Revising the Essentials of Magnetism Tool

Nursing Team Composition and Mortality Following Acute Hospital Admission

Importance

Many studies show the adverse consequences of insufficient nurse staffing in hospitals, but safe and effective staffing is unlikely to be just about staff numbers. There are considerable areas of uncertainty, including whether temporary staff can safely make up shortfalls in permanent staff and whether using experienced staff can mitigate the effect of staff shortages.

Objective

To explore the association of the composition of the nursing team with the risk of patient deaths.

Design, Setting, and Participants

This patient-level longitudinal observational study was conducted in 185 wards in 4 acute hospital trusts in England between April 2015 and March 2020. Eligible participants were patients with an overnight stay and nursing staff on adult inpatient wards. Data analysis was conducted from month April 2022 to June 2023.

Exposure

Naturally occurring variation during the first 5 days of hospital admission in exposure to days of low staffing from registered nurses (RNs) and nursing support (NS) staff, the proportion of RNs, proportion of senior staff, and proportion of hospital-employed (bank) and agency temporary staff.

Main Outcomes and Measures

The primary outcome was death within 30 days of admission. Mixed-effect Cox proportional hazards survival models were used.

Results

Data from 626 313 admissions (319 518 aged ≥65 years [51.0%]; 348 464 female [55.6%]) were included. Risk of death was increased when patients were exposed to low staffing from RNs (adjusted hazard ratio [aHR], 1.08; 95% CI 1.07-1.09) and NS staff (aHR, 1.07; 95% CI, 1.06-1.08). A 10% increase in the proportion of temporary RNs was associated with a 2.3% increase in the risk of death, with no difference between agency (aHR, 1.023; 95% CI, 1.01-1.04) and bank staff (aHR, 1.02; 95% CI, 1.01-1.04). A 10% increase in the proportion of agency NS was associated with a 4% increase in risk of death (aHR, 1.04; 95% CI, 1.02-1.06). Evidence on the seniority of staff was mixed. Model coefficients were used to estimate the association of using temporary staff to avoid low staffing and found that risk was reduced but remained elevated compared with baseline.

Conclusions and Relevance

This cohort study found that having senior nurses in the nursing team did not mitigate the adverse outcomes associated with low nurse staffing. These findings indicate that while the benefits of avoiding low staffing may be greater than the harms associated with using temporary staff, particularly for RNs, risk remains elevated if temporary staff are used to fill staffing shortages, which challenges the assumption that temporary staff are a cost-effective long-term solution to maintaining patient safety.

Validation and Measurement of Psychometric Properties of the "Nursing Work Environment Questionnaire" (NWE-q) in Italian Nurses

Background

Evidence suggests that an optimal workplace is a physical, chemical, biological, organizational, social, and cultural condition in which each element contributes to the employer's condition.

Purpose

To develop a nursing work environment questionnaire (NWE-Q).

Patients and Methods

Convergent validity was measured using Pearson's correlation test. Internal consistency for each dimension of the Nursing Work Environment questionnaire (NWE-q) was performed thanks to the Cronbach's alpha coefficient. Construct validity and factor structure of the data were also assessed. Reliability was evaluated by measuring internal consistency. Interclass correlation coefficient and convergent validity were also assessed. Group validity was evaluated according to the sociodemographic characteristics collected using an independent t-test.

Results

376 nurses participated in this study. Both Kaiser-Meyer-Olkin measures of sampling adequacy were, and the Bartlett test of sphericity showed very strong evidence. Owing to oblique rotation, three main sub-dimensions were defined with good internal consistency for all items of the NWE-q (27 items), and each sub-dimension was registered. Very strong interclass correlations were assessed for the NWE-q total scores and for each sub-dimension, with the exception of the system dimensions, in which the interclass correlation showed a weak relationship. Strong positive evidence was found between the NWE-q for both the total and each sub-dimension correlated with the items of both the individual and organizational validated nursing performance questionnaires. Strong evidence was observed for both the organizational and system subdimensions according to shift and gender.

Conclusion

The NWE-q was promptly completed in the online mode, and its scoring characteristics seemed to be more accessible and simpler to adopt.

