Ward Organization Research Articles

Work organization in hospital wards and nurses’ emotional exhaustion: A multi-method study of observation-based assessment and nurses’ self-reports

BackgroundWard organization is a major determinant for nurses’ well-being on the job. The majority of previous research on this relationship is based on single source methods, which have been criticized as skewed estimations mainly due to subjectivity of the ratings and due to common source bias. ObjectivesTo investigate the association of ward organization characteristics and nurses’ exhaustion by combining observation-based assessments with nurses’ self-reports. Design and participantsCross-sectional study on 25 wards of four hospitals and 245 nurses. SettingOur multi-method approach to evaluate hospital ward organization consisted of on-site observations with a standardized assessment tool and of questionnaires to evaluate nurses’ self-reports and exhaustion. MethodsAfter establishing the reliability of our measures, we applied multi-level regression analyses to determine associations between determinant and outcome variables. ResultsWe found substantial convergence in ward organization between the observation-based assessments and nurses’ self-reports, which supports the validity of our external assessments. Furthermore, two observation-based characteristics, namely participation and patient-focused care, were significantly associated with lower emotional exhaustion among the nurses. ConclusionsOur results suggest that observation-based assessments are a valid and feasible way to assess ward organization in hospitals. Nurses’ self-reported as well as observation-based ratings on ward organization were associated with nurses’ emotional exhaustion. This is of interest mainly for identifying alternative measures in evaluating nurses’ work environments, to inform health promotion activities and to evaluate job redesign intervention.

Antipsychotic prescription amongst hospitalized patients with dementia.

Antipsychotic drugs are used to treat behavioural and psychological symptoms of dementia, despite significant safety concerns regarding increased risk of stroke and mortality. The numbers of patients with dementia and related behavioural symptoms being treated in acute hospitals is increasing. (i) to determine pre-admission and in-hospital prevalence of antipsychotic use in a national sample of patients with dementia and acute illness; (ii) identify reasons for antipsychotic use; (iii) assess features of the ward environment which impact on patients with dementia; (iv) determine availability of dementia-specific policies, training, appraisal and mentorship programs which influence service delivery. Four-part standardized audit in 35 public acute hospitals comprising (i) retrospective healthcare record review (n = 660); (ii) prospective assessment of ward environment (n = 77); (iii) ward organization interview with clinical managers (n = 77); (iv) hospital organisation interview with senior managers (n = 35). Antipsychotic drugs were prescribed to 29% of patients with dementia before hospitalization and to 41% during hospitalization; one quarter received new or additional prescriptions. Assessments for delirium (45%), dementia symptoms (39%), mood (26%), mental state (64%) and distress-provoking factors (3%) were suboptimal. Drug indications were documented in 78%. Non-pharmacological interventions were not documented. Most wards lacked environmental cues to promote orientation. Dementia-specific care pathways existed in 2 of 35 hospitals. Staff support and training programmes were suboptimal. 12% of patients were discharged with new antipsychotic prescriptions. Antipsychotic medications are commonly prescribed for hospitalized patients with dementia in Ireland. Ward environments and dementia-related governance structures are suboptimal.

Staff perceptions of leadership during implementation of task-shifting in three surgical units

Registered nurses are difficult to recruit and retain. Task shifting, which involves reallocation of delegation, can reduce demand for registered nurses. Effective leadership is needed for successful task shifting. This study explored leadership styles of three surgical nurse unit managers. Staff completed surveys before and after the implementation of task shifting. Task shifting involved the introduction of endorsed enrolled nurses (licensed nurses who must practise under registered nurse supervision) to better utilize registered nurses. Implementation of task shifting occurred over 4 months in a 700-bed tertiary hospital, in southeast Queensland, Australia. A facilitator assisted nurse unit managers during implementation. The impact was assessed by comparison of data before (n = 49) and after (n = 72) task shifting from registered nurses and endorsed enrolled nurses (n = 121) who completed the Ward Organization Features Survey. Significant differences in leadership and staff organization subscales across the settings suggest that how change involving task shifting is implemented influences nurses' opinions of leadership. Leadership behaviours of nurse unit managers is a key consideration in managing change such as task shifting. Consistent and clear messages from leaders about practice change are viewed positively by nursing staff. In the short term, incremental change possibly results in staff maintaining confidence in leadership.

The Productive Ward: encouraging teambuilding and innovation

The aim of the NHS Institute for Innovation and Improvement's Productive Ward series is to remove wasteful activities from ward processes and reinvest the time saved in making care more interactive, stimulating, reliable and safe. This article describes how the introduction of Productive Ward on one unit in a mental health trust has delivered improvements in general ward organisation and a range of ward processes, and has motivated and empowered team members to make changes and innovate. The article also describes leadership and teamworking lessons that the ward matron and project facilitator have learnt.

