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1.  Associations between Stroke Mortality and Weekend Working by Stroke Specialist Physicians and Registered Nurses: Prospective Multicentre Cohort Study 
PLoS Medicine  2014;11(8):e1001705.
In a multicenter observational study, Benjamin Bray and colleagues evaluate whether weekend rounds by stroke specialist physicians, or the ratio of registered nurses to beds on weekends, is associated with patient mortality after stroke.
Please see later in the article for the Editors' Summary
Observational studies have reported higher mortality for patients admitted on weekends. It is not known whether this “weekend effect” is modified by clinical staffing levels on weekends. We aimed to test the hypotheses that rounds by stroke specialist physicians 7 d per week and the ratio of registered nurses to beds on weekends are associated with mortality after stroke.
Methods and Findings
We conducted a prospective cohort study of 103 stroke units (SUs) in England. Data of 56,666 patients with stroke admitted between 1 June 2011 and 1 December 2012 were extracted from a national register of stroke care in England. SU characteristics and staffing levels were derived from cross-sectional survey. Cox proportional hazards models were used to estimate hazard ratios (HRs) of 30-d post-admission mortality, adjusting for case mix, organisational, staffing, and care quality variables. After adjusting for confounders, there was no significant difference in mortality risk for patients admitted to a stroke service with stroke specialist physician rounds fewer than 7 d per week (adjusted HR [aHR] 1.04, 95% CI 0.91–1.18) compared to patients admitted to a service with rounds 7 d per week. There was a dose–response relationship between weekend nurse/bed ratios and mortality risk, with the highest risk of death observed in stroke services with the lowest nurse/bed ratios. In multivariable analysis, patients admitted on a weekend to a SU with 1.5 nurses/ten beds had an estimated adjusted 30-d mortality risk of 15.2% (aHR 1.18, 95% CI 1.07–1.29) compared to 11.2% for patients admitted to a unit with 3.0 nurses/ten beds (aHR 0.85, 95% CI 0.77–0.93), equivalent to one excess death per 25 admissions. The main limitation is the risk of confounding from unmeasured characteristics of stroke services.
Mortality outcomes after stroke are associated with the intensity of weekend staffing by registered nurses but not 7-d/wk ward rounds by stroke specialist physicians. The findings have implications for quality improvement and resource allocation in stroke care.
Please see later in the article for the Editors' Summary
Editors' Summary
In a perfect world, a patient admitted to hospital on a weekend or during the night should have as good an outcome as a patient admitted during regular working hours. But several observational studies (investigations that record patient outcomes without intervening in any way; clinical trials, by contrast, test potential healthcare interventions by comparing the outcomes of patients who are deliberately given different treatments) have reported that admission on weekends is associated with a higher mortality (death) rate than admission on weekdays. This “weekend effect” has led to calls for increased medical and nursing staff to be available in hospitals during the weekend and overnight to ensure that the healthcare provided at these times is of equal quality to that provided during regular working hours. In the UK, for example, “seven-day working” has been identified as a policy and service improvement priority for the National Health Service.
Why Was This Study Done?
Few studies have actually tested the relationship between patient outcomes and weekend physician or nurse staffing levels. It could be that patients who are admitted to hospital on the weekend have poor outcomes because they are generally more ill than those admitted on weekdays. Before any health system introduces potentially expensive increases in weekend staffing levels, better evidence that this intervention will improve patient outcomes is needed. In this prospective cohort study (a study that compares the outcomes of groups of people with different baseline characteristics), the researchers ask whether mortality after stroke is associated with weekend working by stroke specialist physicians and registered nurses. Stroke occurs when the brain's blood supply is interrupted by a blood vessel in the brain bursting (hemorrhagic stroke) or being blocked by a blood clot (ischemic stroke). Swift treatment can limit the damage to the brain caused by stroke, but of the 15 million people who have a stroke every year, about 6 million die within a few hours and another 5 million are left disabled.
What Did the Researchers Do and Find?
The researchers extracted clinical data on 56,666 patients who were admitted to stroke units in England over an 18-month period from a national stroke register. They obtained information on the characteristics and staffing levels of the stroke units from a biennial survey of hospitals admitting patients with stroke, and information on deaths among patients with stroke from the national register of deaths. A quarter of the patients were admitted on a weekend, almost half the stroke units provided stroke specialist physician rounds seven days per week, and the remainder provided rounds five days per week. After adjustment for factors that might have affected outcomes (“confounders”) such as stroke severity and the level of acute stroke care available in each stroke unit, there was no significant difference in mortality risk between patients admitted to a stroke unit with rounds seven days/week and patients admitted to a unit with rounds fewer than seven days/week. However, patients admitted on a weekend to a stroke unit with 1.5 nurses/ten beds had a 30-day mortality risk of 15.2%, whereas patients admitted to a unit with 3.0 nurses/ten beds had a mortality risk of 11.2%, a mortality risk difference equivalent to one excess death per 25 admissions.
What Do These Findings Mean?
These findings show that the provision of stroke specialist physician rounds seven days/week in stroke units in England did not influence the (weak) association between weekend admission for stroke and death recorded in this study, but mortality outcomes after stroke were associated with the intensity of weekend staffing by registered nurses. The accuracy of these findings may be affected by the measure used to judge the level of acute care available in each stroke unit and by residual confounding. For example, patients admitted to units with lower nursing levels may have shared other unknown characteristics that increased their risk of dying after stroke. Moreover, this study considered the impact of staffing levels on mortality only and did not consider other relevant outcomes such as long-term disability. Despite these limitations, these findings support the provision of higher weekend ratios of registered nurses to beds in stroke units, but given the high costs of increasing weekend staffing levels, it is important that controlled trials of different models of physician and nursing staffing are undertaken as soon as possible.
Additional Information
Please access these websites via the online version of this summary at
This study is further discussed in a PLOS Medicine Perspective by Meeta Kerlin
Information about plans to introduce seven-day working into the National Health Service in England is available; the 2013 publication “NHS Services—Open Seven Days a Week: Every Day Counts” provides examples of how hospitals across England are working together to provide routine healthcare services seven days a week; a “Behind the Headlines” article on the UK National Health Service Choices website describes a recent observational study that investigated the association between admission to hospital on the weekend and death, and newspaper coverage of the study's results; the Choices website also provides information about stroke for patients and their families, including personal stories
A US nurses' site includes information on the association of nurse staffing with patient safety
The US National Institute of Neurological Disorders and Stroke provides information about all aspects of stroke (in English and Spanish); its Know Stroke site provides educational materials about stroke prevention, treatment, and rehabilitation, including personal stories (in English and Spanish); the US National Institute of Health SeniorHealth website has additional information about stroke
The Internet Stroke Center provides detailed information about stroke for patients, families, and health professionals (in English and Spanish)
PMCID: PMC4138029  PMID: 25137386
2.  Sleep and recovery in physicians on night call: a longitudinal field study 
It is well known that physicians' night-call duty may cause impaired performance and adverse effects on subjective health, but there is limited knowledge about effects on sleep duration and recovery time. In recent years occupational stress and impaired well-being among anaesthesiologists have been frequently reported for in the scientific literature. Given their main focus on handling patients with life-threatening conditions, when on call, one might expect sleep and recovery to be negatively affected by work, especially in this specialist group. The aim of the present study was to examine whether a 16-hour night-call schedule allowed for sufficient recovery in anaesthesiologists compared with other physician specialists handling less life-threatening conditions, when on call.
Sleep, monitored by actigraphy and Karolinska Sleep Diary/Sleepiness Scale on one night after daytime work, one night call, the following first and second nights post-call, and a Saturday night, was compared between 15 anaesthesiologists and 17 paediatricians and ear, nose, and throat surgeons.
Recovery patterns over the days after night call did not differ between groups, but between days. Mean night sleep for all physicians was 3 hours when on call, 7 h both nights post-call and Saturday, and 6 h after daytime work (p < 0.001). Scores for mental fatigue and feeling well rested were poorer post-call, but returned to Sunday morning levels after two nights' sleep.
