Nurse managers who can observe their own behaviour and its effects on employees can adjust to a better leadership style. The intention of this study was to explore nurses' and supervisors' perceptions of nurse managers' leadership styles. Open-ended interviews were conducted with 11 nurses and 10 superiors. The data were analysed by content analysis. In the study, six leadership styles were identified: visionary, coaching, affiliate, democratic, commanding, and isolating. Job satisfaction and commitment as well as operation and development work, cooperation, and organizational climate in the work unit were the factors, affected by leadership styles. The nurse managers should consider their leadership style from the point of view of employees, situation factors, and goals of the organization. Leadership styles where employees are seen in a participatory role have become more common.
Despite recent high-quality evidence for their cost-effectiveness, thiazides are underused for controlling hypertension. The goal of this study was to design and test a practice-based intervention aimed at increasing the use of thiazide-based antihypertensive regimens.
This quasi-experimental study was carried out in general medicine ambulatory practices of a large, academically-affiliated Veterans Affairs hospital. The intervention group consisted of the practitioners (13 staff and 215 trainees), nurses, and patients (3,502) of the teaching practice; non-randomized concurrent controls were the practitioners (31 providers) and patients (18,292) of the non-teaching practices. Design of the implementation intervention was based on Rogers' Diffusion of Innovations model. Over 10.5 months, intervention teams met weekly or biweekly and developed and disseminated informational materials among themselves and to trainees, patients, and administrators. These teams also reviewed summary electronic-medical-record data on thiazide use and blood pressure (BP) goal attainment. Outcome measures were the proportion of hypertensive patients prescribed a thiazide-based regimen, and the proportion of hypertensive patients attaining BP goals regardless of regimen. Thirty-three months of time-series data were available; statistical process control charts, change point analyses, and before-after analyses were used to estimate the intervention's effects.
Baseline use of thiazides and rates of BP control were higher in the intervention group than controls. During the intervention, thiazide use and BP control increased in both groups, but changes occurred earlier in the intervention group, and primary change points were observed only in the intervention group. Overall, the pre-post intervention difference in proportion of patients prescribed thiazides was greater in intervention patients (0.091 vs. 0.058; p = 0.0092), as was the proportion achieving BP goals (0.092 vs. 0.044; p = 0.0005). At the end of the implementation period, 41.4% of intervention patients were prescribed thiazides vs. 30.6% of controls (p < 0.001); 51.6% of intervention patients had achieved BP goals vs. 44.3% of controls (p < 0.001).
This multi-faceted intervention appears to have resulted in modest improvements in thiazide prescribing and BP control. The study also demonstrates the value of electronic medical records for implementation research, how Rogers' model can be used to design and launch an implementation strategy, and how all members of a clinical microsystem can be involved in an implementation effort.
Foot ulcers are a significant problem for people with diabetes. Comprehensive assessments of risk factors associated with diabetic foot ulcer are recommended in clinical guidelines to decrease complications such as prolonged healing, gangrene and amputations, and to promote effective management. However, the translation of clinical guidelines into nursing practice remains fragmented and inconsistent, and a recent homecare chart audit showed less than half the recommended risk factors for diabetic foot ulcers were assessed, and peripheral neuropathy (the most significant predictor of complications) was not assessed at all.
Strong leadership is consistently described as significant to successfully transfer guidelines into practice. Limited research exists however regarding which leadership behaviours facilitate and support implementation in nursing.
The purpose of this pilot study is to evaluate the impact of a leadership intervention in community nursing on implementing recommendations from a clinical guideline on the nursing assessment and management of diabetic foot ulcers.
Two phase mixed methods design is proposed (ISRCTN 12345678). Phase I: Descriptive qualitative to understand barriers to implementing the guideline recommendations, and to inform the intervention. Phase II: Matched pair cluster randomized controlled trial (n = 4 centers) will evaluate differences in outcomes between two implementation strategies. Primary outcome: Nursing assessments of client risk factors, a composite score of 8 items based on Diabetes/Foot Ulcer guideline recommendations.
Intervention: In addition to the organization's 'usual' implementation strategy, a 12 week leadership strategy will be offered to managerial and clinical leaders consisting of: a) printed materials, b) one day interactive workshop to develop a leadership action plan tailored to barriers to support implementation; c) three post-workshop teleconferences.
This study will provide vital information on which leadership strategies are well received to facilitate and support guideline implementation. The anticipated outcomes will provide information to assist with effective management of foot ulcers for people with diabetes.
By tracking clinical outcomes associated with guideline implementation, health care administrators will be better informed to influence organizational and policy decision-making to support evidence-based quality care. Findings will be useful to inform the design of future multi-centered trials on various clinical topics to enhance knowledge translation for positive outcomes.
