Adult Medical-surgical Units Research Articles

Patient Safety Culture from a Nursing Perspective in a Chilean Hospital.

Patient safety culture is relevant both in the delivery of care and in the training of nursing staff, its purpose being to prevent and reduce risks associated with health care. This research aims to evaluate patient safety culture from the perspective of the nursing teams in a highly complex public hospital in the city of Valparaíso, Chile. A cross-sectional study with a quantitative approach applying descriptive, bivariate, and inferential statistical analysis was conducted on 259 nurses and nursing assistants from 13 adult medical-surgical units of the Carlos Van Buren hospital. The participants were obtained through a non-probabilistic convenience sample, answering the hospital survey on Patient Safety Culture version 2.0 (HSOPS 2.0), adapted to the Chilean population. The best-evaluated dimension was communication and receptivity; the worst was the support administrators provide for patient safety. This study identified the weaknesses and strengths of the hospital, the most worrying weakness being the shortage of human capital, material, and financial resources necessary to improve patient safety. This study was not registered.

Diverse perspectives on unit-level nurse staffing ratios in medical–surgical units: A Delphi policy analysis

BackgroundAppropriate staffing is essential to acute care delivery. Staffing ratio policy generates controversy. PurposeThis study examines perspectives on unit-level nurse-to-patient ratio policy in adult medical–surgical units. MethodDelphi methodology uses an invited diverse panel to analyze a policy’s effects. Panelists completed iterative surveys about the impact they expect from unit-level ratio policy. FindingsPanelists demonstrated moderate agreement that the proposed policy could increase staffing levels, decrease patient length of stay, and reduce nurse attrition. Other potential outcomes included reducing staffing in units above the minimum and increasing short-term costs. Panelists agreed that the policy could increase patient safety and nurse satisfaction and did not agree about the effect on long-term cost and innovation. Panelists also anticipated a mostly positive effect on patients and nurses. DiscussionPolicies that set unit-level nurse-to-patient ratios offer a potential strategy to improve medical–surgical staffing. Policy design should consider the range of expected outcomes.

A Peer-to-Peer Approach to Increasing Staff Competency and Engagement in Wound and Ostomy Care: A Quality Improvement Project.

The purpose of this quality improvement (QI) project was to provide an innovative, participatory approach to the education of staff nurses and nursing support personnel to improve skills and competencies in wound and ostomy care while enhancing staff engagement and empowerment. Project planning occurred between January and October 2020 and implementation began in November 2020. The project was implemented in 1 intensive care unit and 6 adult medical-surgical units of a 288-bed community hospital in the northeastern United States (Bronxville, New York). Participants included RNs and nursing support staff working in intensive care and medical-surgical units. A postimplementation survey was conducted in May 2021. The Plan-Do-Study-Act (PDSA) model was used as a framework for this QI intervention. A peer-to-peer approach to staff education addressing different learning styles was used to improve knowledge and competencies of staff nurses pertaining to wound and ostomy care. There were 72 participants; 68% (n = 49) exhibited knowledge retention 5 months after initial participation; 85% (n = 61) reported a high level of engagement; and 97.5% (n = 70) reported a high level of satisfaction 5 months after project implementation. An emerging need exists for educational innovation regarding wound and ostomy care to improve quality of care, nursing care outcomes, and staff engagement. Through a peer-to-peer approach to wound and ostomy care education, enhanced clinical knowledge and competencies can result in improved patient safety and increase care outcomes.

Multisite Evaluation of Toothbrushes and Microbial Growth in the Hospital Setting.

This observational, descriptive study was conducted to determine the prevalence of microbial growth on toothbrushes found in hospital patient rooms. Toothbrush sampling was conducted in 136 acute care hospitals and medical centers from November 2018 through February 2022. Inclusion criteria for the units and patient rooms sampled were as follows: general adult medical-surgical units or critical care units; rooms occupied by adults 18 years or older who were capable of (1) mobilizing to the bathroom; (2) using a standard manual, bristled toothbrush; and (3) room did not have signage indicating isolation procedures. A total of 5340 patient rooms were surveyed. Of the rooms included, 46% (2455) of patients did not have a toothbrush available or had not used a toothbrush (still in package and/or toothpaste not opened). Of the used toothbrushes collected (n = 1817): 48% (872/1817) had at least 1 organism; 14% (251/1817) of the toothbrushes were positive for 3 or more organisms. These results identify the lack of availability of toothbrushes for patients and support the need for hospitals to incorporate a rigorous, consistent, and comprehensive oral care program to address the evident risk of microbe exposure in the oral cavity.

