Identifying Effective Nurse-Led Care Transition Interventions for Older Adults With Complex Needs Using a Structured Expert Panel.

BACKGROUND: Nursing plays a central role in facilitating care transitions for complex older adults, yet there is no consensus of the components of nurse-led care transitions interventions to facilitate high quality care transitions among complex older adults. A structured expert panel was established with the purpose of identifying effective nurse-led care transition interventions. METHODS: A modified Delphi consensus technique based on the RAND method was employed. Panelists (n = 23) were asked to individually rate a series of statements derived from a realist synthesis of the literature for relevance, feasibility and likely impact. Statements receiving an aggregate score of ≥75% (7/9) were reviewed and revised at a face-to-face consensus meeting. A second round of rating following the same process as round one was used, followed by a final ranking of the statements. RESULTS: The five highest ranked intervention components and contextual factors were: (a) educating and coaching patients, their family members and caregivers about self-management skills; (b) ensuring patients, their family members and caregivers are aware of follow-up medical appointments and postdischarge care plan; (c) using standardized documentation tools and comprehensive communication strategies during care transitions; (d) optimizing nurses' roles and scopes of practice across the care transitions spectrum; and (e) having strong leadership, strategic alignment and accountability structures in organizations to enable quality care transitions for the complex older person population. LINKING EVIDENCE TO ACTION: Key insights on optimizing the nurses' roles and scope of practice during care transitions included having nurses provide "warm hand-offs" and serve as the "go-to person." The panel also identified current challenges to optimizing the nurses' roles and scope of practice across care transition points. Future research is required to determine effective nurse-led intervention components and in which context do they work or do not.

The effect of an organizational network for patient safety on safety event reporting.

Health care organizations continue to implement organization-wide educational approaches to enhance patient safety with less attention on evaluating the impact of these approaches. In this context, a study was conducted to measure the impact of an organization-wide patient safety network approach on patient safety event reporting. A time-series analysis with reported rates of adverse events (major and moderate), near misses, sentinel events, and incidents from 2 years prior through 13 months following implementation was conducted. Study findings include a significant increase in reporting of patient safety events (an approximately 50% increase in overall reporting of safety events was observed; p < .001), especially near misses (an approximately 100% increase following implementation; p = .002). Study findings suggest that a multifaceted networked approach does contribute to improving patient safety event reporting.

Enablers and barriers to implementing bedside reporting: insights from nurses.

As part of efforts to improve patient safety, quality of care and patient- and family-centred care, there is a growing interest in moving away from traditional taped nursing reports or reporting at the nursing station to reporting at the bedside. Although a body of knowledge exists regarding what nurses view as benefits and challenges experienced in nurse-to-nurse bedside reporting, less is known about the perceptions of nurses who have experienced this change in reporting practice on their unit. In this context, a qualitative study using semi-structured interviews was undertaken to explore nurses' perceptions of a newly implemented nurse-to-nurse bedside reporting practice at one acute care hospital. A total of 43 interviews were conducted on four units with seven nurses from respirology, 10 from obstetrics and gynecology, 10 from nephrology and 16 from general surgery. Data were analyzed using a directed content analysis approach. Three themes emerged that captured nurses' perceptions of the implementation of nurse-to-nurse bedside reporting: (a) being supported to change and embrace bedside reporting, (b) maintaining confidentiality and respecting patients' preferences and (c) experiencing challenges with bedside reporting. Our findings provide insight for other organizations in their efforts to change reporting practices. Specifically, there is a need for multi-pronged initiatives including leadership support, educational opportunities and ongoing monitoring and feedback mechanisms. Future research is required to examine how enablers can be leveraged and barriers mitigated or removed to ensure successful implementation and sustainability of nurse-to-nurse bedside reporting.

Defining what evidence is, linking it to patient outcomes, and making it relevant to practice: insight from clinical nurses.

