Accountability focus and nurses' performance: A moderated-mediation model by using experiment design simulations.

AIM: The aim of this study was to test a moderated-mediation model, explaining how and under which circumstances a process- or an outcome-accountability focus affects performance. DESIGN: Randomized controlled design, using screen-based simulations. METHODS: Data were collected during 2021. Two screen-based simulations of medication administration (for low- and high-complexity tasks) were used. Each participant was randomly assigned to one of the six experimental conditions. Nurses completed validated questionnaires on strain levels and their perceptions of the simulated task complexity and accountability focus. Performance was assessed via validated checklists assessing nurses' performance of the simulation. RESULTS: Task complexity significantly moderated the relationship between accountability-focus conditions and strain. For the process-accountability-focus condition, strain levels were lower during high-complexity tasks compared with low-complexity tasks, while for the outcome-accountability-focus condition, strain levels were lower during low-complexity tasks compared with high-complexity tasks. The highest strain levels were observed under the no accountability-focus condition. Additionally, this interaction had an impact on performance, with nurses' strain playing a mediating role. CONCLUSIONS: Any accountability focus reduces strain levels and enhances performance compared with having no accountability focus. The choice of accountability focus should be based on task-complexity considerations. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE: Managers can effectively reduce nurses' strain and improve performance by prioritizing outcome accountability focus for simpler tasks and process accountability focus for complex tasks. IMPACT: The study addressed previous ambiguous findings regarding the type of accountability focus that better motivates nurses' performance. By considering accountability focus, nurse managers can balance nurses' strain levels with improved performance. REPORTING METHOD: We have adhered to the relevant EQUATOR guidelines: CONSORT. PATIENT OR PUBLIC CONTRIBUTION: There is no patient or public contribution, as the study only concerns the providers of the service, that is the nurses themselves.

The dual protective role of accountability: Mitigating missed nursing care and nurse moral distress in a nested diary study design.

AIMS: To examine a novel moderated-mediation model, investigating whether personal accountability moderates the link between nurse workload and missed nursing care and whether missed nursing care mediates the association between workload and moral distress. DESIGN: Nested diary study. METHODS: Data spanning from February 2019 to February 2023 were collected from 137 nurses working in various inpatient wards in two medium-sized hospitals. Nurses reported care given to specific patients on three to five occasions across different shifts, establishing nurse-patient dyads. Validated measures of missed nursing care, personal accountability, moral distress and workload were analyzed using mixed linear models to test the nested moderated-mediation model. RESULTS: Under high workload conditions, nurses with higher personal accountability reported lower frequencies of missed nursing care compared to those with lower personal accountability. In contrast, under low workload conditions, personal accountability did not significantly influence missed nursing care occurrences. Furthermore, the interaction between workload and personal accountability indirectly affected nurses' moral distress through missed nursing care. Specifically, higher personal accountability combined with lower missed nursing care contributed to reduced levels of moral distress among nurses. CONCLUSION: The study highlights accountability's dual role-safeguarding against care omissions and influencing nurses' moral distress amid rising workload pressures. IMPLICATION FOR THE PROFESSION AND/OR PATIENT CARE: Cultivating a culture of accountability within healthcare settings can serve as a protective factor against the negative effects of workload on patient care quality and nurse psychological distress, highlighting the need for organizational interventions to promote accountability among nursing staff. IMPACT: By recognizing accountability's pivotal role, organizations can implement targeted interventions fostering accountability among nurses, including training programs focused on enhancing responsibility/ownership in care delivery and creating supportive environments prioritizing accountability to achieve positive patient outcomes. REPORTING METHOD: The study has adhered to STROBE guidelines. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Haemodialysis patient's adherence to treatment: Relationships among nurse-patient-initiated participation and nurse's attitude towards patient participation.