Defining adequacy of staffing in general hospital wards: a Delphi study

OBJECTIVES

To gain consensus on the items that determine adequacy of shift staffing.

DESIGN

This was a three-round Delphi study to establish consensus on what defines adequacy of shift staffing in a general hospital ward. A literature review, focus group and five semistructured expert interviews were used to generate items for the Delphi study.

SETTING

Multicentre study in The Netherlands.

PARTICIPANTS

Nurses, head nurses, nursing managers, and capacity consultants and managers working for Dutch hospitals.

RESULTS

Twenty-six items were included in the Delphi study. One hundred and sixty-eight, 123 and 93 participants were included in the first, second and third round, respectively. After three rounds, six items were included (mostly related to direct patient care) and nine items were excluded. No consensus was reached on 12 items, including one item that was added after the first round.

CONCLUSIONS

This is the first study to specify items that determine adequacy of staffing. These items can be used to measure adequacy of staffing, which is crucial for enhancing nurse staffing methods. Further research is needed to refine the items of staffing adequacy and to further develop and psychometrically test an instrument for measuring staffing adequacy.

Measuring perceived adequacy of staffing to incorporate nurses' judgement into hospital capacity management: a scoping review

BACKGROUND

Matching demand and supply in nursing work continues to generate debate. Current approaches focus on objective measures, such as nurses per occupied bed or patient classification. However, staff numbers do not tell the whole staffing story. The subjective measure of nurses' perceived adequacy of staffing (PAS) has the potential to enhance nurse staffing methods in a way that goes beyond traditional workload measurement or workforce planning methods.

OBJECTIVES

To detect outcomes associated with nurses' PAS and the factors that influence PAS and to review the psychometric properties of instruments used to measure PAS in a hospital setting.

DESIGN AND METHODS

A scoping review was performed to identify outcomes associated with PAS, factors influencing PAS and instruments measuring PAS. A search of PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Business Source Complete and Embase databases identified 2609 potentially relevant articles. Data were independently extracted, analysed and synthesised. The quality of studies describing influencing factors or outcomes of PAS and psychometric properties of instruments measuring PAS were assessed following the National Institute for Health and Care Excellence quality appraisal checklist and the COnsensus-based Standards for the selection of health Measurement INstruments guidelines.

RESULTS

Sixty-three studies were included, describing 60 outcomes of PAS, 79 factors influencing PAS and 21 instruments measuring PAS. In general, positive PAS was related to positive outcomes for the patient, nurse and organisation, supporting the relevance of PAS as a staffing measure. We identified a variety of factors that influence PAS, including demand for care, nurse supply and organisation of care delivery. Associations between these factors and PAS were inconsistent. The quality of studies investigating the development and evaluation of instruments measuring PAS was moderate.

CONCLUSIONS

Measuring the PAS may enhance nurse staffing methods in a hospital setting. Further work is needed to refine and psychometrically evaluate instruments for measuring PAS.

The Relationship Between Work Environment Satisfaction and Retention Intention Among Nursing Administrators in Taiwan

BACKGROUND

Nursing administrators are essential to ensuring the quality of healthcare provided in hospitals. The nursing manpower shortage that has affected hospitals in Taiwan over the past decade has weighed particularly heavily on nursing administrators, who are expected to maintain high levels of nursing care quality in frequently understaffed healthcare settings.

PURPOSE

The objective of this study was to explore the relationship between work environment satisfaction and nursing administrator retention in Taiwan.

METHODS

This study used a cross-sectional, questionnaire-based survey to collect data from a sample population of nursing administrators. A set of indicators of quality nursing work environments was developed and included in the questionnaire. A total of 1,829 questionnaires were distributed, and the effective response rate was 95.57%.

