Intentional rounding: a realist evaluation using case studies in acute and care of older people hospital wards.

BACKGROUND: In response to concerns about high hospital mortality rates, patient and carer complaints, a Mid Staffordshire NHS Foundation Trust public inquiry was conducted at the request of the UK government. This inquiry found serious failures in the quality of basic care provided and as a consequence, recommended that patients should have more regular visits, organised at predictable times from nursing staff. Intentional rounding, also known as nursing ward rounds, was widely adopted to meet this need. OBJECTIVE: To test, refine or refute eight programme theories to understand what works, for whom, and in what circumstances. SETTING: Six wards (older people and acute wards) in three NHS trusts in England. PARTICIPANTS: Board level and senior nursing managers (N = 17), nursing ward staff (N = 33), allied health and medical professionals (N = 26), patients (N = 34) and relatives (N = 28) participated in an individual, in-depth interview using the realist method. In addition, ward-based nurses (N = 39) were shadowed whilst they conduced intentional rounds (240 rounds in total) and the direct care of patients (188 h of patient care in total) was observed. METHODS: The mixed methods design included: Phase (1) Theory development - A realist synthesis was undertaken to identify any programme theories which were tested, refined and/or refuted, using data from phases 2 and 3; Phase (2) A survey of all English NHS acute Trusts; Phase (3) Six case studies of wards involving realist interviews, shadowing and non-participant observations, analysis of ward outcome and cost data; and Phase (4) Synthesis of findings from phases 1, 2 and 3. RESULTS: The realist synthesis identified eight programme theories of intentional rounding: 'Consistency and comprehensiveness', 'Accountability', 'Visibility of nurses', 'Anticipation', 'Allocated time to care', 'Nurse-patient relationships', 'Multi-disciplinary teamwork and communication' and 'Patient empowerment'. Key findings showed that of the original eight programme theories of intentional rounding, only two partially explained how the intervention worked ('Consistency and comprehensiveness' and 'Accountability'). Of the remaining six programme theories, the evidence for two was inconclusive ('Visibility of nurses' and 'Anticipation') and there was no evidence for four ('Allocated time to care'; 'Nurse-patient relationships'; 'Multi-disciplinary teamwork and communication'; and 'Patient empowerment'). CONCLUSIONS: This first theory-informed evaluation of intentional rounding, demonstrates that the effectiveness of intentional rounding in the English healthcare context is very weak. Furthermore, the evidence collected in this study has challenged and refuted some of the underlying assumptions about how intentional rounding works. This study has demonstrated the crucial role context plays in determining the effectiveness of an intervention and how caution is needed when implementing interventions developed for the health system of one country into another.

Implementing mixed nursing care teams in intensive care units during COVID-19: A rapid qualitative descriptive study.

AIMS: The goal of this study was to gain insight into the views and experiences of an intensive care team working in a new nursing-care delivery model during the COVID-19 waves. A new model of care was implemented to augment nursing capacity and provide sufficient intensive care beds. DESIGN: A qualitative monocentric study using rapid qualitative descriptive methods was reported in line with the COREQ checklist. METHODS: Nurse, ward manager and physician participants were purposively recruited between January and March 2021 in a tertiary university-affiliated hospital in the Flemish-speaking part of Belgium. Semistructured interviews were conducted and analysed using thematic analysis methods. RESULTS: The participants were seventeen expert nurses, twelve supporting nurses, seven ward managers and four physicians. A central theme of ensuring safe, high-quality care emerged from the findings. There was a sense of losing one's grip on clinical practice when working in the mixed nursing-care teams. Different underlying experiences played a part in this sense of losing control: dealing with unknown elements, experiencing role ambiguity, struggling with responsibility and the absence of trust. Several coping mechanisms were developed by the nursing-care team to deal with those experiences, including attempts to create stability, to strike a balance between delegating and educating, to build in control and to communicate openly. CONCLUSION: In this rapid qualitative descriptive study, the implementation of a new nursing-care delivery model during a pandemic was seen to lead to several challenges for all members of the care team. Coping mechanisms were developed by the team to deal with these experienced challenges. IMPACT: When rethinking nursing-care delivery models, the findings of this study may help guide the process of implementing mixed nursing-care teams. Special attention needs to be paid to clarifying roles, sharing responsibility and clinical leadership. Other significant influences (such as moral distress) should also be taken into account.