AIMS AND OBJECTIVES: To evaluate the relationship between nurse-patient-initiated participation, nurses' attitudes towards patient's participation, and patients' adherence to treatment. Specifically, to (1) explore nurse-patient participation during haemodialysis and quantify the information into measurable indices; (2) determine the haemodialysis patient's adherence to treatment; (3) describe nurses' attitudes towards patient participation; and (4) establish the relationships between nurse-patient-initiated participation, nurses' attitudes towards patient participation and patients' adherence to treatment. BACKGROUND: To improve haemodialysis patients' health, it is crucial to identify nurses' and patients' factors facilitating adherence to treatment. DESIGN: An exploratory-sequential mixed-methods (quantitative and qualitative) design. METHODS: All nurses working at a dialysis ward (n = 30) and their randomly selected patients (n = 102) participated. Qualitative data on nurse-patient-initiated participation were derived from transcribed nurse-patient conversations and quantified for further analyses. Nurses' attitudes towards patient participation were collected via questionnaire, and adherence to treatment via observed reduction in prescribed haemodialysis time. [CONSORT-SPI guidelines]. RESULTS: Content analysis of the conversations indicated that nurse-initiated participation focused on patient's medical condition, treatment plan and education; while patients initiated more small talk. Non-adherence to treatment was significant (Mean = 0.19 h; SD = 0.33). Regression analyses indicated that nurses' attitude towards participation was negatively linked to patient adherence, while patient-nurse-initiated participation was unrelated. Nurses' attitudes towards patient participation moderated the relationship between nurse-patient-initiated participation and patient adherence: the more positive the attitude towards inclusion the more negative the link between patient or nurse-initiated participation and patient adherence. CONCLUSIONS: The findings provided paradoxical insights: Nurses' positive attitudes towards participation lead them to accept the patient's position for shortening haemodialysis treatment, so that adherence to care decreases. RELEVANCE TO CLINICAL PRACTICE: Nurses require education on negotiating methods to help achieve patient adherence while respecting the patient's opinion. Patients should be educated how to approach nurses, seeking the information they need.

A multi-level examination of nursing students' resilience in the face of the COVID-19 outbreak: A cross-sectional design.

AIMS: To examine nursing students' stress and coping with the coronavirus disease 2019 (COVID-19) pandemic through an ecological model of resilience. Specifically, to examine the relative contribution of different resilience levels in decreasing nursing students' strain symptoms: at the individual level, resilience trait; at the relational level, students' coping strategies; at the university level, nursing students' perceptions on their university's readiness to handle the virus outbreak; and at the national level, nursing students' trust in policymakers' decisions. DESIGN: The study used a cross-sectional design. METHODS: Undergraduate students of five universities were recruited via an electronic link sent to their emails during the first months of the COVID-19 outbreak: May-July 2020. Of them, 492 participants completed the research questionnaire. RESULTS: Hierarchical Regression Analysis revealed that nursing students' resilience, as a multi-level factor, decreased the students' level of strain symptoms above and beyond their stress levels and control variables. Specifically, the nursing students' trait resilience, perceptions of their university's positive response to the pandemic and trust in their national policymakers were negatively associated with their strain symptoms. Conversely, disengagement-in-emotion coping strategies was positively associated with the students' strain symptoms. CONCLUSIONS: Nursing students' resilience should be seen as a flexible resource that can be developed and influenced by their academic and clinical training, and by the intentions and actions of their university and the nursing administration at the Ministry of Health (MOH). IMPACT: The findings call for the nursing administration at the MOH and for the university deans and department heads to prepare in advance a crisis plan that could be rapidly and effectively implemented when needed. Furthermore, topics such as developing flexible coping strategies should be integrated into the nursing curricula. These would allow students to prepare and cope better with adversity in their routine and in times of crisis.

Picking the 'proper hat?' Emerging ethical dilemmas while juggling nursing and research roles.

AIM: The aim of this study is to explore ethical dilemmas inherent in two potentially conflicting roles: practising nurse and researcher. BACKGROUND: Ethical guidelines for practice and research in nursing have been widely discussed. Yet examining ethical dilemmas that emerge from engaging in the dual role of nurse-researcher is rare. METHOD: A qualitative approach was employed, using semi-structured interviews with 15 nurse-researchers. Data were analysed using thematic analysis. RESULTS: One theme emerged with three subthemes of nurse-researcher role definitions: primarily nurse, primarily researcher and combined nurse-researcher. Each subtheme had three dimensions: (a) how ethical dilemmas were expressed in encounters with role colleagues, (b) coping strategies and (c) implications for nurse-researchers. CONCLUSION: Primarily nurses or primarily researchers experienced conflict in encounters with role colleagues, developed less effective coping strategies and reported impaired well-being. Conversely, combined nurse-researchers said each role nourished the other. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing policymakers and managers should support the nurse-researcher role by developing a code of ethics that acknowledges the dual role's inherent dilemmas, assimilate organisational routines and roles that support nursing research and encourage forums for discussing staff dilemmas.

