Satisfaction with inpatient acquired immunodeficiency syndrome care. A national comparison of dedicated and scattered-bed units

Understanding health outcome drivers among adherence club patients in clinics of Gauteng, South Africa: a structural equation modelling (SEM) approach

BACKGROUND

There has been growing interest in understanding the drivers of health outcomes, both in developed and developing countries. The drivers of health outcomes, on the other hand, are the factors that influence the likelihood of experiencing positive or negative health outcomes. Human Immunodeficiency Virus (HIV) continues to be a significant global public health challenge, with an estimated 38 million people living with the aim of this study was therefore to develop and empirically test a conceptual research model using SEM, aimed at explaining the magnitude of various factors influencing HIV and other health outcomes among patients attending Adherence Clubs.

METHOD

This was a cross sectional survey study design conducted in 16 health facilities in the City of Ekurhuleni in Gauteng Province, South Africa. A total of 730 adherence club patients were systematically sampled to participate in a closed ended questionnaire survey. The questionnaire was assessed by Cronbach's alpha coefficient for internal consistency. The proposed model was tested using structural equation modelling (AMOS software: ADC, Chicago, IL, USA).

RESULTS

A total of 730 adherence club members participated in the study. Of these, 425 (58.2%) were female and 305 (41.8%) were male. The overall results indicated a good reliability of all the scale involved in this study as Cronbach alphas ranged from 0.706 to 0.874, and composite reliability from 0.735 to 0.874. The structural model showed that the constructs health seeking behavior (β = 0.267, p = 0.000), health care services (β = 0.416, p = 0.000), stigma and discrimination (β = 0.135, p = 0.022) significantly predicted health outcomes and explained 45% of its variance. The construct healthcare service was the highest predictor of health outcomes among patients in adherence clubs.

CONCLUSION

Patient health seeking behaviour, healthcare services, stigma and discrimination were associated with perceived health outcomes. Since adherence clubs have been found to have a significant impact in improving patient outcomes and quality of life, there is a need to ensure replication of this model.

Developing nurse and physician questionnaires to assess primary work areas in intensive care units

The objective of the study was to develop instruments for describing and assessing some aspects of design of the primary work areas of nurses and physicians in intensive care units (ICUs). Separate questionnaires for ICU physicians and nurses were developed. Items related to individual- and unit-level design features of the primary work areas of nurses and physicians were organized using constructs found in the literature. Items related to staff satisfaction and staff use of time in relation to primary work area design were also included. All items and constructs were reviewed by experts for content validity and were modified as needed before use. The final questionnaires were administered to a convenience sample of 4 ICUs in 2 large urban hospitals. A total of 55 nurses and 29 physicians completed the survey. The Cronbach α was used to measure internal consistency, and factor analysis was used to provide construct-related validity. Convergent and discriminant validity were assessed through examining bivariate correlations between relevant scales/items. Analysis of variance was used to identify whether the between-group member responses were significant among the 4 units. The Cronbach α values for all except 3 preliminary scales indicated acceptable reliability. Factor analysis indicated that some preliminary scales could be partitioned into subscales for finer descriptions of the primary work areas. Correlational analysis provided strong evidence of convergent and discriminant validity of all the scales and subscales. The significance level of F-statistics showed that the units were significantly different from each other, providing evidence of more between-unit variance than within-unit variance. Therefore, the questionnaires developed in the study offer a promising departure point for rigorous description and evaluation of the primary work areas in relation to staff satisfaction and use of time in ICUs at a time when the importance of such studies is growing.

O ambiente de trabalho em unidades de terapia intensiva privadas e públicas

OBJETIVO: Analisar o ambiente de trabalho em Unidades de Terapia Intensiva em hospitais privados e públicos. MÉTODOS: Estudo transversal realizado em quatro unidades de terapia intensiva do qual participaram 66 enfermeiros. Utilizou-se dois instrumentos de pesquisa, um para caracterização socioeconômica e as subescalas do Nursing Work Index Revised versão brasileira validadas (B-NWI-R). RESULTADOS: Os enfermeiros consideraram que as unidades de terapia intensivapossuem ambientes de trabalho favoráveis ao exercício da prática profissional em enfermagem (média geral= 1,95 e dp=0,40).Ao comparar as UTI dos hospitais privados e públicos observa-se que o escore geral do B-NWI-R alcançou os valores de 1,91 (dp=0,39) e 1,99 (dp=0,42) respectivamente com p=0,459. CONCLUSÃO: As quatro UTI analisadas apresentaram ambientes favoráveis à prática profissional em enfermagem. O fato de pertencer a hospitais privados e públicos não foi significativo na análise.

The importance of a high-performance work environment in hospitals

OBJECTIVE

To examine the benefits of a high-performance work environment (HPWE) for employees, patients, and hospitals.

STUDY SETTING

Forty-five adult, medical-surgical units in nine hospitals in upstate New York.

STUDY DESIGN

Cross-sectional study.

DATA COLLECTION

Surveys were collected from 1,527 unit-based hospital providers (68.5 percent response rate). Hospitals provided unit turnover and patient data (16,459 discharge records and 2,920 patient surveys).

PRINCIPAL FINDINGS

HPWE, as perceived by multiple occupational groups on a unit, is significantly associated with desirable work processes, retention indicators, and care quality.

CONCLUSION

Our findings underscore the potential benefits for providers, patients, and health care organizations of designing work environments that value and support a broad range of employees as having essential contributions to make to the care process and their organizations.

The relationship between hospital work environment and nurse outcomes in Guangdong, China: a nurse questionnaire survey

AIMS AND OBJECTIVES

This study examines the relationship between hospital work environments and job satisfaction, job-related burnout and intention to leave among nurses in Guangdong province, China.

BACKGROUND

The nursing shortage is an urgent global problem and also of concern in China. Studies in Western countries have shown that better work environments are associated with higher nurse satisfaction and lower burnout, thereby improving retention and lowering turnover rates. However, there is little research on the relationship between nurse work environments and nurse outcomes in China.

