The importance of recovery and staffing on midwives' emotional wellbeing: A UK national survey.

BACKGROUND: There is currently a gap in the evidence on how working practices, such as the ability to take rest breaks, finish on time or intershift recovery influence outcomes. AIM: The aim of this study was to explore the association of individual characteristics, work-related factors and working practices on emotional wellbeing outcomes of UK midwives. METHODS: An online cross-sectional survey collated data between September and October 2020. Outcomes explored were work-related stress, burnout, being pleased with their standard of care, job satisfaction and thoughts about leaving midwifery. Univariate analysis identified the explanatory variables to be investigated using multivariable logistic regression. FINDINGS: A total of 2347 midwives from the four UK nations completed the survey. No standard approach in monitoring safe staffing or in-shift or intershift recovery was found. There were high levels of work-related stress, burnout and thoughts about leaving midwifery, and low levels of job satisfaction, with just half of midwives reporting they were satisfied with the standard of care they could provide. Multivariable regression revealed that working practices variables, generally related to impeded recovery or compounded by staffing issues, had a significant association with poorer emotional wellbeing outcomes. CONCLUSION: This research has demonstrated an association between impeded recovery, including a lack of formal methods to monitor this, and poorer emotional wellbeing outcomes, and that staffing levels are highly influential in determining outcomes. There is a need to re-evaluate current approaches to job design and how midwives are expected to work.

Racial Disparities in Stroke Readmissions Reduced in Hospitals With Better Nurse Staffing.

BACKGROUND: Racial minorities are disproportionately affected by stroke, with Black patients experiencing worse poststroke outcomes than White patients. A modifiable aspect of acute stroke care delivery not yet examined is whether disparities in stroke outcomes are related to hospital nurse staffing levels. OBJECTIVES: The aim of this study was to determine whether 7- and 30-day readmission disparities between Black and White patients were associated with nurse staffing levels. METHODS: We conducted a secondary analysis of 542 hospitals in four states. Risk-adjusted, logistic regression models were used to determine the association of nurse staffing with 7- and 30-day all-cause readmissions for Black and White ischemic stroke patients. RESULTS: Our sample included 98,150 ischemic stroke patients (87% White, 13% Black). Thirty-day readmission rates were 10.4% (12.7% for Black patients, 10.0% for White patients). In models accounting for hospital and patient characteristics, the odds of 30-day readmissions were higher for Black than White patients. A significant interaction was found between race and nurse staffing, with Black patients experiencing higher odds of 30- and 7-day readmissions for each additional patient cared for by a nurse. In the best-staffed hospitals (less than three patients per nurse), Black and White stroke patients' disparities were no longer significant. DISCUSSION: Disparities in readmissions between Black and White stroke patients may be linked to the level of nurse staffing in the hospitals where they receive care. Tailoring nurse staffing levels to meet the needs of Black ischemic stroke patients represents a promising intervention to address systemic inequities linked to readmission disparities among minority stroke patients.

For the People and the Profession.

In 1982 Dean Warren delivered the presidential address "Not for the Profession… For the People" in which he identified substandard surgical residency programs graduating residents who were unable to pass American Board of Surgery exams. Drs. Warren and Shires as members of the independent ACGME began to close the substandard programs in order to improve surgical care for average Americans i.e. "for the people". By 2003 these changes dramatically reduced the failure rate for the ABS exams and trained good surgeons who could operate independently however the residents were on duty for every other or every third night. In 2003 the ACGME mandated duty hour restrictions in order improve resident wellness and improve the training environment for the profession. However, work hour restrictions reduced the time surgical residents spent in the hospital environment primarily when residents had more autonomy and had exposure to emergency cases which degraded readiness for independent practice. Surgical educators in the 2 decades after the work hour restrictions have improved techniques of training so graduates could not only pass the board exams but also be prepared for independent practice. Surgical residency training has improved by both the changes implemented by the independent ACGME in 1981 and by the work hour restrictions mandated in 2003. Five recommendations are made to ensure that Dr Warren's culture of excellence in surgical training continues in an environment that enhances wellbeing of the trainee i.e. "For the People and the Profession".

The Impact of COVID-19: Nurses Occupational Stress and Strategies to Manage It.

