A theoretical framework for Acute Care Nurse Stress Appraisal: Application of the transactional model of stress and coping.

AIM: To develop a framework for understanding the stress appraisal process among acute care nurses during the COVID-19 pandemic. DESIGN: A secondary analysis of open-ended responses from a cross-sectional survey of 3030 frontline, acute care nurses in New Jersey and the effect of burnout during the COVID-19 pandemic. METHODS: Lazarus and Folkman's transactional model of stress and coping guided the study. Thematic analysis was used to analyse 1607 open-ended responses. RESULTS: Nine themes emerged during the secondary appraisal of stress. Five themes contributed to distress and burnout including (1) high patient acuity with scarce resources, (2) constantly changing policies with inconsistent messaging, (3) insufficient PPE, (4) unprepared pandemic planning and (5) feeling undervalued. Four themes led to eustress and contributed to post-traumatic growth including (1) team nursing to ensure sufficient resource allocation, (2) open channels of communication, (3) sense- of-duty and (4) personal strength from new possibilities. CONCLUSION: The COVID-19 pandemic was a traumatic event for patients and the nursing workforce. Internal and external demands placed on acute care nurses increased burnout, however, a subset of nurses with adequate support experienced personal growth. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Beyond mental health interventions for acute care nurses, organizational interventions such as reevaluation of emergency action plans to optimize resource allocation, and work environment strategies such as improved communication and decision-making transparency are necessary. IMPACT: To better understand how frontline acute care nurses experienced stress during COVID-19, a data-informed framework was developed that included a primary and secondary appraisal of stress. Themes contributing to distress and burnout were identified, and themes leading to eustress and post-traumatic growth were also identified. These findings can assist nurse leaders in optimizing strategies to reduce burnout and promote post-traumatic growth in the post-COVID years. REPORTING METHOD: No patient or public contribution.

Factors contributing to nurses' intent to leave during COVID-19.

To examine the association between demographic characteristics (i.e., gender, race, age, and years of experience), burnout, and nurses' intent to leave their jobs during the first wave of COVID-19 in New Jersey. COVID-19 has exacerbated burnout and intent to leave among acute care nurses. Nonetheless, little is known about demographic factors contributing to nurses' desire to leave their jobs. A cross-sectional survey of actively licensed registered nurses who provided direct patient care in an acute care hospital in New Jersey during COVID-19. Among 2760 nurses, those who reported burnout were 4.78 times more likely to report intent to leave their job within 1 year as compared to nurses who did not report burnout. Black RNs were 2.06 times more likely to report intent to leave as compared to White RNs. Older nurses (aged 40-49) were 36% less likely to report intent to leave as compared to younger nurses (aged 21-29). RNs with 30 years of experience or more were 58% less likely to report intent to leave as compared to RNs with less than 5 years of experience. In addition, Black RNs with 6-12 years of experience were 2.07 times more likely to report intent to leave as compared to White RNs with less than 5 years of experience. Nurses' intent to leave during the first wave of the pandemic was influenced by burnout, race, age, and years of experience. Based on the results of the current study, Black nurses were more likely to report intent to leave their job within 1 year as compared to White RNs. Nurses' intention to leave is one of the most important global issues facing the healthcare system. Findings of the current study demonstrate that burnout, race, age, and years of experience are significant predictors of nurses' intent to leave their jobs. Therefore, organizations should prioritize strategies to reduce burnout and create diverse and inclusive work environments.

Health Information Technology Adoption at U.S. Home Health Care Agencies: Results from a Multi-Methods Study.

