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1.  How Do People Make Continence Care Happen? An Analysis of Organizational Culture in Two Nursing Homes 
The Gerontologist  2009;50(3):327-339.
Purpose: Although nursing homes (NHs) are criticized for offering poor quality continence care, little is known about the organizational processes that underlie this care. This study investigated the influence of organizational culture on continence care practices in two NHs. Design and Methods: This ethnographic study explored continence care from the perspectives of NH stakeholders, including residents and interdisciplinary team members. Data were collected through participant observation, interviews, and archival records. Results: Human relations dimensions of organizational culture influenced continence care by affecting institutional missions, admissions and hiring practices, employee tenure, treatment strategies, interdisciplinary teamwork, and group decision making. Closed system approaches, parochial identity, and an employee focus stabilized staff turnover, fostered evidence-based practice, and supported hierarchical toileting programs in one facility. Within a more dynamic environment, open system approaches, professional identity, and job focus allowed flexible care practices during periods of staff turnover. Neither organizational culture fully supported interdisciplinary team efforts to maximize the bladder and bowel health of residents. Implications: Organizational culture varies in NHs, shaping the continence care practices of interdisciplinary teams and leading to the selective use of treatments across facilities. Human relations dimensions of organizational culture, including open or closed systems, professional or parochial identity, and employee or job focus are critical to the success of quality improvement initiatives. Evidence-based interventions should be tailored to organizational culture to promote adoption and sustainability of resident care programs.
doi:10.1093/geront/gnp157
PMCID: PMC2867496  PMID: 20008040
Organizational culture; Incontinence; Interdisciplinary teams; Qualitative research
2.  Randomized Multilevel Intervention to Improve Outcomes of Residents in Nursing Homes in Need of Improvement 
Purpose
A comprehensive multilevel intervention was tested to build organizational capacity to create and sustain improvement in quality of care and subsequently improve resident outcomes in nursing homes in need of improvement. Intervention facilities (n=29) received a two-year multilevel intervention with monthly on-site consultation from expert nurses with graduate education in gerontological nursing. Attention control facilities (n=29) that also needed to improve resident outcomes received monthly information about aging and physical assessment of elders.
Design and Methods
Randomized clinical trial of nursing homes in need of improving resident outcomes of bladder and bowel incontinence, weight loss, pressure ulcers, and decline in activities of daily living (ADL). It was hypothesized that following the intervention, experimental facilities would have better resident outcomes, higher quality of care, higher staff retention, more organizational attributes of improved working conditions than control facilities, similar staffing and staff mix, and lower total and direct care costs.
Results
The intervention did improve quality of care (p=0.02); there were improvements in pressure ulcers (p=0.05), weight loss (p=0.05). Staff retention, organizational working conditions, staffing, and staff mix and most costs were not affected by the intervention. Leadership turnover was surprisingly excessive in both intervention and control groups.
Implications
Some facilities that are in need of improving quality of care and resident outcomes are able to build the organizational capacity to improve while not increasing staffing or costs of care. Improvement requires continuous supportive consultation and leadership willing to involve staff and work together to build the systematic improvements in care delivery needed.
doi:10.1016/j.jamda.2011.06.012
PMCID: PMC3379965  PMID: 21816681
randomized clinical trial; nursing homes; outcomes of care; cost analysis; quality improvement; staff retention; working conditions
3.  The Influence of Staffing Characteristics on Quality of Care in Nursing Homes 
Health Services Research  2007;42(5):1822-1847.
Objective
The influence staffing levels, turnover, worker stability, and agency staff had on quality of care in nursing homes was examined.
Data Sources/Study Setting
Staffing characteristics came from a survey of nursing homes (N=1,071) conducted in 2003. The staffing characteristics were collected for Nurse Aides, Licensed Practical Nurses, and Registered Nurses. Fourteen quality indicators came from the Nursing Home Compare website report card and nursing home organizational characteristics came from the Online Survey, Certification, and Recording system.
Study Design
One index of quality (the outcome) was created by combining the 14 quality indicators using exploratory factor analysis. We used regression analyses to assess the effect of the four staffing characteristics for each of the three types of nursing staff on this quality index in addition to individual analyses for each of the 14 quality indicators. The effect of organizational characteristics as well as the markets in which they operated on outcomes was examined. We examined a number of different model specifications.
Principal Findings
Quality of care was influenced, to some degree, by all of these staffing characteristics. However, the estimated interaction effects indicated that achieving higher quality was dependent on having more than one favorable staffing characteristic—the effect of quality was larger than the sum of the independent effects of each favorable staffing characteristic.