Perceptual differences in nursing implementation leadership and climate: a cross-sectional study

BackgroundThe literature on perceptual differences between managers and staff regarding social dynamic factors (e.g., leadership, climate) in nursing settings is sparse. Addressing this gap in knowledge is critical for informing implementation efforts and improving patient and organizational outcomes. The purpose of this study was to test the perceptual differences regarding implementation leadership and implementation climate between nursing staff and their managers.MethodsThis study was a secondary analysis of cross-sectional survey data collected in 2016–2017. The setting included 22 adult medical-surgical units nested in 7 acute care hospitals in the Eastern and Midwestern United States. Participants were registered nurses (N = 261) and nurse managers (N = 22) who completed an electronic survey consisting of the Implementation Leadership Scale (ILS), the Implementation Climate Scale (ICS), and demographic items. Differences in perception were analyzed at the unit level using structural equation modeling to develop latent difference score models (LDS). We assessed associations of the LDSs with manager ILS and ICS scores, years of nursing experience, and years of experience working on the current unit. The association of ILS LDS with the observed nursing staff ICS scores was also analyzed.ResultsHigher manager scores on the ILS and ICS were associated with greater perceptual differences in implementation leadership and implementation climate. Greater years of experience as a nurse were associated with greater perceptual differences in ILS and ICS scores. Greater tenure on the unit was associated with smaller differences on the ILS knowledge domain. Greater perceptual differences regarding implementation leadership were associated with worse staff ratings of implementation climate.ConclusionsAlthough this study observed significant relationships among manager ILS and ICS scores, staff-manager perceptual differences, and staff ratings of implementation climate in nursing settings, it is still unclear why perceptual differences in implementation leadership and climate exist and how to address them. Future studies are warranted to test the effect of perceptual differences on implementation and patient outcomes.

Frontline Nurses' clinical judgment in recognizing, understanding, and responding to patient deterioration: A qualitative study

BackgroundEarly warning systems and rapid response teams have been widely implemented in hospitals worldwide to facilitate early recognition and response to patient deterioration. Unfortunately, evidence suggests that these interventions have made little impact on unexpected cardiac or respiratory arrest, hospital mortality, unplanned admission to intensive care units, or hospital length of stay. These programs depend on nurses recognizing at risk patients and initiating a timely response. Although physiologic abnormalities commonly precede serious adverse events, nurses often fail to recognize or respond effectively. Clinical judgment is a critical component in the effective response to deterioration, yet little is known about factors that influence nurses' clinical judgment in these situations. Noticing, interpreting, and responding are aspects of clinical judgment and are essential to preventing further patient deterioration and serious adverse events. ObjectiveTo describe medical-surgical nurses' perceptions of factors that influenced their clinical judgment in situations of patient deterioration. DesignA qualitative descriptive design using individual, semi-structured interviews. Tanner's Clinical Judgment Model served as the framework for interview questions and data analysis. ParticipantsA purposive sample of 20 medical-surgical registered nurses were recruited from 10 adult medical-surgical units at an academic medical center hospital in the United States. MethodsTelephone interviews occurred between March and July 2018. A directed approach to content analysis was used to code the transcribed data and identify themes. ResultsEight themes related to each aspect of clinical judgment emerged from the analysis: Knowing the patient, Experience matters, Lots of small points where the system can fail, Making sense of the data, Something doesn't go together, Caught in the middle, Culture of teamwork, and Increased nursing workload. An overarching theme was Nurses' keen sense of responsibility. Findings revealed that factors within the nurse, the patient, and the work environment influence each component of noticing, interpreting, and initiating an effective response to deteriorating patients. ConclusionsFindings have implications for health care systems regarding interventions to support timely recognition and response to deterioration. Nurses' clinical judgment and factors that influence each aspect (noticing, interpreting, and responding) should be a key consideration in organizational efforts to improve the overall response to patient deterioration. Research is needed to enhance understanding of the contextual factors that impact nurses' clinical judgment to inform interventions to support timely recognition and response.

