Beyond the significance test in administrative research and policy decisions.

PURPOSE: To describe confidence interval (CI) analysis and show how it can be used in administrative decisions. ORGANIZING CONSTRUCT: Statistical significance testing should be supplemented, if not replaced, by effect size (ES) estimation and confidence interval analysis. Hypothesis testing based on the statistical significance test is the dominant paradigm in statistics; however, this approach has inherent problems which can ultimately diminish the usefulness of research for operational decisions. After identifying major difficulties with significance testing, the authors use hypothetical examples to demonstrate how ES and CI analysis provide more informative answers to nursing administrative research questions. CONCLUSIONS: CI analysis provides the basis for both improving the interpretation of findings from individual studies and for facilitating the analysis of cumulative evidence. By clarifying the meaning of results, CI analysis can increase the relevance and usefulness of research for health care executives and practitioners.

Publishing as a career development tool: don't forget to write.

Publishing is a powerful career development tool. This article specifically explains how publication can increase credibility, both within and outside your current organization. For example, writing for publication can establish you as an expert, lead to speaking engagements, and enhance graduate school applications. After discussing why publishing is so important, the author shares personal strategies for success.

Sources of satisfaction in hospital nursing practice. A guide to effective job design.

OBJECTIVE: As the healthcare system restructures, changes are being made that appear to influence nurses' jobs and satisfaction, yet little is known about effects on job characteristics and related outcomes. The authors present findings from a research project designed to identify links between specific aspects of hospital staff nurse (SN) practice and perceived job characteristics and psychological states, thought to have motivational consequences. BACKGROUND: The Job Characteristics Model (JCM) is the dominant paradigm in contemporary job design theory and research. Although generally well-supported, the JCM has limitations that constrain its usefulness: first, the Job Diagnostic Survey used to assess perceived characteristics does not indicate the specific aspects of activities that lead to these perceptions, and second, the JCM, based primarily on manufacturing research, does not include interpersonal job characteristics that seem important in human service jobs. METHODS: Two studies were conducted using a similar methodology. Focus groups of SNs were held to identify links between specific activities and characteristics and sources of satisfaction in SNs' job content. The Staff Nurse Job Characteristics Index (SNJCI) was developed to assess the presence of certain elements and activities in a nurse's job. An initial sample of 63 and a second sample of 146 SNs from Medical/Surgical and Coronary Care units completed the SNJCI, the JDS, and a demographic form through a mail survey. RESULTS: Internal consistency reliabilities (Cronbach's alpha) for eight of the nine SNJCI scales were acceptable. Correlation analysis indicates that job characteristics are meaningfully related to psychological states and job satisfaction. Findings support the hypothesis that specific aspects of SNs' jobs are reliably related to characteristics. CONCLUSIONS: Aspects of SNs' jobs important to their satisfaction include continuity in nurse-patient relationships, authority to initiate independent nursing actions, individual accountability for clinical outcomes, and regular performance feedback from managers.

Job design for nurse case managers. Intended and unintended effects on satisfaction and well-being.

As managed care expands, nursing case management is becoming increasingly widespread. Yet little is known about the characteristics of the case manager job and its effects on nurses' workplace well-being. This study investigated hypothesized differences between the characteristics of nurse case manager and staff nurse jobs, including both intended positive and unintended negative effects associated with changes incorporated in the nurse case manager job. Nurse case managers reported significantly higher levels of autonomy, job identity, feedback from agents, and collaboration with physicians than staff nurses; however, they also reported higher levels of required interaction, role conflict, overload, and ambiguity. These findings have important implications for nurse case manager and the organizations that employ them, in relation to job design, career/candidate selection, and orientation and ongoing development.

Doing well by doing good. The case for objective feedback in case management.

Social service programs that do not generate sufficient revenues will not survive in a Fee-For-Service (FFS) system. Yet a concern about finances is alien to many social workers' client-centered orientation. This article presents findings from a study that evaluated the effect of an objective feedback intervention on social workers' productivity in an FFS HIV/AIDS case management program. Results showed a substantial increase in billable hours (13.4% year-to-year; 6.4% pre- to-post intervention) which enable the program to reverse its operating deficit and raise staff salaries.

The white water of change. A survivor's guide.

Managing in an environment of fast, continuous change requires a special perspective and skill set. This article describes a systems framework for understanding the forces behind the turbulence and develops approaches to managing in a dynamically complex environment. Building on this background, five principles guide nurse managers to stay on top of change and thrive in turbulent times.

Integration of emerging designs for the practice and management of nursing.

Work redesign and shared governance represent two of the most popular administrative innovations in contemporary nursing. Whereas work redesign creates changes in the content of nurses' jobs, shared governance addresses the organizational context within which nurses are employed. Although the content and context of nurses' work are closely interrelated, many organizations have attended to one of these issues, but failed to give consideration to the other. Building on this background, the state of the art in nursing redesign and restructuring is summarized, and emerging directions in job and organizational design are identified.

