The Impact of Nursing Skill Mix on the Outcomes of Hospitalized Adult Surgical Patients

ABSTRACT THE IMPACT OF NURSING SKILL MIX ON THE OUTCOMES OF HOSPITALIZED ADULT SURGICAL PATIENTS Danielle Altares Sarik Ann Kutney-Lee Rates of harm to surgical patients remain largely unchanged despite decades of initiatives to address safety concerns, while wide variations in mortality and failure to rescue (FTR) persist between hospitals. Despite the critical role that registered nurses (RNs) play in providing care to hospitalized patients, there has been limited exploration of the relationship between nursing skill mix and surgical patient outcomes. The purpose of this study was to examine the association between nursing skill mix and adult surgical patient 30-day mortality and FTR. This retrospective, cross-sectional, secondary data analysis utilized three datasets to study surgical patient outcomes in four states (California, Florida, New Jersey, Pennsylvania): the 2006-2007 Multi-State Nursing Care and Patient Safety Survey, the 2006-2007 American Hospital Association Annual Survey, and hospital discharge abstracts for patients age 18-85 years who underwent general, orthopedic, or vascular surgical procedures in non-federal acute care hospitals in 2006-2007. A total of 1,267, 516 surgical patients, 29,391 nurses, and 665 hospitals comprised the final sample. Logistic regression models were used to assess the association of nursing skill mix, defined as the proportion of RNs to all nursing staff (RNs, licensed practical and vocational nurses (LPN/LVNs), and unlicensed assistive personnel (UAPs)) on 30-day mortality and FTR. After analysis, each 10% increase in RN skill mix was associated with a 7% decrease in the odds of 30-day mortality (P\u3c0.001) and FTR (P\u3c0.01) in the surgical patient population. Additionally, each 10% increase in the proportion of LPN/LVNs was associated with a 6% increase in the odds of both 30-day mortality (P\u3c0.05) and FTR (P\u3c0.05), while every 10% increase in UAP proportion was associated with a 6% increase in the odds of 30-day mortality (P\u3c0.01) and a 5% increase in the odds of FTR (P\u3c0.05). As healthcare reform continues to place pressure on hospital administrators to increase quality and decrease costs, maintaining a nursing skill mix with a high proportion of RNs may be one strategy to improve surgical patient mortality and FTR

Baby Steps: Improving the Transition from Hospital to Home for Neonatal Patients and Caregivers Through a Nurse-Led Telehealth Program

The Baby Steps program, a nurse-led telehealth transition of care intervention for infants cared for in the neonatal intensive care unit (NICU) and their caregivers, was developed to address a gap in care after discharge. The program focused on providing integral support during the discharge process and after the infant returned to home and community. Led by an interprofessional team composed of researchers, NICU professionals, and telehealth specialists, the program was guided by the Theory of Transition Model to support the situational, developmental, and health transitions that occur during this time period. Central to the intervention was nurse-led telehealth follow-up within 24–48 h after discharge, coupled with on-demand services available for 2 weeks. During these encounters, a trained NICU nurse offered clinical support, addressed concerns, and provided anticipatory guidance. Within the first 24 months of the program, a total of 450 infants were enrolled, and 492 total encounters were completed. Significant decreases in readmissions were noted (57%). Additionally, caregivers reported a high level of satisfaction, with 99.2% reporting they were satisfied or highly satisfied (n = 141). In conclusion, we found that nurses effectively counseled caregivers, and that the use of telehealth intervention after discharge was feasible

Implementation Quality: Implications for Intervention and Translational Science

Implementation quality (IQ), a critical concept for translational science, measures the discrepancy between an intervention's intended design and its implementation. Quantifying the impact of IQ on intervention outcomes informs efforts to improve intervention translatability. The purpose of this article is to define and describe IQ and its dimensions (content adherence, quality of delivery, and engagement) with a focus on individualized interventions being delivered in research and practice settings. We apply IQ concepts from intervention science in two contexts: (a) an intervention currently being investigated in an efficacy trial, and (b) a practice situation involving the application of evidence-based practice guidelines during clinic visits. IQ measurement approaches are presented using a study protocol, progress notes, interdisciplinary meeting notes, or clinical guidelines, depending upon whether the intervention is delivered during a research study or a clinical encounter. The investigators describe the necessary infrastructure and support for capturing IQ data and the subsequent complexities and challenges of collecting, measuring, and analyzing these data. Understanding IQ is critical to advancing translational science. Such understanding informs application of appropriate IQ measures, and promotes effective translation of evidence-based interventions into practice. Policy changes are needed to promote IQ assessment to ensure high-quality clinical encounters during which interventions are effectively delivered. In both research and practice settings, the conceptualization and measurement of IQ will improve patient outcomes by advancing translational science and integrating evidence-based interventions into nursing practice

Effects of Regulation and Payment Policies on Nurse Practitioners’ Clinical Practices

Barnes H, Maier CB, Altares Sarik D, Germack HD, Aiken LH, McHugh MD. Effects of Regulation and Payment Policies on Nurse Practitioners’ Clinical Practices. Medical Care Research and Review. 2017;74(4):431-451.Increasing patient demand following health care reform has led to concerns about provider shortages, particularly in primary care and for Medicaid patients. Nurse practitioners (NPs) represent a potential solution to meeting demand. However, varying state scope of practice regulations and Medicaid reimbursement rates may limit efficient distribution of NPs. Using a national sample of 252,657 ambulatory practices, we examined the effect of state policies on NP employment in primary care and practice Medicaid acceptance. NPs had 13% higher odds of working in primary care in states with full scope of practice; those odds increased to 20% if the state also reimbursed NPs at 100% of the physician Medicaid fee-for-service rate. Furthermore, in states with 100% Medicaid reimbursement, practices with NPs had 23% higher odds of accepting Medicaid than practices without NPs. Removing scope of practice restrictions and increasing Medicaid reimbursement may increase NP participation in primary care and practice Medicaid acceptance