OBJECTIVE: The aim of this study was to explore the occupational stress perception of nurses and how they manage it during the COVID-19 pandemic. BACKGROUND: The management of occupational stress is a key factor in promoting nurses' well-being. METHODS: A descriptive cross-sectional study was conducted. RESULTS: The top occupational stressors from the nurses' perspectives (N = 236) as measured by using an updated version of the Nursing Stress Scale (NSS) included wearing a face mask at all times in the hospital, unpredictable staffing and scheduling, not enough staff to adequately cover the unit, feeling helpless in the case a patient fails to improve, and being assigned to a COVID-19 patient. The mean stress score was 31.87. The updated NSS Cronbach's α was 0.92, and the interclass interclass correlation coefficient was 0.914. CONCLUSION: Nurse administrators are in a strategic position to develop interventions (eg, open door policy, meetings, and employee assistance programs) to assist nurses in effectively managing stress.

Comparison of Sleep and Attention Metrics Among Nurses Working Shifts on a Forward- vs Backward-Rotating Schedule.

Importance: The association of fast backward-rotating shift work (ie, anticlockwise sequence of afternoon, morning, and night shifts) with subjective and objective measures of sleep-wake quality, daytime attention, and tiredness of health care workers has not yet been established. Objective: To investigate the association of shift rotation direction with tiredness, sleepiness, and sustained attention among nurses working forward- and backward-rotating shifts. Design, Setting, and Participants: Data of this cohort study were collected from nurses working at 5 midsized Italian hospitals. The nurses had either a forward-rotating schedule (ie, morning to afternoon to night) and or a backward-rotating schedule (ie, afternoon to morning to night). The data were collected from July 2017 to February 2020. Data analysis was performed from May to October 2020. Exposures: Participants were working either forward- or backward-rotating schedules, in which the sequence of 3 shifts (morning, afternoon, and night) changed in a clockwise or anticlockwise direction. Main Outcomes and Measures: Sleep data were collected using the Karolinska Sleepiness Scale and Pittsburgh Sleep Quality Index. Sustained attention was measured using the Psychomotor Vigilance Task. Tiredness was evaluated using the Tiredness Symptom Scale. Results: A total of 144 nurses (mean [SE] age, 41.3 [0.8] years; 92 women [63.9%]) participated in the study; 80 nurses had forward-rotating schedules, and 64 had backward-rotating schedules. Nurses with irregular sleep-wake patterns due to night shift work had poor sleep quality (46 [57.5%] in forward-rotating schedule group; 37 [57.8%] in backward-rotating schedule group). Nurses working backward-rotating shifts exhibited significantly greater sleepiness (F1,139 = 41.23; P < .001) and cognitive slowing (ie, longer median reaction times; F1,139 = 42.12; P < .001) than those working forward rotations. Importantly, these differences were not affected by age, years of employment, and quality of sleep. Of nurses working on a backward-rotating schedule, 60 (93.8%) reported elevated sleepiness (Karolinska Sleepiness Scale score ≥7) after the night shift. The median reaction time (F1,139 = 42.12; P < .001), 10% fastest reaction time (F1,139 = 97.07; P < .001), minor lapses (F1,139 = 46.29; P < .001), and reaction time distribution (F1,139 = 60.13; P < .001) of nurses on backward-rotating schedules indicated a lower level of vigilance, which is negatively associated with neurobehavioral performance. Conclusions and Relevance: In this study, both shift rotation models were negatively associated with health and cognitive performance. These findings suggest that forward shift rotation may be more beneficial than backward rotation for several measured performance attentional outcomes and sleepiness. Optimization of shift rotations should be implemented to decrease the combination of the negative outcomes associated with shift work and reduce the potential risk of medical errors in health care systems.

Adaptation and restructuring of an academic anesthesiology department during the COVID-19 pandemic in New York City: Challenges and lessons learned.

The novel SARS-CoV-2 pandemic starting in 2019 profoundly changed the world, and thousands of residents of New York City were affected, leading to one of the most acute surges in regional hospital capacity. As the largest academic medical center in the Bronx, Montefiore Medical Center was immediately impacted, and the entire hospital was mobilized to address the needs of its community. In this article, we describe our experiences as a large academic anesthesiology department during this pandemic. Our goals were to maximize our staff's expertise, maintain our commitment to wellness and safety, and preserve the quality of patient care. Lessons learned include the importance of critical care training presence and leadership, the challenges of converting an ambulatory surgery center to an intensive care unit (ICU), and the management of effective communication. Lastly, we provide suggestions for institutions facing an acute surge, or subsequent waves of COVID-19, based on a single center's experiences.

