Improving measurement-invariance assessments: correcting entrenched testing deficiencies.

BACKGROUND: Factor analysis historically focused on measurement while path analysis employed observed variables as though they were error-free. When factor- and path-analysis merged as structural equation modeling, factor analytic notions dominated measurement discussions - including assessments of measurement invariance across groups. The factor analytic tradition fostered disregard of model testing and consequently entrenched this deficiency in measurement invariance assessments. DISCUSSION: Applying contemporary model testing requirements to the so-called configural model initiating invariance assessments will improve future assessments but a substantial backlog of deficient assessments remain to be overcome. This article summarizes the issues, demonstrates the problem using a recent example, illustrates a superior model assessment strategy, and documents disciplinary entrenchment of inadequate testing as exemplified by the journal Organizational Research Methods. Employing the few methodologically and theoretically best, rather than precariously-multiple, indicators of latent variables increases the likelihood of achieving properly causally specified structural equation models capable of displaying measurement invariance. Just as evidence of invalidity trumps reliability, evidence of configural model misspecification trumps invariant estimates of misspecified coefficients.

Shame for disrespecting evidence: the personal consequences of insufficient respect for structural equation model testing.

BACKGROUND: Inappropriate and unacceptable disregard for structural equation model (SEM) testing can be traced back to: factor-analytic inattention to model testing, misapplication of the Wilkinson task force's [Am Psychol 54:594-604, 1999] critique of tests, exaggeration of test biases, and uncomfortably-numerous model failures. DISCUSSION: The arguments for disregarding structural equation model testing are reviewed and found to be misguided or flawed. The fundamental test-supporting observations are: a) that the null hypothesis of the χ2 structural equation model test is not nil, but notable because it contains substantive theory claims and consequences; and b) that the amount of covariance ill fit cannot be trusted to report the seriousness of model misspecifications. All covariance-based fit indices risk failing to expose model problems because the extent of model misspecification does not reliably correspond to the magnitude of covariance ill fit - seriously causally misspecified models can fit, or almost fit. SUMMARY: The only reasonable research response to evidence of non-chance structural equation model failure is to diagnostically investigate the reasons for failure. Unfortunately, many SEM-based theories and measurement scales will require reassessment if we are to clear the backlogged consequences of previous deficient model testing. Fortunately, it will be easier for researchers to respect evidence pointing toward required reassessments, than to suffer manuscript rejection and shame for disrespecting evidence potentially signaling serious model misspecifications.

Comparing two approaches for studying symptom clusters: factor analysis and structural equation modeling.

PURPOSE: We investigated alternative ways of understanding the relationships among co-occurring symptoms in individuals with advanced cancer. While factor analysis has been increasingly used to identify symptom clusters, we argue that structural equation modeling is more appropriate because it permits investigating and testing of a greater variety of potential causal interconnections among symptoms. METHODS: The sample included 82 palliative patients whose symptom scores were obtained from a database of the Capital Health Regional Palliative Care Program in Alberta, Canada, from 1995 to 2000. Data were analyzed using exploratory factor analysis (SPSS PASW 18.0.0, 2009) and compared to previous results obtained using structural equation modeling (LISREL 8.8, 2009). RESULTS: Factor models failed to fit the covariance data, even though a single factor "explained" nearly half the variance. Structural equation models fit the data and explained an average of 66 % of the variance in the dependent latent variables. The factor analytic estimates were not clinically useful because they failed to correspond to the reasonable underlying common causes of the symptoms. Structural equation models, on the other hand, incorporated and tested specific clinically anticipated causal relationships among the symptoms and changes in those symptoms over time. CONCLUSION: We used factor analysis to reanalyze data previously investigated with structural equation modeling and found that the structural equation models fit the data better and were more interpretable from a clinical perspective. We caution that factor models should be tested for consistency with the data and critically examined for inconsistencies with clinical understandings of the causal foundations of coordinated symptoms.

Precision of the Conceptual Research Utilization Scale.