Conclusions
Our results indicate that staff characteristics such as turnover, staffing levels, worker stability, and agency staff should be addressed simultaneously to improve the quality of nursing homes.
doi:10.1111/j.1475-6773.2007.00704.x
PMCID: PMC2254574  PMID: 17850522
Nursing homes; quality; staffing
4.  A Formative and Summative Evaluation of an Electronic Health Record in Community Nursing 
Implementation of an electronic health record (EHR) system is generally believed to improve the quality of patient care. However due to the variability of systems and users, there is little agreement on successful implementation. The purpose of this research is to evaluate the implementation of a BlackBerry hosted application enabling wireless documentation and access to electronic decision support resources in one home care agency in Ontario. Through mixed-methods including surveys, corporate data collection and interviews, this study investigates nurses’ perceptions of barriers and facilitators to adoption of the electronic clinical information system. Early results highlight usability, organizational culture, evidence-based practice, and factors influencing nurses’ adaptation of this electronic clinical information system.
PMCID: PMC3799176  PMID: 24199063
5.  Nurses’ information management at patients’ discharge from hospital to home care 
Abstract
Purpose
The purpose of this paper is to explore and compare hospital and home care nurses’ assessment of their information management at patients’ discharge from hospital to home care before and after the hospital implemented an electronic nursing discharge note.
Theory
This paper draws on the concept of inter-organizational continuity of care, and specifically addresses the contribution of the implementation of an electronic patient record (EPR).
Methods
The study has a prospective descriptive design. A questionnaire addressing the information that hospital and home care nurses exchange when patients need continuing care after hospitalization was developed and used.
Results
Hospital and home care nurses differed in the way they assessed the structures and content of the information they exchanged, both before and after the EPR implementation.
Conclusion and discussion
There is a need to take account of the different organizational contexts within which the two nursing groups work. The organizational context (hospital versus home care) has implications for the nurses’ assessment of the information they exchange. In further development of EPR, it is therefore essential to clarify the context-related information needs of the various health care provider groups as part of the commitment to patient safety.
PMCID: PMC1395517  PMID: 16773162
inter-organizational continuity of care; hospital and home care nurses; nursing discharge note; exchange of information
6.  Communication, advice exchange and job satisfaction of nursing staff: a social network analyses of 35 long-term care units 
Background
The behaviour of individuals is affected by the social networks in which they are embedded. Networks are also important for the diffusion of information and the influence of employees in organisations. Yet, at the moment little is known about the social networks of nursing staff in healthcare settings. This is the first study that investigates informal communication and advice networks of nursing staff in long-term care. We examine the structure of the networks, how they are related to the size of units and characteristics of nursing staff, and their relationship with job satisfaction.
Methods
We collected social network data of 380 nursing staff of 35 units in group projects and psychogeriatric units in nursing homes and residential homes in the Netherlands. Communication and advice networks were analyzed in a social network application (UCINET), focusing on the number of contacts (density) between nursing staff on the units. We then studied the correlation between the density of networks, size of the units and characteristics of nursing staff. We used multilevel analyses to investigate the relationship between social networks and job satisfaction of nursing staff, taking characteristics of units and nursing staff into account.
Results
Both communication and advice networks were negatively related to the number of residents and the number of nursing staff of the units. Communication and advice networks were more dense when more staff worked part-time. Furthermore, density of communication networks was positively related to the age of nursing staff of the units. Multilevel analyses showed that job satisfaction differed significantly between individual staff members and units and was influenced by the number of nursing staff of the units. However, this relationship disappeared when density of communication networks was added to the model.
Conclusions
Overall, communication and advice networks of nursing staff in long-term care are relatively dense. This fits with the high level of cooperation that is needed to provide good care to residents. Social networks are more dense in small units and are also shaped by characteristics of staff members. The results furthermore show that communication networks are important for staff's job satisfaction.
doi:10.1186/1472-6963-11-140
PMCID: PMC3133544  PMID: 21631936
7.  Implementation and testing of a digital pen and paper tool to support patients with heart failure and their health care providers in detecting early signs of deterioration and monitor adherence 
Aim
To implement and evaluate a HF management tool for patients with chronic HF using digital pen and paper for improvement of patient self-management.
Methods
Developmental and implementation phase: researchers within medical technology and HF care will together with staff from home care and primary care (physicians and nurses) a small group of users (patients) and companies develop a HF management tool based on digital pen and paper and implement it in clinical practice.
