Strengthening tRansparent reporting of reseArch on uNfinished nursing CARE: The RANCARE guideline.

Unfinished, rationed, missed, or otherwise undone nursing care is a phenomenon observed across health-care settings worldwide. Irrespective of differing terminology, it has repeatedly been linked to adverse outcomes for both patients and nursing staff. With growing numbers of publications on the topic, scholars have acknowledged persistent barriers to meaningful comparison across studies, settings, and health-care systems. The aim of this study was thus to develop a guideline to strengthen transparent reporting in research on unfinished nursing care. An international four-person steering group led a consensus process including a two-round online Delphi survey and a workshop with 38 international experts. The study was embedded in the RANCARE COST Action: Rationing Missed Nursing Care: An international and multidimensional Problem. Participation was voluntary. The resulting 40-item RANCARE guideline provides recommendations for transparent and comprehensive reporting on unfinished nursing care regarding conceptualization, measurement, contextual information, and data analyses. By increasing the transparency and comprehensiveness in reporting of studies on unfinished nursing care, the RANCARE guideline supports efficient use of the research results, for example, allowing researchers and nurses to take purposeful actions, with the goal of improving the safety and quality of health-care services.

Using GIS to detect cluster and spatial disparity in maternal health indicators: a need for social health interventions.

Maternal mortality remains a serious global health concern. Although global efforts have produced some encouraging results in some World Health Organization's health regions, disparities persist within many countries. Additionally, in many developing countries, inadequate documentation of various health events including maternal mortality and morbidity, make it difficult to determine the true extent of the problem. Maternal health indicators are therefore proxies used in estimating health status in developing countries. Using geospatial and geovisualization techniques, this study examines district level disparities in two maternal health indicators in Ghana antenatal care (ANC) visits and skilled birth attendance (SBA). The results reveal districts with complete lack of access to higher health care professionals and others with underutilization of antenatal services. The findings provide important input for targeting location-specific public health and maternal health interventions.

Evaluating the Performance of a Single-Item, Global, Estimate of Missed Nursing Care.

BACKGROUND AND PURPOSE: Current measures of missed nursing care employ inventories of tasks which are rated for the frequency with which each is missed. These lists have shortcomings for research and clinical evaluation. There is a need for measures with less response burden, wider generalizability, and greater sensitivity and specificity for identifying poor quality care. METHODS: We tested a single-item, global, measure using data from a large study of missed care in Australia. We employed traditional and innovative analysis techniques such as receiver operating characteristic curve and item response theory. RESULTS: The single-item measure had adequate concurrent and convergent validity when compared to one list-format measure of missed care and strong sensitivity and specificity for identifying poor quality care. CONCLUSIONS: A well-crafted single-item measure, such as the one tested, can be useful for measuring missed nursing care.

Measuring Unfinished Nursing Care: What to Consider When Choosing and Scoring Surveys.

Unfinished nursing care is common in the inpatient setting and is associated with negative patient outcomes. This indicator is being assessed with increasing frequency to determine the quality of nursing services. Measurement bias was identified in this comparison of unfinished care surveys. Potential sources of bias should be considered when selecting and scoring unfinished nursing care surveys for quality assessment.

Texas Nurse Staffing Trends Before and After Mandated Nurse Staffing Committees.

This article describes the evolution of mandated nurse staffing committees in Texas from 2002 to 2009 and presents a study that analyzed nurse staffing trends in Texas using a secondary analysis of hospital staffing data (N = 313 hospitals) from 2000 to 2012 obtained from the American Hospital Association Annual Survey. Nurse staffing patterns based on three staffing variables for registered nurses (RNs), licensed vocational nurses (LVNs), and total licensed nurses were identified: full-time equivalents per 1,000 adjusted patient days, productive hours per adjusted patient day, and RN skill mix. Similar to national trends between 2000 and 2012, most Texas hospitals experienced an increase in RN and total nurse staffing, decrease in LVN staffing, and an increase in RN skill mix. The magnitude of total nurse staffing changes in Texas (5% increase) was smaller than national trends (13.6% increase). Texas's small, rural, government hospitals and those with the highest preregulation staffing levels experienced the least change in staffing between 2000 and 2012: median change of 0 to .13 full-time equivalents per 1,000 adjusted patient days and median change in productive hours per patient day of 0 to .23. The varying effects of staffing committees in different organizational contexts should be considered in future staffing legislative proposals and other policy initiatives.

