A dimensional analysis of nursing unit culture.

AIM(S): Organizational culture has been studied for over four decades among nurses, across countries and contexts. However, wide variation exists in how the concept has been defined and at what level of the organization it is measured. The aim of this study was to use a dimensional analysis to conduct a conceptual synthesis of unit culture from a nursing perspective. DESIGN: Dimensional analysis, rooted in grounded theory methodology, was used to describe unit culture from a nursing perspective. METHODS: A literature search was conducted in April 2022. Inclusion criteria were (1) peer review publications, (2) used the term 'unit culture' or 'ward culture', (3) references nurses' role in unit culture, (4) published in the last 20 years and (5) written in English. One hundred fifteen articles met inclusion criteria, but dimensional saturation was researched after coding 24 articles. RESULTS: Findings were synthesized into four core dimensions and 10 subdimensions. Dimensions of unit culture included customs (practice norms, communication and prioritization), shared beliefs (assumptions, values and attitudes), hierarchy (social and informational) and atmosphere (emotional climate and collaboration). Conditions that shape unit culture include individual nurse characteristics, working conditions, unit policies/procedures and leadership. Unit culture impacts nurse work experiences and decision-making processes, which can affect outcomes including nurse wellbeing, practice behaviours and adherence to unit policies. CONCLUSIONS: Identifying the dimensions of unit culture helps to bring clarity to a concept that is not well defined in existing literature. IMPACT: This model of unit culture can be used to guide development of new instruments to measure unit culture or guide researchers in utilizing existing measures. Developing measures specific to unit culture are warranted to strengthen researchers' ability to assess how changing conditions of a unit (e.g. leadership, workload) changes unit culture and its related outcomes. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution.

Psychosocial Factors Associated With Alcohol Use Among Nurses: An Integrative Review.

Background: Understanding alcohol use among nurses may inform interventions related to the coping mechanisms nurses use for workplace stress and trauma. Alcohol use can be caused by a variety of factors and has serious implications on a nurse's personal health and professional practice. Understanding psychosocial factors and preventive measures may assist in the development of interventions to improve coping mechanisms and reduce the incidence of alcohol misuse. Purpose: To review the psychosocial factors and preventive measures associated with alcohol use among nurses. Methods: For this integrative review, systematic searches were conducted in CINAHL, PubMed, PsychNet, and ProQuest Central. Included studies were peer-reviewed and addressed alcohol use among nurses in the United States. Articles were appraised using methods-specific tools indicated by the Whittemore and Knafl framework. Data were extracted and themes identified using constant comparison. Results: Of 6,214 nonduplicate articles screened, 78 were selected for full-text review and 13 were included after application of inclusion criteria. Synthesis resulted in four themes: (1) occupational stress and trauma, (2) workplace characteristics, (3) mental health implications, and (4) protective factors. The data show that workplace stress and trauma contribute to alcohol use among nurses. Night shifts, rotating shifts, and shift length are factors related to alcohol use, as are mental health problems such as anxiety, depression, trauma, and suicide. Protective factors that reduce alcohol use among nurses include faith, resilience, and perceived organizational support. Conclusion: Alcohol use among nurses presents challenges for the nursing profession and regulatory bodies with specific and interrelated phenomena related to the role and identity of nurses. A better understanding of these factors through research will facilitate a healthier nursing workforce that is better prepared to take on the rewards and challenges of a nursing career.

Work Organization Factors Associated With Nurses' Stress, Sleep, and Performance: A Pre-pandemic Analysis.

