Examining adaptive models of care implemented in hospital ICUs during the COVID-19 pandemic: a qualitative study.

BACKGROUND: The emergence of the COVID-19 pandemic led to an increased demand for hospital beds, which in turn led to unique changes to both the organisation and delivery of patient care, including the adoption of adaptive models of care. Our objective was to understand staff perspectives on adaptive models of care employed in intensive care units (ICUs) during the pandemic. METHODS: We interviewed 77 participants representing direct care staff (registered nurses) and members of the nursing management team (nurse managers, clinical educators and nurse practitioners) from 12 different ICUs. Thematic analysis was used to code and analyse the data. RESULTS: Our findings highlight effective elements of adaptive models of care, including appreciation for redeployed staff, organising aspects of team-based models and ICU culture. Challenges experienced with the pandemic models of care were heightened workload, the influence of experience, the disparity between model and practice and missed care. Finally, debriefing, advanced planning and preparation, the redeployment process and management support and communication were important areas to consider in implementing future adaptive care models. CONCLUSION: The implementation of adaptive models of care in ICUs during the COVID-19 pandemic provided a rapid solution for staffing during the surge in critical care patients. Findings from this study highlight some of the challenges of implementing redeployment as a staffing strategy, including how role clarity and accountability can influence the adoption of care delivery models, lead to workarounds and contribute to adverse patient and nurse outcomes.

Relationship between three aspects of resilience-adaptive characteristics, withstanding stress, and bouncing back-in hospital workers exposed to prolonged occupational stress during the COVID-19 pandemic: a longitudinal study.

BACKGROUND: The term resilience is used to refer to multiple related phenomena, including: (i) characteristics that promote adaptation to stressful circumstances, (ii) withstanding stress, and (iii) bouncing back quickly. There is little evidence to understand how these components of resilience are related to one another. Skills-based adaptive characteristics that can respond to training (as opposed to personality traits) have been proposed to include living authentically, finding work that aligns with purpose and values, maintaining perspective in the face of adversity, managing stress, interacting cooperatively, staying healthy, and building supportive networks. While these characteristics can be measured at a single time-point, observing responses to stress (withstanding and bouncing back) require multiple, longitudinal observations. This study's aim is to determine the relationship between these three aspects of resilience in hospital workers during the prolonged, severe stress of the COVID-19 pandemic. METHODS: We conducted a longitudinal survey of a cohort of 538 hospital workers at seven time-points between the fall of 2020 and the spring of 2022. The survey included a baseline measurement of skills-based adaptive characteristics and repeated measures of adverse outcomes (burnout, psychological distress, and posttraumatic symptoms). Mixed effects linear regression assessed the relationship between baseline adaptive characteristics and the subsequent course of adverse outcomes. RESULTS: The results showed significant main effects of adaptive characteristics and of time on each adverse outcome (all p < .001). The size of the effect of adaptive characteristics on outcomes was clinically significant. There was no significant relationship between adaptive characteristics and the rate of change of adverse outcomes over time (i.e., no contribution of these characteristics to bouncing back). CONCLUSIONS: We conclude that training aimed at improving adaptive skills may help individuals to withstand prolonged, extreme occupational stress. However, the speed of recovery from the effects of stress depends on other factors, which may be organizational or environmental.

Randomized trial of personalized psychological feedback from a longitudinal online survey and simultaneous evaluation of randomized stepped wedge availability of in-person peer support for hospital staff during the COVID-19 pandemic.