A telehealth nursing intervention to improve the transition from the neonatal intensive care unit to home for infants & caregivers: Preliminary evaluation

The purpose of this nurse-led telehealth intervention was to support caregivers and infants during the difficult period of transition from the neonatal intensive care unit (NICU) to home. The Baby Steps project was designed using quality improvement methodology, and was implemented in April 2020 at a stand-alone pediatric institution in South Florida. Using a nurse-led telehealth model, follow-up nursing care was provided in the home setting for two weeks after discharge. Any infant cared for in the NICU and discharged to a home setting in the state of Florida was eligible for services. Encounters included assessment, anticipatory guidance, connection with community resources, and general support. Caregiver satisfaction, unplanned emergency care use, and 30-day readmissions were assessed. Within the first 18 months of the program, a total of 378 infants were enrolled, and 74.6% received follow-up services in the home setting (n = 282). Caregivers reported high satisfaction with the program (100% strongly agree or agree). There was a 46% decrease in 30-day readmissions from baseline rates, and a substantial decrease in use of emergency care services within a month of discharge as compared to infants discharged during the same time period who did not receive services (30.9% vs.13.8%). This nurse-led intervention was found to be a feasible and highly satisfactory approach to improve NICU patient outcomes and support caregivers during transition from hospital to home. Nurses can provide post-discharge telehealth support, which not only improves caregiver satisfaction but also decreases readmissions and emergency care use among NICU patients. •Transition from the neonatal intensive care unit (NICU) to home is challenging•A nurse-led telehealth intervention, Baby Steps, addresses this gap•Within the first 18 months of the program, 378 infants were enrolled•Caregivers indicated high satisfaction and high likelihood to act on nursing advice•Readmissions and unplanned emergency care use were significantly decrease

Baby Steps Program: Telehealth Nursing Simulation for Undergraduate Public Health Nursing Students

•The (Blinded for review) Program, provided through telehealth, is a novel approach to support caregivers of infants discharged from the neonatal intensive care unit.•Nursing students expressed high levels of satisfaction with the telehealth simulation.•Telehealth simulation and training is a growing modality and should be integrated into nursing curricula. Telehealth has become a staple form of healthcare delivery, yet training is lacking in nursing curricula. The purpose of this study is to assess undergraduate nursing students’ learning outcomes and experience with a novel telehealth simulation. A descriptive, mixed-methods design was used with 59 undergraduate nursing students. Based on the quantitative data, all of the students indicated that the simulation experience improved their knowledge about telehealth. Major categories emerging from the qualitative analysis were (a) importance of assessing home environment, (b) importance of therapeutic communication, (c) benefits of telehealth visits, (d) awareness of the challenges associated with telehealth encounters, (e) role of the telehealth nurse, and (f) importance of detailed assessment by asking questions. The telehealth simulation contributed to nursing students’ clinical growth and should be integrated into nursing curricula

The revised Humpty Dumpty Fall Scale: An update to improve tool performance and predictive validity

The purpose of this study was to identify potential modifications to the Humpty Dumpty Fall Scale (HDFS) in order to enhance the accuracy of fall prediction in the pediatric population, thus contributing to the safest possible environment for the hospitalized child. A secondary analysis of data collected by Gonzalez et al. (2020), including a total of 2428 patients, was conducted for this study. Multiple logistic regression was used to examine the relationship between each parameter of the HDFS (e.g., age, gender, diagnosis, cognitive impairments, environmental factors, response to surgery/sedation/anesthesia, and medication usage) and the outcome of fall status. After reviewing associations between HDFS parameters and fall risk, neither gender nor medication use were found to be associated with fall risk. These two parameters were removed from the scoring algorithms, and the HDFS was modified to a minimum score of 5 and maximum score of 20, with a score of 12 or above indicative of high risk of fall. The modified scale demonstrated a sensitivity of 84% and specificity of 57%. These revisions are anticipated to help support clinical practice and improve fall prevention, thus supporting a safer pediatric environment for the hospitalized child. •The Humpty Dumpty Fall Scale is widely used to identify hospitalized children at risk of fall.•After analysis, several parameters were removed from the scale, and the scoring was updated.•The modified scale demonstrated a sensitivity of 84% and specificity of 57%.•These changes support clinical practice and improve fall prevention.•The updated tool is anticipated to provide a safer pediatric environment for the hospitalized child

Psychological and Socioeconomic Burdens Faced by Family Caregivers of Children With Asthma: An Integrative Review

Asthma affects nearly 1 in every 12 children in the United States. Caring for a child with asthma poses significant challenges for the parent or caregiver. The purpose of this integrative review was to identify the psychological and socioeconomic burdens faced by family caregivers of children with asthma. An integrative review was conducted to review and appraise 80 studies. Psychosocial burdens included decreased mental health, quality of life, sleep, family stress, educational deficits, cultural and health disparities, and health care communication challenges. Socioeconomic burdens included poor access to care, as well as work and financial challenges. Studies demonstrated a link between family caregiver health and child health outcomes. Facilitators included education and empowerment, social support, and use of technology. As the family caregiver's health directly affects the asthmatic child's health, addressing the burdens of family caregivers should be a key consideration in pediatric asthma care