Assessment of nursing management and utilization of nursing resources with the RAFAELA patient classification system--case study from the general wards of one central hospital

Background. RAFAELA is a new Finnish PCS, which is used in several University Hospitals and Central Hospitals and has aroused considerable interest in hospitals in Europe. Aims and objectives. The aim of the research is firstly to assess the feasibility of the RAFAELA Patient Classification System (PCS) in nursing staff management and, secondly, whether it can be seen as the transferring of nursing resources between wards according to the information received from nursing care intensity classification. Methods. The material was received from the Central Hospital's 12 general wards between 2000 and 2001. The RAFAELA PCS consists of three different measures: a system measuring patient care intensity, a system recording daily nursing resources, and a system measuring the optimal nursing care intensity/nurse situation. The data were analysed in proportion to the labour costs of nursing work and, from that, we calculated the employer's loss (a situation below the optimal level) and savings (a situation above the optimal level) per ward as both costs and the number of nurses. Results. In 2000 the wards had on average 77 days below the optimal level and 106 days above it. In 2001 the wards had on average 71 days below the optimal level and 129 above it. Converting all these days to monetary and personnel resources the employer lost €307,745 or 9.84 nurses and saved €369,080 or 11.80 nurses in total in 2000. In 2001 the employer lost in total €242,143 or 7.58 nurses and saved €457,615 or 14.32 nurses. During the time period of the research nursing resources seemed not have been transferred between wards. Conclusions. RAFAELA PCS is applicable to the allocation of nursing resources but its possibilities have not been entirely used in the researched hospital. The management of nursing work should actively use the information received in nursing care intensity classification and plan and implement the transferring of nursing resources in order to ensure the quality of patient care. Relevance to clinical practice. Information on which units resources should be allocated to is needed in the planning of staff resources of the whole hospital. More resources do not solve the managerial problem of the right allocation of resources. If resources are placed wrongly, the problems of daily staff management and cost control continue.     

Assessment and documentation of bowel care management in palliative care: incorporating patient preferences into the care regimen

Nurses in a palliative care unit (PCU) recognized that there were several inconsistencies relating to assessment and documentation of patient preferences in bowel care management. Although bowel care is recognized as of key importance to the wellbeing of palliative care patients, there is little evidence in current literature about accommodation of patient preferences in bowel care management. A questionnaire was developed to assess whether patient preferences were elicited on admission to the PCU, were documented, and were included in the bowel care regimen. Data were collected from 100 patients in two PCUs in Australia. The findings suggested that little was assessed or documented about bowel care management on admission except functional or pharmacological information. According to patients in the study, their preferences were seldom incorporated into the bowel care regimen. Lack of documentation of bowel care preferences was also found following an audit of patient notes. Techniques for eliciting information, awareness of alternative or complementary methods of bowel care and better documentation procedures are all recommended for inclusion in nursing practice in the palliative care setting.     

Patient safety on psychiatric wards: A cross‐sectional,multilevel study of factors influencing nurses' willingness to share power and responsibility with patients

The World Health Organization highlights the need for more patient participation in patient safety. In mental health care, psychiatric nurses are in a frontline position to support this evolution. The aim of the present study was to investigate the demographic and contextual factors that influence the willingness of psychiatric nurses to share power and responsibility with patients concerning patient safety. The patient participation culture tool for inpatient psychiatric wards was completed by 705 nurses employed in 173 psychiatric wards within 37 hospitals. Multilevel modelling was used to analyse the self‐reported data. The acceptance of a role wherein nurses share power and responsibility with patients concerning patient safety is influenced by the nurses' sex, age, perceived competence, perceived support, and type of ward. To support nurses in fulfilling their role in patient participation, patient participation‐specific basic and continuing education should be provided. Managers and supervisors should recognize and fulfil their facilitating role in patient participation by offering support to nurses. Special attention is needed for young nurses and nurses on closed psychiatric wards, because these particular groups report being less willing to accept a new role. Ward characteristics that restrict patient participation should be challenged so that these become more patient participation stimulating. More research is needed to explore the willingness and ability of psychiatric nurses to engage in collaborative safety management with patients who have specific conditions, such as suicidal ideation and emotional harm.     