Contribution of Italian spine research to peer reviewed publications

In 2011, Italy celebrates 150 years of unification of the country, when various kingdoms and states became a Nation. There are still many differences among regions of Italy, despite a long-lasting political and economical commitment in homogenizing the social discrepancies and assuring common standards and rules for all the citizens and for all the territories. The coming of the European Community was more important than the national profile, but, paradoxically, the creation of a great Europe developed the requests and hopes of smaller entities, in Italy but also in other countries. Differences among regions are plain also in health and social services. In Italy, a Servizio Sanitario Nazionale (National Health Service) was built 30 years ago, but regional health services, born from the new federal evolution of state organization, could have some discrepancies. However, the Servizio Sanitario Nazionale was internationally known and renowned and it is one of the best in the world. This result was mainly derived from the high scientific level and professional engagement of Italian doctors, supported by universities and medical and scientific associations. The quality of care is directly linked to basic and applied research. The research centers in Italy are not only academic, industrial or independent from healthcare services, but are also organized in a network coordinated by the Ministry of Health, which controls and supports the Scientific Institutes of Research and Care (Istituti di Ricerca e Cura a Carattere Scientifico-IRCCS), i.e., public and private hospitals, which have common and parallel missions: care and science. This model is now widely appreciated in the world and represents a concrete example of a real investment and commitment in translational research, in collaboration with industries, governments, non-profit organizations and patients’ associations. The high basic level of medicine should always be accompanied by excellence and reference centers, especially for special surgery. It is particularly noted for spine surgery. We outline the engagement and effort of Italian spine surgeons in improving scientific activities, surgery techniques, ward organization, hospitalization, diagnostic services integration, but also research and teaching. In fact, in 2011 the annual meeting of the Spine Society of Europe will be held in Italy. Every year, the National Congress of the Italian Spine Society—GIS collects many hundreds of participants, every month educational programmes of international and national associations are organized in different cities. This issue aims to stimulate Italian spine surgeons to be represented in the international spinal literature in a way that better reflects the scientific level achieved by them and their national medical organization. We reviewed the articles which appeared in the journals devoted to spine surgery included in Journal Citation Report (JCR), namely Spine, European Spine Journal and Journal of Spinal Disorders and Techniques, comparing the Italian contribution to the total knowledge represented by published papers (Table 1). It is obviously a rough evaluation, because contributions from engineering, biomechanics, and general orthopaedics journals should be added, but it is sufficient to define a rising and stable contribution from Italy to the spine surgery science, considering that the national level is between the 5th and 8th rank in the observed years. Table 1 Values of impact factor scores of the three specialized spine journal quoted in JCR: the partial impact factor values are the value obtained by Italian professionals Our aim is to stimulate and to improve the Italian contribution to peer-reviewed international journals. This Supplement including a selection of the oral presentations of the National Congress of the Italian Spine Society—GIS held in Ragusa in 2009, is a seminal part of this effort. Giuseppe Banfi, MD Scientific Director IRCCS Istituto Ortopedico Galeazzi Claudio Lamartina, MD Chief of II Spine Surgery Dept. IRCCS Istituto Ortopedico Galeazzi

Restructuring patient flow logistics around patient care needs: implications and practicalities from three critical cases

To make hospitals more patient-centered it is necessary to intervene on patient flow logistics. The study analyzes three innovative redesign projects implemented at three Italian hospitals. The three hospitals have reorganized patient flow logistics around patient care needs using, as proxies, the expected length of stay and the level of nursing assistance. In order to do this, they have extensively revised their logistical configuration changing: (1) the organization of wards, (2) the hospital's physical lay-out, (3) the capacity planning system, and (4) the organizational roles supporting the patient flow management. The study describes the changes implemented as well as the results achieved and draws some general lessons that provide useful hints for those other hospitals involved in such type of redesign projects. The paper ends by discussing some policy implications. In fact, the results achieved in the three cases investigated provide interesting material for further discussion on clinical, operational, and economic issues.

