Registered nurse leadership style and confidence in delegation

Saccomano S.J. & Pinto- Zipp G. (2011) Journal of Nursing Management 19 , 522–533
Registered nurse leadership style and confidence in delegation Background and aims Leadership and confidence in delegation are two important explanatory constructs of nursing practice. The relationship between these constructs, however, is not clearly understood. To be successful in their roles as leaders, regardless of their experience, registered nurses (RNs) need to understand how to best delegate. The present study explored and described the relationship between RN leadership styles, demographic variables and confidence in delegation in a community teaching hospital. Methods Utilizing a cross-sectional survey design, RNs employed in one acute care hospital completed questionnaires that measured leadership style [Path-Goal Leadership Questionnaire (PGLQ)] and confidence in delegating patient care tasks [Confidence and Intent to Delegate Scale (CIDS)]. Results Contrary to expectations, the data did not confirm a relationship between confidence in delegating tasks to unlicensed assistive personnel (UAPs) and leadership style. Nurses who were diploma or associate degree prepared were initially less confident in delegating tasks to UAPs as compared with RNs holding a bachelor’s degree or higher. Further, after 5 years of clinical nursing experience, nurses with less educational experience reported more confidence in delegating tasks as compared with RNs with more educational experience. Conclusions The lack of a relationship between leadership style and confidence in delegating patient care tasks were discussed in terms of the PGLQ classification criteria and hospital unit differences. As suggested by the significant two-way interaction between educational preparation and clinical nursing experience, changes in the nurse’s confidence in delegating patient care tasks to UAPs was a dynamic changing variable that resulted from the interplay between amount of educational preparation and years of clinical nursing experience in this population of nurses. Clearly, generalizability of these findings to nurses outside the US is questionable, thus nurse managers must be familiar with the Nurse Practice Act in their country in order to ensure proper delegation of tasks to appropriate assistive personnel. Implications for nurse managers It is imperative that nurse managers provide nurses with the educational opportunities necessary to develop delegation and supervision strategies to adapt to the changing RN role while adhering to differences in scope of practice. Globally, RNs are caring for increasing numbers of acutely ill patients with scarce resources ensuring an adequately trained RN/UAP team can help support optimal patient care.     

Delegation within municipal health care

bystedt m., eriksson m. & wilde-larsson b. (2011) Journal of Nursing Management 19 , 534–541
Delegation within municipal health care Aim To describe how registered nurses (RNs) perceive delegation to unlicensed personnel (UP) in a municipal healthcare context in Sweden. Background Within municipal health care RNs often delegate tasks to UP. The latter have practical training, but lack formal competence. Method Twelve RNs were interviewed and the material was analysed using a phenomenographic approach. Results Owing to a shortage of RNs, delegation is seen as a prerequisite for a functioning organization. This necessity also involves a number of perceived contradictions in three areas: (1) the work situation of RNs – facilitation and relief vs. lack of control, powerlessness, vagueness regarding responsibility, and resignation; (2) the relationship with unlicensed personnel – stimulation, possibility for mentoring, use of UP competence and the creation of fairness vs. questioning UP competence; and (3) The patients – increase in continuity, quicker treatment, and increased security vs. insecurity (with respect to, for example, the handling of medicine). Conclusion Registered nurses perceptions of delegation within municipal healthcare involve their own work situation, the UP and the patients. Implications for nursing management Registered nurses who delegate to UP must be given time for mentoring such that the nursing care is safe care of high quality.     

Patient identification of caregivers' titles: do they know who you are?

This study investigated patients' abilities to identify licensed nurse and unlicensed assistive personnel (UAP) and whether this knowledge is related to satisfaction with care. Of 100 patients from two hospitals, 28% did not know whether caregivers were nurses or UAP on sight. Fifteen percent of patients asked to identify UAP assumed that the caregiver was a nurse. Patients could not recognize their nurse or UAP caregivers 59% of the time from a list of names. Patients were three times more likely to know the names and titles of their nurses. Older patients were less likely to remember the names and titles of their caregivers. Satisfaction with nursing care was not predicted by patients' knowledge of caregiver name or title.     

