The impact of nurse/physician collaboration on patient length of stay

Aim  This study examines the relationship between nurse/physician collaboration and patient length of stay (LOS).
Background  The quality of nurse/physician relationships has been shown to have an impact on patient outcomes. As the acuity level of patients admitted to hospitals continue to rise, the need for collaboratively determined care is essential for avoiding errors and promoting quality.
Methods  Data were collected on four units located in two Midwest hospitals. Nurses ( n  = 135) were asked to complete a survey seeking perceptions of nurse/physician collaboration. The survey data were then linked with patient ( n  = 310) data, including LOS, diagnostic-related groups (DRG) category and other patient-specific characteristics.
Results  Perceptions of nurse/physician collaboration were positively linked with actual LOS ( P  < 0.001) and inversely related to deviation from expected LOS (i.e. patient stay longer than expected) ( P  < 0.01). Patients receiving care from nurses who perceived greater collaboration were elderly and had higher levels of acuity. Longer LOS for these patients may be a result of their higher acuity level.
Conclusions and implications for Nursing Management  This study found that collaboratively determined care may result in longer LOS, but could prevent complications that may otherwise go untreated. Nurse administrators must implement strategies that foster the development of nurse/physician collaboration.     

Nursing morale: predictive variables among a sample of registered nurses in Australia

Aim  This study investigates the determinants of morale among Registered Nurses in Queensland, Australia.
Background  In light of the public discussions on the issues facing the future of nursing, it is critical to understand the factors that influence morale.
Methods  A 160-question instrument sought information from Registered Nurses on their perceptions of 'self', work and morale. A response rate of 41% was achieved ( n  = 343) from a convenience sample of three acute hospitals.
Results  Following binary logistic regression modelling for organizational morale, significant relationships were found with patient care provision and team interaction. Binary logistic regression modelling for personal morale revealed positive relationships with team interaction, consultation, professional recognition and lower levels of patient abuse.
Conclusion  The results point to a number of organizational and professional issues that can be considered by health care administrators and policy makers to develop workplaces that have a positive impact on the morale of nurses.     

Physiotherapists’ perceptions of collaborations with inter-professional team members in an ICU setting

Background In the intensive care unit (ICU) environment, inter-professional team collaborations have direct impact on patient care outcomes. Current evidence shows that providing physiotherapy to ICU patients shortens their length of stay and reduces their incidence of ventilator associated pneumonia and severity of critical illness neuropathy. Physiotherapists’ perceptions of their interactions with nurses and doctors as inter-professional team members in the ICU is important. Objectives To identify barriers and enablers of physiotherapists’ interactions with inter-professional team members in adult ICU settings, identify solutions to the barriers and determine if perceptions of interactions with ICU team members differ between junior and senior physiotherapists. Methods A qualitative study was done using semi-structured group discussions. Participants were recruited using convenience sampling. Participants were junior and senior physiotherapists from four private and four public sector hospitals in urban Johannesburg, South Africa. Interviews were audio recorded. Recordings were transcribed and direct content analysis of data was done to create categories, subcategories and themes. Results Twenty-two junior and 17 senior ICU physiotherapists participated in the study. Barriers raised by physiotherapists regarding communication with inter-professional team members in the ICU were non-ICU trained staff working in ICU, personality types, lack of professional etiquette, and frequent rotation of ICU staff. Enablers of communication with inter-professional team members were presence of team members in ICU during the day, good time management, teamwork approach to care and sharing of knowledge. Differing paradigms of teamwork among health professionals was highlighted as a cause of tension in the ICU inter-professional collaborations. Conclusion Physiotherapists are important members of the inter-professional ICU team. Exploring their interactions with other team members identified solutions that may improve collaboration between inter-professional team members to facilitate improved patient outcomes. Inter-professional education should inform ICU policies to create an environment that fosters teamwork. Finding creative ways to adequately staff the ICU without losing quality or driving up costs of care are matters that should take priority among policy makers. Contributions of the study Physiotherapists are essential and strategically placed in the ICU to reduce length of stay, and prevent patient physical function decline post ICU admission. This work explored physiotherapists’ perceptions of collaboration within inter-professional teams in the ICU and identified barriers that impede communication in inter-professional teams and suggested solutions. This research will contribute in improving collaboration between inter-professional teams in the ICU setting.     