Current Control Trials ISRCTN06910890
Children being cared for in hospital undergo multiple painful procedures daily. However, little is known about the frequency of these procedures and associated interventions to manage the pain. We undertook this study to determine, for children in Canadian hospitals, the frequency of painful procedures, the types of pain management interventions associated with painful procedures and the influence of the type of hospital unit on procedural pain management.
We reviewed medical charts for infants and children up to 18 years of age who had been admitted to 32 inpatient units at eight Canadian pediatric hospitals between October 2007 and April 2008. We recorded all of the painful procedures performed and the pain management interventions that had been implemented in the 24-hour period preceding data collection. We performed descriptive and comparative (analysis of variance, χ2) analyses.
Of the 3822 children included in the study, 2987 (78.2%) had undergone at least one painful procedure in the 24-hour period preceding data collection, for a total of 18 929 painful procedures (mean 6.3 per child who had any painful procedure). For 2334 (78.1%) of the 2987 children who had a painful procedure, a pain management intervention in the previous 24 hours was documented in the chart: 1980 (84.8%) had a pharmacologic intervention, 609 (26.1%) a physical intervention, 584 (25.0%) a psychologic intervention and 753 (32.3%) a combination of interventions. However, for only 844 (28.3%) of the 2987 children was one or more pain management interventions administered and documented specifically for a painful procedure. Pediatric intensive care units reported the highest proportion of painful procedures and analgesics administered.
For less than one-third of painful procedures was there documentation of one or more specific pain management interventions. Strategies for implementing changes in pain management must be tailored to the type of hospital unit.
Prior studies measuring fidelity of complex interventions have mainly evaluated adherence, and not taken factors affecting adherence into consideration. A need for studies that clarify the concept of fidelity and the function of factors moderating fidelity has been emphasized. The aim of the study was to systematically evaluate implementation fidelity and possible factors influencing fidelity of a complex care continuum intervention for frail elderly people.
The intervention was a systematization of the collaboration between a nurse with geriatric expertise situated at the emergency department, the hospital ward staff, and a multi-professional team with a case manager in the municipal care services for older people. Implementation was evaluated between September 2008 and May 2010 with observations of work practices, stakeholder interviews, and document analysis according to a modified version of The Conceptual Framework for Implementation Fidelity.
A total of 16 of the 18 intervention components were to a great extent delivered as planned, while some new components were added to the model. No changes in the frequency or duration of the 18 components were observed, but the dose of the added components varied over time. Changes in fidelity were caused in a complex, interrelated fashion by all the moderating factors in the framework, i.e., context, staff and participant responsiveness, facilitation, recruitment, and complexity.
The Conceptual Framework for Implementation Fidelity was empirically useful and included comprehensive measures of factors affecting fidelity. Future studies should focus on developing the framework with regard to how to investigate relationships between the moderating factors and fidelity over time.
Adherence; Adaptation; Process evaluation; Complex intervention; Implementation; Care chain; Elderly
Pediatric asthma remains a significant burden upon patients, families, and the healthcare system. Despite the availability of evidence-based best practice asthma management guidelines for over a decade, published studies suggest that many primary care physicians do not follow them. This article describes the Provider Quality Improvement (PQI) intervention with six diverse community-based practices. A pediatrician and a nurse practitioner conducted the yearlong intervention, which was part of a larger CDC-funded project, using problem-based learning within an academic detailing model. Process and outcome assessments included (1) pre- and post-intervention chart reviews to assess eight indicators of quality care, (2) post-intervention staff questionnaires to assess contact with the intervention team and awareness of practice changes, and (3) individual semi-structured interviews with physician and nurse champions in five of the six practices. The chart review indicated that all six practices met predefined performance improvement criteria for at least four of eight indicators of quality care, with two practices meeting improvement criteria for all eight indicators. The response rate for the staff questionnaires was high (72%) and generally consistent across practices, demonstrating high staff awareness of the intervention team, the practice “asthma champions,” and changes in practice patterns. In the semi-structured interviews, several respondents attributed the intervention’s acceptability and success to the expertise of the PQI team and expressed the belief that sustaining changes would be critically dependent on continued contact with the team. Despite significant limitations, this study demonstrated that interventions that are responsive to individual practice cultures can successfully change practice patterns.
Electronic supplementary material
The online version of this article (doi:10.1007/s11524-010-9471-3) contains supplementary material, which is available to authorized users.
