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PURPOSE/AIMS Development and implementation of a predictive analytic scoring system in a system of 21 hospitals required 24-hour surveillance to ensure alerts were responded and acted upon. Identification of gaps in patient care created an opportunity to innovate and develop a team to integrate both workflows. DESCRIPTION OF PROJECT/PROGRAM A Virtual Nurse team of master's degree-prepared nurses with backgrounds in intensive care and management led by a clinical nurse specialist work remotely from their homes. Each nurse is assigned to either of 2 workflows: Advance Alert Monitor-predictive analytic scores or e-Hospital involving capturing of care gaps. The Virtual Nurse team covers 24 hours a day/7 days a week. OUTCOMES The program has resulted in 169 lives saved and an observed-to-expected mortality of 0.8. Improvements in standard workflows across the system have enabled Rapid Response Teams to be implemented in each hospital. CONCLUSIONS The success of the Virtual Nurse team has resulted in developments to spread the program into other Kaiser Permanente regions. The Virtual Nurse team has grown to 40 nurses and will expand as the program spreads.

Background An opportunity was identified to compare perceptions of the occurrence and types of missed care at a comprehensive cancer center. Purpose The purpose was to evaluate the difference in perceived occurrence and types of missed care between medical, surgical, and hematologic oncology units in the context of a newly implemented patient care delivery system, Primary Team Nursing (PTN). Methods A descriptive, repeated-measures design was used. The MISSCARE survey was distributed electronically to 580 staff members across 6 inpatient units. Results Frequently perceived elements of missed nursing care were ambulation, turning every 2 hours, and care conference attendance. At the time of study implementation, surgical units reported 0.24 higher scores than medical units (P = .017); hematology units reported 0.26 lower scores than surgical units (P = .005). PTN status did not affect MISSCARE scores (P = .525). Conclusions Study findings suggest that perceived missed care in a comprehensive cancer center is similar to that in other hospital settings.

With the support of colleagues and hospital management, the author, an RN with board certification in therapeutic massage and bodywork, developed and implemented the role of the integrative therapy nurse on the spinal cord injury and disorders unit at the Minneapolis Veterans Affairs Medical Center. The goal of this initiative was to provide patients with additional nonpharmacologic options for addressing their symptoms through the creation of an integrative therapy nurse role within the existing interdisciplinary team of physicians, NPs, psychologists, registered dieticians, physical therapists, occupational therapists, speech pathologists, and staff nurses. This article outlines the process of creating this role, discusses implications for practice, and reports the outcomes of three years of its implementation. The outcomes of decreased pain and increased relaxation among the veterans who participated in this initiative warrant its further expansion to additional clinical settings.

The coexisting conditions of traumatic injury coupled with a comorbid condition such as heart failure create a complex scenario for the trauma nurse to manage. Initial care of the trauma patient includes following the Advanced Trauma Life Support guidelines and managing the airway, breathing, and circulation (ABC) of the patient. Once the airway is secure and breathing is managed, the team addresses circulation. At this point in the patient's care, the team typically does not know which, if any, comorbid conditions exist. Managing circulation for a hypotensive or hypoperfused patient will most likely include 1-2 L of crystalloid solution being given intravenously. Although most patients can tolerate this fluid volume challenge, excess volume can be difficult for a patient with heart failure. This article describes the monitoring and management techniques that are recommended for patients presenting with trauma and the comorbid condition of heart failure.

Evidence-based practice (EBP) occurs when the integration of best evidence is brought to the bedside to ground patient care decisions. Barriers to EBP have lingered for years and held unabated. The experiences of an academic medical center offer fresh perspectives in devolving the accountability for EBP where care is provided and received by patients. More specifically, the initiative is a focused engagement of nurse leaders in administrative positions for energizing bedside nurses to reform the enculturation of EBP. The goal is not to control but to explore approaches of handling the barriers with a complexity mindset amidst uncertainties. Nurses' collective engagement is envisioned to spark or refine creative ideas that will steer and account for EBP outcomes. The flight of the butterfly is used as a metaphor; hence, the title for the Monarch Moments Initiative.

