AIDS education for health care professionals in an organizational or systems context.

Traditionally, health education for practicing health professionals, as well as members of the public, focuses on the individual and relies on changing personal behavior. However, health care for persons with acquired immunodeficiency syndrome (AIDS), and members of their families, mainly is delivered within health and human services organizations. Providing AIDS education for health care professionals in an organizational or systems context shifts the focus from the individual to the group and from changing a person's behavior to offering health care professionals opportunities for interaction. In an organizational or systems approach, they can address patient care issues collectively, share interdisciplinary knowledge, identify problems of common concern, plan coordinated and integrated responses, and provide mutual support. A strategy for planning AIDS education is proposed for key administrators, supervisors, and care providers, who are the gatekeepers, opinion makers, and role models of organizations. Addressing organizational, community, and health care delivery system issues as part of an education program provides a forum for defining problems and a basis for uniting professionals and developing solutions.     

Emergency department psychiatric consultation arrangements

The effects of organizational and environmental factors on emergency department psychiatric consultation arrangements and the influence of arrangement on service effectiveness are examined. The findings have implications for health care researchers, administrators, and policymakers, encouraging further exploration into arrangement type and conditions that produce optimal patient and organizational outcomes.     

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.     

Determinants in the development of advanced nursing practice: a case study of primary-care settings in Hong Kong

Different factors have been shown to influence the development of models of advanced nursing practice (ANP) in primary-care settings. Although ANP is being developed in hospitals in Hong Kong, China, it remains undeveloped in primary care and little is known about the factors determining the development of such a model. The aims of the present study were to investigate the contribution of different models of nursing practice to the care provided in primary-care settings in Hong Kong, and to examine the determinants influencing the development of a model of ANP in such settings. A multiple case study design was selected using both qualitative and quantitative methods of data collection. Sampling methods reflected the population groups and stage of the case study. Sampling included a total population of 41 nurses from whom a secondary volunteer sample was drawn for face-to-face interviews. In each case study, a convenience sample of 70 patients were recruited, from whom 10 were selected purposively for a semi-structured telephone interview. An opportunistic sample of healthcare professionals was also selected. The within-case and cross-case analysis demonstrated four major determinants influencing the development of ANP: (1) current models of nursing practice; (2) the use of skills mix; (3) the perceived contribution of ANP to patient care; and (4) patients' expectations of care. The level of autonomy of individual nurses was considered particularly important. These determinants were used to develop a model of ANP for a primary-care setting. In conclusion, although the findings highlight the complexity determining the development and implementation of ANP in primary care, the proposed model suggests that definitions of advanced practice are appropriate to a range of practice models and cultural settings. However, the findings highlight the importance of assessing the effectiveness of such models in terms of cost and long-term patient outcomes.     

Nurses' attitudes of a web patient portal prior to its implementation in home health care nursing

ObjectivesEffective communication is essential in home health care nursing in order to meet the needs of both the patients and the caregivers. Given the key role of nursing staff inpatient training through the patient portal; nursing staffs' attitudes toward the use of this technology thus need to be further evaluated. The present study evaluated Iranian nurses' attitudes before the web-based patient portal implementation in home health care nursing.MethodsThis study was conducted on 600 nursing staff working in health care organizations affiliated to Semnan University of Medical Sciences in Iran. A questionnaire was used to evaluate the nurses’ attitudes.ResultsThe study subjects' attitudes scores were 3.06±0.71 on "patient education", 3.02±0.78 on "health care plan" and 2.95±0.82 on the cost of nursing services, based on the 5-point Likert scale (1-5: completely disagree to completely agree). There was a statistically significant relationship between nurses' attitudes and computer skill (B=0.07, SE=0.03, P=0.021) and nurses' acceptance of IT (B=0.085, SE=0.039, P=0.030), and sex (B=0.176, SE=0.058, P=0.003).ConclusionThe nurses agreed that the use of this self-management tool can ease patient education, easily implement a health care plan for patients and reduce the cost of nursing services. The nurses also agreed that changes are required at the minor and major levels of in-home health care institutions to support the implementation and meaningful use of this portal for home health care nursing.Public interest (lay) summaryHome health care is one of the alternative solutions to continue hospital care that is performed by nursing staff. The nursing staff in-home care should effectually cooperate to render secure and high-quality patient care. The web-based patient portals have confirmed effectiveness to improve patient gratification, engagement, and health outcomes, improve the quality and efficacy of the healthcare settings, decrease emergency unit appointments and ease patient-centered care. Nurses agree the implementation of the patient portal in home health care nursing depends on organizational and individual preparation in healthcare organizations and this technology should be also adopted by the nursing staff to meaningful use of the patient portal to attain significant improvements in home health care nursing.     