A personal network approach to the study of nurse champions of innovation and their innovation projects' spread.

AIMS: To develop and test the relationship between nurse champions' personal social networks and innovation success in terms of spread. DESIGN: A cross sectional. METHOD(S): Data were collected on 94 nurse champions at three medium-large tertiary medical centres from 2015-2016. Data from champions on their personal network were assessed via a standardized and acceptable three-step network survey. Success in terms of innovation spread was assessed via perceived extent of spread. Network structural and relational characteristics were depicted by level of spread. Multivariate linear regression was used to assess the relationship between network characteristics and innovation spread. FINDINGS: Above and beyond various project and network control variables, network density was significantly and positively related to project spread, tie-strength diversity was significantly and negatively related to project spread and difference in ethnic origin between champions and alters was significantly and positively related to project spread. Maximum age of network members was marginally significantly related to project spread. CONCLUSION(S): Our findings show that high-density personal social networks; networks where tie strength among network members is similar, thus, creating liking and trust among members; having at least one older network member who might have close access to professional and organizational resources acquired throughout their career; and having ties with network members from different ethnic groups to prevent knowledge stickiness, all promote innovation spread. Champions should be carefully nominated based on their ability to engage network members and to build ties with various network members inside and outside the nursing unit; once selected, champions should be aware of their social networks. IMPACT: The current study explored champions' personal-network structure, composition and variance measures and their implications for innovation project spread. The findings demonstrated that nursing champions' personal social networks matter for innovation spread. This finding has implications for the nominating and the coaching of champions.

Effect of nurses' resilience on fall prevention in acute-care hospital: A mixed-methods qualitative study.

AIMS: To understand the distinctive experience and use of strategies of high- and low-resilience nurses aiming to prevent patient falls. BACKGROUND: Falls among inpatients continue to threaten patient safety in the hospital. Nurses may have the greatest impact on reducing patient falls. However, little is known about whether nurses' personal resilience is associated with patients' fall prevention strategies. METHOD: The study employed a descriptive mixed-methods design combining quantitative (questionnaires) and qualitative (observations, semi-structured interviews). RESULTS: One major theme, from maintaining routine to taking control over patients' falls, and three subthemes, scepticism, anticipation and proactivity representing feelings, cognitions and behaviours characterizing high- versus low-resilience nurses emerged from the findings. CONCLUSION: Three successive resilience strategies, starting with hunches that elicit scepticism, through cognitions of anticipation the worst-case scenario that could happen to the patient, and concluding with proactive behaviours characterize resilient nurses, helping them to prevent patients' falls. IMPLICATION FOR NURSING MANAGEMENT: Nursing managers seeking to decrease the devastating rate of patient falls can encourage nurses to have an inquiring mind (scepticism), be alert for the unexpected (anticipation) and take control over the environment (proactive behaviours) to make things happen instead of watching them happen.

The Effects of a Novel Mindfulness-based Intervention on Nurses' State Mindfulness and Patient Satisfaction in the Emergency Department.

INTRODUCTION: The objective of this study was to examine the effect of a novel mindfulness-based time-out intervention on state of mindfulness among emergency nurses and, accordingly, on patient satisfaction. METHODS: A pre-post intervention design among nurses in the emergency department was used with a between-subjects factor of patients who were nested within each nurse. The study was conducted between January 2017 and June 2018 among 48 nurses in the emergency department of a public tertiary academic hospital. For each nurse, a consecutive sample of 20 patients who attended the emergency department was recruited (n = 1920 patients; 960 in each phase). The mindfulness-based time-out intervention was based on theoretical mindfulness principles and carried out every 4 hours with direct communication to the patient at their bedside. Nurses' sociodemographic and professional characteristics and trait mindfulness were collected preintervention. Pre- and postintervention, data was collected on patients' sociodemographic and satisfaction, nurses' state mindfulness, and ED workload. RESULTS: An increase in nurses' state mindfulness and patients' satisfaction was found after the mindfulness-based time-out intervention compared with before the intervention (4.35 [SD = 0.64] vs 4.03 [0.82], P < .001 and 4.03 [0.41] vs 3.16 [0.44], P < .001, respectively). A positive correlation was found between patients' satisfaction and nurses' state mindfulness (r = 0.29, P < .001). The findings also demonstrated that state mindfulness was higher among nurses, characterized by high trait mindfulness, after the mindfulness-based time-out intervention implementation. DISCUSSION: By adapting mindfulness principles to the dynamic environment of the emergency department, we showed that the mindfulness-based time-out intervention was associated with a significant improvement in state mindfulness and patient satisfaction. The findings elucidate the interrelation among several conceptualizations of mindfulness that are increasingly reported in the literature, namely trait and state mindfulness, and interventions to promote mindfulness.