The effect of nursing care delivery models on quality and safety outcomes of care: A cross-sectional survey study of medical-surgical nurses.

AIMS: This study examined the effect of two components of a model of nursing care delivery, the mode of nursing care delivery, and skill-mix on: (a) quality of nursing care; and (b) patient adverse events, after controlling for nurse demographics, work environment, and workload factors. DESIGN: A cross-sectional exploratory correlational study that drew on secondary data was conducted. METHODS: Survey data from 416 direct care registered nurses from medical-surgical settings across British Columbia were analysed using hierarchical multiple regression. Larger study data were collected in 2015. RESULTS: Nurses working in a team-based mode reported a greater number of nursing tasks left undone compared with those working in a total patient care. Nurses working in a skill-mix with licensed practical nurses reported a higher frequency of patient adverse events compared with those working in a skill-mix without licensed practical nurses. At higher levels of acuity, nurses in a team-based mode reported a higher frequency of patient adverse events than did nurses in a total patient care. CONCLUSION: Models of nursing care delivery components, mode and skill-mix, influenced quality and safety outcomes. Some of the team-based medical-surgical nurses in British Columbia are not functioning as effective teams. Team building strategies should be used to enhance collaboration among them. IMPACT: Research into redesigning care delivery has typically focused on only one care delivery component at a time. The study findings could have implications for nurses and patients, nursing leadership and policymakers particularly in medical-surgical settings in British Columbia.

Do Bedside Handovers Reduce Handover Duration? An Observational Study With Implications for Evidence-Based Practice.

INTRODUCTION: Bedside handover is increasingly used and studied in nursing due to the method's acclaimed positive effects on patient safety, patient participation, communication, and efficiency. Still, reported results about its impact on handover duration are ambiguous. Revealing the root cause of these ambiguous effects is important, as increased duration could lead to overtime, lower job satisfaction, and failure in implementation. In contrast, decreased handover duration could lead to more efficient nursing care and facilitate implementation. AIM: To explore the effects of bedside handovers on the handover duration by comparing wards before and after the implementation of bedside handovers. METHODS: As part of a multicentered longitudinal study, observations (N = 638) with time measurement were performed. Approximately 22% of the observations were performed by two researchers to check reliability. These time measurements were compared to the handover duration before the implementation of bedside handover, determined through interviews (n = 105), unstructured observations (n = 40), and a review of time schedules (n = 12). A descriptive, comparative research design was used. RESULTS: On average, a bedside handover takes 146 s for one patient (83 s-204 s). Depending on the previously used handover model, the number of patients allocated to each nurse, and the use of a structured handover content, time gain or loss as a result of introducing the bedside handover can be expected. LINKING EVIDENCE TO ACTION: The effect on time depends on the organizational changes necessary for the implementation of bedside handovers, most importantly the use of a decentralized handover model and structured handover content. Implementing bedside handover will therefore not always lead to a decrease in time use. A matrix for estimating the effects of bedside handover on time use is presented. While using bedside handovers will not always lead to decreased handover time, it will increase direct patient contact, increasing the possibilities for patient participation and enhancing patient safety.

Clinical Nurse Leader Integrated Care Delivery to Improve Care Quality: Factors Influencing Perceived Success.

PURPOSE: Clinical nurse leader(TM) (CNL)-integrated care delivery is a new model for organizing master's-level nursing clinical leadership at the microsystem level. While there is growing evidence of improved patient care quality and safety outcomes associated with CNL practice, organizational and implementation characteristics that influence CNL success are not well characterized. The purpose of this study was to identify organization and implementation factors associated with perceived success of CNL integration into microsystem care delivery models. METHODS: A survey was developed and administered to a nationwide sample of certified CNLs and managers, leaders, educators, clinicians, and change agents involved in planning or integrating CNLs into a health system's nursing care delivery model. Items addressed organizational and implementation characteristics and perceived level of CNL initiative success. Generalized linear modeling was used to analyze data. RESULTS: The final sample included 585 respondents. The final model accounted for 35% of variance in perceived CNL initiative success, and included five variables: phase of CNL initiative, CNL practice consistency, CNL instructor or preceptor involvement, CNL reporting structure, and CNL setting ownership status. CONCLUSIONS: CNL initiative success is associated with modifiable organizational and implementation factors. CLINICAL RELEVANCE: Study findings can be used to inform the development of successful implementation strategies for CNL practice integration into care delivery models to improve care quality outcomes.

