The relationship between inpatient cardiac surgery mortality and nurse numbers and educational level: Analysis of administrative data

Background

In most multicenter studies that examine the relationship between nurse staffing and patient safety, nurse-staffing levels are measured per hospital. This can obscure relationships between staffing and outcomes at the unit level and lead to invalid inferences.

Objective

In the present study, we examined the association between nurse-staffing levels in nursing units that treat postoperative cardiac surgery patients and the in-hospital mortality of these patients.

Design-setting-participants

We illustrated our approach by using administrative databases (Year 2003) representing all Belgian cardiac centers (n = 28), which included data from 58 intensive care and 75 general nursing units and 9054 patients.

Methods

We used multilevel logistic regression models and controlled for differences in patient characteristics, nursing care intensity, and cardiac procedural volume.

Results

Increased nurse staffing in postoperative general nursing units was significantly associated with decreased mortality. Nurse staffing in postoperative intensive care units was not significantly associated with in-hospital mortality possibly due to lack of variation in ICU staffing across hospitals.

Conclusion

This study, together with the international body of evidence, suggests that nurse staffing is one of several variables influencing patient safety. These findings further suggest the need to study the impact of nurse-staffing levels on in-hospital mortality using nursing-unit-level specific data.     

The impact of the nursing hours per patient day (NHPPD) staffing method on patient outcomes: A retrospective analysis of patient and staffing data

Background

In March 2002 the Australian Industrial Relations Commission ordered the introduction of a new staffing method - nursing hours per patient day (NHPPD) - for implementation in Western Australia public hospitals. This method used a “bottom up” approach to classify each hospital ward into one of seven categories using characteristics such as patient complexity, intervention levels, the presence of high dependency beds, the emergency/elective patient mix and patient turnover. Once classified, NHPPD were allocated for each ward.

Objectives

The objective of this study was to determine the impact of implementing the NHPPD staffing method on 14 nursing-sensitive outcomes: central nervous system complications, wound infections, pulmonary failure, urinary tract infection, pressure ulcer, pneumonia, deep vein thrombosis, ulcer/gastritis/upper gastrointestinal bleed, sepsis, physiologic/metabolic derangement, shock/cardiac arrest, mortality, failure to rescue and length of stay.

Design and setting

The research design was an interrupted time series using retrospective analysis of patient and staffing administrative data from three adult tertiary hospitals in metropolitan Perth over a 4-year period.

Sample

All patient records (N = 236,454) and nurse staffing records (N = 150,925) from NHPPD wards were included.

Results

The study found significant decreases in the rates of nine nursing-sensitive outcomes when examining hospital-level data following implementation of NHPPD; mortality, central nervous system complications, pressure ulcers, deep vein thrombosis, sepsis, ulcer/gastritis/upper gastrointestinal bleed shock/cardiac arrest, pneumonia and average length of stay. At the ward level, significant decreases in the rates of five nursing-sensitive outcomes; mortality, shock/cardiac arrest, ulcer/gastritis/upper gastrointestinal bleed, length of stay and urinary tract infections occurred.

Conclusions

The findings provide evidence to support the continuation of the NHPPD staffing method. They also add to evidence about the importance of nurse staffing to patient safety; evidence that must influence policy. This study is one of the first to empirically review a specific nurse staffing method, based on an individual assessment of each ward to determine staffing requirements, rather than a “one-size-fits-all” approach.     

Development and validation of nursing resource weights for the Belgian Nursing Minimum Dataset in general hospitals: a Delphi questionnaire survey approach

Background

Internationally, nursing is not well represented in hospital financing systems. In Belgium a nursing weight system exists to adjust budget allocation for differences in nurse staffing requirements, but there is a need for revision. Arguments include the availability of a nursing minimum dataset and the adverse consequences of the current historically based nursing weight system.

Objectives

The development and validation of nursing resource weights for the revised Belgium nursing minimum dataset (NMDS).

Design

Two independent cross sectional Delphi—surveys.

Setting and participants

A convenience sample of 222 head nurses from 69 Belgian hospitals participated in the cross sectional survey methods. To assess validity 112 patient case records from 61 nursing wards of 35 Belgian general hospitals representing general, surgical, pediatric, geriatric and intensive care were selected.

