An Examination of Hospital Safety Climate.

Safety Climate (SC) is a point in time measurement of an organization’s culture relative to safety. Safety, both for patients and caregivers, is an important goal for healthcare organizations. SC is a complex phenomenon that is poorly understood. The purpose of this study was to deepen the understanding of SC, identify elements of SC commonly measured by hospitals, and then test relationships between those elements and registered nurses’ perceptions of SC. This was a study conducted in two phases. A modified Delphi method was used in the first phase of the study to gain the insights of 38 healthcare safety experts’ into 1) the key elements of SC as identified by Sammer et al. (2010), and 2) identify data sets commonly collected by acute care hospitals that operationalize these elements. A retrospective, cross-sectional design using hierarchical multivariable linear modeling was used in Phase II of the study to examine the relationships between the SC elements and SC. SC data were derived from the AHRQ’s Hospital Survey of Patient Safety Culture (2012), with other data derived from institutional administrative warehouses. The findings of Phase I resulted in the modification of the Phase II study model, which included the independent variables of Leadership, Communication, Justice, Patient-Centeredness, RN staffing, Falls with Injury, and Serious Reportable Events (SRE). The dependent variable was SC as operationalized by Overall Patient Safety. Hierarchical multivariable linear modelling supported the inclusion of Leadership, Communication, and Justice in the Safety Climate model. These three variables, with the addition of the type of unit, were statistically significant in independently predicting SC. This study is an important addition to the Safety Climate body of knowledge. As the first known testing of Sammer’s (2010) SC model, safety experts affirmed four of the seven elements of the model (Leadership, Communication, Justice, and Patient-Centeredness) and added three new elements (RN staffing, Falls with Injury, and SRE). The Phase II preliminary validations study supported the inclusion of Leadership, Communication and Justice in the SC model.PhDNursingUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/111563/1/gllands_1.pd

Dissemination of the nurse-administered Tobacco Tactics intervention versus usual care in six Trinity community hospitals: study protocol for a comparative effectiveness trial

Abstract Background The objectives of this smoking cessation study among hospitalized smokers are to: 1) determine provider and patient receptivity, barriers, and facilitators to implementing the nurse-administered, inpatient Tobacco Tactics intervention versus usual care using face-to-face feedback and surveys; 2) compare the effectiveness of the nurse-administered, inpatient Tobacco Tactics intervention versus usual care across hospitals, units, and patient characteristics using thirty-day point prevalence abstinence at thirty days and six months (primary outcome) post-recruitment; and 3) determine the cost-effectiveness of the nurse-administered, inpatient Tobacco Tactics intervention relative to usual care including cost per quitter, cost per life-year saved, and cost per quality-adjusted life-year saved. Methods/Design This effectiveness study will be a quasi-experimental design of six Michigan community hospitals of which three will get the nurse-administered Tobacco Tactics intervention and three will provide their usual care. In both the intervention and usual care sites, research assistants will collect data from patients on their smoking habits and related variables while in the hospital and at thirty days and six months post-recruitment. The intervention will be integrated into the experimental sites by a research nurse who will train Master Trainers at each intervention site. The Master Trainers, in turn, will teach the intervention to all staff nurses. Research nurses will also conduct formative evaluation with nurses to identify barriers and facilitators to dissemination. Descriptive statistics will be used to summarize the results of surveys administered to nurses, nurses’ participation rates, smokers’ receipt of specific cessation services, and satisfaction with services. General estimating equation analyses will be used to determine differences between intervention groups on satisfaction and quit rates, respectively, with adjustment for the clustering of patients within hospital units. Regression analyses will test the moderation of the effects of the interventions by patient characteristics. Cost-effectiveness will be assessed by constructing three ratios including cost per quitter, cost per life-year saved, and cost per quality-adjusted life-year saved. Discussion Given that nurses represent the largest group of front-line providers, this intervention, if proven effective, has the potential for having a wide reach and thus decrease smoking, morbidity and mortality among inpatient smokers. Trial registration Dissemination of Tobacco Tactics for Hospitalized Smokers NCT01309217http://deepblue.lib.umich.edu/bitstream/2027.42/109462/1/13063_2011_Article_1134.pd

Implementation of the Tobacco Tactics intervention versus usual care in Trinity Health community hospitals