DESIGN

This is a cross-sectional study. Survey data were collected from 1104 bedside nurses in 89 medical, surgical and intensive care units in 21 hospitals across the Guangdong province in China.

METHODS

Stratified convenience sampling was used to select hospitals, and systematic sampling was used to select units. All staff nurses working on participating units were surveyed. The China Hospital Nurse Survey, including the Practice Environment Scale of the Nursing Work Index and Maslach Burnout Inventory, was employed to collect data from nurses. Statistical significance level was set at 0·05.

RESULTS

Thirty-seven per cent of the nurses experienced high burnout, and 54% were dissatisfied with their jobs. Improving nurses' work environments from poor to better was associated with a 50% decrease in job dissatisfaction and a 33% decrease in job-related burnout among nurses.

CONCLUSION

Burnout and job dissatisfaction are high among hospital nurses in Guangdong province, China. Better work environments for nurses were associated with decreased job dissatisfaction and job-related burnout, which may successfully address the nursing shortage in China.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study indicate that improving work environments is essential to deal with the nursing shortage; the findings provide motivation for nurse managers and policy makers to improve work environments of hospital nurses in China.

Patient-derived outcome measures for HIV services in the developed world: a systematic review

This review sought to establish the themes and approaches used in the measurement of patient satisfaction regarded by HIV service users as crucial to improving service quality. It also investigated how feedback has been measured previously and whether a gold standard instrument exists that is generalizable across HIV inpatient and clinic settings. Twelve databases and other sources yielded 1474 titles. Using a clinically-focused question and pre-defined inclusion and exclusion criteria, 32 articles were retrieved and reviewed for quality using a quality appraisal checklist. Two reviewers used a data extraction form to identify and verify key patient experiences. Thematic analysis revealed that clinic staffs' current knowledge of HIV was an essential factor in positive feedback. Treating patients with dignity and respecting their autonomy and confidentiality were also important. Developments in treatment, extended life expectancy and quality of life have altered patients' experience and level of satisfaction. Three instruments developed to assess patient satisfaction with HIV care were identified but there was no gold standard method of measuring it. There is a need to develop a specific, valid instrument that is easy to complete and analyse, and the data should be used to inform the redesign of services to promote a dynamic model of care.

A pilot study of a systematic method for translating patient satisfaction questionnaires

AIMS

This paper is a report of a descriptive comparative pilot study of use of a method that simultaneously tests the content validity and quality of translation of English-to-Chinese translations of two patient satisfaction questionnaires: the La Monica-Oberst Patient Satisfaction Scale and Hospital Consumer Assessment of Healthcare Providers and Systems.

BACKGROUND

Patient satisfaction is an important indicator of the quality of healthcare services. In China, however, few good translations of patient satisfaction instruments sensitive to nursing services exist.

METHODS

The descriptive pilot study took place in 2009 and used content validity indexing techniques to evaluate the content, context and criterion relevance of a survey question. The expert raters were 10 nursing faculty and 10 patients who evaluated the two patient satisfaction questionnaires. The experts evaluated the relevance of each item on a scale of 1-4 and the research team compared their responses to choose the most appropriate. Only the nurse faculty experts, who were bilingual, evaluated the quality of the translation using a binary rating.

RESULTS

The 'Nurse Rater' relevance scores of the LaMonica-Oberst Patient Satisfaction Scale and the Hospital Consumer Assessment of Healthcare Providers and Systems were 0·96 and 0·95 respectively, whereas the patient's overall relevance scores were 0·89 and 0·95. A Mann-Whitney U-test demonstrated that results between the two groups were statistically significantly different (P = 0·0135).

CONCLUSIONS

Using content validity indexing simultaneously with translation processes was valuable for selecting and evaluating survey instruments in different contexts.

Taiwanese nurses' cognition and attitudes towards the Magnet Hospitals Recognition Programme

AIMS

To explore the relevance and feasibility of using the Magnet Recognition Programme (MRP) at a Taiwanese hospital.

BACKGROUND

Since no hospitals in Taiwan have applied for American Nurses Credentialing Center Magnet Recognition, and the American medical system and customs are different from those in Taiwan, this study explores whether or not the MRP is appropriate for Taiwanese hospitals.

METHOD

This study used a cross-sectional design with data collected from 905 nurses at a 1200-bed Taiwanese military hospital. The authors created the structured questionnaire from a framework based on the 14 Forces of Magnetism. The study used descriptive and inferential statistical analyses to explain the nurses' cognitions and attitudes towards the MRP and to discover if variations in these concepts occurred across nurses' demographics and their job classification.

FINDINGS

The mean nurses' cognitive score on each item varies from 3.3 to 4.1, and the mean nurses' attitude score on each item varies from 3.0 to 4.0 (both with the highest possible score related to the 14 Forces of Magnetism being 5.0). Using regression analysis, overall cognitive score, working in the operating room, or the sub-critical Neonatal Care Unit, and part-time hours of work explained 42% of the variance in the total attitude score towards the MRP.

CONCLUSION

The findings indicate that when nurses have a higher cognition towards MRP, the more positive are their attitudes towards seeking the MRP. Using these findings and information about the nurses, the authors suggest strategies that hospital executives and nursing supervisors can use to improve nurses' cognition and attitudes when preparing to seek recognition through the MRP.

Magnet Hospital attributes in European hospitals: a multilevel model of job satisfaction

BACKGROUND

The Magnet Recognition Program in the USA has been based on 14 hospital characteristics that were common in hospitals that were "magnets" for professional nurses. While the program has expanded to other countries, no research has explored how the concept translates to other cultures and healthcare systems, nor have multilevel approaches been used.

OBJECTIVE

The primary aim of this study was to explore the presence of Magnet Hospital attributes in hospitals in two European countries. In addition, the relationship between Magnet Hospital attributes and nurses' job satisfaction was examined at both the nurse and the hospital level.

