Audit and Feedback: An Evidence-Based Practice Literature Review of Nursing Report Cards.

BACKGROUND: As more hospitals transition to electronic health records (EHR) and rely on technology to inform practice, what is done with that information is increasingly important. Performance report cards for physicians and nurses are not new, yet there is little recent evidence on nurse-specific audit and feedback. AIM: The aim of the project was to conduct an evidence-based practice (EBP) review to answer the question, "Does implementing an individualized audit and feedback report tool for nurses improve compliance, adherence, and/or performance of nursing tasks?". METHODS: Evidence was gathered from several databases. Reviewers read and appraised articles that answered the EBP question using the Johns Hopkins Nursing EBP Model. Data were then collated to synthesize and generate recommendations. RESULTS: Of the initial 613 unique articles, eight (two research and six quality improvement) were included. Six articles demonstrated improvements while two did not. Articles analyzed nursing documentation (n = 3), tasks or skills (n = 2), and best practice compliance (n = 3). One manuscript utilized an EHR-generated report; all others were completed by hand. Overall, there was not consistent and compelling evidence to support individualized audit and feedback report tools in nursing. However, several themes emerged related to sustainability, timing of feedback, audit, and feedback in the context of quality improvement, and the methods of acquiring and distributing data. LINKING EVIDENCE TO ACTION: The ubiquity and ease of the EHR make providing automated feedback to nurses tempting, yet it is not supported by the literature. More implementation science research is needed to explore audit and feedback reports in nursing. This article adds to the literature by highlighting a significant lack of consistent and compelling positive results from the well-established quality improvement strategy of audit and feedback in the nursing population. The absence of good data is as telling as its presence.

Propuesta de estándares y elementos medibles para conformar auditorías concurrentes de enfermería en el contexto hospitalario / Proposed Standards and Measurable Elements for Carrying Out Concurrent Nursing Audits in the Hospital Setting

Introducción: La auditoría de enfermería basada en estándares bien definidos, enfocados a la calidad asistencial de enfermería y la seguridad del paciente, permiten identificar desviaciones de manera eficaz. Objetivo: Proponer un grupo de estándares y elementos medibles que permitan conformar auditorías concurrentes de enfermería en el contexto hospitalario. Métodos: Se realizó una investigación de desarrollo tecnológico en el Hospital Hermanos Ameijeiras, desde enero de 2016 a enero de 2018. En el primer momento del estudio participaron 20 expertos, seleccionados a través de criterios. En el segundo momento, a través del muestreo intencional, se incorporaron dos licenciadas en enfermería del Grupo Médico Auditor. Como métodos teóricos se aplicaron: análisis-síntesis; inducción-deducción; enfoque de sistema y la modelación. Como empírico en el primer momento el método Delphi y en el segundo, la verificación en la práctica. Se aplicaron las consideraciones éticas para este tipo de estudio. Resultados: La propuesta quedó conformada por 17 estándares, agrupados en las 4 funciones generales de enfermería. Los estándares, a su vez, agruparon 166 elementos medibles, que permitieron revisar y evaluar el cumplimiento de los estándares. Conclusiones: Los estándares propuestos y elementos medibles, enfocados a la calidad asistencial de enfermería y la seguridad del paciente, permitirán conformar las auditorías concurrentes de enfermería en el contexto hospitalario(AU)

Introduction: Nursing audit based on well-defined standards, focused on the quality of nursing care and on patient safety, allows that deviations be identified effectively. Objective: To propose a group of standards and measurable elements that allow structuring concurrent nursing audits in the hospital setting. Methods: A technological development research was carried out at Hermanos Ameijeiras Hospital, from January 2016 to January 2018. In the first moment of the study, 20 experts participated, selected through criteria. In the second moment, through intentional sampling, two Nursing graduates were incorporated from the Audit Medical Group. The theoretical methods applied were analysis-synthesis, induction-deduction, system approach, and modeling. The empirical method applied in the first moment was the Delphi method and, in the second moment, verification in practice. Ethical considerations were applied for this type of study. Results: The proposal was made up of 17 standards, grouped into the four general functions of nursing. The standards, in turn, grouped 166 measurable elements, which made it possible to review and evaluate compliance with the standards. Conclusions: The proposed standards and measurable elements, focused on nursing care quality and patient safety, will make it possible to shape concurrent nursing audits in the hospital setting(AU)

Drug Diversion: Best Practices and Support for a Staff Assessment Process.

