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Clinical Rounds

doi: 10.1097/01.NURSE.0000553291.10203.e2
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Higher workload leads to missed nursing care



To investigate correlations between shift-level workloads for individual nurses and missed care for assigned patients, researchers studied 136 neonatal ICU (NICU) nurses caring for 418 infants during 332 shifts. Enrolled participants were a convenience sample of nurses who provided direct patient care and had completed unit orientation. Workload was assessed each shift with objective measures and one subjective measure. Cross-classified, multilevel logistic regression models were used to estimate associations of workload with missed care.

The researchers found that an increased infant-to-nurse ratio during a shift was associated with more missed nursing care in about half of the measured missed care items. For this study, missed nursing care was measured by self-report of omission of 11 essential care practices.

Researchers also found that NICU nurses' subjective workload ratings were particularly significant. For example, each 5-point increase in a nurse's subjective workload rating during a shift was associated with a 34% increase in the likelihood of missing a nursing assessment during the same shift. The researchers write that “subjective workload represents an important aspect of nurse workload that remains largely unmeasured despite high potential for intervention.”

Source: Tubbs-Cooley HL, Mara CA, Carle AC, Mark BA, Pickler RH. Association of nurse workload with missed nursing care in the neonatal intensive care unit. JAMA Pediatr. [e-pub November 12, 2018]

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Establish a “reporting culture” to prevent errors

In a recent Sentinel Event Alert, The Joint Commission calls on healthcare organizations to develop a reporting culture that encourages learning from close calls and hazardous conditions. Specific steps healthcare leaders can take to support such a culture are based on the “Four Es of a reporting culture:”

  • Establish trust
  • Encourage reporting
  • Eliminate fear of punishment
  • Examine errors, close calls, and hazardous conditions.

In a reporting culture, “those who report human errors and at-risk behaviors are not punished, so that the organization can learn and make improvements. Those responsible for at-risk behaviors are coached, and those committing reckless acts are disciplined fairly and equitably, no matter the outcome of the reckless act. Senior leaders, unit leaders, physicians, nurses, and all other staff are held to the same standards.”

Read the complete Alert at

Source: The Joint Commission. Sentinel Event Alert, Issue 60. December 11, 2018.

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Nurses dissatisfied with hospital quality of care

In a study of 12,870 clinical nurses in 491 acute care hospitals, nurse researchers investigated RNs' perceptions of the quality of end-of-life (EOL) care in US hospitals and the relationship between the nurse practice environment and EOL care quality. Nurses responding to a survey reported on EOL care quality for patients likely to die within a year. Nurse practice environment was measured using the Practice Environment Scale of the Nursing Work Index, a scale validated by the National Quality Forum.

The results: Most nurses (58%) gave their hospitals an unfavorable overall rating for EOL care; 53% reported that patients often experienced painful procedures that were unlikely to change the outcome. In addition, nurse practice environment was the best predictor of EOL care quality. Compared with nurses in poor practice environments, those in the best environments were 55% less likely to rate their hospital's EOL care unfavorably. The authors note that nurses in high-quality practice environments are more likely to be included in team decision-making and empowered to discuss care options with patients and their families. The authors found no differences in EOL care quality based on hospital size, teaching status, or technology status, and profit status produced only modest differences.

“Our study lends credence to the hypothesis that when nurses have adequate time to spend with patients/families, establish rapport, and elicit patient/family understanding about prognosis and treatment options, and when nurses are involved in team decision making as patient advocates and knowledgeable clinicians, patients/families experience better care,” the authors write.

Source: Lasater KB, Sloane DM, McHugh MD, Aiken LH. Quality of end-of-life care and its association with nurse practice environments in U.S. hospitals. J Am Geriatr Soc. [e-pub December 2, 2018]

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Screening breath test under development

A clinical trial is underway to evaluate a noninvasive screening test for multiple cancer types. The technology analyzes breath samples for the presence of volatile organic compounds (VOCs) associated with cancer. This is the first test of its kind designed to investigate multiple cancer types, according to Professor Rebecca Fitzgerald, lead trial investigator at the Cancer Research UK Cambridge Centre.

Researchers will collect breath samples from 1,500 people, including healthy people as trial controls, to identify VOCs in the breath. The trial will start with patients suspected to have esophageal and stomach cancers and then expand to include patients with prostate, kidney, bladder, liver, and pancreatic cancers. The trial is expected to run until 2021. Researchers hope the results will help pave the way for a universal noninvasive cancer screening test.

Source: Clinical trial launches to develop breath test for multiple cancers. Cancer Research UK. News release. January 2, 2019.