DESIGN

A secondary data analysis with cross-sectional design was conducted. A multilevel approach was taken to account for the hospital effect due to the nested nature of the data.

SETTINGS

Nurses practicing in acute care hospitals in Germany (16) and Belgium (15) were examined. Hospitals that had less than five respondents were excluded.

PARTICIPANTS

Survey responses from 2303 registered nurses (RNs) from Belgium and 2646 RNs from Germany were included. Non-RN providers, RNs with administrative positions, and those working in non-inpatient areas were excluded. The final sample was 3182 staff nurses working in acute care hospitals.

METHODS

Magnet Hospital attributes that might be represented in NEXT survey items were reviewed by an expert panel before psychometric testing. Only six Magnet Forces could be measured. Latent constructs of these forces and job satisfaction were established. The measurement models and structural regression models were estimated using multilevel modeling in Mplus 4.21.

RESULTS

Six Magnet Forces were validated by two-level confirmatory factor analyses, with good fit to the data as demonstrated by the fit indices. All six Magnet Forces significantly predicted job satisfaction at the nurse level, with personnel policies having the strongest effect (b=0.96). At the hospital level, management style had the strongest effect (b=0.84) in predicting job satisfaction, followed by professional development, interdisciplinary relationship, and autonomy.

CONCLUSIONS

Magnet Hospital attributes are evident in hospitals in two European countries and were found to be associated with job satisfaction. Further multilevel research should explore these attributes particularly at the nursing unit-level where work environment is experienced.

Innovations in transforming organizations

Transformations take as many forms as the organizations they change. However, the success of healthcare-based transformations requires significant cultural shifts and operational changes, many of which mirror the tenets of classic transformer W. Edward Deming. Attaining Magnet hospital status and the integration of the e-health record into nursing school curricula are 2 examples of how healthcare leaders have championed a series of changes that produced sweeping transformations. Success is likely to elude healthcare leaders who mount massive transformations, while those who focus on making seemingly small, interconnected changes are more likely to see the results they envision over time.

A collaborative curricular model for implementing evidence-based nursing in a critical care setting

This article discusses how a curricular model for introducing nurses to the Registered Nurses' Association of Ontario Best Practice Guideline Risk Assessment and Prevention of Pressure Ulcers was used to reduce pressure ulcer prevalence in the critical care setting. This curricular model is particularly relevant to hospitals that are on the Magnet Journey or are involved in other quality improvement efforts to develop an evidence-based nursing practice culture.

A national cross-sectional study on nurses' intent to leave and job satisfaction in Lebanon: implications for policy and practice

Background

Lebanon is perceived to be suffering from excessive nurse migration, low job satisfaction, poor retention and high turnover. Little is known about the magnitude of nurse migration and predictors of intent to leave. The objective of this study is to determine the extent of nurses' intent to leave and examine the impact of job satisfaction on intent to leave. Intent to leave was explored to differentiate between nurses who intend to leave their current hospital and those intending to leave the country.

Methods

A cross-sectional design was used to survey nurses currently practicing in Lebanese hospitals. A total of 1,793 nurses employed in 69 hospitals were surveyed. Questions included those relating to demographic characteristics, intent to leave, and the McCloskey Mueller Satisfaction Scale. Univariate descriptive statistics were conducted on sample's demographic characteristics including gender, age, marital status and educational level. Bivariate associations between intent to leave and demographic characteristics were tested using Pearson Chi-square. Differences in satisfaction scores between nurses with and without intent to leave were tested using t-test and ANOVA f-test. A multinomial logistic regression model was created to predict intent to leave the hospital and intent to leave the country.

Results

An alarming 67.5% reported intent to leave within the next 1 to 3 years, many of whom disclosed intent to leave the country (36.7%). Within nurses who reported an intent to leave the hospital but stay in Lebanon, 22.1% plan to move to a different health organization in Lebanon, 29.4% plan to leave the profession and 48.5% had other plans. Nurses reported being least satisfied with extrinsic rewards. A common predictor of intent to leave the hospital and the country was dissatisfaction with extrinsic rewards. Other predictors of intent to leave (country or hospital) included age, gender, marital status, degree type, and dissatisfaction with scheduling, interaction opportunities, and control and responsibility.

Conclusion

Study findings demonstrate linkages between job satisfaction, intent to leave, and migration in a country suffering from a nursing shortage. Findings can be used by health care managers and policy makers in managing job satisfaction, intent to leave and nurse migration.

Translating theory into practice: using Action Research to introduce a coordinated approach to emotional care

OBJECTIVE

This paper describes a translational project that explored the feasibility and effect of introducing a coordinated approach to emotional care.

METHODS

The project was undertaken using Action Research on one ward at St John of God Hospital Subiaco, Western Australia. A senior Registered Nurse was appointed to provide the leadership and direction to staff regarding emotional care and an education program for staff was provided. The project was evaluated using both quantitative and qualitative data.

RESULTS

Data demonstrated an increase in the patient's evaluation of emotional care, although levels were found to fluctuate throughout the project. Factors such as the emotional distress of the staff were hypothesised as impacting on the delivery of emotional care.

CONCLUSION

The approach used in this project was found to be a useful method of improving emotional care. However, the data collected in this study revealed the complexity of emotional care delivery and the possible impact of a number of factors within the environment.

PRACTICE IMPLICATIONS

Emotional care delivery can be improved by using a coordinated research-based educational approach led by a clinical champion. However, the impact of other factors within the hospital environment needs to be considered and more research is required.

The balancing act: patient care time versus cost

BACKGROUND

With demands to improve patients' clinical outcomes and decrease the escalating costs of inpatient care, nurse executives are focusing on how nurses spend their time rather than just raising staffing levels to positively impact patient outcomes. Because nursing wages constitute a high proportion of a hospital's budget, understanding the costs of nursing activities is critical to managing them.