Compliance of non-pharmacological preventive practice of venous thromboembolism among Jordanian nurses.

Many practices, such as non-pharmacological preventive practices, have demonstrated significant improvement and reduced the venous thromboembolism incidence. This study aims at investigating the compliance with non-pharmacological preventive practice of venous thromboembolism guidelines among Jordanian intensive care and medical and surgical nurses. Descriptive and cross-sectional with the non-participant observational design was used. This study recruited 271 registered nurses in adult medical-surgical units and intensive care units of 12 different government hospitals in Jordan's middle and north regions. The observational checklist included 10 preventive practices based on the non-pharmacological preventive of venous thromboembolism guidelines. In the observational checklist, the highest score was 20, and the lowest was 0. If the nurse received equal to or higher than (>14) score were classified as sufficient compliance, while insufficient compliance was (≤14) score. The observations period started from September 2019 until March 2020. The participants' overall mean venous thromboembolism compliance score was insufficient compliance (10.6 ± 1.6). The majority of nurses were classified as insufficient compliance 67%. "Doing foot exercise and early ambulation 2 times per day 50.3%" and "checked the integrity of the patient's skin at regular intervals 50.0%" were the highest practices done rightly and completely by half of the participants. The participants who had a bachelor of nursing degree, staff nurse, and works in the intensive care unit, are less experienced and have no previous venous thromboembolism education reported low venous thromboembolism compliance. This study presents expanded compliance regarding venous thromboembolism preventive practices among Jordanian intensive care and medical & surgical nurses, so the policymakers need to develop an initiative to improve nurses' compliance.

Dedicated Education Units: A Unique Evaluation.

Traditional models of clinical nursing education do not deliver the most effective learning experiences to undergraduate nursing students. An innovative way to clinically prepare nursing students is the use of dedicated education units (DEUs). This model utilizes staff nurses to provide supervision and hands-on teaching to students. The purpose of this project was to evaluate an evidence-based change from a traditional model of clinical instruction to a DEU. DEUs were implemented on three adult medical-surgical units. Two unpaired identical pre-DEU and post-DEU questionnaires were used to evaluate the practice change in both nursing students and staff nurse mentors. A total of 41 students and 22 nurses participated in the project. Students reported feeling comfortable, engaged, and satisfied in their clinical experiences on the DEU. Nurses' responses revealed the DEU to be a rewarding experience and found satisfaction in their role. The paradigm shift from traditional to DEU models has enhanced the quality of learning experiences for students and improved the professional environment for nurses at large academic medical institutions located in central Ohio. Implications for future inquiry include standardizing educational training/orientation programs for DEU staff nurse mentors.

Effect of Implementing Discharge Readiness Assessment in Adult Medical-Surgical Units on 30-Day Return to Hospital

The downward trend in readmissions has recently slowed. New enhancements to hospital readmission reduction efforts are needed. Structured assessment of patient readiness for discharge has been recommended as an addition to discharge preparation standards of care to assist with tailoring of risk-mitigating actions. To determine the effect of unit-based implementation of readiness evaluation and discharge intervention protocols on readmissions and emergency department or observation visits. The Readiness Evaluation and Discharge Interventions (READI) cluster randomized clinical trial conducted in medical-surgical units of 33 Magnet hospitals between September 15, 2014, and March 31, 2017, included all adult (aged ≥18 years) patients discharged to home. Baseline and risk-adjusted intent-to-treat analyses used difference-in-differences multilevel logistic regression models with controls for patient characteristics. Of 2 adult medical-surgical nursing units from each hospital, 1 was randomized to the intervention and 1 to usual care conditions. Using the 8-item Readiness for Hospital Discharge Scale, the 33 intervention units implemented a sequence of protocols with increasing numbers of components: READI1, in which nurses assessed patients to inform discharge preparation; READI2, which added patient self-assessment; and READI3, which added an instruction to act on a specified Readiness for Hospital Discharge Scale cutoff score indicative of low readiness. Thirty-day return to hospital (readmission or emergency department and observation visits). Intervention units above median baseline readmission rate (>11.3%) were categorized as high-readmission units. Among the 33 intervention units, 17 were low-readmission units and 16 were high-readmission units. The sample included 144 868 patient discharges (mean [SD] age, 59.6 [17.5] years; 51% female; 74 605 in the intervention group and 70 263 in the control group); 17 667 (12.2%) were readmitted and 12 732 (8.8%) had an emergency department visit or observation stay. None of the READI protocols reduced the primary outcome of return to hospital in intent-to-treat analysis of the full sample. In exploratory subgroup analysis, when patient self-assessments were combined with readiness assessment by nurses (READI2), readmissions were reduced by 1.79 percentage points (95% CI, -3.20 to -0.40 percentage points; P = .009) on high-readmission units. With nurse assessment alone and on low-readmission units, results were mixed. Implemented in a broad range of hospitals and patients, the READI interventions were not effective in reducing return to hospital. However, adding a structured discharge readiness assessment that incorporates the patient's own perspective to usual discharge care practices holds promise for mitigating high rates of return to the hospital following discharge. ClinicalTrials.gov Identifier: NCT01873118.