Reengineering. The work redesign--technology link.

Computerization in healthcare is a vital component of operational restructuring, but simply automating existing systems will not achieve the maximum benefit information technology has to offer. The authors present a discussion of information technology and healthcare, addressing a forecast of the predominant technologies in this decade, the impact of information technology in healthcare, and the use of reengineering to explore potential changes in the design of work made possible by information technology. The implications of reengineering in hospitals for nursing and nurse executives are explored.

"Running the vicious cycle backward" and other systems solutions to nursing problems.

Peter Senge's book, The Fifth Discipline: The Art and Practice of the Learning Organization, is a business bestseller. The fifth discipline refers to systems thinking, a conceptual framework for making the full pattern of complex, interrelated actions clearer and helping people see how to change them. This article summarizes selected key concepts from Senge's work and explains how nurse executives can use systems thinking to gain a deeper understanding of the forces operating in recurrent situations and identify opportunities for leverage to benefit patients, staff, and healthcare organizations.

Redesigned nursing practice: a case management model for critical care.

Changes within the health care system necessitate changes in nursing practice. Given the financial environment and the need to balance the cost/quality equation, case management will become increasingly important and has the potential to become the predominant care delivery system of the 1990s. This transition represents a tremendous opportunity for nursing. The CCM role offers many potential advantages and benefits for individual nurses and the profession as a whole. Nurses practicing as case managers have the opportunity to function in a highly professional, independent manner with a great deal of interdisciplinary collaboration. In addition to the challenges and satisfactions of the work itself, the nurse case manager may also enjoy a higher salary and more scheduling control and flexibility. The broader advantages of case management include its benefits to patients and institutions and its fit with current trends in the health care environment. Nurse case managers manage hospital systems to produce optimal clinical outcomes for patients in the shortest time using as few resources as possible. This approach to care delivery places nurses in a position to demonstrate the tremendous contribution they can make to achieving the institution's goal of delivering high-quality, cost-effective care. Thus, case management fits extremely well with current trends in health care financing and outcome measurement. The model described in this article illustrates one approach to implementing these important concepts in a critical care setting.

Work redesign in high-intensity environments. ProACT for critical care.

Hospitals are becoming immense intensive care units despite a continuing shortage of critical care nurses. While there has been widespread application of work redesign concepts in nursing during the last several years, few projects involving critical care have been reported. The authors describe a comprehensive restructuring initiative in the critical care setting and focus on the administrative implications of this work.

Implementing the ten-step monitoring and evaluation process in nursing practice.

Implementation of the ten-step monitoring and evaluation process as recommended by the Joint Commission leads to the development of a program that meets the requirements of the quality assurance standard. The Professional Practice Program at Robert Wood Johnson University Hospital (New Brunswick, New Jersey) demonstrates the application of this process within the Nursing Division. A conceptual model of nursing practice based on nursing diagnosis provides the framework for the program. Responsibility for the system belongs to the professional nursing staff through the election of unit-based representatives.

An interview at Robert Wood Johnson University Hospital. ProACT model.

In its deliberations on the shortage of nurses, the Executive Board of NAON charged the Orthopaedic Nursing journal with bringing information to our readers concerning innovations in nursing care which have resulted partly in response to the current nursing crisis. This article presents an innovative care model implemented on an orthopaedic unit at Robert Wood Johnson University Hospital in New Brunswick, New Jersey. It describes not only the developed system but also the process that was used in implementing the design.

Restructured patient care delivery: evaluation of the ProAct model.

This budget-neutral model uses fewer RNs with increased clinical and nonclinical support and demonstrates potential to improve quality of care, reduce length of stay, and increase revenue.

Redesigning hospital nursing practice: the Professionally Advanced Care Team (ProACT) model, Part 2.

The pressures of the current nursing shortage have created an unparalleled opportunity to restructure hospital nursing practice and care delivery. The potential exists to create new systems which simultaneously advance the goals of the profession and solve the problems of the shortage. Part 1 of this article (JONA, July/August, 1989) examined the similarities and differences among existing models and described the Robert Wood Johnson University Hospital ProACT model. Part 2 outlines the process of developing and implementing ProACT, an alternative nursing practice and care delivery model.

Redesigning hospital nursing practice: the Professionally Advanced Care Team (ProACT) model, Part 1.

Nurse executives must lead in proactively managing care delivery in the face of an increasingly severe nursing shortage. Failure to do so invites the imposition of untenable "solutions" by outside parties. Much has been written about the magnitude and causes of the current nursing shortage. This article focuses on alternative practice models as a viable solution. Part 1 examines similarities and differences among existing models and describes the Robert Wood Johnson University Hospital ProACT model. Part 2 will discuss the process of developing and implementing this alternative nursing practice and care delivery model.