Associated Factors of Under and Over-Triage Based on The Emergency Severity Index; a Retrospective Cross-Sectional Study.

Introduction: Under-triage increases patients' risks for morbidity and mortality, whereas over-triage limits the resources available to sicker patients. This study aimed to determine the rates as well as associated factors of under-triage and over-triage in emergency department (ED), based on Emergency Severity Index (ESI) triage system. Methods: In this retrospective cross-sectional study, triage level of ED patients based on the ESI version 4, was studied during a 9-month period in 2019. Patients' ESI level, which were examined by triage nurses were reevaluated by 3 emergency physicians and the rate of correct, under-, and over-triage as well as their associated factors were analyzed. Results: 1000 cases of triage were evaluated. Triage was correct in 69.1% of cases. The rate of under-triage was 4.9%, and that of over-triage was 26.0%. Over-triage was significantly more common among patients aged 18-30 years than for those aged ≥65 years (adjusted odds ratio [OR] = 1.73; 95% confidence interval [CI]: 1.07-2.81; p = 0.026); those with traumatic injuries (adjusted OR = 1.80; 95% CI: 1.29-2.52; p = 0.001); those arriving at the hospital during the evening shift (adjusted OR = 1.42; 95% CI: 1.01-2.0; p = 0.046); patients who were hospitalized (adjusted OR = 0.35; 95% CI: 0.22-0.54; p < 0.001); and those with severe pain (adjusted OR = 0.28; 95% CI: 0.10-0.84; p = 0.023). Younger age was also significantly associated with under-triage. Patients aged 18-30 years were under-triaged more often than those aged ≥65 years (adjusted OR = 3.05; 95% CI: 1.16-8.00; p = 0.023). Conclusions: Over-triage was substantially more common than under-triage in Vajira Hospital. Factors associated with over-triage were younger age, traumatic injury, arrival time, hospital admission, and severe pain. Younger age was the only factor related to under-triage.

Moral Distress Regarding End-of-Life Care Among Healthcare Personnel in Korean University Hospitals: Features and Differences Between Physicians and Nurses.

BACKGROUND: Healthcare professionals often experience moral distress while providing end-of-life care. This study explored how physicians and nurses experienced moral distress when they cared for critically and terminally ill patients in tertiary hospitals in South Korea. METHODS: This study used semi-structured in-depth interviews. A total of 22 people in two tertiary hospitals were interviewed, nine (40.9%) of which were physicians and 13 (59.1%) were nurses. The recorded interview files and memos were analyzed using grounded theory. RESULTS: Most physicians and nurses encountered similar feelings of anger, helplessness, and burden owing to a lack of appropriate resources for end-of-life care. However, the factors and contexts of their moral distress differed. Nurses mainly addressed poorly organized end-of-life care, intensive labor conditions without support for nurses, and providing care without participation in decision-making. Meanwhile, physicians addressed the prevailing misperceptions on end-of-life care, communication failure between physicians owing to hierarchy and fragmented disciplines, the burden of responsibility in making difficult decisions, and the burden of resource allocation. CONCLUSION: Differences in moral distress between physicians and nurses leave them isolated and can affect communication regarding healthcare. Mutual understanding between job disciplines will enhance their communication and help resolve conflicts in end-of-life care.

Cluster randomised trial of a complex interprofessional intervention (interprof ACT) to reduce hospital admission of nursing home residents.

BACKGROUND: Some hospital admissions of nursing home residents (NHRs) might be attributed to inadequate interprofessional collaboration. To improve general practitioner-nurse collaboration in nursing homes (NHs), we developed an intervention package (interprof ACT) in a previous study. OBJECTIVE: To assess the impact of interprof ACT on the proportion of hospitalisation and other clinical parameters within 12 months from randomisation among NHRs. METHODS: Multicentre, cluster randomised controlled trial in 34 German NHs. NHRs of the control group received usual care, whereas NHRs in the intervention group received interprof ACT. Eligible NHs had at least 40 long-term care residents. NHs were randomised 1:1 pairwise. Blinded assessors collected primary outcome data. RESULTS: Seventeen NHs (320 NHRs) were assigned to interprof ACT and 17 NHs (323 NHRs) to usual care. In the intervention group, 136 (42.5%) NHRs were hospitalised at least once within 12 months from randomisation and 151 (46.7%) in the control group (odds ratio (OR): 0.82, 95% confidence interval (CI): [0.55; 1.22], P = 0.33). No differences were found for the average number of hospitalisations: 0.8 hospitalisations per NHR (rate ratio (RR) 0.90, 95% CI: [0.66, 1.25], P = 0.54). Average length of stay was 5.7 days for NHRs in the intervention group and 6.5 days in the control group (RR: 0.70, 95% CI: [0.45, 1.11], P = 0.13). Falls were the most common adverse event, but none was related to the study intervention. CONCLUSIONS: The implementation of interprof ACT did not show a statistically significant and clinically relevant effect on hospital admission of NHRs.

