Leslie A. Hayduk

Influence of organizational characteristics and context on research utilization.

Background: Despite three decades of empirical investigation into research utilization and a renewed emphasis on evidence-based medicine and evidence-based practice in the past decade, understanding of factors influencing research uptake in nursing remains limited. There is, however, increased awareness that organizational influences are important. Objectives: To develop and test a theoretical model of organizational influences that predict research utilization by nurses and to assess the influence of varying degrees of context, based on the Promoting Action on Research Implementation in Health Services (PARIHS) framework, on research utilization and other variables. Methods: The study sample was drawn from a census of registered nurses working in acute care hospitals in Alberta, Canada, accessed through their professional licensing body (n = 6,526 nurses; 52.8% response rate). Three variables that measured PARIHS dimensions of context (culture, leadership, and evaluation) were used to sort cases into one of four mutually exclusive data sets that reflected less positive to more positive context. Then, a theoretical model of hospital- and unit-level influences on research utilization was developed and tested, using structural equation modeling, and 300 cases were randomly selected from each of the four data sets. Results: Model test results were as follows-low context: &khgr;2 = 124.5, df = 80, p <. 001; partially low: &khgr;2 = 144.2, p <. 001, df = 80; partially high: &khgr;2 = 157.3, df = 80, p <. 001; and partially low: &khgr;2 = 146.0, df = 80, p <. 001. Hospital characteristics that positively influenced research utilization by nurses were staff development, opportunity for nurse-to-nurse collaboration, and staffing and support services. Increased emotional exhaustion led to less reported research utilization and higher rates of patient and nurse adverse events. Nurses working in contexts with more positive culture, leadership, and evaluation also reported significantly more research utilization, staff development, and lower rates of patient and staff adverse events than did nurses working in less positive contexts (i.e., those that lacked positive culture, leadership, or evaluation). Conclusion: The findings highlight the combined importance of culture, leadership, and evaluation to increase research utilization and improve patient safety. The findings may serve to strengthen the PARIHS framework and to suggest that, although it is not fully developed, the framework is an appropriate guide to implement research into practice.

Mitigating the impact of hospital restructuring on nurses: the responsibility of emotionally intelligent leadership.

BackgroundA decade of North American hospital restructuring in the 1990s resulted in the layoff of thousands of nurses, leading to documented negative consequences for both nurses and patients. Nurses who remained employed experienced significant negative physical and emotional health, decreased job satisfaction, and decreased opportunity to provide quality care. ObjectiveTo develop a theoretical model of the impact of hospital restructuring on nurses and determine the extent to which emotionally intelligent nursing leadership mitigated any of these impacts. MethodsThe sample was drawn from all registered nurses in acute care hospitals in Alberta, Canada, accessed through their professional licensing body (N = 6,526 nurses; 53% response rate). Thirteen leadership competencies (founded on emotional intelligence) were used to create 7 data sets reflecting different leadership styles: 4 resonant, 2 dissonant, and 1 mixed. The theoretical model was then estimated 7 times using structural equation modeling and the seven data sets. ResultsNurses working for resonant leaders reported significantly less emotional exhaustion and psychosomatic symptoms, better emotional health, greater workgroup collaboration and teamwork with physicians, more satisfaction with supervision and their jobs, and fewer unmet patient care needs than did nurses working for dissonant leaders. DiscussionResonant leadership styles mitigated the impact of hospital restructuring on nurses, while dissonant leadership intensified this impact. These findings have implications for future hospital restructuring, accountabilities of hospital leaders, the achievement of positive patient outcomes, the development of practice environments, the emotional health and well-being of nurses, and ultimately patient care outcomes.

Should researchers use single indicators, best indicators, or multiple indicators in structural equation models?

BackgroundStructural equation modeling developed as a statistical melding of path analysis and factor analysis that obscured a fundamental tension between a factor preference for multiple indicators and path modeling’s openness to fewer indicators.DiscussionMultiple indicators hamper theory by unnecessarily restricting the number of modeled latents. Using the few best indicators – possibly even the single best indicator of each latent – encourages development of theoretically sophisticated models. Additional latent variables permit stronger statistical control of potential confounders, and encourage detailed investigation of mediating causal mechanisms.SummaryWe recommend the use of the few best indicators. One or two indicators are often sufficient, but three indicators may occasionally be helpful. More than three indicators are rarely warranted because additional redundant indicators provide less research benefit than single indicators of additional latent variables. Scales created from multiple indicators can introduce additional problems, and are prone to being less desirable than either single or multiple indicators.

