Marjorie J. Bott

The experiences of families with a relative in the intensive care unit

OBJECTIVE To describe the experiences of families with a relative in the intensive care unit (ICU). DESIGN Retrospective, descriptive, and qualitative. SETTING The surgical-trauma ICU in a midwestern university-affiliated tertiary medical center. PARTICIPANTS Eighteen women and 2 men with relatives in a surgical trauma ICU. OUTCOME MEASURES Focus group and individual unstructured interviews. RESULTS A group interpretive process was used to code, categorize, and identify themes found in the transcribed interviews. Four categories of experiences were identified: hovering, information seeking, tracking, and the garnering of resources. Hovering is an initial sense of confusion, stress, and uncertainty. Information seeking is a tactic used both to move out of the hovering state and to identify the patients progress. Tracking is the process of observing, analyzing, and evaluating patient care and status and the familys own satisfaction with the environment and with care givers. The garnering of resources is the act of acquiring what family members perceive as needed for themselves or their relative. CONCLUSIONS Families experience a sense of uncertainty that is eventually resolved by seeking information and resources. Health care professionals can minimize the stress associated with hospitalization of relatives in the ICU by anticipating and addressing the familys needs for information and resources.

Manager Leadership and Retention of Hospital Staff Nurses

This study used causal modeling to trace the effects of manager leadership characteristics on staff registered nurse (RN) retention in 4 urban hospitals. Unique to the study were the all-RN sample, using Leavitts (1958) model of behavior within an organization to group variables, manager characteristics and unit structure variables as predictors, and focus on the work unit rather than the hospital. Effects of manager characteristics were traced to retention through work characteristics, job stress, job satisfaction, commitment, and intent to stay. Theoretical variables explained 22% of the retention variance. Managerconsideration of staffand RN intent to remain directly affected retention; other variable effects passed through intent to stay. Different predictors were important to retention, unit separation, and turnover.

Patient outcomes. Are they linked to registered nurse absenteeism, separation, or work load?

Using a correlation design, the authors explored the possible associations between patient outcomes and staff registered nurse absenteeism, separation from the work unit, and work load. Data analysis included a search for consistent patterns of relationships across acute care hospitals and over time. Nosocomial urinary tract and bloodstream infections correlated positively with absenteeism. The authors discuss clinical and methodological issues related to the findings.

The NDNQI-Adapted Index of work satisfaction.

The valid measurement of nurses’ job satisfaction is critical because job satisfaction is important for the retention of qualified nurses to provide patient care in hospitals. Two studies were conducted to adapt the Stamps Index of Work Satisfaction (1997b) to measure work satisfaction at the patient care unit level for use by the National Database of Nursing Quality Indicators (NDNQI). In Study 1 (n = 918 RNs) exploratory factor analysis of data obtained using the NDNQI-Adapted Index replicated the conceptual dimensions of the Stamps measure. Associations with scores on Job Enjoyment were evidence that the Index measured the intended construct. Using theta, the reliability of the composite subscales was .91. The adapted Work Satisfaction subscale scores explained 46% of the variance in Job Enjoyment, with each subscale contributing uniquely (p < .001). In Study 2 (n = 2277 RNs) confirmatory factor analysis using structural equation modeling supported the 7-subscale structure for the Adapted Index (CFI [719] = .88; RMR = .05). Replication of associations between scores on the Index subscales and Job Enjoyment provided further evidence regarding validity of the data, since the Work Satisfaction subscales explained 56% of the variance in Job Enjoyment. The feasibility of using an on-line version of the Adapted-Index for data collection was demonstrated. The findings from the two studies indicate that the adapted Index of Work Satisfaction has a structure similar to the original instrument and is a reliable and valid measure of work satisfaction at the patient care unit level.

Playful and rebellious states vs. negative affect in explaining the occurrence of temptations and lapses during smoking cessation

Reversal theory constructs of playful and rebellious states are compared with negative affect as predictors of temptations and lapses and as predictors of three important correlates of resisting temptations to smoke: Cigarette availability, urge level, and coping during temptations. A total of 61 participants entered data in palmtop computers and tape recorders for the first 14 days of a cessation attempt. Multilevel, random-effects logistic regression analyses showed that fluctuations in playfulness, rebelliousness, negative affect, and cigarette availability all significantly discriminated temptations from nontemptations. Fluctuations in playfulness and rebelliousness, but not negative affect, significantly predicted being in situations where cigarettes were easily available. Fluctuations in playfulness, rebelliousness, and cigarette availability, but not urge levels or negative affect, significantly predicted coping during temptations, whereas coping, rebelliousness, cigarette availability, and urge levels predicted lapsing. Treatment and policy implications of these findings are discussed.