BACKGROUND AND PURPOSE: Conceptual research utilization (CRU) is one indicator of an optimum practice environment that leads to improved patient and organizational outcomes. Yet, its measurement has not been adequately addressed. In this study, we investigated precision of scores obtained with a new CRU scale using item response theory (IRT) methods. METHODS: We analyzed the responses from 1,349 health care aides from 30 Canadian nursing homes using Samejima's (1969, 1996) graded response model (GRM). RESULTS: Findings suggest that the CRU scale is most precise at low to average trait levels with significantly less precision at higher trait levels. CONCLUSIONS: The scale showed acceptable precision at low to average trait levels. New items and/or different response options that capture higher trait levels are needed. Future development of the scale is discussed.

A nursing perspective on the antecedents and consequences of incivility in higher education: A scoping review.

Background: Understanding antecedents and consequences of incivility across higher education is necessary to create and implement strategies that prevent and slow uncivil behaviors. Purpose: To identify the nature, extent, and range of research related to antecedents and consequences of incivility in higher education. Objectives: 1) To identify disciplines and programs sampled in higher education incivility research, and 2) to compare antecedents and consequences examined in nursing education research with other disciplines and programs in higher education. Design: A scoping review of the literature. Data sources: Eight electronic databases searched in January 2023 including MEDLINE Ovid, CINAHL, ERIC, PsycINFO, Scopus, ProQuest Education Database, Education Research Complete, and ProQuest Dissertations and Theses Global. Review methods: We included primary research articles examining antecedents or consequences of incivility in higher education. Two reviewers independently screened and determined inclusion of each study. Data extraction was completed. We employed a numerical descriptive summary to analyze the range of data and content analysis to categorize the antecedents and consequences of incivility in higher education. Results: Database searches yielded 6678 unique articles. One hundred and nineteen studies published between 2003 and 2023 met the inclusion criteria, of which, 65 reported research in nursing education, and 54 in other programs and disciplines. A total of 91 antecedents and 50 consequences of incivility in higher education were reported. Stress (n = 12 nursing, n = 4 other programs), faculty incivility (n = 9 nursing, n = 5 other programs), and student incivility (n = 4 nursing, n = 5 other programs) were reported as antecedents of incivility in higher education. Physiological and psychological negative outcomes (n = 25 nursing, n = 12 other programs), stress (n = 6 nursing, n = 6 other programs), and faculty job satisfaction (n = 3 nursing, n = 2 other programs) were reported as consequences of incivility in higher education. Conclusions: Supporting development of teaching practices and role modeling of civility by faculty is a crucial element to slowing the frequency of uncivil interactions between faculty and students. Specific strategies that target stress, such as, cognitive behavioral therapy, coping skills, and social support could mitigate incivility in higher education. Future research needs to examine the strength of the negative effects of incivility on physiological and psychological outcomes through advanced statistical methods, as well as the cumulative effects of uncivil behavior on these outcomes over time for both students and faculty. Application of advanced statistical methods can also support our understanding of sources of incivility as well as the accuracy of causal connections between its antecedents and consequences.

How context links to best practice use in long-term care homes: a mixed methods study.

BACKGROUND: Context (work environment) plays a crucial role in implementing evidence-based best practices within health care settings. Context is multi-faceted and its complex relationship with best practice use by care aides in long-term care (LTC) homes are understudied. This study used an innovative approach to investigate how context elements interrelate and influence best practice use by LTC care aides. METHODS: In this secondary analysis study, we combined coincidence analysis (a configurational comparative method) and qualitative analysis to examine data collected through the Translating Research in Elder Care (TREC) program. Coincidence analysis of clinical microsystem (care unit)-level data aggregated from a survey of 1,506 care aides across 36 Canadian LTC homes identified configurations (paths) of context elements linked consistently to care aides' best practices use, measured with a scale of conceptual research use (CRU). Qualitative analysis of ethnographic case study data from 3 LTC homes (co-occurring with the survey) further informed interpretation of the configurations. RESULTS: Three paths led to very high CRU at the care unit level: very high leadership; frequent use of educational materials; or a combination of very high social capital (teamwork) and frequent communication between care aides and clinical educators or specialists. Conversely, 2 paths led to very low CRU, consisting of 3 context elements related to unfavorable conditions in relationships, resources, and formal learning opportunities. Our qualitative analysis provided insights into how specific context elements served as facilitators or barriers for best practices. This qualitative exploration was especially helpful in understanding 2 of the paths, illustrating the pivotal role of leadership and the function of teamwork in mitigating the negative impact of time constraints. CONCLUSIONS: Our study deepens understanding of the complex interrelationships between context elements and their impact on the implementation of best practices in LTC homes. The findings underscore that there is no singular, universal bundle of context-related elements that enhance or hinder best practice use in LTC homes.

