Influences of context, process and individual differences on nurses' readiness for change to Magnet status

Title.  Influences of context, process and individual differences on nurses' readiness for change to Magnet status.
Aim.  The aim of this study was to test hypotheses associated with a model which explains individuals' readiness in early stages of a change.
Background.  In an effort to improve the quality of nursing care, hospitals in the United States of America seek to obtain Magnet recognition. While it is commonly known that Magnet hospitals provide higher quality patient care, little is known about the variability in nurses' attitudes and behaviour within Magnet hospitals.
Method.  We collected data in 2006 from 310 Registered Nurses to investigate the factors that influence their willingness to embrace the changes necessary for the high levels of excellence accompanying Magnet status. Hierarchical linear modelling was used because the data were multi-level.
Results.  Both change-specific context, such as a culture of research exhibited by the manager, and formal education of the nurse moderated the positive influences of the organization's procedural justice actions. Specifically, procedural justice was stronger when the nurse manager demonstrated a culture of research, and negative effects of low justice were mitigated when nurses had a higher level of formal education.
Conclusion.  Preparing managers beforehand to appreciate and adopt new behaviours associated with a forthcoming organizational change should enhance the success of change practices as new changes are initiated. Moreover, education that exposes employees to the pending realities of their industry, such as nursing research, can play an important role in the development of positive beliefs about changes facing their organizations.     

Nurses' moral strength: a hermeneutic inquiry in nursing practice

Title.  Nurses' moral strength: a hermeneutic inquiry in nursing practice.
Aim.  This paper is a report of a study to interpret nurses' experiences of moral strength in practice.
Background.  Moral strength is said to be beneficial in providing nursing care for patients, thereby contributing to high qualitative care. However, few studies focus on the meaning of nurses' moral strength.
Methods.  This study included eight Registered Nurses working in different aspects of health care in southern Sweden. Individual interviews were conducted in 2006 and 2007. We recorded, transcribed verbatim, and interpreted the interviews by a method grounded in hermeneutics.
Findings.  Three themes were interpreted on three different levels: the action level as 'having courage to act on one's convictions', the relational level as 'being attentive and recognizing vulnerability', and the existential level as 'facing the unpredictable' . Overall, moral strength was understood as a driving force to be someone special in the care of patients, i.e. someone who makes a difference.
Conclusion.  The value of nurses' moral strength in patient care should be recognized. Attention must be given to aspects outside the individual, e.g. professional and institutional processes that influence the work environment. Clinical team supervision can help make such processes visible and supportive.     

Shielding or caging? Healthcare staffs’ views on fall risk and protection in Stockholm

Aim.  To describe Registered Nurses' and enrolled nurses' views and reasoning on falls, fall risk, use of physical restraints and patients' safety and security in nursing homes.
Background.  Nursing home patients frequently suffer from diseases which require medication. Both Registered Nurses and enrolled nurses must make decisions about how to protect patients from falls and fall-related injuries. Physical restraints are frequently used. When patients are unable to understand or do not wish to limit their freedom of movement, staff must consider each decision carefully.
Method.  A qualitative approach was used. Data were analysed using a thematic content analysis method.
Findings.  Staff have sufficient knowledge about which pathologically related conditions lead to fall risk. An insufficient number of staff on duty jeopardizes patient safety. Wheelchairs with safety belts, and bed rails, are sometimes used. For Registered Nurses it was not an easy decision to use restraints. Enrolled nurses' actions were based on standard procedure, to protect and supervise patients.
Conclusion.  Staff often use restraints to protect their patients, even though this may mean compromising the patient's integrity.
Relevance to clinical practice.  Nurses, occupational therapists, physiotherapists and physicians should plan the care together. Restrictive measures should be adapted to each individual patient.     

Improving geriatric transitional care through inter-professional care teams

Objectives  The aim of this study was to examine the impact of the use of an inter-professional care team on patient length of stay and payer charges in a geriatric transitional care unit.
Methods  An analysis of de-identified administrative records for transitional care patients for the 12-month period (2003–2004) cared for by the inter-professional team ( n  = 163) and cared for by traditional single provider care model ( n  = 176) was carried out. We conducted logistic regression on length of stay and charges controlling for patient demographics and acuity levels.
Results  The inter-professional care team patients had significantly shorter lengths of stay, fewer patient days and lower total charges. Patient diagnosis and acuity were similar across groups.
Conclusion  This study provides empirical evidence of the impact of an inter-professional care model in providing cost-effective transitional care in a nursing home setting. Evidence of shorter lengths of stay, shorter patient days and lower charges suggests benefit in the development and financing of inter-professional care teams for transitional care services.     

