Factorial Validity of the Decisional Involvement Scale as a Measure of Content and Context of Nursing Practice.

Decisional involvement is widely recognized as an essential component of a professional nursing practice environment. In recent years, researchers have added to the conceptualization of nurses' role in decision-making to differentiate between the content and context of nursing practice. Yet, instruments that clearly distinguish between these two dimensions of practice are lacking. The purpose of this study was to examine the factorial validity of the Decisional Involvement Scale (DIS) as a measure of both the content and context of nursing practice. This secondary analysis was conducted using data from a longitudinal action research project to improve the quality of nursing practice and patient care in six hospitals (N = 1,034) in medically underserved counties of Pennsylvania. A cross-sectional analysis of baseline data from the parent study was used to compare the factor structure of two models (one nested within the other) using confirmatory factor analysis. Although a comparison of the two models indicated that the addition of second-order factors for the content and context of nursing practice improved model fit, neither model provided optimal fit to the data. Additional model-generating research is needed to develop the DIS as a valid measure of decisional involvement for both the content and context of nursing practice.

Quality and strength of patient safety climate on medical-surgical units.

BACKGROUND: Describing the safety climate in hospitals is an important first step in creating work environments where safety is a priority. Yet, little is known about the patient safety climate on medical-surgical units. PURPOSES: Study purposes were to describe quality and strength of the patient safety climate on medical-surgical units and explore hospital and unit characteristics associated with this climate. METHODOLOGY: Data came from a larger organizational study to investigate hospital and unit characteristics associated with organizational, nurse, and patient outcomes. The sample for this study was 3,689 RNs on 286 medical-surgical units in 146 hospitals. FINDINGS: Nursing workgroup and managerial commitment to safety were the two most strongly positive attributes of the patient safety climate. However, issues surrounding the balance between job duties and safety compliance and nurses' reluctance to reveal errors continue to be problematic. Nurses in Magnet hospitals were more likely to communicate about errors and participate in error-related problem solving. Nurses on smaller units and units with lower work complexity reported greater safety compliance and were more likely to communicate about and reveal errors. Nurses on smaller units also reported greater commitment to patient safety and participation in error-related problem solving. PRACTICE IMPLICATIONS: Nursing workgroup commitment to safety is a valuable resource that can be leveraged to promote a sense of personal responsibility for and shared ownership of patient safety. Managers can capitalize on this commitment by promoting a work environment in which control over nursing practice and active participation in unit decisions are encouraged and by developing channels of communication that increase staff nurse involvement in identifying patient safety issues, prioritizing unit-level safety goals, and resolving day-to-day operational problems the have the potential to jeopardize patient safety.

Bridging the gap between problem recognition and treatment: the use of proactive work behaviors by experienced critical care nurses.

Delayed access to physicians has been identified as a factor in preventable adverse patient events during hospitalization. Nurses as front-line providers are well positioned to provide a timely response to the needs of patients. Yet legal regulations and hospital policies limit the actions nurses can initiate without physician authorization. The purpose of this qualitative study was to describe what experienced critical care nurses do when they recognize a problem that warrants treatment but lack physician authorization to intervene. The 13 nurses who participated in this study bridged the gap between problem recognition and treatment by communicating proactively, being persistent, running interference for other nurses, and, in some situations, acting without physician authorization. Revising legal regulations and hospital policies to incorporate greater acknowledgment of the overlapping functions between medicine and nursing and recognition of the knowledge and expertise of experienced nurses may be important in reducing unnecessary treatment delays during hospitalization.

Organizational influences on patient perceptions of symptom management.

We tested a theoretical model of the relationships of hospital context, nursing unit structure, and patient characteristics to patients' perceptions of the extent to which nurses met their expectations for management of troubling symptoms. In our sample of 2,720 patients randomly selected from 278 nursing units in 143 hospitals, we found that patient age was positively associated with patients' perceptions of symptom management. The proportion of registered nurses as caregivers on the unit was not a significant predictor of symptom management, but better work conditions on the unit (nurses' autonomy, participation in decision-making, and collaboration with other disciplines [relational coordination]) significantly contributed to patients' perceptions of better symptom management.

Quality and strength of patient safety climate on medical-surgical units.

BACKGROUND: Describing the safety climate in hospitals is an important first step in creating work environments where safety is a priority. Yet, little is known about the patient safety climate on medical-surgical units. PURPOSES: Study purposes were to describe quality and strength of the patient safety climate on medical-surgical units and explore hospital and unit characteristics associated with this climate. METHODOLOGY: Data came from a larger organizational study to investigate hospital and unit characteristics associated with organizational, nurse, and patient outcomes. The sample for this study was 3,689 RNs on 286 medical-surgical units in 146 hospitals. FINDINGS: Nursing workgroup and managerial commitment to safety were the two most strongly positive attributes of the patient safety climate. However, issues surrounding the balance between job duties and safety compliance and nurses' reluctance to reveal errors continue to be problematic. Nurses in Magnet hospitals were more likely to communicate about errors and participate in error-related problem solving. Nurses on smaller units and units with lower work complexity reported greater safety compliance and were more likely to communicate about and reveal errors. Nurses on smaller units also reported greater commitment to patient safety and participation in error-related problem solving. PRACTICE IMPLICATIONS: Nursing workgroup commitment to safety is a valuable resource that can be leveraged to promote a sense of personal responsibility for and shared ownership of patient safety. Managers can capitalize on this commitment by promoting a work environment in which control over nursing practice and active participation in unit decisions are encouraged and by developing channels of communication that increase staff nurse involvement in identifying patient safety issues, prioritizing unit-level safety goals, and resolving day-to-day operational problems the have the potential to jeopardize patient safety.

