Understanding nursing units with data and theory.

Nursing units are social systems whose function depends on many variables. Available nursing data, combined with a theory of organizational diagnosis, can be used to understand nursing unit performance. One troubled unit served as a case study in organizational diagnosis and treatment using modern methods of data mining and performance improvement. Systems theory did not prescribe how to fix an underbounded system. The theory did suggest, however, that addressing the characteristics of overbounded and underbounded systems can provide some order and structure and identify helpful resources. In this instance, the data analysis served to help define the unit's problems in conjunction with information gained from talking with the nurses and touring the unit, but it was the theory that gave hints for direction for change.

The silence of the unblown whistle: the Nevada hepatitis C public health crisis.

In 2008, one of the worst public health crises occurred in the state of Nevada, where authorities discovered up to 63,000 patients were potentially exposed to hepatitis C infection, largely due to substandard infection control and other negligent practices at two endoscopy clinics in Las Vegas. In the subsequent grand jury proceedings that followed, it was discovered that several clinic employees not only participated in these egregious practices, but doctors, nurses, and other health care professionals witnessed yet failed to report these incidents, largely due to fears of whistleblower retaliation. In response, the Nevada state legislature attempted to strengthen whistleblower protection laws, but it remains unclear if such laws actually protect employees who attempt to report patient safety concerns. As the push for quality patient outcomes becomes more prominent with health care reform, whistleblower concerns must be effectively addressed to ensure that health care professionals can report patient safety concerns without fear of retaliation.

Perceptions of policy and political leadership in nursing in New Zealand.

This qualitative study was focused on the landscape of nursing policy and political leadership in New Zealand. A volunteer sample (N = 18) of nurse leaders (Fellows of the College of Nurses Aotearoa (NZ) Inc) drawn from across the country was interviewed with respect to issues that affect their interest in participating in political action and policy work. The framework of stages of nursing's political development published by Cohen and colleagues (1996) was used as an interview guide. Respondents were asked to describe their own stage of political development, their perception of the political development of New Zealand nurses and nursing organisations at large, and also their thoughts on what could be done to better position nursing in healthcare policy development. In general, respondents agreed that the major nursing organisations in New Zealand (the College of Nurses-- Aotearoa and New Zealand Nurses Organisation [NZNO]) were moving toward increasing policy sophistication. Qualitative content analysis suggested five themes which, taken together, describe nursing's policy/political development in New Zealand: languaging; succession/legacy planning; Tall Poppies and Queen Bees; "it's a small country"; and speaking with one voice. Although limited by sample size, the information collected provides a beginning focus for discussion that can steer New Zealand nursing activities toward the wider involvement of nurse leaders in healthcare policy work on behalf of the discipline.

Strengthening the nursing and midwifery unit manager role: an interim programme evaluation.

AIMS: An interim evaluation was conducted on the professional development components of the New South Wales (NSW) Health 'take the lead' ('ttl') programme, an initiative aimed at enhancing nursing/midwifery unit managers' (N/MUM) skills. BACKGROUND: Previous research has highlighted the importance of strong nurse leaders, and shown that training programmes may assist in improving leadership skills. The NSW Nursing and Midwifery Office (NaMO) developed the 'ttl' programme for N/MUMs with the intention of improving hospital quality by strengthening nurse leadership. The programme had three strands, with the professional development modules a key component. METHOD: Semi-structured interviews were conducted with 17 participants who had completed components of the 'ttl' programme. The interviews explored participants' perceptions of the programme, and suggestions for improvement. Qualitative analysis was conducted on the transcribed interviews. RESULTS: The N/MUMs reported feeling increasingly empowered, knowledgeable and supported as a result of attending the 'ttl' workshops. CONCLUSIONS: The results suggest that the studied components of the 'ttl' programme may be effective in assisting nurse leaders gain new leadership skills and institute positive changes in the nursing work environment. IMPLICATIONS FOR NURSING MANAGEMENT: Leadership programmes such as 'ttl' may provide an effective tool for improving N/MUM performance and role confidence.