Despite considerable sleep loss during work on night call, and unexpectedly short sleep after ordinary day work, the physicians' self-reports indicate full recovery after two nights' sleep. We conclude that these 16-hour night duties were compatible with a short-term recovery in both physician groups, but the limited sleep duration in general still implies a long-term health concern. These results may contribute to the establishment of safe working hours for night-call duty in physicians and other health-care workers.
PMCID: PMC2928216  PMID: 20712854
3.  Rotating Night Shift Work and Risk of Type 2 Diabetes: Two Prospective Cohort Studies in Women 
PLoS Medicine  2011;8(12):e1001141.
An Pan and colleagues examined data from two Nurses' Health Studies and found that extended periods of rotating night shift work were associated with a modestly increased risk of type 2 diabetes, partly mediated through body weight.
Rotating night shift work disrupts circadian rhythms and has been associated with obesity, metabolic syndrome, and glucose dysregulation. However, its association with type 2 diabetes remains unclear. Therefore, we aimed to evaluate this association in two cohorts of US women.
Methods and Findings
We followed 69,269 women aged 42–67 in Nurses' Health Study I (NHS I, 1988–2008), and 107,915 women aged 25–42 in NHS II (1989–2007) without diabetes, cardiovascular disease, and cancer at baseline. Participants were asked how long they had worked rotating night shifts (defined as at least three nights/month in addition to days and evenings in that month) at baseline. This information was updated every 2–4 years in NHS II. Self-reported type 2 diabetes was confirmed by a validated supplementary questionnaire. We documented 6,165 (NHS I) and 3,961 (NHS II) incident type 2 diabetes cases during the 18–20 years of follow-up. In the Cox proportional models adjusted for diabetes risk factors, duration of shift work was monotonically associated with an increased risk of type 2 diabetes in both cohorts. Compared with women who reported no shift work, the pooled hazard ratios (95% confidence intervals) for participants with 1–2, 3–9, 10–19, and ≥20 years of shift work were 1.05 (1.00–1.11), 1.20 (1.14–1.26), 1.40 (1.30–1.51), and 1.58 (1.43–1.74, p-value for trend <0.001), respectively. Further adjustment for updated body mass index attenuated the association, and the pooled hazard ratios were 1.03 (0.98–1.08), 1.06 (1.01–1.11), 1.10 (1.02–1.18), and 1.24 (1.13–1.37, p-value for trend <0.001).
Our results suggest that an extended period of rotating night shift work is associated with a modestly increased risk of type 2 diabetes in women, which appears to be partly mediated through body weight. Proper screening and intervention strategies in rotating night shift workers are needed for prevention of diabetes.
Please see later in the article for the Editors' Summary
Editors' Summary
Around 346 million people worldwide have diabetes—a chronic disease affecting blood glucose levels, which over time may lead to serious damage in many body systems. In 2004, an estimated 3.4 million people died from consequences of high blood sugar, with more than 80% of deaths occurring in low-and middle-income countries. Type 2 diabetes accounts for 90% of people with diabetes and is largely the result of excess body weight and physical inactivity, which causes the body to use insulin ineffectively. One strategy in the public health response to the increasing prevalence and incidence of type 2 diabetes is to focus on the prevention and management of obesity by targeting risk factors of obesity.
Previous studies have suggested that rotating night shift work, which is common and becoming increasingly prevalent in countries worldwide, is associated with an increased risk of obesity and metabolic syndrome, conditions closely related to type 2 diabetes.
Why Was This Study Done?
Some studies have investigated the association between rotating night shift work and type 2 diabetes but have experienced methodological problems (such as minimal information on the rotating shift work, small sample sizes, and limited study populations), which make interpretation of the results difficult. In this study, the researchers attempted to overcome these methodological issues by prospectively examining the relationship between duration of rotating night shift work and risk of incident type 2 diabetes and, also if the duration of shift work was associated with greater weight gain, in two large cohorts of women in the United States.
What Did the Researchers Do and Find?
The researchers used data from the Nurses' Health Study I (NHS I, established in 1976 and included 121,704 women) and the Nurses' Health Study II (NHS II, established in 1989 and included 116,677 women), in which participating women completed regular questionnaires about their lifestyle practices and the development of chronic diseases. In both studies, the women also gave information about how long they had done rotating night shifts work (defined as at least three nights/month in addition to 19 days and evenings in that month), and this information was updated at regular intervals over the study follow-up period (18 years). The comparison group was women who did not report a history of rotating night shift work.
To assess the incidence of diabetes in both cohorts, the researchers sent a supplementary questionnaire to women who reported a diagnosis of diabetes, which asked about the symptoms, diagnostic tests, and medical management: if at least one of the National Diabetes Data Group criteria was reported, the researchers considered confirmed a diagnosis of type 2 diabetes. The researchers then used statistical methods (time-dependent Cox proportional hazards models) to estimate the hazard ratios of the chance of women working rotating shifts developing type 2 diabetes as a ratio of the chance of women not working rotating shifts developing diabetes.
The researchers found that in NHS I, 6,165 women developed type 2 diabetes and in NHS II 3,961 women developed type 2 diabetes. Using their statistical models, the researchers found that the duration of rotating night shift work was strongly associated with an increased risk of type 2 diabetes in both cohorts. The researchers found that in both cohorts, compared with women who reported no rotating night shift work, the HR of women developing type 2 diabetes, increased with the numbers of years working rotating shifts (the HRs of working rotating shifts for 1–2, 3–9, 10–19, and ≥20 years were 0.99, 1.17, 1.42, and 1.64, respectively, in NHS I, and in NHS II, 1.13, 1.34, 1.76, and 2.50, respectively). However, these associations were slightly weaker after the authors took other factors into consideration, except for body mass index (BMI).
What Do These Findings Mean?
These findings show that in these women, there is a positive association between rotating night shift work and the risk of developing type 2 diabetes. Furthermore, long duration of shift work may also be associated with greater weight gain. Although these findings need to be confirmed in men and other ethnic groups, because a large proportion of the working population is involved in some kind of permanent night and rotating night shift work, these findings are of potential public health significance. Additional preventative strategies in rotating night shift workers should therefore be considered.
Additional Information
Please access these Web sites via the online version of this summary at
This study is further discussed in a PLoS Medicine Perspective by Mika Kivimki and colleagues
Wikipedia has information about the Nurses’ Health study (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
Detailed information about the Nurses’ Health Study is available
The World Health Organization provides comprehensive information about all kinds of diabetes
For more information about diabetes that is useful for patients see Diabetes UK
PMCID: PMC3232220  PMID: 22162955
4.  Recognition of cognitive impairment by day and night nursing staff among acute geriatric patients. 
The recognition of cognitive impairment by day and night nursing staff was studied in an acute geriatric unit. Seventy-six patients were randomly selected from a prospective sample of admissions. DSM-III-R diagnoses were established on all patients. Day and night staff were interviewed about each patient's clinical condition and asked to state whether or not they thought they were cognitively impaired or confused. Day staff were reasonably good at differentiating cognitively unimpaired from those with dementia and or delirium [kappa = 0.62, 95% confidence interval (CI) = 0.46-0.78]. All patients thought by day staff to be cognitively impaired were found to be so, although day staff did fail to identify some patients with cognitive impairment. Night staff performed less well (kappa = 0.37, 95% CI 0.18-0.57) and identified cognitively normal patients as being cognitively impaired, as well as failing to identify patients who were cognitively impaired. Night nursing interviews were not thought to have contributed to the management of any patient. The usefulness of night-time nursing interviews for research and general inpatient management purposes is questioned and the importance of daytime nursing interviews emphasized.
PMCID: PMC1295162  PMID: 7745564
5.  Rotating night shifts too quickly may cause anxiety and decreased attentional performance, and impact prolactin levels during the subsequent day: a case control study 
BMC Psychiatry  2014;14(1):218.
We investigated circadian changes and effects on mood, sleep-related hormones and cognitive performance when nurses worked consecutive night shifts in a rapidly rotating shift system. Daytime cognitive function, sleep propensity and sleep-related hormones (growth hormone, cortisol, prolactin, thyrotropin) were compared after participants worked two and four consecutive night shifts.
