The RANA Model Revisited: How a Primary Nursing Model for Professional Psychiatric Nursing Practice Has Withstood the Test of Time.

OBJECTIVE: This article revisits the responsible, accountable nurse with authority (RANA) model and its continued application to psychiatric-mental health nursing care nearly 30 years after its development. It will ascertain key elements of the model that remain in use today, while identifying parts of the model that have transformed over the years. METHODS: This article will also explore the theoretical underpinnings of the model, including Peplau's interpersonal relations theory. The impact of the primary nursing and relationship-based care models that influenced the RANA role will also be explored. RESULTS: Specific examples of how the RANA model has affected unit outcomes will be identified, such as improved patient safety measures and satisfaction with care. CONCLUSIONS: The nurse-patient relationship and therapeutic alliance is fundamental to the RANA model and directly affects patient outcomes.

Simulation-Based Mastery Learning Improves Central Line Maintenance Skills of ICU Nurses.

OBJECTIVE: This study evaluated the impact of a simulation-based mastery learning (SBML) curriculum on central line maintenance and care among a group of ICU nurses. METHODS: The intervention included 5 tasks: (a) medication administration, (b) injection cap (needleless connector) changes, (c) tubing changes, (d) blood drawing, and (e) dressing changes. All participants underwent a pretest, engaged in deliberate practice with directed feedback, and completed a posttest. We compared pretest and posttest scores and assessed correlations between demographics, self-confidence, and pretest performance. RESULTS: The number of nurses passing each task at pretest varied from 24 of 49 (49%) for dressing changes to 44 of 49 (90%) for tubing changes. At pretest, scores ranged from a median of 0.0% to 73.1%. At posttest, all scores rose to a median of 100.0%. Total years in nursing and ICU nursing had significant, negative correlations with medication administration pretest performance (r = -0.42, P = .003; r = -0.42, P = .003, respectively). CONCLUSION: ICU nurses displayed large variability in their ability to perform central line maintenance tasks. After SBML, there was significant improvement, and all nurses reached a predetermined level of competency.

Implementation of unit-based interventions to improve teamwork and patient safety on a medical service.

In a prior study involving 2 medical units, Structured Interdisciplinary Rounds (SIDRs) improved teamwork and reduced adverse events (AEs). SIDR was implemented on 5 additional units, and a pre- versus postintervention comparison was performed. SIDR combined a structured format for communication with daily interprofessional meetings. Teamwork was assessed using the Safety Attitudes Questionnaire (score range = 0-100), and AEs were identified using queries of information systems confirmed by 2 physician researchers. Paired analyses for 82 professionals completing surveys both pre and post implementation revealed improved teamwork (mean 76.8 ± 14.3 vs 80.5 ± 11.6; P = .02), which was driven mainly by nurses (76.4 ± 14.1 vs 80.8 ± 10.4; P = .009). The AE rate was similar across study periods (3.90 vs 4.07 per 100 patient days; adjusted IRR = 1.08; P = .60). SIDR improved teamwork yet did not reduce AEs. Higher baseline teamwork scores and lower AE rates than the prior study may reflect a positive cultural shift that began prior to the current study.

Assessment of teamwork during structured interdisciplinary rounds on medical units.

BACKGROUND: Interdisciplinary rounds (IDR) provide a means to assemble hospital team members and improve collaboration. Little is known about teamwork during IDR. OBJECTIVE: To evaluate and characterize teamwork during IDR. DESIGN: Cross-sectional observational study. SETTING: Six medical units which had implemented structured interdisciplinary rounds (SIDR). MEASUREMENTS: We adapted the Observational Teamwork Assessment for Surgery (OTAS) tool, a behaviorally anchored rating scale shown to be reliable and valid in surgical settings. OTAS provides scores ranging from 0 to 6 (0 = problematic behavior; 6 = exemplary behavior) across 5 domains (communication, coordination, cooperation/backup behavior, leadership, and monitoring/situational awareness) and for prespecified subteams. Two researchers conducted direct observations using the adapted OTAS tool. RESULTS: We conducted 7-8 independent observations for each unit (total = 44) and 20 joint observations. Inter-rater reliability was excellent at the unit level (Spearman's rho = 0.75), and good across domains (rho = 0.53-0.68) and subteams (rho = 0.53-0.76) with the exception of the physician subteam, for which it was poor (rho = 0.35). Though teamwork scores were generally high, we found differences across units, with a median (interquartile range [IQR]) 4.5 (3.9-4.9) for the lowest and 5.4 (5.3-5.5) for the highest performing unit (P < 0.01). Domain scores differed, with leadership receiving the lowest (median [IQR] = 5.0 [4.6-5.3]), and cooperation/backup behavior and monitoring/situational awareness receiving highest scores (median [IQR] = 5.4 [5.0-5.5] and 5.4 [5.0-5.7]). Differences across subteams were of borderline significance (P = 0.05). CONCLUSIONS: The adapted OTAS instrument demonstrated acceptable reliability for assessing teamwork during SIDR across units, domains, and most subteams. Variation in performance suggests a need to improve consistency of teamwork and emphasizes the importance of leadership.