Critical care nurses' experiences of grief in an adult intensive care unit

Title.  Critical care nurses' experiences of grief in an adult intensive care unit.
Aim.  This paper is a report a study of critical care nurses' experiences of grief and their coping mechanisms when a patient dies.
Background.  The goal of patients entering critical care is survival and recovery. However, despite application of advanced technologies and intensive nursing care, many patients do not survive their critical illness. Nurses experience death in their everyday work, exposing them to the emotional and physical repercussions of grief.
Method.  This study adopted a Heideggerian phenomenological approach, interviewing eight critical care nurses. Data collection occurred in 2007/8. Interviews were transcribed verbatim and themes generated through Colaizzi's framework.
Findings.  Participants reported feelings of grief for patients they had cared for. The death of a patient was reported as being less traumatic if the participant had perceived the death to be a 'good death', incorporating expectedness and good nursing care. They described how a patient's death was more significant if it 'struck a chord', or if they had developed 'meaningful engagement' with the patient and relatives. They denied accessing formal support: however, informal conversations with colleagues were described as a means of coping. Participants exhibited signs of normalizing death and described how they disassociated themselves emotionally from dying patients.
Conclusion.  There are many predisposing factors and circumstantial occurrences that shape both the nature of care of the dying and subsequent grief. Repeated exposure to death and grief may lead to occupational stress, and ultimately burn out. Emotional disengagement from caring for the dying may have an impact on the quality of care for both the dying patient and their family.     

Relationship between the length of hospital stay after hip fracture surgery and ambulatory ability or mortality after discharge in Japan

Aim:  To examine whether the length of hospital stay after hip fracture surgery is related to patients' ambulatory ability or mortality after discharge.
Methods:  This is a retrospective observational study of patients who had undergone hip fracture surgery at one of three hospitals in Japan. The medical records of patients who were ≥65 years and who had hip fracture surgery within the past 2.5 years were reviewed regarding the demographics, treatments, and health outcomes during the hospital stay. A mail survey, asking about health outcomes after discharge, was sent to the study participants and/or their family members. The response rate of the survey was 70% ( n  = 149).
Results:  The patients who were discharged between 30 and 39 days after surgery had significantly lower current ambulatory ability, compared to the patients who stayed for ≥40 days, after adjusting for patient characteristics, treatments, and hospital. The patients who were discharged within 2 weeks after surgery and the patients who were discharged between 30 and 39 days after surgery had a significantly higher risk of mortality, compared to the patients who stayed in the hospital for ≥40 days, after adjustments were made.
Conclusions:  If patients are discharged to a rehabilitation hospital before they are totally recovered from surgery, the emphasis might be on their rehabilitation without adequate management of their comorbidities. Additional prospective studies are needed to determine the effects of a shorter length of hospital stay after hip fracture surgery on patient outcomes.     

Characteristics of deaths in paediatric intensive care: a 10-year study

Objective: To describe the patient mortality over a 10-year period in a paediatric intensive care unit (PICU) including patient demographics, length of stay, cause and mode of death and to compare these findings with pre-existing literature from the western world.
Design: A retrospective chart review.
Setting: A UK tertiary PICU.
Patients: All children who died in the PICU over a 10-year period between 1 November 1997 and 31 October 2007 ( n = 204).
Interventions: None.
Measurements and main results: Data recorded for each patient included patient demographics, length of stay and cause of death according to the International Classification of Disease-10 classification, and mode of death. Mode of death was assigned for each patient by placement in one of four categories: (i) brain death (BD), (ii) managed withdrawal of life-sustaining medical therapy (MWLSMT), (iii) failed cardiopulmonary resuscitation (CPR) and (iv) limitation of treatment (LT). Over the study period, findings showed a median length of stay of 2 days (IQR 0–5 days), with a mortality rate of 5%. The most common mode of death was MWLSMT ( n = 112, 54.9%) and this was consistent across the 10-year period. Linear regression analysis demonstrated no significant change in trend over the 10 years in each of the modes of death; BD ( p = 0.84), MWLSMT ( p = 0.88), CPR ( p = 0.35) and LT ( p = 0.67).
Conclusion: End-of-life care is an important facet of paediatric intensive nursing/medicine. Ten years on from the Royal College of Paediatrics and Child Health publication 'Withholding or withdrawing life sustaining treatment in children: A framework for practice', this study found managed withdrawal of MWLSMT to be the most commonly practised mode of death in a tertiary PICU, and this was consistent over the study period.     

