Tag Archives: Doran

The Emerging Role of PDAs in Information Use and Clinical Decision Making

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Author(s): Doran, D. M.

Publication: Evidence Based Nursing, 2009;12:35-38.

Abstract: One of the great challenges facing healthcare professionals today is the effective and efficient management of an ever-increasing amount of clinically related health information. An important dimension of this challenge is the accessibility of information at times of decision making. Mobile information terminals, such as personal digital assistants (PDAs), have the potential to address this challenge by bringing the most relevant information directly to the point of care. Providing information through convenient electronic sources may address some of the barriers that inhibit access and clinical use of new and relevant research by nurses. The purpose of this Notebook is to explore the use of PDAs to increase nurses’ access to and use of evidence-based resources in practice. It will explore how information and communication technologies, such as PDAs, can support evidence-based practice and will examine the role of information and communication technologies within the context of established knowledge-translation approaches. Recognising that information technologies alone will not change evidence-based practice, the limitations of current technologies will be discussed, drawing on research evidence to argue the importance of considering technological innovation within the context of other knowledge-translation strategies. New or enhanced competencies that will be needed to ensure quality health care were outlined in the publication Crossing the quality chasm.1 They included expertise in evidence-based practice, quality improvement, informatics, and patient-centred care. Each of the skills identified represents a key component of evidence-informed decision making, and they all come together where nurses and patients meet—at the point of care. Nurses must be engaged in continuous learning to acquire patient-centred and treatment-focused information in new and more rewarding ways. Our team has been studying the effectiveness of PDAs and mobile tablet personal computers (tablet PCs) for improving nurses’ access to evidence-based resources at the point of care. Point of care in this context is where nurses and patients interact and could include the bedside, an ambulatory clinic, the home, or even an electronic communication.

An Evaluation of Communication Practices in Ontario Family Health Teams (FHT)

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Research Team:

Dan Laporte
Diane Doran
Linda O’Brien-Pallas

Executive Summary:

The Family Health Team (FHT) initiative is providing care to more than 1.7 million Ontarians, including 180,000 patients who did not previously have a family physician Furthermore, early Ministry estimates suggest that physicians in these new settings will be able to see “up to 52%” more patients a day than physicians working in traditional practice settings.

The Ministry of Health and Long Term Care (MOHLTC) has set a target of implementing an additional 50 family health teams and 25 nurse practitioner-led health care clinics, over the next four years. This will bring the total FHTs to 200 with the hopes of facilitating around-the-clock care for Ontarians and reducing the strain on the already over burdened Emergency departments around the province.

This study is preliminary in nature, and will investigate participant’s experiences working in FHTs, as well as investigate collaboration, role conflict and ambiguity. Although this study is largely exploratory the researchers hope to examine the data for trends linking collaborative practices to wait times, job satisfaction and stress.

Nurses interviewees were asked to provide recommendations to improve the overall efficiency of the Family Health Team initiative. The full list of suggestions included:

1. Improve collaboration and communication within the FHT to enhance inter –disciplinary practice (e.g., teach skills and strategies to implement).

2. Ensure healthcare professionals are working to their full professional capacity

3. Encourage physicians to put forward referrals to other healthcare professionals (e.g., nurse practitioners, dietician etc) to collaboratively manage complex patients, as it is not always necessary for them to see a physician.

4. Implement clinical meetings with all FHT providers to enable conversation about patient care.

5. Encourage physicians to advise patients that they don’t always need to be seen by the physician.

6. Both hire and speed up the hiring process of more RNs, NPs, Pharmacists and Psychiatrists.

7. Develop chronic disease self management programs. 8. Educate the community to what a FHT does and advertise the concept to increase awareness (e.g., community newsletter).

