Rationing of nursing care and nurse–patient outcomes: a systematic review of quantitative studies

Bedside rationing in nursing care refers to withholding or failure to carry out certain aspects of care because of limited resources such as time, staffing or skill mix. The absence of previous systematic reviews on nursing care rationing leads to a gap of synthesized knowledge on the factors and processes related to rationing and the potential negative consequences on both patients and nurses. The aim of this study was to gain an in‐depth understanding of the factors and processes related to nursing care rationing. Selected papers were methodologically assessed based on their design, sampling, measurement and statistical analysis. Seventeen quantitative studies were reviewed, and findings were categorized into four themes: elements of nursing care being rationed, causes of rationing, nurse outcomes and patient outcomes. Results revealed that communication with patients and families, patient ambulation, and mouth care were common elements of rationed care. Nurse–patient workload and communication barriers were reported as potential causes of rationing. Patient‐related outcomes included patient falls, nosocomial infections and low patient satisfaction levels. Nurse‐related outcomes included low job and occupational satisfaction. In addition, rationing appears to be an important organizational variable linked with patient safety and quality of care. This review increases understanding of what is actually occurring at the point of care delivery so that managers will be able to improve processes that lead to high quality of care and better patient and nurse outcomes. Copyright © 2013 John Wiley & Sons, Ltd.     

Addressing the nurse shortage to improve the quality of patient care

Nurses are the largest group of health care professionals providing direct patient care in hospitals, and the quality of care for hospital patients is strongly linked to the performance of nursing staff, according to an Institute of Medicine report. This paper describes the Robert Wood Johnson Foundation's (RWJF's) work in nursing, which focuses on improving the hospital work environment to attract and retain high-quality nursing staff, with the ultimate goal of improving patient care and outcomes in hospitals. Other organizations' efforts to address the nurse shortage are also explored.     

Promoting mental health care in a rural paediatric unit through participatory action research

Objective:  To explore, advance and evaluate mental health practices in a rural general paediatric unit through participatory action research.
Design:  A participatory action research approach guided this study, providing an opportunity for nursing staff to become actively involved in the design, direction and outcomes of the research.
Setting:  A 16-bed paediatric unit of a rural general hospital.
Participants:  A purposive convenience sample of all paediatric nursing staff ( n =  20; of 24 nurses).
Outcome measures:  In the first phase of this study, focus groups were conducted to explore the experiences of nurses.
Results:  Participants considered mental health to be a specialist discipline area and the role of the mental health nurse to be complex. They felt that their lack of training and experience with mental health issues was detrimental to the delivery of optimal patient care. There was concern about differing approaches to treatment, relationships with other mental health services and the suitability of the ward environment for young people with a mental health problem. Participants called for training by qualified mental health staff and the development of policies and clinical guidelines to facilitate their delivery of care to patients with a mental health problem in an acute medical environment.
Conclusions:  There is a clear need for nursing specialities to work together to ensure that optimal care is given to patients admitted to general hospital with a mental health issue. Given the absence of accessible specialist child mental health inpatient units in regional and remote areas, upskilling paediatric nurses must be a priority.     

Impact of the nurse shortage on hospital patient care: comparative perspectives

National surveys of registered nurses, physicians, and hospital executives document considerable concern about the U.S. nurse shortage. Substantial proportions of respondents perceived negative impacts on care processes, hospital capacity, nursing practice, and the Institute of Medicine's six aims for improving health care systems. There were also many areas of divergent opinion within and among these groups, including the impact of the shortage on safety and early detection of patient complications. These divergences in perceptions could be important barriers to resolving the current nurse shortage and improving the quality and safety of patient care.     

Residency performance of graduates from a problem-based and a conventional curriculum

Performance of 130 graduates in residency from a community-oriented, problem-based medical curriculum, and from a parallel, conventional track, were compared on eight dimensions: knowledge, communication with patients, independent learning ability, teamwork, patient education, critical thinking ability, attention to health care costs, and self-assessment. Ratings were obtained from three evaluators: a doctor-supervisor, a nurse and the resident him/herself. The study was undertaken to identify differences between graduates from the two curricular tracks. Differences were observed in the areas of health care costs (supervisors) and communication with patients (residents), and a trend was observed in patient education (supervisors) and knowledge (nurses), The outcomes of the study are discussed in light of the literature on residency performance, and in terms of the educational experiences that characterize the two medical curricula.     