Evaluation phase
The HF management tool will be tested in ten HF patients admitted to hospital-based home care. The technical equipment and clinical follow-up routines will be evaluated (reliability, stability, acceptance, user friendliness, and patient- and staff satisfaction). The patients will monitor and register shortness of breath, intake of medications, weight, blood pressure, pulse and saturation daily.
Data will be collected through patient and staff interviews and observations as well as through questionnaires evaluating health-related quality of life, HF self-care and knowledge, quality of care, participation and perceived control. Health care and organisational costs will be estimated from patient and staff records.
Innovative aspects and significance of the study: There is a great need for less labour-intensive and more cost-effective innovations that improve care and facilitate follow-up of patients with moderate to severe HF and at high risk for deterioration needing hospitalisation.
PMCID: PMC3184791
heart failure; home care; digital pen
8.  Technology Implementation and Workarounds in the Nursing Home 
Objective
This study sought to explore the relationship of workarounds related to the implementation of an electronic medication administration record and medication safety practices in five Midwestern nursing homes.
Design
As a part of a larger study, this qualitative evaluation was conducted to identify workarounds associated with the implementation of an electronic medication administration record. Data were collected using multimethods including direct observation, process mapping, key informant interviews, and review of field notes from medication safety team meetings.
Measurements
Open and axial coding techniques were used to identify and categorize types of workarounds in relation to work flow blocks.
Results
Workarounds presented in two distinct patterns, those related to work flow blocks introduced by technology and those related to organizational processes not reengineered to effectively integrate with the technology. Workarounds such as safety alert overrides and shortcuts to documentation resulted from first-order problem solving of immediate blocks. Nursing home staff as individuals frequently used first-order problem solving instead of the more sophisticated second-order problem solving approach used by the medication safety team.
Conclusion
This study provides important practical examples of how nursing home staff work around work flow blocks encountered during the implementation of technology. Understanding these workarounds as a means of first-order problem solving is an important consideration to understanding risk to medication safety.
doi:10.1197/jamia.M2378
PMCID: PMC2274876  PMID: 17947626
9.  Rationing of nursing care and its relationship to patient outcomes: the Swiss extension of the International Hospital Outcomes Study 
Objectives
To explore the association between implicit rationing of nursing care and selected patient outcomes in Swiss hospitals, adjusting for major organizational variables, including the quality of the nurse practice environment and the level of nurse staffing. Rationing was measured using the newly developed Basel Extent of Rationing of Nursing Care (BERNCA) instrument. Additional data were collected using an adapted version of the International Hospital Outcomes Study questionnaire.
Design
Multi-hospital cross-sectional surveys of patients and nurses.
Setting
Eight Swiss acute care hospitals
Participants
Nurses (1338) and patients (779) on 118 medical, surgical and gynecological units.
Main outcome measures
Patient satisfaction, nurse-reported medication errors, patient falls, nosocomial infections, pressure ulcers and critical incidents involving patients over the previous year.
Results
Generally, nurses reported rarely having omitted any of the 20 nursing tasks listed in the BERNCA over their last 7 working days. However, despite relatively low levels, implicit rationing of nursing care was a significant predictor of all six patient outcomes studied. Although the adequacy of nursing resources was a significant predictor for most of the patient outcomes in unadjusted models, it was not an independent predictor in the adjusted models. Low nursing resource adequacy ratings were a significant predictor for five of the six patient outcomes in the unadjusted models, but not in the adjusted ones.
Conclusion
As a system factor in acute general hospitals, implicit rationing of nursing care is an important new predictor of patient outcomes and merits further study.
doi:10.1093/intqhc/mzn017
PMCID: PMC2582013  PMID: 18436556
healthcare rationing; organizational factors; patient outcomes; quality of hospital care
10.  Rationing of nursing care and its relationship to patient outcomes: the Swiss extension of the International Hospital Outcomes Study 
Objectives
To explore the association between implicit rationing of nursing care and selected patient outcomes in Swiss hospitals, adjusting for major organizational variables, including the quality of the nurse practice environment and the level of nurse staffing. Rationing was measured using the newly developed Basel Extent of Rationing of Nursing Care (BERNCA) instrument. Additional data were collected using an adapted version of the International Hospital Outcomes Study questionnaire.
Design
Multi-hospital cross-sectional surveys of patients and nurses.
Setting
Eight Swiss acute care hospitals
Participants
Nurses (1338) and patients (779) on 118 medical, surgical and gynecological units.
