The Acceptability and Feasibility of Implementing an Online Educational Intervention With Nurses in a Provincial Prison Context.

BACKGROUND: Correctional nursing requires a strong knowledge base with access to continuing education (CE) to maintain and enhance competencies. Nurses working in provincial prisons have reported many challenges in accessing CE, with online learning being identified as a potential solution. Limited research was found, however, which examined the correctional context in the development and delivery of online learning for nurses. The purpose of this study was to develop an online educational intervention tailored to correctional nurses and determine the feasibility and acceptability of implementing the intervention in a provincial prison context. METHODS: A sequential mixed methods study was conducted. Participants included nurses from three correctional settings in the province of Ontario, Canada. Semistructured interviews examined contextual factors and educational needs. Delphi surveys determined the educational topic. Preintervention and postintervention questionnaires examined the context, educational content, and intervention's acceptability and feasibility. RESULTS: The online intervention focused on mental health and addictions with two 30-minute webinars delivered back-to-back over 15 weeks. Respondents expressed satisfaction with the convenience of online learning at work using short webinars, as well as the topics, relevance of information, and teaching materials, but dissatisfaction with presentation style. The feasibility of the intervention was limited by access to technology, time to attend, education space, and comfort with technology. DISCUSSION: The findings from this study provide insight to guide the future development of online CE for correctional nurses. If changes are made within correctional facilities in collaboration with nurses and managers, online learning holds the potential to facilitate access to ongoing professional development.

Structural positioning of nurse leaders and empowerment.

AIMS AND OBJECTIVES: To analyse the reporting structures of nursing leaders of publicly funded hospitals and seek both the views of nurse leaders and Chief Executive Officers/Chief Operating Officers on the structural positioning of nurse leaders in the organisation. BACKGROUND: Concern that the continuing restructuring within hospital structures and focus on economic outputs in health services is diminishing the value of nursing leadership. DESIGN: Qualitative surveys with Nursing leaders and Chief Executive Officers of public hospitals. METHODS: Seventeen Directors of Nursing and 10 Chief Executive Officer/Chief Operating Officers' responses were received using two semi-structured questionnaires. Themes were developed from data coded and analysed by hand. RESULTS: Four broad themes emerged from analysis of the data: (1) variable positional reporting between Director of Nursing and Chief Executive Officers occurred; (2) variable levels of inclusion and influence at the executive decision-making level; (3) ambiguous financial responsibilities and accountabilities held by Director of Nursing; and (4) blurred lines existed between operational and professional reporting lines. Findings unique to the research indicate that the varying levels of visibility and inclusion impact on the structural positioning of nurse leaders which influences authority and empowerment. CONCLUSION: Responses from the data analysis indicate that the structural power of nurse leaders defined by the factors of opportunity, power and proportion were hindered by dual accountability reporting lines and a lack of financial control. RELEVANCE TO CLINICAL PRACTICE: The structural positioning of nurse leaders is vital to ensure that they are empowered and able to meet the adaptations required in a changing environment that supports the delivery of effective, quality healthcare.

The relationship among evidence-based practice and client dyspnea, pain, falls, and pressure ulcer outcomes in the community setting.

BACKGROUND: There are gaps in knowledge about the extent to which home care nurses' practice is based on best evidence and whether evidence-based practice impacts patient outcomes. AIM: The purpose of this study was to investigate the relationship between evidence-based practice and client pain, dyspnea, falls, and pressure ulcer outcomes in the home care setting. Evidence-based practice was defined as nursing interventions based on best practice guidelines. METHODS: The Nursing Role Effectiveness model was used to guide the selection of variables for investigation. Data were collected from administrative records on percent of visits made by Registered Nurses (RN), total number of nursing visits, and consistency of visits by principal nurse. Charts audits were used to collect data on nursing interventions and client outcomes. The sample consisted of 338 nurses from 13 home care offices and 939 de-identified client charts. Hierarchical generalized linear regression approaches were constructed to explore which variables explain variation in client outcomes. RESULTS: The study found documentation of nursing interventions based on best practice guidelines was positively associated with improvement in dyspnea, pain, falls, and pressure ulcer outcomes. Percent of visits made by an RN and consistency of visits by a principal nurse were not found to be associated with improved client outcomes, but the total number of nursing visits was. LINKING EVIDENCE TO ACTION: Implementation of best practice is associated with improved client outcomes in the home care setting. Future research needs to explore ways to more effectively foster the documentation of evidence-based practice interventions.