Unfinished nursing care, missed care, and implicitly rationed care: State of the science review.

OBJECTIVES: The purposes of this review of unfinished care were to: (1) compare conceptual definitions and frameworks associated with unfinished care and related synonyms (i.e. missed care, implicitly rationed care; and care left undone); (2) compare and contrast approaches to instrumentation; (3) describe prevalence and patterns; (4) identify antecedents and outcomes; and (5) describe mitigating interventions. METHODS: A literature search in CINAHL and MEDLINE identified 1828 articles; 54 met inclusion criteria. Search terms included: implicit ration*, miss* care, ration* care, task* undone, and unfinish*care. Analysis was performed in three phases: initial screening and sorting, comprehensive review for data extraction (first author), and confirmatory review to validate groupings, major themes, and interpretations (second author). RESULTS: Reviewed literature included 42 quantitative reports; 7 qualitative reports; 1 mixed method report; and 4 scientific reviews. With one exception, quantitative studies involved observational cross-sectional survey designs. A total of 22 primary samples were identified; 5 involved systematic sampling. The response rate was >60% in over half of the samples. Unfinished care was measured with 14 self-report instruments. Most nursing personnel (55-98%) reported leaving at least 1 task undone. Estimates increased with survey length, recall period, scope of response referent, and scope of resource scarcity considered. Patterns of unfinished care were consistent with the subordination of teaching and emotional support activities to those related to physiologic needs and organizational audits. Predictors of unfinished care included perceived team interactions, adequacy of resources, safety climate, and nurse staffing. Unfinished care is a predictor of: decreased nurse-reported care quality, decreased patient satisfaction; increased adverse events; increased turnover; decreased job and occupational satisfaction; and increased intent to leave. DISCUSSION & CONCLUSIONS: Unfinished care is a significant problem in acute care hospitals internationally. Prioritization strategies of nurses leave patients vulnerable to unmet educational, emotional, and psychological needs. Key limitations of the science include the threat of common method/source bias, a lack of transparency regarding the use of combined samples and secondary analysis, inconsistency in the reporting format for unfinished care prevalence, and a paucity of intervention studies.

Nurses and midwives perceptions of missed nursing care--A South Australian study.

BACKGROUND: Budgetary restrictions and shorter hospital admission times have increased demands upon nursing time leading to nurses missing or rationing care. Previous research studies involving perceptions of missed care have predominantly occurred outside of Australia. This paper reports findings from the first South Australian study to explore missed nursing care. AIM: To determine and explore nurses' perceptions of reasons for missed care within the South Australian context and across a variety of healthcare settings. METHOD: The survey was a collaborative venture between the Flinders University of South Australia, After Hours Nurse Staffing Work Intensity and Quality of Care project team and the Australian Nursing and Midwifery Federation, SA Branch. Electronic invitations using Survey Monkey were sent to randomly selected nurses and midwives and available online for two months. Three hundred and fifty-four nurses and midwives responded. This paper reports qualitative data from answers to the open questions. FINDINGS: Three main reasons for missed care were determined as: competing demands that reduce time for patient care; ineffective methods for determining staffing levels; and skill mix including inadequate staff numbers. These broad issues represented participants' perceptions of missed care. CONCLUSION: Issues around staffing levels, skill mix and the ability to predict workload play a major role in the delivery of care. This study identified the increasing work demands on nurses/midwifes. Solutions to the rationing of care need further exploration.

Mapping social processes at work in nursing knowledge development.