Background: The COVID-19 pandemic put extreme stress on an already strained healthcare workforce. Suboptimal work organization, exacerbated by the pandemic, is associated with poor worker, patient, and organizational outcomes. However, there are limited qualitative studies exploring how the interconnections of work organization factors related to shift work, sleep, and work stress influence registered nurses and their work performance in the United States. Purpose: We sought to understand how nurses perceive work organization factors that impact their performance. Knowledge in this area could direct efforts to implement policies and design tailored interventions to support nurses in the post-pandemic period. Methods: We used a qualitative descriptive design with the Work, Stress, and Health framework as an overarching guide to understand the interconnectedness of work organization factors, work stress, and outcomes. Participants were randomly assigned to one of two anonymous, asynchronous virtual focus groups (i.e., threaded discussion boards) in 2019. Registered nurses (N = 23) working across the United States were recruited and engaged until data saturation was achieved. Directed content analysis was used to analyze the data. Results: Findings aligned with the Work, Stress, and Health framework and revealed three themes: (1) "Our Voice Should Matter" (nurses' desire to have their voices heard in staffing policies); (2) "Tired But Wired" (the harmful cycle of work stress, rumination, and poor sleep); and (3) "We're Only Human" (nurses' physical, emotional, and mental exhaustion linked to critical performance impairments). Conclusion: These findings underscore that high work stress and poor sleep were present before the pandemic and impacted nurses' perceptions of their performance. As leaders look forward to recovery and work redesign efforts, these findings can guide decision-making and resource allocation for optimal nurse, patient, and organization outcomes.

The intellectual capital supporting nurse practice in a post-emergency state: A case study.

AIM: To explore the resources supporting current nurse practice in the post-emergency country of Liberia, using the nursing intellectual capital framework, as nurses work to meet the targets set by Government of Liberia's Essential Package of Health Services. DESIGN: Case study. METHODS: Data were collected in Liberia February-June 2019. Direct observation, semi-structured interviews and photographs were used to investigate how nurse practice is supported. Field notes, transcripts and photographs were coded using both directed and conventional content analysis. Reports were then generated by code to triangulate the data. RESULTS: Thirty-seven nurses at 12 health facilities participated. The intellectual capital supporting inpatient and outpatient nurse practice differs in important ways. Inpatient nurse practice is more likely to be supported by facility-based protocols and trainings, whereas outpatient nurse practice is more likely to be supported by external protocols and trainings, often developed by the Liberian government or non-governmental organizations. This can lead to uneven provision of inpatient protocols and trainings, often favouring private facilities. Similarly, inpatient nurses rely primarily on other nurses at their facilities for clinical support while outpatient nurses often have external professional relationships that provided them with clinical guidance. CONCLUSION: Much has been accomplished to enable outpatient nurses to provide the primary- and secondary-care target services in the Essential Package of Health Services. However, as the Liberian government and its partners continue to work towards providing certain tertiary care services, developing analogous protocols, trainings and clinical mentorship networks for inpatient nurses will likely be fruitful, and will decrease the burden on individual facilities. IMPACT: Nurses are often expected to meet new service provision targets in post-emergency states. Further research into how best to support nurses as they work to meet those targets has the potential to strengthen health systems.

Original Research: Losing the Art and Failing the Science of Nursing: The Experiences of Nurses Working During the COVID-19 Pandemic.

PURPOSE: RNs have served as the bedrock of the response to the COVID-19 pandemic, working under unprecedented and difficult conditions. In this study, we sought to understand the experiences of nurses working across a range of care settings in the United States during the first six months of the pandemic, and to learn more about barriers to and facilitators of their work. METHODS: This is a qualitative descriptive study. We recruited participants online through regional professional nursing membership listservs, program directors of occupational health nursing training programs, and social media. After completing a survey, potential participants were invited to complete an individual semistructured interview via the Zoom platform. From June through August 2020, we conducted 34 interviews. Content analysis was performed using ATLAS.ti software. RESULTS: The overarching theme-"Losing the art and failing the science of nursing"-underscored the barriers nurses faced in the early months of this pandemic. It reflected the deeply painful disruptions in the care nurses were accustomed to providing their patients. Themes that reflected barriers included disrupted nurse-patient connection, lack of personal protective equipment and fear of infection, lack of evidence-based guidance, and understaffing, all of which drastically altered the delivery of nursing care. Themes that reflected facilitators to nurses' work included camaraderie and strength and resourcefulness. CONCLUSIONS: The study findings give important direction to nurse leaders, researchers, and organizations concerning potential areas of support that nurses need during and after this pandemic. Future research should investigate the long-term impact of COVID-19 and similar public health crises on nurses, as well as interventions that could support the workforce after an extended crisis.

