Bruce J. Fried

Impact of Nursing Unit Turnover on Patient Outcomes in Hospitals

PURPOSE The aim of this study was to examine how nursing unit turnover affects key workgroup processes and how these processes mediate the impact of nursing turnover on patient outcomes. METHODS A secondary data analysis was used to test the hypothesized model. This study used registered nurse and patient data from 268 nursing units at 141 hospitals collected as part of the Outcomes Research in Nursing Administration (ORNA II) project. Nursing units provided monthly nursing unit turnover rates for 6 consecutive months, and registered nurses completed questionnaires measuring workgroup processes (group cohesion, relational coordination, and workgroup learning). Patient outcome measures included unit-level average length of patient stay, patient falls, medication errors, and patient satisfaction scores. RESULTS Nursing units with moderate levels of turnover were likely to have lower levels of workgroup learning compared to those with no turnover (p<.01). Nursing units with low levels of turnover were likely to have fewer patient falls than nursing units with no turnover (p<.05). Additionally, workgroup cohesion and relational coordination had a positive impact on patient satisfaction (p<.01), and increased workgroup learning led to fewer occurrences of severe medication errors (p<.05). CONCLUSIONS The findings of this study provide specific information on the operational impact of turnover so as to better design, fund, and implement appropriate intervention strategies to prevent registered nurse exit from nursing units. Further investigation is needed to assess the turnover-outcomes relationship as well as the mediating effect of workgroup processes on this relationship. CLINICAL RELEVANCE Managing nursing unit turnover within appropriate levels at the nursing unit is critical to delivering high-quality patient care.

An Empirical Assessment of Rural Community Support Networks for Individuals with Severe Mental Disorders

The community support network has beenwell-established as a requirement for communitytreatment of individuals with severe mental disorders.This network generally consists of a multidisciplinaryset of organizations that interrelate in some mannerwith individuals in the community. The question ofcoordination within this network has been muchdiscussed; however little published research hasempirically examined the types and extent of coordinationamong network organizations. In particular, littleattention has been given to community support networksin rural communities. In each of seven rural counties, information was obtained on interactions amongorganizations in the community support network. Thesenetworks were analyzed to yield information on networkdensity and centralization. Using measures of centrality, the most central organizations ineach network were identified. Exchanges of informationwere the most common type of interaction amongorganizations in each network. Client referrals occurred less frequently, and sharing of resources wasan even rarer phenomenon. Network analysis of communitysupport networks provides an objective perspective onthe structure of community support networks. An understanding of exchange among organizationswithin these networks is of value to administrators,clinicians, and planners interested in achieving greatereffectiveness, as well as to patients, their families, and advocacy groups concerned with access andquality of care.

Use of temporary nurses and nurse and patient safety outcomes in acute care hospital units

Background: To deal with nursing shortages and inadequate hospital nurse staffing, many solutions have been tried, including utilizing temporary nurses. Relatively little attention has been given to use of temporary nurses and its association with both nurse and patients outcomes. Purpose: The purpose of this study is to investigate the association between use of temporary nurses and nurse (needlesticks and back injuries) and patient (patient falls and medication errors) safety outcomes at the nursing unit level. Methodology/Approach: Data came from a large organizational study which investigated the relationship between registered nurse (RN) staffing adequacy, work environments, organizational, and patient outcomes. The sample for this study was 4,954 RNs on 277 nursing units in 142 hospitals. Findings: Nurses working on nursing units with high levels (more than 15%) of external temporary RN hours were more likely to report back injuries than nurses working on nursing units that did not use external temporary RNs. Nurses working on these nursing units also reported greater levels of patient falls compared with those who did not use temporary RNs. This study found that nurses working on nursing units with moderate levels (5-15%) of external temporary RN hours reported fewer medication errors than those without using any external temporary RNs. Practice Implications: Hospitals need to monitor the levels of temporary nurse use and maintain a level of approximately 15% to ensure both nurse and patient safety outcomes. The temporary nurse use to manage nursing shortfall may provide both benefit and harm to nurse and patient safety depending on the level of the use.

Comparing provider perceptions of access and utilization management in full-risk and no-risk medicaid programs for adults with serious mental illness

This article compares provider perceptions of access to services and utilization management (UM) procedures in two Medicaid programs in the same state: a full-risk capitated managed care (MC) program and a no-risk, fee-for-service (FFS) program. Survey data were obtained from 198 mental health clinicians and administrators. The only difference found between respondents in the FFS and MC sites was that outpatient providers in the MC site reported significantly lower levels of access to high-intensity services than did providers in the FFS site (p<.001). Respondents in the two sites reported similar attitudes toward UM procedures, including a strong preference for internal over external UM procedures. These findings support the conclusion that through diffusion of UM procedures, all care in the Medicaid program for persons with a serious mental illness is managed, regardless of risk arrangement. Implications for mental health services and further research are discussed.