In this paper, we suggest a blueprint for combining bibliometrics and critical analysis as a way to review published scientific works in nursing. This new approach is neither a systematic review nor meta-analysis. Instead, it is a way for researchers and clinicians to understand how and why current nursing knowledge developed as it did. Our approach will enable consumers and producers of nursing knowledge to recognize and take into account the social processes involved in the development, evaluation, and utilization of new nursing knowledge. We offer a rationale and a strategy for examining the socially-sanctioned actions by which nurse scientists signal to readers the boundaries of their thinking about a problem, the roots of their ideas, and the significance of their work. These actions - based on social processes of authority, credibility, and prestige - have bearing on the careers of nurse scientists and on the ways the knowledge they create enters into the everyday world of nurse clinicians and determines their actions at the bedside, as well as their opportunities for advancement.

Balancing interests of hospitals and nurse researchers: lessons learned.

While nurse researchers and administrators in health care organizations need to collaborate to understand the variables that affect nursing practice environments and patient care outcomes, there are inherent risks associated with these collaborations that require careful consideration. A team of academic and hospital researchers found that in studying the off-peak (nights and weekends) nursing environment using institutional ethnography, which involved interviews of nurses and administrators, the subject of the research was frequently the hospitals where these individuals worked. Although the individuals who participated in the research consented to be interviewed about their work, it was less clear how and to what extent the anonymity of their organizations could be maintained. The risks and benefits encountered suggest the need for a decision-making process to be undertaken by collaborative research teams. This decision process and analysis can help ensure a fruitful research relationship that protects sensitive concerns of hospital entities while advancing our understanding of nursing practice environments and patient care outcomes. Important strategies include having all leaders and research team members discuss the agendas of all entities and individuals involved, including clearly delineating the roles, responsibilities, and contributions of all parties. In addition, any constraints or expectations of first right of review of publications needs to be negotiated from the outset. Collaborators need to review their agreements throughout the research process to avoid pitfalls that could adversely impact the relationships as well as the dissemination of knowledge gained.

Knowledge for re-forming nursing's future: standpoint makes a difference.

We draw on our recent research that has convinced us of the importance of nurses' participating in re-forming health care on their own terms. The empirical evidence we present here shows how "boardroom knowledge" of health care is constructed with different priorities than is the knowledge of direct care on which nurses' safe, efficient, and effective work relies. The 2 forms of knowledge are not the same. Nurses' knowledge is routinely transposed through a procrustean process of "working up" direct care nurses' knowledge into new informational forms without attention to the importance of the full range of what nurses know from their unique standpoint.

Evaluating the impact of scenario-based high-fidelity patient simulation on academic metrics of student success.

Despite the ongoing nursing shortage, nurse educators are responsible for preparing students to practice in highly complex health care systems. As nurse educators explore new learning strategies to support an increase in student admissions, they must also evaluate the impact of these strategies on the quality of the educational experience. The study reported here evaluated the impact of scenario-based, high-fidelity patient simulation used to increase student admissions in an associate degree and baccalaureate nursing program in north-central Texas upon students' sense of their own clinical competence, graduating grade point average (GPA), and performance on standardized exit examinations. These are measures commonly used by nurse educators as metrics of success.

Off-peak nurse staffing: critical-care nurses speak.

The off-peak work environment is important to understand because the risk for mortality increases for patients at night and on the weekend in hospitals. Because critical-care nurses are on duty in hospitals 24 hours a day, 7 days a week, they are excellent sources of information regarding what happens on a unit during off-peak times. Inadequate nurse staffing on off-peak shifts was described as a major problem by the nurses we interviewed. The study reported here contributes the type of information needed to better understand the organization of nursing units and nurse staffing on outcomes.

Expanding what we know about off-peak mortality in hospitals.

For more than 30 years, a negative "off-peak effect" on patient outcomes has been associated with weekend and/or nighttime hospitalization in more than 25 diagnostic groups. Descriptive studies have verified the presence of this off-peak effect on patient outcomes but have done little to explain its cause. Institutional ethnography is a promising method for describing challenges nurses encounter and deal with on off-peak shifts and for exploring how those challenges arose in institutions designed to avoid such outcomes. The authors discuss their research and suggest a number of steps that nurse administrators might take to enhance their knowledge for handling off-peak challenges in their hospitals.