Nurse staffing and patient outcomes in Veterans Affairs hospitals

OBJECTIVE: To assess characteristics and perceptions of nurses working in the Veterans Health Administration (VHA), comparing types of nursing personnel, to benchmark to prior studies across healthcare systems. BACKGROUND: Prior studies have shown relationships between positive registered nurse (RN) perceptions of the practice environment and patient outcomes. To date, no study has reported the comparison of RN perceptions of the practice environment in hospital nursing with those of non-RN nursing personnel. This study is the first to offer a more comprehensive look at perceptions of practice environment from the full range of the nursing work force and may shed light on issues such as the relationship of skill mix to nurse and patient outcomes. METHODS: Cross-sectional observational study with a mailed survey administered to all nursing personnel in 125 VA Medical Centers between February and June 2003. RESULTS: Compared with other types of nursing personnel in the VHA, RNs are generally less positive about their practice environments. However, compared with RNs in other countries and particularly with other RNs in the United States (Pennsylvania), VHA RNs are generally more positive about their practice environment and express more job satisfaction. CONCLUSIONS: The nursing work force of the VHA has some unique characteristics. The practice environment for nurses in the VHA is relatively positive, and may indicate that the VHA, as a system, provides an environment that is more like magnet hospitals. This is significant for a public sector hospital system.     

State and territorial boards of nursing approaches to the use of unlicensed assistive personnel

This study examined U.S. state and territorial boards of nursing approaches to the regulation of the use of: unlicensed assistive personnel (UAP) in acute care hospitals; state and jurisdictional authority, oversight and disciplinary action related to registered nurse (RN) delegation, supervision and assignment; educational preparation requirements for UAP; and future projections for their use. A survey was administered to 53 state and territorial boards of nursing officials in 1998. A majority of the states reported that they had regulations/guidelines for RN's who supervised UAP and regulations that protected the use of the RN title. Few states used the American Nurses Association or National Council of State Boards of Nursing definitions for delegation, supervision, or assignment. The majority have formulated their own definitions. The majority of states reported no standardized curriculum in place for UAP employed in acute care hospitals. More than half of the states reported that no plans existed for developing a curriculum.     

Nurse delegation of medication administration for older adults in assisted living

Assisted living (AL) is a relatively new form of long-term care that offers residents personal care services and more independence in a home-like environment. Introduced to the United States in the 1980s, AL is changing the conventional thinking about how to care for frail older adults. One important issue to explore is registered nurse (RN) delegation to unlicensed assistive personnel (UAP), particularly for medication administration. This study provides a national perspective on medication delivery in AL settings from the perspectives of state Board of Nursing (BON) executives. Qualitative interviews using semi-structured interview guides were conducted with BON executives to validate a legal summary of AL regulations and nurse practice acts, and to identify nursing issues pertaining to medication management in AL across the United States. In this study, there was considerable variation across states regarding medication administration and the role of both the RN and the UAP. BON executives displayed a range of knowledge about nursing practice issues in AL, with many reporting low familiarity with this setting. Mechanisms for systematic review of quality of delegation were not in place. Medication administration and nurse delegation were dynamic issues, with practice and policy evolving concurrently. This study highlights the limited articulation of policies between agencies and across states in the important and growing setting of assisted living. Nurses have the opportunity to shape this evolving practice arena and to enhance awareness of the professional and clinical issues inherent in working with UAP in medication delivery.     

How to optimise the registered nurse contribution in care homes

This article aims to offer ideas that may be useful to care homes when considering priorities for registered nurse (RN) work. Drawing on the findings of research into the work of RNs and care assistants in UK care homes (Heath 2006), it discusses the distinct contribution of RNs, the delegation of nursing interventions and the need for a 24-hour RN presence. International debates on the distinct contribution of RNs in residential settings for older people are also acknowledged.     