La colaboración interdisciplinar en las unidades de cuidados intensivos / Interdisciplinary collaboration in intensive care units from the experience of nurses

Objetivo: Comprender la experiencia vivida por las enfermeras que trabajan en las UCI polivalentes de un hospital de tercer nivel de la ciudad de Barcelona en relación con la colaboración interprofesional. Metodología: Diseño cualitativo exploratorio, multicéntrico de tipo descripción interpretativa. El ámbito de estudio fue cuatro UCI polivalentes de cuatro hospitales públicos y universitarios de tercer nivel. La muestra estuvo formada por 8 enfermeras. El muestreo teórico de variación máxima. La técnica de obtención de información fue el grupo de discusión con grabación de audio. Se realizó un análisis temático de contenido. Se siguieron los criterios de confiabilidad y autenticidad, así como el proceso de reflexividad durante todo el estudio. El estudio fue aprobado por el Comité de Ética de Investigación Clínica (CEIC). Resultados: Emergieron 2 grandes temas: la definición de colaboración interprofesional y propuestas de futuro. Las enfermeras consideran que la confianza y el respeto son la base de la colaboración interprofesional y aseguran la continuidad de los objetivos planificados. La comunicación y la relación entre iguales son dos de los factores que intervienen en la colaboración interprofesional. Es necesario cambiar de una jerarquía convencional a una visión compartida que mejoraría la participación de las enfermeras. Conclusiones: Los grandes pilares de la colaboración interdisciplinar son la comunicación efectiva y el trabajo en equipo, basado en la confianza y el respeto. Las líneas futuras de trabajo van enfocadas a la formación interdisciplinar de los futuros profesionales, la implantación real del pase conjunto y la mejora del clima laboral. (AU)

Purpose: Understanding the nurses experience who work in the ICUs of a high complexity hospital in Barcelona in relation to interprofessional collaboration. Methodology: Interpretative description by a qualitative exploratory and multicenter design. The study area was four ICUs from four high complexity, public and universitary hospitals. The sample consisted of 8 nurses. Theoretical sampling of maximum variation was used. The information gathering technique was the discussion group with audio recording. A thematic content analysis was carried out. The criteria of reliability and authenticity, as well as the process of reflexivity, were followed throughout the study. The study was approved by the Clinical Research Ethics Committee (CEIC). Results: Two major themes emerged: the definition of interprofessional collaboration and proposals for the future. Nurses consider that trust and respect are the basis of interprofessional collaboration and ensure the continuity of planned objectives. Communication and the relationship between equals are two of the factors involved in interprofessional collaboration. It is necessary to change from a conventional hierarchy to a shared vision that would improve the participation of nurses. Conclusions: The great pillars of interdisciplinary collaboration are effective communication and teamwork, based on trust and respect. Future lines of work are focused on the interdisciplinary training of future professionals, the actual implementation of the clinical sessions and the improvement of the work environment. (AU)

Interprofessional team-based collaboration between designated GPs and care home staff: a qualitative study in an urban Danish setting.

BACKGROUND: Being a general practitioner for residents in many care homes may challenge communication with residents, relatives, and care home staff, and potentially lead to lower quality of care. Several countries have therefore introduced different solutions to reduce the number of general practitioners at each care home. In 2017, the designated general practitioner model was introduced at many Danish care homes. This study aimed to evaluate experiences from the interprofessional team-based collaboration between designated general practitioners and care home staff with regular contact with the designated general practitioners in an urban Danish setting. METHODS: A qualitative design was applied using semi-structured interviews. Eight interviews (three group interviews and five individual interviews) were conducted with four designated general practitioners and seven care home staff members at four care homes in an urban setting of Central Denmark Region, Denmark. The interviews were transcribed verbatim, and data were analysed using content analysis with inspiration from the theory of relational coordination. The study followed the guidelines addressed in the COREQ (Consolidated Criteria for Reporting Qualitative Research) framework. RESULTS: The initiation of the designated general practitioner model was experienced to contribute to more clear, precise, and timely communication between care homes and the general practitioner. An improved mutual acknowledgement of roles and competencies was experienced between designated general practitioners, care home nurses, and sometimes also social and health care assistants. The more frequent visits by the general practitioners at the care homes, as a result of the designated general practitioner model, resulted in more face-to-face communication between care home staff and designated general practitioners. Professional differences in the interpretation of the patient's needs were still present, which at times caused a frustrating compromise of own professional competencies. An important reason for the overall perception of improved collaboration was attributed to the more frequent dialogue in which the care homes staff and the designated general practitioners exchanged knowledge that could be applied in future patient encounters. CONCLUSION: The designated general practitioner model implied an improved collaboration between general practitioners and care homes staff. Clear, precise, and timely communication between care homes and the general practitioners, as well as mutual trust and acknowledgement was experienced to be essential for the collaboration. An important reason for the overall perception of an improved collaboration was attributed to the more frequent dialogue (more frequent general practitioner visits at the care homes) in which the care homes staff and the designated general practitioners exchange knowledge which again could be applied in future patient encounters.

