Humane and Comprehensive Management of Challenging Behaviour in Health and Social Care: Cross-Sectional Study Testing Newly Developed Instrument.

BACKGROUND: Management of challenging behaviour causes victimization and violates the human rights of service users in psychiatric and long-term settings for people having mental health issues and learning disabilities. The purpose of the research was to develop and test an instrument for measuring humane behaviour management (HCMCB). The research was guided by the following questions: (1) What is the structure and content of the Human and Comprehensive management of Challenging Behaviour (HCMCB) instrument, (2) What are the psychometric properties of the HCMCB instrument, and (3) How do Finnish health and social care professionals evaluate their humane and comprehensive management of challenging behaviour? METHODS: A cross-sectional study design and STROBE checklist were applied. A convenience sample of health and social care professionals (n = 233) studying at the University of Applied Sciences (n = 13) was recruited. RESULTS: The EFA revealed a 14-factor structure and included a total of 63 items. The Cronbach's alpha values for factors varied from 0.535 to 0.939. The participants rated their individual competence higher than leadership and organizational culture. CONCLUSIONS: HCMCB is a useful tool for evaluating competencies, leadership, and organizational practices in the context of challenging behaviour. HCMCB should be further tested in various international contexts involving challenging behaviour with large samples and longitudinal design.

Structural and psychological empowerment of students obtaining continuing leadership education in Finland-a national survey.

BACKGROUND: In nursing, empowerment may be deemed one's potential to gain power, achieve goals and promote one's skills to advance positive changes in the working environment, or decentralization of authority. Empowerment is associated with nurses' and nurse leaders' satisfaction, performance and organizational commitment, as well as burnout, emotional exhaustion and intentions to leave the profession. Research on nurse empowerment in relation to continuing education is sparse. OBJECTIVES: This study describes the structural and psychological empowerment levels of students beginning a collaboratively implemented continuing leadership education program. DESIGN: Cross-sectional electronic survey. SETTINGS: National, continuing nursing leadership education program (37 ECT) organized by five universities that provide masters level education to nurse leaders in Finland. PARTICIPANTS: Students (N = 85) working at nine healthcare organizations across the service system as current or prospective nurse leaders and enrolled in the continuing leadership education program. METHODS: The Conditions of Work Effectiveness Questionnaire and the Work Empowerment Questionnaire were each used to measure structural and psychological empowerment, respectively. The data were collected between October 2019 and February 2020. RESULTS: A total of 69 students participated (response rate 81 %). Moderate levels of both structural and psychological empowerment were observed. In structural empowerment, the strongest dimension was access to opportunity (4.1, SD 0.7), whereas access to support was the weakest (2.7, SD 0.7). The strongest psychological empowerment dimension was verbal empowerment (8.5, SD 1.9) and the weakest was outcome empowerment (7.0, SD 1.6). CONCLUSIONS: Nurses and nurse leaders seem to lack the status and power required to impact their organizations, possibly causing them to apply for nursing leadership education. Nurse leaders should be given opportunities for continuing leadership education to improve empowerment and, as a result, staff outcomes.

Conceptual framework for a comprehensive competence in managing challenging behaviour: The views of trained instructors.