Methods

Nursing resource weights were constructed based on Delphi survey results by NMDSII intervention. The patient case Delphi survey results were used as the primary source for validation. A series of additional validation measures were calculated, based on the different patient classification systems. Finally, three validated nursing resource weighting systems were compared to the constructed NMDSII weighting system: the use of ‘Closon’, ‘Ghent’ and WIN weights.

Results

A coherent set of nursing resource weights was developed. The comparison of nurse resource weights, based on the survey per NMDS intervention versus the survey on patient cases, yielded high correlations: r = 0.74 to r = 0.97 (p < 0.01) between three case rating questions, as an indication of reliability in terms of internal consistency, and r = 0.90 (p < 0.01) between summed intervention weights and patient case weights, as an indication of criterion validity in terms of concurrent validity. Other concurrent validity measures based on summed intervention weights versus patient classification dependency weights showed a correlation ranging from r = 0.14 to r = 0.74. The correlation of summed intervention weights with the Closon, Ghent and WIN weights ranged from r = 0.93 to r = 0.96 (p < 0.01), as a third indication of concurrent validity.

Conclusions

A system of valid nursing resource weights has been developed. The system should be further validated within an international context.     

The impact of Nursing Rounds on the practice environment and nurse satisfaction in intensive care: pre-test post-test comparative study

Background

Factors previously shown to influence patient care include effective decision making, team work, evidence based practice, staffing and job satisfaction. Clinical rounds have the potential to optimise these factors and impact on patient outcomes, but use of this strategy by intensive care nurses has not been reported.

Objectives

To determine the effect of implementing Nursing Rounds in the intensive care environment on patient care planning and nurses’ perceptions of the practice environment and work satisfaction.

Design

Pre-test post-test 2 group comparative design.

Settings

Two intensive care units in tertiary teaching hospitals in Australia.

Participants

A convenience sample of registered nurses (n = 244) working full time or part time in the participating intensive care units.

Methods

Nurses in participating intensive care units were asked to complete the Practice Environment Scale-Nursing Work Index (PES-NWI) and the Nursing Worklife Satisfaction Scale (NWSS) prior to and after a 12 month period during which regular Nursing Rounds were conducted in the intervention unit. Issues raised during Nursing Rounds were described and categorised. The characteristics of the sample and scale scores were summarised with differences between pre and post scores analysed using t-tests for continuous variables and chi-square tests for categorical variables. Independent predictors of the PES-NWI were determined using multivariate linear regression.

Results

Nursing Rounds resulted in 577 changes being initiated for 171 patients reviewed; these changes related to the physical, psychological - individual, psychological - family, or professional practice aspects of care. Total PES-NWI and NWSS scores were similar before and after the study period in both participating units. The NWSS sub-scale of interaction between nurses improved in the intervention unit during the study period (pre - 4.85 ± 0.93; post - 5.36 ± 0.89, p = 0.002) with no significant increase in the control group. Factors independently related to higher PES-NWI included intervention site and less years in critical care (p < 0.05).

Conclusions

Implementation of Nursing Rounds within the intensive care environment is feasible and is an effective strategy for initiating change to patient care. Application and testing of this strategy, including identification of the most appropriate methods of measuring impact, in other settings is needed to determine generalisability.     

The relationship between nurse staffing and quality of care in nursing homes: a systematic review

Background

Nursing homes have an important role in the provision of care for dependent older people. Ensuring quality of care for residents in these settings is the subject of ongoing international debates. Poor quality care has been associated with inadequate nurse staffing and poor skills mix.

Objectives

To review the evidence-base for the relationship between nursing home nurse staffing (proportion of RNs and support workers) and how this affects quality of care for nursing home residents and to explore methodological lessons for future international studies.

Design

A systematic mapping review of the literature.

Data sources

Published reports of studies of nurse staffing and quality in care homes.

Review methods

Systematic search of OVID databases. A total of 13,411 references were identified. References were screened to meet inclusion criteria. 80 papers were subjected to full scrutiny and checked for additional references (n = 3). Of the 83 papers, 50 were included. Paper selection and data extraction completed by one reviewer and checked by another. Content analysis was used to synthesise the findings to provide a systematic technique for categorising data and summarising findings.

