Do educational interventions improve nurses' clinical decision making and judgement? A systematic review

Objectives

Despite the growing popularity of decision making in nursing curricula, the effectiveness of educational interventions to improve nursing judgement and decision making is unknown. We sought to synthesise and summarise the comparative evidence for educational interventions to improve nursing judgements and clinical decisions.

Design

A systematic review.

Data sources

Electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, CINAHL and PsycINFO, Social Sciences Citation Index, OpenSIGLE conference proceedings and hand searching nursing journals.

Review methods

Studies published since 1960, reporting any educational intervention that aimed to improve nurses’ clinical judgements or decision making were included. Studies were assessed for relevance and quality. Data extracted included study design; educational setting; the nature of participants; whether the study was concerned with the clinical application of skills or the application of theory; the type of decision targeted by the intervention (e.g. diagnostic reasoning) and whether the evaluation of the intervention focused on efficacy or effectiveness. A narrative approach to study synthesis was used due to heterogeneity in interventions, study samples, outcomes and settings and incomplete reporting of effect sizes.

Results

From 5262 initial citations 24 studies were included in the review. A variety of educational approaches were reported. Study quality and content reporting was generally poor. Pedagogical theories were widely used but use of decision theory (with the exception of subjective expected utility theory implicit in decision analysis) was rare. The effectiveness and efficacy of interventions was mixed.

Conclusions

Educational interventions to improve nurses’ judgements and decisions are complex and the evidence from comparative studies does little to reduce the uncertainty about ‘what works’. Nurse educators need to pay attention to decision, as well as pedagogical, theory in the design of interventions. Study design and reporting requires improvement to maximise the information contained in reports of educational interventions.     

Work motivation of nurses: a literature review

Objectives

The aim of this review is to describe nurses’ work motivation from the perspective of staff nurses. This information would be useful for the development of motivation strategies and further research into nurses’ work motivation.

Design

A thorough review of the research literature.

Data sources

The literature search was performed using four databases: CINAHL, PubMed, PsychINFO, and SocINDEX. Only studies that met the following criteria were selected for review: (1) were published between 1990 and 2009, (2) were written in English, (3) dealt with work motivation, (4) concerned working staff nurses, (5) involved empirical research, (6) clearly and explicitly provided the research results about the factors affecting nurses’ work motivation. Altogether 24 studies met these criteria and were included in this review.

Review methods

Inductive content analysis was carried out to analyse and categorise the data.

Results

Nursing research has neither clear understanding nor consensus about the concept of work motivation; nor has a universal definition been adopted. Despite limited empirical evidence it may be concluded that staff nurses appear to be motivated. Five categories of factors affecting their work motivation were identified: (1) work-place characteristics, (2) working conditions, (3) personal characteristics, (4) individual priorities, and (5) internal psychological states.

Conclusions

Further research is needed to gain a more comprehensive insight into nurses’ work motivation and the factors affecting it. This can be achieved by defining the concept of work motivation as precisely as possible, working out a pertinent research methodology, and subsequently developing and testing a theoretical model of nurses’ work motivation.     

Rescuing A Patient In Deteriorating Situations (RAPIDS): an evaluation tool for assessing simulation performance on clinical deterioration

Aim

This article is a report of a study which developed and tested the validity and reliability of the RAPIDS-Tool to measure student nurses’ simulation performance in assessing, managing and reporting of clinical deterioration.

Background

The importance for nurses to recognize and respond to deteriorating patients has led educators to advocate for increasing use of simulation for developing this competency. However, there is a lack of evaluation tools to objectively evaluate nurses’ simulation performance on clinical deterioration.

Method

The study was conducted in three phases. Phase 1 began with development of items for the RAPIDS-Tool from the basis of a literature review and a panel of national experts’ consensus. Phase 2 established the content validity of the RAPIDS-Tool by a panel of international experts and by undertaking a pilot test. Phase 3 involved testing the psychometric properties of the RAPIDS-Tool, on 30 video-recorded simulation performances, for construct validity, inter-rater reliability, and correlation between two scoring systems.

Results

The process of development and validation produced a 42-item RAPIDS-Tool. Significant differences (t = 15.48, p < 0.001) in performance scores among participants with different levels of training supported the construct validity. The RAPIDS-Tool demonstrated a high inter-rater reliability (ICC = 0.99) among the three raters and a high correlation between the global rating and checklist scores (r = 0.94, p < 0.001).