Asthma; Quality improvement; Pediatrics; Physician behavior change
Rationale and Aim:
There is a lack of evidence about how to successfully implement standardized nursing care plans (SNCP) in various settings. The aim of this study was to use the “Promotion Action on Research Implementation in Health Services framework” (PARIHS) to explore important factors and conditions at hospital wards that had implemented SNCPs.
We employed a retrospective, cross-sectional design and recruited nurses from four units at a rural hospital and seven units at a university hospital in the western and southern region of Sweden where SNCPs had been implemented. Outcome was measured by means of a questionnaire based on the PARIHS-model.
In total, 137 nurses participated in the study. The main factors that had motivated the nurses to implement SNCPs were that they were easy to understand and follow as well as corresponding to organisational norms. The SNCPs were normally based on clinical experience, although research more frequently formed the basis of the SNCPs at the university hospital. Internal facilitators acted as important educators, who provided reminders to use the SNCP and feedback to the SNCP users. The patient experience was not considered valuable. Those who claimed that the implementation was successful were generally more positive in all measurable aspects. The use of SNCPs was rarely evaluated.
Clinical experience was considered important by the nurses, while they attributed little value to the patient experiences. Successful implementation of research based SNCPs requires internal facilitators with knowledge of evidence-based nursing.
Implementation; standardized nursing care plans; PARIHS; questionnaire.
Investigators recently tested the effectiveness of a collaborative-care intervention for anxiety disorders: Coordinated Anxiety Learning and Management(CALM) ) in 17 primary care clinics around the United States. Investigators also conducted a qualitative process evaluation. Key research questions were as follows: (1) What were the facilitators/barriers to implementing CALM? (2) What were the facilitators/barriers to sustaining CALM after the study was completed?
Key informant interviews were conducted with 47 clinic staff members (18 primary care providers, 13 nurses, 8 clinic administrators, and 8 clinic staff) and 14 study-trained anxiety clinical specialists (ACSs) who coordinated the collaborative care and provided cognitive behavioral therapy. The interviews were semistructured and conducted by phone. Data were content analyzed with line-by-line analyses leading to the development and refinement of themes.
Similar themes emerged across stakeholders. Important facilitators to implementation included the perception of "low burden" to implement, provider satisfaction with the intervention, and frequent provider interaction with ACSs. Barriers to implementation included variable provider interest in mental health, high rates of part-time providers in clinics, and high social stressors of lower socioeconomic-status patients interfering with adherence. Key sustainability facilitators were if a clinic had already incorporated collaborative care for another disorder and presence of onsite mental health staff. The main barrier to sustainability was funding for the ACS.
The CALM intervention was relatively easy to incorporate during the effectiveness trial, and satisfaction was generally high. Numerous implementation and sustainability barriers could limit the reach and impact of widespread adoption. Findings should be interpreted with the knowledge that the ACSs in this study were provided and trained by the study. Future research should explore uptake of CALM and similar interventions without the aid of an effectiveness trial.
The purpose of this paper is to present a study exploring how an electronic message (e-message) system was adapted and used in health care. The e-message system was developed to support and strengthen communication and information exchange between health care providers in a university hospital and the affiliated municipality. Implementing e-messages is expected to enhance quality of care for patients in need of municipal health care services post-hospital.
Latour's (1987) model of translation is used to analyse users' adoption of the e-message system. The translation model emphasises agency on part of all users, and is therefore useful for understanding varying acceptance of technologies and consequently varying technological working practices.
In total 25 semi-structured interviews were conducted with approx. 50 different actors, covering physicians, nurses, nursing assistants, clerical staff and project leaders for the e-message system. The interviews took place over three periods during 2006 and 2007.
Results and conclusion
The e-message system is understood and deployed in different ways by various actors, though the overall conclusion by the health personnel is that e-messages are a useful service.
Applying a translation approach is useful for understanding how people put a technology to use, including providing knowledge about both enabling and constraining elements when implementing a technological tool. Changes in working practices and internal routines should accompany the implementation of e-messages in order to utilise its potential.
electronic message system; ICT
Objective: To analyze whether computer-generated reminders about infections could influence clinicians' practice patterns and consequently improve the detection and management of nosocomial infections.
Design: The conclusions produced by an expert system developed to detect and manage infections were presented to the attending clinicians in a pediatric hospital to determine whether this information could improve detection and management. Clinician interventions were compared before and after the implementation of the system.
Measurements: The responses of the clinicians (staff physicians, physician assistants, and nurse practitioners) to the reminders were determined by review of paper medical charts. Main outcome measures were the number of suggestions to treat and manage infections that were followed before and after the implementation of compiss (Computerized Pediatric Infection Surveillance System). The clinicians' opinions about the system were assessed by means of a paper questionnaire distributed following the experiment.