The motivation to care: application and extension of motivation theory to professional nursing work

PURPOSE: The purpose of this research is to describe a model of nurses' work motivation relevant to the human caring stance of professional nursing work. DESIGN/METHODOLOGY/APPROACH: The model was derived from selected theories of behavioral motivation and work motivation. Evidence-based theory addressing nurses' work motivation and nurses' motivational states and traits in relation to characteristics of organizational culture and patient health outcomes is suggested in an effort to make a distinct contribution to health services research. An integrated review of selected theories of motivation is presented, including conceptual analyses, theory-building techniques, and the evidence supporting the theoretical propositions and linkages among variables intrinsic to nurses' work motivation. FINDINGS: The model of the Motivation to Care for Professional Nursing Work is a framework intended for empirical testing and theory building. The model proposes specific leadership and management strategies to support a culture of motivational caring and competence in health care organizations. ORIGINALITY/VALUE: Attention to motivation theory and research provides insights and suggests relationships among nurses' motivation to care, motivational states and traits, individual differences that influence nurses' work motivation, and the special effects of nurses' work motivation on patient care outcomes. Suggestions for nursing administrative direction and research are proposed.     

What knowledge-accessing modes tell administrators about interdisciplinary crises and conflicts.

In hospitals administrators work with two major groups of medical professionals: physicians and nurses. Together, these three groups of professionals are primarily responsible for the care of patients. The quality of the service they provide is dependent on the working relationships among these disciplines. Potentially, the more harmony among administrators, physicians, and nurses, the better care patients can receive. The research reported in this article addresses the issue of interdisciplinary misunderstanding among these groups of professionals. The research was premised on the assumption that hospital administrators, physicians, and nurses differ in the way they access knowledge. That is, administrators, physicians, and nurses access knowledge in dissimilar ways and, by doing so, set the stage for crises and conflicts. Using a standardized instrument to assess knowledge-accessing modes, data were collected from samples of health administration, medical, and nursing students. The data indicated that the three groups did differ in the way they accessed knowledge. The individual discipline profiles generated from the data also revealed a finding common to the three disciplines, a finding may help resolve a very real problem for hospital patients. Based on the research results, the article discusses ways that administrators may be able to prevent crises and conflicts and enhance harmonious relations among the three disciplines, and thereby improve patient care. Avenues for further research are also suggested.     

Rationing of nursing care and its relationship to patient outcomes: the Swiss extension of the International Hospital Outcomes Study.

OBJECTIVE: To explore the association between implicit rationing of nursing care and selected patient outcomes in Swiss hospitals, adjusting for major organizational variables, including the quality of the nurse practice environment and the level of nurse staffing. Rationing was measured using the newly developed Basel Extent of Rationing of Nursing Care (BERNCA) instrument. Additional data were collected using an adapted version of the International Hospital Outcomes Study questionnaire. DESIGN: Multi-hospital cross-sectional surveys of patients and nurses. SETTING: Eight Swiss acute care hospitals PARTICIPANTS: Nurses (1338) and patients (779) on 118 medical, surgical and gynecological units. MAIN OUTCOME MEASURES: Patient satisfaction, nurse-reported medication errors, patient falls, nosocomial infections, pressure ulcers and critical incidents involving patients over the previous year. RESULTS: Generally, nurses reported rarely having omitted any of the 20 nursing tasks listed in the BERNCA over their last 7 working days. However, despite relatively low levels, implicit rationing of nursing care was a significant predictor of all six patient outcomes studied. Although the adequacy of nursing resources was a significant predictor for most of the patient outcomes in unadjusted models, it was not an independent predictor in the adjusted models. Low nursing resource adequacy ratings were a significant predictor for five of the six patient outcomes in the unadjusted models, but not in the adjusted ones. CONCLUSION: As a system factor in acute general hospitals, implicit rationing of nursing care is an important new predictor of patient outcomes and merits further study.     