The influence of organizational context on the use of research by nurses in Canadian pediatric hospitals.

BACKGROUND: Organizational context is recognized as an important influence on the successful implementation of research by healthcare professionals. However, there is relatively little empirical evidence to support this widely held view. METHODS: The objective of this study was to identify dimensions of organizational context and individual (nurse) characteristics that influence pediatric nurses' self-reported use of research. Data on research use, individual, and contextual variables were collected from registered nurses (N = 735) working on 32 medical, surgical and critical care units in eight Canadian pediatric hospitals using an online survey. We used Generalized Estimating Equation modeling to account for the correlated structure of the data and to identify which contextual dimensions and individual characteristics predict two kinds of self-reported research use: instrumental (direct) and conceptual (indirect). RESULTS: Significant predictors of instrumental research use included: at the individual level; belief suspension-implement, research use in the past, and at the hospital unit (context) level; culture, and the proportion on nurses possessing a baccalaureate degree or higher. Significant predictors of conceptual research use included: at the individual nurse level; belief suspension-implement, problem solving ability, use of research in the past, and at the hospital unit (context) level; leadership, culture, evaluation, formal interactions, informal interactions, organizational slack-space, and unit specialty. CONCLUSIONS: Hospitals, by focusing attention on modifiable elements of unit context may positively influence nurses' reported use of research. This influence of context may extend to the adoption of best practices in general and other innovative or quality interventions.

Should researchers use single indicators, best indicators, or multiple indicators in structural equation models?

BACKGROUND: Structural equation modeling developed as a statistical melding of path analysis and factor analysis that obscured a fundamental tension between a factor preference for multiple indicators and path modeling's openness to fewer indicators. DISCUSSION: Multiple indicators hamper theory by unnecessarily restricting the number of modeled latents. Using the few best indicators - possibly even the single best indicator of each latent - encourages development of theoretically sophisticated models. Additional latent variables permit stronger statistical control of potential confounders, and encourage detailed investigation of mediating causal mechanisms. SUMMARY: We recommend the use of the few best indicators. One or two indicators are often sufficient, but three indicators may occasionally be helpful. More than three indicators are rarely warranted because additional redundant indicators provide less research benefit than single indicators of additional latent variables. Scales created from multiple indicators can introduce additional problems, and are prone to being less desirable than either single or multiple indicators.

The Influence of Context on Implementation and Improvement: Protocol for a Mixed Methods, Secondary Analyses Study.

BACKGROUND: Caring for the well-being of older adults is one of the greatest challenges in modern societies. Improving the quality of care and life for older adults and the work lives of their care providers calls for effective knowledge translation of evidence-based best practices. OBJECTIVE: This study's purpose is to contribute to knowledge translation by better understanding the roles of organizational context (workplace environment) and facilitation (process or role) in implementation and improvement success. Our study has 2 goals: (1) to advance knowledge translation science by further developing and testing the Promoting Action on Research Implementation in Health Services framework (which outlines how implementation relies on the interplay of context, facilitation, and evidence) and (2) to advance research by optimizing implementation success via tailoring of modifiable elements of organizational context and facilitation. METHODS: This is secondary analyses of 15 years of longitudinal data from the Translating Research in Elder Care (TREC) program's multiple data sources. This research is ongoing in long-term care (LTC) homes in western Canada. TREC data include the following: 5 waves of survey collection, 2 clinical trials, and regular ongoing outcome data for LTC residents. We will use a sequential exploratory and confirmatory mixed methods design. We will analyze qualitative and quantitative data holdings in an iterative process: (1) comprehensive reanalysis of qualitative data to derive hypotheses, (2) quantitative modeling to test hypotheses, and (3) action cycles to further refine and integrate qualitative and quantitative analyses. The research team includes 4 stakeholder panels: (1) system decision- and policy makers, (2) care home managers, (3) direct care staff, and (4) a citizen engagement group of people living with dementia and family members of LTC residents. A fifth group is our panel of external scientific advisors. Each panel will engage periodically, providing their perspectives on project direction and findings. RESULTS: This study is funded by the Canadian Institutes of Health Research. Ethics approval was obtained from the University of Alberta (Pro00096541). The results of the secondary analyses are expected by the end of 2023. CONCLUSIONS: The project will advance knowledge translation science by deepening our understanding of the roles of context, the interactions between context and facilitation, and their influence on resident and staff quality outcomes. Importantly, findings will inform understanding of the mechanisms by which context and facilitation affect the success of implementation and offer insights into factors that influence the implementation success of interventions in nursing homes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/40611.

