Healthcare Provider Perceptions of Causes and Consequences of ICU Capacity Strain in a Large Publicly Funded Integrated Health Region: A Qualitative Study.

OBJECTIVES: Discrepancy in the supply-demand relationship for critical care services precipitates a strain on ICU capacity. Strain can lead to suboptimal quality of care and burnout among providers and contribute to inefficient health resource utilization. We engaged interprofessional healthcare providers to explore their perceptions of the sources, impact, and strategies to manage capacity strain. DESIGN: Qualitative study using a conventional thematic analysis. SETTING: Nine ICUs across Alberta, Canada. SUBJECTS: Nineteen focus groups (n = 122 participants). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Participants' perspectives on strain on ICU capacity and its perceived impact on providers, families, and patient care were explored. Participants defined "capacity strain" as a discrepancy between the availability of ICU beds, providers, and ICU resources (supply) and the need to admit and provide care for critically ill patients (demand). Four interrelated themes of contributors to strain were characterized (each with subthemes): patient/family related, provider related, resource related, and health system related. Patient/family-related subthemes were "increasing patient complexity/acuity," along with patient-provider communication issues ("paucity of advance care planning and goals-of-care designation," "mismatches between patient/family and provider expectations," and "timeliness of end-of-life care planning"). Provider-related factor subthemes were nursing workforce related ("nurse attrition," "inexperienced workforce," "limited mentoring opportunities," and "high patient-to-nurse ratios") and physician related ("frequent turnover/handover" and "variations in care plan"). Resource-related subthemes were "reduced service capability after hours" and "physical bed shortages." Health system-related subthemes were "variable ICU utilization," "preferential "bed" priority for other services," and "high ward bed occupancy." Participants perceived that strain had negative implications for patients ("reduced quality and safety of care" and "disrupted opportunities for patient- and family-centered care"), providers ("increased workload," "moral distress," and "burnout"), and the health system ("unnecessary, excessive, and inefficient resource utilization"). CONCLUSIONS: Engagement with frontline critical care providers is essential for understanding their experiences and perspectives regarding strained capacity and for the development of sustainable strategies for improvement.

Variability of staffing and staff mix across acute care units in Alberta, Canada.

BACKGROUND: The health workforce has a crucial position in healthcare, and effective distribution of the workforce is one of the critical areas for healthcare improvement. This requires a proper understanding of the allocation of healthcare providers including staffing levels and staffing variability within a healthcare system. High variability may imply significant differences in outcomes and greater opportunity to better distribute staffing and improve patient outcomes. The objective of this study was to examine staffing variation across acute care units in a large and integrated healthcare system. METHODS: We used survey and administrative data on full time equivalencies of Registered Nurses, Licensed Practical Nurses, Health Care Aides, and allied health staff for 287 acute care units to examine staffing levels across multiple unit types. We used a subsample of 157 units in a more detailed analysis of staffing levels and staff distribution. RESULTS: Results from the full sample indicate that staffing levels, particularly for Registered Nurses, vary substantially across unit types. Subsample analyses showed that the highest variation in staffing levels occurred in rural units, which also had higher average staffing for licensed practical nurses and allied health staff. Rural units had fewer Health Care Aides than did other units. The majority of units were staffed with a combination of all three nursing providers, but the most common arrangement in rural units was staffing of Registered Nurses and Licensed Practical Nurses only. We also found that units with the highest number Registered Nurses also tended to have higher numbers of other staff, particularly allied health providers. CONCLUSIONS: We observed significant variation in staffing levels and mix in acute care units. Some of the differences might be attributable to differences in patient needs and unit types. However, we also observed high variability in units with similar services and patient populations. As other research has shown that staffing is linked to differences in patient outcomes, there is an important opportunity to improve staffing for greater efficiency and higher quality care.

Introduction of a team-based care model in a general medical unit.

