Implementing the Synergy Model: A Qualitative Descriptive Study.

Hospitals across our nation are seeking to implement models of care that meet the primary goals of Quadruple Aim: Improved population health, cost-effective care delivery, and patient and provider satisfaction. In an effort to address the Quadruple Aim and our patients' care needs, Hamilton Health Sciences (HHS) embarked on a model of care delivery redesign, beginning with nursing care delivery. From 2013 to 2018, 12 clinical programs at HHS implemented the Synergy Model with its accompanying synergy patient needs assessment tool for nurses to objectively assess patients' acuity and dependency needs. Data on patients' priority care needs were used to inform a nursing model of care redesign at HHS, including skill mix and staffing levels. This five-year project was an organization-wide quality improvement initiative. As part of the evaluation, HHS leaders partnered with health services nurse researchers to conduct a mixed methods study. This paper describes the evaluation outcomes from the qualitative component of the study, which included interviews with clinical nurse leaders and direct care nurses. Data were analyzed using descriptive thematic analysis. Some key findings were increased nurse awareness of patients' holistic care needs and leaders' capacity to plan staffing assignments based on patients' priority care needs. Themes helped inform recommendations for key stakeholders, including nurse leaders and direct care nurses.

Rationale and design of the HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) Trial: a protocol for an international randomised controlled trial evaluating early surgery for hip fracture patients.

INTRODUCTION: Annually, millions of adults suffer hip fractures. The mortality rate post a hip fracture is 7%-10% at 30 days and 10%-20% at 90 days. Observational data suggest that early surgery can improve these outcomes in hip fracture patients. We designed a clinical trial-HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) to determine the effect of accelerated surgery compared with standard care on the 90-day risk of all-cause mortality and major perioperative complications. METHODS AND ANALYSIS: HIP ATTACK is a multicentre, international, parallel group randomised controlled trial (RCT) that will include patients ≥45 years of age and diagnosed with a hip fracture from a low-energy mechanism requiring surgery. Patients are randomised to accelerated medical assessment and surgical repair (goal within 6 h) or standard care. The co-primary outcomes are (1) all-cause mortality and (2) a composite of major perioperative complications (ie, mortality and non-fatal myocardial infarction, pulmonary embolism, pneumonia, sepsis, stroke, and life-threatening and major bleeding) at 90 days after randomisation. All patients will be followed up for a period of 1 year. We will enrol 3000 patients. ETHICS AND DISSEMINATION: All centres had ethics approval before randomising patients. Written informed consent is required for all patients before randomisation. HIP ATTACK is the first large international trial designed to examine whether accelerated surgery can improve outcomes in patients with a hip fracture. The dissemination plan includes publishing the results in a policy-influencing journal, conference presentations, engagement of influential medical organisations, and providing public awareness through multimedia resources. TRIAL REGISTRATION NUMBER: NCT02027896; Pre-results.

Quality-based procedures in Ontario: exploring health-care leaders' responses.

AIM: To examine health-care leaders' initial response to the implementation of orthopaedic quality based procedures (QBPs) in hospitals across Ontario, Canada. BACKGROUND: In 2012, Ontario, Canada shifted 91 hospitals to a patient-based funding (PBF) approach. This approach funds health-care organisations based on the number of patients treated with select procedures known as QBPs. METHODS: An exploratory descriptive design was employed to better understand health-care leaders' early implementation experiences. Seventy organisational leaders from 20 hospitals participated in six focus groups and four interviews to discuss their initial responses to the implementation of two QBPs (primary unilateral hip replacement and primary unilateral knee replacement). Qualitative data underwent content analysis. FINDINGS: Three key major themes emerged; (1) responding to change, (2) leading the change and (3) managing the change. Within each of these themes, barriers and benefits were identified. CONCLUSION: Leaders are accepting of PBF and QBPs. However, challenges exist that require further exploration including the need for a strong infrastructure, accurate and timely clinical and financial data, and policies to prevent unintended consequences. IMPLICATIONS FOR NURSING MANAGEMENT: Implementing QBPs requires careful planning, adequate and appropriate resources, vertical and horizontal communication strategies, and policies to ensure that unintended consequences are avoided and positive outcomes achieved.

Development and evaluation of an RN/RPN utilization toolkit.

PURPOSE: To develop and evaluate a toolkit for Registered Nurse/Registered Practical Nurse (RN/RPN) staff mix decision-making based on the College of Nurses of Ontario's practice standard for utilization of RNs and RPNs. METHODS: Descriptive exploratory. The toolkit was tested in a sample of 2,069 inpatients on 36 medical/surgical units in five academic and two community acute care hospitals in southern Ontario. Survey and focus group data were used to evaluate the toolkit's psychometric properties, feasibility of use and utility. RESULTS: Results support the validity and reliability of the Patient Care Needs Assessment (PCNA) tool and the consensus-based process for conducting patient care reviews. Review participants valued the consensus approach. There was limited evidence for the validity and utility of the Unit Environmental Profile (UEP) tool. Nursing unit leaders reported confidence in planning unit staff mix ratios based on information generated through application of the toolkit, specifically the PCNA, although they were less clear about how to incorporate environmental data into staff mix decisions. CONCLUSIONS: Results confirm that the toolkit consistently measured the constructs that it was intended to measure and was useful in informing RN/RPN staff mix decision-making. Further refinement and testing of the UEP is required. Future research is needed to evaluate the quality of decisions resulting from the application of the toolkit, illuminate processes for integrating data into decisions and adapt the toolkit for application in other sectors.

