Effects of shift length on quality of patient care and health provider outcomes: systematic review.

BACKGROUND: Healthcare providers work increasingly under a variety of shift work systems to cover the continuous care required by patients. However, the effects of shift work on patient and provider outcomes in healthcare settings has not been systematically evaluated. OBJECTIVE: To identify and analyse the available evidence on the effect of shift length (8-h vs 12-h shifts) on quality of patient care and healthcare provider outcomes. METHODS: Systematic searching of eight online databases, key governmental/organisational websites and academic journals with ancestry search of relevant articles (limited to articles published in English and Spanish). RESULTS: Of 562 articles that were retrieved from 20 446 titles identified through database and manual searches, 27 satisfied the inclusion criteria, of which 15 were rejected because of low methodological quality. The 12 final studies included cross-sectional/survey (7), before-after (3) and prospective cohort (2) designs. The main primary outcomes evaluated were: (1) quality of patient care and (2) healthcare provider outcomes. The results were equivocal. With respect to the effect of shift length on quality of patient care, two studies found that errors and near errors were associated with working longer shifts, and another study reported decreased patient complications and length of stay with longer shifts. Specific healthcare provider outcomes such as health complaints, well-being, drug and alcohol consumption, stress and job satisfaction were mostly evaluated by single studies and therefore there was insufficient evidence from which to draw conclusions. CONCLUSIONS: Methodological quality of the studies generally was low and results equivocal with insufficient evidence to determine the effects of shift length on quality of patient care and healthcare provider outcomes. Clearly, robust well-designed studies are needed to examine the effect of shift length on patient and healthcare provider outcomes.

Clinical nurse educators as agents for change: increasing research utilization.

The purpose of this study was to examine the determinants of research utilization among clinical nurse educators. The primary goal for clinical nurse educators is the facilitation of professional development of practicing nurses. Responsibilities include promoting best practice by mentoring others, acting as an information source, and assisting in the development of policies and procedures based on available research evidence. Using Rogers' (Diffusion of Innovations, 4th edn., The Free Press, New York) diffusion of innovations theory as a theoretical foundation, we conducted a secondary analysis to test a predictive model of research utilization using linear regression. Results show that educators report significantly higher research use than staff nurses and managers. Predictors of research utilization include attitude toward research, awareness of information based on research, and involvement in research activities. Localite communication predicted conceptual research use and mass media predicted symbolic use, lending support to the idea that overall, instrumental, conceptual, and symbolic research utilization are conceptually different from one another. Our findings show that the research utilization behaviors of clinical nurse educators position them to facilitate evidence-based nursing practice in organizations. We discuss the theoretical, conceptual, and nursing role implications of our findings for nursing practice, education, and research. Suggestions for future research includes studying actual use of research findings of clinical nurse educators and designing intervention studies that assesses the effectiveness of clinical nurse educators as facilitators of research utilization in organizations.

Ingredients for change: revisiting a conceptual framework.

Finding ways to deliver care based on the best possible evidence remains an ongoing challenge. Further theoretical developments of a conceptual framework are presented which influence the uptake of evidence into practice. A concept analysis has been conducted on the key elements of the framework--evidence, context, and facilitation--leading to refinement of the framework. While these three essential elements remain key to the process of implementation, changes have been made to their constituent sub-elements, enabling the detail of the framework to be revised. The concept analysis has shown that the relationship between the elements and sub-elements and their relative importance need to be better understood when implementing evidence based practice. Increased understanding of these relationships would help staff to plan more effective change strategies. Anecdotal reports suggest that the framework has a good level of validity. It is planned to develop it into a practical tool to aid those involved in planning, implementing, and evaluating the impact of changes in health care.

Decision aids: are they worth it? A systematic review.

OBJECTIVES: The field of consumer decision support interventions has grown rapidly in the last 20 years, particularly since the increased formalization of evidence-based decision-making in health care. However, little is known as yet about the effect these decision aids have on relevant outcomes. To identify outcomes influenced by consumer decision aids (CDAs) and the particular effects of CDAs on those outcomes. METHOD: Published reports of randomized controlled trials and other designs in English identified from searches of Medline, Cancerlit, CINAHL, PsycINFO, Social Science Abstracts, the Cochrane Library and Current Contents, and from ancestry searches, hand searches and consultation with key informants. Studies were included if consumers were the decision-makers, decisions were real and not hypothetical, the intervention met a strict definition of a CDA and decisions involved treatment or screening. Data on setting, subjects, decision types, decision aid features and outcomes were extracted. The validity of each study included was evaluated by two team members. Summative ratings were calculated and categorized as high, medium and low. RESULTS: Over 500 titles were initially assessed; 96 study reports were obtained and screened for inclusion. Twenty-two reports representing 20 studies met the inclusion criteria. Eight studies with a low rating were excluded. Results were synthesized from the remaining 12 studies. Published studies of CDAs are increasing although still few in number. Outcomes such as knowledge and decision-making processes are influenced by CDAs but effects on treatment preferences, the actual decision or other outcomes have yet to be clearly established. CONCLUSIONS: Improved outcomes result from the use of CDA in some categories of outcome but insufficient evidence exists yet to support improved outcomes in all categories or to evaluate whether, given the considerable costs of many CDAs, funding for extensive ongoing development and testing can be sustained.