Healthcare Team Vitality Instrument (HTVI): developing a tool assessing healthcare team functioning

Title.  Healthcare Team Vitality Instrument (HTVI): developing a tool assessing healthcare team functioning.
Aim.  This paper is a report of a study conducted to refine, shorten and validate the Healthcare Team Vitality Instrument.
Background.  The Healthcare Team Vitality Instrument was developed to assess team vitality of nurses as well as other licensed and unlicensed personnel working as part of healthcare teams in inpatient hospital units. This instrument was necessary for two reasons. First, other commonly used instruments assess characteristics of Registered Nurses or perceptions about and characteristics of the organizations in which they work, but not these factors in combination with critical factors of interdisciplinary team functioning and collaboration. Second, a short tool for repeated, regular measurement of team vitality was needed to track the impact of changes to improve work environments.
Method.  Revisions to the Healthcare Team Vitality Instrument occurred in two phases. Phase 1 entailed collecting preliminary data and conducting cognitive interviews to refine the initial items. During Phase 2, the factor structure of the Healthcare Team Vitality Instrument was identified and a brief form developed and validated. Data were collected in 2006 and 2007.
Findings.  Exploratory factor analyses suggested a four-factor solution with the following dimensions: (1) support structures, (2) engagement and empowerment, (3) patient care transitions and (4) team communication.
Conclusion.  The Healthcare Team Vitality Instrument can contribute both to better management practices and advancing knowledge to promote retention of nurses, and to some extent other healthcare professionals, as well as efforts to transform the acute healthcare work environment.     

Factors That Influence the Decisions of Men and Women Nurses to Leave Nursing

PROBLEM.  The health and long-term care systems in the United States rely heavily on the services of registered nurses, but concerns exist about the adequacy of the current and projected supply of registered nurses to meet the nation's needs. One way to increase the nursing supply is to increase the retention rates of nurses, especially men nurses who are much more likely to leave nursing than are women. The study hypothesizes that the different retention rates of men and women can be explained in part by their different gender roles and careers goals.
METHODS.  A secondary analysis was conducted of the registered nurses who left nursing for other occupations in the National Sample Survey of Registered Nurses, 2000.
FINDINGS.  Three reasons for leaving nursing were cited most often by the male and female nurses who left nursing: better salaries available in current type of position, hours more convenient in other position, and find current position more rewarding professionally. Results of a multivariate logistic regression analysis show that men were 2.5 times more likely than women to cite better salaries as a reason for leaving the nursing profession, but no more likely to cite more convenient hours or to state that the non-nursing position was more professionally more rewarding.
CONCLUSIONS.  Thus, the men differed from the women in their attitudes toward the financial aspects of nursing but not the professional aspects. Suggestions are provided to redress the dissatisfactions of men nurses.     

Empowerment and its application in health promotion in acute care settings: nurses' perceptions

Title.  Empowerment and its application in health promotion in acute care settings: nurses' perceptions.
Background.  Empowerment has long been a central tenet of health promotion theory. Globally, governments have advocated the use of empowerment in their public health policies. Nurses are seen as essential in the delivery of this agenda using the empowerment model to engage patients in self-care and decision-making.
Method.  Six different vignettes requiring a health promotion intervention were shown to a convenience sample of 20 Registered Nurses in a United Kingdom acute care hospital. The nurses were asked to describe how they would meet the health promotion needs of the patients described in the vignettes. The data were collected between 2005 and 2006 and analysed using thematic analysis.
Findings.  Two types of practitioner were identified: Type I divergent nurse health promotion practitioner and Type II convergent nurse health promotion practitioner. The main factor distinguishing the two types was the way in which they conceptualized the verb 'to empower'.
Conclusion.  The theory of health promotion taught to participants does not seem to be applied in acute care settings. This raises the possibility that Registered Nurses acting as mentors and role models are convergent rather than divergent thinkers.     

