign derangements. DESIGN: Pre- and post Early Warning Score-guided proactive rapid response team model intervention. SETTING: 237-bed community hospital in the southeastern United States. PARTICIPANTS: All hospitalized adults (n = 12,148) during a pre- and post-intervention period. METHODS: Logistic regressions used to examine the relationship between unplanned ICU transfers and rapid response team models (rapid response team vs. Early Warning Score-guided proactive rapid response team). RESULTS: Unplanned ICU transfers were 1.4 times more likely to occur during the rapid response team baseline period (OR = 1.392, 95% CI [1.017-1.905]) compared with the Early Warning Score-guided proactive rapid response team intervention period. CONCLUSIONS: This study reports a difference in the frequency of unplanned escalations using different rapid response models, with fewer unplanned ICU transfers occurring during the use of Early Warning Score-guided proactive rapid response team model while accounting for differences in admission volumes, age, gender and comorbidities. Implementation of this model has implications for patient outcomes, hospital operations and costs.

The Nurse Reinvestment Act: the impact of governmental and nongovernmental administrative tools.

The Nurse Reinvestment Act has ushered in a new wave of federal involvement intended to address the issue of the critical nursing shortage. To implement this act, administrators will rely on a series of governance tools often called upon to address issues related to the social welfare of the country. Included among these tools are grants and loans through which the intent of the legislation will be formalized. The purpose of this analysis is to provide an overview of the characteristics associated with these tools, specifically as they relate to nursing education. Consideration will be given to the political environment through which funding, and thus the ability to implement the Nurse Reinvestment Act, will be realized, and the potential obstacles when executing federal programs in a market-driven economy.

Lessons from the past: Confronting past discriminatory practices to alleviate the nursing shortage through increased professional diversity.

A critical shortage of nurses has focused attention on the current demographics of practicing nurses. Data from the most recent analysis of the nursing workforce reveals that only 4.9 percent of practicing nurses are African American as compared with 12.1 percent of the general population. This disparity of representation has implications as resources are established from which the future workforce might be drawn. Efforts to achieve parity require recognition of the lingering effects of past social injustice and determination of strategies to overcome current barriers in education and practice. Strategies designed to encourage an increase in ethnic participation include efforts directed to recruitment, retention, graduation, and practice.

Fostering ethical competency: an ongoing staff development process that encourages professional growth and staff satisfaction.

The subject of ethics is integral to the modern practice of nursing. Research suggests that successful application of ethical decision-making skills is also integral to nurse satisfaction and, subsequently, nurse retention. The nurse manager is key to the development of those ethical decision-making skills. An increased appreciation of the process by which those skills are attained will assist the nurse manager in developing these skills in staff and thereby improve staff retention.

The influence of staff nurse perception of leadership style on satisfaction with leadership: a cross-sectional survey of pediatric nurses.

BACKGROUND: There is evidence that transformational leadership style promotes nursing excellence. Differences in how supervisees and supervisors perceive the supervisor's leadership style may also be related to satisfaction with leadership. Research demonstrates that satisfaction with leadership is a critical element in the retention of nurses. OBJECTIVE: To evaluate staff nurse and nurse leader perceptions of leadership style. METHODS: 16 supervisors and 179 supervisees completed the Multifactor Leadership Questionnaire and a demographic survey. Data were analyzed using parametric statistical techniques. RESULTS: Although staff perceived leaders as employing largely transformative leadership strategies, differences existed in leader-staff congruence in interpretation of leadership style and as related to the role of the leader. CONCLUSIONS: Differences in interpretation of leadership style between supervisors and supervisees were associated with diminished satisfaction with leadership. In addition, those serving in a direct operational role (assistant nurse manager) were viewed as less transformative than leaders who maintained broader administrative responsibilities.

Using a structured review of the literature to identify key factors associated with the current nursing shortage.