Nursing work directions in Australia: does evidence drive the policy?

A significant body of research has shown a relationship between nurse staffing (in particular, skill-mix: the proportion of Registered Nurses [RNs]) and both morbidity and mortality. This relationship is typically investigated by measuring the incidence of Nursing Sensitive Outcomes (NSOs) under different skill-mix levels. Yet whilst the evidence suggests that richer skill-mix is associated with a lower incidence of NSOs, recent Australian policy reforms have proposed the replacement of Registered Nurses with less qualified staff. The present study sought to examine the relationship between staffing, skill-mix, and incidence of NSOs at two hospitals in one Australian state. The study sought to determine the rate of occurrence of several NSOs, the relationship of skill-mix to that rate, and the number of patients affected per annum. It was found that the current rate of NSOs across wards ranged from 0.17% to 1.05%, and that there was an inverse relationship between the proportion of hours worked by RNs and NSO rates: an increase of 10% in the proportion of hours worked by RNs was linked to a decrease in NSO rates by between 11% and 45%. It was estimated that increasing the RN staffing percentage by 10% would mean 160 fewer adverse outcomes for patients per year across these two hospitals. Importantly, increases in nursing hours overall (without increases in skill-mix) had no significant effect on patient outcomes. These findings challenge current policy recommendations, which propose increasing the number of unregistered staff without increasing skill-mix.

A modest proposal: nurse practitioners to improve clinical quality and financial viability in critical access hospitals.

Rural health care has achieved a new focus of attention with the passage of the Affordable Care Act (ACA). This article argues that nurse practitioners may be an important resource to help rural hospitals, especially critical access hospitals (CAH), achieve their mission of community service while protecting their always-delicate financial sustainability. Nurse practitioners' scope of practice is well suited to the needs of rural patients, and their ability to participate in expanding preventive services is especially essential in remote areas. Barriers to nurse practitioner practice include restrictive state laws and federal and state policies.

Nursing staffing, nursing workload, the work environment and patient outcomes.

Nurse staffing (fewer RNs), increased workload, and unstable nursing unit environments were linked to negative patient outcomes including falls and medication errors on medical/surgical units in a mixed method study combining longitudinal data (5 years) and primary data collection.

Creating a medical home through the 340B Drug Pricing Program.

OBJECTIVE: This study was designed to track inpatient and outpatient utilization before and after the implementation of the 340B Drug Pricing Program in a public university hospital. METHODS: Before and after design built upon administrative clinical and financial data. RESULTS: Outpatient and emergency department utilization rates increased with small increments of direct cost. Inpatient utilization decreased while inpatient length of stay increased with over three million dollars in direct cost savings. CONCLUSIONS: Improving continuity of care for patients without a usual source of care may have the effect of creating a "medical home." The 340B Drug Pricing Program may be one policy tool to improve care for the underserved while increasing outpatient utilization and decreasing inpatient utilization and costs.

Staffing, skill mix and the model of care.

AIMS AND OBJECTIVES: The study aimed to explore whether nurse staffing, experience and skill mix influenced the model of nursing care in medical-surgical wards. BACKGROUND: Methods of allocating nurses to patients are typically divided into four types: primary nursing, patient allocation, task assignment and team nursing. Research findings are varied in regard to the relationship between these models of care and outcomes such as satisfaction and quality. Skill mix has been associated with various models, with implications for collegial support, teamwork and patient outcomes. DESIGN: Secondary analysis of data collected on 80 randomly selected medical-surgical wards in 19 public hospitals in New South Wales, Australia during 2004-2005. METHODS: Nurses (n = 2278, 80.9% response rate) were surveyed using The Nursing Care Delivery System and the Nursing Work Index-Revised. Staffing and skill mix was obtained from the ward roster and other data from the patient record. Models of care were examined in relation to these practice environment and organisational variables. RESULTS: The models of nursing care most frequently reported by nurses in medical-surgical wards in this study were patient allocation (91%) and team nursing (80%). Primary nursing and task based models were unlikely to be practised. Skill mix, nurse experience, nursing workload and factors in the ward environment significantly influenced the model of care in use. Wards with a higher ratio of degree qualified, experienced registered nurses, working on their 'usual' ward were more likely to practice patient allocation while wards with greater variability in staffing levels and skill mix were more likely to practice team nursing. CONCLUSIONS: Models of care are not prescriptive but are varied according to ward circumstances and staffing levels based on complex clinical decision making skills. RELEVANCE TO CLINICAL PRACTICE: Variability in the models of care reported by ward nurses indicates that nurses adapt the model of nursing care on a daily or shift basis, according to patients' needs, skill mix and individual ward environments.

