Retention of nurses in the primary and community care workforce after the age of 50 years: database analysis and literature review

Title.  Retention of nurses in the primary and community care workforce after theage of 50 years: database analysis and literature review.
Aim.  This paper is a report of a study conducted to explore strategies for retaining nurses and their implications for the primary and community care nursing workforce.
Background.  An ageing nursing workforce has forced the need for recruitment and retention of nurses to be an important feature of workforce planning in many countries. However, whilst there is a growing awareness of the factors that influence the retention of nurses within secondary care services, little is known about those that influence retention of nurses in primary and community care. Little is known about the age profile of such nurses or the impact of the ageing nursing workforce on individual nursing specialities in the England.
Methods.  Nursing databases were analysed to explore the impact of age on nursing specialities in primary and community care. The nurse retention literature was reviewed from 1995 to 2006.
Findings.  Workforce statistics reveal that primary and community care nurses have a higher age profile than the National Health Service nursing workforce as a whole. However, there are important gaps in the literature in relation to the factors influencing retention of older primary and community care nurses. Specific factors exist for older nurses within primary care that are unique. Implications for their retention are suggested.
Conclusion.  Particular attention needs to be paid to factors influencing retention of older nurses in primary and community care. These factors need to be incorporated into local and national policy planning and development.     

Career trajectories of nurses leaving the hospital sector in Ontario, Canada (1993–2004)

Title.  Career trajectories of nurses leaving the hospital sector in Ontario, Canada (1993–2004).
Aim.  This paper is a report of an analysis of the career trajectories of nurses 1 year after leaving hospitals.
Background.  Although hospitals are traditionally the largest employers of nurses, technological advances and budgetary constraints have resulted in many countries in relative shrinkage of the hospital sector and a shift of care (and jobs) into home/community settings. It has been often assumed that nurses displaced from hospitals will move to work in the other workplaces, especially the community sector.
Method.  Employment patterns were tracked by examining a longitudinal database of all 201,463 nurses registered with the College of Nurses Ontario (Canada) between 1993 and 2004. Focusing on the employment categories Active (Working in nursing), Eligible-Seeking nursing employment or Dropout from the nursing labour market, year-to-year transition matrixes were generated by sector and sub-sector of employment, nurse type, age group and work status.
Findings.  For every nurse practising nursing in any non-hospital job or in the community a year after leaving hospitals, an average of 1·3 and four nurses, respectively, dropped out of Ontario's labour market. The proportion of nurses leaving hospitals transitioning to the Dropout category ranged from 63·3% (1994–95) to 38·6% (2001–02). The proportion dropping out of Ontario's market was higher for Registered Practical Nurses (compared to Registered Nurses), increased with age and decreased with degree of casualization in nurses' jobs.
Conclusion.  Downsizing hospitals without attention to the potentially negative impact on the nursing workforce can lead to retention difficulties and adversely affects the overall supply of nurses.     

Decision-making: initiating insulin therapy for adults with diabetes

Title.  Decision-making: initiating insulin therapy for adults with diabetes.
Aim.  This paper is a report of a study to describe nurses' perceptions of decision-making and the evidence base for the initiation of insulin therapy.
Background.  Several theoretical perspectives and professional's attributes underpin decision-making to commence insulin therapy. The management of type 2 diabetes is moving from secondary to primary care and this affects how clinical decisions are made, by whom and the evidence base for these decisions.
Method.  A postal survey was conducted with a stratified sample of 3478 Diabetes Specialist Nurses and Practice Nurses with a special interest in diabetes across the four countries of the United Kingdom. A total of 1310 valid responses were returned, giving a response rate of 37·7%. The questionnaire was designed for the study and pilot-tested before use. Responses were given using Likert-type scales. Data were collected during 2005 and 2006, and one reminder was sent.
Results.  People with diabetes are seen as having little influence in decision-making. Consultant physicians appear to be influential in most decisions, and the nursing groups held varying perceptions of who made clinical decisions. Nurses' identified different responsibilities for those working solely in secondary care from those working in both community and secondary care. Practice nurses were not as involved as anticipated.
Conclusion.  Nurses working with people with diabetes need to encourage them to become more active partners in care. Clinical guidelines can assist in decision-making where nurses are least experienced in initiating insulin therapy.     