RESULTS

The average overall rate of satisfaction with the current work environment across all domains was 3.59 (SD = 0.61). The highest level of satisfaction was found in the domain of safe practice environment (M = 3.83, SD = 0.70), and the lowest was found in the domain of informatics (M = 3.38, SD = 0.91). Length of administrative position tenure was significantly correlated with retention. Each of the eight domains significantly influenced retention. The domain of support and caring was the most significant predictor of nursing administrator retention.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Length of administrator position tenure was significantly correlated with nursing administrator retention. Moreover, intention to stay among junior administrators was particularly affected by the support and caring domain. Therefore, it is recommended that nursing departments develop effective strategies to assist and encourage junior administrators to strengthen their career prospects and satisfaction.

Essential Professional Nursing Practices in mental health: A cross-sectional study of hospital inpatient care

Quality organizational structures and nursing practices are key to positive patient outcomes. Whereas structures have been largely studied over the past few decades, less is known of the nursing practices that account for patient outcomes, such as patient satisfaction. This is especially true in psychiatric, mental health care settings. The aim of the present study is to determine the relative importance of eight Essential Professional Nursing Practices (EPNPs) on the satisfaction of hospitalized patients on mental health care units. A cross-sectional design was selected; 226 point-of-care mental health nurses completed the online EPNP questionnaire in Spring 2015. Statistical analyses included MANOVAs and a 2-step linear regression. A significant relationship was found between university preparation and scores on two EPNP subscales: autonomous decision-making and practicing with competent nurses. Scores on patient advocacy and control over practice subscales were significantly related to nurse-rated patient satisfaction. The findings reinforce the positive link between university education and the work of nurses and highlight the power dynamics that are salient in mental health care. The pertinence of EPNPs in psychiatric settings is brought to the fore, with practices of patient advocacy and nurse control over care examined in relation to empowerment. Implications for clinical and administrative leaders are addressed, with a focus on strategies for empowering patients and nurses.

Measuring nurses' perception of work environment: a scoping review of questionnaires

Background

Nurses’ work environment has been shown to be associated with quality of care and organizational outcomes. In order to monitor the work environment, it is useful for all stakeholders to know the questionnaires that assess or evaluate conditions for delivering nursing care. The aim of this article is: to review the literature for assessed survey questionnaires that measure nurses’ perception of their work environment, make a brief assessment, and map the content domains included in a selection of questionnaires.

Methods

The search included electronic databases of internationally published literature, international websites, and hand searches of reference lists. Eligible papers describing a questionnaire had to be; a) suitable for nurses working in direct care in general hospitals, nursing homes or home healthcare settings; and b) constructed to measure work environment characteristics that are amenable to change and related to patient and organizational outcomes; and c) presented along with an assessment of their measurement properties.

Results

The search yielded 5077 unique articles. For the final synthesis, 65 articles met inclusion criteria, consisting of 34 questionnaires measuring nursing work environments in different settings. Most of the questionnaires that we found were developed, and tested, for registered nurses in a general hospital setting. Six questionnaires were developed specifically for use in nursing home settings and one for home healthcare. The content domains covered by the questionnaires were both overlapping and unique and the terminology in use was inconsistent. The most common content domains in the work environment questionnaires were supportive managers, collaborative relationships with peers, busyness, professional practice and autonomy.

Conclusions

The findings from this review enhance the understanding of how “work environment” can be measured by an overview of existing questionnaires and domains. Our results indicate that there are very many work environment questionnaires with varying content.

Electronic supplementary material

The online version of this article (10.1186/s12912-017-0256-9) contains supplementary material, which is available to authorized users.

Nurses' reports of staffing adequacy and surgical site infections: A cross-sectional multi-centre study

BACKGROUND

It is indicated that healthcare personnel's perceptions of the work environment may reflect the clinical outcomes for the patients they care for. However, the body of evidence is inconsistent when it comes to the association between work environment and surgical site infection.

OBJECTIVES

The aim of this study is to examine the associations between nurse-reported characteristics of the work environment and incidence of surgical site infections after total hip arthroplasty.

DESIGN AND SETTINGS

This is a cross-sectional multicentre study conducted in 16 Norwegian hospitals.

PARTICIPANTS

Clinical outcomes for 2885 patients >18years that underwent total hip arthroplasty are combined with work environment descriptions from 320 nurses.