Twenty-three off-duty nurses, 20 nurses working two consecutive night shifts and 16 nurses working four consecutive night shifts were enrolled. All participants completed the Maintenance of Wakefulness Test, State-Trait Anxiety Inventory, Stanford Sleepiness Scale, visual attention tasks (VAT), Wisconsin Card Sorting Test, and modified Multiple Sleep Latency Test. Hormone levels were also measured four times throughout the day, at 2-h intervals.
During the day, the participants in the night shift groups were less able to maintain wakefulness, had poor performance on VAT, and higher thyrotropin levels than did those in the off-duty group. Participants who worked two night shifts were better able to maintain wakefulness, had higher anxiety scale scores, poorer initial performance and lack of learning effect on VAT, and higher prolactin levels compared with those who worked four night shifts. There were no differences in cortisol levels between the two- and four- shift groups.
Rotating night shifts too quickly may cause anxiety and decreased attentional performance, and may impact daytime prolactin levels after night shifts. It is possible that the two-shift group had a higher cortisol level than did the four-shift group, which would be consistent with the group’s higher state anxiety scores. The negative findings may be due to the small sample size. Further studies on the effects of consecutive night shifts on mood and cortisol levels during the daytime after sleep restriction would be valuable.
PMCID: PMC4141954  PMID: 25091387
Anxiety; Cognitive function; Nurse; Night shift; Sleep-related hormone; Circadian; Shift work
6.  Nurses’ lifestyle behaviours, health priorities and barriers to living a healthy lifestyle: a qualitative descriptive study 
BMC Nursing  2014;13(1):38.
Nurses have an increased risk for non-communicable diseases (NCDs), along with a high prevalence of obesity, poor eating habits and insufficient physical activity. The aim of this study was to determine the health concerns, health priorities and barriers to living a healthy lifestyle among nurses and hospital management staff from public hospitals in the Western Cape Metropole, South Africa.
Participants were purposively sampled (n = 103), and included management personnel (n = 9), night shift (n = 57) and day-shift nurses (n = 36). Twelve focus groups (FGDs) were conducted with nursing staff to obtain insight into nurses’ health concerns, lifestyle behaviours and worksite health promotion programmes (WHPPs). Seven key informant interviews (KII) were conducted with management personnel, to gain their perspective on health promotion in the worksite. Thematic analysis was used to analyse the data with the assistance of Atlas.ti Qualitative Data Analysis Software.
Night shift nurses frequently identified weight gain and living with NCDs such as hypertension as their main health concerns. Being overweight was perceived to have a negative impact on work performance. All nurses identified backache and exposure to tuberculosis (TB) as occupation-related health concerns, and both management and nurses frequently reported a stressful working environment. Nurses frequently mentioned lack of time to prepare healthy meals due to long working hours and being overtired from work. The hospital environment was perceived to have a negative influence on the nurses’ lifestyle behaviours, including food service that offered predominantly unhealthy foods. The most commonly delivered WHPPs included independent counselling services, an online employee wellness programme offered by the Department of Health and wellness days in which clinical measures, such as blood glucose were measured. Nurses identified a preference for WHPPs that provided access to fitness facilities or support groups.
Public hospitals are a stressful work environment and shift work places an additional strain on nurses. The risk of NCDs and exposure to infectious disease remains a concern in this working population. Our findings highlight the need for WHPPs that support nurses in managing stress and transforming the work environment to facilitate healthy lifestyles.
PMCID: PMC4264254  PMID: 25506262
Nurses’ health; Lifestyle behaviours; Perceptions; Shift workers
7.  Associations Between Night Work and Anxiety, Depression, Insomnia, Sleepiness and Fatigue in a Sample of Norwegian Nurses 
PLoS ONE  2013;8(8):e70228.
Night work has been reported to be associated with various mental disorders and complaints. We investigated relationships between night work and anxiety, depression, insomnia, sleepiness and fatigue among Norwegian nurses.
The study design was cross-sectional, based on validated self-assessment questionnaires. A total of 5400 nurses were invited to participate in a health survey through the Norwegian Nurses' Organization, whereof 2059 agreed to participate (response rate 38.1%). Nurses completed a questionnaire containing items on demographic variables (gender, age, years of experience as a nurse, marital status and children living at home), work schedule, anxiety/depression (Hospital Anxiety and Depression Scale), insomnia (Bergen Insomnia Scale), sleepiness (Epworth Sleepiness Scale) and fatigue (Fatigue Questionnaire). They were also asked to report number of night shifts in the last 12 months (NNL). First, the parameters were compared between nurses i) never working nights, ii) currently working nights, and iii) previously working nights, using binary logistic regression analyses. Subsequently, a cumulative approach was used investigating associations between NNL with the continuous scores on the same dependent variables in hierarchical multiple regression analyses.
Nurses with current night work were more often categorized with insomnia (OR = 1.48, 95% CI = 1.10–1.99) and chronic fatigue (OR = 1.78, 95% CI = 1.02–3.11) than nurses with no night work experience. Previous night work experience was also associated with insomnia (OR = 1.45, 95% CI = 1.04–2.02). NNL was not associated with any parameters in the regression analyses.
Nurses with current or previous night work reported more insomnia than nurses without any night work experience, and current night work was also associated with chronic fatigue. Anxiety, depression and sleepiness were not associated with night work, and no cumulative effect of night shifts during the last 12 months was found on any parameters.
PMCID: PMC3737208  PMID: 23950914
8.  ‘Letting Go’: delegating responsibility for non-clinical tasks in a telehealth service 
The implementation of telehealth into the delivery of chronic conditions management within Hywel Dda Health Board has provided an opportunity to enhance close working relationships with Carmarthenshire County Council’s well-established telecare team. The responsibilities of the telecare team were initially limited to the installation and removal of telehealth devices in patients’ homes and training on its use but as the use of telehealth has widened, an increasing number of non-clinical tasks, several of which were previously undertaken by clinical staff, have been delegated to members of the telecare team and linked to the monitoring centre. In addition, all the tasks associated with managing and administering the patients on the telehealth system backend are undertaken by the chronic conditions management administrative support team within the Health Board.
Aims and objectives
This presentation will describe our experience of bringing together clinical and non-clinical staff from two separate organisations to deliver a more appropriate, comprehensive and timely telehealth service to patients. It will explain how strong working relationships have developed, the importance of a clear understanding of different roles within the team and the need for building trust and confidence in colleagues, resulting in the clinical nurse specialists ‘letting go’ and responding to change that supports effective monitoring and still providing quality care. We will report on the lessons learned during the process, from both staff groups’ perspectives and the patient’s perspective, as tasks previously undertaken by clinicians have shifted to non-clinical staff.
Our current approach to telehealth has evolved into a model which ensures that the specialist nursing team are able to focus solely on delivering quality clinical care enabled and supported by telehealth where appropriate. All the non-clinical tasks are now undertaken by the telecare team staff and chronic conditions management administrative support and include:
Installing devices in patients’ homes and providing education and training
First-line monitoring/triage of uploaded patient data Escalation of clinical alerts to nursing team by Telephone
Resolving technical alerts and missing uploads/data
Provision of refresher training to patients as required (telephone-based or face-to-face)
Responding to patient or nurse-reported technical problems, including battery/faulty device replacement
Providing advice on home set-up e.g., recommending changes
System administrator, patient administration and management function of backend
The results of patient and staff questionnaires seeking feedback on our model will be given together with an economic evaluation comparing the current approach, which utilises telecare and specialist staff to deliver the service compared to the previous delivery model using specialist nursing staff only. We will also show that through embedding telehealth into a well-established community specialist nursing service has the following impact and outcomes:
Patients to take more responsibility for their day-to-day care
Nurses to monitor patients remotely and contact those who need support reducing the number if inappropriate home visits
Reducing travelling for the nursing service
Improving relationships between patient and nurse
Supporting carers
We have embedded our telehealth service into existing service models which have now been enhanced utilising a partnership approach and ensuring the best use of the skills and expertise, across the organisations involved. This has been a key factor in developing an efficient, effective and sustainable approach.
