Nursing Research Methods and Critical Appraisal for Evidence-Based Practice

April 10, 2022/in Nursing /by admin

Nursing Research

Methods and Critical Appraisal for Evidence-Based Practice

NINETH EDITION

Geri LoBiondo-Wood, PhD, RN, FAAN Professor and Coordinator, PhD in Nursing Program, University of Texas Health Science Center at Houston, School of Nursing, Houston, Texas

Judith Haber, PhD, RN, FAAN

The Ursula Springer Leadership Professor in Nursing, New York University, Rory Meyers College of Nursing, New York, New York

Table of Contents

Cover image

Title page

About the authors

Contributors

Reviewers

To the faculty

To the student

Acknowledgments I. Overview of Research and Evidence-Based Practice

Introduction

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References

1. Integrating research, evidence-based practice, and quality improvement processes

References

2. Research questions, hypotheses, and clinical questions

References

3. Gathering and appraising the literature

References

4. Theoretical frameworks for research

References

II. Processes and Evidence Related to Qualitative Research

Introduction

References

5. Introduction to qualitative research

References

6. Qualitative approaches to research

References

7. Appraising qualitative research

Critique of a qualitative research study

References

III. Processes and Evidence Related to Quantitative Research

Introduction

References

8. Introduction to quantitative research

References

9. Experimental and quasi-experimental designs

References

10. Nonexperimental designs

References

11. Systematic reviews and clinical practice guidelines

References

12. Sampling

References

13. Legal and ethical issues

References

14. Data collection methods

References

15. Reliability and validity

References

16. Data analysis: Descriptive and inferential statistics

References

17. Understanding research findings

References

18. Appraising quantitative research

Critique of a quantitative research study

References

IV. Application of Research: Evidence-Based Practice

Introduction

References

19. Strategies and tools for developing an evidence-based practice

References

20. Developing an evidence-based practice

References

21. Quality improvement

References

Example of a randomized clinical trial (Nyamathi et al., 2015) Nursing case management peer coaching and hepatitis A and B vaccine completion among homeless men recently released on parole

Example of a longitudinal/Cohort study (Hawthorne et al., 2016) Parent spirituality grief and mental health at 1 and 3 months after their infant schild s death in an intensive care unit

Example of a qualitative study (van dijk et al., 2015) Postoperative patients perspectives on rating pain: A qualitative study

Example of a correlational study (Turner et al., 2016) Psychological functioning post traumatic growth and coping in parents and siblings of adolescent cancer survivors

Example of a systematic Review/Meta analysis (Al mallah et al., 2015) The impact of nurse led clinics on the mortality and morbidity of patients with cardiovascular diseases

Glossary

Index

Special features

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NURSING RESEARCH: METHODS AND CRITICAL APPRAISAL FOR EVIDENCE-BASED PRACTICE, NINTH EDITION ISBN: 978- 0-323-43131-6

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Notices Knowledge and best practice in this field are constantly changing.

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As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

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Library of Congress Cataloging-in-Publication Data

Names: LoBiondo-Wood, Geri, editor. | Haber, Judith, editor. Title: Nursing research : methods and critical appraisal for evidence-based practice / [edited by] Geri LoBiondo-Wood, Judith Haber. Other titles: Nursing research (LoBiondo-Wood) Description: 9th edition. | St. Louis, Missouri : Elsevier, [2018] |

Includes bibliographical references and index. Identifiers: LCCN 2017008727 | ISBN 9780323431316 (pbk. : alk. paper) Subjects: | MESH: Nursing Research—methods | Research Design | Evidence-Based Nursing—methods Classification: LCC RT81.5 | NLM WY 20.5 | DDC 610.73072—dc23 LC record available at https://lccn.loc.gov/2017008727

Executive Content Strategist: Lee Henderson Content Development Manager: Lisa Newton Content Development Specialist: Melissa Rawe Publishing Services Manager: Jeff Patterson Book Production Specialist: Carol O’Connell Design Direction: Renee Duenow

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

https://lccn.loc.gov/2017008727

About the authors

Geri LoBiondo-Wood, PhD, RN, FAAN, is Professor and Coordinator of the PhD in Nursing Program at the University of Texas Health Science Center at Houston, School of Nursing (UTHSC-Houston) and former Director of Research and Evidence- Based Practice Planning and Development at the MD Anderson Cancer Center, Houston, Texas. She received her Diploma in Nursing at St. Mary’s Hospital School of Nursing in Rochester, New York; Bachelor’s and Master’s degrees from the University of Rochester; and a PhD in Nursing Theory and Research from New York University. Dr. LoBiondo-Wood teaches research and evidence-based practice principles to undergraduate, graduate, and doctoral students. At MD Anderson Cancer Center, she developed and implemented the Evidence-Based Resource Unit Nurse (EB- RUN) Program. She has extensive national and international experience guiding nurses and other health care professionals in the development and utilization of research. Dr. LoBiondo-Wood is an Editorial Board member of Progress in Transplantation and a reviewer for Nursing Research, Oncology Nursing Forum, and Oncology Nursing. Her research and publications focus on chronic

illness and oncology nursing. Dr. Wood has received funding from the Robert Wood Johnson Foundation Future of Nursing Scholars program for the past several years to fund full-time doctoral students.

Dr. LoBiondo-Wood has been active locally and nationally in many professional organizations, including the Oncology Nursing Society, Southern Nursing Research Society, the Midwest Nursing Research Society, and the North American Transplant Coordinators Organization. She has received local and national awards for teaching and contributions to nursing. In 1997, she received the Distinguished Alumnus Award from New York University, Division of Nursing Alumni Association. In 2001 she was inducted as a Fellow of the American Academy of Nursing and in 2007 as a Fellow of the University of Texas Academy of Health Science Education. In 2012 she was appointed as a Distinguished Teaching Professor of the University of Texas System and in 2015 received the John McGovern Outstanding Teacher Award from the University of Texas Health Science Center at Houston School of Nursing.

Judith Haber, PhD, RN, FAAN, is the Ursula Springer Leadership Professor in Nursing at the Rory Meyers College of Nursing at New York University. She received her undergraduate nursing education at Adelphi University in New York, and she holds a Master’s degree in Adult Psychiatric–Mental Health Nursing and a PhD in Nursing Theory and Research from New York University. Dr. Haber is internationally recognized as a clinician and educator in psychiatric–mental health nursing. She was the editor of the award- winning classic textbook, Comprehensive Psychiatric Nursing, published for eight editions and translated into five languages. She has extensive clinical experience in psychiatric nursing, having been an advanced practice psychiatric nurse in private practice for over

30 years, specializing in treatment of families coping with the psychosocial impact of acute and chronic illness. Her NIH-funded program of research addressed physical and psychosocial adjustment to illness, focusing specifically on women with breast cancer and their partners and, more recently, breast cancer survivorship and lymphedema prevention and risk reduction. Dr. Haber is also committed to an interprofessional program of clinical scholarship related to interprofessional education and improving oral-systemic health outcomes and is the Executive Director of a national nursing oral health initiative, the Oral Health Nursing Education and Practice (OHNEP) program, funded by the DentaQuest and Washington Dental Service Foundations.

Dr. Haber is the recipient of numerous awards, including the 1995 and 2005 APNA Psychiatric Nurse of the Year Award, the 2005 APNA Outstanding Research Award, and the 1998 ANA Hildegarde Peplau Award. She received the 2007 NYU Distinguished Alumnae Award, the 2011 Distinguished Teaching Award, and the 2014 NYU Meritorious Service Award. In 2015, Dr. Haber received the Sigma Theta Tau International Marie Hippensteel Lingeman Award for Excellence in Nursing Practice. Dr. Haber is a Fellow in the American Academy of Nursing and the New York Academy of Medicine. Dr. Haber has consulted, presented, and published widely on evidence-based practice, interprofessional education and practice, as well as oral-systemic health issues.

Contributors

Terri Armstrong, PhD, ANP-BC, FAANP, Senior Investigator, Neuro-oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland

Julie Barroso, PhD, ANP, RN, FAAN, Professor and Department Chair, Medical University of South Carolina, Charleston, South Carolina

Carol Bova, PhD, RN, ANP, Professor of Nursing and Medicine, Graduate School of Nursing, University of Massachusetts, Worcester, Massachusetts

Dona Rinaldi Carpenter, EdD, RN, Professor and Chair, University of Scranton, Department of Nursing, Scranton, Pennsylvania

Maja Djukic, PhD, RN, Assistant Professor, Rory Meyers College of Nursing, New York University, New York, New York

Mei R. Fu, PhD, RN, FAAN, Associate Professor, Rory Meyers College of Nursing, New York University, New York, New York

Mattia J. Gilmartin, PhD, RN, Senior Research Scientist , Executive Director, NICHE Program, Rory Meyers College of Nursing, New York University, New York, New York

Deborah J. Jones, PhD, MS, RN, Margaret A. Barnett/PARTNERS Professorship , Associate Dean for Professional Development and Faculty Affairs , Associate Professor, University of Texas Health Science Center at Houston, School of Nursing, Houston, Texas

Carl Kirton, DNP, RN, MBA, Chief Nursing Officer, University Hospital, Newark, New Jersey; , Adjunct Faculty, Rory Meyers College of Nursing, New York University, New York, New York

Barbara Krainovich-Miller, EdD, RN, PMHCNS-BC, ANEF, FAAN, Professor, Rory Meyers College of Nursing, New York University, New York, New York

Elaine Larson, PhD, RN, FAAN, CIC, Anna C. Maxwell Professor of Nursing Research , Associate Dean for Research, Columbia University School of Nursing, New York, New York

Melanie McEwen, PhD, RN, CNE, ANEF, Professor, University of Texas Health Science Center at Houston, School of Nursing, Houston, Texas

Gail D’Eramo Melkus, EdD, ANP, FAAN, Florence & William Downs Professor in Nursing Research, Associate Dean for Research, Rory Meyers College of Nursing, New York University, New York, New York

Susan Sullivan-Bolyai, DNSc, CNS, RN, FAAN, Associate

Professor, Rory Meyers College of Nursing, New York University, New York, New York

Marita Titler, PhD, RN, FAAN, Rhetaugh G. Dumas Endowed Professor , Department Chair, Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor, Michigan

Mark Toles, PhD, RN, Assistant Professor, University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, North Carolina

Reviewers Karen E. Alexander, PhD, RN, CNOR, Program Director RN- BSN, Assistant Professor, Department of Nursing, University of Houston Clear Lake-Pearland, Houston, Texas

Donelle M. Barnes, PhD, RN, CNE, Associate Professor, College of Nursing, University of Texas, Arlington, Arlington, Texas

Susan M. Bezek, PhD, RN, ACNP, CNE, Assistant Professor, Division of Nursing, Keuka College, Keuka Park, New York

Rose M. Kutlenios, PhD, MSN, MN, BSN, ANCC Board Certification, Adult Psychiatric/Mental Health Clinical Specialist, ANCC Board Certification, Adult Nurse Practitioner, Nursing Program Director and Associate Professor, Department of Nursing, West Liberty University, West Liberty, West Virginia

Shirley M. Newberry, PhD, RN, PHN, Professor, Department of Nursing, Winona State University, Winona, Minnesota

Sheryl Scott, DNP, RN, CNE, Assistant Professor and Chair, School of Nursing, Wisconsin Lutheran College, Milwaukee, Wisconsin

To the faculty Geri LoBiondo-Wood, Geri.L.Wood@uth.tmc.edu, Judith Haber, jh33@nyu.edu

The foundation of the ninth edition of Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice continues to be the belief that nursing research is integral to all levels of nursing education and practice. Over the past three decades since the first edition of this textbook, we have seen the depth and breadth of nursing research grow, with more nurses conducting research and using research evidence to shape clinical practice, education, administration, and health policy.

The National Academy of Medicine has challenged all health professionals to provide team-based care based on the best available scientific evidence. This is an exciting challenge. Nurses, as clinicians and interprofessional team members, are using the best available evidence, combined with their clinical judgment and patient preferences, to influence the nature and direction of health care delivery and document outcomes related to the quality and cost-effectiveness of patient care. As nurses continue to develop a unique body of nursing knowledge through research, decisions about clinical nursing practice will be increasingly evidence based.

As editors, we believe that all nurses need not only to understand the research process but also to know how to critically read, evaluate, and apply research findings in practice. We realize that understanding research, as a component of evidence-based practice and quality improvement practices, is a challenge for every student, but we believe that the challenge can be accomplished in a

stimulating, lively, and learner-friendly manner. Consistent with this perspective is an ongoing commitment to

advancing implementation of evidence-based practice. Understanding and applying research must be an integral dimension of baccalaureate education, evident not only in the undergraduate nursing research course but also threaded throughout the curriculum. The research role of baccalaureate graduates calls for evidence-based practice and quality improvement competencies; central to this are critical appraisal skills—that is, nurses should be competent research consumers.

Preparing students for this role involves developing their critical thinking skills, thereby enhancing their understanding of the research process, their appreciation of the role of the critiquer, and their ability to actually critically appraise research. An undergraduate research course should develop this basic level of competence, an essential requirement if students are to engage in evidence-informed clinical decision making and practice, as well as quality improvement activities.

The primary audience for this textbook remains undergraduate students who are learning the steps of the research process, as well as how to develop clinical questions, critically appraise published research literature, and use research findings to inform evidence- based clinical practice and quality improvement initiatives. This book is also a valuable resource for students at the master’s, DNP, and PhD levels who want a concise review of the basic steps of the research process, the critical appraisal process, and the principles and tools for evidence-based practice and quality improvement.

This text is also an important resource for practicing nurses who strive to use research evidence as the basis for clinical decision making and development of evidence-based policies, protocols, and standards or who collaborate with nurse-scientists in conducting clinical research and evidence-based practice. Finally, this text is an important resource for considering how evidence-based practice, quality improvement, and interprofessional collaboration are essential competencies for students and clinicians practicing in a transformed health care system, where nurses and their interprofessional team members are accountable for the quality and cost-effectiveness of care provided to their patient population.

Building on the success of the eighth edition, we reaffirm our commitment to introducing evidence-based practice, quality improvement processes, and research principles to baccalaureate students, thereby providing a cutting-edge, research consumer foundation for their clinical practice. Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice prepares nursing students and practicing nurses to become knowledgeable nursing research consumers by doing the following:

• Addressing the essential evidence-based practice and quality improvement role of the nurse, thereby embedding evidence- based competencies in clinical practice.

• Demystifying research, which is sometimes viewed as a complex process.

• Using a user-friendly, evidence-based approach to teaching the fundamentals of the research process.

• Including an exciting chapter on the role of theory in research and evidence-based practice.

• Providing a robust chapter on systematic reviews and clinical guidelines.

• Offering two innovative chapters on current strategies and tools for developing an evidence-based practice.

• Concluding with an exciting chapter on quality improvement and its application to practice.

• Teaching the critical appraisal process in a user-friendly progression.

• Promoting a lively spirit of inquiry that develops critical thinking and critical reading skills, facilitating mastery of the critical appraisal process.

• Developing information literacy, searching, and evidence-based practice competencies that prepare students and nurses to

effectively locate and evaluate the best research evidence.

• Emphasizing the role of evidence-based practice and quality improvement initiatives as the basis for informing clinical decisions that support nursing practice.

• Presenting numerous examples of recently published research studies that illustrate and highlight research concepts in a manner that brings abstract ideas to life for students. These examples are critical links that reinforce evidence-based concepts and the critiquing process.

• Presenting five published articles, including a meta-analysis, in the Appendices, the highlights of which are woven throughout the text as exemplars of research and evidence-based practice.

• Showcasing, in four new inspirational Research Vignettes, the work of renowned nurse researchers whose careers exemplify the links among research, education, and practice.

• Introducing new pedagogical interprofessional education chapter features, IPE Highlights and IPE Critical Thinking Challenges and quality improvement, QSEN Evidence-Based Practice Tips.

• Integrating stimulating pedagogical chapter features that reinforce learning, including Learning Outcomes, Key Terms, Key Points, Critical Thinking Challenges, Helpful Hints, Evidence-Based Practice Tips, Critical Thinking Decision Paths, and numerous tables, boxes, and figures.

• Featuring a revised section titled Appraising the Evidence, accompanied by an updated Critiquing Criteria box in each chapter that presents a step of the research process.

• Offering a student Evolve site with interactive review questions that provide chapter-by-chapter review in a format consistent with that of the NCLEX® Examination.

• Offering a Student Study Guide that promotes active learning and assimilation of nursing research content.

• Presenting Faculty Evolve Resources that include a test bank, TEACH lesson plans, PowerPoint slides with integrated audience response system questions, and an image collection. Evolve resources for both students and faculty also include a research article library with appraisal exercises for additional practice in reviewing and critiquing, as well as content updates.

The ninth edition of Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice is organized into four parts. Each part is preceded by an introductory section and opens with an engaging Research Vignette by a renowned nurse researcher.

Part I, Overview of Research and Evidence-Based Practice, contains four chapters: Chapter 1, “Integrating Research, Evidence- Based Practice, and Quality Improvement Processes,” provides an excellent overview of research and evidence-based practice processes that shape clinical practice. The chapter speaks directly to students and highlights critical reading concepts and strategies, facilitating student understanding of the research process and its relationship to the critical appraisal process. The chapter introduces a model evidence hierarchy that is used throughout the text. The style and content of this chapter are designed to make subsequent chapters user friendly. The next two chapters address foundational components of the research process. Chapter 2, “Research Questions, Hypotheses, and Clinical Questions,” focuses on how research questions and hypotheses are derived, operationalized, and critically appraised. Students are also taught how to develop clinical questions that are used to guide evidence-based inquiry, including quality improvement projects. Chapter 3, “Gathering and Appraising the Literature,” showcases cutting-edge information literacy content and provides students and nurses with the tools necessary to effectively search, retrieve, manage, and evaluate research studies and their findings. Chapter 4, “Theoretical Frameworks for Research,” is a user-friendly theory chapter that provides students with an understanding of how theories provide the foundation of research studies and evidence-based practice projects.

Part II, Processes and Evidence Related to Qualitative Research, contains three interrelated qualitative research chapters. Chapter 5,

“Introduction to Qualitative Research,” provides an exciting framework for understanding qualitative research and the significant contribution of qualitative research to evidence-based practice. Chapter 6, “Qualitative Approaches to Research,” presents, illustrates, and showcases major qualitative methods using examples from the literature as exemplars. This chapter highlights the questions most appropriately answered using qualitative methods. Chapter 7, “Appraising Qualitative Research,” synthesizes essential components of and criteria for critiquing qualitative research reports using published qualitative research study.

Part III, Processes and Evidence Related to Quantitative Research, contains Chapters 8 to 18Chapter 8Chapter 9Chapter 10Chapter 11Chapter 12Chapter 13Chapter 14Chapter 15Chapter 16Chapter 17Chapter 18. This group of chapters delineates essential steps of the quantitative research process, with published clinical research studies used to illustrate each step. These chapters are streamlined to make the case for linking an evidence-based approach with essential steps of the research process. Students are taught how to critically appraise the strengths and weaknesses of each step of the research process in a synthesized critique of a study. The steps of the quantitative research process, evidence- based concepts, and critical appraisal criteria are synthesized in Chapter 18 using two published research studies, providing a model for appraising strengths and weaknesses of studies, and determining applicability to practice. Chapter 11, a unique chapter, addresses the use of the types of systematic reviews that support an evidence-based practice as well as the development and application of clinical guidelines.

Part IV, Application of Research: Evidence-Based Practice, contains three chapters that showcase evidence-based practice models and tools. Chapter 19, “Strategies and Tools for Developing an Evidence-Based Practice,” is a revised, vibrant, user-friendly, evidence-based toolkit with exemplars that capture the essence of high-quality, evidence-informed nursing care. It “walks” students and practicing nurses through clinical scenarios and challenges them to consider the relevant evidence-based practice “tools” to develop and answer questions that emerge from clinical situations.

Chapter 20, “Developing an Evidence-Based Practice,” offers a dynamic presentation of important evidence-based practice models that promote evidence-based decision making. Chapter 21, “Quality Improvement,” is an innovative, engaging chapter that outlines the quality improvement process with information from current guidelines. Together, these chapters provide an inspirational conclusion to a text that we hope motivates students and practicing nurses to advance their evidence-based practice and quality improvement knowledge base and clinical competence, positioning them to make important contributions to improving health care outcomes as essential members of interprofessional teams.

Stimulating critical thinking is a core value of this text. Innovative chapter features such as Critical Thinking Decision Paths, Evidence-Based Practice Tips, Helpful Hints, Critical Thinking Challenges, IPE Highlights, and QSEN Evidence-Based Practice Tips enhance critical thinking, promote the development of evidence-based decision-making skills, and cultivate a positive value about the importance of collaboration in promoting evidence- based, high quality and cost-effective clinical outcomes.

Consistent with previous editions, we promote critical thinking by including sections called “Appraising the Evidence,” which describe the critical appraisal process related to the focus of the chapter. Critiquing Criteria are included in this section to stimulate a systematic and evaluative approach to reading and understanding qualitative and quantitative research and evaluating its strengths and weaknesses. Extensive resources are provided on the Evolve site that can be used to develop critical thinking and evidence-based competencies.

The development and refinement of an evidence-based foundation for clinical nursing practice is an essential priority for the future of professional nursing practice. The ninth edition of Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice will help students develop a basic level of competence in understanding the steps of the research process that will enable them to critically analyze research studies, judge their merit, and judiciously apply evidence in clinical practice. To the extent that this goal is accomplished, the next generation of nursing professionals will have a cadre of clinicians who inform their

practice using theory, research evidence, and clinical judgment, as they strive to provide high-quality, cost-effective, and satisfying health care experiences in partnership with individuals, families, and communities.

To the student Geri LoBiondo-Wood, Geri.L.Wood@uth.tmc.edu, Judith Haber, jh33@nyu.edu

We invite you to join us on an exciting nursing research adventure that begins as you turn the first page of the ninth edition of Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice. The adventure is one of discovery! You will discover that the nursing research literature sparkles with pride, dedication, and excitement about the research dimension of professional nursing practice. Whether you are a student or a practicing nurse whose goal is to use research evidence as the foundation of your practice, you will discover that nursing research and a commitment to evidence-based practice positions our profession at the forefront of change. You will discover that evidence-based practice is integral to being an effective member of an interprofessional team prepared to meet the challenge of providing quality whole person care in partnership with patients, their families/significant others, as well as with the communities in which they live. Finally, you will discover the richness in the “Who,” “What,” “Where,” “When,” “Why,” and “How” of nursing research and evidence-based practice, developing a foundation of knowledge and skills that will equip you for clinical practice and making a significant contribution to achieving the Triple Aim, that is, contributing to high quality and cost-effective patient outcomes associated with satisfying patient experiences!

We think you will enjoy reading this text. Your nursing research course will be short but filled with new and challenging learning

experiences that will develop your evidence-based practice skills. The ninth edition of Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice reflects cutting-edge trends for developing evidence-based nursing practice. The four-part organization and special features in this text are designed to help you develop your critical thinking, critical reading, information literacy, interprofessional, and evidence-based clinical decision- making skills, while providing a user-friendly approach to learning that expands your competence to deal with these new and challenging experiences. The companion Study Guide, with its chapter-by-chapter activities, serves as a self-paced learning tool to reinforce the content of the text. The accompanying Evolve website offers review questions to help you reinforce the concepts discussed throughout the book.

Remember that evidence-based practice skills are used in every clinical setting and can be applied to every patient population or clinical practice issue. Whether your clinical practice involves primary care or critical care and provides inpatient or outpatient treatment in a hospital, clinic, or home, you will be challenged to apply your evidence-based practice skills and use nursing research as the foundation for your evidence-based practice. The ninth edition of Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice will guide you through this exciting adventure, where you will discover your ability to play a vital role in contributing to the building of an evidence-based professional nursing practice.

Acknowledgments Geri LoBiondo-Wood, Judith Haber

No major undertaking is accomplished alone; there are those who contribute directly and those who contribute indirectly to the success of a project. We acknowledge with deep appreciation and our warmest thanks the help and support of the following people:

• Our students, particularly the nursing students at the University of Texas Health Science Center at Houston School of Nursing and the Rory Meyers College of Nursing at New York University, whose interest, lively curiosity, and challenging questions sparked ideas for revisions in the ninth edition.

• Our chapter contributors, whose passion for research, expertise, cooperation, commitment, and punctuality made them a joy to have as colleagues.

• Our vignette contributors, whose willingness to share evidence of their research wisdom made a unique and inspirational contribution to this edition.

• Our colleagues, who have taken time out of their busy professional lives to offer feedback and constructive criticism that helped us prepare this ninth edition.

• Our editors, Lee Henderson, Melissa Rawe, and Carol O’Connell, for their willingness to listen to yet another creative idea about teaching research in a meaningful way and for their expert help

with manuscript preparation and production.

• Our families: Rich Scharchburg; Brian Wood; Lenny, Andrew, Abbe, Brett, and Meredith Haber; and Laurie, Bob, Mikey, Benjy, and Noah Goldberg for their unending love, faith, understanding, and support throughout what is inevitably a consuming—but exciting—experience.

PART I

Overview of Research and Evidence-Based Practice Research Vignette: Terri Armstrong

OUTLINE

Introduction

1. Integrating research, evidence-based practice, and quality improvement processes

2. Research questions, hypotheses, and clinical questions

3. Gathering and appraising the literature

4. Theoretical frameworks for research

Introduction

Research vignette

With a little help from my friends Terri Armstrong, PhD ANP-BC, FAANP, FAAN

Senior Investigator Neuro-Oncology Branch National Cancer Institute National Institute of Health Bethesda, Maryland I grew up surrounded by family and strong role models of

women working in health care in a small town in Ohio. When in college, the three most important women in my life (my mom, grandmother, and great-grandmother) were all diagnosed with cancer. This led me to seek out a nursing position in oncology, and over time, I was able to be actively involved in their care. This experience taught me so much and led to the desire to do more to make the daily lives of people with cancer better. After obtaining a master’s in oncology and a postmaster’s nurse practitioner, an opportunity to work with Dr. M. Gilbert, a well-known caring physician who specialized in the care and treatment of patients with central nervous system (CNS) tumors and a great mentor, became available, so my work with people with CNS tumors began.

After several years, I realized that the quality of life of the brain tumor patients and families was significantly impacted by the symptoms they experienced. Over 80% were unable to return to work from the time of diagnosis, and their daily lives (and those of their families) were often consumed with managing the neurologic

and treatment-related symptoms. I realized that obtaining my PhD would be an important step to learn the skills I would need to try to find answers to solve the problems CNS tumor patients were facing.

At that time, many of the conceptual models identified solitary symptoms and their impact on the person. I learned from my experience and in caring for patients that symptoms seldom occurred in isolation and that the meaning the symptoms had for patients’ daily lives was important, as was learning about the patients’ perception of that impact. I developed a conceptual model to identify those relationships and guide my research (Armstrong, 2003). My focus since then has been on patient-centered outcomes research, focusing on the impact of symptoms on the illness trajectory, tolerance of therapy, and potential to influence survival. My work is never done in isolation. I have been fortunate to work with research teams, including those who work alongside me and important collaborators across disciplines and the world. Team research, in which the views of various disciplines are brought together, is important in every step of research—from the hypothesis to study design and finally interpretation of the results.

My work is interconnected, but I believe it can be categorized into three general areas:

1. Improving assessment and our understanding of the experience of patients with CNS tumors.

Patients with primary brain tumors are highly symptomatic, with implications for functional status, and are used in making treatment decisions. I led a team that developed the M.D. Anderson Symptom Inventory for Brain Tumors (MDASI-BT) (Armstrong et al., 2005; Armstrong et al., 2006) and spinal cord tumors (MDASI-Spine) (Armstrong, Gning, et al., 2010). We have completed studies showing that symptoms are associated with tumor progression (Armstrong et al., 2011). We have also been able to quantify limitations of patients’ functional status (Armstrong et al., 2015), in a way that caregivers report is congruent with the patient, and have found that electronic technology (such as iPads) can be used for this (Armstrong et al., 2012). Our work with the Collaborative Ependymoma Research

Organization (CERN, www.cern-foundation.org) has allowed us to reach out to patients with this rarer tumor to understand the natural history and impact of the disease and its treatment on patients around the world (Armstrong, Vera-Bolanos, et al., 2010; Armstrong, Vera-Bolanos, & Gilbert, 2011). Based on these surveys, we have developed materials to inform patients and are launching an expansion of this project, in which we will evaluate risk factors (both based on history and genetics) for the occurrence of these tumors in both adults and children.

2. Incorporation of clinical outcomes assessment into brain tumor clinical trials.

Clinical trials often assess the impact of therapy on how the tumor appears on imaging or survival, but the impact on the person is often not assessed. I have been fortunate to work with Dr. M. Gilbert and Dr. J. Wefel to incorporate these outcomes into large clinical trials, providing clear evidence that it was feasible to incorporate patient outcomes measures and that the results of these evaluations could impact the interpretation of the clinical trial (Armstrong et al., 2013; Gilbert et al., 2014). As a result of my involvement in these efforts, I recently chaired a daylong workshop exploring the use of clinical outcomes assessments (COAs) in brain tumor trials, a workshop cosponsored by the FDA and the Jumpstarting Brain Tumor Drug Development (JSBTDD) consortia that also included members of the academic community, patient advocates, pharmaceutical industry, and the NIH. This successful workshop has resulted in a series of white papers that were recently published on the importance of including these in clinical trials (Armstrong, Bishof, et al., 2016; Helfer et al., 2016).

3. Identification of clinical and genomic predictors of toxicity.

Toxicity associated with treatment also impacts the patient. For example, Temozolomide, the most common agent used in the treatment of brain tumors, has a low overall incidence of myelotoxicity (impact on blood counts that help to fight infection or clot the blood). However, in the select patients who develop

http://www.cern-foundation.org

toxicity, there are significant clinical implications (treatment holds or cessation, and even death). I work with an interdisciplinary group that began to explore the clinical predictors of this toxicity and then explored associated genomic changes associated with risk (Armstrong et al., 2009). Currently, I am also working with a research team exploring risk factors and pathogenesis of radiation-induced fatigue and sleepiness, which is a major symptom in a large percentage of patients undergoing cranial radiotherapy for their brain tumor (Armstrong, Shade, et al., 2016). The ultimate goal of this part of my research is to begin to uncover phenotypes associated with symptoms and to uncover the underlying biologic processes, so that we can initiate measures prior to the occurrence of symptoms, rather than waiting for them to occur and then trying to mitigate them.

In addition to conducting focused outcomes research as outlined previously, I have over 25 years’ dedication to the clinical care of persons with tumors of the CNS. This work is the best part of my job and is a critical linkage and inspiration in my research, with the goal of improving the daily life of patients and improving our understanding of the underlying biology of symptoms and experience that our patients have.

References 1. Armstrong T. S. Symptoms experience a concept analysis.

Oncology Nursing Society 2003;30(4):601-606. 2. Armstrong T. S, Cohen M. Z, Eriksen L., Cleeland C.

Content validity of self-report measurement instruments an illustration from the development of the Brain Tumor Module of the M. D. Anderson Symptom Inventory. Oncology Nursing Society 2005;32(3):669-676.

3. Armstrong T. S, Mendoza T., Gning I., et al. Validation of the M. D. Anderson Symptom Inventory Brain Tumor Module (MDASI-BT). Journal of Neuro-Oncology 2006;80(1):27-35.

4. Armstrong T. S, Cao Y., Scheurer M. E, et al. Risk analysis of severe myelotoxicity with temozolomide The effects of clinical and genetic factors. Neuro-Oncology 2009;11(6):825-832.

5. Armstrong T. S, Gning I., Mendoza T. R, et al. Reliability and validity of the M. D. Anderson Symptom Inventory-Spine Tumor Module. Journal of Neurosurgery Spine 2010;12(4):421- 430.

6. Armstrong T. S, Vera-Bolanos E., Bekele B. N, et al. Adult ependymal tumors prognosis and the M. D. Anderson Cancer Center experience. Neuro-Oncology 2010;12(8):862-870.

7. Armstrong T. S, Vera-Bolanos E., Gilbert M. R. Clinical course of adult patients with ependymoma results of the Adult Ependymoma Outcomes Project. Cancer 2011;117(22):5133- 5141.

8. Armstrong T. S, Vera-Bolanos E., Gning I., et al. The impact of symptom interference using the MD Anderson Symptom Inventory-Brain Tumor Module (MDASI-BT) on prediction of recurrence in primary brain tumor patients. Cancer 2011;117(14):3222-3228.

9. Armstrong T. S, Wefel J. S, Gning I., et al. Congruence of primary brain tumor patient and caregiver symptom report. Cancer 2012;118(20):5026-5037.

10. Armstrong T. S, Wefel J. S, Wang M., et al. Net clinical benefit analysis of radiation therapy oncology group 0525 a phase III trial comparing conventional adjuvant temozolomide with dose-intensive temozolomide in patients with newly diagnosed glioblastoma. Journal of Clinical Oncology 2013;31(32):4076-4084.

11. Armstrong T. S, Vera-Bolanos E., Acquaye A. A, et al. The symptom burden of primary brain tumors evidence for a core set of tumor and treatment-related symptoms. Neuro- Oncology 2015;18(2):252-260 Epub August 19, 2015.

12. Armstrong T. S, Bishof A. M, Brown P. D, et al. Determining priority signs and symptoms for use as clinical outcomes assessments in trials including patients with malignant gliomas panel 1 report. Neuro-Oncology 2016;18(Suppl. 2):ii1-ii12.

13. Armstrong T. S, Shade M. Y, Breton G., et al. Sleep-wake disturbance in patients with brain tumors.;: Neuro-Oncology, in press2016;

14. Gilbert M. R, Dignam J. J, Armstrong T. S, et al. A randomized trial of bevacizumab for newly diagnosed

glioblastoma. New England Journal of Medicine 2014;370(8):699-708.

15. Helfer J. L, Wen P. Y, Blakeley J., et al. Report of the Jumpstarting Brain Tumor Drug Development Coalition and FDA clinical trials clinical outcome assessment endpoints workshop (October 15, 2014, Bethesda, MD). Neuro-Oncology 2016;18(Suppl. 2):ii26-ii36.

CHAPTER 1

Integrating research, evidence-based practice, and quality improvement processes Geri LoBiondo-Wood, Judith Haber

Learning outcomes

After reading this chapter, you should be able to do the following:

• State the significance of research, evidence-based practice, and quality improvement (QI). • Identify the role of the consumer of nursing research. • Define evidence-based practice. • Define QI. • Discuss evidence-based and QI decision making.

• Explain the difference between quantitative and qualitative research. • Explain the difference between the types of systematic reviews. • Identify the importance of critical reading skills for critical appraisal of research. • Discuss the format and style of research reports/articles. • Discuss how to use an evidence hierarchy when critically appraising research studies.

KEY TERMS

abstract

clinical guidelines

consensus guidelines

critical appraisal

critical reading

critique

evidence-based guidelines

evidence-based practice

integrative review

levels of evidence

meta-analysis

meta-synthesis

quality improvement

qualitative research

quantitative research

research

systematic review

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

We invite you to join us on an exciting nursing research adventure that begins as you read the first page of this chapter. The adventure is one of discovery! You will discover that the nursing research literature sparkles with pride, dedication, and excitement about this dimension of professional practice. As you progress through your educational program, you are taught how to ensure quality and safety in practice through acquiring knowledge of the various sciences and health care principles. A critical component of clinical knowledge is understanding research as it applies to practicing from a base of evidence.

Whether you are a student or a practicing nurse whose goal is to use research as the foundation of your practice, you will discover that research, evidence-based practice, and quality improvement (QI) positions our profession at the cutting edge of change and improvement in patient outcomes. You will also discover the cutting edge “who,” “what,” “where,” “when,” “why,” and “how” of nursing research, and develop a foundation of evidence-based practice knowledge and competencies that will equip you for your clinical practice.

Your nursing research adventure will be filled with new and challenging learning experiences that develop your evidence-based practice skills. Your critical thinking, critical reading, and clinical decision-making skills will expand as you develop clinical questions, search the research literature, evaluate the research evidence found in the literature, and make clinical decisions about applying the “best available evidence” to your practice. For example, you will be encouraged to ask important clinical questions, such as, “What makes a telephone education intervention more effective with one group of patients with a diagnosis of congestive heart failure but not another?” “What is the effect of computer learning modules on self-management of diabetes in children?” “What research has been conducted in the area of identifying barriers to breast cancer screening in African

http://evolve.elsevier.com/LoBiondo/

American women?” “What is the quality of studies conducted on telehealth?” “What nursing-delivered smoking cessation interventions are most effective?” This book will help you begin your adventure into evidence-based practice by developing an appreciation of research as the foundation for evidence-based practice and QI.

Nursing research, evidence-based practice, and quality improvement Nurses are challenged to stay abreast of new information to provide the highest quality of patient care (Institute of Medicine [IOM], 2011). Nurses are challenged to expand their “comfort zone” by offering creative approaches to old and new health problems, as well as designing new and innovative programs that make a difference in the health status of our citizens. This challenge can best be met by integrating rapidly expanding research and evidence-based knowledge about biological, behavioral, and environmental influences on health into the care of patients and their families.

It is important to differentiate between research, evidence-based practice, and QI. Research is the systematic, rigorous, critical investigation that aims to answer questions about nursing phenomena. Researchers follow the steps of the scientific process, outlined in this chapter and discussed in detail in each chapter of this textbook. There are two types of research: quantitative and qualitative. The methods used by nurse researchers are the same methods used by other disciplines; the difference is that nurses study questions relevant to nursing practice. Published research studies are read and evaluated for use in clinical practice. Study findings provide evidence that is evaluated, and applicability to practice is used to inform clinical decisions.

Evidence-based practice is the collection, evaluation, and integration of valid research evidence, combined with clinical expertise and an understanding of patient and family values and preferences, to inform clinical decision making (Sackett et al., 2000). Research studies are gathered from the literature and assessed so that decisions about application to practice can be made,

culminating in nursing practice that is evidence based. ➤ Example: To help you understand the importance of evidence-based practice, think about the systematic review and meta-analysis from Al- Mallah and colleagues (2015), which assessed the impact of nurse- led clinics on the mortality and morbidity of patients with cardiovascular disease (see Appendix E). Based on their synthesis of the literature, they put forth several conclusions regarding the implications for practice and further research for nurses working in the field of cardiovascular care.

QI is the systematic use of data to monitor the outcomes of care processes as well as the use of improvement methods to design and test changes in practice for the purpose of continuously improving the quality and safety of health care systems (Cronenwett et al., 2007). While research supports or generates new knowledge, evidence-based practice and QI uses currently available knowledge to improve health care delivery. When you first read about these three processes, you will notice they have similarities. Each begins with a question. The difference is that in a research study the question is tested with a design appropriate to the question and specific methodology (i.e., sample, instruments, procedures, and data analysis) used to test the research question and contribute to new, generalizable knowledge. In the evidence-based practice and QI processes, a question is used to search the literature for already completed studies in order to bring about improvements in care.

All nurses share a commitment to the advancement of nursing science by conducting research and using research evidence in practice. Research promotes accountability, which is one of the hallmarks of the nursing profession and a fundamental concept of the American Nurses Association (ANA) Code for Nurses (ANA, 2015). There is a consensus that the research role of the baccalaureate and master’s graduate calls for critical appraisal skills. That is, nurses must be knowledgeable consumers of research, who can evaluate the strengths and weaknesses of research evidence and use existing standards to determine the merit and readiness of research for use in clinical practice. Therefore, to use research for an evidence-based practice and to practice using the highest quality processes, you do not have to conduct research; however, you do need to understand and appraise the steps of the

research process in order to read the research literature critically and use it to inform clinical decisions.

As you venture through this text, you will see the steps of the research, evidence-based practice, and QI processes. The steps are systematic and relate to the development of evidence-based practice. Understanding the processes that researchers use will help you develop the assessment skills necessary to judge the soundness of research studies.

throughout the chapters, terminology pertinent to each step is identified and illustrated with examples. Five published studies are found in the appendices and used as examples to illustrate significant points in each chapter. Judging the study’s strength and quality, as well as its applicability to practice, is key. Before you can judge a study, it is important to understand the differences among studies. There are different study designs that you will see as you read through this text and the appendices. There are standards not only for critiquing the soundness of each step of a study, but also for judging the strength and quality of evidence provided by a study and determining its applicability to practice.

This chapter provides an overview of research study designs and appraisal skills. It introduces the overall format of a research article and provides an overview of the subsequent chapters in the book. It also introduces the QI and evidence-based practice processes, a level of evidence hierarchy model, and other tools for helping you evaluate the strength and quality of research evidence. These topics are designed to help you read research articles more effectively and with greater understanding, so that you can make evidence-based clinical decisions and contribute to quality and cost-effective patient outcomes.

Types of research: Qualitative and quantitative Research is classified into two major categories: qualitative and quantitative. A researcher chooses between these categories based on the question being asked. That is, a researcher may wish to test a cause-and-effect relationship, or to assess if variables are related, or may wish to discover and understand the meaning of an experience

or process. A researcher would choose to conduct a qualitative research study if the question is about understanding the meaning of a human experience such as grief, hope, or loss. The meaning of an experience is based on the view that meaning varies and is subjective. The context of the experience also plays a role in qualitative research. That is, the experience of loss as a result of a miscarriage would be different than the experience of losing a parent.

Qualitative research is generally conducted in natural settings and uses data that are words or text rather than numeric to describe the experiences being studied. Qualitative studies are guided by research questions, and data are collected from a small number of subjects, allowing an in-depth study of a phenomenon. ➤ Example: vanDijk et al. (2016) explored how patients assign a number to their postoperative pain experience (see Appendix C). Although qualitative research is systematic in its method, it uses a subjective approach. Data from qualitative studies help nurses understand experiences or phenomena that affect patients; these data also assist in generating theories that lead clinicians to develop improved patient care and stimulate further research. Highlights of the general steps of qualitative studies and the journal format for a qualitative article are outlined in Table 1.1. Chapters 5 through 7 provide an in-depth view of qualitative research underpinnings, designs, and methods.

TABLE 1.1 Steps of the Research Process and Journal Format: Qualitative Research

Research Process Steps and/or Format Issues Usual Location in Journal Heading or Subheading

Identifying the phenomenon

Abstract and/or in introduction

Research question study purpose

Abstract and/or in beginning or end of introduction

Literature review Introduction and/or discussion Design Abstract and/or in introductory section or under method section

entitled “Design” or stated in method section Sample Method section labeled “Sample” or “Subjects” Legal-ethical issues Data collection or procedures section or in sample section Data collection procedure Data collection or procedures section Data analysis Methods section under subhead “Data Analysis” or “Data

Analysis and Interpretation” Results Stated in separate heading: “Results” or “Findings” Discussion and recommendation

Combined in separate section: “Discussion” or “Discussion and Implications”

References At end of article

Whereas qualitative research looks for meaning, quantitative research encompasses the study of research questions and/or hypotheses that describe phenomena, test relationships, assess differences, seek to explain cause-and-effect relationships between variables, and test for intervention effectiveness. The numeric data in quantitative studies are summarized and analyzed using statistics. Quantitative research techniques are systematic, and the methodology is controlled. Appendices A, B, and D illustrate examples of different quantitative approaches to answering research questions. Table 1.2 indicates where each step of the research process can usually be located in a quantitative research article and where it is discussed in this text. Chapters 2, 3, and 8 through 18 describe processes related to quantitative research.

TABLE 1.2 Steps of the Research Process and Journal Format: Quantitative Research

Research Process Steps and/or Format Issue

Usual Location in Journal Heading or Subheading TextChapter

Research problem Abstract and/or in article introduction or separately labeled: “Problem”

Purpose Abstract and/or in introduction, or end of literature review or theoretical framework section, or labeled separately: “Purpose”

Literature review At end of heading “Introduction” but not labeled as such, or labeled as separate heading: “Literature Review,” “Review of the Literature,” or “Related Literature”; or not labeled or variables reviewed appear as headings or subheadings

TF and/or CF Combined with “Literature Review” or found in separate section as TF or CF; or each concept used in TF or CF may appear as separate subheading

3, 4

Hypothesis/research questions

Stated or implied near end of introduction, may be labeled or found in separate heading or subheading: “Hypothesis” or “Research Questions”; or reported for first time in “Results”

Research design Stated or implied in abstract or introduction or in “Methods” or “Methodology” section

8–10

Sample: type and size

“Size” may be stated in abstract, in methods section, or as separate subheading under methods section as “Sample,” “Sample/Subjects,” or “Participants”; “Type” may be implied or stated in any of previous headings described under size

Legal-ethical issues Stated or implied in sections: “Methods,” “Procedures,” “Sample,” or “Subjects”

Instruments Found in sections: “Methods,” “Instruments,” or “Measures” 14

Validity and reliability

Specifically stated or implied in sections: “Methods,” “Instruments,” “Measures,” or “Procedures”

Data collection procedure

In methods section under subheading “Procedure” or “Data Collection,” or as separate heading: “Procedure”

Data analysis Under subheading: “Data Analysis” 16 Results Stated in separate heading: “Results” 16, 17 Discussion of findings and new findings

Combined with results or as separate heading: “Discussion” 17

Implications, limitations, and recommendations

Combined in discussion or as separate major headings 17

References At end of article 4 Communicating research results

Research articles, poster, and paper presentations 1, 20

CF, Conceptual framework; TF, theoretical framework.

The primary difference is that a qualitative study seeks to interpret meaning and phenomena, whereas quantitative research seeks to test a hypothesis or answer research questions using statistical methods. Remember as you read research articles that, depending on the nature of the research problem, a researcher may vary the steps slightly; however, all of the steps should be addressed systematically.

Critical reading skills To develop an expertise in evidence-based practice, you will need to be able to critically read all types of research articles. As you read a research article, you may be struck by the difference in style or format of a research article versus a clinical article. The terms of a research article are new, and the content is different. You may also be thinking that the research article is hard to read or that it is technical and boring. You may simultaneously wonder, “How will I possibly learn to appraise all the steps of a research study, the terminology, and the process of evidence-based practice? I’m only on Chapter 1. This is not so easy; research is as hard as everyone says.”

Remember that learning occurs with time and help. Reading research articles can be difficult and frustrating at first, but the best

way to become a knowledgeable research consumer is to use critical reading skills when reading research articles. As a student, you are not expected to understand a research article or critique it perfectly the first time. Nor are you expected to develop these skills on your own. An essential objective of this book is to help you acquire critical reading skills so that you can use research in your practice. Becoming a competent critical thinker and reader of research takes time and patience.

Learning the research process further develops critical appraisal skills. You will gradually be able to read a research article and reflect on it by identifying assumptions, key concepts, and methods, and determining whether the conclusions are based on the study’s findings. Once you have obtained this critical appraisal competency, you will be ready to synthesize the findings of multiple studies to use in developing an evidence-based practice. This will be a very exciting and rewarding process for you. Analyzing a study critically can require several readings. As you review and synthesize a study, you will begin an appraisal process to help you determine the study’s worth. An illustration of how to use critical reading strategies is provided in Box 1.1, which contains an excerpt from the abstract, introduction, literature review, theoretical framework literature, and methods and procedure section of a quantitative study (Nyamathi et al., 2015) (see Appendix A). Note that in this article there is both a literature review and a theoretical framework section that clearly support the study’s objectives and purpose. Also note that parts of the text from the article were deleted to offer a number of examples within the text of this chapter. BOX 1.1 Example of Critical Appraisal Reading Strategies

Introductory Paragraphs, Study’s Purpose and Aims

Globally, incarcerated populations encounter a host of public health care issues; two such issues—HAV and HBV diseases—are vaccine preventable. In addition, viral hepatitis disproportionately impacts the homeless because of increased risky sexual behaviors and drug use (Stein, Andersen, Robertson, & Gelberg, 2012), along with substandard living conditions (Hennessey, Bangsberg, Weinbaum, & Hahn, 2009). Purpose—Despite knowledge of awareness of risk factors for HBV infection, intervention programs designed to enhance completion of the three-series

Twinrix HAV/HBV vaccine and identification of prognostic factors for vaccine completion have not been widely studied. The purpose of this study was to first assess whether seronegative parolees previously randomized to any one of three intervention conditions were more likely to complete the vaccine series as well as to identify the predictors of HAV/HBV vaccine completion.

Literature Review— Concepts

Despite the availability of the HBV vaccine, there has been a low rate of completion for the three-dose core of the accelerated vaccine series (Centers for Disease Control and Prevention, 2012). Among incarcerated populations, HBV vaccine coverage is low; in a study among jail inmates, 19% had past HBV infection, and 12% completed the HBV vaccination series (Hennessey, Kim, et al., 2009). Although HBV is well accepted behind bars—because of the lack of funding and focus on prevention as a core in the prison system— few inmates complete the series (Weinbaum, Sabin, & Santibanez, 2005). In addition, prevention may not be priority.

Preventable disease vaccinations Homelessness

Authors contend that, although the HBV vaccine is cost-effective, it is underutilized among high-risk (Rich et al., 2003) and incarcerated populations (Hunt & Saab, 2009). For homeless men on parole, vaccination completion may be affected by level of custody; generally, the higher the level of custody, the higher the risk an inmate poses.

Conceptual Framework

The comprehensive health seeking and coping paradigm (Nyamathi, 1989), adapted from a coping model (Lazarus & Folkman, 1984), and the health seeking and coping paradigm (Schlotfeldt, 1981) guided this study and the variables selected (see Fig. 1.1). The comprehensive health seeking and coping paradigm has been successfully applied by our team to improve our understanding of HIV and HBV/hepatitis C virus (HCV) protective behaviors and health outcomes among homeless adults (Nyamathi, Liu, et al., 2009)—many of whom had been incarcerated (Nyamathi et al., 2012).

Methods/Design The study used a randomized clinical trial. Specific Aims and Hypotheses

In this model, a number of factors are thought to relate to the outcome variable, completion of the HAV/HBV vaccine series. These factors include sociodemographic factors, situational factors, personal factors, social factors, and health seeking and coping responses.

Subject Recruitment and Accrual

An RCT where 600 male parolees participating in an RDT program were randomized into one of three intervention conditions aimed at assessing program efficacy on reducing drug use and recidivism at 6 and 12 months, as well as vaccine completion in eligible subjects. There were four inclusion criteria for recruitment purposes in assessing program efficacy on reducing drug use and recidivism: (1) history of drug use prior to their latest incarceration, (2) between ages of 18 and 60, (3) residing in the participating RDT program, and (4) designated as homeless as noted on the prison or jail discharge form.

Procedure The study was approved by the University of California, Los Angeles Institutional Review Board and registered with clinical Trials.gov. Building upon previous studies, we developed varying levels of peer- coached and nurse-led programs designed to improve HAV/HBV vaccine receptivity at 12-month follow-up among homeless offenders recently released to parole. See Appendix A for details in the “Interventions” section.

Intervention Fidelity

Several strategies for treatment fidelity included study design, interventionist’s training, and standardization of interventions. See the Interventions section in Appendix A.

HBA, Hepatitis A virus; HBV, hepatitis B virus; RCT, randomized clinical trial.

http://Trials.gov

HIGHLIGHT Start an IPE Journal Club with students from other health professions programs on your campus. Select a research study to read, understand, and critically appraise together. It is always helpful to collaborate on deciding whether the findings are applicable to clinical practice.

Strategies for critiquing research studies Evaluation of a research article requires a critique. A critique is the process of critical appraisal that objectively and critically evaluates a research report’s content for scientific merit and application to practice. It requires some knowledge of the subject matter and knowledge of how to critically read and use critical appraisal criteria. You will find:

• Summarized examples of critical appraisal criteria for qualitative studies and an example of a qualitative critique in Chapter 7

• Summarized critical appraisal criteria and examples of a quantitative critique in Chapter 18

• An in-depth exploration of the criteria for evaluation required in quantitative research critiques in Chapters 8 through 18

• Criteria for qualitative research critiques presented in Chapters 5 through 7

• Principles for qualitative and quantitative research in Chapters 1 through 4

Critical appraisal criteria are the standards, appraisal guides, or questions used to assess an article. In analyzing a research article, you must evaluate each step of the research process and ask questions about whether each step meets the criteria. For instance, the critical appraisal criteria in Chapter 3 ask if “the literature review identifies gaps and inconsistencies in the literature about a subject, concept, or problem,” and if “all of the concepts and

variables are included in the review.” These two questions relate to critiquing the research question and the literature review components of the research process. Box 1.1 lists several gaps identified in the literature by Nyamathi and colleagues (2015) and how the study intended to fill these gaps by conducting research for the stated objective and purpose (see Appendix A). Remember that when doing a critique, you are pointing out strengths as well as weaknesses. Standardized critical appraisal tools such as those from the Center for Evidence Based Medicine (CEBM) Critical Appraisal Tools (www.cebm.net/critical-appraisal) can be used to systematically appraise the strength and quality of evidence provided in research articles (see Chapter 20).

Critiquing can be thought of as looking at a completed jigsaw puzzle. Does it form a comprehensive picture, or is a piece out of place? What is the level of evidence provided by the study and the findings? What is the balance between the risks and benefits of the findings that contribute to clinical decisions? How can I apply the evidence to my patient, to my patient population, or in my setting? When reading several studies for synthesis, you must assess the interrelationship of the studies, as well as the overall strength and quality of evidence and applicability to practice. Reading for synthesis is essential in critiquing research. Appraising a study helps with the development of an evidence table (see Chapter 20).

Overcoming barriers: Useful critiquing strategies throughout the text, you will find features that will help refine the skills essential to understanding and using research in your practice. A Critical Thinking Decision Path related to each step of the research process in each chapter will sharpen your decision- making skills as you critique research articles. Look for Internet resources in chapters that will enhance your consumer skills. Critical Thinking Challenges, which appear at the end of each chapter, are designed to reinforce your critical reading skills in relation to the steps of the research process. Helpful Hints, designed to reinforce your understanding, appear at various points throughout the chapters. Evidence-Based Practice Tips, which will

http://www.cebm.net/critical-appraisal

help you apply evidence-based practice strategies in your clinical practice, are provided in each chapter.

When you complete your first critique, congratulate yourself; mastering these skills is not easy. Best of all, you can look forward to discussing the points of your appraisal, because your critique will be based on objective data, not just personal opinion. As you continue to use and perfect critical analysis skills by critiquing studies, remember that these skills are an expected competency for delivering evidence-based and quality nursing care.

Evidence-based practice and research Along with gaining comfort while reading and critiquing studies, there is one final step: deciding how, when, and if to apply the studies to your practice so that your practice is evidence based. Evidence-based practice allows you to systematically use the best available evidence with the integration of individual clinical expertise, as well as the patient’s values and preferences, in making clinical decisions (Sackett et al., 2000). Evidence-based practice involves processes and steps, as does the research process. These steps are presented throughout the text. Chapter 19 provides an overview of evidence-based practice steps and strategies.

When using evidence-based practice strategies, the first step is to be able to read a study and understand how each section is linked to the steps of the research process. The following section introduces you to the research process as presented in published articles. Once you read a study, you must decide which level of evidence the study provides and how well the study was designed and executed. Fig. 1.1 illustrates a model for determining the levels of evidence associated with a study’s design, ranging from systematic reviews of randomized clinical trials (RCTs) (see Chapters 9 and 10) to expert opinions. The rating system, or evidence hierarchy model, presented here is just one of many. Many hierarchies for assessing the relative worth of both qualitative and quantitative designs are available. Early in the development of evidence-based practice, evidence hierarchies were thought to be very inflexible, with systematic reviews or meta-analyses at the top and qualitative research at the bottom. When assessing a clinical

question that measures cause and effect, this may be true; however, nursing and health care research are involved in a broader base of problem solving, and thus assessing the worth of a study within a broader context of applying evidence into practice requires a broader view.

FIG 1.1 Levels of evidence: Evidence hierarchy for rating levels of evidence associated with a study’s

design. Evidence is assessed at a level according to its source.

The meaningfulness of an evidence rating system will become clearer as you read Chapters 8 through 11. ➤ Example: The Nyamathi et al. (2015) study is Level II because of its experimental, randomized control trial design, whereas the vanDijk et al. (2016) study is Level VI because it is a qualitative study. The level itself does not tell a study’s worth; rather it is another tool that helps you think about a study’s strengths and weaknesses and the nature of

the evidence provided in the findings and conclusions. Chapters 7 and 18 will provide an understanding of how studies can be assessed for use in practice. You will use the evidence hierarchy presented in Fig. 1.1 throughout the book as you develop your research consumer skills, so become familiar with its content.

This rating system represents levels of evidence for judging the strength of a study’s design, which is just one level of assessment that influences the confidence one has in the conclusions the researcher has drawn. Assessing the strength of scientific evidence or potential research bias provides a vehicle to guide evaluation of research studies for their applicability in clinical decision making. In addition to identifying the level of evidence, one needs to grade the strength of a body of evidence, incorporating the domains of quality, quantity, and consistency (Agency for Healthcare Research and Quality, 2002).

• Quality: Extent to which a study’s design, implementation, and analysis minimize bias.

• Quantity: Number of studies that have evaluated the research question, including overall sample size across studies, as well as the strength of the findings from data analyses.

• Consistency: Degree to which studies with similar and different designs investigating the same research question report similar findings.

The evidence-based practice process steps are: ask, gather, assess and appraise, act, and evaluate (Fig. 1.2). These steps of asking clinical questions; identifying and gathering the evidence; critically appraising and synthesizing the evidence or literature; acting to change practice by coupling the best available evidence with your clinical expertise and patient preferences (e.g., values, setting, and resources); and evaluating if the use of the best available research evidence is applicable to your patient or organization will be discussed throughout the text.

FIG 1.2 Evidence-based practice steps.

To maintain an evidence-based practice, studies are evaluated using specific criteria. Completed studies are evaluated for strength, quality, and consistency of evidence. Before one can proceed with an evidence-based project, it is necessary to understand the steps of the research process found in research studies.

Research articles: Format and style Before you begin reading research articles, it is important to understand their organization and format. Many journals publish research, either as the sole type of article or in addition to clinical or theoretical articles. Many journals have some common features but also unique characteristics. All journals have guidelines for manuscript preparation and submission. A review of these guidelines, which are found on a journal’s website, will give you an idea of the format of articles that appear in specific journals.

Remember that even though each step of the research process is discussed at length in this text, you may find only a short paragraph or a sentence in an article that provides the details of the step. A publication is a shortened version of the researcher(s) completed work. You will also find that some researchers devote more space in an article to the results, whereas others present a longer discussion of the methods and procedures. Most authors give more emphasis to the method, results, and discussion of implications than to details of assumptions, hypotheses, or definitions of terms. Decisions about the amount of material presented for each step of the research process are bound by the following:

• A journal’s space limitations

• A journal’s author guidelines

• The type or nature of the study

• The researcher’s decision regarding which component of the study is the most important

The following discussion provides a brief overview of each step of the research process and how it might appear in an article. It is important to remember that a quantitative research article will differ from a qualitative research article. The components of qualitative research are discussed in Chapters 5 and 6, and are summarized in Chapter 7.

Abstract An abstract is a short, comprehensive synopsis or summary of a study at the beginning of an article. An abstract quickly focuses the reader on the main points of a study. A well-presented abstract is accurate, self-contained, concise, specific, nonevaluative, coherent, and readable. Abstracts vary in word length. The length and format of an abstract are dictated by the journal’s style. Both quantitative and qualitative research studies have abstracts that provide a succinct overview of the study. An example of an abstract can be found at the beginning of the study by Nyamathi et al. (2015) (see Appendix A). Their abstract follows an outline format that highlights the major steps of the study. It partially reads as follows:

Purpose/Objective: “The study focused on completion of the HAV and HBV vaccine series among homeless men on parole. The efficacy of the three levels of peer counseling (PC) and nurse delivered intervention was compared at 12 month follow up.”

In this example, the authors provide a view of the study variables. The remainder of the abstract provides a synopsis of the background of the study and the methods, results, and conclusions. The studies in Appendices A through D all have abstracts.

HELPFUL HINT An abstract is a concise short overview that provides a reference to the research purpose, research questions, and/or hypotheses, methodology, and results, as well as the implications for practice or

future research.

Introduction Early in a research article, in a section that may or may not be labeled “Introduction,” the researcher presents a background picture of the area researched and its significance to practice (see Chapter 2).

Definition of the purpose The purpose of the study is defined either at the end of the researcher’s initial introduction or at the end of the “Literature Review” or “Conceptual Framework” section. The study’s purpose may or may not be labeled (see Chapters 2 and 3), or it may be referred to as the study’s aim or objective. The studies in Appendices A through D present specific purposes for each study in untitled sections that appear in the beginning of each article, as well as in the article’s abstract.

Literature review and theoretical framework Authors of studies present the literature review and theoretical framework in different ways. Many research articles merge the “Literature Review” and the “Theoretical Framework.” This section includes the main concepts investigated and may be called “Review of the Literature,” “Literature Review,” “Theoretical Framework,” “Related Literature,” “Background,” “Conceptual Framework,” or it may not be labeled at all (see Chapters 2 and 3). By reviewing Appendices A through D, you will find differences in the headings used. Nyamathi et al. (2015) (see Appendix A) use no labels and present the literature review but do have a section labeled theoretical framework, while the study in Appendix B has a literature review and a conceptual framework integrated in the beginning of the article. One style is not better than another; the studies in the appendices contain all the critical elements but present the elements differently.

HELPFUL HINT Not all research articles include headings for each step or component of the research process, but each step is presented at

some point in the article.

Hypothesis/research question A study’s research questions or hypotheses can also be presented in different ways (see Chapter 2). Research articles often do not have separate headings for reporting the “Hypotheses” or “Research Question.” They are often embedded in the “Introduction” or “Background” section or not labeled at all (e.g., as in the studies in the appendices). If a study uses hypotheses, the researcher may report whether the hypotheses were or were not supported toward the end of the article in the “Results” or “Findings” section. Quantitative research studies have hypotheses or research questions. Qualitative research studies do not have hypotheses, but have research questions and purposes. The studies in Appendices A, B, and D have hypotheses. The study in Appendix C does not, since it is a qualitative study; rather it has a purpose statement.

Research design The type of research design can be found in the abstract, within the purpose statement, or in the introduction to the “Procedures” or “Methods” section, or not stated at all (see Chapters 6, 9, and 10). For example, the studies in Appendices A, B, and D identify the design in the abstract.

One of your first objectives is to determine whether the study is qualitative (see Chapters 5 and 6) or quantitative (see Chapters 8, 9, and 10). Although the rigor of the critical appraisal criteria addressed do not substantially change, some of the terminology of the questions differs for qualitative versus quantitative studies. Do not get discouraged if you cannot easily determine the design. One of the best strategies is to review the chapters that address designs. The following tips will help you determine whether the study you are reading employs a quantitative design:

• Hypotheses are stated or implied (see Chapter 2).

• The terms control and treatment group appear (see Chapter 9).

• The terms survey, correlational, case control, or cohort are used (see

Chapter 10).

• The terms random or convenience are mentioned in relation to the sample (see Chapter 12).

• Variables are measured by instruments or scales (see Chapter 14).

• Reliability and validity of instruments are discussed (see Chapter 15).

• Statistical analyses are used (see Chapter 16).

In contrast, qualitative studies generally do not focus on “numbers.” Some qualitative studies may use standard quantitative terms (e.g., subjects) rather than qualitative terms (e.g., informants). Deciding on the type of qualitative design can be confusing; one of the best strategies is to review the qualitative chapters (see Chapters 5 through 7). Begin trying to link the study’s design with the level of evidence associated with that design as illustrated in Fig. 1.1. This will give you a context for evaluating the strength and consistency of the findings and applicability to practice. Chapters 8 through 11 will help you understand how to link the levels of evidence with quantitative designs. A study may not indicate the specific design used; however, all studies inform the reader of the methodology used, which can help you decide the type of design the authors used to guide the study.

Sampling The population from which the sample was drawn is discussed in the section “Methods” or “Methodology” under the subheadings of “Subjects” or “Sample” (see Chapter 12). Researchers should tell you both the population from which the sample was chosen and the number of subjects that participated in the study, as well as if they had subjects who dropped out of the study. The authors of the studies in the appendices discuss their samples in enough detail so that the reader is clear about who the subjects are and how they were selected.

Reliability and validity

The discussion of the instruments used to study the variables is usually included in a “Methods” section under the subheading of “Instruments” or “Measures” (see Chapter 14). Usually each instrument (or scale) used in the study is discussed, as well as its reliability and validity (see Chapter 15). The studies in Appendices A, B, and D discuss each of the measures used in the “Methods” section under the subheading “Measures” or “Instruments.” The reliability and validity of each measure is also presented.

In some cases, the reliability and validity of commonly used, established instruments in an article are not presented, and you are referred to other references.

Procedures and collection methods The data collection procedures, or the individual steps taken to gather measurable data (usually with instruments or scales), are generally found in the “Procedures” section (see Chapter 14). In the studies in Appendices A through D, the researchers indicate how they conducted the study in detail under the subheading “Procedure” or “Instruments and Procedures.” Notice that the researchers in each study included in the Appendices provided information that the studies were approved by an institutional review board (see Chapter 13), thereby ensuring that each study met ethical standards.

Data analysis/results The data-analysis procedures (i.e., the statistical tests used and the results of descriptive and/or inferential tests applied in quantitative studies) are presented in the section labeled “Results” or “Findings” (see Chapters 16 and 17). Although qualitative studies do not use statistical tests, the procedures for analyzing the themes, concepts, and/or observational or print data are usually described in the “Method” or “Data Collection” section and reported in the “Results,” “Findings,” or “Data Analysis” section (see Appendix C and Chapters 5 and 6).

Discussion The last section of a research study is the “Discussion” (see Chapter

17). In this section the researchers tie together all of the study’s pieces and give a picture of the study as a whole. The researchers return to the literature reviewed and discuss how their study is similar to, or different from, other studies. Researchers may report the results and discussion in one section but usually report their results in separate “Results” and “Discussion” sections (see Appendices A through D). One particular method is no better than another. Journal and space limitations determine how these sections will be handled. Any new or unexpected findings are usually described in the “Discussion” section.

Recommendations and implications In some cases, a researcher reports the implications and limitations based on the findings for practice and education, and recommends future studies in a separate section labeled “Conclusions”; in other cases, this appears in several sections, labeled with such titles as “Discussion,” “Limitations,” “Nursing Implications,” “Implications for Research and Practice,” and “Summary.” Again, one way is not better than the other—only different.

References All of the references cited are included at the end of the article. The main purpose of the reference list is to support the material presented by identifying the sources in a manner that allows for easy retrieval. Journals use various referencing styles.

Communicating results Communicating a study’s results can take the form of a published article, poster, or paper presentation. All are valid ways of providing data and have potential to effect high-quality patient care based on research findings. Evidence-based nursing care plans and QI practice protocols, guidelines, or standards are outcome measures that effectively indicate communicated research.

HELPFUL HINT If you have to write a paper on a specific concept or topic that requires you to critique and synthesize the findings from several studies, you might find it useful to create an evidence table of the

data (see Chapter 20). Include the following information: author, date, study type, design, level of evidence, sample, data analysis, findings, and implications.

Systematic reviews: Meta-analyses, integrative reviews, and meta-syntheses Systematic reviews Other article types that are important to understand for evidence- based practice are review articles. Review articles include systematic reviews, meta-analyses, integrative reviews (sometimes called narrative reviews), meta-syntheses, and meta-summaries. A systematic review is a summation and assessment of a group of research studies that test a similar research question. Systematic reviews are based on a clear question, a detailed plan which includes a search strategy, and appraisal of a group of studies related to the question. If statistical techniques are used to summarize and assess studies, the systematic review is labeled as a meta-analysis. A meta-analysis is a summary of a number of studies focused on one question or topic, and uses a specific statistical methodology to synthesize the findings in order to draw conclusions about the area of focus. An integrative review is a focused review and synthesis of research or theoretical literature in a particular focus area, and includes specific steps of literature integration and synthesis without statistical analysis; it can include both quantitative and qualitative articles (Cochrane Consumer Network, 2016; Uman, 2011; Whittemore, 2005). At times reviews use the terms systematic review and integrative review interchangeably. Both meta-synthesis and meta-summary are the synthesis of a number of qualitative research studies on a focused topic using specific qualitative methodology (Kastner et al., 2016; Sandelowski & Barrosos, 2007).

The components of review articles will be discussed in greater detail in Chapters 6, 11, and 20. These articles take a number of studies related to a clinical question and, using a specific set of criteria and methods, evaluate the studies as a whole. While they may vary somewhat in approach, these reviews all help to better

inform and develop evidence-based practice. The meta-analysis in Appendix E is an example of a systematic review that is a meta- analysis.

Clinical guidelines Clinical guidelines are systematically developed statements or recommendations that serve as a guide for practitioners. Two types of clinical guidelines will be discussed throughout this text: consensus, or expert-developed guidelines, and evidence-based guidelines. Consensus guidelines, or expert-developed guidelines, are developed by an agreement of experts in the field. Evidence- based guidelines are those developed using published research findings. Guidelines are developed to assist in bridging practice and research and are developed by professional organizations, government agencies, institutions, or convened expert panels. Clinical guidelines provide clinicians with an algorithm for clinical management or decision making for specific diseases (e.g., breast cancer) or treatments (e.g., pain management). Not all clinical guidelines are well developed and, like research, must be assessed before implementation. Though they are systematically developed and make explicit recommendations for practice, clinical guidelines may be formatted differently. Guidelines for practice are becoming more important as third party and government payers are requiring practices to be based on evidence. Guidelines should present scope and purpose of the practice, detail who the development group included, demonstrate scientific rigor, be clear in its presentation, demonstrate clinical applicability, and demonstrate editorial independence (see Chapter 11).

Quality improvement As a health care provider, you are responsible for continuously improving the quality and safety of health care for your patients and their families through systematic redesign of health care systems in which you work. The Institute of Medicine (2001) defined quality health care as care that is safe, effective, patient- centered, timely, efficient, and equitable. Therefore, the goal of QI is to bring about measurable changes across these six domains by

applying specific methodologies within a care setting. While several QI methods exist, the core steps for improvement commonly include the following:

• Conducting an assessment

• Setting specific goals for improvement

• Identifying ideas for changing current practice

• Deciding how improvements in care will be measured

• Rapidly testing practice changes

• Measuring improvements in care

• Adopting the practice change as a new standard of care

Chapter 21 focuses on building your competence to participate in and lead QI projects by providing an overview of the evolution of QI in health care, including the nurse’s role in meeting current regulatory requirements for patient care quality. Chapter 19 discusses QI models and tools, such as cause-and-effect diagrams and process mapping, as well as skills for effective teamwork and leadership that are essential for successful QI projects.

As you venture through this textbook, you will be challenged to think not only about reading and understanding research studies, but also about applying the findings to your practice. Nursing has a rich legacy of research that has grown in depth and breadth. Producers of research and clinicians must engage in a joint effort to translate findings into practice that will make a difference in the care of patients and families.

Key points • Research provides the basis for expanding the unique body of

scientific evidence that forms the foundation of evidence-based nursing practice. Research links education, theory, and practice.

• As consumers of research, nurses must have a basic understanding of the research process and critical appraisal skills to evaluate research evidence before applying it to clinical practice.

• Critical appraisal is the process of evaluating the strengths and weaknesses of a research article for scientific merit and application to practice, theory, or education; the need for more research on the topic or clinical problem is also addressed at this stage.

• Critical appraisal criteria are the measures, standards, evaluation guides, or questions used to judge the worth of a research study.

• Critical reading skills will enable you to evaluate the appropriateness of the content of a research article, apply standards or critical appraisal criteria to assess the study’s scientific merit for use in practice, or consider alternative ways of handling the same topic.

• A level of evidence model is a tool for evaluating the strength (quality, quantity, and consistency) of a research study and its findings.

• Each article should be evaluated for the study’s strength and consistency of evidence as a means of judging the applicability of findings to practice.

• Research articles have different formats and styles depending on journal manuscript requirements and whether they are quantitative or qualitative studies.

• Evidence-based practice and QI begin with the careful reading and understanding of each article contributing to the practice of nursing, clinical expertise, and an understanding of patient values.

• QI processes are aimed at improving clinical care outcomes for patients and better methods of system performance.

Critical thinking challenges • How might nurses discuss the differences between evidence-

based practice and research with their colleagues in other professions?

• From your clinical practice, discuss several strategies nurses can undertake to promote evidence-based practice.

• What are some strategies you can use to develop a more comprehensive critique of an evidence-based practice article?

• A number of different components are usually identified in a research article. Discuss how these sections link with one another to ensure continuity.

• How can QI data be used to improve clinical practice?

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

References 1. Agency for Healthcare Research and Quality. Systems to

rate the strength of scientific evidence. File inventory, Evidence Report/Technology Assessment No. 47. AHRQ Publication No. 02-E0162002.

2. Al-Mallah M.H, Farah I, Al-Madani W, et al. The impact of nurse-led clinics on the mortality and mortality of patients with cardiovascular diseases A systematic review and meta- analysis. Journal of Cardiovascular Nursing 2015;31(1):89-95 Available at: doi:10.1097/JCN.00000000000000224.

3. American Nurses Association (ANA). Code of ethics for nurses for nurses with interpretive statements. Washington, DC: The Association;2015.

4. Cochrane Consumer Network, The Cochrane Library, 2016, retrieved online. Available at: www.cochranelibrary.com

http://evolve.elsevier.com/LoBiondo/

http://dx.doi:10.1097/JCN.00000000000000224

http://www.cochranelibrary.com

5. Cronenwett L, Sherwood G, Barnsteiner J, et al. Quality and safety education for nurses. Nursing Outlook 2007;55(3):122- 131.

6. Institute of Medicine [IOM]. The future of nursing Leading change, advancing health. Washington, DC: National Academic Press;2011.

7. Institute of Medicine Committee on Quality of Health Care in America. Crossing the quality chasm A new health system for the 21st century. Washington, DC: National Academy Press;2001.

8. Kastner M, Antony J, Soobiah C, et al. Conceptual recommendations for selecting the most appropriate knowledge synthesis method to answer research questions related to complex evidence. Journal of Clinical Epidemiology 2016;73:43-49.

9. Nyamathi A, Salem B.E, Zhang S, et al. Nursing case management, peer coaching, and hepatitus A and B vaccine completion among homeless men recently released on parole. Nursing Research 2015;64:177-189 Available at: doi:10.1097/NNR.0000000000000083.

10. Sackett D.L, Straus S, Richardson S, et al. Evidence-based medicine How to practice and teach EBM. 2nd ed. London: Churchill Livingstone;2000.

11. Sandelowski M, Barroso J. Handbook of Qualitative Research. New York, NY: Springer Pub. Co.;2007.

12. Uman L.S. Systematic reviews and meta-analyses. Journal of the Canadian Academy of Child and Adolescent Psychiatry 2011;20(1):57-59.

13. vanDijk J.F.M, Vervoot S.C.J.M, vanWijck A.J.M, et al. Postoperative patients’ perspectives on rating pain A qualitative study. International Journal of Nursing Studies 2016;53:260- 269.

14. Whittemore R. Combining evidence in nursing research. Nursing Research 2005;54(1):56-62.

http://dx.doi:10.1097/NNR.0000000000000083

CHAPTER 2

Research questions, hypotheses, and clinical questions Judith Haber

Learning outcomes

After reading this chapter, you should be able to do the following:

• Describe how the research question and hypothesis relate to the other components of the research process. • Describe the process of identifying and refining a research question or hypothesis. • Discuss the appropriate use of research questions versus hypotheses in a research study. • Identify the criteria for determining the significance of a research question or hypothesis. • Discuss how the purpose, research question, and hypothesis suggest the level of evidence to be obtained from the findings of a research study. • Discuss the purpose of developing a clinical question.

• Discuss the differences between a research question and a clinical question in relation to evidence-based practice. • Apply critiquing criteria to the evaluation of a research question and hypothesis in a research report.

KEY TERMS

clinical question

complex hypothesis

dependent variable

directional hypothesis

hypothesis

independent variable

nondirectional hypothesis

population

purpose

research hypothesis

research question

statistical hypothesis

testability

theory

variable

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

At the beginning of this chapter, you will learn about research questions and hypotheses from the perspective of a researcher, which, in the second part of this chapter, will help you generate

http://evolve.elsevier.com/LoBiondo/

your own clinical questions that you will use to guide the development of evidence-based practice projects. From a clinician’s perspective, you must understand the research question and hypothesis as it aligns with the rest of a study. As a practicing nurse, developing clinical questions (see Chapters 19, 20, and 21) is the first step of the evidence-based practice process for quality improvement programs like those that decrease risk for development of pressure ulcers.

When nurses ask questions such as, “Why are things done this way?” “I wonder what would happen if . . . ?” “What characteristics are associated with . . . ?” or “What is the effect of ____ on patient outcomes?”, they are often well on their way to developing a research question or hypothesis. Research questions are usually generated by situations that emerge from practice, leading nurses to wonder about the effectiveness of one intervention versus another for a specific patient population.

The research question or hypothesis is a key preliminary step in the research process. The research question tests a measureable relationship to be examined in a research study. The hypothesis predicts the outcome of a study.

Hypotheses can be considered intelligent hunches, guesses, or predictions that provide researchers with direction for the research design and the collection, analysis, and interpretation of data. Hypotheses are a vehicle for testing the validity of the theoretical framework assumptions and provide a bridge between theory (a set of interrelated concepts, definitions, and propositions) and the real world (see Chapter 4).

For a clinician making an evidence-informed decision about a patient care issue, a clinical question, such as whether chlorhexidine or povidone-iodine is more effective in preventing central line catheter infections, would guide the nurse in searching and retrieving the best available evidence. This evidence, combined with clinical expertise and patient preferences, would provide an answer on which to base the most effective decision about patient care for this population.

Often the research questions or hypotheses appear at the beginning of a research article, but may be embedded in the purpose, aims, goals, or even the results section of the research

report. This chapter provides you with a working knowledge of quantitative research questions and hypotheses. It also highlights the importance of clinical questions and how to develop them.

Developing and refining a research question: Study perspective A researcher spends a great deal of time refining a research idea into a testable research question. Research questions or topics are not pulled from thin air. In Table 2.1, you will see that research questions can indicate that practical experience, critical appraisal of the scientific literature, or interest in an untested theory forms the basis for the development of a research idea. The research question should reflect a refinement of the researcher’s initial thinking. The evaluator of a research study should be able to identify that the researcher has:

• Defined a specific question area

• Reviewed the relevant literature

• Examined the question’s potential significance to nursing

• Pragmatically examined the feasibility of studying the research question

TABLE 2.1 How Practical Experience, Scientific Literature, and Untested Theory Influence the Development of a Research Idea

Area Influence Example Clinical experience

Clinical practice provides a wealth of experience from which research problems can be derived. The nurse may observe a particular event or pattern and become curious about why it occurs, as well as its relationship to other factors in the patient’s environment.

Health professionals observe that despite improvements in symptom management for cancer patients receiving chemotherapy, side effects remain highly prevalent. Symptoms such as nausea/vomiting, diarrhea, constipation, and fatigue are common, and patients report that they negatively affect functional status and quality of life, including costly and distressing hospitalizations. A study by Traeger et al. (2015) tested a model integrated into outpatient care for patients with breast cancer, lung cancer, and colorectal cancer, designed to reduce symptom

burden to be delivered by each patient’s oncology team nurse practitioner that included telephone follow-up, symptom assessment, advice, and triage according to actual clinical practice. The aim was to ensure optimal patient-NP management of side effects early in the course of care.

Critical appraisal of the scientific literature

Critical appraisal of studies in journals may indirectly suggest a clinical problem by stimulating the reader’s thinking. The nurse may observe the outcome data from a single study or a group of related studies that provide the basis for developing a pilot study, quality improvement project, or clinical practice guideline to determine the effectiveness of this intervention in their setting.

At a staff meeting with members of an interprofessional team at a cancer center, it was noted that the center did not have a standardized clinical practice guideline for mucositis, a painful chemotherapy side effect involving the oral cavity that has a negative impact on nutrition, oral hygiene, and comfort. The team wanted to identify the most effective approaches for treating adults and children experiencing mucositis. Their search for, and critical appraisal of, existing research studies led the team to develop an interprofessional mucositis guideline that was relevant to their patient population and clinical setting (NYU Langone Medical Center, 2016).

Gaps in the literature

A research idea may also be suggested by a critical appraisal of the literature that identifies gaps in the literature and suggests areas for future study. Research ideas also can be generated by research reports that suggest the value of replicating a particular study to extend or refine the existing scientific knowledge base.

Obesity is a widely recognized risk factor for many conditions treated in primary care settings including type 2 diabetes, cardiovascular disease, hypertension, and osteoarthritis. Although weight and achieving a healthy weight for children and adults is a Healthy People 2020 goal and a national priority, the prevalence of obesity remains high, and there is little research on targeted interventions for weight loss in primary care settings. Therefore, the purpose of a study by Thabault, Burke, and Ades (2015) was to evaluate an NP-led motivational interviewing IBT program implemented in an adult primary care practice with obese patients to determine feasibility and acceptance of the intervention.

Interest in untested theory

Verification of a theory and its concepts provides a relatively uncharted area from which research problems can be derived. Inasmuch as theories themselves are not tested, a researcher may consider investigating a concept or set of concepts related to a nursing theory or a theory from another discipline. The researcher would pose questions like, “If this theory is correct, what kind of behavior would I expect to observe in particular patients and under which conditions?” “If this theory is valid, what kind of supporting evidence will I find?”

Bandura’s (1997) health self-efficacy construct, an individual’s confidence in the ability to perform a behavior, overcome barriers to that behavior, and exert control over the behavior through self- regulation and goal setting, was used by Richards, Ogata, and Cheng (2016) to investigate whether health-related self-efficacy provides the untested theoretical foundation for behavior change related to increasing physical activity using a dog walking (Dogs PAW) intervention.

IBT, Intensive behavioral therapy.

Defining the research question Brainstorming with faculty or colleagues may provide valuable feedback that helps the researcher focus on a specific research question area. Example: ➤ Suppose a researcher told a colleague that her area of interest was health disparities about the effectiveness of peer coaching or case management in improving health outcomes with challenging patient populations such as those who are homeless. The colleague may have asked, “What is it about the topic that specifically interests you?” This conversation may have initiated a chain of thought that resulted in a decision to explore the effectiveness of a nursing case management and peer coaching intervention on hepatitis A and B (HAV and HBV) vaccine completion rates among homeless men recently released on parole (Nyamathi et al., 2015) (see Appendix A). Fig. 2.1 illustrates how a broad area of interest (health disparities, nursing case management, peer coaching) was narrowed to a specific research topic (effectiveness of nursing case management and peer coaching on HAV and HBV vaccine completion among homeless men recently released on parole).

FIG 2.1 Development of a research question.

EVIDENCE-BASED PRACTICE TIP A well-developed research question guides a focused search for scientific evidence about assessing, diagnosing, treating, or providing patients with information about their prognosis related to a specific health problem.

Beginning the literature review

The literature review should reveal a relevant collection of studies and systematic reviews that have been critically examined. Concluding sections in such articles (i.e., the recommendations and implications for practice) often identify remaining gaps in the literature, the need for replication, or the need for additional knowledge about a particular research focus (see Chapter 3). In the previous example, the researcher may have conducted a preliminary review of books and journals for theories and research studies on factors apparently critical to vaccine completion rates for preventable health problems like HAV and HBV, as well as risk factors contributing to the disproportionate impact of HAV and HBV on the homeless, such as risky sexual activity, drug use, substandard living conditions, and older age. These factors, called variables, should be potentially relevant, of interest, and measurable.

EVIDENCE-BASED PRACTICE TIP The answers to questions generated by qualitative data reflect evidence that may provide the first insights about a phenomenon that has not been previously studied.

Other variables, called demographic variables, such as race, ethnicity, gender, age, education, and physical and mental health status, are also suggested as essential to consider. Example: ➤ Despite the availability of the HAV and HBV vaccines, there has been a low completion rate for the three-dose core of the accelerated vaccine series, particularly following release from prison. This information can then be used to further define the research question and continue the search of the literature to identify effective intervention strategies reported in other studies with similar high- risk populations (e.g., homeless) that could be applied to this population. Example: ➤ One study documented the effectiveness of a nurse case management program in improving vaccine completion rates in a group of homeless adults, but no studies were found about the effectiveness of peer coaching. At this point, the researcher could write the tentative research question: “What is the effectiveness of peer coaching and nursing case management on completion of an HAV and HBV vaccine series among homeless men on parole?” You can envision the interrelatedness of the initial

definition of the question area, the literature review, and the refined research question.

HELPFUL HINT Reading the literature review or theoretical framework section of a research article helps you trace the development of the implied research question and/or hypothesis.

Examining significance When considering a research question, it is crucial that the researcher examine the question’s potential significance for nursing. This is sometimes referred to as the “so what” question, because the research question should have the potential to contribute to and extend the scientific body of nursing knowledge. Guidelines for selecting research questions should meet the following criteria:

• Patients, nurses, the medical community in general, and society will potentially benefit from the knowledge derived from the study.

• Results will be applicable for nursing practice, education, or administration.

• Findings will provide support or lack of support for untested theoretical concepts.

• Findings will extend or challenge existing knowledge by filling a gap or clarifying a conflict in the literature.

• Findings will potentially provide evidence that supports developing, retaining, or revising nursing practices or policies.

If the research question has not met any of these criteria, the researcher is wise to extensively revise the question or discard it. Example: ➤ In the previously cited research question, the significance of the question includes the following facts:

• HAV and HBV are vaccine preventable.

• Viral hepatitis disproportionately impacts the homeless.

• Despite its availability, vaccine completion rates are low among high-risk and incarcerated populations.

• Accelerated vaccine programs have shown success in RCT studies.

• The use of nurse case management programs in accelerated vaccine programs also provides evidence of effectiveness.

• Little is known about vaccine completion among ex-offender populations on parole using varying intensities of nurse case management and peer coaches.

• This study sought to fill a gap in the related literature by assessing whether seronegative parolees randomized to one of three intervention conditions were more likely to complete the vaccine series as well as to identify predictors of HAV/HBV vaccine completion.

HIGHLIGHT It is helpful to collaborate with colleagues from other professions to identify an important clinical question that provides data for a quality improvement on your unit.

The fully developed research question When a researcher finalizes a research question, the following characteristics should be evident:

• It clearly identifies the variables under consideration.

• It specifies the population being studied.

• It implies the possibility of empirical testing.

Because each element is crucial to developing a satisfactory research question, the criteria will be discussed in greater detail. These elements can often be found in the introduction of the published article; they are not always stated in an explicit manner.

Variables Researchers call the properties that they study “variables.” Such properties take on different values. Thus a variable, as the name suggests, is something that varies. Properties that differ from each other, such as age, weight, height, religion, and ethnicity, are examples of variables. Researchers attempt to understand how and why differences in one variable relate to differences in another variable. Example: ➤ A researcher may be concerned about the variable of pneumonia in postoperative patients on ventilators in critical care units. It is a variable because not all critically ill postoperative patients on ventilators have pneumonia. A researcher may also be interested in what other factors can be linked to ventilator-acquired pneumonia (VAP). There is clinical evidence to suggest that elevation of the head of the bed and frequent oral hygiene are associated with decreasing risk for VAP. You can see that these factors are also variables that need to be considered in relation to the development of VAP in postoperative patients.

When speaking of variables, the researcher is essentially asking, “Is X related to Y? What is the effect of X on Y? How are X1 and X2 related to Y?” The researcher is asking a question about the relationship between one or more independent variables and a dependent variable. (Note: In cases in which multiple independent or dependent variables are present, subscripts are used to indicate the number of variables under consideration.)

An independent variable, usually symbolized by X, is the variable that has the presumed effect on the dependent variable. In experimental research studies, the researcher manipulates the independent variable (see Chapter 9). In nonexperimental research, the independent variable is not manipulated and is assumed to have occurred naturally before or during the study (see Chapter 10).

The dependent variable, represented by Y, varies with a change in the independent variable. The dependent variable is not manipulated. It is observed and assumed to vary with changes in the independent variable. Predictions are made from the independent variable to the dependent variable. It is the dependent variable that the researcher is interested in understanding, explaining, or predicting. Example: ➤ It might be assumed that the

perception of pain intensity (the dependent variable) will vary in relation to a person’s gender (the independent variable). In this case, we are trying to explain the perception of pain intensity in relation to gender (i.e., male or female). Although variability in the dependent variable is assumed to depend on changes in the independent variable, this does not imply that there is a causal relationship between X and Y, or that changes in variable X cause variable Y to change.

Table 2.2 presents a number of examples of research questions. Practice substituting other variables for the examples in Table 2.2. You will be surprised at the skill you develop in writing and critiquing research questions with greater ease.

TABLE 2.2 Research Question Format

HBHC, Hospital-based home care.

Although one independent variable and one dependent variable are used in the examples, there is no restriction on the number of variables that can be included in a research question. Research questions that include more than one independent or dependent variable may be broken down into subquestions that are more concise.

Finally, it should be noted that variables are not inherently independent or dependent. A variable that is classified as independent in one study may be considered dependent in another study. Example: ➤ A nurse may review an article about depression

that identifies depression in adolescents as predictive of risk for suicide. In this case, depression is the independent variable. When another article about the effectiveness of antidepressant medication alone or in combination with cognitive behavioral therapy (CBT) in decreasing depression in adolescents is considered, change in depression is the dependent variable. Whether a variable is independent or dependent is a function of the role it plays in a particular study.

Population The population is a well-defined set that has certain characteristics and is either clearly identified or implied in the research question. Example: ➤ In a retrospective cohort study studying the number of ED visits and hospitalizations in two different transition care programs, a research question may ask, “What is the differential effectiveness of nurse-led or physician-led intensive home visiting program providing transition care to patients with complex chronic conditions or receiving palliative care (Morrison, Palumbo, & Rambur, 2016)? Does a relationship exist between type of transition care model (nurse-led focused on chronic disease self-management or physician-led focused on palliative care and managing complex chronic conditions) and the number of ED visits and rehospitalizations 120 days pre- and posttransitional care interventions?” This question suggests that the population includes community-residing adults with complex chronic conditions or receiving palliative care who participated in either a nurse or physician-led transitional care program.

EVIDENCE-BASED PRACTICE TIP Make sure that the population of interest and the setting have been clearly described so that if you were going to replicate the study, you would know exactly who the study population needed to be.

Testability The research question must imply that it is testable, measurable by either qualitative or quantitative methods. Example: ➤ The research question “Should postoperative patients control how much pain medication they receive?” is stated incorrectly for a

variety of reasons. One reason is that it is not testable; it represents a value statement rather than a research question. A scientific research question must propose a measureable relationship between an independent and a dependent variable. Many interesting and important clinical questions are not valid research questions because they are not amenable to testing.

HELPFUL HINT Remember that research questions are used to guide all types of research studies but are most often used in exploratory, descriptive, qualitative, or hypothesis-generating studies.

The question “What are the relationships between vaccine completion rates among the ex-offender population and use of varying intensities of nurse case management and peer coaches?” is a testable research question. It illustrates the relationship between the variables, identifies the independent and dependent variables, and implies the testability of the research question. Table 2.3 illustrates how this research question is congruent with the three research question criteria.

TABLE 2.3 Components of the Research Question and Related Criteria

This research question was originally derived from a general area of interest: health-seeking behavior and coping (HAV and HBV vaccine completion rates) in a high-risk population (ex-offenders on parole, homeless), factors related to vaccine completion (age, education, race/ethnicity, marital, and parental status), and potential strategies (nurse case management and peer coaching) to

improve protective behaviors and health outcomes. The question crystallized further after a preliminary literature review (Nyamathi et al., 2015).

HELPFUL HINT

• Remember that research questions are often not explicitly stated. The reader has to infer the research question from the title of the report, the abstract, the introduction, or the purpose.

• Using your focused question, search the literature for the best available answer to your clinical question.

Study purpose, aims, or objectives The purpose of the study encompasses the aims or objectives the investigator hopes to achieve with the research. These three terms are synonymous. The researcher selects verbs to use in the purpose statement that suggest the planned approach to be used when studying the research question as well as the level of evidence to be obtained through the study findings. Verbs such as discover, explore, or describe suggest an investigation of an infrequently researched topic that might appropriately be guided by research questions rather than hypotheses. In contrast, verb statements indicating that the purpose is to test the effectiveness of an intervention or compare two alternative nursing strategies suggest a hypothesis- testing study for which there is an established knowledge base of the topic.

Remember that when the purpose of a study is to test the effectiveness of an intervention or compare the effectiveness of two or more interventions, the level of evidence is likely to have more strength and rigor than a study whose purpose is to explore or describe phenomena. Box 2.1 provides examples of purpose, aims, and objectives. BOX 2.1 Examples of Purpose Statements

• The purpose of this study was to explore the relationship between

future expectations, attitude toward use of violence to solve problems, and self-reported physical and relational bullying perpetration in a sample of seventh grade students (Stoddard, Varela, & Zimmerman, 2015). The aim of this study was to determine knowledge, awareness, and practices of Turkish hospital nurses in relation to cervical cancer, HPV, and HPV (Koc & Cinarli, 2015).

• The purposes of this longitudinal study with a sample composed of Hispanic, Black non-Hispanic, and White non-Hispanic bereaved parents were to test the relationships between spiritual/religious coping strategies and grief, mental health, and personal growth for mothers and fathers at 1 and 3 months after the infant/child’s death in the NICU/PICU (Hawthorne et al., 2016). The goals of the current study were to examine psychological functioning and coping in parents and siblings of adolescent cancer survivors (Turner-Sack et al., 2016).

EVIDENCE-BASED PRACTICE TIP The purpose, aims, or objectives often provide the most information about the intent of the research question and hypotheses, and suggest the level of evidence to be obtained from the findings of the study.

Developing the research hypothesis Like the research question, hypotheses are often not stated explicitly in a research article. You will often find that hypotheses are embedded in the data analysis, results, or discussion section of the research report. Similarly, the population may not be explicitly stated, but will have been identified in the background, significance, and literature review. It is then up to you to figure out the hypotheses and population being tested. Example: ➤ In a study by Turner-Sack and colleagues (2016) (see Appendix B), the hypotheses are embedded in the “Data Analysis” and “Results” sections of the article. You must interpret that the statement, “Independent sample t-tests were conducted to compare the survivors, siblings, and parents on measures of psychological

distress, life satisfaction, posttraumatic growth (PTG), and that of their matched parents” to understand that it represents hypotheses used to compare psychological functioning, PTG, coping, and cancer-related characteristics of adolescent cancer survivors’ parents and siblings.

Hypotheses flow from the study’s purpose, literature review, and theoretical framework. Fig. 2.2 illustrates this flow. A hypothesis is a declarative statement about the relationship between two or more variables. A hypothesis predicts an expected outcome of a study. Hypotheses are developed before the study is conducted because they provide direction for the collection, analysis, and interpretation of data.

FIG 2.2 Interrelationships of purpose, literature review,

theoretical framework, and hypothesis.

HELPFUL HINT When hypotheses are not explicitly stated by the author at the end of the introduction section or just before the methods section, they will be embedded or implied in the data analysis, results, or discussion section of a research article.

Relationship statement The first characteristic of a hypothesis is that it is a declarative statement that identifies the predicted relationship between two or more variables: the independent variable (X) and a dependent variable (Y). The direction of the predicted relationship is also specified in this statement. Phrases such as greater than, less than, positively, negatively, or difference in suggest the directionality that is proposed in the hypothesis. The following is an example of a directional hypothesis: “Nurse staff members’ perceptions of transformational leadership among their nurse leaders (independent variable) is that it is negatively associated with nurse staff burnout (dependent variable)” (Lewis & Cunningham, 2016). The dependent and independent variables are explicitly identified, and the relational aspect of the prediction in the hypothesis is contained in the phrase “negatively associated with.”

The nature of the relationship, either causal or associative, is also implied by the hypothesis. A causal relationship is one in which the researcher can predict that the independent variable (X) causes a change in the dependent variable (Y). In research, it is rare that one is in a firm enough position to take a definitive stand about a cause- and-effect relationship. Example: ➤ A researcher might hypothesize selected determinants of the decision-making process, specifically expectation, socio-demographic factors, and decisional conflict would predict postdecision satisfaction and regret about their choice of treatment for breast cancer in Chinese-American women (Lee & Knobf, 2015). It would be difficult for a researcher to predict a cause-and-effect relationship, however, because of the multiple intervening variables (e.g., values, culture, role, support from others, personal resources, language literacy) that might also influence the subject’s decision making about treatment for their breast cancer diagnosis.

Variables are more commonly related in noncausal ways; that is, the variables are systematically related but in an associative way. This means that the variables change in relation to each other. Example: ➤ There is strong evidence that asbestos exposure is related to lung cancer. It is tempting to state that there is a causal relationship between asbestos exposure and lung cancer. Do not overlook the fact, however, that not all of those who have been

exposed to asbestos will have lung cancer, and not all of those who have lung cancer have had asbestos exposure. Consequently, it would be scientifically unsound to take a position advocating the presence of a causal relationship between these two variables. Rather, one can say only that there is an associative relationship between the variables of asbestos exposure and lung cancer, a relationship in which there is a strong systematic association between the two phenomena.

Testability The second characteristic of a hypothesis is its testability. This means that the variables of the study must lend themselves to observation, measurement, and analysis. The hypothesis is either supported or not supported after the data have been collected and analyzed. The predicted outcome proposed by the hypothesis will or will not be congruent with the actual outcome when the hypothesis is tested.

HELPFUL HINT When a hypothesis is complex (i.e., it contains more than one independent or dependent variable), it is difficult for the findings to indicate unequivocally that the hypothesis is supported or not supported. In such cases, the reader must infer which relationships are significant in the predicted direction from the findings or discussion section.

Theory base The third characteristic is that the hypothesis is consistent with an existing body of theory and research findings. Whether a hypothesis is arrived at on the basis of a review of the literature or a clinical observation, it must be based on a sound scientific rationale. You should be able to identify the flow of ideas from the research idea to the literature review, to the theoretical framework, and through the research question(s) or hypotheses. Example: ➤ Nyamathi and colleagues (2015) (see Appendix A) investigated the effectiveness of a nursing case management intervention in comparison to a peer coaching intervention based on the comprehensive health-seeking and coping paradigm developed by

Nyamathi in 1989, adapted from a coping model by Lazarus and Folkman (1984), and the health-seeking and coping paradigm by Schlotfeldt (1981), which is a useful theoretical framework for case management, peer coaching interventions, and vaccine completion outcomes.

Wording the hypothesis As you read the scientific literature and become more familiar with it, you will observe that there are a variety of ways to word a hypothesis that are described in Tables 2.4 and 2.5. Information about hypotheses may be further clarified in the instruments, sample, or methods sections of a research report (see Chapters 12 and 15).

TABLE 2.4 Examples of How Hypotheses are Worded

BP, Blood pressure; CRNA, Certified Nurse Anesthetists; DV, dependent variable; IV, independent variable; TM, telemonitoring; UC, usual care.

TABLE 2.5 Examples of Statistical Hypotheses

ANPs, Adult nurse practitioners; FNPs, family nurse practitioners; DV, dependent variable; IV, independent variable.

Statistical versus research hypotheses You may observe that a hypothesis is further categorized as either a research or a statistical hypothesis. A research hypothesis, also known as a scientific hypothesis, consists of a statement about the expected relationship of the variables. A research hypothesis indicates what the outcome of the study is expected to be. A research hypothesis is also either directional or nondirectional. If the researcher obtains statistically significant findings for a research hypothesis, the hypothesis is supported. The examples in Table 2.4 represent research hypotheses.

A statistical hypothesis, also known as a null hypothesis, states that there is no relationship between the independent and dependent variables. The examples in Table 2.5 illustrate statistical hypotheses. If, in the data analysis, a statistically significant relationship emerges between the variables at a specified level of significance, the null hypothesis is rejected. Rejection of the statistical hypothesis is equivalent to acceptance of the research hypothesis.

Directional versus nondirectional hypotheses Hypotheses can be formulated directionally or nondirectionally. A

directional hypothesis specifies the expected direction of the relationship between the independent and dependent variables. An example of a directional hypothesis is provided in a study by Parry and colleagues (2015) that investigated a novel noninvasive device to assess sympathetic nervous system functioning in patients with heart failure. The researchers hypothesized that participants with heart failure reduced ejection fraction (HFrEF), who have internal cardiac defibrillators or CRT pacemakers, will have a decrease in pre-ejection period (reflective of increased sympathetic nervous system activity) and decrease in left ventricular ejection time (reflective of an increased heart rate) with a postural change from sitting to standing.

In contrast, a nondirectional hypothesis indicates the existence of a relationship between the variables, but does not specify the anticipated direction of the relationship. Example: ➤ Rattanawiboon and colleagues (2016) evaluated the effectiveness of fluoride mouthwash delivery methods, swish, spray, or swab application, in raising salivary fluoride in comparison to conventional fluoride mouthwash, but did not predict which form of fluoride delivery would be most effective. Nurses who are learning to critically appraise research studies should be aware that both the directional and the nondirectional forms of hypothesis statements are acceptable.

Relationship between the hypothesis and the research design Regardless of whether the researcher uses a statistical or a research hypothesis, there is a suggested relationship between the hypothesis, the design of the study, and the level of evidence provided by the results of the study. The type of design, experimental or nonexperimental (see Chapters 9 and 10), will influence the wording of the hypothesis. Example: ➤ When an experimental design is used, you would expect to see hypotheses that reflect relationship statements, such as the following:

• X1 is more effective than X2 on Y.

• The effect of X1 on Y is greater than that of X2 on Y.

• The incidence of Y will not differ in subjects receiving X1 and X2 treatments.

• The incidence of Y will be greater in subjects after X1 than after X2.

EVIDENCE-BASED PRACTICE TIP Think about the relationship between the wording of the hypothesis, the type of research design suggested, and the level of evidence provided by the findings of a study using each kind of hypothesis. You may want to consider which type of hypothesis potentially will yield the strongest results applicable to practice.

Hypotheses reflecting experimental designs also test the effect of the experimental treatment (i.e., independent variable X) on the outcome (i.e., dependent variable Y). This suggests that the strength of the evidence provided by the results is Level II (experimental design) or Level III (quasi-experimental design).

In contrast, hypotheses related to nonexperimental designs reflect associative relationship statements, such as the following:

• X will be negatively related to Y.

• There will be a positive relationship between X and Y.

This suggests that the strength of the evidence provided by the results of a study that examined hypotheses with associative relationship statements would be at Level IV (nonexperimental design).

Table 2.6 provides an example of this concept. The Critical Thinking Decision Path will help you determine the type of hypothesis or research question presented in a study.

TABLE 2.6 Elements of a Clinical Question

CAUTIs, Catheter acquired urinary tract infections.

CRITICAL THINKING DECISION PATH Determining the Use of a Hypothesis or Research Question

Developing and refining a clinical question: A consumer’s perspective Practicing nurses, as well as students, are challenged to keep their practice up to date by searching for, retrieving, and critiquing

research articles that apply to practice issues that are encountered in their clinical setting (see Chapter 20). Practitioners strive to use the current best evidence from research when making clinical and health care decisions. As research consumers, you are not conducting research studies; however, your search for information from clinical practice is converted into focused, structured clinical questions that are the foundation of evidence-based practice and quality improvement projects. Clinical questions often arise from clinical situations for which there are no ready answers. You have probably had the experience of asking, “What is the most effective treatment for . . . ?” or “Why do we still do it this way?”

Using similar criteria related to framing a research question, focused clinical questions form a basis for searching the literature to identify supporting evidence from research. Clinical questions have four components:

• Population

• Intervention

• Comparison

• Outcome

These components, known as PICO, provide an effective format for helping nurses develop searchable clinical questions. Box 2.2 presents each component of the clinical question. BOX 2.2 Components of a Clinical Question Using the PICO Format Population: The individual patient or group of patients with a particular condition or health care problem (e.g., adolescents age 13–18 with type 1 insulin-dependent diabetes)

Intervention: The particular aspect of health care that is of interest to the nurse or the health team (e.g., a therapeutic [inhaler or nebulizer for treatment of asthma], a preventive [pneumonia vaccine], a diagnostic [measurement of blood pressure], or an organizational [implementation of a bar coding system to reduce

medication errors] intervention) Comparison intervention: Standard care or no intervention (e.g.,

antibiotic in comparison to ibuprofen for children with otitis media); a comparison of two treatment settings (e.g., rehabilitation center vs. home care)

Outcome: More effective outcome (e.g., improved glycemic control, decreased hospitalizations, decreased medication errors)

The significance of the clinical question becomes obvious as research evidence from the literature is critically appraised. Research evidence is used together with clinical expertise and the patient’s perspective to confirm, develop, or revise nursing standards, protocols, and policies that are used to plan and implement patient care (Cullum, 2000; Sackett et al., 2000; Thompson et al., 2004). Issues or questions can arise from multiple clinical and managerial situations. Using the example of catheter acquired urinary tract infections (CAUTIs), a team of staff nurses working on a medical unit in an acute care setting were reviewing their unit’s quarterly quality improvement data and observed that the number of CAUTIs had increased by 25% over the past 3 months. The nursing staff reviewed the unit’s standard of care and noted that although nurses were able to discontinue an indwelling catheter, according to a set of criteria and without a physician order, catheters were remaining in place for what they thought was too long and potentially contributing to an increase in the prevalence of CAUTIs. To focus the nursing staff’s search of the literature, they developed the following question: Does the use of daily nurse-led catheter rounds in hospitalized older adults with indwelling urinary catheters lead to a decrease in CAUTIs? Sometimes it is helpful for nurses who develop clinical questions from a quality improvement perspective to consider three elements as they frame their focused question: (1) the situation, (2) the intervention, and (3) the outcome.

• The situation is the patient or problem being addressed. This can be a single patient or a group of patients with a particular health problem (e.g., hospitalized adults with indwelling urinary catheters).

• The intervention is the dimension of health care interest, and often asks whether a particular intervention is a useful treatment (e.g., daily nurse-led catheter rounds).

• The outcome addresses the effect of the treatment (e.g., intervention) for this patient or patient population in terms of quality and cost (e.g., decreased CAUTIs). It essentially answers whether the intervention makes a difference for the patient population.

The individual parts of the question are vital pieces of information to remember when it comes to searching for evidence in the literature. One of the easiest ways to do this is to use a table, as illustrated in Table 2.6. Examples of clinical questions are highlighted in Box 2.3. Chapter 3 provides examples of how to effectively search the literature to find answers to questions posed by researchers and research consumers. BOX 2.3 Examples of Clinical Questions

• Does using a Discharge Bundle combined with Teachback Methodology reduce pediatric readmissions? (Shermont et al., 2016)

• What is the most effective IV insulin practice guideline for cardiac surgery patients? (Westbrook et al., 2016)

• Does using a structured content and electronic nursing handover reduce patient clinical management errors? (Johnson et al., 2016)

• What is the impact of nursing teamwork on nurse-sensitive quality indicators? (Rahn, 2016)

• Do PCMH access and care coordination measures reflect the contributions of all team members? (Annis et al., 2016)

• Is a patient-family-staff partnership video the most effective approach for preventing falls in hospitalized patients? (Silkworth et al., 2016)

• What is the impact of prompt nutrition care on patient outcomes and health care costs? (Meehan et al., 2016)

PCMH, Patient-centered medical home.

EVIDENCE-BASED PRACTICE TIP You should be formulating clinical questions that arise from your clinical practice. Once you have developed a focused clinical question using the PICO format, you will search the literature for the best available evidence to answer your clinical question.

Appraisal for evidence-based practice the research question and hypothesis When you begin to critically appraise a research study, consider the care the researcher takes when developing the research question or hypothesis; it is often representative of the overall conceptualization and design of the study. In a quantitative research study, the remainder of a study revolves around answering the research question or testing the hypothesis. In a qualitative research study, the objective is to answer the research question. Because this text focuses on you as a research consumer, the following sections will primarily pertain to the evaluation of research questions and hypotheses in published research reports.

Critiquing the research question and hypothesis The following Critical Appraisal Criteria box provides several criteria for evaluating the initial phase of the research process—the research question or hypothesis. Because the research question or hypothesis guides the study, it is usually introduced at the beginning of the research report to indicate the focus and direction of the study. You can then evaluate whether the rest of the study logically flows from its foundation—the research question or hypothesis. The author will often begin by identifying the background and significance of the issue that led to crystallizing development of the research question or hypothesis. The clinical and scientific background and/or significance will be summarized,

and the purpose, aim, or objective of the study is then identified. Often the research question or hypothesis will be proposed

before or after the literature review. Sometimes you will find that the research question or hypothesis is not specifically stated. In some cases, it is only hinted at or is embedded in the purpose statement, and you are challenged to identify the research question or hypothesis. In other cases, the research question is embedded in the findings toward the end of the article. To some extent, this depends on the style of the journal.

Although a hypothesis can legitimately be nondirectional, it is preferable, and more common, for the researcher to indicate the direction of the relationship between the variables in the hypothesis. Quantifiable words such as “greater than,” “less than,” “decrease,” “increase,” and “positively,” “negatively,” or “related” convey the idea of objectivity and testability. You should immediately be suspicious of hypotheses or research questions that are not stated objectively. You will find that when there is a lack of data available for the literature review (i.e., the researcher has chosen to study a relatively undefined area of interest), a nondirectional hypothesis or research question may be appropriate.

You should recognize that how the proposed relationship of the hypothesis or research question is phrased suggests the type of research design that will be appropriate for the study, as well as the level of evidence to be derived from the findings. Example: ➤ If a hypothesis proposes that treatment X1 will have a greater effect on Y than treatment X2, an experimental (Level II evidence) or quasi- experimental design (Level III evidence) is suggested (see Chapter 9). If a research question asks if there will be a positive relationship between variables X and Y, a nonexperimental design (Level IV evidence) is suggested (see Chapter10).

Hypotheses and research questions are never proven beyond the shadow of a doubt. Researchers who claim that their data have “proven” the validity of their hypothesis or research question should be regarded with grave reservation. You should realize that, at best, findings that support a hypothesis or research question are considered tentative. If repeated replication of a study yields the same results, more confidence can be placed in the conclusions advanced by the researchers.

When critically appraising clinical questions, think about the fact that the clinical question should be focused and specify the patient population or clinical problem being addressed, the intervention, and the outcome for a particular patient population. There should be evidence that the clinical question guided the literature search and that appropriate types of research studies are retrieved in terms of the study design and level of evidence needed to answer the clinical question.

CRITICAL APPRAISAL CRITERIA Developing Research Questions and Hypotheses The research question

1. Does the research question express a relationship between two or more variables, or at least between an independent and a dependent variable, implying empirical testability?

2. How does the research question specify the nature of the population being studied?

3. How has the research question been supported with adequate experiential and scientific background material?

4. How has the research question been placed within the context of an appropriate theoretical framework?

5. How has the significance of the research question been identified?

6. Have pragmatic issues, such as feasibility, been addressed?

7. How have the purpose, aims, or goals of the study been identified?

The hypothesis

1. Is the hypothesis concisely stated in a declarative form?

2. Are the independent and dependent variables identified in the

statement of the hypothesis?

3. Is each hypothesis specific to one relationship so that each hypothesis can be either supported or not supported?

4. Is the hypothesis stated in such a way that it is testable?

5. Is the hypothesis stated objectively, without value-laden words?

6. Is the direction of the relationship in each hypothesis clearly stated?

7. How is each hypothesis consistent with the literature review?

8. How is the theoretical rationale for the hypothesis made explicit?

9. Given the level of evidence suggested by the research question, hypothesis, and design, what is the potential applicability to practice?

The clinical question

1. Does the clinical question specify the patient population, intervention, comparison intervention, and outcome?

2. Does the clinical question address an outcome applicable to practice?

Key points • Developing the research question and stating the hypothesis are

key preliminary steps in the research process.

• The research question is refined through a process that proceeds from the identification of a general idea of interest to the definition of a more specific and circumscribed topic.

• A preliminary literature review reveals related factors that appear critical to the research topic of interest and helps further define the research question.

• The significance of the research question must be identified in terms of its potential contribution to patients, nurses, the medical community in general, and society. Applicability of the question for nursing practice, as well as its theoretical relevance, must be established. The findings should also have the potential for formulating or altering nursing practices or policies.

• The final research question is a statement about the relationship of two or more variables. It clearly identifies the relationship between the independent and dependent variables, specifies the nature of the population being studied, and implies the possibility of empirical testing.

• Research questions that are nondirectional may be used in exploratory, descriptive, or qualitative research studies.

• Research questions can be directional, depending on the type of study design being used.

• Focused clinical questions arise from clinical practice and guide the literature search for the best available evidence to answer the clinical question.

• A hypothesis is a declarative statement about the relationship between two or more variables that predicts an expected outcome. Characteristics of a hypothesis include a relationship statement, implications regarding testability, and consistency with a defined theory base.

• Hypotheses can be formulated in a directional or a nondirectional manner and be further categorized as either research or statistical hypotheses.

• The purpose, research question, or hypothesis provides information about the intent of the research question and hypothesis and suggests the level of evidence to be obtained from the study findings.

• The interrelatedness of the research question or hypothesis and the literature review and the theoretical framework should be

apparent.

• The appropriateness of the research design suggested by the research question or hypothesis is also evaluated.

Critical thinking challenges • Discuss how the wording of a research question or hypothesis

suggests the type of research design and level of evidence that will be provided.

• Using the study by Hawthorne, Youngblut, and Brooten (2016) (see Appendix B), describe how the background, significance, and purpose of the study are linked to the research questions.

• The prevalence of catheter acquired urinary infections (CAUTIs) has increased on your hospital unit by 10% in the last two quarters. As a member of the Quality Improvement (QI) Committee on your unit, collaborate with your committee colleagues from other professions to develop an interprofessional action plan. Deliberate to develop a clinical question to guide the QI project.

• A nurse is in charge of discharge planning for frail older adults with congestive heart failure. The goal of the program is to promote self-care and prevent rehospitalizations. Using the PICO approach, the nurse wants to develop a clinical question for an evidence-based practice project to evaluate the effectiveness of discharge planning for this patient population. How can the nurse accomplish that objective?

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

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22. Stoddard S.A, Varela J.J, Zimmerman M. Future expectations, attitude toward violence, and bullying perpetration during adolescence A mediation evaluation. Nursing Research 2015;64(6):422-433.

23. Thabault P.J, Burke P.J, Ades P.A. Intensive behavioral treatment weight loss program in an adult primary care practice. Journal of the American Association of Nurse Practitioners 2015;28:249-257.

24. Thompson C, Cullum N, McCaughan D, et al. Nurses, information use, and clinical decision-making The real world potential for evidence-based decisions in nursing. Evidence- Based Nursing 2004;7(3):68-72.

25. Traeger L, McDonnell T.M, McCarty C.E, et al. Nursing

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intervention to enhance outpatient chemotherapy symptom management Patient-reported outcomes of a randomized controlled trial. Cancer Nursing 2015;121(21):3905-3913.

26. Turner-Sack A.M, Menna R, Setchell S.R, et al. Psychological functioning, post-traumatic growth, and coping in parents and siblings of adolescent cancer survivors. Oncology Nursing Forum 2016;43(1):48-56.

27. Westbrook A, Sherry D, McDermott M, et al. Examining IV insulin practice guidelines Nurses evaluating quality outcomes. Journal of Nursing Care Quality 2016;31(4):344-349.

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CHAPTER 3

Gathering and appraising the literature Barbara Krainovich-Miller

Learning outcomes

After reading this chapter, you should be able to do the following:

• Discuss the purpose of a literature review in a research study. • Discuss the purpose of reviewing the literature for an evidence- based and quality improvement (QI) project. • Differentiate the purposes of a literature review from the evidence- based practice and the research perspective. • Differentiate between primary and secondary sources. • Differentiate between systematic reviews/meta-analyses and preappraised synopses. • Discuss the purpose of reviewing the literature for developing evidence-based practice and QI projects. • Use the PICO format to guide a search of the literature. • Conduct an effective search of the literature.

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• Apply critical appraisal criteria for the evaluation of literature reviews in research studies.

KEY TERMS

Boolean operator

citation management software

controlled vocabulary

electronic databases

electronic search

Grey literature

literature review

preappraised synopses

primary source

refereed, or peer-reviewed, journals

secondary source

web browser

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

You may wonder why an entire chapter of a research text is devoted to gathering and appraising the literature. The main reason is because searching for, retrieving, and critically appraising the literature is a key step for researchers and for practitioners who are basing their practice on evidence. Searching for, retrieving, critically appraising, and synthesizing research evidence is essential to support an evidence-based practice (EBP). A question you might ask is, “Will knowing more about how to search efficiently and critically appraise research really help me as a student and as a practicing nurse?” The answer is, “Yes, it most certainly will!” Your

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ability to locate, retrieve, critically appraise, and synthesize research articles will enable you to determine whether or not you have the best available evidence to inform your clinical practice (CP).

The critical appraisal of research studies is an organized, systematic approach to evaluating a research study or group of studies using a set of standardized critical appraisal criteria. The criteria are used to objectively determine the strength, quality, quantity, and consistency of evidence provided by the available literature to determine its applicability to practice, policy, and education (see Chapters 7, 11, and 18).

The purpose of this chapter is to introduce you to how to evaluate the literature review in a research study and how to critically appraise a group of studies for EBP and quality improvement (QI) projects. This chapter provides you with the tools to (1) locate, search, and retrieve individual research studies, systematic reviews/meta-analyses, and meta-syntheses (see Chapters 6, 9, 10, and 11), and other documents (e.g., CP guidelines); (2) differentiate between a research article and a theoretical/conceptual article or book; (3) critically appraise a research study or group of research studies; and (4) differentiate between a research article and a conceptual article or book. These tools will help you develop your competencies to develop EBP and develop QI projects.

Review of the literature The literature review: The researcher’s perspective The overall purpose of the literature review in a study is to present a systematic state of the science (i.e., what research exists) on a topic. In Box 3.1, Objectives 1 to 8 and 11 present the main purposes of a literature review found in a research article. In a published study, the literature review generally appears near the beginning of the report and may or may not be labeled. It provides an abbreviated version of the literature review conducted by a researcher and represents the building blocks, or framework, of the study. Keep in mind that researchers are constrained by page limitations and so do not expect to see a comprehensive literature

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review in an article. The researcher must present in a succinct manner an overview and critical appraisal of the literature on a topic in order to generate research questions or hypotheses. A literature review is essential to all steps of the quantitative and qualitative research process, and is a broad, systematic critical review and evaluation of the literature in an area. BOX 3.1 Overall Purposes of a Literature Review Major goal To develop a strong knowledge base to conduct a research study or implement an evidence-based practice/QI project (1–3, 8–11) and carry out research (1–6, 11).

Objectives A review of the literature supports the following:

1. Determine what is known and unknown about a subject, concept, or problem.

2. Determine gaps, consistencies, and inconsistencies in the literature about a subject, concept, or problem.

3. Synthesize the strengths and weaknesses of available studies to determine the state of the science on a topic/problem.

4. Describe the theoretical/conceptual frameworks that guide a study.

5. Determine the need for replication or refinement of a study.

6. Generate research questions and hypotheses.

7. Determine an appropriate research design, methodology, and analysis for a study.

8. Provide information to discuss the findings of a study, draw conclusions, and make recommendations for future research, practice, education, and/or policy changes.

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9. Uncover a new practice intervention(s) or gain supporting evidence for revising, maintaining current intervention(s), protocols, and policies, or developing new ones.

10. Generate clinical questions that guide development of EBP/QI projects, policies, and protocols.

11. Identify recommendations from the conclusion for future research, practice, education, and/or policy actions.

QI, Quality improvement.

The following overview about use of the literature review in relation to the steps of the quantitative and qualitative research process will help you understand the researcher’s focus. In quantitative studies, the literature review is at the beginning of the published research articles, and may or may not be titled literature review (see Appendix A, B, C, and D). As you read the selected research articles found in the appendices, you will see that none of these reports have a section titled Literature Review. But each has a literature review at the beginning of the article. Example: ➤ van Dijk and colleagues (2016) labeled this beginning section with the title Introduction (see Appendix C). Hawthorne and colleagues (2016), after a brief introduction about their topic, used sublevel headings for two major concepts of their review and then provided a sublevel heading to introduce their Conceptual Framework (see Appendix B). Appendix A’s study by Nyamathi and colleagues (2015), after presenting their nonlabeled literature review, also provided a sublevel heading labeled “Theoretical Framework.”

A review of the relevant literature found in a quantitative study (Fig. 3.1) is valuable, as it provides the following:

• Theoretical or conceptual framework

• Identifies concepts/theories used as a guide or map for developing research questions or hypotheses

• Suggests the presumed relationship between the

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independent and dependent variables

• Provides a rationale and definition for the variable(s) and concepts studied (see Chapters 1 and 2)

• Primary and secondary sources

• Provides the researcher with a road map for designing the study

• Includes primary sources, which are research articles, theoretical documents, or other documents used by the author(s) who is conducting the study, developing a theory, or writing an autobiography

• Includes secondary sources, which are published articles or books written by persons other than the individual who conducted the research study or developed the theory. Table 3.1 provides definitions and examples of primary and secondary sources.

• Research question and hypothesis

• Helps the researcher identify completed studies about the research topic of interest, including gaps or inconsistencies that suggest potential research questions or hypotheses about a subject, theory, or problem

• Design and method

• Helps the researcher choose the appropriate design,

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sampling strategy, data collection methods, setting, measurement instruments, and data analysis method. Journal space guidelines limit researchers to include only abbreviated information about these areas

• Data analysis, discussion, conclusions, implications, recommendations

• Helps the researcher interpret, discuss, and explain the study results/findings

• Provides an opportunity for the researcher to return to the literature review and selects relevant studies to inform the discussion of the findings, conclusions, limitations, and recommendations. Example: ➤ Turner-Sack and colleagues’ (2016) discussion section noted several times how their findings were similar to previous studies (Appendix D)

• Useful when considering implications of research findings and making practice, education, and recommendations for practice, education, and research

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FIG 3.1 Relationship of the review of the literature to

the steps of the quantitative research process.

TABLE 3.1 Examples of Primary and Secondary Sources

Primary: Essential Secondary: Useful Publications written by the person(s) who conducted the study or developed the theory/conceptual model.

Publications written by a person(s) other than the person who conducted the study or developed the theory or model. It usually appears as a summary/critique of another author’s original work (research study, theory, or model); may appear in a study as the theoretical/conceptual framework, or paraphrased theory of the theorist.

Eyewitness accounts of historic events, autobiographies, oral histories, diaries, films, letters, artifacts, periodicals, and Internet communications on e-mail, Listservs, interviews, e- photographs, and audio/video recordings.

A biography or clinical article that cites original author’s work.

Can be published or unpublished. Can be published or unpublished. A published research study (e.g., research articles in ).

An edited textbook (e.g., LoBiondo-Wood, G., & Haber, J. [2018]. Nursing research: Methods and critical appraisal for evidence-based practice [9th ed.], Elsevier).

Theory example: Dr. Jeffries in collaboration with the National League for Nursing developed and published a monograph entitled, The NLN Jeffries Simulation Theory (2015).

Theoretical framework example: Nyamathi and colleague’s 2015 study used “comprehensive health seeking and coping paradigm” theoretical framework by Nyamathi (1989), which Nyamathi adopted from Lazarus and Folkman’s (1984) “coping model” and Schlotfeldt’s (1981) “health seeking and coping paradigm” (see study presented in Appendix A).

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HINT: Critical appraisal of primary sources is essential to a thorough and relevant literature review.

HINT: Use secondary sources sparingly; however, secondary sources, especially a study’s literature review that presents a critique of studies, are a valuable learning tool from an EBP perspective.

In contrast to the styles of quantitative studies, literature reviews of qualitative studies are usually handled differently (see Chapters 5 to 7). In qualitative studies, often little is known about the topic under study, and thus the literature review may appear more abbreviated than in a quantitative study. However, qualitative researchers use the literature review in the same manner as quantitative researchers to interpret and discuss the study findings, draw conclusions, identify limitations, and suggest recommendations for future study.

Conducting a literature review: The EBP perspective The purpose of the literature review, from an EBP perspective, focuses on the critical appraisal of research studies, systematic reviews, CP guidelines, and other relevant documents. The literature review informs the development and/or refinement of the clinical question that will guide an EBP or QI project. When a clinical problem is identified, nurses and other team members collaborate to identify a clinical question using the PICO format (Yensen, 2013; see Chapter 2).

Once your clinical question is formulated, you will need to conduct a search in electronic database(s) (you may seek the help of a librarian) to gather and critically appraise relevant studies, and synthesize the strengths and weaknesses of the studies to determine if this is the “best available” evidence to answer your clinical question. Objectives 1 to 3 and 7 to 10 in Box 3.1 specifically reflect the purposes of a literature review for these projects.

A clear and precise articulation of a clinical question is critical to finding the best evidence. Clinical questions may sound like research questions, but they are questions used to search the literature for evidence-based answers, not to test research questions or hypotheses (see Chapter 2). The PICO format is as follows:

P Problem/patient population—What is the specifically defined group?

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I Intervention—What intervention or event will be used to address the problem or population?

C Comparison—How does the intervention compare to current standards of care or another intervention?

O Outcome—What is the effect of the proposed or comparison intervention?

One group of students was interested in whether regular exercise prevented osteoporosis for postmenopausal women who had osteopenia. The PICO format for the clinical question that guided their search was as follows:

P Postmenopausal women with osteopenia (Age is part of the definition for this population.)

I Regular exercise program (How often is regular? Weekly? Twice a week?)

C No regular exercise program (comparing outcomes of regular exercise [I] and no regular exercise [C])

O Prevention of osteoporosis (How and when was this measured?)

These students’ assignment to answer the PICO question requires the following:

• Search the literature using electronic databases (e.g., Cumulative Index to Nursing and Allied Health Literature [CINAHL via EBSCO], MEDLINE, and Cochrane Database of Systematic Reviews) for the information to identify the significance of osteopenia and osteoporosis as a women’s health problem.

• Identify systematic reviews, practice guidelines, and research studies that provide the “best available evidence” related to the effectiveness of regular exercise programs for prevention of osteoporosis.

• Critically appraise information gathered using standardized

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critical appraisal criteria and tools (see Chapters 7, 11, 18, 19, and 20).

• Synthesize the overall strengths and weaknesses of the evidence provided by the literature.

• Draw a conclusion about the strength, quality, and consistency of the evidence.

• Make recommendations about applicability of evidence to CP to guide development of a health promotion project about osteoporosis risk reduction for postmenopausal women with osteopenia.

As a practicing nurse, you may be asked to work with colleagues to develop or create an EBP/QI project and/or to update current EBP protocols, CP standards/guidelines, or policies in your health care organization using the best available evidence. This will require that you know how to retrieve and critically appraise individual research articles, practice guidelines, and systematic reviews to determine each study’s overall quality and then to determine if there is sufficient support (evidence) to change a current practice and/or policy or guideline.

HELPFUL HINT Hunting for a quantitative study’s literature review? Don’t expect to find it labeled as Literature Review—many are not. Assume that the beginning paragraphs of the article comprise the literature review; the length and style will vary.

EVIDENCE-BASED PRACTICE TIPS

• Formulating a clinical question using the PICO format provides a focus that will guide an efficient electronic literature search.

• Remember, the findings of one study on a topic do not provide sufficient evidence to support a change in practice.

• The ability to critically appraise and synthesize the literature is

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essential to acquiring skills for making successful presentations, as well as participating in EBP/QI projects.

Searching for evidence Students often state, “I know how to do research; why I need to go see the librarian?” Perhaps you have thought the same thing because you too have “researched” a topic for many of your course requirements. However, it would be more accurate for you to say that you have “searched” the literature to uncover research studies and conceptual information to prepare an academic paper on a topic. During this process, you search for primary sources and secondary sources. It is best to use a primary source when available. Table 3.1 provides definitions and examples of primary and secondary sources, and Table 3.2 identifies the steps and strategies for conducting an efficient literature search. Table 3.3 indicates recommended databases. The top two, CINAHL Plus with full text and PubMed (MEDLINE), are always a must. There are multiple databases that health science libraries offer, and most offer online tutorials for how to use each database. Using the CINAHL Plus and PubMed databases and at least one additional resource database is recommended. Example: ➤ If your topic is about changing a patient’s behavior, such as promoting smoking cessation or increasing weight-bearing exercises, you would use the top two as well as PsycINFO. Another recommendation if your clinical question focuses on interventions is to use the Cochrane Library (http://www.cochranelibrary.com), which has full text systematic reviews as well as an extensive list of randomized control trials (RCTs) and other sources of studies.

TABLE 3.2 Steps and Strategies for Conducting a Literature Search: An EBP Perspective

Steps of Literature Review

Strategy

Step I: Determine clinical

Focus on the types of patients (population) of interest.

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http://www.cochranelibrary.com

question or research topic.

If the goal is to develop an EBP project, start with a PICO question. If the goal is to develop a research study, a researcher starts with a broad review of the literature to refine the research question or hypothesis (see Chapter 2).

Step II: Identify key variables/terms.

Review your library’s online Help and Tutorial modules related to conducting a search, including the use of each databases’ vocabulary, prior to meeting with your librarian for help. Make sure you have your PICO format completed so the librarian can help you limit the research articles that fit the parameters of your PICO question. If, after reviewing tutorials on Boolean connectors “AND, OR, and NOT” that connect your search terms when using a specific database, you don’t understand the use of these connectors, clarify with a librarian.

Step III: Conduct electronic search using at least two, preferably three if needed for your topic, recognized electronic databases.

Conduct the search, and make a decision regarding which databases, in addition to CINAHL PLUS with Full Text via EBSCO and MEDLINE via Ovid, you should search; use key mesh terms and Boolean logic (AND, OR, NOT) to address your clinical question.

Step IV: Review abstracts online and weed out irrelevant articles.

Scan through your retrieved articles, read the abstracts, mark only those that fit the topic and are research; select “references” as well as “search history” and “full-text articles” if available, before printing and saving or e-mailing your search.

Step V: Retrieve relevant sources.

Organize by type or study design and year and reread the abstracts to determine if the articles chosen are relevant research to your topic and worth retrieving.

Step VI: Store or print relevant articles; if unable to print directly from the database, order through interlibrary loan.

Download the search to a web-based bibliography and database manager/writing and collaboration tool (e.g., RefWorks, EndNote); most academic institutions have “free” management tools, such as Zotero. Using a system will ensure that you have the information for each citation (e.g., journal name, year, volume number, pages), and it will format the reference list. Download PDF versions of articles as needed.

Step VII: Conduct preliminary reading; eliminate irrelevant sources.

First read each abstract to assess if the article is relevant.

Step VIII: Critically read each source (summarize and critique each source).

Use critical appraisal strategies (e.g., use an evidence table [see Chapter 20] or a standardized critiquing tool) to summarize and critique each articles; include references in APA format.

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Step IX: Synthesize critical summaries of each article.

Decide how you will present the synthesis of overall strengths and weaknesses of the reviewed research articles (e.g., present chronologically or according to the designs); thus, the reader can review the evidence. Compare and contrast the studies in terms of the research process steps, so you conclude with the overall similarities and differences between and among studies. In the end, summarize the findings of the review—that is, determine if the strengths of the group of studies outweigh the limitations in order to determine confidence in the findings and draw a conclusion about the state of the science. Include the reference list.

CINAHL, Cumulative Index to Nursing and Allied Health Literature.

TABLE 3.3 Databases for Nursing

Database Source CINAHAL PLUS with FULL TEXT (EBSCO)

Full text database for nursing and allied health widely used by nursing and health care—a useful starting point (Source: https://health.ebsco.com/products/cinahl- plus-with-full-text)

PubMed (MEDLINE)

Provides free access to MEDLINE, NLM’s database of citations and abstracts in medicine, nursing, dentistry, veterinary medicine, health care systems, and preclinical sciences, including full text (Source: https://www.nlm.nih.gov/bsd/pmresources.html)

PsycINFO Centered on psychology, behavioral, and social sciences; interdisciplinary content, one of the most widely used databases (Source: http://www.apa.org/pubs/databases/psycinfo/)

Education Source with ERIC (EBSCO)

The largest and most complete collection of full-text education journals. This database provides research and information to meet needs of students, professionals, and policy makers, covers all levels of education—from early childhood to higher education—as well as all educational specialties such as multilingual education, health education, and testing. (Source: https://www.ebscohost.com/academic/education-source)

CINAHL, Cumulative Index to Nursing and Allied Health Literature.

Sources of literature

Preappraised literature Preappraised literature is a secondary source of evidence, sometimes referred to as preappraised synopses, or simply synopses. Reading an expert’s comment about another author’s research can help develop your critical appraisal and synthesis skills. Some synopses include a commentary about the strength and applicability of the evidence to a patient population. It is important to keep in mind that there are limitations to using preappraised sources. These sources are useful for giving you a preview about

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https://health.ebsco.com/products/cinahl-plus-with-full-text

https://www.nlm.nih.gov/bsd/pmresources.html

http://www.apa.org/pubs/databases/psycinfo/

https://www.ebscohost.com/academic/education-source

the potential relevance of the publication to your clinical question and the strength of the evidence. You can then make a decision about whether to search for and critically appraise the primary source. Preappraised synopses can be found in journals such as Evidence-Based Nursing (http://ebn.bmj.com) and Evidence-Based Medicine (http://ebm.bmj.com) or the Joanna Briggs Institute (JBI) EBP Database (http://joannabriggs.org).

EVIDENCE-BASED PRACTICE TIP If you find a preappraised commentary on an individual study related to your PICO question, read the preappraised commentary first. As a beginner, this strategy will make it easier for you to pick out the strengths and weaknesses in the primary source study.

Primary sources When searching the literature, primary sources should be a search strategy priority. Review Table 3.1 to identify the differences between primary and secondary sources. Then, as noted in Step VIII of Table 3.2, strategies to conduct a literature search, you need to apply your critiquing skills to determine the quality of the primary source publications. Review Chapters 7, 11, and 18 so you can apply the critical appraisal criteria outlined in these chapters to your retrieved studies. Example: ➤ For your PICO question, you searched for and found two types of primary source publications. One primary source was a rigorous systematic review related to your clinical question that provided strong evidence to support your PICO comparison intervention, the current standard of care; you also found two poorly designed RCTs that provided weak evidence supporting your proposed intervention. Which primary source would you recommend? You would need to make an evidence-based decision about the applicability of the primary source evidence supporting or not supporting the proposed or comparison intervention. The well-designed systematic review provided the highest level of evidence (Level I on the Fig. 1.1 evidence hierarchy). It also provided strong evidence that supported continuation of the current standard of care in comparison to the weak evidence supporting the proposed intervention provided by two poorly designed RCTs (Level II on

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http://ebn.bmj.com

http://ebm.bmj.com

http://joannabriggs.org

the Fig. 1.1 evidence hierarchy). Your team would conclude that the primary source systematic review provided the strongest evidence supporting that the current standard of care be retained and recommended, and that there was insufficient evidence to recommend a practice change.

HELPFUL HINT

• If possible, consult a librarian before conducting your searches to determine which databases and keywords to use for your PICO question. Save your search history electronically.

• Learn how to use an online search management tool such as RefWorks, EndNote, or Zotero.

EVIDENCE-BASED PRACTICE TIP

• If you do not retrieve any studies from your search, review your PICO question and search strategies with a librarian.

• Every meta-analysis begins with a systematic review; however, not every systematic review results in a meta-analysis. Read Chapter 11 and find out why.

Performing an electronic search

Why use an electronic database? Perhaps you still are not convinced that electronic database searches are the best way to acquire information for a review of the literature. Maybe you have searched using Google or Yahoo! and found relevant information. This is an understandable temptation. Try to think about it from another perspective and ask yourself, “Is this the most appropriate and efficient way to find the latest and strongest research on a topic that affects patient care?” Yes, Google Scholar might retrieve some studies, but from an EBP perspective, you need to retrieve all the studies available on your topic/clinical question. The “I” and “C” of your PICO question require that you retrieve from your search all types of interventions, not just what

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you have proposed. To understand the literature in a specific area requires a review of all relevant studies. A way to decrease your frustration is to take the time to learn how to conduct an efficient database search by reviewing the steps presented in Table 3.2. Following these strategies and reviewing the Helpful Hints and EBP Tips provided in this chapter will help you gain the essential competencies needed for you to be successful in your search. The Critical Thinking Decision Path provides a means for locating evidence to support your clinical question (Kendall, 2008). Path shows a way to locate evidence to support your research or clinical question.

CRITICAL THINKING DECISION PATH

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Types of resources

Print and electronic indexes: Books and journals Most college/university libraries have management retrieval

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systems or databases to retrieve both print and online books, journals, videos, and other media items, scripts, monographs, conference proceedings, masters’ theses, doctoral dissertations, archival materials, and Grey literature (e.g., information produced by government, industry, health care organizations, and professional organizations in the form of committee reports and policy documents; dissertations are included in the Grey literature). Print indexes are useful for finding sources that have not been entered into online databases. Print resources such as the Grey literature are still necessary if a search requires materials not entered into a database before a certain year. Also, another source is the citations/reference lists from the articles you retrieved; often they contain studies not captured with your search.

Refereed journals A major portion of most literature reviews consist of journal articles. Journals are published in print and online. In contrast to textbooks, which take much longer to publish, journals are a ready source of the latest information on almost any subject. Therefore, journals are the preferred mode of communicating the latest theory or study results. You should use refereed or peer-reviewed journals as your first choice when looking for primary sources of theoretical, clinical, or research articles. A refereed or peer- reviewed journal has a panel of internal and external reviewers who review submitted manuscripts for possible publication. The external reviewers are drawn from a pool of nurse scholars and scholars from related disciplines who are experts in various specialties. In most cases, the reviews are “blind”; that is, the manuscript to be reviewed does not include the name of the author(s). The reviewers use a set of criteria to judge whether a manuscript meets the publication journal’s standards. These criteria are similar to what you will use to critically appraise the evidence you obtained in order to determine the strengths and weaknesses of a study (see Chapters 7 and 18). The credibility of a published research or theoretical/conceptual article is strengthened by the peer-review process.

Electronic: Bibliographic and abstract databases

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Electronic databases are used to find research and theoretical/conceptual articles on a variety of topics, including doctoral dissertations. Electronic databases contain bibliographic citation information such as the author name, title, journal, and indexed terms for each record. Libraries have lists of electronic databases, including the ones indicated in Table 3.3 and Table 3.4. Usually these include the abstract, and some have the full text of the article or links to the full text. If the full text is not available, look for other options such as the abstract to learn more about the article before requesting an interlibrary loan of the article. Reading the abstract (see Chapter 1) is a critical step of the process to determine if you need to retrieve the full text article through another mechanism. Use both CINAHL and MEDLINE electronic databases as well as a third database; this will facilitate all steps of critically reviewing the literature, especially identifying the gaps. Your college/university most likely enables you to access such databases electronically whether on campus or not.

TABLE 3.4 Selected Examples of Websites for Evidence-Based Practice

Website Scope Notes Virginia Henderson International Nursing Library (www.nursinglibrary.org)

Access to the Registry of Nursing Research database contains abstracts and the full text of research studies and conference papers

Offered without charge. Supported by Sigma Theta Tau International, Honor Society of Nursing.

National Guideline Clearinghouse (www.guidelines.gov)

Public resource for evidence- based CP guidelines

Offers a useful online feature of side-by-side comparison of guidelines and the ability to browse by disease/condition and treatment/intervention.

JBI (www.joannabriggs.org)

JBI is an international not-for- profit research and development center

Membership required for access. Recommended links worth reviewing, as well as descriptions on their levels of evidence and grading scale is provided.

TRIP (www.tripdatabase.com)

Content from free online resources, including synopses, guidelines, medical images, e- textbooks, and systematic reviews, organized under the TRIP search engine.

Site offers a wide sampling of available evidence and ability to filter by publication type—that is, evidence based synopses, systematic reviews, guidelines, textbooks, and research.

Agency for Health Research and Quality (www.ahrq.gov)

Evidence-based reports, statistical briefs, research findings and reports, and policy

Free source of government documents, searchable via PubMed.

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http://www.nursinglibrary.org

http://www.guidelines.gov

http://www.joannabriggs.org

http://www.tripdatabase.com

http://www.ahrq.gov

reports. Cochrane Collaboration (www. cochrane.org)

Access to abstracts from Cochrane Database of Systematic Reviews. Full text of reviews and access to databases that are part of the Cochrane Library. Information is high quality and useful for health care decision making. It is a powerful tool for enhancing health care knowledge and decision making.

Abstracts are free and can be browsed or searched; uses many databases in its reviews, including CINAHL via EBSCO and MEDLINE; some are primary sources (e.g., systematic reviews/meta-analyses); others (if commentaries of single studies) are a secondary source; important source for clinical evidence.

CP, Clinical practice; CINAHL, Cumulative Index to Nursing and Allied Health Literature; JBI, Joanna Briggs Institute; TRIP, Turning Research into Practice.

Electronic: Secondary or summary databases Some databases contain more than journal article information. These resources contain either summaries or synopses of studies, overviews of diseases or conditions, or a summary of the latest evidence to support a particular treatment. Table 3.4 provides a few examples.

Internet: Search engines You are probably familiar with accessing a web browser (e.g., Internet Explorer, Mozilla Firefox, Chrome, Safari) to conduct searches, and with using search engines such as Google or Google Scholar to find information. However, “surfing” the web is not a good use of your time when searching for scholarly literature. Table 3.4 indicates sources of online information; all are free except JBI. Most websites are not a primary source for research studies.

HELPFUL HINTS Be sure to discuss with your instructor regarding the use of theoretical/conceptual articles and other Grey literature in your EBP/QI project or a review of the literature paper.

Less common and less used sources of scholarly material are audio, video, personal communications (e.g., letters, telephone or in-person interviews), unpublished doctoral dissertations, masters’ theses, and conference proceedings.

EVIDENCE-BASED PRACTICE TIP

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http://www.cochrane.org

Reading systematic reviews, if available, on your clinical question/topic will enhance your ability to implement evidence- based nursing practice because they generally offer the strongest and most consistent level of evidence and can provide helpful search terms. A good first step for any question is to search the Cochrane Database of Systematic Reviews to see if someone has already completed a systematic review addressing your clinical question.

How far back must the search go? Students often ask questions such as, “How many articles do I need?”; “How much is enough?”; “How far back in the literature do I need to go?” When conducting a search, you should use a rigorous focused process or you may end up with hundreds or thousands of citations. Retrieving too many citations is usually a sign that there was something wrong with your search technique, or you may not have sufficiently narrowed your clinical question.

Each electronic database offers an explanation of its features; take the time and click on each icon and explore the explanations offered, because this will increase your confidence. Also, take advantages of tutorials offered to improve your search techniques. Keep in mind the types of articles you are retrieving. Many electronic resources allow you to limit your search to the article type (e.g., systematic reviews/meta-analyses, RCTs). Box 3.2 provides a number of features through which CINAHL Plus with Full Test allows you to choose and/or insert information so that your search can be targeted. BOX 3.2 Tips: Using Cumulative Index to Nursing and Allied Health Literature via EBSCO

• Locate CINAHL from your library’s home page. It may be located under databases, online resources, or nursing resources.

• In the Advanced Search, type in your keyword, subject heading, or phrase (e.g., maternal-fetal attachment, health behavior). Do not use complete sentences. (Ask your librarian for any tip sheets,

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or online tutorials or use the HELP feature in the database.)

• Before choosing “Search,” make sure you mark “Research Articles” to ensure that you have retrieved articles that are actually research.

• In the “Limit Your Results” section, you can limit by year, age group, clinical queries, and so on.

• Using the Boolean connector “AND” between each of the words of your PICO variables narrows your search—that is, it will exclude an article that doesn’t use both terms; using “OR” broadens your search.

• Once the search results appear, save them, review titles and abstracts online, export to your management system (e.g., RefWorks), and/or e-mail the results to yourself.

CINAHL, Cumulative Index to Nursing and Allied Health Literature.

When conducting a literature review for any purpose, there is always a question of how far back one should search. There is no general time period. But if in your search you find a well-done meta-analysis that was published 6 years ago, you could continue your search, moving forward from that time period. Some research and EBP projects may warrant going back 10 or more years. Extensive literature reviews on particular topics or a concept clarification helps you limit the length of your search.

As you scroll through and mark the citations you wish to include in your downloaded or printed search, make sure you include all relevant fields when you save or print. In addition to indicating which citations you want and choosing which fields, there is an opportunity to indicate if you want the “search history” included. It is always a good idea to include this information. It is especially helpful if you feel that some citations were missed; then you can replicate your search and determine which variable(s) you missed. This is also your opportunity to indicate if you want to e-mail the search to yourself. If you are writing a paper and need to develop a reference list, you can export your citations to citation management

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software, which formats and stores your citations so that they are available for electronic retrieval when they are needed for a paper. Quite a few of these software programs are available; some are free, such as Zotero, and others your institution has most likely purchased, including EndNote and RefWorks.

HELPFUL HINT Ask your faculty for guidance if you are uncertain how far back you need to conduct your search. If you come across a systematic review/meta-analysis on your specific topic, review it to see what years the review covers; then begin your search from the last year of the studies included in the review and conduct your search from that year forward to the present to fill in the gap.

EVIDENCE-BASED PRACTICE TIP You will be tempted to use Google, Google Scholar, or even Wikipedia instead of going through Steps I through III of Table 3.2 and using the databases suggested, but this will most likely result in thousands of citations that aren’t classified as research and are not specific to your PICO question. Instead, use the specific parameters of your electronic database.

What do I need to know? Each database usually has a specific search guide that provides information on the organization of the entries and the terminology used. Academic and health science libraries continually update their websites in order to provide tutorials, guides, and tips for those who are using their databases. The strategies in Table 3.2 incorporate general search strategies, as well as those related to CINAHL and MEDLINE. Finding the right terms to “plug in” as keywords for a computer search is important for conducting an efficient search. In many electronic databases you can browse the controlled vocabulary terms and see how the terms of your question match up and then add them before you search. If you encounter a problem, ask your librarian for assistance.

HELPFUL HINT One way to discover new terms for searching is to find a systematic

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review that includes the search strategy. Match your PICO words with the controlled vocabulary terms of each database.

In CINAHL the Full Text via EBSCO host provides you with the option of conducting a basic or advanced search using the controlled vocabulary of CINAHL headings. This user-friendly feature has a built-in tutorial that reviews how to use this option. You also can click on the “Help” feature at any time during your search. It is recommended that you conduct an Advanced Search with a Guided Style tutorial that outlines the steps for conducing your search. If you wanted to locate articles about maternal-fetal attachment as they relate to the health practices or health behaviors of low-income mothers, you would first want to construct your PICO:

P Maternal-fetal attachment in low-income mothers (specifically defined group)

I Health behaviors or health practices (event to be studied)

C None (comparison of intervention)

O Neonatal outcomes (outcome)

In this example, the two main concepts are maternal-fetal attachment and health practices and how these impact neonatal outcomes. Many times when conducting a search, you only enter in keywords or controlled vocabulary for the first two elements of your PICO—in this case, maternal-fetal attachment and health practices or behaviors. The other elements can be added if your list of results is overwhelming (review the Critical Thinking Decision Path).

Maternal-fetal attachment should be part of your keyword search; however, when you click the CINAHL heading, it indicates that you should use “prenatal bonding.” To be comprehensive, you should use the Boolean operator of “OR” to link these terms together. The second concept, of health practices OR health behavior, is accomplished in a similar manner. The subject heading or controlled vocabulary assigned by the indexers could be added

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in for completeness. Boolean operators are “AND,” “OR,” and “NOT,” and they dictate the relationship between words and concepts. Note that if you use “AND,” then this would require that both concepts be located within the same article, while “OR” allows you to group together like terms or synonyms, and “NOT” eliminates terms from your search. It is suggested that you limit your search to “peer-reviewed” and “research” articles. Refine the publication range date to 10 years, or whatever the requirement is for your search, and save your search. Once these limits were chosen for the PICO search related to maternal-fetal attachment described previously, the search results decreased from an unmanageable 294 articles to 6 research articles. The key to understanding how to use this process is to try the search yourself using the terms just described. Developing search skills takes time, even if you complete the library tutorials and meet with a librarian to refine your PICO question, search terms, and limits. You should search several databases. Library database websites are continually being updated, so it is important to get to know your library database site.

HELPFUL HINT When combining synonyms for a concept, use the Boolean operator “OR”—OR is more!

Review your library’s tutorials on conducting a search for each type database (e.g., CINAHL and MEDLINE).

Use features in your database such as “limit search to” and choose peer review journal, research article, date range, age group, and country (e.g., United States).

How do I complete the search? Once you are confident about your search strategies for identifying key articles, it is time to critically read what you have found. Critically reading research articles requires several readings and the use of critical appraisal criteria (see Chapters 1, 7, and 18). Do not be discouraged if all of the retrieved articles are not as useful as you first thought, even though you limited your search to “research.” This happens to even the most experienced searcher. If most of the articles you retrieved were not useful, be prepared to do another

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search, but before you do, discuss the search terms with your librarian and faculty. You may also want to add a fourth database. It is a good practice to always save your search history when conducting a search. It is very helpful if you provide a printout of the search you have completed when consulting with your librarian or faculty. Most likely your library will have the feature that allows you to save your search, and it can be retrieved during your meeting. In the example of maternal-fetal bonding and health behaviors in low-income women, the third database of choice may be PsycINFO (see Table 3.3).

HELPFUL HINT Read the abstract carefully to determine if it is a research article; you will usually see the use of headings such as “Methodology” and “Results” in research articles. It is also a good idea to review the reference list of the research articles you retrieved, as this strategy might uncover additional related articles you missed in your database search, and then you can retrieve them.

Literature review format: What to expect Becoming familiar with the format of a literature review in the various types of review articles and the literature review section of a research article will help you use critical appraisal criteria to evaluate the review. To decide which style you will use so that your review is presented in a logical and organized manner, you must consider:

• The research or clinical question/topic

• The number of retrieved sources reviewed

• The number and type of research versus theoretical/conceptual materials and/or Grey literature

Some reviews are written according to the variables or concepts being studied and presented chronologically under each variable. Others present the material chronologically with subcategories or variables discussed within each time period. Still others present the

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variables and include subcategories related to the study’s type or designs or related variables.

Hawthorne and colleagues (2016) (see Appendix B) stated that the purpose of their “longitudinal study was to test the relationships between spirituality/religious coping strategies and grief, mental health (depression and post-traumatic stress disorder), and mothers and fathers” at selected time periods after experiencing the death of an infant in the neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU). At the beginning of their article, after some basic overall facts on infant deaths and parents’ grieving, they logically presented the concepts they addressed in their quantitative study (see Appendix B). The researchers did not title the beginning of their article with a section labeled Literature Review. However, it is clear that the beginning of their article is a literature review. Example: ➤ After presenting general facts on infant deaths and parents grieving and related research, the authors title a section Use of Spirituality/Religion as a Coping Strategy and the next section Parent Mental Health and Personal Growth. In these sections they discuss studies related to each topic. Then, they present a section labeled Conceptual Framework, indicating that will use a specific grief framework to guide their study.

HIGHLIGHT Each member of your QI committee should be responsible for searching for one research study, using the agreed upon search terms and reviewing the abstract to determine its relevance to your QI project’s clinical question.

HELPFUL HINT The literature review for an EBP/QI project or another type of scholarly paper is different than one found in a research article.

Make an outline that will later become the level headings in your paper (i.e., title the concepts of your literature review). This is a good way to focus your writing and will let the reader know what to expect to read and demonstrate your logic and organization.

Include your search strategies so that a reader can re-create your search and come up with the same results. Include information on

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databases searched, time frame of studies chosen, search terms used, and any limits used to narrow the search.

Include any standardized tools used to critically appraise the retrieved literature.

Appraisal for evidence-based practice When writing a literature review for an EBP/QI project, you need to critically appraise all research reports using appropriate criteria. Once you have conducted your search and obtained all your references, you need to evaluate the articles using standardized critical appraisal criteria (see Chapters 7, 11, and 18). Using the criteria, you will be able to identify the strengths and weaknesses of each study.

Critiquing research or theoretical/conceptual reports is a challenging task for seasoned consumers of research, so do not be surprised if you feel a little intimidated by the prospect of critiquing and synthesizing research. The important issue is to determine the overall value of the literature review, including both research and theoretical/conceptual materials. The purposes of a literature review (see Box 3.1) and the characteristics of a well-written literature review (Box 3.3) provide the framework for evaluating the literature. BOX 3.3 Characteristics of a Well-Written Review of the Literature—An EBP Perspective Each reviewed source reflects critical thinking and writing and is relevant to the study/topic/project, and the content meets the following criteria:

• Uses mainly primary sources—that is, a sufficient number of research articles for answering a clinical question with a justification of the literature search dates and search terms used

• Organizes the literature review using a systematic approach

• Uses established critical appraisal criteria for specific study designs to evaluate strengths, weaknesses, conflicts, or gaps

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related to the PICO question

• Provides a synthesis and critique of the references indicating similarities, differences, strengths, and weaknesses between and among the studies

• Concludes with a summary that provides recommendations for practice and research

• In a table format, summarizes each article succinctly with references

The literature review should be presented in an organized manner. Theoretical/conceptual and research literature can be presented chronologically from earliest work of the theorist or first studies on a topic to most recent; sometimes the theoretical/conceptual literature that provided the foundation for the existing research will be presented first, followed by the research studies that were derived from this theoretical/conceptual base. Other times, the literature can be clustered by concepts, pro or con positions, or evidence that highlights differences in the theoretical/conceptual and/or research findings. The overall question to be answered from an EBP perspective is, “Does the review of the literature develop and present a knowledge base to provide sufficient evidence for an EBP/QI project?” Objectives 1 to 3, 5, 8, 10, and 11 in Box 3.1 specifically reflect the purposes of a literature review for EBP/QI project. Objectives 1 to 8 and 11 reflect the purposes of a literature review when conducting a research study.

Regardless of how the literature review is organized, it should provide a strong knowledge base for a CP or a research project. When a literature review ends with insufficient evidence, this provides a gap in knowledge and requires further research. The more you read published systematic and integrative reviews, as well as studies, the more competent you become at differentiating a well-organized literature review from one that has a limited organizing framework.

Another key to developing your competency in this area is to read both quantitative (meta-analyses) and qualitative (meta-

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syntheses) systematic reviews. A well-done meta-analysis adheres to the rigorous search, appraisal, and synthesis process for a group of like studies to answer a question and to meet the required guidelines, which include that it should be conducted by a team.

The systematic review on how nurses who lead clinics for patients with cardiovascular disease found in Appendix E is an example of a well-done quantitative systematic review that critically appraises and synthesizes the evidence from research studies related to the effect of the mortality and morbidity rates of patients with cardiovascular disease who are followed in nurse-led clinics.

The Critical Appraisal Criteria box summarizes general critical appraisal criteria for a review of the literature. Other sets of critical appraisal criteria may phrase these questions differently or more broadly. Example: ➤ “Does the literature search seem adequate?” “Does the report demonstrate scholarly writing?” These may seem to be difficult questions for you to answer; one place to begin, however, is by determining whether the source is a refereed journal. It is reasonable to assume that a refereed journal publishes manuscripts that are adequately searched, use mainly primary sources, and are written in a scholarly manner. This does not mean, however, that every study reported in a refereed journal will meet all of the critical appraisal criteria for a literature review and other components of the study in an equal manner. Because of style differences and space constraints, each citation summarized is often very brief, or related citations may be summarized as a group and lack a critique. You still must answer the critiquing questions. Consultation with a faculty advisor may be necessary to develop skill in answering these questions.

The key to a strong literature review is a careful search of published and unpublished literature. When critically appraising a literature review written for a published research study, it should reflect a synthesis or pulling together of the main points or value of all of the sources reviewed in relation to your research question, hypothesis, or clinical question (see Box 3.1). The relationship between and among these studies must be explained. The summary synthesis of a review of the literature in an area should appear at the end of a paper or article. When reading a research article, the

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summary of the literature appears before the methodology section and is referred to again when reviewing the results of the study.

CRITICAL APPRAISAL CRITERIA Literature Review

1. Are all of the relevant concepts and variables included in the literature review?

2. Is the literature review presented in an organized format that flows logically (e.g., chronologically, clustered by concept or variables), enhancing the reader’s ability to evaluate the need for the particular research study or evidence-based practice project?

3. Does the search strategy include an appropriate and adequate number of databases and other resources to identify key published and unpublished research and theoretical/conceptual sources?

4. Are both theoretical/conceptual and research sources used?

5. Are primary sources mainly used?

6. What gaps or inconsistencies in knowledge does the literature review uncover?

7. Does the literature review build on earlier studies?

8. Does the summary of each reviewed study reflect the essential components of the study design (e.g., type and size of sample, reliability and validity of instruments, consistency of data collection procedures, appropriate data analysis, identification of limitations)?

9. Does the critique of each reviewed study include strengths, weaknesses, or limitations of the design, conflicts, and gaps in information related to the area of interest?

10. Does the synthesis summary follow a logical sequence that presents the overall strengths and weaknesses of the reviewed

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studies and arrive at a logical conclusion on its topic?

11. Does the literature review for an evidence-based practice project answer a clinical question?

12. Is the literature review presented in an organized format that flows logically (e.g., chronologically, clustered by concepts or variables), enhancing the reader’s ability to evaluate the need for the particular research study or evidence-based practice project?

HELPFUL HINT

• If you are doing an academic assignment, make sure you check with your instructor as to whether or not the following sources may be used: (1) unpublished material, (2) theoretical/conceptual articles, and (3) Grey literature.

• Use a standardized critical appraisal criteria appropriate to the study’s design to evaluate research articles.

• Make a table of the studies found (see Chapter 20 for an example of a summary table).

• Synthesize the results of your analysis by comparing and contrasting the similarities and differences between the studies on your topic/clinical question and draw a conclusion.

Key points • Review of the literature is defined as a broad, comprehensive, in-

depth, systematic critique and synthesis of publications, unpublished print and online materials, audiovisual materials, and personal communication.

• Review of the literature is used for the development of EBP/QI clinical projects as well as research studies.

• There are differences between a review of the literature for research and for EBP/QI projects. For an EBP/QI project, your

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search should focus on the highest level of primary source literature available per the hierarchy of evidence, and it should relate to the specific clinical problem.

• The main objectives for conducting and writing a literature review are to acquire the ability to (1) conduct a comprehensive and efficient electronic research and/or print research search on a topic; (2) efficiently retrieve a sufficient amount of materials for a literature review in relation to the topic and scope of project; (3) critically appraise (i.e., critique) research and theoretical/conceptual material based on accepted critical appraisal criteria; (4) critically evaluate published reviews of the literature based on accepted standardized critical appraisal criteria; (5) synthesize the findings of the critique materials for relevance to the purpose of the selected scholarly project; and (6) determine applicability to answer your clinical question.

• Primary research and theoretical/conceptual resources are essential for literature reviews.

• Review the Grey literature for white papers and theoretical/conceptual materials not published in journals, and conduct “hand searches” of the reference list of your retrieved research articles as both provide background as well as uncover other studies.

• Secondary sources, such as commentaries on research articles from peer-reviewed journals, are part of a learning strategy for developing critical critiquing skills.

• It is more efficient to use electronic databases rather than print resources or general web search engines such as Google for retrieving materials.

• Strategies for efficiently retrieving literature for nursing include consulting the librarian and using at least three online sources (e.g., CINAHL, MEDLINE, and one that relates more specifically to your clinical question or topic).

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• Literature reviews are usually organized according to variables, as well as chronologically.

• Critiquing and synthesizing a number of research articles, including systematic reviews, is essential to implementing evidence-based nursing practice.

Critical thinking challenges • Why is it important for your QI team colleagues to be able to

challenge each other about the overall strength and quality of evidence provided by the group of studies retrieved from your search?

• For an EBP project, why is it necessary to critically appraise studies that are published in a refereed journal?

• How does reading preappraised commentaries of a study and systematic reviews/meta-analyses develop your critical appraisal skills?

• A general guideline for a literature search is to use a timeline of 5 years or more. Would your timeline possibly differ if you found a well-done systematic review?

• What is the relationship of the research article’s literature review to the theoretical or conceptual framework?

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

References 1. Hawthorne D.M, Youngblut J.M, Brooten D. Parent

spirituality, grief, and mental health at 1 year and 3 months after their infants/child’s death in an intensive care unit. Journal of Pediatric Nursing 2016;31:73-80.

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http://evolve.elsevier.com/LoBiondo/

2. Jeffries P, National League for Nursing (NLN). The NLN Jeffries simulation theory. Philadelphia, PA: Wolters Kluwer;2015.

3. Kendall S. Evidence-based resources simplified. Canadian Family Physician 2008;54(2):241-243.

4. Nyamathi A, Salem B.E, Zhang S, et al. Nursing care management, peer coaching, and Hepatitis A and B vaccine completion among homeless men recently released on parole. Nursing Research 2015;64(3):177-189.

5. Turner-Sack A.M, Menna R, Setchell S.R, et al. Psychological functioning, post traumatic growth, and coping in parent and siblings of adolescent cancer survivors. Oncology Nursing Forum 2016;43:48-56.

6. van Dijk J.F, Vervoort S.C, van Wijck A.J, et al. Postoperative patients’ perspective on rating pain A qualitative study. International Journal of Nursing Studies 2016;53:260- 269.

7. Yensen J. PICO search strategies. Online Journal of Nursing Informatics 2013;17(3) Retrieved from http://ojni.org/issues/? p=2860

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http://ojni.org/issues/?p=2860

CHAPTER 4

Theoretical frameworks for research Melanie McEwen

Learning outcomes

After reading this chapter, you should be able to do the following:

• Describe the relationship among theory, research, and practice. • Identify the purpose of conceptual and theoretical frameworks for nursing research. • Differentiate between conceptual and operational definitions. • Identify the different types of theories used in nursing research. • Describe how a theory or conceptual framework guides research. • Explain the points of critical appraisal used to evaluate the appropriateness, cohesiveness, and consistency of a framework guiding research.

KEY TERMS

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concept

conceptual definition

conceptual framework

construct

deductive

grand theory

inductive

middle range theory

model

operational definition

situation-specific theory

theoretical framework

theory

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

To introduce the discussion of the use of theoretical frameworks for nursing research, consider the example of Emily, a novice oncology nurse. From this case study, reflect on how nurses can understand the theoretical underpinnings of both nursing research and evidence-based nursing practice, and re-affirm how nurses should integrate research into practice.

Emily graduated with her bachelor of science in nursing (BSN) a little more than a year ago, and she recently changed positions to work on a pediatric oncology unit in a large hospital. She quickly learned that working with very ill and often dying children is tremendously rewarding, even though it is frequently heartbreaking.

One of Emily’s first patients was Benny, a 14-year-old boy admitted with a recurrence of leukemia. When she first cared for

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Benny, he was extremely ill. Benny’s oncologist implemented the protocols for cases such as his, but the team was careful to explain to Benny and his family that his prognosis was guarded. In the early days of his hospitalization, Emily cried with his mother when they received his daily lab values and there was no apparent improvement. She observed that Benny was growing increasingly fatigued and had little appetite. Despite his worsening condition, however, Benny and his parents were unfailingly positive, making plans for a vacation to the mountains and the upcoming school year.

At the end of her shift one night before several days off, Emily hugged Benny’s parents, as she feared that Benny would die before her next scheduled workday. Several days later, when she listened to the report at the start of her shift, Emily was amazed to learn that Benny had been heartily eating a normal diet. He was ambulatory and had been cruising the halls with his baseball coach and playing video games with two of his cousins. When she entered Benny’s room for her initial assessment, she saw the much-improved teenager dressed in shorts and a T-shirt, sitting up in bed using his iPad. A half-finished chocolate milkshake was on the table in easy reaching distance. He joked with Emily about Angry Birds as she performed her assessment. Benny steadily improved over the ensuing days and eventually went home with his leukemia again in remission.

As Emily became more comfortable in the role of oncology nurse, she continued to notice patterns among the children and adolescents on her unit. Many got better, even though their conditions were often critical. In contrast, some of the children who had better prognoses failed to improve as much, or as quickly, as anticipated. She realized that the kids who did better than expected seemed to have common attributes or characteristics, including positive attitudes, supportive family and friends, and strong determination to “beat” their cancer. Over lunch one day, Emily talked with her mentor, Marie, about her observations, commenting that on a number of occasions she had seen patients rebound when she thought that death was imminent.

Marie smiled. “Fortunately this is a pattern that we see quite frequently. Many of our kids are amazingly resilient.” Marie told

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Emily about the work of several nurse researchers who studied the phenomenon of resilience and gave her a list of articles reporting on their findings. Emily followed up with Marie’s prompting and learned about “psychosocial resilience in adolescents” (Tusaie et al., 2007) and “adolescent resilience” (Ahern, 2006; Ahern et al., 2008). These works led her to a “middle range theory of resilience” (Polk, 1997). Focusing her literature review even more, Emily was able to discover several recent research studies (Chen et al., 2014; Ishibashi et al., 2015; Wu et al., 2015) that examined aspects of resilience among adolescents with cancer, further piquing her interest in the subject.

From her readings, she gained insight into resilience, learning to recognize it in her patients. She also identified ways she might encourage and even promote resilience in children and teenagers. Eventually, she decided to enroll in a graduate nursing program to learn how to research different phenomena of concern to her patients and discover ways to apply the evidence-based findings to improve nursing care and patient outcomes.

Practice-theory-research links Several important aspects of how theory is used in nursing research are embedded in Emily’s story. First, it is important to notice the links among practice, theory, and research. Each is intricately connected with the others to create the knowledge base for the discipline of nursing (Fig. 4.1). In her practice, Emily recognized a pattern of characteristics in some patients that appeared to enhance their recovery. Her mentor directed her to research that other nurses had published on the phenomenon of “resilience.” Emily was then able to apply the information on resilience and related research findings as she planned and implemented care. Her goal was to enhance each child’s resilience as much as possible and thereby improve their outcomes.

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FIG 4.1 Discipline knowledge: Theory-practice-

research connection.

Another key message from the case study is the importance of reflecting on an observed phenomenon and discussing it with colleagues. This promotes questioning and collaboration, as nurses seek ways to improve practice. Finally, Emily was encouraged to go to the literature to search out what had been published related to the phenomenon she had observed. Reviewing the research led her to a middle range theory on resilience as well as current nursing research that examined its importance in caring for adolescents with cancer. This then challenged her to consider how she might ultimately conduct her own research.

Overview of theory Theory is a set of interrelated concepts that provides a systematic view of a phenomenon. A theory allows relationships to be proposed and predictions made, which in turn can suggest potential actions. Beginning with a theory gives a researcher a logical way of collecting data to describe, explain, and predict nursing practice, making it critical in research.

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In nursing, science is the result of the interchange between research and theory. The purpose of research is to build knowledge through the generation or testing of theory that can then be applied in practice. To build knowledge, research should develop within a theoretical structure or blueprint that facilitates analysis and interpretation of findings. The use of theory provides structure and organization to nursing knowledge. It is important that nurses understand that nursing practice is based on the theories that are generated and validated through research (McEwen & Wills, 2014).

In an integrated, reciprocal manner, theory guides research and practice; practice enables testing of theory and generates research questions; and research contributes to theory building and establishing practice guidelines (see Fig. 4.1). Therefore, what is learned through practice, theory, and research interweaves to create the knowledge fabric of nursing. From this perspective, like Emily in the case study, each nurse should be involved in the process of contributing to the knowledge or evidence-based practice of nursing.

Several key terms are often used when discussing theory. It is necessary to understand these terms when considering how to apply theory in practice and research. They include concept, conceptual definition, conceptual/theoretical framework, construct, model, operational definition, and theory. Each term is defined and summarized in Box 4.1. Concepts and constructs are the major components of theories and convey the essential ideas or elements of a theory. When a nurse researcher decides to study a concept/construct, the researcher must precisely and explicitly describe and explain the concept, devise a mechanism to identify and confirm the presence of the concept of interest, and determine a method to measure or quantify it. To illustrate, Table 4.1 shows the key concepts and conceptual and operational definitions provided by Turner-Sack and colleagues (2016) in their study on psychological issues among parents and siblings of adolescent cancer survivors (see Appendix D).

TABLE 4.1 Concepts and Variables: Conceptual and Operational Definitions

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BOX 4.1 Definitions Concept Image or symbolic representation of an abstract idea; the key identified element of a phenomenon that is necessary to understand it. Concept can be concrete or abstract. A concrete concept can be easily identified, quantified, and measured, whereas an abstract concept is more difficult to quantify or measure. For example, weight, blood pressure, and body temperature are concrete concepts. Hope, uncertainty, and spiritual pain are more abstract concepts. In a study, resilience is a relatively abstract concept.

Conceptual definition Much like a dictionary definition, a conceptual definition conveys the general meaning of the concept. However, the conceptual definition goes beyond the general language meaning found in the dictionary by defining or explaining the concept as it is rooted in theoretical literature.

Conceptual framework/theoretical framework A set of interrelated concepts that represents an image of a phenomenon. These two terms are often used interchangeably. The conceptual/theoretical framework refers to a structure that provides guidance for research or practice. The framework identifies the key concepts and describes their relationships to each other and to the phenomena (variables) of concern to nursing. It serves as the foundation on which a study can be developed or as a

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map to aid in the design of the study.

Construct Complex concept; constructs usually comprise more than one concept and are built or “constructed” to fit a purpose. Health promotion, maternal-infant bonding, health-seeking behaviors, and health-related quality of life are examples of constructs.

Model A graphic or symbolic representation of a phenomenon. A graphic model is empirical and can be readily represented. A model of an eye or a heart is an example. A symbolic or theoretical model depicts a phenomenon that is not directly observable and is expressed in language or symbols. Written music or Einstein’s theory of relativity are examples of symbolic models. Theories used by nurses or developed by nurses frequently include symbolic models. Models are very helpful in allowing the reader to visualize key concepts/constructs and their identified interrelationships.

Operational definition Specifies how the concept will be measured. That is, the operational definition defines what instruments will be used to assess the presence of the concept and will be used to describe the amount or degree to which the concept exists.

Theory Set of interrelated concepts that provides a systematic view of a phenomenon.

Types of theories used by nurses As stated previously, a theory is a set of interrelated concepts that provides a systematic view of a phenomenon. Theory provides a foundation and structure that may be used for the purpose of explaining or predicting another phenomenon. In this way, a theory is like a blueprint or a guide for modeling a structure. A blueprint depicts the elements of a structure and the relationships among the elements; similarly, a theory depicts the concepts that compose it and suggests how the concepts are related.

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Nurses use a multitude of different theories as the foundation or structure for research and practice. Many have been developed by nurses and are explicitly related to nursing practice; others, however, come from other disciplines. Knowledge that draws upon both nursing and non-nursing theories is extremely important in order to provide excellent, evidence-based care.

Theories from related disciplines used in nursing practice and research Like engineering, architecture, social work, and teaching, nursing is a practice discipline. That means that nurses use concepts, constructs, models, and theories from many disciplines in addition to nursing-specific theories. This is, to a large extent, the rationale for the “liberal arts” education that is required before entering a BSN program. Exposure to knowledge and theories of basic and natural sciences (e.g., mathematics, chemistry, biology) and social sciences (e.g., psychology, sociology, political science) provides a fundamental understanding of those disciplines and allows for application of key principles, concepts, and theories from each, as appropriate.

Likewise, BSN-prepared nurses use principles of administration and management and learning theories in patient-centered, holistic practices. Table 4.2 lists a few of the many theories and concepts from other disciplines that are commonly used by nurses in practice and research that become part of the foundational framework for nursing.

TABLE 4.2 Theories Used in Nursing Practice and Research

Discipline Examples of Theories/Concepts Used by Nurses Biomedical sciences Germ theory (principles of infection), pain theories, immune

function, genetics/genomics, pharmacotherapeutics Sociologic sciences Systems theory (e.g., VonBertalanffy), family theory (e.g., Bowen),

role theory (e.g., Merton), critical social theory (e.g., Habermas), cultural diversity (e.g., Leininger)

Behavioral sciences Developmental theories (e.g., Erikson), human needs theories (e.g., Maslow), personality theories (e.g., Freud), stress theories (e.g., Lazarus & Folkman), health belief model (e.g., Rosenstock)

Learning theories Behavioral learning theories (e.g., Pavlov, Skinner), cognitive development/interaction theories (e.g., Piaget), adult learning

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theories (e.g., Knowles) Leadership/management Change theory (e.g., Lewin), conflict management (e.g., Rapaport),

quality framework (e.g., Donabedian)

Nursing theories used in practice and research In addition to the theories and concepts from disciplines other than nursing, the nursing literature presents a number of theories that were developed specifically by and for nurses. Typically, nursing theories reflect concepts, relationships, and processes that contribute to the development of a body of knowledge specific to nursing’s concerns. Understanding these interactions and relationships among the concepts and phenomena is essential to evidence-based nursing care. Further, theories unique to nursing help define how it is different from other disciplines.

HELPFUL HINT In research and practice, concepts often create descriptions or images that emerge from a conceptual definition. For instance, pain is a concept with different meanings based on the type or aspect of pain being referred to. As such, there are a number of methods and instruments to measure pain. So a nurse researching postoperative pain would conceptually define pain based on the patient’s perceived discomfort associated with surgery, and then select a pain scale/instrument that allows the researcher to operationally define pain as the patient’s score on that scale.

Nursing theories are often described based on their scope or degree of abstraction. Typically, these are reported as “grand,” “middle range,” or “situation specific” (also called “microrange”) nursing theories. Each is described in this section.

Grand nursing theories Grand nursing theories are sometimes referred to as nursing conceptual models and include the theories/models that were developed to describe the discipline of nursing as a whole. This comprises the works of nurse theorists such as Florence Nightingale, Virginia Henderson, Martha Rogers, Dorthea Orem, and Betty Neuman. Grand nursing theories/models are all-inclusive

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conceptual structures that tend to include views on persons, health, and environment to create a perspective of nursing. This most abstract level of theory has established a knowledge base for the discipline. These works are used as the conceptual basis for practice and research, and are tested in research studies.

One grand theory is not better than another with respect to research. Rather, these varying perspectives allow a researcher to select a framework for research that best depicts the concepts and relationships of interest, and decide where and how they can be measured as study variables. What is most important about the use of grand nursing theoretical frameworks for research is the logical connection of the theory to the research question and the study design. Nursing literature contains excellent examples of research studies that examine concepts and constructs from grand nursing theories. See Box 4.2 for an example. BOX 4.2 Grand Theory Example Wong and colleagues (2015) used Orem’s self-care deficit nursing theory to examine the relationships among several factors such as parental educational levels, pain intensity, and self-medication on self-care behaviors among adolescent girls with dysmenorrhea. The researchers used a correlational study design that surveyed 531 high school–aged girls. Using constructs from Orem’s theory, they determined health care providers should design interventions that promote self-care behaviors among adolescents with dysmenorrhea, specifically targeting those who are younger, those who report higher pain intensity, and those who do not routinely self-medicate for menstrual pain.

Middle range nursing theories Beginning in the late 1980s, nurses recognized that grand theories were difficult to apply in research, and considerable attention moved to the development and research of “middle range” nursing theories. In contrast to grand theories, middle range nursing theories contain a limited number of concepts and are focused on a limited aspect of reality. As a result, they are more easily tested through research and more readily used as frameworks for research

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studies (McEwen & Wills, 2014). A growing number of middle range nursing theories have been

developed, tested through research, and/or are used as frameworks for nursing research. Examples are Pender’s Health Promotion Model (Pender et al., 2015), the Theory of Uncertainty in Illness (Mishel, 1988, 1990, 2014), the Theory of Unpleasant Symptoms (Lenz, Pugh, et al., 1997; Lenz, Gift, et al., 2017), and the Theory of Holistic Comfort (Kolcaba, 1994, 2017).

Examples of development, use, and testing of middle range theories and models are becoming increasingly common in the nursing literature. The comprehensive health-seeking and coping paradigm (Nyamathi, 1989) is one example. Indeed, Nyamathi’s model served as the conceptual framework of a recent research study that examined interventions to improve hepatitis A and B vaccine completion among homeless men (Nyamathi et al., 2015) (see Box 4.3 and Appendix A). In this study, the findings were interpreted according to the model. The researchers identified several predictors of vaccine completion and concluded that providers work to recognize factors that promote health-seeking and coping behaviors among high-risk populations. BOX 4.3 Middle Range Theory Exemplars An integrative research review was undertaken to evaluate the connection between symptom experience and illness-related uncertainty among patients diagnosed with brain tumors. The Theory of Uncertainty in Illness (Mishel, 1988, 1990, 2014) was the conceptual framework for interpretation of the review’s findings. The researchers concluded that somatic symptoms are antecedent to uncertainty among brain tumor patients, and that nursing strategies should attempt to understand and manage symptoms to reduce anxiety and distress by mitigating illness-related uncertainty (Cahill et al., 2012).

Bryer and colleagues (2013) conducted a study of health promotion behaviors of undergraduate nursing students. This study was based on Pender’s HPM (Pender et al., 2015). Several variables for the study were operationalized and measured using the Health Promotion Lifestyle Profile II, a survey instrument that

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was developed to be used in studies that focus on HPM concepts.

HPM, Health Promotion Model.

Situation-specific nursing theories: Microrange, practice, or prescriptive theories Situation-specific nursing theories are sometimes referred to as microrange, practice, or prescriptive theories. Situation-specific theories are more specific than middle range theories and are composed of a limited number of concepts. They are narrow in scope, explain a small aspect of phenomena and processes of interest to nurses, and are usually limited to specific populations or field of practice (Chinn & Kramer, 2015; Im, 2014; Peterson, 2017). Im and Chang (2012) observed that as nursing research began to require theoretical bases that are easily operationalized into research, situation-specific theories provided closer links to research and practice. The idea and practice of identifying a work as a situation-specific theory is still fairly new. Often what is noted by an author as a middle range theory would more appropriately be termed situation specific. Most commonly, however, a theory is developed from a research study, and no designation (e.g., middle range, situation specific) is attached to it.

Examples of self-designated, situation-specific theories include the theory of men’s healing from childhood maltreatment (Willis et al., 2015) and a situation-specific theory of health-related quality of life among Koreans with type 2 diabetes (Chang & Im, 2014). Increasingly, qualitative studies are being used by nurses to develop and support theories and models that can and should be expressly identified as situation specific. This will become progressively more common as more nurses seek graduate study and are involved in research, and increasing attention is given to the importance of evidence-based practice (Im & Chang, 2012; McEwen & Wills, 2014).

Im and Chang (2012) conducted a comprehensive research review that examined how theory has been described in nursing literature for the last decade. They reported a dramatic increase in the number of grounded theory research studies, along with increases in studies using both middle range and situation-specific

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theories. In contrast, the number and percentage directly dealing with grand nursing theories have fluctuated. Table 4.3 provides examples of grand, middle range, and situation-specific nursing theories used in nursing research.

TABLE 4.3 Levels of Nursing Theory: Examples of Grand, Middle Range, and Situation-Specific Nursing Theories

Grand Nursing Theories Middle Range NursingTheories Situation-Specific (or Micro) Nursing Theories

Florence Nightingale: Notes on Nursing (1860)

Dorothy Johnson: The Behavioral Systems Model for Nursing (1990)

Martha Rogers: Nursing: A Science of Unitary Human Beings (1970, 1990)

Betty Neuman: The Neuman Systems Model (2009)

Dorthea Orem: The Self Care Deficit Nursing Theory (2001)

Callista Roy: Roy Adaptation Model (2009)

Health promotion model (Pender et al., 2015)

Uncertainty in illness theory (Mishel, 1988, 1990, 2014)

Theory of unpleasant symptoms (Lenz, Gift, et al., 2017)

Theory of holistic comfort/theory of comfort (Kolcaba, 1994, 2017)

Theory of resilience (Polk, 1997)

Theory of health promotion in preterm infants (Mefford, 2004)

Theory of flight nursing expertise (Reimer & Moore, 2010)

Theory of the peaceful end of life (Ruland & Moore, 1998)

Theory of chronic sorrow (Eakes, 2017; Eakes et al., 1998)

Asian immigrant women’s menopausal symptom experience in the United States (Im, 2012)

Theory of Caucasians’ cancer pain experience (Im, 2006)

Becoming a mother (Mercer, 2004)

How theory is used in nursing research Nursing research is concerned with the study of individuals in interaction with their environments. The intent is to discover interventions that promote optimal functioning and self-care across the life span; the goal is to foster maximum wellness (McEwen & Wills, 2014). In nursing research, theories are used in the research process in one of three ways:

• Theory is generated as the outcome of a research study (qualitative designs).

• Theory is used as a research framework, as the context for a study (qualitative or quantitative designs).

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• Research is undertaken to test a theory (quantitative designs).

Theory-generating nursing research When research is undertaken to create or generate theory, the idea is to examine a phenomenon within a particular context and identify and describe its major elements or events. Theory- generating research is focused on “What” and “How,” but does not usually attempt to explain “Why.” Theory-generating research is inductive; that is, it uses a process in which generalizations are developed from specific observations. Research methods used by nurses for theory generation include concept analysis, case studies, phenomenology, grounded theory, ethnography, and historical inquiry. Chapters 5, 6, and 7 describe these research methods. As you review qualitative methods and study examples in the literature, be attuned to the stated purpose(s) or outcomes of the research and note whether a situation-specific (practice or micro) theory or model or middle range theory is presented as a finding or outcome.

Theory as framework for nursing research In nursing research, theory is most commonly used as the conceptual framework, theoretical framework, or conceptual model for a study. Frequently, correlational research designs attempt to discover and specify relationships between characteristics of individuals, groups, situations, or events. Correlational research studies often focus on one or more concepts, frameworks, or theories to collect data to measure dimensions or characteristics of phenomena and explain why and the extent to which one phenomenon is related to another. Data is typically gathered by observation or self-report instruments (see Chapter 10 for nonexperimental designs).

HELPFUL HINT When researchers use conceptual frameworks to guide their studies, you can expect to find a system of ideas synthesized for the purpose of organizing, thinking, and providing study direction. Whether the researcher is using a conceptual or a theoretical framework, conceptual and then operational definitions will

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emerge from the framework.

Often in correlational (nonexperimental/quantitative) research, one or more theories will be used as the conceptual/theoretical framework for the study. In these cases, a theory is used as the context for the study and basis for interpretation of the findings. The theory helps guide the study and enhances the value of its findings by setting the findings within the context of the theory and previous works, describing use of the theory in practice or research. When using a theory as a conceptual framework for research, the researcher will:

• Identify an existing theory (or theories) and designate and explain the study’s theoretical framework.

• Develop research questions/hypotheses consistent with the framework.

• Provide conceptual definitions taken from the theory/framework.

• Use data collection instrument(s) (and operational definitions) appropriate to the framework.

• Interpret/explain findings based on the framework.

• Determine support for the theory/framework based on the study findings.

• Discuss implications for nursing and recommendations for future research to address the concepts and relationships designated by the framework.

Theory-testing nursing research Finally, nurses may use research to test a theory. Theory testing is deductive—that is, hypotheses are derived from theory and tested, employing experimental research methods. In experimental research, the intent is to move beyond explanation to prediction of relationships between characteristics or phenomena among different groups or in various situations. Experimental research

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designs require manipulation of one or more phenomena to determine how the manipulation affects or changes the dimension or characteristics of other phenomena. In these cases, theoretical statements are written as research questions or hypotheses. Experimental research requires quantifiable data, and statistical analyses are used to measure differences (see Chapter 9).

In theory-testing research, the researcher (1) chooses a theory of interest and selects a propositional statement to be examined; (2) develops hypotheses that have measurable variables; (3) conducts the study; (4) interprets the findings considering the predictive ability of the theory; and (5) determines if there are implications for further use of the theory in nursing practice and/or whether further research could be beneficial.

EVIDENCE-BASED PRACTICE TIP In practice, you can use observation and analysis to consider the nuances of situations that matter to patient health. This process often generates questions that are cogent for improving patient care. In turn, following the observations and questions into the literature can lead to published research that can be applied in practice.

HIGHLIGHT When an interprofessional QI team launches a QI project to develop evidence-based behavior change self-management strategies for a targeted patient population, it may be helpful to think about the Transtheoretical Model of Change and health self- efficacy as an appropriate theoretical framework to guide the project.

Application to research and evidence-based practice To build knowledge that promotes evidence-based practice, research should develop within a theoretical structure that facilitates analysis and interpretation of findings. When a study is placed within a theoretical context, the theory guides the research process, forms the questions, and aids in design, analysis, and

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interpretation. In that regard, a theory, conceptual model, or conceptual framework provides parameters for the research and enables the researcher to weave the facts together.

As a consumer of research, you should know how to recognize the theoretical foundation of a study. Whether evaluating a qualitative or a quantitative study, it is essential to understand where and how the research can be integrated within nursing science and applied in evidence-based practice. As a result, it is important to identify whether the intent is to (1) generate a theory, (2) use the theory as the framework that guides the study, or (3) test a theory. This section provides examples that illustrate different types of theory used in nursing research (e.g., non-nursing theories, middle range nursing theories) and examples from the literature highlighting the different ways that nurses can use theory in research (e.g., theory-generating study, theory testing, theory as a conceptual framework).

Application of theory in qualitative research As discussed, in many instances, a theory, framework, or model is the outcome of nursing research. This is often the case in research employing qualitative methods such as grounded theory. From the study’s findings, the researcher builds either an implicit or an explicit structure explaining or describing the findings of the research.

Example: ➤ van Dijk and colleagues (2016) (see Appendix C) reported findings from a study examining how postoperative patients rated their pain experiences. The researchers were interested in understanding potential differences in how postoperative patients interpret numeric pain rating scales. Using a qualitative approach to data collection, the team interviewed 27 patients 1 day after surgery. They discovered three themes (score- related factors, intrapersonal factors, and anticipated consequences of a pain score). The result of the research was a model that may be used by health providers to understand the factors that influence how pain scales may be interpreted by patients. Appropriate questions for calcification were also suggested.

Generally, when the researcher is using qualitative methods and inductive reasoning, you will find the framework or theory at the

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end of the manuscript in the discussion section (see Chapters 5 to 7). You should be aware that the framework may be implicitly suggested rather than explicitly diagrammed (Box 4.4). BOX 4.4 Research Martz (2015) used grounded theory research methods to examine actions taken by hospice nurses to alleviate the feelings of guilt often experienced by caregivers. In this study, 16 hospice providers (most were nurses) were interviewed to identify interventions they used to reduce feelings of guilt among family caregivers during the transition from caring for their loved one at home to enlisting their loved one in an assisted living facility. The hospice nurses explained that the family caregivers worked through a five-stage process in their guilt experiences, moving from “feeling guilty” to “resolving their guilt” during the transition period. The actions of the hospice nurses varied based on the stage of the family caregiver’s feelings of guilt. These actions included supporting, managing, navigating, negotiating, encouraging, monitoring, and coaching. A situation-specific model was proposed to explain the relationships among these processes and suggesting congruent hospice nursing interventions.

The nursing literature is full of similar examples in which inductive, qualitative research methods were used to develop theory. Example: ➤ A team headed by Oneal and colleagues (2015) used grounded theory methods to conduct interviews with 10 low- income families who were involved in a program to reduce environmental risks to their children. Their findings were developed into the “theory of re-forming the risk message,” which can be used by designing nursing interventions to reduce environmental risk. It was concluded that nurses working with low-income families should seek to discover how risk messages are heard and interpreted and develop interventions accordingly. Finally, a team led by Taplay and colleagues (2015) used grounded theory methods to develop a model to describe the process of adopting and incorporating simulation into nursing education. The researchers interviewed 27 nursing faculty members from several

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schools to learn about their experiences incorporating simulation activities into their nursing programs. From the interviews, the researchers identified a seven-phase process of simulation adoption: securing resources, leaders working in tandem, “getting it out of the box,” learning about simulation and its potential, trialing the equipment, finding a fit, and integrating simulation into the curriculum.

Examples of theory as research framework When the researcher uses quantitative methods, the framework is typically identified and explained at the beginning of the paper, before the discussion of study methods. Example: ➤ In their study examining the relationships among spirituality, coping strategies, grief, and mental health in bereaved parents, Hawthorne and colleagues (2016) (see Appendix B) indicated that their “conceptual framework” was derived from a Theory of Bereavement developed by Hogan and colleagues (1996). Specifically, Hawthorne’s team used tools developed to measure variables from the Theory of Bereavement. In addition to grief, their research examined spiritual coping, mental health, and personal growth—all variables implicit or explicit in the bereavement theory. Their conclusions were interpreted with respect to the theory, suggesting that nurses and other health care providers promote coping strategies, including religious and spiritual activities, as these appear to be helpful for mental health and personal growth in many bereaved parents.

In another example, one of the works read by Emily from the case study dealt with resilience in adolescents (Tusaie et al., 2007). The researchers in this work used Lazarus and Folkman’s (1984) theory of stress and coping as part of the theoretical framework, researching factors such as optimism, family support, age, and life events.

Examples of theory-testing research Although many nursing studies that are experimental and quasi- experimental (see Chapter 9) are frequently conducted to test interventions, examples of research expressly conducted to test a theory are relatively rare in nursing literature. One such work is a multisite, multimethods study examining women’s perceptions of

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cesarean birth (Fawcett et al., 2012). This work tested multiple relationships within the Roy Adaptation Model as applied to the study population.

CRITICAL APPRAISAL CRITERIA Critiquing Theoretical Framework

1. Is the framework for research clearly identified?

2. Is the framework consistent with a nursing perspective?

3. Is the framework appropriate to guide research on the subject of interest?

4. Are the concepts and variables clearly and appropriately defined?

5. Was sufficient literature presented to support study of the selected concepts?

6. Is there a logical, consistent link between the framework, the concepts being studied, and the methods of measurement?

7. Are the study findings examined in relationship to the framework?

Critiquing the use of theory in nursing research It is beneficial to seek out, identify, and follow the theoretical framework or source of the background of a study. The framework for research provides guidance for the researcher as study questions are fine-tuned, methods for measuring variables are selected, and analyses are planned. Once data are collected and analyzed, the framework is used as a base of comparison. Ideally, the research should explain: Did the findings coincide with the framework? Did the findings support or refute findings of other researchers who used the framework? If there were discrepancies, is there a way to explain them using the framework? The reader of research needs to know how to critically appraise a framework for research (see the Critical Appraisal Criteria box).

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The first question posed is whether a framework is presented. Sometimes a structure may be guiding the research, but a diagrammed model is not included in the manuscript. You must then look for the theoretical framework in the narrative description of the study concepts. When the framework is identified, it is important to consider its relevance for nursing. The framework does not have to be one created by a nurse, but the importance of its content for nursing should be clear. The question of how the framework depicts a structure congruent with nursing should be addressed. For instance, although the Lazarus Transaction Model of Stress and Coping was not created by a nurse, it is clearly related to nursing practice when working with people facing stress. Sometimes frameworks from different disciplines, such as physics or art, may be relevant. It is the responsibility of the author to clearly articulate the meaning of the framework for the study and to link the framework to nursing.

Once the meaning and applicability of the theory (if the objective of the research was theory development) or the theoretical framework to nursing are articulated, you will be able to determine whether the framework is appropriate to guide the research. As you critically appraise a study, you would identify a mismatch, for example, in which a researcher presents a study of students’ responses to the stress of being in the clinical setting for the first time within a framework of stress related to recovery from chronic illness. You should look closely at the framework to determine if it is “on target” and the “best fit” for the research question and proposed study design.

Next, the reader should focus on the concepts being studied. Does the researcher clearly describe and explain concepts that are being studied and how they are defined and translated into measurable variables? Is there literature to support the choice of concepts? Concepts should clearly reflect the area of study. Example: ➤ Using the concept of “anger,” when “incivility” or “hostility” is more appropriate to the research focus creates difficulties in defining variables and determining methods of measurement. These issues have to do with the logical consistency among the framework, the concepts being studied, and the methods of measurement.

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Throughout the entire critiquing process, from worldview to operational definitions, the reader is evaluating the fit. Finally, the reader will expect to find a discussion of the findings as they relate to the theory or framework. This final point enables evaluation of the framework for use in further research. It may suggest necessary changes to enhance the relevance of the framework for continuing study, and thus serves to let others know where one will go from here.

Evaluating frameworks for research requires skills that must be acquired through repeated critique and discussion with others who have critiqued the same work. As with other abilities and skills, you must practice and use the skills to develop them further. With continuing education and a broader knowledge of potential frameworks, you will build a repertoire of knowledge to assess the foundation of a research study and the framework for research, and/or to evaluate findings where theory was generated as the outcome of the study.

Key points • The interaction among theory, practice, and research is central to

knowledge development in the discipline of nursing.

• The use of a framework for research is important as a guide to systematically identify concepts and to link appropriate study variables with each concept.

• Conceptual and operational definitions are critical to the evolution of a study.

• In developing or selecting a framework for research, knowledge may be acquired from other disciplines or directly from nursing. In either case, that knowledge is used to answer specific nursing questions.

• Theory is distinguished by its scope. Grand theories are broadest in scope and situation-specific theories are the narrowest in scope and at the lowest level of abstraction; middle range theories are

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in the middle.

• In critiquing a framework for research, it is important to examine the logical, consistent link among the framework, the concepts for study, and the methods of measurement.

Critical thinking challenges • Search recent issues of a prominent nursing journal (e.g., Nursing

Research, Research in Nursing & Health) for notations of conceptual frameworks of published studies. How many explicitly discussed the theoretical framework? How many did not mention any theoretical framework? What kinds of theories were mentioned (e.g., grand nursing theories, middle range nursing theories, non- nursing theories)? How many studies were theory generating? How many were theory testing?

• Identify a non-nursing theory that you would like to know more about. How could you find out information on its applicability to nursing research and nursing practice? How could you identify whether and how it has been used in nursing research?

• Select a nursing theory, concept, or phenomenon (e.g., resilience from the case study) that you are interested in and would like to know more about and consider: How could you find studies that have used that theory in research and practice? How could you locate published instruments and tools that reportedly measure concepts and constructs of the theory?

• You have just joined an interprofessional primary care QI Team focused on developing evidence-based self-management strategies to decrease hospital admissions for the practice’s heart failure patients. Which theoretical framework could be used to guide your project?

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

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http://evolve.elsevier.com/LoBiondo/

The author would like to acknowledge the contribution of Patricia Liehr, who contributed this chapter in a previous edition.

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37. Peterson S.J. Introduction to the nature of nursing knowledge. In: Peterson S.J, Bredow T.S. Middle range theories Application to nursing research 4th ed. Philadelphia, PA: Wolters Kluwer 2017;3-41.

38. Polk L.V. Toward a middle range theory of resilience. Advances in Nursing Science 1997;19(3):1-13.

39. Reimer A.P, Moore S.M. Flight nursing expertise towards a middle-range theory. Journal of Advanced Nursing 2010;66(5):1183-1192.

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40. Rogers M.E. An introduction to the theoretical basis of nursing. Philadelphia, PA: Davis;1970.

41. Rogers M.E. Nursing the science of unitary, irreducible, human beings: Update: 1990. In: Barrett E.A.M. Visions of Rogers’ science-based nursing. New York, NY: National League for Nursing Press 1990;5-11

42. Roy C. The Roy adaptation model. 3rd ed. Upper Saddle River, NJ: Pearson;2009.

43. Ruland C.M, Moore S.M. Theory construction based on standards of care A proposed theory of the peaceful end of life. Nursing Outlook 1998;46(4):169-175.

44. Taplay K, Jack S.M, Baxter P, et al. The process of adopting and incorporating simulation into undergraduate nursing curricula A grounded theory study. Journal of Professional Nursing 2015;31(1):26-36.

45. Turner-Sack A.M, Menna R, Setchell S.R, et al. Psychological functioning, post-traumatic growth and coping in parents and sibling of adolescent cancer survivors. Oncology Nursing Forum 2016;43(10):48-56.

46. Tusaie K, Puskar K, Sereika S.M. A predictive and moderating model of psychosocial resilience in adolescents. Journal of Nursing Scholarship 2007;39(1):54-60.

47. van Dijk J.F.M, Vervoort S.C.J.M, van Wijck A.J.M, et al. Postoperative patients’ perspectives on rating pain A qualitative study. International Journal of Nursing Studies 2016;53:260- 269.

48. Willis D.G, DeSanto-Madeya S, Fawcett J. Moving beyond dwelling in suffering A situation-specific theory of men’s healing form childhood maltreatment. Nursing Science Quarterly 2015;28(1):57-63.

49. Wong C.L, Ip W.Y, Choi K.C, Lam L.W. Examining self-care behaviors and their associated factors among adolescent girls with dysmenorrhea An application of Orem’s Self-care Deficit Nursing Theory. Journal of Nursing Scholarship 2015;47(3):219-227.

50. Wu W.W, Tsai S.Y, Liang S.Y, et al. The mediating role of resilience on quality of life and cancer symptom distress in adolescent patients with cancer. Journal of Pediatric Oncology

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Nursing 2015;32(5):304-313.

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PART I I

Processes and Evidence Related to Qualitative Research Research Vignette: Gail D’Eramo Melkus

OUTLINE

Introduction

5. Introduction to qualitative research

6. Qualitative approaches to research

7. Appraising qualitative research

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Introduction

Research vignette

Type 2 diabetes: Journey from description to biobehavioral intervention

Gail D’Eramo Melkus, EdD, ANP, FAAN

Florence and William Downs Professor in Nursing Research

Director, Muriel and Virginia Pless Center for Nursing Research

Associate Dean for Research

New York University Rory Meyers College of Nursing

My nursing career began at a time when there was an emphasis on health promotion, disease prevention, and active participation of patients and families in health care decision making and interactions. This emphasis was consistent with an ever-increasing incidence and prevalence of chronic conditions, particularly diabetes and cardiovascular disease. It became apparent in time through epidemiological studies that certain populations had a disproportionate burden of these chronic conditions that resulted in premature morbidity and mortality. It also became apparent that the health care workforce was not prepared to deal with the changing paradigm of chronic disease management that necessitated active patient involvement. Thus I came to understand the best way to enhance diabetes care for all persons was to

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improve clinical practice through research and professional education.

Diabetes is a prevalent chronic illness affecting approximately 29 million individuals in the United States and 485 million globally. Thus the dissemination and translation of research findings to clinical practice is necessary to decrease the personal and economic burden of disease. In order to contribute to the improvement of diabetes care and outcomes, my role as a direct care provider extended to and encompassed clinical research and education and served as a model for my mentees. My integrated scholarship addresses the quality and effectiveness of diabetes behavioral interventions and care in the context of the patient and culture, primary care, and professional practice while also serving as a training ground for clinical practice and clinical research. This work has extended to collaborations with colleagues nationally and internationally. My research collectively demonstrated the beneficial effects of behavioral self-management interventions combined with diabetes care in primary care.

My program of research has contributed to the body of literature that has demonstrated the effectiveness of behavioral interventions in improving metabolic control (hemoglobin A1c [HbA1c], BP, lipids, and weight) and diabetes-related emotional distress. One of my early studies tested a comprehensive intervention for obese men and women with type 2 diabetes that demonstrated efficacy in significantly improving diabetes control and weight loss compared to a control group that received a customary intervention of diabetes patient education (D’Eramo-Melkus et al., 1992). Post-hoc analysis of study participants with equal weight loss yet disparate HbA1c levels revealed that persons with elevated HbA1c levels had decreased insulin secretion capacity that was associated with a 10 years or greater duration of type 2 diabetes. This study contributed to clinical practice recommendations that called for assessment of insulin secretion capacity to direct therapeutic interventions such that persons with low insulin secretory reserve should be started on insulin rather than continued weight loss intervention alone. It became apparent during the implementation of the intervention study that the majority of participants received diabetes care in primary care settings where diabetes care and self-management

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resources were scarce or nonexistent. In an effort to better understand the delivery of diabetes care within primary care settings so that we could best develop effective patient centered interventions, my research turned to assessing nurse practitioner (NP) and physician diabetes care practice patterns in a large urban primary care center. This study showed that both primary NPs and physicians were not providing diabetes care according to the American Diabetes Association clinical care guidelines. In fact, screening for diabetes complications occurred in fewer than 50% of cases, and NPs performed foot exams less often than physicians (Fain & D’Eramo-Melkus, 1994). These findings along with other studies that found similar results provided an impetus to develop and implement a model program of advanced practice nursing education and subspecialty training in diabetes care (D’Eramo- Melkus & Fain, 1995). Graduates of this program (over 300 to date) have assumed leadership roles in facilitating diabetes care in generalist and specialty settings throughout the United States, Canada, and various international sites. During this education and training program, many of the students participated in my program of research and contributed to a growing body of literature on diabetes care.