The changing boundaries of nursing: a qualitative study of the transition to a new nursing care delivery model.

AIMS AND OBJECTIVES: To explore how nursing personnel have experienced the introduction of a new nursing care delivery model within their setting. BACKGROUND: New ways of nursing care are being implemented in many countries to contain rising health care costs and deal with ongoing nursing shortages. The adoption of new nursing care delivery models will have a substantial impact on the nature of nursing practice. DESIGN: A qualitative design was used for this study. Symbolic interactionism was used as a guiding framework. METHODS: Semi-structured interviews were held with 20 nurses (17 registered nurses and 3 ancillary nursing personnel) in two hospitals in eastern Canada following the introduction of a new nursing care nursing model. The constant comparative method was used to analyse interview data. RESULTS: Four themes emerged from the data: (1) the ownership of tasks, (2) managing the workers, (3) a different way of knowing the patient and (4) the struggle to change. CONCLUSIONS: Nursing boundaries were flexible, regardless of the implementation of a new nursing care delivery model. Nursing tasks shifted from one group of workers to another during the course of the day to meet patient needs. RELEVANCE TO CLINICAL PRACTICE: This study highlights the challenges in relation to the introduction of new nursing care delivery models within hospital settings.

The specialized role of the RN in the Program of All-inclusive Care for the Elderly (PACE) interdisciplinary care team.

There is an increasing volume of literature supporting the Program of All-inclusive Care for the Elderly (PACE) as an innovative model of health care delivery for frail seniors. Registered Nurses (RN) hold an essential position among the PACE interdisciplinary teams (IDT) which serve as the foundational practice approach to patient care. There are currently 97 PACE programs in 31 states. Federal and respective state laws provide comprehensive specifications for IDT composition, minimum qualification of team members and services provided. The role of the RN is not fully defined beyond the requirement of periodic assessments. The intent of this study was to explore and describe the role of the nurse in PACE and to compare nursing care delivery models. Focused interviews and survey results show great variation in nursing roles as well as some common themes among nursing leaders for the vision of PACE nurses.

Nursing Care Delivery Models and Intraprofessional Collaborative Care: Canadian Nurse Leaders' Perspectives.

Introduction: There are many different types of nursing care delivery models used to organize and provide care in hospitals. These models are comprised of different organizational structures and staffing skill mixes. Objective: The aim of this study was to explore how nursing care delivery models promote intraprofessional collaborative care in acute care hospitals from the perspectives of nurse leaders. Methods: A qualitative descriptive approach was used for this study. Telephone interviews were conducted between January 2021 and August 2021 using an interview guide comprised of semi-structured and structured questions. Using a purposeful sampling technique, ten leaders from nine hospital systems, representing both urban and rural hospitals in the province of Ontario, Canada, participated in the study. Content analysis was conducted resulting in two overarching themes. Results: The first theme, Fluidity of the Model addresses the flexibility of the models and the impact of contextual factors such as changes in nurses' scope of practice, government funding changes, staffing mix, and organizational policies and rules. The second theme, Tools of the Trade describes the resources that hospitals implement to promote intraprofessional collaboration that indirectly impacts on patient safety. Conclusion: Nursing care delivery models need to be flexible and adaptable. All nursing care delivery models in this study used various tools to promote intraprofessional collaborative care.

The Relationship Between Nursing Care Delivery Models, Emotional Exhaustion, and Quality of Nursing Care Among Jordanian Registered Nurses.