View PDF Full Report

 

Sector Specific Components that Contribute to Positive Work Environments and Job Satisfaction For Nurses/ Issues in Long-Term Care and Community Care

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Executive Summary:

Most data examining the correlation between work environment conditions and job satisfaction for nurses is derived from studies conducted in the acute care/hospital sector. There are fewer studies examining the relationship between work environment and nurse job satisfaction in other employment sectors. In November 2007, the Ontario Ministry of Health and Long-Term Care (MOHLTC) asked the Nursing Health Services Research Unit (University of Toronto site) to conduct a study to explore factors that contribute to job satisfaction for nurses working outside of the acute care (hospital) sector.

This study explored sector specific components that contribute to positive work environments and job satisfaction for nurses working outside of the acute care sector. Specifically, this study examined the recruitment and retention initiatives being implemented by nursing employers in the community, public health and long-term care sectors in various geographic areas of Ontario. The study sought to elicit the perceptions of nurse leaders and front-line staff nurses. The following are the research questions of the study.

1. What recruitment and retention initiatives/Healthy Work Environment (HWE) strategies are nursing employers currently implementing?
2. What are the perceptions of nurse leaders and front line staff regarding the effectiveness of the retention initiatives? What is working and what isn’t?
3. What are the specific recruitment and retention challenges being experienced by nursing employers?
4. What are the main work environment concerns as perceived by nurse leaders and staff nurses? 5. What keeps nurses in their current jobs?
6. Are there generational differences regarding nurses’ job satisfaction?

In a second phase of the study, completed over the winter and spring of 2009, the following questions were also posed to the community care nurses:

1. How are your case loads and working hours decided?
2. How would you characterize or describe the role of the CCACs?
3. What would you describe as some of the positive aspects of working with the CCACs? How about negative aspects?
4. What unique challenges do nurses in your sector face when trying to provide care?
5. How efficient do you feel the current system for administering care in the community is? What recommendations do you have for improving the current system?
6. What are your thoughts on the current model for managing community services (i.e., competitive bidding)? Does it have any impact on your feelings of job security or job satisfaction? Does it have any impact on your ability to provide quality care? Probe: If yes, please describe.

View PDF Full Report

Research Team

Linda O’Brien-Pallas
Diane Doran, RN, PhD

On the Ball: Leadership for Patient Safety and Learning in Critical Care

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Author(s): Tregunno, Deborah, Jeffs, Lianne, McGillis Hall, Linda, Baker, Ross, Doran, Diane, Bookey Bassett, Sue

Publication: Journal of Nursing Administration, 2009 Jul-Aug; 39(7-8): 334-9.

Abstract

Objective: To explore nursing leadership for patient safety in critical care and identify opportunities to improve leadership that promotes patient safety. Background: There is limited systematic evidence about how nurses lead the microsystem of critical care and to the creation of a culture of patient safety.

Methods: Focus groups of multidisciplinary frontline providers and managers were used to gain insight into leadership that promotes patient safety and learning.

Results: Gains in critical care patient safety require a skilled nursing leader who is mindful of bedside situations and has real-time decision-making authority. Patient safety is seen as management of the moment, rather than a function of organizational systems and processes.

Conclusion: Leadership for improved patient safety resides primarily with nurses who provide direct patient care. These nurse leaders play 3 critical roles: they are the “go-to,” they are “on the ball,” and they “keep the ball rolling.”

Integrating Evidence-Based Interventions into Client Care Plans

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Author(s): Doran D. M., Carryer J, Paterson J, Goering P, Nagle L, Kushniruk A, Bajnok I, Clark C, Srivastava R.

Publication: Studies in Health Technologies and Informatics. 2009;143:9-13.

Abstract: Within the mental health care system, there is an opportunity to improve patient safety and the overall quality of care by integrating clinical practice guidelines with the care planning process through the use of information technology. Electronic assessment tools such as the Resident Assessment Inventory – Mental Health (RAI-MH) are widely used to identify the health care needs and outcomes of clients. In this knowledge translation initiative, an electronic care planning tool was enhanced to include evidence-based clinical interventions from schizophrenia guidelines. This paper describes the development of a mental health decision support prototype, a field test by clinicians, and user experiences with the application.