The characteristics of opioid prescribing and administration in cancer centers include large quantities and less restrictive regulatory mandates governing cancer-related pain, which may increase the risk of drug diversion by staff members. The purpose of this article is to provide a framework for creating respectful investigative processes for staff suspected of drug diversion. Organizations, including cancer centers, need to engage in careful oversight of potential drug diversions while simultaneously promoting a psychologically safe work environment for individuals to successfully seek help.

A retrospective audit of nursing-related morbidity recorded in a state hospital in KwaZulu-Natal.

BACKGROUND:  Health care professionals are expected to deliver safe and effective health services; however there is increased realisation that adverse events in the health system are a major cause of preventable morbidity and mortality. OBJECTIVES:  To conduct a retrospective audit of nursing-related morbidities in a state hospital in KwaZulu-Natal, South Africa. METHOD:  A retrospective audit of nursing-related morbidities documented by the surgical service was carried out using the Hybrid Electronic Medical Registry data for a period of 3 years - 01 November 2013 to 31 October 2016. RESULTS:  There were a total of 12 444 admissions to surgical service during the study period, with 461 nursing-related morbidities reported. There was an increase in the number of documented nursing-related morbidities noted during November 2015 to October 2016, with 79% of all reported nursing-related morbidities documented during this period. A total of 54% of nursing-related morbidities were associated with males (n = 248) and 46% (n = 213) with females. The most commonly documented nursing-related morbidity was drugs/medication (n = 167, 36%) with the second most common being adjunct management (n = 130, 28%). CONCLUSION:  The study has identified the most commonly documented nursing-related morbidities in the surgical service of a state hospital. The findings of the study could provide direction for further research and educational initiatives.

Prevention and management of primary postpartum hemorrhage among puerperae in a teaching hospital in São Paulo, Brazil: a best practice implementation project.

OBJECTIVES: The aim of this project was to develop and implement strategies to promote standardization and formal documentation of increased bleeding within the first 24 h after birth, in compliance with best practice. INTRODUCTION: Official data from Brazil shows a maternal mortality rate of around 52 to 75 deaths per 100,000 live births, 8% of which are caused by hemorrhage. Early diagnosis is promoted through standardization and formal documentation of the first signs of hemorrhage. METHODS: The current implementation project used the Joanna Briggs Institute Practical Application of Clinical Evidence System, a baseline audit was conducted on a sample size of 108 patients and 67 nursing staff. Based on the results of the baseline audit, strategies to address non-compliance were developed and implemented. A follow-up audit was conducted on a sample size of 110 patients and 68 nursing staff, using the same audit criteria. RESULTS: The baseline audit showed poor compliance with evidence-based best practice in every criterion. The implemented protocol for postpartum hemorrhage was well received by the nursing staff, promoting early diagnosis of increased bleeding within 24 h after birth and providing support for further medical treatment. There were significant improvements in every best practice criterion in the follow-up audit. CONCLUSION: The current implementation project managed to improve the nursing staff professional practice, reducing the absence of records while promoting greater awareness of the first signs of primary postpartum hemorrhage.

Quality of Electronic Nursing Records: The Impact of Educational Interventions During a Hospital Accreditation Process.

Hospital accreditation is a strategy for the pursuit of quality of care and safety for patients and professionals. Targeted educational interventions could help support this process. This study aimed to evaluate the quality of electronic nursing records during the hospital accreditation process. A retrospective study comparing 112 nursing records during the hospital accreditation process was conducted. Educational interventions were implemented, and records were evaluated preintervention and postintervention. Mann-Whitney and χ tests were used for data analysis. Results showed that there was a significant improvement in the nursing documentation quality postintervention. When comparing records preintervention and postintervention, results showed a statistically significant difference (P < .001) between the two periods. The comparison between items showed that most scores were significant. Findings indicated that educational interventions performed by nurses led to a positive change that improved nursing documentation and, consequently, better care practices.