Epidemiological studies in the early 1990s showed that increasingly ethnic minorities suffered a disproportionate burden of type 2 diabetes and related complications. In particular, black women had and continue to have the highest rate of disease and diabetes-related complications, with the poorest health outcomes, and a 40% greater mortality compared to black men and white men and women. Therefore my program of research came to focus on this group, beginning with descriptive studies that described the context of type 2 diabetes for black women. The first study of a small convenience sample of volunteers from an urban center revealed a group of midlife black women, the majority of whom were employed and customary utilizers of primary care. Despite their poor glycemic control (average HbA1c 12.8%), only 68% received diabetes medications, and less than 50% of the time were they screened for diabetes complications. In order to better understand factors contributing to such findings, we conducted focus groups to elicit information on diabetes beliefs and practices

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of black women with type 2 diabetes. Key themes that emerged were a need for diabetes education and health care provider rapport, importance of culturally appropriate diabetes education materials, and the importance of family support (Maillet et al., 1996; Melkus et al., 2002).

Based on an informant survey and focus group data, using social learning theory and cognitive behavioral methods that incorporated the context of culture for black women with type 2 diabetes and input from a community advisory board, we developed and tested a culturally relevant intervention of group diabetes self- management education and skills training (DSME/T), along with nurse practitioner care. This intervention was first tested for feasibility using a one group repeated measures pretest, posttest design that demonstrated participant acceptability based on high rates of attendance at both group sessions and NP care visits, and feasibility of methods based on formative and summative process and fidelity measures. Further glycemic control was significantly improved baseline to 3 months and maintained at 6 months (p =.008), and the psychosocial outcome of diabetes-related emotional distress was also greatly reduced (p =.06) (Melkus et al., 2004). Given these promising results, we went on to test the efficacy of the DSME/T intervention using a two-group repeated measures design with a comparison group (control) that received customary group diabetes education; time and attention were controlled for in both groups. The primary outcome of glycemic control as measured by HbA1c was significantly improved from baseline to 3 and 6 months (p =.01, F = 6.15). The gold standard for glycemic control is HbA1c. HbA1c, when maintained in a normal range (≥7.0%), has been shown to prevent or slow the progression of diabetes-related complications (The Diabetes Control and Complications Trial Research Group, 1993).

One of the salient findings in all of the work-up to this point was that the women reported high levels of diabetes-related emotional distress, given the demands of diabetes self-management and complex lives that often included multigenerational family caregiving and work. The majority were grandmothers responsible for some extent of child care, which for many negatively affected their diabetes control (Balukonis et al., 2008). Recognizing the need

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to address this concern, we added a coping skills training component that followed DSME/T when we conducted a prospective randomized clinical trial (RCT) to test intervention effectiveness. The control/comparison group received a customary diabetes education program followed by drop-in question and answer sessions equivalent in time so to control for a potential attention effect. The experimental (n = 52) and control group (n = 57) participants were in active intervention for 12 months, consisting of assigned group sessions and monthly NP visits for the first 2 months and quarterly thereafter; they were followed for a total of 24 months. As with any prospective behavioral intervention, trial attrition occurred resulting in a sample of 77 study completers. An intention to treat analysis that included all participants as randomly assigned showed that the primary outcome of HbA1c was significantly improved over time for both groups (p <.0001) up to 12 months, after which time control group levels showed an increase from 12 to 24 months while the intervention group remained stable (Melkus et al., 2010). This finding demonstrates the importance of active intervention that includes numerous contacts and feedback in order to facilitate optimal diabetes self-management and glycemic control. When data of completers (n = 77) were analyzed, the same significant finding resulted over time for HbA1c at 12 and 24 months. Low-density and high-density lipoprotein cholesterol levels also significantly improved over time for both groups. Quality of life (MOS-36) vitality domain, social support, and diabetes-related emotional distress were all significantly changed in the intervention group at 24 months compared to the control group. The results showed that we reached the intended target group of black women with suboptimal glycemic control, cardiovascular risk factors, poor quality of life, and high levels of emotional distress, in need of social support. Moreover, it is important to note that both groups received intervention beyond standard “real world” primary care. Thus patients with type 2 diabetes cared for in primary care settings when given the opportunity to participate in DSME/T may improve in both physiological and psychosocial outcomes. Further evidence is needed to promote the need for chronic disease self-management programs and psychosocial care beyond the medical visit that focuses on physiological parameters

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and prescribing of therapeutic regimens.

References 1. Balukonis J., Melkus G. D., Chyun D. Grandparenthood

status and health outcomes in midlife African American women with type 2 diabetes. Ethnicity and Disease 2008;18(2):141-146.

2. D’Eramo Melkus G., Fain J. A. Diabetes care concentration a program of study for advanced practice nurses. Clinical Nurse Specialist 1995;9(6):313-316.

3. D’Eramo-Melkus G., Wylie-Rosett J., Hagan J. Metabolic impact of education on NIDDM. Diabetes Care 1992;15(7):864- 869.

4. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. New England Journal of Medicine 1993;329:977-986.

5. Fain J. A., D’Eramo G. Nurse practitioner practice patterns based on standards of medical care for patients with diabetes. Diabetes Care 1994;17(8):879-881.

6. Maillet N. A., D’Eramo Melkus G., Spollett G. Using focus groups to characterize beliefs and practices of African American women with NIDDM. The Diabetes Educator 1996;22(1):39-45.

7. Melkus G. D., Chyun D., Newlin K., et al. Effectiveness of a diabetes self-management intervention on physiological and psychosocial outcomes. Biological Research in Nursing 2010;12(1):7-19.

8. Melkus G. D., Maillet N., Novak J., et al. Primary care cancer screening and diabetes complications screening for black women with type 2 diabetes. Journal of the American Academy of Nurse Practitioners 2002;4(1):43-48.

9. Melkus G. D., Spollett G., Jefferson V., et al. Feasibility testing of a culturally competent intervention of education and care for black women with type 2 diabetes. Applied Nursing Research 2004;17(1):10-20.

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CHAPTER 5

Introduction to qualitative research Mark Toles, Julie Barroso

Learning outcomes

After reading this chapter, the student should be able to do the following:

• Describe the components of a qualitative research report. • Describe the beliefs generally held by qualitative researchers. • Identify four ways qualitative findings can be used in evidence- based practice.

KEY TERMS

context dependent

data saturation

grand tour question

inclusion and exclusion criteria

inductive

naturalistic setting

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paradigm

qualitative research

theme

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

Let’s say that you are reading an article that reports findings that HIV-infected men are more adherent to their antiretroviral regimens than HIV-infected women. You wonder, “Why is that? Why would women be less adherent in taking their medications? Certainly, it is not solely due to the fact that they are women.” Or say you are working in a postpartum unit and have just discharged a new mother who has debilitating rheumatoid arthritis. You wonder, “What is the process by which disabled women decide to have children? How do they go about making that decision?” These, like so many other questions we have as nurses, can be best answered through research conducted using qualitative methods. Qualitative research gives us the answers to those difficult “why?” questions. Although qualitative research can be used at many different places in a program of research, you will most often find it answering questions that we have when we understand very little about some phenomenon in nursing.

What is qualitative research? Qualitative research is a broad term that encompasses several different methodologies that share many similarities. Qualitative studies help us formulate an understanding of a phenomenon. Nurse scholars who are trained in qualitative methods use these methods to best answer discovery-oriented research questions.

Qualitative research is explanatory, descriptive, and inductive in nature. It uses words, as opposed to numbers, to explain a phenomenon. Qualitative research lets us see the world through the eyes of another—the woman who struggles to take her antiretroviral medication, or the woman who has carefully thought

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http://evolve.elsevier.com/LoBiondo/

through what it might be like to have a baby despite a debilitating illness. Qualitative researchers assume that we can only understand these things if we consider the context in which they take place, and this is why most qualitative research takes place in naturalistic settings. Qualitative studies make the world of an individual visible to the rest of us. Qualitative research involves an “interpretative, naturalistic approach to the world; meaning that qualitative researchers study things in their natural settings, attempting to make sense of or interpret phenomena in terms of the meaning people bring to them” (Denzin & Lincoln, 2011, p. 3).

What do qualitative researchers believe? Qualitative researchers believe that there are multiple realities that can be understood by carefully studying what people can tell us or what we can observe as we spend time with them. Example: ➤ The experience of having a baby, while it has some shared characteristics, is not the same for any two women, and it is definitely different for a disabled mother. Thus qualitative researchers believe that reality is socially constructed and context dependent. Even the experience of reading this book is different for any two students; one may be completely engrossed by the content, while another is reading but at the same time worrying about whether or not her financial aid will be approved soon.

Because qualitative researchers believe that the discovery of meaning is the basis for knowledge, their research questions, approaches, and activities are often quite different from quantitative researchers (see the Critical Thinking Decision Path). Qualitative researchers seek to understand the “lived experience” of the research participants. They might use interviews or observations to gather new data, and use new data to create narratives about research phenomena. Thus qualitative researchers know that there is a very strong imperative to clearly describe the phenomenon under study. Ideally, the reader of a qualitative research report, if even slightly acquainted with the phenomenon, would have an “aha!” moment in reading a well-written qualitative report.

So, you may now be saying, “Wow! This sounds great!

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Qualitative research is for me!” Many nurses feel very comfortable with this approach because we are educated with regard to how to speak with people about the health issues concerning them; we are used to listening, and listening well. But the most important consideration for any research study is whether or not the methodology fits the question. This means that qualitative researchers must select an approach for exploring phenomena that will actually answer their research questions. Thus, as you read studies and are considering them as evidence on which to base your practice, you should ask yourself, “Does the methodology fit with the research question under study?”

HELPFUL HINT All research is based on a paradigm, but this is seldom specifically stated in a research report.

Does the methodology fit with the research question being asked? As we said before, qualitative methods are often best for helping us determine the nature of a phenomenon and the meaning of experience. Sometimes authors will state that they are using qualitative methods because little is known about a phenomenon, but that alone is not a good reason for conducting a study. Little may be known about a phenomenon because it does not matter! When researchers ask people to participate in a study, to open themselves and their lives for analysis, they should be asking about things that will help make a difference in people’s lives or help provide more effective nursing care. You should be able to articulate a valid reason for conducting a study, beyond “little is known about this topic.”

Considering the examples at the start of this chapter, we may want to know why HIV-infected women are less adherent to their medication regimens, so we can work to change these barriers and anticipate them when our patients are ready to start taking these pills. Similarly, we need to understand the decision-making processes women use to decide whether or not to have a child when they are disabled, so we can guide or advise the next woman who is

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going through this process. To summarize, a qualitative approach “fits” a research question when the researchers seek to understand the nature or experience of phenomena by attending to personal accounts of those with direct experiences related to the phenomena. Keeping in mind the purpose of qualitative research, let’s discuss the parts of a qualitative research study.

CRITICAL THINKING DECISION PATH Selecting a Research Process

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Components of a qualitative research study The components of a qualitative research study include the review of literature, study design, study setting and sample, approaches for data collection and analysis, study findings, and conclusions with implications for practice and research. As we reflect on these parts of qualitative studies, we will see how nurses use the qualitative research process to develop new knowledge for practice

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(Box 5.1). BOX 5.1 Steps in the Research Process

• Review of the literature

• Study design

• Sample

• Setting: Recruitment and data collection

• Data collection

• Data analysis

• Findings

• Conclusions

Review of the literature When researchers are clear that a qualitative approach is the best way to answer the research question, their first step is to review the relevant literature and describe what is already known about the phenomena of interest. This may require creativity on the researcher’s part, because there may not be any published research on the phenomenon in question. Usually there are studies on similar subjects, or with the same patient population, or on a closely related concept. Example: ➤ Researchers may want to study how women who have a disabling illness make decisions about becoming pregnant. While there may be no other studies in this particular area, there may be some on decision making in pregnancy when a woman does not have a disabling illness. These studies would be important in the review of the literature because they identify concepts and relationships that can be used to guide the research process. Example: ➤ Findings from the review can show us the precise need for new research, what participants should be in the study sample, and what kinds of questions should

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be used to collect the data. Let’s consider an example. Say a group of researchers wanted to

examine HIV-infected women’s adherence to antiretroviral therapy. If there was no research on this exact topic, the researcher might examine studies on adherence to therapy in other illnesses, such as diabetes or hypertension. They might include studies that examine gender differences in medication adherence. Or they might examine the literature on adherence in a stigmatizing illness, or look at appointment adherence for women, to see what facilitates or acts as a barrier to attending health care appointments. The major point is that even though there may be no literature on the phenomenon of interest, the review of the literature will identify existing related studies that are useful for exploring the new questions. At the conclusion of an effective review, you should be able to easily identify the strengths and weaknesses in prior research and a clear understanding of the new research questions, as well as the significance of studying them.

Study design The study design is a description of how the qualitative researcher plans to go about answering the research questions. In qualitative research, there may simply be a descriptive or naturalistic design in which the researchers adhere to the general tenets of qualitative research but do not commit to a particular methodology. There are many different qualitative methods used to answer the research questions. Some of these methods will be discussed in the next chapter. What is important, as you read from this point forward, is that the study design must be congruent with the philosophical beliefs that qualitative researchers hold. You would not expect to see a qualitative researcher use methods common to quantitative studies, such as a random sample, a battery of questionnaires administered in a hospital outpatient clinic, or a multiple regression analysis. Rather, you would expect to see a design that includes participant interviews or observation, strategies for inductive analysis, and plans for using data to develop narrative summaries with rich description of the details from participants’ experiences. You may also read about a pilot study in the description of a study design; this is work the researchers did before undertaking the

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main study to make sure that the logistics of the proposed study were reasonable. For example, pilot data may describe whether the investigators were able to recruit participants and whether the research design led them to the information they needed.

Sample The study sample refers to the group of people that the researcher will interview or observe in the process of collecting data to answer the research questions. In most qualitative studies, the researchers are looking for a purposeful or purposively selected sample (see Chapter 10). This means that they are searching for a particular kind of person who can illuminate the phenomenon they want to study. Example: ➤ The researchers may want to interview women with multiple sclerosis or rheumatoid arthritis. There may be other parameters—called inclusion and exclusion criteria—that the researchers impose as well, such as requiring that participants be older than 18 years, not under the influence of illicit drugs, or experiencing a first pregnancy (as opposed to subsequent pregnancies). When researchers are clear about these criteria, they are able to identify and recruit participants with the experiences needed to shed light on the phenomenon in question. Often the researchers make decisions such as determining who might be a “long-term survivor” of a certain illness. In this case, they must clearly describe why and how they decided who would fit into this category. Is a long-term survivor someone who has had an illness for 5 years or 10 years? What is the median survival time for people with this diagnosis? Thus, as a reader of nursing research, you are looking for evidence of sound scientific reasoning behind the sampling plan.

When the researchers have identified the type of person to include in the research sample, the next step is to develop a strategy for recruiting participants, which means locating and engaging them in the research. Recruitment materials are usually very specific. Example: ➤ If the researchers want to talk to HIV-infected women about adherence to their medication regimen, they may distribute flyers or advertise their interest in recruiting women who consistently take their medication as indicated, as well as those who do not. Or, they may want to talk to women who fit into only one of

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those categories. Similarly, the researchers who are examining decision making in pregnancy among women with disabling conditions would develop recruitment strategies that identify subjects with the conditions or characteristics they want to study.

In a research report, the researcher may include a description of the study sample in the findings. (This can also be reported in the description of the sample.) In any event, besides a demographic description of the study participants, a qualitative researcher should also report on key axes of difference in the sample. Example: ➤ In a sample of HIV-infected women, there should be information about the stage of illness, what kind/how many pills they must take, how many children they have, and so on. This information helps you place the findings into a context.

Setting: Recruitment and data collection The study setting refers to the places where participants are recruited and the data are collected. Settings for recruitment are usually a point of contact for people of common social, medical, or other individual traits. In the example of HIV-infected women who are having difficulties adhering to their antiretroviral regimens, researchers might distribute flyers describing the study at AIDS service organizations, support groups for HIV-infected women, clinics, online support groups, and other places people with HIV may seek services. The settings for data collection are another critical area of difference between quantitative and qualitative studies. Data collection in a qualitative study is usually done in a naturalistic setting, such as someone’s home, not in a clinic interview room or researcher’s office. This is important in qualitative research because the researcher’s observations can inform the data collection. To be in someone else’s home is a great advantage, as it helps the researcher to understand what that participant values. An entire wall in a participant’s living room might contain many pictures of a loved one, so anyone who enters the home would immediately understand the centrality of that person in the participant’s life. In the home of someone who is ill, many household objects may be clustered around a favorite chair: perhaps an oxygen tank, a glass of water, medications, a telephone, tissues, and so on. A good qualitative researcher will use clues like

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these in the study setting to complete the complex, rich drawing that is being rendered in the study.

HIGHLIGHT Reading and critically appraising qualitative research studies may be the best way for interprofessional teams to understand the experience of living with a chronic illness so they can provide more effective whole person care.

Data collection The procedures for data collection differ significantly in qualitative and quantitative studies. Where quantitative researchers focus on statistics and numbers, qualitative researchers are usually concerned with words: what people can tell them and the narratives about meaning or experience. Qualitative researchers interview participants; they may interview an individual or a group of people in what is called a focus group. They may observe individuals as they go about daily tasks, such as sorting medications into a pill minder or caring for a child. But in all cases, the data collected are expressed in words. Most qualitative researchers use voice recorders so that they can be sure that they have captured what the participant says. This reduces the need to write things down and frees researchers to listen fully. Interview recordings are usually transcribed verbatim and then listened to for accuracy. In a research report, investigators describe their procedures for collecting the data, such as obtaining informed consent, the steps from initial contact to the end of the study visit, and how long each interview or focus group lasted or how much time the researcher spent “in the field” collecting data.

A very important consideration in qualitative data collection is the researcher’s decision that they have a sufficient sample and that data collection is complete. Researchers generally continue to recruit participants until they have reached redundancy or data saturation, which means that nothing new is emerging from the interviews. There usually is not a predetermined number of participants to be selected as there is in quantitative studies; rather, the researcher keeps recruiting until she or he has all of the data needed. One important exception to this is if the researcher is very

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interested in getting different types of people in the study. Example: ➤ In the study of HIV-infected women and medication adherence, the researchers may want some women who were very adherent in the beginning but then became less so over time, or they may want women who were not adherent in the beginning but then became adherent; alternately, they may want to interview women with children and women without children to determine the influence of having children on adherence. Whatever the specific questions may be, sample sizes tend to be fairly small (fewer than 30 participants) because of the enormous amounts of written text that will need to be analyzed by the researcher.

Investigators use great care to design the interview questions because they must be crafted to help study participants describe their personal experiences and perceptions. Interview questions are different from research questions. Research questions are typically broad, encompassing, and written in scientific language. The interview questions may also be broad, like the overview or grand tour question that seeks the “big picture.” Example: ➤ Researchers might ask, “Tell me about taking your medications—the things that make it easier, and the things that make it harder,” or “Tell me what you were thinking about when you decided to get pregnant.” Along with overview questions, there are usually a series of prompts (additional questions) that were derived from the literature. These are areas that the researcher believes are important to cover (and that the participant will likely cover), but the prompts are there to remind the researcher in case the material is not mentioned. Example: ➤ With regard to medication adherence, the researcher may have read in other studies that motherhood can influence adherence in two very different ways: children can become a reason to live, which would facilitate taking antiretroviral medication; and children can be all-demanding, leaving the mother with little to no time to take care of herself. Thus, a neutrally worded question about the influence of children would be a prompt if the participants do not mention it spontaneously. In a research report, you should expect to find the primary interview questions identified verbatim; without them, it is impossible to know how the data were collected and how the researcher shaped what was discovered in the interviews.

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EVIDENCE-BASED PRACTICE TIP Qualitative researchers use more flexible procedures than quantitative researchers. While collecting data for a project, they consider all of the experiences that may occur.

Data analysis Next is the description of data analysis. Here, researchers tell you how they handled the raw data, which, in a qualitative study, are usually transcripts of recorded interviews. The goal of qualitative analysis is to find commonalities and differences in the interviews, and then to group these into broader, more abstract, overarching categories of meaning, sometimes called themes, that capture much of the data. In the example we have been using about decision making regarding pregnancy for disabled women, one woman might talk about discussing the need for assistance with her friends if she became pregnant, and finding out that they were willing and able to help her with the baby. Another woman might talk about how she discussed the decision with her parents and siblings, and found them to be a ready source of aid. And yet a third woman may say that she talked about this with her church study group, and they told her that they could arrange to bring meals and help with housework during the pregnancy and afterward. On a more abstract level, these women are all talking about social support. So an effective analysis would be one that identifies this pattern in social support and, perhaps, goes further by also describing how social support influences some other concept in the data. Example: ➤ Consider women’s decision making about having a baby. In an ideal situation, written reports about the data will give you an example like the one you just read, but the page limitations of most journals limit the level of detail that researchers can present.

Many qualitative researchers use computer-assisted qualitative data analysis programs to find patterns in the interviews and field notes, which, in many studies, can seem overwhelming due to the sheer quantity of data to be dealt with. With a computer-assisted data analysis program, researchers from multiple sites can simultaneously code and analyze data from hundreds of files without using a single piece of paper. The software is a tool for

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managing and remembering steps in analysis; however, it does not replace the thoughtful work of the researcher who must apply the program to guide the analysis of the data. In research reports, you should see a description of the way data were managed and analyzed, and whether the researchers used software or other paper-based approaches, such as using index cards with handwritten notes.

Findings At last, we come to the results. Findings in qualitative reports, as we have suggested already, are words—the findings are patterns of any kind in the data, such as the ways that participants talked, the things that they talked about, even their behaviors associated with where the researcher spent time with them. When researchers describe patterns in the data, they may describe a process (such as the way decision making occurs); they may identify a list of things that are functioning in some way (such as a list of barriers and facilitators to taking medications for HIV-infected women); they may specify a set of conditions that must be present for something to occur (such as what parents state they need to care for a ventilator-dependent child at home); or they may describe what it is like to go through some health-related transition (such as what it is like to become the caregiver for a parent with dementia). This is by no means an all-inclusive list; rather, it is a range of examples to help you recognize what types of findings might be possible. It may help to think of the findings as discoveries. The qualitative researcher has explored a phenomenon, and the findings are a report on what he or she “found” —that is, what was discovered in the interviews and observations.

When researchers describe their results, they usually break the data down into units of meaning that help the data cohere and tell a story. Effective research reports will describe the logic that was used for breaking down the units of data. Example: ➤ Are the themes—a means of describing a large quantity of data in a condensed format—identified from the most prevalent to the least prevalent? Are the researchers describing a process in temporal (time ordered) terms? Are they starting with things that were most important to the subject, then moving to less important items? As a

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report on the findings unfolds, the researcher should proceed with a thorough description of the phenomenon, defining each of the themes and fleshing out each of the themes with a thorough explanation of the role that it plays in the question under study. The researcher should also provide quotations that support their themes. Ideally, they will stage the quote, giving you some information about the subject from whom it came. For example, was the subject a newly diagnosed HIV-infected African American woman without children? Or was it a disabled woman who has chosen to become pregnant, but who has suffered two miscarriages? The staging of quotes is important because it allows you to put the information into some social context.

In a well-written report of qualitative research, some of the quotes will give you an “aha!” feeling. You will have a sense that the researcher has done an excellent job of getting to the core of the problem. Quotes are as critical to qualitative reports as numbers are to a quantitative study; you would not have a great deal of confidence in a quantitative or qualitative report in which the author asks you to believe the conclusion without also giving concrete, verifiable findings to back it up.

HELPFUL HINT Values are involved in all research. It is important, however, that they not influence the results of the research.

Discussion of the results and implications for evidence-based practice When the researchers are satisfied that their findings answer the research questions, they should summarize the results for you and should compare their findings to the existing literature. Researchers usually explain how these findings are similar to or different from the existing literature. This is one of the great contributions of qualitative research—using findings to open up new venues of discovery that were not anticipated when the study was designed. Example: ➤ The researchers can use findings to develop new concepts or new conceptual models to explain broader phenomena. The conceptual work also identifies implications for how findings

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can be used in practice and can direct future research. Another alternative is for researchers to use their findings to extend or refine existing theoretical models. For example, a researcher may learn something new about stigma that has not been described in the literature, and in writing about these findings, the researcher may refer to an existing stigma theory, pointing out how his or her work extends that theory.

Nursing is a practice discipline, and the goal of nursing research is to use research findings to improve patient care. Qualitative methods are the best way to start to answer clinical and research questions that have not been addressed or when a new perspective is needed in practice. The qualitative answers to these questions provide important evidence that offers the first systematic insights into phenomena previously not well understood and often lead to new perspectives in nursing practice and improved patient care outcomes.

Kearney (2001) developed a typology of levels and applications of qualitative research evidence that helps us see how new evidence can be applied to practice (Table 5.1). She described five categories of qualitative findings that are distinguished from one another in their levels of complexity and discovery: those restricted by a priori frameworks, descriptive categories, shared pathway or meaning, depiction of experiential variation, and dense explanatory description. She argued that the greater the complexity and discovery within qualitative findings, the stronger the potential for clinical application.

TABLE 5.1 Kearney’s Categories of Qualitative Findings, from Least to Most Complex

Category Definition Example Restricted by a priori frameworks

Discovery aborted because researcher has obscured the findings with an existing theory

Use of the theory of “relatedness” to describe women’s relationships without substantiation in the data, or when there may be an alternative explanation to describe how women exist in relationship to others; the data seem to point to an explanation other than “relatedness”

Descriptive categories

Phenomenon is vividly portrayed from a new perspective; provides a map into previously uncharted

Children’s descriptions of pain, including descriptors, attributed causes, and what constitutes good care during a painful episode

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territory in the human experience of health and illness

Shared pathway or meaning

Synthesis of a shared experience or process; integration of concepts that provides a complex picture of a phenomenon

Description of women’s process of recovery from depression; each category was fully described, and the conditions for progression were laid out; able to see the origins of a phase in the previous phase

Depiction of experiential variation

Describes the main essence of an experience, but also shows how the experience varies, depending on the individual or context

Description of how pregnant women recovering from cocaine addiction might or might not move forward to create a new life, depending on the amount of structure they imposed on their behavior and their desire to give up drugs and change their lives

Dense explanatory description

Rich, situated understanding of a multifaceted and varied human phenomenon in a unique situation; portray the full range and depth of complex influences; densely woven structure to findings

Unique cultural conditions and familial breakdown and hopelessness led young people to deliberately expose themselves to HIV infection in order to find meaning and purpose in life; describes loss of social structure and demands of adolescents caring for their diseased or drugged parents who were unable to function as adults

Findings developed with only a priori frameworks provide little or no evidence for changing practice, because the researchers have prematurely limited what they are able to learn from participants or describe in their analysis. Findings that identify descriptive categories portray a higher level of discovery when a phenomenon is vividly portrayed from a new perspective. For nursing practice, these findings serve as maps of previously uncharted territory in human experience. Findings in Kearney’s third category, shared pathway or meaning, are more complex. In this type of finding, there is an integration of concepts or themes that results in a synthesis of a shared process or experience that leads to a logical, complex portrayal of the phenomenon. The researcher’s ideas at this level reveal how discrete bits of data come together in a meaningful whole. For nursing practice, this allows us to reflect on the bigger picture and what it means for the human experience (Kearney, 2001). Findings that depict experiential variation describe the essence of an experience and how this experience varies, depending on the individual or context. For nursing practice, this type of finding helps us see a variety of viewpoints, realizations of a human experience, and the contextual sources of that variety. In nursing practice, these findings explain how different variables can produce different consequences in different people or settings. Finally, findings that are presented as a dense explanatory description are at the highest level of complexity and discovery.

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They provide a rich, situated understanding of a multifaceted and varied human phenomenon in a unique situation. These types of findings portray the full depth and range of complex influences that propel people to make decisions. Physical and social contexts are fully accounted for. There is a densely woven structure of findings in these studies that provide a rich fund of clinically and theoretically useful information for nursing practice. The layers of detail work together in the findings to increase understanding of human choices and responses in particular contexts (Kearney, 2001).

EVIDENCE-BASED PRACTICE TIP Qualitative research findings can be used in many ways, including improving ways clinicians communicate with patients and with each other.

So how can we further use qualitative evidence in nursing? The evidence provided by qualitative studies is used conceptually by the nurse: qualitative studies let nurses gain access to the experiences of patients and help nurses expand their ability to understand their patients, which should lead to more helpful approaches to care (Table 5.2).

TABLE 5.2 Kearney’s Modes of Clinical Application for Qualitative Research

Mode of Clinical Application Example Insight or empathy: Better understanding our patients and offering more sensitive support

Nurse is better able to understand the behaviors of a woman recovering from depression

Assessment of status or progress: Descriptions of trajectories of illness

Nurse is able to describe trajectory of recovery from depression and can assess how the patient is moving through this trajectory

Anticipatory guidance: Sharing of qualitative findings with the patient

Nurse is able to explain the phases of recovery from depression to the patient and to reassure her that she is not alone, that others have made it through a similar experience

Coaching: Advising patients of steps they can take to reduce distress or improve adjustment to an illness, according to the evidence in the study

Nurse describes the six stages of recovery from depression to the patient, and in ongoing contact, points out how the patient is moving through the stages, coaching her to recognize signs that she is improving and moving through the stages

Kearney (2001) proposed four modes of clinical application:

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insight or empathy, assessment of status or progress, anticipatory guidance, and coaching. The simplest mode, according to Kearney, is to use the information to better understand the experiences of our patients, which in turn helps us to offer more sensitive support. Qualitative findings can also help us assess the patient’s status or progress through descriptions of trajectories of illness or by offering a different perspective on a health condition. They allow us to consider a range of possible responses from patients. We can then determine the fit of a category to a particular client, or try to locate them on an illness trajectory. Anticipatory guidance includes sharing of qualitative findings directly with patients. The patient can learn about others with a similar condition and can learn what to anticipate. This allows them to better garner resources for what might lie ahead or look for markers of improvement. Anticipatory guidance can also be tremendously comforting in that the sharing of research results can help patients realize they are not alone, that there are others who have been through a similar experience with an illness. Finally, coaching is a way of using qualitative findings; in this instance, nurses can advise patients of steps they can take to reduce distress, improve symptoms, or monitor trajectories of illness (Kearney, 2001).

Unfortunately, qualitative research studies do not fare well in the typical systematic reviews upon which evidence-based practice recommendations are based. Randomized clinical trials and other types of intervention studies traditionally have been the major focus of evidence-based practice. Typically, the selection of studies to be included in systematic reviews is guided by levels of evidence models that focus on the effectiveness of interventions according to their strength and consistency of their predictive power. Given that the levels of evidence models are hierarchical in nature and they perpetuate intervention studies as the “gold standard” of research design, the value of qualitative studies and the evidence offered by their results have remained unclear. Qualitative studies historically have been ranked lower in a hierarchy of evidence, as a “weaker” form of research design.

Remember, however, that qualitative research is not designed to test hypotheses or make predictions about causal effects. As we use qualitative methods, these findings become more and more

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valuable as they help us discover unmet patient needs, entire groups of patients that have been neglected, and new processes for delivering care to a population. Though qualitative research uses different methodologies and has different goals, it is important to explore how and when to use the evidence provided by findings of qualitative studies in practice.

Appraisal for evidence-based practice foundation of qualitative research A final example illustrates the differences in the methods discussed in this chapter and provides you with the beginning skills of how to critique qualitative research. The information in this chapter, coupled with information presented in Chapter 7, provides the underpinnings of critical appraisal of qualitative research (see the Critical Appraisal Criteria box, Chapter 7). Consider the question of nursing students learning how to conduct research. The empirical analytical approach (quantitative research) might be used in an experiment to see if one teaching method led to better learning outcomes than another. The students’ knowledge might be tested with a pretest, the teaching conducted, and then a posttest of knowledge obtained. Scores on these tests would be analyzed statistically to see if the different methods produced a difference in the results.

In contrast, a qualitative researcher may be interested in the process of learning research. The researcher might attend the class to see what occurs and then interview students to ask them to describe how their learning changed over time. They might be asked to describe the experience of becoming researchers or becoming more knowledgeable about research. The goal would be to describe the stages or process of this learning. Alternately, a qualitative researcher might consider the class as a culture and could join to observe and interview students. Questions would be directed at the students’ values, behaviors, and beliefs in learning research. The goal would be to understand and describe the group members’ shared meanings. Either of these examples are ways of viewing a question with a qualitative perspective. The specific qualitative methodologies are described in Chapter 6.

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Many other research methods exist. Although it is important to be aware of the qualitative research method used, it is most important that the method chosen is the one that will provide the best approach to answering the question being asked. One research method does not rank higher than another; rather, a variety of methods based on different paradigms are essential for the development of a well informed and comprehensive approach to evidence-based nursing practice.

Key points • All research is based on philosophical beliefs, a worldview, or a

paradigm.

• Qualitative research encompasses different methodologies.

• Qualitative researchers believe that reality is socially constructed and is context dependent.

• Values should be acknowledged and examined as influences on the conduct of research.

• Qualitative research follows a process, but the components of the process vary.

• Qualitative research contributes to evidence-based practice.

Critical thinking challenges • Discuss how a researcher’s values could influence the results of a

study. Include an example in your answer.

• Can the expression, “We do not always get closer to the truth as we slice and homogenize and isolate [it]” be applied to both qualitative and quantitative methods? Justify your answer.

• What is the value of qualitative research in evidence-based practice? Give an example.

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• Discuss how your interprofessional team could apply the findings of a qualitative study about coping with a diagnosis of multiple sclerosis.

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

References 1. Denzin N.K, Lincoln Y.S. The SAGE handbook of qualitative

research. 4th ed. Thousand Oaks, CA: Sage;2011. 2. Kearney M.H. Levels and applications of qualitative research

evidence. Research in Nursing and Health 2001;24:145-153.

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http://evolve.elsevier.com/LoBiondo/

CHAPTER 6

Qualitative approaches to research Mark Toles, Julie Barroso

Learning outcomes

After reading this chapter, you should be able to do the following:

• Identify the processes of phenomenological, grounded theory, ethnographic, and case study methods. • Recognize appropriate use of community-based participatory research (CBPR) methods. • Discuss significant issues that arise in conducting qualitative research in relation to such topics as ethics, criteria for judging scientific rigor, and combination of research methods. • Apply critical appraisal criteria to evaluate a report of qualitative research.

KEY TERMS

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auditability

bracketing

case study method

community-based participatory research

constant comparative method

credibility

culture

data saturation

domains

emic view

ethnographic method

etic view

fittingness

grounded theory method

instrumental case study

intrinsic case study

key informants

lived experience

meta-summary

meta-synthesis

mixed methods

phenomenological method

theoretical sampling

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

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http://evolve.elsevier.com/LoBiondo/

Qualitative research combines the science and art of nursing to enhance understanding of the human health experience. This chapter focuses on four commonly used qualitative research methods: phenomenology, grounded theory, ethnography, and case study. Community-based participatory research (CBPR) is also presented. Each of these methods, although distinct from the others, shares characteristics that identify it as a method within the qualitative research tradition.

Traditional hierarchies of research evaluation and how they categorize evidence from strongest to weakest, with emphasis on support for the effectiveness of interventions, are presented in Chapter 1. This perspective is limited because it does not take into account the ways that qualitative research can support practice, as discussed in Chapter 5. There is no doubt about the merit of qualitative studies; the problem is that no one has developed a satisfactory method for including them in current evidence hierarchies. In addition, qualitative studies can answer the critical why questions that emerge in many evidence-based practice summaries. Such summaries may report the answer to a research question, but they do not explain how it occurs in the landscape of caring for people.

As a research consumer, you should know that qualitative methods are the best way to start to answer clinical and research questions when little is known or a new perspective is needed for practice. The very fact that qualitative research studies have increased exponentially in nursing and other social sciences speaks to the urgent need of clinicians to answer these why questions and to deepen our understanding of experiences of illness. Thousands of reports of well-conducted qualitative studies exist on topics such as the following:

• Personal and cultural constructions of disease, prevention, treatment, and risk

• Living with disease and managing the physical, psychological, and social effects of multiple diseases and their treatment

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• Decision-making experiences at the beginning and end of life, as well as assistive and life-extending, technological interventions

• Contextual factors favoring and mitigating against quality care, health promotion, prevention of disease, and reduction of health disparities (Sandelowski, 2004; Sandelowski & Barroso, 2007)

Findings from qualitative studies provide valuable insights about unique phenomena, patient populations, or clinical situations. In doing so, they provide nurses with the data needed to guide and change practice.

In this chapter, you are invited to look through the lens of human experience to learn about phenomenological, grounded theory, ethnographic, CBPR, and case study methods. You are encouraged to put yourself in the researcher’s shoes and imagine how it would be to study an issue of interest from the perspective of each of these methods. No matter which method a researcher uses, there is a focus on the human experience in natural settings.

The researcher using these methods believes that each unique human being attributes meaning to their experience and that experience evolves from one’s social and historical context. Thus one person’s experience of pain is distinct from another’s and can be elucidated by the individual’s subjective description of it. Example: ➤ Researchers interested in studying the lived experience of pain for the adolescent with rheumatoid arthritis will spend time in the adolescents’ natural settings, perhaps in their homes and schools (see Chapter 5). Research efforts will focus on uncovering the meaning of pain as it extends beyond the number of medications taken or a rating on a pain scale. Qualitative methods are grounded in the belief that objective data do not capture the whole of the human experience. Rather, the meaning of the adolescent’s pain emerges within the context of personal history, current relationships, and future plans, as the adolescent lives daily life in dynamic interaction with the environment.

Qualitative approach and nursing science The evidence provided by qualitative studies that consider the unique perspectives, concerns, preferences, and expectations each

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patient brings to a clinical encounter offers in-depth understanding of human experience and the contexts in which they occur. Thus findings in qualitative research often guide nursing practice, contribute to instrument development (see Chapter 15), and develop nursing theory (Fig. 6.1).

FIG 6.1 Qualitative approach and nursing science.

Qualitative research methods Thus far you have studied an overview of the qualitative research approach (see Chapter 5). Recognizing how the choice to use a qualitative approach reflects one’s worldview and the nature of some research questions, you have the necessary foundation for exploring selected qualitative methodologies. Now, as you review the Critical Thinking Decision Path and study the remainder of Chapter 6, note how different qualitative methods are appropriate for distinct areas of interest. Also note how unique research questions might be studied with each qualitative research method. In this chapter, we will explore five qualitative research methods in depth, including phenomenological, grounded theory, ethnographic, case study, and CBPR methods.

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CRITICAL THINKING DECISION PATH Selecting a Qualitative Research Method

Phenomenological method The phenomenological method is a process of learning and constructing the meaning of human experience through intensive dialogue with persons who are living the experience. It rests on the assumption that there is a structure and essence to shared experiences that can be narrated (Marshall & Rossman, 2011). The researcher’s goal is to understand the meaning of the experience as it is lived by the participant. Phenomenological studies usually incorporate data about the lived space, or spatiality; the lived body, or corporeality; lived time, or temporality; and lived human relations, or relationality. Meaning is pursued through a process of dialog, which extends beyond a simple interview and requires thoughtful presence on the part of the researcher. There are many schools of phenomenological research, and each school of thought uses slight differences in research methods. Example: ➤ Husserl belonged to the group of transcendental phenomenologists, who saw phenomenology as an interpretive, as opposed to an objective, mode of description. Using vivid and detailed attentiveness to

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description, researchers in this school explore the ways knowledge comes into being. They seek to understand knowledge that is based on insights rather than objective characteristics (Richards & Morse, 2013). In contrast, Heidegger was an existential phenomenologist who believed that the observer cannot separate him/herself from the lived world. Researchers in this school of thought study how being in the world is a reality that is perceived; they study a reciprocal relationship between observers and the phenomenon of interest (Richards & Morse, 2013). In all forms of phenomenological research, you will find researchers asking a question about the lived experience and using methods that explore phenomena as they are embedded in people’s lives and environments.

Identifying the phenomenon Because the focus of the phenomenological method is the lived experience, the researcher is likely to choose this method when studying a dimension of day-to-day existence for a particular group of people. An example of this is provided later in this chapter, in which Cook and colleagues (2015) studied the complex issues surrounding the residential status of assisted living residents in terms of fundamental human needs.

Structuring the study When thinking about methods, we say the methodological approach “structures the study.” This phrase means that the method shapes the way we think about the phenomenon of interest and the way we would go about answering a research question. For the purpose of describing structuring, the following topics are addressed: the research question, the researcher’s perspective, and sample selection.

Research question. The question that guides phenomenological research always asks about some human experience. It guides the researcher to ask the participant about some past or present experience. In most cases, the research question is not exactly the same as the question used to initiate dialogue with study participants. Example: ➤ Cook and colleagues (2015) state that the objective of their study was to

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explore the meaning and meaningfulness that older people attribute to their everyday experiences in an assisted living facility and how these experiences define their status as residents. They describe their methodology as hermeneutic phenomenology. Their goal was to provide knowledge that assisted living facility administrators and staff could use so that residents could feel “at home” in the facility.

Researcher’s perspective. When using the phenomenological method, the researcher’s perspective is bracketed. This means that the researcher identifies their own personal biases about the phenomenon of interest to clarify how personal experience and beliefs may color what is heard and reported. Further, the phenomenological researcher is expected to set aside their personal biases—to bracket them—when engaged with the participants. By becoming aware of personal biases, the researcher is more likely to be able to pursue issues of importance as introduced by the participant, rather than leading the participant to issues the researcher deems important (Richards & Morse, 2013).

HIGHLIGHT Discuss with your interprofessional QI team why searching for qualitative studies might be most appropriate for understanding about living with Hepatitis C and managing the physical, psychological, and social effects of multiple treatments and their effects.

Using phenomenological methods, researchers strive to identify personal biases and hold them in abeyance while querying the participant. Readers of phenomenological articles may find it difficult to identify bracketing strategies because they are seldom explicitly identified in a research manuscript. Sometimes a researcher’s worldview or assumptions provide insight into biases that have been considered and bracketed.

Sample selection. As you read a phenomenological study, you will find that the participants were selected purposively (selecting subjects who are considered typical of the population) and that members of the

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sample either are living the experience the researcher studies or have lived the experience in their past. Because phenomenologists believe that each individual’s history is a dimension of the present, a past experience exists in the present moment. For the phenomenologist, it is a matter of asking the right questions and listening. Even when a participant is describing a past experience, remembered information is being gathered in the present at the time of the interview.

HELPFUL HINT Qualitative studies often use purposive sampling (see Chapter 12).

Data gathering Written or oral data may be collected when using the phenomenological method. The researcher may pose the query in writing and ask for a written response, or may schedule a time to interview the participant and record the interaction. In either case, the researcher may return to ask for clarification of written or recorded transcripts. To some extent, the particular data collection procedure is guided by the choice of a specific analysis technique. Different analysis techniques require different numbers of interviews. A concept known as data saturation usually guides decisions regarding how many interviews are enough. Data saturation is the situation of obtaining the full range of themes from the participants, so that in interviewing additional participants, no new data emerge (Marshall & Rossman, 2011).

Data analysis Several techniques are available for data analysis when using the phenomenological method. Although the techniques are slightly different from each other, there is a general pattern of moving from the participant’s description to the researcher’s synthesis of all participants’ descriptions. Colaizzi (1978) suggests a series of seven steps:

1. Read the participants’ narratives to acquire a feeling for their ideas in order to understand them fully.

2. Extract significant statements to identify keywords and sentences

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relating to the phenomenon being studied.

3. Formulate meanings for each of these significant statements.

4. Repeat this process across participants’ stories and cluster recurrent meaningful themes. Validate these themes by returning to the informants to check interpretation.

5. Integrate the resulting themes into a rich description of the phenomenon under study.

6. Reduce these themes to an essential structure that offers an explanation of the behavior.

7. Return to the participants to conduct further interviews or elicit their opinions on the analysis in order to cross-check interpretation.

Cook and colleagues (2015) do not cite a reference for data analysis; they describe using narrative analysis to interpret how participants viewed their experiences and environment over a series of up to eight interviews with each resident over 6 months.

It is important to note that giving verbatim transcripts to participants can have unanticipated consequences. It is not unusual for people to deny that they said something in a certain way, or that they said it at all. Even when the actual recording is played for them, they may have difficulty believing it. This is one of the more challenging aspects of any qualitative method: every time a story is told, it changes for the participant. The participant may sincerely feel that the story as it was recorded is not the story as it is now.

EVIDENCE-BASED PRACTICE TIP Phenomenological research is an important approach for accumulating evidence when studying a new topic about which little is known.

Describing the findings When using the phenomenological method, the nurse researcher provides you with a path of information leading from the research question, through samples of participants’ words and the

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researcher’s interpretation, to the final synthesis that elaborates the lived experience as a narrative. When reading the report of a phenomenological study, the reader should find that detailed descriptive language is used to convey the complex meaning of the lived experience that offers the evidence for this qualitative method (Richards & Morse, 2013). Cook and colleagues (2015) described five themes that emerged from the narratives that collectively demonstrate that residents wanted their residential status to involve “living with care” rather than “existing in care.”

1. Caring for oneself/being cared for

2. Being in control/losing control

3. Relating to others/putting up with others

4. Active choosers and users of space/occupying space

5. Engaging in meaningful activity/lacking meaningful activity

The themes in their phenomenological report describe the need for assisted living facility staff to be more focused on recognizing, acknowledging, and supporting residents’ aspirations regarding their future lives and their status as residents. By using direct participant quotes, researchers enable readers to evaluate the connections between what individual participants said and how the researcher labeled or interpreted what they said.

Grounded theory method The grounded theory method is an inductive approach involving a systematic set of procedures to arrive at a theory about basic social processes (Silverman & Marvasti, 2008). The emergent theory is based on observations and perceptions of the social scene and evolves during data collection and analysis (Corbin & Strauss, 2015). Grounded theory describes a research approach to construct theory where no theory exists, or in situations where existing theory fails to provide evidence to explain a set of circumstances.

Developed originally as a sociologist’s tool to investigate interactions in social settings (Glaser & Strauss, 1967), the grounded

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theory method is used in many disciplines; in fact, investigators from different disciplines use grounded theory to study the same phenomenon from their varying perspectives (Corbin & Strauss, 2015; Denzin & Lincoln, 2003; Marshall & Rossman, 2011; Strauss & Corbin, 1994, 1997). Example: ➤ In an area of study such as chronic illness, a nurse might be interested in coping patterns within families, a psychologist might be interested in personal adjustment, and a sociologist might focus on group behavior in health care settings. In grounded theory, the usefulness of the study stems from the transferability of theories; that is, a theory derived from one study is applicable to another. Thus the key objective of grounded theory is the development of theories spanning many disciplines that accurately reflect the cases from which they were derived (Sandelowski, 2004).

Identifying the phenomenon Researchers typically use the grounded theory method when interested in social processes from the perspective of human interactions or patterns of action and interaction between and among various types of social units (Denzin & Lincoln, 2003). The basic social process is sometimes expressed in the form of a gerund (i.e., the -ing form of a verb when functioning as a noun), which is designed to indicate change occurring over time as individuals negotiate social reality. Example: ➤ Hyatt and colleagues (2015) explore soldiers and their family reintegration experiences, as described by married dyads, following a combat-related mild traumatic brain injury.

Structuring the study

Research question. Research questions for the grounded theory method are those that address basic social processes that shape human behavior. In a grounded theory study, the research question can be a statement or a broad question that permits in-depth explanation of the phenomenon. For example, Hyatt and colleagues (2015) examined the following research question: “How do soldiers and their spouses identify the special challenges, sources of support, and

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overall rehabilitation process of post–mild traumatic brain injury family reintegration?”

Researcher’s perspective. In a grounded theory study, the researcher brings some knowledge of the literature to the study, but an exhaustive literature review may not be done. This allows theory to emerge directly from data and to reflect the contextual values that are integral to the social processes being studied. In this way, the new theory that emerges from the research is “grounded in” the data (Richards & Morse, 2013).

Sample selection. Sample selection involves choosing participants who are experiencing the circumstance and selecting events and incidents related to the social process under investigation. Hyatt and colleagues (2015) obtained their purposive (see Chapter 12) sample through self-referral from flyers posted in military health care clinics, health care provider referrals, and directly approaching potential participants while in the traumatic brain injury clinic of a military health care system; it is important to note that Hyatt was an active military member herself at the time of data collection.

Data gathering In the grounded theory method, data are collected through interviews and skilled observations of individuals interacting in a social setting. Interviews are recorded and transcribed, and observations are recorded as field notes. Open-ended questions are used initially to identify concepts for further focus. At their first data collection point, Hyatt and colleagues (2015) interviewed couples (soldiers and their spouses) together; then they interviewed each of them separately, to probe the themes that emerged in the joint interviews.

Data analysis A unique and important feature of the grounded theory method is that data collection and analysis occur simultaneously. The process requires systematic data collection and documentation using field

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notes and transcribed interviews. Hunches about emerging patterns in the data are noted in memos that the researcher uses to direct activities in fieldwork. This technique, called theoretical sampling, is used to select experiences that will help the researcher to test hunches and ideas and to gather complete information about developing concepts. The researcher begins by noting indicators or actual events, actions, or words in the data. As data are concurrently collected and analyzed, new concepts, or abstractions, are developed from the indicators (Charmaz, 2003; Strauss, 1987).

The initial analytical process is called open coding (Strauss, 1987). Data are examined carefully line by line, broken down into discrete parts, then compared for similarities and differences (Corbin & Strauss, 2015). Coded data are continuously compared with new data as they are acquired during research. This is a process called the constant comparative method. When data collection is complete, codes in the data are clustered to form categories. The categories are expanded and developed, or they are collapsed into one another, and relationships between the categories are used to develop new “grounded” theories. As a result, data collection, analysis, and theory generation have a direct, reciprocal relationship which grounds new theory in the perspectives of the research participants (Charmaz, 2003; Richards & Morse, 2013; Strauss & Corbin, 1990).

HELPFUL HINT In a report of research using the grounded theory method, you can expect to find a diagrammed model of a theory that synthesizes the researcher’s findings in a systematic way.

Describing the findings Grounded theory studies are reported in detail, permitting readers to follow the exact steps in the research process. Descriptive language and diagrams of the research process are used as evidence to document the researchers’ procedures for moving from the raw data to the new theory. Hyatt and colleagues (2015) found the basic social process of family reintegration after mild traumatic brain injury to be “finding a new normal.” The couples described this new normal as the phenomenon of finding or adjusting to changes

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in their new, post-mild traumatic brain injury family roles or routines. The following were the core categories:

1. Facing the unexpected—“Homecoming”—and adjusting to having the soldier back home; noticing changes in the soldier

2. Managing unexpected change—Assuming a caregiver role, managing the post-mild traumatic brain injury changes within the context of the married relationship

3. Experiencing mismatched expectations—Coping with the shifting state of the relationship, losing a career, or a shifting future

4. Adjusting to new expectations—Accepting changes, building a new family life

5. Learning to live with new expectations—Accepting the new normal

EVIDENCE-BASED PRACTICE TIP When thinking about the evidence generated by the grounded theory method, consider whether the theory is useful in explaining, interpreting, or predicting the study phenomenon of interest.

Ethnographic method Derived from the Greek term ethnos, meaning people, race, or cultural group, the ethnographic method focuses on scientific description and interpretation of cultural or social groups and systems (Creswell, 2013). The goal of the ethnographer is to understand the research participants’ views of their world, or the emic view. The emic view (insiders’ view) is contrasted with the etic view (outsiders’ view), which is obtained when the researcher uses quantitative analyses of behavior. The ethnographic approach requires that the researcher enter the world of the study participants to watch what happens, listen to what is said, ask questions, and collect whatever data are available. It is important to note that the term ethnography is used to mean both the research technique and the product of that technique—that is, the study

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itself (Creswell, 2013; Richards & Morse, 2013; Tedlock, 2003). Vidick and Lyman (1998) trace the history of ethnography, with roots in the disciplines of sociology and anthropology, as a method born out of the need to understand “other” and “self.” Nurses use the method to study cultural variations in health and patient groups as subcultures within larger social contexts.

Identifying the phenomenon The phenomenon under investigation in an ethnographic study varies in scope from a long-term study of a very complex culture, such as that of the Aborigines (Mead, 1949), to a short-term study of a phenomenon within subunits of cultures. Kleinman (1992) notes the clinical utility of ethnography in describing the “local world” of groups of patients who are experiencing a particular phenomenon, such as suffering. The local worlds of patients have cultural, political, economic, institutional, and social-relational dimensions in much the same way as larger complex societies. An example of ethnography is found in Grassley and colleagues’ (2015) study of nurses’ support of breastfeeding on the night shift. Grassley and colleagues used institutional ethnography, which has as its goal to explore how social experiences and processes, in particular those of everyday work, are organized. Institutional ethnography also considers the institutional processes and interactions that mediate the context of nurses’ everyday work (Grassley et al., 2015).

Structuring the study

Research question. In ethnographic studies, questions are asked about “lifeways” or particular patterns of behavior within the social context of a culture or subculture. In this type of research, culture is viewed as the system of knowledge and linguistic expressions used by social groups that allows the researcher to interpret or make sense of the world (Aamodt, 1991; Richards & Morse, 2013). Thus ethnographic nursing studies address questions that concern how cultural knowledge, norms, values, and other contextual variables influence people’s health experiences. Example: ➤ Grassley and colleagues’ (2015) research question is implied in their purpose statement: “To

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describe nurses’ support of breastfeeding on the night shift and to identify the interpersonal interactions and institutional structures that affect their ability to offer breastfeeding support and to promote exclusive breastfeeding on the night shift.” Remember that ethnographers have a broader definition of culture, where a particular social context is conceptualized as a culture. In this case, nurses who provide care on a mother/baby unit to mother/infant dyads in the immediate postpartum period are seen as a cultural entity that is appropriate for ethnographic study.

Researcher’s perspective. When using the ethnographic method, the researcher’s perspective is that of an interpreter entering an alien world and attempting to make sense of that world from the insider’s point of view (Richards & Morse, 2013). Like phenomenologists and grounded theorists, ethnographers make their own beliefs explicit and bracket, or set aside, their personal biases as they seek to understand the worldview of others.

Sample selection. The ethnographer selects a cultural group that is living the phenomenon under investigation. The researcher gathers information from general informants and from key informants. Key informants are individuals who have special knowledge, status, or communication skills, and who are willing to teach the ethnographer about the phenomenon (Richards & Morse, 2013). Example: ➤ Grassley and colleagues’ (2015) research took place in a tertiary care hospital with 4200 births per year (20% of the state’s total births) and an exclusive breastfeeding rate of 75% on discharge. They described the setting and its employees in detail.

HELPFUL HINT Managing personal bias is an expectation of researchers using all of the methods discussed in this chapter.

Data gathering Ethnographic data gathering involves immersion in the study setting and the use of participant observation, interviews of

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informants, and interpretation by the researcher of cultural patterns (Richards & Morse, 2013). Ethnographic research involves face-to- face interviewing with data collection and analysis taking place in the natural setting. Thus fieldwork is a major focus of the method. Other techniques may include obtaining life histories and collecting material items reflective of the culture. Example: ➤ Photographs and films of the informants in their world can be used as data sources. In their study, Grassley and colleagues (2015) collected data using focus groups, individual and group interviews, and mother/baby unit observations.

Data analysis Like the grounded theory method, ethnographic data are collected and analyzed simultaneously. Data analysis proceeds through several levels as the researcher looks for the meaning of cultural symbols in the informant’s language. Analysis begins with a search for domains or symbolic categories that include smaller categories. Language is analyzed for semantic relationships, and structural questions are formulated to expand and verify data. Analysis proceeds through increasing levels of complexity until the data, grounded in the informant’s reality, are synthesized by the researcher (Richards & Morse, 2013). Grassley and colleagues (2015) described analysis of data as beginning with interview transcripts using content analysis, with subsequent team meetings to discuss findings and agree on categories. The observation notes were used to substantiate the themes.

Describing the findings Ethnographic studies yield large quantities of data that reflect a wide array of evidence amassed as field notes of observations, interview transcriptions, and sometimes other artifacts such as photographs. The first level description is the description of the scene, the parameters or boundaries of the research group, and the overt characteristics of group members (Richards & Morse, 2013). Strategies that enhance first level description include maps and floor plans of the setting, organizational charts, and documents. Researchers may report item-level analysis, followed by pattern and structure level of analysis. Ethnographic research articles

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usually provide examples from data, thorough descriptions of the analytical process, and statements of the hypothetical propositions and their relationship to the ethnographer’s frame of reference, which can be rather detailed and lengthy. Grassley and colleagues (2015) identified three main themes that described nurses’ support of breastfeeding on the night shift: competing priorities, incongruent expectations, and influential institutional structure; these described the interpersonal interactions and institutional structures that affected the nurses. Competing priorities included maternal rest, the newborn night feeding pattern, the presence of visitors, support of the breastfeeding dyad, and other patients’ care needs. Incongruent expectations included the breastfeeding expectations of parents, the newborn’s breastfeeding behaviors, parental night feeding expectations, the newborn’s nocturnal sleep pattern, the nurses’ expectations about support, and challenging breastfeeding dyads. Finally, influential institutional structures included hospital practices, staffing (including the nurse/patient ratio, RN experience, and lactation of RNs), and feeding policies.

EVIDENCE-BASED PRACTICE TIP Evidence generated by ethnographic studies will answer questions about how cultural knowledge, norms, values, and other contextual variables influence the health experience of a particular patient population in a specific setting.

Case study Case study research, which is rooted in sociology, has a complex history and many definitions (Aita & McIlvain, 1999). As noted by Stake (2000), a case study design is not a methodological choice; rather, it is a choice of what to study. Thus the case study method is about studying the peculiarities and the commonalities of a specific case, irrespective of the actual strategies for data collection and analysis that are used to explore research questions. Case studies include quantitative and/or qualitative data but are defined by their focus on uncovering an individual case and, in some instances, identifying patterns in variables that are consistent across a set of cases. Stake (2000) distinguishes intrinsic from instrumental case studies. Intrinsic case study is undertaken to have a better

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understanding of the case—for example, one child with chickenpox, as opposed to a group or all children with chickenpox. The researcher at least temporarily subordinates other curiosities so that the stories of those “living the case” will be teased out (Stake, 2000). Instrumental case study is used when researchers are pursuing insight into an issue or want to challenge some generalization—for example, the qualities of sleep and restfulness in a set of four children with chickenpox. Very often, in case studies, there is an emphasis on holism, which means that researchers are searching for global understanding of a case within a spatially or temporally defined context.

Identifying the phenomenon Although some definitions of case study demand that the focus of research be contemporary, Stake’s (1995, 2000) defining criterion of attention to the single case broadens the scope of phenomenon for study. By a single case, Stake is designating a focus on an individual, a family, a community, an organization—some complex phenomenon that demands close scrutiny for understanding. Walker and colleagues (2015) used a case study design to examine how older, early-stage breast and prostate cancer patients managed the transition from active treatment of cancer to recovery when treatment was completed. To explore the strategies that cancer patients used, Walker and colleagues used a purposive sampling strategy to select a sample of 11 patient and caregiver dyads from a larger group of dyads enrolled in a randomized clinical trial of a new cancer treatment.

Structuring the study

Research question. Stake (2000) suggests that research questions be developed around issues that serve as a foundation to uncover complexity and pursue understanding. Although researchers pose questions to begin discussion, the initial questions are never all-inclusive; rather, the researcher uses an iterative process of “growing questions” in the field. That is, as data are collected to address these questions, it is expected that other questions will emerge and serve as guides to

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the researcher to untangle the complex, context-laden story within the case. Example: ➤ In Walker and colleagues’ (2015) study, data were collected from patients’ daily written journals, patient interview transcripts, and researcher notes from telephone calls with patients and caregivers. By using multiple ways of identifying how patients recovered after treatment, the researchers were able to describe a central theme about cancer recovery—with the return of a sense of “normalcy,” patients experienced less anxiety and greater quality of life. Using rich description in the case study data, the researchers were also able to describe resources, such as conversations with family members and health care workers, which promote a sense of normalcy and well-being after treatment.

Researcher’s perspective. When the researcher begins with questions developed around suspected issues of importance, they are said to have an “etic” focus, which means the research is focused on the perspective of the researcher. As case study researchers engage the phenomenon of interest in individual cases, the uniqueness of individual stories unfold and shift from an etic (researcher orientation) to an “emic” (participant orientation) focus (Stake, 2000). Ideally, the case study researcher will develop an insider view that permits narration of the way things happen in the case. Example: ➤ In the study by Walker and colleagues (2015), the etic focus on the abstract concept of “recovery” shifted to the emic focus on the precise details about the way patients returned to a sense of normalcy after treatment.

Sample selection. This is one of the areas where scholars in the field present differing views, ranging from only choosing the most common cases to only choosing the most unusual cases (Aita & McIlvain, 1999). Stake (2000) advocates selecting cases that may offer the best opportunities for learning. In some instances, the convenience of studying the case may even be a factor. For instance, if there are several patients who have undergone heart transplantation and are willing to participate in the study, practical factors may influence which patient offers the best opportunity for learning. Persons who live in the area and can be easily visited at home or in the medical

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center might be better choices than those living much farther away (where multiple contacts over time might be impossible). Similarly, the researcher may choose to study a case in which a potential participant has an actively involved family, because understanding the family context of transplant patients may shed important new light on their healing. It can safely be said that no choice is perfect when selecting a case; however, selecting cases for their contextual features fosters the strength of data that can be learned at the level of the individual case. Example: ➤ In the Walker and colleagues’ (2015) study, the selection of 11 patient and caregiver dyads permitted the detailed data collection necessary to describe the actual process of returning to normalcy and how factors in the environment contributed to this process.

Data gathering Case study data are gathered using interviews, field observations, document reviews, and any other methods that accumulate evidence for describing or explaining the complexity of the case. Stake (1995) advocates development of a data gathering plan to guide the progress of the study from definition of the case through decisions regarding data collection involving multiple methods, at multiple time points, and sometimes with multiple participants within the case. In the Walker and colleagues’ (2015) study, multiple methods for collecting data were used, including daily written diaries, interview transcripts, and notes from phone calls. Using data from multiple sources, the researchers used data from different times and points of view to describe the step-by-step process of returning to normal after cancer treatment.

Data analysis/describing findings Data analysis is often concurrent with data gathering and description of findings as the narrative in the case develops. Qualitative case study is characterized by researchers spending extended time on site, personally in contact with activities and operations of the case, and reflecting and revising meanings of what transpires (Stake, 2000). Reflecting and revising meanings are the work of the case study researcher, who records data, searches for patterns, links data from multiple sources, and develops

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preliminary thoughts regarding the meaning of collected data. This reflective and iterative process for writing the case narrative produces a unique form of evidence. Many times case study research reports do not list all of the research activities. However, reported findings are usually embedded in the following: (1) a chronological development of the case; (2) the researcher’s story of coming to know the case; (3) the one-by-one description of case dimensions; and (4) vignettes that highlight case qualities (Stake, 1995). Example: ➤ As Walker and colleagues (2015) analyzed “cases” of patient recovery after treatment, the diversity of cases in the study permitted the researchers to identify behaviors, such as conversations with trusted health care workers, which patients used to reassess their wellness and realize they were healing after treatment. Analysis consisted of the search for patterns in raw data, variation in the patterns within and between cases, and identification of themes that described common patterns within and between the cases. In the study by Walker and colleagues (2015), the researchers ultimately used patterns in the case data to develop a theory about the process of working toward normalcy after cancer treatment; this was significant because the new theory is focused on patient experiences and will be a guide for assisting cancer patients in the future.

EVIDENCE-BASED PRACTICE TIP Case studies are a way of providing in-depth evidence-based discussion of clinical topics that can be used to guide practice.

Community-based participatory research Community-based participatory research is a research method that systematically accesses the voice of a community to plan context- appropriate action. CBPR provides an alternative to traditional research approaches that assume a phenomenon may be separated from its context for purposes of study. Investigators who use CBPR recognize that engaging members of a study population as active and equal participants, in all phases of the research, is crucial for the research process to be a means of facilitating change (Holkup et al., 2004). Change or action is the intended end product of CBPR, and “action research” is a term related to CBPR. Many scholars

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consider CBPR to be a type of action research and group this within the tradition of critical science (Fontana, 2004).

In his book Action Research, Stringer (1999) distilled the research process into three phases: look, think, and act. In the look phase Stringer (1999) describes “building the picture” by getting to know stakeholders so that the problem is defined in their terms and the problem definition is reflective of the community context. He characterizes the think phase as interpretation and analysis of what was learned in the look phase. As investigators “think,” the researcher is charged with connecting the ideas of the stakeholders so that they provide evidence that is understandable to the larger community group (Stringer, 1999). Finally, in the act phase, Stringer (1999) advocates planning, implementation, and evaluation based on information collected and interpreted in the other phases of research.

Bisung and colleagues (2015) used photovoice as a CBPR tool to understand water, sanitation, and hygiene behaviors and to catalyze community-led solutions to change behaviors among women in Western Kenya. Changing these behaviors is essential for reducing waterborne and water-related diseases. Photovoice is a CBPR tool that can be used to foster trust and capacity building for community-led solutions to environment and health issues. Through photography, participants, who take the pictures themselves, are able to identify, represent, discuss, and find solutions to their everyday environment and health problems. In the first part of their study, photovoice one-on-one interviews were used to explore local perceptions and practices around water-health linkages and how the ecological and sociopolitical environment shapes these perceptions and practices. The second component consisted of using photovoice group discussions to explore participants’ experiences with and reactions to the photographs and the photovoice project. From the group discussions, three major themes emerged: awareness, immediate reactions, and planned actions. Awareness involved the photos serving as prompts to certain behaviors and practices in the community and the influence of these practices on their health. Immediate reactions involved spontaneous decisions to educate people and stop children from certain negative practices and having discussions on how to find

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solutions to common negative behaviors and practices. Planned actions involved working with village leaders and the whole community.

Mixed methods research Mixed methods research is basically the use of both qualitative and quantitative methods in one study. Mixed methods research has evolved over the past decade. There are several types of mixed methods designs (Creswell & Plano Clark, 2011). Researchers who choose a mixed methods study choose on the basis of the question. (See Chapter 10 for further information.)

Data from different sources can be used to corroborate, elaborate, or illuminate the phenomenon in question. Example: ➤ Bhandari and Kim (2016) conducted a mixed methods study. The study aimed to develop an exploratory model for self-care in type 2 diabetic adults and enhance the model’s interpretation through qualitative input. For the qualitative component, the researchers conducted semistructured interviews with a subset (N = 13) of the total sample (N = 230). For the quantitative component, the subjects responded to several questionnaires related to self-care behaviors. As you read research, you will quickly discover that approaches and methods, such as mixed methods, are being combined to contribute to theory building, guide practice, and facilitate instrument development.

Although certain questions may be answered effectively by combining qualitative and quantitative methods in a single study, this does not necessarily make the findings and related evidence stronger. In fact, if a researcher inappropriately combines methods in a single study, the findings could be weaker and less credible.

Synthesizing qualitative evidence: Meta- synthesis The depth and breadth of qualitative research has grown over the years, and it has become important to qualitative researchers to synthesize critical masses of qualitative findings.

The terms most commonly used to describe this activity are qualitative meta-summary and qualitative meta-synthesis.

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Qualitative meta-summary is a quantitatively oriented aggregation of qualitative findings that are topical or thematic summaries or surveys of data. Meta-summaries are integrations that are approximately equal to the sum of parts, or the sum of findings across reports in a target domain of research. They address the manifest content in findings and reflect a quantitative logic: to discern the frequency of each finding and to find in higher frequency the evidence of replication foundational to validity in most quantitative research. Qualitative meta-summary involves the extraction and further abstraction of findings, and the calculation of manifest frequency effect sizes (Sandelowski & Barroso, 2003a). Qualitative meta-synthesis is an interpretive integration of qualitative findings that are interpretive syntheses of data, including the phenomenologies, ethnographies, grounded theories, and other integrated and coherent descriptions or explanations of phenomena, events, or cases that are the hallmarks of qualitative research. Meta-syntheses are integrations that are more than the sum of parts in that they offer novel interpretations of findings. These interpretations will not be found in any one research report; rather, they are inferences derived from taking all of the reports in a sample as a whole. Meta-syntheses offer a description or explanation of a target event or experience, instead of a summary view of unlinked features of that event or experience. Such interpretive integrations require researchers to piece the individual syntheses constituting the findings in individual research reports together to craft one or more meta-syntheses. Their validity does not reside in a replication logic, but in an inclusive logic whereby all findings are accommodated and the accumulative analysis displayed in the final product. Meta-synthesis methods include constant comparison, taxonomic analysis, the reciprocal translation of in vivo concepts, and the use of imported concepts to frame data (Sandelowski & Barroso, 2003b). Meta-synthesis integrates qualitative research findings on a topic and is based on comparative analysis and interpretative synthesis of qualitative research findings that seek to retain the essence and unique contribution of each study (Sandelowski & Barroso, 2007).

Fleming and colleagues (2015) published a meta-synthesis of qualitative studies related to antibiotic prescribing in long-term care

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facilities. The synthesis of qualitative research was used to facilitate determination of antibiotic prescribing in long-term care settings. This meta-synthesis provided a way to describe findings across a set of qualitative studies and create knowledge that is relevant to clinical practice. Sandelowski (2004) cautions that the use of qualitative meta-synthesis is laudable and necessary, but requires careful application of qualitative meta-synthesis methods. There are a number of meta-synthesis studies being conducted by nurse scientists. It will be interesting for research consumers to follow the progress of researchers who seek to develop criteria for appraising a set of qualitative studies and use those criteria to guide the incorporation of these studies into systematic literature reviews.

EVIDENCE-BASED PRACTICE TIP Although qualitative in its approach to research, community-based participatory research leads to an action component in which a nursing intervention is implemented and evaluated for its effectiveness in a specific patient population.

Issues in qualitative research Ethics Protection of human subjects is a critical aspect of all scientific investigation. This demand exists for both quantitative and qualitative research approaches. Protection of human subjects in quantitative approaches is discussed in Chapter 13. These basic tenets hold true for the qualitative approach. However, several characteristics of the qualitative methodologies outlined in Table 6.1 generate unique concerns and require an expanded view of protecting human subjects.

TABLE 6.1 Characteristics of Qualitative Research Generating Ethical Concerns

Characteristics Ethical Concerns Naturalistic setting

Some researchers using participant observation methods may believe that consent is not always possible or necessary.

Emergent Planning for questioning and observation emerges over the time of the study.

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nature of design

Thus it is difficult to inform the participant precisely of all potential threats before he or she agrees to participate.

Researcher- participant interaction

Relationships developed between the researcher and participant may blur the focus of the interaction.

Researcher as instrument

The researcher is the study instrument, collecting data and interpreting the participant’s reality.

Naturalistic setting The central concern that arises when research is conducted in naturalistic settings focuses on the need to gain informed consent. The need to obtain informed consent is a basic researcher responsibility but is not always easy to obtain in naturalistic settings. For instance, when research methods include observing groups of people interacting over time, the complexity of gaining consent becomes apparent: Have all parties consented for all periods of time? Have all parties been consented? What have all parties consented to doing? These complexities generate controversy and debate among qualitative researchers. The balance between respect for human participants and efforts to collect meaningful data must be continuously negotiated. The reader should look for information indicating that the researcher has addressed this issue of balance by recording attention to human participant protection.

Emergent nature of design The emergent nature of the research design in qualitative research underscores the need for ongoing negotiation of consent with participants. In the course of a study, situations change, and what was agreeable at the beginning may become intrusive. Sometimes, as data collection proceeds and new information emerges, the study shifts direction in a way that is not acceptable to participants. For instance, if the researcher were present in a family’s home during a time when marital discord arose, the family may choose to renegotiate the consent. From another perspective, Morse (1998) discussed the increasing involvement of participants in the research process, sometimes resulting in their request to have their names published in the findings or be included as a coauthor. If the participant originally signed a consent form and then chose an

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active identified role, Morse (1998) suggests that the participant then sign a “release for publication” form to address this request. The emergent qualitative research process demands ongoing negotiation of researcher-participant relationships, including the consent relationship. The opportunity to renegotiate consent establishes a relationship of trust and respect characteristic of the ethical conduct of research.

Researcher-participant interaction The nature of the researcher-participant interaction over time introduces the possibility that the research experience will become a therapeutic one. It is a case of research becoming practice. It is important to recognize that there are basic differences between the intent of nurses when engaging in practice and when conducting research (Smith & Liehr, 2003). In practice, the nurse has caring- healing intentions. In research, the nurse intends to “get the picture” from the perspective of the participant. The process of “getting the picture” may be a therapeutic experience for the participant. When a research participant talks to a caring listener about things that matter, the conversation may promote healing, even though it was not intended. From an ethical perspective, the qualitative researcher is promising only to listen and encourage the other’s story. If this experience is therapeutic for the participant, it becomes an unplanned benefit of the research. If it becomes harmful, the ethics of continuing the research becomes an issue and the study design will require revision.

Researcher as instrument The responsibility to establish rigor in data collection and analysis requires that the researcher acknowledge any personal bias and strive to interpret data in a way that accurately reflects the participant’s point of view. This serious ethical obligation may require that researchers return to the subjects at critical interpretive points and ask for clarification or validation.

Credibility, auditability, and fittingness Quantitative studies are concerned with reliability and validity of

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instruments, as well as internal and external validity criteria as measures of scientific rigor (see the Critical Thinking Decision Path), but these are not appropriate for qualitative work. The rigor of qualitative methodology is judged by unique criteria appropriate to the research approach. Credibility, auditability, and fittingness were scientific criteria proposed for qualitative research studies by Guba and Lincoln (1981). Although these criteria were proposed decades ago, they still capture the rigorous spirit of qualitative inquiry and persist as reasonable criteria for appraisal of scientific rigor in the research. The meanings of credibility, auditability, and fittingness are briefly explained in Table 6.2.

TABLE 6.2 Criteria for Judging Scientific Rigor: Credibility, Auditability, Fittingness

Criteria Criteria Characteristics Credibility Truth of findings as judged by participants and others within the discipline. For

instance, you may find the researcher returning to the participants to share interpretation of findings and query accuracy from the perspective of the persons living the experience.

Auditability Accountability as judged by the adequacy of information leading the reader from the research question and raw data through various steps of analysis to the interpretation of findings. For instance, you should be able to follow the reasoning of the researcher step by step through explicit examples of data, interpretations, and syntheses.

Fittingness Faithfulness to participants’ everyday reality, described in enough detail so that others can evaluate importance for practice, research, and theory development. For instance, you will know enough about the human experience being reported that you can decide whether it “rings true” and is useful for guiding your practice.

EVIDENCE-BASED PRACTICE TIPS

• Mixed methods research offers an opportunity for researchers to increase the strength and consistency of evidence provided by the use of both qualitative and quantitative research methods.

• The combination of stories with numbers (qualitative and quantitative research approaches) through use of mixed methods may provide the most complete picture of the phenomenon being studied and, therefore, the best evidence for guiding practice.

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Appraisal for evidence-based practice qualitative research General criteria for critiquing qualitative research are proposed in the following Critical Appraisal Criteria box. Each qualitative method has unique characteristics that influence what the research consumer may expect in the published research report, and journals often have page restrictions that penalize qualitative research. The criteria for critiquing are formatted to evaluate the selection of the phenomenon, the structure of the study, data collection, data analysis, and description of the findings. Each question of the criteria focuses on factors discussed throughout the chapter. Appraising qualitative research is a useful activity for learning the nuances of this research approach. You are encouraged to identify a qualitative study of interest and apply the criteria for critiquing. Keep in mind that qualitative methods are the best way to start to answer clinical and/or research questions that previously have not been addressed in research studies or that do not lend themselves to a quantitative approach. The answers provided by qualitative data reflect important evidence that may provide the first insights about a patient population or clinical phenomenon.

CRITICAL APPRAISAL CRITERIA Qualitative Approaches Identifying the phenomenon

1. Is the phenomenon focused on human experience within a natural setting?

2. Is the phenomenon relevant to nursing and/or health?

Structuring the study Research question

3. Does the question specify a distinct process to be studied?

4. Does the question identify the context (participant group/place)

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of the process that will be studied?

5. Does the choice of a specific qualitative method fit with the research question?

Researcher’s perspective

6. Are the biases of the researcher reported?

7. Do the researchers provide a structure of ideas that reflect their beliefs?

Sample selection

8. Is it clear that the selected sample is living the phenomenon of interest?

Data collection

9. Are data sources and methods for gathering data specified?

10. Is there evidence that participant consent is an integral part of the data-gathering process?

Data analysis

11. Can the dimensions of data analysis be identified and logically followed?

12. Does the researcher paint a clear picture of the participant’s reality?

13. Is there evidence that the researcher’s interpretation captured the participant’s meaning?

14. Have other professionals confirmed the researcher’s interpretation?

Describing the findings

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15. Are examples provided to guide the reader from the raw data to the researcher’s synthesis?

16. Does the researcher link the findings to existing theory or literature, or is a new theory generated?

In summary, the term qualitative research is an overriding description of multiple methods with distinct origins and procedures. In spite of distinctions, each method shares a common nature that guides data collection from the perspective of the participants to create a story that synthesizes disparate pieces of data into a comprehensible whole that provides evidence and promises direction for building nursing knowledge.

Key points • Qualitative research is the investigation of human experiences in

naturalistic settings, pursuing meanings that inform theory, practice, instrument development, and further research.

• Qualitative research studies are guided by research questions.

• Data saturation occurs when the information being shared with the researcher becomes repetitive.

• Qualitative research methods include five basic elements: identifying the phenomenon, structuring the study, gathering the data, analyzing the data, and describing the findings.

• The phenomenological method is a process of learning and constructing the meaning of human experience through intensive dialogue with persons who are living the experience.

• The grounded theory method is an inductive approach that implements a systematic set of procedures to arrive at theory about basic social processes.

• The ethnographic method focuses on scientific descriptions of cultural groups.

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• The case study method focuses on a selected phenomenon over a short or long time period to provide an in-depth description of its essential dimensions and processes.

• CBPR is a method that systematically accesses the voice of a community to plan context-appropriate action.

• Ethical issues in qualitative research involve issues related to the naturalistic setting, emergent nature of the design, researcher- participant interaction, and researcher as instrument.

• Credibility, auditability, and fittingness are criteria for judging the scientific rigor of a qualitative research study.

• Mix methods approaches to research are promising.

Critical thinking challenges • How can mixed methods increase the effectiveness of qualitative

research?

• How can a nurse researcher select a qualitative research method when he or she is attempting to accumulate evidence regarding a new topic about which little is known?

• How can the case study approach to research be applied to evidence-based practice?

• Describe characteristics of qualitative research that can generate ethical concerns.

• Your interprofessional team is asked to provide a rationale about why they are searching for a meta-synthesis rather than individual qualitative studies to answer their clinical question.

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

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http://evolve.elsevier.com/LoBiondo/

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CHAPTER 7

Appraising qualitative research Dona Rinaldi Carpenter

Learning outcomes

After reading this chapter, you should be able to do the following:

• Understand the role of critical appraisal in research and evidence- based practice. • Identify the criteria for critiquing a qualitative research study. • Identify the stylistic considerations in a qualitative study. • Apply critical reading skills to the appraisal of qualitative research. • Evaluate the strengths and weaknesses of a qualitative study. • Describe applicability of the findings of a qualitative study. • Construct a written critique of a qualitative study.

KEY TERMS

bracketing

phenomenology

auditability

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credibility

phenomena

saturation

theme

trustworthiness

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

Qualitative and quantitative research methods vary in terms of purpose, approach, analysis, and conclusions. Therefore, the use of each requires an understanding of the traditions on which the methods are based. This chapter aims to provide a set of criteria that can be used to critique qualitative research studies through a process of critical analysis and evaluation.

The critical appraisal of qualitative research continues to be discussed in nursing and related health care professions, providing a framework that includes key concepts for evaluation (Beck, 2009; Bigby, 2015; Flannery, 2016; Horsburgh, 2003; Ingham-Broomfield, 2015; Pearson et al., 2015; Russell & Gregory, 2003; Sandelowski, 2015; Williams, 2015).

Critical appraisal and qualitative research considerations Qualitative research represents a basic level of inquiry that seeks to discover and understand concepts, phenomena, or cultures. In a qualitative study, you should not expect to find hypotheses; theoretical frameworks; dependent and independent variables; large, random samples; complex statistical procedures; scaled instruments; or definitive conclusions about how to use the findings. A primary reason for conducting a qualitative study is to develop a theory or to discover knowledge about a phenomenon. Sample size is expected to be small. This type of research is not generalizable, nor should it be. Findings are presented in a

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narrative format with raw data used to illustrate identified themes. Thick, rich data are essential in order to document the rigor of the research, which is called trustworthiness in a qualitative research study. Ensuring trustworthiness in qualitative inquiry is critical, as qualitative researchers seek to have their work recognized in an evidence-driven world (Beck, 2009; Bigby, 2015).

Application of qualitative research findings The purpose of qualitative research is to describe, understand, or explain phenomenon important to nursing. Phenomena are those things that are perceived by our senses. For example, pain and losing a loved one are considered phenomena. In a qualitative study, the researcher gathers narrative data that uses the participants’ voices and experiences to describe the phenomenon under investigation. Barbour and Barbour (2003) offer that qualitative research can provide the opportunity to give voice to those who have been disenfranchised and have no history. Therefore, the application of qualitative findings will necessarily be context-bound (Russell & Gregory, 2003).

Qualitative research also has the ability to contribute to evidenced-based practice literature (Anthony & Jack, 2009; Cesario et al., 2002; Donnelly & Wiechula, 2013; Walsh & Downe, 2005). Describing the lived human experience of patients can contribute to the improvement of care, adding a dimension of understanding to our work as it is described by those who live it on a day-to-day basis. Fundamentally, principles for evaluating qualitative research are the same. Reviewers are concerned with the plausibility and trustworthiness of the researcher’s account of the findings and its potential and/or actual relevance to current or future theory and practice (Horsburgh, 2003; Ingham-Bloomfield, 2015; Pearson et al., 2015; Sandelowski, 2015; Williams, 2015). As a framework for understanding how the appraisal of qualitative research can support evidence-based practice, a published research report and critical appraisal criteria follow (Table 7.1). The critical appraisal criteria will be used to demonstrate the process of appraising a qualitative research report. For information on specific guidelines for appraisal of phenomenology, ethnography, grounded theory,

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and action research, see Chapters 5 and 6 and Streubert and Carpenter (2011).

TABLE 7.1 Critical Appraisal of Qualitative Research

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CRITICAL APPRAISAL CRITERIA Qualitative Research Study As evidenced by published works, phenomenology is one approach to qualitative research. From a nursing perspective, qualitative research allows caregivers to understand the life experience of the patients they care for. Excerpts from “A Woman’s Experience: Living With an Implantable Cardioverter Defibrillator” by Jaclyn Conelius are provided throughout this chapter as examples of phenomenological research. The article was published in Applied Nursing Research in 2015. The following sections critique Conelius’s study. The primary purpose of this critique is to carefully examine how each step of the research process has been articulated in the study and to examine how the research has contributed to nursing knowledge. The article by Conelius (2015) provides an example of a phenomenological study true to qualitative methods.

Critique of a qualitative research study

The research study The study “A Woman’s Experience: Living With an Implantable Cardioverter Defibrillator” by Jaclyn Conelius, published in Applied Nursing Research, is critiqued. The article is presented in its entirety and followed by the critique.

A woman’s experience: Living with an implantable cardioverter defibrillator Jaclyn Conelius, PhD, FNP-BC

Abstract The implantable cardioverter defibrillators (ICD) have decreased mortality rates from those who are at risk for sudden cardiac death or who have survived sudden cardiac death and has been shown to

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be superior to antiarrhythmic medications (Greenburg et al., 2004). This advance in technology may improve physical health but can impose some challenges to patients, such as depression, anxiety, fear, and unpredictability. Published research on how ICD affects a woman’s life experience using phenomenology is limited. Therefore, the purpose of this article is to describe the experiences of women who have an ICD using Colaizzi’s method of phenomenology since their implant. Analysis of the three interviews resulted in five themes that described the essence of this experience. The results of this study could not only help clinicians understand what their patients are experiencing but also it can be used as an education tool.

Introduction Implantable cardioverter defibrillators (ICDs) have decreased mortality rates from those who are at risk for sudden cardiac death or who have survived sudden cardiac death and has been shown to be superior to anti-arrhythmic medications (Greenburg et al., 2004). ICDs have been supported by many clinical trials and it is now the treatment of choice in primary and secondary prevention for these patients (Bardy et al., 2005; Bristow et al., 2004; Moss et al., 2002). This mainstay of treatment has increased steadily from 486,025 implants from 2006 to 2009 to 850,068 from 2010 to 2011 (Hammill et al., 2010; Kremers et al., 2013). Of these implants approximately 28% were female only.

This advance in technology may improve physical health but can impose some challenges to patients. They include the adjustments to the device in their everyday living, such as; quality of life issues as well as psychological issues. Through quantitative research the following have been reported; a fear of physical activity and a fear of shock from the device to prevent the sudden cardiac arrest (Lampert et al., 2002; Wallace et al., 2002; Whang et al., 2005). Other studies have reported anxiety, fear, and depression in these patients. Some specific fears included; malfunctioning, unpredictability, and the inability to control events (Dickerson, 2005; Dunbar, 2005; Eckert & Jones, 2002; Kamphuis et al., 2004; Lemon, Edelman, & Kirkness, 2004). These quality of life and

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psychological issues reported in the studies are not reported as gender specific; therefore, female specific challenges are not well studied. Furthermore, there have been few qualitative studies based on a patient’s experience of living with an ICD. Previous studies reported themes such as the feeling of gratitude, safety, belief in the future, adjustment to the device, lifesaving yet changing, fear of receiving a shock, physical/mental deterioration, confrontation with mortality and conditional acceptance (Dickerson, 2002; Fridlund et al., 2000; Kamphuis et al., 2004; Morken, Severinsson, & Karlsen, 2009; Tagney, James, & Alberran, 2003).

Based on the available research studies, there is very little reported data specific to females and specifically how an ICD affects a woman’s lived experience. A lived experience is how a person immediately experiences the world (Husserl, 1970). In order to understand a woman’s lived experience living with an ICD, phenomenology was used. Phenomenology is a philosophy and a research method used to understand everyday lived experiences. Therefore, the purpose of this study was to describe what those experiences were, specifically, to describe their thoughts, feelings, and perceptions that they have experienced since their implant. It is important to gain an understanding and formulate a description of what life is for a woman who had received an implantable cardioverter defibrillator in order to describe the universal essence of that experience. Descriptive phenomenology emphasizes describing universal essences, viewing the person as one representative of the world in which she lives, an assumption of self-reflection, a belief that the consciousness is what people share and a belief that stripping of previous knowledge (bracketing) helps prevent investigator bias and interpretation bias (Wojnar & Swanson, 2007). Specifically, Colaizzi’s (1978) descriptive phenomenological method uses seven steps as a method of analyzing data so that by the end of the study a description of the lived experience could be reported.

Method Descriptive phenomenology originated from the philosopher Husserl (1970), who believed that the meaning of a lived experience may be discovered though one to one interaction between the

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researcher and the subject. It assumes that for any human experience, there are distinct structures that make up the phenomenon. Studying the individual experiences highlights these essential structures. It is an inductive method that describes a phenomenon as it is experienced by an individual rather than by transforming it into an operationally defined behavior. An important aspect of descriptive phenomenology, according to Husserl, is the process of bracketing in which he describes as separating the phenomenon from the world and having the researcher suspend all preconceptions (Wojnar & Swanson, 2007). The goal of descriptive phenomenology is to provide a universal description of the lived experience as described by the participants of the phenomenon. Colaizzi’s (1978) method of descriptive phenomenology is the method used for this study. In his method, interviewing is the selected strategy for collecting data, which is necessary for describing an experience. This method works well with a small sample size.

Sample. Ten women were asked to participate, of these, three women agreed to participate from a private cardiology office in the United States. This convenient sample of women were all Caucasian and their ages ranged from 34 to 50 years old. All three women had college degrees and have had the device over one year. None of the women were previously diagnosed with any psychiatric disease.

Procedure. After receiving approval from the university’s institutional review board (IRB), women were recruited from a private cardiology office in the United States for 4 months. The participant population only included women that had an implantable cardioverter defibrillator (ICD). Women needed to be 18 years or older, and speak English. Women of all ethnic backgrounds were eligible to participate. There was no cost to the participant and no compensation provided. Once the informed consent was signed, they were asked to stay for an interview that day. All women were interviewed privately in the office and each interview lasted approximately 45 minutes to an hour. They were asked to “describe their experiences after having

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received an ICD, specifically, to describe their thoughts, feelings, and perceptions that they had experienced since their implant?” They were then asked to share as much of those experiences to the point that they did not have anything else to contribute. The interviews were recorded and then transcribed. The researcher conducted all of the interviews since the researcher in trained in the method. Interviews were conducted until an accurate description of the phenomenon had occurred, repetition of data and no new themes where described. This saturation of data did occurs after the three interviews. After each interview, follow up questions were asked in order to clarify any points the participant described. The researcher kept a journal to write down any notes needed during the interview.

In order for the description to be pure, the researcher’s prior knowledge was bracketed to capture the essence of the description without bias (Wojnar & Swanson, 2007). Husserl (1970) introduced the term, and it means to set aside one’s own assumption and preunderstanding. In order to be true to the method, the researcher reflected and kept a journal of all assumptions, clinical experiences, understandings and biases to reference during the entire study.

Significant statements and phrases pertaining to a woman’s experience living with an ICD were extracted from each transcript. These statements were written on separate sheets and coded. Meanings were formulated from the significant statements. Accordingly, each underlying meaning was coded into a specific category as it reflected an exhaustive description. Then the significant statements with the formulated meanings where grouped into themes.

To ensure confidentiality, the signed informed consent forms were kept separate from the transcripts. The recorded tapes and hard copy were in a locked cabinet. Identifying information was deleted and names were never used in any research reports. Audiotapes were destroyed once the pilot study was completed.

Data analysis. Each transcript was analyzed using Colaizzi’s (1978) method. The method of data analysis consisted of the following steps; (1) read all the participants’ descriptions of the phenomenon, (2) extract

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significant statements that pertain directly to the phenomenon, (3) formulate meanings for each significant statement, (4) categorizing into clusters of themes and validation with the original transcript, (5) describing, (6) validate the description by returning to the participant to ask them how it compares with their experience, and (7) incorporate any changes offered by the participant into the final description of the essence of the phenomenon.

Rigor. There were efforts made to limit any potential bias of the researcher. One such effort was to bracket any of the researcher’s prior perspective and knowledge of the subject (Aher, 1999). To ensure the credibility of the data collected, two of the women in the study reviewed the description of the lived experiences as suggested by Lincoln and Guba (1985). This was performed as a validity check of the data. In order to address for auditability, a tape recorder was used and the researcher reviewed the transcripts and cross-referenced the field noted (Beck, 1993).

Additionally, the transcripts were transcribed verbatim by a secretary in order to ensure they were free of bias. Also, the data analysis and description of the lived experience were reviewed by an independent judge with phenomenological experience to ensure intersubjective agreement. All of the themes reported were agreed upon by the judge.

Finally, the researcher validated the description by returning to the participants to ask them how it compared with their experience and incorporated any changes offered by the participants into the final description of the essence of the phenomenon. This final description was reviewed by other women with ICDs who were not a part of the study to ensure fittingness.

Results At the conclusion of verifying and reviewing the transcripts, there were 46 significant statements extracted that pertained directly to the phenomenon. From each significant statement formulated meanings were created. These statements were then formed into five themes (Table 1) that described the essence of these experiences.

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TABLE 1 Selected Examples of Significant Statements and their Formulated Meaning for Five Themes

Theme Number Significant Statement Formulated Meaning

1 Security blanket: lf it keeps me alive It’s worth it.

“I do not have anything to worry about anymore. I used to worry that if something happened, how soon I can get to a hospital or what could they do to try to save me.”

The women did not have to worry anymore about medical emergencies.

2 A piece of cake: I do more than before.

“Actually, I probably do a little more than before. But I can do everything that I did before. I have not eased up on anything.”

She felt as if nothing has changed. She does everything she did prior.

3 A constant reminder: I know it’s there.

“The children sometimes bump into that side and I am literally guarding that side all the time.”

She is aware of it and guards it when others come in contact with it.

4 Living on the edge: I do not want it to go off.

“I do have a little fear of that but so far, it hasn’t happened.”

She has an extreme fear of the device shocking her.

5 Catch 22: I’d rather not have it.

“I would rather not personally have it but I know medically, I need to have it, which is a good thing.”

She would rather not have to have it, but she knows she needs it.

Theme 1: Security blanket: If it keeps me alive it’s worth it. Women who had an ICD felt a sense of security with the device. They felt that this device acted as a security blanket. Prior to their device they had a constant worry about how soon they could get medical treatment and now that they had the device, that worry was lifted. The feeling of worry was no longer apparent for them. One woman said:

Now I just think this will keep me alive long enough for somebody to make a decision, at least it will give me a chance. I do not have anything to worry about anymore. I used to worry that if something happened, how soon I could get to a hospital or what could they do to try to save me.

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The women also described how their worry decreased should they require medical treatment while they were with their family also was decreased. “Now I do not have to worry if I am with my family, I have ICD in my chest to give me treatment right away.”

Another woman felt that the device just being there saved her life. “If the device can save her life it’s worth it.” The device prevents the heart from having sustained lethal arrhythmias.

She explained: “I feel like it saved my life, I feel like it keeps my heart beating nice and smooth.”

There was an overall feeling that the device improved their lives. Based on their past medical history, the device was needed since it is the next step in their medical treatment. All the women were glad they were able to receive the device. One woman explained:

It could be both ways. I mean, I feel knowing what my family history is, yeah, I am glad I have it. I needed it. It made me feel that I can go anywhere and do anything because it acts like my insurance policy.

Theme 2: A piece of cake: I do more than before. The women did not have a decrease in physical functioning or quality of life. Their quality of life remained stable or improved once the post operative period was over.

One woman explained:

Actually, I probably do a little more than before. But I can do everything that I did before. I have not eased up on anything. I felt like after the surgery, I was tired for 2 days then I could go on and do everything I used to do; now I do not even think about it. I just go about my day as usual and even do more because I know I have this to protect me.

The women felt that the whole process of receiving an ICD was easy. Nothing much changed in their everyday lives. They live and

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do everything that they did before with no restrictions. Another woman shared,

After that, I really have had no change in lifestyle. My life has been as normal as it was before. Physically, I see no change, or even see an improvement.

Theme 3: A constant reminder. I know it’s there. The women felt as if they had a constant reminder of the ICD. Their family was aware of the device in their body since they can see the scar. Some family members would comment on the device if they could feel it when given a hug. This in turn would remind the women that it was there. The device did affect their body image; it made them more conscious of the device in their chest.

One woman with school aged children explained:

And it is hard when the kids cuddle up to me and I have to say I can’t have you on my left side anymore. With four kids, you know the pile up, at least the two youngest ones, they want to lie next to me while watching TV or when we are praying or reading books or doing anything. I have to remind them that you can’t put your head up there. The children sometimes bump into that side and I am literally guarding that side all the time.

The most amount of pain that women had experienced was postoperative. After that, it varied when the pain decreased. The actual incision is “hardly noticeable” in all of the women although the knowledge that the device is in fact in their chest is a “constant reminder.” The degree at which it reminds them varies depending on body type.

One woman stated: “I am reminded of this all the time, I can feel it, I know it is there. Everyday activities like opening a jar, it pops and moves. Anytime I use my pectoral muscle, I know it is there, which is a lot of what I do during the day, like laundry.”

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Another woman stated: “The only thing that bothers me a little bit sometimes, it feels like it moves in my chest when I am in bed. When I lay a certain way it sometimes feels like it is popping out or something.”

Yeah, I mean just being that it is there and it should not be there and it shows itself all the time. I especially know it’s there in the summer when you were fewer clothes, especially bathing suits. To me it is constant reminder that I may feel fine, but I am technically sick.

Theme 4: Living on the edge. I do not want it to go off. All of the women had a common fear that was constantly in their thoughts. They feared that the device would have to do its job; it would have to “fire.” They did not want this fear to become a reality. They feared that they would be somewhere in public and the device would have to administer therapy or shock them. The women stated such things as:

I do have a little fear of that but so far, it hasn’t happened. Oh! I don’t want it to go off! I am completely scared it will go off and no one will know what the heck happened.

The fear of the device firing has a significant impact on these women. The most concerning part, is the wonder on what it will actually feel like, the uncertainty. These women could not possibly know how it would feel like since none of them have ever received a shock. They have been told that it feels like an “animal kicking you in the chest.” None of them to date have yet to experience it. To them that is unimaginable until it becomes a reality.

I am scared. I am afraid it is going to kick off and I was told it would feel like a pair of boots kicking you in the chest. And I am afraid, but it has never gone off. You know, I am wondering what it would feel

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like. The doctor explained it almost like getting kicked in the chest by a horse. Well, that would be a jolt, I guess? I am afraid that I will be doing something, not feel anything, then all of a sudden boom!

Theme 5: Catch 22: I’d rather not have it. The women received these ICDs because it was medically necessary for them to have it based on the current guidelines. They have various cardiac medical conditions that require an implant of a defibrillator. The women understood that it was essential and yet they would rather not have had to go through it. They would rather not have the heart disease that comes with needing the device.

I would rather not personally have it but I know it is medically, I need to have it, which is a good thing that I have it. Mentally it bothers me, mentally; I know I cannot avoid it.

The women felt that the experience was depressing. They were mostly depressed immediately preceding the implantation. Although, it had decreased over time, there was a constant reminder of the device still there. They needed to adjust to the device, which was hard for them. They felt as if they had no choice to adjust to this new situation.

One woman explained:

Well, I have adjusted to it, I had no choice. But in another aspect, no, I would rather not be going through this. Interestingly, no one has ever asked me how I feel about having one before. I just got it and the doctor does not even ask me about it. I mean it comes and goes, because a lot of things I know are happening are like, it could get depressing. I do feel anxious at times, then I feel depressed at times, then I am fine at times. So, I guess it depends on what is going on.

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Discussion Aspects of the five themes that describe the essence of a woman’s experience living with an ICD have been reported in previous studies, but nowhere is there a study that is an exact comparison to this study. For instance, theme 1 (security blanket: if it keeps me alive it’s worth it) is similar to the concept in Fridlund et al. (2000), a feeling of gratitude, and a feeling of safety. The women in this study expressed a feeling of safety and appreciation since they received their ICDs. This sense of safety and trust in the device is consistent with other studies (Bilge et al., 2006; Dickerson, 2002; Morken et al., 2009).

Theme 3 (a constant reminder: I know it’s there) described the women “knowing that the device was in their chest,” and it was a reminder of their condition. They also described how it affected their body image. There were two other studies that had mentioned this as a concern for women. One study by Walker et al. (2004) reported body image concerns of women. The women in that study were more concerned on how the device appeared in their chest (i.e. the scar) than any other aspect. A second study by Tagney et al. (2003), also reported body image concerns in women since it can be seen in their chest which makes them aware of the device. There were similarities with respect to body image only. They were not concerned with the constant reminder aspect of the cardiac disease, only a constant reminder of their mortality (Dickerson, 2002).

The common concern as described in theme 4 (Living on the Edge: I do not want my device going off) was the fear of the device having to shock them as well as the uncertainty of when, where,

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and who would be around for support. This was foremost in their thoughts. There have been common themes of fear of the device going off or shocking them in the literature reviewed. Dickerson (2002, 2005) reported that uncertainty of when and where shocks can be triggered was a prevailing concern of the male and female participants. Also, participants in Albarran, Tagney, and James (2004) study reported a feeling of uncertainty regarding the device firing.

The prevailing concern in theme 5 (catch 22: I’d rather not have it.) is the conflict women have after receiving a device. These women knew that they medically needed the device yet would have rather not have gone through with it. Dickerson (2005) reported the theme of conditional acceptance that touches on the same concept. Also, a greater acceptance of the new situation was reported in previous studies (Carroll & Hamilton, 2005; Kamphuis et al., 2004).

The women in this study offered specific experiences of living with an ICD which is not completely seen in any previous study as stated previously. Moreover, there were some similar aspects identified in other studies such as receiving a shock and feeling of safety but most were not specific to women (Bilge et al., 2006; Dickerson, 2002, 2005; Morken et al., 2009). This study was able to describe the essence of women who are living with an ICD. As stated previously, the majority of the patients who receive ICD s are male and all of the samples in previous studies have been predominantly male. This study is specific to women and allows special insight to women who are living with cardiac disease and more specifically cardiac disease requiring a medical device.

Clinical implications and future research This study can have an impact on clinical practice as a whole by helping clinicians understand what their patients are experiencing. The women in this study stated that they experienced a lot of uncertainty regarding the need for the device and its functionality. This uncertainty can be reduced or eliminated by educating the patients with respect to how the device operates. An increase in education pre and post operatively on device functionality would benefit patients by relieving some of that uncertainty. These

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concerns are not being addressed properly in the healthcare system. This study can help clinicians gain the understanding of the experience these women are having and perhaps pay closer attention to these issues when they are seen in outpatient settings.

Furthermore, this study can also advocate for support groups for women. Support groups would allow these patients to converse with other women with the same health condition. There are multiple studies in the literature regarding the use of support groups in heart failure patients, however, there are very few studies involving patients with ICDs. Support groups can expose women to different types of resources in order to cope better, decrease anxiety and answer any questions that arise (Myers & James, 2008). Also, it would give them a security knowing that they would be able to have each other as a support system.

The women in this study were similar in that they were Caucasian from affluent areas with numerous resources available to them (Smeulders et al., 2010). An additional study involving women of various ethnical backgrounds and ages would allow capture of a wider range of experiences. Also, since the women have an outstanding fear of the device firing/shocking them, a noteworthy follow-up study would be to describe their experience post firing/shock. These studies would help clinicians understand what their patients are experiencing. lt would allow them to be more empathetic and identify the gaps in knowledge. The results would become a valuable teaching tool to help educate patients regarding their device function.

The critique This is a critical appraisal of the article, “A Woman’s Experience: Living With an Implantable Cardioverter Defibrillator” (Conelius, 2015) to determine its usefulness and applicability for nursing practice.

Abstract The purpose of the abstract is to provide a clear overview of the study and summarize the main features of the findings and recommendations. The abstract should accurately represent the

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remainder of the article. Conelius (2015) summarized the research in the following narrative:

The implantable cardioverter defibrillators (ICD) have decreased mortality rates from those who are at risk for sudden cardiac death or who have survived sudden cardiac death and has been shown to be superior to antiarrhythmic medications (Greenburg et al., 2004). This advance in technology may improve physical health but can impose some challenges to patients, such as depression, anxiety, fear, and unpredictability. Published research on how an ICD affects a woman’s life experience using phenomenology is limited. Therefore, the purpose of this article is to describe the experiences of women who have an ICD using Colaizzi’s method of phenomenology since their implant. Analysis of the three interviews resulted in five themes that described the essence of this experience. The results of this study could not only help clinicians understand what their patients are experiencing but also it can be used as an education tool.

Introduction/review of literature All research requires the investigator to review the literature. This is the point at which gaps are identified with regard to what is known about a particular topic and what is not known.

In qualitative research, the literature review is generally brief, because there is not a great deal known about the topic; nor is there an existing body of research studies. This essentially means that the researcher needs to have an understanding of the substantive body of knowledge on the topic and a clear perspective of what areas still need to be explored. A clear rationale for why the research is needed should be established. The researcher must be clear that a gap in nursing knowledge was identified, there is a clear need for the study, and the selected research method is appropriate. Bracketing what is known about the phenomenon is one way to prevent bias and keep what is known about the topic separate, prior to data collection and analysis (see Chapter 6). Conelius (2015)

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discusses bracketing in the data collection section of her research on women and implantable cardiac defibrillators. The background information provided in her introduction establishes a need for a qualitative study. Conelius (2015) emphasizes the fact that to date much of the research has been quantitative. She further notes that qualitative studies to date have not been gender specific, emphasizing the need for a study related to women’s experiences.

Implantable cardioverter defibrillators (ICDs) have decreased mortality rates from those who are at risk for sudden cardiac death or who have survived sudden cardiac death and has been shown to be superior to anti-arrhythmic medications (Greenburg et al., 2004). ICDs have been supported by many clinical trials and it is now the treatment of choice in primary and secondary prevention for these patients (Bardy et al., 2005; Bristow et al., 2004; Moss et al., 2002). This mainstay of treatment has increased steadily from 486,025 implants from 2006 to 2009 to 850,068 from 2010 to 2011 (Hammill et al., 2010; Kremers et al., 2013). Of these implants approximately 28% were female only. (Conelius, 2015)

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on a patient’s experience of living with an ICD. Previous studies reported themes such as the feeling of gratitude, safety, belief in the future, adjustment to the device, lifesaving yet changing, fear of receiving a shock, physical/mental deterioration, confrontation with mortality and conditional acceptance (Dickerson, 2002; Fridlund et al., 2000; Kamphuis et al., 2004; Morken, Severinsson, & Karlsen, 2009; Tagney, James, & Alberran, 2003). Based on the available research studies, there is very little reported data specific to females and specifically how an ICD affects a woman’s lived experience. (Conelius, 2015)

Phenomenology is a philosophy and a research method used to understand everyday lived experiences and is an appropriate methodology for the phenomena of interest. The subjective experience of women with an ICD is central to study and key to developing interventions to help these women cope. Conelius (2015) clearly articulates the focus of the study and makes a clear case for why a qualitative design is appropriate.

When critiquing the literature review of a qualitative study, it is important to remember that this component of the study must be critiqued within the context of the qualitative methodology selected. In phenomenological studies, the literature review may be delayed until the data analysis is complete in order to minimize bias. Conelius (2015) does not indicate that the review was delayed.

Philosophical underpinnings In addition to making a case for the study and qualitative approach, it is also important to give the reader perspective on the philosophical traditions of the method selected. Conelius (2015) describes the philosophical underpinnings of phenomenology and then relates the traditions to the method used in the study. In most published studies, the author is most concerned about sharing the findings of the study. This limits the space for in-depth literature reviews or discussion of the method used. Conelius (2015) discusses the work of Husserl (1970) as being an integral component of her philosophical grounding of phenomenology as method. She then connects this fundamental work to the method developed by

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Colaizzi (1978).

A lived experience is how a person immediately experiences the world (Husserl, 1970). In order to understand a woman’s lived experience living with an ICD, phenomenology was used. Phenomenology is a philosophy and a research method used to understand everyday lived experiences. Descriptive phenomenology emphasizes describing universal essences, viewing the person as one representative of the world in which she lives, an assumption of self-reflection, a belief that the consciousness is what people share and a belief that stripping of previous knowledge (bracketing) helps prevent investigator bias and interpretation bias (Wojnar & Swanson, 2007). Specifically, Colaizzi’s (1978) descriptive phenomenological method uses seven steps as a method of analyzing data so that by the end of the study a description of the lived experience could be reported. (Conelius, 2015)

The specific qualitative research approach selected helps determine the focus of the research and the manner in which sampling, data collection, and analysis are undertaken. The qualitative research example provided here used phenomenology as method. Research studies using a qualitative approach other than phenomenology should be critiqued relative to the philosophical underpinnings of the method.

Purpose The author explained why the study was important and the significant contribution the study would make to nursing’s body of knowledge. The background information justified the use of a qualitative approach as well as why phenomenology was used.

The researcher states that “The purpose of this study was to describe a woman’s experience living with an ICD. More specifically to describe their thoughts, feelings and perceptions that they have experienced since their implant” (Conelius, 2015). The purpose is clearly articulated, first in the abstract and then in the

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introduction of the study. Conelius (2015) makes it clear that there is a gap in nursing knowledge related to ICDs and the experience of women living with an ICD.

Ethical considerations Addressing the ethical aspect of a research report involves being able to know whether participants were told what the research entailed, how their autonomy and confidentiality were protected, and what arrangements were made to avoid harm. In qualitative research the data collection tools generally include interview and participant observation, making anonymity impossible. Because the interviews are open-ended, the possibility of disclosing personal information or uncomfortable experiences related to the topic may occur. Consent must be a process of continuous negotiation (Oye et al., 2016).

The study by Conelius (2015) was approved by the Institutional Review Board. The author clearly states how the participants were protected. “To ensure confidentiality the signed informed consent forms were kept separate from the transcripts. The recorded tapes and hard copy were in a locked cabinet. Identifying information was deleted and names were never used in any research reports. Audiotapes were destroyed once the pilot study was completed” (Conelius, 2015). Participants were fully informed about the nature of the research and were protected from harm; their autonomy and confidentiality were protected.

Conelius (2015) also made clear to the participants that they had the right to withdraw from the research at any time. This is true for any research; however, in a qualitative investigation, ethical issues may arise at any point in the study (Hegney & Chan, 2010). Conelius (2015) clearly articulated the ethical rigor of this study.

Sample In qualitative research, participants are recruited because of their life experience with the phenomena of interest. This is referred to as purposeful sampling. The goal is to ensure rich, thick data about the phenomenon of interest. Data are generally collected until no new material is emerging and data saturation has been reached. Cleary and colleagues (2014) discuss sampling in qualitative

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research in relationship to sample size. Qualitative studies generally have a small sample. Following the steps for sampling in qualitative research, Conelius (2015) offers the following information related to participant selection:

After receiving approval from the university’s institutional review board (IRB), women were recruited from a private cardiology office in the United States for 4 months. The participant population only included women that had an implantable cardioverter defibrillator (ICD). Women needed to be 18 years or older, and speak English. Women of all ethnic backgrounds were eligible to participate. There was no cost to the participant and no compensation provided. Once the informed consent was signed, they were asked to stay for an interview that day. (Conelius, 2015)

In qualitative research, purposive sampling is the approach of choice. Participants must have experience with the phenomenon of interest and be appropriate to inform the research. In this case, Conelius (2015) needed women with an ICD. Her selection process supports a qualitative sampling paradigm that is appropriate for phenomenology.

Data generation The data generation approach should be sufficiently described so that it is clear to the reader why a particular strategy was selected.

Conelius (2015) clearly articulates that the data generation method supports a qualitative paradigm and allows for discovery, description, and understanding of the participants’ lived experience. The researcher uses open-ended questioning and asks each individual to exhaust their ideas and describe their experiences. She also completes three in-depth interviews with each participant, allowing for clarification of responses as well as an opportunity for the participants to add experiences that may have been omitted at the first interview. Recording and transcribing the interview verbatim helps maintain authenticity of the data. The following excerpts from the article illustrate these points:

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All women were interviewed privately in the office and each interview lasted approximately 45 minutes to an hour. They were asked to “describe their experiences after having received an ICD, specifically, to describe their thoughts, feelings, and perceptions that they had experienced since their implant?” They were then asked to share as much of those experiences to the point that they did not have anything else to contribute. The interviews were recorded and then transcribed. The researcher conducted the interviews since the researcher was trained in the method. Interviews were conducted until an accurate description of the phenomenon had occurred, repetition of data and no new themes where described. This saturation of data did occur after the three interviews. (Conelius, 2015)

The researcher kept a journal to write down any notes needed during the interview. “In order for the description to be pure, the researcher’s prior knowledge was bracketed to capture the essence of the description without bias (Wojnar & Swanson, 2007). Husserl (1970) introduced the term, and it means to set aside one’s own assumption and preunderstanding. In order to be true to the method, the researcher reflected and kept a journal of all assumptions, clinical experiences, understandings and biases to reference during the entire study. Significant statements and phrases pertaining to a woman’s experience living with an ICD were extracted from each transcript. These statements were written on separate sheets and coded. Meanings were formulated from the significant statements. Accordingly, each underlying meaning was coded into a specific category as it reflected an exhaustive description. Then the significant statements with the formulated meanings where grouped into themes.” (Conelius, 2015)

Data generation was appropriate for this study and followed the steps described by Colaizzi (1978).

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Data analysis The process of data analysis is fundamental to determining the credibility of qualitative research findings. Data analysis involves the transformation of raw data into a final description or narrative, identifying common thematic elements found in the raw data. The description should enable a reviewer to confirm the processes of concurrent data collection and analysis as well as steps in coding and identifying themes.

Data analysis followed the method described by Colaizzi (1978). The author developed a table to allow the reader to follow the line of thinking and establish thematic elements. The reader can clearly follow the researcher’s stated processes. Further, Conelius (2015) followed clear processes to establish authenticity and trustworthiness of the data. The findings reported demonstrate the participants’ realities. During data analysis the researcher made every effort to eliminate potential bias. Bracketing, verbatim transcription of taped interviews, and an independent reviewer were used to establish intersubjective agreement.

Authenticity and trustworthiness Critical to the meaning of the findings is the researcher’s ability to demonstrate that the data were authentic and trustworthy or valid. Rigor ensures there is a correlation between the steps of the research process and the actual study. Procedural rigor relates to accuracy of data collection and analysis. Rigor or trustworthiness is a means of demonstrating the credibility and integrity of the qualitative research process (Cope, 2014). A study’s rigor may be established if the reviewer is able to audit the actions and development of the researcher. It is at this point that the review of literature becomes critical and should be systematically related to the findings. This was addressed by the author, and every effort was clearly employed to reduce any bias or misinterpretation of findings.

Conelius (2015) was able to demonstrate rigor with regard to data analysis in multiple ways. She stated:

There were efforts made to limit any potential bias of the

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researcher. One such effort was to bracket any of the researcher’s prior perspective and knowledge of the subject (Aher, 1999). To ensure the credibility of the data collected, two of the women in the study reviewed the description of the lived experiences as suggested by Lincoln and Guba (1985).

This was performed as a validity check of the data. In order to address for auditability, a tape recorder was used and the research was reviewed the transcripts and cross-referenced the field noted (Beck, 1993). Additionally, the transcripts were transcribed verbatim by a secretary in order to ensure they were free of bias. The data analysis and description of the lived experience were reviewed by an independent judge with phenomenological experience to ensure intersubjective agreement. All of the themes reported were agreed upon by the judge. Finally, the researcher validated the description by returning to the participants to ask them how it compared with their experience and incorporated any changes offered by the participants into the final description of the essence of the phenomenon were created.

Conelius (2015) provided clear evidence of rigor for the reader. Bracketing, having participants read the final description and thematic elements, taping and transcribing interviews verbatim, and using an independent judge to establish intersubjective agreement are key elements in a well done qualitative study. The author also left an audit trail illustrated in table format. This table establishes the researcher’s line of thinking. Examples of how raw data lead to the identification of thematic elements were provided and further establish rigor for this study.

Findings, conclusions, implications, and recommendations Findings from a qualitative study generally are discussed in a narrative format that tells the story of the experience through an

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exhaustive description and thematic elements. Conelius (2015) summarized conclusions, implications, and recommendations from the study. The findings were also compared to prior research studies. In qualitative research, this is the area that must include a comprehensive incorporation of current research on the topic. According to Conelius (2015):

Aspects of the five themes that describe the essence of a woman’s experience living with an ICD have been reported in previous studies, but nowhere is there a study that is an exact comparison to this study. For instance, theme 1 (security blanket: if it keeps me alive it’s worth It) is similar to the concept in Fridlund et al. (2000), a feeling of gratitude, and a feeling of safety. The women in this study expressed a feeling of safety and appreciation since they received their ICDs. This sense of safety and trust in the device is consistent with other studies. (Bilge et al., 2006; Dickerson, 2002; Morken et al., 2009)

Contrary to what is found in the literature, the women in this study reported how they have more energy than before and noticed an actual increase in physical functioning. Previous studies have identified decreased physical functioning (Dickerson, 2005; Kamphuis et al., 2004; Williams, Young, Nikoletti, & McRae, 2007) and a decrease in activity levels in their day-to-day lives (Bolse, Hamilton, Flanangan, Caroll, & Fridlund, 2005; Eckert & Jones, 2002). This contradiction can be related to the types of studies conducted. Previous studies have used questionnaires while this study focused on actual descriptions experienced by participants who had undergone the device implant. Theme 3 (a constant reminder: I know it’s there) described the women “knowing that the device was in their chest,” and it was a reminder of their condition. They also described how it affected their body image. There were two other studies that had mentioned this as a concern for women. One study by Walker et al. (2004) reported body image concerns of women. The women in that study were more concerned on how the

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device appeared in their chest (i.e., the scar) than any other aspect. A second study by Tangney et al. (2003), also reported body image concerns in women since it can be seen in their chest which makes them aware of the device. There were similarities with respect to body image only. They were not concerned with the constant reminder aspect of the cardiac disease, only a constant reminder of their mortality. (Dickerson, 2002)

The common concern as described in theme 4 (Living on the Edge: I do not want my device going off) was the fear of the device having to shock them as well as the uncertainty of when, where, and who would be around for support. This was foremost in their thoughts. There have been common themes of fear of the device going off or shocking them in the literature reviewed. Dickerson (2002, 2005) reported that uncertainty of when and where shocks can be triggered was a prevailing concern of the male and female participants. Also, participants in Albarran, Tagney, and James’ (2004) study reported a feeling of uncertainty regarding the device firing. The prevailing concern in theme 5 (catch 22: I’d rather not have it.) Is the conflict women have after receiving a device. These women knew that they medically needed the device yet would have rather not have gone through with it. Dickerson (2005) reported the theme of conditional acceptance that touches on the same concept. Also, a greater acceptance of the new situation was reported in previous studies. (Carroll & Hamilton, 2005; Kamphuis et al., 2004)

The women in this study offered specific experiences of living with an ICD which is not completely seen in any previous study. Moreover, there were some similar aspects identified in other studies such as receiving a shock and feeling of safety but most were not specific to women. (Bilge et al., 2006; Dickerson, 2002, 2005; Morken et al., 2009)

This study was able to describe the essence of women who are

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living with an ICD. The study remained true to qualitative research design. The focus on women was important, as there have been no gender specific studies to date. Capturing the fear and uncertainty for women with an ICD can have an impact on clinical practice and patient education. The author emphasized that these concerns are not being addressed properly in the healthcare system. This study can help clinicians gain an understanding of the experience these women are having and perhaps pay closer attention to these issues when they are seen in outpatient settings (Conelius, 2015).

The research may also be helpful in the establishment of support groups for women with ICDs. “Support groups can expose women to different types of resources in order to cope better, decrease anxiety, and answer any questions that arise” (Myers & James, 2008). “Since the women have an outstanding fear of the device firing/shocking them, a noteworthy follow-up study would be to describe their experience post firing/shock” (Conelius, 2015). By capturing the experiences of women with ICDs, the potential for better sensitivity toward the patient experience exists. This may be critical to overall quality of life and extends beyond the actual purpose and operation of the device. Conelius (2015) has made an important contribution to the understanding of women’s experiences with an ICD.

The critical appraisal of a qualitative study involves an in-depth review of each step of the research process. The example of a qualitative critique in this chapter provides a foundation for the development of critiquing skills in qualitative research.

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

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bracketing. Qualitative Health Research 1999;9:407-411. 2. Albarran J.W, Tagney J, James J. Partners of ICD patients—

An exploratory study of their experiences. European Journal of Cardiovascular Nursing 2004;3(3):201-210.

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26. Smeulders J., van Haastregt T, Ambergen T, Uszko-Lencer N.H., Janssen-Boyne J.J., Gorgeis P, et al. Nurse-led self- management group programme for patients with congestive heart failure Randomized control trial. Journal of Advanced Nursing 2010;66:1487-1499.

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PART I I I

Processes and Evidence Related to Quantitative Research Research Vignette: Elaine Larson

OUTLINE

Introduction

8. Introduction to quantitative research

9. Experimental and quasi-experimental designs

10. Nonexperimental designs

11. Systematic reviews and clinical practice guidelines

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12. Sampling

13. Legal and ethical issues

14. Data collection methods

15. Reliability and validity

16. Data analysis: Descriptive and inferential statistics

17. Understanding research findings

18. Appraising quantitative research

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Introduction

Research vignette

Sometimes the simplest things are the most complicated

Elaine Larson, PhD, RN, FAAN, CIC

Professor of Epidemiology

Associate Dean of Scholarship & Research

Columbia University

School of Nursing

New York, New York

Every nurse researcher has a story, which usually emanates from clinical experiences. I had several such experiences that instilled in me a passion for research. In the year following my graduation decades ago from a BSN program, I was working on a medical unit and a young patient of mine with mitral valve disease called me to her bedside to tell me that she did not feel well, was having trouble breathing, and that something was terribly wrong. I took her vital signs, did not detect anything serious, and set her up with a pillow on the bedside stand so she could breathe more easily. Within a few minutes she was in acute pulmonary edema, and within the hour she was dead. Of course, this would not happen today because of more sophisticated monitoring, but as a novice nurse I was

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devastated and promised myself that I would do everything in my power to keep this from happening again. So I learned what I could about acute pulmonary edema and submitted a paper to the American Journal of Nursing about the case (Larson, 1986). The paper would never be published now, as it was primarily a summary of information from medical textbooks, but putting my thoughts down on paper was a helpful way for me to deal with my feelings of failure and wanting to be a better nurse. The editor of the journal wrote me a letter to say that she hoped more clinical nurses would submit articles addressing relevant practice issues. So I was hooked on publishing!

The second clinical experience that cinched my passion for research and dissemination of findings happened when I was a clinical nurse specialist in a surgical intensive care unit. At that time, the unit was designed with a central nursing station surrounded by five patient beds in a semicircle so that they could all be observed. The ICU had several sinks adjacent to the patient beds, but at least one of them was usually unavailable because it was hooked up to a dialysis machine. When plans were made for a new, updated unit with many more beds in separate rooms (for the stated purposes of improving patients’ privacy and ability to sleep and preventing transmission of infections), a colleague and I decided to formally evaluate the impact of this architectural change on rates of infection. We wrote a protocol, collected data before and after the ICU design change, did air sampling, monitored numbers of interactions between staff and patients and hand hygiene, and obtained cultures from patients for six surveillance organisms every 4 days. Rates of infection did not change after the ICU was redesigned, nor did staff infection prevention or hand hygiene practices, despite the fact that there was a sink available at the entrance to every patient room (Preston et al., 1981). It was clear from that project that just changing the physical environs of the ICU was insufficient to reduce the risk of infections; in fact, the problem seemed to be more behavioral than structural.

As a result of the ICU project, completed while I was working fulltime as a clinician, I returned to school for a PhD. With a small grant from the American Nurses Foundation (http://www.anfonline.org/), I studied the hand flora of patient care

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staff and found that 21% of nosocomial infections over a 7-month period were caused by species found on personnel hands and that such organisms were much more prevalent on normal skin than generally thought (Larson, 1981). Ironically, I had to provide a strong rationale for choosing to study such a simple topic as hand hygiene, because the doctoral faculty of epidemiology at the time felt that there was really little to study about the issue that was not already known. Since that time, however, hand hygiene has become a major topic of interdisciplinary research and has resulted in the publication in this decade of two international evidence-based guidelines citing hundreds of publications (Boyce & Pittet, 2002; Pittet et al., 2009). The point is that our research must go full circle, from clinical observation, to scholarly and rigorous data collection, and then back to evidence-based practice. Sometimes nurse researchers stop at the second step, but evidence-based practice is the raison d’être for pursuing a research career in nursing.

Conducting a well-designed, rigorous study is a primary responsibility of the nurse researcher, but only one responsibility among many. Evidence-based practice and the increasing adoption of practice guidelines (similar to what was previously referred to as research utilization) help ensure that important research findings are translated into clinical practice and public policy (Melnyk & Gallagher-Ford, 2014; Melnyk et al., 2014). It is often at the translational gap between publishing findings, even in influential, peer-reviewed journals, and communicating these findings in meaningful ways that the potential impact of nursing research is lost. In reality, research matters only to the extent that it is communicated and that it results in improved practice and policy— in the work environment, in the quality of life of our individual patients, and in the general health of the public. For that reason, the dissemination of research is essential in all appropriate media and to all appropriate audiences, not just to other researchers.

For me, the simple research related to hand hygiene and infections has become increasingly complex over the years. Despite multiple, intensive interventions, international dissemination of practice guidelines, and changes in national policy and mandates from The Joint Commission and the Centers for Disease Control and Prevention, hand hygiene remains stubbornly resistant to change,

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requiring more sophisticated interventions and conceptual underpinnings (Carter et al., 2016; Haas & Larson, 2007; Srigley et al., 2015). It is clearer now than it has been for several decades that new, emerging, and re-emerging infectious diseases will be a constant. While my research contributions have been primarily in one small field—that of the prevention and control of infectious diseases—the cumulative contributions of each of us to the broader scholarly community in our respective areas of concentration together make up the building blocks of a healthier world. That’s my fundamental belief and commitment—nursing research as part of a global collective to improve health. Sounds simple, but it’s not!

References 1. Boyce J. M, Pittet D. Guideline for hand hygiene in health-care

settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. American Journal of Infection Control 2002;30(8):S1-S46.

2. Carter E. J, Wyer P., Giglio J., et al. Environmental factors and their association with emergency department hand hygiene compliance an observational study. BMJ Quality and Safety 2016;25(5):372-378.

3. Haas J. P, Larson E. L. Measurement of compliance with hand hygiene. Journal of Hospital Infection 2007;66(1):6-14.

4. Larson E. The patient with acute pulmonary edema. American Journal of Nursing 1986;68:1019-1022.

5. Larson E. L. Persistent carriage of gram-negative bacteria on hands. American Journal of Infection Control 1981;9(4):112-119.

6. Melnyk B. M, Gallagher-Ford L. Evidence-based practice as mission critical for healthcare quality and safety a disconnect for many nurse executives. Worldviews on Evidence-Based Nursing/Sigma Theta Tau International, Honor Society of Nursing 2014;11(3):145-146.

7. Melnyk B. M, Gallagher-Ford L., Long L. E, Fineout- Overholt E. The establishment of evidence-based practice competencies for practicing registered nurses and advanced practice nurses in real-world clinical settings proficiencies to

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improve healthcare quality, reliability, patient outcomes, and costs. Worldviews on Evidence-Based Nursing/Sigma Theta Tau International, Honor Society of Nursing 2014;11(1):5-15.

8. Pittet D., Allegranzi B., Boyce J. World Health Organization World Alliance for Patient Safety First Global Patient Safety Challenge Core Group of E. The World Health Organization Guidelines on Hand Hygiene in Health Care and their consensus recommendations. Infection Control and Hospital Epidemiology 2009;30(7):611-622.

9. Preston G. A, Larson E. L, Stamm W. E. The effect of private isolation rooms on patient care practices, Colonization and infection in an intensive care unit. American Journal of Medicine 1981;70(3):641-645.

10. Srigley J. A, Corace K., Hargadon D. P, et al. Applying psychological frameworks of behaviour change to improve healthcare worker hand hygiene a systematic review. Journal of Hospital Infection 2015;91(3):202-210.

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CHAPTER 8

Introduction to quantitative research Geri LoBiondo-Wood

Learning outcomes

After reading this chapter, you should be able to do the following:

• Define research design. • Identify the purpose of a research design. • Define control and fidelity as it affects research design and the outcomes of a study. • Compare and contrast the elements that affect fidelity and control. • Begin to evaluate what degree of control should be exercised in a study. • Define internal validity. • Identify the threats to internal validity. • Define external validity. • Identify the conditions that affect external validity. • Identify the links between study design and evidence-based practice. • Evaluate research design using critiquing questions.

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KEY TERMS

bias

constancy

control

control group

dependent variable

experimental group

external validity

extraneous or mediating variable

generalizability

history

homogeneity

independent variable

instrumentation

internal validity

intervening variable

intervention fidelity

maturation

measurement effects

mortality

pilot study

randomization

reactivity

selection

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selection bias

testing

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

The word design implies the organization of elements into a masterful work of art. In the world of art and fashion, design conjures up images that are used to express a total concept. When an individual creates a structure such as a dress pattern or blueprints for a house, the type of structure depends on the aims of the creator. The same can be said of the research process. The framework that the researcher creates is the design. When reading a study, you should be able to recognize that the literature review, theoretical framework, and research question or hypothesis all interrelate with, complement, and assist in the operationalization of the design (Fig. 8.1). The degree to which there is a fit between these elements and the steps of the research process strengthens the study and also your confidence in the evidence’s potential for applicability to practice.

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FIG 8.1 Interrelationships of design, problem

statement, literature review, theoretical framework, and hypothesis.

How a researcher structures, implements, or designs a study affects the results of a study and ultimately its application to practice. For you to understand the implications and usefulness of a study for evidence-based practice, the key issues of research design must be understood. This chapter provides an overview of the meaning, purpose, and issues related to quantitative research design, and Chapters 9 and 10 present specific types of quantitative designs.

Research design—purpose Researchers choose from different design types. But the design choice must be consistent with the research question/hypotheses. Quantitative research designs include:

• A plan or blueprint

• Vehicle for systematically testing research questions and hypotheses

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• Structure for maintaining control in the study

The design coupled with the methods and analysis provides control for the study. Control is defined as the measures that the researcher uses to hold the conditions of the study consistent and avoid possible potential of bias or error in the measurement of the dependent variable (outcome variable). Control measures help control threats to the validity of the study.

An example that demonstrates how the design can aid in the solution of a research question and maintain control is illustrated in the study by Nyamathi and colleagues (2015; Appendix A), whose aim was to evaluate the effectiveness of peer coaching, and hepatitis A and B vaccine completion in subjects who met the study’s inclusion criteria were randomly assigned to one of the three groups. The interventions were clearly defined. The authors also discuss how they maintained intervention fidelity or constancy of interventionists, data-collector training and supervision, and follow-up throughout the study. By establishing the sample criteria and subject eligibility (inclusion criteria; see Chapter 12) and by clearly describing and designing the experimental intervention, the researchers demonstrated that they had a well-developed plan and were able to consistently maintain the study’s conditions. A variety of considerations, including the type of design chosen, affect a study’s successful completion and utility for evidence-based practice. These considerations include the following:

• Objectivity in conceptualizing the research question or hypothesis

• Accuracy

• Feasibility (Table 8.1)

• Control and intervention fidelity

• Validity—internal

• Validity—external

TABLE 8.1

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Pragmatic Considerations in Determining the Feasibility of a Research Question

Factor Pragmatic Considerations Time A question must be one that can be studied within a realistic time period. Subject availability

A researcher must determine if a sufficient number of subjects will be available and willing to participate. If one has a captive audience (e.g., students in a classroom), it may be relatively easy to enlist subjects. If a study involves subjects’ independent time and effort, they may be unwilling to participate when there is no apparent reward. Potential subjects may have fears about harm and confidentiality and be suspicious of research. Subjects with unusual characteristics may be difficult to locate. Dependent on the design, a researcher may consider enlisting more subjects than needed to prepare for subject attrition. At times, a research report may note how the inclusion criteria were liberalized or the number of subjects altered, as a result of some unforeseen recruitment or attrition consideration.

Facility and equipment availability

All research requires equipment such as questionnaires or computers. Most research requires availability of a facility for data collection (e.g., a hospital unit or laboratory space).

Money Research requires expenditure of money. Before starting a study, the researcher itemizes expenses and develops a budget. Study costs can include postage, printing, equipment, computer charges, and salaries. Expenses can range from about $1000 for a small study to hundreds of thousands of dollars for a large federally funded project.

Ethics Research that places unethical demands on subjects is not feasible for study. Ethical considerations affect the design and methodology choice.

There are statistical principles associated with the mechanisms of control, but it is more important that you have a clear conceptual understanding of these mechanisms.

The next two chapters present experimental, quasi-experimental, and nonexperimental designs. As you will recall from Chapter 1, a study’s type of design is linked to the level of evidence. As you appraise the design, you must also take into account other aspects of a study’s design and conduct. These aspects are reviewed in this chapter. How they are applied depends on the type of design (see Chapters 9 and 10).

Objectivity in the research question conceptualization Objectivity in the conceptualization of the research question is derived from a review of the literature and development of a theoretical framework (see Fig. 8.1). Using the literature, the researcher assesses the depth and breadth of available knowledge

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on the question (see Chapters 3 and 4), which in turn affects the design chosen. Example: ➤ A research question about the length of a breastfeeding teaching program in relation to adherence to breastfeeding may suggest either a correlational or an experimental design (see Chapters 9 and 10), whereas a question related to coping of parents and siblings of adolescent cancer survivors may suggest a survey or correlational study (see Chapter 10).

HIGHLIGHT There is usually more than one threat to internal and external validity in a research study. It is helpful to have a team discussion to summarize specific threats that affect the overall strength and quality of evidence provided by the studies your team is critically appraising.

Accuracy Accuracy in determining the appropriate design is aided by a thoughtful theoretical framework and literature review (see Chapters 3 and 4). Accuracy means that all aspects of a study systematically and logically follow from the research question or hypothesis. The simplicity of a research study does not render it useless or of less value. You should feel that the researcher chose a design that was consistent with the research question or hypothesis and offered the maximum amount of control. Issues of control are discussed later in this chapter.

Many research questions have not yet been researched. Therefore, a preliminary or pilot study is also a wise approach. A pilot study can be thought of as a beginning study in an area conducted to test and refine a study’s data collection methods, and it helps to determine the sample size needed for a larger study. Example: ➤ Patterson (2016) published a report of a pilot study that tested the effect of an emotional freedom technique on stress and anxiety in nursing students. The key is the accuracy, validity, and objectivity used by the researcher in attempting to answer the question. Accordingly, when consulting research, you should read various types of studies and assess how and if the criteria for each step of the research process were followed.

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Control and intervention fidelity A researcher chooses a design to maximize the degree of control, fidelity, or uniformity of the study methods. Control is maximized by a well-planned study that considers each step of the research process and the potential threats to internal and external validity. In a study that tests interventions (randomized controlled trial; see Chapter 9), intervention fidelity (also referred to as treatment fidelity) is a key concept. Fidelity means trustworthiness or faithfulness. In a study, intervention fidelity means that the researcher standardized the intervention and planned how to administer the intervention to each subject in the same manner under the same conditions. A study designed to address issues related to fidelity maximizes results, decreases bias, and controls preexisting conditions that may affect outcomes. The elements of control and fidelity differ based on the design type. Thus, when various research designs are critiqued, the issue of control is always raised but with varying levels of flexibility. The issues discussed here will become clearer as you review the various designs types discussed in later chapters (see Chapters 9 and 10).

Control is accomplished by ruling out mediating or intervening variables that compete with the independent variables as an explanation for a study’s outcome. An extraneous, mediating, or intervening variable is one that occurs in between the independent and dependent variable and interferes with interpretation of the dependent variable. An example would be the effect of the stage of cancer and depression during different phases of cancer treatment. Means of controlling mediating variables include the following:

• Use of a homogeneous sample

• Use of consistent data-collection procedures

• Training and supervision of data collectors and interventionists

• Manipulation of the independent variable

• Randomization

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EVIDENCE-BASED PRACTICE TIP As you read studies, assess if the study includes an intervention and whether there is a clear description of the intervention and how it was controlled. If the details are not clear, it should make you think that the intervention may have been administered differently among the subjects, therefore affecting bias and the interpretation of the results.

Homogeneous sampling In a smoking cessation study, extraneous variables may affect the dependent variable. The characteristics of a study’s subjects are common extraneous variables. Age, gender, length of time smoked, amount smoked, and even smoking rules may affect the outcome in a smoking cessation study. These variables may therefore affect the outcome. As a control for these and other similar problems, the researcher’s subjects should demonstrate homogeneity, or similarity, with respect to the extraneous variables relevant to the particular study (see Chapter 12). Extraneous variables are not fixed but must be reviewed and decided on, based on the study’s purpose and theoretical base. By using a sample of homogeneous subjects, based on inclusion and exclusion criteria, the researcher has implemented a straightforward method of control.

Example: ➤ In the study by Nyamathi and colleagues (2015; see Appendix A), the researchers ensured homogeneity of the sample based on age, history of drug use, homelessness, and participation in a drug treatment unit. This step limits the generalizability or application of the findings to similar populations when discussing the outcomes (see Chapter 17). As you read studies, you will often see the researchers limit the generalizability of the findings to similar samples.

HELPFUL HINT When critiquing studies, it is better to have a “clean” study with clearly identified controls that enhance generalizability from the sample to the specific population than a “messy” one from which you can generalize little or nothing.

If the researcher feels that an extraneous variable is important, it

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may be included in the design. In the smoking example, if individuals are working in an area where smoking is not allowed and this is considered to be important, the researcher could establish a control for it. This can be done by comparing two different work areas: one where smoking is allowed and one where it is not. The important idea to keep in mind is that before data are collected, the researcher should have identified, planned for, or controlled the important extraneous variables.

Constancy in data collection A critical component of control is constancy in data collection. Constancy refers to the notion that the data-collection procedures should reflect a cookbook-like recipe of how the researcher controlled the study’s conditions. This means that environmental conditions, timing of data collection, data-collection instruments, and data-collection procedures are the same for each subject (see Chapter 14). Constancy in data collection is also referred to as intervention fidelity. The elements of intervention fidelity (Breitstein et al., 2012; Gearing et al., 2011; Preyde & Burnham, 2011) are as follows:

• Design: The study is designed to allow an adequate testing of the hypothesis (or hypotheses) in relation to the underlying theory and clinical processes

• Training: Training and supervision of the data collectors and/or interventionists to ensure that the intervention is being delivered as planned and in a similar manner with all the subjects

• Delivery: Assessing that the intervention is delivered as intended, including that the “dose” (as measured by the number, frequency, and length of contact) is well described for all subjects and that the dose is the same in each group, and that there is a plan for possible problems

• Receipt: Ensuring that the treatment has been received and understood by the subject

• Enactment: Assessing that the intervention skills of the subject are

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enlisted as intended

The study by Nyamathi and colleagues (Appendix A; see the “Interventions” section) is an example of how intervention fidelity was maintained. A review of this study shows that data were collected from each subject in the same manner and under the same conditions by trained data collectors. This type of control aided the investigators’ ability to draw conclusions, discuss limitations, and cite the need for further research. When interventions are implemented, researchers will often describe the training of and supervision of interventionists and/or data collectors that took place to ensure constancy. All study designs should demonstrate constancy (fidelity) of data collection, but studies that test an intervention require the highest level of intervention fidelity.

Manipulation of independent variable A third means of control is manipulation of the independent variable. This refers to the administration of a program, treatment, or intervention to one group within the study and not to the other subjects in the study. The first group is known as the experimental group or intervention group, and the other group is known as the control group. In a control group, the variables under study are held at a constant or comparison level. Example: ➤ Nyamathi and colleagues (2015; see Appendix A) manipulated the provision of three levels of peer coaching and nurse-delivered interventions.

Experimental and quasi-experimental designs are used to test whether a treatment or intervention affects patient outcomes. Nonexperimental designs do not manipulate the independent variable and thus do not have a control group. The use of a control group in an experimental or quasi-experimental design is related to the aim of the study (see Chapter 9).

HELPFUL HINT The lack of manipulation of the independent variable does not mean a weaker study. The type of question, amount of theoretical development, and the research that has preceded the study affects the researcher’s design choice. If the question is amenable to a design that manipulates the independent variable, it increases the

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power of a researcher to draw conclusions—that is, if all of the considerations of control are equally addressed.

Randomization Researchers may also choose other forms of control, such as randomization. Randomization of subjects is used when the required number and type of subjects from the population are obtained in such a manner that each potential subject has an equal chance of being assigned to a treatment group. Randomization eliminates bias, aids in the attainment of a representative sample, and can be used in various designs (see Chapter 12). Nyamathi and colleagues (2015; see Appendix A) randomized subjects to intervention and control groups.

Randomization can also be accomplished with questionnaires. By randomly ordering items on the questionnaires, the investigator can assess if there is a difference in responses that can be related to the order of the items. This may be especially important in longitudinal studies where bias from giving the same questionnaire to the same subjects on a number of occasions can be a problem.

Quantitative control and flexibility The same level of control or elimination of bias cannot be exercised equally in all design types. When a researcher wants to explore an area in which little or no literature and/or research on the concept exists, the researcher may use a qualitative method or a nonexperimental design (see Chapters 5 through 7 and 10). In these types of studies, the researcher is interested in describing a phenomenon in a group of individuals.

Control must be exercised as strictly as possible in quantitative research. All studies should be evaluated for potential variables that may affect the outcomes; however, all studies, based on their design, exercise different levels of control. You should be able to locate in the research report how the researcher maintained control in accordance with its design.

EVIDENCE-BASED PRACTICE TIP Remember that establishing evidence for practice is determined by

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assessing the validity of each step of the study, assessing if the evidence assists in planning patient care, and assessing if patients respond to the evidence-based care.

Internal and external validity When reading research, you must be convinced that the results of a study are valid, are obtained with precision, and remain faithful to what the researcher wanted to measure. For the findings of a study to be applicable to practice and provide the foundation for further research, the study should indicate how the researcher avoided bias. Bias can occur at any step of the research process. Bias can be a result of which research questions are asked (see Chapter 2), which hypotheses are tested (see Chapter 2), how data are collected or observations made (see Chapter 14), the number of subjects and how subjects are recruited and included (see Chapter 12), how subjects are randomly assigned in an experimental study (see Chapter 9), and how data are analyzed (see Chapter 16). There are two important criteria for evaluating bias, credibility, and dependability of the results: internal validity and external validity. An understanding of the threats to internal validity and external validity is necessary for critiquing research and considering its applicability to practice. Threats to validity are listed in Box 8.1, and discussion follows. BOX 8.1 Threats to Validity Internal validity

• History

• Maturation

• Testing

• Instrumentation

• Mortality

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• Selection bias

External validity

• Selection effects

• Reactive effects

• Measurement effects

Internal validity Internal validity asks whether the independent variable really made the difference or the change in the dependent variable. To establish internal validity, the researcher rules out other factors or threats as rival explanations of the relationship between the variables— essentially sources of bias. There are a number of threats to internal validity. These are considered by researchers in planning a study and by clinicians before implementing the results in practice (Campbell & Stanley, 1966). You should note that threats to internal validity can compromise outcomes for all studies, and thereby the overall strength and quality of evidence of a study’s findings should be considered to some degree in all quantitative designs. How these threats may affect specific designs are addressed in Chapters 9 and 10. Threats to internal validity include history, maturation, testing, instrumentation, mortality, and selection bias. Table 8.2 provides examples of the threats to internal validity. Generally, researchers will note the threats to validity that they encountered in the discussion and/or limitations section of a research article.

TABLE 8.2 Examples of Internal Validity Threats

Threat Example History A study tested an exercise program intervention in a cardiac care

rehabilitation center at one center and compared outcomes to those of another center in which usual care was given. During the final months of data collection, the control hospital implemented an e-health physical activity intervention; as a result data from the control hospital (cohort) was not included in the analysis.

Maturation Hernandez-Martinez and colleagues (2016) evaluated the effects of prenatal

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nicotine exposure on infants’ cognitive development at 6, 12, and 30 months. They noted that cognitive development and intelligence are clearly influenced by environment and genetics and not just by nicotine exposure.

Testing Nyamathi and colleagues (2015) discussed the lack of treatment differences found in terms of vaccine completion rates possibly due to the bundled nature of the program (see Appendix A).

Instrumentation Lee and colleagues (in press) acknowledged in a study of obesity and disability in young adults that “our measures of disability are not directly comparable to more traditional measures of disability used in studies of older adults.”

Mortality Nyamathi and colleagues (2015) noted that more than one-quarter (27%) did not complete the vaccine series, despite being informed of their risk for HBV infection (see Appendix A).

Selection bias Nyamathi and colleagues (2015) controlled for selection bias by establishing inclusion and exclusion participation criteria for participation. Subjects were also stratified using a specific procedure that ensured balance across the three groups (see Nyamathi et al., 2015, Appendix A, Fig. 1).

History In addition to the independent variable, another specific event that may have an effect on the dependent variable may occur either inside or outside the experimental setting; this is referred to as history. An example may be that of an investigator testing the effects of a research program aimed at young adults to increase bone marrow donations in the community. During the course of the educational program, an ad featuring a known television figure is released on television and Facebook about the importance of bone marrow donation. The release of this information on social media with a television figure engenders a great deal of media and press attention. In the course of the media attention, medical experts are interviewed widely, and awareness is raised regarding the importance of bone marrow donation. If the researcher finds an increase in the number of young adults who donate bone marrow in their area, the researcher may not be able to conclude that the change in behavior is the result of the teaching program, as the change may have been influenced by the result of the information on social media and the resultant media coverage. See Table 8.2 for another example.

Maturation Maturation refers to the developmental, biological, or psychological processes that operate within an individual as a

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function of time and are external to the events of the study. Example: ➤ Suppose one wishes to evaluate the effect of a teaching method on baccalaureate students’ achievement on a skills test. The investigator would record the students’ abilities before and after the teaching method. Between the pretest and posttest, the students have grown older and wiser. The growth or change is unrelated to the study and may explain the differences between the two testing periods rather than the experimental treatment. It is important to remember that maturation is more than change resulting from an age-related developmental process, but could be related to physical changes as well. Example: ➤ In a study of new products to stimulate wound healing, one might ask whether the healing that occurred was related to the product or to the natural occurrence of wound healing. See Table 8.2 for another example.

Testing Taking the same test repeatedly could influence subjects’ responses the next time the test is completed. Example: ➤ The effect of taking a pretest on the subject’s posttest score is known as testing. The effect of taking a pretest may sensitize an individual and improve the score of the posttest. Individuals generally score higher when they take a test a second time, regardless of the treatment. The differences between posttest and pretest scores may not be a result of the independent variable but rather of the experience gained through the testing. Table 8.2 provides an example.

Instrumentation Instrumentation threats are changes in the measurement of the variables or observational techniques that may account for changes in the obtained measurement. Example: ➤ A researcher may wish to study types of thermometers (e.g., tympanic, oral, infrared) to compare the accuracy of using a digital thermometer to other temperature-taking methods. To prevent instrumentation threat, a researcher must check the calibration of the thermometers according to the manufacturer’s specifications before and after data collection.

Another example that fits into this area is related to techniques of observation or data collection. If a researcher has several raters

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collecting observational data, all must be trained in a similar manner so that they collect data using a standardized approach, thereby ensuring interrater reliability (see Chapter 13) and intervention fidelity (see Table 8.2). At times, even though the researcher takes steps to prevent instrumentation problems, this threat may still occur and should be evaluated within the total context of the study.

Mortality Mortality is the loss of study subjects from the first data-collection point (pretest) to the second data-collection point (posttest). If the subjects who remain in the study are not similar to those who dropped out, the results could be affected. The loss of subjects may be from the sample as a whole or, in a study that has both an experimental and a control group, there may be differential loss of subjects. A differential loss of subjects means that more of the subjects in one group dropped out than the other group. See Table 8.2 for an example.

Selection bias If the precautions are not used to gain a representative sample, selection bias could result from how the subjects were chosen. Suppose an investigator wishes to assess if a new exercise program contributes to weight reduction. If the new program is offered to all, chances are only individuals who are more motivated to exercise will take part in the program. Assessment of the effectiveness of the program is problematic, because the investigator cannot be sure if the new program encouraged exercise behaviors or if only highly motivated individuals joined the program. To avoid selection bias, the researcher could randomly assign subjects to groups. In a nonexperimental study, even with clearly defined inclusion and exclusion criteria, selection bias is difficult to avoid completely. See Table 8.2 for an example.

HELPFUL HINT More than one threat can be found in a study, depending on the type of study design. Finding a threat to internal validity in a study does not invalidate the results and is usually acknowledged by the

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investigator in the “Results” or “Discussion” or “Limitations” section of the study.

EVIDENCE-BASED PRACTICE TIP Avoiding threats to internal validity can be quite difficult at times. Yet this reality does not render studies that have threats useless. Take them into consideration and weigh the total evidence of a study for not only its statistical meaningfulness but also its clinical meaningfulness.

External validity External validity concerns the generalizability of the findings of one study to additional populations and other environmental conditions. External validity questions under what conditions and with what types of subjects the same results can be expected to occur.

The factors that may affect external validity are related to selection of subjects, study conditions, and type of observations. These factors are termed selection effects, reactive effects, and testing effects. You will notice the similarity in the names of the factors of selection and testing to those of the threats to internal validity. When considering internal validity threats factors as internal threats, you should assess them as they relate to the testing of independent and dependent variables within the study. When assessing external validity threats, you should consider them in terms of the generalizability or use outside of the study to other populations and settings. The internal validity threats ask if the independent variable changed or was related to the dependent variable or if was affected by something else. The Critical Thinking Decision Path for threats to validity displays the way threats to internal and external validity can interact with each other. It is important to remember that this decision path is not exhaustive of the type of threats and their interaction. Problems of internal validity are generally easier to control. Generalizability issues are more difficult to deal with because they indicate that the researcher is assuming that other populations are similar to the one being tested.

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CRITICAL THINKING DECISION PATH Potential Threats to a Study’s Validity

EVIDENCE-BASED PRACTICE TIP Generalizability depends on who actually participates in a study. Not everyone who is approached actually participates, and not everyone who agrees to participate completes a study. As you review studies, think about how well the subjects represent the population of interest.

Selection effects Selection refers to the generalizability of the results to other populations. An example of selection effects occurs when the researcher cannot attain the ideal sample. At times, the numbers of available subjects may be low or not accessible (see Chapter 12).

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Therefore, the type of sampling method used and how subjects are assigned to research conditions affect the generalizability to other groups, the external validity.

Examples of selection effects are reported when researchers note any of the following:

• “There are several limitations to the study. At 1 and 3 months’ post-death, parents were in early stages of grieving. Thus these findings may not be applicable to parents who are later in their grieving process” (Hawthorne et al., 2016, Appendix B).

• “The sample size was small, which could have limited the power and obscured significant effects that may have been revealed with a larger sample” (Turner-Sack et al., 2016, Appendix D).

These remarks caution you about potentially generalizing beyond the type of sample in a study, but also point out the usefulness of the findings for practice and future research aimed at building the research in these areas.

Reactive effects Reactivity is defined as the subjects’ responses to being studied. Subjects may respond to the investigator not because of the study procedures but merely as an independent response to being studied. This is also known as the Hawthorne effect, which is named after Western Electric Corporation’s Hawthorne plant, where a study of working conditions was conducted. The researchers developed several different working conditions (i.e., turning up the lights, piping in music loudly or softly, and changing work hours). They found that no matter what was done, the workers’ productivity increased. They concluded that production increased as a result of the workers’ realization that they were being studied rather than because of the experimental conditions.

In another study that compared daytime physical activity levels in children with and without asthma and the relationships among asthma, physical activity and body mass index, and child report of symptoms, the researchers noted, “Children may change their

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behaviors due to the Hawthorne effect” (Tsai et al., 2012, p. 258). The researchers made recommendations for future studies to avoid such threats.

Measurement effects Administration of a pretest in a study affects the generalizability of the findings to other populations and is known as measurement effects. Pretesting can affect the posttest responses within a study (internal validity) and affects the generalizability outside the study (external validity). Example: ➤ Suppose a researcher wants to conduct a study with the aim of changing attitudes toward breast cancer screening behaviors. To accomplish this, an education program on the risk factors for breast cancer is incorporated. To test whether the education program changes attitudes toward screening behaviors, tests are given before and after the teaching intervention. The pretest on attitudes allows the subjects to examine their attitudes regarding cancer screening. The subjects’ responses on follow-up testing may differ from those of individuals who were given the education program and did not see the pretest. Therefore, when a study is conducted and a pretest is given, it may “prime” the subjects and affect the researcher’s ability to generalize to other situations.

HELPFUL HINT When reviewing a study, be aware of the internal and external validity threats. These threats do not make a study useless—but actually more useful—to you. Recognition of the threats allows researchers to build on data, and allows you to think through what part of the study can be applied to practice. Specific threats to validity depend on the design type.

There are other threats to external validity that depend on the type of design and methods of sampling used by the researcher, but these are beyond the scope of this text. Campbell and Stanley (1966) offer detailed coverage of the issues related to internal and external validity.

Appraisal for evidence-based practice

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quantitative research Critiquing a study’s design requires you to first have knowledge of the overall implications that the choice of a design may have for the study as a whole (see the Critical Appraisal Criteria box). When researchers ask a question they design a study, decide how the data will be collected, what instruments will be used, what the sample’s inclusion and exclusion criteria will be, and how large the sample will be, to diminish threats to the study’s validity. These choices are based on the nature of the research question or hypothesis. Minimizing threats to internal and external validity of a study enhances the strength of evidence. In this chapter, the meaning, purpose, and important factors of design choice, as well as the vocabulary that accompanies these factors, have been introduced.

Several criteria for evaluating the design related to maximizing control and minimizing threats to internal/external validity and, as a result, sources of bias can be drawn from this chapter. Remember that the criteria are applied differently with various designs (see Chapters 9 and 10). The following discussion pertains to the overall appraisal of a quantitative design.

The research design should reflect that an objective review of the literature and establishment of a theoretical framework guided the development of the hypothesis and the design choice. When reading a study, there may be no explicit statement regarding how the design was chosen, but the literature reviewed will provide clues as to why the researcher chose the study’s design. You can evaluate this by critiquing the study’s theoretical framework and literature review (see Chapters 3 and 4). Is the question new and not extensively researched? Has a great deal of research been done on the question, or is it a new or different way of looking at an old question? Depending on the level of the question, the investigators make certain choices. Example: ➤ In the study by Nyamathi and colleagues (2015), the researchers wanted to test a controlled intervention; thus they developed a randomized controlled trial (Level II design). However, the purpose of the study by Turner- Sack and colleagues (2016) was much different. The Turner-Sack study examined the relationship between and among variables. The study did not test an intervention but explored how variables related to each other in a specific population (Level IV design).

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CRITICAL APPRAISAL CRITERIA Quantitative Research

1. Is the type of design used appropriate?

2. Are the various concepts of control consistent with the type of design chosen?

3. Does the design used seem to reflect consideration of feasibility issues?

4. Does the design used seem to flow from the proposed research question, theoretical framework, literature review, and hypothesis?

5. What are the threats to internal validity or sources of bias?

6. What are the controls for the threats to internal validity?

7. What are the threats to external validity or generalizability?

8. What are the controls for the threats to external validity?

9. Is the design appropriately linked to the evidence hierarchy?

You should be alert for the means investigators use to maintain control (i.e., homogeneity in the sample, consistent data-collection procedures, how or if the independent variable was manipulated, and whether randomization was used). Once it has been established whether the necessary control or uniformity of conditions has been maintained, you must determine whether the findings are valid. To assess this aspect, the threats to internal validity should be reviewed. If the investigator’s study was systematic, well grounded in theory, and followed the criteria for each step of the research process, you will probably conclude that the study is internally valid. No study is perfect; there is always the potential for bias or threats to validity. This is not because the research was poorly conducted or the researcher did not think through the process completely; rather, it is that when conducting research with human

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subjects there is always some potential for error. Subjects can drop out of studies, and data collectors can make errors and be inconsistent. Sometimes errors cannot be controlled by the researcher. If there are policy changes during a study, an intervention can be affected. As you read studies, note how each facet of the study was conducted, what potential errors could have arisen, and how the researcher addressed the sources of bias in the limitations section of the study.

Additionally, you must know whether a study has external validity or generalizability to other populations or environmental conditions. External validity can be claimed only after internal validity has been established. If the credibility of a study (internal validity) has not been established, a study cannot be generalized (external validity) to other populations. Determination of external validity of the findings goes hand in hand with sampling issues (see Chapter 12). If the study is not representative of any one group or one event of interest, external validity may be limited or not present at all. The issues of internal and external validity and applications for specific designs (see Chapters 9 and 10) provide the remaining knowledge to fully critique the aspects of a study’s design.

Key points • The purpose of the design is to provide the master plan for a

study.

• There are many types of designs.

• You should be able to locate within the study the question that the researcher wished to answer. The question should be proposed with a plan for the accomplishment of the study. Depending on the question, you should be able to recognize the steps taken by the investigator to ensure control, eliminate bias, and increase generalizability.

• The choice of a design depends on the question. The research question and design chosen should reflect the investigator’s attempts to maintain objectivity, accuracy, and, most important,

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control.

• Control affects not only the outcome of a study but also its future use. The design should reflect how the investigator attempted to control both internal and external validity threats.

• Internal validity must be established before external validity can be established.

• The design, literature review, theoretical framework, and hypothesis should all interrelate.

• The choice of the design is affected by pragmatic issues. At times, two different designs may be equally valid for the same question.

• The choice of design affects the study’s level of evidence.

Critical thinking challenges • How do the three criteria for an experimental design,

manipulation, randomization, and control, minimize bias and decrease threats to internal validity?

• Argue your case for supporting or not supporting the following claim: “A study that does not use an experimental design does not decrease the value of the study even though it may influence the applicability of the findings in practice.” Include examples to support your rationale.

• Have your interprofessional team provide rationale for why evidence of selection bias and mortality are important sources of bias in research studies. As you critically appraise a study that uses an experimental or quasi-experimental design, why is it important for you to look for evidence of intervention fidelity? How does intervention fidelity increase the strength and quality of the evidence provided by the findings of a study using these types of designs?

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for

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http://evolve.elsevier.com/LoBiondo/

review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

References 1. Breitstein S, Robbins L, Cowell M. Attention to fidelity Why

is it important? Journal of School Nursing 2012;28(6):407-408 Available at: doi:1186/1748-5908-1-1.

2. Campbell D, Stanley J. Experimental and quasi-experimental designs for research. Chicago, IL: Rand-McNally;1966.

3. Gearing R.E, El-Bassel N, Ghesquiere A, et al. Major ingredients of fidelity A review and scientific guide to improving quality of intervention research implementation. Clinical Psychology Review 2011;31:79-88 Available at: doi:10.1016/jcpr.2010.09.007.

4. Hawthorne D.M, Youngblut J.M, Brooten D. Parent spirituality, grief, and mental health at 1 and 3 months after their infant/child’s death in an intensive care unit. Journal of Pediatric Nursing 2016;31:73-80.

5. Hernandez-Martinez Moreso N.V, Serra B.R, Val V.A, et al. Maternal Child Health Journal. Epub ahead of print;2016.

6. Lee H, Pantazis A, Cheng P, et al. The association between adolescent obesity and disability incidence in young adulthood. Journal of Adolescent Health 2016;59(4):472-478.

7. Nyamathi A, Salem B, Zhang S, et al. Nursing case management, peer coaching, and Hepatitis A and B vaccine completion among homeless men recently released on parole A randomized trial. Nursing Research 2015;64(3):177-189.

8. Patterson S.L. The effect of emotional freedom technique on stress and anxiety in nursing students. Nurse Education Today 2016;5(40):104-111.

9. Preyde M, Burnham P.V. Intervention fidelity in psychosocial oncology. Journal of Evidence-Based Social Work 2011;8:379-396 Available at: doi:10.1080/15433714.2011.54234.

10. Tsai S.Y, Ward T, Lentz M, Kieckhefer G.M. Daytime physical activity levels in school-age children with and without asthma. Nursing Research 2012;61(4):159-252.

11. Turner-Sack A.M, Menna R, Setchell S.R, et al. Psychological

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http://dx.doi:1186/1748-5908-1-1

http://dx.doi:10.1016/jcpr.2010.09.007

http://dx.doi:10.1080/15433714.2011.54234

functioning, post traumatic growth, and coping in parent and siblings of adolescent cancer survivors. Oncology Nursing Forum 2016;43(1):48-56.

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CHAPTER 9

Experimental and quasi-experimental designs Susan Sullivan-Bolyai, Carol Bova

Learning outcomes

After reading this chapter, you should be able to do the following:

• Describe the purpose of experimental and quasi-experimental research. • Describe the characteristics of experimental and quasi- experimental designs. • Distinguish between experimental and quasi-experimental designs. • List the strengths and weaknesses of experimental and quasi- experimental designs. • Identify the types of experimental and quasi-experimental designs. • Identify potential internal and external validity issues associated with experimental and quasi-experimental designs. • Critically evaluate the findings of experimental and quasi-

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experimental studies. • Identify the contribution of experimental and quasi-experimental designs to evidence-based practice.

KEY TERMS

after-only design

after-only nonequivalent control group design

antecedent variable

classic experiment

control

dependent variable

design

effect size

experimental design

extraneous variable

independent variable

intervening variable

intervention fidelity

manipulation

mortality

nonequivalent control group design

one-group (pretest-posttest) design

power analysis

quasi-experimental design

randomization (random assignment)

randomized controlled trial

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Solomon four-group design

testing

time series design

treatment effect

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

Research process One purpose of research is to determine cause-and-effect relationships. In nursing practice, we are concerned with identifying interventions to maintain or improve patient outcomes, and base practice on evidence. We test the effectiveness of nursing interventions by using experimental and quasi-experimental designs. These designs differ from nonexperimental designs in one important way: the researcher does not observe behaviors and actions, but actively intervenes by manipulating study variables to bring about a desired effect. By manipulating an independent variable, the researcher can measure a change in behavior(s) or action(s), which is the dependent variable. Experimental and quasi- experimental studies provide the two highest levels of evidence, Level II and Level III, for a single study (see Chapter 1).

Experimental designs are particularly suitable for testing cause- and-effect relationships because they are structured to minimize potential threats to internal validity (see Chapter 8). To infer causality requires that these three criteria be met:

• The causal (independent) and effect (dependent) variables must be associated with each other.

• The cause must precede the effect.

• The relationship must not be explainable by another variable.

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When critiquing experimental and/or quasi-experimental designs, the primary focus is on to what extent the experimental treatment, or independent variable, caused the desired effect on the outcome, the dependent variable. The strength of the conclusion depends on how well other extraneous study variables may have influenced or contributed to the findings.

The purpose of this chapter is to acquaint you with the issues involved in interpreting and applying to practice the findings of studies that use experimental and quasi-experimental designs (Box 9.1). The Critical Thinking Decision Path shows an algorithm that influences a researcher’s choice of experimental or quasi- experimental design. In the literature, these types of studies are often referred to as therapy or intervention articles. BOX 9.1 Summary of Experimental and Quasi- Experimental Research Designs Experimental designs

• True experiment (pretest-posttest control group) design

• Solomon four-group design

• After-only design

Quasi-experimental designs

• Nonequivalent control group design

• After-only nonequivalent control group design

• One group (pretest-posttest) design

• Time series design

CRITICAL THINKING DECISION PATH Experimental and Quasi-Experimental Designs

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Experimental design An experimental design has three identifying properties:

• Randomization

• Control

• Manipulation

A study using an experimental design is commonly called a randomized controlled trial (RCT). In clinical settings, it may be referred to as a clinical trial and is commonly used in drug trials. An RCT is considered the “gold standard” for providing information about cause-and-effect relationships. An RCT generates Level II evidence (see Chapter 1) because randomization, control, and manipulation minimize bias or error. A well-controlled RCT using these properties provides more confidence that the intervention is effective and will produce the same results over time (see Chapters 1 and 8). Box 9.2 shows examples of how these properties were used in the study in Appendix A.

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BOX 9.2 Experimental Design Exemplar: Nursing Case Management, Peer Coaching, and Hepatitis A and B Vaccine Completion among Homeless Men Recently Released on Parole, Randomized Clinical Trial

• This study reports specifically on whether seronegative parolees involved and randomized in the original education and support intervention study were more likely to complete the hepatitis A and B vaccination series and variable predictors of their adherence for completion. The study consisted of parolee participants randomization to one of three groups:

• Peer coaching–nurse case management over 6 months whereby a combination of a peer coach who provided weekly (∼45 minutes) interactions focused on using coping and communication skills, self-management, and access to community resources; and interactions with a nurse case manager (∼20 minutes over 8 consecutive weeks) focused on health promotion, completion of drug treatment, vaccination adherence, and reduction of risky drug and sexual behaviors

• Peer coaching alone as described in group 1 along with a one-time nurse interaction (20 minutes) focused on hepatitis and HIV risk reduction

• Usual care that consisted of encouragement by a nurse to complete the three-series HAV/HBV vaccine and a one-time 20-minute peer counselor

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session on health promotion. A detailed power analysis for sample size was reported.

• Fig. 2 in Appendix A: The CONSORT diagram illustrates how N = 669 study participants were approached, of which 69 were excluded, and why; followed by the N of 600 participants who were randomized to one of the three study arms to control for confounding variables and to ensure balance across groups: n = 195 in peer coaching–nurse care manager group; n = 120 in peer coaching group; and n = 209 in usual care group.

• The researchers also statistically assessed whether random assignment produced groups that were similar; Table 1 illustrates that except for personal health status there were no differences in the baseline characteristics (each group had similar distribution of study participants) across the three intervention arms for demographics, social, situational, coping, and personal characteristics. Fair/poor health was more commonly reported for the usual care group (37.2%). Thus, we would want to consider the fact that randomization did not work for that variable. Subanalyses might be necessary (controlling for that variable) to determine if perception of health affected that group’s adherence for completion of the vaccination series.

• There is no report within this article of attention-control (all groups receiving same amount of attention time), so we do not know the average amount of time each study arm received. Thus time alone could explain adherence improvement (spending more time teaching/interacting with group members).

• Of the 345 study participants, the vaccination completion rate for three or more doses was 73% across all three groups with no differences across groups. In other words, there was not a higher rate of vaccination completion for the study participants who were in arm 1 or 2 compared to usual care.

• The authors identify several limitations that could have attributed to the findings, such as the fact that self-report has the potential

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for bias.

Randomization Randomization, or random assignment, is required for a study to be considered an experimental design with the distribution of subjects to either the experimental or the control group on a random basis. As shown in Box 9.2, each subject has an equal chance of being assigned to one of the three groups. This ensures that other variables that could affect change in the dependent variable will be equally distributed among the groups, reducing systematic bias. It also decreases selection bias (see Chapter 8). Randomization may be done individually or by groups. Several procedures are used to randomize subjects to groups, such as a table of random numbers or computer-generated number sequences (Suresh, 2011). Note that random assignment to groups is different from random sampling as discussed in Chapter 12.

Control Control refers to the process by which the investigator holds conditions constant to limit bias that could influence the dependent variable(s). Control is acquired by manipulating the independent variable, randomly assigning subjects to a group, using a control group, and preparing intervention and data collection protocols that are consistent for all study participants (intervention fidelity) (see Chapters 8 and 14). Box 9.2 illustrates how a control group was used by Nyamathi and colleagues (2015; see Appendix A). In an experimental study, the control group (or in Nyamathi’s study, referred to as Usual Care group) receives the usual treatment or a placebo (an inert pill in drug trials).

Manipulation Manipulation is the process of “doing something,” a different dose of “something,” or comparing different types of treatment by manipulating the independent variable for at least some of the involved subjects (typically those randomly assigned to the experimental group). The independent variable might be a treatment, a teaching plan, or a medication. The effect of this

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manipulation is measured to determine the result of the experimental treatment on the dependent variable compared with those who did not receive the treatment.

Box 9.2 provides an illustration of how the properties of experimental designs, randomization, control, and manipulation are used in an intervention study and how the researchers ruled out other potential explanations or bias (threats to internal validity) influencing the results. The description in Box 9.2 is also an example of how the researchers used control to minimize bias and its effect on the intervention (Nyamathi et al., 2015). This control helped rule out the following potential internal validity threats:

• Selection effect: Bias in the sample contributed to the results versus the intervention.

• History: External events may have contributed to the results versus the intervention.

• Maturation: Developmental processes that occur and potentially alter the results versus the intervention.

Researchers also tested statistically for differences among the groups and found that there were none, reassuring the reader that the randomization process worked. We have briefly discussed RCTs and how they precisely use control, manipulation, and randomization to test the effectiveness of an intervention.

• RCTs use an experimental and control group, sometimes referred to as experimental and control arms.

• Have a specific sampling plan, using clear-cut inclusion and exclusion criteria (see Chapter 12).

• Administer the intervention in a consistent way, called intervention fidelity.

• Perform statistical comparisons to determine any baseline and/or postintervention differences between groups.

• Calculate the sample size needed to detect a treatment effect.

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It is important that researchers establish a large enough sample size to ensure that there are enough subjects in each study group to statistically detect differences among those who receive the intervention and those who do not. This is called the ability to statistically detect the treatment effect or effect size—that is, the impact of the independent variable/intervention on the dependent variable (see Chapter 12). The mathematical procedure to determine the number for each arm (group) needed to test the study’s variables is called a power analysis (see Chapter 12). You will usually find power analysis information in the sample section of the research article. Example: ➤ You will know there was an appropriate plan for an adequate sample size when a statement like the following is included: “With at least 114 men in each intervention condition there was 80% power to detect differences of 15-20 percentage points (e.g., 50% vs. 70%, 75% vs. 90%) for vaccine completion between either of the two intervention conditions and the UC intervention condition at p =.05” (Nyamathi et al., 2015). This information demonstrates that the researchers sought an adequate sample size. This information is critical to assess because with a small sample size, differences may not be statistically evident, thus creating the potential for a type II error—that is, acceptance of the null hypothesis when it is false (see Chapter 16). Carefully read the intervention and control group section of an article to see exactly what each group received and what the differences were between groups either at baseline or following the intervention.

In Appendix A, Nyamathi and colleagues (2015) provide a detailed description and illustration of the intervention. The discussion section reports that the patients’ self-report (they may report doing better than they really did) may have posed an accuracy bias in reporting health behaviors. When reviewing RCTs, you also want to assess how well the study incorporates intervention fidelity measures. Fidelity covers several elements of an experimental study (Gearing et al., 2011; Preyde & Burnham, 2011; Wickersham et al., 2011) that must be evaluated and that can enhance a study’s internal validity. These elements are as follows:

1. Well-defined intervention, sampling strategy, and data collection

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procedures

2. Well-described characteristics of study participants and environment

3. Clearly described protocol for delivering the intervention systematically to all subjects in the intervention group

4. Discussion of threats to internal and external validity

Types of experimental designs There are numerous experimental designs (Campbell & Stanley, 1966). Each is based on the classic experimental design called the RCT (Fig. 9.1A). The classic RCT is conducted as follows:

1. The researcher recruits a sample from the accessible population.

2. Baseline measurements are taken of preintervention demographics, personal characteristics.

3. Baseline measurement is taken of the dependent variable(s).

4. Subjects are randomized to either the intervention or the control group.

5. Each group receives the experimental intervention or comparison/control intervention (usual care or standard treatment, or placebo).

6. Both groups complete postintervention measures to see which, if any, changes have occurred in the dependent variables (determining the differential effects of the treatment).

7. Reliability and validity data are clearly described for measurement instruments.

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FIG 9.1 Experimental Designs. A, Classic randomized clinical trial. B, Solomon four-group

design. C, After-only experimental design.

EVIDENCE-BASED PRACTICE TIP The term RCT is often used to refer to an experimental design in health care research and is frequently used in nursing research as the gold standard design because it minimizes bias or threats to study validity. Because of ethical issues, rarely is “no treatment” acceptable. Typically, either “standard treatment” or another version or dose of “something” is provided to the control group. Only when there is no standard or comparable treatment available

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is a no-treatment control group appropriate.

The degree of difference between the groups at the end of the study indicates the confidence the researcher has in a causal link (i.e., the intervention caused the difference) between the independent and dependent variables. Because random assignment and control minimizes the effects of many threats to internal validity or bias (see Chapter 8), it is a strong design for testing cause-and-effect relationships. However, the design is not perfect. Some threats to internal validity cannot be controlled in RCTs, including but not limited to:

• Mortality: People tend to drop out of studies, especially those that require participation over an extended period of time. When reading RCTs, examine the sample and the results carefully to see if excessive dropouts or deaths occurred, or one group had more dropouts than the other, which can affect the study findings.

• Testing: When the same measurement is given twice, subjects tend to score better the second time just by remembering the test items. Researchers can avoid this problem in one of two ways: They might use different or equivalent forms of the same test for the two measurements (see Chapter 15), or they might use a more complex experimental design called the Solomon four-group design.

Solomon four-group design. The Solomon four-group design, shown in Fig. 9.1B, has two groups that are identical to those used in the classic experimental design, plus two additional groups: an experimental after-group and a control after-group. As the diagram shows, subjects are randomly assigned to one of four groups before baseline data are collected. This design results in two groups that receive only a posttest (rather than pretest and posttest), which provides an opportunity to rule out testing biases that may have occurred because of exposure to the pretest (also called pretest sensitization). In other words, pretest sensitization suggests that those who take the pretest learn what to concentrate on during the study and may

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score higher after the intervention is completed. Although this design helps evaluate the effects of testing, the threat of mortality (dropout) is a potential threat to internal validity.

Example: ➤ Ishola and Chipps (2015) used the Solomon four- group design to test a mobile phone intervention based on the theory of psychological flexibility to improve pregnant women’s mental health outcomes in Nigeria. They hypothesized that those who received the mobile phone intervention would have greater psychological flexibility (the ability to be present and act when necessary).

• The subjects were randomly assigned to one of four groups:

1. Pretest, mobile phone intervention, immediate posttest

2. Pretest, no mobile phone intervention, immediate posttest

3. No pretest, mobile phone intervention, posttest only

4. No pretest, no mobile phone intervention, posttest only

• The study found that although psychological flexibility was improved in the mobile phone intervention groups, this effect was influenced by a significant interaction between the pretests and the intervention; thus, pretest sensitization was present in this study.

After-only design. A less frequently used experimental design is the after-only design (see Fig. 9.1C). This design, which is sometimes called the posttest- only control group design, is composed of two randomly assigned groups, but unlike the classic experimental design, neither group is

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pretested. The independent variable is introduced to the experimental group and not to the control group. The process of randomly assigning the subjects to groups is assumed to be sufficient to ensure lack of bias so that the researcher can still determine whether the intervention created significant differences between the two groups. This design is particularly useful when testing effects that are expected to be a major problem, or when outcomes cannot be measured beforehand (e.g., postoperative pain management).

When critiquing research using experimental designs, to help inform your evidence-based decisions, consider what design type was used; how the groups were formed (i.e., if the researchers used randomization); whether the groups were equivalent at baseline; if they were not equivalent, what the possible threats to internal validity were; what kind of manipulation (i.e., intervention) was administered to the experimental group; and what the control group received.

HELPFUL HINT Look for evidence of pre-established inclusion and exclusion criteria for the study participants.

Strengths and weaknesses of the experimental design Experimental designs are the most powerful for testing cause-and- effect relationships due to the control, manipulation, and randomization components. Therefore, the design offers a better chance of measuring if the intervention caused the change or difference in the two groups. Example: ➤ Nyamathi and colleagues (2015) tested several types of interventions (peer coaching with nurse case management, peer coaching alone, and usual care) with paroled men to examine hepatitis A and B vaccine completion rates and found no significant differences between the groups. If you were working in a clinic caring for this population, you would consider this evidence as a starting point for putting research findings into clinical practice.

Experimental designs have weaknesses as well. They are complicated to design and can be costly to implement. Example: ➤ There may not be an adequate number of potential study

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participants in the accessible population. These studies may be difficult or impractical to carry out in a clinical setting. An example might be trying to randomly assign patients from one hospital unit to different groups when nurses might talk to each other about the different treatments. Experimental procedures also may be disruptive to the setting’s usual routine. If several nurses are involved in administering the experimental program, it may be impossible to ensure that the program is administered in the same way with each subject. Another problem is that many important variables that are related to patient care outcomes are not amenable to manipulation for ethical reasons. Example: ➤ Cigarette smoking is known to be related to lung cancer, but you cannot randomly assign people to smoking or nonsmoking groups. Health status varies with age and socioeconomic status. No matter how careful a researcher is, no one can assign subjects randomly by age or by a certain income level. Because of these problems in carrying out experimental designs, researchers frequently turn to another type of research design to evaluate cause-and-effect relationships. Such designs, which look like experiments but lack some of the control of the true experimental design, are called quasi-experimental designs.

Quasi-experimental designs Quasi-experimental designs also test cause-and-effect relationships. However, in quasi-experimental designs, random assignment or the presence of a control group is lacking. The characteristics of an experimental study may not be possible to include because of the nature of the independent variable or the available subjects.

Without all the characteristics associated with an experimental study, internal validity may be compromised. Therefore, the basic problem with the quasi-experimental approach is a weakened confidence in making causal assertions that the results occurred because of the intervention. Instead, the findings may be a result of other extraneous variables. As a result, quasi-experimental studies provide Level III evidence. Example: ➤ Letourneau and colleagues (2015) used a quasi-experimental design to evaluate the effect of telephone peer support on maternal depression and social support

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with mothers diagnosed with postpartum depression. This one- group pretest-posttest design, where peer volunteers were trained and delivered phone social support, resulted in promising improvement in lower depression and higher perception of social support scores among the participants. However, there was a small group (11%) of mothers who had a “relapse” of depressive symptoms despite peer phone support. In this study there was no comparison group to see if the peer support was more effective than a comparison group and if the 11% of relapse to depression was a common occurrence among women with postpartum depression.

HELPFUL HINT Remember that researchers often make trade-offs and sometimes use a quasi-experimental design instead of an experimental design because it may be impossible to randomly assign subjects to groups. Not using the “purest” design does not decrease the value of the study even though it may decrease the strength of the findings.

Types of quasi-experimental designs There are many different quasi-experimental designs, but we will limit the discussion to only those most commonly used in nursing research. Refer back to the experimental design shown in Fig. 9.1A, and compare it with the nonequivalent control group design shown in Fig. 9.2A. Note that this design looks exactly like the true experiment, except that subjects are not randomly assigned to groups. Suppose a researcher is interested in the effects of a new diabetes education program on the physical and psychosocial outcomes of patients newly diagnosed with diabetes. Under certain conditions, the researcher might be able to randomly assign subjects to either the group receiving the new program or the group receiving the usual program, but for any number of reasons, that might not be possible.

• For example, nurses on the unit where patients are admitted might be so excited about the new program that they cannot help but include the new information for all patients.

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• The researcher has two choices: to abandon the study or to conduct a quasi-experiment.

• To conduct a quasi-experiment, the researcher might use one unit as the intervention group for the new program, find a similar unit that has not been introduced to the new program, and study the newly diagnosed patients with diabetes who are admitted to that unit as a comparison group. The study would then involve a quasi-experimental design.

FIG 9.2 Quasi-experimental designs. A, Nonequivalent control group design. B, After-only nonequivalent control group design. C, One-group (pretest-posttest) design. D, Time series design.

Nonequivalent control group. The nonequivalent control group design is commonly used in nursing studies conducted in clinical settings. The basic problem with this design is the weakened confidence the researcher can have in assuming that the experimental and comparison groups are similar at the beginning of the study. Threats to internal validity,

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such as selection effect, maturation, testing, and mortality, are possible. However, the design is relatively strong because by gathering pretest data, the researcher can compare the equivalence of the two groups on important antecedent variables before the independent variable is introduced. Antecedent variables are variables that occur within the subjects prior to the study, such as in the previous example, where the patients’ motivation to learn about their medical condition might be important in determining the effect of the diabetes education program. At the outset of the study, the researcher could include a measure of motivation to learn. Thus, differences between the two groups on this variable could be tested, and if significant differences existed, they could be controlled statistically in the analysis.

After-only nonequivalent control group. Sometimes the outcomes simply cannot be measured before the intervention, as with prenatal interventions that are expected to affect birth outcomes. The study that could be conducted would look like the after-only nonequivalent control group design shown in Fig. 9.2B. This design is similar to the after-only experimental design, but randomization is not used to assign subjects to groups and makes the assumption that the two groups are equivalent and comparable before the introduction of the independent variable. The soundness of the design and the confidence that we can put in the findings depend on the soundness of this assumption of preintervention comparability. Often it is difficult to support the assertion that the two nonrandomly assigned groups are comparable at the outset of the study, because there is no way of assessing its validity.

One-group (pretest-posttest). Another quasi-experimental design is a one-group (pretest- posttest) design (see Fig. 9.2C), such as the Letourneau and colleagues (2015) example described earlier. This is used when only one group is available for study. Data are collected before and after an experimental treatment on one group of subjects. In this design, there is no control group and no randomization, which are important characteristics that enhance internal validity. Therefore,

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it becomes important that the evidence generated by the findings of this type of quasi-experimental design is interpreted with careful consideration of the design limitations.

Time series. Another quasi-experimental approach used by researchers when only one group is available to study over a longer period of time is called a time series design (see Fig. 9.2D). Time series designs are useful for determining trends over time. Data are collected multiple times before the introduction of the treatment to establish a baseline point of reference on outcomes. The experimental treatment is introduced, and data are collected on multiple occasions to determine a change from baseline. The broad range and number of data collection points help rule out alternative explanations, such as history effects. However, the internal validity of testing is always present because of multiple data collection points. Without a control group, the internal validity threats of selection and maturation cannot be ruled out (see Chapter 8).

HIGHLIGHT When your team is critically appraising studies that use experimental and quasi-experimental designs, it is important to make sure that your team members understand the difference between random selection and random assignment (randomization).

Strengths and weaknesses of quasi-experimental designs Quasi-experimental designs are used frequently because they are practical, less costly, and feasible, with potentially generalizable findings. These designs are more adaptable to the real-world practice setting than the controlled experimental designs. For some research questions and hypotheses, these designs may be the only way to evaluate the effect of the independent variable.

The weaknesses of the quasi-experimental approach involve the inability to make clear cause-and-effect statements.

EVIDENCE-BASED PRACTICE TIP Experimental designs provide Level II evidence, and quasi-

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experimental designs provide Level III evidence. Quasi- experimental designs are lower on the evidence hierarchy because of lack of control, which limits the ability to make confident cause- and-effect statements that influence applicability to practice and clinical decision making.

Evidence-based practice As nursing science expands, and accountability for cost-effective quality clinical outcomes increases, nurses must become more cognizant of what constitutes best practice for their patient population. An understanding of the value of intervention studies that use an experimental or quasi-experimental design is critical for improving clinical outcomes. These study designs provide the strongest evidence for making informed clinical decisions. These designs are those most commonly included in systematic reviews (see Chapter 11).

One cannot assume that because an intervention study has been published that the findings apply to your practice population. When conducting an evidence-based practice project, the clinical question provides a guide for you and your team to collect the strongest, most relevant evidence related to your problem. If your search of the literature reveals experimental and quasi-experimental studies, you will need to evaluate them to determine which studies provide the best available evidence. The likelihood of changing practice based on one study is low, unless it is a large clinical RCT based on prior research evidence.

Key points for evaluating the evidence and whether bias has been minimized in experimental and quasi-experimental designs include:

• Random group assignment (experimental or intervention and control or comparison)

• Inclusion and exclusion criteria that are relevant to the clinical problem studied

• Equivalence of groups at baseline on key demographic variables

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• Adequate sample size recruitment of a homogeneous sample

• Intervention fidelity and consistent data collection procedures

• Control of antecedent, intervening, or extraneous variables

CRITICAL APPRAISAL CRITERIA Experimental and Quasi-Experimental Designs

1. Is the design used appropriate to the research question or hypothesis?

2. Is there a detailed description of the intervention?

3. Is there a clear description of the intervention group treatment in comparison to the control group? How is intervention fidelity maintained?

4. Is power analysis used to calculate the appropriate sample size for the study?

Experimental designs

1. What experimental design is used in the study?

2. How are randomization, control, and manipulation implemented?

3. Are the findings generalizable to the larger population of interest?

Quasi-experimental designs

1. What quasi-experimental design is used in the study, and is it appropriate?

2. What are the most common threats to internal and external validity of the findings of this design?

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3. What does the author say about the limitations of the study?

4. To what extent are the study findings generalizable?

Appraisal for evidence-based practice experimental and quasi-experimental designs Research designs differ in the amount of control the researcher has over the antecedent and intervening variables that may affect the study’s results. Experimental designs, which provide Level II evidence, provide the most possibility for control. Quasi- experimental designs, which provide Level III evidence, provide less control. When conducting an evidence-based practice or quality improvement project, you must always look for studies that provide the highest level of evidence (see Chapter 1). For some PICO questions (see Chapter 2), you will find both Level II and Level III evidence. You will want to determine if the choice of design, experimental or quasi-experimental, is appropriate to the purpose of the study and can answer the research question or hypotheses.

HELPFUL HINT When reviewing the experimental and quasi-experimental literature, do not limit your search only to your patient population. For example, it is possible that if you are working with adult caregivers, related parent caregiver intervention studies may provide you with strategies as well. Many times, with some adaptation, interventions used with one sample may be applicable for other populations.

Questions that you should pose when reading studies that test cause-and-effect relationships are listed in the Critical Appraisal Criteria box. These questions should help you judge whether a causal relationship exists.

For studies in which either experimental or quasi-experimental designs are used, first try to determine the type of design that was used. Often a statement describing the design of the study appears

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in the abstract and in the methods section of the article. If such a statement is not present, you should examine the article for evidence of control, randomization, and manipulation. If all are discussed, the design is probably experimental. On the other hand, if the study involves the administration of an experimental treatment but does not involve the random assignment of subjects to groups, the design is quasi-experimental. Next, try to identify which of the experimental and quasi-experimental designs was used. Determining the answer to these questions gives you a head start, because each design has its inherent threats to internal and external validity. This step makes it a bit easier to critically evaluate the study. It is important that the author provide adequate accounts of how the procedures for randomization, control, and manipulation were carried out. The report should include a description of the procedures for random assignment to such a degree that the reader could determine just how likely it was for any one subject to be assigned to a particular group. The description of the intervention that each group received provides important information about what intervention fidelity strategies were implemented.

The inclusion of this information helps determine if the intervention group and control group received different treatments that were consistently carried out by trained interventionists and data collectors. The question of threats to internal validity, such as testing and mortality, is even more important to consider when critically evaluating a quasi-experimental study, because quasi- experimental designs cannot possibly feature as much control; there may be a lack of randomization or a control group. A well-written report of a quasi-experimental study systematically reviews potential threats to the internal and external validity of the findings. Your work is to decide if the author’s explanations make sense. For either experimental or quasi-experimental studies, you should also check for a reported power analysis that assures you that an appropriate sample size for detecting a treatment effect was planned.

Key points

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• Experimental designs or RCTs provide the strongest evidence (Level II) for a single study that tests whether an intervention or treatment affects patient outcomes.

• Experimental designs are characterized by the ability of the researcher to control extraneous variation, to manipulate the independent variable, and to randomly assign subjects to intervention groups.

• Experimental studies conducted either in clinical settings or in the laboratory provide the best evidence in support of a causal relationship because the following three criteria can be met: (1) the independent and dependent variables are related to each other; (2) the independent variable chronologically precedes the dependent variable; and (3) the relationship cannot be explained by the presence of a third variable.

• Researchers turn to quasi-experimental designs to test cause-and- effect relationships because experimental designs may be impractical or unethical.

• Quasi-experiments may lack the randomization and/or the comparison group characteristics of true experiments. The usefulness of quasi-experiments for studying causal relationships depends on the ability of the researcher to rule out plausible threats to the validity of the findings, such as history, selection, maturation, and testing effects.

Critical thinking challenges • Describe the ethical issues included in a true experimental

research design used by a nurse researcher.

• Describe how a true experimental design could be used in a hospital setting with patients.

• How should a nurse go about critiquing experimental research articles in the research literature so that his or her evidence-based practice is enhanced?

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• Discuss whether your QI team would use an experimental or quasi-experimental design for a quality improvement project.

• Identify a clinical quality indicator that is a problem on your unit (e.g., falls, ventilator-acquired pneumonia, catheter-acquired urinary tract infection), and consider how a search for studies using experimental or quasi-experimental designs could provide the foundation for a quality improvement project.

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

References 1. Campbell D, Stanley J. Experimental and quasi-experimental

designs for research. Chicago, IL: Rand-McNally;1966. 2. Gearing R.E, El-Bassel N, Ghesquiere A, et al. Major

ingredients of fidelity A review and scientific guide to improving quality of intervention research implementation. Clinical Psychology Review 2011;31:79-88 Available at: doi:10.1016/jcpr.2010.09.007.

3. Ishola A.G, Chipps J. The use of mobile phones to deliver acceptance and commitment therapy in the prevention of mother- child HIV transmission in Nigeria. Journal of Telemedicine and Telecare 2015;21:423-426 Available at: doi:10.1177/1357633X15605408.

4. Letourneau N, Secco L, Colpitts J, et al. Quasi-experimental evaluation of a telephone-based peer support intervention for maternal depression. Journal of Advanced Nursing 2015;71:1587- 1599 Available at: doi:10.1111/jan.12622.

5. Nyamathi A, Salem B.E, Zhang S, et al. Nursing care management, peer coaching, and hepatitis A and B vaccine completion among homeless men recently released on parole. Nursing Research 2015;64(3):177-189.

6. Preyde M, Burnham P.V. Intervention fidelity in psychosocial oncology. Journal of Evidence-Based Social Work 2011;8:379-396 Available at: doi:10.1080/15433714.2011.54234.

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http://evolve.elsevier.com/LoBiondo/

http://dx.doi:10.1016/jcpr.2010.09.007

http://dx.doi:10.1177/1357633X15605408

http://dx.doi:10.1111/jan.12622

http://dx.doi:10.1080/15433714.2011.54234

7. Suresh K.P. An overview of randomization techniques An unbiased assessment of outcome in clinical research. Journal of Human Reproductive Science 2011;4:8-11.

8. Wickersham K, Colbert A, Caruthers D, et al. Assessing fidelity to an intervention in a randomized controlled trial to improve medication adherence. Nursing Research 2011;60:264- 269.

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CHAPTER 10

Nonexperimental designs Geri LoBiondo-Wood, Judith Haber

Learning outcomes

After reading this chapter, you should be able to do the following:

• Describe the purpose of nonexperimental designs. • Describe the characteristics of nonexperimental designs. • Define the differences between nonexperimental designs. • List the advantages and disadvantages of nonexperimental designs. • Identify the purpose and methods of methodological, secondary analysis, and mixed method designs. • Identify the critical appraisal criteria used to critique nonexperimental research designs. • Evaluate the strength and quality of evidence by nonexperimental designs.

KEY TERMS

case control study

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cohort study

correlational study

cross-sectional study

developmental study

ex post facto study

longitudinal study

methodological research

mixed methods

prospective study

psychometrics

repeated measures studies

retrospective study

secondary analysis

survey studies

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

Many phenomena relevant to nursing do not lend themselves to an experimental design. For example, nurses studying cancer- related fatigue may be interested in the amount of fatigue, variations in fatigue, and patient fatigue in response to chemotherapy. The investigator would not design an experimental study and implement an intervention that would potentially intensify an aspect of a patient’s fatigue just to study the fatigue experience. Instead, the researcher would examine the factors that contribute to the variability in a patient’s cancer-related fatigue experience using a nonexperimental design. Nonexperimental designs are used when a researcher wishes to explore events, people, or situations as they occur; or test relationships and

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differences among variables. Nonexperimental designs construct a picture of variables at one point or over a period of time.

In nonexperimental research the independent variables have naturally occurred, so to speak, and the investigator cannot directly control them by manipulation. As the researcher does not actively manipulate the variables, the concepts of control and potential sources of bias (see Chapter 8) should be considered. Nonexperimental designs provide Level IV evidence. The information yielded by these types of designs is critical to developing an evidence base for practice and may represent the best evidence available to answer research or clinical questions.

Researchers are not in agreement on how to classify nonexperimental studies. A continuum of quantitative research design is presented in Fig. 10.1. Nonexperimental studies explore the relationships or the differences between variables. This chapter divides nonexperimental designs into survey studies and relationship/difference studies as illustrated in Box 10.1. These categories are somewhat flexible, and other sources may classify nonexperimental studies differently. Some studies fall exclusively within one of these categories, whereas other studies have characteristics of more than one category (Table 10.1). As you read the research literature, you will often find that researchers use several design classifications for one study. This chapter introduces the types of nonexperimental designs and discusses their advantages and disadvantages, the use of nonexperimental research, the issues of causality, and the critiquing process as it relates to nonexperimental research. The Critical Thinking Decision Path outlines the path to the choice of a nonexperimental design.

FIG 10.1 Continuum of quantitative research design.

TABLE 10.1 Examples of Studies With More Than One Design Label

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Design Type Study’s Purpose Retrospective, predictive correlation

To identify predictors of initial and repeated unplanned hospitalizations and potential financial impact among Medicare patients with early stage (Stages I– III) colorectal cancer receiving outpatient chemotherapy using the SEER Medicare database (Fessele et al., 2016)

Descriptive, exploratory, secondary analysis of a randomized controlled trial

To describe drug use and sexual behavior (sex with multiple partners) prior to incarceration and 6 and 12 months after study enrollment using data obtained as part of a randomized controlled trial designed to study the effects of intensive peer coaching and nurse case management, intensive peer coaching, and brief nurse counseling on hepatitis A and B vaccination adherence (Nyamathi et al., 2015, 2016; see Appendix A)

Longitudinal, descriptive

This longitudinal, single group study was conducted to determine whether empirically selected and social cognitive theory-based factors, including baseline characteristics and modifiable behavioral and psychosocial factors, were determinants of PA maintenance in breast cancer survivors after a physical activity intervention (Lee, Von, et al., 2016).

PA, Physical activity; SEER, Surveillance, Epidemiology, and End Results.

BOX 10.1 Summary of Nonexperimental Research Designs I. Survey studies

A. Descriptive

B. Exploratory

C. Comparative

II. Relationship/difference studies

A. Correlational studies

B. Developmental studies

1. Cross-sectional

2. Cohort, longitudinal, and prospective

3. Case control, retrospective, and ex post facto

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EVIDENCE-BASED PRACTICE TIPS When critically appraising nonexperimental studies, you need to be aware of possible sources of bias that can be introduced at any point in the study.

CRITICAL THINKING DECISION PATH Nonexperimental Design Choice

Survey studies The broadest category of nonexperimental designs is the survey study. Survey studies are further classified as descriptive, exploratory, or comparative. Surveys collect detailed descriptions of variables and use the data to justify and assess conditions and practices or to make plans for improving health care practices. You will find that the terms exploratory, descriptive, comparative, and survey are used either alone, interchangeably, or together to

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describe this type of study’s design (see Table 10.1).

• A survey is used to search for information about the characteristics of particular subjects, groups, institutions, or situations, or about the frequency of a variable’s occurrence, particularly when little is known about the variable. Box 10.2 provides examples of survey studies.

• Variables can be classified as opinions, attitudes, or facts.

• Fact variables include gender, income level, political and religious affiliations, ethnicity, occupation, and educational level.

• Surveys provide the basis for the development of intervention studies.

• Surveys are described as comparative when used to determine differences between variables.

• Survey data can be collected with a questionnaire or an interview (see Chapter 14).

• Surveys have small or large samples of subjects drawn from defined populations, can be either broad or narrow, and can be made up of people or institutions.

• Surveys relate one variable to another or assess differences between variables, but do not determine causation.

BOX 10.2 Survey Design Examples

• Bender and colleagues (2016) developed and administered a survey to a nationwide sample (n = 585) of certified clinical nurse leaders (CNLs) and managers, leaders, educators, clinicians, and change agents involved in planning and integrating CNLs into a health system’s nursing care delivery model. Items addressed organizational and implementation characteristics and perceived level of CNL initiative success.

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• Lee, Fan, and colleagues (2016) conducted a survey to investigate the differences between perceptions of injured patients and their caregivers. Participants completed the Chinese Illness Perception Questionnaire Revised–Trauma. Exploring the differences in illness perceptions between injured patients and their caregivers can help clinicians provide individualized care and design interventions that meets patients’ and caregivers’ needs.

The advantages of surveys are that a great deal of information can be obtained from a large population in a fairly economical manner, and that survey research information can be surprisingly accurate. If a sample is representative of the population (see Chapter 12), even a relatively small number of subjects can provide an accurate picture of the population.

Survey studies do have disadvantages. The information obtained in a survey tends to be superficial. The breadth rather than the depth of the information is emphasized.

EVIDENCE-BASED PRACTICE TIPS Evidence gained from a survey may be coupled with clinical expertise and applied to a similar population to develop an educational program, to enhance knowledge and skills in a particular clinical area (e.g., a survey designed to measure the nursing staff’s knowledge and attitudes about evidence-based practice where the data are used to develop an evidence-based practice staff development course).

HELPFUL HINT You should recognize that a well-constructed survey can provide a wealth of data about a particular phenomenon of interest, even though causation is not being examined.

Relationship and difference studies Investigators also try to assess the relationships or differences between variables that can provide insight into a phenomenon. These studies can be classified as relationship or difference studies. The following types of relationship/difference studies are

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discussed: correlational studies and developmental studies.

Correlational studies In a correlational study the relationship between two or more variables is examined. The researcher does not test whether one variable causes another variable. Rather, the researcher is:

• Testing whether the variables co-vary (i.e., As one variable changes, does a related change occur in another variable?)

• Interested in quantifying the strength of the relationship between variables, or in testing a hypothesis or research question about a specific relationship

The direction of the relationship is important (see Chapter 16 for an explanation of the correlation coefficient). For example, in their correlational study, Turner-Sack and colleagues (2016) examined psychological functioning, post-traumatic growth (PTG), and coping and cancer–related characteristics of adolescent cancer survivors’ parents and siblings (see Appendix D). This study tested multiple variables to assess the relationship and differences among the sample. One finding was that parents’ psychological distress was negatively correlated with their survivor child’s active coping (r = −0.53, p <.001). The study findings revealed that younger age, higher life satisfaction, and less avoidant coping were strong predictors of lower psychological distress in parents of adolescent cancer survivors. Thus the variables were related to (not causal of) outcomes. Each step of this study was consistent with the aims of exploring relationships among variables.

When reviewing a correlational study, remember what relationship the researcher tested and notice whether the researcher implied a relationship that is consistent with the theoretical framework and research question(s) or hypotheses being tested. Correlational studies offer the following advantages:

• An efficient and effective method of collecting a large amount of data about a problem

• A potential for evidence-based application in clinical settings

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• A potential foundation for future experimental research studies

• A framework for exploring the relationship between variables that cannot be manipulated

The following are disadvantages of correlational studies:

• Variables are not manipulated.

• Randomization is not used because the groups are preexisting, and therefore generalizability is decreased.

• The researcher is unable to determine a causal relationship between the variables because of the lack of manipulation, control, and randomization.

• The strength and quality of evidence is limited by the associative nature of the relationship between the variables.

Correlational studies may be further labeled as descriptive correlational or predictive correlational. In terms of evidence for practice, the researchers based on the literature review and findings, frame the utility of the results in light of previous research and therefore help establish the “best available” evidence that, combined with clinical expertise, informs clinical decisions regarding the study’s applicability to a specific patient population. A correlational design is a very useful design for clinical studies because many of the phenomena of clinical interest are beyond the researcher’s ability to manipulate, control, and randomize.

HIGHLIGHT When your QI team’s search of the literature for intervention studies reporting evidence-based strategies for preventing ventilator acquired pneumonia (VAP) yields only studies using nonexperimental designs, your team members should debate whether the evidence is of sufficient quality to be applied to answering your clinical question.

Developmental studies

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There are also classifications of nonexperimental designs that use a time perspective. Investigators who use developmental studies are concerned not only with the existing status and the relationship and differences among phenomena at one point in time, but also with changes that result from elapsed time. The following types of designs are discussed: cross-sectional, cohort/longitudinal/prospective, and case control/retrospective/ex post facto. In the literature, studies may be designated by more than one design name. This practice is accepted because many studies have elements of several designs. Table 10.1 provides examples of studies classified with more than one design label.

EVIDENCE-BASED PRACTICE TIPS Replication of significant findings in nonexperimental studies with similar and/or different populations increases your confidence in the conclusions offered by the researcher and the strength of evidence generated by consistent findings from more than one study.

Cross-sectional studies A cross-sectional study examines data at one point in time; that is, data are collected on only one occasion with the same subjects rather than with the same subjects at several time points. For example, a cross-sectional study was conducted by Koc and Cinarli (2015) to determine knowledge, awareness, and practices of Turkish hospital nurses in relation to cervical cancer, human papillomavirus (HPV), and HPV vaccination. The researchers aimed to answer several research questions:

• What is the level of knowledge about cancer risk factors?

• What is the level of knowledge about early diagnosis?

• What are the awareness, knowledge, information sources, and practices regarding HPV infection and HPV vaccine administration?

• What are the relationships between the sociodemographic (age, willingness to receive HPV vaccination, willingness for their

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children to receive HPV vaccination) and professional characteristics (education, belief that cervical cancer can be prevented by HPV vaccination), and overall level of knowledge about cervical cancer, HPV, and HPV vaccines?

As you can see, the variables were related to, not causal of, outcomes. Each step of this study was consistent with the aims of exploring the relationship and differences among variables in a cross-sectional design.

In this study the sample subjects participated on one occasion; that is, data were collected on only one occasion from each subject and represented a cross section of 464 Turkish nurses working in hospital settings, rather than the researchers following a group of nurses over time. The purpose of this study was not to test causality, but to explore the potential relationships between and among variables that can be related to knowledge about HPV, belief in the effectiveness of early cervical cancer screening, and HPV vaccination. The authors concluded that higher levels of knowledge among nurses may increase their willingness to recommend the HPV vaccine to patients. Cross-sectional studies can explore relationships and correlations, or differences and comparisons, or both. Advantages and disadvantages of cross-sectional studies are as follows:

• Cross-sectional studies, when compared to longitudinal/cohort/prospective studies are less time-consuming, less expensive, and thus more manageable.

• Large amounts of data can be collected at one point, making the results more readily available.

• The confounding variable of maturation, resulting from the elapsed time, is not present.