Health information technology (HIT) holds potential to transform Home Health Care (HHC), yet, little is known about its adoption in this setting. In the context of infection prevention and control, we aimed to: (1) describe challenges associated with the adoption of HIT, for example, electronic health records (EHR) and telehealth and (2) examine HHC agency characteristics associated with HIT adoption. We conducted in-depth interviews with 41 staff from 13 U.S. HHC agencies (May-October 2018), then surveyed a stratified random sample of 1506 agencies (November 2018-December 2019), of which 35.6% participated (N = 536 HHC agencies). We applied analytic weights, generating nationally-representative estimates, and computed descriptive statistics, bivariate and multivariable analyses. Four themes were identified: (1) Reflections on providing HHC without EHR; (2) Benefits of EHR; (3) Benefits of other HIT; (4) Challenges with HIT and EHR. Overall, 10% of the agencies did not have an EHR; an additional 2% were in the process of acquiring one. Sixteen percent offered telehealth, and another 4% were in the process of acquiring telehealth services. In multivariable analysis, EHR use varied significantly by geographic location and ownership, and telehealth use varied by geographic location, ownership, and size. Although HIT use has increased, our results indicate that many HHC agencies still lack the HIT needed to implement technological solutions to improve workflow and quality of care. Future research should examine the impact of HIT on patient outcomes and the impact of the COVID-19 pandemic on HIT use in HHC.

Burnout and intent to leave during COVID-19: A cross-sectional study of New Jersey hospital nurses.

AIM: The aim of this work is to examine staffing, personal protective equipment (PPE) adequacy and physical exhaustion that contributed to burnout and intent to leave among hospital nurses during the first peak of the COVID-19 pandemic. BACKGROUND: Burnout is associated with adverse nurse and patient outcomes. Identifying the magnitude of burnout that occurred during the pandemic can prepare managers for the long-term mental health effects on nurses. METHODS: A cross-sectional, electronic survey was administered to examine perceptions of burnout and intent to leave among all New Jersey hospital nurses from October 6 to October 26, 2020. RESULTS: A total of 3030 nurses responded with 64.3% reporting burnout and 36.5% reporting intent to leave the hospital within a year. There was a significant association between high levels of burnout and intent to leave (χ2  = 329.4; p = .001). There was no association between staffing and burnout; however, reporting inadequate PPE (OR = 1.77 [95% CI: 1.34-2.34]) and physical exhaustion (OR = 3.89 [95% CI: 3.19-4.76]) remained predictors of burnout among nurses. CONCLUSION: Inadequate PPE and physical exhaustion coupled with short staffing contributed to burnout and intent to leave. IMPLICATIONS FOR NURSING MANAGEMENT: Managers should continue to utilize evidence-based mental health interventions and advocate within their nursing professional organizations for relief funds to reduce burnout.

The impact of COVID-19 on the hospice and palliative care workforce.

OBJECTIVE: To understand the impact of the COVID-19 pandemic on the hospice and palliative workforce and service delivery. DESIGN AND SAMPLE: This was a cross-sectional survey of 36 hospice and palliative care workforce members representing all United States geographic regions. RESULTS: Most respondents (70%) reported an increase in specific palliative care services as a result of the pandemic. Two thirds (78%) of respondents reported their agency has cared for confirmed COVID-19 patients. Only half reported the agency had access to laboratory facilities for surveillance and detection of outbreaks in both patients and staff (58%) and that the agency could test patients and providers for COVID-19 (55%). Qualitative comments described the impact of the pandemic and resulting social distancing measures on the emotional well-being of patients, families, and staff. CONCLUSIONS: Our findings suggest that the COVID-19 pandemic has strained the palliative and hospice care workforce as it provides increased services at an unprecedented rate to patients and families. The implications of these findings are important for public health nurses who are skilled in disaster management and quickly responding to emergencies. The expertise of public health nurses can be leveraged to support palliative care agencies as they strive to manage the pandemic in the communities they serve.

COVID-19 vaccination readiness among nurse faculty and student nurses.

BACKGROUND: Unprecedented efforts are underway to develop COVID-19 vaccines, widely seen as critical to controlling the pandemic. Academic nursing leaders must be proactive in assuring widespread faculty and student vaccination uptake. PURPOSE: The purpose of this study was to describe nursing faculty and student nurse factors associated with COVID-19 vaccine readiness. METHODS: Cross-sectional online survey of nursing faculty and student nurses at a university affiliated with an academic medical center was conducted. FINDINGS: Most full-time faculty (60%) intended to receive the vaccine; but only 45% of adjunct faculty and students reported intending to get vaccinated. The major reasons for not getting vaccinated were vaccine safety and side effects. Collectively, participants reported a low level of knowledge related to vaccine development. DISCUSSION: As the most trusted profession, nurses will play a decisive role in counseling patients about COVID-19 risks and benefits. Findings suggest that academic nursing leaders need to consider faculty and student vaccine concerns and provide vaccine development education.