Background: Inappropriately selected models of nursing care delivery and emotional exhaustion of nurses at work not only affect the nurses' health, but also the health of their patients. Purpose: To examine the relationship between nursing care delivery models, nurses' emotional exhaustion, and quality of nursing care. Methods: A cross-sectional survey that used a convenience sampling technique was employed. A total of 160 participants completed the study. Participants provided information about nursing care delivery models, nurses, emotional exhaustion, and quality of nursing care. Results: Participants had a moderate level of emotional exhaustion. No statistically significant difference in the scores of quality of nursing care and emotional exhaustion were found according to the type of care delivery model (P > .05). Emotional exhaustion was significantly and negatively correlated with the (nursing staff characteristics) subscale of quality of nursing care (r = -.183, P = .021). There was a significant difference in emotional exhaustion in regard to shift duty, marital status, education level, years of experience, salary, and working area). Only marital status significantly predicted emotional exhaustion (t = 2.57, B = -8.98, P = .011). Conclusions: Quality of nursing care was associated with nurses' emotional exhaustion rather than models of nursing care delivery. As nurses' emotional exhaustion could negatively affect the quality of nursing care, addressing the emotional exhaustion of nurses is important to improve patient outcomes.

Care Perceptions in two ICU Nursing Care Delivery Models: A qualitative-comparative approach.

OBJECTIVES: Analyzed in compared perspective perceptions about nursing care, nurse-patient interaction, and nursing care outcomes in two ICU nursing staff in a high-complexity hospital institution, whose Nursing are Delivery Models (NCDM) are differentiated by the proportion of nurses and nurse assistants (NA) per team and by the assigned tasks and responsibilities. METHODS: Particularist ethnography with adaptation to virtual methodologies. It included the sociodemographic characteristics of 19 nurses and 23 NA, 14 semi-structured interviews, review of patients' clinical records, and a focus group. Coding, categorization, inductive analysis, validation of results with participants were conducted and thematic saturation was achieved. RESULTS: Four themes were identified: i) Professionalized care: a nursing of superior value; ii) senses and feelings of care; iii) nursing workload, generating factors and impacts; and iv) nursing missed care as concrete expression of the nursing workload. CONCLUSIONS: Compared nursing teams perceived nursing care in different ways, since it was experienced based on the assigned responsibilities and the possibilities of interaction with patients. Nursing care in the NCDM of the ICU with prevalence of direct bedside care by nurses with support from NA, it was perceived as holistic, comprehensive, and empathetic; whereas in the ICU with prevalence of delegated care to NA, it was related with administrative leadership and management of the ICU. Regarding the results, the NCDM of the ICU of direct bedside care by nurses showed better performance in patient safety and was closer to the skill level and legal responsibility of the nursing staff.

Nursing care delivery models and outcomes: A literature review.

OBJECTIVE: The purpose of this literature review was to determine the types of nursing care delivery models currently being used in acute care hospitals to determine the effectiveness of the model and the outcomes being measured. METHOD: A literature search was conducted, and databases searched included CINAHL, Nursing and Allied Health, Medline, EMBASE, ProQuest Theses, and Dissertations for the years 2000-2020. Sixteen studies were retrieved. Patient outcomes measured included falls, adverse events, and infections. Nursing outcomes measured included satisfaction, communication, and perceived quality of care. RESULTS: Findings from this review showed there was no single model of nursing care delivery that resulted in positive patient or nurse outcomes, thus a "one size fits all" approach to selecting or utilizing a model of care is not realistic. CONCLUSION: Given the number of nursing care delivery models that were hybrids, clearer descriptions of each model and further research on patient and nursing outcomes is warranted.

A study protocol to evaluate the implementation and effectiveness of the Clinical Nurse Leader Care Model in improving quality and safety outcomes.

AIMS: Patients are harmed or die every year because of unsafe, inappropriate or inadequate healthcare delivery. Registered Nurses are a recognized patient safety strategy. However, variability in research findings indicate the relationship is not as simple as "more nurses=better outcomes." Hence, currently there exists no evidence-based frontline nursing care model. One emerging model is the Clinical Nurse Leader care model. DESIGN: This Hybrid Type II Implementation-Effectiveness study will evaluate the effect of the care model on standardized quality and safety outcomes and identify implementation characteristics that are sufficient and necessary to achieve outcomes. METHODS: This study leverages a natural experiment in 66 clinical care units in nine hospitals across five states in the United States that have implemented the Clinical Nurse Leader care model. RESULTS: Findings will elucidate Registered Nurse's mechanisms of action as organized into frontline models of care and link actions to improved care quality and safety.

