RESUMO
BACKGROUND: The patient-centered medical home (PCMH) is a primary care delivery model predicated on shared responsibility for patient care among members of an interprofessional team. Effective task sharing may reduce burnout among primary care providers (PCPs). However, little is known about the extent to which PCPs share these responsibilities, and which, if any, of the primary care tasks performed independently by the PCPs (vs. shared with the team) are particularly associated with PCP burnout. A better understanding of the relationship between these tasks and their effects on PCP burnout may help guide focused efforts aimed at reducing burnout. OBJECTIVE: To investigate (1) the extent to which PCPs share responsibility for 14 discrete primary care tasks with other team members, and (2) which, if any, of the primary care tasks performed by the PCPs (without reliance on team members) are associated with PCP burnout. DESIGN: Secondary data analysis of Veterans Health Administration (VHA) survey data from two time periods. PARTICIPANTS: 327 providers from 23 VA primary care practices within one VHA regional network. MAIN MEASURES: The dependent variable was PCP report of burnout. Independent variables included PCP report of the extent to which they performed 14 discrete primary care tasks without reliance on team members; team functioning; and PCP-, clinic-, and system-level variables. KEY RESULTS: In adjusted models, PCP reports of intervening on patient lifestyle factors and educating patients about disease-specific self-care activities, without reliance on their teams, were significantly associated with burnout (intervening on lifestyle: b = 4.11, 95% CI = 0.39, 7.83, p = 0.03; educating patients: b = 3.83, 95% CI = 0.33, 7.32, p = 0.03). CONCLUSIONS: Performing behavioral counseling and self-management education tasks without relying on other team members for assistance was associated with PCP burnout. Expanding the roles of nurses and other healthcare professionals to assume responsibility for these tasks may ease PCP burden and reduce burnout.
Assuntos
Esgotamento Profissional/diagnóstico , Esgotamento Profissional/psicologia , Pessoal de Saúde/psicologia , Atenção Primária à Saúde/métodos , Inquéritos e Questionários , United States Department of Veterans Affairs , Adulto , Esgotamento Profissional/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos/epidemiologia , Saúde dos VeteranosRESUMO
AIM: To describe the presence and operationalisation of organisational strategies to support implementation of pressure ulcer prevention programmes across acute care hospitals in a large, integrated health-care system. BACKGROUND: Comprehensive pressure ulcer programmes include nursing interventions such as use of a risk assessment tool and organisational strategies such as policies and performance monitoring to embed these interventions into routine care. The current literature provides little detail about strategies used to implement pressure ulcer prevention programmes. METHODS: Data were collected by an e-mail survey to all chief nursing officers in Veterans Health Administration acute care hospitals. Descriptive and bivariate statistics were used to summarise survey responses and evaluate relationships between some variables. RESULTS: Organisational strategies that support implementation of a pressure ulcer prevention programme (policy, committee, staff education, wound care specialists, and use of performance data) were reported at high levels. Considerable variations were noted in how these strategies were operationalised within individual hospitals. CONCLUSION: Organisational strategies to support implementation of pressure ulcer preventive programmes are often not optimally operationalised to achieve consistent, sustainable performance. IMPLICATIONS FOR NURSING MANAGEMENT: The results of the present study highlight the role and influence of nurse leaders on pressure ulcer prevention program implementation.
