The impact of restructuring on professional nursing practice

Decentralisation - A Portmanteau Concept That Promises Much but Fails to Deliver? Comment on "Decentralisation of Health Services in Fiji: A Decision Space Analysis"

Decentralisation has been described as an empty concept that lacks clarity. Yet there is an enduring interest in the process of decentralisation within health systems and public services more generally. Many claims about the benefits of decentralisation are not supported by evidence. It may be useful as an organising framework for analysis of health systems but in this context it lacks conceptual clarity and particularly often ignores level context issues given the focus on a principal-agent/vertical centre/local axis or other aspects of limits on autonomy such as standards for professional practice. Both these aspects are relevant in discussing the establishment of "decentralised" health centres in Fiji. In the end decentralisation may be nothing more than a useful descriptive label that can be used in an increasingly wide range of ways but actually have little meaning in practice as an analytical concept.

Developing relationships: A strategy for compassionate nursing care of the dying in Japan

Objectives:

The aim of this study was to explore the type of relationship and the process of developing these relationships between nurses and patients in palliative care units in Japan. The special contribution that culture makes was examined to better understand the intensity of nurses’ grief after the death of their patient.

Methods:

Thirteen Japanese registered nurses currently practicing in palliative care units were interviewed between July 2006 to June 2009. Theoretical sampling was utilised and the data were analysed using grounded theory methodology. Constant comparison was undertaken during coding processes until data saturation was achieved.

Results:

Significant cultural influences emerged both in the type of relationship nurses formed with patients and in the way they developed relationships. The type of relationship was termed ‘human-to-human’, meaning truly interpersonal. The cultural values of ‘Uchi (inside) and Soto (outside)’ have particular implications for the relationship. Four actions Being open, Trying to understand, Devoting time and energy, and Applying a primary nurse role, were identified as strategies for nurses to develop such relationships. The quality of this deeply committed encounter with patients caused nurses to grieve following patients’ death.

Significance of results:

Culture is a major influence upon the reasons, complexities, and impact that lie behind nurses’ behaviours. Attention is needed to support nurses to sustain a fundamental caring quality in their relationships with patients.

The Circle of Caring Model for Neonatal Transport

The Circle of Caring Model serves as a guide that superimposes nursing and medical practice models. This transformative template was formulated for advanced practice nursing in all health care settings, including neonatal care. This article proposes an extension of this model specific to neonatal transport. It also shows how the Circle of Caring Model for Neonatal Transport functions within the framework of a hypothetical patient case.

Nurse autonomy in cancer care

BACKGROUND

The concept of autonomy is regarded as an essential element for gaining professional status. Yet, it remains poorly defined and understood. To date, there is little research that has focused on exploring how nurses in different specialty areas perceive autonomy.

OBJECTIVE

The purpose of this research was to explore oncology nurses' perceptions of autonomy and understand how they develop and exhibit autonomy in their everyday practice.

METHODS

Using Leininger's ethnonursing method, data were collected from 15 oncology nurses using semistructured interviews. Participant observation was also carried out through job shadowing to complement interview data.

RESULTS

Three themes emerged from the findings: autonomy is an unspoken opportunity in the workplace; autonomy is developed through professional and personal growth acquired over time; and demonstrating autonomous behaviors is a conscious choice.

CONCLUSION

The findings provide insight into how oncology nurses perceive, develop, and exhibit autonomy in everyday practice and how autonomous and collaborative clinical decision making contributes to quality cancer care.

IMPLICATIONS FOR PRACTICE

Descriptions of the meaning of autonomy and its explication in a nursing specialty practice can add to nursing knowledge by clarifying nurse autonomy and its relevance to nurses' work life. Descriptive studies can identify nurse behaviors and attitudes related to autonomy that may be measurable and relevant to real life.

Integrated primary nursing: a care delivery model for the 21st-century knowledge worker

Care delivery models are an integral component for delivering patient care. Although models may be abstract, nursing care delivery models need to be evolving and reality-based, as they serve to organize the allocation of nursing resources. How nursing resources are allocated is associated with patient and professional RN satisfaction, RN perceived autonomy, and quality outcomes. Care delivery models must be evolving within today's dynamic healthcare environment and must be structured within the context of a professional practice model. At the Hospital of the University of Pennsylvania, a Magnet-designated organization, a blend of traditional primary nursing and the updated relationship-based care has been developed and actualized. This model, Integrated Primary Nursing, exists within the framework of the Hospital of the University of Pennsylvania Nursing Excellence in Professional Practice. The coalescence of the 2 has yielded a care delivery model for the 21-st century RN knowledge worker.

