Examining the relationship between therapeutic self-care and adverse events for home care clients in Ontario, Canada: a retrospective cohort study.

BACKGROUND: In an era of a rapidly aging population who requires home care services, clients must possess or develop therapeutic self-care ability in order to manage their health conditions safely in their homes. Therapeutic self-care is the ability to take medications as prescribed and to recognize and manage symptoms that may be experienced, such as pain. The purpose of this research study was to investigate whether therapeutic self-care ability explained variation in the frequency and types of adverse events experienced by home care clients. METHODS: A retrospective cohort design was used, utilizing secondary databases available for Ontario home care clients from the years 2010 to 2012. The data were derived from (1) Health Outcomes for Better Information and Care; (2) Resident Assessment Instrument-Home Care; (3) National Ambulatory Care Reporting System; and (4) Discharge Abstract Database. Descriptive analysis was used to identify the types and prevalence of adverse events experienced by home care clients. Logistic regression analysis was used to examine the association between therapeutic self-care ability and the occurrence of adverse events in home care. RESULTS: The results indicated that low therapeutic self-care ability was associated with an increase in adverse events. In particular, logistic regression results indicated that low therapeutic self-care ability was associated with an increase in clients experiencing: (1) unplanned hospital visits; (2) a decline in activities of daily living; (3) falls; (4) unintended weight loss, and (5) non-compliance with medication. CONCLUSIONS: This study advances the understanding about the role of therapeutic self-care ability in supporting the safety of home care clients. High levels of therapeutic self-care ability can be a protective factor against the occurrence of adverse events among home care clients. A clear understanding of the nature of the relationship between therapeutic self-care ability and adverse events helps to pinpoint the areas of home care service delivery required to improve clients' health and functioning. Such knowledge is vital for informing health care leaders about effective strategies that promote therapeutic self-care, as well as providing evidence for policy formulation in relation to risk mitigation in home care.

The Role of Interpersonal Relations in Healthcare Team Communication and Patient Safety: A Proposed Model of Interpersonal Process in Teamwork.

Patient safety is compromised by medical errors and adverse events related to miscommunications among healthcare providers. Communication among healthcare providers is affected by human factors, such as interpersonal relations. Yet, discussions of interpersonal relations and communication are lacking in healthcare team literature. This paper proposes a theoretical framework that explains how interpersonal relations among healthcare team members affect communication and team performance, such as patient safety. We synthesized studies from health and social science disciplines to construct a theoretical framework that explicates the links among these constructs. From our synthesis, we identified two relevant theories: framework on interpersonal processes based on social relation model and the theory of relational coordination. The former involves three steps: perception, evaluation, and feedback; and the latter captures relational communicative behavior. We propose that manifestations of provider relations are embedded in the third step of the framework on interpersonal processes: feedback. Thus, varying team-member relationships lead to varying collaborative behavior, which affects patient-safety outcomes via a change in team communication. The proposed framework offers new perspectives for understanding how workplace relations affect healthcare team performance. The framework can be used by nurses, administrators, and educators to improve patient safety, team communication, or to resolve conflicts.

Nurses' Perceptions of Interventions for the Management of Patient-Oriented Outcomes: A Key Factor for Evidence-Based Practice.

BACKGROUND: Various barriers and facilitators to implementing evidence-based interventions in practice have been acknowledged. Nurses' perspectives on these interventions were overlooked as potential factors that influence their uptake in practice. The purpose of this study was to explore nurses' perception of evidence-based interventions targeting patient-oriented outcomes. METHODS: A mixed method design involving concurrent application of quantitative and qualitative approaches was used. Nurses (n = 56) working in acute and rehabilitation care settings completed the Intervention Acceptability scale and responded to open-ended questions. The scale presented information on the components, activities, dose, and mode of delivering evidence-based interventions targeting each patient-oriented outcome (fatigue, nausea and vomiting, dyspnea, pain, physical function, self-care) and items to rate the interventions on five attributes (relevance, applicability, frequency of use, likelihood, and comfort in implementation). The open-ended questions inquired about the appropriateness and resources needed to use the interventions in practice. RESULTS: The quantitative results indicated favorable perceptions of most interventions. Nurses rated acupressure, guided imagery, massage, and relaxation as having limited appropriateness and they reported low levels of comfort in applying them. The qualitative themes clarified the reasons underlying nurses' ratings. LINKING EVIDENCE TO ACTION: This study's findings highlight the importance of examining nurses' perceptions of evidence-based interventions as an initial step toward promoting the adoption of interventions in practice. Effective interventions that are considered of limited relevance are unlikely to be implemented in practice. Nurses' perceptions can guide the design or selection of dissemination strategies to clarify any misconception about the effectiveness and risk of evidence-based interventions.