WHAT IS KNOWN ON THE SUBJECT?: There is body of knowledge available about the harms associated with restrictive interventions used in behaviour management, service users' perceptions of the use of restraints, and staff competence in behaviour management. The staff perspective has been studied in terms of staff exposure, responses to and prevention of aggression, staff-related factors associated with service user aggression, and staff attitudes and perceptions towards violence. The definitions of competence in behaviour management provided in training interventions are fragmented and based on unilateral measurements. Training interventions with the purpose of enhancing staff competence in behaviour management are organized regularly, yet there is a lack of clarity on how effective these interventions are. Inadequate conceptual understanding of behaviour management can weaken the effectiveness of these interventions. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Our study produced new knowledge by providing a preliminary conceptual framework that can be used to comprehensively describe and assess competence in managing challenging behaviour and to cover safely the whole care process. Humane care and ethical sensitivity should be the premises of interaction with people in distress. We also pointed out the needs for conceptual clarification of the concepts of confidence, support and restraint. We provide important new insight into the leadership and cultural issues of behaviour management that is relevant for patients, staff members and healthcare organizations. We found that staff members do not consider service user safety and workplace safety as opposing issues. Further, we provide new perspectives for prevention, the risk assessment process and effective communication in the context of behaviour management. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: A comprehensive understanding of the competences related to behaviour management will foster universal definitions for "support" and "restraint," which can then be used to ensure that the best practices are used for behaviour management. Organizational culture and participative leadership on behaviour management should be developed with a special focus on safety issues, common understanding of comprehensive competence, risk assessment and prevention, views regarding the use of restraints, and teamwork. ABSTRACT: Introduction Previous research concerning staff views of behaviour management has not considered instructors' views. The definitions of competence in behaviour management are fragmented, which can undermine the effectiveness of training interventions. Aim/Question This study aimed to describe Finnish and British Management of Actual or Potential Aggression instructors' perceptions of safety and behaviour management-related competences and create a conceptual framework for comprehensive competence. Method An explorative-descriptive qualitative approach with purposive sampling (N = 22), semi-structured interviews and abductive content analysis. Results Conceptual framework of comprehensive competence in managing challenging behaviour includes five categories-knowledge, skills, attitude, confidence and ethical sensitivity-and 21 subcategories. Competent staff and supportive leadership ensured safety, while inconsistent risk management culture, the health and behaviour of service users, and inadequate staff orientation endangered safety. Discussion The study produced new knowledge of safety issues and competences from the perspective of the instructors who deliver behaviour management training. Implications for practice Competence to manage challenging behaviour should be developed based on our conceptual framework to provide an effective and safe training. Prevention, the risk assessment process, alternative communication, and the definitions of "confidence," "support" and "restraint" should all be sufficiently addressed in future training.

Patient safety and staff competence in managing challenging behavior based on feedback from former psychiatric patients.

PURPOSE: This study aimed to describe the perceptions and lived experiences of former psychiatric patients of their own and/or co-patients' behavior that nursing staff has regarded as challenging and that has resulted in behavior management. DESIGN AND METHODS: An explorative-descriptive qualitative design with video vignettes, semistructured interviews, and abductive content analysis. FINDINGS: Many reasons for different kinds of patient behavior that were considered challenging by staff were identified. Delivering care based on patients' needs was identified as core staff competence. PRACTICE IMPLICATIONS: Findings can be utilized when pursuing restraint reduction in psychiatric care by enhancing staff competence.

Older people nursing in care homes: An examination of nursing professionals' self-assessed competence and its predictors.

BACKGROUND: The need for older people nursing expertise is increasing, and every effort is required to ensure that personnel taking care of older people are capable of providing high-quality care. AIMS: To explore care home nursing professionals' self-rated competence in older people nursing and to identify predictors of this competence. DESIGN: A cross-sectional survey design. METHOD: Data were collected in August-September 2017 via an electronic questionnaire using the newly developed Nurse Competence in Care Home Scale (NCCHS). Participants (n = 781) were recruited via nurses' associations and social media. They were working in care homes either as licensed practical nurses (n = 680) or as registered nurse and/or in managerial position (n = 101). FINDINGS: Approximately 65% of the respondents had "adequate competence," and 35% had "inadequate competence" in older people nursing based on self-assessed overall competence. Respondents rated their competence highest in "observation, communication, interaction" and lowest in "group guidance and activities" subscale. Age and further training were predictors of licensed practical nurses' competence, and length of work experience predicted registered nurses' competence. CONCLUSIONS: Self-assessments revealed the need for competence development especially in relation to holistic support of a person's well-being. It is recommended that care home nurses, managers, educators and curriculum developers all strive to develop care home staff's ability to support residents' well-being holistically. IMPLICATIONS FOR PRACTICE: Nursing personnel should consider all aspects of older people's well-being holistically. In care homes, it is essential to assess nursing staff competence and to provide possibilities for competence development for personnel.

Patient participation in patient safety-An exploration of promoting factors.