Identifying key nursing and team behaviours to achieve high reliability

Aim  The aim of the present study was to measure markers of key nursing behaviours in interdisciplinary teams during critical events to assess the extent of high reliability.
Background  Technical and team competence are necessary to achieve high reliability to ensure safe patient care. Technical competence is generally assured because of professional training, licensure and practice standards. During critical events, team competence is difficult to observe, measure and evaluate in interdisciplinary teams.
Method  During critical events, in situ simulation was the method used to observe interdisciplinary interaction of nursing behaviours regarding communication. Seventeen trials were conducted and videotaped for evaluation at four hospital sites.
Results  Key nursing behavioural markers for interdisciplinary interaction were described: situational awareness, use of situation, background, assessment, recommendation-response (SBAR-R), closed-loop communication and shared mental model.
Conclusion  Skills necessary for nurses to contribute to highly reliable, interdisciplinary teams are not consistently observed during critical events and constitute breaches in defensive barriers for ensuring patient safety.
Implications for nursing management  Nurses have a key role in assuring effective team performance through the transfer of critical information. Nurses need to recognize and identify important clinical and environmental cues, and act in order to ensure that the team progresses along the optimal course for patient safety.     

Ineffective participation: reactions to absentee and incompetent nurse leadership in an intensive care unit

Aim  The aim of the present study was to analyse reactions to ineffective leader participation in an intensive care unit (ICU).
Background  Critical examination of leadership failures helps identify nurse manager behaviours to avoid.
Method  An online survey collected data from 51 interacting healthcare providers who work in an intensive care unit.
Results  Participants reported dissatisfaction with nurse leaders who were perceived as absent or ill prepared. Participants categorized intensive care unit productivity and morale as moderate to low. Multiple regression suggested the best predictor of perceived unit productivity was supervisor communication; the best predictor of employee morale was perceived leader mentoring.
Conclusions  Intensive care unit nurses reported wanting active participation from their leaders and expressed dissatisfaction when supervisors were perceived as absent or incompetent. Ineffective leader participation significantly correlated with lower employee perceptions of productivity and morale.
Implications for nursing management  Senior managers should recruit and develop supervisors with effective participation skills. Organizations primarily concerned about productivity should focus on developing the communication skills of nurse leaders. Units mainly concerned with employee morale should emphasize mentorship and role modelling. Formal assessment of nurse leaders by all intensive care unit team members should also be used to proactively identify opportunities for improvement.     

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.     

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.     

The Management of Aggression and Violence Attitude Scale (MAVAS): a cross-national comparative study

Title.  The Management of Aggression and Violence Attitude Scale (MAVAS): a cross-national comparative study.
Aim.  This paper is a report of a study to determine the transferability of the Management of Aggression and Violence Attitude Scale to European mental health inpatient settings.
Background.  Incidents of patient aggression and violence are common in psychiatric in-patient facilities, and nurses' attitudes may play a part in how they are managed.
Methods.  Nursing staff from acute psychiatric in-patient units in Switzerland and the United Kingdom completed the Management of Aggression and Violence Attitude Scale. Data were collected in the UK in 2001 and Switzerland in 2003. The Swiss sample comprised 75 respondents: 45 female, mean age 36·24, mean experience 7·35 years, 60 Registered Nurses. The United Kingdom sample was 75 respondents: 58 female, mean age 32, mean experience 5·25 years, 48 Registered Nurses. T -tests identified differences between the groups in their responses to each Management of Aggression and Violence Attitude Scale statement.
Results.  There was 66% concordance of views between the groups. Swiss nurses were, however, more likely to regard factors internal to the patient as contributory to aggression while United Kingdom nurses perceived environmental factors to be more important. Both groups endorsed physical means of aggression management, Swiss nurses more so.
Conclusion.  There are both commonalities and differences between the attitudes of Swiss and United Kingdom nursing staff regarding patient aggression. Differences may relate to rates of aggression, variations in management approaches, training and policy. The Management of Aggression and Violence Attitude Scale is a potentially effective tool for making comparisons about perspectives on patient aggression.     

GLB Adolescent's "Coming out"

TOPIC:  A greater number of gay males, lesbians, and bisexual females or males (GLB) are "coming out" during adolescence. Discussion includes nursing implications.
PURPOSE:  The purpose of this paper is to review the process of GLB disclosure, highlight the trend toward earlier outing, and discuss its implications for nursing practice.
SOURCES:  Sources include scholarly published literature, professional organization documents, and GLB advocacy publications.
CONCLUSIONS:  Nurses need to update their knowledge of coming-out issues, as well as nondisclosing sexual behavior, to assess youth and family needs and direct care appropriately.     

