Evaluating the Validity and Measurement Invariance of the Patient Health Questionnaire-9 Among Canadian Nurses.

Background and Purpose: The patient health questionnaire 9 item (PHQ-9) is a widely used self-reported measure for screening depressive symptoms. This study aims to examine measurement invariance and psychometric properties of the PHQ-9 for screening depressive symptoms in nurses across different nursing roles, gender, and workplace sector. Methods: The study is a secondary analysis of pre-COVID and COVID-19 survey data from 4,176 nurses and 3,238 nurses in British Columbia. Data from the PHQ-9 tested the assumption of unidimensionality, reliability, and presence of differential item functioning (DIF). Results: The PHQ-9 showed excellent internal consistency (r = .9) and a unidimensional factor structure. PHQ-9 items were free of DIF across nursing roles, gender, and workplace sector. Conclusions: This study supported the valid use of the PHQ-9 as a screening tool for depressive symptoms among nurses.

Resident Impact of the Single Site Order Restricting Staff Mobility across Long-Term Care Homes in British Columbia, Canada.

The Single Site Order (SSO)-a policy restricting staff from working at multiple long-term care (LTC) homes-was mandated by the Public Health Agency of Canada to control the spread of COVID-19 in LTC homes, where nearly 70% of COVID-19-related deaths in Canada occurred. This mixed methods study assesses the impact of the SSO on LTC residents in British Columbia. Interviews were conducted (residents (n = 6), family members (n = 9), staff (n = 18), and leadership (n = 10) from long-term care homes (n = 4)) and analyzed using thematic analysis. Administrative data were collected between April 2019 and March 2020 and between April 2020 and March 2021 and analyzed using descriptive statistics and data visualization. Qualitative and quantitative data were triangulated and demonstrated that staffing challenges became worse during the implementation of the SSO, resulting in the mental and physical health deterioration of LTC residents. Qualitative data demonstrated decreased time for personalized and proactive care, increased communication challenges, and increased loneliness and isolation. Quantitative data showed a decline in activities of daily living, increased antipsychotic medication use, pressure ulcers, behavioural symptoms, and an increase in falls. Addressing staff workload and staffing shortages during SSO-related policy implementation is essential to avoid resident health deterioration.

COVID-19 and British Columbia's volunteer search and rescue workers: risk recognition and risk mitigation.

Background: Early during COVID-19, British Columbia coordinated collaboration between academic researchers, public healthcare systems, and private sector partners to focus research resources on knowledge gaps in a timely manner, avoid duplication, and identify overlooked aspects. At a collaboration symposium, it became evident that BC's volunteer search & rescue (SAR) cadre was overlooked. Objective: Our exploratory project studied volunteer SAR's operational readiness; use and perceived value of information sources; consistency in infection prevention measures among volunteer stations, and with their professional counterparts for comparable first aid medical interventions throughout the pandemic. Methods: We partnered with the 2 organizations that govern BC's volunteer SAR stations. Local station leaders completed a short confidential survey. Guidance documents issued by associations governing voluntary and professional first responders were compared. Results: Survey responses were received from 33 of 109 local stations, spanning all regions of BC. Most remained operationally ready throughout the entire pandemic (12.1% had to stand down at times). Except for 21% lacking eye protection, all had personal protective equipment commensurate with that of healthcare professionals; however, few used this PPE in a manner consistent with professional counterparts. Usage and perceived usefulness of various information sources differed. There was no communication link between the province's infection control experts and 2 volunteer SAR organizations. Conclusions: Search & rescue capability was maintained despite pandemic impacts. Results reveal strengths and opportunities for improvement in the ways volunteers are informed and protected. Infection control experts providing advice for emergency health services professional responders should remember to include their volunteer counterparts.

Working through a pandemic: The mediating effect of nurses' health on the relationship between working conditions and turnover intent.

