Nursing Services Delivery Theory: an open system approach.

AIM: This paper is a discussion of the derivation of the Nursing Services Delivery Theory from the application of open system theory to large-scale organizations. BACKGROUND: The underlying mechanisms by which staffing indicators influence outcomes remain under-theorized and unmeasured, resulting in a 'black box' that masks the nature and organization of nursing work. Theory linking nursing work, staffing, work environments, and outcomes in different settings is urgently needed to inform management decisions about the allocation of nurse staffing resources in organizations. DATA SOURCES: A search of CINAHL and Business Source Premier for the years 1980-2008 was conducted using the following terms: theory, models, organization, organizational structure, management, administration, nursing units, and nursing. Seminal works were included. DISCUSSION: The healthcare organization is conceptualized as an open system characterized by energy transformation, a dynamic steady state, negative entropy, event cycles, negative feedback, differentiation, integration and coordination, and equifinality. The Nursing Services Delivery Theory proposes that input, throughput, and output factors interact dynamically to influence the global work demands placed on nursing work groups at the point of care in production subsystems. IMPLICATIONS FOR NURSING: THE Nursing Services Delivery Theory can be applied to varied settings, cultures, and countries and supports the study of multi-level phenomena and cross-level effects. CONCLUSION: The Nursing Services Delivery Theory gives a relational structure for reconciling disparate streams of research related to nursing work, staffing, and work environments. The theory can guide future research and the management of nursing services in large-scale healthcare organizations.

Development and psychometric testing of the Relational Care Scale.

The purpose of this article is to report the development and testing of the self-report Relational Care Scale (RCS). The RCS was specifically designed to evaluate the relational care that nursing staff provides to residents living in nursing homes. The scale's content validity was assessed with the assistance of experts and related research in the area of nurse-resident interactions, and then the scale was pilot tested with 30 residents of a long-term care (LTC) facility to determine its clarity and stability. The 6-item scale was then administered to a sample of 50 residents in an intervention study and then to 72 residents in a correlational study in two other LTC facilities in Ontario, Canada. Construct validity was demonstrated with positive correlations between RCS scores and a Relationship VAS measure (r = .63, p < .0001) and between RCS scores and an observational Relational Behavior Scale (r = .42, p < .001), which was also developed to assess relational care. Study results demonstrated that the RCS is a reliable and valid instrument that may be used to measure relational care to test interventions focusing on enhancing the relational care staff provides to residents.

Analysis of the moral habitability of the nursing work environment.

BACKGROUND: Following health reform, nurses have experienced the tremendous stress of heavy workloads, long hours and difficult professional responsibilities. In recognition of these problems, a study was conducted that examined the impact of the working environment on the health of nurses. After conducting focus groups across Canada with nurses and others well acquainted with nursing issues, it became clear that the difficult work environments described had significant ethical implications. AIM: The aim of this paper is to report the findings of research that examined the moral habitability of the nursing working environment. METHODS: A secondary analysis was conducted using the theoretical work of Margaret Urban Walker. Moral practices and responsibilities from Walker's perspective cannot be extricated from other social roles, practices and divisions of labour. Moral-social orders, such as work environments in this research, must be made transparent to examine their moral habitability. Morally habitable environments are those in which differently situated people experience their responsibilities as intelligible and coherent. They also foster recognition, cooperation and shared benefits. FINDINGS: Four overarching categories were developed through the analysis of the data: (1) oppressive work environments; (2) incoherent moral understandings; (3) moral suffering and (4) moral influence and resistance. The findings clearly indicate that participants perceived the work environment to be morally uninhabitable. The social and spatial positioning of nurses left them vulnerable to being overburdened by and unsure of their responsibilities. Nevertheless, nurses found meaningful ways to resist and to influence the moral environment. CONCLUSIONS: We recommend that nurses develop strong moral identities, make visible the inseparability of their proximity to patients and moral accountability, and further identify what forms of collective action are most effective in improving the moral habitability of their work environments.

Effects of a relationship-enhancing program of care on outcomes.

PURPOSE: To examine the effects of a relationship-enhancing program of care (REPC) on resident and care provider outcomes. DESIGN AND METHODS: A quasi-experimental, repeated measures design, with intervention and comparison groups. Questionnaires were distributed to 50 residents, and observations were conducted of 40 residents and 34 nursing staff at baseline and 3 months after the intervention, on two Canadian nursing home units. An investigator-designed educational program based on Winnicott's theory of relationships and the empirical literature, was provided to care providers and their supervisors on the intervention unit. Repeated measures analysis of variance (RM-ANOVA) was used to compare the intervention and comparison groups in regard to changes in the outcomes over time. FINDINGS: The REPC had statistically significant effects on (a) residents' perceptions of care providers' relational care, (b) care providers' relational behaviors, and (c) continuity of care. CONCLUSIONS: Evidence showed that these care providers were taught how to enhance their relational skills with residents living in long-term care facilities without added staff. Recommendations for practice and research are discussed.