Main outcome measures
Patient satisfaction, nurse-reported medication errors, patient falls, nosocomial infections, pressure ulcers and critical incidents involving patients over the previous year.
Results
Generally, nurses reported rarely having omitted any of the 20 nursing tasks listed in the BERNCA over their last 7 working days. However, despite relatively low levels, implicit rationing of nursing care was a significant predictor of all six patient outcomes studied. Although the adequacy of nursing resources was a significant predictor for most of the patient outcomes in unadjusted models, it was not an independent predictor in the adjusted models. Low nursing resource adequacy ratings were a significant predictor for five of the six patient outcomes in the unadjusted models, but not in the adjusted ones.
Conclusion
As a system factor in acute general hospitals, implicit rationing of nursing care is an important new predictor of patient outcomes and merits further study.
doi:10.1093/intqhc/mzn017
PMCID: PMC2582013  PMID: 18436556
healthcare rationing; organizational factors; patient outcomes; quality of hospital care
11.  Cost-effectiveness of a pressure ulcer quality collaborative 
Background
A quality improvement collaborative (QIC) in the Dutch long-term care sector (nursing homes, assisted living facilities, home care) used evidence-based prevention methods to reduce the incidence and prevalence of pressure ulcers (PUs). The collaborative consisted of a core team of experts and 25 organizational project teams. Our aim was to determine its cost-effectiveness from a healthcare perspective.
Methods
We used a non-controlled pre-post design to establish the change in incidence and prevalence of PUs in 88 patients over the course of a year. Staff indexed data and prevention methods (activities, materials). Quality of life (Qol) weights were assigned to the PU states. We assessed the costs of activities and materials in the project. A Markov model was built based on effectiveness and cost data, complemented with a probabilistic sensitivity analysis. To illustrate the results of longer term, three scenarios were created in which change in incidence and prevalence measures were (1) not sustained, (2) partially sustained, and (3) completely sustained.
Results
Incidence of PUs decreased from 15% to 4.5% for the 88 patients. Prevalence decreased from 38.6% to 22.7%. Average Quality of Life (Qol) of patients increased by 0.02 Quality Adjusted Life Years (QALY)s in two years; healthcare costs increased by €2000 per patient; the Incremental Cost-effectiveness Ratio (ICER) was between 78,500 and 131,000 depending on whether the changes in incidence and prevalence of PU were sustained.
Conclusions
During the QIC PU incidence and prevalence significantly declined. When compared to standard PU care, the QIC was probably more costly and more effective in the short run, but its long-term cost-effectiveness is questionable. The QIC can only be cost-effective if the changes in incidence and prevalence of PU are sustained.
doi:10.1186/1478-7547-8-11
PMCID: PMC2895580  PMID: 20515473
12.  Determinants of staff job satisfaction of caregivers in two nursing homes in Pennsylvania 
Background
Job satisfaction is important for nursing home staff and nursing home management, as it is associated with absenteeism, turnover, and quality of care. However, we know little about factors associated with job satisfaction and dissatisfaction for nursing home workers.
Methods
In this investigation, we use data from 251 caregivers (i.e., Registered Nurses, Licensed Practical Nurses, and Nurse Aides) to examine: job satisfaction scores of these caregivers and what characteristics of these caregivers are associated with job satisfaction. The data were collected from two nursing homes over a two and a half year period with five waves of data collection at six-month intervals. The Job Description Index was used to collect job satisfaction data.
Results
We find that, overall nursing home caregivers are satisfied with the work and coworkers, but are less satisfied with promotional opportunities, superiors, and compensation. From exploratory factor analysis three domains represented the data, pay, management, and work. Nurse aides appear particularly sensitive to the work domain. Of significance, we also find that caregivers who perceived the quality of care to be high have higher job satisfaction on all three domains than those who do not.
Conclusion
These results may be important in guiding caregiver retention initiatives in nursing homes. The finding for quality may be especially important, and indicates that nursing homes that improve their quality may have a positive impact on job satisfaction of staff, and thereby reduce their turnover rates.
doi:10.1186/1472-6963-6-60
PMCID: PMC1524956  PMID: 16723022
13.  Doing Better to Do Good: The Impact of Strategic Adaptation on Nursing Home Performance 
Health Services Research  2007;42(3 Pt 1):1200-1218.
Objective
To test the hypothesis that a greater commitment to strategic adaptation, as exhibited by more extensive implementation of a subacute/rehabilitation care strategy in nursing homes, will be associated with superior performance.
