The Effects of Organizational Characteristics, Individual Nurse Characteristics, and Occupational Fatigue on Missed Care at Night.

BACKGROUND: Missed care is defined as the omission or delay of necessary patient care and is internationally reported by nurses as a significant safety risk. Nurses working at night also report high levels of occupational fatigue that, coupled with inadequate staffing and practice environment support, may impede a nurse's ability to carry out the nursing process and lead to more missed care. OBJECTIVE: The study's objective was to examine the interrelationships among organizational and nurse characteristics, occupational fatigue, and missed care among nurses working at night. METHODS: A cross-sectional design was used. Participants included registered nurses (RNs) who worked at night in New Jersey acute care hospitals. Multiple linear regression and simple moderation analyses were performed to examine the associations. RESULTS: Nurses reported missing necessary care at night. Unsupportive practice environments, high RN workloads, high patient-RN ratios, high chronic fatigue levels, and low intershift recovery were individually associated with missed care at night. High patient-to-RN ratios and chronic fatigue were independently associated with missed care. However, patient-to-registered-staffing levels had the most considerable effect on missed care at night. Nurses' years of experience and the number of hours of sleep between shifts were significant moderators of the relationship between occupational fatigue states and missed care. DISCUSSION: This study is the first to examine the interrelationship between occupational fatigue levels, organizational and nurse characteristics, and missed care at night. There is an urgent need to implement strategies in hospital organizations that foster work schedules and adequate staffing patterns that lessen nurses' occupational fatigue levels to ensure our workforce's and patients' safety.

Family type and cognitive function in older Chinese Americans: acculturation as a moderator.

OBJECTIVES: Acculturation to the mainstream culture and the settlement contexts could shape cognitive function of older immigrants. Guided by ecological theory, this study examines the interaction effect between individual acculturation and ecology of family on cognitive function among older Chinese Americans. METHODS: Data were derived from the Population Study of Chinese Elderly in Chicago (n = 3,019). Family types included tight-knit (high solidarity and low conflicts), unobligated-ambivalent (high solidarity and conflicts), commanding-conflicted (low solidarity and high conflicts), and detached (low solidarity and low conflicts). Acculturation was measured via language ability, media use, and ethnic social relations. Cognitive function was evaluated by global cognition, episodic memory, working memory, processing speed, and mini-mental state examination. Multiple regression analyses and interaction terms were used. RESULTS: Older adults in the commanding-conflicted type had the lowest cognitive function. After controlling confounding variables, higher levels of acculturation (b = 0.009, SE = 0.003, p < .01) were associated with higher levels of global cognition. Acculturation buffered the negative impact of having a commanding-conflicted relationship with children on global cognition (b = 0.070, SE = 0.016, p < .001). Language ability, media use, and ethnic social relations played a unique role in the relationships between family types and cognitive domains. CONCLUSION: Acculturation to the dominant culture is identified as a cultural asset for cognitive function in older Chinese Americans. Social services could protect cognitive function of older immigrants in the commanding-conflicted type through enhancing cultural participation. Future research could test how affective and cognitive aspects of acculturation affect health.

Effects of Race, Workplace Racism, and COVID Worry on the Emotional Well-Being of Hospital-Based Nurses: A Dual Pandemic.

Persons of color in the US experience the worst COVID-related outcomes and account for the majority of COVID-19 cases and hospitalizations among healthcare workers. In a pandemic where minority populations and healthcare workers are among the hardest hit, nurses of color are undoubtedly taxed. Moreover, their workplace racism experiences represent a dual pandemic in that the effects of COVID-19 worries and workplace racism may synergize to the detriment of their emotional well-being. The purpose of this study was to examine the direct, indirect, and interactive effects of individual (race, COVID worry), interpersonal (workplace racial microaggressions), and institutional (racial climate) factors on hospital-based nurses' emotional well-being. A sample of 788 registered nurses who worked in New Jersey hospitals completed an electronic survey. Compared to White nurses, nonwhite nurses reported higher emotional distress, more negative racial climates, more racial microaggressions, and higher levels of COVID worry. Nurses' worry about getting sick from COVID and multiple racial microaggression experiences had the largest effects on the likelihood of high emotional distress. Racism variables and worry about COVID mediated indirect effects of nonwhite race on emotional distress. Racial microaggressions mediated an indirect effect of racial climate on this outcome. Nurses who were worried about getting sick from COVID and experienced multiple microaggressions and/or the most negative racial climates had severe emotional distress. There is a need for sustained investment in a racially diverse nursing workforce. Mitigating workplace racism in hospitals is crucial, particularly during public health crises that disproportionately threaten minority populations and healthcare workers.