Results

A growing body of literature is examining the relationships between nurse staffing levels in nursing homes and quality of care provided to residents, but predominantly focuses on US nursing facilities. The studies present a wide range and varied mass of findings that use disparate methods for defining and measuring quality (42 measures of quality identified) and nurse staffing (52 ways of measuring staffing identified).

Conclusions

A focus on numbers of nurses fails to address the influence of other staffing factors (e.g. turnover, agency staff use), training and experience of staff, and care organisation and management. ‘Quality’ is a difficult concept to capture directly and the measures used focus mainly on ‘clinical’ outcomes for residents. This systematic mapping review highlights important methodological lessons for future international studies and makes an important contribution to the evidence-base of a relationship between the nursing workforce and quality of care and resident outcomes in nursing home settings.     

The relationship between nurse staffing and patient outcomes: a case study

Background

Research has shown a direct relationship between staffing levels and patient outcomes for specific nurse-sensitive indicators, with lower patient to nurse ratios (i.e. less patients per nurse) associated with better outcomes.

Objectives

To explore the relationship between nurse staffing characteristics (the nursing hours worked by permanent and temporary staff and nurse hours per patient day) and patient outcomes: pressure sores, patient falls, upper gastrointestinal bleed, pneumonia, sepsis, shock and deep vein thrombosis.

Design

A case study using retrospective hospital data, at ward level.

Setting

A tertiary cardio-respiratory NHS Trust in England, comprising two hospitals.

Participants

All patients, including day cases, who were admitted to either hospital as an in-patient over 12 months.

Methods

Data were extracted from corporate hospital systems. The clinical areas were categorised as lower dependency, i.e. wards, or critical care which included ICU and high dependency units. The relationship between nurse staffing characteristics and patient outcomes was assessed using either a Poisson or negative binomial regression model as appropriate. We sought to establish whether the outcomes were affected by the nurse hours per patient day, the permanent nurse hours worked as a percentage of the total hours, and the permanent nurse hours worked as a percentage of the permanent and bank hours combined.

Results

In the lower dependency category wards there was only a weak association demonstrated between nurse staffing and the majority of the outcomes. The results from the high dependency critical care areas showed few significant results with only the rate of sepsis being significantly reduced as the ratio of permanent staff hours increased.

Conclusions

The study demonstrated the possibility of using existing hospital data to examine the relationship between nurse staffing and patient outcomes, however the associations found were weak and did not replicate reliably the findings from previous work.     

Bed-to-nurse ratios, provision of basic nursing care, and in-hospital and 30-day mortality among acute stroke patients admitted to an intensive care unit: Cross-sectional analysis of survey and administrative data

Background

The literature reports inconsistent evidence of the effects of nurse staffing on mortality despite continuing examination of this association.

Objective

To examine differences in provision of basic nursing care and in-hospital and 30-day mortality by nurse staffing of ICUs and general wards among acute stroke patients admitted to ICUs during hospitalization.

Design

A cross-sectional design that included survey and administrative data.

Settings and participants

The study included 6957 patients with hemorrhagic and ischemic stroke who were admitted to ICUs of 185 Korean hospitals.

Methods

Nurse staffing of ICUs and general wards was graded based on the bed-to-nurse ratios of each hospital. Provision of basic care was measured by whether five activities, such as bathing and feeding assistance, were fully provided by ICU nursing staff without delegation to patient families. Hospitals were categorized into low, middle, and high mortality groups for in-hospital and 30-day mortality based on z-scores that indicated standardized difference between observed and expected mortality after controlling for patient characteristics.

Results

In 83.8% of hospitals, basic care was provided fully by ICU nursing staff. The overall in-hospital and 30-day mortality rates were 21.9 and 25.4%, respectively. Hospitals with higher ICU staffing were more likely to fully provide basic care. Better ICU and general staffing tended to be associated with lower in-hospital and 30-day mortality. Compared with in-hospital mortality, 30-day mortality had a more distinct increase as nurse staffing became worse.

Conclusion

The findings provide evidence that nurse staffing may impact provision of basic care and patient mortality and suggest the need for policies for providing adequate nurse staffing.     

