Family caregivers' perspectives on the acceptability of four interventions proposed for rural transitional care: A multi-method study.

BACKGROUND: There is a critical need for hospital-to-home transitional care interventions to prepare family caregivers for patients' post-discharge care in rural communities. Four evidence-based interventions (named discharge planning, treatments, warning signs, and physical activity) have the potential to meet this need but family caregivers' perspectives on the acceptability of the interventions have not been examined. This gap is significant because unacceptable interventions are unlikely to be used or used as designed, thereby undermining outcome achievement. Accordingly, this study examined the perceived acceptability of the four interventions to rural family caregivers. MATERIALS AND METHODS: A multi-method descriptive design was used. The quantitative method entailed the administration of an established scale to assess the interventions' perceived acceptability to family caregivers. The qualitative method involved semi-structured interviews to explore family caregivers' perceived acceptability of the interventions in greater depth, including acceptable and unacceptable aspects, in the context of their own transitional care experience. Participants were the family caregivers of a relative who had been discharged home in a rural community from an acute care hospital in Ontario, Canada. RESULTS: The purposive sample included 16 participants who were mostly middle-aged women (n = 14; 87.5%) caring for a parent (n = 9; 56.3%) at high risk for hospital readmission. The mean scores on the acceptability measure were 3 or higher for all interventions, indicating that, on average, the four interventions were perceived as acceptable. In terms of acceptable aspects, four themes were identified: the interventions: 1) involve family caregivers and proactively prepare them for discharge, 2) provide clear, written, and detailed guidance, 3) place the onus on healthcare providers to initiate communication, and 4) ensure post-discharge follow-up. In terms of unacceptable aspects, one theme was identified: the physical activity intervention would be challenging to implement. DISCUSSION: The findings support implementing the four interventions in practice throughout the hospital-to-home transition. Healthcare providers should assess family caregivers' comfort in participating in the physical activity intervention and tailor their role accordingly.

Boundary spanning by nurse managers: effects of managers' characteristics and scope of responsibility on teamwork.

Increasing role complexity has intensified the work of managers in supporting healthcare teams. This study examined the influence of front-line managers' characteristics and scope of responsibility on teamwork. Scope of responsibility considers the breadth of the manager's role. A descriptive, correlational design was used to collect cross-sectional survey and administrative data in four acute care hospitals. A convenience sample of 754 staff completed the Relational Coordination Scale as a measure of teamwork that focuses on the quality of communication and relationships. Nurses (73.9%), allied health professionals (14.7%) and unregulated staff (11.7%) worked in 54 clinical areas, clustered under 30 front-line managers. Data were analyzed using hierarchical linear modelling. Leadership practices, clinical support roles and compressed operational hours had positive effects on teamwork. Numbers of non-direct report staff and areas assigned had negative effects on teamwork. Teamwork did not vary by span, managerial experience, worked hours, occupational diversity or proportion of full-time employees. Large, acute care teaching hospitals can enable managers to foster teamwork by enhancing managers' leadership practices, redesigning the flow or reporting structure for non-direct reports, optimizing managerial hours relative to operational hours, allocating clinical support roles, reducing number of areas assigned and, potentially, introducing co-manager models.

Perspectives on leadership: moving out of the corner of our room.

Perspectives on leadership developed through a career as a nurse leader are shared, including the author's guiding vision, a valuing of nursing as knowledge work, how to create a learning organization that supports professional practice, and other lessons learned through experience. Readers are urged to find the leadership voice within, be courageous, engage surrounding opportunities, and be guided by their vision of what nursing should be in the future.

Front-line managers as boundary spanners: effects of span and time on nurse supervision satisfaction.

AIM: To examine the influence of nurse manager span (number of direct report staff), time in staff contact, transformational leadership practices and operational hours on nurse supervision satisfaction. BACKGROUND: Increasing role complexity has intensified the boundary spanning functions of managers. Because work demands and scope vary by management position, time in staff contact rather than span may better explain managers' capacity to support staff. METHODS: A descriptive, correlational design was used to collect cross-sectional survey and prospective work log and administrative data from a convenience sample of 558 nurses in 51 clinical areas and 31 front-line nurse managers from four acute care hospitals in 2007-2008. Data were analysed using hierarchical linear modelling. RESULTS: Span, but not time in staff contact, interacted with leadership and operational hours to explain supervision satisfaction. CONCLUSIONS: With compressed operational hours, supervision satisfaction was lower with highly transformational leadership in combination with wider spans. With extended operational hours, supervision satisfaction was higher with highly transformational leadership, and this effect was more pronounced under wider spans. IMPLICATIONS FOR NURSING MANAGEMENT: Operational hours, which influence the manager's daily span (average number of direct report staff working per weekday), should be factored into the design of front-line management positions.