The current population of nurses is aging and rapidly approaching retirement, and graduation of new nurses is not expected to meet demand. Multiple reports have offered information regarding the pending shortage and made recommendations regarding interventions. It is important that suggested interventions be based upon current evidence. An integrated review of literature was undertaken, searching CINAHL, PubMed, Academic Search Premier, Medline, and PsychInfo. Studies were limited to those conducted in the United States and published in English between 2000 and 2007. Search terms were nursing shortage, job satisfaction in nursing, stress in nursing, nursing turnover, nursing image, nursing work environment, physical demands of nursing, and nursing faculty shortage. The identified reasons for nurses leaving hospital practice were management issues, job design, job stress, physical demands, and the failure to nurture new nurses. The education issues include a lack of qualified faculty and clinical sites to allow for more students to be accepted into the programs. These are issues that can be addressed; and changes, implemented. Steps must be taken immediately to resolve these issues in an effort to keep an adequate supply of nurses at the bedside.

The nurse manager: job satisfaction, the nursing shortage and retention.

A critical shortage of registered nurses exists in the United States and this shortage is expected to worsen. It is predicted that unless this issue is resolved, the demand for nursing services will exceed the supply by nearly 30% in 2020. Extensive analysis of this pending crisis has resulted in numerous recommendations to improve both recruitment and retention. The purpose of this article is to clearly outline the issues contributing to this problem, and to provide the nurse manager with information regarding specific influences on job satisfaction as it relates to job turnover and employee retention. To accomplish this, an analysis of the literature using both national and international sources is used to formulate the lessons learned as well as strategies and future courses of action designed to address this shortage.

Laryngopharyngeal dysfunction after the Norwood procedure.

OBJECTIVE: We sought to evaluate the incidence and significance of recurrent laryngeal nerve and swallowing dysfunction after a Norwood procedure compared with that after biventricular aortic arch reconstruction. METHODS: From April 2003 through December 2004, 36 neonates underwent a Norwood procedure; 33 of 36 had postoperative fiberoptic laryngoscopy and modified barium swallow. Study results were used to guide the transition from nasogastric tube to oral feeding and placement of gastrostomy tubes. During the same time period, 18 neonates underwent aortic arch reconstruction as part of a biventricular repair. RESULTS: After a Norwood procedure, laryngoscopy showed left true vocal fold (cord) paralysis in 3 (9%) of 33 patients. The results of a modified barium swallow were abnormal in 16 (48%) of 33 patients, with aspiration in 8 (24%) of 33 patients. Of the 3 patients with vocal fold paralysis, 2 had a normal modified barium swallow result, and 1 had aspiration. Gastrostomy tubes were placed in 6 (18%) of 33 patients, all with an abnormal modified barium swallow result. Hospital stay was longer in patients with an abnormal modified barium swallow result: 34 +/- 13 versus 22 +/- 7 days (P < .01). After biventricular repair with aortic arch reconstruction, left true vocal fold paralysis occurred in 4 (25%) of 16 patients; results of a modified barium swallow were abnormal in 10 (59%) of 17 patients, with aspiration in 6 (35%) of 17 patients (all nonsignificant vs patients undergoing the Norwood procedure). Follow-up laryngoscopy in 4 patients with vocal fold paralysis showed no change in 3 of 4 patients and improvement in 1 patient. Follow-up modified barium swallow showed resolution of aspiration in 11 (85%) of 13 patients. Hospital survival was 32 (89%) of 36 patients for the Norwood procedure and 18 (100%) of 18 patients for biventricular repair. There has been 1 sudden death before second-stage palliation. CONCLUSIONS: After a Norwood procedure, swallowing dysfunction occurs in 48% of patients, with aspiration in 24%, and results in increased length of hospital stay. Left recurrent laryngeal nerve injury, seen in 9% of patients, is an uncommon cause of swallowing dysfunction. Postoperative aspiration generally resolves over time, whereas vocal fold paralysis does not. Systematic evaluation of swallowing function allows appropriate tailoring of feeding regimens and might contribute to decreased hospital and interstage mortality.