Factors affecting triage competence among emergency room nurses: A cross-sectional study.

AIMS AND OBJECTIVES: The purpose of this study was to examine work-related stress, nurse-physician collaboration and clinical reasoning competence to identify the factors that affected the triage competence of emergency room nurses. BACKGROUND: A quick and accurate treatment plan for patients is first determined by a triage nurse. Triage competence is an indispensable requirement for emergency room nurses. DESIGN: A cross-sectional design was adopted. METHODS: The participants comprised 156 emergency room nurses in South Korea who had more than 1 year of experience working in an emergency room. The collected data were analysed using SPSS 28.0. Self-reported data were collected via the Korean Nursing Stress, Nurse-Physician Collaboration, Nurse Clinical Reasoning, Emergency Room Nurse Triage Competence assessing work-related stress, nurse-physician collaboration, clinical reasoning competence and triage competence. In the analyses, multiple regression analysis using the enter method was conducted. We have followed through the STROBE checklist for the preparation of this manuscript. RESULTS: Triage competence significantly differed according to the age (F = 9.93, p < .001), clinical experience (F = 18.82, p < .001), emergency department experience (F = 12.07, p < .001), triage experience (t = 4.40, p < .001) and if nurses had a triage certificate (t = 4.85, p < .001). The factors that influenced triage competence included clinical reasoning competence (ß = .36, p < .001), emergency department experience (ß = .21, p = .006), work-related stress (ß = .18, p = .007) and nurse-physician collaboration (ß = -.17, p = .009); these factors accounted for 38.1% of the variance in triage competence. CONCLUSION: The results of this study show that efforts to improve triage competence should be based on clinical reasoning. In addition, an effective plan should be devised to improve nurse-physician collaboration and work-related stress. RELEVANCE TO CLINICAL PRACTICE: Education programmes should be developed to enhance clinical reasoning competence in order to improve triage competence. In addition, a method for managing work-related stress among nurses in emergency departments and programmes to enhance collaborative physician-nurse relations should be developed.

Cross-Cultural Adaptation of the Instrument "Nurse-Physician Relationship Survey: Impact of Disruptive Behavior in Patient Care" to the Spanish Context.

Disruptive behavior in the healthcare context has an impact on patient care, healthcare personnel, and the health organization, and it also influences the therapeutic relationship, communication process, and adverse events. However, there is a lack of instruments that could be used for its analysis in the hospital care environment in the Spanish context. The objective of the study was to culturally adapt and perform a content validation of the tool "Nurse−Physician Relationship Survey: Impact of Disruptive Behavior on Patient Care", to the Spanish content (Spain). An instrumental study was conducted, which included an analysis of conceptual and semantic equivalence. A panel of experts analyzed the translations, by analyzing the Content Validity Index (CVI) of the group of items in the scale through the Relevance Index (RI) and the Pertinence Index (PI). Only a single item obtained an RI value of 0.72, although with PI value of 0.81, with consensus reached for not deleting this item. The CVI of all the items was >0.80 for the mean value of the RI, as well as the PI. The instrument was adapted to the Spanish context and is adequate for evaluating the disruptive behaviors on nurse−physician relationships and its impact on patient care. However, the importance of continuing the analysis of the rest of the psychometric properties in future studies is underlined.

Nurse-physician collaboration, intention to leave job, and professional commitment among new graduate nurses.

BACKGROUND: The quality of communication and collaboration with colleagues, managers, and physicians affects the intention to leave a job and the profession for new graduate nurses (NGNs). New graduates have difficulties communicating and collaborating with physicians, especially. AIM: This study aimed to determine the relationship between the attitudes of nurse-physician collaboration and the levels of intention to leave the current job and professional commitment among NGNs. METHODOLOGY: This descriptive, cross-sectional study was carried out with 231 NGNs in four private hospitals affiliated with an university. Data were collected by using a self-administered questionnaire, including a personal information form, the Jefferson Scale of Attitudes towards Physician-Nurse Collaboration, Intention to Leave Scale, and Nursing Professional Commitment Scale. Data analysis was performed using descriptive statistics, and Spearman's rank correlation coefficients. RESULTS: NGNs had a high positive attitude towards nurse-physician collaboration with a median score of 49 (45-54). The professional commitment of NGNs was high level with a median score of 75 (69-86). The intention to leave the current job median score was 3 (2.3-3.6) out of 5. There was a statistically significant correlation between attitudes towards nurse-physician collaboration and the levels of intention to leave the current job (rs = -0.22; p < 0.01) and professional commitment (rs = 0.42; p < 0.01). CONCLUSION: The results showed that improving NGNs' attitudes towards nurse-physician collaboration increases the professional commitment and reduces turnover intention.

Paging Patterns Among Junior Surgery Residents in a Tertiary Care Center.