The effect of patients' race on provider treatment choices in coronary care: a literature review for model development.

This selective literature review provides insight into the depth and breadth of the problem of unequal medical treatment of Blacks compared with Whites, with particular focus on coronary heart disease. Poor health outcomes among Blacks, when compared with Whites, are well documented, and these disparities are linked to lower quality of and less aggressive medical treatment. It is not clear why these disparities in treatment occur. This review provides theoretical frameworks that attempt to explain the effect of race on treatment and presents an analysis of the quality and strength of existing evidence of racial disparity related to coronary care. Based on the review, implications for policy makers and providers are identified.

Differences between weekend and weekday nurse work environments and patient outcomes: a focus group approach to model testing.

DESIGN: This focus group study was exploratory and descriptive. PURPOSE: To identify differences between weekend and weekday nurse work environments that might explain higher rates of neonatal mortality among babies born on weekends. SAMPLE: The convenience sample consisted of 14 nurses from labor and delivery and neonatal intensive care units in 4 hospitals in 3 Texas cities. METHODOLOGY: Focus group sessions were audiotaped and then transcribed verbatim. Responses were analyzed inductively and then compared to the model of Organizational Support of Nursing Care presented by Aiken, Clarke, and Sloane. RESULTS: The focus group responses fit the model moderately well. However, there were additional constructs found in the data that went beyond the model. Additional constructs included patient need/demand, nurse characteristics/skill level, and external motivating and inhibiting factors. CONCLUSIONS: Nurses identified significant differences between weekend and weekday work environments such as less direct supervision and problems getting physician backup for emergencies on weekends. They gave examples where they felt weekend work environments resulted in both negative and positive patient outcomes. The nurses made no real distinction between night shift and weekend environments. The knowledge gained can be used to design effective strategies to improve the process of care and patient outcomes on weekends.

Conflict management styles in the health professions.

The purpose of the study was to determine prevalent conflict management styles chosen by students in nursing and to contrast these styles with those chosen by students in allied health professions. The associations among the level of professional health care education and the style chosen were also determined. A convenience sample of 126 students in a comprehensive university completed the Thomas-Kilmann Conflict Mode Instrument (TKI), which requires respondents to choose behaviors most characteristic of their response to conflict and classifies these behaviors as one of five styles. There was no significant difference between the prevalent conflict management styles chosen by graduate and undergraduate nursing students and those in allied health. Some of the students were already licensed in their discipline; others had not yet taken a licensing exam. Licensure and educational level were not associated with choice of styles. Women and men had similar preferences. The prevalent style for nursing students was compromise, followed by avoidance. In contrast, avoidance, followed by compromise and accommodation, was the prevalent style for allied health students. When compared to the TKI norms, slightly more than one half of all participants chose two or more conflict management styles, commonly avoidance and accommodation at the 75th percentile or above. Only 9.8% of the participants chose collaboration at that level. Implications for nurse educators, researchers, and administrators are discussed.

Sociodemographic factors associated with weekend birth and increased risk of neonatal mortality.

OBJECTIVE: To learn whether weekend risk of neonatal mortality is related to selected sociodemographic factors. DESIGN: A retrospective cohort design. Logistic regression was used to obtain odds ratios, and analysis of variance and chi-square to identify differences in values and incidence of key variables. SAMPLES: The data were derived from matched Texas birth and infant death certificates from 1999 through 2001. MAIN OUTCOME MEASURES: A subset of deaths up to 28 days of life attributable to conditions originating in the perinatal period. These deaths were called neonatal mortality-p. RESULTS: Women who were White, married, had Medicaid assistance, and had private prenatal care were less likely to deliver on weekends. Odds of neonatal mortality-p increased 36.5% when a birth took place on the weekend. The weekend crude odds of neonatal mortality-p increased for all racial/ethnic groups, but the differences were not statistically significant. CONCLUSIONS: The likelihood of delivering on the weekend increases with certain sociodemographic factors. This fact is important because the risk of neonatal mortality is higher among weekend births.