Willing But Not Quite Ready: Nurses' Knowledge, Attitudes, and Practices of Research in an Academic Healthcare System.

OBJECTIVE: To describe nurses' research knowledge, attitudes, and practices within an academic hospital system. BACKGROUND: Hospitals are investing in research resources to meet Magnet® goals and advance the science of nursing, but nurses' specific needs for support are not well characterized and may vary by setting. METHODS: We conducted an anonymous online survey of RNs at an academic hospital system in 2019-2020 using the validated Nurses' Knowledge, Attitudes, and Practices of Research Survey. RESULTS: Respondents (N = 99) indicated high willingness to engage in research-related tasks but low or moderate knowledge of and ability to perform them. Knowledge, attitudes, and practices of research increased with level of education, although gaps between willingness to engage versus knowledge and ability persisted even among doctorally prepared nurses. CONCLUSIONS: Research support for clinical nurses should leverage enthusiasm for research and focus on developing and applying specific practical skills, even among nurses with advanced degrees.

An Integrative Review of Team Nursing and Delegation: Implications for Nurse Staffing during COVID-19.

BACKGROUND: During the COVID-19 pandemic, providing care for critically ill patients has been challenging due to the limited number of skilled nurses, rapid transmission of the virus, and increased patient acuity in relation to the virus. These factors have led to the implementation of team nursing as a model of nursing care out of necessity for resource allocation. Nurses can use prior evidence to inform the model of nursing care and reimagine patient care responsibilities during a crisis. PURPOSE: To review the evidence for team nursing as a model of patient care and delegation and determine how it affects patient, nurse, and organizational outcomes. METHODS: We conducted an integrative review of team nursing and delegation using Whittemore and Knafl's (2005) methodology. RESULTS: We identified 22 team nursing articles, 21 delegation articles, and two papers about U.S. nursing laws and scopes of practice for delegation. Overall, team nursing had varied effects on patient, nursing, and organizational outcomes compared with other nursing care models. Education regarding delegation is critical for team nursing, and evidence indicates that it improves nurses' delegation knowledge, decision-making, and competency. LINKING EVIDENCE TO ACTION: Team nursing had both positive and negative outcomes for patients, nurses, and the organization. Delegation education improved team nursing care.

A Glimpse Into the Magnet® Program Office: The High-Performing Senior Magnet® Program Analyst Team.

The Magnet Recognition Program® has a dedicated team of RNs and non-RNs who are committed to advancing nursing and supporting healthcare organizations on their Magnet® journeys. Healthcare organizations who are either Magnet-designated or applicants for Magnet designation regularly communicate with the various members of the Magnet program office team. This perspective will highlight the roles of the senior Magnet program analysts and the assistant director of Magnet program operations.

Fatal Underfunding? Explaining COVID-19 Mortality in Spanish Nursing Homes.

The COVID-19 pandemic has exerted a disproportionate effect on older European populations living in nursing homes. This article discusses the 'fatal underfunding hypothesis', and reports an exploratory empirical analysis of the regional variation in nursing home fatalities during the first wave of the COVID-19 pandemic in Spain, one of the European countries with the highest number of nursing home fatalities. We draw on descriptive and multivariate regression analysis to examine the association between fatalities and measures of nursing home organisation, capacity and coordination plans alongside other characteristics. We document a correlation between regional nursing home fatalities (as a share of excess deaths) and a number of proxies for underfunding including nursing home size, occupancy rate and lower staff to a resident ratio (proxying understaffing). Our preliminary estimates reveal a 0.44 percentual point reduction in the share of nursing home fatalities for each additional staff per place in a nursing home consistent with a fatal underfunding hypothesis.

Variation in referral rates to emergency departments and inpatient services from a GP out of hours service and the potential impact of alternative staffing models.