The nurse's experience of decision-making processes in missed nursing care: A qualitative study.

AIMS: To explore nurses' perspectives regarding the decision-making processes that lead to missed nursing care and to identify the personal and contextual attributes involved in these processes. DESIGN: A qualitative study was undertaken between April - October 2018. METHODS: A total of 28 registered nurses working in different wards in hospital settings participated in nine focus groups with semi-structured interviews. An interview guide encouraged nurses to share perceptions of missed care and the personal and contextual attributes shaping their decision-making. RESULTS: Content analysis revealed three themes related to nurses' decision-making processes for whether to omit or delay care. First, nurses emphasized the role of nurses' agency, suggesting explicit or implicit rationing of care, regardless of scarce resources. Second, nurses distinguished between two modes of thinking that they labelled "automated thinking," activated in routine situations and "effortful thinking," initiated in more novel situations. Finally, nurses identified situational factors triggering fluctuations in their awareness such as task type, difficult patients and the presence of relatives and the head nurse. CONCLUSIONS: Nurses are aware of the processes guiding a decision to omit or delay care. They pointed to patient, nurse and ward conditions that serve as cues in their decision whether to miss care. Identifying these cues supports Hammond's cognitive continuum theory of decision-making and may serve in the development of training programmes for nurses aimed at limiting the phenomenon. IMPACT: The study addressed missed nursing care through a decision-making lens. The findings pointed to nurses' agency as shaping decisions about whether to miss care and identified the personal and contextual cues that guide nurses' decisions. These findings call for organizational training programmes encouraging nurses to identify barriers and facilitators of missed nursing care and how to overcome them.

Power Gaps Among Stakeholders in Israel's Primary Care and the Role of Primary Care Physicians' Relative Power in Their Intention to Use Video-Consultations with Patients.

Introduction: Although some correlates of primary care physicians (PCPs) telemedicine adoption have been studied, little is known about whether the intention to use video-consultations (VCs) relates to how PCPs view their power, relative to other stakeholder groups in primary care. The aim of this study was (1) to describe PCPs', patients', and policy makers' (PMs) views of their power and (2) to explore how PCPs views of power are associated with their intention to use VC. Methods: A convergent parallel mixed-methods design was used. Interviews were conducted with five focus groups that comprised 42 patients; five focus groups with 52 PCPs; and 24 individual interviews with PMs. A total of 508 patients, 311 PCPs, and 141 PMs completed the questionnaire, assessing intention to use VC and stakeholders' relative power. The qualitative data were analyzed using the thematic method; survey data were analyzed using quantitative methods. Results: All stakeholder groups rated PCPs' power as significantly lower, relative to that of patients and managers. PCPs' intention to use telemedicine was found to be significantly related to perceived power gaps between them and patients (r = -0.24, p < 0.001) and between them and managers (r = -0.45, p < 0.001). Themes revealed in the analysis describing how PCPs' low power influences their intention to use VC were as follows: PCPs' low-impact telemedicine-related decisions, increased work overload, "big brother" control, and Health Maintenance Organization demands for telemedicine mandatory usage. Conclusions: To successfully adopt VC, efforts should be made to increase PCPs' relative power, by strengthening their involvement in decision-making procedures and by increasing PCPs' control over their work environment.

Systems, economics, and neoliberal politics: Theories to understand missed nursing care.

The phenomenon of missed nursing care is endemic across all sectors. Nurse leaders have drawn attention to the implications of missed care for patient outcomes, with calls to develop clear political, methodological, and theoretical approaches. As part of this call, we describe three structural theories that inform frameworks of missed care: systems theory, economic theory, and neoliberal politics. The final section provides commentary on the strengths and limitations of these three theories, in the light of structuration theory and calls to balance this research agenda by reinstating nurse agency and examining the interactions between nurses as agents and the health systems as structures. The paper argues that a better understanding of variations in structure-agency interaction across the healthcare system might lead to more effective interventions at strategic leverage points.