AIMS: To study how internal medicine patients experienced patient safety during their recent periods of care and to identify explanatory factors for patient participation. BACKGROUND: Patient participation is recognized as one of the main factors promoting quality and safety and the identification of effective interventions that encourage safe care. METHODS: A cross-sectional survey of patients (n = 462) in the internal medicine wards (n = 18) of all five Finnish university hospitals. Data were analysed using principal component analysis and multiple linear regression. RESULTS: Most patients (78%) assessed the level of patient safety on their ward as "very good" or "excellent," 20% of patients assessed it as acceptable or worse. The following were considered to be the most important factors explaining higher patient participation: informing patients about the research and encouraging them to participate (ß = 0.378, p < 0.001), providing necessary information promptly and comprehensibly (ß = 0.393, p < 0.001), and enhancing patients' ability to identify patient safety incident(s) (ß = 0.186, p < 0.001). CONCLUSIONS: Healthcare workers must improve by encouraging patient participation and providing relevant information to patients. IMPLICATION FOR NURSING MANAGEMENT: Nursing leaders must be competent to support, lead, and allocate resources for the creation of an environment where patient participation can occur and is valued by health care workers.

An Integrative Review of Interventions for Enhancing Leadership in the Implementation of Evidence-Based Nursing.

BACKGROUND: The most common barriers to evidence-based nursing (EBN) are related to nurse leadership and to organizational characteristics. Scientific evidence is needed regarding interventions that support nurse leadership. AIMS: The aim was to gather, assess, and synthesize the current empirical evidence regarding interventions for enhancing nursing leadership in EBN implementation. METHODS: We conducted an integrative review of interventions that enhance the roles of nurse leaders in EBN implementation using reporting guidance according to the PRISMA statement. RESULTS: The search identified five studies, which described two intervention types: interventions improving nurse leaders' capabilities for EBN implementation and supporting the activities for EBN implementing. The interventions focused on strategic, teamwork, and individual levels. All interventions produced positive outcomes on primary outcomes, however all not statistically significant. LINKING EVIDENCE TO ACTION: The studies mainly had descriptive designs and short follow-up times, so it was not possible to propose evidence-based recommendations for effective interventions. The certainty of evidence was very low due to the study designs and the risk of bias. Structured clinical education might promote new innovations in evidence-based leadership in nursing. Conclusions about the impact of the interventions must be drawn with caution. They might be useful for promoting the abilities of nurse leaders to implement EBN, but further studies are needed to provide more reliable recommendations.

Patient-reported experiences of patient safety incidents need to be utilized more systematically in promoting safe care.

OBJECTIVE: To analyze patient safety incidents (PSIs) reported by patients and their use in Finnish healthcare organizations. STUDY DESIGN: Cross-sectional study. SETTING: About 15 Finnish healthcare organizations ranging from specialized hospital care to home care, outpatient and inpatient clinics, and geographically diverse areas of Finland. PARTICIPANTS: The study population included all Finnish patients who had voluntarily reported PSI via web-based system in 2009-15. MAIN OUTCOME MEASURE(S): Quantitative analysis of patients' safety reports, inductive content analysis of patients' suggestions to prevent the reoccurrence incidents and how those suggestions were used in healthcare organizations. RESULTS: Patients reported 656 PSIs, most of which were classified by the healthcare organizations' analysts as problems associated with information flow (32.6%) and medications (18%). Most of the incidents (65%) did not cause any harm to patients. About 76% of the reports suggested ways to prevent reoccurrence of PSIs, most of which were feasible, system-based amendments of processes for reviewing or administering treatment, anticipating risks or improving diligence in patient care. However, only 6% had led to practical implementation of corrective actions in the healthcare organizations. CONCLUSIONS: The results indicate that patients report diverse PSIs and suggest practical systems-based solutions to prevent their reoccurrence. However, patients' reports rarely lead to corrective actions documented in the registering system, indicating that there is substantial scope to improve utilization of patients' reports. There is also a need for strong patient safety management, including willingness and commitment of HCPs and leaders to learn from safety incidents.

