Effect of a nurse team coordinator on outcomes for hospitalized medicine patients. The efficacy and effectiveness of process consultation in improving staff morale and absenteeism. Randomised controlled trial of specialist nurse intervention in heart failure. An evaluation of nurse-led team care within a rehabilitation ward for elderly people. Evaluation of a MS specialist nurse programme. The effectiveness of primary nursing on burnout among psychiatric nurses in long-stay settings. A randomized control trial of nursing-based case management for patients with chronic obstructive pulmonary disease. Patient, carer and health service outcomes of nurse-led early discharge after breast cancer surgery: a randomised controlled trial. The effect of a respiratory home nurse intervention in patients with chronic obstructive pulmonary disease (COPD). Expanding the role of the stroke nurse: a pragmatic clinical trial. Introducing Critical Care Outreach: a ward-randomised trial of phased introduction in a general hospital. Evaluation of an open-rota system in a Danish psychiatric hospital: a mechanism for improving job satisfaction and work-life balance. Nurses' well-being in a primary nursing care setting in The Netherlands. Substitution of a nursing-led inpatient unit for acute services: randomized controlled trial of outcomes and cost of nursing-led intermediate care.
Several randomized trials have found that discharge planning improves outcomes for hospitalized patients. We do not know if adding a clinical nurse specialist (CNS) to physician teams in hospitals that already have discharge planning services makes a difference.
                In 2 teaching hospitals, patients were randomly assigned to regular hospital care or care with a clinical nurse specialist. The clinical nurse specialist facilitated hospital care by retrieving preadmission information, arranging in-hospital consultations and investigations, organizing postdischarge follow-up visits, and checking up on patients postdischarge with a telephone call. In-hospital outcomes included mortality and length of stay. Postdischarge outcomes included time to readmission or death, patient satisfaction, and the risk of adverse event. Adverse events were poor outcomes due to medical care rather than the natural history of disease.
                A total of 620 sequential patients were randomized (CNS n = 307, control n = 313), of which 361 were followed after discharge from hospital (CNS n = 175, control n = 186). The groups were similar for the probability of in-hospital death (CNS 9.3% vs control 9.7%) or being discharged to the community (58.0% vs 60.0%). The groups did not differ for postdischarge outcomes including readmission or death (21.6% vs 15.6%; P = 0.16) or risk of adverse event (23.6% vs 22.8%). Mean [SD] patient ratings of overall quality of care on a scale of 10 was higher in the clinical nurse specialist group (8.2 [2.2] vs 7.6 [2.4]; P = 0.052).
                The addition of a clinical nurse specialist to a medical team improved patient satisfaction but did not impact hospital efficiency or patient safety. The purpose of this randomized controlled trial was to test the efficacy and effectiveness of process consultation consisting of a series of nurse manager-consultant problem-solving meetings for leadership development that would lead to their staff's improved morale, quality of care, and reduced absenteeism.
                Thirteen consenting clinical inpatient units were stratified for four variables known to affect outcome and were then randomly assigned to treatment and control conditions. The nurse managers from the seven experimental units were paired with outside nurse consultants from the McMaster University School of Nursing (Hamilton, Ontario, Canada) in a cooperative form of retraining in problem-solving through process consultation. Morale was determined through measures of perceptions of the work environment, an attitude scale concerning work (alienation), a personality measure (hardiness), and one of each scale for work satisfaction and for sources of satisfaction and dissatisfaction. Demographic data and information regarding family life responsibilities were collected as well. Assessment of quality of care was determined by the frequency and type of incident reports and by patients' perception of their satisfaction. A ratio of absence hours to total paid hours of work was used to compare experimental and control units' absenteeism rates.
                Experimental subjects reported a statistically significant improvement in the characteristics of their work setting and in the quality of working relationships. The consultation process facilitated a perceived change in the organizational context of the experimental hospital units with less centralization of authority and more clarity about expectation. These organizational changes were accompanied by improved working relationships and less alienation from work. There was no statistically significant difference in absenteeism. However, a subanalysis of the units by "dose" of the intervention identified those who benefited from the effects of the consultation. Subjects whose nurse managers participated more actively in the consultation process accounted for the changes in working relationships and perceived organizational changes. The "low-dose" experimental subjects were more like the control subjects, with the exception of absenteeism, for which they had higher rates.
                The findings of this study suggest that process consultation can alter the staff's perceptions of the characteristics of the work setting, can reverse negative attitudes (alienation), and can create a more positive and supportive working environment (improved working relationship). However, the results suggest the need to target this type of intervention to managers who have the personal resources to engage in self-evaluation and personal development and thus to participate in the consultative process. To determine whether specialist nurse intervention improves outcome in patients with chronic heart failure.
