Barbara B. Brewer

Nurse Manager Support: What Is It? Structures and Practices That Promote It

Professional nursing organizations identify nurse manager (NM) support of staff nurses as an essential component of a productive, healthy work environment. Role behaviors that constitute this support must be identified by staff nurses. In this mixed-method study, supportive role behaviors were identified by 2382 staff nurses who completed the investigator-developed Nurse Manager Support Scale. In addition, semistructured interviews were conducted with 446 staff nurses, managers, and physicians from 101 clinical units in 8 Magnet hospitals in which staff nurses had previously confirmed excellent nurse manager support. Through individual and focus group interviews with NM and chief nurse executives in the 8 participating hospitals, the organizational structures and practices that enabled NM to be supportive to staff were determined. The 9 most supportive role behaviors cited by interviewees were as follows: is approachable and safe, cares, “walks the talk,” motivates development of self-confidence, gives genuine feedback, provides adequate and competent staffing, “watches our back,” promotes group cohesion and teamwork, and resolves conflicts constructively. Supporting structures and programs identified by managers and leaders include the following: “support from the top,” peer group support, educational programs and training sessions, a “lived” culture, secretarial or administrative assistant support, private office space, and computer classes and seminars.

Structures and Practices Enabling Staff Nurses to Control Their Practice

This mixed-methods study uses interviews, participant observations, and the CWEQII empowerment tool to identify structures and attributes of structures that promote control over nursing practice (CNP). Nearly 3,000 staff nurses completed the Essentials of Magnetism (EOM), an instrument that measures CNP, one of the eight staff nurse-identified essential attributes of a productive work environment. Strategic sampling is used to identify 101 high CNP-scoring clinical units in 8 high-EOM scoring magnet hospitals. In addition to 446 staff nurses, managers, and physicians on these high-scoring units, chief nursing officers, chief operating officers, and representatives from other professional departments are interviewed; participant observations are made of all unit/departmental/hospital council and interdisciplinary meetings held during a 4 to 6 day site visit. Structures and components of viable shared governance structures that enabled CNP are identified through constant comparative analysis of interviews and observations, and through analysis of quantitative measures.

Accurate assessment of clinical nurses' work environments: Response rate needed

Improvement of hospital unit work environments is key to quality patient care, productivity, nurse retention, and job satisfaction. Accurate measurement of such environments is necessary prior to introduction and evaluation of improvement structures and strategies. Characteristics and attributes of work environments are group level phenomena. Accurate assessment of these phenomena requires survey response rates of sufficient size to ensure sample representativeness and data that can reliably be aggregated to group level. What is the sufficient response rate? This question was answered through psychometric testing of five random samples from the population of 23 M.D. Anderson Cancer Center clinical units that had 100% response rates on an environmental survey. Response rates of 40% or more had acceptable psychometric properties for unit-specific scales.

Relationships among teams, culture, safety, and cost outcomes

The objective of this study is to test the transtheoretical integration model, which proposes relationships among team-based phenomena and patient safety and resource-use outcome variables. The sample consisted of 411 nursing staff (n = 372) and multidisciplinary team members (n = 39) from 16 medical surgical units. Staff were surveyed to evaluate their perceptions of hospital culture, work group design, and positive and negative team processes. Managers provided data concerning outcome variables of patient falls with injury, average length of stay (LOS), and labor and supply expenses for their patient care units. A group-type hospital culture predicted fewer patient falls with injury; a developmental-type hospital culture predicted higher patient care unit costs. Team design and processes were predictive of longer LOS for patients on medical-surgical units. Conclusions of the study were that hospital contexts external to the patient care unit may be important contributors to patient safety and resource use on nursing units.

Walk the Talk: Promoting Control of Nursing Practice and a Patient-Centered Culture

at the unit level unless parallel sanction and endorsement for these activities exist at the organizational level. After clarifying and illustrating the walk-the-talk metaphor and the constructs control of nursing practice and shared governance, we present the results of research that pertain to control of nursing practice and a patient-centered culture. We then suggest ways in which clinical nurses can operationalize the walk aspect of the talk, the values and beliefs inherent in control of nursing practice and a patient-centered culture.

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.

A collaborative approach to building the capacity for research and evidence-based practice in community hospitals.

The use of best evidence to support nursing practice and the generation of new knowledge to use in practice are hallmarks of excellence. Nurses at the bedside, however, often lack the resources and knowledge necessary to change the traditional nursing culture to one in which the use of evidence is incorporated into daily care. This article describes the experience in two hospitals using a program designed to give nurses the skills needed to engage in evidence-based care.

Impact of Residency Programs on Professional Socialization of Newly Licensed Registered Nurses

Do Nurse Residency Programs (NRPs) reflect the professional socialization process? Residency facilitators in 34 Magnet hospitals completed Residency Program Questionnaires constructed to reflect the goals, themes, components, and strategies of the professional socialization process described in the literature. NRPs in 4 hospitals exemplified the complete two-stage (role transition and role/community integration) process. In 14 hospitals, NRPs were of sufficient length and contained components that reflected the professional socialization process. In 16 hospitals, NRPs exemplified the “becoming” role transition stage. What components are most effective in the professional socialization of new graduate nurses? A total of 907 new and experienced nurses, nurse managers, and educators working on clinical units with confirmed healthy work environments in 20 Magnet hospitals with additional “excellence designations” were interviewed. Components identified as most instrumental were precepted experience, reflective seminars, skill acquisition, reflective practice sessions, evidence-based management projects, and clinical coaching–mentoring sessions. Suggestions for improvement of NRPs are offered.

Using ORA to explore the relationship of nursing unit communication to patient safety and quality outcomes

PURPOSE We used ORA, a dynamic network analysis tool, to identify patient care unit communication patterns associated with patient safety and quality outcomes. Although ORA had previously had limited use in healthcare, we felt it could effectively model communication on patient care units. METHODS Using a survey methodology, we collected communication network data from nursing staff on seven patient care units on two different days. Patient outcome data were collected via a separate survey. Results of the staff survey were used to represent the communication networks for each unit in ORA. We then used ORAs analysis capability to generate communication metrics for each unit. ORAs visualization capability was used to better understand the metrics. RESULTS We identified communication patterns that correlated with two safety (falls and medication errors) and three quality (e.g., symptom management, complex self care, and patient satisfaction) outcome measures. Communication patterns differed substantially by shift. CONCLUSION The results demonstrate the utility of ORA for healthcare research and the relationship of nursing unit communication patterns to patient safety and quality outcomes.

Using *ORA, a Network Analysis Tool, to Assess the Relationship of Handoffs to Quality and Safety Outcomes

Communication during patient handoffs has been widely implicated in patient safety issues. However, few studies have actually been able to quantify the relationship between handoffs and patient outcomes. We used *ORA, a dynamic network analysis tool, to examine handoffs between day and night shifts on seven units in three hospitals in the Southwest. Using *ORA’s visualization and analysis capabilities, we examined the relationships between the handoff communication network metrics and a variety of patient safety quality and satisfaction outcomes. Unique network patterns were observed for different types of outcome variable (eg, safety, symptom management, self-care, and patient satisfaction). This exploratory project demonstrates the power of *ORA to identify communication patterns for large groups, such as patient care units. *ORA’s network metrics can then be related to specific patient outcomes.