"Anything that Benefits the Workers Should Benefit the Client": Opportunities and Constraints in Self-Directed Care During the COVID-19 Pandemic.

Self-directed care (SDC) models allow Home and Community Based Services (HCBS) consumers to direct their own care, thus supporting flexible, person-centered care. There are many benefits to the SDC model but access to resources is essential to successful outcomes. Considering the autonomy and flexibility associated with SDC, it is important to understand how SDC responded to the COVID-19 pandemic and the resources available to help manage this situation. We conducted 54 in-depth interviews with HCBS consumers, direct support workers, family caregivers, and providers to examine the impact of COVID-19 on HCBS services in Kansas. Findings illuminate how self-directed consumers carried a lot of employer responsibility, with limited resources and systemic barriers constraining self-determination and contributing to unmet care needs, stress, and burden. Policy flexibilities expanding the hiring of family members were beneficial but insufficient to address under-resourced working conditions and labor shortages that were exacerbated by the pandemic.

Comparing the Nurse Work Environment, Job Satisfaction, and Intent to Leave Among Military, Magnet®, Magnet-Aspiring, and Non-Magnet Civilian Hospitals.

OBJECTIVE: This study aimed to compare the nurse work environment, job satisfaction, and intent to leave (ITL) among military, Magnet®, Magnet-aspiring, and non-Magnet civilian hospitals. BACKGROUND: The professional nurse work environment is an important, modifiable, organizational trait associated with positive nurse and patient outcomes; creating and maintaining a favorable work environment should be imperative for nursing leaders. METHODS: Secondary data from the Army Nurse Corps and the National Database of Nursing Quality Indicators included the Practice Environment Scale of the Nursing Work Index (PES-NWI) and single-item measures of job satisfaction and ITL. RESULTS: Magnet and military hospitals had identical PES-NWI composite scores; however, statistically significant differences existed among the subscales. Military nurses were the most satisfied among all groups, although this difference was not statistically significant, yet their ITL was highest. CONCLUSIONS: Favorable work environments may exist in other organizational forms besides Magnet; however, the specific components must be considered.

Identifying Potentially Preventable Reasons Nurses Intend to Leave a Job.

OBJECTIVE: The aim of this study was to describe the relationships between intent to leave, reasons nurses intend to leave, and the nursing work environment in military hospitals. BACKGROUND: Intention to leave is a precursor of nurse turnover. The reasons nurses intend to leave may be influenced by leader interventions and potentially preventable. METHODS: This descriptive, correlational secondary analysis included 724 nurse survey responses from 23 US Army hospitals. Bivariate correlations and predictive modeling techniques were used. RESULTS: Forty-nine percent of nurses indicated they intended to leave, 44% for potentially preventable reasons. Dissatisfaction with management and the nursing work environment were the top potentially preventable reasons to leave. Nurses who intended to leave for potentially preventable reasons scored aspects of the nursing work environment significantly lower than those intending to leave for nonpreventable reasons. CONCLUSIONS: Identifying potentially preventable reasons in conjunction with intent to leave can provide leaders opportunities to intervene and influence turnover intention.

Comparison of Documentation on Inpatient Discharge and Ambulatory End-of-Visit Summaries.

INTRODUCTION: Providing complete pending diagnostic test information and medication lists on inpatient discharge and ambulatory end-of-visit summaries decreases adverse events, reduces medical errors, and improves patient satisfaction. The purpose was to compare inpatient and ambulatory settings regarding percentages of records with documentation of pending diagnostic test result information and medication lists given at discharge/end of visit. METHODS: Using a cross-sectional, observational design, 2018 NDNQI discharge/end-of-visit data from 133 inpatient and 90 ambulatory units in 20 hospitals were examined. Trained site coordinators reviewed records for documentation of discharge/end-of-visit elements. Mann-Whitney U tests were used to compare inpatient and ambulatory percent of elements completed. RESULTS: Across all discharge/end-of-visit elements, there were differences (all p < .001) between inpatient and ambulatory settings. Ambulatory units had a lower percent completion for all medication list and pending diagnostic result elements. Depending on the element, the sample means for documentation in discharge/end-of-visit summaries were 18.6-98.8% for inpatient and 4.5-61.8% for ambulatory settings. CONCLUSIONS: Discharge instructions and end-of-visit summaries are crucial forms of communication between clinicians and patients. However, many patients are not receiving complete information. IMPLICATIONS: In a large nationwide sample, we found substantial opportunities to improve completeness of summaries, particularly in ambulatory settings.