Taking PROs and patient-centered care seriously: incremental and disruptive ideas for incorporating PROs in oncology practice

Using patient-reported outcomes (PROs) in clinical practice poses challenges for health care teams and organizations to respond to individual patient needs in a timely fashion. Well-validated tools and feasibility studies are available, but successful spread will require knowledge of effective technology dissemination in complex health delivery systems. Given what has been learned about effective implementation, it is reasonable to ask whether the broad adoption of PROs can occur incrementally using current models of care to apply PRO technology. Another approach is to start with patient needs and focus on how to meet those needs most effectively using PROs in new ways of organizing health care.     

Implementing practice guidelines through clinical quality improvement

The American health care delivery environment is changing. As provider-at-risk payment strategies become increasingly dominant, they will force health care providers to replace old strategies that measured and managed revenues with new strategies that measure and manage costs. Quality improvement (QI) theory provides a set of tools to do exactly that--to understand, measure, and manage health care delivery processes and their associated costs. As a methodology for process management, QI theory merges case management, practice guidelines, and outcomes research into a single coordinated effort. It appropriately redirects management focus to care delivery processes, rather than to physicians. It also defines and illustrates a set of principles by which health care administrators can constructively team with physicians to find and document the best patient care outcomes at the lowest necessary cost, using QI-based practice guidelines as a decision support and measurement tool.     

A review of the evaluation of clinical teaching: new perspectives and challenges

PURPOSE: This article discusses the importance of the process of evaluation of clinical teaching for the individual teacher and for the programme. Measurement principles, including validity, reliability, efficiency and feasibility, and methods to evaluate clinical teaching are reviewed. CONTEXT: Evaluation is usually carried out from the perspective of the learner. This article broadens the evaluation to include the perspectives of the teacher, the patient and the institutional administrators and payers in the health care system and recommends evaluation strategies. RESULTS: Each perspective provides specific feedback on factors or attributes of the clinical teacher's performance in the domains of medical expert, professional, scholar, communicator, collaborator, patient advocate and manager. Teachers should be evaluated in all domains relevant to their teaching objectives; these include knowledge, clinical competence, teaching effectiveness and professional attributes. CONCLUSIONS AND IMPLICATIONS: Using this model of evaluation, a connection can be made between teaching and learning about all the expected roles of a physician. This can form the basis for systematic investigation into the relationship between the quality of teaching and the desired outcomes, the improvement of student learning and the achievement of better health care practice. It is suggested that the extent of effort and resources devoted to evaluation should be commensurate with the value assigned to the evaluation process and its outcomes.     

Organizing community nursing: an exploratory study

The NHS in the 1990s places increasing emphasis on primary care and puts pressure on general practitioners (GPs) and community nurses to deliver a broad range of high quality care in the most cost-effective possible way. In attempting to achieve these objectives, the British National Health Service (NHS) and its individual health authorities have re-examined the available range of organizational choices and increasingly the tendency is to organize community nursing around the focal point of general practice. The authors' evaluation of six innovative 'pilot projects' showed the effects of different organizational choices with respect to basing, purchasing, provision and management of community nursing services. It was found that there are some advantages to focusing primary care on the GP; basing of nurses on the practice is particularly advantageous. There are, however, some very clear indications that the adoption by GPs of multiple, and sometimes conflicting, roles of manager, provider and purchaser of community nursing inhibits the development of fully integrated primary health care teams and can be detrimental to the nursing function. It is concluded that the NHS needs to explore other less GP-centred organizational configurations within primary care.     

Statewide Implementation of Recovery Support Groups for People with Serious Mental Illness: A Multidimensional Evaluation

This study evaluated a statewide demonstration project to implement a group-based intervention called Procovery in selected inpatient and community mental health centers. Procovery is a facilitated mutual support group designed to build hope and a sense of social inclusion by raising consciousness and helping people develop an understanding of the ways one can move toward recovery in their own lives. This evaluation sought to determine both consumer outcomes and perceptions of the program and implementation efforts held by consumers and the facilitators of the intervention. A multidimensional approach was used, including a quasi-experimental design with consumers, questionnaires and focus groups with the intervention facilitators, and individual interviews with administrators. The Procovery model was shown to have a positive impact on consumers’ recoveries and was viewed favorably by consumers, facilitators, and administrators. Several barriers to effective implementation were identified. These findings and their implications for future practice and research are discussed.     

