The Effects of Organizational Characteristics, Individual Nurse Characteristics, and Occupational Fatigue on Missed Care at Night.

BACKGROUND: Missed care is defined as the omission or delay of necessary patient care and is internationally reported by nurses as a significant safety risk. Nurses working at night also report high levels of occupational fatigue that, coupled with inadequate staffing and practice environment support, may impede a nurse's ability to carry out the nursing process and lead to more missed care. OBJECTIVE: The study's objective was to examine the interrelationships among organizational and nurse characteristics, occupational fatigue, and missed care among nurses working at night. METHODS: A cross-sectional design was used. Participants included registered nurses (RNs) who worked at night in New Jersey acute care hospitals. Multiple linear regression and simple moderation analyses were performed to examine the associations. RESULTS: Nurses reported missing necessary care at night. Unsupportive practice environments, high RN workloads, high patient-RN ratios, high chronic fatigue levels, and low intershift recovery were individually associated with missed care at night. High patient-to-RN ratios and chronic fatigue were independently associated with missed care. However, patient-to-registered-staffing levels had the most considerable effect on missed care at night. Nurses' years of experience and the number of hours of sleep between shifts were significant moderators of the relationship between occupational fatigue states and missed care. DISCUSSION: This study is the first to examine the interrelationship between occupational fatigue levels, organizational and nurse characteristics, and missed care at night. There is an urgent need to implement strategies in hospital organizations that foster work schedules and adequate staffing patterns that lessen nurses' occupational fatigue levels to ensure our workforce's and patients' safety.

Racial Disparities and Pressure Injuries Among Hospitalized Patients.

OBJECTIVE: To describe the demographic factors, hospitalization-related factors, comorbid states, and social determinants of health among racial groups in a sample of patients with a primary or secondary diagnosis of pressure injury (PI) admitted to New Jersey hospitals during the year 2018. METHODS: Researchers conducted a retrospective analysis of the Health Care Utilization Project's 2018 New Jersey State Inpatient Database. Patients with a primary or secondary diagnosis of PI (sacrum, buttocks, or heels; N = 17,781) were included in the analytic sample. Analysis compared patients who identified as Black (n = 3,515) with all other racial groups combined (n = 14,266). RESULTS: A higher proportion of Black patients were admitted for a PI (P < .001) and had higher proportions of stage 4 PIs (P < .001) but a lower proportion of stage 1 PIs (P < .001). Higher proportions of Black patients were younger, resided in lower income communities, and identified Medicaid as their primary payor source. CONCLUSIONS: Results highlight the racial disparities that exist among patients with PIs in this diverse state and may represent a much larger problem. Clinical research examining the impact of skin tone rather than by racial group is needed. The impact of racial disparities on social determinants of health with regard to PIs remains largely unknown, but its importance cannot be underestimated.

Differences in elective epilepsy monitoring unit admission rates by race/ethnicity and primary payer in New Jersey.

Elective admission to the epilepsy monitoring unit (EMU) is an essential service provided by epilepsy centers, particularly for those with drug-resistant epilepsy. Given previously characterized racial and socioeconomic healthcare disparities in the management of epilepsy, we sought to understand access and utilization of this service in New Jersey (NJ). We examined epilepsy hospitalizations in NJ between 2014 and 2016 using state inpatient and emergency department (ED) databases. We stratified admissions by race/ethnicity and primary payer and used these to estimate and compare (1) admission rates per capita in NJ, as well as (2) admission rates per number of ED visits for each group. Patients without insurance underwent elective EMU admission at the lowest rates across all racial/ethnic groups and payer types studied. Black patients with Medicaid and private insurance were admitted at disproportionately low rates relative to their number of ED visits. Hispanic/Latino and Asian/Pacific Islanders with private insurance, Hispanic/Latinos with Medicaid, and Asian/Pacific Islanders with Medicare were also admitted at low rates per capita within each respective payer category. Future studies should focus on addressing causal factors driving healthcare disparities in epilepsy, particularly for patients without adequate health insurance coverage and those who have been historically underserved by the healthcare system.