Results: The results failed to show a statistical difference between the clinicians' treatment strategies before and after implementation of the system (P > 0.33 for clinicians working in the emergency room and P > 0.45 for clinicians working in the pediatric intensive care unit). The questionnaire results showed that the respondents appreciated the information presented by the system.
Conclusion: The computer-generated reminders about infections were unable to influence the practice patterns of clinicians. The methodologic problems that may have contributed to this negative result are discussed.
To test an interdisciplinary, multifaceted, translating research into practice (TRIP) intervention to (a) promote adoption, by physicians and nurses, of evidence-based (EB) acute pain management practices in hospitalized older adults, (b) decrease barriers to use of EB acute pain management practices, and (c) decrease pain intensity of older hospitalized adults.
Experimental design with the hospital as the unit of randomization.
Twelve acute care hospitals in the Midwest.
(a) Medical records (MRs) of patients ≥65 years or older with a hip fracture admitted before and following implementation of the TRIP intervention and (b) physicians and nurses who care for those patients.
Data were abstracted from MRs and questions distributed to nurses and physicians.
The Summative Index for Quality of Acute Pain Care (0–18 scale) was significantly higher for the experimental (10.1) than comparison group (8.4) at the end of the TRIP implementation phase. At the end of the TRIP implementation phase, patients in the experimental group had a lower mean pain intensity rating than those in the comparison group (p<.0001).
The TRIP intervention improved quality of acute pain management of older adults hospitalized with a hip fracture.
Translation; implementation; intervention; pain; elderly; hip fracture
Capacity management systems create insight into required resources like staff and equipment. For inpatient hospital care, capacity management requires information on beds and nursing staff capacity, on a daily as well as annual basis. This paper presents a comprehensive capacity model that gives insight into required nursing staff capacity and opportunities to improve capacity utilization on a ward level.
A capacity model was developed to calculate required nursing staff capacity. The model used historical bed utilization, nurse-patient ratios, and parameters concerning contract hours to calculate beds and nursing staff needed per shift and the number of nurses needed on an annual basis in a ward. The model was applied to three different capacity management problems on three separate groups of hospital wards. The problems entailed operational, tactical, and strategic management issues: optimizing working processes on pediatric wards, predicting the consequences of reducing length of stay on nursing staff required on a cardiology ward, and calculating the nursing staff consequences of merging two internal medicine wards.
It was possible to build a model based on easily available data that calculate the nursing staff capacity needed daily and annually and that accommodate organizational improvements. Organizational improvement processes were initiated in three different groups of wards. For two pediatric wards, the most important improvements were found to be improving working processes so that the agreed nurse-patient ratios could be attained. In the second case, for a cardiology ward, what-if analyses with the model showed that workload could be substantially lowered by reducing length of stay. The third case demonstrated the possible savings in capacity that could be achieved by merging two small internal medicine wards.
A comprehensive capacity model was developed and successfully applied to support capacity decisions on operational, tactical, and strategic levels. It appeared to be a useful tool for supporting discussions between wards and hospital management by giving objective and quantitative insight into staff and bed requirements. Moreover, the model was applied to initiate organizational improvements, which resulted in more efficient capacity utilization.
To implement and evaluate a HF management tool for patients with chronic HF using digital pen and paper for improvement of patient self-management.
Developmental and implementation phase: researchers within medical technology and HF care will together with staff from home care and primary care (physicians and nurses) a small group of users (patients) and companies develop a HF management tool based on digital pen and paper and implement it in clinical practice.
The HF management tool will be tested in ten HF patients admitted to hospital-based home care. The technical equipment and clinical follow-up routines will be evaluated (reliability, stability, acceptance, user friendliness, and patient- and staff satisfaction). The patients will monitor and register shortness of breath, intake of medications, weight, blood pressure, pulse and saturation daily.
Data will be collected through patient and staff interviews and observations as well as through questionnaires evaluating health-related quality of life, HF self-care and knowledge, quality of care, participation and perceived control. Health care and organisational costs will be estimated from patient and staff records.
Innovative aspects and significance of the study: There is a great need for less labour-intensive and more cost-effective innovations that improve care and facilitate follow-up of patients with moderate to severe HF and at high risk for deterioration needing hospitalisation.
heart failure; home care; digital pen
Although pediatric nurses working in children's hospitals often provide care to dying children, little is known about their palliative care beliefs and experiences as individuals or members of groups within the hospital.
To describe pediatric nurses' ratings of palliative care goals and problems, as individuals and members of clusters of nurses with similar views, and nurses' degree of collaboration with an inpatient palliative care team across hospital units.