MATERIALS AND METHODS

We combine data about surgical site infections from The Norwegian Surveillance System for Antibiotic Consumption and Healthcare-Associated Infections and hospital characteristics such as overall survival probability (from administrative patient data) and nurses' reports of characteristics of the work environment (from a multicentre survey among nurses in Norwegian hospitals). Stepwise mixed-effects logistic regression model was performed to examine the associations between characteristics of the work environment and surgical site infections.

RESULTS

The incidence of surgical site infection among 2885 patients undergoing total hip arthroplasty in 16 Norwegian hospitals was 2.6%. Older age, elective procedures and high scores for staffing adequacy were associated with risk for surgical site infection. The association between high scores for adequate staffing and low risk for surgical site infections was present for patients that were admitted for an elective procedure, but not for patients admitted for a non-elective procedure.

CONCLUSION

Our results show that the risk of surgical site infections after elective total hip arthroplasty was lower in hospitals where nurses assessed staffing as adequate. Our findings add to the existing literature that examines the linkage between work environment and clinical outcomes.

The Effect of Nurse-Physician Collaboration on Job Satisfaction, Team Commitment, and Turnover Intention in Nurses

Voluntary turnover in nursing can lead to nursing shortages that affect both individuals and the entire hospital unit. We investigated the relationship between group- and individual-level variables by examining the association of nurses' job satisfaction and team commitment at the individual level, and nurse-physician collaboration at the group level, with individuals' intention to leave the unit at the individual level. A self-report questionnaire was administered to 1,024 nurses on 72 units in 3 Italian hospitals. At the individual level, affective commitment partially mediated the relationship between job satisfaction and nursing turnover intention. Moreover, a cross-level interaction was found. Nurses with high levels of job satisfaction showed high levels of identification with their team, and this relationship was stronger when the group perception of nurse-physician collaboration was high. Results suggested that managerial strategies to promote nurse-physician collaboration may be important to increase nurses' affective commitment to the team. At the individual level, job satisfaction and team affective commitment are important factors for retaining staff, and at the group level, good work collaboration with physicians is instrumental in developing nurses' affective identification with the team. © 2016 Wiley Periodicals, Inc.

An observational study: associations between nurse-reported hospital characteristics and estimated 30-day survival probabilities

Background

There is a growing body of evidence for associations between the work environment and patient outcomes. A good work environment may maximise healthcare workers’ efforts to avoid failures and to facilitate quality care that is focused on patient safety. Several studies use nurse-reported quality measures, but it is uncertain whether these outcomes are correlated with clinical outcomes. The aim of this study was to determine the correlations between hospital-aggregated, nurse-assessed quality and safety, and estimated probabilities for 30-day survival in and out of hospital.

Methods

In a multicentre study involving almost all Norwegian hospitals with more than 85 beds (sample size=30, information about nurses’ perceptions of organisational characteristics were collected. Subscales from this survey were used to describe properties of the organisations: quality system, patient safety management, nurse–physician relationship, staffing adequacy, quality of nursing and patient safety. The average scores for these organisational characteristics were aggregated to hospital level, and merged with estimated probabilities for 30-day survival in and out of hospital (survival probabilities) from a national database. In this observational, ecological study, the relationships between the organisational characteristics (independent variables) and clinical outcomes (survival probabilities) were examined.

Results

Survival probabilities were correlated with nurse-assessed quality of nursing. Furthermore, the subjective perception of staffing adequacy was correlated with overall survival.

Conclusions

This study showed that perceived staffing adequacy and nurses’ assessments of quality of nursing were correlated with survival probabilities. It is suggested that the way nurses characterise the microsystems they belong to, also reflects the general performance of hospitals.

Validation of the Perceived Implicit Rationing of Nursing Care (PIRNCA) instrument

BACKGROUND

An inverse relationship between implicit rationing and quality patient outcomes has been demonstrated in European hospitals, but this relationship has not been explored in the United States.

OBJECTIVE

To evaluate the psychometric properties of a new measure of implicit rationing, the Perceived Implicit Rationing of Nursing Care (PIRNCA).