OBJECTIVE: An excessive amount of nonurgent pages may disrupt patient care, reduce efficiency, and contribute to burnout. We present detailed paging data to analyze frequency, content, and urgency of pages received by surgery residents to provide recommendations to reduce resident distractions and fatigue. DESIGN: Prospective review of pages received by surgery residents over 15 weeks in 2019. Pages were analyzed by content and urgency (routine, important, emergent) by author consensus and compared among day and night shifts, and page senders' profession. SETTING: University tertiary-care hospital PARTICIPANTS: Seventeen junior surgery residents (PGY-1 and PGY-2) RESULTS: Total 1,740 resident-hours yielded 1,871 pages. Residents working day and night shift received a median of 11 (IQR 7-14) and 13 (IQR 6-22) pages, respectively. Pages from nurses were most common for both shifts but constituted a significantly increased proportion at night (71.3% vs 36.7%, p < 0.00005). Most pages during day shift were routine (74.4%) and pertained to plan of care and order request (38.4% and 15.7%, respectively). Emergent and important pages were more common at night (8.9% and 24.7% vs 1.8 and 14.8%, p < 0.00005) which paralleled an increase in pages reporting change in patient condition compared to day shift (19.7 from 6.7%, p < 0.00005). Routine pages pertaining care plan and order requests remained common at night (26.5 and 28%, respectively). CONCLUSIONS: Over half of pages received by residents contain routine communications about care plan and request for non-urgent orders, even during night shift. Resident-nurse collaboration and support from technology services might optimizing communication pathways.

A cross-sectional survey on workplace psychological violence among operating room nurses in Mainland China.

AIM: To investigate the status of workplace psychological violence (WPV) from managers, coworkers, or subordinates against operating room (OR) nurses in mainland China and identify risk factors. BACKGROUND: WPV is a serious problem for nurses. However, limited information is available regarding the prevalence and risk factors of WPV against OR nurses in mainland China. METHODS: A multi-center, cross-sectional study was conducted. OR nurses (n = 1557) from 26 hospitals, located in 13 cities of China, participated in this study. RESULTS: Of the participants, 92.1% experienced WPV (30.9% from surgeons and 18.1% from senior nurses). Only 30.1% of the sufferers would report WPV. A logistic regression analysis revealed that nurses who had been in service longer and with senior professional titles were more likely to experience WPV. CONCLUSION: Nursing managers should identify and resolve issues in a timely manner. Measures that promote effective team communication and facilitate teamwork, as well as inter-disciplinary educational workshops may be effective.

Hipodermóclise na história da enfermagem: atribuições para enfermeiras no Brasil (1916-1943) / Hypodermoclysis in the history of nursing: attributions for nurses in Brazil (1916-1943) / ipodermoclisis en la historia de la enfermería: atribuciones de las enfermeras en Brasil (1916-1943)

Objetivo: Analisar a construção histórica entre a hipodermóclise e a enfermagem brasileira sob a ótica da dialética marxista. Métodos: Revisão integrativa com discussão sócio-histórica. A coleta de dados foi baseada em livros publicados no Brasil até o ano de 1949. Extraíram-se informações sobre o tema. As atribuições da enfermagem foram discutidas à luz do materialismo histórico-dialético. Resultados:Os autores disponibilizaram o posicionamento dos enfermeiros sobre conceito, indicação terapêutica, material de consumo, local de administração, precaução, evento adverso e cuidado. Houve maior ênfase a algumas atribuições em detrimento de outras, empoderando os enfermeiros preferencialmente nas questões operacionais. Esse fato influenciou as relações de produção e estabeleceu uma dialética entre o fazer de médicos e enfermeiros. Considerações finais: Dentro da produção econômica da hipodermóclise, houve visões convergentes que fizeram com que as atribuições da enfermagem ganhassem mais empoderamento profissional, situando a posição da enfermagem na infraestrutura do cuidado.

Objective: Analyze the historical construction between hypodermoclysis and Brazilian nursing from the perspective of the Marxist dialectics. Methods: Integrative review with socio-historical discus-sion. Data collection was based on books published in Brazil until 1949. Information on the subject was extracted. The attributions of nursing were discussed in the light of the historical-dialectical materialism. Results: The authors provided the nurses' position on the concept, therapeutic indica-tion, consumption material, place of administration, precaution, adverse event and care. There was greater emphasis on some assignments to the detriment of others, empowering nurses preferentially in operational matters. This fact influenced the production relations and established a dialectic be-tween the actions of doctors and nurses. Final considerations: Within the economic production of hypodermoclysis, there were converging views that made nursing attributions gain more professional empowerment, placing the position of nursing in the care infrastructure.

