[THE IMPACT OF ACCREDITATION - ACHIEVEMENTS, BENEFITS AND BARRIERS: COMPARING THE VIEWPOINTS OF THE PROCESS LEADERS AND THE HOSPITAL STAFF].

AIMS: Evaluating the impact of the accreditation process on the basis of achievements, benefits and barriers from the viewpoint of leaders of the hospital accreditation in comparison to the hospital staff members. BACKGROUND: The implementation of standards for accreditation aim to improve the safety and quality of treatment. Partaking in this process has raised dilemmas regarding the actual benefits of accreditation in relation to the efforts invested in its achievement. Examining the standpoints of leaders of the process can reflect on the influence of this mechanism both on hospital activity and on hospital staff. METHODS: A survey was conducted among two groups: The first group, the JCI accreditation leaders group, included 35 participants (the steering committee, 15 chapter heads and the hospital management); and 71 participants from the extended headquarters (senior physicians, nurses and administration staff). The second group included 564 hospital personnel from the medical, nursing, alternative medicine, administrators and housekeeping staff. The questionnaire included 46 statements in five fields: the effectiveness and benefit from the process, weaknesses, barriers, leadership and administration of the accreditation. RESULTS: All the respondents to the survey perceived the process as a leverage for implementing significant changes in all levels of the organization. There were high levels of agreement on the benefit of the process regarding the effective and affective contribution - high morale, feelings of accomplishment and team pride, improvement in communication, cooperation and social cohesion. The weaknesses of the process, including financial costs, bureaucracy, paper overflow and work overload, were awarded relatively low scores. The advantages of the process were ranked high in both groups; the accreditation leaders group attributed the process benefits to the organization as a whole, ranking it significantly higher, as well as for the individual. The hospital staff rated as significantly higher: the contribution of the process on the department level and the opportunity to promote accomplishments that were not reached in the past. CONCLUSIONS: The survey raised organizational discussion which minimized the objections to the process of change. Focusing on chosen aspects bridged between managers and on-site staff to find effective solutions. DISCUSSION: In order to promote successful inter-organizational processes the hospital requires both leadership and a well-formulated strategic program. The secondary gains from the broad process encompassing the whole organization, such as in the case of accreditation, are expressed in the form of social cohesion, cooperation, group pride and high staff morale.

Identification of the Learning Styles and "On-the-Job" Learning Methods Implemented by Nurses for Promoting Their Professional Knowledge and Skills.

The aim of this study was to identify the learning styles and methods used by nurses to promote their professional knowledge and skills. 928 nurses from 11 hospitals across Israel completed 2 questionnaires, (1) Kolb's Learning Style Inventory, Version 3.1. and (2) the On-The-Job Learning Styles Questionnaire for the Nursing Profession. The most common learning style was the convergent style. The other learning styles were rated in the following descending order: accommodation, assimilation, and divergence. The on-the-job learning style consistently ranked highest was experience of relevant situations. On the other hand, seeking knowledge from books, journals, television, or the Internet was ranked lowest on all the indicators examined. With respect to general and on-the-job learning styles, statistically significant differences were found between groups of nurses by: country of birth, gender, department, age, education, and role. Nurses required to take more personal responsibility for their own professional development by deepening their self-learning skills.

An evaluation of preventing pressure ulcers in the urinary meatus.

As many as 5% of male hospital patients develop pressure ulcers. This brief study was done to obtain more research about this topic by evaluating the effectiveness of an intervention designed to prevent pressure ulcers in the urinary meatus as a result of urethral catheterization. Implications for critical care nurses are included.

Retrospective study of emerging themes in the decision-making process of patients considering amputation.

How patients make decisions about their future treatment has been sparsely study and with respect to limb amputation, a particularly difficult decision, not at all. An examination of this should furnish nurses vital knowledge about how patients come to the decision to give or refuse this consent. To reach as deep understanding as possible of how from the patients' point of view they reach the decision to consent to the amputation of a lower limb. The research was conducted in the qualitative method. Thirty lower-limb amputees (aged 32-88) took part in the study. In-depth interviews were held with the participants. The data were processed by means of content analysis. The main thematic categories identified were, in the chronological order of their appearance: 'The trail of torment leading to the decision to amputate', 'The turning point--taking the decision' "I just couldn't take any more pain" "We opt for life, we don't want to die". The more protracted and pain-filled the 'the trail of torment' the more mentally prepared patients were to give consent to amputation. Asked to look back on their choice, almost all interviewees had no regrets and even found virtues in it. The patients' decisions represented a mix of their grasp of the medical information supplied them by their doctors, their own personal values--opting for life prevailing over the desire for a whole body, and consideration for their family. The patients saw the decision-making process about amputation as a process of achieving consensus between themselves, their doctors and their family.