Family members' expectations regarding nurses' competence in care homes: a qualitative interview study.

BACKGROUND: Structural and cultural changes in the care of older people have influenced nursing practice, creating a need to identify current competency requirements for nurses working in care homes. Family members have an important role in ensuring the well-being of older people living in care homes, and family members' can provide valuable information about competence requirements. AIM: To explore the expectations of the care home residents' family members regarding the competence of nurses in care homes for older people. METHODS: A qualitative descriptive design was used. Semi-structured interviews were conducted with 18 care home residents' family members between March and September 2016. Participants were recruited with help from regional associations and member associations of The Central Association of Carers in Finland and from regional associations of The Alzheimer's Society of Finland. The snowball technique was also used. The data were analysed using inductive content analysis. ETHICS: Ethics committee approval was obtained from the university committee on research ethics, and written informed consent was obtained from participants. FINDINGS: The care home residents' family members expected that nurses would be able to interact with and treat people respectfully. Reflective collaboration between the nurse and a family member was also emphasised. Family members expected nurses to provide high-quality basic care and nursing and support residents' well-being individually and holistically. CONCLUSIONS: Family members' expectations reflect the need for ethical and interactional competence in the care home. In addition, evidence-based practice competencies are required to provide high-quality care. Nurses' ability to provide person-centred, individual and holistic care is vital to ensure care home residents' well-being.

Increasing value-adding patient care by applying a modified TCAB program.

Purpose The purpose of this study is to evaluate a development process aimed at increasing registered nurses' (RNs) working time use in value-adding patient care by applying a modified Transforming Care at the Bedside (TCAB) program at inpatient units of two tertiary hospitals. Design/methodology/approach Basic data for the development process were collected on RNs' working time use via external observation in 2011 (RNs = 113). Nursing work was redesigned and implemented by 12 multi-professional teams during 2012-2013. The development process was evaluated by repeating the collection of RNs' working time use data in 2013 (RNs = 95) and by analyzing the memos of the development teams via deductive content analysis ( N = 64). Findings RNs' working time use showed statistically significant increases in value-adding care and direct patient care but decreases in non-value-added work and miscellaneous work. Changes in the nursing work model, division of labor and the nursing work environment all affected RNs' working time use. Practical implications The development process progressed distinctively in each unit, as shown by the results of the development work. Clinical RNs had key roles as innovators and change agents, yet the engagement of nursing managers was most essential for the success of the development work. Originality/value Even minor changes in nurses' daily work profile can have considerable effects on RNs' work. The TCAB program was shown to be a useful method in developing RNs' work also in psychiatric units.

A quantitative systematic review of the effects of training interventions on enhancing the competence of nursing staff in managing challenging patient behaviour.

AIMS: This systematic quantitative review identifies and summarizes the current knowledge and effects of training interventions for managing patients' challenging behaviour. BACKGROUND: Challenging behaviour is an acknowledged worldwide healthcare problem and its management can have a huge impact on quality of care. Evidence-based training interventions that focus on managing challenging behaviour are needed, but few tools for the systematic evaluation of these interventions are currently offered. DESIGN: A quantitative systematic review following the 2008 Centre for Reviews and Dissemination guidelines. DATA SOURCES: CINAHL, Scopus, PsycInfo, PubMed and Cochrane were searched using the same terms for papers published in English from 2005-2015. REVIEW METHODS: Studies were assessed for quality and risk of bias, according to the Cochrane Effective Practice and Organisation of Care Group criteria. A narrative summary was conducted. RESULTS: We included 17 studies and evaluated 16 training interventions. Interventions were classified into four key themes: disengagements, communication, controlling behavioural symptoms and restrictive measures. Our review showed that interventions were more likely to decrease violent incident rates and increase staff confidence than change staff attitudes or increase knowledge. The elements of competence used to manage challenging behaviour were measured unilaterally. The evidence provided by studies was largely weak. CONCLUSION: The variety of measurements used in the studies made comparing the effectiveness of the training interventions difficult. An individual's competence to manage challenging behaviour needs to be defined and a comprehensive scale for evaluating competence is also needed. Patient safety should be included in future evaluations.