Care Perceptions in two ICU Nursing Care Delivery Models: A qualitative-comparative approach / Percepciones del cuidado en dos modelos de atención de enfermería en UCI: aproximación cualitativa-comparativa / Percepções de cuidado em dois modelos de assistência de enfermagem em UTI: uma abordagem qualitativo-comparativa

Objective. Analyzed in compared perspective perceptions about nursing care, nurse-patient interaction, and nursing care outcomes in two ICU nursing staff in a high-complexity hospital institution, whose Nursing are Delivery Models (NCDM) are differentiated by the proportion of nurses and nurse assistants (NA) per team and by the assigned tasks and responsibilities. Methods. Particularist ethnography with adaptation to virtual methodologies. It included the sociodemographic characteristics of 19 nurses and 23 NA, 14 semi-structured interviews, review of patients' clinical records, and a focus group. Coding, categorization, inductive analysis, validation of results with participants were conducted and thematic saturation was achieved. Results. Four themes were identified: i) Professionalized care: a nursing of superior value; ii) senses and feelings of care; iii) nursing workload, generating factors and impacts; and iv) nursing missed care as concrete expression of the nursing workload. Conclusion. Compared nursing teams perceived nursing care in different ways, since it was experienced based on the assigned responsibilities and the possibilities of interaction with patients. Nursing care in the NCDM of the ICU with prevalence of direct bedside care by nurses with support from NA, it was perceived as holistic, comprehensive, and empathetic; whereas in the ICU with prevalence of delegated care to NA, it was related with administrative leadership and management of the ICU. Regarding the results, the NCDM of the ICU of direct bedside care by nurses showed better performance in patient safety and was closer to the skill level and legal responsibility of the nursing staff.

Objetivo. Analizar en perspectiva comparada las percepciones sobre el cuidado de enfermería, el relacionamiento con los pacientes y los resultados del cuidado en dos equipos de enfermería de UCI de una institución hospitalaria de alta complejidad, cuyos Modelos de Atención de Enfermería (MAE) se diferencian por la proporción de enfermeras y Auxiliares de Enfermería (AE) por equipo y por las tareas y responsabilidades asignadas. Métodos. Etnografía particularista con adaptación a metodologías virtuales. Incluyó la caracterización sociodemográfica a 19 enfermeras y 23 AE, 14 entrevistas semiestructuradas, revisión de historias clínicas de pacientes y un grupo focal. Se realizó codificación, categorización, análisis inductivo, validación de resultados con participantes y se logró la saturación temática. Resultados. Se identificaron cuatro temas: i) Cuidados profesionalizados: una enfermería de valor superior ii) sentidos y sentires del cuidado iii) carga de cuidado, factores generadores e impactos y iv) omisión del cuidado como expresión concreta de la carga de trabajo. Conclusión. Los equipos de Enfermería comparados percibieron el cuidado de enfermería de maneras distintas, pues se vivenció a partir de las responsabilidades asignadas y las posibilidades de relacionamiento con los pacientes. En el MAE de la UCI donde predomina el cuidado directo de enfermeras con apoyo AE, se percibió el cuidado como atención holista, integral y empática, mientras que en la UCI donde predomina el cuidado delegado a AE se relacionó con el liderazgo administrativo y la gestión de la sala de UCI. En cuanto a resultados, el MAE de la UCI de cuidado directo por enfermeras mostró mejor desempeño en seguridad del paciente y fue más cercano al nivel de competencias y de responsabilidad legal de los equipos de enfermería.

