Exploring Sacred Moments in Hospitalized Patients: An Exploratory Qualitative Study.

BACKGROUND: "Sacred moments" are brief periods of time in which people experience a deep interconnectedness that may possess spiritual qualities and emotions. This concept has been shown to have a positive impact on individuals' overall well-being and stress in mental health settings. The concept of sacred moments has not been studied in acute care hospital settings. OBJECTIVE: To better understand the occurrence of sacred moments among hospitalized patients and their healthcare workers. DESIGN: An exploratory qualitative study that included in-depth interviews with patients and healthcare workers at two academic medical centers in the Midwestern United States. PARTICIPANTS: Hospital healthcare workers (e.g., physicians, nurses, ancillary staff) and discharged patients with a recent hospital stay. APPROACH: Semi-structured telephone interviews were conducted with 30 participants between August 2020 and April 2021. Interviews were recorded and transcribed before conducting thematic analysis. KEY RESULTS: Both healthcare workers and patients reported having experienced at least one sacred moment. Interview findings were organized into three main domains including (1) several common elements described by participants as marking these moments; (2) benefits experienced by both patients and healthcare workers; and (3) suggestions for fostering sacred moments within the hospital setting. CONCLUSIONS: Among our participants, sacred moments were extremely common with the vast majority reporting to have experienced at least one in their lifetime. These moments were described as profound and important and shared many common elements. Our findings can be used to help recognize, understand, and promote sacred moments between hospitalized patients and healthcare workers.

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.

How Do Resuscitation Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest Succeed? A Qualitative Study.

BACKGROUND: In-hospital cardiac arrest (IHCA) is common, and outcomes vary substantially across US hospitals, but reasons for these differences are largely unknown. We set out to better understand how top-performing hospitals organize their resuscitation teams to achieve high survival rates for IHCA. METHODS: We calculated risk-standardized IHCA survival to discharge rates across American Heart Association Get With The Guidelines-Resuscitation registry hospitals between 2012 and 2014. We identified geographically and academically diverse hospitals in the top, middle, and bottom quartiles of survival for IHCA and performed a qualitative study that included site visits with in-depth interviews of clinical and administrative staff at 9 hospitals. With the use of thematic analysis, data were analyzed to identify salient themes of perceived performance by informants. RESULTS: Across 9 hospitals, we interviewed 158 individuals from multiple disciplines including physicians (17.1%), nurses (45.6%), other clinical staff (17.1%), and administration (20.3%). We identified 4 broad themes related to resuscitation teams: (1) team design, (2) team composition and roles, (3) communication and leadership during IHCA, and (4) training and education. Resuscitation teams at top-performing hospitals demonstrated the following features: dedicated or designated resuscitation teams; participation of diverse disciplines as team members during IHCA; clear roles and responsibilities of team members; better communication and leadership during IHCA; and in-depth mock codes. CONCLUSIONS: Resuscitation teams at hospitals with high IHCA survival differ from non-top-performing hospitals. Our findings suggest core elements of successful resuscitation teams that are associated with better outcomes and form the basis for future work to improve IHCA.

Understanding Workflow and Personal Protective Equipment Challenges Across Different Healthcare Personnel Roles.

BACKGROUND: Hospitals use standard and transmission-based precautions, including personal protective equipment (PPE), to prevent the spread of infectious organisms. However, little attention has been paid to the potentially unique challenges of various healthcare personnel (HCP) in following precaution practices. METHODS: From September through December 2016, 5 physicians, 5 nurses, and 4 physical therapists were shadowed for 1 hour 30 minutes to 3 hours 15 minutes at an academic medical center. Observers documented activities using unstructured field notes. Focus groups were conducted to better understand HCP perspectives about precautions and PPE-related challenges. Data were analyzed by comparing workflow and challenges (observed and stated) in precaution practices across HCP roles. RESULTS: Precaution patients were interspersed throughout physician rounds, which covered a broad geographic range throughout the hospital. Patient encounters were generally brief, and appropriate use of gowns and cleaning of personal stethoscopes varied among observed physicians. Nurses were unit based and frequently entered/exited rooms. Frustration with donning/doffing was especially apparent when needing supplies while in a precaution room, which nurses acknowledged was a time when practice lapses could occur. The observed physical therapists worked in one geographic location, spent extended periods of time with patients, and noted that given their close physical contact with patients, gowns do not fully protect them. CONCLUSIONS: Movement patterns, time with patients, care activities, and equipment use varied across HCP, leading to a diverse set of challenges in following precaution practices and PPE use. Attention to these differences among HCP is important for understanding and developing effective strategies to prevent the potential spread of infectious organisms.