Assuntos
Objetivos Organizacionais , Úlcera por Pressão/prevenção & controle , Desenvolvimento de Programas/métodos , Membro de Comitê , Estudos Transversais , Humanos , Enfermeiros Administradores/estatística & dados numéricos , Desenvolvimento de Programas/estatística & dados numéricos , Inquéritos e Questionários , Estados Unidos , United States Department of Veterans Affairs/organização & administração , United States Department of Veterans Affairs/estatística & dados numéricosRESUMO
PURPOSE: To describe the presence or absence of key components of hospital pressure ulcer (PU) prevention programs in 6 acute care hospitals. DESIGN: Multisite comparative case study. SUBJECTS AND SETTING: Using purposeful selection based on PU rates (high vs low) and hospital size, 6 hospitals within the Veterans Health Administration health care system were invited to participate. Key informant interviews (n = 48) were conducted in each of the 6 participating hospitals among individuals playing key roles in PU prevention: senior nursing leadership (n = 9), nurse manager (n = 7), wound care specialist (n = 6), frontline RNs (n = 26). METHODS: Qualitative data were collected during face-to-face, semistructured interviews. Interview protocols were tailored to each interviewee's role with a core set of common questions covering 3 major content areas: (1) practice environment (eg, policies and wound care specialists), (2) current prevention practices (eg, conduct of PU risk assessment and skin inspection), and (3) barriers to PU prevention. We conducted structured coding of 5 key components of PU prevention programs and cross-case analysis to identify patterns in operationalization and implementation of program components across hospitals based on facility size and PU rates (low vs high). RESULTS: All hospitals had implemented all PU prevention program components. Component operationalization varied considerably across hospitals. Wound care specialists were integral to the operationalization of the 4 other program components examined; however, staffing levels and work assignments of wound care specialists varied widely. Patterns emerged among hospitals with low and high PU rates with respect to wound care specialist staffing, data monitoring, and staff education. CONCLUSION: We found hospital-level variations in PU prevention programs. Wound care specialist staffing may represent a potential point of leverage in achieving other PU program components, particularly performance monitoring and staff education.
Assuntos
Pesquisa em Avaliação de Enfermagem/métodos , Pesquisa em Avaliação de Enfermagem/normas , Objetivos Organizacionais , Úlcera por Pressão/prevenção & controle , Qualidade da Assistência à Saúde , Humanos , Úlcera por Pressão/enfermagem , Pesquisa Qualitativa , Estados Unidos , United States Department of Veterans Affairs/organização & administração , United States Department of Veterans Affairs/normasRESUMO
BACKGROUND: A systematic review of the literature on nurse-focused interventions conducted in the hospital setting informs the evidence base for implementation of pressure ulcer (PU) prevention programs. Despite the availability of published guidelines, there is little evidence about which interventions can be successfully integrated into routine care through quality improvement (QI). The two previous literature syntheses on PU prevention have included articles from multiple settings but have not focused specifically on QI. METHODS: A search of six electronic databases for publications from January 1990 to September 2009 was conducted. Trial registries and bibliographies of retrieved studies and reviews, and Internet sites of funding agencies were also searched. Using standardized forms, two independent reviewers screened publications for eligibility into the sample; data were abstracted and study quality was assessed for those that passed screening. FINDINGS: Thirty-nine studies met the inclusion criteria. Most of them used a before-and-after study design in a single site. Intervention strategies included PU-specific changes in combination with educational and/or QI strategies. Most studies reported patient outcome measures, while fewer reported nursing process of care measures. For nearly all the studies, the authors concluded that the intervention had a positive effect. The pooled risk difference for developing PUs was -.07 (95% confidence interval [CI]: -0.0976, -0.0418) comparing the pre- and postintervention status. CONCLUSION: Future research can build the evidence base for implementation through an increased emphasis on understanding the mechanisms by which improved outcomes are achieved and describing the conditions under which specific intervention strategies are likely to succeed or fail.
Assuntos
Processo de Enfermagem/normas , Úlcera por Pressão/prevenção & controle , Melhoria de Qualidade/normas , Higiene da Pele/enfermagem , Hospitalização , Humanos , Avaliação de Processos e Resultados em Cuidados de Saúde , Úlcera por Pressão/enfermagem , Higiene da Pele/normasAssuntos
