James M. Vardaman

Implementing childhood obesity policy in a new educational environment: the cases of Mississippi and Tennessee.

OBJECTIVES Our purpose was to investigate the processes involved in, and outcomes of, implementing 3 new state-level, school-oriented childhood obesity policies enacted between 2004 and 2007. METHODS We followed policy implementation in 8 high schools in Mississippi and Tennessee. We collected data between 2006 and 2009 from interviews with policymakers, administrators, teachers, and students; observations of school-based activities; and documents. RESULTS Significant barriers to the effective implementation of obesity-related policies emerged. These most notably include a value system that prioritizes performances in standardized tests over physical education (PE) and a varsity sport system that negatively influences opportunities for PE. These and other factors, such as resource constraints and the overloading of school administrators with new policies, mitigate against the implementation of policies designed to promote improvements in student health through PE. CONCLUSIONS Policies designed to address health and social problems in high-school settings face significant barriers to effective implementation. To have a broad impact, obesity-related policies must be tied to mainstream educational initiatives that both incentivize, and hold accountable, the school-level actors responsible for their implementation.

Beyond communication: The role of standardized protocols in a changing health care environment

Background: Communication errors have grave consequences in health care settings. The situation–background–assessment–recommendation (SBAR) protocol has been theorized to improve communication by creating a common language between nurses and physicians in acute care situations. This practice is gaining acceptance across the health care field. However, as yet, there has been little investigation of the ways in which SBAR may have an impact on how health care professionals operate beyond the creation of a common language. Purpose: The purposes of the study were to explore the implementation of the SBAR protocol and investigate the potential impact of SBAR on the day-to-day experiences of nurses. Methods: We performed a qualitative case study of 2 hospitals that were implementing the SBAR protocol. We collected data from 80 semistructured interviews with nurses, nurse manager, and physicians; observation of nursing and other hospital activities; and documents that pertained to the implementation of the SBAR protocol. Data were analyzed using a thematic approach. Findings: Our analysis revealed 4 dimensions of impact that SBAR has beyond its use as a communication tool: schema formation, development of legitimacy, development of social capital, and reinforcement of dominant logics. Practice Implications: The results indicate that SBAR may function as more than a tool to standardize communication among nurses and physicians. Rather, the findings indicate that SBAR may aid in schema development that allows rapid decision making by nurses, provide social capital and legitimacy for less-tenured nurses, and reinforce a move toward standardization in the nursing profession. Our findings further suggest that standardized protocols such as SBAR may be a cost-effective method for hospital managers and administrators to accelerate the socialization of nurses, particularly new hires.

Toward a Comprehensive Understanding of Readiness for Change: The Case for an Expanded Conceptualization

One important factor influencing the successful implementation of system-wide change is initial readiness. Readiness is defined as the degree to which those involved are individually and collectively primed, motivated and technically capable of executing the change. We present a conceptual framework that highlights how the extant understanding of readiness has addressed three broad areas that include individual factors (i.e. characteristics of those being asked to change), structural factors (i.e. circumstances under which the change is occurring) and the level of analysis (i.e. individual and organizational levels). Following on from this, we provide an outline of how the articles making up this Special Issue are contributing to this understanding offering theoretical support which will provide for meaningful and substantial extensions as readiness research advances.

Should I stay or should I go? The role of risk in employee turnover decisions

The decision to leave a job has long been infused with risk for the worker deciding whether or not to leave the organization. However, the role of risk in employee turnover decisions has been largely unexplored in the turnover literature. This article integrates concepts from the turnover and risk literatures to better understand the decision processes of workers contemplating the decision to leave a job. The article offers two studies that investigate the impact of risk perceptions and turnover risk propensity on that decision. Study 1, a field study based on a sample of 155 US service workers in the gaming industry, shows that risk perceptions and propensity for risk moderate the relationship between turnover intentions and turnover behavior. Study 2, a laboratory experiment based on a sample of 222 working students, explores the role of framing and social influences on perceptions of risk and individual tendencies for risk-taking in a turnover context. Findings from Study 2 suggest that positive framing impacts on an individuals propensity for risk-taking when considering leaving a job, but does not impact on individual perceptions of risk, thus supporting the predictions of prospect theory in a turnover context. Taken in concert, these studies provide insight into how risk influences the decision processes of workers considering whether to sever an employment relationship. The implications and limitations of the research are discussed, and the relevance for future research is highlighted.