METHODS

An activity-based costing approach was used in 14 medical-surgical nursing units to study nursing activities and their related costs. Time use for 4 patient care activities (assess, teach, treat, provide psychosocial support) and 2 support activities (coordinate care and manage clinical records) including the percent of non-value-added (NVA) time for each of these activities was identified through focus groups, interviews, and timed observations. Annualized wage costs were assigned to these activities to determine average wage-related costs of each activity as well as NVA-related costs.

RESULTS

More than one-third of nurses' time was considered NVA, averaging dollars 757,000 per nursing unit in wage costs annually. Nurses spent more time on support activities (56%) than in providing patient care (44%), with the least amount of time being spent on patient teaching and psychosocial support.

CONCLUSION

Findings indicate a huge opportunity to both improve clinical outcomes in these units and, at the same time, reduce costs by focusing on processes to reduce the high amount time spent performing NVA and support activities and increase patient care time, particularly patient teaching and psychosocial support.

Review: how do hospital organizational structure and processes affect quality of care?: a critical review of research methods

Interest in organizational contributions to the delivery of care has risen significantly in recent years. A challenge facing researchers, practitioners, and policy makers is identifying ways to improve care by improving the organizations that provide this care, given the complexity of health care organizations and the role organizations play in influencing systems of care. This article reviews the literature on the relationship between the structural characteristics and organizational processes of hospitals and quality of care. The review uses Donabedian's structure-process-outcome and level of analysis frameworks to organize the literature. The results of this review indicate that a preponderance of studies are conducted at the hospital level of analysis and are predominantly focused on the organizational structure-quality outcome relationship. The article concludes with recommendations of how health services researchers can expand their research to enhance one's understanding of the relationship between organizational characteristics and quality of care.

Extending work environment research into home health settings

Organizational attributes in work environments that support nursing practice are theoretically associated with superior nurse and patient outcomes, and lower frequencies of adverse events. This study explored associations between organizational support for nursing practice in home health care agencies and (a) the frequency of nurse-reported adverse events, (b) nurse-assessed quality of care, (c) nurse job satisfaction, and (d) nurses' intentions to leave their employing agency. Data were collected from a sample of 137 registered nurses employed as home health staff nurses in the United States and analyzed using descriptive techniques and bivariate correlation. As anticipated, organizational support for nursing was negatively associated with nurse-reported adverse patient events and intent to leave, and positively associated with nurse-assessed quality of care and job satisfaction. These findings may be helpful to nursing administrators who seek to create work environments in home health agencies that maximize patient outcomes and nurse satisfaction.

An Exploration of the Factor Structure of the Nursing Work Index

RATIONALE

The nurse shortage is increasing in the developed world. Organisational context is important in determining issues associated with nurse shortages, such as retention, recruitment, and job satisfaction. Recent research has utilised the Nursing Work Index-Revised (NWI-R) as a measure of organisational context traits. Within the NWI-R a four-factor model has been reported as being important in determining good organisational context, yet researchers have recently questioned the stability of the four-factor structure.

AIM

No known study has attempted to replicate the four-factor structure reported in the NWI-R. The aim of this research is to examine the factor structure of the 15 items that comprise the four factors of the NWI-R.

METHODS

The NWI-R is an instrument that is focused on capturing organisational attributes that characterise professional nursing environments. A random sample of 172 (50%) acute care hospital nurses completed the NWI-R as part of a larger research project. The sample was diverse concerning nursing grade and specialty. Data were analysed using SPSS.11.0 to extract factors' structures (principal component and maximum likelihood), measures of homogeneity and descriptive statistics were generated from the findings.

RESULTS

The four-factor structure of the NWI-R was not replicated in the data analysis. Instead a modified three-factor structure was identified accounting for 57% of the variance. Measures of internal consistency were acceptable.

DISCUSSION

Previous research utilised the four factors of the NWI-R as a method to identify supportive organisational context and practice. The three-factor model raises questions regarding the stability of the findings using the NWI-R. This research shows the synthesis of the two models in light of previous findings.

CONCLUSIONS/IMPLICATIONS

The findings might have far reaching implications for research that has utilised the NWI-R as a measure of organisational context. Further research is required to examine this study's findings and literature.

Nurse Practice Environments and Outcomes: Implications for Oncology Nursing

PURPOSE/OBJECTIVES

To examine practice environments and outcomes of nurses working in oncology units or Magnet hospitals and to understand the association between the two.

DESIGN

Secondary analysis of survey data collected in 1998.

SETTING

Medical and surgical units of 22 hospitals, of which 7 were recognized by the American Nurses Credentialing Center Magnet program.

SAMPLE

1,956 RNs, of whom 305 worked in oncology units.

METHODS

Chi-square tests compared nurse-reported outcomes by work setting, analysis of variance tested practice environment differences by setting, and logistic regression estimated the effects of practice environment, specialty, and Magnet status on outcomes.

MAIN RESEARCH VARIABLES

Practice environments, emotional exhaustion, job satisfaction, and quality of care.

FINDINGS

Oncology nurses had superior outcomes compared with nononcology nurses. Emotional exhaustion was significantly lower among oncology nurses working in Magnet hospitals. Scores on the Collegial Nurse-Physician Relations subscale were highest among oncology nurses. Outcomes were associated with Practice Environment Scale of the Nursing Work Index scores and Magnet status. Oncology nurses with favorable collegial nurse-physician relations were twice as likely to report high-quality care.

CONCLUSIONS

Oncology nurses benefit from working in American Nurses Credentialing Center Magnet hospitals. Adequate staffing and resources are necessary to achieve optimal outcomes. Collegial nurse-physician relations appear to be vital to optimal oncology practice settings.

IMPLICATIONS FOR NURSING

In addition to pursuing American Nurses Credentialing Center Magnet recognition, nurse managers should assess practice environments and target related interventions to improve job satisfaction and retention. High-priority areas for interventions include ensuring adequate staff and resources, promoting nurse-physician collaboration, and strengthening unit-based leadership.