The nature of safety problems among Canadian home care clients: evidence from the RAI-HC Reporting System.

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Author(s): Doran, D.M., Hirdes, J., Blais, R., Baker, G.R., White, N., Pickard, J., & Jantzi, M.

Publication: Healthcare Quarterly Vol. 12 Special Issue 2009.

Abstract

Objective: The objective of this study was to assess the burden of safety problems among Canadian home care (HC) clients.

Methodology: The study methodology involved a secondary analysis of data collected through the Canadian Home Care (HC) Reporting System, which utilizes the RAI-HC© assessment tool. The study sample consisted of all home care clients who qualified to receive a RAI-HC assessment from Ontario, Nova Scotia, Winnipeg Regional Health Authority, and Yukon Territory for the 2003 -2007 reporting period.

Key Findings: The majority of HC clients were in the 75+ age range, female, living with someone else, and cognitively intact. The incidence of new fall was 11%; unintended weight loss 10%; new emergency room visit 8.3%; new hospital visit 7.7%; decline in cognitive performance 5.7%; urinary tract infection 1.9%; deterioration in pressure ulcer 1.8%; new pressure ulcer 1.7%; pneumonia 0.9%; new bowel problem 0.8%; dehydration 0.7%; and caregiver decline 3.3%. Homecare clients presented with multiple risk factors, such as polypharmacy, living alone, and no recent medication review. These risk factors were differentially related to potential adverse outcomes. For example, the odds of emergency room visits increased with history of two or more falls (OR=1.2), cancer diagnosis (OR=1.2), receiving anxiolytic medication (OR=1.2), receiving antidepressant medication (OR=1.4), and polypharmacy (OR=1.5). It decreased with lower self-reliance (OR=0.9) and activities of daily living (0.8).

Conclusion: The RAI-HC© assessment tool provides valuable information about adverse outcomes and risk factors for Canadian home care clients. New fall and emergency room visits were among the most frequent adverse outcomes. Many of the safety risk factors are modifiable but require client behaviour change, health provider behaviour change, and health system policy change. Policies should be developed to encourage best practice related to risk mitigation.

Identification of Safety Outcomes for Canadian Home Care Clients: Evidence From the RAI-HC Reporting System Concerning Emergency Room Visits

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Author(s): Doran, D.M., Hirdes, J., Poss, J., Jantzi, M., Blais, R., Baker, G.R., & Pickard, J.

Publication: Healthcare Quarterly Vol. 12 Special Issue 2009.

Abstract: Problems of patient safety have been well documented in hospitals. However, we have very limited data about patient safety problems among home care clients. The purpose of this study was to assess the burden of safety problems among Canadian home care clients using data collected through the Resident Assessment Instrument – Home Care (RAI HC), and to explore the role of age and patient safety risk factors in explaining variations in adverse outcomes, with a particular focus on emergency room visits. The study methodology involved a secondary analysis of data collected through the Canadian Home Care Reporting System. The study sample consisted of all home care clients who qualified to receive an RAI HC assessment from Ontario, Nova Scotia and Winnipeg Regional Health Authority for the 2003-2007 reporting period. There were a total of 30,396 cases with a paired intake and 12-month follow-up assessment available for analysis. New falls, unintended weight loss, new emergency room (ER) visits and new hospital visits were the most prevalent adverse outcomes. A history of falls, a cancer diagnosis, polypharmacy, receiving an anxiolytic medication and receiving an antidepressant medication were associated with an increased risk of ER visits, while low self reliance and limitation in activities of living were associated with a decreased risk of ER visits. Understanding clients’ risk profiles is foundational to effective patient care.

Work Empowerment in Multidisciplinary Teams During Organizational Change

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Author(s): Rankinen, S., Suominen, T., Kuokkanen, L., Kukkurainen, M.L., & Doran, D.M.

Publication: International Journal of Nursing Practice Volume 15, Issue 5, pages 403–416, October 2009.