PMCID: PMC3571134
partnership; comprehensive; timely telehealth service
9.  Junior doctor titles following implementation of Modernising Medical Careers in the UK 
JRSM Short Reports  2011;2(3):22.
Recent changes in postgraduate medical training in the UK collectively organized under the auspices of Modernising Medical Careers (MMC) have created new labels for junior doctors in training. It would appear that many nurses and other health workers do not understand the new terminology. We aimed to investigate the knowledge of nursing staff about new junior doctor titles in a district general hospital. As far as we are aware, this is the first survey to determine the views and knowledge of the new terms among staff working in the NHS.
Questionnaire study.
District general hospital, West Midlands, UK.
Fifty-five randomly selected staff nurses working in the surgical directorate.
Main outcome measure
Questions were asked about their views and knowledge of the current nomenclature. To objectively assess knowledge of the new titles respondents were asked to match equivalent positions with those based on the old system.
Only 22% (n = 12) of respondents felt that they fully understand current terms in usage. Seventy-six percent (n = 42) felt that it was ‘very important’ that titles accurately convey role and seniority of the doctor. The most common titles correctly matched were FY1 and House Officer (n = 45, 81%) and FY2 and First Year Senior House Officer (n = 35, 64%). Only 9% (n = 5) of staff nurses correctly matched ST3 to Junior Registrar and 13% (n = 7) correctly matched ST7 to Senior Registrar. Ward-based staff nurses demonstrated greater familiarity with titles when compared to nurses who work mainly in the outpatient clinic and theatre setting (p = 0.017). We did not identify a statistically significant association with demographic characteristics (age, gender, experience) and knowledge of the new terms (p > 0.05). Approximately 98% (n = 54) of the staff surveyed felt that terms are confusing to nurses and need to be simplified.
Our survey revealed that nursing staff lacked knowledge of the current terminology to describe doctors in training. This may have implications for staff expectations regarding specific role of junior doctor in terms of clinical decision-making, working relationships and communication between team members, and ultimately patient care.
PMCID: PMC3086326  PMID: 21541090
10.  Job stress and job satisfaction of physicians, radiographers, nurses and physicists working in radiotherapy: a multicenter analysis by the DEGRO Quality of Life Work Group 
Ongoing changes in cancer care cause an increase in the complexity of cases which is characterized by modern treatment techniques and a higher demand for patient information about the underlying disease and therapeutic options. At the same time, the restructuring of health services and reduced funding have led to the downsizing of hospital care services. These trends strongly influence the workplace environment and are a potential source of stress and burnout among professionals working in radiotherapy.
Methods and patients
A postal survey was sent to members of the workgroup "Quality of Life" which is part of DEGRO (German Society for Radiooncology). Thus far, 11 departments have answered the survey. 406 (76.1%) out of 534 cancer care workers (23% physicians, 35% radiographers, 31% nurses, 11% physicists) from 8 university hospitals and 3 general hospitals completed the FBAS form (Stress Questionnaire of Physicians and Nurses; 42 items, 7 scales), and a self-designed questionnaire regarding work situation and one question on global job satisfaction. Furthermore, the participants could make voluntary suggestions about how to improve their situation.
Nurses and physicians showed the highest level of job stress (total score 2.2 and 2.1). The greatest source of job stress (physicians, nurses and radiographers) stemmed from structural conditions (e.g. underpayment, ringing of the telephone) a "stress by compassion" (e.g. "long suffering of patients", "patients will be kept alive using all available resources against the conviction of staff"). In multivariate analyses professional group (p < 0.001), working night shifts (p = 0.001), age group (p = 0.012) and free time compensation (p = 0.024) gained significance for total FBAS score. Global job satisfaction was 4.1 on a 9-point scale (from 1 – very satisfied to 9 – not satisfied). Comparing the total stress scores of the hospitals and job groups we found significant differences in nurses (p = 0.005) and physicists (p = 0.042) and a borderline significance in physicians (p = 0.052).
In multivariate analyses "professional group" (p = 0.006) and "vocational experience" (p = 0.036) were associated with job satisfaction (cancer care workers with < 2 years of vocational experience having a higher global job satisfaction). The total FBAS score correlated with job satisfaction (Spearman-Rho = 0.40; p < 0.001).
Current workplace environments have a negative impact on stress levels and the satisfaction of radiotherapy staff. Identification and removal of the above-mentioned critical points requires various changes which should lead to the reduction of stress.
PMCID: PMC2661891  PMID: 19200364
11.  Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety 
Long working hours and sleep deprivation have been a facet of physician training in the US since the advent of the modern residency system. However, the scientific evidence linking fatigue with deficits in human performance, accidents and errors in industries from aeronautics to medicine, nuclear power, and transportation has mounted over the last 40 years. This evidence has also spawned regulations to help ensure public safety across safety-sensitive industries, with the notable exception of medicine.
In late 2007, at the behest of the US Congress, the Institute of Medicine embarked on a year-long examination of the scientific evidence linking resident physician sleep deprivation with clinical performance deficits and medical errors. The Institute of Medicine’s report, entitled “Resident duty hours: Enhancing sleep, supervision and safety”, published in January 2009, recommended new limits on resident physician work hours and workload, increased supervision, a heightened focus on resident physician safety, training in structured handovers and quality improvement, more rigorous external oversight of work hours and other aspects of residency training, and the identification of expanded funding sources necessary to implement the recommended reforms successfully and protect the public and resident physicians themselves from preventable harm.
Given that resident physicians comprise almost a quarter of all physicians who work in hospitals, and that taxpayers, through Medicare and Medicaid, fund graduate medical education, the public has a deep investment in physician training. Patients expect to receive safe, high-quality care in the nation’s teaching hospitals. Because it is their safety that is at issue, their voices should be central in policy decisions affecting patient safety. It is likewise important to integrate the perspectives of resident physicians, policy makers, and other constituencies in designing new policies. However, since its release, discussion of the Institute of Medicine report has been largely confined to the medical education community, led by the Accreditation Council for Graduate Medical Education (ACGME).
To begin gathering these perspectives and developing a plan to implement safer work hours for resident physicians, a conference entitled “Enhancing sleep, supervision and safety: What will it take to implement the Institute of Medicine recommendations?” was held at Harvard Medical School on June 17–18, 2010. This White Paper is a product of a diverse group of 26 representative stakeholders bringing relevant new information and innovative practices to bear on a critical patient safety problem. Given that our conference included experts from across disciplines with diverse perspectives and interests, not every recommendation was endorsed by each invited conference participant. However, every recommendation made here was endorsed by the majority of the group, and many were endorsed unanimously. Conference members participated in the process, reviewed the final product, and provided input before publication. Participants provided their individual perspectives, which do not necessarily represent the formal views of any organization.
In September 2010 the ACGME issued new rules to go into effect on July 1, 2011. Unfortunately, they stop considerably short of the Institute of Medicine’s recommendations and those endorsed by this conference. In particular, the ACGME only applied the limitation of 16 hours to first-year resident physicans. Thus, it is clear that policymakers, hospital administrators, and residency program directors who wish to implement safer health care systems must go far beyond what the ACGME will require. We hope this White Paper will serve as a guide and provide encouragement for that effort.
