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.     

Impact of a severe influenza vaccine shortage on primary care practice

BACKGROUND: Because of influenza vaccine shortages during the 2004-2005 influenza season, vaccine was targeted for high-risk priority groups. OBJECTIVES: To assess among primary care physicians: (1) ability to identify priority patients; (2) extent of shortages; and (3) effects of shortages on vaccine redistribution, patient referral and future plans for vaccine delivery. METHODS: Mailed surveys of pediatric (Peds), family medicine (FM), and general internal medicine (GIM) physicians randomly selected from the American Medical Association master file. RESULTS: Response rate was 37% and the study population included 377 Peds, 319 FM, and 251 GIM physicians. Seventy-five percent of Peds, 58% of FM and 60% of GIM had some method to identify priority patients, although only 39%, 21%, and 18%, respectively, had a computerized method. Forty-five percent of Peds, 73% of FM, and 75% of GIM experienced shortages, for a median of 2-3 months. Approximately 48%-50% of Peds, FM, and GIM obtained additional influenza doses; among these, 53% received vaccine from a public health entity. Fifty-one percent of Peds, 79% of FM, and 80% of GIM referred high-risk patients for immunization, 94% of the time to a public health clinic. More than 95% planned to administer influenza vaccine next season. CONCLUSIONS: The majority of physicians experienced influenza vaccine shortages for prioritized patients, especially those providers caring for adults. There was significant vaccine redistribution and patient referral, primarily involving the public health system. Enhancing methods of targeting priority patients and increasing cooperation with public health entities should be priorities in dealing with future influenza vaccine shortages.     

The patient and power: sociological perspectives on the consequences of holistic care

In contemporary community health care, practitioners are encouraged to view clients as rounded individuals who have the right to participate in health care decisions. This broader and more egalitarian view is termed here ‘holistic care’. It is contended that such an approach is at least partially a response to sociological critiques of earlier, more authoritarian and bio-reductionist forms of professional-client interaction. This paper examines how sociological commentators have responded to this new approach by contrasting two, very different perspectives. Interpretations based on the work of Jürgen Habermas tend to see holistic care as an advance on bio-medical approaches, in that it introduces mutual understanding and communication free from coercion into the professional/client relationship. Conversely, commentaries based on the ideas of Michel Foucault regard holistic care, with its surveillance of the psycho-social circumstances of clients, as extending bio-medicine's control of the body to include control of the human personality as well. It is argued that these differing interpretations of the consequences of holistic care reflect a wider debate concerning the possibility of human progress.     

Strategically addressing the nurse shortage: a closer look at the nurse funders collaborative

Despite consistent public and private investments in nursing over several decades, nurse shortages persist, appearing more acute today than ever before. The Nurse Funders Collaborative, a group of foundations, government agencies, and corporations convened by the Robert Wood Johnson Foundation, has been meeting since 2003, seeking opportunities to address issues facing nursing and health care more strategically. This paper reports on a study conducted under the collaborative's auspices, which highlights the categorical and regional funding patterns of funders of nursing over five years. This information provides nursing funders with ways to craft new solutions to the nurse shortage.     

Critical pathway effectiveness: assessing the impact of patient, hospital care, and pathway characteristics using qualitative comparative analysis