METHOD

A cross-sectional survey design with a stratified random sample of 226 medical surgical nurses was used to evaluate the PIRNCA. The internal structure was evaluated using exploratory factor analysis. Pearson correlations were used to assess the associations between implicit rationing and three related constructs: work environment, overall job satisfaction, and quality of care.

RESULTS

A single-factor solution explaining 55% of the total variance and excellent reliability, Cronbach's alpha = 0.97, was supported for the PIRNCA. Moderate inverse relationships with related constructs provided evidence of concurrent validity: work environment (-0.44), overall job satisfaction (-0.48), and quality of care (-0.56). The majority of nurses (97%) reported rationing at least one of the 30 care activities listed; however, mean scores reflected a low frequency ("rarely") of rationing overall.

CONCLUSION

The phenomenon of implicit rationing is experienced by nurses in U.S. hospitals, and the PIRNCA instrument is a valid and reliable measure of this phenomenon.

A realist logic model of the links between nurse staffing and the outcomes of nursing

Background:

There has been a long-standing debate over the definition and nature of the quality of healthcare and factors that influence and enhance quality. Within nursing, the challenge is to identify the outcomes that are measurable and amenable to change as a result of nursing care. Arising originally from concerns over potential nurse staffing shortages and nurse retention within the United States, an extensive literature has developed in the acute sector, exploring nurse staffing and its consequences. All of these studies raise the generic question of what potential causal mechanisms might link nurse staffing levels and skill mix to issues of patient safety and outcome.

Objectives:

To generate a tentative logic model to understand existing findings and to elucidate possible ways in which nurse staffing and skill mix may affect patient and nurse outcomes.

Methods:

This study was grounded within the principles of realist evaluation, realist review and logic modelling. The existing literature was reviewed to bring to light the underlying rationale suggested by the authors of this study on how nursing care might affect patient outcomes. A step-by-step process was followed to demonstrate the generation of a tentative logic model of how nurse staffing might influence patient, and nursing, outcomes.

Results:

The final logic model depicts staffing adequacy as having a complex link with patient outcomes. This is mediated at a general level through factors in the process of care (for example, nurse surveillance, clinical judgement, level of education, level of nurse training and length of nursing experience) and tasks left undone. These operate in conjunction with working with other nurses who are clinically competent, having good nurse–physician relationships and communication, supportive nurse manager/supervisor and good teamwork.

Conclusions:

This study extends the understanding of the mechanisms through which nurse staffing levels may result in adverse patient outcomes in the acute sector. Key intervening variables are the application of nurse intuition, operation of clinical judgement and missed nursing care/tasks left undone. The tentative logic model can be used to draw up areas and hypotheses to guide the direction of future research and to aid interpretation of existing research.

A taxonomy of nursing care organization models in hospitals

BACKGROUND

Over the last decades, converging forces in hospital care, including cost-containment policies, rising healthcare demands and nursing shortages, have driven the search for new operational models of nursing care delivery that maximize the use of available nursing resources while ensuring safe, high-quality care. Little is known, however, about the distinctive features of these emergent nursing care models. This article contributes to filling this gap by presenting a theoretically and empirically grounded taxonomy of nursing care organization models in the context of acute care units in Quebec and comparing their distinctive features.

METHODS

This study was based on a survey of 22 medical units in 11 acute care facilities in Quebec. Data collection methods included questionnaire, interviews, focus groups and administrative data census. The analytical procedures consisted of first generating unit profiles based on qualitative and quantitative data collected at the unit level, then applying hierarchical cluster analysis to the units' profile data.

RESULTS

The study identified four models of nursing care organization: two professional models that draw mainly on registered nurses as professionals to deliver nursing services and reflect stronger support to nurses' professional practice, and two functional models that draw more significantly on licensed practical nurses (LPNs) and assistive staff (orderlies) to deliver nursing services and are characterized by registered nurses' perceptions that the practice environment is less supportive of their professional work.

CONCLUSIONS

This study showed that medical units in acute care hospitals exhibit diverse staff mixes, patterns of skill use, work environment design, and support for innovation. The four models reflect not only distinct approaches to dealing with the numerous constraints in the nursing care environment, but also different degrees of approximations to an "ideal" nursing professional practice model described by some leaders in the contemporary nursing literature. While the two professional models appear closer to this ideal, the two functional models are farther removed.