Modeling Efficiency at the Process Level: An Examination of the Care Planning Process in Nursing Homes

OBJECTIVE To examine the efficiency of the care planning process in nursing homes. METHODS We collected detailed primary data about the care planning process for a stratified random sample of 107 nursing homes from Kansas and Missouri. We used these data to calculate the average direct cost per care plan and used data on selected deficiencies from the Online Survey Certification and Reporting System to measure the quality of care planning. We then analyzed the efficiency of the assessment process using corrected ordinary least squares (COLS) and data envelopment analysis (DEA). RESULTS Both approaches suggested that there was considerable inefficiency in the care planning process. The average COLS score was 0.43; the average DEA score was 0.48. The correlation between the two sets of scores was quite high, and there was no indication that lower costs resulted in lower quality. For-profit facilities were significantly more efficient than not-for-profit facilities. CONCLUSIONS Multiple studies of nursing homes have found evidence of inefficiency, but virtually all have had measurement problems that raise questions about the results. This analysis, which focuses on a process with much simpler measurement issues, finds evidence of inefficiency that is largely consistent with earlier studies. Making nursing homes more efficient merits closer attention as a strategy for improving care. Increasing efficiency by adopting well-designed, reliable processes can simultaneously reduce costs and improve quality.

Shared governance. From vision to reality.

Quality patient care is best provided by competent clinical staff members who are committed to their work, organizational values, and goals, and who maintain employment over time. Shared governance has provided the framework for clinical nurses to become more committed to their practice through decision making and to assume accountability for the outcomes of their decisions. At a tertiary teaching facility, shared governance resulted in increased job satisfaction, commitment, and retention among staff nurses. The authors describe the journey from creation of the shared governance vision to reality, and the impact of the changes.

Unmet symptom management needs of nursing home residents with cancer.

Nursing home residents living with cancer have unacceptably high percentages of unrelieved pain and other symptoms. However, residents with cancer have received relatively little attention in the literature to date. This article provides an overview of previous symptom research for residents with cancer, explores clinical and organizational factors that impede effective symptom management, and proposes an agenda for future research and clinical practice. Residents with cancer have numerous symptoms that tend to be different from the symptoms of other nursing home residents. Symptom management for residents with cancer is often complicated by cognitive impairment, declining physical functioning, and comorbid illnesses. Barriers to symptom management include underuse of analgesics and hospice, nursing home staffing patterns, and lack of resources. Additional research is necessary to provide a more comprehensive understanding of residents with cancer, explore how organizational factors affect the care of residents with cancer, and evaluate interventions for effective symptom assessment and management. Collaboration of oncology nurses with clinicians and researchers in nursing home settings is needed to improve care for residents with cancer.

A measure of palliative care in nursing homes.

CONTEXT Efforts to improve care for nursing home residents stand to be enhanced by measures to assess the degree to which staff provide palliative care. As the incidence of death in nursing homes increases with the aging population, the gap in measurement must be addressed. To that end, we report the development and psychometric testing of a nursing home palliative care survey. OBJECTIVES The purpose of this study was to evaluate the psychometric properties of the Palliative Care Survey (PCS) for use in nursing homes. METHODS Psychometric evaluation of the instrument was completed in two phases. Phase 1 focused on individual item analyses and subsequent revision or deletion of items, and Phase 2 evaluated evidence for reliability and validity. Phase 1 included 26 nursing homes and staff (n=717), and Phase 2 included 85 nursing homes and staff (n=2779). Data were analyzed using item-total correlations, Cronbachs alpha, confirmatory factor analysis, and analysis of variance. RESULTS Support was obtained for a 51-item PCS made up of two constructs, Palliative Care Practice and Palliative Care Knowledge. CONCLUSION The PCS measures the extent to which the nursing home staff engage in palliative care practices and have knowledge consistent with good end-of-life care. Both practice and knowledge are an essential foundation to providing good end-of-life care to nursing home residents. Efforts to improve care for the dying in nursing homes have been slowed by an absence of measurement tools that capture care processes, a gap that the PCS reported here helps fill.

Symptom occurrence and associated clinical factors in nursing home residents with cancer.

Little is known about the factors that contribute to symptoms in nursing home residents with cancer. We compared rates of symptoms in residents with (n = 1,022) and without cancer (n = 9,910) and examined physiologic, psychologic and situational factors potentially related to symptoms in residents with cancer. Pain, shortness of breath, vomiting, weight loss, and diarrhea were significantly (p < .05) more prevalent in residents with cancer. Cancer treatments, comorbid illnesses, and situational factors were not consistently correlated with symptoms. Improved symptom control was especially needed for the 30% of residents with cancer who clinically deteriorated within 3 months of admission; physical dependence and deteriorating clinical status were associated with pain, shortness of breath, and weight loss.