Anti-oxidized LDL antibody levels are reduced in women with hypertension

Background  Previous studies have suggested that hypertension may be associated with increased oxidized low-density lipoprotein (LDL). Increased in vitro oxidizability of LDL or elevated titers of anti-oxidized LDL antibodies have been shown in subjects with essential hypertension. However, the relationship between oxidized LDL and hypertension is equivocal. We examined the association between hypertension and levels of IgG anti-oxidized LDL antibodies in a group of women from the general population.
Materials and methods  The study included 619 women classified according to their blood pressure values. IgG anti-oxidized LDL antibodies were measured by enzyme-linked immunosorbent assay and the women were classified as being above or below the 50th percentile.
Results  Hypertension was present in 54·3% of the women. These women had significantly lower levels of IgG anti-oxidized LDL antibodies than the normotensive women (0·280 ± 0·117 vs. 0·336 ± 0·125, P  <   0·001). Both systolic and the diastolic blood pressures showed a significant negative correlation with the levels of IgG anti-oxidized LDL antibodies ( r  = −0·204, P  <   0·001; r  = −0·225, P  <   0·001, respectively). Women with IgG anti-oxidized LDL antibody levels above the 50th percentile had a lower prevalence of hypertension than those with IgG anti-oxidized LDL antibody levels below the 50th percentile (40·2% vs. 59·8%) ( P  <   0·001).
Conclusions  Women with hypertension had lower levels of IgG anti-oxidized LDL antibodies than normotensive women.     

Effect of supportive care on the anxiety of women with suspected breast cancer

Title.  Effect of supportive care on the anxiety of women with suspected breast cancer.
Aim.  This paper is a report of a study of the effect of supportive care on anxiety levels of women with suspected breast cancer during the diagnostic period.
Background.  Informational and psychosocial support has been shown to improve care outcomes for women with breast cancer. However, little is known about the effect of supportive care on women's psychological status during the breast cancer diagnostic period.
Methods.  For this longitudinal quasi-experimental study, 122 participants were recruited from a large teaching hospital in Taiwan. The experimental group ( n  =   62) received a supportive care programme that included health education pamphlets about breast cancer diagnosis and treatment, three face-to-face sessions of informational and emotional support, and two follow-up telephone consultations. The control group ( n  =   60) received routine care. Data were collected from October 2006 to April 2007 using the State-Trait Anxiety Inventory at baseline (notification of need for breast biopsy), before biopsy, and after receiving biopsy result (diagnosis).
Findings.  After adjusting for covariance of breast discomfort, regular breast self-examination, and biopsy result, the anxiety levels of women receiving supportive care were significantly lower before biopsy ( P  =   0·017) and after diagnosis ( P  =   0·001) than those of women receiving routine care.
Conclusion.  Supportive care that incorporates informational and emotional support and follow-up telephone consultations can decrease anxiety levels of women with suspected breast cancer. These findings can serve as a reference for clinical nursing staff to improve care quality during the breast cancer diagnostic period by providing women with individualized and culturally sensitive care.     

Foot health in older people and the nurses' role in foot health care–a review of literature

Scand J Caring Sci; 2010; 24; 194–201
Foot health in older people and the nurses' role in foot health care–a review of literature
Aims:  To describe foot health in older people and the role of nurses in foot health care. There is value in developing preventive measures in foot health care in older people, in creating educational programmes for nurses of foot care and in developing foot health evaluation instrument for nurses.
Methods:  The literature was retrieved from the Medline and CINAHL databases between 1980 and January 2008. Altogether 35 articles were reviewed.
Findings:  Based on the review, older people have a variety of foot health problems. Nurses have a theoretical knowledge of foot care, but they do not consider their clinical skills adequate.
Conclusions:  Future research should focus on evaluating in which areas of foot care nurses' knowledge is strongest and how effective their foot caring activities are. Nurses work closely with older people and are in a position to identify and prevent their foot health problems.     

Is the grass any greener? Canada to United States of America nurse migration

Aim:  Little or no attempt has been made to determine why nurses leave Canada, remain outside of Canada, or under what circumstances might return to Canada. The purpose of this study was to gain an understanding of Canadian-educated registered nurses working in the USA.
Data sources:  Data for this study include the 1996, 2000 and 2004 USA National Sample Survey of Registered Nurses and reports from the same time period from the Canadian Institute for Health Information.
Findings:  This research demonstrates that full-time work opportunities and the potential for ongoing education are key factors that contribute to the migration of Canadian nurses to the USA. In addition, Canada appears to be losing baccalaureate-prepared nurses to the USA.
Discussion:  These findings underscore how health care policy decisions such as workforce retention strategies can have a direct influence on the nursing workforce. Policy emphasis should be on providing incentives for Canadian-educated nurses to stay in Canada, and obtain full-time work while continuing to develop professionally.
Conclusion:  Findings from this study provide policy leaders with important information regarding employment options of interest to migrating nurses.
Study limitations:  This study describes and contrasts nurses in the data set, thus providing information on the context of nurse migration from Canada to the USA. Data utilized in this study are cross-sectional in nature, thus the opportunity to follow individual nurses over time was not possible.     