The effects of race and workplace racism on nurses' intent to leave the job: The mediating roles of job dissatisfaction and emotional distress.

BACKGROUND: There is scant evidence of quantifiable effects of workplace racism on nurses' job-related outcomes. PURPOSE: The study aimed to examine associations among race, workplace racism, emotional distress, job dissatisfaction, and intent to leave among hospital-based nurses. METHODS: This study used a correlational design with six measures in a statewide sample of 788 hospital-based nurses. FINDINGS: Non-White nurses intended to leave the job at a higher rate than White nurses. Non-White nurses reported negative racial climates, multiple racial microaggression experiences, and high job dissatisfaction and emotional distress. Non-white race and workplace racism had significant individual effects on intent to leave. Job dissatisfaction and emotional distress significantly mediated indirect effects of non-White race, negative racial climates, and racial microaggressions on nurses' intent to leave. DISCUSSION: In efforts to retain nurses of color in hospitals, there is an urgent need to mitigate workplace racism in these settings.

Registered Nurse Staffing, Workload, and Nursing Care Left Undone, and Their Relationships to Patient Safety in Hemodialysis Units.

Patient safety is an important foundation of high-quality care. Yet little is known regarding the effects of nursing indicators on patient safety in dialysis units. The purpose of this study was to examine interrelationships among registered nurse (RN) staffing, workload, nursing care left undone, and patient safety outcomes in hemodialysis settings. The sample consisted of 104 staff nurses who worked in hemodialysis facilities and completed a mailed survey. Low RN staffing, high RN workloads, and RN nursing care left undone were significantly associated with unsafe patient shift change periods and low safety ratings. Care left undone was an indirect pathway through which low RN staffing and high workloads impacted safety. Patient safety in hemodialysis units can be enhanced by ensuring adequate RN staffing and reasonable RN workloads, as well as redesigning responsibilities so RNs can complete necessary care activities.

Associations among race, residential segregation, community income, and emergency department use by adults with end-stage renal disease.

OBJECTIVE: The purpose of this study was to examine independent and interactive effects of race, community income, and racial residential segregation on the likelihood of ED revisits by persons with end-stage renal disease (ESRD). DESIGN: A retrospective analysis of de-identified data abstracted from Health Care Utilization and Cost Project's (HCUP) 2014 New Jersey State Emergency Department (ED) Database and American Community Survey (ACS) was conducted. SAMPLE: The analytic sample was comprised of 2,859 ED encounters in 2014 by non-Hispanic Black and White persons over 18 years of age with ESRD who were treated and released from the ED. MEASUREMENTS: The HCUP database was the data source for ED revisit, race, median community income, and covariate (age, gender, marital status, number of chronic conditions) variables in the study. The 2014 ACS was the source for racial segregation Dissimilarity Index scores across NJ counties. RESULTS: Living in communities with lower median income and high racial segregation was associated with a higher likelihood of ED revisits. Black race interacted with community income and racial segregation in its effect on ED revisits. CONCLUSION: Efforts are needed to direct geo-targeted interventions and resources to socially disadvantaged communities to lessen disparities in ED visits among dialysis patients.

The Effects of Anesthesia on the Pediatric Developing Brain: Strategies to Reduce Anesthesia Use in Pediatric MRI and Nursing's Role in Driving Patient Safety.

PURPOSE: To describe the physiological and biological principles of anesthesia for children; nonanesthesia practices; the state of the evidence of patient- and family-centered care strategies to reduce anesthesia use; and role of nursing in ensuring patient safety through reducing anesthesia use for pediatric magnetic resonance imaging (MRI). DESIGN: Integrative literature review. METHODS: Review and synthesis of experimental and nonexperimental literature. FINDINGS: Anesthesia use in pediatric MRI: 20 studies met inclusion criteria. Physiological and biological side effects of anesthesia in children are substantial. Of significance is the developing research on the extent to which anesthesia affects the developing brain of children. Nonanesthesia in pediatric MRI: 16 studies met inclusion criteria. Common themes were noted between patient- and family-centered care strategies and reducing anesthesia use in children requiring MRI. CONCLUSIONS: There are significant risks associated with anesthesia on the developing brain. Nurses play an important role in using patient-centered strategies to reduce pediatric anesthesia use and advocate for patient safety.

Relationships Among Nurse Manager Leadership Skills, Conflict Management, and Unit Teamwork.

