Caitlin W. Brennan

State of the Science The Relationship Between Nurse Staffing and Patient Outcomes

Over a decade of research on the relationship between nurse staffing and patient outcomes has demonstrated the important role of nurses in the provision of high-quality, safe care, yet currently, no evidence-based nurse staffing guidelines exist. A systematic review of reviews was conducted to explore reasons why this is the case and recommend directions for future research to improve upon this gap. Authors of the 29 included reviews reported variability in methods and measurement approaches, lack of incorporation of nurse processes and system factors that potentially affect relationships among variables, and overall inconsistencies in results across primary studies. We propose use of an Integrated Framework for a Systems Approach to Nurse Staffing Research to inform the development of applicable conceptual models. Future studies that use a systems approach and focus on establishing causal relationships among variables will potentially strengthen the evidence and advance the science in this area.

Time-series and risk-adjusted control charts

Presentation There are several statistical process control (SPC) methods used in industry that can be applied in healthcare. However, as noted in the earlier discussion by Toulany et al. regarding quasi-experimental designs for quality improvement research, several considerations must be taken into account when adapting these methods for the complex, high-risk healthcare arena. Industrial methods should be adjusted for (a) heterogeneity at the patient level, including illness type, individualized care, and demographics, (b) heterogeneity at the process level, including geographical and longitudinal clinical care variation, (c) lack of pre-existing standards of comparison for new products or processes, and (d) the critical difference between statistical variation and acceptable clinical risk. Potential methods for successful adaptation of industrial SPC methods for healthcare monitoring and improvement include (a) converting periodic data into cumulative charts to increase detection of trends and (b) addressing heterogeneity through risk adjustment, using a prediction model or propensity score matching. These adjustments tend to inflate Type I errors, however, due to repeated measurements. Thus, the Sequential Probability Ratio Testing (SPRT) method may be of particular use [1]. SPRT uses the more commonly available retrospective control data, accounts for repeated measurements, utilizes risk adjustment, and incorporates both alpha and beta error into the formal framework [2,3]. The upper control limit is the desired odds ratio, as determined by the hypothesis. Industrial SPC methods assume process homogeneity and that the outcome rate from the population establishes the threshold for detecting changes in the process. Using these techniques to analyze processes in healthcare often requires addressing the risk and complexities inherent in healthcare in order to obtain meaningful results. As with any data-driven project, the clinical question and limitations of the available data drive the selection of the patient cohort, SPC method, risk adjustment framework, alerting thresholds, and the interpretation of clinical significance. However, regardless of the SPC method used and the risk-adjustment framework, it is important to realize that performance of the risk adjustment model drives the overall result; thus understanding the strengths and weaknesses of each particular model is critical to clinical interpretations. In addition, detecting adverse outcomes over a long period requires recalibrating the model over time to adjust for systematic changes in clinical care. Finally, all signals detected using these methods require root cause analyses (RCA) and sensitivity analyses as they are hypothesis-generating, not confirming.

The Impact of Personalized Prenotification on Response Rates to an Electronic Survey

The purpose of this post-hoc investigation was to determine the difference in response rates between respondents who received personalized prenotification prior to receiving an electronic survey and those who did not. An electronic survey was e-mailed to 236 program directors or other designated individuals from nurse practitioner (NP) programs around the United States. Seventy six percent of the NP program directors were personally contacted about the survey in advance, and 97.5% agreed to participate. The remaining 24% were sent e-mails with a link to the survey without prenotification. Response rates for those in the prenotification group who had agreed to participate versus those who did not receive prenotification were 49% and 45%, respectively. Personalized prenotification did not affect the electronic survey response rates. Electronic research methodology offers a unique opportunity to potentially survey an entire population (e.g., nursing faculty), thus further investigation regarding factors associated with electronic survey response rates and ways to improve these rates is warranted.

Learning by doing: observing an interprofessional process as an interprofessional team

Abstract New competencies exist for interprofessional education, which are centered on the goal of improving quality of care and patient safety through improved interprofessional collaboration. Interprofessional education and effective interprofessional collaboration are cornerstones of the Veterans Affairs Quality Scholars fellowship program. The purpose of this project was to evaluate an innovative interprofessional education strategy in which teams of physicians and nurses were “learning by doing” as they observed and analyzed the functioning of an interprofessional process, specifically, inpatient discharge. Fellows completed voluntary, anonymous surveys seeking their perspectives about the project. Fellows’ feedback revealed several themes, with both positive and negative characteristics related to team functioning, interprofessional understanding, microsystem knowledge, pooled knowledge and assignment challenges. The strength of this strategy is exemplified by the fact that fellows not only learned from each other’s separate professional observations, but also observed the emergence of a shared interprofessional perspective through working together.