Effects of Race, Workplace Racism, and COVID Worry on the Emotional Well-Being of Hospital-Based Nurses: A Dual Pandemic.

Persons of color in the US experience the worst COVID-related outcomes and account for the majority of COVID-19 cases and hospitalizations among healthcare workers. In a pandemic where minority populations and healthcare workers are among the hardest hit, nurses of color are undoubtedly taxed. Moreover, their workplace racism experiences represent a dual pandemic in that the effects of COVID-19 worries and workplace racism may synergize to the detriment of their emotional well-being. The purpose of this study was to examine the direct, indirect, and interactive effects of individual (race, COVID worry), interpersonal (workplace racial microaggressions), and institutional (racial climate) factors on hospital-based nurses' emotional well-being. A sample of 788 registered nurses who worked in New Jersey hospitals completed an electronic survey. Compared to White nurses, nonwhite nurses reported higher emotional distress, more negative racial climates, more racial microaggressions, and higher levels of COVID worry. Nurses' worry about getting sick from COVID and multiple racial microaggression experiences had the largest effects on the likelihood of high emotional distress. Racism variables and worry about COVID mediated indirect effects of nonwhite race on emotional distress. Racial microaggressions mediated an indirect effect of racial climate on this outcome. Nurses who were worried about getting sick from COVID and experienced multiple microaggressions and/or the most negative racial climates had severe emotional distress. There is a need for sustained investment in a racially diverse nursing workforce. Mitigating workplace racism in hospitals is crucial, particularly during public health crises that disproportionately threaten minority populations and healthcare workers.

The effects of race and workplace racism on nurses' intent to leave the job: The mediating roles of job dissatisfaction and emotional distress.

BACKGROUND: There is scant evidence of quantifiable effects of workplace racism on nurses' job-related outcomes. PURPOSE: The study aimed to examine associations among race, workplace racism, emotional distress, job dissatisfaction, and intent to leave among hospital-based nurses. METHODS: This study used a correlational design with six measures in a statewide sample of 788 hospital-based nurses. FINDINGS: Non-White nurses intended to leave the job at a higher rate than White nurses. Non-White nurses reported negative racial climates, multiple racial microaggression experiences, and high job dissatisfaction and emotional distress. Non-white race and workplace racism had significant individual effects on intent to leave. Job dissatisfaction and emotional distress significantly mediated indirect effects of non-White race, negative racial climates, and racial microaggressions on nurses' intent to leave. DISCUSSION: In efforts to retain nurses of color in hospitals, there is an urgent need to mitigate workplace racism in these settings.

The Growing Demand for Home Dialysis Therapies: Challenges and Potential Solutions.

The End-Stage Renal Disease Treatment (ETC) Model, an aspect of the Advancing American Kidney Health Initiative implemented by the Centers for Medicare and Medicaid Services (CMS) in 2019, is designed to shift the predominant in-center hemodialysis dialysis model in the United States to a home dialysis model. This shift represents a monumental change in the treatment of end stage kidney failure and is occurring amid a strained nursing workforce. The CMS Conditions for Coverage for dialysis facilities mandate registered nurse responsibility for the conduct of patients' home dialysis training, and the current nursing shortage presents challenges because the need for nephrology nurses will increase to meet the growing demand for home dialysis during the ETC implementation period. As the ETC Model is implemented in randomly selected dialysis facilities across the United States, nephrology nurses must have leading roles as full partners with CMS and other stakeholders for the mutual determination of short- and long-term solutions for meeting the growing home dialysis training demands.

Effects of End-of-Life Communication Knowledge, Attitudes, and Perceived Behavioral Control on End-of-Life Communication Behaviors Among Nephrology Nurse Practitioners.

The scope of end-of-life communication is not well known among nephrology advanced practice nurses (APNs). Guided by the Theory of Planned Behavior, the study aimed to examine the independent effects of knowledge, attitude, and perceived behavioral control on the engagement of APNs in end-of-life communication and the mediating and moderating effects of attitude and perceived behavioral control on the relationships between knowledge and end-of-life communication. A theoretically derived 17-item survey measuring the concepts was administered to a convenience sample of 127 APNs. Descriptive statistics, Pearson's correlation, and multiple linear regression were employed. Attitudes and perceived behavioral control on end-of-life communication mediated and moderated the relationship between knowledge of end-of-life communication and engagement in end-of-life communication among nephrology APNs.

