Value-added care: a new way of assessing nursing staffing ratios and workload variability

OBJECTIVE: To thoroughly understand the implications of California regulatory staffing ratios on nursing units, the present study examines the relative amounts of time allocated to workload activities among registered nurses. BACKGROUND: Nursing is a synergistic, intuitive process and may not be capable of being translated into minimum patient-to-nurse ratios that work across an entire region or state. A fundamental step in evaluating the appropriateness of prescribed ratios lies in assessing how registered nurses spend their time while caring for patients. Once workload intensity is assessed, additional factors can be identified to design mandated staffing levels for acute care settings. METHODS: Variability in workload intensity was assessed using the Robert Woods Johnson Foundation "Transforming Care at the Bedside" work flow methodology approach in evaluating value-added care and assessing the amount of time nurses spent on direct care and other categorical activities. RESULTS: The results revealed a marked variation in the medical-surgical unit compared with the 2 telemetry units regarding the amount of time spent by registered nurses on value-added, necessary, and non-value-added activities, as well as variability in the amount of time that registered nurses spent on direct care, indirect care, documentation, waste, and other activities. CONCLUSION: By evaluating patient quality of care in acute care settings, we can return to a basic aspect of how nurses spend their time caring for patients-the activities that not only involve direct care but also benefit the patient.     

Nursing agency and governance: registered nurses' perceptions

AIM: To explore registered nurses' perceptions of standards of nursing practice and factors that affect nursing practice standards. BACKGROUND: Nursing governance affects nurses' ability to manage nursing practice standards. Lack of nursing professional autonomy has been associated with occupational dissatisfaction, stress, turnover and low morale, which impact upon care quality. METHOD: Grounded theory was used. Data, gathered by semistructured interviews with 142 nurses, theoretically sampled from three National Health Service hospitals were analysed using constant comparative analysis. FINDINGS: Nurses were dissatisfied with their governance over factors that they believed had most influence on nursing practice standards. Perceived lack of control over factors that affect practice standards generated dissatisfaction, frustration and demoralization. CONCLUSIONS: Nurses' perceived lack of governance over their practice requires investigation and attention if occupational dissatisfaction, stress, turnover and low morale, which impact on quality care, are to be reduced. Dissatisfaction with nursing governance indicates a need to review nurses' professional involvement in clinical governance.     

我院危重、Ⅰ级护理分级管理对护理质量的影响

目的：探讨危重、Ⅰ级病人护理分亚类管理的方法和效果。方法：拟定危重、Ⅰ级护理病人的亚类标准，对住院病人中危重和Ⅰ级护理病人进行质量观察与管理。结果：危重、Ⅰ级护理病人护理分亚类管理后，基础护理工作量、护士长的访视率和护理质量检查结果均有较大的提升。结论：危重、Ⅰ级护理病人的护理进行亚类管理可以提升护理工作质量，调动护士的积极性，使护理人力资源的管理以病人需求为依据，使有限的护士资源得到充分的利用。     

Are nurses’ assessments of their workload affected by non‐patient factors? An analysis of the RAFAELA system

Aims To identify (1) the contribution of non‐patient factors to patient classification systems and (2) the explanatory power of nursing care intensity and non‐patient factors to Professional Assessment of Optimal Nursing Care Intensity Level workload. Background In the Rainio, Fagerström and Rauhala (RAFAELA) patient classification system, nursing care intensity per nurse is measured daily by the Oulu Patient Classification/Qualisan instrument. The optimal nursing care intensity is determined using Professional Assessment of Optimal Nursing Care Intensity Level instrument. However, nurses’ workload may be affected by factors other than nursing care intensity. Therefore, RAFAELA contains 12 non‐patient questions. Methods A retrospective study of all 22 somatic wards of a secondary healthcare hospital in Finland. Results Non‐patient questions were answered in 26% of 4870 questionnaires. They added to workload in 62%. Eight questions were grouped into four factors: administration; staff resources and mental stress; co‐operation within and between units. The explanatory value between Oulu Patient Classification/Qualisan and Professional Assessment of Optimal Nursing Care Intensity Level had a median of 0.45. Including the non‐patient questions raised it to 0.55. Conclusions Non‐patient factors affect the nurses’ assessments of their workload, but less than nursing care intensity. They contribute valuable information on the functioning and problems of wards.     