Objetivo: Analizar la construcción histórica entre la hipodermoclisis y la enfermería brasileña desde la perspectiva de la dialéctica marxista. Métodos: Revisión integradora con discusión sociohistórica. La re-copilación de datos se basó en libros publicados en Brasil hasta 1949. Se extrajo información sobre el tema. Las atribuciones de la enfermería se discutieron a la luz del materialismo histórico-dialéctico. Resultados:Los autores aportaron la posición de los enfermeros sobre el concepto, indicación terapéutica, material de consumo, lugar de administración, precaución, evento adverso y cuidados. Se destacaron algunas asignaciones en detrimento de otras, empoderando preferentemente a los enfermeros en cuestiones operativas. Este hecho influyó en las relaciones de producción y estableció una dialéctica entre las acciones de médicos y enfermeros. Consideraciones finales: Dentro de la producción económica de la hipodermoclisis, hubo visiones convergentes que hicieron que las atribuciones de la enfermería ganaran un mayor empoderamiento profesional, ubicando la posición de la enfermería en la infraestructura asistencial.

Professional practice environment and nursing work stress in neonatal units / Ambiente de práctica profesional y estrés en el trabajo de enfermería en las unidades neonatales / Ambiente de prática profissional e estresse no trabalho da enfermagem em unidades neonatais

ABSTRACT Objective: To assess the nurse professional practice environment of neonatal units and its relationship with the levels and main sources of occupational stress. Method: Cross-sectional descriptive, exploratory, correlational study performed with nursing professionals of neonatal units of four public hospitals. A sociodemographic/professional questionnaire, the Brazilian version of Practice Environment Scale, and the Work Stress Scale were applied. In the analysis, mean, standard deviation, and Pearson chi-squared, Likelihood Ratio, and Mann Whitney U tests were adopted for association among variables. Results: Participating professionals amounted to 269. The practice environment was evaluated as favorable by more than half of the sample (63.6%), showing a significant statistical association which was inversely proportional with occupational stress (p < 0.001). The insufficient number of professionals for quality care was the major source of stress for nursing technicians, whereas teamwork with doctors was the predominant factor for the evaluation of environment quality and high stress levels of nurses. Conclusion: Unfavorable practice environments increase the stress levels of nursing professionals in neonatal units and may compromise patient safety.

RESUMEN Objetivo: Evaluar la práctica profesional de enfermería en unidades neonatales y su relación con los niveles y las principales fuentes de estrés ocupacional. Método: Estudio transversal, descriptivo, exploratorio y correlacional conducido con profesionales de enfermería de unidades neonatales de cuatro hospitales públicos. Se aplicaron el cuestionario sociodemográfico/profesional, la versión brasileña de Practice Environment Scale y la Escala de Estrés en el Trabajo. En el análisis, se adoptaron la media, la desviación típica y las pruebas chi-cuadrado de Pearson, Razón de Verosimilitud y Mann Whitney U para la asociación entre las variables. Resultados: Los participantes fueron 269 profesionales. El ambiente de práctica fue evaluado como favorable por más de la mitad de la muestra (63,6%), con una asociación estadística significativa e inversamente proporcional con el estrés ocupacional (p < 0,001). El número insuficiente de profesionales para una atención de calidad fue la mayor fuente de estrés para las técnicas de enfermería, mientras que el trabajo en equipo con los médicos fue el factor predominante en la evaluación de la calidad del ambiente y del nivel de estrés elevado para las enfermeras. Conclusión: Los ambientes de práctica desfavorables aumentan el nivel de estrés de los profesionales de enfermería en las unidades neonatales y pueden comprometer la seguridad del paciente.

RESUMO Objetivo: Avaliar o ambiente de prática profissional da enfermagem em unidades neonatais e sua relação com os níveis e as principais fontes de estresse ocupacional. Método: Estudo transversal, descritivo, exploratório e correlacional, realizado com profissionais de enfermagem das unidades neonatais de quatro hospitais públicos. Aplicaram-se o questionário sociodemográfico/profissional, Versão Brasileira da Practice Environment Scale e a Escala de Estresse no Trabalho. Na análise, adotaram-se média, desvio padrão e testes qui-quadrado de Pearson, Razão de Verossimilhança e U de Mann Whitney para associação entre variáveis. Resultados: Participaram 269 profissionais. O ambiente de prática foi avaliado como favorável por mais da metade da amostra (63,6%), demonstrando associação estatística significante e inversamente proporcional com o estresse ocupacional (p < 0,001). O número insuficiente de profissionais para um cuidado de qualidade foi a maior fonte de estresse para as técnicas de enfermagem, enquanto o trabalho em equipe com médicos foi fator preponderante na avaliação da qualidade do ambiente e do nível de estresse elevado para as enfermeiras. Conclusão: Ambientes de prática desfavoráveis aumentam o nível de estresse de profissionais de enfermagem em unidades neonatais, podendo comprometer a segurança do paciente.

[Cancer nursing on tumor boards]. / Onkologische Pflege im Tumorboard: Rolle der Pflege in der multidisziplinären onkologischen Versorgung.

