Staffing in acute hospital wards: part 1. The relationship between number of nurses and ward organizational environment

This paper is one of two that explores relationships between nursing staff resources, ward organizational practice and nurses' perceptions of ward environments. Here we examine relationships between staff numbers, care organization and nursing practice. A subsequent paper examines the effects of grade mix and staff stability. The data were collected in the mid-1990s from a nationally representative sample of 100 acute hospital wards and 825 nurses. Our analyses provide important insights for managers seeking to achieve the strategic aims set out in Working Together, and subsequent National Health Service (NHS) policy placing emphasis on making the best use of nurses, focussing on mobilising their knowledge, skills and talents within the context of extended work roles. Findings show that number of nurses is associated not only with ward organizational systems but also with a range of care processes and staff outcomes which hitherto have been linked only to ward organizational systems. The latter have been identified as providing different opportunities for developing multidisciplinary working and nurses' autonomy but the central importance of having an adequate number of staff to achieve these aims has been largely overlooked in research. Having fewer nurses was associated with both hierarchical ward organizational structures and hierarchical attitudes to care provision, denoting lower standards of nursing practice. A larger nursing complement was significantly associated with devolved organizational structures but no link was established between more staff and higher standards of nursing practice. When there were more staff there was a positive association with nurses' perceptions of multidisciplinary collaboration, their ability to cope with workload and job satisfaction. Employing an adequate number of nurses to provide care is clearly beneficial for nurses themselves. Patients are also likely to benefit from a lower incidence of 'hierarchical practice' associated with having a low nurse/bed ratio within a ward.     

Understanding nurses' psychosomatic complications that relate to the practice of nursing

The literature acknowledges that nursing practice can create physical and emotional stresses for its practitioners. This study aimed to acquire an in-depth understanding of being a nurse in the Greek National Health System. Interpretive phenomenology was used and Van Manen's method of analysis was implemented. Conversational interviews were conducted with a purposive sample of nine nurses employed at the University Hospital of Ioannina in Greece. The findings produced three essential themes: a dissonance between the images and reality of nursing, emotional burnout, and psychosomatic entanglement. The dissonance between the idealization of nursing and the reality of nursing, along with the emotional crisis created by daily practice, constituted the two fundamental factors for developing psychosomatic complications. These impacted negatively on the participants' personal and professional well-being. Psychosomatic complications can be prevented by clearly delineating roles, enabling collaboration between education and practice, developing mentorship programs, and using reflection in practice.     

Working relationships between practice nurses and general practitioners in Australia: a critical analysis

This research set out to explore shared care between practice nurses and general practitioners in South Australia. Nine practice nurses (PNs), two nurse practitioners and 10 general practitioners (GPs) were interviewed in urban and rural practices in order to build up a picture of how GPs and PNs worked together. The interviews showed that shared care was not a reality, although practice nurses were very busy, enjoyed their work and were no longer performing as receptionists doing a little nursing on the side, but as highly skilled nurses. Questions that emerged included whether or not practice nurses are specialists or generalists; their relationship to nurse practitioners; the extent to which the doctor–nurse game explains the relationship between practice nurses and general practitioners; and the potential for expanding the practice nurse role.     

Exploring new nurse teachers' perception and understanding of reflection: an exploratory study

Reflection and the development of reflective practitioners are integral in many nursing programmes. This study set out to explore new lecturers’ perception and understanding of reflection and how well they are preparing nurses to be reflective practitioners. Using a mixed method, new lecturers appointed to the school of nursing within the last 18 months were questioned using a semi-structured questionnaire. Participants were recruited from the purposeful sample and two focus groups interviews were carried out.Data analysis revealed five major themes: (1) perceived lack of efficacy in teaching reflection; (2) skills required for reflection: (3) reflection in the curriculum: (4) strategies used in teaching reflection and (5) educators preparation.It is suggested that new lecturers need more preparation in the highly complex skill of reflection in order to facilitate the reflective learning process in their students. The use of more overt and innovative ways of facilitating reflection in the nursing curriculum is advocated.     

