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.

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.

Transition Into Practice: Beyond Hospital Walls.

BACKGROUND: Historically, evidence has shown the importance of nurse residency programs, yet few organizations have implemented them outside of hospital settings. This article shares nurses' experiences and outcomes in an out-of-hospital nurse residency program that transitioned bachelor of science in nursing graduates through an academic-practice partnership. METHOD: A mixed methods design was used that consisted of qualitative interviews (pre- and postresidency) and quantitative surveys (Casey-Fink Graduate Nurse Experience Survey, a job satisfaction survey, and a preceptee evaluation survey). RESULTS: Forty-four nurses participated. Qualitative findings were supported by the quantitative data. Results showed that confidence, competence, job satisfaction, and retention improved with an out-of-hospital residency program. CONCLUSION: Ensuring that every new graduate is afforded a nurse residency should be the goal, regardless of setting, to reduce turnover, ensure workforce stability, and ultimately improve patient outcomes. Academic-practice partnerships can help build resource capacity, especially in these settings, to achieve this goal. [J Contin Educ Nurs. 2023;54(7):327-336.].

Nursing Home Patient Safety Culture Perceptions Among Licensed Practical Nurses.

BACKGROUND: Licensed practical nurses (LPNs) working in nursing homes are the primary licensed nurses providing care and ensuring patient safety in New Jersey. As such, it is important to understand LPNs' perception of patient safety culture (PSC) and job satisfaction, which may impact resident safety. PURPOSE: To describe the relationship between LPNs' perception of PSC in nursing homes and job satisfaction. METHODS: A cross-sectional study design was used to survey LPNs in New Jersey. RESULTS: LPNs working in nursing homes were less satisfied than LPNs working in other settings, and their perception of PSC was lower than that in 2019 national data report. CONCLUSION: LPNs in nursing homes indicated that PSC needs improvement. Now is an opportune time to implement initiatives to foster a culture of safety in nursing homes.

Experiences and perceptions of nurses working night shift: a qualitative systematic review.

OBJECTIVE: The objective of this review was to examine the available evidence on the experiences and perceptions of nurses working the night shift within any specialty in the acute care, subacute, or long-term care setting. INTRODUCTION: Nurses are required for around-the-clock patient care. Night shift nurses can experience detrimental effects because of their work hours, which disrupt their normal circadian rhythm. Understanding nurses' experiences and perceptions when working night shift will facilitate the development of strategies to minimize the potential negative effects of working at night. In examining nurses' experiences and perceptions of working night shift, there is scope to explore how to improve night shift nurses' practice environment and job satisfaction, which will then translate to improved nurse and patient outcomes. INCLUSION CRITERIA: This review included qualitative studies focused on the experiences and perceptions of registered nurses and licensed practical nurses who work the night shift or rotate between day and night shift. METHODS: This review followed the JBI methodology for systematic reviews of qualitative evidence. The methodology used was consistent with the a priori protocol. Studies included in this review were those published in full text, English, and between 1983 (when the seminal work on hospitals that attract and retain nurses was published) and February 2021, when the search was completed. The main databases searched for published and unpublished studies included MEDLINE, CINAHL, Embase, PsycINFO, and Web of Science.From the search, two reviewers independently screened the studies against the inclusion criteria, and then papers selected for inclusion were assessed for methodological quality. Qualitative data were extracted from the included papers independently by the four reviewers. Results from each reviewer were discussed and clarified to reach agreement. The extracted findings were pooled and examined for shared meaning, coded, and grouped into categories. Common categories were grouped into meta-synthesis to produce a comprehensive set of synthesized findings. The final synthesized findings were graded using the ConQual approach to determine the level of confidence (trust) users may have in the value of the synthesized findings. RESULTS: Thirty-four papers, representing 33 studies, met the criteria for inclusion. The studies were conducted in 11 countries across six continents, with a total of 601 participants. From these, a total of 220 findings were extracted and combined to form 11 categories based on similarity in meaning, and three syntheses were derived: i) The "Other" Shift: the distinctiveness of night nursing; ii) Juggling sleep and all aspects of life when working nights; and iii) Existing in the Twilight Zone: battling the negative impact of sleep deprivation consumes nurses who strive to keep patients, self, and others safe. CONCLUSIONS: The major conclusions from this review are the uniqueness of working the night shift and the sleep deprivation of night nurses. Organizational strategies and support are needed for those working this shift, which will enhance nurse and patient safety. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42019135294.