OBJECTIVE: We tested if automated Personalized Self-Awareness Feedback (PSAF) from an online survey or in-person Peer Resilience Champion support (PRC) reduced emotional exhaustion among hospital workers during the COVID-19 pandemic. METHOD: Among a single cohort of participating staff from one hospital organization, each intervention was evaluated against a control condition with repeated measures of emotional exhaustion at quarterly intervals for 18 months. PSAF was tested in a randomized controlled trial compared to a no-feedback condition. PRC was tested in a group-randomized stepped-wedge design, comparing individual-level emotional exhaustion before and after availability of the intervention. Main and interactive effects on emotional exhaustion were tested in a linear mixed model. RESULTS: Among 538 staff, there was a small but significant beneficial effect of PSAF over time (p = .01); the difference at individual timepoints was only significant at timepoint three (month six). The effect of PRC over time was non-significant with a trend in the opposite direction to a treatment effect (p = .06). CONCLUSIONS: In a longitudinal assessment, automated feedback about psychological characteristics buffered emotional exhaustion significantly at six months, whereas in-person peer support did not. Providing automated feedback is not resource-intensive and merits further investigation as a method of support.

Can fundamental care be advanced using the science of care framework?

AIMS: This manuscript aims to provide a description of an evidence-informed Science of Care practice-based research and innovation framework that may serve as a guiding framework to generate new discoveries and knowledge around fundamental care in a more integrated manner. BACKGROUND: New ways of thinking about models of care and implementation strategies in transdisciplinary teams are required to accelerate inquiry and embed new knowledge and innovation into practice settings. A new way of thinking starts with an explicit articulation and commitment to the core business of the healthcare industry which is to provide quality fundamental care. DESIGN: This discursive paper delineates an iteratively derived Science of Care research and innovation framework (Science of Care Framework) that draws from a targeted literature review. METHOD: The Science of Care Framework integrates caring science with safety and symptom sciences with implementation, improvement, innovation and team sciences. Each science dimension is described in terms of seminal and evolving evidence and theoretical explanations, focusing on how these disciplines can support fundamental care. CONCLUSIONS: The Science of Care Framework can serve as a catalyst to guide future efforts to propel new knowledge and discoveries around fundamental care and how best to implement it into clinical practice through a transdisciplinary lens. IMPACT ON NURSING SCIENCE, PRACTICE, OR DISCIPLINARY KNOWLEDGE: The Science of Care Framework can accelerate nursing discipline-specific knowledge generation alongside inter and transdisciplinary insights. The novel articulation of the Science of Care Framework can be used to guide further inquiries that are co-designed, and led, by nurses into integrated models of care and innovations in clinical practice.

Enculturating, embedding and investing in fundamental care in an academic health science centre.

AIM: This manuscript aims to provide a discursive description of how one academic health care centre is enculturating, embedding and investing in the fundamental care framework and lessons learned that can serve as a blueprint for other organizations. BACKGROUND: A call to action to focus on fundamental care is not new as the initial Fundamentals of Care (FoC) Framework has been evolving over the last decade through efforts lead by the International Learning Collaborative (ILC). Now more than ever, there is a pressing need for leaders to influence a humane, compassionate evidence-informed approach to the COVID-19 pandemic and beyond by embedding an FoC framework and focusing on fundamental care as part of their academic mandate and daily care practices. DESIGN: This discursive paper delineates an evolving and ongoing enculturation, embeddedness and investment in advancing fundamental care as part of a larger academic practice strategy and quality improvement plan that is evidence-informed and collaborative in nature. METHOD: The action framework (value, talk, do, own and research fundamental care) developed by ILC guides efforts to how the FoC framework was embedded into one academic health science centre's strategic directions, academic practice strategy, professional practice model, quality plan and research and innovation platform. CONCLUSION: An overview of how we leveraged the FoC and ILC Leadership frameworks in our efforts to enculturate, embed and invest in advancing fundamental care and lessons learned that may inform other healthcare organizations in their efforts. IMPACT ON NURSING SCIENCE, PRACTICE OR DISCIPLINARY KNOWLEDGE: Underpinning all of our efforts is the integral value we place on fundamental care to guide how we practice, educate and learn, discover and innovate and lead at x. We shared how we value, talk, do, own and research fundamental care by having it embedded into our strategic directions, academic practice strategy, professional practice model, quality aims and research and innovation platform. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution.

Focusing on fundamentals of care in an ICU setting during a pandemic.