VA Quality Scholars Quality Improvement Coach Model to Facilitate Learning and Success.

Despite the increase in quality improvement (QI) education both in practice and in health professions' education, gaps exist in the usefulness and success of QI projects. Barriers to successful QI are a result of delays in implementation, teamwork issues, and lack of QI knowledge. These barriers can be addressed using a QI Coach. A QI Coach is an expert in QI principles who has excellent communication and collaboration skills, and is experienced with organizational policies. The purpose of this article is to (a) describe the VA Quality Scholars (VAQS) QI Coach Model that includes the role of a coach and effective coaching strategies and (b) discuss lessons learned from the application of the VAQS QI Coach Model. The QI Coach facilitates success by providing novice QI teams with practical skills, encouragement, and support.

Association of nurse work environment and safety climate on patient mortality: A cross-sectional study.

BACKGROUND: There are two largely distinct research literatures on the association of the nurse work environment and the safety climate on patient outcomes. OBJECTIVE: To determine whether hospital safety climate and work environment make comparable or distinct contributions to patient mortality. DESIGN: Cross-sectional secondary analysis of linked datasets of Registered Nurse survey responses, adult acute care discharge records, and hospital characteristics. SETTING: Acute care hospitals in California, Florida, New Jersey, and Pennsylvania. PARTICIPANTS: The sample included 600 hospitals linked to 27,009 nurse survey respondents and 852,974 surgical patients. METHODS: Nurse survey data included assessments of the nurse work environment and hospital safety climate. The outcome of interest was in-hospital mortality. Data analyses included descriptive statistics and multivariate random intercept logistic regression. RESULTS: In a fully adjusted model, a one standard deviation increase in work environment score was associated with an 8.1% decrease in the odds of mortality (OR 0.919, p<0.001). A one-standard deviation increase in safety climate score was similarly associated with a 7.7% decrease in the odds of mortality (OR 0.923, p<0.001). However, when work environment and safety climate were modeled together, the effect of the work environment remained significant, while safety climate became a non-significant predictor of mortality odds (OR 0.940, p=0.035 vs. OR 0.971, p=0.316). CONCLUSIONS: We found that safety climate perception is not predictive of patient mortality beyond the effect of the nurse work environment. To advance hospital safety and quality and improve patient outcomes, organizational interventions should be directed toward improving nurse work environments.

An online course improves nurses' awareness of their role as antimicrobial stewards in nursing homes.

BACKGROUND: To support the role of nurses as active proponents of antimicrobial stewardship in long-term care facilities, we developed an educational intervention consisting of a free online course comprised of 6 interactive modules. Here, we report the effect of the course on the knowledge, beliefs, and attitudes toward antimicrobial stewardship of nurses working in long-term care facilities. METHODS: We used a paired pre- and postcourse survey instrument to assess nurses' knowledge regarding the care of long-term care facility residents with infections and attitudes and beliefs regarding antimicrobial stewardship. RESULTS: There were 103 respondents, registered nurses or licensed practical nurses, who completed the pre- and postsurveys. Their mean knowledge scores improved from 75% (precourse) to 86% (postcourse, P <.001). After the course, nurses' agreement that their role influences whether residents receive antimicrobials increased significantly (P <.001). CONCLUSIONS: The online course improves nurses' knowledge regarding the care of long-term care facility residents with infections and improves their confidence to engage in antimicrobial stewardship activities. Empowering nurses to be antimicrobial stewards may help reduce unnecessary antibiotic use among institutionalized older adults.

Nursing Skill Mix, Nurse Staffing Level, and Physical Restraint Use in US Hospitals: a Longitudinal Study.

