The associations between work-life balance behaviours, teamwork climate and safety climate: cross-sectional survey introducing the work-life climate scale, psychometric properties, benchmarking data and future directions.

BACKGROUND: Improving the resiliency of healthcare workers is a national imperative, driven in part by healthcare workers having minimal exposure to the skills and culture to achieve work-life balance (WLB). Regardless of current policies, healthcare workers feel compelled to work more and take less time to recover from work. Satisfaction with WLB has been measured, as has work-life conflict, but how frequently healthcare workers engage in specific WLB behaviours is rarely assessed. Measurement of behaviours may have advantages over measurement of perceptions; behaviours more accurately reflect WLB and can be targeted by leaders for improvement. OBJECTIVES: 1. To describe a novel survey scale for evaluating work-life climate based on specific behavioural frequencies in healthcare workers.2. To evaluate the scale's psychometric properties and provide benchmarking data from a large healthcare system.3. To investigate associations between work-life climate, teamwork climate and safety climate. METHODS: Cross-sectional survey study of US healthcare workers within a large healthcare system. RESULTS: 7923 of 9199 eligible healthcare workers across 325 work settings within 16 hospitals completed the survey in 2009 (86% response rate). The overall work-life climate scale internal consistency was Cronbach α=0.790. t-Tests of top versus bottom quartile work settings revealed that positive work-life climate was associated with better teamwork climate, safety climate and increased participation in safety leadership WalkRounds with feedback (p<0.001). Univariate analysis of variance demonstrated differences that varied significantly in WLB between healthcare worker role, hospitals and work setting. CONCLUSIONS: The work-life climate scale exhibits strong psychometric properties, elicits results that vary widely by work setting, discriminates between positive and negative workplace norms, and aligns well with other culture constructs that have been found to correlate with clinical outcomes.

A randomized, controlled trial to evaluate topical anesthetic for 15 minutes before venipuncture in pediatrics.

OBJECTIVES: The aim of the study was to assess the differences in reported pain from venipuncture comparing liposomal 4% lidocaine with placebo cream in a pediatric population. Other factors assessed were patient anxiety, difficulty of venipuncture, and history of venipuncture. METHODS: A prospective, randomized, double-blind, placebo control study design was used in which subjects were assigned to receive either liposomal 4% lidocaine or placebo cream. The study population consisted of pediatric patients aged 5 to 18 years old who presented to 1 site of a multisite, academic, community emergency department. Once subjects had consented and randomized, the liposomal 4% lidocaine or placebo cream was applied for 15 minutes under occlusion. A 6-point validated FACES pain scale was used to evaluate each patient's level of pain during venipuncture. Patient anxiety was evaluated using a 100-mm visual analogue scale before, during, and after the venipuncture. Heart rate was captured as an indirect measurement of pain. RESULTS: There were no significant differences between the study and placebo groups (P > .05) in mean levels of patient ratings of anxiety, patient heart rate, or the patient's mean rating of pain before, during, or after the venipuncture procedure. There was an association between increased anxiety with an increase in venipuncture pain and an inverse association between age and pain. CONCLUSION: Topical liposomal 4% lidocaine cream in this case did not prove to be effective with a 15-minute dwell time under occlusion because there were no differences in pain between study groups.

The "dance" continues ... evaluating differences in call bell use between patients in private rooms and patients in double rooms using ethnography.

Staff response to patient call bells is a communication issue that influences patient assessment of care quality and satisfaction. An ethnographic, grounded theory approach was used to examine nurses and nursing support staff perspectives about call bell use on single- versus double-patient-room units. We used the dance metaphor to describe differences in staff behaviors related to answering call bells on the 2 units in the study. Unit culture as exemplified by an enhanced call bell system and a relationship-centered leadership style were associated with a well- choreographed call bell answering process that promoted safety and patient satisfaction.

Development of a reliable and valid organization-specific professional practice assessment tool.