Bringing back the house call: how an emergency mobile nursing service is reducing avoidable emergency department visits for residents in long-term care homes.

Avoidable emergency department (ED) visits are a source of clinical risk, stress and anxiety for older, more vulnerable patients. The complexity of health conditions and the unique challenges associated with the care of older patients can also contribute to overcrowding and longer wait times in EDs--issues of significant concern for both healthcare providers and patients. Generally, older patients are more likely than younger patients to visit EDs and be admitted to hospital. In addition, older adults living in long-term care (LTC) homes are more likely to be transferred to EDs for preventable issues than those living in other settings. This paper describes how mobilizing a team of registered nurses working at full scope of practice might reduce the number of avoidable transfers of older patients to the ED. Utilizing nurses in this capacity demonstrates how the nursing profession can drive systemwide change to improve care between healthcare sectors for older adults.

Going blank: factors contributing to interruptions to nurses' work and related outcomes.

AIM: To examine interruptions to nurses' work, the systems issues related to these and the associated outcomes. BACKGROUND: While some research has described the role interruptions play in medication errors, work is needed to examine specific factors in the nursing work environment that cause interruptions and to assess the impact of these on nurses' work and patient outcomes. METHODS: The present study utilized a mixed method design that involved work observation to detect nursing interruptions in the workplace followed by focus groups with a subsample of nurses. RESULTS: A total of 13,025 interruptions were observed. Equal numbers of these took place on medical and surgical units. The predominant source of interruptions was members of the health team, who interrupted more frequently on medical units. CONCLUSIONS: Differences in the type of patient and the care needs between medical and surgical units may be a contributing factor to these findings. As members of the health team were among the leading source of interruptions, an interdisciplinary team-based approach to changing the organization and design of work should be explored. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse leaders should examine ways in which nurses' work can benefit from system improvements to reduce interruptions that lead to patient safety issues such as treatment delays and loss of concentration.

The Ontario nursing workload demonstration projects: rethinking how we measure, cost and plan the work of nurses.

BACKGROUND: In 2008 the Nursing Secretariat of Ontario's Ministry of Health and Long-Term Care formed a Nursing Workload Steering Committee to oversee the implementation of three demonstration projects with the objectives: to assess the feasibility of Health Outcomes for Better Information and Care (HOBIC) data as a measure of nursing workload, determine the indicators that best support nurse leaders to measure nursing work and make informed staffing decisions, and develop a model that predicts acute care nursing costs. RESULTS: Three HOBIC scales--activities of daily living (ADLs), continence and fatigue--explained a small amount of the variance in nurse judgment of the amount of nursing time patients require in the first 24 hours of care. Nurses in the study appreciated providing their professional judgment to help estimate the nursing work requirements of patients. The priority and secondary indicators most important for decision-making included medical severity of patients, environmental complexity, nurse experience, patient turnover, nurse-to-patient ratio, cognitive status, infection control, nurse vacancy, predictability of patient types, nursing interventions, patient volumes, co-morbidities, patient self-care abilities, physical and psychosocial functioning, unit type and medical diagnosis. A fairly robust model was developed using existing data sources to estimate nursing input into a patient's costs. The model explained between 69% and 80% of the variation in nursing costs for each patient. CONCLUSION: In order to effectively measure, plan and cost nursing, we need to determine what nursing is. In the future, recognition of nurses as knowledge workers will require us to consider the many patient and environmental factors that affect the ability of nurses to apply their professional judgment to care for patients.

Collaboration to change the landscape of nursing: a journey between urban and remote practice settings.

