Research Brief: Nurse Presenteeism

A team at the University of North Carolina, Greensboro, led by Susan Letvak and Christopher Ruhm, evaluated the influence of presenteeism (decreased productivity due to health problems) on hospital registered nurses' (RNs) quality of patient care. This study focused on presenteeism among RNs suffering musculoskeletal pain and/or depression. In addition, they assessed the economic costs to the health care system associated with presenteeism. Using a mixed methods approach, including a survey and focus groups of RNs in North Carolina, researchers documented a depression prevalence of 18% in hospital nurses. Seventy-one percent of nurses interviewed reported working with some pain and the majority of nurses interviewed reported that a health problem had negatively affected their productivity on the job in the previous two weeks. The team found that pain and depression were significantly associated with presenteeism and that presenteeism was significantly associated with patient falls, medication errors and the perceived quality of care. Finally, the team found that the productivity loss due to pain and/or depression was $14,339 per nurse and $876.9 million for the state of North Carolina. If these numbers were extrapolated to the nation, the productivity loss would be $22.7 billion.

Access the research brief.

This post is part of a series to provide the public with research briefs on INQRI-funded projects across a range of interests.

Research Brief: Quality of Nursing Care on Acute Inpatient Units

Does the composition of hospital nurse staffing levels matter when it comes to preventing costly complications and death following those complications? A team at the University of California, led by Mary Blegen, Tom Vaughn (from the University of Iowa) and Colleen Goode (from the University of Colorado), examined the extent to which nurse staffing levels affected the incidence of complications and the failure to rescue from those complications, (i.e. death following complications). Their examination showed that nursing hours per patient day were strongly associated with lower rates of pressure ulcers and hospital acquired infections, and fewer deaths from complications. Further, more RN hours in the mix had additional benefit with still lower rates of failure to rescue and hospital acquired infections. Their work shows that higher levels of nursing hours per patient day and RN skill mix in intensive care units and in general units will lead to better patient outcomes, information that can guide states considering regulation of nurse-patient staffing ratios to address patient safety gaps.

Access the research brief.

This post is part of a series to provide the public with research briefs on INQRI-funded projects across a range of interests.

Research Brief: Supplemental Nurse Staffing

A team of researchers at the University of Rochester, led by Ying Xue and Deborah Freund, conducted a study to better understand one hospital's use of supplemental registered nurses (SRNs) and examine its impact on patient and nurse outcomes and cost. Using focus groups, interviews, mail surveys, chart reviews and reviewing hospital administration data, the team found that use of SRNs varied greatly by unit and that typically permanent RNs have similar experience and more education (BSN or higher degree). Although, the use of supplemental nurses occurred more frequently in units that were rated as having poor working environments, the team did not find that their use had any negative impact on patient or nurse outcomes. The findings of this project will further understanding of the impact of SRNs on quality and cost outcomes and help hospital administrators make evidence-based strategic plan for nurse staffing.
Access the research brief.

This post is part of a series to provide the public with research briefs on INQRI-funded projects across a range of interests.

Research Brief: Tailored Plan to Prevent Patient Falls

This week, we present the work of a team led by Patti Dykes and Blackford Middleton which has created a tool designed to prevent patient falls by translating an individual patient's fall risk assessment into a decision support intervention that communicates fall risk status, and creates a tailored plan that is accessible to care team members (including patients and family members). The team constructed the Fall Prevention Toolkit (FPTK), and conducted a randomized controlled trial to examine whether the FPTK led to a decrease in the incidence of patient falls and a decrease in the incidence of patient falls with injury. The use of their toolkit did significantly lower the incidence of falls in the intervention units and several units wished to continue using the tool after the conclusion of the study. By establishing links between nursing fall risk assessment, risk communication and tailored interventions to prevent falls, Dykes and Middleton hope to raise awareness of fall risks for patients, nurses and other providers and to lower mortality and morbidity for potential fall victims.

Access the research brief.

