"Where You Feel Like a Family Instead of Co-workers": a Mixed Methods Study on Care Teams and Burnout.

BACKGROUND: Physicians and nurses face high levels of burnout. The role of care teams may be protective against burnout and provide a potential target for future interventions. OBJECTIVE: To explore levels of burnout among physicians and nurses and differences in burnout between physicians and nurses, to understand physician and nurse perspectives of their healthcare teams, and to explore the association of the role of care teams and burnout. DESIGN: A mixed methods study in two school of medicine affiliated teaching hospitals in an urban medical center in Baltimore, Maryland. PARTICIPANTS: Participants included 724 physicians and 971 nurses providing direct clinical care to patients. MAIN MEASURES AND APPROACH: Measures included survey participant characteristics, a single-item burnout measure, and survey questions on care teams and provision of clinical care. Thematic analysis was used to analyze qualitative survey responses from physicians and nurses. KEY RESULTS: Forty-three percent of physicians and nurses screened positive for burnout. Physicians reported more isolation at work than nurses (p<0.001), and nurses reported their care teams worked efficiently together more than physicians did (p<0.001). Team efficiency was associated with decreased likelihood of burnout (p<0.01), and isolation at work was associated with increased likelihood of burnout (p<0.001). Free-text responses revealed themes related to care teams, including emphasis on team functioning, team membership, and care coordination and follow-up. Respondents provided recommendations about optimizing care teams including creating consistent care teams, expanding interdisciplinary team members, and increasing clinical support staffing. CONCLUSIONS: More team efficiency and less isolation at work were associated with decreased likelihood of burnout. Free-text responses emphasized viewpoints on care teams, suggesting that better understanding care teams may provide insight into physician and nurse burnout.

Leadership Principles to Decrease Psychological Casualties in COVID-19 and Other Disasters of Uncertainty.

Coronavirus disease (COVID-19) is a "disaster of uncertainty" with ambiguity about its nature and trajectory. These features amplify its psychological toxicity and increase the number of psychological casualties it inflicts. Uncertainty was fueled by lack of knowledge about the lethality of a disaster, its duration, and ambiguity in messaging from leaders and health care authorities. Human resilience can have a buffering effect on the psychological impact. Experts have advocated "flattening the curve" to slow the spread of the infection. Our strategy for crisis leadership is focused on flattening the rise in psychological casualties by increasing resilience among health care workers. This paper describes an approach employed at Johns Hopkins to promote and enhance crisis leadership. The approach is based on 4 factors: vision for the future, decisiveness, effective communication, and following a moral compass. We make specific actionable recommendations for implementing these factors that are being disseminated to frontline leaders and managers. The COVID-19 pandemic is destined to have a strong psychological impact that extends far beyond the end of quarantine. Following these guidelines has the potential to build resilience and thus reduce the number of psychological casualties and speed the return to normal - or at least the new normal in the post-COVID world.

A scoping review of new implementations of interprofessional bedside rounding models to improve teamwork, care, and outcomes in hospitals.

Poor communication within healthcare teams occurs commonly, contributing to inefficiency, medical errors, conflict, and other adverse outcomes. Interprofessional bedside rounds (IBR) are a promising model that brings two or more health professions together with patients and families as part of a consistent, team-based routine to share information and collaboratively arrive at a daily plan of care. The purpose of this systematic scoping review was to investigate the breadth and quality of IBR literature to identify and describe gaps and opportunities for future research. We followed an adapted Arksey and O'Malley Framework and PRISMA scoping review guidelines. PubMed, CINAHL, PsycINFO, and Embase were systematically searched for key IBR words and concepts through June 2020. Seventy-nine articles met inclusion criteria and underwent data abstraction. Study quality was assessed using the Mixed Methods Assessment Tool. Publications in this field have increased since 2014, and the majority of studies reported positive impacts of IBR implementation across an array of team, patient, and care quality/delivery outcomes. Despite the preponderance of positive findings, great heterogeneity, and a reliance on quantitative non-randomized study designs remain in the extant research. A growing number of interventions to improve safety, quality, and care experiences in hospital settings focus on redesigning daily inpatient rounds. Limited information on IBR characteristics and implementation strategies coupled with widespread variation in terminology, study quality, and design create challenges in assessing the effectiveness of models of rounds and optimal implementation strategies. This scoping review highlights the need for additional studies of rounding models, implementation strategies, and outcomes that facilitate comparative research.

Development and Evaluation of a Nurse Leadership Succession Planning Strategy in an Academic Medical Center.