Resident physician workload and supervision
By the end of training, a resident physician should be able to practice independently. Yet much of resident physicians’ time is dominated by tasks with little educational value. The caseload can be so great that inadequate reflective time is left for learning based on clinical experiences. In addition, supervision is often vaguely defined and discontinuous. Medical malpractice data indicate that resident physicians are frequently named in lawsuits, most often for lack of supervision. The recommendations are: The ACGME should adjust resident physicians workload requirements to optimize educational value. Resident physicians as well as faculty should be involved in work redesign that eliminates nonessential and noneducational activity from resident physician dutiesMechanisms should be developed for identifying in real time when a resident physician’s workload is excessive, and processes developed to activate additional providersTeamwork should be actively encouraged in delivery of patient care. Historically, much of medical training has focused on individual knowledge, skills, and responsibility. As health care delivery has become more complex, it will be essential to train resident and attending physicians in effective teamwork that emphasizes collective responsibility for patient care and recognizes the signs, both individual and systemic, of a schedule and working conditions that are too demanding to be safeHospitals should embrace the opportunities that resident physician training redesign offers. Hospitals should recognize and act on the potential benefits of work redesign, eg, increased efficiency, reduced costs, improved quality of care, and resident physician and attending job satisfactionAttending physicians should supervise all hospital admissions. Resident physicians should directly discuss all admissions with attending physicians. Attending physicians should be both cognizant of and have input into the care patients are to receive upon admission to the hospitalInhouse supervision should be required for all critical care services, including emergency rooms, intensive care units, and trauma services. Resident physicians should not be left unsupervised to care for critically ill patients. In settings in which the acuity is high, physicians who have completed residency should provide direct supervision for resident physicians. Supervising physicians should always be physically in the hospital for supervision of resident physicians who care for critically ill patientsThe ACGME should explicitly define “good” supervision by specialty and by year of training. Explicit requirements for intensity and level of training for supervision of specific clinical scenarios should be providedCenters for Medicare and Medicaid Services (CMS) should use graduate medical education funding to provide incentives to programs with proven, effective levels of supervision. Although this action would require federal legislation, reimbursement rules would help to ensure that hospitals pay attention to the importance of good supervision and require it from their training programs
Resident physician work hours
Although the IOM “Sleep, supervision and safety” report provides a comprehensive review and discussion of all aspects of graduate medical education training, the report’s focal point is its recommendations regarding the hours that resident physicians are currently required to work. A considerable body of scientific evidence, much of it cited by the Institute of Medicine report, describes deteriorating performance in fatigued humans, as well as specific studies on resident physician fatigue and preventable medical errors.
The question before this conference was what work redesign and cultural changes are needed to reform work hours as recommended by the Institute of Medicine’s evidence-based report? Extensive scientific data demonstrate that shifts exceeding 12–16 hours without sleep are unsafe. Several principles should be followed in efforts to reduce consecutive hours below this level and achieve safer work schedules. The recommendations are: Limit resident physician work hours to 12–16 hour maximum shiftsA minimum of 10 hours off duty should be scheduled between shiftsResident physician input into work redesign should be actively solicitedSchedules should be designed that adhere to principles of sleep and circadian science; this includes careful consideration of the effects of multiple consecutive night shifts, and provision of adequate time off after night work, as specified in the IOM reportResident physicians should not be scheduled up to the maximum permissible limits; emergencies frequently occur that require resident physicians to stay longer than their scheduled shifts, and this should be anticipated in scheduling resident physicians’ work shiftsHospitals should anticipate the need for iterative improvement as new schedules are initiated; be prepared to learn from the initial phase-in, and change the plan as neededAs resident physician work hours are redesigned, attending physicians should also be considered; a potential consequence of resident physician work hour reduction and increased supervisory requirements may be an increase in work for attending physicians; this should be carefully monitored, and adjustments to attending physician work schedules made as needed to prevent unsafe work hours or working conditions for this group“Home call” should be brought under the overall limits of working hours; work load and hours should be monitored in each residency program to ensure that resident physicians and fellows on home call are getting sufficient sleepMedicare funding for graduate medical education in each hospital should be linked with adherence to the Institute of Medicine limits on resident physician work hours
Moonlighting by resident physicians
The Institute of Medicine report recommended including external as well as internal moonlighting in working hour limits. The recommendation is: All moonlighting work hours should be included in the ACGME working hour limits and actively monitored. Hospitals should formalize a moonlighting policy and establish systems for actively monitoring resident physician moonlighting
Safety of resident physicians
The “Sleep, supervision and safety” report also addresses fatigue-related harm done to resident physicians themselves. The report focuses on two main sources of physical injury to resident physicians impaired by fatigue, ie, needle-stick exposure to blood-borne pathogens and motor vehicle crashes. Providing safe transportation home for resident physicians is a logistical and financial challenge for hospitals. Educating physicians at all levels on the dangers of fatigue is clearly required to change driving behavior so that safe hospital-funded transport home is used effectively. Fatigue-related injury prevention (including not driving while drowsy) should be taught in medical school and during residency, and reinforced with attending physicians; hospitals and residency programs must be informed that resident physicians’ ability to judge their own level of impairment is impaired when they are sleep deprived; hence, leaving decisions about the capacity to drive to impaired resident physicians is not recommendedHospitals should provide transportation to all resident physicians who report feeling too tired to drive safely; in addition, although consecutive work should not exceed 16 hours, hospitals should provide transportation for all resident physicians who, because of unforeseen reasons or emergencies, work for longer than consecutive 24 hours; transportation under these circumstances should be automatically provided to house staff, and should not rely on self-identification or request
Training in effective handovers and quality improvement
Handover practice for resident physicians, attendings, and other health care providers has long been identified as a weak link in patient safety throughout health care settings. Policies to improve handovers of care must be tailored to fit the appropriate clinical scenario, recognizing that information overload can also be a problem. At the heart of improving handovers is the organizational effort to improve quality, an effort in which resident physicians have typically been insufficiently engaged. The recommendations are: Hospitals should train attending and resident physicians in effective handovers of careHospitals should create uniform processes for handovers that are tailored to meet each clinical setting; all handovers should be done verbally and face-to-face, but should also utilize written toolsWhen possible, hospitals should integrate hand-over tools into their electronic medical records (EMR) systems; these systems should be standardized to the extent possible across residency programs in a hospital, but may be tailored to the needs of specific programs and services; federal government should help subsidize adoption of electronic medical records by hospitals to improve signoutWhen feasible, handovers should be a team effort including nurses, patients, and familiesHospitals should include residents in their quality improvement and patient safety efforts; the ACGME should specify in their core competency requirements that resident physicians work on quality improvement projects; likewise, the Joint Commission should require that resident physicians be included in quality improvement and patient safety programs at teaching hospitals; hospital administrators and residency program directors should create opportunities for resident physicians to become involved in ongoing quality improvement projects and root cause analysis teams; feedback on successful quality improvement interventions should be shared with resident physicians and broadly disseminatedQuality improvement/patient safety concepts should be integral to the medical school curriculum; medical school deans should elevate the topics of patient safety, quality improvement, and teamwork; these concepts should be integrated throughout the medical school curriculum and reinforced throughout residency; mastery of these concepts by medical students should be tested on the United States Medical Licensing Examination (USMLE) stepsFederal government should support involvement of resident physicians in quality improvement efforts; initiatives to improve quality by including resident physicians in quality improvement projects should be financially supported by the Department of Health and Human Services
Monitoring and oversight of the ACGME
While the ACGME is a key stakeholder in residency training, external voices are essential to ensure that public interests are heard in the development and monitoring of standards. Consequently, the Institute of Medicine report recommended external oversight and monitoring through the Joint Commission and Centers for Medicare and Medicaid Services (CMS). The recommendations are: Make comprehensive fatigue management a Joint Commission National Patient Safety Goal; fatigue is a safety concern not only for resident physicians, but also for nurses, attending physicians, and other health care workers; the Joint Commission should seek to ensure that all health care workers, not just resident physicians, are working as safely as possibleFederal government, including the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality, should encourage development of comprehensive fatigue management programs which all health systems would eventually be required to implementMake ACGME compliance with working hours a “ condition of participation” for reimbursement of direct and indirect graduate medical education costs; financial incentives will greatly increase the adoption of and compliance with ACGME standards
Future financial support for implementation
The Institute of Medicine’s report estimates that $1.7 billion (in 2008 dollars) would be needed to implement its recommendations. Twenty-five percent of that amount ($376 million) will be required just to bring hospitals into compliance with the existing 2003 ACGME rules. Downstream savings to the health care system could potentially result from safer care, but these benefits typically do not accrue to hospitals and residency programs, who have been asked historically to bear the burden of residency reform costs. The recommendations are: The Institute of Medicine should convene a panel of stakeholders, including private and public funders of health care and graduate medical education, to lay down the concrete steps necessary to identify and allocate the resources needed to implement the recommendations contained in the IOM “Resident duty hours: Enhancing sleep, supervision and safety” report. Conference participants suggested several approaches to engage public and private support for this initiativeEfforts to find additional funding to implement the Institute of Medicine recommendations should focus more broadly on patient safety and health care delivery reform; policy efforts focused narrowly upon resident physician work hours are less likely to succeed than broad patient safety initiatives that include residency redesign as a key componentHospitals should view the Institute of Medicine recommendations as an opportunity to begin resident physician work redesign projects as the core of a business model that embraces safety and ultimately saves resourcesBoth the Secretary of Health and Human Services and the Director of the Centers for Medicare and Medicaid Services should take the Institute of Medicine recommendations into consideration when promulgating rules for innovation grantsThe National Health Care Workforce Commission should consider the Institute of Medicine recommendations when analyzing the nation’s physician workforce needs
Recommendations for future research
Conference participants concurred that convening the stakeholders and agreeing on a research agenda was key. Some observed that some sectors within the medical education community have been reluctant to act on the data. Several logical funders for future research were identified. But above all agencies, Centers for Medicare and Medicaid Services is the only stakeholder that funds graduate medical education upstream and will reap savings downstream if preventable medical errors are reduced as a result of reform of resident physician work hours.