Improving the quality of registered nurses' working time use data.

AIMS AND OBJECTIVES: To examine the advantages and disadvantages of external observation and self-reporting methods in investigating registered nurses' working time use in order to improve the quality of working time use data. BACKGROUND: External observation and self-reporting methods are the most widely used approaches for studying nurses' working time use in observational work sampling studies, but there is scarce information of the data collection procedures and results in the same research context and in the same study. DESIGN: A cross-sectional quantitative study with a structured data collection instrument developed for this study. The same instrument was used in both data collections. METHODS: Data were collected from six inpatient units at two Finnish tertiary hospitals in autumn 2013 over two consecutive weeks. All registered nurses (n = 95) from two internal medical units, two surgical units and two psychiatric units participated in this study. RESULTS: Statistically significantly divergent information was produced by the two data collection methods in the major nursing categories of value-adding care and non-value-adding work as well as in each of the seven nursing subcategories. CONCLUSIONS: External observation and self-reporting gave an overall picture of how registered nurses are using their working time, and both methods were useful in examining registered nurses' working time use when taking into account the advantages and disadvantages of these methods. The deviations between the results improved the quality of data because both methods address recognised shortcomings of the other. RELEVANCE TO CLINICAL PRACTICE: This research promotes awareness of the divergent study results by investigating registered nurses' working time use with these two different data collection methods. In future, it would be wise to aim for more comparable data by applying external observation and self-reporting techniques simultaneously.

Competence for older people nursing in care and nursing homes: An integrative review.

BACKGROUND: People living in care and nursing homes are vulnerable individuals with complex needs; therefore, a wide array of nursing competence is needed to ensure their well-being. When developing the quality of care in these units, it is essential to know what type of competence is required for older people nursing. AIMS AND OBJECTIVES: The aim of this integrative review was to identify the competence needed for older people nursing in licensed practical nurses' and registered nurses' work in care and nursing homes. DESIGN: Integrative literature review. METHODS: We performed an integrative review using Whittemore and Knafl's method. The CINAHL, MEDLINE, PsycINFO, SocINDEX and Scopus databases were searched for studies published from 2006 to April 2016. We assessed the quality of the studies using Joanna Briggs Institute critical appraisal tools and analysed the data by applying qualitative content analysis. RESULTS: Ten articles were included in the review. Most of the studies focused on registered nurses' work. We identified five competence areas that are needed for older people nursing in registered nurses' work in care and nursing homes: attitudinal and ethical, interactional, evidence-based care, pedagogical, and leadership and development competence. Empirical evidence of competence requirements related to licensed practical nurses' work in these facilities was scarce. CONCLUSIONS: The competence required for registered nurses and licensed practical nurses should be clearly identified to support competence management in the care and nursing home context. IMPLICATIONS FOR PRACTICE: Well-educated nursing staff are needed in care and nursing homes to provide high-quality care because comprehensive and advanced nurse competence is required to meet the needs of older people.

Patient participation in patient safety still missing: Patient safety experts' views.

The aim of this study was to elicit patient safety experts' views of patient participation in promoting patient safety. Data were collected between September and December in 2014 via an electronic semi-structured questionnaire and interviews with Finnish patient safety experts (n = 21), then analysed using inductive content analysis. Patient safety experts regarded patients as having a crucial role in promoting patient safety. They generally deemed the level of patient safety as 'acceptable' in their organizations, but reported that patient participation in their own safety varied, and did not always meet national standards. Management of patient safety incidents differed between organizations. Experts also suggested that patient safety training should be increased in both basic and continuing education programmes for healthcare professionals. Patient participation in patient safety is still lacking in clinical practice and systematic actions are needed to create a safety culture in which patients are seen as equal partners in the promotion of high-quality and safe care.

The relationship between nurse staffing and length of stay in acute-care: a one-year time-series data.