Retaining older nurses in primary care and the community

Title.  Retaining older nurses in primary care and the community.
Aim.  This paper is a report of a study conducted to examine issues associated with the impact of age on the retention of female primary and community care nurses in the National Health Service in England.
Background.  Little is known about why older nurses in the primary and community care workforce leave and what might encourage them to stay.
Methods.  A cross-sectional survey using a semi-structured postal questionnaire was carried out during 2005. Responses were received from 485 (61%) district nurses, health visitors, school nurses and practice nurses in five primary care trusts in England. Data were analysed to test for associations.
Results.  Older nurses were more likely than younger ones to report that their role had lived up to expectations ( P  = 0·001). Issues important for older nurses were feeling valued and being consulted when change was implemented. Important factors encouraging nurses to stay were pension considerations, reduced working hours near retirement, and reduced workload. For those with degree-level qualifications, enhanced pay was a factor encouraging retention ( P  = 0·044). Nurses might leave in response to high administrative workloads, problems in combining work and family commitments ( P ≤  0·001), and lack of workplace support ( P  = 0·029). Retirement and pensions advice was not widely available.
Conclusion.  Since two-thirds of nurses were generally happy in their role, it is important that the conditions necessary to maintain this level of satisfaction are continued throughout a nurse's working life. Nurses may all too easily consider leaving prematurely unless policy makers and managers ensure that their working environment reflects the issues nurses consider to be conducive to retention.     

Impact of community care in enabling older people with complex needs to remain at home

Aim.  This aim of the study was to explore the impact of community care in enabling older people with complex needs to remain at home.
Background.  Changing demographic trends and successive government policies have led to an increase in the number of older people with complex needs residing in the community.
Design.  A qualitative approach using semi-structured interviews was used to collect data from older people ( n  = 17) and carers ( n  = 14).
Method.  Social workers were asked to identify community dwelling older people (65+ years) with multiple needs requiring interventions from a range of health and social care practitioners.
Results.  Community care enabled older people with complex needs who would otherwise have required residential or nursing home care to remain in their own homes. This was the expressed wish of both the older people and carers interviewed.
Conclusions.  The provision of high-quality community care for older people is a globally significant challenge and one that requires creative solutions, both at a local and strategic level.
Relevance to clinical practice.  Nurses and other health and social care professionals need to understand the significance of 'home' for older people and take steps to ensure that additional and appropriate resources are targeted towards community care.     

Effects of a nurse practitioner on a multidisciplinary consultation team

Title.  Effects of a nurse practitioner on a multidisciplinary consultation team.
Aim.  This paper is a report of a study to evaluate the impact on office hours capacity, patient satisfaction, quality of life and costs of including a nurse practitioner in a multidisciplinary consultation team for patients with hand problems caused by rheumatoid arthritis.
Background.  Over 90% of patients with rheumatoid arthritis suffer symptoms in their hand joints and may be seriously disabled in performing daily, work or leisure activities. A recent promising development in the treatment of patients with a chronic disease is the co-ordinating and accompanying role of a nurse, such as a nurse practitioner, in a multidisciplinary treatment team.
Methods.  A two successive group time-series design was adopted. The intervention group ( n  = 78) visited a clinic with a nurse practitioner assigned to the team during 2003–2004. The control group ( n  = 69) was seen before inclusion of the nurse practitioner. Office hours capacity, patient satisfaction, quality of life and costs were assessed using questionnaires directly after consulting the team, and 3 and 6 months later.
Results.  Between-group comparisons of patient satisfaction and quality of life revealed no statistically significant differences. Changes within groups over time were not demonstrable. Mean office hour capacity increased by 17% ( t  = −1·906, d.f. = 32·879, P  = 0·065). The costs for professional home care or informal care were equal in the two groups.
Conclusion.  Evaluation of clinical practice using pre- and post-test design was impeded by changes in clinical practice, which made concrete conclusions difficult to draw. In future studies the satisfaction of participating clinicians should be evaluated, in addition to that of patients.     