• The investigator’s ability to establish an in-depth developmental assessment of the relationships of the variables being studied is lessened. The researcher is unable to determine whether the change that occurred is related to the change that was predicted because the same subjects were not followed over a period of

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time. In other words, the subjects are unable to serve as their own controls (see Chapter 8).

Cohort/prospective/longitudinal/repeated measures studies In contrast to the cross-sectional design, cohort studies collect data from the same group at different points in time. Cohort studies are also referred to as longitudinal, prospective, and repeated measures studies. These terms are interchangeable. Like cross- sectional studies, cohort studies explore differences and relationships among variables. An example of a longitudinal (cohort) study is found in the study by Hawthorne and colleagues (2016; see Appendix B). This study tested the relationships between spiritual/religious coping strategies and grief, mental health (depression and post-traumatic stress disorder), and personal growth for mothers and fathers at 1 and 3 months after their infant/child’s death in the NICU/PICU with and without control for race/ethnicity and religion. They concluded that spiritual strategies and activities were associated with lower symptoms of grief and depression in parents and post-traumatic stress in mothers but not post-traumatic stress in fathers.

Cohort designs have advantages and disadvantages. When assessing the appropriateness of a cross-sectional study versus a cohort study, first assess the nature of the research question or hypothesis: Cohort studies allow clinicians to assess the incidence of a problem over time and potential reasons for changes in the study’s variables. However, the disadvantages inherent in a cohort study also must be considered. Data collection may be of long duration; therefore, subject loss or mortality can be high due to the time it takes for the subjects to progress to each data collection point. The internal validity threat of testing is also present and may be unavoidable in a cohort study. Subject loss to follow-up or attrition, may lead to unintended sample bias affecting both the internal validity and external validity of the study.

These realities make a cohort study costly in terms of time, effort, and money. There is also a chance of confounding variables that could affect the interpretation of the results. Subjects in such a study may respond in a socially desirable way that they believe is congruent with the investigator’s expectations (Hawthorne effect).

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Advantages of a cohort study are as follows:

• Each subject is followed separately and thereby serves as his or her own control.

• Increased depth of responses can be obtained and early trends in the data can be analyzed.

• The researcher can assess changes in the variables of interest over time, and both relationships and differences can be explored between variables.

In summary, cohort studies begin in the present and end in the future, and cross-sectional studies look at a broader perspective of a population at a specific point in time.

Case control/retrospective/ex post facto studies A case control study is essentially the same as an ex post facto study and a retrospective study. In these studies, the dependent variable already has been affected by the independent variable, and the investigator attempts to link present events to events that occurred in the past. When researchers wish to explain causality or the factors that determine the occurrence of events or conditions, they prefer to use an experimental design. However, they cannot always manipulate the independent variable, or use random assignments. When experimental designs that test the effect of an intervention or condition cannot be employed, case control (ex post facto or retrospective) studies may be used. Ex post facto literally means “from after the fact.” Case control, ex post facto, retrospective, or case control studies also are known as causal- comparative studies or comparative studies. As we discuss this design further, you will see that many elements of this category are similar to quasi-experimental designs because they explore differences between variables (Campbell & Stanley, 1963).

In case control studies, a researcher hypothesizes, for instance:

• That X (cigarette smoking) is related to and a determinant of Y (lung cancer).

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• But X, the presumed cause, is not manipulated and subjects are not randomly assigned to groups.

• Rather, a group of subjects who have experienced X (cigarette smoking) in a normal situation is located and a control group of subjects who have not experienced X is chosen.

• The behavior, performance, or condition (lung tissue) of the two groups is compared to determine whether the exposure to X had the effect predicted by the hypothesis.

Table 10.2 illustrates this example. Examination of Table 10.2 reveals that although cigarette smoking appears to be a determinant of lung cancer, the researcher is still not able to conclude that a causal relationship exists between the variables, because the independent variable has not been manipulated and subjects were not randomly assigned to groups.

TABLE 10.2 Paradigm for the Ex Post Facto Design

Groups (Not Randomly Assigned)

Independent Variable (Not Manipulated by Investigator)

Dependent Variable

Exposed group: Cigarette smokers

X Ye

Cigarette smoking Lung cancer Control group: Nonsmokers — Yc

— No lung cancer

Kousha and Castner (2016) conducted a case control study to explore novel multipollutant exposure assessments using the Air Quality Health Index in relation to emergency department (ED) visits over a 6-year period for otitis media (OM). They used information from ED visits (n = 4815 children from 3 years of age and younger) for OM, air pollution, and weather databases. The findings indicate that there was an increase in ED visits with OM diagnoses 6 to 7 days after exposure to increased ozone and 3 to 4 days after exposure to particulate matter. These findings confirm that there is an association between changes in the Air Quality Index and ED visits for OM. These findings can be used to inform risk communication, patient education, and policy.

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EVIDENCE-BASED PRACTICE TIPS The quality of evidence provided by a cohort/longitudinal/prospective study is stronger than that from other nonexperimental designs because the researcher can determine the incidence of a problem and its possible causes.

The advantages of the case control/retrospective/ex post facto design are similar to those of the correlational design. The additional benefit is that it offers a higher level of control than a correlational study, thereby increasing the confidence the research consumer would have in the evidence provided by the findings. For example, in the cigarette smoking study, a group of nonsmokers’ lung tissue samples are compared with samples of smokers’ lung tissue. This comparison enables the researcher to establish the existence of a differential effect of cigarette smoking on lung tissue. However, the researcher remains unable to draw a causal linkage between the two variables, and this inability is the major disadvantage of the case control/retrospective/ex post facto/case control design.

Another disadvantage is the problem of an alternative hypothesis being the reason for the documented relationship. If the researcher obtains data from two existing groups of subjects, such as one that has been exposed to X and one that has not, and the data support the hypothesis that X is related to Y, the researcher cannot be sure whether X or some extraneous variable is the real cause of the occurrence of Y. As such, the impact or effect of the relationship cannot be estimated accurately. Finding naturally occurring groups of subjects who are similar in all respects except for their exposure to the variable of interest is very difficult. There is always the possibility that the groups differ in some other way, such as exposure to other lung irritants (e.g., asbestos), that can affect the findings of the study and produce spurious or unreliable results. Consequently, you need to cautiously evaluate the conclusions drawn by the investigator.

HELPFUL HINT When reading research reports, you will note that at times researchers classify a study’s design with more than one design

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type label. This is correct because research studies often reflect aspects of more than one design label.

Cohort/longitudinal/prospective studies are considered to be stronger than case control/retrospective studies because of the degree of control that can be imposed on extraneous variables that might confound the data and lead to bias.

HELPFUL HINT Remember that nonexperimental designs can test relationships, differences, comparisons, or predictions, depending on the purpose of the study.

Prediction and causality in nonexperimental research A concern of researchers and research consumers is the issues of prediction and causality. Researchers are interested in explaining cause-and-effect relationships—that is, estimating the effect of one phenomenon on another without bias. Historically, researchers thought that only experimental research could support the concept of causality. For example, nurses are interested in discovering what causes anxiety in many settings. If we can uncover the causes, we could develop interventions that would prevent or decrease the anxiety. Causality makes it necessary to order events chronologically; that is, if we find in a randomly assigned experiment that event 1 (stress) occurs before event 2 (anxiety) and that those in the stressed group were anxious whereas those in the unstressed group were not, we can say that the hypothesis of stress causing anxiety is supported by these empirical observations. If these results were found in a nonexperimental study where some subjects underwent the stress of surgery and were anxious and others did not have surgery and were not anxious, we would say that there is an association or relationship between stress (surgery) and anxiety. But on the basis of the results of a nonexperimental study, we could not say that the stress of surgery caused the anxiety.

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EVIDENCE-BASED PRACTICE TIPS Studies that use nonexperimental designs often precede and provide the foundation for building a program of research that leads to experimental designs that test the effectiveness of nursing interventions.

Many variables (e.g., anxiety) that nurse researchers wish to study cannot be manipulated, nor would it be wise or ethical to manipulate them. Yet there is a need to have studies that can assert a predictive or causal sequence. In light of this need, many nurse researchers are using several analytical techniques that can explain the relationships among variables to establish predictive or causal links. These analytical techniques are called causal modeling, model testing, and associated causal analysis techniques (Kline, 2011; Plichta & Kelvin, 2013).

When reading studies, you also will find the terms path analysis, LISREL, analysis of covariance structures, structural equation modeling (SEM), and hierarchical linear modeling (HLM) to describe the statistical techniques (see Chapter 16) used in these studies. These terms do not designate the design of a study, but are statistical tests that are used in many nonexperimental designs to predict how precisely a dependent variable can be predicted based on an independent variable. For example, SEM was used to understand risk and promotive factors for youth violence and bullying in a sample of US seventh grade students who completed a survey containing items about future expectations, attitudes towards violence, past 30-day bullying experiences, and violent behavior. SEM was used to establish a model of how the variables related to one another. The findings supported the hypothesis that more positive future expectations would be related to lower levels of both physical and relational bullying and that relational bullying would be mediated by attitudes towards violence (Stoddard et al., 2015). This sophisticated design aids understanding of bullying behavior and the positive aspects of early adolescents’ lives that may help them avoid such behavior and provide useful direction for professionals like school nurses and other school-based mental health professionals when developing interventions focused on decreasing bullying. Sometimes researchers want to make a forecast

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or prediction about how patients will respond to an intervention or a disease process or how successful individuals will be in a particular setting or field of specialty. In this case, a model may be tested to assess which physical activity scores were not significant.

Many nursing studies test models. The statistics used in model- testing studies are advanced, but you should be able to read the article, understand the purpose of the study, and determine if the model generated was logical and developed with a solid basis from the literature and past research. This section cites several studies that conducted sound tests of theoretical models.

HELPFUL HINT Nonexperimental research studies have progressed to the point where prediction models are often used to explore or test relationships between independent and dependent variables.

Additional types of quantitative methods Other types of quantitative studies complement the science of research. The additional research methods provide a means of viewing and interpreting phenomena that give further breadth and knowledge to nursing science and practice. The additional types include methodological research, secondary analysis, and mixed methods.

Methodological research Methodological research is the development and evaluation of data collection instruments, scales, or techniques. As you will find in Chapters 14 and 15, methodology greatly influences research and the evidence produced.

The most significant and critically important aspect of methodological research addressed in measurement development is called psychometrics. Psychometrics focuses on the theory and development of measurement instruments (such as questionnaires) or measurement techniques (such as observational techniques) through the research process. Nurse researchers have used the principles of psychometrics to develop and test measurement instruments that focus on nursing phenomena. Many of the phenomena of interest to practice and research are intangible, such

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as interpersonal conflict, resilience, quality of life, coping, and symptom experience. The intangible nature of various phenomena —yet the recognition of the need to measure them—places methodological research in an important position. Methodological research differs from other designs of research in two ways. First, it does not include all of the research process steps as discussed in Chapter 1. Second, to implement its techniques, the researcher must have a sound knowledge of psychometrics or must consult with a researcher knowledgeable in psychometric techniques. The methodological researcher is not interested in the relationship of the independent variable and dependent variable or in the effect of an independent variable on a dependent variable. The methodological researcher is interested in identifying an intangible construct (concept) and making it tangible with a paper-and-pencil instrument or observation protocol.

A methodological study basically includes the following steps:

• Defining the concept or behavior to be measured

• Formulating the instrument’s items

• Developing instructions for users and respondents

• Testing the instrument’s reliability and validity

These steps require a sound, specific, and exhaustive literature review to identify the theories underlying the concept. The literature review provides the basis of item formulation. Once the items have been developed, the researcher assesses the tool’s reliability and validity (see Chapter 15). As an example of methodological research, Rini (2016) identified that the concept of a women’s experience of childbirth had not been adequately measured. In order to measure this concept, Rini’s (2016) review of the literature and an earlier concept analysis provided the basis for the development of the instrument, the Women’s Experience in Childbirth Survey (WECS). The instrument was developed in order to “provide a comprehensive measure of a women’s perception of the childbirth experience and its effects on maternal and neonatal outcomes” (Rini, 2016, p. 269). Having developed a conceptual

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definition, Rini followed through by testing the instrument for reliability and validity (see Chapter 15). Common considerations that researchers incorporate into methodological research are outlined in Table 10.3. Many more examples of methodological research can be found in the research literature. The specific procedures of methodological research are beyond the scope of this book, but you are urged to closely review the instruments used in studies.

TABLE 10.3 Common Considerations in the Development of Measurement Tools

Consideration Example A well-constructed scale, test, or interview schedule should consist of an objective, standardized measure of a behavior that has been clearly defined.

Observations should be made on a small but carefully chosen sampling of the behavior of interest, thus permitting the reader to feel confident that the samples are representative.

Rini (2016) provided a comprehensive literature review and definitions of the concepts that she operationalized for the WECS.

Rini (2016) piloted the instrument with 11 mothers to determine the clarity and sufficiently of the items as well as a preferred scaling method (Likert or Semantic Differential Scale).

An instrument should be standardized. It should be a set of uniform items and response possibilities, uniformly administered and scored.

Based on the initial pilot test of the instrument. The 49-item scale was developed using a 5-point Likert scale. Thirteen of the items are reversed scored and the answers summed. A higher score indicates a more positive birth experience. Potential scores range from 49 to 245.

The items should be unambiguous; clear-cut, concise, exact statements with only one idea per item.

A pilot study was conducted to evaluate the WECS items and the administration procedures. The pilot data indicated that several items needed to be dropped.

The item types should be limited in the type of variations. Subjects who are expected to shift from one type of item to another may fail to provide a true response as a result of the distraction of making such a change.

Mixing true-or-false items with questions that require a yes-or-no response and items that provide a response format of five possible answers is conducive to a high level of measurement error. The WECS contained only a 5-point Likert scale.

Items should not provide irrelevant clues. Unless carefully constructed, an item may furnish an indication of the expected response or answer. Furthermore, the correct answer or expected response to one item should not be given by another item.

An item that provides a clue to the expected answer may contain value words that convey cultural expectations, such as the following: “A good wife enjoys caring for her home and family.”

Instruments should not be made difficult by requiring unnecessarily complex or exact operations. Furthermore, the difficulty of an instrument should be appropriate to the level of the subjects being assessed. Limiting each

A test constructed to evaluate learning in an introductory course in research methods may contain an item that is inappropriate for the designated group, such as the following: “A nonlinear transformation of data to linear data is

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item to one concept or idea helps accomplish this objective.

a useful procedure before testing a hypothesis of curvilinearity.”

An instrument’s diagnostic, predictive, or measurement value depends on the degree to which it serves as an indicator of a relatively broad and significant behavior area, known as the universe of content for the behavior. A behavior must be clearly defined before it can be measured. The extent to which test items appear to accomplish this objective is an indication of the instrument’s content and/or construct validity.

The WECS development included establishment of acceptable content validity. The WECS items were submitted to a panel of experts of a nurse midwife, two maternal infant nursing instructors and a nurse with instrument development experience. The Content Validity Index = 0.75–1.0, which means that the items are deemed to reflect the universe of content related to collaborative trust. Construct validity was established using factor analysis.

An instrument should adequately cover the defined behavior. A primary consideration is whether the number and nature of items are adequate. If there are too few items, the accuracy or reliability of the measure must be questioned.

Rini (2016) presented a complete overview of the validity and reliability testing for the scale and provided a detailed discussion of the findings and needed future testing.

The measure must prove its worth empirically through tests of reliability and validity.

A researcher should demonstrate that a scale is accurate and measures what it purports to measure (see Chapter 15). Rini (2016) provided the data on the reliability and validity testing of the WECS scale.

WECS, Women’s experience in childbirth survey.

Secondary analysis Secondary analysis is also not a design but rather a research method in which the researcher takes previously collected and analyzed data from one study and reanalyzes the data or a subset of the data for a secondary purpose. The original study may be either an experimental or a nonexperimental design. As large data sets become more available, secondary analysis has become more prominent and a useful methodology for answering questions related to population health issues. Data for secondary analysis may be derived from a large clinical trial and data available through large health care organizations and databases. For example, Knight and colleagues (2016) conducted a secondary analysis of data from a larger observational prospective study (DeVon et al., 2014). The aim of the secondary analysis was to identify common trajectories of symptom severity in the 6 months following an ED visit for potential acute coronary syndrome (ACS). In the parent study, a convenience sample of participants was recruited from the ED of four academic medical centers and one community hospital. Data from a total of 1005 male (62.6%) and female (37.4%) participants with a mean age of 60.2 years (SD =

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14.17 years) were analyzed for common trajectories of symptom severity using the validated 13-item ACS Symptom Checklist. Findings from this secondary analysis identified seven types of trajectories across eight symptoms, labeled “tapering off,” “mild/persistent,” “moderate/worsening,” “moderate/improving,” “late onset,” and “severe/improving.” Trajectories differed by age, gender, and diagnosis. The data from this study allowed further in- depth exploration of distinct symptoms trajectories in the 6 months after an ED visit for potential ACS. This has the potential to improve clinical assessment of ongoing symptoms and patient education. Identification of at-risk patients can target specific subpopulations for individualized education, post-ED discharge support and evidence-based symptom management plans, and gender differences in risky sexual behavior among urban adolescents exposed to violence.

Mixed methods Over the years, mixed methods have been defined in various ways. Historically mixed methods included the use of multimethod research or thought, which means including in one study use of a variety of data sources, such as use of different investigators, use of multiple theories in one study, or use of multiple methods (Denzin, 1978). Over the years these terms and methods have been refined and clarified (Johnson et al., 2007). The definition and core characteristics that integrate the diverse meaning of mixed methods research are as follows:

In mixed methods, the researcher:

• “Based on the research question collects and analyzes rigorously both qualitative and quantitative data

• Mixes the two forms of data concurrently by combining the data

• Gives priority to one or both forms of data in terms of emphasis

• Uses the procedures of both in one study or in multiple phases of a program of study

• Frames the procedures within philosophical worldviews and

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theoretical lenses

• Combines the procedures into specific research designs that direct the plan for conducting the study” (Creswell & Plano Clark, 2011, pp. 5–6).

The order of data collection in a mixed methods study varies depending on the question that a researcher wishes to answer. In a mixed methods study the quantitative data may be collected simultaneously with the qualitative data, or one may follow the other. Studying a question using both methods can contribute to a better understanding of an area of research. An example of a mixed methods study was completed by Christian and colleagues (2016). The aim of the study was to assess the feasibility of overcoming barriers to physical activity in a group of teenagers over a period of 1 year using a voucher system of rewards. The qualitative portion of the study included three focus groups on three different occasions at baseline, 6 months, and post-intervention 1 year. The purpose of the groups was to understand the effects of physical activity, fitness, and motivation, as well as barriers to the use of the vouchers during the study with students and teachers. The quantitative portion included the use of an aerobic fitness test, a self-reported activity scale, and a physical activity measure using an accelerometer. The measurement instruments and interviews were administered on three occasions over a year. The design of this study allowed the research team to assess how well the voucher program supported physical activity, aerobic fitness, and increased motivation using multiple methods in a group of adolescents. The study’s findings supported that the use of vouchers provided access to more physical activity, increased socialization, and improved fitness activity in the adolescents during the year.

There is a diversity of opinion on how to evaluate mixed methods studies. Evaluation can include analyzing the quantitative and qualitative designs of the study separately, or as proposed by Creswell and Plano Clark (2011), there should be a separate set of criteria for mixed methods studies dependent on the designs and methods used.

HELPFUL HINT

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As you read the literature, you will find labels such as outcomes research, needs assessments, evaluation research, and quality assurance. These studies are not designs per se. These studies use either experimental or nonexperimental designs. Studies with these labels are designed to test the effectiveness of health care techniques, programs, or interventions. When reading such a research study, the reader should assess which design was used and if the principles of the design, sampling strategy, and analysis are consistent with the study’s purpose.

Appraisal for evidence-based practice nonexperimental designs Criteria for appraising nonexperimental designs are presented in the Critical Appraisal Criteria box. When appraising nonexperimental research designs, you should keep in mind that such designs offer the researcher a lower level of control and an increased risk of bias. The level of evidence provided by nonexperimental designs is not as strong as evidence generated by experimental designs; however, there are other important clinical research questions that need to be answered beyond the testing of interventions and experimental or quasi-experimental designs.

The first step in critiquing nonexperimental designs is to determine which type of design was used in the study. Often a statement describing the design of the study appears in the abstract and in the methods section of the report. If such a statement is not present, you should closely examine the paper for evidence of which type of design was employed. You should be able to discern that either a survey or a relationship design was used. For example, you would expect an investigation of self-concept development in children from birth to 5 years of age to be a relationship study using a cohort/prospective/longitudinal design. If a cohort/prospective/longitudinal study was used, you should assess for possible threats to internal validity or bias, such as mortality, testing, and instrumentation. Potential threats to internal or external validity should be recognized by the researchers at the end of the study and, in particular, the limitations section.

Next, evaluate the literature review of the study to determine if a

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nonexperimental design was the most appropriate approach to the research question or hypothesis. For example, many studies on pain (e.g., intensity, severity, perception) are suggestive of a relationship between pain and any of the independent variables (diagnosis, coping style, and ethnicity) under consideration where the independent variable cannot be manipulated. As such, these studies suggest a nonexperimental correlational, longitudinal/prospective/cohort, a retrospective/ex post facto/case control, or a cross-sectional design. Investigators will use one of these designs to examine the relationship between the variables in naturally occurring groups. Sometimes you may think that it would have been more appropriate if the investigators had used an experimental or a quasi-experimental design. However, you must recognize that pragmatic or ethical considerations also may have guided the researchers in their choice of design (see Chapters 8 through 18).

CRITICAL APPRAISAL CRITERIA Nonexperimental Designs

1. Based on the theoretical framework, is the rationale for the type of design appropriate?

2. How is the design congruent with the purpose of the study?

3. Is the design appropriate for the research question or hypothesis?

4. Is the design suited to the data collection methods?

5. Does the researcher present the findings in a manner congruent with the design used?

6. Does the research go beyond the relational parameters of the findings and erroneously infer cause-and-effect relationships between the variables?

7. Where appropriate, how does the researcher discuss the threats to internal validity (bias) and external validity (generalizability)?

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8. How does the author identify the limitations of the study?

9. Does the researcher make appropriate recommendations about the applicability based on the strength and quality of evidence provided by the nonexperimental design and the findings?

Finally, the factor or factors that actually influence changes in the dependent variable can be ambiguous in nonexperimental designs. As with all complex phenomena, multiple factors can contribute to variability in the subjects’ responses. When an experimental design is not used for controlling some of these extraneous variables that can influence results, the researcher must strive to provide as much control as possible within the context of a nonexperimental design, to decrease bias. For example, when it has not been possible to randomly assign subjects to treatment groups as an approach to controlling an independent variable, the researchers will use strict inclusion and exclusion criteria and calculate an adequate sample size using power analysis that will support a valid testing of the research question or hypothesis (see Chapter 12). Threats to internal and external validity or potential sources of bias represent a major influence when interpreting the findings of a nonexperimental study because they impose limitations to the generalizability of the results. It is also important to remember that prediction of patient clinical outcomes is of critical value for clinical researchers. Nonexperimental designs can be used to make predictions if the study is designed with an adequate sample size (see Chapter 12), collects data consistently, and uses reliable and valid instruments (see Chapter 15).

If you are appraising methodological research, you need to apply the principles of reliability and validity (see Chapter 15). A secondary analysis needs to be reviewed from several perspectives. First, you need to understand if the researcher followed sound scientific logic in the secondary analysis completed. Second, you need to review the original study that the data were extracted from to assess the reliability and validity of the original study. Even though the format and methods vary, it is important to remember that all research has a central goal: to answer questions scientifically and provide the strongest, most consistent evidence possible, while

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controlling for potential bias.

Key points • Nonexperimental designs are used in studies that construct a

picture or make an account of events as they naturally occur. Nonexperimental designs can be classified as either survey studies or relationship/difference studies.

• Survey studies and relationship/difference studies are both descriptive and exploratory in nature.

• Survey research collects detailed descriptions of existing phenomena and uses the data either to justify current conditions and practices or to make more intelligent plans for improving them.

• Correlational studies examine relationships.

• Developmental studies are further broken down into categories of cross-sectional studies, cohort/longitudinal/prospective studies, and case control/retrospective/ex post facto studies.

• Methodological research, secondary analysis, and mixed methods are examples of other means of adding to the body of nursing research. Both the researcher and the reader must consider the advantages and disadvantages of each design.

• Nonexperimental research designs do not enable the investigator to establish cause-and-effect relationships between the variables. Consumers must be wary of nonexperimental studies that make causal claims about the findings unless a causal modeling technique is used.

• Nonexperimental designs also offer the researcher the least amount of control. Threats to validity impose limitations on the generalizability of the results and as such should be fully assessed by the critical reader.

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• The critiquing process is directed toward evaluating the appropriateness of the selected nonexperimental design in relation to factors, such as the research problem, theoretical framework, hypothesis, methodology, and data analysis and interpretation.

• Though nonexperimental designs do not provide the highest level of evidence (Level I), they do provide a wealth of data that become useful pieces for formulating both Level I and Level II studies that are aimed at developing and testing nursing interventions.

Critical thinking challenges • The mid-term assignment for your interprofessional research

course is to critically appraise an assigned study on the relationship of perception of pain severity and quality of life in advanced cancer patients. You and your nursing student colleagues think it is a cross-sectional design, but your medical student colleagues think it is a quasi-experimental design because it has several specific hypotheses. How would each group of students support their argument, and how would they collaborate to resolve their differences?

• You are completing your senior practicum on a surgical unit, and for preconference your student group has just completed a search for studies related to the effectiveness of handwashing in decreasing the incidence of nosocomial infections, but the studies all use an ex post facto/case control design. You want to approach the nurse manager on the unit to present the evidence you have collected and critically appraised, but you are concerned about the strength of the evidence because the studies all use a nonexperimental design. How would you justify that this is the “best available evidence”?

• You are a member of a journal club at your hospital. Your group is interested in the effectiveness of smoking cessation interventions provided by nurses. An electronic search indicates

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that 12 individual research studies and one meta-analysis meet your inclusion criteria. Would your group begin with critically appraising the 12 individual studies or the one meta-analysis? Provide rationale for your choice, including consideration of the strength and quality of evidence provided by individual studies versus a meta-analysis.

• A patient in a primary care practice who had a history of a “heart murmur” called his nurse practitioner for a prescription for an antibiotic before having a periodontal (gum) procedure. When she responded that according to the new American Heart Association (AHA) clinical practice guideline, antibiotic prophylaxis is no longer considered appropriate for his heart murmur, the patient got upset, stating, “But I always take antibiotics! I want you to tell me why I should believe this guideline. How do I know my heart will not be damaged by listening to you?” What is the purpose of a clinical practice guideline, and how would you as a nurse practitioner respond to this patient?

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

References 1. Bender M, Williams M, Su W, et al. Clinical nurse leader

integrated care delivery to improve care quality Factors influencing perceived success. Journal of Nursing Scholarship 2016;48(4):414-422.

2. Campbell D.T, Stanley J.C. Experimental and quasi- experimental designs for research. Chicago, IL: Rand- McNally;1963.

3. Christian D, Todd C, Hill R, et al. Active children through incentive vouchers-evaluation (ACTIVE) A mixed methods feasibility study. BMC Public Health 2016;16:890.

4. Creswell J.W, Plano V.L. Designing and conducting mixed methods research. Thousand Oaks, CA: Sage

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http://evolve.elsevier.com/LoBiondo/

Publications;2011. 5. DeVon H.A, Burke L.A, Nelson H, et al. Disparities in

patients presenting to the emergency department with potential acute coronary syndrome It matters if you are black or white. Heart & Lung 2014;43:270-277.

6. Denzin N.K. The research act A theoretical introduction to sociological methods. New York: McGraw Hill;1978.

7. Fessele K.L, Hayat M.J, Mayer D.K, Atkins R.L. Factors associated with unplanned hospitalizations among patients with nonmetastatic colorectal cancers intended for treatment in ambulatory settings. Nursing Research 2016;65(1):24-33.

8. Hawthorne D.M, Youngblut J.M, Brooten D. Parent spirituality, grief, and mental health at 1 and 3 months after their infant’s/child’s death in an intensive care unit. Journal of Pediatric Nursing 2016;(31):73-80.

9. Johnson R.B, Onwuegbuzie A.J, Turner L.A. Toward a definition of mixed methods research. Journal of Mixed Methods Research 2007;1(2):122-133.

10. Kline R. Principles and practices of structural equation modeling. 3rd ed. New York, NY: Guilford Press;2011.

11. Knight E.P, Shea K, Rosenfeld A.G, et al. Symptom trajectories after an emergency department visit for potential acute coronary syndrome. Nursing Research 2016;65(4):268-289.

12. Koc Z, Cinarli T. Cervical cancer, human papillomavirus, and vaccination. Nursing Research 2015;64(6):452-465.

13. Kousha T, Castner J. The air quality health index and emergency department visits for otitis media. Journal of Nursing Scholarship 2016;48(2):163-171.

14. Lee B, Fan J, Hung C, et al. Illness representations of injury a comparison of patients and their caregivers. Journal of Nursing Scholarship 2016;48(3):254-264.

15. Lee C.E, Von Ah D, Szuck B, Lau Y.J. Determinants of physical activity maintenance in breast cancer survivors after a community-based intervention. Oncology Nursing Forum 2016;43(1):93-102.

16. Nyamathi A, Salem B.E, Zhang S, et al. Nursing case management, peer coaching, and hepatitis A and B vaccine completion among homeless men recently released on parole;

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randomized clinical trial. Nursing Research 2015;64(3):177-189. 17. Nyamathi A.M, Zhang S.X, Wall S, et al. Drug use and

multiple sex partners among homeless ex-offenders secondary findings from an experimental study. Nursing Research 2016;65(3):179-190.

18. Plichta S, Kelvin E. Munro’s statistical methods for health care research. 6th ed. Philadelphia: Lippincott, Williams & Wilkins;2013.

19. Rini E.V. The development and psychometric analysis of the women’s experience in childbirth survey. Journal of Nursing Measurement 2016;124(2):268-280.

20. Stoddard S.A, Varela J.J, Zimmerman M.A. Future expectations, attitude, toward violence, and bullying perpetration during early adolescence. Nursing Research 2015;64(6):422-433.

21. Turner-Sack A.M, Menna R, Setchell S.R, et al. Psychological functioning, post-traumatic growth, and coping in parents and siblings of adolescent cancer survivors. Oncology Nursing Forum 2016;43(1):48-56.

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CHAPTER 11

Systematic reviews and clinical practice guidelines Geri LoBiondo-Wood

Learning outcomes

After reading this chapter, you should be able to do the following:

• Describe the types of research reviews. • Describe the components of a systematic review. • Differentiate between a systematic review, meta-analysis, and integrative review. • Describe the purpose of clinical guidelines. • Differentiate between an expert- and an evidence-based clinical guideline. • Critically appraise systematic reviews and clinical practice guidelines.

KEY TERMS

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AGREE II

clinical practice guidelines

effect size

evidence-based practice guidelines

expert-based practice guidelines

forest plot

integrative review

meta-analysis

systematic review

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

The breadth and depth of clinical research has grown. As the number of studies focused on a similar area conducted by multiple research teams has increased, it has become important to have a means of organizing and assessing the quality, quantity, and consistency among the findings of a group of like studies. The previous chapters have introduced the types of qualitative and quantitative designs and how to critique these studies for quality and applicability to practice. The purpose of this chapter is to acquaint you with systematic reviews and clinical guidelines that assess multiple studies focused on the same clinical question, and how these reviews and guidelines can support evidence-based practice. Terminology used to define systematic reviews and clinical guidelines has changed as this area of research and literature assessment has grown. The definitions used in this textbook are consistent with the definitions from the Cochrane Collaboration and the Preferred Reporting for Systematic Reviews and Meta-Analyses (PRISMA) Group (Higgins & Green, 2011; Moher et al., 2009; Stroup et al., 2000). Systematic reviews and clinical guidelines are critical and meaningful for the development of quality improvement practices.

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Systematic review types A systematic review is a summation and assessment of research studies found in the literature based on a clearly focused question that uses systematic and explicit criteria and methods to identify, select, critically appraise, and analyze relevant data from the selected studies to summarize the findings in a focused area (Liberati et al., 2009; Moher et al., 2009; Moher, Shamseer, et al., 2015). Statistical methods may or may not be used to analyze the studies reviewed. Multiple terms and methods are used to systematically review the literature, depending on the review’s purpose. See Box 11.1 for the components of a systematic review. Some terms are used interchangeably. The terms systematic review and meta-analysis are often used interchangeably or together. The only review type that can be labeled a meta-analysis is one that reviewed studies using statistical methods. When evaluating a systematic review, it is important to assess how well each of the studies in the review minimized bias or maintained the elements of control (see Chapters 8 and 9). BOX 11.1 Systematic Review Components With or Without Meta-Analysis Introduction Review of rationale and a clear clinical question (PICO)

Methods Information sources, databases used, and search strategy identified: how studies were selected and data extracted as well as the variables extracted and defined

Description of methods used to assess risk of bias, summary measures identified (e.g., risk, ratio); identification of how data are combined, if studies are graded, what quality appraisal system was used (see Chapters 1, 17, and 18)

Results Number of studies screened and characteristics, risk of bias within studies; if a meta-analysis there will be a synthesis of results

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including confidence intervals, risk of bias for each study, and all outcomes considered

Discussion Summary of findings, including the strength, quality, quantity, and consistency of the evidence for each outcome

Any limitations of the studies; conclusions and recommendations of findings for practice

Funding Sources of funding for the systematic review

You will also find reviews of an area of research or theory synthesis termed integrative reviews. Integrative reviews critically appraise the literature in an area but without a statistical analysis and are the broadest category of review (Whittemore, 2005; Whittemore & Knafl, 2005). Recently new types of reviews have been developed. These include rapid reviews, scoping reviews, and realist reviews (Moher, Stewart, et al., 2015). Systematic, integrative, and additional types of reviews are not designs per se, but methods for searching and integrating the literature related to a specific clinical issue. These methods take the results of many studies in a specific area; assess the studies critically for reliability and validity (quality, quantity, and consistency) (see Chapters 1, 7, 17, and 18); and synthesize findings to inform practice. No matter what type of review you are reading, it is important that the authors have clearly detailed the methods that were used and that those methods can be replicated (Moher, Stewart, et al., 2015). Meta-analysis provides Level I evidence as the studies in the review are statistically analyzed and integrates the results of many studies. Systematic reviews and meta-analyses also grade the level of design or evidence of the studies reviewed. The Critical Thinking Decision Path outlines the path for completing a systematic review.

CRITICAL THINKING DECISION PATH Completing a Systematic Review

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Systematic review A systematic review is a summary of a search of quantitative studies that use similar designs based on a focused clinical question (PICO). The goal is to assess the strength and quality of the evidence found in the literature on a clinical subject. The review uses rigorous inclusion and exclusion criteria, an explicit reproducible methodology to identify all studies that meet the eligibility criteria, and an assessment of the validity of the findings from the included studies (Moher et al., 2009). The goal is to bring together all of the studies related to a focused clinical question in order to assess the strength and quality of the evidence provided by the chosen studies in relation to:

• Sampling issues

• Internal validity (bias) threats

• External validity

• Data analysis

• Applicability of findings to practice

The purpose is to report, in a consolidated fashion, the most

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current and valid research on intervention effectiveness and clinical knowledge, which will ultimately inform evidence-based decision making about the applicability of findings to practice.

Once the studies in a systematic review are gathered from a comprehensive literature search (see Chapter 3), assessed for quality, and synthesized according to quality or focus, then practice recommendations are made and presented in an article. More than one person independently evaluates the studies to be included or excluded in the review. The articles critically appraised are discussed and presented in a table format within the article, which helps you to easily identify the studies gathered for the review and their quality (Moher et al., 2009). The most important principle to assess when reading a systematic review is how the author(s) identified the studies evaluated and how they systematically reviewed and appraised the literature that led to the reviewers’ conclusions.

The components of a systematic review are the same as a meta- analysis (see Box 11.1) except for the analysis of the studies. An example of a systematic review was completed by Conley and Redeker (2016) on the self-management interventions for inflammatory bowel disease. In this review, the authors:

• Synthesized studies from the literature on self-management interventions for inflammatory disease

• Included a clear clinical question; all of the sections of a systematic review were presented, except there was no statistical meta-analysis (combination of studies data) of the studies as a whole because the interventions and outcomes varied across the studies reviewed

• Summarized studies according to the health-related outcomes and assessed for quality

Each study in this review was considered individually, not analyzed collectively, for its sample size, effect size, and its contribution to knowledge in the area based on a set of criteria. Although systematic reviews are highly useful, they also have to be reviewed for potential bias and carefully critiqued for scientific

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rigor.

Meta-analysis A meta-analysis is a systematic summary using statistical techniques to assess and combine studies of the same design to obtain a precise estimate of effect (impact of an intervention on the dependent variable/outcomes or association between variables). The terms meta-analysis and systematic review are often used interchangeably. The main difference is only a meta-analysis includes a statistical assessment of the studies reviewed. A meta- analysis treats all the studies reviewed as one large data set in order to obtain a precise estimate of the effect (impact) of the results (outcomes) of the studies in the review.

Meta-analysis uses a rigorous process of summary and determines the impact of a number of studies rather than the impact derived from a single study alone (see Chapter 10). After the clinical question is identified and the search of the review of published and unpublished literature is completed, a meta-analysis is conducted in two phases:

Phase I: The data are extracted (i.e., outcome data, sample sizes, quality of the studies, and measures of variability from the identified studies).

Phase II: The decision is made as to whether it is appropriate to calculate what is known as a pooled average result (effect) of the studies reviewed.

Effect sizes are calculated using the difference in the average scores between the intervention and control groups from each study (Cochrane Handbook of Systematic Reviews for Interventions, 2016). Each study is considered a unit of analysis. A meta-analysis takes the effect size (see Chapter 12) from each of the studies reviewed to obtain an estimate of the population (or the whole) to create a single effect size of all the studies. Thus the effect size is an estimate of how large of a difference there is between intervention and control groups in the summarized studies. Example: ➤ The meta-analysis in Appendix E studied the question

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“What is the impact of nurse-led clinics (NLCs) on the mortality and morbidity of patients with cardiovascular disease (CVD)?” In this review, the authors synthesized the literature from studies on the effectiveness of NLCs in terms of mortality and morbidity outcomes (Al-Mallah et al., 2015). The studies that assessed this question were reviewed and each weighted for its impact or effect on improving mortality and morbidity. This estimate helps health care providers decide which intervention, if any, was more useful for improving well-being. Detailed components of a systematic review with or without meta-analysis (Moher et al., 2009) are listed in Box 11.1.

In addition to calculating effect sizes, meta-analyses use multiple statistical methods to present and depict the data from studies reviewed (see Chapters 19 and 20). One of these methods is a forest plot, sometimes called a blobbogram. A forest plot graphically depicts the results of analyzing a number of studies.Fig. 11.1 is an example of a forest plot from Al-Mallah and colleagues’ meta- analysis (Al-Mallah et al., 2015; Appendix E, Fig. 2, Box A). This review identified that the available evidence suggests a favorable effect of NLCs on all-cause mortality, rate of major adverse cardiac events, and adherence to medications in patients with CVD.

FIG 11.1 An example of a forest plot. Source: (Adapted from

Al-Mallah, M. H., Farah, I., Al-Madani, W., et al. [2015]. The impact of nurse- led clinics on the mortality and morbidity of patients with cardiovascular

diseases: A systematic review and meta-analysis. Journal of Cardiovascular Nursing, 31[1], 89–95.)

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EVIDENCE-BASED PRACTICE TIP Evidence-based practice methods such as meta-analysis increase your ability to manage the ever-increasing volume of information produced to develop the best evidence-based practices.

Fig. 11.1 displays nine studies that compared all-cause mortality in nurse-led groups versus the control groups (usual care). Each study analyzed is listed. To the right of the listed study is a horizontal line that identifies the effect size estimate for each study. The box on the vertical line represents the effect size of each study, and the diamond is the effect or significance of the combined studies. The boxes to the left of the zero line mean that NLC care was favored or produced a significant effect. The box to the right of the line indicates studies in which usual care was not favored or significant. The diamond is a more precise estimate of the interventions as it combines the data from all the studies. The exemplar provided is basic, as meta-analysis is a sophisticated methodology. For a fuller understanding, several references are provided (Borenstein et al., 2009; da Costa & Juni, 2014; Higgins & Green, 2011); see also Chapters 19 and 20.

A well-done meta-analysis assesses for bias in studies and provides clinicians a means of evaluating the merit of a body of clinical research. The Cochrane Library published by the Cochrane Collaboration provides a repository of sound meta-analyses. Example: ➤ Martineau and colleagues (2016) completed a meta- analysis to assess the use of vitamin D to prevent asthma exacerbation and improve asthma control in children and adults. The report presents an introduction, details of the methods used to search the literature (databases, search terms, and years), data extraction, and analysis. The report also includes an evidence table of the studies reviewed, a description of how the data were summarized, results of the meta-analysis, a forest plot of the reviewed studies (see Chapter 19), conclusions, and implications for practice and research.

Cochrane collaboration The largest repository of meta-analyses is the Cochrane

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Collaboration/Review. The Cochrane Collaboration prepares and maintains a body of systematic reviews that focus on health care interventions (Box 11.2). The reviews are found in the Cochrane Database of Systematic Reviews. The Cochrane Collaboration collaborates with a wide range of health care individuals with different skills and backgrounds for developing reviews. These partnerships assist with developing reviews that minimize bias while keeping current with assessment of health care interventions, promoting access to the database, and ensuring the quality of the reviews (Cochrane Handbook for Systematic Reviews, 2016). The steps of a Cochrane Report mirror those of a meta-analysis except for the inclusion of a plain language summary. This useful feature is a straightforward summary of the meta-analysis. The Cochrane Library also publishes several other useful databases (Box 11.3). BOX 11.2 Cochrane Review Sections

Review information: Authors and contact person

Abstract

Plain language summary

The review

Background of the question

Objectives of the search

Methods for selecting studies for review

Type of studies reviewed

Types of participants, types of intervention, types of outcomes in the studies

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Search methods for finding studies

Data collection

Analysis of the located studies, including effect sizes

Results including description of studies, risk of bias, intervention effects

Discussion

Implications for research and practice

References and tables to display the data

Supplementary information (e.g., appendices, data analysis)

BOX 11.3 Cochrane Library Databases

• Cochrane Database of Systematic Reviews: Full-text Cochrane reviews

• DARE: Critical assessments and abstracts of other systematic reviews that conform to quality criteria

• CENTRAL: Information of studies published in conference proceedings and other sources not available in other databases

• CMR: Bibliographic information on articles and books on reviewing research and methodological studies

CENTRAL, Cochrane Central Register of Controlled Trials; CMR, Cochrane Methodology Register; DARE, Database of Abstracts of Review of Effects.

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Integrative review You will also find critical reviews of an area of research without a statistical analysis or a theory synthesis, termed integrative reviews. An integrative review is the broadest category of review (Whittemore, 2005; Whittemore & Knafl, 2005). It can include theoretical literature, research literature, or both. An integrative review may include methodology studies, a theory review, or the results of differing research studies with wide-ranging clinical implications (Whittemore, 2005). An integrative review can include quantitative or qualitative research, or both. Statistics are not used to summarize and generate conclusions about the studies. Several examples of an integrative review are found in Box 11.4. Recommendations for future research are suggested in each review. BOX 11.4 Integrative Review Examples

• Brady and colleagues (2014) published an integrative review on the management and effects of steroid-induced hyperglycemia in hospitalized patients with cancer with or without preexisting diabetes. This review included a purpose, description of the methods used (databases searched, years included), key terms used, and parameters of the search. These components allow others to evaluate and replicate the search. Eighteen studies that assessed steroid-induced hyperglycemia in hospitalized patients with cancer were reviewed in the text and via a table format.

• Kestler and LoBiondo-Wood (2012) published an integrative review of symptom experience in children and adolescents with cancer. The review was a follow-up of a 2003 review published by Docherty (2003) and was completed to assess the progress that has been made since the 2003 research publication on the symptoms of pediatric oncology patients. The review included a description of the search strategy used including databases, years searched, terms used, and the results of the search. Literature on each symptom was described, and a table of the 52 studies reviewed was included.

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Reporting guidelines: Systematic reviews and meta-analysis Systematic reviews and meta-analysis publications are found widely in the research literature. As these resources present an accumulation of potentially clinically relevant knowledge, there was also a need to develop a standard for what information should be included in these reviews. There are several guidelines available for reporting systematic reviews. These are the PRISMA (Moher et al., 2009) and MOOSE (Meta-analysis of Observational Studies in Epidemiology) (Stroup et al., 2000). A review of these guidelines will help you critically read meta-analyses and interpret if there is any bias in the review.

Tools for evaluating individual studies As the importance of practicing from a base of evidence has grown, so has the need to have tools or instruments available that can assist practitioners in evaluating studies of various types. When evaluating studies for clinical evidence, it is first important to assess if the study is valid. At the end of each chapter of this text are critiquing questions that will aid you in assessing if studies are valid and if the results are applicable to your practice. In addition to these questions, there are standardized appraisal tools that can assist with appraising the evidence. The Center for Evidence Based Medicine (CEBM), whose focus is on teaching critical appraisal, developed tools known as Critical Appraisal Tools that provide an evidence-based approach for assessing the quality, quantity, and consistency of specific study designs (CEBM, 2016). These instruments are part of an international network that provides consumers with specific questions to help assess study quality. Each checklist has a number of general questions as well as design- specific questions. The tools center on assessing a study’s methodology, validity, and reliability. The questions focus on the following:

1. Does this study address a clearly focused question?

2. Did the study use valid methods to address the question?

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3. Are the valid results of the study important?

4. Are these valid, important results applicable to my patient or population?

There are four critical appraisal worksheets with targeted questions relevant to a specific design. The checklist with instructions can be found at http://www.cebm.net/critical appraisal. The design-specific CEBM tools with critical evaluative information for each design are available online and include:

• Systematic reviews

• Randomized controlled studies

• Diagnostic studies

• Prognosis

Clinical practice guidelines Clinical practice guidelines are systematically developed statements or recommendations that link research and practice and serve as a guide for practitioners. Guidelines have been developed to assist in bridging practice and research. Guidelines are developed by professional organizations, government agencies, institutions, or convened expert panels. Guidelines provide clinicians with an algorithm for clinical management or decision making for specific diseases (e.g., colon cancer) or treatments (e.g., pain management). Not all guidelines are well developed, and, like research, they must be assessed before implementation (see Chapter 9). Guidelines should present scope and purpose of the practice, detail who the development group included, demonstrate scientific rigor, be clear in their presentation, demonstrate clinical applicability, and demonstrate editorial independence. An example is the National Comprehensive Cancer Network, which is an interdisciplinary consortium of 21 cancer centers around the world. Interdisciplinary groups develop practice guidelines for practitioners and education guidelines for patients. These

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guidelines are accessible at www.nccn.org. Practice guidelines can be either expert-based or evidence-based.

Evidence-based practice guidelines are those developed using a scientific process. This process includes first assembling a multidisciplinary group of experts in a specific field. This group is charged with completing a rigorous search of the literature and completing an evidence table that summarizes the quality and strength of the evidence from which the practice guideline is derived (see Chapters 19 and 20). For various reasons, not all areas of clinical practice have a sufficient research base; therefore, expert- based practice guidelines are developed. Expert-based guidelines depend on having a group of nationally known experts in the field who meet and solely use opinions of experts along with whatever research evidence is developed to date. If limited research is available for such a guideline, a rationale should be presented for the practice recommendations.

Many national organizations develop clinical practice guidelines. It is important to know which one to apply to your patient population. Example: ➤ There are numerous evidence-based practice guidelines developed for the management of pain. These guidelines are available from organizations such as the Oncology Nurses Society, American Academy of Pediatrics, National Comprehensive Cancer Network, National Cancer Institute, American College of Physicians, and American Academy of Pain Medicine. You need to be able to evaluate each of the guidelines and decide which is the most appropriate for your patient population.

The Agency for Healthcare Research and Quality supports the National Guideline Clearinghouse (NGC). The NGC’s mission is to provide health care professionals from all disciplines with objective, detailed information on clinical practice guidelines that are disseminated, implemented, and issued. The NGC encourages groups to develop guidelines for implementation via their site; it is a very useful site for finding well-developed clinical guidelines on a wide range of health- and illness-related topics. Specific guidelines can be found on the AHRQ Effective Health Care Program website.

HIGHLIGHT When evaluating a Clinical Practice Guideline (CPG), it is

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important for an interprofessional team to use an evidence-based critical appraisal tool like AGREE II to determine the strength and quality of the CPG for applicability to practice.

Evaluating clinical practice guidelines As evidence-based practice guidelines proliferate, it becomes increasingly important that you critique these guidelines with regard to the methods used for guideline formulation and consider how they might be used in practice. Critical areas that should be assessed when critiquing evidence-based practice guidelines include the following:

• Date of publication or release and authors

• Endorsement of the guideline

• Clear purpose of what the guideline covers and patient groups for which it was designed

• Types of evidence (research, theoretical) used in guideline formulation

• Types of research included in formulating the guideline (e.g., “We considered only randomized and other prospective controlled trials in determining efficacy of therapeutic interventions.”)

• Description of the methods used in grading the evidence

• Search terms and retrieval methods used to acquire evidence used in the guideline

• Well-referenced statements regarding practice

• Comprehensive reference list

• Review of the guideline by experts

• Whether the guideline has been used or tested in practice and, if so, with what types of patients and in which types of settings

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Evidence-based practice guidelines that are formulated using rigorous methods provide a useful starting point for understanding the evidence base of practice. However, more research may be available since the publication of the guideline, and refinements may be needed. Although information in well-developed, national, evidence-based practice guidelines are a helpful reference, it is usually necessary to localize the guideline using institution-specific evidence-based policies, procedures, or standards before application within a specific setting.

There are several tools for appraising the quality of clinical practice guidelines. The Appraisal of Guidelines Research and Evaluation II (AGREE II) instrument is one of the most widely used to evaluate the applicability of a guideline to practice (Brouwers et al., 2010, AGREE Collaboration). The AGREE II was developed to assist in evaluating guideline quality, provide a methodological strategy for guideline development, and inform practitioners about what information should be reported in guidelines and how it should be reported. The AGREE II is available online. The instrument focuses on six domains, with a total of 23 questions rated on a seven-point scale and two final assessment items that require the appraiser to make overall judgments of the guideline based on how the 23 items were rated. Along with the instrument itself, the AGREE Enterprise website offers guidance on tool usage and development. The AGREE II has been tested for reliability and validity. The guideline assesses the following components of a practice guideline:

1. Scope and purpose of the guideline

2. Stakeholder involvement

3. Rigor of the guideline development

4. Clarity and presentation of the guideline

5. Applicability of the guideline to practice

6. Demonstrated editorial independence of the developers

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CRITICAL APPRAISAL CRITERIA Systematic reviews

1. Does the PICO question match the studies included in the review?

2. Are the review methods clearly stated and comprehensive?

3. Are the dates of the review’s inclusion clear and relevant to the area reviewed?

4. Are the inclusion and exclusion criteria for studies in the review clear and comprehensive?

5. What criteria were used to assess each of the studies in the review for quality and scientific merit?

6. If studies were analyzed individually, were the data clear?

7. Were the methods of study combination clear and appropriate?

8. If the studies were reviewed collectively, how large was the effect?

9. Are the clinical conclusions drawn from the studies relevant and supported by the review?

Clinical practice guidelines, although they are systematically developed and make explicit recommendations for practice, may be formatted differently. Practice guidelines should reflect the components listed. Guidelines can be located on an organization’s website, at the AHRQ, on the NGC website (www.AHRQ.gov), or on MEDLINE (see Chapters 3 and 20). Well-developed guidelines are constructed using the principles of a systematic review.

Appraisal for evidence-based practice systematic reviews and clinical guidelines

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For each of the review methods described—systematic, meta- analysis, integrative, and clinical guidelines—think about each method as one that progressively sifts and sorts research studies and the data until the highest quality of evidence is used to arrive at the conclusions. First the researcher combines the results of all the studies based on a focused, specific question. The studies that do not meet the inclusion criteria are then excluded and the data assessed for quality. This process is repeated sequentially, excluding studies until only the studies of highest quality available are included in the analysis. An alteration in the overall results as an outcome of this sorting and separating process suggests how sensitive the conclusions are to the quality of studies included (Whittemore, 2005). No matter which type of review is completed, it is important to understand that the research studies reviewed still must be examined through your evidence-based practice lens. This means that evidence that you have derived through your critical appraisal and synthesis or derived through other researchers’ reviews must be integrated with an individual clinician’s expertise and patients’ wishes.

CRITICAL APPRAISAL CRITERIA Critiquing clinical guidelines

1. Is the date of publication or release current?

2. Are the authors of the guideline clear and appropriate to the guideline?

3. Is the clinical problem and purpose clear in terms of what the guideline covers and patient groups for which it was designed?

4. What types of evidence were used in formulating the guideline, and are they appropriate to the topic?

5. Is there a description of the methods used to grade the evidence?

6. Were the search terms and retrieval methods used to acquire research and theoretical evidence used in the guideline clear and relevant?

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7. Is the guideline well-referenced and comprehensive?

8. Are the recommendations in the guideline sourced according to the level of evidence for its basis?

9. Has the guideline been reviewed by experts in the appropriate field of discipline?

10. Who funded the guideline development?

You should note that a researcher who uses any of the systematic review methods of combining evidence does not conduct the original studies or analyze the data from each study, but rather takes the data from all the published studies and synthesizes the information by following a set of systematic steps. Systematic methods for combining evidence are used to synthesize both nonexperimental and experimental research studies.

Finally, evidence-based practice requires that you determine— based on the strength and quality of the evidence provided by the systematic review coupled with your clinical expertise and patient values—whether or not you would consider a change in practice. For example, the meta-analysis by Al-Mallah and colleagues (2015) in Appendix E details the important findings from the literature, some of which could be used in nursing practice and some that need further research.

Systematic reviews that use multiple randomized controlled trials (RCTs) to combine study results offer stronger evidence (Level I) in estimating the magnitude of an effect for an intervention (see Chapter 2, Table 2.3). The strength of evidence provided by systematic reviews is a key component for developing a practice based on evidence. The qualitative counterpart to systematic reviews is meta-synthesis, which uses qualitative principles to assess qualitative research and is described in Chapter 6.

Key points • A systematic review is a summary of a search of quantitative

studies that use similar designs based on a PICO question.

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• A meta-analysis is a systematic summary of studies using statistical techniques to assess and combine studies of the same design to obtain a precise estimate of the impact of an intervention.

• The terms systematic review and meta-analysis are used interchangeably, but only a meta-analysis includes a statistical assessment of the studies reviewed.

• An integrative review is the broadest category of reviews and can include a theoretical literature review, or a review of both quantitative and qualitative research literature.

• The Cochrane Collaboration prepares and maintains a body of up-to-date systematic reviews focused on health care interventions.

• There are standardized tools available for evaluating individual studies. An example of such tools are available from the Centre for Evidence Based Medicine.

• Clinical practice guidelines are systematically developed statements or recommendations that link research and practice. There are two types of clinical practice guidelines: evidence- based practice guidelines and expert-based practice guidelines.

• Evidence-based guidelines are practice guidelines developed by experts who assess the research literature for the quality and strength of the evidence for an area of practice.

• Expert-based guidelines are developed typically by a nationally known group of experts in an area using opinions of experts along with whatever research evidence is available to date.

• The Appraisal of Guidelines Research and Evaluation II is a tool for appraising the quality of clinical practice guidelines.

Critical thinking challenges

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• An assignment for your research class is to critically appraise the systematic review in Appendix E by Malwallah and colleagues using the Systematic Review Critical Appraisal Tool from the Center for Evidence-based Medicine (CEBM) using the following link, www.cebm.net, to determine whether the effect size reveals a significant difference between the intervention and control group in the summarized studies. How does the effect size pertain to applicability of findings to practice.

• Your interprofessional primary care team is asked to write an evidence-based policy that will introduce depression screening as a required part of the admission protocol in your practice. Debate the pros and cons of considering the evidence to inform your protocol provided by a meta-analysis of 10 RCT studies with a combined sample size of n = 859, in comparison to 10 individual RCTs, only 2 of which have a sample size of n = 100.

• Explain why it is important to have an interprofessional team conducting a systematic review.

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

References 1. Al-Mallah M. H., Farah I., Al-Madani W., et al. The impact

of nurse-led clinics on the mortality and morbidity of patients with cardiovascular diseases A systematic review and meta- analysis. Journal of Cardiovascular Nursing 2015;31(1):89-95.

2. Borenstein M., Hedges L. V., Higgins J. P. T., Rothstein H. R. Introduction to meta-analysis. United Kingdom: Wiley 2009;

3. Brady V. J., Grimes D., Armstrong T., LoBiondo-Wood G. Management of steroid-induced hyperglycemia in hospitalized patients with cancer A review. Oncology Nursing Forum 2014;41:E355-E365.

4. Brouwers M., Kho M. E., Browman G. P., for the AGREE

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http://evolve.elsevier.com/LoBiondo/

Next Steps Consortium, et al. AGREE II Advancing guideline development, reporting and evaluation in healthcare. Canadian Medical Association Journal 2010;182:E839-E842 Available at: doi:10.1503/090449

5. Center for Evidence-Based Medicine Critical Appraisal Tools. Available at: www.cebm.net/critical-appraisal 2016;

6. Cochrane Handbook for Systematic Reviews. Available at: http://www.cochrane-handbook.org 2016;

7. Conley S., Redeker N. A systematic review of management interventions for inflammatory bowel disease. Journal of Nursing Scholarship 2016;48(2):118-127.

8. da Costa B. R., Juni P. Systematic reviews and meta-analyses of randomized trials Principles and pitfalls. European Heart Journal 2014;35:3336-3345.

9. Docherty S. L. Symptom experiences of children and adolescents with cancer. Annual Review Nursing Research 2003;21(2):123-149.

10. Higgins J. P. T., Green S. Cochrane handbook for systematic reviews of interventions version 5.1.0. Available at: http://www.cochrane-handbook.org 2011;

11. Kestler S. A., LoBiondo-Wood G. Review of symptom experiences in children and adolescents with cancer. Cancer Nursing 2012;35(2):E31-E49 Available at: doi:10.1097/NCC.0b013e3182207a2a

12. Liberati A., Altman D. G., Tetzlaff J., et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions Explanation and elaboration. Annuals of Internal Medicine 2009;151(4):w65- w94.

13. Martineau A. R., Cates C. J., Urashima M., et al. Vitamin D for the management of asthma. Cochrane Database of Systematic Reviews 2016;9:CD011511 Available at: doi:10.1002/14651858.CD011511.pub2

14. Moher D., Liberati A., Tetzlaff J., Altman D. G. Preferred reporting items for systematic reviews and meta-analyses The PRISMA statement. PLOS Medicine 2009;62(10):1006-1012 Available at: doi:10.1016/j.jclinepi.2009.06.005

15. Moher D., Shamseer L., Clarke M., et al. Preferred reporting

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http://dx.doi:10.1503/090449

http://www.cebm.net/critical-appraisal

http://www.cochrane-handbook.org

http://dx.doi:10.1097/NCC.0b013e3182207a2a

http://dx.doi:10.1002/14651858.CD011511.pub2

http://dx.doi:10.1016/j.jclinepi.2009.06.005

items for systematic review and meta-analysis protocols (PRISMA—P) 2015 Statement. Systematic Reviews 2015;4(1):1.

16. Moher D., Stewart L., Shekelle P. All in the family Systematic reviews, rapid reviews, scoping reviews, realist reviews and more. Systematic Reviews 2015;4:183.

17. Stroup D. F., Berlin J. A., Morton S. C., et al. Meta-analysis of observational studies in epidemiology A proposal for reporting. Meta-analysis of observational studies in epidemiology (MOOSE) group. The Journal of the American Medical Association 2000;283:2008-2012.

18. Whittemore R. Combining evidence in nursing research Methods and implications. Nursing Research 2005;54(1):56- 62.

19. Whittemore R., Knafl K. The integrative review Updated methodology. Journal of Advanced Nursing 2005;52(5):546- 553.

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CHAPTER 12

Sampling Judith Haber

Learning outcomes

After reading this chapter, you should be able to do the following:

• Identify the purpose of sampling. • Define population, sample, and sampling. • Compare a population and a sample. • Discuss the importance of inclusion and exclusion criteria. • Define nonprobability and probability sampling. • Identify the types of nonprobability and probability sampling strategies. • Compare the advantages and disadvantages of nonprobability and probability sampling strategies. • Discuss the contribution of nonprobability and probability sampling strategies to strength of evidence provided by study findings. • Discuss the factors that influence sample size. • Discuss potential threats to internal and external validity as sources of sampling bias. • Use the critical appraisal criteria to evaluate the “Sample” section of a research report.

KEY TERMS

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accessible population

convenience sampling

data saturation

delimitations

element

eligibility criteria

exclusion criteria

inclusion

multistage (cluster) sampling

network (snowball) sampling

nonprobability sampling

pilot study

population

probability sampling

purposive sampling

quota sampling

random selection

representative sample

sample

sampling

sampling frame

sampling unit

simple random sampling

snowballing

stratified random sampling

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target population

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

The sampling section of a study is usually found in the “Methods” section of a research article. You will find it important to understand the sampling process and the elements that contribute to a researcher using the most appropriate sampling strategy for the type of research being conducted. Equally important is knowing how to critically appraise the sampling section of a study to identify how the strengths and weaknesses of the sampling process contributed to the overall strength and quality of evidence provided by the findings of a study.

When you are critically appraising the sampling section of a study, the threats to internal and external validity as sources of bias need to be considered (see Chapter 8). Your evaluation of the sampling section is very important in your overall critical appraisal of a study’s findings and applicability to practice.

Sampling is the process of selecting representative units of a population in a study. Many problems in research cannot be solved without employing rigorous sampling procedures. Example: ➤ When testing the effectiveness of a medication for patients with type 2 diabetes, the drug is administered to a sample of the population for whom the drug is potentially appropriate. The researcher must come to conclusions without giving the drug to every patient with diabetes or laboratory animal. Because human lives are at stake, the researcher cannot afford to arrive casually at conclusions that are based on the first dozen patients available for study.

The impact of arriving at conclusions that are not accurate or making generalizations from a small nonrepresentative sample is much more severe in research than in everyday life. Essentially, researchers sample representative segments of the population because it is rarely feasible or necessary to sample the entire population of interest to obtain relevant information.

This chapter will familiarize you with the basic concepts of

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sampling as they primarily pertain to the principles of quantitative research design, nonprobability and probability sampling, sample size, and the related critical appraisal process. Sampling issues that relate to qualitative research designs are discussed in Chapters 5, 6, and 7.

Sampling concepts Population A population is a well-defined set with specified properties. A population can be composed of people, animals, objects, or events. Examples of populations might be all of the female patients older than 65 years admitted to a specific hospital for congestive heart failure (CHF) during the year 2017, all of the children with asthma in the state of New York, or all of the men and women with a diagnosis of clinical depression in the United States. These examples illustrate that a population may be broadly defined and potentially involve millions of people or narrowly specified to include only several hundred people.

The population criteria establish the target population—that is, the entire set of cases about which the researcher would like to make generalizations. A target population might include all undergraduate nursing students enrolled in accelerated baccalaureate programs in the United States. Because of time, money, and personnel, however, it is often not feasible to pursue a study using a target population.

An accessible population, one that meets the target population criteria and that is available, is used instead. Example: ➤ An accessible population might include all full-time accelerated baccalaureate students attending school in Oregon. Pragmatic factors must also be considered when identifying a potential population of interest.

It is important to know that a population is not restricted to humans. It may consist of hospital records; blood, urine, or other specimens taken from patients at a clinic; historical documents; or laboratory animals. Example: ➤ A population might consist of all the HgbA1C blood test specimens collected from patients in the City

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Hospital diabetes clinic or all of the patient charts on file who had been screened during pregnancy for HIV infection. A population can be defined in a variety of ways. The basic unit of the population must be clearly defined because the generalizability of the findings will be a function of the population criteria.

Inclusion and exclusion criteria When reading a research report, you should consider whether the researcher has identified the population characteristics that form the basis for the inclusion (eligibility) or exclusion (delimitations) criteria used to select the sample—whether people, objects, or events. The terms inclusion or eligibility criteria and exclusion criteria or delimitations define characteristics that limit the population to a homogenous group of subjects. The population characteristics that provide the basis for inclusion (eligibility) criteria should be evident in the sample—that is, the characteristics of the population and the sample should be congruent in order to assess the representativeness of the sample. Examples of inclusion or eligibility criteria and exclusion criteria or delimitations include the following:

• gender

• age

• marital status

• socioeconomic status

• religion

• ethnicity

• level of education

• age of children

• health status

• diagnosis

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Think about the concept of inclusion or eligibility criteria applied to a study where the subjects are patients. Example: ➤ Participants in a study investigating the effectiveness of a nurse practitioner (NP) delivered symptom management intervention for patients initiating chemotherapy for nonmetastatic cancer compared to standard oncology care. The aim was to reduce patient reported symptom burden by facilitating patient-NP collaboration and early management of symptoms (Traeger et al., 2015). Participants had to meet the following inclusion (eligibility) criteria:

1. Age: At least 18 years

2. Newly diagnosed with Stage I to Stage III breast cancer (BC), lung cancer (LC), or colorectal cancer (CRC)

3. Scheduled to initiate chemotherapy for nonmetastatic disease

4. Able to respond to questionnaires in English

Inclusion and exclusion criteria are established to control for extraneous variability or bias that would limit the strength of evidence contributed by the sampling plan in relation to the study’s design. Each inclusion or exclusion criterion should have a rationale, presumably related to a potential contaminating effect on the dependent variable. Example: ➤ Subjects were excluded from this study if they had:

• A concurrent cognitive or psychiatric condition or substance abuse problem that would prevent adherence to the protocol

• Evidence of metastatic cancer

• Had already received chemotherapy for their malignancy

The careful establishment of sample inclusion or exclusion criteria will increase a study’s precision and strength of evidence, thereby contributing to the accuracy and generalizability of the findings (see Chapter 8). Fig. 12.1 provides an example of a flow chart that illustrates how potential study participants were screened using the above inclusion (eligibility) and exclusion criteria for

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enrollment in the NP delivered symptom management intervention study by Traeger and colleagues (2015).

FIG 12.1 Subject selection using a proportional

stratified random sampling strategy.

HELPFUL HINT Researchers may not clearly identify the population under study, or the population is not clarified until the “Discussion” section when the effort is made to discuss the group (population) to which the study findings can be generalized.

Samples and sampling Sampling is the selection of a portion or subset of the designated population that represents the entire population. A sample is a set of elements that make up the population; an element is the most basic unit about which information is collected. The most common element in nursing research is individuals, but other elements (e.g., places, objects) can form the basis of a sample or population. Example: ➤ A researcher was planning a study that investigated barriers that may underlie the decline in girls’ physical activity

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(PA), beginning at the onset of adolescence. Eight midwestern US schools were randomly assigned to either receive a multicomponent PA intervention called “Girls on the Move” or serve as a control. The schools were identified as the sampling units rather than the treatment alone (Vermeesch et al., 2015). The purpose of sampling is to increase a study’s efficiency. If you think about it, you will realize that it is not feasible to examine every element in the population. When sampling is done properly, the researcher can draw inferences and make generalizations about the population without examining each element in the population. Sampling procedures identify specific selection criteria to ensure that the characteristics of the phenomena of interest will be, or are likely to be, present in all of the units being studied. The researcher’s efforts to ensure that the sample is representative of the target population strengthens the evidence generated by the sample, which allows the researcher to draw conclusions that are generalizable to the population and applicable to practice (see Chapter 8).

After having reviewed a number of research studies, you will recognize that samples and sampling procedures vary in terms of merit. The foremost criterion in appraising a sample is its representativeness. A representative sample is one whose key characteristics closely match those of the population. If 70% of the population in a study of child-rearing practices consisted of women and 40% were full-time employees, a representative sample should reflect these characteristics in the same proportions.

EVIDENCE-BASED PRACTICE TIP Consider whether the choice of participants was biased, thereby influencing the strength of evidence provided by the outcomes of the study.

Types of samples Sampling strategies are generally grouped into two categories: nonprobability sampling and probability sampling. In nonprobability sampling, elements are chosen by nonrandom methods. The drawback of this strategy is that there is no way of estimating each element’s probability of being included in a particular sample. Essentially, there is no way of ensuring that

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every element has a chance for inclusion in a nonprobability sample.

Probability sampling uses some form of random selection when the sample is chosen. This type of sample enables the researcher to estimate the probability that each element of the population will be included in the sample. Probability sampling is the more rigorous type of sampling strategy and is more likely to result in a representative sample. A summary of sampling strategies appears in Table 12.1 and is discussed in the following sections.

TABLE 12.1 Summary of Sampling Strategies

EVIDENCE-BASED PRACTICE TIP Determining whether the sample is representative of the population being studied will influence your interpretation of the evidence provided by the findings and decision making about their relevance to the patient population and practice setting.

HELPFUL HINT A research article may not be explicit about the sampling strategy used. If the sampling strategy is not specified, assume that a convenience sample was used for a quantitative study and a purposive sample was used for a qualitative study.

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Nonprobability sampling Because of lack of random selection, the findings of studies using nonprobability sampling are less generalizable than those using a probability sampling strategy, and they tend to produce less representative samples. When a nonprobability sample is carefully chosen to reflect the target population through the careful use of inclusion and exclusion criteria and adequate sample size, you can have more confidence in the sample’s representativeness and the external validity of the findings (see Chapter 8). The three major types of nonprobability sampling are convenience, quota, and purposive sampling strategies.

Convenience sampling Convenience sampling is the use of the most readily accessible persons or objects as subjects. The subjects may include volunteers, the first 100 patients admitted to hospital X with a particular diagnosis, all of the people enrolled in program Y during the month of September, or all of the students enrolled in course Z at a particular university during 2014. The subjects are convenient and accessible to the researcher and are thus called a convenience sample. Example: ➤ A study evaluating an NP-led intensive behavioral treatment program for obesity implemented in an adult primary care practice used a convenience sample of obese adults (18 years and older) who were primary care patients of a patient-centered medical home (PCMH) practice who met the eligibility criteria and volunteered to participate in the study (Thabault et al., 2016).

The advantage of a convenience sample is that generally it is easier to obtain subjects. The researcher will still have to be concerned with obtaining a sufficient number of subjects who meet the inclusion criteria. The major disadvantage of a convenience sample is that the risk of bias is greater than in any other type of sample (see Table 12.1). The fact that convenience samples use voluntary participation increases the probability of researchers recruiting those people who feel strongly about the issue being studied, which may favor certain outcomes. In this case, ask yourself the following as you think about the strength and quality of evidence contributed by the sampling component of a study:

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• What motivated some people to participate and others not to participate (self-selection)?

• What kind of data would have been obtained if nonparticipants had also responded?

• How representative are the people who did participate in relation to the population?

• What kind of confidence can you have in the evidence provided by the findings?

Researchers may recruit subjects in clinic settings, stop people on a street corner to ask their opinion on some issue, place advertisements in the newspaper, or place signs in local churches, community centers, or supermarkets, indicating that volunteers are needed for a particular study. To assess the degree to which a convenience sample approximates a random sample, the researcher checks for the representativeness of the convenience sample by comparing the sample to population percentages and, in that way, assesses the extent to which bias is or is not evident (Sousa et al., 2004).

Because acquiring research subjects is a problem that confronts many researchers, innovative recruitment strategies may be used. A unique method of accessing and recruiting subjects is the use of online computer networks (e.g., disease-specific chat rooms, blogs, and bulletin boards). Example: ➤ In the study by Traeger et al. (2015) that implemented a nursing intervention to enhance outpatient chemotherapy symptom management, trained staff screened chemotherapy schedules and electronic health record data to identify all potential participants. When you appraise a study you should recognize that the convenience sampling strategy, although most common, is the weakest sampling strategy with regard to strength of evidence and generalizability (external validity) unless it is followed by random assignment to groups, as you will find in studies that are randomized clinical trials (RCT) (see Chapter 9). When a convenience sample is used, caution should be exercised in interpreting the data and assessing the researcher’s comments about the external validity and applicability

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of the findings (see Chapter 8).

Quota sampling Quota sampling refers to a form of nonprobability sampling in which subjects who meet the inclusion criteria are recruited and consecutively enrolled until the target sample size is reached. The study by Traeger and colleagues provides an example of quota sampling when trained study coordinators approached eligible chemotherapy patients during their first chemotherapy visit to introduce the study, obtained informed consent, and enrolled interested and eligible consecutive patients until the target enrollment was reached.

Sometimes knowledge about the population of interest is used to build some representativeness into the sample (see Table 12.1). A quota sample can identify the strata of the population and proportionally represents the strata in the sample. Example: ➤ The data in Table 12.2 reveal that 40% of the 5000 nurses in city X are associate degree graduates, 20% are 4-year baccalaureate degree graduates, and 40% are accelerated second-degree baccalaureate graduates. Each stratum of the population should be proportionately represented in the sample. In this case, the researcher used a proportional quota sampling strategy and decided to sample 10% of a population of 5000 (i.e., 500 nurses). Based on the proportion of each stratum in the population, 200 associate degree graduates, 100 4-year baccalaureate graduates, and 200 accelerated baccalaureate graduates were the quotas established for the three strata. The researcher recruited subjects who met the study’s eligibility criteria until the quota for each stratum was filled. In other words, once the researcher obtained the necessary 200 associate degree graduates, 100 4-year baccalaureate degree graduates, and 200 accelerated baccalaureate degree graduates, the sample was complete.

TABLE 12.2 Numbers and Percentages of Students in Strata of a Quota Sample of 5000 Graduates of Nursing Programs in City X

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The characteristics chosen to form the strata are selected according to a researcher’s knowledge of the population and the literature review. The criterion for selection should be a variable that reflects important differences in the dependent variables under investigation. Age, gender, religion, ethnicity, medical diagnosis, socioeconomic status, level of completed education, and occupational rank are among the variables that are likely to be important stratifying variables in nursing research studies.

The researcher systematically ensures that proportional segments of the population are included in the sample. The quota sample is not randomly selected (i.e., once the proportional strata have been identified, the researcher recruits and enrolls subjects until the quota for each stratum has been filled) but does increase the sample’s representativeness. This sampling strategy addresses the problem of overrepresentation or underrepresentation of certain segments of a population in a sample.

As you critically appraise a study, your aim is to determine whether the sample strata appropriately reflect the population under consideration and whether the stratifying variables are homogeneous enough to ensure a meaningful comparison of differences among strata. Establishment of strict inclusion and exclusion criteria and using power analysis to determine appropriate sample size increase the rigor of a quota sampling strategy by creating homogeneous subject categories that facilitate making meaningful comparisons across strata.

Purposive sampling Purposive sampling is a common strategy. The researcher selects subjects who are considered to be typical of the population. Purposive sampling can be found in both quantitative and qualitative studies. When a researcher is considering the sampling strategy for a randomized clinical trial focusing on a specific diagnosis or patient population, the sampling strategy is often purposive in nature. In such studies the researcher first purposively selects subjects who are then randomized to groups.

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Purposive sampling is commonly used in qualitative research studies. Example: ➤ The objective of the qualitative study by van Dijk et al. (2015) was to examine how patients assign a number to their currently experienced postoperative pain. They selected a purposive sample of patients who had surgery the day before and were experiencing postoperative pain with a score of at least 4 on the Numeric Rating Scale (NRS). Subjects were selected until the new information obtained did not provide further insight into the themes or no new themes emerged (data saturation; see Chapters 5, 6, and 14). A purposive sample is used also when a highly unusual group is being studied, such as a population with a rare genetic disease (e.g., Huntington chorea). In this case, the researcher would describe the sample characteristics precisely to ensure that the reader will have an accurate picture of the subjects in the sample.

Today, computer networks (e.g., online services) can be a valuable resource in helping researchers access and recruit subjects for purposive samples. Online support group bulletin boards that facilitate recruitment of subjects for purposive samples exist for people with cancer, rheumatoid arthritis, multiple sclerosis, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), postpartum depression, Lyme disease, and many others.

The researcher who uses a purposive sample assumes that errors of judgment in overrepresenting or underrepresenting elements of the population in the sample will tend to balance out. As indicated in Table 12.1, there may be conscious bias in the selection of subjects; the ability to generalize from the evidence provided by the findings is very limited. Box 12.1 lists examples of when a purposive sample may be appropriate. BOX 12.1 Criteria for Use of a Purposive Sampling Strategy

• Effective pretesting of newly developed instruments with a purposive sample of divergent types of people

• Validation of a scale or test with a known-group technique

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• Collection of exploratory data in relation to an unusual or highly specific population, particularly when the total target population remains an unknown to the researcher

• Collection of descriptive data (e.g., as in qualitative studies) that seek to describe the lived experience of a particular phenomenon (e.g., postpartum depression, caring, hope, surviving childhood sexual abuse)

• Focus of the study population relates to a specific diagnosis (e.g., type 1 diabetes, ovarian cancer) or condition (e.g., legal blindness, terminal illness) or demographic characteristic (e.g., same-sex twin pairs)

Network sampling Network sampling, sometimes referred to as snowballing, is used for locating samples that are difficult or impossible to locate in other ways. This strategy takes advantage of social networks and the fact that friends tend to have characteristics in common. When a few subjects with the necessary eligibility criteria are found, the researcher asks for their assistance in getting in touch with others with similar criteria. Example: ➤ Online computer networks, as described in the section on purposive sampling and in this last example, can be used to assist researchers in acquiring otherwise difficult to locate subjects, thereby taking advantage of the networking or snowball effect. In a study that aimed to gain consensus from experts on the priorities for clinical nursing and midwifery research in southern and eastern African countries, the researchers used contacts with networks of regional nursing colleagues and leaders, snowball sampling, to compile a list of potential research experts who met the inclusion criteria and agreed to participate by responding to the Delphi research priority survey. To expand their network of experts, they asked survey respondents for referrals to others who met the criteria and might be willing to participate. Surveys were sent to the new potential participants who were identified (Sun et al., 2015).

HELPFUL HINT When convenience or purposive sampling is used as the first step

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in recruiting a sample for a randomized clinical trial, as illustrated in Fig. 12.1, it is followed by random assignment of subjects to an intervention or control group, which increases the generalizability of the findings.

Probability sampling The primary characteristic of probability sampling is the random selection of elements from the population. Random selection occurs when each element of the population has an equal and independent chance of being included in the sample. When probability sampling is used, you have greater confidence that the sample is representative of the population being studied rather than biased. Three commonly used probability sampling strategies are simple random, stratified random, and cluster.

Random selection of sample subjects should not be confused with randomization or random assignment of subjects. The latter, discussed earlier in this chapter and in Chapter 8, refers to the assignment of subjects to either an experimental or a control group on a random basis. Random assignment is most closely associated with RCT.

Simple random sampling Simple random sampling is a carefully controlled process. The researcher defines the population (a set), lists all of the units of the population (a sampling frame), and selects a sample of units (a subset) from which the sample will be chosen. Example: ➤ If American hospitals specializing in the treatment of cancer were the sampling unit, a list of all such hospitals would be the sampling frame. If certified school nurses constituted the accessible population, a list of those nurses would be the sampling frame.

Once a list of the population elements has been developed, the best method of selecting a random sample is to use a computer program that generates the order in which the random selection of subjects is to be carried out.

The advantages of simple random sampling are as follows:

• Sample selection is not subject to the conscious biases of the researcher.

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• Representativeness of the sample in relation to the population characteristics is maximized.

• Differences in the characteristics of the sample and the population are purely a function of chance.

• Probability of choosing a nonrepresentative sample decreases as the size of the sample increases.

Example: ➤ Simple random sampling was used in a study testing the feasibility of collecting hair for cortisol measurement from a probability sample of 516 racially and socioeconomically diverse urban adolescents aged 11 to 17 years participating in a larger prospective study on adolescent health and well-being (Ford et al., 2016). The sampling frame was based on a combination of eligible households and public school data from the study area. The addresses were sorted by zip code, and random replicates of 500 participants were drawn. The randomly selected households were contacted to solicit participation in the study.

The major disadvantage of simple random sampling is that it can be a time-consuming and inefficient method of obtaining a random sample. Example: ➤ Consider the task of listing all of the baccalaureate nursing students in the United States. With random sampling, it may also be impossible to obtain an accurate or complete listing of every element in the population. Example: ➤ Imagine trying to obtain a list of all suicides in New York City for the year 2016. It often is the case that although suicide may have been the cause of death, another cause (e.g., cardiac failure) appears on the death certificate. It would be difficult to estimate how many elements of the target population would be eliminated from consideration. The issue of bias would definitely enter the picture despite the researcher’s best efforts. In the final analysis, you, as the evaluator of a research article, must be cautious about generalizing from findings, even when random sampling is the stated strategy or if the target population has been difficult or impossible to list completely.

EVIDENCE-BASED PRACTICE TIP When thinking about applying study findings to your clinical

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practice, consider whether the participants making up the sample are similar to your own patients.

Stratified random sampling Stratified random sampling requires that the population be divided into strata or subgroups as illustrated in Fig. 12.1. The subgroups or subsets that the population is divided into are homogeneous. An appropriate number of elements from each subset are randomly selected on the basis of their proportion in the population. The goal of this strategy is to achieve a greater degree of representativeness. Stratified random sampling is similar to the proportional stratified quota sampling strategy discussed earlier in the chapter. The major difference is that stratified random sampling uses a random selection procedure for obtaining sample subjects.

The population is stratified according to any number of attributes, such as age, gender, ethnicity, religion, socioeconomic status, or level of education completed. The variables selected to form the strata should be adaptable to homogeneous subsets with regard to the attributes being studied. Example: ➤ A study by Wong et al. (2016) examined whether high-comorbidity patients had larger increases in primary care provider (PCP) visits attributable to primary care medical home (PCMH) implementation in a large integrated health system in comparison to other patients enrolled in primary care. The data were obtained from the Veterans Health Association (VHA) Corporate Data Warehouse (CDW), which contains comprehensive administrative data tracking patient utilization, demographics, and clinical measures including ICD-9 diagnostic codes. For each quarter of the study, they identified a 1% random sample of all VHA primary care patients in the database that quarter. The final sample consisted of 8.4 million patient quarter observations. All analyses were stratified by age group (under 65 and age 65+), comorbidity burden score, and outpatient visits. As illustrated in Table 12.1, several advantages to a stratified random sampling strategy include (1) representativeness of the sample is enhanced; (2) researcher has a valid basis for making comparisons among subsets; and (3) researcher is able to oversample a disproportionately small stratum to adjust for their underrepresentation, statistically weigh the data accordingly, and

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continue to make legitimate comparisons. The obstacles encountered by a researcher using this strategy

include (1) difficulty of obtaining a population list containing complete critical variable information, (2) time-consuming effort of obtaining multiple enumerated lists, (3) challenge of enrolling proportional strata, and (4) time and money involved in carrying out a large-scale study using a stratified sampling strategy.

Multistage sampling (cluster sampling) Multistage (cluster) sampling involves a successive random sampling of units (clusters) that progress from large to small and meet sample eligibility criteria. The first-stage sampling unit consists of large units or clusters. The second-stage sampling unit consists of smaller units or clusters. Third-stage sampling units are even smaller. Example: ➤ If a sample of critical care nurses is desired, the first sampling unit would be a random sample of hospitals, obtained from an American Hospital Association list, that meet the eligibility criteria (e.g., size, type). The second-stage sampling unit would consist of a list of critical care nurses practicing at each hospital selected in the first stage (i.e., the list obtained from the vice president for nursing at each hospital). The criteria for inclusion in the list of critical care nurses would be as follows:

1. Certified as a Certified Critical Care Registered Nurse (CCRN) with at least 3 years’ experience as a critical care nurse

2. At least 75% of the CCRN’s time spent in providing direct patient care in a critical care unit

3. Full-time employment at the hospital

The second-stage sampling unit would obtain a random selection of 10 CCRNs from each hospital who met the previously mentioned eligibility criteria.

When multistage sampling is used in relation to large national surveys, states are used as the first-stage sampling unit; followed by successively smaller units such as counties, cities, districts, and blocks as the second-stage sampling unit; and finally households as

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the third-stage sampling unit. Sampling units or clusters can be selected by simple random or

stratified random sampling methods. Example: ➤ Sun et al. (2015) conducted a survey using the Delphi method to gain consensus about regional clinical nursing and midwifery research priorities from experts in participating eastern and southern African countries. Clinical nursing and midwifery experts from 13 countries participated in the first round of the survey by completing the electronic survey, and experts from 14 countries participated in the second round. This approach to multistage sampling was chosen because the electronic format facilitates obtaining consensus from a large panel of experts in a wide geographic region by providing anonymity, eliminating the potential for leaders to dominate the process, and providing a chance in Round 2 to change their mind after considering the group opinion. The main advantage of cluster sampling, as illustrated in Table 12.1, is that it can be more economical in terms of time and money than other types of probability sampling. There are two major disadvantages: (1) more sampling errors tend to occur than with simple random or stratified random sampling, and (2) appropriate handling of the statistical data from cluster samples is very complex. When you are critically appraising a study, you will need to consider whether the use of cluster sampling is justified in light of the research design, as well as other pragmatic matters, such as economy.

EVIDENCE-BASED PRACTICE TIP The sampling strategy, whether probability or nonprobability, must be appropriate to the design and evaluated in relation to the level of evidence provided by the design.

CRITICAL THINKING DECISION PATH Assessing the Relationship Between the Type of Sampling Strategy and the Appropriate Generalizability

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The Critical Thinking Decision Path illustrates the relationship between the type of sampling strategy and the appropriate generalizability.

Sample size There is no single rule that can be applied to the determination of a sample’s size. When arriving at an estimate of sample size, many factors, such as the following, must be considered:

• Type of design

• Type of sampling procedure

• Type of formula used for estimating optimum sample size

• Degree of precision required

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• Heterogeneity of the attributes under investigation

• Relative frequency that the phenomenon of interest occurs in the population (i.e., a common versus a rare health problem)

• Projected cost of using a particular sampling strategy

HELPFUL HINT Look for a brief discussion of a study’s sampling strategy in the “Methods” section of a research article. Sometimes there is a separate subsection with the heading “Sample,” “Subjects,” or “Study Participants.” A statistical description of the characteristics of the actual sample often does not appear until the “Results” section of a research article. You may also find a table in the Results section that summarizes the sample characteristics using descriptive statistics (see Chapter 14).

The sample size should be determined before a study is conducted. A general rule is always to use the largest sample possible. The larger the sample, the more representative of the population it is likely to be; smaller samples produce less accurate results.

One exception to this principle occurs when using qualitative designs. In this case, sample size is not predetermined. Sample sizes in qualitative research tend to be small because of the large volume of verbal data that must be analyzed and because this type of design tends to emphasize intensive and prolonged contact with subjects (Speziale & Carpenter, 2011). Subjects are added to the sample until data saturation is reached (i.e., new data no longer emerge during the data-collection process). Fittingness of the data is a more important concern than representativeness of subjects (see Chapters 5, 6, and 7).

Another exception is in the case of a pilot study, which is defined as a small sample study conducted as a prelude to a larger scale study that is often called the “parent study.” The pilot study is typically a smaller scale of the parent study, with similar methods and procedures that yield preliminary data to determine the feasibility of conducting a larger scale study and establish that

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sufficient scientific evidence exists to justify subsequent, more extensive research.

The principle of “larger is better” holds true for both probability and nonprobability samples. Results based on small samples (under 10) tend to be unstable—the values fluctuate from one sample to the next, and it is difficult to apply statistics meaningfully. Small samples tend to increase the probability of obtaining a markedly nonrepresentative sample. As the sample size increases, the mean more closely approximates the population values, thus introducing fewer sampling errors.

HIGHLIGHT Remember to have your interprofessional Journal Club evaluate the appropriateness of the generalizations made about the studies you critically appraise in light of the sampling procedure and any sources of bias that affect applicability of the findings to your patient population.

It is possible to estimate the sample size needed with the use of a statistical procedure known as power analysis (Cohen, 1988). Power analysis is an advanced statistical technique that is commonly used by researchers and is a requirement for external funding. When it is not used, you will have less confidence provided by the findings because the study may be based on a sample that is too small. A researcher may commit a type II error of accepting a null hypothesis when it should have been rejected if the sample is too small (see Chapter 16). No matter how high a research design is located on the evidence hierarchy (e.g., Level II—experimental design consisting of a randomized clinical trial), the findings of a study and their generalizability are weakened when power analysis is not calculated to ensure an adequate sample size to determine the effect of the intervention.

It is beyond the scope of this chapter to describe this complex procedure in great detail, but a simple example will illustrate its use. Nyamathi and colleagues (2015) wanted to assess the impact of three interventions: peer coaching with nurse case management (PC-NCM), peer coaching (PC), and usual care (UC) on completion of hepatitis A and B vaccination series. How would a research team such as Nyamathi and colleagues know the appropriate number of

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subjects that should be used in the study? When using power analysis, the researcher must estimate how large an impact (effect) will be observed between the three intervention groups (i.e., to test differences among PC-NCM, PC., and UC groups in terms of vaccination completion rates). If a moderate difference is expected, a conventional effect size of.20 is assumed. With a significance level of.05, a total of 114 participants would be needed for each intervention group to detect a statistically significant difference between the groups with a power of.80. The total sample in this study (n = 600) exceeded the minimum number of 114 per intervention group.

HELPFUL HINT Remember to evaluate the appropriateness of the generalizations made about the study findings in light of the target population, the accessible population, the type of sampling strategy, and the sample size.

When calculating sample size using power analysis, the total sample size needs to consider that attrition, or dropouts, will occur and build in approximately 15% extra subjects to make sure that the ability to detect differences between groups or the effect of an intervention remains intact. When expected differences are large, it does not take a very large sample to ensure that differences will be revealed through statistical analysis.

When critically appraising a study, you should evaluate the sample size in terms of the following: (1) how representative the sample is relative to the target population, and (2) to whom the researcher wishes to generalize the study’s results. The goal is to have a sample as representative as possible with as little sampling error as possible. Unless representativeness is ensured, all the data in the world become inconsequential. When an appropriate sample size, including power analysis for calculation of sample size, and sampling strategy have been used, you can feel more confident that the sample is representative of the accessible population rather than biased (Fig. 12.2) and the potential for generalizability of findings is greater (see Chapter 8).

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FIG 12.2 Summary of general sampling procedure.

EVIDENCE-BASED PRACTICE TIP Research designs and types of samples are often linked. When a nonprobability purposive sampling strategy is used to recruit participants to a study using an experimental design, you would expect random assignment of subjects to an intervention or control group to follow.

Appraisal for evidence-based practice sampling The criteria for critical appraisal of a study’s sample are presented in the Critical Appraisal Criteria box. As you evaluate the sample section of a study, you must raise two questions:

1. If this study were to be replicated, would there be enough information presented about the nature of the population, the sample, the sampling strategy, and sample size of another investigator to carry out the study?

2. What are the sampling threats to internal and external validity that are sources of bias?

The answers to these questions highlight the important link of the sample to the findings and the strength of the evidence used to make clinical decisions about the applicability of the findings to clinical practice (see Chapter 8).

In Chapter 8, we talked about how selection effect as a threat to internal validity could occur in studies where a convenience, quota, or purposive sampling strategy was used. In these studies, individuals themselves decide whether or not to participate. Subject mortality or attrition is another threat to internal validity related to sampling (see Chapter 8). Mortality is the loss of subjects from the study, usually from the first data-collection point to the second. If

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the subjects who remain in the study are different from those who drop out, the results can be affected. When more of the subjects in one group drop out than the other group, the results can also be influenced. It is common for journals to require authors reporting on research results to include a flow chart that diagrams the screening, recruitment, enrollment, random assignment, and attrition process and results. Threats to external validity related to sampling are concerned with the generalizability of the results to other populations. Generalizability depends on who actually participates in a study. Not everyone who is approached meets the inclusion criteria, agrees to enroll, or completes the study. Bias in sample representativeness and generalizability of findings are important sampling issues that have generated national concern because the presence of these factors decreases confidence in the evidence provided by the findings and limits applicability. Historically, many of the landmark adult health studies (e.g., the Framingham heart study, the Baltimore longitudinal study on aging) excluded women as subjects. Despite the all-male samples, the findings of these studies were generalized from males to all adults, in spite of the lack of female representation in the samples. Similarly, the use of largely European-American subjects in clinical trials limits the identification of variant responses to interventions or drugs in ethnic or racially distinct groups (Ward, 2003). Findings based on European-American data cannot be generalized to African Americans, Asians, Hispanics, or any other cultural group.

CRITICAL APPRAISAL CRITERIA Sampling

1. Have the sample characteristics been completely described?

2. Can the parameters of the study population be inferred from the description of the sample?

3. To what extent is the sample representative of the population as defined?

4. Are the eligibility/inclusion criteria for the sample clearly identified?

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5. Have sample exclusion criteria/delimitations for the sample been established?

6. Would it be possible to replicate the study population?

7. How was the sample selected? Is the method of sample selection appropriate?

8. What kind of bias, if any, is introduced by this sampling method?

9. Is the sample size appropriate? How is it substantiated?

10. Are there indications that rights of subjects have been ensured?

11. Does the researcher identify limitations in generalizability of the findings from the sample to the population? Are they appropriate?

12. Is the sampling strategy appropriate for the design of the study and level of evidence provided by the design?

13. Does the researcher indicate how replication of the study with other samples would provide increased support for the findings?

When appraising the sample of a study, you must remember that despite the use of a carefully controlled sampling procedure that minimizes error, there is no guarantee that the sample will be representative. Factors such as sample heterogeneity and subject dropout may jeopardize the representativeness of the sample despite the most stringent random sampling procedure.

When a purposive sample is used in experimental and quasi- experimental studies, you should determine whether or how the subjects were randomly assigned to groups. If criteria for random assignment have not been followed, you have a valid basis for being cautious about the strength of evidence provided by the proposed conclusions of the study.

Although random selection may be the ideal in establishing the representativeness of a study population, more often realistic barriers (e.g., institutional policy, inaccessibility of subjects, lack of

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time or money, and current state of knowledge in the field) necessitate the use of nonprobability sampling strategies. Many important research questions that are of interest to nursing do not lend themselves to probability sampling. A well-designed, carefully controlled study using a nonprobability sampling strategy can yield accurate and meaningful evidence that makes a significant contribution to nursing’s scientific body of knowledge.

The greatest difficulty in nonprobability sampling stems from the fact that not every element in the population has an equal chance of being represented. Therefore it is likely that some segment of the population will be systematically underrepresented. If the population is homogeneous on critical characteristics, such as age, gender, socioeconomic status, and diagnosis, systematic bias will not be very important. Few of the attributes that researchers are interested in, however, are sufficiently homogeneous to make sampling bias an irrelevant consideration.

Basically you will decide whether the sample size for a quantitative study is appropriate and its size is justifiable. You want to make sure that the researcher indicated how the sample size was determined. The method of arriving at the sample size and the rationale should be briefly mentioned. In the study designed to examine the role of resilience in the relationships of hallucination and delusion-like experiences to psychological distress in a nonclinical population, the sample was selected through a stratified cluster sampling procedure (Barahmand & Ahmad, 2016). The sampling frame consisted of 11,000 students. The power analysis indicated that based on a 5% margin of error and a 95% confidence level and expecting the sample proportion to be 50%, a sample size of at least 372 individuals (3.38% of the population) was needed to detect a significant difference. To allow for data loss through mortality, data loss, or incomplete answers, a sample of 440 individuals (4% of the population) were enrolled in the study. When appraising qualitative research designs, you also apply criteria related to sampling strategies that are relevant for a particular type of qualitative study. In general, sampling strategies for qualitative studies are purposive because the study of specific phenomena in their natural setting is emphasized; any subject belonging to a specified group is considered to represent that

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group. Keep in mind that qualitative studies will not discuss predetermining sample size or method of arriving at sample size. Rather, sample size will tend to be small and a function of data saturation. Finally, evidence that the rights of human subjects have been protected should appear in the “Sample” section of the research report and probably consists of no more than one sentence. Remember to evaluate whether permission was obtained from an institutional review board that reviewed the study relative to the maintenance of ethical research standards (see Chapter 13).

Key points • Sampling is a process that selects representative units of a

population for study. Researchers sample representative segments of the population because it is rarely feasible or necessary to sample entire populations of interest to obtain accurate and meaningful information.

• Researchers establish eligibility criteria; these are descriptors of the population and provide the basis for selection of a sample. Eligibility criteria, which are also referred to as delimitations, include the following: age, gender, socioeconomic status, level of education, religion, and ethnicity.

• The researcher must identify the target population (i.e., the entire set of cases about which the researcher would like to make generalizations). Because of the pragmatic constraints, however, the researcher usually uses an accessible population (i.e., one that meets the population criteria and is available).

• A sample is a set of elements that makes up the population.

• A sampling unit is the element or set of elements used for selecting the sample. The foremost criterion in appraising a sample is the representativeness or congruence of characteristics with the population.

• Sampling strategies consist of nonprobability and probability sampling.

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• In nonprobability sampling, the elements are chosen by nonrandom methods. Types of nonprobability sampling include convenience, quota, and purposive sampling.

• Probability sampling is characterized by the random selection of elements from the population. In random selection, each element in the population has an equal and independent chance of being included in the sample. Types of probability sampling include simple random, stratified random, and multistage sampling.

• Sample size is a function of the type of sampling procedure being used, the degree of precision required, the type of sample estimation formula being used, the heterogeneity of the study attributes, the relative frequency of occurrence of the phenomena under consideration, and cost.

• Criteria for drawing a sample vary according to the sampling strategy. Systematic organization of the sampling procedure minimizes bias. The target population is identified, the accessible portion of the target population is delineated, permission to conduct the research study is obtained, and a sampling plan is formulated.

• When critically appraising a research report, the sampling plan needs to be evaluated for its appropriateness in relation to the particular research design and level of evidence generated by the design.

• Completeness of the sampling plan is examined in light of potential replicability of the study. The critiquer appraises whether the sampling strategy is the strongest plan for the particular study under consideration.

• An appropriate systematic sampling plan will maximize the efficiency of a research study. It will increase the strength, accuracy, and meaningfulness of the evidence provided by the findings and enhance the generalizability of the findings from the sample to the population.

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Critical thinking challenges • How do inclusion and exclusion criteria contribute to increasing

the strength of evidence provided by the sampling strategy of a research study?

• Why is it important for a researcher to use power analysis to calculate sample size? How does adequate sample size affect subject mortality, representativeness of the sample, the researcher’s ability to detect a treatment effect, and your ability to generalize from the study findings to your patient population?

• How does a flow chart such as the one in Fig. 12.1 of the Thomas article in Appendix A contribute to the strength and quality of evidence provided by the findings of research study and their potential for applicability to practice?

• Your interprofessional team member argues that a random sample is always better, even if it is small and represents ONLY one site. Another team member counters that a very large convenience sample with random assignment to groups representing multiple sites can be very significant. Which colleague would you defend and why? How would each scenario affect the strength and quality of evidence provided by the findings?

• Your research classmate argues that a random sample is always better, even if it is small and represents only one site. Another student counters that a very large convenience sample representing multiple sites can be very significant. Which classmate would you defend and why? How would each scenario affect the strength and quality of evidence provided by the findings?

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

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References 1. Barahmand U., Ahmad R. H. S. Psychotic-like experiences

and psychological distress the role of resilience. Journal of the American Psychiatric Nurses Association 2016;22(4):312-319.

2. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. New York, NY: Academic Press 1988;

3. Ford J. L., Boch S. J., McCarthy D. O. Feasibility of hair collection for cortisol measurement in population research on adolescent health. Nursing Research 2016;65(3):k249-k255.

4. Nyamathi A., Salem B. E., Zhang S., et al. Nursing case management, peer coaching, and hepatitis A and B vaccine completion among homeless men recently released on parole; Randomized clinical trial. Nursing Research 2015;64(3):177-189.

5. Sousa V. D., Zauszniewski J. A., Musil C. M. How to determine whether a convenience sample represents the population. Applied Nursing Research 2004;17(2):130-133.

6. Speziale S., Carpenter D. R. Qualitative research in nursing. 4th ed. Philadelphia, PA: Lippincott 2011;

7. Sun C., Dohrn J., Klopper H., et al. Clinical nursing and midwifery research priorities in eastern and southern African countries Results from a Delphi Survey. Nursing Research 2015;64(6):466-475.

8. Thabault P. J., Burke P. J., Ades P. A. Intensive behavioral treatment weight loss program in an adult primary care practice. Journal of the American Association of Nurse Practitioners 2016;28:249-257.

9. Traeger L., McDonnell T. M., McCarty C. E., et al. Nursing intervention to enhance outpatient chemotherapy symptom management patient reported outcomes of a randomized controlled trial. Cancer 2015;121:3905-3913.

10. Van Dijk J. F. M., Vervoort S. C. J. M., van Wijck A. J. M., et al. Postoperative patients perspectives on rating pain A qualitative study. International Journal of Nursing Studies 2016;53:260-269.

11. Vermeesch A. L., Ling J., Voskull V. R., et al. Biological and sociocultural differences in perceived barriers to physical activity among firth-to-seventh grade urban girls. Nursing Research

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2015;64(5):342-350. 12. Ward L. S. Race as a variable in cross-cultural research.

Nursing Outlook 2003;51(3):120-125. 13. Wong E. S., Rosland A. M., Fihn S. D., Nelson K. M. Patient-

centered medical home implementation in the veterans’ health administration and primary care use differences by patient co- morbidity burden. Journal of General Internal Medicine 2016;31(12):1467-1474.

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CHAPTER 13

Legal and ethical issues Judith Haber, Geri LoBiondo-Wood

Learning outcomes

After reading this chapter, you should be able to do the following:

• Describe the historical background that led to the development of ethical guidelines for the use of human subjects in research. • Identify the essential elements of an informed consent form. • Evaluate the adequacy of an informed consent form. • Describe the institutional review board’s role in the research review process. • Identify populations of subjects who require special legal and ethical research considerations. • Describe the nurse’s role as patient advocate in research situations. • Critique the ethical aspects of a research study.

KEY TERMS

anonymity

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assent

beneficence

confidentiality

consent

ethics

informed consent

institutional review boards

justice

respect for persons

risk/benefit ratio

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

The focus of this chapter is the legal and ethical considerations that must be addressed before, during, and after the conduct of research. Informed consent, institutional review boards (IRBs), and research involving vulnerable populations—elderly people, pregnant women, children, and prisoners—are discussed. The nurse’s role as patient advocate, whether functioning as researcher, caregiver, or research consumer, is addressed.

Ethical and legal considerations in research: A historical perspective Ethical and legal considerations with regard to research first received attention after World War II, when the US Secretary of State and Secretary of War learned that the trials for war criminals would focus on justifying the atrocities committed by Nazi physicians as “medical research.” The American Medical Association appointed a group to develop a code of ethics for research that would serve as a standard for judging the medical atrocities committed on concentration camp prisoners.

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The resultant Nuremberg Code and its definitions of the terms voluntary, legal capacity, sufficient understanding, and enlightened decision have been the subject of numerous court cases and presidential commissions involved in setting ethical standards in research (Amdur & Bankert, 2011). The code requires informed consent in all cases but makes no provisions for any special treatment of children, the elderly, or the mentally incompetent. In the United States, federal guidelines for the ethical conduct of research were developed in the 1970s. Despite the safeguards provided by the federal guidelines, some of the most atrocious, and hence memorable, examples of unethical research took place in the United States as recently as the 1990s. These examples are highlighted in Table 13.1. They are sad reminders of our own tarnished research heritage and illustrate the human consequences of not adhering to ethical research standards.

TABLE 13.1 Highlights of Unethical Research Studies Conducted in the United States

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In 1973 the first set of proposed regulations on the protection of human subjects were published. The most important provision was a regulation mandating that an institutional review board must review and approve all studies. In 1974, the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research was created. A major charge brought forth by the commission was to identify the basic principles that should underlie the conduct of biomedical and behavioral research involving human subjects and to develop guidelines to ensure that research is conducted in accordance with those principles (Amdur & Bankert, 2011). Three ethical principles were identified as relevant to the conduct of research involving human subjects: the principles of respect for persons, beneficence, and justice (Box 13.1). Included in the report called the Belmont Report, these principles provided the basis for regulations affecting research (National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1978).

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BOX 13.1 Basic Ethical Principles Relevant to the Conduct of Research Respect for persons People have the right to self-determination and to treatment as autonomous agents. Thus they have the freedom to participate or not participate in research. Persons with diminished autonomy are entitled to protection.

Beneficence Beneficence is an obligation to do no harm and maximize possible benefits. Persons are treated in an ethical manner, decisions are respected, they are protected from harm, and efforts are made to secure their well-being.

Justice Human subjects should be treated fairly. An injustice occurs when a benefit to which a person is entitled is denied without good reason or when a burden is imposed unduly.

The US Department of Health and Human Services (USDHHS) also developed a set of regulations which have been revised several times (USDHHS, 2009). They include:

• General requirements for informed consent

• Documentation of informed consent

• IRB review of research proposals

• Exempt and expedited review procedures for certain kinds of research

• Criteria for IRB approval of research

Protection of human rights Human rights are the claims and demands that have been justified in

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the eyes of an individual or by a group of individuals. The term refers to the rights outlined in the American Nurses Association (ANA, 2001) guidelines:

1. Right to self-determination

2. Right to privacy and dignity

3. Right to anonymity and confidentiality

4. Right to fair treatment

5. Right to protection from discomfort and harm

These rights apply to all involved in research, including research team members who may be involved in data collection, practicing nurses involved in the research setting, and subjects participating in the study. As you read a research article, you must realize that any issues highlighted in Table 13.2 should have been addressed and resolved before a research study is approved for implementation.

TABLE 13.2 Protection of Human Rights

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Procedures for protecting basic human rights

Informed consent Elements of informed consent illustrated by the ethical principles of respect and by its related right to self-determination are outlined in Box 13.2 and Table 13.2. It is critical to note that informed consent is not just giving a potential subject a consent form, but is a process that the researcher completes with each subject. Informed consent is documented by a consent form that is given to prospective subjects and contains standard elements. BOX 13.2 Elements of Informed Consent

1. Title of protocol

2. Invitation to participate

3. Basis for subject selection

4. Overall purpose of study

5. Explanation of procedures

6. Description of risks and discomforts

7. Potential benefits

8. Alternatives to participation

9. Financial obligations

10. Assurance of confidentiality

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11. In case of injury compensation

12. HIPAA disclosure

13. Subject withdrawal

14. Offer to answer questions

15. Concluding consent statement

16. Identification of investigators

Informed consent is a legal principle that means that potential subjects understand the implications of participating in research and they knowingly agree to participate (Amdur & Bankert, 2011). Informed consent (USDHHS, 2009; Food and Drug Administration [FDA], 2012a) is defined as follows:

The knowing consent of an individual or his/her legally authorized representative, under circumstances that provide the prospective subject or representative sufficient opportunity to consider whether or not to participate without undue inducement or any element of force, fraud, deceit, duress, or other forms of constraint or coercion.

No investigator may involve a person as a research subject before obtaining the legally effective informed consent of a subject or legally authorized representative. The study must be explained to all potential subjects, including the study’s purpose; procedures; risks, discomforts, and benefits; and expected duration of participation (i.e., when the study’s procedures will be implemented, how many times, and in what setting). Potential subjects must also be informed about any appropriate alternative procedures or treatments, if any, that might be advantageous to the subject. For example, in the Tuskegee Syphilis Study, the researchers should have disclosed that penicillin was an effective treatment for syphilis. Any compensation for subjects’ participation must be delineated when there is more than minimal risk through disclosure about medical treatments and/or compensation that is

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available if injury occurs.

HIGHLIGHT It is important for your team to remember that the right to personal privacy may be more difficult to protect when researchers are carrying out qualitative studies because of the small sample size and the subjects’ verbatim quotes are often used in the findings/results section of the research article to highlight the findings.

Prospective subjects must have time to decide whether to participate in a study. The researcher must not coerce the subject into participating, nor may researchers collect data on subjects who have explicitly refused to participate in a study. An ethical violation of this principle is illustrated by the halting of eight experiments by the US Food and Drug Administration (FDA) at the University of Pennsylvania’s Institute for Human Gene Therapy 4 months after the death of an 18-year-old man, Jesse Gelsinger, who received experimental treatment as part of the institute’s research. The institute could not document that all patients had been informed of the risks and benefits of the procedures. Furthermore, some patients who received the therapy should have been considered ineligible because their illnesses were more severe than allowed by the clinical protocols. Mr. Gelsinger had a non-life-threatening genetic disorder that permits toxic amounts of ammonia to build up in the liver. Nevertheless, he volunteered for an experimental treatment in which normal genes were implanted directly into his liver, and he subsequently died of multiple organ failure. The institute failed to report to the FDA that two patients in the same trial as Mr. Gelsinger had suffered severe side effects, including inflammation of the liver as a result of the treatment. This should have triggered a halt to the trial (Brainard & Miller, 2000). Of course, subjects may discontinue participation or withdraw from a study at any time without penalty or loss of benefits.

HELPFUL HINT Research reports rarely provide readers with detailed information regarding the degree to which the researcher adhered to ethical principles, such as informed consent, because of space limitations

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in journals that make it impossible to describe all aspects of a study. Failure to mention procedures to safeguard subjects’ rights does not necessarily mean that such precautions were not taken.

The language of the consent form must be understandable. The reading level should be no higher than eighth grade for adults, in lay language, and the avoidance of technical terms should be observed (USDHHS, 2009). Subjects should not be asked to waive their rights or release the investigator from liability for negligence. The elements for an informed consent form are listed in Box 13.2.

Investigators obtain consent through personal discussion with potential subjects. This process allows the person to obtain immediate answers to questions. However, consent forms, which are written in narrative or outline form, highlight elements that both inform and remind subjects of the nature of the study and their participation (Amdur & Bankert, 2011).

Assurance of anonymity and confidentiality (defined in Table 13.2) is conveyed in writing and describes how confidentiality of the subjects’ records will be maintained. The right to privacy is also protected through protection of individually identifiable health information (IIHI). The USDHHS developed the following guidelines to help researchers, health care organizations, health care providers, and academic institutions determine when they can use and disclose IIHI:

• IIHI has to be “de-identified” under the HIPAA Privacy Rule.

• Data are part of a limited data set, and a data use agreement with the researcher is in place.

• A potential subject provides authorization for the researcher to use and disclose protected health information (PHI).

• A waiver or alteration of the authorization requirement is obtained from the IRB.

• The consent form must be signed and dated by the subject. The presence of witnesses is not always necessary but does constitute evidence that the subject actually signed the form. If the subject is

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a minor or is physically or mentally incapable of signing the consent, the legal guardian or representative must sign. The investigator also signs the form to indicate commitment to the agreement.

A copy of the signed informed consent is given to the subject. The researcher maintains the original for their records. Some research, such as a retrospective chart audit, may not require informed consent—only institutional approval. In some cases, when minimal risk is involved, the investigator may have to provide the subject only with an information sheet and verbal explanation. In other cases, such as a volunteer convenience sample, completion and return of research instruments provide evidence of consent. The IRB will help advise on exceptions to these guidelines, and there are cases in which the IRB might grant waivers or amend its guidelines in other ways. The IRB makes the final determination regarding the most appropriate documentation format. You should note whether and what kind of evidence of informed consent has been provided in a research article.

HELPFUL HINT Researchers may not obtain written, informed consent when the major means of data collection is through self-administered questionnaires. The researcher usually assumes implied consent in such cases—that is, the return of the completed questionnaire reflects the respondent’s voluntary consent to participate.

Institutional review boards IRBs are boards that review studies to assess that ethical standards are met in relation to the protection of the rights of human subjects. The National Research Act (1974) requires that agencies such as universities, hospitals, and other health care organizations (e.g., managed care companies) where the conduct of biomedical or behavioral research involving human subjects is conducted must submit an application with assurances that they have an IRB, sometimes called a human subjects’ committee, that reviews the research projects and protects the rights of the human subjects (Food and Drug Administration [FDA], 2012b). At agencies where

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no federal grants or contracts are awarded, there is usually a review mechanism similar to an IRB process, such as a research advisory committee. The National Research Act requires that the IRBs have at least five members of various research backgrounds to promote complete and adequate study reviews. The members must be qualified by virtue of their expertise and experience and reflect professional, gender, racial, and cultural diversity. Membership must include one member whose concerns are primarily nonscientific (lawyer, clergy, ethicist) and at least one member from outside the agency. IRB members have mandatory training in scientific integrity and prevention of scientific misconduct, as do the principal investigator of a study and their research team members. In an effort to protect research subjects, the HIPAA Privacy Rule has made IRB requirements much more stringent for researchers (Code of Federal Regulations, Part 46, 2009).

The IRB is responsible for protecting subjects from undue risk and loss of personal rights and dignity. The risk/benefit ratio, the extent to which a study’s benefits are maximized and the risks are minimized such that the subjects are protected from harm, is always a major consideration. For a research proposal to be eligible for consideration by an IRB, it must already have been approved by a departmental review group, such as a nursing research committee that attests to the proposal’s scientific merit and congruence with institutional policies, procedures, and mission. The IRB reviews the study’s protocol to ensure that it meets the requirements of ethical research that appear in Box 13.3. BOX 13.3 Code of Federal Regulations for IRB Approval of Research Studies To approve research, the IRB must determine that the following has been satisfied:

1. Risks to subjects are minimized.

2. Risks to subjects are reasonable in relation to anticipated benefits.

3. Selection of the subjects is equitable.

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4. Informed consent must be and will be sought from each prospective subject or the subject’s legally authorized representative.

5. Informed consent form must be properly documented.

6. Where appropriate, the research plan makes adequate provision for monitoring the data collected to ensure subject safety.

7. There are adequate provisions to protect subjects’ privacy and the confidentiality of data.

8. Where some or all of the subjects are likely to be vulnerable to coercion or undue influence, additional safeguards are included.

IRBs provide guidelines that include steps to be taken to receive IRB approval. For example, guidelines for writing a standard consent form or criteria for qualifying for an expedited rather than a full IRB review may be made available. The IRB has the authority to approve research, require modifications, or disapprove a research study. A researcher must receive IRB approval before beginning to conduct research. IRBs have the authority to audit, suspend, or terminate approval of research that is not conducted in accordance with IRB requirements or that has been associated with unexpected serious harm to subjects.

IRBs also have mechanisms for reviewing research in an expedited manner when the risk to research subjects is minimal (Code of Federal Regulations, 2009). Keep in mind that although a researcher may determine that a project involves minimal risk, the IRB makes the final determination, and the research may not be undertaken until approved. A full list of research categories eligible for expedited review is available from any IRB office. Examples include the following:

• Prospective collection of specimens by noninvasive procedure (e.g., buccal swab, deciduous teeth, hair/nail clippings)

• Research conducted in established educational settings in which subjects are de-identified

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• Research involving materials collected for clinical purposes

• Research on taste, food quality, and consumer acceptance

• Collection of excreta and external secretions, including sweat

• Recording of data on subjects 18 years or older, using noninvasive procedures routinely employed in clinical practice

• Voice recordings

• Study of existing data, documents, records, pathological specimens, or diagnostic data

An expedited review does not automatically exempt the researcher from obtaining informed consent, and most importantly, the department or agency mechanisms retains the final judgment as to whether or not a study may be exempt.

CRITICAL THINKING DECISION PATH Evaluating the Risk/Benefit Ratio of a Research Study

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When critiquing research, it is important to be conversant with current regulations to determine whether ethical standards have been met. The Critical Thinking Decision Path illustrates the ethical decision-making process an IRB might use in evaluating the risk/benefit ratio of a research study.

Protecting basic human rights of vulnerable groups Researchers are advised to consult their agency’s IRB for the most recent federal and state rules and guidelines when considering research involving vulnerable groups who may have diminished

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autonomy, such as the elderly, children, pregnant women, the unborn, those who are emotionally or physically disabled, prisoners, the deceased, students, and persons with AIDS. In addition, researchers should consult the IRB before planning research that potentially involves an oversubscribed research population, such as organ transplantation patients or AIDS patients, or “captive” and convenient populations, such as prisoners. It should be emphasized that use of special populations does not preclude undertaking research; extra precautions must be taken to protect their rights.

Research with children. The age of majority differs from state to state, but there are some general rules for including children as subjects (Title 45, CFR46 Subpart D, USDHHS, 2009). Usually a child can assent between the ages of 7 and 18 years. Research in children requires parental permission and child assent. Assent contains the following fundamental elements:

1. A basic understanding of what the child will be expected to do and what will be done to the child

2. A comprehension of the basic purpose of the research

3. An ability to express a preference regarding participation

In contrast to assent, consent requires a relatively advanced level of cognitive ability. Informed consent reflects competency standards requiring abstract appreciation and reasoning regarding the information provided. The federal guidelines have specific criteria and standards that must be met for children to participate in research. If the research involves more than minimal risk and does not offer direct benefit to the individual child, both parents must give permission. When individuals reach maturity, usually at age 18 years, they may render their own consent. They may do so at a younger age if they have been legally declared emancipated minors. Questions regarding this are addressed by the IRB and/or research administration office and not left to the discretion of the researcher to answer.

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Research with pregnant women, fetuses, and neonates. Research with pregnant women, fetuses, and neonates requires additional protection but may be conducted if specific criteria are met (HHS Code of Federal Regulations, Title 45, CFR46 Subpart B, 2009). Decisions are made relative to the direct or indirect benefit or lack of benefit to the pregnant woman and the fetus. For example, pregnant women may be involved in research if the research suggests the prospect of direct benefit to the pregnant women and fetus by providing data for assessing risks to pregnant women and fetuses. If the research suggests the prospect of direct benefit to the fetus solely, then both the mother and father must provide consent.

Research with prisoners. The federal guidelines also provide guidance to IRBs regarding research with prisoners. These guidelines address the issues of allowable research, understandable language, adequate assurances that participation does not affect parole decisions, and risks and benefits (HHS Code of Federal Regulations, Title 45 Part 46, Subpart C, 2009).

Research with the elderly. Elderly individuals have been historically and are potentially vulnerable to abuse and as such require special consideration. There is no issue if the potential subject can supply legally effective informed consent. Competence is not a clear issue. The complexity of the study may affect one’s ability to consent to participate. The capacity to obtain informed consent should be assessed in each individual for each research protocol being considered. For example, an elderly person may be able to consent to participate in a simple observational study but not in a clinical drug trial. The issue of the necessity of requiring the elderly to provide consent often arises, and each situation must be evaluated for its potential to preserve the rights of this population.

No vulnerable population may be singled out for study because it is convenient. For example, neither people with mental illness nor prisoners may be studied because they are an available and convenient group. Prisoners may be studied if the studies pertain to them—that is, studies concerning the effects and processes of

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incarceration. Similarly, people with mental illness may participate in studies that focus on expanding knowledge about psychiatric disorders and treatments. Students also are often a convenient group. They must not be singled out as research subjects because of convenience; the research questions must have some bearing on their status as students. In all cases, the burden is on the investigator to show the IRB that it is appropriate to involve vulnerable subjects in research.

HELPFUL HINT Keep in mind that researchers rarely mention explicitly that the study participants were vulnerable subjects or that special precautions were taken to appropriately safeguard the human rights of this vulnerable group. Research consumers need to be attentive to the special needs of groups who may be unable to act as their own advocates or are unable to adequately assess the risk/benefit ratio of a research study.

Appraisal for evidence-based practice legal and ethical aspects of a research study Research reports do not contain detailed information regarding the ways in which the investigator adhered to the legal and ethical principles presented in this chapter. Lack of written evidence regarding the protection of human rights does not imply that appropriate steps were not taken.

The Critical Appraisal Criteria box provides guidelines for evaluating the legal and ethical aspects of a study. When reading a study, due to space constraints, you will not see all areas explicitly addressed in the article. Box 13.4 provides examples of statements in research articles that illustrate the brevity with which the legal and ethical component of a study is reported. BOX 13.4 Examples of Legal and Ethical Content in Published Research Reports Found in the Appendices

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• “The study was approved by the Institutional Review Board (IRB) from the university, the 4 recruitment facilities and the State Department of Health prior to recruitment of study participants” (Hawthorne et al., 2016, p. 76).

• “Following institutional ethics approvals from the University of Windsor in Ontario, Canada and the University of Western Ontario, Canada data were collected from the pediatric oncology patients” (Turner-Sack et al., 2016, p. 50).

CRITICAL APPRAISAL CRITERIA Legal and Ethical Issues

1. Was the study approved by an IRB or other agency committees?

2. Is there evidence that informed consent was obtained from all subjects or their representatives? How was it obtained?

3. Were the subjects protected from physical or emotional harm?

4. Were the subjects or their representatives informed about the purpose and nature of the study?

5. Were the subjects or their representatives informed about any potential risks that might result from participation in the study?

6. Is the research study designed to maximize the benefit(s) to human subjects and minimize the risks?

7. Were subjects coerced or unduly influenced to participate in this study? Did they have the right to refuse to participate or withdraw without penalty? Were vulnerable subjects used?

8. Were appropriate steps taken to safeguard the privacy of subjects? How have data been kept anonymous and/or confidential?

Information about the legal and ethical considerations of a study

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is usually presented in the methods section of an article. The subsection on the sample or data-collection methods is the most likely place for this information. The author most often indicates in a sentence that informed consent was obtained and that approval from an IRB was granted. To protect subject and institutional privacy, the locale of the study frequently is described in general terms in the sample subsection of the report. For example, the article might state that data were collected at a 1000-bed tertiary care center in the southwest, without mentioning its name. Protection of subject privacy may be explicitly addressed by statements indicating that anonymity or confidentiality of data was maintained or that grouped data were used in the data analysis.

When considering the special needs of vulnerable subjects, you should be sensitive to whether the special needs of groups, unable to act on their own behalf, have been addressed. For instance, has the right of self-determination been addressed by the informed consent protocol identified in the research report?

When qualitative studies are reported, verbatim quotes from informants often are incorporated into the findings section of the article. In such cases, you will evaluate how effectively the author protected the informant’s identity, either by using a fictitious name or by withholding information such as age, gender, occupation, or other potentially identifying data (see Chapters 5, 6, and 7 for ethical issues related to qualitative research).

It should be apparent from the preceding sections that although the need for guidelines for the use of human subjects in research is evident and the principles themselves are clear, there are many instances when you must use your best judgment both as a patient advocate and as a research consumer when evaluating the ethical nature of a research project. When conflicts arise, you must feel free to raise suitable questions with appropriate resources and personnel. In an institution these may include contacting the researcher first and then, if there is no resolution, the director of nursing research and the chairperson of the IRB. In cases where ethical considerations in a research article are in question, clarification from a colleague, agency, or IRB is indicated. You should pursue your concerns until satisfied that the patient’s rights and your rights as a professional nurse are protected.

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Key points • Ethical and legal considerations in research first received

attention after World War II during the Nuremberg Trials, from which developed the Nuremberg Code. This became the standard for research guidelines protecting the human rights of research subjects.

• The Belmont Report discusses three basic ethical principles (respect for persons, beneficence, and justice) that underlie the conduct of research involving human subjects.

• Protection of human rights includes (1) right to self- determination, (2) right to privacy and dignity, (3) right to anonymity and confidentiality, (4) right to fair treatment, and (5) right to protection from discomfort and harm.

• Procedures for protecting human rights include gaining informed consent, which illustrates the ethical principle of respect, and obtaining IRB approval, which illustrates the ethical principles of respect, beneficence, and justice.

• Special consideration should be given to studies involving vulnerable populations, such as children, the elderly, prisoners, and those who are mentally or physically disabled.

• Nurses must be knowledgeable about the legal and ethical components of research so they can evaluate whether a researcher has ensured protection of patient rights.

Critical thinking challenges • A state government official interested in determining the number

of infants infected with the human immunodeficiency virus (HIV) has approached your hospital to participate in a state-wide funded study. The protocol will include the testing of all newborns for HIV, but the mothers will not be told that the test is being done, nor will they be told the results. Using the basic ethical principles found in Box 13.2, defend or refute the practice.

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How will the findings of the proposed study be affected if the protocol is carried out?

• As a research consumer, what kind of information related to the legal and ethical aspects of a research study would you expect to see written about in a published research study? How does that differ from the data the researcher would have to prepare for an IRB submission?

• A randomized clinical trial (RCT) testing the effectiveness of a new Lyme disease vaccine is being conducted as a multisite RCT. There are two vaccine intervention groups, each of which is receiving a different vaccine, and one control group that is receiving a placebo. Using the information in Table 13.2, identify the conditions under which the RCT is halted due to potential legal and ethical issues to subjects.

• Your interprofessional QI team is asked to do a presentation about risk/benefit ratio and how it influences clinical decision making and resource allocation in your clinical organization.

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

References 1. Amdur R., Bankert E. A. Institutional Review Board Member

Handbook. 3rd ed. Boston, MA: Jones & Bartlett 2011; 2. American Nurses Association. Code for nurses with

interpretive statements. Kansas City, MO: Author 2001; 3. Brainard J., Miller D. W. U. S. regulators suspend medical

studies at two universities. Chronicle of Higher Education 2000;A30.

4. Code of Federal Regulations. Part 46, Vol. 1. Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfresearch.cfm 2009;

5. French H. W. AIDS research in Africa Juggling risks and

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http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfresearch.cfm

hopes. New York Times 1997, October 9;A1-A12. 6. Hawthorne D., Youngblut J. M, Brooten D. Parent

spirituality, grief, and mental health at 1 and 3 months after their infant’s/child’s death in an intensive care unit. Journal of Pediatric Nursing 2016;31:73-80.

7. Hershey N., Miller R. D. Human experimentation and the law. Germantown, MD: Aspen 1976;

8. Hilts P. J. Agency faults a UCLA study for suffering of mental patients.;: New York Times1995, March 9;A1-A11.

9. Levine R. J. Ethics and regulation of clinical research. 2nd ed. Baltimore, MD-Munich, Germany: Urban & Schwartzenberg 1986;

10. National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. Belmont report ethical principles and guidelines for research involving human subjects, DHEW pub no 05. Washington, DC: US Government Printing Office 1978; 78–0012.

11. Turner-Sack A. M, Menna R., Setchell S. R, et al. Psychological functioning, post-treatment growth, and coping in parents and siblings of adolescent cancer survivors. 2016;43(1):48-56.

12. US Department of Health and Human Services (USDHHS). 45 CFR 46. Code of Federal Regulations protection of human subjects. Washington, DC: Author 2009;

13. US Food and Drug Administration (FDA). A guide to informed consent, Code of Federal Regulations, Title 21, Part 50. Available at: www.fda.gov/oc/ohrt/irbs/informedconsent.html 2012;

14. US Food and Drug Administration (FDA). Institutional Review Boards, Code of Federal Regulations, Title 21, Part 56. Available at: www.fda.gov/oc/ohrt/irbs/appendixc.html 2012;

15. Wheeler D. L. Three medical organizations embroiled in controversy over use of placebos in AIDS studies abroad. Chronicle of Higher Education 1997;A15-A16.

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http://www.fda.gov/oc/ohrt/irbs/informedconsent.html

http://www.fda.gov/oc/ohrt/irbs/appendixc.html

CHAPTER 14

Data collection methods Susan Sullivan-Bolyai, Carol Bova

Learning outcomes

After reading this chapter, you should be able to do the following:

• Define the types of data collection methods used in research. • List the advantages and disadvantages of each data collection method. • Compare how specific data collection methods contribute to the strength of evidence in a study. • Identify potential sources of bias related to data collection. • Discuss the importance of intervention fidelity in data collection. • Critically evaluate the data collection methods used in published research studies.

KEY TERMS

anecdotes

closed-ended questions

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concealment

consistency

content analysis

debriefing

demographic data

existing data

field notes

intervention

interview guide

interviews

Likert scales

measurement

measurement error

objective

observation

open-ended questions

operational definition

participant observation

physiological data

questionnaires

random error

reactivity

respondent burden

scale

scientific observation

self-report

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systematic

systematic error

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

Nurses are always collecting information (or data) from patients. We collect data on blood pressure, age, weight, and laboratory values as part of our daily work. Data collected for practice purposes and for research have several key differences. Data collection procedures in research must be objective, free from the researchers’ personal biases, attitudes, and beliefs, and systematic. Systematic means that everyone who is involved in the data collection process collects the data from each subject in a uniform, consistent, or standard way. This is called fidelity. When reading a study, the data collection methods should be identifiable, transparent, and repeatable. Thus, when reading the research literature to inform your evidence-based practice, there are several issues to consider regarding data collection methods.

It is important that researchers carefully define the concepts or variables they measure. The process of translating a concept into a measurable variable requires the development of an operational definition. An operational definition is how the researcher measures each variable. Example: ➤ Turner-Sack and colleagues (2016) (see Appendix D) conceptually defined coping for adolescents (cancer survivors) and their siblings as active, emotion-focused avoidant and acceptance coping; for parents, the definition was similar but slightly different, with active, social support, and emotion-focused avoidant and acceptance coping. They operationally defined coping as measured by the COPE, a measurement scale that assesses coping in adolescents and adults.

The purpose of this chapter is to familiarize you with the ways that researchers collect data from subjects. The chapter provides you with the tools for evaluating data collection procedures commonly used in research, their strengths and weaknesses, how consistent data collection operations (fidelity) can increase study rigor and decrease bias that affects study internal and external validity (see Chapter 8), and how useful each technique is for

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providing evidence for nursing practice. This information will help you critique the research literature and decide whether the findings provide evidence that is applicable to your practice setting.

Measuring variables of interest Largely the success of a study depends on the fidelity (consistency and quality) of the data collection methods or measurement used. Determining what measurement to use in a study may be the most difficult and time-consuming step in study design. Thus, the process of evaluating and selecting the instruments to measure variables of interest is of critical importance to the potential success of the study.

As you read research articles and the data collection techniques used, look for consistency with the study’s aim, hypotheses, setting, and population. Data collection may be viewed as a two- step process. First, the researcher chooses the study’s data collection method(s). An algorithm that influences a researcher’s choice of data collection methods is diagrammed in the Critical Thinking Decision Path. The second step is deciding if the measurement scales are reliable and valid. Reliability and validity of instruments are discussed in Chapter 15 (for quantitative research) and in Chapter 6 (for qualitative research).

CRITICAL THINKING DECISION PATH Consumer of Research Literature Review

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Data collection methods When reading a study, be aware that investigators decide early in the process whether they need to collect their own data or whether data already exist in the form of records or databases. This decision is based on a thorough literature review and the availability of existing data. If the researcher determines that no data exist, new data can be collected through observation, self-report (interviewing or questionnaires), or by collecting physiological data using standardized instruments or testing procedures (e.g., laboratory tests, x-rays). Existing data can be collected by extracting data from medical records or local, state, and national databases. Each of these methods has a specific purpose, as well as pros and cons inherent in its use. It is important to remember that all data collection methods rely on the ability of the researcher to standardize these procedures to increase data accuracy and reduce measurement error.

Measurement error is the difference between what really exists and what is measured in a study. Every study has some amount of measurement error. Measurement error can be random or systematic (see Chapter 15). Random error occurs when scores vary in a random way. Random error occurs when data collectors do not use standard procedures to collect data consistently among all

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subjects in a study. Systematic error occurs when scores are incorrect but in the same direction. An example of systematic error occurs when all subjects were weighed using a weight scale that is under by 3 pounds for all subjects in the study. Researchers attempt to design data collection methods that will be consistently applied across all subjects and time points to reduce measurement error.

HELPFUL HINT Remember that the researcher may not always present complete information about the way the data were collected, especially when established instruments were used. To learn about the instrument that was used in greater detail, you may need to consult the original article describing the instrument.

To help decipher the quality of the data collection section in a research article, we will discuss the three main methods used for collecting data: observation, self-report, and physiological measurement.

EVIDENCE-BASED PRACTICE TIP It is difficult to place confidence in a study’s findings if the data collection methods are not consistent.

Observational methods Observation is a method for collecting data on how people behave under certain conditions. Observation can take place in a natural setting (e.g., in the home, in the community, on a nursing unit) or laboratory setting and includes collecting data on communication (verbal, nonverbal), behavior, and environmental conditions. Observation is also useful for collecting data that may have cultural or contextual influences. Example: ➤ If a researcher wanted to understand the emergence of obesity among immigrants in the United States, it might be useful to observe food preparation, exercise patterns, and shopping practices in the communities of the specific groups.

Although observing the environment is a normal part of living, scientific observation places a great deal of emphasis on the objective and systematic nature of the observation. The researcher is not merely looking at what is happening, but rather is watching

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with a trained eye for specific events. To be scientific, observations must fulfill the following four conditions:

1. Observations undertaken are consistent with the study’s aims/objectives.

2. There is a standardized and systematic plan for observation and data recording.

3. All observations are checked and controlled.

4. The observations are related to scientific concepts and theories.

Observational methods may be structured or unstructured. Unstructured observation methods are not characterized by a total absence of structure, but usually involve collecting descriptive information about the topic of interest. In participant observation, the observer keeps field notes (a short summary of observations) to record the activities, as well as the observer’s interpretations of these activities. Field notes usually are not restricted to any particular type of action or behavior; rather, they represent a narrative set of written notes intended to paint a picture of a social situation in a more general sense. Another type of unstructured observation is the use of anecdotes. Anecdotes are summaries of a particular observation that usually focus on the behaviors of interest and frequently add to the richness of research reports by illustrating a particular point (see Chapters 5 and 6 for more on qualitative data collection strategies). Structured observations involve specifying in advance what behaviors or events are to be observed. Typically standardized forms are used for record keeping and include categorization systems, checklists, or rating scales. Structured observation relies heavily on the formal training and standardization of the observers (see Chapter 15 for an explanation of interrater reliability).

Observational methods can also be distinguished by the role of the observer. The observer’s role is determined by the amount of interaction between the observer and those being observed. These methods are illustrated in Fig. 14.1. Concealment refers to whether the subjects know they are being observed. Concealment has ethical

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implications for the study. Whether concealment is permitted in a study will be decided by an institutional review board. The decision will be based on the potential risk to the subjects, the scientific rationale for the concealment, as well as the plan to debrief the participants about the concealment once the study is completed. Intervention deals with whether the observer provokes actions from those who are being observed. Box 14.1 describes the basic types of observational roles implemented by the observer(s). These are distinguishable by the amount of concealment or intervention implemented by the observer.

FIG 14.1 Types of observational roles in research.

BOX 14.1 Basic Types of Observational Roles

1. Concealment without intervention. The researcher watches subjects without their knowledge and does not provoke the subject into action. Often such concealed observations use hidden television cameras, audio recording devices, or one-way mirrors. This method is often used in observational studies of children and their parents. You may be familiar with rooms with one-way mirrors in which a researcher can observe the behavior of the occupants of the room without being observed by them. Such studies allow for the observation of children’s natural behavior

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and are often used in developmental research.

2. Concealment with intervention. Concealed observation with intervention involves staging a situation and observing the behaviors that are evoked in the subjects as a result of the intervention. Because the subjects are unaware of their participation in a research study, this type of observation has fallen into disfavor and rarely is used in nursing research.

3. No concealment without intervention. The researcher obtains informed consent from the subject to be observed and then simply observes his or her behavior.

4. No concealment with intervention. No concealment with intervention is used when the researcher is observing the effects of an intervention introduced for scientific purposes. Because the subjects know they are participating in a research study, there are few problems with ethical concerns; however, reactivity is a problem in this type of study.

Observing subjects without their knowledge may violate assumptions of informed consent, and therefore researchers face ethical problems with this approach. However, sometimes there is no other way to collect such data, and the data collected are unlikely to have negative consequences for the subject. In these cases, the disadvantages of the study are outweighed by the advantages. Further, the problem is often handled by informing subjects after the observation, allowing them the opportunity to refuse to have their data included in the study and discussing any questions they might have. This process is called debriefing.

When the observer is neither concealed nor intervening, the ethical question is not a problem. Here the observer makes no attempt to change the subjects’ behavior and informs them that they are to be observed. Because the observer is present, this type of observation allows a greater depth of material to be studied than if the observer is separated from the subject by an artificial barrier, such as a one-way mirror. Participant observation is a commonly used observational technique in which the researcher functions as a part of a social group to study the group in question. The problem

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with this type of observation is reactivity (also referred to as the Hawthorne effect), or the distortion created when the subjects change behavior because they know they are being observed.

EVIDENCE-BASED PRACTICE TIP When reading a research report that uses observation as a data collection method, note evidence of consistency across data collectors through use of interrater reliability (see Chapter 15) data. When this is present, it increases your confidence that the data were collected systematically.

Scientific observation has several advantages, the main one being that observation may be the only way for the researcher to study the variable of interest. Example: ➤ What people say they do often may not be what they really do. Therefore, if the study is designed to obtain substantive findings about human behavior, observation may be the only way to ensure the validity of the findings. In addition, no other data collection method can match the depth and variety of information that can be collected when using these techniques. Such techniques also are quite flexible in that they may be used in both experimental and nonexperimental designs. As with all data collection methods, observation also has its disadvantages. Data obtained by observational techniques are vulnerable to observer bias. Emotions, prejudices, and values can influence the way behaviors and events are observed and recorded. In general, the more the observer needs to make inferences and judgments about what is being observed, the more likely it is that distortions will occur. Thus in judging the adequacy of observation methods, it is important to consider how observation forms were constructed and how observers were trained and evaluated.

Ethical issues can also occur if subjects are not fully aware that they are being observed. For the most part, it is best to inform subjects of the study’s purpose and the fact that they are being observed. However, in certain circumstances, informing the subjects will change behaviors (Hawthorne effect; see Chapter 8). Example: ➤ If a nurse researcher wanted to study hand-washing frequency in a nursing unit, telling the nurses that they were being observed for their rate of hand washing would likely increase the hand-washing rate and thereby make the study results less valid.

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Therefore, researchers must carefully balance full disclosure of all research procedures with the ability to obtain valid data through observational methods.

HIGHLIGHT It is important for members of your team to remember to look for evidence of fidelity, that data collectors and those carrying out the intervention were trained on how to collect data and/or implement an intervention consistently. It is also important to determine that there was periodic supervision to make sure that the consistency was maintained.

Self-report methods Self-report methods require subjects to respond directly to either interviews or questionnaires about their experiences, behaviors, feelings, or attitudes. Self-report methods are commonly used in nursing research and are most useful for collecting data on variables that cannot be directly observed or measured by physiological instruments. Some variables commonly measured by self-report in nursing research studies include quality of life, satisfaction with nursing care, social support, pain, resilience, and functional status.

The following are some considerations when evaluating self- report methods:

• Social desirability. There is no way to know for sure if a subject is telling the truth. People are known to respond to questions in a way that makes a favorable impression. Example: ➤ If a nurse researcher asks patients to describe the positive and negative aspects of nursing care received, the patient may want to please the researcher and respond with all positive responses, thus introducing bias into the data collection process. There is no way to tell whether the respondent is telling the truth or responding in a socially desirable way, so the accuracy of self-report measures is always open for scrutiny.

• Respondent burden is another concern for researchers who use self- report (Ulrich et al., 2012). Respondent burden occurs when the length of the questionnaire or interview is too long or the

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questions are too difficult to answer in a reasonable amount of time considering respondents’ age, health condition, or mental status. It also occurs when there are multiple data collection points, as in longitudinal studies when the same questionnaires have to be completed multiple times. Respondent burden can result in incomplete or erroneous answers or missing data, jeopardizing the validity of the study findings.

Interviews and questionnaires Interviews are a method of data collection where a data collector asks subjects to respond to a set of open-ended or closed-ended questions as described in Box 14.2. Interviews are used in both quantitative and qualitative research, but are best used when the researcher may need to clarify the task for the respondent or is interested in obtaining more personal information from the respondent. BOX 14.2 Uses for Open-Ended and Closed-Ended Questions

• Open-ended questions are used when the researcher wants the subjects to respond in their own words or when the researcher does not know all of the possible alternative responses. Interviews that use open-ended questions often use a list of questions and probes called an interview guide. Responses to the interview guide are often audio-recorded to capture the subject’s responses. An example of an open-ended question is used for the interview in Appendix D.

• Closed-ended questions are structured, fixed-response items with a fixed number of responses. Closed-ended questions are best used when the question has a finite number of responses and the respondent is to choose the one closest to the correct response. Fixed-response items have the advantage of simplifying the respondent’s task but result in omission of important information about the subject. Interviews that use closed-ended questions typically record a subject’s responses

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directly on the questionnaire. An example of a closed-ended item is found in Box 14.3.

Open-ended questions allow more varied information to be collected and require a qualitative or content analysis method to analyze responses (see Chapter 6). Content analysis is a method of analyzing narrative or word responses to questions and either counting similar responses or grouping the responses into themes or categories (also used in qualitative research). Interviews may take place face to face, over the telephone, or online via a web- based format.

Questionnaires are paper-and-pencil instruments designed to gather data from individuals about knowledge, attitudes, beliefs, and feelings. Questionnaires, like interviews, may be open-ended or closed-ended, as presented in Box 14.2. Questionnaires are most useful when there is a finite set of questions. Individual items in a questionnaire must be clearly written so that the intent of the question and the nature of the response options are clear. Questionnaires may be composed of individual items that measure different variables or concepts (e.g., age, race, ethnicity, and years of education) or scales. Survey researchers rely almost entirely on questionnaires for data collection.

Questionnaires can be referred to as instruments, measures, scales, or tools. When multiple items are used to measure a single concept, such as quality of life or anxiety, and the scores on those items are combined mathematically to obtain an overall score, the questionnaire or measurement instrument is called a scale. The important issue is that each of the items must measure the same concept or variable. An intelligence test is an example of a scale that combines individual item responses to determine an overall quantification of intelligence.

Scales can have subscales or total scale scores. For instance, in the study by Turner-Sack and colleagues (2016) (see Appendix D), the COPE scale has four separate subscales to measure coping for adolescents (cancer survivors) and their siblings, and four for parents with subjects responding to a four-point scale ranging from 1 to 4, with 1 indicating “I usually do not do this” and 4 indicating “I usually do this a lot.” The investigators also added a religious

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coping subscale for adolescents and siblings and parents. Higher scores reflect more use of that particular type of coping strategy. The response options for scales are typically lists of statements on which respondents indicate, for example, whether they “strongly agree,” “agree,” “disagree,” or “strongly disagree.” This type of response option is called a Likert-type scale.

EVIDENCE-BASED PRACTICE TIP Scales used in research should have evidence of adequate reliability and validity so that you feel confident that the findings reflect what the researcher intended to measure (see Chapter 15).

Box 14.3 shows three items from a survey of nursing job satisfaction. The first item is closed-ended and uses a Likert scale response format. The second item is also closed-ended, and it forces respondents to choose from a finite number of possible answers. The third item is open-ended, and respondents use their own words to answer the question, allowing an unlimited number of possible answers. Often researchers use a combination of Likert- type, closed-ended, and open-ended questions when collecting data in nursing research. BOX 14.3 Examples of Open-Ended and Closed-Ended Questions Open-ended questions Please list the three most important reasons why you chose to stay in your current job:

1. ______________________________

2. ______________________________

3. ______________________________

Closed-ended questions (likert scale) How satisfied are you with your current position?

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Closed-ended questions On average, how many patients do you care for in 1 day?

1. 1 to 3

2. 4 to 6

3. 7 to 9

4. 10 to 12

5. 13 to 15

6. 16 to 18

7. 19 to 20

8. More than 20

Turner-Sack and colleagues (2016; see Appendix D) used all self- report instruments to examine differences among adolescents, siblings, and parents and their psychological functioning, post- traumatic growth, and coping strategies. They also collected demographic data. Demographic data includes information that describes important characteristics about the subjects in a study (e.g., age, gender, race, ethnicity, education, marital status). It is important to collect demographic data in order to describe and compare different study samples so you can evaluate how similar the sample is to your patient population.

When reviewing articles with numerous questionnaires, remember (especially if the study deals with vulnerable populations) to assess if the author(s) addressed potential respondent burden such as:

• Reading level (eighth grade)

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• Questionnaire font size (14-point font)

• Need to read and assist some subjects

• Time it took to complete the questionnaire (30 minutes)

• Multiple data collection points

This information is very important for judging the respondent burden associated with study participation. It is important to examine the benefits and caveats associated with using interviews and questionnaires as self-report methods. Interviews offer some advantages over questionnaires. The response rate is almost always higher with interviews, and there are fewer missing data, which helps reduce bias.

HELPFUL HINT Remember, sometimes researchers make trade-offs when determining the measures to be used. Example: ➤ A researcher may want to learn about an individual’s attitudes regarding job satisfaction; however, practicalities may preclude using an interview, so a questionnaire may be used instead.

Another advantage of the interview is that vulnerable populations such as children, the blind, and those with low literacy may not be able to fill out a questionnaire. With an interview, the data collector knows who is giving the answers. When questionnaires are mailed, for example, anyone in the household could be the person who supplies the answers. Interviews also allow for some safeguards, such as clarifying misunderstood questions, and observing and recording the level of the respondent’s understanding of the questions. In addition, the researcher has flexibility over the order of the questions.

With questionnaires, the respondent can answer questions in any order. Sometimes changing the order of the questions can change the response. Finally, interviews allow for richer and more complex data to be collected. This is particularly so when open-ended responses are sought. Even when closed-ended response items are used, interviewers can probe to understand why a respondent

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answered in a particular way. Questionnaires also have certain advantages. They are much less

expensive to administer than interviews that require hiring and thoroughly training interviewers. Thus if a researcher has a fixed amount of time and money, a larger and more diverse sample can be obtained with questionnaires. Questionnaires may allow for more confidentiality and anonymity with sensitive issues that participants may be reluctant to discuss in an interview. Finally, the fact that no interviewer is present assures the researcher and the reader that there will be no interviewer bias. Interviewer bias occurs when the interviewer unwittingly leads the respondent to answer in a certain way. This problem can be especially pronounced in studies that use open-ended questions. The tone used to ask the question and/or nonverbal interviewer responses such as a subtle nod of the head could lead a respondent to change an answer to correspond with what the researcher wants to hear.

Finally, the use of Internet-based self-report data collection (both interviewing and questionnaire delivery) has gained momentum. The use of an online format is economical and can capture subjects from different geographic areas without the expense of travel or mailings. Open-ended questions are already typed and do not require transcription, and closed-ended questions can often be imported directly into statistical analysis software, and therefore reduce data entry mistakes. The main concerns with Internet-based data collection procedures involve the difficulty of ensuring informed consent (e.g., Is checking a box indicating agreement to participate the same thing as signing an informed consent form?) and the protection of subject anonymity, which is difficult to guarantee with any Internet-based venue. In addition, the requirement that subjects have computer access limits the use of this method in certain age groups and populations. However, the advantages of increased efficiency and accuracy make Internet- based data collection a growing trend among nurse researchers.

Physiological measurement Physiological data collection involves the use of specialized equipment to determine the physical and biological status of subjects. Such measures can be physical, such as weight or

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temperature; chemical, such as blood glucose level; microbiological, as with cultures; or anatomical, as in radiological examinations. What separates these data collection procedures from others used in research is that they require special equipment to make the observation.

Physiological or biological measurement is particularly suited to the study of many types of nursing problems. Example: ➤ Examining different methods for taking a patient’s temperature or blood pressure or monitoring blood glucose levels may yield important information for determining the effectiveness of certain nursing monitoring procedures or interventions. However, it is important that the method be applied consistently to all subjects in the study. Example: ➤ Nurses are quite familiar with taking blood pressure measurements. However, for research studies that involve blood pressure measurement, the process must be standardized (Bern et al., 2007; Pickering et al., 2005). The subject must be positioned (sitting or lying down) the same way for a specified period of time, the same blood pressure instrument must be used, and often multiple blood pressure measurements are taken under the same conditions to obtain an average value.

The advantages of using physiological data collection methods include the objectivity, precision, and sensitivity associated with these measures. Unless there is a technical malfunction, two readings of the same instrument taken at the same time by two different nurses are likely to yield the same result. Because such instruments are intended to measure the variable being studied, they offer the advantage of being precise and sensitive enough to pick up subtle variations in the variable of interest. It is also unlikely that a subject in a study can deliberately distort physiological information.

Physiological measurements are not without inherent disadvantages and include the following:

• Some instruments may be quite expensive to obtain and use.

• Physiological instruments often require specialized training to be used accurately.

• The variable of interest may be altered as a result of using the

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instrument. Example: ➤ An individual’s blood pressure may increase just because a health care professional enters the room (called white coat syndrome).

• Although thought as being nonintrusive, the presence of some types of devices might change the measurement. Example: ➤ The presence of a heart rate monitoring device might make some patients anxious and increase their heart rate.

• All types of measuring devices are affected in some way by the environment. A simple thermometer can be affected by the subject drinking something hot or smoking a cigarette immediately before the temperature is taken. Thus it is important to consider whether the researcher controlled such environmental variables in the study.

Existing data All of the data collection methods discussed thus far concern the ways that researchers gather new data to study phenomena of interest. Sometimes existing data can be examined in a new way to study a problem. The use of records (e.g., medical records, care plans, hospital records, death certificates) and databases (e.g., US Census, National Cancer Database, Minimum Data Set for Nursing Home Resident Assessment and Care Screening) are frequently used to answer research questions about clinical problems. Typically, this type of research design is referred to as secondary analysis.

The use of available data has advantages. First, data are already collected, thus eliminating subject burden and recruitment problems. Second, most databases contain large populations; therefore sample size is rarely a problem and random sampling is possible. Larger samples allow the researcher to use more sophisticated analytic procedures, and random sampling enhances generalizability of findings. Some records and databases collect standardized data in a uniform way and allow the researcher to examine trends over time. Finally, the use of available records has the potential to save significant time and money.

On the other hand, institutions may be reluctant to allow

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researchers to have access to their records. If the records are kept so that an individual cannot be identified (known as de-identified data), this is usually not a problem. However, the Health Insurance Portability and Accountability Act (HIPAA), a federal law, protects the rights of individuals who may be identified in records (Bova et al., 2012; see Chapter 13). Recent escalation in the computerization of health records has led to discussion about the desirability of access to such records for research. Currently, it is not clear how much computerized health data will be readily available for research purposes.

Another problem that affects the quality of available data is that the researcher has access only to those records that have survived. If the records available are not representative of all of the possible records, the researcher may have to make an intelligent guess as to their accuracy. Example: ➤ A researcher might be interested in studying socioeconomic factors associated with the suicide rate. Frequently, these data are underreported because of the stigma attached to suicide, so the records would be biased.

EVIDENCE-BASED PRACTICE TIP Critical appraisal of any data collection method includes evaluating the appropriateness, objectivity, and consistency of the method employed.

Construction of new instruments Sometimes researchers cannot locate an instrument with acceptable reliability and validity to measure the variable of interest (see Chapter 15). In this situation, a new instrument or scale must be developed.

Instrument development is complex and time consuming. It consists of the following steps:

• Define the concept to be measured.

• Clarify the target population.

• Develop the items.

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• Assess the items for content validity.

• Develop instructions for respondents and users.

• Pretest and pilot test the items.

• Estimate reliability and validity.

Defining the concept to be measured requires that the researcher develop expertise in the concept, which includes an extensive review of the literature and of all existing measurements that deal with related concepts. The researcher will use all of this information to synthesize the available knowledge so that the construct can be defined.

Once defined, the individual items measuring the concept can be developed. The researcher will develop many more items than are needed to address each aspect of the concept. The items are evaluated by a panel of experts in the field to determine if the items measure what they are intended to measure (content validity) (see Chapter 15). Items will be eliminated if they are not specific to the concept. In this phase, the researcher needs to ensure consistency among the items, as well as consistency in testing and scoring procedures.

Finally, the researcher pilot tests the new instrument to determine the quality of the instrument as a whole (reliability and validity), as well as the ability of each item to discriminate among individual respondents (variance in item response). Pilot testing can also yield important evidence about the reading level (too low or too high), length of the instrument (too short or too long), directions (clear or not clear), response rate (the percent of potential subjects who return a completed scale), and the appropriateness of culture or context. The researcher also may administer a related instrument to see if the new instrument is sufficiently different from the older one (construct validity). Instrument development and testing is an important part of nursing science because our ability to evaluate evidence related to practice depends on measuring nursing phenomena in a clear, consistent, and reliable way.

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Appraisal for evidence-based practice data collection methods Assessing the adequacy of data collection methods is an important part of evaluating the results of studies that provide evidence for clinical practice. The data collection procedures provide a snapshot of the rigor with which the study was conducted. From an evidence-based practice perspective, you can judge if the data collection procedures would fit within your clinical environment and with your patient population. The manner in which the data were collected affects the study’s internal and external validity. A well-developed methods section of a study decreases bias in the findings. A key element for evidence-based practice is if the procedures were consistently completed. Also consider the following:

• If observation was used, was an observation guide developed, and were the observers trained and supervised until there was a high level of interrater reliability? How was the training confirmed periodically throughout the study to maintain fidelity and decrease bias?

• Was a data collection procedure manual developed and used during the study?

• If the study tested an intervention, were there interventionist and data collector training?

• If a physiological instrument was used, was the instrument properly calibrated throughout the study and the data collected in the same manner from each subject?

• If there were missing data, how were the data accounted for?

Some of these details may be difficult to discern in a research article, due to space limitations imposed by the journal. Typically, the interview guide, questionnaires, or scales are not available for review. However, research articles should indicate the following:

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• Type(s) of data collection method used (self-report, observation, physiological, or existing data)

• Evidence of training and supervision for the data collectors and interventionists

• Consistency with which data collection procedures were applied across subjects

• Any threats to internal validity or bias related to issues of instrumentation or testing

• Any sources of bias related to external validity issues, such as the Hawthorne effect

• Scale reliability and validity discussed

• Interrater reliability across data collectors and time points (if observation was used)

When you review the data collection methods section of a study, it is important to think about the data strength and quality of the evidence. You should have confidence in the following:

• An appropriate data collection method was used

• Data collectors were appropriately trained and supervised

• Data were collected consistently by all data collectors

• Respondent burden, reactivity, and social desirability was avoided

You can critically appraise a study in terms of data collection bias being minimized, thereby strengthening potential applicability of the evidence provided by the findings. Because a research article does not always provide all of the details, it is not uncommon to contact the researcher to obtain added information that may assist you in using results in practice. Some helpful questions to ask are listed in the Critical Appraisal Criteria box.

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CRITICAL APPRAISAL CRITERIA Data collection methods

1. Are all of the data collection instruments clearly identified and described?

2. Are operational definitions provided and clear?

3. Is the rationale for their selection given?

4. Is the method used appropriate to the problem being studied?

5. Were the methods used appropriate to the clinical situation?

6. Was a standardized manual used to guide data collection?

7. Were all data collectors adequately trained and supervised?

8. Are the data collection procedures the same for all subjects?

Observational methods

1. Who did the observing?

2. Were the observers trained to minimize bias?

3. Was there an observation guide?

4. Were the observers required to make inferences about what they saw?

5. Is there any reason to believe that the presence of the observers affected the subject’s behavior?

6. Were the observations performed using the principles of informed consent?

7. Was interrater agreement between observers established?

Self-report: Interviews

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1. Is the interview schedule described adequately enough to know whether it covers the topic?

2. Is there clear indication that the subjects understood the task and the questions?

3. Who were the interviewers, and how were they trained?

4. Is there evidence of interviewer bias?

Self-report: Questionnaires

1. Is the questionnaire described well enough to know whether it covers the topic?

2. Is there evidence that subjects were able to answer the questions?

3. Are the majority of the items appropriately closed-ended or open-ended?

Physiological measurement

1. Is the instrument used appropriate to the research question or hypothesis?

2. Is a rationale given for why a particular instrument was selected?

3. Is there a provision for evaluating the accuracy of the instrument?

Existing data: Records and databases

1. Are the existing data used appropriately, considering the research question and hypothesis being studied?

2. Are the data examined in such a way as to provide new information?

3. Is there any indication of selection bias in the available records?

Key points

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• Data collection methods are described as being both objective and systematic. The data collection methods of a study provide the operational definitions of the relevant variables.

• Types of data collection methods include observational, self- report, physiological, and existing data. Each method has advantages and disadvantages.

• Physiological measurement involves the use of technical instruments to collect data about patients’ physical, chemical, microbiological, or anatomical status. They are suited to studying patient clinical outcomes and how to improve the effectiveness of nursing care. Physiological measurements are objective, precise, and sensitive. Expertise, training, and consistent application of these tests or procedures are needed to reduce the measurement error associated with this data collection method.

• Observational methods are used in nursing research when the variables of interest deal with events or behaviors. Scientific observation requires preplanning, systematic recording, controlling the observations, and providing a relationship to scientific theory. This method is best suited to research problems that are difficult to view as a part of a whole. The advantages of observational methods are that they provide flexibility to measure many types of situations and they allow for depth and breadth of information to be collected. Disadvantages include that data may be distorted as a result of the observer’s presence and observations may be biased by the person who is doing the observing.

• Interviews are commonly used data collection methods in nursing research. Either open-ended or closed-ended questions may be used when asking the subject questions. The form of the question should be clear to the respondent, free of suggestion, and grammatically correct.

• Questionnaires, or paper-and-pencil tests, are useful when there are a finite number of questions to be asked. Questions need to be clear and specific. Questionnaires are less costly in terms of time

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and money to administer to large groups of subjects, particularly if the subjects are geographically widespread. Questionnaires also can be completely anonymous and prevent interviewer bias.

• Existing data in the form of records or large databases are an important source for research data. The use of available data may save the researcher considerable time and money when conducting a study. This method reduces problems with subject recruitment, access, and ethical concerns. However, records and available data are subject to problems of authenticity and accuracy.

Critical thinking challenges • When a researcher opts to use observation as the data collection

method, what steps must be taken to minimize bias?

• In a randomized clinical trial investigating the differential effect of an educational video intervention in comparison to a telephone counseling intervention, data were collected at four different hospitals by four different data collectors. What steps should the researcher take to ensure intervention fidelity?

• What are the strengths and weaknesses of collecting data using existing sources such as records, charts, and databases?

• Your interprofessional Journal Club just finished reading the research article by Nyamathi and colleagues in Appendix A. As part of your critical appraisal of this study, your team needed to identify the strengths and weaknesses of the data collection section. Discuss the sources of bias in the data collection procedures and evidence of fidelity.

• How does a training manual decrease the possibility of introducing bias into the data collection process, thereby increasing intervention fidelity?

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for

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review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

References 1. Bern L., Brandt M., Mbelu N., et al. Differences in blood

pressure values obtained with automated and manual methods in medical inpatients. MEDSURG Nursing 2007;16:356-361.

2. Bova C., Drexler D., Sullivan-Bolyai S. Reframing the influence of HIPAA on research. Chest 2012;141:782-786.

3. Pickering T., Hall J., Appel L., et al. Recommendations for blood pressure measurement in humans and experimental animals part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Hypertension 2005;45:142-161.

4. Turner-Sack A., Menna R., Setchell S., et al. Psychological functioning, post-traumatic growth, and coping in parents and siblings of adolescent cancer survivors. Oncology Nursing Forum 2016;43:48-56 Available at: doi:10.1188/16.ONF.48-56

5. Ulrich C. M., Knafl K. A., Ratcliffe S. J., et al. Developing a model of the benefits and burdens of research participation in cancer clinical trials. American Journal of Bioethics Primary Research 2012;3(2):10-23.

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http://dx.doi:10.1188/16.ONF.48-56

CHAPTER 15

Reliability and validity Geri LoBiondo-Wood, Judith Haber

Learning outcomes

After reading this chapter, you should be able to do the following:

• Discuss how measurement error can affect the outcomes of a study. • Discuss the purposes of reliability and validity. • Define reliability. • Discuss the concepts of stability, equivalence, and homogeneity as they relate to reliability. • Compare and contrast the estimates of reliability. • Define validity. • Compare and contrast content, criterion-related, and construct validity. • Identify the criteria for critiquing the reliability and validity of measurement tools. • Use the critical appraisal criteria to evaluate the reliability and validity of measurement tools. • Discuss how reliability and validity contribute to the strength and

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quality of evidence provided by the findings of a research study.

KEY TERMS

chance (random) errors

concurrent validity

construct

construct validity

content validity

content validity index

contrasted-groups (known-groups) approach

convergent validity

criterion-related validity

Cronbach’s alpha

divergent/discriminant validity

equivalence

error variance

face validity

factor analysis

homogeneity

hypothesis-testing approach

internal consistency

interrater reliability

item to total correlations

kappa

Kuder-Richardson (KR-20) coefficient

Likert scale

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observed test score

parallel or alternate form reliability

predictive validity

reliability

reliability coefficient

split-half reliability

stability

systematic (constant) error

test-retest reliability

validity

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

The measurement of phenomena is a major concern of nursing researchers. Unless measurement instruments validly (accurately) and reliably (consistently) reflect the concepts of the theory being tested, conclusions drawn from a study will be invalid or biased. Issues of reliability and validity are of central concern to researchers, as well as to appraisers of research. From either perspective, the instruments that are used in a study must be evaluated. Researchers often face the challenge of developing new instruments and, as part of that process, establishing the reliability and validity of those instruments.

When reading studies, you must assess the reliability and validity of the instruments to determine the soundness of these selections in relation to the concepts (concepts are often called constructs in instrument development studies) or variables under study. The appropriateness of instruments and the extent to which reliability and validity are demonstrated have a profound influence on the strength of the findings and the extent to which bias is present. Invalid measures produce invalid estimates of the relationships between variables, thus introducing bias, which affects the study’s internal and external validity. As such, the assessment of reliability

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and validity is an extremely important critical appraisal skill for assessing the strength and quality of evidence provided by the design and findings of a study and its applicability to practice.

This chapter examines the types of reliability and validity and demonstrates the applicability of these concepts to the evaluation of instruments in research and evidence-based practice.

Reliability, validity, and measurement error Reliability is the ability of an instrument to measure the attributes of a variable or construct consistently. Validity is the extent to which an instrument measures the attributes of a concept accurately. To understand reliability and validity, you need to understand potential errors related to instruments. Researchers may be concerned about whether the scores that were obtained for a sample of subjects were consistent, true measures of the behaviors and thus an accurate reflection of the differences among individuals. The extent of variability in test scores that is attributable to error rather than a true measure of the behaviors is the error variance. Error in measurement can occur in multiple ways.

An observed test score that is derived from a set of items actually consists of the true score plus error (Fig. 15.1). The error may be either chance or random error, or it may be systematic or constant error. Validity is concerned with systematic error, whereas reliability is concerned with random error. Chance or random errors are errors that are difficult to control (e.g., a respondent’s anxiety level at the time of testing). Random errors are unsystematic in nature; they are a result of a transient state in the subject, the context of the study, or the administration of an instrument. Example: ➤ Perceptions or behaviors that occur at a specific point in time (e.g., anxiety) are known as state or transient characteristics and are often beyond the awareness and control of the examiner. Another example of random error is in a study that measures blood pressure. Random error resulting in different blood pressure readings could occur by misplacement of the cuff, not waiting for a specific time period before taking the blood pressure, or placing the arm randomly in relationship to the heart while

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measuring blood pressure.

FIG 15.1 Components of observed scores.

Systematic or constant error is measurement error that is attributable to relatively stable characteristics of the study sample that may bias their behavior and/or cause incorrect instrument calibration. Such error has a systematic biasing influence on the subjects’ responses and thereby influences the validity of the instruments. For instance, level of education, socioeconomic status, social desirability, response set, or other characteristics may influence the validity of the instrument by altering measurement of the “true” responses in a systematic way. Example: ➤ A subject is completing a survey examining attitudes about caring for elderly patients. If the subject wants to please the investigator, items may constantly be answered in a socially desirable way rather than reflecting how the individual actually feels, thus making the estimate of validity inaccurate. Systematic error occurs also when an instrument is improperly calibrated. Consider a scale that consistently gives a person’s weight at 2 pounds less than the actual body weight. The scale could be quite reliable (i.e., capable of reproducing the precise measurement), but the result is consistently invalid.

The concept of error is important when appraising instruments in a study. The information regarding the instruments’ reliability and validity is found in the instrument or measures section of a study, which can be separately titled or appear as a subsection of the

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methods section of a research report, unless the study is a psychometric or instrument development study (see Chapter 10). HELPFUL HINT Research articles vary considerably in the amount of detail included about reliability and validity. When the focus of a study is instrument development, psychometric evaluation—including reliability and validity data—is carefully documented and appears throughout the article rather than briefly in the “Instruments” or “Measures” section, as in a research article.

Validity Validity is the extent to which an instrument measures the attributes of a concept accurately. When an instrument is valid, it reflects the concept it is supposed to measure. A valid instrument that is supposed to measure anxiety does so; it does not measure another concept, such as stress. A measure can be reliable but not valid. Let’s say that a researcher wanted to measure anxiety in patients by measuring their body temperatures. The researcher could obtain highly accurate, consistent, and precise temperature recordings, but such a measure may not be a valid indicator of anxiety. Thus the high reliability of an instrument is not necessarily congruent with evidence of validity. A valid instrument, however, is reliable. An instrument cannot validly measure a variable if it is erratic, inconsistent, or inaccurate. There are three types of validity that vary according to the kind of information provided and the purpose of the instrument (i.e., content, criterion-related, and construct validity). As you appraise research articles, you will want to evaluate whether sufficient evidence of validity is present and whether the type of validity is appropriate to the study’s design and the instruments used in the study.

As you read the instruments or measures sections of studies, you will notice that validity data are reported much less frequently than reliability data. DeVon and colleagues (2007) note that adequate validity is frequently claimed, but rarely is the method specified. This lack of reporting, largely due to publication space constraints, shows the importance of critiquing the quality of the instruments and the conclusions (see Chapters 14 and 17).

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EVIDENCE-BASED PRACTICE TIP Selecting instruments that have strong evidence of validity increases your confidence in the study findings—that the researchers actually measured what they intended to measure.

Content validity Content validity represents the universe of content or the domain of a given variable/construct. The universe of content provides the basis for developing the items that will adequately represent the content. When an investigator is developing an instrument and issues of content validity arise, the concern is whether the measurement instrument and the items it contains are representative of the content domain that the researcher intends to measure. The researcher begins by defining the concept and identifying the attributes or dimensions of the concept. The items that reflect the concept and its domain are developed.

The formulated items are submitted to content experts who judge the items. Example: ➤ Researchers typically request that the experts indicate their agreement with the scope of the items and the extent to which the items reflect the concept under consideration. Box 15.1 provides an example of content validity. BOX 15.1 Published Examples of Content Validity and Content Validity Index Content validity An expert panel of key stakeholders assisted with validation of the items on the adherence subscale on the modified version of the Fidelity Checklist. To determine adherence items, the expert panel of key stakeholders identified items that were deemed mandatory for clinicians to cover during the intervention. The mandatory items were used to develop the adherence subscale. Through in- person discussion, key stakeholders arrived at a 100% agreement on the relevance of each item of the adherence subscale, ensuring the content validity of both the intervention and the adherence subscale ( Clark et al., 2016).

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Content validity index For the Chinese Illness Perception Questionnaire Revised Trauma (the Chinese IPQ-Revised-Trauma), the Item-level Content Validity Index (I-CVI) was calculated by a panel of five trauma content experts. An average of 88% for all subscale items was scored by the experts, indicating that the validity of the score was reguaranteed. A few words were fixed after expert checking. The ratings were on a four-point scale with a response format of 1 = not relevant to 4 = highly relevant. The I-CVI for each item was computed based on the percentage of experts giving a rating of 3 or 4, indicating item relevance ( Lee et al., 2016).

Another method used to establish content validity is the content validity index (CVI). The CVI moves beyond the level of agreement of a panel of expert judges and calculates an index of interrater agreement or relevance. This calculation gives a researcher more confidence or evidence that the instrument truly reflects the concept or construct. When reading the instrument section of a research article, note that the authors will comment if a CVI was used to assess content validity. When reading a psychometric study that reports the development of an instrument, you will find great detail and a much longer section indicating how exactly the researchers calculated the CVI and the acceptable item cutoffs. In the scientific literature there has been discussion of accepting a CVI of 0.78 to 1.0, depending on the number of experts (DeVon et al., 2007; Lynn, 1986). An example from a study that used CVI is presented in Box 15.1. A subtype of content validity is face validity, which is a rudimentary type of validity that basically verifies that the instrument gives the appearance of measuring the concept. It is an intuitive type of validity in which colleagues or subjects are asked to read the instrument and evaluate the content in terms of whether it appears to reflect the concept the researcher intends to measure.

EVIDENCE-BASED PRACTICE TIP If face and/or content validity, the most basic types of validity, was (or were) the only type(s) of validity reported in a research article, you would not appraise the measurement instrument(s) as having strong psychometric properties, which would negatively influence

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your confidence about the study findings.

Criterion-related validity Criterion-related validity indicates to what degree the subject’s performance on the instrument and the subject’s actual behavior are related. The criterion is usually the second measure, which assesses the same concept under study. Two forms of criterion-related validity are concurrent and predictive.

Concurrent validity refers to the degree of correlation of one test with the scores of another more established instrument of the same concept when both are administered at the same time. A high correlation coefficient indicates agreement between the two measures and evidence of concurrent validity.

Predictive validity refers to the degree of correlation between the measure of the concept and some future measure of the same concept. Because of the passage of time, the correlation coefficients are likely to be lower for predictive validity studies. Examples of concurrent and predictive validity as they appear in research articles are illustrated in Box 15.2. BOX 15.2 Published Examples of Reported Criterion- Related Validity Concurrent validity The Patient-Reported Outcomes Measurement Information System Fatigue-Short Form (PROMIS-SF) consists of seven items that measure both the experience of fatigue and the interference of fatigue on daily activities over the past week (NIH, 2007). Concurrent validity of the PROMIS-SF was established through correlations between the PROMIS-SF and the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF), as well as the Brief Fatigue Inventory (BFI). Correlations between the PROMIS-SF and the MFSI-SF ranged from r = 0.70 to 0.85, and correlations between the PROMIS-F-SF and the BFI ranged from r = 0.60 to 0.71. Correlations between measures of like constructs are expected to be strong. As all three were measures of fatigue, strong correlations were expected and provided evidence of concurrent validity

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(Ameringer et al., 2016).

Predictive validity In a study modifying the Champion Health Belief Model Scale (Champion, 1993) to fit with prostate cancer screening (PCS), translate it into Arabic, and test the psychometric properties of the Champion Health Belief Model Scale for Prostate Cancer Screening (CHBMS-PCS), the predictive validity of the Arabic version was established by using regression analysis (Chapter 16) to predict the combined predictive effect of all seven subscales of the CHBMS- PCS on the performance of the PCS. All of the subscales were found to be significantly correlated and predictive for the performance of the PCS at the p <.05 level or less (Abudas et al., 2016).

Construct validity Construct validity is based on the extent to which a test measures a theoretical construct, attribute, or trait. It attempts to validate the theory underlying the measurement by testing of the hypothesized relationships. Testing confirms or fails to confirm the relationships that are predicted between and/or among concepts and, as such, provides more or less support for the construct validity of the instruments measuring those concepts. The establishment of construct validity is complex, often involving several studies and approaches. The hypothesis-testing, factor analytical, convergent and divergent, and contrasted-groups approaches are discussed in the following sections. Box 15.3 provides examples of different types of construct validity as it is reported in published research articles. BOX 15.3 Published Examples of Reported Construct Validity Contrasted groups (known groups) In the study to examine the psychometric properties of the Patient- Reported Outcomes Measurement Information System Fatigue Short-Form across diverse populations, known group validity was

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established by correlating the four study samples’ levels of fatigue (e.g., fibromyalgia, sickle cell disease, cardio metabolic risk, pregnancy) with healthy controls. The study samples had significantly higher levels of fatigue than the healthy controls (Ameringer et al., 2016).

Convergent validity “Convergent construct validity of the Spiritual Coping Strategies Scale (SCS) subscales is supported by correlations of 0.40 with the well-established Spiritual Well Being instrument (Baldacchino & Bulhagiar, 2003). In this study, parents’ subscales internal consistencies at T1 and T2 were r = 0.87 to 0.90 for religious activities and r = 0.80 to 0.82 for spiritual activities” (Hawthorne et al., 2016; Appendix B).

Divergent (discriminant) validity Pearson correlations between the Patient-Reported Outcomes Measurement Information System Fatigue Short-Form (PROMIS-F- SF), and the Perceived Stress Scale (PSS) and depressive symptoms (CES-D) were calculated to assess the discriminant validity. Since correlations between measures of constructs that are related but not alike are expected to be weak to moderate, correlations between the PROMIS-F-SF and CES-D ranged from r = 0.45 to 0.64 and the PROMIS-F-SF and the PSS ranged from r = 0.37 to 0.62 supported the discriminant validity of the PROMIS-F-SF (Ameringer et al., 2016).

Factor analysis In a study assessing nurses’ perceived leadership abilities during episodes of clinical deterioration, Hart and colleagues (2016) did psychometric testing of the Clinical Deterioration Leadership Ability Scale (CDLAS). Construct validity was supported by a Principal Components Analysis with varimax rotation. The factor analysis determined a 1-factor structure with factor loadings that ranged from 0.655 to 0.792; exceeding the factor loading cutoff of 0.40, this factor was named leadership abilities.

Hypothesis testing In a study assessing nurses’ perceived leadership abilities during

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episodes of clinical deterioration, it was hypothesized that nurses with 11 or more years of practice experience would score significantly higher on the Clinical Deterioration Leadership Ability Scale (CDLAS) than nurses with 10 years or less of practice experience. A statistically significant difference in CDLAS mean t- test scores (p = 0.047) supported this hypothesis, thereby providing evidence of construct validity (Hart et al., 2016).

Hypothesis-testing approach When the hypothesis-testing approach is used, the investigator uses the theory or concept underlying the measurement instruments to validate the instrument. The investigator does this by developing hypotheses regarding the behavior of individuals with varying scores on the measurement instrument, collecting data to test the hypotheses, and making inferences on the basis of the findings concerning whether the rationale underlying the instrument’s construction is adequate to explain the findings and thereby provide support for evidence of construct validity (see Box 15.2).

Convergent and divergent approaches Strategies for assessing construct validity include convergent and divergent approaches. Convergent validity, sometimes called concurrent validity, refers to a search for other measures of the construct. Sometimes two or more instruments that theoretically measure the same construct are identified, and both are administered to the same subjects. A correlational analysis (i.e., test of relationship; see Chapter 16) is performed. If the measures are positively correlated, convergent validity is said to be supported.

Divergent validity, sometimes called discriminant validity, uses measurement approaches that differentiate one construct from others that may be similar. Sometimes researchers search for instruments that measure the opposite of the construct. If the divergent measure is negatively related to other measures, validity for the measure is strengthened.

HELPFUL HINT When validity data about the measurements used in a study are

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not included in a research article, you have no way of determining whether the intended concept is actually being captured by the measurement. Before you use the results in such a case, it is important to go back to the original primary source to check the instrument’s validity.

Contrasted-groups approach When the contrasted-groups approach (sometimes called the known-groups approach) is used to test construct validity, the researcher identifies two groups of individuals who are suspected to score extremely high or low in the characteristic being measured by the instrument. The instrument is administered to both the high- scoring and the low-scoring group, and the differences in scores are examined. If the instrument is sensitive to individual differences in the trait being measured, the mean performance of these two groups should differ significantly and evidence of construct validity would be supported. A t test or analysis of variance could be used to statistically test the difference between the two groups (see Box 15.2 and Chapter 16).

EVIDENCE-BASED PRACTICE TIP When the instruments used in a study are presented, note whether the sample(s) used to develop the measurement instrument(s) is (are) similar to your patient population.

Factor analytical approach A final approach to assessing construct validity is factor analysis. This is a procedure that gives the researcher information about the extent to which a set of items measures the same underlying concept (variable) of a construct. Factor analysis assesses the degree to which the individual items on a scale truly cluster around one or more concepts. Items designed to measure the same concept should load on the same factor; those designed to measure different concepts should load on different factors (Anastasi & Urbina, 1997; Furr & Bacharach, 2008; Nunnally & Bernstein, 1993). This analysis, as illustrated in the example in Box 15.2, will also indicate whether the items in the instrument reflect a single construct or several constructs.

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The Critical Thinking Decision Path will help you assess the appropriateness of the type of validity and reliability selected for use in a particular study.

CRITICAL THINKING DECISION PATH Determining the Appropriate Type of Validity and Reliability Selected for a Study

Reliability Reliable people are those whose behavior can be relied on to be

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consistent and predictable. Likewise, the reliability of an instrument is defined as the extent to which the instrument produces the same results if the behavior is repeatedly measured with the same scale. Reliability is concerned with consistency, accuracy, precision, stability, equivalence, and homogeneity. Concurrent with the questions of validity or after they are answered, you ask about the reliability of the instrument. Reliability refers to the proportion of consistency to inconsistency in measurement. In other words, if we use the same or comparable instruments on more than one occasion to measure a set of behaviors that ordinarily remains relatively constant, we would expect similar results if the instruments are reliable.

The main attributes of a reliable scale are stability, homogeneity, and equivalence. The stability of an instrument refers to the instrument’s ability to produce the same results with repeated testing. The homogeneity of an instrument means that all of the items in an instrument measure the same concept, variable, or characteristic. An instrument is said to exhibit equivalence if it produces the same results when equivalent or parallel instruments or procedures are used. Each of these attributes and an understanding of how to interpret reliability are essential.

Reliability coefficient interpretation Reliability is concerned with the degree of consistency between scores that are obtained at two or more independent times of testing and is expressed as a correlation coefficient. Reliability coefficient ranges from 0 to 1. The reliability coefficient expresses the relationship between the error variance, the true (score) variance, and the observed score. A zero correlation indicates that there is no relationship. When the error variance in a measurement instrument is low, the reliability coefficient will be closer to 1. The closer to 1 the coefficient is, the more reliable the instrument. Example: ➤ A reliability coefficient of an instrument is reported to be 0.89. This tells you that the error variance is small and the instrument has little measurement error. On the other hand, if the reliability coefficient of a measure is reported to be 0.49, the error variance is high and the instrument has a problem with measurement error. For a research instrument to be considered

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reliable, a reliability coefficient of 0.70 or above is necessary. If it is a clinical instrument, a reliability coefficient of 0.90 or higher is considered to be an acceptable level of reliability.

The tests of reliability used to calculate a reliability coefficient depends on the nature of the instrument. The tests are test-retest, parallel or alternate form, item to total correlation, split-half, Kuder-Richardson (KR-20), Cronbach’s alpha, and interrater reliability. These tests as they relate to stability, equivalence, and homogeneity are listed in Box 15.4, and examples of the types of reliability are in Box 15.5. There is no best means to assess reliability. The reliability method that the researcher uses should be consistent with the study’s aim and the instrument’s format. BOX 15.4 Measures Used to Test Reliability Stability Test-retest reliability

Parallel or alternate form

Homogeneity Item to total correlation

Split-half reliability Kuder-Richardson coefficient Cronbach’s alpha

Equivalence Parallel or alternate form

Interrater reliability

BOX 15.5 Published Examples of Reported Reliability Internal consistency In a study by Bhandari and Kim (2016) investigating self-care behaviors of Nepalese adults with type 2 diabetes, self-care behaviors were measured by the DMSE scale (Bijl et al., 1999). Cronbach’s alpha was 0.81 in a study of European adults with type

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2 DM (Bijl et al., 1999); it was 0.86 in the current study.

Test-retest reliability In a study by Ganz and colleagues (2016) that examined whether nurses fully implement their scope of practice, the Implementation of Scope of Practice Scale, developed by the researchers for the study, established strong test-retest reliability (r = 0.92) by administering the scale at baseline and again 3 weeks later.

Kuder-richardson (kr-20) A study by Jessee and Tanner (2016) aimed to develop a Clinical Coaching Interactions Inventory, a tool to evaluate one-to-one teaching, verbal questioning, and feedback behaviors of clinical faculty and/or preceptors interacting with students in clinical settings. The teaching-questioning dimension demonstrated Kuder-Richardson Formula 20 (KR-20) of 0.70 overall, 0.63 for the faculty version, and 0.71 for the staff nurse preceptor version. The inventory is composed of binary items (e.g., Yes/No), and therefore a lower KR-20 reliability estimate is not unexpected and a KR-20 reliability estimate can still be considered acceptable.

Interrater reliability and kappa In the Johansson and colleagues (2016) study evaluating the oral health status of older adults in Sweden receiving elder care, the ROAG-J was used to assess oral health by evaluating the condition of the voice, lips, oral mucosa, tongue, gums, teeth, saliva, swallowing, and any prostheses. Moderate to good interrater reliability was reported for the trained examiners (mean kappa estimate 0.59); interrater reproducibility (kappa estimate 1.00) and high sensitivity and specificity within elderly care in previous studies have been reported (Anderson et al., 2002; Ribeiro et al., 2014).

Item to total Abuadas and colleagues (2016) examined the item-to-total correlations as part of the assessment of reliability for the Arabic version of the Champion’s Health Belief Model Scales for Prostate Cancer Screening (CHBMS-PCS). The aim was to identify poorly functioning items on the CHBMS-PCS. A cutoff score of 0.30 was

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established; all of the corrected item-to-total correlations were greater than 0.30 and ranged from 0.60 to 0.79. This indicated that the scale items have distinguishing consistency with each other. This was reinforced by the Cronbach’s alpha coefficient for the total scale of 0.87.

Stability An instrument is stable or exhibits stability when the same results are obtained on repeated administration of the instrument. Measurement over time is important when an instrument is used in a longitudinal study and therefore used on several occasions. Stability is also a consideration when a researcher is conducting an intervention study that is designed to effect a change in a specific variable. In this case, the instrument is administered and then again later, after the experimental intervention has been completed. The tests that are used to estimate stability are test-retest and parallel or alternate form.

Test-retest reliability Test-retest reliability is the administration of the same instrument to the same subjects under similar conditions on two or more occasions. Scores from repeated testing are compared. This comparison is expressed by a correlation coefficient, usually a Pearson r (see Chapter 16). The interval between repeated administrations varies and depends on the variable being measured. Example: ➤ If the variable that the test measures is related to the developmental stages in children, the interval between tests should be short. The amount of time over which the variable was measured should also be identified in the study.

HELPFUL HINT When a longitudinal design with multiple data collection points is being conducted, look for evidence of test-retest or parallel form reliability.

Parallel or alternate form Parallel or alternate form reliability is applicable and can be tested only if two comparable forms of the same instrument exist. Not many

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instruments have a parallel form, so it is unusual to find examples in the literature. It is similar to test-retest reliability in that the same individuals are tested within a specific interval, but it differs because a different form of the same test is given to the subjects on the second testing. Parallel forms or tests contain the same types of items that are based on the same concept, but the wording of the items is different. The development of parallel forms is desired if the instrument is intended to measure a variable for which a researcher believes that “test-wiseness” will be a problem (see Chapter 8). Example: ➤ Consider a study to establish the reliability and validity of the Social Attribution Task-Multiple Choice (SAT- MC), a measurement instrument of geometric figures designed to assess implicit social attribution formation while reducing verbal and cognitive demands required of other common measures (Johannesen et al., 2013). The authors conducted a comparable analysis of the SAT-MC and the new SAT-MC II, a comparable form created for repeated testing to decrease threats to internal validity related to practice effect. External validation measures between the two forms were nearly identical, with evidence supporting convergent and divergent validity. Practically speaking, it is difficult to develop alternate forms of an instrument when one considers the many issues of reliability and validity. If alternate forms of a test exist, they should be highly correlated if the measures are to be considered reliable.

Internal consistency/homogeneity Another attribute of an instrument related to reliability is the internal consistency or homogeneity. In this case, the items within the scale reflect or measure the same concept. This means that the items within the scale correlate or are complementary to each other. This also means that a scale is unidimensional. A unidimensional scale is one that measures one concept, such as self-efficacy. Box 15.5 provides several examples of how internal consistency is reported. Internal consistency can be assessed using one of four methods: item to total correlations, split-half reliability, Kuder- Richardson (KR-20) coefficient, or Cronbach’s alpha.

EVIDENCE-BASED PRACTICE TIP

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When the characteristics of a study sample differ significantly from the sample in the original study, check to see if the researcher has reestablished the reliability of the instrument with the current sample.

Item to total correlations Item to total correlations measure the relationship between each of the items and the total scale. When item to total correlations are calculated, a correlation for each item on the scale is generated (Table 15.1). Items that do not achieve a high correlation may be deleted from the instrument. Usually in a research study, all of the item to total correlations are not reported unless the study is a report of a methodological study. The lowest and highest correlations are typically reported.

TABLE 15.1 Examples of Cronbach’s Alpha From the Alhusen Study (Appendix B)

Cronbach’s alpha The fourth and most commonly used test of internal consistency is Cronbach’s alpha, which is used when a measurement instrument uses a Likert scale. Many scales used to measure psychosocial variables and attitudes have a Likert scale response format. A Likert scale format asks the subject to respond to a question on a scale of varying degrees of intensity between two extremes. The two extremes are anchored by responses ranging from “strongly agree” to “strongly disagree” or “most like me” to “least like me.” The points between the two extremes may range from 1 to 4, 1 to 5, or 1 to 7. Subjects are asked to identify the response closest to how

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they feel. Cronbach’s alpha simultaneously compares each item in the scale with the others. A total score is then used in the data analysis as illustrated in Table 15.1. Alphas above 0.70 are sufficient evidence for supporting the internal consistency of the instrument. Fig. 15.2 provides examples of items from an instrument that use a Likert scale format.

FIG 15.2 Examples of a Likert scale. (Redrawn from Roberts, K. T., & Aspy, C. B. (1993). Development of the serenity scale. Journal of Nursing Measurement,

1(2), 145–164.)

Split-half reliability Split-half reliability involves dividing a scale into two halves and making a comparison. The halves may be odd-numbered and even- numbered items or may be a simple division of the first from the second half, or items may be randomly selected into halves that will be analyzed opposite one another. The split-half method provides a measure of consistency. The two halves of the test or the contents in both halves are assumed to be comparable, and a reliability

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coefficient is calculated. If the scores for the two halves are approximately equal, the test may be considered reliable. See Box 15.5 for an example.

Kuder-richardson (kr-20) coefficient The Kuder-Richardson (KR-20) coefficient is the estimate of homogeneity used for instruments that have a dichotomous response format. A dichotomous response format is one in which the question asks for a “yes/no” or “true/false” response. The technique yields a correlation that is based on the consistency of responses to all the items of a single form of a test that is administered one time. The minimum acceptable KR-20 score is r = 0.70 (see Box 15.5).

HIGHLIGHT Your team is critically appraising a research study reporting on an innovative intervention for reducing risk for hospital acquired pressure ulcers. Data are collected using observation and multiple observers. You want to find evidence that the observers have been trained until there is a high level of interrater reliability so that you are confident that they were observing the subjects’ skin according to standardized criteria and completing their Checklist ratings in a consistent way across observers.

Equivalence Equivalence either is the consistency or agreement among observers using the same measurement instrument or is the consistency or agreement between alternate forms of an instrument. An instrument is thought to demonstrate equivalence when two or more observers have a high percentage of agreement of an observed behavior or when alternate forms of a test yield a high correlation. There are two methods to test equivalence: interrater reliability and alternate or parallel form.

Interrater reliability Some measurement instruments are not self-administered questionnaires but are direct measurements of observed behavior. Instruments that depend on direct observation of a behavior that is

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to be systematically recorded must be tested for interrater reliability. To accomplish interrater reliability, two or more individuals should make an observation, or one observer should examine the behavior on several occasions. The observers should be trained or oriented to the definition and operationalization of the behavior to be observed. The consistency or reliability of the observations among observers is extremely important. Interrater reliability tests the consistency of the observer rather than the reliability of the instrument. Interrater reliability is expressed as a percentage of agreement between scorers or as a correlation coefficient of the scores assigned to the observed behaviors.

Kappa (κ) expresses the level of agreement observed beyond the level that would be expected by chance alone. κ ranges from +1 (total agreement) to 0 (no agreement). A κ of 0.80 or better indicates good interrater reliability. κ between 0.80 and 0.68 is considered acceptable/substantial agreement; less than 0.68 allows tentative conclusions to be drawn at times when lower levels are accepted (McDowell & Newell, 1996) (see Box 15.5).

EVIDENCE-BASED PRACTICE TIP Interrater reliability is an important approach to minimizing bias.

Parallel or alternate form Parallel or alternate form was described in the discussion of stability in this chapter. Use of parallel forms is a measure of stability and equivalence. The procedures for assessing equivalence using parallel forms are the same.

Classic test theory versus item response theory The methods of reliability and validity described in this chapter are considered classical test theory (CTT) methods. There are newer methods that you will find described in research articles under the category of item response theory (IRT). The two methods share basic characteristics, but some feel that IRT methods are superior for discriminating test items. Several terms and concepts linked with IRT are Rasch models and one (or two) parameter logistic

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models. The methodology of these methods is beyond the scope of this text, but several references are cited for future use (DeVellis, 2012; Furr & Bacharach, 2008).

How validity and reliability are reported When reading a research article, a lengthy discussion of how the different types of reliability and validity were obtained will typically not be found. What is found in the methods section is the instrument’s title, a definition of the concept/construct that it measures, and a sentence or two about discussion is appropriate. Examples of what you will see include the following:

• “Tedeschi and Calhoun (1996) reported an internal consistency coefficient of 0.9 for the full scale the PTG (Post-traumatic Growth Inventory) for the full scale and a test-retest reliability of 0.71 after two months. Yaskowich (2003) reported an internal consistency for the full scale of the modified PTGI in a sample of 35 adolescent cancer survivors. The internal consistency of the modified PTGI was 0.94 for survivors and siblings and 0.96 for parents in the current study” (Turner-Sack et al., 2016, p. 51; Appendix D).

• The Connor-Davidson Resilience Scale (CD-RISC) reports the “Cronbach’s alpha for the full scale is reported to be.89 and item- total correlations range from.30 to.70. The CD-RISC possess good validity and reliability in the Iranian population (Khoshouei, 2009) and Cronbach’s alpha for the scale in the current study was.93” (Barahmand & Ahmad, 2016).

• “Content, construct, and criterion-related validity has been documented for the Bakas Caregiving Outcomes Scale (BCOS) that measures Life changes (e.g., Changes in social functioning, subjective well-being, and physical health). Evidence of internal consistency reliability has been documented in primary care and with stroke care givers. The Cronbach alpha for the BCOS in this study was 0.87” (Bakas et al., 2015).

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Appraisal for evidence-based practice reliability and validity Reliability and validity are crucial aspects in the critical appraisal of a measurement instrument. Criteria for critiquing reliability and validity are presented in the Critical Appraisal Criteria box. When reviewing a research article, you need to appraise each instrument’s reliability and validity. In a research article, the reliability and validity for each measure should be presented or a reference should be provided where it was described in more detail. If this information is not been presented at all, you must seriously question the merit and use of the instrument and the evidence provided by the study’s results.

CRITICAL APPRAISAL CRITERIA Reliability and validity

1. Was an appropriate method used to test the reliability of the instrument?

2. Is the reliability of the instrument adequate?

3. Was an appropriate method(s) used to test the validity of the instrument?

4. Is the validity of the measurement instrument adequate?

5. If the sample from the developmental stage of the instrument was different from the current sample, were the reliability and validity recalculated to determine if the instrument is appropriate for use in a different population?

6. What kinds of threats to internal and/or external validity are presented by weaknesses in reliability and/or validity?

7. Are strengths and weaknesses of the reliability and validity of the instruments appropriately addressed in the “Discussion,” “Limitations,” or “Recommendations” sections of the report?

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8. How do the reliability and/or validity affect the strength and quality of the evidence provided by the study findings?

The amount of information provided for each instrument will vary depending on the study type and the instrument. In a psychometric study (an instrument development study) you will find great detail regarding how the researchers established the reliability and validity of the instrument. When reading a research article in which the instruments are used to test a research question or hypothesis, you may find only brief reference to the type of reliability and validity of the instrument. If the instrument is a well- known, reliable, and valid instrument, it is not uncommon that only a passing comment may be made, which is appropriate. Example: ➤ In the study by Vermeesch and colleagues (2015) examining biological and sociocultural differences in perceived barriers to physical activity among fifth to seventh grade urban girls, the researchers noted acceptable face, content and construct validity, and reliability estimated by Cronbach’s alpha of 0.78 have been reported (Robbins et al., 2008, 2009). As in the previously provided example, authors often will cite a reference that you can locate if you are interested in detailed data about the instrument’s reliability or validity. If a study does not use reliable and valid questionnaires, you need to consider the sources of bias that may exist as threats to internal or external validity. It is very difficult to place confidence in the evidence generated by a study’s findings if the measures used did not have established validity and reliability. The following discussion highlights key areas related to reliability and validity that should be evident as you read a research article.

The investigator determines which type of reliability procedures need to be used in the study, depending on the nature of the measurement instrument and how it will be used. Example: ➤ If the instrument is to be administered twice, you would expect to read that test-retest reliability was used to establish the stability of the instrument. If an alternate form has been developed for use in a repeated-measures design, evidence of alternate form reliability should be presented to determine the equivalence of the parallel forms. If the degree of internal consistency among the items is relevant, an appropriate test of internal consistency should be

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presented. In some instances, more than one type of reliability will be presented, but as you assess the instruments section of a research report, you should determine whether all are appropriate. Example: ➤ The Kuder-Richardson formula implies that there is a single right or wrong answer, making it inappropriate to use with scales that provide a format of three or more possible responses. In the latter case, another formula is applied, such as Cronbach’s coefficient alpha. Another important consideration is the acceptable level of reliability, which varies according to the type of test. Reliability coefficients of 0.70 or higher are desirable. The validity of an instrument is limited by its reliability; that is, less confidence can be placed in scores from tests with low reliability coefficients.

Satisfactory evidence of validity will probably be the most difficult item for you to ascertain. It is this aspect of measurement that is most likely to fall short of meeting the required criteria. Page count limitations often account for this brevity. Detailed validity data usually are only reported in studies focused on instrument development; therefore validity data are mentioned only briefly or, sometimes, not at all. The most common type of reported validity is content validity. When reviewing a study, you want to find evidence of content validity. Once again, you will find the detailed reporting of content validity and the CVI in psychometric studies; Box 15.2 provides a good example of how content validity is reported in a psychometric study. Such procedures provide you with assurance that the instrument is psychometrically sound and that the content of the items is consistent with the conceptual framework and construct definitions. In studies where several instruments are used, the reporting of content validity is either absent or very brief.

Construct validity and criterion-related validity are more precise statistical tests of whether the instrument measures what it is supposed to measure. Ideally an instrument should provide evidence of content validity, as well as criterion-related or construct validity, before one invests a high level of confidence in the instrument. You will see evidence that the reliability and validity of a measurement instrument are reestablished periodically, as you can see in the examples that appear in Boxes 15.2 to 15.5. You would expect to see the strengths and weaknesses of instrument

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reliability and validity presented in the “Discussion,” “Limitations,” and/or “Recommendations” sections of an article. In this context, the reliability and validity might be discussed in terms of bias—that is, threats to internal and/or external validity that affect the study findings. Example: ➤ In the study by Hart and colleagues (2016), evaluating the psychometric properties of the Clinical Deterioration Leadership Ability Scale (CDLAS), the authors note that despite satisfactory reliability and validity findings, limitations include the homogeneous sample of mostly white, female registered nurses practicing in one integrated five hospital health system in the southeast United States. This sample limits the generalizability of the results to other populations. The authors suggest that further research is needed with diverse groups of nurses in multiple geographic locations. In addition, further research should focus on conducting test-retest reliability to further establish the psychometric properties of the CDLAS.

The findings of any study in which the reliability and validity are sparse does limit generalizability of the findings, but also adds to our knowledge regarding future research directions. Finally, recommendations for improving future studies in relation to instrument reliability and validity may be proposed.

As you can see, the area of reliability and validity is complex. You should not feel intimidated by the complexity of this topic; use the guidelines presented in this chapter to systematically assess the reliability and validity aspects of a research study. Collegial dialogue is also an approach for evaluating the merits and shortcomings of an existing, as well as a newly developed, instrument that is reported in the nursing literature. Such an exchange promotes the understanding of methodologies and techniques of reliability and validity, stimulates the acquisition of a basic knowledge of psychometrics, and encourages the exploration of alternative methods of observation and use of reliable and valid instruments in clinical practice.

Key points • Reliability and validity are crucial aspects of conducting and

critiquing research.

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• Validity is the extent to which an instrument measures the attributes of a concept accurately. Three types of validity are content validity, criterion-related validity, and construct validity.

• The choice of a method for establishing reliability or validity is important and is made by the researcher on the basis of the characteristics of the measurement instrument and its intended use.

• Reliability is the ability of an instrument to measure the attributes of a concept or construct consistently. The major tests of reliability are test-retest, parallel or alternate form, split-half, item to total correlation, Kuder-Richardson, Cronbach’s alpha, and interrater reliability.

• The selection of a method for establishing reliability or validity depends on the characteristics of the instrument, the testing method that is used for collecting data from the sample, and the kinds of data that are obtained.

• Critical appraisal of instrument reliability and validity in a research report focuses on internal and external validity as sources of bias that contribute to the strength and quality of evidence provided by the findings.

Critical thinking challenges • Discuss the types of validity that must be established before you

invest a high level of confidence in the measurement instruments used in a research study.

• What are the major tests of reliability? Why is it important to establish the appropriate type of reliability for a measurement instrument?

• A journal club just finished reading the research report by Thomas and colleagues in Appendix A. As part of their critical appraisal of this study, they needed to identify the strengths and weaknesses of the reliability and validity section of this research

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report. If you were a member of this journal club, how would you assess the reliability and validity of the instruments used in this study?

• How does the strength and quality of evidence related to reliability and validity influence the applicability of findings to clinical practice?

• When your QI Team finds that a researcher does not report reliability or validity data, which threats to internal and/or external validity should your team consider? In your judgment, how would these threats affect your evaluation of the strength and quality of evidence provided by the study and your team’s confidence in applying the findings to practice?

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

References 1. Abuadas M. H, Petro-Nustas W., Albikawi Z. F, Nabolski

M. Transcultural adaptation and validation of Champion’s health belief model scales for prostate cancer screening. Journal of Nursing Measurement 2016;24(2):296-313.

2. Ameringer S., Jr. Menzies V., et al. Psychometric evaluation of the patient-reported outcomes measurement information system fatigue-short form across diverse populations. Nursing Research 2016;65(4):279k-289k

3. Anastasi A., Urbina S. Psychological testing. 7th ed. New York, NY: Macmillan 1997;

4. Bakas T., Austin J. K, Habermann B., et al. Telephone assessment and skill-building kit for stroke caregivers; A randomized controlled clinical trial. Stroke 2015;46:3478-3487.

5. Baldacchino D. R, Bulhagiar A. Psychometric evaluation of the spiritual coping strategies in English, Maltese Back translation and bilingual versions. Journal of Advanced Nursing 2003;42:558-570.

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6. Barahmand U., Ahmad R.H.S. Psychotic-like experiences and psychological distress The role of resilience. Journal of the American Psychiatric Nurses Association 2016;22(4):312-319.

7. Bhandari P., Kim M. Self-care behaviors of Nepalese adults with type 2 diabetes A mixed methods analysis. Nursing Research 2016;65(3):202-214.

8. Bijl J. V, Peolgeest-Eeltink A. V, Shortbridge-Baggett L. The psychometric properties of the diabetes management self-efficacy scale for patients with type 2 diabetes mellitus. Journal of Advanced Nursing 1999;30:352-359.

9. Champion V. L. Instrument refinement for breast cancer screening behaviors. Nursing Research 1993;42(3):139-143.

10. Clark A., Breitenstein S., Martsolf D. S, Winstanley E. L. Assessing fidelity of a community-based opioid overdose prevention program Modification of the fidelity checklist. Journal of Nursing Scholarship 2016;48(4):377-378.

11. DeVon F. A, Block M. E, Moyle-Wright P., et al. A psychometric toolbox for testing validity and reliability. Journal of Nursing Scholarship 2007;39(2):155-164.

12. DeVellis R. F. Scale development Theory and applications. Los Angeles, CA: Sage Publications 2012;

13. Furr M. R, Bacharach V. R. Psychometrics An introduction. Los Angeles, CA: Sage Publications 2008;

14. Ganz F. D, Toren O., Fadion F. Factors associated with full implementation of scope of practice. Journal of Nursing Scholarship 2016;48(3):285-293.

15. Hart P. L, Spiva L. A, Mareno N. Clinical deterioration leadership ability scale A psychometric study. Journal of Nursing Measurement 2016;24(2):314-322.

16. Hawthorne D. M, Youngblut J. M, Brooten D. Parent spirituality, grief, and mental health at 1 and 3 months after their infant’s/child’s death in an intensive care unit. Journal of Pediatric Nursing 2016;31:73-80.

