Transformational Leadership and Structural Empowerment for Nurse Managers to Improve Nursing Job Satisfaction, Engagement, and Retention

Problem Description Low nurse job satisfaction and engagement have historically been associated with high attrition. While it is too soon to fully quantify the impact of Covid-19 on nurse satisfaction, engagement, and turnover, evidence is emerging that high chronic fatigue and persistent feelings of being overwhelmed are causing nurses to either leave the bedside or quit nursing altogether, exacerbating existing nurse staffing challenges caused by a decades long nursing shortage that, pre-pandemic, predicted a national deficit of over one-half million nurses by 2030. The financial impact of competing for experienced nurses, and recruiting, hiring, and training new nurses to replace those who have left, is high. Additionally, chronic short staffing and/or an overreliance of new graduates negatively impacts the quality and safety of patient care by either not having enough resources to perform necessary care or by diluting the experience level at the bedside. Setting This project occurs in a middle sized tertiary acute care hospital in California. Project participants are the managers and registered nurses from the Intensive Care Unit, Emergency Department, Nursing Float Pool, General Medical-Surgical unit, and Oncology unit. Rationale Kanter’s Theory of Structural Empowerment states that empowerment is promoted in work environments that provide employees with access to information, resources, support, and the opportunity to learn and develop. The literature reveals a theme of successful interventions that fall within these four constructs and contribute to nurse job satisfaction and engagement, which has been shown to reduce turnover and contribute to nurse retention. Transformational leaders create an empowered work environment where employees can innovate, create, and problem solve. The behaviors associated with transformational leadership cultivate and enable structural empowerment to not only exist but thrive. Nurses who perceive their manager’s leadership style as transformational have lower intention to leave than nurses who view their manager’s style as transactional or passive avoidant. These traits are associated with hospital Magnet Status, and thus are desirable attributes for organizations to achieve. Specific Aims This project aimed to improve nursing leadership by implementing an evidence-based education and coaching program. Managers received education, coaching, and mentoring on structural empowerment and transformational leadership concepts and behaviors. Project Outcomes This project has nine short term change outcomes. Five outcomes were developed based on select questions from the organization’s annual caregiver engagement survey that measure specific elements of structural empowerment and nurses’ intent to stay directly and by asking about burnout. Four additional outcomes were developed to assess overall leader engagement and uptake and utilization of knowledge obtained during the implementation phase of the project. Implementation and Evaluation Plan Managers and the registered nurses from participating units were emailed a pre-project survey. Following a three-week period for completion of the surveys, managers participated in an education session on transformational leadership and structural empowerment. Each manager subsequently participated in weekly 1:1 coaching and mentoring sessions with their DNP-student coach/mentor. The project culminated in post-project surveys to assess project outcomes. Results While there was improvement in four outcome measures, only one was met and one was partially met. Four of nine outcomes had decreased scores compared to pre-project survey scores and one outcome remained unchanged overall. The best improvements were in leader level of uptake and utilization of transformational leadership and structural empowerment, and appreciation demonstrated by the nurse leader. Communication, access to supplies and equipment, and the ISA scores for registered nurses decreased. Burn out was unchanged. A contextual element that may have interacted with the results was the implementation of a new, all-in-one, timekeeping, payroll, procurement, human resources and talent acquisition platform that resulted in widespread pay discrepancies, procurement problems for minor but necessary supplies and equipment, and position requisition issues that delayed hiring, exacerbating staffing challenges. Interpretation The five managers who responded to the Level of Knowledge Use Surveys (LOKUS) had significant individual improvement in their individual knowledge uptake and utilization (KUU) for both transformational leadership (TL) and structural empowerment (SE). While the 50% threshold for SE KUU was not reached, each manager had individual improvement of two to four levels in TL and SE. While the contextual issues experienced at the hospital during the project implementation period had a significant impact on individual employees, small improvements in some ISA domains, only small increases in others, and lack of change in burnout suggests that TL with SE can prevent a bad situation from getting worse. Conclusions Although the stated outcomes were not met seven of nine times, multiple outcomes did improve despite significant organizational adversities. TL and SE may serve as stabilizing forces during the time of organizational strife. This model is dependent upon senior nurse leaders who value TL characteristics and the empowerment of staff. Embarking on a Magnet journey could serve to embed and codify this into the organization’s nursing leadership DNA. TL and SE should be nurtured so that the desired behaviors do not degrade during times of stress or high transactional demands from nursing leaders. TL and SE are not exclusive to nursing. Including other health disciplines in this training has the potential to create a standard and aligned leadership approach. An engaged and empowered workforce is primed to collaborate across disciplines, embracing evidence-based practice to and improve patient care