Conclusion

The RAPIDS-Tool provides a valid and reliable tool to evaluate nurses’ simulation performances in clinical deterioration. This may prove useful for future studies that investigate outcomes of simulation training.     

What patient characteristics guide nurses’ clinical judgement on pressure ulcer risk? A mixed methods study

Background

Nurses’ clinical judgement plays a vital role in pressure ulcer risk assessment, but evidence is lacking which patient characteristics are important for nurses’ perception of patients’ risk exposure.

Objectives

To explore which patient characteristics nurses employ when assessing pressure ulcer risk without use of a risk assessment scale.

Design

Mixed methods design triangulating observational data from the control group of a quasi-experimental trial and data from semi-structured interviews with nurses.

Setting

Two traumatological wards at a university hospital.

Participants

Quantitative data: A consecutive sample of 106 patients matching the eligibility criteria (age ≥18 years, no pressure ulcers category ≥2 at admission and ≥5 days expected length of stay). Qualitative data: A purposive sample of 16 nurses.

Methods

Quantitative data: Predictor variables for pressure ulcer risk were measured by study assistants at the bedside each second day. Concurrently, nurses documented their clinical judgement on patients’ pressure ulcer risk by means of a 4-step global judgement scale. Bivariate correlations between predictor variables and nurses’ risk estimates were established. Qualitative data: In interviews, nurses were asked to assess fictitious patients’ pressure ulcer risk and to justify their risk estimates. Patient characteristics perceived as relevant for nurses’ judements were thematically clustered. Triangulation: Firstly, predictors of nurses’ risk estimates identified in bivariate analysis were cross-mapped with interview findings. Secondly, three models to predict nurses’ risk estimates underwent multiple linear regression analysis.

Results

Nurses consider multiple patient characteristics for pressure ulcer risk assessment, but regard some conditions more important than others. Triangulation showed that these are measures reflecting patients’ exposure to pressure or overall care dependency. Qualitative data furthermore indicate that nurses are likely to trade off risk-enhancing conditions against conditions perceived to be protective. Here, patients’ mental capabilities like willingness to engage in one owns care seem to be particularly important. Due to missing information on these variables in the quantitative data, they could not be incorporated into triangulation.

Conclusions

Nurses’ clinical judgement draws on well-known aetiological factors, and tends to expand conditions covered by risk assessment scales. Patients’ care dependency and self-care abilities seem to be core concepts for nurses’ risk assessment.     

Job characteristics, organizational conditions, and distress/well-being among Italian and Dutch nurses: a cross-national comparison

Background

Among health care workers, nursing has been identified as particularly stressful. Several studies have shown cross-national differences in nurses’ levels of occupational stress and burnout.

Objectives

The purpose of the study was to compare job characteristics, organizational conditions, and strain reactions in Italian (N = 609) and Dutch (N = 873) nurses. It was also examined how and to what extent various job characteristics and organizational conditions explain occupational and general strain.

Design

The study was a cross-sectional questionnaire survey.

Method

Based on the Job Demand-Control-Support Model and the Tripod accident causation model, respectively job characteristics and organizational conditions were assessed as independent variables. Strain was operationalized in terms of job satisfaction, burnout, and psychosomatic complaints.

Results

Italian nurses perceived their job characteristics, organizational conditions, and well-being as more unfavourable than their Dutch colleagues. Hierarchical regression analyses showed that high job demands, low skill discretion, and low social support from supervisor were the most consistent predictors of occupational and general strain across samples. Organizational conditions added significantly to the prediction of job satisfaction and burnout. Furthermore, lack of personnel was a stronger predictor of burnout in the Italian nurses than in the Dutch nurses.

Conclusions

The study provides cross-national confirmation of the impact of job characteristics and organizational conditions on nurses’ well-being. Differences in job characteristics partially explain the observed cross-national differences in distress/well-being. Furthermore, some evidence for crossnational differential effects of job characteristics and organizational conditions on well-being was found.     

Nurses’ attitudes to mental illness: A comparison of a sample of nurses from five European countries

Background

Mental health problems are of serious concern across Europe. A major barrier to the realisation of good mental health and well-being is stigma and discrimination. To date there is limited knowledge or understanding of mental health nurses’ attitudes towards mental illness and individuals experiencing mental health problems.