AIMS: This manuscript aims to describe one acute care hospital's ICU journey during the COVID-19 pandemic and how fundamental care was central to the implementation of team-based models of care. BACKGROUND: Over the course of the COVID-19 pandemic, team-based and alternative models of care are being employed to manage and address global shortages and surge capacity. Employing these alternate models of care required attention to ensure fundamental care needs of patients were being met. DESIGN/METHOD: The following paper describes an ICU's journey of focusing on the delivery of the fundamentals of care through the implementation of team-based models of care to address the surge in patient care demands experienced in response to our global pandemic. CONCLUSIONS: The implementation of an evidence-informed approach to optimizing models of care and staffing in the ICU amid the evolving COVID-19 waves in one acute-care hospital is provided. This local approach focused on meeting patients' fundamental care needs throughout the necessary introduction of team-based care models and staffing changes and drew from evolving evidence, the ILC Fundamentals of Care Framework, and regulatory guidance.

"It Takes a Virtual Village" Achieving Magnet Redesignation Amidst the COVID-19 Pandemic: Canada's Magnet Hospital Journey.

This article outlines how a Canadian hospital achieved the American Nursing Credentialing Center Magnet Recognition Program redesignation after participating in a virtual site visit (VSV) appraisal process amidst the COVID-19 pandemic. Within our current COVID-19 landscape, being a resilient Magnet-designated organization is paramount. In this context, the American Nurses Credentialing Center (ANCC) has developed a VSV model that (1) extends the use of audio/video (A/V) conferencing technology to showcase nursing excellence; (2) maintains the integrity of the appraisal process; and (3) ensures the safety and well-being of staff, patients and their care partners, and the appraisers. Key narrative insights are highlighted around planning and on-site execution of a successful VSV. The redesignation is a culmination of several stakeholders' efforts who shared their sense of pride, inspiration, and accomplishment during the VSV. The redesignation status notification exemplifies resiliency and was welcomed amidst uncertainty with the evolving COVID-19 pandemic. The planning and on-site implementation plan may serve as a blueprint for others who will be engaged in a VSV as part of their designation or redesignation journey. Insights are shared around preparing for the VSV, hosting the VSV, and achieving the ANCC Magnet Recognition Program redesignation.

An Academic Health Sciences Centre's Strategy to Enhance Nurse Resilience and Psychological Safety.

The rapid cadence of change and the fear of acquiring and spreading COVID-19 - coupled with moral distress exacerbated by fulfilling one's duty to care under extremely challenging conditions - continue to impact nurses' coping ability, resilience and psychological safety globally (McDougall et al. 2020). This paper provides an overview of how an academic health sciences centre (AHSC) has responded to the evolving waves of the COVID-19 pandemic. Specifically, we share our context and the strategies we used to build and enhance nurse resilience and psychological safety at the organizational, clinical team and individual levels. This is followed by a description of our nurses' achievements amid the pandemic.

Co-Designing a Collaborative Academic Professional Practice Model for an Integrated Health System: Sinai Health's Journey.

In the current environment of increasingly complex healthcare needs, evidence-informed practice, stronger partnerships and collaborative foundations with nursing professions, health professions and physicians (referred to as collaborative academic practice) are required to deliver integrated, value-based services across the care continuum. This paper outlines the co-design of a collaborative academic practice model in a recently integrated health system. An overview of key concepts from the literature around professional practice models is provided that lays the foundation for the integrated healthcare system's inaugural collaborative academic practice model.

Balancing Resiliency and New Accountabilities: Insights from Chief Nurse Executives amid the COVID-19 Pandemic.

This article outlines how chief nurse executives (CNEs) in an urban regional hospital network are navigating the balancing act of organizational (internal) and system-level (regional and/or provincial) accountabilities amid the coronavirus disease 2019 (COVID-19) pandemic. Key to their leadership efforts is finding the right balance in making critical decisions and building trust to ensure staff resiliency and safety amid managing their own resilience while enacting both internal and external accountabilities. These accountabilities include having presence and influence at the regional planning, executive planning and incident command decision-making tables. Insights from their experiences and lessons learned will be shared alongside recent calls to action for nursing leadership that can serve as a playbook for CNEs dealing with future waves of COVID-19 and unplanned events.