Early childhood caries in Switzerland: a marker of social inequalities

BACKGROUND: Early childhood caries (ECC) is a marker of social inequalities worldwide because disadvantaged children are more likely to develop caries than their peers. This study aimed to define the ECC prevalence among children living in French-speaking Switzerland, where data on this topic were scarce, and to assess whether ECC was an early marker of social inequalities in this country. METHODS: The study took place between 2010 and 2012 in the primary care facility of Lausanne Children's Hospital. We clinically screened 856 children from 36 to 71 months old for ECC, and their caregivers (parents or legal guardians) filled in a questionnaire including items on socioeconomic background (education, occupation, income, literacy and immigration status), dental care and dietary habits. Prevalence rates, prevalence ratios and logistic regressions were calculated. RESULTS: The overall ECC prevalence was 24.8 %. ECC was less frequent among children from higher socioeconomic backgrounds than children from lower ones (prevalence ratios ≤ 0.58). CONCLUSIONS: This study reported a worrying prevalence rate of ECC among children from 36 to 71 months old, living in French-speaking Switzerland. ECC appears to be a good marker of social inequalities as disadvantaged children, whether from Swiss or immigrant backgrounds, were more likely to have caries than their less disadvantaged peers. Specific preventive interventions regarding ECC are needed for all disadvantaged children, whether immigrants or Swiss

A hidden side of the COVID-19 pandemic in children: the double burden of undernutrition and overnutrition.

The COVID-19 pandemic has deteriorated key determinants of health and caused major upheavals around the world. Children, although less directly affected by the virus, are paying a heavy price through the indirect effects of the crisis, including poor diet, mental health impact, social isolation, addiction to screens and lack of schooling and health care, particularly among vulnerable groups. This paper is aimed at discussing the potential impact of this pandemic on children's nutrition and lifestyle. Preliminary data from the literature and from our survey show significant disruptions in nutrition and lifestyle habits of children. While undernutrition is expected to worsen in poor countries, obesity rates could increase in middle- and high-income countries especially among precarious groups widening the gap in health and social inequalities.The real impact of the COVID-19 pandemic on children extends well beyond that of a viral infection. This crisis has public health implications that could have life-long consequences on children. It requires effective and targeted measures mainly for vulnerable children and households to guarantee children's basic rights for optimal nutrition, health and development

Iron deficiency in infancy: is an immigrant more at risk?

QUESTIONS UNDER STUDY: Iron deficiency with or without anaemia is the most common deficiency in the world. Its prevalence is higher in developing countries and in low socioeconomic populations. We aimed at determining and comparing the prevalence of iron deficiency in an immigrant and non-immigrant population. METHODS: Every child scheduled for a routine check-up at 12 months of age was allowed to participate in the study. Haemoglobin, ferritin, anthropometric data, familial and nutritional status were measured. RESULTS: 586 infants were eligible and 463 were included in the study as they had assessment data at 12 months. Children were divided into two groups: immigrants' children and non-immigrants' children. The global prevalence of iron deficiency was 5.7% at 12 months. A significant difference for iron deficiency was noticed between the groups at 12 months (p = 0.01). Among risk factors, immigration (odds ratio 2.91; 95% CI 1.05-8.04) and unemployment (odds ratio 6.08; 95% CI 1.18-31.30) had the higher odds in the multivariable analysis. CONCLUSION: The prevalence of iron deficiency in the immigrant population is higher than in non-immigrants. Immigration and the category of employment are risk factors for iron deficiency, as starting baby cereals before 9 months is a protective factor. Good socioeconomic conditions in Switzerland, the quality of food for pregnant women and young infants may be the explanation. A study up to five years of age is necessary before drawing general conclusions on infancy

Prevalence and risk factors of lactic acidosis in children with acute moderate and severe asthma, a prospective observational study.

