Building a Taxonomy to Understand Health Care Worker's Response to Workplace 'Pressure' in Complex, Volatile and Emergency Situations.

This research aims to better understand performance under pressure as experienced by health and emergency staff in the workplace. Three basic questions underpin the work: (1) how do health and emergency workers experience and make sense of the 'pressures' entailed in their jobs? (2) What impacts do these pressures have on their working lives and work performance, both positively and negatively? (3) Can we develop a useful explanatory model for 'working under pressure' in complex, volatile and emergency situations? The present article addresses the first question regarding the nature of pressure; a subsequent article will address the question of its impact on performance. Using detailed interviews with workers in a range of roles and from diverse settings across Ecuador, our analysis aims to better understand the genesis of pressure, how people respond to it and to gain insights into managing it more effectively, especially with a view to reducing workplace errors and staff burnout. Rather than imposing preformulated definitions of either 'pressure' or 'performance', we took an emic approach to gain a fresh understanding of how workers themselves experience, describe and make sense of workplace pressure. This article catalogues a wide range of pressures as experienced by our participants and maps relationships between them. We argue that while individuals are often held responsible for workplace errors, both 'pressure' and 'performance' are multifactorial, involving individuals, teams, case complexity, expertise and organizational systems and these must be considered in order to gain better understandings of performing under pressure.

Decision-making under pressure: medical errors in uncertain and dynamic environments.

Objective This paper provides a narrative overview of the literature concerning clinical decision-making processes when staff come under pressure, particularly in uncertain, dynamic and emergency situations. Methods Studies between 1980 and 2015 were analysed using a six-phase thematic analysis framework to achieve an in-depth understanding of the complex origins of medical errors that occur when people and systems are under pressure and how work pressure affects clinical performance and patient outcomes. Literature searches were conducted using a Summons Search Service platform; search criteria included a variety of methodologies, resulting in the identification of 95 papers relevant to the present review. Results Six themes emerged in the present narrative review using thematic analysis: organisational systems, workload, time pressure, teamwork, individual human factors and case complexity. This analysis highlights that clinical outcomes in emergency situations are the result of a variety of interconnecting factors. These factors may affect the ability of clinical staff in emergency situations to provide quality, safe care in a timely manner. Conclusions The challenge for researchers is to build the body of knowledge concerning the safe management of patients, particularly where clinicians are working under pressure. This understanding is important for developing pathways that optimise clinical decision making in uncertain and dynamic environments. What is known about the topic? Emergency departments (EDs) are characterised by high complexity, high throughput and greater uncertainty compared with routine hospital wards or out-patient situations, and the ED is therefore prone to unpredictable workflows and non-replicable conditions when presented with unique and complex cases. What does this paper add? Clinical decision making can be affected by pressures with complex origins, including organisational systems, workload, time constraints, teamwork, human factors and case complexity. Interactions between these factors at different levels of the decision-making process can increase the complexity of problems and the resulting decisions to be made. What are the implications for practitioners? The findings of the present study provide further evidence that consideration of medical errors should be seen primarily from a 'whole-of-system' perspective rather than as being primarily the responsibility of individuals. Although there are strategies in place in healthcare organisations to eliminate errors, they still occur. In order to achieve a better understanding of medical errors in clinical practice in times of uncertainty, it is necessary to identify how diverse pressures can affect clinical decisions, and how these interact to influence clinical outcomes.

Nursing students' belongingness and workplace satisfaction: Quantitative findings of a mixed methods study.

BACKGROUND: The relationship between nursing students' belongingness and workplace satisfaction has received limited attention in the literature to date. AIM: The aim of this study was to explore the relationship between, and factors that may influence final semester nursing students' need to belong, sense of belonging and workplace satisfaction while on clinical placements. METHODS: A cross-national longitudinal multiphase explanatory sequential mixed methods study underpinned by a pragmatic theoretical framework was used for this study. A convenience sample of third-year nursing students from two Australian and one Canadian university (n=468) were recruited. Participants were asked to complete a 62 item survey which was a composite of three previously validated surveys: the 10 item 'Need to Belong Scale', the 34 item 'Belongingness Scale: Clinical Placement Experience (BES:CPE)' and the 18 item 'Nursing Workplace Satisfaction Questionnaire'. Data were analysed using descriptive and inferential statistics. RESULTS: Key results indicated that participants wanted to have someone to turn to, and to be accepted; they found nursing work interesting and considered it worthwhile to make an effort in this meaningful job. Participants were usually comfortable to ask for and accept help but many felt discriminated against during clinical placements. Only belongingness was strongly correlated with workplace satisfaction. CONCLUSIONS: Irrespective of site, nursing students' satisfied sense of belonging influenced their workplace satisfaction while on clinical placements. Workplace satisfaction is a key determinant of career decisions and the results from this study have the potential to inform clinical placement practices and policies and to influence beginning nurses' decisions to continue in the profession.

Successful linking of patient records between hospital services and general practice to facilitate integrated care in a hospital and health service in south-east Queensland.

This brief paper describes a recent exercise undertaken within a hospital and health service in south-east Queensland to attempt to link patient records between general practice and hospital services. It describes the technical and governance processes undertaken to achieve this link and the challenges experienced to date in linking the two data sources.