Registered nurses and licensed/registered practical nurses: a description and comparison of their decision-making process.

In many parts of Canada, nursing care is provided by registered nurses (RNs) and licensed/registered practical nurses (L/RPNs). The profession, regulatory bodies and employers are struggling to define their similarities and differences in their attempts to ensure patients are receiving the right care by the right care provider. An understanding of the decision making of nurses presents one way of differentiating between their overlapping roles. Nursing decision-making is a complex cognitive process. Assessment occurs and problems are postulated. Possible alternatives, with their risks and benefits, outcomes and likelihood of outcomes are identified. Preferences and values are considered, and an intervention is selected. The best way to implement an intervention is determined, implementation follows and evaluation takes place. In this research, a triangulated design was used to examine and compare the decision-making process of RNs and L/RPNs. Analysis revealed that nurses consider themselves to be frequently involved in elements that are part of the decision-making process. Nurses attribute the difficulty encountered to the context within which decision making occurs. Differences exist between the RN and L/RPN in the frequency of their involvement with most of the elements of the process. Differences in difficulty encountered with these elements were less pronounced.

Factors influencing implementation of medical directives by registered nurses: the experience of a large Ontario teaching hospital.

OBJECTIVE: To understand factors that affect the implementation of medical directives by registered nurses in a large teaching hospital. DESIGN: Qualitative nested case study. PARTICIPANTS AND SETTING: A large multi-site teaching hospital that utilizes over 20 different medical directives was chosen as the setting for this case study. Three distinct medical directives within this setting were selected to obtain maximum variation in the number of individuals involved in a particular directive and type of clinical area. Between March and October 2005, 27 individuals concerned with clinical implementation of these medical directives were interviewed using a semi-structured interview schedule. The registrars of two regulatory bodies that oversee policies related to medical directives and a consultant with expertise in medical directives were also interviewed. Eleven documents related to the use of medical directives were identified using purposive document sampling methods and were included in the study. RESULTS: Implementation of medical directives is influenced by a variety of factors, including nurse confidence and willingness to assume responsibility, the amount of new learning needed to carry out the directive and additional paperwork required. Perceived usefulness of the medical directive, physician support of nurses' use of the directives and frequency of encounter with that type of patient were also important factors. The implementation of a medical directive is a complex process; directives are difficult to write well and often affect the scope of practice of other healthcare professionals. The amount of education and monitoring required to implement a directive needs careful consideration to ensure the appropriate resources are available to support implementation. CONCLUSIONS: Greater attention to the factors that facilitate implementation of medical directives is required in order to implement directives in an efficient and effective manner.

Transfer of accountability: transforming shift handover to enhance patient safety.

Communication of information between healthcare providers is a fundamental component of patient care. The information shared between providers who are changing shifts, referred to as "handover," helps plan patient care, identifies safety concerns and facilitates continuity of information. Absent or inaccurate information can have deleterious effects on patient care. According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO 2003), almost 70% of all sentinel events are caused by breakdown in communication. Issues and concerns regarding the effectiveness of handover at shift change were raised by nurses throughout Hamilton Health Sciences (HHS), leading to the approval of a hospital-wide project to implement evidenced-based Transfer of Accountability (TOA) Guidelines and a bedside patient safety checklist. This article describes the development of the guidelines, the results of the pilot study and the ongoing implementation of the project. The observed impact on patient safety within HHS is presented.

Incorporating documents into qualitative nursing research.

PURPOSE: To present an overview of how documents can be incorporated as key sources of data in qualitative nursing research. METHODS: Analysis of the nature of documents and the distinctive features of any research strategy to analyze documents. CONCLUSIONS: Many different strategies can be used in the analysis of documentary sources that are relevant to nursing practice. A systematic approach to the analysis of these textual resources, using one or several of the analytic strategies described here, can support and advance nursing scholarship.

Cultivating APNs for the future: a hospital-based advanced practice nursing internship program.

This paper describes a clinical nurse specialist/clinical nurse specialist-nurse practitioner (CNS/CNS-NP) internship program in a tertiary care teaching hospital Hamilton Health Sciences, located in south-central Ontario, Canada. The goal of the program is to increase the number of fully qualified CNS/CNS-NPs in the organization. With this program, Hamilton Health Sciences (HHS) is able to recognize and reward nurses already employed within the hospital. The program assists nurses in transition to the CNS/CNS-NP role while they are completing the required educational requirements. The authors describe the components of the internship program, responsibilities of participants and the infrastructure required to support the program. Overall the internship program is a valuable mechanism for supporting the development of advanced practice roles in the hospital setting.