'A pacemaker in my heart' -- classification of questions asked by pacemaker patients as a basis for intervention.

AIMS: The research aimed to identify the information patients find necessary, following pacemaker implantation. BACKGROUND: Although pacemaker devices do not have an adverse impact on lifestyle, they evoke anxiety related to the patient's activities and lifestyle. DESIGN: Survey. METHODS: A convenience sample of participants was taken from the entire population of patients who attended the cardiology clinic between January-June 2007; 274 individual meetings were held with 123 pacemaker patients in three periods, reflecting different stages of recovery. In the meeting, patients were invoked to ask any question they may have regarding pacemaker implantation. The questions were collected from the patients and categorised chronologically, in accordance with their frequency in three periods, reflecting different stages of recovery. RESULTS: Eight categories, representing common issues and content were raised: motion and effort, environmental influences, personal hygiene, knowledge concerning the pacemaker operation, medical treatment, eating and drinking, clothing and general questions. Findings show that the common factor for most of the questions was the loss of confidence in the various aspects of life. The largest relative question proportion was in the motion and effort (27%) (e.g. may I swim? how many kg may I lift?) and environmental influences (26%) (e.g. may I use a cellular phone? may I use a shaving machine?). CONCLUSIONS: A coherent, continuous pattern was found, characterising the different points of measurement where, at the first point, questions were characterised as more existential, related to daily routine activities and as time passed and patients were exposed to non-daily activities and conditions, other questions were raised. RELEVANCE TO CLINICAL PRACTICE: Pacemaker implant guidance should be based upon experimental evidence, arranged according to each category's relative weight and take into account the patient's point of view.

Familial polyposis: a case study.

This article presents a case study of a patient who was treated for 5 years from the time of diagnosis until his death. The patient was diagnosed with familial polyposis at the age of 35 due to a family history of the same. He suffered from low body image and showed a poor response to treatment, especially regarding nutrition. The period of time related to the presentation of symptoms and the patient's subsequent deterioration was characterized by attempts on the part of nursing staff to improve the patient's quality of life. Treatment of multiple fistulae was employed, while keeping the skin intact, along with the creative development of a unique bandaging method. This article describes the course of the patient's disease and specifies his problems and their solutions. It is hoped that presentation of this case will benefit caregiving staff in dealing with similar cases.

Nurses' professional and personal values.

The purpose of this study was to measure professional and personal values among nurses, and to identify the factors affecting these values. The participants were 323 Israeli nurses, who were asked about 36 personal values and 20 professional values. The three fundamental professional nursing values of human dignity, equality among patients, and prevention of suffering, were rated first. The top 10 rated values all concerned nurses' responsibility towards patients. Altruism and confidentiality were not highly rated, and health promotion and nursing research were rated among the last three professional values. For personal (instrumental) values, honesty, responsibility and intelligence were rated first, while ambition and imagination were rated 14th and 16th respectively out of 18. Significant differences (P < 0.05) were found among some personal and professional values rated as functions of culture, education, professional seniority, position and field of expertise. The results may assist in understanding the motives of nurses with different characteristics and help to promote their work according to professional ethical values.

Emergency department staff preparedness for mass casualty events involving children.