AIM: While research has demonstrated that nurses' health and working conditions are important predictors of turnover in COVID-19, the relationship between these factors is not well understood. Our study investigated the mechanism through which working conditions and nurses' physical and mental health could impact intent to leave the nursing profession. DESIGN: Secondary data from a cross-sectional survey of 3478 nurses in British Columbia administered in May 2021 were analysed using structural equation modelling. METHODS: Two models were assessed utilizing workplace conditions as the predictor, nurses' health as the mediator, and reported turnover intent (Model 1), and anticipated time to turnover (Model 2) as the outcomes. RESULTS: Nurses' health partially mediated the relationship between working conditions and turnover intent, where poorer workplace conditions were directly and indirectly associated with greater likelihood of leaving the profession. Nurses' health fully mediated the relationship between working conditions and nurses' anticipated time to turnover, after controlling for age. The findings from this study underscore the importance of enhancing working conditions and improving nurses' mental health and safety on the job. PATIENT OR PUBLIC CONTRIBUTION: The British Columbia Nurses' Union provided the data for this study; survey data from 3478 nurses were utilized in our study.

A Mixed Methods Study to Implement the Synergy Tool and Evaluate Its Impact on Long-Term Care Residents.

BACKGROUND: There are ongoing workforce challenges with the delivery of long-term care (LTC), such as staffing decisions based on arbitrary standards. The Synergy tool, a resident-centered approach to staffing, provides objective, real-time acuity and dependency scores (Synergy scores) for residents. The purpose of this study was to implement and evaluate the impact of the Synergy tool on LTC delivery. METHODS: A longitudinal mixed methods study took place within two publicly funded LTC homes in British Columbia, Canada. Quantitative data included weekly Synergy scores for residents (24 weeks), monthly aggregated resident falls data (18 months) and a six-month economic evaluation. Qualitative data were gathered from family caregivers and thematically analyzed. RESULTS: Quantitative findings from Synergy scores revealed considerable variability for resident acuity/dependency needs within and across units; and falls decreased during implementation. The six-month economic evaluation demonstrated some cost savings by comparing Synergy tool training and implementation costs with savings from resident fall rate reductions. Qualitative analyses yielded three positive impact themes (improved care delivery, better communication, and improved resident-family-staff relationships), and two negative structural themes (language barrier and staff shortages). CONCLUSIONS: The Synergy tool provides useful data for enhancing a 'fit' between resident needs and available staff.

Predictors of Nursing Faculty Job and Career Satisfaction, Turnover Intentions, and Professional Outlook: A National Survey.

BACKGROUND: Retaining talented and experienced nurses in clinical practice and academia is crucial for maintaining continuity, ensuring high-quality care and education, and fostering a positive work environment. Although factors influencing nursing staff retention are well documented, little is known about how workplace factors impact nursing faculty retention outcomes. METHODS: A national survey involving 645 nursing faculty across Canada was undertaken. Multivariate regression analysis with interaction effects was conducted to determine the association between work-related factors (i.e., workplace culture and work-life imbalance) and faculty job and career satisfaction, turnover intentions, and professional outlook. RESULTS: Supportive workplace culture positively influenced faculty job and career satisfaction and professional outlook, while it negatively impacted turnover intentions. Conversely, work-life imbalance decreased faculty job and career satisfaction and professional outlook (i.e., confidence in nursing program, profession), and it increased intentions to leave the job. CONCLUSION: Our results offer insights into the work-life experiences of Canadian faculty members and shed light on key factors that impact their job-related outcomes. In the context of competing resources, every effort must be made to improve modifiable workplace factors such as the academic work environment and create targeted interventions and policies to promote faculty retention.

Impact of the single site order in LTC: exacerbation of an overburdened system.