BACKGROUND/RATIONALE: Factors that impede or enable successful evidence based practice for nurses in their daily work is well documented. Less known is how nurses define evidence in their daily clinical practice and how this knowledge can inform strategies to enhance evidence based patient care and outcomes. AIMS/METHODS: A qualitative study was undertaken to explore nurses' perceptions of what constitutes evidence as part of EBP and how applicable evidence is to their daily practice. A qualitative design using semi-structured interviews was employed for this study. Data were analyzed using directed content analysis. RESULTS: The following four key themes emerged: viewing evidence as research based and a proven practice; linking evidence to patient outcomes; basing evidence on experience; and making evidence relevant to practice. IMPLICATIONS: Study findings point to having accessible, practical tools to make evidence credible and relevant for nurses tailored to their clinical contexts.

Using theory and evidence to drive measurement of patient, nurse and organizational outcomes of professional nursing practice.

An evolving body of literature suggests that the implementation of evidence based clinical and professional guidelines and strategies can improve patient care. However, gaps exist in our understanding of the effect of implementation of guidelines on outcomes, particularly patient outcomes. To address this gap, a measurement framework was developed to assess the impact of an organization-wide implementation of two nursing-centric best-practice guidelines on patient, nurse and organizational level outcomes. From an implementation standpoint, we anticipate that our data will show improvements in the following: (i) patient satisfaction scores and safety outcomes; (ii) nurses ability to value and engage in evidence based practice; and (iii) organizational support for evidence-informed nursing care that results in quality patient outcomes. Our measurement framework and multifaceted methodological approach outlined in this paper might serve as a blueprint for other organizations in their efforts to evaluate the impacts associated with implementation of clinical and professional guidelines and best practices.

Investing in nursing research in practice settings: a blueprint for building capacity.

Engaging clinical nurses in practice-based research is a cornerstone of professional nursing practice and a critical element in the delivery of high-quality patient care. Practising staff nurses are well suited to identify the phenomena and issues that are clinically relevant and appropriate for research. In response to the need to invest in and build capacity in nursing research, hospitals have developed creative approaches to spark interest in nursing research and to equip clinical nurses with research competencies. This paper outlines a Canadian hospital's efforts to build research capacity as a key strategy to foster efficacious, safe and cost-effective patient care practices. Within a multi-pronged framework, several strategies are described that collectively resulted in enhanced research and knowledge translation productivity aimed at improving the delivery of safe and high-quality patient care.

Quality nursing care and opportunities for improvement: insights from patients and family members.

A study was undertaken to delineate patients' and families' experiences and perceptions associated with their nurse-patient therapeutic relationships and nursing care. Data were analyzed using a directed content analysis approach. Two key themes emerged: patients and family members described primarily receiving excellent nursing care and to a lesser extent substandard care. Study findings have implications for nurse leaders to enhance nurses' therapeutic relationships with patients and family members and patient-centered care within their organizations.

Exploring nurses' perceptions of collecting and using HOBIC measures to guide clinical practice and improve care.

Ontario's Health Outcomes for Better Information and Care (HOBIC) is designed to help organizations and nurses plan and evaluate care by comparing patient outcomes with historical data on similar cases. Yet, fewer than 15% of patients in a 2010 study were found to have complete admission and discharge data sets. This low utilization rate of HOBIC measures prompted the current qualitative study, in which nurses from three clinical settings in an academic teaching hospital were interviewed to gain their perceptions related to collecting and using HOBIC measures in practice. The objective was to identify factors that promote or impede the collection and use of HOBIC data in clinical practice to improve patient care and outcomes. Analysis of interview results produced four key themes related to (a) use of HOBIC measures to inform patient care, (b) collecting and documenting HOBIC measures, (c) HOBIC as an afterthought and "black hole" and (d) impediments to assessing and documenting HOBIC measures because of language barriers, patients' cognitive status and lack of time. Recommendations to improve uptake include developing, implementing and evaluating a communication and learning plan that promotes HOBIC's values and benefits, and determining how managers and administrators perceive utilization of HOBIC at the clinical unit and organizational levels.

Linking HOBIC measures with length of stay and alternate levels of care: implications for nurse leaders in their efforts to improve patient flow and quality of care.

Integral to understanding and leveraging performance data to monitor and drive quality improvement (QI) efforts to enhance patient care is a partnership between researchers (who generate data) and nurse executives (who lead QI efforts). In Canada, evidence-based, nursing-sensitive patient outcome data are included in the Health Outcomes for Better Information and Care (HOBIC) initiative. A descriptive study was undertaken to examine the relationships and predictive abilities of HOBIC measures with length of stay (LOS) and alternate levels of care (ALC) measures. Specifically, we were interested in determining (a) whether relationships among the HOBIC measures exist and (b) whether any of the HOBIC measures are associated with, and could subsequently be used to predict, the patient and the destination to which he or she is discharged (ALC). Our interest in understanding these relationships and predictive abilities was both research driven and practice driven, with the intent eventually to use study findings to target clinical practice and data feedback strategies. To address the two research aims, this study employed both descriptive and inferential statistical approaches with multiple analytic approaches. Study results suggest that many of the HOBIC measures are related, with a higher score in one measure corresponding to a higher score in another measure. The exception is the therapeutic self-care (TSC) measure, in which higher scores on other HOBIC measures were correlated with lower TSC scores. Associations were also found with the predictive ability of certain HOBIC measures on LOS and ALC. Our study findings call for nurse leaders to emphasize the importance to clinical nurses on hospital units of focusing their efforts on assisting patients in managing their fatigue and dyspnoea effectively; increasing their ability to engage in activities of daily living, functional status and therapeutic self-care; and preventing or minimizing pressure ulcers and falls in acute care patients. In turn, these efforts may decrease patients' LOS.

Going blank: factors contributing to interruptions to nurses' work and related outcomes.

AIM: To examine interruptions to nurses' work, the systems issues related to these and the associated outcomes. BACKGROUND: While some research has described the role interruptions play in medication errors, work is needed to examine specific factors in the nursing work environment that cause interruptions and to assess the impact of these on nurses' work and patient outcomes. METHODS: The present study utilized a mixed method design that involved work observation to detect nursing interruptions in the workplace followed by focus groups with a subsample of nurses. RESULTS: A total of 13,025 interruptions were observed. Equal numbers of these took place on medical and surgical units. The predominant source of interruptions was members of the health team, who interrupted more frequently on medical units. CONCLUSIONS: Differences in the type of patient and the care needs between medical and surgical units may be a contributing factor to these findings. As members of the health team were among the leading source of interruptions, an interdisciplinary team-based approach to changing the organization and design of work should be explored. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse leaders should examine ways in which nurses' work can benefit from system improvements to reduce interruptions that lead to patient safety issues such as treatment delays and loss of concentration.

Building knowledge for safer care: nursing research advancing practice.

Organizational and professional efforts to support nurses engaging in research projects that advance patient safety practices are needed. In this context, the purpose of this article is to provide a description of the design, implementation, and evaluation of a research capacity strategy designed for clinical nurses and the lessons learned. Participating nurses evolved from research novices to key champions in advancing nursing practice, patient safety, and quality improvement.

Nursing leaders' accountability to narrow the safety chasm: insights and implications from the collective evidence base on healthcare safety.

Challenges continue to exist in bridging the safety gap to ensure that consistent, high-quality nursing care is provided based on the best scientific knowledge available. This paper examines findings from nursing research presented at the symposium Advancing Nursing Leadership for a Safer Healthcare System, held in Toronto, Ontario in 2007. Four central themes emerged: (1) place the patient in safety; (2) generate a broader knowledge base on safety across the continuum of care; (3) create a safe culture and healthy work environment to mitigate current threats to patient safety; and (4) advance translation of evidence to practice at the organizational and clinical levels. The aim of this exchange of knowledge was to equip nursing leaders and their decision partners with evidence that can become a catalyst for mobilizing change in practice to address the safety chasm.

Case study: reconciling the quality and safety gap through strategic planning.

An essential outcome of professional practice environments is the provision of high-quality, safe nursing care. To mitigate the quality and safety chasm, nursing leadership at St. Michael's Hospital undertook a strategic plan to enhance the nursing professional practice environment. This case study outlines the development of the strategic planning process: the driving forces (platform); key stakeholders (process and players); vision, guiding principles, strategic directions, framework for action and accountability (plan); lessons learned (pearls); and next steps to moving forward the vision, strategic directions and accountability mechanisms (passion and perseverance).