Identification of serious and reportable events in home care: a Delphi survey to develop consensus.

OBJECTIVE: To assess which client events should be considered reportable and preventable in home care (HC) settings in the opinion of HC safety experts. BACKGROUND: Patient safety in acute care settings has been well documented; however, there are limited data about this issue in HC. While many organizations collect information about 'incidents', there are no standards for reporting and it is challenging to compare incident rates among organizations. DESIGN: A 29-item electronic survey that included potential HC safety issues was used in a two-round Delphi study. SETTING AND PARTICIPANTS: Twenty-four pan-Canadian HC safety experts participated in an electronic survey. MAIN OUTCOME MEASURES: Perceived reportability and preventability of patient safety events, HC. RESULTS: The events that were perceived as being most reportable and preventable included the following: a serious injury related to inappropriate client service plan (e.g. incomplete/inaccurate assessments, poor care plan design, flawed implementation); an adverse reaction requiring emergency room visit or hospitalization related to a medication-related event; a catheter-site infection (e.g. a new peritoneal dialysis infection or peritonitis); any serious event related to care or services that are contrary to current professional or other practice standards (e.g. incorrect treatment regimen, theft, retention of a foreign object in a wound, individual practicing outside scope or competence). CONCLUSION: These data represent an important step in the development and validation of standard metrics about client safety in HC. The results address an expanding area of health services where there is a need to improve standardization and reporting.

The role of organizational context and individual nurse characteristics in explaining variation in use of information technologies in evidence based practice.

BACKGROUND: There is growing awareness of the role of information technology in evidence-based practice. The purpose of this study was to investigate the role of organizational context and nurse characteristics in explaining variation in nurses' use of personal digital assistants (PDAs) and mobile Tablet PCs for accessing evidence-based information. The Promoting Action on Research Implementation in Health Services (PARIHS) model provided the framework for studying the impact of providing nurses with PDA-supported, evidence-based practice resources, and for studying the organizational, technological, and human resource variables that impact nurses' use patterns. METHODS: A survey design was used, involving baseline and follow-up questionnaires. The setting included 24 organizations representing three sectors: hospitals, long-term care (LTC) facilities, and community organizations (home care and public health). The sample consisted of 710 participants (response rate 58%) at Time 1, and 469 for whom both Time 1 and Time 2 follow-up data were obtained (response rate 66%). A hierarchical regression model (HLM) was used to evaluate the effect of predictors from all levels simultaneously. RESULTS: The Chi square result indicated PDA users reported using their device more frequently than Tablet PC users (p = 0.001). Frequency of device use was explained by 'breadth of device functions' and PDA versus Tablet PC. Frequency of Best Practice Guideline use was explained by 'willingness to implement research,' 'structural and electronic resources,' 'organizational slack time,' 'breadth of device functions' (positive effects), and 'slack staff' (negative effect). Frequency of Nursing Plus database use was explained by 'culture,' 'structural and electronic resources,' and 'breadth of device functions' (positive effects), and 'slack staff' (negative). 'Organizational culture' (positive), 'breadth of device functions' (positive), and 'slack staff '(negative) were associated with frequency of Lexi/PEPID drug dictionary use. CONCLUSION: Access to PDAs and Tablet PCs supported nurses' self-reported use of information resources. Several of the organizational context variables and one individual nurse variable explained variation in the frequency of information resource use.

Nursing structures in New Zealand public hospitals: current configurations.