The role of the trauma program manager (TPM) has evolved since the early 1980s. Duties of TPM historically included broad responsibilities such as education, data collection, system, EMS, clinical activities, research, and quality assurance. The purpose of this study was to use survey sampling to evaluate self-perceived functions and scope of work of TPMs in the United States. Results show that TPMs from higher volume centers spend more time on program administration duties whereas TPMs from lower volume centers focus more on registry and clinical duties. Across time, the role has been expanded, refined, and customized, but much role variability remains.

The organization of the work of nurses, according to recognized models of care, can have a significant impact on the wellbeing and performance of nurses and nursing teams. This review focuses on two models of nursing care delivery, namely, team and total patient care, and their effect on nurses' wellbeing.To examine the effectiveness of team nursing compared to total patient care on staff wellbeing when organizing nursing work in acute care wards.Participants were nurses working on wards in acute care hospitals.The intervention was the use of a team nursing model when organizing nursing work. The comparator was the use of a total patient care model.This review considered quantitative study designs for inclusion in the review.The outcome of interest was staff wellbeing which was measured by staff outcomes in relation to job satisfaction, turnover, absenteeism, stress levels and burnout.The search strategy aimed to find both published and unpublished studies from 1995 to April 21, 2014.Quantitative papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute.Data was extracted from papers included in the review using the standardized data extraction tool from the Joanna Briggs Institute. The data extracted included specific details about the interventions, populations, study methods and outcomes of significance to the review question and its specific objectives.Due to the heterogeneity of the included quantitative studies, meta-analysis was not possible. Results have been presented in a narrative form.The database search returned 10,067 records. Forty-three full text titles were assessed, and of these 40 were excluded, resulting in three studies being included in the review. Two of the studies were quasi experimental designs and the other was considered an uncontrolled before and after experimental study. There were no statistically significant differences observed in any study in the overall job satisfaction of nurses using a team nursing model compared with a total patient care model. Some differences in job satisfaction were however observed within different subgroups of nurses. There were no statistically significant differences in either stress or job tension. Within the selected studies, the specific outcomes of absenteeism and burnout were not addressed.Due to the limited number of quantitative studies identified for inclusion in this systematic review it is not possible to determine whether organizing nursing work in a team nursing or total patient care model is more effective in terms of staff wellbeing in acute care settings. Neither a team nursing or total patient care model had a significant influence on nurses' overall job satisfaction, stress levels or staff turnover. This review could not ascertain if the type of model of care affects absenteeism or burnout as these were not addressed in any of the identified studies.Caution should be taken when evaluating which model of care is appropriate and the decision needs to incorporate staff experience levels and staff skill mix. There needs to be clear definition of nursing roles.This review demonstrates the need for further quantitative studies of these models of care that are well designed with sufficient sample sizes to allow for attrition of participants, and that explore the impact each model has on nurse's wellbeing, in particular, studies that address burnout and absenteeism. There is a need for consistent terminology to allow for future comparison and research to occur at an international level. Future studies on models of care should include economic analysis to fully inform policy and practice.

Purpose/objectives This article describes the value of a clinical nurse specialist (CNS) team in partnering with interdisciplinary stakeholders to improve care for women with gynecological cancers receiving radiation via intracavitary-interstitial pelvic implants (IPI). Background Intracavitary-interstitial pelvic implants can prolong survival but is associated with significant impacts on quality of life. Intracavitary-interstitial pelvic implants is a complex and invasive intervention that requires patients to be immobile for 3 days and creates challenges related to dignity, hygiene, nutrition, pain management, emotional health, skin care, and overall patient satisfaction. The nursing staff shared concerns with their respective CNSs regarding patients' quality of care. Lack of standardized practice/orders and gaps in knowledge created challenges. Rationale Clinical nurse specialist practice requires collaborative efforts within the 3 spheres of influence to improve the care of patients receiving IPI therapy. Description The CNSs recognized and addressed needs of patients/families, staff, and the organization across the continuum. The team's efforts relied on reflection of nurses' concerns, collaboration, and a unified vision for exceptional care. Outcomes This CNS-led initiative was successful in establishing processes to ensure quality care. Improvement in patient care was achieved through creation of standardized order sets, a focused plan of care, and patient/family/staff education. Nurse satisfaction, confidence, and empowerment to provide patient care with dignity and sensitivity have been verbalized. Conclusion The CNS team's broad scope of practice, across inpatient, outpatient, and evidence-based practice, is a strength. Key to the team's success was the recognition of challenges and a unified vision to bring together stakeholders to facilitate improvement of care. Future direction includes evaluating nutritional choices and examining psychosocial aspects of the patient's experience. An interdisciplinary nursing grand rounds is planned to highlight the outcomes of this team. Implications The leadership of CNS teams with varied scopes is critical to affecting change within the spheres of influence and improving patient care across the continuum.