BACKGROUND: The increasingly complex treatment options for oncological diseases with multimodal treatment strategies transcend the boundaries of a single discipline and require multidisciplinary cooperation in order to ensure guideline-based and patient-oriented care. MATERIAL AND METHODS: The implementation of an effective tumour board is required in the goals of the National Cancer Plan of the Federal Ministry of Health and the certification guidelines of the German Cancer Society. RESULTS: In Germany, specialist competence in the field of oncological nursing has so far rarely been integrated. CONCLUSION: The Konferenz Onkologischer Kranken- und Kinderkrankenpflege (KOK), a working group of Section B in the German Cancer Society, is working intensively on strengthening the role of oncological nursing so that oncological nurses and advanced practice nurses specialising in oncology, as an integral part of the multidisciplinary team, can contribute valuable nursing aspects, taking into account the individual patient perspective, and thus improve the quality of oncological care.

Quality improvement of end­of­life decision-making and communication in the ICU : Effect on clinicians' burnout and relatives' distress.

PURPOSE: End-of-life (EOL) decision-making is stressful. We conducted a quality improvement initiative to EOL decision-making and reduce stress for clinicians and patients' relatives. METHODS: A before-after study running from 2010-2014 at four interdisciplinary intensive care units (ICU) in a German university hospital was performed. Between periods, a multifaceted intervention was implemented to improve timeliness, clinician involvement, and organisational support. Consecutive patients with severe sepsis and therapy limitations were included. Relatives were interviewed by telephone after 90 days to assess their psychological symptoms. Clinician burnout was assessed by staff surveys in each period. RESULTS: Participation in the pre- and postintervention period was 84/145 and 90/159 among relatives, and 174/284 and 122/297 among ICU clinicians. Staff judged intervention elements as mostly helpful, but implementation of intervention elements was heterogeneous. From pre- to postintervention, relatives' risk of posttraumatic stress, depression and anxiety did not change (all p ≥ 0.464). Clinicians' risk of burnout increased (29% vs. 41%, p = 0.05). Relatives were highly satisfied in both periods (median of 9 vs. 9.2 on a 1-10 scale each). Attendings involved residents and nurses more often (both p ≤ 0.018). Nurses more often had sufficient information to talk with relatives (41% vs. 62%, p = 0.002). Time to first EOL decision as well as barriers and facilitators of EOL decision-making did not change. CONCLUSIONS: The intervention may have increased involvement in EOL decision-making, but was accompanied by an increased risk of clinician burnout maybe due to lack of improving communication skills and organisational support. More research is needed to understand which interventions can decrease clinician burnout.

Development and Validation of a Scale to Measure Nurse/Medical Resident Physician Collaboration.

Introduction: The purpose of this pilot study is to investigate the reliability of an interprofessional collaboration measurement scale used for nursing interactions with resident physicians. To date, the collaboration between nurses and residents has not been adequately investigated and a validated tool specifically for this purpose is not yet available. Our objective is to adapt a previously validated interprofessional scale for health care settings to the specific nurse/resident physician collaboration. Methods: In 2019, nurses from two hospitals were contacted via email and were invited to complete an anonymous survey that asked about the nurses' interaction and collaboration with resident physicians. Results: Our inquiry of 850 nurses with 59 completing a survey, returned a response rate of about 7%. Internal consistency for the scale was very high (alpha = 0.92) with no single item disproportionally reducing the reliability of the scale. Conclusion: Despite the limited sample size of the present pilot study, this scale was effective for examining nurse/resident collaboration. Further research will seek to expand our sample size and include measures of concurrent validity.

Using Qualitative Methods to Explore Communication Practices in the Context of Patient Care Rounds on General Care Units.

BACKGROUND: Poor communication between physicians and nurses is a significant contributor to adverse events for hospitalized patients. Overcoming communication difficulties requires examining communication practices to better understand some of the factors that affect the nurse-physician communication process. OBJECTIVE: To develop a more detailed understanding of communication practices between nurses and physicians on general care units. We focused on patient care rounds as an important activity in the care delivery process for communication. DESIGN: Qualitative study design PARTICIPANTS: A total of 163 physicians, registered nurses, and nurse practitioners who worked on pre-specified general care units in each of four hospitals in the Midwest. APPROACH: On each unit, data collection consisted of 2 weeks of observing and shadowing clinicians during rounds and at other times, as well as asking clinicians questions about rounds and communication during interviews and focus groups. A directed content analysis approach was used to code and analyze the data. KEY RESULTS: Workflow differences contributed to organizational complexity, affecting rounds and subsequently communication practices, both across and within provider types. Nurse and patient participation during rounds appeared to reduce interruptions and hence cognitive load for physicians and nurses. Physicians adopted certain behaviors within the social context to improve communication, such as socializing and building relationships with the nurses, which contributed to nurse participation in rounds. When rapport was lacking, some nurses felt uncomfortable joining physicians during rounds unless they were explicitly invited. CONCLUSIONS: Improving communication requires bringing attention to three contextual dimensions of communication: organizational complexity, cognitive load, and the social context. Initiatives that seek to improve communication may be more successful if they acknowledge the complexity of communication and the context in which it occurs.