A cross-sectional survey of nurses at a freestanding children's hospital in 2005.
Nurses rated the most important goals as managing pain, maintaining the child's quality of life, and improving communication. Commonly cited problems were lack of opportunity to debrief after a patient's death, uncertainty about the goals of care, and the health care team's reluctance to discuss hospice with family. Based on individual views about goals and problems, nurses clustered into 5 groups that differed in terms of the adamancy of their views and the scope of the goals and problems they considered important or significant. The hospital unit was the most important factor in predicting nurses' degree of collaboration with the palliative care team even after accounting for individual characteristics.
Pediatric nurses broadly endorse both the importance of palliative care goals and the presence of problems yet perceive the importance of these goals and problems differently. Further, they vary in their level of collaborative practice with a palliative care team in ways that should be accounted for when planning and implementing palliative care programs.
Many challenges arise in complex organizational interventions that threaten research integrity. This article describes a Tool for Evaluating Research Implementation Challenges (TECH), developed using a complexity science framework to assist research teams in assessing and managing these challenges.
During the implementation of a multi-site, randomized controlled trial (RCT) of organizational interventions to reduce resident falls in eight nursing homes, we inductively developed, and later codified the TECH. The TECH was developed through processes that emerged from interactions among research team members and nursing home staff participants, including a purposive use of complexity science principles.
The TECH provided a structure to assess challenges systematically, consider their potential impact on intervention feasibility and fidelity, and determine actions to take. We codified the process into an algorithm that can be adopted or adapted for other research projects. We present selected examples of the use of the TECH that are relevant to many complex interventions.
Complexity theory provides a useful lens through which research procedures can be developed to address implementation challenges that emerge from complex organizations and research designs. Sense-making is a group process in which diverse members interpret challenges when available information is ambiguous; the groups’ interpretations provide cues for taking action. Sense-making facilitates the creation of safe environments for generating innovative solutions that balance research integrity and practical issues. The challenges encountered during implementation of complex interventions are often unpredictable; however, adoption of a systematic process will allow investigators to address them in a consistent yet flexible manner, protecting fidelity. Research integrity is also protected by allowing for appropriate adaptations to intervention protocols that preserve the feasibility of ‘real world’ interventions.
Long-term care; Complexity science; Nursing homes; Implementation research; Intervention research; Research design; Staff intervention; Sense-making; Research fidelity
The increasing resources available for and number of partners providing health sector aid have stimulated innovations, notably, the Paris Declaration on Aid Effectiveness, which aim to improve aid coordination. In this, one of the first studies to analyse implementation of aid coordination below national level, the aim was to investigate the effect of the Paris Declaration on coordination of health sector aid at the district level in Zambia.
The study was carried out in three districts of Zambia. Data were collected via interviews with health centre staff, district managers and officials from the Ministry of Health, and from district action plans, financial reports and accounts, and health centre ledger cards. Four indicators of coordination related to external-partner activity, common arrangements used by external partners and predictability of funding were analysed and assessed in relation to the 2010 targets set by the Paris Declaration.
While the activity of external partners at the district level has increased, funding and activities provided by these partners are often not included in local plans. HIV/AIDS support show better integration in planning and implementation at the district level than other support. Regarding common arrangements used for fund disbursement, the share of resources provided as programme-based support is not increasing. The predictability of funds coming from outside the government financing mechanism is low.
Greater efforts to integrate partners in district level planning and implementation are needed. External partners must improve the predictability of their support and be more proactive in informing the districts about their intended contributions. With the deadline for achieving the targets set by the Paris Declaration fast approaching, it is time for the signatories to accelerate its implementation.
To explore the relational challenges for general practitioner (GP) leaders setting up new network-centric commissioning organisations in the recent health policy reform in England, we use innovation network theory to identify key network leadership practices that facilitate healthcare innovation.
Mixed-method, multisite and case study research.
Six clinical commissioning groups and local clusters in the East of England area, covering in total 208 GPs and 1 662 000 population.
Semistructured interviews with 56 lead GPs, practice managers and staff from the local health authorities (primary care trusts, PCT) as well as various healthcare professionals; 21 observations of clinical commissioning group (CCG) board and executive meetings; electronic survey of 58 CCG board members (these included GPs, practice managers, PCT employees, nurses and patient representatives) and subsequent social network analysis.
Main outcome measures
Collaborative relationships between CCG board members and stakeholders from their healthcare network; clarifying the role of GPs as network leaders; strengths and areas for development of CCGs.