17. Johansson I., Jansson H., Lindmark U. Oral health status of older adults in Sweden receiving elder care Findings from nursing assessments. Nursing Research 2016;65(3):215-223.

18. Johannesen J. K, Lurie J. B, Fiszdon J. M, Bell M. D. The social attribution task-multiple choice (SAT-MC) A

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psychometric and equivalence study of an alternate form. ISRN Psychiatry 2013;2013:1-9.

19. Khoshouei M. S. Psychometric evaluation of the Connor- Davidson resilience scale (CD-RISC) using Iranian students. International Journal of Testing 2009;9(1):60-66.

20. Lee C. E, Von Ah D., Szuck B., Lau Y. J. Determinants of physical activity maintenance in breast cancer survivors after a community-based intervention. Oncology Nursing Forum 2016;43(1):93-102.

21. Lynn M. R. Determination and quantification of content validity. Nursing Research 1986;35:382-385.

22. McDowell I., Newell C. Measuring health A guide to rating scales and questionnaires. New York, NY: Oxford Press 1996;

23. Nunnally J. C, Bernstein I. H. Psychometric theory. 3rd ed. New York, NY: McGraw-Hill 1993;

24. Robbins L. B, Sikorski A., Hamel L. M, et al. Gender comparisons of perceived benefits of and barriers to physical activity in middle school youth. Research in Nursing and Health 2009;32:163-176.

25. Robbins L. B, Sikorski A., Morely B. Psychometric assessment of the adolescent physical activity perceived benefits and barriers scale. Journal of Nursing Measurement 2008;16:98-112.

26. Tedeschi R. G, Calhoun L. G. The post-traumatic growth inventory Measuring the positive legacy of trauma. Journal of Traumatic Stress 1996;9:455k-471k

27. Turner-Sack A. M, Menna R., Setchell S. R, et al. Psychological functioning, post-traumatic growth, and coping in parents and siblings of adolescent cancer survivors. Oncology Nursing Forum 2016;43(1):48-56.

28. Vermeesch A. L, Ling J., Voskull V. R, et al. Biological and sociocultural differences in perceived barriers to physical activity among fifth-to-seventh-grade urban girls. Nursing Research 2015;64(5):342-350.

29. Yaskowich E. Posttraumatic growth in children and adolescents with cancer. Digital Dissertation 2003;63:3948.

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CHAPTER 16

Data analysis: Descriptive and inferential statistics Susan Sullivan-Bolyai, Carol Bova

Learning outcomes

After reading this chapter, you should be able to do the following:

• Differentiate between descriptive and inferential statistics. • State the purposes of descriptive statistics. • Identify the levels of measurement in a study. • Describe a frequency distribution. • List measures of central tendency and their use. • List measures of variability and their use. • State the purpose of inferential statistics. • Explain the concept of probability as it applies to the analysis of sample data. • Distinguish between a type I and type II error and its effect on a study’s outcome. • Distinguish between parametric and nonparametric tests.

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• List some commonly used statistical tests and their purposes. • Critically appraise the statistics used in published research studies. • Evaluate the strength and quality of the evidence provided by the findings of a research study and determine applicability to practice.

KEY TERMS

analysis of covariance

analysis of variance

categorical variable

chi-square (χ2)

continuous variable

correlation

degrees of freedom

descriptive statistics

dichotomous variable

factor analysis

Fisher exact probability test

frequency distribution

inferential statistics

interval measurement

levels of measurement

level of significance (alpha level)

mean

measures of central tendency

measures of variability

median

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measurement

modality

mode

multiple analysis of variance

multiple regression

multivariate statistics

nominal measurement

nonparametric statistics

normal curve

null hypothesis

ordinal measurement

parameter

parametric statistics

Pearson correlation coefficient (Pearson r; Pearson product moment correlation coefficient)

percentile

probability

range

ratio measurement

sampling error

scientific hypothesis

standard deviation

statistic

t statistic

type I error

type II error

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Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

It is important to understand the principles underlying statistical methods used in quantitative research. This understanding allows you to critically analyze the results of research that may be useful in practice. Researchers link the statistical analyses they choose with the type of research question, design, and level of data collected.

As you read a research article, you will find a discussion of the statistical procedures used in both the methods and results sections. In the methods section, you will find the planned statistical analyses. In the results section, you will find the data generated from testing the hypotheses or research questions. The data are analyzed using both descriptive and inferential statistics.

Procedures that allow researchers to describe and summarize data are known as descriptive statistics. Descriptive statistics include measures of central tendency, such as mean, median, and mode; measures of variability, such as range and standard deviation (SD); and some correlation techniques, such as scatter plots. For example, Nyamathi and colleagues (2015; Appendix A) used descriptive statistics to inform the reader about the 345 subjects who were eligible for the HAV/HBV vaccine in their study (51% African American, 31% Latino, 59% not married, with a mean education of 11.6 years).

Statistical procedures that allow researchers to estimate how reliably they can make predictions and generalize findings based on the data are known as inferential statistics. Inferential statistics are used to analyze the data collected, test hypotheses, and answer the research questions in a research study. With inferential statistics, the researcher is trying to draw conclusions that extend beyond the study’s data.

This chapter describes how researchers use descriptive and inferential statistics in studies. This will help you determine the appropriateness of the statistics used and to interpret the strength and quality of the reported findings, as well as the clinical significance and applicability of the results for your evidence-based practice.

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Levels of measurement Measurement is the process of assigning numbers to variables or events according to rules. Every variable in a study that is assigned a specific number must be similar to every other variable assigned that number. The measurement level is determined by the nature of the object or event being measured. Understanding the levels of measurement is an important first step when you evaluate the statistical analyses used in a study. There are four levels of measurement: nominal, ordinal, interval, and ratio (Table 16.1). The level of measurement of each variable determines the statistic that can be used to answer a research question or test a hypothesis. The higher the level of measurement, the greater the flexibility the researcher has in choosing statistical procedures. The following Critical Thinking Decision Path illustrates the relationship between levels of measurement and the appropriate use of descriptive statistics.

TABLE 16.1 Level of Measurement Summary Table

CRITICAL THINKING DECISION PATH Descriptive Statistics

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Nominal measurement is used to classify variables or events into categories. The categories are mutually exclusive; the variable or event either has or does not have the characteristic. The numbers assigned to each category are only labels; such numbers do not indicate more or less of a characteristic. Nominal-level measurement is used to categorize a sample on such information as gender, marital status, or religious affiliation. For example, Hawthorne and colleagues (2016; Appendix B) measured race using a nominal level of measurement. Nominal-level measurement is the lowest level and allows for the least amount of statistical manipulation. When using nominal-level variables, the frequency and percent are typically calculated. For example, Hawthorne and colleagues (2016) found that among their sample of mothers, 44% were black, non-Hispanic; 37% Hispanic; and 19% white, non- Hispanic.

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A variable at the nominal level can also be categorized as either a dichotomous or a categorical variable. A dichotomous (nominal) variable is one that has only two true values, such as true/false or yes/no. For example, in the Turner-Sack and colleagues (2016; Appendix D) study the variable gender (male/female) is dichotomous because it has only two possible values. On the other hand, nominal variables that are categorical still have mutually exclusive categories but have more than two true values, such as religion in the Hawthorne and colleagues study (Protestant, Catholic, Jewish, other, none).

Ordinal measurement is used to show relative rankings of variables or events. The numbers assigned to each category can be compared, and a member of a higher category can be said to have more of an attribute than a person in a lower category. The intervals between numbers on the scale are not necessarily equal, and there is no absolute zero. For example, ordinal measurement is used to formulate class rankings, where one student can be ranked higher or lower than another. However, the difference in actual grade point average between students may differ widely. Another example is ranking individuals by their level of wellness or by their ability to carry out activities of daily living. Hawthorne and colleagues used an ordinal variable to measure the total family annual income of families in their study and found that 37% (n = 34) of the sample had household incomes greater or equal to $50,000. Ordinal-level data are limited in the amount of mathematical manipulation possible. Frequencies, percentages, medians, percentiles, and rank order coefficients of correlation can be calculated for ordinal-level data.

Interval measurement shows rankings of events or variables on a scale with equal intervals between the numbers. The zero point remains arbitrary and not absolute. For example, interval measurements are used in measuring temperatures on the Fahrenheit scale. The distances between degrees are equal, but the zero point is arbitrary and does not represent the absence of temperature. Test scores also represent interval data. The differences between test scores represent equal intervals, but a zero does not represent the total absence of knowledge.

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The term continuous variable is also used to represent a measure that contains a range of values along a continuum and may include ordinal-, interval-, and ratio-level data ( Plichta & Kelvin, 2012). An example is heart rate.

In many areas of science, including nursing, the classification of the level of measurement of scales that use Likert-type response options to measure concepts such as quality of life, depression, functional status, or social support is controversial, with some regarding these measurements as ordinal and others as interval. You need to be aware of this controversy and look at each study individually in terms of how the data are analyzed. Interval-level data allow more manipulation of data, including the addition and subtraction of numbers and the calculation of means. This additional manipulation is why many argue for classifying behavioral scale data as interval level. For example, Turner-Sack and colleagues (2016) used the Brief Symptom Inventory (BSI) to evaluate psychological distress of adolescent cancer survivors and siblings. The BSI has 53 items and uses a five-point Likert scale from 0 (not at all) to 4 (extremely), with higher scores indicating greater psychological distress. They reported the mean BSI score as 47.31 for cancer survivors and 48.94 for siblings.

Ratio measurement shows rankings of events or variables on scales with equal intervals and absolute zeros. The number represents the actual amount of the property the object possesses. Ratio measurement is the highest level of measurement, but it is most often used in the physical sciences. Examples of ratio-level data that are commonly used in nursing research are height, weight, pulse, and blood pressure. All mathematical procedures can be performed on data from ratio scales. Therefore, the use of any statistical procedure is possible as long as it is appropriate to the design of the study.

HELPFUL HINT Descriptive statistics assist in summarizing data. The descriptive statistics calculated must be appropriate to the purpose of the study and the level of measurement.

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Descriptive statistics

Frequency distribution One way of organizing descriptive data is by using a frequency distribution. In a frequency distribution the number of times each event occurs is counted. The data can also be grouped and the frequency of each group reported. Table 16.2 shows the results of an examination given to a class of 51 students. The results of the examination are reported in several ways. The columns on the left give the raw data tally and the frequency for each grade, and the columns on the right give the grouped data tally and grouped frequencies.

TABLE 16.2 Frequency Distribution

Mean, 73.1; standard deviation, 12.1; median, 74; mode, 72; range, 36 (54–90).

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When data are grouped, it is necessary to define the size of the group or the interval width so that no score will fall into two groups and each group will be mutually exclusive. The grouping of the data in Table 16.2 prevents overlap; each score falls into only one group. The grouping should allow for a precise presentation of the data without a serious loss of information.

Information about frequency distributions may be presented in the form of a table, such as Table 16.2, or in graphic form. Fig. 16.1 illustrates the most common graphic forms: the histogram and the frequency polygon. The two graphic methods are similar in that both plot scores, or percentages of occurrence, against frequency. The greater the number of points plotted, the smoother the resulting graph. The shape of the resulting graph allows for observations that further describe the data.

FIG 16.1 Frequency distributions. A, Histogram. B,

Frequency polygon.

Measures of central tendency Measures of central tendency are used to describe the pattern of responses among a sample. Measures of central tendency include the mean, median, and mode. They yield a single number that describes the middle of the group and summarize the members of a sample. Each measure of central tendency has a specific use and is most appropriate to specific kinds of measurement and types of distributions.

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The mean is the arithmetical average of all the scores (add all of the values in a distribution and divide by the total number of values) and is used with interval or ratio data. The mean is the most widely used measure of central tendency. Most statistical tests of significance use the mean. The mean is affected by every score and can change greatly with extreme scores, especially in studies that have a limited sample size. The mean is generally considered the single best point for summarizing data when using interval- or ratio-level data. You can find the mean in research reports by looking for the symbol x̅.

The median is the score where 50% of the scores are above it and 50% of the scores are below it. The median is not sensitive to extremes in high and low scores. It is best used when the data are skewed (see the Normal Distribution section in this chapter) and the researcher is interested in the “typical” score. For example, if age is a variable and there is a wide range with extreme scores that may affect the mean, it would be appropriate to also report the median. The median is easy to find either by inspection or by calculation and can be used with ordinal-, interval-, and ratio-level data.

The mode is the most frequent value in a distribution. The mode is determined by inspection of the frequency distribution (not by mathematical calculation). For example, in Table 16.2 the mode would be a score of 72 because nine students received this score and it represents the score that was attained by the greatest number of students. It is important to note that a sample distribution can have more than one mode. The number of modes contained in a distribution is called the modality of the distribution. It is also possible to have no mode when all scores in a distribution are different. The mode is most often used with nominal data but can be used with all levels of measurement. The mode cannot be used for calculations, and it is unstable; that is, the mode can fluctuate widely from sample to sample from the same population.

HELPFUL HINT Of the three measures of central tendency, the mean is the affected by every score and the most useful. The mean can only be calculated with interval and ratio data.

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When you examine a study, the measures of central tendency provide you with important information about the distribution of scores in a sample. If the distribution is symmetrical and unimodal, the mean, median, and mode will coincide. If the distribution is skewed (asymmetrical), the mean will be pulled in the direction of the long tail of the distribution and will differ from the median. With a skewed distribution, all three statistics should be reported.

HELPFUL HINT Measures of central tendency are descriptive statistics that describe the characteristics of a sample.

Normal distribution The concept of the normal distribution is based on the observation that data from repeated measures of interval- or ratio-level data group themselves about a midpoint in a distribution in a manner that closely approximates the normal curve illustrated in Fig. 16.2. The normal curve is one that is symmetrical about the mean and is unimodal. The mean, median, and mode are equal. An additional characteristic of the normal curve is that a fixed percentage of the scores fall within a given distance of the mean. As shown in Fig. 16.2, about 68% of the scores or means will fall within 1 SD of the mean, 95% within 2 SD of the mean, and 99.7% within 3 SD of the mean. The presence or absence of a normal distribution is a fundamental issue when examining the appropriate use of inferential statistical procedures.

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FIG 16.2 The normal distribution and associated

standard deviations.

EVIDENCE-BASED PRACTICE TIP Inspection of descriptive statistics for the sample will indicate whether the sample data are skewed.

Interpreting measures of variability Variability or dispersion is concerned with the spread of data. Measures of variability answer questions such as: “Is the sample homogeneous (similar) or heterogeneous (different)?” If a researcher measures oral temperatures in two samples, one sample drawn from a healthy population and one sample from a hospitalized population, it is possible that the two samples will have the same mean. However, it is likely that there will be a wider range of temperatures in the hospitalized sample than in the healthy sample. Measures of variability are used to describe these differences in the dispersion of data. As with measures of central tendency, the various measures of variability are appropriate to specific kinds of measurement and types of distributions.

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The descriptive statistics related to variability will enable you to evaluate the homogeneity or heterogeneity of a sample.

The range is the simplest but most unstable measure of variability. Range is the difference between the highest and lowest scores. A change in either of these two scores would change the range. The range should always be reported with other measures of variability. The range in Table 16.2 is 36, but this could easily change with an increase or decrease in the high score of 90 or the low score of 54. Turner-Sack and colleagues (2016; Appendix D) reported the range of BSI scores among their sample of adolescent cancer survivors (range = 25 to 79).

A percentile represents the percentage of cases a given score exceeds. The median is the 50% percentile, and in Table 16.2 it is a score of 74. A score in the 90th percentile is exceeded by only 10% of the scores. The zero percentile and the 100th percentile are usually dropped.

The standard deviation (SD) is the most frequently used measure of variability, and it is based on the concept of the normal curve (see Fig. 16.2). It is a measure of average deviation of the scores from the mean and as such should always be reported with the mean. The SD considers all scores and can be used to interpret individual scores. The SD is used in the calculation of many inferential statistics.

HELPFUL HINT Many measures of variability exist. The SD is the most useful because it helps you visualize how the scores disperse around the mean.

Inferential statistics Inferential statistics allow researchers to test hypotheses about a population using data obtained from probability samples. Statistical inference is generally used for two purposes: to estimate the probability that the statistics in the sample accurately reflect the population parameter and to test hypotheses about a population.

A parameter is a characteristic of a population, whereas a statistic is a characteristic of a sample. We use statistics to estimate

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population parameters. Suppose we randomly sample 100 people with chronic lung disease and use an interval-level scale to study their knowledge of the disease. If the mean score for these subjects is 65, the mean represents the sample statistic. If we were able to study every subject with chronic lung disease, we could calculate an average knowledge score, and that score would be the parameter for the population. As you know, a researcher rarely is able to study an entire population, so inferential statistics provide evidence that allows the researcher to make statements about the larger population from studying the sample.

CRITICAL THINKING DECISION PATH Inferential Statistics—Difference Questions

The example given alludes to two important qualifications of how a study must be conducted so that inferential statistics may be used. First, it was stated that the sample was selected using

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probability methods (see Chapter 12). Because you are already familiar with the advantages of probability sampling, it should be clear that if we wish to make statements about a population from a sample, that sample must be representative. All procedures for inferential statistics are based on the assumption that the sample was drawn with a known probability. Second, the scale used has to be at either an interval or a ratio level of measurement. This is because the mathematical operations involved in calculating inferential statistics require this higher level of measurement. It should be noted that in studies that use nonprobability methods of sampling, inferential statistics are also used. To compensate for the use of nonprobability sampling methods, researchers use techniques such as sample size estimation using power analysis. The following two Critical Thinking Decision Paths examine inferential statistics and provide matrices that researchers use for statistical decision making. CRITICAL THINKING DECISION PATH Inferential Statistics—Relationship Questions

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Hypothesis testing Inferential statistics are used for hypothesis testing. Statistical hypothesis testing allows researchers to make objective decisions about the data from their study. The use of statistical hypothesis testing answers questions such as the following: “How much of this effect is the result of chance?” “How strongly are these two variables associated with each other?” “What is the effect of the intervention?”

HIGHLIGHT Members of your interprofessional team may have diverse data analysis preparation. Capitalizing on everybody’s background, try to figure out whether the statistical tests chosen for the studies your team is critically appraising are appropriate for the design, type of data collection, and level of measurement.

The procedures used when making inferences are based on principles of negative inference. In other words, if a researcher studied the effect of a new educational program for patients with chronic lung disease, the researcher would actually have two hypotheses: the scientific hypothesis and the null hypothesis. The research or scientific hypothesis is that which the researcher believes will be the outcome of the study. In our example, the scientific hypothesis would be that the educational intervention would have a marked effect on the outcome in the experimental group beyond that in the control group. The null hypothesis, which is the hypothesis that actually can be tested by statistical methods, would state that there is no difference between the groups. Inferential statistics use the null hypothesis to test the validity of a scientific hypothesis. The null hypothesis states that there is no relationship between the variables and that any observed relationship or difference is merely a function of chance.

HELPFUL HINT Most samples used in clinical research are samples of convenience, but often researchers use inferential statistics. Although such use violates one of the assumptions of such tests, the tests are robust

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enough to not seriously affect the results unless the data are skewed in unknown ways.

Probability Probability theory underlies all of the procedures discussed in this chapter. The probability of an event is its long-run relative frequency (0% to 100%) in repeated trials under similar conditions. In other words, what are the chances of obtaining the same result from a study that can be carried out many times under identical conditions? It is the notion of repeated trials that allows researchers to use probability to test hypotheses.

Statistical probability is based on the concept of sampling error. Remember that the use of inferential statistics is based on random sampling. However, even when samples are randomly selected, there is always the possibility of some error in sampling. Therefore, the characteristics of any given sample may be different from those of the entire population. The tendency for statistics to fluctuate from one sample to another is known as sampling error.

EVIDENCE-BASED PRACTICE TIP The strength and quality of evidence are enhanced by repeated trials that have consistent findings, thereby increasing generalizability of the findings and applicability to clinical practice.

Type I and type II errors Statistical inference is always based on incomplete information about a population, and it is possible for errors to occur. There are two types of errors in statistical inference—type I and type II errors. A type I error occurs when a researcher rejects a null hypothesis when it is actually true (i.e., accepts the premise that there is a difference when actually there is no difference between groups). A type II error occurs when a researcher accepts a null hypothesis that is actually false (i.e., accepts the premise that there is no difference between the groups when a difference actually exists). The relationship of the two types of errors is shown in Fig. 16.3.

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FIG 16.3 Outcome of statistical decision making.

When critiquing a study to see if there is a possibility of a type I error having occurred (rejecting the null hypothesis when it is actually true), one should consider the reliability and validity of the instruments used. For example, if the instruments did not accurately measure the intervention variables, one could conclude that the intervention made a difference when in reality it did not. It is critical to consider the reliability and validity of all the measurement instruments reported (see Chapter 15). For example, Turner-Sack and colleagues (2016) reported the reliability of the BSI in their sample and found it was reliable, as evidenced by a Cronbach’s alpha, of 0.97 for survivors and siblings and 0.98 for parents (refer to Chapter 15 to review scale reliability). This gives the reader greater confidence in the study’s results.

In a practice discipline, type I errors usually are considered more serious because if a researcher declares that differences exist where none are present, the potential exists for patient care to be affected adversely. Type II errors (accepting the null hypothesis when it is false) often occur when the sample is too small, thereby limiting the opportunity to measure the treatment effect, the true difference between two groups. A larger sample size improves the ability to detect the treatment effect—that is, the difference between two groups. If no significant difference is found between two groups with a large sample, it provides stronger evidence (than with a small sample) not to reject the null hypothesis.

Level of significance The researcher does not know when an error in statistical decision making has occurred. It is possible to know only that the null hypothesis is indeed true or false if data from the total population are available. However, the researcher can control the risk of

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making type I errors by setting the level of significance before the study begins (a priori).

The level of significance (alpha level) is the probability of making a type I error, the probability of rejecting a true null hypothesis. The minimum level of significance acceptable for most research is.05. If the researcher sets alpha, or the level of significance, at.05, the researcher is willing to accept the fact that if the study were done 100 times, the decision to reject the null hypothesis would be wrong 5 times out of those 100 trials. As is sometimes the case, if the researcher wants to have a smaller risk of rejecting a true null hypothesis, the level of significance may be set at.01. In this case the researcher is willing to be wrong only once in 100 trials.

The decision as to how strictly the alpha level should be set depends on how important it is to avoid errors. For example, if the results of a study are to be used to determine whether a great deal of money should be spent in an area of patient care, the researcher may decide that the accuracy of the results is so important that an alpha level of.01 is needed. In most studies, however, alpha is set at.05.

Perhaps you are thinking that researchers should always use the lowest alpha level possible to keep the risk of both types of errors at a minimum. Unfortunately, decreasing the risk of making a type I error increases the risk of making a type II error. Therefore the researcher always has to accept more of a risk of one type of error when setting the alpha level.

HELPFUL HINT Decreasing the alpha level acceptable for a study increases the chance that a type II error will occur. When a researcher is doing many statistical tests, the probability of some of the tests being significant increases as the number of tests increases. Therefore, when a number of tests are being conducted, the researcher may decrease the alpha level to.01.

Clinical and statistical significance It is important for you to realize that there is a difference between statistical significance and clinical significance. When a researcher

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tests a hypothesis and finds that it is statistically significant, it means that the finding is unlikely to have happened by chance. For example, if a study was designed to test an intervention to help a large sample of patients lose weight, and the researchers found that a change in weight of 1.02 pounds was statistically significant, one might find this questionable because few would say that a change in weight of just over 1 pound would represent a clinically significant difference. Therefore as a consumer of research it is important for you to evaluate the clinical significance as well as the statistical significance of findings.

Some people believe that if findings are not statistically significant, they have no practical value. However, knowing that something does not work is important information to share with the scientific community. Nonsupported hypotheses provide as much information about the intervention as supported hypotheses. Nonsignificant results (sometimes called negative findings) force the researcher to return to the literature and consider alternative explanations for why the intervention did not work as planned.

EVIDENCE-BASED PRACTICE TIP You will study the results to determine whether the new treatment is effective, the size of the effect, and whether the effect is clinically important.

Parametric and nonparametric statistics Tests of significance may be parametric or nonparametric. Parametric statistics have the following attributes:

1. Involve the estimation of at least one population parameter

2. Require measurement on at least an interval scale

3. Involve certain assumptions about the variables being studied

One important assumption is that the variable is normally distributed in the overall population.

In contrast to parametric tests, nonparametric statistics are not based on the estimation of population parameters, so they involve less restrictive assumptions about the underlying distribution.

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Nonparametric tests usually are applied when the variables have been measured on a nominal or ordinal scale, or when the distribution of scores is severely skewed.

HELPFUL HINT Just because a researcher has used nonparametric statistics does not mean that the study is not useful. The use of nonparametric statistics is appropriate when measurements are not made at the interval level or the variable under study is not normally distributed.

There has been some debate about the relative merits of the two types of statistical tests. The moderate position taken by most researchers and statisticians is that nonparametric statistics are best used when data are not at the interval level of measurement, when the sample is small, and data do not approximate a normal distribution. However, most researchers prefer to use parametric statistics whenever possible (as long as data meet the assumptions) because they are more powerful and more flexible than nonparametric statistics.

Tables 16.3 and 16.4 list the commonly used inferential statistics. The test used depends on the level of the measurement of the variables in question and the type of hypothesis being studied. These statistics test two types of hypotheses: that there is a difference between groups (see Table 16.3) or that there is a relationship between two or more variables (see Table 16.4).

TABLE 16.3 Tests of Differences Between Means

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ANOVA, Analysis of variance; ANCOVA, analysis of covariance; MANOVA, multiple analysis of variance.

TABLE 16.4 Tests of Association

EVIDENCE-BASED PRACTICE TIP Try to discern whether the test chosen for analyzing the data was chosen because it gave a significant p value. A statistical test should be chosen on the basis of its appropriateness for the type of data collected, not because it gives the answer that the researcher hoped to obtain.

Tests of difference The type of test used for any particular study depends primarily on whether the researcher is examining differences in one, two, or three or more groups and whether the data to be analyzed are nominal, ordinal, or interval (see Table 16.3). Suppose a researcher

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has conducted an experimental study (see Chapter 9). What the researcher hopes to determine is that the two randomly assigned groups are different after the introduction of the experimental treatment. If the measurements taken are at the interval level, the researcher would use the t test to analyze the data. If the t statistic was found to be high enough as to be unlikely to have occurred by chance, the researcher would reject the null hypothesis and conclude that the two groups were indeed more different than would have been expected on the basis of chance alone. In other words, the researcher would conclude that the experimental treatment had the desired effect.

EVIDENCE-BASED PRACTICE TIP Tests of difference are most commonly used in experimental and quasi-experimental designs that provide Level II and Level III evidence.

The t statistic tests whether two group means are different. Thus this statistic is used when the researcher has two groups, and the question is whether the mean scores on some measure are more different than would be expected by chance. To use this test, the dependent variable (DV) must have been measured at the interval or ratio level, and the two groups must be independent. By independent we mean that nothing in one group helps determine who is in the other group. If the groups are related, as when samples are matched, and the researcher also wants to determine differences between the two groups, a paired or correlated t test would be used. The degrees of freedom (represents the freedom of a score’s value to vary given what is known about the other scores and the sum of scores; often df = N − 1) are reported with the t statistic and the probability value (p). Degrees of freedom is usually abbreviated as df.

The t statistic illustrates one of the major purposes of research in nursing—to demonstrate that there are differences between groups. Groups may be naturally occurring collections, such as gender, or they may be experimentally created, such as the treatment and control groups. Sometimes a researcher has more than two groups, or measurements are taken more than once, and then analysis of variance (ANOVA) is used. ANOVA is similar to the t test. Like the

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t statistic, ANOVA tests whether group means differ, but rather than testing each pair of means separately, ANOVA considers the variation between groups and within groups.

HELPFUL HINT A research report may not always contain the test that was done. You can find this information by looking at the tables. For example, a table with t statistics will contain a column for “t” values, and an ANOVA table will contain “F” values.

Analysis of covariance (ANCOVA) is used to measure differences among group means, but it also uses a statistical technique to equate the groups under study on an important variable. Another expansion of the notion of ANOVA is multiple analysis of variance (MANOVA), which also is used to determine differences in group means, but it is used when there is more than one DV.

Nonparametric statistics When data are at the nominal level and the researcher wants to determine whether groups are different, the researcher uses the chi- square (χ2). Chi-square is a nonparametric statistic used to determine whether the frequency in each category is different from what would be expected by chance. As with the t test and ANOVA, if the calculated chi-square is high enough, the researcher would conclude that the frequencies found would not be expected on the basis of chance alone, and the null hypothesis would be rejected. Although this test is quite robust and can be used in many different situations, it cannot be used to compare frequencies when samples are small and expected frequencies are less than six in each cell. In these instances the Fisher exact probability test is used.

When the data are ranks, or are at the ordinal level, researchers have several other nonparametric tests at their disposal. These include the Kolmogorov-Smirnov test, the sign test, the Wilcoxon matched pairs test, the signed rank test for related groups, the median test, and the Mann-Whitney U test for independent groups. Explanation of these tests is beyond the scope of this chapter; those readers who desire further information should consult a general statistics book.

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HELPFUL HINT Chi-square is the test of difference commonly used for nominal level demographic variables such as gender, marital status, religion, ethnicity, and others.

Tests of relationships Researchers often are interested in exploring the relationship between two or more variables. Such studies use statistics that determine the correlation, or the degree of association, between two or more variables. Tests of the relationships between variables are sometimes considered to be descriptive statistics when they are used to describe the magnitude and direction of a relationship of two variables in a sample and the researcher does not wish to make statements about the larger population. Such statistics also can be inferential when they are used to test hypotheses about the correlations that exist in the target population.

EVIDENCE-BASED PRACTICE TIP You will often note that in the results or findings section of a research study, parametric (e.g., t tests, ANOVA) and nonparametric (e.g., chi-square, Fisher exact probability test) measures will be used to test differences among variables depending on their level of measurement. For example, chi-square may be used to test differences among nominal level demographic variables, t tests will be used to test the hypotheses or research questions about differences between two groups, and ANOVA will be used to test differences among groups when there are multiple comparisons.

Null hypothesis tests of the relationships between variables assume that there is no relationship between the variables. Thus when a researcher rejects this type of null hypothesis, the conclusion is that the variables are in fact related. Suppose a researcher is interested in the relationship between the age of patients and the length of time it takes them to recover from surgery. As with other statistics discussed, the researcher would design a study to collect the appropriate data and then analyze the data using measures of association. In this example, age and length

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of time until recovery would be considered interval-level measurements. The researcher would use a test called the Pearson correlation coefficient, Pearson r, or Pearson product moment correlation coefficient. Once the Pearson r is calculated, the researcher consults the distribution for this test to determine whether the value obtained is likely to have occurred by chance. Again, the research reports both the value of the correlation and its probability of occurring by chance.

Correlation coefficients can range in value from −1.0 to +1.0 and also can be zero. A zero coefficient means that there is no relationship between the variables. A perfect positive correlation is indicated by a +1.0 coefficient, and a perfect negative correlation by a −1.0 coefficient. We can illustrate the meaning of these coefficients by using the example from the previous paragraph. If there were no relationship between the age of the patient and the time required for the patient to recover from surgery, the researcher would find a correlation of zero. However, if the correlation was +1.0, it would mean that the older the patient, the longer the recovery time. A negative coefficient would imply that the younger the patient, the longer the recovery time.

Of course, relationships are rarely perfect. The magnitude of the relationship is indicated by how close the correlation comes to the absolute value of 1. Thus a correlation of −.76 is just as strong as a correlation of +.76, but the direction of the relationship is opposite. In addition, a correlation of.76 is stronger than a correlation of.32. When a researcher tests hypotheses about the relationships between two variables, the test considers whether the magnitude of the correlation is large enough not to have occurred by chance. This is the meaning of the probability value or the p value reported with correlation coefficients. As with other statistical tests of significance, the larger the sample, the greater the likelihood of finding a significant correlation. Therefore researchers also report the df associated with the test performed.

Nominal and ordinal data also can be tested for relationships by nonparametric statistics. When two variables being tested have only two levels (e.g., male/female; yes/no), the phi coefficient can be used to test relationships. When the researcher is interested in the relationship between a nominal variable and an interval variable,

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the point-biserial correlation is used. Spearman rho is used to determine the degree of association between two sets of ranks, as is Kendall’s tau. All of these correlation coefficients may range in value from −1.0 to +1.0.

EVIDENCE-BASED PRACTICE TIP Tests of relationship are usually associated with nonexperimental designs that provide Level IV evidence. Establishing a strong statistically significant relationship between variables often lends support for replicating the study to increase the consistency of the findings and provide a foundation for developing an intervention study.

Advanced statistics Nurse researchers are often interested in health problems that are very complex and require that we analyze many different variables at once using advanced statistical procedures called multivariate statistics. Computer software has made the use of multivariate statistics quite accessible to researchers. When researchers are interested in understanding more about a problem than just the relationship between two variables, they often use a technique called multiple regression, which measures the relationship between one interval-level DV and several independent variables (IVs). Multiple regression is the expansion of correlation to include more than two variables, and it is used when the researcher wants to determine what variables contribute to the explanation of the DV and to what degree. For example, a researcher may be interested in determining what factors help women decide to breastfeed their infants. A number of variables, such as the mother’s age, previous experience with breastfeeding, number of other children, and knowledge of the advantages of breastfeeding, might be measured and analyzed to see whether they separately and together predict the duration of breastfeeding. Such a study would require the use of multiple regression.

Another advanced technique often used in nursing research is factor analysis. There are two types of factor analysis, exploratory and confirmatory factor analysis. Exploratory factor analysis is used to reduce a set of data so that it may be easily described and used. It

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is also used in the early phases of instrument development and theory development. Factor analysis is used to determine whether a scale actually measured the concepts that it is intended to measure. Confirmatory factor analysis resembles structural equation modeling and is used in instrument development to examine construct validity and reliability and to compare factor structures across groups (Plichta & Kelvin, 2012).

Many studies use statistical modeling procedures to answer research questions. Causal modeling is used most often when researchers want to test hypotheses and theoretically derived relationships. Path analysis, structured equation modeling (SEM), and linear structural relations analysis (LISREL) are different types of modeling procedures used in nursing research.

Many other statistical techniques are available for nurse researchers. It is beyond the scope of this chapter to review all statistical analyses available. You should consider having several statistical texts available to you as you sort through the evidence reported in studies that are important to your clinical practice (e.g., Field, 2013; Plichta & Kelvin, 2012).

Appraisal for evidence-based practice descriptive and inferential statistics Nurses are challenged to understand the results of studies that use sophisticated statistical procedures. Understanding the principles that guide statistical analysis is the first step in this process. Statistics are used to describe the samples of studies and to test for hypothesized differences or associations in the sample. Knowing the characteristics of the sample of a study allows you to determine whether the results are potentially useful for your patients. For example, if a study sample was primarily white with a mean age of 42 years (SD 2.5), the findings may not be applicable if your patients are mostly elderly and African American. Cultural, demographic, or clinical factors of an elderly population of a different ethnic group may contribute to different results. Thus understanding the descriptive statistics of a study will assist you in determining the applicability of findings to your practice setting.

Statistics are also used to test hypotheses. Inferential statistics

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used to analyze data and the associated significance level (p values) indicate the likelihood that the association or difference found in a study is due to chance or to a true difference among groups. The closer the p value is to zero, the less likely the association or difference of a study is due to chance. Thus inferential statistics provide an objective way to determine if the results of the study are likely to be a true representation of reality. However, it is still important for you to judge the clinical significance of the findings. Was there a big enough effect (difference between the experimental and control groups) to warrant changing current practice?

CRITICAL APPRAISAL CRITERIA Descriptive and Inferential Statistics

1. Were appropriate descriptive statistics used?

2. What level of measurement was used to measure each of the major variables?

3. Is the sample size large enough to prevent one extreme score from affecting the summary statistics used?

4. What descriptive statistics are reported?

5. Were these descriptive statistics appropriate to the level of measurement for each variable?

6. Are there appropriate summary statistics for each major variable (e.g., demographic variables) and any other relevant data?

7. Does the hypothesis indicate that the researcher is interested in testing for differences between groups or in testing for relationships? What is the level of significance?

8. Does the level of measurement permit the use of parametric statistics?

9. Is the size of the sample large enough to permit the use of parametric statistics?

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10. Has the researcher provided enough information to decide whether the appropriate statistics were used?

11. Are the statistics used appropriate to the hypothesis, the research question, the method, the sample, and the level of measurement?

12. Are the results for each of the research questions or hypotheses presented clearly and appropriately?

13. If tables and graphs are used, do they agree with the text and extend it, or do they merely repeat it?

14. Are the results understandable?

15. Is a distinction made between clinical significance and statistical significance? How is it made?

The systematic review and meta-analysis by Al-Mallah and colleagues (2016; Appendix E) provides an excellent example of how a meta-analysis (the summarization of many studies) can help us understand the mortality and morbidity of patients who are cared for at nurse-led clinics.

EVIDENCE-BASED PRACTICE TIP A basic understanding of statistics will improve your ability to think about the effect of the IV on the DV and related patient outcomes for your patient population and practice setting.

There are a few steps to follow when critiquing the statistics used in studies (see the Critical Appraisal Criteria box). Before a decision can be made as to whether the statistics that were used make sense, it is important to return to the beginning of the research study and review the purpose of the study. Just as the hypotheses or research questions should flow from the purpose of a study, so should the hypotheses or research questions suggest the type of analysis that will follow. The hypotheses or the research questions should indicate the major variables that are expected to be tested and presented in the “Results” section. Both the summary descriptive

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statistics and the results of the inferential testing of each of the variables should be in the “Results” section with appropriate information.

After reviewing the hypotheses or research questions, you should proceed to the “Methods” section. Next, try to determine the level of measurement for each variable. From this information it is possible to determine the measures of central tendency and variability that should be used to summarize the data. For example, you would not expect to see a mean used as a summary statistic for the nominal variable of gender. In all likelihood, gender would be reported as a frequency distribution. However, you would expect to find a mean and SD for a variable that used a questionnaire. The means and SD should be provided for measurements performed at the interval level. The sample size is another aspect of the “Methods” section that is important to review when evaluating the researcher’s use of descriptive statistics. The sample is usually described using descriptive summary statistics. Remember, the larger the sample, the less chance that one outlying score will affect the summary statistics. It is also important to note whether the researchers indicated that they did a power analysis to estimate the sample size needed to conduct the study.

If tables or graphs are used, they should agree with the information presented in the text. Evaluate whether the tables and graphs are clearly labeled. If the researcher presents grouped frequency data, the groups should be logical and mutually exclusive. The size of the interval in grouped data should not obscure the pattern of the data, nor should it create an artificial pattern. Each table and graph should be referred to in the text, but each should add to the text—not merely repeat it.

The following are some simple steps for reading a table:

1. Look at the title of the table and see if it matches the purpose of the table.

2. Review the column headings and assess whether the headings follow logically from the title.

3. Look at the abbreviations used. Are they clear and easy to understand? Are any nonstandard abbreviations explained?

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4. Evaluate whether the statistics contained in the table are appropriate to the level of measurement for each variable.

After evaluating the descriptive statistics, inferential statistics can then be evaluated. The best place to begin appraising the inferential statistical analysis of a research study is with the hypothesis or research question. If the hypothesis or research question indicates that a relationship will be found, you should expect to find tests of correlation. If the study is experimental or quasi-experimental, the hypothesis or research question would indicate that the author is looking for significant differences between the groups studied, and you would expect to find statistical tests of differences between means that test the effect of the intervention. Then as you read the “Methods” section of the paper, again consider what level of measurement the author has used to measure the important variables. If the level of measurement is interval or ratio, the statistics most likely will be parametric statistics. On the other hand, if the variables are measured at the nominal or ordinal level, the statistics used should be nonparametric. Also consider the size of the sample, and remember that samples have to be large enough to permit the assumption of normality. If the sample is quite small (e.g., 5 to 10 subjects), the researcher may have violated the assumptions necessary for inferential statistics to be used. Thus the important question is whether the researcher has provided enough justification to use the statistics presented.

Finally, consider the results as they are presented. There should be enough data presented for each hypothesis or research question studied to determine whether the researcher actually examined each hypothesis or research question. The tables should accurately reflect the procedure performed and be in harmony with the text. For example, the text should not indicate that a test reached statistical significance while the tables indicate that the probability value of the test was above.05. If the researcher has used analyses that are not discussed in this text, you may want to refer to a statistics text to decide whether the analysis was appropriate to the hypothesis or research question and the level of measurement.

There are two other aspects of the data analysis section that you should appraise. The results of the study in the text of the article

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should be clear. In addition, the author should attempt to make a distinction between the clinical and statistical significance of the evidence related to the findings. Some results may be statistically significant, but their clinical importance may be doubtful in terms of applicability for a patient population or clinical setting. If this is so, the author should note it. Alternatively, you may find yourself reading a research study that is elegantly presented, but you come away with a “So what?” feeling. From an evidence-based practice perspective, a significant hypothesis or research question should contribute to improving patient care and clinical outcomes. The important question to ask is “What is the strength and quality of the evidence provided by the findings of this study and their applicability to practice?”

Note that the critical analysis of a research paper’s statistical analysis is not done in a vacuum. It is possible to judge the adequacy of the analysis only in relationship to the other important aspects of the paper: the problem, the hypotheses, the research question, the design, the data collection methods, and the sample. Without consideration of these aspects of the research process, the statistics themselves have very little meaning.

Key points • Descriptive statistics are a means of describing and organizing

data gathered in research.

• The four levels of measurement are nominal, ordinal, interval, and ratio. Each has appropriate descriptive techniques associated with it.

• Measures of central tendency describe the average member of a sample. The mode is the most frequent score, the median is the middle score, and the mean is the arithmetical average of the scores. The mean is the most stable and useful of the measures of central tendency and, combined with the standard deviation, forms the basis for many of the inferential statistics.

• The frequency distribution presents data in tabular or graphic

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form and allows for the calculation or observations of characteristics of the distribution of the data, including skew symmetry, and modality.

• In nonsymmetrical distributions, the degree and direction of the off-center peak are described in terms of positive or negative skew.

• The range reflects differences between high and low scores.

• The SD is the most stable and useful measure of variability. It is derived from the concept of the normal curve. In the normal curve, sample scores and the means of large numbers of samples group themselves around the midpoint in the distribution, with a fixed percentage of the scores falling within given distances of the mean. This tendency of means to approximate the normal curve is called the sampling distribution of the means.

• Inferential statistics are a tool to test hypotheses about populations from sample data.

• Because the sampling distribution of the means follows a normal curve, researchers are able to estimate the probability that a certain sample will have the same properties as the total population of interest. Sampling distributions provide the basis for all inferential statistics.

• Inferential statistics allow researchers to estimate population parameters and to test hypotheses. The use of these statistics allows researchers to make objective decisions about the outcome of the study. Such decisions are based on the rejection or acceptance of the null hypothesis, which states that there is no relationship between the variables.

• If the null hypothesis is accepted, this result indicates that the findings are likely to have occurred by chance. If the null hypothesis is rejected, the researcher accepts the scientific hypothesis that a relationship exists between the variables that is unlikely to have been found by chance.

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• Statistical hypothesis testing is subject to two types of errors: type I and type II.

• A type I error occurs when the researcher rejects a null hypothesis that is actually true.

• A type II error occurs when the researcher accepts a null hypothesis that is actually false.

• The researcher controls the risk of making a type I error by setting the alpha level, or level of significance; however, reducing the risk of a type I error by reducing the level of significance increases the risk of making a type II error.

• The results of statistical tests are reported to be significant or nonsignificant. Statistically significant results are those whose probability of occurring is less than.05 or.01, depending on the level of significance set by the researcher.

• Commonly used parametric and nonparametric statistical tests include those that test for differences between means, such as the t test and ANOVA, and those that test for differences in proportions, such as the chi-square test.

• Tests that examine data for the presence of relationships include the Pearson r, the sign test, the Wilcoxon matched pairs, signed rank test, and multiple regression.

• The most important aspect of critiquing statistical analyses is the relationship of the statistics employed to the problem, design, and method used in the study. Clues to the appropriate statistical test to be used by the researcher should stem from the researcher’s hypotheses. The reader also should determine if all of the hypotheses have been presented in the paper.

• A basic understanding of statistics will improve your ability to think about the level of evidence provided by the study design and findings and their relevance to patient outcomes for your patient population and practice setting.

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Critical thinking challenges • When reading a research study, what is the significance of

applying findings if a nurse researcher made a type I error in statistical inference?

• What is the relationship between the level of measurement a researcher uses and the choice of statistics used? As you read a research study, identify the statistics, level of measurement, and the associated level of evidence provided by the design.

• When reviewing a study you find the sample size provided does not seem adequate. Before you make this final decision, think about how the design type (e.g., pilot study, intervention study), data collection methods, the number of variables, and the sensitivity of the data collection instruments can affect your decision.

• When your team finishes critically appraising a research study, those team members responsible for the critique report that the findings are not statistically significant. Consider how those findings are or are not applicable to your practice.

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

References 1. Al-Mallah M. H., Faraf I., Al-Madani W., et al. The impact of

nurse-led clinics on mortality and morbidity of patients with cardiovascular diseases a systematic review and meta- analysis. Journal of Cardiovascular Nursing 2016;31:89-95 Available at: doi:10.1097/JCN.0000000000000224

2. Field A. Discovering statistics using SPSS. 4th ed. Thousand Oaks, CA: Sage 2013;

3. Hawthorne D. M., Youngblut J. M., Brooten D. Parent spirituality, grief, and mental health at 1-year and 3 months after

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http://evolve.elsevier.com/LoBiondo/

http://dx.doi:10.1097/JCN.0000000000000224

their infant’s/child’s death in an intensive care unit. Journal of Pediatric Nursing 2016;31:73-80 Available at: doi:org/10.1016/j.pedn.2015.07.008

4. Nyamathi A., Salem B. E., Zhang S., et al. Nursing care management, peer coaching, and hepatitis A and B vaccine completion among homeless men recently released on parole. Nursing Research 2015;64:177-189 Available at: doi:10.1097/NNR.0000000000000083

5. Plichta S. B., Kelvin E. Munro’s statistical methods for health care research. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins 2012;

6. Turner-Sack A. M., Menna R., Setchell S. R., et al. Psychological functioning, post traumatic growth, and coping in parents and siblings of adolescent cancer survivors. Oncology Nursing Forum 2016;43:48-57 Available at: doi:10.1188/16.ONF.48-56

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http://dx.doi:org/10.1016/j.pedn.2015.07.008

http://dx.doi:10.1097/NNR.0000000000000083

http://dx.doi:10.1188/16.ONF.48-56

CHAPTER 17

Understanding research findings Geri LoBiondo-Wood

Learning outcomes

After reading this chapter, you should be able to do the following:

• Discuss the difference between the “Results” and the “Discussion” sections of a research study. • Determine if findings are objectively discussed. • Describe how tables and figures are used in a research report. • List the criteria of a meaningful table. • Identify the purpose and components of the “Discussion” section. • Discuss the importance of including generalizability and limitations of a study in the report. • Determine the purpose of including recommendations in the study report. • Discuss how the strength, quality, and consistency of evidence provided by the findings are related to a study’s results, limitations, generalizability, and applicability to practice.

KEY TERMS

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confidence interval

findings

generalizability

limitations

recommendations

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

The ultimate goal of nursing research is to develop knowledge that advances evidence-based nursing practice and quality patient care. From a clinical application perspective, analysis, interpretation, discussion, and generalizability of the results become highly important pieces of the research study. After the analysis of the data, the researcher puts the final pieces of the jigsaw puzzle together to view the total picture with a critical eye. This process is analogous to evaluation, the last step in the nursing process. You may view these last sections as an easier step for the investigator, but it is here that a most critical and creative process comes to the forefront. In the final sections of the report, after the statistical procedures have been applied, the researcher relates the findings to the research question, hypotheses, theoretical framework, literature, methods, and analyses; reviews the findings for any potential bias; and makes decisions about the application of the findings to future research and practice.

The final sections of published studies are generally titled “Results” and “Discussion.” Other topics, such as conclusions, limitations of findings, recommendations, and implications for future research and nursing practice, may be addressed separately or included in these sections. The presentation format is a function of the author’s and the journal’s stylistic considerations. The function of these final sections is to integrate all aspects of the research process, as well as to discuss, interpret, and identify the limitations, the threats related to bias, and the generalizability relevant to the investigation, thereby furthering evidence-based

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practice. The process that both an investigator and you use to assess the results of a study is depicted in the Critical Thinking Decision Path.

The goal of this chapter is to introduce the purpose and content of the final sections of a research study where data are presented, interpreted, discussed, and generalized.

Findings The findings of a study are the results, conclusions, interpretations, recommendations, and implications for future research and nursing practice, which are addressed by separating the presentation into two major areas. These two areas are the results and the discussion of the results. The “Results” section focuses on the results or statistical findings of a study, and the “Discussion” section focuses on the remaining topics. For both sections, the rule applies—as it does to all other sections of a report—that the content must be presented clearly, concisely, and logically.

EVIDENCE-BASED PRACTICE TIP Evidence-based practice is an active process that requires you to consider how, and if, research findings are applicable to your patient population and practice setting.

Results The “Results” section of a study is the data-bound section of the report and is where the quantitative data or numbers generated by the descriptive and inferential statistical tests are presented. Other headings that may be used for the results section are “Statistical Analyses,” “Data Analysis,” or “Analysis.” The results of the data analysis set the stage for the interpretation or discussion and the limitations sections that follow the results. The “Results” section should reflect analysis of each research question and/or hypothesis tested. The information from each hypothesis or research question should be sequentially presented. The tests used to analyze the data should be identified. If the exact test that was used is not explicitly stated, the values obtained should be noted. The researcher does this by providing the numerical values of the statistics and stating

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the specific test value and probability level achieved (see Chapter 16). Examples ➤ of these statistical results can be found in Table 17.1. The numbers are important, but there is much more to the research process than the numbers. They are one piece of the whole. Chapter 16 conceptually presents the meanings of the numbers found in studies. Whether you only superficially understand statistics or have an in-depth knowledge of statistics, it should be obvious that the results are clearly stated, and the presence or lack of statistically significant results should be noted.

TABLE 17.1 Examples of Reported Statistical Results

Statistical Test Examples of Reported Results Mean m = 118.28 Standard deviation SD = 62.5 Pearson correlation r =.49, P <.01 Analysis of variance F = 3.59, df = 2, 48, P <.05 t test t = 2.65, P <.01 Chi-square χ2 = 2.52, df = 1, P <.05

CRITICAL THINKING DECISION PATH Assessing Study Results

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HELPFUL HINT In the results section of a research report, the descriptive statistics results are generally presented first; then the inferential results of each hypothesis or research question that was tested are presented.

At times the researchers will begin the “Results” or “Data Analysis” section by identifying the name of the statistical software program they used to analyze the data. This is not a statistical test

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but a computer program specifically designed to analyze a variety of statistical tests. Example: ➤ Li and colleagues (2016) state that “SPSS version 22.0 software and Mplus7 were used for the statistical analysis” (see Chapter 16). Information on the statistical tests used is presented after this information.

The researcher will present the data for all of the hypotheses tested or research questions asked (e.g., whether the hypotheses or research questions were accepted, rejected, supported, or partially supported). If the data supported the hypotheses or research questions, you may be tempted to assume that the hypotheses or research questions were proven; however, this is not true. It only means that the hypotheses or research questions were supported. The results suggest that the relationships or differences tested, derived from the theoretical framework, were statistically significant and probably logical for that study’s sample. You may think that if a study’s results are not supported statistically or are only partially supported, the study is irrelevant or possibly should not have been published, but this also is not true. If the data are not supported, you should not expect the researcher to bury the work in a file. It is as important for you, as well as the researcher, to review and understand studies where the hypotheses or research questions are not supported by the study findings. Information obtained from these studies is often as useful as data obtained from studies with supported hypotheses and research questions.

Studies that have findings that do not support one or more hypotheses or research questions can be used to suggest limitations (issues with the study’s validity, bias, or study weaknesses) of particular aspects of a study’s design and procedures. Findings from studies with data that do not support the hypotheses or research questions may suggest that current modes of practice or current theory may not be supported by research evidence and therefore must be reexamined, researched further, and not be used at this time to support practice changes. Data help generate new knowledge and evidence, as well as prevent knowledge stagnation. Generally, the results are interpreted in a separate section of the report. At times, you may find that the “Results” section contains the results and the researcher’s interpretations, which are generally found in the “Discussion” section. Integrating the results with the

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discussion is the author’s or journal editor’s decision. Both sections may be integrated when a study contains several segments that may be viewed as fairly separate subproblems of a major overall problem.

The investigator should also demonstrate objectivity in the presentation of the results. The investigators would be accused of lacking objectivity if they state the results in the following manner: “The results were not surprising as we found that the mean scores were significantly different in the comparison group, as we expected.” Opinions or reactionary statements about the data are therefore avoided in the “Results” section. Box 17.1 provides examples of objectively stated results. As you appraise a study, you should consider the following points when reading the “Results” section:

• Investigators responded objectively to the results in the discussion of the findings.

• Investigators interpreted the evidence provided by the results, with a careful reflection on all aspects of the study that preceded the results. Data presented are summarized. Much data are generated, but only the critical summary numbers for each test are presented. Examples of summarized demographic data are the means and standard deviations of age, education, and income. Including all data is too cumbersome. The results should be viewed as a summary.

• Reduction of data is provided in the text and through the use of tables and figures. Tables and figures facilitate the presentation of large amounts of data.

• Results for the descriptive and inferential statistics for each hypothesis or research question are presented. No data are omitted, even if they are not significant. Untoward events during the course of the study should be reported.

BOX 17.1 Examples of Results Section

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• “Parents’ psychological distress was positively associated with age (r = 0.53, P < 0.01) and avoidant coping (e.g., denial, disengagement) (r = 0.53, P < 0.01)” (Turner-Sack et al., 2016).

• “Bereaved fathers’ greater use of spiritual activities was significantly related to lower symptoms of grief (despair, detachment and disorganization at T1 and T2 [Table 2])” (Hawthorne et al., 2012).

In their study, Hawthorne and colleagues (2016) developed tables to present the results visually. Table 17.2 provides a portion of the descriptive results about the subjects’ demographics. Table 17.3 provides the correlations among the study’s variables. Tables allow researchers to provide a more visually thorough explanation and discussion of the results. If tables and figures are used, they must be concise. Although the article’s text is the major mode of communicating the results, the tables and figures serve a supplementary but independent role. The role of tables and figures is to report results with some detail that the investigator does not explore in the text. This does not mean that tables and figures should not be mentioned in the text. The amount of detail that an author uses in the text to describe the specific tabled data varies according to the needs of the author. A good table is one that meets the following criteria:

• Supplements and economizes the text

• Has precise titles and headings

• Does not repeat the text

TABLE 17.2 Description of the Sample

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From Hawthorne, D. M., Youngblut, J. M., & Brooten, D. (2016). Parent spirituality, grief, and mental health at 1 and 3 months after their infant’s/child’s death in an intensive care unit. Journal of Pediatric Nursing, 31, 73–80.

TABLE 17.3 Correlations of Parents’ Use of Spiritual and Religious Activities With Grief, Mental Health, and Personal Growth at 1 (T1) and 3 (T2) Months Post-Death

*P <.05. **P <.01. From Hawthorne, D. M., Youngblut, J. M., & Brooten, D. (2016). Parent spirituality, grief, and mental health at 1 and 3 months after their infant’s/child’s death in an intensive care unit. Journal of Pediatric Nursing, 31, 73–80.

Tables are found in each of the studies in the appendices. Each of these tables helps to economize and supplement the text clearly, with precise data that help you to visualize the variables quickly

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and to assess the results.

EVIDENCE-BASED PRACTICE TIP As you reflect on the results of a study, think about how the results fit with previous research on the topic and the strength and quality of available evidence on which to base clinical practice decisions.

Discussion In this section, the investigator interprets and discusses the study’s results. The researcher makes the data come alive and gives meaning to and provides interpretations for the numbers in quantitative studies or the concepts in qualitative studies. This discussion section contains a discussion of the findings, the study’s limitations, and recommendations for practice and future research. At times these topics are separated as stand-alone sections of the research report, or they may be integrated under the title of “Discussion.” You may ask where the investigator extracted the meaning that is applied in this section. If the researcher does the job properly, you will find a return to the beginning of the study. The researcher returns to the earlier points in the study where the purpose, objective, and research question and/or a hypothesis was identified, and independent and dependent variables were linked on the basis of a theoretical framework and literature review (see Chapters 3 and 4). It is in this section that the researcher discusses

• Both the supported and nonsupported data

• Limitations or weaknesses (threats to internal or external validity) of a study in light of the design, sample, instruments, data collection procedures, and fidelity

• How the theoretical framework was supported or not supported

• How the data may suggest additional or previously unrealized findings

• Strength and quality of the evidence provided by the study and its findings interpreted in relation to its applicability to practice and future research

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Even if the data are supported, this is not the final word. Statistical significance is not the endpoint of a researcher’s thinking; statistically significant but low P values may not be indicative of research breakthroughs. It is important to think beyond statistical significance to clinical significance. This means that statistical significance in a study does not always indicate that the results of a study are clinically significant. A key step in the process of evaluation is the ability to critically analyze beyond the test of significance by assessing a research study’s applicability to practice. Chapters 19 through 21 review the methods used to analyze the usefulness and applicability of research findings. Within nursing and health care literature, discussion of clinical significance, evidence-based practice, and quality improvement are focal points (Titler, 2012). As indicated throughout this text, many important pieces in the research puzzle must fit together for a study to be evaluated as a well-done study. The evidence generated by the findings of a study is appraised in order to validate current practice or support the need for a change in practice. Results of unsupported hypotheses or research questions do not require the investigator to go on a fault-finding tour of each piece of the study—this can become an overdone process. All research studies have weaknesses as well as strengths. The final discussion is an attempt to identify the strengths as well as the weaknesses or bias of the study.

HELPFUL HINT A well-written “Results” section is systematic, logical, concise, and drawn from all of the analyzed data. The writing in the “Results” section should allow the data to reflect the testing of the research questions and hypotheses. The length of this section depends on the scope and breadth of the analysis.

Researchers and appraisers should accept statistical significance with prudence. Statistically significant findings are not the sole means of establishing a study’s merit. Remember that accepting statistical significance means accepting that the sample mean is the same as the population mean. Statistical significance is a measure of assessment that, if true, does not automatically support the merit to a study and, if untrue, does not necessarily negate the value of a study (see Chapter 12). Another method to assess the merit of a

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study and determine whether the findings from one study can be generalized is to calculate a confidence interval. A confidence interval quantifies the uncertainty of a statistic or the probable value range within which a population parameter is expected to lie (see Chapter 19). The process used to calculate a confidence interval is beyond the scope of this text, but references are provided for further explanation (Altman, 2005; Altman et al., 2005; Kline, 2004). Other aspects, such as the sample, instruments, data collection methods, and fidelity, must also be considered.

Whether the results are or are not statistically supported, in this section, the researcher returns to the conceptual/theoretical framework and analyzes each step of the research process to accomplish a discussion of the following issues:

• Suggest what the possible or actual problems are in the study.

• Whether findings are supported or not supported, the researcher is obliged to review the study’s processes.

• Was the theoretical thinking correct? (See Chapters 3 and 4.)

• Was the correct design chosen? (See Chapters 9 and 10.)

• In terms of sampling methods (see Chapter 12), was the sample size adequate? Were the inclusion and exclusion criteria delineated well?

• Did any bias arise during the course of the study; that is, threats to internal and external validity? (See Chapter 8.)

• Was data collection consistent, and did it exhibit fidelity? (See Chapter 14.)

• Were the instruments sensitive to what was being tested? Were they reliable and valid? (See Chapters 14 and 15.)

• Were the analysis choices appropriate? (See Chapter 16.)

The purpose of this section is not to show humility or one’s technical competence but rather to enable you to judge the validity

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of the interpretations drawn from the data and the general worth of the study. It is in this section of the report that the researcher ties together all the loose ends of the study and returns to the beginning to assess if the findings support, extend, or counter the theoretical framework of the study. It is from this point that you can begin to think about clinical relevance, the need for replication, or the germination of an idea for further research. The researcher also includes generalizability and recommendations for future research, as well as a summary or a conclusion.

Generalizations (generalizability) are inferences that the data are representative of similar phenomena in a population beyond the study’s sample. Rarely, if ever, can one study be a recommendation for action. Beware of research studies that may overgeneralize. Generalizations that draw conclusions and make inferences for a specific group within a particular situation and at a particular time are appropriate. An example ➤ of such a limitation is drawn from the study conducted by Hawthorne and colleagues (2016; Appendix B). The researchers appropriately noted the following:

There are several additional limitations of the study. At 1 and 3 months post-death, parents were in early stages of grieving. Thus, these findings may not be applicable to parents who are later in the grieving process.

This type of statement is important for consumers of research. It helps to guide our thinking in terms of a study’s clinical relevance and also suggests areas for research. One study does not provide all of the answers, nor should it. In fact, the risk versus the benefit of the potential change in practice must be considered in terms of the strength and quality of the evidence (see Chapter 19). The greater the risk involved in making a change in practice, the stronger the evidence needs to be to justify the merit of implementing a practice change. The final steps of evaluation are critical links to the refinement of practice and the generation of future research. Evaluation of research, like evaluation of the nursing process, is not the last link in the chain but a connection between the strength of the evidence that may serve to improve patient care and inform

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clinical decision making and support an evidence-based practice.

HIGHLIGHT Your team should remember the saying that a good study is one that raises more questions than it answers. So your team should not view a researcher’s review of a study’s limitations and recommendations for future research as evidence of the researcher’s lack of research skills. Rather, it reflects the next steps in building a strong body of evidence.

The final element that the investigator integrates into the “Discussion” is the recommendations. The recommendations are the investigator’s suggestions for the study’s application to practice, theory, and further research. This requires the investigator to reflect on the following questions:

• What contribution does this study make to clinical practice?

• What are the strengths, quality, and consistency of the evidence provided by the findings?

• Does the evidence provided in the findings validate current practice or support the need for change in practice?

Box 17.2 provides examples ➤ of recommendations for future research and implications for nursing practice. This evaluation places the study into the realm of what is known and what needs to be known before being used. Nursing knowledge and evidence- based practice have grown tremendously over the last century through the efforts of many nurse researchers and scholars. BOX 17.2 Examples of Research Recommendations and Practice Implications Research recommendations

• “The findings support the need to continue examining the effects of childhood and adolescent cancer on the entire family. Additional studies would benefit from having all members of

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each family participate to obtain a true family systems perspective on the impact of childhood and adolescent cancer” (Turner-Sack et al., 2016).

• “Further research is needed to determine if any changes, whether negative or positive, occurred in parents’ use of religious and spiritual activities to cope and the effect on their grief response, mental health and personal growth in the later stages of bereavement” (Hawthorne et al., 2016).

Practice implications

• “The results from this longitudinal study with a racially and ethnically diverse sample provide evidence for healthcare professionals about the importance of spiritual coping activities for bereaved mothers and fathers” (Hawthorne et al., 2016).

• “Healthcare providers have contact not only with their patients, but also with their patients’ family members. These findings demonstrate the need to be aware of the potential impact of cancer on all family members” (Turner-Sack et al., 2016).

Appraisal for evidence-based practice research findings The “Results” and the “Discussion” sections are the researcher’s opportunity to examine the logic of the hypothesis (or hypotheses) or research question(s) posed, the theoretical framework, the methods, and the analysis (see the critical appraisal criteria box). This final section requires as much logic, conciseness, and specificity as employed in the preceding steps of the research process. You should be able to identify statements of the type of analysis that was used and whether the data statistically supported the hypothesis or research question. These statements should be straightforward and should not reflect bias (see Tables 17.2 and 17.3). Auxiliary data or serendipitous findings also may be presented. If such auxiliary findings are presented, they should be as dispassionately presented as the hypothesis and research

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question data.

CRITICAL APPRAISAL CRITERIA Research Findings

1. Are the results of each of the hypotheses presented?

2. Is the information regarding the results concisely and sequentially presented?

3. Are the tests that were used to analyze the data presented?

4. Are the results presented objectively?

5. If tables or figures are used, do they meet the following standards?

a. They supplement and economize the text.

b. They have precise titles and headings.

c. They are not repetitious of the text.

6. Are the results interpreted in light of the hypotheses, research questions, and theoretical framework, and all of the other steps that preceded the results?

7. If the hypotheses or research questions are supported, does the investigator provide a discussion of how the theoretical framework was supported?

8. How does the investigator attempt to identify the study’s weaknesses (i.e., threats to internal and external validity) and strengths, as well as suggest possible solutions for the research area?

9. Does the researcher discuss the study’s clinical relevance?

10. Are any generalizations made, and if so, are they within the

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scope of the findings or beyond the findings?

11. Are any recommendations for future research stated or implied?

12. What is the study’s strength of evidence?

The statistical test(s) used should also be noted. The numerical value of the obtained data should also be presented (see Tables 17.1 to 17.3). The presentation of the tests, the numerical values found, and the statements of support or nonsupport should be clear, concise, and systematically reported. For illustrative purposes that facilitate readability, the researchers should present extensive findings in tables. If the findings were not supported, you should— as the researcher did—attempt to identify, without finding fault, possible methodological problems (e.g., sample too small to detect a treatment effect).

From a consumer perspective, the “Discussion” section at the end of a research article is very important for determining the potential application to practice. The “Discussion” section should interpret the study’s data for future research and implications for practice, including its strength, quality, gaps, limitations, and conclusions of the study. Statements reflecting the underlying theory are necessary, whether or not the hypotheses were supported. Included in this discussion are the limitations for practice. This discussion should reflect each step of the research process and potential threats to internal validity or bias and external validity or generalizability.

This last presentation can help you begin to rethink clinical practice, provoke discussion in clinical settings (see Chapters 19 and 20), and find similar studies that may support or refute the phenomena being studied to more fully understand the problem.

One study alone does not lead to a practice change. Evidence- based practice and quality improvement require you to critically read and understand each study—that is, the quality of the study, the strength of the evidence generated by the findings and its consistency with other studies in the area, and the number of studies that were conducted in the area. This assessment along with the active use of clinical judgment and patient preference leads to evidence-based practice.

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Key points • The analysis of the findings is the final step of a study. It is in this

section that the results will be presented in a straightforward manner.

• All results should be reported whether or not they support the hypothesis. Tables and figures may be used to illustrate and condense data for presentation.

• Once the results are reported, the researcher interprets the results. In this presentation, usually titled “Discussion,” readers should be able to identify the key topics being discussed. The key topics, which include an interpretation of the results, are the limitations, generalizations, implications, and recommendations for future research.

• The researcher draws together the theoretical framework and makes interpretations based on the findings and theory in the section on the interpretation of the results. Both statistically supported and unsupported results should be interpreted. If the results are not supported, the researcher should discuss the results, reflecting on the theory as well as possible problems with the methods, procedures, design, and analysis.

• The researcher should present the limitations or weaknesses of the study. This presentation is important because it affects the study’s generalizability. The generalizations or inferences about similar findings in other samples also are presented in light of the findings.

• Be alert for sweeping claims or overgeneralizations. An overextension of the data can alert the consumer to possible researcher bias.

• The recommendations provide the consumer with suggestions regarding the study’s application to practice, theory, and future research. These recommendations provide a final perspective on the utility of the investigation.

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• The strength, quality, and consistency of the evidence provided by the findings are related to the study’s limitations, generalizability, and applicability to practice.

Critical thinking challenges • Do you agree or disagree with the statement that “a good study is

one that raises more questions than it answers”? Support your perspective with examples.

• As the number of resources such as the Cochrane Library, meta- analysis, systematic reviews, and evidence-based reports in journals grow, why is it necessary to be able to critically read and appraise the studies within the reports yourself? Justify your answer.

• Engage your interprofessional team in a debate to defend or refute the following statement. “All results should be reported and interpreted whether or not they support the research question or hypothesis.” If all findings are not reported, how would this affect the applicability of findings to your patient population and practice setting?

• How does a clear understanding of a study’s discussion of the findings and implications for practice help you rethink your practice?

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

References 1. Altman D. G. Why we need confidence intervals. World Journal

of Surgery 2005;29:554-556. 2. Altman D. G, Machin D., Bryant T., Gardener S. Statistics

with confidence confidence intervals and statistical guidelines. 2nd ed. London, UK: BMJ Books 2005;

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3. Hawthorne D. M, Youngblut J. M, Brooten D. Parent spirituality, grief, and mental health at 1 and 3 months after their infant’s/child’s death in an intensive care unit. Journal of Pediatric Nursing 2016;31:73-80.

4. Kline R. B. Beyond significance testing reforming data analysis methods in behavioral research. 1st ed. Washington, DC: American Psychological Association 2004;

5. Li J., Zhuang H., Luo Y., Zhang R. Perceived transcultural self-efficacy of nurses in general hospitals in Guangzhiou, China. Nursing Research 2016;65(5):371-379.

6. Titler M. G. Nursing science and evidence-based practice. Western Journal of Nursing Research 2012;33(3):291-295.

7. Turner-Sack A. M, Menna R., Setchell S. R, et al. Psychological functioning, post traumatic growth, and coping in parent and siblings of adolescent cancer survivors. Oncology Nursing Forum 2016;43(1):48-56.

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CHAPTER 18

Appraising quantitative research Deborah J. Jones

Learning outcomes

After reading this chapter, you should be able to do the following:

• Identify the purpose of the critical appraisal process. • Describe the criteria for each step of the critical appraisal process. • Describe the strengths and weaknesses of a research report. • Assess the strength, quality, and consistency of evidence provided by a quantitative research report. • Discuss applicability of the findings of a research report for evidence-based nursing practice. • Conduct a critique of a research report.

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

The critical appraisal and interpretation of the findings of a research article is an acquired skill that is important for nurses to master as they learn to determine the usefulness of the published literature. As we strive to make recommendations to change or

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support nursing practice, it is important for you to be able to assess the strengths and weaknesses of a research report.

Critical appraisal is an evaluation of the strength and quality, as well as the weaknesses, of the study, not a “criticism” of the work, per se. It provides a structure for reviewing and evaluating the sections of a research study. This chapter presents critiques of two quantitative studies, a randomized controlled trial (RCT) and a descriptive study, according to the critical appraisal criteria shown in Table 18.1. These studies provide Level II and Level IV evidence.

TABLE 18.1 Summary of Major Content Sections of a Research Report and Related Critical Appraisal Guidelines

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As reinforced throughout each chapter of this book, it is not only important to conduct and read research, but to actively use research findings to inform evidence-based practice. As nurse researchers increase the depth (quality) and breadth (quantity) of studies, the data to support evidence-informed decision making regarding applicability of clinical interventions that contribute to quality outcomes are more readily available. This chapter presents critiques of two studies, each of which tests research questions reflecting different quantitative designs. Criteria used to help you in judging the relative merit of a research study are found in previous chapters. An abbreviated set of critical appraisal questions presented in Table 18.1 summarize detailed criteria found at the end of each chapter and are used as a critical appraisal guide for the two sample research critiques in this chapter. These critiques are included to illustrate the critical appraisal process and the potential applicability of research findings to clinical practice, thereby enhancing the evidence base for nursing practice.

For clarification, you are encouraged to return to earlier chapters for the detailed presentation of each step of the research process, key terms, and the critical appraisal criteria associated with each step of the research process. The criteria and examples in this chapter apply to quantitative studies using experimental and nonexperimental designs.

Stylistic considerations When you are reading research, it is important to consider the type

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of journal in which the article is published. Some journals publish articles regarding the conduct, methodology, or results of research studies (e.g., Nursing Research). Other journals (e.g., Journal of Obstetric, Gynecologic, and Neonatal Research) publish clinical, educational, and research articles. The author decides where to submit the manuscript based on the focus of the particular journal. Guidelines for publication, also known as “Information for Authors,” are journal-specific and provide information regarding style, citations, and formatting. Typically research articles include the following:

• Abstract

• Introduction

• Background and significance

• Literature review (sometimes includes theoretical framework)

• Methodology

• Results

• Discussion

• Conclusions

Critical appraisal is the process of identifying the methodological flaws or omissions that may lead the reader to question the outcome(s) of the study or, conversely, to document the strengths and limitations. It is a process for objectively judging that the study is sound and provides consistent, quality evidence that supports applicability to practice. Such judgments are the hallmark of promoting a sound evidence base for quality nursing practice.

Critique of a quantitative research study

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The research study The study “Telephone Assessment and Skill-Building Kit for Stroke Caregivers: A Randomized Controlled Clinical Trial,” by Tamilyn Bakas and colleagues, published in Stroke, is critiqued. The article is presented in its entirety and followed by the critique.

Telephone assessment and skill-building kit for stroke caregivers

A randomized controlled clinical trial Tamilyn Bakas, PhD, RN; Joan K. Austin, PhD, RN; Barbara Habermann, PhD, RN;

Nenette M. Jessup, MPH, CCRP; Susan M. McLennon, PhD, RN; Pamela H. Mitchell, PhD, RN; Gwendolyn Morrison, PhD; Ziyi

Yang, MS; Timothy E. Stump, MA; Michael T. Weaver, PhD, RN

Background and Purpose—There are few evidence-based programs for stroke family caregivers postdischarge. The purpose of this study was to evaluate efficacy of the Telephone Assessment and Skill-Building Kit (TASK II), a nurse-led intervention enabling caregivers to build skills based on assessment of their own needs.

Methods—A total of 254 stroke caregivers (primarily female TASK II/information, support, and referral 78.0%/78.6%; white 70.7%/72.1%; about half spouses 48.4%/46.6%) were randomized to the TASK II intervention (n=123) or to an information, support, and referral group (n=131). Both groups received 8 weekly telephone sessions, with a booster at 12 weeks. General linear models with repeated measures tested efficacy, controlling for patient hospital days and call minutes. Prespecified 8-week primary outcomes were depressive symptoms (with Patient Health Questionnaire Depressive Symptom Scale PHQ-9 ≥5), life changes, and unhealthy days.

Results—Among caregivers with baseline PHQ-9 ≥5, those randomized to the TASK II intervention had a greater reduction in depressive symptoms from baseline to 8, 24, and 52 weeks and

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greater improvement in life changes from baseline to 12 weeks compared with the information, support, and referral group (P<0.05); but not found for the total sample. Although not sustained at 12, 24, or 52 weeks, caregivers randomized to the TASK II intervention had a relatively greater reduction in unhealthy days from baseline to 8 weeks (P<0.05).

Conclusions—The TASK II intervention reduced depressive symptoms and improved life changes for caregivers with mild to severe depressive symptoms. The TASK II intervention reduced unhealthy days for the total sample, although not sustained over the long term.

Clinical Trial Registration—URL: https://www.clinicaltrials.gov. Unique identifier: NCT01275495.

Despite decline in stroke mortality in past decades, stroke remains a leading cause of disability, with ≈45% of stroke survivors being discharged home, 24% to inpatient rehabilitation facilities, and 31% to skilled nursing facilities.1 Most stroke survivors eventually return home, although many family members are unprepared for the caregiving role and have many unmet needs during the early discharge period.2-4 Despite this, caregivers commonly receive little attention from healthcare providers.5,6

Caregiver depressive symptoms, negative life changes, and unhealthy days (UD) often result from unmet caregiver needs. Many caregivers (30%-52%) have depression,7-10 with a study reporting higher rates in the caregivers than in the stroke survivors.7 Studies show that family caregivers are at risk for negative life changes, psychosocial impairments, poor health, and even mortality as a result of providing care.8,9,11-13 Furthermore, the caregiver’s emotional well-being can influence the stroke survivor’s depressive symptoms.14-16 In addition, the caregiver’s depressive symptoms can affect the stroke survivor’s recovery,15 communication, social participation, and mood.16 Finally, caregiver stress is a leading cause of institutionalization for stroke survivors and other older adults.9,17,18

Recommendations for stroke family caregiver education and support include: (1) assessment of caregiver needs and concerns, (2)

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counseling focused on problem solving and social support, (3) information on stroke-related care, and (4) attention to caregivers’ emotional and physical health.19 Scientific statements and practice guidelines on stroke family caregiving recommend individualized caregiver interventions that combine skill building (eg, problem solving, stress management, and goal setting) with psychoeducational strategies to improve caregiver outcomes.20-23 There are few evidence-based, easy-to-deliver programs for family caregivers of stroke survivors postdischarge that incorporate these recommendations. The revised Telephone Assessment and Skill- Building Kit (TASK II) clinical trial addressed these recommendations by offering a comprehensive, multicomponent program that enables caregivers to assess their needs, build skills in providing care, deal with personal responses to caregiving, and incorporate skill-building strategies into their daily lives.

Methods

Design A prospective randomized controlled clinical trial design, with outcome data collectors blinded to treatment assignment, was used to evaluate the efficacy of the revised TASK II relative to an information, support, and referral (ISR) comparison group. Both the groups received written materials, 8 weekly calls from a nurse, and a booster session 1 month later. The study was approved by the Indiana University Office of Research Compliance Human Subjects Office (Institutional Review Board) for protection of human subjects and by each facility where recruitment occurred. Recruitment occurred May 1, 2011 through October 7, 2013. Enrolled subjects gave informed consent.

The primary aim was to examine the short-term (immediately postintervention at 8 weeks) and long-term, sustained (12, 24, and 52 weeks) efficacy of the TASK II intervention relative to the ISR comparison group for improving caregivers’ depressive symptoms, caregiving-related life changes, and UD. For depressive symptoms, primary analyses were performed for the subgroup with mild to severe depressive symptoms at baseline; secondary analyses for depressive symptoms used the entire cohort. Selected covariates

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were included in the analyses to adjust for group differences in potential confounders.

Participants A total of 254 stroke family caregivers were randomized either to the TASK II group (n=123) or to the ISR comparison group (n=131). Family caregivers were recruited from 2 rehabilitation hospitals and 6 acute care hospitals in the Midwest. Participants were screened within 8 weeks after the survivor was discharged home. Caregivers were included if the following criteria were met: was the primary caregiver (unpaid family member or significant other), 21 or more years of age, fluent in the English language, had access to a telephone, had no difficulties hearing or talking on the telephone, planned to be providing care for ≥1 year, and were willing to participate in 9 calls from a nurse, and 5 data collection interviews. Caregivers were excluded if: the patient had not had a stroke, did not need help from the caregiver, or was going to reside in a nursing home or long-term care facility; the caregiver scored <16 on the Oberst Caregiving Burden Scale Task Difficulty Subscale24 or <4 on a 6-item cognitive impairment screener.25 In addition, caregivers and stroke survivors were excluded if either was pregnant; a prisoner or on house arrest; had a terminal illness (eg, cancer, end- of-life condition, and renal failure requiring dialysis); had a history of Alzheimer, dementia, or severe mental illness (eg, suicidal tendencies, severe untreated depression or manic depressive disorder, and schizophrenia); or had been hospitalized for alcohol or drug abuse.

Study protocol

Study instruments The Patient Health Questionnaire Depressive Symptom Scale (PHQ-9), measuring 9 depressive indicators from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), has been widely used in clinical and research settings.26 Depressive symptom severity are categorized as: no depressive symptoms (0−4), mild (5−9), moderate (10−14), moderately severe (15−19), or severe (20−27).26 Evidence of internal consistency reliability has been

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documented in primary care26 and with stroke caregivers.11,12 The Cronbach α for the PHQ-9 for this study was 0.82.

The 15-item Bakas Caregiving Outcomes Scale (BCOS) was used to measure life changes (ie, changes in social functioning, subjective well-being, and physical health), specifically as a result of providing care.11 Content, construct, and criterion-related validity have been documented, as well as internal consistency reliability in stroke caregivers.11 Cronbach α for the BCOS for this study was 0.87.

UD were measured by summing 2 items asking caregivers to estimate the number of days in the past 30 days that their own physical or mental health had not been good, with a cap of 30 days.27 The UD measure has been used to track population health status as part of the Behavioral Risk Factor Surveillance System used across states and communities in support of Healthy People 2010.27 Strong evidence of construct, concurrent, and predictive validity has been documented, as well as reliability and responsiveness.27

Caregiver and survivor characteristics were measured using a demographic form, along with the Chronic Conditions Index,28 Cognitive Status Scale,29 and the Stroke-Specific Quality of Life Proxy (SS SSQOL proxy)30; all instruments have acceptable psychometric properties and have been used in the context of stroke.

Task II intervention arm Stroke caregivers randomized to the TASK II intervention group received the TASK II Resource Guide and a pamphlet from the American Heart Association entitled Caring for Stroke Survivors.31 The TASK II Resource guide included the caregiver needs and concerns checklist2 addressing 5 areas of needs: (1) finding information about stroke, (2) managing the survivor’s emotions and behaviors, (3) providing physical care; (4) providing instrumental care, and (5) dealing with personal responses to providing care, along with corresponding tip sheets addressing each of the items on the caregiver needs and concerns checklist.32 Five skill-building tip sheets were included that respectively addressed strengthening existing skills, screening for depressive symptoms, maintaining

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realistic expectations, communicating with healthcare providers, and problem solving, as well as a stress management workbook for the caregiver and stroke survivor.32 The TASK II intervention added the use of the BCOS at the fifth call for caregivers to further assess their life changes and to select corresponding tip sheets.33 Calls to caregivers in the TASK II group focused on training caregivers how to identify and prioritize their needs and concerns, find corresponding tip sheets, and address their priority needs and concerns using innovative skill-building strategies.

ISR comparison arm Stroke caregivers randomized to the ISR group received only the American Heart Association pamphlet.31 Calls to caregivers in the ISR group focused on providing support through the use of active listening strategies.32,33 Both the groups received 8 weekly calls from a nurse with a booster call at 12 weeks. Caregivers in both the groups were encouraged to seek additional information from the American Stroke Association or from their healthcare providers.

Treatment fidelity and training The treatment fidelity checklist34 addressing design, training, delivery, receipt, and enactment was used to maintain and track treatment fidelity for both the TASK II intervention and ISR procedures.35 Training included the use of detailed training manuals and podcasts, training booster sessions, self-evaluation of audio recordings, evaluation by supervisors, quality checklists, and frequent team meetings.35 Protocol adherence was excellent at 80% for the TASK II and 92% for the ISR.35 Focus groups with nurses yielded further evidence for treatment fidelity.35

Study timetable and assessments Baseline data collection occurred within 8 weeks after the stroke survivor was discharged home because the early discharge period is a time when caregivers need the most information and skills related to providing care.2,3,6,36,37 Follow-up data were collected at 8 weeks (immediately postintervention), with longer term follow-up data collected at 12 weeks (after the booster session) and at 24 and 52 weeks to explore sustainability of the intervention. Enrollment

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occurred from January 21, 2011 to July 10, 2013, with follow-up data collection at 52 weeks completed on July 9, 2014.

Randomization and masking After baseline, caregivers were assigned to groups using a block randomized approach with stratification by recruitment site, type of relationship (spouse versus adult child/other), and baseline depressive symptoms (PHQ-9 <5 no depressive symptoms; PHQ-9 ≥5 mild to severe depressive symptoms). Random allocation sequence was generated using SAS PROC PLAN38 to create the randomized blocks within strata to obtain, as closely as possible, similar numbers and composition (balance) between the groups, and facilitate maintenance of blinding of data collectors. After baseline data collection, the project manager informed the biostatistician of the caregiver’s recruitment site, type of relationship, and depressive symptoms (PHQ-9 score). The biostatistician then notified the project manager of the group assignment, who mailed the appropriate materials to the caregiver and assigned a nurse. Separate nurses were used for TASK II and ISR groups to prevent treatment diffusion. Data collectors were blinded to the caregiver’s randomization status at subsequent data collection points. Separate team meetings were held with outcome data collectors to maintain blinding.

Sample size and statistical analysis The participant flow diagram is provided in Figure 1. Of the 2742 stroke caregivers assessed for eligibility, 254 were randomized to the TASK II intervention (n=123) or to the ISR comparison group (n=131). The refusal rate was minimal at 17.1%; 29.8% caregivers were unable to contact; and 43.8% were ineligible, primarily because the survivor did not need help from a family caregiver, or the survivor was residing in a nursing home or long-term care facility. Attrition rates ranged from 8.1% at 8 weeks to 32.5% at 52 weeks for the TASK II group and 8.4% at 8 weeks to 29.0% at 52 weeks for the ISR group. The sample size was determined based on pilot data anticipating a 10% attrition rate for the 8-week time point for the primary outcomes, using power estimates. Given the full sample of 100 subjects per group, a 0.20 effect size provided a

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power of 0.81 to detect the treatment by time interactions. Given the 10% attrition rate, a sample of 220 caregivers would be needed. To complete those being assessed for eligibility, enrollment exceeded the projected 220 caregivers by an additional 34 caregivers (total, 254 caregivers). On the basis of pilot data of 38% screening positive for depressive symptoms (PHQ-9 ≥5), it was estimated that there would be a total of 76 caregivers (38 per group), which would provide a power of 0.81 to detect an effect size of 0.33 for the treatment by time interaction using a 5% type I error rate. The sample consisted of a total of 111 caregivers (49 TASK II and 62 ISR) who screened positive for depressive symptoms.

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FIG 1 Participant flow diagram. ISR indicates information, support, and referral; and TASK, Telephone Assessment and Skill-Building Kit.

Study data were collected and managed using REDCap electronic data capture tools hosted at Indiana University.39 All analyses were conducted using SAS version 9.4.38 Baseline equivalence in demographic characteristics and outcome measures between TASK II and ISR groups was tested using independent samples t (continuous variables) or χ2 (categorical variables). Variables with significant differences between the 2 groups were selected as covariates. Using an intent-to-treat approach, dependent variables

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consisting of change relative to baseline value for depressive symptoms, life changes, and UD were entered into general linear models.40 These models incorporated covariates and took into account the correlation among repeated measures on the same individual.41

Results Caregivers in TASK II and ISR groups were similar across all demographic characteristics (Table 1). Caregivers were primarily female (78.0%, TASK II; 78.6% ISR), about half spouses (48.4%, TASK II; 46.6%, ISR), predominantly white (70.7%, TASK II; 72.1%, ISR), and ranged in age from 22 to 87 years. Stroke survivors were similar across demographic characteristics, except that survivors whose caregivers were in the ISR group had spent relatively more days in the hospital (TASK II mean [SD]=17.8 [15.7]; ISR mean [SD]=23.1 [23.4]; P=0.037; Table 2). Although stroke severity was not directly measured, caregiver perceptions of the survivor’s functioning as measured by the SSQOL Proxy30 were similar for both the groups (Table 2). As expected, the number of minutes across all calls with the nurse (ie, intervention dosage) differed between groups and was used as a covariate in the models (TASK II mean [SD]=215.2 [100.8]; ISR mean [SD]=128.1 [85.8], t=−7.38; P<0.001).35 Primary outcome means were similar between caregivers in the 2 groups at baseline (Table 3).

TABLE 1 Caregiver Characteristics With Group Equivalence

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Independent samples t test (continuous variables) and χ2 (categorical variables) were used to test equivalence. CG indicates caregiver; ISR, information, support, and referral; and TASK, Telephone Assessment and Skill-Building Kit.

TABLE 2 Survivor Characteristics With Group Equivalence

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*P<0.05. Independent samples t test (continuous variables) and χ2 (categorical variables) were used to test equivalence. ISR indicates information, support, and referral; SS, Status Scale; SSQOL, stroke-specific quality of life; and TASK, Telephone Assessment and Skill-Building Kit.

TABLE 3 Primary Outcomes at Baseline With Group Equivalence

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Independent samples t test (continuous variables) was used to test equivalence. BCOS indicates Bakas Caregiving Outcomes Scale; CG, caregiver; ISR, information, support, and referral; PHQ, patient health questionnaire; and TASK, Telephone Assessment and Skill-Building Kit.

Primary end point (8 weeks) At baseline, 47.2% of caregivers in the TASK II group and 50.4% in the ISR group reported mild to severe depressive symptoms (PHQ- 9 ≥5; Table 3). Among these caregivers, those in the TASK II group reported a greater reduction in depressive symptoms from baseline to 8 weeks than those in the ISR group (mean difference [SE]=−2.6 [1.1]; P=0.013; Table 4). This represented a statistically significant interaction between time and treatment. Secondary analyses for depressive symptoms were not significant using the total sample. Groups were similar from baseline to 8 weeks for life changes. Caregivers in the TASK II group reported a greater reduction in UD from baseline to 8 weeks than those in the ISR group (mean difference [SE]=−2.9 [1.3]; P=0.025; Table 4). Caregivers within the TASK II group reported improvements in depressive symptoms in both the subgroup (P<0.001) and the entire cohort (P<0.05) and life changes (P<0.05) from baseline to 8 weeks (Table 4).

TABLE 4 Least Square Means of Change Scores From Baseline to Postbaseline for Primary Outcomes by Group

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*P<0.05; †P<0.01; ‡P<0.001. §Primary end point. IlSubgroup who had PHQ-9 ≥5 at baseline. ¶Further analyses of the BCOS using the PHQ-9 ≥5 subgroup showed a significant group difference from baseline to 12 weeks (difference mean [SE], 5.8 [2.9]; 95% CI, [0.1–11.6]; t=2.0; P=0.046). Change scores were calculated by subtracting baseline from postbaseline scores. BCOS indicates Bakas Caregiving Outcomes Scale; CI, confidence interval; ISR, information, support, and referral; PHQ, Patient Health Questionnaire; and TASK, Telephone Assessment and Skill-Building Kit.

Secondary end points (12, 24, and 52 weeks) Similar to results at the primary end point, caregivers with PHQ-9 ≥5 in the TASK II group reported a greater reduction in depressive symptoms than those in the ISR group from baseline to 24 weeks (mean difference [SE]=−1.9 [0.09]; P=0.041) and from baseline to 52 weeks (mean difference [SE]=−3.0 [1.1]; P=0.008); although these results were not significant using the entire cohort (Table 4). Although life changes were similar for the full sample from baseline to 12 weeks (P=0.178; Table 4), for caregivers with PHQ-9 ≥5 at baseline, TASK II participants had greater improvement in life changes than ISR participants from baseline to 12 weeks (mean difference [SE]=5.8 [2.9]; P=0.046). Moreover, caregivers within the TASK II group reported improvements in depressive symptoms for the PHQ-9 ≥5 subgroup (P<0.001) and the entire cohort (P<0.05) and

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life changes (P<0.05) from baseline to 12, 24, and 52 weeks (Table 4). Caregivers within the ISR group reported improvement in depressive symptoms in the PHQ ≥5 subgroup from baseline to 12 and 24 weeks (P<0.01; Table 4).

Discussion At 8 weeks, the TASK II intervention, compared with the ISR group, reduced UD, did not significantly affect life changes, and reduced depressive symptoms in the subgroup that had mild to severe baseline depressive symptoms. As expected, secondary analyses of depressive symptoms using the entire cohort from baseline to 8, 12, 24, and 52 weeks were not significant. Some caregivers who were not depressed at baseline may have developed depressive symptoms over time; however, TASK II within group differences showed improvement in depressive symptoms at each follow-up time point.

Fewer depressive symptoms Nevertheless, the TASK II program for family caregivers of stroke survivors postdischarge successfully reduced depressive symptoms within a subgroup experiencing mild to severe depressive symptoms compared with those in the ISR group. These results were evident at our primary end point of 8 weeks and were sustained at both 24 and 52 weeks. Although other stroke caregiver intervention studies have reported improvements in caregiver depressive symptoms,20 only one study reported sustainability at 52 weeks.42 The study by Kalra et al42 was a well-designed, randomized controlled clinical trial that tested the efficacy of a hands-on caregiver training program in a sample of 300 stroke caregivers. The intervention group received 3 to 5 inpatient sessions and 1 home visit focused on a variety of skills that included goal setting and tailored psychoeducation, although tailoring of the intervention was based on the needs of the stroke survivor rather than the caregiver. The TASK II intervention is unique in that it is delivered completely by telephone, trains caregivers how to assess and address their own needs, and is applicable to a wide variety of stroke caregivers (eg, spouses, adult children, and others). Screening for and addressing caregiver depressive symptoms, as in

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the TASK II program, not only have the potential to improve caregiver outcomes,10,12,19,20 but may improve the survivors’ recovery15 and reduce the potential for their long-term institutionalization.9,17,18

Improvement in life changes At 8, 12, 24, and 52 weeks, the TASK II intervention did not significantly affect life changes for the total sample. However, the TASK II program improved caregiver life changes in caregivers with mild to severe depressive symptoms compared with those randomized to the ISR group at 12 weeks. Although life changes were similar for both TASK II and ISR groups across the total sample, it is possible that caregivers with some depressive symptoms experienced more life changes as a result of providing care. Life changes and depressive symptoms have been found to be correlated.10–12 Improvement in life changes in caregivers with some depressive symptoms builds on our previous work with the original TASK intervention, which had little effect on life changes.33 For the TASK II intervention, we incorporated the BCOS into the intervention during the fifth call with the nurse as an additional assessment, encouraging caregivers to select priority needs that were targeted toward improving their own personal life changes. Further refinement of the TASK II intervention may be to use the BCOS earlier, (eg, second or third call) to allow caregivers more time to address their own life changes. Only one other intervention study has reported life changes as an outcome in stroke caregivers.43 King et al43 found that life changes improved for a group of caregivers who received a problem-solving intervention immediately postintervention; however, results were not sustained at 6 months or 1 year, and there were high attrition rates. Generalizability was limited to spousal caregivers. Other intervention studies have measured similar quality of life concepts with mixed results.20 Caregivers commonly experience adverse life changes because they neglect their own needs while providing care, and they often need encouragement to care for themselves.2,3,10–12,36 The TASK II intervention encourages caregivers to attend the needs of the survivor and their own changes in social functioning, subjective well-being, and physical health.

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Reduction of UD Most notably, UD were reduced for the caregivers in the TASK II group compared with those randomized to the ISR group at our primary end point of 8 weeks. A trend toward fewer UD was noted for the TASK II group at 12, 24, and 52 weeks (Figure 2). Future enhancements of the TASK II program may be warranted to include a stronger focus on referring caregivers to healthcare providers to address their own physical and mental health needs. Addressing health conditions as well as preventive healthcare measures is important for both stroke survivors and family caregivers. The stroke family caregiver intervention literature is limited with regard to caregiver health20; only 2 studies found improvement in general health of the caregiver.43,44 Other studies had nonsignificant findings using the SF-36 general health subscale.33,45 TASK II intervention having a significant impact on a global measure of UD27 underscores the strength of the TASK II intervention and its potential to improve population health in general for family caregivers.

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FIG 2 Change plots by treatment and by time for

depressive symptoms, life changes, and unhealthy days. ISR indicates information, support, and referral; and TASK, Telephone Assessment and Skill-Building

Kit.

Limitations The study used a convenience sample of stroke caregivers recruited

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from acute care and inpatient rehabilitation settings in the Midwest where most of the participants were white and Non-Hispanic. Caregivers were recruited within 8 weeks of the survivor’s discharge to home, making findings less generalizable to long-term caregivers. Caregivers were older (mean age, 54–55 years), making findings less applicable to younger caregivers who were also parents of young children. Survivor characteristics were collected by caregiver proxy. Future studies should incorporate more objective data from medical records or directly from the stroke survivors themselves. Finally, there were group differences in protocol adherence, time spent reading materials, and longer call time; although, longer call time with the nurses was used as a covariate in the analyses. Although overall adherence for the TASK II group was 80% and the ISR group was 92%, the checklist for the TASK II group included additional items specific to the TASK II intervention that were repetitive and not needed during every call. Comparison with adherence percentages for shared items on the checklist was 90% for the TASK II group and 92% for the ISR group.35

Implications and future directions Despite these limitations, the TASK II intervention is useful. It includes a close connection with current scientific and practice guidelines that recommend assessment of caregiver needs and concerns, as well as the use of a combination of psychoeducational and skill-building strategies.19–22 Training caregivers to assess their own needs and concerns and to address those using individualized skill-building strategies provides a caregiver-driven approach to self-care. The TASK II intervention is unique among intervention studies20 because it is delivered completely by telephone, making it accessible to caregivers in both rural and urban home settings.32,33,35 Key attributes of the nurses delivering the intervention included the hiring of qualified, engaged nurses who had a registered nurses licence.35 Education level did not matter as much as the quality of communication skills and the ability to follow the caregiver’s lead.35 Nurses commented on how telephone delivery sharpened their listening skills,35 similar to findings from another study in which telephone delivery allowed interveners to develop enhanced

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listening skills to compensate for the absence of visual cues.46 Future development of the intervention may involve enhanced use of other telehealth modes of delivery, such as video, web-based, and remote monitoring technologies.47 The TASK II intervention has a documented track record of treatment fidelity, including structured protocols for nurse training.35 The challenge is how to implement the program into stroke systems of care. Future research is needed to enhance the TASK II program using innovative telehealth technologies and to implement the TASK II program into ongoing systems of stroke care.

Acknowledgments We acknowledge the assistance of Phyllis Dexter, PhD, RN, Indiana University School of Nursing, for her helpful review of this article.

Sources of funding This study was funded by the National Institutes of Health, National Institute of Nursing Research, R01NR010388, and registered with the clinical trials identifier NCT01275495 https://www.clinicaltrials.gov/ct2/show/NCT01275495? term=Bakas&rank=3.

Disclosures None.

The critique This is a critical appraisal of the article “Telephone Assessment and Skill-Building Kit for Stroke Caregivers: A Randomized Controlled Clinical Trial” (Bakas et al., 2015) to determine its usefulness and applicability for nursing practice.

Problem and purpose The purpose of this study, to evaluate the short-term and long-term efficacy of the Telephone Assessment and Skill-Building Kit (TASK II) intervention on caregivers’ depressive symptoms, caregiving- related life changes, and unhealthy days, is concise and clearly stated. The purpose of the study is substantiated in the review of

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https://www.clinicaltrials.gov/ct2/show/NCT01275495?term5Bakas%26rank53

literature. The independent variable is the method of caregiver information and support (TASK II vs. information, support, and referral [ISR]), and the dependent variables are depressive symptoms, life changes, and unhealthy days. The population under study is clearly defined, and the results are important to assist caregivers of stroke survivors in dealing with their own unmet needs and build skills in providing care.

Review of the literature The authors provide a thorough summary of the literature related to the needs of caregivers of stroke survivors. They accurately describe literature that supports higher rates of depression, risks of negative life changes, and poor health of caregivers. Stress of caregivers is a leading cause of stroke survivor’s institutionalization. Although recommendations and guidelines for education and support of stroke caregivers have been reported, few “easy-to-deliver” programs that incorporate all of the recommendations exist. Therefore this study helps to meet that identified gap in the literature.

Research questions The clearly stated primary purpose or aim of the study was to examine the short- and long-term effects of the TASK II intervention compared with the ISR comparison group on improving caregivers’ depressive symptoms, caregiving-related life changes, and unhealthy days. Although a hypothesis was not explicitly stated, the information reported in the background, methods, and results provided imply the hypothesis of the study.

Sample The convenience sample consisted of 254 stroke family caregivers recruited from rehabilitation and acute care hospitals in the Midwest. The sample size was appropriately justified by power analysis, as 100 subjects per group provided a power of 81%. The authors accounted for 10% attrition, which meant an additional 10 subjects per group would be needed. The effect size was determined by using analyses of pilot data to determine a difference in group means of the primary measures.

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Inclusion and exclusion criteria were clearly specified. Screening and enrollment procedures were provided.

Although the sample was not randomly selected, there was appropriate random assignment to the TASK II intervention or ISR groups. There were no significant demographic differences between the two caregiver groups. Table 18.1 provides an overview of the group characteristics. Although there were no differences among the groups at baseline, a strength, the sample was predominantly female and predominantly white. This should be mentioned in the discussion section and considered when assessing external validity of the study. The stroke survivors were similar in demographics, with the exception that survivors whose caregivers were in the ISR group had spent significantly more days in the hospital compared with the TASK II group. The difference should be acknowledged when the study results are interpreted.

Research design The three required elements of an RCT are present in this study, which provides Level II evidence. After baseline, participants were randomly assigned to the TASK II intervention group or the ISR comparison group. A randomized block design with stratification by recruitment site, type of relationship of caregiver/survivor, and baseline depressive symptoms was appropriately used to allocate participants to groups. The stratified randomization after baseline strengthens the representativeness of the sample.

Threats to internal validity Selection bias may be an issue in studies that use convenience sampling, and in this study all subjects were recruited from acute and inpatient rehabilitation facilities; a majority of the sample was non-Hispanic and white. The sample was also recruited within 8 weeks of discharge home, early in the start of caregiving. However, the randomization used in this study helped control for selection bias. In this study, there is also the risk of instrumentation bias as stroke survivor data was collected by caregiver proxy report. Self- report was also used as an instrument in this study. However, all of the instruments had appropriate reliability and validity, decreasing the risks of instrumentation bias.

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Threats to external validity The investigators appropriately recognized and reported threats to external validity in the limitations section of the manuscript. As mentioned previously, subjects were randomized to each intervention group when enrolled in the study. However, the sample size was predominately white and non-Hispanic; therefore generalizability to other ethnic groups and races could be minimal. Also, all participants were enrolled in the same geographical area and facility types; therefore the ability to generalize to other geographical areas is a threat to external validity. The investigators used masking (blinding) and took efforts to maximize treatment fidelity. These factors minimize the threats to external validity.

Research methodology The research methodology is clearly described. Data collection occurred by telephone at baseline, 8, 12, 24, and 52 weeks post intervention. The procedures to maintain treatment fidelity were provided and indicate systematic and consistent data collection. Data collectors were blinded to caregiver treatment groups, which decreases the chance of differential treatment of the participants.

Legal-ethical issues The study was reviewed and approved by the appropriate institutional review board, and informed consent was obtained from all participants before study initiation.

Instruments Acceptable reliability and validity data were reported for the Patient Health Questionnaire Depressive Symptom Scale (PHG-9) and the Bakas Caregiving Outcomes Scale (BCOS). The authors provided references that describe the reliability and validity of the instruments for the two-item scale used to measure unhealthy days, and the instruments used to measure the caregiver and survivor characteristics.

Data analysis Demographic characteristics were appropriately summarized and

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analyzed for equivalence using descriptive statistics. The analysis used for both categorical and continuous variables is appropriate. These variables are presented clearly in Tables 1 and 2. General linear models with repeated measures were appropriately used to examine the effect of the intervention. Three tables are used to visually display the data.

Conclusions, implications, and recommendations The authors reported that at 8 weeks the total TASK II intervention group experienced reduced depressive symptoms and greater reduction in unhealthy days compared with the ISR group: (P =.013). However, in a subgroup of caregivers experiencing mild to severe depressive symptoms, those in the TASK II intervention group had reduced depressive symptoms from baseline to 8 weeks (P =.001), 24 weeks (P =.041), and 52 weeks (P =.008) and larger improvement in life changes from baseline to 12 weeks (P ≤.05) than the ISR group.

The Level II RCT design, when including all required elements (i.e., randomization, intervention and control groups, and manipulation of the independent variable), is what allows the investigator to determine cause-and-effect relationships. In this case, minimizing threats to internal validity strengthens the study. By ensuring a relatively homogeneous sample, maintaining consistency in data collection, manipulating the independent variables, and randomly assigning patients to groups, the threat to external validity is minimized.

Limitations of the study, as clearly described by the investigator, included generalizability and differences in adherence to the protocol. However, overall protocol adherence is impressive at 80% for the TASK II group and 92% for the ISR group.

Implications for nursing practice This is a well-designed and well-conducted RCT that provides Level II evidence. The interventions pose minimal risk and seem feasible to implement in larger studies of more heterogeneous populations. The strengths in the study design, data collection methods, and measures to minimize threats to internal and external validity make this strong Level II evidence that demonstrates that

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the TASK II intervention is useful in incorporating the assessment of caregivers’ needs with delivery of education and skill-building training for caregivers of stroke survivors.

Critique of a quantitative research study The research study The study “Symptoms as the Main Predictors of Caregivers’ Perception of the Suffering of Patients with Primary Malignant Brain Tumors” by Renata Zelenikova and colleagues, published in Cancer Nursing, is critiqued. The article is presented in its entirety and followed by the critique.

Symptoms as the main predictors of caregivers’ perception of the suffering of patients with primary malignant brain tumors Renáta Zeleníková, PhD

Dianxu Ren, MD, PhD Richard Schulz, PhD Barbara Given, PhD Paula R. Sherwood, PhD

Key words

Brain neoplasms

Caregivers

Neurobehavioral

manifestations

Background: The perception of suffering causes distress. Little is known about what predicts the perception of suffering in caregivers. Objective: The aims of this study were to determine the predictors of caregivers’ perceptions of the suffering of patients

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with a primary malignant brain tumor and to find to what extent perceived suffering predicts the caregivers’ burden and depression. Methods: Data were obtained as part of a descriptive longitudinal study of adult family caregivers of persons with a primary malignant brain tumor. Recruitment took place in outpatient neuro- oncology and neurosurgery clinics. Caregiver perception of care recipient suffering was measured by 1 item on a scale from 1 to 6. Results: The sample of caregiver interviews 4 months after recipients were diagnosed consisted of 86 dyads. While controlling for age, years of education, tumor type, being a spousal caregiver, spiritual well-being, and anxiety, perception of overall suffering was predicted by such symptoms as difficulty understanding, difficulty remembering, difficulty concentrating, feeling of distress, weakness, and pain. Caregivers’ perception of the patient’s degree of suffering was the main predictor of caregiver burden due to schedule 4 months following diagnosis. Conclusions: Care recipient symptoms play an important role in caregivers’ perception of the care recipients’ suffering. Perception of care recipient suffering may influence caregiver burden. Implications for Practice: Identifying specific predictors of overall suffering provides meaningful information for healthcare providers in the field of neuro-oncology and neurosurgery.

In the nursing and healthcare literature, suffering is commonly described in terms of an awareness of the impact of a deteriorating physical state on an individual1: the construction of events such as pain or loss as threats to the individual self2; a visceral awareness of the self’s vulnerability to being broken or diminished at any time and in many ways3; and the experience of having to endure, undergo, or submit to an evil of some sort.4 Suffering is an intensely personal experience5 whose presence and extent can be known only to the sufferer,1 something unsharable6 that, paradoxically, involves asking the question “why.”5 Researchers in diverse settings consistently have concluded that suffering exists across dimensions of physical, psychological and emotional, social and interpersonal, and spiritual and existential well-being.5 For our purposes, suffering is a broad construct defined as a state of severe distress associated with events that threaten the intactness of the person as a complex physical, social, psychological, and spiritual being and that

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is subjective and unique to the individual.7,8 Serious disease can result in serious suffering.9 Analogous to the

association of pain with suffering is the association of cancer with death. Another major factor in the association of cancer with suffering is the recognition of the drastic effects of cancer treatments. Even with a good prognosis, the effects of surgery, chemotherapy, and radiation therapy are distressing and can be devastating.5 Suffering of patients with primary malignant brain tumors (PMBTs) can be particularly notable across the cancer trajectory encompassing initial diagnosis, treatment, remission, and even long-term survival. In addition, patients with PMBT can have cognitive deficits including difficulty speaking, difficulty remembering, or difficulty concentrating. These neurologic deficits can drastically interfere with daily life and function. Persons diagnosed with a PMBT are faced with a unique and challenging set of circumstances that affect not only them but also those close to them.10 Caregivers of persons with a PMBT must deal with both oncological and neurologic issues. They are charged with caring for a person with a potentially terminal diagnosis who is undergoing active cancer treatment and may have cognitive and neuropsychiatric sequelae.11 Suffering typically occurs in an interpersonal context and is shaped by and affects others exposed to it.12 Predictors of caregivers’ perceptions of suffering in persons diagnosed with PMBT are not established in part because of a lack of valid and reliable instruments to measure the caregiver’s perception of the care recipient suffering.

The main purpose of this study was to determine the predictors of caregivers’ perceptions of the suffering of patients with PMBT. We predicted that care recipients’ symptoms would be the main predictors of caregivers’ perceptions of the suffering while controlling for tumor type and caregivers’ characteristics (age, years of education, being a spousal caregiver, spiritual well being, and anxiety).

Theoretical framework The study framework was derived from the work of Schulz and colleagues13 and reflected perceived suffering, caregiver compassion, and caregiver helping and health; this framework

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guided identifying potential predictors of caregivers’ perceptions of the suffering of patients with PMBT and to find out to what extent caregivers’ perceptions of the patients’ suffering predicted the burden borne by caregivers and caregiver depression. Although the framework emphasizes the directional effects of perceived suffering on compassion, 1 of the framework components depicts perceived suffering as directly linked to psychiatric and physical morbidity. Therefore, we hypothesized that perceived suffering can impact caregiver burden and caregiver depression.

Being exposed to the suffering of others is an important and unique source of distress.12 Research in dementia patient populations indicates that perceived suffering can contribute to care giver depression and caregiver burden.7,12 Similarly, descriptive findings in a longitudinal study in 1330 older married couples enrolled in the Cardiovascular Health Study confirmed that exposure to spousal suffering is an independent and unique source of distress in couples and contributes to psychiatric and physical morbidity.14

Psychobehavioral responses of caregivers that include depression, burden, anxiety, and positive responses to care have been studied previously, mostly in patients’ population with dementia or oncology disease. Caregiver burden and depression may be considered as a general distress response for caregivers.15 Caregiver burden is a multidimensional concept and represents the impact of providing care on different areas of the caregiver’s life (schedule, self-esteem, health, finances, feeling of abandonment), psychosocial reaction resulting from an imbalance of care demands relative to caregivers’ personal time, social roles, physical and emotional states, financial resources, and on formal care resources given the other multiple roles they fulfill.15

Depression is 1 of the most important potential adverse consequences for caregivers because it is common, associated with poor quality of life, and is a risk factor for other adverse outcomes including functional decline and mortality.16 Caregiver depression is a complex process, mediated by cultural factors (as measured by the ethnicity of the patient), patient characteristics, and caregiver characteristics.16 Positive aspects of caregiving may decrease feelings of being burdened and subsequently lead to a more

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positive effect of health outcomes.

Measuring suffering Research methods for approaching human suffering are often qualitative and are based on interviews with people who are assumed to have experienced suffering.17 Some authors believe that attempting to measure suffering is reductionist and futile because of its personal and unsharable nature.7 While suffering is personal and potentially ultimately incommunicable, from a practical standpoint, that is, in order to design suitable interventions to relieve suffering, measures that approximately capture a communicable core of suffering are needed. According to Monin and Schulz,18 both the experience of suffering and the perception of suffering by others can be measured. Ultimately, measures of suffering should focus on the patient’s experience, the patient’s direct and indirect expressions of suffering, caregiver perceptions of the patient’s degree of suffering, and caregiver perceptions of whether the patient’s expression of suffering is an accurate reflection of his/her actual degree of suffering.13

Measuring suffering via caregiver perceptions of suffering is useful and important, especially for patients with impaired cognitive status because this patient population may not be able to report suffering. To better understand the perceived suffering, we examined caregivers’ anxiety and spirituality. Caregivers can play a role in relieving the suffering of their loved one by sharing the experiences, or if the suffering cannot be relieved, then caregivers can help their loved one to bear it through their companionship and compassion. To help caregivers cope with caregiving distress, researchers need to identify how caregivers perceive the suffering of their patients and the predictors of these perceptions.

Aim The main aim of this study was to determine the predictors of caregivers’ perceptions of the suffering of patients with PMBTs. The secondary aim was to find out to what extent caregivers’ perceptions of the care recipients’ suffering predicted the care givers’ burden and depression.

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Methods

Design and setting Data were obtained as part of a descriptive longitudinal study of adult family caregivers of persons with PMBT (R01 CA118711). Care recipient and caregiver dyads were recruited from suburban neurosurgery and neuro-oncology clinics in Western Pennsylvania. Recruitment took place in outpatient neuro-oncology and neurosurgery clinics from October 2005 through June 2011. Data were collected from persons with a PMBT and their family caregivers. Interviews with caregivers were conducted in person or via telephone. Data were collected at 3 timepoints over the disease trajectory—right after diagnosis and 4 and 8 months after diagnosis. Data for this analysis are from the second timepoint—4 months after diagnosis to focus on a time of illness progression. Approval from the institutional review board at the University of Pittsburgh and informed consent from participants were obtained prior to data collection. Both the patient and caregiver had to consent to enroll in the study.

Participants Caregivers were queried regarding sociodemographic characteristics, personal characteristics, and psychological responses, and care recipients were queried regarding the tumor grade, functional and neurologic ability, and symptom status. Care recipients were required to be older than 21 years, newly diagnosed (within 1 month of recruitment) with a PMBT verified by a pathology report. After the death of the care recipient, the corresponding caregiver was given the option of continuing to participate in the study. Caregivers were required to be older than 21 years, nonprofessional (ie, not paid caregivers), not a primary caregiver for anyone else (excluding children aged <21 years), and English speaking and to have regular and reliable access to a phone.

Overall, 228 caregiver and care recipient dyads were approached, with 164 agreeing to participate (70%). The main reasons for declining participation (n = 64) were lack of interest (52%), feeling overwhelmed (33%), reason not given (11%), too busy (3%), and too ill (1%). Of 164 dyads who agreed to participate, 78 ended study

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participation (47.6%) for various reasons: care recipients died, caregivers were overwhelmed by caregiving duties and life changes, or caregivers were not interested anymore. As a result, the sample of caregivers at the 4-month data point consisted of 86 dyads.

Procedures

Dependent variables The primary outcome variable in this study was caregiver perception of the care recipient’s suffering during the past week as measured by 1 item; caregivers were asked at the fourth month to rate the care recipient’s suffering during the previous week on a scale of 1 (care recipient is not suffering) to 6 (care recipient is suffering terribly). This item was developed by the study investigators. A single-item was purposefully used for its simplicity and ease of use.

Secondary outcomes included caregiver burden and caregiver depression. Caregiver burden was measured using the Caregiver Reaction Assessment (CRA) scale. The CRA is a feasible, reliable, and valid instrument for assessing specific caregiver experiences, including both negative and positive experiences, in caregivers of cancer patients.19 The CRA comprises 24 items forming 5 distinct unidimensional subscales: disrupted schedule (5 items), financial problems (3 items), lack of family support (5 items), health problems (4 items), and self-esteem (7 items).20 Respondents were asked to indicate their level of agreement with statements about their feelings regarding caregiving over the previous month. Responses were scaled on a 5-point Likert-type format (5 = strongly agree to 1 = strongly disagree). This analysis focuses on 3 subscales: the self-esteem subscale, the abandonment subscale, and the schedule subscale (which measures the perception of burden on the caregiver’s daily activities as a result of providing care). For the self-esteem subscale, a higher score indicates a lower burden related to self-esteem, that is, a positive reaction to caregiving. For abandonment and schedule subscales, a higher score indicates a higher burden, that is, negative reactions to caregiving. Reported reliability analyses19 showed sufficient internal consistency based

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on standardized Cronbach’s α (.62–.83). Caregivers’ depressive symptoms were measured using the

Shortened Center for Epidemiologic Studies Depression Scale (CES- D). The original CES-D scale is a 20-item self-report scale designed to measure depressive symptoms in the general population. The items on the scale are symptoms associated with depression that were chosen from previously validated scales.21 We used a shortened CES-D with 10 items.22 Response categories indicate the frequency of occurrence of each item and are scored on a 4-point scale ranging from 0 (rarely or none of the time/<1 day) to 3 (most or all of the time/5–7 days). Scores for items 5 and 8 were reversed before summing up all items to yield a total score. Total scores can range from 0 to 30. Higher scores indicate more severe symptoms.23 Validity for the CES-D has been well established in caregivers and well adults.22

Independent/predictor variables Independent variables were chosen based on previous associations reported in the literature as well as hypotheses generated from clinical knowledge in neuro-oncology. Perceived severity of the care recipient’s symptoms was measured using the M. D. Anderson Symptom Inventory–Brain Tumor (MDASI-BT). Caregivers were asked to rate the severity of the care recipient’s difficulty understanding (speaking, remembering, concentrating) at its worst in the last 24 hours. The MDASI-BT questionnaire is a valid and reliable 22-item measure of the severity of cancer- and treatment- related symptoms based on 6 criteria: affective, cognitive, focal neurologic deficits, treatment-related symptoms, general disease status, and gastrointestinal symptoms.24–26 Each of the care recipient’s symptoms was rated on an 11-point scale (0–10) to indicate its severity, with 0 being “not present” to 10 being “symptom was as bad as you can imagine it could be.”24 This instrument can be used to identify symptom occurrence throughout the disease trajectory and to evaluate interventions designed for symptom management. The MDASI-BT has established validity and reliability. Reported internal consistency (reliability) of the instrument is.91.24

Positive aspects of caregiving were assessed using 11 items on the

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Positive Aspects of Care scale, phrased as statements about the caregiver’s mental-affective state in relation to the caregiving experience. Each item began with the statement “Providing help to care recipient has . . . ” followed by specific items such as “made me feel more useful.”27 Each item is rated on a scale from 0 (strongly disagree) to 4 (strongly agree). Higher scores indicate greater caregiver benefit. Reported reliability measured by Cronbach’s α is.89.27

Caregivers’ anxiety was measured using the Shortened Profile of Mood States (POMS)–Anxiety. The Shortened POMS-Anxiety consists of 3 items. Each item has 5 grading possibilities from 1 (never) to 5 (always). Caregivers were asked how often during the previous week they felt on edge, nervous, or tense. The original scale28 incorporated 65 adjectives rated on a 5-point Likert scale ranging from 1 (not at all) to 5 (extremely).29 Six subscales (depression, vigor, confusion, anxiety, anger, and fatigue) were derived. Our study used a shortened version of 3 items. A higher score indicates greater anxiety. Internal consistency reliability coefficients for the shortened 3-item version of Anxiety subscale were reported as.91 to.92.30 Validity for the POMS has been established using several other measures.

Caregivers’ spirituality was measured using the FACIT-Sp (The Functional Assessment of Chronic Illness Therapy–Spiritual Well- being Scale). FACIT-Sp (version 4) consists of 12 items. Each item has a rating scale score of 0 to 4 indicating the degree to which one agrees with the statements (0 = not at all, 1 = a little bit, 2 = somewhat, 3 = quite a bit, 4 = very much). The instrument comprises 2 subscales: one measuring a sense of meaning and peace and the other assessing the role of faith in illness.31 The FACIT-Sp is 1 of the most validated instruments for the assessment of a person’s perception of spirituality.32 The reported α coefficients for the total scale and the 2 subscales range from.81 to.88.31 Participants were required to indicate how true each statement had been for them during the previous 7 days.

Sociodemographic Characteristics. Several sociodemographic characteristics were included in the statistical analysis: age, gender, years of education, relationship of caregivers to the care recipients, and tumor type.

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Statistical analyses Statistical analyses were conducted using SAS for Windows (version 9.3; SAS Institute Inc, Cary, North Carolina). First, descriptive analyses of the study sample were performed. Correlation between the dependent and independent variables were analyzed. The Spearman correlation coefficient was used to examine the correlation between the main outcome (caregivers’ perceptions of care recipients’ suffering) and each item of the MDASI-BT (severity of symptoms) as well as the correlation among items of the MDASI-BT. Univariate analyses of measures were then conducted to identify potential predictors of perception of care recipient suffering. Finally, a multivariable linear regression model was built, including all predictors significant at P <.15 in univariate analyses. The statistical significance of individual regression coefficients was tested using the Wald χ2 statistic.

Results

Sample This analysis includes a total of 86 caregiver-care recipient dyads who completed follow-up assessment 4 months after diagnosis. The majority of caregivers were female (n = 59; 69%) and caring for spouses (n = 69; 80%). The average age of caregivers was 52.23 (SD, 12.7) years (range, 24–99 years); the average age of care recipients was 52.66 (SD, 14.6) years (range, 22–76 years). The caregivers had completed 14.55 (SD, 2.6) years of education on average (range, 8– 23 years); the care recipients had completed 15.2 (SD, 3.0) years of education on average (range, 12–22 years). The majority of care recipients were diagnosed with a glioblastoma (n = 49; 57%) (Table 1). Other dyad characteristics are presented in Table 2.

TABLE 1 Dyad Characteristics (n = 86)

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Abbreviation: GBM, glioblastoma multiforme.

TABLE 2 Others Selected Dyad Characteristics

Abbreviations: CES-D, Center for Epidemiologic Studies Depression Scale; CRA, Caregiver Reaction Assessment; MDASI-BT, M. D. Anderson Symptom Inventory– Brain Tumor; FACIT, The Functional Assessment of Chronic Illness Therapy– Spiritual Well-being Scale; PAC, Positive Aspects of Care scale; POMS, Shortened Profile of Mood States.

Suffering at 4 months after diagnosis, 37% of caregivers reported that the patient was not suffering; 24% of caregivers rated the patient’s suffering as moderate (score of 3), whereas only 4% of caregivers rated the patient’s suffering as terrible (score of 6). The average score of perceived suffering was 2.63 (SD 1.56) (Table 3).

TABLE 3 Perception of Overall Suffering

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Overall Suffering n (%) Mean (SD) 1 (Not suffering) 32 (37) 2.63 (1.56) 2 9 (10) 3 21 (24) 4 10 (12) 5 11 (13) 6 (Suffering terribly) 3 (4)

Preliminary analysis A strong correlation (Table 4) was found only between the perceived suffering of the care recipient and severity of weakness (rs = 0.67). This suggests that care recipients’ weakness is associated with caregiver reports of the care recipient’s suffering. Moderate correlations were found between perceived suffering and 3 cognitive symptoms: difficulty understanding (rs = 0.41), difficulty remembering (rs = 0.46), and difficulty concentrating (rs = 0.42); and between perceived suffering and a feeling of distress (rs = 0.4) and pain (rs = 0.41) (Table 4).

TABLE 4 Correlation of the Severity of Each Symptom With Caregiver Reports of Care Recipient’s Overall Suffering at the 4-Month Point

Item of MDASI-BT rs P Strong correlation How severe was care recipient’s weakness? 0.67343 <.0001 Moderate correlations How severe was care recipient’s difficulty remembering? 0.45803 <.0001 How severe was care recipient’s difficulty concentrating? 0.41597 .0001 How severe was care recipient’s pain? 0.41068 .0001 How severe was care recipient’s difficulty understanding? 0.40915 .0001 How severe were care recipient’s feelings of distress? 0.40362 .0002 Weak or very weak correlations How severe was care recipient’s fatigue (tiredness)? 0.38545 .0004 How severe was care recipient’s disturbed sleep? 0.34661 .0015 How severe was care recipient’s drowsiness (sleepy)? 0.31780 .0038 How severe was care recipient’s difficulty speaking? 0.30383 .0058 How severe were care recipient’s feelings of sadness? 0.26399 .0172 How severe was care recipient’s numbness? 0.24600 .0278 How severe was care recipient’s shortness of breath? 0.22094 .0475 How severe were changes in the care recipient’s vision? 0.20204 .0705 How severe was care recipient’s nausea? 0.20157 .0711 How severe was care recipient’s irritability? 0.14288 .2032 How severe was care recipient’s lack of appetite? 0.13284 .2371 How severe was care recipient’s vomiting? 0.08530 .4490

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Abbreviation: MDASI-BT, M. D. Anderson Symptom Inventory–Brain Tumor.

Correlations among symptoms that were strongly and moderately correlated (a correlation exceeding 0.4) with perceived suffering were examined. Strong correlations were found between difficulty understanding and difficulty remembering (0.69), difficulty understanding and difficulty concentrating (0.7), and difficulty remembering and difficulty concentrating (0.74). Thus, caregivers giving higher ratings of the severity of the care recipient’s difficulty understanding also provided higher ratings of the care recipient’s difficulty concentrating and other cognitive symptoms. Moderate correlations were found among the symptoms difficulty concentrating and feelings of distress (0.59), difficulty remembering and feelings of distress (0.51), feelings of distress and pain (0.46), and difficulty concentrating and pain (0.4). Other correlations were weak.

A multivariate model was constructed to evaluate the relationship between the continuous outcome variable of perceived suffering and each of 6 individual symptoms that were correlated (with a correlation exceeding 0.4) with perceived suffering. Other variables—potentially important predictors of perception of suffering—were identified from the univariate analyses of the 4- month measures (all predictors significant at P <.15 in univariate analyses). The dependent variable was the caregiver’s rating of the care recipient’s suffering over the previous week.

In all the models tested (Table 5), the only variables that significantly affected perceived suffering were individual symptoms. While controlling for age, years of education, tumor type, being a spousal caregiver, spiritual well-being (FACIT), and anxiety (POMS), caregiver’s perception of the care recipient’s suffering at the 4-month point was predicted by such symptoms as difficulty understanding, difficulty remembering, difficulty concentrating, feeling of distress, weakness, and pain. Caregivers who reported perceiving higher levels of the previously mentioned symptoms tended to report higher levels of perceived suffering in the care recipient. In the models, the variables accounted for 22.8% to 43.71% of the variance of the outcome variable (suffering).

TABLE 5

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Association of Continuous Outcome Variable Overall Suffering With Each of 6 Individual Symptoms While Controlling for Age, Years of Education, Tumor Type, Being a Spousal Caregiver, Spiritual Well-being (FACIT-Sp), and Anxiety (POMS)

Abbreviations: FACIT, Functional Assessment of Chronic Illness Therapy–Spiritual Well-being Scale; POMS, Shortened Profile of Mood States.

Four items (severity of seizures, severity of dry mouth, severity of change in appearance, severity of disruptions in bowel movement patterns) from the MDASI-BT were excluded, and the total score was considered as 1 of the predictors (designated “total symptoms”). The 4 items were excluded on the basis of weak correlations, a low incidence rate, and expert panel discussion. Other regression models were developed to examine predictors of the continuous outcome variable caregivers’ perceptions of the care recipients’ suffering and predictors of the following psychological outcomes: depression and caregiver burden due to schedule at 4 months, while controlling for age, years of education, tumor type, being a spousal caregiver, spiritual well-being (FACIT), and anxiety (POMS).

Four months after the patient’s diagnosis, total symptoms of MDASI-BT were the single predictor of perceived suffering (P <.0001). The total symptoms score (MDASI-BT) represents the severity of the symptoms. The higher the total score, the more severe the patient’s symptoms. The model accounted for 36.56% (F = 4.68; P =.0001) of the variance in the outcome variable suffering (model A).

Caregiver depressive symptoms were predicted by the caregiver’s age (P =.0223) and total symptoms (P =.0067) (model B).

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Caregivers who were younger had a tendency to report more depressive symptoms. Another predictor of caregiver depression was total symptoms; the higher the caregiver’s perception of the severity of the care recipient’s symptoms, the more depressive symptoms they tended to report.

Being a spousal caregiver (P =.0054) and caregiver perception of care recipient suffering (P =.0052) were the main predictors of burden related to schedule (model C). Caregivers who were a spouse to the care recipient and those who reported higher perception of the care recipient’s suffering were more likely to report higher levels of burden due to schedule (Table 6).

TABLE 6 Regression Models

Discussion Persons with PMBTs have a specific treatment and disease trajectory. Having a brain tumor subjects the person to the rigors of a cancer and its treatment (eg, adverse effects from chemotherapy and radiation) but often causes significant neurologic deficits that interfere with daily life and function.33 The presence of complications in patients with advanced cancer as well as neuropsychological and neurologic dysfunction, such as memory problems, affects the family caregivers of persons with PMBT who are likely to perceive their loved one’s suffering as quite distressing. The main purpose of this study was to determine the predictors of caregivers’ perceptions of the suffering of persons with PMBT and how perceived suffering relates to caregivers’ burden and depression.

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Care recipient symptoms as the main predictors of caregiver perception of suffering Our study contributes a number of interesting findings regarding the care recipient’s symptoms and the caregiver’s perception of suffering. Care recipients’ symptoms are the main predictors of caregiver perception of care recipient suffering. The results of this study showed moderate correlations between caregiver perceptions of the care recipient’s degree of suffering and 3 cognitive symptoms (difficulty understanding, difficulty remembering, and difficulty concentrating) and between perceived suffering and a feeling of distress and pain. Our results showed the dominance of the physical component of perceived suffering in persons with a PMBT.

Wilson et al8 found that although suffering had a multidimensional character, the physical component was uppermost for many participants with advanced cancer at the end of life. Hebert et al34 characterized patient suffering as a constellation of physical, psychosocial, and spiritual signs and symptoms. Little is known about what contributes to suffering in patients, about the variability in its display to caregivers, or about the factors that contribute to the accurate or inaccurate assessment of suffering by caregivers.34 Of all care recipient symptoms in our study, neurologic symptoms seemed to be the most important in predicting caregiver perception of care recipient suffering. In addition to neurologic symptoms, pain and weakness were also important in predicting perceived suffering. Although symptoms are clearly an important component of patient suffering, they do not constitute the whole suffering.34 A lower percentage of variance in all our models indicates that there are other variables that can affect and predict suffering of patients with PMBT.

Perceived suffering and caregivers’ burden and depression The perception of suffering causes distress.35 Our results confirm that caregivers’ perception of the patient’s degree of suffering is the main predictor of caregiver burden at 4 months following diagnosis. Another predictor of caregivers’ burden was being a spousal caregiver. Given the relationship between patient suffering and caregiver well-being, it is reasonable to expect that, to the extent that these symptoms are successfully treated, caregiver well-

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being should improve.34 The hypothesis that caregivers’ perception of the patient’s degree

of suffering is the main predictor of caregiver depression was not confirmed. The caregiver’s age and total symptoms (MDASI-BT) were the main predictors of caregiver depression. Neurologic dysfunction in the care recipient forces caregivers of persons with a PMBT to face stressors similar to those of caregivers of persons with dementia, a subset of caregivers who have been shown to suffer from negative psychobehavioral responses such as depressive symptoms, anxiety, and difficulty sleeping.10 According to Covinsky et al,16 there is strong evidence that difficult patient behaviors such as anger and aggressiveness influence caregiver depression, and behavioral manifestations of dementia may be more influential than the degree of cognitive impairment. Schulz et al7 assessed the relationship between suffering in persons with dementia, caregiver depression, and antidepressant medication use in 1222 dementia patients and their caregivers and assessed the prevalence of 2 types of patient suffering, emotional and existential distress. Each aspect of perceived suffering independently contributed to caregiver depression. Their study was the first using a large sample to show that perceived patient suffering independently contributed to caregiver depression and medication use.7 The variance in results in our study suggests that analyses should be conducted using a larger sample. Furthermore, Schulz et al,12 in their study of older individuals, showed that perceived care recipient suffering is associated with caregiver depression and burden, after controlling for the physical and cognitive functioning of the care recipient. They reported that caregivers may overestimate the magnitude of suffering of their care recipient.12 In a study of 109 caregivers of patients with heart failure, caregivers’ poor functional status, overall perception of caregiving distress, and perceived control were associated with depressive symptoms.36

Our study provides evidence that the perception of suffering may influence caregiver burden due to schedule. Suffering evokes compassion and respect for someone who bears it with dignity— and intimidates as well.4 While being able to recognize and respond to the outward signs of a person’s distress, we cannot actually enter into the realm of their personal experience of suffering.6 We need to

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better understand moderating variables such as the level of contact, intimacy, and attachment between patient and caregiver that likely contribute to patient suffering and caregiver well-being. Most important are studies that seek to identify methods for diminishing or eliminating suffering.

Counseling interventions that empower the caregiver to address the suffering of the patient and/or help caregivers appraise their care recipients’ suffering as less threatening should be beneficial. Clinicians can play an important role in the process by monitoring the suffering of the patient, observing its impact on the caregiver, and intervening to address patient suffering and/or caregiver’s concerns about patient suffering.7

Limitations The study has several limitations. The first is its small sample size, which limits generalizability. The second limitation arises from the use of proxy accounts of suffering, given the care recipients’ neurologic dysfunction. It is possible that caregivers overestimate the magnitude of suffering of their care recipients.12 The third limitation is associated with rating the care recipients’ suffering during the week prior to data collection, which opens up the possibility of faulty recall. The fourth limitation of the study is that caregivers’ perception of care recipients’ suffering was measured by a single item. Internal consistency cannot be computed for a single- item measure. A single-item instrument provides clinicians with limited information about caregivers’ perception of care recipients’ suffering, but it can serve as a screening tool. Future research should focus on developing a multi-item instrument measuring perception of suffering in patients with PMBT.

Conclusion In summary, our study provides initial evidence of the role of care recipients’ symptoms in perceived suffering. These results suggest that care recipient symptoms (mostly cognitive symptoms) play an important role in caregivers’ perception of the care recipients’ suffering. Identifying specific predictors such as these provides meaningful information for healthcare providers in the field of neuro-oncology and neurosurgery. Specifically targeted

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interventions can relieve symptoms of patients with PMBT as well as their caregivers’ distress. Interventions that focus on the relief of patients’ cognitive symptoms can be seen as a way to improve caregiver well-being.

The critique This is a critical appraisal of the article, “Symptoms as the Main Predictors of Caregivers’ Perception of the Suffering of Patients with Primary Malignant Brain Tumors” (Zelenikova et al., 2016) to determine its usefulness and applicability for nursing practice.

Problem and purpose Patients with primary malignant brain tumors (PMBTs) experience a unique cancer trajectory that can affect their daily life and function. Suffering of patients with PMBTs not only affects the patient but also their caregivers. The purpose of this study is clearly stated as follows: “To determine the predictors of caregivers’ perceptions of the suffering of patients with PMBT.”

Review of the literature The introduction of the article explains that suffering is a state of severe distress, is subjective, and is unique to the individual. Any threat to the intactness of a person, like serious disease, can result in suffering. Patients with PMBTs are unique in the course of their treatment and the effects of the cancer and treatment on their neurological and physical functioning. Caregivers of patients with PMBT experience suffering related to caring for the patient faced with terminal diagnosis who is also undergoing treatment and may be exhibiting cognitive deficits.

The authors describe the lack of literature related to predictors of caregivers’ perceptions of suffering in persons with PMBT. The authors clearly describe the theoretical framework and gaps in the literature that support the need for the current study. Although published studies have explored caregivers’ perceived suffering and responses to the suffering, most of this work has been done in populations with dementia or general oncology disease. The current study will fill the gap in the literature related specifically to predictors of caregiver suffering and the effect on caregiver burden

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and depression in patients with PMBTs.

Research questions The objective of this study is to determine the predictors of caregivers’ perceptions of the suffering of patients with PMBTs, and determine the extent caregivers’ perceptions of the care recipient’s suffering predicted the caregivers’ burden and depression. Although this is a descriptive study, the authors hypothesized that the care recipient’s main symptoms would predict the caregiver’ perceptions of suffering, and the perceived suffering would impact caregiver burden and depression.

Sample A convenience sample of 164 care recipient and caregiver dyads were enrolled in the study. Of the 164 who consented to the study, 86 dyads remained enrolled in the study at the 4-month data period. The authors clearly described the recruitment and enrollment process and the inclusion criteria. The sample size was not justified with use of power analysis. Given the exploratory nature of the study, the sampling procedure is adequate, but the results must be interpreted cautiously because of limited generalizability.

Research design A descriptive, correlational longitudinal design was used, providing Level IV evidence. Data were collected at three time points. This is a nonexperimental study because no randomization was done and there is no manipulation of the independent variables, nor is there a control group. The relationship of the variables can be explored, but no causality can be inferred. It is important to note that although this study provides a lower level of evidence than an RCT, as long as the design is sound and appropriate for the research questions, it may provide preliminary data to support future intervention studies. Since there is a gap in the literature, the findings of this study may provide the best available evidence.

Threats to internal validity

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No threats from history, mortality (or attrition), or maturation affect this study. Selection bias is a common threat when a convenience sample is used. Psychometric properties of the instrument used to measure the primary outcome variable, caregiver perception, are not reported, which is acknowledged by the authors in the limitation section. Validity is not reported for the Caregiver Reaction Assessment (CRA) or Center for Epidemiologic Studies Depression Scale (CES-D); however, the authors cite the original reference of the tool, which reports adequate validity. The threat of testing is also apparent in this study, with the time of rating the care recipient’s suffering during the week prior to data collection.

Threats to external validity As this is a convenience sample, potential bias may unknowingly be introduced, limiting generalizability of the results. The sample is predominantly female and caregivers are predominantly spouses. All participants were recruited from a suburban area, which also limits generalizability.

Research methods Interviews of caregivers were conducted in person or via telephone. It appears that data collection methods were carried out consistently with each participant, although there was no mention of the specific data collection process, including training or supervision of data collectors, thereby posing questions about fidelity.

Legal-ethical issues The protocol was approved by the appropriate institutional review board. Both caregivers and care recipients completed the informed consent prior to enrolling in the study.

Instruments The primary outcome of caregiver perception of the care recipient’s suffering was measured by a single-item scale that was developed by the study investigators for this protocol. Reliability and validity data are not reported on this scale. The CRA scale was used to measure caregiver burden. Reliability of the 24-item scale is

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acceptable with Cronbach’s alpha.62 to.83. Validity was not reported. The shortened CES-D was used to measure caregivers’ depression. Reliability is not reported; however, the authors cite other studies in support of validity of the scale.

Several instruments were used to measure the predictor variables. The authors report an acceptable reliability for each of those instruments.

Reliability and validity All of the instruments used in this study do not demonstrate adequate psychometric properties, or the authors do not present the reliability and validity of the instrument. This is a weakness and leads to questions about the accuracy with which the tools measure the variables of interest.

Data analysis To assess the relationship between the dependent and independent variables, Spearman’s correlation was appropriately used to assess the relationship between the caregivers’ perceptions of care recipients’ suffering, and the severity of symptoms measured by the M. D. Anderson Symptom Inventory-Brain Tumor (MDASI-BT). Potential predictors of perception of care recipients’ suffering were analyzed using a univariate analysis of measures and multivariable linear regression model. Six tables appropriately were used to visually display the data.

Conclusions, implications, and recommendations Conclusions and implications for practice are clearly stated and are consistent with the reported results. Recommendations for future research are implied in the discussion. Care recipient symptoms are found to be the main predictors of caregivers’ perception of the care recipients’ suffering. Specifically, difficulty understanding, difficulty remembering, difficult concentrating, feeling distress, and pain showed moderate correlations with the caregivers’ perception of the care recipients’ suffering. In addition, the findings indicated that the caregivers’ perception of the care recipients’ degree of suffering and the relationship as a spousal caregiver were the main predictors of caregivers’ burden. The age of the caregiver and the

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total symptoms of the care recipient were the main predictors of caregiver depression.

Application to nursing practice This nonexperimental, correlational study provides data that may eventually lead to an intervention study. The findings support the association between caregivers’ perceptions of care recipients’ suffering and care recipients’ symptoms. Knowing predictors of the perception and how this relates to the caregivers’ burden and depression can lead to targeted interventions to relieve symptoms and caregiver distress. The strengths outweigh the weaknesses, although the results must be interpreted with caution because of limited generalizability. The risks are minimal, and there are no potential benefits for the individual subjects, but there may be a benefit to the greater society by the dissemination of findings in the literature and applicability to future studies. Further studies with larger sample size would be useful to confirm this.

Critical thinking challenges

• Discuss how the stylistic considerations of a journal affect the researcher’s ability to present the research findings of a quantitative report.

• Discuss how the limitations of a research study affect generalizability of the findings.

• Discuss how you differentiate the “critical appraisal” process from simply “criticizing” a research report.

• Analyze how threats to internal and external validity affect the strength and quality of evidence provided by the findings of a research study.

• How would a staff nurse who has just critically appraised the study by Bakas and colleagues determine whether the findings of this study were applicable to practice?

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Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

Received August 6, 2015; final revision received September 24, 2015; accepted October 13, 2015. From the Indiana University School of Nursing, Indianapolis (T.B., J.K.A., S.M.M.); University of Cincinnati College of Nursing, OH (T.B.); College of Health Sciences, University of Delaware, Newark (B.H.); Indiana University Melvin and Bren Simon Cancer Center, Indianapolis (N.M.J.); School of Nursing, University of Washington, Seattle (P.H.M.); Indianapolis Economics Department, Indiana University Purdue University (G.M.); Richard M. Fairbanks School of Public Health, Indianapolis, IN (Z.Y., T.E.S.); and College of Nursing, University of Florida, Gainesville (M.T.W.). Guest Editor for this article was Eric E. Smith, MD. Presented in part at the American Heart Association Scientific Sessions, Orlando, FL, November 7–11, 2015. Correspondence to Tamilyn Bakas, PhD, RN, College of Nursing, University of Cincinnati, 3110 Vine St, Procter Hall No. 231, PO Box 210038, Cincinnati, OH 45221. E-mail tamilyn.bakas@uc.edu © 2015 American Heart Association, Inc. Author Affiliations: Department of Nursing and Midwifery, Faculty of Medicine, University of Ostrava, Czech Republic (Dr Zeleníková); Department of Health and Community Systems, School of Nursing, University of Pittsburgh, Pennsylvania (Dr Ren); University Center for Social and Urban Research, University of Pittsburgh, Pennsylvania (Dr Schulz); College of Nursing, Michigan State University, East Lansing (Dr Given); and Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pennsylvania (Dr Sherwood). This study was funded by the National Cancer Institute (award R01 CA118711, principal investigator P.R.S.). The authors have no conflicts of interest to disclose. Correspondence: Renáta Zeleníková, PhD, Department of Nursing and Midwifery, Faculty of Medicine, University of Ostrava, Syllabova 19, Ostrava, 703 00 Czech Republic (renata.zelenikova@osu.cz).Accepted for publication February 16, 2015. DOI: 10.1097/NCC.0000000000000261

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50. Black H. K., Rubenstein R. L. Themes of suffering in later life. J Gerontol B Psychol Sci Soc Sci 2004;59(1):S17-S24.

51. Harris I. The gift of suffering. In: Johnston N. E., Scholler- Jaquish A. Meaning in Suffering. Caring Practices in the Health Professions. Madison, WI: The University of Wisconsin Press 2007;60-97.

52. Ferrell B. R., Coyle N. The nature of suffering and the goals of nursing. Oncol Nurs Forum 2008;35(2):217-247.

53. Wilkinson I. Suffering A Sociological Introduction.. Cambridge: Polity Press 2005;

54. Schulz R., McGinnis K. A., Zhang S., et al. Dementia patient suffering and caregiver depression. Alzheimer Dis Assoc Disord 2008;22(2):170-176.

55. Wilson K. G., Chochinov H. M., McPherson C. J., et al. Suffering with advanced cancer. J Clin Oncol 2007;25(13):1691- 1697.

56. Ruijs K. D. M, Onwuteaka-Philipsen B. D., der Wal G., Kerkhof A.J.F.M. Un-bearability of suffering at the end of life the development of a new measuring device, the SOS-V..

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58. Sherwood P. R., Given B. A., Given Ch. W., et al. Predictors of distress in caregivers of persons with a primary malignant brain tumor. Res Nurs Health 2006;29:105-120.

59. Schulz R., Monin J. K., Czaja S. J., et al. Measuring the experience and perception of suffering. Gerontologist 2010;50(6):774-784.

60. Schulz R., Hebert R. S., Dew M. A., et al. Patient suffering and caregiver compassion new opportunities for research, practice, and policy. Gerontologist 2007;47(1):4-13.

61. Schulz R., Beach S. R., Hebert R. S., et al. Spousal suffering and partner’s depression and cardiovascular disease the cardiovascular health study. Am J Geriatr Psychiatry 2009;17(3):246-254.

62. Given B., Wyatt G., Given Ch, et al. Burden and depression among caregivers of patients with cancer at the end of life. Oncol Nurs Forum 2004;31(6):1105-1117.

63. Covinsky K. E., Newcomer R., Fox P., et al. Patient and caregiver characteristics associated with depression in caregivers of patients with dementia. J Gen Intern Med 2003;18(12):1006- 1014.

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65. Monin J. K., Schulz R. Interpersonal effects of suffering in older adult caregiving relationships. Psychol Aging 2009;24(3):681- 695.

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76. Nyenhuis D. L., Yamamoto Ch, Luchetta T., et al. Adult and geriatric normative data and validation of the profile of mood states. J Clin Psychol 1999;55(1):79-86.

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78. Peterman A. H., Fitchett G., Brady M. J., et al. Measuring spiritual wellbeing in people with cancer the Functional Assessment of Chronic Illness Therapy–Spiritual Well- Being Scale (FACIT-Sp). Ann Behav Med 2002;24(1):49-58.

79. Monod S., Brennan M., Theologian Rochat E., et al. Instruments measuring spirituality in clinical research – systematic review. J Gen Intern Med 2011;26(11):1345-1357.

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81. Hebert R. S., Arnold R. M., Schulz R. Improving well-being in caregivers of terminally ill patients. Making the case for patient suffering as a focus for intervention research. J Pain Symptom Manage 2007;34(5):539-546.

82. Monin J. K., Schulz R., Feeney B. C., Cook T. B. Attachment insecurity and perceived partner suffering as predictors of personal distress. J Exp Soc Psychol 2010;46(6):1143-1147.

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assessment and skill-building kit for stroke caregivers A randomized controlled clinical trial. Stroke 2015;46:3478- 3487.

85. Zelenikova R., Dianxu R., Schulz R., et al. Symptoms as the main predictors of caregivers’ perception of the suffering of patients with primary malignant brain tumors. Cancer Nursing 2016;39(2):97-105.

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PART IV

Application of Research: Evidence-Based Practice Research Vignette: Mei R. Fu

OUTLINE

Introduction

19. Strategies and tools for developing an evidence- based practice

20. Developing an evidence-based practice

21. Quality improvement

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Introduction

Research vignette

Lymphedema symptom science: Synergy between biological underpinnings of symptomology and technology-driven self-care interventions

Mei R. Fu, PhD, RN, FAAN

Associate Professor

NYU Rory Meyers College of Nursing

New York University

Each year, millions of women worldwide are diagnosed with breast cancer. Lymphedema, an abnormal accumulation of lymph fluid in the ipsilateral body area or upper limb, remains an ongoing major health problem affecting more than 40% of 3.1 million breast cancer survivors in the United States (Fu, 2014). Many breast cancer survivors suffer from daily distressing symptoms related to lymphedema, including arm swelling, breast swelling, chest wall swelling, heaviness, firmness, tightness, stiffness, pain, aching, soreness, tenderness, numbness, burning, stabbing, tingling, arm fatigue, arm weakness, and limited movement in the shoulder, arm, elbow, wrist, and fingers (Fu & Rosedale, 2009; Fu, Axelrod, Cleland, et al., 2015). The experience of lymphedema symptoms has been linked to clinically relevant and detrimental outcomes, such as disability and psychological distress, both of which are known risk

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factors for breast cancer survivors’ poor quality of life (QOL). My program of research on lymphedema symptom science grew

out of my passion and desire to understand how patients manage lymphedema in their daily lives. Being a nurse who witnessed patients’ daily suffering from lymphedema, I felt it imperative to help patients relieve their symptoms. I was determined to pursue doctoral studies so I could systematically and scientifically investigate the phenomenon of managing lymphedema from a patient’s perspective.

During my doctoral program, I received funding from the National Institute of Health (NIH) to complete three descriptive phenomenology studies about the phenomenon of managing lymphedema in different ethnic groups, including white, Chinese American, and African American breast cancer survivors. These studies provide important evidence: (1) breast cancer survivors were distressed that no or limited education was given to them about lymphedema (Fu, 2005); (2) they described the lymphedema symptom experience as living with “a plethora of perpetual discomfort”; and (3) feasible self-care behaviors that were easy to integrate into a daily routine were central to lymphedema management in breast cancer survivors’ daily lives (Fu, 2010).

From my early research, I have purposefully built my research in two related lines of scientific inquiry: (1) lymphedema symptom science to discover the biological underpinnings of lymphedema symptomology; and (2) technology-driven interventions to develop pragmatic symptom assessment and self-care mobile health (mHealth) interventions to reduce the risk of lymphedema and optimize lymphedema management through symptom assessment and management. Starting with qualitative inquiry to understand patients’ daily symptom experience, I have developed and tested instruments to effectively assess symptoms (Fu et al., 2007; Fu, Axelrod, et al., 2008), pushed the boundaries of using cutting-edge technology for quantifying lymphedema (Fu, Axelrod, Guth, et al., 2015a), and conducted prospective studies to discover the biological pathway of lymphedema symptomology using a genomic approach (Fu, Conley, Axelrod, et al., 2016). My research has documented evidence that lymphedema symptoms are strongly associated with increased limb volume; symptoms alone can accurately detect

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lymphedema defined by greater than 200 mL limb volume difference, as well as evidence for patterns of obesity and lymph fluid level. Supported by NIH, my research findings reveal that lymphedema symptoms do have inflammatory biological mechanisms, evidenced by significant relationships with several inflammatory genes. This important study provides a foundation for precision assessment of heterogeneity of lymphedema phenotype and understanding the biological mechanism of each phenotype through the exploration of inherited genetic susceptibility, which is essential for finding a cure. Further exploration of investigative intervention in the context of genotype and gene expressions will advance our understanding of heterogeneity of lymphedema phenotype.

I also played a leadership role by conducting two studies supported by the Oncology Nursing Society and the International American Lymphedema Framework Project, documenting the need for oncology nurses to enhance their lymphedema knowledge and identify predictors for effective lymphedema care. This work identifies (1) the critical need for patient and clinician education about the importance of managing lymphedema symptoms, and (2) the critical need to manage lymphedema symptoms among breast cancer survivors through self-care behavioral interventions addressing physiological personal factors such as a compromised lymphatic system and body mass index (BMI). Based on the identified research gap, my team and I developed the Optimal Lymph Flow intervention, a face-to-face-nurse-delivery, patient- centered, feasible, and safe self-care program for managing lymphedema symptoms and reducing the risk of lymphedema (Fu, 2014). Grounded in research-driven self-care strategies, The Optimal Lymph Flow self-care program focuses on innovative self- care to promote lymph flow by empowering, rather than inhibiting, how breast cancer survivors live their lives. It features a safe, feasible 5-minute lymphatic exercise program that is easily integrated into the daily routine and easy to follow nutrition guidance. This program is effective in enhancing lymphedema risk reduction. The study provides initial evidence that translates research findings to support an emerging change in lymphedema care from a treatment-focus to a proactive risk reduction approach.

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Advancing lymphedema self-management using the Internet, a venue that offers universal access to web-based programs, was the next evidence-based innovation. Patient requests inspired my team to develop and pilot test a web-based mHealth system for lymphedema symptom assessment and management (Fu, Axelrod, Guth, et al., 2016a, 2016b). The Optimal Lymph Flow mHealth system (TOLF) is a technologically driven delivery model featuring patient-centered, web- and mobile-based educational and behavioral interventions focusing on safe, innovative, and pragmatic electronic assessment and self-care strategies for lymphedema management. Based on principles fostering accessibility, convenience, and efficiency of an mHealth system to enhance training and motivating assessment of and self-care for lymphedema symptoms, the TOLF innovation includes self-care skills to promote symptom management among breast cancer survivors at risk for lymphedema. TOLF is guided by the Model of Self-Care for Lymphedema Symptom Management program. Avatar video simulations provide a novel and standardized training system to assist in building self-care skills by visually showing how lymph fluid drains in the lymphatic system when performing lymphatic exercises. Patients can use the TOLF mHealth system to monitor and evaluate their lymphedema symptoms virtually anytime and anywhere. Upon the submission of their symptom report, patients immediately receive a symptom evaluation in terms of fluid accumulation and recommended self- care strategies.

Currently, I am the principal investigator for a web- and mobile- based pilot clinical trial funded by Pfizer to evaluate the effectiveness of TOLF mHealth intervention in managing chronic pain and symptoms related to lymph fluid accumulation (Fu, Axelrod, Guth, et al., 2016c). Collaborating with engineering expert Dr. Yao Wang, I am also the principal investigator for an R01 technology innovation research award from National Cancer Institute to develop a precision assessment of lymphedema risk from patient self-reported symptoms through machine learning, as well as to develop a Kinect-enhanced intervention training system, which can track patients’ movement and provide instant audio- visual feedback to patients, to enable them to follow prescribed

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movements more accurately, thereby making self-care interventions more effective. The innovation of precision risk prediction and intervention will be hosted in TOLF. This project has the potential to enhance lymphedema risk assessment and risk reduction for patients worldwide to achieve automated precision symptom assessment, detection, and prediction of lymphedema based on lymphedema symptom evaluation.

For more than a decade, my research has advanced symptom science, an important focus that has contributed to building an evidence-based applicable for nursing practice. The sustained funding for my research has allowed me to pioneer research innovation in genomics, biomarkers, and technology in symptom science research and to seamlessly build a program of research. From early on in my career, I have been building a global research network for symptom science, significant in today’s global health network world. The international funding for my research, in collaboration with researchers from China, South Korea, and Brazil has allowed me and my international team to build a global platform in symptom science research by translating and testing culturally appropriate symptom assessment instruments and interventions to relieve patients’ distressful symptoms (Fu et al., 2002; Fu, Xu, et al., 2008; Li et al., 2016; Paim et al., 2008; Ryu et al., 2013; Shi et al., 2016). The multidisciplinary nature of my work is an important key to success. I have worked collaboratively as a nurse scientist with researchers from many other fields, including medicine, surgery, radiation, pathology, engineering, molecular biology, biostatistics and physical therapy, front-line clinicians, hospital administrators, and patients. The findings derived from my research have informed policy related to development of national practice standards, the National Lymphedema Network position paper on screening and measurement for early detection of breast cancer related lymphedema, and the American Cancer Society guideline for breast cancer survivorship care. Cancer centers in the United States and China have implemented digital technology for patients to report lymphedema symptoms and lymphedema risk reduction programs to automate referrals for early detection and treatment of lymphedema. My ongoing research on mHealth will continue to impact health care delivery

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and future policy for cancer survivorship and lymphedema care.

References 1. Fu M. R. Breast cancer survivors’ intentions of managing

lymphedema. Cancer Nursing 2005;28(6):446-457 PMID:; 16330966.

2. Fu M. R. Cancer Survivors’ views of lymphoedema management. Journal of Lymphoedema 2010;5(2):39-48.

3. Fu M. R. Breast cancer-related lymphedema symptoms, diagnosis, risk reduction, and management. Available at: doi: 10.5306/wjco.v5.i3.241. World Journal of Clinical Oncology 2014;5(3):241-247 PMID:; 25114841.

4. Fu M. R., Rosedale M. Breast cancer survivors’ experience of lymphedema related symptoms. Journal of Pain and Symptom Management 2009;38(6):849-859 PMID:; 19819668.

5. Fu M. R., Rhodes V. A., Xu B. The Chinese translation The index of nausea, vomiting, and retching (INVR). Cancer Nursing 2002;25(2):134-140 PMID:; 11984101.

6. Fu M. R., McDaniel R. W., Rhodes V. A. Measuring symptom occurrence and symptom distress Development of the symptom experience index. Journal of Advanced Nursing 2007;59(6):623-634 PMID:; 17672849.

7. Fu M. R., Axelrod D., Haber J. Breast cancer-related lymphedema Information, symptoms, and risk reduction behaviors. Journal of Nursing Scholarship 2008;40(4):341-348 PMID:; 19094149.

8. Fu M. R., Xu B., Liu Y., et al. “Making the best of it” Chinese women’s experiences of adjusting to breast cancer diagnosis and treatment. Journal of Advanced Nursing 2008;63(2):155- 165 PMID:; 18537844.

9. Fu M. R., Axelrod D., Cleland C. M., et al. Symptom reporting in detecting breast cancer-related lymphedema. Breast Cancer Targets and Therapy 2015;7:345-352 Available at: doi: 10.2147/BCTT.S87854 (#1825502)PMID:; 26527899.

10. Fu M. R., Axelrod D., Guth A., et al. Patterns of obesity and lymph fluid level during the first year of breast cancer treatment a prospective study. Journal of Personalized Medicine

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http://dx.doi:%2010.2147/BCTT.S87854

2015;5(3):326-340 Available at: doi: 10.3390/jpm5030326 PMID:; 26404383.

11. Fu M. R., Axelrod D., Guth A. A., et al. Usability and feasibility of health IT interventions to enhance self-care for lymphedema symptom management in breast cancer survivors. Internet Interventions 2016;5:56-64.

12. Fu M. R., Axelrod D., Guth A. A., et al. mHealth self-care interventions managing symptoms following breast cancer treatment. mHealth 2016;2:28 Available at: doi: 10.21037/mhealth.2016.07.03 PMID:; 27493951.

13. Fu M. R., Axelrod D., Guth A. A., et al. A web- and mobile- based intervention for women treated for breast cancer to manage chronic pain and symptoms related to lymphedema Randomized clinical trial rationale and protocol. JMIR Research Protocol 2016;5(1):e7 Available at: http://www.researchprotocols.org/2017/1/e7/ Available at: doi: 10.2196/resprot.5104

14. Fu M. R., Conley Y. P., Axelrod D., et al. Precision assessment of heterogeneity of lymphedema phenotype, genotypes and risk prediction. The Breast 2016; Available at: doi: 10.1016/j.breast.2016.06.023 PMID: 27460425 (Epub ahead print)

15. Li K., Fu M. R., Zhao Q., et al. Translation and evaluation of Chinese version of the symptom experience index. International Journal of Nursing Practice 2016;22:556-564 Available at: doi: 10.1111/ijn.12464 PMIC:; 27560042.

16. Paim C. R., de Paula Lima E. D., Fu M. R., et al. Post lymphadenectomy complications and quality of life among breast cancer patients in Brazil. Cancer Nursing 2008;31(4):302-309 quiz 310–311. PMID:; 18600117.

17. Ryu E., Kim K., Choi S. Y., et al. The Korean version of the symptom experience index A psychometric study. International Journal of Nursing Studies 2013;50(8):1098-1107 Available at: doi: 10.1016/j.ijnurstu.2012.12.008 PMID: 23290258 (Epub 2013 Jan 3)

18. Shi S., Lu Q., Fu M. R., et al. Psychometric properties of the breast cancer and lymphedema symptom experience index The Chinese version. European Journal of Oncology Nursing

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http://dx.doi:%2010.21037/mhealth.2016.07.03

http://www.researchprotocols.org/2017/1/e7/

http://dx.doi:%2010.2196/resprot.5104

http://dx.doi:%2010.1016/j.breast.2016.06.023

http://dx.doi:%2010.1111/ijn.12464

http://dx.doi:%2010.1016/j.ijnurstu.2012.12.008

2015;20:10-16 Available at: doi: 10.1016/j.ejon.2015.05.002 pii: S1462-3889(15)00076-9PMID: 26071198 (Epub ahead print)

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CHAPTER 19

Strategies and tools for developing an evidence-based practice Carl A. Kirton

Learning outcomes

After reading this chapter, you should be able to do the following:

• Identify the key elements of a focused clinical question. • Discuss the use of databases to search the literature. • Screen a research article for relevance and validity. • Critically appraise study results and apply the findings to practice. • Make clinical decisions based on evidence from the literature combined with clinical expertise and patient preferences.

KEY TERMS

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confidence interval

electronic index

information literacy

likelihood ratio

negative likelihood ratio

negative predictive value

null value

number needed to treat

odds ratio

positive likelihood ratio

positive predictive value

prefiltered evidence

relative risk

relative risk reduction

sensitivity

specificity

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

In today’s environment of knowledge explosion, new investigations that potentially impact maintaining a practice that is based on evidence can be challenging. However, the development of an evidence-based nursing practice is contingent on applying new and important evidence to clinical practice. A few simple strategies will help you move to a practice that is evidence oriented. This chapter will assist you in becoming a more efficient and effective reader of the literature. Through a few important tools and a crisp understanding of the important components of a study, you will be able to use an evidence base to determine the merits of a study for your practice and for your patients.

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Consider the case of a nurse who uses evidence from the literature to support her practice: Sheila Tavares is a staff registered nurse who works in the prenatal clinic. She is teaching a class to pregnant women. Sheila teaches the future mothers that they should avoid sugar-sweetened beverages during pregnancy because it causes weight gain in the infant. The mothers want to know if artificially sweetened beverages (diet drinks) can be consumed. Sheila is not sure about the effect on infant weight and decides to consult the literature to answer this question.

Evidence-based strategy #1: Asking a focused clinical question Developing a focused clinical question will help Sheila focus on the relevant issue and prepare her for subsequent steps in the evidence- based practice process (see Chapters 1, 2, and 3). A focused clinical question using the PICO format (see Chapters 2 and 3) is developed by answering the following four questions:

1. What is the population I am interested in?

2. What is the intervention I am interested in?

3. What will this intervention be compared with? (Note: Depending on the study design, this step may or may not apply.)

4. How will I know if the intervention makes things better or worse (thus identifying an outcome that is measurable)?

As you recall from Chapters 2 and 3, the simple mnemonic PICO is used to develop a well-designed clinical question (Table 19.1). Using this format Sheila develops the following clinical question: Does consumption of artificially sweetened beverages [intervention] among pregnant women [population] affect infant body weight [outcome]?

TABLE 19.1 Using PICO to Formulate Clinical Questions

Patient What group do you want information on? Pregnant mothers

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population Intervention (or exposure)

What event do you want to study the effect of? Artificially sweetened beverages

Comparison Compared with what? Is it better or worse than no intervention at all, or than another intervention?

No artificially sweetened beverages

Outcomes What is the effect of the intervention? Infant body weight

Once a clinical question has been framed, it is useful to assign the question to a clinical category. These categories are predominately based on study designs that you read about in previous chapters. These categories help you search for the correct type of study to answer the clinical question. Being able to critique research is an important skill in evidence-based practice. Because clinicians may feel they lack the skills to critique published research, clinical category worksheets are available to guide your assessment of the extent to which the author implemented a well-designed study. It also helps you answer the important question of whether or not the study finding applies to your specific patient or group.

• Therapy category: When you want to answer a question about the effectiveness of a particular treatment or intervention, you will select studies that have the following characteristics:

• An experimental or quasi-experimental study design (see Chapter 9)

• Outcome known or of probable clinical importance observed over a clinically significant period of time

• For studies in this category, you use a therapy appraisal tool to evaluate the study. A therapy tool can be accessed at http://www.cebm.net/critical- appraisal/.

• Diagnosis category: When you want to answer a question about the usefulness, accuracy, selection, or interpretation of a particular measurement instrument or laboratory test, you will

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select studies that have the following characteristics:

• Cross-sectional/case control/retrospective study design (see Chapter 10) with people suspected to have the condition of interest

• Administration to the patient of both the new instrument or diagnostic test and the accepted “gold standard” measure

• Comparison of the results of the new instrument or test and the “gold standard”

• When studies are in this category, you use a diagnostic test appraisal tool to evaluate the article. A diagnostic tool can be accessed at http://www.cebm.net/critical-appraisal/.

• Prognosis category: When you want to answer a question about a patient’s likely course for a particular disease state or identify factors that may alter the patient’s prognosis, you will select studies that have the following characteristics:

• Nonexperimental, usually a longitudinal/cohort/prospective study of a particular group for a specific outcome or disease (see Chapter 10)

• Follow-up for a clinically relevant period of time (time is the exposure)

• Determination of factors in those who do and do not develop a particular outcome

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• For studies in this category, you use a prognosis appraisal tool (sometimes called a cohort tool) to evaluate the study. A prognosis tool can be accessed at http://www.cebm.net/critical-appraisal/.

• Harm category: When you want to determine the cause(s) of a particular symptom, problem, or disorder, you will select studies that have the following characteristics:

• Nonexperimental, usually longitudinal or retrospective (ex post facto/case control study designs over a clinically relevant period of time; see Chapter 10)

• Assessment of whether or not the patient has been exposed to the independent variable

• For studies in this category, you use a harm appraisal tool (sometimes called a case-control tool) to evaluate the study. A harm tool can be accessed at http://www.cebm.net/critical-appraisal/.

Evidence-based strategy #2: Searching the literature All the skills that Sheila needs to consult the literature and answer a clinical question are conceptually defined as information literacy. Your librarian is the best person to help you develop the necessary skills to become information literate. Part of being information literate is having the skills necessary to electronically search the literature to obtain the best evidence for answering your clinical question.

The literature is organized into electronic indexes or databases. Chapter 3 discusses the differences among databases and how to

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use these databases to search the literature. You can also learn how to effectively search databases through a web-based tutorial located at https://www.nlm.nih.gov/bsd/disted/nurses/cover.html.

Using the PubMed database (www.pubmed.gov), Sheila uses the search function and enters the term “artificial sweeteners AND pregnancy.” This strategy provides her with 6069 articles. Of course, there are too many articles for Sheila to review, and she does a quick scan and realizes that many of the articles do not answer her clinical question. Many are not research studies, and some articles have nothing to do with artificial sweeteners consumed by pregnant women. She recalls that the PubMed database has a filter option that helps her find citations that correspond to a specific clinical category. A careful perusal of the list of articles and a well-designed clinical question help Sheila select the key articles.

EVIDENCE-BASED PRACTICE TIP Prefiltered sources of evidence can be found in journals and electronic format. Prefiltered evidence is evidence in which an editorial team has already read and summarized articles on a topic and appraised its relevance to clinical care. Prefiltered sources include Clinical Evidence, available online at http://clinicalevidence.com/x/index.html and in print; Evidence- based Nursing, available online at http://ebn.bmj.com/ and in print; and The Joanna Briggs Institute, available online at http://joannabriggs.org.

Evidence-based strategy #3: Screening your findings Once you have searched and selected the potential articles, how do you know which articles are appropriate to answer your clinical question? This is accomplished by screening the articles for quality, relevance, and credibility by answering the following questions (Munn et al., 2015; Warren, 2015):

1. Is each study from a peer-reviewed journal? Studies published in peer-reviewed journals have had an extensive review and editing process (see Chapter 3).

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http://www.pubmed.gov

http://clinicalevidence.com/x/index.html

http://ebn.bmj.com/

http://joannabriggs.org

2. Are the setting and sample of each study similar to mine so that results, if valid, would apply to my practice or to my patient population (see Chapter 12)?

3. Are any of the studies sponsored by an organization that may influence the study design or results (see Chapter 13)?

Your responses to these questions can help you decide to what extent you want to appraise each article. Example: ➤ If the study population is markedly different from the one to which you will apply the results, you may want to consider selecting a more appropriate study. If an article is worth evaluating, you should use the category-specific tool identified in evidence-based strategy 1 to critically appraise the article.

Sheila reviews the abstract of the articles retrieved from her PubMed citation lists and selects the following article: “Association Between Artificially Sweetened Beverage Consumption During Pregnancy and Infant Body Mass Index” (Azad et al., 2016). This study was published in 2016 in JAMA Pediatrics, a peer-reviewed journal. This is an observational study that has a longitudinal/cohort design and is a prognosis clinical category study. Sheila reads the abstract and finds that the objective of the study was to observe maternal consumption of artificial sweeteners during pregnancy and evaluate its influence on infant body mass index, measured at 1 year of age. The population and setting of the study were mothers from Canada. The study authors received funding for this investigation from the Children’s Hospital Research Institute of Manitoba and supported by the Canadian Institute of Health Research and the Allergy, Genes and Environment Network of Centres of Excellence. Sheila finds that there were no funding or conflict of interest issues noted; she decides that this study is worth evaluating and selects the prognosis category tool.

HELPFUL HINT If you are selecting a therapy study, consider both studies with significant findings (treatment is better) and studies with nonsignificant findings (treatment is worse or there is no difference). Studies reporting nonsignificant findings are more

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difficult to find but are equally important.

Evidence-based strategy #4: Appraise each article’s findings Applying study results to individual patients or to a specific patient population and communicating study findings to patients in a meaningful way are the hallmark of evidence-based practice. Common evidence-based practice conventions that researchers and research consumers use to appraise and report study results are identified by four different types of clinical categories: therapy, diagnosis (sensitivity and specificity), prognosis, and harm. The language common to meta-analysis was discussed in Chapter 11. An appraisal tool for a meta-analysis (systematic review) can be found at http://www.cebm.net/critical-appraisal/. Familiarity with these evidence-based practice clinical categories will help Sheila search for, screen, select, and appraise articles appropriate for answering clinical questions.

Therapy category In articles that belong to the therapy category (experimental, randomized controlled trials [RCTs], or intervention studies), investigators attempt to determine if a difference exists between two or more interventions. The evidence-based language used in a therapy article depends on whether the numerical values of the study variables are continuous (a variable that measures a degree of change or a difference on a range, such as blood pressure) or discrete, also known as dichotomous (measuring whether or not an event did or did not occur, such as the number of people diagnosed with type 2 diabetes) (Table 19.2).

TABLE 19.2 Difference Between Continuous and Discrete Variables

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Generally speaking, therapy studies measure outcomes using discrete variables and present results as measures of association as relative risk (RR), relative risk reduction, or odds ratio (OR), as illustrated in Table 19.3. Understanding these measures is challenging but particularly important because they are used by all health care providers to communicate with each other and to patients the risks and benefits or lack of benefits of a treatment (or treatments). They are particularly useful to nurses, as they inform decision making that validates current practice or provides evidence that supports the need for a clinical practice change.

TABLE 19.3 Measures of Association for Trials That Report Discrete Outcomes

Measure of Association Definition Comment

Relative risk, also called risk ratio

Compares the probability of the outcome in each group.

The RR is calculated by dividing the EER/CER.

If CER and EER are the same, the RR = 1 (this means there is no difference between the experimental and control group outcomes). If the risk of the event is reduced in EER compared with CER, RR < 1. The further to the left of 1 the RR is, the greater the event, the less likely the event is to occur. If the risk of an event is greater in EER compared with CER, RR > 1. The further to the right of 1 the RR is, the greater the event is likely to occur.

Relative risk reduction

This value tells us the reduction in risk in relative terms. The RRR is an estimate of the percentage of baseline risk that is removed as a result of the therapy; it is calculated as the ARR between the treatment and control groups divided by the absolute risk among patients in the control group.

Percent reduction in risk that is removed after considering the percent of risk that would occur anyway (the control group’s risk), calculated as EER − CER/CER

OR Estimates the odds of an event If the OR = 1.0, this means there is no difference

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occurring. The OR is usually the measure of choice in the analysis of nonexperimental design studies. It is the probability of a given event occurring to the probability of the event not occurring.

in the probability of an event occurring between the experimental and control group outcomes. If the probability of the event is reduced between groups, the OR is < 1.0 (i.e., the event is less likely in the treatment group than the control group). If the odds of an event is increased between groups, the OR > 1.0 (i.e., the event is more likely to occur in the treatment group than the control group).

CER, Control group event rate; EER, experimental group event rate; OR, odds ratio; RR, relative risk; RRR, relative risk reduction.Note: When the experimental treatment increases the probability of a good outcome (e.g., satisfactory hemoglobin A1c levels), there is a benefit increase rather than a risk reduction. The calculations remain the same.

Example: ➤ Haas and colleagues (2015) examined a smoking cessation intervention among individuals of lower socioeconomic status (low-SES). Investigators randomized the smokers to usual care from their health care team or to an intervention group that received care from a tobacco treatment specialist along with other resources. Abstinence was measured 9 months after randomization. The data revealed that smokers in the intervention group were more likely to report quitting than individuals in the control group (OR, 2.5; 95% CI, and 1.5 to 4.0) (Haas et al., 2015). This means that those receiving care from a tobacco treatment specialist and other resources were two and a half times more likely to quit smoking than those who received usual care.

Two other measures can help you determine if the reported or calculated measures are clinically meaningful. They are the number needed to treat (NNT) and the confidence interval (CI). These measures allow you to make inferences about how realistically the results about the effectiveness of an intervention can be generalized to individual patients and to a population of patients with similar characteristics.

The NNT is a useful measure for determining intervention effectiveness and its application to individual patients. It is defined as the number of people who need to receive a treatment (or the intervention) in order for one patient to receive any benefit. The NNT may or may not be reported by the study researchers but is easily calculated. Interventions with a high NNT require considerable expense and human resources to provide any benefit or to prevent a single episode of the outcome, whereas a low NNT

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is desirable because it means that more individuals will benefit from the intervention. In the Haas and colleagues (2015) study that studied smoking cessation interventions, the NNT = 10. The interpretation for the NNT is that we would have to provide 10 patients with the study intervention for one of them to benefit from the intervention. In other words, 1 in 10 patients will quit smoking. This gives us a very different and clinically useful perspective of the intervention; obviously the lower the NNT, the better the intervention.

The second clinically useful measure is the CI. The CI is a range of values, based on a random sample of the population that often accompanies measures of central tendency and measures of association and provides you with a measure of precision or uncertainty about the sample findings. Typically investigators record their CI results as a 95% degree of certainty; at times you may also see the degree of certainty recorded as 99%. Journals often include CIs as one of the statistical methods used to interpret study findings. Even when CIs are not reported, they can be easily calculated from study data. The method for performing these calculations is widely available in statistical texts.

Returning to the Haas and colleagues (2015) study, it was found that the OR for smoking cessation for study participants who received the intervention was 2.5. The authors accompanied this data with a 95% CI so that the OR with CI is reported as 2.5 (1.5 to 4.0). The CI, the number in parentheses, helps us place the study results in context for all patients similar to those in the study (generalizability).

As a result of the calculated CI for the Haas and colleagues (2015) study, it can be stated that in adults who smoke (the study population) we can be 95% certain that when they receive counseling, nicotine replacement therapy, and community based resources, the odds of abstinence are between 1.5 and 4.0; this is the range of effectiveness of the intervention. Recall that the odds of something happening is the ratio between success and failure (or something happening or not happening). Thus, at a minimum, you can expect that with the intervention treatment the odds of smoking cessation are one and half times greater than the odds of continued smoking. At best, you can expect that with the intervention the

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odds of smoking cessation are four times greater than the odds of continued smoking.

Another unique feature of the CI is that it can tell us whether or not the study results are statistically significant. When an experimental value is obtained that indicates there is no difference between the treatment and control groups (e.g., no difference in the abstinence rates in smokers who received the intervention and those who didn’t), we label that value “the value of no effect,” or the null value. The value of no effect varies according to the outcome measure.

When examining a CI, if the interval does not include the null value, the effect is said to be statistically significant. When the CI does contain the null value, the results are said to be nonsignificant because the null value represents the value of no difference—that is, there is no difference between the treatment and control groups. In studies of equivalence (e.g., a study to determine if two treatments are similar) this is a desired finding, but in studies of superiority or inferiority (e.g., a study to determine if one treatment is better than the other), this is not the case.

The null value varies depending on the outcome measure. For numerical values determined by proportions/ratio (e.g., RR, OR), the null value is “1.” That is, if the CI does not include the value “1,” the finding is statistically significant. If the CI does include the value “1,” the finding is not statistically significant. If we examine an actual result from Table 3 in Appendix A, we can see an excellent demonstration of this concept; the authors report the factors associated with noncompletion of a vaccination series. The factors are accompanied by ORs and CIs. Can you identify which factors are significant and which are not by examining the CIs? For numerical values determined by a mean difference between the score in the intervention group and the control group (usually with continuous measures), the null value is zero. In this case if the CI includes the null value of zero, the result is not statistically significant. If the CI does not include the null value of zero, the result is statistically significant, as illustrated in Fig. 19.1A–D.

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FIG 19.1 A, Confidence interval (CI) (nonsignificant) for

a hypothesized trial comparing the ratio of events in the experimental group and control group. B, CI

(significant) for a hypothesized trial comparing the ratio of events in the experimental group and control group. C, CI (nonsignificant) for a hypothesized control trial comparing the difference between two treatments. D,

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CI (significant) for a hypothesized control trial comparing the difference between two treatments.

Diagnosis articles In studies that answer clinical questions of diagnosis, investigators study the ability of screening or diagnostic tests, or components of the clinical examination to detect (or not detect) disease when the patient has (or does not have) the particular disease of interest. The accuracy of a test, or technique, is measured by its sensitivity and specificity (Table 19.4).

TABLE 19.4 Reporting the Outcome Results of Diagnostic Trials

FN, False negative; FP, false positive; LR, likelihood ratio; NPV, negative predictive value; PPV, positive predictive value; TN, true negative; TP, true positive.

Sensitivity is the proportion of those with disease who test positive; that is, sensitivity is a measure of how well the test detects disease when it is really there—a highly sensitive test has few false negatives. Specificity is the proportion of those without disease who test negative. It measures how well the test rules out disease when it is really absent; a specific test has few false positives.

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Sensitivity and specificity have some deficiencies in clinical use, primarily because sensitivity and specificity are merely characteristics of the performance of the test.

Describing diagnostic tests in this way tells us how good the test is, but what is more useful is how well the test performs in a particular population with a particular disease prevalence. This is important because in a population in which a disease is quite prevalent, there are fewer incorrect test results (false positives) as compared with populations with low disease prevalence, for which a positive test may truly be a false positive. Predictive values are a measure of accuracy that accounts for the prevalence of a disease. As illustrated in Table 19.4, a positive predictive value (PPV) expresses the proportion of those with positive test results who truly have disease, and a negative predictive value (NPV) expresses the proportion of those with negative test results who truly do not have disease. Let us observe how these characteristics of diagnostic tests are used in nursing practice.

Nurses developed a four-step tool to screen stroke patients for dysphagia (difficulty swallowing) (Cummings et al., 2015). A total of 49 patients were evaluated following their stroke. An experienced speech language therapist evaluated all patients for dysphagia using standard objective methods and determined if dysphagia was present or absent. Nurses used the four-step dysphagia tool (the new test) to evaluate whether or not dysphagia was present or absent. The nurse’s dysphagia tool had a sensitivity of 89% and a specificity of 90%. Table 19.5 shows how sensitivity and specificity are easily calculated and how these numbers are interpreted. Sensitivity and specificity apply to the diagnostic test and tell what portion of the people will have a positive or negative test. Clinicians and patients often want to know when a test is negative or positive what the probability is of actually having the disease. The PPV and NPV answer these question. Table 19.5 shows how the PPV and NPV are calculated. In the study, the probability of having dysphagia when screened positive on the dysphagia tool is 84%, and the probability of not having dysphagia when screened negative on the dysphagia tool is 93%.

TABLE 19.5

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Results for Dysphagia Screen With a Standardized Speech and Language Pathology Screen and Nurse Dysphagia Screen

FN, False negative; FP, false positive; LR, likelihood ratio; TN, true negative; TP, true positive.

Combining sensitivity, specificity, PPV, NPV, and prevalence to make clinical decisions based on the results of testing is cumbersome and complex. Fortunately, all of these measures can be described by one number, the likelihood ratio (LR). This value takes a pretest probability, and when the test is applied (either a positive test or a negative test) gives us a new probability. In other words, it tells us how much more we are certain the patient has the disease as a result of the test. As you can see from Table 19.5, the LR is calculated from the test’s sensitivity and specificity, and with more training in determining disease prevalence (or pretest probability), you could actually state the numerical probability that a patient might have a disease based on the test’s LR.

As illustrated in Table 19.6, a test with a large positive likelihood ratio (e.g., greater than 10), when applied, provides the clinician with a high degree of certainty that the patient has the suspected disorder. Conversely, tests with a very low positive likelihood ratio (e.g., less than 2), when applied, provide you with little to no

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change in the degree of certainty that the patient has the suspected disorder.

TABLE 19.6 How Much Do Likelihood Ratio Changes Affect Probability of Disease?

Likelihood Ratio Positive

Likelihood Ratio Negative

Probability That Patient Has (LR) or Does Not Have (LR)

LR > 10 LR < 0.1 Large LR 5–10 LR 0.1–0.2 Moderate LR 2–5 LR 0.2–0.5 Small LR < 2 LR > 0.5 Tiny LR = 1.0 — Test provides no useful information

LR, Likelihood ratio.

When a test has a LR of 1 (the null value), the test will not contribute to decision making in any meaningful way and should not be used. A test with a large negative likelihood ratio provides the clinician with a high degree of certainty that the patient does not have the disease. The further away from 1 the negative LR is, the better the test will be for its use in ruling out disease (i.e., there will be few false negatives). More and more journal articles require authors to provide test LRs; they may also be available in secondary sources.

Prognosis articles In studies that answer clinical questions of prognosis, investigators conduct studies in which they want to determine the outcome of a particular disease or condition. Prognosis studies can often be identified by their longitudinal cohort design (see Chapter 10). At the conclusion of a longitudinal study, investigators statistically analyze data to determine which factors are strongly associated with the study outcomes, usually through a technique called multivariate regression analysis or simply multiple regression (see Chapter 16).

From this advanced statistical analysis, several factors are usually identified that predict the probability of developing the outcome or a particular disease. The probability is called an odds ratio. The OR (see Table 19.3) indicates how much more likely certain

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independent variables (factors) predict the probability of developing the dependent variable (outcome or disease).

Returning to our case, Sheila reviews a prospective cohort, longitudinal study of pregnant mothers. The authors collected data on maternal consumption of artificially sweetened beverages during pregnancy. At 1 year of age infants were weighed; 5% of the infants were overweight. Daily consumption of artificially sweetened beverages was significantly associated with having an infant overweight at 1 year of age (OR, 2.19; 95% CI, 1.23 to 3.88). The interpretation of the ORs is described in Table 19.7. A higher OR indicates a greater probability of the development of the outcome. An OR below 1 indicates that the probability of developing the outcome is reduced. Also recall from our discussion that whenever we are appraising CIs (to determine statistical significance) we have to examine the CI for the presence of the null value. Because we are evaluating a “ratio,” the null value is equal to 1. Thus any OR CI interval that contains a null value of 1 is not a significant finding. Looking at the CI given previously, we can see that all of the values are above 1 and this does not include the null value; as such, this is a statistically significant finding.

TABLE 19.7 Measures of Association for Trials That Report Discrete Outcomes

Using prognostic information with an evidence-based lens helps the nurse and patient focus on reducing factors that may lead to disease or disability. It also helps the nurse with providing education and information to patients and their families regarding the course of the condition.

HIGHLIGHT

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It is important that all members of your team understand the importance of being able to read tables included in research reports. The information you need to answer your clinical question should be contained in one or more of the tables.

Harm articles In studies that answer clinical questions of harm, investigators want to determine if an individual has been harmed by being exposed to a particular event. Harm studies can be identified by their case- control design (see Chapter 10). In this type of study, investigators select the outcome they are interested in (e.g., pressure ulcers), and they examine if any one factor explains those who have and do not have the outcome of interest. The measure of association that best describes the analyzed data in case-control studies is the OR.

Tomlinson and colleagues (2016) used a case-control study design to identify factors that contribute to delirium in hospitalized patients (incident delirium). Table 19.8 presents data examining factors that might be associated with incident delirium.

TABLE 19.8 Comparisons of Predisposing Risk Factors for Incident Delirium

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From Tomlinson, E. J., Phillips, N., Mohebbi, M., & Hutchinson, A. M. (2016). Risk factors for incident delirium in an acute general medical setting: a retrospective case- control study. Journal of Clinical Nursing. doi:10.1111/jocn.13529.

The interpretation of the data is relatively straightforward. You can see from the table that most of the ORs are greater than 1. Examining the table, you can see being >80 years of age, having anemia, having chronic obstructive airway disease, and many other factors are associated with the development of incident delirium while hospitalized. Based on the previous discussion of CIs you know that the CI indicates how well the study findings can be generalized. A quick review of the CIs demonstrates that some of these factors are not statistically significant findings; for example, having anemia and cancer are not statistically significant findings.

Harm data, with its measure of probabilities, help you identify factors that may or may not contribute to an adverse or beneficial outcome. This information will be useful for the nursing plan of care, program planning, or patient and family education.

Meta-analysis Meta-analysis statistically combines the results of multiple studies (usually RCTs) to answer a focused clinical question through an objective appraisal of carefully synthesized research evidence. The strength of a meta-analysis lies in its use of statistical analysis to summarize studies. As discussed in Chapter 11:

• A clinical question is used to guide the process.

• All relevant studies, published and unpublished, on the question are gathered using pre-established inclusion and exclusion criteria to determine the studies to be used in the meta-analysis.

• At least two individuals independently assess the quality of each study based on pre-established criteria.

• Statistically combine the results of individual studies and present a balanced and impartial quantitative and narrative evidence summary of the findings that represents a “state-of-the-science” conclusion about the strength, quality, and consistency of evidence supporting benefits and risks of a given health care

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practice (García-Perdomo, 2016).

A methodologically sound meta-analysis is more likely than an individual study to be successful in identifying the true effect of an intervention because it limits bias. An RR or, more commonly, the OR is the statistic of choice for use in a meta-analysis (see Tables 19.3 and 19.7). Meta-analysis can also report on continuous data; typically the mean difference in outcomes will be reported.

The typical manner of displaying data in a meta-analysis is by a pictorial representation known as a blobbogram, accompanied by a summary measure of effect size in RR, OR, or mean difference (see Chapter 11). Let us see how blobbograms (sometimes called forest plots) and ORs are used to summarize the studies in a systematic review by practicing with the data from the article in Appendix E. Box A lists nine studies that looked at all-cause mortality. The next four columns list the number of deaths in the nursing group and the nonnursing group (control group). The next column assigns a weight to each study based on the number of subject participants. The larger the sample size, the greater the weight assigned to the study for analysis purposes. In the next column you will note the OR for each of the studies along with its CI. At the end of the table you see a horizontal line represents each trial in the analysis. The findings from each individual study are represented as a blob or square (the measured effect) on the horizontal line. You may also note that each blob or square is a bit different in size. This size reflects the weight the study has on the overall analysis. This is determined by the sample size and the quality of the study. The width of the horizontal line represents the 95% CI. The vertical line is the line of no effect (i.e., the null value), and we know that when the statistic is the OR, the null value is 1.

HELPFUL HINT When appraising the different review types, it is important to be able to distinguish a meta-analysis that analytically assesses studies, from a systematic review that appraises the literature with or without an analytic approach, to an integrative review that also appraises and synthesizes the literature but without an analytic process (see Chapter 11).

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When the CI of the result (horizontal line) touches or crosses the line of no effect (vertical line), we can say that the study findings did not reach statistical significance. If the CI does not cross the vertical line, we can say that the study results reached statistical significance. Can you tell which studies are significant and which ones are not? (Hint: There are only two significant studies.)

You will also notice other important information and additional statistical analyses that may accompany the blobbogram table, such as a test to determine how well the results of each of the individual trials are mathematically compatible (heterogeneity) and a test for overall effect. The reader is referred to a book of advanced research methods for discussion of these topics.

A diamond represents the summary ratio for all studies combined. There is a subtotal diamond for the effect of a nurse led clinic on all-cause mortality. In this case, after statistically pooling the results of each of the controlled trials, it shows that these studies, statistically combined, overall favor the treatment (the nurse led clinic). You will note that the diamond does not touch the line of no effect and as such is a statistically significant finding. The overall interpretation is that a nurse led clinic reduces all-cause mortality in patients with cardiovascular disease. If this is a methodologically sound review, it can be used to support or change nursing practice or specific nursing interventions. A simple tool to help determine whether or not a systematic review is methodologically sound can be found at http://www.cebm.net/critical-appraisal/.

EVIDENCE-BASED PRACTICE TIP When answering a clinical question, check to see if a Cochrane review has been performed. This will save you time searching the literature. A Cochrane review is a systematic review that primarily uses meta-analysis to investigate the effects of interventions for prevention, treatment, and rehabilitation in a health care setting or on health-related disorders. Most Cochrane reviews are based on RCTs, but other types of evidence may also be taken into account, if appropriate. If the data collected in a review are of sufficient quality and similar enough, they are summarized statistically in a meta-analysis. You should always check the Cochrane website, www. cochrane.org, to see if a review has been published on the

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http://www.cochrane.org

topic of interest.

Evidence-based strategy #5: Applying the findings Evidence-based practice is about integrating individual clinical expertise and patient preferences with the best external evidence to guide clinical decision making (Sackett et al., 1996). With a few simple tools (see the links listed earlier in this chapter) and some practice, your day-to-day practice can be more evidence based. We know that using evidence in clinical decision making by nurses and all other health care professionals interested in matters associated with the care of individuals, communities, and health systems is increasingly important to achieving quality patient outcomes and cannot be ignored. Let us see how Sheila uses evidence to answer the expectant mothers’ question.

Sheila critically appraises the article. This was a cohort study of mother–infant dyads in Canada. Women in the study completed dietary assessments during pregnancy, and their infants’ weights were measured at 1 year of age. Twenty-six percent of the women consumed artificially sweetened beverages; 5% of the women drank these beverages daily. Compared with no consumption, daily consumers have a twofold higher risk of having an overweight infant at 1 year of age (OR, 2.19; 95% CI 1.23 to 3.88). Sheila knows that an OR greater than 1 means that there was an increase in the number of overweight babies in the consumers of artificially sweetened beverages relative to the control group (nonconsumers). She also examines the CIs and notes that the range does not include the null value of 1, making this finding statistically significant. Sheila is surprised by the study’s findings and plans to examine other studies on this subject. She will report back to the mothers that they should avoid drinking artificially sweetened beverages, as this is associated with weight gain in their baby at 1 year. She will be sure to tell the mothers that this effect was measured at 1 year; she does not know if this effect remains beyond the first year of life. She will also tell the mothers that although the findings are statistically significant there could be other factors that were not examined that could have influenced study results, such as

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smoking, diet quality, and breastfeeding duration.

Summary Clinical questions about nursing practice occur frequently; these questions come from nursing assessments, planning, and interventions; from patients; and from questions about the effectiveness of care. Nurses need to think about how they can effectively review the literature for research evidence to answer a clinical question. It is important for nurses and all health care providers and the teams they are part of to be competent at using critical appraisal tools as a resource to evaluate clinical studies that can be used to inform clinical decision making about whether research findings are applicable to clinical practice. Nurses should understand and be able to interpret common measures of association, such as the OR and CIs, and apply this understanding to how data can be used to support current “best practices” or recommend changes in clinical care.

Key points • Asking a focused clinical question using the PICO approach is an

important evidence-based practice tool.

• Several types of evidence-based practice clinical categories used for evaluating research studies are therapy, diagnosis, prognosis, and harm. These categories focus on development of the clinical question, the literature search, and critical appraisal of research.

• An efficient and effective literature search, using information literacy skills, is critical in locating evidence to answer the clinical question.

• Sources of evidence (e.g., articles, evidence-based practice guidelines, evidence-based practice protocols) must be screened for relevance and credibility.

• Appraising the evidence generated by a study using an accepted critiquing tool is essential in determining the strength, quality,

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and consistency of evidence offered by a study.

• Studies that belong to the therapy category are designed to determine if a difference exists between two or more treatments.

• Studies that belong to the diagnosis category are designed to investigate the ability of screening or diagnostic tests, tools, or components of the clinical examination to detect whether or not the patient has a particular disease using LRs.

• Studies in the prognosis category are designed to determine the outcomes of a particular disease or condition.

• Studies in the harm category are designed to determine if an individual has been harmed by being exposed to a particular event.

• Meta-analysis is a research method that statistically combines the results of multiple studies (usually RCTs) and is designed to answer a focused clinical question through objective appraisal of synthesized evidence.

Critical thinking challenges • How would you use the PICO format to formulate a clinical

question? Provide a clinical example.

• How can the nurse determine if reported or calculated measures in a research study are clinically significant enough to inform evidence-based clinical decisions?

• How can a nurse in clinical practice determine whether the strength and quality of evidence provided by a diagnostic tool is sufficient to justify ordering it as a diagnostic test? Provide an example of a diagnostic test used to diagnose a specific illness.

• How could your interprofessional QI team use the PICO format to formulate a clinical question? Provide a clinical example from the QI data from your unit.

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• Choose a meta-analysis from a peer-reviewed journal and describe how you as a nurse would use the findings of this meta- analysis in making a clinical decision about the applicability of a nursing intervention for your specific patient population and clinical setting.

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

References 1. Azad M. B, Sharma A. K, de Souza R. J, et al. Association

between artificially sweetened beverage consumption during pregnancy and infant body mass index. JAMA Pediatrics 2016;170(7):662-670 Available at: doi:10.1001/jamapediatrics.2016.0301

2. Cummings J., Soomans D., O’Laughlin J., et al. Sensitivity and specificity of a nurse dysphagia screen in stroke patients. Medsurg Nursing 2015;24(4):219-263.

3. García-Perdomo H. A. Evidence synthesis and meta-analysis a practical approach. International Journal of Urological Nursing 2016;10(1):30-36 Available at: doi:10.1111/ijun.12087

4. Haas J. S, Linder J. A, Park E. R, et al. Proactive tobacco cessation outreach to smokers of low socioeconomic status a randomized clinical trial. JAMA Internal Medicine 2015;175(2):218-226 Available at: doi:10.1001/jamainternmed.2014.6674

5. Munn Z., Lockwood C., Moola S. The development and use of evidence summaries for point of care information systems a streamlined rapid review approach. Worldviews on Evidence Based Nursing 2015;12(3):131-138.

6. Sackett D. L, Rosenberg W. M. C., Gray J. A. M., et al. Evidence based medicine what it is and what it isn’t. British Medical Journal 1996;312:71-72.

7. Tomlinson E. J, Phillips N., Mohebbi M., et al. Risk factors for incident delirium in an acute general medical setting a

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http://evolve.elsevier.com/LoBiondo/

http://dx.doi:10.1001/jamapediatrics.2016.0301

http://dx.doi:10.1111/ijun.12087

http://dx.doi:10.1001/jamainternmed.2014.6674

retrospective case-control study. Journal of Clinical Nursing 2016; Available at: doi:10.1111/jocn.13529

8. Warren E. Evidence-based practice. Practice Nurse 2015;45(12):27-32.

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http://dx.doi:10.1111/jocn.13529

CHAPTER 20

Developing an evidence-based practice Marita Titler

Learning outcomes

After reading this chapter, you should be able to do the following:

• Differentiate among conduct of nursing research, evidence-based practice, and translation science. • Describe the steps of evidence-based practice. • Describe strategies for implementing evidence-based practice changes. • Identify steps for evaluating an evidence-based change in practice. • Use research findings and other forms of evidence to improve the quality of care.

KEY TERMS

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conduct of research

dissemination

evaluation

evidence-based practice

evidence-based practice guidelines

knowledge-focused triggers

opinion leaders

problem-focused triggers

translation science

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

Evidence-based health care practices are available for a number of conditions. However, these practices are not always implemented in care delivery settings. Variation in practices abounds, and availability of high-quality research does not ensure that the findings will be used to affect patient outcomes (Agency for Healthcare Research and Quality [AHRQ], 2015; Titler et al., 2011, 2013). The use of evidence-based practices (EBPs) is now an expected standard, as demonstrated by regulations from the Centers for Medicare and Medicaid Services (CMS) regarding nonpayment for hospital acquired events such as injury from falls, Foley catheter-associated urinary tract infections, and stage 3 and 4 pressure ulcers. These practices all have a strong evidence base and, when enacted, can prevent these events. However, implementing such evidence-based safety practices is a challenge and requires the use of strategies that address the systems of care, individual practitioners, and senior leadership, and ultimately change health care cultures to be EBP environments (Dockham et al., 2016; Moore et al., 2014; Newhouse et al., 2013; Titler et al., 2016).

Translation of research into practice (TRIP) is a multifaceted, systemic process of promoting adoption of EBPs in delivery of health care services that goes beyond dissemination of evidence-

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based guidelines (Berwick, 2003; Rogers, 2003). Dissemination activities take many forms, including publications, conferences, consultations, and training programs, but promoting knowledge uptake and changing practitioner behavior requires active interchange with those in direct care (Titler et al., 2013, 2016). This chapter presents an overview of EBP and the process of applying evidence in practice to improve patient outcomes.

Overview of evidence-based practice The relationships among conduct, dissemination, and use of research are illustrated inFig. 20.1. Conduct of research is the analysis of data collected from subjects who meet study inclusion and exclusion criteria for the purpose of answering research questions or testing hypotheses. The conduct of research includes dissemination of findings via research reports in journals and at scientific conferences.

FIG 20.1 The model of the relationship among conduct,

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dissemination, and use of research. Source: (From Weiler, K., Buckwalter, K., & Titler, M. [1994]. Debate: Is nursing research used in

practice? In J. McCloskey, & H. Grace [Eds.], Current issues in nursing [4th ed.]. St Louis, MO: Mosby.)

Evidence-based practice is the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values and circumstances to guide health care decisions (Straus et al., 2011; Titler, 2014). Best evidence includes findings from randomized controlled trials, evidence from other scientific methods such as descriptive and qualitative research, as well as information from case reports and scientific principles. When adequate research evidence is available, practice should be guided by research evidence in conjunction with clinical expertise and patient values. In some cases, however, a sufficient research base may not be available, and health care decision making is derived principally from evidence sources such as scientific principles, case reports, and quality improvement projects. As illustrated in Fig. 20.1, the application of research findings in practice may not only improve quality care but also create new and exciting questions to be addressed via conduct of research.

In contrast, translation science focuses on testing implementation interventions to improve uptake and use of evidence to improve patient outcomes and population health, as well as to explicate what implementation strategies work for whom, in what settings, and why (Titler, 2014). An emerging body of knowledge in translation science provides an empirical base for guiding the selection of implementation strategies to promote adoption of EBPs in real-world settings (Dobbins et al., 2009; Titler et al., 2016). Thus EBP and translation science, though related, are not interchangeable terms; EBP is the actual application of evidence in practice (the “doing of” EBP), whereas translation science is the study of implementation interventions, factors, and contextual variables that effect knowledge uptake and use in practices and communities.

Models of evidence-based practice Multiple models of EBP and translation science are available (Milat et al., 2015; Rycroft-Malone & Bucknall, 2010; Schaffer et al., 2013;

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Wilson et al., 2010). Common elements of these models are:

• Syntheses of evidence

• Implementation

• Evaluation of the impact on patient care

• Consideration of the context/setting in which the evidence is implemented.

Although review of these models is beyond the scope of this chapter, implementing evidence in practice must be guided by a conceptual model to organize the strategies being used and to clarify extraneous variables (e.g., behaviors, facilitators) that may influence adoption of EBPs (e.g., organizational size, characteristics of users).

The iowa model of evidence-based practice An overview of the Iowa Model of Evidence-Based Practice as an example ➤ of an EBP model is illustrated in Fig. 20.2. This model has been widely disseminated and adopted in academic and clinical settings (Titler et al., 2001).

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FIG 20.2 The Iowa model of evidence-based practice to promote quality care. Source: (From Titler, M. G., Kleiber, C.,

Steelman, V. J., et al. [2001]. The Iowa model of evidence-based practice to promote quality care. Critical Care Nursing Clinics of North America,

13[4]:497–509.)

In this model, knowledge- and problem-focused “triggers” lead staff members to question current nursing practices and whether patient care can be improved through the use of research findings. If through the process of literature review and critique of studies, it is found that there is not a sufficient number of scientifically sound studies to use as a base for practice, consideration is given to

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conducting a study. Findings from such studies are then combined with findings from existing scientific knowledge to develop and implement these practices. If there is insufficient research to guide practice and conducting a study is not feasible, other types of evidence (e.g., case reports, scientific principles, theory) are used and/or combined with available research evidence to guide practice. Priority is given to projects in which a high proportion of practice is guided by research evidence. Practice guidelines usually reflect research and nonresearch evidence and therefore are called evidence-based practice guidelines (NAM, formally Institute of Medicine [IOM], 2011; see Chapter 11).

Recommendations for practice are developed based on evidence synthesis. The recommended practices, based on evidence, are compared with current practice, and a decision is made about the necessity for a practice change. If a practice change is warranted, changes are implemented using a planned change process. The practice is first implemented with a small group of patients, and a pilot evaluation is conducted. The EBP is then refined based on evaluation data, and the change is implemented with additional patient populations for which it is appropriate. Patient/family, staff, and fiscal outcomes are monitored.

Steps of evidence-based practice The Iowa Model of Evidence-Based Practice to Promote Quality Care (Titler et al., 2001; see Fig. 20.2), in conjunction with Rogers’s diffusion of innovations model (Rogers, 2003), provides steps for actualizing EBP. A team approach is most helpful in fostering a specific EBP.

Selection of a topic The first step is to select a topic. Ideas for EBP come from several sources categorized as problem- and knowledge-focused triggers. Problem-focused triggers are those identified by staff through quality improvement, risk surveillance, benchmarking data, financial data, or recurrent clinical problems. An example of a problem-focused trigger is increased incidence of central line occlusion in pediatric oncology patients.

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Knowledge-focused triggers are ideas generated when staff read research, listen to scientific papers at conferences, or encounter EBP guidelines published by federal agencies or specialty organizations. This includes those EBPs that CMS expects are implemented in practice, and CMS now bases reimbursement of care on adherence to indicators of the EBPs. Examples include treatment of heart failure, community-acquired pneumonia, and prevention of nosocomial pressure ulcers. Each of these topics includes a nursing component, such as discharge teaching, instructions for patient self- care, or pain management. Sometimes topics arise from a combination of problem- and knowledge-focused triggers, such as the length of bed rest time after femoral artery catheterization. In selecting a topic, it is essential to consider how the topic fits with organization, department, and unit priorities to garner support from leaders within the organization and the necessary resources to successfully complete the project. Criteria to consider when selecting a topic are outlined in Box 20.1. BOX 20.1 Selection Criteria for an Evidence-Based Practice Project

1. Priority of the topic for nursing and for the organization

2. Magnitude of the problem (small, medium, large)

3. Applicability to several or few clinical areas

4. Likelihood of the change to improve quality of care, decrease length of stay, contain costs, or improve patient satisfaction

5. Potential “land mines” associated with the topic and capability to diffuse them

6. Availability of baseline quality improvement or risk data that will be helpful during evaluation

7. Multidisciplinary nature of the topic and ability to create collaborative relationships to effect the needed changes

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8. Interest and commitment of staff to the potential topic

9. Availability of a sound body of evidence, preferably research evidence

HIGHLIGHT Regardless of which approach is used to select an evidence-based practice topic, it is critical that your team who will implement the potential practice change are involved in selecting the topic, developing the clinical question, and viewing it as contributing significantly to the quality of care for your patient population.

