Comparison of Nurse Staffing Based on Changes in Unit-level Workload Associated with Patient Churn

Aim This analysis compares the staffing implications of three measures of nurse staffing requirements: midnight census, turnover adjustment based on length of stay, and volume of admissions, discharges and transfers. Background Midnight census is commonly used to determine registered nurse staffing. Unit-level workload increases with patient churn, the movement of patients in and out of the nursing unit. Failure to account for patient churn in staffing allocation impacts nurse workload and may result in adverse patient outcomes. Method(s) Secondary data analysis of unit-level data from 32 hospitals, where nursing units are grouped into three unit-type categories: intensive care, intermediate care, and medical surgical. Result Midnight census alone did not account adequately for registered nurse workload intensity associated with patient churn. On average, units were staffed with a mixture of registered nurses and other nursing staff not always to budgeted levels. Adjusting for patient churn increases nurse staffing across all units and shifts. Conclusion Use of the discharges and transfers adjustment to midnight census may be useful in adjusting RN staffing on a shift basis to account for patient churn. Implications for nursing management Nurse managers should understand the implications to nurse workload of various methods of calculating registered nurse staff requirements

Undergraduate Nursing Students’ Attitudes Toward Mental Health Nursing

Objectives: The purpose of this study was to describe undergraduate nursing students’ attitudes toward mental health nursing and how these attitudes influenced their professional career choices in mental health nursing. Design: A descriptive, online survey was utilized to examine students’ perceptions of mental health nursing. A total of 229 junior and senior nursing students were recruited from eight nursing colleges in Midwestern United States to participate in this survey. Results: Students of different ages, genders, ethnicities, and nursing programs did not report significantly different perceptions of: (a) knowledge of mental illness; (b) negative stereotypes; (c) interest in mental health nursing as a future career; and (d), and beliefs that psychiatric nurses provide a valuable contribution to consumers and the community. Negative stereotypes were significantly different between students who had mental health nursing preparation either in class (p = 0.0147) or in clinical practice (p = 0.0018) and students who had not. There were significant differences in anxiety about mental illness between students who had classes on mental health nursing (p = .0005), clinical experience (p = 0.0035), and work experience in the mental health field (p = 0.0012). Significant differences in an interest in a future career in mental health nursing emerged between students with and without prior mental health experience and between students with and without an interest in an externship program with p-values of 0.0012 and \u3c 0.0001, respectively. Conclusions: The more exposure that students have to mental health nursing through clinical experiences, theory classes, and previous work in the field, the more prepared they feel about caring for persons with mental health issues

A Model for Hospital Discharge Preparation: From Case Management to Care Transition

There has been a proliferation of initiatives to improve discharge processes and outcomes for the transition from hospital to home and community-based care. Operationalization of these processes has varied widely as hospitals have customized discharge care into innovative roles and functions. This article presents a model for conceptualizing the components of hospital discharge preparation to ensure attention to the full range of processes needed for a comprehensive strategy for hospital discharge

An Online Educational Program Improves Pediatric Oncology Nurses’ Knowledge, Attitudes, and Spiritual Care Competence

This study evaluated the potential impact of an online spiritual care educational program on pediatric nurses’ attitudes toward and knowledge of spiritual care and their competence to provide spiritual care to children with cancer at the end of life. It was hypothesized that the intervention would increase nurses’ positive attitudes toward and knowledge of spiritual care and increase nurses’ level of perceived spiritual care competence. A positive correlation was expected between change in nurses’ perceived attitudes toward and knowledge of spiritual care and change in nurses’ perceived spiritual care competence. A prospective, longitudinal design was employed, and analyses included one-way repeated-measures analysis of variance, linear regression, and partial correlation. Statistically significant differences were found in nurses’ attitudes toward and knowledge of spiritual care and nurses’ perceived spiritual care competence. There was a positive relationship between change scores in nurses’ attitudes toward and knowledge of spiritual care and nurses’ spiritual care competence. Online spiritual care educational programs may exert a lasting impact on nurses’ attitudes toward and knowledge of spiritual care and their competence to provide spiritual care to children with cancer at the end of life. Additional studies are required to evaluate the direct effects of educational interventions patient outcomes

