Decisional involvement in Magnet®, magnet-aspiring, and non-magnet hospitals

An Exploration of Factors Associated With Nurses' Perceptions of Decisional Involvement

OBJECTIVE

The purpose of this study was to evaluate nurses' perceptions of decisional involvement (DI).

BACKGROUND

Decisional involvement is a measure or gauge of nurses' perceived shared leadership. There has been limited research examining factors associated with actual and preferred DI.

METHODS

A descriptive, observational study design was used. A total of 189 RNs completed the Decisional Involvement Scale and Evidence-Based Practice Implementation Scale. Nurses' preferred DI (DI-P) and actual DI (DI-A) were analyzed, and DI total and subscale scores were compared based on nurses' demographic and clinical practice characteristics.

RESULTS

The DI-A and DI-P total scores were significantly different, including subscales for DI-A compared with DI-P score. Dissonance scores by subscale were highest for recruitment, governance, and support. Unit-based council (UBC) participants had significantly higher actual DI, compared with non-UBC participants. Nurses' perceptions of implementing evidence-based practice (EBP) was not significantly different by low versus high EBP implementation; nor were the scores significantly correlated with their DI-A or DI-P scores.

CONCLUSIONS

Findings indicate nurses' perceptions of DI-A and DI-P. This study provided further examination of the differences and interrelationships between DI and nurses' demographic and clinical practice characteristics. Dissonance DI scores provide opportunities for targeting interventions to engage nurses in shared leadership.

Nurses' Participation in Clinical and Administrative Decisions in Different Types of Hospital Units

OBJECTIVE

This study explored the types of decisions and differences in decision making that nurses made in different types of hospital units.

BACKGROUND

The relationship between nurses' participation in decision making and the different types of hospital units where they work is not well understood.

METHODS

Nurses' participation in decision making was explored using the Participation in Decision Activities Questionnaire. The final sample included 307 nurses in 24 nursing units in 6 hospitals.

RESULTS

Nurses overall participated more in clinical than administrative decisions, and there were significant differences based on unit type. Critical care nurses had the highest and general care units the lowest levels of participation in decision making.

CONCLUSIONS

Nurses in critical care units participated in higher amounts and at higher levels of clinical decisions overall than either intermediate or general care units. Nurse leaders should determine barriers to decision making in general care units and explore mechanisms to increase participation by clinical nurses.

The Effects of Nursing Satisfaction and Turnover Cognitions on Patient Attitudes and Outcomes: A Three-Level Multisource Study

OBJECTIVE

To explore antecedents and outcomes of nurse self-reported job satisfaction and dissatisfaction-based turnover cognitions, theorizing (using Self-Determination Theory) that leaders can foster work conditions that help fulfill innate needs, thereby fostering satisfaction of nurses and patients, and reducing adverse events.

DATA SOURCES/STUDY SETTING

Primary and secondary data were collected within a 4-month period in 2015, from 2,596 nurses in 110 Army treatment facilities (hospitals and clinics) across 35 health care systems.

DATA COLLECTION/EXTRACTION

We collected individual nurse responses to the Practice Environment Scale-Nursing Work Index, in addition to aggregated archival data from the same timeframe, including both facility-level patient satisfaction records (the Army Provider Level Satisfaction Survey) and health care system-level adverse events records (provided by the Army Programming, Analysis, and Evaluation office).

PRINCIPAL FINDINGS

Five predictors of nurse satisfaction and turnover cognitions emerged-supportive leadership, staffing levels, nurse-physician teamwork, adoption of nursing care practice, and advancement opportunities. Aggregated nurse satisfaction was the most consistent predictor of both patient satisfaction and adverse events.

CONCLUSION

These findings provide evidence of the importance of nurse attitudes in improving perceived and actual performance across facilities and health care systems; in addition to practical steps, managers can take to improve satisfaction and retention.

Association of Hospitalization for Neurosurgical Operations in Magnet Hospitals With Mortality and Length of Stay

BACKGROUND

The association of Magnet hospital status with improved surgical outcomes remains an issue of debate.

OBJECTIVE

To investigate whether hospitalization in a Magnet hospital is associated with improved outcomes for patients undergoing neurosurgical operations.