Nursing and health care reform: implications for curriculum development

The health care system is undergoing profound changes. Cost containment efforts and restructuring have resulted in cutbacks in registered nurse (RN) positions. These changes are often related to the increased market penetration by managed care companies. To determine how RN graduates perceive these changes and their impact on the delivery of patient care, Healthcare Environment Surveys were mailed to graduates of the classes of 1986 and 1991. Using the Survey's 5-point Likert Scale, we measured the graduates' satisfaction with their salary, quality of supervision they received, opportunities for advancement, recognition for their job, working conditions, the overall job and the changes in their careers over the previous five year period. Our study suggests that the changes in the health care system are having an impact on how health care is being delivered and the way nurses view their jobs. Respondents reported that insurance companies are exerting increased control over patient care and perceive that the quality of patient care is declining. Increased workloads and an increase in the amount of paperwork were reported. Participants perceived that there were fewer jobs available and that job security was decreasing. The percentage of nurses who see job satisfaction as remaining the same or increasing are a majority. However, the relatively high percent of nurses who see job satisfaction as declining should provide a note of warning. The major implications of this study are that the professional nursing curriculum must be modified to include content on communication, organization, legislative/policy skills, and leadership. The nation's health care system is undergoing profound changes. There are numerous forces at work that are effecting the delivery of care and, consequently, the work of health professionals. These forces include significant efforts at cost containment, restructuring and downsizing of hospitals, and the movement of health care delivery out of acute care centers and into the community. Even though cutbacks in registered nurse (RN) positions appear to have leveled off in sections of the country that have gone through restructuring and reengineering of the work place, there still remains a heavy emphasis on lowering costs by decreasing employee benefits and increasing productivity through the substitution of part-time RNs for full-time RNs and the substitution of unlicensed assistive personnel (UAP) for RNs. These changes are often related to the increased market penetration by managed care companies, which are not expected to abate any time soon. It is important to determine what impact these changes are having on the delivery of patient care since there is some evidence to suggest that reduction in nursing staff below certain levels is related to poor patient outcomes (Fridken et al, 1996). It is also important to assess the effect of system changes on the satisfaction level health professionals have in their jobs. This is particularly important since some researchers suggest that job dissatisfaction, over a period of time, can result in burnout and eventually, turnover (Cameron, Horsburgh, & Armstrong-Stassen, 1994; Cotterman, 1991). Finally, understanding the impact of these health care delivery system changes has significant implications for baccalaureate nursing education and the preparation needed by future nurses to help them adjust to the changed environment.     

Understanding RN and unlicensed assistive personnel working relationships in designing care delivery strategies

How a registered nurse and unlicensed assistive personnel partner together has implications for care delivery and, ultimately, patient outcomes. The authors summarize findings from a study that examined the characteristics of registered nurse and unlicensed assistive personnel working relationships and the care delivery practices that influence those relationships. Strategies are recommended for deploying registered nurses and unlicensed assistive personnel to promote collaboration and to improve patient care delivery.     

The nurse apprentice and fundamental bedside care: An historical perspective

This historical study aims to explain how the transition from student nurse service to fully qualified “graduate nurse” service in the United States in the 20th century affected assumptions about fundamental patient care in hospital wards and provide historical context for current apprenticeship programs. Through analysis of documents from 1920 when student nurse service, a nurse apprentice model, was the norm to 1960 when the nurse apprentice model was waning in favor of registered nurse service, this study found that the replacement of student nurses with registered nurses led to weakened standardization of fundamental bedside care and the introduction of large numbers of unlicensed nursing assistants. While student nurses could perform all the functions of fully qualified graduate nurses, nursing assistants could not, resulting in a separation of fundamental nursing care from the professional nurse role and changes in assumptions and attitudes toward fundamental care. These changes had a negative effect on fundamental nursing care. New apprenticeship programs provide opportunities for improvement.     

Nursing home staffing: is there a nurse in the house?

With an ever-increasing emphasis on cost containment, the health care industry has been expanding its use of unlicensed personnel. The danger of substituting unlicensed assistive personnel for registered nurses threatens the public's ability to secure the full range of nursing care services.     