PMCID: PMC3630963  PMID: 23616719
resident; hospital; working hours; safety
12.  Flow situations during everyday practice in a medical hospital ward. Results from a study based on experience sampling method 
BMC Nursing  2011;10:3.
Nursing is a constant balance between strain and stimulation and work and health research with a positive reference point has been recommended. A health-promoting circumstance for subjective experience is flow, which is a psychological state, when individuals concurrently experience happiness, motivation and cognitive efficiency. Flow situations can be identified through individuals' estimates of perceived challenge and skills. There is, to the best of our knowledge, no published study of flow among health care staff. The aim of this study was to identify flow-situations and study work-related activities and individual factors associated with flow situations, during everyday practice at a medical emergency ward in Sweden, in order to increase the knowledge on salutogenic health-promoting factors.
The respondents consisted of 17 assistant nurses and 14 registered nurses, who randomly and repeatedly answered a small questionnaire, through an experience sampling method, during everyday nursing practice. The study resulted in 497 observations. Flow situations were defined as an exact match between a high challenge and skill estimation and logistic regression models were used to study different variables association to flow situations.
The health care staff spent most of its working time in individual nursing care and administrative and communicative duties. The assistant nurses were more often occupied in individual nursing care, while the registered nurses were more involved in medical care and administrative and communicative duties. The study resulted in 11.5% observations of flow situations but the relative number of flow situations varied between none to 55% among the participants. Flow situations were positively related to medical care activities and individual cognitive resources. Taking a break was also positively associated with flow situations among the assistant nurses.
The result showed opportunities for work-related interventions, with an adherent increase in flow situations, opportunity for experience of flow and work-related health among the nursing staff in general and among the assistant nurses in particular.
PMCID: PMC3042404  PMID: 21288329
13.  Nursing home staff’s views on residents’ dignity: a qualitative interview study 
Maintaining dignity is an important element of end-of-life care and also of the care given in nursing homes. Factors influencing personal dignity have been studied from both nursing home residents’ and staff’s perspective. Little is however known about the way nursing home staff perceive and promote the personal dignity of individual residents in daily practice, or about staff’s experiences with preserving dignity within the nursing home. The aim of this study is to gain more insight in this.
A qualitative descriptive interview study was designed, in which in-depth interviews were performed with 13 physicians and 15 nurses. They expressed their views on the personal dignity of 30 recently admitted nursing home residents on the general medical wards of four nursing homes in The Netherlands. Interviews were transcribed and analyzed following the principles of thematic analysis.
According to both physicians and nurses, physical impairment and being dependent on others threatened the residents’ dignity. Whether or not this led to a violation of an individual resident’s dignity, depended - in staff’s opinion - on the resident’s ability to show resilience and to keep his/her individuality. Staff mentioned treating residents with respect and taking care of their privacy as most important elements of dignity-conserving care and strived to treat the residents as they would like to be treated themselves. They could often mention aspects that were important for a particular resident’s dignity. But, when asked what they could contribute to a particular resident’s dignity, they often mentioned general aspects of dignity-conserving care, which could apply to most nursing home residents. By attempting to give dignity-conserving care, physicians and nurses often experienced conflicting values in daily care and barriers caused by the lack of resources.
Tailoring dignity-conserving care to an individual nursing home resident appears hard to bring about in daily practice. Both attention to solve contextual barriers within the nursing home as well as more awareness of staff members for their own values, which they take as a reference point in treating residents, is needed to promote personal dignity in the nursing home setting.
PMCID: PMC3850947  PMID: 24041222
Dignity; Elderly care physicians; End-of-life issues; Interviews; Nurses; Nursing home; Older people
14.  Napping on the Night Shift: A Study of Sleep, Performance, and Learning in Physicians-in-Training 
Physicians in training experience fatigue from sleep loss, high workload, and working at an adverse phase of the circadian rhythm, which collectively degrades task performance and the ability to learn and remember. To minimize fatigue and sustain performance, learning, and memory, humans generally need 7 to 8 hours of sleep in every 24-hour period.
In a naturalistic, within-subjects design, we studied 17 first- and second-year internal medicine residents working in a tertiary care medical center, rotating between day shift and night float every 4 weeks. We studied each resident for 2 weeks while he/she worked the day shift and for 2 weeks while he/she worked the night float, objectively measuring sleep by wrist actigraphy, vigilance by the Psychomotor Vigilance Task test, and visual-spatial and verbal learning and memory by the Brief Visuospatial Memory Test-Revised and the Rey Auditory-Verbal Learning Test.
Residents, whether working day shift or night float, slept approximately 7 hours in every 24-hour period. Residents, when working day shift, consolidated their sleep into 1 main sleep period at night. Residents working night float split their sleep, supplementing their truncated daytime sleep with nighttime on-duty naps. There was no difference in vigilance or learning and memory, whether residents worked day shift or night float.
Off-duty sleep supplemented with naps while on duty appears to be an effective strategy for sustaining vigilance, learning, and memory when working night float.
PMCID: PMC3886464  PMID: 24455014
15.  Safety during night shifts: a cross-sectional survey of junior doctors’ preparation and practice 
BMJ Open  2013;3(9):e003567.
We aimed to determine whether junior doctors and trusts in the region make use of published evidence relating to best practice during night shift work that can safeguard alertness, reduce fatigue and limit mistakes. We surveyed junior doctors’ preparation for and practice during night shifts, and the working and living conditions offered by hospitals for junior doctors carrying out night duties.
Cross-sectional survey.
An anonymous online questionnaire was sent to junior doctors training within Health Education North West from 13 December 2012 to 14 February 2013.
32% (16/42) of trusts within Health Education North West sent the survey to 2139 junior doctor email addresses; 24.5% (524/2139) entered data into the survey.
91.6% of surveyed junior doctors worked night shifts. Prior to starting night shifts, 65% do not have a ‘prophylactic’ afternoon nap. At work, half (49%) can access a room with a reclining chair while 24% have a room with a bed. 37% ‘never’ achieve a ‘natural break’ on night shift; 53% ‘never’ achieve the recommended 20–45 min nap. 91% of respondents were unaware of the duration of sleep inertia that can affect alertness upon waking. When converting between day/night shifts, 2% use light lamps and 6% use non-benzodiazepine sedatives. Principal themes from free text analysis were feeling lethargic or unwell during night shifts, concern for patient and personal safety and inability to rest or take breaks.
The trainees surveyed find night shifts difficult, yet do not/are unable to implement evidence-based recommendations to limit fatigue. Results suggest those surveyed experience a lack of rest facilities within their place of work and a demanding workload. The results may indicate the need to increase awareness of the potential benefits associated with different interventions that can help mitigate the fatigue associated with rotating shift work.