Managing nurses through disciplinary power: a Foucauldian analysis of workplace violence

AIMS

This paper describes discipline as a specific technique of power which constitutes, in our view, a form of institutional violence.

BACKGROUND

The need to create and maintain safe and healthy work environments for healthcare professionals is well documented.

EVALUATION

Foucault's concept of disciplinary power was used to explore institutional violence from a critical perspective.

KEY ISSUE

Violence is identified as an important factor in the recruitment and retention of healthcare professionals. Given the shortage of such professionals, there is an urgent need to take a fresh look at their working environments and working conditions.

CONCLUSION

Power, surveillance and disciplinary techniques are used at all levels of hospital management to control and contain both human resources and costs.

IMPLICATIONS FOR NURSING MANAGEMENT

By associating common workplace practices with institutional violence, employers who have a policy of zero tolerance toward workplace violence will need to re-examine their current ways of operating.

How unit level nursing responsibilities are structured in US hospitals

OBJECTIVES

To describe (1) the extent to which acute and intensive care units use the elements of nursing models (team, functional, primary, total patient care, patient-focused care, case management) and (2) the deployment of non-unit-based personnel resources.

BACKGROUND

The lack of current data-based behavioral descriptions of the extent to which elements of nursing models are implemented makes it difficult to determine how work models may influence outcomes.

METHODS

Nurse managers of 56 intensive care units and 80 acute care adult units from 40 randomly selected US hospitals participated in a structured interview regarding (1) day-shift use of patient assignment behaviors associated with nursing models and (2) the availability and consistency of assignment of non-unit-based support personnel.

RESULTS

No model was implemented fully. Almost all intensive care units reported similar assignment behaviors except in the consistency of patient assignment. Non-intensive care units demonstrated wide variation in assignment patterns. Patterns differed intra-institutionally. There were large differences in the availability and deployment of non-unit-based supportive resources.

CONCLUSIONS

Administrators must recognize the differences in work models within their institutions as a part of any quality improvement effort. Attempts to test new work models must be rigorous in the measurement of their implementation.

Job satisfaction of Italian nurses: an exploratory study

AIM

The purpose of this research was to determine the factors that lead to feelings of job satisfaction and dissatisfaction experienced by nurses operating in three Italian hospitals.

BACKGROUND

A high level of job satisfaction is related to a feeling of well-being, productivity and patient satisfaction. Furthermore, job satisfaction is considered capable of reducing turnover and absenteeism.

METHOD

Data were collected using the narrative interview technique. Sixty-four interviews were undertaken, resulting in the collection of 381 stories: 207 referring to job satisfaction experiences and 174 referring to job dissatisfaction experiences.

RESULTS

The five job satisfaction factors are: job content; professional relationships; responsibility, independence and professional growth; relationships with patients and their families; and relationships with coordinators. The four job dissatisfaction factors are: coordinator management style; activity programming and organization; relationships with doctors; and relationships with patients.

CONCLUSIONS

Results indicate that the present nursing management techniques should be improved to become more effective in increasing job satisfaction. To be more precise there emerge three separate areas of improvement: investment in professional training and managerial training; renovation of organizational models; and permanent monitoring of job satisfaction.

Excellence through evidence: structures enabling clinical autonomy

Autonomy is a multidimensional process. Clinical autonomy, the dimension in which patients are the primary beneficiaries, is the focus of this study. Despite high valuation and persistent challenges to nurses to function autonomously, the relationship between autonomous practice and patient outcomes has not been empirically established due, in large measure, to a lack of correspondence between concepts and measurement of autonomy and to a lack of knowledge of enabling structures. The purpose of the research reported here is to identify the structures, practices, elements in the environment, and interventions that nurses, nurse managers, and physicians identify as promoting staff nurse clinical autonomy. Implementation of these interventions would then enable clinical decision making at the frontline and would foster studies to determine whether the expected linkage between clinical autonomy and positive patient outcomes prevails.