A mixed methods study was conducted to identify trauma patients' family members' perceptions of nurses' caring behaviors on a trauma step-down unit at a level I trauma center. Family members completed Caring Behaviors Inventory-Short Form 24 and a qualitative section. Quantitative data were analyzed using descriptive statistics. On a scale of 1 to 6, the mean score for individual items was 5.2 (median = 5.3). Participants considered the nurses' behaviors to be indicative of caring in each of the 4 areas measured-assurance, knowledge/skills, respectfulness, and connectedness. Four themes were identified-technical, nonverbal, personal connections, and addressing comfort.

An organizational goal to decrease fall rates was initiated using a multidisciplinary, multimodal approach. One innovative strategy was the Friday fall review, where nurse managers present each fall that occurred to determine causes and potential preventive measures. Results of the project include a fall rate below the benchmark for 9 of 10 recent consecutive quarters. Because of the success of this initiative, the quality department has adopted the format to review all core measure indicators where there is noncompliance or less than optimal performance.

Walker and Avant's method of concept analysis was used to delve into the initial understanding of compassion fatigue, a relatively new concept being explored with critical care nurses and other health care professionals. The term was originally used in 1992 involving research exploring burnout experienced by critical care nurses when a trend emerged where nurses appeared to have lost their "ability to nurture." The term has since been used synonymously with secondary traumatic stress disorder. Two important goals exist for this article: First, theoretically to conduct a concept analysis of compassion fatigue, thereby providing information for critical care nurses to understand the concept as a universal human experience. Second, from a caring perspective, identifying the effects related to critical care nurses provides an opportunity to address physical and somatic consequences of compassion fatigue that will ultimately become important to nursing practice, education, and research.

The objective of this study was to test the congruence of the perceptions of unit-based nurse leaders (managers, advanced practice nurses) and nursing staff members (registered nurses, nursing assistants, unit secretaries) in acute care hospitals as to the extent and type of missed nursing care and nursing teamwork. Based on the leader-member exchange congruence framework (LMX), nursing staff and nursing leaders completed the MISSCARE Survey, and a segment of the participants completed the Nursing Teamwork Survey. The findings of this study show a lack of LMX congruence between leaders and nursing staff members. Nursing staff report less missed care and lower teamwork than do leaders, and nursing staff list more problems with having adequate material and labor resources than do leaders. LMX congruence has been associated with positive organizational outcomes.

Nurse administrators are challenged to determine the best use of limited resources to support organizational patient safety improvement efforts. This article reviews the literature on techniques to reduce errors and improve patient safety in hospitals with a focus on team training initiatives. Implications for nurse administrators are discussed.

Perceptions of trauma team members and their roles may impact team performance, requiring intervention. Participant observation and semistructured interviews were performed with trauma team members: attendings, nurses, fellows, residents, and medical students. Some team members do not include nurses as members of the team. A greater proportion of male than female team leaders perceived their role as teacher or educator. Nurses, attendings, and fellows, provided parallel descriptions of good leaders, whereas medical students and residents stressed other qualities. Inconsistencies in trauma team role definition and membership should be addressed, toward the goal of improving team communication and patient outcomes.

The admission and discharge (AD) process involves a significant amount of nursing time. The organization explored the use of an AD nurse team on the basis on recommendations from the organization's aging nurse workforce and in an effort to provide bedside nurses more time in direct patient care. A pre-post design was used to evaluate the intervention. Postimplementation patient and nurse satisfaction and the quality of the AD process significantly improved. Findings support the use of an AD team as a method to improve patient and nurse satisfaction and nursing documentation and promote retention of older nurses.