Impact of Healthy Work Environments on New Graduate Nurses’ Environmental Reality Shock

Do healthy work environments (HWEs) facilitate new graduate transition into professional practice in hospitals? Are such environments related to a decrease in Environmental Reality Shock? Experienced nurses in 17 Magnet hospitals completed the Essentials of Magnetism II© (EOMII©) instrument that measures health of unit work environments. New graduates ( N = 468) were then tracked with modified versions of the EOMII© from immediate post hire to 4, 8, and 12 months post hire to ascertain degree of Environmental Reality Shock. New graduate nurses have extremely high anticipations of unit work environments that would enable delivery of quality patient care. HWE is the most-significant variable in Environmental Reality Shock, number of related Issues and Concerns, and perceptions of quality of patient care. Suggestions of how to improve quality of unit work environments are offered.

Classifying nursing organization in wards in Norwegian hospitals: self-identification versus observation

BACKGROUND

The organization of nursing services could be important to the quality of patient care and staff satisfaction. However, there is no universally accepted nomenclature for this organization. The objective of the current study was to classify general hospital wards based on data describing organizational practice reported by the ward nurse managers, and then to compare this classification with the name used in the wards to identify the organizational model (self-identification).

METHODS

In a cross-sectional postal survey, 93 ward nurse managers in Norwegian hospitals responded to questions about nursing organization in their wards, and what they called their organizational models. K-means cluster analysis was used to classify the wards according to the pattern of activities attributed to the different nursing roles and discriminant analysis was used to interpret the solutions. Cross-tabulation was used to validate the solutions and to compare the classification obtained from the cluster analysis with that obtained by self-identification. The bootstrapping technique was used to assess the generalizability of the cluster solution.

RESULTS

The cluster analyses produced two alternative solutions using two and three clusters, respectively. The three-cluster solution was considered to be the best representation of the organizational models: 32 team leader-dominated wards, 23 primary nurse-dominated wards and 38 wards with a hybrid or mixed organization. There was moderate correspondence between the three-cluster solution and the models obtained by self-identification. Cross-tabulation supported the empirical classification as being representative for variations in nursing service organization. Ninety-four per cent of the bootstrap replications showed the same pattern as the cluster solution in the study sample.

CONCLUSIONS

A meaningful classification of wards was achieved through an empirical cluster solution; this was, however, only moderately consistent with the self-identification. This empirical classification is an objective approach to variable construction and can be generally applied across Norwegian hospitals. The classification procedure used in the study could be developed into a standardized method for classifying hospital wards across health systems and over time.

Nine structures and leadership practices essential for a magnetic (healthy) work environment

Improving clinical nurse work environments is a major challenge faced by nurse executives today. To meet this challenge, nurse leaders must implement the "right" structures and best leadership practices so that clinical nurses can engage in the work processes and relationships that are empirically linked to quality patient outcomes. What are these "right" structures and best leadership practices? Meta-analyses of 2 sets of publications were used to identify organizational structures and best leadership practices essential to a healthy work environment, that is, a work environment that enables them to engage in the work processes and relationships needed for quality patient care outcomes. The first set was 12 publications from 7 professional organizations/regulatory bodies that advocated forces, hallmarks, and standards for a healthy work environment. The second set was 18 publications from the Essentials of Magnetism structure-identification studies, in which the aggregated results from 1300 interviews with staff nurse, manager, and physician "experts" were compared with the agency results. Broadening the categories and final aggregation yielded the 9 most important and influential structures essential to a quality work environment. Suggestions for implementing these structures are provided.

The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis

OBJECTIVE

To examine the association between registered nurse (RN) staffing and patient outcomes in acute care hospitals.

STUDY SELECTION

Twenty-eight studies reported adjusted odds ratios of patient outcomes in categories of RN-to-patient ratio, and met inclusion criteria. Information was abstracted using a standardized protocol.