Excellence Through Evidence

Despite high valuation and persistent challenges to nurses to function autonomously, neither the structures fostering clinical autonomy nor the relationship between autonomous practice and positive patient outcomes has been empirically established. Much of this is caused by the lack of precision in definition and measurement of the concept and identification of autonomy-enabling structures. The goal of this multisite, evidence-based management practice study is to provide an in-depth analysis of the concept and an articulation of a grounded theory of clinical autonomy preparatory to the identification of structures supporting autonomy. This article describes the research design and methodology and explicates the grounded theory by answering the following questions: What is clinical autonomy? When and where does it occur? Suggestions and recommendations for what could be done to clarify the concept and promote clinical autonomy are provided.

Collaboration, credibility, compassion, and coordination: professional nurse communication skill sets in health care team interactions

This study explored how nurses communicate professionalism in interactions with members of their health care teams. Extant research show that effective team communication is a vital aspect of a positive nursing practice environment, a setting that has been linked to enhanced patient outcomes. Although communication principles are emphasized in nursing education as an important component of professional nursing practice, actual nurse interaction skills in team-based health care delivery remain understudied. Qualitative analysis of interview transcripts with 50 participants at a large tertiary hospital revealed four communicative skill sets exemplified by nursing professionals: collaboration, credibility, compassion, and coordination. Study findings highlight specific communicative behaviors associated with each skill set that exemplify nurse professionalism to members of health care teams. Theoretical and pragmatic conclusions are drawn regarding the communicative responsibilities of professional nurses in health care teams. Specific interaction techniques that nurses could use in nurse-team communication are then offered for use in baccalaureate curriculum and organizational in-service education.

The changing nature of the measurement of the economic impact of nursing care on health care organizations

This paper adapts the perspective of organizational contingency theory to consider the changing nature of how the economic impact of nursing care upon health care organizations is measured. It is argued that useful measures of the economic impact of nursing care are a function of environmental, organizational, and technological circumstances. The increasing and diverse demands of health care consumers (environmental), the dramatic restructuring and re-engineering of the health care delivery system (organizational), and recent developments in the capabilities of and insights from information measurement practices (technological), have all provided opportunities for more meaningful measurement of the contributions of nursing care to the economic well-being of health care organizations.

Revising the Essentials of Magnetism Tool

In the Essentials of Magnetism (EOM) study, staff nurses in 9 of 16 hospitals known to have excellent staffing structures, ie Magnet hospitals, perceived staffing on their units as less than adequate. These hospitals did not fit the Magnet profile when compared to 26 Magnet, Magnet-aspiring, and non-Magnet hospitals. In the EOM study, the process "perception of adequacy of staffing" (PAS) was measured with a single-item indicator. A multi-item scale incorporating the results of a delivery system survey reported here, as well as other factors known to affect PAS, was constructed and evaluated. Results indicate that the 6-item PAS Scale is valid and reliable and is a more accurate measure of PAS than is a single-item indicator. The Magnet hospitals scored significantly higher on all 6 items of the scale than did the comparison hospitals. The 2 Magnet hospitals that did not score in the Magnet profile in the EOM study scored similarly to the Magnet hospital that scored very high in the Magnet profile. Measurement of the PAS process indicates whether staffing structures are viable and enabling and may account for the mixed results seen in some studies assessing the impact of staffing structures on patient outcomes. Discussion includes suggestions on how to promote smooth handoffs and accountability with flex delivery models, and emphasizes the need to evaluate the relationship between staff nurses' perceptions of adequate staffing and patient outcomes.

Reshaping the Practice Environment

Today's nurse leader is challenged to create a practice environment that fosters multidisciplinary collaboration, professional development, and a culture of safety. Fostering a sense of coherence among staff nurses about their place within the nursing department and the department's place within the broader organization id essential to the development of such environments. When nurses have a sense of coherence about their work setting, they are more likely to feel confident that their care of patients and families is fully supported by the organization in which they work. The authors describe the concept of coherence, discuss findings from a preliminary study regarding attributes that may contribute to coherence in individual nurses, and describe systems ans programs that have been implemented in a large academic medical center to foster a sense of coherence in individual nurses, the nursing department, and the institution as a whole.

A Practice Model for Patient Safety

Creating a culture of patient safety often involves developing nursing care models that effectively use nursing resources. These authors discuss a nursing care model that focuses on the experienced nurses to enhance the use of their expertise. They provide more direct oversight and surveillance for the care given to all patients through leadership, mentoring, and collaborative practice. The experienced nurse is valued as a clinical leader, instrumental to the development of a safe practice environment. Implementation of this model has resulted in dramatic improvements in safety and registered nurse retention.