PMCID: PMC3780329  PMID: 24056488
Education & Training (see Medical Education & Training); Qualitative Research; Occupational & Industrial Medicine
16.  Improving compliance with requirements on junior doctors' hours 
BMJ : British Medical Journal  2003;327(7409):270-273.
Problem Compliance with UK regulations on junior doctors' working hours cannot be achieved by manipulating rotas that maintain existing tiers of cover and work practices. More radical solutions are needed.
Design Audit of change.
Setting Paediatric night rota in large children's hospital.
Key measures for improvement Compliance with regulations on working hours assessed by diary cards; workload assessed by staff attendance on wards; patient safety assessed through critical incident reports.
Strategies for change Development of new staff roles, followed by change from a partial shift rota comprising 11 doctors and one senior nurse, to a full shift night team comprising three middle grade doctors and two senior nurses.
Effects of change Compliance with regulations on working hours increased from 33% to 77%. Workload changed little and was well within the capacity of the new night team. The effect on patient care and on medical staff requires further evaluation.
Lessons learnt Reduction of junior doctors' working hours requires changes to roles, processes, and practices throughout the organisation.
PMCID: PMC1126659  PMID: 12896942
17.  Perioperative nursing in public university hospitals: an ethnography 
BMC Nursing  2014;13(1):45.
In recent years, perioperative nursing has received ongoing attention as part of an interprofessional collaboration. Perioperative nursing is constantly faced with new challenges and opportunities that necessitate continual updates of nursing knowledge and technical skills. In light of the longstanding relationship between nursing and technology, it is interesting that few studies with this focus have been performed. Therefore, our research question was: What is the content of perioperative nursing and how do nurses facilitate the interaction between nursing care and technology in highly specialized operating rooms in public university hospitals?
An ethnography involving participant observations and interviews was conducted during a 9-month study period. The participants comprised 24 nurses from 9 different operating wards at 2 university hospitals in different regions of Denmark.
Patients were addressed as either human beings or objects. Likewise, the participants’ technical skills were observed and described as either technical flair or a lack of technical skills/technophobia. The different ways in which the technical skills were handled and the different ways in which the patients were viewed contributed to the development of three levels of interaction between technology and nursing care: the interaction, declining interaction, and failing interaction levels.
Nursing practice at the interaction level is characterized by flexibility and excellence, while practice at the declining interaction level is characterized by inflexibility and rigidity. Nursing practice at the failing interaction level is characterized by staff members working in isolation with limited collaboration with other staff members in operating rooms. Considering that the declining and failing interaction levels are characterized by inflexibility, rigidity, and isolation in nursing practice, nurses at these two levels must develop and improve their qualifications to reach a level of flexible, excellent interaction. Nurse leaders must therefore refocus their skills on proficiency in perioperative nursing.
PMCID: PMC4264328  PMID: 25506263
Anthropology; Cultural; Ethnography; Nursing care; Perioperative nursing; Technology
18.  Nursing churn and turnover in Australian hospitals: nurses perceptions and suggestions for supportive strategies 
BMC Nursing  2014;13:11.
This study aimed to reveal nurses’ experiences and perceptions of turnover in Australian hospitals and identify strategies to improve retention, performance and job satisfaction. Nursing turnover is a serious issue that can compromise patient safety, increase health care costs and impact on staff morale. A qualitative design was used to analyze responses from 362 nurses collected from a national survey of nurses from medical and surgical nursing units across 3 Australian States/Territories.
A qualitative design was used to analyze responses from 362 nurses collected from a national survey of nurses from medical and surgical nursing units across 3 Australian States/Territories.
Key factors affecting nursing turnover were limited career opportunities; poor support; a lack of recognition; and negative staff attitudes. The nursing working environment is characterised by inappropriate skill-mix and inadequate patient-staff ratios; a lack of overseas qualified nurses with appropriate skills; low involvement in decision-making processes; and increased patient demands. These issues impacted upon heavy workloads and stress levels with nurses feeling undervalued and disempowered. Nurses described supportive strategies: improving performance appraisals, responsive preceptorship and flexible employment options.
Nursing turnover is influenced by the experiences of nurses. Positive steps can be made towards improving workplace conditions and ensuring nurse retention. Improving performance management and work design are strategies that nurse managers could harness to reduce turnover.
PMCID: PMC3985533  PMID: 24708565
Nursing staff; Hospital personnel; Turnover; Personnel management
19.  A taxonomy of nursing care organization models in hospitals 
Over the last decades, converging forces in hospital care, including cost-containment policies, rising healthcare demands and nursing shortages, have driven the search for new operational models of nursing care delivery that maximize the use of available nursing resources while ensuring safe, high-quality care. Little is known, however, about the distinctive features of these emergent nursing care models. This article contributes to filling this gap by presenting a theoretically and empirically grounded taxonomy of nursing care organization models in the context of acute care units in Quebec and comparing their distinctive features.
This study was based on a survey of 22 medical units in 11 acute care facilities in Quebec. Data collection methods included questionnaire, interviews, focus groups and administrative data census. The analytical procedures consisted of first generating unit profiles based on qualitative and quantitative data collected at the unit level, then applying hierarchical cluster analysis to the units’ profile data.
The study identified four models of nursing care organization: two professional models that draw mainly on registered nurses as professionals to deliver nursing services and reflect stronger support to nurses’ professional practice, and two functional models that draw more significantly on licensed practical nurses (LPNs) and assistive staff (orderlies) to deliver nursing services and are characterized by registered nurses’ perceptions that the practice environment is less supportive of their professional work.
This study showed that medical units in acute care hospitals exhibit diverse staff mixes, patterns of skill use, work environment design, and support for innovation. The four models reflect not only distinct approaches to dealing with the numerous constraints in the nursing care environment, but also different degrees of approximations to an “ideal” nursing professional practice model described by some leaders in the contemporary nursing literature. While the two professional models appear closer to this ideal, the two functional models are farther removed.
PMCID: PMC3471046  PMID: 22929127
20.  One size does not fit all: a qualitative content analysis of the importance of existing quality improvement capacity in the implementation of Releasing Time to Care: the Productive Ward™ in Saskatchewan, Canada 
Releasing Time to Care: The Productive Ward™ (RTC) is a method for conducting continuous quality improvement (QI). The Saskatchewan Ministry of Health mandated its implementation in Saskatchewan, Canada between 2008 and 2012. Subsequently, a research team was developed to evaluate its impact on the nursing unit environment. We sought to explore the influence of the unit’s existing QI capacity on their ability to engage with RTC as a program for continuous QI.
We conducted interviews with staff from 8 nursing units and asked them to speak about their experience doing RTC. Using qualitative content analysis, and guided by the Organizing for Quality framework, we describe the existing QI capacity and impact of RTC on the unit environment.
The results focus on 2 units chosen to highlight extreme variation in existing QI capacity. Unit B was characterized by a strong existing environment. RTC was implemented in an environment with a motivated manager and collaborative culture. Aided by the structural support provided by the organization, the QI capacity on this unit was strengthened through RTC. Staff recognized the potential of using the RTC processes to support QI work. Staff on unit E did not have the same experience with RTC. Like unit B, they had similar structural supports provided by their organization but they did not have the same existing cultural or political environment to facilitate the implementation of RTC. They did not have internal motivation and felt they were only doing RTC because they had to. Though they had some success with RTC activities, the staff did not have the same understanding of the methods that RTC could provide for continuous QI work.
RTC has the potential to be a strong tool for engaging units to do QI. This occurs best when RTC is implemented in a supporting environment. One size does not fit all and administrative bodies must consider the unique context of each environment prior to implementing large-scale QI projects. Use of an established framework, like Organizing for Quality, could highlight the distinctive supports needed in particular care environments to increase the likelihood of successful engagement.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-014-0642-x) contains supplementary material, which is available to authorized users.
PMCID: PMC4279911  PMID: 25523134
Productive ward; Releasing time to care; Organizing for quality; Nursing; Qualitative methodology; Quality improvement capacity; Change mechanisms
21.  The effect of an electronic health record system on nursing staff time in a nursing home: a longitudinal cohort study 
The Australasian Medical Journal  2014;7(7):285-293.