Devolution to democratic health authorities in Saskatchewan: an interim report.

BACKGROUND: In 1995 Saskatchewan adopted a district health board structure in which two-thirds of members are elected and the rest are appointed. This study examines the opinions of board members about health care reform and devolution of authority from the province to the health districts. METHODS: All 357 members of Saskatchewan district health boards were surveyed in 1997; 275 (77%) responded. Analyses included comparisons between elected and appointed members and between members with experience as health care providers and those without such experience, as well as comparisons with hypotheses about how devolution would develop, which were advanced in a 1997 report by another group. RESULTS: Most respondents felt that devolution had resulted in increased local control and better quality of decisions. Ninety-two percent of respondents believed extensive reforms were necessary and 83% that changes made in the previous 5 years had been for the best. However, 56% agreed that there was no clear vision of the reformed system. A small majority (59%) perceived health care reform as having been designed to improve health rather than reduce spending, contrary to a previous hypothesis. Many respondents (76%) thought that boards were legally responsible for things over which they had insufficient control, and 63% perceived that they were too restricted by rules laid down by the provincial government, findings that confirm the expectation of tensions surrounding the division of authority. Respondents with current or former experience as health care providers were less likely than nonprovider respondents to believe that nonphysician health care providers support decisions made by the regional health boards (45% v. 63%, p = 0.02), a result that confirmed the contention that the role of health care providers on the boards would be a source of tension. INTERPRETATION: Members of Saskatchewan district health boards supported the general goals of health care reform and believed that changes already undertaken had been positive. There were few major differences in views between appointed and elected members and between provider and nonprovider members. However, tensions related to authority and representation will require resolution.

Nurses' experience of violence in Alberta and British Columbia hospitals.

This study examined responses to a survey on violence in the workplace from a sample of 8,780 registered nurses practising in 210 hospitals in the Canadian provinces of Alberta and British Columbia. Findings relate to the frequency of violence against nurses, reported as the number of times they experienced a violent incident in the workplace. Nearly half (46%) of those surveyed had experienced 1 or more types of violence in the last 5 shifts worked. Frequency varied by type: emotional abuse 38%, threat of assault 19%, physical assault 18%, verbal sexual harassment 7.6%, sexual assault 0.6%. Further, 70% of those who had experienced violence indicated they had not reported it. Patients constituted the main source of all types of violence. The most prevalent type, emotional abuse, was further explored for its possible determinants. This was also the type of violence most evenly distributed among sources (patients, families, co-workers, physicians). Multiple regression modelling using the individual nurse as the unit of analysis showed the significant predictors of emotional abuse to be age, casual job status, quality of care, degree of hospital restructuring, type of unit, relationships among hospital staff, nurse-to-patient ratios, and violence-prevention measures; using the hospital as the unit of analysis the predictors were found to be quality of care, age, relationships with hospital staff, presence of violence-prevention measures, and province. These findings illustrate important differences in models that use the individual and the institution as the unit of analysis. Implications include targeting prevention strategies not only at the nurse but, perhaps more importantly, at the hospital. Overall, the findings suggest that health-care institutions are not always healthy workplaces and may increasingly be stressful and hazardous ones.

Evidence-based nursing Web sites: finding the best resources.

Evidence-based nursing is becoming an increasingly widespread phenomenon in the nursing profession. As the evidence-based nursing movement grows, the Internet/World Wide Web has become a vital information link for keeping pace with current science and medical advancements. This article describes Internet resources currently available to support evidence-based nursing practice, presents practical search methods for locating these resources, and suggests criteria for evaluating the "evidence" available on the Internet. Results of an Internet search for Web sites that met the proposed criteria for support of an evidence-based nursing practice located only three sites. The sites are described and evaluated for their usefulness. The authors demonstrate that although many Internet resources are available to nurses, few sites provide information or evidence supported by valid research.

Mapping the research utilization field in nursing.

The recent increase in interest in the field of research utilization, often embedded in the notions of evidence-based practice, presents a rich opportunity to advance the field in nursing. While an extensive literature on the subject exists in nursing, close examination reveals that much of it is opinion and anecdotal literature, and that sustained and programmatic theory building and testing in this field has been sporadic at best. This article maps the field of research utilization, proposing that we focus on major areas of inquiry: scientific, historical, and philosophical foundations, synthesis, determinants, policy, interventions to increase research utilization, and outcomes. In so doing, alternative ways of viewing and conceptualizing this field are possible. In conducting the kinds of studies and supporting the kinds of programs identified in this map, nursing, in collaboration with appropriate partners, can significantly advance the field of research dissemination and utilization studies and practice at many levels in the health system.

The conceptual structure of research utilization.