Managing ventilatory insufficiency and failure in a patient with kyphoscoliosis: a case study

This article reports a case study of ‘Sue’, a 37 year old female who was transferred to a metropolitan hospital's intensive care unit in acute respiratory failure secondary to severe kyphoscoliosis (KS). KS is defined as a deformity of the spine involving both lateral displacement (scoliosis) and anteroposterior angulation (kyphosis). Over time, this anatomical distortion results in ventilatory insufficiency due to muscle weakness. Sue displayed a restrictive lung pattern, evidenced by a decreased vital capacity and tidal volume with severe nocturnal dyspnoea, resulting in raised carbon dioxide levels in arterial blood and decreased oxygenation.

This paper reviews Sue's progress throughout her hospitalisation and examines the key issues involved in her care. Particular attention is given to specific problems encountered on the acute care ward related to oxygen delivery, tracheostomy care, non-invasive ventilation and rehabilitation. The paper highlights the increased acuity of respiratory ward patients who require the use of substantial technological support to optimise their management. Nurses working in these wards need specialised knowledge, excellent patient communication ability and well-developed technical skills. The trend is to treat patients with respiratory failure, either chronic or acute, on wards rather than in critical care units which has promoted the development of a specialised role in respiratory nursing.     

Complications and side effects associated with epidural bupivacaine/morphine analgesia

Postoperative analgesia is a responsibility that physicians should fulfil in every patient. It is not only an act of kindness, but also an improved clinical outcome may be derived from this service when epidural techniques are used. However, complications and side effects may occur with postoperative epidural analgesia. Thus, there have been concerns among some clinicians regarding the use of local anaesthetics and opioids for epidural analgesia in the surgical wards where monitoring of patients is not as strict as it is in critical care or step down units. A review of the literature reflects a low incidence of side effects and complications in the surgical wards where the nursing staff have been trained in the early recognition of potential complications and the treatment of side effects. Many issues remain to be addressed via further research efforts. However, we believe that the current knowledge on potential complications and side effects of postoperative epidural analgesia and their treatment, allow for the safe epidural delivery of combinations of local anaesthetics and opioids in a wide range of postoperative patients. We also present the protocols that we currently use in our Acute Pain Treatment Service for the management of these complications and side effects.     

Constipation,patients and lifestyles

Constipation is an issue which nurses in palliative care deal with on a day-to-day basis. As with many problems in this specialty, constipation is multifactorial in nature and therefore it can be a complex problem to treat. It is known to be caused or exacerbated by the use of opiods and therefore should be anticipated and treated prophylactically. Good assessment is important and a thorough history of the patient's bowel habits and patterns should be obtained. Management of constipation should incorporate both pharmacological and non-pharmacological approaches. Education plays an important role in both the prevention and treatment of constipation. In conclusion, the nursing care of patients with constipation is aimed at providing a realistic and acceptable bowel pattern for each patient as an individual according to patient need, general condition and lifestyle.     

Survival of critically ill patients hospitalized in and out of intensive care

OBJECTIVE: A lack of intensive care units beds in Israel results in critically ill patients being treated outside of the intensive care unit. The survival of such patients is largely unknown. The present study's objective was to screen entire hospitals for newly deteriorated patients and compare their survival in and out of the intensive care unit. DESIGN: A priori developed intensive care unit admission criteria were used to screen, during 2 wks, the patient population for eligible incident patients. A screening team visited every hospital ward of five acute care hospitals daily. Eligible patients were identified among new admissions in the emergency department and among hospitalized patients who acutely deteriorated. Patients were followed for 30 days for mortality regardless of discharge. SETTING: Five acute care hospitals. PATIENTS: A total of 749 newly deteriorated patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Crude survival of patients in and out of the intensive care unit was compared by Kaplan-Meier curves, and Cox models were constructed to adjust the survival comparisons for residual case-mix differences. A total of 749 newly deteriorated patients were identified among 44,000 patients screened (1.7%). Of these, 13% were admitted to intensive care unit, 32% to special care units, and 55% to regular departments. Intensive care unit patients had better early survival (0-3 days) relative to regular departments (p=.0001) in a Cox multivariate model. Early advantage of intensive care was most pronounced among patients who acutely deteriorated while on hospital wards rather than among newly admitted patients. CONCLUSIONS: Only a small proportion of eligible patients reach the intensive care unit, and early admission is imperative for their survival advantage. As intensive care unit benefit was most pronounced among those deteriorating on hospital wards, intensive care unit triage decisions should be targeted at maximizing intensive care unit benefit by early admitting patients deteriorating on hospital wards.     