Data Sources
Online Survey, Certification, and Reporting (OSCAR) data from 1997 to 2004, and the area resource file (ARF).
Study Design
The extent of strategic adaptation was measured by an aggregate weighted implementation score. Nursing home performance was measured by occupancy rate and two measures of payer mix. We conducted multivariate regression analyses using a cross-sectional time series generalized estimating equation (GEE) model to examine the effect of nursing home strategic implementation on each of the three performance measures, controlling for market and organizational characteristics that could influence nursing home performance.
Data Collection/Abstraction Methods
OSCAR data was merged with relevant ARF data.
Principal Findings
The results of our analysis provide strong support for the hypothesis.
Conclusions
From a theoretical perspective, our findings confirm that organizations that adjust strategies and structures to better fit environmental demands achieve superior performance. From a managerial perspective, these results support the importance of proactive strategic leadership in the nursing home industry.
doi:10.1111/j.1475-6773.2006.00649.x
PMCID: PMC1955259  PMID: 17489910
Nursing homes; strategic adaptations; financial performance
14.  Implementation Interventions Used in Nursing Homes and Hospitals: A Descriptive, Comparative Study between Austria, Germany, and The Netherlands 
ISRN Nursing  2013;2013:706054.
Translating guidelines into nursing practice remains a considerable challenge. Until now, little attention has been paid to which interventions are used in practice to implement guidelines on changing clinical nursing practice. This cross-sectional study determined the current ranges and rates of implementation-related interventions in Austria, Germany, and The Netherlands and explored possible differences between these countries. An online questionnaire based on the conceptual framework of implementation interventions (professional, organizational, financial, and regulatory) from the Cochrane Effective Practice and Organization of Care (EPOC) data collection checklist was used to gather data from nursing homes and hospitals. Provision of written materials is the most frequently used professional implementation intervention (85%), whereas changes in the patient record system rank foremost among organisational interventions (78%). Financial incentives for nurses are rarely used. More interventions were used in Austria and Germany than in The Netherlands (20.3/20.2/17.3). Professional interventions are used more frequently in Germany and financial interventions more frequently in The Netherlands. Implementation efforts focus mainly on professional and organisational interventions. Nurse managers and other responsible personnel should direct their focus to a broader array of implementation interventions using the four different categories of EPOC's conceptual framework.
doi:10.1155/2013/706054
PMCID: PMC3727135  PMID: 23956875
15.  Effects of computerized nurse careplanning on selected health care effectiveness measures. 
A computerized nurse careplanning system (CNCP) was implemented on two nursing units of the Veterans' Affairs Medical Center, Washington, DC. This pretest, post-test experimental study sought to determine the effects of implementing this system on selected nursing care activities and associated patient outcomes. Effects on outcomes of job satisfaction, use of careplanning and competency of staff nurses were also examined. The sample consists of four medical nursing wards with registered nurses (n = 40) and patients (n = 160 as subjects). Data collection included nurse questionnaires, patient interviews and chart reviews. Results of the multiple regression analyses will be summarized here. Plans for further enhancement of CNCP will be discussed.
PMCID: PMC2247491  PMID: 1807627
16.  Nurse forecasting in Europe (RN4CAST): Rationale, design and methodology 
BMC Nursing  2011;10:6.
Background
Current human resources planning models in nursing are unreliable and ineffective as they consider volumes, but ignore effects on quality in patient care. The project RN4CAST aims innovative forecasting methods by addressing not only volumes, but quality of nursing staff as well as quality of patient care.
Methods/Design
A multi-country, multilevel cross-sectional design is used to obtain important unmeasured factors in forecasting models including how features of hospital work environments impact on nurse recruitment, retention and patient outcomes. In each of the 12 participating European countries, at least 30 general acute hospitals were sampled. Data are gathered via four data sources (nurse, patient and organizational surveys and via routinely collected hospital discharge data). All staff nurses of a random selection of medical and surgical units (at least 2 per hospital) were surveyed. The nurse survey has the purpose to measure the experiences of nurses on their job (e.g. job satisfaction, burnout) as well as to allow the creation of aggregated hospital level measures of staffing and working conditions. The patient survey is organized in a sub-sample of countries and hospitals using a one-day census approach to measure the patient experiences with medical and nursing care. In addition to conducting a patient survey, hospital discharge abstract datasets will be used to calculate additional patient outcomes like in-hospital mortality and failure-to-rescue. Via the organizational survey, information about the organizational profile (e.g. bed size, types of technology available, teaching status) is collected to control the analyses for institutional differences.