Choosing Video Instead of In-Clinic Consultations in Primary Care in Israel: Discrete Choice Experiment Among Key Stakeholders-Patients, Primary Care Physicians, and Policy Makers.

BACKGROUND: Despite its innovative benefits, the adoption of video consultations (VCs) in primary care settings is complex and slow. OBJECTIVES: To quantify the preferences of key stakeholders in Israel's primary care-patients, primary care practitioners, and policy makers-regarding VCs compared with traditional in-clinic consultations (ICC) in nonurgent conditions. METHODS: Discrete choice experiment surveys were completed by 508 patients, 311 physicians, and 141 policy makers. These consisted of 12 choice tasks of 2 labeled alternatives (VC or ICC), with the 4 attributes most relevant to each stakeholder group. A random effects logit model analysis was used to estimate stakeholders' preferences. RESULTS: All 4 experiments' attributes were significantly important in choosing VC versus ICC for the patient group and the physician group. Three out of 4 attributes were significantly important to policy makers. Differences and similarities between stakeholders were identified in attribute rank order, trade-offs, and VC uptake probabilities. Policy makers' VC uptake rate was 86%. Patients' preferences suggested that 68% of ICCs could be replaced by VCs. Physicians' VC uptake was 30% in cases in which the consultation purpose was to diagnose and provide treatment and 48% in cases in which the consultation purpose was follow-up. CONCLUSIONS: Our findings show key stakeholders' preferences about VC integration, to be considered when these systems are introduced into primary care and optimize the implementation process. Although there is a stronger preference for ICC among physicians and patients, alternative combinations of attribute levels might be used to compensate and reconfigure a more preferred VC service.

The personality profile of the accountable nurse and missed nursing care.

AIM: The aim of this study was to examine the mediating role of nurses' personal accountability in the relationships between nurse's personality and missed nursing care. BACKGROUND: Personal accountability is considered as a core value in nursing, shaped by the nurse's personality, education, socialization into the profession and experience. Personality antecedents may be uniquely suited to predicting accountability, since it reflects variation in individuals' deep-seated values and beliefs. Personal accountability can be related to the prevalent phenomenon of missed nursing care (tasks that are omitted or delayed). DESIGN: A multicentre cross-sectional study with 290 nurses from direct-care nursing wards during 2017. Personality traits were assessed with the 44-item Big Five Inventory. Personal accountability was assessed with a 19-item scale. Missed nursing care was assessed with the 22-item MISSCARE survey. An indirect mediated path analysis was performed and compared with an alternative model with direct effects. RESULTS: Path-analyses findings supported a full-mediation model of accountability in the relationships between personality traits and missed nursing care. Conscientiousness, Agreeableness, Openness and Neuroticism, but not Extraversion, were significantly related to personal accountability. In addition, greater personal accountability was significantly related to lower frequency of missed nursing care. CONCLUSIONS: Personal traits are important antecedents of personal accountability, which relates to missed nursing care. Findings delineate the profile of the accountable nurse and might help in developing strategies for the selection of nurses with high personal accountability and determining the best means to strengthen accountable behaviours in the workplace.

Understanding the concept of missed nursing care from a cross-cultural perspective.

AIMS: To investigate how nursing experts and experts from other health professions understand the concept of rationing/missed/unfinished nursing care and how this is compared at a cross-cultural level. DESIGN: The mixed methods descriptive study. METHODS: The semi-structured questionnaires were sent to the sample of 45 scholars and practitioners from 26 countries. Data were collected from November 2017-February 2018. RESULTS: Assigning average cultural values to participants from each country revealed three cultural groups: high individualism-high masculinity, high individualism-low masculinity and low individualism-medium masculinity. Content analysis of the findings revealed three main themes, which were identified across cultural clusters: (a) projecting blame for the phenomenon: Blaming the nurse versus blaming the system; (b) intentionality versus unintentionality; and (c) focus on nurses in comparison to focus on patients. CONCLUSION: Consistent differences in the understanding of missed nursing care can be understood in line with the nation's standing on two main cultural values: individualism and masculinity. IMPACT: The findings call for scholars' caution in interpreting missed nursing care from different cultures, or in comparing levels and types of missed nursing tasks across nations. The findings further indicated that mimicking interventions to limit missed nursing care from one cultural context to the other might be ineffective. Interventions to mitigate the phenomenon should be implemented thoughtfully, considering the cultural aspects.