"It goes beyond good camaraderie": A qualitative study of the process of becoming an interprofessional healthcare "teamlet".

Within the US, the patient-centred medical home has become a predominant model in the delivery of primary care. This model requires a shift from the physician-centric model to an interprofessional team-based approach. Thus, healthcare staff are being reorganized into teams, resulting in having to work and relate to one another in new ways. In 2010, the Veterans Health Administration implemented the patient aligned care team (PACT) model, its version of the patient-centred medical home. The transition to the PACT model involved restructuring primary care staff into "teamlets", consisting of a registered nurse, licensed practical nurse, and administrative clerk for each full-time-equivalent primary care provider. This qualitative study used observation and semi-structured interviews to understand the factors that affect teamlet functioning as they implement this new model of care and how teams are interacting to address those factors. Findings suggest that role understanding includes understanding how each teamlet member's tasks are performed in the daily operations of the clinic. In addition, willingness to perform tasks that benefit the teamlet and acceptance of delegation from all teamlet members were found to be important for teamlet functioning and cohesion. In order for healthcare teams to provide patient-centred care, it is important to provide guidance and support about what these new relationships and roles will entail. The building of team relationships is not a static process; ways of working together build over time and, therefore, should be seen as a continuous cycle of quality improvement.

The use of multiple qualitative methods to characterize communication events between physicians and nurses.

Despite the importance of communication to patient safety in hospital settings, we know surprisingly little about communication patterns between physicians and nurses, particularly on general medical-surgical units. Poor communication is the leading cause of preventable adverse events in hospitals, as well as a major root cause of sentinel events. The literature provides little guidance on what qualitative methods are best for capturing different types of communication events and patterns. The purpose of this study was to develop a methodology for identifying and characterizing communication events between physicians and nurses to better understand communication patterns on general medical-surgical units. We used a sequential qualitative mixed method design beginning with general observation, progressing to shadowing and focus groups of physicians and nurses who worked on two medical-surgical units at one academically affiliated U.S. Department of Veterans Affairs (VA) hospital. Each data collection method (observation, shadowing, and focus groups) had its own advantages and disadvantages for capturing communication events and patterns. Through observation we were able to see the "what": communication activities. Shadowing was most useful for understanding "how" physicians and nurses communicated. Focus groups helped answer "why" certain patterns emerged and allowed us to further explore communication events within a group setting. By using all three methods we were able to more thoroughly characterize communication events than by using a single method alone, providing a more holistic picture of how communication occurs on an inpatient medical-surgical unit.

First things first: foundational requirements for a medical home in an academic medical center.

BACKGROUND: In 2010, the Veterans Health Administration (VHA) began implementation of its medical home, Patient Aligned Care Teams (PACT), in 900 primary care clinics nationwide, with 120 located in academically affiliated medical centers. The literature on Patient-Centered Medical Home (PCMH) implementation has focused mainly on small, nonacademic practices. OBJECTIVE: To understand the experiences of primary care leadership, physicians and staff during early PACT implementation in a VHA academically affiliated primary care clinic and provide insights to guide future PCMH implementation. DESIGN: We conducted a qualitative case study during early PACT implementation. PARTICIPANTS: Primary care clinical leadership, primary care providers, residents, and staff. APPROACH: Between February 2011 and March 2012, we conducted 22 semi-structured interviews, purposively sampling participants by clinic role, and convenience sampling within role. We also conducted observations of 30 nurse case manager staff meetings, and collected data on growth in the number of patients, staff, and physicians. We used a template organizing approach to data analysis, using select constructs from the Consolidated Framework for Implementation Research (CFIR). KEY RESULTS: Establishing foundational requirements was an essential first step in implementing the PACT model, with teamlets able to do practice redesign work. Short-staffing undermined development of teamlet working relationships. Lack of co-location of teamlet members in clinic and difficulty communicating with residents when they were off-site hampered communication. Opportunities to educate and reinforce PACT principles were constrained by the limited clinic hours of part-time primary care providers and residents, and delays in teamlet formation. CONCLUSIONS: Large academic medical centers face special challenges in implementing the medical home model. In an era of increasing emphasis on patient-centered care, our findings will inform efforts to both improve patient care and train clinicians to move from physician-centric to multidisciplinary care delivery.

Characterizing infection prevention programs and urinary tract infection prevention practices in nursing homes: A mixed-methods study.