A Pilot Observational Exploratory Study of Well-Being in Hospice Interdisciplinary Team Members.

INTRODUCTION: Well-being and turnover intent represent key aspects to the promotion of a healthy workforce. Alarming levels of burnout and low levels of well-being have been documented in health professionals across care settings. Not only do high levels of burnout, low well-being and high turnover affect health professionals, but they are associated with poor patient care. However, limited research has investigated this topic specifically in hospice interdisciplinary team (IDT) members, nurses, chaplains, social workers. Thus, the purpose of this study was to explore hospice IDT members' well-being, and turnover intent. METHODS: This observational, pilot study used quantitative surveys to examine the well-being, and turnover intention at baseline and at 3 months. Twenty-five hospice IDT members at one site participated. RESULTS: Paired t-tests and percent change demonstrated significant decreases in compassion satisfaction (44.5 vs. 42.1, p = 0.04) and secondary traumatic stress score (18.5 vs. 13.3, p = 0.0001) and a significant increase in burnout score (17.6 vs. 20.5, p = 0.03) from baseline to follow up. Employee turnover slightly decreased from baseline to follow-up. CONCLUSIONS: In this pilot study, hospice IDT members had low levels of well-being at baseline that worsened over 3-months indicating a higher potential risk for burnout. Moreover, given the COVID-19 pandemic, this may be an ominous sign of what lies ahead for hospice providers regarding turnover, leading to significant long-term staffing problems in the field. If these results hold true in a larger sample, it could necessitate developing and testing further strategies to ensure a healthy and stable workforce.

How clinicians manage routinely low supplies of personal protective equipment.

BACKGROUND: Recommended personal protective equipment (PPE) is routinely limited or unavailable in low-income countries, but there is limited research as to how clinicians adapt to that scarcity, despite the implications for patients and workers. METHODS: This is a qualitative secondary analysis of case study data collected in Liberia in 2019. Data from the parent study were included in this analysis if it addressed availability and use of PPE in the clinical setting. Conventional content analysis was used on data including: field notes documenting nurse practice, semi-structured interview transcripts, and photographs. RESULTS: Data from the majority of participants (32/37) and all facilities (12/12) in the parent studies were included. Eighty-three percent of facilities reported limited PPE. Five management strategies for coping with limited PPE supplies were observed, reported, or both: rationing PPE, self-purchasing PPE, asking patients to purchase PPE, substituting PPE, and working without PPE. Approaches to rationing PPE included using PPE only for symptomatic patients or not performing physical exams. Substitutions for PPE were based on supply availability. CONCLUSIONS: Strategies developed by clinicians to manage low PPE likely have negative consequences for both workers and patients; further research into the topic is important, as is better PPE provision in low-income countries.

Infection Prevention and Control in Liberia 5 Years After Ebola: A Case Study.

BACKGROUND: Effective management of health emergencies is an important strategy to improve health worldwide. One way to manage health emergencies is to build and sustain national capacities. The Ebola epidemic of 2014 to 2015 resulted in greater infection prevention and control (IPC) capacity in Liberia, but few studies have investigated if and how that capacity was sustained. The purpose of this study was to examine the maintenance of IPC capacity in Liberia after Ebola. METHODS: For this case study, data were collected via direct observation of nurse practice, semistructured interviews, and document collection. Data were collected in two counties in Liberia. Data were analyzed using directed content and general thematic analysis using codes generated from the safety capital theoretical framework, which describes an organization's intangible occupational health resources. FINDINGS: Thirty-seven nurses from 12 facilities participated. Ebola was a seminal event in the development of safety capital in Liberia, particularly regarding nurse knowledge of IPC and facilities' investments in safety. The safety capital developed during Ebola is still being applied at the individual and organizational levels. Tangible resources, including personal protective equipment, however, have been depleted. CONCLUSIONS/APPLICATION TO PRACTICE: IPC capacity in Liberia had been sustained since Ebola but was threatened by under-investments in physical resources. Donor countries should prioritize sustained support, both financial and technical, in partnership with Liberian leaders. Occupational health nurses participating in disaster response should advocate for long-term investment by donor countries in personal protective equipment, access to water, and clinician training.