Individual Nurse Productivity in Preparing Patients for Discharge Is Associated with Patient Likelihood of 30-Day Return to Hospital

Objective: Applied to value-based health care, the economic term “individual productivity” refers to the quality of an outcome attributable through a care process to an individual clinician. This study aimed to (1) estimate and describe the discharge preparation productivities of individual acute care nurses and (2) examine the association between the discharge preparation productivity of the discharging nurse and the patient’s likelihood of a 30-day return to hospital [readmission and emergency department (ED) visits]. Research Design: Secondary analysis of patient-nurse data from a cluster-randomized multisite study of patient discharge readiness and readmission. Patients reported discharge readiness scores; postdischarge outcomes and other variables were extracted from electronic health records. Using the structure-process-outcomes model, we viewed patient readiness for hospital discharge as a proximal outcome of the discharge preparation process and used it to measure nurse productivity in discharge preparation. We viewed hospital return as a distal outcome sensitive to discharge preparation care. Multilevel regression analyses used a split-sample approach and adjusted for patient characteristics. Subjects: A total 522 nurses and 29,986 adult (18+ y) patients discharged to home from 31 geographically diverse medical-surgical units between June 15, 2015 and November 30, 2016. Measures: Patient discharge readiness was measured using the 8-item short form of Readiness for Hospital Discharge Scale (RHDS). A 30-day hospital return was a categorical variable for an inpatient readmission or an ED visit, versus no hospital return. Results: Variability in individual nurse productivity explained 9.07% of variance in patient discharge readiness scores. Nurse productivity was negatively associated with the likelihood of a readmission (−0.48 absolute percentage points, P\u3c0.001) and an ED visit (−0.29 absolute percentage points, P=0.042). Conclusions: Variability in individual clinician productivity can have implications for acute care quality patient outcomes

Using the Consolidated Framework for Implementation Research to Evaluate Clinical Trials: An Example from Multisite Nursing Research

Background The Consolidated Framework for Implementation Research (CFIR) is a comprehensive guide for determining the factors that affect successful implementation of complex interventions embedded in real-time clinical practice. Purpose The study aim was to understand implementation constructs in a multi-site translational research study on readiness for hospital discharge that distinguished study sites with low versus high implementation fidelity. Methods In this descriptive study, site Principal Investigator interviews (from 8 highest and 8 lowest fidelity sites) were framed with questions from 20 relevant CFIR constructs. Analysis used CFIR rules and rating scale (+2 to −2 per site) and memos created in NVivo 11. Findings From a bimodal distribution of differences (1.5 and 5), 7 constructs distinguished high and low fidelity sites with ≥5-point difference. Discussion CFIR provided a determinant framework for identifying elements of a study site\u27s context that impact implementation fidelity and clinical research outcomes

Clinical Nurses\u27 Perspectives on Discharge Practice Changes from Participating in a Translational Research Study

Aim To describe clinical nurses\u27 experiences with practice change associated with participation in a multi‐site nursing translational research study implementing new protocols for hospital discharge readiness assessment. Background Nurses\u27 participation in translational research studies provides an opportunity to evaluate how implementation of new nursing interventions affects care processes within a local context. These insights can provide information that leads to successful adoption and sustainability of the intervention. Methods Semi‐structured focus groups from 30 of 33 participating study hospitals lead by team nurse researchers. Results Nurses reported improved and earlier awareness of patients\u27 discharge needs, changes in discharge practices, greater patient/family involvement in discharge, synergy and enhanced discharge processes, and implementation challenges. Participating nurses related the benefits of participation in nursing research. Conclusion Participation in a unit‐level translational research project was a successful strategy for engaging nurses in practice change to improve hospital discharge. Implications for Nursing Management Leading unit‐based implementation of a structured discharge readiness assessment including nurse assessment and patient self‐assessment encourages earlier awareness of patients\u27 discharge needs, improved patient assessment and greater patient/family involvement in discharge preparation. Integrating discharge readiness assessments into existing discharge care promotes communication between health team members that facilitates a timely, coordinated discharge

Effectiveness of Home Health Care in Reducing Return to Hospital: Evidence from a Multi-hospital Study in the US

