The Impact of Leadership in the Autonomy and Engagement of Nurses: A Cross-sectional Multicenter Study Among Nurses Outside the United States.

OBJECTIVE: To add to the body of evidence regarding nurse engagement and related factors from a non-US sample of nurses. BACKGROUND: Leadership has a positive impact on nurses' autonomy and engagement experiences. It is necessary to explore the factors that explain the relationships between leadership, autonomy, and engagement level. METHODS: Nurses (n = 4393) from 9 hospitals participated in a survey in March 2020. Multivariable logistic regression analysis was performed to identify engagement and autonomy predictors. RESULTS: Of the respondents, 9% were engaged, 28% content, 29% ambivalent, and 34% disengaged. Respondents' separate background variables were not significant predictors in multivariate models, whereas the leadership- and autonomy-related variables were. CONCLUSIONS: A manager's responsiveness, an organization's readiness to follow nurse suggestions for performance improvement, and receiving recognition and regular feedback promote engagement. Furthermore, engagement is enhanced when nurses have an active role in decision-making and their contributions are respected. Visible nurse managers and leaders who are effective advocates for nurses strengthen nurses' autonomy.

Nursing interventions in preventing pressure injuries in acute inpatient care: a cross-sectional national study.

BACKGROUND: Several nursing interventions for pressure injury prevention have been identified, including risk and skin status assessment. The aim of this study was to explore prevention of pressure injuries in Finnish acute inpatient care. The data were collected on pressure injury risk and skin status assessments, repositioning, the use of support surfaces, preventive skin care, malnutrition risk assessment, and nutritional care. METHODS: This multicentre, cross-sectional study was conducted in 16 acute care hospitals, excluding psychiatric care. Adult patients from inpatient care were recruited on the annual international Stop Pressure Ulcers Day in 2018 and 2019. Enrolment covered 6,160 participants in 503 units. Descriptive statistics were used to describe pressure injuries, risk assessments, and preventive nursing interventions. Cross tabulation, Pearson's chi-square and Fisher's exact tests were also used. Reporting follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. RESULTS: In all, 30% of the participants had their pressure injury risk assessed during the care, and for 19% within 8 h after admission. The same time limit in risk assessment was fulfilled for 16% of the participants with a pressure injury, and 22% of the participants using a wheelchair or being bedridden. A skin status assessment within 8 h after admission was conducted for 30% of all participants, and for 29% of the participants with a pre-existing pressure injury, and for 38% of the participants using a wheelchair or being bedridden. The risk of malnutrition was screened in 20% of the participants. Preventive interventions were targeted to participants with a pressure injury instead of patients with a high-pressure injury risk. CONCLUSION: This study adds evidence about pressure injury risk assessments and the implementation of preventive nursing interventions in Finnish acute care. Skin status and pressure injury risk assessments were irregularly conducted, and the outcome was not used by nurses to guide the implementation of preventive interventions. The results reveal the gaps in evidence-based nursing practice, which require further efforts to prevent pressure injuries. Improving the national focus on pressure injury prevention practice is critical for improving healthcare for our patients.

Advanced practice role delineation within Finland: A comparative descriptive study.

AIM: To identify and differentiate the practice patterns of generalist, specialist and advanced practice nursing roles in specialist and central hospital contexts. BACKGROUND: In Finland, as in other Nordic countries, advanced practice nursing roles emerged around 2000. There are over 60,000 registered nurses/midwives in Finland and the clinical career pathway from a registered nurse to advanced practice nurse has been described yet not fully implemented in healthcare organizations. However, the number and activities of nonadvanced and advanced practitioner roles are not well known. DESIGN: A descriptive comparative study. METHODS: An online self-report survey was conducted between August and October 2020 using an advanced practice role delineation tool. A census sample of registered nurses, registered midwives, specialist nurses and advanced practice nurses in five university hospitals and one central hospital was recruited. Descriptive statistics were used to summarize the characteristics of participants and group differences were compared using analysis of variance (ANOVA). The STROBE checklist was used as the reporting guideline. RESULTS: A total of 1497 responses were obtained (response rate = 10%). Overall, nurses used comprehensive care and education activities most frequently. The least used activities were research and publication and professional leadership. Univariate analysis of variance test between role effects, when education and grouped age were taken into account, showed statistically significant difference in all of the observed five activities (p < .001). CONCLUSION: Identifying activities in different levels of nursing is a crucial first step in delineating nursing roles thus improving the governance of the human resource management. IMPACT: The study results add to the international literature, delineating nursing roles in the spectrum of generalist to advanced practice nursing. As these roles become more formalized, we may incorporate novel ways of promoting the career development and optimal use and assessment of nursing roles and practice in various career levels.