University Health Network (UHN) became a demonstration site to test a health human resource planning model to foster inter-organizational collaboration, knowledge transfer and exchange of nurses between an urban academic health science centre and a remote region in northern Ontario. Funding support was provided by the Ontario Ministry of Health and Long-Term Care. The partnership between UHN, Weeneebayko Health Ahtuskaywin (WHA) and James Bay General Hospital (JBGH) addressed retention, recruitment, professional practice development, planning and succession planning objectives. The primary goal of this partnership was to supply the staffing needs of WHA/JBGH with UHN nurses at a decreased cost for four- to six-week placement periods. This resulted in a marked decrease in agency use by approximately 40% in the WHA site during the months UHN nurses were practicing in the north, with an overall agency cost savings of $165,000 reported in the pilot year. The project also served as a recruitment and retention strategy for all organizations. It provided an opportunity to practice in new clinical settings and to engage in knowledge transfer experiences and professional development initiatives between remote and urban practice environments. In the pilot year, 37 nurses (30 from UHN and 7 from WHA) participated. They returned to their respective organizations re-energized by the different "landscape" of practice experience and toward the nursing profession itself.

NursesforTomorrow: a proactive approach to nursing resource analysis.

This paper describes the background, development, implementation and utilization of NursesforTomorrow (N4T), a practical and comprehensive nursing human resources analysis method to capture regional, institutional and patient care unit-specific actual and predicted nurse vacancies, nurse staff characteristics and nurse staffing changes. Reports generated from the process include forecasted shortfalls or surpluses of nurses, percentage of novice nurses, occupancy, sick time, overtime, agency use and other metrics. Readers will benefit from a description of the ways in which the data generated from the nursing resource analysis process are utilized at senior leadership, program and unit levels to support proactive hiring and resource allocation decisions and to predict unit-specific recruitment and retention patterns across multiple healthcare organizations and regions.

Examining the relationship between patient-centred care and outcomes.

PURPOSE: to examine the extent to which staff nurses provided patient-centred care (PCC), as perceived by staff nurses and patients, and to explore the relationships between implementation of PCC and patient outcomes. DESIGN: A descriptive correlational design with repeated measures was used. Descriptive statistics, correlations and t-tests were calculated. METHODS: Data were collected from 63 nurses and 44 patients admitted to cardiology, neurology/neurosurgery and orthopedic units. Nurses' and patients' perception of implementation of dimensions of PCC, and patient outcomes were measured with validated instruments. FINDINGS: Overall, nurses and patients reported implementation of PCC to a moderate extent. Provision of different aspects of PCC was associated with high levels of patient self-care. CONCLUSIONS: Implementation of PCC is expected to improve patient outcome by increasing patient self-care ability and improving satisfaction with care and quality of life. CLINICAL RELEVANCE: The findings will guide further improvement in the implementation of PCC to continuously enhance quality of nursing care, the patients' hospital experience and readiness for discharge.

We are called upon to lead.

The paper "Global Nurse Migration: Its Impact on Developing Countries and Prospects for the Future" by Khaliq, Broyles and Mwachofi explores the global nurse migration experience in developed and developing countries. Nurses choose to migrate from developing countries in response to economic and political instability, and poor salaries and working conditions in their home countries. These factors also interfere with the home countries' capacity to deliver education for health professions and to provide adequate support for a healthcare system. The paper clearly outlines the catastrophic outcomes of nurse migration for developing countries where inadequate numbers of trained and experienced nurses remain to support education and administration. Many well-documented references in the paper report overburdening of the remaining workforce, reduced access to care, increased risk of patient mortality, increased maternal, infant and under-five-year mortality rates, reduced life expectancy, increased incidence of communicable diseases and reduced immunization, all resulting from shortages of health professionals, leading to increased nursing workload and burnout.

Human becoming and 80/20: an innovative professional development model for nurses.

The authors describe a study that evaluated implementation of a professional development model in which nurses spend 80% of their salaried time in direct patient care and 20% of their salaried time on professional development. The professional development time includes focused learning about patient-centered practice guided by the human becoming nursing theory. A qualitative descriptive preproject-process-postproject method and a longitudinal, repeated measures, descriptive-comparative method were used to answer the research questions. Participants were 33 nurses, 11 other nurse leaders and health professionals, and 55 patients and family members. The findings show that on the study unit overtime hours decreased significantly, the education hours were sustained throughout the study period, workload hours per patient day increased significantly, sick time stayed low, patient satisfaction scores increased, staff satisfaction scores were significantly higher than for comparator groups, and turnover was non-existent among study participants in year 2. Average variable direct labor cost increased over time, but the increase was not significantly higher than on the control units. Themes from the interviews with participants are presented. Ongoing evaluation of the model and implications for future research are discussed.

The business case for patient safety.

The leadership team at University Health Network describes why it decided to pursue a new information technology initiative to substantially reduce human and system errors and omissions associated with medication management.