Abstract Background Guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) implementation framework, a National Institutes of Health-sponsored study compared the nurse-administered Tobacco Tactics intervention to usual care. A prior paper describes the effectiveness of the Tobacco Tactics intervention. This subsequent paper provides data describing the remaining constructs of the RE-AIM framework. Methods This pragmatic study used a mixed methods, quasi-experimental design in five Michigan community hospitals of which three received the nurse-administered Tobacco Tactics intervention and two received usual care. Nurses and patients were surveyed pre- and post-intervention. Measures included reach (patient participation rates, characteristics, and receipt of services), adoption (nurse participation rates and characteristics), implementation (pre-to post-training changes in nurses' attitudes, delivery of services, barriers to implementation, opinions about training, documentation of services, and numbers of volunteer follow-up phone calls), and maintenance (continuation of the intervention once the study ended). Results Reach: Patient participation rates were 71.5 %. Compared to no change in the control sites, there were significant pre- to post-intervention increases in self-reported receipt of print materials in the intervention hospitals (n = 1370, p < 0.001). Adoption: In the intervention hospitals, all targeted units and several non-targeted units participated; 76.0 % (n = 1028) of targeted nurses and 317 additional staff participated in the training, and 92.4 % were extremely or somewhat satisfied with the training. Implementation: Nurses in the intervention hospitals reported increases in providing advice to quit, counseling, medications, handouts, and DVD (all p < 0.05) and reported decreased barriers to implementing smoking cessation services (p < 0.001). Qualitative comments were very positive (“user friendly,” “streamlined,” or “saves time”), although problems with showing patients the DVD and charting in the electronic medical record were noted. Maintenance: Nurses continued to provide the intervention after the study ended. Conclusions Given that nurses represent the largest group of front-line providers, this intervention, which meets Joint Commission guidelines for treating inpatient smokers, has the potential to have a wide reach and to decrease smoking, morbidity, and mortality among inpatient smokers. As we move toward more population-based interventions, the RE-AIM framework is a valuable guide for implementation. Trial registration ClinicalTrials.gov, NCT0130921

Missed Nursing Care During Labor and Birth and Exclusive Breast Milk Feeding During Hospitalization for Childbirth.

PurposeThe purpose of this study was to determine associations between missed nursing care and nurse staffing during labor and birth, and exclusive breast milk feeding at hospital discharge.Study design and methodsLabor and birth nurses in three states were surveyed about missed nursing care and their maternity units' adherence to the AWHONN (2010) nurse staffing guidelines for care during labor and birth, using the Perinatal Misscare Survey. Nursing responses were aggregated to the hospital level and estimated associations between missed nursing care, nurse staffing, and hospitals' exclusive breast milk feeding rates were measured using The Joint Commission's Perinatal Care Measure (PC-05).ResultsSurveys from 512 labor nurses in 36 hospitals were included in the analysis. The mean exclusive breast milk feeding rate was 53% (range 13%-76%). Skin-to-skin care, breastfeeding within 1 hour of birth, and appropriate recovery care were on average occasionally missed (2.33 to 2.46 out of 4; 1 = rarely, 2 = occasionally, 3 = frequently, or 4 = always) and were associated with PC-05 [B(CI) -17.1(-29, -6.3), -17.9(-30.5, -6.2), and -15.4(-28.7, -2.1), respectively]. Adherence with overall staffing guidelines was associated with PC-05 [12.9(3.4, 24.3)]. Missed nursing care was an independent predictor of PC-05 [-14.6(-26.4, -2.7)] in a multilevel model adjusting for staffing guideline adherence, perceived quality, mean age of respondents, and nurse burnout.Clinical implicationsExclusive breast milk feeding is a national quality indicator of inpatient maternity care. Nurses have substantial responsibility for direct support of infant feeding during the childbirth hospitalization. These results support exclusive breast milk feeding (PC-05) as a nurse-sensitive quality indicator

Adaptation of the MISSCARE Survey to the Maternity Care Setting

Missed nursing care is an important measure of nursing care quality that is sensitive to nurse staffing and is associated with patient outcomes in medical-surgical and pediatric inpatient settings. Missed nursing care during labor and birth has not been studied, yet childbirth represents the most common reason for hospitalization in the United States. The Missed Nursing Care (MISSCARE) Survey, a measure of medical-surgical nursing quality with substantial evidence for validity and reliability, was adapted to maternity nursing care using data from focus groups of labor nurses, physicians, and new mothers and an online survey of labor nurses. Content validity was evaluated via participant feedback, and exploratory factor analysis was performed to identify the factor structure of the instrument. The modified version, the Perinatal Missed Care Survey, appears to be a feasible and promising instrument with which to evaluate missed nursing care of women during labor and birth in hospitals