Lactic acidosis is a common complication of status asthmaticus in adults. However, data is sparse in children. The aim of this study was to describe the prevalence and risk factors for lactic acidosis in children hospitalised for acute moderate or severe asthma. A total of 154 children 2-17 years of age were enrolled in a prospective observational study conducted in a tertiary hospital. All had capillary blood gas assessment 4 h after the first dose of salbutamol in hospital. The primary endpoint was the prevalence of lactic acidosis. Potential contributing factors such as age, sex, BMI, initial degree of asthma severity, type of salbutamol administration (nebuliser or inhaler), steroids, ipratropium bromide, and glucose-containing maintenance fluid represented secondary endpoints. All in all, 87% of patients had hyperlactatemia (lactate concentration > 2.2 mmol/l). Lactic acidosis (lactate concentration > 5 mmol/l and anion gap ≥ 16 mmol/l) was observed in 26%. In multivariate analysis, age more than 6 years (OR = 2.8, 95% CI 1.2-6.6), glycemia above 11 mmol/l (OR = 3.2 95% CI 1.4-7.4), and salbutamol administered by nebuliser (OR = 10, 95% CI 2.7-47) were identified as risk factors for lactic acidosis in children with moderate or severe asthma.Conclusion: Lactic acidosis is a frequent and early complication of acute moderate or severe asthma in children. What is Known: • Lactic acidosis during acute asthma is associated with b2-mimetics administration. • Salbutamol-related lactic acidosis is self-limited but important to recognise, as compensatory hyperventilation of lactic acidosis can be mistaken for respiratory worsening and lead to inappropriate supplemental bronchodilator administration. What is New: • Lactic acidosis is a frequent complication of acute asthma in the paediatric population. • Age older than 6 years, hyperglycaemia, and nebulised salbutamol are risk factors for lactic acidosis during asthma

Risk behaviours among native and immigrant youths in Switzerland: a cross-sectional study.

Switzerland has been receiving migrants of various origins for more than 50 years. The adoption of risk-taking behaviours among migrant youths is unclear. Moreover, when studied, migrant youths are rarely analysed according to whether they are first or second generation, or just young people with mixed origins. The aim of this study was to assess whether there are any differences between first-and second-generation immigrants, youths of mixed origins and their native peers in Switzerland concerning their engagement in risk behaviours. A total of 5834 youths from eleven post-mandatory schools in the canton of Fribourg (Switzerland) participated in the baseline survey of the GenerationFRee study, a longitudinal study to assess their lifestyle. Participants were divided by gender and by origin into: (a) natives: Swiss-born youths with Swiss-born parents, (b) first-generation migrants: foreign-born youths with foreign-born parents, (c) second-generation migrants: Swiss-born youths with foreign-born parents, (d) mixed-origin youths: Swiss-born youths with one Swiss-born parent and one foreign-born parent. Participants reported personal, family and school information, and attitudes towards eight risk behaviours. All significant variables at the bivariate level were included in a binary logistic regression. The logistic regression showed that, compared with natives, first-and second-generation migrant boys were less likely to misuse alcohol. Boys of mixed origins were similar to migrants, although at the bivariate level they were more exposed to risk behaviours than were migrants. First-and second-generation migrant girls were less likely to misuse alcohol but three times more likely to be excessive Internet users. Girls of mixed origin were more likely to have their parents not living together and reported antisocial behaviours almost twice more often. Our findings expose a lower engagement in risk behaviours among migrants. The migrant status in these two groups is clearly buffered if other control variables are considered. Thus, we can affirm that in the present study, migrants are not a high-risk population or not more at risk than the native group. Mixed origin youths showed higher risk behaviours than natives and migrants. Special attention should be given to this specific group, as they may be more vulnerable during adolescence