Análise da prática profissional de enfermeiras obstétricas: transformá-la para conhecer a realidade / Analysis of the professional practice of obstetric nurses: transforming it to know the reality

No campo da obstetrícia, identificam-se avanços na regulação, formação e qualificação de profissionais, na humanização da assistência ao parto e nascimento, entre outros aspectos relacionados à prática profissional. Entretanto, persistem imensos desafios para se proporcionar condições seguras ao nascimento no país. No sistema de saúde brasileiro ainda prevalece o chamado modelo biomédico como controle da atenção obstétrica e neonatal. No cenário do hospital de ensino, as disputas e legitimidades profissionais são ainda mais acirradas, uma vez que nele se encontram docentes e discentes de residência e graduação em medicina e enfermagem dedicados à assistência ao parto e nascimento para consolidar sua formação profissional. O objetivo geral deste estudo foi analisar as práticas profissionais das enfermeiras obstétricas de uma maternidade em um hospital universitário público situado em Belo Horizonte-MG. Trata-se de uma pesquisa-intervenção de abordagem qualitativa na qual se utilizou o referencial teórico metodológico da Análise Institucional na sua vertente socioclínica. Para a produção dos dados foram realizados 4 encontros socioclínicos que contaram com a participação de 15 enfermeiras. Além disso, foram realizadas entrevistas semiestruturadas com 6 gestores, sendo que alguns ainda atuam e outros já atuaram na maternidade. Outra ferramenta de coleta e produção de dados foi o diário institucional do pesquisador. A pesquisa compreendeu o período de novembro de 2018 a fevereiro de 2020. Os resultados englobam as dificuldades das enfermeiras obstétricas em relação ao processo de inserção na maternidade, os conflitos de atuação com a gestão e a equipe médica, além dos desafios cotidianos na prática profissional, como a inadequação do dimensionamento de pessoal de enfermagem e os processos de trabalho. Dentre as dificuldades relatadas se destaca o fato de que as enfermeiras obstétricas não conseguem atuar de forma mais efetiva junto à parturiente em um cuidado contínuo e humanizado, por imposição das rotinas institucionais e das atividades administrativas, que absorvem a maior parte do seu tempo. Os encontros socioclínicos possibilitaram a análise das implicações libidinais, ideológicas, profissionais e organizacionais das enfermeiras, trazendo à tona sua luta por autonomia e reconhecimento profissional, além das diversas instituições que atravessam a sua prática profissional, como a medicina, o ensino, a gestão e a própria enfermagem. Diante do reconhecimento de tais instituições, pôde-se buscar estratégias de fortalecimento e ações voltadas às mudanças necessárias para consolidar a prática profissional das enfermeiras obstétricas. Nesse sentido, como um dos produtos desta pesquisa-intervenção, adotou-se o planejamento estratégico como uma ferramenta capaz de contribuir na organização e sistematização das ações propostas pelo grupo, na corresponsabilização da equipe, na continuidade do trabalho e, sobremaneira, no avanço da produção do conhecimento da enfermagem obstétrica no cenário do hospital de ensino.

In the field of obstetrics, advances are identified in professional regulation, education, and qualification, in childbirth and birth care humanization, among other aspects related to professional practice. However, immense challenges remain to provide safe conditions for birth in the country. In the Brazilian health system, the so-called biomedical model still prevails as control of obstetric and neonatal care. In the teaching hospital scenario, professional disputes and legitimacies are even fiercer, because, in this setting, residency and undergraduate medicine and nursing professors and students devoted to childbirth and birth care gather to consolidate their professional qualification. The general objective of this study was analyzing obstetric nurses' professional practices at a maternity hospital in a public university hospital located in Belo Horizonte, Minas Gerais, Brazil. This is an intervention research with a qualitative approach in which the methodological theoretical framework of Institutional Analysis was used according to its socioclinical orientation. For data production, 4 socioclinical meetings were held, which had the participation of 15 nurses. Also, semi-structured interviews were conducted with 6 managers, some of whom still work and others have worked in the maternity hospital. Another tool for data collection and generation was the researcher's institutional diary. The survey covered the period from November 2018 to February 2020. The results encompass the difficulties faced by obstetric nurses during their entry into the maternity hospital, the conflicts of action with management and the medical team, in addition to the daily challenges in professional practice, such as the inadequate nursing staff sizing and the work processes. Among the reported difficulties, the fact that obstetric nurses are unable to work more effectively along with parturient women in a continuous and humanized care stands out, due to the imposition of institutional routines and administrative activities, which absorb most of their time. The socioclinical meetings made it possible to analyze the nurses' libidinal, ideological, professional, and organizational implications, bringing to the fore their struggle for professional autonomy and recognition, as well as the various institutions that permeate their professional practice, such as medicine, teaching, management, and nursing itself. By acknowledging such institutions, we could look for strengthening strategies and transformative actions needed to consolidate the obstetric nurses' professional practice. Thus, as one of the products of this intervention research, strategic planning was adopted as a tool capable of contributing to the organization and systematization of actions proposed by the group, to team shared accountability, to work continuity, and above all to the advancement of knowledge production in obstetric nursing within the teaching hospital scenario.