Violence toward nurses, the work environment, and patient outcomes.

PURPOSE: To relate nurses' self-rated perceptions of violence (emotional abuse, threat, or actual violence) on medical-surgical units to the nursing working environment and to patient outcomes. DESIGN: Cross-sectional collection of data by surveys and primary data collection for 1-week periods on 94 nursing wards in 21 hospitals in two states of Australia. METHODS: Nursing Work Index-Revised (NWI-R); Environmental Complexity Scale (ECS) PRN-80 (a measure of patient acuity); and a nursing survey with three questions on workplace violence; combined with primary data collection for staffing, skill mix, and patient outcomes (falls, medication errors). FINDINGS: About one third of nurses participating (N=2,487, 80.3% response rate) perceived emotional abuse during the last five shifts worked. Reports of threats (14%) or actual violence (20%) were lower, but there was great variation among nursing units with some unit rates as high as 65%. Reported violence was associated with increased ward instability (lack of leadership; difficult MD and RN relationships). Violence was associated with unit operations: unanticipated changes in patient mix; proportion of patients awaiting placement; the discrepancy between nursing resources required from acuity measurement and those supplied; more tasks delayed; and increases in medication errors. Higher skill mix (percentage of registered nurses) and percentage of nurses with a bachelor of science in nursing degrees were associated with fewer reported perceptions of violence at the ward level. Intent to leave the present position was associated with perceptions of emotional violence but not with threat or actual assault. CONCLUSIONS: Violence is a fact of working life for nurses. Perceptions of violence were related to adverse patient outcomes through unstable or negative qualities of the working environment. Perceptions of violence affect job satisfaction. CLINICAL RELEVANCE: In order to manage effectively the delivery of nursing care in hospitals, it is essential to understand the complexity of the nursing work environment, including the relationship of violence to patient outcomes.

Effects of health policy reforms on nursing resources and patient outcomes in New Zealand.

Health policy reforms in New Zealand during the 1990s impacted on hospital operations, on the nursing workforce, and on patients. This study analyses changes in rates of 20 adverse patient outcomes that are potentially sensitive to nursing (OPSNs) before (1989-1993), during (1993-2000), and after (2000-2006) the policy reforms, using all New Zealand public hospital inpatient discharge data for this period. Comparisons of changes in mean annual rates across periods revealed the expected trajectory of acceleration during the reform period relative to the prereform period, and a subsequent deceleration in the postreform period. This S-shaped pattern was clearly evident in 16 of the 20 OPSNs, and partially evident in the remaining 4. These results are interpreted as evidence that the 1990s policy reforms inspired by managerialism had deleterious effects on patient outcomes, and that these effects coincided with changes in nursing resources and the work environment.

Churn: patient turnover and case mix.

Patient throughput and casemix changes on nursing wards are little understood aspects of nursing's responsibility for nursing wards/units as hospital operations. In this study, the movement of patients on and off wards in 27 Australian public hospitals (286 wards) were analyzed over a 5-year period. Casemix change at the nursing unit level was also examined. In the data here, medical/surgical patients moved on average more than twice in an average hospital stay of only about 4 days. The absence of ward-level metrics compromises the ability of nursing unit/ward managers to meet their own efficiency and quality standards. Measurements of churn would give nurses another way to talk about the work of nursing to senior management and would give nurse executives a way to describe hospital operations and throughput and the impact on staff, patients, and resource allocation.

