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- Berg, Lena M
(författare)
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Patient safety at emergency departments : challenges with crowding, multitasking and interruptions
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Several challenges with patient safety in the emergency department (ED) context have beenpreviously identified, and some commonly mentioned are crowding, multitasking, andinterruptions. The ED is a complex, high-risk work environment where multiple clinicians(physicians, registered nurses [RNs], and licensed practical nurses [LPNs]) are constantlyworking in parallel work processes, in an often crowded ED, while conducting tasksinvolving cognitively demanding decision-making processes. ED crowding has for the past20 years been identified as a problem internationally, resulting in extended ED length of stay(LOS) and increased morbidity and mortality for patients. ED crowding is also considered tohave negative effects on the clinicians' workload and work satisfaction.Both multitasking and interruptions have been identified as risk factors for patient safety byhaving negative effects on a clinician's decision-making processes and thus increasing therisk of forgetting important details and events because of memory overload. However,information has been lacking about what specific work assignments ED clinicians conduct,and thus there is little information about the types of assignments they perform whilemultitasking and being exposed to interruptions. Further, because not all interruptions lead toerrors and because they are not all preventable, a more refined account of interruptions iscalled for. Moreover, it seems that previous studies have not identified which specific factorsinfluence the ED clinicians' perceptions of interruptions. The work environment has beenreferred to as a possible influencing factor, but specific details on the relationship between thework environment and negative effects from interruptions are pending.The overall aim of the thesis was to describe ED crowding, and its influence on EDclinicians' work processes (activities, multitasking, and interruptions) and patient outcomes,from a patient safety perspective. The thesis addressed six research questions: 1) How has EDcharacteristics, patient case mix and occurrence of ED crowding changed over time? 2) Whatwork activities are performed by ED clinicians? 3) What kind of multitasking situations areclinicians exposed to during ED work? 4) What kind of interruptions are clinicians exposedto during ED work? 5) How do ED clinicians perceive interruptions? 6) Is there anassociation between ED crowding and mortality for stable patients without the need for acutehospital care upon departure from the ED?The data in the thesis were generated from two data collections: 1) registry data containingpatient characteristics and measures of ED crowding (ED occupancy ratio [EDOR], ED LOS,and patient/clinician ratios) extracted from the patients' electronic health records (paper I andIV) and 2) observations and interviews with ED clinicians (physicians, RNs, and LPNs)(paper II and III). Nonparametric statistics were used in paper I and III, quantitative and qualitative content analysis were used in paper II and III, and multivariate logistic regressionanalysis was used in paper IV.The main results in the thesis are presented based on Asplin's conceptual model of EDcrowding, from the aspect of input-throughput-output, and how parts of a sub-optimalthroughput influence patient safety through ED clinicians' work processes and patientoutcomes. During 2009 – 2016 there has been a change in patient case mix at the EDs at thestudy hospital, primarily with an increase in unstable patients (input) and a decrease in thenumber of patients admitted to in-hospital care (output). The median for ED LOS over thestudy period increased, and the largest increases occurred among the subgroups of unstablepatients, patients ≥80 years of age, and those admitted to in-hospital care (throughput).Further, an increase in crowding, in terms of median EDOR and median patients per RNratios, was identified, with an increase in EDOR from 0.8 in 2009 to 1.1 in 2016 and anaverage increase of 0.164 patients/RN/year (throughput). The ED clinicians' workassignments consisted of 15 categories of activities, and information exchange was found tobe the most common activity (42.1%). In contrast, the clinicians only spent 9.4% of theiractivities on direct interaction with patients and their families (ED clinicians' workprocesses). The clinicians multitasked during 23% of their total number of performedactivities, and there was an overall interruption rate of 5.1 interruptions per hour. Themajority of the observed multitasking situations and interruptions in the ED clinicians' workoccurred during demanding activities that required focus or concentration (ED clinicians'work processes). Finally, an association was identified between an increase in ED LOS andEDOR and 10-day mortality for stable patients without the need for acute hospital care upondeparture from the ED (patient outcomes).This thesis illustrates how a sub-optimal throughput, affected by conditions in both the inputand output components, negatively influence the ED clinicians' work processes as well aspatient outcomes.