Unit Leadership and Climates for Evidence-Based Practice Implementation in Acute Care: A Cross-Sectional Descriptive Study.

The purposes of this study were to (a) describe nurse manager (NM) leadership behaviors for evidence-based practice, NM evidence-based practice competencies, and unit climates for evidence-based practice implementation in acute care, and (b) test for differences in NMs' and staff nurses' (RNs') perceptions. A multisite cross-sectional design was used to collect data from a sample of 24 NMs and 553 RNs from 24 adult medical-surgical units in seven U.S. community hospitals. Responses were collected using electronic questionnaires, inclusive of the Nurse Manager Evidence-Based Practice Competency Scale (NM only), Implementation Leadership Scale, and Implementation Climate Scale. E-mail reminders and gift card lottery drawings encouraged response. Descriptive statistics described total and subscale scores by role. Differences in perceptions were evaluated using independent t-tests with Bonferroni correction (α = .05). 23 NMs and 287 RNs responded (95.8% and 51.9% response rates, respectively). NMs reported they were "somewhat competent" in evidence-based practice (M = 1.62 [SD = 0.5]; 0-3 scale). NMs and RNs perceived leadership behaviors (NM: M = 2.73 [SD = 0.46]; RN: M = 2.88 [SD = 0.78]; 0-4 scale) and unit climates for evidence-based practice implementation (NM: M = 2.16 [SD = 0.67]; RN: M = 2.24 [SD = 0.74]; 0-4 scale) as evident to a "moderate extent." RN and NM perceptions differed significantly on the Proactive (p = .01) and Knowledgeable (p < .001) leadership subscales. Evidence-based practice competencies and leadership behaviors of NMs, and unit climates for evidence-based practice were modest at best and interventions are needed. To close the research to practice gap, future studies should investigate the interplay between social dynamic context factors and implementation strategies to promote uptake of evidence-based practices. Critical attention is needed to build organizational capacity for evidence-based practices through development of unit leadership and climate for evidence-based practice to accelerate routine use of evidence-based practices for improving care delivery and patient outcomes. The three instruments described herein provide a foundation for nurse leaders to assess these dynamic context factors and design interventions or programs where there is opportunity for improvement.

Associations among unit leadership and unit climates for implementation in acute care: a cross-sectional study

BackgroundNurse managers have a pivotal role in fostering unit climates supportive of implementing evidence-based practices (EBPs) in care delivery. EBP leadership behaviors and competencies of nurse managers and their impact on practice climates are widely overlooked in implementation science. The purpose of this study was to examine the contributions of nurse manager EBP leadership behaviors and nurse manager EBP competencies in explaining unit climates for EBP implementation in adult medical-surgical units.MethodsA multi-site, multi-unit cross-sectional research design was used to recruit the sample of 24 nurse managers and 553 randomly selected staff nurses from 24 adult medical-surgical units from 7 acute care hospitals in the Northeast and Midwestern USA. Staff nurse perceptions of nurse manager EBP leadership behaviors and unit climates for EBP implementation were measured using the Implementation Leadership Scale and Implementation Climate Scale, respectively. EBP competencies of nurse managers were measured using the Nurse Manager EBP Competency Scale. Participants were emailed a link to an electronic questionnaire and asked to respond within 1 month. The contributions of nurse manager EBP leadership behaviors and competencies in explaining unit climates for EBP implementation were estimated using mixed-effects models controlling for nurse education and years of experience on current unit and accounting for the variability across hospitals and units. Significance level was set at α < .05.ResultsTwo hundred sixty-four staff nurses and 22 nurse managers were included in the final sample, representing 22 units in 7 hospitals. Nurse manager EBP leadership behaviors (p < .001) and EBP competency (p = .008) explained 52.4% of marginal variance in unit climate for EBP implementation. Leadership behaviors uniquely explained 45.2% variance. The variance accounted for by the random intercepts for hospitals and units (p < .001) and years of nursing experience in current unit (p < .05) were significant but level of nursing education was not.ConclusionNurse managers are significantly related to unit climates for EBP implementation primarily through their leadership behaviors. Future implementation studies should consider the leadership of nurse managers in creating climates supportive of EBP implementation.