A meta-analysis of studies of nurses' job satisfaction

Although several variables have been correlated with nursing job satisfaction, the findings are not uniform across studies. Three commonly noted variables from the nursing literature are: autonomy, job stress, and nurse-physician collaboration. This meta-analysis examined the strength of the relationships between job satisfaction and autonomy, job stress, and nurse-physician collaboration among registered nurses working in staff positions. A meta-analysis of 31 studies representing a total of 14,567 subjects was performed. Job satisfaction was most strongly correlated with job stress (ES = -.43), followed by nurse-physician collaboration (ES = .37), and autonomy (ES = .30). These findings have implications for the importance of improving the work environment to increase nurses' job satisfaction.

Unit type differences in RN workgroup job satisfaction

Using cross-sectional data from the 2004 National Database of Nursing Quality Indicators (NDNQI) RN Satisfaction Survey, differences in RN workgroup job satisfaction were examined among 10 unit types--medical-surgical, step-down, critical care, pediatric, maternal-newborn, psychiatric, emergency department, rehabilitation, surgical services, and outpatient clinics and labs. The national sample included RN workgroups in 2,900 patient care units (55,516 RNs; 206 hospitals in 44 states). Workgroup satisfaction across all unit types was moderate. RN workgroups in pediatric units were the most satisfied, whereas those in surgical services and emergency department unit types were least satisfied. A consistent finding across all unit types was high satisfaction with the specific domains of nurse-to-nurse interaction, professional status, and professional development versus much lower satisfaction with task, decision making, and pay. Findings can be used to inform and develop investigations that examine specific aspects of the work environment for RN workgroups in various unit types.

Best quality patient care: a historical perspective on Magnet hospitals

Donabedian's Structure-Process-Outcome paradigm is used to analyze the evolution and research on the concept of magnetism through 4 phases. The identifying foci of the original 1983 study were 4 outcomes. A large number and array of structural features were derived from the identified Magnet hospitals. The quest for excellence in nursing care continued with the Gold Standard of Magnetism case studies utilizing all identified Magnet structures, processes, and outcomes. The advent of the American Nurses Credentialing Center Magnet Recognition Program stimulated much valuable and insightful research related to outcomes associated with the large group of magnetic structures. Magnet hospital staff nurses (SNs) identification of processes/functions most essential to quality patient care highlights the Process phase. Many of the vast array of structural features attributed to Magnet hospital in 1983 are outdated and differentially defined and have not been tested for their relationship to either processes or outcomes. Identification of magnetism from an SN perspective has lagged. Recommendations include updating and clarifying structural criteria; increasing focus on the SN perspective of magnetism by continuing identification of processes; and challenging leadership in Magnet hospitals to initiate multisite evidence-based practice initiatives to link structures with process-enabling outcomes. Now may well be the time for nursing to exert leadership in expanding the Magnet concept to the total patient-care operation in a hospital.

Access and equity in HIV/AIDS palliative care: a review of the evidence and responses

The high prevalence of pain and other symptoms throughout the HIV disease trajectory, the need for management of side effects related to antiretroviral therapy, the continuing incidence of cancers and new emerging co-morbidities as a result of extended life expectancy under new therapeutic regimes, and the ongoing need for terminal care all prove the curative versus palliative dichotomy to be inappropriate. Although there is evidence for both need and effectiveness of palliative care in HIV patient care, access is often poor and care less than optimal. This review aimed to identify evidence of barriers and inequalities in HIV palliative care in order to inform policy and service development. Biomedical databases were searched using a specific strategy, and evidence extracted into the barrier and inequity categories of patient, clinician, service and disease factors. A model of the barriers and inequalities is presented from the evidence. Recommendations are made from the evidence for promoting access and outcomes through integrated palliative care from diagnosis to end-of-life, alongside antiretroviral therapy when initiated. Service responses that have attempted to increase access to palliative care are presented.

Organizational Attributes Valued by Hospital, Home Care, and District Nurses in the United States and New Zealand

PURPOSE

To determine whether hospital-based, home care, and district nurses identify a core set of organizational attributes in the nursing work environment that they value as important to the support of professional practice.

DESIGN

Survey data, collected in 2002-2003 from 403 home care nurses in the United States (US) and 320 district nurses in New Zealand (NZ), were pooled with an existing data set of 669 hospital-based nurses to conduct this descriptive, nonexperimental study.

METHODS

The importance of organizational attributes in the nursing work environment was measured using the Nursing Work Index-Revised (NWI-R). Frequency distributions and analysis of variance were used to analyze the data.

FINDINGS

At least 80% of hospital-based, home care, and district nurses either agreed or strongly agreed that 47 of the 49 items comprising the NWI-R represented organizational attributes they considered important to the support of their professional nursing practice. Mean importance scores among home care nurses, however, were significantly lower than were those of the other two groups.

CONCLUSIONS

Overall, hospital-based, home care, and district nurses had a high level of agreement regarding the importance of organizational traits to the support of their professional practice. The intensity of the attributes' importance was less among home care nurses. Further research is needed to determine whether this set of organizational traits, measured using the NWI-R, is associated with positive nurse and patient outcomes in home care and district nursing practice, as has been shown in acute care settings.

Nursing work environment and quality of care: differences between units at the same hospital

The literature suggests that improvements in nurses' work environments may improve the quality of patient care. Furthermore, monitoring the work environment through staff surveys may be a feasible method of identifying opportunities for quality improvement. This study aimed to confirm five proposed sub-scales from the Nursing Work Index - Revised (NWI-R) to assess the nursing work environment and the performance of these sub-scales across different units in a hospital. Data were derived from a cross-sectional survey of 243 nurses from 13 units of a 300-bed university-affiliated hospital in Quebec, Canada, during 2001. Using confirmatory factor analysis, the five subscales were confirmed; three of the sub-scales had greater ability to discriminate between units. Using hierarchical regression models, "resource adequacy" was the sub-scale most strongly associated with the perceived quality of care at the last shift. The NWI-R sub-scales are potentially useful for comparison of work environments of different nursing units at the same hospital.