                Randomised controlled trial.
                Acute medical admissions unit in a teaching hospital.
                165 patients admitted with heart failure due to left ventricular systolic dysfunction. The intervention started before discharge and continued thereafter with home visits for up to 1 year.
                Time to first event analysis of death from all causes or readmission to hospital with worsening heart failure.
                31 patients (37%) in the intervention group died or were readmitted with heart failure compared with 45 (53%) in the usual care group (hazard ratio=0.61, 95% confidence interval 0.33 to 0.96). Compared with usual care, patients in the intervention group had fewer readmissions for any reason (86 v 114, P=0.018), fewer admissions for heart failure (19 v 45, P<0.001) and spent fewer days in hospital for heart failure (mean 3.43 v 7.46 days, P=0.0051).
                Specially trained nurses can improve the outcome of patients admitted to hospital with heart failure. This small exploratory study evaluated the effects of introducing a system of nurse-led team care on a ward providing intensive nursing and rehabilitation to elderly people. A quasi-experimental design compared three variables between the study ward and two similar wards within the unit. These were: quality of care, job satisfaction, length of patient stay. Quantitative data were complemented by semi-structured interviews with team members and by observation of team meetings. Quality of care scores showed an improvement on the study ward, but no difference on the main comparison ward. There were no differences between nurse job satisfaction between the study and comparison wards or in length of patient stay throughout the period of evaluation. Observation of team meetings suggested that communication was more structured and focused on the study ward and that patient goals were more clearly specified. Interviews suggested three main factors in successful implementation of the change to nurse-led team care: commitment of the team, open communication about difficulties, the support of managers and medical staff. The main effects noted were: partnership with patients, equality between team members, improved decision making and quality of care. Further studies of nurse-led team care are required, and the stress and anxiety for staff consequent on developing the nurse's role in this way should be considered. Specialist nurses are being promoted as a means of improving the health care provided to people with multiple sclerosis (MS).
                To identify the impact of a programme of MS specialist nurses on MS health care provision and on the health and well-being of people with MS.
                A quasi-experimental design comparing an intervention group in which new MS nurse posts were installed with a control group that had no MS nurse posts.
                Six neurological services in four English regions.
                Seven hundred and fifty-three of the 1510 people invited to participate returned completed questionnaires at baseline. Follow-up of participants was 82% with 616 patients participating in the main outcome analysis.
                Data were collected prospectively before the appointment of the MS nurses and then at 12 and 24 months. Data were collected via a postal questionnaire comprising questions related to care processes (information provision and care quality) and health outcome measures, hospital admissions, MS complications, health-related quality of life (SF36) and disease impact (MS Impact Scale-29). Analysis repeated measures in CAT MOD for process variables and ANCOVA to longest follow-up for outcome measures.
                Information provision was higher in the intervention group (68% (n=153) compared to 53% (n=98) at 24 months) but no significant improvement was observed in information provision through time compared to the control group. There was an increase in the availability of a contact person in the intervention group, at 24 months 83% (n=42) had a contact person compared to 44% in the control (p=0.01). The only significant finding in relation to MS complications was a reduction of 17% in the incidence of pressure ulcers in the intervention sites compared to a 3% reduction in the control (p<0.001). In relation to the disease and health-related quality of life measures, the intervention group showed a small but significant (p<0.05) worsening in the physical and symptom scales of the SF36 compared to the control (mean differences: physical function -2.81, CI -5.45 to -0.1; bodily pain -4.09, CI -7.2 to -0.9; general health -5.35, CI -8.1 to -2.5; and energy and vitality -2.82, CI -5.5 to -0.1). No differences were observed in relation to disease impact or psychosocial well-being, although a relative benefit in mental health (with a 7.8 point advantage on the SF36 mental health scale, p=0.04) was observed in some of the intervention sites for people with relapsing/remitting MS.