Absence of nurse manager succession planning in an academic medical center necessitated a quality improvement project to identify, select, and enroll emerging leaders into a development program. The authors used organizational competencies and an evidence-based approach to effectively identify barriers, select future nurse leaders, and discover opportunities for process improvement.

Triggers Contributing to Health Care Clinicians' Disruptive Behaviors.

OBJECTIVES: This study's objective was to explore the possible triggers of clinicians' disruptive behavior and to consider whether the type of trigger resulting in disruptive behavior differed by type of clinician, clinician characteristics, professional role, and ethnic background. METHODS: Using data collected from 1559 clinicians working at an urban academic medical center in the United States, we examined intrapersonal, interpersonal, and organizational triggers. In addition, we measured 3 subscales of disruptive behavior including incivility, psychological aggression, and violence. Multivariate regression and logit models were used to examine the relationship between triggers and disruptive behavior. RESULTS: We found that higher levels of intrapersonal, interpersonal, and organizational triggers related to a greater frequency of disruptive behaviors after controlling for clinician characteristics. Among nurses, all 3 types of triggers were significantly related to disruptive behaviors with the same direction and magnitude of difference. However, in the physician/affiliate group, only intrapersonal and interpersonal triggers were statistically significant factors for disruptive behavior. CONCLUSIONS: In the present study, important triggers were found to contribute to clinicians' disruptive behaviors. Strategies to prevent disruptive behaviors should be multipronged and reflect intrapersonal and interpersonal features for both clinician groups. For nurses, organizational triggers should be addressed through process and system improvements. Because disruptive behavior continues to be frequent among clinicians, efforts to implement evidence-based practices to prevent disruptive behaviors must continue, and future research should evaluate them.

Do Clinician Disruptive Behaviors Make an Unsafe Environment for Patients?

The magnitude of negative consequences of clinician disruptive behaviors on patients and clinicians was examined using data collected from 1559 clinicians working at an urban academic medical center in the United States. For the impact of disruptive behavior on patient safety, psychological aggression as caused by disruptive behavior or incivility increased the likelihood of patient harm as well as job dissatisfaction and physical symptoms.

Heavy Metal Ion Regulation of Gene Expression: MECHANISMS BY WHICH LEAD INHIBITS OSTEOBLASTIC BONE-FORMING ACTIVITY THROUGH MODULATION OF THE Wnt/ß-CATENIN SIGNALING PATHWAY.

Exposure to lead (Pb) from environmental sources remains an overlooked and serious public health risk. Starting in childhood, Pb in the skeleton can disrupt epiphyseal plate function, constrain the growth of long bones, and prevent attainment of a high peak bone mass, all of which will increase susceptibility to osteoporosis later in life. We hypothesize that the effects of Pb on bone mass, in part, come from depression of Wnt/ß-catenin signaling, a critical anabolic pathway for osteoblastic bone formation. In this study, we show that depression of Wnt signaling by Pb is due to increased sclerostin levels in vitro and in vivo. Downstream activation of the ß-catenin pathway using a pharmacological inhibitor of GSK-3ß ameliorates the Pb inhibition of Wnt signaling activity in the TOPGAL reporter mouse. The effect of Pb was determined to be dependent on sclerostin expression through use of the SOST gene knock-out mice, which are resistant to Pb-induced trabecular bone loss and maintain their mechanical bone strength. Moreover, isolated bone marrow cells from the sclerostin null mice show improved bone formation potential even after exposure to Pb. Also, our data suggest that the TGFß canonical signaling pathway is the mechanism by which Pb controls sclerostin production. Taken together these results support our hypothesis that the osteoporotic-like phenotype observed after Pb exposure is, in part, regulated through modulation of the Wnt/ß-catenin pathway.

Development and validation of the Johns Hopkins Disruptive Clinician Behavior Survey.

Although the negative impact of disruptive clinician behavior on quality health care delivery has gained attention recently, little systematic effort to address this issue has been reported. To facilitate empirical research to reduce disruptive clinician behaviors, an assessment tool (Johns Hopkins Disruptive Clinician Behavior Survey [JH-DCBS]) with 5 discrete subscales was developed using a 2-step design. First a pool of items was generated from focus group studies and the literature, and then a psychometric evaluation of the survey was conducted with a sample of clinicians (N = 1198) practicing in a large urban academic medical center. The results indicated that the tool was reliable (Cronbach α = .79-.91), showed high content validity (Content Validity Index = .97), and had significantly high correlations with theoretically selected variables. The study team concluded that the JH-DCBS provides a valid empirical assessment of disruptive behavior. Assessment results may be used to design strategies to improve the health and safety of practice environments.

A clinical academic practice partnership: a clinical education redesign.