DATA SYNTHESIS

Random effects models assessed heterogeneity and pooled data from individual studies. Increased RN staffing was associated with lower hospital related mortality in intensive care units (ICUs) [odds ratios (OR), 0.91; 95% confidence interval (CI), 0.86-0.96], in surgical (OR, 0.84; 95% CI, 0.80-0.89), and in medical patients (OR, 0.94; 95% CI, 0.94-0.95) per additional full time equivalent per patient day. An increase by 1 RN per patient day was associated with a decreased odds ratio of hospital acquired pneumonia (OR, 0.70; 95% CI, 0.56-0.88), unplanned extubation (OR, 0.49; 95% CI, 0.36-0.67), respiratory failure (OR, 0.40; 95% CI, 0.27-0.59), and cardiac arrest (OR, 0.72; 95% CI, 0.62-0.84) in ICUs, with a lower risk of failure to rescue (OR, 0.84; 95% CI, 0.79-0.90) in surgical patients. Length of stay was shorter by 24% in ICUs (OR, 0.76; 95% CI, 0.62-0.94) and by 31% in surgical patients (OR, 0.69; 95% CI, 0.55-0.86).

CONCLUSIONS

Studies with different design show associations between increased RN staffing and lower odds of hospital related mortality and adverse patient events. Patient and hospital characteristics, including hospitals' commitment to quality of medical care, likely contribute to the actual causal pathway.

Essentials of a productive nurse work environment

BACKGROUND

Staff nurse work environments must be improved. To do so, their quality must be measured. The Essential of Magnetism (EOM) tool measures eight characteristics of a productive and satisfying work environment identified by staff nurses in magnet hospitals as essential to quality patient care. The EOM items are based on grounded theory and are used to measure attributes of the work environment as functional processes. The EOMII is a revision of two of the subscales of the EOM.

OBJECTIVES

To test the hypotheses that staff nurses in hospitals designated as having excellent work environments (Magnet) will score significantly higher on the EOMII and on two outcome indicators than will their counterparts in Comparison hospitals. Additional aims include establishing the psychometric properties of the EOMII; updating the National Magnet Hospital Profile; ascertaining relationships between nurse attribute, work, and contextual variables and the characteristics of a productive work environment; and investigating the relationship between the magnet structure, care processes and relationships and two single-item indicators, overall job satisfaction, and nurse-assessed quality of patient care.

METHODS

This was a secondary analysis of aggregated data from 10,514 staff nurses in 34 hospitals who completed the EOMII and the two outcome indicators.

RESULTS

The EOMII is a valid and reliable measure of the quality of work environment from a staff nurse perspective. The hypotheses were confirmed. There are differences in essentials and outcome variables by (a) context-nurses in magnet hospitals report the most productive work environment; (b) education-master's prepared nurses report the most favorable environments; (c) experience-the most inexperienced and the most experienced report the most satisfying, productive environments; and (d) clinical unit-medical and surgical specialty and outpatient units report the healthiest work environments.

DISCUSSION

The primacy of magnet designation as a contextual variable indicating a quality work environment was affirmed. A larger percentage of magnet hospitals meet the magnet profile now than in 2003. Item analysis of the EOMII subscales provides guidance on how to improve the unit work environment. Suggestions are made for additional study and research.

A conceptual framework contributing to nursing administration and research

The health care system has undergone major changes in the last decade. With greater acuity and complexity of illness, the adoption of innovative technologies and the shortage of health care personnel, the coordination and integration of health care services has become increasingly demanding for administrators. Growing dissatisfaction and concerns about safety issues are being expressed by the users of care who need to navigate through an increasingly complex system and by health care personnel who feel less efficient within the organization. Nursing administrators have a responsibility to address these issues but there is little scientific evidence to guide their actions. There are also few comprehensive models highlighting the main components of nursing administration - models that could guide nursing administration research. This paper presents a conceptual framework for nursing administration and research that links patient health care needs, nursing resources and the nursing care processes to the context of the health care system, and the social, political and cultural environments of care. A selected review of the oncology and cancer care literature is presented to demonstrate how this framework can organize existing knowledge about these concepts in the context of cancer care.