Technological aspects of hospital communication challenges: an observational study.

OBJECTIVE: To gain insights into how technological communication tools impact effective communication among clinicians, which is critical for patient safety. DESIGN: This multi-site observational study analyzes inter-clinician communication and interaction with information technology, with a focus on the critical process of patient transfer from the Emergency Department to General Internal Medicine. SETTING: Mount Sinai Hospital, Sunnybrook Health Sciences Centre and Toronto General Hospital. PARTICIPANTS: At least five ED and general internal medicine nurses and physicians directly involved in patient transfers were observed on separate occasions at each institution. INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: N/A. RESULTS: The study provides insight into clinician workflow, evaluates current hospital communication systems and identifies key issues affecting communication: interruptions, issues with numeric pagers, lack of integrated communication tools, lack of awareness of consultation status, inefficiencies related to the paper chart, unintuitive user interfaces, mixed use of electronic and paper systems and lack of up-to-date contact information. It also identifies design trade-offs to be negotiated: synchronous communication vs. reducing interruptions, notification of patient status vs. reducing interruptions and speed vs. quality of handovers. CONCLUSIONS: The issues listed should be considered in the design of new technology for hospital communications.

Implementation of the National Nursing Quality Report Initiative in Canada: Insights From Pilot Participants.

A qualitative study was undertaken to explore the perceptions and experiences of nurse leaders associated with their participation in the pilot testing of a national nursing database. Interviews with 18 participants were conducted and analyzed using a direct content analysis approach. Three themes emerged including selecting, accessing, and uploading indicators; using indicators and monitoring tools for improvement; and perceiving involvement as a catalyst. Study findings may inform quality improvement efforts in health care organizations.

Evaluating the late career nurse initiative: a cross-sectional survey of senior nurses in Ontario.

AIM: This study evaluated the impact of the late career nurse initiative on nurse perceptions of their work environment, workplace burnout, job satisfaction, organisational commitment and intention to remain. BACKGROUND: The Ontario Ministry of Health and Long-Term Care introduced the late career nurse initiative with the goal of improving the retention of front-line nurses aged 55 and over by implementing a 0.20 full-time equivalent reduction of physically or psychologically demanding duties, enabling nurses to engage in special projects for the improvement of their organisations and patient care. METHODS: A sample of 902 nurses aged 55 and over from acute and long-term care facilities were surveyed using valid and reliable questionnaires. RESULTS: Nurses who had participated in the initiative did not differ significantly from those who had not in terms of workplace burnout, job satisfaction, length of service or intention to remain within their current organisation. The late career nurse initiative participants reported significantly higher perceptions of managers' ability, leadership and support and their level of participation in hospital affairs. CONCLUSION: The late career nurse initiative was associated with perceived differences in nurses' work environment but not outcomes. IMPLICATIONS FOR NURSING MANAGEMENT: Leaders need to pay attention to how late career nurses are selected and matched to organisational projects.

Identification of serious and reportable events in home care: a Delphi survey to develop consensus.

OBJECTIVE: To assess which client events should be considered reportable and preventable in home care (HC) settings in the opinion of HC safety experts. BACKGROUND: Patient safety in acute care settings has been well documented; however, there are limited data about this issue in HC. While many organizations collect information about 'incidents', there are no standards for reporting and it is challenging to compare incident rates among organizations. DESIGN: A 29-item electronic survey that included potential HC safety issues was used in a two-round Delphi study. SETTING AND PARTICIPANTS: Twenty-four pan-Canadian HC safety experts participated in an electronic survey. MAIN OUTCOME MEASURES: Perceived reportability and preventability of patient safety events, HC. RESULTS: The events that were perceived as being most reportable and preventable included the following: a serious injury related to inappropriate client service plan (e.g. incomplete/inaccurate assessments, poor care plan design, flawed implementation); an adverse reaction requiring emergency room visit or hospitalization related to a medication-related event; a catheter-site infection (e.g. a new peritoneal dialysis infection or peritonitis); any serious event related to care or services that are contrary to current professional or other practice standards (e.g. incorrect treatment regimen, theft, retention of a foreign object in a wound, individual practicing outside scope or competence). CONCLUSION: These data represent an important step in the development and validation of standard metrics about client safety in HC. The results address an expanding area of health services where there is a need to improve standardization and reporting.