Example of a Fall TIPS Bed Poster
Example of a Fall TIPS Plan of Care
Example of Fall TIPS Patient Instructions

This post is part of a series to provide the public with research briefs on INQRI-funded projects across a range of interests.

Research Brief: Effect of NQF Safe Practices on Patient Outcomes

Led by Richard Lindrooth and John Welton, an interdisciplinary team at the Medical University of South Carolina examined how adoption of the National Quality Forum safe practices affects nursing sensitive patient safety outcomes. Barriers to adoption of these practices were also explored. This team took a step beyond existing literature by testing whether the implementation of safe practices leads to more effective use of nurses, and whether this leads to better performance on patient safety outcomes.

Access the research brief.

Histogram of Adoption of Safe Practices, 2004-2006

This post is part of a series to provide the public with research briefs on INQRI-funded projects across a range of interests.

Research Brief: Rural Hospital Collaborative and HF Outcomes

This week, we'd like you to introduce you to a team of researchers at the University of Maryland and Johns Hopkins University, led by Robin Newhouse and Laura Morlock.  This team conducted a study which identified the linkages between processes of nursing care and the quality of patient outcomes, while also addressing the pressing need for mentorship in implementing evidence-based heart failure (HF) care in rural hospitals. The team conducted a randomized control trial with twenty three rural hospitals from five states in the eastern United States. In the course of their project, the team found that heart failure core measures improved significantly between 2007 and 2009, but that nursing support and staffing does not predict core measure improvement. Heart failure core measures are reported by acute care hospitals as a measure of quality care for HF patients. They found that there is no relationship between the smoking cessation core measure, nursing smoking cessation counseling activity, and patient intent to quit smoking. Finally, they found that nurses in better practice environments use more evidence-based smoking cessation interventions. This study is one of the first to focus on linkages between rural nursing and patient outcomes, and has affected the engagement of nurses in 23 rural hospitals in improvements in heart failure care. Qualitative evidence suggests profound changes in the uptake of evidence and the formation of multidisciplinary teams.

Access the research brief.

This post is part of a series to provide the public with research briefs on INQRI-funded projects across a range of interests.

Research Brief: Impact of Nurse Characteristics and Practices on Patient Outcomes

An INQRI team led by Nancy Donaldson and Carolyn Aydin examined individual and collective effects of unit level nurse workload, staff nurse characteristics and selected risk assessment and preventive intervention processes of care on variance in nursing sensitive outcomes of acute care medical-surgical units. The team found that patient outcomes were predicted by combinations of all elements in their model, including: unit/patient characteristics, nursing workload, registered nurse expertise and clinical processes. Interestingly, they found that falls and falls with injury were predicted by patient characteristics and clinical process variables, but not by nurse expertise. However, hospital acquired pressure ulcer prevalence was predicted by a combination of all elements in the model. Finally, the team also found that unit and patient characteristics and workload could predict medication practice errors and that workload and practice errors predicted medication outcome errors. These findings can guide hospitals in efforts to improve staffing effectiveness and patient safety, reducing medication administration errors and understanding prevalence of facility acquired pressure ulcers.

Access the research brief.

This post is part of a series to provide the public with research briefs on INQRI-funded projects across a range of interests.

If I’d Only Known Then What I Know Now (A Letter to Myself)

We asked our grantees to write a letter to their "pre-INQRI" selves to share what they would have wanted to know before their funding began. Susan Letvak PhD, RN, FAAN, Professor of Nursing, UNC Greensboro, shares hers:

Dear Susan,

Just over three years from now you will have finished your Robert Wood Johnson INQRI-funded research project. While you were grateful you were able to finish your project on time, there are things you would do differently. Most importantly, when you started the project you never would have known the impact your study will have on nurses. I’m writing this letter to share some of those lessons.

1. Interdisciplinary teams can work together very well, even though you have not always had positive experiences as a co-investigator on other teams. Choosing a team that was vested in the project and in nursing outcomes made all the difference.