BACKGROUND: The long-term care (LTC) sector has been at the epicentre of COVID-19 in Canada. This study aimed to understand the impact that the Single Site Order (SSO) had on staff and leadership in four LTC homes in the Lower Mainland of British Columbia, Canada. METHODS: A mixed method study was conducted by analyzing administrative staffing data. Overtime, turnover, and job vacancy data were extracted and analyzed from four quarters before (April 2019 - March 2020) and four quarters during the pandemic (April 2020 - March 2021) using scatterplots and two-part linear trendlines across total direct care nursing staff and by designation (i.e., registered nurses (RNs), licenced practical nurses (LPNs) and care aids (CAs)). Virtual interviews were conducted with a purposive sample of leadership (10) and staff (18) from each of the four partner care homes (n = 28). Transcripts were analyzed in NVivo 12 using thematic analysis. RESULTS: Quantitative data indicated that the total overtime rate increased from before to during the pandemic, with RNs demonstrating the steepest rate increase. Additionally, while rates of voluntary turnover showed an upward trend before the pandemic for all direct care nursing staff, the rate for LPNs and, most drastically, for RNs was higher during the pandemic, while this rate decreased for CAs. Qualitative analysis identified two main themes and sub-themes: (1) overtime (loss of staff, mental health, and sick leave) and (2) staff turnover (the need to train new staff, and gender/race) as the most notable impacts associated with the SSO. CONCLUSIONS: The results of this study indicate that the outcomes due to COVID-19 and the SSO are not equal across nursing designations, with the RN shortage in the LTC sector highly evident. Quantitative and qualitative data underscore the substantial impact the pandemic and associated policies have on the LTC sector, namely, that staff are over-worked and care homes are understaffed.

Workplace Predictors of Violence against Nurses Using Machine Learning Techniques: A Cross-Sectional Study Utilizing the National Standard of Psychological Workplace Health and Safety.

BACKGROUND: Nurses experience an alarming rate of violence in the workplace. While previous work has indicated that working conditions play an important role in workplace violence outcomes, these studies have not used comprehensive and systematically operationalized variables. METHODS: Through cross-sectional survey responses from 4066 British Columbian nurses, we identified which of the 13 psychosocial factors, as outlined in the National Standard of Psychological Workplace Health and Safety, are most predictive of workplace violence perpetrated against nurses by patients and their visitors (Type II violence) and organizational employees (Type III violence). RESULTS: Eighty-seven percent of respondents indicated that they had experienced Type II violence, whereas 48% indicated they had experienced Type III violence over the last year. Lack of physical safety, workload management, and psychological protection were the top three psychosocial factors in the workplace predictive of Type II violence, whereas lack of civility and respect, organizational culture, and psychological support were the top three factors associated with Type III violence. CONCLUSIONS: The findings in this study shed light on the distinct psychosocial factors in the workplace in need of investment and intervention to address Type II and III violence.

Culture Change in Long-Term Care-Post COVID-19: Adapting to a New Reality Using Established Ideas and Systems.

The response to the COVID-19 pandemic in long-term care (LTC) has threatened to undo efforts to transform the culture of care from institutionalized to de-institutionalized models characterized by an orientation towards person- and relationship-centred care. Given the pandemic's persistence, the sustainability of culture-change efforts has come under scrutiny. Drawing on seven culture-change models implemented in Canada, we identify organizational prerequisites, facilitatory mechanisms, and frontline changes relevant to culture change that can strengthen the COVID-19 pandemic response in LTC homes. We contend that a reversal to institutionalized care models to achieve public health goals of limiting COVID-19 and other infectious disease outbreaks is detrimental to LTC residents, their families, and staff. Culture change and infection control need not be antithetical. Both strategies share common goals and approaches that can be integrated as LTC practitioners consider ongoing interventions to improve residents' quality of life, while ensuring the well-being of staff and residents' families.

Experiences of Healthcare Workers in Long-Term Care during COVID-19: A Scoping Review.

Background: Although healthcare workers (HCWs) in long-term care (LTC) have experienced significant emotional and psychological distress throughout the pandemic, little is known about their unique experiences. Objective: This scoping review synthesizes existing research on the experiences of HCWs in LTC during the COVID-19 pandemic. Method: Following Arksey and O'Malley's framework, data published between March 2020 to June 2022, were extracted from six databases. Results: Among 3808 articles screened, 40 articles were included in the final analysis. Analyses revealed three interrelated themes: carrying the load (moral distress); building pressure and burning out (emotional exhaustion); and working through it (a sense of duty to care). Conclusion: Given the impacts of the pandemic on both HCW wellbeing and patient care, every effort must be made to address the LTC workforce crisis and evaluate best practices for supporting HCWs experiencing mental health concerns during and post-COVID-19.

Priority Nursing Populations for Mental Health Support Before and During COVID-19: A Survey Study of Individual and Workplace Characteristics.