Importance of continence advice for people with multiple sclerosis

Bladder and bowel problems are a common feature in patients with multiple sclerosis (MS). This article demonstrates how patients benefit from specialist input relating to continence as part of a multidisciplinary neurological rehabilitation service (MNRS). The implementation of the MNRS has offered a 'one-stop' referral system for people with an acquired or progressive neurological condition. The patient's condition should be such that active and effective rehabilitation can take place. One of the key aims of the service is to enable people to function as independently as possible by improving/maintaining their physical, social, and psychological well-being through appropriate assessment and treatment regimes. The Multiple Sclerosis Society recommends the involvement of specialist nurses and specialist multidisciplinary teams in the management of patients. The recommended standards suggest that people with MS should be put in contact with a specialist multidisciplinary team in their area where appropriate treatment in relation to tone management, posture, fatigue management and continence can be provided. Without specialist advice, patients may develop more serious and intractable problems in the longer term. The author will describe how working in a specialized team has moved towards meeting these recommendations and in so doing has enhanced care for people with MS.     

Stability in shifting sands: contemporary leadership roles in critical care

Background Contemporary nursing leadership roles in critical care are a reflection of the changing environment in which critical care is provided. Key issues In the UK, critical care nursing faces challenges in the form of: reduced number and seniority of medical staff cover for acute wards; mandated responsibility for management of patients outside of critical care units, without corresponding responsibility for managing staff; increased public and political awareness of deficits in critical care; increased use of Assistant Practitioners; and emphasis on longer‐term outcomes from intensive care. Evaluation New leadership roles have met these challenges head on with two main foci: patient management across the acute/critical care interface and hospital wide policies and practice. Conclusions The leadership roles examined in this paper highlight three underpinning goals: improved quality and safety of patient care; improved communication between professionals; and empowerment of junior nurses and doctors. Implications for nursing management There has been considerable investment in strategic leadership roles for critical care nursing; evidence is developing of the return on this investment for patient and service outcomes. Consideration must now be given to the preparation, mentorship and development of leadership roles for the next generation of nurse leaders.     

Nursing dependency and the costs of nursing care

The observed costs of nursing care for individual patients are compared with their stated dependency levels. The average costs of the dependency groups rise with dependency, but there are very large overlaps between the distributions. The derivation of a systematic method for allocating extra staff to wards illustrates the difficulty in matching staff supplied to labour demanded, especially in view of the small size of wards as management units. Nurses are warned against the consequences of cost-inefficiency.     

Multi-disciplinary interpretations of pain in older patients on medical units

The aim of this study was to assess the knowledge and attitudes of the health care team caring for older patients on acute medical wards. Pain is probably the most distressing symptom experienced by hospital patients. Pain management has traditionally been seen as part of the anaesthetist’s role, within the UK, establishment of acute pain teams was a response to the report ‘pain after surgery’ which cemented the link between pain and surgery. However, in 2004–2005, 63% of admissions to general medicine in the UK were individuals in the 60+ age group suggesting that older people are significant users of general medicine services. Treatment of pain is multi-disciplinary and effective pain management should be a universal response by health care professionals and non-professionals. A questionnaire was distributed to all nurses; registered and non-registered, junior doctors who worked on the acute medical wards, all physiotherapists and all pharmacists in the hospital. There were varying levels of pain management education identified across the professional groups and, whilst there is a reasonable level of pain knowledge both general and specific to the older person, there is still a need to improve the knowledge and attitudes of all health care professional groups caring for older patients in pain on acute medical wards.     