OBJECTIVE: US policies require robust nursing home (NH) infection prevention and control (IPC) programs to ensure safe care. We assessed IPC resources and practices related to catheter and non-catheter-associated urinary tract infection (CAUTI and UTI) prevention among NHs. METHODS: We conducted a mixed-methods study from April 2018 through November 2019. Quantitative surveys assessed NH IPC program resources, practices, and communication during resident transfer. Semistructured qualitative interviews focused on IPC programs, CAUTI and UTI prevention practices, and resident transfer processes. Using a matrix as an analytic tool, findings from the quantitative survey data were combined with the qualitative data in the form of a joint display. RESULTS: Representatives from 51 NHs completed surveys; interviews were conducted with 13 participants from 7 NHs. Infection preventionists (IPs) had limited experience and/or additional roles, and in 36.7% of NHs, IPs had no specific IPC training. IP turnover was often mentioned during interviews. Most facilities were aware of their CAUTI and UTI rates and reported using prevention practices, such as hydration (85.7%) or nurse-initiated catheter discontinuation (65.3%). Qualitative interviewees confirmed use of these practices and expressed additional concerns about overuse of urine testing and antibiotics. Although transfer sheets were used by 84% to communicate about infections, the information received was described as suboptimal. CONCLUSIONS: NHs identified IP challenges related to turnover, limited education, and serving multiple roles. However, most NHs reported awareness of their CAUTI and UTI rates as well as their use of prevention practices. Importantly, we identified opportunities to enhance communication between NHs and hospitals to improve resident care and safety.

Prognosis Communication in Heart Failure: Experiences and Preferences of End-Stage Heart Failure Patients and Care Partners.

BACKGROUND: Patients with heart failure (HF) overestimate survival compared with model-predicted estimates, but the reasons for this discrepancy are poorly understood. We characterized how patients with end-stage HF and their care partners understand prognosis and elicited their preferences around prognosis communication. METHODS: We conducted in-depth, semistructured interviews with patients with end-stage HF and their care partners between 2021 and 2022 at a tertiary care center in Michigan. Participants were asked to describe barriers they faced to understanding prognosis. All interviews were coded and analyzed using an iterative content analysis approach. RESULTS: Fifteen patients with end-stage HF and 15 care partners participated, including 7 dyads. The median patient age was 66.5 years (range, 31-80) and included 9 of 15 (60%) White participants and 9 of 15 (60%) were males. Care partners included 10 of 15 (67%) White participants and 6 of 15 (40%) were males. Care partners were partners (n=7, 47%), siblings (n=4, 27%), parents (n=2, 13%), and children (n=2, 13%). Most patients demonstrated a poor understanding of their prognosis. In contrast, care partners commonly identified the patient's rapidly declining trajectory. Patients and care partners described ineffective prognosis communication with clinicians, common barriers to understanding prognosis, and similar suggestions on improving prognosis communication. Barriers to understanding prognosis included (1) conversation avoidance by physicians, (2) information inconsistency across different physicians, (3) distractions during prognosis communication due to emphasis on other conditions, and (4) confusion related to the use of medical jargon. Most patients and care partners wanted discussions around prognosis to begin early in the course of the disease, repeated routinely using layperson's terms, incorporating both quality of life and survival assessments, and involving care partners. Both patients and care partners did not expect precise survival estimates. CONCLUSIONS: Patients with end-stage HF demonstrate a poor understanding of their prognosis compared with their care partners. Patients and care partners are open to discussing prognosis early, using direct and patient-centered language.

Variations in risk perceptions: a qualitative study of why unnecessary urinary catheter use continues to be problematic.

BACKGROUND: Catheter associated urinary tract infection (CAUTI) is one of the most commonly acquired health care associated infections within the United States. We examined the implementation of an initiative to prevent CAUTI, to better understand how health care providers' perceptions of risk influenced their use of prevention practices and the potential impact these risk perceptions have on patient care decisions. Understanding such perceptions are critical for developing more effective approaches to ensure the successful uptake of key patient safety practices and thus safer care for hospitalized patients. METHODS: We conducted semi-structured phone and in-person interviews with staff from 12 hospitals. A total of 42 interviews were analyzed using open coding and a constant comparative approach. This analysis identified "risk" as a central theme and a "risk explanatory framework" was identified for its sensitizing constructs to organize and explain our findings. RESULTS: We found that multiple perceptions of risk, some non-evidence based, were used by healthcare providers to determine if use of the indwelling urethral catheter was necessary. These risks included normative work where staff deal with competing priorities and must decide which ones to attend too; loosely coupled errors where negative outcomes and the use of urinary catheters were not clearly linked; process weaknesses where risk seemed to be related to both the existing organizational processes and the new initiative being implemented and; workarounds that consisted of health care workers developing workarounds in order to bypass some of the organizational processes created to dissuade catheter use. CONCLUSIONS: Hospitals that are implementing patient safety initiatives aimed at reducing indwelling urethral catheters should be aware that the risk to the patient is not the only risk of perceived importance; implementation plans should be formulated accordingly.