Calling all nurses—Now is the time to take action on improving the quality of care in nursing homes

For a number of decades, nurses have raised concerns about nursing-related issues in nursing homes (NH) such as inadequate registered nurse (RN) staffing, insufficient RN and advanced practice registered nurse (APRN) gerontological expertise, and lack of RN leadership competencies. The NASEM Committee on the Quality of Care in Nursing Homes illuminated the long-standing issues and concerns affecting the quality of care in nursing homes and proposed seven goals and associated recommendations intended to achieve the Committee's vision: Nursing home residents receive care in a safe environment that honors their values and preferences, addresses goals of care, promotes equity, and assesses the benefits and risks of care and treatments. This paper outlines concrete and specific actions nurses and nursing organizations can take to ensure the recommendations are implemented     

Development and Validation of the Ambulance Nurse Competence Scale

IntroductionIn recent decades, major competency shifts have taken place in prehospital care in Sweden because staffing ambulances with registered/specialized nurses has become a priority. The aim of this study was to develop and validate a new instrument to measure the self-reported professional competency of specialist ambulance nursing students and registered/specialist nurses working in prehospital care.MethodsThis study used a quantitative cross-sectional design to evaluate psychometric properties of a new instrument. The sample included 179 registered/specialist ambulance nurses and 34 specialist ambulance nursing students.ResultsThe analyses resulted in the Ambulance Nurse Competence (ANC) scale, consisting of 43 items and covering 8 factors: Nursing Care (n = 8), Value-based Nursing Care (n = 5), Medical Technical Care (n = 5), Care Environment’s Community (n = 4), Care Environment’s Serious Events (n = 8), Leadership Management (n = 3), Supervision and Professional Conduct (n = 4), and Research and Development (n = 6). All factors except Leadership Management achieved a Cronbach’s alpha value greater than 0.71, explaining 59.62% of the total variance.DiscussionThe ANC scale was systematically tested and showed satisfactory psychometrical properties. The ANC scale can be used in the education programs of future registered/specialist ambulance nurses as a tool for self-reflected learning and could also be of potential use in identifying competence gaps in registered/specialist ambulance nurses, which could direct the design of introductory programs. The scale could also be used as an outcome measure together with other instruments.     

Nursing work life in acute care

The purpose of this project was to explore how acute care nurses in a midwestern state rate the quality of their work life. A simple random sample of 1500 registered nurses was surveyed. Data were collected using Brooks' Quality of Nursing Worklife Survey (Brooks BA. Development of an Instrument to Measure Quality of Nursing Work Life [unpublished doctoral dissertation]. Chicago: University of Illinois at Chicago; 2001). Findings suggested that nursing workload was too heavy, and there was not enough time todo the job well. This study revealed that there remain ongoing and fundamental work life concerns for staff nurses that the profession has neither addressed nor resolved in any meaningful, long-term way.     

Clinical major option: a model for implementing critical care nursing into baccalaureate preparation

What was initiated as a directive from a provincial government in an attempt to increase the number of critical care nurses has evolved into an exciting educational opportunity for many nurses and student nurses in the year 2000. Between 1993 and 1997 there has been significant downsizing of acute care beds across Canada (Code Blue: Critical Care Nursing in Nova Scotia, 1998). At the same time patient acuity has increased, due to shorter hospital stays, and the number of nurses working full-time has decreased with the increased use of casual nurses. Several studies at both the provincial and national levels report current and future shortages of specialized nurses (emergency, critical care and perioperative). It is expected that this shortage will continue into the future, a shortage that is driven by technological advances, as well as an aging general and nursing population. Continued shortages of these acute care nurses will result in fierce competition for skilled nurses as well as aggressive recruitment and retention strategies (Code Blue: Critical Care Nursing in Nova Scotia, 1998). It is generally agreed within the nursing community that specialty nurses in critical care require a unique body of knowledge that is not acquired in a basic undergraduate nursing program (Fitzsimmons, Hadley, & Shively, 1999). This specialized knowledge can be gained informally through experience; however, it is largely developed in additional formal education programs. The purpose of this article is to outline a strategy for the delivery of specialty education at three educational levels in acute care nursing with three streams: emergency, critical care and perioperative nursing. This clinical major option is to be delivered in partnership among the Queen Elizabeth Hospital II, the Health Science Centre and Dalhousie University School of Nursing, Halifax, Nova Scotia, Canada. This model of offering specialty education in university preparation could be a template for preparing nurses in the new millennium.     