This article reports research reviewing the configuration of nursing leadership in New Zealand public hospitals. It represents an analysis of Phase 1 of a larger study. Leadership in nursing is critical if the profession is to meet the challenges of health services in the 21st century. The research focuses on how leadership in public hospitals is structured at a strategic level. The preliminary summary of findings of this phase of the research show that reporting lines between directors of nursing (DON) and the chief executive officer (CEO) are not always direct, and organizational charts and nursing structures are not readily aligned. Clear financial or budget holding reporting lines by nursing leadership are not easily identified, or are professional and operational accountability lines clearly defined. From 15 total responses received, the organizations are structured differently both organizationally and in the nursing structures.

A pilot study of an electronic interprofessional evidence-based care planning tool for clients with mental health problems and addictions.

BACKGROUND: The health system must develop effective solutions to the growing challenges it faces with respect to individuals who suffer with mental health disorders and addictions. The purpose of this study was to evaluate the usability and potential impact on outcomes of a knowledge translation system aimed at improving client-centered, evidence-based care for hospitalized individuals with schizophrenia. METHODOLOGY: A pre-posttest design was used. The e-Volution-TREAT system was implemented on two inpatient units at a large mental health facility. Thirty-seven nurses, allied health workers, and physicians participated from two units. Data collection involved questionnaires, semistructured interviews, and observations. Thirty-eight consenting clients' outcome data were collected from organizational records. RESULTS: Overall, staff participants were very satisfied with the functions of the e-Volution-TREAT system. Barriers to using the system were identified by participants related to the work environment, to understaffing, equipment problems, discomfort with technology, and a focus on short-term rather than long-term goals. There was moderate uptake of guidelines related to social issues, and low uptake of guidelines related to family support and addictions. There were significant improvements in four client outcomes over time, specifically aggressive behavior, depression, withdrawal, and psychosis. CONCLUSIONS: In conclusion, users were overall satisfied with the e-Volution-TREAT system, although expressed challenges related to workload that interfered with time to utilize the system. It would be premature to conclude the change in client outcomes was related to the e-Volution-TREAT system without a randomized controlled trial with outcomes compared to a control group. Future research needs to incorporate strategies for modifying the context and engage clinicians who are in a position of influence to model change.

Effects of health policy reforms on nursing resources and patient outcomes in New Zealand.

Health policy reforms in New Zealand during the 1990s impacted on hospital operations, on the nursing workforce, and on patients. This study analyses changes in rates of 20 adverse patient outcomes that are potentially sensitive to nursing (OPSNs) before (1989-1993), during (1993-2000), and after (2000-2006) the policy reforms, using all New Zealand public hospital inpatient discharge data for this period. Comparisons of changes in mean annual rates across periods revealed the expected trajectory of acceleration during the reform period relative to the prereform period, and a subsequent deceleration in the postreform period. This S-shaped pattern was clearly evident in 16 of the 20 OPSNs, and partially evident in the remaining 4. These results are interpreted as evidence that the 1990s policy reforms inspired by managerialism had deleterious effects on patient outcomes, and that these effects coincided with changes in nursing resources and the work environment.

Supporting evidence-based practice for nurses through information technologies.

PURPOSE: To evaluate the usability of mobile information terminals, such as personal digital assistants (PDAs) or Tablet personal computers, to improve access to information resources for nurses and to explore the relationship between PDA or Tablet-supported information resources and outcomes. BACKGROUND: The authors evaluated an initiative of the Nursing Secretariat, Ontario Ministry of Health and Long-Term Care, which provided nurses with PDAs and Tablet PCs, to enable Internet access to information resources. Nurses had access to drug and medical reference information, best practice guidelines (BPGs), and to abstracts of recent research studies. METHOD: The authors took place over a 12-month period. Diffusion of Innovation theory and the Promoting Action on Research Implementation in Health Services (PARIHS) model guided the selection of variables for study. A longitudinal design involving questionnaires was used to evaluate the impact of the mobile technologies on barriers to research utilization, perceived quality of care, and on nurses' job satisfaction. The setting was 29 acute care, long-term care, home care, and correctional organizations in Ontario, Canada. The sample consisted of 488 frontline-nurses. RESULTS: Nurses most frequently consulted drug and medical reference information, Google, and Nursing PLUS. Overall, nurses were most satisfied with the Registered Nurses Association of Ontario (RNAO) BPGs and rated the RNAO BPGs as the easiest resource to use. Among the PDA and Tablet users, there was a significant improvement in research awareness/values, and in communication of research. There was also, for the PDA users only, a significant improvement over time in perceived quality of care and job satisfaction, but primarily in long-term care settings. IMPLICATIONS: It is feasible to provide nurses with access to evidence-based practice resources via mobile information technologies to reduce the barriers to research utilization.