Clinical Nurse Preparation and Partnership in Antibiotic Stewardship Programs: National Survey Findings Are a Call to Action for Nurse Leaders.

OBJECTIVE: Describe clinical nurse involvement in antibiotic stewardship programs (ASPs). BACKGROUND: The extent to which clinical nurses are supported and integrated into ASPs is unknown. METHODS: Electronic survey of infection preventionists (IPs) working in acute care hospitals. RESULTS: A total of 207 IPs nationwide reported on clinical nurses' involvement in their hospital's ASP. Among respondents, 42% reported the presence of a designated nurse executive that championed nurses' involvement in ASPs; 33% reported that the hospital provides antibiotic stewardship education and training to clinical nurses, and only 14% believed that clinical nurses have adequate stewardship knowledge to participate in ASP activities. CONCLUSIONS: Study findings indicate the need for nurse leaders to improve the preparation and integration of clinical nurses in ASPs. While clinical nurses routinely perform activities that contribute to optimal antibiotic use, the knowledge and competency of clinical nurses in these activities and their formal integration in ASPs are minimal.

Hospital Staffing and Health Care-Associated Infections: A Systematic Review of the Literature.

BACKGROUND: Previous literature has linked the level and types of staffing of health facilities to the risk of acquiring a health care-associated infection (HAI). Investigating this relationship is challenging because of the lack of rigorous study designs and the use of varying definitions and measures of both staffing and HAIs. METHODS: The objective of this study was to understand and synthesize the most recent research on the relationship of hospital staffing and HAI risk. A systematic review was undertaken. Electronic databases MEDLINE, PubMed, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for studies published between January 1, 2000, and November 30, 2015. RESULTS: Fifty-four articles were included in the review. The majority of studies examined the relationship between nurse staffing and HAIs (n = 50, 92.6%) and found nurse staffing variables to be associated with an increase in HAI rates (n = 40, 74.1%). Only 5 studies addressed non-nurse staffing, and those had mixed results. Physician staffing was associated with an increased HAI risk in 1 of 3 studies. Studies varied in design and methodology, as well as in their use of operational definitions and measures of staffing and HAIs. CONCLUSION: Despite the lack of consistency of the included studies, overall, the results of this systematic review demonstrate that increased staffing is related to decreased risk of acquiring HAIs. More rigorous and consistent research designs, definitions, and risk-adjusted HAI data are needed in future studies exploring this area.

Nursing Home Infection Control Program Characteristics, CMS Citations, and Implementation of Antibiotic Stewardship Policies: A National Study.

Recently, the Centers for Medicare & Medicaid Services (CMS) final rule required that nursing homes (NHs) develop an infection control program that includes an antibiotic stewardship component and employs a trained infection preventionist (IP). The objectives of this study were to provide a baseline assessment of (1) NH facility and infection control program characteristics associated with having an infection control deficiency citation and (2) associations between IP training and the presence of antibiotic stewardship policies, controlling for NH characteristics. A cross-sectional survey of 2514 randomly sampled US NHs was conducted to assess IP training, staff turnover, and infection control program characteristics (ie, frequency of infection control committee meetings and the presence of 7 antibiotic stewardship policies). Responses were linked to concurrent Certification and Survey Provider Enhanced Reporting data, which contain information about NH facility characteristics and citations. Descriptive statistics and multivariable regression analyses were conducted to account for NH characteristics. Surveys were received from 990 NHs; 922 had complete data. One-third of NHs in this sample received an infection control deficiency citation. The NHs that received deficiency citations were more likely to have committees that met weekly/monthly versus quarterly ( P < .01). The IPs in 39% of facilities had received specialized training. Less than 3% of trained IPs were certified in infection control. The NHs with trained IPs were more likely to have 5 of the 7 components of antibiotic stewardship in place (all P < .05). The IP training, although infrequent, was associated with the presence of antibiotic stewardship policies. Receiving an infection control citation was associated with more frequent infection control committee meetings. Training and support of IPs is needed to ensure infection control and antibiotic stewardship in NHs. As the CMS rule becomes implemented, more research is warranted. There is a need for increase in trained IPs in US NHs. These data can be used to evaluate the effectiveness of the CMS final rule on infection management processes in US NHs.