Nurses’ perceptions of feedback to nursing teams on quality measurements: An embedded case study design

BackgroundProviding nursing teams with feedback on quality measurements is used as a quality improvement instrument in healthcare organizations worldwide. Previous research indicated contradictory results regarding the effect of such feedback on both nurses’ well-being and performance.ObjectivesBuilding on the Job Demands-Resources model this study explores: (1) whether and how nurses’ perceptions of feedback on quality measurements (as a burdening job demand or rather as an intrinsically or extrinsically motivating job resource) are respectively related to nurses’ well-being and performance; and (2) whether and how team reflection influences nurses’ perceptions.DesignAn embedded case study.SettingsFour surgical wards within three different acute teaching-hospital settings in the Netherlands.MethodsDuring a period of four months, the nurses on each ward were provided with similar feedback on quality measurements. After this period, interviews with eight nurses and the ward manager for each ward were conducted. Additionally, observational data were collected from three oral feedback moments on each of the participating wards.ResultsThe data revealed that individual nurses perceive the same feedback on quality measurements differently, leading to different effects on nurses’ well-being and performance: 1) feedback can be perceived as a job demand that pressures nurses to improve the results on the quality measurements; 2) feedback can be perceived as an extrinsically motivating job resource, that is instrumental to improve the results on quality measurements; 3) feedback can be perceived as an intrinsically motivating job resource that stimulates nurses to improve the results on the quality measurements; and 4) feedback can be perceived neither as a job demand, nor as a job resource, and has no effect on nurses’ well-being and performance. Additionally, this study indicates that team reflection after feedback seems to be very low in practice, while our data also provides evidence that nursing teams using the feedback to jointly reflect and analyse their performance and strategies will be able to better translate information about quality measurements into corrective behaviours, which may result in more positive perceptions of feedback on quality measurements among individual nurses.ConclusionsTo better understand the impact of feedback to nursing teams on quality measurements, we should take nurses’ individual perceptions of this feedback into account. Supporting nursing teams in team reflection after them having received feedback on quality measurements may help in eliciting positive perceptions among nurses, and therewith create positive effects of feedback on both their well-being and performance.     

Service quality in hospital wards with different nursing organization: nurses' ratings

Title. Service quality in hospital wards with different nursing organization: nurses’ ratings. Aim. This paper is a report of a study to assess: (1) the relations between nursing organization models in hospital wards and nurses’ perception of the quality of patient care and dimensions of the practice environment, and (2) if these relations were modified by variations in local conditions at the ward level. Background. Previous literature is inconclusive concerning what model of nursing organization maximizes the quality of nursing services. Method. A cross‐sectional survey was carried out in a representative sample of Norwegian hospital wards in 2005. Intra‐ward organization models were classified as: (1) Team leader (n = 30), characterized by extensive responsibilities for team leaders, (2) Primary nurse (n = 18), with extensive responsibilities for named nurses, and (3) Hybrid (n = 37), (1) and (2) combined. We prepared multilevel regression models using scales describing quality of patient care, learning climate, job satisfaction, and relationships with physicians as dependent variables. As independent variables, we used variables representing local ward conditions. Results. Eighty‐seven wards and 1137 nurses (55% response rate) provided complete data. The ward level proportion of variance ranged from 0·10 (job satisfaction) to 0·22 (relationships with physicians). The univariate effect of organization models on quality ratings was not statistically significant. Introducing local ward conditions led to a statistically significant effect of primary nurse organization on relationships with physicians, and to a substantial proportional reduction in ward level variance, ranging from 32% (quality of patient care) to 24% (learning climate). Conclusion. Caution is needed about using service quality arguments when considering the possible benefits and drawbacks of different organizational models.     

Nursing organizational practice and its relationship with other features of ward organization and job satisfaction

This paper describes a new classification of ward organizational practice in nursing. Data related to aspects of ward nursing practice were collected by postal survey from a nationally representative sample of 74 acute hospital wards, and subjected to hierarchical cluster analysis. The model which was deemed to best 'fit' the data, provided three types of ward practices, which have been named: 'devolved', 'two tier' and 'centralized' nursing. The distinguishing features of the three classifications are similar but not identical to accepted 'ideal types' of primary, team and functional systems. The relationships between wards in each of the three identified categories and other ward organizational practice processes of nursing care and job satisfaction are described.     