Creating the Virtual Team

The increased reliance on patient self-generated data has had a major impact on the development of the virtual team in the management of diabetes mellitus. Only recently has the concept of the virtual team been taken seriously in the management of the individual with diabetes, in part due to the availability of large amounts of patient self-generated data. Team development, especially for a virtual team, is a careful process, in which self-assessment, team building, and identification of roles and responsibilities take place before the team performs. This process has been termed ‘forming, storming, norming, and performing’ in recognition of the stages of team development and the importance of passing through each stage before initiating the next. Research has identified four additional factors that need to be addressed for the virtual team to complete its development and to assure improved clinical outcomes: organizational support, a common approach to diabetes care based on specific clinical protocols, ongoing measurement, and incentives. The creation, organization, and implementation of virtual teams depend upon several inter-related factors. The ideal model permits synchronized communications between team members so that timely decisions can be made in a transparent manner, enabling the person with diabetes to fully participate. From a structural perspective, the team needs organizational support, common care protocols, a means of measuring performance (including, but not limited to, outcomes), and incentives for all participants.     

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.     

Resident smoking in long-term care facilities--policies and ethics.

Objective: To characterize smoking behavior, facility policies related smoking, and administrators'' views of smoking-related problems in Veterans Affairs nursing home care units nationwide. Methods: An anonymous mail survey of long-term care facilities was administered to 106 nursing home supervisors at VA Medical Centers with nursing home care units. The response rate was 82%. Results: Administrators from 106 VA nursing home units reported smoking rates ranging from 5% to 80% of long-term care residents, with an average of 22%. Half of the nursing homes had indoor smoking areas. Frequent complaints from nonsmokers about passive smoke exposure were reported in 23% of the nursing homes. The nursing administrators reported that patient safety was their greatest concern. Seventy- eight percent ranked health effects to the smokers themselves a "major concern," while 70% put health effects to exposed nonsmokers in that category. Smoking in the nursing home was described as a "right" by 59% of respondents and a ¿privilege¿ by 67%. Some individuals reported that smoking was both a right and a privilege. Conclusion: Smoking is relatively common among VA long-term care patients. The promotion of personal autonomy and individual resident rights stressed in the Omnibus Budget Reconciliation Act of 1987 may conflict with administrative concerns about the safety of nursing home smokers and those around them.     

An organizational approach to understanding patient safety and medical errors

Progress in patient safety, or lack thereof, is a cause for great concern. In this article, we argue that the patient safety movement has failed to reach its goals of eradicating or, at least, significantly reducing errors because of an inappropriate focus on provider and patient-level factors with no real attention to the organizational factors that affect patient safety. We describe an organizational approach to patient safety using different organizational theory perspectives and make several propositions to push patient safety research and practice in a direction that is more likely to improve care processes and outcomes. From a Contingency Theory perspective, we suggest that health care organizations, in general, operate under a misfit between contingencies and structures. This misfit is mainly due to lack of flexibility, cost containment, and lack of regulations, thus explaining the high level of errors committed in these organizations. From an organizational culture perspective, we argue that health care organizations must change their assumptions, beliefs, values, and artifacts to change their culture from a culture of blame to a culture of safety and thus reduce medical errors. From an organizational learning perspective, we discuss how reporting, analyzing, and acting on error information can result in reduced errors in health care organizations.     

Implementing practice management strategies to improve patient care: the EPIC project

Healthcare gaps, the difference between usual care and best care, are evident in Canada, particularly with respect to our aging, ailing population. Primary care practitioners are challenged to identify, prevent and close care gaps in their practice environment given the competing demands of informed, litigious patients with complex medical needs, ever-evolving scientific evidence with new treatment recommendations across many disciplines and an enhanced emphasis on quality and accountability in healthcare. Patient-centred health and disease management partnerships using measurement, feedback and communication of practice patterns and outcomes have been shown to narrow care gaps. Practice management strategies such as the use of patient registries and recall systems have also been used to help practitioners better understand, follow and proactively manage populations of patients in their practice. The Enhancing Practice to Improve Care project was initiated to determine the impact of a patient-centred health and disease management partnership using practice management strategies to improve patient care and outcomes for patients with chronic kidney disease (CKD). Forty-four general practices from four regions of British Columbia participated and, indeed, demonstrated that care and outcomes for patients with CKD could be improved via the implementation of practice management strategies in a patient-centred partnership measurement model of health and disease management.