Advancing the argument for validity of the Alberta Context Tool with healthcare aides in residential long-term care.

BACKGROUND: Organizational context has the potential to influence the use of new knowledge. However, despite advances in understanding the theoretical base of organizational context, its measurement has not been adequately addressed, limiting our ability to quantify and assess context in healthcare settings and thus, advance development of contextual interventions to improve patient care. We developed the Alberta Context Tool (the ACT) to address this concern. It consists of 58 items representing 10 modifiable contextual concepts. We reported the initial validation of the ACT in 2009. This paper presents the second stage of the psychometric validation of the ACT. METHODS: We used the Standards for Educational and Psychological Testing to frame our validity assessment. Data from 645 English speaking healthcare aides from 25 urban residential long-term care facilities (nursing homes) in the three Canadian Prairie Provinces were used for this stage of validation. In this stage we focused on: (1) advanced aspects of internal structure (e.g., confirmatory factor analysis) and (2) relations with other variables validity evidence. To assess reliability and validity of scores obtained using the ACT we conducted: Cronbach's alpha, confirmatory factor analysis, analysis of variance, and tests of association. We also assessed the performance of the ACT when individual responses were aggregated to the care unit level, because the instrument was developed to obtain unit-level scores of context. RESULTS: Item-total correlations exceeded acceptable standards (> 0.3) for the majority of items (51 of 58). We ran three confirmatory factor models. Model 1 (all ACT items) displayed unacceptable fit overall and for five specific items (1 item on adequate space for resident care in the Organizational Slack-Space ACT concept and 4 items on use of electronic resources in the Structural and Electronic Resources ACT concept). This prompted specification of two additional models. Model 2 used the 7 scaled ACT concepts while Model 3 used the 3 count-based ACT concepts. Both models displayed substantially improved fit in comparison to Model 1. Cronbach's alpha for the 10 ACT concepts ranged from 0.37 to 0.92 with 2 concepts performing below the commonly accepted standard of 0.70. Bivariate associations between the ACT concepts and instrumental research utilization levels (which the ACT should predict) were statistically significant at the 5% level for 8 of the 10 ACT concepts. The majority (8/10) of the ACT concepts also showed a statistically significant trend of increasing mean scores when arrayed across the lowest to the highest levels of instrumental research use. CONCLUSIONS: The validation process in this study demonstrated additional empirical support for construct validity of the ACT, when completed by healthcare aides in nursing homes. The overall pattern of the data was consistent with the structure hypothesized in the development of the ACT and supports the ACT as an appropriate measure for assessing organizational context in nursing homes. Caution should be applied in using the one space and four electronic resource items that displayed misfit in this study with healthcare aides until further assessments are made.

Model of Post-traumatic Growth in Newly Traumatized vs. Retraumatized Adolescents.

Background: In our analysis of adolescents affected by the 2016 Fort McMurray wildfire, we observed many negative mental health effects in individuals with a prior history of psychological trauma. Elevated rates of depression and markers of post-traumatic stress disorder (PTSD) were observed, consistent with the hypothesis that prior trauma may reduce sensitivity thresholds for later psychopathology (stress sensitization). Surprisingly, levels of anxiety did not differ based on prior trauma history, nor were retraumatized individuals at increased risk for recent (past month) suicidal ideation. These results are more suggestive of inoculation by prior trauma than stress sensitization. This led us to consider whether individuals with a prior trauma history showed evidence of Post-Traumatic Growth (PTG), a condition in which the experience of a previous trauma leads to areas of sparing or even improvement. Method: To investigate this issue, we generated a structural equation model (SEM) exploring the role of anxiety in previously traumatized (n = 295) and wildfire trauma alone (n = 740) groups. Specifically, models were estimated to explore the relationship between hopelessness, anxiety, PTSD symptoms, self-efficacy and potential protective factors such as friend and family support in both groups. The model was tested using a cross-sectional sample of affected youth, comparing effects between the two groups. Results: While both models produced relatively good fit, differences in the effects and chi-squared values led us to conclude that the groups are subject to different causal specifications in a number of areas, although details warrant caution pending additional investigation. Discussion: We found that adolescents with a prior trauma history appear to have a more realistic appraisal of potential difficulties associated with traumatic events, and seem less reactive to potentially unsettling PTSD symptoms. They also seemed less prone to overconfidence as they got older, an effect seen in the adolescents without a history of trauma. Our findings provide preliminary evidence that the construct of anxiety may work differently in newly traumatized and retraumatized individuals, particularly in the context of mass trauma events.