Objectives

To describe and compare attitudes towards mental illness and those experiencing mental health problems across a sample of registered nurses working in mental health settings from five European countries and the factors associated with these attitudes.

Design

A questionnaire survey.

Settings

A total of 72 inpatient wards and units and five community facilities in Finland, Lithuania, Ireland, Italy and Portugal.

Participants

810 registered nurses working in mental health settings.

Methods

The data were collected using The Community Attitudes towards the Mentally Ill (CAMI) scale, which is a 40-item self-report questionnaire. The data were analysed using quantitative methods.

Results

Nurses’ attitudes were mainly positive. Attitudes differed across countries, with Portuguese nurses’ attitudes being significantly more positive and Lithuanian nurses’ attitudes being significantly more negative than others’. Positive attitudes were associated with being female and having a senior position.

Conclusions

Though European mental health nurses’ attitudes to mental illness and people with mental health problems differ significantly across some countries, they are largely similar. The differences observed could be related to wider social, cultural and organisational circumstances of nursing practice.     

Prevalence and impact on quality of life of lower urinary tract symptoms among a sample of employed women in Taipei: A questionnaire survey

Background

Previous studies about the prevalence and impact of lower urinary tract symptoms (LUTS) were focused on urinary incontinence or overactive bladder in the general population. Little research has been focused on the role that the workplace has in employed women's experiences with LUTS or the impact of LUTS on their health-related quality of life (HRQL).

Objectives

To estimate the prevalence of LUTS among employed female nurses in Taipei and to compare the HRQL for nurses with and without LUTS.

Design

This study was a cross-sectional, questionnaire survey.

Settings

Three medical centers and five regional hospitals in Taipei were selected randomly.

Participants

In the selected hospitals, 1065 female nurses were selected randomly. Data analyses were based on 907 usable surveys. All participants were native Taiwanese; most of the female nurses were 26-35 years of age (mean = 31.02, SD = 6.32), had normal body mass index, and had never given birth. Most nurses’ bladder habits were poor or very poor and their personal habits of fluid consumption at work were inadequate.

Methods

Data were collected using the Taiwan Nurse Bladder Survey and the Short Form 36 Taiwan version. Chi-square tests were used to compare the prevalence rates of different LUTS for nurses in different age groups. Student's t-tests were conducted to compare the mean scores of HRQL for nurses with and without LUTS.

Results

Based on 907 usable surveys, 590 (65.0%) experienced at least one type of LUTS. The prevalence for different LUTS ranged from 8.0% to 46.5%. Nurses who reported LUTS also reported lower HRQL, more so on physical health than mental health, than nurses who did not report LUTS.

Conclusions

Although most of the nurses in this study were young (≦35 years) and nulliparous, LUTS were common among this group. The high prevalence rate of LUTS leads to concerns about nurses’ possible dysfunctional voiding patterns and possible effects of working environment and poor bladder and personal habits on LUTS. Study results showed a possible negative impact of LUTS on nurses’ physical health. Designing a continence-related education program for this group is essential for delivering information about LUTS prevention and management.     

Reward frustration at work and intention to leave the nursing profession--prospective results from the European longitudinal NEXT study

Background

Many countries are facing a serious situation of nursing shortage, and retention of nurses is a challenge.

Objectives

To examine whether reward frustration at work, as measured by the effort-reward imbalance model, predicts intention to leave the nursing profession, using data from the European longitudinal nurses’ early exit study.

Design

A prospective study with one-year follow-up.

Methods

6469 registered female nurses working in hospitals in seven European countries who did not have intention to leave the nursing profession at baseline were included in our analyses by multivariate Poisson regression.

Results

8.24% nurses newly developed intention to leave during follow-up. High effort-reward imbalance at baseline predicted an elevated risk of intention to leave the profession (relative risk 1.33, 95% confidence interval 1.22-1.45), and reward frustration (poor salary and promotion prospects, lack of esteem) showed the strongest explanatory power. Findings were similar in a majority of the countries.

Conclusions

Results suggest that improving the psychosocial work environment, and specifically occupational rewards, may be helpful in retaining nurses and consequently reducing nursing shortage in Europe.     