OBJECTIVE: The aim of this study is to examine the relationships among staff nurse perceptions of their nurse manager (NM) leadership ability, conflict management, and team backup on medical-surgical units. BACKGROUND: Team backup, an important component of teamwork, is crucial to patient safety and outcomes. A threat to successful teamwork is ineffective conflict management. There is scant knowledge, however, about NM conflict management skills and unit teamwork through the concept of team backup. METHODS: Secondary analyses were conducted utilizing data previously collected from a sample of 257 staff nurses. A series of multiple regressions, including a mediation model, were estimated to determine relationships among variables. RESULTS: Positive relationships were substantiated among the variables of NM leadership ability, conflict management, and team backup. Staff nurse perceptions of NM leadership ability were a significant predictor of conflict management and team backup. CONCLUSION: Findings support the importance of the NM demonstrating skilled leadership and the ability to manage conflicts and to develop team backup. This study further highlights the importance of conflict management as a leadership competency.

Report From the Night Shift: How Administrative Supervisors Achieve Nurse and Patient Safety.

The administrative supervisor role (the nurse leader on the evening or night shift) has been present in hospitals for more than 100 years, but research is just commencing regarding how this leader achieves nurse and patient safety. This focused ethnographic study was conducted in 2 parts. The first part consisted of focus groups with night-shift staff nurses, held at 7 hospitals in the mid-Atlantic region of the United States, with the objective of obtaining the staff nurses' perception of the supervisors' role. The second part consisted of interviews with 30 administrative supervisors, recruited nationally from 20 different states, to explore the supervisors' perspective on practices used to enhance safety. The focus group and interview transcripts were thematically analyzed, using an iterative, comparative method to identify codes and sort for patterns. The findings reveal that administrative supervisors "make it (whatever needs to be done) work" and achieve nurse and patient safety by building trust with the staff, doing rounds, educating, and providing support to the front line team. These shift leaders foster a culture of safety with their relationship-oriented leadership style. By gaining further understanding about the administrative supervisor role, new workflow processes can be explored; specific continuing education programs can be developed; and additional research can be conducted.

Work Environment Characteristics Valued by Outpatient Hemodialysis Unit Nurse Managers.

Competent nurse managers of outpatient hemodialysis (HD) units are invaluable in enhancing patient safety, creating a culture of safety, and preventing adverse events. Yet little is known regarding the characteristics of a professional work environment that supports their important managerial role. The purpose of this qualitative study was to identify those organizational characteristics that outpatient HD unit nurse managers describe as important to a supportive managerial work environment. A total of six major themes with descriptive categories and exemplars emerged from the analysis. Findings from this study can inform HD administrators in their efforts to create and sustain work environments that support the professional practice of outpatient HD unit nurse managers. Notably, findings can also provide guidelines for nurse managers considering employment opportunities in that they can be used to assess and compare the work environments of outpatient HD facilities and organizations.

Relationship between missed care and urinary tract infections in nursing homes.

The aim of this study was to describe the frequencies and types of missed nursing care in nursing homes, and to determine the relationship between missed care and the incidence of UTI among nursing home residents. A secondary data analysis was conducted including New Jersey nurse survey data and data from Nursing Home Compare. The data included responses from 340 direct-care RNs from 63 nursing homes. Nearly one half of nurses reported missing at least one necessary care activity during their last shift. Of the 12 categories or types of reported missed care activities, seven categories of missed care were significantly correlated with UTI. Regression analysis indicated that failure to administer medications on time and failure to provide adequate patient surveillance explained 40% of the variance in the percent of residents with UTI in this sample.

Nurse Manager Safety Practices in Outpatient Hemodialysis Units.

Little is known regarding the specific managerial activities or best practices that nurse managers in outpatient hemodialysis settings use to achieve positive safety outcomes. The purpose of this study was to identify and describe specific managerial practices used by nurse managers in outpatient hemodialysis units to enhance patient safety and quality of care. A descriptive qualitative design was used. Seventeen nurse managers in outpatient hemodialysis units comprised the study sample. Telephone interviews were conducted, and qualitative content analysis was used to encode the data. Nurse managers identified patients, staff, the dialysis unit environment, and the dialysis organization as sources of safety risks. Nurse manager safety practices illuminated from the data were complex and multifaceted, and were aimed at reducing patient, staff environmental, and organization risks. The findings from this study offer a description and a better understanding of the practices in which nurse managers in outpatient hemodialysis units engage to keep patients safe in their units, and they underscore the critical role of nurse managers in creating and maintaining patient safety within outpatient hemodialysis settings.

Impact of Heath Information Technology on the Quality of Patient Care.

