Toward a learning-to-performance program for interprofessional long-term care teams: Team Essentials to foster engagement, reciprocity, and meaningful, sustained practice change.

This paper presents the design, delivery, and preliminary evaluation of a gerontological learning-to-performance program. An interprofessional educational team sought to integrate leading clinical and educational practices into Team Essentials to engage long-term care teams in learning to improve performance. Although the association between skilled, trained staff and quality of care is well-established in research, how best to engage learners from an increasingly diverse workforce is less well understood. This paper outlines the context, framework, methods, and preliminary evaluation of the program. Data from participant surveys, interviews, and field notes suggest that program content and delivery positively impacted participants. Four major themes emerged: Enabling engagement through experiential learning; Valuing reciprocity in long-term care training; Creating meaningful change through significant learning; and, Fostering sustained practice change through leadership involvement. The paper concludes with implications for LTC workforce training.

Examining the relationships between span of control and manager job and unit performance outcomes.

AIM: Our aim was to examine the combination of frontline manager (FLM) personal characteristics and span of control (SOC) on their job and unit performance outcomes. BACKGROUND: Healthcare downsizing and reform have contributed to larger spans for FLMs in Canadian hospitals and increased concerns about manager workload. Despite a heightened awareness of SOC issues among decision makers, there is limited empirical evidence related to the effects of SOC on outcomes. METHODS: A non-experimental predictive survey design was used to examine FLM SOC in 14 Canadian academic hospitals. Managers (n = 121) completed an online survey of work characteristics and The Ottawa Hospital (TOH) SOC tool. Unit turnover data were collected from organisational databases. RESULTS: The combination of SOC and core self-evaluation significantly predicted role overload, work control and job satisfaction, but only SOC predicted unit adverse outcomes and neither significantly predicted unit turnover. CONCLUSIONS: The findings contribute to an understanding of connections between the combination of SOC and core self-evaluation and manager job and unit performance outcomes. IMPLICATIONS FOR NURSING MANAGEMENT: Organisational strategies to create manageable FLM SOC are essential to ensure exemplary job and unit outcomes. Core self-evaluation is a personality characteristic that may enhance manager performance in the face of high spans of control.

Development of communication tool for resident- and family-led care discussions in long-term care through patient and family engagement.

BACKGROUND: Effective communication between residents (older adults), families, and the healthcare team supports person-centred care. However, communication breakdowns can occur that can impact care and outcomes. The aim of this paper is to describe a feedback approach to developing a communication tool for residents and families to guide information sharing during care discussions with the healthcare team in long-term care. METHODS: Development of the communication tool included consultation with key stakeholders for their feedback and input. Following initial development of the tool template by our research team, we invited feedback from our study collaborators. Next, individual interviews and a focus group were conducted with family members, followed by individual interviews with selected residents from two long-term care homes in Ontario, Canada. Participants were asked to provide input and feedback on the tool's content and usability and to share ideas for improving the tool. Content analysis was used to analyse the interview data. RESULTS: Feedback from residents and family included suggestions to enhance the tool's content and use of plain language, and suggestions for potential application of the tool. CONCLUSION: Feedback highlighted the value of engaging residents and family members in the development of a communication tool. The communication tool offers a structured format to support participation of residents and families in information sharing for care discussions with the healthcare team.

The Patient Care Delivery Model--an open system framework: conceptualisation, literature review and analytical strategy.

AIMS AND OBJECTIVES: This paper presents the Patient Care Delivery Model to illustrate interrelationships between model components and to support its application in research using advanced analytical techniques, including structural equation modelling. BACKGROUND: Many complex factors contribute to the nature of healthcare environments and to nurse, patient and system outcomes. A better understanding of these factors and their interrelationships would provide insight for decision-makers to develop strategies to improve outcomes. DESIGN: A literature review approach was used to address the objectives. METHOD: A threefold approach used existing theory to explicate a comprehensive conceptual framework, reviewed empirical studies of the proposed relationships and considered the application of advanced analytical techniques to inform future research directions. RESULTS: As per general system theory, inputs (patient, nurse and system characteristics) to the Patient Care Delivery Model interact with throughputs (nursing interventions, work environments and environmental complexity) to produce intermediate (staffing levels) and distal outputs (patient, nurse and system outcomes). Application of the model in research and its relevance for healthcare settings is supported in the current literature. Statistical techniques that allow model testing and the investigation of multiple relationships simultaneously have demonstrated the interconnections among the model components. CONCLUSIONS: Development of the Patient Care Delivery Model is a step towards understanding work environments and providing healthcare managers with evidence-based management tools. Formal testing of comprehensive, multilevel conceptual models will provide empirical linkages between inputs and outputs and will identify potential mediators between predictors and outcomes to offer new insight into organisational practices. RELEVANCE TO CLINICAL PRACTICE: A better understanding of how factors in the work environment impact clinical outcomes can facilitate care processes in the nursing unit. Future studies using comprehensive conceptual frameworks and sophisticated analytical approaches will enhance professional nursing practice and improve clinical outcomes in healthcare organisations.