The effect of the SAFE or SORRY? programme on patient safety knowledge of nurses in hospitals and nursing homes: A cluster randomised trial

Background

Patients in hospitals and nursing homes are at risk for the development of often preventable adverse events. Guidelines for the prevention of many types of adverse events are available, however compliance with these guidelines appears to be lacking. As a result many patients do not receive appropriate care. We developed a patient safety program that allows organisations to implement multiple guidelines simultaneously and therefore facilitates guideline use to improve patient safety. This program was developed for three frequently occurring nursing care related adverse events: pressure ulcers, urinary tract infections and falls. For the implementation of this program we developed educational activities for nurses as a main implementation strategy.

Objectives

The aim of this study is to describe the effect of interactive and tailored education on the knowledge levels of nurses.

Design

A cluster randomised trial was conducted between September 2006 and July 2008.

Settings

Ten hospital wards and ten nursing home wards participated in this study. Prior to baseline, randomisation of the wards to an intervention or control group was stratified for centre and type of ward.

Participants

All nurses from participating wards.

Methods

A knowledge test measured nurses’ knowledge on the prevention of pressure ulcers, urinary tract infections and falls, during baseline en follow-up. The results were analysed for hospitals and nursing homes separately.

Results

After correction for baseline, the mean difference between the intervention and the control group on hospital nurses’ knowledge on the prevention of the three adverse events was 0.19 points on a zero to ten scale (95% CI: −0.03 to 0.42), in favour of the intervention group. There was a statistically significant effect on knowledge of pressure ulcers, with an improved mean mark of 0.45 points (95% CI: 0.10-0.81). For the other two topics there was no statistically significant effect. Nursing home nurses’ knowledge did neither improve (0 points, CI: −0.35 to 0.35) overall, nor for the separate subjects.

Conclusion

The educational intervention improved hospital nurses’ knowledge on the prevention of pressure ulcers only. More research on long term improvement of knowledge is needed.

Trial registration

ClinicalTrials.gov ID [NCT00365430].     

Nurses’ ethical reasoning and behaviour: A literature review

Background

Today's healthcare system requires that nurses have strong medical-technical competences and the ability to focus on the ethical dimension of care. For nurses, coping with the ethical dimension of care in practise is very difficult. Often nurses cannot act according to their own personal values and norms. This generates internal moral distress, which has a negative impact on both nurses and patients.

Objectives

The objective of this review is a thorough analysis of the literature about nurses’ ethical practise particularly with regard to their processes of ethical reasoning and decision making and implementation of those decisions in practise.

Design

We conducted an extensive search of the electronic databases Medline, Embase, Cinahl, and PsycInfo for papers published between January 1988 and September 2008. A broad range of search keywords was used. The 39 selected articles had a quantitative, qualitative, or mixed-method design.

Findings

Despite the conceptual difficulties that the literature on the ethical practise of nurses suffers, in this review we understand nurses’ ethical practise a complex process of reasoning, decision making, and implementation of the decision in practise. The process of decision making is more than a pure cognitive process; it is influenced by personal and contextual factors. The difficulties nurses encounter in their ethical conduct are linked to their difficult work environment. As a result, nurses often capitulate to the decisions made by others, which results in a conformist way of acting and less individually adapted care.

Conclusions

This review provides us with a more nuanced understanding of the way nurses reason and act in ethically difficult situations than emerged previously. If we want to support nurses in their ethical care and if we want to help them to change their conformist practises, more research is needed. Especially needed are in-depth qualitative studies that explore the experiences of nurses. Such studies could help us better understand not only how nurses reason and behave in practise but also the relationship between these two processes.     

Front-line management, staffing and nurse-doctor relationships as predictors of nurse and patient outcomes. a survey of Icelandic hospital nurses

Objective

To investigate aspects of nurses’ work environments linked with job outcomes and assessments of quality of care in an Icelandic hospital.

Background

Prior research suggests that poor working environments in hospitals significantly hinder retention of nurses and high quality patient care. On the other hand, hospitals with high retention rates (such as Magnet hospitals) show supportive management, professional autonomy, good inter-professional relations and nurse job satisfaction, reduced nurse burnout and improved quality of patient care.

Methods

Cross-sectional survey of 695 nurses at Landspitali University Hospital, Reykjavík. Nurses’ work environments were measured using the nursing work index—revised (NWI—R) and examined as predictors of job satisfaction, the Maslach burnout inventory (MBI) and nurse-assessed quality of patient care using linear and logistic regression approaches.