Telemedicine and Telehealth in Nursing Homes: An Integrative Review.

OBJECTIVES: Telemedicine and telehealth are increasingly used in nursing homes (NHs). Their use was accelerated further by the COVID-19 pandemic, but their impact on patients and outcomes has not been adequately investigated. These technologies offer promising avenues to detect clinical deterioration early, increasing clinician's ability to treat patients in place. A review of literature was executed to further explore the modalities' ability to maximize access to specialty care, modernize care models, and improve patient outcomes. DESIGN: Whittemore and Knafl's integrative review methodology was used to analyze quantitative and qualitative studies. SETTING AND PARTICIPANTS: Primary research conducted in NH settings or focused on NH residents was included. Participants included clinicians, NH residents, subacute patients, and families. METHODS: PubMed, Web of Science, CINAHL, Embase, PsycNET, and JSTOR were searched, yielding 16 studies exploring telemedicine and telehealth in NH settings between 2014 and 2020. RESULTS: Measurable impacts such as reduced emergency and hospital admissions, financial savings, reduced physical restraints, and improved vital signs were found along with process improvements, such as expedient access to specialists. Clinician, resident, and family perspectives were also discovered to be roundly positive. Studies showed wide methodologic heterogeneity and low generalizability owing to small sample sizes and incomplete study designs. CONCLUSIONS AND IMPLICATIONS: Preliminary evidence was found to support geriatrician, psychiatric, and palliative care consults through telemedicine. Financial and clinical incentives such as Medicare savings and reduced admissions to hospitals were also supported. NHs are met with increased challenges as a result of the COVID-19 pandemic, which telemedicine and telehealth may help to mitigate. Additional research is needed to explore resident and family opinions of telemedicine and telehealth use in nursing homes, as well as remote monitoring costs and workflow changes incurred with its use.

Organization of Work Factors Associated with Work Ability among Aging Nurses.

The United States (U.S.) workforce is aging. There is a paucity of literature exploring aging nurses' work ability. This study explored the work-related barriers and facilitators influencing work ability in older nurses. We conducted a qualitative descriptive study of aging nurses working in direct patient care (N = 17). Participants completed phone or in-person semi-structured interviews. We used a content analysis approach to analyzing the data. The overarching theme influencing the work ability of aging nurses was intrinsically motivated. This was tied to the desire to remain connected with patients at bedside. We identified factors at the individual, unit-based work level and the organizational level associated with work ability. Individual factors that were protective included teamwork, and feeling healthy and capable of doing their job. Unit-based level work factors included having a schedule that accommodated work-life balance, and one's chronotype promoted work ability. Organizational factors included management that valued worker's voice supported work ability.

Home health care services to persons with dementia and language preference.

Despite the rapid increase in the number of persons with dementia (PWD) receiving home health care (HHC), little is known of HHC services patterns to PWD of varied backgrounds, including language preference other than English. Analyzing data of 12,043 PWD from an urban home health agency, we found on average PWD received 2.48 skilled visits or 1.88-hour skilled care and 5.81 aide visits or 24.13-hour aide care weekly. Approximately 63% of the skilled visits were from nurses. More non-English preferred PWD received aide visits, compared to English preferred PWD (44% vs. 36%). The type and intensity of HHC services were associated with language preference; when stratified by insurance, non-English preference was still significantly associated with more HHC aide care. Our study indicated that HHC services (both type and amount) varied by language preference and insurance type as an indicator of access disparities was a significant contributor to the observed differences.

Nurses' sleep, work hours, and patient care quality, and safety.

