Coincidence Analysis: A Novel Approach to Modeling Nurses' Workplace Experience.

OBJECTIVES: The purpose of this study is to identify combinations of workplace conditions that uniquely differentiate high, medium, and low registered nurse (RN) ratings of appropriateness of patient assignment during daytime intensive care unit (ICU) work shifts. METHODS: A collective case study design and coincidence analysis were employed to identify combinations of workplace conditions that link directly to high, medium, and low RN perception of appropriateness of patient assignment at a mid-shift time point. RN members of the study team hypothesized a set of 55 workplace conditions as potential difference makers through the application of theoretical and empirical knowledge. Conditions were derived from data exported from electronic systems commonly used in nursing care. RESULTS: Analysis of 64 cases (25 high, 24 medium, and 15 low) produced three models, one for each level of the outcome. Each model contained multiple pathways to the same outcome. The model for "high" appropriateness was the simplest model with two paths to the outcome and a shared condition across pathways. The first path comprised of the absence of overtime and a before-noon patient discharge or transfer, and the second path comprised of the absence of overtime and RN assignment to a single ICU patient. CONCLUSION: Specific combinations of workplace conditions uniquely distinguish RN perception of appropriateness of patient assignment at a mid-shift time point, and these difference-making conditions provide a foundation for enhanced observability of nurses' work experience during hospital work shifts. This study illuminates the complexity of assessing nursing work system status by revealing that multiple paths, comprised of multiple conditions, can lead to the same outcome. Operational decision support tools may best reflect the complex adaptive nature of the work systems they intend to support by utilizing methods that accommodate both causal complexity and equifinality.

Registered Nurse Strain Detection Using Ambient Data: An Exploratory Study of Underutilized Operational Data Streams in the Hospital Workplace.

BACKGROUND: Registered nurses (RNs) regularly adapt their work to ever-changing situations but routine adaptation transforms into RN strain when service demand exceeds staff capacity and patients are at risk of missed or delayed care. Dynamic monitoring of RN strain could identify when intervention is needed, but comprehensive views of RN work demands are not readily available. Electronic care delivery tools such as nurse call systems produce ambient data that illuminate workplace activity, but little is known about the ability of these data to predict RN strain. OBJECTIVES: The purpose of this study was to assess the utility of ambient workplace data, defined as time-stamped transaction records and log file data produced by non-electronic health record care delivery tools (e.g., nurse call systems, communication devices), as an information channel for automated sensing of RN strain. METHODS: In this exploratory retrospective study, ambient data for a 1-year time period were exported from electronic nurse call, medication dispensing, time and attendance, and staff communication systems. Feature sets were derived from these data for supervised machine learning models that classified work shifts by unplanned overtime. Models for three timeframes -8, 10, and 12 hours-were created to assess each model's ability to predict unplanned overtime at various points across the work shift. RESULTS: Classification accuracy ranged from 57 to 64% across three analysis timeframes. Accuracy was lowest at 10 hours and highest at shift end. Features with the highest importance include minutes spent using a communication device and percent of medications delivered via a syringe. CONCLUSION: Ambient data streams can serve as information channels that contain signals related to unplanned overtime as a proxy indicator of RN strain as early as 8 hours into a work shift. This study represents an initial step toward enhanced detection of RN strain and proactive prevention of missed or delayed patient care.

Subtle cues: Qualitative elicitation of signs of capacity strain in the hospital workplace.

Through everyday care experiences, nurses develop expertise in recognition of capacity strain in hospital workplaces. Through qualitative interview, experienced nurses identify common activity changes and adaptive work strategies that may signal an imbalance between patient demand and service supply at the bedside. Activity change examples include nurse helping behaviors across patient assignments, increased volume of nurse calls from patient rooms, and decreased presence of staff at the nurses' station. Adaptive work strategies encompass actions taken to recruit resources, move work in time, reduce work demands, or reduce thoroughness of task performance. Nurses' knowledge of perceptible signs of strain provides a foundation for future exploration and development of real-time indicators of capacity strain in hospital-based work systems.

Informal caregiving in Hematopoietic Blood and Marrow Transplant patients.

PURPOSE: Hematopoietic cell transplant patients are among the most vulnerable and acutely ill cancer populations (Bevans et al., 2008). The responsibility of caring for the daily physical and psychosocial needs of these patients after transplant is placed mostly on family caregivers (Williams, 2007). The purpose of this descriptive correlational research study was to describe caregiving experiences of 56 caregivers of HCT patients 3-12 months following transplant. METHODS & SAMPLE: Patients and caregivers were recruited from two west coast regional transplant programs in the United States. Variables studied were: relationship quality, rewards of caregiving, predictability, role strain, patient function, caregiving activities, and caregiver quality of life (QOL). KEY RESULTS: Results indicated that all areas of role strain are significantly negatively correlated with caregiver's QOL. Predictability was negatively associated with problem solving and emotional strain indicating that as the level of predictability of the situation decreases, caregiver strain and problem solving increase. Predictability was positively correlated to caregiver QOL indicating that as the situation is more predictable caregiver QOL increases. Emotional strain, problem-solving strain, and usual care strain were significantly positively related, indicating that emotional strain and problem-solving strain increased together. As usual care strain increased, so did problem-solving strain and emotional strain. CONCLUSIONS: Suggestions for interventions include assessing and responding to caregiver issues such as emotional strain, problem-solving strain, usual care strain, unpredictability, and QOL. Examples of caregiver-focused interventions include providing timely appropriate information about these caregiver concerns including elements that make the caregiving situation predictable, and incorporating best practices for preventing and minimizing caregiver emotional strain.

Explaining family caregiver role strain following autologous blood and marrow transplantation.

