Ronda G. Hughes

Advance care planning: preferences for care at the end of life.

Predictors of patient wishes and influence of family and clinicians are discussed. Research findings on patient decision-making relating to preferences in end-of-life care are described. Advance directives and durable powers of attorney are defined and differentiated. Most patients have not participated in advance care planning and the need for more effective planning is documented. Appropriate times for discussions of such planning are described. Scenarios discussed include terminal cancer, chronic obstructive pulmonary disease, AIDS, stroke, and dementia. Patient satisfaction is discussed, as is a structured process for discussions about patient preferences. Results of patient responses to hypothetical scenarios are described. Invasiveness of interventions, prognosis and other factors that favor or discourage patient preferences for treatment are discussed. Findings resulting from research funded by the Agency for Healthcare Research and Quality (AHRQ) are discussed. This research can help providers offer end-of-life care based on preferences held by the majority of patients under similar circumstances.

Working conditions that support patient safety.

THE conditions in which nurses work can influence the likelihood of errors and the quality of care afforded to patients. Key elements of the workplace include staffing levels, working hours, physical environment, workflow design, and organizational culture. Past research has examined the association between the working conditions in which nurses provide patient care, the quality of care provided, and patient outcomes.1–3 These conditions include how work is organized, workload, management and leadership style and capability, workplace characteristics, and communication. Last year, the Institute of Medicine released a seminal report on the impact of nurses’ working conditions on patient safety. This report, Keeping Patients Safe: Transforming the Work Environment of Nurses,4 was an important step in providing insight into the implications of unfavorable, adverse, and poor working conditions for nurses, who are the backbone of healthcare. Research funded by the Agency for Healthcare Research and Quality (AHRQ) has taken this knowledge a step further.5 In addition

Palliative wound care at the end of life

Wound care, a form of palliative care, supports the health care needs of dying patients by focusing on alleviating symptoms. Although wound care can be both healing and palliative, it can impair the quality of the end of life for the dying if it is done without proper consideration of the patient’s wishes and best interests. Wound care may be optional for dying patients. This article will discuss the ethical responsibilities and challenges of providing wound care for surgical wounds, pressure ulcers, and wounds associated with cancer as well as wound care in home health compared to end of life.

Credentialing: The need for a national research agenda

A national research agenda is needed to promote inquiry into the impact of credentialing on health care outcomes for nurses, patients, and organizations. Credentialing is used here to refer to individual credentialing, such as certification for nurses, and organizational credentialing, such as American Nurses Credentialing Center Magnet recognition for health care organizations or accreditation of providers of continuing education in nursing. Although it is hypothesized that credentialing leads to a higher quality of care, more uniform practice, and better patient outcomes, the research evidence to validate these views is limited. This article proposes a conceptual model in which both credentials and standards are posited to affect outcomes in health care. Potential research questions as well as issues in research design, measurement, data collection, and analysis are discussed. Credentialing in nursing has implications for the health care professions and national policy. A growing body of independent research that clarifies the relationship of credentialing in nursing to outcomes can make important contributions to the improvement of health care quality.

Implementing evidence-based nursing with student nurses and clinicians: Uniting the strengths

Implementing evidence-based practice (EBP) is challenging for both clinicians and students. Facilitating collaboration among students and clinicians can improve the process of both teaching EBP in the academic setting and utilizing EBP in the clinical setting. A unique and successful EBP program is described, and other schools are encouraged to emulate this model.

Improving the Health Care Work Environment: A Sociotechnical Systems Approach

This issue examines findings on key elements of the hospital environment, identifies risks to safety and quality, and proposes operational and policy solutions.

Complexity, bullying, and stress: analyzing and mitigating a challenging work environment for nurses.

LIKE many workplace environments, the healthcare work setting can be a positive or negative one for its frontline staff, depending on circumstances. These circumstances may include physical comfort, relationships with coworkers, work-induced stresses, and many other factors. The everyday pressures that can be found in any workplace, however, are magnified in the healthcare workplace, a fast-paced environment with higher stakes than most. The setting in which care is provided to patients can determine the quality and safety of that care1; thus, it does not overstate matters to declare that an orderly, a cohesive, and a supportive work environment for clinicians, including nurses, is a critical quality and patient safety issue. Unfortunately, it is rare that the healthcare work setting is described as orderly, cohesive, and supportive. So much happens and so quickly. Life-and-death decisions need to be made at the point of care, often without the benefit of a full slate of all the necessary data or evidence to inform them. The envi-

Comparison of nurse staffing based on changes in unit-level workload associated with patient churn

AIM This analysis compares the staffing implications of three measures of nurse staffing requirements: midnight census, turnover adjustment based on length of stay, and volume of admissions, discharges and transfers. BACKGROUND Midnight census is commonly used to determine registered nurse staffing. Unit-level workload increases with patient churn, the movement of patients in and out of the nursing unit. Failure to account for patient churn in staffing allocation impacts nurse workload and may result in adverse patient outcomes. METHOD(S) Secondary data analysis of unit-level data from 32 hospitals, where nursing units are grouped into three unit-type categories: intensive care, intermediate care, and medical surgical. RESULT Midnight census alone did not account adequately for registered nurse workload intensity associated with patient churn. On average, units were staffed with a mixture of registered nurses and other nursing staff not always to budgeted levels. Adjusting for patient churn increases nurse staffing across all units and shifts. CONCLUSION Use of the discharges and transfers adjustment to midnight census may be useful in adjusting RN staffing on a shift basis to account for patient churn. IMPLICATIONS FOR NURSING MANAGEMENT Nurse managers should understand the implications to nurse workload of various methods of calculating registered nurse staff requirements.

A Model for Hospital Discharge Preparation: From Case Management to Care Transition

There has been a proliferation of initiatives to improve discharge processes and outcomes for the transition from hospital to home and community-based care. Operationalization of these processes has varied widely as hospitals have customized discharge care into innovative roles and functions. This article presents a model for conceptualizing the components of hospital discharge preparation to ensure attention to the full range of processes needed for a comprehensive strategy for hospital discharge.

Models of Discharge Care in Magnet® Hospitals

OBJECTIVE: The aim of this article is to describe how the discharge preparation process is operationalized in Magnet® hospitals. BACKGROUND: Nationally, there are intensive efforts toward improving discharge transitions and reducing readmissions. Discharge preparation is a core hospital function, yet there are few reports of operational models. METHODS: This was a descriptive, Web-based survey of 32 Magnet hospitals (64 units) participating in the Readiness Evaluation and Discharge Interventions study. RESULTS: Most hospitals have adopted 1 or more national readmission reduction initiatives. Most unit models include several discharge preparation roles; RN case managers, and discharging RNs lead the process. Nearly one-half of units actively screen for readmission risk. More than three-fourths report daily discharge rounds, but less than one-third include the patient and family. More than two-thirds report a follow-up phone call, mostly to assess patient satisfaction. CONCLUSIONS: Magnet hospitals operationalize discharge preparation differently. Recommended practices from national discharge initiatives are inconsistently used. RNs play a central role in discharge planning, coordination, and teaching.