A 5-year retrospective audit of prescribing by a critical care outreach team.

UK prescribing legislation changes made in 2006 and 2012 enabled appropriately qualified nurses to prescribe any licensed medication, and all controlled drugs in schedule 2-5 of the Misuse of Drugs Regulations 2001, for any medical condition within their clinical competence. Critical Care Outreach nurses who are independent nurse prescribers are ideally placed to ensure that acutely ill patients receive treatment without delay. The perceived challenge was how Critical Care Outreach nurses would be able to safely prescribe for a diverse patient group. This study informs this developing area of nurse prescribing in critical care practice. The aims of the audit were to: identify which medications were prescribed; develop a critical care outreach formulary; identify the frequency, timing and number of prescribing decisions being made; identify if prescribing practice changed over the years and provide information for our continuing professional development. This article reports on data collected from a 5-year retrospective audit; of prescribing activity undertaken by nine independent nurse prescribers working in a 24/7 Critical Care Outreach team of a 600-bedded district general hospital in the UK. In total, 8216 medication items were prescribed, with an average of 2·6 prescribed per shift. The most commonly prescribed items were intravenous fluids and analgesia, which were mostly prescribed at night and weekends. The audit has shown that Critical Care Outreach nurse prescribing is feasible in a whole hospital patient population. The majority of prescribing occurred after 16:00 and at night. Further research would be beneficial, particularly looking at patient outcomes following reviews from prescribing critical care outreach nurses. The audit is one of the only long-term studies that describes prescribing practice in Critical Care Outreach teams in the UK.

Improving the ward-based care of patients post-thyroidectomy.

Nursing staff play a crucial role in managing surgical patients in the postoperative period. However, with an increasing risk of subspecialty wards facing closure as a result of financial pressures within the NHS, the knowledge base and expertise of ward-based nursing staff of surgical subspecialties is becoming increasingly limited. Using patients undergoing thyroidectomy as an example, a quality improvement multidisciplinary audit is presented, which shows how simple targeted interventions through a multidisciplinary approach can help maintain high standards of patient care in a secondary care setting.

Purposeful and timely nursing rounds: a best practice implementation project.

BACKGROUND: Purposeful and timely rounding is a best practice intervention to routinely meet patient care needs, ensure patient safety, decrease the occurrence of patient preventable events, and proactively address problems before they occur. The Institute for Healthcare Improvement (IHI) endorsed hourly rounding as the best way to reduce call lights and fall injuries, and increase both quality of care and patient satisfaction. Nurse knowledge regarding purposeful rounding and infrastructure supporting timeliness are essential components for consistency with this patient centred practice. OBJECTIVES: The project aimed to improve patient satisfaction and safety through implementation of purposeful and timely nursing rounds. Goals for patient satisfaction scores and fall volume were set. Specific objectives were to determine current compliance with evidence-based criteria related to rounding times and protocols, improve best practice knowledge among staff nurses, and increase compliance with these criteria. METHODS: For the objectives of this project the Joanna Briggs Institute's Practical Application of Clinical Evidence System and Getting Research into Practice audit tool were used. Direct observation of staff nurses on a medical surgical unit in the United States was employed to assess timeliness and utilization of a protocol when rounding. Interventions were developed in response to baseline audit results. A follow-up audit was conducted to determine compliance with the same criteria. For the project aims, pre- and post-intervention unit-level data related to nursing-sensitive elements of patient satisfaction and safety were compared. RESULTS: Rounding frequency at specified intervals during awake and sleeping hours nearly doubled. Use of a rounding protocol increased substantially to 64% compliance from zero. Three elements of patient satisfaction had substantive rate increases but the hospital's goals were not reached. Nurse communication and pain management scores increased modestly (5% and 11%, respectively). Responsiveness of hospital staff increased moderately (15%) with a significant sub-element increase in toileting (41%). Patient falls decreased by 50%. CONCLUSIONS: Nurses have the ability to improve patient satisfaction and patient safety outcomes by utilizing nursing round interventions which serve to improve patient communication and staff responsiveness. Having a supportive infrastructure and an organized approach, encompassing all levels of staff, to meet patient needs during their hospital stay was a key factor for success. Hard-wiring of new practices related to workflow takes time as staff embrace change and understand how best practice interventions significantly improve patient outcomes.