This research project explores family caregiving processes during the first 100 days following autologous blood and marrow transplantation (ABMT). In this paper, we (1) explore patterns in caregiving, and ABMT recipient function early recovery from ABMT; (2) examine the relationships among caregiver demographics, relationship quality, preparedness, ABMT recipient function, predictability of caregiving, caregiver role strain and rewards of caregiving; and (3) examine the relative contribution of caregiver age, preparedness, relationship quality, and ABMT recipient function on caregiver role strain, and rewards of caregiving. Fifty-two family caregivers of ABMT recipients completed questionnaires about caregiving at hospital discharge, and again 2, 6, and 12 weeks following discharge. The amount of caregiving activities performed, and caregiver role strain, declined steadily from 2 weeks to 12 weeks of recovery. The caregiving situation was relatively predictable during recovery, and caregivers reported that caregiving was consistently rewarding. The caregiving activities rated as most difficult were those related to supporting recipients' emotional well-being. Strain from caregiving, although low, was explained by disruption in recipients' emotional and physical functioning, while caregiving rewards were explained by caregivers' preparedness for caregiving. Relationship quality, a significant predictor of strain in other samples, did not influence caregiving strain or rewards in this population. Caregiving processes delineated in studies of caregivers of persons with chronic illness are quite different from those described in this study. The acuity of the recipients' illness, the life threatening nature of the treatment, and the younger age of caregivers, and recipients, may underlie these differences.

Variables predicting trauma patient survival following massive transfusion.

INTRODUCTION: The literature contains little information regarding demographic or transfusion-related factors associated with survival following massive blood transfusion in trauma patients. The objective of this study was to describe patient, transfusion, and laboratory variables contributing to survival in this population during the first and second days after arrival at the hospital. A secondary objective was to identify costs associated with massive blood transfusion. METHODS: A 7-year, retrospective review of 13,005 consecutive trauma patient records yielded a sample of 46 who were transfused with > or =50 units of blood products in the first postinjury day. Descriptive statistics were computed to describe the sample, transfusion data, and laboratory values. Logistic regression was used to predict survival using selected patient characteristics, laboratory data, and transfusion characteristics for both the first and second days. RESULTS: Overall survival among this group who received massive transfusion was 63%. No significant differences were found between survivors and nonsurvivors in age, sex, type of trauma, or amount of any of the blood components administered on Day 1. Nonsurvivors had higher Injury Severity Scores and shorter ICU and hospital lengths of stay. Controlling for other variables, only arterial base deficit levels made a significant unique contribution to predicting survival. The volume of blood transfused on Day 2 did not contribute to survival prediction. The average cost of blood transfusion was more than 49,000 US dollars per survivor and 51,000 US dollars per nonsurvivor. CONCLUSION: Defining medical futility based solely on the volume of blood products transfused currently is unjustified. The search for other early indicators of survival in the trauma population must continue.

Hormonal responses to the 6-minute walk test in women and men with coronary heart disease: a pilot study.

BACKGROUND: Women with coronary heart disease (CHD) are more likely than men to develop congestive heart failure (CHF). Dysregulation of sympathetic and volume-regulatory hormones may contribute to the onset of symptomatic CHF. We hypothesized that this hormonal dysregulation develops at an earlier stage of CHD in women than in men. OBJECTIVES: The study goals were (1) to determine the effect of gender on basal and exercise-induced plasma concentrations of catecholamines and volume-regulatory hormones in patients diagnosed with CHD, New York Heart Association class I and (2) to determine efficacy of the 6-minute walk test as a stimulus for release of these hormones. METHODS: Study participants were 9 women and 9 men with normal left ventricular ejection fraction (>50%) and CHD confirmed by arteriography. Data were collected under resting conditions, and after the 6-minute walk test, in the general clinical research center of a northeastern university medical center. RESULTS: Basal plasma vasopressin (VP) concentration was significantly higher in men than in women (P = .018). Exercise, for women and men combined, significantly increased atrial natriuretic peptide (P < .0005), VP (P = .04), norepinephrine (P < .0005), and epinephrine (P = .038) but not plasma renin activity (P = .09). No further gender differences were detected for basal levels, or for the magnitude of exercise-induced increases, for any of the hormones measured. CONCLUSIONS: The 6-minute walk test is an exercise of sufficient intensity and duration to initiate the release of hormones associated with sympathetic activation and fluid-electrolyte regulation in both women and men with CHD. It appears that a gender difference was detected only for basal VP levels.

Perception of risk for coronary heart disease in women undergoing coronary angiography.

BACKGROUND: Even though coronary heart disease (CHD) is the leading cause of death among women in the United States, most women underestimate their risk of developing CHD. DESIGN: Survey to examine the relationship between women's recollection of being told they were at risk for CHD and the presence of risk factors. SETTING/PARTICIPANTS: A convenience sample of 450 women undergoing coronary angiography at 1 university hospital. MAIN OUTCOME MEASURES: Self-recollection of being told one was at risk for CHD and presence of CHD risk factors. RESULTS: Most women (83.6%) had 3 or more risk factors, 12.2% had 1 or 2 risk factors, and 0.9% had no risk factors. Only 35% of women recalled being told that they were at risk for CHD. Few relationships were found between being told one was at risk for CHD and the presence of individual risk factors. No difference was found in the mean number of risk factors among women who did and did not recall being told they were at risk. In logistic regression analysis, only 5% of the variance in recollection of being told one was at risk was predicted, with only age, education, and having a high cholesterol level significantly contributing to the equation. CONCLUSIONS: Even though women may not remember conversations with their health care provider about CHD risk, the possibility that risk factors were not adequately assessed cannot be discounted. Patient-provider conversations about CHD risk factors should be encouraged as the first step toward successful risk reduction.