2. Stuffing envelopes takes longer than you think it will. While you had done mailed survey projects in the past, you never had to stuff 2,000 envelopes before. Thank goodness you had a research assistant built into the budget or you may still be stuffing envelopes today.

3. Your decision to use a professional graphic designer to design the survey was a great idea. The colorful and expertly designed survey was instrumental in the high response rate you received.

4. Your findings will not make everyone happy and you should be prepared for the angry responses you will receive from some nurses. Your findings will support that health problems in nurses leads to presenteeism which has a negative impact on quality of care. You will learn learn to always present positive strategies to overcome presenteeism so those nurses who have health problems will not feel maligned.

5. You will learn the importance of social media and blogs for reaching large audiences. In the past you relied only on manuscript publication and conference presentations to disseminate your research. This project will allow you to garner national attention in health blogs (including the NY Times) and as a guest on NPR.

6. You will not realize the positive impact you will make on increasing awareness and recognition of mental health problems in nurses and healthcare workers. At the onset of the project you thought that nurse pain would be the largest problem impacting nurses. Surprisingly your team found an 18% rate of depression in nurses. You remember reading the following poem written by Annabel Sheila:

Until it affects someone we love, 

We don’t even know it’s there. 

It’s really not our problem, 

So why should we care. 

The statistics are quite shocking, 

One in four they say 

Will suffer from depression 

In their lives one day. 

No one would choose to live with it, 

And some don’t even try. 

Most people turn the other cheek, 

They’ve been doing it for years. 

But it takes only one… 

ONE to know they care. 

You never realized the ONE would soon be you.

Have a great time with your INQRI project and the terrific people you will meet on your journey.

Susan

Research Brief: How Do Nurses Influence Discharge Teaching?

This week, we introduce you to the INQRI project conducted by Marianne Weiss, Olga Yakusheva, and their team.

Improving how patients are discharged from the hospital to reduce unnecessary readmissions is a critical issue now being debated at the national level. With one in five elderly readmitted to the hospital within 30 days at an annual cost to Medicare of $17 billion, policymakers are seeking cost-effective solutions to better transition patients from hospital to home. Researchers at Marquette University, led by Weiss and Yakusheva, have been studying what hospital-based nurses do to influence outcomes after a patient is discharged from a hospital. Specifically, they identified the contributions that nursing staff make to the quality of discharge teaching and the impact of that teaching on patient outcomes, readiness and readmission rates of patients who are discharged home. They have found that when units had more RN hours per patient day, fewer overtime hours and fewer vacancies, the discharge teaching was of higher quality, patients reported greater readiness for hospital discharge, and post-discharge utilization of readmission and emergency room visits was lower.

Access the research brief.

This post is part of a series to provide the public with research briefs on INQRI-funded projects across a range of interests.

INQRI Grantee on Diabetes Prevention in the Community

INQRI grantee Robin Whittemore recently wrote about her INQRI-funded project, "A Diabetes Prevention Program in the Community" for the U.S. Department of Health and Human Services' National Partnership for Action blog.

Dr. Whittemore, her co-project investigator Alana Rosenberg, MPH, and their team conducted a randomized clinical trial to reduce the risk of type 2 diabetes in at-risk adults with a diabetes prevention program provided by visiting nurses in subsidized housing units. They modified a research-based diabetes prevention program; evaluated the preliminary effects of the modified diabetes prevention program provided by visiting nurses; and explored the reach, adoption, implementation and cost of a diabetes prevention program delivered by visiting nurses to residents in subsidized housing units.

To check out Dr. Whittemore's post, please visit the the National Partnership for Action blog.