PURPOSE: This article describes a study to devise an organization-specific professional practice model (PPM) assessment that reflects actual unit involvement. A secondary study goal is the development of a unit-based index that can be used to conduct comparative analyses in an efficient way. DESIGN: Each of the 5 elements of the organization's PPM was represented by 1 or more items on an author-developed instrument. The tool was structured so that item scores could be summed to achieve a single subscale for each PPM element and further aggregated into a total score. METHODS: The instrument was administered to a 40% random sample of all regularly scheduled, full- and part-time registered nurses in an academic, community Magnet hospital in 2003 and 2005. Descriptive statistics were calculated for items, subscales, and summary scores for each patient care unit and overall. A weighted, unit-based index was developed to reflect each unit's score on a scale of 100. FINDINGS: The 2003 assessment response rate was 51% (n = 200); the 2005 response rate was 48% (n = 193). Subscale scores and a total PPM score were calculated by summing the values of each individual item. Submissions enabled calculations of total scores by unit, mean scores by item, and the development of a unit-specific PPM index of performance. CONCLUSIONS: Beyond shared principles of empowerment, the specifics of each organization's PPM may differ in those key components of care delivery nurses are empowered to effect. Thus, fidelity to the organization-specific PPM is not well tested with generic decisional-involvement instruments. An organization-specific assessment such as this one can provide evidence of not only organizational PPM fidelity but a quantitative method to ensure that staff nurse decisional involvement is continuously evolving to an ever higher state.

A randomized trial to evaluate compliance in terms of patient comfort and satisfaction of two pneumatic compression devices.

PURPOSE: Venous thromboembolism (VTE) incidence can be substantially reduced with prophylaxis, which includes pneumatic compression device (PCD) use. METHODS: To determine whether patient comfort and satisfaction correlated to compliance in wearing PCDs, patients were randomly assigned to either of two effective calf-high PCDs. Education and handouts were provided to both groups. Patients were given a survey rating their comfort, satisfaction, and compliance. At the conclusion of the study, healthcare providers completed a questionnaire comparing both PCDs. RESULTS: A total of 65 patients participated. The main significant differences between groups were seen in the patient perceptions questionnaire for two items: "the device was hot" (p = .014) and "device made my legs sweat" (p = .029). The PCD that provided more comfort and satisfaction was worn for a greater amount of time, 85% vs. 81%, respectively. CONCLUSIONS: Results suggest that patients are more compliant with a PCD that promotes patient comfort when worn.

Dance of the call bells: using ethnography to evaluate patient satisfaction with quality of care.

Ethnographic methods can provide insights into patients' perceptions of quality of care. We used ethnographic methods to examine problems related to answering patient call lights on one inpatient unit in the hospital. Communication through call bells consisted of 3 interrelated components. These included answering the call bell, communicating the patient's request, and following through with the request. Results of this study provided a deeper understanding of the nuances of power and control embedded within the issue of patient-caregiver communication and empowered unit staff to find solutions to the call bell problem.

Research on the frontlines of healthcare: a cooperative learning approach.

BACKGROUND: Evidence-based practice is a common goal in hospitals, but learning about research so that the practice can be done is often challenging for clinicians. OBJECTIVES: The aims of this study were to (a) develop a process that supports organizational and staff development while conducting research and (b) conduct a research study in the emergency department (ED) to examine patient population, satisfaction, and waiting room issues. METHODS: A multidisciplinary team of clinicians and scientists was assembled to learn and do research while evaluating the ED waiting room of a Level I trauma center. A cooperative learning method approach was used to teach research concepts as the study was designed and implemented. RESULTS: The team demonstrated their knowledge and understanding of research concepts by being involved actively in the creation and implementation of the preintervention study. Using information from photographs, observations, and a questionnaire, the team identified the following key dissatisfaction areas: (a) atmosphere (including comfort with environment, neatness and cleanliness, and noise), (b) telephones, (c) parking and thoroughfare, (d) professional behavior and staff presence (including personal attention), (e) security, and (f) triage and confidentiality. DISCUSSION: The model of working in partnership with researchers and using cooperative, collaborative research is an effective way to evaluate and address issues related to quality of care while learning about the research concepts needed to put evidence into practice.

Use of a validated model to evaluate the impact of the work environment on outcomes at a magnet hospital.

Using a structural model, we evaluated the impact of leadership, staff stability, resources, workload, work environment, and staff expertise on nurse-sensitive patient outcomes to determine elements that can be modified.

Understanding discharge instructions after vascular surgery: an observational study.

Patient education is a dynamic ongoing process that occurs from admission to discharge. Vascular surgery is an intensive procedure that causes stress to patient and family members. High stress levels in patients are a barrier to learning. There is a large body of knowledge available on patient education. However, research is lacking on patient retention of discharge instructions after vascular surgery. This study describes patient responses to 4 questions that were asked 3 days after in-hospital teaching was completed by a registered nurse regarding either femoral-popliteal bypass surgery or abdominal aortic aneurysm repair surgery.

Work flow analysis: eliminating non-value-added work.