Front-line managers as boundary spanners: effects of span and time on nurse supervision satisfaction.

AIM: To examine the influence of nurse manager span (number of direct report staff), time in staff contact, transformational leadership practices and operational hours on nurse supervision satisfaction. BACKGROUND: Increasing role complexity has intensified the boundary spanning functions of managers. Because work demands and scope vary by management position, time in staff contact rather than span may better explain managers' capacity to support staff. METHODS: A descriptive, correlational design was used to collect cross-sectional survey and prospective work log and administrative data from a convenience sample of 558 nurses in 51 clinical areas and 31 front-line nurse managers from four acute care hospitals in 2007-2008. Data were analysed using hierarchical linear modelling. RESULTS: Span, but not time in staff contact, interacted with leadership and operational hours to explain supervision satisfaction. CONCLUSIONS: With compressed operational hours, supervision satisfaction was lower with highly transformational leadership in combination with wider spans. With extended operational hours, supervision satisfaction was higher with highly transformational leadership, and this effect was more pronounced under wider spans. IMPLICATIONS FOR NURSING MANAGEMENT: Operational hours, which influence the manager's daily span (average number of direct report staff working per weekday), should be factored into the design of front-line management positions.

ECHO Care of the Elderly: Innovative Learning to Build Capacity in Long-term Care.

BACKGROUND: Older adults are entering long-term care (LTC) homes with more complex care needs than in previous decades, resulting in demands on point-of-care staff to provide additional and specialty services. This study evaluated whether Project ECHO® (Extension for Community Healthcare Outcomes) Care of the Elderly Long-Term Care (COE-LTC)-a case-based online education program-is an effective capacity-building program among interprofessional health-care teams caring for LTC residents. METHODS: A mixed-method, pre-and-post study comprised of satisfaction, knowledge, and self-efficacy surveys and exploration of experience via semi-structured interviews. Participants were interprofessional health-care providers from LTC homes across Ontario. RESULTS: From January-March 2019, 69 providers, nurses/nurse practitioners (42.0%), administrators (26.1%), physicians (24.6%), and allied health professionals (7.3%) participated in 10 weekly, 60-minute online sessions. Overall, weekly session and post-ECHO satisfaction were high across all domains. Both knowledge scores and self-efficacy ratings increased post-ECHO, 3.9% (p = .02) and 9.7 points (p < .001), respectively. Interview findings highlighted participants' appreciation of access to specialists, recognition of educational needs specific to LTC, and reduction of professional isolation. CONCLUSION: We demonstrated that ECHO COE-LTC can be a successful capacity-building educational model for interprofessional health-care providers in LTC, and may alleviate pressures on the health system in delivering care for residents.

Building Long-Term Care Staff Capacity During COVID-19 Through Just-in-Time Learning: Evaluation of a Modified ECHO Model.

OBJECTIVES: The onset of the COVID-19 pandemic significantly challenged the capacity of long-term care (LTC) homes in Canada, resulting in new, pressing priorities for leaders and health care providers (HCPs) in the care and safety of LTC residents. This study aimed to determine whether Project ECHO (Extension for Community Healthcare Outcomes) Care of the Elderly Long-Term Care (COE-LTC): COVID-19, a virtual education program, was effective at delivering just-in-time learning and best practices to support LTC teams and residents during the pandemic. DESIGN: Mixed methods evaluation. SETTING AND PARTICIPANTS: Interprofessional HCPs working in LTC homes or deployed to work in LTC homes primarily in Ontario, Canada, who participated in 12 weekly, 60-minute sessions. METHODS: Quantitative and qualitative surveys assessing reach, satisfaction, self-efficacy, practice change, impact on resident care, and knowledge sharing. RESULTS: Of the 252 registrants for ECHO COE-LTC: COVID-19, 160 (63.4%) attended at least 1 weekly session. Nurses and nurse practitioners represented the largest proportion of HCPs (43.8%). Overall, both confidence and comfort level working with residents who were at risk, confirmed, or suspected of having COVID-19 increased after participating in the ECHO sessions (effect sizes ≥ 0.7, Wilcoxon signed rank P < .001). Participants also reported impact on intent to change behavior, resident care, and knowledge sharing. CONCLUSIONS AND IMPLICATIONS: The results demonstrate that ECHO COE-LTC: COVID 19 effectively delivered time-sensitive information and best practices to support LTC teams and residents. It may be a critical platform during this pandemic and in future crises to deliver just-in-time learning during periods of constantly changing information.

Nursing Services Delivery Theory: an open system approach.

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

Evaluation of a patient care delivery model: system outcomes in acute cardiac care.