Is the nursing work index measuring up? : Moving beyond estimating reliability to testing validity

Background: The Nursing Work Index (NWI) provided the foundation for three published instruments, each presented as a valid measure of the nursing practice environment. Aiken and Patrician [Aiken, L. H., & Patrician, P. A. (2000). Measuring organizational traits of hospitals: The Revised Nursing Work Index. Nursing Research, 49, 146-153] revised the NWI to the Revised Nursing Work Index (NWI-R), reporting four conceptually derived subscales. Lake [Lake, E. T.(2002). Development of the Practice Environment Scale of the Nursing Work Index. Research in Nursing and Health, 25,176-188] used factor analysis to empirically derive five subscales with a composite overarching practice environment factor. Estabrooks et al. [Estabrooks, C. A., Tourangeau, A. E., Humphrey,C. K., Hesketh, K. L., Giovannetti, P., Thomson, D., et al. (2002). Measuring the hospital practice environment: A Canadian context. Research in Nursing and Health, 25, 256-268] reported a single empirically derived factor solution that represented the nursing practice environment. Objective: To examine the validity of three instruments (based on the NWI) as measures of the nursing practice environment. Methods: The measurement models underlying the three instruments were reconstructed from the information provided by each author in published manuscripts and then were estimated using structural equation modeling (SEM), the chi-square test of model fit, and data from the 1998 Canadian Nurse Survey. Results: Each of the three underlying measurement models was factor analytic in design (multiple indicators of each concept) and failed significantly when compared with the data (Aiken & Patrician; &khgr;2 = 939.12, p <.001, df = 50; Lake, &khgr;2 = 17,872.73, p <.001, df = 319; Estabrooks et al., &khgr;2 = 38,590.29, p <.001). This lack of model fit with the data raises questions about the validity of these instruments as measures of the nursing practice environment. Discussion: The nursing practice environment is complex and has been examined inadequately by factor-analytic approaches, largely because insufficient attention has been paid to implicit underlying theory. The development and testing of robust theory using powerful research methods available to examine causal relationships in complex theoretical models will advance understanding of constructs such as the nursing practice environment.

Measuring Quality of Life

This paper considers quality of life (QOL) to be a global, yet unidimensional, subjective assessment of ones satisfaction with life. This conceptualization is consistent with viewing QOL assessments as resulting from the interaction of multiple causal dimensions, but it is inconsistent with proposals to limit QOL to health-related quality of life (HRQOL). We test the unidimensional yet global conceptualization of QOL using data from coronary artery bypass graft (CABG) patients. The Self-Anchoring Striving Scale (SASS) and four other indicators derived from the literature, all seemed to function as indicators of a single concept (QOL) that was repeatedly drawn upon as the patients determined their responses to these indicators. However, only about half the variance in each indicator was attributable to that common QOL source. Several structural equation models are used to assess whether the superior performance of the Life 3 indicator is an artifact of the repetition of an item within this indicator. The data convincingly indicate that the superior performance is not a memory artifact, and that even the repetition of an identically worded item prodded the patients into drawing yet again upon the same QOL factor that grounded all the other measures.

Advancing the argument for validity of the Alberta Context Tool with healthcare aides in residential long-term care

BackgroundOrganizational context has the potential to influence the use of new knowledge. However, despite advances in understanding the theoretical base of organizational context, its measurement has not been adequately addressed, limiting our ability to quantify and assess context in healthcare settings and thus, advance development of contextual interventions to improve patient care. We developed the Alberta Context Tool (the ACT) to address this concern. It consists of 58 items representing 10 modifiable contextual concepts. We reported the initial validation of the ACT in 2009. This paper presents the second stage of the psychometric validation of the ACT.MethodsWe used the Standards for Educational and Psychological Testing to frame our validity assessment. Data from 645 English speaking healthcare aides from 25 urban residential long-term care facilities (nursing homes) in the three Canadian Prairie Provinces were used for this stage of validation. In this stage we focused on: (1) advanced aspects of internal structure (e.g., confirmatory factor analysis) and (2) relations with other variables validity evidence. To assess reliability and validity of scores obtained using the ACT we conducted: Cronbachs alpha, confirmatory factor analysis, analysis of variance, and tests of association. We also assessed the performance of the ACT when individual responses were aggregated to the care unit level, because the instrument was developed to obtain unit-level scores of context.ResultsItem-total correlations exceeded acceptable standards (> 0.3) for the majority of items (51 of 58). We ran three confirmatory factor models. Model 1 (all ACT items) displayed unacceptable fit overall and for five specific items (1 item on adequate space for resident care in the Organizational Slack-Space ACT concept and 4 items on use of electronic resources in the Structural and Electronic Resources ACT concept). This prompted specification of two additional models. Model 2 used the 7 scaled ACT concepts while Model 3 used the 3 count-based ACT concepts. Both models displayed substantially improved fit in comparison to Model 1. Cronbachs alpha for the 10 ACT concepts ranged from 0.37 to 0.92 with 2 concepts performing below the commonly accepted standard of 0.70. Bivariate associations between the ACT concepts and instrumental research utilization levels (which the ACT should predict) were statistically significant at the 5% level for 8 of the 10 ACT concepts. The majority (8/10) of the ACT concepts also showed a statistically significant trend of increasing mean scores when arrayed across the lowest to the highest levels of instrumental research use.ConclusionsThe validation process in this study demonstrated additional empirical support for construct validity of the ACT, when completed by healthcare aides in nursing homes. The overall pattern of the data was consistent with the structure hypothesized in the development of the ACT and supports the ACT as an appropriate measure for assessing organizational context in nursing homes. Caution should be applied in using the one space and four electronic resource items that displayed misfit in this study with healthcare aides until further assessments are made.