Videoconferencing to Enhance the Integration between Clinical Medicine and Teaching: A Feasibility Study

The aim of the study was to analyze the feasibility of a setting up of a radiotherapy department using videoconferencing technology. A videoconferencing network was started to link an academic center of radiotherapy to a peripheral center of research at the start of its activity. Two years of data of involved professionals, subjects of links, audio, video link problems and running costs were recorded. A total of 418 links was established for an overall duration of 458 hours. The participants included all departmental staff. Videoconferencing involved teaching, ward organization, medical care and scientific subjects. In the second year ofexperience, the number of videoconferencing links was higher than the first (232 vs 186). Link times were reasonable for both skilled and unskilled operators. Overall, the cost per minute of link was 0.2 Euro, and the mean cost per link was 13 Euros. Videoconferencing was integrated with fax and computer networks to enhance sharing paper and electronic documents. Audio-video technical problems progressively decreased: the link was definitively interrupted or its activation unfeasible in only 1.0% of cases. Our experience suggests that the establishment of a link between radiotherapy departments addressed to these aims is feasible by a videoconferencing network.

'One patient amongst many': a qualitative analysis of intensive care unit patients' experiences of transferring to the general ward

IntroductionMany patients experience 'relocation stress' when they are transferred from an intensive care unit (ICU) to step-down (high dependency) or general ward care, and much has been written about the psychological causes. This qualitative analysis of in-depth, narrative interviews with former ICU patients explores and examines patients' accounts in order to identify additional causes of relocation stress.MethodsForty former ICU patients were recruited throughout the UK, using maximum variation sampling, to achieve a broad range of experiences of intensive care. Interviews in people's homes were recorded on video and audio equipment as part of a study for the Database of Personal Experiences of Health and Illness (DIPEx) web resource. All interviews were transcribed, checked and returned to respondents. For this report, a qualitative thematic analysis was used to explore experiences of transfer.ResultsWe found that most people experienced relocation distress not only because of physical and emotional difficulties relating to their illness and treatment and the inevitable anxiety resulting from leaving a protected environment, but also from concrete, practical causes. These included specific concerns about communication, feeding, nursing care and support, as well as ward organization and environment. Written excerpts from the interviews and two video excerpts taken from the DIPEx website illustrate our findings.ConclusionWe conclude that there are several aspects of care that deserve further examination by researchers and service providers, and that not all of the factors associated with relocation stress should be seen as an inevitable consequence of the psychological adjustment involved in transfer from an ICU.

Properties of a Norwegian version of the Ward Organisational Features Scales

To assess the association between nurses' practice environment and established measures of discharged patients' experiences during hospitalisation it is necessary to have a validated instrument to collect data on nurses' work environment in hospital wards. The purpose of this study was to assess the reliability and validity of a Norwegian version of the Ward Organisational Features Scales (WOFS), an instrument developed in the UK to describe environmental factors influential on the effectiveness of nursing services. After linguistic adaptation of the questionnaire, the reliability and validity were assessed in a sample of 99 nurses, of whom 46 (45%) responded. Most of the 12 tested scales showed acceptable internal consistency (10 had Cronbach's alpha > 0.70) and test-retest reliability (eight had intraclass correlation coefficient >0.70). The WOFS scales' correlations with external variables were in line with hypothesised correlations, thus supporting their validity. Scales describing nurses' influence on ward organisation and management did not perform well, probably due to differences in intraward organisation in the two countries. In spite of a limited sample size this study suggests that the majority of the scales of the WOFS showed satisfactory psychometric properties. They can be useful for assessing and describing aspects of nurses' work environment in Norwegian hospitals.

Improving the quality of emergency care for children in developing countries

The paper by Molyneux et al. in this issue of the Bulletin contains several valuable lessons for health professionals in developing countries. (1) Beyond the specific technical content, it shows how problems in health service delivery can be solved successfully through a systematic process of quality improvement: identifying a specific problem, addressing that problem through simple, low-cost, locally available and effective solutions, and evaluating the approach. Molyneux et al. improved emergency care for children by providing training in emergency care and triage and improving patient flow and collaboration between inpatient and outpatient services. Emergency triage assessment and treatment (ETAT) was developed in Malawi, based upon and validated against the Advanced Paediatric Life Support course used as the standard training for paediatric emergencies in many developed countries. The ETAT course has been conducted as a 3 1/2-day training course in several resource-poor countries, and trainer of trainer courses have been held in the Africa and South-East Asia Regions. (2) The ETAT course materials have been translated into several languages. Similar emergency care guidelines have been used in Brazil. (3) Good quality emergency care can be the first step in improving hospital care for children, which is deficient in many countries. (3-5) Experience is accumulating from resource-poor countries: the management of cases of severe malnutrition, (6-8) pneumonia (9) and neonatal care (10) has been improved with better ward organization, clinical guidelines and staff participation. Quality improvement as a strategy has been used by several projects. In Nicaragua, the Russian Federation and South Africa, projects improving services for neonatal care have resulted in good outcomes ranging from immediate care of the newborn to a reduction in neonatal mortality. In Peru, a large-scale maternal and neonatal quality improvement project with self-identification of problems by the clinical teams, training, supervision and an accreditation system resulted in a range of improvements. (11) These included the availability of data on which to base clinical care, patient satisfaction, the availability of essential supplies, a participatory working approach and standardized care. Quality improvement depends on showing a discrepancy between the existing situation and desired standards. In Brazil, a hospital assessment tool was initially developed and field-tested with involvement of local professionals and concurrent data collection, assessment and planning of identified improvements. (11) This tool was the prototype for subsequent hospital assessments in countries such as Cambodia, Indonesia, Kazakhstan, Kenya, Solomon Islands and Timor Leste, where the findings were the basis for initiating hospital improvement activities. …