Forming a team A team is responsible for development, implementation, and evaluation of the EBP. A task force approach also may be used, in which a group is appointed to address a practice issue. The composition of the team is directed by the topic selected and should include interested stakeholders. Example: ➤ A team working on evidence-based pain management should be interdisciplinary and include pharmacists, nurses, physicians, and psychologists. In contrast, a team working on the EBP of bathing might include a nurse expert in skin care, assistive nursing personnel, and staff nurses. Although not traditionally included in the team, the engagement of patients, family members, and consumers as team members is receiving more attention in EBP (Moore et al., 2014, 2015; Shuman et al., 2016). Consideration should be given to including a layperson team who has experience with the topic. Example: ➤ A team focusing on prevention of necrotizing enterocolitis (NEC) in premature neonates may invite a parent to participate on the team because feeding breast milk (instead of formula) is one strategy to prevent NEC.

In addition to forming a team, key stakeholders who can facilitate the EBP project or put up barriers against successful implementation should be identified. A stakeholder is a key individual or group of individuals who will be directly or indirectly affected by the implementation of the EBP. Some of these stakeholders are likely to be members of the team. Others may not

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be team members but are key individuals within the organization or unit who can adversely or positively influence the adoption of the practice. Questions to consider in identification of key stakeholders include the following:

• How are decisions made in the areas where the EBP will be implemented?

• What types of system changes will be needed?

• Who is involved in decision making?

• Who is likely to lead and champion implementation of the EBP?

• Who can influence the decision to proceed with implementation of the practice?

• What type of cooperation is needed from stakeholders for the project to be successful?

Failure to involve or keep supportive stakeholders informed may place the success of the project at risk because they are unable to anticipate and/or defend the rationale for changing practice, particularly with resistors (e.g., nonsupportive stakeholders) who have a great deal of influence among their peer group.

An important early task for the EBP team is to formulate the PICO question. This helps set boundaries around the project and assists in evidence retrieval. This approach is illustrated in Table 20.1 (see Chapters 1 to 3, and 19).

TABLE 20.1 Using PICO to Formulate the Evidence-Based Practice Question

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From University of Illinois at Chicago, P.I.C.O. Model for Clinical Questions, www.uic.edu/depts/lib/lhsp/resources/pico.shtml.

Evidence retrieval Once a topic is selected, relevant research and related literature need to be retrieved (see Chapters 3 and 11). AHRQ (www.AHRQ.gov) sponsors the Evidenced-Based Practice Centers and a National Guideline Clearinghouse, where abstracts of EBP guidelines are available. Current best evidence from specific studies of clinical problems can be found in an increasing number of electronic databases such as the Cochrane Library (www.thecochranelibrary.com), the Centers for Health Evidence (www.cche.net), and Best Evidence (www.acponline.org) (see Chapters 3 and 11). Once the literature is located, it is helpful to classify the articles as clinical (nonresearch), theory, research, systematic reviews, and EBP guidelines. Before reading and critiquing the research, it is useful to read background articles to have a broad view of the topic and related concepts, and to then critique the existing EBP guidelines. It is helpful to read/critique articles in the following order:

1. Clinical articles to understand the state of the practice

2. Theory articles to understand the theoretical perspectives and concepts that may be encountered in critiquing studies

3. Systematic reviews and synthesis reports to understand the state of the science

4. EBP guidelines and evidence reports

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http://www.uic.edu/depts/lib/lhsp/resources/pico.shtml

http://www.AHRQ.gov

http://www.thecochranelibrary.com

http://www.cche.net

http://www.acponline.org

5. Research articles, including meta-analyses

Schemas for grading the evidence There is no consensus among professional organizations or across health care disciplines regarding the best system to use for denoting the type and quality of evidence, or the grading schemas to denote the strength of the body of evidence (Balshem et al., 2011; NAM, formally IOM., 2011). See Tables 20.2 and 20.3 for grading and assessing quality of research studies. The information posted on the GRADE website (www.gradeworkinggroup.org) is important information to understand the challenges and approaches for assessing the quality of evidence and strength of recommendations. The important domains and elements to include in grading the strength of the evidence are defined in Table 20.4.

TABLE 20.2 Examples of Evidence Rating Systems

Grade Working Group (www.gradeworkinggroup.org)

US Preventative Services Task Force (USPSTF) (www.uspreventiveservicestaskforce.org/)

Quality of the Evidence (Balshem et al., 2011; Guyatt et al., 2011, 2013)

Levels of Certainty Regarding Net Benefit (Quality of Evidence) (USPSTF, 2015)

High: Very confident that the true effect lies close to that of the estimate of the effect. Scientific evidence provided by welldesigned, well- conducted, controlled trials (randomized and nonrandomized) with statistically significant results that consistently support the recommendation. Moderate: Moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low: Confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect. Very low: Very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect. Note: The type of evidence is first ranked as follows: Randomized trial = High Observational study = Low Any other evidence = Very low Quality may be downgraded due to design flaws/threats to internal validity (risk of bias), important inconsistency of results, uncertainty about the directness of the evidence, imprecise or

High: Available evidence usually includes consistent results from a multitude of well- designed, well-conducted studies in representative primary care populations. These studies assess effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies. Moderate: The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by such factors as: • The number, size, or quality of individual

studies • Some heterogeneity of outcome findings

or intervention models across the body of studies

• Mild to moderate generalizability of findings to routine primary care practice

As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be

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http://www.gradeworkinggroup.org

http://www.uspreventiveservicestaskforce.org/

sparse data, and high probability of publication bias can lower the evidence grade. Factors that may increase quality of evidence of observational studies: 1. Large magnitude of effect (direct evidence,

relative risk [RR] = 2-5 or RR=0.5-0.2 with no plausible confounders); very large with RR >5 or RR < 0.2 and no serious problems with risk of bias or precision (sufficiently narrow confidence intervals); more likely to rate up if the effect is rapid and out of keeping with prior trajectory; usually supported by indirect evidence.

2. Dose-response gradient 3. All plausible residual confounders or biases

would reduce a demonstrated effect, or suggest a spurious effect when results show no effect.

large enough to alter the conclusion. Low: The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of one or more of the following: • The very limited number or size of

studies • Inconsistency of direction or magnitude

of findings across the body of evidence • Critical gaps in the chain of evidence • A lack of information on prespecified

health outcomes • Lack of coherence across the linkages in

the chain of evidence • More information may allow estimation

of effects on health outcomes.

Strength of Recommendations (Andrews et al., 2013)

Recommendation Grades (USPSTF, 2015)

Strong: Confident that desirable effects of adherence to a recommendation outweigh undesirable effects.

Weak: Desirable effects of adherence to a recommendation probably outweigh the undesirable effects, but developers are less confident.

Note: Strength of recommendation is determined by the balance between desirable and undesirable consequences of alternative management strategies, quality of evidence, variability in values and preferences (trade- offs), and resource use.

A. USPSTF recommends the service. There is high certainty that the net benefit is substantial.

B. USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

C. USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.

D. USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

E. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

In grading the evidence, two important areas are essential to address: (1) the quality of the evidence (e.g., individual studies, systematic reviews, meta-analyses), and (2) the strength of the body of evidence. Important domains and elements of any system used to rate quality of individual studies are listed in Table 20.3 by type of study. The domains and elements to include in grading the strength of the evidence are defined in Table 20.4. In Chapter 1, Fig. 1.1 provides an evidence hierarchy used for grading evidence that is an adaptation similar to the evidence hierarchies that appear in

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Table 20.2.

TABLE 20.3 Important Domains and Elements for Systems to Rate Quality of Individual Articles

From Agency for Healthcare Research and Quality (AHRQ). (2002). Systems to rate the strength of scientific evidence: evidence report/technology assessment number 47. Rockville, MD: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. Key domains are in italics.

TABLE 20.4 Important Domains and Elements for Systems to Grade the Strength of Evidence

Quality The aggregate of quality ratings for individual studies, predicated on the extent to which bias was minimized

Quantity Magnitude of effect, numbers of studies, and sample size or power Consistency For any given topic, the extent to which similar findings are reported using

similar and different study designs Relevance Relevance of findings to characteristics of individual groups Benefits and harms

The overall benefits and harms. Net benefits. Do the benefits outweigh the harms?

Modified from Institute of Medicine (IOM). (2011). Clinical practice guidelines we can trust. Washington, DC: The National Academies Press.

Critique and synthesis of research Critique of evidence-based guidelines (see Chapter 11) and studies (see Chapters 8 to 10) should use the same methodology, and the critique process should be a shared responsibility. It is helpful,

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however, to have one individual provide leadership for the project and design strategies for completing critiques. A group approach to critiques is recommended because it distributes the workload, helps those responsible for implementing the changes understand the scientific base for the practice change, arms nurses with citations and research-based language to use in advocating for changes with peers and other disciplines, and provides novices an environment to learn critique and application of research findings. Methods to make the critique process fun and interesting include the following:

• Using a journal club to discuss critiques done by each member of the group

• Pairing a novice and expert to do critiques

• Eliciting assistance from students who may be interested in the topic and want experience doing critiques

• Assigning the critique process to graduate students interested in the topic

• Making a class project of critique and synthesis of research for a given topic

• Using the critique criteria at the end of each chapter and the critique criteria summary tables in Chapters 6 and 18

HELPFUL HINT Keep critique processes simple, and encourage participation by staff members who are providing direct patient care.

Once studies are critiqued, a decision is made regarding the use of each study in the synthesis of the evidence for application in practice. Factors that should be considered for inclusion of studies in the synthesis of findings are (1) overall scientific merit; (2) type of subjects enrolled (e.g., age, gender, pathology) and the similarity to the patient population to which the findings will be applied; and (3) relevance of the study to the topic of question. Example: ➤ If the practice area is prevention of deep venous thrombosis in

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postoperative patients, a descriptive study using a heterogeneous population of medical patients is not appropriate for inclusion in the synthesis of findings.

To synthesize the findings from research critiques, it is helpful to use a summary table in which critical information from studies can be documented. Essential information to include in such a summary is as follows:

• Research questions/hypotheses

• Independent and dependent variables studied

• Description of the study sample and setting

• Type of research design

• Methods used to measure each variable and outcome

• Study findings

An example ➤ of a summary form is illustrated in Table 20.5.

TABLE 20.5 Example of a Summary Table for Research Critiques

aUse a consistent rating system (e.g., good, fair, poor).

HELPFUL HINT Use of a summary form helps identify commonalities across studies with regard to study findings and the types of patients to which findings can be applied. It also helps in synthesizing the overall strengths and weakness of the studies as a group.

Setting forth evidence-based practice recommendations

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Based on the critique of practice guidelines and synthesis of research, recommendations for practice are set forth. The type and strength of evidence used to support the practice needs to be clearly delineated in your evidence table. Box 20.2 is another useful tool to assist with this activity. BOX 20.2 Consistency of Evidence from Critiqued Research, Appraisals of Evidence-Based Practice Guidelines, Critiqued Systematic Reviews, and Nonresearch Literature

1. Are there replication of studies with consistent results?

2. Are the studies well designed?

3. Are recommendations consistent among systematic reviews, evidence-based practice guidelines, and critiqued research?

4. Are there identified risks to the patient by applying evidence- based practice recommendations?

5. Are there identified benefits to the patient?

6. Have cost analysis studies been conducted on the recommended action, intervention, or treatment?

7. Summary recommendations about assessments, actions, interventions/treatments from the research, systematic reviews, evidence-based guidelines with an assigned evidence grade.

From Titler, M. G. (2002). Toolkit for promoting evidence-based practice. Iowa City, IA: Department of Nursing Services and Patient Care, University of Iowa Hospitals and Clinics.

Decision to change practice After studies are critiqued and synthesized, the next step is to decide if the findings are appropriate for use in practice. Criteria to consider include:

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• Relevance of evidence for practice

• Consistency in findings across studies and/or guidelines

• A significant number of studies and/or EBP guidelines with sample characteristics similar to those to which the findings will be used

• Consistency among evidence from research and other nonresearch evidence

• Feasibility for use in practice

• The risk/benefit ratio (risk of harm versus the potential benefit for the patient)

Synthesis of study findings and other evidence may result in supporting current practice, making minor practice modifications, undertaking major practice changes, or developing a new area of practice.

Development of evidence-based practice The next step is to document the evidence base of the practice using the agreed-upon grading schema. When critique results and synthesis of evidence support practice or suggest a practice change, a written EBP standard (e.g., policy, standard of practice protocol, guideline) is warranted. This is necessary so that individuals know (1) that the practices are based on evidence and (2) the type of evidence (e.g., randomized controlled trial, expert opinion) used in development of the practice.

It is imperative that once the EBP standard is written, key stakeholders have an opportunity to review it and provide feedback to the individual(s) responsible for developing it. Focus groups are a useful way to provide discussion about the EBP and to identify key areas that may be potentially troublesome during the implementation phase. Key questions that can be used in focus groups are in Box 20.3. BOX 20.3

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Key Questions for Focus Groups

1. What is needed by staff (e.g., nurses, physicians) to use the evidence-based practice in your setting?

2. In your opinion, how will this standard improve patient care in your unit/practice?

3. What modifications would you suggest in the evidence-based practice standard before using it in your practice?

4. What content in the evidence-based practice standard is unclear? What needs revision?

5. What would you change about the format of the evidence-based practice standard?

6. What part of this evidence-based practice change do you view as most challenging?

7. Do you have any other suggestions?

HELPFUL HINT Use a consistent approach to developing EBP standards and referencing the research and related literature.

Implementing the practice change If a practice change is warranted, the next steps are to make the changes. This goes beyond writing a policy or procedure that is evidence based; it requires interaction among direct care providers to champion and foster evidence adoption, leadership support, and system changes. The diffusion of innovations model (Rogers, 2003) is extremely useful in selecting strategies for promoting the adoption of EBPs. According to this model, the adoption of EBP innovations is influenced by the nature of the innovation (e.g., the type and strength of evidence, the clinical topic) and the manner in which it is communicated (disseminated) to care providers of a social system (organization, health care professions). Strategies for

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promoting EBP adoption must address these areas within a context of participative, planned change.

Nature of the innovation/evidence-based practice Characteristics of an innovation or EBP that affect adoption include the relative advantage of the EBP (e.g., effectiveness, relevance to the task, social prestige); the compatibility with values, norms, work, and perceived needs of users; and complexity of the EBP topic (Rogers, 2003). Example: ➤ EBP topics that are perceived by users as relatively simple (e.g., influenza vaccines for older adults) are more easily adopted in less time than those that are more complex (e.g., acute pain management for hospitalized older adults).

A key principle to remember when planning implementation of an EBP is that the attributes of the practice topic as perceived by users and stakeholders (e.g., ease of use, valued part of practice) are neither stable features nor sure determinants of their adoption. Rather, it is the interaction among the characteristics of the EBP topic, the intended users, and a particular context of practice that determines the rate and extent of adoption (Dogherty et al., 2012).

Practitioner review and “reinvention” of EBP recommendations to fit the local context, along with the use of clinical reminders, decision aids, and quick reference guides (QRGs), are implementation strategies to educate and promote the nature of the EBP topic (Berwick, 2003; IOM, 2011; Titler et al., 2016; Wilson et al., 2016). An example of a quick reference guide is shown in Fig. 20.3.

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FIG 20.3 Quick reference guide fall prevention:

interventions to mitigate mobility risk factors. Source: (From Titler, M. G., Conlon, P., Reynolds, M. A., et al. [2016]. The effect of

translating research into practice intervention to promote use of evidence- based fall prevention interventions in hospitalized adults: a prospective pre- post implementation study in the U.S. Applied Nursing Research, 31, 52–

59.)

Empirical support for evidence-based electronic clinical decision support interventions is mixed (IOM, 2011). Electronic reminders have small to modest effects on clinician behavior and appear to be more effective than alerts alone when included as a part of multifaceted implementation strategies (Arditi et al., 2012; Kahn et al., 2013).

Methods of communication Interpersonal communication and influence among social networks of users affect adoption of EBPs (Rogers, 2003). Education, use of opinion leaders, change champions, and educational outreach are tested strategies that promote adoption of EBPs. Education is necessary but not sufficient to change practice, and didactic continuing education alone does little to change practice behavior

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(Flodgren et al., 2013; Giguère et al., 2012). It is important that staff know the scientific basis for improvements in quality of care anticipated by the changes. Disseminating information to staff needs to be done creatively. A staff in-service may not be the most effective method nor reach the majority of the staff. Although it is unrealistic for all staff to have participated in the critique process or to have read all studies used, it is important that they know the myths and realities of the EBP. Staff education must also ensure competence in the skills necessary to carry out the new practice.

One method of communicating information to staff is through use of colorful posters that identify myths and realities or describe the essence of the change in practice (Titler et al., 2016). Visibly identifying those who have learned the information and are using the EBP (e.g., via buttons, ribbons, pins) stimulates interest in others who may not have internalized the change. As a result, the “new” learner may begin asking questions about the practice and be more open to learning. Other educational strategies such as train-the- trainer programs, computer-assisted instruction, and competency testing are helpful in education of staff (Titler et al., 2016). Several studies have demonstrated that opinion leaders are effective in changing behaviors of health care practitioners (Dagenais et al., 2015; Flodgren et al., 2011), especially in combination with educational outreach or performance feedback. Opinion leaders are from the local peer group, viewed as a respected source of influence, considered by associates as technically competent, and trusted to judge the fit between the EBPs and the local situation (Dobbins et al., 2009; Flodgren et al., 2011). The key characteristic of an opinion leader is a trusted ability to evaluate new information in the context of group norms. To do this, an opinion leader must be considered by associates as technically competent and a full and dedicated member of the local group (Rogers, 2003).

Opinion leadership is multifaceted and complex, with role functions varying by the circumstances, but few successful projects that have implemented EBPs have managed without the input of identifiable opinion leaders. Social interactions such as “hallway chats,” one-on-one discussions, and addressing questions are important yet often overlooked components of translation (Jordan et al., 2009). If the EBP that is being implemented is

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interdisciplinary, discipline-specific opinion leaders should be used to promote the practice change. Role expectations of an opinion leader are listed in Box 20.4. BOX 20.4 Role Expectations of an Opinion Leader

1. Be/become an expert in the evidence-based practice.

2. Provide organizational/unit leadership for adopting the evidence- based practice.

3. Implement various strategies to educate peers about the evidence-based practice.

4. Work with peers, other disciplines, and leadership staff to incorporate key information about the evidence-based practice into organizational/unit standards, policies, procedures, and documentation systems.

5. Promote initial and ongoing use of the evidence-based practice by peers.

From Titler, M. G., Herr, K., Everett, L. Q., et al. (2006). Book to bedside: Promoting and sustaining EBPs in elders. Iowa City, IA: University of Iowa College of Nursing.

Change champions are also helpful for implementing innovations (Dogherty et al., 2012). They are practitioners within the local group setting (e.g., clinic, patient care unit) who are expert clinicians, are passionate about the innovation, are committed to improving quality of care, and have a positive working relationship with other health professionals (Rogers, 2003). They circulate information, encourage peers to adopt the innovation, arrange demonstrations, and orient staff to the innovation (Titler et al., 2016). The change champion believes in an idea; will not take “no” for an answer; is undaunted by insults and rebuffs; and above all, persists.

Multiple studies have demonstrated the effectiveness of educational outreach, also known as academic detailing, in improving the practice behaviors of clinicians (Avorn, 2010; NAM, formally IOM, 2011; Wilson et al., 2016). Educational outreach

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involves interactive face-to-face education of practitioners in their practice setting by an individual (usually a clinician) with expertise in a particular topic (e.g., cancer pain management). Academic detailers are able to explain the research foundations of the EBP recommendations and respond convincingly to specific questions, concerns, or challenges that a practitioner might raise. An academic detailer also might deliver feedback on provider or team performance with respect to an EBP recommendation (e.g., frequency of pain assessment).

Users of the innovation/evidence-based practice Members of a social system (e.g., nurses, physicians, clerical staff) influence how quickly and widely EBPs are adopted (Rogers, 2003). Audit and feedback, performance gap assessment (PGA), and trying the EBP are strategies that have demonstrated effectiveness in improving EBP behaviors (Hysong et al., 2012; Ivers et al., 2012; Titler et al., 2016).

PGA (baseline practice performance) provides information of current practices relative to recommended EBPs at the beginning of a practice change. This implementation strategy is used to engage clinicians in discussions of practice issues and formulation strategies to promote alignment of their practices with EBP recommendations. Specific practice indicators selected for PGA are derived from the EBP recommendations for the specified topic such as every-4-hour pain assessment for acute pain management. Studies have demonstrated improvements in performance when PGA is part of multifaceted implementation strategies (see Chapters 19 and 21) (Titler et al., 2016; Yano, 2008).

Audit and feedback is ongoing auditing of performance indicators, aggregating data into reports, and discussing the findings with practitioners during the practice change (Ivers et al., 2012; Hysong et al., 2012; Wilson et al., 2016). This strategy helps staff know and see how their efforts to improve care and patient outcomes are progressing throughout the implementation process (Ivers et al., 2014).

Users of an innovation usually try it for a period of time before adopting it in their practice. When “trying an evidence-based practice” (i.e., piloting a change) is incorporated as part of the

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implementation process, users have an opportunity to use it, provide feedback to those in charge of implementation, and modify the practice if necessary. Piloting the practice as part of implementation has a positive influence on the extent of adoption of the new practice (Rogers, 2003).

Social system Clearly, the social system or context of care delivery matters when implementing EBPs (Rogers, 2003; Squires et al., 2015; Titler, 2010; Yousefi-Nooraie et al., 2014). Example: ➤ Investigators demonstrated the effectiveness of a prompted voiding intervention for urinary incontinence in nursing homes, but sustaining the intervention in day-to-day practice was limited when the responsibility of carrying out the intervention was shifted to nursing home staff (rather than the investigative team) and required staffing levels in excess of a majority of nursing home settings (Engberg et al., 2004). This illustrates the importance of embedding interventions into ongoing care processes.

As part of the work of implementing EBPs, it is important that the social system (e.g., unit, service line, clinic) ensure that policies, procedures, standards, clinical pathways, and documentation systems support the use of the EBPs (Titler, 2010). Documentation forms or clinical information systems may need revision to support practice changes; documentation systems that fail to readily support the new practice thwart change. Example: ➤ If staff members are expected to reassess and document pain intensity within 30 minutes after administration of an analgesic agent, documentation forms must reflect this practice standard. It is the role of leadership to ensure that organizational documents and systems are flexible and supportive of the EBPs.

A learning organizational culture and proactive leadership that promotes knowledge sharing are important components for building an EBP (Duckers et al., 2009; Stetler et al., 2009). Components of a receptive context for EBP include the following:

• Strong leadership

• Clear strategic vision

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• Good managerial relations

• Visionary staff in key positions

• A climate conducive to experimentation and risk taking

• Effective data-capture systems

An organization may be generally amenable to innovations, but not ready or willing to assimilate a particular EBP. Elements of system readiness include the following (French et al., 2009; Litaker et al., 2008):

• Tension for change

• EBP practice–system fit

• Assessment of implications

• Support and advocacy for the EBP

• Dedicated time and resources

• Capacity to evaluate the impact of the EBP during and following implementation

Leadership support is critical for promoting the use of EBPs (French et al., 2009), and is expressed verbally and by providing necessary resources, materials, and time to fulfill responsibilities (Stetler et al., 2009). Senior leadership needs to create an organizational mission, vision, and strategic plan that incorporates EBP, implements performance expectations for staff that include EBP work, integrates the work of EBP into the governance structure of the health care system, demonstrates the value of EBPs through administrative behaviors, and establishes explicit expectations that nurse leaders will create microsystems that value and support clinical inquiry (see Chapter 21).

In summary, making an evidence-based change in practice involves a series of action steps in a complex, nonlinear process. Implementing the change takes time to integrate, depending on the

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nature of the practice change. Merely increasing staff knowledge about an EBP and passive dissemination strategies are unlikely to work, particularly in complex health care settings. Strategies that seem to have a positive effect on promoting use of EBPs include audit and feedback, use of clinical reminders and practice prompts, opinion leaders, change champions, interactive education, educational outreach/academic detailing, and the context of care delivery (e.g., leadership, learning, questioning). It is important that senior leadership and those leading EBP improvements are aware of change as a process and continue to encourage and teach peers about the change in practice. The new practice must be continually reinforced and sustained or the practice change will be intermittent and soon fade, allowing more traditional methods of care to return.

Evaluation Evaluation provides an opportunity to collect and analyze data with regard to the use of new EBPs and then to modify the practice as necessary. It is important that the evidence-based change is evaluated, both at the pilot testing phase and when the practice is changed in additional settings or sites of care. The importance of the evaluation cannot be overemphasized; it provides information for performance gap assessment, audit, and feedback, and provides information necessary to determine if the EBP should be retained, modified, or eliminated.

An outcome achieved in a controlled environment (as when a researcher is implementing a study protocol for a homogeneous group of study patients) may not result in the same outcome when the practice is implemented in the clinical setting by several caregivers to a more heterogeneous patient population. Steps of the evaluation process are summarized in Box 20.5. BOX 20.5 Steps of Evaluation for Evidence-Based Projects

1. Identify process and outcome variables of interest.

Example: Process variable—Patients > 65 years will

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have a Braden scale completed on admission.

Outcome variable—Presence/absence of nosocomial pressure ulcer; if present, determine stage as I, II, III, IV.

2. Determine methods and frequency of data collection.

Example: Process variable—Chart audit of all patients > 65 years, 1 day a month.

Outcome variable—Patient assessment of all patients > 65 years, 1 day a month.

3. Determine baseline and follow-up sample sizes.

4. Design data collection forms.

Example: Process chart audit abstraction form.

Outcome variable—pressure ulcer assessment form.

5. Establish content validity of data collection forms.

6. Train data collectors.

7. Assess interrater reliability of data collectors.

8. Collect data at specified intervals.

9. Provide “on-site” feedback to staff regarding the progress in achieving the practice change.

10. Provide feedback of analyzed data to staff.

11. Use data to assist staff in modifying or integrating the evidence- based practice change.

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Evaluation should include both process and outcome measures (Titler et al., 2016). The process component focuses on how the practice change is being implemented. It is important to know if staff are using the practice and implementing the practice as noted in the EBP guideline. Evaluation of the process also should note (1) barriers that staff encounter in carrying out the practice (e.g., lack of information, skills, or necessary equipment), (2) differences in opinions among health care providers, and (3) difficulty in carrying out the steps of the practice as originally designed (e.g., shutting off tube feedings 1 hour before aspirating contents for checking placement of nasointestinal tubes). Process data can be collected from staff and/or patient self-reports, medical record audits, or observation of clinical practice. Examples of process and outcome questions are shown in Table 20.6.

TABLE 20.6 Examples of Evaluation Measures

A, Agree; D, disagree; NA/D, neither agree nor disagree; SA, strongly agree; SD, strongly disagree.

Outcome data are an equally important part of evaluation. The purpose of outcome evaluation is to assess whether the patient, staff, and/or fiscal outcomes expected are achieved. Therefore it is important that baseline data be used for a preintervention/postintervention comparison (Titler et al., 2016). The outcome variables measured should be those that are projected to change as a result of changing practice. Example: ➤ Research demonstrates that less restricted family visiting practices in critical care units result in improved satisfaction with care. Thus patient and family member satisfaction should be an outcome measure that is evaluated as part of changing visiting practices in adult critical

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care units. Outcome measures should be assessed before the change in practice is implemented, after implementation, and every 6 to 12 months thereafter. Findings must be provided to clinicians to reinforce the impact of the change and to ensure that they are incorporated into quality improvement programs. When collecting process and outcome data for evaluation of a practice change, it is important that the data collection tools are user-friendly, short, concise, easy to complete, and have content validity. Focus must be on collecting the most essential data. Those responsible for collecting evaluative data must be trained on data collection methods and be assessed for interrater reliability (see Chapters 14 and 15). It is our experience that those individuals who have participated in implementing the protocol can be very helpful in evaluation by collecting data, providing timely feedback to staff, and assisting staff to overcome barriers encountered when implementing the changes in practice (see Chapter 21).

One question that often arises is how much data are needed to evaluate this change. The preferred number of patients (N) is somewhat dependent on the size of the patient population affected by the practice change. Example: ➤ If the practice change is for families of critically ill adult patients and the organization has 1000 adult critical care patients annually, 50 to 100 satisfaction responses preimplementation, and 25 to 50 responses postimplementation, 3 and 6 months should be adequate to look for trends in satisfaction and possible areas that need to be addressed in continuing this practice (e.g., more bedside chairs in patient rooms). The rule of thumb is to keep the evaluation simple, because data often are collected by busy clinicians who may lose interest if the data collection, analysis, and feedback are too long and tedious. It is also important to check with your institution’s guidelines for collecting data related to practice changes, because institutional approval may be needed.

The evaluation process includes planned feedback to staff who are making the change. The feedback includes verbal and/or written appreciation for the work and visual demonstration of progress in implementation and improvement in patient outcomes. The key to effective evaluation is to ensure that the evidence-based change in practice is warranted (e.g., will improve quality of care) and that

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the intervention does not bring harm to patients.

HELPFUL HINT Include patient outcome measures (e.g., pressure ulcer prevalence) and cost (e.g., cost savings, cost avoidance) in evaluation practice projects.

Future directions Education must include knowledge and skills in the use of research evidence in practice. Nurses are increasingly being held accountable for practices based on scientific evidence. Thus we must communicate and integrate into our profession the expectation that it is the professional responsibility of all nurses to read and use research in their practice, and to communicate with nurse scientists the many and varied clinical problems for which we do not yet have a scientific base.

Key points • EBP and translation science, though related, are not

interchangeable terms; EBP is the actual application of evidence in practice (the “doing of” EBP), whereas translation science is the study of implementation interventions, factors, and contextual variables that effect knowledge uptake and use in practices and communities.

• There are several models of EBP. A key feature of all models is the judicious review and synthesis of research and other types of evidence to develop an EBP standard.

• The steps of EBP using the Iowa Model of Evidence-Based Practice are as follows: (1) selecting a topic, (2) forming a team, (3) retrieving the evidence, (4) grading the evidence, (5) developing an EBP standard, (6) implementing the EBP, and (7) evaluating the effect on staff, patient, and fiscal outcomes.

• Adoption of EBPs requires education of staff, as well as the use of change strategies such as opinion leaders, change champions,

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educational outreach, performance gap assessment, and audit and feedback.

• It is important to evaluate the change. Evaluation provides data for performance gap assessment, audit, and feedback, and provides information necessary to determine if the practice should be retained.

• Evaluation includes both process and outcome measures.

• It is important for organizations to create a culture of EBP. Creating this culture requires an interactive process. Organizations need to provide access to information, access to individuals who have skills necessary for EBP, and a written and verbal commitment to EBP in the organization’s operations.

Critical thinking challenges • Discuss the differences among nursing research, EBP, and

translation science. Support your discussion with examples.

• Why would it be important to use an EBP model, such as the Iowa Model of Evidence-Based Practice, to guide a practice project focused on justifying and implementing a change in clinical practice?

• You are a staff nurse working on a cardiac step-down unit. You are asked to join an interprofessional QI team for the cardiac division. You find that many of your colleagues from other disciplines do not understand evidence-based practice. How would you help your colleagues to understand the relevance of evidence-based practice to providing care that addresses the Triple Aim for this patient population?

• What barriers do you see to applying EBP in your clinical setting? Discuss strategies to use in overcoming these barriers.

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for

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review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

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9. Dobbins M., Robeson P., Ciliska D., et al. A description of a knowledge broker role implemented as part of a randomized controlled trial evaluating three knowledge translation strategies. Implementation Science 2009;4:23 Available at: doi:10.1186/1748-5908-4-23

10. Dockham B., Schafenacker A., Yoon H., et al. Implementation of a psychoeducational program for cancer survivors and family caregivers at a cancer support community affiliate a pilot effectiveness study. Cancer Nursing 2016;39(3):169-180 Available at: doi:10.1097/NCC.0000000000000311

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12. Duckers M. L. A., Spreeuwenberg P., Wagner C., Groenewegen P. P. Exploring the black box of quality improvement collaboratives modelling relations between conditions, applied changes and outcomes. Implementation Science 2009;4:74 Available at: doi:10.1186/1748-5908-4-74

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17. Giguère A., Légaré F., Grimshaw J., et al. Printed educational materials effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews 2012;10 Available at: doi:10.1002/14651858.CD004398.pub3 Article No. CD004398 PMID:; 23076904.

18. Guyatt G. H., Oxman A. D., Sultan S., et al. GRADE guidelines 11. Making an overall rating of confidence in effect estimates for a single outcome and for all outcomes. Journal of Clinical Epidemiology 2013;66(2):151-157 Available at: doi:10.1016/j.jclinepi.2012.01.006

19. Guyatt G. H., Oxman A. D., Sultan S., et al. GRADE guidelines 9. Rating up the quality of evidence. Journal of Clinical Epidemiology 2011;64(12):1311-1316 Available at: doi:10.1016/j.jclinepi.2011.06.004

20. Hysong S. J., Teal C. R., Khan M. J., Haidet P. Improving quality of care through improved audit and feedback.. Implementation Science 2012;7:45 Available at: doi:10.1186/1748-5908-7-45 PMID: 22607640PMCID: PMC3462705.

21. Institute of Medicine (IOM). Clinical practice guidelines we can trust. Washington, DC: The National Academies Press 2011; Available at: doi:10.17226/13058 PMID:; 24983061.

22. Ivers N., Jamtvedt G., Flottorp S., et al. Audit and feedback effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews 2012;6 Available at: doi:10.1002/14651858.CD000259.pub3 Article No. CD000259 PMID:; 22696318.

23. Ivers N. M., Sales A., Colquhoun H., et al. No more “business as usual” with audit and feedback interventions towards an agenda for a reinvigorated intervention. Implementation Science 2014;9:14 Available at: doi:10.1186/1748-5908-9-14

24. Jordan M. E., Lanham H. J., Crabtree B. F., et al. The role of conversation in health care interventions enabling sensemaking

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and learning. Implementation Science 2009;4:15 Available at: doi:10.1186/1748-5908-4-15 PMID: 19284660PMCID: PMC2663543.

25. Kahn S. R., Morrison D. R., Cohen J. M., et al. Interventions for implementation of thromboprophylaxis in hospitalized medical and surgical patients at risk for venous thromboembolism. Cochrane Database of Systematic Reviews 2013;7 Available at: doi:10.1002/14651858.CD008201.pub2 PMID:; 23861035.

26. Litaker D., Ruhe M., Weyer S., Stange K. C. Association of intervention outcomes with practice capacity for change subgroup analysis from a group randomized trial. Implementation Science 2008;3:25 Available at: doi:10.1186/1748-5908-3-25

27. Milat A. J., Bauman A., Redman S. Narrative review of models and success factors for scaling up public health interventions. Implementation Science 2015;10:113 Available at: doi:10.1186/s13012-015-0301-6 PMID: 26264351PMCID: PMC4533941.

28. Moore J. E., Kane-Low L., Titler M. G., et al. Moving towards patient centered care Women’s decisions, perceptions, and experiences of the induction of labor process. Birth 2014;41(2):138-146 Available at: doi:10.1111/birt.12080 PMID:; 24702312.

29. Moore J. E., Titler M. G., Kane-Low L., et al. Transforming patient-centered care development of the evidence-informed decision-making through engagement model. Women’s Health Issues 2015;25(3):276-282 Available at: doi:10.1016/j.whi.2015.02.002 PMID:; 25864022.

30. Newhouse R., Bobay K., Dykes P. C., et al. Methodology issues in implementation science. Medical Care 2013;51(4 Suppl 2):32-40 Available at: doi:10.1097/MLR.0b013e31827feeca PMID:; 23502915.

31. Rogers E. M. Diffusion of innovations. 5th ed. New York, NY: Free Press 2003;

32. Rycroft-Malone J., Bucknall T. Models and frameworks for implementing evidence-based practice. Hoboken, NJ: Wiley- Blackwell 2010;

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34. Shuman C. J., Liu J., Montie M., et al. Patient perception and experiences with falls during hospitalization and after discharge. Applied Nursing Research 2016;31:79-85 Available at: doi:10.1016/j.apnr.2016.01.009 PMID:; 27397823.

35. Squires J. E., Graham I. D., Hutchinson A. M., et al. Identifying the domains of context important to implementation science a study protocol. Implementation Science 2015;10(1):135 Available at: doi:10.1186/s13012-015-0325-y PMID: 26416206PMCID: PMC4584460.

36. Stetler C. B., Ritchie J. A., Rycroft-Malone J., et al. Institutionalizing evidence-based practice an organizational case study using a model of strategic change. Implementation Science 2009;4:78 Available at: doi:10.1186/1748-5908-4-78 PMID: 19948064PMCID: PMC2795741.

37. Straus E., Richardson R. B., Glasziou P., et al. Evidence-based medicine How to practice and teach. 4th ed. New York, NY: Elsevier 2011;

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44. Titler M. G., Wilson D. S., Resnick B., Shever L. L. Dissemination and implementation INQRI’s potential impact. Medical Care 2013;51(4 Suppl 2):S41-S46 Available at: doi:10.1097/MLR.0b013e3182802fb5 PMID:; 23502916.

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CHAPTER 21

Quality improvement Maja Djukic, Mattia J. Gilmartin

Learning outcomes

After reading this chapter, you should be able to do the following:

• Discuss the characteristics of quality health care defined by the Institute of Medicine. • Compare the characteristics of the major quality improvement (QI) models used in health care. • Identify two databases used to report health care organizations’ performance to promote consumer choice and guide clinical QI activities. • Describe the relationship between nursing-sensitive quality indicators and patient outcomes. • Describe the steps in the improvement process, and determine appropriate QI tools to use in each phase of the improvement process. • List four themes for improvement to apply to the unit where you work. • Describe ways that nurses can lead QI projects in clinical settings. • Use the SQUIRE Guidelines to critique a journal article reporting the results of a QI project.

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KEY TERMS

accreditation

benchmarking

Clinical Microsystems

common cause and special cause variation

control chart

flowchart

Lean

nursing-sensitive quality indicators

Plan-Do-Study-Act Improvement Cycle

public reporting

quality health care

quality improvement

root cause analysis

run chart

Six Sigma

SQUIRE Guidelines

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

Total quality management/continuous quality improvement The Institute of Medicine (IOM, 2001) defines quality health care as care that is safe, effective, patient-centered, timely, efficient, and equitable (Box 21.1). The quality of the health care system was

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brought to the forefront of national attention in several important reports (IOM, 1999, 2001), including Crossing the Quality Chasm, which concluded that “between the health care we have and the care we could have lies not just a gap, but a chasm” (IOM, 2001, p. 1). The report notes that “the performance of the health care system varies considerably. It may be exemplary, but often is not, and millions of Americans fail to receive effective care” (IOM, 2001, p. 3). BOX 21.1 Six Dimensions and Definitions of Health Care Quality

1. Safe: Avoiding injuries to patients from the care that is intended to help them.

2. Effective: Providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit.

3. Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.

4. Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care.

5. Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy.

6. Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

From Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21st century. Executive summary. Washington, DC: The National Academies Press.

Since the IOM (2001) report was published, quality of care has improved for some conditions (Nuti et al., 2015). Based on data from over 4000 US hospitals, core composite quality process

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measures for acute myocardial infarction (e.g., aspiring on arrival), heart failure (e.g., smoking cessation advice), and pneumonia (e.g., influenza vaccine) improved from 96% to 99%, 85% to 98%, and 83% to 97%, respectively, from 2006 to 2011 (Nuti et al., 2015). Also, overall positive improvement trends across more than 200 quality measures are noted, led by 17% reduction of hospital-acquired conditions from 2010 to 2014 (Agency for Healthcare Research and Quality [AHRQ], 2016). Improvements are, however, needed for about 20% of measures in person-and-family-centered care, such as receiving care as soon as needed, and for about 40% of measures of healthy living, such as getting prompt smoking cessation help for people trying to quit (AHRQ, 2016). Further, disparities in quality based on earnings, race, and ethnicity continue to persist. For example, “people from poor households compared to those from high-income households received worse care for about 60% of quality measures; Blacks, Hispanics, American Indians, and Alaska Natives compared to Whites received worse care for about 40% of quality measures” (AHRQ, 2016, p. 11). Despite these quality issues, the United States spends twice as much on health care per capita per year at $8508, compared with other developed nations, while ranking last in health care quality in comparison with 10 other countries (Davis et al., 2014).

The purpose of this chapter is to introduce you to the principles of quality improvement (QI) and provide examples of how to apply these principles in your practice so you can effectively contribute to needed health care improvements. QI “uses data to monitor the outcomes of care processes and improvement methods to design and test changes to continuously improve the quality and safety of health care systems” (Cronenwett et al., 2007, p. 127).

Nurses’ role in health care quality improvement Florence Nightingale championed QI by systematically documenting high rates of morbidity and mortality resulting from poor sanitary conditions among soldiers serving in the Crimean War of 1854 (Henry et al., 1992). She used statistics to document changes in soldiers’ health, including reductions in mortality

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resulting from a number of nursing interventions such as hand hygiene, instrument sterilization, changing of bed linens, ward sanitation, ventilation, and proper nutrition (Henry et al., 1992). Today, nurses continue to be vital to health system improvement efforts (IOM, 2015). One main initiative developed to bolster nurses’ education in health system improvements is Quality and Safety Education for Nurses (QSEN) (Cronenwett et al., 2007). The overall goal of this project is to help build nurses’ competence in the areas of QI, patient-centered care, teamwork and collaboration, patient safety, informatics, and evidence-based practice (EBP). Other initiatives, such as the Care Innovation and Transformation Program (American Organization of Nurse Executives, 2016), have been developed to increase nurses’ engagement in QI. To effectively influence improvements in the work setting and ensure that all patients consistently receive excellent care, it is important to:

• Align national, organizational, and unit level goals for QI.

• Recognize external drivers of quality, such as accreditation, payment, and performance measurement.

• Develop skills to apply QI models and tools.

National goals and strategies for health care quality improvement The National Quality Strategy, first published in 2011 and established by the Affordable Care Act to pursue the triple health care improvement aim of better care, affordable care, and healthy people/healthy communities (US Department of Health and Human Services [USDHHS], 2016a), set aims and priorities for QI (Box 21.2). Achieving these national quality targets requires major redesign of the health care system. One way you can contribute to this redesign is to familiarize yourself with the national priorities, corresponding improvement goals, and national initiatives (Table 21.1) and use them to guide improvements in your work setting.

TABLE 21.1

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National Quality Strategy Priorities, Improvement Goals, and Related Initiatives

National Quality Strategy Priority

Long-Term Goals Related National Initiatives

Patient safety 1. Reduce preventable hospital admissions and readmissions.

2. Reduce the incidence of adverse health care-associated conditions.

3. Reduce harm from inappropriate or unnecessary care.

Partnership for Patients, Hospital Readmission Reduction Program, Children’s Hospital of Pittsburgh of UPMC

Person- and family- centered care

1. Improve patient, family, and caregiver experience of care related to quality, safety, and access across settings.

2. In partnership with patients, families, and caregivers—and using a shared decision- making process—develop culturally sensitive and understandable care plans.

3. Enable patients and their families and caregivers to navigate, coordinate, and manage their care appropriately and effectively.

Consumer Assessment of Healthcare Providers and Systems, National Partnership for Women and Families, Colorado Coalition for the Homeless

Effective communication and care coordination

1. Improve the quality of care transitions and communications across care settings.

2. Improve the quality of life for patients with chronic illness and disability by following a current care plan that anticipates and addresses pain and symptom management, psychosocial needs, and functional status.

3. Establish shared accountability and integration of communities and health care systems to improve quality of care and reduce health disparities.

Argonaut Project, Boston Children’s Hospital Community Asthma Initiative

Prevention and treatment of leading causes of morbidity and mortality

1. Promote cardiovascular health through community interventions that result in improvement of social, economic, and environmental factors.

2. Promote cardiovascular health through interventions that result in adoption of the most healthy lifestyle behaviors across the life span.

3. Promote cardiovascular health through receipt of effective clinical preventive services across the life span in clinical and community settings.

The Million Hearts Campaign, Wind River Reservation

Health and well-being of communities

1. Promote healthy living and well-being through community interventions that result in improvement of social, economic, and environmental factors.

2. Promote healthy living and well-being through interventions that result in adoption of the most important healthy lifestyle behaviors across the life span.

3. Promote healthy living and well-being

Let’s Move!, Health Leads

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through receipt of effective clinical preventive services across the life span in clinical and community settings.

Making quality care more affordable

1. Ensure affordable and accessible high- quality health care for people, families, employers, and governments.

2. Support and enable communities to ensure accessible, high-quality care while reducing waste and fraud.

Blue Cross Blue Shield Massachusetts

Alternative Quality Contract, Medicare

Shared Savings Program, Pioneer Accountable Care Organization

Model Arkansas Center for Health

Improvement

From the US Department of Health and Human Services. (2016a). National quality strategy overview. Retrieved from http://www.ahrq.gov/workingforquality/nqs/overview.pdf.

BOX 21.2 National Quality Aims and Priorities

National Quality Aims National Quality Priorities forAchieving the Aims • Better Care: Improve the overall quality of care by

making health care more patient-centered, reliable, accessible, and safe.

• Make care safer by reducing harm caused in the delivery of care.

• Ensure all people and families are engaged as partners in their care.

• Healthy People/Healthy Communities: Improve the health of the US population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care.

• Promote effective communication and care coordination.

• Promote the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.

• Work with communities to promote wide use of best practices to enable healthy living.

• Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.

• Make quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.

From 2015 National Healthcare Quality and Disparities Report and 5th Anniversary Update on the National Quality Strategy. Agency of Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhqdr15/index.html.

Quality strategy levers QI relies on aligning institutional priorities with several strategy levers that drive QI. The National Quality Strategy encourages

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multiple members of the health care community, including individuals, family members, payers, providers, and employers, to collaborate on using one or more of the nine strategy levers (USDHHS, 2016a, p. 8); we describe briefly how each lever is used for QI:

1. Measurement and feedback—Provide performance feedback to plans and providers to improve care. National health care performance standards are developed using a consensus process in which stakeholder groups, representing the interests of the public, health professionals, payers, employers, and government, identify priorities, measures, and reporting requirements to document and manage the quality of care (National Quality Forum [NQF], 2004). See Box 21.3 for examples of groups responsible for developing measurement standards.

2. Public reporting—Compare treatment results, costs, and patient experience for the consumer. Several major public reporting systems are described in Box 21.4.

3. Learning and technical assistance—Foster learning environments that offer training, resources, tools, and guidance to help organizations achieve quality improvement goals.

4. Certification, accreditation, regulation—Adopt or adhere to approaches to meet safety and quality standards. Several accrediting bodies are listed in Box 21.5.

5. Consumer incentives and benefits designs—Help consumers adopt healthy behaviors and make informed decisions.

6. Payment—Reward and incentivize providers to deliver high- quality, patient-centered care. Box 21.6 shows examples of payment incentives.

7. Health information technology—Improve communications, transparency, and efficiency for better coordinated health and health care.

8. Innovation and diffusion—Foster innovation in health care

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quality improvement, and facilitate rapid adoption within and across organizations and communities.

9. Workforce development—Invest in people to prepare the next generation of health care professionals and support lifelong learning for providers.

BOX 21.3 Performance Measurement Standard Setting Groups Introduction to performance measurement standards National Quality Forum (NQF) is a nonprofit organization that seeks to measure and improve the quality of health care in the United States by establishing national healthcare quality and safety goals and priorities. The NQF’s evidence-based measure endorsement process is the gold standard for healthcare quality measurement. The NQF endorsement process is a transparent, consensus-based model that brings together stakeholders from the private and public sectors to foster quality improvement. Approximately 300 NQF-endorsed measures are used by federal public and private pay-for-performance programs, as well as, in private-sector and state healthcare quality programs. a

Agency for Healthcare Research and Quality, Quality Indicators (AHRQ). The AHRQ Quality Indicators are standardized, evidence-based measures of the quality of hospital care that are readily available using hospital administrative data. There are 101 Quality Indicators organized into the four main categories of inpatient quality for adult and pediatric patients; preventative quality indicators for ambulatory care and avoidable complications. Approximately half of the AHRQ quality indicators are endorsed by the National Quality Forum and used to support hospital quality improvement, health system planning and pay for performance initiatives. b

aNational Quality Forum. (2015). National Quality Forum, What We Do. Retrieved from http://www.qualityforum.org/what_we_do.aspx. bAgency for Healthcare Research and Quality. (2015). About AHRQ Quality Indicators. Retrieved from: http://qualityindicators.ahrq.gov/FAQs_Support/FAQ_QI_Overview.aspx.

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BOX 21.4 Public Reporting Systems

• Hospital Compare allows consumers to compare information on hospitals. The database includes performance measures on timely and efficient care, readmissions and deaths, complications, use of medical imaging, survey of patients’ experiences, and payment and value of care. For more information, visit www.hospitalcompare.hhs.gov/.

• Nursing Home Compare allows consumers to compare information about nursing homes. It contains quality of care information on every Medicare and Medicaid-certified nursing home in the country. The database includes performance measures on health inspections, staffing, and clinical quality. For more information, visit www.medicare.gov/NursingHomeCompare/.

• Home Health Compare has information about the quality of care provided by Medicare-certified home health agencies that meet federal health and safety requirements throughout the nation. For more information, visit www.medicare.gov/homehealthcompare.

• Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Developed by the Agency for Healthcare Research and Quality, the HCAHPS is a standardized survey and data collection method for measuring patients’ perspectives on hospital care. The HCAHPS survey contains 32 questions about patient perspectives on care for eight key topics: communication with doctors; communication with nurses; responsiveness of hospital staff; pain management; communication about medicines; discharge information; cleanliness of the hospital environment; and quietness of the hospital environment, posthospital transitions, admissions through the emergency room, and mental and emotional health. HCAHPS performance is used to calculate incentive payments in the Hospital Value- Based Purchasing program for hospital discharges beginning in October 2012. For more information, visit

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http://www.medicare.gov/NursingHomeCompare/

http://www.medicare.gov/homehealthcompare

http://www.hcahpsonline.org/Files/HCAHPS_Fact_Sheet_June_2015.pdf

• Physician Quality Reporting Initiative is a program administered by the CMS that collects performance data at the physician/provider clinical level in the ambulatory and primary care sectors. For more information, visit www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/PQRS/index.html.

• The Leapfrog Group is an initiative of organizations that buy health care who are working to improve the safety, quality, and affordability of health care for Americans. The Leapfrog Group conducts a survey for comparing hospitals’ performance on the national standards of safety, quality, and efficiency that are most relevant to consumers and purchasers of care. For more information, visit www.leapfroggroup.org/.

CMS, Center for Medicare and Medicaid Services.

BOX 21.5 Quality Improvement Accrediting Organizations

• Joint Commission: Responsible for ensuring a minimum standard of structures, processes, and outcomes for patient care. Accreditation by the Joint Commission is voluntary, but it is required to receive reimbursement for patient care services. For more information, see www.jointcommission.org/.

• National Committee for Quality Assurance Accreditation for Health Plans (NCQA): A private not-for-profit organization dedicated to improving health care quality. The NCQA is responsible for accrediting health insurance programs. Accredited health insurance programs are exempt from many or all elements associated with annual state audits. The NCQA developed and maintains the Healthcare Effectiveness Data and Information Set (HEDIS).

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http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html

http://www.leapfroggroup.org/

http://www.jointcommission.org/

• The Healthcare Effectiveness Data and Information Set (HEDIS): A tool used by the majority of America’s health plans to measure performance on important dimensions of care and service. HEDIS allows for comparison of performance across health plans. For more information, see http://www.ncqa.org/HEDISQualityMeasurement.aspx.

• American Nurses’ Credentialing Center Magnet Recognition Program recognizes health care organizations that provide the very best in nursing care and uphold the tradition of professional nursing practice. For more information, see www.nursecredentialing.org/Magnet.aspx.

BOX 21.6 Financial Incentives to Promote Quality in the Health Care Sector Capitation: A payment arrangement for health care services. Pays a provider (physician or nurse practitioner) or provider group a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care. These providers generally are contracted with a type of health maintenance organization (HMO). Payment levels are based on average expected health care use of a particular patient, with greater payment for patients with significant medical history. a

Bundled Payments Initiative: Links payments for multiple services that patients receive during an episode of care. Payments seek to align incentives for hospitals, post acute care providers, doctors, and other practitioners to improve the patient’s care experience during a hospital stay in an acute care hospital through postdischarge recovery. b

Pay for Performance: An emerging movement in health insurance where providers are rewarded for meeting pre- established targets for health care delivery services. This model rewards physicians, hospitals, medical groups, and other health care providers for meeting certain performance measures for quality and efficiency. c

Value-Based Health Care Purchasing: A project of participating

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http://www.nursecredentialing.org/Magnet.aspx

health plans, including the CMS, where buyers hold providers of health care accountable for both cost and quality of care. Value- based purchasing brings together information on health care quality, patient outcomes, and health status, with data on the dollar outlays going toward health. The focus is on managing health care system use to reduce inappropriate care and to identify and reward the best-performing providers. d

Accountable Care Organization (ACO): A payment and care delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients. A group of coordinated health care providers form an ACO, which then provides care to a group of patients. The ACO may use a range of payment models (e.g., capitation, fee-for-service). The ACO is accountable to the patients and the third-party payer for the quality, appropriateness, and efficiency of the health care provided. e

CMS, Center for Medicare and Medicaid Services. aAmerican Medical Association. (2012). Capitation. Retrieved from http://www.ama- assn.org/ama/pub/advocacy/state-advocacy-arc/state-advocacy-campaigns/private-payer- reform/state-based-payment-reform/evaluating-payment-options/capitation.page. bCenters for Medicare and Medicaid Services. (2016). Bundled payments for care improvement initiative: General information. Retrieved from https://innovation.cms.gov/initiatives/Bundled-Payments/index.html. cIntegrated Healthcare Association. (2013). National pay for performance issue brief. Retrieved from http://www.iha.org/sites/default/files/resources/issue-brief-value-based-p4p- 2013.pdf. dDamberg, C. L., Sorbero, M. E., Lovejoy, S. L., et al. (2014). Measuring success in health care value-based purchasing programs: Summary and recommendations. Santa Monica, CA: RAND Corporation, RR-306/1-ASPE, Retrieved from http://www.rand.org/pubs/research_reports/RR306z1.html. eAmerican Hospital Association. (2014). Accountable care organizations: Findings from the survey of care systems and payment. Retrieved from http://www.aha.org/content/14/14aug- acocharts.pdf.

Measuring nursing care quality Nurses deliver the majority of health care and therefore have a substantial influence on its overall quality (IOM, 2015). However, nursing’s contribution to the overall quality of health care has been difficult to quantify, owing in part to insufficient standardized measurement systems capable of capturing nursing care contribution to patient outcomes. The Robert Wood Johnson

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https://innovation.cms.gov/initiatives/Bundled-Payments/index.html

http://www.iha.org/sites/default/files/resources/issue-brief-value-based-p4p-2013.pdf

http://www.rand.org/pubs/research_reports/RR306z1.html

http://www.aha.org/content/14/14aug-acocharts.pdf

Foundation has funded the NQF to recommend nursing-sensitive consensus standards to be used to set standards for public accountability and QI. The work of the NQF (2004) resulted in the endorsement of 15 nursing-sensitive quality indicators (Table 21.2). Since the endorsement of “NQF 15,” several data reporting mechanisms have been established for performance sharing internally among providers to identify areas in need of improvement, externally for purposes of accreditation and payment, and with health care consumers so that they can choose providers based on the quality of services provided. Examples include Hospital Compare (USDHHS, 2016b) and the nursing-specific databases described by Alexander (2007):

• The National Database of Nursing Quality Indicators is a proprietary database of the Press Ganey. The database collects and evaluates unit-specific nurse-sensitive data from hospitals in the United States. Participating facilities receive unit-level comparative data reports to use for QI purposes. For more information, visit http://www.pressganey.com/solutions/clinical- quality/nursing-quality.

• California Nursing Outcomes Coalition (CalNOC) is a data repository of hospital-generated, unit-level, acute nurse staffing and workforce characteristics and processes of care, as well as key NQF-endorsed, nursing-sensitive outcome measures, submitted electronically via the web. For more information, visit http://www.calnoc.org.

• Veterans Affairs Nursing Outcomes Database was originally modeled after CalNOC. Data are collected at the unit and hospital levels to facilitate the evaluation of quality and enable benchmarking within and among Veterans Affairs facilities.

TABLE 21.2 National Voluntary Standards for Nursing-Sensitive Care

Framework Category Measure Description

Patient- centered

Death among surgical inpatients with

Percent of major surgical inpatients who experience hospital-acquired complications (e.g., sepsis, pneumonia,

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outcome measures

treatable serious complications (failure to rescue)

Pressure ulcer prevalence a

Falls prevalence a Falls with injury Restraint prevalence

(vest and limb only) Urinary catheter–

associated UTI for ICU patients a

Central line catheter- associated blood stream infection rate for ICU and HRN patients a

Ventilator-associated pneumonia for ICU and HRN patients a

gastrointestinal bleeding, shock/cardiac arrest, deep vein thrombosis/pulmonary embolism) that result in death.

Percent of inpatients who have hospital-acquired pressure ulcers (Stage 2 or greater).

Number of inpatient falls per inpatient days. Number of inpatient falls with injuries per inpatient days. Percent of patients who have a vest or limb restraint. Rate of UTI associated with use of urinary catheters for ICU

patients. Rate of bloodstream infections associated with use of central

line catheters for ICU or HRN patients. Rate of pneumonia associated with use of ventilators for ICU

and HRN patients.

Nursing- centered intervention measures

Smoking cessation counseling for AMI a

Smoking cessation counseling for HF a

Smoking cessation counseling for pneumonia a

Percent of AMI inpatients with smoking history in the past year who received smoking cessation advice or counseling during hospitalization.

Percent of HF inpatients with smoking history within the past year who received smoking cessation advice or counseling during hospitalization.

Percent of pneumonia inpatients with smoking history within the past year who received smoking cessation advice or counseling during hospitalization.

System- centered measures

Skill mix (RN, LVN/LPN, UAP and contract)

Nursing care hours per inpatient day (RN, LVN/LPN, and UAP)

PES-NWI (composite and five subscales)

Voluntary turnover

• Percent of RN care hours to total nursing care hours. • Percent of LVN/LPN care hours to total nursing care

hours. • Percent of UAP care hours to total nursing care hours. • Percent of contract hours (RN, LVN/LPN, and UAP) to

total nursing care hours. • Number of RN care hours per patient day. • Number of nursing staff hours (RN, LVN, LPN, UAP). Composite score and mean presence scores for each of

the following subscales derived from PES-NWI: • Nurse participation in hospital affairs. • Nursing foundations for quality of care. • Nurse manager ability, leadership, and support of

nurses. • Staffing and resource adequacy. • Collegial nurse–physician relations. Number of voluntary uncontrolled separations during

the month for RNs and advanced practice nurses, LVN/LPNs, and nurse assistant/aides.

aNQF-endorsed national voluntary consensus standard for hospital care. From National Quality Forum. (2012). Measuring performance. Retrieved from www.qualityforum.org/Measuring_Performance/ABCs_of_Measurement.aspx. AMI, Acute myocardial infarction; HF, heart failure; HRN, high-risk nursery; ICU, intensive care unit; LVP/LPN, licensed vocational/practical nurse; PES-NWI, practice environment scale-nursing work index; RN, registered nurse; UAP, unlicensed assistive personnel; UTI, urinary tract infection.

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HELPFUL HINT To find out how your hospital compares in nursing-sensitive quality indicators such as pressure ulcers, infections, and falls with another hospital in your area, go to https://www.medicare.gov/hospitalcompare/search.html. Identify high-performing organizations in your area from which you can learn.

Benchmarking The measurement of quality indicators must be done methodically using standardized tools. Standardized measurement allows for benchmarking, which is “a systematic approach for gathering information about process or product performance and then analyzing why and how performance differs between business units” (Massoud et al., 2001, p. 74). Benchmarking is critical for QI because it helps identify when performance is below an agreed- upon standard and signals the need for improvement. For example, when you record assessment of your patient’s risk for falls using one of the standardized assessment tools such as the Hendrich II Fall Risk Model or Morse Fall Scale and newly identified risk factors such as use of antidepressants, hypnotics, diuretics, antidiabetic medications, and polypharmacy (Callis, 2016), it allows for comparison of your assessment to those of providers in other organizations who provide care to a similar patient population and who use the same tools to document assessments. Tracking changes in the overall fall risk score over time allows you to intervene if the score falls below a set standard, indicating high risk for falls. Equally, after you implement needed interventions focused on altered elimination, mental status, or musculoskeletal weakness, you can track changes in the fall risk score to determine whether the interventions were effective in reducing risk for falls. Therefore standardized measurement can tell you when changes in care are needed and whether implemented interventions have resulted in the actual improvement of patient outcomes.

When all clinical units document care in the same way, it is possible to document pressure ulcer care across units. These performance data are useful for benchmarking efforts where clinical

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teams learn from each other how to apply best practices from high- performing units to the care processes of lower-performing units. Benchmarking (Massoud et al., 2001, p. 75) can be used to:

• Develop plans to address improvement needs.

• Borrow and adapt successful ideas from others.

• Understand what has already been tried.

Common quality improvement perspectives and models QI as a management model is both a philosophy of organizational functioning and a set of statistical analysis tools and change techniques used to reduce variations in the quality of goods or services that an organization produces (Nelson et al., 2007). The QI model emphasizes customer satisfaction, teams and teamwork, and the continuous improvement of work processes. Other defining features of QI include the use of transformational leadership by leaders at all levels to set performance goals and expectations, use of data to make decisions, and standardization of work processes to reduce variation across providers and service encounters (Nelson et al., 2007). The key principles associated with QI are shown in Table 21.3.

TABLE 21.3 Principles of Quality Improvement

Improvement Principle Key Benefits Principle 1—Customer focus/Patient focus

Health care organizations rely on patients and therefore should understand current and future patient needs, should meet patient requirements, and strive to exceed patient expectations.

• Increased customer value • Increased revenue and market

share obtained through flexible and fast responses to market opportunities

• Increased effectiveness in the organization’s resources use to enhance patient satisfaction

• Improved patient loyalty leading to repeat business

Principle 2—Leadership Leaders establish unity of purpose, and the organization’s

direction should create and maintain an internal

• People understand and are motivated toward the organization’s goals and

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environment in which people can become fully involved in organization’s objectives achievement.

objectives • Activities are evaluated,

aligned and implemented in a unified way

• Miscommunication between organization levels are minimized

Principle 3—Engagement of people People at all levels are the essence of an organization and are

essential to enhance organizational capability to create and deliver value.

• Motivated, committed, and involved people within the organization

• Innovation and creativity further the organization’s objectives

• People are accountable for own performance

• Enhanced involvement of people in improvement activities

Principle 4—Process approach Consistent results are achieved with more efficiently and

effectively when activities are understood and managed as a system of interrelated processes.

• Lower costs and shorter cycle times through effective use of resources

• Improved, consistent, and predictable results through a system of aligned processes

• Focused and prioritized improvement opportunities

Principle 5—Improvement Successful organizations have an ongoing focus on

improvement. Continual improvement is essential creating new opportunities.

• Performance advantage through improved organizational capabilities

• Focus on root-cause analysis, followed by prevention and corrective action

• Consideration of incremental and breakthrough improvements

Principle 6—Evidence-based decision making Effective decisions are based on the analysis and evaluation of

data and information are more likely to produce desired results.

• Improved decision-making processes

• Increased ability to demonstrate effectiveness of past decisions

• Increased ability to review, challenge, and change opinions and decisions

Principle 7—Relationship Management An organization and its suppliers are interdependent and a

mutually beneficial relationship enhances ability of both to create value.

• Increased capability to create value for both parties by sharing resources and managing quality-related risks

• A well-managed supply chain that provides a stable flow of goods and services

• Optimization of costs and resources

From International Organization for Standardization. (2015). ISO 9001 quality management principles. Retrieved from http://www.iso.org/iso/home/standards/management-standards/iso_9000.htm.

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Although QI has its roots in the manufacturing sector, many of the ideas, tools, and techniques used to measure and manage quality have been applied in health care organizations to improve clinical outcomes and reduce waste (McConnell et al., 2016). The major QI models used in health care include:

• Total Quality Management/Continuous Quality Improvement (TQM/CQI)

• Six Sigma

• Lean

• Clinical Microsystems

The key characteristics of each of these models are described in Table 21.4. Because QI uses a holistic approach, leaders often select one quality model that is used to guide the organization’s overarching improvement agenda.

TABLE 21.4 Overview of Quality Improvement Models Used in Health Care

Model MainCharacteristics Related Resources

TQM/CQI ( Langley et al., 2009)

• A holistic management approach used to improve organizational performance

• Seeks to understand and manage variation in service delivery

• Emphasizes customer satisfaction as an important performance measure

• Relies on team work and collaboration among workers to deliver

Institute for Healthcare Improvement: http://www.ihi.org/resources/Pages/default.aspx

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technically excellent and customer/patient- centered services

• Quality management science uses tools and techniques from statistics, engineering, operations research, management, market research and psychology

• TQM/CQI tools and techniques are applied to specific performance problems in the form of improvement projects

• The extent to which unit-level QI projects align with larger organizational quality goals, is related to their success and sustainability

Six Sigma ( DelliFraine et al., 2010)

• Developed at Motorola in the 1980s

• Six Sigma takes its name from the statistical notation of sigma (σ) used to measure variation from the mean

• Emphasizes meeting customer requirements and eliminating errors or rework with the goal of reducing process variation

• Focuses on tightly controlling variations in

AHRQ Innovations Exchange: www.innovations.ahrq.gov https://innovations.ahrq.gov/qualitytools/lean-hospitals-six-sigma-and-lean-

healthcare-forms

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production processes with the goal of reducing the number of defects to 3.4 units per 1 million units produced

• Process control achieved by applying DMAIC improvement model

• DMAIC includes defining, measuring, analyzing, improving, and controlling

• Practitioners achieve mastery levels using statistical tools to measure and manage process variation (e.g., yellow-belt, green-belt, black- belt)

Lean ( DelliFraine et al., 2010)

• Sometimes referred to as the Toyota Quality Model

• Focus: Eliminating waste from the production system by designing the most efficient and effective system

• Production controlled through standardization and placing the right person and materials at each step of the process

• Uses the PDSA improvement cycle

• Statistical tools include value

Institute for Healthcare Improvement: www.ihi.org/knowledge/Pages/IHIWhitePapers/GoingLeaninHealthCare.aspx

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stream mapping and Kanban, or a visual cue, used to warn clinicians that there is a process problem

• Performance measures vary from project to project and may inform the creation of new performance measures

• Uses a master teacher (“Sensei”) to spread the practices of Lean though the organizational culture

Clinical Microsystems ( Nelson et al., 2007)

• Model of service excellence developed specifically for health care

• Clinical microsystem is considered the building block of any health care system and is the smallest replicable unit in an organization

• Members of a clinical microsystem are interdependent and work together toward a common aim

Clinical Microsystems:www.clinicalmicrosystem.org

AHRQ, Agency for Healthcare Research and Quality; CQI, continuous quality improvement; PDSA, plan-do-study-act; QI, quality improvement; TQM, total quality management.

It is important to note that health care organizations have adopted principles and practices associated with the industrial QI approach relatively recently. Historically, the quality of health care was assessed retrospectively using the quality assurance (QA) model. The QA model uses chart audits to compare care against a predetermined standard. Corrective actions associated with QA

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focus on assigning individual blame and correcting deficiencies in operations. Another model commonly associated with health care QI is the Structure-Process-Outcome Framework (Donabedian, 1966). This framework is used to examine the resources that make up health care delivery services, clinicians’ work practices, and the outcomes associated with the structure and processes. The evolution of the key perspectives used to understand and manage QI in health care organizations is summarized in Table 21.5.

TABLE 21.5 Evolution of Quality Improvement Perspectives in Health Care

CQI, Continuous quality improvement; HAPU, hospital-acquired pressure ulcers; HCAHPS, Hospital consumer assessment of health care providers and systems; PDSA, plan-do-study-act; QA, quality assurance; TQM, total quality management.

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Quality improvement steps and tools Similar to the nursing process, which you use to guide your assessment, diagnoses, and treatment of patient problems, you can use the QI process steps (Massoud et al., 2001) for the following:

1. Assessing health system performance by collecting and monitoring data

2. Analyzing data to identify a problem in need of improvement

3. Developing a plan to treat the identified problem

4. Testing and implementing the improvement plan

Several tools facilitate each step of the QI process (Table 21.6). You can use these tools to assist with collecting and analyzing data and to identify and test improvement ideas. A case example, Nurse Response Time to Patient Call Light Requests (Box 21.7), is presented to introduce the steps of the improvement process and apply several basic QI tools used to measure and manage system performance.

TABLE 21.6 Quality Improvement Tools and Activities

From Massoud R, Askov K, Reinke J, et al. (2001). A modern paradigm for improving healthcare quality. QA Monograph Series 1(1). Bethesda, MD: Published for the US Agency for International Development by the Quality Assurance Project.

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BOX 21.7 Applying the Quality Improvement Steps to a Clinical Performance Problem A Case Study of a Call Bell Response Time Improvement Project Case study background After reviewing a year of HCAHPS patient satisfaction data, the QI team on the 6 East orthopedic unit noticed that the unit’s scores were consistently below the hospital average on the call bell response time. In addition to the somewhat mediocre patient satisfaction scores, the nurses were also frustrated with the way that the unit staff responded to patient calls. Using the patient and staff satisfaction HCAHPS data as a starting point, the QI team selected call bell response time as an opportunity for improvement.

Improvement step 1: Assessment The goal of the 6 East QI project was to understand and manage system variation associated with patient’s satisfaction with call bell response times. The QI team began the improvement project by asking the broad questions:

• What time of day is associated with a higher frequency of call bell use?

• What is the average time that it takes a staff member to answer a call bell?

• Are there variations in call bell response time based on the location of the patient’s room in relation to the central nursing station?

The QI team designed a check sheet to collect data on the number of call bell requests each hour by patient room number. The charge nurse and unit clerk took turns recording call bell requests during a 24-h period. The QI team downloaded data from the call bell system to gain information on the average response time as well as information about unit staffing patterns and

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patient’s admitting diagnoses.

Improvement step 2: Analysis To begin, the QI team tallied the call response time with a histogram using 5-min intervals. In graphing the data, a clear pattern emerged. The patient wait times fell into three groups:

• One group waited an average of 8 min.

• The second group waited an average of 12 min.

• A third group waited an average of 20 min for a member of staff to respond to the call bell request.

Upon further analysis of the data, the QI team discovered that the patients with the longest waiting times were in rooms that are the furthest from the central nursing station. The QI team constructed a Pareto diagram to understand the nature and frequency of the patients’ requests. This analysis revealed that the three most frequently occurring patient requests were:

• Pain medication

• Assistance with repositioning

• Assistance with opening and positioning food on the tray table during meal time

Finally, the team constructed a fishbone diagram to identify the factors associated with the 20-min response delays. Using these data, the QI team was able to identify the likely cause of the problem and its symptoms.

Improvement step 3: Develop a plan for improvement The QI team worked with the hospital librarian to identify relevant studies to develop their improvement project plan. The QI team reviewed a number of research studies about patient requests and response rates from both the patient and nurse perspectives. The team also reviewed studies about work redesign to involve the food service team more directly into the unit’s workflow. Based on

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a critical appraisal of the evidence, the QI team decided to try two interventions for the improvement project:

1. Hourly nurse rounding to improve responsiveness for patient’s pain medication requests, and

2. Role redesign for the dietary staff to reduce patient’s request for meal assistance.

The QI team agreed on the specific aim statements to guide the project:

1. In 30 days, we aim to reduce the number of call bell requests for pain medication from 15 per hour to 3 per 8-h shift.

2. In 30 days, we aim to decrease average wait time for pain medication from 12 min to 5 min.

Improvement step 4: Test and implement the improvement plan Case Study Continues: The QI team tested the two change ideas using PDSA cycles over two successive weeks. Hourly nurse rounding was tested using three nurses on the day and evening shift with patients admitted to three randomly assigned rooms for a 3-day period. During the hourly rounds, the nurses conducted pain assessments and administered medication and other pain management interventions. The nurses recorded their interventions on a data collection sheet in each patient’s bedside chart. The unit clerk collected the call bell frequency and response time from the central system for the patients in the randomly assigned rooms during the PDSA testing period. During the testing period, the improvement team reviewed the data at the end of each shift to assess changes in performance.

During the next week, the improvement team piloted the change in the dietary aid’s work responsibilities to include opening the food trays at the bedside, positioning patients to eat, and filling the water pitchers at the time the meals were served. The change in the dietary aid job responsibilities required training in infection control, body mechanics, and the creating of a new sign system to

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alert the dietary staff about the patients’ dietary restrictions. This change idea was piloted using the same number of staff members, duration, patient rooms, and unit clerk documentation responsibilities as the PDSA cycle for the hourly nurse rounds. Staff feedback about the strengths and drawbacks of the hourly rounding and expanded food preparation responsibilities for the dietary aids, including suggestions for improving the practice changes, were collected.

Finally, to evaluate the effectiveness of the change ideas, the QI team used a run chart to track performance for the unit’s call bell response time. The run chart was annotated to include the days that the team implemented the PDSA cycles to refine the process used for hourly nurse rounding and the change in the dietary aid’s responsibilities to set up patients’ meal trays. At the end of a month of experimentation, the QI team was able to reduce the number of call bell requests for pain medication from a high of 15 per hour at the beginning of the project, to three per shift. Similarly, the average time that patients waited for their pain medication dropped from 12 to 5 min. The team was able to achieve similar reductions in the call bell requests at meal time by expanding the role of the dietary aid to include meal setup. Based on the performance data, the QI team recommended that hourly nurse rounding and meal setup by the dietary aids become the standard of practice on the unit.

To embed the new practices into the unit routines, the QI team supervised PDSA cycles until the entire unit reached the performance goal in the specific aim statement. The run chart data suggested that the call bell response process was mostly stable with some variation attributed to new staff hired for the weekend day shift who were not fully oriented to the new routines for hourly nurse rounding and meal tray setup.

Forming a lead quality improvement team QI is inherently an interprofessional team process and requires contributions from various perspectives to assess the potential causes of system malfunction and improvement ideas (Nelson et al., 2007). A lead QI team should be composed of representatives from multiple professions involved in patient care, support staff,

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patients, and families. While all professional staff, support staff, and patients should be involved throughout the improvement process, members of the lead team are responsible for planning, coordinating, implementing, and evaluating improvement efforts. To maintain a productive lead team, it is important to set a meeting schedule and use effective meeting tools such as the following (Nelson et al., 2007):

• Meeting agenda

• Meeting roles

• Ground rules

• Brainstorming

• Multivoting

Other tools that can help with project management to keep team and activities organized and focused include action plans and Gantt charts (Nelson et al., 2007). To download templates of meeting agendas, meeting role cards, action plans, and Gantt charts, go to the Clinical Microsystems website at https://clinicalmicrosystem.org and select the Materials/Worksheets tabs. After the lead team is assembled and team processes established, the team can begin assessment of the health system. To access resources on how to best facilitate interprofessional teamwork, visit The National Center for Interprofessional Education and Practice at https://nexusipe.org.

HIGHLIGHT To keep the interprofessional QI lead team engaged and on schedule, hold team meetings at least weekly and display a timeline of QI activities such as data collection, analysis, and results of PDSA cycles, with completion progress for each activity where all team members can see it.

Improvement process step 1: Assessment In the assessment phase, the first step is to complete a structured assessment to understand more about performance patterns. The

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https://clinicalmicrosystem.org

http://https://nexusipe.org

improvement team typically begins with a series of broad questions that are used to guide data collection. Common methods used to collect system performance data include check sheets and data sheets to understand performance patterns and surveys, focus groups, and interviews to gather information about patient and staff perceptions of system performance. Commonly collected data elements include information about the following (Nelson et al., 2007):

• Patients: What are the average age, gender, top diagnoses, and satisfaction scores?

• Professionals: What is the level of staff satisfaction? What is their skill set?

• Processes and patterns: What are the processes for admitting and discharging patients?

• Common performance metrics: What are the rates of pressure ulcers and falls with injury?

For useful data collection templates, select the Tools tab at https://clinicalmicrosystem.org/.

HELPFUL HINT To reduce data collection burden related to QI projects, when starting the assessment phase of the QI process, first identify what performance data already exist in your organization. For example, find out if your organization is participating in the National Database of Nursing Care Quality Indicators program, which collects quarterly data on pressure ulcers, infections, falls, staff satisfaction, and other quality indicators.

Improvement step 2: Analysis The next phase of the improvement process focuses on data analysis. Because QI uses a team problem-solving approach, data are displayed in graphic form so all team members can see how the system is performing and generate ideas for what to improve. Several tools exist to help display and analyze performance data.

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http://https://clinicalmicrosystem.org/

Trending variation in system performance with run and control charts If quality health care means that the right care is delivered to the right people, in the right way, at the right time, for every person, during each clinical encounter, it is important to learn when criteria are not met and why (IOM, 2001). One method is to track performance over time and understand sources of variation in system performance, which can guide improvement activities to design a better-functioning health system. Minimizing performance variation is one of the main QI goals. There are two main types of system variation (Nelson et al., 2007, p. 346):

• Common cause variation occurs at random and is considered a characteristic of the system. For example, you might never leave your house in time for prompt arrival to class. In this case, you must work on better managing multiple random causes of tardiness, such as getting up late or taking too long to shower, dress, and eat to improve your overall punctuality record.

• Special cause variation arises from a special situation that disrupts the causal system beyond what can be accounted for by random variation. An example might be that you usually leave your house on time for a prompt arrival to class, but special circumstances such as road construction or a broken elevator delay your arrival to class. Once these special causes of tardiness are resolved, you will arrive to class on time.

Variations in system performance over time are commonly displayed with run charts and control charts. A run chart is a graphical data display that shows trends in a measure of interest; trends reveal what is occurring over time (Nelson et al., 2007). The vertical axis of the run chart depicts the value of measure of interest, and the horizontal axis depicts the value of each measure running over time. A run chart shows whether the outcome of interest is running in a targeted area of performance, and how much variation there is from point to point and over time. For example, a patient newly diagnosed as having diabetes can record her blood glucose levels over a month using a run chart. By

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regularly charting blood glucose levels, the patient is able to reveal when blood glucose runs higher or lower than the target level of less than 100 mg/dL for fasting plasma glucose (FPG) test. The run chart in Fig. 21.1 shows that FPG levels are consistently higher than the target, with a median FPG of 130 mg/dL; the trend of FPG readings in the first 19 days of the month is indicative of common cause variation. These random variations in FPG readings are likely caused by a confluence of several factors such as diet, exercise, and medication adherence. To correct the undesirable variation, the patient can assess which factors might be influencing the higher FPG values and then work with her primary care provider to develop necessary interventions to better control her blood glucose by better managing multiple causal factors. To determine whether interventions were successful, the patient and her provider should continue to document blood glucose levels and then compare the median FPG values before and after interventions are implemented.

FIG 21.1 Run chart of daily fasting plasma glucose

levels.

In addition, special cause variation in FPG is evident on days 19 to 28, where nine consecutive FPG readings are above the median line. It turns out that on these days, the patient had run out of her glucose-lowering medication; this special circumstance caused increased FPG. Although various rules exist for accurately determining the presence of special cause variation, generally special cause variation is present if the following are true (Nelson et al., 2007, p. 349):

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• Eight data points in a row are above or below the median or mean.

• Six data points in a row are going up.

• Six data points in a row are going down.

Determining common and special causes of variation is important because treatment strategies for eliminating each type of variation will vary.

A control chart (Fig. 21.2) is also used to track system performance over time, but it is a more sophisticated data tool than a run chart (Nelson et al., 2007). A control chart includes information on the average performance level for the system depicted by a center line displaying the system’s average performance (the mean value), and the upper and lower limits depicting one to three standard deviations from average performance level. The rules to detect special cause variation are the same for run and control charts, except that for control charts the upper and lower limits are additional tools used to detect special cause variation. Any point that falls outside the control limit is considered an outlier that merits further examination.

FIG 21.2 Control chart of average wait time before and after a redesign. Source: (From Massoud R, Askov K, Reinke J, et al. [2001]. A modern paradigm for improving healthcare quality. QA Monograph

Series 1[1]. Bethesda, MD: Published for the US Agency for International Development by the Quality Assurance Project.)

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HELPFUL HINT Use a run chart in step two of the QI process to analyze causes of variation in fasting plasma glucose (FPG) levels from the target level of 100 mg/dL and in step four of the QI process to evaluate if changes in diet, exercise, and medication adherence helped the patient achieve the targeted FPG.

Graphs Graphs commonly used to understand system performance, displayed in Fig. 21.3, include pie charts, bar charts, and histograms. Selecting the appropriate chart depends on the type of data collected and the performance pattern the improvement team is trying to understand. A bar chart is used to display categorical- level data. A Pareto diagram is a special type of bar chart used to understand the frequency of factors that contribute to a common effect. It is used to display the Pareto Principle, sometimes referred to as the 80-20 Rule, or the Law of the Few (Massoud et al., 2001), which states that 80% of variation in a problem originates with 20% of cases. In a Pareto diagram, the bars are displayed in descending order of frequency. A histogram is another type of bar chart used for continuous-level data to show the distribution of the data around the mean, commonly called the bell curve (Massoud et al., 2001).

FIG 21.3 Examples of bar chart, pie chart, and histogram. Source: (From Massoud R, Askov K, Reinke J, et al. [2001]. A modern paradigm for improving healthcare quality. QA Monograph Series

1[1]. Bethesda, MD: Published for the US Agency for International Development by the Quality Assurance Project.)

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Cause and effect diagrams More sophisticated visual data displays include cause and effect diagrams used to identify and treat the causes of performance problems. Two common tools in this category are a fishbone or Ishikawa diagram and a tree diagram (Massoud et al., 2001). The fishbone diagram facilitates brainstorming about potential causes of a problem by grouping potential causes into the categories of environment, people, materials, and process (Fig. 21.4). Fishbone diagrams can be used proactively to prevent quality defects, including errors, and retrospectively to identify factors that potentially contributed to quality defect or an error that has already occurred. An example of when a fishbone diagram is used retrospectively is during root cause analyses (RCAs) to identify system design failures that caused errors.

FIG 21.4 Fishbone diagram. Source: (Adapted from Massoud R, Askov K, Reinke J, et al. [2001]. A modern paradigm for improving

healthcare quality. QA Monograph Series 1[1]. Bethesda, MD: Published for the US Agency for International Development by the Quality Assurance

Project.)

An RCA is a structured method used to understand sources of

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system variation that lead to errors or mistakes, including sentinel events, with the goal of learning from mistakes and mitigating hazards that arise as a characteristic of the system design (Zastrow, 2015). An RCA is conducted by a team that includes representatives from nursing, medicine, management, QI, or risk management and the individual(s) involved in the incident (sometimes including the patient or family members in the discovery process), and it emphasizes system failures while avoiding individual blame (Zastrow, 2015). An RCA seeks to answer three questions to learn from mistakes:

• What happened?

• Why did it happen?

• What can be done to prevent it from happening again?

Because the RCA is viewed as an opportunity for organizational learning and improvement, the most effective RCAs include a change in practice or work system design to lessen the chances of similar errors occurring in the future.

A tree diagram is particularly useful for identifying the chain of causes, with the goal of identifying the root cause of a problem. For example, consider medication errors. The improvement team could use the Five Whys method to establish the chain of causes leading to the medication error:

• Question 1: Why did the patient get the incorrect medicine?

Answer 1: Because the prescription was wrong.

• Question 2: Why was the prescription wrong?

Answer 2: Because the doctor made the wrong decision.

• Question 3: Why did the doctor make the wrong decision?

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Answer 3: Because he did not have complete information in the patient’s chart.

• Question 4: Why wasn’t the patient’s chart complete?

Answer 4: Because the doctor’s assistant had not entered the latest laboratory report.

• Question 5: Why hadn’t the doctor’s assistant charted the latest laboratory report?

Answer 5: Because the lab technician telephoned the results to the receptionist, who forgot to tell the assistant.

In this case, using the Five Whys technique suggests that a potential solution for avoiding wrong prescriptions in the future might be to develop a system for tracking lab reports (Massoud et al., 2001).

Flowcharting A flowchart depicts how a process works, detailing the sequence of steps from the beginning to the end of a process (Massoud et al., 2001). Several types of flowcharts exist, including the most simple (high level), a detailed version (detailed), and one that also indicates the people involved in the steps (deployment or matrix). Fig. 21.5 shows an example of a detailed flowchart. Massoud and colleagues (2001, p. 59) suggest using flowcharts to:

• Understand processes.

• Consider ways to simplify processes.

• Recognize unnecessary steps in a process.

• Determine areas for monitoring or data collection.

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• Identify who will be involved in or affected by the improvement process.

• Formulate questions for further research.

FIG 21.5 Detailed flowchart of patient registration. Source: (Adapted from Massoud R, Askov K, Reinke J, et

al. [2001]. A modern paradigm for improving healthcare quality. QA Monograph Series 1[1]. Bethesda, MD: Published for the US Agency for

International Development by the Quality Assurance Project.)

When flowcharting, it is important to identify a start and an end point of a process, then make a record of the actual, not the ideal, process. To obtain an accurate picture of the process, perform direct observation of the process steps and communicate with people who are directly part of the process to clarify all the steps.

Improvement step 3: Develop a plan for improvement By identifying potential sources of variation, the improvement team can pinpoint the problem areas in need of improvement. The next phase is to treat the performance problem. This phase involves developing and testing a plan for improvement. A simple yet powerful model for developing and testing improvements is the Model for Improvement (Langley et al., 2009). It begins with three questions to guide the change process and focus the improvement work (Langley et al., 2009):

1. Aim. What are we trying to accomplish? Set a clear aim with

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specific measurable targets.

2. Measures. How will we know that the change is an improvement? Use qualitative and quantitative measures to support real improvement work to guide change progress toward the stated goal.

3. Changes. What changes can we make that will result in an improvement? Develop a statement about what the team believes they can change to cause improvement.

The change ideas reflect the team’s hypotheses about what could improve system performance. There are several ways in which change ideas can be generated. The change ideas can be identified from the root causes of the performance problems that are identified during cause and effect and process analyses using fishbone diagram, the Five Whys, and flowcharting tools in the analysis step of the improvement process. Another approach is to select common areas for change associated with the goals and philosophy of QI. Common change topics, also referred to as themes for improvement, include (Langley et al., 2009, p. 359):

• Eliminating waste

• Improving work flow

• Optimizing inventory

• Changing the work environment

• Managing time more effectively

• Managing variation

• Designing systems to avoid mistakes

• Focusing on products or services

Change ideas can also come from the evidence provided by your review of the available literature. This is where your EBP skills will

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be most helpful. You will need to critically appraise both research studies and QI studies of interventions that can be applied to remedy the identified problem. To help you decide whether a journal article is a research study or a QI study, see the critical decision tree in Fig. 21.6. Because QI studies capture the experiences of a particular organization or unit, the results of these studies are usually not generalizable. In an effort to promote knowledge transfer and learning from others’ improvement experiences, the Standards for Quality Improvement Reporting Excellence, or the SQUIRE Guidelines (Ogrinc et al., 2015), were developed to promote the publication and interpretation of this type of applied research. The SQUIRE Guidelines are presented in Table 21.7; you should use them to evaluate QI studies.

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FIG 21.6 Differentiating QI from research projects. SQUIRE, Standards for Quality Improvement

Reporting Excellence. Source: (Adapted with permission from King, D. L. [2008]. Research and quality improvement: Different processes,

different evidence. Medsurg Nursing, 17[3], 167.)

TABLE 21.7 Revised Squire Guidelines Standards for Quality Improvement Reporting Excellence (Squires 2.0)

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From Ogrinc G, Davies L, Goodman D, et al. (2015). SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process. BMJ Quality and Safety, 0, 1–7. doi:10.1136/bmjqs- 2015-004411. Note: See www.squire-statement.org/ for more information on publishing QI studies.

Improvement step 4: Test and implement the improvement plan

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http://www.squire-statement.org/

The improvement changes that are identified in the planning phase are tested using the Plan-Do-Study-Act (PDSA) Improvement Cycle, which is the last step of the Improvement Model (Langley et al., 2009; Massoud et al., 2001) depicted in Fig. 21.7. The focus of PDSA is experimentation using small and rapid tests of change. Actions involved in each phase of the PDSA cycle are detailed in Fig. 21.7. In this step, you evaluate the success of the intervention in bringing about improvement. It is important for the team to monitor the intended and unintended changes in system performance, the patient and staff perceptions of the change, and ideally, the costs of the change. Also, in this phase of the improvement process, it is useful to track the stability and sustainability of the new work process by monitoring system performance over time. Results data should be presented in graphic data displays (explained earlier in the chapter) and compared with the baseline performance.

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FIG 21.7 Summary of the QI process. Source: (Adapted from Massoud R, Askov K, Reinke J, et al. [2001]. A modern paradigm for

improving healthcare quality. QA Monograph Series 1[1]. Bethesda, MD: Published for the US Agency for International Development by the Quality

Assurance Project.)

Taking on the quality improvement challenge and leading the way Hospital leaders and other key stakeholders agree that enabling nurses to lead and participate in QI is vital for strengthening our

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health system’s capacity to provide high-quality patient care (Draper et al., 2008; IOM, 2015). Nurses are on the front lines of delivering care, and they offer unique perspectives on the root causes of dysfunctional care, as well as what interventions might work reliably and sustainably in everyday clinical practice to achieve best care. However, multiple barriers to nurses’ participation in QI exist, including insufficient staffing, lack of leadership support and resources for nurses’ participation in QI, and not enough educational preparation for knowledgeable and meaningful QI involvement (Draper et al., 2008). For nurses to contribute their knowledge and expertise to patient care delivery and the organization’s quality enterprise, nursing leadership must engage in (Berwick, 2011, p. 326):

• Setting aims and building the will to improve

• Measurement and transparency

• Finding better systems

• Supporting PDSA activities, risk, and change

• Providing resources

Several common elements that make improvement work possible are captured in two bodies of knowledge (Berwick, 2011). One is professional knowledge that includes knowledge of one’s discipline, subject matter, and values of the discipline. The other is knowledge of improvement, which includes knowledge of complex systems functioning through dynamic interplay among various technical and human elements; knowledge of how to detect and manage variation in system performance; knowledge of managing group processes through effective conflict resolution and communication; and knowledge of how to gain further knowledge by continual experimentation in local settings through rapid tests of change. Linking these two knowledge systems promotes continuous improvement in health care. This chapter provides a starting point for you to develop basic knowledge and skills for the improvement work, so you can better meet the challenges and

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expectations of a contemporary nursing practice.

Key points • There is much room for improvement in the quality of care in the

United States.

• The quality of health care is evaluated in terms of its effectiveness, efficiency, access, safety, timeliness, and patient centeredness.

• As the largest group of health professionals, nurses play a key role in leading QI efforts in clinical settings.

• Accreditation, payment, and performance measurement are external incentives used to improve the quality of care delivered by hospitals and health professionals. One example of such is the Joint Commission accreditation for health care delivery organizations.

• The National Quality Forum “15” (NQF 15) is a set of 15 nursing- sensitive measures to assess and improve the quality of nursing care delivered in the United States.

• Standardized measures such as patient fall rates are used to compare performance across nursing units and organizations.

• Health care payers use quality performance measures such as 30- day readmission rates as a basis for paying hospitals and providers.

• QI is both a philosophy of organizational functioning and a set of statistical analysis tools and change techniques used to reduce variation.

• The major approaches used to manage quality in health care are Total Quality Management/Continuous Quality Improvement, Lean, Six Sigma, and the Clinical Microsystems model.

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• The defining characteristics of QI are focus on patients/customers; teams and teamwork to improve work processes; and use of data and statistical analysis tools to understand system variation.

• QI uses benchmarking to compare organizational performance and learn from high-performing organizations.

• QI tools, techniques, and principles are applied to clinical performance problems in the form of improvement projects, such as using a presurgical checklist to prevent wrong-side surgeries, a national patient safety goal.

• Unit-level improvement projects should align with organizational-level improvement priorities to promote the sustainability of the unit-level projects.

• There are four major steps in the QI process: assessment, analysis, improvement, and evaluation.

• Patient safety focuses on designing systems to remove factors known to cause errors or adverse events.

• Barriers exist that impede nurses’ participation in QI, including insufficient staffing, lack of leadership support, and nurses’ unfamiliarity with QI principles and practices.

Critical thinking challenges • Have your team discuss the similarities and differences

among total quality improvement, Lean, Six Sigma, and the Clinical Microsystems models. Choose one of the models for your team to use to guide your improvement project.

• Consider your unit’s performance on the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey. What suggestions do you have for applying QI principles to improve your unit’s score on these key performance indicators?

• Why is it important to document nurse-sensitive care outcomes

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using standardized performance measurement systems? How does performance measurement relate to QI activities?

• What barriers do you see for participating in unit-level quality improvement initiatives? What suggestions do you have for overcoming these barriers?

• In what ways do QI studies differ from research studies? How would you use the results of a QI study to inform a change in practice on your unit?

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

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2. Alexander G. R. Nursing sensitivity databases Their existence, challenges, and importance. Medical Care Research and Review 2007;64(2):44S-63S Available at: doi:10.1177/558707299244

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12. Donabedian A. Evaluating the quality of medical care. The Milbank Memorial Fund Quarterly 1966;44(3):166-206.

13. Draper D. A, Felland L. E, et al. The role of nurses in hospital quality improvement (CSHSC Report no. 3). Available at: http://www.hschange.org/CONTENT/972/ 2008; Retrieved from

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16. Institute of Medicine (IOM). Crossing the quality chasm A new health system for the 21st century: executive summary.

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Washington, DC: The National Academies Press 2001; Available at: http://books.nap.edu/catalog/10027.html Retrieved from

17. Institute of Medicine (IOM). Assessing progress on the IOM report The Future of Nursing. Washington, DC: The National Academies Press 2015;

18. Langley G. J, Moen R. D, Nolan K. M, et al. The improvement guide A practical approach to enhancing organizational performance. 2nd ed. San Francisco, CA: Jossey-Bass 2009;

19. Massoud R., Askov K., Reinke J., et al. A modern paradigm for improving healthcare quality. . QA Monograph Series. Bethesda, MD: The Quality Assurance Project 2001;1; 1.

20. McConnell J. K, Lindrooth R. C, Wholey D. R, et al. Modern management practices and hospital admissions. Health Economics 2016;25:470-485 Available at: doi:10.1002/hec.3171

21. National Quality Forum (NQF). National voluntary consensus standard for nursing-sensitive care an initial performance measure set. Available at: http://www.qualityforum.org/Publications/2004/10/National_Voluntary_Consensus_Standards_for_Nursing- Sensitive_Care__An_Initial_Performance_Measure_Set.aspx 2004; Retrieved from

22. Nelson E. C, Batalden P. B, Godfrey M. M. Quality by design A clinical microsystems approach. San Francisco, CA: Jossey-Bass 2007;

23. Nuti S. V, Wang Y., Masoudi F. A, et al. Improvements in the distribution of hospital performance for the care of patients with acute myocardial infarction, heart failure, and pneumonia, 2006– 2011. Medical Care 2015;53(6):485-491.

24. Ogrinc G., Davies L., Goodman D., et al. SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence) Revised publication guidelines from a detailed consensus process. BMJ Quality and Safety 2015;0:1-7 Available at: doi:10.1136/bmjqs-2015-004411

25. Tidwell J., Busby R., Lewis B., et al. The race Quality assurance performance improvement project aimed at achieving superior patient outcomes. Journal of Nursing Care Quality 2016;31(2):99-104.

26. Tripathi S., Arteaga G., Rohlik G, et al. Implementation of

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http://dx.doi:10.1136/bmjqs-2015-004411

patient-centered bedside rounds in the pediatric intensive care unit. Journal of Nursing Care Quality 2015;30(2):160-166.

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29. Zastrow R. L. Root cause analysis in infusion nursing Applying quality improvement tools for adverse events. Journal of Infusion Nursing 2015;38(3):225-231 Available at: doi:10.1097/NAN.0000000000000104

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http://dx.doi:10.1097/NAN.0000000000000104

Appendix A. Example of a randomized clinical trial (nyamathi et al., 2015) Nursing case management, peer coaching, and hepatitis A and B vaccine completion among homeless men recently released on parole

Adeline Nyamathi, Benissa E. Salem, Sheldon Zhang, David Farabee, Betsy Hall, Farinaz Khalilifard, Barbara Leake

Background: Although hepatitis A virus (HAV) and hepatitis B virus (HBV) infections are vaccine-preventable diseases, few homeless parolees coming out of prisons and jails have received the hepatitis A and B vaccination series.

Objectives: The study focused on completion of the HAV and HBV vaccine series among homeless men on parole. The efficacy of three levels of peer coaching (PC) and nurse-delivered interventions was compared at 12-month follow-up: (a) intensive peer coaching and nurse case management (PC-NCM); (b) intensive PC intervention condition, with minimal nurse involvement; and (c) usual care (UC) intervention condition, which included minimal PC and nurse involvement. Furthermore, we assessed predictors of vaccine completion among this targeted sample.

Methods: A randomized control trial was conducted with 600 recently paroled men to assess the impact of the three intervention conditions (PC-NCM vs. PC vs. UC) on reducing drug use and recidivism; of these, 345 seronegative, vaccine- eligible subjects were included in this analysis of completion of the Twinrix HAV/HBV vaccine. Logistic regression was added to assess predictors of completion of the HAV/HBV vaccine series

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and chi-square analysis to compare completion rates across the three levels of intervention.

Results: Vaccine completion rate for the intervention conditions were 75.4% (PC-NCM), 71.8% (PC), and 71.9% (UC; p = .78). Predictors of vaccine noncompletion included being Asian and Pacific Islander, experiencing high levels of hostility, positive social support, reporting a history of injection drug use, being released early from California prisons, and being admitted for psychiatric illness. Predictors of vaccine series completion included reporting having six or more friends, recent cocaine use, and staying in drug treatment for at least 90 days.

Discussion: Findings allow greater understanding of factors affecting vaccination completion in order to design more effective programs among the high-risk population of men recently released from prison and on parole.

Key Words: accelerated Twinrix hepatitis A/B vaccine; ex-offenders; homelessness; parolees; prisoners; substance abuse

Nursing Research, May/June 2015, Vol 64, No 3, 177-189

With 1.6 million men and women behind bars, the United States has one of the largest numbers of incarcerated persons when compared to other nations (Pew Charitable Trusts, 2008). In California, over 130, 000 are in custody and over 54, 000 are on parole (California Department of Corrections and Rehabilitation, 2013b). Incarcerated populations are at significant risk for homelessness. When compared to the general population, those who were in jail were more likely to be homeless (Greenberg & Rosenheck, 2008). In one study, homeless inmates were more likely to have past criminal justice system involvement for both nonviolent and violent offenses, mental health and substance abuse problems, and lack of personal assets (Greenberg & Rosenheck, 2008).

Globally, incarcerated populations encounter a host of public healthcare issues; two such issues—hepatitis A virus (HAV) and hepatitis B virus (HBV) diseases—are vaccine preventable. In addition, viral hepatitis disproportionately impacts the homeless

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because of increased risky sexual behaviors and drug use (Stein, Andersen, Robertson, & Gelberg, 2012), along with substandard living conditions (Hennessey, Bangsberg, Weinbaum, & Hahn, 2009). Other risk factors include, but are not limited to, injection drug use (IDU), alcohol use, and older age, which place the population at risk for being seropositive (Stein et al., 2012).

Incarcerated populations are at significant risk for homelessness. As a member of the hepatovirus family, HAV is primarily transmitted via the fecal-oral route (Zuckerman, 1996). The rate of acute hepatitis in the United States is 0.5 per 100, 000 (Centers for Disease Control and Prevention, 2010). Although the rate among paroled populations is hard to ascertain, data suggest that HAV infection is related to unsanitary living conditions, that is, poor water sanitation (World Health Organization, 2014), for which homeless populations are at risk.

A member of the Hepadnavirus family, HBV (Immunization Action Coalition, 2013; Zuckerman, 1996) disproportionately burdens homeless (Nyamathi, Liu, et al., 2009; Nyamathi, Sinha, Greengold, Cohen, & Marfisee, 2010) and incarcerated populations (Immunization Action Coalition, 2013; Khan et al., 2005), leading to fulminant liver failure, chronic liver disease, hepatocellular carcinoma, and death (Rich et al., 2003). HBV can be transmitted through unprotected sexual activity, needle sharing, IDU (Diamond et al., 2003; Maher, Chant, Jalaludin, & Sargent, 2004), and percutaneous blood exposure. National prevalence statistics indicate that HBV affects between 13% and 47% of U.S. prison inmates (Centers for Disease Control and Prevention, 2004). Illicit drug use is a major contributor to incarceration and homelessness among ex-offenders (McNeil & Guirguis-Younger, 2012; Tsai, Kasprow, & Rosenheck, 2014), placing ex-offenders who use drugs at high risk for HBV infection.

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among jail inmates, 19% had past HBV infection, and 12% completed the HBV vaccination series (Hennessey, Kim, et al., 2009). Although HBV vaccination is well accepted behind bars— because of a lack of funding and focus on prevention as a core in the prison system—few inmates may complete the series (Weinbaum, Sabin, & Santibanez, 2005). In addition, prevention may not be a priority for those who are struggling with managing mental health, drug use, and dependency issues, along with the need to meet basic necessities (Nyamathi, Shoptaw, et al., 2010). Authors contend that, although the HBV vaccine is cost-effective, it is underutilized among high-risk (Rich et al., 2003) and incarcerated populations (Hunt & Saab, 2009).

For homeless men on parole, vaccination completion may be affected by level of custody; generally, the higher the level of custody, the higher the risk an inmate poses. In addition, various contract types, such as drug treatment related, and length of time in residential drug treatment (RDT)—for those with drug histories— may also affect completion of the vaccine series. For those transitioning into the community, stress, family reunification issues, and the potential for relapse and recidivism may represent real challenges (Seiter & Kadela, 2003) and may influence vaccine completion.

Until 1981, the HBV vaccine was not licensed in the U.S. (Centers for Disease Control and Prevention, 2012). Twenty years later, in 2001, a combination of the HAV and HBV vaccine, Twinrix, was developed by GlaxoSmithKline and approved by the Food and Drug Administration (Centers for Disease Control and Prevention, 2012). The standard dosing for this regimen is 0, 1, and 6 months. An alternative dosing schedule (core doses at 0, 7, and 21–31 days and a booster dose 12 months) was approved by the Food and Drug Administration in 2007 (Centers for Disease Control and Prevention, 2012). Thus, many individuals, particularly older individuals, may not have been vaccinated.

One strategy to improve vaccination for HAV and HBV among high-risk populations has been to utilize the accelerated Twinrix HAV/HBV vaccination, which provides the core doses at 0, 7, and 21–30 days (Nyamathi, Liu, et al., 2009). The Twinrix recombinant vaccination is administered intramuscularly (GlaxoSmithKline,

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2011) by a licensed nurse. In a randomized controlled trial (RCT) comparing vaccination completion among incarcerated IDUs in Denmark—using the accelerated versus a standard vaccine schedule (0, 1, and 6 months)—63% completed the three accelerated dose series compared to 20% of those who received the nonaccelerated series (Christensen et al., 2004). In another RCT conducted among 297 homeless adults with a history of incarceration, findings revealed that 50% completed the Twinrix vaccine series. Logistic regression analysis revealed that those who were more likely to complete the HBV vaccination were over 40 years of age (p = .02), partnered (p = .02), homeless for more than 1 year (p = .025), recent binge drinkers (p = .03), and had attended recent alcohol anonymous or narcotic anonymous meetings (p = .006; Nyamathi, Marlow, Branson, Marfisee, & Nandy, 2012). In another RCT focused on improving HAV/HBV vaccine completion among 256 homeless adults who were on methadone maintenance, a greater percentage of participants who completed the vaccine series also reduced their alcohol consumption by 50% as compared to those who were unsuccessful in reducing their alcohol consumption (74.4% vs. 64.1%; Nyamathi, Shoptaw, et al., 2010).

Finally, in a larger, three-group RCT with 865 homeless adults in shelters located in Los Angeles, individuals were randomly assigned to one of three groups: (a) nurse case-managed sessions plus hepatitis education, incentives, and tracking; (b) standard hepatitis education plus incentives and tracking; and (c) standard hepatitis education and incentives only. Findings reveal that those who were in the nurse case management education, incentives, and tracking program were significantly more likely to complete a standard three-series Twinrix vaccination or core of the accelerated dosing schedule (68% vs. 61% vs. 54%, respectively; p = .01) compared to those who were in the other two programs (Nyamathi, Liu, et al., 2009). Although accelerated vaccination programs have shown success in RCT studies, including those utilizing nurse case management, little is known about vaccine completion among an ex-offender population using varying intensities of nurse case management and peer coaches.

Theoretical framework

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The comprehensive health seeking and coping paradigm (Nyamathi, 1989), adapted from a coping model (Lazarus & Folkman, 1984), and the health seeking and coping paradigm (Schlotfeldt, 1981) guided this study and the variables selected (see Figure 1). The comprehensive health seeking and coping paradigm has been successfully applied by our team to improve our understanding of HIV and HBV/hepatitis C virus (HCV) protective behaviors and health outcomes among homeless adults (Nyamathi, Liu, et al., 2009)—many of whom had been incarcerated (Nyamathi et al., 2012).

FIG 1 Comprehensive health seeking and coping paradigm.

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include age, education, race/ethnicity, and marital and parental status (Hennessey, Kim, et al., 2009; Salem et al., 2013). Situational factors such as being homeless (Nyamathi et al., 2012), history of criminal activities, and severity of criminal history (level of custody and contract type) may likewise influence interest in completing a vaccination series. Similarly personal factors, such as history of psychiatric and drug use problems (Hennessey, Kim, et al., 2009; Salem et al., 2013), having hostile tendencies (Nyamathi et al., 2014), or dealing with physical and mental health problems (Nyamathi et al., 2011), may interfere with health protective strategies, whereas having social factors present, such as social support, may facilitate health promotion. Finally, health seeking and coping strategies may also be known to impact health promotion (Nyamathi, Stein, Dixon, Longshore, & Galaif, 2003) and compliance with hepatitis vaccine completion.

Purpose Despite knowledge of awareness of risk factors for HBV infection, intervention programs designed to enhance completion of the three-series Twinrix HAV/HBV vaccine and identification of prognostic factors for vaccine completion have not been widely studied. The purpose of this study was to first assess whether seronegative parolees previously randomized to any one of three intervention conditions were more likely to complete the vaccine series as well as to identify the predictors of HAV/HBV vaccine completion.

Methods Design An RCT where 600 male parolees from prison or jail and participating in an RDT program were randomized into one of three intervention conditions aimed at assessing program efficacy on reducing drug use and recidivism at 6 and 12 months as well as vaccine completion in eligible subjects: (a) a 6-month intensive peer coaching and nurse case management (PC-NCM) intervention condition; (b) an intensive peer coaching (PC) intervention

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condition, with minimal nurse involvement; and (c) the usual care (UC) intervention condition, which had minimal PC and nurse involvement. Of these 600, 345 were eligible for the vaccine (seronegative) and constitute the sample for this report. Data were collected from February 2010 to January 2013. The study was approved by the University of California, Los Angeles Institutional Review Board and registered with Clinical Trials.gov (NCT01844414).

Sample and site There were four inclusion criteria for recruitment purposes in assessing program efficacy on reducing drug use and recidivism: (a) history of drug use prior to their latest incarceration, (b) between ages of 18 and 60, (c) residing in the participating RDT program, and (d) designated as homeless as noted on the prison or jail discharge form. A homeless individual was defined as one who does not have a fixed, regular, and adequate nighttime residence (National Health Care for the Homeless Council, 2014). Exclusion criteria included (a) monolingual speakers of languages other than English or Spanish and (b) persons judged to be cognitively impaired by the research staff. A total of 42 men were screened out because of the following reasons: age, not being on parole, had not been released from jail or prison within 6 months prior to entering the study, or had not used drugs 12 months prior to their most recent incarceration. Eligibility for receiving the HAV/HBV vaccine series was not considered an inclusion criterion regarding drug use and recidivism. Among those eligible and interested, urn randomization (Stout, Wirtz, Carbonari, & Del Boca, 1994) was used to allocate participants. The variables used in the urn randomization included age (18–29 and 30 and over), level of custody (1–2 vs. 3–4), HBV vaccine eligibility (HBV seronegative or seropositive), and level of substance use prior to prison time (low vs. moderate/high severity). For the present analysis, only vaccine- eligible subjects were included.

Amistad De Los Angeles (Amity) served as the main research site. For the last three decades, Amity, a nonprofit organization located in California, Arizona, and New Mexico, has been focused on substance abuse treatment and works with individuals and

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http://www.Trials.gov

families (Amity Foundation, 2014) utilizing a therapeutic environment.

The State of California Assembly passed a criminal justice realignment legislation (Assem. Bill 109, 2011) on October 1, 2011, allowing low-level offenders (nonviolent, nonserious, and nonsex offenders) to serve their sentence in county jails instead of state prisons (California Department of Corrections and Rehabilitation, 2011). Postrealignment offenders were more likely to be convicted of a felony for drug and property crimes (California Department of Corrections and Rehabilitation, 2013a).

Power analysis With at least 114 men in each intervention condition, there was 80% power to detect differences of 15–20 percentage points (e.g., 50% vs. 70%, 75% vs. 90%) for vaccine completion between either of the two intervention conditions and the UC intervention condition at p = .05.

Vaccine eligibility Vaccine eligibility included being HBV seronegative and no absolute contraindications (having an allergy to yeast or neomycin, history of neurological disease [e.g., Guillian-Barre]), prior anaphylactic reaction to HAV/HBV vaccine, a fever of over 100.5°F, and reporting any moderate or severe acute illness beyond mild cold symptoms (e.g., nonproductive cough, rhinorrhea, or other upper respiratory symptoms). Of the total sample of 600 study participants, 345 men were eligible for the HAV/HBV vaccine. Figure 2 (CONSORT diagram) reflects both the larger sample and the subsample of vaccine-eligible participants.

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FIG 2 CONSORT diagram. PC = peer coaching; PC- NCM = peer coaching-nursing case management; UC

= usual care.

Interventions Building upon previous studies, we developed varying levels of peer-coached and nurse-led programs designed to improve HAV/HBV vaccine receptivity at 12-month follow-up among homeless offenders recently released to parole.

Peer coaching-nurse case management The peer coach interacted weekly for about 45 minutes with their assigned participants in person, and for those who left the facility (interaction was by phone). Their focus was on building effective coping skills, personal assertiveness, self-management, therapeutic nonviolent communication, and self-esteem building. Attention was given to supporting avoidance of health-risk behaviors, increasing access to medical and psychiatric treatment, and improving compliance with medications, skill-building, and personal

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empowerment. Discussions also centered on strategies to assist in seeking support and assistance from community agencies as parolees prepare for completion of the drug treatment program. Integrated throughout, skill building in communication and negotiation and issues of empowerment were highlighted.

Peer coaches were also trained to deliver nonviolent communication, the goal of which was to increase participants’ mastery of empathic communication skills via a specific process. The intervention comprised a series of interactive exercises and role-playing based on conflict in social situations, as identified by the participants. In our study, peer coaches were former parolees who successfully completed a similar RDT program; as paraprofessionals, they were positive role models with whom the parolees could identify and have successfully reintegrated into society. The peer coachers were selected based on having excellent social skills and found joy helping recent parolees to be successful. The assigned coach worked with up to 15 parolees at any given time. The coaches in the PC-NCM and PC intervention conditions were trained in (a) understanding the needs and challenges faced by parolees discharged to the community; (b) gaining information about the resources that are available in the community; and (c) normalizing parolee experiences, setting realistic expectations, and helping the parolee to problem solve with day-to-day events and build on strengths. The training period for coaches took about 1 month and consisted mock role-plays of coaching sessions—with many simulations of problematic and challenging participants and situations.

Case management, provided by a dedicated nurse (about 20 minutes), was delivered in a culturally competent manner weekly over eight consecutive weeks. Case management focused on health promotion, completion of drug treatment, vaccination compliance, and reduction of risky drug and sexual behaviors. Furthermore, the nurse engaged participants in role-playing exercises to help them identify potential barriers to appointment keeping and asked them to identify personal risk triggers that may hinder vaccine series completion and successful HAV, HBV, HCV, and HIV risk reduction. Nurses were trained by experts in nurse case management, hepatitis infection and transmission, and barriers that

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impede HAV/HBV vaccination.

Peer coaching Participants assigned to the PC intervention condition received weekly PC interaction similar to the PC component of the PC-NCM intervention condition. However, although nurse case management was not included, an intervention-specific nurse encouraged the HAV/HBV vaccination and provided a brief 20-minute education session on hepatitis and HIV risk reduction.

Usual care Participants assigned to the UC intervention condition received the encouragement by a nurse to complete the three-series HAV/HBV vaccine. In addition, they received a brief 20-minute session by a peer counselor about health promotion. They did not receive any intensive PC sessions or nurse case management sessions.

At the RDT site, all participants received recovery and rehabilitation services traditionally delivered for the parolee population, such as residential substance abuse services, assistance with independent living skills, job skills assistance, literacy, individual, group (small and large) and family counseling, and coordinated discharge planning. Residents also receive highly structured curriculum and aftercare services in this generally 6- month, 24-hour-per-day, and 7-day-per-week community. All coordination for services took place through the efforts of the in- prison treatment staff, RDT community-based staff, and the parole office.

Procedure This RCT was conducted in a setting close to the one participating RDT program from which all participants were enrolled. Posted flyers announced the study to all incoming residents, and research staff visited the RDT frequently to respond to questions and provide information in group sessions and individually to those interested in a private location in the RDT setting. Among interested participants, an informed consent was signed that allowed the research staff to administer a brief screening questionnaire to assess eligibility criteria. Among participants who

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met eligibility criteria, a second informed consent allowed administration of a baseline questionnaire; a detailed locator guide allows participants to fill out contact information, addresses, and phone numbers for research staff to follow-up.

Vaccine administration Alter pretest counseling, the research nurses collected serum for testing HBV, HCV, and HIV (hepatitis B core antibody, hepatitis B surface antibody, hepatitis C antibody, and human immunodeficiency virus antibodies) and provided test results 1 week later. On the basis of the HBV test result, participants were educated regarding the timeline for the HAV/HBV vaccine series, provided consent regarding administration, were inoculated intramuscularly using three doses of the Standard Twinrix (hepatitis A inactivated and hepatitis B recombinant vaccines) for the accelerated dosing schedule of 0, 7, and 21–30 days. The recommended series of three intramuscular injections of 1.0 ml of Twinrix was administered in the deltoid muscle of the nondominant arm. All eligible study participants were encouraged to accept the HAV/HBV vaccine; however, this was not coercive. The nurse documented refusal for vaccination.

Vaccine tracking On a weekly basis, the research nurse or peer coach reviewed the vaccine dosing and tracked progress. To encourage participants to complete the vaccine series, participants were reminded regarding their next dose by the nurse or peer coach and provided appointment cards. Furthermore, they were called if not present any longer at the RDT facility as a reminder. A detailed locator guide, completed by the participant and interviewer, supported follow-up to be successful. Information included contact information to be used by the research staff for vaccine scheduling as well as administration of structured questionnaires at 6- and12- month follow-up.

Measures

Vaccine completion

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Receipt of three core doses on the accelerated schedule was considered completion. This was assessed by the vaccine tracking system.

Sociodemographics Sociodemographic information was collected by a structured questionnaire assessing age, education, race/ethnicity, marital status, and parental status.

Situational factors Situational factors included being homeless, history of criminal activity, and severity of criminal history such as level of custody and contract type. Contract type was measured by asking participants whether they were in-custody drug treatment program, residential multiservice center, or parolee substance abuse program. Time in RDT was assessed by the total time participants resided at the RDT study site after discharge from jail/prison to RDT placement. RDT site was dichotomized at the median of 90 days for analysis.

Personal factors Personal factors included drug, alcohol, and tobacco use. A modified version of the Texas Christian University Drug History form (Simpson & Chatham, 1995) was used to measure use 6 months preceding the latest incarceration. Information regarding the frequency of use of alcohol, tobacco, and seven other drugs was collected, allowing us to review the use of these drugs and selected combinations of these drugs in terms of use by injection and orally, as well as to extract information about lifetime drug and alcohol use. Anglin et al. (1996) have verified the reliability and validity of this format. History of hospitalization for psychiatric and substance use problems and past treatment for alcohol or drug problems (number of times in formal treatment for alcohol and for drugs) was also obtained.

General health was assessed by a single item, which asked participants to rate their overall health on a 5-point scale (Stewart, Hays, & Ware, 1988). Responses included poor, fair, good, very good, and excellent—with a higher score indicating better

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perceived health. General health was dichotomized at fair/poor versus good/very good/excellent.

Hostility was measured by the five-item hostility subscale of the Brief Symptom Inventory (Derogatis & Melisaratos, 1983), in which participants rated the extent to which they have been bothered (0 = not at all to 4 = extremely) by selected issues. Cronbach’s alpha for the hostility scale in this sample was .81. The cut-point for hostility was the upper quartile of 2. Depressive symptoms were assessed by the 10-item, short form of the Center for Epidemiological Studies Depression Scale (Radloff, 1977), which was previously used to assess depressive symptoms in homeless populations (Nyamathi, Christiani, Nahid, Gregerson, & Leake, 2006; Nyamathi et al., 2008). The 10-item, self-report Center for Epidemiological Studies Depression questionnaire measures the frequency of 10 depressive symptoms in the past week on a 4-point response scale, from 0 = rarely or none of the time (less than 1 day) to 3 = all of the time (5–7days). Scale scores range from 0 to 30, with higher scores indicating greater severity of depressive symptoms. Reliability in this sample was .80.

Social factors Social factors included ever having been removed from their parents as children and having spent time in juvenile hall. In addition, social support was measured by the Medical Outcomes Study Social Support Survey (Sherbourne & Stewart, 1991). This 18- item scale includes four subscales: emotional support (eight items, reliability in this sample = .95), tangible support (three items, reliability = .88), positive support (three items, reliability = .89), and affective support (three items, reliability = .90). Items had 5-point, Likert-type response options ranging from 1 = none of the time to 5 = all of the time. Responses were summed for subscale formation with higher scores indicating more support. Respondents were also asked how many close friends they had outside of prison, which was dichotomized at the upper quartile of 6 for analysis.

Health seeking and coping were captured by history of drug use and treatment style, as well as coping. The Carver Brief Cope instrument (Carver, 1997) was used to measure six dimensions. Coping was assessed with two items for each; planning,

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instrumental support, religious, disengagement, denial, and self- blame. Item responses ranged from 1 = I do not do this at all to 4 = I do this a lot. Coping subscales were dichotomized at their medians for analysis.

Data analysis Sample characteristics were described with frequencies and percentages or means, and standard deviations and continuous variables were evaluated for normality. Because of highly skewed distributions that were not resolved by transformations, some variables had to be categorized for analysis. Associations of sample characteristics with intervention condition and vaccine noncompletion were assessed with chi-square tests or analysis of variance and two-sample tests. Because IDU may have confounded the relationship between intervention condition and vaccine noncompletion, we examined the impact of intervention condition on vaccine noncompletion controlling for IDU using multiple logistic regression analysis. The model contained IDU and dummy variables for each intervention condition; the only significant predictor of noncompletion was IDU (p values for the PC-NCM and PC intervention conditions were .70 and .79, respectively).

In examining other potential predictors of vaccine noncompletion, we emphasized noncompletion because individuals who did not complete the vaccine series are the ones who need to be targeted for future interventions. Variables that were related to vaccine noncompletion at the .10 level in unadjusted analyses were used as predictors in multiple logistic regression modeling of noncompliance. Although the overall significance level for race/ethnicity did not meet this inclusion criterion, it was included in the modeling because subgroupings (African American, “‘other’ race/ethnicity”) did so. Predictors that were not significant at the .10 level were removed one by one in descending order of significance. The final model was checked for multicollinearity, and the Hosmer- Lemeshow test was used to assess model goodness of fit.

Results In terms of sociodemographic characteristics, the 345 participants

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who were eligible for the HAV/HBV vaccine reported a mean age of 42.0 (SD = 9 5) and were predominantly African American (51%) or Latino (31%), as shown in Table 1. The small subsample of men from “other” ethnicities comprised mostly Asian Americans and Pacific Islanders. The mean education was 11.6 (SD = 1.4). Over half of the participants had never been married (59%). The distribution of participant characteristics was similar across the three intervention conditions.

TABLE 1 Demographic, Social, Situational, Coping, and Personal Characteristics by Intervention Condition

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Note. N = 345. CES-D = Center for Epidemiological Studies-Depression; HCV = hepatitis C virus; HIV = human immuno-deficiency virus; ICDTP = in-custody drug treatment program; PC = peer coaching; PC-NCM = peer coachingnursing case management; RDT = residential drug treatment; RMSC = residential multiservice service center; SAP = substance abuse program; UC = usual care. aUpper quartile. bScore above median. cWithin 6 months prior to most recent incarceration.

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Vaccine completion rates by intervention condition In total, there were 345 individuals who were eligible for the Twinrix recombinant vaccine (PC-NCM: n = 114; PC: n = 117; and UC: n =114). The vaccine completion rate for three or more doses was 73% among all three intervention conditions. Using chi-square tests (Group x Vaccine completion), findings revealed no differences in vaccine completion across groups (p = .780): PC- NCM, n = 86 (75.4%); PC, n = 84 (71.8%); and UC, n = 82 (71.9%).

Associations with vaccine noncompletion A number of social, personal, coping, and situational factors were found to be related to vaccine noncompletion (Table 2). In particular, having six or more friends and high instrumental coping were related to vaccine completion, whereas having been taken away from parents or spending time in juvenile hall were related to noncompletion. A history of alcohol treatment was associated with vaccine completion while having been hospitalized for mental health problems was related to noncompletion. In terms of drug use, cocaine use within 6 months prior to the last incarceration was associated with vaccine completion, whereas the opposite was true for IDU ever. Being HCV positive was also associated with not completing the vaccine series. No association was found between vaccine noncompletion and childhood physical abuse, whereas a very weak association was found with childhood sexual abuse.

TABLE 2 Associations Between Hepatitis A Virus/Hepatitis B Virus Vaccine Completion Status and Selected Variables

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Note. CES-D = Center for Epidemiological Studies-Depression; HCV= hepatitis C virus; HIV = human immunodeficiency virus; ICDTP = in-custody drug treatment program; RDT = residential drug treatment; RMSC = residential multiservice center; SAP = substance abuse program. aOctober 1, 2011. bTime in RDT program (days). cBased on 298 men. dFishers exact test.

Finally, those who were released following prison realignment and those tested positive for HCV at baseline were both related to vaccine noncompletion. Those who spent 90 days or more in RDT facilities following release were more likely to complete the vaccine series. On the other hand, incarceration location (prison vs. jail) and

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contract type had no relationship with vaccine completion, as shown in Table 2.

Table 3 presents the findings of logistic regression analysis. Asian/Pacific Islander ethnicity (compared to White), higher levels of hostility, higher levels of positive social support, and history of IDU were related to vaccine noncompletion. Moreover, having been admitted for a psychiatric illness was related to noncompletion of the HAV/HBV vaccine. Alternatively, reporting six or more friends was a protective factor. Recent cocaine use was also found to be related to vaccine completion. Being part of postrealignment was related to vaccine noncompletion, whereas having been in RDT for at least 90 days was a strong predictor of completion. Although there were no multicollinearity problems and the zero-order correlation between having six or more friends and positive social support was low (.23), we performed sensitivity analyses alternatively dropping one and then the other variable from the regression model. The direction of the effect of the social support variable that remained in the model did not change, but the significance was no longer below the p < .05 level.

TABLE 3 Logistic Regression Model for Noncompletion of Hepatitis A Virus/Hepatitis B Virus Vaccine Series

Note. N = 345. CI = confidence interval; OR = odds ratio; PC = peer coaching; PC-

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NCM = peer coaching-nursing case management; RDT = residential drug treatment. aReference class is usual care. bReference class is White.

Discussion Although homeless men on parole from California jails and prisons are at high risk for hepatitis A and B infection (Weinbaum et al., 2005), few studies have focused on improving HAV/HBV vaccination completion for this population. This article presents findings of varying levels of PC and nurse-delivered intervention that encouraged all participants—regardless of intervention condition assignment—to complete the three-series HAV/HBV accelerated Twinrix vaccine among those eligible. Although no treatment differences were found in terms of vaccine completion rates—because of the bundled nature of the programs—it is not possible to say whether the PC or nurse-delivered intervention resulted in the overall successful 73% completion rate of the three- series vaccine. Clearly, an intensive nurse case management approach did not necessarily result in a greater vaccine completion rate for the PC-NCM intervention condition. Furthermore, regardless of level of interaction by peer coaches or nurses, encouragement of vaccine completion was helpful across all intervention conditions (PC-NCM vs. PC vs. UC). However, we must acknowledge that more than one quarter (27%) did not complete the vaccine series, despite being informed of their risk for HBV infection.

The fact that Asian American/Pacific Islander (AA/PI) ethnicity was found to be related to noncompletion of the HAV/HBV vaccine is novel. Minimal work has been done understanding vaccination compliance among various races and ethnicities within homeless populations. AA/PIs are a large umbrella group composed of many subgroups; thus, it is somewhat challenging to decipher why AA/PIs had a higher level of noncompletion. However, in one study focused on ethnic-specific influences and barriers among AA/PI children, speaking limited English at home, length of time in the U.S., and not discussing HBV vaccination with a healthcare provider were found to be barriers to vaccination (Pulido, Alvarado, Berger, Nelson, & Todoroff, 2001). Despite these

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findings, the authors contended that greater understanding of nuances between groups is necessary to understand barriers (Pulido et al., 2001).

Interestingly, this was not the case for African Americans or Hispanics. In one study, understanding psychosocial predictors of HAV/HBV vaccination among young African American men in the south (n = 143), data reveal that increased vaccination was related to decreased barrier perception, increased perceived medical severity, and perceived barriers of HBV infection (Rhodes & Diclemente, 2003).

High levels of hostility and having a history of psychiatric hospitalization were likewise related to noncompletion of the HAV/HBV vaccine series. Adequate assessment of psychiatric comorbidity may be necessary to improve HAV/HBV vaccine completion by helping individuals to contend with hostility. Furthermore, adequate mental health referral may enable homeless ex-offenders to improve vaccine receipt. Future intervention work should focus on reducing hostility by providing additional group sessions that may aid in managing the hostility and, ultimately, increasing vaccine receptivity. Furthermore, anger management has been shown to likewise result in improved outcomes such as sustained reduction in feeling of anger and physical aggression (Wilson et al., 2013) and improved behavioral and cognitive coping mechanisms (Tang, 2001).

A history of IDU was also related to vaccine noncompliance. For those struggling with drug and alcohol addiction, prevention of infection may not be a high priority as meeting the challenges of overcoming addiction becomes paramount. Despite these findings, recent cocaine use was found to be related to vaccine completion. It may be that cocaine was not used heavily or that it served as a proxy for unmeasured variables associated with vaccine completion. Daily crack users were less likely to initiate the HBV vaccine series (Ompad et al., 2004). In this study, however, men who refused the vaccine were counted as not having completed it.

Increased social support in terms of self-report of having six or more friends was a protective factor for noncompletion, whereas the positive social support subscale predicted noncompletion. Another study found that partner support was predictive of vaccine

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completion (Nyamathi et al., 2012); therefore, social support does appear to play a role in vaccine compliance. When either six or more friends or positive social support was dropped from the model, the effect of the remaining measure was reduced. Thus, more information related to the individuals providing social support and the nature of their support is needed to understand how social support influences HAV/HBV vaccine completion. However, it seems likely that vaccine completion would be enhanced by interventions aimed at improving positive social support networks. There was also a trend for those who had any alcohol treatment to be more likely to complete the vaccine series, perhaps because of increased access to health education and care. However, drug treatment was unrelated.

Length of time at the RDT site was positively associated with vaccine completion. In fact, in our sample, homeless men on parole who spent at least 3 months in RDT programs were far more likely to complete the vaccination series. Other studies have found that those who complete RDT are less likely to relapse and use drugs; in addition, they may be less likely to recidivate (Condelli & Hubbard, 1994; Conner, Hampton, Hunter, & Urada, 2011). Preventive care, such as vaccination, may be further improved by RDT sites with access to healthcare practitioners such as public health nurses.

Policies enacted in the California state prison system, in particular, realignment (or reducing state prison population by transferring inmates to county jails), may affect vaccination completion. Realignment has shifted responsibility for the custody, treatment, and supervision of individuals convicted of nonviolent, nonserious, nonsex crimes from the state to counties (California Realignment, 2013). Our study sample included individual’s pre- and postrealignment, and our findings show that, following realignment, vaccination completion dropped markedly. As this is a relatively new policy enacted in California, it is challenging to ascertain the possible causes; however, contract types may have been altered for some individuals at the RDT site, whereas others may have been shifted from RDT to community supervision. Thus, the long-term impact of realignment will need to be assessed in the near future. Findings in this study point to the need for greater understanding of the ramifications of major criminal justice policies

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and their effect on preventive care. This study provides preliminary evidence of the need to

incorporate public health nurses along with peer coaches at RDT sites to improve health promotion, education, and prevention and, in particular, HAV/HBV vaccination. In fact, RDT facilities are in a prime position to address the healthcare needs of homeless ex- offenders who are exiting prison and jail. Partnering with nurses may improve HAV/HBV vaccination rates but may also promote health in general. In particular, it would be important for nurses to understand predictors of vaccine completion in this targeted population and to promote greater attention and focus in the screening process to those individuals less likely to complete.

Equally important, future studies need to incorporate more therapeutic resources and medical resources for a population that emerges from penitentiaries having experienced abuse, victimization, and a history of drug use and dependency issues. This study points to the need for a greater awareness of the needs of IDUs and of the efficacy of tailored programs focused on these issues. Likewise, we propose that more effort be spent on understanding the thought process of IDU users regarding their beliefs of HAV/HBV prevention.

Limitations Homeless men on parole constitute a population with unique health concerns and life issues affected by the laws and penal practices in their areas. The degree to which findings from Los Angeles County generalize to other jurisdictions is unknown. Furthermore, self-report is liable to distortion and impression management. To enhance the vaccination efforts of ex-offenders, more research is needed to better understand how homeless men on parole perceive their health, report their health behaviors, and access healthcare.

Conclusions Vaccine completion rates were similar to those reported by others and did not differ according to level of intervention delivered. Asian/Pacific Islander ethnicity, having been admitted for a psychiatric illness, having higher levels of hostility, having higher

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levels of positive social support, having a history of IDU, and being part of post realignment were independently associated with noncompletion, whereas recent cocaine use, having six or more friends, and RDT stay of at least 90 days were predictive of completion. Findings advocate for special attention to screening and enhanced intervention focused among these high-risk individuals.

Accepted for publication January 13, 2015. The authors acknowledge this study was funded by the National

Institute on Drug Abuse (1R01DA27213–01). This protocol was registered at ClinicalTrials.gov (NCT 01844414).

The authors have no conflicts of interest to report. Corresponding author: Adeline Nyamathi, ANP, PhD, FAAN,

School of Nursing, University of California, Los Angeles, Room 2– 250, Factor Building, Los Angeles, CA 90095–1702 (e-mail: anyamath@sonnet.ucla.edu).

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Appendix B. Example of a longitudinal/cohort study (hawthorne et al., 2016) Parent spirituality, grief, and mental health at 1 and 3 months after their infant’s/child’s death in an intensive care unit

Dawn M. Hawthorne PhD, RNa,*, JoAnne M. Youngblut PhD, RN, FAANb, Dorothy Brooten PhD, RN, FAANc

Problem: The death of an infant/child is one of the most devastating experiences for parents and immediately throws them into crisis. Research on the use of spiritual/religious coping strategies is limited, especially with Black and Hispanic parents after a neonatal (NICU) or pediatric intensive care unit (PICU) death.

Purpose: The purpose of this longitudinal study was to test the relationships between spiritual/religious coping strategies and grief, mental health (depression and post-traumatic stress disorder) and personal growth for mothers and fathers at 1 (T1) and 3 (T2) months after the infant’s/child’s death in the NICU/PICU, with and without control for race/ethnicity and religion.

Results: Bereaved parents’ greater use of spiritual activities was associated with lower symptoms of grief, mental health (depression and post-traumatic stress), but not post-traumatic stress in fathers. Use of religious activities was significantly related to greater personal growth for mothers, but not fathers.

Conclusion: Spiritual strategies and activities helped parents cope with their grief and helped bereaved mothers maintain their mental health and experience personal growth.

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IN 2008 IN the United States, 28, 033 infants (0–1 year old) and 22, 844 children and adolescents under the age of 18 died (Matthews, Minino, Osterman, Strobino, & Guyer, 2011). Most died in an intensive care unit (Fontana, Farrell, Gauvin, Lacroix, & Janvier, 2013). The death of an infant/child is unimaginable and one of the most devastating events that parents can experience. The resulting stress disrupts their mental and physical health (Youngblut, Brooten, Cantwell, del Moral, & Totapally, 2013). While parents’ symptoms of depression and PTSD diminished over the first 13 months post-death, about one-third continued to have symptoms indicative of clinical depression and/or PTSD. The number of chronic health conditions parents reported at 13 months post-death was more than double that before the ICU death (Youngblut et al., 2013). Physical and emotional symptoms occur during the early phase of grieving and continue for years afterwards (Werthmann, Smits, & Li, 2010).

Some parents turn to spirituality and religion to cope with their loss. Although often used interchangeably, spirituality involves caring for the human spirit; achieving a state of wholeness; connecting with oneself, others, nature and God/life forces; and an attempt to understand the meaning and purpose of life (O’Brien, 2014) even in the most difficult circumstances. In contrast, religion is an organized system of faith with a set of rules that individuals may use in guiding their lives (Koenig, 2009). Religion may be an explicit expression of spirituality. Therefore an individual may be spiritual without espousing a specific religion or very religious without having a well-developed sense of spirituality (Subone & Baider, 2010).

Research about bereaved parents’ use of spiritual coping strategies and its effects on their psychological adjustment after their child’s NICU/PICU death is limited. Most studies in this area have focused on religious coping neglecting the potential effect of non-religious spiritual coping strategies in helping bereaved parents (primarily White) cope with their grief. There is minimal research on whether bereaved parents use religious and/or spiritual coping strategies in early grief and on the differences between mothers’ and fathers’ coping strategies. Additionally, most studies on spirituality as a coping strategy in the grieving process have

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examined spirituality at one time point with very little research on the use of spirituality over time. The purpose of this longitudinal study with a sample of Hispanic, Black non-Hispanic, and White non-Hispanic bereaved parents was to test the relationships between spiritual/religious coping strategies and grief, mental health, (depression and post-traumatic stress disorder) and personal growth for mothers and fathers at 1 (T1) and 3 (T2) months after the infant’s/child’s death in the NICU/PICU, with and without control for race/ethnicity and religion.

Use of spirituality/religion as a coping strategy The few studies on the use of spiritual/religious coping strategies by bereaved parents whose infants/children died in the NICU/PICU have described using rituals, sacred text, and prayer; putting their trust in God; having access to their clergy/pastor; connecting with others and remaining connected to the deceased child as spiritual strategies that help to alleviate the parents’ pain, provide inner strength and comfort, and give meaning and purpose to their child’s death (Ganzevoort & Falkenburg, 2012; Meert, Thurston, & Briller, 2005).

Bereaved parents may find solace (Klass, 1999) in using spiritual and/or religious coping strategies. Parents who believe in a heaven or an afterlife find comfort in believing that their deceased child is in a better place and close to God and that when they die they will be reunited with their child (Armentrout, 2009; Ganzevoort & Falkenburg, 2012; Klass, 1999). Similar beliefs were identified by Lichtenhal, Currier, Neimeyer, and Keese (2010) who found that bereaved parents’ reliance on spiritual or religious beliefs proved helpful in coping with their grief. In that study, 28 (18%) of 156 bereaved parents believed that their child’s death was God’s will and 25 parents (16%) believed that their child was safe in heaven. Bereaved parents also can find healing or bring meaning to their own lives through spirituality, independent of religion, with meditation, inspirational writings, poetry, nature walks, listening to or creating music, painting or sculpting, and therapeutic touch, among others (Klass, 1999; Meert et al., 2005).

Research has found that some bereaved parents expressed anger with God for their infant’s/child’s death. Some felt that God was

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punishing them; others questioned or abandoned their belief in a perfect omniscient and omnipotent God, instead choosing to believe in a higher power that can make mistakes (Armentrout, 2009; Bakker & Paris, 2013). Meert et al. (2005) found that 30 to 60% of bereaved parents expressed anger and blame at themselves and God for their infant’s/child’s death.

An infant’s/child’s admission, stay and subsequent death in the NICU/PICU is overwhelming and painful for parents. Many are faced with the difficult decision of limiting treatment or withdrawing life support from their very sick infant/child (Buchi et al., 2007). Researchers have found that bereaved parents described their grief as feelings of emptiness, sadness, deep suffering, emotional devastation and being nonfunctional following the death of their infant/child in the ICU (Armentrout, 2009; Meert, Briller, Myers-Shim, Thurston, & Karbel, 2009).

Parent mental health and personal growth Research on the effects of an infant’s/child’s death on parents’ mental health and personal growth has found symptoms of PTSD, depression, and anxiety; lower quality of life; and minimal involvement in social activities up to 6 years after the loss (Werthmann et al., 2010). However few studies have examined parent mental health and personal growth following an infant’s/child’s death in the NICU/PICU. In bereaved parents 13 months after the death of their infant/child in the NICU/PICU, Youngblut et al. (2013) found that 30% of parents had scores indicative of depression and 35% of PTSD.

Personal growth is described by bereaved parents as a positive change in themselves, their family and social life (Armentrout, 2009; Buchi et al., 2007). These changes included beginning to find meaning and purpose in their lives, moving forward with their lives and becoming emotionally stronger (Armentrout, 2009; Buchi et al., 2007). They describe their values and priorities as being redefined, often finding material things less important and a greater appreciation for family relationships (Armentrout, 2009). Parents often became involved in community activities that transformed their lives and honored the memory of the deceased infant/child; some joined organizations whose goals were to help others

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(Armentrout, 2009). In summary, parents have difficulty dealing with their infant’s or

child’s death, even when studied years after the death. Youngblut et al. (2013) found that bereaved parents had symptoms of depression, panic attacks, anxiety, chest pain, hypertension, and headaches after the child’s death. Religion and spirituality have been used interchangeably in research, so it is unclear whether religious and spiritual activities are equally effective or have differing effects. Most of the research on bereaved parents has been after a child’s death due to cancer or trauma in primarily White families (Youngblut & Brooten, 2012). The study reported here is part of a racially/ethnically diverse sample of parents in a larger longitudinal study of parent health and family functioning through the first 13 months after an infant’s or child’s death in a NICU or PICU.

Conceptual framework Hogan, Morse, and Tason (1996) defines grief as “a process of coping, learning and adapting” (p. 44) irrespective of the relationship of the bereaved person to the deceased with six phases. The first phase is “Getting the news” that a loved one has a terminal diagnosis, or “Finding out” their loved one has died. The bereaved person responds to the news with shock, especially if the death was sudden. “Facing reality” is the second phase where the bereaved person experiences intense feelings of grief. In the third phase, “Becoming engulfed in the suffering, ” the bereaved person longs for the deceased and often experiences feelings of sadness, loneliness, guilt, and reliving the past. As the bereaved person gradually “Emerges from the suffering” in the fourth phase, they begin to experience some good days and by the fifth phase, “Getting on with their lives, ” hope and happiness gradually begin to return. In the final phase “Experiencing personal growth, ” the bereaved person develops a new perspective on life. They often reorganize and re-prioritize aspects of their lives, making it more purposeful and meaningful. These stages are hypothesized to be cyclical, not linear (Hogan et al., 1996). Greater parent use of spiritual/religious coping activities is expected to help parents through this process, resulting in less severe parent grief (despair,

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detachment and disorganization) and better parent mental health (depression, post-traumatic stress) and personal growth at 1 and 3 months post-death.

Methods The sample for this study consisted of 165 bereaved parents (114 mothers, 51 fathers) of 124 deceased infants/children (69 NICU and 55 PICU) recruited for the larger study from four level III NICUs and four tertiary care PICUs. Death records from the Office of Vital Statistics, Florida Department of Health, were used to identify infants and children who died in other NICUs or PICUs in South Florida. Parents were eligible for the study if their deceased newborn was from a singleton pregnancy and lived for more than 2 hours in the NICU or their deceased infant/child was 18 years or younger and a patient in the PICU for at least 2 hours. Parents had to understand spoken English or Spanish. Exclusion criteria were multiple gestation pregnancy if the deceased was a newborn, being in a foster home before hospitalization, injuries suspected to be due to child abuse, and death of a parent in the illness/injury event.

Measures of dependent variables Grief was measured with four of the six subscales in the Hogan Grief Reaction Checklist (HGRC; Hogan, Greenfield, & Schmidt, 2001): despair (hopelessness, sadness and loneliness), detachment (detached from others, avoidance of intimacy), disorganization (difficulty in concentrating and/or retaining new information), and personal growth (personal transformation; becoming more compassionate, tolerant and hopeful). Bereaved parents rated each of the 61 items on a 5-point scale from 1 “does not describe me at all” to 5 “describes me very well” with higher summative scores indicating higher grief symptoms or personal growth in the previous two weeks. Hogan et al. (2001) reported internal consistencies for the 4 subscales of .82 to .89 and test-retest reliabilities from .77 to .85. In this study, Cronbach’s alphas for the four subscales at T1 and T2 were .84–.93 for mothers and .79–.89 for fathers.

Depression was measured with the Beck Depression Inventory (BDI-II) (Beck, Steer, & Brown, 1996). Parents rated each of the 21

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items on a scale from 0 to 3 with higher summative scores indicating greater severity of depressive symptoms. Beck et al. reported an internal consistency of .92 and test-retest reliability of .93. In this study, internal consistencies were .89–.93 for mothers and fathers at T1 andT2.

Post-traumatic stress disorder (PTSD) was measured with the Impact of Events Scale-Revised (IES-R; Weiss & Marmar, 1997). Bereaved parents rated each of the 22 items from 0 “not at all” to 4 “extremely” to indicate how distressing each item had been during the past 1 weeks with respect to the death of their infant/child. Higher summative scores indicate greater severity of PTSD symptoms. Weiss and Marmar reported internal consistencies for the three subscales as .79–.92. In this study, Cronbach’s alphas for the subscales at T1 and T2 were .76–.86 for mothers and .71–.91 for fathers.

Measures of independent variables Spiritual coping was measured with the Spiritual Coping Strategies Scale (SCS) (Baldacchino & Bulhagiar, 2003). The SCS contains two subscales: religious strategies/activities (9 items) and spiritual strategies/activities (11 items). Activities on the religious subscale are oriented toward religion and belief in God (attending church, praying, and trusting in God). Activities on the spiritual subscale are oriented toward relationship with self (reflection), others (relating to relatives and friends by confiding in them) and the environment (appreciating nature and the arts). Parents rated each activity on a 4–point scale ranging from 0 “never used” to 3 “used often” with higher scores indicating greater use of religious and spiritual activities. Baldacchino and Bulhagiar reported Cronbach’s alphas of .82 for the religious and .74 for the spiritual strategies/activities subscales. Construct validity of the SCS subscales is supported by correlations of .40 with the well- established Spiritual Well Being instrument (Baldacchino & Bulhagiar, 2003). In this study, parents’ subscales internal consistencies at T1 and T2 were .87 to .90 for religious activities and .80 to .82 for spiritual activities.

Race/ethnicity was categorized as “White, non-Hispanic,” “Black non-Hispanic,” or “Hispanic/Latino(a)” based on parent self-

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identified race (White, Black, Asian, Native American) and Ethnicity (Hispanic-yes/no). Two dummy- coded variables were created to represent race/ethnicity in the regression analyses: Black non-Hispanic (yes/no) and Hispanic/Latino (yes/no). White non- Hispanic was coded as the comparison group.

Religion indicated by the parent was categorized as Protestant, Catholic, none (atheists, agnostics) and other (Jewish, Buddhist, Muslim, Santeria/Espiritismo, Mormon and Rastafarian). Three dummy-coded variables were created to represent religion in the regression analyses: “Protestant” (yes/no), “Catholic” (yes/no), and “other” (yes/no). The “none” group was coded as the comparison group.

Procedure The study was approved by the Institutional Review Boards (IRB) from the University, the 4 recruitment facilities, and the State Department of Health prior to recruitment of study participants. A clinical co-investigator from each NICU/PICU identified eligible families. The project director sent a letter to each family (Spanish on one side and English on the other) describing the study and called the family to explain the study. Of the 348 families contacted for the larger study, 188 (54%) families signed consent forms for their participation and review of their deceased child’s medical record. The SCS was added to the study after 64 families were recruited. The remaining 124 families completed the SCS. Data were collected in the family’s home or another place of their choosing at 1 (T1) and 3 (T2) months post-death. Data were collected from mothers and fathers separately.

Data analysis Analyses were conducted separately for mothers and fathers for each time point. Correlations were used to test the relationships of the SCS subscales with bereaved mothers’ and fathers’ grief (despair, detachment, disorganization), mental health (depression and PTSD) and personal growth at T1 and T2. Multiple regression analyses were used to test whether these relationships changed when the influence of race/ethnicity and religion were controlled. A priori power analysis showed that a sample size of 115 would

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provide sufficient power (≥80%) to detect an adjusted R2 of 0.02 representing a medium effect and with alpha set at .05.

Results In this sample of 114 mothers and 51 fathers from 124 families, fathers were older than mothers on average. Most parents were married or living with a partner, Hispanic (38%) or Black non- Hispanic (40%), high school graduates, employed, and Protestant (53%) or Catholic (27%). Of the 93 families who provided income data, 39% had annual incomes less than $30, 000 (Table 1).

TABLE 1 Description of the Sample.

Characteristic Mothers (n = 114) Fathers (n = 51) Age [M (SD)] 31.1 (7.73) 36.8 (9.32) Race [n (%)] White non-Hispanic 22 (19%) 14 (28%) Black non-Hispanic 50 (44%) 16 (31%) Hispanic 42 (37%) 21 (41%) Education [n (%)] <High school 12 (11%) 7 (14%) High school graduate 31 (27%) 13 (25%) Some college 36 (32%) 12 (24%) College degree 35 (30%) 19 (37%) Partnered [n (%)] 84 (74%) 43 (84%) Employed [n (%)] 63 (55%) 32 (78%) Religion [n (%)] Protestant 62 (54%) 26 (51%) Catholic 33 (29%) 11 (22%) Jewish 4 (4%) 2 (4%) Other 1 (1%) 2 (4%) None 14 (12%) 10 (20%) Total family annual income [n (%)] N =93 families <$3000 4 (4%) $3000–29, 999 33 (35%) $30, 000–49, 999 22 (24%) ≥$50, 000 34 (37%)

More infants/children died in the NICU (n = 69, 56%) than the PICU (n = 55, 44%); 70 (56%) were boys. The average infant/child age was 34.9 (SD = 60.38) months at death. More than half were infants (n = 95, 76%), followed by toddlers/preschoolers (n = 5, 4%), school age children (n = 12, 10%) and adolescents (n = 12, 10%). Mean length of stay was 32 days (SD = 63.10). Causes of death were

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respiratory conditions (n = 36, 29%), prematurity (n = 27, 22%), congenital anomalies (n = 20, 16%), infection (n = 13, 10%), accidents (n = 11, 9%), neurological disorders (n = 6, 5%), cardiac arrest (n = 5, 4%), cancer (n = 4, 3%), and complications of surgery (n = 2, 2%).

Grief and mental health Use of spiritual activities was more strongly related to all outcomes for mothers and fathers than use of religious activities. Bereaved mothers’ greater use of spiritual activities, but not religious activities, was significantly related to lower symptoms of grief (despair, detachment and disorganization), depression, and PTSD at T1 and T2 (Table 2). Controlling for race/ethnicity and religion, spiritual activities continued to have a significant influence on mothers’ grief and mental health outcomes, except for disorganization at T2 (Table 3). The influence of religious activities remained non-significant when race/ethnicity and religion were controlled.

TABLE 2 Correlations of Parents’ Use of Spiritual and Religious Activities with Grief, Mental Health and Personal Growth at 1 (T1) and 3 (T2) Months Post-Death.

*p < .05.

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**p < .01.

TABLE 3 Effects of Mothers’ Use of Spiritual Activities at T1 on Outcomes at 1 and 3 Months After their Infant’s/Child’s Death, Controlling for Race/Ethnicity and Religion.

*p < .05. **p < .01. a Scored yes = 1, no= 0.

Bereaved fathers’ greater use of spiritual activities was significantly related to lower symptoms of grief (despair, detachment and disorganization) and depression at T1 and T2 (Table 2). Fathers’ greater use of religious activities was related to lower symptoms of grief and depression at T1 but not at T2 (Table 2). Controlling for race/ethnicity and religion, the influence of spiritual activities on fathers’ grief, but not depression or PTSD, remained statistically significant at T1, but not at T2 (Table 4). The influence of religious activities was no longer significant for any of the fathers’ T1 and T2 outcomes when race/ethnicity and religion were controlled.

TABLE 4 Effects of Fathers’ Use of Spiritual Activities on Grief at 1 and 3 Months After their Infant’s/Child’s Death, Controlling for Race/Ethnicity and Religion.

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*p < .05. **p < .01. a Scored yes = 1, no = 0.

Personal growth For mothers, use of spiritual and religious activities was significantly related to greater personal growth at both T1 and T2, with (T1: adjusted R2 = .10, β = .34, T2: R2 = .10, β = .33, p < .01) and without control for race/ethnicity and religion (Table 2) For fathers, spiritual activities were related to greater personal growth at T1 and T2, but the positive effects of religious activities on fathers’ personal growth was significant at T2 only (Table 2). Fathers’ spiritual and religious activities were not related to their personal growth when race/ethnicity and religion were controlled.

Discussion Loss of an infant or child is devastating for mothers and fathers and it is often associated with increased morbidity (Youngblut et al., 2013) and mortality (Espinosa & Evans, 2013). Youngblut et al. reported that about one third of the bereaved parents in their sample had clinical depression and/or PTSD at 13 months after their infant’s or child’s death in the NICU/PICU. Identifying strategies that help parents cope with the death of their child may mitigate some of these negative health effects.

Spiritual coping strategies may be helpful to parents at this time of very high stress. In this study, mothers’ and fathers’ spiritual activities at 1 month post-death were related to less severe symptoms of grief at both 1 and 3 months. Use of religious activities

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was helpful in reducing fathers’ grief at 1 month, but not at 3 months; these activities were not related to mothers’ grief at either time point. These findings suggest that fathers may find more solace in religious activities than mothers. If so, use of both spiritual and religious activities may help fathers move through the grieving process faster, allowing them to return to their previous routines such as returning to work earlier than bereaved mothers (Aho, Tarkka, Kurki, & Kaunonen, 2006; Armentrout, 2009).

Mothers’ use of spiritual activities, but not religious activities, was related to less severe symptoms of depression and PTSD at 1 and 3 months. Fathers’ use of spiritual activities was related to less severe symptoms of depression at both 1 and 3 months. Use of religious activities was related to less severe symptoms of depression at 1 month for fathers’ after their infant’s/child’s death.

Gender differences in coping with grief are supported in the literature. Bereaved mothers need to talk more about the death than bereaved fathers (Barrera et al., 2007; Buchi et al., 2007), whereas bereaved fathers were found to cope with their grief by isolating themselves from family and friends (Aho et al., 2006). Religious activities such as praying privately or watching religious programs may allow fathers periods of solitude grieving, not requiring discussion of the infant/child and their feelings about the death. These activities also may serve to limit the opportunities for mothers and others to engage fathers in conversation about the deceased infant/child.

In contrast, spiritual activities involve engaging with others, discussing difficulties with others who have endured similar circumstances, spending time with and confiding in relatives and/or friend. These activities provide the mothers with the discussion they reportedly want and need. This suggests that bereaved mothers valued the social support received from family and friends and used non-religious activities to relieve feelings of hopelessness, sadness and loneliness, to connect with their inner self, to acknowledge their strengths and ultimately find peace (Bakker & Paris, 2013). Additionally, studies of gender differences in bereaved couples’ grief reaction have found mothers to have a longer recovery time in adjusting to their grief than fathers (Armentrout, 2009; Lang, Gottlieb, & Amsel, 1996). Perhaps it

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reflects societal expectations that men should be stoic which is reinforced in the workplace and social gatherings.

Personal growth at 1 and 3 months was greater for mothers using greater spiritual and religious activities. Fathers had greater personal growth at 1 and 3 months with greater use of spiritual activities and at 3 months with religious activities. This is consistent with other studies in which bereaved parents describe a transformation in their lives. Personal growth was identified as becoming more compassionate, caring, and sensitive to the needs of others and becoming more giving of themselves by reaching out to other bereaved parents (Armentrout, 2009; Lichtenhal et al., 2010).

Stronger associations were found between greater use of spiritual activities as compared to religious activities and positive bereavement outcomes over time. A possible explanation for this relationship may be that in times of crisis bereaved parents engaged in coping activities that are based on their personal beliefs and values to buffer their grief. Spiritual practices can be characterized as being more personal, individualistic and include secular terms that are free from religious rules or regulations. Religious coping gives indirect control to God/the sacred and reduces the need for personal control (Koenig, 2009).

Additionally, some research studies found that bereaved parents expressed negative feelings such as anger at God for their infant’s/child’s death; some felt that God was punishing them and others questioned God their faith (Armentrout, 2009; Ganzevoort & Falkenburg, 2012). Meert et al. (2005) found that 30 to 60% of bereaved parents expressed anger and blame at themselves and God for their infant’s/child’s death and this may result in using less religious coping activities to cope with early grief.

Controlling for race/ethnicity and religion made little difference in the influence of spiritual activities on mothers’ and fathers’ grief and mothers’ mental health. However, most of the bivariate relationships with religious activities did not remain when race/ethnicity and religion were controlled

Limitations of the study There are several additional limitations of the study. At 1 and 3 months post-death, parents were in early stages of grieving. Thus,

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these findings may not be applicable to parents who are later in the grieving process. In this study most of the bereaved parents reported spiritual activities, not religious activities as effective in helping them to cope with their grief and mental health for a longer period of time. The average age for these bereaved parents was early to mid-thirties and it is possible that individuals of this age may not be strongly affiliated to a religious group (Fowler, 1995).

Additionally, the use of religious and spiritual strategies was not significantly related to bereaved fathers’ PTSD at both T1 and T2 and personal growth at T1. This is possibly related to the small number of men who participated in this study, which is a common occurrence in these studies (Lichtenhal et al., 2010) and is a limitation of this study.

Conclusion Research studies have found that bereaved parents experience many emotional benefits associated with the use of religious coping to deal with their grief and mental health (Lichtenhal et al., 2010; Meert et al., 2005). In this study, religious activities were not effective in lowering symptoms of grief, depression, and PTSD for bereaved mothers at 1 month and fathers at 3 months post-death. This suggests that spiritual activities may assist bereaved mothers to reduce their symptoms of grief, depression, PTSD and increase personal growth over a longer period of time than religious activities. While religious activities might be helpful in the first month after the child’s death, maybe religious activities come into play later when their anger with God has diminished. The use of spiritual activities such as self-refection, confiding in others and cultivating friendships may be more helpful to parents over time.

The findings when race/ethnicity and religion were controlled suggested that the use of spiritual, and not religious activities helped both mothers and fathers cope with their grief but the use and/or effect of using spiritual activities was helpful for bereaved mothers with their mental health and personal growth for a longer time.

Clinical relevance The results from this longitudinal study with a racially and

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ethnically diverse sample provide evidence for healthcare professionals about the importance of spiritual coping activities for bereaved mothers and fathers. Dissemination of this information in the clinical areas to nurses and other healthcare team members will enable bereaved parents to receive relevant and appropriate support following the death of their infant/child.

The study findings suggest that nurses may encourage bereaved parents, especially mothers to identify and use an array of spiritual activities, such as self-reflection, relating to family and friends by confiding in them; finding meaning and purpose to live through their situation may help parents cope with their infant’s or child’s death, decreasing their symptoms of grief and improving their mental health. Intervening in this manner may enable bereaved parents to receive relevant and appropriate support following the death of their infant/child.

Future research Findings from this research study provide implications for future research. The responses obtained from bereaved parents at 1 month and 3 months are applicable to parents in the early stages of bereavement. Further research is needed to determine if any changes, whether negative or positive, occurred in bereaved parents’ use of religious and spiritual activities to cope and the effect on their grief response, mental health and personal growth in the later stage of bereavement.

Additionally, future research that specifically examines differences in bereaved mothers’ and fathers’ use of religious and spiritual activities, with a larger sample of fathers, can determine the specific supportive spiritual coping activities that may be used to help bereaved mothers and fathers cope with their grief.

Acknowledgments This research was supported by a grant from the National Institutes of Health, National Institute for Nursing Research, R01 NR009120 (Youngblut/Brooten) & Diversity Supplement R01 NR009120–S1 (Hawthorne).

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aChristine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL bDr. Herbert & Nicole Wertheim Professor in Prevention and Family Health, Nicole Wertheim College of Nursing & Health Sciences, Florida International University, Miami, FL cNicole Wertheim College of Nursing & Health Sciences, Florida International University, Miami, FL

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http://dx.doi.org/10.1542/peds.2013-1194

Appendix C. Example of a qualitative study (van dijk et al., 2015) Postoperative patients’ perspectives on rating pain: A qualitative study

Jacqueline F.M. van Dijka,*, Sigrid C.J.M. Vervoortb, Albert J.M. van Wijcka, Cor J. Kalkmanc, Marieke J. Schuurmansd

Abstract Background: In postoperative pain treatment patients are asked to

rate their pain experience on a single uni-dimensional pain scale. Such pain scores are also used as indicator to assess the quality of pain treatment. However, patients may differ in how they interpret the Numeric Rating Scale (NRS) score.

Objectives: This study examines how patients assign a number to their currently experienced postoperative pain and which considerations influence this process.

Methods: A qualitative approach according to grounded theory was used. Twenty-seven patients were interviewed one day after surgery.

Results: Three main themes emerged that influenced the Numeric Rating Scale scores (0–10) that patients actually reported to professionals: score-related factors, intrapersonal factors, and the anticipated consequences of a given pain score. Anticipated consequences were analgesic administration—which could be desired or undesired—and possible judgements by professionals. We also propose a conceptual model for the relationship between factors that influence the pain rating process. Based on patients’ score-related and intrapersonal factors, a preliminary pain score was “internally” set. Before reporting the pain score to the healthcare professional, patients considered the anticipated

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consequences (i.e., expected judgements by professionals and anticipation of analgesic administration) of current Numeric Rating Scale scores.

Conclusions: This study provides insight into the process of how patients translate their current postoperative pain into a numeric rating score. The proposed model may help professionals to understand the factors that influence a given Numeric Rating Scale score and suggest the most appropriate questions for clarification. In this way, patients and professionals may arrive at a shared understanding of the pain score, resulting in a tailored decision regarding the most appropriate treatment of current postoperative pain, particularly the dosing and timing of opioid administration.

What is already known about the topic?

• Patients are asked to rate their pain experience on a single uni- dimensional pain scale.

• Patients’ pain scores are the leading indicator in postoperative pain treatment.

• It is unknown how patients interpret the NRS scores.

What this paper adds

• Three main themes emerged that influenced patients’ NRS scores actually reported to professionals: score-related factors, intrapersonal factors and the anticipated consequences of assigning a particular NRS score.

• A conceptual model emerged for the relationship between factors that influence the pain rating process. When assigning an NRS score to their pain, patients process the first two themes in stages: They first weigh score-related factors and intrapersonal factors. Some patients go through a last stage before telling the professional: weighing the judgements by healthcare professionals and the anticipated consequences of reporting a particular NRS score against their actual desire for more or less

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analgesics.

• The proposed model could help professionals to better understand the complex process by which patients assign pain scores and could serve as a basis for a dialogue beyond the given pain scores.

1. Introduction The adequacy of pain treatment is an important healthcare quality indicator. Many patients still experience severe pain after surgery, suggesting that there is considerable room for improvement in postoperative pain management (Apfelbaum et al., 2003; Sommer et al., 2008). The quality of pain management is in many quality systems operationalized in terms of measuring patients’ pain scores.

Pain is subjective, and nociception cannot be measured directly. In clinical practice, patients are asked to rate their (sometimes complex) pain experience on a single unidimensional pain scale. However, in contrast to the high number of quantitative studies using the Numeric Rating Scale (NRS), only one study is found how chronic pain patients use the NRS (Williams et al., 2000) but no study has explored how postoperative patients interpret the NRS, how they assign a number from 0 to 10 to their pain, and what considerations come into play when translating a highly subjective pain experience into a single number.

Patients’ pain scores are the leading indicator in postoperative pain treatment (Aubrun et al., 2003; Idvall et al., 2008; Gordon et al., 2005; Max et al., 1995; VMS, 2009). Clinical observations and physiological parameters used in pain treatment should be considered with caution. Nurses often underestimate patients’ pain (Idvall et al., 2005; Sloman et al., 2005) and vital signs can be influenced by other factors besides pain (Arbour and Gelinas, 2010; Gelinas and Arbour, 2009). Several guidelines advise healthcare professionals to administer additional analgesics when patients report an NRS score greater than 3 or 4 (Gordon et al., 2005; Hartrick et al., 2003; Max et al., 1995; VMS, 2009). In a previous study, we reported that patients with NRS scores of 4, 5, or 6 vary in the interpretation of their score (Van Dijk et al., 2012). In that

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study, we observed that some patients reporting NRS scores between 4 and 6 considered their pain “bearable” and refused opioids, while other patients with identical NRS scores considered their pain “unbearable” and requested more opioids. This raises the question of whether simple thresholds such as “NRS > 3 or 4” are the most appropriate cut-off points upon which professionals should base their decisions regarding administering additional analgesics. In postoperative pain management, both undertreatment and overtreatment are undesirable. Unrelieved pain has adverse psychological and physiological consequences, including increased rates of postoperative complications and prolonged hospital stays (Watt-Watson, 1999). Conversely, unnecessary use of analgesics, especially opioids, increases the patient’s discomfort due to the side effects (e.g., nausea, vomiting, and pruritus) and potentially harmful adverse effects (e.g., oversedation and respiratory depression) (Cashman and Dolin, 2004; Taylor et al., 2005). For optimal pain treatment, patients and professionals must communicate effectively and have a shared understanding of the burden of the patient’s currently experienced pain.

The aim of this qualitative study was to explore how patients assign a number on the basis of the NRS to their currently experienced postoperative pain and which considerations influence this process.

2. Methods

2.1. Study design The study was descriptive and qualitative in nature. The method used was based on grounded theory (Charmaz, 2014), a qualitative research method designed to aid in the systematic collection and analysis of data and the construction of a model. Individual interviews were used as the data-collection method. Guidelines for conducting qualitative studies established by the Consolidated Criteria for Reporting Qualitative Research (COREQ) were followed (Tong et al., 2007).

2.2. Participants

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The study was conducted between November 2012 and July 2013 in a university hospital. Patients were eligible for selection if they had surgery the day before and currently experienced postoperative pain with a reported NRS score of at least 4. Patients were selected purposively by the researcher (JvD) and to create a diverse sample patients were selected with regard to sex, age, ethnicity, previous pain experiences, and previous experience with rating an NRS score. Theoretical sampling was used as much as possible; we started with a homogeneous sample of patients, and as the data collection proceeded and themes emerged, we turned to a more heterogeneous sample to see under what conditions the themes hold (Charmaz, 2014).

The researcher was not involved in the patients’ care. Exclusion criteria were as follows: younger than 18 years, unable to read and understand Dutch, cognitive impairment, having impaired hearing, or not being well enough to be interviewed. The researcher identified eligible patients by consulting the Electronic Patient Dossiers (EPDs) and asked the nurse on the ward whether identified eligible patients could be interviewed. None of the eligible patients were unable to be interviewed. Thereafter, the researcher approached the patients, provided information about the study, and handed over an information letter. After reading the letter, patients were asked to consider participation in the study. All 27 patients who were asked agreed to participate, and written informed consent was obtained. The study was approved by the medical ethics committee of the University Medical Centre Utrecht in which the study took place.

2.3. Data collection Data were collected using semi-structured, in-depth interviews on the day after surgery. The researcher’s (JvD) interview technique (validity and reliability of the interview style) during the first two interviews was discussed with experts). The questions were open- ended, and all interviews started with, “The nurse regularly asks you to assign a number from 0 to 10 to your pain, where 0 is no pain and 10 is the ‘worst imaginable’ pain. We heard from some patients that they perceived it as difficult to assign a number to their pain. How is that for you? Can you tell me how you assign a

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number to your pain?” A topic guide for the interviews based on the literature, the knowledge of nursing experts, and preliminary studies of the research group was used (Table 1). The Dutch school grades were chosen as a topic because the meaning of these grades (where 1 is insufficient and 10 is excellent) are the opposite of meaning of the pain scores. Therefore, Dutch patients could be confused when they were asked to score their pain on the NRS.

TABLE 1 The Topic Guide for the Interviews.

The value of the numbers from 0 to 10 Pain score at that moment Bearable or unbearable pain Assigning scores at the upper extreme of the scale Previous experiences with pain Upbringing The role of the healthcare professional Analgesics: when desiring light or strong analgesics fear of addiction and side effects Grades at school from 1 to 10

Insights from the interim analyses were incorporated in the interview guidelines used in subsequent interviews. Interviews were conducted in a private room on the ward, digitally recorded and transcribed verbatim. Identifying details were removed from the transcripts. The interviews lasted between 5 and 32 min (mean 12 min). Information concerning age, gender, ethnicity, surgical procedure, presence of chronic pain, and education was obtained using a structured questionnaire.

During data collection, memos were made containing impressions and thoughts about the themes and their relationships. Data collection stopped after saturation was reached (i.e., interviewees were selected until the new information obtained did not provide further insight into the themes or no further new themes emerged) (Charmaz, 2014).

2.4. Data analysis The data analysis was conducted by two researchers (SV and JvD) and supported by NVivo 10 software (QSR International, Cambridge, MA, USA). Data were analysed applying constant comparison analysis. First the texts were read out in full to obtain

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an overall picture and then reread to elucidate the details. During open coding meaningful paragraphs were analysed and initial concepts identified leading to fragmentation of the data. Axial coding enabled the concepts to be aggregated according to their similarities leading to categories (themes). New data were compared with the evolved categories. Throughout selective coding relations between the categories were defined and a preliminary model was described (Boeije, 2010). The theoretical model in development was compared with the interview transcripts to verify the interpretation into the original interview texts. During the coding process, the researchers discussed the concepts and categories. When their opinions differed, they discussed the issue until consensus was reached. A third researcher (CK, an expert in the field of pain treatment with a different background), read the transcripts, checked the coding, and discussed his opinion if different, allowing us to verify the themes and the preliminary model. The research team reviewed the main categories and its relations and worked towards consensus about the interpretations and finally the theoretical model was developed.

2.5. Trustworthiness The trustworthiness of the study was enhanced by the use of different techniques (Lincoln and Guba, 1985). The credibility was established by generating a non-judgemental atmosphere during interviews ensuring to learn from patients. Transcribing the interviews verbatim reduces the chances for bias. During data collection and data analysis memos were written supporting the research process and the creation of theoretical ideas and hypothesis. Researcher triangulation during data analysis and peer debriefing by the researchers team enhanced both the credibility and conformability of the interpretation. By means of peer debriefing broader perspectives and possible meanings were uncovered and reflexivity, guaranteed by the critical stance to the interview style and feedback of other researchers led to more depth which enhanced accurateness. To guarantee the transferability as much as possible, thick description was pursued by the amount of respondents, diversity of the sample, duration of interviews and describing the details for imitability.

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3. Results The age of the 14 men and 13 women who participated in the study was between 18 and 79 years old (mean 51). The severity of surgery varied from minor (e.g., thyroidectomy) to major (e.g., spinal fusion). Demographic and medical data are presented in Table 2.

TABLE 2 Demographic Data.

N 27 Male, n 14 Age, mean (range) 51 (18–79) Ethnicity, n Caucasian 23 Other 4 Surgical type, n Orthopaedic 16 General 5 Gynaecologic 3 Plastic surgery 2 Vascular surgery 1 Education, n Low 10 Median 10 High 7 Patients with chronic pain, n 6

Translating currently experienced pain into an NRS score between 0 and 10 appeared to be a complex process for the patients. From the analysis, three main themes emerged regarding the process of scoring one’s pain experience: score-related factors, intrapersonal factors, and the anticipated consequences of rating one’s pain with an NRS score. The latter theme comprised two subthemes: expected judgements by professionals and anticipation of analgesic administration, particularly opioids. Factors that were reported to influence the rating of pain using an NRS score are shown in Table 3.

TABLE 3 Three Main Themes and Associated Factors that Emerged from the Interview Analyses.

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A model emerged of the interrelation between the themes clarifying what underlies patients’ rating of their pain on the NRS (Fig. 1). Patients went through consecutive stages wherein the themes were at play. However, not all patients were affected by the themes in the same way. Based on the patients’ score-related and intrapersonal patient factors, a preliminary pain score was “internally” set. Before reporting the pain score to the healthcare professional, the patient considered the anticipated consequences of the current NRS score. Based on these expectations, this preliminary pain score was sometimes adjusted to a definitive pain score that was reported to the professional. First, patients expected that professionals would judge them regarding the magnitude of the reported pain score. Second, patients considered what pain treatment would likely be administered as a result of their reported pain score. Some patients wanted to meet the expectations of the professional and considered what would be the most socially acceptable pain score. Based on these considerations, the “adjusted” pain score was then communicated to the healthcare professional.

FIG 1 The model for the patients’ underlying process of rating an NRS score to their pain.

3.1. Score-related factors Unique pain experience: Patients found it difficult to rate their pain using an NRS score, because they felt they had an “unique” pain

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experience. They said it was difficult to explain to another person exactly what they felt or what their pain level was in relation to what they felt. Several patients said that everyone experiences pain differently and therefore will assign their own value from 0 to 10.

“It’s difficult to measure. You’ve got your interpretation and I’ve got mine” (male, age 51).

“I think about worst pain as something I’ve never felt before and zero is no pain. I always find it a very difficult question to assign a number” (female, age 51).

Many patients perceived it as difficult to assign a number from 0 to 10 to their experienced pain, especially when it concerned the intermediate pain scores (NRS scores of 4 to 6). For some patients who had chronic pain in addition to acute postoperative pain, it was even more difficult to rate their current pain experience, because they often experienced different types of pain that differed in intensity.

Distinction between “bearable” and “unbearable” pain: To make it easier to rate their pain, some patients first created a cut-off point between bearable and unbearable pain, the latter often expressed as an NRS score of 6 or higher.

“I balance between bearable and severe. If it is bearable then it is a six, it is not good, but I can bear it. But when I feel it with any movement and it’s really painful, then it is eight or sometimes nine”(female, age 79).

The number 5 was seen by many patients as a natural midpoint of the pain scale. Therefore, patients themselves often used an NRS score of 5 as a cut-off point: At 5 and below, the pain was considered bearable, and at above 5, the pain was called “real pain.”

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“‘Five’ I would consider the average, that is bearable. Over five, then I’d say: give me something. That is not really bearable I think. So, as long it is up to five, I’d say I am doing OK” (female, age 45).

Patients concluded that there clearly was a difference between their interpretation of bearable and unbearable pain and that of professionals. In the patients’ opinion, many professionals considered only NRS scores below 4 as representing bearable pain, while many patients considered an NRS score of 6 as indicating bearable pain. In the Netherlands school system, a grade system from 1 to 10 is traditionally used, where 1 means completely insufficient and 10 denotes excellent. In this system, a score of 6 is sufficient to pass an exam. One patient mentioned that this had an effect on how she used the NRS.

“The grades at school that is something you are familiar with, that is also a validation, that has an effect, because that’s what you grew up with. Because it is also a kind of validation, when you give the pain a number then you also validate something, you know? Yes, I think so” (male, age 77).

Most patients said that they were not confused when rating their pain experience in relation to scores they were used to getting at Dutch schools.

Avoiding high extremes: Most patients assign an extreme score on the NRS as follows: 0 and 1 meaning no or light pain and 9 and 10 meaning the worst imaginable pain. Some patients explained that they would never use the highest pain score, because “10” is so extreme that they could not imagine having so much pain.

“If it hurts a little, then it is often two or three. Higher than five, then it has to hurt a lot. I would never give a ten. Yeah, ‘unbearable’ wouldn’t cross my mind” (male, age 36).

Other patients said that they would never assign a very high

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number to their pain, because they mentally compared their current situation to a more severe imagined situation.

Different pain level at rest and movement: When patients were asked how they assigned a number to their pain, many patients said they experienced a difference between pain at rest and pain at movement. Patients mostly assigned two different numbers to their pain: an NRS score below four at rest and an NRS score above six or seven at movement.

“If I lie very still and I have used the PCA pump then it is a three or four, and when I move it goes up to a seven, eight” (male, age 41).

Some patients consider their pain at rest as bearable and only move if necessary. Patients accepted a brief moment of pain at movement and did not want additional analgesics for such short severe pain episodes.

3.2. Intrapersonal patient factors Previous pain experiences: When rating their current pain using an NRS score, patients used past pain experiences as a benchmark to judge their current pain level. Patients who had experienced severe pain in the past tended to consider their current pain as less severe than patients who had not experienced severe pain before. They explained that they understood what “worst imaginable” pain was and accordingly recalibrated the NRS.

“I now rate it a three, almost no pain, but I’ve had surgery before and then they asked it as well. I’ve had a tonsillectomy and then you’re actually constantly in pain, so I had an eight or something, that’s really very painful, that’s not normal anymore” (female, age 18).

“My neuropathic pain was severe and then you know how ‘worst imaginable’ pain can be. And that’s quite irritating because I’ve had

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a lot of pain and if you have to compare then I say, ‘it’s a four’ and you compare it with a ten that is not as high as someone else’s, I always find it difficult to distinguish. And then they (the nurses) say, ‘oh, then it’s okay’. But they don’t know with what I’m comparing it” (female, age 26).

Being tough on oneself: Regarding their postoperative pain experience, many patients said that they were tough on themselves.

“They have often told me that I am very hard on myself. I didn’t allow myself to complain. I was very hard on myself” (male, age 41).

Patients said that they expected pain after surgery and that they could bear some pain. Moreover, patients indicated that postoperative pain is temporary. Sometimes, high NRS scores were given, yet patients considered the experienced pain bearable and did not want additional analgesic treatment. Several patients said that they thought it was appropriate to be tough on themselves, and they often traced that back to their own upbringing and the way they were taught to handle pain during childhood.

“I don’t moan quickly. I don’t often visit the doctor. I get that from my upbringing. Yeah, it has to be really necessary before I make a fuss” (female, age 45).

Pain threshold: Many patients thought they had a high pain threshold, because they could bear a lot of pain.

“My pain threshold is quite high because I’ve been through a lot. My knees had to be bent three years ago. So, I can take quite a lot because that was very severe” (male, age 41).

One patient said that the individual pain threshold depends on the degree of resilience that one has and that this differs between

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people. Patients who also had chronic pain considered their postoperative pain intermediate but bearable, explaining that they were used to having pain. They explained that because they were accustomed to pain, they had a high pain threshold and could handle more pain than patients without chronic pain.

“You learn to live with it, but there are limits. Anyone else would already be screaming because of the pain, but my pain threshold is a bit higher” (male, age 45).

Few patients said they had a low pain threshold because they could not bear a lot of pain. One patient told the interviewer that after giving birth to her children, she could not bear pain anymore.

Holding oneself to one’s own standards: Many patients considered NRS scores of 4 and higher, especially scores between 4 and 6, still bearable. During the interviews, the researcher explained to the patients how professionals are taught that NRS scores of 4 and higher are unacceptable and require intervention. Even after this explanation, patients continued to maintain their own point of view (i.e., that NRS scores between 4 and 6 were bearable). They said they had their own standards about the meaning of the different numbers of the pain scale.

Interviewer: “You told me a six, seven is bearable. Would you alter it if I told you that nurses consider zero to four as bearable pain?”

Patient: “No, because I have got my own norm, I am more used to pain and I think it is bearable. If I’m in pain and I can handle it, it is bearable for me” (male, age 47).

Desiring confirmation from professionals: Patients sometimes doubt about the NRS score they assign to their pain. Patients appreciated it when the professional confirmed their assignment of a high number to their pain. They were more convinced that they had

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correctly assigned a number to their pain experience if the doctor or nurse had said that a high level of pain was expected or normal.

“When I actually told him (the doctor), he said ‘yes I can imagine, because it’s all bruised’. So then I thought ‘see, I’m not exaggerating!’. I have the idea that they will then think I’m being a wimp” (female, age 63).

3.3. Anticipated consequences of assigning a particular NRS score Patients appeared to take the anticipated consequences of a given NRS score into account before telling the professional a number. They sometimes purposefully assigned a lower NRS score than the pain actually experienced in anticipation of the reaction of healthcare professionals. Patients were sometimes reluctant to provide an NRS score, fearing it is “too high” or “too low” that possibly lead to a reaction of the professional they did not expect. With giving a particular score, patients tried to anticipate whether professionals will administrate analgesics or not. Therefore, this distinction led to two subthemes: “judgment by care professionals” and “analgesic administration.”

3.3.1 Judgements by healthcare professionals. Being seen as a bother: Patients were worried that healthcare professionals would consider them being a bother if they reported high NRS scores.

“That is not because I want to be tough or anything, that is not the issue, but I just don’t want to be a bother. That’s the point, I just don’t want to be bothersome” (male, age 47).

“In the past, you didn’t complain, you just got on with it. That’s what’s in me and always will be” (female, age 63).

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Patients fear that professionals think that they exaggerate pain. Consequently patients anticipated on the risk of being judged as bothersome by the professional and therefore do not want to complain. Many patients said they were afraid of being seen as troublesome while hospitalized. To avoid being seen as troublesome, they did not ask for analgesics, especially when they observed that the nurses were busy.

Interviewer: “Why did you wait two hours before you requested any analgesics?”

Patient: “Because I didn’t want to be troublesome” (male, age 70).

Experiencing basic mistrust: The expression of pain using a number from 0 to 10 was influenced by patients’ perception of professionals; some patients hesitated to report a high NRS score, thinking that healthcare professionals would not believe that they were really in so much pain.

“This week I gave a high pain score and I noticed that they (the nurses) looked at me as if to say, ‘mmm, that is a very high score’. They almost don’t believe you. Probably because it is rare that the pain score is that high. Like they can’t handle it that the pain is so severe, I think, I noticed that” (male, age 45).

This basic mistrust, patients said, led them to intentionally report lower NRS scores than they actually perceived.

“Well, there are interpretation differences between people. You’re not allowed to complain. So, you lessen your pain score because you feel that no-one will accept if you say ‘I feel so awful. I’m in so much pain’, then you minimize your pain” (female, age 65).

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One patient defined basic mistrust as “mental pain”: “It hurt when someone said to me, ‘Nothing is wrong with you!’” Patients thought that this disbelief was due to a lack of visible tissue damage. Patients felt they were not taken seriously by healthcare professionals when reporting an NRS score. They perceived that the professionals did not consider their pain serious. Patients clearly indicated that they wanted to be taken seriously, even when professionals thought that the reported NRS score was (too) high. Some patients indicated that it was important that the professional just listened to them, without judging.

“Being taken seriously is pleasant for a patient. Knowing that you are being taken seriously, even though from an objective point of view it (the pain score) is not quite the right number on the scale” (female, age 65).

Wish to meet the expectations of professionals: Some patients wanted to meet the expectations of the professional in what pain score fits best on the experienced pain, considering what would be the most socially acceptable pain score. They adjusted their pain score to the estimated level of which they thought the professional will find it logical.

“Then I think I will lower my score, otherwise they (the nurses) will think ‘do you really have so much pain?’ (female, age 63).

“I am just going to give my usual scores and for now, I just not take my neuralgia into account. When my neuralgia gets worse again, then I will give it a score of 20 because adjusting my measure to even worse pain has been proven not efficacious to give a clear explanation of my experienced pain (to the nurses)” (female, age 26).

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3.3.2 Analgesic administration. Encounter ambivalence: Many patients were ambivalent towards analgesics. On the one hand, they needed analgesics after surgery to recover, but on the other hand, they actually thought analgesics were not good for them because of toxicity.

“If it really hurts, after surgery for example, then I think it’s necessary. But if it’s not necessary, then preferably no painkiller, because ultimately it’s junk what you’re putting in your body” (female, age 18).

Some patients accepted analgesics and other patients said that most pain is transient, and therefore, refused analgesics. The different negative terms for analgesics given by patients, like “junk” or “rubbish, ” supported this opinion.

“There is so much rubbish in and I think every time ‘O my God, it’s morphine and it’s better if I can do without.’ They (the nurses) have explicitly told me that it’s okay, but it plays on my mind” (female, age 71).

Suffering side effects: Some patients said that they refused opioids because they had previously experienced typical opioid side effects, such as sedation and nausea, even when the nausea had been treated appropriately. Once they are no longer opioid naive, patients often consciously weigh the desired analgesic effects of opioids against the negative side effects.” One patient expressed this eloquently as follows:

“But as soon as I use too much morphine then I become very nauseous. You are constantly trying to find a balance between bearable pain and bearable nausea, shall we say” (female, age 65).

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Variation on timing of opioids: There was significant variation in the pain levels at which patients wanted opioids to be administered. Some patients said they could bear the pain and did not need any analgesics. Other patients wanted light analgesics to be administered at NRS scores of 4–6. However, a large variability was seen when patients needed opioids: Some patients said they needed opioids at NRS scores from 6 onwards, while some only required opioids from NRS 7 or even higher:

“I want painkillers from a four and above and morphine, no, then I would say: eight or above” (male, age 36).

Patients gave different reasons for not wanting opioids (e.g., they had heard terrifying stories about opioids from family and friends, they had previously suffered from the side effects of opioids, they wanted to bear their own pain, they believed that pain was a signal telling the body it needed to rest or that they had to get used to pain).

Nurses have own point of view: Patients said that nurses had their own point of view about the meaning of the numbers from 0 to 10 and do not use the score to communicate about pain with the patient:

“As far as I can remember nobody asked me a question like that if the pain was mild because if it is severe, six or seven, then they (the nurses) say, ‘what can we do about it?’ But when it is three or four then they immediately say, ‘okay’ and write it down. I would prefer if they said, ‘do you want us to do something about it or can you handle it’, instead of saying, ‘so, you’re okay then”’ (female, age 26).

Patients said that there was no agreement in terms of the NRS score at which nurses administered analgesics. One patient describes this as follows:

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“Well I thought, the pain is easing, so I said five or four, one of those I said and then she (the nurse) said, ‘well then you don’t need any more painkillers.’ And then I said no, then it is a six because it hurt and I needed them. Now I assume with five I won’t get any painkillers so I think ok, with five no painkillers and I want some so I give a six and then I get them” (female, age 32).

In contrast, some patients who rated their pain as NRS 6 or 7 did not want additional analgesic medication, but nurses insisted that they accept additional pain medication according to acute pain treatment guidelines.

4. Discussion The qualitative approach in this study identifies several elements underlying the process of a patient translating his/her currently experienced postoperative pain into a reported rating on the NRS. A model of this decision-making process is proposed made of the interrelationship between the factors that influence this rating process. The model may help healthcare professionals to better understand this process and the factors that possibly influence the NRS score that is actually reported to them. When assigning an NRS score to their pain, patients process the first two themes in stages: They first weigh score-related factors and intrapersonal factors. Some patients go through a last stage before telling the professional: weighing the anticipated consequences of reporting a particular NRS score against their actual desire for more or less analgesics. Patients can be aware of these factors, but most often, the entire process appears to be implicit and subconscious.

Quantifying pain through the self-reported NRS score from 0 to 10 is often referred to as the gold standard for pain assessment (Schiavenato and Craig, 2010). However, for a gold standard, self- report is fraught with limitations. Nowadays, pain professionals develop guidelines for pain treatment including the manner for instructing and informing patients how they should interpret NRS scores from 0 to 10. Our data suggest that this single number does not tell the whole story. Instead, healthcare professionals should listen to the patient’s story about the experienced pain rather than

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simply administering analgesics as soon as a single pain score exceeds a numeric threshold. Without a pain assessment beyond the NRS by healthcare professionals, postoperative patients may be at risk of both undertreatment and overtreatment of their pain. The scores on the NRS are only important to detect change in postoperative pain treatment. Knowledge of the factors in this study that influence a patient’s pain scoring can help professionals use simple questions to explore patients’ unique pain experiences and consequently titrate analgesic treatment in dialogue with the patient, improving the quality and safety of care.

The current study also confirmed that patients find it especially difficult to rate their unique pain experience on the NRS when their score is in the middle of the sequence (i.e., 4 to 6) (Eriksson et al., 2014; Williams et al., 2000). Therefore, many patients considered an NRS score of 7 as the limit of pain acceptance, and at 7 or above, opioids were desired. This is clearly a much higher pain threshold than currently taught to professionals based on guidelines for acute pain management. There is no agreement on the optimal NRS cut- off score in guidelines for pain treatment and there is no agreement on how to identify an optimal NRS cut-off score for pain treatment (Gerbershagen et al., 2011). Rigid cut-off scores in guidelines for pain treatment should not be used with individual patients to prevent a risk of over- or undertreatment. Therefore, patients should be asked what their individual cut-off score is when they require a particular intervention.

Many factors are known to affect the experience of pain, including gender, age, culture, previous experiences, types of surgery, the meaning the pain has to the individual experiencing it, and psychological factors (e.g., coping skills) (Gerbershagen et al., 2013; Mackintosh, 2007). Patients often arrived at a new NRS score by comparing their worst previous pain experience with the current pain sensation (Dionne et al., 2005; Manias et al., 2004). In the current study, we found that the NRS scores from 0 to 10 can conceal real differences in pain intensity across patients, because previous pain experiences differ between patients. In line with this finding, a previous study concluded that it is impossible to compare pain scores between patients, because we cannot share pain experiences (Bartoshuk et al., 2003).

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Subjective norms influence the social pressure on the individual to exhibit (or not exhibit) a particular behaviour (Rhodes and Courneya, 2003). Our findings confirmed the idea that patients do not want to deviate from perceived social norms and be known as an individual who complains a lot (Eriksson et al., 2014; Hansson et al., 2011). Patients are afraid of being judged by healthcare professionals when the NRS score they report is perceived as “too high.” This exact situation, called basic mistrust, is described in a phenomenological study in which nurses did not believe the patients (Söderhamn and Idvall, 2003). Only when there is confirmation by the professional does the patient feel empowered to assign a high NRS score.

Patients also envision what their reported pain scores will mean regarding the subsequent administration of analgesics, especially opioids. There appears to be a wide variation in how patients interpret NRS scores in relation to if, when, and how much analgesia needs to be given. The NRS cut-off points used in guidelines for acute pain are often lower than those of patients; patients tend to use the midpoint of the scale as the NRS cut-off value for additional analgesia. Therefore, most patients with NRS scores of 4, 5, and even 6 consider their pain “bearable” and do not want opioid analgesics. It seems that many professionals have learned this from patients and do not administer analgesics when patients’ NRS pain scores are in the middle of the scale. In turn, patients have learned from previous reactions of professionals at what NRS score they will be administered a certain analgesic. A study of chronic pain patients also showed that patients have to give an NRS score higher than 5 in order to receive more analgesics from the nurse (Hansson et al., 2011).

Understanding the process by which patients make decisions is important to understand the decisions they make. In previous studies several factors are described that influence patients’ decision-making process, e.g., past experiences, cognitive biases, age, and belief in personal relevance (Dietrich, 2010; Juliusson et al., 2005; Sagi and Frieland, 2007). Once the decision is made, levels of regret or satisfaction will impact future decisions (Juliusson et al., 2005; Sagi and Frieland, 2007). In the current study, patients anticipate on the consequences on reporting a particular pain score

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whether professionals will administrate analgesics or not depending on their past experiences in pain treatment. Additionally, patients anticipate on the judgement by healthcare professionals; some patients hesitated to report a high NRS score, thinking that healthcare professionals would not believe that they were really in so much pain (Idvall et al., 2008).

When the NRS score is used, a shared understanding of patients and professionals is crucial to the adequate treatment of pain. However, this seems difficult to realize, because the interpretation of pain scores differs between individuals. Everyone has its own standards and values that are impossible to change in favour of looking the same way to the pain scores from 0 to 10. Culture influences how each person experiences and responds to pain. Some cultures value stoicism and tend to avoid saying that there is pain and other cultural groups tend to be more expressive about pain (Narayan, 2010). Patients’ diverse cultural patterns are not right or wrong, just different. The purpose is to achieve individualized pain assessment and pain treatment. Professionals evaluate patients’ pain and make judgements that are required for prescribing pain treatment. Therefore, healthcare professionals must learn to think about analgesic administration in a more “patient- oriented” way: a patient has to be seen as a whole person in his/her social context, and his/her feelings, wishes, expectations, norms, and experiences have to be taken into account (Ouwens et al., 2012). Patients want to participate in the treatment of their pain and tell the healthcare professionals if and when they need analgesics because patients know what pain they have (Idvall et al., 2008; McTier et al., 2014; Joelsson et al., 2010).

Many patients could tolerate short bouts of severe pain during movement as well and did not desire additional opioids. For some patients, the pain can be so severe as to preclude adequate coughing. In these cases, it is important that patients accept additional analgesia to prevent pneumonia. In a previous study, we educated patients about the principles in postoperative pain management (Van Dijk et al., 2015). Patients’ knowledge and beliefs changed, moreover, their behaviour did not change. Postoperative patients still gave high pain scores and considered this as bearable and did not want (extra) analgesics. Changing patients’ habits is

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very difficult, as patients in the current qualitative study say that they want to hold their own standards and remain having their own point of view about pain management.

Although our study was restricted to only one university hospital, the richness of the data makes us confident that our analysis has captured the most typical aspects of patients’ underlying processes for rating their pain on the NRS. Moreover, the current study is strengthened by the number of interviews and the fact that the new insights that emerged during data collection were incorporated into the interview topic list. In this qualitative study, only Dutch patients were interviewed, and the results are, therefore, not immediately generalizable to other countries and cultures. While we believe that many of the themes that we elicited (e.g., fear of being judged) will also emerge when repeated in other countries in the Western world, ideally a cross-cultural international study should be conducted to expand on the themes and to validate or extend our conceptual model of how patients arrive at their reported NRS scores. Such a study would possibly give interesting and important insights into crosscultural differences in the pain experience and responses to pharmacologic and non-pharmacologic pain treatments offered.

5. Conclusions In postoperative pain management, NRS cut-off scores are widely used as a basis for administering or withholding opioid analgesics. Patients however, have a different view on these NRS cut-off scores; many patients consider NRS scores 4, 5 and 6 as bearable and do not need analgesics. Therefore, it is necessary to communicate with patients beyond the NRS score. The current qualitative study identified several elements of the underlying process (e.g., previous pain experiences, being tough on oneself, basic mistrust by healthcare professionals, and variation on timing of opioids) by which patients translate acute postoperative pain into a rating on the NRS. The factors in the model are subsumed under three main themes: score-related factors, intrapersonal factors, and the anticipated consequences of reporting a particular NRS score. Knowing these factors could help healthcare professionals to better understand the complex process by which patients assign pain

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scores and the factors that influence the scores that are ultimately reported to them. This could serve as basis for a dialogue aimed at clarifying the patient’s current needs and result in more patient- centred, shared decision making regarding (opioid) analgesic administration improving the quality and safety of care.

6. Relevance to clinical practice Pain assessment is the foundation of pain management when a patient is experiencing postoperative pain. Frequent and thorough assessment of patients’ pain provides information to achieve optimal pain relief. We recommend assessing patients’ pain on the NRS. Asking patients to score their pain on the NRS ensures that all professionals assess pain in the same way and with adequate treatment of postoperative pain, subsequent NRS scores are expected to be lower. Nevertheless, the NRS score is not an absolute number. Once the patient has reported an NRS score, the professional is not finished. Rather, the professional should communicate with the patient to understand the meaning of this particular score without being judgemental. Healthcare professionals should understand that patients can have their own interpretation of the pain scale and might have different ideas regarding the particular NRS score that signifies the need for additional analgesics. Rigid cut-off scores in guidelines for postoperative pain treatment should not be used with individual patients; patients should be asked what their individual cut-off score is when requiring a particular intervention.

Acknowledgments

The authors would like to thank all the participants for their contribution to this study.

Conflict of interest: None declared.

Funding: Support was provided solely by departmental sources.

Ethical approval: This study was approved by the Medical Ethics Committee of the University Medical Center Utrecht.

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Appendix A. Supplementary data

Supplementary material related to this article can be found, in the online version, at http://dx.doi.org/10.1016/j.ijnurstu.2015.08.007.

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aPain Clinic, Department of Anesthesiology, University Medical Center Utrecht, The Netherlands bDepartment of Internal Medicine & Infectious Diseases, University Medical Center Utrecht, The Netherlands cDepartment of Anesthesiology, University Medical Center Utrecht, The Netherlands dDepartment of Nursing Science, University Medical Center Utrecht, The Netherlands

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http://www.vmszorg.nl

Appendix D. Example of a correlational study (turner et al., 2016) Psychological functioning, post-traumatic growth, and coping in parents and siblings of adolescent cancer survivors

Andrea M. Turner-Sack, PhD, Rosanne Menna, PhD, Sarah R. Setchell, PhD, Cathy Maan, PhD, and Danielle Cataudella, PsyD

Purpose/Objectives: To examine psychological functioning, post- traumatic growth (PTG), coping, and cancer-related characteristics of adolescent cancer survivors’ parents and siblings.

Design: Descriptive, correlational.

Setting: Children’s Hospital of Western Ontario in London, Ontario, Canada.

Sample: Adolescents who finished cancer treatment 2–10 years prior (n = 31), as well as their parents (n = 30) and siblings (n = 18).

Methods: Participants completed self-report measures of psychological distress, PTG, life satisfaction, coping, and cancer- related characteristics.

Main Research Variables: Psychological functioning, PTG, and coping.

Findings: Parents’ and siblings’ PTG levels were similar to survivors’ PTG levels; however, parents reported higher PTG than siblings. Parents who used less avoidant coping, were younger, and had higher life satisfaction experienced less

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psychological distress. Parents whose survivor children used more active coping reported less psychological distress. Siblings who were older used more active coping, and the longer it had been since their brother or sister was diagnosed, the less avoidant coping they used.

Conclusions: Childhood and adolescent cancer affects survivors’ siblings and parents in unique ways.

Implications for Nursing: Relationship to the survivor, use of coping strategies, life satisfaction, and time since diagnosis affect family members’ postcancer experiences.

Since the 1980s, the incidence rates of childhood and adolescent cancer have increased and the mortality rates have decreased in the United States and Canada (National Cancer Institute, n.d.; National Cancer Institute of Canada, 2008). This has resulted in a growing population of young cancer survivors with a unique set of psychological issues. Researchers have explored some of these issues, including survivors’ moods, anxieties, and coping strategies (Dejong & Fombonne, 2006; Schultz et al., 2007; Turner-Sack, Menna, Setchell, Mann, & Cataudella, 2012). However, the focus is often on the negative aspects of childhood cancer, such as depression, with fewer studies addressing a more positive aspect, such as positive changes in perspectives, life priorities, and interpersonal relationships (Kamibeppu et al., 2010; Seitz, Besier, & Goldbeck, 2009). In addition, the experiences of young cancer survivors’ families often are ignored.

The diagnosis and treatment of cancer in childhood or adolescence can be exceptionally stressful not only for the young patients with cancer, but also for members of their family. Several studies suggest that parents of children and adolescents with cancer experience psychological distress, post-traumatic stress, and poor quality of life (Brown, Madan-Swain, & Lambert, 2003; Kazak et al., 1997, 2004; Witt et al., 2010). Other studies indicate that parents of cancer survivors appear to function just as well as parents of healthy controls or in accordance with standardized norms (Dahlquist, Czyzewski, & Jones, 1996; Greenberg, Kazak, & Meadows, 1989; Radcliffe, Bennett, Kazak, Foley, & Phillips, 1996).

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Similar to research on parents of young cancer survivors, studies of the psychological impact on siblings within these families are scarce. Several studies have found that siblings of young cancer survivors have more negative emotional reactions (e.g., fear, worry, anger), more post-traumatic stress, and poorer quality of life than controls (Alderfer et al., 2010; Alderfer, La-bay, & Kazak, 2003). Other studies found that siblings of survivors function similarly to their peers whose siblings are healthy (Dolgin et al., 1997; Kamibeppu et al., 2010). Together, these findings suggest that family members of young cancer survivors experience a range of psychological responses to cancer and that additional research could provide some clarification.

Although understanding how survivors’ cancer affects their parents and siblings is important, equally important is understanding the associations among family members’ psychological functioning. In accordance with a family systems perspective, a person’s well-being is related to other family members’ wellbeing (Nichols & Schwartz, 2001). In support of this perspective, research generally has found that most young cancer survivors’ psychological functioning is related to their parents’ psychological functioning (Barakat et al., 1997; Brown et al., 2003; Phipps, Long, Hudson, & Rai, 2005). Few studies have examined the relations between young cancer survivors’ psychological distress and their siblings’ psychological distress.

Although coping with a traumatic experience, such as cancer, tends to be distressing, it also may provide individuals with the opportunity to achieve positive change, such as post-traumatic growth (PTG). PTG is defined as mastering a previously experienced trauma, perceiving benefits from it, and developing beyond the original level of psychological functioning (Tedeschi, Park, & Calhoun, 1998). Similar to the literature concerning young cancer survivors, PTG in parents of young survivors has received little attention. The few studies that exist suggest that parents of young survivors may experience at least some degree of PTG (Best, Streisand, Catania, & Kazak, 2001; Yaskowich, 2003). Research of PTG in other family members of patients with cancer also is limited. Kamibeppu et al. (2010) found that young adult sisters of young adult childhood cancer survivors reported experiencing greater

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PTG than female controls. Other studies identified some positive changes that siblings experienced (e.g., feeling more mature, independent, and empathic; valuing life more) (Barbarin et al., 1995; Chesler, Allswede, & Barbarin, 1992; Havermans & Eiser, 1994), but the researchers did not determine whether the siblings perceived as much benefit from the trauma or developed beyond their original level of functioning enough to be consistent with PTG. In keeping with the familial model of illness-related stress and growth, the current study examined PTG in parents and siblings of adolescent cancer survivors.

The lack of research examining the relations among family members’ levels of PTG is not surprising given the limited research examining PTG in parents and siblings of young cancer survivors. Two studies have found that parents’ PTG was not correlated with adolescent cancer survivors’ overall PTG (Michel, Taylor, Absolom, & Eiser, 2010; Yaskowich, 2003). However, parents’ PTG accounted for as much as 10% of the variance in two aspects of survivors’ PTG: improved relationships and appreciation for life (Yaskowich, 2003). These results suggest that the association between survivor PTG and PTG among other family members warrants further investigation. The current study fills a notable gap in the literature by examining the associations between adolescent cancer survivors’ PTG and PTG in parents and siblings of survivors.

An additional goal of the current study was to examine whether coping strategies were related to psychological functioning and PTG in parents and siblings of adolescent cancer survivors. Available studies suggest that parents of young patients with cancer and survivors who use more self-directed and active coping report lower levels of psychological distress, and those who use more emotion-focused and avoidant coping report higher levels of psychological distress (Fuemmeler, Mullins, & Marx, 2001; Norberg, Lindblad, & Boman, 2005). Other studies indicate that siblings of adolescent cancer survivors who have high emotional social support tend to be less depressed, be less anxious, and have fewer behavioral problems than siblings with low emotional social support (Barrera, Fleming, & Khan, 2004). To the researchers’ knowledge, no studies have examined the associations between parents’ and siblings’ coping strategies and their levels of PTG, but

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Calhoun and Tedeschi’s (1998) model of PTG suggests that active social support and acceptance coping are most closely associated with PTG.