OBJECTIVES: To describe sleep duration and work characteristics among registered nurses ("nurses") across health care settings and unit types and determine the association between sleep duration and quality of care and patient safety. DESIGN: We used an observational, retrospective design. Survey data were collected from two cohorts of nurses in 2015 and 2016. SETTING: Health care and community settings across the United States, primarily acute care hospitals. PARTICIPANTS: Nurses working in a staff or general duty position (N=1,568). MEASUREMENTS: The independent variable was nurses' sleep duration before work and nonwork days. The two dependent variables were nurse reported quality of care (single item rating) and overall patient safety, measured by the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture. RESULTS: Nurses reported an average of 414 minutes, or just less than 7 hours, of sleep before a work day and 497 minutes, or just over 8 hours, before a nonwork day. Short sleep duration was statistically significantly associated with lower ratings of quality of care (p=.002) and patient safety (p=.000). CONCLUSIONS: Nurses are sleeping, on average, less than recommended amounts before work, which may be impacting their health and performance on the job. Health care managers may consider interventions to support nurses' sleep to improve patient care. Further research is warranted.

The Occupational Health of Nurses in the Economic Community of West African States: A Review of the Literature.

Nurses provide the majority of health care in sub-Saharan Africa, which has high rates of Hepatitis B Virus (HBV) and human immunodeficiency virus (HIV). This systematic review used PRISMA methodology to synthesize the literature published between January 2008 and December 2018 examining the occupational health of nurses practicing in the Economic Community of West African States (ECOWAS). The United States' National Institute for Occupational Safety and Health's Hierarchy of Controls is used to frame the findings. This research was mostly conducted in Nigeria and Ghana and focused on administrative controls. Nurses practicing in ECOWAS are at high risk of acquiring a bloodborne illness due to inadequate engineering and administrative controls, as well as limited access to personal protective equipment (PPE). These findings indicate interventions to improve these controls would likely lower the occupational risks faced by nurses practicing in ECOWAS. Research in more countries in ECOWAS would likely find differences in occupational health practices in Nigeria and Ghana, which are relatively wealthy, and other countries in the region. This literature showed nurses practicing in ECOWAS did not have adequate protection from biological hazards. Regional health groups, such as the West African Health Organization, should commit to improving occupational health practice. Needle recapping and double gloving must be discontinued, and PPE must be made more widely available in ECOWAS. Occupational health professionals in the region should advocate for better distribution of PPE and consider offering trainings on these behaviors.

A comparison of scheduling, work hours, overtime, and work preferences across four cohorts of newly licensed Registered Nurses.

AIMS: To conduct a comparative analysis of four cohorts of newly licensed Registered Nurses and their work schedule, daily shift length, weekly work hours, second job, and weekly overtime hours. Nurses also reported their preferences regarding work schedule and daily shift length. DESIGN: We used a retrospective, comparative design analysing four cross-sectional surveys from new nurses first licensed between 2004-2015. METHODS: Using state licensure lists, nurses who were first licensed between 1 August 2004 and 31 July 2005 were randomly sampled using a nested design in 23 geographical areas in 13 states and Washington, DC. The same sampling strategy was conducted for subsequent cohorts in January 2009, 2012, and 2016. We sent a mailed survey measuring demographics, education, work attributes, and attitudes to participants with a $5 incentive, following methods by Dillman. RESULTS: There were no statistically significant differences in average weekly work hours (39.4 hrs) or holding more than one job for pay (11.6-14.6% across all cohorts). There were statistically significant differences in overtime across cohorts and shift length by unit type. The preferred shift length was 12 hrs and day shift was the preferred work schedule. CONCLUSION: New nurses are predominantly scheduled for 12-hrs shifts and nearly half work weekly overtime, trends that have remained relatively stable over the past 10 years. Nurse managers, policy-makers, and researchers should pay attention to new nurses' schedule and shift preferences and guard against mandatory overtime hours.

Common predictors of nurse-reported quality of care and patient safety.