Advancing the science of unfinished nursing care: Exploring the benefits of cross-disciplinary knowledge exchange, knowledge integration and transdisciplinarity.

AIMS: The aims of this paper are to explore the role of cross-disciplinary knowledge exchange and integration in advancing the science of unfinished nursing care and to offer preliminary guidance for theory development activities for this growing international community of scholars. BACKGROUND: Unfinished nursing care, also known as missed care or rationed care is a highly prevalent problem with negative consequences for patients, nurses and healthcare organizations around the world. It presents as a 'wicked' sustainability problem resulting from structural obstacles to effective resource allocation that have been resistant to conventional solutions. Research activity related to this problem is on the rise internationally but is hindered by inconsistencies in conceptualizations of the problem and lack of robust theory development around the phenomenon. A unified conceptual framework is needed to focus scholarly activities and facilitate advancement of a robust science of unfinished nursing care. DESIGN: Discussion paper. DATA SOURCES: This discussion paper is based on our own experiences in international and interdisciplinary research partnerships related to unfinished nursing care. These experiences are placed in the context of both classic and current literature related to the evolution of scientific knowledge. IMPLICATIONS FOR NURSING: The problem of unfinished nursing care crosses multiple scientific disciplines. It is imperative that the community of scholars interested in solving this wicked problem engage in meaningful cross-disciplinary knowledge integration and move towards transdisciplinarity. CONCLUSION: Metatheorizing guided by structuration theory should be considered as a strategy to promote transdiciplinarity around the problem of unfinished nursing care.

Characteristics and behaviours of formal versus informal nurse champions and their relationship to innovation success.

AIMS: To identify the sociodemographic attributes, project characteristics and champion strategies that differentiate formal from informal nursing champions, and to test their success in terms of project spread and novelty. BACKGROUND: Champions spread innovation in healthcare organizations. Empirical research has not explored the differences between formal and informal champions in terms of their antecedents and success. DESIGN: A quantitative cross-sectional design. METHOD: Data were collected on 93 nursing champions in three hospitals from 2015 - 2016. Champions were identified according to a validated approach; data on their sociodemographic attributes, project characteristics and strategies were assembled through interviews and validated questionnaires. Their success in terms of novelty and spread was assessed via expert ratings and validated questionnaire. FINDINGS: Informal champions had longer tenure and were involved mainly in bottom-up projects aimed mostly at improving human resources and services; formal champions were mostly involved in top-down projects aimed at quality control. Informal champions expressed more enthusiasm and confidence about the innovation; formal champions tended to use more online resources and peer-monitoring strategies. Projects of informal champions were more novel than those of formal champions. Project spread did not differ between the two groups. CONCLUSION: Formal and informal champions differ in their characteristics and implementation strategies. To encourage project's innovation, the organizational climate should encourage the emergence of informal champions; formal and informal champions should be chosen wisely, assuring that they possess enough organizational resources; and coaching programmes for junior champions should be planned to equip them with championing behaviours.

Nursing innovation: The joint effects of championship behaviors, project types, and initiation levels.

BACKGROUND: Frontline nurse champions are key innovation-implementation agents. Despite the growing interest in nurse champions' innovation, whether project novelty is a product of championship behavior (e.g., expressing confidence in the innovation's success and network building), the project's contextual characteristics (project type and initiation level), or their joint effects, remains unsolved. PURPOSE: To develop and test an interactionist model of project novelty in nursing. METHODS: A cross-sectional design with a multisource approach to data collection. FINDINGS: Results demonstrated a direct effect of project type, a two-way interaction effect of level of initiation and project type, a two-way interaction effect of championship and project type, and a three-way interaction effect of project type, initiation level, and championship on project's novelty. DISCUSSION: Bottom-up service and administrative projects require champions' championship behaviors to foster novelty, whereas for bottom-up quality-improvement projects, such behaviors can harm project novelty. For human-resource projects and for top-down projects, championship behaviors do not matter.

The Relationship Between Mindfulness, Triage Accuracy, and Patient Satisfaction in the Emergency Department: A Moderation-Mediation Model.