Integrating evidence-based interventions into client care plans.

Within the mental health care system, there is an opportunity to improve patient safety and the overall quality of care by integrating clinical practice guidelines with the care planning process through the use of information technology. Electronic assessment tools such as the Resident Assessment Inventory - Mental Health (RAI-MH) are widely used to identify the health care needs and outcomes of clients. In this knowledge translation initiative, an electronic care planning tool was enhanced to include evidence-based clinical interventions from schizophrenia guidelines. This paper describes the development of a mental health decision support prototype, a field test by clinicians, and user experiences with the application.

What nurses want: diffusion of an innovation.

We investigated the usability of personal digital assistants (PDAs) to improve research utilization and timely access to electronic practice information to assist in clinical decisions. Nurses used a decision support tool on a PDA to collect point-of-care outcomes data. Follow-up interviews documented usability. Nurses liked the portability and size of the PDA, as well as ease of use of the PDA software. Electronic decision support tools at point of care have the potential to improve nurses' research utilization and quality of care.

The relationship between managed competition in home care nursing services and nurse outcomes.

The objective of this study was to investigate the relationship between the characteristics of home-care contracts, as indicators of employment relationships, and nurses'job satisfaction and perceived job security. A cross-sectional design was used to collect data on the study variables.The setting was 11 Community Care Access Centres and 11 nursing provider agencies in the Canadian province of Ontario. The sample included 700 nurses. A mailed survey was used to collect data from CCACs on length of contract awarded to provider agencies, potential for renewal, volume of service awarded, and profit status of the agency. Data were collected, via a mailed survey, on nurses' age, gender, work status, and years of employment in the community and at the current agency. The Nursing Job Satisfaction Scale was used to collect data on nurses'job satisfaction. Perceived job security was assessed using a single item measured on a 5-point Likert scale. Significant differences were found among provider agencies in nurses' perception of the quality of care, work enjoyment, satisfaction with time for care, and job security. Older nurses rated work enjoyment higher than younger nurses. Nurses paid on an hourly basis were more satisfied with their time for care than those paid on a per-visit basis. Nurses employed on a casual basis were less satisfied with job security than those employed on a full-time basis. Differences in nurse outcomes were observed among nursing provider agencies, but these were not related to the profit status of the agency. Further research is needed on the best practices within agencies that result in more satisfied staff.

Evidence in the palm of your hand: development of an outcomes-focused knowledge translation intervention.

AIM: The aim of the project was to develop an electronic information gathering and dissemination system to support both nursing-sensitive outcomes data collection and evidence-based decision-making at the point-of-patient care. BACKGROUND: With the current explosion of health-related knowledge, it is a challenge for nurses to regularly access information that is most current. The Internet provides timely access to health information, however, nurses do not readily use the Internet to access practice information because of being task-driven and coping with heavy workloads. Mobile computing technology addresses this reality by providing the opportunity for nurses to access relevant information at the time of nurse-patient contact. METHOD: A cross-sectional, mixed-method design was used to describe nurses' requirements for point-of-care information collection and utilization. The sample consisted of 51 nurses from hospital and home care settings. Data collection involved work sampling and focus group interviews. FINDINGS: In the hospital sector, 40% of written information was recorded onto "personal papers" at point-of-care and later transcribed into the clinical record. Nurses often sought information away from the point-of-care; for example, centrally located health records, or policy and procedure manuals. In home care, documentation took place in clients' homes. The most frequent source of information was "nurse colleagues." Nurses' top priorities for information were vital signs data, information on intravenous (IV) drug compatibility, drug references, and manuals of policies and procedures. IMPLICATIONS: A prototype software system was designed that enables nurses to use handheld computers to simultaneously document patients' responses to treatment, obtain real-time feedback about patient outcomes, and access electronic resources to support clinical decision-making. CONCLUSION: The prototype software system has the potential to increase nurses' access to patient outcomes information and evidence for point-of-care decision-making.