Saving nurses, saving patients: responses to the labor crisis

While numerous task forces have spent enormous time and energy studying the size and scope of the nursing shortage, other organizations have been hard at work solving the difficulties faced by nurses and reducing the effects of the labor shortages on patient care. These efforts range from national legislative activities to grassroots innovations. Many of these efforts have already produced tangible results and take the form of major investments in professional development and improvements to the workplace environment. Physicians play an important role in the hospital work environment and can affect teamwork, a clear driver of nurse satisfaction.     

Case management: managing the nurse case manager

Nurse executives and nurse managers have become proactive in response to the health care crisis by creating and implementing innovative health care delivery models such as nursing case management. Nursing case management utilizes a nurse as case manager and the unit-based system of managed care to achieve financial and clinical outcomes for target patient groups. Nurse managers can support the nursing case management model best by practicing good managerial skills, developing a participative style of leadership, and empowering the nurse case manager.     

Nurse Value-Added and Patient Outcomes in Acute Care

ObjectiveThe aims of the study were to (1) estimate the relative nurse effectiveness, or individual nurse value-added (NVA), to patients’ clinical condition change during hospitalization; (2) examine nurse characteristics contributing to NVA; and (3) estimate the contribution of value-added nursing care to patient outcomes.ConclusionsNurses differ in their value-added to patient outcomes. The ability to measure individual nurse relative value-added opens the possibility for development of performance metrics, performance-based rankings, and merit-based salary schemes to improve patient outcomes and reduce costs.     

团体心理咨询在合同制护士心理调适中的应用

目的探讨团体心理咨询对合同制护士工作压力的影响。方法选取某军队医院合同制护士80名作为干预组进行6周团体心理咨询,同时选取该院80名合同制护士作为观察组,不进行任何心理干预。采用自编护士一般资料调查表、护士工作压力源量表对两组护士分别进行评估。结果两组护士在年龄、级别、受教育程度、工作年限和婚姻状况方面均无统计学差异（P〉0.01）;采取干预措施后干预组护士在护理专业及工作方面的问题、时间分配及工作量问题、患者护理方面问题、管理及人际关系方面的问题工作压力明显低于观察组护士。两组护士在护理专业、时间分配、工作环境、患者护理、管理以及工作压力源总分方面有统计学差异（P〈0.01）。结论团体心理咨询有助于帮助合同制护士了解自己、减轻工作压力、改善人际关系,提高工作积极性和效率。     

Nurse-perceived Patient Adverse Events and Nursing Practice Environment

Objectives:

To evaluate the occurrence of patient adverse events in Korean hospitals as perceived by nurses and examine the correlation between patient adverse events with the nurse practice environment at nurse and hospital level.

Methods:

In total, 3096 nurses working in 60 general inpatient hospital units were included. A two-level logistic regression analysis was performed.

Results:

At the hospital level, patient adverse events included patient falls (60.5%), nosocomial infections (51.7%), pressure sores (42.6%) and medication errors (33.3%). Among the hospital-level explanatory variables associated with the nursing practice environment, ‘physician- nurse relationship’ correlated with medication errors while ‘education for improving quality of care’ affected patient falls.

Conclusions:

The doctor-nurse relationship and access to education that can improve the quality of care at the hospital level may help decrease the occurrence of patient adverse events.     

重症监护病房构建和谐护患关系的探讨

目的:探讨重症监护病房(ICU)构建和谐护患关系的影响因素及护理对策,以适应新形势下的和谐医院,和谐科室。方法:通过自制问卷对入住ICU的患者及家属进行问卷调查。了解影响ICU护患关系的因素及患者的需求。结果:调查显示影响护患关系的主要因素是:(1)病人和家属对ICU期望值过高。(2)病人和家属对ICU工作性质和环境的知识缺乏。(3)护患之间缺乏沟通。(4)ICU的收费相对病房较高。(5)社会支持系统的缺乏。结论:提高医疗护理质量,确保医疗安全;定期召开工休座谈会,与患者和家属进行有效的沟通;加强ICU的宣教工作让患者和家属对ICU的工作性质有所了解;实行收费透明化;寻求社会支持系统。     

Predictors of Communication Quality: The Patient,Provider, and Nurse Call Center Triad

The purpose of this studywas to examine characteristics of communication quality in a managed care context in which a nurse call center was used as the patient point of entry to the health system. The study sought to determine the level of communication quality among patients, health care providers, and nurses in the call center. Having measured the timeliness, accuracy, usefulness, and quantity of communication variables, a reasonable picture of communication quality emerged. The study explored patient differences in their perception of communication quality due to socioeconomic status, needs, experience, age, and various other factors. Likewise, providers who differ in training, specialty, and experience should have different perceptions and expectations of communication through nurse call center interaction.     

