Lusine Poghosyan

Importance of work environments on hospital outcomes in nine countries

PURPOSE To determine the effect of hospital work environments on hospital outcomes across multiple countries. DESIGN Primary survey data using a common instrument were collected from separate cross sections of 98 116 bedside care nurses practising in 1406 hospitals in 9 countries between 1999 and 2009. MAIN OUTCOME MEASURES Nurse burnout and job dissatisfaction, patient readiness for hospital discharge and quality of patient care. RESULTS High nurse burnout was found in hospitals in all countries except Germany, and ranged from roughly a third of nurses to about 60% of nurses in South Korea and Japan. Job dissatisfaction among nurses was close to 20% in most countries and as high as 60% in Japan. Close to half or more of nurses in every country lacked confidence that patients could care for themselves following discharge. Quality-of-care rated as fair or poor varied from 11% in Canada to 68% in South Korea. Between one-quarter and one-third of hospitals in each country were judged to have poor work environments. Working in a hospital with a better work environment was associated with significantly lower odds of nurse burnout and job dissatisfaction and with better quality-of-care outcomes. CONCLUSIONS Poor hospital work environments are common and are associated with negative outcomes for nurses and quality of care. Improving work environments holds promise for nurse retention and better quality of patient care.

Poor work environments and nurse inexperience are associated with burnout, job dissatisfaction and quality deficits in Japanese hospitals

AIMS To describe nurse burnout, job dissatisfaction and quality of care in Japanese hospitals and to determine how these outcomes are associated with work environment factors. BACKGROUND Nurse burnout and job dissatisfaction are associated with poor nurse retention and uneven quality of care in other countries but comprehensive data have been lacking on Japan. DESIGN Cross-sectional survey of 5956 staff nurses on 302 units in 19 acute hospitals in Japan. METHODS Nurses were provided information about years of experience, completed the Maslach Burnout Inventory and reported on resource adequacy and working relations with doctors using the Nursing Work Index-Revised. RESULTS Fifty-six per cent of nurses scored high on burnout, 60% were dissatisfied with their jobs and 59% ranked quality of care as only fair or poor. About one-third had fewer than four years of experience and more than two-thirds had less than 10. Only one in five nurses reported there were enough registered nurses to provide quality care and more than half reported that teamwork between nurses and physicians was lacking. The odds on high burnout, job dissatisfaction and poor-fair quality of care were twice as high in hospitals with 50% inexperienced nurses than with 20% inexperienced nurses and 40% higher in hospitals where nurses had less satisfactory relations with physicians. Nurses in poorly staffed hospitals were 50% more likely to exhibit burnout, twice as likely to be dissatisfied and 75% more likely to report poor or fair quality care than nurses in better staffed hospitals. CONCLUSIONS Improved nurse staffing and working relationships with physicians may reduce nurse burnout, job dissatisfaction and low nurse-assessed quality of care. RELEVANCE TO CLINICAL PRACTICE Staff nurses should engage supervisors and medical staff in discussions about retaining more experienced nurses at the bedside, implementing strategies to enhance clinical staffing and identifying ways to improve nurse-physician working relations.

Screening strategies for autism spectrum disorders in pediatric primary care.

Background: Two strategies have been proposed for early identification of children with autism spectrum disorders (ASD): (1) using a general screening tool followed by an ASD-specific screening tool for those who screen positive on the former or (2) using an ASD-specific tool for all children. The relative yield of these two strategies has not been examined. Objectives: This study compared the number of children identified at risk for ASD at their well child visits between the ages of 18 and 30 months using a general developmental screening tool and an autism-specific screening tool. Methods: The Parents’ Evaluation of Developmental Status (PEDS) was used as the general developmental screening tool and the Modified Checklist for Autism in Toddlers (M-CHAT) was used as the autism-specific tool. These tools were administered concurrently to 152 children. Results: Cross tabulations and &khgr;2 tests were used to determine the utility of the PEDS as the first step of a two-part screen for ASD. Of those who screened positive for developmental concerns on the PEDS (n = 38), 16% screened positive for ASD on the M-CHAT; of those who did not screen positive for developmental concerns on the PEDS (n = 114), 14% screened positive for ASD on the M-CHAT (p = .79). Conclusion: The PEDS missed the majority of children who screened positive for ASD on the M-CHAT, suggesting that these two tools tap into very different domains of developmental concerns. The findings support the use of an ASD-specific tool for all children in conjunction with regular standardized developmental screening.