Speaking Up for Fundamental Care: the ILC Aalborg Statement.

OBJECTIVE: The International Learning Collaborative (ILC) is an organisation dedicated to understanding why fundamental care, the care required by all patients regardless of clinical condition, fails to be provided in healthcare systems globally. At its 11th annual meeting in 2019, nursing leaders from 11 countries, together with patient representatives, confirmed that patients' fundamental care needs are still being ignored and nurses are still afraid to 'speak up' when these care failures occur. While the ILC's efforts over the past decade have led to increased recognition of the importance of fundamental care, it is not enough. To generate practical, sustainable solutions, we need to substantially rethink fundamental care and its contribution to patient outcomes and experiences, staff well-being, safety and quality, and the economic viability of healthcare systems. KEY ARGUMENTS: We present five propositions for radically transforming fundamental care delivery:Value: fundamental care must be foundational to all caring activities, systems and institutionsTalk: fundamental care must be explicitly articulated in all caring activities, systems and institutions.Do: fundamental care must be explicitly actioned and evaluated in all caring activities, systems and institutions.Own: fundamental care must be owned by each individual who delivers care, works in a system that is responsible for care or works in an institution whose mission is to deliver care. RESEARCH: fundamental care must undergo systematic and high-quality investigations to generate the evidence needed to inform care practices and shape health systems and education curricula. CONCLUSION: For radical transformation within health systems globally, we must move beyond nursing and ensure all members of the healthcare team-educators, students, consumers, clinicians, leaders, researchers, policy-makers and politicians-value, talk, do, own and research fundamental care. It is only through coordinated, collaborative effort that we will, and must, achieve real change.

Engaging Stakeholders to Co-design an Academic Practice Strategic Plan in an Integrated Health System: The Key Roles of the Nurse Executive and Planning Team.

As key members of the executive team, nurse executives play an integral role in the planning process and operationalization of strategic imperatives to ensure the overall success of the organization. Nurse executives are leading organizations through transition periods that require transformational leadership. Leaders must design a shared vision and set strategic priorities; empower others to lead; ensure access to resources needed for safe care delivery; and inspire people to meet the demands of the future. Paramount to effective strategic planning and achievement of positive outcomes is a leadership team that engages key stakeholders in the strategic planning process. This article provides an overview of a recently integrated health system's strategic planning process that included the engagement of patients and caregivers. This can serve as a blueprint for others in their efforts to implement a systematic approach for enhancing collaborative academic practice in their organizations.

Attributes and Actions Required to Advance Quality and Safety in Hospitals: Insights from Nurse Executives.

To lead effectively within their organizations, nurse executives must possess quality and safety literacy and be able to engage and motivate clinicians to participate in safety and quality initiatives. Given the paucity of research in Canada, a study was undertaken to explore nurse executives' understanding of the key concepts and strategies associated with patient safety and quality improvement, and their engagement with patient safety and quality improvement in their hospitals and healthcare systems. This study used an exploratory qualitative design with a content analysis approach on 20 nurse executives working in hospitals in Ontario. Three key themes emerged from the narrative data set including: (1) being a strategic and system thinker while possessing the emotional intelligence to influence staff; (2) building credibility and relationships with point-of-care staff, board of directors, and leadership team and (3) creating a culture of safety and high reliability. Study findings can be useful in informing future learning opportunities for nurse executives and nurses leaders at all levels to enhance their quality and safety literacy.

Developing a Nursing Scorecard Using the National Database of Nursing Quality Indicators®: A Canadian Hospital's Experience.