METHODS

A cohort study was executed using all patients undergoing neurosurgical operations in New York registered in the Statewide Planning and Research Cooperative System database from 2009 to 2013. We examined the association of Magnet status hospitalization after neurosurgical operations with inpatient case fatality and length of stay (LOS). We employed an instrumental variable analysis to simulate a randomized trial.

RESULTS

Overall, 190 787 patients underwent neurosurgical operations. Of these, 68 046 (35.7%) were hospitalized in Magnet hospitals, and 122 741 (64.3%) in non-Magnet institutions. Instrumental variable analysis demonstrated that hospitalization in Magnet hospitals was associated with decreased case fatality (adjusted difference, -0.8%; -95% confidence interval, -0.7% to -0.6%), and LOS (adjusted difference, -1.9; 95% confidence interval, -2.2 to -1.5) in comparison to non-Magnet hospitals. These associations were also observed in propensity score adjusted mixed effects models. These associations persisted in prespecified subgroups of patients undergoing spine surgery, craniotomy for tumor resection, or neurovascular interventions.

CONCLUSION

We identified an association of Magnet hospitals with lower case fatality, and shorter LOS in a comprehensive New York State patient cohort undergoing neurosurgical procedures.

Correlation of hospital magnet status with the quality of physicians performing neurosurgical procedures in New York State

PURPOSE

The quality of physicians practicing in hospitals recognized for nursing excellence by the American Nurses Credentialing Center has not been studied before. We investigated whether Magnet hospital recognition is associated with higher quality of physicians performing neurosurgical procedures.

MATERIALS AND METHODS

We performed a cohort study of patients undergoing neurosurgical procedures from 2009-2013, who were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Propensity score adjusted multivariable regression models were used to adjust for known confounders, with mixed effects methods to control for clustering at the facility level. An instrumental variable analysis was used to control for unmeasured confounding and simulate the effect of a randomized trial.

RESULTS

During the study period, 185,277 patients underwent neurosurgical procedures, and met the inclusion criteria. Of these, 66,607 (35.6%) were hospitalized in Magnet hospitals, and 118,670 (64.4%) in non-Magnet institutions. Instrumental variable analysis demonstrated that undergoing neurosurgical operations in Magnet hospitals was associated with a 13.6% higher chance of being treated by a physician with superior performance in terms of mortality (95% CI, 13.2% to 14.1%), and a 4.3% higher chance of being treated by a physician with superior performance in terms of length-of-stay (LOS) (95% CI, 3.8% to 4.7%) in comparison to non-Magnet institutions. The same associations were present in propensity score adjusted mixed effects models.

CONCLUSIONS

Using a comprehensive all-payer cohort of neurosurgical patients in New York State we identified an association of Magnet hospital recognition with superior physician performance.

Access disparities to Magnet hospitals for patients undergoing neurosurgical operations

BACKGROUND

Centers of excellence focusing on quality improvement have demonstrated superior outcomes for a variety of surgical interventions. We investigated the presence of access disparities to hospitals recognized by the Magnet Recognition Program of the American Nurses Credentialing Center (ANCC) for patients undergoing neurosurgical operations.

METHODS

We performed a cohort study of all neurosurgery patients who were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2009 to 2013. We examined the association of African-American race and lack of insurance with Magnet status hospitalization for neurosurgical procedures. A mixed effects propensity adjusted multivariable regression analysis was used to control for confounding.

RESULTS

During the study period, 190,535 neurosurgical patients met the inclusion criteria. Using a multivariable logistic regression, we demonstrate that African-Americans had lower admission rates to Magnet institutions (OR 0.62; 95% CI, 0.58-0.67). This persisted in a mixed effects logistic regression model (OR 0.77; 95% CI, 0.70-0.83) to adjust for clustering at the patient county level, and a propensity score adjusted logistic regression model (OR 0.75; 95% CI, 0.69-0.82). Additionally, lack of insurance was associated with lower admission rates to Magnet institutions (OR 0.71; 95% CI, 0.68-0.73), in a multivariable logistic regression model. This persisted in a mixed effects logistic regression model (OR 0.72; 95% CI, 0.69-0.74), and a propensity score adjusted logistic regression model (OR 0.72; 95% CI, 0.69-0.75).

CONCLUSIONS

Using a comprehensive all-payer cohort of neurosurgery patients in New York State we identified an association of African-American race and lack of insurance with lower rates of admission to Magnet hospitals.