A review of workload measures: a context for a new staffing methodology in Western Australia

Objectives

This paper critically reviews various approaches to measuring nursing workload to provide a context for the introduction of a different approach to staffing. Nurse hours per patient day (NHPPD), which classifies wards into various groupings, was applied to all public hospitals in Western Australia.

Results

This method was introduced in response to industrial imperatives to determine reasonable workloads for nurses. As a result, the limited evaluation has focused only on the impact on workload management; reporting target versus actual nurse hours, staff retention and nurse feedback. This method improved ward staffing significantly without imposing restrictive nurse-to-patient ratios and facilitates the use of professional discretion within ward groupings to enable diversion of resources to match reported acuity changes.

Conclusion

While successful in attracting nurses back into hospitals and increasing nursing numbers, there is no empirical evidence of the impact this method had on patient outcomes or whether the guiding principles used in the development of this method are appropriate. The model would also benefit from further refinement to be more sensitive to direct acuity measures.     

Nurse specialty subcultures and patient outcomes in acute care hospitals: A multiple-group structural equation modeling

Background

Hospital organizational culture is widely held to matter to the delivery of services, their effectiveness, and system performance in general. However, little empirical evidence exists to support that culture affects provider and patient outcomes; even less evidence exists to support how this occurs.

Objectives

To explore causal relationships and mechanisms between nursing specialty subcultures and selected patient outcomes (i.e., quality of care, adverse patient events).

Method

Martin's differentiation perspective of culture (nested subcultures within organizations) was used as a theoretical framework to develop and test a model. Hospital nurse subcultures were identified as being reflected in formal practices (i.e., satisfactory salary, continuing education, quality assurance program, preceptorship), informal practices (i.e., autonomy, control over practice, nurse-physician relationships), and content themes (i.e., emotional exhaustion). A series of structural equation models were assessed using LISREL on a large nurse survey database representing four specialties (i.e., medical, surgical, intensive care, emergency) in acute care hospitals in Alberta, Canada.

Results

Nursing specialty subcultures differentially influenced patient outcomes. Specifically, quality of care (a) was affected by nurses’ control over practice, (b) was better in intensive care than in medical specialty, and (c) was related to lower adverse patient events; nurses in intensive care and emergency specialties reported fewer adverse events than did their counterparts in medical specialties.

Conclusions

Understanding the meaning of subcultures in clinical settings would influence nurses and administrators efforts to implement clinical change and affect outcomes. More research is needed on nested subcultures within healthcare organizations for better understanding differentiated subspecialty effects on complexity of care and outcomes in hospitals.     

Front-line management, staffing and nurse-doctor relationships as predictors of nurse and patient outcomes. a survey of Icelandic hospital nurses

Objective

To investigate aspects of nurses’ work environments linked with job outcomes and assessments of quality of care in an Icelandic hospital.

Background

Prior research suggests that poor working environments in hospitals significantly hinder retention of nurses and high quality patient care. On the other hand, hospitals with high retention rates (such as Magnet hospitals) show supportive management, professional autonomy, good inter-professional relations and nurse job satisfaction, reduced nurse burnout and improved quality of patient care.

Methods

Cross-sectional survey of 695 nurses at Landspitali University Hospital, Reykjavík. Nurses’ work environments were measured using the nursing work index—revised (NWI—R) and examined as predictors of job satisfaction, the Maslach burnout inventory (MBI) and nurse-assessed quality of patient care using linear and logistic regression approaches.

Results

An Icelandic adaptation of the NWI—R showed a five-factor structure similar to that of Lake (2002). After controlling for nurses’ personal characteristics, job satisfaction, emotional exhaustion and nurse rated quality of care were found to be independently associated with perceptions of support from unit-level managers, staffing adequacy, and nurse-doctor relations.

Conclusions

The NWI—R measures elements of hospital nurses’ work environments that predict job outcomes and nurses’ ratings of the quality of patient care in Iceland. Efforts to improve and maintain nurses’ relations with nurse managers and doctors, as well as their perceptions of staffing adequacy, will likely improve nurse job satisfaction and employee retention, and may improve the quality of patient care.     