Weekend birth and higher neonatal mortality: a problem of patient acuity or quality of care?

OBJECTIVE: To address the differences in neonatal mortality among births to teenage mothers on weekdays and weekends. DESIGN: A retrospective descriptive design. Rates of neonatal mortality linked to maternal risk factors, low birth weight, gestational age, day of the week of the birth, and ethnicity/race were examined. PATIENTS/PARTICIPANTS: The population consisted of all recorded births to teenage mothers (< 20 years of age) in Texas in 1999 and 2000 (N = 111,749). These births were linked to death certificates for a subset of neonatal deaths within the same time period (n = 397). MAIN OUTCOME MEASURES: The outcome of interest was any death attributed to conditions originating in the perinatal period and recorded as such on the infant death certificate. RESULTS: Neonatal mortality was higher among the births on weekends than those during the week. Maternal risks and patient acuity levels of mothers and babies were not consistently higher on weekends. However, when risk factors were present, weekend births were more dangerous for Hispanics than for other ethnic or racial groups. CONCLUSIONS: Differences in patient acuity did not satisfactorily explain higher neonatal mortality rates on weekends. Thus, quality of care indicators such as lower hospital staffing and reduced availability of services on weekends may be critical sources of unnecessary neonatal deaths.

Fluoroquinolone-induced retinal degeneration in cats.

Although the exact mechanism of fluoroquinolone-induced retinal degeneration in cats remains to be elucidated, it appears from the literature that a similar retinal degeneration can be reproduced from either direct intravitreal injection of high concentrations of drug or exposure to UVA light and drug in laboratory animals. (19,25) The fluoroquinolone molecular structure is also similar structurally to other drugs that are known to directly induce retinal degeneration, including the cinchona alkaloids and halogenated hydroquinolones. Experimental evidence suggests that both the parent compound and its breakdown products via metabolism and photodegradation are active inducers of retinal degeneration. (18,25) Development of toxicoses also appears to be dependent on the maximum concentration of active drug, metabolite, or both reaching the retina over time. (18) Evaluation of the literature suggests that risk factors predisposing cats to fluoroquinolone-induced retinal degeneration may include the following: 1) large doses or plasma concentrations of drug, 2) rapid IV infusion of the antibiotic, 3) prolonged courses of treatment, and 4) age. Theoretically, other risk factors may also be involved including the following: 1) prolonged exposure to UVA light while the antibiotic is being administered, 2) drug interactions, and 3) drug or metabolite accumulation from altered metabolism or reduced elimination. To date, there are no published reports suggesting that the dose of fluoroquinolones should be reduced in geriatric cats or those with renal or hepatic failure. However, accumulation of fluoroquinolone metabolites in dogs and of the parent compound in humans with decreased renal function has been reported. (8-10) In humans with decreased renal function has been reported. (8-10) humans, fluoroquinolone doses are typically decreased in response to the degree of renal impairment. (28) In general, all fluoroquinolone antibiotics should be reserved for severe or recurrent infections, and whenever possible their use should be based on results whenever possible their use should be based on results of culture and susceptibility tests. When indicated, the fluoroquinolones, including enrofloxacin, can be used with limited risk of developing retinal degeneration in cats, provided the manufacturer's guidelines are adhered to and dose reduction is considered in geriatric cats or those with renal impairment. Dosing on renal impairment. Dosing on exact body weight using split dosing (2.5 mg/kg, PO, q 12 h) and avoidance of rapid IV infusions, and drug interactions may help to reduce the risk of retinal degeneration in some cases. Furthermore, monitoring cats for mydriasis and avoidance of UVA light while undergoing treatment may also be of benefit. Further evaluation of the pharmacokinetics of enrofloxacin and the other fluoroquinolones is required in geriatric cats or those with mild to moderate renal or liver impairment to determine whether drug accumulation, elevated peak concentrations of drug, or both may be occurring in this subset of cats. Therapeutic monitoring of drug concentrations may not always be feasible because of time and cost, but renal panels with dose or frequency reduction in response to the degree of renal impairment and the site and severity of infection may help to reduce retinal toxicosis.