Establishing Policy Foundations and Regulatory Systems to Enhance Nursing Practice in the United Arab Emirates.

In 2009, the United Arab Emirates (UAE) established a Nursing and Midwifery Council with a mandate to develop standards for the registration and regulation of nursing and midwifery and to strengthen the nursing and midwifery workforce. Priorities included workforce Emiratization and the development of regulatory standards to support advanced and speciality nursing practice and new models of care-particularly for the management of noncommunicable diseases. This article provides background, context for, and best practice inputs to the effort to provide one unified framework of nursing regulation and licensure across the whole of the UAE. This article is intended for nurse leaders, policy makers, and regulators who are reviewing or developing nursing regulatory processes and advancing nursing workforce capacity building activities; and nurse educators and nurses wishing to work in the UAE.

From leader to leadership: clinician managers and where to next?

Individual clinician leadership is at the forefront of health reforms in Australia as well as overseas with many programs run by health departments (and hospitals) generally focus on the development of individual leaders. This paper argues, along with others, that leadership in the clinician management context cannot be understood from an individualistic approach alone. Clinician managers, especially in the ranks of doctors, are usually described as 'hybrid-professional managers' as well as reluctant leaders for whom most leadership theories do not easily apply. Their experiences of leadership development programs run by health departments both in Australia and internationally are likely to be based on an individual leader-focussed approach that is driving health care reforms. These approaches work from three key assumptions: (1) study and fix the person; (2) give them a position or title; and (3) make them responsible for results. Some would argue that the combination of these three approaches equates to heroic and transformational leadership. Several alternative approaches to leadership development are presented to illustrate how reforms in healthcare, and notably in hospitals, must incorporate alternative approaches, such as those based on collective and relational forms of leadership. This does not mean eschewing individual approaches to leadership but rather, thinking of them differently and making them more relevant to the daily experiences of clinician managers. We conclude by highlighting several significant challenges facing leadership development for clinician managers that arise from these considerations.

Treating an unhealthy organisational culture: the implications of the Bundaberg Hospital Inquiry for managerial ethical decision making.

This paper explores the interplay between individual values, espoused organisational values and the values of the organisational culture in practice in light of a recent Royal Commission in Queensland, Australia, which highlighted systematic failures in patient care. The lack of congruence among values at these levels impacts upon the ethical decision making of health managers. The presence of institutional ethics regimes such as the Public Sector Ethics Act 1994 (Qld) and agency codes of conduct are not sufficient to counteract the negative influence of informal codes of practice that undermine espoused organisational values and community standards. The ethical decision-making capacity of health care managers remains at the front line in the battle against unethical and unprofessional practice.

Self-reported perceptions of Registered Nurses working in Australian hospitals.

AIM: The purpose of this study is to develop an understanding of work environments by analysing the perceptions of a sample of Registered Nurses (RNs). BACKGROUND: Within the context of high staff turnover and a shortage of nurses in the health workforce, it is important that we understand how nurses perceive their work context and view the organisational factors that influence their attitudes towards their workplace. METHODS: Data was collected using a 160-question survey instrument seeking information from RNs in relation to work and perceptions of the work environment and the organisation. The sample was recruited from a convenience sample of three acute hospitals in Queensland, Australia. A response rate of 41% was achieved (n=343). RESULTS: Respondents across the three survey sites identified a number of variables that had particular impact on their working lives. Team interaction, providing good patient care, communication, and abuse towards RNs elicited strong responses by the study respondents. As well, organisational direction, strategy and management returned strong negative responses. In responding to the questions related to personal and organisational morale it was clear that respondents saw them as two distinct concepts. CONCLUSIONS: The results of this study have implications for nurse managers in terms of understanding the nursing workforce as well as key organisational factors that have both positive and negative influences on the perceptions of nurses.

Nursing morale: predictive variables among a sample of registered nurses in Australia.

AIM: This study investigates the determinants of morale among Registered Nurses in Queensland, Australia. BACKGROUND: In light of the public discussions on the issues facing the future of nursing, it is critical to understand the factors that influence morale. METHODS: A 160-question instrument sought information from Registered Nurses on their perceptions of 'self', work and morale. A response rate of 41% was achieved (n = 343) from a convenience sample of three acute hospitals. RESULTS: Following binary logistic regression modelling for organizational morale, significant relationships were found with patient care provision and team interaction. Binary logistic regression modelling for personal morale revealed positive relationships with team interaction, consultation, professional recognition and lower levels of patient abuse. CONCLUSION: The results point to a number of organizational and professional issues that can be considered by health care administrators and policy makers to develop workplaces that have a positive impact on the morale of nurses.

Nursing morale: what does the literature reveal?

There is increasing attention to nursing workforce issues such as recruitment, retention, turnover, workplace health and safety issues and their impact on quality patient care. A number of these problems have been linked to poor morale. While there has been a lack of consensus on the determinants of morale, it is clear that the outcomes of poor morale not only add considerable cost to the organisation but also impact negatively on patient care. This article provides a systematic overview of the literature surrounding nursing morale and the variables identified in the literature that impact upon morale, and discusses the implications for future research.