AIM: To examine the relationship between nurse staffing and patient length of stay in an acute-care hospital over a 1-year period. BACKGROUND: Although there has been prior research on the relationship between nurse staffing and length of stay in acute-care hospitals, there is a need for more information on how nurse staffing is related to length of stay longitudinally. METHODS: Retrospective time-series registry data from 20 acute-care inpatient units of a Finnish university hospital as a monthly time series in 2008 were analysed by linear mixed models. RESULTS: The ratio of registered nurses to all nurses was 72.4%. Nurses worked mainly (96%) full time, and 63% had permanent employment contracts. Statistically significant variation was found in time series of five variables. Statistically significant relationships were found between length of stay and patient acuity, diagnosis-related group-volume, census and nursing hours per patient day at the unit level. Nursing hours per patient day had the strongest correlation with length of stay. CONCLUSION AND IMPLICATIONS FOR NURSING MANAGEMENT: A rational response to the variations in patient care needs and intensity in the complex care environment is flexible nurse staffing. Increasing nursing hours per patient day to achieve shorter length of stays is not the only solution, well-functioning care processes are also essential.

Learning to ensure patient safety in clinical settings: comparing Finnish and British nursing students' perceptions.

AIMS AND OBJECTIVES: To explore and compare Finnish and British nursing students' perceptions of their learning about patient safety in clinical settings. BACKGROUND: Patient safety culture and practices in different health care organisations and clinical units varies, posing challenges for nursing students' learning about patient safety during their clinical placements. Patient safety as a growing international concern has challenged health care professionals globally requiring a comprehensive review. International studies comparing nursing education about patient safety are lacking. DESIGN: A cross-sectional comparative study. METHOD: The participants were final year preregistration nursing students from two universities of applied sciences in Finland (n = 195) and from two universities in England, UK (n = 158). The data were collected with the Patient Safety in Nursing Education Questionnaire and analysed with principal component analysis, Pearson Chi-Square and Mann-Whitney U tests and logistic regression. RESULTS: Finnish nursing students had significantly more critical perceptions on their learning about patient safety in clinical settings than their British peers. A strong predictor for differences was supportive and systems-based approaches in learning to ensure patient safety. Notably, fewer Finnish students had practiced reporting of incidents in clinical settings compared to British students. In both countries, the students held learning about patient safety in higher esteem compared to their learning experiences in clinical settings. CONCLUSIONS: Nursing students appear to want more learning opportunities related to patient safety compared to the reality in clinical settings. Learning systematically from errors in a supportive environment and having systems-based approaches to ensure patient safety are essential elements for nursing students' learning about safe practice. Finnish students seem to experience more barriers in learning about safe practices and to report errors than the British students. RELEVANCE TO CLINICAL PRACTICE: Health care organisations and professionals with responsibilities for patient safety should seek to standardise the preparation of nursing students incorporating requisite international standards and benchmarks.

Learning Patient Safety in Academic Settings: A Comparative Study of Finnish and British Nursing Students' Perceptions.

BACKGROUND: Globalization of health care demands nursing education programs that equip students with evidence-based patient safety competences in the global context. Nursing students' entrance into clinical placements requires professional readiness. Thus, evidence-based learning activities about patient safety must be provided in academic settings prior to students' clinical placements. AIMS: To explore and compare Finnish and British nursing students' perceptions of learning about patient safety in academic settings to inform nursing educators about designing future education curriculum. METHODS: A purpose-designed instrument, Patient Safety in Nursing Education Questionnaire (PaSNEQ) was used to examine the perceptions of Finnish (n = 195) and British (n = 158) nursing students prior to their final year of registration. Data were collected in two Finnish and two English nursing schools in 2012. Logistic regressions were used to analyze the differences. RESULTS: British students reported more inclusion (p < .001) of "gaining knowledge," "training skills," and "highlighting affirmative attitudes and motivation" related to patient safety in their programs. Both student groups considered patient safety education to be more valuable for their own learning than what their programs had provided. Training patient safety skills in the academic settings were the strongest predictors for differences (odds ratio [OR] = 34.69, 95% confidence interval [CI] 7.39-162.83), along with work experience in the healthcare sector (OR = 3.02, 95% CI 1.39-6.58). LINKING EVIDENCE TO ACTION: To prepare nursing students for practical work, training related to clear communication, reporting errors, systems-based approaches, interprofessional teamwork, and use of simulation in academic settings requires comprehensive attention, especially in Finland. Overall, designing patient safety-affirming nursing curricula in collaboration with students may enhance their positive experiences on teaching and learning about patient safety. An international collaboration between educators could help to develop and harmonize patient safety education and to better prepare nurses for practice in the global context.