Results

An Icelandic adaptation of the NWI—R showed a five-factor structure similar to that of Lake (2002). After controlling for nurses’ personal characteristics, job satisfaction, emotional exhaustion and nurse rated quality of care were found to be independently associated with perceptions of support from unit-level managers, staffing adequacy, and nurse-doctor relations.

Conclusions

The NWI—R measures elements of hospital nurses’ work environments that predict job outcomes and nurses’ ratings of the quality of patient care in Iceland. Efforts to improve and maintain nurses’ relations with nurse managers and doctors, as well as their perceptions of staffing adequacy, will likely improve nurse job satisfaction and employee retention, and may improve the quality of patient care.     

Frequencies of falls in Swiss hospitals: concordance between nurses' estimates and fall incident reports

Background

Patient falls are frequent incidents in hospitals, and various measurement methods are described in the literature to assess in-patient fall rates. However, the literature includes no validation of nurses’ estimates of fall frequencies, which are the preferred assessment method in multi-centre surveys.

Objectives

To explore the concordance of nurses’ estimated fall frequencies with continuously collected data.

Design

Cross-sectional, correlational secondary data analysis.

Sample/Setting

Patient fall data from 21 wards in 2 Swiss acute care hospitals participating in the RICH Nursing Study.

Methods

Registered nurses’ (N = 233) estimated fall frequencies, assessed by the International Hospital Outcome Study questionnaire in absolute number of falls over the last month, and, using a four-point Likert scale (never = 1; frequently = 4), over the last year, were compared to standardized hospital fall incident reports compiled over the same periods. Fall incident reports for the last month were assessed in absolute numbers and were calculated as fall rates per 1000 patient days, with data computed at the ward level. The concordance with nurses’ estimates was then tested using Spearman’s rho and Kendall’s tau correlations.

Results

The mean last-year fall frequencies estimated by nurses on the four-point Likert scale ranged from 1.4 to 3.1 for non-injurious falls and from 1.0 to 2.6 for injurious falls per ward. The fall rates assessed using fall incident reports over the same period ranged from 0.1 to 3.8 non-injurious falls per 1000 patient days and from 0.1 to 2.6 injurious falls per ward.Nurses’ estimates and fall incident reports correlated significantly regarding the last year, both for injurious falls (r = 0.685, p = 0.014) and non-injurious falls (r = 0.630, p = 0.028), although no statistically significant correlations were found regarding the 1 month estimates.

Conclusions

Nurses’ long-term estimates of patient incidents are concordant with continuously and systematically assessed data, and offer valid data where other measurement methods are unavailable.     

Patient dignity in an acute hospital setting: a case study

Background

Nurses have a professional duty to respect patients’ dignity. There is a dearth of research about patients’ dignity in acute hospital settings.

Objective

The study investigated the meaning of patient dignity, threats to patients’ dignity, and how patient dignity can be promoted, in acute hospital settings.

Design

A qualitative, triangulated single case study design (one acute hospital), with embedded cases (one ward and its staff, and 24 patients).

Setting

The study was based on a 22-bedded surgical ward in an acute hospital in England.

Participants

Twenty-four patients, aged 34-92 years were purposively selected. There were 15 men and 9 women of varied socio-economic backgrounds. They could all communicate verbally and speak English. Twelve patients, who had stayed in the ward at least 2 days, were interviewed following discharge. The other 12 patients were observed and interviewed on the ward. The ward-based staff (26 registered nurses and healthcare assistants) were observed in practice. 13 were interviewed following observation. Six senior nurses were purposively selected for interviews.

Methods

The data were collected during 2005. The Local Research Ethics Committee gave approval. Unstructured interviews using topic guides were conducted with the 24 patients, 13 ward-based staff and 6 senior nurses. Twelve 4-h episodes of participant observation were conducted. The data were analysed thematically using the framework approach.

Findings

Patient dignity comprised feelings (feeling comfortable, in control and valued), physical presentation and behaviour. The environment, staff behaviour and patient factors impacted on patient dignity. Lack of environmental privacy threatened dignity. A conducive physical environment, dignity-promoting culture and other patients’ support promoted dignity. Staff being curt, authoritarian and breaching privacy threatened dignity. Staff promoted dignity by providing privacy and interactions which made patients feel comfortable, in control and valued. Patients’ impaired health and older age rendered them vulnerable to a loss of dignity. Patients promoted their own dignity through their attitudes (rationalisation, use of humour, acceptance), developing relationships with staff and retaining ability and control.