BACKGROUND: In recent years, the World Health Organization in general, and Israel in particular, have dealt with mass casualty events (MCEs) resulting from terrorism. Children are the casualties in many of these events-a reality that forces hospitals to prepare to deal with such a scenario. A literature review designed to identify unique recommendations regarding pediatric MCEs highlights both a lack of existing training programs and uncertainty on the part of health care staff when dealing with these events. OBJECTIVES: The purpose of the study was to examine the preparedness level of emergency department staff to deal with MCEs involving pediatric casualties. The study included 104 physicians and nurses working in, or responding to, the emergency department at a hospital in Israel. METHOD: The study included a 41-item questionnaire examining perception, approaches, and staff knowledge regarding dealing with pediatric MCEs versus those involving adults. The reliability of all sections of the questionnaire ranged between Chronbach's alpha coefficient 0.6 alpha-0.94. RESULTS: The preparedness levels for MCEs involving children were found to be low. Study participants ranked the likelihood of a pediatric MCE lower than one involving adults, while ranking significantly higher (P = .000) their ability to cope mentally and the knowledge and skills required when treating adults involved in MCEs. While nurses ranked higher than physicians regarding their knowledge and skills in dealing with pediatric MCE casualties, the level of knowledge for MCEs involving children was low in all subjects. Staff agreement for the parent of an MCE victim to be present during treatment was medium-low. IMPLICATIONS: On the basis of these findings, additional research involving a larger number of individuals and hospitals is indicated to determine if these results are consistent throughout the region.

"Between the fixed and the changing": examining and comparing reliability and validity of 3 sedation-agitation measuring scales.

The goal of the study was to compare the reliability and validity of 3 Sedation Agitation Scale. Two nurses and a physician conducted 130 observations simultaneously. They found an excellent interrater reliability in the Richmond Agitation Sedation Scale (r>0.86), and high correlations between the Richmond Agitation Sedation Scale and the Sedation Agitation Scale and Visual Analog Scale scales (r=0.92, r=0.85). The research findings will help to assert Richmond Agitation Sedation Scale as a daily assessment tool in the intensive care unit, and it will pave the way for construction a sedation protocol according to the Richmond Agitation Sedation Scale level.

Personal medical documents management--how patients perceive, keep and manage their medical documents: a qualitative study.

BACKGROUND: Absence of medical documents damages the quality of treatment and service. Despite the computerized medical folder, its use is still limited, and not all countries have a national health communications systems. That is why the patients are asked to bring with them the documents they hold. However, some patients lose the documents and others are uncooperative due to forgetfulness, and a lack of knowledge. OBJECTIVES: To examine how patients perceive, keep and manage medical documents. DESIGN: The research was conducted in the qualitative method. SETTINGS: A cardiology clinic, in a big medical center in Israel. PARTICIPANTS: A total of 28 patients suffering from ischemic heart disease and/or rhythm disorders. The sample was a convenience one, and were taken from the population visiting the Cardiology Clinic from May to October 2003. METHODS: Semi-structured interviews were held with the participants. The data were processed by means of content analysis. RESULTS: The findings indicate that, even though the participants expressed that it is the health system's responsibility to manage medical documents, most of them kept, and some even managed, their medical documents via a personal folder. By keeping documents and deciding to whom and when to show them the patient functions as a self-care manager. This made them more involved in their treatment and, they felt in control and empowered. CONCLUSION: Patient's attention to documents, as keeper and router, results in demonstrations of responsibility and involvement in treatment, consequently empowering the patient.

Caregivers' role in breaking bad news: patients, doctors, and nurses' points of view.

The aim of the research was to identify the caregivers' response patterns when breaking bad news at the first time of cancer diagnosis and their affect on the patient. These issues were examined from 3 points of view: patients, doctors, and nurses. A total of 152 Israelis subjects participated in the research: 51 patients with cancer, 51 nurses, and 50 doctors. They filled out a questionnaire developed for the research that included 35 items. Support patterns identified as effective were as follows: allowing for the expression of emotions, empathetic silence, support through touch, and the use of participatory, commendation, and encouragement statements. The research findings indicate the crucial need in the involvement of a family member and a nurse in the process and in supplying written information for the receiver of the news. Significant differences (P < .05) between patients and caregivers were found in the type of information given, in the timing and quantity, and in the support and communication patterns. The principal emotions professional caregivers experienced were identification and helplessness. Most of them were not trained in this field. The research findings could bridge the gap between what patients want and what caregivers do and would benefit in designing guidelines for breaking bad news and formulating a workshop program for furthering the team skills.

[Caregivers' role in breaking bad news: patients, doctors, and nurses' points of view].