北京市三级甲等综合医院住院病人对护理服务满意度的影响因素研究

目的 探讨影响住院病人对护理服务满意度的因素.方法采用多阶段抽样的方法选取北京市4所三级甲等综合医院的1 496例病人,进行护理服务满意度测量;采用自行设计的问卷调查护理人力配置和病区工作量情况.结果 病人对护理服务满意度得分为(79.25±15.48)分;多元线性回归分析结果显示,病区中手术量和床位使用率影响病人对护...     

Effective management of peristomal pyoderma gangrenosum

Peristomal pyoderma gangrenosum (PPG) is a skin disorder which manifests as painful exudating, ulcerative lesions. It is generally associated with inflammatory bowel disease (IBD) when affecting patients with a stoma. Patients with PPG typically present to the stoma care nurse (SCN) in the first instance, when the discharging ulcers cause pain, prevent effective stoma appliance application and result in leakage. Anecdotal evidence suggests that clinical nurse specialist posts, such as that of the SCN, are being diluted within some trusts, with a demand for staff to work on wards to cover clinical shifts. As a consequence there is a possibility that these patients will not receive a prompt diagnosis and treatment plan. This article will examine the role of the SCN in managing the patient with PPG, including the use of effective topical treatments. The importance of early diagnosis to prevent escalation of PPG and subsequent prolonged patient discomfort-and the SCN's crucial role in this-is discussed.     

Registered nurses’ experience of care for adult patients with a temporary tracheostomy at general hospital wards. A phenomenological-hermeneutic explorative study

BackgroundCaring for adult patients with a temporary tracheostomy in general wards can be challenging and complex. Little research has explored registered nurses’ experiences with caring for these groups of patients.ObjectivesThis study sought to interpret and describe registered nurses’ lived experiences of caring for adult patients with a tracheostomy in general wards.Research design/methodologySix registered nurses were interviewed in this study. The interviews were analysed to gain comprehensive knowledge about caring for adult patients with a temporary tracheostomy. The interviews were transcribed, analysed, and interpreted by using Gadameŕs philosophical hermeneutics and Kvale and Brinkmann’s three steps of understanding.SettingThree different wards medical, surgical, and neurological of a teaching hospital in Norway.FindingsThree themes emerged from data analysis. These included experiencing clinically challenging patients, a lack of clinical support from the intensive care nurses, and a lack of professional confidence.ConclusionThis study highlighted the challenges surrounding the care of an adult patient with a tracheostomy in the general wards. Identifying these challenges would lead to further improvement in registered nurses’ experiences and, in turn, in the quality of competent care for adult patients with a tracheostomy in the general ward.Implications for Clinical PracticeUnderstanding the registered nurses’ experiences will assist the head nurses in planning and providing relevant information and education to provide safe and holistic patient care. Adequate support from intensive care unit nurses and professional development are required to ensure high-quality care. This study recommends that healthcare managers focus on establishing step-down units to improve patient outcomes, especially for high-risk patients and to increase the competencies of registered nurses in caring for adult patients with a tracheostomy as a whole person.     

Antegrade continence enema for the treatment of neurogenic constipation and fecal incontinence after spinal cord injury

OBJECTIVE: To describe the effects of an antegrade continence enema stoma formed in a paraplegic man with intractable constipation and fecal incontinence. DESIGN: Case report. SETTING: Spinal cord injury unit, Veterans Affairs hospital. PARTICIPANTS: Spinal cord injury (SCI) patient with T12 paraplegia. INTERVENTION: Surgical formation of antegrade continence enema stoma. MAIN OUTCOME MEASURES: Time of bowel program care, ease of fecal elimination, safety of procedure. RESULTS: Bowel care time was decreased from 2 hours to 50 minutes daily; 6 bowel medications were discontinued; fecal incontinence was eliminated; and no surgical or medical side effects noted after the procedure. CONCLUSION: The antegrade continence enema procedure is a safe and effective means of treating intractable constipation and fecal incontinence in the adult SCI patient. This option should be considered for those persons in whom medical management of bowel care has been unsuccessful.     