OBJECTIVE: To evaluate the impact of implemented work environment changes on nursing and support staff roles. BACKGROUND: In 1999, the authors identified key drivers of unnecessary work associated with the day-to-day delivery of patient care in their institution and implemented changes based on their results. METHODS: Both quantitative and qualitative methods were used. Work sampling and focus groups were used to evaluate work flow. Activity categories were identified and clearly defined by advanced practice nurses. All compiled data were subsequently synthesized and cross-checked with the information acquired through independent, multidisciplinary validation studies. RESULTS: There were significant changes (P <.0001) noted in overall distribution of observed activities for nurses and all support staff. CONCLUSIONS: The significant changes noted in overall distribution of observed activities reflect the important adjustments made in both job descriptions and the environment to eliminate key drivers of unnecessary work in the delivery of patient care.

A randomized controlled trial using the school for anti-inflammatory therapy in asthma.

This study investigated the impact of providing low-dose inhaled corticosteroids (ICS) at school or at home to asthmatic inner city children over a 14-week period, compared with the existing community standard. Eight elementary schools in the Dallas Independent School District with a high incidence of asthma located in predominantly urban African-American communities were randomly assigned to one of four groups. The treatment arms were school-based delivery of inhaled steroids, home-based delivery of inhaled steroids, and home-based delivery of inhaled steroids with school-based asthma education, and the control group was no change in current therapy. Fifty students were objectively diagnosed with mild, persistent asthma and participated in the study. Students in the treatment arms received beclomethasone (42 mcg/puff) 4 puffs, twice a day, either at school or at home. Students in the control, "community standard of care" group received no additional medical intervention. Higher peak flows for the treatment groups were seen in the first week and maintained throughout the study (P = .047). By week 5 significant differences were found in frequency of bronchodilator use (P = .025), episodes of nocturnal awakening with asthma symptoms (P = .022), and visits to the primary health care provider (P = .022). Treatment groups rated their asthma as "better than the week before" more frequently than the control group (P = .001). Delivering ICS in school is associated with improved asthma control than when anti-inflammatory medication was delivered to children with asthma in a home-based setting, and both are superior when compared with a control, "community standard of care" group in which no additional medical intervention occurred.

Results of an inner-city school-based asthma and allergy screening pilot study: a combined approach using written questionnaires and step testing.

BACKGROUND: A questionnaire alone may not be an adequate screening tool for asthma. OBJECTIVE: To determine whether an asthma questionnaire used in combination with an exercise step test is better than a questionnaire alone in screening for asthma in children and to evaluate the validity of a rhinitis questionnaire in determining atopy. METHODS: The International Study of Asthma and Allergies in Childhood (ISAAC) asthma core questionnaire was used to screen for asthma in 307 inner-city first through third graders. All children who had scores consistent with a diagnosis of asthma underwent step testing, as did a subset of children who had negative overall scores. All children who had inconsistent asthma scores and step test results underwent methacholine challenge testing. The same 307 children underwent rhinitis screening and children who had one or more positive responses on the ISAAC rhinitis questionnaire underwent skin testing as did a subset of children who had all negative responses. RESULTS: Three hundred of 307 asthma and rhinitis questionnaires were returned. Twenty-eight children (9%) had global asthma scores that were considered to be positive (5 or above). Twenty-four of these children underwent step testing as did 34 randomly selected children who had negative global asthma scores. Thirty-one (91%) of the 34 children who had negative global asthma scores had negative step tests. Similarly, 20 of 24 children (83%) of the children who had positive global asthma scores had negative step tests. Only 4 children who had positive global asthma scores were step test-positive or had reversible airway obstruction at baseline. Using a positive methacholine challenge as the gold standard for establishing bronchial hyperresponsiveness, the global asthma score derived from the eight-item ISAAC asthma questionnaire yielded a sensitivity of 64%, a specificity of 11%, a positive predictive value of 47%, and a negative predictive value of 20%. Comparing the six-item ISAAC rhinitis questionnaire results to the gold standard, skin test reactivity, the questionnaire yielded a sensitivity of 76%, a specificity of 21%, a positive predictive value of 56%, and a negative predictive value of 40%. CONCLUSIONS: Step testing was not useful as a screening tool for asthma. In addition, the ISAAC asthma questionnaire may not be a good asthma screening tool for inner-city pediatric populations, especially if the form is self-administered. Investigators should first validate both the ISAAC asthma and rhinitis screening questionnaires in the particular population to be studied before widespread asthma and allergy screening efforts are initiated using these tools.