Four days in a strange place…

NHS research governance makes it almost impossible to collect certain kinds of data on the everyday life of hospitals and the experience of patients. Fortunately, those of us who get sick enough to be admitted can write about the experience without fear of regulation. This paper presents some observations on clinical ethics, ward organization and infection control that would have been difficult to obtain in any other way, but which illustrate the policy and information costs of the present system. While not personally recommending this as a research strategy, the paper identifies a growing evidence gap and comments on its implications for the delivery of humane and well-organized care.

Priority setting in clinical nursing practice: literature review.

Time is a valuable resource. When nurses experience demands on their services which exceed their available time, then 'rationing' must occur. In clinical practice such rationing requires practitioners to set priorities for care. The aim of this paper is establish what is currently known about priority setting in nursing, including how nurses set priorities and what factors influence this. CINAHL, Medline, ASSIA, and PsychLit databases for the years 1982-2002 were searched, using the terms (clinical decision-making or problem-solving or planning) and (setting priorities or prioriti*). The publications found were used in a selective, descriptive review. Priority setting is an important skill in nursing, and a skill deficit can have serious consequences for patients. Recent studies have suggested that it is a difficult skill for newly qualified nurses to acquire and may not be given sufficient attention in nurse education. Priority setting can be defined as the ordering of nursing problems using notions of urgency and/or importance, in order to establish a preferential order for nursing actions. A number of factors that may impact on priority setting have been identified in the literature. These include: the expertise of the nurse; the patient's condition; the availability of resources; ward organization; philosophies and models of care; the nurse-patient relationship; and the cognitive strategy used by the nurse to set priorities. However, very little empirical work has been conducted in this area. Further study of priority setting in a range of clinical practice settings is necessary. This could inform both practice and education, promote better use of limited resources and maximize patient outcomes.

Crowding and violence on psychiatric wards: explanatory models.

Violence is widely prevalent on acute-care psychiatric wards, and crowding has been identified as a major risk factor. This paper explores why patients may respond to crowding with violence. We carried out a literature review on Medline, using the key words "violence" and "crowding." We conducted an additional hand search of the references collected from the reviewed papers. Factors specific to the relation between crowding on acute-care inpatient psychiatric wards and violence can be divided under the following headings: 1) patient density, privacy, and control; 2) ward architecture; 3) the social organization of psychiatric wards; 4) interpersonal space; 5) phylogenic theories; and 6) anthropological theories of human behaviour. We offer explanatory models for this relation and suggest strategies to counter the effects of crowding. Recommendations are made for future studies.

Collaborative record keeping: a review

Much has been written about the importance of integrative professional documentation. However, a review of the literature indicates that this approach requires careful consideration as it involves a radical change in ward organization and it is not quantifiably supported in terms of positive patient outcomes.

Hospital nurses' job satisfaction, individual and organizational characteristics.

Hospital nurses' job satisfaction, individual and organizational characteristics Using the Ward Organizational Features Scales (WOFS), relationships between aspects of the organization of acute hospital wards, nurses' personal characteristics and nurses' job satisfaction are examined among a nationally representative sample of 834 nurses in England. The analysis contributes to a growing body of evidence demonstrating the importance of interpersonal relationships to nurses' job satisfaction. In particular, the positive contribution of the cohesiveness of ward nursing staff is highlighted, but the potential for many current NHS staffing strategies and work environments to undermine the development of cohesive working relationships is also noted. Other influential factors are nurses' relationships with medical staff, perceptions of their workload and their evaluation of the appropriateness of the system of nursing being practised. The importance of measuring nurses' subjective assessments of their work environment is emphasized. A weak association was found between grade and job satisfaction. Individual nurse characteristics were found not to be associated with job satisfaction.