Nursing-sensitive indicators are often reported on scorecards that enable nurse leaders to evaluate their progress in achieving their strategic goals and operational and quality targets. Providing unit-level reporting of nursing-sensitive indicators is one of the requirements of the American Nursing Credentialing Center's Magnet Recognition Program®. This descriptive article outlines one healthcare organization's experience in refining their nursing scorecard using the indicators as part of their Magnet Recognition Program® re-designation efforts.

The role of caregivers in interfacility care transitions: a qualitative study.

A qualitative design was used to explore the nature of caregiver involvement in care transitions of patients being transferred from an acute care hospital to a rehabilitation hospital. Participants included older adults (n=13), informal caregivers (n=9), and health care professionals (n=50) from inpatient orthopedic units in two academic health science centers and one orthopedic inpatient rehabilitation unit. Semistructured interviews were conducted, audio-taped, and transcribed. Directed content analysis revealed the following four themes: watching, being an active care provider, advocating, and navigating the health care system. Participants described being actively involved in the care of their family member, yet they were not actively engaged by health care professionals to be involved in the care of their family member. There is a need to reconcile the tension between the level of involvement of caregivers in the care of family members who are patients and the level of engagement throughout the care transition. By providing relevant information and authentically engaging caregivers as equal partners in the care transition, they are better able to navigate the health care system post-transfer to the rehabilitation setting and discharge to home.

Elucidating the information exchange during interfacility care transitions: Insights from a Qualitative Study.

OBJECTIVE: To explore the perceptions of patients, their caregivers and healthcare professionals associated with the exchange of information during transitioning from two acute care hospitals to one rehabilitation hospital. DESIGN: An exploratory qualitative study using semi-structured interviews and observation. PARTICIPANTS AND SETTING: Patients over the age of 65 years admitted to an orthopaedic unit for a non-elective admission, their caregivers and healthcare professionals involved in their care. Participating sites included orthopaedic inpatient units from two acute care teaching hospitals and one orthopaedic unit at a rehabilitation hospital in an urban setting. FINDINGS: Three distinct themes emerged from participants' narrative of their transitional care experience: (1) having no clue what the care plan is, (2) being told and notified about the plan and (3) experiencing challenges absorbing information. Participating patients and their caregivers reported not being engaged in an active discussion with healthcare professionals about their care transition plan. Several healthcare professionals described withholding information within the plan until they themselves were clear about the transition outcomes. CONCLUSION: This study highlights the need to increase efforts to ensure that effective information exchanges occur during transition from acute care hospital to rehabilitation settings.

Identifying Effective Nurse-Led Care Transition Interventions for Older Adults With Complex Needs Using a Structured Expert Panel.

BACKGROUND: Nursing plays a central role in facilitating care transitions for complex older adults, yet there is no consensus of the components of nurse-led care transitions interventions to facilitate high quality care transitions among complex older adults. A structured expert panel was established with the purpose of identifying effective nurse-led care transition interventions. METHODS: A modified Delphi consensus technique based on the RAND method was employed. Panelists (n = 23) were asked to individually rate a series of statements derived from a realist synthesis of the literature for relevance, feasibility and likely impact. Statements receiving an aggregate score of ≥75% (7/9) were reviewed and revised at a face-to-face consensus meeting. A second round of rating following the same process as round one was used, followed by a final ranking of the statements. RESULTS: The five highest ranked intervention components and contextual factors were: (a) educating and coaching patients, their family members and caregivers about self-management skills; (b) ensuring patients, their family members and caregivers are aware of follow-up medical appointments and postdischarge care plan; (c) using standardized documentation tools and comprehensive communication strategies during care transitions; (d) optimizing nurses' roles and scopes of practice across the care transitions spectrum; and (e) having strong leadership, strategic alignment and accountability structures in organizations to enable quality care transitions for the complex older person population. LINKING EVIDENCE TO ACTION: Key insights on optimizing the nurses' roles and scope of practice during care transitions included having nurses provide "warm hand-offs" and serve as the "go-to person." The panel also identified current challenges to optimizing the nurses' roles and scope of practice across care transition points. Future research is required to determine effective nurse-led intervention components and in which context do they work or do not.