This article discusses a volunteer medical mission of 50 people traveling to Ecuador. Included were surgeons, an anesthesiologist, a gastroenterologist, and an ear, nose, and throat surgeon as well as certified registered nurse anesthetists, registered nurses for pre-, intra-, and postrecovery, a certified registered gastroenterology nurse, and helpers. The focus is on the people involved, starting as strangers, working together, crossing bridges, and helping others in a third world country.

The prevalence of obesity has nearly doubled in the last 3 decades. Nurses practicing in all care settings are looking for creative strategies to achieve safe, effective care for this patient population. Understanding skin injury events and the resulting complications is essential in the development of protocols for care, educational approaches, and interventions providing the best outcomes of care. Areas of concern for the WOC nurse with regard to bariatric patients include bathing, toileting, skin fold management, odor and genital care.

Transforming Care at the Bedside program was developed as a way to improve care on medical-surgical units, patients' and family members' experience of care, and teamwork among care team members and to increase satisfaction and retention of nurses. Average turnover rates for this program's RNs decreased to about 3%, a 58% reduction in rate. The time RNs spent in direct patient care increased 10% compared to the control unit, and value-added care also increased from 10% to 15% over baseline. Patient and staff satisfaction improved.

Shared governance (SG), a process for empowering nurses in practice settings, has been widely used for decades. However, despite enthusiasm for the concept, the process is not always successful or falters after successful initiation. To assist nursing leaders trying to implement or maintain SG processes, the author summarizes literature on both human and structural factors that contribute to the success or breakdown of SG practice models. Barriers to implementation and strategies to support implementation, as well as enculturation of SG, are discussed.

Purpose The focus on recovery for persons with severe and persistent mental illness is leading state psychiatric hospitals to transform their method of care delivery. This article describes a quality improvement project involving a hospital's administration and multidisciplinary state-university affiliation that collaborated in the development and implementation of a nursing care delivery model in a state psychiatric hospital. Description of the project The quality improvement project team instituted a new model to promote the hospital's vision of wellness and recovery through utilization of the therapeutic relationship and greater clinical accountability. Implementation of the model was accomplished in 2 phases: first, the establishment of a structure to lay the groundwork for accountability and, second, the development of a mechanism to provide a clinical supervision process for staff in their work with clients. Effectiveness of the model was assessed by surveys conducted at baseline and after implementation. Outcome Results indicated improvement in clinical practices and client living environment. As a secondary outcome, these improvements appeared to be associated with increased safety on the units evidenced by reduction in incidents of seclusion and restraint. Conclusions Restructuring of the service delivery system of care so that clients are the center of clinical focus improves safety and can enhance the staff's attention to work with clients on their recovery. Implications The role of the advanced practice nurse can influence the recovery of clients in state psychiatric hospitals. Future research should consider the impact on clients and their perceptions of the new service models.

Missed nursing care is a pervasive problem in acute care hospitals as is dysfunctional nursing teamwork. Given that teamwork has a significant impact on healthcare quality and patient safety, the author reports findings from a study that examined differences in perceptions between RNs and nursing assistants as to the extent of missed nursing care and the reasons for missing that care. Study findings point to a lack of essential elements of teamwork (ie, closed-looped communication, leadership, team orientation, trust, and shared mental models). The author analyzes what this reveals about teamwork between these 2 groups of nursing personnel who work side by side caring for the same patients and offers specific interventions.

Purpose This study aimed to explore whether and how staff characteristics, staffing, and scheduling variables are associated with the level of teamwork in nursing staff on acute care hospital patient units. Design This was a cross-sectional study with a sample of 1,758 nursing staff members from two different hospitals on 38 patient care units who completed the Nursing Teamwork Survey in 2008. This study focused on nursing teams who are stationed on a particular patient care unit (as opposed to visitors to the units). The return rate was 56.9%. The sample was made up of 77.4% nurses (registered nurses and licensed practical nurses), 11.9% assistive personnel, and 7.9% unit secretaries. Findings Teamwork varied by unit and service type, with the highest scores occurring in pediatrics and maternity and the lowest scores on the medical-surgical and emergency units. Staff with less than 6 months of experience, those working 8- or 10-hour shifts (as opposed to 12 hours or a combination of 8 and 12 hours), part-time staff (as opposed to full time), and those working on night shift had higher teamwork scores. The higher teamwork scores were also associated with no or little overtime. The higher perception of the adequacy of staffing and the fewer patients cared for on a previous shift, the higher the teamwork scores. Conclusions There is a relationship between selected staff characteristics, aspects of work schedules, staffing, and teamwork. Nursing staff want to work where teamwork is high, and perceptions of good staffing lead to higher teamwork. Higher teamwork scores correlated with those who worked less overtime.