Abstract: Conducted as part of a project dealing with work empowerment in multidisciplinary teams in a Finnish hospital specializing in providing care and treatment for different rheumatic conditions, this study set out to explore the associations between organizational change factors and perceived work empowerment in a setting where patients with chronic diseases are being cared for by multiprofessional teams. All health-care professionals working at the hospital under investigation were invited to take part in the survey. Data were collected in 2005 with a structured questionnaire consisting of five parts: background variables, organizational change factors, aspects of work empowerment as well as factors promoting and impeding empowerment. Organizational change factors correlated with work empowerment as well as factors promoting and impeding empowerment. There was little agreement by multiprofessional teams that factors relating to organizational change were present in their work setting. Organizational change factors are important in order to be able to meet the demands by facilitating optimal action during organizational changes. The planning and implementing of organizational changes should be performed in cooperation with personnel throughout the organization at all stages. It would be important to address potential difficulties and try to pre-empt any problems from the planning stage.

Uptake of a Team Briefing in the Operating Theatre: A Burkean Dramatistic Analysis. Social Science & Medicine

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Author(s): Whyte S, Cartmill C, Gardezi F, Reznick R, Orser D, Doran D, Lingard L.

Publication: Social Science & Medicine, 2009 Dec; 69 (12): 1757-66.

Abstract: Communication among healthcare professionals is a focus for research and policy interventions designed to improve patient safety, but the challenges of changing interprofessional communication patterns are rarely described. We present an analysis of 756 preoperative briefings conducted by general surgery teams (anesthesiologists, nurses, and surgeons) at four urban Canadian hospitals in the context of two research studies conducted between August 2004 and December 2007. We ask the questions: how and why did briefings succeed, how and why did they fail, and what did they mean for different participants? Ethnographic fieldnotes documenting the coordination and performance of team briefings were analyzed using Kenneth Burke’s concepts of motive and attitude. The language and behaviour of participants were interpreted as purposive and situated actions which reveal perceptions, beliefs and values. Motives and attitudes varied both within and across sites, professions, individuals, and briefings. They were contingent on the organizational, medical and social scenes in which the briefings took place and on participants’ multiple perceived purposes for participating (protecting patient safety, exchanging information, engaging with the team, fulfilling professional commitments, participating in research, and meeting social expectations). Participants’ attitudes reflected their recognition (or rejection) of specific purposes, the briefings’ perceived effectiveness in serving these purposes, and the briefings’ perceived alignment (or conflict) with other priorities. Our findings illustrate the intrinsically rhetorical and variable nature of change.

Effects of leadership and span of control on nurses’ job satisfaction and patient satisfaction

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Author(s): McCutcheon, A., Doran, D.M., Evans, M., McGillis Hall, L., Pringle, D.

Publication: Nursing Leadership, 22(3) 2009: 48-67.

Abstract

Background: Hospital restructuring has resulted in nurse managers’ having direct responsibility for a greatly expanded number of units and staff. However, very little research has examined the impact of these larger spans of control on nurse and patient outcomes.

Objective: This study examined the relationships between leadership style, span of control, nurses’ job satisfaction and patient satisfaction, as well as the moderating effect of span of control on the relationship between leadership style and the two outcomes.

Methods: The study was conducted at seven teaching and community hospitals with a sample of 51 units, 41 nurse managers, 717 nurses and 680 patients. Data analyses included multiple regression and hierarchical linear modelling.

Results: The study findings provided support for the theoretical relationships among leadership style, span of control, nurse job satisfaction and patient satisfaction. In addition, the results showed that higher spans of control decreased the positive effects of transformational and transactional leadership styles on job satisfaction and patient satisfaction, and increased the negative effects of management by exception and laissez-faire leadership styles on job satisfaction.

Discussion: Leadership matters, and certain leadership styles, particularly transformational, are better than others. Span of control also matters: the wider the span, the lower the nurses’ job satisfaction and patient satisfaction. However, as spans of control increase in size, no leadership style, even transformational, can overcome the negative effects.