Access disparities to Magnet hospitals for ischemic stroke patients

Access disparities to centers of excellence can have detrimental consequences for population health. We investigated the presence of racial disparities in the access of stroke patients to hospitals recognized by the Magnet Recognition Program of the American Nurses Credentialing Center (ANCC). We performed a cohort study of all ischemic stroke patients who were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2009 to 2013. We examined the association of African-American race with Magnet status hospitalization after ischemic stroke. A mixed effects propensity adjusted multivariable regression analysis was used to control for confounding. During the study period, 176,557 patients presented with ischemic stroke, and met the inclusion criteria. Overall, 4,624 (13.7%) African-Americans, and 27,468 (19.2%) non African-Americans with ischemic stroke were admitted to Magnet hospitals. Using a multivariable logistic regression, we demonstrate that African-Americans were associated with lower admission rates to Magnet institutions (OR 0.70; 95% CI, 0.68-0.73) (Table 2). This persisted in a mixed effects logistic regression model (OR 0.75; 95% CI, 0.71-0.78) to adjust for clustering at the county level, and a propensity score adjusted logistic regression model (OR 0.87; 95% CI, 0.83-0.90). Using a comprehensive all-payer cohort of ischemic stroke patients in New York State we identified an association of African-American race with lower rates of admission to Magnet hospitals.

Association of Magnet Status With Hospitalization Outcomes for Ischemic Stroke Patients

BACKGROUND

It is not clear whether Magnet recognition by the American Nurses Credentialing Center (nursing excellence program) is associated with improved patient outcomes. We investigated whether hospitalization in a Magnet hospital is associated with improved outcomes for patients with ischemic stroke.

METHODS AND RESULTS

We performed a cohort study of patients with ischemic stroke from 2009 to 2013, who were registered in the New York Statewide Planning and Research Cooperative System database. Propensity-score-adjusted multivariable regression models were used to adjust for known confounders, with mixed effects methods to control for clustering at the facility level. An instrumental variable analysis was used to control for unmeasured confounding and simulate the effect of a randomized trial. During the study period, 176 557 patients were admitted for ischemic stroke, and met the inclusion criteria. Of these, 32 092 (18.2%) were hospitalized in Magnet hospitals, and 144 465 (81.8%) in non-Magnet institutions. Instrumental variable analysis demonstrated that hospitalization in Magnet hospitals was associated with lower case-fatality (adjusted difference, -23.9%; 95% CI, -29.0% to -18.7%), length of stay (adjusted difference, -0.4; 95% CI, -0.8 to -0.1), and rate of discharge to a facility (adjusted difference, -16.5%; 95% CI, -20.0% to -13.0%) in comparison to non-Magnet hospitals. The same associations were present in propensity-score-adjusted mixed effects models.

CONCLUSIONS

Using a comprehensive all-payer cohort of patients with ischemic stroke in New York State, we identified an association of treatment in Magnet hospitals with lower case-fatality, discharge to a facility, and length of stay. Further research into the factors contributing to the superiority of Magnet hospitals in stroke care is warranted.

Nurses' Perception of Shared Decision-Making Processes: Quantifying a Shared Governance Culture

OBJECTIVE

The aim of this study is to describe how measuring the perceived and desired decision-making capacity of nurses in a model of shared governance (SG) can be beneficial.

BACKGROUND

Shared governance (SG) increases nurse's control over professional practice. Engagement in SG can be impacted by how much decision-making power nurses desire. This concept related to decision making has been termed decisional involvement (DI). Few studies exist that examine the concept of DI.

METHODS

Using the Decisional Involvement Scale, acute care nurses were sampled concerning desired and perceived decision making on 21 topics related to nursing practice.

RESULTS

Analysis of the data identified different governance priorities for several areas. Of particular interest was that those nurses on SG councils for more than 5 years did not report higher satisfaction with decision involvement.

CONCLUSIONS

A comprehensive evaluation of shared decision making was a valuable tool to establish a baseline of data and seek opportunities for improvement. A well-integrated model of SG requires continuous improvement and analysis to be sustained. Measuring and evaluating staff nurses desire to control varied aspects of DI can allow organizations to make focused efforts to strengthen SG.