The Role of Public Relations for Image Creating in Health Services: A Sample Patient Satisfaction Survey

This study discusses the role of public relations for image creating in health services. Hospitals require public relations activities to distinguish them from competitors, provide bidirectional communication between the society and the hospital, and assist to create of a strong hospital image and culture. A satisfaction survey was conducted on 264 patients who have received health services at Maltepe University Hospital. The research focused on how the Hospital's examination, care, catering and physical services; doctor and nurse politeness towards patients and patient relatives, their attitudes and behaviors; examination, check-in, bedding and discharge operations; public relations activities in and out of the hospital were perceived. Another subject of the study was the degree of recommendation of patients who have been served by the hospital's health services to prospective patients seeking treatment.     

Measurement of nursing practice models using multiattribute utility theory: relationship to patient and organizational outcomes

Workforce shortages are challenging administrators in the health care environments to examine existing models of providing care. Although characteristics of nursing care delivery contribute in important ways to the success or failure of hospital care, factors common to all practice models have not been identified nor have measurement strategies been designed that assess the impact of care on patient and organizational outcomes. The purpose of this study was to test a measurement model of nursing practice that was developed using multiattribute utility theory. A total of 24 factors identified by expert nurse administrators as being common to all nursing practice models were mathematically formulated into a multidimensional composite index that represented the degree to which a practice model on a nursing unit approached the professional ideal. The index was tested with 298 registered nurses working on 28 medical surgical nursing units in 3 hospitals. The model was evaluated in 2 ways: first by comparing the composite index scores to a qualitative appraisal of the nursing unit's practice model and patient and organizational outcomes. Secondly, individual factors in the model were evaluated in the same manner. While the composite index was not fully validated, there is strength in the evidence of the relationship between individual factors and outcomes. Specifically, factors that addressed interactions among health care team members were most often related to outcomes.     

The nursing shortage: a worldwide problem

A worldwide shortage of nurses has been acknowledged by the multidisciplinary Global Advisory Group of the World Health Organization. The shortage is caused by an increased demand for nurses, while fewer people are choosing nursing as a profession and the current nurses worldwide are aging. The shortage applies to nurses in practice as well as the nurse faculty who teach students. The inter-country recruitment and migration of nurses from developing countries to developed countries exacerbates the problem. Although public opinion polls identifies the nurse as the person who makes the health care system work for them, the conditions of the work environment in which the nurse functions is unsatisfactory and must change. Numerous studies have shown the positive effects on the nurse of a healthy work environment and the positive relationships between nursing care and patient outcomes. It is important that government officials, insurance companies, and administrators and leaders of health care systems acknowledge and operationalize the value of nurses to the health care system in order to establish and maintain the integrity and viability of that system.     

Implications of interprofessional primary care team characteristics for health services and patient health outcomes: A systematic review with narrative synthesis

Interprofessional primary care (IPPC) teams are promoted as an alternative to single profession physician practices in primary care with focus on preventive care and chronic disease management. Characteristics of teams can have an impact on their performance.We synthesized quantitative, qualitative or mixed-methods evidence addressing the design of IPPC teams. We searched Ovid MEDLINE, Embase, CINAHL, and PAIS using search terms focused on IPPC teams. Studies were included if they discussed the influence of team structure, organization, financial arrangements, or policies and procedures, or either health care processes or outputs, health outcomes, or costs, and were conducted in Australia, Canada, the United Kingdom or New Zealand between 2003 and 2016. We screened 11,707 titles, 5366 abstracts, and selected 77 full text articles (38 qualitative, 31 quantitative and 8 mixed-methods).Literature focused on the implications of team characteristics on team processes, such as teamwork, collaboration, or satisfaction of patients or providers. Despite heterogeneity of contexts, some trends are observable: shared space, common vision and goals, clear definitions of roles, and leadership as important to good teamwork. The impacts of these on health care outputs or patient health are not clear. To move the state of knowledge beyond perception of what works well for IPPC teams, researchers should focus on quantitative causal inference about the linkages between team characteristics and patient health.     