Does safety climate moderate the influence of staffing adequacy and work conditions on nurse injuries?

PROBLEM: Hospital nurses have one of the highest work-related injury rates in the United States. Yet, approaches to improving employee safety have generally focused on attempts to modify individual behavior through enforced compliance with safety rules and mandatory participation in safety training. We examined a theoretical model that investigated the impact on nurse injuries (back injuries and needlesticks) of critical structural variables (staffing adequacy, work engagement, and work conditions) and further tested whether safety climate moderated these effects. METHOD: A longitudinal, non-experimental, organizational study, conducted in 281 medical-surgical units in 143 general acute care hospitals in the United States. RESULTS: Work engagement and work conditions were positively related to safety climate, but not directly to nurse back injuries or needlesticks. Safety climate moderated the relationship between work engagement and needlesticks, while safety climate moderated the effect of work conditions on both needlesticks and back injuries, although in unexpected ways. DISCUSSION AND IMPACT ON INDUSTRY: Our findings suggest that positive work engagement and work conditions contribute to enhanced safety climate and can reduce nurse injuries.

Fitting in or standing out: nursing workgroup diversity and unit-level outcomes.

BACKGROUND: Despite growing diversity in the nursing workforce, there has been limited investigation of the implications of diversity to the performance of nursing workgroups. OBJECTIVES: The aim of this study was to examine relationships among two categories of nursing workgroup diversity (highly visible and job related), intervening workgroup processes (workgroup cohesion and initiative), and workgroup performance (affective and cognitive). METHODS: A descriptive design with path analysis was used to test two models derived from Pelled's intervening process theory. Registered nurse (RN) and patient data from 222 nursing units at 126 hospitals, collected as part of the Outcomes Research in Nursing Administration Project (ORNA-II), were used. Registered nurses provided demographic data used to estimate workgroup diversity (age, race, unit tenure, educational background, and RN experience) and completed questionnaires measuring workgroup cohesion and initiative. Patients completed a satisfaction survey, and these data, along with unit-level patient falls and medication errors, were used to measure workgroup performance. RESULTS: Our findings failed to support the intervening process theory. No direct effects between diversity and intervening process variables were found. Cohesion and initiative did not mediate the relationships between diversity and workgroup performance. However, workgroup cohesion predicted greater patient satisfaction (p < .01) and higher levels of met expectations for symptom management (p < .01), whereas workgroup initiative predicted fewer patient falls (p < .01). DISCUSSION: Diversity may have little, if any, effect on nursing workgroup performance. Cohesion and initiative warrant further research as possible mediators of the relationship between patient outcomes and variables like nurse staffing, experience, and expertise.

Evaluation of an informal peer group experience on baccalaureate nursing students' emotional well-being and professional socialization.

Although studies have documented the importance of the academic environment in promoting positive outcomes among students, few quantitative studies in nursing have been performed to identify strategies through which a nurturing learning environment can be created. A randomized two-group pretest-posttest design was used to investigate effects of an informal peer group experience on baccalaureate nursing students' emotional well-being and professional socialization as caring practitioners. Groups did not differ significantly on the outcomes measured in this study. As a whole, students showed statistically significant increases in anxiety, depression, and negative affect, along with decreased self-esteem and positive affect during the junior year of nursing school. Psychological problems and stress-related symptoms have been well documented among college students in general and professional students in particular. Although the findings from this study are not unique, they suggest the need to reconsider strategies by which the affective and professional socialization goals of undergraduate nursing education can be achieved.

Describing an episode of home nursing care for elderly postsurgical cancer patients.

BACKGROUND: While studies have documented the beneficial effect of home care for cancer patients, the actual interventions implemented during these studies have not been well described. OBJECTIVES: Purposes of this study were to analyze interventions documented in narrative form by advanced practice nurses during a four-week episode of home care and describe intervention type, frequency, range, and variation over time in intervention emphasis and dose intensity. METHODS: Chart audits were performed on records kept for 148 postsurgical cancer patients who were assigned to the experimental group in a randomized clinical trial to evaluate the effect of home care on quality of life outcomes (McCorkle et al., 2000). Interventions statements (N = 7,275) were analyzed using Grobe's (1996) Nursing Intervention Lexicon and Taxonomy. RESULTS: Teaching accounted for the highest percentage of interventions documented, followed by provision of psychological support and reassurance, determination of patient needs and nursing care requirements, assessment of current status, and indirect care. Physical care and actions to promote self-care independence were documented least frequently. Differences in nursing care were found by cancer site with the greatest diversity of interventions documented for breast cancer patients. Intervention emphasis and dose intensity varied over time, suggesting that these nurses altered their care in response to the changing needs of their patients. CONCLUSIONS: These nurses responded to complex problems and used a variety of interventions to assist patients and families in management of the illness experience. They also tailored their care to each patient's location along the illness trajectory. These findings provide beginning support for the clinical utility of Nursing Intervention Lexicon and Taxonomy as a way to quantify an episode of nursing care.