BACKGROUND: Although it is plausible that nurse staffing is associated with use of physical restraints in hospitals, this has not been well established. This may be due to limitations in previous cross-sectional analyses lacking adequate control for unmeasured differences in patient-level variables among nursing units. OBJECTIVE: To conduct a longitudinal study, with units serving as their own control, examining whether nurse staffing relative to a unit's long-term average is associated with restraint use. DESIGN: We analyzed 17 quarters of longitudinal data using mixed logistic regression, modeling quarterly odds of unit restraint use as a function of quarterly staffing relative to the unit's average staffing across study quarters. SUBJECTS: 3101 medical, surgical, and medical-surgical units in US hospitals participating in the National Database of Nursing Quality Indicators during 2006-2010. Units had to report at least one quarter with restraint use and one quarter without. MAIN MEASURES: We studied two nurse staffing variables: staffing level (total nursing hours per patient day) and nursing skill mix (proportion of nursing hours provided by RNs). Outcomes were any use of restraint, regardless of reason, and use of restraint for fall prevention. KEY RESULTS: Nursing skill mix was inversely correlated with restraint use for fall prevention and for any reason. Compared to average quarters, odds of fall prevention restraint and of any restraint were respectively 16 % (95 % CI: 3-29 %) and 18 % (95 % CI: 8-29 %) higher for quarters with very low skill mix. CONCLUSIONS: In this longitudinal study there was a strong negative correlation between nursing skill mix and physical restraint use. Ensuring that skill mix is consistently adequate should reduce use of restraint.

Nurse work environment and quality of care by unit types: A cross-sectional study.

BACKGROUND: Nursing unit is the micro-organization in the hospital health care system in which integrated patient care is provided. Nursing units of different types serve patients with distinct care goals, clinical tasks, and social structures and norms. However, empirical evidence is sparse on unit type differences in quality of care and its relation with nurse work environment. Nurse work environment has been found as an important nursing factor predicting nurse and patient outcomes. OBJECTIVES: To examine the unit type differences in nurse-reported quality of care, and to identify the association between unit work environment and quality of care by unit types. METHODS: This is a cross-sectional study using nurse survey data (2012) from US hospitals nationwide. The nurse survey collected data on quality of care, nurse work environment, and other work related information from staff nurses working in units of various types. Unit types were systematically classified across hospitals. The unit of analysis was the nursing unit, and the final sample included 7677 units of 14 unit types from 577 hospitals in 49 states in the US. Multilevel regressions were used to assess the relationship between nurse work environment and quality of care across and by unit types. RESULTS: On average, units had 58% of the nurses reporting excellent quality of care and 40% of the nurses reporting improved quality of care over the past year. Unit quality of care varied by unit types, from 43% of the nurses in adult medical units to 73% of the nurses in interventional units rating overall quality of care on unit as excellent, and from 35% of the nurses in adult critical care units to 44% of the nurses in adult medical units and medical-surgical combined units reporting improved quality of care. Estimates from regressions indicated that better unit work environments were associated with higher quality of care when controlling various hospital and unit covariates; and this association persisted among units of different types. CONCLUSIONS: Unit type differences exist in the overall quality of care as well as achievement in improving quality of care. The low rates of nurses reporting improvement in the quality of nursing care to patients suggest that further interventions focusing at the unit-level are needed for achieving high care quality. Findings from our study also suggest that improving nurse work environments can be an effective strategy to improve quality of care.

Learning by doing: observing an interprofessional process as an interprofessional team.

New competencies exist for interprofessional education, which are centered on the goal of improving quality of care and patient safety through improved interprofessional collaboration. Interprofessional education and effective interprofessional collaboration are cornerstones of the Veterans Affairs Quality Scholars fellowship program. The purpose of this project was to evaluate an innovative interprofessional education strategy in which teams of physicians and nurses were "learning by doing" as they observed and analyzed the functioning of an interprofessional process, specifically, inpatient discharge. Fellows completed voluntary, anonymous surveys seeking their perspectives about the project. Fellows' feedback revealed several themes, with both positive and negative characteristics related to team functioning, interprofessional understanding, microsystem knowledge, pooled knowledge and assignment challenges. The strength of this strategy is exemplified by the fact that fellows not only learned from each other's separate professional observations, but also observed the emergence of a shared interprofessional perspective through working together.

Specialty care delivery: bringing infectious disease expertise to the residents of a Veterans Affairs long-term care facility.

OBJECTIVE: To initiate a long-term care facility (LTCF) infectious disease (LID) service that provides on-site consultations to LTCF residents to improve the care of residents with possible infections. DESIGN: Clinical demonstration project. SETTING: A 160-bed LTCF affiliated with a tertiary care Veterans Affairs (VA) hospital. PARTICIPANTS: Residents referred to the LID team. MEASUREMENTS: The reason for and source of LTCF residents' referral to the LID team and their demographic characteristics, infectious disease diagnoses, interventions, and hospitalizations were determined. RESULTS: Between July 2009 and December 2010, the LID consultation service provided 291 consultations for 250 LTCF residents. Referrals came from LTCF staff (75%) or the VA hospital's ID consult service (25%). The most common diagnoses were Clostridium difficile infection (14%), asymptomatic bacteriuria (10%), and urinary tract infection (10%). More than half of referred residents were receiving antibiotic therapy when they first saw the LID team; 46% of residents required an intervention. The most common interventions, stopping (32%) or starting (26%) antibiotics, were made in accordance with principles of antibiotic stewardship. CONCLUSION: The LID team represents a novel and effective means to bring subspecialty care to LTCF residents.