Differences in work environment for staff as an explanation for variation in central line bundle compliance in intensive care units.

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) are a common and costly quality problem, and their prevention is a national priority. A decade ago, researchers identified an evidence-based bundle of practices that reduce CLABSIs. Compliance with this bundle remains low in many hospitals. PURPOSE: The aim of this study was to assess whether differences in core aspects of work environments-workload, quality of relationships, and prioritization of quality-are associated with variation in maximal CLABSI bundle compliance, that is, compliance 95%-100% of the time in intensive care units (ICUs). METHODOLOGY/APPROACH: A cross-sectional study of hospital medical-surgical ICUs in the United States was done. Data on work environment and bundle compliance were obtained from the Prevention of Nosocomial Infections and Cost-Effectiveness Refined Survey completed in 2011 by infection prevention directors, and data on ICU and hospital characteristics were obtained from the National Healthcare Safety Network. Factor and multilevel regression analyses were conducted. FINDINGS: Reasonable workload and prioritization of quality were positively associated with maximal CLABSI bundle compliance. High-quality relationships, although a significant predictor when evaluated apart from workload and prioritization of quality, had no significant effect after accounting for these two factors. PRACTICE IMPLICATIONS: Aspects of the staff work environment are associated with maximal CLABSI bundle compliance in ICUs. Our results suggest that hospitals can foster improvement in ensuring maximal CLABSI bundle compliance-a crucial precursor to reducing CLABSI infection rates-by establishing reasonable workloads and prioritizing quality.

The Use and Effectiveness of Bundles for Prevention of Central Line-Associated Bloodstream Infections in Neonates: A Review of the Literature.

Central line-associated bloodstream infections (CLABSIs) are an important cause of increased morbidity, mortality, and costs in neonatal intensive care unit (NICU) patients. In recent years, central line bundles have been developed and implemented as a means to reduce infection rates in intensive care units. The objective of this review was to describe central line bundles that are utilized in the neonatal population and evaluate the current evidence on the effectiveness of bundles for prevention of CLABSIs in the NICU. This review shows that care bundles have been successfully used in NICUs (as part of both single-site quality improvement initiatives and large multisite collaboratives) to decrease CLABSI rates. The individual components that comprise the bundle between individual studies varied, but all studies showed a significant reduction in CLABSI rates. The pre- and postintervention design employed by these studies does not allow for conclusions to be drawn as to what specific bundle components are most effective in reducing rates. Further research is needed both to examine the effectiveness of specific components or combinations of components in the bundle and to examine factors that are associated with implementation and adherence to bundles.

"Striving for Excellence": Minimum Data Set Coordinators' Perceptions of Their Role in the Nursing Home.

The purpose of the current study was to explore how Minimum Data Set (MDS) coordinators perceive their role and the assessment process. Eleven MDS coordinators from 10 geographically dispersed nursing homes (NHs) were interviewed between May and September 2013. Four broad themes emerged from content analysis: (a) information gathering, (b) interdisciplinary coordination, (c) role challenges, and (d) resources. The first two themes referred to key components and competencies in the MDS coordinators' role, the third theme dealt with certain challenges inherent in the role, and the fourth theme highlighted resources that helped address these challenges. The current study provides insight into how MDS coordinators perceive their role, as well as some of the challenges they face to successfully enact that role. The current findings can help inform NH management staff, such as directors of nursing and NH administrators, and policy makers, on how best to support MDS coordinators' work to enable efficient and accurate resident assessment processes.