"Noses and eyes": nurse practitioners in New Zealand.

Principles for understanding and evolving nurse practitioner practice, politics and policy are distilled from 40 years of experience in the United States and Australia. The issues in all countries are remarkably similar. Some historical and conceptual grounding may assist the continuing development of this expanded role for nursing in New Zealand.

Finding midwifery in administrative data systems.

Nurse-midwifery has accomplished remarkable clinical, policy, and political achievements using specially-collected data. Today, midwifery practice data can be found in existing administrative data systems: birth registration, hospital data depositories, and claims files. Issues in finding midwifery as practice and profession in these data systems are discussed. Improving the integrity of data that reveal midwives as caregivers should be a priority.

Inpatient nursing unit volume, length of stay, cost, and mortality.

Nursing unit volume-outcome relationships exist for patients assigned selected DRGs. This finding suggests that, in some cases, aggregating inpatients with similar clinical conditions may result in lower cost of care, shorter length of stay, and fewer hospital deaths.

Targeting educational initiatives.

The nursing education department of a large teaching hospital faced the challenge of prioritizing the delivery of staff education programs after reductions in personnel and resources. Patient population data were used to guide curricula development. Results included improved clinical practice in a cost-effective manner.

An analysis of high-cost users at an Australian public health service organization.

High-cost users generate extremely high costs when compared with average users in the same diagnostic-related group (DRG). They represent a major financial loss for a health service organization. The research was conducted using an area health service patient database for online analytical processing to produce descriptive statistics and graphs of 'high-cost' and 'non-high-cost users'. Trends and patterns were identified across key variables derived from clinical, financial and operational categories. The main results are: 20% of costs are spent by 3% of the population; elective admission is higher in the high-cost group; tracheostomy has the most number of cases and is the most expensive DRG; LOS is mostly longer for complex cases however, high costs can be attributed to other factors. In conclusion, these findings are potentially useful to patients, medical staff, management and health service decision-makers. The limitation of this study is the exclusion of profitability.

Effects of New Zealand's health reengineering on nursing and patient outcomes.

BACKGROUND: In 1993, New Zealand (NZ) implemented policies aimed at controlling costs in the country's public health care system through market competition, generic management, and managerialism. The cost control focus was similar to reengineering efforts implemented by other countries struggling with escalating health care costs, particularly the United States. OBJECTIVE: The study's purpose was to examine the effects hospital reengineering may have on adverse patient outcomes and the nursing workforce. RESEARCH DESIGN: The study was a retrospective, longitudinal analysis of administrative data. Relationships between adverse outcome rates and nursing workforce characteristics were examined using autoregression analysis. SUBJECTS: All medical and surgical discharges from NZ's public hospitals (n = 3.3 million inpatient discharges) from 1989 through 2000 and survey data from the corresponding nursing workforce (n = 65,221 nurse responses) from 1993 through 2000 were examined. MEASURES: Measures included the frequency of 11 nurse sensitive patient outcomes, average length of stay, and mortality along with the number of nursing full time equivalents (FTEs), hours worked, and skill mix. RESULTS: After 1993, nursing FTEs and hours decreased 36% and skill mix increased 18%. Average length of stay decreased approximately 20%. Adverse clinical outcome rates increased substantially. Mortality decreased among medical patients and remained stable among surgical patients. The relationship between changes in nursing and adverse outcomes rates over time were consistently statistically significant. CONCLUSIONS: In the chaotic environment created in NZ by reengineering policy, patient care quality declined as nursing FTEs and hours decreased. The study provides insight into the role organizational change plays in patient outcomes, the unintended consequences of health care reengineering and market approaches in health care, and nursing's unique contribution to quality of care.