Patti Hamilton

Unfinished nursing care, missed care, and implicitly rationed care: State of the science review

OBJECTIVES The purposes of this review of unfinished care were to: (1) compare conceptual definitions and frameworks associated with unfinished care and related synonyms (i.e. missed care, implicitly rationed care; and care left undone); (2) compare and contrast approaches to instrumentation; (3) describe prevalence and patterns; (4) identify antecedents and outcomes; and (5) describe mitigating interventions. METHODS A literature search in CINAHL and MEDLINE identified 1828 articles; 54 met inclusion criteria. Search terms included: implicit ration*, miss* care, ration* care, task* undone, and unfinish*care. Analysis was performed in three phases: initial screening and sorting, comprehensive review for data extraction (first author), and confirmatory review to validate groupings, major themes, and interpretations (second author). RESULTS Reviewed literature included 42 quantitative reports; 7 qualitative reports; 1 mixed method report; and 4 scientific reviews. With one exception, quantitative studies involved observational cross-sectional survey designs. A total of 22 primary samples were identified; 5 involved systematic sampling. The response rate was >60% in over half of the samples. Unfinished care was measured with 14 self-report instruments. Most nursing personnel (55-98%) reported leaving at least 1 task undone. Estimates increased with survey length, recall period, scope of response referent, and scope of resource scarcity considered. Patterns of unfinished care were consistent with the subordination of teaching and emotional support activities to those related to physiologic needs and organizational audits. Predictors of unfinished care included perceived team interactions, adequacy of resources, safety climate, and nurse staffing. Unfinished care is a predictor of: decreased nurse-reported care quality, decreased patient satisfaction; increased adverse events; increased turnover; decreased job and occupational satisfaction; and increased intent to leave. DISCUSSION & CONCLUSIONS Unfinished care is a significant problem in acute care hospitals internationally. Prioritization strategies of nurses leave patients vulnerable to unmet educational, emotional, and psychological needs. Key limitations of the science include the threat of common method/source bias, a lack of transparency regarding the use of combined samples and secondary analysis, inconsistency in the reporting format for unfinished care prevalence, and a paucity of intervention studies.

THE THERMODYNAMICS OF SOCIAL PROCESSES: THE TEEN BIRTH PHENOMENON

We argue that a process of social interest is a balance of order and randomness, thereby producing a departure from a stationary diffusion process. The strength of this effect vanishes if the order to randomness intensity ratio vanishes, and this property allows us to reveal, although in an indirect way, the existence of a finite order to randomness intensity ratio. We aim at detecting this effect. We introduce a method of statistical analysis alternative to the compression procedures, with which the limitations of the traditional Kolmogorov-Sinai approach are bypassed. We prove that this method makes it possible for us to build up a memory detector, which signals the presence of even very weak memory, provided that this is persistent over large time intervals. We apply the analysis to the study of the teen birth phenomenon and we find that the unmarried teen births are a manifestation of a social process with a memory more intense than that of the married teens. We attempt to give a social interpretation of this effect.

Compression and Diffusion: A Joint Approach to Detect Complexity

Abstract The adoption of the Kolmogorov–Sinai entropy is becoming a popular research tool among physicists, especially when applied to a dynamical system fitting the conditions of validity of the Pesin theorem. The study of time series that are a manifestation of system dynamics whose rules are either unknown or too complex for a mathematical treatment, is still a challenge since the KS entropy is not computable, in general, in that case. Here we present a plan of action based on the joint action of two procedures, both related to the KS entropy, but compatible with computer implementation through fast and efficient programs. The former procedure, called compression algorithm sensitive to regularity (CASToRE), establishes the amount of order by the numerical evaluation of algorithmic compressibility. The latter, called complex analysis of sequences via scaling and randomness assessment (CASSANDRA), establishes the complexity degree through the numerical evaluation of the strength of an anomalous effect. This is the departure, of the diffusion process generated by the observed fluctuations, from ordinary Brownian motion. The CASSANDRA algorithm shares with CASToRE a connection with the Kolmogorov complexity. This makes both algorithms especially suitable to study the transition from dynamics to thermodynamics, and the case of non-stationary time series as well. The benefit of the joint action of these two methods is proven by the analysis of artificial sequences with the same main properties as the real time series to which the joint use of these two methods will be applied in future research work.

Differences between weekend and weekday nurse work environments and patient outcomes: a focus group approach to model testing.

Design This focus group study was exploratory and descriptive. Purpose To identify differences between weekend and weekday nurse work environments that might explain higher rates of neonatal mortality among babies born on weekends. Sample The convenience sample consisted of 14 nurses from labor and delivery and neonatal intensive care units in 4 hospitals in 3 Texas cities. Methodology Focus group sessions were audiotaped and then transcribed verbatim. Responses were analyzed inductively and then compared to the model of Organizational Support of Nursing Care presented by Aiken, Clarke, and Sloane. Results The focus group responses fit the model moderately well. However, there were additional constructs found in the data that went beyond the model. Additional constructs included patient need/demand, nurse characteristics/skill level, and external motivating and inhibiting factors. Conclusions Nurses identified significant differences between weekend and weekday work environments such as less direct supervision and problems getting physician backup for emergencies on weekends. They gave examples where they felt weekend work environments resulted in both negative and positive patient outcomes. The nurses made no real distinction between night shift and weekend environments. The knowledge gained can be used to design effective strategies to improve the process of care and patient outcomes on weekends.