OBJECTIVE: To examine the relationships among Electronic Health Record (EHR) adoption and adverse outcomes and satisfaction in hospitalized patients. MATERIALS AND METHODS: This secondary analysis of cross sectional data was compiled from four sources: (1) State Inpatient Database from the Healthcare Cost Utilization Project; (2) Healthcare Information and Management Systems Society (HIMSS) Dorenfest Institute; (3) Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) and (4) New Jersey nurse survey data. The final analytic sample consisted of data on 854,258 adult patients discharged from 70 New Jersey hospitals in 2006 and 7,679 nurses working in those same hospitals. The analytic approach used ordinary least squares and multiple regression models to estimate the effects of EHR adoption stage on the delivery of nursing care and patient outcomes, controlling for characteristics of patients, nurses, and hospitals. RESULTS: Advanced EHR adoption was independently associated with fewer patients with prolonged length of stay and seven-day readmissions. Advanced EHR adoption was not associated with patient satisfaction even when controlling for the strong relationships between better nursing practice environments, particularly staffing and resource adequacy, and missed nursing care and more patients reporting "Top-Box," satisfaction ratings. CONCLUSIONS: This innovative study demonstrated that advanced stages of EHR adoption show some promise in improving important patient outcomes of prolonged length of stay and hospital readmissions. Strongly evident by the relationships among better nursing work environments, better quality nursing care, and patient satisfaction is the importance of supporting the fundamentals of quality nursing care as technology is integrated into practice.

Home health agency work environments and hospitalizations.

BACKGROUND: An important goal of home health care is to assist patients to remain in community living arrangements. Yet home care often fails to prevent hospitalizations and to facilitate discharges to community living, thus putting patients at risk of additional health challenges and increasing care costs. OBJECTIVES: To determine the relationship between home health agency work environments and agency-level rates of acute hospitalization and discharges to community living. METHODS AND DESIGN: Analysis of linked Center for Medicare and Medicaid Services Home Health Compare data and nurse survey data from 118 home health agencies. Robust regression models were used to estimate the effect of work environment ratings on between-agency variation in rates of acute hospitalization and community discharge. RESULTS: Home health agencies with good work environments had lower rates of acute hospitalizations and higher rates of patient discharges to community living arrangements compared with home health agencies with poor work environments. CONCLUSION: Improved work environments in home health agencies hold promise for optimizing patient outcomes and reducing use of expensive hospital and institutional care.

Patient- and family-centered care: a call to action for new knowledge and innovation.

This article summarizes the findings of an integrative literature review of 19 publications exploring patient- and family-centered care (PFCC) in children's hospitals. The authors provide recommendations for nurse executives who are implementing PFCC in clinical practice. Findings from this review inform the evidence-based practices of nurse executives as they contemplate innovations in PFCC.

Palliative Care Use in Advanced Cancer in the Garden State.

BACKGROUND: Cancer is the second leading cause of death in the United States. Patients with metastatic cancer have a high symptom burden. Major global and domestic cancer care recommendations advise integration of palliative care services for these patients. Palliative care is specialized care that can decrease cost, improve symptom burden, and improve quality of life. Patient factors driving the use of palliative care remain poorly understood but may include both physiological and psychological needs, namely, pain and depression, respectively. OBJECTIVE: The objective of this study was to identify patient-level predictors associated with inpatient palliative care use in patients with metastatic cancer. METHODS: This was a secondary analysis of the 2018 New Jersey State Inpatient Database. The sample was limited to hospitalized adults with metastatic cancer in New Jersey. Descriptive statistics characterized the sample. Generalized linear modeling estimated the effects of pain and depression on the use of inpatient palliative care. RESULTS: The sample included 28 697 hospitalizations for patients with metastatic cancer. Within the sample, 4429 (15.4%) included a palliative care consultation. There was a 9.3% documented occurrence of pain and a 10.9% rate of depression. Pain contributed to palliative care use, but depression was not predictive of an inpatient care consultation. Age, income category, and insurance status were significant factors influencing use. CONCLUSION: Understanding demographic and clinical variables relative to palliative care use may help facilitate access to palliative care for adults experiencing metastatic cancer. IMPLICATION FOR PRACTICE: Increased screening for pain and depression may expand palliative care use for adults with metastatic cancer receiving inpatient care.

Nurses' practice environments, error interception practices, and inpatient medication errors.