BACKGROUND: Nursing is a high-risk profession and nurses' exposure to workplace risk factors such as heavy workloads and inadequate staffing is well documented. The COVID-19 pandemic has exacerbated nurses' exposure to workplace risk factors, further deteriorating their mental health. Therefore, it is both timely and important to determine nursing groups in greatest need of mental health interventions and supports. PURPOSE: The purpose of this study is to provide a granular examination of the differences in nurse mental health across nurse demographic and workplace characteristics before and after COVID-19 was declared a pandemic. METHODS: This secondary analysis used survey data from two cross-sectional studies with samples (Time 1 study, 5,512 nurses; Time 2, 4,523) recruited from the nursing membership (∼48,000) of the British Columbia nurses' union. Data was analyzed at each timepoint using descriptive statistics and ordinal logistic regression. RESULTS: Several demographic and workplace characteristics were found to predict significant differences in the number of positive screenings on measures of poor mental health. Most importantly, in both survey times younger age was a strong predictor of worse mental health, as was full-time employment. Nurse workplace health authority was also a significant predictor of worse mental health. CONCLUSIONS: Structural and psychological strategies must be in place, proactively and preventively, to buffer nurses against workplace challenges that are likely to increase during the COVID-19 crisis.

The Canadian Long-Term Care Sector Collapse from COVID-19: Innovations to Support People in the Workforce.

The COVID-19 pandemic rattled Canada's long-term care (LTC) sector by exacerbating the ingrained systemic and structural issues, resulting in tragic consequences for the residents, family members and LTC staff. At the core of LTC's challenges is chronic under-staffing, leading to lower quality of care for residents and higher degrees of moral distress among staff. A rejuvenation of the LTC sector to support its workforce is overdue. A group of diverse and renowned researchers from across Canada set out to implement innovative evidence-informed solutions in various LTC homes. Their findings call for immediate action from policy makers and LTC decision makers.

Using Photovoice as a Method for Capturing the Lived Experiences of Caregivers During COVID-19: A Methodological Insight.

Although the extant literature identifies photovoice as one of the most innovative and creative research methods that encourage reflection and introspection, few studies have described the use of photovoice with family/informal caregivers. This paper discusses the implementation of photovoice as a novel approach in exploring the experiences of informal caregivers (n = 10) of older adults in long-term care homes during the COVID-19 pandemic. The article describes the four stages of the photovoice process undertaken: (1) preparation; (2) pre-focus group meeting; (3) taking photographs; and (4) reflection and implementation insights, to researchers. The different stages in the research process inspired several key learnings, including the use of co-learning tools, the valuable combination of photographic images and words to provide rich description of participants' perspectives, and creative ways to engage and support caregivers in sharing their stories. This paper also addresses some practical challenges of using this methodology with informal caregivers and explore issues surrounding research ethics and photographs. Knowledge gained from this case example provides strong support for the use of photovoice as a creative approach to better illuminate and understand the experiences of caregivers and can inform the design of future virtual studies.

Unintended Consequences of Pandemic Management Strategies on Residents and Family in One Long-term Care Home in British Columbia: A Patient-Supported Qualitative Study.

Background and Objectives: In March 2020, pandemic management strategies were mandated across long-term care homes in British Columbia, Canada, to control the effects of COVID-19. This study describes and contextualizes the impact of visitation, infection prevention and control, and staffing strategies on the perceived health and well-being of residents and families. Research Design and Methods: This interpretive description study was part of a larger mixed-methods study at a publicly funded not-for-profit long-term care home in British Columbia, Canada. Eleven family members and 10 residents were interviewed between October and December 2020, and resident and family partners participated in a steering committee throughout all stages of the research. Findings: Early pandemic management strategies had an adverse impact on the perceived health and well-being of families and residents. Visitation restrictions eliminated care routinely provided by families and prevented in-person communication between residents, families, and care providers. Other infection prevention and control strategies isolated residents; group enrichment programs were stopped, and lockdowns created a perception of incarceration. Donning and doffing personal protective equipment took time away from staff-resident interactions and the single-site order reduced staff numbers, placing additional time restraints on residents' care. Discussion and Implications: Unintended adverse consequences of pandemic management strategies demonstrate the risks of creating policies based on a medicalized definition of health. Clear lines of communication are vital to increase a sense of control for families and residents. Elimination of care provided by families and paid companions exposed a gap in Canada's public long-term care system. This care gap raises concerns about equitable care access for residents without families or financial means to pay for additional care.