Development and evaluation of essentials of magnetism tool

Staff nurses in 14 magnet hospitals identified 8 attributes associated with the original concept of magnetism as essential to their ability to give quality care. The 8 Essentials of Magnetism (EOM) tool was generated from participant observation and interviews with 289 magnet hospital staff nurses. The psychometric properties of the EOM tool were established in a study involving 3602 staff nurses in 16 magnet and 10 nonmagnet hospitals. The authors discuss the EOM tool and its use in diagnosing elements needed in the environment to produce what staff nurses say is essential for productivity of quality patient care.

An invitation to Magnet accreditation

Review Magnet program basics and eligibility requirements to determine your organization's readiness for undergoing certification.

Nurse burnout and patient satisfaction

BACKGROUND

Amid a national nurse shortage, there is growing concern that high levels of nurse burnout could adversely affect patient outcomes.

OBJECTIVES

This study examines the effect of the nurse work environment on nurse burnout, and the effects of the nurse work environment and nurse burnout on patients' satisfaction with their nursing care. RESEARCH DESIGN/SUBJECTS: We conducted cross-sectional surveys of nurses (N=820) and patients (N=621) from 40 units in 20 urban hospitals across the United States.

MEASURES

Nurse surveys included measures of nurses' practice environments derived from the revised Nursing Work Index (NWI-R) and nurse outcomes measured by the Maslach Burnout Inventory (MBI) and intentions to leave. Patients were interviewed about their satisfaction with nursing care using the La Monica-Oberst Patient Satisfaction Scale (LOPSS).

RESULTS

Patients cared for on units that nurses characterized as having adequate staff, good administrative support for nursing care, and good relations between doctors and nurses were more than twice likely as other patients to report high satisfaction with their care, and their nurses reported significantly lower burnout. The overall level of nurse burnout on hospital units also affected patient satisfaction.

CONCLUSIONS

Improvements in nurses' work environments in hospitals have the potential to simultaneously reduce nurses' high levels of job burnout and risk of turnover and increase patients' satisfaction with their care.

Quality of Evidence

BACKGROUND

In 1998, the Committee on Health Care Quality in America was created and given the charge of devising a strategy to achieve substantial improvement in the quality of health care for all Americans. One strategy to move the quality agenda forward is the use of evidence by both providers of health care and consumers of health care. One feature of this agenda, evidence-based practice, refers to a hierarchy of evidence ranging from individual randomized, controlled trials to expert opinion.

OBJECTIVES

The purposes of this article are to describe the evidence base in nursing, discuss the quality and strength of nursing's evidence, illustrate the application of the Quality Health Outcomes Model, and present recommendations for practice, research, and policy to increase nursing's contribution to quality health care.

RESULTS AND RECOMMENDATIONS

Nurses everywhere must use innovative solutions to operationalize the "evidence" in evidence-based nursing. The Quality Health Outcomes Model (QHOM) provides a useful way of advancing research and evidence about the quality of health care in America. In concert with the conceptual framework for the National Health Care Quality Report, the QHOM provides a map for identifying evidence gaps and research questions arising from the model and conceptual framework, as well as evidence synthesis (integrating methodologic quality) driven by theoretical understanding.

Workplace empowerment and magnet hospital characteristics: making the link

OBJECTIVE

To test a theoretical model linking nurses' perceptions of workplace empowerment, magnet hospital characteristics, and job satisfaction in 3 independent studies of nurses in different work settings.

BACKGROUND

Strategies proposed in Kanter's structural empowerment theory have the potential to result in work environments that are described in terms of magnet hospital characteristics. Identifying factors that contribute to work conditions that attract and retain highly qualified committed nurses, such as those found in magnet hospitals, that can be put in place by nursing administrators is extremely important for work redesign to promote professional nursing practice.

METHODS

Secondary analyses of data from 3 studies were conducted--2 of staff nurses and 1 with acute care nurse practitioners working in Ontario, Canada. The Conditions of Work Effectiveness Questionnaire-II, the NWI-R, and measures of job satisfaction were used to measure the major study variables.RESULTS The results of all 3 studies support the hypothesized relationships between structural empowerment and the magnet hospital characteristics of autonomy, control over practice environment, and positive nurse-physician relationships. The combination of access to empowering work conditions and magnet hospital characteristics was significantly predictive of nurses' satisfaction with their jobs.

CONCLUSIONS/IMPLICATIONS

These findings suggest that nursing leaders' efforts to create empowering work environments can influence nurses' ability to practice in a professional manner, ensuring excellent patient care quality and positive organizational outcomes.

Securing "good" nurse/physician relationships

Responses to a study of 279 staff nurses from 14 Magnet hospitals enabled researchers to develop a five-category nurse/physician relationship scale.

Magnet hospital nurses describe control over nursing practice

Staff nurses describe control over nursing practice (C/NP) as a professional nursing function made up of a variety of activities and outcomes. Greater acclaim, status, and prestige for nursing in the organization are viewed as a result, not a precursor, of C/NP. Interviews with 279 staff nurses working in 14 magnet hospitals indicated that effective C/NP requires some kind of empowered, formal organizational structure, extends beyond clinical decision making at the patient care interface, and is the same as or highly similar to what the literature describes as professional autonomy. From constant comparative analysis of nurses' descriptions of C/NP activities, five ranked categories of this real-life event emerged. The basis for the categories and ranking was "who owned the problem, issue, and solution" and the "degree of effectiveness of control" as reflected in visibility, viability, and recognition of a formal structure allowing and encouraging nurses' control over practice. Hospital mergers and structural reorganization were reported to negatively affect the structure needed for effective C/NP. Almost 60% of these magnet hospital staff nurses stated and/or described little or no C/NP.