A qualitative study was conducted applying a theoretically based model of teamwork to determine relevant team processes among nurses. Nurses from 5 patient care units participated in focus groups, describing team processes in their daily work. Responses were analyzed in the Salas framework to develop a concrete conceptualization of teamwork within nursing teams. Results support the framework as a means for describing teamwork among nurses.

This is a descriptive study conducted at a multinational working environment, where 1500 nurses representing 52 nationalities are employed. The study aimed at exploring the predominant leadership style of nurse managers through self-evaluation and staff nurses' evaluation and the impact of working in a multinational environment on their intention to stay or quit. The value lies in its focus on leadership styles in an environment where national diversity among managers, staff, and patients is very challenging. The study included 31 nurse managers and 118 staff nurses using Bass and Avolio's (1995) Multifactor Leadership Questionnaire. The results showed that nurse managers and staff nurses reported transformational leadership as predominant with significant difference in favor of nurse managers. Participants' nationality and intention to stay or quit affected their perception of transformational leadership as a predominant style. The implications highlight the need for senior nursing management to set effective retention strategies for transformational nurse managers who work at multinational environments.

In acute care facilities, the orientation period for new graduates has been lengthened to ensure that the new nurse can confidently care for patients. The resulting extension of precepted time places preceptors at a high risk for burnout. To address this issue, team preceptorships during a nurse residency program were implemented as an alternative to a single-preceptor approach. The development, implementation, and evaluation of the team preceptorship model are discussed.

Sexual Assult Nurse Examiner (SANE) programs have become the standard of care for sexual assault victims in many urgent care settings. This study examines SANE clinical nursing practices at one Canadian sexual assault urgent care centre. Language: en

Objective To determine whether a transport team composed of advanced practice nurses could function as effectively as a physician-nurse team, as measured by patient outcome. Design Observational cohort study. Setting The interfacility transport team at a tertiary care children's hospital. Patients and other participants Fourteen transport nurses and 539 patients. Methods A transport team was studied during a previously planned change in composition from a physician-nurse team to a nurse-nurse team. Data were recorded by transport nurses and by subsequent review of the medical record during two 4-month periods, 1 before and 1 after the team change. Pediatric risk of mortality scores (a marker for degree of illness) were assigned for the periods before, during, and after transport. Transport time intervals, demographic data, and patient outcomes were also recorded. Data were assessed using frequency tables for discrete variables, as well as mean and standard deviation for continuous variables. For identification of group differences, chi test was used. Main outcome measures Mortality, transport-related morbidity, overall transport times and interval times, and outcome of procedures performed by transport nurses. Results Five hundred thirty-nine data sheets were received: 228 before (group 1) and 311 after (group 2) the team change. Physicians attended 128 (56.1%) group 1 transports and 15 (4.82%) group 2 transports. There were no significant differences in mean pediatric risk of mortality scores between group 1 and group 2 patients. Mortality was equivalent. Group 2 transport times were significantly shorter than group 1 times. Transport nurses performed 8 intubations; all were successful. Conclusions Outcomes for the 2 types of teams were equivalent. Nonphysician teams responded more quickly and spent less time at the referring facility.

Measurable indicators create a profile of an organization's function and provide direction. In this study structure, process and outcome indicators for sexual assault victims are assessed and evaluated. The results present a portrait of the function, weaknesses, and benefits of one community SART program. The research findings suggest the need for improved documentation in the acute setting as well as the need for regular case review and case tracking to identify gaps in services.