Nursing homes are increasingly introducing electronic health record (EHR) systems into nursing practice; however, there is limited evidence about the effect of these systems on nursing staff time.
To investigate the effect of introducing an EHR system on time spent on activities by nursing staff in a nursing home.
An observational work sampling study was undertaken with nursing staff between 2009 and 2011 at two months before, and at 3, 6, 12, and 23 months after implementation of an EHR system at an Australian nursing home. An observer used pre-determined tasks to record activities of the nursing staff at nine-minute intervals.
There was no significant change in registered nurses and endorsed enrolled nurses’ time on most activities after implementation. Personal carers’ time on oral-communication reduced, and time on documentation increased at most measurement periods in the first 12 months after implementation. At 23 months, time on these activities had returned to pre-implementation levels. Nursing staff time on direct care remained stable after implementation. No considerable change was observed in time spent on other activities after implementation.
Findings suggest that successful introduction of an EHR system in a nursing home may not interfere with nursing staff time on direct care duties. However, there is scope for improving the support provided by EHR systems through incorporation of functions to support collaborative nursing care.
PMCID: PMC4127959  PMID: 25157268
Activity; electronic health record; HER; impact; nurse; nursing home
22.  Caring Relationships in Home-Based Nursing Care - Registered Nurses’ Experiences 
The Open Nursing Journal  2013;7:89-95.
The caring relationship between the nurse and the person in need of nursing care has been described as a key concept in nursing and could facilitate health and healing by involving the person’s genuine needs. The aim of this study was to explore registered nurses’ experiences of their relationships with persons in need of home-based nursing care. Individual interviews with nurses (n=13 registered nurses and 11 district nurses) working in home-based nursing care were performed. A thematic content analysis was used to analyze the transcribed interviews and resulted in the main theme Good nursing care is built on trusting relationship and five sub-themes, Establishing the relationship in home-based nursing care, Conscious efforts maintains the relationship, Reciprocity is a requirement in the relationship, Working in different levels of relationships and Limitations and boundaries in the relationship. A trusting relationship between the nurse and the person in need of healthcare is a prerequisite for good home-based nursing care whether it is based on face-to-face encounters or remote encounters through distance-spanning technology. A trusting relationship could reduce the asymmetry of the caring relationship which could strengthen the person’s position. The relationship requires conscious efforts from the nurse and a choice of level of the relationship. The trusting relationship was reciprocal and meant that the nurse had to communicate something about themself as the person needs to know who is entering the home and who is communicating through distance-spanning technology.
PMCID: PMC3722540  PMID: 23894261
Relationship; home-based nursing care; registered nurses; experiences; distance-spanning technology; interviews; thematic content analysis.
23.  The ward atmosphere important for the psychosocial work environment of nursing staff in psychiatric in-patient care 
BMC Nursing  2011;10:12.
The nursing staff working in psychiatric care have a demanding work situation, which may be reflected in how they view their psychosocial work environment and the ward atmosphere. The aims of the present study were to investigate in what way different aspects of the ward atmosphere were related to the psychosocial work environment, as perceived by nursing staff working in psychiatric in-patient care, and possible differences between nurses and nurse assistants.
93 nursing staff working at 12 general psychiatric in-patient wards in Sweden completed two questionnaires, the Ward Atmosphere Scale and the QPSNordic 34+. Data analyses included descriptive statistics, the Mann-Whitney U-test, Spearman rank correlations and forward stepwise conditional logistic regression analyses.
The data revealed that there were no differences between nurses and nurse assistants concerning perceptions of the psychosocial work environment and the ward atmosphere. The ward atmosphere subscales Personal Problem Orientation and Program Clarity were associated with a psychosocial work environment characterized by Empowering Leadership. Program Clarity was related to the staff's perceived Role Clarity, and Practical Orientation and Order and Organization were positively related to staff perceptions of the Organizational Climate.
The results from the present study indicate that several ward atmosphere subscales were related to the nursing staff's perceptions of the psychosocial work environment in terms of Empowering Leadership, Role Clarity and Organizational Climate. Improvements in the ward atmosphere could be another way to accomplish improvements in the working conditions of the staff, and such improvements would affect nurses and nurse assistants in similar ways.
PMCID: PMC3141688  PMID: 21679430
24.  How does it really feel to be in my shoes? Patients' experiences of compassion within nursing care and their perceptions of developing compassionate nurses 
Journal of Clinical Nursing  2014;23(19-20):2790-2799.
Aims and objectives
To understand how patients experience compassion within nursing care and explore their perceptions of developing compassionate nurses.
Compassion is a fundamental part of nursing care. Individually, nurses have a duty of care to show compassion; an absence can lead to patients feeling devalued and lacking in emotional support. Despite recent media attention, primary research around patients' experiences and perceptions of compassion in practice and its development in nursing care remains in short supply.
A qualitative exploratory descriptive approach.
In-depth, semi-structured interviews were conducted with a purposive sample of 10 patients in a large teaching hospital in the United Kingdom. Interviews were digitally recorded and transcribed verbatim. Thematic networks were used in analysis.
Three overarching themes emerged from the data: (1) what is compassion: knowing me and giving me your time, (2) understanding the impact of compassion: how it feels in my shoes and (3) being more compassionate: communication and the essence of nursing.
Compassion from nursing staff is broadly aligned with actions of care, which can often take time. However, for some, this element of time needs only be fleeting to establish a compassionate connection. Despite recent calls for the increased focus compassion at all levels in nurse education and training, patient opinion was divided on whether it can be taught or remains a moral virtue. Gaining understanding of the impact of uncompassionate actions presents an opportunity to change both individual and cultural behaviours.
Relevance to clinical practice
It comes as a timely reminder that the smallest of nursing actions can convey compassion. Introducing vignettes of real-life situations from the lens of the patient to engage practitioners in collaborative learning in the context of compassionate nursing could offer opportunities for valuable and legitimate professional development.
PMCID: PMC4263156  PMID: 24479676
compassion; empathy; interviews; nursing care; patients' experience; patients' perceptions
25.  Qualified and Unqualified (N-R C) mental health nursing staff - minor differences in sources of stress and burnout. A European multi-centre study 
Unqualified/non-registered caregivers (N-R Cs) will continue to play important roles in the mental health services. This study compares levels of burnout and sources of stress among qualified and N-R Cs working in acute mental health care.
A total of 196 nursing staff - 124 qualified staff (mainly nurses) and 72 N-R Cs with a variety of different educational backgrounds - working in acute wards or community mental teams from 5 European countries filled out the Maslach Burnout Inventory (MBI), the Mental Health Professional Scale (MHPSS) and the Psychosocial Work Environment and Stress Questionnaire (PWSQ).
(a) The univariate differences were generally small and restricted to a few variables. Only Social relations (N-R Cs being less satisfied) at Work demands (nurses reporting higher demands) were different at the .05 level. (b) The absolute scores both groups was highest on variables that measured feelings of not being able to influence a work situation characterised by great demands and insufficient resources. Routines and educational programs for dealing with stress should be available on a routine basis. (c) Multivariate analyses identified three extreme groups: (i) a small group dominated by unqualified staff with high depersonalization, (ii) a large group that was low on depersonalisation and high on work demands with a majority of qualified staff, and (iii) a small N-R C-dominated group (low depersonalization, low work demands) with high scores on professional self-doubt. In contrast to (ii) the small and N-R C-dominated groups in (i) and (iii) reflected mainly centre-dependent problems.
The differences in burnout and sources of stress between the two groups were generally small. With the exception of high work demands the main differences between the two groups appeared to be centre-dependent. High work demands characterized primarily qualified staff. The main implication of the study is that no special measures addressed towards N-R Cs in general with regard to stress and burnout seem necessary. The results also suggest that centre-specific problems may cause more stress among N-R Cs compared to the qualified staff (e.g. professional self-doubt).
PMCID: PMC2902466  PMID: 20546587

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