Development and validation of an instrument to measure nurse-patient bonding

Background

Most instruments on nurse-patient relationship determine the caring behavior of the nurse, but have minimal consideration of the patient's role in the interaction. Moreover, it is the patients that complete many of those instruments, thus leaving out the perspective of the nurse. There is then a need to account for the contributions that both the nurse and the patient bring into their encounter where bonding is formed.

Objective

This study aimed to develop and validate an instrument that determines the degree of bonding between nurse and patient based on their openness to each other and their engagement in patient care.

Settings

Data were collected from nurses and patients in the wards of four public and private tertiary hospitals in Manila, Philippines, where most Filipino nurses render care to patients before getting employed in other countries.

Participants

A total of 420 nurses and patients (i.e., 210 dyads) participated in this research conducted in 2008. Most of the nurses were young females with beginning clinical experience, while the patients had a wider age range with the majority having no college education and no employment.

Methods

The Nurse-Patient Bonding Instrument (NPBI), which dimensions were generated from qualitative observations and interviews, and corroborated by literature, was validated at the bedside setting. To determine interrater reliability, two trained raters unobtrusively observed actual nurse-patient interactions and ticked on the NPBI behavioral indicators of openness and engagement. Construct validity was established using known-groups technique. Moreover, bonding score was correlated with patient satisfaction for predictive validity.

Results

Reliability ranged from r = .80 to .95 (p < .01). Factor analysis demonstrated that the subscale scores of patient openness, nurse openness, patient engagement, and nurse engagement all loaded on one factor, the bonding factor, demonstrating a unified structure of the NPBI. Nurses and patients had higher bonding scores in interactions of longer duration than shorter duration, controlling for number of previous encounters. This provided evidence for construct validity using known-groups technique. The NPBI was likewise shown to distinguish groups based on age, education, and civil status. Patient satisfaction correlated positively with bonding score, providing evidence suggestive of the predictive validity of the NPBI.

Conclusion

The NPBI was shown to be a reliable and valid tool for assessing nurse-patient bonding, and can possibly predict patient satisfaction. The openness and engagement of nurse and patient were demonstrated to result in a structure, a nurse-patient dyad. This finding invites further investigations on the characteristics and development of this dyad.     

Practice environments and their associations with nurse-reported outcomes in Belgian hospitals: development and preliminary validation of a Dutch adaptation of the Revised Nursing Work Index

Aim

To study the relationship between nurse work environment, job outcomes and nurse-assessed quality of care in the Belgian context.

Background

Work environment characteristics are important for attracting and retaining professional nurses in hospitals. The Revised Nursing Work Index (NWI-R) was originally designed to describe the professional nurse work environment in U.S. Magnet Hospitals and subsequently has been extensively used in research internationally.

Method

The NWI-R was translated into Dutch to measure the nurse work environment in 155 nurses across 13 units in three Belgian hospitals. Factor analysis was used to identify a set of coherent subscales. The relationship between work environments and job outcomes and nurse-assessed quality of care was investigated using logistic and linear regression analyses.

Results

Three reliable, consistent and meaningful subscales of the NWI-R were identified: nurse-physician relations, nurse management at the unit level and hospital management and organizational support. All three subscales had significant associations with several outcome variables. Nurse-physician relations had a significant positive association with nurse job satisfaction, intention to stay the hospital, the nurse-assessed unit level quality of care and personal accomplishment. Nurse management at the unit level had a significant positive association with the nurse job satisfaction, nurse-assessed quality of care on the unit and in the hospital, and personal accomplishment. Hospital management and organizational support had a significant positive association with the nurse-assessed quality of care in the hospital and personal accomplishment. Higher ratings of nurse-physician relations and nurse management at the unit level had significant negative associations with both the Maslach Burnout Inventory emotional exhaustion and depersonalization dimensions, whereas hospital management and organizational support was inversely associated only with depersonalization scores.

Conclusion

A Dutch version of the NWI-R questionnaire produced comparable subscales to those found by many other researchers internationally. The resulting measures of the professional practice environment in Belgian hospitals showed expected relationships with nurse self-reports of job outcomes and perceptions of hospital quality.     

Prevalence of deep tissue injuries in hospitals and nursing homes: Two cross-sectional studies

Background

Deep tissue injuries are severe damages underneath the intact skin caused by long-endured, unrelieved pressure or shear forces. Empirical evidence regarding the magnitude of this health problem is limited.