Weekend Birth and Higher Neonatal Mortality: A Problem of Patient Acuity or Quality of Care?

OBJECTIVE To address the differences in neonatal mortality among births to teenage mothers on weekdays and weekends. DESIGN A retrospective descriptive design. Rates of neonatal mortality linked to maternal risk factors, low birth weight, gestational age, day of the week of the birth, and ethnicity/race were examined. PATIENTS/PARTICIPANTS The population consisted of all recorded births to teenage mothers (< 20 years of age) in Texas in 1999 and 2000 (N = 111,749). These births were linked to death certificates for a subset of neonatal deaths within the same time period (n = 397). MAIN OUTCOME MEASURES The outcome of interest was any death attributed to conditions originating in the perinatal period and recorded as such on the infant death certificate. RESULTS Neonatal mortality was higher among the births on weekends than those during the week. Maternal risks and patient acuity levels of mothers and babies were not consistently higher on weekends. However, when risk factors were present, weekend births were more dangerous for Hispanics than for other ethnic or racial groups. CONCLUSIONS Differences in patient acuity did not satisfactorily explain higher neonatal mortality rates on weekends. Thus, quality of care indicators such as lower hospital staffing and reduced availability of services on weekends may be critical sources of unnecessary neonatal deaths.

SBAR and Nurse-Physician Communication: Pilot Testing an Educational Intervention

Poor communication in hospitals leads to medical errors and adverse events, which can jeopardize patient safety and threaten nurse retention.1,2 SBAR was introduced in 2004 as a tool to improve communication primarily between nurses and physicians in hospitals.3 SBAR stands for Situation, Background, Assessment, and Recommendation and is a helpful framework for organizing information that must be communicated rapidly and concisely. In less than 2 years, SBAR has entered healthcare vernacular and is now considered “best practice”for use in rapid transmission of information in hospitals. However, there is very little evidence as to the effect of SBAR on quality of communication between nurses and physicians and even less evidence of its impact on patient outcomes. SBAR is typically introduced in hospitals using some form of classroom training. The study described here was a pilot test to assess the effect of classroomonly SBAR training and to lay the foundation for a subsequent full-scale test of SBAR’s efficacy and effectiveness.

Memory beyond memory in heart beating, a sign of a healthy physiological condition.

We describe two types of memory and illustrate each using artificial and actual heartbeat data sets. The first type of memory, yielding anomalous diffusion, implies the inverse power-law nature of the waiting time distribution and the second the correlation among distinct times, and consequently also the occurrence of many pseudoevents, namely, not genuinely random events. Using the method of diffusion entropy analysis, we establish the scaling that would be determined by the real events alone. We prove that the heart beating of healthy patients reveals the existence of many more pseudoevents than in the patients with congestive heart failure.

Off-peak nurse staffing: critical-care nurses speak.

The off-peak work environment is important to understand because the risk for mortality increases for patients at night and on the weekend in hospitals. Because critical-care nurses are on duty in hospitals 24 hours a day, 7 days a week, they are excellent sources of information regarding what happens on a unit during off-peak times. Inadequate nurse staffing on off-peak shifts was described as a major problem by the nurses we interviewed. The study reported here contributes the type of information needed to better understand the organization of nursing units and nurse staffing on outcomes.

Measuring educational quality by appraising theses and dissertations: pitfalls and remedies

In this paper, we argue that, as indicators of the educational quality of graduate degree programs, student theses and dissertations are best used in specific contexts. High-quality theses and dissertations, that is, may be the result of factors such as verbal skills students already possessed at admission or of complex interactions between supervisors and students, not only effective class design or offerings. Consequently, this paper recommends ways for programs to avoid making post hoc errors in assessing educational quality and suggests strategies to make the critical appraisal of theses and dissertations a productive, quality-enhancing activity.

Scaling in non-stationary time series. (I)

Most data processing techniques, applied to biomedical and sociological time series, are only valid for random fluctuations that are stationary in time. Unfortunately, these data are often non-stationary and the use of techniques of analysis resting on the stationary assumption can produce a wrong information on the scaling, and so on the complexity of the process under study. Herein, we test and compare two techniques for removing the non-stationary influences from computer generated time series, consisting of the superposition of a slow signal and a random fluctuation. The former is based on the method of wavelet decomposition, and the latter is a proposal of this paper, denoted by us as step detrending technique. We focus our attention on two cases, when the slow signal is a periodic function mimicking the influence of seasons, and when it is an aperiodic signal mimicking the influence of a population change (increase or decrease). For the purpose of computational simplicity the random fluctuation is taken to be uncorrelated. However, the detrending techniques here illustrated work also in the case when the random component is correlated. This expectation is fully confirmed by the sociological applications made in the companion paper. We also illustrate a new procedure to assess the existence of a genuine scaling, based on the adoption of diffusion entropy, multiscaling analysis and the direct assessment of scaling. Using artificial sequences, we show that the joint use of all these techniques yield the detection of the real scaling, and that this is independent of the technique used to detrend the original signal.