Socioemotional Wealth Conflict in Family Firms

While Cruz, Larraza–Kintana, Garcés–Galdeano, and Berrone demonstrate how SEW can simultaneously elicit good and bad behavior in regard to corporate social responsibility, their findings also give rise to the idea that maintaining control and influence over day–to–day operations (internal socioemotional wealth [SEW]) and maintaining positive assessments of the firms reputation (external SEW) may at times be in conflict. This commentary builds upon this notion by highlighting the need to explicitly examine SEW conflict, as well as offering initial theorizing on how family firms will pursue SEW preservation in these situations. Drawing on image theory, we theorize a process where preserving internal SEW is generally used as the guiding script in family firms because it is more salient on an everyday basis. However, we propose that if its preservation threatens the organizations identity and reputation, the script will be disrupted, precipitating a shift to preserving external SEW. The article concludes by discussing the broader theoretical implications of SEW conflict for family firms.

Interpreting change as controllable: The role of network centrality and self-efficacy

Interpreting organizational change initiatives as controllable can mean the difference between achieving positive or negative outcomes. However, little is known about the factors that underpin such interpretations. This study examines how interpretations of controllability are influenced by individual centrality in social networks and change-related self-efficacy. Drawing on a sample of 148 US public school teachers facing a significant organizational transformation, our analysis reveals that change-related self-efficacy fully mediates relationships between centrality within instrumental and expressive organizational social networks and individual interpretations of change controllability. Network centrality, and the associated access to information and social support that accompany it, are theorized to provide the confidence necessary to interpret change as within one’s control. Drawing upon social network theory, we provide insights into how change is interpreted as controllable, and how the nature of change may dictate which types of centrality are most important for such interpretations. Implications for the broader understanding of change are also discussed.

Improving shift report focus and consistency with the situation, background, assessment, recommendation protocol.

OBJECTIVE: The Situation, Background, Assessment, Recommendation (SBAR) protocol was used to improve shift reports in 4 medical-surgical units. BACKGROUND: The SBAR protocol is increasingly advocated for use during shift reports, but data on the efficacy are limited. METHODS: Nurses were trained on SBAR in 4 medical-surgical units in a tertiary care hospital. Nurse tasks, tools, and locations were recorded during observation audits. RESULTS: The average time for shift reports did not decrease using SBAR. Nurses spent significantly more time on tasks specific to report. There was significantly more dialogue and less writing with SBAR. CONCLUSION: The introduction of SBAR made reports more focused, with more time spent discussing the patient and less on transcribing information. The SBAR protocol provides a concise and prioritized structure that enables consistent, comprehensive, and patient-centric reports.

Improving situation awareness and patient outcomes through interdisciplinary rounding and structured communication.

OBJECTIVE: To measure the impact of interdisciplinary rounds (IDRs) and the situation-background-assessment-recommendation (SBAR) communication protocol on staff situation awareness and patient outcomes. BACKGROUND: Communication frequency and consistency improve speed and clarity, especially between disciplines. Daily IDR using SBAR potentially facilitates the process. METHODS: Four patient review conditions were observed across 3 medical-surgical units of an acute care hospital: baseline, mobile (IDR only), paper-SBAR, and electronic-SBAR (IDR and SBAR). Observations occurred over a 9-month span. Review time (seconds), tools used, location, and field notes were recorded for 960 patient reviews. RESULTS: Patient review times were significantly shorter with IDR, decreasing from 102 to 69 seconds, but SBAR did not reduce times further. One patient satisfaction index did not change, whereas the other improved slightly. Length of stay did not change. CONCLUSION: The structure, consistency, and familiarity afforded by SBAR and IDR resulted in improved situation awareness and provided process, staff, and patient benefits.

Interdisciplinary Rounds and Structured Communication Reduce Re-Admissions and Improve Some Patient Outcomes.

Hospital communication is more than access to information. Among staff, it is about achieving situation awareness—an understanding of a patient’s current condition and likely trajectory. In the multidisciplinary context of providing care, structure, consistency, and repeatability of communication will enable a shared understanding of the patient and plan, leading to improved patient satisfaction and outcomes. This was tested using the Situation-Background-Assessment-Recommendation (SBAR) protocol, a re-admissions risk assessment and daily interdisciplinary rounds (IDR) in the medical/surgical units of a hospital. The impact of these interventions on patient satisfaction, Foley catheter removal compliance, and patient re-admission rates was assessed. Over the 3 year period, Foley compliance improved from 78% to 94%, and re-admissions decreased from 14.5% to 2.1%, both significant. Patient satisfaction trended positively, but was not significant. These results support the value of SBAR and IDR, and are advocated to improve situation awareness and maintain focus on key patient data.

Complexity and change in nurse workflows.

As systems evolve over time, their natural tendency is to become increasingly more complex. Studies in the field of complex systems have generated new perspectives on management in social organizations such as hospitals. Much of this research appears as a natural extension of the cross-disciplinary field of systems theory. This is the 20th in a series of articles applying complex systems science to the traditional management concepts of planning, organizing, directing, coordinating, and controlling. In this article, the authors discuss how nurse workflow is characteristic of complex adaptive systems and the need for caution when selecting a performance improvement method.