Conclusion

Patients are vulnerable to loss of dignity in hospital. Staff behaviour and the hospital environment can influence whether patients’ dignity is lost or upheld.     

The work of nurses in Australian general practice: A national survey

Background

Following recent reforms to Australia's health system, nurses now comprise a significant and growing sector of the Australian primary care workforce, but there is little data describing the services they provide.

Objectives

This study aimed to describe the patient consultations of nurses in Australian general practice, including patient characteristics, reasons for the consultation, treatments provided and other actions taken.

Design

The study was a national cross-sectional survey, with each participating nurse collecting information about 50 nurse-patient encounters.

Setting

General practice settings in all regions of Australia.

Participants

108 nurses volunteered in response to advertisements and 104 returned completed study materials. Participants included Registered (Division 1) and Enrolled (Division 2) nurses working in a general practice setting.

Methods

Data were collected between May 2007 and May 2008 using a profile questionnaire and a series of encounter forms. Information was gathered on reasons for encounter, patient characteristics, and actions taken. Data were classified using the International Classification of Primary Care.

Results

The final data set included 5,253 nurse-patient encounters. 37.2% of patients (95% CI 33.3-41.2) were aged 65 and over, and 57.1% were female (95% CI 54.9-59.5). The majority of encounters (90.7%) were with existing patients of the practice (95% CI 89.1-92.7). The most common reasons for encounter were general and unspecified problems (35.4 per 100 encounters; 95% CI 31.8-39.1), followed by skin-related problems (20.0; 95% CI 17.3-22.8), and cardiovascular problems (11.0; 95% CI 8.7-13.3). Common management actions included medical examinations (20.7 per 100 encounters), immunisations (22.5), diagnostic tests (10.6), and dressings (15.8). Approximately 30% of encounters involved advice-giving.

Conclusions

The findings confirm the generalist nature of the General Practice Nurse role, with a wide range of patient types and clinical conditions. There is a clear influence of current funding and organisational arrangements on work patterns, with tasks that have specific funding (including immunisations and wound care) featuring prominently in nurses’ work. Whilst nurses’ rates for presenting conditions were similar to doctors at a general level, specific actions taken and problems managed differed. New policy reforms in Australia are supporting greater flexibility in the General Practice Nurse role, maximising efficient use of nurses’ skills in the primary health care context.     

Writing ourselves into a web of obedience: A nursing policy analysis

Background

Nursing work is governed by a web of overarching documents from professional bodies, registration bodies, and individual health care organisations. The focus for these documents is to maintain high standards and protect patients and organisations from unnecessary risk. The presentation of the nurse within these documents has important implications for the ability of nurses to function as autonomous professionals.

Objectives

How the role of the nurse is situated in hospital procedural policy, and more specifically how these presentations of the nurse define, limit, and enable nursing practice is the focus of this paper.

Design

A combination of random and purposive sampling of the nursing policies of one tertiary level hospital was utilised to collect policy documents for thematic content analysis.

Setting

The study was completed in a tertiary level health institution, in one Australian jurisdiction with a population of approximately 500,000 people. This health institution employs over 4000 people and admitted 49,000 patients in the 2004-2005 financial year.

Methods

An inductive approach, which utilised theoretical and contextual comprehension of the nursing policies, informed the collation of coded data which determined the themes of the study.

Findings

Analysis consisted of coding of particular words, textual structure and theory content. Practice was presented in the nursing procedural policies in two themes, called ‘lingering tradition’ and ‘bureaucratic template’.

Conclusions

The discourse of hospital procedural policy situates the nurse as obedient to organisational requirements by limiting practice to a performance of actions without explicit recognition of professional autonomy. This sets up a puzzling contradiction between performance expectations from the employing organisation and the nursing profession. Writing hospital policy in the discourse of procedural directives reduces nurses’ ability to act as autonomous, critically thinking professionals, with implications for patient safety, nurse autonomy and the professional status of nursing.     

Early-career burnout among new graduate nurses: A prospective observational study of intra-individual change trajectories

Background

Newly qualified and inexperienced nurses are at particular risk of suffering emotional exhaustion and burnout in unsupportive practice environments. Despite new nurses’ potential vulnerability, development of burnout after graduation has rarely been studied longitudinally and in relation to demographic and educational characteristics prior to working life entry, i.e. during education.