Drawing upon innovation network theory provides unique insights of the CCG leaders’ activities in establishing best practices and introducing new clinical pathways. In this context we identified three network leadership roles: managing knowledge flows, managing network coherence and managing network stability. Knowledge sharing and effective collaboration among GPs enable network stability and the alignment of CCG objectives with those of the wider health system (network coherence). Even though activities varied between commissioning groups, collaborative initiatives were common. However, there was significant variation among CCGs around the level of engagement with providers, patients and local authorities. Locality (sub) groups played an important role because they linked commissioning decisions with patient needs and brought the leaders closer to frontline stakeholders.
With the new commissioning arrangements, the leaders should seek to move away from dyadic and transactional relationships to a network structure, thereby emphasising on the emerging relational focus of their roles. Managing knowledge mobility, healthcare network coherence and network stability are the three clinical leadership processes that CCG leaders need to consider in coordinating their network and facilitating the development of good clinical commissioning decisions, best practices and innovative services. To successfully manage these processes, CCG leaders need to leverage the relational capabilities of their network as well as their clinical expertise to establish appropriate collaborations that may improve the healthcare services in England. Lack of local GP engagement adds uncertainty to the system and increases the risk of commissioning decisions being irrelevant and inefficient from patient and provider perspectives.
Health Services Administration & Management; Qualitative Research
For decades anatomic pathology (AP) workflow have been a highly manual process based on the use of an optical microscope and glass slides. Recent innovations in scanning and digitizing of entire glass slides are accelerating a move toward widespread adoption and implementation of a workflow based on digital slides and their supporting information management software. To support the design of digital pathology systems and ensure their adoption into pathology practice, the needs of the main users within the AP workflow, the pathologists, should be identified. Contextual inquiry is a qualitative, user-centered, social method designed to identify and understand users’ needs and is utilized for collecting, interpreting, and aggregating in-detail aspects of work.
Contextual inquiry was utilized to document current AP workflow, identify processes that may benefit from the introduction of digital pathology systems, and establish design requirements for digital pathology systems that will meet pathologists’ needs.
Materials and Methods:
Pathologists were observed and interviewed at a large academic medical center according to contextual inquiry guidelines established by Holtzblatt et al. 1998. Notes representing user-provided data were documented during observation sessions. An affinity diagram, a hierarchal organization of the notes based on common themes in the data, was created. Five graphical models were developed to help visualize the data including sequence, flow, artifact, physical, and cultural models.
A total of six pathologists were observed by a team of two researchers. A total of 254 affinity notes were documented and organized using a system based on topical hierarchy, including 75 third-level, 24 second-level, and five main-level categories, including technology, communication, synthesis/preparation, organization, and workflow. Current AP workflow was labor intensive and lacked scalability. A large number of processes that may possibly improve following the introduction of digital pathology systems were identified. These work processes included case management, case examination and review, and final case reporting. Furthermore, a digital slide system should integrate with the anatomic pathologic laboratory information system.
To our knowledge, this is the first study that utilized the contextual inquiry method to document AP workflow. Findings were used to establish key requirements for the design of digital pathology systems.
Anatomic pathology; contextual inquiry; workflow; digital pathology
Pain is a major quality issue. The objective of this study was to evaluate the effectiveness of a series of interventions on pain management.
This controlled clinical trial (April 1, 2002, to February 28, 2003) involved the staggered implementation of 3 interventions into 2 blocks of matched hospital units. The setting was an 1171-bed hospital. A total of 3964 adults were studied. Interventions included education, standardized pain assessment using a 1- or 4-item (enhanced) pain scale, audit and feedback of pain scores to nursing staff, and a computerized decision support system. The main outcome measures were pain assessment and severity and analgesic prescribing.
Units using enhanced pain scales had significantly higher pain assessment rates than units using 1-item pain scales (64% vs 32%; P<.001), audit and feedback of pain results was associated with increases in pain assessment rates compared with units in which audit and feedback was not used (85% vs 64%; P<.001), and the addition of the computerized decision support system was associated with significant increases in pain assessment only when compared with units without audit and feedback (79% vs 64%; P<.001). The enhanced pain scale was associated with significant increases in prescribing of World Health Organization step 2 or 3 analgesic for patients with moderate or severe pain compared with the 1-item scale (83% vs 66%; P=.01). The interventions did not improve pain scores.
A clinically meaningful pain assessment instrument combined with either audit and feedback or a computerized decision support system improved pain documentation to more than 80%. The enhanced pain scale was associated with improved analgesic prescribing. Future interventions should be directed toward altering physician behavior related to titration of opioid analgesics.
To determine which staff behaviours and interventions were helpful to a family who had a child die in the intensive care unit (ICU) and which behaviours could be improved.