RN4Cast Study in Portugal: Nurses and care left undone

Background: Over the past decades, nursing in Portugal has evolved greatly both academically and professionally and this evolution brought along growing concerns about the quality of the healthcare provided. Due to lack of time or poor organization of the workload, nurses are often faced with the need to choose between what must be done and what will have to be postponed or even not be done at all.Objective: To investigate the care activities that are most frequently left undone or are postponed by nurses working in medical and surgical inpatient units in Portugal.Methods: A descriptive, cross-sectional, quantitative study that follows the RN4CAST (Nurse Forecasting in Europe) methodology was carried out from October 2013 to April 2014. A total of 31 hospitals and a random sample of adult medical-surgical units were involved. The data were collected using a socio-demographic questionnaire and a nursing questionnaire that included the identification of the nursing activities of surveillance and direct patient care that were necessary but postponed or not performed by nurses in their most recent shift.Results: A total of 2,235 nurses participated. Almost all participants had a nursing bachelor degree (98.2%). The most frequently left undone or postponed care items were “Educating patients and family” (50.2%) and “Comfort/talk with patients” (50.1%); the least frequently left undone items were “Treatments and procedures” (3.9%) and “Pain management” (5.6%). Nurses in the North and Center regions of the country were the ones who reported less care left undone due to lack of time. Nurses under the age of 40 were those who reported a highest number of activities left undone.Conclusions: Nurses make selective choices about the care activities that are crucial for the patient. Some activities that may not have an immediate impact on the health of the patients are sidelined, although they may have an impact on other important healthcare quality indicators.

The effect of a translating research into practice intervention to promote use of evidence-based fall prevention interventions in hospitalized adults: A prospective pre–post implementation study in the U.S.

BackgroundFalls are a major public health problem internationally. Many hospitals have implemented fall risk assessment tools, but few have implemented interventions to mitigate patient-specific fall risks. Little research has been done to examine the effect of implementing evidence-based fall prevention interventions to mitigate patient-specific fall risk factors in hospitalized adults. ObjectivesTo evaluate the impact of implementing, in 3 U.S. hospitals, evidence-based fall prevention interventions targeted to patient-specific fall risk factors (Targeted Risk Factor Fall Prevention Bundle). Fall rates, fall injury rates, types of fall injuries and adoption of the Targeted Risk Factor Fall Prevention Bundle were compared prior to and following implementation. DesignA prospective pre–post implementation cohort design. SettingThirteen adult medical-surgical units from three community hospitals in the Midwest region of the U.S. ParticipantsNurses who were employed at least 20hours/week, provided direct patient care, and licensed as an RN (n=157 pre; 140 post); and medical records of patients 21years of age or older, who received care on the study unit for more than 24hours during the designated data collection period (n=390 pre and post). MethodsA multi-faceted Translating Research Into Practice Intervention was used to implement the Targeted Risk Factor Fall Prevention Bundle composed of evidence-based fall prevention interventions designed to mitigate patient-specific fall risks. Dependent variables (fall rates, fall injury rates, fall injury type, use of Targeted Risk Factor Fall Prevention Bundle) were collected at baseline, and following completion of the 15month implementation phase. Nurse questionnaires included the Stage of Adoption Scale, and the Use of Research Findings in Practice Scale to measure adoption of evidence-based fall prevention practices. A Medical Record Abstract Form was used to abstract data about use of targeted risk-specific fall prevention interventions. Number of falls, and number and types of fall injuries were collected for each study unit for 3months pre- and post-implementation. Data were analyzed using multivariate analysis. ResultsFall rates declined 22% (p=0.09). Types of fall injuries changed from major and moderate to minor injuries. Fall injury rates did not decline. Use of fall prevention interventions improved significantly (p<0.001) for mobility, toileting, cognition, and risk reduction for injury, but did not change for those targeting medications. ConclusionsUsing the Translating Research Into Practice intervention promoted use of many evidence-based fall prevention interventions to mitigate patient-specific fall risk factors in hospitalized adults.