Research Brief: Reducing Blood Stream Infections

The next grantee project in our series comes from Johns Hopkins University.  Led by David Thompson and Jill Marsteller, the team's goal was to implement a comprehensive safety program including an evidence based intervention to reduce central line-associated blood stream infections (CLABSIs) while examining the context of nursing care delivery on patient outcomes. This interdisciplinary research team used the expertise of nurses to develop and deliver a quality improvement initiative that reflects the positive clinical contributions of nurses in the critical care setting. This study is likely to inform other nurse-led medical error reduction interventions, contribute to the quality improvement literature and to the science of rigorously evaluated evidence based interdisciplinary nursing practice.

Access the research brief.

Access a chart on the quarterly number of perceived CLABSI prevention practices during the implementation period.

This post is part of a series to provide the public with research briefs on INQRI-funded projects across a range of interests.

Policy Research to Inform Discussion on Scope of Practice

Alex Hoyt, PhD, RN, a Massachusetts General Hospital Institute of Health Professions School of Nursing Assistant Professor is using his recently awarded RWJF grant to bring policy research to the political debate over nurse practitioners’ (NPs') scope of practice. Dr. Hoyt was recently awarded a $250,000 grant via the Future of Nursing National Research Agenda initiative.

Dr. Hoyt plans to study the influence of regulatory changes on the NP workforce over time, how organizations interpret state practice regulations, and how these factors impact cost, quality, and access to care.

Click here to learn more about this impressive work.

Research Brief: Testing Quality Measures with Consumers

At this phase of the program, INQRI is focusing almost completely on dissemination.  To that end, we will be featuring a weekly presentation of grantee findings along with access to a research brief which is targeted to the largest possible audience.

This week, we would like to introduce you to the work of Shoshanna Sofaer and Jean Johnson.  The work of their team at Baruch College and The George Washington University has helped shed light on whether some of the National Quality Forum's (NQF) nursing sensitive measures are perceived as meaningful by consumers. The team designed and conducted focus groups with recently hospitalized patients to understand their perception of the nursing sensitive measures. Consumers found several patient safety measures to be very compelling, and clearly believed that nurses had a significant role in hospital quality. On the other hand, consumers didn't think nurses should be advising patients to quit smoking, arguing that nurses have better things to do with their time. They also found measures of nurse skill mix and turnover rates confusing. The team learned that overall, the public, while valuing nurses highly, has an incomplete understanding of what they do, including what they do based on their own assessments, and to whom they are accountable. Researchers performed a thorough literature review regarding the actions of nurses in care coordination and conducted interviews with nurses in four hospitals and held nine focus groups with recent patients. They found that while consumers clearly recognize the importance of care coordination, their perceptions of the nurses' role differed from the perspective of the nurses. The team found that there are limits to the patients' ability to truly observe many aspects of care coordination, which may explain why nurses see their role as broader and more central than do the patients. This research provides great weight to the importance of seeking public views when creating measures of nurse quality and showed that the public has much to contribute to the process. Findings could influence the process by which NQF endorses measures. In part because of this research, NQF recently dropped smoking cessation counseling for myocardial infarction, heart failure and pneumonia from the nursing sensitive measures.

Access the Research Brief.

This post is part of a series to provide the public with research briefs on INQRI-funded projects across a range of interests.

Upcoming AACN Webinar on Managing Delirium

The American Association of Critical-Care Nurses (AACN) is continuing its webinar series devoted to understanding and implementing updated clinical practice guidelines for pain, agitation and delirium with a session on Thursday, September 19, 10 a.m. PDT, presented by Leanne Boehm, RN, MSN, ACNS-BC.

Registration is now open for the webinar, "Delirium Challenge: Assessing and Managing in Acute/Critical Care."

This work mirrors that of INQRI grantees Michele Balas and William Burke who conducted a project which focuses on preventing complications in mechanically ventilated patients through use of the "Awakening and Breathing Coordination, Delirium assessment and management and Early Exercise and progressive mobility (ABCDE)" bundle.  Balas and Burke led a team to implement, analyze and disseminate an evidence-based, nurse-led, inter-professional, multi-component program focused on improving the care and outcomes of critically ill adults.  In fact, their "Implementing the ABCDE Bundle at the Bedside" was selected as the American Association of Critical-Care Nurses' first PEARL (Practice, Evidence, Application, Resources and Leadership) web-based tool.