Development and Validation of a Self-Care Ability Measure.

Self-care is an outcome of nursing care that is instrumental for promoting recovery and preventing complications following hospitalization. The Therapeutic Self-Care (TSC) measure was developed to assess self-care ability in acute-care settings. Its content was derived from a conceptualization of selfcare generated from an extensive literature review. Clinical experts considered the 13 items of the TSC measure as relevant, supporting its content validity. Findings of 1 study indicate that the items are internally consistent and loaded on 1 factor. The TSC scores correlate with relevant concepts. The TSC measure quantifies patients' perceived ability for self-care, operationalized in behaviours related to taking medications, recognizing and managing symptoms, carrying out activities of daily living, and managing changes in condition. It can be used to guide and evaluate nursing care.

L'autogestion des soins est un résultat de soins infirmiers déterminant pour le rétablissement du patient et la prévention des complications après une hospitalisation. Dans le but d'évaluer la capacité d'autogestion dans un contexte de soins actifs, nous avons élaboré un instrument de mesure appelé Therapeutic Self-Care (TSC). Son contenu est dérivé d'une conceptualisation de l'autogestion fondée sur une vaste synthèse de la recherche sur le sujet. Des experts cliniques ont confirmé la pertinence de ses 13 items et corroboré la validité de son contenu. Une étude a montré que les items ont une cohérence interne et sont représentés par un seul facteur. Les scores corrèlent avec les concepts pertinents. L'instrument quantifie la capacité d'autogestion des soins telle que perçue par le patient, opérationnalisée notamment dans les comportements touchant la prise des médicaments, la reconnaissance des symptômes et leur gestion, l'exécution des activités de la vie quotidienne et la modification de l'état de santé. Il peut servir à guider la prestation des soins infirmiers et à évaluer celle-ci.

The relation of critical care nurses' information-seeking behaviour with perception of personal control, training, and non-routineness of the task.

AIMS: The purpose of the study was to examine the relationship between (1) critical care nurses' information-seeking behaviour and the non-routineness of tasks; and (2) the extent to which nurses' perception of their problem-solving abilities when completing patient care tasks, moderate the relationship between information-seeking behaviour and non-routineness of tasks. METHODS: A cross-sectional survey design was used. A random sample (n = 177) of critical care nurses working in hospital settings was selected from the College of Nurses of Ontario (CNO) database. Descriptive statistics and multiple regression were used to analyze the data. RESULTS: Previous information-seeking training (p = 0.008), non-routineness of the task (p = 0.018), and the perception of the problem-solving ability domain of personal control (p = 0.040) had positive relationships with information-seeking behaviour. CONCLUSIONS: The development of problem-solving skills such as personal control, in addition to information-seeking training is essential so critical care nurses will have the skills to aid their information needs when faced with the completion of non-routine tasks.

The relationship among evidence-based practice and client dyspnea, pain, falls, and pressure ulcer outcomes in the community setting.

BACKGROUND: There are gaps in knowledge about the extent to which home care nurses' practice is based on best evidence and whether evidence-based practice impacts patient outcomes. AIM: The purpose of this study was to investigate the relationship between evidence-based practice and client pain, dyspnea, falls, and pressure ulcer outcomes in the home care setting. Evidence-based practice was defined as nursing interventions based on best practice guidelines. METHODS: The Nursing Role Effectiveness model was used to guide the selection of variables for investigation. Data were collected from administrative records on percent of visits made by Registered Nurses (RN), total number of nursing visits, and consistency of visits by principal nurse. Charts audits were used to collect data on nursing interventions and client outcomes. The sample consisted of 338 nurses from 13 home care offices and 939 de-identified client charts. Hierarchical generalized linear regression approaches were constructed to explore which variables explain variation in client outcomes. RESULTS: The study found documentation of nursing interventions based on best practice guidelines was positively associated with improvement in dyspnea, pain, falls, and pressure ulcer outcomes. Percent of visits made by an RN and consistency of visits by a principal nurse were not found to be associated with improved client outcomes, but the total number of nursing visits was. LINKING EVIDENCE TO ACTION: Implementation of best practice is associated with improved client outcomes in the home care setting. Future research needs to explore ways to more effectively foster the documentation of evidence-based practice interventions.