Construct validity of Advanced Practice Role Delineation tool: A confirmatory factor analysis.

AIM: To test the psychometric properties and latent structure of the modified Strong Model of Advanced Practice tool. BACKGROUND: The Strong Model of Advanced Practice tool, developed in the United States in 1990s and its Australia modification, has been increasingly used to delineate nursing and advanced practice nursing roles. Few research-driven efforts to develop and validate these tools have taken place. DESIGN: Psychometric testing of the modified Strong Model of Advanced Practice tool. METHODS: A confirmatory factor analysis was undertaken to examine the factors of the modified Strong Model of Advanced Practice tool and compare the model to the Australian Advanced Practice Role Delineation tool. The data were collected in September 2020. RESULTS: The analysis of the data provided construct validity evidence of the underlying theoretical structures of the five-factor modified Strong Model of Advanced Practice tool. The 45-item modified Strong Model of Advanced Practice tool demonstrated satisfactory, slightly better psychometric properties and construct validity than the 40-item Advanced Practice Role Delineation tool. CONCLUSIONS: Psychometric properties of the scale were evaluated and reported. Based on the statistical analysis, we suggest the use of the 45-item modified Strong Model of Advanced Practice tool.

Professional governance in Finnish nursing - measured by the Index of Professional Nursing Governance.

AIM: To translate and validate the Index of Professional Nursing Governance (IPNG) 2.0 and assess the state of professional nursing governance in Finland. BACKGROUND: Raising and maintaining quality of care while retaining staff are common problems in healthcare globally. Professional governance is a modern way to tackle them, but a reliable instrument is needed to measure the state of nursing governance in Finland, and elsewhere. METHODS: The IPNG that was translated into Finnish by forward-backward translation, culturally adapted and pilot tested with 20 nurses. A sample of 419 nurses was utilised in a cross-sectional study to assess the state of professional governance in Finland 2018. RESULTS: Principal component analysis yielded six components with good Cronbach's α values. The results clearly indicate that the IPNG version developed and evaluated in this study has suitable psychometric properties for use in Finnish healthcare settings. The validated IPNG scores indicate that nursing governance in Finland is in the professional governance range. The staff have some input in the governance of Finnish healthcare organisations. However, this perception is strongest among the nurse leaders and experts; other groups do not perceive much change yet. CONCLUSION: Participants, particularly nurse leaders in Finland, had self-reported impact in decision-making. The translated IPNG has acceptable internal consistency and can be used to assess healthcare organisations' governance models in Finland and broader in Nordic countries and Europe.

Nurses' critical reflections of working in unit practice councils-A qualitative interview study.

AIM: This study aimed to describe nurses' experiences of working as members of unit practice councils. BACKGROUND: Health care organisations worldwide want personnel to participate in decision-making. Unit practice councils promote unit-level decision-making over unit-specific issues. Despite extensive research on shared decision-making, few studies have examined the experiences of nurses serving as members of these councils. METHODS: A descriptive qualitative study design was used with semi-structured interviews of 16 nurses in two clinics of a Finnish university hospital. Interviews were analysed using thematic analysis. RESULTS: The analysis revealed two themes describing nurses' experiences as members of unit practice councils: (i) inchoate unit practice councils with insufficient allocated working time and (ii) partial empowerment of nurses through the organisation's evolving Magnet project. CONCLUSIONS: Unit practice councils in the studied organisations are inchoate and unable to effectively advance shared decision-making or support nurses' professional autonomy. In the future, the councils require constant support from all leadership levels of the organisation. IMPLICATIONS FOR NURSING MANAGEMENT: Sharing decision-making power could be a win-win situation where nurse leaders relinquishing power over certain matters gain time to immerse in wider issues. While acknowledging different organisational roles, there is room for trusting each other's professionality and respecting autonomous work.

Pressure injury prevalence and incidence in acute inpatient care and related risk factors: A cross-sectional national study.