Hierarchical linear modelling was used to evaluate the influence of nurse staffing, work environment, and nurse and patient variables on system outcomes based on data collected in Canadian cardiac and cardiovascular inpatient units. Staffing utilization levels below 80% at the unit level and less overtime optimized perceived care quality and the completion of therapeutic interventions. Fewer patients per nurse improved perceived care quality and reduced longer-than-expected length of stay. Nurse reports of greater resource adequacy were associated with less absenteeism and fewer uncompleted or delayed nursing interventions. System outcomes were also influenced by patient characteristics (health, pre-operative education, nursing diagnoses); nurse characteristics (experience, expertise, health, effort-reward imbalance); and work-environment factors (autonomy, unit instability).

Evaluation of a patient care delivery model: patient outcomes in acute cardiac care.

PURPOSE: To evaluate the influence of nurse staffing and work environment variables on patient outcomes by testing a conceptual model. DESIGN: A prospective, correlational design with cross-sectional and longitudinal components was conducted in Canadian cardiac and cardiovascular care inpatient units. METHODS: Data were collected from multiple sources. Hierarchical linear modeling was used to examine relationships among variables. CONCLUSIONS: The findings indicate that patient outcomes are influenced not only by patient and nurse characteristics, but also by organizational staffing practices. Organizations that manage the complexity of work conditions and target staffing utilization levels between 80% and 88% at the unit level can optimize patient outcomes. CLINICAL RELEVANCE: Empirical validation of the model provides evidence to inform management decisions about hospital nurse staffing.

Span of management: concept analysis.

AIM: This paper is a report of a concept analysis of span of management. BACKGROUND: Span of management is an important structural variable in evaluating the contributions of nursing managers to healthcare systems. Span of management is typically measured as a ratio. A wide variety of operational definitions have been applied and these differences have not been reconciled. DATA SOURCES: A search of CINAHL, PsychINFO and Business Source Premier was completed in 2007 using the terms span of management, span of control, organizational structure, hierarchy, supervisory ratio and work group size. Key publications (1975-2007) and seminal works were included. Review methods. Morse's concept analysis approach was used to determine the pragmatic utility of the concept. A critical appraisal of the literature assessed the use of the concept across disciplines, identified inconsistencies within the concept, and uncovered assumptions and conceptual gaps. FINDINGS: At the organizational level, span represents supervisory capability. At the level of the manager, span may reflect reporting structure, closeness of contact, or scope of the role. At the work group level, span quantifies work group size. At the employee level, span represents employee support. These measures are influenced by units of measurement and by context. CONCLUSION: A systematic understanding of span of management concepts, measures and determinants will assist nurse executives in selecting parameters to quantify the allocation of managerial resources. Researchers can incorporate these parameters in comparisons across studies and in advancing the science of nursing management.

Boundary spanning by nurse managers: effects of managers' characteristics and scope of responsibility on teamwork.

Increasing role complexity has intensified the work of managers in supporting healthcare teams. This study examined the influence of front-line managers' characteristics and scope of responsibility on teamwork. Scope of responsibility considers the breadth of the manager's role. A descriptive, correlational design was used to collect cross-sectional survey and administrative data in four acute care hospitals. A convenience sample of 754 staff completed the Relational Coordination Scale as a measure of teamwork that focuses on the quality of communication and relationships. Nurses (73.9%), allied health professionals (14.7%) and unregulated staff (11.7%) worked in 54 clinical areas, clustered under 30 front-line managers. Data were analyzed using hierarchical linear modelling. Leadership practices, clinical support roles and compressed operational hours had positive effects on teamwork. Numbers of non-direct report staff and areas assigned had negative effects on teamwork. Teamwork did not vary by span, managerial experience, worked hours, occupational diversity or proportion of full-time employees. Large, acute care teaching hospitals can enable managers to foster teamwork by enhancing managers' leadership practices, redesigning the flow or reporting structure for non-direct reports, optimizing managerial hours relative to operational hours, allocating clinical support roles, reducing number of areas assigned and, potentially, introducing co-manager models.

Exploring managers' views on span of control: more than a headcount.

The purpose of this qualitative study was to explore front-line managers' (FLMs') perceptions of their span of control (SOC) and how they manage it. As part of a larger quantitative study examining relationships between FLMs' SOC and performance outcomes, 10 manager focus groups were conducted by teleconference, involving 48 managers from 14 academic healthcare organizations. Themes and subthemes were identified according to (a) perceptions of the size and scope of SOC; (b) factors influencing the complexity of SOC; (c) supports needed to manage SOC; (d) changing leadership style; and (e) ways of coping with role overload. Participants described system demands as a significant contributor to their work responsibilities and a sense of role overload. About half of managers stated their SOC was unreasonable and that they lacked the necessary supports to manage it. Many managers who described their SOC as reasonable still expressed concerns about internal and external workload pressures that contributed to changing leadership style and role overload. Findings reinforce the importance of organizational strategies to create regular dialogue with FLMs regarding the size, complexity and appropriateness of current spans and to provide the resource supports necessary to ensure they can manage their SOC effectively.