The safety at home study: an evidence base for policy and practice change.

This paper explores the policies and practices that are needed to improve the safety of home care in light of the most recent evidence about home care safety in Canada. Four areas for policy and practice change are addressed: 1) the promotion of effective communication processes in home care through cross-sector collaboration, case management and technology innovations; 2) screening for safety risk factors; 3) standardizing care processes, packaging and equipment; and 4) supporting family/caregivers and strengthening clients' ability to engage in therapeutic self-care. Evidence-based strategies for change are presented within the context of the evidence about home care safety issues.

Core domains for a person-focused outcome measurement system in cancer (PROMS-Cancer Core) for routine care: a scoping review and Canadian Delphi Consensus.

OBJECTIVES: The objectives of this scoping review study were 1) to identify core domains and dimensions for inclusion in a person-focused and self-reported outcome measurement system for cancer and 2) to reach consensus among key stakeholders including cancer survivors on the relevance, acceptability, and feasibility of a core outcome set for collection in routine clinical care. METHODS: Following a scoping review of the literature, a Rand Delphi consensus method was used to engage key interdisciplinary decision makers, clinicians, and cancer survivors in reaching consensus on a core patient-reported outcome domain taxonomy and outcome measures. RESULTS: Of the 21,900 citations identified in the scoping review, 1,503 citations were included in the full article review (380 conceptual articles, 461 psychometric evaluation articles, and 662 intervention studies) and subjected to data abstraction and mapping. Final consensus was reached on 20 domains, related subdimensions, and 45 self-report measures considered relevant and feasible for routine collection in cancer by the Delphi panel (PROMS-Cancer Core). CONCLUSIONS: Standardization of patient-reported outcome data collection is key to assessing the impact of cancer and treatment on the person for population comparison and monitoring the quality of clinical care. The PROMS-Cancer Core taxonomy of domains and outcome measures can be used to guide the development of a patient-reported outcome information system for cancer.

Adverse events among Ontario home care clients associated with emergency room visit or hospitalization: a retrospective cohort study.

BACKGROUND: Home care (HC) is a critical component of the ongoing restructuring of healthcare in Canada. It impacts three dimensions of healthcare delivery: primary healthcare, chronic disease management, and aging at home strategies. The purpose of our study is to investigate a significant safety dimension of HC, the occurrence of adverse events and their related outcomes. The study reports on the incidence of HC adverse events, the magnitude of the events, the types of events that occur, and the consequences experienced by HC clients in the province of Ontario. METHODS: A retrospective cohort design was used, utilizing comprehensive secondary databases available for Ontario HC clients from the years 2008 and 2009. The data were derived from the Canadian Home Care Reporting System, the Hospital Discharge Abstract Database, the National Ambulatory Care Reporting System, the Ontario Mental Health Reporting System, and the Continuing Care Reporting System. Descriptive analysis was used to identify the type and frequency of the adverse events recorded and the consequences of the events. Logistic regression analysis was used to examine the association between the events and their consequences. RESULTS: The study found that the incident rate for adverse events for the HC clients included in the cohort was 13%. The most frequent adverse events identified in the databases were injurious falls, injuries from other than a fall, and medication-related incidents. With respect to outcomes, we determined that an injurious fall was associated with a significant increase in the odds of a client requiring long-term-care facility admission and of client death. We further determined that three types of events, delirium, sepsis, and medication-related incidents were associated directly with an increase in the odds of client death. CONCLUSIONS: Our study concludes that 13% of clients in homecare experience an adverse event annually. We also determined that an injurious fall was the most frequent of the adverse events and was associated with increased admission to long-term care or death. We recommend the use of tools that are presently available in Canada, such as the Resident Assessment Instrument and its Clinical Assessment Protocols, for assessing and mitigating the risk of an adverse event occurring.