Nursing organizational practice and its relationship with other features of ward organization and job satisfaction.

This paper describes a new classification of ward organizational practice in nursing. Data related to aspects of ward nursing practice were collected by postal survey from a nationally representative sample of 74 acute hospital wards, and subjected to hierarchical cluster analysis. The model which was deemed to best 'fit' the data, provided three types of ward practices, which have been named: 'devolved', 'two tier' and 'centralized' nursing. The distinguishing features of the three classifications are similar but not identical to accepted 'ideal types' of primary, team and functional systems. The relationships between wards in each of the three identified categories and other ward organizational practice processes of nursing care and job satisfaction are described.

Reimbursement budgets and treatment demands require cost saving--a short operations day as a possible solution in the hospital

Implementation of case related budgeting (similar to diagnosis related groups) has forced hospitals into more cost efficient management particularly with respect to surgery. Efforts to increase efficiency are concentrated on the labor intensive organization of the surgical ward. Operations of short duration are a major focal point. An analysis of the organizational structure of our hospital showed that significant improvement in operating theater management and utilization can be achieved in order to improve efficiency. A new pilot project was tested for economic efficiency. On eleven specified surgery days (129 patients) only short operations with a duration of less than 20 min were allowed (tonsillectomy, adenectomy, etc.). On each day 15 operations were performed in one operating room with two anesthesiology teams and one surgery team. This type of "short-operation day" was compared with a "regular" surgery day with two operating rooms, two anesthesiology teams, and two surgery teams. Efficiency, complication rates, economic outcome, and patient satisfaction were assessed. Due to reduction of staff and a more efficient organization, we were able to reduce the costs for staff and the operating theater maintenance from DM 378,20 to DM 243,90 for each operation. Additionally, only one operating room was required instead of two. Complication rates (postoperative bleeding) were lower than before and patient acceptance and satisfaction was remarkable. Economic efficiency of short operations could be increased by organizational restricturing. The quality of the operations and the patients' satisfaction did not decrease.

The importance of ward atmosphere in inpatient treatment of schizophrenia on short-term units.

The reorganization in 1981 of a general hospital psychiatric ward in Oslo, Norway, to achieve a more suitable treatment milieu for patients with schizophrenia resulted in a change in patients' perceptions of the ward atmosphere. Reduced group participation and increased individualized support from staff led patients to perceive of the ward as having a low level of anger and aggression and a high level of order and organization. This study examined whether the reorganization was associated with improved treatment outcome. Psychiatrists retrospectively examined the charts of all patients with a DSM-III-R diagnosis of schizophrenia or schizophreniform disorder who were admitted to the ward the year before and the second year after the reorganization. Multiple regression analyses were used to examine treatment outcomes for both groups. Outcome was measured indirectly by length of stay, level of functioning at discharge, and whether the patient was rehospitalized during the following seven years. Patients treated after the reorganization had significantly shorter stays with no reductions in either level of functioning at discharge or length of community tenure after discharge. Differences in demographic characteristics, illness history, or psychopharmacological treatment could not account for differences in outcome. The results supported the hypothesis that the organization and milieu of brief-stay wards influence the short-term outcome of inpatient treatment of patients with schizophrenia.

Stroke units: centres of nursing innovation.

The results of a survey of stroke units in the English regions of the NHS are reviewed. A total of 43 units were identified and contacted of which 34 responded. The article briefly discusses the nature and development of stroke units and considers features of stroke units that reflect the level of nursing development such as ward nursing philosophy, model of nursing used, method of ward organization, unit manpower and educational attainment. The overall results indicate that the respondent units have achieved a high level of development which has, until now, gone generally unnoticed.

Obtaining Patients' Views of Nursing Care to Inform the Development of a Patient Satisfaction Scale

Patient satisfaction is increasingly being measured as an indication of the effectiveness of nursing care. At present, however, there are no validated UK scales available specifically addressed to nursing. The aim of the present study was to develop a sensitive, valid and reliable measure of patient satisfaction. This paper describes the first phase of the study, the development of a multidimensional concept of satisfaction from the patients' perspective. Using qualitative methods, patients were interviewed both in hospital and following discharge. Eleven main concepts were identified: nurses' manner, attentiveness, availability, reassurance, individual treatment, openness/informality, information, professionalism, ward organization, nurses' knowledge and ward environment. Beginning with customer-defined values has provided the starting point for the development of a scale to measure patients' satisfaction with nursing using concepts important to patients, rather than hospital personnel or research teams.