Retaining nurses in a changing health care environment: The role of job embeddedness and self-efficacy.

BACKGROUND: Because nurses are on the front lines of care delivery, they are subject to frequent changes to their work practices. This change-laden environment puts nurses at higher risk for turnover. Given the frequent disruption to the way nurses perform their jobs, change-related self-efficacy (CSE), or confidence that one can handle change, may be vital to their retention. PURPOSE: The purpose of this article is to examine the roles of CSE and job embeddedness in reducing turnover intentions among nurses. Specifically, this article tests a model in which CSE is the intervening mechanism through which job embeddedness influences turnover intentions. METHODS: Drawing on a sample of 207 nurses working in the medical/surgical unit of a major metropolitan hospital in the United States, this study employs OLS regression to test for direct effects of job embeddedness and CSE on turnover intentions and bias-corrected bootstrapping to test for the indirect effects of job embeddedness on turnover intentions through CSE. FINDINGS: Results show that CSE is directly linked to turnover intentions, and the effects of job embeddedness on turnover intentions become fully manifest through CSE. PRACTICE IMPLICATIONS: Improved nurse retention may lead to stable patient care and less disruption in service delivery. Improved retention also benefits health care organizations financially, as costs of replacing a nurse can exceed 100% of the salary for the position. Given the shortage of nurses in some geographic areas, retention remains an important goal.

Fostering acceptance of computerized physician order entry: insights from an implementation study.

Computerized physician order entry (CPOE) allows physicians to enter orders in a computer rather than handwriting them. Computerized physician order entry is touted as a major improvement in patient safety, and although the literature suggests that such systems have the potential to improve patient outcomes, studies also suggest that CPOE may have significant drawbacks that accompany those benefits. Physicians have often been resistant to accept its implementation. This study investigates the implementation of CPOE at a 217-bed rural hospital in the southeastern United States. Drawing on a mixed-method approach, we identify correlates of change acceptance and propose a set of recommendations for health care managers to foster acceptance of CPOE. Findings from physician surveys (n = 19) indicate that older physicians are less accepting of CPOE, but high-quality change communication may overcome resistance even among older physicians. With insights derived from the organizational change literature, findings bring to the fore a set of practices that managers can use to foster acceptance of CPOE. The thrust of these practices is that managers should make physicians active participants in fine-tuning CPOE within the unique needs and constraints of the local hospital setting.

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.

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.

Part of the job: the role of physical work conditions in the nurse turnover process.

BACKGROUND: Retention of nursing staff remains an important issue for health care managers. Turnover research has focused primarily on motivational and social factors as keys to retention, whereas the role of the physical work conditions has received considerably less attention. However, work design theory suggests that physical work conditions may be an important factor in fostering retention among nursing staff. PURPOSE: The aim of this study was to integrate work design theory with turnover process models to explore the influence of perceptions of physical work conditions on the development of turnover intentions among nursing staff. METHODS: Drawing on two samples of registered nurses working in cancer units in metropolitan hospitals in the southeastern United States, this study explores the impact of perceptions of physical work conditions on turnover intentions using ordinary least squares regression. Hypotheses are tested in Study 1 and replicated in Study 2. A measure of perceptions of physical work conditions is also developed and validated using exploratory (Study 1) and confirmatory (Study 2) factor analyses. FINDINGS: Perceptions of physical work conditions explain variance in turnover intentions above than that explained by motivational and social factors. Specifically, employee perceptions of noisy work conditions are found to significantly increase turnover intentions, whereas perceptions that work conditions facilitate tasks were found to significantly reduce turnover intentions. Perceptions of temperature and health hazard did not show significant effects. PRACTICE IMPLICATIONS: Results suggest that health care managers and scholars should re-examine the role of physical work conditions in the turnover process. Investments in upgrades that facilitate tasks may foster retention better than investments that simply improve employee comfort. Negative perceptions of work conditions may have no impact if they are considered a normal "part of the job," although negative perceptions of conditions that are viewed as under the organization's control may be important in creating a desire to leave.

Impact of SBAR on Nurse Shift Reports and Staff Rounding.

The Situation-Background-Assessment-Recommendation (SBAR) protocol was used to improve shift reports and interdisciplinary rounding. On a medical-surgical unit, observations were conducted before and after implementation. Both processes were significantly shorter and more consistent. SBAR enabled more focused and efficient communication.

Ward warriors: the complex nature of nurse mobility.

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 the application of management strategies in health systems. Much of this research appears as a natural extension of the cross-disciplinary field of systems theory. In this article, the authors discuss the impact of complex system behavior on nurse workflow and its broader implications.

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.

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.

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.