Corporatization and deprivatization of health services in Canada

Canadas system of health services has been shaped by the forces and values in the Canadian political, cultural, social, and economic environment; these forces continue to place constraints on future changes. We distinguish between “corporatization” and “privatization,” and the implications of each for improved efficiency of the system. Although the organization of health services is, in certain provinces, undergoing significant structural changes, there is evidence that rather than privatizing, the system may actually be continuing to experience what we have termed deprivatization, as the scope of government involvement expands to include a more comprehensive definition of health care. Trends in Canada differ considerably from those in the United States; universal health insurance has curbed the ability and desire of institutions to exclude members of some socioeconomic groups from receiving care. U.S.-based models, if applied to Canada, could lead to both higher costs and lower quality of care. Considerable efficiencies can be realized within Canadas current system.

Multidisciplinary Teams in Health Care: Lessons from Oncology and Renal Teams

An indepth study conducted on units treating renal disease and cancer clinics determined that multidisciplinary teams are relatively commonplace in these areas. Developing four team organizational structures — sequential, primary, nucleus and dynamic — the authors hypothesize that each varies on a continuum in terms of how highly structured they are. The framework suggests that the ideology of equal participation on the team is the most difficult to sustain, and that difficulties typically arise as organization requirements become more complex. More research seems to be indicated to develop a comprehensive organizational framework, and the probable effect of organizational form on team performance. One of the key issues addressed is team leadership.

Disasters and the Public Health Safety Net: Hurricane Floyd Hits the North Carolina Medicaid Program

OBJECTIVES We measured the effect of Hurricane Floyd on Medicaid enrollment and health services use in the most severely affected counties of North Carolina. METHODS We used differences-in-differences models on balanced panels of Medicaid claims and enrollment data. RESULTS Overall spending per enrollee showed little short-term effect but demonstrated a moderate increase 1 year after the storm. We found very modest short-term increases in Medicaid enrollment, a small long-term decrease in enrollment, and large increases in the long-term use of emergency room and outpatient services. CONCLUSIONS Our findings suggest that hurricane victims experienced substantial changes in patterns of care that endured for much longer than the initial crisis period. These findings can have important implications for the management of disaster relief for this population.

The role of helplessness, outcome expectation for exercise and literacy in predicting disability and symptoms in older adults with arthritis

OBJECTIVE To examine the effect of outcome expectation for exercise (OEE), helplessness, and literacy on arthritis outcomes in 2 community-based lifestyle randomized controlled trials (RCTs) conducted in urban and rural communities with older adults with arthritis. METHODS Data from 391 participants in 2 RCTs were combined to examine associations of 2 psychosocial variables: helplessness and OEE, and literacy with arthritis outcomes. Arthritis outcomes namely, the Health Assessment Questionnaire-Disability Index (HAQ-DI) and arthritis symptoms pain, fatigue and stiffness Visual Analogue Scales (VAS), were measured at baseline and at the end of the interventions. Complete baseline and post-intervention data were analyzed using STATA version 9. RESULTS Disability after intervention was not predicted by helplessness, literacy, or OEE in the adjusted model. Arthritis symptoms after the intervention were all significantly predicted by helplessness at various magnitudes in adjusted models, but OEE and literacy were not significant predictors. CONCLUSION When literacy, helplessness, and OEE were examined as predictors of arthritis outcomes in intervention trials, they did not predict disability. However, helplessness predicted symptoms of pain, fatigue, and stiffness, but literacy did not predict symptoms. PRACTICE IMPLICATIONS Future sustainable interventions may include self-management components that address decreasing helplessness to improve arthritis outcomes.

A randomized trial of a decisional aid for mental capacity assessments

The objective of this study was to evaluate the clinical utility of a decisional aid for mental capacity assessments which was developed using a group judgment methodology. This was carried out by a randomized, controlled trial. The subjects comprised 64 University of Toronto psychiatry residents in postgraduate years 1 through 4. Residents were randomized to carry out mental capacity assessments on simulated cases with, or without, the use of the decisional aid. The main outcome measure was the extent of agreement between the mental capacity determinations of residents and those of experts. There was no difference between the intervention and control groups with respect to the overall mean level of agreement with experts (0.87 vs 0.86, p = 0.88; 95% confidence interval for the difference between the study groups, -0.07 to +0.08). A logistic regression analysis, which adjusted for imbalances between the groups, also revealed no difference between the groups in their agreement with experts. The mean time per competency assessment was significantly longer in the intervention group (19.1 vs 10.8 min; p < 0.001). It was concluded that the decisional aid did not improve the ability of the psychiatry residents to make mental capacity assessments on simulated cases. Despite relatively limited formal training, the psychiatry residents had a high level of agreement with experts.

Power Acquisition in a Health Care Setting: An Application of Strategic Contingencies Theory

Strategic contingencies theory suggests that uncertainty coping, nonsubstitutability, and centrality predict intra-organizational group power. This theory was tested in 20 ambulatory care clinic settings. Physician, nurse, and administrator power and roles were examined. Theoretical support was greatest among nurses, but less conclusive for physicians and administrative personnel, whose roles in the clinics were more clearly prescribed and determined, and influenced to a lesser degree by power-enhancing dynamics. Implications are discussed of the relevance and usefulness of strategic contingencies theory and other theories of organization in health services organizations.