Predictors of burnout, work engagement and nurse reported job outcomes and quality of care: a mixed method study

Background

High levels of work-related stress, burnout, job dissatisfaction, and poor health are common within the nursing profession. A comprehensive understanding of nurses’ psychosocial work environment is necessary to respond to complex patients’ needs. The aims of this study were threefold: (1) To retest and confirm two structural equation models exploring associations between practice environment and work characteristics as predictors of burnout (model 1) and engagement (model 2) as well as nurse-reported job outcome and quality of care; (2) To study staff nurses’ and nurse managers’ perceptions and experiences of staff nurses’ workload; (3) To explain and interpret the two models by using the qualitative study findings.

Method

This mixed method study is based on an explanatory sequential study design. We first performed a cross-sectional survey design in two large acute care university hospitals. Secondly, we conducted individual semi-structured interviews with staff nurses and nurse managers assigned to medical or surgical units in one of the study hospitals. Study data was collected between September 2014 and June 2015. Finally, qualitative study results assisted in explaining and interpreting the findings of the two models.

Results

The two models with burnout and engagement as mediating outcome variables fitted sufficiently to the data. Nurse-reported job outcomes and quality of care explained variances between 52 and 62%. Nurse management at the unit level and workload had a direct impact on outcome variables with explained variances between 23 and 36% and between 12 and 17%, respectively. Personal accomplishment and depersonalization had an explained variance on job outcomes of 23% and vigor of 20%. Burnout and engagement had a less relevant direct impact on quality of care (≤5%). The qualitative study revealed various themes such as organisation of daily practice and work conditions; interdisciplinary collaboration, communication and teamwork; staff nurse personal characteristics and competencies; patient centeredness, quality and patient safety. Respondents’ statements corresponded closely to the models’ associations.

Conclusion

A deep understanding of various associations and impacts on studied outcome variables such as risk factors and protective factors was gained through the retested models and the interviews with the study participants. Besides the softer work characteristics — such as decision latitude, social capital and team cohesion — more insight and knowledge of the hard work characteristic workload is essential.

Hospitals In 'Magnet' Program Show Better Patient Outcomes On Mortality Measures Compared To Non-'Magnet' Hospitals

Hospital executives pursue external recognition to improve market share and demonstrate institutional commitment to quality of care. The Magnet Recognition Program of the American Nurses Credentialing Center identifies hospitals that epitomize nursing excellence, but it is not clear that receiving Magnet recognition improves patient outcomes. Using Medicare data on patients hospitalized for coronary artery bypass graft surgery, colectomy, or lower extremity bypass in 1998-2010, we compared rates of risk-adjusted thirty-day mortality and failure to rescue (death after a postoperative complication) between Magnet and non-Magnet hospitals matched on hospital characteristics. Surgical patients treated in Magnet hospitals, compared to those treated in non-Magnet hospitals, were 7.7 percent less likely to die within thirty days and 8.6 percent less likely to die after a postoperative complication. Across the thirteen-year study period, patient outcomes were significantly better in Magnet hospitals than in non-Magnet hospitals. However, outcomes did not improve for hospitals after they received Magnet recognition, which suggests that the Magnet program recognizes existing excellence and does not lead to additional improvements in surgical outcomes.

Staff Nurse Decisional Involvement in the United States and Turkey

The purpose of this descriptive comparative study is to compare the levels of decisional involvement of staff nurses between one Midwestern health care system in the United States with a nongovernmental University hospital in Turkey. The Decisional Involvement Scale was used for data collection. U.S. ( n = 163) and Turkey ( n = 50) staff nurses were included in the study. Both samples preferred more decisional involvement than they currently experienced. However, Turkish nurses experienced and preferred lower levels of decisional involvement than the U.S. sample. Shared governance structures may be a strategy used to enhance staff nurse decisional involvement.

Physician Perceptions of Magnet Nurses and Magnet Designation

This exploratory study uses focus group methodology to examine physician perceptions of Magnet nurses and Magnet designation. No studies have explored physicians' insights, which are becoming increasingly important to implementing and sustaining a Magnet culture. Qualitative content analysis demonstrated that physicians highly regard Magnet nurses and benefit from Magnet status. Key themes emerged related to Magnet nurse characteristics, relationships with physicians, nursing leadership, shared governance, and Magnet as a marketing tool. "Magnet marginalization" emerged as a new concept.