Can Technology Improve Intershift Report? What the Research Reveals

Shift report is a multifaceted process that serves to provide nurses with vital patient information to facilitate clinical decisions and patient care planning. A shift report also provides nurses with a forum for functions, such as patient problem solving and collaboration. The authors conducted a literature review, which indicates that current methodologies used to collect and convey patient information are ineffective and may contribute to negative patient outcomes. Data incongruence, legal implications, time constraints augmented by the nursing shortage, and the financial impact of shift report are also addressed. The literature reveals significant rationale for pioneering new and innovative methods of shift-to-shift communication. In the report To Err is Human: Building a Safe Health System, the Institute of Medicine attributes the deaths of up to 98,000 hospitalized Americans to medical errors, including communication failures [Institute of Medicine. (1999). To err is human: Building a safe health system. Report by the Committee on Quality of Health Care in America. Washington, DC: National Academy Press]. As a result, government policy makers and health care agencies have focused their attention on determining the root cause of errors to identify preventative measures, including the use of information technology [Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment of nurses. Report by the Committee on Quality of Health Care in America. Washington, DC: National Academy Press]. Under these premises, the authors examined the process of nursing shift report and how it impacts patient outcomes. The use of computer technology and wireless modes of communication is explored as a means of improving the shift report process and, subsequently, health care outcomes and patient safety.

Is the Nursing Work Index Measuring Up?

BACKGROUND

The Nursing Work Index (NWI) provided the foundation for three published instruments, each presented as a valid measure of the nursing practice environment. Aiken and Patrician [Aiken, L. H., & Patrician, P. A. (2000). Measuring organizational traits of hospitals: The Revised Nursing Work Index. Nursing Research, 49, 146-153] revised the NWI to the Revised Nursing Work Index (NWI-R), reporting four conceptually derived subscales. Lake [Lake, E. T.(2002). Development of the Practice Environment Scale of the Nursing Work Index. Research in Nursing and Health, 25,176-188] used factor analysis to empirically derive five subscales with a composite overarching practice environment factor. Estabrooks et al. [Estabrooks, C. A., Tourangeau, A. E., Humphrey,C. K., Hesketh, K. L., Giovannetti, P., Thomson, D., et al. (2002). Measuring the hospital practice environment: A Canadian context. Research in Nursing and Health, 25, 256-268] reported a single empirically derived factor solution that represented the nursing practice environment.

OBJECTIVE

To examine the validity of three instruments (based on the NWI) as measures of the nursing practice environment.

METHODS

The measurement models underlying the three instruments were reconstructed from the information provided by each author in published manuscripts and then were estimated using structural equation modeling (SEM), the chi-square test of model fit, and data from the 1998 Canadian Nurse Survey.

RESULTS

Each of the three underlying measurement models was factor analytic in design (multiple indicators of each concept) and failed significantly when compared with the data (Aiken & Patrician; chi2 = 939.12, p <.001, df = 50; Lake, chi2 = 17,872.73, p <.001, df = 319; Estabrooks et al., chi2= 38,590.29, p <.001). This lack of model fit with the data raises questions about the validity of these instruments as measures of the nursing practice environment.

DISCUSSION

The nursing practice environment is complex and has been examined inadequately by factor-analytic approaches, largely because insufficient attention has been paid to implicit underlying theory. The development and testing of robust theory using powerful research methods available to examine causal relationships in complex theoretical models will advance understanding of constructs such as the nursing practice environment.

Excellence Through Evidence

Multiple nurse-physician (RNMD) relationships coexist on hospital units; collegial and collaborative (C/C) relationships positively impact patient outcomes more than the others. The goal of this multisite evidence-based management practice initiative was to identify structures that enable C/C RNMD relationships. In part 1, the authors discussed the methodology of the study, presented the results of the literature analysis, and the description and characteristics of the clinical units, experts interviewed, and of the collegial and collaborative RNMD relationships found in the 5 participating hospitals. Part 2 analyzes the extent to which the 5 structures identified by the National Joint Practice Commission as necessary for RNMD collaboration are present in the 5 hospitals, the structures identified by the experts in this study, and suggestions and implications for management practice.