Traditional models of patient care delivery include total patient care and functional, team, and primary nursing. These models differ in clinical decision making, work allocation, communication, and management, with differing social and economic forces driving the choice of model. Studies regarding quality of care, cost, and satisfaction for the models provide little evidence for determining which model of care is most effective in any given situation. Despite lack of evidence, newer models continue to be implemented. This article compares the advantages and disadvantages of models, critiques the existing studies, and offers recommendations regarding the evidence needed to make informed decisions regarding care delivery models.

To offer advanced nursing care for people living with HIV, a participatory action research project was initiated that enabled constant learning and change at the levels of (a) the culture and organization of an outpatient department, (b) clinical leadership and interdisciplinary collaboration, and (c) development of new services. In this project, the development of the Advanced Nursing Practice (ANP) Team not only affected the practice of individual nurses with advanced degrees but also created a team of nurses educated at different levels. Through a systematic process, the nurses on the team became more educated and refined their clinical expertise. An essential aspect of the ANP Team was the specialization of each nurse in a self-selected topic within HIV/AIDS care. As members of the ANP Team, the nurses offer state-of-the-art nursing care including patient assessment, medication management and adherence support, symptom management, health maintenance and prevention, and family support for persons living with HIV.

Creating a culture of patient safety often involves developing nursing care models that effectively use nursing resources. These authors discuss a nursing care model that focuses on the experienced nurses to enhance the use of their expertise. They provide more direct oversight and surveillance for the care given to all patients through leadership, mentoring, and collaborative practice. The experienced nurse is valued as a clinical leader, instrumental to the development of a safe practice environment. Implementation of this model has resulted in dramatic improvements in safety and registered nurse retention.

Although numerous studies have focused on conflict management, few have considered the effects of unit technology and intrapersonal, intragroup, and intergroup conflict on team performance effectiveness and work satisfaction. The model was tested using a nonexperimental design. Path analysis using multiple regression was used to test the model. The nonrandom sample consisted of 141 nurses employed on 13 inpatient units at a state-supported, 597-bed academic medical center in a southeastern city. Findings indicated that intrapersonal conflict had a direct negative impact on intragroup conflict and work satisfaction. Intragroup conflict had direct negative effects on work satisfaction and team performance effectiveness. Unit technology had a direct negative impact on work satisfaction. Findings have implications for administrators to implement strategies to decrease a stressful work environment and increase team-building activities.

In today's ever-changing acute care setting, justifying the allocation of resources for development and implementation of a Vascular Access Team (VAT) can often be challenging. The Infusion Nurses Society (2000), which establishes standards of practice for the infusion nursing profession, states that "the profession itself must seek control of its practice to assure the quality of its services to the public. A profession's concerns for quality services reflects its commitment to serving the community." This article discusses the steps that were taken in the development of a VAT in the acute care setting of Froedtert Memorial Lutheran Hospital, a teaching hospital affiliated with the Medical College of Wisconsin.

Using the FOCUS-PDCA process, this article outlines an early intervention project focusing on improving patient interventions for skin care using OASIS data.

All neuroscience nurses must be able to evaluate different avenues to inform their practice and solve clinical problems. The three methodologies discussed in this article have particular strengths in certain situations and require different skill sets, time, and resources. Quality improvement, evidence-based practice, and research are interconnected and inform each other. It can be difficult at times for the practitioners to identify the right method to answer clinical questions. The state of readiness for frontline staff to manage clinical problems with evidence-based practice and research must be advanced for the scientific knowledge employed by our profession to be visible in our clinical care.

This paper reviews the literature on the psychological effects of change and discusses the impact of an overarching organizational change on the staff nurses of a large oncology unit in the Midwest. Their reactions are compared with a grief-change framework synthesized from the literature. This framework was useful in explaining staff nurse behaviors and attitudes, and offered interventions specific to each stage of the change process useful to the CNS. Dissemination of this information is discussed, as well as implications for advanced nursing practice.

To handle increased asaultive behavior on three psychiatric units while keeping staff and other patients safe, a Crisis Response Team was developed consisting of staff from psychiatry and officers from security. A written manual included the new policies and procedures and teaching content for verbal and physical deescalation techniques. A special inservice education program for assaultive crisis management was implemented. This model can be replicated in other areas of healthcare where it is necessary to deal with patients who lose verbal or physical control. Language: en