INTRODUCTION: Individual and collective mindfulness attracts growing research attention, yet reports of their impact on health care professionals' work behaviors are scarce, especially in the emergency department. The aim of the current study was to explore whether the association between trait mindfulness and triage accuracy is moderated by the emergency workload environment, and whether this association promotes patient satisfaction subject to levels of collective mindfulness. METHODS: A prospective consecutive nested design was conducted. Data were collected from ED teams (nurses and physicians, N = 96) on individual characteristics and trait mindfulness. Data were also collected on triage accuracy, triage team characteristics, collective mindfulness, workload, and patient satisfaction (N = 960) at a specific patient-ED team encounter. RESULTS: Findings indicated that ED workload environment (b = 0.24, P < 0.01), trait mindfulness (b = 1.80, P < 0.01), and their interaction (b = -0.04, P < 0.05) were associated with triage accuracy. Triage accuracy (b = 1.81, P < 0.001), collective mindfulness (b = 1.29, P < 0.001), and their interaction (b = -0.32, P < 0.001) were associated with patient satisfaction. The moderated-mediation model was significant under high, but not under extreme, levels of ED workload environment and all levels of collective mindfulness. DISCUSSION: Trait and collective mindfulness are relevant to ED triage and patient satisfaction, but their effects are bounded by workload. The beneficial gain of nurses' trait mindfulness on triage accuracy and collective mindfulness on patient satisfaction is demonstrated only under high-workload environments but limited under extreme-workload environments.

Towards a measure of accountability in nursing: A three-stage validation study.

AIMS: The aim of this study was to develop and psychometrically evaluate a three-dimensional questionnaire suitable for evaluating personal and organizational accountability in nurses. BACKGROUND: Accountability is defined as a three-dimensional value, directing professionals to take responsibility for their decisions and actions, to be willing to explain them (transparency), and to be judged according to society's accepted values (answerability). Despite the relatively clear definition, measurement of accountability lags well behind. Existing self-report questionnaires do not fully capture the complexity of the concept nor do they capture the different sources of accountability (e.g., personal accountability, organizational accountability). DESIGN: A three-stage measure development. METHODS: Data were collected during 2015-2016. In Phase 1, an initial database of items (N = 74) was developed, based on literature review and qualitative study, establishing face and content validity. In Phase 2, the face, content, construct, and criterion-related validity of the initial questionnaires (19 items for personal and organizational accountability questionnaire) were established with a sample of 229 nurses. In Phase 3, the final questionnaires (19 items each) were validated with a new sample of 329 nurses and established construct validity. RESULTS: The final version of the instruments comprised 19 items, suitable for assessing personal and organizational accountability. The questionnaire referred to the dimensions of responsibility, transparency, and answerability. The findings established the instrument's content, construct, and criterion-related validity as well as good internal reliability. CONCLUSION: The questionnaire portrays accountability in nursing, by capturing nurses' subjective perceptions of accountability dimensions (responsibility, transparency, answerability), as demonstrated by personal and organizational values.

Who is sleepier on the night shift? The influence of bio-psycho-social factors on subjective sleepiness of female nurses during the night shift.

Sleepiness is a common complaint during the night shift and may impair performance. The current study aims to identify bio-psycho-social factors associated with subjective sleepiness during the night shift. Ninety-two female nurses working rotating shifts completed a sociodemographic questionnaire, the Munich ChronoType Questionaire for shift workers, the Pittsburg Sleep Quality Index, and the Pre-sleep Arousal Scale. Subjective sleepiness was measured hourly during two night shifts using the Karolinska Sleepiness Scale, and activity monitors assessed sleep duration 24-h before each shift. Findings showed that increased sleepiness was associated with increased age in nurses with early chronotypes and with more children. High cognitive pre-sleep arousal, but not sleep, was associated with increased sleepiness, especially in late chronotypes. The impact of bio-psycho-social factors on night shift sleepiness is complex, and depends on mutual interactions between these factors. Nurses most prone to increased sleepiness must develop personal strategies for maintaining vigilance on the night shift. Practitioner Summary: This study aims to identify bio-psycho-social factors associated with subjective sleepiness of female nurses during the night shift. Increasing sleepiness was associated with increased age in nurses with early chronotypes and with more children. Increased cognitive pre-sleep arousal, but not sleep, was associated with increased sleepiness, especially in late chronotypes.