An exploration of Pender's health promotion model using LISREL

A causal model based on Penders (1987) Health Promotion Model was tested to evaluate Penders hypothesis that demographic and biological characteristics affect health-promoting behaviors indirectly through three mediating cognitive-perceptual variables. A sample of 3,025 noninstitutionalized adults completed a telephone survey from which indicators of the conceptual variables were selected. Initial tests of the causal model using the LISREL 7 program indicated that the basic model did not fit the data. Therefore, the model was modified so that the exogenous variables—sex, age, income, marital status, education, and body mass index—had direct effects on select health-promoting behaviors. Further, the variables of self-actualization and interpersonal support were required to share common indicators as were health responsibility and interpersonal support. Though the modified model fit the data, little of the variance in health-promoting behaviors was explained, since all significant effects were weak.

Understanding hierarchical linear models: applications in nursing research.

Nurses practice within hierarchical organizations and occupational structures. Hence, data emanating from nursing environments are structured, often inherently, hierarchically. From the perspective of ordinary regression, such structuring constitutes a statistical problem because this violates the assumption that we have observed independent and identical cases. A preferable approach is to employ analytical methods that mesh with the kinds of natural aggregations present in nursing environments. Consequently, there has been increasing interest in applying hierarchical, or multilevel, linear models to nursing contexts because this powerful analytical tool recognizes and accommodates naturally hierarchical data structures. The purpose of this article is to foster an understanding of both the strengths and limitations of hierarchical models. A hypothetical nursing example is progressively extended from the most basic hierarchical linear model toward a full two-level model. The structural similarities between two-level and three-level models are pointed out while focusing on the hierarchical nature of models rather than statistical technicalities. The limitations of hierarchical models are discussed also.

Does organizational context influence the use of best practices by healthcare aides in residential long term care

Knowledge translation researchers in the last decade have seen a torrent of publications arguing for the central importance of organizational context in influencing implementation success. The Translating Research in Elder Care (TREC) program investigates the role of organizational context on the use of best practices, provider and resident outcomes in residential long-term care facilities (nursing homes) in three western Canadian provinces. The purpose of this presentation is to present findings from our study examining the influence of organizational context on the use of best practices by healthcare aides.

The influence of organizational context on the use of research by nurses in Canadian pediatric hospitals.

BackgroundOrganizational context is recognized as an important influence on the successful implementation of research by healthcare professionals. However, there is relatively little empirical evidence to support this widely held view.MethodsThe objective of this study was to identify dimensions of organizational context and individual (nurse) characteristics that influence pediatric nurses’ self-reported use of research. Data on research use, individual, and contextual variables were collected from registered nurses (N = 735) working on 32 medical, surgical and critical care units in eight Canadian pediatric hospitals using an online survey. We used Generalized Estimating Equation modeling to account for the correlated structure of the data and to identify which contextual dimensions and individual characteristics predict two kinds of self-reported research use: instrumental (direct) and conceptual (indirect).ResultsSignificant predictors of instrumental research use included: at the individual level; belief suspension-implement, research use in the past, and at the hospital unit (context) level; culture, and the proportion on nurses possessing a baccalaureate degree or higher. Significant predictors of conceptual research use included: at the individual nurse level; belief suspension-implement, problem solving ability, use of research in the past, and at the hospital unit (context) level; leadership, culture, evaluation, formal interactions, informal interactions, organizational slack-space, and unit specialty.ConclusionsHospitals, by focusing attention on modifiable elements of unit context may positively influence nurses’ reported use of research. This influence of context may extend to the adoption of best practices in general and other innovative or quality interventions.