The Association between Mental Health Symptoms and Quality and Safety of Patient Care before and during COVID-19 among Canadian Nurses.

(1) Background: While the association between nurse mental health and quality and safety of patient care delivery was well documented pre-pandemic, fewer research studies have examined this relationship in the context of COVID-19. This study examines the impact of various mental health symptoms experienced by nurses on quality and safety before and during the COVID-19 pandemic; (2) Methods: A secondary analysis of cross-sectional survey data from 4729 and 3585 nurses in one Canadian province between December 2019 and June-July 2020 was conducted. Data were analyzed using between group difference tests and logistic regression; (3) Results: Compared to pre-COVID-19, during COVID-19 nurses reported a higher safety grade, a greater likelihood of recommending their units for care and lower quality of nursing care. Most mental health symptoms were higher during COVID-19 and higher levels of mental health symptoms were correlated with lower ratings of quality and safety both pre- and during COVID-19; (4) Conclusion: Mental health symptoms have implications for nurses' quality and safety of patient care delivery, with the association between mental health symptoms and quality and safety following a dose-response relationship before and during COVID-19. These findings suggest that it is worthwhile for nurse mental health symptoms to be included as hospital level performance metrics.

Striking a Balance between Work and Play: The Effects of Work-Life Interference and Burnout on Faculty Turnover Intentions and Career Satisfaction.

BACKGROUND: The interactions between work and personal life are important for ensuring well-being, especially during COVID-19 where the lines between work and home are blurred. Work-life interference/imbalance can result in work-related burnout, which has been shown to have negative effects on faculty members' physical and psychological health. Although our understanding of burnout has advanced considerably in recent years, little is known about the effects of burnout on nursing faculty turnover intentions and career satisfaction. OBJECTIVE: To test a hypothesized model examining the effects of work-life interference on nursing faculty burnout (emotional exhaustion and cynicism), turnover intentions and, ultimately, career satisfaction. DESIGN: A predictive cross-sectional design was used. SETTINGS: An online national survey of nursing faculty members was administered throughout Canada in summer 2021. PARTICIPANTS: Nursing faculty who held full-time or part-time positions in Canadian academic settings were invited via email to participate in the study. METHODS: Data were collected from an anonymous survey housed on Qualtrics. Descriptive statistics and reliability estimates were computed. The hypothesized model was tested using structural equation modeling. RESULTS: Data suggest that work-life interference significantly increases burnout which contributes to both higher turnover intentions and lower career satisfaction. Turnover intentions, in turn, decrease career satisfaction. CONCLUSIONS: The findings add to the growing body of literature linking burnout to turnover and dissatisfaction, highlighting key antecedents and/or drivers of burnout among nurse academics. These results provide suggestions for suitable areas for the development of interventions and policies within the organizational structure to reduce the risk of burnout during and post-COVID-19 and improve faculty retention.

Implementation of the Synergy Tool: A Potential Intervention to Relieve Health Care Worker Burnout.

(1) Background: Healthcare workers experienced rising burnout rates during and after the COVID-19 pandemic. A practice-academic collaboration between health services researchers and the surgical services program of a Canadian tertiary-care urban hospital was used to develop, implement and evaluate a potential burnout intervention, the Synergy tool. (2) Methods: Using participatory action research methods, this project involved four key phases: (I) an environmental scan and a baseline survey assessment, (II), a workshop, (III) Synergy tool implementation and (IV) a staffing plan workshop. A follow-up survey to evaluate the impact of Synergy tool use on healthcare worker burnout will be completed in 2023. (3) Results: A baseline survey assessment indicated high to severe levels of personal and work-related burnout prior to project initiation. During the project phases, there was high staff engagement with Synergy tool use to create patient care needs profiles and staffing recommendations. (4) Conclusions: As in previous research with the Synergy tool, this patient needs assessment approach is an efficient and effective way to engage direct care providers in identifying and scoring acuity and dependency needs for their specific patient populations. The Synergy tool approach to assessing patient needs holds promise as a means to engage direct care providers and to give them greater control over their practice-potentially serving as a buffer against burnout.