The connection between personnel resources with work loading and patient satisfaction on in-patient wards

Aim  The aim of the study is to describe the connection between the burden of nurses' work experience and patient dissatisfaction using electronic indicators available in databases.
Background  The hospitals in this study have a lot of information stored in electronic databases, but the data is stored in different databases and there are no straight connections between them.
Methods  This study was retrospective. Inpatient rates, workload statistics, patient classification, patient satisfaction and financial statistics were collected on 39 hospital wards from electronic databases. The data were analysed statistically.
Results  The results showed that the higher care intensity index and number of gross treatment days are, the greater was the burden on nurses. The burden was smaller on those wards using a named nurse system.
Conclusions  Nurses' workload varies according to the condition of patients and patient flow. There is a connection between high workload and patient dissatisfaction. Nurse Managers should easily be able to use significant indicators.
Implications for nursing management  Nursing management must have tools that are easy to use in every day workload measurement, burden adjustment and personnel planning in the long run. This article presents patient classification and the number of beds used including daily change percentage of wards as instruments for nursing management.     

Nombre de lits dédiés à la pathologie vasculaire cérébrale en soins de suite et de réadaptation. Les recommandations nationales sont-elles pertinentes ?

OBJECTIVE: We sought to determine the number of beds necessary for stroke patients in postacute care units and to measure the relevance of the national guidelines on required number of beds. METHODOLOGY: We conducted an epidemiological follow-up of a cohort, what allowed for evaluating stroke care under real-life conditions. We applied the French guidelines for transfer of patients to postacute care wards. RESULTS: Of the 605 stroke patients hospitalised, 156 with a mean age of 72 years were included. A total of 64 (41%) could return home directly from the acute care wards and 73 (47%) were referred to postacute care wards. Among the latter patients, 31 (43%) were transferred to a physical medicine and rehabilitation (PMR) unit and 42 (57%) to a geriatric unit. The 19 remaining patients died in acute care. Of the 137 surviving patients, 46.7% returned directly home and 53.2% were referred to postacute care wards. Of patients older than 80 years, 74% were transferred to a geriatric unit, whereas 76% of the patients less than 80 years were transferred to a PMR unit. DISCUSSION-CONCLUSION: The national guidelines are based on a rate of discharge of about 24% of stroke patients to postacute care wards. In our study, we found that 47% were transferred to such wards. If the guidelines are applied, 19 beds dedicated to stroke patients would be necessary for postacute stroke care on a national level, or double that (36) on a regional level. Of these 36 beds, 16 to 24 should be PMR beds. The calculation of the number of beds necessary often rests on a simple transposition of the results of the studies and not on an objective evaluation according to the local context. Studies of longitudinal follow-up of cohorts such as this seem essential to evaluate needs and measure the relevance of the national guidelines.     

Conceptions of patients and personnel concerning the substance of post-ward outpatient visits in psychiatric care

In post-ward outpatient services patients discharged from hospital are provided further care by the same ward personnel. The aim of this study was to describe and analyse the conceptions concerning the substance of post-ward outpatient visits (PWOV). A phenomenographic approach was used. The data were gathered by interviewing post-ward outpatients, personnel at psychiatric wards and in outpatient care and administrative personnel in psychiatric units. Seven main categories of describing the PWOV were formed: natural interaction, continuous assessment, follow-up of the implementation of pharmacotherapy, relapse prevention, search for coping methods, establishing motivation for treatment and family members' participation in care. The patient's health, life situation and coping in everyday life were constantly evaluated and followed up in diverse ways during the PWOV. To make PWOV successful, treatment should be planned individually based on the patient's needs, and the patient should have a close and functional cooperative relationship with the nurse.