Click here to learn more about the Balas-Burke project "Implementation and Dissemination of an Interdisciplinary Nurse-Led Plan to Manage Delirium in Critically Ill Adults."

Massachusetts Hospital Quality & Patient Safety Issue Brief Series

In 2004, the National Quality Forum endorsed a set of nursing sensitive measures, with the goal to provide hospitals, the public and purchasers with comparative measures that accurately reflect nursing performance. Massachusetts and Maine were among the first states to adopt statewide initiatives for the public reporting of nursing performance through the use of nurse sensitive measures. An INQRI team, led by Pat Noga and Barry Kitch, conducted a hospital leadership survey, including interviews with key stakeholders and hospital case studies to analyze these states' experiences implementing the initiatives. The team found that reaching agreement on the measures was a substantial and lengthy undertaking, and that while hospital leaders believed that public reporting of nurse sensitive measures was likely to have a positive impact both on the quality of nursing care and patient outcomes, they also found the initiatives to be burdensome. However, in both states, most believed that a public mandatory program would work best to improve quality of nursing care. Respondents were concerned about the accuracy and consistency of data collection and reporting across hospitals and wondered if the reports would be useful to the general public. Based on the experiences in Maine and Massachusetts, the researchers believe that it is possible to publicly report measures of nursing quality and that doing so can have a positive impact on the quality of care. The team theorizes that these initiatives are likely generalizable to other quality measurement initiatives not focused on nurse sensitive measures. The work of Noga and Kitch suggests that despite the perceived burden of implementing hospital reporting programs, public mandatory reporting may be viewed as a substantial impetus for improving the quality of nursing care.

Since completion of their study in 2008, the team has continued to educate stakeholders, mainly by creating issue briefs for their member audiences, such as the Massachusetts Hospital Association and the Organization of Nurse Leaders of Massachusetts and Rhode Island, and legislators.

Briefs include:

• Summary of Trends in Selected Nursing-Sensitive Care Measures in Massachusetts Hospitals and Related Cost Savings Estimates 
• Summary of Trends in Nurse Staffing in Massachusetts Acute Care Hospitals

This research also lives on in Massachusetts through the ongoing public reporting of various nurse sensitive measures that posted on the quality and safety website PatientCareLink. This site is a joint initiative of the Massachusetts Hospital Association and the Massachusetts Organization of Nurse Executives.

Improving Function Among Older Adults

A recent article on the Advance for Nurses website shares the way that care is delivered to older adults in the Senior Adult Unit at Addison Gilbert Hospital in Massachusetts.  This geriatric nursing unit is finding success by focusing on getting patients out of their beds and keeping them active.  Patients are encouraged to eat meals in a dining room and not in their beds.  Classes are offered to keep them engaged and healthy.

INQRI grantees Barbara Resnick and Sheryl Zimmerman also found success with an intervention designed to deliver Function Focused Care to residents in assisted living facilities. Their intervention was designed to maintain and improve function, physical activity, muscle strength, psychosocial outcomes (efficacy expectations and life satisfaction) and decrease adverse events (pain, falls and hospitalizations) among assisted living residents. Residents in intervention treatment sites demonstrated fewer declines in function and spent more time in moderate level physical activity at 4 months and more overall counts of activity at 12 months when compared to residents in control sites. There were also fewer transfers to the hospital among those in the treatment sites.

To learn more about the Resnick-Zimmerman study, please click here.

Twitter Chat Recap

Last week, INQRI grantee Marianne Weiss participated in a Twitter chat on patient empowerment, hosted by U.S. News and World Report.  With 263 participants, the chat moved pretty fast!  Panel members and many others shared tips for patients on how to prepare for doctor visits, keep track of medical information, ask the right questions, and ensure that they become partners in their care.