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| 2. |
- Göras, Camilla, 1969-
(författare)
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Open the door to complexity : Safety climate and work processes in the operating room
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- A complex adaptive system such as the operating room (OR), consists of different safety cultures, sub-cultures and ways of working. When measuring, a strong safety climate has been associated with lower rates of surgical complications. Teamwork is an important factor of safety climate. Discrepancies among professionals’ perceptions of teamwork climate exists. Hence it seems crucial to explore if diversity exists in the perception of factors related to safety climate and between managers and front-line staff in the OR. Complex work processes including multitasking and interruptions are other challenges with potential effect on patient safety. However, multitasking and interruptions may have positive impact on patient safety, but are not well understood in clinical work. Despite challenges a lot of things go well in the OR. Thus, the overall aim of this thesis was to evaluate an instrument for assessing safety climate, to describe and compare perceptions of safety climate, and to explore the complexity of work processes in the OR.To evaluate the Safety Attitudes Questionnaire-operating room (SAQ-OR) version and elicit estimations of the surgical team a cross-sectional study design was used. How work was done was studied by observations using the Work Observation Method by Activity Timing and by group interviews with OR professionals.The results show that the SAQ-OR is a relatively acceptable instrument to assess perceptions of safety climate within Swedish ORs. OR professionals´ perceptions of safety climate showed variations and some weak areas which cohered fairly well with managers' estimations. Work in the OR was found to be complex and consisting of multiple tasks where communication was most frequent. Multitasking and interruptions, mostly followed by communication, were common. This reflects interactions and adaptations common for a complex adaptive system. Managing complexity and creating safe care in the OR was described as a process of planning and preparing for the expected and preparedness to be able to adapt to the unexpected.
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| 3. |
- Nilsson, Karin, 1962-
(författare)
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Adherence to Venous Blood Specimen Collection Practice Guidelines Among Nursing Students and Healthcare Staff
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background Patient safety is an undisputable part of healthcare. The use of clinical practice guidelines, usually based on evidence-based practice/best practice, promotes patient safety and high quality care, reduces unnecessary patient suffering, and healthcare costs. Analysing results from venous blood specimen collection is one of the most commonly used services within healthcare, and a substantial number of decisions on diagnosis, treatment, and treatment evaluation are based on the results. Hence, the accuracy of these tests are vitally important. Earlier research has demonstrated that healthcare staff report suboptimal adherence to venous blood specimen collection guidelines together with the need for improved practices. Blood sample collection is carried out by several professionals, among them registered nurses and, as a consequence, nursing students too. University nursing students learn and practice venous blood specimen collection in one of their first semesters. After initial skill training at clinical skill laboratories, they continue to perform the task during clinical placements in various clinical settings. Few or no studies have been performed on nursing students, hence it seemed important to assess guideline adherence to venous blood specimen collection among university students as well as to further explore adherence to guidelines among healthcare staff. Therefore, the overall aim for this thesis was to explore adherence to, and factors influencing venous blood specimen collection guidelines practice among university nursing students and healthcare staff.Methods The thesis includes four studies. Study I-III had a quantitative, cross-sectional design, study IV had a qualitative approach. Study I included 164 healthcare staff from 25 primary healthcare centres. Study II included 101 nursing students in their 5th and 6th semesters, and study III included 305 nursing students in their 2nd, 4th, and 6th semesters. To assess adherence to venous blood specimen collection guidelines, data were collected using the Venous Blood Specimen Questionnaire, completed with background variables (I, II, III) and additional scales (III). Descriptive statistics, multilevel and multiple logistic regression analyses were used to analyse the data. In study IV, data were collected through five focus group interviews among 6th semester nursing students (n=26). Data were analysed using qualitative content analysis.Results Workplace affiliation was found to explain variances in reported adherence between different primary healthcare centres. Associations between reported venous blood specimen collection practices and individual as well as workplace factors were revealed. Nursing students were found to increasingly deviate from guideline adherence during their education. Also among students, several associations between guideline adherence and other ivfactors were revealed. Reported research use at clinical practice was associated with higher levels of adherence, as were higher capability beliefs regarding both evidence-based practice and academic ability. Analyses from focus group interviews summarised students’ reflections on deviations from VBSC guidelines in the overall theme ‘Striving to blend in and simultaneously follow guidelines’.Conclusion Both healthcare staff at primary healthcare centres and nursing students demonstrate decreasing levels of guideline adherence with time. Factors influencing adherence are both individual as well as contextual. This indicate that both students and staff are subjected to socialisation processes that influences levels of adherence. In order to enhance venous blood specimen collection practices and thereby patient safety, actions must be taken - both in healthcare clinical contexts and by educators. The use of models in practical skill training, and in the ambition to bridge the theory-practice gap may be the path to success. It is reasonable to assume that collaboration between, on the one hand, education representatives and on the other, supervising RNs in clinical settings, will be fruitful. Finally, by empowering students their self-efficacy may be strengthened, and hence their ability to maintain guideline adherence.
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