Nurse Practitioner Organizational Climate in Primary Care Settings: Implications for Professional Practice

The expansion of the nurse practitioner (NP) workforce in primary care is key to meeting the increased demand for care. Organizational climates in primary care settings affect NP professional practice and the quality of care. This study investigated organizational climate and its domains affecting NP professional practice in primary care settings. A qualitative descriptive design, with purposive sampling, was used to recruit 16 NPs practicing in primary care settings in Massachusetts. An interview guide was developed and pretested with two NPs and in 1 group interview with 7 NPs. Data collection took place in spring of 2011. Individual interviews lasted from 30-70 minutes, were audio recorded, and transcribed. Data were analyzed using Atlas.ti 6.0 software by 3 researchers. Content analysis was applied. Three previously identified themes, NP-physician relations, independent practice and autonomy, and professional visibility, as well as two new themes, organizational support and resources and NP-administration relations emerged from the analyses. NPs reported collegial relations with physicians, challenges in establishing independent practice, suboptimal relationships with administration, and lack of support. NP contributions to patient care were invisible. Favorable organizational climates should be promoted to support the expanding of NP workforce in primary care and to optimize recruitment and retention efforts.

Revisiting Scope of Practice Facilitators and Barriers for Primary Care Nurse Practitioners: A Qualitative Investigation

Revisiting scope of practice (SOP) policies for nurse practitioners (NPs) is necessary in the evolving primary care environment with goals to provide timely access, improve quality, and contain cost. This study utilized qualitative descriptive design to investigate NP roles and responsibilities as primary care providers (PCPs) in Massachusetts and their perceptions about barriers and facilitators to their SOP. Through purposive sampling, 23 NPs were recruited and they participated in group and individual interviews in spring 2011.The interviews were audio recorded and transcribed. Data were analyzed using Atlas.ti 6.0 software, and content analysis was applied. In addition to NP roles and responsibilities, three themes affecting NP SOP were: regulatory environment; comprehension of NP role; and work environment. NPs take on similar responsibilities as physicians to deliver primary care services; however, the regulatory environment and billing practices, lack of comprehension of the NP role, and challenging work environments limit successful NP practice.

A new model for nurse practitioner utilization in primary care: increased efficiency and implications.

BACKGROUND Nurse practitioners (NPs) play an important role in providing quality primary care. However, little is known about organizational processes that best utilize NPs in care delivery and what kind of resources and support NPs need to deliver quality care within their organizations. In primary care settings, NPs often receive little support from ancillary personnel compared with physicians. PURPOSE The aim of this article was to compare the productivity and cost efficiency of NP utilization models implemented in primary care sites with and without medical assistant (MA) support. METHODOLOGY/APPROACH We develop queueing models for these NP utilization models, of which the parameters are extracted from literature or government reports. Appropriate analyses are conducted to generate formulas and values for the productivity and cost efficiency. Sensitivity analyses are conducted to investigate different scenarios and to verify the robustness of findings. FINDINGS The productivity and cost efficiency of these models improve significantly if NPs have access to MA support in serving patients. On the basis of the model parameters we use, the average cost of serving a patient can be reduced by 9%-12% if MAs are hired to support NPs. Such improvements are robust across practice environments with different variability in provider service times. Improving provider service rate is a much more effective strategy to increase productivity compared with reducing the variability in provider service times. PRACTICE IMPLICATIONS To contain costs and improve the utilization of NPs in primary care settings, MA assistance for NPs is necessary.

Nurse Burnout, Nurse-Reported Quality of Care, and Patient Outcomes in Thai Hospitals.

PURPOSE The purpose of this study was to investigate the effect of nurse burnout on nurse-reported quality of care and patient adverse events and outcomes in Thai hospitals. METHODS Cross-sectional analysis of data from 2,084 registered nurses working in 94 community hospitals across Thailand. Data were collected through survey questionnaire, including the Maslach Burnout Inventory (MBI), which measures of nurse perceived quality of care and patient outcomes. Multiple logistic regression modeling was performed to explore associations between nurse burnout on quality of care and patient outcomes. FINDINGS Thirty-two percent of nurses reported high emotional exhaustion, 18% high depersonalization, and 35% low personal accomplishment. In addition, 16% of nurses rated quality of care on their work unit as fair or poor, 5% reported patient falls, 11% reported medication errors, and 14% reported infections. All three subscales of the MBI were associated with increased reporting of fair or poor quality of care, patient falls, medication errors, and infections. Every unit of increasing emotional exhaustion score was associated with a 2.63 times rise in reporting fair or poor quality of care, a 30% increase in patient falls, a 47% increase in medication errors, and a 32% increase in infection. CONCLUSIONS Findings clearly indicate that nurse burnout is associated with increased odds of reporting negative patient outcomes. Implementing interventions to reduce nurse burnout is critical to improving patient care in Thai hospitals. CLINICAL RELEVANCE Hospital administrators, nurse managers, and health leaders urgently need to create favorable work environments supporting nursing practice in order to reduce burnout and improve quality of care.