The clinical academic practice partnership (CAPP), a clinical redesign based on the dedicated education unit concept, was developed and implemented by large, private school of nursing in collaboration with 4 clinical partners to provide quality clinical education, to explore new clinical models for the future, and to test an innovative clinical education design. An executive steering committee consisting of nursing leaders and educators from the school of nursing and the clinical institutions was established as the decision-making and planning components, with several collaborative task forces initiated to conduct the work and to accomplish the goals. This article will describe methods to initiate and to organize the key elements of this dedicated education unit-type clinical model, providing examples and an overview of the steps and elements needed as the development proceeded. After 18 months of implementation in 4 different nursing programs in 4 different clinical institutions, the clinical redesign has shown to be a positive initiative, with students actively requesting CAPP units for their clinical experiences. Preliminary findings and outcomes will be discussed, along with nursing education implications for this new clinical redesign.

An organizational assessment of disruptive clinician behavior: findings and implications.

This study investigated registered nurses' (RNs) and physicians' (MD) experiences with disruptive behavior, triggers, responses, and impacts on clinicians, patients, and the organization. Using the Disruptive Clinician Behavior Survey for Hospital Settings, it was found that RNs experienced a significantly higher frequency of disruptive behaviors and triggers than MDs; MDs (45% of 295) and RNs (37% of 689) reported that their peer's disruptive behavior affected them most negatively. The most frequently occurring trigger was pressure from high census, volume, and patient flow; 189 incidences of harm to patients as a result of disruptive behavior were reported. Findings provide organizational leaders with evidence to customize interventions to strengthen the culture of safety.

Hospital RNs' experiences with disruptive behavior: a qualitative study.

Disruptive behavior in healthcare has been identified as a threat to quality of care, nurse retention, and a culture of safety. A qualitative study elicited registered nurse experiences with disruptive clinician behavior in an acute care hospital. A conceptual framework was developed to provide a structure for organizing and describing this complex construct that includes 4 primary concepts: disruptive behaviors and its triggers, responses, and impacts.

An evaluation framework for faculty practice.

Faculty practice is promoted in schools of nursing for the purposes of strengthening the clinical expertise of faculty, maintaining clinically relevant curricula, fostering student learning, and generating revenue. For clinical faculty, this practice often provides the foundation for academic scholarship. The integration of this scholarship into the traditional academic triad of education, research, and service has proved difficult. Pohl et al notes, "In promotion and tenure decisions, 68 percent of faculty reported that practice was weighted less than teaching and research in their institutions." There appears to be an inherent tension between the requirements for scholarly faculty practice and the academic missions of schools of nursing. The purpose of this article is to describe a framework for the evaluation of faculty practice at the Johns Hopkins University School Nursing (JHUSON) and the actions taken to align the scholarship of faculty practice with the academic research mission of the School.

Quest for the ideal: a redesign of the medication use system.

Medication use systems in hospitals are complex and prone to error. A redesign of the system using idealized design methodology is a starting point in preventing patient harm from medication errors. An interdisciplinary team identified system properties, proposed and gathered feedback on an ideal design, and established a structure to plan changes in the system and monitor their impact.

Postoperative complications: does intensive care unit staff nursing make a difference?

OBJECTIVE: The purpose of this study was to examine the association between intensive care unit nurse (ICU) staffing and the likelihood of complications for patients undergoing abdominal aortic surgery. DESIGN: The study is a retrospective review of hospital discharge data linked to data on ICU organizational characteristics. SETTING: Research took place in ICUs in non-federal, short-stay hospitals in Maryland. PATIENTS: Study included 2606 patients undergoing abdominal aortic surgery in Maryland between January 1994 and December 1996. OUTCOME MEASURES: Outcome measures included cardiac, respiratory, and other complications. RESULTS: Cardiac complications occurred in 13% of patients, respiratory complications occurred in 30%, and other complications occurred in 8% of patients. Multiple logistic regression revealed a statistically significant increased likelihood of respiratory complications (odds ratio [OR], 2.33; 95% confidence interval [CI], 1.50-3.60) in abdominal aortic surgery patients cared for in ICUs with low- versus high-intensity nurse staffing, an increased likelihood of cardiac complications (OR, 1.78; CI, 1.16-2.72) and other complications (OR, 1.74; CI, 1.15-2.63) in ICUs with medium- versus high-intensity nurse staffing, after controlling for patient and organizational characteristics. CONCLUSIONS: Within the range of ICU nurse staffing levels present in Maryland hospitals, decreased nurse staffing was significantly associated with an increased risk of complications in patients undergoing abdominal aortic surgery.