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New guidelines for pregnant patients

In two new practice bulletins, the American College of Obstetricians and Gynecologists (ACOG) has updated its guidelines for the management of chronic hypertension, gestational hypertension, and preeclampsia in pregnant women. Among the highlights:

  • Women with any high-risk factors or more than one moderate risk factor for preeclampsia should receive low-dose aspirin therapy (81 mg/day) for prophylaxis, initiated between 12 and 28 weeks of gestation (preferably, before 16 weeks) and continue the regimen until delivery. High-risk factors for preeclampsia include previous pregnancy with preeclampsia, multifetal gestation, renal disease, autoimmune disease, diabetes mellitus, and chronic hypertension.
  • The same regimen of low-dose aspirin is recommended for pregnant patients with chronic hypertension.
  • Magnesium sulfate is indicated to prevent and treat seizures in women with gestational hypertension and preeclampsia with severe features or eclampsia.
  • Rather than expectant management, delivery is recommended for women with gestational hypertension or preeclampsia without severe features at or beyond 37 0/7 weeks of gestation.
  • Nonsteroidal anti-inflammatory medications are preferred over opioid analgesics.

Sources: ACOG practice bulletin no. 202. Obstet Gynecol. 2019; 133(1):211-214. ACOG practice bulletin no. 203. Obstet Gynecol. 2019;133(1):215-219.

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Nurse-led intervention increases new diagnoses

Early detection of liver disease, which causes few symptoms in its early stages, is essential to arrest or slow progression to cirrhosis. To determine if additional noninvasive testing would increase the number of new liver disease diagnoses compared with usual care, nurses established a nurse-led primary care intervention involving 10 general practitioner (GP) practices. The 10 practices were randomized to either intervention (assessment by a liver health nurse) or control (care as usual). Liver assessment for patients in the intervention arm included a noninvasive fibrosis marker panel and transient elastography. Patients were categorized as follows: no fibrosis, liver warning, progressive fibrosis, or probable cirrhosis. Each new diagnosis was reviewed by a hepatologist.

From July 2014 to September 2016, 544 incident cases of liver disease were identified in the intervention arm compared with 221 in the control arm. Nearly half of participants (n = 910) had some degree of liver disease. The authors concluded that “the incorporation of a liver health nurse into GP practices was simple to arrange and yielded a much higher number of new diagnoses of liver disease compared to usual care.”

For more about assessing and managing liver disease, see “Caring for Patients with Chronic Hepatitis C Infection” on page 36 of this issue.

Source: El-Gohary M, Moore M, Roderick P, et al. Local care and treatment of liver disease (LOCATE) – a cluster-randomized feasibility study to discover, assess and manage early liver disease in primary care. PLoS One. 2018;13(12):e0208798.

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Night-shift work plus unhealthy lifestyles compounds the risk



To investigate the association of type 2 diabetes risk with rotating night-shift work and lifestyle factors, researchers conducted a prospective cohort study involving 143,410 women without type 2 diabetes, cardiovascular disease, or cancer at baseline. The participants were drawn from the Nurses Health Study and Nurses Health Study II. Unhealthy lifestyle was defined as current smoking, low levels of physical activity, low diet quality, and body mass index of 25 or above. Rotating night-shift work was defined as working at least three night shifts per month in addition to day and evening shifts in the same month.

During 22 to 24 years of follow-up, researchers found 10,915 cases of incident type 2 diabetes. The authors write, “The excess risk of rotating night-shift work combined with unhealthy lifestyle was higher than the addition of risk associated with each individual factor. These findings suggest that most cases of type 2 diabetes could be prevented by adhering to a healthy lifestyle, and the benefits could be greater in rotating night-shift workers.”

Source: Shan Z, Li Y, Zong G, et al. Rotating night shift work and adherence to unhealthy lifestyle in predicting risk of type 2 diabetes: results from two large US cohorts of female nurses. BMJ. 2018;363:k4641.

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In March, celebrate

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Once again, nurses come out on top



For the 17th consecutive year, the American public voted nurses as the most honest and ethical among a diverse list of professionals. When asked to rate the honesty and ethical standards of people in 20 select professions, 84% of Americans rated nurses high/very high, followed by medical doctors (67%), pharmacists (66%), and high-school teachers (60%). Members of Congress ranked lowest, with only 41% rating their ethical standards high/very high and 58% rating them low/very low.

Gallup has conducted this survey on various occupations since 1976. The organization notes that except for 2001, when firefighters were on the list after the 9/11 terrorist attacks, “nurses have far outpaced all other professions since they were added to the list two decades ago.”

Source: Gallup. Brenan M. Nurses again outpace other professions for honesty, ethics. December 20, 2018.

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