Temporal changes in the causal foundations of palliative care symptoms.

PURPOSE: We use longitudinal data to test and extend a structural equation model documenting changes in the causal connections among symptoms experienced in the final weeks of life. Our central thesis is that the relief of suffering and the promotion of quality end of life care require tailoring interventions to reflect the shifting causal foundations of symptoms. METHODS: Symptom information on pain, anxiety, nausea, shortness of breath, drowsiness, loss of appetite, tiredness, depression, and well-being was extracted from a palliative care database. For each of the 82 study participants, symptom scores measured at 4 full weeks and 1 full week prior to death were used to test a structural equation model of the causal structures underlying symptom clusters. RESULTS: This investigation confirms the reasonableness of our previously developed model. Tiredness, depression, and well-being were sufficiently labile that the observations at one week before death were not significantly dependent on the corresponding observations 3 weeks earlier. Patients' assessments of pain, anxiety, nausea, shortness of breath, drowsiness, and appetite were only moderately stable over this same period. CONCLUSIONS: The stability in some, and instability in other, symptoms meshed convincingly with the changes in symptom causal structures previously derived from cross-sectional data. Investigations assessing temporal shifts in palliative symptom coordination over longer periods of time and for specific medical conditions and social contexts seem warranted.

Fusion Validity: Theory-Based Scale Assessment via Causal Structural Equation Modeling.

Fusion validity assessments employ structural equation models to investigate whether an existing scale functions in accordance with theory. Fusion validity parallels criterion validity by depending on correlations with non-scale variables but differs from criterion validity because it requires at least one theorized effect of the scale, and because both the scale and scaled-items are included in the model. Fusion validity, like construct validity, will be most informative if the scale is embedded in as full a substantive context as theory permits. Appropriate scale functioning in a comprehensive theoretical context greatly enhances a scale's validity. Inappropriate scale functioning questions the scale but the scale's theoretical embedding encourages detailed diagnostic investigations potentially challenging specific items, the procedure used to calculate scale values, or aspects of the theory, but also possibly recommends incorporating additional items into the scale. The scaled items should have survived prior content and methodological assessments but the items may or may not reflect a common factor because items having diverse causal backgrounds can sometimes fuse to form a unidimensional entity. Though items reflecting a common cause can be assessed for fusion validity, we illustrate fusion validity in the more challenging context of a scale comprised of diverse items and embedded in a complicated theory. Specifically we consider the Leadership scale from the Alberta Context Tool with care aides working in Canadian long-term care homes.

The changing causal foundations of cancer-related symptom clustering during the final month of palliative care: a longitudinal study.

BACKGROUND: Symptoms tend to occur in what have been called symptom clusters. Early symptom cluster research was imprecise regarding the causal foundations of the coordinations between specific symptoms, and was silent on whether the relationships between symptoms remained stable over time. This study develops a causal model of the relationships between symptoms in cancer palliative care patients as they approach death, and investigates the changing associations among the symptoms and between those symptoms and well-being. METHODS: Complete symptom assessment scores were obtained for 82 individuals from an existing palliative care database. The data included assessments of pain, anxiety, nausea, shortness of breath, drowsiness, loss of appetite, tiredness, depression and well-being, all collected using the Edmonton Symptom Assessment System (ESAS). Relationships between the symptoms and well-being were investigated using a structural equation model. RESULTS: The model fit acceptably and explained between 26% and 83% of the variation in appetite, tiredness, depression, and well-being. Drowsiness displayed consistent effects on appetite, tiredness and well-being. In contrast, anxiety's effect on well-being shifted importantly, with a direct effect and an indirect effect through tiredness at one month, being replaced by an effect working exclusively through depression at one week. CONCLUSION: Some of the causal forces explaining the variations in, and relationships among, palliative care patients' symptoms changed over the final month of life. This illustrates how investigating the causal foundations of symptom correlation or clustering can provide more detailed understandings that may contribute to improved control of patient comfort, quality of life, and quality of death.