This information will be linked via common identifiers and the relationships between different aspects of the nursing work environment and patient and nurse outcomes will be studied by using multilevel regression type analyses. These results will be used to simulate the impact of changing different aspects of the nursing work environment on quality of care and satisfaction of the nursing workforce.
Discussion
RN4CAST is one of the largest nurse workforce studies ever conducted in Europe, will add to accuracy of forecasting models and generate new approaches to more effective management of nursing resources in Europe.
doi:10.1186/1472-6955-10-6
PMCID: PMC3108324  PMID: 21501487
17.  Relationship of Nursing Home Staffing to Quality of Care 
Health Services Research  2004;39(2):225-250.
Objective
To compare nursing homes (NHs) that report different staffing statistics on quality of care.
Data Sources
Staffing information generated by California NHs on state cost reports and during onsite interviews. Data independently collected by research staff describing quality of care related to 27 care processes.
Study Design
Two groups of NHs (n=21) that reported significantly different and stable staffing data from all data sources were compared on quality of care measures.
Data Collection
Direct observation, resident and staff interview, and chart abstraction methods.
Principal Findings
Staff in the highest staffed homes (n=6), according to state cost reports, reported significantly lower resident care loads during onsite interviews across day and evening shifts (7.6 residents per nurse aide [NA]) compared to the remaining homes that reported between 9 to 10 residents per NA (n=15). The highest-staffed homes performed significantly better on 13 of 16 care processes implemented by NAs compared to lower-staffed homes.
Conclusion
The highest-staffed NHs reported significantly lower resident care loads on all staffing reports and provided better care than all other homes.
doi:10.1111/j.1475-6773.2004.00225.x
PMCID: PMC1361005  PMID: 15032952
Staffing; quality of care
18.  Exploring the impact of mentoring functions on job satisfaction and organizational commitment of new staff nurses 
Background
Although previous studies proved that the implementation of mentoring program is beneficial for enhancing the nursing skills and attitudes, few researchers devoted to exploring the impact of mentoring functions on job satisfaction and organizational commitment of new nurses. In this research we aimed at examining the effects of mentoring functions on the job satisfaction and organizational commitment of new nurses in Taiwan's hospitals.
Methods
We employed self-administered questionnaires to collect research data and select new nurses from three regional hospitals as samples in Taiwan. In all, 306 nurse samples were obtained. We adopted a multiple regression analysis to test the impact of the mentoring functions.
Results
Results revealed that career development and role modeling functions have positive effects on the job satisfaction and organizational commitment of new nurses; however, the psychosocial support function was incapable of providing adequate explanation for these work outcomes.
Conclusion
It is suggested in this study that nurse managers should improve the career development and role modeling functions of mentoring in order to enhance the job satisfaction and organizational commitment of new nurses.
doi:10.1186/1472-6963-10-240
PMCID: PMC2929231  PMID: 20712873
19.  Work and health conditions of nursing staff in palliative care and hospices in Germany  
Aims of this representative study were to assess the relevant differences between the work and organisational characteristics as well as the subjective resources and health status of nurses occupied in hospice care, compared to nurses from palliative stations. Further, the assessment of the predictive correlations between the work situation of this nurses as a factor influencing their health and perceived strains was also a leading intention.
Method: In a written survey conducted in Germany in 2001, 820 nursing staff of 113 palliative stations and stationary hospices were included. A qualified diagnostic procedure for the assessment of health promoting work was implemented. In order of obtaining a secure comparison, a sample of 320 nurses working in 12 homes for old people in Saxony was also considered.
Results: The nurses referred generally to favourable working conditions, still they informed about deficiencies in the perceived participation, organizational benefits and experienced gratification. Hospice nurses experienced overall more favourable work conditions than palliative nurses or than the staff of homes for old people (regarding identification with the institution, organizational benefits, accurate gratification and little time pressure during work). Hospice personnel were psychologically and physically healthier than the staff of palliative stations. Important predictors for health stability that could be assessed by multiple regression analysis were: positively evaluated work contents, the identification with the institution, little time pressure and a positive working atmosphere.
Conclusions: The assessed organisational framework is generally more favourable in the institutions of professional terminal care than in common hospitals and homes for old people. Therefore, the conditions in hospices could have a modelling function for the inner-institutional work organisation and for the anchorage of the intrinsic motivation of nurses in the health care system.