The aim of this national cross-sectional study was to explore the prevalence of pressure injuries and incidence of hospital-acquired pressure injuries, and the relating factors in somatic-specialised inpatient care in Finland. The study was conducted in 16 (out of 21) Finnish health care organisations offering specialised health care services. Data were collected in 2018 and 2019 from adult patients (N = 5902) in inpatient, emergency follow-up, and rehabilitation units. Pressure injury prevalence (all stages/categories) was 12.7%, and the incidence of hospital-acquired pressure injuries was 10%. Of the participants, 2.6% had at least one pressure injury at admission. The risk of hospital-acquired pressure injuries was increased for medical patients with a higher age, the inability to move independently, mode of arrival, being underweight, and the absence of a skin assessment or pressure injury risk assessment at admission. For surgical patients, the risk was associated with the inability to move independently, mode of arrival, and lack of skin assessment at admission, while being overweight protected the patients. Overall, medical patients were in greater risk of hospital-acquired pressure injuries than the surgical patients. An assessment of the pressure injury risk and skin status should be carried out more systematically in Finnish acute care hospitals.

An integrative review on interventions for strengthening professional governance in nursing.

AIM: To identify the interventions for strengthening professional nursing governance and describe their outcomes. BACKGROUND: The ever-changing health care environment requires empowering governance structures and shared decision-making. The costly nature of reshaping governance makes the identification of effective interventions vital. EVALUATION: An integrative review was carried out between January 2007 and May 2020 in the CINAHL, PubMed, Scopus, PsycINFO, Business source, Cochrane and Medic databases. The quality of the 12 included studies was evaluated with the Joanna Briggs Institute critical appraisal tools. KEY ISSUES: Eight studies reported that the implemented interventions had positively influenced organisation regarding creating positive work environments, building new leadership competencies and increasing personnel's ability to take part in decision-making. The overall quality of the evidence was judged to be moderate. CONCLUSION: Comprehensive decision-making structures, efficient teamwork and transformational leadership competencies among nurse leaders enable personnel to participate in decision-making. Further research is needed to identify the most effective interventions for improving professional governance. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse leaders have to ensure that personnel have adequate opportunities to congregate and decide over matters concerning their work. Positive organisational climate and relational leadership style, along with highly functioning teams, are important prerequisites to nursing councils producing the desired outcomes.

Systematic education has a positive impact on nurses' evidence-based practice: Intervention study results.

AIMS: To evaluate how an education program on evidence-based practice (EBP) affected nurses´ knowledge, practices, and attitudes related to EBPs in patient care. METHODS: Nurses of one Finnish university hospital participated in two separate EBP education programs in 2016-2017 and 2018-2019. Data was collected by a questionnaire given before and after each program. Reliable instruments for measuring EBP were used: The Evidence-Based Practice Questionnaire (24 items) and the Attitudes to Evidence-Based Practice Questionnaire (17 items). Means and frequencies were evaluated with the Mann-Whitney U test and linear regression. RESULTS: Nurses reported that their EBP practice, skills and the Work based on EBPs improved substantially after the education program. We found that scores on the Work based on EBPs and the attitudes towards EBP could predict the nurses' overall self-evaluations of practices, attitudes, and skills. DISCUSSION: EBP education affects positively on implementation of nurses' practices and skills. There is still a need to change attitudes towards evidence based practice. IMPLICATIONS FOR PRACTICE, RESEARCH, POLICY, MANAGEMENT, AND EDUCATION: Organizations need to maintain and develop efficient, attractive EBP educational programs to promote lifelong learning. CONCLUSIONS: When designing EBP educational content, it is crucial to teach participants to develop evidence-based methods and consider how to implement them in practice.

A Qualitative Study of Nursing Students' Experiences in Fall Prevention for Older Home Care Clients.

The aim of this study was to describe the experiences of nursing students in fall prevention during clinical practice in the context of older home care clients. This was a qualitative focus group study of nursing students (n = 9) who had completed clinical practice in older clients' home care. The data were analysed using inductive content analysis. The nursing students described their experiences regarding falls and fall prevention in older clients' home care from two perspectives: evaluation of falls at older people's homes and fall prevention during home visits. Systematic evaluation of falls was based on physical examination and is the basis of fall prevention. However, evaluation of nutrition and adverse drug effects seemed to be ignored. In addition, fall prevention during home visits included concrete fall prevention in authentic client situations, confidential relationships with older clients, and evidence-based knowledge. From the perspective of fall prevention, there was a lack of comprehensive evaluation and understanding of the meaning of psychological factors, such as fear of falling. In order to be able to prevent falls in the older client population, students need more guidance regarding a comprehensive approach based on evaluation of falls. In addition, there is a need for continuous collaboration between education and home care services to develop educational approaches that interlink knowledge and skills in fall prevention.