Psychometric Evaluation of the Korean Version of Hospital Survey on Patient Safety Culture.

OBJECTIVES: This study evaluated the psychometric properties of the Korean-language version of the Hospital Survey on Patient Safety Culture (HSOPSC) among Korean nurses. METHODS: We analyzed secondary data from 801 direct care nurses working at a tertiary, private, nonprofit, teaching hospital in South Korea. Descriptive statistics, internal consistency coefficients, and intercorrelations were calculated. The latent factor structure of the HSOPSC was examined using exploratory structural equation modeling techniques, which account for the noncontinuous nature of ordinal data. RESULTS: Although a majority of subscales showed acceptable to good internal consistency, 4 dimensions (staffing, overall perceptions of patient safety, organizational learning-continuous improvement, and nonpunitive response to errors) had reliability levels less than 0.6. The HSOPSC items loaded somewhat diffusely on 3 subscales: staffing, teamwork across units, and organizational learning-continuous improvement. Correlations between the 12 HSOPSC factors indicated discriminant validity. Convergent validity was supported by correlations between the 12 subscales and a single-item outcome variable, namely, patient safety grade. Several items did not load well on their respective subscales, but most items fit the underlying theoretical model implied by the HSOPSC, resulting in an acceptable model fit (confirmatory fit index = 0.985, root mean square error of approximation = 0.034, weighted root mean square residual = 0.54). CONCLUSIONS: Despite the acceptable model fit of the Korean version of HSOPSC, the psychometric properties of this instrument require further investigation to ensure it is an effective tool to measure patient safety culture and identify areas for improvement in the Korean health care system.

Workplace Predictors of Quality and Safe Patient Care Delivery Among Nurses Using Machine Learning Techniques.

BACKGROUND: Working in unhealthy environments is associated with negative nurse and patient outcomes. Previous body of evidence in this area is limited as it investigated only a few factors within nurses' workplaces. PURPOSE: The purpose of this study was to identify the most important workplace factors predicting nurses' provision of quality and safe patient care using a 13-factor measure of workplace conditions. METHODS: A cross-sectional correlational survey study involving 4029 direct care nurses in British Columbia was conducted using random forest data analytics methods. RESULTS: Nurses' reports of healthier workplaces, particularly workload management, psychological protection, physical safety and engagement, were associated with higher ratings of quality and safe patient care. CONCLUSION: These workplace conditions are perceived to impact patient care through influencing nurses' mental health. To ensure a high standard of patient care, data-driven policies and interventions promoting overall nurse mental health and well-being are urgently required.

Identifying the most important workplace factors in predicting nurse mental health using machine learning techniques.

OBJECTIVES: Nurses are at a high risk of developing mental health problems due to exposure to work environment risk factors. Previous research in this area has only examined a few factors within nurses' work environments, and those factors were not conceptualized with the goal of improving workplace mental health. The purpose of this study is to identify the most important work environment predictors of nurse mental health using a comprehensive and theoretically grounded measure based on the National Standard of Psychological Health and Safety in the Workplace. METHODS: This is an exploratory cross-sectional survey study of nurses in British Columbia, Canada. For this study, responses from a convenience sample of 4029 actively working direct care nurses were analyzed using random forest regression methods. Key predictors include 13 work environment factors. Study outcomes include depression, anxiety, post-traumatic stress disorder (PTSD), burnout and life satisfaction. RESULTS: Overall, healthier reports of work environment conditions were associated with better nurse mental health. More specifically balance, psychological protection and workload management were the most important predictors of depression, anxiety, PTSD and emotional exhaustion. While engagement, workload management, psychological protection and balance were the most important predictors of depersonalization, engagement was the most important predictor of personal accomplishment. Balance, psychological protection and engagement were the most important predictors of life satisfaction. CONCLUSIONS: Routine assessment with standardized tools of nurses' work environment conditions and mental health is an important, evidence-based organizational intervention. This study suggests nurses' mental health is particularly influenced by worklife balance, psychological protection and workload management.