Impact of community care in enabling older people with complex needs to remain at home

Aim.  This aim of the study was to explore the impact of community care in enabling older people with complex needs to remain at home.
Background.  Changing demographic trends and successive government policies have led to an increase in the number of older people with complex needs residing in the community.
Design.  A qualitative approach using semi-structured interviews was used to collect data from older people ( n  = 17) and carers ( n  = 14).
Method.  Social workers were asked to identify community dwelling older people (65+ years) with multiple needs requiring interventions from a range of health and social care practitioners.
Results.  Community care enabled older people with complex needs who would otherwise have required residential or nursing home care to remain in their own homes. This was the expressed wish of both the older people and carers interviewed.
Conclusions.  The provision of high-quality community care for older people is a globally significant challenge and one that requires creative solutions, both at a local and strategic level.
Relevance to clinical practice.  Nurses and other health and social care professionals need to understand the significance of 'home' for older people and take steps to ensure that additional and appropriate resources are targeted towards community care.     

Coming and staying: a qualitative exploration of Registered Nurses' experiences working in nursing homes

Aim. This paper reports on a qualitative study that explored the reasons why Registered Nurses (RNs) chose to work in nursing homes in Southern Ontario, Canada and what factors attracted them to remain.
Background.  There is a paucity of information about factors associated with the recruitment and retention of RNs within long-term care (LTC) in Canada. As the population of older people is growing in Canada and elsewhere, it is essential that we better understand what attracts RNs to work and remain in this setting.
Design and method. A case study approach was used in this study of nine RNs working in three nursing homes. Data were collected through in-depth interviews.
Findings. Six sub-themes were identified: 'Job of Choice', 'Job of Convenience', 'Caring for the Residents', 'A Supportive Environment', 'Heavy Workload' and 'Supervisory Role of the RN'.
Conclusion. Nurses chose to work in the nursing home because it was a 'Job of Convenience'. However, characteristics of the organizational environment played a major role in their remaining. Also, the caring relationship with residents played a role in the nurses remaining in this setting.
Relevance to clinical practice. Strategies are provided that nurse managers may consider when planning recruitment and retention activities for LTC settings.     

Emotional stability of nurses: impact on patient safety

Title.  Emotional stability of nurses: impact on patient safety.
Aim.  This paper is a report of a study conducted to examine the influence of the emotional stability of nurses on patient safety.
Background.  Individuals with greater emotional stability are less likely to exhibit strong emotional reactions to stressful situations, and tend to be more proactive and successful in problem-solving. Effectively managing patient safety is a priority concern in countries where nurses face high pressure. A heavy work load leads to burnout (a syndrome associated with negative emotions), reduced job satisfaction and increased turnover. While emotional stability influences job performance in various contexts, its influence on patient safety has not been addressed.
Method.  A cross-sectional design was adopted. The sample comprised 263 nurses working in two Taiwanese medical centres. The data were collected in 2007–2008, with a response rate of 92·6%. All participants were nursing college graduates aged below 50 years. Participants provided information on both their emotional stability and patient safety. Staffing adequacy, hospital, and years of nursing experience served as control variables.
Findings.  Hierarchical regression analysis indicated that emotional stability predicted patient safety (β = 0·18, P  < 0·01). The addition of emotional stability as a predictor of patient safety increased the associated explained variance (Δ R ² = 0·03, P  < 0·01).
Conclusion.  It is important for to managers create an organisational climate that promotes the emotional stability of nurses. This could help to improve global patient safety by reducing the frequency of adverse events.     