Mental Health and Health-Related Quality of Life Among Nephrology Nurses: A Survey-Based Cross-Sectional Study.

Nephrology nurses face health and wellness challenges due to significant work-related stressors. This survey, conducted online between July 24 and August 17, 2020, assessed the psychological well-being of nephrology nurses in the United States during the COVID-19 pandemic (n = 393). Respondents reported feeling burned out from work (62%), symptoms of anxiety (47% with Generalized Anxiety Disorder-7 [GAD-7] scores ≥ 5), and major depressive episodes (16% with Patient Health Questionnaire-2 [PHQ-2] scores ≥ 3). Fifty-six percent (56%) of survey respondents reported caring for COVID-19 patients, and 62% were somewhat or very worried about COVID-19. Factors, including high workload, age, race, and the COVID-19 pandemic, may partially explain the high proportion of nephrology nurses who reported symptoms of burnout, anxiety, and depression.

Using ICD-10 codes to identify elective epilepsy monitoring unit admissions from administrative billing data: A validation study.

Video-electroencephalogram (EEG) monitoring in the epilepsy monitoring unit (EMU) is essential for managing epilepsy and seizure mimics. Evaluation of care in the EMU would benefit from a validated code set capable of identifying EMU admissions from administrative databases comprised of large, diverse cohorts. We assessed the ability of code-based queries to parse EMU admissions from administrative billing records in a large academic medical center over a four-year period, 2016-2019. We applied prespecified queries for admissions coded as follows: 1) elective, 2) receiving video-EEG monitoring, and 3) including diagnoses typically required by major US healthcare payers for EMU admission. Sensitivity (Sn), specificity (Sp), and predictive value positive/negative (PVP, PVN) were determined. Two approaches were highly effective. Incorporating epilepsy, seizure, or seizure mimic codes as the admitting diagnosis (assigned at admission; Sn 96.3%, Sp 100.0%, PVP 98.3%, and PVN 100.0%) or the principal diagnosis (assigned after discharge; Sn 94.9%, Sp 100.0%, PVP 98.8%, and PVN 100.0%) identified elective adult EMU admissions with comparable reliability (p = 0.096). The addition of surgical procedure codes further separated EMU admissions for intracranial EEG monitoring. When applied to larger, more comprehensive datasets, these code-based queries should enhance our understanding of EMU utilization and access to care on a scalable basis.

Registered Nurse Staffing, Workload, and Nursing Care Left Undone, and Their Relationships to Patient Safety in Hemodialysis Units.

Patient safety is an important foundation of high-quality care. Yet little is known regarding the effects of nursing indicators on patient safety in dialysis units. The purpose of this study was to examine interrelationships among registered nurse (RN) staffing, workload, nursing care left undone, and patient safety outcomes in hemodialysis settings. The sample consisted of 104 staff nurses who worked in hemodialysis facilities and completed a mailed survey. Low RN staffing, high RN workloads, and RN nursing care left undone were significantly associated with unsafe patient shift change periods and low safety ratings. Care left undone was an indirect pathway through which low RN staffing and high workloads impacted safety. Patient safety in hemodialysis units can be enhanced by ensuring adequate RN staffing and reasonable RN workloads, as well as redesigning responsibilities so RNs can complete necessary care activities.

The Perfect Storm: Stakeholder Perspectives on Factors Contributing to Hospital Admissions for Patients Undergoing Maintenance Hemodialysis.

Patients living with end stage renal disease (ESRD) who are undergoing hemodialysis experience frequent hospitalizations associated with complications of care and exacerbations of illness. Efforts to reduce hospitalizations have had limited success. The purpose of this study was to explore why hospitalizations occur from the perspectives of patients undergoing hemodialysis treatment, their caregivers, and health care providers. Semi-structured interviews and focus groups were conducted with 21 patients living with ESRD, 10 caregivers, and three focus groups with health care professionals. Findings are discussed under four main themes: Graft site/Catheter/Access issues, "My resistance is low," "I could not breathe,"" and "The perfect storm." Results highlight the complexity of care and vulnerability of patients with ESRD. Further interprofessional research is needed to improve transitional care and care delivery for patient populations receiving hemodialysis.