Adherence to the AWHONN Staffing Guidelines as Perceived by Labor Nurses

ObjectiveTo evaluate the degree to which registered nurses perceive their labor and delivery units to be adhering to Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) staffing guidelines.DesignProspective, cross-sectional study via an online survey of labor nurses recruited from hospitals in three states.Setting/local problemIn late 2016 and early 2017, labor nurses in selected hospitals in California, Michigan, and New Jersey were contacted via e-mail invitation to participate in a study about nursing care during labor and birth. Nurse leaders in each hospital facilitated the invitations.ParticipantsA total of 615 labor nurses from 67 hospitals.Intervention/measurementsDescriptive statistics and linear regression models were used for data analysis.ResultsMost nurses reported that the AWHONN nurse staffing guidelines were frequently or always followed in all aspects of care surveyed. Hospitals with annual birth volumes of 500 to 999 range were significantly more likely than hospitals with 2,500 or more annual births to be perceived as compliant with AWHONN staffing guidelines.ConclusionWhen the AWHONN staffing guidelines were first published in 2010, there was concern among some nurse leaders that they would not be adopted into clinical practice, yet nurses in our sample overwhelmingly perceived their hospitals to be guideline compliant. There remains much more work to be done to determine nurse-sensitive outcomes for maternity care and to ensure that all women in labor in the United States are cared for by nurses who are not overburdened or distracted by being assigned more women than can be safely handled

Psychometric properties of the perinatal missed care survey and missed care during labor and birth

AIM:: To evaluate the psychometric characteristics of the Perinatal Missed Care Survey and assess the prevalence of nurse-reported missed care during labor and birth. BACKGROUND:: Nursing care during labor and birth differs from other nursing care. Empirical evidence is scant regarding nursing quality and missed nursing care during labor and birth, which are important aspects of quality in maternity care. METHODS:: We conducted exploratory and confirmatory factor analysis on a previously developed perinatal missed nursing care instrument using data from 3,466 registered nurses. Measures included missed nursing care, reasons for missed nursing care, and demographic characteristics. All birth hospitals in each of 37 states were invited to distribute surveys electronically via email to their labor and delivery RN staff. The overall response rate from 277 hospitals that facilitated the survey was 35%. RESULTS:: Some missed care was reported for each of 25 missed care items. Labor support, intake and output, patient teaching, timely documentation, timely medication administration, and thorough review of prenatal records were missed at least occasionally by &gt;50% respondents. Labor resources (83%), material resources (77%), and communication (60%) were reported reasons for missed nursing care. Exploratory factor analysis aligned with previous testing. Confirmatory factor analysis demonstrated good model fit. CONCLUSIONS:: The Perinatal Missed Care Survey demonstrates good validity and reliability as a measure of missed nursing care during labor and birth. Our findings suggest missed nursing care during labor and birth is prevalent and occurs in aspects of care that could contribute to patient harm when missed

Nurse-Reported Staffing Guidelines and Exclusive Breast Milk Feeding

BackgroundNursing care is essential to overall quality of healthcare experienced by patients and families-especially during childbearing. However, evidence regarding quality of nursing care during labor and birth is lacking, and established nurse-sensitive outcome indicators have limited applicability to maternity care. Nurse-sensitive outcomes need to be established for maternity care, and prior research suggests that the initiation of human milk feeding during childbirth hospitalization is a potentially nurse-sensitive outcome.ObjectiveThe aim of this study was to determine the relationship between nurse-reported staffing, missed nursing care during labor and birth, and exclusive breast milk feeding during childbirth hospitalization as a nurse-sensitive outcome.Methods2018 Joint Commission PC-05 Exclusive Breast Milk Feeding rates were linked to survey data from labor nurses who worked in a selected sample of hospitals with both PC-05 data and valid 2018 American Hospital Association Annual Survey data. Nurse-reported staffing was measured as the perceived compliance with Association of Women's Health, Obstetric and Neonatal Nurses staffing guidelines by the labor and delivery unit. Data from the nurse survey were aggregated to the hospital level. Bivariate linear regression was used to determine associations between nurse and hospital characteristics and exclusive breast milk feeding rates. Generalized structural equation modeling was used to model relationships between nurse-reported staffing, nurse-reported missed care, and exclusive breast milk feeding at the hospital level.ResultsThe sample included 184 hospitals in 29 states and 2,691 labor nurses who worked day, night, or evening shifts. Bivariate analyses demonstrated a positive association between nurse-reported staffing and exclusive breast milk feeding and a negative association between missed nursing care and exclusive breast milk feeding. In structural equation models controlling for covariates, missed skin-to-skin mother-baby care and missed breastfeeding within 1 hour of birth mediated the relationship between nurse-reported staffing and exclusive breast milk feeding rates.DiscussionThis study provides evidence that hospitals' nurse-reported compliance with Association of Women's Health, Obstetric and Neonatal Nurses staffing guidelines predicts hospital-exclusive breast milk feeding rates and that the rates are a nurse-sensitive outcome