Disrupted Lives: Caregivers' Experiences of In-Hospital Cardiac Arrest Survivors' Recovery 5 Years Later.

Background Survivors of in-hospital cardiac arrest (IHCA) experience ongoing physical and cognitive impairments, often requiring support from a caregiver at home afterwards. Caregivers are important in the survivor's recovery, yet there is little research specifically focused on their experiences once the survivor is discharged home. In this study, we highlight how caregivers for veteran IHCA survivors described and experienced their caregiver role, the strategies they used to fulfill their role, and the additional needs they still have years after the IHCA event. Methods and Results Between March and July 2019, semistructured telephone interviews were conducted with 12 caregivers for veteran IHCA survivors. Interviews were transcribed, and content analysis was performed. Patterns within the data were further analyzed and grouped into themes. A predominant theme of "disruption" was identified across 3 different domains including the following: (1) disruption in caregiver's life, (2) disruption in caregiver-patient relationship, and (3) disruption in caregiver's well-being. Disruption was associated with both positive and negative caregiver experiences. Strategies caregivers used and resources they felt would have helped them adjust to their caregiver role were also identified. Conclusions Caregivers for veteran IHCA survivors experienced a disruption in many facets of their lives. Caregivers felt the veterans' IHCA impacted various aspects of their lives, and they continued to need additional support in order to care for the IHCA survivor and themselves. Although some were able to procure coping strategies, such as counseling and engaging in stress-relieving activities, most indicated additional help and resources were still needed.

Outreach to facilitate return to VA care for veterans with serious mental illness: A mixed-methods evaluation of best practices.

Outreach to people with serious mental illness who are disengaged from treatment can facilitate return to care. However, little is known regarding what outreach strategies are effective. This mixed-methods evaluation assessed best practices for conducting outreach to Veterans with serious mental illness via the national Veterans Health Administration Re-Engaging Veterans with Serious Mental Illness program by comparing the strategies used by high-performing sites and low-performing sites. Quantitative data included the types and number of contact attempts used to reach Veterans. Qualitative data included interviews with clinicians from high- and low-performing sites. Results indicated making at least four contact attempts using methods of phone, certified letter, and next of kin differentiated high from low-performing facilities. Clinicians from high-performing sites also differed from low-performing sites in their expressed philosophy about outreach, demonstrated a broader array of strategies in attempting to contact Veterans, and described greater connections with others at their site, with clinicians around the country, and with national program resources. Implications of evaluation findings for outreach programs and research are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Early changes in hospital resuscitation practices during the COVID-19 pandemic.

Background: The coronavirus disease 2019 (COVID-19) pandemic resulted in many disruptions in care for patients experiencing in-hospital cardiac arrest (IHCA). We sought to identify changes made in hospital resuscitation practices during progression of the COVID-19 pandemic. Methods: We conducted a descriptive qualitative study using in-depth interviews of clinical staff leadership involved with resuscitation care at a select group of U.S. acute care hospitals in the national American Heart Association Get With The Guidelines-Resuscitation registry for IHCA. We focused interviews on resuscitation practice changes for IHCA since the initiation of the COVID-19 pandemic. We used rapid analysis techniques for qualitative data summarization and analysis. Results: A total of 6 hospitals were included with interviews conducted with both physicians and nurses between November 2020 and April 2021. Three topical themes related to shifts in resuscitation practice through the COVID-19 pandemic were identified: 1) ensuring patient and provider safety and wellness (e.g., use of personal protective equipment); 2) changing protocols and training for routine educational practices (e.g., alterations in mock codes and team member roles); and 3) goals of care and end of life discussions (e.g., challenges with visitor and family policies). We found advances in leveraging technology use as an important topic that helped institutions address challenges across all 3 themes. Conclusions: Early on, the COVID-19 pandemic resulted in many changes to resuscitation practices at hospitals placing an emphasis on enhanced safety, training, and end of life planning. These lessons have implications for understanding how systems may be better designed for resuscitation efforts.