Outpatient prescription writing quality in a paediatric general hospital

Introduction The writing of prescriptions is an important aspect of medical practice. Since 2006, the Swiss authorities have decided to impose incentives to prescribe generic drugs. The objectives of this study were 1) to determine the evolution of the outpatient prescription practice in our paediatric university hospital during 2 periods separated by 5 years; 2) to assess the writing quality of outpatient prescriptions during the same period.Materials & Methods Design: Copies of prescriptions written by physicians were collected twice from community pharmacies in the region of our hospital for a 2-month period in 2005 and 2010. They were analysed according to standard criteria regarding both formal and pharmaceutical aspects. Drug prescriptions were classified as a) complete when all criteria for safety were fulfilled, b) ambiguous when there was a danger of a dispensing error because of one or more missing criteria, or c) containing an error.Setting: Paediatric university hospital.Main outcome measures: Proportion of generic drugs; outpatient prescription writing quality.Results: A total of 651 handwritten prescriptions were reviewed in 2005 and 693 in 2010. They contained 1570 drug prescriptions in 2005 (2.4 ± 1.2 drugs per patient) and 1462 in 2010 (2.1 ± 1.1). The most common drugs were paracetamol, ibuprofen, and sodium chloride. A higher proportion of drugs were prescribed as generic names or generics in 2010. Formal data regarding the physicians and the patients were almost complete, except for the patients' weight. Of the drug prescriptions, 48.5% were incomplete, 11.3% were ambiguous, and 3.0% contained an error in 2005. These proportions rose to 64.2%, 15.5% and 7.4% in 2010, respectively.Discussions, Conclusion This study showed that physicians' prescriptions comprised numerous omissions and errors with minimal potential for harm. Computerized prescription coupled with advanced decision support is eagerly awaited.Disclosure of Interest None Declare

Outpatient prescriptions practice and writing quality in a paediatric university hospital.

BACKGROUND: The writing of prescriptions is an important aspect of medical practice. This activity presents some specific problems given a danger of misinterpretation and dispensing errors in community pharmacies. The objective of this study was to determine the evolution of the prescription practice and writing quality in the outpatient clinics of our paediatric university hospital.¦METHODS: Copies of prescriptions written by physicians were collected from community pharmacies in the region of our hospital for a two-month period in 2005 and 2010. They were analysed according to standard criteria, including both formal and pharmaceutical aspects.¦RESULTS: A total of 597 handwritten prescriptions were reviewed in 2005 and 633 in 2010. They contained 1,456 drug prescriptions in 2005 and 1,348 in 2010. Fifteen drugs accounted for 80% of all prescriptions and the most common drugs were paracetamol and ibuprofen. A higher proportion of drugs were prescribed as International Nonproprietary Names (INN) or generics in 2010 (24.7%) compared with 2005 (20.9%). Of the drug prescriptions examined, 55.5% were incomplete in 2005 and 69.2% in 2010. Moreover in 2005, 3.2% were legible only with difficulty, 22.9% were ambiguous, and 3.0% contained an error. These proportions rose respectively to 5.2%, 27.8%, and 6.8% in 2010.¦CONCLUSION: This study showed that fifteen different drugs represented the majority of prescriptions, and a quarter of them were prescribed as INN or generics in 2010; and that handwritten prescriptions contained numerous omissions and preventable errors. In our hospital computerised prescribing coupled with advanced decision support is eagerly awaited

Unlicensed and off-label drug use in a Swiss paediatric university hospital.

BACKGROUND: Many medicines used in newborns, infants, children and adolescents are not licensed ("unlicensed") or are prescribed outside the terms of the marketing authorization ("off-label"). Several studies have shown that this is a common practice in various healthcare settings in the USA, Europe and Australia, but data are scarce in Switzerland. OBJECTIVES: The aim of our prospective study was to determine the proportion of unlicensed or off-label prescriptions in paediatric patients. METHODS: This pilot study was conducted prospectively over a six month period in the department of paediatrics of a university hospital. RESULTS: Sixty patients aged from three days to 14 years were included in the study. A total of 483 prescriptions were written for the patients. More than half of all prescriptions (247; 51%) followed the terms of the marketing authorization. 114 (24%) were unlicensed and 122 (25%) off-label. All patients received at least one unlicensed or offlabel medicine. CONCLUSION: The use of unlicensed or off-label medicines to treat children was found to be common. Co-operation between the pharmaceutical industry, national regulatory authorities, clinical researchers, healthcare professionals and parents is required in order to ensure that children do not remain "therapeutic orphans"