Objectives

To identify and compare typical change trajectories (i.e. common patterns of intra-individual development) in burnout symptoms for new graduate nurses annually over a three-year period, during which there was reason to believe that this group was especially vulnerable.

Design

A prospective longitudinal and national cohort of 1153 nurses within the population-based LANE study (Longitudinal Analyses of Nursing Education), where new graduate nurses were assessed four times annually, i.e. in their final year of nursing education and three times post graduation (after 1, 2 and 3 years).

Participants

A longitudinal sample of 997 respondents was prospectively followed.

Methods

Within-group changes in burnout levels were analysed using a repeated-measures analysis of variance, and cluster analytic techniques were used to identify typical trajectories of burnout.

Results

At group level, mean levels of burnout were rather stable across time. However, underlying these levels we identified eight change trajectories, explaining 74% of all individual variation; seven of them reflected significant changes across time. Almost every fifth nurse reported extremely high levels of burnout at some point during their first three years after graduation. Changes in burnout levels were accompanied by concurrent changes in depressive symptoms and intention to leave the profession. This study also showed that negative development of burnout was predicted by not feeling well prepared for a nursing job, lacking study interest, high levels of performance-based self-esteem and depressive mood in the final year of education.

Conclusions

An investigation of burnout symptoms over time disclosed numerous development patterns, some of which were stable while others changed significantly. Hence, this study gave a more nuanced picture of burnout development among new graduate nurses, highlighted by eight different trajectories. Regarding the time frame, nearly every second new graduate showed a significant increase in levels of burnout during their second year post graduation.     

The clinical learning environment and supervision instrument (CLES): validity and reliability of the Dutch version (CLES+NL)

Background

The clinical learning environment and supervision scale (CLES) is a valid and reliable tool that was developed to assess the quality of nursing students’ clinical placements.

Objectives

To obtain a reliable and valid Dutch version of the CLES that is in line with the Flemish culture and educational context.

Design

Scale validation study on data provided by a cross-sectional survey.

Settings

190 wards in 31 institutions for healthcare in Flanders, Belgium.

Participants

768 student nurses enrolled in the 3 year bachelor programme at University College Ghent, Faculty of Healthcare Vesalius.

Methods

Face and content validation was followed by data collection. Factor analysis was performed using varimax rotation. Subsequently, internal consistency reliability was tested on the total scale and its subdimensions using Cronbach's alpha.

Results

We gathered 768 questionnaires. Factor analysis revealed 5 subdimensions with an eigenvalue greater than 1, explaining 71.281% of the variance. The overall internal consistency and the consistency of the five subdimensions is high. Our data supports face, content and construct validity of the CLES + NL.

Conclusions

The CLES + NL is a valid and reliable instrument that can be used to evaluate the quality of nursing wards as learning environments in Flanders.     

Nursing resources and patient outcomes in intensive care: a systematic review of the literature

Objectives

To evaluate the empirical evidence linking nursing resources to patient outcomes in intensive care settings as a framework for future research in this area.

Background

Concerns about patient safety and the quality of care are driving research on the clinical and cost-effectiveness of health care interventions, including the deployment of human resources. This is particularly important in intensive care where a large proportion of the health care budget is consumed and where nursing staff is the main item of expenditure. Recommendations about staffing levels have been made but may not be evidence based and may not always be achieved in practice.

Methods

We searched systematically for studies of the impact of nursing resources (e.g. nurse-patient ratios, nurses’ level of education, training and experience) on patient outcomes, including mortality and adverse events, in adult intensive care. Abstracts of articles were reviewed and retrieved if they investigated the relationship between nursing resources and patient outcomes. Characteristics of the studies were tabulated and the quality of the studies assessed.

Results

Of the 15 studies included in this review, two reported a statistical relationship between nursing resources and both mortality and adverse events, one reported an association to mortality only, seven studies reported that they could not reject the null hypothesis of no relationship to mortality and 10 studies (out of 10 that tested the hypothesis) reported a relationship to adverse events. The main explanatory mechanisms were the lack of time for nurses to perform preventative measures, or for patient surveillance. The nurses’ role in pain control was noted by one author. Studies were mainly observational and retrospective and varied in scope from 1 to 52 units. Recommendations for future research include developing the mechanisms linking nursing resources to patient outcomes, and designing large multi-centre prospective studies that link patient's exposure to nursing care on a shift-by-shift basis over time.