Curbing the urge to care: A Bourdieusian analysis of the effect of the caring disposition on nurse middle managers' clinical leadership in patient safety practices.

BACKGROUND: Nurse managers play an important role in implementing patient safety practices in hospitals. However, the influence of their professional background on their clinical leadership behaviour remains unclear. Research has demonstrated that concepts of Bourdieu (dispositions of habitus, capital and field) help to describe this influence. It revealed various configurations of dispositions of the habitus in which a caring disposition plays a crucial role. OBJECTIVES: We explore how the caring disposition of nurse middle managers' habitus influences their clinical leadership behaviour in patient safety practices. DESIGN: Our paper reports the findings of a Bourdieusian, multi-site, ethnographic case study. SETTINGS: Two Dutch and two American acute care, mid-sized, non-profit hospitals. PARTICIPANTS: A total of 16 nurse middle managers of adult care units. METHODS: Observations were made over 560h of shadowing nurse middle managers, semi-structured interviews and member check meetings with the participants. RESULTS: We observed three distinct configurations of dispositions of the habitus which influenced the clinical leadership of nurse middle managers in patient safety practices; they all include a caring disposition: (1) a configuration with a dominant caring disposition that was helpful (via solving urgent matters) and hindering (via ad hoc and reactive actions, leading to quick fixes and 'compensatory modes'); (2) a configuration with an interaction of caring and collegial dispositions that led to an absence of clinical involvement and discouraged patient safety practices; and (3) a configuration with a dominant scientific disposition showing an investigative, non-judging, analytic stance, a focus on evidence-based practice that curbs the ad hoc repertoire of the caring disposition. CONCLUSIONS: The dispositions of the nurse middle managers' habitus influenced their clinical leadership in patient safety practices. A dominance of the caring disposition, which meant 'always' answering calls for help and reactive and ad hoc reactions, did not support the clinical leadership role of nurse middle managers. By perceiving the team of staff nurses as pseudo-patients, patient safety practice was jeopardized because of erosion of the clinical disposition. The nurse middle managers' clinical leadership was enhanced by leadership behaviour based on the clinical and scientific dispositions that was manifested through an investigative, non-judging, analytic stance, a focus on evidence-based practice and a curbed caring disposition.

Self-efficacy: measurement and intervention in nursing.

Assisting people with chronic illnesses to change their behavior is important in effecting self-management and in achieving the highest possible level of health. There is increasing evidence that a vital ingredient in health-related behavior change is the perceived self-efficacy of the individual to behave differently; however, disease- and age-specific measures and interventions have received insufficient attention to date. This special issue reports the results of the first stages of an international collaboration that is addressing the development and testing of instruments and interventions to measure and ultimately to enhance self-efficacy in management of diabetes mellitus. These instruments are now being used and tested further by other investigators, as well as in ongoing studies by the authors. Additionally, the issue addresses the importance of theory-based interventions and their use in enhancing self-efficacy as a means of encouraging positive behavior change. The results of two intervention studies designed to improve patients' self-management of obesity and cancer support the use of strategies to enhance self-efficacy in changing behavior. They also underscore the need to continue to identify, develop and test targeted nursing interventions.

The theory and measurement of the self-efficacy construct.

Self-efficacy is the major concept of Bandura's social cognitive theory. Self-efficacy is influenced by four important sources of information: performance accomplishments, vicarious experience, verbal persuasion, and physiological information. Other determinants of self-efficacy are internal personal factors and external environmental factors. The degree of change in self-efficacy is partly a function of the variability and the controllability of its determinants. Level of self-efficacy predicts how people are functioning in terms of choice of behavior, effort expenditure and persistence, thought patterns and emotional reactions. Measurement of self-efficacy is related to three dimensions: magnitude, strength and generality. Self-efficacy should be measured in terms of particularized judgments of capability that may vary across realms of activity, different levels of task demands within a given activity domain, and different situational circumstances.

Early recognition of delirium: review of the literature.

This review focuses on delirium and early recognition of symptoms by nurses. Delirium is a transient organic mental syndrome characterized by disturbances in consciousness, thinking and memory. The incidence in older hospitalized patients is about 25%. The causes of delirium are multi-factorial; risk factors include high age, cognitive impairment and severity of illness. The consequences of delirium include high morbidity and mortality, lengthened hospital stay and nursing home placement. Delirium develops in a short period and symptoms fluctuate, therefore nurses are in a key position to recognize symptoms. Delirium is often overlooked or misdiagnosed due to lack of knowledge and awareness in nurses and doctors. To improve early recognition of delirium, emphasis should be given to terminology, vision and knowledge regarding health in ageing and delirium as a potential medical emergency, and to instruments for systematic screening of symptoms.

International collaborative research on management self-efficacy in diabetes mellitus.

Diabetes mellitus is a leading chronic illness in the United States and in the Netherlands. Assisting persons with diabetes and their families to manage the illness so that they can have satisfying lives is a challenge for all involved. Persons with diabetes mellitus and their significant others (family members, friends, or other caregivers) must learn and perform management behaviors in order to achieve this goal. Self-efficacy has been shown to be an important predictive variable in initiating and continuing management behaviors. In order to test the impact of self-efficacy on the management of diabetes mellitus and to conduct comparative studies in the Netherlands and the United States, a battery of valid and reliable measurement instruments were needed. Six different instruments in two languages were developed to test children with diabetes and their significant other, adults with insulin dependent diabetes and their significant other, and adults with non-insulin dependent diabetes and their significant other. An overview of the instrument development and testing is described. The testing of different formats due to language terminology and the testing of the instruments for the adults with non-insulin dependent diabetes mellitus will be presented.