Client-centred empowering partnering in nursing

AIM: This paper explores nurses' experiences 1 year after an organization's commitment to providing a client-centred and client-empowering partnering approach to care. BACKGROUND: Historically, nurses' approach to providing care in all nursing contexts has been one of doing for clients, and previous studies have focused more on in-hospital care than on home care. However, the isolation inherent in in-home nursing and nurses' limited professional autonomy and power associated with physician control over patients in home care have been reported, as has their difficulty in finding the meaning and satisfaction of human connectedness and mutuality in nurse-client relationships. Overall, research to date does not inform us about how nurses might make a change toward a more client-centred and client-empowering approach to nursing. METHODS: An interpretive phenomenological design was used to elicit in-depth understanding about Registered Nurses' experiences of providing care using this innovative empowerment model. A purposefully selected sample of eight Registered Nurses participated in in-depth interviews. Data were generated during 2002. Hermeneutic analysis was used to elicit themes and patterns emerging from the data. FINDINGS: Caring, client-centredness and the context of in-home care were important in implementing the new partnering approach. Barriers encountered at system, organizational and personal levels distracted nurses from fully comprehending and enacting the approach. After a year, they had begun to contemplate potential strategies for partnering with clients, but had not yet explored the power of their professional autonomy. CONCLUSION: Nurses are inclined to practise within the expert model of service delivery. They need to work through issues of professional autonomy and rise to the challenge of exercising their autonomy within the current healthcare context if they are to attend more consistently to client-centred empowering partnering. The home care setting offers an excellent environment for achieving these aims.     

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.     

Mental health nurses' attitudes towards severe perinatal mental illness

Title.  Mental health nurses' attitudes towards severe perinatal mental illness.
Aim.  This paper reports on a study exploring the experiences and attitudes of generic mental health nurses towards care of women with severe mental illness during the perinatal period.
Background.  Severe mental disorder in the perinatal period is a global public health concern. However, there are concerns that mental health nurses other than dedicated perinatal mental health teams may lack knowledge, skills and experience in caring for such disorders, because of their low prevalence.
Methods.  Sixteen generic Registered Mental Nurses working in public adult mental health services participated in three focus groups during 2007.
Findings.  Participants did not perceive any difference between symptoms during perinatal and non-perinatal periods. There were mixed attitudes towards caring for women with severe mental illness in the perinatal period. Fear and anxiety was expressed by the nurses when caring or feeling responsible for the babies of clients. Lack of communication between professional groups and decreased clinical decision-making following the introduction of the Edinburgh Post Natal Depression Scale caused frustration. Confidence was displayed when working with known and trusted colleagues.
Conclusion.  Generic mental health nurses would benefit from more education on perinatal mental health and there may be a need for them to be supported by specialist perinatal mental health practitioners.     

Transition shock: the initial stage of role adaptation for newly graduated Registered Nurses

Title.  Transition shock: the initial stage of role adaptation for newly graduated Registered Nurses.
Aim.  The aim of this paper is to provide a theoretical framework of the initial role transition for newly graduated nurses to assist managers, educators and seasoned practitioners to support and facilitate this professional adjustment appropriately.
Background.  The theory of Transition Shock presented here builds on Kramer's work by outlining how the contemporary new graduate engaging in a professional practice role for the first time is confronted with a broad range and scope of physical, intellectual, emotional, developmental and sociocultural changes that are expressions of, and mitigating factors within the experience of transition.
Data sources.  This paper offers cumulative knowledge gained from a programme of research spanning the last 10 years and four qualitative studies on new graduate transition.
Discussion.  New nurses often identify their initial professional adjustment in terms of the feelings of anxiety, insecurity, inadequacy and instability it produces. The Transition Shock© theory offered focuses on the aspects of the new graduate's roles, responsibilities, relationship and knowledge that both mediate the intensity and duration of the transition experience and qualify the early stage of professional role transition for the new nursing graduate.
Conclusion.  Transition shock reinforces the need for preparatory theory about role transition for senior nursing students and the critical importance of bridging undergraduate educational curricula with escalating workplace expectations. The goal of such knowledge is the successful integration of new nursing professionals into the stressful and highly dynamic context of professional practice.