Interprofessional Education in Action: The VA Quality Scholars Fellowship Program

Although there are many examples of interprofessional education activities that focus on quality and safety, few include longitudinal experiences of teams working together over time. One exception is the Veterans Affairs Quality Scholars (VAQS) fellowship program. This article describes the integration of interprofessional education into the VAQS fellowship program, offers 2 examples of interprofessional projects conducted by the fellows, and discusses the VAQS program as a model for others to consider in developing interprofessional training programs in safety and quality improvement.

Organization of nursing and quality of care for veterans at the end of life.

CONTEXT The Veterans Health Administration (VA) has improved the quality of end-of-life (EOL) care over the past several years. Several structural and process variables are associated with better outcomes. Little is known, however, about the relationship between the organization of nursing care and EOL outcomes. OBJECTIVES To examine the association between the organization of nursing care, including the nurse work environment and nurse staffing levels, and quality of EOL care in VA acute care facilities. METHODS Secondary analysis of linked data from the Bereaved Family Survey (BFS), electronic medical record, administrative data, and the VA Nursing Outcomes Database. The sample included 4908 veterans who died in one of 116 VA acute care facilities nationally between October 2010 and September 2011. Unadjusted and adjusted generalized estimating equations were used to examine associations between nursing and BFS outcomes. RESULTS BFS respondents were 17% more likely to give an excellent overall rating of the quality of EOL care received by the veteran in facilities with better nurse work environments (P ≤ 0.05). The nurse work environment also was a significant predictor of providers listening to concerns and providing desired treatments. Nurse staffing was significantly associated with an excellent overall rating, alerting of the family before death, attention to personal care needs, and the provision of emotional support after the patients death. CONCLUSION Improvement of the nurse work environment and nurse staffing in VA acute care facilities may result in enhanced quality of care received by hospitalized veterans at the EOL.

The Oncology Acuity Tool: A Reliable, Valid Method for Measuring Patient Acuity for Nurse Assignment Decisions

Background and Purpose: Matching nurse assignments with patient acuity has critical implications for providing safe, effective, and efficient care. Despite this, we lack well-established methods for accurate assessment of acuity. This study aimed to evaluate the reliability and validity of the Oncology Acuity Tool (OAT), which is used for determining nurse assignments. Methods: Inter-rater reliability and concurrent validity were assessed via surveys of current users of the tool. Content validity data were collected from expert oncology nurses. Predictive validity was assessed by tracking patients who sustained either of two acute events. Results: Findings included high inter-rater reliability, moderately strong concurrent validity, and moderate content validity. Acuity significantly predicted rapid response team consults but not falls. Conclusions: The OAT demonstrated sufficient reliability and validity for measuring acuity prospectively in this population.

Methodological Challenges of Validating a Clinical Decision-Making Tool in the Practice Environment

Validating a measurement tool intended for use in the practice environment poses challenges that may not be present when validating a tool intended solely for research purposes. The aim of this article is to describe the methodological challenges of validating a clinical decision-making tool, the Oncology Acuity Tool, which nurses use to make nurse assignment and staffing decisions prospectively each shift. Data were derived from a larger validation study, during which several methodological challenges arose. Revisions to the tool, including conducting iterative feedback cycles with end users, were necessary before the validation study was initiated. The “true” value of patient acuity is unknown, and thus, two approaches to inter-rater reliability assessment were used. Discordant perspectives existed between experts and end users. Balancing psychometric rigor with clinical relevance may be achieved through establishing research–practice partnerships, seeking active and continuous feedback with end users, and weighing traditional statistical rules of thumb with practical considerations.

Improving Palliative Care Team Meetings: Structure, Inclusion, and "Team Care".

Increasing demands on palliative care teams point to the need for continuous improvement to ensure teams are working collaboratively and efficiently. This quality improvement initiative focused on improving interprofessional team meeting efficiency and subsequently patient care. Meeting start and end times improved from a mean of approximately 9 and 6 minutes late in the baseline period, respectively, to a mean of 4.4 minutes late (start time) and ending early in our sustainability phase. Mean team satisfaction improved from 2.4 to 4.5 on a 5-point Likert-type scale. The improvement initiative clarified communication about patients’ plans of care, thus positively impacting team members’ ability to articulate goals to other professionals, patients, and families. We propose several recommendations in the form of a team meeting “toolkit.”

Patient Acuity Related to Clinical Research: Concept Clarification and Literature Review:

In research settings, clinical and research requirements contribute to nursing workload, staffing decisions, and resource allocation. The aim of this article is to define patient acuity in the context of clinical research, or research intensity, and report available instruments to measure it. The design was based on Centre for Reviews and Dissemination recommendations, including defining search terms, developing inclusion and exclusion criteria, followed by abstract review by three members of the team, thorough reading of each article by two team members, and data extraction procedures, including a quality appraisal of each article. Few instruments were available to measure research intensity. Findings provide foundational work for conceptual clarity and tool development, both of which are necessary before workforce allocation based on research intensity can occur.