Nursing Work Environment Staffing Councils: An Alternative to Mandatory Regulated Staffing Ratios.

OBJECTIVE: The aim of this study was to examine the self-reported perceptions of the healthy work environment (HWE) of nurses who are members of Nursing Workplace Environment and Staffing Councils (NWESCs). BACKGROUND: In a statewide initiative, NWESCs were established at hospitals throughout the state of New Jersey as an alternative to nurse staffing ratio laws and to provide clinical nurses a voice in determining resources needed for patient care and support an HWE. METHODS: This quantitative descriptive study presents the results of the Healthy Workplace Environment Assessment Tool (HWEAT) and open-ended questions about NWESCs among a sample of 352 nurses. RESULTS: Three years after NWESC implementation, all HWEAT standard mean scores increased and were rated higher than the American Association of Critical-Care Nurses benchmark. There were statistically significant differences in clinical nurses' perceptions of an HWE compared with nurse leaders. Respondents also shared their NWESC's best practices and challenges. Responses to questions identified NWESC best practices and challenges. CONCLUSION: This study offers insight into the improvement in nurses' perceptions of the HWE after the introduction of a statewide NWESCs. Structures such as the NWESCs may provide an alternative to mandated staffing ratios.

Leading Improvements in the Delivery of Nursing Care for Older Adults with Frailty in Long-Term Care Using Mitchell's Quality Health Outcome Model and Health Outcome Data.

Protecting frail older residents from adverse health outcomes associated with preventable illnesses and conditions, such as geriatric syndromes within the long-term care (LTC) health system requires attention by the health care team, led by professional nurse leaders, to all of the operant contextual factors influencing health outcomes. Mitchell's Health Outcomes Model helps to frame these operant contextual factors to help understand how the person and the situation are viewed, which then directs professional nurse leaders' interventions. Utilization of the LTC facilities Quality Metrics data can shape and inform nurses leaders as to the gaps which can be filled to meet resident care needs operant among these modifiable contextual factors.

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.

Racial and ethnic differences in vaccine hesitancy Among registered nurses in New Jersey: A cross-sectional survey.

Nurses play an important role in the vaccine readiness process and high vaccination rates among nurses are essential to ensuring successful vaccination programs. This study sought to examine whether the intention to get vaccinated varied by race and/or ethnicity among a large sample of registered nurses in New Jersey.

The effect of data aggregation on estimations of nurse staffing and patient outcomes.

OBJECTIVE: To examine how estimates of the association between nurse staffing and patient length of stay (LOS) change with data aggregation over varying time periods and settings, and statistical controls for unobserved heterogeneity. DATA SOURCES/STUDY SETTING: Longitudinal secondary data from October 2002 to September 2006 for 215 intensive care units and 438 general acute care units at 143 facilities in the Veterans Affairs (VA) health care system. RESEARCH DESIGN: This retrospective observational study used unit-level panel data to analyze the association between nurse staffing and LOS. This association was measured over both a month-long and a year-long period, with and without fixed effects. DATA COLLECTION: We used VA administrative data to obtain patient data on the severity of illness and LOS, as well as labor hours and wages for each unit by month. PRINCIPAL FINDINGS: Overall, shorter LOS was associated with higher nurse staffing hours and lower proportions of hours provided by licensed professional nurses (LPNs), unlicensed personnel, and contract staff. Estimates of the association between nurse staffing and LOS changed in magnitude when aggregating data over years instead of months, in different settings, and when controlling for unobserved heterogeneity. CONCLUSIONS: Estimating the association between nurse staffing and LOS is contingent on the time period of analysis and specific methodology. In future studies, researchers should be aware of these differences when exploring nurse staffing and patient outcomes.

Does Public Reporting of Staffing Ratios and Nursing Home Compare Ratings Matter?

OBJECTIVE: Public reporting is a policy to improve quality and increase data transparency. The objective was to examine the association between publicly available staffing ratios and the Five-Star Quality Ratings from Nursing Home Compare over time. DESIGN: Panel data analysis. SETTING AND PARTICIPANTS: About 146 nursing homes with complete quarterly data in New Jersey between January 1, 2012, and December 31, 2019. METHODS: Using data from the State of New Jersey Department of Health and Nursing Home Compare, staff-to-resident ratios were trended for registered nurses, licensed practical nurses, and certified nursing assistants by shift and over time. Panel data analysis was used to test the association between the ratios and the ratings. RESULTS: Compared to 2012, staffing ratios improved slightly for licensed practical nurses but not for registered nurses or certified nursing assistants in 2019 (P < .001). The number of residents assigned doubled at night for all personnel. During the day and evening shifts, registered nurse staffing was significantly associated with the Nursing Home Compare staffing rating (P < .01) but not the overall rating. CONCLUSIONS AND IMPLICATIONS: Decreasing the number of residents assigned to a registered nurse in NHs results in an increase in staffing ratings. Mandatory public reporting holds nursing homes accountable for quality outcomes but does not improve staffing ratios. Quality resident care is the cumulative result of multiple measures inclusive of staffing; therefore, administrators should continue to focus on improving quality in NHs, which may improve staffing ratios across shifts.