The Relationship between Characteristics of Home Care Nursing Service Contracts under Managed Competition and Continuity of Care and Client Outcomes: Evidence from Ontario.

The purpose of this study was to investigate the impact of the Request for Proposal (RFP) process - specifically, the profit status of provider agencies awarded contracts, the service volume awarded and contract duration - on the quality of home care services and outcomes. A cross-sectional (contract characteristics) and repeated measures (clients) design was used to collect data on the study variables. Primary data were collected in 2002-2003 from 11 Community Care Access Centres (CCACs) and 11 nursing provider agencies in Ontario. The sample included 750 home care clients recruited consecutively from home care referrals. Follow-up assessments were completed on 498 clients. CCACs and provider agencies completed written questionnaires about profit status, contract volume, duration of contract, potential for renewal, number of visits made by a principal nurse and number of visits made by a registered nurse. Data were collected on client health outcomes either at admission to home care service for new clients or at entry to the study for long-term clients, and then at discharge from service or at the end of six weeks, whichever came first, using the eight subscales of the Medical Outcome Study SF-36. Analysis was conducted using hierarchical linear modelling.For the most part, contract characteristics were not related to the consistency of principal nurse visits or client outcomes. Where differences existed, they were small. Clients of agencies awarded longer contracts received greater consistency in principal nurse visits than clients of agencies awarded shorter contracts. Clients cared for by for-profit agencies reported slightly higher satisfaction with care and better mental health outcomes than clients cared for by not-for-profit agencies. The percentage of visits made by a registered nurse was positively associated with social function outcome for clients at follow-up. In conclusion, the study findings suggest that contract characteristic variables had a small effect on home care client outcomes.

Health correlates of autonomy, control and professional relationships in the nursing work environment.

BACKGROUND: Internationally, nursing is facing a variety of challenges including changes in health systems, an ageing workforce and escalating shortages of Registered Nurses. New Zealand is no exception. Here as elsewhere these challenges are taking their toll on the resources and demands of hospital environments, on the health and well-being of nurses themselves and most certainly on the people for whom they care. In the United States of America (USA), three aspects of the nursing work environment--autonomy, control and nurse-physician relations--have been identified as linked to staff retention, levels of staff burnout and needlestick injury, as well as to a range of patient outcomes. AIM: To examine the New Zealand nursing situation and to see whether aspects of the work environment are associated with health status. METHODS: A total of 225 Registered Nurses in a general hospital completed the Revised Nursing Work Index (NWI-R) and Medical Outcomes Study (MOS) 36-Item Short-Form Health Survey (SF-36). RESULTS: Ratings indicated that the New Zealand hospital environment was characterized by less autonomy and control and better nurse-physician relations than in USA hospitals. Results of correlations demonstrated that more positive ratings of the three workplace attributes were associated with better health status amongst the nurses. The results of regression analyses were indicative either of a confounding relationship or of a mediating relationship such that nurses' relations with physicians, administration and other departments mediate the associations between autonomy, control and health status. CONCLUSIONS: The study offers an insight into a New Zealand hospital environment and suggests the importance of good relationships with physicians and other departments for the health of nurses.

Achieving clinical improvement: an interdisciplinary intervention.

This study evaluates whether training health care teams in continuous quality improvement methods results in improvements in the care of and outcomes for patients. Nine of the 25 teams who participated in the study were successful in improving the care/outcomes for patients. Successful teams were more effective at problem solving, engaged in more functional group interactions, and were more likely to have physician participation.