Meta-analysis of the reliability and validity of the Anticipated Turnover Scale across studies of registered nurses in the United States

Barlow K.M. & Zangaro G.A. (2010) Journal of Nursing Management 18, 862–873
Meta-analysis of the reliability and validity of the Anticipated Turnover Scale across studies of registered nurses in the United States Background Globally, there are serious human and financial costs associated with registered nurse (RN) turnover. Anticipating turnover before turnover occurs is important to prevent costly and unnecessary turnover. Using a reliable and valid measure of anticipated turnover is essential to credible healthcare research on which nursing policy decisions are based. This meta-analysis provides a systematic way to determine the legitimacy of the use of the Anticipated Turnover Scale (ATS) in RN workforce research. Aims The aims of this meta-analysis were to determine the consistency of reliability estimates and evidence of construct validity of ATS scores across studies of RNs in the US. A secondary purpose was to evaluate variability in reliability and validity according to study quality, century within which studies were conducted and whether studies were published or unpublished. Methods Search strategies included accessing computerized databases, emailing researchers, consulting experts, footnote-chasing and accessing unpublished reports. Two independent reviewers examined studies according to inclusion criteria and quality. Consensus was reached on selected studies and quality ratings. Results Overall mean weighted effect size (MWES) of reliability from 12 studies was 0.89. Overall MWES of validity correlating the ATS and four job satisfaction measures for seven studies was −0.53. There was variability in reliability according to quality of studies. Conclusion The ATS demonstrated excellent reliability and construct validity across studies of RNs in the US. Implications for nursing management Nursing management should consider the ATS in research on prevention of RN turnover.     

Registered nurses and burn care facilities. Factors associated with turnover rates

The health care system in the United States is suffering from a severe shortage of registered nurses. Burn treatment facilities are no exception to this phenomenon. As a result of this shortage, institutions have begun hiring less trained personnel such as licensed practical/vocational nurses (LPNs/LVNs), nursing assistants, burn technicians, and nursing students to fill the void. This shortage is so significant that the American Medical Association (AMA) has proposed a new category of bedside care provider, a "Registered Care Technologist" (RCT). The purpose of this paper is to determine the magnitude of the registered nurse shortage in burn care facilities. A second purpose is to identify factors associated with high turnover rates and to document the reasons why registered burn nurses are leaving their positions.     

Unlicensed persons in patient care settings. Administrative, policy, and ethical issues

The current nursing shortage is a supply-and-demand problem. Factors contributing to the shortage include increased hospital use of RNs; decreased nursing school enrollment; increased demand for RNs outside of hospitals in skilled nursing facilities, health maintenance organizations, and home health care programs; noncompetitive salaries; and lack of autonomy. The nursing shortage has triggered the development and implementation of programs to prepare non-nurse bedside technicians to work in partnership with RNs. The functions of these unlicensed persons range from housekeeping, stocking, and clerical responsibilities to several technical treatments that once fell within the role responsibilities of registered or practical nurses. The partnerships between unlicensed persons and RNs in patient care settings have given rise to several administrative, policy, and ethical issues for nurse leaders. An ethical analysis, based on the application of ethical principles and moral dilemmas found in "The Parable of the Sadhu," offers some guidelines to nursing leaders in the administrative and policy decisions inherent in the development and retention of licensed persons in patient care settings. Some conclusions drawn from the ethically based questions are: The acquisition and retention of RNs and other licensed caregivers should take precedence over the development of programs for non-nurse bedside technicians. RNs in partnership with unlicensed persons in patient care settings must know what they can legitimately delegate. The RN has personal responsibility for ensuring optimal standards of nursing practice in the delegation of duties. The partnership between professional nurses and unlicensed persons must be a participative effort, not a manipulative or coercive one. In putting the organizational principle of subsidiarity into practice, decision makers will be able to maintain respect for human dignity and the uniqueness of patients and caregivers as well. The development and retention of unlicensed persons in patient care settings depends on a well-developed personal ethic that needs to be congruent with the mission, philosophy, and codes of ethics of national and local health care organizations.     

Developing a patient care model for an integrated delivery system.

An integrated healthcare delivery system requires a consistent patient care delivery model. The authors describe the process used to define common elements of the patient care model. These elements include the roles of chief nurse executives, first-line managers, staff registered nurses, and unlicensed assistive personnel. In addition, the philosophy of nursing and support functions (staff education and nursing dashboard for quality measurement) in place across the system are discussed.