PMCID: PMC2736486  PMID: 19742056
20.  Relationship between Organizational Culture, Leadership Behavior and Job Satisfaction 
Background
Organizational culture refers to the beliefs and values that have existed in an organization for a long time, and to the beliefs of the staff and the foreseen value of their work that will influence their attitudes and behavior. Administrators usually adjust their leadership behavior to accomplish the mission of the organization, and this could influence the employees' job satisfaction. It is therefore essential to understand the relationship between organizational culture, leadership behavior and job satisfaction of employees.
Methods
A cross-sectional study was undertaken that focused on hospital nurses in Taiwan. Data was collected using a structured questionnaire; 300 questionnaires were distributed and 200 valid questionnaires were returned. To test the reliability of the data, they were analyzed by Cronbach's α and confirmatory factors. Correlation analysis was used on the relationships between organizational cultures, leadership behavior and job satisfaction.
Results
Organizational cultures were significantly (positively) correlated with leadership behavior and job satisfaction, and leadership behavior was significantly (positively) correlated with job satisfaction.
Conclusions
The culture within an organization is very important, playing a large role in whether it is a happy and healthy environment in which to work. In communicating and promoting the organizational ethos to employees, their acknowledgement and acceptance of it can influence their work behavior and attitudes. When the interaction between the leadership and employees is good, the latter will make a greater contribution to team communication and collaboration, and will also be encouraged to accomplish the mission and objectives assigned by the organization, thereby enhancing job satisfaction.
doi:10.1186/1472-6963-11-98
PMCID: PMC3123547  PMID: 21569537
21.  Formative evaluation of the telecare fall prevention project for older veterans 
Background
Fall prevention interventions for community-dwelling older adults have been found to reduce falls in some research studies. However, wider implementation of fall prevention activities in routine care has yielded mixed results. We implemented a theory-driven program to improve care for falls at our Veterans Affairs healthcare facility. The first project arising from this program used a nurse advice telephone line to identify patients' risk factors for falls and to triage patients to appropriate services. Here we report the formative evaluation of this project.
Methods
To evaluate the intervention we: 1) interviewed patient and employee stakeholders, 2) reviewed participating patients' electronic health record data and 3) abstracted information from meeting minutes. We describe the implementation process, including whether the project was implemented according to plan; identify barriers and facilitators to implementation; and assess the incremental benefit to the quality of health care for fall prevention received by patients in the project. We also estimate the cost of developing the pilot project.
Results
The project underwent multiple changes over its life span, including the addition of an option to mail patients educational materials about falls. During the project's lifespan, 113 patients were considered for inclusion and 35 participated. Patient and employee interviews suggested support for the project, but revealed that transportation to medical care was a major barrier in following up on fall risks identified by nurse telephone triage. Medical record review showed that the project enhanced usual medical care with respect to home safety counseling. We discontinued the program after 18 months due to staffing limitations and competing priorities. We estimated a cost of $9194 for meeting time to develop the project.
Conclusions
The project appeared feasible at its outset but could not be sustained past the first cycle of evaluation due to insufficient resources and a waning of local leadership support due to competing national priorities. Future projects will need both front-level staff commitment and prolonged high-level leadership involvement to thrive.
doi:10.1186/1472-6963-11-119
PMCID: PMC3127979  PMID: 21605438
22.  Assessing an organizational culture instrument based on the Competing Values Framework: Exploratory and confirmatory factor analyses 
Background
The Competing Values Framework (CVF) has been widely used in health services research to assess organizational culture as a predictor of quality improvement implementation, employee and patient satisfaction, and team functioning, among other outcomes. CVF instruments generally are presented as well-validated with reliable aggregated subscales. However, only one study in the health sector has been conducted for the express purpose of validation, and that study population was limited to hospital managers from a single geographic locale.
Methods
We used exploratory and confirmatory factor analyses to examine the underlying structure of data from a CVF instrument. We analyzed cross-sectional data from a work environment survey conducted in the Veterans Health Administration (VHA). The study population comprised all staff in non-supervisory positions. The survey included 14 items adapted from a popular CVF instrument, which measures organizational culture according to four subscales: hierarchical, entrepreneurial, team, and rational.
Results
Data from 71,776 non-supervisory employees (approximate response rate 51%) from 168 VHA facilities were used in this analysis. Internal consistency of the subscales was moderate to strong (α = 0.68 to 0.85). However, the entrepreneurial, team, and rational subscales had higher correlations across subscales than within, indicating poor divergent properties. Exploratory factor analysis revealed two factors, comprising the ten items from the entrepreneurial, team, and rational subscales loading on the first factor, and two items from the hierarchical subscale loading on the second factor, along with one item from the rational subscale that cross-loaded on both factors. Results from confirmatory factor analysis suggested that the two-subscale solution provides a more parsimonious fit to the data as compared to the original four-subscale model.