Structured interdisciplinary rounds in a medical teaching unit: improving patient safety.

BACKGROUND: Effective collaboration and teamwork is essential to providing safe hospital care. The objective of this study was to assess the effect of an intervention designed to improve interdisciplinary collaboration and lower the rate of adverse events (AEs). METHODS: The study was a controlled trial of an intervention, Structured Inter-Disciplinary Rounds, implemented in 1 of 2 similar medical teaching units in a tertiary care academic hospital. The intervention combined a structured format for communication with a forum for regular interdisciplinary meetings. We conducted a retrospective medical record review evaluating 370 randomly selected patients admitted to the intervention and control units (n = 185 each) in the 24 weeks after and 185 admitted to the intervention unit in the 24 weeks before the implementation of Structured Inter-Disciplinary Rounds (N = 555). Medical records were screened for AEs. Two hospitalists confirmed the presence of AEs and assessed their preventability and severity in a masked fashion. We used multivariable Poisson regression models to compare the adjusted incidence of AEs in the intervention unit to that in concurrent and historic control units. RESULTS: The rate of AEs was 3.9 per 100 patient-days for the intervention unit compared with 7.2 and 7.7 per 100 patient-days, respectively, for the concurrent and historic control units (adjusted rate ratio, 0.54; P = .005; and 0.51; P = .001). The rate of preventable AEs was 0.9 per 100 patient-days for the intervention unit compared with 2.8 and 2.1 per 100 patient-days for the concurrent and historic control units (adjusted rate ratio, 0.27; P = .002; and 0.37; P = .02). The low number of AEs rated as serious or life-threatening precluded statistical analysis for differences in rates of events classified as serious or serious and preventable. CONCLUSION: Structured Inter-Disciplinary Rounds significantly reduced the adjusted rate of AEs in a medical teaching unit.

Improving teamwork: impact of structured interdisciplinary rounds on a hospitalist unit.

BACKGROUND: Effective collaboration and teamwork is essential in providing safe and effective care. Research reveals deficiencies in teamwork on medical units involving hospitalists. OBJECTIVE: The aim of this study was to assess the impact of an intervention, Structured Inter-Disciplinary Rounds (SIDR), on nurses' ratings of collaboration and teamwork. METHODS: The study was a controlled trial involving an intervention and control hospitalist unit. The intervention, SIDR, combined a structured format for communication with a forum for regular interdisciplinary meetings. We asked nurses to rate the quality of communication and collaboration with hospitalists using a 5-point ordinal scale. We also assessed teamwork and safety climate using a validated instrument. Multivariable regression analyses were used to assess the impact on length of stay (LOS) and cost using both a concurrent and historic control. RESULTS: A total of 49 of 58 (84%) nurses completed surveys. A larger percentage of nurses rated the quality of communication and collaboration with hospitalists as high or very high on the intervention unit compared to the control unit (80% vs. 54%; P = 0.05). Nurses also rated the teamwork and safety climate significantly higher on the intervention unit (P = 0.008 and P = 0.03 for teamwork and safety climate, respectively). Multivariable analyses demonstrated no difference in the adjusted LOS and an inconsistent effect on cost. CONCLUSIONS: SIDR had a positive effect on nurses' ratings of collaboration and teamwork on a hospitalist unit, yet no impact on LOS and cost. Further study is required to assess the impact of SIDR on patient safety measures.

Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching unit.

BACKGROUND: Effective collaboration and teamwork is essential in providing safe and effective hospital care. Prior research reveals deficiencies in collaboration on medical teaching units. OBJECTIVE: The aim of this study was to assess the impact of an intervention, structured inter-disciplinary rounds (SIDR), on hospital care providers' ratings of collaboration and teamwork. METHODS: The study was a controlled trial comparing an intervention medical teaching unit with a similar control unit. The intervention, SIDR, combined a structured format for communication with a forum for regular interdisciplinary meetings. We surveyed providers on each unit and asked them to rate the quality of communication and collaboration they had experienced with other disciplines using a five-point ordinal scale. We also assessed the teamwork and safety climate using a validated instrument. Multivariable regression analyses were used to assess the impact on length of stay (LOS) and cost. RESULTS: One hundred forty-seven of 159 (92%) eligible providers completed the survey. Although resident physicians on each unit rated the quality of communication and collaboration with nurses similarly, a greater percentage of nurses gave high ratings to the quality of collaboration with resident physicians on the intervention unit as compared to the control unit (74% vs. 44%; p = 0.02). Providers on the intervention unit rated the teamwork climate significantly higher as compared to the control unit (82.4 +/- 11.7 vs. 77.3 +/- 12.3; p = 0.01). The difference was explained by higher teamwork climate ratings on the part of nurses on the intervention unit (83.5 +/- 14.7 vs. 74.2 +/- 14.1; p = 0.005). Ratings of the safety climate were not significantly different between units. Adjusted LOS and hospital costs were not significantly different between units. CONCLUSIONS: SIDR had a positive effect on nurses' ratings of collaboration and teamwork on a medical teaching unit. Further study is required to assess the impact of SIDR on patient safety measures.