Background Home health care, a commonly used bridge strategy for transitioning from hospital to home-based care, is expected to contribute to readmission avoidance efforts. However, in studies using disease-specific samples, evidence about the effectiveness of home health care in reducing readmissions is mixed. Objective To examine the effectiveness of home health care in reducing return to hospital across a diverse sample of patients discharged home following acute care hospitalization. Research design Secondary analysis of a multi-site dataset from a study of discharge readiness assessment and post-discharge return to hospital, comparing matched samples of patients referred and not referred for home health care at the time of hospital discharge. Setting Acute care, Magnet-designated hospitals in the United States Participants The available sample (n = 18,555) included hospitalized patients discharged from medical-surgical units who were referred (n = 3,579) and not referred (n = 14,976) to home health care. The matched sample included 2767 pairs of home health care and non- home health care patients matched on patient and hospitalization characteristics using exact and Mahalanobis distance matching. Methods Unadjusted t-tests and adjusted multinomial logit regression analyses to compare the occurrence of readmissions and Emergency Department/Observation visits within 30 and 60-days post-discharge. Results No statistically significant differences in readmissions or Emergency Department /Observation visits between home health care and non-home health care patients were observed. Conclusions Home health care referral was not associated with lower rates of return to hospital within 30 and 60 days in this US sample matched on patient and clinical condition characteristics. This result raises the question of why home health care services did not produce evidence of lower post-discharge return to hospital rates. Focused attention by home health care programs on strategies to reduce readmissions is needed

Effect of Implementing Discharge Readiness Assessment in Adult Medical-Surgical Units on 30-Day Return to Hospital The READI Randomized Clinical Trial

Importance: The downward trend in readmissions has recently slowed. New enhancements to hospital readmission reduction efforts are needed. Structured assessment of patient readiness for discharge has been recommended as an addition to discharge preparation standards of care to assist with tailoring of risk-mitigating actions. Objective: To determine the effect of unit-based implementation of readiness evaluation and discharge intervention protocols on readmissions and emergency department or observation visits. Design, Setting, and Participants: The Readiness Evaluation and Discharge Interventions (READI) cluster randomized clinical trial conducted in medical-surgical units of 33 Magnet hospitals between September 15, 2014, and March 31, 2017, included all adult (aged ≥18 years) patients discharged to home. Baseline and risk-adjusted intent-to-treat analyses used difference-in-differences multilevel logistic regression models with controls for patient characteristics. Interventions: Of 2 adult medical-surgical nursing units from each hospital, 1 was randomized to the intervention and 1 to usual care conditions. Using the 8-item Readiness for Hospital Discharge Scale, the 33 intervention units implemented a sequence of protocols with increasing numbers of components: READI1, in which nurses assessed patients to inform discharge preparation; READI2, which added patient self-assessment; and READI3, which added an instruction to act on a specified Readiness for Hospital Discharge Scale cutoff score indicative of low readiness. Main Outcomes and Measures: Thirty-day return to hospital (readmission or emergency department and observation visits). Intervention units above median baseline readmission rate (\u3e11.3%) were categorized as high-readmission units. Among the 33 intervention units, 17 were low-readmission units and 16 were high-readmission units. Results: The sample included 144 868 patient discharges (mean [SD] age, 59.6 [17.5] years; 51% female; 74 605 in the intervention group and 70 263 in the control group); 17 667 (12.2%) were readmitted and 12 732 (8.8%) had an emergency department visit or observation stay. None of the READI protocols reduced the primary outcome of return to hospital in intent-to-treat analysis of the full sample. In exploratory subgroup analysis, when patient self-assessments were combined with readiness assessment by nurses (READI2), readmissions were reduced by 1.79 percentage points (95% CI, −3.20 to −0.40 percentage points; P = .009) on high-readmission units. With nurse assessment alone and on low-readmission units, results were mixed. Conclusions and Relevance: Implemented in a broad range of hospitals and patients, the READI interventions were not effective in reducing return to hospital. However, adding a structured discharge readiness assessment that incorporates the patient’s own perspective to usual discharge care practices holds promise for mitigating high rates of return to the hospital following discharge

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

Introduction: The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures. Methods: In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025. Findings: Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2–6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5–5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4–10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32–4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23–11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation. Interpretation: After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification