Outcomes following physical restraint reduction programs in two acute care hospitals.

BACKGROUND: Physical restraint rates can be reduced safely in long term care settings, but the strategies used to prevent wandering, falls, and patient aggression have not been tested for their effectiveness in preventing therapy disruption. A restraint reduction program (RRP) consisting of four core components (administrative, educational, consultative, and feedback) was implemented in 1998-1999 in 14 units at two acute care hospitals in geographically distant cities. METHODS: The RRP was targeted at units with prevalence rates of > or = 4% for non-intensive care units (non-ICUs) and > or = 25% for ICUs, as well as two additional units. The RRP was implemented by an interdisciplinary team consisting of geriatricians and nurse specialists. RESULTS: Of the 16,605 admissions to the RRP units, 2,772 cases received RRP consultations. Only six units (four of seven general units and two of six ICUs) demonstrated a relative reduction of > or = 20% in the physical restraint use rate. No increase in secondary outcomes of patient falls and therapy disruptions (patient-initiated discontinuation or dislodgment of therapeutic devices) occurred, injury rates were low, and no deaths occurred as a direct result of either a fall or therapy disruption event. DISCUSSION: Given the minimal success in the ICU settings, further studies are needed to determine effective nonrestraint strategies for critical care patients. ICU clinicians need to be persuaded of the favorable risk-to-benefit ratio of alternatives to physical restraint before they will change their practice patterns. SUMMARY: Efforts to identify more effective interventions that match patient needs and to identify non-clinician factors that affect physical restraint use are needed.

Use of a faculty investment model to attain the goals of a college of nursing.

Driven by demands for fiscal prudence, new services, and an orderly transition as aging faculty approach retirement, a new model for administrative planning and decision making was tested. In its first year of using an investment model, a private, 600+ student, College of Nursing was able to achieve a labor savings of 10 percent, an enhancement of revenue of 3 percent, and a human capital pool equal to 12 percent of total full-time faculty equivalents. The model, which includes the integration of strategic planning, benchmarking, continuous quality improvement, and management by objectives, was accomplished by taking three investment steps. The steps included goal determination, market understanding, and resource allocation. Investment activity distribution and work determination frameworks were developed as a result of the commitment to the investment process. Suggestions for the future include the need to continue to reorient administrative and faculty thinking as definitions of the educational enterprise evolve.

Retirement, the nursing workforce, and the year 2005.

This analysis of workforce projections confirms that early employment withdrawal by registered nurse baby boomers could have a profound effect on US health care. The available policy mechanisms to encourage or discourage any early withdrawal require several years to implement, which makes timely decisions imperative.

Improving the ability to detect the impact of labor on patient outcomes.

A key part of resource allocation decisions is determining the impact of staffing on clinical outcomes. A national study involving eight hospitals and 77 units lends support for a previously identified labor assignment phenomena that may contribute to an underestimation of the impact of nursing labor on outcomes if only traditional labor measurement methods are used. The authors suggest actions for nurse administrators and researchers who must address frequent queries as to the adequacy of nursing staffing.

Prevalence and patterns of physical restraint use in the acute care setting.

Nurse executives usually have the principal responsibility to respond to the national movement to reduce physical restraint use in hospitals. The results of this three-site, interdisciplinary, prospective incidence study (based on more than 49,000 observations collected on 18 randomly selected days) reveal new patterns in the rationale and types of restraints used. The authors discuss how the results can be used in measuring success and allocating resources for restraint reduction programs.

What influences patients' reports of three aspects of hospital services?

OBJECTIVES: Market forces make it essential to know what policies and actions influence patients' reports of hospital services. No studies have examined the role of patient characteristics, labor quality and staff characteristics, nonlabor resources, managerial practices, and employee attitudes within a single investigation. METHODS: The authors collected, simultaneously, data about labor, management and service processes, nonlabor resources, and employee attitudes on 117 nonintensive medical-surgical inpatient units in 17 hospitals selected from a pool of 69 institutions within a metropolitan area by a stratified random sample. Of the 2,595 patients who agreed to participate, 2,051 (79%) completed telephone interviews regarding their experiences with physical care, education, and pain management services within 26 days of hospital discharge. RESULTS: A significant amount of variation in patients' service reports was explained (adjusted R2 = 0.41 physical care, 0.35 pain management, 0.44 education). Although the predictors varied for each service report, patient characteristics, especially those related to personal resources, had a large explanatory role. A labor assignment pattern that could explain why earlier studies found labor quality and staff characteristics to have only a weak role in the prediction of patients' service reports was noted. CONCLUSIONS: The results related to patient characteristics may indicate opportunities to improve care by confronting service design strategies that erroneously rely on a homogeneous patient population. Measurement challenges identified by this study must be addressed to determine the role of labor quantity and staff characteristics.

How wide is the gap in defining quality care? Comparison of patient and nurse perceptions of important aspects of patient care.

OBJECTIVES: The authors determine the importance that patients, nurses, and nurse managers place on aspects of care and measure nurses' care values based on their perceptions of their patients and nurse manager care values and their desire to meet these care expectations. BACKGROUND: The literature has documented gaps in how nurses and patients define quality and value specific care aspects, but little is known about the situation in the current continuous quality improvement and patient-centered care environment, which emphasizes a customer focus. Misunderstanding patients' values and expectations may impede service improvement. Information about any existing gaps could help managers begin to devise patient satisfaction improvement strategies. METHOD: Two thousand fifty-one medical-surgical patients, 1264 staff members, and 97 nurse managers from 17 randomly selected hospitals participated in study activities related to selected aspects of patient care. Trained interviewers surveyed patients by telephone within 26 days of discharge using a pretested instrument. Staff members and managers completed a coordinated written tool. Descriptive and correlational statistics were used in individual and unit-level analyses. RESULTS: Staff members perceive correctly that patients value differently various aspects of care but do not agree with their managers on patients' value of aspects of care. Unit staff members' and managers' beliefs regarding patients' care values did not match those of their patients (-14 to 0.11 and -0.01 to 0.06 zero order correlations, respectively). CONCLUSIONS: A unit's errors in defining patients' values may be self-reinforcing. Strategies to reorient personnel, including adoption of those suggested by the diffusion of innovation literature, may help bridge the gap and change practice.

The impact of computerized documentation on nurses' use of time.

With increased consideration being given to technological supports as a way to increase productivity, much attention is being paid to automated documentation systems. The purpose of this study was to determine (A) if bedside documentation technology decreased the time nurses spent in documentation activities and (B) if time of day, location, and quality of documentation differed between automated and nonautomated units. Nurses on the automated unit were able to decrease time spent in documentation activities and they were able to increase time spent in direct patient care. Some increase in standby time also was reported. Nurses were not able to increase patient loads as a result of this technology alone. Managers must consider ways to maximize use of time saved as a result of technology. Nurses on the automated unit were able to update care plans more easily and, along with other professionals, reported both positive and negative aspects of the printed output.

Management education for nurses: hospital executives' opinions and hiring practices.

Because registered nurses are assuming expanded roles in hospital management, the appropriate educational preparation for these roles has become a widely debated issue. A national survey of hospital CEOs and CNOs was conducted to assess their personal preferences for management education for nurses and to gather information about their hospitals' policies and practices in hiring nurses for management positions at various levels within the hospital (from unit-level management to executive level). Both CEOs and CNOs preferred the joint MSN/MBA degree option as the best model for graduate management education for nurses, and they perceived greater demand in the future for hospital nurses with graduate management degrees. However, hospital policies and practices with regard to degree requirements and preferences for nurses hired in management positions at all levels varied widely.