Families whose child died six to 18 months earlier were invited to participate. Families whose child’s death involved a coroner’s inquiry were excluded. Family members were interviewed by a grief counselor, and completed the Grief Experience Inventory Profile and an empirically designed questionnaire.
No family refused to participate. All family members (13 families, 24 individuals) reported that they wanted, were offered and had: time to be alone with their child, time to hold the child, chances to discuss their feelings, and an opportunity to cry and express their emotions openly. Tangible mementos of the child were appreciated. Support provided by nursing staff was rated as excellent. Some physicians appeared to be abrupt, cold and unfeeling. Hospital social workers and chaplains, when available, were appreciated. Parents valued access to private space and holding their child, but these options needed to be suggested, as they did not know to ask for them. Some families wanted more information about funeral arrangements; most wanted more timely information about autopsy results and feedback on organ donations. Follow-up contact from the hospital about four weeks after the death was valued. Families saw the study as an opportunity to provide feedback that may help others.
Many acute bereavement interventions need to be initiated by staff because families do not know to request them. Physicians do not always meet individual family’s needs for support. Contact initiated by staff following a death is appreciated.
Communication; Death; Family; Follow-up; Funeral arrangements; Organ retrieval
The study was conducted with the aim to construct a unified nurse appraisal format to be used at hospitals performing under different healthcare organizations in the Eastern Province in the Kingdom of Saudi Arabia.
The study included hospitals representing different healthcare organizations within the Eastern Province. The target population included Hospital head nurses and nurse supervisors and the snowball sampling technique was employed to select the panel subjects.
The final draft resulted into the agreed upon performance dimensions which included namely; quality standards, work habits, supervision/leadership, staff relations and interpersonal skills, attendance and punctuality, problem solving, oral communication, productivity results, coordination, innovation, record keeping.
Nurse managers have to continuously assess competence of practicing nurses to assure qualified and safe patient care. A nurse appraisal form was constructed concurrently with this study results and was proposed to be used at all Eastern Region hospitals. This study is considered an initial step for further efforts and studies to be conducted to reach both national and international nursing appraisal dimensions and unify them for the sake of best health promotion.
nurse; performance; appraisal; Delphi; snowball
To develop and test the validity and reliability of the Withdrawal Assessment Tool - Version 1 (WAT-1) for monitoring opioid and benzodiazepine withdrawal symptoms in pediatric patients.
Prospective psychometric evaluation. Pediatric critical care nurses assessed eligible at-risk pediatric patients for the presence of 19 withdrawal symptoms and rated the patient’s overall withdrawal intensity using a numeric rating scale (NRS) where 0 indicated no withdrawal and 10 indicated worst possible withdrawal. The 19 symptoms were derived from the Opioid and Benzodiazepine Withdrawal Score (OBWS), the literature and expert opinion. Setting: Two Pediatric Intensive Care Units (PICU) in university-affiliated academic children’s hospitals.
83 pediatric patients, median age 35 months (IQR: 7months -10 years), recovering from acute respiratory failure who were weaning from more than 5 days of continuous infusion or round-the-clock opioid and benzodiazepine administration.
Repeated observations during analgesia and sedative weaning. A total of 1040 withdrawal symptom assessments were completed, with a median (IQR) of 11 (6-16) per patient over 6.6 (4.8-11) days.
Measurements and Main Results
Generalized linear modeling was used to analyze each symptom in relation to withdrawal intensity ratings, adjusted for site, subject and age group. Symptoms with high redundancy or low levels of association with withdrawal intensity ratings were dropped, resulting in an 11-item (12-point) scale. Concurrent validity was indicated by high sensitivity (.872) and specificity (.880) (WAT-1 ≥3 predicting NRS ≥4). Construct validity was supported by significant differences in drug exposure, length of treatment and weaning from sedation, length of mechanical ventilation and intensive care unit stay for patients with WAT-1 scores ≥3 compared to those with lower scores.
The WAT-1 shows excellent preliminary psychometric performance when used to assess clinically important withdrawal symptoms in the PICU setting. Further psychometric evaluation in diverse at-risk groups is needed.
drug withdrawal symptoms; opioid analgesia; benzodiazepine; sedation
Along with the increasing prevalence of chronic illness has been an increase in interventions, such as nurse case management programs, to improve outcomes for patients with chronic illness. Evidence supports the effectiveness of such interventions in reducing patient morbidity, mortality, and resource utilization, but other studies have produced equivocal results. Often, little is known about how implementation of an intervention actually occurs in clinical practice. While studies often assume that interventions are used in clinical practice exactly as originally designed, this may not be the case. Thus, fidelity of an intervention's implementation reflects how an intervention is, or is not, used in clinical practice and is an important factor in understanding intervention effectiveness and in replicating the intervention in dissemination efforts. The purpose of this paper is to contribute to the understanding of implementation science by (a) proposing a methodology for measuring fidelity of implementation (FOI) and (b) testing the measure by examining the association between FOI and intervention effectiveness.