Preparing nurses for practice: a phenomenological study of the new graduate in Australia

Aims. To explore the expectations of final year nursing students before they start employment and to describe the experiences of newly graduated nurses during their first six months of employment as registered nurses. Background. Nursing shortages are at crisis point world wide with registered nurses leaving the profession at a high rate and changing occupations. Thus, there is a need to reflect on new graduate nurses experiences in relation to retention and support. Design. Husserl’s phenomenological approach was used to gain insight and understanding into the lived experiences of new graduate nurses. Methods. Students enrolled in a Bachelor of Nursing programme at an Australian University were interviewed in their final semester and during employment in the hospital setting. Semi‐structured interviews were used to gather data from 13 participants. Data were collected at three intervals: prior to commencing employment, one month and six months postemployment and the results were analysed thematically. Results. As students, the participants held positive perceptions surrounding their impending role as a registered nurse and what it would encompass. However, after one month of employment, it became apparent that nursing comprised of a culture that embraced cliques which excluded them. The graduates were unprepared for ‘bitchiness’ and the limited amount of assistance with unfamiliar tasks they received from registered nurses. Participants also found rotating to different wards recreated the feelings they experienced on commencing employment. Conclusions. Nursing curricula should prepare new graduates for foreseeable stressors and oppressive practices so that graduates can become proactive in preventing and responding to factors such as silence and aggression. Moreover, nursing courses need to ensure that socialisation issues are addressed to assist in the eradication of oppressive practices. Finally, organisations need to address socialisation issues such as hostility within the workplace to address the attrition of new graduates from the profession. Relevance to clinical practice. Individuals in clinical practice settings need to be cognisant of the significant role that experienced registered nurses and nurse unit managers occupy in the socialisation of new graduate nurses. Additionally, there needs to be increased awareness that nursing culture can influence recruitment and retention of new graduates. Further, health care organisations need to evaluate the benefits of new graduates rotating through clinical areas in the first 12 months of employment.     

Classification of nursing interventions for care of the integument

The Classification of Nursing Interventions research team at The University of Iowa, College of Nursing is building a taxonomy of nursing interventions that will include all of the direct care treatment activities that nurses perform on behalf of patients. This report describes the study in which 12 nursing interventions and their associated activities for care of the integument were extracted from a large database and validated through a two-round Delphi survey. Using an adaptation of Fehring's model for determining diagnostic content validity of nursing diagnoses, a definition, critical activities, and supporting activities were developed for each of the following interventions: Bathing, Bedrest Care, Hair Care, Nail Care, Oral Health Maintenance, Oral Health Promotion, Oral Health Restoration, Positioning, Pressure Management, Skin Care--Topical Treatments, Skin Surveillance, and Wound Care. Further research is needed to validate supporting activities and to continue classifying interventions and activities that nurses use in treating impaired skin integrity (potential and actual) and altered oral mucous membrane integrity (potential and actual).     

Classification of Nursing Interventions for Care of the Integument

The Classification of Nursing Interventions research team at The University of Iowa, College of Nursing is building a taxonomy of nursing interventions that will include all of the direct care treatment activities that nurses perform on behalf of patients. This report describes the study in which 12 nursing interventions and their associated activities for care of the integument were extracted from a large database and validated through a two-round Delphi survey. Using an adaptation of Fehring's model for determining diagnostic content validity of nursing diagnoses, a definition, critical activities, and supporting activities were developed for each of the following interventions: Bathing, Bedrest Care, Hair Care, Nail Care, Oral Health Maintenance, Oral Health Promotion, Oral Health Restoration, Positioning, Pressure Management, Skin Care–Topical Treatments, Skin Surveillance, and Wound Care. Further research is needed to validate supporting activities and to continue classifying interventions and activities that nurses use in treating impaired skin integrity (potential and actual) and altered oral mucous membrane integrity (potential and actual).     

Standards for nurse staffing in critical care units determined by: The British Association of Critical Care Nurses,The Critical Care Networks National Nurse Leads,Royal College of Nursing Critical Care and In‐flight Forum

Background: Since 1967 the gold standard for nurse staffing levels in intensive care and subsequently critical care units has been one nurse for each patient. However, critical care has changed substantially since that time and in recent years this standard has been challenged. Previously individual nursing organisations such as the British Association of Critical Care Nurses (BACCN) and the Royal College of Nursing have produced guidance on staffing levels for critical care units. This paper represents the first time all three UK Professional Critical Care Associations have collaborated to produce standards for nurse staffing in critical care units. These standards have evolved from previous works and are endorsed by BACCN, Critical Care Networks National Nurse Leads Group (CC3N) and the Royal College of Nursing Critical Care and In‐flight Forum. Aim: The aim of this paper is to provide an overview of the much more detailed document ‘Standards for Nurse Staffing in Critical Care’, which can be found on the BACCN web site at www.baccn.org.uk . The full paper has extensively reviewed the evidence, whereas this short paper provides essential detail and the 12 standard statements. Methods: Representation was sort from each of the critical care associations. The authors extensively reviewed the literature using the terms: (1) critical care nursing, (2) nursing, (3) nurse staffing, (4) skill mix, (5) adverse events, (6) health care assistants and critical care, (7) length of stay, (8) critical care, (9) intensive care, (10) technology, (11) infection control. Outcomes: Comprehensive review of the evidence has culminated in 12 standard statements endorsed by BACCN, CC3N and the Royal College of Nursing Critical Care and In‐flight Forum. The standards act as a reference for nursing staff, managers and commissioners associated with critical care to provide and support safe patient care. Conclusion: The review of the evidence has shown that the contribution of nursing can be difficult to measure and consequently support nurse staffing ratios. However, there is a growing body of evidence which associates higher number of registered nursing staff to patient ratio relates to improved safety and better outcomes for patients. The challenge for nurses is to produce accurate and meaningful outcome measures for nursing and collect data that accurately reflect the input of nursing on patient outcomes and safety.     