Monitoring Compliance to Promote Quality Assurance: Development of a Mental Health Clinical Chart Audit Tool in Belize, 2013.

Belize trained psychiatric nurse practitioners (PNPs) in the early 1990s to provide mental health services throughout the country. Despite overwhelming success, the program is limited by lack of monitoring, evaluation, and surveillance. To promote quality assurance, we developed a chart audit tool to monitor mental healthcare delivery compliance for initial psychiatric assessment notes completed by PNPs. After reviewing the Belize Health Information System electronic medical record system, we developed a clinical audit tool to capture 20 essential components for initial assessment clinical notes. The audit tool was then piloted for initial assessment notes completed during July through September of 2013. One hundred and thirty-four initial psychiatric interviews were audited. The average chart score among all PNPs was 9.57, ranging from 3 to 15. Twenty-three charts-or 17.2%-had a score of 14 or higher and met a 70% compliance benchmark goal. Among indicators most frequently omitted included labs ordered and named (15.7%) and psychiatric diagnosis (21.6%). Explicit statement of medications initiated with dose and frequency occurred in 47.0% of charts. Our findings provide direction for training and improvement, such as emphasizing the importance of naming labs ordered, medications and doses prescribed, and psychiatric diagnoses in initial assessment clinical notes. We hope this initial assessment helps enhance mental health delivery compliance by prompting creation of BHIS templates, development of audits tools for revisit follow-up visits, and establishment of corrective actions for low-scoring practitioners. These efforts may serve as a model for implementing quality assurance programming in other low resource settings.

Indwelling urinary catheter use at the end of life: a retrospective audit.

This audit aimed to measure: the prevalence of indwelling urinary catheters in patients at the end of life; the use of nursing documentation relating to catheter insertion and care; and prevalence of continence screening on admission. The audit involved a retrospective examination of case notes of patients who died on two oncology wards and a hospice at a large teaching hospital in the south of England. The audit showed that 63% of patients had an indwelling catheter during their admission. Documentation relating to urinary catheter insertion and care was present in 75% of cases, and 75% of patients received continence screening on admission. The findings confirm that indwelling urinary catheters are frequently used as a tool to manage urinary difficulties at the end of life, but that the indications for insertion and continued use can be unclear. Research is needed to establish appropriate use.

Making pain visible: an audit and review of documentation to improve the use of pain assessment by implementing pain as the fifth vital sign.

Pain has been promoted as the fifth vital sign for a decade, but there is little empirical evidence to suggest that doing so has affected the care of individuals suffering pain. This was a three-stage audit of pain assessment in one large teaching hospital in the Northwest of England. Stage one measured the baseline pain assessment activity on surgical and medical wards and identified that the pain assessment tool was not visible to nurses. Stage two redesigned the patient observation charts held at the end of the bed and piloted two versions for clinical utility. Version 2 which had pain assessment alongside the early warning score was adopted and introduced throughout the hospital. Stage three audited pain assessment and management 8 months after the introduction of the new charts. Pain was assessed more regularly at the stage three audit than at the baseline audit. On average, pain was assessed alongside other routine observations 70% of the time across surgical and medical wards. Medical wards appeared to improve their pain assessment using the philosophy of pain being the fifth vital sign better than surgical wards, because they assessed pain alongside routine observations in >90% of cases. Stage three identified that where a high pain score was recorded, analgesia was delivered in the majority of cases (88%). Introducing the philosophy of pain as the fifth vital sign and making pain assessment more visible on the patient observation chart improved the uptake of pain assessment. Pain management strategies were stimulated when high pain scores were identified.