We define and measure FOI based on organizational members' level of commitment to using the distinct components that make up an intervention as they were designed. Semistructured interviews were conducted among 18 organizational members in four medical centers, and the interviews were analyzed qualitatively to assess three dimensions of commitment to use--satisfaction, consistency, and quality--and to develop an overall rating of FOI. Mixed methods were used to explore the association between FOI and intervention effectiveness (inpatient resource utilization and mortality).
Predictive validity of the FOI measure was supported based on the statistical significance of FOI as a predictor of intervention effectiveness. The strongest relationship between FOI and intervention effectiveness was found when an alternative measure of FOI was utilized based on individual intervention components that had the greatest variation across medical centers.
In addition to contextual factors, implementation research needs to consider FOI as an important factor in influencing intervention effectiveness. Our proposed methodology offers a systematic means for understanding organizational members' use of distinct intervention components, assessing the reasons for variation in use across components and organizations, and evaluating the impact of FOI on intervention effectiveness.
Improving provider performance is central to strengthening health services in developing countries. Because of critical shortages of physicians, many clinics in sub-Saharan Africa are led by nurses. In addition to clinical skills, nurse managers need practical managerial skills and adequate resources to ensure procurement of essential supplies, quality assurance implementation, and productive work environment. Giving nurses more autonomy in their work empowers them in the workplace and has shown to create positive influence on work attitudes and behaviors. The Infectious Disease Institute, an affiliate of Makerere University College of Health Science, in an effort to expand the needed HIV services in the Ugandan capital, established a community-university partnership with the Ministry of Health to implement an innovative model to build capacity in HIV service delivery. This paper evaluates the impact on the nurses from this innovative program to provide more health care in six nurse managed Kampala City Council (KCC) Clinics.
A mixed method approach was used. The descriptive study collected key informant interviews from the six nurse managers, and administered a questionnaire to 20 staff nurses between September and December 2009. Key themes were manually identified from the interviews, and the questionnaire data were analyzed using SPSS.
Introducing new HIV services into six KCC clinics was positive for the nurses. They identified the project as successful because of perceived improved environment, increase in useful in-service training, new competence to manage patients and staff, improved physical infrastructure, provision of more direct patient care, motivation to improve the clinic because the project acted on their suggestions, and involvement in role expansion. All of these helped empower the nurses, improving quality of care and increasing job satisfaction.
This community-university HIV innovative model was successful from the point of view of the nurses and nurse managers. This model shows promise in increasing effective, quality health service; HIV and other programs can build capacity and empower nurses and nurse managers to directly implement such services. It also demonstrates how MakCHS can be instrumental through partnerships in designing and testing effective strategies, building human health resources and improving Ugandan health outcomes.
To describe a novel process and present results of formative research to develop a pediatric office intervention that uses available systems of care for addressing parental smoking.
The scientific development of the intervention occurred in three stages. In stage one, we designed an office system for parental tobacco control in the pediatric outpatient setting based on complementary conceptual frameworks of preventive services delivery, conceptualized for the child healthcare setting through a process of key interviews with leaders in the field of implementing practice change; existing Public Health Service guidelines that had been shown effective in adult practices; and adaptation of an evidenced-based adult office system for tobacco control. This was an iterative process that yielded a theoretically framed intervention prototype. In stage two, we performed focus group testing in pediatric practices with pediatricians, nurses, clinical assistants, and key office staff. Using qualitative methods, we adapted the intervention prototype based on this feedback to include five key implementation steps for the child healthcare setting. In stage three, we presented the intervention to breakout groups at two national meetings of pediatric practitioners for further refinements.
The main result was a theoretically grounded intervention that was responsive to the barriers and suggestions raised in the focus groups and at the national meetings. The CEASE intervention is designed to be flexible and adaptable to the particular practices' staffing, resources, and physical configuration. Practices can choose materials relevant to their own particular systems of care (www.ceasetobacco.org).
Conceptually-grounded and focus group tested strategies for parental tobacco control are now available for implementation in the pediatric outpatient setting. The tobacco control intervention development process might have particular relevance for other chronic pediatric conditions that have a strong evidence base and have available treatments or resources that are underused.
smoking; tobacco; pediatrics; family practice; parent; smoking cessation; secondhand smoke; environmental tobacco smoke; tobacco control; quitline; telephone counseling