BACKGROUND: In the era of the Patient Protection and Affordable Care Act, quality of care and patient safety in health care have never been more visible to patients or providers. Registered nurses (nurses) are key players not only in providing direct patient care but also in evaluating the quality and safety of care provided to patients and families. PURPOSE: We had the opportunity to study a unique cohort of nurses to understand more about the common predictors of nurse-reported quality of care and patient safety across acute care settings. APPROACH: We analyzed cross-sectional survey data that were collected in 2015 from 731 nurses, as part of a national 10-year panel study of nurses. Variables selected for inclusion in regression analyses were chosen based on the Systems Engineering Initiative for Patient Safety model, which is composed of work system or structure, process, and outcomes. RESULTS: Our findings indicate that factors from three components of the Systems Engineering Initiative for Patient Safety model-Work System (person, environment, and organization) are predictive of quality of care and patient safety as reported by nurses. The main results from our multiple linear and logistic regression models suggest that significant predictors common to both quality and safety were job satisfaction and organizational constraints. In addition, unit type and procedural justice were associated with patient safety, whereas better nurse-physician relations were associated with quality of care. CONCLUSION: Increasing nurses' job satisfaction and reducing organizational constraints may be areas to focus on to improve quality of care and patient safety. PRACTICAL IMPLICATIONS: Our results provide direction for hospitals and nurse managers as to how to allocate finite resources to achieve improvements in quality of care and patient safety alike.

Bachelor's Degree Nurse Graduates Report Better Quality and Safety Educational Preparedness than Associate Degree Graduates.

BACKGROUND: Readiness of the nursing workforce in quality and safety competencies is an essential indicator of a health system's ability to deliver high-quality and safe health care. A previous study identified important quality and safety education gaps between associate- and baccalaureate-prepared new nurses who graduated between 2004 and 2005. The purpose of this study was to assess changes in nursing workforce quality and safety education preparedness by examining educational gaps between associate and bachelor's degree graduates in two additional cohorts of new nurses who graduated between 2007-2008 and 2014-2015. METHODS: A cross-sectional, comparative design and chi-square tests were used to trend the quality and safety educational preparedness differences between associate and bachelor's degree nurse graduates from 13 states and the District of Columbia licensed in 2007-2008 (N = 324) and 2014-2015 (N = 803). RESULTS: The number of quality and safety educational gaps between bachelor's and associate degree nurse graduates more than doubled over eight years. In the 2007-2008 cohort, RNs with a bachelor's degree reported being significantly better prepared than RNs with an associate degree in 5 of 16 topics. In the 2014-2015 cohort, bachelor's degree RNs reported being significantly better prepared than associate degree RNs in 12 of 16 topics. CONCLUSION: Improving accreditation and organizational policies requiring baccalaureate education for all nurses could close quality and safety education gaps to safeguard the quality of patient care.

Factors Predicting Adoption of the Nurses Improving Care of Healthsystem Elders Program.

BACKGROUND: Registered nurses are often underprepared with the knowledge and skills to care for hospitalized older adult patients. One strategy to bridge this gap is for hospitals to adopt the Nurses Improving Care for Healthsystem Elders (NICHE) program: A nurse-led interdisciplinary organizational intervention to improve care of hospitalized older adults. OBJECTIVES: This study aimed to identify the market, organizational and managerial, and sociotechnical factors associated with the adoption of NICHE among U.S. hospitals in order to understand factors that promote and inhibit the adoption of models to improve care for elders and to provide a basis for future studies that evaluate the effects of NICHE participation on patient outcomes. METHODS: We used an observational, retrospective design, linking three national administrative data sources, in a secondary analysis. Data included the 2012-2013 American Hospital Association Annual Survey, NICHE database, and the American Nurses Credentialing Center Magnet database. Multivariate logistic regression models were completed at the hospital level (n = 3,506). RESULTS: Statistically significant variables associated with hospital adoption of the NICHE program include using a medical home model, being in a network, having a pain services program, being in an urban location, and having over 100 beds. DISCUSSION: Understanding factors that promote the adoption of organizational interventions like NICHE holds promise for accelerating the use of evidence-based clinical practices to promote health, function, and well-being for older hospitalized adults. Our results provide a foundation for assessing the effects of NICHE participation on patient outcomes by identifying factors that account for membership in NICHE.