Examining demographic and cancer-related variables, such as age of parents and siblings, survivors’ age at diagnosis, time since diagnosis, and time since treatment completion, can provide insight into the experiences of young cancer survivors and their families. Little is known about the relations between age and psychological functioning, PTG, and coping in siblings of cancer survivors (Alderfer et al., 2003). Several studies have found that adolescent cancer survivors’ age at diagnosis was unrelated to parents’ post- traumatic stress symptoms (Brown et al., 2003; Kazak et al., 1997) and PTG (Barakat, Alderfer, & Kazak, 2006). In terms of PTG, theorists have suggested that, although positive consequences of life crises can happen shortly after the crisis, they are more likely to occur after a long process of crisis resolution and personal recovery (Schaefer & Moos, 1992). However, the only known study to examine the relation between time since cancer treatment and parental PTG found that a shorter time since the end of young cancer survivors’ treatment was associated with more PTG in fathers but not mothers (Barakat et al., 2006).

The goals of the current study were to (a) examine psychological functioning (defined as level of distress and life dissatisfaction), PTG, and coping in parents and siblings of adolescent cancer survivors; (b) compare adolescent cancer survivors, parents, and siblings on those same variables; and (c) examine psychological functioning, PTG, and coping in parents and siblings in relation to age, time, and cancer-related variables.

Methods Sample English-speaking Canadian families with an adolescent (aged 13–20 years) who completed treatment for a solid tumor, leukemia, or lymphoma 2–10 years earlier at a children’s hospital were eligible to participate in the study (see Table 1). They were not eligible if they had a cancer relapse, an organ transplantation, a brain tumor that

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required only surgery, or significant cognitive or neurologic impairments. All siblings reported living with the survivor while he or she was receiving treatment.

TABLE 1 Characteristics of Study Participants

a Several respondents had multiple types of treatment.

Procedure Following institutional ethics approvals from the University of Windsor in Ontario, Canada and the University of Western Ontario in London, Ontario, Canada, data were collected from the pediatric

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oncology population at Children’s Hospital of Western Ontario in London, Ontario, Canada. Questionnaires were mailed to 89 families that met criteria for the study. They were informed that participants’ names would be entered into a drawing for a $50 gift certificate from a local store. Thirty-one adolescents, 30 parents, and 18 siblings returned completed packages. In total, 35 families had at least one member participate in the study. Fourteen families had an adolescent, parent, and sibling participate. The remaining 21 families had various combinations of family member participation, and, as such, the adolescent, parent, and sibling groups represent different sets of families in the current study.

Measures Demographics and cancer variables: Participants completed a background questionnaire that asked about age, gender, ethnicity, education, type of cancer, age at diagnosis, time since diagnosis, time since treatment completion, and length and type of treatment.

Psychological distress: The Brief Symptom Inventory (BSI) (Derogatis & Melisaratos, 1983) was used to assess psychological distress. Participants used this 53-item questionnaire to self-report to what extent they experienced psychological symptoms. Participants rated their symptoms in a number of areas (e.g., somatization, depression, anxiety) on a five-point scale ranging from 0–4, with 0 indicating not at all and 4 indicating extremely. The BSI generates scores on three overall indices of distress: General Severity Index (GSI), Positive Symptom Distress Index, and Positive Symptom Total. Analyses used GSI t scores, with low scores indicating low psychological distress. The internal consistency in the current study was 0.97 for survivors and siblings and 0.98 for parents.

Life satisfaction: Survivors and siblings completed the Students’ Life Satisfaction Scale (SLSS) (Huebner, 1991), a self-report questionnaire that assesses global life satisfaction in children and adolescents. Participants used a six-point scale ranging from 1 (strongly disagree) to 6 (strongly agree) to respond to seven statements about their lives. The average score per SLSS item was used in the analyses, with high scores indicating more life satisfaction. The internal consistency in the current study was 0.87

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for survivors and siblings. Parents completed the Satisfaction With Life Scale (SWLS)

(Diener, Emmons, Larsen, & Griffin, 1985), a self-report questionnaire that assesses adult global life satisfaction. Parents used a seven-point scale ranging from 1 (strongly disagree) to 7 (strongly agree) to respond to five statements about their life. The average score per SWLS item was used in the analyses, with high scores indicating more life satisfaction. In the current study, the internal consistency was 0.91 for parents.

Post-traumatic growth: The PTG Inventory (PTGI) (Tedeschi & Calhoun, 1996) assesses the experience of positive changes following a traumatic event. Participants used the 21-item self- report questionnaire to indicate the extent to which they experienced various positive changes. Participants used a six-point scale ranging from 0–5, with 0 indicating “I did not experience this change as a result of my crisis, ” and 5 indicating “I experienced this change to a very great degree as a result of my crisis.” The PTGI wording was modified to refer specifically to changes resulting from having had a family member with cancer. In addition, the language used in the PTGI given to siblings was modified to better suit a younger population (similar to modifications used by Yaskowich [2003]). The average score per PTGI item was used in the analyses, with high scores indicating more PTG. Tedeschi and Calhoun (1996) reported an internal consistency coefficient of 0.9 for the full scale and a test-retest reliability of 0.71 after two months. Yaskowich (2003) reported an internal consistency of 0.94 for the full scale of the modified PTGI in a sample of 35 adolescent cancer survivors. The internal consistency of the modified PTGI was 0.94 for survivors and siblings and 0.96 for parents in the current study.

Coping strategies: The COPE (Carver, Scheier, & Weintraub, 1989) assesses coping strategies in adolescents and adults. Participants used this 60-item self-report questionnaire to rate the way they respond to stressful events. Participants used a four-point scale ranging from 1–4, with 1 indicating “I usually do not do this at all, ” and 4 indicating “I usually do this a lot.” The COPE yields scores on 15 different scales. Factor analyses have revealed slightly different factor structures for adolescents and adults. Phelps and

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Jarvis (1994) proposed a four-factor structure for adolescents: active coping, emotion-focused coping, avoidant coping, and acceptance coping.

Similarly, Carver et al. (1989) proposed a four-factor structure for adults: active coping, social support and emotion-focused coping, avoidant coping, and acceptance coping. The current study used the four factors proposed by Phelps and Jarvis (1994) for the survivors and siblings and the four factors proposed by Carver et al. (1989) for the parents. The religious coping scale was not associated with any of the factors but was included for all groups. High scores on a particular factor or scale reflect a greater use of that type of coping strategy. In the current study, internal consistency ranged from 0.74 (acceptance coping) to 0.94 (religious coping) for survivors and siblings, and from 0.52 (avoidant coping) to 0.94 (religious coping) for parents.

Data analyses All tests of significance were two-tailed with an alpha level of 0.01 to correct for the number of analyses performed and type I errors. Analyses were completed separately for parents and siblings. Pearson product-moment correlations and standard regressions with forward entry were conducted to examine parents’ and siblings’ reports of demographic and cancer-related variables in relation to their reported levels of psychological distress, life satisfaction, PTG, and coping strategies. Independent sample t tests were conducted to compare the survivors, parents, and siblings on measures of psychological distress, life satisfaction, PTG, and coping strategies. To examine the associations between survivors’ coping, psychological distress, and PTG and that of their matched parents, Pearson product-moment correlations were used.

Results The focus of this article is family members of adolescent cancer survivors, particularly their parents and siblings. Detailed information on the psychological functioning, PTG, and coping of adolescent cancer survivors in the current study are provided in Turner-Sack et al. (2012).

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Parents’ psychological distress was positively associated with age (r = 0.53, p < 0.01) and avoidant coping (e.g., denial, disengagement) (r = 0.52, p < 0.01), and it was negatively associated with life satisfaction (r = –0.62, p < 0.001) and active coping (e.g., focusing on, planning, and actively dealing with problems; seeking helpful social support) (r = –0.57, p < 0.001). Life satisfaction was also positively correlated with active coping (r = 0.56, p < 0.001). Time since treatment completion was positively associated with parents’ social support and emotion-focused coping (r = 0.5, p < 0.01).

A standard regression analysis was performed to predict parents’ psychological distress using parent variables correlated with it: active coping, avoidant coping, life satisfaction, and age. The overall regression model for psychological distress was significant (R2 = 0.51; F[3, 22] = 7.69, p < 0.001). Examination of the squared semipartial correlation coefficients indicated that avoidant coping (β = 0.37, t[25] = 2.42, p < 0.05; sr2 = 0.13), age (β = 0.35, t[25] = –2.26, p < 0.05; sr2 = 0.11), and life satisfaction (β = –0.33, t[25] = 2.14, p < 0.05; sr2 = 0.1) made significant unique contributions to the prediction of psychological distress. Therefore, parents who used less avoidant coping, were younger, and had higher life satisfaction were likely to experience less psychological distress. Parents’ PTG was not significantly associated with any of the study variables.

Siblings’ age was positively associated with active coping (r = 0.73, p < 0.001). Avoidant coping was negatively associated with time since diagnosis (r = –0.67, p < 0.01) and life satisfaction (r = – 0.71, p < 0.001). None of the variables correlated with siblings’ psychological distress or PTG at the 0.01 significance level.

For each measure, the mean scores, standard deviations, and ranges of scores are presented for adolescent cancer survivors and siblings (see Table 2) and parents (see Table 3). Survivors, parents, and siblings reported similar levels of psychological distress but significantly different levels of PTG (F[2, 75] = 5.32, p < 0.01). Parents’ PTG was significantly higher than that of siblings (t[46] = 2.91, p < 0.01), and survivors’ PTG was similar to that of parents (t[58] = –2.43, not significant [NS]) and siblings (t[47] = –0.98, NS). No significant differences were seen between survivors and siblings on their levels of life satisfaction (t[47] = 1.16, NS) or active (t[47] = 0.3, NS), avoidant (t[46] = –0.93, NS), emotion-focused (t[47] = 0.39,

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NS), acceptance (t[47] = 0.38, NS), or religious (t[47] = 1.14, NS) coping strategies. Parents’ coping levels were not compared with survivor or sibling coping levels because the adult COPE factor structure differed from the adolescent COPE factor structure.

TABLE 2 Scores on Measures of Psychological Distress, Coping, Post- Traumatic Growth, and Life Satisfaction for Adolescent Cancer Survivors and Siblings

a Possible scores range from 1 (low psychological distress) to 100 (high psychological distress). b Possible scores range from 1 (lesser use of the coping strategy) to 4 (greater use of the coping strategy). c Possible scores range from 0 (low post-traumatic growth) to 5 (high post-traumatic growth). d Possible scores range from 1 (low life satisfaction) to 6 (high life satisfaction).

TABLE 3 Scores on Measures of Psychological Distress, Coping, Post- Traumatic Growth, and Life Satisfaction for Parents (N = 30)

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In 28 of the 35 participating families, the survivor and one of his or her parents participated, resulting in 28 matched survivor-parent dyads. Correlations for matched dyads are presented in Table 4. Parents’ psychological distress was negatively correlated with their survivor child’s active coping (r = –0.53, p < 0.01).

TABLE 4 Correlations Between Adolescent Cancer Survivors’ and Matched Parents’ Psychological Distress, Post-Traumatic Growth, and Coping (N = 28)

*p < 0.05; ** p < 0.001 ACP—acceptance coping; ACT—active coping; AVD—avoidant coping; EF— emotion-focused coping; PD—psychological distress; PTG—post-traumatic growth; SSEF—social support and emotion-focused coping; RLG—religious coping

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Discussion The current study revealed that younger age, higher life satisfaction, and less avoidant coping were strong predictors of lower psychological distress in parents of adolescent cancer survivors. As parents get older, they may have a greater awareness of the difficulties and possible limitations that their adolescent cancer survivors may face. Younger parents may pay less attention to these difficulties or be more naive about them and, as such, report experiencing less psychological distress. Parents who are more satisfied with their lives (e.g., feel their lives are good, have what they want in life, would change little about their lives) may have fewer concerns and feel assured and grounded, which could contribute to lower levels of psychological distress. This finding is consistent with previous studies that found that parents’ reports of external attributions about cause, rather than self-blame and family satisfaction, are associated with better psychological adjustment (Kazak et al., 1997; Vrijmoet-Wiersma et al., 2008). Finally, parents who face their difficulties to a greater degree are likely less troubled or burdened by neglected ongoing difficulties and, therefore, experience less psychological distress.

Research on how family members of young cancer survivors cope is scarce. The current study found that the longer ago that the adolescent cancer survivors completed treatment, the more social support and emotion-focused coping the parents used. As time passes after treatment is completed, parents may feel that they have more time in their daily lives to use the social support available to them and feel better able to face and deal with their emotions. The findings also suggest that older siblings were likely to use more active coping strategies. When a brother or sister was receiving cancer treatment, parents were occupied with the child with cancer, so older siblings likely had to attend to their own needs (Alderfer et al., 2010). In addition, during this period of time, siblings may have learned about the use of self-reliance, active coping, and problem solving.

Overall, siblings used similar coping strategies to survivors. Siblings whose brother or sister was diagnosed longer ago tended to use less avoidant coping. Siblings may use avoidant coping to deal with the stressors they experience soon after their brother or

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sister is diagnosed. As time passes, they may experience fewer cancer-related stressors, better adapt to such stressors, and find more effective ways of coping with them, using less avoidant coping strategies. The current study also found that siblings with greater life satisfaction used less avoidant coping. Those who are more satisfied with their lives may feel that they have fewer problems or difficult situations to avoid and, therefore, use less avoidant coping.

The researchers’ results indicate that adolescent cancer survivors, parents, and siblings had average levels of psychological distress compared to reported norms. This finding is consistent with previous research that reported that most young cancer survivors have average or above-average levels of global adjustment (Fritz & Williams, 1988; Greenberg et al., 1989; Kazak et al., 1997), and parents of young patients with cancer and survivors have levels of anxiety, depression, and overall distress comparable to reported norms (Dahlquist et al., 1996; Greenberg et al., 1989; Radcliffe et al., 1996). These findings also fit with Van Dongen-Melman, De Groof, Hählen, and Verhulst (1995), who suggested that young siblings of child and adolescent cancer survivors and young siblings of healthy children and adolescents have similar levels of psychological distress.Knowledge Translation

• Parents and adolescent siblings of young cancer survivors can experience post-traumatic growth.

• Healthcare providers can help identify family members of young cancer survivors who are experiencing psychological difficulties by being aware of the risk factors.

• Healthcare providers can educate family members about healthy, effective coping strategies; helping parents learn how to deal with their stressors more directly may enhance their psychological functioning.

In the current study, parents experienced a level of PTG that was similar to survivors, as well as to adult cancer survivors in other research (Cordova, Cunningham, Carlson, & Andrykowski, 2001;

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Weiss, 2002) and parents of child and adolescent cancer survivors in other research (Yaskowich, 2003). However, their level of PTG was higher than husbands of breast cancer survivors (Weiss, 2002) and lower than siblings in the current study. Although their own lives are not at risk, parents of young cancer survivors may be as affected by, and likely to experience PTG in response to, the trauma of cancer as if their own lives were at risk. Because of the close and dependent nature of the child-parent relationship, parents may feel closer to the trauma of cancer and experience a stronger reaction than siblings or husbands of cancer survivors. However, the latter may be related, at least in part, to gender differences.

Siblings experienced less PTG than parents in the current study and less PTG than adult cancer survivors in other research (Cordova et al., 2001). However, they experienced similar levels of PTG to the survivors in the current study, adolescent cancer survivors in other research (Yaskowich, 2003), and husbands of breast cancer survivors in other research (Weiss, 2002). Therefore, proximity to the trauma may influence PTG, as may cognitive maturation. The current study also indicates that even siblings in early adolescence have the capacity to experience PTG in response to their brother or sister having had cancer. To the researchers’ knowledge, this is the first study to report the status of PTG in siblings and parents of adolescent cancer survivors.

Parents’ psychological distress was associated with survivors using less active coping. Active coping involves actively planning and dealing with problems, focusing on problems without getting distracted, and seeking helpful social support. Parents whose survivor children actively address and cope with their challenges may feel relieved and proud that the survivors are capable of dealing with life’s difficulties. In contrast, parents whose survivor children use little active coping may feel the need to plan for them and actively encourage them to solve their problems. These parents may feel burdened by such added responsibilities and more worried about the survivors, which could result in higher levels of psychological distress.

Limitations The sample size was small, which could have limited the power

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and obscured significant effects that may have been revealed with a larger sample. The sample consisted primarily of middle-class European/Canadians who chose to participate in the study; therefore, the results may not generalize to more diverse populations and to family members who chose not to participate. All but one of the parents in the current study were mothers; therefore, the results may not generalize to fathers. Finally, the survivors, parents, and siblings represented different sets of families.

Implications for nursing Healthcare providers have contact not only with their patients, but also with their patients’ family members. These findings demonstrate the need to be aware of the potential impact of cancer on all family members. Parents and siblings of survivors can experience PTG, which suggests that they experience the adolescents’ cancer as personally traumatic. Older parents of adolescent cancer survivors, as well as those who are less satisfied with their lives, are at greater risk for experiencing psychological distress. Family members who are at risk can be provided with education about, and support in developing, healthy and effective coping strategies. Professional consultation may be useful for parents already demonstrating signs of psychological distress. For some parents, using avoidant coping strategies may be self- protective as they deal with extreme stressors. However, others may benefit from learning alternate coping strategies to help them more directly address their needs and struggles.

Conclusion The findings support the need to continue examining the effects of childhood and adolescent cancer on the entire family. Additional studies would benefit from having all members of each family participate to obtain a true family systems perspective on the impact of childhood and adolescent cancer. In addition, studies should continue attempting to identify factors that contribute to PTG in family members of young cancer survivors.

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Appendix E. Example of a systematic review/meta-analysis (al-mallah et al., 2015) The impact of nurse-led clinics on the mortality and morbidity of patients with cardiovascular diseases

Mouaz H. Al-Mallah, MD, MSc, FACC, FAHA, FESC; Iyad Farah, RN; Wedad Al-Madani, MSc; Bassam Bdeir, MD; Samia Al Habib, MD, PhD; Maureen L. Bigelow, RN; Mohammad Hassan Murad, MD, MPH; Mazen Ferwana, MD, PhD

Background: Nurse-led clinics (NLCs) have been developed in several health specialties in recent years. The aim of this analysis is to summarize and appraise the available evidence about the effectiveness of NLCs on the morbidity and mortality outcomes in patients with cardiovascular diseases (CVDs).

Methods: We searched Cochrane databases, MEDLINE, Web of Science, PubMed, EMBASE, Google Scholar, BIOSIS, and bibliography of secondary sources from inception through February 20, 2013. Studies were selected and data were extracted independently by 2 investigators. Eligible studies were randomized trials of NLCs of patients with CVD. Of 56 potentially relevant articles screened initially, 12 trials met the inclusion criteria. The outcomes of interest were all-cause mortality, cardiovascular mortality, nonfatal myocardial infarction, major adverse cardiac events, revascularization, lipids control, and adherence to antiplatelet medications. We performed random-effects meta-analysis to estimate summary risk ratios and quantified between-studies heterogeneity with the I2 statistic.

Results: The 12 trials allocated 4886 patients to NLCs and 4954

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patients to usual care. The NLC patients had decreased all-cause mortality (odds ratio, 0.78; 95% confidence interval [CI], 0.65– 0.95; P < .01) and myocardial infarction (odds ratio, 0.63; 95% CI, 0.39–1.00; P = .05) and had higher adherence to lipid-lowering medication (odds ratio, 1.57; 95% CI, 1.14–2.17; P = .006) compared with controls. They also had increased adherence to antiplatelet therapy compared with controls (odds ratio, 1.42; 95% CI, 1.01–1.98; P = .04). There was no statistically significant difference in the risk of cardiovascular death (odds ratio, 0.68; 95% CI, 0.40–1.15; P = .68), major adverse cardiac events (odds ratio, 0.79; 95% CI, 0.55–1.14; P = .21), or revascularization (odds ratio, 0.87; 95% CI, 0.66–1.16; P = .36) between NLC patients and controls.

Conclusions: The available evidence suggests a favorable effect of NLCs on all-cause mortality, rate of major adverse cardiac events, and adherence to medications in patients with CVD.

Nurse-led clinics (NLCs) have been developed in several health specialties in recent years. This intervention involves monitoring of patients with chronic diseases, managing their medications, providing health education and psychological support, and prescribing medications when permittable by jurisdiction. Therefore, there has been a growing literature regarding the evidence of the effectiveness of NLCs in a variety of chronic diseases including cancer, rheumatoid arthritis, inflammatory bowel disease, preoperative setting, and cardiac disease.1

Cardiovascular diseases (CVDs) constitute a leading cause of morbidity and mortality in many countries. The World Health Organization has projected that by 2030, almost 23.6 million people will die of CVD. 7 Several systematic reviews have suggested that NLCs improve some of the outcomes of patients with CVD, including hypertension and coronary heart disease. 5, 6, 8 However, the focus of these reports was on short-term outcomes (patient satisfaction, patient education, risk factor assessment, and continuity of care). These short-term process outcomes are of importance; however, the long-term efficacy of these clinics has not been sufficiently investigated and is critical. Specifically, what is the impact on all-cause mortality, CVD mortality, myocardial infarction

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incidence, and adherence to medications known to impact other patient-important outcomes? Hence, we conducted this systematic review and metaanalysis to summarize and appraise the available evidence supporting the use of NLCs in the setting of CVD.

Specific review question What is the effectiveness of NLCs in terms of morbidity and mortality in patients with CVD in outpatient settings?

Method Eligibility criteria We included randomized controlled trials that enrolled patients with CVD at the beginning of the study who were followed up by NLCs in outpatients settings. Evaluation of the following outcomes was conducted: all-cause mortality, cardiovascular mortality, myocardial infarction, major adverse cardiac events (MACEs), revascularization rate, adherence to lipid-lowering and antiplatelet medications, and achieving cholesterol and low-density lipoprotein targets, all defined according to the protocols of the included studies.

Cardiovascular disease was defined as previous myocardial infarction, percutaneous or surgical coronary revascularization, angiographic evidence of atherosclerosis in 1 or more major coronary arteries, or a positive stress electrocardiogram, echocardiogram, or nuclear stress test result. Trials that enrolled patients with recent revascularization were included. We included studies in which patients with multiple diseases were enrolled if the outcomes for patients with coronary heart disease were reported separately or if these patients comprised at least half of the study participants.

We excluded studies if they were not randomized, were primary prevention studies, evaluated single modality interventions (such as exercise programs or telephone follow up), or tested inpatient interventions. We excluded noncomparative trials (eg, did not have a control arm). Trials that had a follow-up duration of less than 9 months were excluded.

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Search strategy A comprehensive literature search was conducted by an expert reference librarian with input from study investigators with experience in systematic reviews (M.F, M.A.M., and M.H.M.). We used a 2-level search strategy. First, we searched public domain databases including MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials CENTRAL, Database of Abstracts of Reviews of Effects, Cochrane Database of Systematic Reviews, Web of Science, BIOSIS, and Google Scholar. Searches included MeSH and text words terms, with combinations of ”AND and OR” Boolean operator. We used many terms, including, but not limited to, nurse led clinics, secondary prevention, cardiac disease, coronary artery disease, and myocardial infarction. Other relevant studies were also identified through a manual search of secondary sources, including references of initially identified articles; we hand- searched the bibliographies of all identified studies to identify any studies missed by the literature searches. Specialized journals were also searched, such as the Journal of Clinical Nursing and Canadian Journal of Cardiology. The search was performed without any language restrictions. When an abstract from a meeting and a full article referred to the same trial, only the full article was included in the analysis. When there were multiple reports from the same trial, we used the most complete and/or recent. The last search update was run on February 20, 2013.

Study identification and data abstraction Two investigators (F.I. and W.A.M.) independently reviewed the titles and abstracts of all citations to identify eligible studies. Both investigators used prestandardized data abstraction forms to extract data from relevant articles. Discrepancies were resolved by consensus. The number of events in each eligible trial was extracted, when available, on the basis of the intention-to-treat approach.

Quality of included studies Two reviewers independently assessed quality of the included studies by examining components derived from the Cochrane risk

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of bias tool, including generation of allocation sequence (classified as adequate if based on computer-generated random numbers, tables of random numbers, or similar), concealment of allocation (classified as adequate if based on central randomization, sealed envelopes, or similar), blinding (patients, caregivers outcome assessors, and data analysts), adequacy of follow-up, and the use of intention-to-treat analysis. Disagreements between the reviewers were resolved by discussion or arbitrated with a third reviewer.

Statistical analysis We calculated the odds ratio and 95% confidence intervals (CIs) from each study and pooled across studies using the DerSimonian random-effects models. The number needed to treat to prevent 1 event was calculated by using the inverse of the pooled absolute risk reduction. To assess heterogeneity of treatment effect among trials, we used the I2 statistic. The I2 statistic represents the proportion of heterogeneity of effects across trials that is not attributable to chance or random error. Hence, a value greater than 50% reflects large or substantial heterogeneity that is due to real differences in study populations, protocols, interventions, and outcomes. 9 Publication bias was assessed graphically using a funnel plot. The P value threshold for statistical significance was set at 0.05 for effect sizes. Analyses were conducted using RevMan software (version 5.1). 10 This systematic review is reported according to the recommendations set forth by the Preferred Reporting Items for Systematic Reviews and Meta-analyses work groups. 11

Results Search results and study description A total of 302 abstracts were identified by the electronic search strategy, of which 56 full-text articles met the eligibility for assessment. A total of 12 trials fulfilled the inclusion criteria of prospective randomized controlled trials evaluating the impact of NCLs in patients with CVD.12 Figure 1 shows the results of the search strategy and Table 1 summarizes the included studies.

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FIG 1 Flowchart of the study. RCT indicates

randomized clinical trial; CAD, coronary artery disease.

TABLE 1. Characteristics of the Trials Included in the Meta-analysis

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NA is used to show that these data were not reported in the original studiesAbbreviations: CABG, coronary artery bypass graft; CAD, coronary artery disease; EKG, electrocardiogram; MI, myocardial infarction; NA, not applicable.

There were 9840 patients enrolled in the 12 trials, 4886 in the treatment arm (NLCs) and 4954 in the usual care arm. The mean follow-up duration was 2 years. Seven studies were conducted in the United Kingdom, of which 1 was a multicenter study (Europe); 4 were in the United States; and 1 was in Canada. The studies varied in the frequency of follow-up of their participants; 8 studies saw their patients in 2 to 6 months, and in 2 studies, participants were followed up every week for the first 6 weeks and then assessed after 1 year. Only 1 study in the United States involved a nurse practitioner who was authorized to prescribe, and in the rest of the studies, nurses in the intervention arm were not. Studies varied in their intervention modalities; nurses in 6 studies provided lifestyle advice and medications management, and 3 used only lifestyle, counseling, and educational interventions. 14, 17, 21 The NLCs were managed by nurses, case manager, and/or dietician, as well as supervised by physicians. In terms of communication types between the nurses in charge and the physicians, in 4 of the studies, nurses followed up participants, and if medications were needed or the targets were not obtained, they either telephoned the physicians or referred the patients to them. 12, 21, 23 However, there was no clear description of how nurses communicated with physicians in charge in 5 studies.14,16, 22

Of the 12 trials, 9 reported all-cause mortality outcomes 13 and included 6319 patients, 3, 146 in the NLC group and 3173 in usual care. Five studies reported cardiovascular death results 14, 18, 21; 2973

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patients were included, 1, 492 in the NLC arm and 1481 in usual care.

Meta-analysis Patients in the NLC group had decreased all-cause mortality (odds ratio, 0.78; 95% CI, 0.65–0.95; P < .01) and myocardial infarction (odds ratio, 0.63; 95% CI, 0.39–1.00; P = .05) and had higher adherence to lipid-lowering medication (odds ratio, 1.57; 95% CI, 1.14–2.17; P = .006) compared with controls. They also had increased adherence to antiplatelet therapy compared with controls (odds ratio, 1.42; 95% CI, 1.01–1.98; P = .04). There was no statistically significant difference in the risk of cardiovascular death (odds ratio, 0.68; 95% CI, 0.40–1.15; P = .68), major adverse cardiac events (odds ratio, 0.79; 95% CI, 0.55–1.14; P = .21), or revascularization (odds ratio, 0.87; 95% CI, 0.66–1.16; P = .36) between NLC patients and controls. Results are depicted in Figure 2.

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FIG 2 Forest plot of the outcomes analyzed in this study. A, All-cause mortality; B, cardiovascular

mortality; C, myocardial infarction; D, major adverse events; E, revascularization; F, lipid-lowering

medication adherence; and G, antiplatelet medication adherence. CI indicates confidence interval.

There was no heterogeneity in the analyses of all-cause mortality, cardiovascular mortality, myocardial infarction, and revascularization (I2 < 50%). However, there was large heterogeneity (I2 > 50%) for all the remaining outcomes. The small number of included trials precluded statistical testing for publication bias; however, visual inspection of funnel plot is consistent with symmetry (Figure 3).

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FIG 3 Funnel plot. No indication of publication bias was

seen.

Methodological quality Overall, the trials had moderate risk of bias (Figure 4). Generation of allocation was adequate in all trials, and allocation of concealment was adequate in only 4 studies. Blinding of caregivers, outcome assessment, and data analyst was not clear in all trials. Almost all included trials reported the proportion of patients who were lost to follow-up, ranging from 1.9% to 31%. All trials used an intention-to-treat analysis. Table 2 describes the methodological quality of the 9 randomized controlled trials included in this systematic review.

FIG 4 Study quality assessment.

TABLE 2.

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Quality Assessment of the Trials Included in the Meta-analysis

Discussion This systematic review and meta-analysis provided evidence supporting the effectiveness of NLCs in lowering the risk of all- cause mortality and myocardial infarction and adherence to medications in patients with CVD.

We found that NLCs significantly increase the likelihood of use of lipid-lowering medication adherence. This is consistent with 3 previous systematic reviews that showed a significant reduction in cholesterol level among patients managed by NLCs compared with the usual care clinics. 5, 24 One review investigated interventions related to education, assessment of risk factors, consultations, and/or follow-up. 5 The second review search was conducted from 2002 to 2008, and the main outcomes were smoking cessation, diet adherence, quality of life, and general health status, 6 whereas our review’s main objective is to assess hard endpoints. The third review was on the effect of the clinical nurse specialist practice in acute setting; the main outcomes are length of stay, cost, and functional status. Finally, their search was from 1990 to 2008 and restricted to trials conducted in the United States. It included not only randomized controlled trials but also observational studies. 24 In addition, our review was specifically designed to include only

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randomized controlled trials and studies that used lifestyle advise, assessment, as well as drug interventions by nurses.

On the other hand, the patients included in the trials are relatively young and most often men. This was also seen in a recent non randomized study by Bdeir et al. 25 Although the included trials did not report the outcomes stratified by age and gender, it is possible that the benefit of these clinics is more notable in this age group. Further studies are needed to assess the potential benefit of NLCs in an older population.

The studies included in this review seemed to have fair quality and moderate risk of bias. As blinding participants and researchers is challenging in this context, blinding data analysts and outcome assessors is possible but was not explicitly performed in these trials. Many of the studies followed up patients for a relatively short period; 3 studies were for 1 year, 12, 13, 23 1 study was for 18 months, 21 1 study was for 2 years, 14 2 studies were for 4 years, 18, 22 and 1 study was for 10 years. 16 Hence, although our intention was to evaluate long-term outcomes, the available evidence is of relatively short-term. Lastly, applying this evidence to different settings (managed care, private payers, United States, Europe, developing countries, etc) will be challenging and should be considered a limitation of this evidence. The infrastructure, legislation, insurance coverage, and range of services delegated to nurses vary widely across these settings.

Many of the included outcomes had significant heterogeneity. An obvious potential explanation for heterogeneity is the variation in the intensity of the intervention and the nature of nurses’ expertise, background, and involvement in the care of the patients, as well as differences in the conditions and complexity of the patients. One other possible cause of heterogeneity, however, is the variation in the care provided to the control group. Previous studies of case management in patients with CVD suggested that when the “usual care” arm of studies receives minimal management, the benefits seen in these studies may be larger. 15, 20 Such benefit may not be observed if the control arm received better secondary prevention measures. 23 Considering the observed unexplained heterogeneity, the pooled estimates we provide should be considered an average estimate of NLC effect that is expected when these clinics are

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implemented across various settings. Variations in these settings will affect the expected benefit. This average effect is helpful, nevertheless, from a public health or policy level perspective.

Limitations Our study has several limitations. We included only studies that reported hard endpoints. The mechanism for the decrease in these hard endpoints could be due to better adherence to guidelines recommended medical therapies (as seen in the use of the lipid- lowering and antiplatelet medications). However, there were no data reported on the control of hypertension, diabetes, smoking cessation, and other risk factors. These factors may have contributed to the lower mortality and better outcomes. In addition, the interventions used in each NLC may be different in each clinic. Being nurse led is the main common characteristic of this intervention. Further data may be needed to determine the impact of other interventions in each clinic on outcomes.

Implications for clinical practice and research Our findings suggest that NLCs can have an important role and should be considered when delivering care to patients with CVD. Translating this evidence into effective models of care may be challenging, but the reduction in mortality is compelling. Structured models of care should be developed and tested locally. Patient and community engagement is paramount to develop such programs. Partnership with patients and communities is essential not only for the NLC program development but also for conducting research in these programs, particularly when testing the cultural and ethnic appropriateness of these interventions. Future research is also needed on the cost-effectiveness of NLCs and perhaps on better stratification to determine which patients are most appropriate to receive this care. For example, which stages of CVD are the most amenable or most responsive to NLCs? What type or level of training should be required of a nurse undertaking extended roles in NLCs? A systematic review of worldwide conducted research demonstrates wide variation in nurses’ job titles, duties, and qualifications. 26What’s New and Important

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• A meta-analysis of 12 randomized trials and more than 9000 patients evaluating the role of NLC in management of cardiac patients was conducted.

• Nurse-led clinic is associated with better adherence to medical therapy and better survival compared with usual care.

• This model would be ideal to reduce cost and improves outcomes in the current era.

Conclusion The available evidence suggests a favorable effect of NLCs on all- cause mortality, rate of major adverse cardiac events, and adherence to medications in patients with CVD.

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Glossary A A Priori From Latin: the former; before the study or analysis. Absolute Risk Reduction (ARR) A value that gives reduction of

risk in absolute terms. The ARR is considered the “real” reduction because it is the difference between the risk observed in those who did and did not experience the event.

Abstract A short, comprehensive synopsis or summary of a study at the beginning of an article.

Accessible Population A population that meets the population criteria and is available.

Accreditation A process in which an organization demonstrates attainment of predetermined standards set by an external nongovernmental organization responsible for setting and monitoring compliance in a particular industry sector.

After-Only Design An experimental design with two randomly assigned groups—a treatment group and a control group. This design differs from the true experiment in that both groups are measured only after the experimental treatment.

After-Only Nonequivalent Control Group Design A quasi- experimental design similar to the after-only experimental design, but subjects are not randomly assigned to the treatment or control groups.

AGREE II Guideline A widely used instrument to evaluate the applicability of a guideline to practice. The AGREE II was

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developed to assist in evaluating guideline quality, provide a methodological strategy for guideline development, and inform practitioners about what information should be reported in guidelines and how it should be reported.

Analysis of Covariance (ANCOVA) A statistic that measures differences among group means and uses a statistical technique to equate the groups under study in relation to an important variable.

Analysis of Variance (ANOVA) A statistic that tests whether group means differ from each other, rather than testing each pair of means separately. ANOVA considers the variation among all groups.

Anecdotes Summaries of an observation that records a behavior of interest.

Anonymity A research participant’s protection of identity in a study so that no one, not even the researcher, can link the subject with the information given.

Antecedent Variable A variable that affects the dependent variable but occurs before the introduction of the independent variable.

Assent An aspect of informed consent that pertains to protecting the rights of children as research subjects.

Attention Control Operationalized as the control group receiving the same amount of “attention” as the experimental group.

Auditability The researcher’s development of the research process in a qualitative study that allows a researcher or reader to follow the thinking or conclusions of the researcher.

B Benchmarking A systematic approach for gathering information

about process or product performance and then analyzing why and how performance differs between business units.

Beneficence An obligation to act to benefit others and to maximize possible benefits.

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Bias A distortion in the data-analysis results. Boolean Operator Words used to define the relationships between

words or groups of words in literature searches. Examples of Boolean operators are words such as “AND, ” “OR, ” “NOT, ” and “NEAR.”

Bracketing A process during which the researcher identifies personal biases about the phenomenon of interest to clarify how personal experience and beliefs may color what is heard and reported.

C Case Control Study See ex post facto study. Case Study Method The study of a selected contemporary

phenomenon over time to provide an in-depth description of essential dimensions and processes of the phenomenon.

CASP Tools Checklists that provide an evidence-based approach for assessing the quality, quantity, and consistency of specific study designs.

Categorical Variable A variable that has mutually exclusive categories but has more than two values.

Chance Error Attributable to fluctuations in subject characteristics that occur at a specific point in time and are often beyond the awareness and control of the examiner. Also called random error.

Chi-Square (χ2) A nonparametric statistic that is used to determine whether the frequency found in each category is different from the frequency that would be expected by chance.

Citation Management Software Software that formats citations. Clinical Guidelines Systematically developed practice statements

designed to assist clinicians about health care decisions for specific conditions or situations.

Clinical Microsystems A QI model developed specifically for health care. It is considered the building block of any health care

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system and is the smallest replicable unit in an organization. Members of a clinical microsystem are interdependent and work together toward a common aim.

Clinical Question The first step in development of an evidence- based practice project.

Closed-Ended Question Question that the respondent may answer with only one of a fixed number of choices.

Cluster Sampling A probability sampling strategy that involves a successive random sampling of units. The units sampled progress from large to small. Also known as multistage sampling.

Cohort The subjects of a specific group that are being studied. Cohort Study See longitudinal/prospective studies. Common Cause Variation Variation that occurs at random and is

considered a characteristic of the system.

Community-Based Participatory Research Qualitative method that systematically accesses the voice of a community to plan context-appropriate action.

Concealment Refers to whether the subjects know that they are being observed.

Concept An image or symbolic representation of an abstract idea. Conceptual Definition General meaning of a concept. Conceptual Framework A structure of concepts and/or theories

pulled together as a map for the study. This set of interrelated concepts symbolically represents how a group of variables relates to each other.

Conceptual Literature Published and unpublished non–data-based material, such as reports of theories, concepts, synthesis of research on concepts, or professional issues, some of which underlie reported research, as well as other nonresearch material.

Concurrent Validity The degree of correlation of two measures of the same concept that are administered at the same time.

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Conduct of Research The analysis of data collected from a homogeneous group of subjects who meet study inclusion and exclusion criteria for the purpose of answering specific research questions or testing specified hypotheses.

Confidence Interval Quantifies the uncertainty of a statistic or the probable value range within which a population parameter is expected to lie.

Confidentiality Assurance that a research participant’s identity cannot be linked to the information that was provided to the researcher.

Consent See informed consent. Consistency Data are collected from each subject in the study in

exactly the same way or as close to the same way as possible.

Constancy Methods and procedures of data collection are the same for all subjects.

Constant Comparative Method A process of continuously comparing data as they are acquired during research with the grounded theory method.

Construct An abstraction that is adapted for scientific purpose. Construct Validity The extent to which an instrument is said to

measure a theoretical construct or trait.

Consumer One who actively uses and applies research findings in nursing practice.

Content Analysis A technique for the objective, systematic, and quantitative description of communications and documentary evidence.

Content Validity The degree to which the content of the measure represents the universe of content or the domain of a given behavior.

Content Validity Index A calculation that gives a researcher more confidence or evidence that the instrument truly reflects the concept or construct.

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Context Environment where event(s) occur(s). Context Dependent An observation as defined by its circumstance

or context.

Continuous Variable (Data) A variable that can take on any value between two specified points (e.g., weight).

Contrasted-Group Approach A method used to assess construct validity. A researcher identifies two groups of individuals who are suspected to have an extremely high or low score on a characteristic. Scores from the groups are obtained and examined for sensitivity to the differences. Also called known- group approach.

Control Measures used to hold uniform or constant the conditions under which an investigation occurs.

Control Chart Used to track system performance over time. It includes information on the average performance level for the system depicted by a center line displaying the system’s average performance (the mean value) and the upper and lower limits depicting one to three standard deviations from average performance level.

Control Event Rate (CER) Proportion of patients in a control group in which an event is observed.

Control Group The group in an experimental investigation that does not receive an intervention or treatment; the comparison group.

Controlled Vocabulary The terms that indexers have assigned to the articles in a database. When possible, it is helpful to match the words that you use in your search to those specifically used in the database.

Convenience Sampling A nonprobability sampling strategy that uses the most readily accessible persons or objects as subjects in a study.

Convergent Validity A strategy for assessing construct validity in which two or more tools that theoretically measure the same

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construct are administered to subjects. If the measures are positively correlated, convergent validity is said to be supported.

Correlation The degree of association between two variables. Correlational Study A type of nonexperimental research design

that examines the relationship between two or more variables.

Credibility Steps in qualitative research to ensure accuracy, validity, or soundness of data.

Criterion-Related Validity Indicates the degree of relationship between performance on the measure and actual behavior either in the present (concurrent) or in the future (predictive).

Critical Appraisal Appraisal by a nurse who is a knowledgeable consumer of research and who can appraise research evidence and use existing standards to determine the merit and readiness of research for use in clinical practice.

Critical Reading An active interpretation and objective assessment of an article during which the reader is looking for key concepts, ideas, and justifications.

Critique The process of critical appraisal that objectively and critically evaluates a research report’s content for scientific merit and application to practice.

Cronbach’s Alpha Test of internal consistency that simultaneously compares each item in a scale to all others.

Cross-Sectional Study A nonexperimental research design that looks at data at one point in time—that is, in the immediate present.

Culture The system of knowledge and linguistic expressions used by social groups that allows the researcher to interpret or make sense of the world.

Cumulative Index to Nursing and Allied Health Literature (CINAHL) A print or computerized database; computerized CINAHL is available on CD-ROM and online.

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D Data Information systematically collected in the course of a study;

the plural of datum.

Data-Based Literature Reports of completed research. Data Saturation A point when data collection can cease. It occurs

when the information being shared with the researcher becomes repetitive. Ideas conveyed by the participant have been shared before by other participants; inclusion of additional participants does not result in new ideas.

Database A compilation of information about a topic organized in a systematic way.

Debriefing The opportunity for researchers to discuss the study with the participants; participants may refuse to have their data included in the study at this time.

Deductive A logical thought process in which hypotheses are derived from theory; reasoning moves from the general to the particular.

Degrees of Freedom The number of quantities that are unknown minus the number of independent equations linking these unknowns; a function of the number in the sample.

Delimitations Those characteristics that restrict the population to a homogeneous group of subjects.

Delphi Technique The technique of gaining expert opinion on a subject. It uses rounds or multiple stages of data collection, with each round using data from the previous round.

Demographic Data Data that includes information that describes important characteristics about the subjects in a study (e.g., age, gender, race, ethnicity, education, marital status).

Dependent Variable In experimental studies, the presumed effect of the independent or experimental variable on the outcome.

Descriptive Statistics Statistical methods used to describe and summarize sample data.

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Design The plan or blueprint for conduct of a study. Developmental Study A type of nonexperimental research design

that is concerned not only with the existing status and interrelationship of phenomena, but also with changes that take place as a function of time.

Dichotomous Variable A nominal variable that has two categories (e.g., male/female).

Directional Hypothesis A hypothesis that specifies the expected direction of the relationship between the independent and dependent variables.

Dissemination The communication of research findings. Divergent Validity/Discriminant Validity A strategy for assessing

construct validity in which two or more tools that theoretically measure the opposite of the construct are administered to subjects. If the measures are negatively correlated, divergent validity is said to be supported.

Domains Symbolic categories that include the smaller categories of an ethnographic study.

E Effect Size An estimate of how large of a difference there is

between intervention and control groups in summarized studies.

Electronic Database A database that can be accessed by computers or electronic information services.

Electronic Index The electronic means by which journal sources (periodicals) of data-based and conceptual articles on a variety of topics (e.g., doctoral dissertations) are found, as well as the publications of professional organizations and various governmental agencies.

Element The most basic unit about which information is collected. Eligibility Criteria The characteristics that restrict the population

to a homogeneous group of subjects.

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Emic View A native’s or insider’s view of the world. Empirical The obtaining of evidence or objective data. Empirical Literature A synonym for data-based literature; see data-

based literature.

Equivalence Consistency or agreement among observers using the same measurement tool or agreement among alternate forms of a tool.

Error Variance The extent to which the variance in test scores is attributable to error rather than a true measure of the behaviors.

Ethics The theory or discipline dealing with principles of moral values and moral conduct.

Ethnographic Method A method that scientifically describes cultural groups. The goal of the ethnographer is to understand the native’s view of their world.

Ethnography/Ethnographic Method A qualitative research approach designed to produce cultural theory.

Etic View An outsider’s view of another’s world. Evaluation Research The use of scientific research methods and

procedures to evaluate a program, treatment, practice, or policy outcomes; analytical means are used to document the worth of an activity.

Evidence-Based Clinical Guidelines A set of guidelines that allows the researcher to better understand the evidence base of certain practices.

Evidence-Based Practice The conscious and judicious use of the current “best” evidence in the care of patients and delivery of health care services.

Evidence-Based Practice Guidelines Practice guidelines developed based on research findings.

Ex Post Facto Study A type of nonexperimental research design that examines the relationships among the variables after the

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variations have occurred.

Exclusion Criteria Those characteristics that restrict the population to a homogeneous group of subjects.

Existing Data Data gathered from records (e.g., medical records, care plans, hospital records, death certificates) and databases (e.g., US Census, National Cancer Database, Minimum Data Set for Nursing Home Resident Assessment and Care Screening).

Experiment A scientific investigation in which observations are made and data are collected by means of the characteristics of control, randomization, and manipulation.

Experimental Design A research design that has the following properties: randomization, control, and manipulation.

Experimental Event Rate (EER) The proportion of patients in experimental treatment groups in which an event is observed.

Experimental Group The group in an experimental investigation that receives an intervention or treatment.

Expert-Based Clinical Guidelines Guidelines developed from the combination of opinions from known experts in the field, along with current research evidence.

Exploratory Survey A type of nonexperimental research design that collects descriptions of existing phenomena for the purpose of using the data to justify or assess current conditions or to make plans for improvement of conditions.

External Validity The degree to which findings of a study can be generalized to other populations or environments.

Extraneous Variable Variable that interferes with the operations of the phenomena being studied. Also called mediating variable.

F Face Validity A type of content validity that uses an expert’s

opinion to judge the accuracy of an instrument. (Some would say that face validity verifies that the instrument gives the subject or

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expert the appearance of measuring the concept.)

Factor Analysis A type of validity that uses a statistical procedure for determining the underlying dimensions or components of a variable.

Field Notes Descriptions kept by a researcher that detail the environment and nonverbal communications observed by a researcher that enrich data collected.

Findings Statistical results of a study. Fisher Exact Probability Test A test used to compare frequencies

when samples are small and expected frequencies are less than six in each cell.

Fittingness Answers the following questions: Are the findings applicable outside the study situation? Are the results meaningful to the individuals not involved in the research?

Flowchart Depicts how a process works, detailing the sequence of steps from the beginning to the end of a process.

Forest Plot Also known as a blobbogram, a forest plot graphically depicts the results of analyzing a number of studies.

Frequency Distribution Descriptive statistical method for summarizing the occurrences of events under study.

G Generalizability (Generalize) The inferences that the data are

representative of similar phenomena in a population beyond the studied sample.

Grand Nursing Theories Sometimes referred to as nursing conceptual models, these include the theories/models that were developed to describe the discipline of nursing as a whole.

Grand Theory All-inclusive conceptual structures that tend to include views on people, health, and the environment to create a perspective of nursing.

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Grand Tour Question A broad overview question. Grounded Theory Theory that is constructed inductively from a

base of observations of the world as it is lived by a selected group of people.

Grounded Theory Method An inductive approach that uses a systematic set of procedures to arrive at a theory about basic social processes.

H Hazard Ratio A weighted relative risk based on the analysis of

survival curves over the whole course of the study period.

History The internal validity threat that refers to events outside of the experimental setting that may affect the dependent variable.

Homogeneity Similarity of conditions. Also called internal consistency.

Hypothesis A prediction about the relationship between two or more variables.

Hypothesis-Testing Approach The method used when an investigator uses the theory or concept underlying the measurement instruments to validate the instrument.

Hypothesis-Testing Validity A strategy for assessing construct validity, in which the theory or concept underlying a measurement instrument’s design is used to develop hypotheses that are tested. Inferences are made based on the findings about whether the rationale underlying the instrument’s construction is adequate to explain the findings.

I Inclusion Criteria See eligibility criteria. Independent Variable The antecedent or the variable that has the

presumed effect on the dependent variable.

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Inductive Reasoning A logical thought process in which generalizations are developed from specific observations; reasoning moves from the particular to the general.

Inferential Statistics Procedures that combine mathematical processes and logic to test hypotheses about a population with the help of sample data.

Information Literacy The skills needed to consult the literature and answer a clinical question.

Informed Consent An ethical principle that requires a researcher to obtain the voluntary participation of subjects after informing them of potential benefits and risks.

Institutional Review Boards (IRBs) Boards established in agencies to review biomedical and behavioral research involving human subjects within the agency or in programs sponsored by the agency.

Instrumental Case Study Research that is done when the researcher pursues insight into an issue or wants to challenge a generalization.

Instrumentation Changes in the measurement of the variables that may account for changes in the obtained measurement.

Integrative Review Synthesis review of the literature on a specific concept or topic.

Internal Consistency The extent to which items within a scale reflect or measure the same concept.

Internal Validity The degree to which it can be inferred that the experimental treatment, rather than an uncontrolled condition, resulted in the observed effects.

Interpretive Phenomenology An approach to research that “seeks to reveal and convey deep insight and understanding of the concealed meanings of everyday life experiences” (deWitt & Ploeg, 2006, pp. 216–217).

Interrater Reliability The consistency of observations between two

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or more observers, often expressed as a percentage of agreement between raters or observers or a coefficient of agreement that takes into account the element of chance. This usually is used with the direct observation method.

Interval Measurement Level used to show rankings of events or objects on a scale with equal intervals between numbers but with an arbitrary zero (e.g., centigrade temperature).

Intervening Variable A variable that occurs during an experimental or quasi-experimental study that affects the dependent variable.

Intervention Deals with whether or not the observer provokes actions from those who are being observed.

Intervention Fidelity The process of enhancing the study’s internal validity by ensuring that the intervention is delivered systematically to all subjects.

Interview Guide A list of questions and probes used by interviews that use open-ended questions.

Interviews A method of data collection in which a data collector questions a subject verbally. Interviews may be in person or performed over the telephone, and they may consist of open- ended or close-ended questions.

Intrinsic Case Study Research that is undertaken to gain a better understanding of the essential nature of the case.

Item to Total Correlation The relationship between each of the items on a scale and the total scale.

J Justice The principle that human subjects should be treated fairly.

K Kappa Expresses the level of agreement observed beyond the level

that would be expected by chance alone. Kappa (K) ranges from

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+1 (total agreement) to 0 (no agreement). K greater than 0.80 generally indicates good reliability. K between 0.68 and 0.80 is considered acceptable/substantial agreement. Levels lower than 0.68 may allow tentative conclusions to be drawn when lower levels are accepted.

Key Informants Individuals who have special knowledge, status, or communication skills, and who are willing to teach the ethnographer about the phenomenon.

Knowledge-Focused Triggers Ideas that are generated when staff read research, listen to scientific papers at research conferences, or encounter evidence-based practice guidelines published by government agencies or specialty organizations.

Kuder-Richardson (KR-20) Coefficient The estimate of homogeneity used for instruments that use a dichotomous response pattern.

L Lean A QI model that focuses on eliminating waste from the

production system by designing the most efficient and effective system. It is sometimes referred to as the Toyota Quality Model.

Level of Significance (Alpha Level) The risk of making a type I error, set by the researcher before the study begins.

Levels of Evidence A rating system for judging the strength of a study’s design.

Levels of Measurement Categorization of the precision with which an event can be measured (nominal, ordinal, interval, and ratio).

Likelihood Ratios Provide the nurse with information about the accuracy of a diagnostic test and can also help the nurse to be a more efficient decision maker by allowing the clinician to quantify the probability of disease for any individual patient.

Likert-Type Scales Lists of statements for which respondents indicate whether they “strongly agree, ” “agree, ” “disagree, ” or “strongly disagree.”

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Limitation Weakness of a study. Literature Review A systematic and critical appraisal of the most

important literature on a topic.

Lived Experience In phenomenological research, a term used to refer to the focus on living through events and circumstances (prelingual), rather than thinking about these events and circumstances (conceptualized experience).

Longitudinal Study A nonexperimental research design in which a researcher collects data from the same group at different points in time.

M Manipulation The provision of some experimental treatment, in

one or varying degrees, to some of the subjects in the study.

Matching A special sampling strategy used to construct an equivalent comparison sample group by filling it with subjects who are similar to each subject in another sample group in terms of preestablished variables, such as age and gender.

Maturation Developmental, biological, or psychological processes that operate within an individual as a function of time and are external to the events of the investigation.

Mean A measure of central tendency; the arithmetic average of all scores.

Measurement The standardized method of collecting data. Measurement Effects Administration of a pretest in a study that

affects the generalizability of the findings to other populations.

Measurement Error The difference between what really exists and what is measured in a given study.

Measures of Central Tendency A descriptive statistical procedure that describes the average member of a sample (mean, median, and mode).

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Measures of Variability Descriptive statistical procedure that describes how much dispersion there is in sample data.

Median A measure of central tendency; the middle score. Mediating Variable A variable that intervenes between the

independent and dependent variable.

Meta-Analysis A research method that takes the results of multiple studies in a specific area and synthesizes the findings to make conclusions regarding the area of focus.

Meta-Summary Integrations that are approximately equal to the sum of parts, or the sum of findings across reports in a target domain of research.

Meta-Synthesis Integrates qualitative research findings on a topic and is based on comparative analysis and interpretative synthesis.

Methodological Research The controlled investigation and measurement of the means of gathering and analyzing data.

Microrange Theory The linking of concrete concepts into a statement that can be examined in practice and research.

Middle Range Nursing Theories Theories that contain a limited number of concepts and are focused on a limited aspect of reality.

Modality The number of peaks in a frequency distribution. Mode A measure of central tendency; the most frequent score or

result.

Model A symbolic representation of a set of concepts that is created to depict relationships.

Mortality The loss of subjects from time 1 data collection to time 2 data collection.

Multiple Analysis of Variance (MANOVA) A test used to determine differences in group means; used when there is more than one dependent variable.

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Multiple Regression A measure of the relationship between one interval level dependent variable and several independent variables. Canonical correlation is used when there is more than one dependent variable.

Multistage Sampling (Cluster Sampling) Involves a successive random sampling of units (clusters) that programs from large to small and meets sample eligibility criteria.

Multitrait–Multimethod Approach A type of validity that uses more than one method to assess the accuracy of an instrument (e.g., observation and interview of anxiety).

Multivariate Statistics A statistical procedure that involves two or more variables.

N Naturalistic Setting An environment of familiar “day-to-day”

surroundings.

Negative Likelihood Ratio (LR) The LR of a negative test indicates the accuracy of a negative test result by comparing its performance when the disease is absent to that when the disease is present. The better test to use to rule out disease is the one with the smaller likelihood ratio of a negative test.

Negative Predictive Value Expresses the proportion of those with negative test results who truly do not have the disease.

Network Sampling (Snowball Effect Sample) A strategy used for locating samples that are difficult to locate. It uses social networks and the fact that friends tend to have characteristics in common; subjects who meet the eligibility criteria are asked for assistance in getting in touch with others who meet the same criteria.

Nominal The level of measurement that simply assigns data into categories that are mutually exclusive.

Nominal Measurement Level used to classify objects or events into categories without any relative ranking (e.g., gender, hair

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color).

Nondirectional Hypothesis Indicates the existence of a relationship between the variables but does not specify the anticipated direction of the relationship.

Nonequivalent Control Group Design A quasi-experimental design that is similar to the true experiment, but subjects are not randomly assigned to the treatment or control groups.

Nonexperimental Research Design Research design in which an investigator observes a phenomenon without manipulating the independent variable(s).

Nonparametric Statistics Statistics that are usually used when variables are measured at the nominal or ordinal level because they do not estimate population parameters and involve less restrictive assumptions about the underlying distribution.

Nonprobability Sampling A procedure in which elements are chosen by nonrandom methods.

Normal Curve A curve that is symmetrical about the mean and is unimodal.

Null Hypothesis A statement that there is no relationship between the variables and that any relationship observed is a function of chance or fluctuations in sampling.

Null Value In an experiment, when a value is obtained that indicates that there is no difference between the treatment and control groups.

Number Needed to Treat The number of people who need to receive a treatment (or intervention) in order for one patient to receive any benefit.

O Objective Data that are not influenced by anyone who collects the

information.

Objectivity The use of facts without distortion by personal feelings

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or bias.

Observation A method for measuring psychological and physiological behaviors for the purpose of evaluating change and facilitating recovery.

Observed Score The actual score obtained in a measurement. Observed Test Score Derived from a set of items; actually consists

of the true score plus error.

Odds Ratio (OR) An estimate of relative risk used in logistic regression as a measure of association; describes the probability of an event.

One-Group (Pretest–Posttest) Design Design used by researchers when only one group is available for study. Data are collected before and after an experimental treatment on one group of subjects. In this type of design, there is no control group and no randomization.

Open-Ended Question Question that the respondent may answer in his or her own words.

Operational Definition The measurements used to observe or measure a variable; delineates the procedures or operations required to measure a concept.

Opinion Leaders From the local peer group, viewed as a respected source of influence, considered by associates as technically competent, and trusted to judge the fit between the innovation and the local situation.

Ordinal The level of measurement that systematically categorizes data in an ordered or ranked manner. Ordinal measures do not permit a high level of differentiation among subjects.

Ordinal Measurement Level used to show rankings of events or objects; numbers are not equidistant, and zero is arbitrary (e.g., class ranking).

889

Paradigm From Greek: pattern; it has been applied to science to describe the way people in society think about the world.

Parallel Form Reliability See alternate form reliability. Parameter A characteristic of a population. Parametric Statistics Inferential statistics that involve the

estimation of at least one parameter, require measurement at the interval level or above, and involve assumptions about the variables being studied. These assumptions usually include the fact that the variable is normally distributed.

Participant Observation When the observer keeps field notes (a short summary of observations) to record the activities, as well as the observer’s interpretations of these activities.

Pearson Correlation Coefficient (Pearson r) A statistic that is calculated to reflect the degree of relationship between two interval level variables. Also called the Pearson Product Moment Correlation Coefficient.

Percentile Represents the percentage of cases a given score exceeds.

Performance Measurement A tool that tracks an organization’s performance using standardized measures to document and manage quality.

Phenomena Those things that are perceived by our senses (e.g., pain, losing a loved one).

Phenomenological Method A process of learning and constructing the meaning of human experience through intensive dialogue with persons who are living the experience.

Phenomenological Research Phenomenological research is based on phenomenological philosophy and is research aimed at obtaining a description of an experience as it is lived in order to understand the meaning of that experience for those who have it.

Phenomenology A qualitative research approach that aims to describe experience as it is lived through, before it is

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conceptualized.

Philosophical Beliefs The system of motivating values; concepts; principles; and the nature of human knowledge of an individual, group, or culture.

Philosophical Research Based on the investigation of the truths and principles of existence, knowledge, and conduct.

Pilot Study A small, simple study conducted as a prelude to a larger-scale study that is often called the “parent study.”

Plan-Do-Study-Act (PDSA) Improvement Cycle The last step of the Improvement Model.

Population A well-defined set that has certain specified properties. Positive Likelihood Ratio (LR) The LR of a positive test indicates

the accuracy of a positive test result by comparing its performance when the disease is present to that when the disease is absent. The best test to use for ruling in a disease is the one with the largest likelihood ratio of a positive test.

Positive Predictive Value Expresses the proportion of those with positive test results who truly have disease.

Power Analysis The mathematical procedure to determine the number for each arm (group) of a study.

Predictive Validity The degree of correlation between the measure of the concept and some future measure of the same concept.

Prefiltered Evidence Evidence for which an editorial team has already read and summarized articles on a topic and appraised its relevance to clinical care.

Primary Source Scholarly literature that is written by the person(s) who developed the theory or conducted the research. Primary sources include eyewitness accounts of historic events, provided by original documents, films, letters, diaries, records, artifacts, periodicals, or audio/video recordings.

Probability The probability of an event is the event’s long-run relative frequency in repeated trials under similar conditions.

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Probability Sampling A procedure that uses some form of random selection when the sample units are chosen.

Problem-Focused Triggers Those that are identified by staff through quality improvement, risk surveillance, benchmarking data, financial data, or recurrent clinical problems.

Program A list of instructions in a machine-readable language written so that a computer’s hardware can carry out an operation; software.

Prospective Study A nonexperimental study that begins with an exploration of assumed causes and then moves forward in time to the presumed effect.

Psychometrics The theory and development of measurement instruments.

Public Reporting Provides objective information to promote consumer choice, guide QI efforts, and promote accountability for performance among providers and delivery organizations. It also allows organizations to compare their performance across standard measures against their peer organizations locally and nationally.

Purpose That which encompasses the aims or objectives the investigator hopes to achieve with the research, not the question to be answered.

Purposive Sampling A nonprobability sampling strategy in which the researcher selects subjects who are considered to be representative of the population.

Q Qualitative Measurement The items or observed behaviors are

assigned to mutually exclusive categories that are representative of the kinds of behavior exhibited by the subjects.

Qualitative Research The study of research questions about human experiences. It is often conducted in natural settings and uses data that are words or text, rather than numerical, in order

892

to describe the experiences that are being studied.

Quality Health Care Care that is safe, effective, patient-centered, timely, efficient, and equitable.

Quality Improvement (QI) The systematic use of data to monitor the outcomes of care processes, as well as the use of improvement methods to design and test changes in practice for the purpose of continuously improving the quality and safety of health care systems.

Quantitative Measurement The assignment of items or behaviors to categories that represent the amount of a possessed characteristic.

Quantitative Research The process of testing relationships, differences, and cause and effect interactions among and between variables. These processes are tested with either hypotheses and/or research questions.

Quasi-Experiment Research designs in which the researcher initiates an experimental treatment, but some characteristic of a true experiment is lacking.

Quasi-Experimental Design A study design in which random assignment is not used, but the independent variable is manipulated and certain mechanisms of control are used.

Questionnaires Paper-and-pencil instruments designed to gather data from individuals about knowledge, attitudes, beliefs, and feelings.

Quota Sampling A nonprobability sampling strategy that identifies the strata of the population and proportionately represents the strata in the sample.

R Random Error An error that occurs when scores vary in a random

way. Random error occurs when data collectors do not use standard procedures to collect data consistently among all subjects in a study.

893

Random Selection A selection process in which each element of the population has an equal and independent chance of being included in the sample.

Randomization A sampling selection procedure in which each person or element in a population has an equal chance of being selected to either the experimental group or the control group.

Randomized Controlled Trial (RCT) A research study using a true experimental design.

Range A measure of variability; difference between the highest and lowest scores in a set of sample data.

Ratio The highest level of measurement that possesses the characteristics of categorizing, ordering, and ranking, and also has an absolute or natural zero that has empirical meaning.

Ratio Measurement Level that ranks the order of events or objects, and that has equal intervals and an absolute zero (e.g., height, weight).

Reactivity The distortion created when those who are being observed change their behavior because they know that they are being observed.

Recommendation Application of a study to practice, theory, and future research.

Refereed Journal or Peer-Reviewed Journal A scholarly journal that has a panel of external and internal reviewers or editors; the panel reviews submitted manuscripts for possible publication. The review panels use the same set of scholarly criteria to judge if the manuscripts are worthy of publication.

Relationship/Difference Studies Studies that trace the relationships or differences between variables that can provide a deeper insight into a phenomenon.

Relative Risk (RR) Risk of event after experimental treatment as a percentage of original risk.

Relative Risk Reduction (RRR) A helpful tool to indicate how

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much of the baseline risk (the control group event rate) is removed as a result of having the intervention.

Reliability The consistency or constancy of a measuring instrument.

Reliability Coefficient A number between 0 and 1 that expresses the relationship between the error variance, the true variance, and the observed score. A zero correlation indicates no relationship. The closer to 1 the coefficient is, the more reliable the tool.

Repeated Measures Studies See longitudinal study. Representative Sample A sample whose key characteristics closely

approximate those of the population.

Research The systematic, logical, and empirical inquiry into the possible relationships among particular phenomena to produce verifiable knowledge.

Research Hypothesis A statement about the expected relationship between the variables; also known as a scientific hypothesis.

Research Literature A synonym for data-based literature. Research Problem Presents the question that is to be asked in a

research study.

Research Question A key preliminary step wherein the foundation for a study is developed from the research problem and results in the research hypothesis.

Research Utilization A systematic method of implementing sound research-based innovations in clinical practice, evaluating the outcome, and sharing the knowledge through the process of research dissemination.

Research-Based Protocols Practice standards that are formulated from findings of several studies.

Respect for Persons The principle that people have the right to self-determination and to treatment as autonomous agents; that is, they have the freedom to participate or not participate in

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research.

Respondent Burden Occurs when the length of the questionnaire or interview is too long or the questions are too difficult for respondents to answer in a reasonable amount of time considering their age, health condition, or mental status.

Retrospective Data Data that have been manifested, such as scores on a standard examination.

Retrospective Study A nonexperimental research design that begins with the phenomenon of interest (dependent variable) in the present and examines its relationship to another variable (independent variable) in the past.

Review of the Literature An extensive, systematic, and critical review of the most important published scholarly literature on a particular topic. In most cases it is not considered exhaustive.

Risk Potential negative outcome(s) of participation in a research study.

Risk/Benefit Ratio The extent to which the benefits of the study are maximized and the risks are minimized such that the subjects are protected from harm during the study.

Root Cause Analysis (RCA) A structured method used to understand sources of system variation that lead to errors or mistakes, including sentinel events, with the goal of learning from mistakes and mitigating hazards that arise as a characteristic of the system design.

Run Chart A graphical data display that shows trends in a measure of interest; trends reveal what is occurring over time.

S Sample A subset of sampling units from a population. Sampling A process in which representative units of a population

are selected for study in a research investigation.

Sampling Error The tendency for statistics to fluctuate from one

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sample to another.

Sampling Frame A list of all units of the population. Sampling Interval The standard distance between the elements

chosen for the sample.

Sampling Unit The element or set of elements used for selecting the sample.

Saturation See data saturation. Scale A self-report inventory that provides a set of response

symbols for each item. A rating or score is assigned to each response.

Scientific Approach A logical, orderly, and objective means of generating and testing ideas.

Scientific Hypothesis The researcher’s expectation about the outcome of a study; also known as the research hypothesis.

Scientific Literature A synonym for data-based literature; see data- based literature.

Scientific Observation Collecting data about the environment and subjects. Data collection has specific objectives to guide it, is systematically planned and recorded, is checked and controlled, and is related to scientific concepts and theories.

Secondary Analysis A form of research in which the researcher takes previously collected and analyzed data from one study and reanalyzes the data for a secondary purpose.

Secondary Source Scholarly material written by a person(s) other than the individual who developed the theory or conducted the research. Most are usually published. Often a secondary source represents a response to or a summary and critique of a theorist’s or researcher’s work. Examples are documents, films, letters, diaries, records, artifacts, periodicals, or tapes that provide a view of the phenomenon from another’s perspective.

Selection The generalizability of the results to other populations. Selection Bias The internal validity threat that arises when

897

pretreatment differences between the experimental group and the control group are present.

Self-Report Data collection methods that require subjects to respond directly to either interviews or structured questionnaires about their experiences, behaviors, feelings, or attitudes. These are commonly used in nursing research and are most useful for collecting data on variables that cannot be directly observed or measured by physiological instruments.

Semiquartile Range A measure of variability; range of the middle 50% of the scores. Also known as semi-interquartile range.

Sensitivity The proportion of those with disease who test positive. Simple Random Sampling A probability sampling strategy in

which the population is defined, a sampling frame is listed, and a subset from which the sample will be chosen; members are randomly selected.

Situation-Specific Theories More specific theories than middle range theories, they are composed of a limited number of concepts. They are narrow in scope, explain a small aspect of phenomena and processes of interest to nurses, and are usually limited to specific populations or field of practice.

Snowball Effect Sampling (Network Sampling) A strategy used for locating samples difficult to locate. It uses the social network and the fact that friends tend to have characteristics in common; subjects who meet the eligibility criteria are asked for assistance in getting in touch with others who meet the same criteria.

Solomon Four-Group Design An experimental design with four randomly assigned groups: the pretest–posttest intervention group, the pretest–posttest control group, a treatment or intervention group with only posttest measurement, and a control group with only posttest measurement.

Specificity The proportion of those without disease who test negative. It measures how well the test rules out disease when it is really absent; a specific test has few false positive results.

Split-Half Reliability An index of the comparison between the

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scores on one half of a test with those on the other half to determine the consistency in response to items that reflect specific content.

Stability An instrument’s ability to produce the same results with repeated testing.

Standard Deviation (SD) A measure of variability; measure of average deviation of scores from the mean.

Statistic A descriptive index for a sample such as a sample mean or a standard deviation.

Statistical Hypothesis States that there is no relationship between the independent and dependent variables. The statistical hypothesis is also known as the null hypothesis.

Stratified Random Sampling A probability sampling strategy in which the population is divided into strata or subgroups. An appropriate number of elements from each subgroup are randomly selected based on their proportion in the population.

Survey Studies Descriptive, exploratory, or comparative studies that collect detailed descriptions of existing variables and use the data to justify and assess current conditions and practices, or to make more plans for improving health care practices.

Survival Curve A graph that shows the probability that a patient “survives” in a given state for at least a specified time (or longer).

Systematic Data collection carried out in the same manner with all subjects.

Systematic Error Attributable to lasting characteristics of the subject that do not tend to fluctuate from one time to another. Also called constant error.

Systematic Review The process whereby investigators find all relevant studies, published and unpublished, on the topic or question; at least two members of the review team independently assess the quality of each study, include or exclude studies based on preestablished criteria, statistically

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combine the results of individual studies, and present a balanced and impartial evidence summary of the findings that represents a “state of the science” conclusion about the evidence, supporting benefits and risks of a given health care practice.

Systematic Sampling A probability sampling strategy that involves the selection of subjects randomly drawn from a population list at fixed intervals.

T t Statistic Commonly used in research; it tests whether two group

means are more different than would be expected by chance. Groups may be related or independent.

Target Population A population or group of individuals that meet the sampling criteria.

Test A self-report inventory that provides for one response to each item that the examiner assigns a rating or score. Inferences are made from the total score about the degree to which a subject possesses whatever trait, emotion, attitude, or behavior the test is supposed to measure.

Test–Retest Reliability Administration of the same instrument twice to the same subjects under the same conditions within a prescribed time interval, with a comparison of the paired scores to determine the stability of the measure.

Testability Variables of proposed study that lend themselves to observation, measurement, and analysis.

Testing The effects of taking a pretest on the scores of a posttest. Text Data in a contextual form; that is, narrative or words that are

written and transcribed.

Theme A label that represents a way of describing large quantities of data in a condensed format.

Theoretical Framework Theoretical rationale for the development of hypotheses.

900

Theoretical Literature A synonym for conceptual literature; see conceptual literature.

Theory Set of interrelated concepts, definitions, and propositions that present a systematic view of phenomena for the purpose of explaining and making predictions about those phenomena.

Time Series Design A quasi-experimental design used to determine trends before and after an experimental treatment. Measurements are taken several times before the introduction of the experimental treatment; the treatment is introduced, and measurements are taken again at specified times afterward.

Transferability See fittingness. Treatment Effect The impact of the independent

variable/intervention on the dependent variable.

Triangulation The expansion of research methods in a single study or multiple studies to enhance diversity, enrich understanding, and accomplish specific goals.

True (Classic) Experiment Also known as the pretest–posttest control group design. In this design, subjects are randomly assigned to an experimental or control group, pretest measurements are performed, an intervention or treatment occurs in the experimental group, and posttest measurements are performed.

Trustworthiness The rigor of the research in a qualitative research study.

Type I Error The rejection of a null hypothesis that is actually true. Type II Error The acceptance of a null hypothesis that is actually

false.

V Validity The determination of whether a measurement instrument

actually measures what it is purported to measure.

Variable A defined concept.

901

W Web Browser Software program used to connect to or “read” the

World Wide Web.

902

Index

A priori frameworks, 97–98

Absolute risk reduction, 498–499

Abstract, 15–16, 16b

Abstract databases, 52t, 55, 56t

Accessible population, 213

Accountable Care Organization (ACO), 412b

Accreditation, quality strategy levers and, 410, 411b

Active coping,

of cancer survivors, 492

for parents of cancer survivors, 488–489, 489t

for siblings of cancer survivors, 489, 489t, 490–491 After-only design,

experimental design, 171f, 172, 172b

nonequivalent control group design, 174f, 175 Agency for Healthcare Research and Quality (AHRQ), 207

Quality Indicators, 410b

website of, 56t

903

Aims, of research, 32, 32b

Alpha level, 293

Alternate form reliability, 272

Ambivalence, analgesic administration, 476–477

American Medical Association, Code of Ethics, 232–233

American Nurses Association (ANA),

Code of Ethics, 7

human rights protection, 235 American Nurses’ Credentialing Center Magnet Recognition

Program, 411b

Amity, 439–440

Analgesic administration,

NRS scores and, 472t, 476–478, 479

side effects of, 477 Analysis of covariance (ANCOVA), 297

structures, 189–190 Analysis of variance (ANOVA), 296–297, 297b, 298b

reported statistical results of, 307t Anecdotes, 250

Anonymity, 236–237t, 239

Antecedent variables, 175

Anticipatory guidance, 98–99

Antiplatelet therapy, in NLC group, 501, 502f

Applicability to nursing practice, critiquing of, 328t, 357

Appraisal of Guidelines Research and Evaluation II (AGREE II), 208, 208b

904

Article’s findings, appraisal for, in evidence-based practice, 368–379

diagnosis articles in, 371–376, 374t, 375t, 376t

harm articles in, 377, 378t

meta-analysis in, 377–379, 379b

prognosis articles in, 376–377, 377b, 377t

therapy category in, 368–371, 368t, 369t, 371–373f Article’s text, tables and figures in, 309, 309t, 310t

Asian American/Pacific Islander (AA/PI) ethnicity, vaccine noncompletion and, 449

Assent, of child, 242

Associated causal analysis techniques, 189

Attention-control, 168b

Attrition, internal validity and, 227

Audit, and feedback, 398

Auditability, in qualitative research, 119–120, 119t, 141

Avoidant coping,

for parents, 488, 489t, 490

for siblings of cancer survivors, 489, 489t, 491

Background and significance, critiquing of, 328t

Bar charts, 423, 424f

“Bearable” pain, 479

“unbearable” vs., 473 Beck Depression Inventory (BDI-II), 458

Bell curve, 423

905

Belmont Report, 234–235

Benchmarking, 414–415

Beneficence, 234–235, 235b, 236–237t

Benefit increase, 369t

Benefits designs, quality strategy levers and, 410

Bias, 150

bracketing of, 106, 111b

credibility and, 155–156

dependability and, 155–156

external validity and, 159

internal validity and, 156

interviewer, 255–256

in nonexperimental designs, 181

in sampling, 217t

selection, 158

systematic error and, 264

in systematic reviews, 201 Bibliographic databases, 52t, 55, 56t

Biological measurement, 248, 256–257

Blobbogram, 203, 378–379

Books, print and electronic, literature search and, 55

Boolean operator, 59, 59b

Bracketing, 137–138

researcher’s perspective, 106

906

Brief Symptom Inventory (BSI), 443–444, 487

Browser, 56

Bundled payments initiative, 412b

California Nursing Outcomes Coalition (CalNOC), 414

Capitation, 412b

Cardiovascular diseases, nurse-led clinic impact on mortality and morbidity in, 496–507

implications for clinical practice and research, 505, 505b

limitations, 505

method of, 497–499

data abstraction, 498

eligibility criteria, 497

quality of included studies, 498

search strategy, 498

statistical analysis, 498–499

study identification, 498

results in, 499–501

meta-analysis, 501, 502f, 503f, 505b

methodological quality, 501, 503f, 504t

search results and study description, 499–501, 499f, 500t

907

Caregiver Reaction Assessment (CRA) scale, 345

Case control study, 187–189

Case study method, 113–115, 115b

data analysis in, 115

data gathering in, 114

describing findings in, 115

identifying the phenomenon in, 113

research question in, 113–114

researcher’s perspective in, 114

sample selection in, 114

structuring the study in, 113–114 Categorical variable, 284

Causal modeling, 189

Causal relationship, 33–34

Causal-comparative studies, 187

Causality, in nonexperimental designs, 189–190

Cause and effect diagrams, 424–425

Center for Epidemiologic Studies Depression Scale (CES-D), 345, 443–444

Center for Evidence Based Medicine (CEBM), 206

Certification, quality strategy levers and, 410, 411b

Chance (random) errors, 263–264

Change champions, 397

Change ideas, 426–427

Change topics, 426–427

908

Charts, 423, 423f

Check sheets, 419, 421

Children, as subjects, in research, 242–243

Chi-square (x2), 297

reported statistical results of, 307t CI., See Confidence interval

CINAHL (Cumulative Index to Nursing and Allied Health Literature), 50, 52t, 55, 57b, 58–59

Citation management software, 58

Classic test theory, vs. item response theory, 275

Clinical categories, 365–366, 368

Clinical experience, research question and, 25t

Clinical guidelines, 19–20

consensus, 19–20

evidence-based, 19–20 Clinical Microsystems model, 417t

Clinical practice guidelines, 206–207

definition of, 206–207

evaluation of, 207–209, 207b, 208b

evidence-based, 207

expert-based, 207

systematic reviews and, 199–211 Clinical questions, 23–44, 40b

comparison intervention and, 39b

components of, 39, 39b

909

developing and refining, 38–40, 40b

diagnosis category in, 366

elements of, 37t

focused, in evidence-based practice, 365–366

harm category in, 366

intervention and, 39b

in literature review, 49

outcome and, 39b

PICO format for, 49, 365, 365t

prognosis category in, 366

significance of, 39–40

therapy category in, 365 Clinical significance, 294, 295t

in research findings, 311 Clinical trial, 167

Closed-ended questions, 253, 253b, 255b

Cluster sampling, 217t, 223–224

Cochrane Collaboration, 204–205, 204b

website of, 56t Cochrane Library, 50, 204–205, 205b

Cochrane Report, 204–205

Cochrane Review, 204–205, 204b

Cochrane risk of bias tool, 498

Coercion, 236–237t

910

Cohort studies, 186–187

Collection methods, in research articles, 18

Common cause variation, 421

Community-based participatory research (CBPR), 102, 115–116, 117b

Comparative research question, 30t

Comparative studies, 187

Comparison intervention, clinical questions and, 39b

Competency, informed consent and, 242–243

Complex hypothesis, 34b

Comprehensive health seeking and coping paradigm, 438, 438f

Computer networks, recruitment from, 220

Computer software, citation management, 58

Concealment, in observation, 250, 251b, 251f

Concept, 69, 69b

Conceptual definition, 69b, 70t

Conceptual framework, 69b. See also Theoretical frameworks

Conclusions,

critiquing of, 328t, 340, 356–357

in qualitative research, 125–126t, 141–144 Concurrent validity, 266, 267b

Confidence interval (CI), 311, 369, 370, 371–373f, 378–379

Confidentiality, 236–237t, 239

Confirmation, from professionals, NRS score assigning and, 475

Consensus guidelines, 19. See also Clinical practice guidelines

Consent, 239. See also Informed consent

Consistency, in data collection, 248

911

Constancy, in data collection, 154

Constant comparative method, 109–110

Constant error, 264

Construct validity, 266–269, 267b, 277

Constructs, 69, 69b, 263

Consumer incentives, quality strategy levers and, 410

Content analysis, 253

Content validity, 265–266, 266b

Content validity index, 265b, 266

Context dependent experience, 89

Continuous variables, 284b, 368, 368t

Contrasted-groups approach, for assessing validity, 268, 268b

Control,

constancy and, 154

in experimental designs, 167, 168b

flexibility and, 155

manipulation of independent variable and, 154

in nonexperimental designs, 181

in quantitative research, 152–155

randomization and, 155

in research design, 150 Control chart, 423, 423f

Control group, 154

Controlled vocabulary, 58

Convenience sampling, 217–218, 217t, 221b. See also Nonprobability

912

sampling

Convergent validity, 267b, 268, 268b

COPE, for cancer survivors, 487–488

Coping, in parents and siblings of adolescent cancer survivors, 483– 495, 491b

implications for nursing, 492

methods in, 485–488, 486t

data analysis, 488

measures, 487–488

procedure, 486–487

sample, 485–486

results in, 488–490, 489t, 490t Coping strategy, after infant’s/child’s death,

gender differences and, 463

spirituality/religion as, 456–457 Correlation,

definition of, 297–298

perfect negative, 298

perfect positive, 298 Correlation coefficients, 298

Correlational research question, 30t

Correlational studies, 184–185, 185b

Covert data collection, 236–237t

Credibility,

913

bias and, 155–156

in qualitative research, 119–120, 119t, 140 Criteria, for research findings, 314b

Criterion-related validity, 266, 267b, 277

Critical appraisal, 7. See also Critiquing

definition of, 317, 321

guidelines for, 328t

of qualitative research, 124–125, 125–126t, 127b

abstract in, 136–137

authenticity in, 141

conclusions in, 141–144

data analysis in, 140–141

data generation in, 140

discussion in, 133–134

ethical consideration in, 139

findings in, 141–144

implications in, 141–144

introduction in, 137–138

method in, 128–130

purpose in, 139

recommendations, 141–144

results in, 130–133, 131t

914

sample in, 139–140

trustworthiness in, 141

of scientific literature, 25t

stylistic considerations in, 320–321

in systematic review, 206 Critical decision tree, 427, 428f

Critical reading skills, 10, 10b, 11b. See also Critiquing

Critical Thinking Decision Path,

for assessing study results, 307b, 307f

for consumer of research literature review, 249b, 249f

for descriptive statistics, 282, 283b, 283f

for electronic database, 54b, 54f

for experimental and quasi-experimental designs, 166b, 166f

for inferential statistics, 290b, 291b, 291f

for levels of measurement, 282, 283b, 283f

for literature search, 54b

for nonexperimental designs, 182b, 182f

for qualitative research, 91b, 91f, 105b, 105f

for quantitative research, 91b, 91f

for risk-benefit ratio, 242b, 242f

for sampling, 224b, 224f

for systematic reviews, 201b, 201f

915

for threats to validity, 159b, 159f

for validity and reliability, 269b Critique, 10–12

Critiquing,

of applicability to nursing practice, 328t, 357

of background and significance, 328t

of conclusions, 328t, 340, 356–357

criteria for, 12

of data analysis, 328t, 339, 356

of data collection, 259, 259–260b, 328t

of descriptive and inferential statistics, 300b

of external validity, 328t

guidelines for, 328t

of hypothesis, 40–42, 41–42b, 328t

of implications, 328t, 340, 356–357

of instruments, 339, 356

of internal validity, 328t

of legal-ethical issues, 244, 244b, 328t, 339, 356

of literature review, 61, 62, 63b, 328t, 338, 354–355

of methods, 328t, 356

of nonexperimental designs, 194, 195b

of qualitative research, 120, 120–121b, 136–144

916

of quantitative research, 161, 162b, 321–357, 326f, 329t, 330t, 333f, 348t, 349t, 350t

of recommendations, 328t, 340, 356–357

of reliability, 276b, 328t, 356

of research design, 328t, 338, 355

of research questions, 40–42, 41–42b, 328t, 338, 355

of research studies, 10–12

of sampling, 227, 228b, 328t, 338, 355

strategies for, 12

stylistic considerations in, 320–321

of systematic review, 206

of theoretical frameworks, 78–79, 78b

of validity, 276b, 328t, 356 Cronbach’s alpha, 273, 273t

Cross-sectional studies, 185–186

Culture,

in ethnographic research, 111

pain and, 479 Cumulative Index to Nursing and Allied Health Literature

(CINAHL), 52t, 55, 57b, 58–59

Custody, level of, vaccination completion affected by, 437

Data,

917

demographic, 254

physiological, 248, 256–257 Data analysis, 281–304

in case study method, 115

critiquing of, 328t, 339, 356

in ethnographic method, 112

in grounded theory method, 109–110

in phenomenological method, 107

in qualitative research, 95–96, 125–126t, 140–141

in research articles, 18 Data collection,

anecdotes in, 250

bias in, 255–256

consistency in, 248

constancy in, 154

covert, 236–237t

Critical Thinking Decision Path, 249f

critiquing of, 259, 259–260b, 328t

data saturation in, 94

demographic data in, 254

ethical issues in, 236–237t

existing data in, 248, 257, 257b

918

fidelity in, 247, 248

field notes in, 250

instrument development for, 190, 258

Internet-based, 256

interviews for, 94–95, 253–256, 255b

measurement error in, 249

methods of, 247–257, 249b

in mixed methods, 193

observation in, 248, 250–252, 252b

physiological data in, 248, 256–257

pilot testing in, 258

in qualitative research, 93–94, 95b, 125–126t

questionnaires in, 253–256, 255b

random error in, 249

scale in, 254

secondary analysis and, 257

self-report in, 248, 252–253

steps in, 248

systematic, 247

systematic error in, 249 Data gathering,

in case study method, 114

919

in ethnographic method, 112

in grounded theory method, 109

in phenomenological method, 107 Data saturation, 94, 107, 139, 225

Databases., See Electronic databases

Debriefing, 250–251

Deception, 236–237t

Decision-making process, 479

Deductive research, 75

Definitions,

conceptual, 69b, 70t

operational, 69b, 70t, 248 Degrees of freedom, 296

Delimitations, 214

Demographic data, 254

Demographic variables, 27

Dependability, bias and, 155–156

Dependent variables, 29

control and, 150

in experimental and/or quasi-experimental designs, 166. See also Variables

Depression, measurement of, 458

Descriptive statistics, 281–289, 283b, 283f, 285b, 288b, 289b, 300–302

critical appraisal criteria of, 300b, 301

frequency distribution of, 285, 286f, 286t

920

measures of central tendency, 285–287, 287b

measures of variability, interpreting, 288–289, 289b

normal distribution of, 287–288, 288f

tests of relationships, 297–299 Design., See Research designs

Developmental studies, 185–189, 185b

Diagnosis articles, 371–376, 374t, 375t, 376t

Diagnosis category, in clinical question, 366

Diagnostic tests., See Test(s)

Dichotomous variable, 284

Diffusion, quality strategy levers and, 412

Dignity, 236–237t

Directional hypothesis, 36–37

Discomfort, protection from, 236–237t

Discrete variables, 368, 368t

Discriminant validity, 267b, 268

Discussion,

in research articles, 18

of research findings, 310–313, 313b

clinical significance in, 311

confidence interval in, 311

generalizability in, 312

limitations in, 310–311, 312

purpose of, 312

921

recommendations in, 310–311, 313, 313b

statistical significance in, 311 Dissemination, 383–384

Distribution,

frequency, 285, 286f, 286t

normal, 287–288, 288f Divergent validity, 267b, 268, 268b

Domains, 112

in ethnographic research, 112 Dyad characteristics, 347t

EBSCO, 52t

Education Source with ERIC (EBSCO), 52t

Effect size, 169, 203

80-20 Rule, 423

Elderly, as subjects, in research, 243

Electronic databases, 53–54, 366

abstract, 52t, 55, 56t

bibliographic, 52t, 55, 56t

Critical Thinking Decision Path for, 54b

for evidence-based practice, 56t

for nursing, 52t

search engines for, 56–60, 56b, 57b, 58b, 60b

922

search strategy for, 498. See also Literature search

secondary or summary, 56 Electronic indexes, 55, 366

Electronic search, 53–54

Elements, of sample, 215–216

Eligibility criteria, 214

Emic view, 110

Emotion-focused coping, for parents of cancer survivors, 488, 489t, 490–491

Equivalence, reliability and, 274–275

Error,

measurement., See Measurement error

sampling, 292

type I and type II, 292–294, 293f Error variance, 263

Ethical issues, 232–246

anonymity, 236–237t, 239

assent, of child, 242

beneficence, 234–235, 235b, 236–237t

confidentiality, 236–237t, 239

covert data collection, 236–237t

critiquing of, 244, 244b, 328t, 339, 356

dignity, 236–237t

HIPAA Privacy Rule, 239, 240, 240b

923

historical perspective on, 232–243, 233–234t

informed consent, 233–234t, 235–240, 236. See also Informed consent

institutional review boards and, 240–241, 241b

justice, 234–235, 235b, 236–237t

in observation, 252

privacy, 236–237t, 239

protection of human rights, 235, 236–237t

protection of vulnerable groups, 241–243, 243b

in qualitative research, 118, 118t, 125–126t, 139

respect for persons, 234–235, 235b, 236–237t

self-determination, 236–237t

in unethical research studies, 233–234t, 233–234

US Department of Health and Human Services (USDHHS) and, 235

Ethical research standards, institutional review boards and, 228–229

Ethics, code of, 232–233

American Medical Association, 232–233 Ethnographic method, 110–113, 113b

data analysis in, 112

data gathering in, 112

describing the findings in, 112–113

emic view in, 110

924

etic view in, 110

identifying the phenomenon in, 111

research question in, 111

researcher’s perspective in, 111

sample selection in, 111

structuring the study in, 111 Ethnography, 110

Etic view, 110

Evaluation, in evidence-based practice, 400–402, 400b, 401t, 402b

Evaluation research, 194b

Evidence hierarchy model, 13–14

Evidence-based guidelines, 19–20

Evidence-based practice, 5–8, 13–15, 383–405

appraisal for, 40–42

clinical guidelines in, 19–20

conduct of research in, 384

critique and synthesis of research, 392–394, 392b, 393t, 394b

decision to change practice, 394

development of, 394–395, 395b

evaluation, 400–402, 400b, 401t, 402b

outcome data in, 400–401, 401t

process data in, 400, 401t

925

evidence retrieval, 388–389

experimental and/or quasi-experimental designs in, 176–177, 177b

forming a team, 388

future directions, 402

grading evidence in, 389–392, 390–391t, 391t

implementing the practice change, 395–399

innovation,

nature of, 395–396, 396f

users of, 398

level of evidence of, 13–14, 13f

literature, qualitative research on, 125–127

methods of communication, 396–398, 397b

models of, 385–387

Iowa model, 385–387, 386f

overview of, 384–387, 384f

process steps, 14, 14f

quality improvement in, 20

question, 389t

selection of a topic, 387, 387b

setting forth, recommendations, 394, 394b

social system, 398–399

926

steps of, 387–402

strategies and tools for development of, 364–382

applying the findings in, 380

article’s findings in, appraisal for, 368–379

clinical question in, 365–366, 365t

diagnosis articles in, 371–376, 374t, 375t, 376t, 377b, 377t

findings in, screening, 367, 367b

harm articles in, 377, 378t

literature, searching, 366–367, 367b

meta-analysis in, 377–379, 379b. See also Meta-analysis

therapy category in, 368–371, 368t, 369t, 371–373f Evidence-based practice guidelines, 385

clinical practice guidelines in, 207 Evidenced-Based Practice Centers, 388–389

Ex post facto study, 187–189, 187t

Exclusion criteria, 92–93, 214–215, 215f

Existing data, 248, 257, 257b

Experimental designs, 167–173, 167b

Critical Thinking Decision Path for, 166b, 166f

in evidence-based practice, 176–177

appraisal for, 177–178, 177b

strengths and weaknesses of, 172–173

927

types of, 170–172, 171f

after-only design, 172

Solomon four-group design in, 170–172 Experimental group, 154

Experimental research question, 30t

Expert-based guidelines, 207

clinical guidelines in, 209–210, 209b

systematic reviews in, 209–210, 209b Expert-developed guidelines, 19–20

External validity, 159–160

critiquing of, 328t

threats to, 156b, 339, 356

Critical Thinking Decision Path for, 159b, 159f

measurement effects, 160–161

reactive effects, 160

in sampling, 227

selection effects, 160 Extraneous variable, 153

Face validity, 266

Factor analysis, 267b, 268–269, 299

Fasting plasma glucose (FPG) test, 422

Fathers, bereaved,

928

spiritual activities and, 461, 462t, 463

personal growth in, 461–462, 463 Feedback, quality strategy levers and, 410, 410b

Fetuses, as subjects, in research, 243

Fidelity,

in data collection, 247, 248

intervention, 150–151, 152–155, 169

elements of, 154 Field notes, 250

Figures, in results, of research findings, 309

Findings., See Research findings

Fishbone diagram, 424, 425f

Fisher exact probability test, 297

Fittingness, in qualitative research, 119–120, 119t

Five Whys method, 424–425

Flowchart, 425–426, 426f

Flowcharting, 425–426

Focus group, 94

Forest plot, 203, 203f

Frequency distribution, 285, 286f, 286t

Frequency polygon, 285, 286f

Gelsinger, Jesse, 238–239

Generalizability, 312

external validity and, 159, 160b

929

in sampling, 153, 227

selection and, 160 Google, 56

Google Scholar, 53, 56

Grand nursing theories, 71–72, 72b, 74t

Grand tour question, 94–95

Graphs, 423

bar charts, 423, 424f

of frequency distributions, 285, 286f

frequency polygons, 286f

histograms, 286f

pie charts, 423, 424f

tree diagram, 424–425 Grey literature, 55

Grief,

coping with, gender differences and, 463

defined, 457–458

measurement of, 458

and mental health, 461, 461t

of parent, after infant’s/child’s death, 455–466 Grounded theory method, 108–110, 110b, 469

data analysis in, 109–110

data gathering in, 109

930

describing the findings in, 110

identifying the phenomenon in, 108

open coding in, 109–110

research question in, 109

researcher’s perspective in, 109

sample selection in, 109

structuring the study in, 109

theoretical sampling in, 109

Harm, protection from, 236–237t

Harm articles, 377, 378t

Harm category, in clinical question, 366

Hawthorne effect, 160, 251, 252

Health information technology, quality strategy levers and, 410

Health seeking and coping paradigm, 438

Healthcare Effectiveness Data and Information Set (HEDIS), 411b

Healthcare professionals,

in analgesic administration, 479

confirmation from, NRS score assigning and, 475

expectations of, pain score and, 476

judgements by, in NRS scores, 472t, 475–476, 479, 480– 481

pain assessment and, 478, 479

931

in postoperative pain management, 480 Healthcare providers, in young cancer survivors, 491b, 492

Hepatitis A vaccine, in homeless men released on parole,

administration of, 442

completion of, 443

factors in, 438–439

rates for, by intervention condition, 446

eligibility for, 440, 441f

measures in, 443–444

noncompletion of, 444–445, 446–448, 447t, 448t

peer coaching-nurse case management and, 440–442

randomized clinical trial for, 435–454

data analysis for, 444–445

design of, 439

discussion for, 448–451

interventions in, 440–442

limitations of, 450

methods for, 439–445

procedures for, 442–443

purpose of, 439

results in, 445–446t, 445–448

sample and site for, 439–440

932

theoretical framework for, 438–439, 438f

tracking of, 443

usual care in, 442 Hepatitis A virus, 436

Hepatitis B vaccine, in homeless men released on parole,

administration of, 442

completion of, 443

factors in, 438–439

rates for, by intervention condition, 446

eligibility for, 440, 441f

measures in, 443–444

noncompletion of, 444–445, 446–448, 447t, 448t

peer coaching-nurse case management and, 440–442

randomized clinical trial for, 435–454

data analysis for, 444–445

design of, 439

discussion for, 448–451

interventions in, 440–442

limitations of, 450

methods for, 439–445

procedures for, 442–443

purpose of, 439

933

results in, 445–446t, 445–448

sample and site for, 439–440

theoretical framework for, 438–439, 438f

tracking of, 443

usual care in, 442 Hepatitis B virus, 436

Heterogeneity, of treatment, in NLC, 498–499, 501, 503–505

Hierarchical linear modeling (HLM), 189–190

HIPAA Privacy Rule, 239, 240, 240b

Histograms, 285, 286f, 423, 424f

History, internal validity and, 156

Hogan Grief Reaction Checklist, 458

Home Health Compare, 411b

Homelessness, incarcerated populations and, 436–439

Homogeneity, 153

reliability and, 270, 272–274, 272b Homogeneous sampling, 153–154, 153b

Hospital Compare, 411b

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), 411b

Hostility,

measurement of, 443–444

vaccine noncompletion and, 449 Human rights, protection of, 235, 236t. See also Ethical issues

Human subjects’ committee, 240

934

Hyman vs. Jewish Chronic Disease Hospital case, 233–234t, 236– 237t

Hypothesis, 23–44, 38b

complex, 34b

critiquing of, 40–42, 41–42b, 328t

developing, 32–37, 33b, 33f

directional, 36–37

discussion and, 310–311

literature review and, 48

nondirectional, 36–37

null, 291–292, 298

relationship statement in, 33–34

research, 36, 291–292

research design and, 37–38, 37b

research question and, 16. See also Research questions

results and, 306

statistical, 36, 36t

testability of, 34

theory base of, 34

wording of, 35, 35t Hypothesis testing,

inferential statistics in, 291–292, 291b, 292b

validity and, 267b, 268

935

Impact of Events Scale-Revised, 458–459

Inclusion criteria, 92–93, 214–215, 215f

Independent variables, 29. See also Variables

in experimental design, 167–168

manipulation of, 154–155, 155b

in nonexperimental designs, 181 Indexes,

electronic, 55, 366. See also Electronic indexes

print, 55 Individually identifiable health information (IIHI), 239, 240b

Inductive research, 74

Inferential statistics, 281–299, 290f, 291f, 300–302

clinical significance and, 294

commonly used, 295, 296b, 297b

Critical Thinking Decision Paths for, 290b, 291b

critiquing of, 300b, 301

in hypothesis testing, 291–292, 291b, 292b

level of significance and, 293–294, 294b

nonparametric, 294–297

parametric, 294–297

probability and, 292

probability sampling and, 290

936

sampling error and, 292

statistical significance and, 294

type I and type II errors and, 292–294 Information literacy, 366

Informed consent, 235–240, 239b

assent and, 242

for children, 242

competency and, 242–243

definition of, 238

for elderly, 243

elements of, 238b

for fetuses, 243

for individually identifiable health information, use and disclose of, 239

for neonates, 243

not obtained, 233–234t

for pregnant women, 243

for prisoners, 243

in qualitative research, 118 Innovation, quality strategy levers and, 412

Institutional review boards (IRBs), 240–241, 241b

Instrument(s)., See also Data collection

construction of new, 258

937

critiquing of, 339, 356

development of, 190

constructs in, 263

reliability, 263, 270. See also Reliability

validity of, 264. See also Validity Instrumental case study, 113

Instrumentation, internal validity and, 157–158

Integrative reviews, 19, 200–201, 205, 205b

Internal consistency reliability, 271b, 275

Internal validity, 156

critiquing of, 328t

threats to, 156b, 157t, 158b, 339, 355

Critical Thinking Decision Path for, 159b, 159f

history, 156

instrumentation, 157–158

maturation, 157

mortality, 158

in sampling, 227

selection bias, 158

testing, 157 Internet search engines, 56–60, 56b, 57b, 58b, 60b

Internet-based self-report data collection, 256

Interrater reliability, 270–271, 271b, 274–275, 275b

938

Interval measurement, 283b, 284

Intervening variables, 153, 176

Intervention,

clinical questions and, 39b

in observation, 250, 251b, 251f Intervention articles, 166

Intervention fidelity, 150–151, 152–155, 153b, 169

elements of, 154 Intervention group, 154

Interview(s), 253–256

advantages of, 255

bias, 255–256

online, 256

open-ended or closed-ended questions in, 253, 253b, 255b

respondent burden and, 253, 254

topic guide for, 470t Interview guide, 253b

Interview questions, 94–95

Interviewer bias, 255–256

Intrapersonal patient factors, rating pain, 472f, 472t, 474–475

Intrinsic case study, 113

Introduction, in research articles, 16

Iowa model of Evidence-Based Practice, 385–387, 386f

Item response theory, vs. classic test theory, 275

939

Item to total correlations, reliability, 271b, 273, 273t

Jewish Chronic Disease Hospital case, 233–234t, 236–237t

Joanna Briggs Institute (JBI), website of, 56t

Joint Commission, 411b

Journal,

electronic, 55

in literature review., See Literature review

print, 55

refereed, 55

searching., See Literature search Judgements, by healthcare professionals, NRS score and, 472t, 475–

476, 479

Justice, 234–235, 235b, 236–237t

Kappa, 271b

Kendall’s tau, 298–299

Key informants, 111

Knowledge of improvement, 430

Knowledge-focused triggers, 387

Known-groups approach, for assessing validity, 268

Kolmogorov-Smirnov test, 297

Kuder-Richardson (KR-20) coefficient, 268–269, 270–271, 271b, 274, 274b

940

Law of the Few, 423

Leadership support, 399

Lean, 417t

Leapfrog Group, 411b

Learning, quality strategy levers and, 410

Legal issues, 232–246. See also Ethical issues

critiquing of, 244, 244b

HIPAA Privacy Rule, 239, 240, 240b

historical perspective on, 232–243, 233–234t

protection of human rights, 235, 236–237t

protection of vulnerable groups, 241–243 Legal-ethical issues, critiquing of, 328t, 339, 356

Level of evidence, 13–14, 13f

Level of significance, 293–294, 294b

Levels of measurement, 282–285, 283t

Life satisfaction,

measurement of, 487

for parents of cancer survivors, 488, 489t, 490

for siblings of cancer survivors, 489, 489t, 491 Likelihood ratio (LR), 375, 376t

Likert scale, 273, 273f, 284–285

Likert-type scales, 254, 284–285

Limitations, of research findings, 308

discussion in, 310–311

941

Linear structural relations analysis (LISREL), 299

Lipid-lowering medication, in NLC group, 501, 502f

Literature,

gaps in, 25t

gathering and appraising, 45–65

review of, in qualitative research, 90–92, 137–138

searching, in evidence-based practice, 366–367, 367b Literature review, 46. See also Research articles

characteristics of well-written, 61b

for clinical questions, 49

consumer of, Critical Thinking Decision Path for, 249b, 249f

critiquing of, 61, 62, 63b, 328t, 338, 354–355

EBP perspective of, 49–50, 50b

format for, 60–61, 61b

hypothesis and, 48

in methodological research, 191

primary and secondary sources in, 47, 48t

purposes of, 46b

in qualitative research, 48–49

in quantitative research, 47–48, 47f, 50b

in research articles, 16, 16b

research design and, 48

942

research questions in, 27, 27b, 48

researcher’s perspective of, 46–49

searching for evidence in, 50. See also Literature search

theoretical or conceptual framework and, 47 Literature search, 50–54

Boolean operator in, 59, 59b

citation management software for, 58

controlled vocabulary search in, 58

Critical Thinking Decision Path for, 54b

electronic database in, 53. See also Electronic databases

keyword search in, 59

PICO format and, 49

preappraised literature for, 52, 52b

primary sources in, 52–53, 53b

search history in, 58, 58b

strategies for, 51t Lived experience, in phenomenological method, 105

Longitudinal studies, 186–187

LR., See Likelihood ratio

Manipulation, in experimental designs, 167–169, 168b

943

Mann-Whitney U test, for independent groups, 297

MANOVA (multiple analysis of variance), 297

Maturation, internal validity and, 157

Mean, 287

reported statistical results of, 307t Measurement, 248. See also Data collection

definition of, 282

interval, 283b, 284

levels of, 282–285, 283t

nominal, 284

ordinal, 283b, 284

quality strategy levers and, 410, 410b

ratio, 285 Measurement effects, external validity and, 160–161

Measurement error, 249

chance (random), 263–264

systematic (constant), 264 Measurement instruments, development of, 190–191, 192t, 263

Measures of central tendency, 285–287, 287b

Measures of variability, interpreting, 288–289, 289b

Median, 286t, 287

Median test, 297

Mediating variable, 153

MEDLINE, 52t

Mental health,

944

grief and, 461, 461t

of parent, after infant’s/child’s death, 457 Mental pain, basic mistrust as, 476

Meta-analysis, 19, 200, 200b, 203b, 202–204. See also Systematic reviews

in Cochrane Collaboration, 204–205, 204b

in Cochrane Library, 204–205, 205b

definition of, 202

effect size in, 203

in evidence-based practice, 377–379, 379b

forest plot in, 203, 203f

phases of, 202

reporting guidelines of, 205–206 Meta-summary, 19

qualitative, 117 Meta-synthesis, 19

qualitative, 116–117 Methodological research, 190–191, 192t

Methods,

critiquing of, 328t, 356

in qualitative research, 125–126t, 128–130 Microrange nursing theories, 72–73

Middle range nursing theories, 72, 73b, 74t

Mistrust,

945

basic, on NRS scores, 476, 479

as mental pain, 476 Mixed methods research, 116, 120b, 193–194

Modality, 287

Mode, 286t, 287

Model, 69b

testing of, 189 Mortality,

in experimental designs, 170

internal validity and, 158 Mothers, bereaved, spiritual activities and, 461, 462t, 463

personal growth in, 461–462, 463 Movement, pain level at, 474

Multiple analysis of variance (MANOVA), 297

Multiple regression, 299

Multistage (cluster) sampling, 217t, 223–224

Multivariate statistics, 299

Myocardial infarction, in NLC group, 501, 502f

Narrative format, for qualitative study, 124–125

Narrative reviews, 19

National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 234–235

National Committee for Quality Assurance Accreditation for Health Plans (NCQA), 411b

946

National Database of Nursing Quality Indicators, 414

National Guideline Clearinghouse, 207, 388–389

website of, 56t National Quality Aims, 408b

National Quality Forum (NQF), 410b

National Research Act, 240

Naturalistic setting, for qualitative research, 93–94, 118, 118t

Necrotizing enterocolitis (NEC), 388

Needs assessments, 194b

Negative likelihood ratio, 374t, 376, 376t

Negative predictive value (NPV), 373, 374, 374t

Neonates, as subjects, in research, 243

Network sampling, 220–221

NNT., See Number needed to treat

Nominal measurement, 284

Nondirectional hypothesis, 36–37

Nonequivalent control group design, 174f, 175

after-only, 175 Nonexperimental designs, 180–198, 181b, 181t, 182b, 189b, 190b,

194b

causality in, 189–190

continuum of, 181f

Critical Thinking Decision Path for, 182b, 182f

evidence-based practice, appraisal for, 194–195, 195b

key points in, 195–196

947

prediction in, 189–190

relationship and difference studies in, 184–189, 188b, 189b

case control/retrospective/ex post facto studies, 187– 189

cohort/prospective/longitudinal/repeated measures studies, 186–187

correlational studies, 184–185

cross-sectional studies, 185–186

developmental studies, 185–189

survey studies in, 182–183, 183b Nonparametric statistics, 295b, 297

Nonprobability sampling, 216, 217–221

convenience, 217–218, 217t, 221b

purposive, 217t, 219–220, 220b, 221b

quota, 217t, 218–219, 219t

sample size in, 225b

strategies for, 217t Nonviolent communication, 440–441

Normal curve, 287–288

Normal distribution, 287–288, 288f

NPV., See Negative predictive value

Null (statistical) hypothesis, 291–292, 298. See also Hypothesis

Null value, 370

948

Number needed to treat (NNT), 369

Numeric Rating Scale (NRS) score, 479

analgesic administration and, 477

assigning, consequences of, 472f, 472t, 475–478

avoiding high extreme rating of pain, 473

cut-off points, 479, 480

pain, underlying process of rating, 472, 472f

patients’ standards about pain scale, 475, 479

stages of, 478 Nuremberg Code, 233–234

Nurse Response Time to Patient Call Light Requests, 416, 419–420b

Nurse-led clinics (NLCs), impact on mortality and morbidity of patients with cardiovascular diseases, 496–507

implications for clinical practice and research, 505, 505b

limitations, 505

method of, 497–499

data abstraction, 498

eligibility criteria, 497

quality of included studies, 498

search strategy, 498

statistical analysis, 498–499

study identification, 498

949

results in, 499–501

meta-analysis, 501, 502f, 503f, 505b

methodological quality, 501, 503f, 504t

search results and study description, 499–501, 499f, 500t

Nurses, point of view of, in pain, 477

Nursing, databases for, 52t

Nursing care quality, measurement of, 412–414

Nursing case management, in homeless men released on parole, 435–454

Nursing Home Compare, 411b

Nursing practice,

applicability to, critiquing of, 328t, 357

implications for, 313, 313b

links with theory and research, 68, 68f Nursing research., See Research

Nursing science, qualitative research and, 103–104, 104f

Nursing theories, 70. See also Theory(ies)

grand, 71–72, 72b, 74t

middle range, 72, 73b, 74t

in practice and research, 71, 71b

from related disciplines, 70, 71t

situation-specific, 72–73, 74t Nursing-centered intervention measures, 413t

Nursing-sensitive quality indicators, 412–414

950

Objective, of research, 32, 32b

Observation, 248, 250–252

advantage, and disadvantages of, 252

anecdotes in, 250

concealment in, 250, 251b, 251f

debriefing in, 250–251

ethical issues in, 252

field notes in, 250

intervention in, 250, 251b, 251f

participant, 250

reactivity in, 251

scientific, 250

structured or unstructured, 250 Observed test score, 263–264, 263f

Odds ratio (OR), 369t, 376, 377t

One-group (pretest-posttest) design, 174f, 175

Online computer networks, recruitment from, 218, 220

Online databases., See Electronic databases

Open coding, 109–110

Open-ended questions, 253, 253b, 255b

Operational definition, 69b, 70t, 248

Opinion leaders, 397

Opinion leadership, 397

951

Opioid administration, timing of, 477

OR., See Odds ratio

Ordinal measurement, 283b, 284

Outcome, clinical questions and, 39b

Outcomes research, 194b

Pain, 468

assessment of, 480–481

gold standard for, 478

“bearable” vs. “unbearable, ” 473

level at rest and movement, 474

postoperative management,

NRS cut-off scores in, 480

principles in, 480

threshold, 474

treatment of, adequacy of, 468 Pain experience,

previous, 474, 478–479

unique, 472–473, 478 Pain rating, postoperative patient’s perspectives on, qualitative

study, 467–482

methods for, 469–471

data analysis, 470–471

952

data collection, 469–470, 470t

participants, 469

study design, 469

trustworthiness, 471

relevance to clinical practice, 480–481

results, 471–478, 471t, 472f, 472t

intrapersonal patient factors, 474–475

NRS score and, 475–478

score-related factors, 472–474 Paradigm, 90b

Parallel form reliability, 272, 272b, 275

Parameter,

populations and, 289

vs. statistics, 289 Parametric statistics, 294–295, 295b

Parents,

of adolescent cancer survivors,

active coping of, 488–489, 489t

avoidant coping of, 488, 489t, 490

emotion-focused coping of, 488, 489t, 490–491

life satisfaction of, 488, 489t, 490

post-traumatic growth of, 491

psychological distress of, 488, 489t, 490, 491, 492

953

on Satisfaction With Life Scale (SWLS), 487

spirituality, grief and mental health of, after infant’s/child’s death, 455–466

clinical relevance of, 464–465

conceptual framework in, 457–458

data analysis for, 459–460

dependent variables in, measures of, 458–459

discussion of, 462–465

future research in, 465

independent variables in, measures of, 459

limitations of, 464

methods in, 458

procedure for, 459

results for, 460, 460t, 461t, 462t Pareto principle, 423

Participant observation, 250

Path analysis, 189–190, 299

Patient Safety Systems, 418t

Patient-centered outcome measures, 413t

Pay for performance, 412b

Payment, quality strategy levers and, 410, 412b

Pearson correlation, reported statistical results of, 307t

Pearson correlation coefficient, 298

Pearson product moment correlation coefficient, 298

954

Pearson r, 298

Peer coaching, in homeless men released on parole, 435–454

Peer-reviewed journals, 55

Percentile, 289

Performance gap assessment (PGA), 398

Performance measurement, for quality improvement, 410, 410b

Personal factors, HAV/HAB vaccine series completion and, 438– 439, 443–444

Personal growth, in bereaved parents, 457, 461–462, 463

PGA (performance gap assessment), 398

Phenomena, in qualitative research, 125

Phenomenological method, 104–108, 107b

bracketing personal bias in, 106

data analysis in, 107

data gathering in, 107

describing the findings in, 107–108

identifying the phenomenon in, 105

research question in, 106

researcher’s perspective in, 106

sample selection in, 106

structuring the study in, 105–106 Phenomenology, 127, 138

Phenomenology research question, 30t

Phi coefficient, 298–299

Photovoice, 116

955

Physician Quality Reporting Initiative, 411b

Physiological data, 248, 256–257

PICO format, 49

focused clinical question using, 365, 365t PICO question, 388, 389t

Pie charts, 423, 424f

Pilot studies,

definition of, 225

in quantitative research, 152 Pilot testing, of instruments, 258

Plan-Do-Study-Act (PDSA) Improvement Cycle, 427, 429–430t

Point-biserial correlation, 298–299

Population, 213–214, 215b, 226b

accessible, 213

clinical questions and, 39b

parameter and, 289

research questions and, 30, 30b, 31t

sample size and, 225b

target, 213 Positive likelihood ratio, 374t, 375, 376t

Positive predictive value (PPV), 373, 374, 374t

Post-traumatic growth, in parents and siblings of adolescent cancer survivors, 483–495, 491b

implications for nursing, 492

methods in, 485–488, 486t

956

data analysis, 488

measures, 487–488

procedure, 486–487

sample, 485–486

results in, 488–490, 489t, 490t Post-traumatic stress disorder (PTSD), measurement of, 458–459

Power analysis, 169

sample size and, 225–226 PPV., See Positive predictive value

Practice implications, 313, 313b

critiquing of, 328t, 340, 356–357

in research articles, 18 Practice nursing theories, 72–73

Practice-theory-research links, 68, 68f

Preappraised literature, 52, 52b

Preappraised synopses, 52

Prediction, in nonexperimental designs, 189–190

Predictive validity, 266, 267b

Prefiltered evidence, 367b

Pregnant women, as subjects, in research, 243

Prescriptive nursing theories, 72–73

Pretesting, measurement effects and, 160–161

Pretest-posttest design, 174f, 175

Primary sources,

in literature review, 47, 48t

957

in literature search, 52–53, 53b Print indexes, 55

Prisoners, as subjects, in research, 243

Privacy, 236–237t, 238b, 239

Privacy Act (1974), 236–237t

Probability, 292, 292b

definition of, 292

inferential statistics and, 292 Probability sampling, 216, 221–224

inferential statistics and, 290

multistage (cluster), 217t, 223–224

random selection in, 216, 221

sample size in, 225b

simple random, 217t, 221–222

strategies for, 217t

stratified random, 217t, 222–223 Problem-focused triggers, 387

Professional knowledge, 430

Prognosis articles, 376–377, 377b, 377t

Prognosis category, in clinical question, 366

Prospective studies, 186–187

Psychological distress,

in cancer survivors, 491

measurement of, 487

958

for parents of cancer survivors, 488, 489t, 490, 491, 492

for siblings of cancer survivors, 489, 489t, 491 Psychological functioning, in parents and siblings of adolescent

cancer survivors, 483–495, 491b

implications for nursing, 492

methods in, 485–488, 486t

data analysis, 488

measures, 487–488

procedure, 486–487

sample, 485–486

results in, 488–490, 489t, 490t Psychometrics, 190–191, 192t

PsycINFO, 52t, 59–60

PTG Inventory (PTGI), for cancer survivors, 487

Public reporting, quality strategy levers and, 410, 411b

PubMed, 52t

Purpose,

in qualitative research, 125–126t, 139

of research, 32, 32b Purposive sampling, 217t, 219–220, 220b, 221b. See

also Nonprobability sampling

Qualitative meta-summary, 117

Qualitative meta-synthesis, 116–117

959

Qualitative research, 8–9, 8t, 88–101, 102–123, 106b

application of, 97, 98b, 99t, 125–127

auditability in, 119–120, 119t

components of, 90–96

context dependent, 89

credibility in, 119–120, 119t

critical appraisal of, 124–125, 125–126t, 127b

abstract in, 136–137

auditability in, 141

conclusions in, 141–144

data analysis in, 129–130, 140–141

data generation in, 140

ethical consideration in, 139

findings in, 141–144

implications in, 141–144

introduction in, 137–138

method in, 128–130

procedure in, 129

purpose in, 139

recommendations, 141–144

results in, 130–133, 131t

sample in, 139–140

960

trustworthiness in, 141

Critical Thinking Decision Path for, 91b, 91f, 105b, 105f

critiquing of, 120, 120–121b, 127–144

data analysis in, 95b

data collection in, 93–94, 95b

definition of, 89

emic view in, 110

ethical issues in, 118, 118t

etic view in, 110

in evidence-based practice, 125–127

findings in, 96, 96b

typology of, 97, 98t

fittingness in, 119–120, 119t

foundation of, 100

hypothesis/research question in, 16–17

inductive, 89

informed consent in, 118

interview questions in, 94–95

literature review in, 48–49, 90. See also Literature review

meta-synthesis in, 116–117

961

methodology for, 90–91

methods of, 104. See also specific methods

case study, 113–115, 115b

community-based participatory research, 115–116, 117b

ethnographic, 110–113, 113b

grounded theory, 108–110, 110b

mixed research, 120b

phenomenological, 104–108, 107b

selection of, 105b, 105f

naturalistic setting in, 118, 118t

nature of design in, 118–119, 118t

nursing science and, 103–104, 104f

phenomena in, 125

principles for evaluating, 125–127

process of, 90, 90b, 91b, 91f

recruitment for, 93–94, 94b

research design for, 17

research question in, 30t, 90–91, 94–95

researcher as instrument in, 118t, 119

researcher-participant interaction in, 118t

sample in, 92–93

962

setting for, 93–94

software for, 95–96

study design in, 92

themes in, 95, 124–125, 131t

theory application in, 76–77, 77b

trustworthiness of, 124–125, 141 Quality assurance (QA), 194b, 418t

Quality health care, 406–407, 407b

defined, 20 Quality improvement, 5–8, 406–434

challenge and leading, 427–430

continuous, 406–407, 407b

models for, 415, 416t, 417t

national goals and strategies for health care, 408, 408b, 409t

nurses’ role in health care, 407–408

perspectives, 415

principles of, 407

quality strategy levers, 410–415

benchmarking, 414–415

nursing care quality measurement, 412–414, 413t, 414b

steps and tools for, 415–427, 418t

analysis, 421–426

963

assessment, 421, 421b

develop a plan for, 426–427

lead team formation in, 416–420, 420b

testing and implementation, 427, 431f Quantitative methods,

methodological research, 190–191

mixed methods, 193–194

secondary analysis, 191–193 Quantitative research, 8–9, 9t, 149–164

accuracy in, 152

appraisal for evidence-based practice, 161–162, 162b

appraising, 317–358

bias in, 150

constancy in, 154

control in, 152–155, 155. See also Control

Critical Thinking Decision Path for, 91b, 91f

critique of, 321–357, 326f, 329t, 330t, 333f, 348t, 349t, 350t

external validity in, 159–160

hypothesis/research question in, 16–17

internal validity in, 156

intervention fidelity and, 152–155

964

key points in, 163

literature review in, 47–48, 47f, 50b. See also Literature review

manipulation of independent variable in, 154–155

purpose of, 150–151

randomization in, 155

research question,

conceptualization of, objectivity in, 151–152

feasibility of, 151t

research question in, 30t

stylistic considerations in, 320–321 Quasi-experimental designs, 167b, 173–176, 173b

Critical Thinking Decision Path for, 166b, 166f

in evidence-based practice, 176–177

appraisal for, 177–178, 177b

strengths and weaknesses of, 176, 176b

types of, 174–176, 174f

after-only nonequivalent control group design, 175

nonequivalent control group design, 175

one-group (pretest-posttest) design, 175

time series design, 175–176 Questionnaires, 253–256

965

advantages of, 255–256

bias, 255–256

online, 256

randomization and, 155

respondent burden and, 253, 254 Questions,

clinical., See Clinical questions

closed-ended, 253, 253b, 255b

interview, 94–95

in qualitative research, 94–95

Likert-type, 254, 255b, 255t

open-ended, 253, 253b, 255b

research., See Research questions Quota sampling, 217t, 218–219, 219t. See also Nonprobability

sampling

Random error, 249, 263–264

Random sampling., See also Sampling

multistage (cluster), 217t, 223–224

simple, 217t, 221–222

stratified, 217t, 222–223 Random selection,

in probability sampling, 216, 221

966

vs. random assignment, 221 Randomization,

in experimental designs, 167, 168b, 176b

of subjects, 155

vs. random selection, 221 Randomized controlled trial, 167, 170b. See also True experimental

design

Range, 289

Ranking,

interval measurement in, 283t

ordinal measurement in, 284

ratio measurement in, 285 Ratio measurement, 285

Reactive effects, external validity and, 160

Reactivity,

definition of, 160

967

in observation, 251 Reading skills, critical, 10, 10b, 11b

Realignment, vaccine completion and, 450

Recommendations,

critiquing of, 328t, 340, 356–357

in research articles, 18

in research findings, 310–311, 312, 313, 313b Recruitment,

convenience sampling and, 218

data saturation in, 94

from online computer networks, 218, 220

in qualitative research, 93–94, 94b Refereed journals, 55

References, in research articles, 18

Regression, multiple, 299

Regulation, quality strategy levers and, 410, 411b

Relationship and difference studies, 184–189, 188b189b. See also Nonexperimental designs

case control/retrospective/ex post facto studies, 187– 189

cohort/prospective/longitudinal/repeated measures studies, 186–187, 188b

correlational studies, 184–185, 185b

cross-sectional studies, 185–186

968

developmental studies, 185–189, 185b Relative risk (risk ratio), 369t

Relative risk reduction, 369t

Reliability, 264b, 265b, 266b, 270–275

appraisal for evidence-based practice of, 276–278

classic test theory and, 275

Critical Thinking Decision Path for, 269b

critiquing of, 328t, 356

criteria for, 276b

definition of, 263, 270

determining appropriate type of, 269f

equivalence and, 270

examples of reported, 271b

homogeneity and, 270, 272–274, 272b

internal consistency, 272–274, 272b

interrater, 270–271, 271b, 274–275, 275b

item to total correlations, 273, 273t

Kuder-Richardson (KR-20) coefficient and, 268–269, 270–271, 271b, 274, 274b

parallel (alternate) form, 272, 272b, 275

reported, 275

of research articles, 17–18

split-half, 271b, 274

969

stability and, 270b, 271–272

test, measures used to, 270b

test-retest, 271b, 272 Reliability coefficient interpretation, 270–271

Religion, as coping strategy, 456–457

use of, 461, 461t Repeated measures studies, 186–187

Representative sample, 216, 216b

Research, 5–22, 6. See also Research studies

conduct of, 384

deductive, 75

definition of, 6–8

ethnographic., See Ethnographic method

evaluation, 194b

inductive, 74, 89

qualitative research as, 89

links with theory and practice, 68, 68f

methodological, 190–191, 192t

nonexperimental designs, 180–198. See also Nonexperimental designs

outcomes, 194b

qualitative, 8–9, 8t, 88–101, 102–123, 106b. See also Qualitative research

970

quantitative, 8–9, 9t, 145–164. See also Quantitative research

quasi-experimental designs, 173, 167b, 173b. See also Quasi-experimental designs

study purpose, aims, or objectives of, 32, 32b

theoretical frameworks for, 74–75, 74b, 77. See also Theoretical frameworks

theory-generating, 74

theory-testing, 75, 77–78

translation into practice, 383–384

types of, 8–9 Research articles., See also Research studies

abstract as, 15–16, 16b

collection methods in, 18

communicating results in, 19, 19b

data analysis/results in, 18

definition of purpose of study in, 16

discussion in, 18

format and style of, 15–19, 320–321

hypothesis/research question in, 16–17

implications in, 18

integrative reviews of, 19

introduction in, 16

971

journal type and, 320–321

legal and ethical issues in, 233–234t, 233–234

literature review, 16, 16b

meta-analyses of, 19

meta-syntheses of, 19

procedures in, 18

recommendations in, 18

references in, 18

reliability of, 17–18

research design of, 17

sampling section in, 17, 212, 225b

sections of, 320–321

systematic reviews of, 19

theoretical framework in, 16, 16b

validity of, 17–18 Research designs,

critiquing of, 328t, 338, 355

experimental, 167. See also Experimental designs

hypothesis and, 37–38, 37b

literature review and, 48

in qualitative research, 17. See also Qualitative research

972

in quantitative research, 150f, 150. See also Quantitative research

quasi-experimental, 173b, 173. See also Quasi- experimental designs

of research articles, 17 Research findings, 305–316, 306b

clinical significance in, 311

criteria for, 314b

definition of, 306

discussion in, 310–313, 313b

in evidence-based practice,

applying, 380

appraisal for, 368–379

screening, 367, 367b

evidence-based practice, appraisal for, 313–315

generalizability in, definition of, 312

practice implications of, 313b

in qualitative research, 125–126t, 141–144

recommendations in, 310–311, 312, 313, 313b

results in, 306–310, 308b, 310b, 311b

assessing, Critical Thinking Decision Path, 307b, 307f

section, examples of, 309b

973

statistical, 307t

tables in, 309, 309t, 310, 310t

statistical significance in, 311

statistical tests in, 314 Research hypothesis, 36, 291. See also Hypothesis

Research methods, critiquing of, 328t, 356

Research questions, 23–44, 38b, 94–95

in case study method, 113–114

clinical experience and, 25t

comparative, 30t

conceptualization of, objectivity in, 151–152

correlational, 30t

critiquing of, 40–42, 41–42b, 328t, 338, 355

definition of, 24–27, 27b

development of, 24–28, 26f

elements of, 25t

in ethnographic method, 111

experimental, 30t

feasibility of, 151t

fully developed, 28–31

grand tour, 94–95

in grounded theory method, 109

974

hypothesis and, 16–17, 40. See also Hypothesis

literature review and, 27, 27b, 48

in phenomenological method, 106

phenomenology, 30t

population and, 30, 30b, 31t

in qualitative research, 90–91

refining, 24–28

significance of, 28, 28b

testability of, 31, 31b, 31t

variables and, 29–30, 31t Research recommendations, 313b

Research studies., See also research

critiquing, 10. See also Critiquing

risk-benefit ratio, 240, 242b, 242f

unethical, 233–234, 233t. See also Ethical issues Research subjects,

children as, 242–243

consent of., See Informed consent

elderly as, 243

fetuses as, 243

neonates as, 243

pregnant women as, 243

975

prisoners as, 243 Research vignette, journey from description to biobehavioral

intervention, 84–86

Respect for persons, 234–235, 235b, 236–237t

Respondent burden, 253, 254

Rest, pain level at, 474

Results,

communicating, in research articles, 19, 19b

discussion of, in qualitative research, 97–99, 98b, 98t

in research articles, 18

in research findings, 306–310, 308b, 310b, 311b

assessing, Critical Thinking Decision Path, 307b, 307f

section, examples of, 309b

statistical, 307t

tables in, 309, 309t, 310t Retrospective study, 187–189

Revascularization, in NLC group, 501, 502f

Review boards, 227f, 228–229, 240–241, 241b

Risk ratio (relative risk), 369t

Risk/benefit ratio, for research studies, 240

Critical Thinking Decision Path, 242b, 242f Root cause analyses (RCAs), 424

Run chart, 422, 422f, 423b

976

Samples,

convenience, 217

definition of, 215–216

elements of, 215–216

inclusion and exclusion criteria in, 92–93

in qualitative research, 92–93, 125–126t, 139–140

recruitment for, 93–94, 94b

representative, 216, 216b

size of, 224–226, 225b, 227f

statistic and, 289

types of, 216–224, 216b, 217t, 222b, 223b, 224b, 224f, 226b

vs. population, 289 Sampling, 212–231

bias in, 217t. See also Bias

in case study method, 114

concepts, 213–216

convenience, 217–218, 217t, 221b. See also Nonprobability sampling

Critical Thinking Decision Path, 224b, 224f

critiquing of, 227, 228b, 328t, 338, 355

data saturation in, 225

definition of, 213

977

in ethnographic method, 111

generalizability in, 153, 227

in grounded theory method, 109

homogeneous, 153–154

inclusion/exclusion criteria in, 214–215, 215f

in “methods” section, of research article, 212

mortality in, 227

multistage (cluster), 217t, 223–224

network, 220–221

nonprobability, 216, 217–221, 217t. See also Nonprobability sampling

overview of, 213

in phenomenological method, 106

populations in, 213–214, 215b, 226b. See also Population

power analysis in, 225–226

probability, 216, 217t, 221. See also Probability sampling

purpose of, 215–216

purposive, 217t, 219–220, 220b, 221b. See also Nonprobability sampling

quota, 217t, 218–219, 219t

recruitment in, convenience sampling and, 218

978

in research articles, 17

sample size in, 224–226, 225b, 227f

samples and, 215–216, 216b

snowballing in, 220 Sampling error, 292

Sampling frame, 221

Sampling units, in multistage (cluster) sampling, 223

San Antonio Contraceptive Study, 233–234t, 236–237t

Satisfaction With Life Scale (SWLS), for cancer survivors, 487

Scale, 254

Scientific observation, 250

Scientific (research) hypothesis, 291–292

Score-related factors, rating pain, 472–474, 472f, 472t

Search engines, 56–60, 56b, 57b, 58b, 60b

Search history, 58, 58b

Secondary analysis, 191–193, 257

Secondary databases, 56

Secondary sources, in literature review, 47, 48t

Selection, definition of, 160

Selection bias, 158

Selection effects, 160

Self-determination, 236–237t

Self-report, in data collection, 248, 252–253

Sensitivity, 373, 374, 374t

Siblings, of adolescent cancer survivors, 488, 491

active coping of, 489, 489t, 490–491

979

avoidant coping of, 489, 489t, 491

coping strategies of, 491

life satisfaction of, 489, 489t, 491

psychological distress of, 489, 489t, 491

on Students’ Life Satisfaction Scale (SLSS), 488 Sign test, 297

Signed rank test for related groups, 297

Simple random sampling, 217t, 221–222

Situational factors, HAV/HAB vaccine series completion and, 438– 439, 443

Situation-specific nursing theories, 72–73, 74t

Six Sigma, 417t

Snowballing, 220

Social desirability, self-report and, 252–253

Social factors, HAV/HAB vaccine series completion and, 444

Social networks, 220

Social support, vaccine completion and, 449

Sociodemographic characteristics, 346

Sociodemographic factors, HAV/HAB vaccine series completion and, 438–439, 443

Software, for qualitative research, 95–96

Solomon four-group design, 170–172, 171f

Spearman rho, 298–299

Special cause variation, 421

Specificity, 373, 374, 374t

Spiritual coping, after infant’s/child’s death, 463

980

measurement of, 459 Spiritual Coping Strategies Scale (SCS), 459

Spirituality,

as coping strategy, 456–457

use of, 461, 461t

of parent, after infant’s/child’s death, 455–466 Split-half reliability, 271b, 274

SQUIRE Guidelines, 427, 429–430t

Stability, reliability and, 271–272

Stakeholder, 388

Standard deviation (SD), 288f, 289

reported statistical results of, 307t Statistical decision making, outcome of, 293f

Statistical hypothesis, 36, 36t

Statistical (null) hypothesis, 291–292, 298

Statistical results, reported, examples of, 307t

Statistical significance, 294, 294b, 295t, 311

Statistical tests, 314

of differences, 295t, 296–297

of relationships, 297–299, 298b Statistics, 295b, 301b

advanced, 299

descriptive, 281–289, 283b, 283f, 285b, 289b

inferential, 281–299, 290f, 291f

981

multivariate, 299

nonparametric, 294–297, 295b

parametric, 294–297

vs. parameters, 289 Stoicism, 479

Stratified random sampling, 217t, 222–223

Structural equation modeling (SEM), 189–190, 299

Structure-Process-Outcome Framework, 415, 418t

Students’ Life Satisfaction Scale (SLSS), for cancer survivors, 487

Studies,

limitations of, 308

tables and figures in, 309, 309t, 310t Study design, of qualitative research, 92

Subject mortality, internal validity and, 227

Summary databases, 56

Survey studies, 182–183, 183b

Systematic (constant) error, 249, 264

Systematic reviews, 19, 201. See also Meta-analysis

bias in, 201

clinical guidelines and, 199–211

components of, 202

critical appraisal in, 206

Critical Thinking Decision Path for, 201b, 201f

definition of, 200

982

in expert-based guidelines, 209–210, 209b

integrative reviews and, 200–201

purpose of, 202

reporting guidelines of, 205–206

tools for, 206

types of, 200–201, 200b System-centered measures, 413t

t test/t statistic, 296

reported statistical results of, 307t Tables, in results, of research findings, 309, 309t, 310, 310t

Target population, 213

Task force approach, 388

Technical assistance, quality strategy levers and, 410

Testability,

of hypothesis, 34

of research questions, 31, 31b, 31t Testing,

in experimental designs, 170

internal validity and, 157 Test-retest reliability, 271b, 272

Test(s),

of associations, 296t

983

of differences, 295t, 296–297

of relationships, 297–299, 298b, 299b Themes,

for improvement, 426–427

in qualitative research, 95, 124–125, 131t Theoretical frameworks, 66–82

conceptual, 69b

critiquing, 78–79, 78b

definition of, 69b

literature review and, 47

in research articles, 16, 16b Theoretical sampling, 109

Theory-generating research, 74

Theory(ies), 24

definition of, 68, 69b

as framework for nursing research, 74–75, 74b, 77

generated from nursing research, 74

links with practice and research, 68, 68f

nursing, 70–73

grand, 71–72, 72b, 74t

middle range, 72, 73b, 74t

in practice and research, 71, 71b

situation-specific, 72–73, 74t

984

overview of, 68–69

in qualitative research, 76–77, 77b

from related disciplines, 70, 71t

tested by nursing research, 75

untested, 25t

use in nursing research, 70–75, 71t

in theory generation, 74

in theory-testing, 75, 77–78 Theory-testing nursing research, 75, 75b, 77–78

Therapy articles, 166

Therapy category,

in article’s findings, 368–371, 368t, 369t, 371–373f

in clinical question, 365 Threshold, pain, 474

Time series design, 174f, 175–176

Total Quality Management/Continuous Quality Improvement (TQM/CQI), 415, 417t, 418t. See also Quality improvement

Tough, intrapersonal patient factors, in pain, 474

Training, treatment fidelity and, 325

Translation of research into practice (TRIP), 383–384

website of, 56t Translation science, 385

Treatment effect, 169, 293

Treatment fidelity, training and, 325

Tree diagram, 424–425

985

True experimental design, 173

Trustworthiness, of qualitative research, 124–125, 125–126t, 141

Tuskegee Syphilis Study, 233–234t, 236–237t

Twinrix, 437

accelerated dose series for, 437

administration of, 442 Type I and type II error, 292–294, 293f

Typology, of qualitative research, 97, 98t

UCLA Schizophrenia Medication Study, 233–234t

“Unbearable” pain, “bearable” vs., 473

Untested theory, interest in, 25t

US Department of Health and Human Services (USDHHS), 235

Validity, 152b, 155–161, 155b, 264–269

appraisal for evidence-based practice of, 276–278

assessment of,

contrasted-groups approach in, 268, 268b

factor analytical approach in, 268–269

hypothesis testing in, 267b

concurrent, 266, 267b

construct, 266–269, 267b

content, 265–266

986

convergent, 267b, 268

criterion-related, 266, 267b

Critical Thinking Decision Path for, 269b

critiquing of, 328t, 356

criteria for, 276b

definition of, 264–265

determining appropriate type of, 269f

divergent (discriminant), 268

external, 159–160

face, 266

internal, 156

predictive, 266, 267b

reported, 275

of research articles, 17–18

threats to, 156b, 161b

Critical Thinking Decision Path for, 159b, 159f Value-based health care purchasing, 412b

Variability, measures, 288–289, 289b

Variables,

antecedent, 175

categorical, 284

continuous, 284b

987

definition of, 29

demographic, 27

dependent, 29, 166

control and, 150

in experimental and/or quasi-experimental designs, 166

dichotomous, 284

discrete, 368, 368t

extraneous, 153

hypothesis and, 33–34

independent, 29, 166. See also Independent variables

of interest, measurement of, 248–249

intervening, 153, 176

mediating, 153

nominal-level, 284

research questions and, 29–30, 31t Veterans Affairs Nursing Outcomes Database, 414

Virginia Henderson International Nursing Library, website of, 56t

Web browser, 56

Wilcoxon matched pairs test, 297

Willowbrook Hospital Study, 233–234t, 236–237t

Workforce development, quality strategy levers and, 412

988

World Health Organization, on CVD, 497

989

Special features

These Special Features can be found on the pages listed.

Appraisal for evidence-based practice

Pages: 40, 100, 120, 161, 177, 194, 209, 227, 244, 258, 276, 300, 313

Critical thinking challenges

Pages: 21, 43, 64, 79, 100, 122, 163, 178, 196, 210, 230, 245, 261, 278, 304, 315, 357, 381, 402, 432

Critical thinking decision path

Pages: 38, 54, 91, 105, 159, 166, 182, 201, 224, 242, 249, 269, 283, 290, 291, 307

Critique of a research study

Pages: 127, 321, 340

Critical appraisal criteria

Pages: 41, 63, 78, 120, 127, 162, 177, 195, 208, 209

Research vignette

Pages: 2, 84, 146, 360

990

Table of Contents

Title page 2 Table of Contents 4 Copyright 9 About the authors 12 Contributors 15 Reviewers 18 To the faculty 19 To the student 27 Acknowledgments 29 I. Overview of Research and Evidence-Based Practice 31

Introduction 33 References 36

1. Integrating research, evidence-based practice, and quality improvement processes 39

References 66 2. Research questions, hypotheses, and clinical questions 68

References 100 3. Gathering and appraising the literature 104

References 138 4. Theoretical frameworks for research 140

References 164 II. Processes and Evidence Related to Qualitative Research 169

Introduction 170 References 175

5. Introduction to qualitative research 176 References 197

6. Qualitative approaches to research 198 References 232

7. Appraising qualitative research 235

991

Critique of a qualitative research study 239 References 264 References 268

III. Processes and Evidence Related to Quantitative Research 270

Introduction 272 References 275

8. Introduction to quantitative research 277 References 302

9. Experimental and quasi-experimental designs 304 References 329

10. Nonexperimental designs 331 References 359

11. Systematic reviews and clinical practice guidelines 362 References 383

12. Sampling 386 References 417

13. Legal and ethical issues 419 References 441

14. Data collection methods 443 References 470

15. Reliability and validity 471 References 500

16. Data analysis: Descriptive and inferential statistics 503 References 539

17. Understanding research findings 541 References 559

18. Appraising quantitative research 561 Critique of a quantitative research study 565 Critique of a quantitative research study 590 References 613 References 619 References 622

IV. Application of Research: Evidence-Based Practice 623

992

Introduction 624 References 629

19. Strategies and tools for developing an evidence-based practice 632 References 659

20. Developing an evidence-based practice 661 References 693

21. Quality improvement 700 References 747

Example of a randomized clinical trial (Nyamathi et al., 2015) Nursing case management peer coaching and hepatitis A and B vaccine completion among homeless men recently released on parole

751

Example of a longitudinal/Cohort study (Hawthorne et al., 2016) Parent spirituality grief and mental health at 1 and 3 months after their infant schild s death in an intensive care unit

783

Example of a qualitative study (van dijk et al., 2015) Postoperative patients perspectives on rating pain A qualitative study

802

Example of a correlational study (Turner et al., 2016) Psychological functioning post traumatic growth and coping in parents and siblings of adolescent cancer survivors

831

Example of a systematic review/Meta analysis (Al- mallah et al., 2015) The impact of nurse led clinics on the mortality and morbidity of patients with cardiovascular diseases

852

Glossary 869 Index 903 Special features 990

993

Title page
Table of Contents
Copyright
About the authors
Contributors
Reviewers
To the faculty
To the student
Acknowledgments
I. Overview of Research and Evidence-Based Practice
- Introduction
  - References
- 1. Integrating research, evidence-based practice, and quality improvement processes
  - References
- 2. Research questions, hypotheses, and clinical questions
  - References
- 3. Gathering and appraising the literature
  - References
- 4. Theoretical frameworks for research
  - References
II. Processes and Evidence Related to Qualitative Research
- Introduction
  - References
- 5. Introduction to qualitative research
  - References
- 6. Qualitative approaches to research
  - References
- 7. Appraising qualitative research
  - Critique of a qualitative research study
  - References
  - References
III. Processes and Evidence Related to Quantitative Research
- Introduction
  - References
- 8. Introduction to quantitative research
  - References
- 9. Experimental and quasi-experimental designs
  - References
- 10. Nonexperimental designs
  - References
- 11. Systematic reviews and clinical practice guidelines
  - References
- 12. Sampling
  - References
- 13. Legal and ethical issues
  - References
- 14. Data collection methods
  - References
- 15. Reliability and validity
  - References
- 16. Data analysis: Descriptive and inferential statistics
  - References
- 17. Understanding research findings
  - References
- 18. Appraising quantitative research
  - Critique of a quantitative research study
  - Critique of a quantitative research study
  - References
  - References
  - References
IV. Application of Research: Evidence-Based Practice
- Introduction
  - References
- 19. Strategies and tools for developing an evidence-based practice
  - References
- 20. Developing an evidence-based practice
  - References
- 21. Quality improvement
  - References
Example of a randomized clinical trial (Nyamathi et al., 2015) Nursing case management peer coaching and hepatitis A and B vaccine completion among homeless men recently released on parole
Example of a longitudinal/Cohort study (Hawthorne et al., 2016) Parent spirituality grief and mental health at 1 and 3 months after their infant schild s death in an intensive care unit
Example of a qualitative study (van dijk et al., 2015) Postoperative patients perspectives on rating pain A qualitative study
Example of a correlational study (Turner et al., 2016) Psychological functioning post traumatic growth and coping in parents and siblings of adolescent cancer survivors
Example of a systematic review/Meta analysis (Al-mallah et al., 2015) The impact of nurse led clinics on the mortality and morbidity of patients with cardiovascular diseases
Glossary
Index
Special features

Models of Health Throughout history

April 10, 2022/in Nursing /by admin

Models of Health Throughout history, society has entertained a variety of concepts of health (David, 2000). Smith (1983) describes four distinct models of health in her classic work: Clinical Model In the clinical model, health is defined by the absence and illness by the conspicuous presence of signs and symptoms of disease. People who use this model may not seek preventive health services or they may wait until they are very ill to seek care. The clinical model is the conventional model of the discipline of medicine. Role Performance Model The role performance model of health defines health in terms of individuals’ ability to perform social roles. Role performance includes work, family, and social roles, with performance based on societal expectations. Illness would be the failure to perform roles at the level of others in society. This model is the basis for occupational health evaluations, school physical examinations, and physician-excused absences. The idea of the “sick role,” which excuses people from performing their social functions, is a vital component of the role performance model. It is argued that the sick role is still relevant in health care today (Davis et al., 2011; Shilling, 2002). Adaptive Model In the adaptive model of health, people’s ability to adjust positively to social, mental, and physiological change is the measure of their health. Illness occurs when the person fails to adapt or becomes maladaptive to these changes. As the concept of adaptation has entered other aspects of American culture, this model of health has become more accepted. For example, spirituality can be useful in adapting to a decreased level of functioning in older adults (Haley et al., 2001).

Eudaimonistic Model In the eudaimonistic model exuberant well-being indicates optimal health. This model emphasizes the interactions between physical, social, psychological, and spiritual aspects of life and the environment that contribute to goal attainment and create meaning. Illness is reflected by a denervation or languishing, a lack of involvement with life. Although these ideas may appear to be new when compared with the clinical model of health, aspects of the eudaimonistic model predate the clinical model of health. This model is also more congruent with integrative modes of therapy (National Institutes of Health, National Center for Complementary and Alternative Medicine [NIH/NCCAM], 2011), which are used increasingly by people of all ages in the United States and the world. In this eudaimonistic model, a person dying of cancer may still be healthy if that person is finding meaning in life at this stage of development.

Obesity In Adults

April 10, 2022/in Nursing /by admin

Task 1: Social Media Campaign

Introduction:

Part of cultural competency is advocating for sensitive patient populations with regard to health issues or needed improvements in the community. A big part of advocacy is uncovering effective stories discovered in your community assessment. Equally important is understanding how to broadcast your discoveries to the larger community. In our society today, social media is a powerful leveraging tool to get a story out, build support, and demonstrate advocacy.

Requirements:

Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. Use the Turnitin Originality Report available in Taskstream as a guide for this measure of originality.

You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.

Part 1: Field Experience Project Submission
Note: Your timelog must be submitted with your assessment. If both are not submitted at the same time, your task may be returned to you without evaluation.
A. Submit a completed “Community Health Field Experience Timelog” by doing the following:

1. Include the date of each activity.

2. Include a brief description of each activity.

3. Include the name of the contact person, a working phone number, and a full physical address.
Note: If an email address is available for the contact person, you may choose to include it.
4. Include the number of hours spent on each activity (not including preparation time).

5. Describe how each activity relates to your selected Field Experience topic.

6. Record a total of 90 hours that meet each of the following requirements:

● 65 student planned activity hours based on the attached “Field Experience Activities List”

● a maximum of five individual interview hours (i.e., no more than five interviews, no more than one hour per interview)

● no prep time hours (i.e., prep time is not to be included in reported hours)

Note: If your timelog is returned from evaluation, you are required to do an addendum. Please use the link below to access the DocuSign addendum document. Both the original timelog and the addendum timelog must be submitted with the task.

Note: Random audits and verification of time log activities do occur. Violation of the WGU Code of Student Conduct or the Academic Authenticity Policy could result in disciplinary action.
Part 2: Social Media Campaign

Note: The “CDCynergy” web link provided in the web links section below may be useful in completing your social media campaign. The use of this web link is optional, i.e., not required.
B. Write your community health nursing diagnosis statement.

1. Explain how the health concern from your community health nursing diagnostic statement is linked to a health inequity or health disparity within the target population.

a. Discuss the primary community resources and primary prevention resources currently in place to address the health concern.

b. Discuss the underlying causes of the health concern.
2. Discuss the evidence-based practice associated with the Field Experience topic.

a. Identify data about the selected Field Experience topic from the local (e.g., county), state- Florida, and/or national level.
C. Develop a community health nursing social media campaign strategy that will convey your health message and address the Field Experience topic by doing the following:

1. Describe your social media campaign objective.

2. Recommend two population-focused social marketing interventions and justify how each would improve the health message related to your selected Field Experience topic.

3. Describe a social media platform you would use that is appropriate for communicating with the target population-Adults

a. Discuss the benefits of the selected social media platform in supporting preventative healthcare.
4. Discuss how the target population will benefit from your health message.
D. Describe best practices for implementing social media tools for health marketing.
E. Create a social media campaign implementation plan by doing the following:

1. Describe stakeholder roles and responsibilities in implementing the plan.

2. Discuss potential public and private partnerships that could be formed to aid in the implementation of your campaign.

3. Create a specific timeline for implementing your campaign.

4. Explain how you will evaluate the effectiveness of the campaign.

5. Discuss the costs of implementing your campaign.
F. Reflect on how social media marketing supports the community health nurse’s efforts to promote healthier populations.

1. Reflect on how your social media campaign could apply to your future nursing practice.
G. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized.
H. Demonstrate professional communication in the content and presentation of your submission.

Formulate a PICOT statement using the PICOT format provided in the assigned reading

April 10, 2022/in Nursing /by admin

A PICOT starts with a designated patient population in a particular clinical area and identifies clinical problems or issues that arise from clinical care. The intervention should be an independent, specified nursing change intervention. The intervention cannot require a provider prescription. Include a comparison to a patient population not currently receiving the intervention, and specify the timeframe needed to implement the change process.

Formulate a PICOT statement using the PICOT format provided in the assigned readings. The PICOT statement will provide a framework for your capstone project.

In a paper of 500-750 words, clearly identify the clinical problem and how it can result in a positive patient outcome.

Make sure to address the following on the PICOT statement:

Evidence-Based Solution

Nursing Intervention

Patient Care

Health Care Agency

Nursing Practice

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center

Personal Philosophy of Nursing Paper:

April 10, 2022/in Nursing /by admin

Use the questions in the table in chapter 3 on page 101 of your textbook as a guide as you write your personal philosophy of nursing. The paper should be three typewritten double spaced pages following APA style guidelines. The paper should address the following:

Introduction that includes who you are and where you practice nursing
Definition of Nursing
Assumptions or underlying beliefs
Definitions and examples of the major domains (person, health, and environment) of nursing
Summary that includes:
1. How are the domains connected?
2. What is your vision of nursing for the future?
3. What are the challenges that you will face as a nurse?
4. What are your goals for professional development?

Grading criteria for the Personal Philosophy of Nursing Paper:

Introduction 10%

Definition of Nursing 20%

Assumptions and beliefs 20%

Definitions and examples of domains of nursing 30%

Summary 20%

Total 100%

Your paper must be written in APA style

The Evidence-Based Practice Movement

April 10, 2022/in Nursing /by admin

The Cochrane Collaboration was an early contributor to the EBP movement. The collaboration was founded in the United Kingdom based on the work of British epidemiologist Archie Cochrane. Cochrane published an influential book in the 1970s that drew attention to the dearth of solid evidence about the effects of health care. He called for efforts to make research summaries of clinical trials available to health care providers. This eventually led to the development of the Cochrane Center in Oxford in 1993, and an international partnership called the Cochrane Collaboration, with centers established in locations throughout the world. Its aim is to help providers make good decisions about health care by preparing and disseminating systematic reviews of the effects of health care interventions.

At about the same time, a group from McMaster Medical School in Canada (including Dr. David Sackett) developed a clinical learning strategy they called evidence-based medicine. The evidence-based medicine movement has shifted to a broader conception of using best evidence by all health care practitioners (not just physicians) in a multidisciplinary team. EBP is considered a major shift for health care education and practice. In the EBP environment, a skillful clinician can no longer rely on a repository of memorized information but rather must be adept in accessing, evaluating, and using new evidence.

The EBP movement has advocates and critics. Supporters argue that EBP is a rational approach to providing the best possible care with the most cost-effective use of resources. Advocates also note that EBP provides a framework for self-directed lifelong learning that is essential in an era of rapid clinical advances and the information explosion. Critics worry that the advantages of EBP are exaggerated and that individual clinical judgments and patient inputs are being devalued. They are also concerned that insufficient attention is being paid to the role of qualitative research. Although there is a need for close scrutiny of how the EBP journey unfolds, an EBP path is the one that health care professions will almost surely follow in the years ahead.

TIP: A debate has emerged concerning whether the term “evidence-based practice” should be replaced with evidence-informed practice (EIP). Those who advocate for a different term have argued that the word “based” suggests a stance in which patient values and preferences are not sufficiently considered in EBP clinical decisions (e.g., Glasziou, 2005). Yet, as noted by Melnyk (2014), all current models of EBP incorporate clinicians’ expertise and patients’ preferences. She argued that “changing terms now … will only create confusion at a critical time where progress is being made in accelerating EBP” (p. 348). We concur and we use EBP throughout this book.

Knowledge Translation

Research utilization and EBP involve activities that can be undertaken at the level of individual nurses or at a higher organizational level (e.g., by nurse administrators), as we describe later in this chapter. In the early part of this century, a related movement emerged that mainly concerns system-level efforts to bridge the gap between knowledge generation and use. Knowledge translation (KT) is a term that is often associated with efforts to enhance systematic change in clinical practice.

It appears that the term was coined by the Canadian Institutes of Health Research (CIHR) in 2000. CIHR defined KT as “the exchange, synthesis, and ethically-sound application of knowledge—within a complex system of interactions among researchers and users—to accelerate the capture of the benefits of research for Canadians through improved health, more effective services and products, and a strengthened health care system” (CIHR, 2004, p. 4).

Several other definitions of KT have been proposed. For example, the World Health Organization (WHO) (2005) adapted the CIHR’s definition and defined KT as “the synthesis, exchange and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people’s health.” Institutional projects aimed at KT often use methods and models that are similar to institutional EBP projects.

TIP: Translation science (or implementation science) has emerged as a discipline devoted to developing methods to promote knowledge translation. In nursing, the need for translational research was an important impetus for the development of the Doctor of Nursing Practice degree. Several journals have emerged that are devoted to this field (e.g., the journal Implementation Science).

EVIDENCE-BASED PRACTICE IN NURSING

Before describing procedures relating to EBP in nursing, we briefly discuss some important issues, including the nature of “evidence” and challenges to pursuing EBP, and resources available to address some of those challenges.

Types of Evidence and Evidence Hierarchies

There is no consensus about the definition of evidence nor about what constitutes usable evidence for EBP, but most commentators agree that findings from rigorous research are paramount. Debate continues, however, about what constitutes rigorous research and what qualifies as best evidence.

At the outset of the EBP movement, there was a strong bias toward reliance on information from studies called randomized controlled trials (RCTs). This bias stemmed from the fact that the Cochrane Collaboration initially focused on the effectiveness of therapies rather on other types of health care questions. RCTs are, in fact, very well suited for drawing conclusions about the effects of health care interventions ( Chapter 9 ). The bias in ranking sources of evidence in terms of questions about effective treatments led to some resistance to EBP by nurses who felt that evidence from qualitative and non-RCT studies would be ignored.

Positions about the contribution of various types of evidence are less rigid than previously. Nevertheless, many published evidence hierarchies rank evidence sources according to the strength of the evidence they provide, and in most cases, RCTs are near the top of these hierarchies. We offer a modified evidence hierarchy that looks similar to others, but ours illustrates that the ranking of evidence-producing strategies depends on the type of question being asked.

Figure 2.1 shows that systematic reviews are at the pinnacle of the hierarchy (Level I), regardless of the type of question, because the strongest evidence comes from careful syntheses of multiple studies. The next highest level (Level II) depends on the nature of inquiry. For Therapy questions regarding the efficacy of an intervention (What works best for improving health outcomes?), individual RCTs constitute Level II evidence (systematic reviews of multiple RCTs are Level I). Going down the “rungs” of the evidence hierarchy for Therapy questions results in less reliable evidence—for example, Level III evidence comes from a type of study called quasi-experimental. In-depth qualitative studies are near the bottom, in terms of evidence regarding intervention effectiveness. (Terms in Figure 2.1 will be discussed in later chapters.)

Evidence hierarchy: levels of evidence.

For a Prognosis question, by contrast, Level II evidence comes from a single prospective cohort study, and Level III is from a type of study called case control (Level I evidence is from a systematic review of cohort studies). Thus, contrary to what is often implied in discussions of evidence hierarchies, there really are multiple hierarchies. If one is interested in best evidence for questions about Meaning, an RCT would be a poor source of evidence, for example. We have tried to portray the notion of multiple hierarchies in Figure 2.1 , with information on the right indicating the type of individual study that would offer the best evidence (Level II) for different questions. In all cases, appropriate systematic reviews are at the pinnacle. Information about different hierarchies for different types of cause-probing questions is addressed in Chapter 9 .

Of course, within any level in an evidence hierarchy, evidence quality can vary considerably. For example, an individual RCT could be well designed, yielding strong Level II evidence for Therapy questions, or it could be so flawed that the evidence would be weak.

Thus, in nursing, best evidence refers to research findings that are methodologically appropriate, rigorous, and clinically relevant for answering persistent questions—questions not only about the efficacy, safety, and cost-effectiveness of nursing interventions but also about the reliability of nursing assessment tests, the causes and consequences of health problems, and the meaning and nature of patients’ experiences. Confidence in the evidence is enhanced when the research methods are compelling, when there have been multiple confirmatory studies, and when the evidence has been carefully evaluated and synthesized.

Of course, there continue to be clinical practice questions for which there is relatively little research evidence. In such situations, nursing practice must rely on other sources—for example, pathophysiologic data, chart review, quality improvement data, and clinical expertise. As Sackett and colleagues (2000) have noted, one benefit of the EBP movement is that a new research agenda can emerge when clinical questions arise for which there is no satisfactory evidence.

Evidence-Based Practice Challenges

Nurses have completed many studies about the use of research in practice, including research on barriers to EBP. Studies on EBP barriers, conducted in several countries, have yielded similar results about constraints on clinical nurses. Most barriers fall into one of three categories: (1) quality and nature of the research, (2) characteristics of nurses, and (3) organizational factors.

With regard to the research, one problem is the limited availability of high-quality research evidence for some practice areas. There remains an ongoing need for research that directly addresses pressing clinical problems, for replication of studies in a range of settings, and for greater collaboration between researchers and clinicians. Another issue is that nurse researchers need to improve their ability to communicate evidence, and the clinical implications of evidence, to practicing nurses.

Nurses’ attitudes and education are also potential barriers to EBP. Studies have found that some nurses do not value or know much about research, and others simply resist change. Fortunately, many nurses do value research and want to be involved in research-related activities. Nevertheless, many nurses do not know how to access research evidence and do not possess the skills to critically evaluate research findings—and even those who do may not know how to effectively incorporate research evidence into clinical decision making. Among nurses in non-English-speaking countries, another impediment is that most research evidence is reported in English.

Finally, many of the challenges to using research in practice are organizational. “Unit culture” can undermine research use, and administrative and other organizational barriers also play a major role. Although many organizations support the idea of EBP in theory, they do not always provide the necessary supports in terms of staff release time and availability of resources. Nurses’ time constraints are a crucial deterrent to the use of evidence at the bedside. Strong leadership in health care organizations is essential to making evidence-based practice happen.

RESOURCES FOR EVIDENCE-BASED PRACTICE IN NURSING

The translation of research evidence into nursing practice is an ongoing challenge, but resources to support EBP are increasingly available. We urge you to explore other ideas with your health information librarian because the list of resources is growing as we write.

Preappraised Evidence

Research evidence comes in various forms, the most basic of which is in individual studies. Primary studies published in professional journals are not preappraised for quality or use in practice. Chapter 5 discusses how to access primary studies for a literature review.

Preprocessed (preappraised) evidence is evidence that has been selected from primary studies and evaluated for use by clinicians. DiCenso and colleagues (2005) have described a hierarchy of preprocessed evidence. On the first rung above primary studies are synopses of single studies, followed by systematic reviews, and then synopses of systematic reviews. Clinical practice guidelines are at the top of the hierarchy. At each successive step in the hierarchy, the ease in applying the evidence to clinical practice increases. We describe several types of preappraised evidence sources in this section.

Soap Note 1 Acute Conditions (15 Points)

April 10, 2022/in Nursing /by admin

Soap Note 1 Acute Conditions (15 Points)

Pick any Acute Disease from Weeks 1-5 (see syllabus)

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.

Late Assignment Policy

Assignments turned in late will have 1 point taken off for every day assignment is late, after 7 days assignment will get grade of 0. No exceptions

Follow the MRU Soap Note Rubric as a guide:

Grading Rubric

Student______________________________________

This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

1) Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

2) Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts)

b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.

3) Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).

b) Pertinent positives and negatives must be documented for each relevant system.

c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

4) Assessment (___10pts.): Diagnoses should be clearly listed and worded appropriately.

5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.

6) Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

7) Clarity of the Write-up(___5pts.): Is it literate, organized and complete?

Comments:

Total Score: ____________ Instructor: __________________________________

1 sample SAMPLE Block format Soap Note Template.docx

SOAP NOTE SAMPLE FORMAT FOR MRC

Name: LP

Date:

Time: 1315

Age: 30

Sex: F

SUBJECTIVE

CC:

“I am having vaginal itching and pain in my lower abdomen.”

HPI:

Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx includes the presence of DM and HTN.

Current Medications:

Protonix 40mg PO Daily for GERD

MTV OTC PO Daily

Advil 200mg OTC PO PRN for pain

PMHx:

Allergies:

NKA & NKDA

Medication Intolerances:

Denies

Chronic Illnesses/Major traumas

GERD

Hospitalizations/Surgeries

Denies

Family History

Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known medical issues; No children.

Social History

Lives alone. Currently in a stable sexual relationship with one man. Works for DEFACS. Reports occasional alcohol use, but denies tobacco or illicit drug use.

ROS

General

Denies weight change, fatigue, fever, night sweats

Cardiovascular

Denies chest pain and edema. Reports rare palpitations that are relieved by drinking water

Skin

Denies any wounds, rashes, bruising, bleeding or skin discolorations, any changes in lesions

Respiratory

Denies cough. Reports dyspnea that accompanies the rare palpitations and is also relieved by drinking water

Eyes

Denies corrective lenses, blurring, visual changes of any kind

Gastrointestinal

Abdominal pain (see HPI) and Hx of GERD. Denies N/V/D, constipation, appetite changes

Ears

Denies Ear pain, hearing loss, ringing in ears

Genitourinary/Gynecological

Reports burning with urination, but denies frequency or urgency. Contraceptive and STD prevention includes condoms with every coital event. Current stable sexual relationship with one man. Denies known historic or recent STD exposure. Last PAP was 7/2016 and normal. Regular monthly menstrual cycle lasting 3-4 days.

Nose/Mouth/Throat

Denies sinus problems, dysphagia, nose bleeds or discharge

Musculoskeletal

Denies back pain, joint swelling, stiffness or pain

Breast

Denies SBE

Neurological

Denies syncope, seizures, paralysis, weakness

Heme/Lymph/Endo

Denies bruising, night sweats, swollen glands

Psychiatric

Denies depression, anxiety, sleeping difficulties

OBJECTIVE

Weight 140lb

Temp -97.7

BP 123/82

Height 5’4”

Pulse 74

Respiration 18

General Appearance

Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.

Skin

Skin is normal color for ethnicity, warm, dry, clean and intact. No rashes or lesions noted.

HEENT

Head is norm cephalic, hair evenly distributed. Neck: Supple. Full ROM. Teeth are in good repair.

Cardiovascular

S1, S2 with regular rate and rhythm. No extra heart sounds.

Respiratory

Symmetric chest walls. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

Abdomen flat; BS active in all 4 quadrants. Abdomen soft, suprapubic tender. No hepatosplenomegaly.

Genitourinary

Suprapubic tenderness noted. Skin color normal for ethnicity. Irritation noted at labia majora, minora, and perineum. No ulcerated lesions noted. Lymph nodes not palpable. Vagina pink and moist without lesions. Discharge minimal, thick, dark red, no odor. Cervix pink without lesions. No CMT. Uterus normal size, shape, and consistency.

Musculoskeletal

Full ROM seen in all 4 extremities as patient moved about the exam room.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Psychiatric

Alert and oriented. Dressed in clean clothes. Maintains eye contact. Answers questions appropriately.

Lab Tests

Urinalysis – blood noted (pt. on menstrual period), but results negative for infection

Urine culture testing unavailable

Wet prep – inconclusive

STD testing pending for gonorrhea, chlamydia, syphilis, HIV, HSV 1 & 2, Hep B & C

Special Tests- No ordered at this time.

Diagnosis

Differential Diagnoses

1-Bacterial Vaginosis (N76.0)
2- Malignant neoplasm of female genital organ, unspecified. (C57.9)
3-Gonococcal infection, unspecified. (A54.9)

Diagnosis

o Urinary tract infection, site not specified. (N39.0) Candidiasis of vulva and vagina. (B37.3) secondary to presenting symptoms (Colgan & Williams, 2011) & (Hainer & Gibson, 2011).

Plan/Therapeutics

Plan:
- Medication –

§ Terconazole cream 1 vaginal application QHS for 7 days for Vulvovaginal Candidiasis;

§ Sulfamethoxazole/TMP DS 1 tablet PO twice daily for 3 days for UTI (Woo & Wynne, 2012)

Education –

§ Medications prescribed.

§ UTI and Candidiasis symptoms, causes, risks, treatment, prevention. Reasons to seek emergent care, including N/V, fever, or back pain.

§ STD risks and preventions.

§ Ulcer prevention, including taking Protonix as prescribed, not exceeding the recommended dose limit of NSAIDs, and not taking NSAIDs on an empty stomach.

Follow-up –

§ Pt will be contacted with results of STD studies.

§ Return to clinic when finished the period for perform pap-smear or if symptoms do not resolve with prescribed TX.

References

Colgan, R. & Williams, M. (2011). Diagnosis and Treatment of Acute Uncomplicated Cystitis. American Family Physician, 84(7), 771-776.

Hainer, B. & Gibson, M. (2011). Vaginitis: Diagnosis and Treatment. American Family Physician, 83(7), 807-815.

Woo, T. M., & Wynne, A. L. (2012). Pharmacotherapeutics for Nurse Practitioner Prescribers (3rd ed.). Philadelphia, PA: F.A. Davis Company.

2 sample Sample Regular Soap Note Template.docx

PATIENT INFORMATION

Name: Mr. W.S.

Age: 65-year-old

Sex: Male

Source: Patient

Allergies: None

Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime

PMH: Hypercholesterolemia

Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.

Surgical History: Appendectomy 47 years ago.

Family History: Father- died 81 does not report information

Mother-alive, 88 years old, Diabetes Mellitus, HTN

Daughter-alive, 34 years old, healthy

Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.

SUBJECTIVE:

Chief complain: “headaches” that started two weeks ago

Symptom analysis/HPI:

The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month.

Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.

ROS:

CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizzeness as describe above. Denies changes in LOC. Denies history of tremors or seizures.

HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.

Respiratory: Patient denies shortness of breath, cough or hemoptysis.

Cardiovascular: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal

dyspnea.

Gastrointestinal: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or

diarrhea.

Genitourinary: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.

MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.

Skin: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.

Objective Data

CONSTITUTIONAL: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10.

General appearance: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,.Lids non-remarkable and appropriate for race.

Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.

Cardiovascular: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.

Respiratory: No dyspnea or use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.

Gastrointestinal: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpation

Musculoskeletal: No pain to palpation. Active and passive ROM within normal limits, no stiffness.

Integumentary: intact, no lesions or rashes, no cyanosis or jaundice.

Assessment

Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is confirmed.

Differential diagnosis:

Ø Renal artery stenosis (ICD10 I70.1)

Ø Chronic kidney disease (ICD10 I12.9)

Ø Hyperthyroidism (ICD10 E05.90)

Plan

Diagnosis is based on the clinical evaluation through history, physical examination, and routine laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including evidence of cardiovascular disease.

These basic laboratory tests are:

· CMP

· Complete blood count

· Lipid profile

· Thyroid-stimulating hormone

· Urinalysis

· Electrocardiogram

Ø Pharmacological treatment:

The treatment of choice in this case would be:

Thiazide-like diuretic and/or a CCB

· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.

Ø Non-Pharmacologic treatment:

· Weight loss

· Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat

· Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults

· Enhanced intake of dietary potassium

· Regular physical activity (Aerobic): 90–150 min/wk

· Tobacco cessation

· Measures to release stress and effective coping mechanisms.

Education

· Provide with nutrition/dietary information.

· Daily blood pressure monitoring at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP

· Instruction about medication intake compliance.

· Education of possible complications such as stroke, heart attack, and other problems.

· Patient was educated on course of hypertension, as well as warning signs and symptoms, which could indicate the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes understanding to all

Follow-ups/Referrals

· Evaluation with PCP in 1 weeks for managing blood pressure and to evaluate current hypotensive therapy. Urgent Care visit prn.

· No referrals needed at this time.

References

Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017 (25th ed.). Print (The 5-Minute Consult Series).

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN 978-0-8261-3424-0

Christian concept of imago dei

April 10, 2022/in Nursing /by admin

The Christian concept of imago dei is described by Shelly & Miller (2006) as man being created in the image of God, granting dignity and honor to everyone while separating mankind from everything else on earth.

This is important to healthcare because human lives depend on healthcare. By focusing the attention on preserving life and granting each person dignity, we value each human’s life over and above everything else on earth, as God intended. While postmodernism would hold a humans life less valuable since that philosophy believes the humans are simply another organism on earth, with the same value as a rock (Shelly &, 2006).

This belief is relevant because if we are all viewed as imago dei, then there are moral consequences if we choose to treat humans as
equal to all other animals in creation. As Shelly & Miller (2006) asserts, men may eat other animals in the world, but according to the Christian concept of imago dei, we were placed here as separate and superior beings and it is not appropriate to eat another human being, shoot a person for an illness or disability, and while we are free
to choose, it is our responsibility to treat the sick and dying with dignity and respect with hope for a positive outcome.

Comment 2

The Christian concept of imago Dei as explained by our text is that all humans are created in the image and likeness of god; because of this, human life is deemed valuable and special among all other life forms (Shelly & Miller, 2006). This is an important and basic concept that bares relevance to many aspects within humanity. In the context of healthcare, this is an especially crucial and fundamental understanding. Healthcare providers, caregivers, and all disciplines of the occupation should practice with this core understanding always in mind which transcends across religions and personal beliefs/opinions. Human life is a gift, and as such, each life is significant and meaningful, deserving of respect, empathy, kindness and dignity. A person’s worth and dignity is not determined by their health status, bodily functions or medical prognosis. Healthcare workers should always uphold this truth and honor a person’s right to this understanding. This should be a standard of all care, regardless of if the person’s medical decisions are not in opposition to the healthcare worker’s personal opinion or choice (Sevensky, n.d.).

Nursing Leadership and Management homework

April 10, 2022/in Nursing /by admin

Nursing Leadership and Management homework

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Effective Leadership and Management in Nursing

Eleanor J. Sullivan, PhD, RN, FAAN

Eighth Edition

Boston Columbus Indianapolis New York San Francisco Upper Saddle River Amsterdam Cape Town Dubai London Madrid Milan Munich Paris Montréal Toronto

Delhi Mexico City São Paulo Sydney Hong Kong Seoul Singapore Taipei Tokyo

Eleanor J. Sullivan, PhD, RN, FAAN, is the former dean of the University of Kansas School of Nurs- ing, past president of Sigma Theta Tau International, and previous editor of the Journal of Professional Nursing. She has served on the board of directors of the American Association of Colleges of Nursing, testified before the U.S. Senate, served on a National Institutes of Health council, presented papers to international audiences, been quoted in the Chicago Tribune, St. Louis Post-Dispatch, and Rolling Stone Magazine, and named to the “Who’s Who in Health Care” by the Kansas City Business Journal.

She earned nursing degrees from St. Louis Community College, St. Louis University, and Southern Illinois University and holds a PhD from St. Louis University.

Dr. Sullivan is known for her publications in nursing, including this award-winning textbook, Effective Leadership & Management in Nursing, and Becoming Influential: A Guide for Nurses, 2nd edition, from Prentice Hall. Other publica- tions include Creating Nursing’s Future: Issues, Opportunities and Challenges and Nursing Care for Clients with Sub- stance Abuse.

Today, Dr. Sullivan is a mystery writer. Her first three (Twice Dead, Deadly Diversion, and Assumed Dead) feature nurse sleuth Monika Everhardt.

Her latest book, Cover Her Body, A Singular Village Mystery, is the first in a new series of historical mysteries featur- ing a 19th-century midwife and set in the Northern Ohio village of Dr. Sullivan’s ancestors. Dr. Sullivan’s blog posts, found at www.EleanorSullivan.com, reveal the history behind her historical fiction.

Connect with Dr. Sullivan at www.EleanorSullivan.com.

This book is dedicated to my family for their continuing love and support.

Eleanor J. Sullivan

ABOUT THE AUTHOR

www.EleanorSullivan.com

Our heartfelt thanks go out to our colleagues from schools of nursing across the country who have given their time generously to help us create this exciting new edition of our book. We have reaped the benefit of your collective experi- ence as nurses and teachers and have made many improvements due to your efforts. Among those who gave us their encouragement and comments are:

THANK YOU

Reviewers Theresa Ameri Part-time/adjunct instructor, Marymount University Arlington, VA

Becky Brown, MSN, RN Full-time instructor, College of Southern Idaho Twin Falls, ID

Candace Burns, PhD, ARNP Professor, University of South Florida College of Nursing Tampa, FL

Sandra Janashak Cadena, PhD, APRN, CNE Professor, University of South Florida Tampa, FL

Margaret Decker Full-time instructor, Binghamton University Binghamton, NY

Denise Eccles, MSN/Ed, RN Professor, Miami Dade College Miami, FL

Barb Gilbert, EdD, MSN, RN, CNE Part-time/adjunct instructor, Excelsior College Albany, NY

Karen Joris, MSN, RN Assistant professor, Lorain County Community College Elyria, OH

Jean M. Klein, PhD, PMHCNS, BC Associate professor, Widener University Chester, PA

Jemimah Mitchell-Levy, MSN, ARNP Professor, Miami Dade College Miami, FL

Rorey Pritchard, EdS, MSN, RN, CNOR Full-time instructor, Chippewa Valley Technical College Eau Claire, WI

Heather Saifman, MSN, RN, CCRN Assistant professor, Nova Southeastern University

Miami Kendall, FL Linda Stone Other Cambridge, MA

Sandra Swearingen Part-time/adjunct instructor, UCF Orlando, FL

Diane Whitehead, EdD, RN, ANEF Department chair, Nova Southeastern University Fort Lauderdale, FL

vii

PREFACE

Leading and managing are essential skills for all nurses in today’s rapidly changing health care arena. New graduates find themselves managing unlicensed assistive personnel, and experienced nurses are managing groups of health care providers from a variety of disciplines and educational lev- els. Declining revenues, increasing costs, demands for safe care, and health care reform legislation mandate that every organization use its resources efficiently.

Nurses today are challenged to manage effectively with fewer resources. Never has the information presented in this textbook been needed more. Effective Leadership & Management in Nursing, eighth edition, can help both stu- dent nurses and those with practice experience acquire the skills needed to ensure success in today’s dynamic health care environment.

Features of the Eighth Edition Effective Leadership & Management in Nursing has made a significant and lasting contribution to the education of nurses and nurse managers in its seven previous editions. Used worldwide, this award-winning textbook is now of- fered in an updated and revised edition to reflect changes in the current health care system and in response to sug- gestions from the book’s users. The eighth edition builds upon the work of previous contributors to provide the most up-to-date and comprehensive learning package for today’s busy students and professionals.

This book has been a success for many reasons. It com- bines practicality with conceptual understanding; is respon- sive to the needs of faculty, nurse managers, and students; and taps the expertise of contributors from a variety of dis- ciplines, especially management professionals whose work has been adapted by nurses for current nursing practice. The expertise of management professors in schools of busi- ness and practicing nurse managers is seldom incorporated into nursing textbooks. This unique approach provides students with invaluable knowledge and skills and sets the book apart from others.

Features new or expanded in the eighth edition include:

• Information about the Patient Protection and Afford- able Care Act

• An emphasis on quality initiatives, including Six Sigma, Lean Six Sigma, and DMAIC

• The use of Magnet-certified hospitals as examples of concepts

• The addition of emotional leadership concepts • The use of social media in management • An emphasis on multicratic leadership and interprofes-

sional relationships • Updated legal and legislative content • Tips on how to deal with disruptive staff behaviors,

including bullying • Guidance on preparing for emergencies and mass

casualty incidents • Information on preventing workplace violence

Student-Friendly Learning Tools Designed with the adult learner in mind, the book focuses on the application of the content presented and offers spe- cific guidelines on how to implement the skills included. To further illustrate and emphasize key points, each chapter in this edition includes these features:

• A chapter outline and preview • New MediaLink boxes introduce readers to resources

and activities on the Student Resources site through nursing.pearsonhighered.com.

• Key terms are defined in the glossary at the end of the book

• What You Know Now lists at the end of each chapter • A list of “tools,” or key behaviors, for using the skills

presented in the chapter • Questions to Challenge You to help students relate

concepts to their experiences • Up-to-date references and Web resources identified • Case Studies with a Manager’s Checklist to demonstrate

application of content

Organization The text is organized into four sections that address the es- sential information and key skills that nurses must learn to succeed in today’s volatile health care environment.

Part 1. Understanding Nursing Management and Organizations. Part 1 introduces the context for nursing management, with an emphasis on how organizations are designed, on ways that nursing care is delivered, on the concepts of leading and managing, on how to initiate and manage change, on

viii PREFACE

providing quality care, and on using power and politics— all necessary for nurses to succeed and prosper in today’s chaotic health care world.

Part 2. Learning Key Skills in Nursing Management. Part 2 delves into the essential skills for today’s manag- ers, including thinking critically, making decisions, solv- ing problems, communicating with a variety of individuals and groups, delegating, working in teams, resolving con- flicts, and managing time.

Part 3. Managing Resources. Knowing how to manage resources is vital for nurses to- day. They must be adept at budgeting fiscal resources; recruiting and selecting staff; handling staffing and sched- uling; motivating and developing staff; evaluating staff performance; coaching, disciplining and terminating staff; managing absenteeism, reducing turnover, and retaining staff; and handling disruptive staff behaviors, including bullying. In addition, collective bargaining and preparing for emergencies and preventing workplace violence are in- cluded in Part 3.

Part 4. Taking Care of Yourself. Nurses are their own most valuable resource. Part 4 shows how to manage stress and to advance in a career.

Resources for Teaching and Learning Student and Instructor Resources can be accessed by regis- tering or logging in at nursing.pearsonhighered.com.

Acknowledgments The success of previous editions of this book has been due to the expertise of many contributors. Nursing adminis- trators, management professors, and faculty in schools of nursing all made significant contributions to earlier edi- tions. I am enormously grateful to them for sharing their knowledge and experience to help nurses learn leadership and management skills. Without them, this book would not exist.

At Pearson Health Science, Acquisitions Editor Pamela Fuller and Development Editor Susan Geraghty guided this revision from start to finish. Editorial Assistant Cyn- thia Gates was also especially helpful.

Because health care continues to change, reviewers who are using the book in their management practice and in their classes provided invaluable comments and sugges- tions (see list on pages xi–xii).

I am especially grateful to experienced nurse manager and graduate student Rachel Pepper for her expert research assistance, ability to generate real-life examples, and ex- pertise in creating case scenarios to exemplify the experi- ence of nurses in management roles. She lent assistance throughout with ideas and suggestions. This book and Becoming Influential: A Guide for Nurses, 2nd edition, are better for her contributions.

To everyone who has contributed to this fine book over the years, I thank you.

Eleanor J. Sullivan, PhD, RN, FAAN www.EleanorSullivan.com

www.EleanorSullivan.com

CONTENTS

Thank You vi Preface vii

PART 1 Understanding Nursing Management and Organizations 1

CHAPTER 1 Introducing Nursing Management 1 Learning Outcomes 1

CHANGES IN HEALTH CARE 2 PAYING FOR HEALTH CARE 2

How America Pays for Health Care 2 Pay for Performance 2

DEMAND FOR QUALITY 2 Quality Initiatives 2 The Leapfrog Group 3 Benchmarking 3 Evidence-Based Practice 3 Magnet® Certification 4

EVOLVING TECHNOLOGY 4 Electronic Health Records 5 Virtual Care 5 Robotics 5 Communication Technology 5

CULTURAL, GENDER, AND GENERATIONAL DIFFERENCES 6 VIOLENCE PREVENTION AND DISASTER PREPAREDNESS 6 CHANGES IN NURSING’S FUTURE 6

Even More Change . . . 7 Challenges Facing Nurses and Managers 7

CHAPTER 2 Designing Organizations 11 Learning Outcomes 11

TRADITIONAL ORGANIZATIONAL THEORIES 12

Classical Theory 12 Humanistic Theory 14 Systems Theory 14 Contingency Theory 14 Chaos Theory 15 Complexity Theory 15

TRADITIONAL ORGANIZATIONAL STRUCTURES 15

Functional Structure 16 Hybrid Structure 16

Matrix Structure 16 Parallel Structure 16

SERVICE-LINE STRUCTURES 17 SHARED GOVERNANCE 17 OWNERSHIP OF HEALTH CARE ORGANIZATIONS 18 HEALTH CARE SETTINGS 19

Primary Care 19 Acute Care Hospitals 20 Home Health Care 20 Long-Term Care 20

COMPLEX HEALTH CARE ARRANGEMENTS 21

Health Care Networks 21 Interorganizational Relationships 21 Diversification 22 Managed Health Care Organizations 23 Accountable Care Organizations 23

REDESIGNING HEALTH CARE 23 STRATEGIC PLANNING 24 ORGANIZATIONAL ENVIRONMENT AND CULTURE 25

CHAPTER 3 Delivering Nursing Care 29 Learning Outcomes 29

TRADITIONAL MODELS OF CARE 30 Functional Nursing 30 Team Nursing 31 Total Patient Care 32 Primary Nursing 33

INTEGRATED MODELS OF CARE 34 Practice Partnerships 34 Case Management 34 Critical Pathways 35 Differentiated Practice 36

EVOLVING MODELS OF CARE 36 Patient-Centered Care 36 Synergy Model of Care 37 Clinical Microsystems 37 Chronic Care Model 37

CHAPTER 4 Leading, Managing, Following 40 Learning Outcomes 40

LEADERS AND MANAGERS 41 LEADERSHIP 41 TRADITIONAL LEADERSHIP THEORIES 42

x CONTENTS

CONTEMPORARY THEORIES 42 Quantum Leadership 42 Transactional Leadership 42 Transformational Leadership 43 Shared Leadership 43 Servant Leadership 44 Emotional Leadership 44

TRADITIONAL MANAGEMENT FUNCTIONS 45

Planning 46 Organizing 46 Directing 47 Controlling 47

NURSE MANAGERS IN PRACTICE 47 Nurse Manager Competencies 47 Staff Nurse 48 First-Level Management 48 Charge Nurse 49 Clinical Nurse Leader 50

FOLLOWERSHIP: AN ESSENTIAL COMPONENT OF LEADERSHIP 51 WHAT MAKES A SUCCESSFUL LEADER? 51

CHAPTER 5 Initiating and Managing Change 55 Learning Outcomes 55

WHY CHANGE? 56 THE NURSE AS CHANGE AGENT 56 CHANGE THEORIES 57 THE CHANGE PROCESS 58

Assessment 58 Planning 60 Implementation 60 Evaluation 61

CHANGE STRATEGIES 61 Power-Coercive Strategies 61 Empirical–Rational Model 62 Normative–Reeducative Strategies 62

RESISTANCE TO CHANGE 62 THE NURSE’S ROLE 64

Initiating Change 64 Implementing Change 65

HANDLING CONSTANT CHANGE 66

CHAPTER 6 Managing and Improving Quality 69 Learning Outcomes 69

QUALITY MANAGEMENT 70 Total Quality Management 70 Continuous Quality Improvement 71 Components of Quality Management 72 Six Sigma 73 Lean Six Sigma 73 DMAIC Method 74

IMPROVING THE QUALITY OF CARE 74 National Initiatives 74 How Cost Affects Quality 75 Evidence-Based Practice 75 Electronic Medical Records 75 Dashboards 76 Nurse Staffing 76 Reducing Medication Errors 76 Peer Review 76

RISK MANAGEMENT 77 Nursing’s Role in Risk Management 77 Incident Reports 78 Examples of Risk 78 Root Cause Analysis 80 Role of the Nurse Manager 80 Creating a Blame-Free Environment 81

CHAPTER 7 Understanding Power and Politics 86 Learning Outcomes 86

POWER DEFINED 87 POWER AND LEADERSHIP 87 POWER: HOW MANAGERS AND LEADERS GET THINGS DONE 87 USING POWER 88

Image as Power 89 Using Power Appropriately 91

SHARED VISIONING AS A POWER TOOL 92 POWER, POLITICS, AND POLICY 92

Nursing’s Political History 93 Using Political Skills to Influence Policies 93 Influencing Public Policies 94

USING POWER AND POLITICS FOR NURSING’S FUTURE 96

PART 2 Learning Key Skills in Nursing Management 99

CHAPTER 8 Thinking Critically, Making Decisions, Solving Problems 99 Learning Outcomes 99

CRITICAL THINKING 100 Critical Thinking in Nursing 100 Using Critical Thinking 101 Creativity 101

DECISION MAKING 103 Types of Decisions 104 Decision-Making Conditions 104 The Decision-Making Process 106

CONTENTS xi

Decision-Making Techniques 107 Group Decision Making 108

PROBLEM SOLVING 109 Problem-Solving Methods 109 The Problem-Solving Process 110 Group Problem Solving 112

STUMBLING BLOCKS 114 INNOVATION 115

CHAPTER 9 Communicating Effectively 117 Learning Outcomes 117

COMMUNICATION 118 Modes of Communication 118 Distorted Communication 118 Directions of Communication 120 Effective Listening 120

EFFECTS OF DIFFERENCES IN COMMUNICATION 121

Gender Differences in Communication 121 Generational and Cultural Differences in Communication 121 Differences in Organizational Culture 122

THE ROLE OF COMMUNICATION IN LEADERSHIP 123

Employees 123 Administrators 123 Coworkers 125 Medical Staff 125 Other Health Care Personnel 126 Patients and Families 126

COLLABORATIVE COMMUNICATION 126 ENHANCING YOUR COMMUNICATION SKILLS 129

CHAPTER 10 Delegating Successfully 131 Learning Outcomes 131

DELEGATION 132 BENEFITS OF DELEGATION 132

Benefits to the Nurse 132 Benefits to the Delegate 133 Benefits to the Manager 133 Benefits to the Organization 133

THE FIVE RIGHTS OF DELEGATION 133 The Delegation Process 134

ACCEPTING DELEGATION 137 INEFFECTIVE DELEGATION 138

Organizational Culture 138 Lack of Resources 138 An Insecure Delegator 138 An Unwilling Delegate 139 Underdelegation 140

Reverse Delegation 140 Overdelegation 140

CHAPTER 11 Building and Managing Teams 143 Learning Outcomes 143

GROUPS AND TEAMS 144 GROUP AND TEAM PROCESSES 146

Norms 147 Roles 148

BUILDING TEAMS 149 Assessment 149 Team-Building Activities 150

MANAGING TEAMS 150 Task 151 Group Size and Composition 151 Productivity and Cohesiveness 151 Development and Growth 152 Shared Governance 152

THE NURSE MANAGER AS TEAM LEADER 153

Communication 153 Evaluating Team Performance 153

LEADING COMMITTEES AND TASK FORCES 154

Guidelines for Conducting Meetings 155 Managing Task Forces 156

PATIENT CARE CONFERENCES 157

CHAPTER 12 Handling Conflict 160 Learning Outcomes 160 CONFLICT 161 INTERPROFESSIONAL CONFLICT 161 CONFLICT PROCESS MODEL 162

Antecedent Conditions 163 Perceived and Felt Conflict 164 Conflict Behaviors 165 Conflict Resolved or Suppressed 165 Outcomes 165

MANAGING CONFLICT 165 Conflict Responses 166 Filley’s Strategies 168 Alternative Dispute Strategies 169

CHAPTER 13 Managing Time 172 Learning Outcomes 172

TIME WASTERS 173 Time Analysis 174 The Manager’s Time 175

SETTING GOALS 175 Determining Priorities 176 Daily Planning and Scheduling 176

xii CONTENTS

Grouping Activities and Minimizing Routine Work 177 Personal Organization and Self-Discipline 177

CONTROLLING INTERRUPTIONS 178 Phone Calls, Voice Mail, Text Messages 179 E-Mail 180 Drop-In Visitors 181 Paperwork 181

CONTROLLING TIME IN MEETINGS 182 RESPECTING TIME 182

PART 3 Managing Resources 184

CHAPTER 14 Budgeting and Managing Fiscal Resources 184 Learning Outcomes 184

THE BUDGETING PROCESS 185 APPROACHES TO BUDGETING 186

Incremental Budget 186 Zero-Based Budget 187 Fixed or Variable Budgets 187

THE OPERATING BUDGET 187 The Revenue Budget 187 The Expense Budget 188

DETERMINING THE SALARY (PERSONNEL) BUDGET 189

Benefits 189 Shift Differentials 190 Overtime 190 On-Call Hours 190 Premiums 190 Salary Increases 191 Additional Considerations 191

MANAGING THE SUPPLY AND NONSALARY EXPENSE BUDGET 191 THE CAPITAL BUDGET 192 TIMETABLE FOR THE BUDGETING PROCESS 192 MONITORING BUDGETARY PERFORMANCE DURING THE YEAR 193

Variance Analysis 193 Position Control 195

PROBLEMS AFFECTING BUDGETARY PERFORMANCE 195

Reimbursement Problems 195 Staff Impact on Budget 196

CHAPTER 15 Recruiting and Selecting Staff 199 Learning Outcomes 199

THE RECRUITMENT AND SELECTION PROCESS 200

RECRUITING APPLICANTS 200 Where to Look 201 How to Look 202 When to Look 202 How to Promote the Organization 202 Cross-Training as a Recruitment Strategy 203

SELECTING CANDIDATES 204 INTERVIEWING CANDIDATES 205

Principles for Effective Interviewing 205 Involving Staff in the Interview Process 209 Interview Reliability and Validity 209

MAKING A HIRE DECISION 210 Education, Experience, and Licensure 210 Integrating the Information 210 Making an Offer 211

LEGALITY IN HIRING 211

CHAPTER 16 Staffing and Scheduling 217 Learning Outcomes 217

STAFFING 218 Patient Classification Systems 218 Determining Nursing Care Hours 219 Determining FTEs 219 Determining Staffing Mix 220 Determining Distribution of Staff 220

SCHEDULING 221 Creative and Flexible Staffing 221 Automated Scheduling 222 Supplementing Staff 223

CHAPTER 17 Motivating and Developing Staff 227 Learning Outcomes 227 A MODEL OF JOB PERFORMANCE 228

Employee Motivation 229 Motivational Theories 229

MANAGER AS LEADER 231 STAFF DEVELOPMENT 231

Orientation 231 On-the-Job Instruction 232 Preceptors 233 Mentoring 233 Coaching 234 Nurse Residency Programs 234 Career Advancement 234 Leadership Development 235

SUCCESSION PLANNING 235

CONTENTS xiii

CHAPTER 18 Evaluating Staff Performance 239 Learning Outcomes 239

THE PERFORMANCE APPRAISAL 240 Evaluation Systems 241 Evidence of Performance 244 Evaluating Skill Competency 247 Diagnosing Performance Problems 247 The Performance Appraisal Interview 248

POTENTIAL APPRAISAL PROBLEMS 251 Leniency Error 251 Recency Error 251 Halo Error 252 Ambiguous Evaluation Standards 252 Written Comments Problem 252

IMPROVING APPRAISAL ACCURACY 253 Appraiser Ability 253 Appraiser Motivation 253

RULES OF THUMB 255

CHAPTER 19 Coaching, Disciplining, and Terminating Staff 257 Learning Outcomes 257

DAY-TO-DAY COACHING 258 POSITIVE COACHING 259 DEALING WITH A POLICY VIOLATION 259 DISCIPLINING STAFF 260 TERMINATING EMPLOYEES 262

CHAPTER 20 Managing Absenteeism, Reducing Turnover, Retaining Staff 268 Learning Outcomes 268 ABSENTEEISM 269

A Model of Employee Attendance 269 Managing Employee Absenteeism 272 Absenteeism Policies 273 Selecting Employees and Monitoring Absenteeism 274 Family and Medical Leave 274

REDUCING TURNOVER 275 Cost of Nursing Turnover 275 Causes of Turnover 276 Understanding Voluntary Turnover 276

RETAINING STAFF 277 Employee Engagement 277 Healthy Work Environment 277 Improving Salaries 277 Recognizing Staff Performance 278 Additional Retention Strategies 279

CHAPTER 21 Dealing with Disruptive Staff Problems 283 Learning Outcomes 283

HARASSING BEHAVIORS 284 Bullying 284 Lack of Civility 284 Lateral Violence 285

HOW TO HANDLE PROBLEM BEHAVIORS 286 Marginal Employees 286 Disgruntled Employees 287

THE EMPLOYEE WITH A SUBSTANCE ABUSE PROBLEM 288

State Board of Nursing 289 Strategies for Intervention 289 Reentry 290 The Americans with Disabilities Act and Substance Abuse 291

CHAPTER 22 Preparing for Emergencies 294 Learning Outcomes 294

PREPARING FOR EMERGENCIES 295 TYPES OF EMERGENCIES 295

Natural Disasters 295 Man-Made Disasters 295 Levels of Disasters 295

NATIONAL RESPONSES TO EMERGENCY PREPAREDNESS 296 HOSPITAL PREPAREDNESS FOR EMERGENCIES 296

Emergency Operations Plan 296 Disaster Triage 297 Core Competencies for Nurses 297 Continuation of Services 297 Impact on Employees 298

CHAPTER 23 Preventing Workplace Violence 302 Learning Outcomes 302

VIOLENCE IN HEALTH CARE 303 Incidence of Workplace Violence 303 Consequences of Workplace Violence 303 Factors Contributing to Violence in Health Care 303

PREVENTING VIOLENCE 304 Zero-Tolerance Policies 304 Reporting and Education 304 Environmental Controls 304

DEALING WITH VIOLENCE 305 Verbal Intervention 305 A Violent Incident 305 Other Dangerous Incidents 306 Post-Incident Follow-Up 306

xiv CONTENTS

CHAPTER 24 Handling Collective Bargaining Issues 310 Learning Outcomes 310

LAWS GOVERNING UNIONS 311 PROCESS OF UNIONIZATION 311

The Grievance Process 312 The Nurse Manager’s Role 312

STATUS OF COLLECTIVE BARGAINING FOR NURSES 313

Legal Status of Nursing Unions 313 The Future of Collective Bargaining for Nurses 314

PART 4 Taking Care of Yourself 316

CHAPTER 25 Managing Stress 316 Learning Outcomes 316

THE NATURE OF STRESS 317 CAUSES OF STRESS 318

Organizational Factors 318 Interpersonal Factors 318 Individual Factors 319

CONSEQUENCES OF STRESS 320 MANAGING STRESS 320

Personal Methods 320 Organizational Methods 321

CHAPTER 26 Advancing Your Career 325 Learning Outcomes 325

ENVISIONING YOUR FUTURE 326 MANAGING YOUR CAREER 326 ACQUIRING YOUR FIRST POSITION 326

Applying for the Position 327 The Interview 328 Accepting the Position 331 Declining the Position 331

BUILDING A RÉSUMÉ 331 Tracking Your Progress 333 Identifying Your Learning Needs 334

FINDING AND USING MENTORS 336 CONSIDERING YOUR NEXT POSITION 336

Finding Your Next Position 337 Leaving Your Present Position 337

WHEN YOUR PLANS FAIL 337 Taking the Wrong Job 337 Adapting to Change 338

Glossary 340 Index 348

CHAPTER

Changes in Health Care

Paying for Health Care HOW AMERICA PAYS FOR HEALTH CARE

PAY FOR PERFORMANCE

Demand for Quality QUALITY INITIATIVES

THE LEAPFROG GROUP

BENCHMARKING

EVIDENCE-BASED PRACTICE

MAGNET® CERTIFICATION

Evolving Technology ELECTRONIC HEALTH RECORDS

VIRTUAL CARE

ROBOTICS

COMMUNICATION TECHNOLOGY

Cultural, Gender, and Generational Differences

Violence Prevention and Disaster Preparedness

Changes in Nursing’s Future EVEN MORE CHANGE . . .

CHALLENGES FACING NURSES AND MANAGERS

Introducing Nursing Management 1

1. Describe the forces that are changing the health care system.

2. Discuss changes in paying for health care. 3. Explain how quality initiatives can reduce

medical errors. 4. Describe how evidence-based practice is

changing nursing. 5. Explain how to become a Magnet-certified

hospital.

6. Explain what emerging technologies mean for nursing.

7. Describe how cultural, gender, and genera- tional differences affect management.

8. Explain why preparation is the best defense against violence and disasters.

9. Discuss the changes and challenges that nurses face now and into the future.

Learning Outcomes After completing this chapter, you will be able to:

Key Terms Benchmarking Electronic health records

(EHRs) Evidence-based practice Leapfrog Group

Magnet Recognition Program®

Patient Protection and Affordable Care Act (PPACA)

Quality initiatives Robotics Social media Virtual care

2 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

T oday, all nurses are managers. Whether you work in a freestanding clinic, an ambula-tory surgical center, a critical unit in an acute care hospital, or in hospice care for a home care agency, you must deal with staff, including other nurses and unlicensed as- sistive personnel, who work with you and for you. At the same time, you must be vigilant about costs. To manage well, you must understand the health care system and the organizations where you work. You need to recognize what external forces affect your work and how to influence those forces. You need to know what motivates people and how you can help create an environ- ment that inspires and sustains the individuals who work in it. You must be able to collaborate with others, as a leader, a follower, and a team member, in order to become confident in your ability to be a leader and a manager.

This book is designed to provide new graduates or novice managers with the information they need to become effective managers and leaders in health care. More than ever before, today’s rapidly changing health care environment demands highly refined management skills and superb leadership.

Changes in Health Care Today’s health care system is continuing to undergo significant changes. Costly lifesaving medi- cines, robotics, virtual care, and innovations in imaging technologies, noninvasive treatments, and surgical procedures have combined to produce the most sophisticated and effective health care ever—and the most expensive. Skyrocketing costs and inaccessibility to health care are ongoing concerns for employers, health care providers, policy makers, and the public at large. A number of factors are forcing change on the health care system.

Paying for Health Care

How America Pays for Health Care The United States spends more money on health care than any other country, and health care spending continues to rise with costs of $2.5 trillion in 2009, consuming more than 17 percent of the country’s gross domestic product (GDP) (CMS, 2011). With the goal of providing access to health care to most U.S. citizens and containing costs, Congress passed a health care reform bill known as the Patient Protection and Affordable Care Act (PPACA) that was signed into law March 23, 2010. While implementation of the bill is pending court challenges, the promise of providing adequate and affordable care to more Americans is on the horizon.

Pay for Performance In 1999, the Institute of Medicine (IOM, 1999) reported that 98,000 deaths occurred each year from preventable medical mistakes, such as falls, wrong site surgeries, avoidable infections, and pressure ulcers, among others. By 2008, researchers learned that “the effects of medical mistakes continue long after the patient leaves the hospital” (Encinosa & Hellinger, 2008, p. 2067). In spite of numerous efforts to prevent mistakes, the cost of medical errors has con- tinued to climb. Recent estimates put such costs at $19.5 billion annually (Shreve et al., 2010).

In 2008, the Centers for Medicare and Medicaid Services, the agency that oversees gov- ernment payments for care, tied payment to the quality of care by changing its reimbursement policy to no longer cover costs incurred by medical mistakes (Wachter, Foster, & Dudley, 2008). If medical mistakes occur, the hospital must absorb the costs. Thus, pay for performance became the norm, and performance is now measured by the quality of care (Milstein, 2009).

Demand for Quality

Quality Initiatives In an effort to ameliorate medical mistakes, a number of quality initiatives have emerged. Quality management is a preventive approach designed to address problems before they become crises. The quality movement actually began in post–World War II Japan, when Japanese industries adopted a

CHAPTER 1 • INTRODUCING NURSING MANAGEMENT 3

system that W. Edwards Deming designed to improve the quality of manufactured products. The philosophy of the system is that consumers’ needs should be the focus and that employees should be empowered to evaluate and improve quality. In addition to businesses in the United States and else- where, the health care industry has adopted total quality management or variations on it.

Built into the system is a mechanism for continuous improvement of products and services through constant evaluation of how well consumers’ needs are met and plans adjusted to per- fect the process. Patient satisfaction surveys are one example of how health care organizations evaluate their customers’ needs. Today, quality initiatives address all aspects of patient care and include government efforts as well as private sector endeavors.

Public reporting of heath care organizations has emerged as a strategy to improve quality (Christianson et al., 2010). To further that goal, the Agency for Healthcare Research and Quality (AHRQ)—whose mission is to improve the quality, safety, efficiency, and effectiveness of health care—funds projects that address three quality indicators: prevention, inpatient, quality, and patient safety (Dunton et al., 2011).

The Leapfrog Group Efforts by the Leapfrog Group constitute one private sector initiative to address quality. The Leapfrog Group is a consortium of public and private purchasers established to reduce prevent- able medical mistakes. The organization uses its mammoth purchasing power to leverage quality care for its consumers by rewarding health care organizations that demonstrate quality outcome measures. The quality indicators the group focuses on include ICU staffing, electronic medi- cation ordering systems, and the use of higher performing hospitals for high-risk procedures. Leapfrog estimates that if these three patient safety practices were implemented, more than 57,000 lives could be saved, more than $12 billion dollars could be saved, and more than 3 mil- lion adverse drug events could be avoided (Binder, 2010).