Effects of a transtheoretical model-based WeChat health education programme on self-management among haemodialysis patients: A longitudinal experimental intervention study.

AIM: To examine the effects of a transtheoretical model-based WeChat health education programme on self-management in haemodialysis patients in China. DESIGN: A longitudinal experimental intervention study. METHODS: Patients (N = 120) who underwent haemodialysis from December 2015-November 2017 were recruited and randomly allocated to either group 1 (who received a 3-month WeChat health education immediately after randomization) or group 2 (who was combined with group 1 and received the same intervention at the 5th month after enrolment in the study). Self-management, knowledge and self-efficacy were assessed at baseline (T0 ), 3 months after enrolment in the study (T1 ), 21 months after enrolment in the study (T2 ). RESULTS: There were significant group effects on self-efficacy; time effects on partnership, self-care, emotion management with total self-management; interaction effects on problem-solving and emotion management within total self-management according to the two-way repeated measures ANCOVA. Further between-group comparisons indicated that patients in group 1 had better self-management than those in group 2 at T1 . Within-group comparisons demonstrated that, compared with the baseline values, group 1 had significantly improved self-management at T1 ; however, group 2 had improved self-management at T2 . CONCLUSION: The transtheoretical model-based WeChat health education programme had a potentially positive effect on improving the self-management of haemodialysis patients. IMPACT: Self-management is often difficult yet crucial for haemodialysis patients. This study indicated that the transtheoretical model-based WeChat health education resulted in improved self-management in haemodialysis patients and can be implemented in continuing care during the interdialysis period to improve self-management in patients. TRIAL REGISTRATION: ChiCTR1800018172.

Associations among race, residential segregation, community income, and emergency department use by adults with end-stage renal disease.

OBJECTIVE: The purpose of this study was to examine independent and interactive effects of race, community income, and racial residential segregation on the likelihood of ED revisits by persons with end-stage renal disease (ESRD). DESIGN: A retrospective analysis of de-identified data abstracted from Health Care Utilization and Cost Project's (HCUP) 2014 New Jersey State Emergency Department (ED) Database and American Community Survey (ACS) was conducted. SAMPLE: The analytic sample was comprised of 2,859 ED encounters in 2014 by non-Hispanic Black and White persons over 18 years of age with ESRD who were treated and released from the ED. MEASUREMENTS: The HCUP database was the data source for ED revisit, race, median community income, and covariate (age, gender, marital status, number of chronic conditions) variables in the study. The 2014 ACS was the source for racial segregation Dissimilarity Index scores across NJ counties. RESULTS: Living in communities with lower median income and high racial segregation was associated with a higher likelihood of ED revisits. Black race interacted with community income and racial segregation in its effect on ED revisits. CONCLUSION: Efforts are needed to direct geo-targeted interventions and resources to socially disadvantaged communities to lessen disparities in ED visits among dialysis patients.

Certified Registered Nurse Anesthetist Perceptions of Factors Impacting Patient Safety.

Certified registered nurse anesthetists (CRNAs) provide more than 40 million anesthetics each year in the United States. This article describes a study that investigates relationships among CRNA organizational structures (CRNA practice models, work setting, workload, level of education, work experience), CRNA ratings of patient safety culture, and CRNA adverse anesthesia-related event (ARE) reporting. This is a cross-sectional survey study of 336 CRNAs randomly selected from American Association of Nurse Anesthetists database. Workload was measured using NASA Task-Load Index and the Revised Individual Workload Perception Scale. Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Overall Perceptions of Safety Scale and Hospital Survey on Patient Safety Patient Safety Grade Scale were utilized to measure safety culture. Dependent variables (ARE) included difficult intubation/extubation, inadequate ventilation/oxygenation, and pulmonary aspiration. The Revised Individual Workload Perception Scale workload was significantly associated with ARE. Years' experience and Patient Safety Grade Scale were inversely associated with ARE. Overall Perceptions of Safety Scale was significantly and inversely associated with ARE. Practice model, education, and work setting were not associated with ARE. Based on findings, CRNA workload, years' experience, and patient safety culture may be important markers for ARE. Administrative interventions designed to upgrade patient safety culture and ensure manageable CRNA workload may foster quality patient care.