Configuration of power relations in physicians and nurses' professional practices / Configuración de las relaciones de poder en las prácticas profesionales de médicos y enfermeros / Configuração das relações de poder nas práticas profissionais de médicos e enfermeiros

ABSTRACT Objective: to analyze the configuration of power relations constituted in and by the knowledge and daily practices of physicians and nurses in an Intensive Care Unit (ICU). Method: qualitative study in which data were collected through interviews with physicians and nurses from an ICU of a hospital in Belo Horizonte, Minas Gerais. A semi-structured script was used. Data were analyzed through discourse analysis in a Foucaultian perspective. Results: three categories were developed - Professional Identity: self-recognition in the profession; Discipline: individualizing attitudes or collective need?; and Circularity of knowledge and power in the constitution of daily practices. Final considerations: the identity, discipline and circulation of power are connected in a continuous movement of subjectivation of the subject, which, in turn, uses discourse as a persuasion strategy to modify the position taken over in different situations thereby causing the circulation of power.

RESUMEN Objetivo: analizar la configuración de las relaciones de poder constituidas en y por el conocimiento y las prácticas cotidianas de médicos y enfermeros en una Unidad de Cuidados Intensivos. Método: investigación cualitativa con datos recopilados a través de entrevistas con guiones semiestructurados con médicos y enfermeros de una Unidad de Cuidados Intensivos de un hospital en Belo Horizonte, Minas Gerais. Para analizar los datos, se utilizó el análisis del discurso desde la perspectiva de Foucault. Resultados: se elaboraron tres categorías - Identidad profesional: auto reconocimiento en la profesión; Disciplina: ¿actitudes individualizadoras o necesidad colectiva?; y Circularidad de conocimiento y poder en la constitución de las prácticas cotidianas. Consideraciones finales: la identidad, la disciplina y la circulación del poder se conectan en un movimiento continuo de subjetivación del sujeto, que, a su vez, utiliza el discurso como estrategia de persuasión para modificar la posición asumida en diferentes situaciones, lo que provoca la circulación de poder.

RESUMO Objetivo: analisar a configuração das relações de poder constituídas nos e pelos saberes e práticas cotidianas de médicos e enfermeiros em um Centro de Terapia Intensiva. Método: pesquisa qualitativa, com dados coletados por meio de entrevistas com roteiro semiestruturado com médicos e enfermeiros de um Centro Terapia Intensiva de um hospital de Belo Horizonte, Minas Gerais. Para a análise dos dados, foi utilizada a análise de discurso na perspectiva Foucaultiana. Resultados: foram elaboradas três categorias - Identidade profissional: o reconhecimento de si na profissão; Disciplina: atitudes individualizantes ou necessidade coletiva?; e Circularidade do conhecimento e do poder na constituição das práticas cotidianas. Considerações finais: a identidade, a disciplina e circulação do poder se conectam em um movimento contínuo de subjetivação do sujeito que, por sua vez, utiliza-se do discurso como estratégia de persuasão para modificar a posição assumida em diferentes situações, fazendo com que o poder circule.

Medical Students' Experiences and Outcomes Using a Virtual Human Simulation to Improve Communication Skills: Mixed Methods Study.

BACKGROUND: Attending to the wide range of communication behaviors that convey empathy is an important but often underemphasized concept to reduce errors in care, improve patient satisfaction, and improve cancer patient outcomes. A virtual human (VH)-based simulation, MPathic-VR, was developed to train health care providers in empathic communication with patients and in interprofessional settings and evaluated through a randomized controlled trial. OBJECTIVE: This mixed methods study aimed to investigate the differential effects of a VH-based simulation developed to train health care providers in empathic patient-provider and interprofessional communication. METHODS: We employed a mixed methods intervention design, involving a comparison of 2 quantitative measures-MPathic-VR-calculated scores and the objective structured clinical exam (OSCE) scores-with qualitative reflections by medical students about their experiences. This paper is a secondary, focused analysis of intervention arm data from the larger trial. Students at 3 medical schools in the United States (n=206) received simulation to improve empathic communication skills. We conducted analysis of variance, thematic text analysis, and merging mixed methods analysis. RESULTS: OSCE scores were significantly improved for learners in the intervention group (mean 0.806, SD 0.201) compared with the control group (mean 0.752, SD 0.198; F1,414=6.09; P=.01). Qualitative analysis revealed 3 major positive themes for the MPathic-VR group learners: gaining useful communication skills, learning awareness of nonverbal skills in addition to verbal skills, and feeling motivated to learn more about communication. Finally, the results of the mixed methods analysis indicated that most of the variation between high, middle, and lower performers was noted about nonverbal behaviors. Medium and high OSCE scorers most often commented on the importance of nonverbal communication. Themes of motivation to learn about communication were only present in middle and high scorers. CONCLUSIONS: VHs are a promising strategy for improving empathic communication in health care. Higher performers seemed most engaged to learn, particularly nonverbal skills.