Time to care? Time for reflection

This paper develops a single shared experience within a guided reflection relationship to highlight the process of guiding learning through reflection. The shared experience is a mundane everyday experience concerned with the ward sister on an acute elderly ward responding to a relative's request. From the reflective practice perspective, the analysis of a single experience becomes a significant source of knowledge to inform others'practice. Reflective practitioners always interpret extant knowledge for its relevance to their practice. This process is helped by reflective accounts because they are subjective and contextualized accounts and therefore aid interpretation.     

Reflection: possible strategies to improve its use by qualified staff

Reflection is now a prerequisite for all nurses, midwives and health visitors (UKCC, 2001). It is the method endorsed by the UKCC to promote the development of informed, knowledgeable and safe practice, and qualified practitioners are required to maintain a personal professional profile containing evidence of reflection on practice. The aim of this article is to examine why qualified practitioners may be reluctant to reflect formally, to speculate on the possible barriers to reflection, and to suggest how reflection can be promoted positively as an integral part of nursing practice. The article begins with an examination of definitions of reflection, reflective theory and the purpose of reflection, and continues by questioning whether the concept of reflection has been embraced as eagerly by nurses at 'grass roots' as it has by academia, the nursing press and the UKCC. It is suggested that several barriers to effective reflection may create a division between practitioners and the professional hierarchy regarding the conceived common practice of reflection, and strategies are proposed that may help to overcome these barriers. The discussion concludes by prioritizing the need for a clear definition and concept analysis of reflection, supported by long-term investment into research that explores the effect of reflection on clinical practice and patient care.     

Changing nursing practice through reflection on the Roper, Logan and Tierney model: the enhancement approach to action research

To the clinical practitioner both nursing models and nursing research may currently be viewed as distant and élitist In the current political climate neither may be highly valued by practitioners or managers Yet, by facilitating group reflection on the nursing model identified in the ward philosophy and adopting the enhancement approach to action research, surgical nurses were empowered to effect change and, consequently, to enhance the quality of patient care in their ward The study was undertaken in two phases over a 15-month period and utilized a multi-method approach In phase 1 triangulation of the data enabled the practitioners/co-researchers to identify and reflect on patients 'psychological needs within the independence/dependence continuum of the Roper et al (1990) model Phase 2 involved a collaborative approach to the planning, implementation and evaluation of innovations which resulted from reflection on practice Nurse-doctor relationships including anaesthetist non-compliance were, though, a controversial issue Collaborative practice was undermined by the co-researchers' ambivalence concerning feedback from the medical staff Overall, however, the individual contribution of each co-researcher was recognized and valued They had both choice and control which enabled them to develop personally and professionally Group reflection was seen as an essential feedback strategy during the change process     

The development of clinical leadership through supported reflective practice

• ? The notion of clinical leadership is significant in current nursing practice, particularly since recommendations made by the Department of Health in ‘The Strategy for Nursing’. However, while it is a concept that many nurses aspire to implement, in reality the operationalizing of such a concept is fraught with difficulty.
• ? This paper aims to explore the issue of clinical leadership through a collegiate model developed in a particular practice area.
• ? The development of this collegiate relationship is articulated through the mediums of reflective practice and clinical supervision.
• ? A model of collegiality is offered as an approach to the integration of the spheres of clinical leadership.
• ? If reflective practice is to be a reality then it is essential that both clinical leaders and practitioners engage in such processes within a supportive culture.