Improving family communications at the end of life: implications for length of stay in the intensive care unit and resource use.

BACKGROUND: Inadequate communication persists between healthcare professionals and patients and patients' families in intensive care units. Unwanted or ineffective treatments can occur when patients' goals of care are unknown or not honored, increasing costs and care. Having the primary physician provide medical information and then having a physician and clinical nurse specialist team improve opportunities for patients and their families to process that information could improve the situation. This model has not been tested for its effect on patients' outcomes and resource utilization. OBJECTIVES: To evaluate the effect of a communication team that included a physician and a clinical nurse specialist on length of stay and costs for patients near the end of life in the intensive care unit. METHODS: During a 1-year period, patients judged to be at high risk for death (N = 151) were divided into 2 groups: 43 patients who were cared for by the medical director teamed with a clinical nurse specialist and 108 patients who received standard care, provided by an attending physician. RESULTS: Compared with the control group, patients in the intervention group had significantly shorter stays in both the intensive care unit (6.1 vs 9.5 days) and the hospital (11.3 vs 16.4 days) and had lower fixed ($15,559 vs $24,080) and variable ($5087 vs $8035) costs. CONCLUSIONS: Use of a physician and a clinical nurse specialist focused on improving communication with patients and patients' families reduced lengths of stay and resource utilization.     

Palliative care in nursing homes: exploring care assistants' knowledge

Aim.  To explore the level of palliative care knowledge and to identify educational needs of care assistants (CAs) working within a nursing home context.
Background.  In the United Kingdom (UK) many patients at the end-of-life are admitted to (or reside in) nursing homes, where they receive care from unqualified CAs who have little formal training. Mandatory training in specific skills to meet palliative care needs are absent.
Method.  Questionnaire to CAs in 48 of 91 private nursing homes in one UK region.
Findings.  A population of 1135 CAs were targeted with a response rate of 45% ( n  = 508). A high proportion of CAs in this sample required information about the philosophy and principles of palliative care. Results support the need for an educational initiative to improve palliative care in nursing homes.
Conclusion.  Although recognized as a common place of death for older people, CAs are often unprepared to provide end-of-life care to nursing home residents. It is recommended that attention be given towards developing the skills and knowledge of this staff group.     

Effects of an organized critical care service on outcomes and resource utilization: a cohort study

OBJECTIVE: To determine whether the presence of an on-site, organized, supervised critical service improves care and decreases resource utilization. DESIGN: The study compared two patient cohorts admitted to a surgical intensive care unit during the same period of time. The study cohort was cared for by an on-site critical care team supervised by an intensivist. The control cohort was cared for by a team with patient care responsibilities in multiple sites supervised by a general surgeon. The main outcome measures were duration of stay, resource utilization, and complication rate. SETTING: Study patients were general surgical patients in an academic medical center. RESULTS: Despite having higher Acute Physiology and Chronic Health Evaluation II scores, patients cared for by the critical care service spent less time in the surgical intensive care unit, used fewer resources, had fewer complications and had lower total hospital charges. The difference between the two cohorts was most evident in patients with the worst APACHE II score. CONCLUSIONS: Critical care interventions are expensive and have a narrow safety margin. It is essential to develop structured and validated approaches to study the delivery of this resource. In this study, the critical care service model performed favorably both in terms of quality and cost.     