Texas Nurse Staffing Trends Before and After Mandated Nurse Staffing Committees

This article describes the evolution of mandated nurse staffing committees in Texas from 2002 to 2009 and presents a study that analyzed nurse staffing trends in Texas using a secondary analysis of hospital staffing data (N = 313 hospitals) from 2000 to 2012 obtained from the American Hospital Association Annual Survey. Nurse staffing patterns based on three staffing variables for registered nurses (RNs), licensed vocational nurses (LVNs), and total licensed nurses were identified: full-time equivalents per 1,000 adjusted patient days, productive hours per adjusted patient day, and RN skill mix. Similar to national trends between 2000 and 2012, most Texas hospitals experienced an increase in RN and total nurse staffing, decrease in LVN staffing, and an increase in RN skill mix. The magnitude of total nurse staffing changes in Texas (5% increase) was smaller than national trends (13.6% increase). Texas's small, rural, government hospitals and those with the highest preregulation staffing levels experienced the least change in staffing between 2000 and 2012: median change of 0 to .13 full-time equivalents per 1,000 adjusted patient days and median change in productive hours per patient day of 0 to .23. The varying effects of staffing committees in different organizational contexts should be considered in future staffing legislative proposals and other policy initiatives.

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.

Nurse work engagement impacts job outcome and nurse-assessed quality of care: model testing with nurse practice environment and nurse work characteristics as predictors

Aim: To explore the mechanisms through which nurse practice environment dimensions, such as nurse–physician relationship, nurse management at the unit level and hospital management and organizational support, are associated with job outcomes and nurse-assessed quality of care. Mediating variables included nurse work characteristics of workload, social capital, decision latitude, as well as work engagement dimensions of vigor, dedication and absorption.

Background: Understanding how to support and guide nurse practice communities in their daily effort to answer complex care most accurate, alongside with the demand of a stable and healthy nurse workforce, is challenging.

Design: Cross-sectional survey.

Method: Based on earlier empirical findings, a structural equation model, designed with valid measurement instruments, was tested. The study population included registered acute care hospital nurses (N = 1201) in eight hospitals across Belgium.

Results: Nurse practice environment dimensions predicted nurses’ ratings of job outcome variables as well as quality of care. Features of nurses’ work characteristics, e.g., perceived workload, decision latitude, social capital, and the three dimension of work engagement, played mediating roles between nurse practice environment and outcomes. A revised model, using various fit measures, explained 60% of job outcomes and 47% of nurse-assessed quality of care.

Conclusion: The findings in this study show that nurse work characteristics as workload, decision latitude, and social capital, alongside with nurse work engagement (e.g., vigor, dedication, and absorption) influence nurses’ perspective of their nurse practice environment, job outcomes, and quality of care. The results underline aspects to considerate for various stakeholders, such as executives, nurse managers, physicians, and staff nurses, in setting up and organizing health care services.

Decisional Involvement Among Staff Nurses Based on Educational Level and Certification Status

Mechanisms to enhance the work environment are nurse decisional involvement (DI), obtainment of a baccalaureate or higher degree, and specialty certification. The purpose of this descriptive comparative study was to determine the difference between actual and preferred DI of staff nurses on the overall Decisional Involvement Scale (DIS), the differences based on its subscales, and those based on education level and certification. The sample included 163 staff nurses from a Midwestern health care organization. A statistically significant difference was found between actual and preferred DI, but no difference was found based on educational level and certification. There is a need to focus on nurses with a BSN/master’s degree or specialty certification and to conduct comprehensive studies to address the effects of education and certification on DI. An additional strategy that can be useful for organizations is to provide nurses with the empowerment structures, expectations, and mentoring/coaching to become involved in the process of decision making.

Barriers to participation in governance and professional advancement: a comparison of internationally educated nurses and registered nurses educated in the United States

OBJECTIVE

This study compared the perspectives of internationally educated nurses (IENs) and registered nurses (RNs) educated in the United States regarding participation in hospital governance structures and professional advancement.

BACKGROUND

Nurses' participation in hospital governance is reported to contribute to empowerment. No research has examined how IENs' perceptions about participation in governance compared with those of U.S. RNs.

METHODS

Semistructured interviews were held with 82 nurses in 2 urban hospitals. Forty nurses were reinterviewed to follow up on themes.

RESULTS

Internationally educated nurses and US RNs shared similar perspectives. Nurses in both samples did not value participation in governance, lacked guidance about how to advance, and preferred to at the bedside.

CONCLUSIONS

Strategies to encourage nurses to participate in and value governance and professional advancement opportunities should be explored and adopted.