Difusão de Inovações , Reestruturação Hospitalar/organização & administração , Recursos Humanos de Enfermagem Hospitalar , Gestão da Qualidade Total/organização & administração , Atitude do Pessoal de Saúde , California , Tomada de Decisões Gerenciais , Ambiente de Instituições de Saúde/organização & administração , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Enfermeiros Administradores/organização & administração , Enfermeiros Administradores/psicologia , Pesquisa em Avaliação de Enfermagem , Pesquisa Metodológica em Enfermagem , Recursos Humanos de Enfermagem Hospitalar/educação , Recursos Humanos de Enfermagem Hospitalar/organização & administração , Recursos Humanos de Enfermagem Hospitalar/psicologia , Inovação Organizacional , Avaliação de Resultados em Cuidados de Saúde , Assistência Centrada no Paciente/organização & administração , Projetos Piloto , Avaliação de Programas e Projetos de Saúde , Inquéritos e QuestionáriosAssuntos
Atitude do Pessoal de Saúde , Liderança , Enfermeiros Administradores , Papel do Profissional de Enfermagem/psicologia , Desenvolvimento de Programas/métodos , Gestão da Qualidade Total/organização & administração , California , Diretores de Hospitais/organização & administração , Diretores de Hospitais/psicologia , Difusão de Inovações , Retroalimentação Psicológica , Humanos , Relações Interprofissionais , Enfermeiros Administradores/organização & administração , Enfermeiros Administradores/psicologia , Pesquisa Metodológica em Enfermagem , Recursos Humanos de Enfermagem Hospitalar/educação , Recursos Humanos de Enfermagem Hospitalar/organização & administração , Recursos Humanos de Enfermagem Hospitalar/psicologia , Projetos Piloto , Técnicas de Planejamento , Competência Profissional , Apoio Social , Inquéritos e QuestionáriosAssuntos
Atitude do Pessoal de Saúde , Unidades Hospitalares/organização & administração , Papel do Profissional de Enfermagem , Recursos Humanos de Enfermagem Hospitalar , Gestão da Qualidade Total/organização & administração , Tomada de Decisões Gerenciais , Difusão de Inovações , Humanos , Modelos de Enfermagem , Papel do Profissional de Enfermagem/psicologia , Pesquisa em Avaliação de Enfermagem , Pesquisa Metodológica em Enfermagem , Recursos Humanos de Enfermagem Hospitalar/organização & administração , Recursos Humanos de Enfermagem Hospitalar/psicologia , Inovação Organizacional , Avaliação de Processos e Resultados em Cuidados de Saúde/organização & administração , Projetos Piloto , Autonomia Profissional , Comitê de Profissionais/organização & administração , Desenvolvimento de Programas , Pesquisa Qualitativa , Inquéritos e Questionários , Estados UnidosRESUMO
OBJECTIVE: To identify primary care practice characteristics associated with colorectal cancer (CRC) screening performance, controlling for patient-level factors. DATA SOURCES/STUDY SETTING: Primary care director survey (1999-2000) of 155 VA primary care clinics linked with 38,818 eligible patients' sociodemographics, utilization, and CRC screening experience using centralized administrative and chart-review data (2001). STUDY DESIGN: Practices were characterized by degrees of centralization (e.g., authority over operations, staffing, outside-practice influence); resources (e.g., sufficiency of nonphysician staffing, space, clinical support arrangements); and complexity (e.g., facility size, academic status, managed care penetration), adjusting for patient-level covariates and contextual factors. DATA COLLECTION/EXTRACTION METHODS: Chart-based evidence of CRC screening through direct colonoscopy, sigmoidoscopy, or consecutive fecal occult blood tests, eliminating cases with documented histories of CRC, polyps, or inflammatory bowel disease. PRINCIPAL FINDINGS: After adjusting for sociodemographic characteristics and health care utilization, patients were significantly more likely to be screened for CRC if their primary care practices had greater autonomy over the internal structure of care delivery (p<.04), more clinical support arrangements (p<.03), and smaller size (p<.001). CONCLUSIONS: Deficits in primary care clinical support arrangements and local autonomy over operational management and referral procedures are associated with significantly lower CRC screening performance. Competition with hospital resource demands may impinge on the degree of internal organization of their affiliated primary care practices.
Assuntos
Instituições de Assistência Ambulatorial/organização & administração , Neoplasias Colorretais/prevenção & controle , Programas de Rastreamento/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Atenção Primária à Saúde/organização & administração , United States Department of Veterans Affairs/organização & administração , Veteranos/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , California , Feminino , Pesquisas sobre Atenção à Saúde , Política de Saúde , Humanos , Masculino , Programas de Rastreamento/classificação , Pessoa de Meia-Idade , Política Organizacional , Autonomia Profissional , Qualidade da Assistência à Saúde , Estados UnidosRESUMO
Organizational factors influence the quality of preventive care. Combining facility-level data from a national organizational survey and centrally available, externally abstracted chart review data on prevention performance, we assessed the relationship between structural features of primary care departments and the quality of preventive care delivered. Primary care practice resources were significantly and positively associated with the delivery of 6 of 9 preventive services. Adjusting for facility size and academic affiliation, these resource arrangements accounted for substantial variation in 8 of 9 services. Assuring high-quality prevention performance requires ongoing investment in primary care-based infrastructure.