Clinical relevance of measuring colonic permeability

Background  Gastroduodenal and small intestinal permeability are increased in patients with Crohn's disease (CD) and intensive care patients. The relevance of colonic permeability has not yet been adequately investigated. The aim of this study was to investigate the clinical value of sucralose excretion as indicator for colonic permeability in these patient groups.
Design  After oral administration of four sugars and subsequent analysis of urinary excretion, gastroduodenal and intestinal permeability were calculated from saccharose excretion and lactulose/mannitol (L/M) ratio over 5 h, and sucralose excretion from 5 to 26 h in 100 healthy controls, 29 CD and 35 patients after coronary surgery (CABG).
Results  In controls, sucralose excretion was highly variable (0·67 ± 0·92%) and not related to small intestinal permeability. In CD and CABG, L/M ratio was increased (0·054 ± 0·060; 0·323 ± 0·253 vs. 0·018 ± 0·001 in controls). Sucralose excretion was increased in 77% of CABG but only in 7% of CD. There was an association between gastroduodenal and intestinal permeability in CD and CABG ( r  = 0·72, and r  = 0·51), but sucralose excretion was not related to either one of these two parameters. Other than a weak association between sucralose and length of stay in intensive care in CABG patients ( P  = 0·099), sucralose excretion was not related to clinical outcome.
Conclusions  The proposed cut-off for normal sucralose excretion is 2·11%, but its high variability and lack of association to gastrointestinal permeability or clinical outcome leave it open, if it can provide information beyond established permeability tests.     

PPARγ2 protects against obesity by means of a mechanism that mediates insulin resistance

Background  Many studies have focused on the physiological parameters and genetic predisposition of subjects presenting both obesity and insulin resistance (IR) and it has been suggested that the peroxisome proliferator-activated receptor gamma 2 (PPARγ2) Pro12Ala variant may contribute to the observed variability in insulin sensitivity. We investigated whether the PPARγ2 mRNA expression levels are associated with IR in morbid obesity in adipose and muscle tissues.
Materials and methods  In this study, tissue biopsies were obtained from 26 morbidly obese (MO) patients and eight controls. The MO patients were divided into two groups: those with a low homeostasis model assessment of IR (HOMA-IR < 5) (MO-nonIR) and those with a high HOMA-IR (HOMA-IR ≥ 8) (MO-IR). PPARγ1, PPARγ2 and aP2 mRNA expression levels were measured using quantitative RT-PCR.
Results  The study found that PPARγ2 mRNA expression in visceral adipose tissue (VAT) was significantly lower in the MO patients ( P  = 0·002) than the controls. Moreover, the PPARγ2 mRNA expression was lower in VAT ( P  < 0·05) and muscle tissue ( P  < 0·01), and higher in subcutaneous adipose tissue (SAT) ( P  < 0·01) in the MO-IR than the MO-nonIR group. By contrast, PPARγ1 mRNA expression levels were not dependent on IR. Finally, the MO patients showed a significant negative correlation between PPARγ2 mRNA expression and IR ( r  = −0·396, P  = 0·020) in VAT and a positive correlation in SAT ( r  = 0·826, P  < 0·001). The variable that best explained the IR was PPARγ2 mRNA expression in SAT ( P  = 0·002).
Conclusions  These data show that PPARγ2 mRNA is expressed differently in the two types of MO patients and is associated with IR.     

High extracellular induced sputum haem oxygenase-1 in sarcoidosis and chronic beryllium disease

Background  Sarcoidosis and chronic beryllium disease (CBD) are inflammatory conditions in which oxidative stress state may be crucial for disease outcome. This study compares haem oxygenase-1 (HO-1) extracellular activity for the first time in patients with sarcoidosis or CBD and in healthy controls.
Materials and methods  Induced sputum was recovered using a standard protocol. Pulmonary function tests (PFT) were performed by conventional methods. T lymphocyte subsets (CD4 and CD8) were measured by flow activated cell shorter (FACS). The HO-1 and nitrite levels were measured by a bilirubin-biliverdin reductase-dependant reaction and Greiss reaction respectively. Ferritin and iron levels were measured by enzymatic reaction and chemiluminometric immunoassay respectively.
Results  The mean percentage of lymphocytes was significantly higher in the 36 sarcoid patients compared with that in the 17 controls ( P  =   0·001). The mean CD4/CD8 ratio was significantly higher in the sarcoid and the 10 CBD patients compared to that in controls ( P  =   0·000 and 0·002 respectively), as was the mean HO-1 activity ( P  =   0·045 and 0·041 respectively). The HO-1 activity did not differ with the sarcoidosis stage. The HO-1 level and PFT parameters were negatively correlated. The differences in mean nitrite, ferritin and iron levels were non-significant between the three groups. The HO-1 and ferritin levels were correlated ( P  =   0·008).
Conclusions  We succeeded in non-invasively measuring the activity of HO-1 from cells of airways in spite of its being an intracellular enzyme. The HO-1 levels in sarcoidosis and CBD were abnormally elevated.     