                The specialist nurse programme was found to impact positively on the provision of MS-related health care. However, there was very limited evidence that the programme led to any improvements in disease-related problems, impact or health-related quality of life, These findings were in part explained by the inherent difficulties of measuring effects in evaluations of complex phenomena such as a nursing role. The deterioration observed in the intervention group on the physical outcome measures was explained by a selection bias in which people with worsening health were more likely to seek contact with a specialist nurse. It is contended that future research in this area may be better directed toward identifying specific interventions that nurses and other health professionals might employ in addressing the many problems confronting people with MS. This study was set up to test the effectiveness of primary nursing on the burnout level of psychiatric nurses. It was expected that, under certain conditions, such as a primary nursing care delivery with an adequate feedback system, the burnout level would decrease. In a quasi-experimental research design, a cohort of 161 psychiatric nurses was followed for 2.5 years. Results showed that although the burnout level did not change as a result of primary nursing, psychiatric nurses and the practical nurses seemed able to work according to the principles of primary nursing. Strong indications were found that the job turnover decreased as a result of the introduction of primary nursing. Because two main problems were encountered in this study, a high drop-out due to job turnover among nurses and the imitation of the intervention by the control group, several additional analyses were performed. This study assessed the impact of a randomized trial of nursing-based case management for patients with chronic obstructive pulmonary disease, their caregivers, and nursing and medical staff. Sixty-six patients were matched by FEV on admission to hospital, and randomized into an intervention or control group. Intervention group patients reported significantly less anxiety at 1 month postdischarge; however, this effect was not sustained. There was little difference between groups in terms of unplanned readmissions, depression, symptoms, support, and subjective well being. Interviews with patients and caregivers found that the case management improved access to resources and staff-patient communication. Interviews with nursing and medical staff found that case management improved communication between staff and enhanced patient care.(1) Patients with breast cancer who require axillary clearance traditionally remain in hospital until their wound drains are removed. Early discharge has been shown to improve clinical outcomes, but there has been little assessment of the psychosocial and financial impact of early discharge on patients, carers and the health service. This study aimed to evaluate the effectiveness of a nurse-led model of early discharge from hospital. Main outcome measures were quality of life and carer burden. Secondary outcomes included patient satisfaction, arm morbidity, impact on community nurses, health service costs, surgical cancellations and in-patient nursing dependency. A total of 108 patients undergoing axillary clearance with mastectomy or wide local excision for breast cancer were randomised to nurse-led early discharge or conventional stay. Nurse-led early discharge had no adverse effects on quality of life or patient satisfaction, had little effect on carer burden, improved communication between primary and secondary care, reduced cancellations and was safely implemented in a mixed rural/urban setting. In total, 40% of eligible patients agreed to take part. Nonparticipants were significantly older, more likely to live alone and had lower emotional well being before surgery. This study provides further evidence of the benefits of early discharge from hospital following axillary clearance for breast cancer. However, if given the choice, most patients prefer to stay in hospital until their wound drains are removed. Chronic obstructive pulmomary disease (COPD) is associated with substantial mortality, morbidity, and costs to the health care system. With the increasing interest in outreach care programmes it is important to evaluate their impact upon patients and health services, for conditions such as COPD.
                To determine the effectiveness of an outreach respiratory nurse in a shared care approach, with collaboration between general practitioners and hospital services, in the management of patients with severe COPD.
                Patients with severe COPD attending The Queen Elizabeth Hospital, Adelaide participated in a randomised controlled trial of a home based nursing intervention (HBNI) over 12 months with outcome measures including mortality rate, hospital service utilisation, FEV1 and health related quality of life (HRQL) using a modified Dartmouth Primary Care Co-operative Quality of Life questionnaire.
                There were 48 subjects in each study arm, with no differences in mortality rate (eight deaths in the HBNI group and seven in the control group), hospital admissions, length of stay, number of outpatient and Emergency Service visits. The study had inadequate follow-up of FEV1 and HRQL within the control group. Within the HBNI group, a small improvement in HRQL (in three of ten indices measured) was demonstrated, despite a deterioration in FEV1 (11% reduction, p=0.04) compared to baseline. Quality of life of HBNI subjects' carers did not change.
                An increased level of care given by an outreach respiratory nurse in a shared care approach for patients with severe COPD produced small improvements in HRQL but did not result in the prevention of deaths or reduced health care utilisation. This paper reports a study evaluating whether expanding a specialist nursing role to provide outreach education and support to stroke patients and carers after discharge from hospital is effective in promoting recovery.
                Building therapeutic relationships with patients and carers is a key component of the nursing role in stroke rehabilitation, although this is limited by the constraints of service organization.
                A pragmatic randomized controlled trial was undertaken. Patients with a diagnosis of stroke were randomized to receive continued support from a stroke nurse (n = 87) or usual care and follow-up (n = 89) after discharge from hospital. Patients were recruited from two hospitals in the north-west of England from November 1999 to April 2001. Patient dependence (Barthel Index), general health (Nottingham Health Profile), activities of living (Frenchay Activity of Living Index), depression (Beck Depression Inventory) and carer strain (Carer Strain Index) were assessed at 3 and 12 months after stroke.