OBJECTIVE: To qualitatively describe patient, hospital care, and critical pathway characteristics that may be associated with pathway effectiveness in reducing length of stay. DATA SOURCES/STUDY SETTING: Administrative data and review of pathway documentation and a sample of medical records for each of 26 surgical critical pathways in a tertiary care center's department of surgery, 1988-1998. STUDY DESIGN: Retrospective qualitative study. DATA COLLECTION/ABSTRACTION METHODS: Using information from a literature review and consultation with experts, we developed a list of characteristics that might impact critical pathway effectiveness. We used hypothesis-driven qualitative comparative analysis to describe key primary and secondary characteristics that might differentiate effective from ineffective critical pathways. PRINCIPAL FINDINGS:" All 7 of the 26 pathways associated with a reduced length of stay had at least one of the following characteristics: (1) no preexisting trend toward lower length of stay for the procedure (71 percent), and/or (2) it was the first pathway implemented in its surgical service (71 percent). In addition, pathways effective in reducing length of stay tended to be for procedures with lower patient severity of illness, as indicated by fewer intensive care days and lower mortality. Effective pathways tended to be used more frequently than ineffective pathways (77 versus 59 percent of medical records with pathway documents present), but high rates of documented pathway use were not necessary for pathway effectiveness. CONCLUSIONS: Critical pathway programs may have limited effectiveness, and may be effective only in certain situations. Because pathway utilization was not a strong predictor of pathway effectiveness, the mechanism by which critical pathways may reduce length of stay is unclear.     

The Great Recession in Portugal: Impact on hospital care use

The Great Recession started in Portugal in 2009, coupled with severe austerity. This study examines its impact on hospital care utilization, interpreted as caused by demand-side effects (related to variations in population income and health) and supply-side effects (related to hospitals’ tighter budgets and reduced capacity).The database included all in-patient stays at all Portuguese NHS hospitals over the 2001–2012 period (n = 17.7 millions). We analyzed changes in discharge rates, casemix index, and length of stay (LOS), using a before–after methodology. We additionally measured the association of health care indicators to unemployment.A 3.2% higher rate of discharges was observed after 2009. Urgent stays increased by 2.5%, while elective in-patient stays decreased by 1.4% after 2011. The LOS was 2.8% shorter after the crisis onset, essentially driven by the 4.5% decrease among non-elective stays. A one percentage point increase in unemployment rate was associated to a 0.4% increase in total volume, a 2.3% decrease in day cases, and a 0.1% decrease in LOS.The increase in total and urgent cases may reflect delayed out-patient care and health deterioration; the reduced volume of elective stays possibly signal a reduced capacity; finally, the shorter stays may indicate either efficiency-enhancing measures or reduced quality.     

Hospital-sponsored primary care: II. Impact on patient access

This article, the second of two, considers the impact of a nationwide demonstration of 53 community hospital sponsored group practices (CHPs). Surveys of a sample of the communities in which the CHPs were introduced suggest that about half of the communities were socioeconomically and, to some extent, medically disadvantaged. The CHPs tended to attract people who had previously not had a regular source of care or who used hospital outpatient departments or emergency rooms, as well as patients of established primary care physicians. Access to care and satisfaction appeared to be as good or better for CHP patients compared to regular patients of physicians in the target areas. The programs did not increase the use of inpatient services, emergency rooms, or hospital outpatient departments. The findings suggest that at present community hospital sponsored group practices would not have a profound effect on access to care if adopted nationally, but that targeted implementation by hospitals in lower income and minority communities can improve patient opportunities for appropriate primary care services.     

Opportunities for improving patient care through lateral integration: the clinical nurse leader

Today, healthcare organizations are faced with the growing realization that functional and professional silos within the organization are counter to the provision of efficient and effective patient care and are fertile grounds for errors or sentinel events to occur. The improvement of patient care and prevention of errors require that collaboration among professionals occur at the patient care delivery level, not just within the leadership team. A new nursing role-the clinical nurse leader, the first new nursing role advanced nationally in more than three decades--currently is under development in more than 180 pilot healthcare delivery sites across the United States and Puerto Rico. The clinical nurse leader is a master's-prepared nurse who assumes accountability for healthcare outcomes for a specific group of clients within a unit or setting through the assimilation and application of research-based information to design, implement, and evaluate client plans of care. The clinical nurse leader serves as a lateral integrator for the healthcare team and facilitates, coordinates, and oversees the care provided by the healthcare team. Healthcare administrators should seize the opportunity to work with nurses in healthcare delivery organizations to influence the early evolution and diffusion of this new role.