The patient lock model©: a continuum of care

Nursing as a profession has the responsibility to society to protect and promote the health of individuals and communities. The intent of this conceptual model is to center the patient in his or her environment while allowing qualified, expert health professionals to provide timely, effective, cost-efficient care within their levels of competence and expertise. Significant shortages of registered nurses and other health professionals delay timely provision of quality care and affect the effectiveness of care. Care management issues are due to the complexity of individual patient's health care needs, limited access to providers, inability to afford treatment, and delay in seeking care. These challenges to the system slow efficiency in the provision of care across all settings. In presenting this conceptual model, there will be a review of nursing and the internal and external forces that affect the profession. This is an initial development phase of the model: The Patient Lock Model.     

Rationing home-based nursing care: professional ethical implications

The purpose of this study was to investigate nurses' decisions about priorities in home-based nursing care. Qualitative research interviews were conducted with 17 nurses in home-based care. The interviews were analyzed and interpreted according to a hermeneutic methodology. Nurses describe clinical priorities in home-based care as rationing care to mind the gap between an extensive workload and staff shortages. By organizing home-based care according to tight time schedules, the nurses' are able to provide care for as many patients as possible. Furthermore, legal norms set boundaries for clinical priority decisions, resulting in marginalized care. Hence, rationing care jeopardizes important values in the nurse-patient relationship, in particular the value of individualized and inclusive nursing care. The findings are highly relevant for clinical practice, since they have major implications for provision of nursing care. They revive debates about the protection of values and standards of care, and nurses' role and responsibility when resources are limited.     

A study of transition: the new nurse graduate at 3 months

BACKGROUND: Nursing shortages, increased patient acuity, and early discharges have increased demands on newly graduated nurses. At the same time, financial constraints have curtailed orientation programs. METHOD: Open-ended interviews were conducted with 11 nurses employed in acute care settings at 3 months following graduation. RESULTS: New nurses defined their work as a set of skills and attended to procedural aspects of care. Most lacked the capacity for helpful communications with patients and families. They relied heavily on routines learned from experienced nurses. CONCLUSION: At 3 months, new graduates are apprehensive about their work. Approaches to nursing are largely procedural and guided by the routines of senior colleagues.     

Nursing the dying within a generalist caseload: a focus group study of district nurses

BACKGROUND: Community nurses (members of UK District Nursing teams) have a key role in the provision of palliative care in the community in the UK. However, their views about delivering palliative care within their generalist workload have not been assessed. OBJECTIVES: To explore community nurses' perceptions of their palliative care role, and their provision of such care within the context of their wider generalist workload. DESIGN: Focus group study. SETTING: Four Primary Care Trusts in London, UK. PARTICIPANTS: A purposive sample of 51 community nurses. METHODS: Nine focus groups (four to seven participants in each) were conducted between 2003 and 2004. Data were analysed using the framework approach. RESULTS: We identified five broad themes. Community nurses felt they had a central role in the provision of palliative care to patients at home. Many felt this role was not recognised by other health care professionals and managers. Palliative care was identified as unpredictable and time-consuming within a pressurized context characterised by staff shortages and consequent lack of time. Whilst rewarding, palliative care took its toll on nurses' emotions, compounded by a perceived lack of formal support. Finally, undertaking palliative within a generalist workload created additional pressures for community nurses. CONCLUSIONS: The integration of palliative care into routine generalist caseloads generated workload stresses in time and emotion. Community nurses felt their palliative care role and its impact on workload was not adequately acknowledged. Palliative care specific support mechanisms and ways of working may be necessary to meet patients' and professionals' expectations of effective, compassionate care at the end of life.     

我院精神科优质护理服务实践与成效

目的:总结在精神科开展优质护理服务的实践经验和成效。方法:该院对精神科开展优质护理服务的情况进行回顾性总结。结果:实施优质护理服务后住院病人护理满意度由原来的93.2%提升到99.5%,护士的职业价值感提高了。结论:优质护理服务能提高护理技能水平和质量,增强护士服务意识,提高病人满意度。