Diane M. Doran

Nursing-sensitive outcomes data collection in acute care and long-term-care settings.

Background: Most administrative databases do not contain good information about nursing-sensitive outcomes. Objectives: To determine (a) the reliability of the instruments measuring nursing-sensitive outcomes, (b) whether the outcome measures are sensitive to changes in patients health, and (c) whether the outcome measures are associated with nursing interventions. Methods: The sample consisted of 890 patients from acute care hospitals and long-term-care facilities. A repeated measures design was used. Functional status was assessed on admission and discharge using Minimum Data Set 2.0 items. Symptom (pain, nausea, dyspnea, fatigue) frequency and severity were assessed with 4-point and 11-point numeric scales, respectively. Therapeutic self-care was assessed on discharge from acute care. Nursing interventions were assessed by documentation review. Results: The outcome measures demonstrated very good interrater reliability with weighted Kappa ranging from .64 to .93. The internal consistency reliability was high for functional status and therapeutic self-care. The outcome tools were sensitive to change in patient condition. Select nursing interventions were related to functional status, therapeutic self-care, and symptom outcomes. Discussion: The findings suggest that nurses are able to collect data on nursing-sensitive patient outcomes in a reliable and valid way.

Measurement of Nurse Job Satisfaction Using the McCloskey/Mueller Satisfaction Scale

Background: Originally developed to rank rewards that nurses value and that encourage them to remain in their jobs, the McCloskey/Mueller Satisfaction Scale (MMSS) is being used extensively in research and practice to measure nurse job satisfaction. Since its original development in 1990, limited evidence of psychometric properties of the MMSS has been reported. Objective: To investigate and report the psychometric properties of the MMSS when used in 2003 to measure hospital nurse job satisfaction. Methods: Data from a survey of 8,456 nurses were used to establish psychometric properties of the MMSS. Dimensionality was tested using confirmatory and exploratory factor analyses. Validity of new MMSS factors was tested by investigating relationships of the new factors with theoretically related concepts and by testing ability of the new factors to predict nurses intentions to remain employed in their hospitals. Reliability coefficients of the new factors are reported. Results: The original eight factors could not be replicated satisfactorily using confirmatory factor analysis. Exploratory factor analysis found a seven-factor model rather than the original eight factors previously reported. Validity of this new model was supported. However, similar to the original instrument, weak internal consistency reliability coefficients were found for three of the new MMSS factors. Discussion: From a research perspective, using an instrument with 23 items that measure 7 aspects of nurse job satisfaction is more desirable than an instrument with 31 items. However, MMSS items must be redeveloped to improve internal consistency of factors.

Supporting Evidence-Based Practice for Nurses through Information Technologies

PURPOSEnTo evaluate the usability of mobile information terminals, such as personal digital assistants (PDAs) or Tablet personal computers, to improve access to information resources for nurses and to explore the relationship between PDA or Tablet-supported information resources and outcomes.nnnBACKGROUNDnThe authors evaluated an initiative of the Nursing Secretariat, Ontario Ministry of Health and Long-Term Care, which provided nurses with PDAs and Tablet PCs, to enable Internet access to information resources. Nurses had access to drug and medical reference information, best practice guidelines (BPGs), and to abstracts of recent research studies.nnnMETHODnThe authors took place over a 12-month period. Diffusion of Innovation theory and the Promoting Action on Research Implementation in Health Services (PARIHS) model guided the selection of variables for study. A longitudinal design involving questionnaires was used to evaluate the impact of the mobile technologies on barriers to research utilization, perceived quality of care, and on nurses job satisfaction. The setting was 29 acute care, long-term care, home care, and correctional organizations in Ontario, Canada. The sample consisted of 488 frontline-nurses.nnnRESULTSnNurses most frequently consulted drug and medical reference information, Google, and Nursing PLUS. Overall, nurses were most satisfied with the Registered Nurses Association of Ontario (RNAO) BPGs and rated the RNAO BPGs as the easiest resource to use. Among the PDA and Tablet users, there was a significant improvement in research awareness/values, and in communication of research. There was also, for the PDA users only, a significant improvement over time in perceived quality of care and job satisfaction, but primarily in long-term care settings.nnnIMPLICATIONSnIt is feasible to provide nurses with access to evidence-based practice resources via mobile information technologies to reduce the barriers to research utilization.

Antecedents and consequences of intra-group conflict among nurses

AIMnTo test a theoretical model linking selected antecedent variables to intra-group conflict among nurses, and subsequently conflict management style, job stress and job satisfaction.nnnBACKGROUNDnA contributing factor to the nursing shortage is job dissatisfaction as a result of conflict among nurses. To develop strategies to reduce conflict, research is needed to understand the causes and outcomes of conflict in nursing work environments.nnnMETHODnA predictive, non-experimental design was used in a random sample of 277 acute care nurses. Structural equation modelling was used to analyse the hypothesised model.nnnRESULTSnNurses core self-evaluations, complexity of care and relationships with managers and nursing colleagues influenced their perceived level of conflict. Conflict management style partially mediated the relationship between conflict and job satisfaction. Job stress had a direct effect on job satisfaction and core self-evaluation had a direct effect on job stress.nnnCONCLUSIONnConflict and its associated outcomes is a complex process, affected by dispositional, contextual and interpersonal factors. How nurses manage conflict may not prevent the negative effects of conflict, however, learning to manage conflict using collaboration and accommodation may help nurses experience greater job satisfaction.nnnIMPLICATIONS FOR NURSING MANAGEMENTnStrategies to manage and reduce conflict include building interactional justice practices and positive interpersonal relationships.