The aim of the research was to identify the behavioral patterns employed by caregivers when breaking bad news, and their affect on the patient. These issues were examined from three points of view: patients, doctors, and nurses. A total of 152 interviewees participated in the research: 51 patients, 51 nurses, and 50 doctors. They completed a constructed questionnaire that included 35 items developed for the research. Support patterns identified as effective were: allowing for the expression of emotions, empathic silence, support through touch, and the use of participatory, commendation, and encouragement statements. The research findings point to the crucial need for the involvement of a family-member and a nurse in the process, and providing written information for the receiver of the news. Significant differences (p < 0.05) between patients and caregivers were found in the type of information given, the timing and quantity, as well as in the support and communication patterns. The principal emotions caregivers experienced were identification and helplessness, and most of them were not trained in this field. The research findings could bridge the gap between what patients want and what caregivers actually do, and would be beneficial in designing guidelines for breaking bad news, as well as formulating a workshop program for furthering the team skills.

The characteristics of self-referrals to ER for non-urgent conditions and comparison of urgency evaluation between patients and nurses.

The aim of the study was to identify the characteristics of self-referrals for non-urgent conditions to the ER, and compare urgency evaluation between patients and nurses. The participants were 73 Israeli clients who arrived at ER without referral from a physician, during the morning shift, and were discharged home after treatment. Their average age was 39.4 years. Most of the visits resulted from orthopedic problems. Over 60% indicated that they had chosen the ER because the treatment there was better, and a third reported that they usually turn to ER when they feel sick. In most cases, the visits were within 3 h of the symptoms emerging, and about a third of the participants indicated that lately they had been under situations of stress and anxiety. Significant differences (p=0.000) were found between nurses and patients, in the urgency evaluation of the visit. While most of the clients (77%), evaluated their condition as urgent to most urgent, most of the nurses (78%) evaluated it as non-urgent. Identifying the characteristics of the non-urgent use of the ER and the differences between caregivers and patients regarding the urgency evaluation of the visit, will provide insights into the population perceived as a burden on the work of the ER as well as benefiting and improving services.

Importance of early referral in sudden loss of hearing.

AIM: To examine the personal and clinical characteristics of patients suffering from sudden hearing loss. METHOD: The participants were 45 Israeli patients, and the data was collected retrospectively from their medical files. RESULTS: In most cases the injury was sensory, and in one ear. The common symptom was tinnitus, followed by vertigo. In 20 per cent of the cases no preliminary signs were documented. As many as 60 per cent of the participants suffered from high levels of cholesterol. This finding might indicate a link between the events of hearing loss and patients' vascular background. A total of 42 per cent of the participants delayed their appeal to treatment, despite the appearance of symptoms. CONCLUSION: A significant link was found between quick referral to treatment and recovery. The nurse holds a central role in identifying this group of patients and ensuring their referral to further treatment.

Chronology of medication errors by nurses: accumulation of stresses and PTSD symptoms.

The aim of this research was to examine the influence of medication errors on the mental state of the erring caregiver. In-depth interviews were conducted with 20 erring nurses. The data were analyzed using content analysis. The following categories were identified: "stress, pressure, and inattention," "responsibility," "the double fear," "I might get fired," "he who works, errs," waiting for the inquiry--"every day is like eternity," "absurdly, it got worse with time," and "following the event I learned my lessons." The emotional distress of several subjects was, across time, reminiscent of PTSD symptoms.

Fear, ambivalence, and liminality: key concepts in refusal to donate an organ after brain death.

The refusal to donate an organ is a phenomenon in need of exploration and explanation. This article refers to the major fear of becoming an organ donor in relation to a global culture perspective and to the Halacha (Jewish law). A theoretical critique about the ambivalence demonstrated by health care providers and families will discuss these concepts in relation to brain death, from the stages of hospitalization, through the period prior to the assertion of brain death, ending with brain death, and its perspective as a liminal situation.Finally, we conclude that nursing practices during the care of the "brain dead" patient, and toward the patient's family, should convey an unequivocal message. That is, brain death describes irreversible cessation of all brain function, and therefore, the patient becomes a dead body and can be treated as a potential organ donor.

Developing a computer game to prepare children for surgery.

Computer games are a major part of the culture of children and teenagers in many developed countries. Research shows that children of the computer age prefer computer-assisted learning to any other teaching strategy. Health care workers traditionally have used dolls, games, drawings, creative arts, and even videotapes to prepare children for surgery. No studies have been conducted in Israel on using computers to help ailing children in general or to help children preparing for surgery in particular. This article discusses the potential for using computers to educate patients based on a review of the literature and interviews with children and describes the process of computer game development.