Objective

Investigation of the prevalence, characteristics of persons affected and identification of the most affected body locations.

Design

Two cross-sectional studies in 2008 and 2009.

Settings

Nursing homes and hospitals throughout Germany.

Participants

6919 (year 2008) and 8451 (year 2009) hospital patients and nursing home residents.

Methods

Trained nurses conducted full skin assessments and collected demographic data based on written data collection forms. The Braden scale was used to measure pressure ulcer risk.

Results

Pressure ulcer prevalence including grades 1-4 and deep tissue injuries ranged from 4.3% (95% CI 3.8-4.9) in nursing homes to 7.1% (95% CI 6.2-8.0) in hospitals. Point prevalence rates of deep tissue injuries were 0.4% (95% CI 0.2-0.5) in hospitals and less than 0.1% in nursing homes. In total, 30 persons were affected by 38 deep tissue injuries. The mean age was 73.4 and the mean Braden scale sum score was 12.8. The most frequently affected anatomic sites were heels (n = 24) and ischial tuberosities (n = 6).

Conclusions

Nurses must be aware that deep tissue injuries exist in clinical practice. Deep tissue injuries seem to be more common in hospitals than in nursing homes and heels are more prone to this kind of injuries than other body sites. Whenever such a lesion is suspected, optimal pressure relief is required to enable the affected tissue to heal.     

Evaluating the effect of the new incentive system for high-risk pressure ulcer patients on wound healing and cost-effectiveness: A cohort study

Objective

To evaluate the effectiveness and cost-effectiveness of new incentive system for pressure ulcer management, which focused on skilled nurse staffing in terms of rate of healing and medical costs.

Design, setting and participants

A prospective cohort study included two types of groups: 39 institutions, which introduced the new incentive system, and 20 non-introduced groups (control). Sixty-seven patients suffering from severe pressure ulcers in the introduced group and 38 patients in the non-introduced group were included. Wound healing and medical costs were monitored weekly for three weeks by their skilled nurses in charge.

Main outcome measures

Healing status and related medical costs.

Results

The introduced group showed significantly higher rate of healing compared with the control group at each weekly assessment. Multiple regression analysis revealed that the introduction of the new incentive system was independently associated with the faster healing rate (β = 3.44, P < .001). The budget impact analysis demonstrated that introducing this system could reduce cost of treating severe pressure ulcers by 1.776 billion yen per year.

Conclusions

The new incentive system for the management of pressure ulcers, which focused on staffing with skilled nurses can improve healing rate with reduced medical cost.     

The influence of coronary artery bypass graft harvest site on women's pain, functional status, and health services utilization throughout the first post-operative year: A longitudinal study

Background

Coronary artery bypass graft surgery is a commonly performed procedure aimed at managing coronary symptoms and prolonging life. Researchers have typically examined morbidity and mortality outcomes of predominantly male populations. Less is known about the influence of graft harvest site on recovery outcomes such as surgery-related pain, functional status, and health services utilization, especially in women.

Objectives

We aimed to examine the relationships between coronary artery bypass graft harvest site (saphenous vein, internal mammary arteries or both) and surgery-related pain, functional status, health services use at 6 weeks, 12 weeks and 12 months post-operatively.

Design

Longitudinal extension survey following participation in a clinical trial.

Setting

Ten Canadian centres.

Participants

Women (222) who participated in the Women's Recovery from Sternotomy Trial, underwent coronary artery bypass graft surgery with or without heart valve surgery, and completed the 12-month follow-up interview.

Methods

Harvest site data were collected by health record audit at the time of hospital discharge. Surgery-related pain, functional status, pain medication use and health services use data were collected by standardized interview over the telephone at 6 weeks, 12 weeks and 12 months post-operatively. Surgery-related pain and functional status were measured using the short Health Assessment Questionnaire. Health services use was measured by questionnaire and recorded as reported by the participants.