The relationship between nursing leadership and nurses' job satisfaction in Canadian oncology work environments.

BACKGROUND: Current Canadian oncology work environments are challenged by the same workforce statistics as other nursing specialties: nurses are among the most overworked, stressed and sick workers, and more than 8% of the nursing workforce is absent each week due to illness. AIM: To develop and estimate a theoretical model of work environment factors affecting oncology nurses' job satisfaction. METHODS: The sample consisted of 515 registered nurses working in oncology settings across Canada. The theoretical model was tested as a structural equation model using LISREL 8.54. RESULTS: The final model fitted the data acceptably (chi(2) = 58.0, d.f. = 44, P = 0.08). Relational leadership and physician/nurse relationships significantly influenced opportunities for staff development, RN staffing adequacy, nurse autonomy, participation in policy decisions, support for innovative ideas and supervisor support in managing conflict, which in turn increased nurses' job satisfaction. CONCLUSIONS: These findings suggest that relational leadership and positive relationships among nurses, managers and physicians play an important role in quality oncology nursing environments and nurses' job satisfaction. IMPLICATIONS FOR NURSING MANAGEMENT: Oncology nursing work environments can be improved by focusing on modifiable factors such as leadership, staff development and staffing resources, leading to better job satisfaction and hopefully retention of nurses.

Measuring Depression-Severity in Critically Ill Patients' Families with the Patient Health Questionnaire (PHQ): Tests for Unidimensionality and Longitudinal Measurement Invariance, with Implications for CONSORT.

CONTEXT: Families of intensive care unit patients are at risk for depression and are important targets for depression-reducing interventions. Multi-item scores for evaluating such interventions should meet criteria for unidimensionality and longitudinal measurement invariance. The Patient Health Questionnaire (PHQ), widely used for measuring depression severity, provides standard nine-, eight-, and two-item scores. However, published studies often report no (or weak) evidence of these scores' unidimensionality/invariance, and no tests have evaluated them as measures of depression severity in intensive care unit patients' families. OBJECTIVES: To identify multi-item PHQ constructs with promise for evaluating change in depression severity among family members of critically ill patients. METHODS: Structural equation models with rigorous fit criterion (χ(2), P ≥ 0.05) tested the standard nine-, eight-, and two-item PHQ, and other item subsets, for unidimensionality and longitudinal invariance, using data from a trial evaluating an intervention to reduce depressive symptoms in family members. RESULTS: Neither the standard nine-item nor the eight-item PHQ construct showed longitudinal invariance, although the standard two-item construct and other item subsets did. CONCLUSION: The longer eight- and nine-item PHQ scores appear inappropriate for assessing depression severity in this population, with constructs based on smaller subsets of items being more promising targets for future trials. The Consolidated Standards of Reporting Trials requirement for prespecified trial outcomes is problematic because unidimensionality/invariance testing must occur after trial completion. Consolidated Standards of Reporting Trials could be strengthened by endorsing rigorous assessment of composite scores and encouraging use of the most appropriate substitute, should trial-based evidence challenge the legitimacy of prespecified multi-item scores.

Rural Caregivers for a Family Member With Dementia: Models of Burden and Distress Differ for Women and Men.

Forecasts of increasing prevalence of dementia in rural settings, coupled with reliance on family caregiver support, indicate that a greater understanding of caregiver distress in these contexts is necessary. The purpose of this study was to examine family caregiver burden and severity of distress on the day that a family member was diagnosed with dementia at a memory clinic that serves a rural population. Participants in this retrospective study were 231 primary family caregivers of a rural community-dwelling person with dementia. On the diagnostic day, women reported more burden and severity of distress than men and spouses reported more severity of distress than adult children. A structural equation model was not supported for the entire sample, but was supported for women caregivers only (n = 161). Caregiver distress related to dementia-specific behaviors explained both global distress and burden. Patients' functional decline was related to caregiver burden.