INTRODUCTION: Out of hours (OOHs) primary care is a critical component of the acute care system overnight and at weekends. Referrals from OOH services to hospital will add to the burden on hospital assessment in the ED and on-call specialties. METHODS: We studied the variation in referral rates (to the ED and direct specialty admission) of individual clinicians working in the Oxfordshire, UK OOH service covering a population of 600 000 people. We calculated the referral probability for each clinician over a 13-month period of practice (1 December 2014 to 31 December 2015), stratifying by clinician factors and location and timing of assessment. We used Simul8 software to determine the range of hospital referrals potentially due to variation in clinician referral propensity. RESULTS: Among the 119 835 contacts with the service, 5261 (4.4%) were sent directly to the ED and 3474 (3.7%) were admitted directly to specialties. More referrals were made to ED by primary care physicians if they did not work in the local practices (5.5% vs 3.5%, p=0.011). For clinicians with >1000 consultations, percentage of patients referred varied from 1% to 21% of consultations. Simulations where propensity to refer was made less extreme showed a difference in maximum referrals of 50 patients each week. CONCLUSIONS: There is substantial variation in clinician referral rates from OOHs primary care to the acute hospital setting. The number of patients referred could be influenced by this variation in clinician behaviour. Referral propensity should be studied including casemix adjustment to determine if interventions targeting such behaviour are effective.

Identifying optimal labor and delivery nurse staffing: The case of cesarean births and nursing hours.

BACKGROUND: Numerous studies have identified a relationship between nurse staffing and adverse patient outcomes in medical / surgical patient populations. However, little is known about the impact of labor and delivery (L&D) nurse staffing and adverse birth outcomes, such as unintended cesarean delivery, in low-risk term-gestation women. PURPOSE: We examined nurse staffing patterns on the likelihood of cesarean sections (C-sections) among low- risk, full gestation births and provided a testing framework to distinguish optimal from ineffective levels of nurse staffing. METHODS: This retrospective descriptive study used hours of productive nursing time per delivery as the treatment variable to determine direct nursing time per delivery and its impact on the likelihood of a C-section. For comparisons, we also assessed the likelihood of augmentations and of inductions, as well as the number of neonatal intensive care unit (NICU) hours per birth. We limited our sample to those births between 37 and 42 weeks of gestation. Two complimentary models (the quadratic and piecewise regressions) distinguishing optimal staffing patterns from ineffective staffing patterns were developed. The study was implemented in eleven hospitals that are part of a large, integrated healthcare system in the Southwest. DISCUSSION: While a simple linear regression of the likelihood of a C-section on nursing hours per delivery indicated no statistically distinguishable effect, our 'optimal staffing' model indicated that nurse staffing hours employed by using a large sample of hospitals were actually minimizing C-sections (robustness checks are provided using similar model comparisons for the likelihood of augmentation and induction, and NICU hours). Where the optimal staffing models did not appear to be effective for augmentations, inductions, and NICU hours, we found significant differences between facilities (i.e., significant fixed effects for hospitals). In all specifications, we also controlled for weeks of gestation, race, sex of the child, and mother's age.

Better Nurse Staffing Is Associated With Survival for Black Patients and Diminishes Racial Disparities in Survival After In-Hospital Cardiac Arrests.

BACKGROUND: Racial disparities in survival among patients who had an in-hospital cardiac arrest (IHCA) have been linked to hospital-level factors. OBJECTIVES: To determine whether nurse staffing is associated with survival disparities after IHCA. RESEARCH DESIGN: Cross-sectional data from (1) the American Heart Association's Get With the Guidelines-Resuscitation database; (2) the University of Pennsylvania Multi-State Nursing Care and Patient Safety Survey; and (3) The American Hospital Association annual survey. Risk-adjusted logistic regression models, which took account of the hospital and patient characteristics, were used to determine the association of nurse staffing and survival to discharge for black and white patients. SUBJECTS: A total of 14,132 adult patients aged 18 and older between 2004 and 2010 in 75 hospitals in 4 states. RESULTS: In models that accounted for hospital and patient characteristics, the odds of survival to discharge was lower for black patients than white patients [odds ratio (OR)=0.70; 95% confidence interval (CI), 0.61-0.82]. A significant interaction was found between race and medical-surgical nurse staffing for survival to discharge, such that each additional patient per nurse lowered the odds of survival for black patients (OR=0.92; 95% CI, 0.87-0.97) more than white patients (OR=0.97; 95% CI, 0.93-1.00). CONCLUSIONS: Our findings suggest that disparities in IHCA survival between black and white patients may be linked to the level of medical-surgical nurse staffing in the hospitals in which they receive care and that the benefit of being admitted to hospitals with better staffing may be especially pronounced for black patients.