                The continued intervention of a stroke nurse after discharge was associated with improved patient perceptions of general health at 12 months (median difference 42.6, P = 0.012), and in particular reduced negative emotional reaction (P = 0.037) and perceived social isolation (P = 0.002). In addition, the intervention reduced carer strain at 3 months (P = 0.045), and reduced deterioration in physical dependence from 3 to 12 months (P = 0.049).
                The provision of continued intervention from a stroke nurse after discharge from hospital, focusing on education and support, has tangible benefits for patients and carers. The purpose of the study was to investigate the effects of introducing a critical care outreach service on in-hospital mortality and length of stay in a general acute hospital.
                A pragmatic ward-randomised trial design was used, with intervention introduced to all wards in sequence. No blinding was possible.
                Sixteen adult wards in an 800-bed general hospital in the north of England.
                All admissions to the 16 surgical, medical and elderly care wards during 32-week study period were included (7450 patients in total, of whom 2903 were eligible for the primary comparison).
                Essential elements of the Critical Care Outreach service introduced during the study were a nurse-led team of nurses and doctors experienced in critical care, a 24-h service, emphasis on education, support and practical help for ward staff.
                The main outcome measures were in-hospital mortality and length of stay. Outreach intervention reduced in-hospital mortality compared with control (two-level odds ratio: 0.52 (95% CI 0.32-0.85). A possible increased length of stay associated with outreach was not fully supported by confirmatory and sensitivity analyses.
                The study suggests outreach reduces mortality in general hospital wards. It may also increase length of stay, but our findings on this are equivocal. To evaluate the impact of an open-rota scheduling system on the health, work-life balance and job satisfaction of nurses working in a psychiatric ward in Denmark.
                The effects of shift rotation and scheduling are well known; however, little is known about the wider benefits of open-rota systems. Method A structured questionnaire was distributed to control and intervention groups preintervention and postintervention (20 months). Nurses within the intervention group trialed an open-rota system in which nurses designed their own work-rest schedules.
                Nurses in the intervention group reported that they were more satisfied with their work hours, less likely to swap their shift when working within the open-rota system and reported significant increases in work-life balance, job satisfaction, social support and community spirit when compared with nurses in the control groups.
                The ownership and choice over work-rest schedules has benefits for nurses, and potentially the hospital. A study was conducted in a Dutch hospital to evaluate the effects of the implementation of a Dutch form of Primary Nursing on nurses' well-being in the work situation. The variables used as indicators of well-being at work were job satisfaction, experienced job significance, health complaints and absenteeism. The study included three measuring periods: one pre-intervention (t1) and two post-intervention periods (t2, 8 months after t1, and t3, 14 months after t1). Primary Nursing was implemented in group 1 (consisting of two nursing units) after t1. At this time no changes were introduced into group 2 (three nursing units) but after t2. Primary Nursing was also implemented in group 2. The research variables were measured by means of questionnaires. The results of the study indicate that most of the expected effects of Primary Nursing did not occur. Some methodological and practical explanations for this outcome are given. To evaluate the outcome and cost of transfer to a nursing-led inpatient unit for 'intermediate care'. The unit was designed to replace a period of care in acute hospital wards and promote recovery before discharge to the community.
                Randomized controlled trial comparing outcomes of care on a nursing-led inpatient unit with the system of consultant-managed care on a range of acute hospital wards.
                hospital wards in an acute inner-London National Health Service trust.
                175 patients assessed to be medically stable but requiring further inpatient care, referred to the unit from acute wards.
                89 patients were randomly allocated to care on the unit (nursing-led care with no routine medical intervention) and 86 to usual hospital care.
                Length of hospital stay, discharge destination, functional dependence (Barthel index) and direct healthcare costs.
                Care in the unit had no significant impact on discharge destination or dependence. Length of inpatient stay was significantly increased for the treatment group (P=0.036; 95% confidence interval 1.1-20.7 days). The daily cost of care was lower on the unit, but the mean total cost was pound sterlings 1044 higher-although the difference from the control was not significant (P=0.150; 95% confidence interval - pound sterlings 382 to pound sterlings 2471).
                The nursing-led inpatient unit led to longer hospital stays. Since length of stay is the main driver of costs, this model of care-at least as implemented here-may be more costly. However, since the unit may substitute for both secondary and primary care, longer-term follow-up is needed to determine whether patients are better prepared for discharge under this model of care, resulting in reduced primary-care costs.
The findings suggest interventions relating to hospital nurse staffing models may improve some patient outcomes, particularly the addition of specialist nursing and specialist support roles to the nursing workforce. Interventions relating to hospital nurse staffing models may also improve staff-related outcomes, particularly the introduction of primary nursing and self-scheduling. However, these findings should be treated with extreme caution due to the limited evidence available from the research conducted to date.