Benchmarking In contrast to quality management strategies that compare internal measures across comparable units, such as the Leapfrog Group, benchmarking compares an organization’s data with similar organizations. Outcome indicators are identified that can be used to compare performance across disciplines or organizations. Once the results are known, health care organizations can address areas of weakness and enhance areas of strength (Nolte, 2011). Interestingly, one study found that hospital size didn’t affect the ability of institutions to compare results (Brown et al., 2010).

Evidence-Based Practice Evidence-based practice has emerged as a strategy to improve quality by using the best avail- able knowledge integrated with clinical experience and the patient’s values and preferences to provide care (Houser & Oman, 2010).

Similar to the nursing process, the steps in EBP are:

1. Identify the clinical question.

2. Acquire the evidence to answer the question.

3. Evaluate the evidence.

4. Apply the evidence.

5. Assess the outcome.

Research findings with conflicting results puzzle consumers daily, and nurses are no excep- tion, especially when they search for practice evidence. Hader (2010) suggests that evidence falls into several categories:

● Anecdotal—derived from experience ● Testimonial—reported by an expert in the field

4 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

● Statistical—built from a scientific approach ● Case study—an in-depth analysis used to translate to other clinical situations ● Nonexperimental design research—gathering factors related to a clinical condition ● Quasi-experimental design research—a study limited to one group of subjects ● Randomized control trial—uses both experimental and control groups to determine the

effectiveness of an intervention

While all forms of evidence are useful for clinical decision making, a randomized control design and statistical evidence are the most rigorous (Hader, 2010).

Magnet® Certification The Magnet Recognition Program® designates organizations that “recognize health care orga- nizations that provide nursing excellence” (ANCC, 2011). To qualify for recognition as a mag- net hospital the organization must demonstrate that they are:

● Promoting quality in a setting that supports professional practice ● Identifying excellence in the delivery of nursing services to patients/residents ● Disseminating “best practices” in nursing services.

Becoming a magnet hospital requires a significant investment of time and financial resources. Research shows, however, that patient safety is improved when nurse staffing meets Magnet standards (Lake et al., 2010).

Systems involving participatory management and shared governance create organizational environments that reward decision making, creativity, independence, and autonomy. These orga- nizations retain and recruit independent, accountable professionals. Organizations that empower nurses to make decisions will better meet consumer requests. As the health care environment continues to evolve, more and more organizations are adopting consumer-sensitive cultures that require accountability and decision making from nurses.

Magnet hospitals are those institutions that have met the stringent guidelines for nurses and are credentialed by the American Nurses Credentialing Center. Characteristics common in mag-

net hospitals include:

● Higher ratios of nurses to patients ● Flexible schedules ● Decentralized administration ● Participatory management ● Autonomy in decision making ● Recognition ● Advancement opportunities

To retain the current workforce and attract other nurses, health care organizations can take from the magnet program characteristics to improve work-life conditions for nurses. Encourag- ing nurses to be full participants and to share a vested interest in the success of the organization can help alleviate the nursing shortage in those organizations and in the profession.

See Chapter 6 , Managing and Improving Quality, to learn more about improving quality in health care.

Evolving Technology Rapid changes in technology seem, at times, to overwhelm us. Hospital information systems (HIS); electronic health records (EHR); point-of-care data entry (POC); provider order entry; bar-code medication administration; dashboards to manage, report, and compare data across plat- forms; virtual care provided from a distance; and robotics—to name a few of the many evolving technologies—both fascinate and frighten us simultaneously. At the same time, communication

CHAPTER 1 • INTRODUCING NURSING MANAGEMENT 5

technology—from smartphones to social media—continues to march into the future. It is no wonder that people who work in health care complain that they can’t keep up! The rapidity of technological change promises, unfortunately, to continue unabated.

Electronic Health Records Electronic health records (EHRs) represent a technology destined for rapid expansion. While banks, retailers, airlines, and other industries began to rely on fully integrated systems to man- age communication and reduce redundancies, health care was still continuing to rely on volu- minous paper records duplicated in multiple locations. Keeping data safe continues to worry health care organizations, consumers, and policy makers, but the benefits of integrated systems outweigh the risks (Trossman, 2009a).

EHRs reduce redundancies, improve efficiency, decrease medical errors, and lower health care costs. Continuity of care, discharge planning and follow-up, ambulatory care collaboration, and patient safety are just a few of the additional advantages of EHRs. Furthermore, fully integrated systems allow for collective data analysis across clinical conditions, health care organizations, or worldwide and sup- port evidence-based decision making. With the federal government funding health systems to upgrade to EHRs, the current 12 percent of hospitals with EHRs is expected to increase (Gomez, 2010).

Virtual Care Virtual care, previously known as telemedicine and now more commonly called telehealth, has evolved as technologies to assess, intervene, and monitor patients remotely improved. Both communication technology (i.e., audio and video) and improvements in mobile care technology contribute to the ability of health care professionals to provide care from a distance. Nurses, for example, can watch banks of video screens monitoring ICU patients’ vitals signs miles away from the hospital. Electronic equipment, such as a stethoscope, can be accessed by a health care provider in a distant location. Such systems are especially useful in providing expert consulta- tion for specialty care (Zapatochny-Rufo, 2010).

Robotics Another technological advance is robotics. In the hospital, supplies can be ordered electroni- cally, and then laser-guided robots can fill the order in the pharmacy or central supply and de- liver the requested supplies to nursing units via their own elevators more efficiently, accurately, and in less time than individuals can. Mobile robots can also monitor patients, report changes and conditions, and allow caregivers to communicate from a distance (Markoff, 2010) via a wireless connection to a laptop or a smart phone. Robot functionality will continue to expand, limited only by resources and ingenuity.

Communication Technology Just as rapidly as clinical and data technology are evolving, so are communication technolo- gies, changing forever the ways people keep informed and interact (Sullivan, 2013). Informa- tion (accurate or inaccurate) is disseminated with lightening speed while smartphones capture real-time events and broadcast images instantaneously.

Social media has revolutionized communication beyond the realm of possibilities from just a few years ago (Kaplan & Haenlein, 2010). Social media connects diverse populations and en- courages collaboration, the exchange of images, ideas, opinions, and preferences in networking Web sites, online forums, Web blogs, social blogs, wikis, podcasts, RSS feeds, photos, video content communities, social bookmarking, online chat rooms, microblogs, such as Twitter, and online communities, such as Facebook and LinkedIn (Sullivan, 2013).

Similar to other enterprises, most health care organizations have an online presence with a Web site and social media sites, such as Facebook, Twitter, and blogs. Units within the organiza- tion may have Facebook pages as well, with staff who post on those sites. These opportunities

6 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

for information sharing and relationship building also come with risks (Raso, 2010; Trossman, 2010b). Patient confidentiality, the organization’s reputation, and recruiting efforts can be en- hanced or put in jeopardy by posts to the site (Sullivan, 2013).

Cultural, Gender, and Generational Differences According to the U.S. Census Bureau, the minority population in the U.S. increased from 31 to 36 percent from 2000 to 2010 (U.S. Census, 2011). The largest minority population is Hispanic, and that population increased to 50 million (16 percent of the total U.S. population) in 2010. The Asian population grew to 14 million (5 percent) in the same time period, and the African American population stands at 42 million (14 percent).

The cultural diversity seen in the general population is also reflected in nursing. The Health Resources and Services Administration (HRSA, 2011) reports that 16 percent of nurses are Asian, African American, Hispanic, or other ethnic minorities, an increase from 12 percent in 2004.

The gender mix found in nursing, however, differs from the general population, with men greatly outnumbered by women. Of the population of more than 3 million nurses in the U.S., only 6 percent are men, although changes suggest the ratio is improving. The proportion of men to women has risen to 1 in 10 in the decades since 1990 (HRSA, 2011). Both cultural diversity and gender diversity challenge the nurse manager to consider such differences when working with staff, colleagues, and administrators as well as mediating conflicts between individuals.

Generational differences in the nursing population is unprecedented, with four generational cohorts working together (Keepnews et al., 2010). Referred to as traditionals, baby boomers, Generation X, and Generation Y, each generational group has different expectations in the work- place. Traditionals value loyalty and respect authority. Baby boomers value professional and personal growth and expect that their work will make a difference.

Generation X members strive to balance work with family life and believe that they are not rewarded given their responsibilities (Keepnews et al., 2010). Generation Y (also called milleni- als) are technically savvy and expect immediate access to information electronically.

Similar to dealing with cultural and gender differences, the challenge for managers is to avoid stereotyping within the generations, to value the unique contributions of each generation, to encourage mutual respect for differences, and to leverage these differences to enhance team work (Chambers, 2010).

Violence Prevention and Disaster Preparedness Sadly, violence invades workplaces, and health care is no exception. Moreover, nearly 500,000 nurses are victims of workplace violence (Trossman, 2010c). In addition, recent disasters (e. g., the earthquake and tsunami in Japan, tornadoes in the U.S.) and the threats of terrorism and pan- demics challenge health care organizations to prepare for the unthinkable.

Extensive staff training is required (AHRQ, 2011). Techniques include computer simula- tions, video demonstrations, disaster drills, and a clear understanding of communication sys- tems and the incident command center. A natural disaster, an attack of terrorism, an epidemic, or other mass casualty events may, and probably will, occur at some time. All health care organizations must be prepared to care for a surge in casualties while reducing the impact on patients and staff.

Changes in Nursing’s Future Nurses will face many changes in the future, including an increasing demand for nurses as the population ages, a worsening shortage as nurses age, and recommendations for changes to prac- tice and education. The aging population is surviving previously fatal diseases and conditions

CHAPTER 1 • INTRODUCING NURSING MANAGEMENT 7

due to ever-evolving health care technologies. These patients often require ongoing care for chronic illnesses as well as for acute episodes of illness.

Just as the population is aging and requiring more and more care, nurses too are growing older. The average age of the registered nurse is 46 years, although the number of RNs under age 30 is increasing at a faster pace than before (HRSA, 2011).

Slightly more than 3 million nurses are currently licensed as registered nurses in the U.S., and 85 percent of them practice full- or part-time in the profession (HRSA, 2011). Jobs for nurses, however, are expected to grow to 3.2 million by 2018, much faster than the average for all occupations (U.S. Department of Labor, 2011). Also, with implementation of health care reform, increases in the demand for nurses in primary care and acute care settings are expected.

The Institute of Medicine’s report on the future of nursing makes sweeping recommenda- tions for nursing’s future, including that “nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States” (IOM, 2010, p. 3). In addition, IOM posits that today’s health care environment necessitates better-educated nurses and recommends that 80 percent of nurses be prepared at the baccaluareate or higher level by 2020.

At the same time, the Carnegie Foundation recommends radically transforming nursing education (Benner et al., 2009). Its recommendations include:

1. Focus on how to apply knowledge, not only acquire it.

2. Integrate clinical and classroom teaching, rather than separately.

3. Emphasize clinical reasoning, not only critical thinking.

4. Emphasize formation, rather than socialization and role taking (Benner et al., 2009).

Even More Change . . . What does the future hold for health care? Change is the one constant. Quality of care will continue to be monitored and reported with accompanying demands to tie pay to performance. Technology of care, communication, and data management will become more and more com- plex as computer processing power and storage capacity expand (Clancy, 2010) and equipment becomes smaller and more mobile. Access to care and how to pay for it will continue to drive policy and funding decisions. Everyone in health care must learn to live with ambiguity and be flexible enough to adapt to the changes it brings.

Challenges Facing Nurses and Managers Every nurse must be prepared to manage. Specific training in management skills is needed in nursing school as well as in the work setting. Most important, however, is that nurses be able to transfer their newly acquired skills to the job itself. Thus, nurse managers must be experienced in management themselves and be able to assist their staff in developing adequate management skills. Management training for nurses at all levels is essential for any organization to be effi- cient and effective in today’s cost-conscious and competitive environment.

The challenge for nurse managers and administrators is how to manage in a constantly changing system. Working with teams of administrators and providers to deliver quality health care in the most cost-effective manner offers opportunity as well. Nurses’ unique skills in communication, negotiation, and collaboration position them well for the system of today and for the future.

Nurse managers today are challenged to monitor and improve quality care, manage with limited resources, help design new systems of care, supervise teams of professionals and nonprofessionals from a variety of cultures, and, finally, teach personnel how to function well in

8 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

the new system. This is no small task. It requires that nurses and their managers be committed, involved, enthusiastic, flexible, and innovative; above all else, it requires that they have good mental and physical health. Because the nurse manager of today is responsible for others’ work, the nurse manager must also be a coach, a teacher, and a facilitator. The manager works through others to meet the goals of individuals, of the unit, and of the organization. Most of all, the man- ager must be a leader who can motivate and inspire.

Nurse managers must address the interests of administrators, colleagues in other disciplines, and employees. All want the same result—quality care. Administrators, however, must focus on cost and efficiency in order for the organization to compete and survive. Colleagues want col- laborative and efficient systems of care. Employees want to be supported in their work with ad- equate staffing, supplies, equipment, and, most of all, time. Therein lies the conflict. Between all of them is the nurse manager, who must balance the needs of all. Being a nurse manager today is the most challenging opportunity in health care. This book is designed to prepare you to meet these challenges.

What You Know Now • Health care is radically changing and is expected to continue to change in the foreseeable future. • The tension between providing adequate nursing care and paying for that care will continue to dominate

health policy decisions. • Reducing medical errors is the goal of quality initiatives. • Cultural, gender, and generational diversity will continue to shape the nursing workforce. • Evidence-based practice will guide nursing decisions into the future. • Electronic health records, robotics, and virtual care are just a few of the many technologies continuing to

evolve. • Expansion in communication technologies will continue to offer opportunities and challenges to health

care organizations. • Threats of natural disasters, terrorism, and pandemics require all health care organizations to plan and

prepare for mass casualties. • The nurse manager is challenged to manage in a constantly changing environment.

Questions to Challenge You 1. Name three changes that you would suggest to reduce the cost of health care without compromising

patients’ health and safety. Talk about how you could help make these changes. 2. What mechanisms could you suggest to improve and ensure the quality of care? (Don’t just suggest

adding nursing staff!) 3. How could you help reduce medical errors? What can you suggest that a health care organization

could do? 4. Do your clinical decisions rely on evidence-based practice? If you answer no, why not? 5. What are some ways that nurses could take advantage of emerging technologies in health care and

information systems? Think big. 6. Have you participated in a disaster drill? Did you notice ways to improve the organization’s readi-

ness for mass casualties? Name at least one. 7. What steps can you take to transfer the knowledge and skills you learn in this book into your work

setting?

CHAPTER 1 • INTRODUCING NURSING MANAGEMENT 9

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

Agency for Healthcare Research and Quality. (2011). AHRQ disaster response tools and resources. Retrieved May 25, 2011 from http://www.ahrq. gov/research/altstand

American Nurses Credential- ing Center (2011). Magnet Recognition Program. Retrieved April 27, 2011 from http://www. nursecredentialing.org/ Magnet.aspx

Benner, P., Sutphen, M., Leonard, V., and Day, L. (2009). Educating nurses: A call for radical trans- formation. San Francisco: Jossey-Bass.

Binder, L. (2010). Leapfrog: Unique and salient mea- sures of hospital quality and safety. Prescriptions for Excellence in Health Care, 8, 1–2.

Brown, D. S., Aydin, C. E., Donaldson, N., Fridman, M., & Sandhu, M. (2010). Benchmarking for small hospitals: Size didn’t mat- ter! Journal of Healthcare Quality, 32(4), 50–60.

Centers for Medicare and Medic- aid Services (CMS) (2011). National health expenditure data. Retrieved April 25, 2011 from https://www. cms.gov/NationalHealth- ExpendData/25_NHE_Fact_ Sheet.asp

Chambers, P. D. (2010). Tap the unique strengths of the mil- lennial generation. Nursing

Management, 41(3), 37–39.

Christianson, J. B., Volmar, K. M., Alexander, J., & Scanlon, D. P. (2010). A report card on provider report cards: Current status of the health care transpar- ency movement. Journal of General Internal Medicine, 25(11), 1235–1241.

Clancy, T. R. (2010). Technology and complexity: Trouble brewing? Journal of Nurs- ing Administration, 40(6), 247–249.

Dunton, N., Gonnerman, D., Montalvo, I., & Schumann, M. J. (2011). Incorporating nursing quality indicators in public reporting and value- based purchasing initiatives. American Nurse Today, 6(1), 14–18.

Encinosa, W. E., & Hellinger, F. J. (2008). The impact of medical errors on ninety- day costs and outcomes: An examination of sur- gical patients. Health Services Research, 43(6), 2067–2085.

Hader, R. (2010). The evident that isn’t . . . interpreting research. Nursing Manage- ment, 41(9), 23–26.

Health Resources and Services Administration (HRSA) (2011). The registered nurse population: Findings from the 2008 national sample survey of registered nurses. Retrieved April 26, 2011

from http://bhpr.hrsa.gov/ healthworkforce/ rnsurvey2008.html

Houser, J., & Oman, K. S. (2010). Evidence-based practice: An implementa- tion guide for healthcare organizations. Sudbury, MA: Jones & Bartlett.

Gomez, R. (2010). Automation: HER upgrade consider- ations. Nursing Manage- ment, 41(2), 35–37.

Institute of Medicine (1999). To err is human: Build- ing a safer health system. Washington, DC: National Academy Press.

Institute of Medicine (2010). The future of nursing: Leading change, advancing health. Retrieved April 26, 2011 from http://www. thefutureofnursing.org/ IOM-Report

Kaplan, A. M., & Haenlein, M. (2010). Users of the world, unite! The challenges and opportunities of social media. Business Horizons, 53(1), 59–68.

Keepnews, D. M., Brewer, C. S., Kovner, C. T., & Shin, J. H. (2010). Genera- tional differences among newly licensed registered nurses. Nursing Outlook, 58(3), 155–163.

Lake, E. T., Shang, J., Klaus, S., & Dunton, N. E. (2010). Patient falls: Association with hospi- tal magnet status and nursing unit staffing. Research in

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10 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

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http://stats.bls.gov/oco/ocos083.htm#outlook

CHAPTER

Traditional Organizational Theories

CLASSICAL THEORY

HUMANISTIC THEORY

SYSTEMS THEORY

CONTINGENCY THEORY

CHAOS THEORY

COMPLEXITY THEORY

Traditional Organizational Structures

FUNCTIONAL STRUCTURE

HYBRID STRUCTURE

MATRIX STRUCTURE

PARALLEL STRUCTURE

Service-Line Structures

Shared Governance

Ownership of Health Care Organizations

Health Care Settings PRIMARY CARE

ACUTE CARE HOSPITALS

HOME HEALTH CARE

LONG-TERM CARE

Complex Health Care Arrangements HEALTH CARE NETWORKS

INTERORGANIZATIONAL RELATIONSHIPS

DIVERSIFICATION

MANAGED HEALTH CARE ORGANIZATIONS

ACCOUNTABLE CARE ORGANIZATIONS

Redesigning Health Care

Strategic Planning

Organizational Environment and Culture

Designing Organizations 2

1. Discuss how organizational theories differ.

2. Describe the different types of health care organizations.

3. Explain how health care organizations are structured.

4. Discuss various ways that health care is provided.

5. Demonstrate how strategic planning guides the organization’s future.

6. Discuss how the organizational environment and culture affect workplace conditions.

Learning Outcomes After completing this chapter, you will be able to:

Key Terms Accountable care organization Bureaucracy Capitation Chain of command Diversification Goals Hawthorne effect Horizontal integration Integrated health care networks Line authority

Logic model Medical home Mission Objectives Organization Organizational culture Organizational environment Philosophy Redesign Retail medicine

Service-line structures Shared governance Span of control Staff authority Strategic planning Strategies Throughput Values Vertical integration Vision statement

12 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

A n organization is a collection of people working together under a defined structure to achieve predetermined outcomes using financial, human, and material resources. The justification for developing organizations is both rational and economic. Coordinated efforts capture more information and knowledge, purchase more technology, and produce more goods, services, opportunities, and securities than individual efforts. This chapter discusses or- ganizational theory, structures, and functions.

Traditional Organizational Theories The earliest recorded example of organizational thinking comes from the ancient Sumerian civi- lization, around 5000 b.c. The early Egyptians, Babylonians, Greeks, and Romans also gave thought to how groups were organized. Later, Machiavelli in the 1500s and Adam Smith in 1776 established the management principles we know as specialization and division of labor. Never- theless, organizational theory remained largely unexplored until the Industrial Revolution during the late 1800s and early 1900s, when a number of approaches to the structure and management of organizations developed. The early philosophies are traditionally labeled classical theory and humanistic theory while later approaches include systems theory, contingency theory, chaos theory, and complexity theory.

Classical Theory The classical approach to organizations focuses almost exclusively on the structure of the formal organization. The main premise is efficiency through design. People are seen as operating most productively within a rational and well-defined task or organizational design. Therefore, one designs an organization by subdividing work, specifying tasks to be done, and only then fitting people into the plan. Classical theory is built around four elements: division and specialization of labor, organizational structure, chain of command, and span of control.

Division and Specialization of Labor Dividing the work reduces the number of tasks that each employee must carry out, thereby increasing efficiency and improving the organization’s product. This concept lends itself to proficiency and specialization. Therefore, division of work and specialization are seen as economically beneficial. In addition, managers can standardize the work to be done, which in turn provides greater control.

Organizational Structure Organizational structure describes the arrangement of the work group. It is a rational approach for designing an effective organization. Classical theorists developed the concept of departmentaliza- tion as a means to maintain command, reinforce authority, and provide a formal system for commu- nication. The design of the organization is intended to foster the organization’s survival and success.

Characteristically, the structure takes shape as a set of differentiated but interrelated func- tions. Max Weber (1958) proposed the term bureaucracy to define the ideal, intentionally ratio- nal, most efficient form of organization. Today this word has a negative connotation, suggesting long waits, inefficiency, and red tape.

Chain of Command The chain of command is the hierarchy of authority and responsibility within the organization. Authority is the right or power to direct activity, whereas responsibility is the obligation to attain objectives or perform certain functions. Both are derived from one’s position within the organi- zation and define accountability. The line of authority is such that higher levels of management delegate work to those below them in the organization.

One type of authority is line authority, the linear hierarchy through which activity is directed. Another type is staff authority, an advisory relationship; recommendations and advice

CHAPTER 2 • DESIGNING ORGANIZATIONS 13

are offered, but responsibility for the work is assigned to others. In Figure 2-1, the relationships among the chief nurse executive, nurse manager, and staff nurse are examples of line authority. The relationship between the acute care nurse practitioner and the nurse manager illustrates staff authority. Neither the acute care nurse practitioner nor the nurse manager is responsible for the work of the other; instead, they collaborate to improve the efficiency and productivity of the unit for which the nurse manager is responsible.

Span of Control Span of control addresses the pragmatic concern of how many employees a manager can effec- tively supervise. Complex organizations usually have numerous departments that are highly spe- cialized and differentiated; authority is centralized, resulting in a tall organizational structure with many small work groups. Less complex organizations have flat structures; authority is decentral- ized, with several managers supervising large work groups. Figure 2-2 depicts the differences.

In the professional bureaucracy, the operating core of professionals is the dominant feature. Decision making is usually decentralized, and the technostructure is underdeveloped. The sup- port staff, however, is well developed. Most hospitals are professional bureaucracies.

Chief nurse executive

Staff nurse Staff nurse Staff nurse

Acute care nurse practitioner

Nurse manager

Figure 2-1 • Chain of authority.

Tall

Flat

Figure 2-2 • Contrasting spans of control. From Longest, B. B., Rakich, J. S., & Darr, K. (2000). Managing health services organizations and systems (4th ed.). Baltimore: Health Professions Press, p. 124. Reprinted by permission.

14 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

Organizational theories suggest organizational structures. Traditional structures (described later in the chapter) operationalize the tenets of classical theory.

Humanistic Theory Criticism of classical theory led to the development of humanistic theory, an approach identified with the human relations movement of the 1930s. A major assumption of this theory is that peo- ple desire social relationships, respond to group pressures, and search for personal fulfillment. This theory was developed as the result of a series of studies conducted by the Western Electric Company at its Hawthorne plant in Chicago. The first study was conducted to examine the effect of illumination on productivity. However, this study failed to find any relationship between the two. In most groups, productivity varied at random, and in one study productivity actually rose as illumination levels declined. The researchers concluded that unforeseen psychological factors were responsible for the findings.

Further studies of working conditions, such as rest breaks and the length of the workweek, still failed to reveal a relationship to productivity. The researchers concluded that the social set- ting created by the research itself—that is, the special attention given to workers as part of the research—enhanced productivity. This tendency for people to perform as expected because of special attention became known as the Hawthorne effect.

Although the findings are controversial, they led organizational theorists to focus on the so- cial aspects of work and organizational design. (See Chapter 17 for a description of motivational theories.) One important assertion of this school of thought was that individuals cannot be co- erced or bribed to do things they consider unreasonable; formal authority does not work without willing participants.

Systems Theory Organizational theorists who maintain a systems perspective view productivity as a function of the interplay among structure, people, technology, and environment. Like nursing theories based on systems theory (such as those of Roy and Neuman), organizational theory defines system as a set of interrelated parts arranged in a unified whole. Systems can be closed or open. Closed systems are self-contained and usually can be found only in the physical sciences. An open sys- tem, in contrast, interacts both internally and with its environment, much like a living organism.

An organization is a complex, sociotechnical, open system. This theory provides a frame- work by which the interrelated parts of the system and their functions can be studied. Resources, or input, such as employees, patients, materials, money, and equipment, are imported from the environment. Within the organization, energy and resources are utilized and transformed; work, a process called throughput, is performed to produce a product. The product, or output, is then exported to the environment. An organization, then, is a recurrent cycle of input, throughput, and output. Each health care organization—whether a hospital, ambulatory surgical center, or a home care agency, and so on—requires human, financial, and material resources. Each also provides a variety of services to treat illness, restore function, provide rehabilitation, and protect or promote wellness.

Throughput today is commonly associated with moving patients into and out of the sys- tem. Hospitals everywhere are focused on throughput of patients, such as if emergency depart- ments are on diversion, how long a patient has to wait for a bed, and the number of readmissions (Handel et al., 2010). Using information technology, bed management systems have emerged as a strategy to identify bed availability in real time (Gamble, 2009). Joint Commission accreditation standards now require hospitals to show data “throughput” statistics (Joint Commission, 2011).

Contingency Theory Contingency theory posits that organizational performance can be enhanced by matching an organization’s structure to its environment. The environment is defined as the people, objects,

CHAPTER 2 • DESIGNING ORGANIZATIONS 15

and ideas outside the organization that influence the organization. The environment of a health care organization includes patients and potential patients; third-party payers, including the gov- ernment; regulators; competitors; and suppliers of physical facilities, personnel (such as schools of nursing and medicine), equipment, and pharmaceuticals.

Health care organizations are unique with respect to the kinds of products and services they offer. However, like all other organizations, health care organizations are shaped by external and internal forces. These forces stem from the economic and social environment, the technologies used in patient care, organizational size, and the abilities and limitations of the personnel involved in the delivery of health care, including nurses, physicians, technicians, administrators, and, of course, patients.

Given the variety of health care services and patients served today, it should come as no sur- prise that organizations differ with respect to the environments they face, the levels of training and skills of their caregivers, and the emotional and physical needs of patients. It is naive to think that the form of organization best for one type of patient in one type of environment is appropriate for another type of patient in a completely different environment. Think about the differences in the environment of a substance abuse treatment center compared to a women’s health clinic. Thus, the optimal form of the organization is contingent on the circumstances faced by that organization.

Chaos Theory Chaos theory, which was inspired by the finding of quantum mechanics, challenges us to look at organizations and the nature of relationships and proposes that nature’s work does not follow a straight line. The elements of nature often move in a circular, ebbing fashion; a stream destined for the ocean, for example, never takes a straight path. In fact, very little in life operates as a straight line; people’s relationships to each other and to their work certainly do not. This notion challenges traditional thinking regarding the design of organizations. Organizations are living, self-organizing systems that are complex and self-adaptive.

The life cycle of an organization is fully dependent on its adaptability and response to changes in its environment. The tendency is for the organization to grow. When it becomes a large entity, it tends to stabilize and develop more formal standards. From that point, however, the organization tends to lose its adaptability and responsiveness to its environment.

Chaos theory suggests that the drive to create permanent organizational structures is doomed to fail. The set of rules that guided the industrial notions of organizational function and integrity must be discarded, and newer principles that ensure flexibility, fluidity, speed of adaptability, and cultural sensitivity must emerge. The role of leadership in these changing organizations is to build resilience in the midst of change and to maintain a balance between tension and order, which promotes creativity and prevents instability. This theory requires us to abandon our at- tachment to any particular model of design and to reflect instead on creative and flexible formats that can be quickly adjusted and changed as the organization’s realities shift.

Complexity Theory Complexity theory originated in the computational sciences when scientists noted that random events interfered with expectations. The theory is useful in health care because the environment is rife with randomness and complex tasks. Patients’ conditions change in an instant; necessary staff are not available; or equipment fails, all without warning. Tasks involve intricate interactions between and among staff, patients, and the environment. Managing in such ambiguous circumstances requires considering every aspect of the system as it interacts and adapts to changes. Complexity theory ex- plains why health care organizations, in spite of concerted efforts, struggle with patient safety.

Traditional Organizational Structures The optimal organizational structure integrates organizational goals, size, technology, and envi- ronment. Various organizational structures have been utilized over time. Examples include func- tional structures, hybrid structures, matrix structures, and parallel structures.

16 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

Functional Structure In functional structures, employees are grouped in departments by specialty, with similar tasks being performed by the same group, similar groups operating out of the same depart- ment, and similar departments reporting to the same manager. In a functional structure, all nursing tasks fall under nursing service; the same is true of other functional areas. Functional structures tend to centralize decision making because the functions converge at the top of the organization.

Functional structures have several weaknesses. Coordination across functions is poor. Decision-making responsibilities can pile up at the top and overload senior managers, who may be uninformed regarding day-to-day operations. Responses to the external environment that re- quire coordination across functions are slow. General management training is limited because most employees move up the organization within functional departments. Functional structures are uncommon in today’s rapidly changing health care environment.

Hybrid Structure When an organization grows, it typically organizes both self-contained units and functional units; the result is a hybrid organization. The hybrid structure can provide simultaneous coordi- nation within product divisions, can improve alignment between corporate and service or prod- uct goals, and foster adaptation to the environment while still maintaining efficiency.

The weakness of hybrid structures is conflict between top administration and managers. Managers often resent administrators’ intrusions into what they see as their own area of respon- sibility. Over time, organizations tend to accumulate large corporate staffs to oversee divisions in an attempt to provide functional coordination across service or product structures.

Matrix Structure The matrix structure is unique and complex; it integrates both product and functional structures into one overlapping structure. In a matrix structure, different managers are responsible for func- tion and product. For example, the nurse manager for the oncology clinic may report to the vice president for nursing as well as the vice president for outpatient services.

Matrices tend to develop where there are strong outside pressures for a dual organizational focus on product and function. The matrix is appropriate in a highly uncertain environment that changes frequently but also requires organizational expertise.

A major weakness of the matrix structure is its dual authority, which can be frustrating and confusing for departmental managers and employees. Excellent interpersonal skills are required from the managers involved. A matrix organization is time-consuming because frequent meetings are required to resolve problems and conflicts; the structure will not work unless participants can see beyond their own functional area to the big organizational picture. Finally, if one side of the matrix is more closely aligned with organizational objectives, that side may become dominant.

Parallel Structure Parallel structure is a structure unique to health care. It is the result of complex relationships that exist between the formal authority of the health care organization and the authority of its medi- cal staff. In a parallel structure, the medical staff is separate and autonomous from the organiza- tion. The result is an organizational dilemma: two lines of authority. One line extends from the governing body to the chief executive officer and then to the managerial structure; the other line extends from the governing body to the medical staff. These two intersect in departments such as nursing because decision making involves both managerial and clinical elements.

Parallel structures are found in health care institutions with a functional structure and sepa- rate medical governance structure. Parallel structures are becoming less successful as health care organizations integrate into newer models that incorporate physician practice under the organi- zational umbrella.

CHAPTER 2 • DESIGNING ORGANIZATIONS 17

Service-Line Structures More common in health care organizations today are service-line structures (Nugent et al., 2008). Service-line structures also are called product-line or service-integrated structures. In a service-line structure, clinical services are organized around patients with specific conditions (Figure 2-3).

Integrated structures are preferred in large and complex organizations because the same ac- tivity (for example, hiring) is assigned to several self-contained units, which can respond rapidly to the unit’s immediate needs. This is appropriate when environmental uncertainty is high and the organization requires frequent adaptation and innovation.

One of the strengths of the service-line structure is its potential for rapid change in a chang- ing environment. Because each division is specialized and its outputs can be tailored to the situa- tion, client satisfaction is high. Coordination across function (nursing, dietary, pharmacy, and so on) occurs easily; work partners identify with their own service and can compromise or collabo- rate with other service functions to meet service goals and reduce conflict. Service goals receive priority under this organizational structure because employees see the service outcomes as the primary purpose of their organization.

The major weaknesses of service-integrated structures include possible duplication of resources (such as ads for new positions) and lack of in-depth technical training and specialization. Coordination across service categories (oncology, cardiology, and the burn unit, for example) is difficult; services operate independently and often compete. Each service category, which is independent and autono- mous, has separate and often duplicate staff and competes with other service areas for resources. In addition, some service lines (e. g., pediatrics, obstetrics, bariatric surgery, and transplant centers) pres- ent special challenges due to low usage or the need for specialized personnel (Page, 2010).

Service-line structures are the most common structures found in Magnet-certified organiza- tions (Kaplow & Reed, 2008). Such structures, however, present a challenge to nursing adminis- trators and managers to maintain nursing standards across service lines (Hill, 2009). Armstrong, Laschinger, and Wong (2009) found improved patient safety in Magnet hospitals was related to nurses’ perception of empowerment. This can be explained, possibly, by Magnet standards that encourage staff participation in decision making.

Shared Governance Shared governance is a process for empowering nurses in the practice setting. It is based on a philosophy that nursing practice is best determined by nurses. Participative decision making is the hallmark of shared governance and a standard for Magnet certification. Interdependence and

Nursing Dietary

Oncology

CEO

Pharmacy Storeroom

Nursing Dietary Pharmacy Storeroom

Cardiology

Nursing Dietary

Burn unit

Pharmacy Storeroom

Figure 2-3 • Service line structure.

18 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

accountability are the basis for constructing a network of making nursing practice decisions in a decentralized environment. As a result, nurses gain significant control over their practice, ef- ficiency and accountability are improved, and feelings of powerlessness are mitigated.

The ultimate outcome of shared governance is that nurses participate in an accountable fo- rum to control their own practice within the health care organization. The assumption is that nursing staffs, like medical staffs, will predetermine the clinical skills of staff nurses and moni- tor the work of each through peer review while deciding on other practice issues through ac- countable forums or councils.

Shared governance allows staff nurses significant control over major decisions about nurs- ing practice. Most shared governance systems are similar to and reflect the principles often found in academic or medical governance models. As shown in the example in Figure 2-4, nurses par- ticipate in unit-based councils that interface with divisional councils, specialty councils, and a leadership council, consisting of nurse managers and administrators.

Decisions are made by consensus, rather than by the manager’s order or majority rule, a process that allows staff nurses an active voice in the decision. In the example in Figure 2-4, unit councils make decisions that directly affect the unit, divisional councils address issues that affect more than one unit, and a hospital-wide council determines overall issues.

The hospital-wide council consists of specific councils that address particular issues. The practice council, for example, is responsible for patient care standards. The professional development council maintains educational standards and competency assessments. The quality council monitors patient care quality. The research council assists in implementing evidence- based practice.

Although nursing practice councils have been operational for several decades, changes in health care and in organizational structures often require restructuring the councils, a process not without difficulty (Moore & Wells, 2010). Staffing shortages, patient demands and unfamiliarity with the process or its benefits may discourage participation.

Furthermore, not all shared governance models are successful (Ballard, 2010). Human fac- tors, such as lack of leadership, lack of staff or manager understanding of shared governance, or the absence of knowledgeable mentors, can impede the implementation of the model. Structural factors, such as a known structure for decision making, time available for meetings, and staffing support for attendance also can affect the success of shared governance.

With shared governance a Magnet standard, efforts to implement, refine and restructure the model in health care organizations is expected to continue (McDowell et al., 2010).

Ownership of Health Care Organizations Today’s health care organizations differ in ownership, role, activity, and size. Ownership can be either private or government, voluntary (not for profit) or investor-owned (for profit), and sectarian or non- sectarian (Figure 2-5). Private organizations are usually owned by corporations or religious entities,

Unit-based councils

Divisional council

Leadership council

Practice council

Professional development

council

Quality council

Research council

Figure 2-4 • Shared governance model. Adapted from McDowell, J. B., Williams, R. L., Kautz, D. D., Madden, P., Heilig, A., & Thompson, A. (2010). Shared governance: 10 years later. Nursing Management, 41(7), 32–37.

CHAPTER 2 • DESIGNING ORGANIZATIONS 19

whereas government organizations are operated by city, county, state, or federal entities, such as the Indian Health Service. Voluntary organizations are usually not for profit, meaning that surplus mon- ies are reinvested into the organization. Investor-owned, or for-profit corporations, distribute surplus monies back to the investors, who expect a profit. Sectarian agencies have religious affiliations.

Health Care Settings Organizations are further divided by the setting in which they deliver care. These include pri- mary care, acute care hospitals, home health care, and long-term care organizations.

Primary Care Primary care is considered the patient’s first encounter with the health care system. Primary care is deliv- ered in physician’s offices, emergency rooms, public health clinics, and in sites known as retail medicine.

PRIVATE (NONGOVERNMENT) OWNERSHIP

Voluntary (not for profit)

Roman Catholic, Salvation Army, Lutheran, Methodist, Baptist, Presbyterian, Latter-day Saints, Jewish

Community

Industrial (railroad, lumber, union) Kaiser-Permanente Plan Shriners hospitals

Investor- owned (for profit)

Individual owner partnership corporation

Single hospital (Investor-owned hospitals)

Sectarian

Nonsectarian

GOVERNMENT OWNERSHIP

Federal

State Long-term psychiatric, chronic, and other State university medical centers

Army Navy Air Force

Public Health Service Indian Health Service Other

Local

Hospital district or authority County City-county City

Department of Defense

Department of Veterans Affairs

Department of Health and Human Services

Department of Justice—prisons

Figure 2-5 • Types of ownership in health care organizations. From Longest, B. S., Rakich, J. S., & Darr, K. (2000). Managing Health Services Organizations and Systems (4th ed.). Baltimore: Health Professions Press, p. 173. Reprinted by permission.

20 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

Retail medicine describes walk-in clinics that provide convenient services for low-acuity illnesses without scheduled appointments. Staffed by nurse practitioners with physician backup, these clinics seem a natural expectation of today’s fast food, 24/7 public mindset. The Ameri- can Medical Association, however, has questioned the quality of care provided in these clinics (Costello, 2008).

Rohrer, Angstman, and Furst (2009) addressed quality of care in their study. They com- pared the reutilization rates of patients seen in a retail clinic with those in a large group physician practice. They surmised that if clinic patients had no higher return visits or emer- gency room visits for the same condition than physician office patients, then the quality of care could be assumed to be comparable in both settings. That is exactly what they found. So, according to this study, patients not only benefitted from the convenience of a walk-in clinic, but the quality of care they received was comparable to a private physician’s office visit. In addition, the cost of care was much lower than either physician offices or emer- gency rooms.

Another model of primary care is the logic model. The logic model is a practice-based re- search network (PBRN) that provides a framework for planning and evaluation of primary care (Hayes, Parchman, & Howard, 2011). The goal of this model is to improve the health outcomes of patients. Primary care outcomes are seldom evaluated. The logic model offers one way to determine if efforts and resources are used in the most productive way and if subjective outcomes, such as pa- tient satisfaction and easy access are achieved.

Acute Care Hospitals Hospitals are frequently classified by length of stay and type of service. Most hospitals are acute (short-term or episodic) care facilities, and they may be classified as general or special care fa- cilities, such as pediatric, rehabilitative, and psychiatric facilities. Many hospitals also serve as teaching institutions for nurses, physicians, and other health care professionals.

The term “teaching hospital” commonly designates a hospital associated with a medical school that maintains a house staff of residents on call 24 hours a day. Nonteaching hospitals, in contrast, have only private physicians on staff. Because private physicians are less accessible than house staff, the medical supervision of patient care differs, as may the role of the nurse. This designation is changing dramatically as new forms of physician groups and allied practices emerge in partnerships with hospitals and medical schools. Some organizations hire hospitalists, physicians who provide care only to hospital inpatients; those who care for patients in intensive care are known as intensivists.

Home Health Care Home health care is the intermittent, temporary delivery of health care in the home by skilled or unskilled providers. With shortened lengths of hospital stay, more acutely ill patients are dis- charged to recuperate at home. Furthermore, more people are surviving life-threatening illnesses or trauma and require extended care. The primary service provided by home care agencies is nursing care; however, larger home care agencies also offer other professional services, such as physical or occupational therapy, and durable medical equipment, such as ventilators, hospital beds, home oxygen equipment, and other medical supplies. Hospice care for the final days of a patient’s terminal illness may be provided by a home care agency or a hospital.

An outgrowth of the home health care industry is the temporary service agency. These agencies provide nurses and other health care workers to hospitals that are temporarily short- staffed; they also provide private duty nurses to individual patients either at home or in the hospital.

Long-Term Care Long-term care facilities provide professional nursing care and rehabilitative services. They may be freestanding, part of a hospital, or affiliated with a health care organization. Usually, length of

CHAPTER 2 • DESIGNING ORGANIZATIONS 21

stay is limited. Residential care facilities, also known as nursing homes, are sheltered environ- ments in which long-term care is provided by nursing assistants with supervision from licensed professional or registered nurses.

As the population ages and the frail elderly account for more and more of the nation’s citi- zens, care in long-term care facilities is growing (Weaver et al., 2008). These organizations pose different problems for staff. Ageism and infantilism permeate many settings (Ryvicker, 2009). In addition, patients often transition between the nursing home and the hospital, and that care may be fragmented and lead to poor outcomes (Naylor, Kurtzman, & Pauly, 2009). Challenges in providing care to the elderly include addressing the tendency to stigmatize older, frail adults and to provide continuity of care across settings.

Complex Health Care Arrangements Health Care Networks Integrated health care networks emerged as organizations struggled to find ways to survive in today’s cost-conscious environment. Integrated systems encompass a variety of model organiza- tional structures, but certain characteristics are common. Network systems

● Deliver a continuum of care; ● Provide geographic coverage for the buyers of health care services; and ● Accept the risk inherent in taking a fixed payment in return for providing health care for

all persons in the selected group, such as all employees of one company.

To provide such services, networks of providers evolved to encompass hospitals and physi- cian practices. Most importantly, the focal point for care is primary care rather than the hospital. The goal is to keep patients healthy by treating them in the setting that incurs the lowest cost and thereby reducing expensive hospital treatments. The former goal—to keep hospital beds filled— has been replaced with a new goal: to keep patients out of them!

A variety of other arrangements have emerged, varying from loose affiliations between hos- pitals to complete mergers of hospitals, clinics, and physician practices. These arrangements continue to move and shift as alliances fail, return to separate entities, and form new affiliations. Changes in health care payments offer possibilities for nurses to practice in expanding primary care networks are anticipated.

Interorganizational Relationships With increased competition for resources and public and governmental pressures for better efficiency and effectiveness, organizations have been forced to establish relationships with one another for their continued survival. Multihospital systems and multiorganizational ar- rangements, both formal and informal, are mechanisms by which these relationships have formed.

Arrangements between or among organizations that provide the same or similar services are examples of horizontal integration. For instance, all hospitals in the network provide compa- rable services, as shown in Figure 2-6.

Vertical integration, in contrast, is an arrangement between or among dissimilar but re- lated organizations to provide a continuum of services. An affiliation of a health maintenance organization with a hospital, pharmacy, and nursing facility represents vertical integration (see Figure 2-7).

Numerous arrangements using horizontal and vertical integration can be found, and these models likely will become the common structure for delivery of health care. Examples of such arrangements include affiliations, consortia, alliances, mergers, and consolidations. An assort- ment of health care agencies under the umbrella of a corporate network is shown in the example in Figure 2-8.

22 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

Hospital A

Hospital B

Hospital C

Hospital D

Hospital E

Hospital F

Hospital G

Figure 2-6 • Horizontal integration.

Acute care hospital

Long-term care facility

Home health agency

Ambulatory care clinic

Sports medicine clinic

Hospice care

Figure 2-7 • Vertical integration.

Hospital Imaging center

Home care services

Medical group

practice

Skilled nursing facility

Ambulatory surgical center

Long-term care

Corporate board

Figure 2-8 • Corporate health care network.

Diversification Diversification provides another strategy for survival in today’s economy. Diversification is the expansion of an organization into new arenas. Two types of diversification are common: concen- tric and conglomerate.

Concentric diversification occurs when an organization complements its existing services by expanding into new markets or broadening the types of services it currently has available. For example, a children’s hospital might open a day-care center for developmentally delayed children or offer drop-in facilities for sick child care.

Conglomerate diversification is the expansion into areas that differ from the original product or service. The purpose of conglomerate diversification is to obtain a source of income that will support the organization’s product or service. For example, a long-term care facility might develop real estate or purchase a company that produces durable medical equipment.

Another type of diversification common to health care is the joint venture. A joint venture is a partnership in which each partner contributes different areas of expertise, resources, or services to create a new product or service. In one type of joint venture, one partner (general partner) finances and manages the venture, whereas the other partner (limited partner) pro- vides a needed service. Joint ventures between health care organizations and physicians are becoming increasingly common. Integrated health care organizations, hospitals, and clinics seek physician and/or practitioner groups they can bond (capture) in order to obtain more referrals. The health care organization as financier and manager is the general partner, and physicians are limited partners.

CHAPTER 2 • DESIGNING ORGANIZATIONS 23

Managed Health Care Organizations The managed health care organization is a system in which a group of providers is responsible for delivering services (that is, managing health care) through an organized arrangement with a group of individuals (for example, all employees of one company, all Medicaid patients in the state). Different types of managed-care organizations exist: health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point-of-service plans (POS).

An HMO is a geographically organized system that provides an agreed-on package of health maintenance and treatment services provided to enrollees at a fixed monthly fee per enrollee, called capitation. Patients are required to choose providers within the network.

In a PPO, the managed-care organization contracts with independent practitioners to pro- vide enrollees with established discounted rates. If an enrollee obtains services from a nonpar- ticipating provider, significant copayments are usually required.

Point-of-service (POS) is considered to be an HMO–PPO hybrid. In a POS, enrollees may use the network of managed-care providers to go outside the network as they wish. However, use of a pro- vider outside the network usually results in additional costs in copayments, deductibles, or premiums.

Accountable Care Organizations Effective January 2012, accountable care organizations have been able to contract with Medicare to provide care to a group of Medicare recipients (Ansel & Miller, 2010). Strong incentives to reduce cost, share information across networks and improve quality are included in the provisions for reimbursement.

An accountable care organization consists of a group of health care providers that provide care to a specified group of patients. Various structures can be used in accountable care organiza- tions from loosely affiliated groups of providers to integrated delivery systems. An accountable care organization is more flexible than a HMO because consumers are free to choose providers from outside the network. Cognizant of the potential for Medicare contracts and, later, reim- bursement by other third-party payers, health care providers and organizations are scrambling to establish collaborative arrangements and networks.

Redesigning Health Care Health care is a dynamic environment with multiple factors impinging on continuity and stability. Implementation of accountable care organizations, demands for safe, quality care, Magnet standards that promote decentralized organizational structures and an aging population with multiple chronic conditions are just two of the factors that make redesigning health care a reality today.

Redesign includes strategies to better provide safe, efficient, quality health care. Some ex- amples of redesign strategies include adopting a patient-centered care model, focusing on spe- cific service lines, applying lean thinking to the system, and establishing a flat, decentralized organizational structure.

The Institute of Medicine’s 2001 report, Crossing the Quality Chasm, recommended ways to improve health care. One of those was to adopt a patient-centered care model (IOM, 2001). Success in implementing a patient- and family-centered care model has been reported in the lit- erature (Zarubi, Reiley & McCarter, 2008).

Another patient-centered model is the medical home (Berenson et al., 2008). Centered by a primary care provider (primary care physician or nurse practitioner), a medical home links all care providers in the “home.” The goal is to provide continuous, accessible, and comprehen- sive care. Challenges for coordinating care in a medical home include communication (e.g., ab- sence of electronic medical records for all providers), the multiple needs of patients with chronic health problems, discomfort of patients and providers to use electronic communication of data and information, and compensation for primary care. To offset some of these challenges are sev- eral suggestions (Berenson et al., 2008). These include implementing electronic medical records

24 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

using nurse practitioners to manage patients with chronic conditions, encouraging patients to self-manage chronic conditions, and persuading providers to use electronic communication with patients.

To meet both quality and cost-effective goals, the health care organization may decide to concentrate on specific service lines. Called big-dot focus areas, an organization selects a few major initiatives. They might, for example, put resources into building cardiology, cancer, and neuroscience while maintaining other services as is.

Another strategy is to adopt the quality concepts of lean thinking to redesign (Joosten, Bongers, & Janssen, 2009). Lean thinking focuses on the system rather than on individuals, concentrates on interventions that improve outcomes and disregards those that have little or no effect. A flat, decentralized organizational structure centers decision making closest to the problem. It promotes unit-based decision making and empowers staff to implement process improvements in a timely manner (Kramer, Schmalenberg, & Maguire, 2010). Furthermore, a decentralized structure encourages communication and collaboration and provides a quality im- provement infrastructure.

Redesigning an organization presents numerous challenges. Staff may be concerned that their jobs will change or may disappear. Administrators may complain that loss of authority will result in poor performance. Everyone may worry that cost effective measures may diminish the quality of care. Significant stress is to be expected (Lavoie-Tremblay et al., 2010).

Nurse managers are key players in the redesign efforts. They are expected not only to initi- ate change while reducing costs, maintaining or improving quality of care, coaching and men- toring, and team building, but also to do so in an ever-changing environment full of ambiguities while their own responsibilities are expanded.

Strategic Planning Successful organizations know that they must focus their resources on their unique strengths, and health care is no exception. Organizations that focus on a few strategic initiatives, as dis- cussed previously, do so after an intensive planning process. The competitive health care en- vironment and limited resources require organizations to respond to public demands for safe, accessible quality health care.

This is a time-consuming and demanding process and should not be undertaken hurriedly. Put in use, however, a well-thought-out strategic plan guides the organization toward its goals, helps all the staff stay directed, and prevents the organization from responding to inappropriate requests.

A strategic plan projects the organization’s goals and activities into the future, usually two to five years ahead (Schaffner, 2009). Based on the organization’s philosophy and leaders’ as- sessment of their organization and the environment, strategic planning guides the direction the organization is to take.

The philosophy is a written statement that reflects the organizational values, vision, and mission (Conway-Morana, 2009). Values are the beliefs or attitudes one has about people, ideas, objects, or actions that form a basis for behavior. Organizations use value statements to identify those beliefs or attitudes esteemed by the organizational leaders.

A vision statement describes the goal to which the organization aspires. The vision state- ment is designed to inspire and motivate employees to achieve a desired state of affairs. “Our vision is to be a regional integrated health care delivery system providing premier health care services, professional and community education, and health care research” is an example of a vision statement for a health care system.

The mission of an organization is a broad, general statement of the organization’s reason for existence. Developing the mission is the necessary first step to designing a strategic plan. “Our mission is to improve the health of the people and communities we serve” is an example of a mission statement that guides decision making for the organization. Purchasing a medical equipment company, for example, might not be considered because it fails to meet the mission of improving the community’s health.

CHAPTER 2 • DESIGNING ORGANIZATIONS 25

The strategic plan is based on the organization’s philosophy, vision, and mission. The first steps in strategic planning are:

● Appoint a strategic planning committee ● Interview key stakeholders ● Conduct a SWOT (strengths, weaknesses, opportunities, and threats) analysis ● Develop the plan ● Communicate the plan

People who are enthusiastic, experienced, and committed to the organization are the best representatives to serve on the planning committee. Naysayers can be included once some parts of the plan are formulated. Everyone in the organization must be involved even peripherally. “Buy-in” is critical to the plan’s success.

Stakeholders include physicians, administrators, nurses, ancillary and support staff, and community representatives. They will have differing opinions about what the organization can and should do and provide valuable information unavailable elsewhere.

The SWOT analysis includes assessment of the external and internal environment (Kalisch & Curley, 2008). Data is collected from multiple sources, including stakeholder information.

To develop the plan:

● Determine goals, objectives and strategies ● Assess the projected costs ● Assign responsible units or individuals ● Identify outcome measures and expected dates of completion

Goals are specific statements of what outcome is to be achieved. Goals describe outcomes that are measurable and precise. “Every patient will be satisfied with his or her care” is an example of a goal.

Goals apply to the entire organization, whereas objectives are specific to an individual unit. A nursing objective to meet the above goal might be “Provide appropriate information and ed- ucation to patients from preadmission to discharge.” Strategies follow objectives and specify what actions will be taken. “Implement patient education classes for prenatal patients” is an example of a strategy to meet the patient satisfaction objective.

Other categories in a strategic plan include identifying the personnel responsible for each activity, determining the projected cost, establishing criteria to recognize that the goal has been met, and deciding the expected date of completion.

Strategic planning is an ongoing process, not an end in itself. It requires meticulous atten- tion to how the organization is meeting its goals and, if goals are not met, what the reasons are for the variance. Maybe the goal needs to change, or possibly other personnel should be assigned to the task. Perhaps a change in the environment (reimbursement) or within the organization (shortage of key personnel) requires the goal to be abandoned. Continual evaluation will help the organization target its resources best.

Organizational Environment and Culture The terms organizational environment and organizational culture both describe internal con- ditions in the work setting. Organizational environment is the systemwide conditions that con- tribute to a positive or negative work setting. In 2005, the American Association of Critical-Care Nurses identified six characteristics of a healthy work environment, characteristics that the orga- nization continues to promote (AACN, 2011 ). The characteristics are:

● Skilled communication ● True collaboration ● Effective decision making ● Appropriate staffing ● Meaningful recognition ● Authentic leadership.

26 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

One way to assess the organizational environment is to evaluate the qualities of those hired for key positions in the organization. An organization in which nursing leaders are in- novative, creative, and energetic will tend to operate in a fast-moving, goal-oriented fashion. If humanistic, interpersonal skills are sought in candidates for leadership positions, the or- ganization will focus on human resources, employees, and patient advocacy (Hersey, 2011).

Organizational culture, on the other hand, are the basic assumptions and values held by members of the organization (Sullivan, 2013). These are often known as the unstated “rules of the game.” For example, who wears a lab coat? When is report given? To whom? Is tardiness tolerated? How late is acceptable?

Like environment, organizational culture varies from one institution to the next and subcul- tures and even countercultures, groups whose values and goals differ significantly from those of the dominant organization, may exist. A subculture is a group that has shared experiences or like interests and values. Nurses form a subculture within health care environments. They share a common language, rules, rituals, dress, and have their own unstated rules. Individual units also can become subcultures.

Systems involving participatory management and shared governance create organizational environments that reward decision making, creativity, independence, and autonomy (Kramer, Schmalenberg, & Maguire, 2010). These organizations retain and recruit independent, ac- countable professionals. Organizations that empower nurses to make decisions will better meet consumer requests. As the health care environment continues to evolve, more and more organi- zations are adopting consumer-sensitive cultures that require accountability and decision mak- ing from nurses.

What You Know Now • The schools of organizational theory include classical theory, humanistic theory, systems theory, contin-

gency theory, chaos theory, and complexity theory. • Organizations can be viewed as social systems consisting of people working in a predetermined pattern of

relationships who strive toward a goal. The goal of health care organizations is to provide a particular mix of health services.

• Traditional organizational structures include functional, hybrid, matrix, and parallel structures. • Service-line structures organize clinical services around specific patient conditions. • Shared governance provides the framework for empowerment and partnership within the health care

organization. • Accountable care organizations are recent additions to health care design. They can contract with a payer

to provide care to a specific group of patients. • The medical home is one of the patient-centered models where all services are provided by a group of

health care professionals. • Strategic planning is a process used by organizations to focus their resources on a limited number of

activities. • Organizational environment and culture affect the internal conditions of the work setting.

Questions to Challenge You 1. Secure a copy of the organizational chart from your employment or clinical site. Would you describe

the organization the same way the chart depicts it? If not, redraw a chart to illustrate how you see the organization.

2. What organizational structure would you prefer? Think about how you might go about finding an organization that meets your criteria.

3. Organizational theories explain how organizations function. Which theory or theories describes your organization’s functioning? Do you think it is the same theory your organization’s administrators would use to describe it? Explain.

CHAPTER 2 • DESIGNING ORGANIZATIONS 27

4. Have you been involved in strategic planning? If so, explain what happened and how well it worked in directing the organization’s activities.

5. Using the six characteristics of a healthy work environment in the chapter, evaluate the organiza- tion where you work or have clinicals. How well does it rate? What changes would improve the environment?

American Association of Criti- cal Care Nurses (AACN). (2011). AACN standards for establishing and sustaining healthy work environments. Retrieved May 5, 2011 from http://www.aacn. org/WD/HWE/Docs/ HWEStandards.pdf

Ansel, T. C., & Miller, D. W. (2010). Reviewing the land- scape and defining the core competencies needed for a successful accountable care organization. Louisville, KY: Healthcare Strategy Group.

Armstrong, K., Laschinger, H., & Wong, C. (2009). Work- place empowerment and Magnet hospital characteris- tics as predictors of patient safety climate. Journal of Nursing Care Quality, 24(1), 55–62.

Ballard, N. (2010). Factors as- sociated with success and breakdown of shared gov- ernance. Journal of Nursing Administration, 40(10), 411–416.

Berenson, R. A., Hammons, T., Gans, D. H., Zuckerman, S., Merrell, K., Underwood, W. S., & Williams, A. F. (2008). A house is not a home: Keeping patients at the center of practice

redesign. Health Affairs, 27(5), 1219–1230.

Conway-Morana, P. L. (2009). Nursing strategy: What’s your plan? Nursing Man- agement, 40(3), 25–29.

Costello, D. (2008). Report from the field: A checkup for retail medicine. Health Af- fairs, 27(5), 1299–1303.

Gamble, K. H. (2009). Con- necting the dots: Patient flow systems are being leveraged to increase throughput, improve com- munication, and provide a more complete view of care. Healthcare Informat- ics, 25(13), 27–29.

Handel, D. A., Hilton, J. A., Ward, M. J., Rabin, E., Zwemer, F. L., & Pines, J. M. (2010). Emergency department throughput, crowding, and financial outcomes for hospitals. Academic Emergency Medicine, 17(8), 840–847.

Hayes, H., Parchman, M. L., & Howard, R. (2011). A logic model framework for evaluation and planning in a primary care practice-based research network (PBRN). Journal of the American Board of Family Medicine, 24(5), 576–582.

Hersey, P. H. (2011). Management of organizational behavior (10th ed.). Upper Saddle River, NJ: Prentice Hall.

Hill, K. S. (2009). Service line structures: Where does this leave nursing? Journal of Nursing Administration, 39(4), 147–148.

Institute of Medicine (2001). Crossing the quality chasm: A new health sys- tem for the 21st century. Retrieved October 24, 2011 from http://www. iom.edu/Reports/2001/ Crossing-the-Quality- Chasm-A-New-Health- System-for-the-21st- Century.aspx

Joint Commission (2011). Edition standards. Retrieved May 12, 2011 from http:// www.jcrinc.com/ E-dition-Home/Joosten, T., Bongers, I., & Janssen, R. (2009). Application of lean thinking to health care: Issues and observations. International Journal of Quality in Health Care, 21(5), 341–347.

Kalisch, B. J., and Curley, M. (2008). Transforming a nursing organization. Jour- nal of Nursing Administra- tion, 38(2), 76–83.

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

References

http://www.aacn.org/WD/HWE/Docs/HWEStandards.pdf

http://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx

http://www.jcrinc.com/E-dition-Home/Joosten

www.nursing.pearsonhighered.com

http://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx

28 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

Kaplow, R., & Reed, K. D. (2008). The AACN synergy model for patient care: A nursing model as a force of magnetism. Nursing Eco- nomics, 26(1), 17–25.

Kramer, M., Schmalenberg, C., & Maguire, P. (2010). Nine structures and leadership practices essential for a magnetic (healthy) work environment. Nursing Administration Quarterly, 34(1), 4–17.

Lavoie-Tremblay, M., Bonin, J. P., Lesage, A. D., Bonneville-Roussy, A., Lavigne, G. L., & Laroche, D. (2010). Contribution of the psycho- social work environment to psychological distress among health care profes- sionals before and during a major organizational change. The Health Care Manager, 29(4), 293–304.

McDowell, J. B., Williams, R. L., Kautz, D. D., Madden, P., Heilig, A., & Thompson, A. (2010). Shared Governance: 10 years later. Nursing Management, 41(7), 32–37.

Moore, S. C., & Wells, N. J. (2010). Staff nurses lead the way for improvement to shared governance struc- ture. Journal of Nursing

Administration, 40(11), 477–482.

Naylor, M. D., Kurtzman, E. T., & Pauly, M. V. (2009). Tran- sitions of elders between long-term care and hospitals. Policy, Politics, & Nursing Practice, 10(3), 187–194.

Nugent, M., Nolan, K. C., Brown, F., & Rogers, S. (2008, May 1). Seamless service line management: Service line organization is as important as market strategy if providers are to optimize their limited capital investment pool. Healthcare Financial Man- agement. Retrieved May 3, 2011 from http://www. hfma.org/Templates/Interior Master.aspx?id=1523

Page, L. (2010). Challenges facing 10 hospital service- lines. Retrieved May 3, 2011 from www. beckershospitalreview. com/news-analysis/ challenges-facing-10- hospital-service-lines.html

Rohrer, J. E., Angstman, K. B., & Furst, J. W. (2009). Impact of retail walk-in care on early return visits by adult primary care patients: Evalu- ation via triangulation. Qual- ity Management in Health Care, 18(1), 19–24.

Ryvicker, M. (2009). Preserva- tion of self in the nursing home: Contradictory prac- tices within two models of care. Journal of Aging Stud- ies, 23(1), 12–23.

Schaffner, J. (2009). Roadmap for success: The 10-step nursing strategic plan. Jour- nal of Nursing Administra- tion, 39(4), 152–155.

Sullivan, E. J. (2013). Becom- ing influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall.

Weaver, F. M., Hickey, E. C., Hughes, S. L., Parker, V., Fortunato, D., Rose, J., Cohen, S., Robbins, L., Orr, W., Priefer, B., Wieland, D., & Baskins, J. (2008). Providing all-inclusive care for frail elderly veterans: Evaluation of three mod- els of care. Journal of the American Geriatric Society, 56(2), 345–353.

Zarubi, K. L., Reiley, P. & McCarter, B. (2008). Put- ting patients and families at the center of care. Journal of Nursing Administration, 38(6), 275–281.

http://www.hfma.org/Templates/InteriorMaster.aspx?id=1523

www.beckershospitalreview.com/news-analysis/challenges-facing-10-hospital-service-lines.html

http://www.hfma.org/Templates/InteriorMaster.aspx?id=1523

www.beckershospitalreview.com/news-analysis/challenges-facing-10-hospital-service-lines.html

CHAPTER

Traditional Models of Care FUNCTIONAL NURSING

TEAM NURSING

TOTAL PATIENT CARE

PRIMARY NURSING

Integrated Models of Care PRACTICE PARTNERSHIPS

CASE MANAGEMENT

CRITICAL PATHWAYS

DIFFERENTIATED PRACTICE

Evolving Models of Care PATIENT-CENTERED CARE

SYNERGY MODEL OF CARE

CLINICAL MICROSYSTEMS

CHRONIC CARE MODEL

Delivering Nursing Care 3

Chronic care model Clinical microsystems

Critical pathways Patient-centered care

Practice partnership Synergy model of care

Key Terms

1. Describe how the delivery system structures nursing care.

2. Describe what types of nursing care delivery systems exist.

3. Discuss the positive and negative aspects of different systems.

4. Describe evolving types of delivery systems that have emerged.

5. Explain characteristics of effective delivery systems.

Learning Outcomes After completing this chapter, you will be able to:

30 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

T he core business of a health care organization is providing nursing care to patients. The purpose of a nursing care delivery system is to provide a structure that enables nurses to deliver nursing care to a specified group of patients. The delivery of care

includes assessing care needs, formulating a plan of care, implementing the plan, and evaluating the patient’s responses to interventions. This chapter describes how nursing care is organized to ensure quality care in an era of cost containment.

Since World War II, nursing care delivery systems have undergone continuous and significant changes (Box 3-1). Over the years, various nursing care delivery systems have been tried and critiqued. Debates regarding the pros and cons of each method have focused on identifying the perfect delivery system for providing nursing care to patients with varying degrees of need.

In addition, a delivery system must utilize specific nurses and groups of nurses, optimizing their knowledge and skills while at the same time ensuring that patients receive appropriate care. It’s no small challenge. In fact, researchers have found that a better hospital environment for nurses is associ- ated with lower mortality rates (Aiken et al., 2008) and nurse satisfaction (Spence-Laschinger, 2008).

Traditional Models of Care Functional Nursing Functional nursing, also called task nursing, began in hospitals in the mid-1940s in response to a national nursing shortage (see Figure 3-1). The number of registered nurses (RNs) serving in the armed forces during World War II depleted the supply of nurses at home. As a result of this loss of RNs, the composition of nursing staffs in hospitals changed. Staff that had been composed almost entirely of RNs gave way to the widespread use of licensed practical nurses (LPNs) and unlicensed assistive personnel (UAPs) to deliver nursing care.

In functional nursing, the needs of a group of patients are broken down into tasks that are assigned to RNs, LPNs, or UAPs so that the skill and licensure of each caregiver is used to his or her best advantage. Under this model an RN assesses patients whereas others give baths, make beds, take vital signs, administer treatments, and so forth. As a result, the staff become very efficient and effective at performing their regular assigned tasks.

BOX 3-1 Job Description of a Floor Nurse (1887)

Developed in 1887 and published in a magazine of Cleveland Lutheran Hospital.

In addition to caring for your 50 patients, each nurse will follow these regulations:

1. Daily sweep and mop the floors of your ward, dust the patients’ furniture and window sills.

2. Maintain an even temperature in your ward by bringing in a scuttle of coal for the day’s business.

3. Light is important to observe the patient’s condi- tion. Therefore, each day fill kerosene lamps, clean chimneys, and trim wicks. Wash windows once a week.

4. The nurse’s notes are important to aiding the phy- sician’s work. Make your pens carefully. You may whittle nibs to your individual taste.

5. Each nurse on day duty will report every day at 7 A.M. and leave at 8 P.M., except on the Sabbath, on which you will be off from 12 noon to 2 P.M.

6. Graduate nurses in good standing with the Direc- tor of Nurses will be given an evening off each week for courting purposes, or two evenings a week if you go regularly to church.

7. Each nurse should lay aside from each pay a goodly sum of her earnings for her benefits during her declining years, so that she will not become a burden. For example, if you earn $30 a month you should set aside $15.

8. Any nurse who smokes, uses liquor in any form, gets her hair done at a beauty shop, or frequents dance halls will give the Director of Nurses good reason to suspect her worth, intentions, and integrity.

9. The nurse who performs her labor, serves her patients and doctors faithfully and without fault for a period of five years will be given an increase by the hospital administration of five cents a day providing there are no hospital debts that are outstanding.

CHAPTER 3 • DELIVERING NURSING CARE 31

Disadvantages of functional nursing include:

● Uneven continuity ● Lack of holistic understanding of the patient ● Problems with follow-up

Because of these problems, functional nursing care is used infrequently in acute care facilities and only occasionally in long-term care facilities.

Team Nursing Team nursing (Figure 3-2) evolved from functional nursing and has remained popular since the middle to late 1940s. Under this system, a team of nursing personnel provides total patient care to a group of patients. In some instances, a team may be assigned a certain number of patients; in others, the assigned patients may be grouped by diagnoses or provider services.

The size of the team varies according to physical layout of the unit, patient acuity, and nurs- ing skill mix. The team is led by an RN and may include other RNs, LPNs, and UAPs. Team members provide patient care under the direction of the team leader. The team, acting as a uni- fied whole, has a holistic perspective of the needs of each patient. The team speaks for each patient through the team leader.

Typically, the team leader’s time is spent in indirect patient care activities, such as:

● Developing or updating nursing care plans ● Resolving problems encountered by team members ● Conducting nursing care conferences ● Communicating with physicians and other health care personnel

With team nursing, the unit nurse manager consults with team leaders, supervises patient care teams, and may make rounds with all physicians. To be effective, team nursing requires that all team members have good communication skills. A key aspect of team nursing is the nursing care conference, where the team leader reviews with all team members each patient’s plan of care and progress.

Charge nurse

UAP responsible for transportation

UAP responsible for vital signs

UAP with bath duty

Treatment nurse

Medication nurse

Patients

Figure 3-1 • Functional nursing.

Charge nurse

Team/module leaderTeam/module leaderTeam/module leader

RN, LPN, UAP RN, LPN, UAP RN, LPN, UAP

Patients Patients Patients

Figure 3-2 • Team/modular nursing.

32 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

Advantages of team nursing are:

● It allows the use of LPNs and UAPs to carry out some functions (e.g., making beds, trans- porting patients, collecting some data) that do not require the expertise of an RN.

● It allows patient care needs requiring more than one staff member, such as patient trans- fers from bed to chair, to be easily coordinated.

● The geographical boundaries of team nursing help save steps and time.

Disadvantages of team nursing are:

● A great deal of time is needed for the team leader to communicate, supervise, and coordi- nate team members.

● Continuity of care may suffer due to changes in team members, leaders, and patient assignments.

● No one person considers the total patient. ● There may be role confusion and resentment against the team leader, who staff may

view as more focused on paperwork and less directed at the physical or real needs of the patient.

● Nurses have less control over their assignments due to the geographical boundaries of the unit.

● Assignments may not be equal if they are based on patient acuity or may be monotonous if nurses continuously care for patients with similar conditions (e.g., all patients with hip replacements).

Skills in delegating, communicating, and problem solving are essential for a team leader to be effective. Open communication between team leaders and the nurse manager is also im- portant to avoid duplication of effort, overriding of delegated assignments, or competition for control or power. Problems in delegation and communication are the most common reasons why team nursing is less effective than it theoretically could be.

Total Patient Care The original model of nursing care delivery was total patient care, also called case method (Figure 3-3), in which a registered nurse was responsible for all aspects of the care of one or more patients. During the 1920s, total patient care was the typical nursing care delivery system. Student nurses often staffed hospitals, whereas RNs provided total care to the patient at home. In total patient care, RNs work directly with the patient, family, physician, and other health care staff in implementing a plan of care.

The goal of this delivery system is to have one nurse give all care to the same patient(s) for the entire shift. Total patient care delivery systems are typically used in areas requiring a high level of nursing expertise, such as in critical care units or postanesthesia recovery areas.

The advantages of a total patient care system include:

● Continuous, holistic, expert nursing care ● Total accountability for the nursing care of the assigned patient(s) for that shift ● Continuity of communication with the patient, family, physician(s), and staff from other

departments

Charge nurse

RNRNRN

Patients Patients Patients

Figure 3-3 • Total patient care.

CHAPTER 3 • DELIVERING NURSING CARE 33

The disadvantage of this system is that RNs spend some time doing tasks that could be done more cost-effectively by less skilled persons. This inefficiency adds to the expense of using a total patient care delivery system.

Primary Nursing Conceptualized by Marie Manthey and implemented during the late 1960s after two decades of team nursing, primary nursing (Figure 3-4) was designed to place the registered nurse back at the patient’s bedside (Manthey, 1980). Decentralized decision making by staff nurses is the core principle of primary nursing, with responsibility and authority for nursing care allocated to staff nurses at the bedside. Primary nursing recognized that nursing was a knowledge-based profes- sional practice, not just a task-focused activity.

In primary nursing, the RN maintains a patient load of primary patients. A primary nurse designs, implements, and is accountable for the nursing care of patients in the patient load for the duration of the patient’s stay on the unit. Actual care is given by the primary nurse and/or associate nurses (other RNs).

Primary nursing advanced the professional practice of nursing significantly because it provided:

● A knowledge-based practice model ● Decentralization of nursing care decisions, authority, and responsibility to the staff nurse ● 24-hour accountability for nursing care activities by one nurse ● Improved continuity and coordination of care ● Increased nurse, patient, and physician satisfaction.

Primary nursing also has some disadvantages, including:

● It requires excellent communication between the primary nurse and associate nurses. ● Primary nurses must be able to hold associate nurses accountable for implementing the

nursing care as prescribed. ● Because of transfers to different units, critically ill patients may have several primary care

nurses, disrupting the continuity of care inherent in the model. ● Staff nurses are neither compensated nor legally responsible for patient care outside their

hours of work. ● Associates may be unwilling to take direction from the primary nurse.

Although the concept of 24-hour accountability is worthwhile, it is a fallacy. When primary nursing was first implemented, many organizations perceived that it required an all–RN staff. This practice was viewed as not only expensive but also ineffective because many tasks could be done by less skilled persons. As a result, many hospitals discontinued the use of primary nurs- ing. Other hospitals successfully implemented primary nursing by identifying one nurse who was assigned to coordinate care and with whom the family and physician could communicate, and other nurses or unlicensed assistive personnel assisted this nurse in providing care.

Patient

Other health care providers

Primary nurse Charge nurse

Associate nurse Associate nurse

Figure 3-4 • Primary nursing.

34 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

Integrated Models of Care Practice Partnerships The practice partnership (Figure 3-5) was introduced by Marie Manthey in 1989 (Manthey, 1989). In the practice partnership model, an RN and an assistant—UAP, LPN, or less experi- enced RN—agree to be practice partners. The partners work together with the same schedule and the same group of patients. The senior RN partner directs the work of the junior partner within the limits of each partner’s abilities and within limits of the state’s nurse practice act.

The relationship between the senior and junior partner is designed to create synergistic en- ergy as the two work in concert with patients. The senior partner performs selected patient care activities but delegates less specialized activities to the junior partner. When compared to team nursing, practice partnerships offer more continuity of care and accountability for patient care. When compared to total patient care or primary nursing, partnerships are less expensive for the organization and more satisfying professionally for the partners.

Disadvantages of this model are:

● Organizations tend to increase the number of UAPs and decrease the ratio of professional nurses to nonprofessional staff. If, for example, one UAP is assigned to more than one RN, the UAP must follow the instructions of several people, making a synergistic relation- ship with any one of them difficult.

● Another problem is the potential for the junior member of the team to assume more responsibility than appropriate. Senior partners must be careful not to delegate inappropriate tasks to junior partners.

Practice partnerships can be applied to primary nursing and used in other nursing care delivery systems, such as team nursing, modular nursing, and total patient care. As organizations restructured, practice partnerships offered an efficient way of using the skills of a mix of professional and nonprofessional staff with differing levels of expertise.

Case Management Following the introduction and impact of prospective payments, nursing case management, used for decades in community and psychiatric settings, was adopted for acute inpatient care. Nursing case management (Figure 3-6) is a model for identifying, coordinating, and monitoring the implementation of services needed to achieve desired patient care outcomes within a specified period of time. Nursing case management organizes patient care by major diagnoses or diagnosis-related groups (DRGs) and focuses on attaining predetermined patient outcomes within specific time frames and resources.

Nursing case management requires:

● Collaboration of all members of the health care team ● Identification of expected patient outcomes within specific time frames ● Use of principles of continuous quality improvement (CQI) and variance analysis ● Promotion of professional practice.

Case manager

Patient caseload

Caregivers CaregiversCaregivers

Figure 3-6 • Case management.

Patients

Partner

Figure 3-5 • Practice partnerships.

CHAPTER 3 • DELIVERING NURSING CARE 35

In an acute care setting, the case manager has a caseload of 10 to 15 patients and follows patients’ progress through the system from admission to discharge, accounting for variances from expected progress. One or more nursing case managers on a patient care unit may coordi- nate, communicate, collaborate, problem solve, and facilitate patient care for a group of patients. Ideally, nursing case managers have advanced degrees and considerable experience in nursing.

After a specific patient population is selected to be “case managed,” a collaborative prac- tice team is established. The team, which includes clinical experts from appropriate disciplines (e.g., nursing, medicine, physical therapy) needed for the selected patient population, defines the expected outcomes of care for the patient population. Based on expected patient outcomes, each member of the team, using his or her discipline’s contribution, helps determine appropriate interventions within a specified time frame.

To initiate case management, specific patient diagnoses that represent high-volume, high- cost, and high-risk cases are selected. High-volume cases are those that occur frequently, such as total hip replacements on an orthopedic floor. High-risk cases include patients or case types who have complications, stay in a critical care unit longer than two days, or require ventilatory support. Patients also may be selected because they are treated by one particular physician who supports case management.

Whatever patient population is selected, baseline data must be collected and analyzed first. These data provide the information necessary to measure the effectiveness of case management. Essential baseline data include length of stay, cost of care, and complication information.

Five elements are essential to successful implementation of case management:

● Support by key members of the organization (administrators, physicians, nurses) ● A qualified nurse case manager ● Collaborative practice teams ● A quality management system ● Established critical pathways (see next section)

In case management, all professionals are equal members of the team; thus, one group does not determine interventions for other disciplines. All members of the collaborative practice team agree on the final draft of the critical pathways, take ownership of patient outcomes, and accept responsibility and accountability for the interventions and patient outcomes associated with their discipline. The emphasis must be on managing interdisciplinary outcomes and building consensus with physicians. In addition, outcomes must be specified in measurable terms.

Critical Pathways Successful case management relies on critical pathways to guide care. The term critical path, also called a care map, refers to the expected outcomes and care strategies developed by the col- laborative practice team. Again, interdisciplinary consensus must be reached and specific, and measurable outcomes determined.

Critical paths provide direction for managing the care of a specific patient during a specified time period. Critical paths are useful because they accommodate the unique characteristics of the patient and the patient’s condition. Critical paths use resources appropriate to the care needed and, thus, reduce cost and length of stay. Critical paths are used in every setting where health care is delivered.

A critical path quickly orients the staff to the outcomes that should be achieved for the patient for that day. Nursing diagnoses identify the outcomes needed. If patient outcomes are not achieved, the case manager is notified and the situation analyzed to determine how to modify the critical path.

Altering time frames or interventions is categorized as a variance, and the case manager tracks all variances. After a time, the appropriate collaborative practice teams analyze the vari- ances, note trends, and decide how to manage them. The critical pathway may need to be revised or additional data may be needed before changes are made.

36 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

Some features are included on all critical paths, such as specific medical diagnosis, the expected length of stay, patient identification data, appropriate time frames (in days, hours, minutes, or visits) for interventions, and patient outcomes. Interventions are presented in modality groups (medications, nursing activity, and so on). The critical path must include a means to identify variances easily and to determine whether the outcome has been met.

Differentiated Practice Differentiated practice is a method that maximizes nursing resources by focusing on the struc- ture of roles and functions of nurses according to their education, experience, and competence. Differentiated practice is designed to identify distinct levels of nursing practice based on defined abilities that are incorporated into job descriptions.

In differentiated practice, the responsibilities of RNs (mainly those with bachelor’s and as- sociate degrees) differ according to the competence and training associated with the two edu- cation levels as well as the nurses’ experience and preferences. The scope of nursing practice and level of responsibility are specifically defined for each level. Some organizations differenti- ate roles, responsibilities, and tasks for professional nurses, licensed practical nurses, and unli- censed assistive personnel, which are incorporated into their respective job descriptions.

Evolving Models of Care Recognizing the need for improving patient care, the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement established a program titled Transforming Care at the Bedside (IHI, 2009). The goal was, and continues to be, to help hospitals achieve affordable and lasting improvements to care (Lavizzo-Mourey & Berwick, 2009). One of its premises is the use of a patient-centered care model.

Patient-Centered Care Patient-centered care is a model of nursing care delivery in which the role of the nurse is broadened to coordinate a team of multifunctional unit-based caregivers. In patient-centered care, all patient care services are unit-based, including admission and discharge, diagnostic and treatment services, and support services, such as environmental and nutrition services and medical records. The focus of patient-centered care is decentralization, the promotion of efficiency and quality, and cost control.

In this model of care, the number of caregivers at the bedside is reduced, but their responsibilities are increased so that service time and waiting time are decreased. A typical team in a unit providing patient-centered care consists of:

● Patient care coordinators (RNs) ● Patient care associates or technicians who are able to perform delegated patient care tasks ● Unit support assistants who provide environmental services and can assist with hygiene

and ambulation needs ● Administrative support personnel who maintain patient records, transcribe orders,

coordinate admission and discharge, and assist with general office duties

Success using a patient-centered care model continues to be reported in the literature (Miles & Vallish, 2010; Schneider & Fake, 2010). Furthermore, lower mortality in patients with acute myocardial infarctions has been found (Meterko et al., 2010). Patients with chronic conditions are appropriate candidates for patient-centered care approaches, including the use of complementary and alternative medicine therapies (Maizes, Rakel, & Niemiec, 2009).

The nurse manager’s role in patient-centered care requires considerable time. No longer is the manager doing rounds and assisting with patient care. Instead, being responsible for a staff that is more diverse with fewer professional RN staff demands a strong leader proficient to

CHAPTER 3 • DELIVERING NURSING CARE 37

interview, hire, train, and motivate staff. Some organizations share assistive staff between units, also increasing the need for more communication and coordination with other managers.

Synergy Model of Care Developed by the American Association of Critical Nurses, the American Association of Critical Care Nurses conceptualizes nursing practice based on the needs and characteristics of patients (AACN, 2011). These characteristics drive nurse competencies. Patient characteristics include:

● Resiliency ● Vulnerability ● Stability ● Complexity ● Resource availability ● Participation in care ● Participation in decision making ● Predictability

These characteristics are then matched with nurse competencies, including:

● Clinical judgment ● Advocacy and moral agency ● Caring practices ● Collaboration ● Systems thinking ● Response to diversity ● Facilitation of learning ● Clinical inquiry (AACN, 2011)

When patients’ characteristics and nurses’ competencies match, synergy is the outcome. The model is useful to nurses by delineating job descriptions, evaluation formats, and advancement criteria. Furthermore, a synergy model helps meet the standards for Magnet certification (Kaplow & Reed, 2008).

Clinical Microsystems Clinical microsystems are a recent addition to care delivery structures. Clinical microsystems evolved from the belief that decision making is best given to those involved in the smallest unit of care. Thus, a clinical microsystem is a small unit of care that maintains itself over time.

Clinical microsystems include the following elements:

● Core team of caregivers ● Defined population to receive care ● Informational system for both patients and caregivers ● Support staff, equipment and facilitative environment

The clinical microsystem model has been shown to be effective in neonatal intensive care units (Reis, Scott, & Rempel, 2009) and to increase quality improvement projects among medical residents (Tess et al., 2009). Additionally, using a clinical nurse leader improved quality outcomes in a hospital using a clinical microsystem model (Hix, McKeon, & Walters, 2009).

Chronic Care Model So far our discussion of delivery systems has focused on hospital nursing care. Increasingly, however, care is being delivered in ambulatory care environments. Additionally, most of the patients cared for in those environments suffer from chronic health conditions. The chronic care model addresses these concerns.

38 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

The goal of the chronic care model is not to manage a disease but to change how daily care is delivered by clinical teams (Coleman et al., 2009). Instead of reacting to changes in the patient’s condition, the team provides proactive interventions. The model is systematic and re- quires six components. They are:

● Self-management support ● Decision support ● Delivery system design ● Clinical information systems ● Health care organization ● Community resources

Given that the population is aging and chronic conditions are expected to rise, the chronic care model is an appropriate one to consider for providing care to patients with chronic illnesses.

No delivery system is perfect. Or permanent. As health care adapts to changes in reimbursement, demands for quality, and technological advances, models for delivering care will continue to evolve.

What You Know Now • Nursing care delivery systems provide a structure for nursing care. Most organizations use a combina-

tion of nursing care delivery systems or modify one or more systems to meet their own needs. • Traditional care models include functional nursing, team nursing, total patient care, and primary nursing. • Integrated models of care include practice partnerships, case management, critical pathways, and differen-

tiated practice. • Evolving models of care include patient-centered care, a synergy model of care, clinical microsystems,

and a chronic care model. • Commonly used by Magnet-certified hospitals, the patient-centered care model provides care from admit-

ting to discharge on the unit. • The synergy model, developed by the American Association of Critical Care Nurses, matches patients’

characteristics with nurses’ competencies. • Clinical microsystems use a structure that puts decision making in small units of those who provide the care. • The chronic care model is a systemwide, proactive model designed to provide daily care to patients by

clinical teams. • As health care adapts to changes in reimbursement, demands for quality, and technological advances,

models for delivering care will continue to evolve.

Questions to Challenge You 1. Describe the patient care delivery system(s) at your place of work or clinical placement site. How

well does it work? Can you suggest a better system? 2. Pretend that you are designing a new nursing care delivery system. Select the system or combination

of systems you would use. Explain your rationale. 3. Why have different systems been used in earlier times? Would any of them be useful today? Explain what

characteristics of the health care system today would make them appropriate or inappropriate to use. 4. As a manager, which system would you prefer? Why? 5. If you were a patient, which system do you think would provide you with the best care?

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

www.nursing.pearsonhighered.com

CHAPTER 3 • DELIVERING NURSING CARE 39

References Aiken, L. H., Clarke, S. P.,

Sloane, D. M., Lake, E. T., & Cheney, T. (2008). Effects of hospital care environment on patient mortality and nurse out- comes. Journal of Nursing Administration, 38(5), 223–229.

American Association of Critical Care Nurses (AACN) (2011). The AACN synergy model for patient care. Retrieved May 9, 2011 from http://www.aacn.org/ WD/Certifications/Docs/ SynergyModelforPatient- Care.pdf

Coleman, K., Austin, B. T., Brach, C., & Wagner, E. H. (2009). Evidence on the chronic care model in the new millennium. Health Affairs, 28(1), 75–85.

Hix, C., McKeon, L., and Walters, S. (2009). Clini- cal nurse leader impact on clinical microsystems outcomes. Journal of Nurs- ing Administration, 39(2), 71–76.

Institute for Healthcare Improvement (IHI) (2009). IHI Collaborative: Trans- forming care at the bedside. Retrieved May 9, 2011 from http://www.ihi.org/IHI/ Programs/Collaboratives/ TransformingCareatthe Bedside.htm.

Kaplow, R., & Reed, K. D. (2008). The AACN synergy model for patient care: A nursing model as a force of magnetism. Nursing Economics, 26(1), 17–25.

Lavisso-Mourey, R., & Berwick, D. M. (2009). Nurses trans- forming care. American Journal of Nursing, 109(11), 3.

Maizes, V., Rakel, D., & Niemiec, C. (2009). Integrative medicine and patient-centered care. Explore: The Journal of Science & Healing, 5(5), 277–289.

Manthey, M. (1980). The prac- tice of primary nursing. St. Louis: Mosby.

Manthey, M. (1989). Practice partnerships: The newest concept in care delivery. Journal of Nursing Associa- tion, 19(2), 33–35.

Meterko, M., Wright, S., Lin, H., Lowy, E., & Cleary, P. D. (2010). Mortality among patients with acute myocardial infarction: The influences of patient- centered care and evidence- based medicine. Health Services Research, 45(5), 1188–1204.

Miles, K. S., & Vallish, R. (2010). Creating a personal- ized professional practice framework for nursing.

Nursing Economics, 28(3), 171–189.

Reis, M. D., Scott, S. D., & Rempel, G. R. (2009). Including parents in the evaluation of clinical microsystems in the neonatal intensive care unit. Advances in Neonatal Care, 9(4), 174–179.

Schneider, M. A., & Fake, P. (2010). Implementing a relationship-based care model on a large orthopaedic/neurosurgical hospital unit. Orthopaedic Nursing, 29(6), 374–378.

Spence-Laschinger, H. K. (2008). Effect of empow- erment on professional practice environment, work satisfaction, and patient care quality: Further testing the nursing work life model. Journal of Nursing Care Quality, 23(4), 322–330.

Tess, A. V., Yang, J. J., Smith, C., Fawcett, C. M., Bates, C. K., & Reynolds, E. E. (2009). Combining clinical microsystems and an experiential quality im- provement curriculum to improve residency educa- tion in internal medicine. Academic Medicine, 84(3), 326–334.

http://www.aacn.org/WD/Certifications/Docs/SynergyModelforPatient-Care.pdf

http://www.ihi.org/IHI/Programs/Collaboratives/TransformingCareattheBedside.htm

http://www.aacn.org/WD/Certifications/Docs/SynergyModelforPatient-Care.pdf

http://www.ihi.org/IHI/Programs/Collaboratives/TransformingCareattheBedside.htm

Charge nurse Clinical nurse leader Controlling Directing Emotional intelligence First-level manager

Followership Formal [leadership] Informal [leadership] Leader Manager Organizing

Planning Quantum leadership Servant leadership Shared leadership Transactional leadership Transformational leadership

Key Terms

1. Explain why every nurse is a manager and can be a leader.

2. Differentiate between leaders and managers.

3. Discuss how different theories explain leadership and management.

4. Describe what management roles nurses fill in practice.

5. Discuss how followership is essential to leadership.

6. Describe what makes a leader successful.

Learning Outcomes After completing this chapter, you will be able to:

Leaders and Managers

Leadership

Traditional Leadership Theories Contemporary Theories

QUANTUM LEADERSHIP

TRANSACTIONAL LEADERSHIP

TRANSFORMATIONAL LEADERSHIP

SHARED LEADERSHIP

SERVANT LEADERSHIP

EMOTIONAL LEADERSHIP

Traditional Management Functions

PLANNING

ORGANIZING

DIRECTING

CONTROLLING

Nurse Managers in Practice NURSE MANAGER

COMPETENCIES

STAFF NURSE

FIRST-LEVEL MANAGEMENT

CHARGE NURSE

CLINICAL NURSE LEADER

Followership: An Essential Component of Leadership

What Makes a Successful Leader?

Leading, Managing, Following4

CHAPTER

CHAPTER 4 • LEADING, MANAGING, FOLLOWING 41

M anagers are essential to any organization. A manager’s functions are vital, com-plex, and frequently difficult. They must be directed toward balancing the needs of patients, the health care organization, employees, physicians, and self. Nurse managers need a body of knowledge and skills distinctly different from those needed for nurs- ing practice, yet few nurses have the education or training necessary to be managers. Frequently, managers depend on experiences with former supervisors, who also learned supervisory tech- niques on the job. Often a gap exists between what managers know and what they need to know.

Today, all nurses are managers, not in the formal organizational sense but in practice. They direct the work of nonprofessionals and professionals in order to achieve desired outcomes in patient care. Acquiring the skills to be both a leader and a manager will help the nurse become more effective and successful in any position.

Leaders and Managers Manager, leader, supervisor, and administrator are often used interchangeably, yet they are not the same. A leader is anyone who uses interpersonal skills to influence others to accomplish a specific goal. The leader exerts influence by using a flexible repertoire of personal behaviors and strategies. The leader is important in forging links—creating connections—among an organiza- tion’s members to promote high levels of performance and quality outcomes.

The functions of a leader are to achieve a consensus within the group about its goals, main- tain a structure that facilitates accomplishing the goals, supply necessary information that helps provide direction and clarification, and maintain group satisfaction, cohesion, and performance.

A manager, in contrast, is an individual employed by an organization who is responsible and accountable for efficiently accomplishing the goals of the organization. Managers focus on coordinating and integrating resources, using the functions of planning, organizing, supervising, staffing, evaluating, negotiating, and representing. Interpersonal skill is important, but a man- ager also has authority, responsibility, accountability, and power defined by the organization. The manager’s job is to:

● Clarify the organizational structure ● Choose the means by which to achieve goals ● Assign and coordinate tasks, developing and motivating as needed ● Evaluate outcomes and provide feedback

All good managers are also good leaders—the two go hand in hand. However, one may be a good manager of resources and not be much of a leader of people. Likewise, a person who is a good leader may not manage well. Both roles can be learned; skills gained can enhance either role.

Leadership Leadership may be formal or informal. Leadership is formal when practiced by a nurse with legitimate authority conferred by the organization and described in a job description (e.g., nurse manager, supervisor, coordinator, case manager). Formal leadership also depends on personal skills, but it may be reinforced by organizational authority and position. Insightful formal lead- ers recognize the importance of their own informal leadership activities and the informal leader- ship of others who affect the work in their areas of responsibility.

Leadership is informal when exercised by a staff member who does not have a speci- fied management role. A nurse whose thoughtful and convincing ideas substantially influ- ence the efficiency of work flow is exercising leadership skills. Informal leadership depends primarily on one’s knowledge, status (e.g., advanced practice nurse, quality improvement coordinator, education specialist, medical director), and personal skills in persuading and guiding others.

42 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

Traditional Leadership Theories Research on leadership has a long history, but the focus has shifted over time from personal traits to behavior and style, to the leadership situation, to change agency (the capacity to trans- form), and to other aspects of leadership. Each phase and focus of research has contributed to managers’ insights and understandings about leadership and its development. Traditional leader- ship theories include trait theories, behavioral theories, and contingency theories.

In the earliest studies researchers sought to identify inborn traits of successful leaders. Although inconclusive, these early attempts to specify unique leadership traits provided bench- marks by which most leaders continue to be judged.

Research on leadership in the early 1930s focused on what leaders do. In the behavioral view of leadership, personal traits provide only a foundation for leadership; real leaders are made through education, training, and life experiences.

Contingency approaches suggest that managers adapt their leadership styles in relation to changing situations. According to contingency theory, leadership behaviors range from au- thoritarian to permissive and vary in relation to current needs and future probabilities. A nurse manager may use an authoritarian style when responding to an emergency situation such as a cardiac arrest but use a participative style to encourage development of a team strategy to care for patients with multiple system failure.

The most effective leadership style for a nurse manager is the one that best complements the organizational environment, the tasks to be accomplished, and the personal characteristics of the people involved in each situation.

Contemporary Theories Leaders in today’s health care environment place increasing value on collaboration and team- work in all aspects of the organization. They recognize that as health systems become more complex and require integration, personnel who perform the managerial and clinical work must cooperate, coordinate their efforts, and produce joint results. Leaders must use additional skills, especially group and political leadership skills, to create collegial work environments.

Quantum Leadership Quantum leadership is based on the concepts of chaos theory (see Chapter 2). Reality is constantly shifting, and levels of complexity are constantly changing. Movement in one part of the system reverberates throughout the system. Roles are fluid and outcome oriented. It matters little what you did; it only matters what outcome you produced. Within this framework, employees become di- rectly involved in decision making as equitable and accountable partners, and managers assume more of an influential facilitative role, rather than one of control (Porter-O’Grady & Malloch, 2010).

Quantum leadership demands a different way of thinking about work and leadership. Change is expected. Informational power, previously the purview of the leader, is now available to all. Patients and staff alike can access untold amounts of information. The challenge, however, is to assist patients, uneducated about health care, how to evaluate and use the information they have. Because staff have access to information only the leader had in the past, leadership be- comes a shared activity, requiring the leader to possess excellent interpersonal skills.

Transactional Leadership Transactional leadership is based on the principles of social exchange theory. The primary premise of social exchange theory is that individuals engage in social interactions expecting to give and receive social, political, and psychological benefits or rewards. The exchange process between leaders and followers is viewed as essentially economic. Once initiated, a sequence of exchange behavior continues until one or both parties finds that the exchange of performance and rewards is no longer valuable.

CHAPTER 4 • LEADING, MANAGING, FOLLOWING 43

The nature of these transactions is determined by the participating parties’ assessments of what is in their best interests; for example, staff respond affirmatively to a nurse manager’s re- quest to work overtime in exchange for granting special requests for time off. Leaders are suc- cessful to the extent that they understand and meet the needs of followers and use incentives to enhance employee loyalty and performance. Transactional leadership is aimed at maintaining equilibrium, or the status quo, by performing work according to policy and procedures, maxi- mizing self-interests and personal rewards, emphasizing interpersonal dependence, and routin- izing performance (Weston, 2008).

Transformational Leadership Transformational leadership goes beyond transactional leadership to inspire and motivate fol- lowers (Marshall, 2010). Transformational leadership emphasizes the importance of interper- sonal relationships. Transformational leadership is not concerned with the status quo, but with effecting revolutionary change in organizations and human service. Whereas traditional views of leadership emphasize the differences between employees and managers, transformational lead- ership focuses on merging the motives, desires, values, and goals of leaders and followers into a common cause. The goal of the transformational leader is to generate employees’ commitment to the vision or ideal rather than to themselves.

Transformational leaders appeal to individuals’ better selves rather than these individuals’ self-interests. They foster followers’ inborn desires to pursue higher values, humanitarian ideals, moral missions, and causes. Transformational leaders also encourage others to exercise leader- ship. The transformational leader inspires followers and uses power to instill a belief that follow- ers also have the ability to do exceptional things.

Transformational leadership may be a natural model for nursing managers, because nurs- ing has traditionally been driven by its social mandate and its ethic of human service. In fact, Weberg (2010) found that transformational leadership reduced burnout among employees, and Grant et al., (2010) reports transformational leadership positively affected the practice environ- ment in one medical center. Transformational leadership can be used effectively by nurses with clients or coworkers at the bedside, in the home, in the community health center, and in the health care organization.

Shared Leadership Reorganization, decentralization, and the increasing complexity of problem solving in health care have forced administrators to recognize the value of shared leadership, which is based on the empowerment principles of participative and transformational leadership (Everett & Sitterding, 2011). Essential elements of shared leadership are relationships, dialogues, partnerships, and understanding boundaries. The application of shared leadership assumes that a well-educated, highly professional, dedicated workforce is comprised of many leaders. It also assumes that the notion of a single nurse as the wise and heroic leader is unrealistic and that many individuals at various levels in the organization must be responsible for the organization’s fate and performance.

Different issues call for different leaders, or experts, to guide the problem-solving process. A single leader is not expected always to have knowledge and ability beyond that of other mem- bers of the work group. Appropriate leadership emerges in relation to the current challenges of the work unit or the organization. Individuals in formal leadership positions and their colleagues are expected to participate in a pattern of reciprocal influence processes. Kramer, Schmalenberg, and Maguire (2010) and Watters (2009) found shared leadership common in Magnet-certified hospitals.

Examples of shared leadership in nursing include:

● Self-directed work teams. Work groups manage their own planning, organizing, schedul- ing, and day-to-day work activities.

● Shared governance. The nursing staff are formally organized at the service area and orga- nizational levels to make key decisions about clinical practice standards, quality assurance

44 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

and improvement, staff development, professional development, aspects of unit opera- tions, and research. Decision making is conducted by representatives of the nursing staff who have been authorized by the administrative hierarchy and their colleagues to make decisions about important matters.

● Co-leadership. Two people work together to execute a leadership role. This kind of lead- ership has become more common in service-line management, where the skills of both a clinical and an administrative leader are needed to successfully direct the operations of a multidisciplinary service. For example, a nurse manager provides administrative leader- ship in collaboration with a clinical nurse specialist, who provides clinical leadership. The development of co-leadership roles depends on the flexibility and maturity of both indi- viduals, and such arrangements usually require a third party to provide ongoing consulta- tion and guidance to the pair.

Servant Leadership Founded by Robert Greenleaf (Greenleaf, 1991), servant leadership is based on the premise that leadership originates from a desire to serve and that in the course of serving, one may be called to lead (Keith, 2008; The Greenleaf Center for Servant Leadership, 2011). Servant leaders embody three characteristics:

● Empathy ● Awareness ● Persuasion (Neill & Saunders, 2008)

Servant leadership appeals to nurses for two reasons. First, our profession is founded on principles of caring, service, and the growth and health of others (Anderson et al., 2010). Sec- ond, nurses serve many constituencies, often quite selflessly, and consequently bring about change in individuals, systems, and organizations.

Emotional Leadership Social intelligence (Goleman, 2007), including emotional intelligence (Bradberry & Greaves, 2009; Goleman, 2006), has gained acceptance in the business world and more recently in health care (Veronsesi, 2009). Emotional intelligence involves personal competence, which includes self-awareness and self-management, and social competence, which includes social awareness and relationship management that begins with authenticity. (See Table 4-1.)

Goleman (2007) asserts that attachment to others is an innate trait of human beings. Thus, emotions are “catching.” Consider a person having a pleasant day. Then an otherwise innocuous event turns into a negative experience that spills over into future interactions. Or the reverse. A positive experience lightens the mood and affects the next encounter. When people feel good, they work more effectively.

Emotional intelligence has been linked with leadership (Antonakis, Ashkanasy, & Dasbor- ough, 2009; Cote et al., 2010; Lucas, Spence-Laschinger, & Wong, 2008). One study, however, found no relationship between emotional intelligence and transformational leadership (Linde- baum & Cartwright, 2010).

Nurses, with their well-honed skills as compassionate caregivers, are aptly suited to this direction in leadership that emphasizes emotions and relationships with others as a primary at- tribute for success. These skills fit better with the more contemporary relationship-oriented theo- ries as well. Thus, the workplace is a more complex and intricate environment than previously suggested. The following chapters show you how to put these skills to work.

Health care environments require innovations in care delivery and therefore innovative lead- ership approaches. Quantum, transactional, transformational, shared, servant, and emotional leadership make up a new generation of leadership styles that have emerged in response to the need to humanize working environments and improve organizational performance. In practice, leaders tap a variety of styles culled from diverse leadership theories.

CHAPTER 4 • LEADING, MANAGING, FOLLOWING 45

TABLE 4-1 AONE Five Areas of Competency

AONE BELIEVES THAT MANAGERS AT ALL LEVELS MUST BE COMPETENT IN THE FOLLOWING:

COMMUNICATION AND RELATIONSHIPS-BUILDING COMPETENCIES INCLUDE: ● Effective communication ● Relationship management ● Influence of behaviors ● Ability to work with diversity ● Shared decision making ● Community involvement ● Medical staff relationships ● Academic relationships

KNOWLEDGE OF THE HEALTH CARE ENVIRONMENT INCLUDES: ● Clinical practice knowledge ● Patient care delivery models and work design knowledge ● Health care economics knowledge ● Health care policy knowledge ● Understanding of governance ● Understanding of evidence-based practice ● Outcome measurement ● Knowledge of and dedication to patient safety ● Understanding of utilization/case management ● Knowledge of quality improvement and metrics ● Knowledge of risk management

LEADERSHIP SKILLS INCLUDE: ● Foundational thinking skills ● Personal journey disciplines ● The ability to use systems thinking ● Succession planning ● Change management

PROFESSIONALISM INCLUDES: ● Personal and professional accountability ● Career planning ● Ethics ● Evidence-based clinical and management practice ● Advocacy for the clinical enterprise and for nursing practice ● Active membership in professional organizations

BUSINESS SKILLS INCLUDE: ● Understanding of health care financing ● Human resource management and development ● Strategic management ● Marketing ● Information management and technology

Traditional Management Functions In 1916, French industrialist Henri Fayol first described the functions of management as planning, organizing, directing, and controlling. These are still relevant today, however, the complexity of today’s health care systems make these functions more difficult and less certain (Clancy, 2008).

46 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

Planning Planning is a four-stage process to:

● Establish objectives (goals) ● Evaluate the present situation and predict future trends and events ● Formulate a planning statement (means) ● Convert the plan into an action statement

Planning is important on both an organizational and a personal level and may be an in- dividual or group process that addresses the questions of what, why, where, when, how, and by whom. Decision making and problem solving are inherent in planning. Numerous computer software programs and databases are available to help facilitate planning.

Organization-level plans, such as determining organizational structure and staffing or operational budgets, evolve from the mission, philosophy, and goals of the organization. The nurse manager plans and develops specific goals and objectives for her or his area of responsibility.

Antonio, the nurse manager of a home care agency, plans to establish an in-home photo- therapy program, knowing that part of the agency’s mission is to meet the health care needs of the child-rearing family. To effectively implement this program, he would need to address:

• How the program supports the organization’s mission

• Why the service would benefit the community and the organization

• Who would be candidates for the program

• Who would provide the service

• How staffing would be accomplished

• How charges would be generated

• What those charges should be

Planning can be contingent or strategic. Using contingency planning, the manager identifies and manages the many problems that interfere with getting work done. Contingency planning may be re- active, in response to a crisis, or proactive, in anticipation of problems or in response to opportunities.

What would you do if two registered nurses called in sick for the 12-hour night shift? What if you were a manager for a specialty unit and received a call for an admission, but had no more beds? Or what if you were a pediatric oncology clinic manager and a patient’s sibling exposed a number of immunocompromised patients to chickenpox? Planning for crises such as these are examples of contingency planning.

Strategic planning refers to the process of continual assessment, planning, and evaluation to guide the future (Fairholm & Card, 2009). Its purpose is to create an image of the desired future and design ways to make those plans a reality. A nurse manager might be charged, for example, with developing a business plan to add a time-saving device to commonly used equipment, pre- senting the plan persuasively, and developing operational plans for implementation, such as ac- quiring devices and training staff.

Organizing Organizing is the process of coordinating the work to be done. Formally, it involves identifying the work of the organization, dividing the labor, developing the chain of command, and assign- ing authority. It is an ongoing process that systematically reviews the use of human and material resources. In health care, the mission, formal organizational structure, delivery systems, job de- scriptions, skill mix, and staffing patterns form the basis for the organization.

In organizing the home phototherapy project, Antonio develops job descriptions and pro- tocols, determines how many positions are required, selects a vendor, and orders supplies.

CHAPTER 4 • LEADING, MANAGING, FOLLOWING 47

Directing Directing is the process of getting the organization’s work done. Power, authority, and leader- ship style are intimately related to a manager’s ability to direct. Communication abilities, moti- vational techniques, and delegation skills also are important. In today’s health care organization, professional staff are autonomous, requiring guidance rather than direction. The manager is more likely to sell the idea, proposal, or new project to staff rather than tell them what to do. The manager coaches and counsels to achieve the organization’s objectives. In fact, it may be the nurse who assumes the traditional directing role when working with unlicensed personnel.

In directing the home phototherapy project, Antonio assembles the team of nurses to provide the service, explains the purpose and constraints of the program, and allows the team to decide how they will staff the project, giving guidance and direction when needed.

Controlling Controlling involves comparing actual results with projected results. This includes establishing standards of performance, determining the means to be used in measuring performance, evaluat- ing performance, and providing feedback. The efficient manager constantly attempts to improve productivity by incorporating techniques of quality management, evaluating outcomes and per- formance, and instituting change as necessary.

Today, managers share many of the control functions with the staff. In organizations us- ing a formal quality improvement process, such as continuous quality improvement (CQI), staff participate in and lead the teams. Some organizations use peer review to control quality of care.

When Antonio introduces the home phototherapy program, the team of nurses involved in the program identify standards regarding phototherapy and their individual performances. A subgroup of the team routinely reviews monitors designed for the program and identifies ways to improve the program.

Planning, organizing, directing, and controlling reflect a systematic, proactive approach to management. This approach is used widely in all types of organizations, health care included, but Clancy (2008) asserts that today’s rapidly changing health care environment makes it more difficult to control events and predict outcomes.

Nurse Managers in Practice Putting nursing management into practice in the dynamic health care system of today is a chal- lenge. Organizations are in flux, structures are changing, and roles and functions of nurse man- agers become moving targets.

Titles for nurse managers vary as widely as do their responsibilities. The first level manager may be titled first-line manager or unit manager. A middle manager might be deemed a depart- ment manager. The top-level nursing administrator could be named executive manager, chief nursing officer, or vice president of patient care. In addition, clinical titles might include profes- sional practice leaders who are clinical nurse specialists or nurse practitioners. Regardless of their titles, all nurse managers must hold certain competencies.

Nurse Manager Competencies The American Organization of Nurse Executives (AONE), an organization for the top nursing administrators in health care, identified five areas of competency necessary for nurses at all lev- els of management (AONE, 2005). Nurse managers must be skilled communicators and rela- tionship builders, have a knowledge of the health care environment, exhibit leadership skills, display professionalism, and demonstrate business skills (see Table 4-2). These characteristics intersect to provide a common core of leadership competencies (see Figure 4-1).

48 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

TABLE 4-2 Emotional Intelligence Domains and Associated Competencies

PERSONAL COMPETENCE: These capabilities determine how we manage ourselves.

Self-Awareness • Emotional self-awareness: Reading one’s own emotions and recogniz- ing their impact; using “gut sense” to guide decisions

• Accurate self-assessment: Knowing one’s strengths and limits • Self-confidence: A sound sense of one’s self-worth and capabilities

Self-Management • Emotional self-control: Keeping disruptive emotions and impulses under control

• Transparency: Displaying honesty and integrity; trustworthiness • Adaptability: Flexibility in adapting to changing situations or over-

coming obstacles • Achievement: The drive to improve performance to meet inner stan-

dards of excellence • Initiative: Readiness to act and seize opportunities • Optimism: Seeing the upside in events

SOCIAL COMPETENCE: These capabilities determine how we manage relationships.

Social Awareness • Empathy: Sensing others’ emotions, understanding their perspective, and taking active interest in their concerns

• Organizational awareness: Reading the currents, decision networks, and politics at the organizational level

• Service: Recognizing and meeting follower, client, or customer needs

Relationship Management

• Inspirational leadership: Guiding and motivating with a compelling vision

• Influence: Wielding a range of tactics for persuasion • Developing others: Bolstering others’ abilities through feedback and

guidance • Change catalyst: Initiating, managing, and leading in a new direction • Conflict management: Resolving disagreements • Building bonds: Cultivating and maintaining a web of relationships • Teamwork and collaboration: Cooperation and team building

From Goleman, D., Boyatsis, R., & McKee, A. Primal Leadership (2002). Boston: Harvard Business School Press, 39. Copyright © 2002 by the Harvard Business School Publishing Corporation; all rights reserved.

Staff Nurse Although not formally a manager, the staff nurse supervises LPNs, other professionals, and assistive personnel and so is also a manager who needs management and leadership skills. Com- munication, delegation, and motivation skills are indispensable.

In some organizations, shared governance has been implemented and traditional manage- ment responsibilities are allocated to the work team. In this case, staff nurses have considerable involvement in managing the unit. More information about shared governance and other innova- tive management methods is provided in Chapter 2.

First-Level Management The first-level manager is responsible for supervising the work of nonmanagerial personnel and the day-to-day activities of a specific work unit or units. With primary responsibility for motivat- ing the staff to achieve the organization’s goals, the first-level manager represents staff to upper administration, and vice versa. Nurse managers have 24-hour accountability for the management of a unit(s) or area(s) within a health care organization. In the hospital setting, the first-level

CHAPTER 4 • LEADING, MANAGING, FOLLOWING 49

manager is usually the head nurse, nurse manager, or an assistant. In other settings, such as an ambulatory care clinic or a home health care agency, a first-level manager may be referred to as a coordinator. Box 4-1 describes a first-level manager’s day.

Charge Nurse Another role that does not fit the traditional levels of management is the charge nurse. The charge nurse position is an expanded staff nurse role with increased responsibility. The charge nurse functions as a liaison to the nurse manager, assisting in shift-by-shift coordination and promotion of quality patient care as well as efficient use of resources. The charge nurse of- ten troubleshoots problems and assists other staff members in decision making. Role modeling, mentoring, and educating are additional roles that the charge nurse often assumes. Therefore, the charge nurse usually has extensive experience, skills, and knowledge in clinical practice and is familiar with the organization’s standards and practices.

The charge nurse’s job differs, though, from that of the first-level manager. The charge nurse’s responsibilities are confined to a specific shift or task, whereas the first-level manager has 24-hour responsibility and accountability for all unit activities. Also the charge nurse has limited authority; the charge nurse functions as an agent of the manager and is accountable to the manager for any actions taken or decisions made.

Although often involved in planning and organizing the work to be done, the charge nurse has a limited scope of responsibility, usually restricted to the unit for a specific time period. In the past, the charge nurse had limited involvement in the formal evaluation of performance, but in today’s climate of efficiency, the charge nurse may be involved in evaluations as well. With the trend toward participative management, charge nurses are assuming more of the roles and functions traditionally reserved for the first-level manager.

In some organizations, the position may be permanent and assigned and thus a part of the formal management team; in other organizations, the job may be rotated among experienced staff. The charge nurse, who switches from serving as a manager one day and a staff nurse the next, is especially challenged to balance the rotating roles (Leary & Allen, 2005). In some orga- nizations, a differential amount of compensation is paid to the person performing charge duties; in others, no differential is paid because the position is shared equally among staff or represents a higher rung of a career ladder (possibly the first rung of a management ladder).

The charge nurse is often key to a unit’s successful functioning (Leary & Allen, 2005). A charge nurse usually has considerable influence with the staff and may actually have more infor- mal power than the manager. Therefore, the charge nurse is an important leader and can benefit by developing the skills considered necessary for a manager. Acting as charge nurse is often the first step toward a formal management position.

Professionalism Communication & relationship management

Business skills and principles

Knowledge of health care environment

Leadership

50 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

Clinical Nurse Leader The clinical nurse leader is not a manager, per se, but instead is a lateral integrator of care re- sponsible for a specified group of clients within a microsystem of the health care setting (AACN, 2007). The CNL role is designed to respond more effectively to challenges in today’s rapidly changing, complex technological environment (Harris & Roussel, 2009). Prepared at the mas- ter’s level, the CNL coordinates care at the bedside and supervises the health care team, among other duties (Sherman, 2010).

Use of the clinical nurse leader positions in health care organizations has improved patient outcomes and reduced costs and is expected to expand as the demand for quality continues (Hix, McKeon, & Walters, 2009; Stanley et al., 2008). Problems have emerged, however, as CNLs transition into organizations. These include being drawn into direct patient care, explaining the role to other nurses and health care providers, and acceptance by the staff (Sherman, 2010).

BOX 4-1 A Day in the Life of a First-Level Manager

As the manager for a surgical intensive care unit (SICU), Jamal Johnson is routinely responsible for supervising patient care, trouble shooting, maintain- ing compliance with standards, and giving guidance and direction as needed. In addition, he has fiscal and committee responsibilities and is accountable to the organization for maintaining its philosophies and ob- jectives. The following exemplifies a typical day.

As Jamal came on duty, he learned that there had been a multiple vehicle accident and that three of the victims were currently in the operating room and destined for the unit. The assistant manager for nights had secured more staff for days: two part-time SICU nurses and a staff nurse from the surgical floor. However, she had not had time to arrange for two more patients to be moved out of the unit. From their assigned nurses, Jamal obtained an update on the pa- tients who were candidates for transfer from the SICU to another floor and, in consultation with his assistant, made the appropriate arrangements for the transfers.

Other staffing problems were at hand: in addition to the nurse who had been pulled from the surgical floor, there were two orientees, and the staff needed to attend a safety in-service. As soon as the charge nurse came in, Jamal apprised her of the situation. Together, they reviewed the operating room schedule and identified staffing arrangements. Fortunately, Jamal had only one meeting today and would be avail- able for backup staffing. In the meantime, he would work on evaluations.

After his discussions with the charge nurse, Jamal met with each of the night nurses to get an update on the status of the other patients. Then he went to his office to review his messages and plan his day. Tamera, an RN, had just learned she was pregnant but stated that she planned to work until delivery. Jamal learned that his budget hearing had been scheduled for the following Monday at 10 A.M. A pharmaceutical

representative wanted to provide an in-service for the unit. Fortunately, there were no immediate crises.

Jamal called his supervisor to inform her of the status of affairs on the unit and learned that two other individuals in the accident had been transported to another hospital; one had since died. They discussed the ethical and legal ramifications. Jamal would need to review the policies on relations with the press and law enforcement and update his staff.

As the first patient returned from surgery, Jamal went to help admit the patient and receive a report. Learning that the patient was stable, he informed Lu- cinda, the charge nurse, that the patient they had just received was likely to be charged with manslaughter and reviewed media and legal policies with her. They also discussed how the staff were doing. There were some equipment problems in room 2110; Lucinda had temporarily placed the patient in that room on a transport monitor and was waiting for a biomedi- cal technology staff member to check the monitor. Could Jamal follow up? Jamal agreed and commended Lucinda for her problem solving. She reminded Jamal they would need backup for lunch and in-services.

As Jamal returned to his office, he noted that the alarms were turned off on one of the patients. He pulled aside the nurse assigned to the patient and re- minded her of the necessity to keep the alarms on at all times. Finally, back in his office, he called biomedical technology to ascertain their plans to check the monitor and made notes regarding the charge nurse’s problem- solving abilities and the staff nurse’s negligence.

He reviewed staffing for the next 24 hours and noted that an extra nurse was needed for both the evening and night shifts because of the increased workload. After finding staff, he was able to finish one evaluation before covering for the in-services and lunch and then attending the policy and procedure team meeting.

CHAPTER 4 • LEADING, MANAGING, FOLLOWING 51

Questions about the differences between a clinical nurse specialist and the CNL are also raised. While the CNS is assigned hospital-wide, the CNL is unit based. Ignatius (2010) sug- gests that hospitals are designed for the 19th century with little accommodation for the coordina- tion of care needed in this century. CNLs can help bridge that gap.

Followership: An Essential Component of Leadership Leaders cannot lead without followers in much the same way that instructors need students to teach. Nor is anyone a leader all the time; everyone is a follower as well. Even the hospital CEO follows the board of directors’ instructions.

Followership is interactive and complementary to leadership, and the follower is an active participant in the relationship with the leader. A skilled, self-directed, energetic staff member is an invaluable complement to the leader and to the group. Most leaders welcome active follow- ers; they help leaders accomplish their goals and the team succeed.

Followers are powerful contributors to the relationship with their leaders. Followers can in- fluence leaders in negative ways, as government cover-ups, Medicare fraud, and corporate law- breaking attest. The reverse is also true. Poor managers can undermine good followers by direct and indirect ways, such as criticizing, belittling, or ignoring positive contributions to the team (Arnold & Pulich, 2008). To counter such behaviors, you should note incidents that you experi- ence, enlist others to help, and remain in control of yourself. (See Chapter 21 for more about handling difficult problems, such as bullying.)

Miller (2007) describes followership along two continuums: participative and thinking. Par- ticipation can vary from passive (ineffective follower) to active (successful follower). Thinking can fluctuate between dependent and uncritical to independent and critical. Courage to be active contributors to the team and to the leader characterizes the effective follower.

Followership is fluid in another way. The nurse may be a leader at one moment and become a follower soon afterward. In fact, the ability to move along the continuum of degrees of fol- lowership is a must for successful teamwork. The nurse is a leader with subordinate staff and a follower of the nurse manager, possibly at the same time.

A constructive follower has several positive characteristics:

● Self-directed ● Proactive ● Supportive ● Commitment ● Initiative

Many of these qualities are the same ones that make an excellent leader, discussed next.

What Makes a Successful Leader? Leadership success is an elusive quality. Some people seem to be natural leaders, and others struggle to attain leadership skills.

See how one nurse leader described her work:

I believe that the most important role of a nurse leader is to live the life and exemplify at all times the qualities that every professional nurse leader should. I also believe the nurse leader/manager must be the person to set the bar high and perform at the highest levels in order to inspire their staff to achieve the same.

As a nurse manager, I at all times work to be an excellent communicator, compassionate, caring, vested in my job, willing to go above and beyond, and assist people with any task or issue they just need a little extra support on. I feel that by doing this, there is never a question what I expect from them and those around me. I verbally set expectations, but by living them as a role model.

52 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

For example, at shift change two nights ago, a physician wanted to do a bedside proce- dure. I was actually planning on leaving soon after a long day. I knew it was shift change, and didn’t want the staff to be interrupted, so I volunteered to stay and do the procedure so they could continue with report and the physician and patient were not kept waiting. The staff were very appreciative, but more importantly, I think it set the right example of teamwork, being flexible, being patient focused, etc.

I think it is important for the nurse leader to provide feedback at times other than evalu- ations. The nurse leader should schedule time into the workweek to have informal conver- sations with staff on the floor about comments a patient or coworker has shared or to send an e-mail to a staff member about feedback the leader has received. I think constructive feedback needs to be timely and supportive and the need for improvement discussed long before an evaluation.

I find having conversations about “What are your goals?” or “What can I help you explore or do that you’ve been dreaming about to enhance your nursing career?” People need to feel comfortable having these conversations with their trusted nurse leader. Build- ing relationships with those you lead is important.

Leaders are skilled in empowering others, creating meaning and facilitating learning, developing knowledge, thinking reflectively, communicating, solving problems, making deci- sions, and working with others. Leaders generate excitement; they clearly define their purpose and mission. Leaders understand people and their needs; they recognize and appreciate differ- ences in people, individualizing their approach as needed.

What You Know Now • A leader employs specific behaviors and strategies to influence individuals and groups to attain goals. • Managers are responsible for efficiently accomplishing the goals of the organization. • Leadership approaches are not static; they can be adapted for different situations, tasks, individuals, and

future expectations. • Contemporary theorists assert that reality is fluid, complex, and interrelated and that interpersonal

relationships are core to successful leadership. • Traditional management functions include planning, organizing, directing, and controlling. • Both leaders and followers contribute to the effectiveness of their relationship. • Successful leaders inspire and empower others, generate excitement, and individualize their approach to

differences in people.

Tools for Leading, Managing, and Following 1. Pay attention to the context: Are you leading, managing, or following in this situation? 2. Recognize that each situation requires a specific skill set. Each is described in the chapter. 3. Notice others whose leadership style you admire and try to incorporate their behaviors in your own

leadership if the situation is appropriate. 4. Evaluate yourself at regular opportunities in order to find ways to improve your abilities to lead,

manage, and follow.

Questions to Challenge You 1. Think about people you know in management positions. Are any of them leaders as well?

Describe the characteristics that make them leaders. 2. Consider people you know who are not in management positions but are leaders nonetheless.

What characteristics do they have that make them leaders?

CHAPTER 4 • LEADING, MANAGING, FOLLOWING 53

References

3. Describe the manager to whom you report. (If you are not employed, use the first-level manager on a clinical placement site.) Evaluate this person using the management functions described in the chapter.

4. Imagine yourself as a manager whether you are in a management position or not. What skills do you possess that help you? What skills would you like to improve?

5. Evaluate yourself as a follower. Find at least one characteristic listed in the chapter that you would like to develop or improve. During the next week, try to find opportunities to practice that skill.

6. Assess yourself as a leader. How would you like to improve?

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

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http://www.aone.org/aone/pdf/AONE_NEC.pdf

http://www.aacn.nche.edu/Publications/WhitePapers/ClinicalNurseLeader07.pdf

54 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

Ignatious, A. Fixing healthcare. Harvard Business Review, 88(4), 49–73.

Keith, K. (2008). The case for servant leadership. West- field, IN: Greenleaf Center for Servant Leadership.

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The moderating effect of span of control. Journal of Nursing Management, 16(8), 964–973.

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Porter-O’Grady, T., & Malloch, K. (2010). Quantum leader- ship: Advancing informa- tion, transforming health care (3rd ed.). Sudbury, MA: Jones & Bartlett.

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Weston, M. J. (2008). Transfor- mational leadership at a national perspective. Nurse Leader, 6(4), 41–45.

http://www.greenleaf.org

CHAPTER

Why Change?

The Nurse as Change Agent

Change Theories

The Change Process ASSESSMENT

PLANNING

IMPLEMENTATION

EVALUATION

Change Strategies POWER-COERCIVE STRATEGIES

EMPIRICAL–RATIONAL MODEL

NORMATIVE–REEDUCATIVE STRATEGIES

Resistance to Change

The Nurse’s Role INITIATING CHANGE

IMPLEMENTING CHANGE

Handling Constant Change

Initiating and Managing Change 5

Key Terms Change Change agent Driving forces

1. Explain why nurses have the opportunity to be change agents.

2. Describe how different theorists explain change.

3. Discuss how the change process is similar to the nursing process.

4. Differentiate among change strategies. 5. Discuss how to handle resistance to

change. 6. Describe the nurse’s role in change.

Learning Outcomes After completing this chapter, you will be able to:

Empirical–rational model Normative–reeducative

strategies

Power-coercive strategies Restraining forces Transitions

56 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

Why Change? Change is inevitable, if not always welcome. Organizational change is essential for adaptation; creative change is mandatory for growth (Heath & Heath, 2010). Change, though, is a continu- ally unfolding process rather than an either/or event. The process begins with the present state, is disrupted, moves through a transition period, and ultimately comes to a desired state. Once the desired state has been reached, however, the process begins again.

Leading change is never needed more in today’s rapidly evolving system of health care. Those who initiate and manage change often encounter resistance. Even when planned, it can be threatening and a source of conflict because change is the process of making something different from what it was. There is a sense of loss of the familiar, the status quo. This is particu- larly true when change is unplanned or beyond human control. Even when change is expected and valued, a grief reaction still may occur.

Although nurses should understand and anticipate these reactions to change, they need to develop and exude a different approach. They can view change as a challenge and encourage their colleagues to participate. They can become uncomfortable with the status quo and be willing to take risks.

This is a particular fortuitous time for the nursing profession (Nickitas, 2010). The Institute of Medicine’s report on the future of nursing proposes radical change for the profession (IOM, 2010). Specifically, they propose:

● Nurses should practice to the full extent of their education and training. ● Nurses should achieve higher levels of education and training through an improved

education system that promotes seamless academic progression. ● Nurses should be full partners with physicians and other health care professionals in

redesigning health care in the United States. ● Effective workforce planning and policymaking require better data collection and an

improved information infrastructure.

Furthermore, the IOM makes eight recommendations:

● Remove scope-of-practice barriers. ● Expand opportunities for nurses to lead and diffuse collaborative improvement efforts. ● Implement nurse residency programs. ● Increase the proportion of nurses with baccalaureate degrees to 80 percent by 2020. ● Ensure nurses engage in lifelong learning. ● Prepare and enable nurses to lead change to advance health. ● Build an infrastructure for the collection and analysis of interprofessional health care

workforce data (IOM, 2010).

The Nurse as Change Agent A change agent is one who works to bring about a change. Being a change agent, however, is not easy. Although the end result of change may benefit nurses and patients alike, initially it requires time, effort, and energy, all in short supply in the high-stress environment of health care.

Several recent reports document nurses’ roles in facilitating change. Holtrop et al. (2008) found that nurse consultants improved healthy behaviors in patients served by 10 primary care practices in two health care systems. Also, MacDavitt, Cieplincki, and Walker (2011) report that small changes in communication resulted in improved patient satisfaction on a pediatric inpatient unit. Finally, McMurray et al. (2010) found that nurse managers played a key role in implementing successful change in bedside handover in two hospitals.

Changes will continue at a rapid pace with or without nursing’s expert guidance. Nurses, like organizations, cannot afford merely to survive changes. If they are to exist as a distinct pro- fession that has expertise in helping individuals respond to actual or potential health problems,

CHAPTER 5 • INITIATING AND MANAGING CHANGE 57

they must be proactive in shaping the future. Opportunities exist now for nurses, especially those in management positions, to change the system about which they so often complain.

Change Theories Because change occurs within the context of human behavior, understanding how change does (or doesn’t) occur is helpful in learning how to initiate or manage change. Five theories explain the change process from a social–psychological viewpoint. See Table 5-1 for a comparison.

Lewin (1951) proposes a force-field model, shown in Figure 5-1. He sees behavior as a dynamic balance of forces working in opposing directions within a field (such as an organiza- tion). Driving forces facilitate change because they push participants in the desired direction. Restraining forces impede change because they push participants in the opposite direction.

To plan change, one must analyze these forces and shift the balance in the direction of change through a three-step process: unfreezing, moving, and refreezing. Change occurs by add- ing a new force, changing the direction of a force, or changing the magnitude of any one force. Basically, strategies for change are aimed at increasing driving forces, decreasing restraining forces, or both. The image of people’s attitudes thawing and then refreezing is conceptually use- ful. This symbolism helps to keep theory and reality in mind simultaneously.

Lippitt and colleagues (1958) extended Lewin’s theory to a seven-step process and focused more on what the change agent must do than on the evolution of change itself. (See Table 5-1.) They emphasized participation of key members of the target system throughout the change pro- cess, particularly during planning. Communication skills, rapport building, and problem-solving strategies underlie their phases.

Havelock (1973) described a six-step process, also a modification of Lewin’s model. Have- lock describes an active change agent as one who uses a participative approach.

Rogers (2003) takes a broader approach than Lewin, Lippitt, or Havelock (see Table 5-1). His five-step innovation–decision process details how an individual or decision-making unit

Figure 5-1 • Lewin’s force-field model of change. Adapted from Resolving Social Conflicts and Field Theory in Social Science by K. Lewin. Copyright © 1997, by the American Psychological Association. Adapted with permission.

Restraining forces

Driving forces

Example:

Fear of job loss

Nurse manager lacks change agent skills

Entrenched director of

nurses

Present (status quo)

Force will be toward change

Budget in red (financial incentive

to change)

Administration mandates the

change

Interested vice-president

Need new solution (old one doesn’t work)

Some long-term employees

resist change

Almost complete turnover of staff

(many new nurses)

Restraining forces

Driving forces

(unfreezing) (Refreezing)

New equilibrium

MovingPresent equilibrium (status quo)

Restraining forces

Driving forces

58 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

passes from first knowledge of an innovation to confirmation of the decision to adopt or reject a new idea. His framework emphasizes the reversible nature of change: participants may initially adopt a proposal but later discontinue it, or the reverse—they may initially reject it but adopt it at a later time. This is a useful distinction. If the change agent is unsuccessful in achieving full implementation of a proposal, it should not be assumed the issue is dead. It can be resurrected, perhaps in an altered form or at a more opportune time.

Rogers stresses two important aspects of successful planned change: key people and policy makers must be interested in the innovation and committed to making it happen. Erwin (2009) found that organizational change in hospitals could only be successful and sustained if senior administrators were fully committed to the change.

Used primarily as a tool for patient teaching, Prochaska and DiClemente (2005) proposed a transtheoretical model of behavior change. Five stages characterize their model. The stages occur in sequence, and the person must be ready for change to occur, according to this model.

The Change Process Steps in the change process follow the same path as the nursing process: assessment, planning, implementation, and evaluation (see Table 5-2).

Assessment Emphasis is placed on the assessment phase of change for two reasons. Without data collection and analysis, planned change will not proceed past the “wouldn’t it be a good idea if” stage.

Identify the Problem or the Opportunity Change is often planned to close a discrepancy between the desired and actual state of affairs. Discrepancies may arise because of problems in reaching performance goals or because new goals have been created.

Opportunities demand change as much as (or more than) problems do, but they are often overlooked. Be it a problem or an opportunity, it must be identified clearly. If the issue is perceived differently by key individuals, the search for solutions becomes confused.

TABLE 5-1 Comparison of Change Models

Lewin Lippitt Havelock Rogers Prochaska & DiClemente

1. Unfreezing 1. Diagnose problem 1. Building a relationship 1. Knowledge 1. Precontemplation

2. Moving 2. Assess motivation 2. Diagnosing the problem 2. Persuasion 2. Contemplation

3. Refreezing 3. Assess change agent’s motivations and resources

3. Acquiring resources

4. Choosing the solution

3. Decision

4. Implementation

3. Preparation

4. Action 4. Select progressive change

objects

5. Choose change agent role

5. Gaining acceptance

6. Stabilization and self- renewal

5. Confirmation 5. Maintenance

6. Maintain change

7. Terminate helping relationships

CHAPTER 5 • INITIATING AND MANAGING CHANGE 59

Start by asking the right questions, such as:

1. Where are we now? What is unique about us? What should our business be?

2. What can we do that is different from and better than what our competitors do?

3. What is the driving stimulus in our organization? What determines how we make our final decisions?

4. What prevents us from moving in the direction we wish to go?

5. What kind of change is required?

This last question generates integrative thinking on the potential effect of change on the system. Organizational change involves modifications in the system’s interacting components: technology, structure, and people.

Introducing new technology changes the structure of the organization. The physical plant may be altered if new services are added and then relationships among the people who work in the system change when the structure is changed. Surveillance cameras, cell phones, mag- netic entry cards, bar codes, and communication technology, including social media, have al- tered the care environment as much as they’ve changed our personal world. New rules and regulations, new authority structures, and new budgeting methods may emerge. They, in turn, change staffing needs, requiring people with different skills, knowledge bases, attitudes, and motivations.

Collect Data Once the problem or opportunity has been clearly defined, the change agent collects data external and internal to the system. This step is crucial to the eventual success of the planned change. All driving and restraining forces are identified so the driving forces can be emphasized and the restraining forces reduced. It is imperative to assess the political pulse. Who will gain from this change? Who will lose? Who has more power and why? Can those power bases be altered? How?

Assess the political climate by examining the reasons for the present situation. Who in control may be benefiting now? Egos, commitment of the involved people, and personal likes and dislikes are as important to assess as the formal organizational structures and processes. The innovator has to gauge the potential for resistance.

The costs and benefits of the proposed change are obvious focal points. Also assess resources—especially those the manager can control. A manager who has the respect and support of an excellent nursing staff has access to a powerful resource in today’s climate.

TABLE 5-2 Steps in the Change Process

1. Identify the problem or opportunity.

2. Collect necessary data and information.

3. Select and analyze data.

4. Develop a plan for change, including time frame and resources.

5. Identify supporters or opposers.

6. Build a coalition of supporters.

7. Help people prepare for change.

8. Prepare to handle resistance.

9. Provide a feedback mechanism to keep everyone informed of the progress of change.

10. Evaluate effectiveness of the change and, if successful, stabilize the change.

60 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

Analyze Data The kinds, amounts, and sources of data collected are important, but they are useless unless they are analyzed. The change agent should focus more energy on analyzing and summarizing the data than on just collecting it. The point is to flush out resistance, identify potential solutions and strategies, begin to identify areas of consensus, and build a case for whichever option is selected.

At a not-for-profit hospital in the process of seeking Magnet status, each service line is looking for opportunities to improve standards of care, efficiency, and patient safety. In the ambulatory surgery center, the process of providing preoperative services was often slow and inefficient. The surgery center nurses were charged with finding ways to improve efficiency.

Planning Planning the who, how, and when of the change is a key step. What will be the target system for the change? Members from this system should be active participants in the planning stage. The more involved they are at this point, the less resistance there will be later. Lewin’s unfreezing imagery is relevant here. Present attitudes, habits, and ways of thinking have to soften so mem- bers of the target system will be ready for new ways of thinking and behaving. Boundaries must melt before the system can shift and restructure.

This is the time to make people uncomfortable with the status quo. Plant the seeds of dis- content by introducing information that may make people feel dissatisfied with the present and interested in something new. This information comes from the data collected (e.g., research findings, quantitative data, and patient satisfaction questionnaires or staff surveys). Couch the proposed change in comfortable terms as far as possible, and minimize anxiety about the new change.

Managers need to plan the resources required to make the change and establish feedback mechanisms to evaluate its progress and success. Establish control points with people who will provide the feedback and work with these people to set specific goals with time frames. Develop operational indicators that signal success or failure in terms of performance and satisfaction.

Three surgery center nurses designed a flow chart of how the process could be improved. They took it to their administration and were put in charge of its implementation.

Implementation The plans are put into motion (Lewin’s moving stage). Interventions are designed to gain the nec- essary compliance. The change agent creates a supportive climate, acts as an energizer, obtains and provides feedback, and overcomes resistance. Managers are the key change-process actors. Some methods are directed toward changing individuals in an organization, whereas others are directed toward changing the group.

Methods to Change Individuals The most common method used to change individuals’ perceptions, attitudes, and values is information giving. Providing information is prerequisite to change implementation, but it is inadequate unless a lack of information is the only obstacle to effecting change. Providing infor- mation does not address the motivation to change.

Training is often considered a method to change individuals. Training combines information-giving with skill practice. Training typically shows people how they are to perform in a system, not how to change it. Therefore, it is a strategy to help make the transition to a planned change rather than a mechanism to initiate change.

Selecting and placing personnel or terminating key people often is used to alter the forces for or against change. When key supporters of the planned change are given the authority and

CHAPTER 5 • INITIATING AND MANAGING CHANGE 61

accountability to make the change, their enthusiasm and legitimacy can be effective in leading others to support the change. Conversely, if those opposed to the change are transferred or leave the organization, the change is more likely to succeed.

Methods to Change Groups Some implementation tactics use groups rather than individuals to attain compliance to change. The power of an organizational group to influence its members depends on its authority to act on an issue and the significance of the issue itself. The greatest influence is achieved when group members discuss issues that are perceived as important and make relevant, binding de- cisions based on those discussions. Effectiveness in implementing organizational change is most likely when groups are composed of members who occupy closely related positions in the organization.

Individual and group implementation tactics can be combined. Whatever methods are used, participants should feel their input is valued and should be rewarded for their efforts. Some people are not always persuaded before a beneficial change is implemented. Sometimes behav- ior changes first, and attitudes are modified later to fit the behavior. In this case, the change agent should be aware of participants’ conflicts and reward the desired behaviors. It may take some time for attitudes to catch up.

The surgery center nurses worked with physician offices, insurance companies, and other hospital departments to implement the new process for preoperative services.

Evaluation Evaluate Effectiveness At each control point, the operational indicators established are monitored. The change agent determines whether presumed benefits were achieved from a financial as well as a qualitative perspective, explaining the extent of success or failure. Unintended consequences and undesir- able outcomes may have occurred.

Stabilize the Change The change is extended past the pilot stage, and the target system is refrozen. The change agent terminates the helping relationship by delegating responsibilities to target system members. The energizer role is still needed to reinforce new behaviors through positive feedback.

Over the next three months, the preoperative services department was able to show a 90 percent decrease in duplicate test orders, a 50 percent decrease in patient waiting time, and an 80 percent increase in physician satisfaction with the process.

Change Strategies Regardless of the setting or proposed change, the four-step change process should be followed. However, specific strategies can be used, depending on the amount of resistance anticipated and the degree of power the change agent possesses.

Power-Coercive Strategies Power-coercive strategies are based on the application of power by legitimate authority, economic sanctions, or political clout. Changes are made through law, policy, or financial appropriations. Those in control enforce changes by restricting budgets or creating policies. Those who are not in power may not even be aware of what is happening. Even if they are aware, they have little power to stop it. Health care reform legislation, is an example of power-coercive strategy by the federal government.

62 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

Power-coercive strategies are useful when a consensus is unlikely despite efforts to stimulate participation by those involved. When much resistance is anticipated, time is short, and the change is critical for organizational survival, power-coercive strategies may be necessary.

Empirical–Rational Model In the empirical–rational model of change strategies, the power ingredient is knowledge. The assumption is that people are rational and will follow their rational self-interest if that self- interest is made clear to them. It is also assumed that the change agent who has knowledge has the expert power to persuade people to accept a rationally justified change that will benefit them.

The flow of influence moves from those who know to those who do not know. New ideas are invented and communicated or diffused to all participants. Once enlightened, rational people will either accept or reject the idea based on its merits and consequences. Empirical–rational strategies are often effective when little resistance to the proposed change is expected and the change is perceived as reasonable.

Well-researched, cost-effective technology can be implemented using these strategies. In- troducing a new technology that is easy to use, cuts nursing time, and improves quality of care might be accepted readily after in-service education and a trial use. Using bar codes to match medications to patients is another example.

The change agent can direct the change. There is little need for staff participation in the early steps of the change process, although input is useful for the evaluation and stabilization stages. The benefits of change for the staff and research documenting improved patient out- comes are the major driving forces.

Normative–Reeducative Strategies In contrast to the rational-empirical model, normative–reeducative strategies of change rest on the assumption that people act in accordance with social norms and values. Information and rational arguments are insufficient strategies to change people’s patterns of actions; the change agent must focus on noncognitive determinants of behavior as well. People’s roles and relationships, perceptual orientations, attitudes, and feelings will influence their acceptance of change.

In this mode, the power ingredient is not authority or knowledge, but skill in interpersonal relationships. The change agent does not use coercion or nonreciprocal influence, but col- laboration. Members of the target system are involved throughout the change process. Value conflicts from all parts of the system are brought into the open and worked through so change can progress.

Normative–reeducative strategies are well suited to the creative problem solving needed in nursing and health care today. With their firm grasp of the behavioral sciences and communica- tion skills, nurses are comfortable with this model. Changing from a traditional nursing system to self-governance or initiating a home follow-up service for hospitalized patients are examples of changes amenable to the normative–reeducative approach.

In most cases, the normative–reeducative approach to change will be effective in reduc- ing resistance and stimulating personal and organizational creativity. The obvious drawback is the time required for group participation and conflict resolution throughout the change process. When there is adequate time or when group consensus is fundamental to successful adoption of the change, the manager is well advised to adopt this framework.

Resistance to Change Resistance to change is to be expected for a number of reasons: lack of trust, vested interest in the status quo, fear of failure, loss of status or income, misunderstanding, and belief that change

CHAPTER 5 • INITIATING AND MANAGING CHANGE 63

is unnecessary or that it will not improve the situation (Yukl, 2009; Hellriegel, Jackson, & Slocum, 2007). In fact, if resistance does not surface, the change may not be significant enough.

Employees may resist change because they dislike or disapprove of the person responsible for implementing the change or they may distrust the change process. Regardless, managers continually deal with change—both the change that they themselves initiate and change initiated by the larger organization.

Resistance varies from ready acceptance to full-blown resistance. Rogers (2003) identified six responses to change:

● Innovators love change and thrive on it. ● Less radical, early adopters are still receptive to change. ● The early majority prefer the status quo, but eventually accept the change. ● The late majority are resistive, accepting change after most others have. ● Laggards dislike change and are openly antagonistic. ● Rejecters actively oppose and may even sabotage change.

The change agent should anticipate and look for resistance to change. It will be lurking somewhere, perhaps where least expected. It can be recognized in such statements as:

● We tried that before. ● It won’t work. ● No one else does it like that. ● We’ve always done it this way. ● We can’t afford it. ● We don’t have the time. ● It will cause too much commotion. ● You’ll never get it past the board. ● Let’s wait awhile. ● Every new boss wants to do something different. ● Let’s start a task force to look at it; put it on the agenda.

Expect resistance and listen carefully to who says what, when, and in what circumstances. Open resisters are easier to deal with than closet resisters. Look for nonverbal signs of resis- tance, such as poor work habits and lack of interest in the change.

Resistance prevents the unexpected. It forces the change agent to clarify information, keep in- terest level high, and establish why change is necessary. It draws attention to potential problems and encourages ideas to solve them. Resistance is a stimulant as much as it is a force to be overcome. It may even motivate the group to do better what it is doing now, so that it does not have to change.

On the other hand, resistance is not always beneficial, especially if it persists beyond the planning stage and well into the implementation phase. It can wear down supporters and redirect system energy from implementing the change to dealing with resisters. Morale can suffer.

To manage resistance, use the following guidelines:

1. Talk to those who oppose the change. Get to the root of their reasons for opposition.

2. Clarify information, and provide accurate feedback.

3. Be open to revisions but clear about what must remain.

4. Present the negative consequences of resistance (e.g., threats to organizational survival, compromised patient care).

5. Emphasize the positive consequences of the change and how the individual or group will benefit. However, do not spend too much energy on rational analysis of why the change is good and why the arguments against it do not hold up. People’s resistance frequently flows from feelings that are not rational.

64 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

6. Keep resisters involved in face-to-face contact with supporters. Encourage proponents to empathize with opponents, recognize valid objections, and relieve unnecessary fears.

7. Maintain a climate of trust, support, and confidence.

8. Divert attention by creating a different disturbance. Energy can shift to a more important problem inside the system, thereby redirecting resistance. Alternatively, attention can be brought to an external threat to create a bully phenomenon. When members perceive a greater environmental threat (such as competition or restrictive governmental policies), they tend to unify internally.

The Nurse’s Role Initiating Change Contrary to popular opinion, change often is not initiated by top-level management (Yukl, 2009), but rather emerges as new initiatives or problems are identified. Furthermore, Weiner, Amick, and Lee (2008) posit that organizational readiness is the key to initiating change.

Staff nurses often think that they are unable to initiate and create change, but that is not so.

Home health nurses were often frustrated by not having appropriate supplies with them when seeing a patient for the first time. A team of nurses completed a chart audit to iden- tify commonly used supplies and equipment that nurses were using on their home visits. Each nurse was then supplied with a small plastic container to keep in his or her car with these items. Frustration decreased and efficient use of nursing time was improved.

The manager, as well, may resist leading change. Afraid of “rocking the boat,” fearful that no one will join our efforts, recalling that past efforts at change had failed, or even the reluctance to become involved may prevent the nurse from initiating change.

Making change is not easy, but it is a mandatory skill for managers. Successful change agents demonstrate certain characteristics that can be cultivated and mastered with practice. These characteristics include:

● The ability to combine ideas from unconnected sources ● The ability to energize others by keeping the interest level up and demonstrating a high

personal energy level ● Skill in human relations: well-developed interpersonal communication, group manage-

ment, and problem-solving skills ● Integrative thinking: the ability to retain a big picture focus while dealing with each part

of the system ● Sufficient flexibility to modify ideas when modifications will improve the change, but

enough persistence to resist nonproductive tampering with the planned change ● Confidence and the tendency not to be easily discouraged ● Realistic thinking ● Trustworthiness: a track record of integrity and success with other changes ● The ability to articulate a vision through insights and versatile thinking ● The ability to handle resistance

Energy is needed to change a system. Power is the main source of that energy. Informational power, expertise, and possibly positional power can be used to persuade others.

To access optimum power, use the following strategies:

1. Analyze the organizational chart. Know the formal lines of authority. Identify informal lines as well.

2. Identify key persons who will be affected by the change. Pay attention to those immedi- ately above and below the point of change.

CHAPTER 5 • INITIATING AND MANAGING CHANGE 65

3. Find out as much as possible about these key people. What are their “tickle points”? What interests them, gets them excited, turns them off? What is on their personal and organiza- tional agendas? Who typically aligns with whom on important decisions?

4. Begin to build a coalition of support before you start the change process. Identify the key people who will be affected by the change. Talk informally with them to flush out possible objections to your idea and potential opponents. What will the costs and benefits be to them—especially in political terms? Can your idea be modified in ways that retain your objectives but appeals to more key people?

5. Follow the organizational chain of command in communicating with administrators. Don’t bypass anyone to avoid having an excellent proposal undermined.

This information helps you develop the most sellable idea or at least pinpoint probable resistance. It is a broad beginning to the data-collection step of the change process and has to be fine-tuned once the idea is better defined. The astute manager keeps alert at all times to monitor power struggles.

Although a cardinal rule of change is, “Don’t try to change too much too fast,” the savvy manager develops a sense of exquisite timing by pacing the change process according to the political pulse. For example, the manager unfreezes the system during a period of coalition building and high interest, while resistance is low or at least unorganized.

You may decide to stall the project beyond a pilot stage if resistance solidifies or gains a powerful ally. In this case, do whatever you can to reduce resistance. If resistance continues, two options should be considered:

● The change is not workable and should be modified to meet the strongest objections (compromise).

● The change is fine-tuned sufficiently, but change must proceed now and resistance must be overcome.

Implementing Change In addition to initiating change, nurses and nurse managers are called on to assist with change in other ways. They may be involved in the planning stage, charged with sharing information with coworkers, or they may be asked to help manage the transition to planned change.

Planning Change One Magnet-recognized hospital engaged all its nurses in planning for the desired future of clinical nursing in its organization (Capuano et al., 2007). It held a series of group events to so- licit ideas and opinions. Every nurse—executive, manager, or staff nurse—had an equal vote to approve or veto a proposed change. This process illustrates the normative–reeducative process of change.

Managing Transitions to Change Transitions are those periods of time between the current situation and the time when change is implemented (Bridges, 2009). They are the times ripe for a change agent to act. Just as initiating change is not easy, neither is transitioning to changed circumstances.

Letting go of long-term, comfortable activities is difficult. The tendency is to:

● Add new work to the old ● Make individual decisions about what to add and what to let go ● Toss out everything done before (Bridges, 2009)

Accepting loss and honoring the past with respect is essential. Passion for the work is based on results, not activities, regardless of their necessity or effectiveness.

A large national for-profit health care system purchased a new hospital clinical informa- tion system. Because all paper charting would be eliminated, nurses would be directly

66 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

affected. Their participation could spell success or failure for the new system. To help the transition occur smoothly, nurses from each department met together for a demonstration of the new clinical information system and provided feedback to the IT department about nursing process and integrating patient care with the new system. Then a few nurses on each unit were selected to be trained as experts in the new technology, and they in turn trained other staff members, communicating with the IT department when concerns arose.

A nurse manager in a home health care agency used change management strategies to over- come resistance, as shown in Case Study 5-1.

Handling Constant Change Change has always occurred; what’s different today is both the pace of change and that an initial change causes a chain reaction of more and more change (Bridges, 2009). Change, rather than an occasional event, has become the norm.

Regardless of their position in an organization, nurses find themselves constantly dealing with change. Whether they thrive in such an atmosphere is a function of both their own personal resources and the environment in which change occurs.

ENCOURAGING CHANGE Peter Beasley is the nurse manager of pediatric home care for a private home health care agency. Last year, the agency completed a pilot of wireless devices for use in documenting home visits. As nurses complete the documentation, charges for supplies and medical equip- ment are generated. The agency director informed the nurse managers that all nurses will be required to use the wireless devices within the next three months.

Charlene Ramirez has been a pediatric nurse for 18 years, working for the home health care agency for the past 5 years. Charlene has been active in updating the pediatric documentation and training staff when new paper-based documentation was implemented in the past. Although she was part of the pilot, Charlene is very opposed to using the new wireless devices. She complains that she can barely see the text. At a recent staff meeting, Charlene stated she would rather quit than learn to use the new wireless devices.

Peter empathizes with Charlene’s reluctance to use the new technology. He also recognizes how much Char- lene contributes in expertise and leadership to the de- partment. However, he knows that the new performance standards require all employees to use the wireless de- vices. After three mandatory training sessions, Charlene repeatedly tells coworkers “We’ve tried things like this before, it never works. We’ll be back on paper within six months, so why waste my time learning this stuff?” The program trainer reports that Charlene was disruptive dur- ing the class and failed her competency exam.

Peter meets privately with Charlene to discuss her resistance to the new technology. Charlene again states that she fails to see the need for wireless devices in delivering quality patient care. Peter reviews the new performance standards with Charlene, emphasizing the technology requirements. He asks Charlene if she has difficulty understanding the application or just in using the device. Charlene admits she cannot read the text on the screen and therefore cannot determine what exact- ly she is documenting. Peter informs Charlene that the agency’s health benefits include vision exams and par- tial payment for corrective lenses. He suggests that she talk with an optometrist to see if special glasses would help her see the screen. Peter also makes a note to speak with the technology specialist to see if there are aids to help staff view data on the device.

Manager’s Checklist The nurse manager is responsible for:

● Communicating openly and honestly with employees who oppose change.

● Understanding resistance to change. ● Maintaining support and confidence in staff even if

they are resistive to change. ● Emphasizing the positive outcomes from initiating

change. ● Finding solutions to problems that are obstacles to

change.

CASE STUDY 5-1

CHAPTER 5 • INITIATING AND MANAGING CHANGE 67

If you don’t like the current situation, you may look forward to change. As Midwestern- ers are fond of saying when asked about the weather: “If you don’t like it today, just wait until tomorrow. It will change.”

What You Know Now • In today’s health care system, change is inevitable, necessary, and constant. • With changes proposed for the nursing profession, nurses are in a pivotal position to initiate and

participate in change. • For change to be positive for nurses, they must develop change agent skills. • Critical evaluation of change theories provides guidance and direction for initiating and managing change. • The change process is similar to the nursing process and includes assessment, planning, implementation,

and evaluation. • Resistance to change is to be expected, and it can be a stimulant as well as a force to be overcome. • The nurse may be involved in change by initiating it or participating in implementing change. • Handling constant change is a challenge in today’s health care environment.

Tools for Initiating and Managing Change 1. Communicate openly and honestly with employees who oppose change. 2. Maintain support and confidence in staff even if they are resistive to change. 3. Emphasize the positive outcomes from the change. 4. Find solutions to problems that are obstacles to change. 5. Accept the constancy of change.

Questions to Challenge You 1. Identify a needed change in the organization where you practice. Using the change process, outline

the steps you would take to initiate change. 2. Consider your school or college. What change do you think is needed? Explain how you would

change it to become a better place for learning. 3. Have you had an experience with change occurring in your organization? What was your initial

reaction? Did that change? How well did the change process work? Was the change successful? 4. Do you have a behavior you would like to change? Using the steps in the change process, describe

how you might effect that change. 5. How do you normally react to change? Choose from the following: a. I love new ideas, and I’m ready to try new things. b. I like to know that something will work out before I try it. c. I try to avoid change as much as possible. 6. Did your response to the above question alter how you would like to view change? Think about this

the next time change is presented to you. 7. Think back to your first time on a clinical unit. How did you feel? Overwhelmed? Afraid of failing?

That’s the feeling that people have when facing change. Try to remember how you felt when you encounter resistance to change.

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

www.nursing.pearsonhighered.com

68 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

Bridges, W. (2009). Managing transitions: Making the most of change. Cambridge, MA: Da Capo Press.

Capuano, T., Durishin, L. D., Millard, J. L., & Hitchings, K. S. (2007). The desired future of nursing doesn’t just happen—engaged nurses create it. Journal of Nursing Administration, 37(2), 61–63.

Erwin, D. (2009). Changing or- ganizational performance: Examining the change pro- cess. Hospital Topics: Re- search and Perspectives on Healthcare, 87(3), 28–40.

Havelock, R. (1973). The change agent’s guide to innovation in education. Englewood Liffs, NJ: Educational Tech- nology Publications.

Heath, C., & Heath, D. (2010). Switch: How to change things when change is hard. New York: Crown.

Hellriegel, D., Jackson, S. E., & Slocum, J. W. (2007). Man- agement: A competency- based approach (11th ed.). Eagan, MN: South-Western.

Holtrop, J. S., Baumann, J., Arnold, A. K., & Torres, T. (2008). Nurses as practice

change facilitators for healthy behaviors. Journal of Nursing Care Quality, 23(2), 123–131.

Institute of Medicine (2010). The future of nursing: Leading change, advancing health. Retrieved May 24, 2011 from http://www.iom. edu/Reports/2010/The- Future-of-Nursing-Leading- Change-Advancing- Health.aspx

Lewin, K. (1951). Field theory in social science. New York: Harper & Row.

Lippitt, R., Watson, J., & West- ley, B. (1958). The dynam- ics of planned change. New York: Harcourt & Brace.

MacDavitt, K., Cieplinski, J. A., & Walker, V. (2011). Implementing small tests of change to improve pa- tient satisfaction. Journal of Nursing Administration, 41(1), 5–9.

McMurray, A., Chaboyer, W., Wallis, M., & Fetherston, C. (2010). Implementing bedside handover: Strate- gies for change manage- ment. Journal of Clinical Nursing, 19(17–18), 2580–2589.

Nickitas, D. M. (2010). A vi- sion for future health care: Where nurses lead the change. Nursing Econom- ics, 28(6), 361, 385.

Prochaska, J. O. & DiClemente, C. C. (2005). The transtheo- retical approach. In: Nor- cross, J. C., & Goldfried, M. R. (Eds.), Handbook of psychotherapy integration (2nd ed.). New York: Ox- ford University Press.

Rogers, E. (2003). Diffusion of innovations (5th ed.). New York: Free Press.

Sare, M. V., & Ogilvie, L. (2009). Strategic planning for nurses: Change man- agement in health care. Sudbury, MA: Jones and Bartlett.

Weiner, B. J., Amick, H., & Lee, S. D. (2008). Conceptual- ization and measurement of organizational readiness for change: A review of the literature in health services research and other fields. Medical Care Research and Review, 65(4), 379–436.

Yukl, G. A. (2009). Leadership in organizations (7th ed.). Upper Saddle River, NJ: Prentice Hall.

Web Resources Agency for Healthcare Research and Quality. http://www.ahrq.gov/ Institute of Medicine. http://www.iom.edu/

References

http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

http://www.ahrq.gov/

http://www.iom.edu/

http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

CHAPTER

Quality Management TOTAL QUALITY

MANAGEMENT

CONTINUOUS QUALITY IMPROVEMENT

COMPONENTS OF QUALITY MANAGEMENT

SIX SIGMA

LEAN SIX SIGMA

DMAIC METHOD

Improving the Quality of Care NATIONAL INITIATIVES

HOW COST AFFECTS QUALITY

EVIDENCE-BASED PRACTICE

ELECTRONIC MEDICAL RECORDS

DASHBOARDS

NURSE STAFFING

REDUCING MEDICATION ERRORS

PEER REVIEW

Risk Management NURSING’S ROLE IN RISK

MANAGEMENT

INCIDENT REPORTS

EXAMPLES OF RISK

ROOT CAUSE ANALYSIS

ROLE OF THE NURSE MANAGER

CREATING A BLAME-FREE ENVIRONMENT

Managing and Improving Quality 6

Key Terms Continuous quality

improvement (CQI) Dashboards DMAIC Incident reports Indicator Just culture

1. Describe how total quality management, continuous quality management, Six Sigma, Lean Six Sigma, and DMAIC address quality.

2. Describe national efforts to improve the quality of health care.

3. Explain how evidence-based practice, electronic medical records, and dashboards can improve quality.

4. Point out how nurses are involved in reducing risks.

5. Discuss how to create a blame-free environment.

Learning Outcomes After completing this chapter, you will be able to:

Outcome standards Lean Six Sigma Peer review Process standards Quality management Reportable incident Risk management

Root cause analysis Six Sigma Standards Structure standards Total quality management

(TQM)

70 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

I n today’s highly competitive health care environment, each member of the health care organization must be accountable for the quality and cost of health care. Concern about quality gained national attention after publication of the Institute of Medicine’s (IOM) reports on medical errors in 1999 (IOM, 1999) and their later recommendations for health pro- fessionals’ education (IOM, 2003). Additionally, concern about cost continues unabated. Both quality and cost containment are found in the concept of total quality management, which has evolved into a model of continuous quality improvement designed to improve system and process performance. Risk management is integrated within a quality management program.

Quality Management Quality management moved health care from a mode of identifying failed standards, problems, and problem people to a proactive organization in which problems are prevented and ways to improve care and quality of care are sought. This paradigm shift involves all in the organization and promotes problem solving and experimentation.

A quality management program is based on an integrated system of information and accountability. Clinical information systems can provide the data needed to enable organizations to track activities and outcomes. For example, data from clinical information systems can be used to track patient wait times from admitting to outpatient testing to admission in an inpatient care unit. Delays in the process can be identified so appropriate staff and resources are available at the right time to decrease delays and increase efficiency and patient satisfaction. Methods can be devised to discover problems in the system without blaming the “sharp end,” the last individual in the chain to act (e.g., the nurse gives a wrong medication). The system must be accepted and used by the entire staff.

Total Quality Management Total quality management (TQM) is a management philosophy that emphasizes a commitment to excellence throughout the organization. The creation of Dr. W. Edwards Deming, TQM was adopted by the Japanese after World War II and helped transform their industrial development. Dr. Deming based his system on principles of quality management that were originally applied to improve quality and performance in the manufacturing industry. They are now widely used to improve quality and customer satisfaction in a number of service industries, including health care.

TQM Characteristics Four core characteristics of total quality management are:

● Customer/client focus ● Total organizational involvement ● Use of quality tools and statistics for measurement ● Key processes for improvement identified

Customer/Client Focus. An important theme of quality management is to address the needs of both internal and external customers. Internal customers include employees and departments within the organization, such as the laboratory, admitting office, and environmental services. External customers of a health care organization include patients, visitors, physicians, managed- care organizations, insurance companies, and regulatory agencies, such as the Joint Commission, which accredits health care organizations, and public health departments.

Under the principles of TQM, nurses must know who the customers are and endeavor to meet their needs. Providing flexible schedules for employees, adjusting routines for a.m. care to meet the needs of patients, extending clinic hours beyond 5 p.m., and putting infant changing tables in restrooms are some examples. Putting the customer first requires creative and innova- tive methods to meet the ever-changing needs of internal and external customers.

Total Organizational Involvement. The goal of total quality management is to involve all employees and empower them with the responsibility to make a difference in the quality of

CHAPTER 6 • MANAGING AND IMPROVING QUALITY 71

service they provide. This means all employees must have knowledge of the TQM philosophy as it relates to their job and the overall goals and mission of the organization. Knowledge of the TQM process breaks down barriers between departments. The phrase “That’s not my job” is eliminated. Departments work together as a team. On occasion, nursing personnel might clean a bed for a new admission from the emergency room or an administrator might transport a patient to the radiology department. Sharing processes across departments and patient care functions increases teamwork, productivity, and patient positive outcomes.

Use of Quality Tools and Statistics for Measurement. A common management adage is, “You can’t manage what you can’t (or don’t) measure.” There are many tools, formats, and designs that can be used to build knowledge, make decisions, and improve quality. Tools for data analysis and display can be used to identify areas for process and quality improvement, and then to benchmark the progress of improvements. Deming applied the scientific method to the concept of TQM to develop a model he called the PDCA cycle (Plan, Do, Check, Act) depicted in Figure 6-1.

Identification of Key Processes for Improvement. All activities performed in an organization can be described in terms of processes. Processes within a health care setting can be:

● Systems related (e.g., admitting, discharging, and transferring patients) ● Clinical (e.g., administering medications, managing pain) ● Managerial (e.g., risk management and performance evaluations).

Processes can be very complex and involve multidisciplinary or interdepartmental actions. Processes involving multiple departments must be investigated in detail by members from each department involved in the activity so that they can proactively seek opportunities to reduce waste and inefficiencies and develop ways to improve performance and promote positive outcomes.

Continuous Quality Improvement TQM is the overall philosophy, whereas continuous quality improvement (CQI) is used to im- prove quality and performance. TQM and CQI often are used synonymously. In health care orga- nizations, CQI is the process used to investigate systematically ways to improve patient care. As the name implies, continuous quality improvement is a never-ending endeavor (Hedges, 2006).

CQI means more than just meeting standards and thresholds or solving problems. It involves evaluation, actions, and a mind-set to strive constantly for excellence. This concept is sometimes difficult to grasp because patient care involves the synchronization of activities in multiple de- partments. Therefore, the importance of developing and implementing a well-thought-out pro- cess is key to a successful CQI implementation.

There are four major players in the CQI process:

● Resource group ● Coordinator

PlanPlan

DoAct

Check

Figure 6-1 • PDCA cycle.

72 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

● Team leader ● Team

The resource group is made up of senior management (e.g., CEO, vice presidents). It estab- lishes overall CQI policy, vision, and values for the organization and actively involves the board of directors in this process, thereby ensuring that the CQI program has sufficient emphasis and is provided with the resources needed. The CQI coordinator is often appointed by the CEO to pro- vide day-to-day management of the CQI process and related activities (e.g., training programs).

CQI teams are designated to evaluate and improve select processes. They are formally established and supported by the resource group. CQI teams range in size from 5 to 10 people, representing all major functions of the process being evaluated.

Each CQI team is headed by a team leader who is familiar with the process being evaluated. The leader organizes team meetings, sets the agenda, and guides the group through the discussion, evaluation, and implementation process.

Components of Quality Management A comprehensive quality management program includes:

● A comprehensive quality management plan. A quality management plan is a systematic method to design, measure, assess, and improve organizational performance. Using a multidisciplinary approach, this plan identifies processes and systems that represent the goals and mission of the organization, identifies customers, and specifies opportunities for improvement. Critical paths, which are described in Chapter 3, are an example of a quality management plan. Critical paths identify expected outcomes within a specific time frame. Then variances are tracked and accounted for.

● Set standards for benchmarking. Standards are written statements that define a level of performance or a set of conditions determined to be acceptable by some authorities. Standards relate to three major dimensions of quality care:

a. Structure b. Process c. Outcome

Structure standards relate to the physical environment, organization, and management of an organization. Process standards are those connected with the actual delivery of care. Outcome standards involve the end results of care that has been given.

An indicator is a tool used to measure the performance of structure, process, and outcome standards. It is measurable, objective, and based on current knowledge. Once indicators are identified, benchmarking, or comparing performance using identified quality indicators across institutions or disciplines, is the key to quality improvement.

In nursing, both generic and specific standards are available from the American Nurses Association and specialty organizations; however, each organization and each patient care area must designate standards specific to the patient population being served. These standards are the foundation on which all other measures of quality are based.

An example of a standard is, “Every patient will have a written care plan within 12 hours of admission.”

● Performance appraisals. Based on requirements of the job, employees are evaluated on their performance. This feedback is essential for employees to be professionally accountable. (See Chapter 18 for more on performance appraisals.)

● A focus on intradisciplinary assessment and improvement. There will always be a need for groups to assess, analyze, and improve their own performance. Methods to assess performance should, however, focus on the CQI philosophy, which involves group or intradisciplinary performance. Peer review, discussed later in the chapter, is an example of intradisciplinary assessment.

CHAPTER 6 • MANAGING AND IMPROVING QUALITY 73

● A focus on interdisciplinary assessment and improvement. Multidisciplinary, patient- focused teamwork emphasizing collaboration, communication, coordination, and integra- tion of care is the core of CQI in health care. It is important not to disband departmental quality functions, such as patient satisfaction, utilization review, or infection control, but rather to refocus information on improving the process.

Resources are used to collect data, such as the number of postoperative infections or the number of return clinic visits, to guide the decision-making process. Throughout the evalua- tion and implementation process, the team’s focus is the patient. Implementation is continu- ally evaluated using a patient satisfaction survey, which is just one of the methods used to monitor nursing care. For example, some organizations follow up outpatient surgery clients with direct phone calls from nursing staff to ensure patients understand discharge instructions and that pain was controlled following discharge. Any potential complications are referred to the surgeon.

Six Sigma Six Sigma is another quality management program that uses, primarily, quantitative data to monitor progress. Six Sigma is a measure, a goal, and a system of management.

● As a measure. Sigma is the Greek letter—ó—for standard, meaning how much performance varies from a standard. This is similar to how CQI monitors results against an outcome measure.

● As a goal. One goal might be accuracy. How many times, for example, is the right medication given in the right amount, to the right patient, at the right time, by the right route?

● As a management system. Compared to other quality management systems, Six Sigma involves management to a greater extent in monitoring performance and ensuring favorable results.

The system has six themes:

● Customer (patient) focus ● Data driven ● Process emphasis ● Proactive management ● Boundaryless collaboration ● Aim for perfection; tolerate failure.

The first three themes are similar to other quality management programs. The focus is on the object of the service; in nursing’s case, this is the patient. Data provide the evidence of results, and the emphasis is on the processes used in the system.

The latter three themes, however, differ from other programs. Management is actively involved and boundaries are breached (e.g., the disconnect between departments). More radically, Six Sigma tolerates failure (a necessary condition for creativity) while striving for perfection.

Lean Six Sigma Lean Six Sigma focuses on improving process flow and eliminating waste. Waste occurs when the organization provides more resources than are required. Data driven, Lean Six Sigma focuses on identifying steps that have little or no value to the care and cause unnecessary delays. Further- more, the method strives to eliminate variations in care and improve efficiencies and effective- ness. Because the goal of Lean Six Sigma is to identify and reduce waste, it provides tools that can be used with a Six Sigma management system.

Studies have shown Lean Six Sigma to be effective in reducing inappropriate hospital stays, improving the quality of care and reducing costs at the same time (Yamamoto et al., 2010).

74 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

In addition, when the method was used in one hospital, researchers found that a collaborative effort improved the care of inpatient diabetic patients (Niemeijer et al., 2010).

DMAIC Method DMAIC is a Six-Sigma process improvement method (as shown in Figure 6-2). Steps in the method are:

● Define what measures will indicate success ● Measure baseline performance ● Analyze results ● Improve performance ● Control and sustain performance (DMAIC Tools: Six Sigma Training Tools, 2011)

TQM, CQI, Six Sigma, Lean Six Sigma, and DMAIC are quantifiable systems that measure performance against set standards. The goal is to improve the quality of health care. In addition, other efforts to improve the quality of care are ongoing.

Improving the Quality of Care

National Initiatives The National Quality Forum is a nonprofit organization that strives to improve the quality of health care by building consensus on performance goals and standards for measuring and report- ing them (National Quality Forum, 2011). Additionally, the Institute of Healthcare Improvement (IHI) offers programs to assist organizations in improving the quality of care they provide (IHI, 2011). Their goals are:

● No needless deaths ● No needless pain or suffering ● No helplessness in those served or serving ● No unwanted waiting ● No waste

Joint Commission, hospitals’ accrediting body, has adopted mandatory national patient safety goals (Joint Commission, 2011). They charge hospitals to:

● Identify patients correctly ● Improve staff communication ● Use medicines safely ● Prevent infection ● Check patient medicines ● Identify patient safety risks ● Prevent mistakes in surgery

Define

MeasureControl

Improve Analyze

Figure 6-2 • DMAIC: The Six Sigma Method. Adapted from DMAIC tools: Six Sigma training tools. Retrieved October 21, 2011, from www.dmaictools.com

www.dmaictools.com

CHAPTER 6 • MANAGING AND IMPROVING QUALITY 75

Joint Commission collects data on 57 inpatient measures; 31 of these are currently made public with others scheduled to be publicly reported soon (Chassin et al., 2010). The focus is now on maxi- mizing health benefits to patients. They recommend that quality measures be based on four criteria:

1. The measure must be based on research that shows improved outcomes. More than one research study is required for documentation.

2. Reports document that evidence-based practice has been given. Aspirin following an acute myocardial infarction is an example.

3. The process documents desired outcome. Appropriately administering medications is an example.

4. The process has minimal or no unintended adverse effects (Chassin et al., 2010)

Measured standards are used extensively in industrial settings to reveal errors. However, the same cannot be said when measuring human behavior, which can vary and still be effective. Also, if the organization embraces these systems to such an extent that all variance is discour- aged, then innovation is also suppressed. Improvement in quality is sacrificed at the expense of innovative ideas and processes; organizations fail to allow input, become stagnant, and cease to be effective. This is the danger of all living systems that depend on outside input for survival. This is not to say that quality systems are not essential. They are. Organizations must find ways to foster creativity and innovation without compromising quality management.

How Cost Affects Quality Quality measures can also reduce costs. Wasted resources is an example. These include the time nurses spend looking for missing supplies or lab results, the costs of agency nurses because of unfilled positions, and delays in patient discharge due to a lack of coordination or an adverse event (e.g., medication error).

Using the Institute for Healthcare Improvement (2009) project, Transforming Care at the Bedside (TCAB), Unruh, Agrawal, and Hassmiller (2011) found that improving quality reduces costs. Specifically, the researchers report that in a three-year period, RN overtime was reduced, RN turnover was lowered, and fewer patients suffered falls.

Evidence-Based Practice Evidence-based practice (EBP) suggests that using research to decide on clinical treatments would improve quality of care, and that might be the case. Barriers, however, prevent EBP from being widely used by nurses. Such barriers, consistent across settings, include lack of time, autonomy over their practice, ability to find and assess evidence, and support from administra- tion (Brown et al., 2008).

Furthermore, EBP is most reliable when the research study includes a rigorous design (Hader, 2010), and when more than one study has confirmed the results (Chassin et al., 2010). These are not easily surmountable hurdles due to the fast-paced clinical environment and the barriers mentioned above.

Electronic Medical Records Similar to the argument that EBP improves quality, electronic medical records (EMR) should do so as well. Instant access to identical records should improve accuracy and speed commu- nication among care providers. Kazley and Ozcan (2008), however, found limited correlation between the use of EMR and 10 quality indicators in their study of more than 4,000 hospitals in the U.S. In a review of the literature, Chan, Fowles, and Weiner (2010) could not link quality indicators and EMR. Cebul (2008), however, did find direct correlation between the use of EMR and the quality of care provided to diabetic patients. EMR use, is expected to expand and will provide more data for comparison with quality.

76 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

Dashboards Dashboards are electronic tools that can provide real-time data or retrospective data, known as a scorecard. Both are useful in assessing quality. Ease of access and the visual appearance of the dashboard make its use more likely. Dashboards may report on hospital census or patient satisfac- tion results, for example. Dashboards are also useful to guide staffing and match staffing with pa- tient outcomes (Frith, Anderson, & Sewell, 2010) and to provide accurate financial data on nurse staffing and quality (Anderson, Frith, & Caspers, 2011). As technology advances, widespread use of dashboards to aggregate data and guide decision making is expected (Hyun et al., 2008).

Nurse Staffing Evidence is growing that increased nurse staffing results in better patient outcomes (Frith, Tseng, & Anderson, 2008; Anderson, Frith, & Caspers, 2011). Earlier studies found that a higher RN-to-patient ratio resulted in reduced patient mortality, fewer infections, and shortened lengths of stay (Reeves, 2007). Needleman (2008) agrees that increasing the level of nurse staffing improves quality, but asserts that higher staffing levels also increase costs.

Reducing Medication Errors Ever since Medicare discontinued payment for hospital-based errors, pressure has increased for hospitals to prevent costly errors. In 2009, the federal government passed the Health Information Technology for Economic and Clinical Health Act (HITECH). The purpose of HITECH is to stim- ulate technology use in health care, including improving technology for medication administration.

Studies have shown that when nurses are interrupted during medication preparation, a 25 percent rate of injury-causing errors are made (Westbrook et al., 2010). One strategy to alert others that a nurse should not be interrupted is the use of a sash or vest that the nurse dons to prepare medications (Heath & Heath, 2010).

Other strategies to reduce medication errors include computerized prescriber order entry (CPOE), electronic medication administration record (eMAR), remote order review by pharma- cists, automated dispensing at the bedside, bar code administration, smart pumps, and unit doses ready to be administered (Federico, 2010). Future strategies include radio frequency identification and electronic reconciliation, both expensive technologies currently being tested (Federico, 2010).

Peer Review In addition to its value for self-evaluation and performance appraisal (Davis, Capozzoli, & Parks, 2009), peer review can be used to identify clinical standards of practice that improve the quality of care. Used for quality improvement, the peer review process is not intended to serve as a per- formance appraisal nor to be punitive. The purpose is to review the incident, determine if clinical standards were met or not, and to propose an action plan to prevent a future incident.

The peer review process is appropriate in the following situations:

● An adverse patient outcome has occurred. ● A serious risk or injury to a patient occurred. ● A failure to rescue incident occurred (Fujita et al., 2009).

A shared governance structure facilitates the peer review process, fostering peer-to-peer accountability (Fujita et al., 2009). Furthermore, the process can help determine if a breach in practice is an isolated incident or a trend occurring across a unit or throughout the organization. In a shared governance environment, unit councils or the nursing council can address unit-wide or system problems. To aggregate trends, peer review cases can be categorized as:

● Appropriate care with no adverse outcomes ● Appropriate care with adverse/unexpected outcomes ● Inappropriate care with no adverse outcomes ● Inappropriate care with adverse/unexpected outcomes (Hitchings et al., 2008)

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Risk Management Risk management is a component of quality management, but its purpose is to identify, analyze, and evaluate risks and then to develop a plan for reducing the frequency and severity of accidents and injuries. Risk management is a continuous daily program of detection, education, and intervention.

A risk management program involves all departments of the organization. It must be an organization-wide program, with the board of directors’ approval and input from all depart- ments. The program must have high-level commitment, including that of the chief executive officer and the chief nurse.

A risk management program:

1. Identifies potential risks for accident, injury, or financial loss. Formal and informal communication with all organizational departments and inspection of facilities are essential to identifying problem areas.

2. Reviews current organization-wide monitoring systems (incident reports, audits, committee minutes, oral complaints, patient questionnaires), evaluates completeness, and determines additional systems needed to provide the factual data essential for risk management control.

3. Analyzes the frequency, severity, and causes of general categories and specific types of incidents causing injury or adverse outcomes to patients. To plan risk intervention strategies, it is necessary to estimate the outcomes associated with the various types of incidents.

4. Reviews and appraises safety and risk aspects of patient care procedures and new programs.

5. Monitors laws and codes related to patient safety, consent, and care.

6. Eliminates or reduces risks as much as possible.

7. Reviews the work of other committees to determine potential liability and recommend prevention or corrective action. Examples of such committees are infection, medical audit, safety/security, pharmacy, nursing audit, and productivity.

8. Identifies needs for patient, family, and personnel education suggested by all of the foregoing and implements the appropriate educational program.

9. Evaluates the results of a risk management program.

10. Provides periodic reports to administration, medical staff, and the board of directors.

Nursing’s Role in Risk Management In the organizational setting, nursing is the one department involved in patient care 24 hours a day; nursing personnel are therefore critical to the success of a risk management program. The chief nursing administrator must be committed to the program. Her or his attitude will influence the staff and their participation. After all, it is the staff, with their daily patient contact, who actu- ally implement a risk management program.

High-risk areas in health care fall into five general categories:

● Medication errors ● Complications from diagnostic or treatment procedures ● Falls ● Patient or family dissatisfaction with care ● Refusal of treatment or refusal to sign consent for treatment

Nursing is involved in all areas, but the medical staff may be primarily responsible in cases involving refusal of treatment or consent to treatment.

Medical records and incidence reports serve to document organizational, nurse, and physician accountability. For every reported occurrence, however, many more are unreported. If records are

78 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

faulty, inadequate, or omitted, the organization is more likely to be sued and more likely to lose. Incident reports are used to analyze the severity, frequency, and causes of occurrences within the five risk categories. Such analysis serves as a basis for intervention.

Incident Reports Accurate and comprehensive reporting on both the patient’s chart and in the incident report is essential to protect the organization and caregivers from litigation. Incident reporting is often the nurse’s responsibility. Reluctance to report incidents is usually due to fear of the consequences. This fear can be alleviated by:

● Holding staff education programs that emphasize objective reporting ● Omitting inflammatory words and judgmental statements ● Having a clear understanding that the purposes of the incident reporting process are

documentation and follow-up ● Never using the report, under any circumstances, for disciplinary action.

Nursing colleagues and nurse managers should not berate another employee for an incident, and never in front of other staff members, patients, or patients’ family members. Peer review analysis, however, is a valuable tool to evaluate incidents (Hitchings et al., 2008).

A reportable incident should include any unexpected or unplanned occurrence that affects or could potentially affect a patient, family member, or staff. The report is only as effective as the form on which it is reported, so attention should be paid to the adequacy of the form as well as to the data required.

Reporting incidents involves the following steps:

1. Discovery. Nurses, physicians, patients, families, or any employee or volunteer may report actual or potential risk.

2. Notification. The risk manager receives the completed incident form within 24 hours after the incident. A telephone call may be made earlier to hasten follow-up in the event of a major incident.

3. Investigation. The risk manager or representative investigates the incident immediately.

4. Consultation. The risk manager consults with the referring physician, risk management committee member, or both to obtain additional information and guidance.

5. Action. The risk manager should clarify any misinformation to the patient or family, explaining exactly what happened. The patient should be referred to the appropriate source for help and, if needed, be assured that care for any necessary service will be provided free of charge.

6. Recording. The risk manager should be sure that all records, including incident reports, follow-up, and actions taken, if any, are filed in a central depository.

Examples of Risk The following are some examples of actual events in the various risk categories.

Medication Errors A reportable incident occurs when a medication or fluid is omitted, the wrong medication or fluid is administered, or a medication is given to the wrong patient, at the wrong time, in the wrong dosage, or by the wrong route. Here are some examples.

Patient A. Weight was transcribed incorrectly from emergency room sheet. Medication dose was calculated on incorrect weight; therefore, patient was given double the dose

CHAPTER 6 • MANAGING AND IMPROVING QUALITY 79

required. Error discovered after first dose and corrected. Second dose omitted per physician’s order.

Patient B. Tegretol dosage written in Medex as “Tegretol 100 mg chewable tab—50 mg po BID.” Tegretol 100 mg given po at 1400. Meds checked at 1430 and error noted. 50 mg Tegretol should have been given two times per day to total 100mg in 24 hours. Doctor notified. Second dose held.

Patient C. During rounds at 3:30 p.m. found .9% sodium chloride at 75 mLs per hour hanging. Order was written for D5W to run at 75 mLs per hour. Fluids last checked at 2:00 p.m. Changed to correct fluid. Doctor notified.

Diagnostic Procedure Any incident occurring before, during, or after such procedures as blood sample stick, biopsy, X-ray examination, lumbar puncture, or other invasive procedure is categorized as a diagnostic procedure incident.

Patient A. When I checked the IV site, I saw that it was red and swollen. For this reason, I discontinued the IV. When removing the tape, I noted a small area of skin breakdown where the tape had been. There was also a small knot on the medial aspect of the left antecubital above the IV insertion site. Doctor notified. Wound dressed.

Patient B. Patient found on the floor after lumbar puncture. Right side rail down. Examined by a physician, BP 120/80, T 98.6, P 72, R 18. No injury noted on exam. Patient returned to bed, side rail placed up. Will continue to monitor patient condition.

Medical–Legal Incident If a patient or family refuses treatment as ordered and prescribed or refuses to sign consent forms, the situation is categorized as a medical-legal incident.

Patient A. After a visit from a member of the clergy, patient indicated he was no longer in need of medical attention and asked to be discharged. Physician called. Doctor explained potential side effects if treatment were discontinued to patient. Patient continued to ask for discharge. Doctor explained “against medical advice” (AMA) form. Patient signed AMA form and left at 1300 without medications.

Patient B. Patient refused to sign consent for bone marrow biopsy. States side effects not understood. Doctor reviewed reasons for test and side effects three different times. Doctor informed the patient that without consent he could not perform the test. Offered to call in another physician for second opinion. Patient agreed. After doctor left, patient signed consent form.

Patient or Family Dissatisfaction with Care When a patient or family indicates general dissatisfaction with care and the situation cannot be or has not been resolved, then an incident report is filed.

Patient A. Mother complained that she had found child saturated with urine every morning (she arrived around 0800). Explained to mother that diapers and linen are changed at 0600 when 0600 feedings and meds are given. Patient’s back, buttocks, and perineal areas are free of skin breakdown. Parents continue to be distressed. Discussed with primary nurse.

Patient B. Mr. Smith appeared very angry. Greeted me at the door complaining that his wife had not been treated properly in our emergency room the night before. Wanted to speak to someone from administration. Was unable to reach the administrator on call. Suggested Mr. Smith call administrator in the morning. Mr. Smith thanked me for my time and assured me that he would call the administrator the next day.

80 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

Root Cause Analysis Root cause analysis is a method to work backwards through an event to examine every action that led to the error or event that occurred; it is a complicated process. A simplified method to conduct an event analysis follows:

● Patient—what patient factors contributed to the event? ● Personnel—what personnel actions contributed to the event? ● Policies—are there policies for this type of event? ● Procedures—are there standard procedures for this type of event? ● Place—did the workplace environment contribute to the event? ● Politics—did institutional or outside politics play a role in the event? (Weiss, 2009)

Complaints have emerged, however, that the method uses too many resources for too few improvements (Wu, Lipshutz, & Pronovost, 2008). The authors posit that most organizations try to drill down to a single cause, ignoring system failures. Furthermore, they insist that correc- tive action is seldom taken due to lack of resources, professional disagreements, and absence of management support. They recommend improving system-wide dysfunctions and examining the broader health care environment to find improvements needed across hospitals.

Role of the Nurse Manager The nurse manager plays a key role in the success of any risk management program. Nurse man- agers can reduce risk by helping their staff view health and illness from the patient’s perspective. Usually, the staff’s understanding of quality differs from the patient’s expectations and perceptions. By understanding the meaning of the course of illness to the patient and the family, the nurse will manage risk better because that understanding can enable the nurse to individualize patient care. This individualized attention produces respect and, in turn, reduces risk.

A patient incident or a patient’s or family’s expression of dissatisfaction regarding care indi- cates not only some slippage in quality of care but also potential liability. A distraught, dissatisfied, complaining patient is a high risk; a satisfied patient or family is a low risk. A risk management or liability control program should therefore emphasize a personal approach. Many claims are filed because of a breakdown in communication between the health care provider and the patient. In many instances, after an incident or bad outcome, a quick visit or call from an organization’s repre- sentative to the patient or family can soothe tempers and clarify misinformation.

In the examples given, prompt attention and care by the nurse manager protected the pa- tients involved and may have averted a potential liability claim. Once an incident has occurred, the important factors in successful risk management are:

● Recognition of the incident ● Quick follow-up and action ● Personal contact ● Immediate restitution (where appropriate)

The concerns of most patients’ and their families’ concerns can and should be handled at the unit level. When that first line of communication breaks down, however, the nurse manager needs a resource—usually the risk manager or nursing service administrator.

Handling Complaints Handling a patient’s or family member’s complaints stemming from an incident can be very difficult. These confrontations are often highly emotional; the patient or family member must be calmed down, yet have their concerns satisfied. Sometimes just an opportunity to release the anger or emotion is all that is needed.

The first step is to listen to the person to hear concerns and to help defuse the situation. Arguing or interrupting only increases the person’s anger or emotion. After the patient or fam- ily member has had his or her say, the nurse manager can then attempt to solve the problem by

CHAPTER 6 • MANAGING AND IMPROVING QUALITY 81

asking what is expected in the form of a solution. The nurse manager should ensure that immedi- ate patient care and safety needs are met, collect all facts relevant to the incident, and if possible, comply with the patient or family member’s suggested resolution.

Sometimes, a simple apology from a staff member or moving a patient to a different room on the unit can resolve a difficult situation. If the patient and/or family member’s requested resolution exceeds the nurse manager’s authority, the nurse manager should seek the assistance of a nurse administrator or hospital legal counsel. Offering vague solutions (e.g., “everything will be taken care of”) may only lead to more problems later on if expectations as to solution and timing differ.

All incidents must be properly documented. Information on the incident form should be detailed and include all the factors relating to the incident, as demonstrated in the previous ex- amples. The documentation in the chart, however, should be only a statement of the facts and of the patient’s physical response; no reference to the incident report should be made, nor should words such as error or inappropriate be used.

When a patient receives 100 mg of Demerol instead of 50 mg as ordered, the proper documen- tation in the chart is, “100 mg of Demerol administered. Physician notified.” The remainder of the documentation should include any reaction the patient has to the dosage, such as “Patient’s vital signs unchanged.” If there is an adverse reaction, a follow-up note should be written in the chart, giving an update of the patient’s status. A note related to the patient’s reaction should be written as frequently as the status changes and should continue until the patient returns to his or her previous status.

The chart must never be used as a tool for disciplinary comments, action, or expressions of an- ger. Notes such as, “Incident would never have occurred if Doctor X had written the correct order in the first place” or “This carelessness is inexcusable” or “Paged the doctor eight times, as usual, no reply” are wholly inappropriate and serve no meaningful purpose. Carelessness and incorrect orders do indeed cause errors and incidents, but the place to address and resolve these issues is in the risk management committee or in the nurse manager’s office, not on the patient chart.

Handling a complaint without punishing a staff member is a delicate situation. The manager must determine what happened in order to prevent another occurrence, but using an incident report for discipline might result in fewer or erroneous incident reports in the future. Learn how one manager handled a situation of this kind in Case Study 6-1.

A Caring Attitude With employees, the nurse manager sets the tone that contributes to a safe and low-risk environ- ment. One of the most important ways to reduce risk is to instill a sense of confidence in both patients and families by emphasizing and recognizing that they will receive personalized atten- tion and that their needs will be attended to with competence. This confidence is created envi- ronmentally and professionally.

Examples of environmental factors include cleanliness, attention to patients’ privacy, promptly responding to patients’ and family members’ requests, an orderly looking unit, and engaging in minimal social conversations in front of patients. One example of portraying pro- fessional confidence is to provide patients and families with the name of the person in charge. A sincere visit by that person is reassuring. In addition, a thorough orientation creates indepen- dence for the patient and confidence in an efficient unit.

The nurse manager needs to foster the attitude that any mistake that does occur is perceived as an opportunity to improve a system or a process rather than to punish an individual. If the nurse manager has developed a patient-focused atmosphere in which patients believe their best interests are a priority, the potential for risk will be reduced.

Creating a Blame-Free Environment The health care environment is known to be a blame culture that “is a major source of medical errors and poor quality of patient care” (Khatri, Brown, & Hicks, 2009, p. 320). Such a culture inhibits reporting of inadequate practice, underreporting of adverse events, and inattention to possible safety problems.

82 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

A just culture, in contrast, allows for reporting of errors without fear of undue retribution (Gorzeman, 2008). Khatri, Brown, & Hicks (2009) suggest that transitioning to a just culture does more than improve reporting mechanisms or initiate training programs. A just culture provides an environment in which employees can question policies and practices, express concerns, and admit mistakes without fear of retribution. A just culture requires organizational commitment, mana- gerial involvement, employee empowerment, an accountability system, and a reporting system (Gorzeman, 2008).

Accountability for errors, however, must be maintained (Gorzeman, 2008). Errors can be categorized as:

● Human errors, such as unintentional behaviors that may cause an adverse consequence ● At-risk behaviors, such as unsafe habits, negligence, carelessness ● Reckless behaviors, such as conscious disregard for standards

A just culture is prepared to handle incidents involving human error. At-risk or reckless behaviors, however, are not tolerated.

Managing and improving quality requires ongoing attention to system-wide processes and individual actions. The nurse manager is in a key position to identify problems and encourage a culture of safety and quality.

RISK MANAGEMENT Yasmine Dubois is the nurse manager for the cardiac catheterization lab and special procedures unit in a sub- urban hospital. The hospital has an excellent reputation for its cardiac care program, including the use of cut- ting-edge technology. The cath lab utilizes a specialized computer application that records the case for the nurs- ing staff, requiring little handwritten documentation at the end of a procedure.

Last month, a 56-year-old woman was brought from the ER to the cath lab at approximately 1900 for place- ment of a stent in her left anterior descending coronary artery. During the procedure, the heart wall was perfo- rated. The patient coded and was taken in critical condi- tion to the OR, where she died during surgery.

Two days following the incident, the patient’s hus- band requested a review of his wife’s medical records. During his review, he pointed out to the medical records clerk that the documentation from the cath lab stated that his wife “. . . tolerated the procedure well and was taken in satisfactory condition to the recovery area.” The documentation was signed, dated, and timed by Elizabeth Clark, RN. The medical records director

notified the hospital’s risk manager of the error. The risk manager investigated the incident and determined that Elizabeth Clark’s charting was in error.

Following her meeting with the risk manager, Yas- mine met with Elizabeth to discuss the incident. She showed Elizabeth a copy of the cath lab report. Eliza- beth asked Yasmine if she could have the chart from medical records so she could correct her mistake. Yas- mine informed Elizabeth that she couldn’t correct her charting at this point in time. But, she could, however, write an addendum to the chart, with today’s date and time, to clarify the documentation. Yasmine also told Elizabeth that the addendum would be reviewed by the risk manager and the hospital’s attorney prior to inclusion in the chart.

To ensure compliance with the hospital’s documen- tation standards and to determine if Elizabeth or any other cath lab nurse had committed any similar charting errors, Yasmine requested charts for all patients in the past 12 months who had been sent to surgery from the cath lab due to complications during a procedure. She conducted a retrospective audit and determined that this had been an isolated incident.

CASE STUDY 6-1

CHAPTER 6 • MANAGING AND IMPROVING QUALITY 83

What You Know Now • Total quality management is a philosophy committed to excellence throughout the organization. • Continuous quality improvement is a process to improve quality and performance. • Six Sigma is another quality management program that uses measures, has goals, and is a management

system. • Lean Six Sigma provides tools to improve flow and eliminate waste. • DMAIC is a Six Sigma process improvement method to define, measure, analyze, improve, and control

performance. • A culture of safety and quality permeates efforts at the national level. • Cost may increase or decrease with quality initiatives. • Evidence-based practice, electronic medical records, and dashboards can be used to improve and monitor

quality. • Reducing medication errors is a priority for health care organizations and policy makers. • A risk management program focuses on reducing accidents and injuries and intervening if either occurs. • A caring attitude and prompt attention to complaints help to reduce risk. • A just culture is more likely to encourage reporting of adverse events, including near misses, as well as

point out unsafe practices.

Tools for Managing and Improving Quality 1. Remember: Quality management is a system. When something goes wrong, it is usually due to a

flaw in the system. 2. Become familiar with standards and outcome measures and use them to guide and improve your

practice. 3. Strive for perfection, but be prepared to tolerate failure in order to encourage innovation. 4. Be sure that performance appraisals and incident reports are not used for discipline but rather are the

bases for improvements to the system and/or development of individuals. 5. Remind yourself and your colleagues that a caring attitude is the best prevention of problems.

Following an incident:

1. Meet with the risk manager and hospital attorney to review documentation and determine which staff will be interviewed regarding the incident.

2. Provide any requested information to administration in a timely manner. 3. Audit documentation and processes to determine if an incident is part of a pattern or an isolated

incident. 4. Provide the results of any audits or discussions with staff to appropriate administrators. 5. Educate staff as appropriate. 6. Determine if disciplinary action is required. 7. Follow up with risk management, nursing administration, and human resources as appropriate. 8. Continue to cooperate with the hospital attorney if the incident results in litigation.

Questions to Challenge You 1. Imagine that an organization is debating among several quality management programs. What would

you recommend? Why? 2. Do you know what standards and outcome measures are used in your clinical setting? How are data

handled? Are they shared with employees? 3. What comparable groups, both internal and external, are used for benchmarking performance in

your organization? 4. Universities also use benchmarking. What institutions does your college or university use to bench-

mark its performance? Find out. 5. Have you, a family member, or a friend ever had a serious problem in a health care organization that

resulted in injury? What was the outcome? Is this how you would have handled it? What will you do in the future in a similar situation?

6. Have you or anyone you know ever made a mistake in a clinical setting? What happened? Would you assess the organization as a blame-free environment?

84 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

References Anderson, E. F., Frith, K. H., &

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Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

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Kazley, A. S., & Ozcan, Y. A. (2008). Do hospitals with electronic medical records (EMRs) provide higher quality care? Medical Care Research and Review, 65(4), 496–513.

Khatri, N., Brown, G. D., & Hicks, L. L. (2009). From a blame culture to a just culture in health care. Health Care Man- agement Review, 34(4), 312–322.

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Yamamoto, J. J., Malatestinic, B., Lehman, A., & Juneja, R. (2010). Facilitating process changes in meal delivery and radiological testing to improve inpatient insulin timing using Six Sigma method. Quality Management in Health Care, 19(3), 189–200.

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1. Define power. 2. Describe how power is used. 3. Discuss how image is a source of power. 4. Explain how to use shared visioning

as a power tool.

5. Discuss how politics influence policy. 6. Describe how nurses can use politics

to influence policies.

Learning Outcomes After completing this chapter, you will be able to:

Power Defined

Power and Leadership

Power: How Managers and Leaders Get Things Done

Using Power IMAGE AS POWER

USING POWER APPROPRIATELY

Shared Visioning as a Power Tool

Power, Politics, and Policy NURSING’S POLITICAL HISTORY

USING POLITICAL SKILLS TO INFLUENCE POLICIES

INFLUENCING PUBLIC POLICIES

Using Power and Politics for Nursing’s Future

Understanding Power and Politics7

CHAPTER

Key Terms Coercive power Connection power Expert power Information power Legitimate power Personal power

Policy Politics Position power Power Power plays Punishment

Referent power Reward power Shared visioning Stakeholders Vision

CHAPTER 7 • UNDERSTANDING POWER AND POLITICS 87

Power Defined Power is the potential ability to influence others (Hersey, 2011). Power is involved in every human encounter, whether you recognize it or not. Power can be symmetrical when two parties have equal and reciprocal power, or it may be asymmetrical with one person or group having more control than another (Mason, Leavitt, & Chaffee, 2011). Power can be exclusive to one party or may be shared among many people or groups. To acquire power, maintain it effectively, and use it skillfully, nurses must be aware of the sources and types of power that they will use to influence and transform patient care.

Power and Leadership Real power—principle-centered power—is based on honor, respect, loyalty, and commitment. Principle-centered power is a model congruent with nursing’s values. It is based on respect, honor, loyalty, and commitment. Originally conceived by Stephen Covey (1991), the model is increasingly used by leaders in many fields (Ikeda, 2009). Power sharing evolves naturally when power is centered on one’s values and principles. In fact, the notion that power is something to be shared seems to contradict the usual belief that power is something to be amassed, protected, and used for one’s own purposes.

Leadership power comes from the ability to sustain proactive influence, because followers trust and respect the leader to do the right thing for the right reason. As leaders in health care, nurses must understand and select behaviors that activate principle-centered leadership:

● Get to know people. Understanding what other people want is not always simple. ● Be open. Keep others informed. Trust, honor, and respect spread just as equally as fear,

suspicion, and deceit. ● Know your values and visions. The power to define your goals is the power to choose. ● Sharpen your interpersonal competence. Actively listen to others and learn to express your

ideas well. ● Use your power to enable others. Be attentive to the dynamics of power and pay attention

to ground rules, such as encouraging dissenting voices and respecting disagreement. ● Enlarge your sphere of influence and connectedness. Power sometimes grows out of

someone else’s need.

Power: How Managers and Leaders Get Things Done Classically, managers relied on authority to rouse employees to perform tasks and accomplish goals. In contemporary health care organizations, managers use persuasion, enticement, and inspiration to mobilize the energy and talent of a work group and to overcome resistance to change.

A leader’s use of power alters attitudes and behavior by addressing individual needs and motivations. There are seven generally accepted types of interpersonal power used in organizations to influence others (Hersey, 2011):

1. Reward power is based on the inducements the manager can offer group members in exchange for cooperation and contributions that advance the manager’s objectives. The degree of compliance depends on how much the follower values the expected benefits. For example, a nurse manager may grant paid educational leave as a way of rewarding a staff nurse who agreed to work overtime. Reward power often is used in relation to a manager’s formal job responsibilities.

2. Coercive power is based on the penalties a manager might impose on an individual or a group. Motivation to comply is based on fear of punishment (coercive power) or withholding of rewards. For example, the nurse manager might make undesirable job assignments, mete out

88 PART 1 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

a formal reprimand, or recommend termination for a nurse who engages in disruptive behavior. Coercion is used in relation to a manager’s perceived authority to determine employment status.

3. Legitimate power stems from the manager’s right to make a request because of the author- ity associated with job and rank in an organizational hierarchy. Followers comply because they accept a manager’s prerogative to impose requirements, sanctions, and rewards in keeping with the organization’s mission and aims. For instance, staff nurses will com- ply with a nurse manager’s directive to take time off without pay when the workload has dropped below projected levels because they know that the manager is charged with main- taining unit expenses within budget limitations.

4. Expert power is based on possession of unique skills, knowledge, and competence. Nurse man- agers, by virtue of experience and advanced education, are often the best qualified to determine what to do in a given situation. Employees are motivated to comply because they respect the manager’s expertise. Expert power relates to the development of personal abilities through edu- cation and experience. Newly graduated nurses might ask the nurse manager for advice in learn- ing clinical procedures or how to resolve conflicts with coworkers or other health professionals.

5. Referent power is based on admiration and respect for an individual. Followers comply because they like and identify with the manager. Referent power relates to the manager’s likeability and success. For example, a new graduate might ask the advice of a more expe- rienced and admired nurse about career planning.

6. Information power is based on access to valued data. Followers comply because they want the information for their own needs. Information power depends on a manager’s or- ganizational position, connections, and communication skills. For example, the nurse man- ager is frequently privy to information about pending organizational changes that affect employees’ work situations. A nurse manager may exercise information power by sharing significant information at staff meetings, thereby improving attendance.

7. Connection power is based on an individual’s formal and informal links to influential or prestigious persons within and outside an area or organization. Followers comply because they want to be linked to influential individuals. Connection power also relates to the status and visibility of the individual as well. If, for example, a nurse manager is a neighbor of an organization’s board member, followers may believe that connection will protect or ad- vance their work situation.

Managers have both personal and position power. Position power is determined by the job description, assigned responsibilities, recognition, advancement, authority, the ability to with- hold money, and decision making. Legitimate, coercive, and reward power are positional because they relate to the “right” to influence others based on rank or role. The extent to which managers mete out rewards and punishment is usually dictated by organizational policy. Information and legitimate power are directly related to the manager’s role in the organizational structure.

Expert, referent, information, and connection power are based, for the most part, on personal traits. Personal power refers to one’s credibility, reputation, expertise, experience, control of resources or information, and ability to build trust. The extent to which one may exercise expert, referent, information, and connection power relates to personal skills and positive interpersonal relationships as well as employees’ needs and motivations. Box 7-1 illustrates how nurses can learn to use power in organizations.

Using Power Despite an increase in pride and self-esteem that comes with using power and influence, some nurses still consider power unattractive. Power grabbing, which has been the tradition- ally accepted means of relating to power for one’s own self-interests and use, is how nurses

CHAPTER 7 • UNDERSTANDING POWER AND POLITICS 89

often think of power. Rather, nurses tend to be more comfortable with power sharing and empowerment: power “with” rather than power “over” others.