Nurse staffing levels and nursing outcomes: a Bayesian analysis of Finnish-registered nurse survey data.

AIM: The aim of the present study was to assess the relationship between patient-to-registered nurse (RN) ratios and nursing outcomes: job satisfaction and stress, nursing care quality, control of own practise, intent to leave, adequacy of material resources and attitudes towards technical equipment. BACKGROUND: Although there is a growing body of evidence showing that higher levels of RN staffing are linked to better outcomes, it still is unclear how nurse staffing produces these effects. METHOD: A survey of data of RNs (n = 854) in 46 inpatient units at five university hospitals in Finland was used to create a Bayesian network (BN) model of connections between the variables. RESULTS: A BN model constructed showed that the quality of nursing care is influenced by multifaceted work environment measures. RNs' possibility to control their own practice and the quality of care are mediation between patient-to-RN ratio and other variables examined. CONCLUSIONS: New insight was given to the complex theme of the nursing practice environment and its connections to nursing outcomes. IMPLICATIONS FOR NURSING MANAGEMENT: Work environment should be developed with consideration of many factors, including adequate staffing levels and the ability for nurses to control their own work. This could increase nurses' work satisfaction, retention and patient care quality outcomes.

Nursing shared governance at hospitals - it's Finnish future?

PURPOSE: The purpose of this study is to describe council structure, its benefits, supportive and obstructive factors and developmental needs as a part of shared governance in a university hospital. DESIGN/METHODOLOGY/APPROACH: This is a descriptive study, where semi-structured interviews with 12 nurses was conducted in 2014 and documents from 75 council meetings from 2009 to 2014 were gathered and analyzed. Qualitative content analysis method was used on the data. FINDINGS: The study hospital has been developing nursing shared governance with unique structure and processes of councils. Professors and university researchers act as chair and members are voluntary nursing staff. The factors supporting the councils are nurse managers' support, enthusiastic personnel and neighboring university. The factors obstructing the councils are lack of time, understanding and skills. The work of the councils benefits the organization by improving patient care, harmonizing nursing practices and informing decision-making. The council's developmental needs were more visibility, concentration into everyday problems and interprofessionality. RESEARCH LIMITATIONS/IMPLICATIONS: Applying nursing shared governance structures into an organization improves the professional practice environment of nursing personnel. PRACTICAL IMPLICATIONS: The study hospital has its own, unique council structure. It did not cover the whole hospital or all of the nursing personnel, but it is already producing promising results. It should be given an official status and more support from nurse managers, and it should be developed into an inter-professional discussion. The results presented here indicate that shared governance, even, in its early stage, contributes positively to the quality of care, harmonizes nursing practices and informs decision-making. Applying shared governance structures into an organization improves the professional practice environment of nursing personnel. The study showed concrete supporting and obstructing factors that should be notified in nursing leadership. ORIGINALITY/VALUE: Despite the extensive empirical studies on nursing shared governance, there is very little research on councils in the Scandinavian countries.

Nurses' work environment and nursing outcomes: a survey study among Finnish university hospital registered nurses.

The aim was to assess the interrelationships between nurses' work environment and nursing outcomes. A cross-sectional survey of 664 registered nurses (RN) on 34 acute care inpatient hospital wards was used to measure nurses' perceptions. Patient data (n = 4045) consisting of a total patient satisfaction indicator were collected simultaneously with the nurse data during year 2005. RN's assessments of staffing adequacy, respect and relationships were the most important factors of work environment having an influence on job-related stress, job satisfaction, patient satisfaction and adverse events to patients and nurses. Some 77% of the RN reported adverse nurse events and 96% reported adverse patient events during a 3 month retrospective period. Ensuring sufficient and suitably qualified nurses' availability in delivering nursing care is an important management issue. Nurses are concerned about the quality of care, and the concerns perceived by nurses can influence their clinical work.

Patient satisfaction as a positive nursing outcome.

The purpose of this cross-sectional survey was to assess patient satisfaction and analyze its relationship to nurse staffing levels in 34 inpatient wards at 4 Finnish university hospitals. The patients were satisfied with their care in general. However, the proportion of registered nurses (RNs), the patient-to-RN ratio, and the RNs' working years were highly related to patient satisfaction. Eight patients per RN was the cut-off point for patient satisfaction.