PURPOSE: Medication errors remain a threat to patient safety. Therefore, the purpose of this study was to determine the relationships among characteristics of the nursing practice environment, nurse staffing levels, nurses' error interception practices, and rates of nonintercepted medication errors in acute care hospitals. DESIGN: This study, using a nonexperimental design, was conducted in a sample of 82 medical-surgical units recruited from 14 U.S. acute care hospitals. Registered nurses (RNs) on the 82 units were surveyed, producing a sample of 686 staff nurses. METHODS: Data collected for the 8-month study period included the number of medication errors per 1,000 patient days and the number of RN hours per patient day. Nurse survey data included the Practice Environment Scale of the Nursing Work Index as a measure of environmental characteristics; a metric of nurses' interception practices was developed for the study. All survey measures were aggregated to the unit level prior to analysis with hierarchical linear modeling. FINDINGS: A supportive practice environment was positively associated with error interception practices among nurses in the sample of medical-surgical units. Importantly, nurses' interception practices were inversely associated with medication error rates. CONCLUSIONS: A supportive practice environment enhances nurses' error interception practices. These interception practices play a role in reducing medication errors. CLINICAL RELEVANCE: When supported by their practice environments, nurses employ practices that can assist in interrupting medication errors before they reach the patients.

Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments.

CONTEXT: Better hospital nurse staffing, more educated nurses, and improved nurse work environments have been shown to be associated with lower hospital mortality. Little is known about whether and under what conditions each type of investment works better to improve outcomes. OBJECTIVE: To determine the conditions under which the impact of hospital nurse staffing, nurse education, and work environment are associated with patient outcomes. DESIGN, SETTING, AND PARTICIPANTS: Outcomes of 665 hospitals in 4 large states were studied through linked data from hospital discharge abstracts for 1,262,120 general, orthopedic, and vascular surgery patients, a random sample of 39,038 hospital staff nurses, and American Hospital Association data. MAIN OUTCOME MEASURES: A 30-day inpatient mortality and failure-to-rescue. RESULTS: The effect of decreasing workloads by 1 patient/nurse on deaths and failure-to-rescue is virtually nil in hospitals with poor work environments, but decreases the odds on both deaths and failures in hospitals with average environments by 4%, and in hospitals with the best environments by 9% and 10%, respectively. The effect of 10% more Bachelors of Science in Nursing Degree nurses decreases the odds on both outcomes in all hospitals, regardless of their work environment, by roughly 4%. CONCLUSIONS: Although the positive effect of increasing percentages of Bachelors of Science in Nursing Degree nurses is consistent across all hospitals, lowering the patient-to-nurse ratios markedly improves patient outcomes in hospitals with good work environments, slightly improves them in hospitals with average environments, and has no effect in hospitals with poor environments.

Nurses' clinical reasoning: processes and practices of medication safety.

In this article, we describe the depth of knowledge and skill nurses used in making decisions regarding the safe processes and practices of medication administration. Using grounded theory, we identified the essence of medication safety by nurses as the theme of clinical reasoning. Nurses used two medication safety processes within the clinical reasoning theme-maintaining medication safety and managing the environment-together with six categories of patient-focused medication safety practices in the first process and four categories of environmental-focused safety practices within the second process. These processes and practices present an emerging model of safe medication administration developed from the narratives of 50 medical-surgical nurses. This model provides researchers with the basis for the development of systemic policies for safer medication administration for patients. Health care professional educators might also find the results useful in developing curricula focused on patient safety as the foundation of quality care.

Hospice Referral in Advanced Cancer in New Jersey.

The need for hospice care is increasing in the United States, but insufficient lengths of stay and disparity in access to care continue. Few studies have examined the relationship between the presence of symptoms and hospice referral. The study measured the association between hospice referral and demographic characteristics and the presence of pain and depression in a cohort of people hospitalized with metastatic cancer in New Jersey in 2018. This study was secondary analysis of the 2018 New Jersey State Inpatient Database. The sample was limited to adult patients with metastatic cancer. Descriptive statistics evaluated the composition of the sample. Generalized linear modeling estimated the effect of pain and depression on incidence of hospice referral in a racially and economically diverse population. Absence of pain resulted in lower odds of receiving a referral to hospice upon discharge (adjusted odds ratio [AOR], 0.44; 95% confidence interval [CI], 0.40-0.49; P = .00). Likewise, an absence of depression also resulted in decreased odds of a hospice referral (AOR, 0.85; 95% CI, 0.76-0.96; P = .008). Compared with Whites, Blacks (AOR, 0.86; 95% CI, 0.76-0.97; P = .00) and Hispanics had significantly lower odds of receiving a hospice referral (AOR, 0.84; 95% CI, 0.72-0.96; P = .01). Patients with a primary language other than English, there were significantly lower odds of receiving a hospice referral (AOR, 0.85; 95% CI, 0.73-0.99; P = .03). Patients with pain and depression had increased hospice referrals. Disparities persist in hospice referral, particularly in Black and Hispanic cases and those without a primary language of English.