Nurses' Uncertainty in Decision‐Making: A Literature Review

AIMnThis paper is a report of the results of a review of the literature conducted with the goal of determining how nurses clinical uncertainty has been conceptualized in the nursing literature.nnnBACKGROUNDnAlthough existing research has advanced the body of knowledge regarding the concept of uncertainty in decision-making, this has been largely from physicians viewpoints and from patients perspectives (patients uncertainty). Understanding how nurses experience and act on uncertainty remains relatively unreported.nnnMETHODnA search of Medline, CINAHL, and PubMed databases was conducted to retrieve literature published from 1990 to 2007. The question guiding the literature review was: How has nurses clinical uncertainty been conceptualized in nursing literature?nnnFINDINGSnLittle exploration has been done of nurses experience of uncertainty in practice. Many investigators have not theorized about the uncertainty in their studies, but have described nurses uncertainty in the context of clinical decision-making. The findings from these studies indicated that unfamiliarity with the aspects of patient care is a source of uncertainty, and nurses tended to rely on heuristics or on the expertise of colleagues as sources of information for practice decisions. Expressing uncertainties as information needs might help guide information seeking and reduce uncertainty. However, studies indicated that nurses have difficulty recognizing or expressing uncertainties, and as a result, information needs are not recognized and information seeking is not initiated.nnnCONCLUSIONSnA more comprehensive understanding of nurses uncertainty could lead to the development and implementation of strategies to support nurses in their clinical decision-making and practice. Descriptions are needed about how nurses experience and respond to uncertainty in their practice, and the influence of uncertainty on their information needs and information seeking.

Recognizing and Responding to Uncertainty: A Grounded Theory of Nurses’ Uncertainty

BACKGROUNDnThere has been little research to date exploring nurses uncertainty in their practice. Understanding nurses uncertainty is important because it has potential implications for how care is delivered.nnnPURPOSEnThe purpose of this study is to develop a substantive theory to explain how staff nurses experience and respond to uncertainty in their practice.nnnMETHODSnBetween 2006 and 2008, a grounded theory study was conducted that included in-depth semi-structured interviews. Fourteen staff nurses working in adult medical-surgical intensive care units at two teaching hospitals in Ontario, Canada, participated in the study.nnnFINDINGSnThe theory recognizing and responding to uncertainty characterizes the processes through which nurses uncertainty manifested and how it was managed. Recognizing uncertainty involved the processes of assessing, reflecting, questioning, and/or being unable to predict aspects of the patient situation. Nurses responses to uncertainty highlighted the cognitive-affective strategies used to manage uncertainty.nnnDISCUSSIONnStudy findings highlight the importance of acknowledging uncertainty and having collegial support to manage uncertainty. The theory adds to our understanding the processes involved in recognizing uncertainty, strategies and outcomes of managing uncertainty, and influencing factors.nnnIMPLICATIONSnTailored nursing education programs should be developed to assist nurses in developing skills in articulating and managing their uncertainty. Further research is needed to extend, test and refine the theory of recognizing and responding to uncertainty to develop strategies for managing uncertainty.nnnCONCLUSIONSnThis theory advances the nursing perspective of uncertainty in clinical practice. The theory is relevant to nurses who are faced with uncertainty and complex clinical decisions, to managers who support nurses in their clinical decision-making, and to researchers who investigate ways to improve decision-making and care delivery.

Supportive Decision Making at the Point of Care: Refinement of a Case-based Reasoning Application for Use in Nursing Practice

Variations in nursing care have been observed, affecting patient outcomes and quality of care. Case-based reasoners that benchmark for patient indicators can reduce variation through decision support. This study evaluated and validated a case-based reasoning application to establish benchmarks for nursing-sensitive patient outcomes of pain, fatigue, and toilet use, using patient characteristic variables for generating similar cases. Three graduate nursing students participated. Each ranked 25 patient cases using demographics of age, sex, diagnosis, and comorbidities against 10 patients from a database. Participant judgments of case similarity were compared with the case-based reasoning system. Feature weights for each indicator were adjusted to make the case-based reasoning systems similarity ranking correspond more closely to participant judgment. Small differences were noted between initial weights and weights generated from participants. For example, initial weight for comorbidities was 0.35, whereas weights generated by participants for pain, fatigue, and toilet use were 0.49, 0.42, and 0.48, respectively. For the same outcomes, the initial weight for sex was 0.15, but weights generated by the participants were 0.025, 0.002, and 0.000, respectively. Refinement of the case-based reasoning tool established valid benchmarks for patient outcomes in relation to participants and assisted in point-of-care decision making.