The Effect of Educational Intervention on Nurses' Attitudes and Beliefs about Depression in Heart Failure Patients.

Systematic depression screening is feasible, efficient, and well accepted; however the lack of consistent assessment in heart failure inpatients suggests barriers preventing its effective diagnosis and treatment. This pilot study assessed the impact of an educational intervention on nurses' beliefs about depression and their likelihood of routinely screening heart failure patients. Registered nurses (n = 35) from adult medical-surgical units were surveyed before and after an educational intervention to assess their beliefs about depression prevalence and screening in heart failure patients. There was no significant influence on nurses' beliefs about depression, but the results suggested an increased likelihood that nurses would routinely screen for depression. The moderately significant correlation between beliefs and intent to screen for depression indicates that educational intervention could ultimately have a positive influence on patient outcomes through early detection and treatment of depression in patients with cardiovascular disease; however the observed increase in the intent to screen without a corresponding change in beliefs indicates other influences affecting nurses' intent to screen heart failure patients for depression.

Inappropriate use of urinary catheters: A prospective observational study

Despite the well-recognized role of urinary catheters in nosocomial urinary tract infections, data on risk factors associated with inappropriate urinary catheter use are scarce. A prospective review of electronic medical records of 436 patients admitted to an adult medical-surgical unit between October and December 2007 was performed to examine the appropriateness of urinary catheter use. The use of 157 urinary catheters in 144 patients was observed. A total of 557 urinary catheter-days were recorded in these patients, of which 175 (31.4%) were found to be inappropriate based on the study criteria. The total number of catheters used and the total duration of catheterization were risk factors for inappropriate urinary catheter use (P < .05). Inappropriate catheter use was not associated with such adverse events as mortality, readmission, intensive care unit admission, catheter complications, or urine culture rates, but was associated with a trend toward longer duration of hospitalization. Significant rates of inappropriate urinary catheter use and a trend toward longer duration of hospitalization with inappropriate catheter use were observed. These findings underscore the importance of establishing guidelines and effective policy implementation for the appropriate use of urinary catheters in hospitalized patients.

Quality Assurance

MARY JANE OTT, MN, MA, RN, CS, was Unit Supervisor, Pediatric Unit, Adult Medical Surgical Unit, and Adult Hospice Unit, Kaiser Permanente Medical Center, Oakland, California.

Nosocomial rubella--consequences of an outbreak and efficacy of a mandatory immunization program.

An outbreak of rubella in a large metropolitan hospital is described. Nineteen cases among employees and three secondary cases in family members occurred. Nosocomial cases occurred among the 3,900 employees of an adult medical-surgical unit where a voluntary program of rubella immunization was in effect. No cases occurred among the 1,400 employees of the women's and pediatric units with mandatory policies, despite interfacility and community exposure. Ten pregnant women were among the 377 contacts of the cases. Five were sero-negative to rubella. Two who developed clinical rubella, one asymptomatic sero-conversion and one other, all elected to terminate their pregnancies. The remaining woman, exposed in her third trimester delivered a normal infant. We conclude a policy requiring new employees to be rubella immune is more effective in preventing nosocomial rubella than a voluntary program and is desirable in view of the potential consequences of an outbreak to pregnant employees.

Roommates: To Have or Have Not

quences(2). It would seem that the best way to find out what a patient thinks about sharing a room would be to ask him, not the staff. The purpose of this study was to determine patients' perceptions of certain factors involved in sharing a two-person room. To obtain data, we mailed question aires to 100 people who had been patients in two-bed rooms in a large community hospital. All the patients who the nursing staff indicated were mentally alert and oriented and who were discharged on alternate days over a six-week period from adult medical-surgical units were selected. Questionnaires were sent within three days after a pa ient's discharge. Of the 100 questionnaires mailed, 54 were returned. Of this number, 3 were disqualified because the questions were not answered in the manner indicated on the tool. The