Care of patients with chronic obstructive pulmonary disease in primary health care

Aim.  This paper is a report of a study of nurses' perceptions of caring for patients with chronic obstructive pulmonary disease.
Background.  Chronic obstructive pulmonary disease is a global health problem and the number of patients being treated with this disease in primary healthcare settings is increasing. This places new demands on the nurses involved.
Method.  A phenomenographic approach was adopted, using a purposive sample. Data were generated between February and May 2003 from 20 interviews with district nurses and general nurses who cared for patients in primary healthcare settings with chronic obstructive pulmonary disease.
Findings.  In most cases, nurses cared for older people with moderate to severe chronic obstructive pulmonary disease. They described this care from two overall orientations: task and individual. The nurses' perceptions of the care of these patients were described as creating commitment and participation by establishing a good relationship with patients and supporting them in their personal care, educating patients by supplying information and knowledge in various ways, co-operation by co-operating with or referring to other caregivers, and arranging and implementing clinical examinations and treatments.
Conclusion.  The type of care depended on who the patient met: either a task-oriented nurse or an individual-oriented nurse. Therefore, nursing programmes should pay special attention to the support and guidance of new and inexperienced and task-oriented nurses. Healthcare planners should take into consideration the need for individualized care when organizing care and allocating resources for chronically ill people.     

Differences in physician access patterns to hospice care

Few issues in health care have recently generated as much discussion as the two seemingly unrelated topics of out-of-hospital health care financing and compassionate care of patients at the end of life. These two topics meet where health care costs cross paths with the economic viability of hospice and palliative medicine. In this study, we evaluated 101 admissions to a large Medicare-certified hospice in the last quarter of 1995 to assess factors associated with timing of referral to hospice. Mean length of stay in hospice was 55 days; median was 23 days. The majority of patients had cancer diagnoses (74%). Contrary to our hypothesis, there was no statistically significant difference in mean patient lengths of stay between oncologist-referred and nononcologist-referred patients. However, when we compared patient lengths of stay lasting less than--versus longer than--30 days, more patients referred by nononcologists were in hospice longer than 30 days (chi 2 = 3.92, P < 0.05). With further evaluation, this difference was attributable to longer stays by patients covered by the Medicine hospice benefit, by those with noncancer diagnoses, and by those who were older. More of these patients were referred by nononcologists. The difference in referral patterns between oncologists and nononcologists disappeared when only cancer patients were considered. Consistent with initial hypotheses, caregivers of patients with shorter lengths of stay were significantly less satisfied with hospice care (t = -4.06, P < 0.001). These results suggest that health care benefits and other patient-specific issues influence timing of hospice referral rather than simply preferences by types of physicians. The impact on Medicare expenditures and hospice viability is discussed.     

Resource consumption and costs of palliative care services in Spain: a multicenter prospective study

Patients (n = 395) with terminal-stage cancer receiving attention from palliative care services (PCSs) were recruited over a period of 15 consecutive days from 171 participating PCS units. Resource consumption and costs were evaluated for 16 weeks of follow-up, and the findings were compared with a study conducted in 1992 so as to assess change over time. The most frequent health care interventions were homecare visits, hospital admissions, and patient-consultant phone calls. PCS provided 67% of all services and consultation interventions in 91% of patients. Compared with the historical data, there was a significant shift from the use of conventional hospital beds toward palliative care beds, a reduced hospital stay (25.5–19.2 days; P = 0.002), an increase in the death-at-home option (31%–42%), a lower use of hospital emergency rooms (52%–30.6%; P = 0.001), and an increase in programmed care. Compared to the previous resource consumption and expenditure study in 1992, the current PCS policy implies a cost saving of 61%, with greater efficiency and no compromise of patient care.     

Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients

OBJECTIVE: The purpose of this study was to examine the effect of proactive palliative care consultation on length of stay for high-risk patients in the medical intensive care unit (MICU). DESIGN: A prospective pre/post nonequivalent control group design was used for this performance improvement study. SETTING: Seventeen-bed adult MICU. PATIENTS: Of admissions to the MICU, 191 patients were identified as having a serious illness and at high risk of dying: 65 patients in the usual care phase and 126 patients in the proactive palliative care phase. To be included in the sample, a patient had to meet one of the following criteria: a) intensive care admission following a current hospital stay of >or=10 days; b) age >80 yrs in the presence of two or more life-threatening comorbidities (e.g., end-stage renal disease, severe congestive heart failure); c) diagnosis of an active stage IV malignancy; d) status post cardiac arrest; or e) diagnosis of an intracerebral hemorrhage requiring mechanical ventilation. INTERVENTIONS: Palliative care consultations. MEASUREMENTS AND MAIN RESULTS: Primary measures were patient lengths of stay a) for the entire hospitalization; b) in the MICU; and c) from MICU admission to hospital discharge. Secondary measures included mortality rates and discharge disposition. There were no significant differences between the usual care and proactive palliative care intervention groups in respect to age, gender, race, screening criteria, discharge disposition, or mortality. Patients in the proactive palliative care group had significantly shorter lengths of stay in the MICU (8.96 vs. 16.28 days, p = .0001). There were no differences between the two groups on total length of stay in the hospital or length of stay from MICU admission to hospital discharge. CONCLUSIONS: Proactive palliative care consultation was associated with a significantly shorter MICU length of stay in this high-risk group without any significant differences in mortality rates or discharge disposition.     

Simultaneous care: a model approach to the perceived conflict between investigational therapy and palliative care

Clinical trials of investigational therapy in patients with advanced cancer may not pay sufficient attention to quality of life (QOL) and supportive care issues, resulting in an adverse impact on the quality of care (QOC). We hypothesized that the simultaneous delivery of investigational therapy and a structured program of supportive care would result in measurable improvements in predefined outcomes without adverse events for patients, caregivers, or the physician/patient interaction. This report describes the findings of a trial designed to test the feasibility and initial results of such an approach. Forty-four patients accrued to Phase I or Phase II investigational therapy trials were simultaneously enrolled into a defined home care program focused on supportive care needs of the patient and family, as well as assessment of the toxicities of investigational therapy. These 44 patients constitute the Simultaneous Care (SC) cohort. Twenty patients receiving investigational therapy and the standard supportive care measures available through the Cancer Center served as a control group, designated the Usual Care (UC) cohort. We measured QOL using baseline and monthly assessments of the Functional Assessment of Cancer Therapy (FACT-G) instrument. This instrument measures four domains of well-being: physical, emotional, functional, and social/family. We prospectively defined QOC as: the percentage of hospice referrals; hospice length of stay; and number of cycles of chemotherapy administered. A summary score for the four FACT domains at each time point for each patient was calculated (FACT 4). The FACT 4 scores of the SC group improved compared to the UC group but did not reach a significant difference. Individual scores reflected a wide range of psychometric variability. A statistically significant difference in referral to hospice was seen in the SC group (35/44) compared to the UC group (8/15) (P = 0.034). The median length of stay in hospice was the same for both cohorts but the mean stay was greater in the SC cohort (54 days) compared to the UC cohort (37 days). The mean number of chemotherapy cycles was not different between SC and UC (P = 0.25). The self-reported acceptance by patients, caregivers, physicians and Cancer Center support staff was qualitatively excellent. Patients with advanced cancer at the time of enrollment onto investigational therapy should have made an explicit transition to palliative care goals but often have not. In the current health care environment, patients with advanced cancer without curative potential may be forced by their health provider or health insurer to choose between disease-directed therapy (including investigational therapy) or structured best supportive care programs. In this emerging era of targeted therapies, SC provides an approach designed to optimize palliative care goals while supporting the clinical research mission of offering patients with advanced cancer new and potentially better therapeutic interventions. SC is a system of care that enhances patient choice by allowing patients and families to have concurrent access to two beneficial options. SC may enhance coordination of care and facilitate patients' explicit transition from curative intent to palliative intent. In order to validate this approach, a randomized comparative trial evaluating SC has been initiated.     

Using a simulated chaotic home environment for preparing nursing and social work students for interdisciplinary care delivery in a Scottish context

Communication with the patient's identified family is one of the most important and ongoing service to be provided by the inter-professional team in health care. Placing this importent service within the context of “attachment, security and trust” should help professional team members to learn how to configure patient's families into the circle of health care collaboration. The communication offered to the patient and patient's family is the most important aspect to inter-professionalism within health care. Breakdowns in this communication of trust can have drastic effects with long standing emotional impact.