Health correlates of autonomy, control and professional relationships in the nursing work environment

BACKGROUND

Internationally, nursing is facing a variety of challenges including changes in health systems, an ageing workforce and escalating shortages of Registered Nurses. New Zealand is no exception. Here as elsewhere these challenges are taking their toll on the resources and demands of hospital environments, on the health and well-being of nurses themselves and most certainly on the people for whom they care. In the United States of America (USA), three aspects of the nursing work environment--autonomy, control and nurse-physician relations--have been identified as linked to staff retention, levels of staff burnout and needlestick injury, as well as to a range of patient outcomes.

AIM

To examine the New Zealand nursing situation and to see whether aspects of the work environment are associated with health status.

METHODS

A total of 225 Registered Nurses in a general hospital completed the Revised Nursing Work Index (NWI-R) and Medical Outcomes Study (MOS) 36-Item Short-Form Health Survey (SF-36).

RESULTS

Ratings indicated that the New Zealand hospital environment was characterized by less autonomy and control and better nurse-physician relations than in USA hospitals. Results of correlations demonstrated that more positive ratings of the three workplace attributes were associated with better health status amongst the nurses. The results of regression analyses were indicative either of a confounding relationship or of a mediating relationship such that nurses' relations with physicians, administration and other departments mediate the associations between autonomy, control and health status.

CONCLUSIONS

The study offers an insight into a New Zealand hospital environment and suggests the importance of good relationships with physicians and other departments for the health of nurses.

Professional nursing practice: impact on organizational and patient outcomes

OBJECTIVE

To test a causal model of the impact of (a) nursing unit context on professional nursing practice; (b) professional practice on selected organizational (nurses' work satisfaction, nursing turnover, average length of patient stay) and patient outcomes (patient satisfaction, rate of reported medication errors, and falls); and (c) nursing unit context on these same organizational and patient outcomes.

SUMMARY BACKGROUND DATA

Professional nursing practice has been linked to positive outcomes for both nurses and patients. In contrast to other studies, this study focuses on professional nursing practice specifically at the nursing unit level, and uses a new analytic technique that permits examination of the simultaneous effects of professional nursing practice on both organizational and patient outcomes.

METHODS

Data were collected from 1682 registered nurses, and 1326 patients on 124 general medical-surgical nursing units in 64 general short-term acute care hospitals in the southeast. Multilevel structural equation modeling was used to analyze the data.

RESULTS

We found that professional nursing practice had consistent effects across model levels on nursing satisfaction, but very limited effects on other outcomes. Important differences in the hospital- and nursing unit level models support continued use of multilevel modeling techniques in the study of organizational and patient outcomes.

Magnet hospital staff nurses describe clinical autonomy

BACKGROUND

Considerable and longstanding confusion abounds as to what is meant by the concept "autonomy." The 2 dimensions of autonomy-rooted in the clinical act and the autonomy of the discipline or profession-are used interchangeably and measured with the same tools.

PURPOSE

The purpose of this research was to ascertain staff nurses' concept of autonomy, to empirically quantify nurse autonomy, and to determine the relationship between degree of autonomy and staff nurses' rankings of quality care on their units and their own job satisfaction.

METHOD

Two hundred seventy-nine volunteer staff nurses from 14 magnet hospitals were interviewed individually with the open-ended question and request, "Can you practice autonomously? Give an example of a typical situation that illustrates that you practice autonomously," and with two 10-point rating scales on job satisfaction and quality of care given on their units. Responses were subjected to constant comparative and thematic analyses. On the basis of 3 themes-frequency, organizational sanction, and scope-a 5-category ranked autonomy scale was developed. These magnet hospital staff nurses restrict the concept of autonomy to the clinical act. There is a strong relationship between degree of autonomy as measured by the ranked scale and rankings of job satisfaction and quality of care. An unexpected finding was that 26% of these nurses working in magnet hospital reported situations of unsupported or no autonomy.

DISCUSSION

This research is particularly meaningful for nurse managers and researchers. Nurse managers must empower nurses, provide support, provide opportunities for nurses to increase competence, and reward and sanction staff nurse autonomy. After further refinement, the ranked-category scale will be useful in studying the effect of educational efforts and organizational support on the development of clinical autonomy.

HIV patients' experiences with inpatient and outpatient care: results of a national survey

CONTEXT

Little is known about HIV patients' care experiences.

OBJECTIVE

To assess HIV patients' experiences with inpatient and outpatient care, and to assess the relationship and relative influence of patient characteristics and site of care on care experiences.

DESIGN

Cohort study.

SETTING

Patients with HIV receiving care outside of emergency rooms, prisons, or the military throughout the continental United States. One thousand seventy-four patients provided ratings of an inpatient stay and 2204 rated an outpatient visit; 818 patients provided evaluations of both inpatient and outpatient care.

PATIENTS

A national probability sample of persons in care for HIV from the HIV Cost and Services Utilization Study.

MEASUREMENTS

Outcome variables were rates of problems with, and global ratings of, inpatient and outpatient care.

RESULTS

Mean problem rates were 20.9% and 8.4% (lower score means fewer problems) for inpatient and outpatient care, respectively. On 9 of 10 of the individual inpatient report items, 15% or more of respondents reported problems. Global ratings of inpatient and outpatient care were 65.3 and 75.0 (0-100 scale, higher scores indicate better ratings), respectively. In multivariable models that controlled for site effects, the only patient characteristic that was consistently associated with problem rates and global ratings of care was mental health (P <0.0001 for both inpatient and outpatient care). Models including site effects explained two to four times as much variance as models excluding site effects.

CONCLUSIONS

Inpatients with HIV reported higher problem rates with inpatient than outpatient care. Better provider-patient communication during inpatient stays is needed. For both inpatient and outpatient care, quality improvement efforts may be most productively focused on providers and processes of care at sites rather than on specific patient subgroups.