Effective antimicrobial stewardship in a long-term care facility through an infectious disease consultation service: keeping a LID on antibiotic use.

DESIGN: We introduced a long-term care facility (LTCF) infectious disease (ID) consultation service (LID service) that provides on-site consultations to residents of a Veterans Affairs (VA) LTCF. We determined the impact of the LID service on antimicrobial use and Clostridium difficile infections at the LTCF. SETTING: A 160-bed VA LTCF. METHODS: Systemic antimicrobial use and positive C. difficile tests at the LTCF were compared for the 36 months before and the 18 months after the initiation of the ID consultation service through segmented regression analysis of an interrupted time series. RESULTS: Relative to that in the preintervention period, total systemic antibiotic administration decreased by 30% (P<.001), with significant reductions in both oral (32%; P<.001) and intravenous (25%; P=.008) agents. The greatest reductions were seen for tetracyclines (64%; P<.001), clindamycin (61%; P<.001), sulfamethoxazole/trimethoprim (38%; P<.001), fluoroquinolones (38%; P<.001), and ß-lactam/ß-lactamase inhibitor combinations (28%; P<.001). The rate of positive C. difficile tests at the LTCF declined in the postintervention period relative to preintervention rates (P=.04). CONCLUSIONS: Implementation of an LTCF ID service led to a significant reduction in total antimicrobial use. Bringing providers with ID expertise to the LTCF represents a new and effective means to achieve antimicrobial stewardship.

The care span: The importance of transitional care in achieving health reform.

Under the Affordable Care Act of 2010, a variety of transitional care programs and services have been established to improve quality and reduce costs. These programs help hospitalized patients with complex chronic conditions-often the most vulnerable-transfer in a safe and timely manner from one level of care to another or from one type of care setting to another. We conducted a systematic review of the research literature and summarized twenty-one randomized clinical trials of transitional care interventions targeting chronically ill adults. We identified nine interventions that demonstrated positive effects on measures related to hospital readmissions-a key focus of health reform. Most of the interventions led to reductions in readmissions through at least thirty days after discharge. Many of the successful interventions shared similar features, such as assigning a nurse as the clinical manager or leader of care and including in-person home visits to discharged patients. Based on these findings, we recommend several strategies to guide the implementation of transitional care under the Affordable Care Act, such as encouraging the adoption of the most effective interventions through such programs as the Community-Based Care Transitions Program and Medicare shared savings and payment bundling experiments.

The effect of work hours on adverse events and errors in health care.

INTRODUCTION: We studied the relationship between registered nurses' extended work duration with adverse events and errors, including needlestick injuries, work-related injuries, patient falls with injury, nosocomial infections, and medication errors. METHOD: Using bivariate and multivariate logistic regression, this secondary analysis of 11,516 registered nurses examined nurse characteristics, work hours, and adverse events and errors. RESULTS: All of the adverse event and error variables were significantly related to working more than 40 hours in the average week. Medication errors and needlestick injuries had the strongest and most consistent relationships with the work hour and voluntary overtime variables. DISCUSSION: This study confirms prior findings that increased work hours raise the likelihood of adverse events and errors in healthcare, and further found the same relationship with voluntary overtime. IMPACT ON INDUSTRY: Legislation has focused on mandatory overtime; however, this study demonstrated that voluntary overtime could also negatively impact nurse and patient safety.

Education policy initiatives to address the nurse shortage in the United States.

Employment opportunities are expected to grow much faster for registered nurses (RNs) than for most other occupations. Yet a major shortage of nurses is projected by 2020. A nurse faculty shortage and financially strapped colleges and universities are limiting the ability of U.S. nursing schools to take advantage of historically high numbers of qualified applicants. Increased public subsidies are needed to provide greater access to nursing education, with a priority on baccalaureate and graduate nursing education, where job growth is expected to be the greatest.