Perceived barriers to infection prevention and control for nursing home certified nursing assistants: a qualitative study.

Healthcare-associated infections, while preventable, result in increased morbidity and mortality in nursing home (NH) residents. Frontline personnel, such as certified nursing assistants (CNAs), are crucial to successful implementation of infection prevention and control (IPC) practices. The purpose of this study was to explore barriers to implementing and maintaining IPC practices for NH CNAs as well as to describe strategies used to overcome these barriers. We conducted a multi-site qualitative study of NH personnel important to infection control. Audio-recorded interviews were transcribed verbatim and transcripts were analyzed using conventional content analysis. Five key themes emerged as perceived barriers to effective IPC for CNAs: 1) language/culture; 2) knowledge/training; 3) per-diem/part-time staff; 4) workload; and 5) accountability. Strategies used to overcome these barriers included: translating in-services, hands on training, on-the-spot training for per-diem/part-time staff, increased staffing ratios, and inclusion/empowerment of CNAs. Understanding IPC barriers and strategies to overcome these barriers may better enable NHs to achieve infection reduction goals.

Understanding infection prevention and control in nursing homes: A qualitative study.

Infections have been identified as a priority issue in nursing homes (NHs). We conducted a qualitative study purposively sampling 10 NHs across the country where 6-8 employees were recruited (N = 73). Semi-structured, open-ended guides were used to conduct in-depth interviews. Data were audiotaped, transcribed and a content analysis was performed. Five themes emerged: 'Residents' Needs', 'Roles and Training' 'Using Infection Data,' 'External Resources' and 'Focus on Hand Hygiene.' Infection prevention was a priority in the NHs visited. While all sites had hand hygiene programs, other recommended areas were not a focus and many sites were not aware of available resources. Developing ways to ensure effective, efficient and standardized infection prevention and control in NHs continues to be a national priority.

Translating infection control guidelines into practice: implementation process within a health care institution.

Health-care-associated infections (HAIs) remain a major patient safety problem even as policy and programmatic efforts designed to reduce HAIs have increased. Although information on implementing effective infection control (IC) efforts has steadily grown, knowledge gaps remain regarding the organizational elements that improve bedside practice and accommodate variations in clinical care settings. We conducted in-depth, semistructured interviews in 11 hospitals across the United States with a range of hospital personnel involved in IC (n = 116). We examined the collective nature of IC and the organizational elements that can enable disparate groups to work together to prevent HAIs. Our content analysis of participants' narratives yielded a rich description of the organizational process of implementing adherence to IC. Findings document the dynamic, fluid, interactional, and reactive nature of this process. Three themes emerged: implementing adherence efforts institution-wide, promoting an institutional culture to sustain adherence, and contending with opposition to the IC mandate.

Infection preventionists in public health, consultant and academic roles: Results from the 2020 APIC MegaSurvey.

BACKGROUND: Infection preventionists (IPs) work and practice in a variety of roles across many practice settings. While the health care-based IP role has been well studied, less is known about IPs who work in public health, consultant, and academic roles. METHODS: Data were collected as a subset of the Association for Professionals in Infection Prevention and Control and Epidemiology 2020 MegaSurvey. Descriptive and bivariate analyses were performed to compare the responses of 147 IPs working in public health, consulting, or academic roles. RESULTS: Respondents identified their primary IP role as public health (40%), consulting (39%), or academic (21%). Most were White and non-Hispanic females working in long-term care, acute care, and outpatient settings. Most had over 11 years of experience in health care before IP, with nursing being the most common. More consultants were certified in infection control (74%). While half of the respondents in public health reported being certified in infection control, and a third had 6 or more years of experience in infection prevention and control, they reported the lowest annual salary and satisfaction with total compensation. DISCUSSION: These findings highlight the characteristics and contributions of infection prevention and control in nontraditional roles and settings. Certification and fair compensation are crucial factors for professional development and job satisfaction. CONCLUSIONS: These insights can guide future education, recruitment, and retention strategies for IPs in public health, consulting, and academic roles.