Hospital staffing, organization, and quality of care: Cross-national findings

OBJECTIVE

To examine the effects of nurse staffing and organizational support for nursing care on nurses' dissatisfaction with their jobs, nurse burnout, and nurse reports of quality of patient care in an international sample of hospitals.

DESIGN

Multisite cross-sectional survey

SETTING

Adult acute-care hospitals in the U.S. (Pennsylvania), Canada (Ontario and British Columbia), England and Scotland.

STUDY PARTICIPANTS

10319 nurses working on medical and surgical units in 303 hospitals across the five jurisdictions.

INTERVENTIONS

None Main outcome measures: Nurse job dissatisfaction, burnout, and nurse-rated quality of care.

RESULTS

Dissatisfaction, burnout and concerns about quality of care were common among hospital nurses in all five sites. Organizational/managerial support for nursing had a pronounced effect on nurse dissatisfaction and burnout, and both organizational support for nursing and nurse staffing were directly, and independently, related to nurse-assessed quality of care. Multivariate results imply that nurse reports of low quality care were three times as likely in hospitals with low staffing and support for nurses as in hospitals with high staffing and support.

CONCLUSION

Adequate nurse staffing and organizational/managerial support for nursing are key to improving the quality of patient care, to diminishing nurse job dissatisfaction and burnout and, ultimately, to improving the nurse retention problem in hospital settings.

Development of the practice environment scale of the Nursing Work Index

Five subscales were derived from the Nursing Work Index (NWI) to measure the hospital nursing practice environment, using 1985-1986 nurse data from 16 magnet hospitals. The NWI comprises organizational characteristics of the original magnet hospitals. The psychometric properties of the subscales and a composite measure were established. All measures were highly reliable at the nurse and hospital levels. Construct validity was supported by higher scores of nurses in magnet versus nonmagnet hospitals. Confirmatory analyses of contemporary data from 11,636 Pennsylvania nurses supported the subscales. The soundness of the new measures is supported by their theoretical and empirical foundations, conceptual integrity, psychometric strength, and generalizability. The measures could be used to study how the practice environment influences nurse and patient outcomes.

The nursing shortage: a worldwide problem

A worldwide shortage of nurses has been acknowledged by the multidisciplinary Global Advisory Group of the World Health Organization. The shortage is caused by an increased demand for nurses, while fewer people are choosing nursing as a profession and the current nurses worldwide are aging. The shortage applies to nurses in practice as well as the nurse faculty who teach students. The inter-country recruitment and migration of nurses from developing countries to developed countries exacerbates the problem. Although public opinion polls identifies the nurse as the person who makes the health care system work for them, the conditions of the work environment in which the nurse functions is unsatisfactory and must change. Numerous studies have shown the positive effects on the nurse of a healthy work environment and the positive relationships between nursing care and patient outcomes. It is important that government officials, insurance companies, and administrators and leaders of health care systems acknowledge and operationalize the value of nurses to the health care system in order to establish and maintain the integrity and viability of that system.

Organizational and environmental factors that affect worker health and safety and patient outcomes

This article reviews organizational factors that influence the satisfaction, health, safety, and well-being of health care workers and ultimately, the satisfaction, safety, and quality of care for patients. The impact of the work environment on working conditions and the effects on health care workers and patients are also addressed. Studies focusing on worker health and safety concerns affected by the organization and the physical work environment provide evidence of direct positive and/or adverse effects on performance and suggest indirect effects on the quality of patient care. The strongest links between worker and patient outcomes are demonstrated in literature on nosocomial transmission of infections. Transmission of infections from worker to patient and from patient to patient via health care worker has been well documented in clinical studies. Literature on outbreaks of infectious diseases in health care settings has linked the physical environment with adverse patient and worker outcomes. An increasing number of studies are looking at the relationship between improvement in organizational factors and measurable and positive change in patient outcomes. Characteristics of selected magnet hospitals are reviewed as one model for improving patient and worker outcomes.

HIV-positive women and minority patients' satisfaction with inpatient hospital care

Although patient satisfaction has been examined in relation to HIV services for ambulatory and managed care, less is known about perceptions of hospital care, particularly for HIV-positive women and minorities. The purpose of this study was to examine HIV-positive women and minority patients' satisfaction with hospital care. The study was part of a larger funded study that explored potential health care disparities for HIV-positive women and minority persons in the era of HIV combination drug therapy. A convenience sample of 50 HIV-positive persons was recruited from four medical centers/hospitals in a South Florida community. The multi-ethnic sample included 31 women and 19 men. The survey tool used was Cleary's HIV-Infected Patient's In-Hospital Questionnaire. Findings revealed that participants were generally satisfied with their hospital care. Physicians, nurses, and the hospital environment received satisfactory ratings. However, several problem areas were identified, including pain management and education on side effects of HIV medications, indicating the need for interventions to improve care. Experimental AIDS drugs were discussed with less than half of the participants, suggesting that HIV-positive women and minority patients may not have equal access to clinical drug trials. Further research is also needed to determine whether attitudes conveyed by health care providers influence HIV-positive patients to be wary of advance directives. The competence of nurses experienced in acute-care nursing of persons with HIV/AIDS was an important factor in patient satisfaction. A lack of experienced acute-care AIDS nurses may ultimately lead to a decrease in HIV-positive patients' satisfaction with hospital care.

Nurses' reports on hospital care in five countries

The current nursing shortage, high hospital nurse job dissatisfaction, and reports of uneven quality of hospital care are not uniquely American phenomena. This paper presents reports from 43,000 nurses from more than 700 hospitals in the United States, Canada, England, Scotland, and Germany in 1998-1999. Nurses in countries with distinctly different health care systems report similar shortcomings in their work environments and the quality of hospital care. While the competence of and relation between nurses and physicians appear satisfactory, core problems in work design and workforce management threaten the provision of care. Resolving these issues, which are amenable to managerial intervention, is essential to preserving patient safety and care of consistently high quality.