If you missed it (or missed some of it, considering the speed), you can check out the recap right here.  Dr. Weiss and INQRI were feeling pretty prolific - we had the top number of tweets (71) and the top number of mentions (121).  If you are interested in checking out the metrics of the chat, you can access them here.

INQRI Expert on Discharge to Discuss Patient Empowerment

As we told you yesterday, INQRI grantee Marianne Weiss will participate in a Twitter chat on patient engagement later today.  In advance, we'd like to introduce you to the work of her INQRI team which focused on nurses' contributions to hospital discharge teaching.

Improving hospital discharge and reducing unnecessary readmissions is a critical issue. Policymakers are seeking cost-effective solutions to better transition patients from hospital to home. Dr. Weiss and Dr. Olga Yakusheva led a team at Marquette University to study what hospital-based nurses do to influence outcomes after a patient is discharged from a hospital. They identified the contributions that nursing staff make to the quality of discharge teaching and the impact of that teaching on patient outcomes, readiness and readmission rates of patients who are discharged home. The team found that when units had more RN hours per patient day, fewer overtime hours and fewer vacancies, the discharge teaching was of higher quality, patients reported greater readiness for hospital discharge, and post-discharge utilization of readmission and emergency room visits was lower.

To access the articles published by the Weiss-Yakusheva team on this topic, please visit their page on the INQRI website.

Join us for today's Twitter chat using hashtag #PatientChat from 2pm-3pmET.

Moderator: @USNewsHealth
Experts: @RWJF, @theNPSF, @NPAF_tweets, @TrishaTorrey, @tedeytan, @RWJF_HumanCap, @INQRIprogram (*Dr. Weiss will use the INQRI Twitter handle)

Twitter Chat on Patient Empowerment

Tomorrow, U.S. News and World Report is hosting a live Twitter chat about empowering hospital patients.  Experts (including INQRI grantee Marianne Weiss*) will discuss how patients can become actively engaged and informed about their treatment.

Join us, using hashtag #PatientChat on Thursday, July 25 from 2pm-3pmET.

Moderator: @USNewsHealth
Experts: @RWJF, @theNPSF, @NPAF_tweets, @TrishaTorrey, @tedeytan, @RWJF_HumanCap, @INQRIprogram (*Dr. Weiss will use the INQRI Twitter handle)

Marianne Weiss, DNSc, RN, is a grantee of the Robert Wood Johnson Interdisciplinary Nursing Quality Research Initiative (INQRI) and associate professor at Marquette University College of Nursing. She is an active researcher focusing on improving patients’ experience with hospital discharge and the role nurses play in discharge preparation and the discharge transition. Her research on patient perceptions of discharge teaching, readiness for discharge, and coping difficulty at home following hospital discharge have highlighted the importance of inclusion of patient voice to improve discharge experiences. Her work has included a broad base of patient populations including adult medical-surgical patients, parents of hospitalized children, and postpartum mothers.

 

Do Alarms Really Help Keep Patients Safe?

A recent article in the Washington Post by Lena H. Sun discusses the fact that with so much alarm-caused noise in a hospital (ventilators going off, infusion pumps beeping, blood pressure monitors emitting tone after tone), it's difficult to know when an alarm is indicating a serious problem or is just over-sensitive.  As a result, Sun writes that health care workers suffer "alarm fatigue" that leads them to turning down the volume on devices, turning them off, or just ignoring them.  These actions could definitely put patients at risk when an alarm does indicate an emergency.

An INQRI-funded study found one way to use different sounds to help keep patients safe.  Led by Tracey Yap and Jay Kim, the team used music to reduce the incidence of pressure ulcers. The study used music to cue patients in long-term care facilities to move in order to avoid getting pressure ulcers. The music also cued staff to help to move those patients who couldn't move on their own. Dr. Yap blogged about the study and some unexpected results on the RWJF Human Capital blog for National Nurses Week.

But, what about those traditional alarms?  Do they keep patients safe or do we need to find another way?