Conceptual framework of acute care nurse practitioner role enactment, boundary work, and perceptions of team effectiveness.

AIM: This article describes a new conceptual framework for acute care nurse practitioner role enactment, boundary work and perceptions of team effectiveness. BACKGROUND: Acute care nurse practitioners contribute positively to patient care by enacting an expanded scope of practise. Researchers have found both positive and negative reactions to the introduction of acute care nurse practitioners in healthcare teams. The process of role enactment, shifting role boundaries, and perceptions of team effectiveness has been studied disparately. A framework linking team structures and processes to desirable outcomes is needed. DATA SOURCES: Literature was obtained by searching CINAHL, PsycInfo, MedLine, PubMed, British Nursing Index, Cochrane Library, JSTOR Archive, Web of Science, and Google Scholar from 1985-2010. A descriptive multiple-case study was completed from March 2009-May 2009. DISCUSSION: A new conceptual framework describing how role enactment and boundary work affect perceptions of team effectiveness was developed by combining theoretical and empirical sources. The framework proposes proximal indicators used by team members to assess their team's performance. IMPLICATIONS FOR NURSING: The framework identifies the inter-related dimensions and concepts that different stakeholders need to consider when introducing nurse practitioners in healthcare teams. Further study is needed to identify team-level outcomes that reflect the contributions of all providers to quality patient care, and explore the patients' and families' perceptions of team effectiveness following the introduction of acute care nurse practitioners. CONCLUSION: The new framework can guide decision-making and research related to the structures, processes, and outcomes of nurse practitioner roles in healthcare teams.

A formative evaluation of nurses' use of electronic devices in a home care setting.

The purpose of this study was to evaluate the implementation of a clinical information system (CIS) in a community setting. The researchers used a mixed-method design involving interviews, focus groups, and surveys. An independent cross-sectional sample of nurses was surveyed. At time 1 a total of 118 nurses responded and at time 2 a total of 81. Respondents were moderately satisfied with features of the CIS. User satisfaction was positively associated with access to structural and electronic resources and social capital and negatively associated with nurses' age at time 1. Social capital was positively associated with user satisfaction at time 2. Younger age was associated with overall research use at both time 1 and time 2. Research use was negatively associated with evaluation and feedback but positively associated with formal interactions. This evaluation identified the importance of educational support, user-centred design, and responsiveness to successful implementation of CISs in a community setting.

Boundary work and the introduction of acute care nurse practitioners in healthcare teams.

AIM: This article is a report of a study of boundary work following the introduction of an acute care nurse practitioner role in healthcare teams. BACKGROUND: Acute care nurse practitioners enacting their roles in healthcare teams have faced a number of challenges including a mix of positive and negative views of the acute care nurse practitioner role from healthcare team members and acute care nurse practitioner roles crossing the boundaries between the medical and nursing professions. Understanding the process by which the boundaries between professions changed following the introduction of an acute care nurse practitioner role was important since this could affect scope of practice and the team's ability to give patient care. METHODS: The study was conducted in two university-affiliated teaching hospitals in Canada. A descriptive multiple case study design was used. Data were collected from March to May 2009. RESULTS: Participants (N = 59) described boundary work as a process that included: (1) creating space; (2) loss of a valued function; (3) trust; (4) interpersonal dynamics; and (5) time. The development of trust among team members was essential. The co-location of team members working on common projects, and medical and nursing leadership facilitated boundary work. CONCLUSION: The micro-level processes of boundary work in healthcare teams have important implications for the development of full scope of practice for acute care nurse practitioners, effective inter-professional teamwork and the integration of new roles in healthcare systems. Future research needs to be undertaken in different contexts, and with patients and families.

Examining nursing vital signs documentation workflow: barriers and opportunities in general internal medicine units.