Results

Surgery-related pain, functional disability and health services use decreased over the first post-operative year. Participants who had left internal mammary artery grafts were more likely to have surgery-related pain (Adjusted Odds Ratio (AOR) = 2.79; 95% Confidence Interval (CI) 1.40-5.70) and use pain medication (AOR = 4.32; 95% CI 1.44-12.91) than those who had saphenous vein grafts. Conversely, participants who had saphenous vein grafts reported significantly more functional disability (AOR = 2.63; 95% CI 1.16-6.25) over 12 months post-surgery than those with left internal mammary artery grafts. Participants who had pain over the course of follow-up were more likely to visit their family physician or nurse practitioner (p = 0.017), visit another type of provider (i.e., naturopath or chiropractor, p = 0.004), or use any health care service (p < 0.0001).

Conclusions

Following coronary artery bypass graft surgery, women who had left internal mammary artery grafts reported more pain and health services use while those who had saphenous vein grafts were more functionally disabled. Women who reported surgery-related pain also used more health services.     

The association between nursing diagnoses, resource utilisation and patient and caregiver outcomes in a nurse-led home care service: longitudinal study

Background

The information generated by nurses through standardised nursing languages is insufficiently evaluated and exploited, mainly in home care services, as is its potential impact on outcomes.

Objectives

To find out how often nursing diagnoses are made during nursing home care visits, and to explore their relation with use of resources, mortality, institutionalisation and satisfaction.

Design

Observational, longitudinal follow-up study.

Settings

Home care services delivered by Primary Healthcare Districts in Málaga, Costa del Sol, Almería and Granada, in Spain.

Participants

Patients and caregivers who initiated the Home Care Programme.

Methods

The accumulated incidence of nursing diagnosis was analysed over 34 months of follow-up. Diagnoses were made by nurse case managers in their daily practice. Several regression models were devised to analyse their linkage with the use of resources, mortality, institutionalisation and satisfaction.

Results

Two hundred and forty-seven subjects were included (129 patients and 118 caregivers). 93.8 had been diagnosed (2.8 diagnoses per subject). Risk of caregiver strain and mobility impairment accounted for 40% of total home visits (p = 0.033). Significant differences were observed in the use of physiotherapy and rehabilitation services. The home visits for caregivers were, in 78% of cases, due to the recipient’s baseline functional status. No relation was detected for institutionalisation or for patient satisfaction. There was a higher rate of anxiety diagnosed in the caregiver when the recipient was at greater risk for mortality (RR: 2.08 CI 95%: 1.26-3.42) (p = 0.012).

Conclusions

These data confirm results from other studies which find nursing diagnoses to be sound predictors of resources use. Their synergy with other case-mix systems in home care should be investigated.     

Pulmonary rehabilitation for chronic obstructive pulmonary disease: a pilot study evaluating a once-weekly versus twice-weekly supervised programme

Objectives

To compare the effectiveness of a once-weekly supervised pulmonary rehabilitation programme with a standard twice-weekly format.

Design

Randomised trial of equivalency.

Setting

Pulmonary rehabilitation service of a primary care trust delivered at two physiotherapy outpatient departments.

Participants

Thirty patients with chronic obstructive pulmonary disease.

Outcome measures

Primary outcomes were the Incremental Shuttle Walking Test (ISWT), Endurance Shuttle Walking Test (ESWT) and St George's Respiratory Questionnaire (SGRQ), assessed at baseline and at completion of the supervised programme. Secondary outcomes were home-exercise activity, attendance levels and patient satisfaction with the programme.

Interventions

The once-weekly group (n = 15) received one supervised rehabilitation session per week, and the twice-weekly group (n = 15) received two sessions per week, both for 8 weeks, together with a home-exercise plan.

Results

After pulmonary rehabilitation, the groups showed similar improvements in exercise tolerance (median values: ISWT once-weekly 60 metres, twice-weekly 50 metres; ESWT once-weekly 226 seconds, twice-weekly 109 seconds). However, for health-related quality-of-life, the once-weekly group's score did not change (SGRQ 0), whereas an improvement was seen for the twice-weekly group (SGRQ 3.7). The number of home-exercise sessions and attendance levels were similar between the groups. Patient satisfaction with both formats was high and almost identical between the groups.

Conclusions

This pilot provides data to inform a larger study and shows that the methodology is feasible. The findings suggest that once-weekly supervision may be capable of producing equivalent improvements in exercise tolerance as a twice-weekly programme, but the health-related quality-of-life outcome appeared to be poorer for once-weekly supervision.