     

Reflection: possible strategies to improve its use by qualified staff

Reflection is now a prerequisite for all nurses, midwives and health visitors (UKCC, 2001). It is the method endorsed by the UKCC to promote the development of informed, knowledgeable and safe practice, and qualified practitioners are required to maintain a personal professional profile containing evidence of reflection on practice. The aim of this article is to examine why qualified practitioners may be reluctant to reflect formally, to speculate on the possible barriers to refection, and to suggest how reflection can be promoted positively as an integral part of nursing practice. The article begins with an examination of definitions of reflection, reflective theory and the purpose of reflection, and continues by questioning whether the concept of reflection has been embraced as eagerly by nurses at 'grass roots' as it has by academia, the nursing press and the UKCC. It is suggested that several barriers to effective reflection may create a division between practitioners and the professional hierarchy regarding the conceived common practice of reflection, and strategies are proposed that may help to overcome these barriers. The discussion concludes by prioritizing the need for a clear definition and concept analysis of reflection, supported by long-term investment into research that explores the effect of reflection on clinical practice and patient care.     

Record-keeping and routine nursing practice: the view from the wards

This paper examines general nurses' views of the nursing record and its routine usage in contemporary hospital practice. It draws on ethnographic data generated on a surgical ward and a medical ward in a single District General Hospital in the United Kingdom (UK). A key research finding was ward nurses' equivocal attitudes to the nursing record. On the one hand, because of its links with the nursing process, the nursing record was highly valued as a symbol of professionalism and ward staff were loathe to criticise it directly. On the other hand, however, the nurses in this study clearly found it difficult to reconcile their professional ideals with the ways in which the nursing record was routinely employed on the wards. In this paper it is suggested that at one level, nurses' ambivalence towards the nursing record reflected the distortion of its founding philosophy by the new managerialism in the contemporary UK health care context. At another level, however, there are also difficulties which arise from the tension between the assumptions about the nature of nursing work which underpin the nursing record and the workplace reality on hospital wards.     

Private thoughts in public spheres: issues in reflection and reflective practices in nursing

AIM: This paper aims to problematize the notions of reflection and reflective practice, particularly as they relate to private thoughts in public spheres and the constitution of personal and professional subjectivities. BACKGROUND/RATIONALE: Reflection and reflective practice, through the technologies of power and technologies of the self, permit the previously private thoughts of nurses to enter the public sphere where they are subject to surveillance, assessment, classification and control. Instead of raising serious concerns and debate about such practices, the plethora of literature, whilst using a bewildering array of ambiguous, diverse interpretations of reflection and reflective practice, has been united in claiming them as good for nurses and nursing. APPROACH: The paper draws on Foucauldian concepts of power-knowledge and discourse to interrogate radically the conceptualizations of reflection and reflective practice in contemporary nursing literature. CONCLUSIONS: The paper challenges the hegemonic discourse of reflection in nursing. It argues that new conceptualizations of reflection that acknowledge and value a diversity of perspectives, contexts and dimensions are needed.     

Learning from the severe acute respiratory syndrome (SARS) epidemic

Aims and objectives. This study uses two models of nursing practice, conventional and modular design, to compare nursing activities, hand hygiene, time efficiency and nurse–patient satisfaction in medical and surgical wards. Background. Learning from the SARS epidemic pointed to the importance of quality nursing practice considerations that minimize cross‐transmission of infection while maximizing patient‐focused care. Hence, a modular nursing model was adopted. Design and method. This study comprised pre‐ and postintervention phases. Data collection tools to evaluate modular nursing practice included a work sampling observation checklist, focused group interviews with nurses, questionnaires addressing nurses’ perceived competence and caring attributes, a patient satisfaction questionnaire, and a hand hygiene audit. A series of education sessions were conducted between the two phases. Quantitative and qualitative analyses were used for data triangulation. Results. Modular nursing practice, focusing on continuity of care, led to changes in the nature of direct care activities and improvement in patient/family education frequency. Also, a general increase in nurses’ hand washing frequency was noted. However, when nurses perceived time pressure, a lapse in hand hygiene compliance was found. Because of human resource and inefficiency issues, some nurses in the studied wards did not embrace geographical separation for infection control. Positive correlations were found for nurses’ perceived infection control practice competence and their perceived caring attributes. Relevance to clinical practice. In examining nursing practice models within complex clinical situations, the significance lies not only in the model's effects but also in other operational outcomes.