Do Not Attempt Resuscitation Order Rates in Hospitalized Patients With Heart Failure, Acute Myocardial Infarction, Chronic Obstructive Pulmonary Disease, and Pneumonia.

Background Descriptions of do not attempt resuscitation (DNAR) orders in heart failure (HF) are limited. We describe use of DNAR orders in HF hospitalizations relative to other common conditions, focusing on race. Methods and Results This was a retrospective study of all adult hospitalizations for HF, acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), and pneumonia from 2010 to 2016 using the California State Inpatient Dataset. Using a hierarchical multivariable logistic regression model with random effects for the hospital, we identified factors associated with DNAR orders for each condition. For racial variation, hospitals were divided into quintiles based on proportion of Black patients cared for. Our cohort comprised 399 816 HF, 190 802 AMI, 192 640 COPD, and 269 262 pneumonia hospitalizations. DNAR orders were most prevalent in HF (11.9%), followed by pneumonia (11.1%), COPD (7.9%), and AMI (7.1%). Prevalence of DNAR orders did not change from 2010 to 2016 for each condition. For all conditions, DNAR orders were more common in elderly people, women, and White people with significant site-level variation across 472 hospitals. For HF and COPD, hospitalizations at sites that cared for a higher proportion of Black patients were less likely associated with DNAR orders. For AMI and pneumonia, conditions such as dementia and malignancy were strongly associated with DNAR orders. Conclusions DNAR orders were present in 12% of HF hospitalizations, similar to pneumonia but higher than AMI and COPD. For HF, we noted significant variability across sites when stratified by proportion of Black patients cared for, suggesting geographic and racial differences in end-of-life care.

It's like sending a message in a bottle: A qualitative study of the consequences of one-way communication technologies in hospitals.

OBJECTIVE: We examine how physicians and nurses use available communication technologies and identify the implications for communication and patient care based on the theory of workarounds. MATERIALS AND METHODS: We conducted a qualitative study at 4 U.S. hospitals during 2017. Researchers spent 2 weeks at each hospital conducting unit-based observation, shadowing, interviews, and focus groups with nurses and physicians. Using an iterative process, we inductively coded and thematically analyzed data to derive preliminary themes. The theory of workarounds provides an organizational lens on workarounds, consisting of 5 components: antecedents, types, effects, managerial stance, and organizational challenges of workarounds. The first 3 components of the theory helped us to organize and explain our findings. RESULTS: Communication technologies consisted of pagers and telephones. Antecedents to workarounds included one-way information flow, differential access related to differences in technology types, and technology mismatch. Types of workarounds included bypassing a variety of obstacles and substituting for unavailable resources. Direct effects of workarounds included pager fatigue, interruptions in patient care, and potential errors. DISCUSSION: One-way communication technologies created an environment where workarounds could flourish. By placing results within the context of the theory of workarounds, we extend what we know about why and how workarounds develop, and offer strategies to minimize workarounds' adverse effects. CONCLUSIONS: Through the theory of workarounds, we see that there is a trajectory to workarounds with potential consequences for clinicians and patients. Two-way communication technologies could minimize workarounds and gaps in information exchange, and reduce unnecessary interruptions and the potential for adverse events.

Using observation to better understand the healthcare context.

Despite potential to capture rich contextual information, observation remains an underutilized data collection method. This paper provides a practical guide for using observation to understand complex issues in healthcare settings. Observation is a qualitative data collection method comprised of viewing and documenting phenomena in the usual environment. Drawing on our recent work using observation to better understand personal protective equipment use among healthcare personnel, we describe when to consider collecting data via observation, how to prepare and perform observation, and how to analyze resulting data. Observation data are documented in field notes that contain detailed information about setting, participants, and activity associated with the topic of interest. Field notes can be analyzed alone or triangulated with other types of data using theoretical or conceptual frameworks or by identifying themes. Observation is a valuable data collection method for health services researchers to identify key components involved in a topic of interest, a vital step in forming relevant questions, measuring appropriate variables, and designing effective interventions. Used with other methods or alone, observation yields the detailed data needed to address context-specific factors across a wide range of healthcare research topics and settings.

Clinicians Report Barriers and Facilitators to High-Quality Ambulatory Oncology Care.