Factors leading to self-extubation of endotracheal tubes in the intensive care unit

Aim and objective:  To discuss the factors leading to self-extubation of endotracheal tubes (ETTs) and explore the differences between the groups of patients who did and did not self-remove their ETTs.
Background:  Self-extubation of ETTs has been reported to occur in 4·2% of severely ill patients and is associated with adverse medical effects.
Design:  A case-control study.
Methods:  One hundred and thirty-nine subjects were recruited from a teaching hospital in southern Taiwan based on purposive sampling. The rate of self-extubation of ETTs was 6·4%. Analysis of the two groups demonstrated that significant variables were identified and fell into three categories: (1) the department to which the patient was admitted ( p  < 0·001), (2) whether the patient met the criteria for extubation ( p  < 0·001) and (3) the patient age ( p  < 0·05). Based on multiple logistic regression analysis, whether the patient met the criteria for extubation was a main variable that was associated with self-extubation of the ETT. Among the 44 patients who had self-extubation of their ETT, 28 met the criteria to be extubated, 70% and 81·8% of whom were not sedated, and self-extubation of their ETT was conscious of the act. Of the patients who attempted to self-remove their ETT, 80% were successful and 93·2% did not incur any adverse medical effects.
Conclusion:  The medical doctor and nurse should fully evaluate a patient's oxygenation status, decrease the length of the extubation training session for patients and extubate patients promptly when extubation criteria are met.
Relevance to clinical practice:  Adopting a proactive approach to patient extubation will improve the overall quality of care.     

Older people living in nursing homes or other community care facilities: Registered Nurses' views of their working situation and co-operation with family members

Background. Little attention has been paid to Registered Nurses’ working conditions and how they experience their working situation in community health care. The nurses’ vocational background is of interest, as well as their apprehension about communicating and co‐operating with the older persons’ family members. Aims and objectives. The aim of the study was to describe Registered Nurses’ views of their working situation in community health care and of co‐operation with family members of older people living in nursing homes or similar facilities. Design. The study was carried out in a geographically defined area in the south of Sweden. A questionnaire was sent to all the Registered Nurses (n = 314) working within community health care of whom 210 Registered Nurses replied to the questionnaires. Methods. Latent content analysis was used on the comments to six questions, in order to illuminate the statistical findings from the statements of the questions measured by the Likert scale. Results. The results showed that almost half of the Registered Nurses working in care of older people are not satisfied with their working situation. The nurses with less than 5 years working experience find their working situation most stimulating. All of them expressed that it is important that there is co‐operation between themselves and the family members and it was also considered important to develop models that could improve co‐operation. Male nurses believed, to a lesser extent, that family members were a resource in caring, compared with female nurses; however, all male nurses stressed the importance of facilitating informal caregivers. Nurses with more than 5 years of working experience expressed that it was important that family members show engagement in caring for older people. Furthermore, they expressed that it was necessary that the family members took care of the older persons’ interests. Relevance to clinical practice. The findings that half of the Registered Nurses are dissatisfied with their working situation have relevance in clinical practice because of the risk of losing competent nurses in this area.     

Perceptions of internal marketing and organizational commitment by nurses

Title.  Perceptions of internal marketing and organizational commitment by nurses.
Aim.  This paper is a report of a study to determine whether a favourable perception of internal marketing is associated with increased organizational commitment.
Background.  The role of nurses in healthcare treatment is expanding, and becoming more important as time progresses. Therefore, the primary concern of business of health care is to use internal marketing strategies effectively to enhance and develop nurses' organizational commitment and reduce turnover to promote competitive advantages for the organization.
Methods.  A cross-sectional design was used. Questionnaires were distributed in 2006 to a convenience sample of 450 Registered Nurses in two teaching hospitals in Taiwan, and 318 questionnaires were returned. Eighteen were excluded because of incomplete answers, which left 300 usable questionnaires (response rate 66·7%). Validity and reliability testing of the questionnaire proved satisfactory and Structural Equation Modeling was used to analyse the data.
Results.  A favourable perception of internal marketing was associated with increased organizational commitment. Communication management had the greatest influence on organizational commitment and external activity had the smallest impact.
Conclusion.  Hospital managers need to recognize the importance of internal marketing for staff retention and the survival of their organizations as competitive pressure increases. As a great deal of time and costs are involved in educating nurses, the best way to retain outstanding nurses and reduce turnover costs and personnel problems is for employers to understand the needs and expectations of their nursing staff.