AIMS: To characterise the nursing practices of vital signs collection and documentation in a general internal medicine environment to inform strategies for improving workflow design. BACKGROUND: Clinical workflow analysis is critical to identify barriers and opportunities in current processes. Analysis can guide the design and development of novel technological solutions to produce greater efficiencies and effectiveness in healthcare delivery. Research surrounding vital signs documentation workflow in general internal medicine environments has received very little attention making it difficult to compare the effectiveness of new technologies. DESIGN: Qualitative ethnographic analyses and quantitative time-motion study were conducted. METHODS: Workflows of 24 nurses at three hospitals in five general internal medicine environments were captured, and timeliness of vital signs assessment and documentation was measured. RESULTS: Clinical assessment of vital signs was consistent, but the documentation process was highly variable within groups and between hospitals. Two themes characterised workflow barriers surrounding point-of-care documentation. First, a lack of standardised documentation methods for vital signs resulted in higher rates of transcription, increasing not only the likelihood of errors but delays in recording and accessibility of information. Second, despite advancements in electronic documentation systems, the observed system was not conducive to point-of-care documentation. Average electronic documentation was significantly longer than paper documentation. Nurses developed ad hoc workarounds that were inefficient and undermined the intent of electronic documentation. CONCLUSION: We have identified barriers and opportunities to improve the efficiency of nursing vital signs documentation. Changes in technology, workflows and environmental design allow for significant improvements and deserve further exploration. RELEVANCE TO CLINICAL PRACTICE: Attention to clinical practice and environments can improve the workflow of prompt vital signs documentation and increase clinical productivity and timeliness of information for clinical decisions, as well as minimising transcription errors leading to safer patient care.

Usability evaluation: results from "Evaluation of mobile information technology to improve nurses' access to and use of research evidence".

Usability evaluations are necessary to determine the feasibility of nurses' interactions with computerized clinical decision-support systems. Limitations and challenges of operations that inhibit or facilitate utilization in clinical practice can be identified. This study provided nurses with mobile information terminals, PDAs and tablet PCs, to improve point-of-care access to information. The purpose of this study was to determine usability issues associated with point-of-care technology. Eleven nurses were self-selected. Nurses were videotaped and audiotaped completing four tasks, including setting up the device and three resource search exercises. A research team member completed a usability checklist. Completion times for each task, success rate, and challenges experienced were documented. Four participants completed all tasks, with an average time of 3 minutes 22 seconds. Three participants were unable to complete any of the three tasks. Navigating within resources caused the greatest occurrence of deviations with 39 issues among all participants. Results of the usability evaluation suggest that nurses require a device that (1) is manageable to navigate and (2) utilizes a user-friendly interface, such as a one-time log-in system. Usability testing can be helpful to organizations as they document issues to be cognizant of during the implementation process, increasing the potential for successful implementation and sustained usability.

Work-related empowerment of nurse managers: a systematic review.

The present study discusses how nurse managers' work-related empowerment has been investigated, in order to determine the level and relationships of empowerment among them. A systematic review was carried out, and a literature search was conducted with certain electronic databases for the period 1990-2009, using the main key words in various combinations. Only nine empirical studies in English were selected for review, in accordance with the requirements for the methodological quality and inclusion criteria. The most common type of study design was a descriptive survey (n = 5), and included various questionnaires, scales, and interviews. Nurse managers' structural, psychological, and work empowerment was found to be high or moderately high. The empowerment of nurse managers correlated positively with job satisfaction, perceived organizational support, role satisfaction, and managerial self-efficacy, and correlated negatively with emotional exhaustion and own health outcomes. Different theoretical approaches ensure a clear understanding of empowerment, but difficulties arise when the findings are synthesized across studies and settings because of the different theoretical frameworks used to conceptualize empowerment.

Critical care nurses' information-seeking behaviour during an unfamiliar patient care task.

Critical care nurses complete tasks during patient care to promote the recovery or maintain the health of their patients. These tasks can be routine or non-routine to the nurse. Non-routine tasks are characterized by unfamiliarity, requiring nurses to seek additional information from a variety of sources to effectively complete the tasks. Critical care units are dynamic environments where decisions are often made by nurses under stress and time pressure because patient status changes rapidly. A non-routine task (e.g., administration of an unfamiliar medication) to the critical care nurse can impact patient care outcomes (e.g., increased time to complete task has consequences for the patient). In this article, the authors discuss literature reviewed on nurses' information-seeking and explore an information-seeking conceptual model that will be used as a guide to examine the main concepts found through the empirical evidence.