Engaging Patients to Meet Their Fundamental Needs: Key to Safe and Quality Care.

This paper highlights the relationship between the Fundamentals of Care Framework, patient safety and quality improvement by describing a more holistic view of patient engagement across the healthcare system. By creating reliable and resilient healthcare organizations that enhance nurses' capacity to engage in relational care and vigilance, healthcare agencies can effectively achieve safety and quality aims. Integral to this is the nurse-patient relationship, whereby nurses know patient preferences for care and recognize when patients are deteriorating to prevent harm within the context of care environments.

Clinicians' views on improving inter-organizational care transitions.

BACKGROUND: Patients with complex health conditions frequently require care from multiple providers and are particularly vulnerable to poorly executed transitions from one healthcare setting to another. Poorly executed care transitions can result in negative patient outcomes (e.g. medication errors, delays in treatment) and increased healthcare spending due to re-hospitalization or emergency room visits by patients. Little is known about care transitions from acute care to complex continuing care and rehabilitation settings. Thus, a qualitative study was undertaken to explore clinicians' perceptions of strategies aimed at improving patient care transitions from acute care hospitals to complex continuing care and rehabilitation healthcare organizations. METHODS: A qualitative study using semi-structured interviews was conducted with clinicians employed at two selected healthcare facilities: an acute care hospital and a complex continuing care/rehabilitation organization, respectively. Analysis of the transcripts involved the creation of a coding schema using the content analyses outlined by Ryan and Bernard. In total, 31 interviews were conducted with clinicians at the participating study sites. RESULTS: Three themes emerged from the data to delineate what study participants described as strategies to ensure quality inter-organizational transitions of patients transferred from acute care to the complex continuing care and rehabilitation hospital. These themes are: 1) communicating more effectively; 2) being vigilant around the patients' readiness for transfer and care needs; and 3) documenting more accurately and completely in the patient transfer record. CONCLUSION: Our study provides insights from the perspectives of multiple clinicians that have important implications for health care leaders and clinicians in their efforts to enhance inter-organizational care transitions. Of particular importance is the need to have a collective and collaborative approach amongst clinicians during the inter-organizational care transition process. Study findings also suggest that the written patient transfer record needs to be augmented with a verbal report whereby the receiving clinician has an opportunity to discuss with a clinician from the acute care hospital the patient's status on discharge and plan of care. Integral to future research efforts is designing and testing out interventions to optimize inter-organizational care transitions and feedback loops for complex medical patients.

Safety threats and opportunities to improve interfacility care transitions: insights from patients and family members.

AIM: To explore patients' and family members' perspectives on how safety threats are detected and managed across care transitions and strategies that improve care transitions from acute care hospitals to complex continuing care and rehabilitation health care organizations. BACKGROUND: Poorly executed care transitions can result in additional health care spending due to adverse outcomes and delays as patients wait to transfer from acute care to facilities providing different levels of care. Patients and their families play an integral role in ensuring they receive safe care, as they are the one constant in care transitions processes. However, patients' and family members' perspectives on how safety threats are detected and managed across care transitions from health care facility to health care facility remain poorly understood. METHODS: This qualitative study used semistructured interviews with patients (15) and family members (seven) who were transferred from an acute care hospital to a complex continuing care/rehabilitation care facility. Data were analyzed using a directed content analytical approach. RESULTS: OUR RESULTS REVEALED THREE KEY OVERARCHING THEMES IN THE PERCEPTIONS: lacking information, getting "funneled through" too soon, and difficulty adjusting to the shift from total care to almost self-care. Several patients and families described their expectations and experiences associated with their interfacility care transitions as being uninformed about their transfer or that transfer happened too early. In addition, study participants identified the need for having a coordinated approach to care transitions that engages patients and family members. CONCLUSION: Study findings provide patients' and family members' perspectives on key safety threats and how to improve care transitions. Of particular importance is the need for patients and family members to play a more active role in their care transition planning and self-care management.