Using supervision to protect vulnerable families.

Sandwell Health Visiting Service identified difficulties in recruiting and retaining health visiting staff and fully meeting the needs of vulnerable families. Following the Laming report, the decision was made to introduce health visiting supervision leads. This resulted in improvements in record keeping and care planning and in better protection and support for vulnerable families.

Using evidence to improve satisfaction with medication side-effects education on a neuro-medical surgical unit.

Patient satisfaction is viewed as a significant indicator of quality of care. More specifically, improving patient satisfaction related to communication about medications and potential side effects can improve healthcare outcomes. Patient satisfaction scores related to medication side effects on a neuro-medical surgical unit were monitored following a quality improvement program. These patients frequently experience cognitive impairment and functional difficulties that can affect the way they understand and handle medications. The purpose of this quality improvement practice change was to (a) develop an educational approach for post acute neurosurgical patients and (b) evaluate whether the use of the approach is successful in improving patient satisfaction scores related to medication education on side effects. The quality improvement program interventions included (a) patient informational handouts inserted into admission folders, (b) nurse education about the importance of providing education on side effects to patient and discussion of their involvement with the program, (c) unit flyers with nurse education, and (d) various communications with bedside nurses through personal work mail and emails. The primary focus was for nurses to employ the "teach back" method to review and reinforce the medication side-effect teaching with patients. Evaluation of the data showed an increase in patient satisfaction after the implementation of the "Always Ask" program.

[Determining the quality of long-term care. A comparative analysis of transparency criteria, resident-related indicators, and staff assessment]. / Messung der Pflegequalität in der Langzeitpflege. Eine vergleichende Analyse von Pflegetransparenzkriterien, bewohnerbezogenen Indikatoren und Beurteilungen der Mitarbeiter.

INTRODUCTION: From 2009, the quality of care in nursing homes in Germany is inspected, rated, and publicized. This study investigates the association between staff-perceived nursing quality, clinical quality indicators, and ratings of health insurance medical services based on the transparency of stationary care agreement (PTVS). METHODS: This was a cross-sectional study merging publicly reported data, clinical quality indicators of a national health provider system, and data from staff surveys. Data from 83 nursing homes were adjusted for sample size, age, and care level and analyzed using Kendall's tau coefficients and scatter plots. RESULTS: There were pronounced differences in staff-perceived nursing quality and some of the clinical indicators between facilities that were not detected by the PTVS. There was a weak association between staff-perceived quality and care quality rated by external inspections. No associations were found between the PTVS and clinical quality indicators. CONCLUSIONS: Differences between nursing home providers were detected to varying degrees by the three approaches and were if at all weakly associated. Given the aims followed by public reporting initiatives of nursing home providers, the results stress the importance of revising the PTVS.

Measures of cultural competence in nurses: an integrative review.

BACKGROUND: There is limited literature available identifying and describing the instruments that measure cultural competence in nursing students and nursing professionals. DESIGN: An integrative review was undertaken to identify the characteristics common to these instruments, examine their psychometric properties, and identify the concepts these instruments are designed to measure. METHOD: There were eleven instruments identified that measure cultural competence in nursing. Of these eleven instruments, four had been thoroughly tested in either initial development or in subsequent testing, with developers providing extensive details of the testing. RESULTS: The current literature identifies that the instruments to assess cultural competence in nurses and nursing students are self-administered and based on individuals' perceptions. The instruments are commonly utilized to test the effectiveness of educational programs designed to increase cultural competence. CONCLUSIONS: The reviewed instruments measure nurses' self-perceptions or self-reported level of cultural competence but offer no objective measure of culturally competent care from a patient's perspective which can be problematic. Comparison of instruments reveals that they are based on a variety of conceptual frameworks and that multiple factors should be considered when deciding which instrument to use.