Structural equation model testing and the quality of natural killer cell activity measurements.

BACKGROUND: Browne et al. [Browne, MacCallum, Kim, Andersen, Glaser: When fit indices and residuals are incompatible. Psychol Methods 2002] employed a structural equation model of measurements of target cell lysing by natural killer cells as an example purportedly demonstrating that small but statistically significant ill model fit can be dismissed as "negligible from a practical point of view". METHODS: Reanalysis of the natural killer cell data reveals that the supposedly negligible ill fit obscured important, systematic, and substantial causal misspecifications. RESULTS: A clean-fitting structural equation model indicates that measurements employing higher natural-killer-cell to target-cell ratios are more strongly influenced by a progressively intrusive factor, whether or not the natural killer cell activity is activated by recombinant interferon gamma (rIFN gamma). The progressive influence may reflect independent rate limiting steps in cell recognition and attachment, spatial competition for cell attachment points, or the simultaneous lysings of single target cells by multiple natural killer cells. CONCLUSIONS: If the progressively influential factor is ultimately identified as a mere procedural impediment, the substantive conclusion will be that measurements of natural killer cell activity made at lower effector to target ratios are more valid. Alternatively, if the individual variations in the progressively influential factor are modifiable, this may presage a new therapeutic route to enhancing natural killer cell activity. The methodological conclusion is that, when using structural equation models, researchers should attend to significant model ill fit even if the degree of covariance ill fit is small, because small covariance residuals do not imply that the underlying model misspecifications are correspondingly small or inconsequential.

The influence of organizational context on best practice use by care aides in residential long-term care settings.

OBJECTIVE: This study assessed individual and organizational context (work environment) factors that influence use of best practices by care aides (nursing assistants) in nursing homes. Little scientific attention has been focused on understanding best practice use in nursing homes and almost none on care aides. SETTING AND PARTICIPANTS: A total of 1262 care aides in 25 nursing homes in the 3 Canadian prairie provinces. Care aides are unregulated workers who provide 80% of direct care to residents in Canadian nursing homes. METHOD: We used hierarchical linear modeling to (1) assess the amount of variance in use of best practices, as reported by care aides, that could be attributed to individual or organizational factors, and (2) identify predictors of best practices use by care aides. RESULTS: At the individual level, statistically significant predictors of instrumental use of best practices included sex, age, shift worked, job efficacy, and belief suspension. At the unit level, significant predictors were social capital, organizational slack (staffing and time), number of informal interactions, and unit type. At the facility level, ownership model and province were significant. Significant predictors of conceptual use of best practices at the individual level included English as a first language, job efficacy, belief suspension, intent to use research, adequate knowledge, and number of information sources used. At the unit level, significant predictors were evaluation (feedback mechanisms), structural resources, and organizational slack (time). At the facility level, province was significant. The R(2) was 18.3% for instrumental use of best practices and 43.4% for conceptual use. Unit level factors added a substantial amount of explained variance whereas facility level factors added relatively little explained variance. CONCLUSIONS: Our study suggests that context plays an important role in care aides' use of best practices in nursing homes. Individual characteristics played a more prominent role than contextual factors in predicting conceptual use of best practices.

Reliability and Validity of the Alberta Context Tool (ACT) with Professional Nurses: Findings from a Multi-Study Analysis.

Although organizational context is central to evidence-based practice, underdeveloped measurement hinders its assessment. The Alberta Context Tool, comprised of 59 items that tap 10 modifiable contextual concepts, was developed to address this gap. The purpose of this study to examine the reliability and validity of scores obtained when the Alberta Context Tool is completed by professional nurses across different healthcare settings. Five separate studies (N = 2361 nurses across different care settings) comprised the study sample. Reliability and validity were assessed. Cronbach's alpha exceeded 0.70 for 9/10 Alberta Context Tool concepts. Item-total correlations exceeded acceptable standards for 56/59 items. Confirmatory Factor Analyses coordinated acceptably with the Alberta Context Tool's proposed latent structure. The mean values for each Alberta Context Tool concept increased from low to high levels of research utilization(as hypothesized) further supporting its validity. This study provides robust evidence for reliability and validity of scores obtained with the Alberta Context Tool when administered to professional nurses.