Incentives for physician teams: Effectiveness of performance feedback and payment distribution methods

Best practices in team-based incentive design remain underexplored. This study examines under group-based pay-for-performance, how managers incentivize physicians for teamwork through internal feedback and payment distribution methods. In collaboration with Taiwan Association of Family Medicine, authors conducted a national survey of physician groups, with a response rate of 48.3%. Multilevel linear regression was applied to 134 groups, collectively consisting of 1,245 physicians in Taiwan. The outcome variables were two manager-rated scores for group performance on achieving (a) comprehensive, coordinated, continuous care, and (b) patient health improvement. The results indicate that providing each physician feedback on peer performance is superior to not providing it; when providing peer information within a group, concealing identities is superior to revealing them. These findings imply that application of the principle of social comparison can be effective; however, caution should be taken when disclosure of identifiable peer performance may intensify peer competition and undermine care coordination in team-based models. Further, groups that distribute payments equally among physicians perform better than groups that distributed payment proportionally to physicians’ patient shares. The findings are germane to small teams, where physicians do not have full control over care processes and outcomes, and need to work cooperatively to maximize group-based payment.     

Just-in-Time Evidence-Based E-mail “Reminders” in Home Health Care: Impact on Patient Outcomes

OBJECTIVE: To assess the impact and cost-effectiveness of two information-based provider reminder interventions designed to improve self-care management and outcomes of heart failure (HF) patients. DATA SOURCES/STUDY SETTING: Interview and agency administrative data on 628 home care patients with a primary diagnosis of HF. STUDY DESIGN: Patients were treated by nurses randomly assigned to usual care or one of two intervention groups. The basic intervention was an e-mail to the patient's nurse highlighting six HF-specific clinical recommendations. The augmented intervention supplemented the initial nurse reminder with additional clinician and patient resources. DATA COLLECTION: Patient interviews were conducted 45 days post admission to measure self-management behaviors, HF-specific outcomes (Kansas City Cardiomyopathy Questionnaire-KCCQ), health-related quality of life (EuroQoL), and service use. PRINCIPAL FINDINGS: Both interventions improved the mean KCCQ summary score (15.3 and 12.9 percent, respectively) relative to usual care (p< or =.05). The basic intervention also yielded a higher EuroQoL score relative to usual care (p< or =.05). In addition, the interventions had a positive impact on medication knowledge, diet, and weight monitoring. The basic intervention was more cost-effective than the augmented intervention in improving clinical outcomes. CONCLUSIONS: This study demonstrates the positive impact of targeting evidence-based computer reminders to home health nurses to improve patient self-care behaviors, knowledge, and clinical outcomes. It also advances the field's limited understanding of the cost-effectiveness of selected strategies for translating research into practice.     

A profile of the structure and impact of nursing management in Canadian hospitals

The purpose of this study was to describe the profile of nursing leadership structures in Canada and to assess relationships among structures, processes and outcomes pertaining to nurse leaders' work. Data were collected from nurse leaders in 28 academic health centres and 38 community hospitals in 10 Canadian provinces (n = 1,164). The results of this study revealed that the current contingent of nursing leaders in Canada see themselves as an empowered and influential group within their organizations. Despite very large spans of control, nurse leaders at all levels were positive about their work life and confident in their ability to provide effective leadership on nursing affairs within their organizations. Structural and process factors significantly affected nurse manager outcomes at all levels. Senior nurse leaders' work-life factors had a significant effect on middle and first-line managers' perceptions of patient care quality in the organization. Nurse leaders averaged 49 years of age highlighting the need for succession planning.     

The evaluation of hospital restructuring efforts: satisfaction, quality, and costs

This article reports on study evaluating the effects of hospital restructuring on patient satisfaction, nurse satisfaction, cost of care, and clinical quality. The restructuring involved facility redesign, telecommunications enhancement, and implementation of patient care processes incorporating multiskilled personnel and case facilitation systems. The results indicate improved patient and nurse satisfaction, decreased length of stay and variable cost per patient day, and good clinical outcomes.