BACKGROUND: Ambulatory oncology practices treat thousands of Americans on a daily basis with high-risk and high-cost antineoplastic agents. However, we know relatively little about these diverse practices and the organizational structures influencing care delivery. OBJECTIVE: The aim of this study was to examine clinician-reported factors within ambulatory oncology practices that affect care delivery processes and outcomes for patients and clinicians. METHODS: Survey data were collected in 2017 from 298 clinicians (nurses, physicians, nurse practitioners, and physician assistants) across 29 ambulatory practices in Michigan. Clinicians provided written comments about favorable and unfavorable aspects of their work environments that affected their ability to deliver high-quality care. We conducted inductive content analysis and used the Systems Engineering Initiative for Patient Safety work system model to organize and explain our findings. RESULTS: Clinicians reported factors within all 5 work-system components of the Systems Engineering Initiative for Patient Safety model that affected care delivery and outcomes. Common themes surfaced, such as unfavorable aspects including staffing inadequacy and high patient volume, limited physical space, electronic health record usability issues, and order entry. Frequent favorable aspects focused on the skills of colleagues, collaboration, and teamwork. Some clinicians explicitly reported how work system factors were relational and influenced patient, clinician, and organizational outcomes. CONCLUSIONS: These findings show how work-system components are interactive and relational reflecting the complex nature of care delivery. IMPLICATIONS FOR NURSING PRACTICE: Data obtained from frontline clinicians can support leaders in making organizational changes that are congruent with clinician observations of practices' strengths and opportunities for improvement.

Influences of Physical Layout and Space on Patient Safety and Communication in Ambulatory Oncology Practices: A Multisite, Mixed Method Investigation.

OBJECTIVE: To examine how physical layouts and space in ambulatory oncology practices influence patient safety and clinician communication. BACKGROUND: Ambulatory oncology practices face unique challenges in delivering safe care. With increasing patient volumes, these settings require additional attention to support patient safety and efficient clinical work processes. METHODS: This study used a mixed methods design with sequential data collection. Eight ambulatory oncology practices (of 29 participating practices) participated in both the quantitative and qualitative phases. In surveys, clinicians (n = 56) reported on safety organizing and communication satisfaction measures. Qualitative data included observations and semistructured interviews (n = 46) with insight into how physical layout influenced care delivery. Quantitative analysis of survey data included descriptive and correlational statistics. Qualitative analysis used inductive and thematic content analysis. Quantitative and qualitative data were integrated using side-by-side comparison tables for thematic analysis. RESULTS: Safety organizing performance was positively correlated with clinician communication satisfaction, r(54 df) = .414, p = .002. Qualitative analyses affirmed that the physical layout affected communication around chemotherapy infusion and ultimately patient safety. After data integration, safety organizing and clinician communication were represented by two themes: visibility of patients during infusion and the proximity of clinicians in the infusion center to clinicians in the clinic where providers see patients. CONCLUSIONS: Physical layouts of ambulatory oncology practices are an important factor to promote patient safety. Our findings inform efforts to construct new and modify existing infusion centers to enhance patient safety and clinician communication.

Factors influencing physician responsiveness to nurse-initiated communication: a qualitative study.

BACKGROUND: How quickly physicians respond to communications from bedside nurses is important for the delivery of safe inpatient care. Delays in physician responsiveness can impede care or contribute to patient harm. Understanding contributory factors to physician responsiveness can provide insights to promote timely physician response, possibly improving communication to ensure safe patient care. The purpose of this study was to describe the factors contributing to physician responsiveness to text or numeric pages, telephone calls and face-to-face messages delivered by nurses on adult general care units. METHODS: Using a qualitative design, we collected data through observation, shadowing, interviews and focus groups of bedside registered nurses and physicians who worked in four hospitals in the Midwest USA. We analysed the data using inductive content analysis. RESULTS: A total of 155 physicians and nurses participated. Eighty-six nurses and 32 physicians participated in focus groups or individual interviews; we shadowed 37 physicians and nurses across all sites. Two major inter-related themes emerged, message and non-message related factors. Message-related factors included the medium nurses used to convey messages, physician preference for notification via one communication medium over another and the clarity of the message, all of which could cause confusion and thus a delayed response. Non-message related factors included trust and interpersonal relationships, and different perspectives between nurses and physicians on the same clinical issue that affected perceptions of urgency, and contributed to delays in responsiveness. CONCLUSIONS: Physician responsiveness to communications from bedside nurses depends on a complex combination of factors related to the message itself and non-message related factors. How quickly physicians respond is a multifactorial phenomenon, and strategies to promote a timely response within the context of a given situation must be directed to both groups.