Objetivo. Analisar em perspectiva comparativa as percepções sobre o cuidado de enfermagem, a relação com os pacientes e os resultados do cuidado em duas equipes de enfermagem de UTI de uma instituição hospitalar de alta complexidade, cujos Modelos de Assistência de Enfermagem (MAE) diferem pela proporção de enfermeiros e auxiliares de enfermagem (AE) por equipe e por tarefas e responsabilidades atribuídas. Métodos.Etnografia particularista com adaptação a metodologias virtuais. Incluiu a caracterização sociodemográfica de 19 enfermeiros e 23 EA, 14 entrevistas semiestruturadas, revisão de prontuários e grupo focal. Codificação, categorização, análise indutiva, validação dos resultados com os participantes foram realizadas e a saturação temática foi alcançada. Resultados. Foram identificados quatro temas: i) Cuidado profissionalizado: enfermagem de valor superior ii) sentidos e sentimentos do cuidado iii) sobrecarga do cuidado, fatores geradores e impactos e iv) omissão do cuidado como expressão concreta da carga de trabalho. Conclusão. As equipes de Enfermagem compararam o cuidado de enfermagem percebido de diferentes maneiras, uma vez que foi vivenciado a partir das responsabilidades atribuídas e das possibilidades de relacionamento com os pacientes. No MAE da UTI onde predomina o cuidado direto por enfermeiros com apoio do EA, o cuidado foi percebido como cuidado holístico, integral e empático, enquanto na UTI onde predomina o cuidado delegado ao EA, estava relacionado à liderança administrativa e gestão da sala da UTI. Em termos de resultados, o MAE da UTI de cuidado direto por enfermeiros apresentou melhor desempenho na segurança do paciente e se aproximou mais do nível de competências e responsabilidade legal das equipes de enfermagem.

Clinical Nurse Leader Integration Into Practice: Developing Theory To Guide Best Practice.

Numerous policy bodies have identified the clinical nurse leader (CNL) as an innovative new role for meeting higher health care quality standards. Although there is growing evidence of improved care environment and patient safety and quality outcomes after redesigning care delivery microsystems to integrate CNL practice, significant variation in CNL implementation has been noted across reports, making it difficult to causally link CNL practice to reported outcomes. This variability reflects the overall absence in the literature of a well-defined CNL theoretical framework to help guide standardized application in practice. To address this knowledge gap, an interpretive synthesis with a grounded theory analysis of CNL narratives was conducted to develop a theoretical model for CNL practice. The model clarifies CNL practice domains and proposes mechanisms by which CNL-integrated care delivery microsystems improve health care quality. The model highlights the need for a systematic approach to CNL implementation including a well-thought out strategy for care delivery redesign; a consistent, competency-based CNL workflow; and sustained macro-to-micro system leadership support. CNL practice can be considered an effective approach to organizing nursing care that maximizes the scope of nursing to influence the ways care is delivered by all professions within a clinical microsystem.

[Personalized nursing care in hospital and its effects on the patient-nurse trust relationship]. / Personalización de cuidados hospitalarios y su efecto sobre la relación de confianza enfermera-paciente.

OBJETIVES: To determine the level of implementation of an inpatient personalized nursing care model in four hospitals of the Andalusian Health Service, and to determine if there is an association between this model and the perception of trust in the nurse by the patient. METHOD: An observational cross-sectional study included the patients discharged during a period of 12 months from hospital wards that used the Inpatient Personalized Nursing Care Model of the Andalusian Health Service (based on Primary Nursing Model). The level of implemention was evaluated using the Nursing Care Personalized Index (IPC), made by «patient report¼ methodology, and the nurse-patient trust relationship was evaluated at the same time as the IPC. Statistical analysis included descriptive data analysis, Chi-squared test, and bivariate and multivariate logistic regression, with and without stratifying by hospitals wards. RESULTS: A total of 817 patient were included. The implementation of the inpatient personalized nursing care model varied between 61 and 79%. The IPC values showed a strong association with the nurse-patient trust relationship, and that for each point increase in the IPC score, the probability of a nurse-patient trust relationship increased between 50 and 130% (0.120.58). CONCLUSION: The implementation of a personalized nursing care model in the wards studied was higher in the surgicals wards and at regular level in medical wards. Furthermore, the influence of the inpatient personalized nursing care model on the nurse-patient trust relationship has been demonstrated using the IPC model. This trust is the main component for the establishment of a therapeutic relationship.