APIC Megasurvey 2020: Methodology and overview of results.

BACKGROUND: In 2015, The Association for Professionals in Infection Control and Epidemiology (APIC) conducted the first MegaSurvey of its members to understand key aspects of their practice. Given the evolving role of Infection preventionists (IPs), it is important to understand changes in and the current practice environments of IPs, their demographics, the organizations in which they practice and the relative importance of different domains of IP practice. METHODS: The MegaSurvey 2020 was a cross-sectional, electronic survey of IPs conducted by APIC between January 21 and February 28, 2020. Descriptive statistics were calculated to describe the participants in terms of their characteristics, practice setting, compensation and IP competencies. RESULTS: 2,030 APIC members (response rate 13%) participated in the study. Results indicated that the demographic characteristics of IPs remained the same between the 2015 and 2020 surveys. Similar to 2015 data, slightly less than half of respondents are currently certified and plan to recertify. Less than 50% of IPs reported feeling adequately satisfied with their overall compensation. IPs reported spending the largest proportion of their time on surveillance and epidemiologic investigations and the least amount of time on employee and occupational health, cleaning and sterilization and education/research. CONCLUSIONS: As the healthcare industry continues to evolve, public health emergencies persist, and regulatory requirements expand, the results of the APIC MegaSurvey can inform future educational initiatives, the development of programs and ongoing hiring and retention strategies for this critical profession.

The impact of dementia family caregiving on adolescent well-being: A scoping review.

With rates of dementia on the rise and upward trends in multigenerational households, the number of families providing care to persons with dementia is likely to increase. Although caregiver stress in adults has been well-documented, less is known about the impact of dementia family caregiving on adolescents. We conducted a scoping review to assess research on the impact of dementia family caregiving on adolescents. Eight articles representing five studies were identified. Findings suggest that while adolescents developed strategies to cope with the challenges of dementia caregiving, the long-term impact of caregiving on overall well-being has not been well described. Further, research has shown inconsistent findings with studies reporting both improved and strained adolescent relationships. The paucity of research on the impact of dementia family caregiving on the well-being of adolescents is a serious omission given that adolescents are at high-risk for emerging health problems.

Reevaluating the Significance of Infection Preventionists and Infection Prevention and Control Departments in the Post-COVID-19 Era.

Infection preventionists are specialized health care professionals tasked with developing and implementing infection control policies, educating staff and patients on prevention practices, and investigating outbreaks. Infection preventionists role in developing effective measures for infection prevention and control and ensuring public health and safety became even more vital given the emergence of the COVID-19 pandemic. It is important for health care systems and institutions to incorporate lessons learned, enhance infection prevention and control resources, and grow the infection preventionists workforce to prepare for future pandemic events.

Voices from frontline nurses on care quality and patient safety during COVID-19: An application of the Donabedian model.

BACKGROUND: The COVID-19 pandemic has adversely impacted quality of care and patient safety. This study aimed to describe registered nurses' (RNs) perceptions on the impact of the COVID-19 pandemic on their ability to adhere to patient safety protocols using Donabedian's Health Care Quality model. METHODS: In October 2020, a survey was conducted among all actively licensed RNs in New Jersey who provided direct patient care during the first peak of COVID-19. RESULTS: Of 3,027 participants, 68% reported that the number of patients assigned impacted their ability to adhere to protocols. RNs identified a variety of organizational structures impacting adherence, including inadequate staffing, staff qualifications, and inadequate resources. Impacted processes included the inability to adhere to patient safety protocols and conduct comprehensive assessments and surveillance, the need for additional time spent on personal protective equipment and isolation policies, and difficulty maintaining isolation integrity; the need to prioritize and cluster care; and guidelines limiting personnel who could enter the room. Nurses attributed both adverse patient and staff outcomes to inadequate staffing and high patient acuity. CONCLUSIONS: These findings highlight the need for health care organizations to support frontline nursing staff in adhering to patient safety and infection prevention and control protocols during times of crises. Infection preventionists have substantial contact with bedside nurses and should leverage their collegial relationships to promote patient safety.