A framework for delivering nursing care to older adults with COVID-19 in nursing homes.

Public health emergencies threaten the lives of U.S. citizens, often in disproportionate ways. Hardest hit are vulnerable populations of older adults (OAs) residing in nursing homes (NHs), who comprised nearly 43% of all deaths from COVID-19 in NHs in 2020. New Jersey (NJ) ranks #2 nationally behind New York with the highest numbers of resident deaths; more than 50% of all COVID-19-related deaths in NJ have occurred in NHs. This public health emergency has prompted investigators to evaluate existing structural, resident, process of care, regulatory, and policy characteristics that have impacted the delivery of nursing care within NJ NHs. In this manuscript, we discuss data from NJ NHs during COVID-19, drawing from publicly available data, state reports, and the geriatric literature to offer recommendations. Based on evidence-based practices (EBPs), we present a series of recommendations to modify existing contextual factors in NHs to best prepare for the next health disaster.

Experiences and perceptions of nurses working night shift: a qualitative systematic review protocol.

OBJECTIVE: The objective of this qualitative systematic review is to examine the available evidence on the experiences of nurses working the night shift within any specialty in the acute care, subacute, or long-term care setting. INTRODUCTION: Nurses are required for round-the-clock patient care, and night shift nurses can experience detrimental effects as a result of their work hours. Understanding nurses' experiences when working night shift will facilitate the development of strategies to minimize the potential negative effects of working at night. In examining nurses' perceptions of working night shift, there is scope to explore how to improve night shift nurses' practice environment and job satisfaction, which will then translate to improved patient outcomes. INCLUSION CRITERIA: This review will consider qualitative studies that include registered nurses and licensed practical nurses who work night shift or rotate between day and night shift. Night supervisors and advanced practice nurses will be excluded due to the potential for dissimilar experiences and resources within those groups. The search will be limited to studies published in English from 1983 to the present. METHODS: The search strategy is designed to locate both published and unpublished qualitative studies by searching academic databases for published studies, gray literature, and hand searching reference lists. The study selection, critical appraisal, data extraction, and synthesis for this systematic review will be conducted in accordance with the JBI methodology for systematic reviews of qualitative evidence. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42019135294.

Increased Risk of Severe Sepsis in Hispanic Children Hospitalized With Acute Myeloid Leukemia.

The purpose of this study, a secondary analysis of a publicly available database, was to identify racial and ethnic disparities in the risk of severe sepsis facing children undergoing the intensive therapy necessary to treat acute myeloid leukemia (AML). The sample consisted of 1,913 hospitalizations of children, younger than 21 years, in the United States during the year 2016 with documentation of both AML and at least one infectious complication. Binary logistic regression models were used to examine the association between race/ethnicity and severe sepsis in children with AML and infection. We found that, after controlling for potential confounding variables, the odds of developing severe sepsis were significantly increased for Hispanic children compared with White children. There were no significant differences in the likelihood of the development of sepsis in Black, Asian, or other race children. The increased risk of severe sepsis for Hispanic children may contribute to the disparate rates of overall survival in this group. This inequitable rate of severe sepsis was evident despite the generally accepted practice of retaining children in the hospital throughout recovery of blood counts following AML therapy. Nurses are in a position to identify and eliminate modifiable risk factors contributing to this disparity.

Staffing Trends in Magnet and Non-Magnet Hospitals After State Legislation.