Development and psychometric testing of the Nurse Practitioner Primary Care Organizational Climate Questionnaire.

Background:Policy makers and healthcare organizations are calling for expansion of the nurse practitioner (NP) workforce in primary care settings to assure timely access and high-quality care for the American public. However, many barriers, including those at the organizational level, exist that may undermine NP workforce expansion and their optimal utilization in primary care. Objectives:This study developed a new NP-specific survey instrument, Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ), to measure organizational climate in primary care settings and conducted its psychometric testing. Methods:Using instrument development design, the organizational climate domain pertinent for primary care NPs was identified. Items were generated from the evidence and qualitative data. Face and content validity were established through two expert meetings. Content validity index was computed. The 86-item pool was reduced to 55 items, which was pilot tested with 81 NPs using mailed surveys and then field-tested with 278 NPs in New York State. SPSS 18 and Mplus software were used for item analysis, reliability testing, and maximum likelihood exploratory factor analysis. Results:Nurse Practitioner Primary Care Organizational Climate Questionnaire had face and content validity. The content validity index was .90. Twenty-nine items loaded on four subscale factors: professional visibility, NP–administration relations, NP–physician relations, and independent practice and support. The subscales had high internal consistency reliability. Cronbach’s alphas ranged from.87 to .95. Discussion:Having a strong instrument is important to promote future research. Also, administrators can use it to assess organizational climate in their clinics and propose interventions to improve it, thus promoting NP practice and the expansion of NP workforce.

The prevalence of infections and patient risk factors in home health care: A systematic review

BACKGROUND Home health care (HHC) has been the fastest growing health care sector for the past 3 decades. The uncontrolled home environment, increased use of indwelling devices, and the complexity of illnesses among HHC patients lead to increased risk for infections. METHODS A systematic review of studies evaluating infection prevalence and risk factors among adult patients who received HHC services was conducted and guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Literature was searched using Medline, PubMed, and the Cumulative Index to Nursing and Allied Health as well as hand searching. Two reviewers independently assessed study quality using validated quality assessment checklists. RESULTS Twenty-five studies met the inclusion criteria and were reviewed. The infection rates and identified risk factors for infections varied dramatically between studies. In general, patients receiving home parental nutrition treatments had higher infection rates than patients receiving home infusion therapy. The identified risk factors were limited by small sample sizes and other methodologic flaws. CONCLUSIONS Establishing a surveillance system for HHC infections, identifying patients at high risk for infections, tailoring HHC and patient education based on patient living conditions, and facilitating communication between different health care facilities will enhance infection control in HHC settings. Future studies should use a nationally representative sample and multivariate analysis for the identification of risk factors for infections.

Organizational climate in primary care settings: Implications for nurse practitioner practice

Purpose The purpose of this review is to investigate literature related to organizational climate, define organizational climate, and identify its domains for nurse practitioner (NP) practice in primary care settings. Data sources A search was conducted using MEDLINE, PubMed, HealthSTAR/Ovid, ISI Web of Science, and several other health policy and nursingy databases. Conclusions In primary care settings, organizational climate for NPs is a set of organizational attributes, which are perceived by NPs about their practice setting, emerge from the way the organization interacts with NPs, and affect NP behaviors and outcomes. Autonomy, NP–physician relations, and professional visibility were identified as organizational climate domains. Implications for practice NPs should be encouraged to assess organizational climate in their workplace and choose organizations that promote autonomy, collegiality between NPs and physicians, and encourage professional visibility. Organizational and NP awareness of qualities that foster NP practice will be a first step for developing strategies to creating an optimal organizational climate for NPs to deliver high‐quality care. More research is needed to develop a comprehensive conceptual framework for organizational climate and develop new instruments to accurately measure organizational climate and link it to NP and patient outcomes.Purpose The purpose of this review is to investigate literature related to organizational climate, define organizational climate, and identify its domains for nurse practitioner (NP) practice in primary care settings. Data sources A search was conducted using MEDLINE, PubMed, HealthSTAR/Ovid, ISI Web of Science, and several other health policy and nursingy databases. Conclusions In primary care settings, organizational climate for NPs is a set of organizational attributes, which are perceived by NPs about their practice setting, emerge from the way the organization interacts with NPs, and affect NP behaviors and outcomes. Autonomy, NP–physician relations, and professional visibility were identified as organizational climate domains. Implications for practice NPs should be encouraged to assess organizational climate in their workplace and choose organizations that promote autonomy, collegiality between NPs and physicians, and encourage professional visibility. Organizational and NP awareness of qualities that foster NP practice will be a first step for developing strategies to creating an optimal organizational climate for NPs to deliver high-quality care. More research is needed to develop a comprehensive conceptual framework for organizational climate and develop new instruments to accurately measure organizational climate and link it to NP and patient outcomes.