Nurses' working time use - how value adding it is?

AIM: To investigate registered nurses' (RN) and licensed practical nurses' (LPN) working time use in adult inpatient units. BACKGROUND: There is only scarce information about value-adding patient care. Nursing care can be divided into three major categories: value-adding care (direct care, indirect care, patient documentation), necessary activities (indirect work, unit-related work) and non-value-adding work (personal time, miscellaneous work). METHOD: A cross-sectional quantitative work sampling study. Total of 11,029 nursing activities were collected from two Finnish tertiary hospitals using registered nurses' (n = 66) and licensed practical nurses' (n = 12) self-reporting. RESULTS: Nearly three-quarters of nurses' work was value-adding care (71%). The working time division was almost identical for necessary activities and non-value-adding work. Registered nurses spent more time carrying out unit-related work, while licensed practical nurses' spent more time on direct care. Nurses' working time use was divided nearly identically in somatic units but there were differences when compared with psychiatric units. CONCLUSION AND IMPLICATIONS FOR NURSING MANAGEMENT: Nurses' work seemed to concentrate on value-adding care. The results of working time use studies can be used when developing nursing work for more value-adding care for the patients.

Non-linear relationships between nurse staffing and patients' length of stay in acute care units: Bayesian dependence modelling.

AIMS: This study sought to analyse relationships between nurse staffing and patients' length of stay in acute care units and to determine whether non-linear relationships exist between variables. BACKGROUND: Healthcare systems are complex and it could be assumed that they comprise non-linear associations. However, current planning and evaluation of nurse staffing are based primary on linear reasoning. DESIGN: This quantitative study adopted a retrospective longitudinal design. METHOD: Retrospective register data, consisting of information relating to 35,306 patient episodes and administrative information concerning 381 nurses, were used. Data were collected in 2009 from 20 somatic inpatient units at a university hospital in Finland as a monthly time series of 2008 data and analysed using Bayesian dependency modelling. RESULTS: Patients' acuity was the most important agent that connected all eleven variables in the dependency network of nurse staffing and short length of stay. Non-linear associations were found between short length of stay and the proportion of Registered Nurses. Skill mix consisting of an average proportion of Registered Nurses (65-80%) was conducive to a short length of stay and predicted a 66% likelihood of short length of stay. Higher and lower percentages of Registered Nurses predicted lower likelihood of short length of stay. CONCLUSION: Flexible nurse staffing is preferable to fixed staffing to provide patients with shorter length of stay in acute care units. In the present research, the Bayesian method revealed non-linear relationships between nurse staffing and patient and care outcomes.

Registered nurses' experiences of rewarding in a Finnish University Hospital - an interview study.

AIMS: The purpose was to describe Finnish registered nurses' experiences of rewarding. The aim was to gather detailed information on the rewarding of nurses to help nurse managers and leaders to update existing reward strategy and to develop an effective reward system. BACKGROUND: Rewarding has been found positively to influence nurses' occupational well-being and commitment to their work, and the attractiveness of the health care field. METHODS: A series of focused interviews with 10 registered nurses was conducted in 2011. Qualitative content analysis method was used. RESULT: The nurses reported positive experiences with rewarding in the form of monetary compensation and other benefits, the positive aspects of nursing work and opportunities for professional development. The experiences of unsatisfactory rewarding generally stemmed from negative emotional experiences, lacking rewards and inequality in rewarding. CONCLUSION: It is essential to listen to nurses and to provide appropriate acknowledgement and appreciation of their work in order to develop an effective reward system. IMPLICATIONS FOR NURSING MANAGEMENT: It is important to listen to nurses' experiences of rewarding because it enables nurse managers to maintain and increase the attractiveness of nursing and health care work in general.