BACKGROUND: Evidence suggests that Magnet and non-Magnet hospitals differ with respect to quality of care. PURPOSE: Our study examined registered nurse (RN) staffing over time in Magnet and non-Magnet hospitals using unit-level, publicly available data in New Jersey. METHODS: A secondary analysis of longitudinal RN staffing data was conducted using mandated, publicly reported data of 64 hospitals representing 12 nursing specialties across 8 years (2008-2015). Staffing ratios were trended over time to compare RN staffing changes in Magnet and non-Magnet hospitals. RESULTS: Staffing was comparable in Magnet and non-Magnet hospitals for 9 of 12 specialties. On average, from 2008 until 2015, RN staffing slightly increased, with a greater percent increase in Magnet hospitals (6.9%) than in non-Magnet hospitals (4.7%). CONCLUSIONS: Over 8 years in New Jersey, RN staffing improved in Magnet and non-Magnet hospitals. Although there was a slight increase for Magnet hospitals, there was no meaningful difference in staffing for all 12 specialties.

Effects of Public Reporting Legislation of Nurse Staffing: A Trend Analysis.

Public reporting is a tactic that hospitals and other health care facilities use to provide data such as outcomes to clinicians, patients, and payers. Although inadequate registered nurse (RN) staffing has been linked to poor patient outcomes, only eight states in the United States publicly report staffing ratios-five mandated by legislation and the other three electively. We examine nurse staffing trends after the New Jersey (NJ) legislature and governor enacted P.L.1971, c.136 (C.26:2 H-13) on January 24, 2005, mandating that all health care facilities compile, post, and report staffing information. We conduct a secondary analysis of reported data from the State of NJ Department of Health on 73 hospitals in 2008 to 2009 and 72 hospitals in 2010 to 2015. The first aim was to determine if NJ hospitals complied with legislation, and the second was to identify staffing trends postlegislation. On the reports, staffing was operationalized as the number of patients per RN per quarters. We obtained 30 quarterly reports for 2008 through 2015 and cross-checked these reports for data accuracy on the NJ Department of Health website. From these data, we created a longitudinal data set of 13 inpatient units for each hospital (14,158 observations) and merged these data with American Hospital Association Annual Survey data. The number of patients per RN decreased for 10 specialties, and the American Hospital Association data demonstrate a similar trend. Although the number of patients does not account for patient acuity, the decrease in the patients per RN over 7 years indicated the importance of public reporting in improving patient safety.

Health policy engagement among graduate nursing students in the United States.

AIM: The aim was to understand how health policy education is currently being delivered in the United States' graduate nursing programs. METHODS: This exploratory cross-sectional design used an anonymous online survey to target graduate nursing students attending American Association of College of Nursing (AACN) member institutions. RESULTS: Over 75% of the sample (n = 140) reported taking a dedicated health policy course and 71.5% ( n = 131) of the sample responded that a health policy course was required and an equal distribution among master's and doctoral students. There was no significant difference between type of graduate degree sought and the requirement to take a health policy course ( P = 0.37). For students involved in health policy, there was a greater proportion of master's students involved at the state level, than doctorate of nursing practice (DNP) or PhD students ( P = 0.04). CONCLUSIONS: Health policy and advocacy education are important aspects of graduate nursing curriculum and have been integrated into curricula. Graduate nursing students at all levels reported that health policy AACN Essential competencies are being included in their program, either as stand-alone health policy courses or integrated health policy learning activities during matriculation.

Public Reporting of Cardiac Outcomes for Patients With Acute Myocardial Infarction: A Systematic Review of the Evidence.

BACKGROUND: Percutaneous coronary intervention (PCI) is recognized by both the American Heart Association and the American College of Cardiology as an optimal therapy to treat patients experiencing acute myocardial infarction (AMI) with ST-segment elevation myocardial infarction. A health policy aimed at improving outcomes for the patient with AMI is public reporting of whether a patient received a PCI. OBJECTIVE: A systematic review was conducted to evaluate the effect of public reporting for patients with AMI, specifically for those patients who receive PCI. METHODS: EMBASE, MEDLINE, Academic Search Premier, Google Scholar, and PubMed were searched from inception through August 2017. Articles were selected for inclusion if researchers evaluated public reporting and included an outcome for whether a patient received a PCI during hospitalization for an AMI. Methodological quality of the included studies was evaluated, and findings were synthesized. RESULTS: Eight studies of high methodological quality were included in the review. Most studies found that, in areas of public reporting, patients were less likely to undergo a PCI and high-risk patients did not undergo a PCI. Researchers also found that patients with AMI had lower in-hospital mortality after the implementation of public reporting, but only if these patients received a PCI. CONCLUSIONS: Although public reporting may have had intentions of improving care, there is strong evidence that this policy did not result in more timely PCIs or improved mortality of patients with AMI. In fact, public reporting resulted in unintended consequences of not providing care for the most vulnerable patients in fear of an adverse outcome.