Report From the Night Shift: How Administrative Supervisors Achieve Nurse and Patient Safety.

The administrative supervisor role (the nurse leader on the evening or night shift) has been present in hospitals for more than 100 years, but research is just commencing regarding how this leader achieves nurse and patient safety. This focused ethnographic study was conducted in 2 parts. The first part consisted of focus groups with night-shift staff nurses, held at 7 hospitals in the mid-Atlantic region of the United States, with the objective of obtaining the staff nurses' perception of the supervisors' role. The second part consisted of interviews with 30 administrative supervisors, recruited nationally from 20 different states, to explore the supervisors' perspective on practices used to enhance safety. The focus group and interview transcripts were thematically analyzed, using an iterative, comparative method to identify codes and sort for patterns. The findings reveal that administrative supervisors "make it (whatever needs to be done) work" and achieve nurse and patient safety by building trust with the staff, doing rounds, educating, and providing support to the front line team. These shift leaders foster a culture of safety with their relationship-oriented leadership style. By gaining further understanding about the administrative supervisor role, new workflow processes can be explored; specific continuing education programs can be developed; and additional research can be conducted.

Emphasizing the Value of Nephrology Nursing Through Nursing-Sensitive Indicators: A Call for Action.

Nursing is the largest healthcare profession in the United States (U.S.). As principal frontline caregivers in the U.S. healthcare system, nurses have tremendous influence over a patient's healthcare experience. A growing body of evidence states that the nursing workforce has a direct impact on healthcare quality. A standardized approach to measuring nursing's contribution to patient care and safety using nursing-sensitive quality indicators assists in examining the extent to which nurses and nursing affect the quality and safety of health care. This article focuses on nursing-sensitive quality indicators and discusses healthcare quality indicators and nursing-sensitive indicators used in the U.S. A summary of the work of the American Nephrology Nurses' Association Task Force on Nephrology Nursing-Sensitive Quality Indicators (NNSQI) and an NNSQI exemplar are provided.

A Pilot Study: Testing of the Psychological Conditions Scale Among Hospital Nurses.

OBJECTIVE: The aim of this study was to test the reliability and validity of the Psychological Conditions Scale (PCS), a measure of drivers of engagement in hospital-based nurses. BACKGROUND: Research suggests drivers of engagement are positive links to patient, employee, and hospital outcomes. Although this scale has been used in other occupations, it has not been tested in nursing. METHODS: A cross-sectional, methodological study using a convenience sample of 200 nurses in a large Magnet® hospital in New Jersey. RESULTS: Cronbach's α's ranged from .64 to .95. Principal components exploratory factor analysis with oblique rotation revealed that 13 items loaded unambiguously in 3 domains and explained 76% of the variance. Mean PCS scores ranged from 3.62 to 4.68 on a 5-point Likert scale. CONCLUSIONS: The scale is an adequate measure of drivers of engagement in hospital-based nurses. Leadership efforts to promote the facilitators of engagement are recommended.

Work Environment Characteristics Valued by Outpatient Hemodialysis Unit Nurse Managers.

Competent nurse managers of outpatient hemodialysis (HD) units are invaluable in enhancing patient safety, creating a culture of safety, and preventing adverse events. Yet little is known regarding the characteristics of a professional work environment that supports their important managerial role. The purpose of this qualitative study was to identify those organizational characteristics that outpatient HD unit nurse managers describe as important to a supportive managerial work environment. A total of six major themes with descriptive categories and exemplars emerged from the analysis. Findings from this study can inform HD administrators in their efforts to create and sustain work environments that support the professional practice of outpatient HD unit nurse managers. Notably, findings can also provide guidelines for nurse managers considering employment opportunities in that they can be used to assess and compare the work environments of outpatient HD facilities and organizations.