BACKGROUND: Alberta Health Services is a provincial health authority responsible for healthcare for more than four million people. The organization recognized a need to change its care delivery model to make care more patient- and family-centred and use its health human resources more effectively by enhancing collaborative practice. A new care model including changes to how providers deliver care and skill mix changes to support the new processes was piloted on a medical unit in a large urban acute care hospital Evidence-based care processes were introduced, including an initial patient assessment and orientation, comfort rounds, bedside shift reports, patient whiteboards, Name Occupation Duty, rapid rounds, and team huddles. Small teams of nurses cared for a portion of patients on the unit. The model was intended to enhance safety and quality of care by allowing providers to work to full scope in a collaborative practice environment. METHODS: We evaluated the new model approximately one year after implementation using interviews with staff (n = 15), surveys of staff (n = 25 at baseline and at the final evaluation) and patients (n = 26 at baseline and 37 at the final evaluation), and administrative data pulled from organizational databases. RESULTS: Staff interviews revealed that overall, the new care processes and care teams worked quite well. Unit culture and collaboration were improved, as were role clarity, scope of practice, and patient care. Responses from staff surveys were also very positive, showing significant positive changes in most areas. Patient satisfaction surveys showed a few positive changes; scores overall were very high. Administrative data showed slight decreases in overall length of stay, 30-day readmissions, staff absenteeism, staff vacancies, and the overtime rate. We found no changes in unit length of stay, 30-day returns to emergency department, or nursing sensitive adverse events. CONCLUSIONS: Conclusions from the evaluation were positive, providing initial support for the idea of the collaborative practice model vision for adult medical units across Alberta. There were also a few positive effects on patient care suggesting that models such as this one could improve the organization's ability to deliver sustainable, high-quality, patient- and family-centred care without compromising quality.

Exploring the relationship between governance mechanisms in healthcare and health workforce outcomes: a systematic review.

BACKGROUND: The objective of this systematic review of diverse evidence was to examine the relationship between health system governance and workforce outcomes. Particular attention was paid to how governance mechanisms facilitate change in the workforce to ensure the effective use of all health providers. METHODS: In accordance with standard systematic review procedures, the research team independently screened over 4300 abstracts found in database searches, website searches, and bibliographies. Searches were limited to 2001-2012, included only publications from Canada, the United Kingdom, the Netherlands, New Zealand, Australia, and the United States. Peer- reviewed papers and grey literature were considered. Two reviewers independently rated articles on quality and relevance and classified them into themes identified by the team. One hundred and thirteen articles that discussed both workforce and governance were retained and extracted into narrative summary tables for synthesis. RESULTS: Six types of governance mechanisms emerged from our analysis. Shared governance, Magnet accreditation, and professional development initiatives were all associated with improved outcomes for the health workforce (e.g., decreased turnover, increased job satisfaction, increased empowerment, etc.). Implementation of quality-focused initiatives was associated with apprehension among providers, but opportunities for provider training on these initiatives increased quality and improved work attitudes. Research on reorganization of healthcare delivery suggests that changing to team-based care is accompanied by stress and concerns about role clarity, that outcomes vary for providers in private versus public organizations, and that co-operative clinics are beneficial for physicians. Funding schemes required a supplementary search to achieve adequate depth and coverage. Those findings are reported elsewhere. CONCLUSIONS: The results of the review show that while there are governance mechanisms that consider workforce impacts, it is not to the extent one might expect given the importance of the workforce for improving patient outcomes. Furthermore, to successfully implement governance mechanisms in this domain, there are key strategies recommended to support change and achieve desired outcomes. The most important of these are: to build trust by clearly articulating the organization's goal; considering the workforce through planning, implementation, and evaluation phases; and providing strong leadership.

Emotional and behavioural problems of children with autism spectrum disorder attending mainstream schools.

Emotional and behavioural problems occur more commonly in children with Autism Spectrum Disorder (ASD) compared to other children. Few studies have focused on these problems in children with ASD attending mainstream schools. We assessed via parent report the emotional and behavioural problems in 160 children aged 4-17 years with ASD attending mainstream schools and investigated differences between the primary and secondary aged children. Children with ASD had higher levels of problems across all domains of the Strengths and Difficulties Questionnaire (SDQ) compared to UK norms. Within the ASD sample, SDQ scores were associated with male sex, living in a household with more children, more severe autism symptoms and fewer adaptive skills, and higher levels of family socio-economic risk. No robust primary-secondary school differences were found. Implications for future research and the support of children with ASD in mainstream school settings are discussed.

Mind the gap: governance mechanisms and health workforce outcomes.

Attempts at health system reform have not been as successful as governments and health authorities had hoped. Working from the premise that health system governance and changes to the workforce are at the heart of health system performance, we conducted a systematic review examining how they are linked. Key messages from the report are that: (1) leadership, communication and engagement are crucial to workforce change; (2) workforce outcomes need to be considered in conjunction with patient outcomes; and (3) decision-makers and researchers need to work together to develop an evidence base to inform future reform planning.