Despite the fact that the nursing literature is replete with calls to make the practice of nursing research based, little is known about the structure and function of research utilization. The purpose of this study was to explore the conceptual structure of research utilization. Data were collected from a randomly selected sample of 600 registered nurses practicing in western Canada. Using the techniques of structural equation modeling (with LISREL), competing models representing conceptual structures of research utilization were developed and evaluated. In the first model, a simplex style of model, the investigator proposed that a nurse's early responses would influence subsequent responses to the question measuring research utilization, implying a time ordered causal sequence. In the second style of model, a common cause (or factor-like) model, the investigator proposed a stable underlying concept, research utilization, that was relatively insensitive to prompting and time ordering. The simplex style of model failed to reach acceptable indices of fit. The common cause model fit the data well, suggesting that instrumental, conceptual, and persuasive research utilization exist and that a global measure of research utilization may be defensible.

Modeling the individual determinants of research utilization.

Despite more than two decades of investigation, our accumulated knowledge about what influences nurses' use of research is underdeveloped. This study's objectives were to develop and test a series of structural equation models that included individual factors believed to influence research utilization. Estimates of the models were obtained using maximum likelihood estimation. Model fit was assessed by examining chi-square, the adjusted goodness of fit index, and the standardized residuals. Within a simple model that permitted only direct effects and controlled for instrumental, conceptual, and persuasive research utilization, 3 of 26 concepts exerted significant effects on research utilization. These were a positive attitude toward research, belief suspension, and in-services attended. These results support the assertion that our descriptive body of research on the determinants of research utilization is underdeveloped, limiting our ability to design and test effective strategies to increase the use of research findings in nursing practice.

Nurse staffing and patient outcomes: evolution of an international study.

Industry-wide health sector reforms in the United States, Canada, and Europe have provided a unique opportunity to examine the effects of hospital restructuring on inpatient nursing care and patient outcomes across an array of settings. Seven interdisciplinary research teams--1 each in Alberta, British Columbia, England, Germany, Ontario, Scotland, and the United States--have formed an international consortium whose aim is to study the effects of such restructuring. Each site has enrolled large numbers of hospitals and nurses to explicate the role that organization of nursing care, a target of hospital restructuring, plays in differential patient outcomes. The study seeks to understand more fully the influence of both nurse staffing and the nursing practice environment on patient outcomes. Discussion of the theoretical foundation, study design, and process of developing the study instruments and measures illustrates the process to date, as well as the feasibility of and opportunities inherent in such an international endeavour.

The development of a database for payment card embossing machines.

In order to meet increasing operational demands involving the forensic examination of payment cards, a software program was created to enable the cards to be linked by identifying characteristics found on characters embossed on their plastic surfaces. In doing so, a database was developed, reducing an otherwise insurmountable task into an orderly and efficient process. Counterfeit cards as well as altered genuine cards, from across Canada, can be accurately correlated and linked to the specific embossing machines responsible for their production.

Will evidence-based nursing practice make practice perfect?

Evidence-based practice, or evidence-based decision-making, is rapidly developing as a growth industry in nursing and the health professions more widely. It has its origins in the work of the British epidemiologist Archie Cochrane and has recently been re-energized in Canada by the National Forum on Health and its call for a culture of evidence-based decision-making. Before we adopt evidence-based nursing (EBN) as a mantra for the 21st century, we should examine its origins and its consequences, and we should probe related concepts, 2 of which are the nature and structure of practice-based knowledge and the nature and structure of evidence generally. Findings of a recent survey of nurses in western Canada are used to illustrate that nurses use a broad range of practice knowledge, much of which is experientially based rather than research-based.

What kind of evidence does qualitative research offer cardiovascular nurses?

In this article I have tried to present a brief overview of qualitative research and to suggest some of the ways in which it may be of use to practitioners. Traditionally, we have not included qualitative studies in our discussion of research utilization. I think this is an unfortunate omission. Qualitative studies have a great deal to offer the practitioner and there are ways in which she or he can make use of them without doing so prematurely and without bringing harm to the client or patient. The required ingredients are twofold. First, from the research side we need scientifically sound studies. Second, from the practice side we need curious and informed consumers-consumers who are willing to take new information into their practice repertoires and let it inform those repertoires. Simple ingredients ... hard to get the cake to rise sometimes, though.

Data sharing in nursing research: advantages and challenges.

The sharing of data between investigators has received little attention in the nursing literature. Among other advantages, data sharing reinforces open scientific inquiry, encourages the development of multiple perspectives, and reduces respondent burden. However, ownership and control of the shared data, preservation of respondents' anonymity, and the costs of data sharing are among the issues that need to be addressed in agreements and contracts involving primary investigators, secondary investigators, and data repositories. The original researcher must spend time and energy to make data sharing possible. It is only when such efforts are acknowledged and rewarded that data sharing is likely to become a norm in the nursing profession. The authors argue that research data should be shared and nurse researchers should seek to have data from all publicly funded projects deposited in accessible data repositories. Nurse researchers need to incorporate plans for data sharing into their research programs and press for the infrastructures required to enable data sharing.