Conclusion
This study suggests that there may be problems applying conventional CVF subscales to non-supervisors, and underscores the importance of assessing psychometric properties of instruments in each new context and population to which they are applied. It also further highlights the challenges management scholars face in assessing organizational culture in a reliable and comparable way. More research is needed to determine if the emergent two-subscale solution is a valid or meaningful alternative and whether these findings generalize beyond VHA.
doi:10.1186/1748-5908-2-13
PMCID: PMC1865551  PMID: 17459167
23.  Standardised electronic information exchange between nurses in home care and GPs – the medication information processes 
Improving the transfer of medication information between home care nurses and patient’s general practitioners (GP) is assessed as essential for ensuring safe care. In this paper, we report on a Norwegian study in which we investigated how home care nurses experienced using standardised electronic messages in their communication with the GPs. Standardised electronic solutions were developed and implemented to resolve gaps in the medication information processes when patients received nursing care in their homes. Data was collected combining focus group interviews and individual interviews with nurses from home care in two municipalities in Norway. The data was analysed using systematic text condensation. We found that the nurses reported mostly advantages, but also some disadvantages regarding accuracy, consistency, availability and efficiency in the medication information process when they used standardised electronic messages. Efforts to refine the electronic messages to achieve better work processes and patient safety should be addressed.
PMCID: PMC3799093  PMID: 24199097
24.  Classifying nursing organization in wards in Norwegian hospitals: self-identification versus observation 
BMC Nursing  2010;9:3.
Background
The organization of nursing services could be important to the quality of patient care and staff satisfaction. However, there is no universally accepted nomenclature for this organization. The objective of the current study was to classify general hospital wards based on data describing organizational practice reported by the ward nurse managers, and then to compare this classification with the name used in the wards to identify the organizational model (self-identification).
Methods
In a cross-sectional postal survey, 93 ward nurse managers in Norwegian hospitals responded to questions about nursing organization in their wards, and what they called their organizational models. K-means cluster analysis was used to classify the wards according to the pattern of activities attributed to the different nursing roles and discriminant analysis was used to interpret the solutions. Cross-tabulation was used to validate the solutions and to compare the classification obtained from the cluster analysis with that obtained by self-identification. The bootstrapping technique was used to assess the generalizability of the cluster solution.
Results
The cluster analyses produced two alternative solutions using two and three clusters, respectively. The three-cluster solution was considered to be the best representation of the organizational models: 32 team leader-dominated wards, 23 primary nurse-dominated wards and 38 wards with a hybrid or mixed organization. There was moderate correspondence between the three-cluster solution and the models obtained by self-identification. Cross-tabulation supported the empirical classification as being representative for variations in nursing service organization. Ninety-four per cent of the bootstrap replications showed the same pattern as the cluster solution in the study sample.
Conclusions
A meaningful classification of wards was achieved through an empirical cluster solution; this was, however, only moderately consistent with the self-identification. This empirical classification is an objective approach to variable construction and can be generally applied across Norwegian hospitals. The classification procedure used in the study could be developed into a standardized method for classifying hospital wards across health systems and over time.
doi:10.1186/1472-6955-9-3
PMCID: PMC2832780  PMID: 20181125
25.  Moving Innovations into Treatment: A Stage-based Approach to Program Change 
Treatment programs are expected to change their clients. To adopt evidence-based practices to improve their therapeutic effectiveness in dealing with drug-related problems of clients, they also are expected to change themselves. The process of innovation adoption and implementation is the focus of studies included in this special journal issue. Collectively, this volume examines staff perceptions of program needs, organizational readiness for change (based on pressures, resources, staff attributes, and organizational climate), quality of workshop training, subsequent utilization of training materials, and client self-report of treatment engagement. Approximately 800 treatment programs nationwide contributed data for these studies. A standardized assessment of organizational functioning captured attributes that describe environments, settings, and staffs, and the findings are interpreted in the context of a stage-based approach to program changes. A conceptual model is used to help organize and summarize longitudinal results within the organizational context and according to implementation influences related to qualities of the innovations.
doi:10.1016/j.jsat.2006.12.023
PMCID: PMC1995028  PMID: 17434704
Evidence-based practice; Innovation; Program change; Organizational functioning; Implementation process

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