Image as Power A major source of power for nurses is an image of power. Even if one does not have actual power from other sources, the perception by others that one is powerful bestows a degree of power. The same is true for the profession as a whole. If the public sees the profession of nursing as powerful, the profession’s ability to achieve its goals and agendas is enhanced.

Images emerge from interactions and communications with others. If nurses present themselves as caring and compassionate experts in health care through their interactions and communications with the public, then a strong, favorable image develops for both the individual nurse and the profession. Nurses, as the ambassadors of care, must understand the importance and benefits of positive therapeutic communications and image. Developing a positive image of power is important for both the individual and the profession.

BOX 7-1 Guidelines for the Use of Power in Organizations

Guidelines for Using Legitimate Authority

● Make polite, clear requests.

● Explain the reasons for a request.

● Don’t exceed your scope of authority.

● Verify authority if necessary.

● Follow proper channels.

● Follow-up to verify compliance.

● Insist on compliance if appropriate.

Guidelines for Using Reward Power ● Offer the type of rewards that people desire.

● Offer rewards that are fair and ethical.

● Don’t promise more than you can deliver.

● Explain the criteria for giving rewards and keep it simple.

● Provide rewards as promised if requirements are met.

● Use rewards symbolically (not in a manipulative way).

Guidelines for Using Coercive Power ● Explain rules and requirements and ensure that

people understand the serious consequences of violations.

● Respond to infractions promptly and consistently without showing any favoritism to particular individuals.

● Investigate to get the facts before using repri- mands or punishment and avoid jumping to con- clusions or making hasty accusations.

● Except for the most serious infractions, provide sufficient oral and written warnings before resorting to punishment.

● Administer warnings and reprimands in private and avoid making rash threats.

● Stay calm and avoid the appearance of hostility or personal rejection.

● Express a sincere desire to help the person com- ply with role expectations and thereby avoid punishment.

● Invite the person to suggest ways to correct the problem and seek agreement on a concrete plan.

● Maintain credibility by administering punishment if noncompliance continues after threats and warnings have been made.

Guidelines for Using Expert Power ● Explain the reasons for a request or proposal and

why it is important. ● Provide evidence that a proposal will be successful. ● Don’t make rash, careless, or inconsistent

statements. ● Don’t exaggerate or misrepresent the facts. ● Listen seriously to the person’s concerns and

suggestions. ● Act confidently and decisively in a crisis.

Ways to Acquire and Maintain Referent Power ● Show acceptance and positive regard. ● Act supportive and helpful. ● Use sincere forms of ingratiation. ● Defend and back up people when appropriate. ● Do unsolicited favors. ● Make self-sacrifices to show concern. ● Keep promises.

Adapted from Yukl, G. (2007). Leadership in organizations (6th ed.) (pp. 150–156). Upper Saddle River, NJ: Prentice Hall. Reprinted by permission.

90 PART 1 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

Individual nurses can promote an image of power by a variety of means, such as:

1. Appropriately introducing yourself by saying your name, making eye contact, and shaking hands can immediately establish you as a powerful person. If nurses introduce themselves by first name to the physician, Dr. Smith, they have immediately set forth an unequal power relationship unless the physician also uses his or her first name. Although women are not socialized to initiate handshakes, it is a power strategy in male-dominated circles, including health care organizations. In Western cultures, eye contact conveys a sense of confidence and connection to the individual to whom one is speaking. These seemingly minor behaviors can have a major impact on how competent and powerful the nurse is perceived.

2. Attire can symbolize power and success (Sullivan, 2013). Although nurses may believe that they are limited in choice of attire by uniform codes, it is in fact the presentation of the uniform that can hold the key to power. For example, a nurse manager needs a powerful image both with unit staff and with administrators and other professionals who are setting organizational policy. An astute nurse manager might wear a suit rather than a uniform to work on the day of a high-level interdisciplinary committee meeting. Certainly, attention to details of grooming and uniform selection can enhance the power of the staff nurse as well.

3. Conveying a positive and energetic attitude sends the message that you are a “doer” and someone to be sought out for involvement in important issues. Chronic complaining con- veys a sense of powerlessness, whereas solving problems and being optimistic promote a “can do” attitude that suggests power and instills confidence in others.

4. Pay attention to how you speak and how you act when you speak. Nonverbal signs and signals say more about you than words. Stand erect and move energetically. Speak with an even pace and enunciate words clearly. Make sure your words are reflected in your body language. Keep your facial expression consistent with your message.

5. Use facts and figures when you need to demonstrate your point. Policy changes usually evolve from data presented in a compelling story. Positioning yourself as a powerful player requires the ability to collect and analyze data. Technology facilitates data retrieval. For example, Chapter 6 lists various quality initiatives that yield useful data, including bench- marks and dashboards. Remember that power is a matter of perception; therefore, you must use whatever data are available to support your judgment.

6. Knowing when to be at the right place at the right time is crucial to gain access to key per- sonnel in the organization. This means being invited to events, meetings, and parties not necessarily intended for nurses. It means demanding to sit at the policy table when decisions affecting staffing and patient care are made. Influence is more effective when it is based on personal relationships and when people see others in person: “If I don’t see you, I can’t ask you for needed information, analysis, and alternative recommendations.” Become vis- ible. Be available. Offer assistance. You can be invaluable in providing policy makers with information, interpreting data, and teaching them about the nursing side of health care.

7. In dealing with people outside of nursing, it is important to develop powerful partnerships. Learn how to share both credit and blame. When working on collaborative projects, use “we” instead of “they,” and be clear about what is needed. If something isn’t working well, say so. Never accept another’s opinion as fact. Facts can be easily manipulated to fit one’s personal agenda. Learn how to probe and obtain additional information. Don’t assume you have all the information. Beware of unsolicited commentary. Don’t be fearful of giving strong criticism, but always put criticisms in context. Before giving any criticism, give a compliment, if appropriate. Also, make sure your partners are ready to hear all sides of the issue. It’s never superfluous to ask, “Do you want to talk about such and such right now?” Once an issue is decided—really decided—don’t raise it again.

CHAPTER 7 • UNDERSTANDING POWER AND POLITICS 91

8. Make it a point to get to know the people who matter in your sphere of influence. Become a part of the power network so that when people are discussing issues or seeking people for important appointments of leadership, your name comes to mind. Be sure to deal with senior people. The more contact you have with the “power brokers,” the more support you can generate in the future should the need arise. The more power you use, the more you get.

9. Know who holds the power. Identify the key power brokers. Develop a strategy for gaining access to power brokers through joining alliances and coalitions. Learn how to question others and how to become part of the organizational infrastructure. There is an art to de- termining when, what, and how much information is exchanged and communicated at any one time and to determining who does so. Powerful people have a keen sense of timing. Be sure to position yourself to be at the right place at the right time. Any strategy will involve a good deal of energy and effort. Direct influence and efforts toward issues of highest prior- ity or when greatest benefits are likely to result.

10. Use power appropriately to promote consensus in organizational goals, develop common means to achieve these goals, and enhance a common culture to bind organizational mem- bers together. As the health care providers closest to the patient, nurses best understand patients’ needs and wants. In the hospital, nurses are present on the first patient contact and thereafter for 24 hours a day, 7 days a week. In the clinic, the nurse may be the person the patient sees first and most frequently. By capitalizing on the special relationship that they have with patients, nurses can use marketing principles to enhance their position and image as professional caregivers.

Nursing as a profession must market its professional expertise and ability to achieve the objectives of health care organizations. From a marketing perspective, nursing’s goal is to ensure that identified markets (e.g., patients, physicians, other health professionals, community members) have a clear understanding of what nursing is, what it does, and what it is going to do. In doing so, nursing is seen as a profession that gives expert care with a scientific knowledge base.

Nursing care often is seen as an indicator of an organization’s overall quality. Regardless of the setting, quality nursing care is something that is desired and valued. Through understanding patients’ needs and preferences for programs that promote wellness and maintain and restore health, nurses become the organization’s competitive edge to enhancing revenues. Marketing an image of expertise linked with quality and cost can position nursing powerfully and competi- tively in the health care marketplace.

Using Power Appropriately Using power not only affects what happens at the time, but also has a lasting effect on your re- lationships. Therefore, it is best to use the least amount of power necessary to accomplish your goals. Also, use power appropriate to the situation (Sullivan, 2013). Table 7-1 lists rules for us- ing power.

Improper use of power can destroy a manager’s effectiveness. Power can be overused or un- derused. Overusing power occurs when you use excessive power relative to the situation. If you fail to use power when it is needed, you are underusing your power. In addition to the immediate loss of influence, you may lose credibility for the future.

Power plays are another way that power is used inappropriately. Power plays are attempts by others to diminish or demolish their opponents. Typical power plays include:

“Let’s be fair.” “Can you prove that?” “It’s either this or that; which is it? Take your pick.” “But you said . . . and now you say. . . .”

92 PART 1 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

Such statements engender feelings of insecurity, incompetence, confusion, embarrassment, and anger. You do not need to respond directly in these situations but, rather, you can simply restate your initial point in a firm manner. Keep your expression neutral, ignore accusations, and restate your position, if appropriate. If you refuse to respond to these thinly veiled attacks, your opponent is unable to intimidate and manipulate you.

Nursing must perceive power for what it really is—the ability to mobilize and focus energy and resources. What better position can nurses be in but to assume power to face new problems and re- sponsibilities in reshaping nursing practice to adapt to environmental changes? Power is the means, not the end, to seek new ways for doing things in this uncertain and unsettling time in health care.

Shared Visioning as a Power Tool Shared visioning is a powerful tool to influence the organization’s future. Shared visioning is an interactive process in which both leaders and followers commit to the organization’s goals (Kantabutra, 2009; Pearce, Conger, & Locke, 2008). A vision is a mental model of a possible future (Kantabutra, 2008). It should inspire and challenge both leaders and followers to accom- plish the organization’s goals set forth in the vision.

Top-down management is an out-of-date concept (Pearce, Conger, & Locke, 2008). Today’s leaders recognize that their power must be shared and that integrated leadership styles—bottom-up and lateral—are essential for success. Consensus about the organization’s future can motivate leaders and employees alike to envision their preferred future and do their best to achieve it. In addition, a shared vision makes implementing the necessary, and often difficult, changes easier.

Kantabutra (2009) posits that the leader is not a passive participant in the visioning process. The leader should be an active group member, leading the group toward the desired vision in a participative fashion. The leader helps guide the group toward consensus.

Furthermore, innovation is necessary for organizations to effect positive change (McKeown, 2008). Innovation requires employee buy-in to flourish (Melnyk & Davidson, 2009). Shared visioning is a strategy that encourages innovation.

Power, Politics, and Policy While power is the potential ability to influence others, politics is the art of influencing others to achieve a goal (Mason, Chaffee, & Leavitt, 2011).

TABLE 7-1 Rules for Using Power

1. Use the least amount of power you can to be effective in your interactions with others.

2. Use power appropriate to the situation.

3. Learn when not to use power.

4. Focus on the problem, not the person.

5. Make polite requests, never arrogant demands.

6. Use coercion only when other methods don’t work.

7. Keep informed to retain your credibility when using your expert power.

8. Understand you may owe a return favor when you use your connection power.

From Sullivan, E. J. (2013). Becoming influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall. Reprinted by permission.

CHAPTER 7 • UNDERSTANDING POWER AND POLITICS 93

Politics:

● Is an interpersonal endeavor—uses communication and persuasion ● Is a collective activity—requires the support and action of many people ● Calls for analysis and planning—requires an assessment of the issue and a plan to resolve it ● Involves image—hinges on the image people have of change makers

Nursing’s Political History Nurses’ political activities began with Florence Nightingale, continued with the emergence of nursing schools and women’s suffrage, and improved with the establishment of nursing organizations and the feminist movement (Sullivan, 2013). Establishing the National Center for Nursing Research (later changed to the National Institute of Nursing Research) within the National Institutes of Health is an example of nurses’ powerful political action.

A Brief History of the National Institute of Nursing Research

After the Institute of Medicine report recommended a federal nursing research entity as part of the mainstream scientific community in the early 1980s, nursing leaders in the United States began promoting establishment of a nursing institute at the National Insti- tutes of Health. This effort involved lobbying Congress, the Reagan administration, and the other institutes at NIH—a formidable task. A few members of Congress were interested in the potential that nursing science had for improving health, but the administration was not in favor of another institute at NIH, and the other institutes seemed puzzled as to why nursing would need its own institute to do research. Couldn’t nurse researchers receive funding through existing institutes? Medicine did so without a separate institute.

Step by step, nursing leaders persuaded (harassed?) institute directors and Congress, insisting that nursing research would improve human response to illness and assist in maintaining and enhancing health. A bill was born. Concern about cost and increasing bureaucracy emerged and was overcome. The bill passed only to be vetoed by President Reagan. Then a funny thing happened. Nursing made an unprecedented move. The profession came together, united with one goal: to override President Reagan’s veto (none had been successfully overridden before).

One by one, across the country, nurses called their senators and congressional represen- tatives urging support for a nursing institute, explaining that nurses were represented only among a few funded researchers at other institutes who did not understand the impact of nursing interventions on health and recovery. A modest investment, they explained, would yield exponentially greater results. Thanks to a few persuasive members of Congress, a compromise was negotiated and the National Center for Nursing Research was estab- lished in 1985. Through a statutory revision in 1993, the Center became an Institute.

Similarly, Georgia nurses successfully changed that state’s practice act to include prescrip- tive authority for advanced practice nurses, overcoming fierce opposition from the medical as- sociation (Beall, 2007). Working in concert with each other and with consumers and the media, they generated a letter-writing campaign that countered every obstacle the medical association tried. Georgia became the last state to grant prescribing privileges to nurse practitioners.

Policy, on the other hand, is the decision that determines action. Policies result from political action.

Using Political Skills to Influence Policies Political skill, per se, is not included in nursing education (nor is it tested on state board exams), yet it is a vital skill for nurses to acquire. To improve your political skill:

● Learn self-promotion—report your accomplishments appropriately. ● Be honest and tell the truth—say what you mean and mean what you say. ● Use compliments—recognize others’ accomplishments.

94 PART 1 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

● Discourage gossip—silence is the best response. ● Learn and use quid pro quo—do and ask for favors. ● Remember: appearance matters—attend to grooming and attire. ● Use good manners—be courteous. (Green & Chaney, 2006)

Health care involves multiple special-interest groups all competing for their share of a limited pool of resources. The delivery of nursing services occurs at many levels in health care organizations. The effectiveness of care delivery is linked to the application of power, politics, and marketing. Nurses belong to a complex organization that is continually confronted with limited resources and is in competition for those resources.

How politically savvy are you? Ask yourself the following questions:

● Do you get credit for your ideas? ● Do you know how to deal with a difficult colleague? ● Do you have a mentor? ● Are you “in the loop”? ● Can you manage and influence others’ perceptions of you and your work? ● Are you able to convert enemies to friends? ● Do your ideas get a fair hearing? ● Do you know when and how to present them? (Reardon, 2011)

To take action, first decide what you want to accomplish. Is it realistic? Will you have supporters? Who will be the detractors? The steps in political action are shown in Table 7-2.

Try to find out what other people involved, called stakeholders, want. Maybe you could piggyback on their ideas. Members of Congress do this all the time by adding amendments to proposed bills in an attempt to satisfy their opponents.

Start telling your supporters about your idea and see if they will join with you in a coalition. This is not necessarily a formal group but allows you to know who you can count on in the discussions.

Find out exactly what objections your opponents have. Try to figure out a way to alter your plan accordingly or help your opponents understand how your proposal might help them. Political action is never easy, but the most politically astute people accomplish goals far more often than those who don’t even try.

A case study that exemplifies a nurse using organizational politics is shown in Case Study 7-1.

Influencing Public Policies What happens in the workplace both depends on and influences what is happening in the larger community, professional organizations, and government. Developing influence in each of these three groups takes time and a long-range plan of action. Although the nurse’s first priority should be to establish influence in the workplace, the nurse can gradually increase connections and in- fluence with other groups and, later on, make these other groups a priority.

TABLE 7-2 Steps in Political Action

1. Determine what you want. 2. Learn about the players and what they want. 3. Gather supporters and form coalitions. 4. Be prepared to answer opponents. 5. Explain how what you want can help them.

From Sullivan, E. J. (2013). Becoming influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall. Reprinted by permission.

CHAPTER 7 • UNDERSTANDING POWER AND POLITICS 95

In order to influence public policies, nurses need to know how to work with the public officials who enact those policies. Table 7-3 lists guidelines for working with public officials.

First, be respectful. Public officials have many constituents and demands on their support. Build relationships with officials. Don’t just contact them when you have a request. Keep in touch at other times.

Communicating with Elected Officials Nurses often wish to contact elected officials to support or oppose legislation. You can call, e-mail, tweet, or write to public officials. (Links to state legislators and contact information for federal government officials are listed in the Web resources for this chapter.)

Here’s how to contact state or federal elected officials. Call the official’s staff and ask to speak to the person who handles the issue that concerns you. Tell the aide that you support or oppose a certain bill and state the reasons why. Name the bill by number.

USING ORGANIZATIONAL POLITICS FOR PERSONAL ADVANTAGE Juanita Pascheco has been nurse manager of medical and surgical ICUs in a large, urban, for-profit hospital for the past seven years. Two years ago, Juanita completed her master’s degree in nursing administration. Her the- sis research centered on the acceptance of standardized and computerized documentation methods for critical care units. Juanita is well respected in her current role and is a member of several key committees addressing the need for a replacement health information system (HIS) for the hospital. She reports directly to the director of critical care services.

Although Juanita enjoys her work as nurse man- ager, she believes she is ready to assume additional responsibilities at the director level. Through her work on the hospital’s HIS selection team and as the nursing representative to the physician’s technology committee, Juanita identifies the need for a clinical informatics di- rector role. One of Juanita’s responsibilities on the HIS selection team is to identify talent from clinical areas who could support the HIS implementation. Juanita has also agreed to chair several working committees that will assist in determining required clinical functionality for the HIS.

During her tenure at the hospital, Juanita has cul- tivated solid working relationships with several key de- cision makers within the organization. The human re- sources director, Ken Harding, has worked with Juanita on several large projects over the past two years, in- cluding implementation of multidisciplinary teams in the ICUs. Juanita schedules a lunch with Ken to discuss growth opportunities in the information technology department, the process for creating new roles, and in particular, who will determine the need for and ap- proval of new information technology positions. Using this knowledge and her experience on the HIS selection

team and the physicians’ technology committee, Juanita develops a proposal for the clinical informatics director position.

As the HIS selection team draws closer to selecting a final vendor for the computerized health information system and an implementation timeline is established by the information technology department, Juanita ap- proaches her supervisor, Sherrie Wright, with her pro- posal. Juanita also provides Sherrie with an overview of the clinical support that will be necessary for successful implementation of the HIS product. Since the critical care units are targeted for the initial phase of imple- mentation, Sherrie is aware that Juanita’s high interest in technology and her clinical expertise in the ICU would be invaluable for successful implementation. As a strong manager, Juanita can build acceptance of this change among the nurses, physicians, and other members of the health care team.

Sherrie agrees to take Juanita’s proposal to the chief nursing officer for formal consideration.

Manager’s Checklist The nurse manager is responsible for:

● Knowing and understanding the formal lines of authority within the organization.

● Identifying key decision makers and understanding their priorities and how those priorities affect any new initiatives.

● Recognizing the importance of timing when initiating change.

● Being ready to take advantage of new opportunities. ● Building strong and credible working relationships

with decision makers. ● Being willing to take on new and challenging tasks

that may lead to more responsibility.

CASE STUDY 7-1

96 PART 1 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

E-mail or write directly to the official. Identify the bill in question, state your position on the bill, and explain why you support or oppose it. Keep your comments brief, and address only one issue per correspondence. Hand-written letters get more attention than form letters distributed by organizations.

Use this format to address members of the U.S. Senate:

The Honorable (full name of senator) __(Rm.#)__(name of) Senate Office Building United States Senate Washington, DC 20510

Dear Senator:

To contact the member of the U.S. Congress, use a similar format.

The Honorable (full name) __(Rm.#)__(name of) House Office Building United States House of Representatives Washington, DC 20515

Dear Representative:

Meeting with Elected Officials To meet in person with an elected official, make an appointment, arrive on time, and come pre- pared. Understand the pros and cons of the issue you are bringing to the person’s attention. Be a constructive opponent. Argue for your position and be prepared with additional information and alternative suggestions. Still, be realistic. What you want may not be possible, or it may not be likely at the present time. Always be helpful. Show how your issue benefits the official’s constituents and, thus, the representative.

The American Association of Critical-Care Nurses suggests pointers for working with public officials (AACN, 2010). In addition, the American Nurses Association (ANA) has legislative and government information for nurses (ANA, 2011). (See links to these organizations in the Web resources for this chapter.)

Using Power and Politics for Nursing’s Future Kelly (2007) suggests that apathy prevents nurses from using their political skills. Becoming active in professional associations, learning the legislative issues that affect nursing, gaining political skills, and being willing to advocate for nursing’s causes are necessary for the profes- sion to flex its considerable political muscles. All nurses can participate to some extent in these activities.

Nurses can have a tremendous impact on health care policy. The best impact is often made with a bit of luck and timing, but never without knowledge of the whole system. This includes

TABLE 7-3 How to Work with Public Officials

1. Be respectful. 5. Understand the issue. 2. Build relationships. 6. Be a constructive opponent. 3. Keep in touch. 7. Be realistic. 4. Arrive informed. 8. Be helpful.

From Sullivan, E. J. (2013). Becoming influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall. Reprinted by permission.

CHAPTER 7 • UNDERSTANDING POWER AND POLITICS 97

knowledge of the policy agenda, the policy makers, and the politics that are involved. Once you gain this knowledge, you are ready to move forward with a political base to promote nursing.

To convert your policy ideas into political realities, consider the following power points:

● Use persuasion over coercion. Persuasion is the ability to share reasons and rationale when making a strong case for your position while maintaining a genuine respect for an- other’s perspective.

● Use patience over impatience. Despite the inconveniences and failings caused by health care restructuring, impatience in the nursing community can be detrimental. Patience, along with a long-term perspective on the health care system, is needed.

● Be open-minded rather than closed-minded. Acquiring accurate information is essential if you want to influence others effectively.

● Use compassion over confrontation. In times of change, errors and mistakes are easy to pinpoint. It takes genuine care and concern to change course and make corrections.

● Use integrity over dishonesty. Honest discourse must be matched with kind thoughts and actions. Control, manipulations, and malice must be pushed aside for change to occur.

By using their political skills, nurses can improve patient care in individual institutions, help organizations survive and thrive, and influence public officials.

What You Know Now • Power is the potential ability to influence others. • Power can be positional or personal. • Types of power include reward, coercive, legitimate, expert, referent, information, and connection. • Image is a source of power. • Power can be overused, underused, or used inappropriately. To be effective, the power used must be appro-

priate to the situation. • Shared visioning is an interactive process in which both leaders and followers commit to the organiza-

tion’s goals. • Politics is the art of influencing others to achieve a goal. • Policy is the decision that determines action. Policies result from political action. • Nurses can use political action to influence policies in the organization and to influence public policies.

Tools for Using Power and Politics 1. Learn the formal lines of authority within your organization. 2. Identify key decision makers and build strong and credible relationships with them. 3. Identify decision makers’ priorities and how those affect any new initiatives. 4. Learn the rules for using power and put them into practice. 5. Offer solutions to problems and take advantage of new opportunities. 6. Exhibit a willingness to take on new and challenging tasks that may lead to more responsibility. 7. Pay attention to people who are influential and adopt their strategies if appropriate. 8. Learn strategies for working with public officials.

Questions to Challenge You 1. Consider a person you believe to have power. What are the bases of that person’s power? 2. Evaluate how the person you named uses his or her power. Is it positive or negative? 3. Have you observed people using power inappropriately? Describe what they did and what happened

as a result.

98 PART 1 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

4. Assess your own power using the seven types of power discussed in the chapter. Name three ways you could increase your power.

5. How politically savvy are you? Did you discover areas to challenge you? 6. Have you been involved in developing policies in your organization or have you worked with public

officials? Explain.

References American Association of Critical

Care Nurses. (2010). Advo- cacy 101: Golden rules for those who work with public officials. Retrieved October 22, 2010 from http://www. aacn.org/wd/practice/ content/publicpolicy/ goldenrules.pcms?pid=1& mid=2874&menu=Comm unity

American Nurses Association. (2011). RN activist kit. Retrieved June 3, 2011 from www.nursingworld. org/gova

Beall, F. (2007). Overview and summary: Power to influence patient care: Who holds the keys? Online Journal of Is- sues in Nursing, 12(1). Retrieved October 22, 2010 from http://www. nursingworld.org/MainMe- nuCategories/ANAMar- ketplace/ANAPeriodicals/ OJIN/TableofContents/ Volume122007/No1Jan07/ tpc32ntr16088.aspx

Covey, S. R. (1991). Principle- centered leadership. New York: Simon & Schuster.

Green, C. G., & Chaney, L. H. (2006). The game of office politics. Supervision, 67(8), 3–6.

Hersey, P. H. (2011). Management of organizational behavior (10th ed.). Upper Saddle River, NJ: Prentice Hall.

Ikeda, J. (2009). Principle cen- tered power. Retrieved April 12, 2011 from http:// www.leadwithhonor. com/blog/2009/03/26/ principle-centered-power/

Kantabutra, S. (2008). What do we know about vision? Journal of Applied Business Research, 24(2), 323–342.

Kantabutra, S. (2009). Toward a behavioral theory of vision in organizational settings. Leadership & Organiza- tional Development Jour- nal, 30(4), 319–337.

Kelly, K. (2007). From apathy to political activism. American Nurse Today, 2(8), 55–56.

Mason, D. J., Leavitt, J. K., & Chaffee, M. W. (2011). Policy and politics in nurs- ing and health care (6th ed.). Philadelphia: W. B. Saunders.

McKeown, M. (2008). The truth about innovation. Great Britain: Pearson Education Limited.

Melnyk, B. M., & Davidson, S. (2009). Creating a culture of innovation in nursing education through shared vision, leader- ship, interdisciplinary partnerships, and positive deviance. Nursing Admin- istration Quarterly, 33(4), 288–295.

Pearce, C. L., Conger, J. A., & Locke, E. A. (2008). Shared leadership theory. The Leadership Quarterly, 19(3), 622–628.

Sullivan, E. J. (2013). Becom- ing influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall Health.

Web Resources American Association of Critical-Care Nurses: www.aacn.org American Nurses Association: www.nursingworld.org United States House of Representatives: www.house.gov United States Senate: www.senate.gov National Conference of State Legislatures: www.ncsl.org

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

http://www.aacn.org/wd/practice/content/publicpolicy/goldenrules.pcms?pid=1&mid=2874&menu=Community

www.nursingworld.org/gova

http://www.nursingworld.org/MainMe-nuCategories/ANAMar-ketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No1Jan07/tpc32ntr16088.aspx

http://www.leadwithhonor.com/blog/2009/03/26/principle-centered-power/

www.nursing.pearsonhighered.com

http://www.aacn.org/wd/practice/content/publicpolicy/goldenrules.pcms?pid=1&mid=2874&menu=Community

http://www.leadwithhonor.com/blog/2009/03/26/principle-centered-power/

http://www.nursingworld.org/MainMe-nuCategories/ANAMar-ketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No1Jan07/tpc32ntr16088.aspx

CHAPTER

Critical Thinking CRITICAL THINKING IN NURSING

USING CRITICAL THINKING

CREATIVITY

Decision Making TYPES OF DECISIONS

DECISION-MAKING CONDITIONS

THE DECISION-MAKING PROCESS

DECISION-MAKING TECHNIQUES

GROUP DECISION MAKING

Problem Solving PROBLEM-SOLVING METHODS

THE PROBLEM-SOLVING PROCESS

GROUP PROBLEM SOLVING

Stumbling Blocks

Innovation

Thinking Critically, Making Decisions, Solving Problems

Key Terms Adaptive decisions Artificial intelligence Brainstorming Creativity Critical thinking Decision making Democratic leadership Descriptive rationality model Experimentation

1. Discuss how to use the critical-thinking process.

2. Describe ways to foster creativity. 3. Develop a plan to improve your

decision-making and problem-solving skills.

4. Compare and contrast individual and collective decision-making processes in various situations.

5. Recognize stumbling blocks to making decisions and solving problems.

6. Foster innovation in your work and that of others.

Learning Outcomes After completing this chapter, you will be able to:

Expert systems Groupthink Innovation Innovative decisions Objective probability Political decision-making

model Probability Probability analysis

Problem solving Rational decision-making

model Routine decisions Satisficing Subjective probability Trial-and-error method

100 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

N urse managers are expected to use knowledge from various disciplines to solve prob-lems with patients, staff, and the organization as well as problems in their own personal and professional lives. They must make decisions in dynamic situations, such as: ● After a position vacates should we refill it, given the tighter economy? ● Is the present policy requiring 12-hour shifts adequate for both patients and nurses? ● Which is the best staffing pattern to prevent turnover and ensure quality patient care? ● What is the best time to have staff meetings and council meetings in order to involve the

night shift too?

This chapter explains and differentiates critical thinking, decision making, and problem solv- ing and describes processes and techniques for using each.

Critical Thinking Critical thinking is the process of examining underlying assumptions, interpreting and evaluat- ing arguments, imagining and exploring alternatives, and developing a reflective criticism for the purpose of reaching a conclusion that can be justified. Critical thinking is not the same as criticism, though it does call for inquiring attitudes, knowledge about evidence and analysis, and skills to combine them.

Critical-thinking skills can be used to resolve problems rationally. Identifying, analyz- ing, and questioning the evidence and implications of each problem stimulate and illuminate critical thought processes. Critical thinking is also an essential component of decision making. However, compared to problem solving and decision making, which involve seeking a single solution, critical thinking is a higher-level cognitive process that includes creativity, problem solving, and decision making (Figure 8-1).

Critical Thinking in Nursing The need for critical thinking in nursing has long been accepted. Zori, Nosek, and Musil (2010) used the California Critical Thinking Disposition Inventory to measure critical thinking in nurses. The researchers found that the nurses supervised by managers with higher critical think- ing skills perceived their work environment to be more positive than those whose managers scored lower on critical-thinking skills.

Case scenarios and discussion of clinical experiences taught newly licensed nurses critical thinking and improved their retention rate in one facility (Ashcraft, 2010). Bittner and Gravlin (2009) studied nurses’ critical-thinking skills when delegating to assistive personnel. They found that the nurse’s lack of critical thinking more often resulted in missed or omitted routine care.

Problem solving

Creativity

Decision making

Critical thinking

Figure 8-1 • Critical-thinking model.

CHAPTER 8 • THINKING CRITICALLY, MAKING DECISIONS, SOLVING PROBLEMS 101

The Carnegie Foundation’s call for reform in nursing education argues, however, that nurs- ing should move beyond critical thinking toward clinical reasoning and diverse thinking (Benner et al., 2009).

Using Critical Thinking The critical-thinking process seems abstract unless it can be related to practical experiences. One way to develop this process is to consider a series of questions when examining a specific problem or making a decision, such as:

1. What are the underlying assumptions? Underlying assumptions are unquestioned beliefs that influence an individual’s reasoning. They are perceptions that may or may not be grounded in reality. For example, some people believe the AIDS epidemic is punishment for homosexual behavior. This attitude toward people with AIDS could alter one’s approach to care for an AIDS patient.

2. How is evidence interpreted? What is the context? Interpretation of information also can be value laden. Is the evidence presented completely and clearly? Can the facts be substan- tiated? Are the people presenting the evidence using emotional or biased information? Are there any errors in reasoning?

3. How are the arguments to be evaluated? Is there objective evidence to support the arguments? Have all value preferences been determined? Is there a good chance that the arguments will be accepted? Are there enough people to support decisions? Health care organizations were able to change to smoke-free environments once societal values favored nonsmokers, and public policies reflected those values.

4. What are the possible alternative perspectives? Using different basic assumptions and paradigms can help the critical thinker develop several different views of an issue. Com- pare how a nurse manager who assumes that more RNs equal better care will deal with a budget cut with a manager who is committed to adding assistive personnel instead. What evidence supports the alternatives? What solutions do staff members, patients, physicians, and others propose? What would be the ideal alternative?

Critical-thinking skills are used throughout the nursing process (see Table 8-1). Nurses can build on the knowledge base they began acquiring in school to make the critical-thinking process a conscious one in daily activities. Learning to be a critical thinker requires a commitment over time, but the skills can be learned. The characteristics of an expert critical thinker are shown in Box 8-1.

Creativity Creativity is an essential part of the critical-thinking process. Creativity is the ability to develop and implement new and better solutions. Creativity demands a certain amount of exposure to outside contacts, receptiveness to new and seemingly strange ideas, a certain amount of free- dom, and some permissive management.

Most nurses, however, are employed in bureaucratic settings that do not foster creativity. Control is exercised over staff, and rigid adherence to formal channels of communication jeopardizes innovation. In addition, there is little room for failure, and when failures do occur they are not well tolerated. When staff are afraid of the consequences of failure, their creativity is inhibited and innovation does not take place. (See later section on innovation.)

Maintaining a certain level of creativity is one way to keep an organization alive. New employees, who are not encumbered with details of accepted practices often can make sugges- tions based on their prior experiences or insights before they get set in their ways or have their innovative ideas “turned off.” The advantages offered by new employees should be explored because all staff gain from such use of valuable human resources.

102 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

BOX 8-1 Characteristics of an Expert Critical Thinker

● Outcome-directed ● Open to new ideas ● Flexible ● Willing to change ● Innovative ● Creative ● Analytical ● Communicator ● Assertive

● Persistent ● Caring ● Energetic ● Risk taker ● Knowledgeable ● Resourceful ● Observant ● Intuitive ● “Out of the box” thinker

From Ignatavicius, D.D. (2001). Six critical thinking skills for at-the-bedside success. Nursing Management, 32(1), 37–39.

TABLE 8-1 Critical Thinking Through the Nursing Process

The Nursing Process Critical-Thinking Skills

Assessment Observing Distinguishing relevant from irrelevant data Distinguishing important from unimportant data Validating data Organizing data Categorizing data

Diagnosis Finding patterns and relationships Making inferences Stating the problem Suspending judgment

Planning Generalizing Transferring knowledge from one situation to another Hypothesizing

Implementation Applying knowledge Testing hypotheses

Evaluation Deciding whether hypotheses are correct Making criterion-based evaluations

From Wilkinson, J. (1992). Nursing process in action: A critical thinking approach. Redwood City, CA: Addison-Wesley Nursing, p. 29.

The climate must promote the survival of potentially useful ideas. The nurse manager can foster a climate of support by giving new ideas a fair and adequate hearing, and thereby reduce the tendency to discourage the creative process in individuals and within groups. The challenge for nurse managers is to know when, for whom, and to what extent control is appropriate. If cre- ativity does have a priority in the health care setting, then the reward system should be geared to and commensurate with that priority.

CHAPTER 8 • THINKING CRITICALLY, MAKING DECISIONS, SOLVING PROBLEMS 103

Preparation

Steps Definition

Information gathering

Incubation

Insight

Verification

Unconscious work going on

Solutions emerge

Solutions evaluated

Figure 8-2 • The creative process.

Creativity has four stages: preparation, incubation, insight, and verification. Even people who think they are not naturally creative can learn this process (Figure 8-2).

1. Preparation. A carefully designed planning program is essential. First, acquire informa- tion necessary to understand the situation. Individuals can do this on their own, or groups can work together.

The process follows this sequence:

• Pick a specific task • Gather relevant facts • Challenge every detail • Develop preferred solutions • Implement improvements

2. Incubation. After all the information available has been gathered, allow as much time as possible to elapse before deciding on solutions.

3. Insight. Often solutions emerge after a period of reflection that would not have occurred to anyone without this time lapse.

4. Verification. Once a solution has been implemented, evaluate it for effectiveness. You may need to restart the process or go back to another step and create a different solution.

Case Study 8-1 describes how one nurse manager used creativity to solve a problem.

Decision Making Considering all the practice individuals get in making decisions, it would seem they might become very good at it. However, the number of decisions a person makes does not correspond to the person’s skill at making them. The assumption is that decision making comes naturally, like breathing. It does not.

The decision-making process described in this chapter provides nurses with a system for making decisions that is applicable to any decision. It is a useful procedure for making practical choices. A decision not to solve a problem is also a decision.

Although decision making and problem solving appear similar, they are not synonymous. Decision making may or may not involve a problem, but it always involves selecting one of several alternatives, each of which may be appropriate under certain circumstances. Problem solving, on the other hand, involves diagnosing a problem and solving it, which may or may not entail deciding on one correct

104 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

solution. Most of the time, decision making is a subset of problem solving. However, some decisions are not of a problem-solving nature, such as decisions about scheduling, equipment, or in-services.

Types of Decisions The types of problems nurses and nurse managers encounter and the decisions they must make vary widely and determine the problem-solving or decision-making methods they should use. Relatively well defined, common problems can usually be solved with routine decisions, often using established rules, policies, and procedures. For instance, when a nurse makes a medica- tion error, the manager’s actions are guided by policy and the report form. Routine decisions are more often made by first-level managers than by top administrators.

Adaptive decisions are necessary when both problems and alternative solutions are some- what unusual and only partially understood. Often they are modifications of other well-known problems and solutions. Managers must make innovative decisions when problems are unusual and unclear and when creative, novel solutions are necessary.

Decision-Making Conditions The conditions surrounding decision making can vary and change dramatically. Consider the total system. Whatever solutions are created will succeed only if they are compatible with other parts of the system. Decisions are made under conditions of certainty, risk, or uncertainty.

Decision Making Under Certainty When you know the alternatives and the conditions surrounding each alternative, a state of cer- tainty is said to exist. Suppose a nurse manager on a unit with acutely ill patients wants to decrease the number of venipunctures a patient experiences when an IV is started, as well as reduce costs resulting from failed venipunctures. Three alternatives exist:

● Establish an IV team on all shifts to minimize IV attempts and reduce costs ● Establish a reciprocal relationship with the anesthesia department to start IVs when nurses

experience difficulty ● Set a standard of two insertion attempts per nurse per patient, although this does not sub-

stantially lower equipment costs

CREATIVE PROBLEM SOLVING Jeffrey was just promoted to manager of an acute care clinic, which recently expanded its hours from 6 A.M. un- til 10 P.M. He soon realizes that staff nurses are reluctant to sign up on the schedule and do quality chart audits, an important process used to review clinic operations and patients’ care. He gathers information about qual- ity improvement, reviews the literature on motivation and incentives, and discusses the issue with other nurse managers (preparation).

Jeffrey continues to manage the clinic, thinking about the information he has gathered but does not consciously make a decision or reject new ideas (incuba- tion). When working on a new problem, self-scheduling for the change in hours, he realizes a connection between the two problems. Many nurses complain that by the time they receive the schedule the day shifts are filled.

Jeffrey decides to review the chart audits. Nurses who regularly participate in quality improvement projects will receive a “perk.” They will be allowed, on a rotating basis, first choice at selecting the schedule they want to work (this is the insight stage). He discusses the plan with the staff and proposes a two-month trial period to deter- mine whether the solution is effective (verification).

Manager’s Checklist The nurse manager is responsible for:

● Identifying problem areas ● Generating ideas that might serve as possible

solutions ● Checking with others for advice ● Selecting motivators ● Implementing a solution ● Evaluating the results

CASE STUDY 8-1

CHAPTER 8 • THINKING CRITICALLY, MAKING DECISIONS, SOLVING PROBLEMS 105

The manager knows the alternatives (IV team, anesthesia department, standards) and the conditions associated with each option (reduced costs, assistance with starting IVs, minimum attempts and some cost reduction). A condition of strong certainty is said to exist and the decision can be made with full knowledge of what the payoff probably will be.

Decision Making Under Uncertainty and Risk Seldom do decision makers know everything there is to know about a subject or situation. If everything was known, the decision would be obvious for all to realize.

Most critical decision making in organizations is done under conditions of uncertainty and risk. The individual or group making the decision does not know all the alternatives, attendant risks, or possible consequences of each option. Uncertainty and risk are inevitable because of the complex and dynamic nature of health care organizations.

Here is an example: If the weather forecaster predicts a 40 percent chance of snow, the nurse manager is operating in a situation of risk when trying to decide how to staff the unit for the next 24 hours.

In a risk situation, availability of each alternative, potential successes, and costs are all as- sociated with probability estimates. Probability is the likelihood, expressed as a percentage, that an event will or will not occur. If something is certain to happen, its probability is 100 percent. If it is certain not to happen, its probability is 0 percent. If there is a 50–50 chance, its probability is 50 percent.

Here is another example: Suppose a nurse manager decides to use agency nurses to staff a unit during heavy vacation periods. Two agencies look attractive, and the manager must decide between them. Agency A has had modest growth over the past 10 years and offers the manager a three-month contract, freezing wages during that time. In addition, the unit will have first choice of available nurses. Agency B is much more dynamic and charges more but explains that the reason they have had a high rate of growth is that their nurses are the best and the highest paid in the area. The nurse manager can choose Agency A, which will pro- vide a safe, constant supply of nursing personnel, or B, which promises better care but at a higher cost.

The key element in decision making under conditions of risk is to determine the probabili- ties of each alternative as accurately as possible. The nurse manager can use a probability anal- ysis, whereby expected risk is calculated or estimated. Using the probability analysis shown in Table 8-2, it appears as though Agency A offers the best outcome. However, if the second agency had a 90 percent chance of filling shifts and a 50 percent chance of fixing costs, a completely different situation would exist.

The nurse manager might decide that the potential for increased costs was a small trade-off for having more highly qualified nurses and the best probability of having the unit fully staffed during vacation periods. Objective probability is the likelihood that an event will or will not occur based on facts and reliable information. Subjective probability is

TABLE 8-2 Probability Analysis

Probability Analysis

Agency A 60% Filling shifts 100% Fixed wages

Agency B 50% Filling shifts 70% Fixed wage

106 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

the likelihood that an event will or will not occur based on a manager’s personal judgment and beliefs.

Janeen, a nurse manager of a specialized cardiac intensive care unit, faces the task of recruiting scarce and highly skilled nurses to care for coronary artery bypass graft patients. The obvious alternative is to offer a salary and benefits package that rivals that of all other institutions in the area. However, this means Janeen will have costly special- ized nursing personnel in her budget who are not easily absorbed by other units in the organization. The probability that coronary artery bypass graft procedures will become obsolete in the future is unknown. In addition, other factors (e.g., increased competi- tion, government regulations regarding reimbursement) may contribute to conditions of uncertainty.

The Decision-Making Process The rational decision-making model is a series of steps that managers take in an effort to make logical, well-grounded rational choices that maximize the achievement of objec- tives. First identify all possible outcomes, examine the probability of each alternative, and then take the action that yields the highest probability of achieving the most desirable outcome. Not all steps are used in every decision nor are they always used in the same order. The rational decision-making model is thought of as the ideal but often cannot be fully used.

Individuals seldom make major decisions at a single point in time and often are unable to recall when a decision was finally reached. Some major decisions are the result of many small actions or incremental choices the person makes without regarding larger issues. In addition, decision processes are likely to be characterized more by confusion, disorder, and emotionality than by rationality. For these reasons, it is best to develop appropriate technical skills and the capacity to find a good balance between lengthy processes and quick, decisive action.

The descriptive rationality model, developed by Simon in 1955 and supported by research in the 1990s (Simon, 1993), emphasizes the limitations of the rationality of the decision maker and the situation. It recognizes three ways in which decision makers depart from the rational decision-making model:

● The decision maker’s search for possible objectives or alternative solutions is limited be- cause of time, energy, and money

● People frequently lack adequate information about problems and cannot control the condi- tions under which they operate

● Individuals often use a satisficing strategy

Satisficing is not a misspelled word; it is a decision-making strategy whereby the individual chooses an alternative that is not ideal but either is good enough (suffices) under existing cir- cumstances to meet minimum standards of acceptance or is the first acceptable alternative. Many problems in nursing are ineffectively solved with satisficing strategies.

Elena, a nurse manager in charge of a busy neurosurgical floor with high turnover rates and high patient acuity levels, uses a satisficing alternative when hiring replace- ment staff. She hires all nurse applicants in order of application until no positions are open. A better approach would be for Elena to replace staff only with nurse applicants who possess the skills and experiences required to care for neurosurgical patients, re- gardless of the number of applicants or desire for immediate action. Elena also should develop a plan to promote job satisfaction, the lack of which is the real reason for the vacancies.

CHAPTER 8 • THINKING CRITICALLY, MAKING DECISIONS, SOLVING PROBLEMS 107

Individuals who solve problems using satisficing may lack specific training in problem solv- ing and decision making. They may view their units or areas of responsibility as drastically sim- plified models of the real world and be content with this simplification because it allows them to make decisions with relatively simple rules of thumb or from force of habit.

The political decision-making model describes the process in terms of the particular inter- ests and objectives of powerful stakeholders, such as hospital boards, medical staffs, corporate officers, and regulatory bodies. Power is the ability to influence or control how problems and objectives are defined, what alternative solutions are considered and selected, what information flows, and, ultimately, what decisions are made (see Chapter 7).

The decision-making process begins when a gap exists between what is actually happening and what should be happening, and it ends with action that will narrow or close this gap. The simplest way to learn decision-making skills is to integrate a model into one’s thinking by break- ing the components down into individual steps. The seven steps of the decision-making process (Box 8-2) are as applicable to personal problems as they are to nursing management problems. Each step is elaborated by pertinent questions clarifying the statements, and they should be fol- lowed in the order in which they are presented.

Decision-Making Techniques Decision-making techniques vary according to the nature of the problem or topic, the decision maker, the context or situation, and the decision-making method or process. For routine decisions, choices that are tried and true can be made for well-defined, known situations or problems. Well-designed policies, rules, and standard operating procedures can produce satisfactory results with a minimum of time. Artificial intelligence, including programmed computer systems such as expert systems that can store, retrieve, and manipulate data, can diagnose problems and make limited decisions.

For adaptive decisions involving moderately ambiguous problems and modification of known and well-defined alternative solutions, there are a variety of techniques. Many types of decision grids or tables can be used to compare outcomes of alternative solutions. Decisions about units or services can be facilitated, with analyses comparing output, revenue, and costs over time or under different conditions. Analyzing the costs and revenues of a proposed new service is an example.

Regardless of the decision-making model or strategy chosen, data collection and analy- sis are essential. In many health care organizations, quality teams are using a variety of tools to gather, organize, and analyze data about their work such as decision grids, flow

BOX 8-2 Steps in Decision Making

1. Identify the purpose: Why is a decision necessary? What needs to be determined? State the issue in the broadest possible terms.

2. Set the criteria: What needs to be achieved, preserved, and avoided by whatever decision is made? The answers to these questions are the standards by which solutions will be evaluated.

3. Weigh the criteria: Rank each criterion on a scale of values from 1 (totally unimportant) to 10 (extremely important).

4. Seek alternatives: List all possible courses of action. Is one alternative more significant than another? Does one alternative have weaknesses in some areas? Can these be overcome? Can two alternatives or features of many alternatives be combined?

5. Test alternatives: First, using the same methodology as in step 3, rank each alternative on a scale of 1 to 10. Second, multiply the weight of each criterion by the rating of each alternative. Third, add the scores and compare the results.

6. Troubleshoot: What could go wrong? How can you plan? Can the choice be improved? 7. Evaluate the action: Is the solution being implemented? Is it effective? Is it costly?

108 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

charts, or cause-and-effect diagrams. Figure 8-3 illustrates a cause-and-effect diagram that a team of nurses created to help them improve the documentation process for their ambulatory oncology unit.

Another example of a decision tool is the Dynamic Network Analysis Decision Support (DyNADS) project at the University of Arizona College of Nursing (see http://www.dynads.nursing. arizona.edu). This simulation product enables the manager to predict the consequences of decisions on patient safety and quality outcomes. The tool simulates virtual nursing units, identifies potential errors, and predicts the likely result. Using the tool, the manager can discover if an innovation or a combination of innovations is likely to be successful (Effkenet al., 2010). DyNADS is a decision support tool that improves predictability in today’s complex environment.

Group Decision Making The widespread use of participative management, quality improvement teams, and shared gover- nance in health care organizations requires every nurse manager to determine when group, rather than individual, decisions are desirable and how to use groups effectively. A number of stud- ies have shown that professional people do not function well in a micromanaged environment. As an alternative, group problem solving of substantial issues casts the manager in the role of facilitator and consultant. Compared to individual decision making, groups can provide more in- put, often produce better decisions, and generate more commitment. One group decision-making technique is brainstorming.

In brainstorming, group members meet together and generate many diverse ideas about the nature, cause, definition, or solution to a problem without consideration of their relative value. The focus team whose work is shown in Figure 8-3 used brainstorming.

With brainstorming, a premium is placed on generating lots of ideas as quickly as pos- sible and on coming up with unusual ideas. Most importantly, members do not critique ideas as they are proposed. Evaluation takes place after all the ideas have been generated. Members are

Cause

Equipment

Effect

Materials Methods

People

Staff MDs

Chart design

Lack of chart racks

Inadequate forms

Treatment nurses

Lack of focus

Clinicians

Fellows

Poor communication

Unclear chemotherapy orders

Less than adequate nursing

documentation Patient chart movement from clinics

Lack of procedures and guidelines

Lack of appropriate documentation forms

Figure 8-3 • Brainstorming session of a nursing quality focus team.

http://www.dynads.nursing.arizona.edu

CHAPTER 8 • THINKING CRITICALLY, MAKING DECISIONS, SOLVING PROBLEMS 109

encouraged to improve on each other’s ideas. These sessions are enjoyable but are often unsuc- cessful because members inevitably begin to critique ideas, and as a result, meetings shift to the ordinary interacting group format. Criticisms of this approach are the high cost factor, the time consumed, and the superficiality of many solutions.

Problem Solving People use problem solving when they perceive a gap between an existing state (what is going on) and a desired state (what should be going on). How one perceives the situation influences how the problem is identified or solved. Therefore, perceptions need to be clarified before prob- lem solving can occur.

Problem-Solving Methods A variety of methods can be used to solve problems. People with little management experience tend to use the trial-and-error method, applying one solution after another until the problem is solved or appears to be improving. These managers often cite lack of experience and of time and resources to search for alternative solutions.

In a step-down unit with an increasing incidence of medication errors, Max, the nurse manager, uses various strategies to decrease errors, such as asking nurses to use calcu- lators, having the charge nurse check medications, and posting dosage and medication charts in the unit. After a few months, by which time none of the methods has worked, it occurs to Max that perhaps making nurses responsible for their actions would be more effective. Max develops a point system for medication errors: When nurses accumulate a certain amount of points, they are required to take a medication test; repeated failure of the test may eventually lead to termination. Max’s solution is effective and a low level of medication errors is restored.

As the above example shows, a trial-and-error process can be time-consuming and may even be detrimental. Although some learning can occur during the process, the nurse manager risks being perceived as a poor problem solver who has wasted time and money on ineffective solutions.

Experimentation, another type of problem solving, is more rigorous than trial and error. Pilot projects or limited trials are examples of experimentation. Experimentation in- volves testing a theory (hypothesis) or hunch to enhance knowledge, understanding, or pre- diction. A project or study is carried out in either a controlled setting (e.g., in a laboratory) or an uncontrolled setting (e.g., in a natural setting such as an outpatient clinic). Data are collected and analyzed and results interpreted to determine whether the solution tried has been effective.

Lin, a nurse manager of a pediatric floor, has received many complaints from mothers of children who think the nurses are short-tempered. Lin has a hunch that 12-hour shifts, which have been recently implemented on her floor, are contributing to the problem; she believes that nurses who must interact frequently with families would perform better on eight-hour shifts. She can test her theory by setting up a small study comparing the two staffing patterns with patient satisfaction.

Experimentation may be creative and effective or uninspired and ineffective, depending on how it is used. As a major method of problem solving, experimentation may be inefficient be- cause of the amount of time and control involved. However, a well-designed experiment can be persuasive in situations in which an idea or activity, such as a new staffing system or care proce- dure, can be tried in one of two similar groups and results objectively compared.

110 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

Still other problem-solving techniques rely on past experience and intuition. Everyone has various and countless experiences. Individuals build a repertoire of these experiences and base future actions on what they considered successful solutions in the past. If a particular course of action consistently resulted in positive outcomes, the person will try it again when similar cir- cumstances occur. In some instances, an individual’s past experience can determine how much risk he or she will take in present circumstances.

The nature and frequency of the experience also contribute significantly to the effectiveness of this problem-solving method. How much the person has learned from these experiences, posi- tive or negative, can affect the current viewpoint and can result in either subjective, narrow judg- ments or wise ones. This is especially true in human relations problems. Intuition relies heavily on past experience and trial and error. The extent to which past experience is related to intuition is difficult to determine, but nurses’ wisdom, sensitivity, and intuition are known to be valuable in solving problems.

Some problems are self-solving: if permitted to run a natural course, they are solved by those personally involved. This is not to say that a uniform laissez-faire management style solves all problems. The nurse manager must not ignore managerial responsibilities, but often difficult situations become more manageable when participants are given time, resources, and support to discover their own solutions.

This typically happens, for example, when a newly graduated nurse joins a unit where most of the staff are associate degree RNs who resent the new nurse’s level of education as well as the nurse’s lack of experience. If the nurse manager intervenes, a problem that the staff might have worked out on their own becomes an ongoing source of conflict. The important skill required here is knowing when to act and when not to act. (See Chapter 12 for a discussion of conflict.)

The Problem-Solving Process Many nursing problems require immediate action. Nurses don’t have time for formalized pro- cesses of research and analysis specified by the scientific method. Therefore, learning an orga- nized method for problem solving is invaluable. One practical method for problem solving is to follow this seven-step process, which is also outlined in Box 8-3.

1. Define the problem. The definition of a problem should be a descriptive statement of the state of affairs, not a judgment or conclusion. If one begins the statement of a problem with a judgment, the solution may be equally judgmental, and critical descriptive elements could be overlooked.

Suppose a nurse manager reluctantly implements a self-scheduling process and finds that each time the schedule is posted, evenings and some weekend shifts are not adequately covered. The manager might identify the problem as the immaturity of the staff and their inability to function under democratic leadership. The causes may be lack of interest in group decision making, minimal concern over providing adequate patient coverage, or, per- haps more correctly, a few nurses’ lack of understanding of the process.

If the nurse manager defines the above problem as immaturity and reverts to making out the schedules without further fact-finding, a minor problem could develop into a major upheaval.

BOX 8-3 Steps in Problem Solving

1. Define the problem. 2. Gather information. 3. Analyze the information. 4. Develop solutions.

5. Make a decision. 6. Implement the decision. 7. Evaluate the solution.

CHAPTER 8 • THINKING CRITICALLY, MAKING DECISIONS, SOLVING PROBLEMS 111

Premature interpretation can alter one’s ability to deal with facts objectively. For example, are there other explanations for the apparent behavior that do not entail negative assumptions about the maturity of the staff?

Accurate assessment of the scope of the problem also determines whether the manager needs to seek a lasting solution or just a stopgap measure. Is this just a situational problem requiring only intervention with a simple explanation, or is it more complex, involving the leadership style of the manager? The manager must define and classify problems in order to take action.

To define a problem, ask:

• Do I have the authority to do anything about this myself? • Do I have all the information? The time? • Who else has important information and can contribute? • What benefits could be expected? A list of potential benefits provides the basis for

comparison and choice of solutions. The list also serves as a means for evaluating the solution.

2. Gather information. Problem solving begins with collecting facts. This information gath- ering initiates a search for additional facts that provides clues to the scope and solution of the problem. This step encourages people to report facts accurately. Everyone involved can contribute. Although this may not always provide objective information, it reduces misin- formation and allows everyone an opportunity to tell what he or she thinks is wrong with a situation.

Experience is another source of information—one’s own experience as well as the experience of other nurse managers and staff. The people involved usually have ideas about what should be done. Some data will be useless, some inaccurate, but some will be useful to develop innovative ideas worth pursuing.

3. Analyze the information. Analyze the information only when all of it has been sorted into some orderly arrangement as follows:

• Categorize information in order of reliability. • List information from most important to least important. • Set information into a time sequence. What happened first? Next? What came before

what? What were the concurrent circumstances? • Examine information in terms of cause and effect. Is A causing B, or vice versa? • Classify information into categories: human factors, such as personality, maturity, educa-

tion, age, relationships among people, and problems outside the organization; technical factors, such as nursing skills or the type of unit; temporal factors, such as length of ser- vice, overtime, type of shift, and double shifts; and policy factors, such as organizational procedures or rules applying to the problem, legal issues, and ethical concerns.

• Consider how long the situation has been going on.

Because no amount of information is ever complete or comprehensive enough, critical- thinking skills, discussed earlier, help the manager examine the assumptions, evidence, and potential value conflicts.

4. Develop solutions. As an individual or a group analyzes information, numerous possible solutions will suggest themselves. Do not consider only simple solutions, because that may stifle creative thinking and cause over concentration on detail. Developing alternative solu- tions makes it possible to combine the best parts of several solutions into a superior one. Also, alternatives are valuable in case the first-order solutions prove impossible to implement.

When exploring a variety of solutions, maintain an uncritical attitude toward the way the problem has been handled in the past. Some problems have had a long-standing

112 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

history by the time they reach you, and attempts may have been made to resolve them over a period of time. “We tried this before and it didn’t work” is often said and may apply—or more likely, may not apply—in a changed situation. Past experience may not always supply an answer, but it can aid the critical-thinking process and help prepare for future problem solving.

5. Make a decision. After reviewing the list of potential solutions, select the one that is most applicable, feasible, satisfactory, and has the fewest undesirable consequences. Some solutions have to be put into effect quickly; matters of discipline or compromises in patient safety, for example, need immediate intervention. You must have legitimate authority to act in an emergency and know the penalties to be imposed for various infractions.

If the problem is a technical one and its solution brings about a change in the method of doing work (or using new equipment), expect resistance. Changes that threaten individuals’ personal security or status are especially difficult. In those cases, the change process must be initiated before solutions are implemented. If the solution involves change, the manager should fully involve those who will be affected by it, if possible, or at least inform them of the process. (See Chapter 5 for discussion of the change process.)

6. Implement the decision. Implement the decision after selecting the best course of action. If unforeseen new problems emerge after implementation, evaluate these impediments. Be careful, however, not to abandon a workable solution just because a few people object; a minority always will. If the previous steps in the problem-solving process have been followed, the solution has been carefully thought out, and potential problems have been addressed, implementation should move forward.

7. Evaluate the solution. After the solution has been implemented, review the plan and compare the actual results and benefits to those of the idealized solution. People tend to fall back into old patterns of habit, only giving lip service to change. Is the solution being implemented? If so, are the results better or worse than expected? If they are better, what changes have contributed to its success? How can we ensure that the solution continues to be used and to work? Such a periodic checkup gives you valuable insight and experience to use in other situations and keeps the problem-solving process on course.

See Case Study 8-2 to learn how one nurse manager used critical thinking to solve a problem.

Group Problem Solving Traditionally, managers solved most problems in isolation. This practice, however, is outdated. Both the complexity of problems and the staff’s desire for meaningful involvement create the impetus for using group approaches to problem solving. Today consensus-based problem solv- ing, inherent in shared governance, is the norm.

Advantages of Group Problem Solving Groups collectively possess greater knowledge and information than any single member and may access more strategies to solve a problem. Under the right circumstances and with appropriate leadership, groups can deal with more complex problems than a single individual, especially if there is no one right or wrong solution to the problem. Individuals tend to rely on a small number of familiar strategies; a group is more likely to try several approaches.

Group members may have a greater variety of training and experiences and approach prob- lems from more diverse points of view. Together, a group may generate more complete, accurate, and less biased information than one person. Groups may deal more effectively with problems that cross organizational boundaries or involve change that requires support from other units or

CHAPTER 8 • THINKING CRITICALLY, MAKING DECISIONS, SOLVING PROBLEMS 113

departments. Participative problem solving has additional advantages: it increases the likelihood of acceptance and understanding of the decision, and it enhances cooperation in implementation.

Disadvantages of Group Problem Solving Group problem solving also has disadvantages: it takes time and resources and may involve con- flict. Group problem solving also can lead to the emergence of benign tyranny within the group. Members who are less informed or less confident may allow stronger members to control group discussion and problem solving. A disparity in participation may contribute to a power struggle between the nurse manager and a few assertive group members.

Also managers may resist using groups to make decisions. They may fear that they may not agree with the decision the group makes or that they will not be needed if all decisions are made by the group. Neither is the case. Some decisions are rightfully the managers’ (e.g., handling the budget), others are staff decisions (e.g., peer review, self-scheduling), and some are shared (e.g., joint hiring decisions). Figure 8-4 illustrates this.

CRITICAL THINKING AND PROBLEM SOLVING Latonia Wilson is nurse manager for a busy 20-bed telemetry unit. In addition to providing postsurgical care for cardiac patients, nurses also prepare patients for cardiac catheterization lab procedures. Latonia’s staff includes eight new graduate nurses, almost half of her nursing staff. The new nurses have attended most of the required nursing orientation for the hospital.

Three times in one month, telemetry unit patients who had orders for heparin drips were administered heparin flush instead. Premixed IV bags for heparin drips as well as heparin flush for indwelling arterial catheters are stocked on the IV solutions cart in the medication room. While no adverse patient outcomes had been re- ported, procedures have been delayed.

Geena Donati is a graduate nurse on the telem- etry unit. Recently, she took a bag of heparin drip from the IV cart and started to attach it to the IV tubing. She noticed that the label stated heparin flush in- stead of heparin. Upon returning to the med room, she checked the heparin drip bin and found heparin flush bags mixed in with the heparin drip. The phar- macy technician came into the med room and began stocking the IV cart. Geena noticed that the pharmacy technician put extra heparin drip bags in the heparin flush bin. She questioned the pharmacy technician and he told Geena that since the unit used a lot of heparin

solution, he had started bringing extra to decrease his trips to the unit.

Geena met with Latonia later during her shift. She told her manager about the extra heparin bags be- ing mixed into the wrong bins. Latonia asked Geena if she would be interested in working with two other RNs on the unit to develop new procedures to decrease heparin medication errors. Geena and the task force worked with the pharmacy department to change the label color for heparin drip and heparin flush solutions, physically separated the bins on the IV cart onto differ- ent shelves, and provided a short educational segment at the monthly staff meeting. Since the new procedures were developed, no further heparin errors have oc- curred on the telemetry unit.

Manager’s Checklist The nurse manager is responsible for:

● Tracking and identifying recurring negative perfor- mance issues on the unit

● Analyzing adverse outcomes to determine what fac- tors contributed to the outcome

● Empowering staff to improve work processes on the unit

● Understanding the organizational structure and helping staff work with other departments within the organization

CASE STUDY 8-2

Staff decisions

Shared decision making

field

Manager decisions

Figure 8-4 • Shared decision making goal. From Shiparski, L. (2005). Engaging in shared decision making: Leveraging staff and management expertise. Nurse Leader, 3(1), 40.

114 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

Group problem solving also can be affected by groupthink. Groupthink is a negative phenomenon that occurs in highly cohesive groups that become isolated. Through prolonged close association, group members come to think alike and have similar prejudices and blind spots, such as stereotypical views of outsiders. They exhibit a strong tendency to seek concurrence, which interferes with critical thinking about important decisions. In addition, the leadership of such groups suppresses open, free- wheeling discussion and controls what ideas will be discussed and how much dissent will be tolerated. Groupthink seriously impairs critical thinking and can result in erroneous and damaging decisions.

Also groups tend to make riskier decisions than individuals. Groups are more likely to sup- port unusual or unpopular positions (e.g., public demonstrations). Groups tend to be less con- servative than individual decision makers and frequently display more courage and support for unusual or creative solutions to problems.

Individuals who lack information about alternatives may make a safe choice, but after group dis- cussion they acquire additional information and become more comfortable with a less secure alterna- tive. The group setting also allows for the diffusion of responsibility. If something goes wrong, others also can be assigned the blame or risk. In addition, leaders may be greater risk takers than individuals, and group members may attach a social value to risk taking because they identify it with leadership.

Stumbling Blocks The leader’s personality traits, inexperience, lack of adaptability, and preconceived ideas may be obstacles to decision making and problem solving.

Personality The leader’s personality can and often does affect how and why certain decisions are made. Managers are often selected because of their expert clinical, not managerial, skills. Inexperi- enced in management, they may resort to various unproductive actions. On the one hand, a nurse manager who is insecure may base decisions primarily on approval seeking. When a truly diffi- cult situation arises, the manager, rather than face rejection from the staff, makes a decision that will placate people rather than one that will achieve the larger goals of the unit and organization.

On the other hand, a nurse manager who demonstrates an authoritative type of personality might make unreasonable demands on the staff, fail to reward staff for long hours because he or she has a “workaholic” attitude, or give the staff little control over unit decisions. Similarly, an inexperienced manager may cause a unit to flounder because the manager is not inclined to act on new ideas or solutions to problems. Optimism, humor, and a positive approach are crucial to energizing staff and promoting creativity.

Rigidity Rigidity, an inflexible management style, is another obstacle to problem solving. It may result from ineffective trial-and-error solutions, fear of risk taking, or inherent personality traits. Avoid ineffective trial-and-error problem solving by gathering sufficient information and determining a means for early correction of wrong or inadequate decisions. Also, to minimize risk in problem solving, understand alternative risks and expectations.

The person who uses a rigid style in problem solving easily develops tunnel vision—the ten- dency to look at new things in old ways and from established frames of reference. It then becomes difficult to see things from another perspective, and problem solving becomes a process whereby one person makes all of the decisions with little information or data from other sources. In today’s rapidly changing health care setting, rigidity can be a barrier to effective problem solving.

Preconceived Ideas Effective leaders do not start out with the preconceived idea that one proposed course of action is right and all others wrong. Nor do they assume that only one opinion can be voiced and others

CHAPTER 8 • THINKING CRITICALLY, MAKING DECISIONS, SOLVING PROBLEMS 115

will be silent. They start out with a commitment to find out why others disagree. If the staff, other professionals, or patients see a different reality or even a different problem, leaders need to integrate this information into developing additional problem-solving alternatives.

Innovation Innovation is a strategy to bridge the gap between an existing state and a desired state (Porter- O’Grady & Malloch, 2010). Organized nursing has recognized the importance of innovation to solve health care’s many problems (Lachman, Glasgow, & Donnelly, 2009). The American Academy of Nursing’s campaign “Raise the Voice” highlights “edge runners,” those nurses who create innovative solutions for the health care system (see www.aannet.org).

To stimulate innovation, several techniques include:

● Simulations—uses actors representing standardized patients or high-tech mannequins ● Case studies—encourages participants to use critical thinking to analyze actual patient

situations ● Problem-based learning—incorporates additional information into the case study over

time ● Debate—helps participants examine an issue from more than one viewpoint (Lachman,

Glasgow, & Donnelly, 2009)

One university has even developed a post-master’s certificate program in innovation (Dreher, 2008). Using a case-study model, Drexel University’s College of Nursing offers an online program in innovation and entrepreneurship (see www.Drexel.edu) designed to foster cre- ative thinking to solve internal and external problems (Lachman, Glasgow, & Donnelly, 2009).

Critical thinking, creativity, and innovative thinking, along with the appropriate tools and techniques, will enable nurses and their managers to make decisions and solve problems in the least time and with the best outcomes.

What You Know Now • Critical thinking requires examining underlying assumptions about current evidence, interpreting infor-

mation, and evaluating the arguments presented to reach a new and exciting conclusion. • The creative process involves preparation, incubation, insight, and verification, which can be learned by

individuals and groups. • Problem-solving and decision-making processes use critical-thinking skills. • The decision-making process may employ several models: rational, descriptive rationality, satisficing, and

political. • Decision-making techniques vary according to the problem and the degree of risk and uncertainty in the

situation. • Methods of problem solving include trial and error, intuition, experimentation, past experience, tradition,

and recognizing that some problems are self-solving. • The problem-solving process involves defining the problem, gathering information, analyzing information,

developing solutions, making a decision, implementing the decision, and evaluating the solution. • Group problem solving can be positive, providing more information and knowledge than an individual. It

can also be negative if it generates disruptive conflict or groupthink. • Stumbling blocks to making decisions and solving problems include the leader’s personality, rigidity, or

preconceived ideas. • Innovation helps bridge the gap between the existing state and the desired state.

Tools for Making Decisions and Solving Problems 1. Identify problem areas. 2. Ask questions, interpret data, and consider alternatives to make decisions and solve problems. 3. Evaluate the level of certainty, uncertainty, and risk, and consider appropriate alternatives.

www.aannet.org

www.Drexel.edu

116 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

4. Identify opportunities to use groups appropriately to make decisions and solve problems. 5. Follow the problem-solving process described in the chapter. 6. Challenge yourself to look for creative and innovation solutions.

Questions to Challenge You 1. Identify someone you believe has critical-thinking skills. What critical thinking attributes does this

person possess? 2. Describe a situation when you made an important decision. What content in the chapter applied to

that situation? What was the outcome? 3. Have you been involved in group decision making at school or at work? What techniques were used?

Were they effective? 4. A number of ways that problem solving might fail were discussed in the chapter. Name three

more. 5. Have you ever proposed a creative or innovative idea at work or school? Describe the idea and

explain what happened.

Web Resources DyNADS project: http://www.dynads.nursing.arizona.edu Post-Master’s Certificate Program in Innovation and Intra/Entrepreneurship: http://www.drexel.edu/

gradnursing/msn/post-MastersCertOnline/innovationEntrepreneurship/ American Academy of Nursing Edge Runners: http://www.aannet.org/edgerunners American Academy of Nursing Raise the Voice: http://www.aannet.org/raisethevoice

References Ashcraft, T. (2010). Solving the

critical thinking puzzle. Nursing Management, 41(1), 8–10.

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2009). Educating Nurses: A call for radical transformation. San Fran- cisco: Jossey-Bass.

Bittner, N. P., & Gravlin, G. (2009). Critical thinking, delegation, and missed care in nursing practice. Journal of Nursing Administration, 39(3), 142–146.

Dreher, H. M. (2008). Innova- tion in nursing education:

Preparing for the future of nursing. Holistic Nursing Practice, 22(2), 77–80.

Effken, J. A., Verrn, J. A., Logue, M. D., & Hsu, Y. C. (2010). Nurse managers’ decisions. Journal of Nurs- ing Administration, 40(4), 188–195.

Lachman, V. D., Smith Glasgow, M. E., & Donnelly, G. F. (2009). Teaching in- novation. Nursing Ad- ministration Quarterly, 33(3), 205–211.

Porter-O’Grady, T. & Mal loch, K. (2010). In novation leadership:

Creating the landscape of healthcare. Sudbury, MA: Jones & Bartlett.

Simon, H. A. (1993). Decision making: Rational, non- rational, and irrational. Education Administra- tion Quarterly, 29(3), 392–411.

Zori, S., Nosek, L. J., & Musil, C. M. (2010). Critical thinking of nurse manag- ers related to staff RNs’ perceptions of the practice environment. Journal of Nursing Scholarship, 42(3), 305–313.

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

http://www.dynads.nursing.arizona.edu

http://www.drexel.edu/gradnursing/msn/post-MastersCertOnline/innovationEntrepreneurship/

http://www.aannet.org/edgerunners

http://www.aannet.org/raisethevoice

www.nursing.pearsonhighered.com

CHAPTER

Communication MODES OF COMMUNICATION

DISTORTED COMMUNICATION

DIRECTIONS OF COMMUNICATION

EFFECTIVE LISTENING

Effects of Differences in Communication GENDER DIFFERENCES IN COMMUNICATION

GENERATIONAL AND CULTURAL DIFFERENCES IN COMMUNICATION

DIFFERENCES IN ORGANIZATIONAL CULTURE

The Role of Communication in Leadership EMPLOYEES

ADMINISTRATORS

COWORKERS

MEDICAL STAFF

OTHER HEALTH CARE PERSONNEL

PATIENTS AND FAMILIES

Collaborative Communication

Enhancing Your Communication Skills

Communicating Effectively 9

Key Terms Communication Diagonal communication Downward communication Fogging

1. Identify the factors that influence communication.

2. Discuss how communication can be distorted and misunderstood.

3. Choose which communication mode to use depending on the message and the relationship.

4. Explain how communication strategies vary according to the situation and those involved.

5. Improve your collaborative communication skills.

6. Develop a plan to enhance your communi- cation skills.

Learning Outcomes After completing this chapter, you will be able to:

Intersender conflict Intrasender conflict Lateral communication Metacommunications

Negative assertion Negative inquiry Upward communication

118 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

Communication Communication is a complex, ongoing, dynamic process in which the participants simulta- neously create shared meaning in an interaction. The goal of communication is to approach, as closely as possible, a common understanding of the message sent and the one received. At times, this can be difficult because both participants are influenced by past condition- ing; the present situation; each person’s purpose in the current communication; and each per- son’s attitudes toward self, the topic, and each other. It is important that participants construct messages as clearly as possible, listen carefully, monitor each other’s response, and provide feedback.

Modes of Communication Messages may be oral (face-to-face, one-on-one, or in groups; by telephone, text, voice mail or posted on a social media site; or written (handwritten or typed) and sent by mail, e-mail, or fax. The purpose of the message determines the best mode to use. In general, the more important or delicate the issue, the more intimate the mode should be. Any difficult issue should be commu- nicated face-to-face, such as terminating an individual’s employment. Conflict or confrontation also is usually best handled in person so that the individual’s response, especially nonverbal signals (discussed later), can be seen and answered appropriately.

What mode to use depends on the level of intimacy required based on the person, your rela- tionship, and the message. The levels of intimacy, in descending order, are:

● in person ● by phone ● voice mail ● text ● e-mail ● postal mail ● posting on social media sites, including blogs

Meeting someone face-to-face is the most intimate contact. The individual can see your face, see your body movements, and hear your words simultaneously. The telephone is slightly less intimate than in-person communication. Tone of voice, for instance, can be conveyed, and phone conversations can be two-way. Voice mail is the next level of communication. Voice mail is useful to convey information that is not necessarily sensitive and may or may not require a reply. The time and place of an upcoming meeting, for example, can be communicated by voice mail, which has the added advantage of avoiding “phone tag.”

E-mail is useful for information similar to that conveyed by voice mail and, like some voice mail systems, can be broadcast to large groups at once. The dates and times for a blood drive are a good example of a broadcast message. Conveying complicated information that may require thought before the receiver replies is another value of using e-mail. Texting is similar to e-mail, although briefer. Posting on social media sites or blogs is the least personal communication (Kaplan & Haenlein, 2010).

The level of formality of the communication also affects the mode used. Applying for a position requires a written format even if the letter is e-mailed rather than mailed. The relation- ship between the sender and receiver also affects the mode. If a staff nurse, for example, wants to nominate a coworker for an award given by the hospital board of directors, a written letter or e-mail is required. Memos are less formal than written messages and can be e-mailed, faxed, or mailed. Social media postings are public and impersonal (Raso, 2010; Trossman, 2010).

Distorted Communication Oral messages are accompanied by a number of nonverbal messages known as metacommuni- cations. These behaviors include head or facial agreement or disagreement; eye contact; tone,

CHAPTER 9 • COMMUNICATING EFFECTIVELY 119

volume, and inflection of the voice; gestures of the shoulders, arms, hands, or fingers; body pos- ture and position; dress and appearance; timing; and environment.

Nonverbal communication is more powerful than the words one speaks and can distort the meaning of the spoken words. When a verbal message is incongruent with the nonverbal message, the recipient has difficulty interpreting the intended meaning; this results in intrasender conflict. For example, a manager who states, “Come talk to me anytime,” but keeps on typing at the keyboard while you talk, sends a conflicting message to the staff. Intersender conflict occurs when a person receives two conflicting messages from differing sources. For example, the risk manager may en- courage a nurse to report medication errors, but the nurse manager follows up with discipline over the error. The nurse is caught between conflicting messages from the two managers.

Other common causes of distorted communication are:

● Using inadequate reasoning ● Using strong, judgmental words ● Speaking too fast or too slowly ● Using unfamiliar words ● Spending too much time on details

Distortion also occurs when the recipient is busy or distracted, bases understanding on pre- vious unsatisfactory experience with the sender, or has a biased perception of the meaning of the message or the messenger. Consider the example of distortion of written communication provided in Box 9-1.

BOX 9-1 Distortion in Written Communication

There is ample opportunity for distortion in the complicated process of sending, receiving, and responding to mes- sages, as demonstrated by the following correspondence between a plumber and an official of the National Bureau of Standards (Donaldson & Scannell, 1979).

Bureau of Standards Washington, D.C. Gentlemen:

I have been in the plumbing business for over 11 years and have found that hydrochloric acid works real fine for cleaning drains. Could you tell me if it’s harmless?

Sincerely, Tom Brown, Plumber

Mr. Tom Brown, Plumber Yourtown, U.S.A. Dear Mr. Brown:

The efficacy of hydrochloric acid is indisputable, but the chlorine residue is incompatible with metallic permanence!

Sincerely, Bureau of Standards

Bureau of Standards Washington, D.C. Gentlemen:

I have your letter of last week and am mightily glad you agree with me on the use of hydrochloric acid.

Sincerely, Tom Brown, Plumber

Mr. Tom Brown, Plumber Yourtown, U.S.A. Dear Mr. Brown:

We wish to inform you we have your letter of last week and advise that we cannot assume responsibility for the production of toxic and noxious residues with hydrochloric acid and further suggest you use an alter- nate procedure.

Sincerely, Bureau of Standards

Bureau of Standards Washington, D.C. Gentlemen:

I have your most recent letter and am happy to find you still agree with me.

Sincerely, Tom Brown, Plumber

Mr. Tom Brown, Plumber Yourtown, U.S.A. Dear Mr. Brown:

Don’t use hydrochloric acid, it eats the hell out of pipes!

Sincerely, Bureau of Standards

For communication among more than two people, the chance of distortion increases proportionally.

120 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

E-mail is particularly fraught with opportunities for misunderstanding. From the greeting (e.g., dear, hi, hello, or no salutation) to the sign-off (e.g., warm regards, best wishes, best, or no sign-off), the sender conveys more than the choice of words. A speedy reply is expected and en- courages a response, sometimes without adequate thought. Finally, the possibility of sending the message to the wrong person, especially the dreaded “reply to all,” is another chance for your message to be misinterpreted. Texting shares many of the same dangers as e-mail and has added pressure for a faster response.

Directions of Communication Formal or informal communication may be downward, upward, lateral, or diagonal. Downward communication (manager to staff) is often directive. The staff is told what needs to be done or given information to facilitate the job to be done. Upward communication occurs from staff to management or from lower management to middle or upper management. Upward commu- nication often involves reporting pertinent information to facilitate problem solving and deci- sion making. Lateral communication occurs between individuals or departments at the same hierarchical level (e.g., nurse managers, department heads). Diagonal communication involves individuals or departments at different hierarchical levels (e.g., staff nurse to chief of the medi- cal staff). Both lateral and diagonal communication involve information sharing, discussion, and negotiation.

An informal channel commonly seen in organizations is the grapevine (e.g., rumors and gossip). Grapevine communication is usually rapid, haphazard, and prone to distortion. It can also be useful. Sometimes the only way to learn about a pending change is through the grape- vine. One problem with grapevine communication, however, is that no one is accountable for any misinformation that is relayed. Keep in mind, too, that information gathered this way is a slightly altered version of the truth, changing as the message passes from person to person.

Effective Listening Most nurses believe they are good listeners. Observing and listening to patients are skills nurses learn early in their careers and use every day. Being a good listener, however, involves more than just hearing words and watching body language (Sullivan, 2013). Maintaining eye contact is misleading; it may or may not signal that a person is listening. Barriers to effective listening include preconceived beliefs, lack of self-confidence, flagging energy, defensiveness, and habit (Donaldson, 2007).

Preconceived Beliefs The longer your relationship with someone is, the more apt you are to think you know what the person says or means and, thus, the more likely you are to not listen. This holds true in personal as well as professional relationships and applies to groups of people (known as stereotyping). Not expecting others to have anything worthwhile to say also is an example of preconceptions about them.

Lack of Self-Confidence Listening is difficult if you are nervous, and weak self-confidence frequently is the cause. People tend to talk too much or think about what they’re planning to say next to pay attention to the per- son speaking. Often their mind is racing and they may not be listening even when they’re talking themselves.

Flagging Energy Listening takes energy and sometimes we simply don’t have enough energy to listen carefully. Too many people speaking at once, having too much to do, being worried, or being too tired can all interfere with our ability to listen.

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Defensiveness Survival required that we learned to hear danger approaching, but today humans have translated defense mechanisms into a way to avoid hearing bad news. Then, we think, we don’t have to deal with it. The opposite is true, however. Only when we can hear and consider information can we handle it.

Habit Over time, many people develop the habit of thinking ahead during conversations. Thinking ahead is valuable in most aspects of life, but it’s deadly when you need to be listening. Like all behaviors that have become habits, changing this one is not easy. Reminding yourself to refocus on the speaker can help.

Effects of Differences in Communication

Gender Differences in Communication Men and women communicate differently (Feldhahn, 2009; Tannen, 2001). They have become socialized through communication patterns that reflect their societal roles. Men tend to talk more, longer, and faster, whereas women are more descriptive, attentive, and perceptive. Women tend to use tag questions (e.g., “I can take off this weekend, can’t I?”) and tend to self-disclose more than men. Women tend to ask more questions and solicit more input than their male coun- terparts. Table 9-1 lists differences in the ways that men and women communicate.

Helgeson and Johnson (2010) suggest ways that women can improve their communication at work. Neither men nor women should raise their voices no matter what the provocation. Nor should one omit important details or assume everyone knows what you mean. Not allowing questions or objections also should be avoided, and never walk away and talk at the same time (Donaldson, 2007).

Using gender-neutral language in communication helps bridge the gap between the way men and women communicate. Men and women can improve their ability to communicate with each other by following the recommendations for gender-neutral communication found in Table 9-2.

Generational and Cultural Differences in Communication Generational differences, discussed in Chapter 1, affect communication styles, patterns, and expectations. Traditionals tend to be more formal, following the chain of command without question. Baby boomers question more. They enjoy the process of group problem solving

TABLE 9-1 Gender Differences in Communication

Men tend to Women tend to

Interrupt more frequently Wait to be noticed

Talk more, longer, louder, and faster Use qualifiers (prefacing and tagging)

Disagree more Use questions in place of statements

Focus on the issue more than the person Relate personal experiences

Boast about accomplishments Promote consensus

Use banter to avoid a one-down position Withdraw from conflict

From Sullivan, E. J. (2013). Becoming influential: A guide for nurses. (2nd ed.). Upper Saddle River, NJ: Prentice Hall, p. 57. Reprinted by permission.

122 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

and decision making. Independent Generation X members are just the opposite and want decisions made without unnecessary discussion. Collegial millennials (Generation Y) expect immediate feedback to their messages. E-mail, text, or voice mail is the best way to connect with them. Mutual respect and understanding of the unique differences between and among groups will help to minimize conflict and maximize satisfaction for both managers and staff (Hahn, 2009).

Cultural attitudes, beliefs, and behaviors also affect communication (Robertson-Malt, Herrin-Griffith, & Davies, 2010). Such elements as body movement, gestures, tone, and spatial orientation are culturally defined. A great deal of misunderstanding results from a lack of under- standing of each other’s cultural expectations. For example, people of Asian descent take great care in exchanges with supervisors so that there is no conflict or “loss of face” for either person.

Understanding the cultural heritage of employees and learning to interpret cultural mes- sages is essential to communicate effectively with staff from diverse backgrounds. Personal and professional cultural enrichment training is recommended. This includes reading the literature and history of the culture; participating in open, honest, respectful communication; and explor- ing the meaning of behavior. It is important to recognize, however, that subcultures exist within all cultures; therefore, what applies to one individual will not be true for everyone else in that culture.

Differences in Organizational Culture As discussed in Chapter 2, the customs, norms, and expectations within an organization are powerful forces that shape behavior. Focusing on relevant issues regarding the organizational culture can identify failures in communication. Poor communication is a frequent source of job dissatisfaction as well as a powerful determinant of an organization’s effectiveness. Just as violation of other norms within the organization results in repercussions, so does violation of communication rules.

To discover what rules affect communication in your organization, ask yourself:

● Who has access to what information? Is information withheld? Is it shared widely? ● What modes of communication are used for which messages? Are they used

appropriately? ● How clear are the messages? Or are they often distorted? ● Does everyone receive the same information? ● Do you receive too much information? Not enough? ● How effective is the message?

TABLE 9-2 Recommendations for Gender-Neutral Communication

Men may need to Women may need to

Listen to objections and suggestions State your message clearly and concisely

Listen without feeling responsible Solve problems without personalizing them

Suspend judgment until information is in Say what you want without hinting

Explain your reasons Eliminate unsure words (“sort of”) and nonwords (“truly”)

Not yell Not cry

From Sullivan, E. J. (2013). Becoming influential: A guide for nurses. (2nd ed.). Upper Saddle River, NJ: Prentice Hall, p. 58. Reprinted by permission.

CHAPTER 9 • COMMUNICATING EFFECTIVELY 123

The Role of Communication in Leadership Although communication is inherent in the manager’s role, the manager’s ability to communi- cate often determines his or her success as a leader. Leaders who engage in frank, open, two-way communication and whose nonverbal communication reinforces the verbal communication are seen as informative. Communication is enhanced when the manager listens carefully and is sen- sitive to others. The major underlying factor, however, is an ongoing relationship between the manager and employees.

Successful leaders are able to persuade others and enlist their support. The most effective means of persuasion is the leader’s personal characteristics. Competence, emotional control, as- sertiveness, consideration, and respect promote trustworthiness and credibility. A participative leader is seen as a careful listener who is open, frank, trustworthy, and informative.

Employees Depending on the organization’s policies, the nurse manager’s responsibilities may include se- lecting, interviewing, evaluating, counseling, and disciplining employees; handling their com- plaints; and settling conflicts. The principles of effective communication are especially pertinent in these activities because good communication is the adhesive that builds and maintains an effective work group.

Giving direction is not, in itself, communication. If the manager receives an appropriate response from the subordinate, however, communication has occurred. To give directions and achieve the desired results, develop a message strategy. The techniques that follow can help im- prove effective responses from others.

● Know the context of the instruction. Be certain you know exactly what you want done, by whom, within what time frame, and what steps should be followed to do it. Be clear in your own mind what information a person needs to carry out your instruction, what the outcome will be if the instruction is carried out, and how that outcome can or will be eval- uated. When you have thought through these questions, you are ready to give the proper instruction.

● Get positive attention. Avoid factors that interfere with effective listening. Informing the person that the instructions will be given is one simple way to try to get positive attention. Highlighting the background, giving a justification, or indicating the importance of the instructions also may be appropriate.

● Give clear, concise instructions. Use an inoffensive and nondefensive style and tone of voice. Be precise, and give all the information receivers need to carry out your expecta- tions. Follow a step-by-step procedure if several actions are needed.

● Verify through feedback. Make sure the receiver has understood your specific request for action. Ask for a repeat of the instructions.

● Provide follow-up communication. Understanding does not guarantee performance. Fol- low up to discover if your instruction is clear and if the person has any questions.

The nurse manager is responsible both for the quality of the work life of individual em- ployees and for the quality of patient care in the entire unit. To carry out this job, acknowledge the needs of individual employees, especially if the needs of one conflict with needs of the unit, speak directly with those involved, and state clearly and accurately the rationale for the deci- sions made.

Administrators The manager’s interaction with higher administration is comparable to the interaction between the manager and an employee, except that the manager is now the subordinate. Higher ad- ministration is responsible for the consequences of decisions made for a larger area, such as all of nursing service or the entire organization. The principles used in communicating with

124 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

subordinates are equally appropriate. Managers should be organized and prepared to state their needs clearly, explain the rationale for requests, suggest benefits for the larger organization, and use appropriate channels. Listen objectively to your supervisor’s response and be willing to con- sider reasons for possible conflict with needs of other areas.

Working effectively with an administrator is important because this person directly influ- ences personal success in a career and within the organization. Managing a supervisor, or man- aging upward, is a crucial skill for nurses. To manage upward, remember that the relationship requires participation from both parties. Managing upward is successful when power and influ- ence move in both directions. Rules for managing your supervisor are found in Box 9-2.

One aspect of managing upward is to understand the supervisor’s position from her or his frame of reference. This will make it easier to propose solutions and ideas that the supervisor will accept. Understand that a supervisor is a person with even more responsibility and pressure. Learn about the supervisor from a personal perspective: What pressures, both personal and pro- fessional, does the supervisor face? How does the supervisor respond to stress? What previous experiences are liable to affect today’s issues? This assessment will allow you to identify ways to help your supervisor with his or her job and for your supervisor to help you with yours.

Influencing Your Supervisor Nurses need to approach their supervisor to exert their influence on a variety of issues and prob- lems. Support for the purchase of capital equipment, for changes in staffing, or for a new policy or procedure all require communicating with a supervisor. Your rationale, choice of form or format, and possible objections all are important factors to consider as you prepare to make such a request. Timing is critical; choose an opportunity when the supervisor has time and appears receptive. Also, consider the impact of your ideas on other events occurring at that time.

Should ideas be presented in spoken or written form? Usually some combination is used. Even if you have a brief meeting about a relatively small request, it is a good idea to follow up with an e-mail, detailing your ideas and the plans to which you both agreed. Sometimes the pro- cedure works in reverse. If you provide the supervisor with a written proposal prior to a meeting, both of you will be familiar with the idea at the start. In the latter case, careful preparation of the written material is essential.

What can be done if, in spite of careful preparation, your supervisor says no? First, make sure you have understood the objections and associated feelings. Negative inquiry (e.g., “I don’t understand”) is a helpful technique to use. Do not interrupt or become defensive or distraught; remain diplomatic. Fogging, agreeing with part of what was said, or negative assertion, accept- ing some blame, are two additional techniques that you can use.

The next step is confrontation. Keep your voice low and measured; use “I” language; and avoid absolutes, why questions, put-downs, inflammatory statements, and threatening gestures. Finally, if you feel you have lost and compromise is unlikely, table the issue by saying, “Could

BOX 9-2 Rules for Managing Your Boss

● Give immediate positive feedback for good things that the supervisor does; positive feedback is a wel- come change.

● Never let your supervisor be surprised; keep her or him informed.

● Always tell the truth. ● Find ways to compensate for weaknesses of your su-

pervisor. Fill in weak areas tactfully. Volunteer to do something the supervisor dislikes doing.

● Be your own publicist. Don’t brag, but keep your supervisor informed of what you achieve.

● Keep aware of your supervisor’s achievements and acknowledge them.

● If your supervisor asks you to do something, do it well and ahead of the deadline if possible. If appro- priate, add some of your own suggestions.

● Establish a positive relationship with the supervisor’s assistant.

CHAPTER 9 • COMMUNICATING EFFECTIVELY 125

we continue discussing this at another time?” Then, think through your supervisor’s reasoning and evaluate it.

Afterward ask yourself: “What new information did I get from the supervisor?” “What are ways I can renegotiate?” “What do I need to know or do to overcome objections?” Once you can answer these questions, approach your supervisor again with the new information. This behav- ior shows that the proposal is a high priority, and the new information may cause him or her to reevaluate.

Managers often succeed in influencing supervisors through persistence and repetition, espe- cially if supporting data and documentation are supplied. If the issue is important enough, you may want to take it to a higher authority. If so, tell your supervisor you would like an administra- tor at a higher level to hear the proposal. Keep an open mind, listen, and try to meet objections with suggestions of how to solve problems. Be prepared to compromise, which is better than no movement at all, or to be turned down.

Taking a Problem to Your Supervisor No one wants to hear about a problem, and your boss is no different. Nonetheless, work involves problems, and the manager’s job is to solve them. Go to your supervisor with a goal to problem solve together. Have some ideas about solving the problem in hand if you can but do not be so wedded to them that you are unable to listen to your supervisor’s ideas. Keep an open mind. Use the following steps to take a problem to your supervisor:

● Find an appropriate time to discuss a problem, scheduling an appointment if necessary. ● State the problem succinctly and explain why it is interfering with work. ● Listen to your supervisor’s response and provide more information if needed. ● If you agree on a solution, offer to do your part to solve it. If you cannot discover an

agreeable solution, schedule a follow-up meeting or decide to gather more information. ● Schedule a follow-up appointment.

By solving the problem together and, if necessary, by taking active steps together, you and your supervisor are more likely to accept the decision and be committed to it. Setting a specific follow-up date can prevent a solution from being delayed or forgotten.

If All Else Fails Sometimes no matter what you do, working with your supervisor seems nearly impossible. Some managers foster a negative work environment, and employees become dissatisfied, angry, and depressed. High absenteeism and turnover result. As a manager you are charged with sup- porting your supervisor. If working with that person is too difficult for you to manage your work satisfactorily, you may have to transfer elsewhere or leave.

Coworkers Interactions with coworkers are inevitable. Relationships can vary from comfortable and easy to challenging and complex. Coworkers often share similar concerns. Camaraderie may be present; coworkers can exchange ideas and address problems creatively. They can provide support, and the strengths of one can be developed in the other.

Conversely, there may also be competition or conflicts (e.g., battles over territory, personal- ity clashes, differences of opinion) affected by history, the organization’s mores, or generational or cultural differences. Even when there are conflicts, coworkers should interact on a profes- sional level. Chapter 12 suggests ways to handle conflict.

Medical Staff Communication with the medical staff may be difficult for the nurse manager because the re- lationship of physicians and nurses has been that of superior and subordinate (Kripalani et al., 2007). Complicating physician–nurse relationships is the employee status of the medical staff.

126 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

They may not be employees of the organization but still have considerable power because of their ability to attract patients to the organization, and, finally, the medical staff is in itself di- verse, consisting of physicians who are organizational employees, residents, physicians in pri- vate practice, and consulting physicians.

One program designed to help physicians improve their communication skills is LegacyMd (see http://legacymd.com/). Using improvisational techniques, participants practice interacting in scenes depicting workplace examples, receive feedback, and replay the scene with enhanced skills.

(See the next section on collaborative communication for how to interact more effectively with physicians.)

Other Health Care Personnel The nurse manager has the overwhelming task of coordinating the activities of a number of per- sonnel with varied levels and types of preparation and different kinds of tasks. The patient may receive regular care from a registered nurse, unlicensed assistive personnel, a respiratory thera- pist, a physical therapist, and a dietitian, among others. The nurse manager may supervise all of them. Regardless, the manager needs considerable skill to communicate effectively with diverse personnel, recognize their commonalities, and deal with their differences.

Patients and Families Nurse managers deal with many difficult issues. Patient or family complaints about the delivery of care (e.g., complaints about a staff member, violations of policy) are one example. When dealing with patient or family complaints, keep the following principles in mind:

● The patient and family are the principal customers of the organization. Treat patients and families with respect; keep communication open and honest. Dissatisfied customers fail to continue to use a service and also inform their friends and families about their neg- ative experiences. Handle complaints or concerns tactfully and expeditiously. Many times lawsuits can be avoided if the patient or family feels that someone has taken the time to listen to their complaints. (See the section on risk management in Chapter 6.)

● Most individuals are unfamiliar with medical jargon. Use words that are appropriate to the recipient’s level of understanding. However, take care not to be condescending or intimidating. It is just as important to assess the person’s knowledge base and level of un- derstanding as it is to know his or her vital signs or liver status.

● Maintain privacy and identify a neutral location for dealing with difficult interactions. ● Make special efforts to find interpreters if a patient or family does not speak English.

Have readily available a list of individuals who are able to communicate in a variety of languages. The list also should include individuals experienced in sign language and Braille. Another resource is AT&T’s language line service (800-752-6096), which pro- vides interpreters for over 140 languages 24 hours a day.

● Recognize cultural differences in communicating with patients and their families. People in some cultures do not ask questions for fear of imposing on others (Huber, 2009). Some cultures prefer interpreters from their own culture; others do not. Cultural education for the staff can help identify some of these differences and teach them appro- priate, culturally sensitive responses (Raingruber et al., 2010).

Collaborative Communication Collaboration is central to patient safety, according to a study by Vitalsmarts™ (Maxfield et al., 2005). The researchers found seven areas where health care workers found it difficult to speak up, including seeing colleagues make mistakes, perform incompetently, disrespect others, break rules, fail to support colleagues, exhibit poor teamwork, or micromanage inappropriately.

http://legacymd.com/

CHAPTER 9 • COMMUNICATING EFFECTIVELY 127

Propp and colleagues (2010) found that two processes were critical to ensuring collabora- tion with physicians and other members of the health care team. These were ensuring quality de- cisions and promoting team synergy (see Table 9-3). Developing a collaborative practice model, nurses can build their credibility with physicians and enhance the workplace environment.

Another study found that communication and role understanding crucial to collaborative practice (Suter et al., 2009). Appreciation of one another’s roles was key to improving com- munication and positive patient outcomes. Focusing educational objectives on communication and understanding others’ roles, rather than more diffuse skills, such as respect, is more likely to lead to better practices, the researchers assert.

To support greater collaboration between nurses and physicians and to improve the product of nursing service—patient care—keep these principles in mind:

● Respect physicians as persons, and expect them to respect you. ● Consider yourself and your staff equal partners with physicians in health care. ● Build your staff’s clinical competence and credibility. Ensure that your staff has the clini-

cal preparation necessary to meet required standards of care. ● Actively listen and respond to physician complaints as customer complaints. Create a

problem-solving structure. Stop blaming physicians exclusively for communication problems. ● Use every opportunity to increase your staff’s contact with physicians and to include your

staff in meetings that include physicians. Remember that limited interactions contribute to poor communication.

● Establish a collaborative practice committee on your unit whose membership is composed equally of nurses and physicians. Identify problems, develop mutually satisfactory solu- tions, and learn more about each other. Emphasize similarities and the need for quality care. Begin with those physicians who have a positive attitude toward collaboration.

● Serve as a role model to your staff in nurse–physician communication. ● Support your staff in participating in collaborative efforts by words and by your actions.

If you are confronted with power plays or intimidation, what is the best way to respond? Intimidation can be counteracted by increasing self-confidence and personal feelings of power. Four ways that generate power are:

1. With words: • Use the other person’s name frequently. • Use strong statements. • Avoid discounters, such as “I’m sorry, but . . . ?” • Avoid clichés, such as “hit the nail on the head,” “goes without saying,” “easier said than

done.” • Avoid fillers (such as “ah,” “uh,” and “um”).

TABLE 9-3 Improving Communication

1. Consider your relationship to the receiver.

2. Craft your message, including your goal and how to answer responses.

3. Decide on the medium based on your relationship, the content, and the setting.

4. Check your timing.

5. Deliver your message.

6. Attend to verbal or written responses.

7. Reply appropriately.

8. Conclude when both parties’ messages have been understood.

9. Evaluate communication process.

128 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

2. Through delivery: • Be enthusiastic. • Speak clearly and forcefully. • Make one point at a time. • Do not tolerate interruptions.

3. By listening: • Listen for facts. • Pay attention to emotions. • Listen for what is not being said (e.g., body language, mixed messages, hidden messages).

4. Through body posture and body language: • Sit next to your antagonist; turn 30 degrees toward the person when you address him or her. • Lean forward. • Expand your personal space. • Use gestures. • Stand when you talk. • Smile when you are pleased, not in order to please. • Maintain eye contact, but do not stare.

One nurse manager handled a problem with a physician as shown in Case Study 9-1. Additional techniques to counteract intimidation and threat are included in Chapters 12, 21, and 22.

COMMUNICATION Josie Randolph is nurse manager of a perioperative unit, including responsibility for the preoperative testing unit, 18 OR suites, pre-op holding, and sterile process- ing. The OR department supports the hospital’s Level I trauma service as well as all other surgical services.

Dr. Jonas Welborne is a plastic surgeon with a his- tory of aggressive behavior. He has several cases on today’s OR schedule. While he is in his first surgery, a trauma case is brought to the OR. Susan Richardson, the OR charge nurse, decides to bump Dr. Welborne’s sec- ond case out of OR #3 to make room for the trauma case. When Dr. Welborne has finished his first case, he is informed of the delay in his second case. Dr. Welborne storms into the OR scheduling office and begins yelling at Susan. The situation quickly escalates to the point where Dr. Welborne uses obscenities and throws several charts on the floor. Loretta Donnelly, an OR tech, runs to Josie’s office and asks her to come immediately to the OR scheduling office.

Susan and Dr. Welborne continue to yell at one anoth- er, in full view of patients in the pre-op area. Josie imme- diately steps between Dr. Welborne and Susan and firmly asks both of them to lower their voices. She instructs Susan to wait in the staff lounge while she speaks with Dr. Welborne. Josie asks Dr. Welborne to step into her of- fice so they can calmly discuss the situation. Dr. Welborne is still visibly agitated but agrees to discuss the problem.

After hearing his side of the story, Josie apologizes for the inconvenience, but reminds him of the OR poli- cies. Emergent cases take precedence over elective cases, and no other elective cases were on the schedule at that time. She asks Dr. Welborne if there are alternatives to scheduling his cases that would minimize delays or bumps. As they talk, Dr. Welborne becomes calmer.

Josie informs Dr. Welborne that his earlier behavior is unacceptable. Within a few minutes, he apologizes to Josie and asks to speak with Susan. He also apologizes to Susan. Josie and Susan discuss the incident and ways Susan can help diffuse similar situations in the future. As with Dr. Welborne, Josie indicates that Susan’s behav- ior was unprofessional and, as the OR charge nurse, she is always expected to act as a nursing professional and role model.

Manager’s Checklist The nurse manager is responsible for:

● Mediating conflict in a timely manner ● Knowing organizational policies and procedures that

support staff decisions ● Allowing open and complete discussion of the

problem ● Actively listening to both participants ● Using assertive communication to facilitate problem

solving

CASE STUDY 9-1

CHAPTER 9 • COMMUNICATING EFFECTIVELY 129

Enhancing Your Communication Skills Communication skills can be learned. Suggestions to improve your communication skills are shown in Table 9-3.

To communicate effectively, first consider your relationship to the receiver (e.g., boss or patient). Then craft your message. Be clear about your goal in your mind so that you can com- municate it appropriately. Then think about what the other person is liable to say and consider how you might respond.

Next decide on the medium. Is this message best conveyed in person, by phone, e-mail, or text? Should you leave a message if the person isn’t available? Note the personal intimacy con- tent earlier in the chapter for guidance.

Timing plays a critical role in successful communication. Catch your boss in the midst of planning for a budget shortfall and you are less apt to get a receptive hearing.

Be prepared when you deliver your message. The best-crafted message, delivered by the appro- priate medium can misfire by a sender who fails to listen carefully, avoids responding out of fear of consequences, or undermines the message with qualifiers, such as “I don’t know if you’re interested.”

(For more information on communicating effectively, see Sullivan, E. J. (2013). Becoming influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall.

What You Know Now • Communication is a complex, ongoing, dynamic process. • How to deliver a message depends on the purpose, the content, and the relationship. • Messages can be distorted or misconstrued. • Gender, generation, cultural background, and the organizational culture influence communication and its

outcome. • Expert communication skills are essential for a leader to be successful. • Communication strategies vary according to the situation and the roles of people involved. • Collaborative communication is challenging, and specific skills can help. • Nurses can enhance their communication skills with effort and practice.

Tools for Communicating Effectively 1. Identify and use the appropriate method (in person, phone, voice mail, text, e-mail, letter) for your

communications. 2. Evaluate your communication skills in various situations. Think of ways to improve. 3. Practice using the skills described in specific situations, such as with your coworkers, the medical

staff, and with patients and their families. 4. Become sensitive to others’ responses, both verbal and nonverbal, and craft your messages

appropriately. 5. Gather feedback and continue to assess the effectiveness of your communications. 6. Strive to improve your communication skills.

Questions to Challenge You 1. Consider a recent interaction you witnessed.

Did the sender express the message clearly? Use the appropriate medium? Listen and respond to questions and comments? What was the outcome?

2. Now think about a recent interaction where you were the sender using the above criteria. If you could replay the interaction, what would you do differently?

3. How well does communication function in your workplace, school, or clinical site? 4. To improve your communication, practice the skills described in the chapter by role playing or

recording yourself (Sullivan, 2013).

130 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

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Trossman, S. (2010). Sharing too much? Nurses nationwide need more information on social networking pitfalls. American Nurse Today, 5(11), 38–39.

Web Resources LegacyMD: http://legacymd.com Silence Kills: The Seven Crucial Conversations in HealthCare:

http://silenttreatmentstudy.com/Silent%20Treatment%20Executive%20Summary.pdf

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

http://www.silencekills.com/UPDL/Si-lenceKillsExecSummary.pdf

http://silenttreatmentstudy.com/Silent%20Treatment%20Executive%20Summary.pdf

www.nursing.pearsonhighered.com

http://www.silencekills.com/UPDL/Si-lenceKillsExecSummary.pdf

http://legacymd.com

CHAPTER

Delegation

Benefits of Delegation BENEFITS TO THE NURSE

BENEFITS TO THE DELEGATE

BENEFITS TO THE MANAGER

BENEFITS TO THE ORGANIZATION

The Five Rights of Delegation

The Delegation Process

Accepting Delegation

Ineffective Delegation ORGANIZATIONAL CULTURE

LACK OF RESOURCES

AN INSECURE DELEGATOR

AN UNWILLING DELEGATE

UNDERDELEGATION

REVERSE DELEGATION

OVERDELEGATION

Delegating Successfully 10

Key Terms Accountability Assignment Authority

Delegation Overdelegation Responsibility

Reverse delegation Underdelegation

1. Describe how delegation involves responsi- bility, accountability, and authority.

2. Describe how effective delegation benefits the delegator, the delegate, the unit, and the organization.

3. Discuss how to be an effective delegator. 4. Identify obstacles that can impede effec-

tive delegation. 5. Explain how liability affects delegation.

Learning Outcomes After completing this chapter, you will be able to:

132 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

Delegation Delegation is the process by which responsibility and authority for performing a task (function, activity, or decision) is transferred to another individual who accepts that authority and responsi- bility. Although the delegator remains accountable for the task, the delegate is also accountable to the delegator for the responsibilities assumed. Delegation can help others to develop or en- hance their skills, promote teamwork, and improve productivity.

It is easy to say delegate, but delegation is a difficult leadership skill for nurses to learn and one that may not be taught in undergraduate education. Given the confusion over what tasks assistive personnel can perform and what are those that are the unique purview of RNs, nurses and nurse managers may be reluctant to delegate. Never before, however, has delegation been as critical a skill for nurses and nurse managers to perfect as it is today, with the emphasis on doing more with less.

The benefits of delegating appropriately are many. (See the next section.) In fact, a leader who models delegation promotes collaboration between nurses and support personnel (Orr, 2010) as well as a positive workplace environment (Standing & Anthony, 2008).

Responsibility, accountability, and authority are concepts related to delegation. Although responsibility and accountability are often used synonymously, the two words represent differ- ent concepts that go hand in hand. Responsibility denotes an obligation to accomplish a task, whereas accountability is accepting ownership for the results or lack thereof. Responsibility can be transferred, but accountability is shared.

You can delegate only those tasks for which you are responsible. If you have no direct respon- sibility for the task, then you can’t delegate that task. For instance, if a manager is responsible for filling holes in the staffing schedule, the manager can delegate this responsibility to another indi- vidual. However, if staffing is the responsibility of a central coordinator, the manager can make suggestions or otherwise assist the staffing coordinator, but cannot delegate the task.

Likewise, if an orderly who is responsible for setting up traction is detained and a nurse asks a physical therapist on the unit to assist with traction, this is not delegation, because setting up traction is not the responsibility of the nurse. However, if the orderly (the person responsible for the task) had asked the physical therapist to help, this could be an act of delegation if the other principles of delegation are met.

Along with responsibility, you must transfer authority. Authority is the right to act. There- fore, by transferring authority, the delegator is empowering the delegate to accomplish the task. Too often this principle of delegation is neglected. Nurses retain authority, crippling the del- egate’s abilities to accomplish the task, setting the individual up for failure, and minimizing efficiency and productivity.

Delegation is often confused with work assignment. Delegation involves transfer of respon- sibility and authority. In assignment no transfer of authority occurs. Instead, assignments are a bureaucratic function that reflect job descriptions and patient or organizational needs. Effective delegation benefits the delegator, the delegate, the manager, and the organization.

Benefits of Delegation

Benefits to the Nurse Nurses also benefit from delegation. If the nurse is able to delegate some tasks to UAPs, more time can be devoted to those tasks that cannot be delegated, especially complex patient care. Thus, patient care is enhanced, the nurse’s job satisfaction increases, and retention is improved.

Nancy, RN, has three central line dressing changes to complete as well as two patients to transfer to another unit before the end of shift in one hour. Nancy delegates the transfer duties to Shelley, LPN, and completes the central line dressing changes.

CHAPTER 10 • DELEGATING SUCCESSFULLY 133

Benefits to the Delegate The delegate also benefits from delegation. The delegate gains new skills and abilities that can facilitate upward mobility. In addition, delegation can bring trust and support, and thereby build self-esteem and confidence. Subsequently, job satisfaction and motivation are enhanced as in- dividuals feel stimulated by new challenges. Morale improves; a sense of pride and belonging develops as well as greater awareness of responsibility. Individuals feel more appreciated and learn to appreciate the roles and responsibilities of others, increasing cooperation and enhancing teamwork.

Benefits to the Manager Delegation also yields benefits for the manager. First, if staff are using UAPs appropriately, the manager will have a better functioning unit. Also the manager may be able to delegate some tasks to staff members and devote more time to management tasks that cannot be delegated. With more time available, the manager can develop new skills and abilities, facilitating the op- portunity for career advancement.

Benefits to the Organization As teamwork improves, the organization benefits by achieving its goals more efficiently. Over- time and absences decrease. Subsequently, productivity increases, and the organization’s finan- cial position may improve. As delegation increases efficiency, the quality of care improves. As quality improves, patient satisfaction increases.

The Five Rights of Delegation Fear of liability often keeps nurses from delegating. State nurse practice acts determine the legal parameters for practice, professional associations set practice standards, and organizational pol- icy and job descriptions define delegation appropriate to the specific work setting. Also guide- lines from the National Council of State Boards of Nursing (NCSBN) can help.

The NCSBN identified the five rights of delegation shown in Table 10-1. In addition, each state board of nursing has its own rules regarding delegation.

● The right task specifies what can be safely delegated to a specific patient. These are com- monly assigned tasks. Tasks that require nursing assessment or judgment should not be delegated (Austin, 2008).

● The right circumstances include an appropriate setting and available resources. Evaluate the patient’s needs and the skills of personnel who could be assigned to meet those specific needs.

● The right person refers to both the delegator and the delegate. The delegator must have the authority and responsibility for the patient’s care and for the task to be assigned. The del- egate must be capable of performing the task and be available to assist. Give the right task to the right person for the right patient.

TABLE 10-1 The Five Rights of Delegation

● Right task ● Right circumstances ● Right person ● Right direction and communication ● Right supervision

National Council of State Boards of Nursing. (2007). The five rights of delegation. Retrieved June 28, 2011 at https://www.ncsbn.org/Joint_statement.pdf

www.ncsbn.org/Joint_statement.pdf

134 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

Is the task consistent with the recommended criteria for delegation to nursing assistive personnel (NAP)?

Are there agency policies, procedures and/or protocols in place for this task/activity?

Is appropriate supervision available?

Proceed with delegation

Does the nursing assistive personnel have the appropriate knowledge, skills and abilities (KSA) to accept the delegation?

Does the ability of the NAP match the care needs of the client?

Is the delegating nurse competent to make delegation decisions?

Has there been assessment of the client needs?

Is the task within the scope of the delegating nurse?

Yes

Are there laws and rules in place that support the delegation?

Do not delegate

Assess client needs then delegate appropriately

Figure 10-1 • Decision tree for delegation to nursing assistive personnel. Source: Adapted from National Council of State Boards of Nursing. (2006). Joint statement on delegation. Retrieved December 2007 from www.ncsbn.org/Joint_ statement.pdf

● The right direction and communication requires the delegator to give clear, concise description of the task as well as describe the objectives, the limits, and the expectations as a result. The delegate should be able to recognize that the patient is responding as expected.

● The right supervision includes monitoring the delegate, evaluating the person’s perfor- mance, giving feedback as required, and intervening if necessary. The delegator remains responsible for the patient’s care regardless of who performs it.

Also the National Council of State Boards of Nursing decision tree can help guide nurses’ decisions about delegation. (See Figure 10-1.)

The Delegation Process The delegation process has five steps as shown in Table 10-2.

1. Define the task. Delegate only an aspect of your own work for which you have responsibil- ity and authority. These include:

• Routine tasks • Tasks for which you do not have time • Tasks that have moved down in priority

www.ncsbn.org/Joint_statement.pdf

CHAPTER 10 • DELEGATING SUCCESSFULLY 135

Define the aspects of the task. Ask yourself:

• Does the task involve technical skills or cognitive abilities? • Are specific qualifications necessary? • Is performance restricted by practice acts, standards, or job descriptions? • How complex is the task? • Is training or education required? • Are the steps well defined, or are creativity and problem solving required? • Would a change in circumstances affect who could perform the task?

While you are trying to define the complexity of the task and its components, it is important not to fall into the trap of thinking no one else is capable of performing this task. Often others can be prepared to perform a task through education and training. The time taken to prepare others can be recouped many times over. Also know well the task to be delegated.

An alternative would be to subdivide the task into component parts and delegate the components congruent with the available delegate’s capabilities. For example, developing a budget is a managerial responsibility that cannot be delegated, but someone else could explore the types of tympanic thermometers on the market, their costs, advantages, and so on. A committee of staff nurses could evaluate the options and make a recommendation that you could include in the budget justification.

But how do you know what should not be delegated? Before a task is delegated, determine what areas of authority and what resources you con-

trol to achieve the expected results. A unit manager who is responsible for maintaining ade- quate supplies needs budget authority. The authority to spend money on supplies, however, may be limited to a specific amount for specific supplies or may be allocated to supplies in general.

Certain tasks should never be delegated. Discipline should not be delegated, nor should a highly technical task. Also any situation that involves confidentiality or controversy should not be delegated to others.

2. Decide on delegate. Match the task to the individual. Analyze individuals’ skill levels and abilities to evaluate their capability to perform the various tasks; also determine charac- teristics that might prevent them from accepting responsibility for the task. Conversely experience and individual characteristics, such as initiative, intelligence, and enthusiasm, can expand the individual’s capabilities. A rule of thumb is to delegate to the lowest person in the hierarchy who has the requisite capabilities and who is allowed to do the task legally and by organizational policy.

Next determine availability. For example, Su Ling might be the best candidate, but she leaves for vacation tomorrow and won’t be back before the project is due. Then ask who would be willing to assume responsibility. Delegation is an agreement that is entered into voluntarily.

3. Determine the task. The next step in delegation is to clearly define your expectations for the delegate. Also plan when to meet. Attempting to delegate in the middle of a crisis is not del- egation; that is directing. Provide for enough time to describe the task and your expectations and to entertain questions. Also, meet in an environment as devoid of distractions as possible.

TABLE 10-2 Delegation Process

1. Define the task. 2. Decide on delegate. 3. Determine the task. 4. Reach agreement. 5. Monitor performance and provide feedback.

136 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

Key behaviors in delegating tasks are shown in Table 10-3

a. Describe the task using “I” statements, such as “I would like . . .” and appropriate non- verbal behaviors—open body language, face-to-face positioning, and eye contact. The delegate needs to know what is expected, when the task should be completed, and where and how, if that is appropriate. The more experienced delegates may be able to define for themselves the where and how. Decide whether written reports are necessary or if brief oral reports are sufficient. If written reports are required, indicate whether tables, charts, or other graphics are necessary. Be specific about reporting times. Identify criti- cal events or milestones that might be reached and brought to your attention. For patient care tasks, determine who has responsibility and authority to chart certain tasks. For ex- ample, UAPs can enter vital signs, but if they observe changes in patient status, the RN must investigate and chart the assessment.

b. Discuss the importance to the organization, you, the patient, and the delegate. Provide the delegate with an incentive for accepting both the responsibility and the authority to do the task.

c. Explain the expected outcome and the timeline for completion. Establish how closely the assignment will be supervised. Monitoring is important because you remain accountable for the task, but controls should never limit an individual’s opportunity to grow.

d. Identify any constraints for completing the task or any conditions that could change. For example, you may ask an assistant to feed a patient for you as long as the patient is coherent and awake, but you might decide to feed the patient if he were confused.

e. Validate understanding of the task and your expectations by eliciting questions and pro- viding feedback.

4. Reach agreement. Once you have outlined your expectations, you must be sure that the delegate agrees to accept responsibility and authority for the task. You need to be prepared to equip the delegate to complete the task successfully. This might mean providing ad- ditional information or resources or informing others about the arrangement as needed to empower the delegate. Before meeting with the individual, anticipate areas of negotiation, and identify what you are prepared and able to provide.

5. Monitor performance and provide feedback. Monitoring performance provides a mecha- nism for feedback and control that ensures that the delegated tasks are carried out as agreed. Give careful thought to monitoring efforts when objectives are established. When defining the task and expectations, clearly establish the where, when, and how. Remain accessible. Support builds confidence and reassures the delegate of your interest in the del- egate and negates any concerns about dumping undesirable tasks.

Monitoring the delegate too closely, however, conveys distrust. Analyze performance with respect to the established goal. If problem areas are identified, privately investigate and explain the problem, provide an opportunity for feedback, and inform the individual how to correct the mistake in the future. Provide additional support as needed. Also, be sure to give the praise and recognition due, and don’t be afraid to do so publicly.

TABLE 10-3 Key Behaviors in Delegating Tasks

● Describe the task using “I” statements. ● Discuss the importance to the organization. ● Explain the expected outcome and timeline for completion. ● Identify any constraints for completing the task. ● Validate understanding of the task and your expectations.

CHAPTER 10 • DELEGATING SUCCESSFULLY 137

Accepting Delegation Accepting delegation means that you accept full responsibility for the outcome and its benefits or liabilities. Just as the delegator has the option to delegate parts of a task, you also have the option to negotiate for those aspects of a task you feel you can accomplish. Recognize, however, that this may be an opportunity for growth. You may decide to capitalize on it, obtaining new skills or resources in the process.

When you accept delegation, you must understand what is being asked of you. First, ac- knowledge the delegator’s confidence in you, but realistically examine whether you have the skills and abilities for the task and the time to do it. If you do not have the skills, you must in- form the delegator. However, it does not mean you cannot accept the responsibility. See whether the person is willing to train or otherwise equip you to accomplish the task. If not, then you need to refuse the offer.

Once you agree on the role and responsibilities you are to assume, make sure you are clear on the time frame, feedback mechanisms, and other expectations. Don’t assume any- thing. As a minimum, repeat to the delegator what you heard said; better yet, outline the task in writing.

Throughout the project, keep the delegator informed. Report any concerns you have as they come up. Foremost, complete the task as agreed. Successful completion can open more doors in the future.

If you are not qualified or do not have the time, do not be afraid to say no. Thank the delega- tor for the offer and clearly explain why you must decline at this time. Express your interest in working together in the future.

See how a school nurse handled delegation in Case Study 10-1.

DELEGATION Lisa Ford is a school nurse for a suburban school district. She has responsibility for three school buildings, includ- ing a middle school, a high school, and a vocational rehabilitation workshop for mentally and physically handicapped secondary students. Her management re- sponsibilities include providing health services for 1,000 students, 60 faculty members, and 25 staff members, as well as supervising two unlicensed school health aides and three special education health aides. The logistics of managing multiple school sites results in the delegation of many daily health room tasks, including medication administration, to the school-based health aides.

Nancy Andrews is an unlicensed health aide at the middle school. This is her first year as a health aide and she has a limited background in health care. The nurse practice act in the state allows for the delega- tion of medication administration in the school setting. Lisa is responsible for training Nancy to safely adminis- ter medication to students, documenting the training, evaluating Nancy’s performance, and providing ongo- ing supervision. Part of Nancy’s training will also include a discussion of those medication-related decisions that must be made by a registered nurse.

Manager’s Checklist The nurse manger is responsible for:

● Understanding the state nurse practice act and its applicability to the school setting

● Implementing school district policies related to health services and medication administration

● Developing and implementing an appropriate train- ing program

● Limiting opportunities for error and decreasing liability by ensuring that unlicensed health aides are appropriately trained to handle delegated tasks

● Maintaining documentation related to training and observing medication administration by unlicensed staff

● Auditing medication administration records to en- sure accuracy and completeness

● Conducting several “drop in” visits during the school year to track competency of health aides

● If necessary, reporting any medication errors to ad- ministration and following up with focused training and closer supervision

CASE STUDY 10-1

138 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

Ineffective Delegation Ineffective delegation results in missed or omitted routine care, such as feeding, turning, am- bulating, and toileting (Bittner & Gravlin, 2009; Gravlin & Bittner, 2010). Poor communica- tion and interpersonal relationship between nurses and unlicensed assistive personnel (UAP) has been found to result in ineffective delegation (Standing & Anthony, 2008).

The RN/UAP unit is a microsystem in health care and when that unit is dysfunctional or functioning at less than optimal performance, the quality of care suffers. One reason for prob- lems with delegation is the assignment of a single UAP to more than one RN. The UAP’s work- load may be more than one person can handle but each nurse may be unaware of the assistant’s overload.

Another reason for ineffective delegation is that nurses define delegation differently (Stand- ing & Anthony, 2008). Some nurses define delegation as explicit instructions to carry out a spe- cific task. Others think that delegation is both specific and implicit in expected tasks, such as ambulating or toileting.

Potential barriers to effective delegation include organizational factors or the delegator’s or delegate’s beliefs or inexperience.

Organizational Culture The culture within the organization may restrict delegation. Hierarchies, management styles, and norms may all preclude delegation. Rigid chains of command and autocratic leadership styles do not facilitate delegation and rarely provide good role models. The norm is to do the work oneself because others are not capable or skilled. An atmosphere of distrust prevails as well as a poor tolerance for mistakes. A norm of crisis management or poorly defined job descriptions or chains of command also impede successful delegation.

Lack of Resources Another difficulty frequently encountered is a lack of resources. For example, there may be no one to whom you can delegate. Consider the sole registered nurse in a skilled nursing facility. If practice acts define a task as one that only a registered nurse can perform, there is no one else to whom that nurse can delegate that task.

Financial constraints also can interfere with delegation. For instance, someone from your department must attend the annual conference in your nursing specialty area. However, the or- ganization will only pay the manager’s travel and conference expenses, which precludes anyone else from attending.

Educational resources may be another limiting factor. Perhaps others could learn how to do a task if they could practice with the equipment, but the equipment or a trainer is not available.

Time can also be a limiting factor. For example, it is Friday, and the schedule needs to be posted on Monday. No one on your staff has experience developing schedules and you need to go out of town for a family emergency, so there is no one else to do the schedule.

An Insecure Delegation The majority of the barriers to delegation arise from the delegator. Reasons people give to fail to delegate include:

“I can do it better.”

“I can do it faster.”

“I’d rather do it myself.”

“I don’t have time to delegate.”

Often underlying these statements are erroneous beliefs, fears, and inexperience in delega- tion. Certainly, the experienced person can do the task better and faster. Indeed, delegation takes

CHAPTER 10 • DELEGATING SUCCESSFULLY 139

time, but failing to delegate is a time waster. Time invested in developing staff today is later repaid many times over.

Common fears are:

● Fear of competition or criticism. What if someone else can do the job better or faster than I? Will I lose my job? Be demoted? What will others think? Will I lose respect and control? This fear is unfounded if the delegator has selected the right task and matched it with the right individual. In fact, the delegate’s success in the task provides evidence of the delegator’s leadership and decision-making abilities.

● Fear of liability. Some individuals are not risk takers and shy away from delegation for this reason. There are risks associated with delegation, but the delegator can minimize these risks by following the steps of delegation. A related concern is a fear of being blamed for the delegate’s mistakes. If the delegator selected the task and delegate appro- priately, then the responsibility for any mistakes made are solely those of the delegate; it is not necessary to take on guilt for another’s mistakes.

Review the five rights of delegation and the decision tree for the National Council of State Boards of Nursing as well as the state’s nurse practice act and the organization’s policies. RNs often fear blame from management if something goes wrong when a task has been delegated to an LPN or UAP, but those fears can be relieved if state law, organi- zational policies, and job descriptions are followed.

● Fear of loss of control. Will I be kept informed? Will the job be done right? How can I be sure? The more one is insecure and inexperienced in delegation, the more this fear is an issue. This is also a predominant concern in individuals who tend toward autocratic styles of leadership and perfectionism. The key to retaining control is to clearly identify the task and expectations and then to monitor progress and provide feedback.

● Fear of overburdening others. They already have so much to do; how can I suggest more? Everyone has work to do. Such a statement belittles the decisional capabilities of others. Recall that delegation is a voluntary, contractual agreement; acceptance of a delegated task indicates the availability and willingness of the delegate to perform the task. Often, the delegate welcomes the diversion and stimulation, and what the delegator perceives as a burden is actually a blessing. The onus is on the delegator to select the right person for the right reason.

● Fear of decreased personal job satisfaction. Because the type of tasks recommended to delegate are those that are familiar and routine, the delegator’s job satisfaction should ac- tually increase with the opportunity to explore new challenges and obtain other skills and abilities.

An Unwilling Delegate Inexperience and fear of failure can motivate a potential delegate to refuse to accept a delegated task. Much reassurance and support are needed. In addition, the delegate should be equipped to handle the task. If proper selection criteria are used and the steps of delegation followed, then the delegate should not fail. The delegator can boost the delegate’s lack of confidence by build- ing on simple tasks. The delegate needs to be reminded that everyone was inexperienced at one time. Another common concern is how mistakes will be handled. When describing the task, the delegator should provide clear guidelines for handling problems, guidelines that adhere to orga- nizational policies.

Another barrier is the individual who avoids responsibility or is overdependent on others. Success breeds success; therefore, it is important to use an enticing incentive to engage the indi- vidual in a simple task that guarantees success.

When the steps of delegation are not followed or barriers remain unresolved, delegation is often ineffective. Inefficient delegation can result from unnecessary duplication, underdelega- tion, reverse delegation, and overdelegation.

140 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

Underdelegation Underdelegation occurs when

● The delegator fails to transfer full authority to the delegate; ● The delegator takes back responsibility for aspects of the task; or ● The delegator fails to equip and direct the delegate.

As a result, the delegate is unable to complete the task, and the delegator must resume re- sponsibility for its completion.

Sharon, RN, is a school nurse with three separate buildings under her direction. UAPs, called health clerks, operate in the school health office when Sharon is at another build- ing. Joye, a first-year health clerk, has had minimal medication administration instruction and experience. During the first week of school, Joye tries to “speed up” the medication administration process and sets out all of the noon medications in individual, unlabeled cups for the students. The cups are rearranged by students trying to find their meds and Joye cannot identify what meds belong to which students. Sharon is called back to the school to administer the correct medications, students are late to class, and Joye is frus- trated that she couldn’t handle the task.

It may be that the RN fears liability or lacks confidence or experience in delegating and decides to do all the tasks rather than delegate to an assistant (Mitty et al., 2010). Conversely, the assistant may not be prepared for the tasks or may not believe the task is within the assistant’s scope of practice. In addition, the assistant may not be able to complete all the tasks, especially if the person is assigned to several nurses.

Reverse Delegation In reverse delegation, someone with a lower rank delegates to someone with more authority.

Thomas is a nurse practitioner for the burn unit. He recently arrived on the unit to find several patients whose dressing changes have not been completed due to a code situa- tion earlier in the morning. Dawn, LPN, asks Thomas to help the staff complete dressing changes before physician rounds begin.

Overdelegation Overdelegation occurs when the delegator loses control over a situation by providing the del- egate with too much authority or too much responsibility. This places the delegator in a risky position, increasing the potential for liability. In this instance, the nurse assumes that any task that doesn’t involve nursing assessment or judgment should be assigned to assistive personnel.

Ellen, GN, is in her sixth week of orientation in the trauma ICU. Her mentor, Dolores, RN, notes that Mr. Anderson is scheduled for an MRI off the unit. Dolores delegates the task of escorting Mr. Anderson to the MRI unit to Ellen who is not ACLS certified. During the MRI, Mr. Anderson is accidentally extubated and suffers respiratory and cardiac ar- rest. A code is called in the MRI suite and ER nurses must respond since an ACLS certified nurse is not with the patient.

Not delegating appropriately negatively affects other staff on the unit as well. Here are two examples:

Sally, RN, always says she “likes to do everything herself” for her patients. She doesn’t like to ask aides for assistance. Her patients are usually happy, but Sally is ex- tremely busy all day and doesn’t ever have time to help a peer RN when asked or answer call lights to help the team. Sally’s peers get frustrated because her lack of delegating

CHAPTER 10 • DELEGATING SUCCESSFULLY 141

appropriate tasks to her nurse’s aide partner makes the aide feel not valued, Sally feels too busy in her job, and her peers feel like they get no help from Sally when needed.

Bridgett, RN, feels that she has spent her time doing aide work while she was in nurs- ing school. Now that she has taken NCLEX boards and is working as a nurse, she won’t help patients to the bathroom or empty a bedpan, or change bed linens. She will call an aide to do these tasks even if she is in the room and has time to do the tasks herself. Bridgett’s inappropriate delegation causes aides to be angry, peer RNs to be frustrated because the aides don’t have time to help them because they are always doing Bridgett’s work, and results in inconsistency in the practice between Bridgett and other nurses, which Bridget’ patients’ notice.

Delegation is a skill that can be learned. Like other skills, successfully delegating requires practice. Sometimes it seems it might be easier to do it yourself. But it is not. Once you learn how to delegate, you will extend your ability to accomplish more by using others’ help.

By delegating appropriately, managers can role model this behavior and teach their staff to do likewise. In addition, it is the best use of their time.

No one in health care today can afford not to delegate.

What You Know Now • Delegation is a contractual agreement in which authority and responsibility for a task is transferred by

the person accountable for the task to another individual. • Delegation benefits the delegator, delegate, the manager, the unit, and the organization.

• The five rights of delegation are the right task, the right circumstances, the right person, the right direction, and the right supervision.

• Delegation involves skill in identifying and determining the task and level of responsibility, deciding who has the requisite skills and abilities, describing expectations clearly, reaching mutual agreement, and monitoring performance and providing feedback.

• Delegatable tasks are personal, routine tasks that the delegator can perform well; that do not involve discipline, highly technical tasks, or confidential information; and that are not controversial.

• To accept delegation, agree on roles and responsibilities, the time frame for completion, feedback mechanisms, and expectations.

• Ineffective delegation can occur with organizational constraints or the delegate’s or delegator’s lack of experience or beliefs.

• Managers can role model appropriate delegation. • Delegation is essential in health care today.

Tools for Delegating Successfully 1. Delegate only tasks for which you have responsibility. 2. Transfer authority when you delegate responsibility. 3. Be sure you follow state regulations, job descriptions, and organizational policies when delegating. 4. Follow the delegation process and key behaviors for delegating described in the chapter. 5. Accept delegation when you are clear about the task, time frame, reporting, and other expectations. 6. Review the five rights of delegation and the NCSBN’s decision tree to delegate appropriately.

Questions to Challenge You 1. Review your state’s nurse practice act. How is delegation defined? What tasks can and cannot be

delegated? How is supervision defined? Are there any other guidelines for supervision? Are respon- sibilities regarding advanced practice delineated? How does the scope of practice differ between registered and licensed practical/vocational nurses? What is the scope of practice of other health care providers?

2. What are your organization’s policies on delegation?

142 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

Austin, S. (2008). 7 legal tips for safe nursing practice. Nursing 2008, 38(3), 34–39.

Bittner, N. P., & Gravlin, G. (2009). Critical thinking, delegation, and missed care in nursing practice. Journal of Nursing Administration, 39(3), 142–146.

Gravlin, G., & Bittner, N. P. (2010). Nurses’ and nursing assistants’ reports of missed care and delegation. Journal

of Nursing Administration, 40(7/8), 329–335.

Mitty, E., Resnick, B., Bakerjian, D., Gardner, W., Rainbard, S., Mezey, M. (2010). Nursing delegation and medication administration in assisted living. Nursing Administration Quarterly, 34(2), 162–171.

National Council of State Boards of Nursing. (2007). The five rights of delegation. Retrieved June 28, 2011 at

https://www.ncsbn.org/ Joint_statement.pdf

Orr, S. E. (2010). Characteristics of positive working rela- tionships between nursing and support service em- ployees. Journal of Nurs- ing Administration, 40(3), 129–134.

Standing, T. S., & Anthony, M. K. (2008). Delegation: What it means to acute care nurses. Applied Nursing Research, 21(1), 8–14.

3. Describe a situation when you delegated a task to someone else. Did you follow the steps of delega- tion explained in the chapter? Was the outcome positive? If not, what went wrong?

4. Describe a situation when someone else delegated a task to you. Did your delegator explain what to do? Did you receive too much information? Not enough? Was supervision appropriate to the task and to your abilities? What was the outcome?

References

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

https://www.ncsbn.org/Joint_statement.pdf

www.nursing.pearsonhighered.com

CHAPTER

Groups and Teams

Group and Team Processes NORMS

ROLES

Building Teams ASSESSMENT

TEAM-BUILDING ACTIVITIES

Managing Teams TASK

GROUP SIZE AND COMPOSITION

PRODUCTIVITY AND COHESIVENESS

DEVELOPMENT AND GROWTH

SHARED GOVERNANCE

The Nurse Manager as Team Leader

COMMUNICATION

EVALUATING TEAM PERFORMANCE

Leading Committees and Task Forces

GUIDELINES FOR CONDUCTING MEETINGS

MANAGING TASK FORCES

Patient Care Conferences

Building and Managing Teams 11

1. Describe how groups and teams function. 2. Differentiate between team building and man-

aging teams. 3. Describe various methods of team

building.

Learning Outcomes After completing this chapter, you will be able to:

4. Discuss factors that influence team management. 5. Explain why the nurse manager’s leadership

skills are essential to team performance. 6. Discuss how to lead groups, task forces, and

patient care conferences.

Key Terms Additive task Adjourning Clinical ladder Cohesiveness Committees or task

forces Competing groups Conjunctive task Disjunctive task Divisible task Formal committees Formal groups

Forming Group Hidden agendas Informal committees Informal groups Norming Norms Ordinary interacting

groups Performing Pooled interdependence Productivity

Real (command) groups Reciprocal interdependence Re-forming Role Sequential interdependence Status Status incongruence Storming Task forces Task group Team building Teams

144 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

M ost often, nursing occurs in a team environment. Work groups that share common objectives function in a harmonious, coordinated, purposeful manner as teams. The staff nurse is constantly involved in teamwork. The nurse/aide/unit secretary team works together every day on a nursing unit. With shared governance more often the norm and interprofessional team work common, the nurse may participate or lead a team broader in scale than one unit. For example, a nurse might lead the acute care practice council or be on a team to implement supplies at the bedside.

High-performance teams require expert leadership skills. In a health care delivery system integrated across settings, a team environment becomes increasingly essential. Nurse managers must skillfully orchestrate the activity and interactions of interprofessional teams as well as con- ventional nursing work groups. Understanding the nature of groups and how groups are trans- formed into teams is essential for the nurse to be effective.

Groups and Teams A group is an aggregate of individuals who interact and mutually influence each other. Both formal and informal groups exist in organizations. Formal groups are clusters of individuals designated temporarily or permanently by an organization to perform specified organizational tasks. Formal groups may be structured laterally, vertically, or diagonally. Task groups, teams, task forces, and committees may be structured in all of these ways, whereas command groups generally are structured vertically.

Group members include:

● Individuals from a single work group (e.g., nurses on one unit) or individuals at similar job levels from more than one work group (e.g., all professional staff)

● Individuals from different job levels (e.g., nurses and UAPs) ● Individuals from different work groups and different job levels in the organization

(e.g., committee to review staff orientation classes)

Groups may be permanent or temporary. Command groups, teams, and committees usually are permanent, whereas task groups and task forces are often temporary.

Informal groups evolve naturally from social interactions. Groups are informal in the sense that they are not defined by an organizational structure. Examples of informal groups include individuals who regularly eat lunch together or who convene spontaneously to discuss a clinical dilemma.

Real (command) groups accomplish tasks in organizations and are recognized as a legitimate organizational entity. Its members are interdependent, share a set of norms, generally differentiate roles and duties among themselves, are organized to achieve ongoing organizational goals, and are collectively held responsible for measurable outcomes.

The group’s manager has line authority in relation to group members individually and col- lectively. The group’s assignments are usually routine and designed to fulfill the specific mission of the agency or organization. The regularly assigned staff who work together under the direction of a single manager constitute a command group.

A task group is composed of several persons who work together, with or without a desig- nated leader, and are charged with accomplishing specific time-limited assignments. A group of nurses selected by their colleagues to plan an orientation program for new staff constitute a task group. Usually, several task groups exist within a service area and may include representatives from several disciplines (e.g., nurse, physician, dietitian, social worker).

Other special groups include committees or task forces formed to deal with specific issues involving several service areas. A committee responsible for monitoring and improving patient safety or a task force assigned to develop procedures to adhere to patient privacy regulations are examples of special work groups.

Health care organizations depend on numerous committees, which nurses participate in and often lead. Some of these committees are mandated by accrediting and regulatory

CHAPTER 11 • BUILDING AND MANAGING TEAMS 145

bodies, such as committees for education, standards, disaster, and patient care evaluation. Others are established to meet a specific need (e.g., to formulate a new policy on substance abuse).

Teams are real groups in which individuals must work cooperatively with each other in order to achieve some overarching goal. Teams have command or line authority to perform tasks, and membership is based on the specific skills required to accomplish the tasks. Similar to groups described above, teams may include individuals from a single work group or individuals at similar job levels from more than one work group, individuals from different job levels, or in- dividuals from different work groups and different job levels in the organization. They may have a short life span or exist indefinitely.

Metropolitan Hospital has established a clinical ladder system for nursing staff. Each quarter, members of the clinical excellence committee meet to review applications from staff nurses who are seeking promotion to the next clinical ladder level. The committee is made up of staff nurses and nurse managers from each service line. Each applicant is responsible for completing a comprehensive application. The committee members evalu- ate each application and make recommendations to the vice president for patient care on those nurses who should be considered for promotion.

Not all work groups, however, are teams. For example, groups of individuals who perform their tasks independently of each other are not teams. Competing groups, in which members compete with each other for resources to perform their tasks or compete for recognition, are also not teams.

A work group becomes a team when the individuals must apply group process skills to achieve specific results. They must exchange ideas, coordinate work activities, and develop an understanding of other team members’ roles in order to perform effectively. Members appreciate the talents and contributions of each individual on the team and find ways to capital- ize on them. Most work teams have a leader who maintains the integrity of the team’s function and guides the team’s activities, performance, and development. Teams may be self-directed, that is, led jointly by group members who decide together about work objectives and activities on an ongoing basis.

In a given service area, the entire staff might not function as a team, but a subgroup may. For example, case managers for the inpatient and ambulatory cystic fibrosis population in a chil- dren’s medical center might be called a team. Individual members of an interdisciplinary team, such as this one, may report formally to different managers, but in delivering care to the cystic fibrosis population there is no designated individual in charge. In meetings, the team members discuss clients’ problems and jointly decide on plans of action.

Many different types of groups and teams are used throughout organizations. Examples are ad hoc task groups, quality improvement teams, quality circles, self-directed work teams, shared governance councils, and focus groups.

Nurse managers at a large university hospital are responsible for educating their staff about patient satisfaction. Patient satisfaction surveys are sent to randomly selected pa- tients. Results are compiled, and each department receives a detailed report of the results. Staff members review the data at monthly staff meetings, using both positive and negative comments to guide their patient care activities. As needed, department standards and pro- tocols are updated to reflect improved processes.

Most groups are considered ordinary interacting groups. These groups usually have a des- ignated formal leader, but they may be leaderless. Most work teams, task groups, and commit- tees are ordinary interacting groups. Discussions usually begin with a statement of the problem by the group leader followed by an open, unstructured conversation. Normally, the final deci- sion is made by consensus (without formal voting; members indicate concurrence with a group agreement that everyone can live with and support publicly). The decision may also be made by the leader or someone in authority, majority vote, an average of members’ opinions, minority

146 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

control, or an expert member. Interacting groups enhance the cohesiveness and esprit de corps among group members. Participants are able to build strong social ties and will be committed to the solution decided on by the group.

Infection control nurses have been tracking occurrences of MRSA infections among patients in their hospital system. In addition to implementing patient care protocols as recommended by federal and state infectious disease agencies, the nurses track compliance in high-risk units and tailor education programs to meet the needs of nursing and assistive staffs.

Ordinary interacting groups, however, may be dominated by one or a few members. If the group is highly cohesive, its decision-making ability may be affected by groupthink (dis- cussed in Chapter 8). Groupthink results in pressure for every member to conform, usually to the leader’s beliefs, even to violating personal norms.

Sometimes groups spend excessive time dealing with socioemotional relationships, reducing the time spent on the problem and slowing consensus. Ordinary groups may reach compromise decisions that may not really satisfy any of the participants. Because of these problems, the func- tioning of ordinary groups is dependent on the leader’s skills.

Each type of group presents unique opportunities and challenges. An important role of the nurse manager is to link service areas with groups at higher levels in the organization. This link facilitates problem solving, coordination, and communication throughout the organization. Leadership roles in work groups are important and may also be either formal or informal. For example, the nurse manager formally leads the unit or service area staff but may also informally lead a support group of nurse managers.

The leader’s influence on group processes, formal or informal, and the ability of the group to work together as a team often determine whether the group accomplishes its goals. Nurse manag- ers may effectively manage work groups and turn them into teams by understanding principles of group processes and applying them to group decision making, team building, and leading com- mittees and task forces.

Group and Team Processes The modified version of Homans’s (1950, 1961) social system conceptual scheme presented in Figure 11-1 provides a framework for understanding group inputs, processes, and outcomes. The schematic depicts the effects of organizational and individual background factors on group leadership, including dynamics (tasks, activities, interactions, attitudes) and processes (forming, storming, norming, performing, adjourning). Elements of the required group system and pro- cesses influence each other and the emergent group system and social structure.

This system determines the productivity of the group as well as members’ quality of work life, such as job satisfaction, development, growth, and similarity in thinking. The framework distinguishes required factors that are imposed by the external system from factors that emerge from the internal dynamics of the group.

According to Homans’s framework, the three essential elements of a group system are activities, interactions, and attitudes. Activities are the observable behaviors of group members. Interactions are the verbal or nonverbal exchanges of words or objects among two or more group members. Attitudes are the perceptions, feelings, and values held by individual group members, which may be both positive and negative. To understand and guide group functioning, a manager should analyze the activities, interactions, and attitudes of work group members.

Homans’s framework indicates that background factors, the manager’s leadership style, and the organizational system influence the normal development of the group. Groups, whether formal or informal, typically develop in these phases: form, storm, norm, perform, and adjourn or re-form. In the initial stage, forming, individuals assemble into a well-defined cluster. Group members are cautious in approaching each other as they come together as a group and begin to understand requirements of group membership. At this stage, the members often depend on a leader to define purpose, tasks, and roles.

CHAPTER 11 • BUILDING AND MANAGING TEAMS 147

As the group begins to develop, storming occurs. Members wrestle with roles and relation- ships. Conflict, dissatisfaction, and competition arise on important issues related to procedures and behavior. During this stage, members often compete for power and status, and informal leadership emerges. During the storming stage, the leader helps the group to acknowledge the conflict and to resolve it in a win–win manner.

In the third stage, norming, the group defines its goals and rules of behavior. The group determines what are or are not acceptable behaviors and attitudes. The group structure, roles, and relationships become clearer. Cohesiveness develops. The leader explains standards of per- formance and behavior, defines the group’s structure, and facilitates relationship building.

In the fourth stage, performing, members agree on basic purposes and activities and carry out the work. The group’s energy becomes task-oriented. Cooperation improves, and emotional issues subside. Members communicate effectively and interact in a relaxed atmosphere of sharing. The leader provides feedback on the quality and quantity of work, praises achievement, critiques poor work and takes steps to improve it, and reinforces interpersonal relationships within the group.

The fifth stage is either adjourning (the group dissolves after achieving its objectives) or re-forming, when some major change takes place in the environment or in the composition or goals of the group that requires the group to refocus its activities and recycle through the four stages. When a group adjourns, the leader must prepare group members for dissolution and facil- itate closure through celebration of success and leave-taking. If the group is to refocus its activi- ties, the leader will explain the new direction and provide guidance in the process of re-forming.

Norms Norms are the informal rules of behavior shared and enforced by group members. Norms emerge whenever humans interact. Groups develop norms that members believe must be adhered to for fruitful, stable group functioning. Nursing groups often establish norms related to how members

Feedback

Required system

Tasks Activities Interactions Attitudes

Group processes

Form Storm Norm Perform Adjourn/Re-form

Consequences

Productivity Satisfaction Development Conflict Groupthink

Background factors

Organizational requirements External status Personal characteristics

Leadership style

AffectAffect

Affect

Results in

Affect

Influence

Emergent group system

Activities Interactions Sentiments Roles Status Communication

Norms

Figure 11-1 • Conceptual scheme of a basic social system. Source: Adapted from Homans, G. (1950). The human group. New York: Harcourt Brace Jovanovich; and Homans, G. (1961). Social behavior: Its elementary forms. New York: Harcourt Brace. By permission of Transaction Publishers.

148 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

deal with absences that affect the workload of colleagues. Norms may include not calling in sick on weekends, readily accommodating requests for trading shifts, and returning from breaks in a timely manner. In a team environment, norms are more likely to be linked to each team member’s expected contribution to the performance and products of the team’s efforts. If an individual agrees to take on a specific assignment on the team’s behalf and fails to complete the assignment on time, a group norm has been violated.

Group norms are likely to be enforced if they serve to facilitate group survival, ensure predict- ability of behavior, help avoid embarrassing interpersonal problems, express the central values of the group, and clarify the group’s distinctive identity.

Groups go through several stages in enforcing norms with deviant members. First, members use rational argument or present reasons for adhering to the norms to the deviant individual. Second, if rational argument is not effective, members may use persuasive or manipulative tech- niques, reminding the deviant of the value of the group. The third stage is attack. Attacks may be verbal or even physical and sometimes include sabotaging the deviant’s work. The final stage is ignoring the deviant.

It becomes increasingly difficult for a deviant to acquiesce to the group as these strategies escalate. Agreeing to rational argument is easy, but agreeing after an attack is difficult. When the final stage (ignoring) is reached, acquiescence may be impossible because group members refuse to acknowledge the deviant’s surrender. A nurse manager has a responsibility to help groups deal with members who violate group norms related to performance, including counsel- ing the employee and preventing destructive conflict.

Roles Norms apply to all group members, whereas roles are specific to positions in the group. A role is a set of expected behaviors that fit together into a unified whole and are characteristic of persons in a given context. Roles commonly seen in groups can be classified as either task roles or socioemotional (nurturing) roles. Often, individuals fill several roles. Individuals performing task roles attempt to keep the group focused on its goals.

Task roles include:

● Initiator–contributor. Redefines problems and offers solutions, clarifies objectives, suggests agenda items, and maintains time limits

● Information seeker. Pursues descriptive bases for the group’s work ● Information giver. Expands information given by sharing experiences and making

inferences ● Opinion seeker. Explores viewpoints that clarify or reflect the values of other members’

suggestions ● Opinion giver. Conveys to group members what their pertinent values should be ● Elaborator. Predicts outcomes and provides illustrations or expands suggestions,

clarifying how they could work ● Coordinator. Links ideas or suggestions offered by others ● Orienter. Summarizes the group’s discussions and actions ● Evaluator-critic. Appraises the quantity and quality of the group’s accomplishments

against set standards ● Energizer. Motivates group to accomplish, qualitatively and quantitatively, the group’s

goals ● Procedural technician. Supports group activity by arranging the environment

(e.g., scheduling meeting room) and providing necessary tools (e.g., ordering visual equipment)

● Recorder. Documents the group’s actions and achievements

Nurturing roles facilitate the growth and maintenance of the group. Individuals assuming these roles are concerned with group functioning and interpersonal needs.

CHAPTER 11 • BUILDING AND MANAGING TEAMS 149

Nurturing roles include:

● Encourager. Compliments members for their opinions and contributions to the group ● Harmonizer. Relieves tension and conflict ● Compromiser. Suppresses own position to maintain group harmony ● Gatekeeper. Encourages all group members to communicate and participate ● Group observer. Takes note of group processes and dynamics and informs group

of them ● Follower. Passively attends meetings, listens to discussions, and accepts group’s

decisions

Status is the social ranking of individuals relative to others in a group based on the position they occupy. Status comes from factors the group values, such as achievement, personal char- acteristics, the ability to control rewards, or the ability to control information. Status is usually enjoyed by members who most conform to group norms. Higher-status members often exercise more influence in group decisions than others.

Status incongruence occurs when factors associated with group status are not congruent, such as when a younger, less experienced person becomes the group leader. Status incongru- ence can have a disruptive impact on a group. For example, isolates are members who have high external status and different backgrounds from regular group members. They usually work at acceptable levels but are isolated from the group because they do not fit the group member profile. Sometimes status incongruence occurs because the individual does not need the group’s approval and makes no effort to obtain it.

The most important role in a group is the leadership role. Leaders are appointed for most formal groups, such as command groups, teams, committees, or task forces. Leaders in informal groups tend to emerge over time and in relation to the task to be performed. Some of the factors contributing to the emergence of leadership in small groups include the ability to accomplish the group’s goals, sociability, good communication skills, self-confidence, and a desire for recognition. Guidelines for performing this leadership role are discussed later in this chapter.

Building Teams Team building focuses on both task and relationship aspects of a group’s functioning and is intended to increase efficiency and productivity. The group’s work and problem-solving proce- dures, member–member relations, and leadership are analyzed, and exercises are prescribed to help members modify their patterns of interaction or processes of decision making.

Assessment The most important initial activities in team building are data gathering and diagnosis. Questions must be asked about the group’s context (organizational structure, climate, culture, mission, and goals); characteristics of the group’s work, including group members’ roles, styles, procedures, job complexity; and the team, its problem-solving style, interpersonal relationships, and relations with other groups.

The following questions may be asked:

1. To what extent do the team’s members understand and accept the goals of the organization?

2. What, if any, hidden agendas interfere with the group’s performance? Hidden agendas are members’ individual unspoken objectives that interfere with commitment or enthusiasm.

3. How effective is the group’s leadership?

4. To what extent do group members understand and accept their roles?

5. How does the group make decisions?

150 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

6. How does the group handle conflict? Are conflicts dealt with through avoidance, forcing, accommodating, compromising, competing, or collaborating?

7. What personal feelings do members have about each other?

8. To what extent do members trust and respect each other?

9. What is the relationship between the team and other units in the organization?

Only after assessing and diagnosing problems can the leader take actions to improve team functioning (Hill, 2010).

Team-Building Activities Team-building activities, originally designed to improve interpersonal workplace relation- ships, have expanded to include meeting goals and accomplishing tasks (Salas et al., 2008). A recent study found that female students in medicine and nursing were more open-minded about cooperating with other health professions than were male medical or nursing students (Wilhelmsson et al., 2011). This is positive news for those involved in team building with women, less so with male participants.

Training sessions for team-building can be effective in helping participants acquire skills, but the results are short-lived if the skills are not reinforced on the job. To effectively maintain the team performance, learned behaviors should be measured and rewarded (Salas et al., 2008).

Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is a program developed by the Department of Defense and the Agency for Healthcare Research and Quality (AHRQ) to integrate teamwork into practice (Henriksen et al., 2008; King et al., 2008). TeamSTEPPS involves three phases:

● Assessing the need ● Training onsite ● Implementing and sustaining training

McKeon, Cunningham, and Detty Oswaks (2009) tested TeamSTEPPS in a health care set- ting and found that these safety-oriented skills can be taught and that nurses can learn to practice and evaluate high-reliability behaviors in practice.

Simulation-based training can also be used for team building (Rosen et al., 2008). Partic- ipants act out a simulated incident, receive feedback on their performance, and repeat the performance incorporating the learned behaviors. The program, LegacyMD (mentioned in Chapter 9) is an example (see Web resources for the URL). Rosen and colleagues (2008) found quality measures improved after simulation training.

Thoughtful team-building strategies allow group members to acknowledge the developmen- tal process and respond to it in constructive ways. Team-building activities may also be used to facilitate the normal stages of group development (forming, storming, norming, performing, and adjourning or re-forming), an important process in managing teams.

In traditional work groups experiencing problems, team-building strategies may help improve performance. Numerous techniques and commercial resources are available.

A nurse manager may decide to assume personal responsibility for team building when the team is basically functional and simply needs some fine-tuning to deal more effectively with minor interpersonal issues or changing circumstances.

Managing Teams Managing teams differs from team building and depends on the task, group size and composition, productivity and cohesiveness, the group’s development and growth, and the extent of shared governance in the organization.

CHAPTER 11 • BUILDING AND MANAGING TEAMS 151

Task The size of the group can influence its effectiveness, depending on the type of task: additive, disjunctive, divisible, or conjunctive (Steiner, 1972, 1976). The more people who work on an additive task (group performance depends on the sum of individual performance), the more inputs are available to produce a favorable result. For example, the game tug-of-war involves the combined effort of the team.

For a disjunctive task (the group succeeds if one member succeeds), the greater the number of people, the higher the probability that one group member will solve the problem. Consider the Olympics. The more athletes on one team, the greater the opportunity for a gold medal. Regard- less of the event, a medalist from the United States team brings recognition to the country, and every citizen is able to share the honor.

With a divisible task (tasks that can break down into subtasks with division of labor), more people provide a greater opportunity for specialization and interdependence in performing the tasks. For instance, the construction of a car is a complex task. From design of the car to inser- tion of the last bolt, each individual involved has a specialized task. With a conjunctive task (the group succeeds only if all members succeed), more people increase the likelihood that one person can slow up the group’s performance (e.g., a jury trial).

On many tasks, interdependence is important. There are three kinds:

● Pooled interdependence, in which each individual contributes but no one contribution is dependent on any other (e.g., a committee discussion)

● Sequential interdependence, in which group members must coordinate their activities with others in some designated order (e.g., an assembly line)

● Reciprocal interdependence, in which members must coordinate their activities with every other individual in the group (e.g., team nursing)

Group Size and Composition Groups with 5 to 10 members tend to be optimal for most complex organizational tasks, which require diversity in knowledge, skills, and attitudes and allow full participation. In larger groups, members tend to contribute less of their individual potential while the leader is called on to take more corrective action, do more role clarification, manage more disruption, and make recogni- tion more explicit. Groups tend to perform better with competent individuals as members. How- ever, coordination of effort and proper utilization of abilities and task strategies must occur as well. Homogeneous groups tend to function more harmoniously, whereas heterogeneous groups may experience considerable conflict.

Productivity and Cohesiveness Productivity represents how well the work group or team uses the resources available to achieve its goals and produce its services. If patient care is satisfactorily completed at the end of each shift in relation to the levels of staffing, supplies, equipment, and support services used, the group has been productive. Productivity is influenced by work-group dynamics, especially a group’s cohesiveness and collaboration.

Cohesiveness is the degree to which the members are attracted to the group and how much they are willing to contribute. Cohesiveness is also related to homogeneity of interests, values, attitudes, and background factors. Strong group cohesiveness leads to a feeling of “we” as more important than “I” and ensures a higher degree of cooperation and interpersonal support among group members.

Group norms may support or subvert organizational objectives, depending on the level of group cohesiveness. High group cohesiveness may foster high or low individual performance, depending on the prevailing group norms for performance. When cohesiveness is low, productiv- ity may vary significantly. Although groups, in general, tend toward lower productivity, nursing

152 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

education and practice have especially high standards of performance that help to counter this tendency.

Groups are more likely to become cohesive when members:

● Share similar values and beliefs ● Are motivated by the same goals and tasks ● Must interact to achieve their goals and tasks ● Work in proximity to each other (on the same unit and on the same shift, for example) ● Have specific needs that can be satisfied by involvement in the group

Group cohesiveness is also influenced by the formal reward system. Groups tend to be more cohesive when group members receive comparable treatment and pay and perform similar tasks that require interaction among the members. Similarities in values, education, social class, gen- der, age, and ethnicity that lead to similar attitudes strengthen group cohesiveness.

Cohesiveness can produce intense social pressure. Highly cohesive groups can demand and enforce adherence to norms regardless of their practicality or effectiveness. In this circumstance, the nurse manager may have a difficult time influencing individual nurses, especially if the group norms deviate from the manager’s values or expectations. For example, operating room nurses may be used to arriving at the time their shift starts and then changing into scrubs. The nurse manager, in contrast, may expect the staff to be changed and ready for work by the time the shift starts. In addition, group dynamics can affect absenteeism and turnover. Groups with high levels of cohesiveness exhibit lower turnover and absenteeism than groups with low levels of cohesiveness.

For most individuals, the work group provides one of the most important social contacts in life; the experience of working on an effective work team contributes significantly to one’s pro- fessional confidence and to the quality of work life and job satisfaction. The work group often provides the primary motivation for returning to the job day after day even when employees are dissatisfied with the employing organization or other working conditions.

Work groups not only perform tasks but also provide the context in which novices learn basic skills and become socialized and experts engage in clinical mentorship, standard setting, quality improvement, and innovation. Work-group relations influence the satisfaction of staff with their jobs, the overall quality of work life, and the quality of the environment for patient care. Managers play key roles in guiding the tasks of work groups and ensuring efficient and effective performance; managers also encourage relationships among members of work teams that will promote coordination and cooperation.

Development and Growth Groups can also provide learning opportunities by increasing individual skills or abilities. The group may facilitate socialization of new employees into the organization by “showing them the ropes.” The nurse manager must establish an atmosphere that encourages learning new skills and knowledge, creating a group-oriented learning environment by continuously encouraging group members to improve their technical and interpersonal skills and knowledge through training and development. Group cohesiveness and effectiveness improve as staff members take responsibil- ity for teaching each other and jointly seeking new information or techniques.

Shared Governance Shared decision making is a hallmark of shared governance. That is, both managers and staff members participate in making decisions. Such participation can improve collaboration, staff retention, job satisfaction, productivity, and patient outcomes. Measuring the distribution of con- trol, influence, power, and authority, Hess (2011) found that managers perceived staff to have more power in making decisions than staff perceived that they did. Workload issues offered op- portunities for shared decision making in another study (MacPhee, Wardrop, & Campbell, 2010).

CHAPTER 11 • BUILDING AND MANAGING TEAMS 153

As a requirement for Magnet certification, shared governance increases staff involvement in the organization’s functioning and future planning and, at the same time, increases staff allegiance to the organization.

The Nurse Manager as Team Leader Because staff nurses work in close proximity and frequently depend on each other to perform their work, the nurse manager’s leadership is vital. A positive climate is one in which there is mutual high regard and in which group members safely may discuss work-related concerns, critique and offer suggestions about clinical practice, and comfortably experiment with new behaviors. Maintaining a positive work group climate and building a team is a complex and demanding leadership task.

Communication Communication is a central component of the nurse manager’s leadership. The Joint Commis- sion, the organization that accredits hospitals, found that poor interprofessional communication was the cause of nearly 70 percent of unexpected events causing death or serious injury (Joint Commission, 2011).

Effective nurse managers can facilitate communication in groups by maintaining an atmo- sphere in which group members feel free to discuss concerns, make suggestions, critique ideas, and show respect and trust. An important leadership function related to communication is gatekeeping, that is, keeping communication channels open, refocusing attention on critical issues, identifying and processing conflict, fostering self-esteem, checking for understanding, actively seeking the participation of all group members, and suggesting procedures for discussing group problems.

The manager’s communication style also affects group cohesiveness. If the manager main- tains a high degree of information power and controls not only what information is received but also who receives it, group performance may suffer. By interrupting, changing the subject, monopolizing the conversation, or ignoring the feedback, problems escalate and the leader re- mains uninformed and both individuals in the group and the group’s ability to function suffer.

If, on the other hand, the manager shares information freely, encourages a high degree of mutual communication and participative problem solving, performance and job satisfaction improves. In participative groups, each individual has the opportunity, and is encouraged, to seek and share information and to communicate frequently with anyone and everyone in the group. Managers and staff alike check with each other to ensure that information is clear, to offer suggestions, and to provide feedback.

Handling conflict (Chapter 12) and change management (Chapter 5) are essential manage- ment skills as well (MacPhee & Bouthillette, 2008).

Evaluating Team Performance The manager may be accustomed to evaluating individual performance, but evaluating how well a team performs requires different assessments. Patient outcomes and team functioning are the criteria by which teams can be evaluated (Rosen et al., 2008). Outcome data, such as clinical pathway information, variances in critical paths, complication rates, falls, and medication errors, can help evaluate team performance.

Group functioning can be assessed by the level of work-group cohesion, involvement in the job, and willingness to help each other. Conversely aggression, competition, hostility, aloofness, shaming, or blaming are characteristics of poorly functioning groups. Stability of members is an additional measure of group functioning.

Influencing team processes toward the attainment of organizational objectives is the direct responsibility of the nurse manager. By publicizing team accomplishments, creating opportuni- ties for team members to demonstrate new skills, and supporting social activities, the manager

154 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

can increase the perceived value of group membership. Members of groups who have a history of success are attracted to each other more than those who have not been successful.

See how one nurse handled his new assignment as manager for an interprofessional team in Case Study 11-1.

Leading Committees and Task Forces Committees are generally permanent and deal with recurring problems. Membership on com- mittees is usually determined by organizational position and role. Formal committees are part of the organization and have authority as well as a specific role. Informal committees are pri- marily for discussion and have no delegated authority. Task forces are ad hoc committees ap- pointed for a specific purpose and a limited time. Task forces work on problems or projects that cannot be readily handled by the organization through its normal activities and structures. Task forces often deal with problems crossing departmental boundaries. They tend to generate recom- mendations and then disband.

Nurses are often selected for leadership roles on committees and task forces. In these leader- ship roles and as unit managers and team leaders, they conduct numerous meetings. The follow- ing section provides guidance for leading and conducting meetings.

INTRODUCING MULTIDISCIPLINARY TEAMS Bruce Shapiro was promoted six months ago to nurse manager for the stroke rehabilitation unit of a nationally owned rehabilitation hospital. Patient care delivery sys- tems have been under intensive review at the corporate level, and major changes in staffing are underway. Previ- ously, physical and occupational therapists were staffed out of a separate department and reported to the direc- tor of physical therapy. Now all therapists will be unit based and report to the nurse manager. Documentation will now be team centered instead of being split among nursing, therapists, and other care providers.

Janice Simpson has been a physical therapist for 25 years and has been at the rehab hospital for the past 6 years. She worked as a shift leader for physical therapy until the new unit-based staffing was implemented. Janice has been assigned to the stroke rehab unit and will report to Bruce. She feels uncomfortable in her new role and is concerned about how she will fit in with the established nursing staff. Janice is also concerned that with the new documentation system, the physical therapy patient evaluations will not be included in determining patient goals.

Bruce is eager for Janice to join the staff of the stroke rehabilitation unit. He schedules individual meetings with Janice and the three other therapists who will be assigned to his unit. Bruce outlines the roles and expec- tations of staff on the unit and listens attentively to their questions and concerns. He also reviews the physical and occupational therapy job descriptions and reviews their respective documentation standards. At the monthly

staff meeting, Bruce discusses the roles and responsibili- ties of the therapists with the nursing staff. A mentor is assigned to meet daily with each therapist for their first two weeks on the unit.

Manager’s Checklist The nurse manager is responsible for:

● Understanding the new staffing policies and the impact on the unit

● Gaining knowledge related to physical and occupational therapy practice

● Easing the transition of new staff into the existing staff group and helping build trust and respect

● Educating all staff on the new staffing policies ● Ensuring that all therapists and nurses attend

mandatory documentation training and audit patient records for compliance with new documentation standards

● Communicating with human resources if there are any questions regarding performance evaluation, scheduling, or compensation

● Reviewing the personnel files of new staff ● Establishing roles for the therapists in the unit

governance structure ● Facilitating open communication with therapists

and nurses to discuss concerns or suggestions ● Providing appropriate feedback to nursing

management related to the new staffing changes

CASE STUDY 11-1

CHAPTER 11 • BUILDING AND MANAGING TEAMS 155

Guidelines for Conducting Meetings Although meetings are vital to the conduct of organizational work, they should be held princi- pally for problem solving, decision making, and enhancing working relationships. Other uses of meetings, such as socializing, giving or clarifying information, or soliciting suggestions must be thoroughly justified. Meetings should be conducted efficiently and should result in relevant and meaningful outcomes. Meetings should not result in damaged interpersonal relations, frustration, or inconclusiveness.

Preparation The first key to a successful meeting is thorough preparation. Preparation includes clearly defining the purpose of the meeting. The leader should prepare an agenda, determine who should attend, make assignments, distribute relevant material, arrange for recording of minutes, and select an appropriate time and place for the meeting. The agenda should be distributed well ahead of time, 7 to 10 days prior to the meeting, and it should include what topics will be cov- ered, who will be responsible for each topic, what prework should be done, what outcomes are expected in relation to each topic, and how much time will be allotted for each topic.

Sometimes a “meeting before the meeting” is advisable (Sullivan, 2013). This is especially important if you are going into a meeting where you expect dissension. It may involve simply chatting with a few key people to identify any problems or issues they expect, or you may need to actually sit down with a key decision maker who has veto power. Also asking people you expect might have opposing points of view their opinion might be helpful as well.

Participation In general, the meeting should include the fewest number of stakeholders who can actively and effectively participate in decision making, who have the skills and knowledge necessary to deal with the agenda, and who adequately can represent the interests of those who will be affected by decisions made. Too few or too many participants may limit the effectiveness of a committee or task force.

Place and Time Meetings should be held in places where interruptions can be controlled and at a time when there is a natural time limit to the meeting, such as late in the morning or afternoon, when lunch or dinner make natural time barriers. Meetings should be limited to 50 to 90 minutes, except when members are dealing with complex, detailed issues in a one-time session. Meetings that exceed 90 minutes should be planned to include breaks at least every hour. Meetings should start and finish on time. Starting late positively reinforces latecomers, while penalizing those who arrive on time or early. If sanctions for late arrival are indicated, they should be applied respect- fully and objectively. If it is the leader who is late, the cost of starting meetings late should be reiterated and an appropriate designee should begin the meeting on time.

Member Behaviors The behavior of each member may be positive, negative, or neutral in relation to the group’s goals. Members may contribute very little, or they may use the group to meet personal needs. Some members may assume most of the responsibility for the group action, thereby enabling less participative members to avoid contributing.

Group members should:

● Be prepared for the meeting, having read pertinent materials ahead of time ● Ask for clarification as needed ● Offer suggestions and ideas as appropriate ● Encourage others to contribute their ideas and opinions ● Offer constructive criticism as appropriate

156 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

● Help the discussion stay on track ● Assist with implementation as agreed

These behaviors facilitate group performance. All attendees should be familiar with behaviors that they may employ to facilitate well-managed meetings. All meeting participants must be helped to understand that they share responsibility for successful meetings.

A leader can increase meeting effectiveness greatly by not permitting one individual to dominate the discussion; separating idea generation from evaluation; encouraging members to refine and develop the ideas of others (a key to the success of brainstorming); recording problems, ideas, and solutions on a white board or flip chart; checking for understanding; peri- odically summarizing information and the group’s progress; encouraging further discussion; and bringing disagreements out into the open and facilitating their reconciliation. The leader is also responsible for drawing out the members’ hidden agendas (personal goals or needs). Revealing hidden agendas ensures that these agendas either contribute positively to group performance or are neutralized. Guidelines for leading group meetings are provided in Box 11-1.

Managing Task Forces There are a few critical differences between task forces and formal committees. For example, members of a task force have less time to build relationships with each other, and, because task forces are temporary, there may be no desire for long-term positive relationships. Formation of a task force may suggest that the organization’s usual problem-solving mechanisms have failed. This perception may lead to tensions among task force members and between the task force and other units in the organization. The various members of a task force usually come from different parts of the organization and, therefore, have different values, goals, and viewpoints. The leader will need to take specific action to efficiently familiarize task force members with each other and create bonds in relation to the task.

Preparing for the First Meeting Prior to the task force’s first meeting, the leader must clarify the objectives in specific measur- able outcomes, determine its membership, set a task completion date, plan how often and to whom the task force should report while working on the project, and ascertain the group’s scope of authority, including its budget, availability of relevant information, and decision-making power. The task force leader should communicate directly and regularly with the administrator

BOX 11-1 Guidelines for Leading Group Meetings

● Begin and end on time. ● Create a warm, accepting, and nonthreatening

climate. ● Arrange seating to minimize differences in power,

maximize involvement, and allow visualization of all meeting activities. (A U-shape is optimal.)

● Use interesting and varied visuals and other aids. ● Clarify all terms and concepts. Avoid jargon. ● Foster cooperation in the group. ● Establish goals and key objectives. ● Keep the group focused. ● Focus the discussion on one topic at a time.

● Facilitate thoughtful problem solving. ● Allocate time for all problem-solving steps. ● Promote involvement. ● Facilitate integration of material and ideas. ● Encourage exploration of implications of ideas. ● Facilitate evaluation of the quality of the

discussion. ● Elicit the expression of dissenting opinions. ● Summarize discussion. ● Finalize the plan of action for implementing

decisions. ● Arrange for follow-up.

CHAPTER 11 • BUILDING AND MANAGING TEAMS 157

or governing body that commissioned the task force’s work so that ongoing clarification of its charge and progress can be tracked and adjusted.

Task force members should be selected on the basis of their knowledge, skills, personal con- cern for the task, time availability, and organizational credibility. They should also be selected on the basis of their interpersonal skills. Those who relish group activities and can facilitate the group’s efforts are especially good members. The group leader should also plan to include one or two individuals who potentially may oppose task force recommendations in order to solicit their input, involve them in the decision-making process, and win their support. By holding personal conversations with task force members before the first meeting, the group leader can explore individual expectations, concerns, and potential contributions. It also provides the leader with an opportunity to identify potential needs and conflicts and to build confidence and trust.

Conducting the First Meeting The goal of the first meeting is to come to a common understanding of the group’s task and to define the group’s working procedures and relationships. Task forces must rely on the general norms of the organization to function. The task force leader should legitimize the representative nature of participation on the task force and encourage members to discuss the task force’s process with the other members of the organization.

During the first meeting, a standard of total participation should be well established. The leader should remain as neutral as possible and should prevent premature decision making. Working procedures and relationships among the various members, subgroups, and the rest of the organization need to be established. The frequency and nature of full task force meetings and the number of subgroups must be determined. Ground rules for communicating must be estab- lished, along with norms for decision making and conflict resolution.

Managing Subsequent Meetings and Subgroups In running a task force, especially when several subgroups are formed, the leader should hold full task force meetings often enough to keep all members informed of the group’s progress. Unless a task force is small, subgroups are essential. The leader must not be aligned too closely with one position or subgroup. A work plan should be developed that includes realistic interim project deadlines. The task force and subgroups should be held to these deadlines. The leader plays a key role in coaching subgroups and the task force to meet its deadlines.

The leader must also be sensitive to the conflicting loyalties sometimes created by belong- ing to a task force. One of the leader’s most important roles is to communicate information to both task force members and the rest of the organization in a timely and regular fashion. The leader should solicit feedback from other key organizational representatives during the course of the task force’s work.

Completing the Task Force’s Report In bringing a project to completion, the task force should prepare a written report for the com- missioning administrators that summarizes the findings and recommendations. Drafts of this report should be shared with the full task force prior to presentation. To identify any overlooked or sensitive information and reduce defensive reactions, it is especially important that the task force leader personally brief key administrators prior to presenting the report. This gives admin- istrators a chance to read and respond to the report before making recommendations. The leader should consider involving a few task force members in the administrative presentation.

Patient Care Conferences Patient-related conferences are held to address the needs of individual patients or patient popula- tions. The purpose of the conference determines the composition of the group. Patient-focused meetings are usually interprofessional and used for case management to discuss specific patient

158 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

care problems. For example, an interprofessional team may form to discuss the failure of a reha- bilitation regimen to help a home care patient and to develop new plans for intervention.

Often nurses are also involved in activities associated with improving the quality of care for various patient groups and their families. For example, a nurse manager might organize meetings with primary care physicians and other managers to discuss how to improve discharge planning, to explore strategies to reduce the length of inpatient stays, or to improve coordination with out- patient clinics.

The team leader of a patient care conference often may not be a manager with line respon- sibility to supervise, evaluate, or hire employees. Frequently in patient rounds, the nurse is the person who can lead the conversation because the nurse has spent the most amount of time with the patient. The team leader is, however, a coach, teacher, and facilitator. Thus, the team leader needs to have excellent leadership skills. The task of a team leader varies according to the task and the skill level of the team members.

Nurses may be members of teams as well as leaders. Understanding how groups and teams function (or do not) is essential to contribute to the organization, be successful in your position, and to garner satisfaction from your work.

What You Know Now • A group is an aggregate of individuals who interact and mutually influence each other. • Groups may be classified as real or task, formal or informal, permanent or temporary. • A team is a group of individuals with complementary skills, a common purpose and performance goals,

and a set of methods for which they hold themselves accountable. • Assessment of problems should precede team-building activities. • Team-building now includes a focus on meeting goals and accomplishing tasks as well as improving

interpersonal relationships. • Team-building activities are more likely to be successful if skills are reinforced on the job. • Managing teams depends on the task, group size and composition, productivity and cohesiveness,

development and growth, and the extent of shared governance in the organization. • The nurse manager’s communication skills affect the team’s productivity and performance. • Managing meetings involves preparing thoroughly, facilitating participation, and completing the

group’s work.

Tools for Building and Managing Teams 1. Notice how groups around you function. Use the best ideas with your own groups. 2. Watch effective leaders. Identify skills you could incorporate into your own leadership repertoire. 3. Recognize that you can develop good team leadership skills. Practice those discussed in the chapter. 4. At the next opportunity be prepared to follow the directions for leading meetings. 5. Make a development plan to enhance your leadership skills.

Questions to Challenge You 1. Identify the groups that include you in your work or school. How are they different? Similar?

Explain. 2. Describe an example of effective group leadership and an example of poor leadership. 3. Evaluate your own leadership performance. How could you improve? 4. Have you been involved in team building at work or school? Was it effective? Explain. 5. What roles do you usually play in a group meeting (or class)? What role would you like to play?

Describe it.

CHAPTER 11 • BUILDING AND MANAGING TEAMS 159

References

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

Henriksen, K., Battles, J. B., Keyes, M. A., & Grady, M. L. (Eds.), (2008). Advances in patient safety: New directions and alternative approaches (Vol. 3: Performance and tools). Rockville, MD: Agency for Healthcare Research and Quality.

Hess, R. G. (2011). Slicing and dicing shared governance. Nursing Administration Quarterly, 35(3), 235–241.

Hill, K. S. (2010). Building leadership teams. Journal of Nursing Administration, 40(3), 1031–1035.

Homans, G. (1950). The human group. New York: Harcourt.

Homans, G. (1961). Social behavior: Its elementary forms. New York: Harcourt.

Joint Commission on Ac- creditation of Healthcare Organizations. (2011). Root causes for sentinel events. Retrieved July 8, 2011 from http://www. jointcommission.org/ Sentinel_Event_Statistics/

King, H. B., Battles, J., Baker, D. P., Alonso, A., Salas, E., Webster, J., Toomey, L., & Salisbury, M. (2008). TeamSTEPPS: Team strate- gies and tools to enhance performance and patient

safety. Retrieved December 12, 2011 from http://www. ahrq.gov/downloads/pub/ advances2/vol3/Advances- King_1.pdf

MacPhee, M., & Bouthillette, F. (2008). Developing leader- ship in nurse managers: The British Columbia Nursing Leadership Insti- tute. The Canadian Journal of Nursing Leadership, 21(3), 64–75.

MacPhee, M., Wardrop, A., & Campbell, C. (2010). Transforming work place relationships through shared decision making. Journal of Nursing Management, 18(8), 1016–1126.

McKeon, L. M., Cunningham, P. D., & Detty Oswaks, J. S. (2009). Improving pat- ent safety: Patient-focused, high-reliability team train- ing. Journal of Nursing Care Quality, 24(1), 76–82.

Rosen, M. A., Salas, E., Wilson, K. A., King, H. B., Salisbury, M., Augenstein, J. S., Robinson, D. W., & Birnbach, D. J. (2008). Measuring team perfor- mance in simulation-based training: Adopting best practices for healthcare. Simulation in Healthcare, 3(1), 33–41.

Salas, E., DiazGranados, D., Weaver, S. J., & King, H. (2008). Does team training work? Principles for health care. Academic Emergency Medicine, 15(11), 1002–1009.

Steiner, I. D. (1972). Group process and productivity. New York: Academic Press.

Steiner, I. D. (1976). Task- performing groups. In J. W. Thibaut, J. T. Spence, & R. C. Carson (Eds.), Con- temporary topics in social psychology (pp. 94–108). Morristown, NJ: General Learning Press.

Sullivan, E. J. (2013). Becom- ing influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall.

Thompson, J. D. (1967). Organizations in action. New York: McGraw-Hill.

Wilhelmsson, M., Ponzer, S., Dahlgren, L. O., Timpka, T., & Faresjö, T. (2011). Are female students in gen- eral and nursing students more ready for teamwork and interprofessional col- laboration in healthcare? BMC Medical Education. Retrieved July 8, 2011 from http://www.biomedcentral. com/1472-6920/11/15

Web Resources TeamSTEPPS: http://teamstepps.ahrq.gov/ Legacy MD: http://legacymd.com

www.nursing.pearsonhighered.com

http://www.jointcommission.org/Sentinel_Event_Statistics/

http://www.ahrq.gov/downloads/pub/advances2/vol3/Advances-King_1.pdf

http://www.biomedcentral.com/1472-6920/11/15

http://teamstepps.ahrq.gov/

http://legacymd.com

http://www.ahrq.gov/downloads/pub/advances2/vol3/Advances-King_1.pdf

http://www.jointcommission.org/Sentinel_Event_Statistics/

Handling Conflict

Key Terms Accommodating Avoiding Collaboration Competing Competitive conflict Compromise Conflict Confrontation

Conflict

Interprofessional Conflict

Conflict Process Model ANTECEDENT CONDITIONS

PERCEIVED AND FELT CONFLICT

CONFLICT BEHAVIORS

CONFLICT RESOLVED OR SUPPRESSED

OUTCOMES

Managing Conflict CONFLICT RESPONSES

FILLEY’S STRATEGIES

ALTERNATIVE DISPUTE STRATEGIES

1. Describe why conflict can be positive or negative.

2. Discuss how conflict can help generate change.

3. Describe the components of conflict.

4. Identify different approaches that can be used to manage conflict.

5. Explain how to manage conflict.

Learning Outcomes After completing this chapter, you will be able to:

CHAPTER

Consensus Disruptive conflict Felt conflict Forcing Integrative decision making Lose–lose strategy Mediation Negotiation

Perceived conflict Resistance Resolution Smoothing Suppression Win–lose strategy Win–win strategy Withdrawal

CHAPTER 12 • HANDLING CONFLICT 161

Conflict Conflict is a natural, inevitable condition in organizations, and a manager’s communication frequently centers on conflict. It is often a prerequisite to change in people and organizations.

Conflict is defined as the consequence of real or perceived differences in mutually exclu- sive goals, values, ideas, attitudes, beliefs, feelings, or actions (a) within one individual (intra- personal conflict), (b) between two or more individuals (interpersonal conflict), (c) within one group (intragroup conflict), or (d) between two or more groups (intergroup conflict). Conflict is dynamic. It can be positive or negative, healthy or dysfunctional.

A certain amount of conflict is beneficial to an organization. It can provide heightened sen- sitivity to an issue, further piquing the interest and curiosity of others. Conflict can also increase creativity by acting as a stimulus for developing new ideas or identifying methods for solving problems. Disagreements can help all parties become more aware of the trade-offs, especially costs versus benefits, of a particular service or technique.

Conflict also helps people recognize legitimate differences within the organization or pro- fession and serves as a powerful motivator to improve performance and effectiveness as well as satisfaction. For example, during intergroup conflict, individual groups become more cohesive and task oriented, whereas communication between groups diminishes.

Competition occurs when two or more groups attempt the same goals and only one group can attain those goals. Filley (1975) defines competitive conflict as a victory for one side and a loss for the other side. The process by which the conflict is resolved is determined by a set of rules. The goals of each side are mutually incompatible, but the emphasis is on winning, not the defeat or reduction of the opponent. When one side has clearly won, competition is terminated.

Disruptive conflict, in contrast, does not follow any mutually acceptable set of rules and does not emphasize winning. The parties involved are engaged in activities to reduce, defeat, or eliminate the opponent. This type of conflict takes place in an environment charged with fear, anger, and stress.

Interprofessional Conflict Working in high-stress jobs, nurses often have conflicts with other health care professionals, ad- ministrators, or coworkers. A common example is conflict in the interprofessional team is feel- ing like each other’s time isn’t respected. To do multidisciplinary rounds, the doctor might want to meet at 1 p.m., the nurse at 1:30 p.m., the social worker at 10 a.m., etc. A time that works with the work flow of each job is important so that conflict doesn’t arise over a person feeling that he or she isn’t valued or respected.

Conflicts between physicians and nurses, however, dominate problems reported by both professions (Leever et al., 2010). For example, the physician may want to send the patient home today, while the nurse knows the patient is struggling to understand ordered medications. In addition, the physical therapist tells the nurse that the patient needs another day of practicing exercises before she can be safely discharged.

The nurse manager can teach staff how to handle interprofessional conversations to advo- cate for the patient, explaining the following:

● Use facts to support your point ● Speak from the vantage point of the patient ● Explain what will best help the patient ● Do not inject what you personally want

Interprofessional conflict is expected to escalate as the most effective and least expen- sive care is promoted (Webb, 2010). For example, nurse practitioners (NPs) already handle a considerable amount of routine care (e.g., minor injuries, sinusitis, sports exams) because of accessibility (often in retail clinics) and because of cost. Physicians and NPs may have

162 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

conflicts over which profession should provide and—more importantly, be reimbursed— for this care.

How nurses handle conflict has been studied. The relationship between the nurse’s person- ality type and how the person handles conflict was reported by Whitworth (2008). Using the Thomas Kilmann Mode Instrument (Thomas & Kilmann, 1974) the researcher found no statisti- cal correlation between the two constructs. Whitworth suggested, however, that the environment may have more influence than personality factors.

Using the same instrument, Morrison (2008) examined nurses’ emotional intelligence com- petencies and how nurses handle conflict. Emotional intelligence (Goleman, 2006) measures self-awareness, self-management, social awareness, and relationship management. In the nurses studied, higher emotional intelligence scores in all four measures correlated with collaborating, but negatively with accommodating.

Outcomes and conflict have also been studied. One study compared how groups managed conflict with their performance and satisfaction (Behfar et al., 2008). Researchers found that three conflict resolution styles more often led to positive performance and job satisfaction out- comes: focusing on content of the conflict rather than the delivery; explicitly discussing rea- sons for work assignments; and making assignments based on expertise rather than volunteering, default, or convenience. Cole, Bedeian, and Bruch (2011) found that transformational leader behavior and team performance was indirect, leading them to conclude that team empowerment improved performance.

Conflict Process Model Several authors have proposed models for examining conflict (Pondy, 1967; Filley, 1975; Thomas, 1976). All follow a generalized format for examining conflict. These models provide a framework that helps explain how and why conflict occurs and, ultimately, how one can mini- mize conflict or resolve it with the least amount of negative aftermath.

Conflict and its resolution develop according to a specific process (see Figure 12-1). This process begins with certain preexisting conditions (antecedent conditions). The parties are in- fluenced by their feelings or perceptions about the situation (perceived or felt conflict), which initiates behavior, and conflict is exhibited. The conflict is either resolved or suppressed, and the outcome results in new attitudes and feelings between the parties.

Antecedent conditions

Conflict behavior

Conflict resolved or suppressed

Outcomes

Felt conflictPerceived conflict

Figure 12-1 • The conflict process.

CHAPTER 12 • HANDLING CONFLICT 163

Antecedent Conditions Antecedent conditions are associated with increases in conflict. Antecedent conditions propel a situation toward conflict; they may or may not be the cause. In nursing, antecedent conditions include incompatible goals, differences in values and beliefs, task interdependencies (especially asymmetric dependencies, in which one party is dependent on the other but not vice versa), unclear or ambiguous roles, competition for scarce resources, differentiation or distancing mechanisms, and unifying mechanisms.

Incompatible Goals The most important antecedent condition to conflict is incompatible goals. As discussed in Chapter 2, goals are desired results toward which behavior is directed. Even though the com- mon goal in health care organizations is to give quality patient care in a cost-effective manner, conflict in achieving these goals is inevitable because individuals often view this from different perspectives.

The dichotomy between health care providers and third-party payers is an example. Health care providers want to maximize the quality of care, whereas payers are concerned with mini- mizing costs.

A health care organization may have specific goals to achieve the best possible care for patients and control costs to stay within budget and, at the same time, to provide intrinsically satisfying jobs for its employees. These multiple goals will frequently conflict with each other, so they will have to be prioritized. Priority setting can be one of the most difficult but important activities a health care manager must face. Goals are important because they become the basis for allocating resources and thus become an important source (antecedent) of conflict in the organization.

Similarly, individuals themselves have multiple goals, and those goals may also conflict. Individuals allocate scarce resources, such as their time, on the basis of priority and, therefore, might achieve one goal at the expense of others. The inability to attain multiple (and mutually incompatible) goals—whether those goals are personal or organizational—can cause conflict.

Role Conflicts Roles are defined as other people’s expectations regarding behavior and attitudes. Roles become unclear when one or more parties have related responsibilities that are ambiguous or overlapping. A manager might experience conflict between his or her responsibilities as an administrator and responsibilities as a staff member. Similarly, unclear or overlapping job descriptions or assign- ments may lead to conflict. For example, there could be conflict over such mundane issues as who has responsibility to deliver a patient to the radiology department—the nurse or the transport staff?

Task interdependence is another potential source of conflict. Nursing and housekeeping, for example, are interdependent. Housekeeping cannot completely clean a room until nursing has discharged the patient. Other examples of interdependence are the relationships among shifts and those between physicians and nurses. Interdependent relationships have the potential to ini- tiate conflict.

Structural Conflict One conflict commonly seen in the health care environment is structural conflict. Structured relationships (manager to staff, peer to peer) provoke conflict because of poor communication, competition for resources, opposing interests, or a lack of shared perceptions or attitudes. The nurse manager following up on a patient complaint with corrective counseling or coaching with a staff nurse is an example of structural conflict. The staff member may dispute the complaint and become defensive. In this situation, the manager may impose positional power. Positional power is the authority inherent in a certain position—for example, the nurse administrator has greater positional power than a nurse manager.

164 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

Competition for Resources Competition for scarce resources can be internal (among different units in the organization) or external (among different organizations). Internally, competition for resources may involve assigning staff from one unit to another or purchasing high-technology equipment when another unit is desperate for staff.

Externally, health care organizations compete for finite external resources (e.g., desig- nation as an accountable care organization for Medicare). Organizations are using a variety of means, such as developing new services and advertising, to try to capture the market in health care.

Values and Beliefs Differences in values and beliefs frequently contribute to conflict in health care organizations. Values and beliefs result from the individual’s socialization experience. Conflicts between phy- sicians and nurses, between nurses and administrators, or even between nurses with associate degrees versus those with baccalaureate degrees, often occur because of differences in values, beliefs, and experiences.

Distancing mechanisms or differentiation serve to divide a group’s members into small, distinct groups, thus increasing the chance for conflict. This tends to lead to a “we–they” distinction. One of the more frequently seen examples is distancing between physicians and nurses. Opposition between intensive care nurses and nurses on medical floors, night versus day shifts, and unlicensed versus licensed personnel are also examples. Differentiation among subunits also occurs and is due to differences in structure. The administrative unit may be bu- reaucratic, the nursing unit structured on a more professional basis, and staff physicians on an even different structure. Nonstaff physicians may be relatively independent of the health care organization.

Unifying mechanisms occur when greater intimacy develops or when unity is sought. All nurses might be expected to reach consensus over an issue, but they might experience internal conflict if they are forced to accept a group position even though individually they may not be wholly committed to the decision. A nurse manager’s friendship with a staff member may also lead to this type of conflict.

Perceived and Felt Conflict Perceived and felt conflict account for the conflict that may occur when the parties involved view situations or issues from differing perspectives, when they misunderstand each other’s position, or when positions are based on limited knowledge. Perceived conflict refers to each party’s per- ception of the other’s position. Felt conflict refers to the negative feelings between two or more parties. It is characterized by mistrust, hostility, and fear.

To demonstrate how this process works, consider this situation. A nurse manager and a surgeon have worked together for years. They have mutual respect for each other’s ability and skills, and they communicate frequently. When their subordinates clash, they are left with con- flicting accounts of a situation, in which the only agreed-upon fact is that a patient received less- than-appropriate care. Now consider the same scenario if the nurse and doctor have never dealt with each other or if one feels that the other will not approach the problem constructively.

In the first situation (perceived conflict), their positive regard for each other’s abilities makes the nurse and physician believe they can constructively solve the conflict. The nurse does not feel the physician will try to dominate, and the physician respects the nurse manager’s lead- ership ability. With these preexisting attitudes, the physician and nurse can remain neutral while helping their subordinates solve the conflict.

If the nurse and physician were experiencing felt conflict, on the other hand, they might ap- proach the situation differently. Each might assume the other will defend her or his subordinates at all costs and communication will be inhibited. The conflict is resolved by domination of the stronger person, either in personality or position. One wins; the other loses.

CHAPTER 12 • HANDLING CONFLICT 165

Conflict Behaviors Conflict behavior results from the parties’ perceived or felt conflict. Behaviors may be overt or covert. Overt behavior may take the form of aggression, competition, debate, or problem solv- ing. Covert behavior may be expressed by a variety of indirect tactics, such as scapegoating, avoidance, or apathy.

Conflict Resolved or Suppressed In the next stage of the process conflict is resolved or suppressed. Resolution occurs when a mu- tually agreed-upon solution is arrived at and both parties commit themselves to carrying out the agreement. Suppression occurs when one person or group defeats the other. Only the dominant side is committed to the agreement, and the loser may or may not carry out the agreement.

Outcomes The outcome affects how conflict will be addressed by the parties in the future. The optimal solution is to manage the issues in a way that will lead to a solution wherein both parties see themselves as winners and the problem is solved. This leaves a positive aftermath that will affect future relations and influence feelings and attitudes. In the example of conflict between the nurse manager and the physician, consider the difference in the aftermath and how future issues would be approached if both parties felt positive about the outcome, as compared to future interactions if one or both parties felt they had lost.

Managing Conflict Managing conflict is an important part of the nurse manager’s job. Managers are often involved in conflict management on several different levels. They may be participants in the conflict as individuals, administrators, or representatives of a unit. In fact, they must often initiate conflict by confronting staff, individually or collectively, when a problem develops. They may also serve as mediators or judges to conflicting parties. There could be a conflict within the unit, between parties from different units, or between internal and external parties (for example, a university nursing instructor may have a conflict with staff on a particular unit).

Everyone must be realistic regarding the outcome. Often those inexperienced in conflict ne- gotiation expect unrealistic outcomes. When two or more parties hold mutually exclusive ideas, attitudes, feelings, or goals, it is extremely difficult, without the commitment and willingness of all concerned, to arrive at an agreeable solution that meets the needs of both. Battles between Democrats and Republicans in Congress are an example.

Conflict management begins with a decision regarding if and when to intervene. Failure to intervene can allow the conflict to get out of hand, whereas early intervention may be detri- mental to those involved, causing them to lose confidence in themselves and reduce risk-taking behavior in the future.

Some conflicts are so minor, particularly if they are between only two people, that they do not require intervention and would be better handled by the two people involved. Allowing them to resolve their conflict might provide a developmental experience and improve their abilities to resolve conflict in the future.

Sometimes it is best to postpone intervention purposely to allow the conflict to escalate, because increased intensity can motivate participants to seek resolution. You could escalate the conflict even further by exposing participants to each other more frequently without the presence of others and without an easy means of escape. Participants are then forced to face the conflict between them.

Giving participants a shared task or shared goals not directly related to the conflict may help them understand each other better and increase their chances to resolve their conflicts by themselves. Using such a method is useful only if the conflict is not of high intensity, if the

166 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

participants are not highly anxious about it, and if the manager believes that the conflict will not decrease the efficiency of the unit in the meantime. When the conflict might result in consider- able harm, however, the nurse manager must intervene.

If you decide to intervene in a conflict between two or more parties, you can apply me- diation techniques, deciding when, where, and how the intervention should take place. Routine problems can be handled in either party’s office, but serious confrontations should take place in a neutral location unless the parties involved are of unequal power. In this case, the setting should favor the disadvantaged participant, thereby equalizing their power.

The place should be one where distractions will not interfere and adequate time is available. Because conflict management takes time, the manager must be prepared to allow sufficient time for all parties to explain their points of view and arrive at a mutually agreeable solution. A quick solution that inexperienced managers often resort to is to impose positional power and make a premature decision. This results in a win–lose outcome, which leads to feelings of elation and eventual complacency for the winners, and loss of morale for the losers.

The following are basic rules on how to mediate a conflict between two or more parties:

1. Protect each party’s self-respect. Deal with a conflict of issues, not personalities.

2. Do not put blame or responsibility for the problem on the participants. The participants are responsible for developing a solution to the problem.

3. Allow open and complete discussion of the problem from each participant.

4. Maintain equity in the frequency and duration of each party’s presentation. A person of higher status tends to speak more frequently and longer than a person of lower status. If this occurs, the mediator should intervene and ask the person of lower status for response and opinion.

5. Encourage full expression of positive and negative feelings in an accepting atmosphere. The novice mediator tends to discourage expressions of disagreement.

6. Make sure both parties listen actively to each other’s words. One way to do this is to ask one person to summarize the other person’s comments before stating her or his own.

7. Identify key themes in the discussion and restate them at frequent intervals.

8. Encourage the parties to provide frequent feedback to each other’s comments; each must truly understand the other’s position.

9. Help the participants develop alternative solutions, select a mutually agreeable one, and develop a plan to carry it out. All parties must agree to the solution for successful resolu- tion to occur.

10. At an agreed-upon interval, follow up on the progress of the plan.

11. Give positive feedback to participants regarding their cooperation in solving the conflict.

Conflict management is a difficult process, consuming both time and energy. Management and staff must be concerned and committed to resolving conflict by being willing to listen to others’ positions and to find agreeable solutions.

Conflict Responses Confrontation is considered the most effective means for resolving conflicts. This is a problem- oriented technique in which the conflict is brought out into the open and attempts are made to resolve it through knowledge and reason. The goal of this technique is to achieve win–win solutions. Facts should be used to identify the problem. The desired outcome should be ex- plicit. “This is the third time this week that you have not been here for report. According to

CHAPTER 12 • HANDLING CONFLICT 167

hospital policy, you are expected to be changed, scrubbed, and ready for report in the lounge at 7:00 a.m.” is an example.

Confrontation is most effective when delivered in private as soon as possible after the inci- dent occurs. Employee respect and manager credibility are two important considerations when a situation warrants confrontation. A more immediate confrontation also helps both the employee and manager sort out pertinent facts. In an emotionally charged situation, however, it may be best for the parties to wait. Regardless of timing, the message is usually more effective if the manager listens and is empathetic.

Negotiation involves give-and-take on various issues among the parties. Its purpose is to achieve agreement even though consensus will never be reached. Therefore, the best solution is not often achieved. Negotiation often becomes a structured, formal procedure, as in collec- tive bargaining (see Chapter 24). However, negotiation skills are important in arriving at an agreeable solution between any two parties. Staff learn to negotiate schedules, advanced prac- tice nurses negotiate with third-party payers for reimbursement, insurance companies negotiate with vendors and hospitals for discounts, and clinic managers negotiate employment contracts with physicians. Although negotiation involves adept communication skills, its usefulness re- volves around issues of conflict. Without differences in opinion, there would be no need for negotiation.

Collaboration implies mutual attention to the problem, in which the talents of all parties are used. In collaboration, the focus is on solving the problem, not defeating the opponent. The goal is to satisfy both parties’ concerns. Collaboration is useful in situations in which the goals of both parties are too important to be compromised.

Compromise is used to divide the rewards between both parties. Neither gets what she or he wants. Compromise can serve as a backup to resolve conflict when collaboration is ineffective. It is sometimes the only choice when opponents of equal power are in conflict over two or more mutually exclusive goals. Compromising is also expedient when a solution is needed rapidly.

Competing is an all-out effort to win, regardless of the cost. Competing may be needed in situations involving unpopular or critical decisions. Competing is also used in situations in which time does not allow for more cooperative techniques.

Accommodating is an unassertive, cooperative tactic used when individuals neglect their own concerns in favor of others’ concerns. Accommodating frequently is used to preserve har- mony when one person has a vested interest in an issue that is unimportant to the other party. You may recall that Morrison (2008) found that nurses with higher emotional intelligence scores seldom used accommodating as a conflict response.

In situations where conflict is discouraged, suppression is often used. Suppression could even include the elimination of one of the conflicting parties through transfer or termination. Other, less effective techniques for managing conflict include withdrawing, smoothing, and forc- ing, although each mode of response is useful in given situations.

In avoiding, the participants never acknowledge that a conflict exists. Avoidance is the con- flict resolution technique often used in highly cohesive groups. The group avoids disagreement because its members do not want to do anything that may interfere with the good feelings they have for each other.

Withdrawal from the conflict simply removes at least one party, thereby making it impos- sible to resolve the situation. The issue remains unresolved, and feelings about the issue may resurface inappropriately. If the conflict escalates into a dangerous situation, avoiding and with- drawing are appropriate strategies.

Smoothing is accomplished by complimenting one’s opponent, downplaying differences, and focusing on minor areas of agreement, as though little disagreement existed. Smoothing may be appropriate in dealing with minor problems, but in response to major problems, it pro- duces the same results as withdrawing.

Forcing is a method that yields an immediate end to the conflict but leaves the cause of the conflict unresolved. A superior can resort to issuing orders, but the subordinate will lack

168 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

commitment to the demanded action. Forcing may be appropriate in life-or-death situations but is otherwise inappropriate.

Resistance can be positive or negative. It may mean a resistance to change or disobedience, or it may be an effective approach to handling power differences, especially verbal abuse.

Filley’s Strategies Filley (1975) identified three basic strategies for dealing with conflict according to the outcome: win–lose, lose–lose, and win–win. In the win–lose strategy, one party exerts dominance, usu- ally by power of authority, and the other party submits and loses. Forcing, competing, and nego- tiating are techniques likely to lead to win–lose competition.

Majority rule is another example of the win–lose outcome, especially within groups. It may be a satisfactory method of resolving conflict, however, if various factions vote differently on different issues and the group functions over time so that members win some and lose some. Win–lose outcomes often occur between groups. Frequent losing, however, can lead to the loss of cohesiveness within groups and diminish the authority of the group leader.

In the lose–lose strategy, neither side wins. The settlement reached is unsatisfactory to both sides. Avoiding, withdrawing, smoothing, and compromising may lead to lose–lose outcomes. One compromising strategy is to use a bribe to influence another’s cooperation in doing some- thing he or she dislikes. For example, the nurse manager may promise a future raise in an at- tempt to coerce a staff member to work an extra weekend.

Using a third party as arbitrator can also lead to a lose–lose outcome. Because an outsider may want to give something to each side, neither gets exactly what he or she desires, resulting in a lose–lose outcome. This is a common strategy in arbitration of labor-management disputes. Another strategy that may result in a lose–lose or win–lose outcome is resorting to rules. The outcome is determined by whatever the rules say, and confrontation is avoided.

The win–lose and lose–lose methods share some common characteristics:

1. The conflict is person-centered (we–they) rather than problem-centered. This is likely to occur when two cohesive groups that do not share common values or goals are in conflict.

2. Parties direct their energy toward total victory for themselves and total defeat for the other. This can cause long-term problems for the organization.

3. Each side sees the issue from her or his own point of view rather than as a problem in need of a solution.

4. The emphasis is on outcomes rather than definition of goals, values, or objectives.

5. Conflicts are personalized.

6. Conflict-resolving activities are not differentiated from other group processes.

7. There is a short-run view of the conflict; the goal is to settle the immediate problem rather than resolve differences.

The win–win strategy focuses on goals and attempt to meet the needs of both parties. Two specific win–win strategies are consensus and integrative decision making. Consensus involves attention to the facts and to the position of the other parties and avoidance of trading, voting, or averaging, where everyone loses something. The consensus decision is often superior to even the best individual one. This technique is most useful in a group setting because it is sensitive to the negative characteristics of win–lose and lose–lose outcomes. True consensus occurs when the problem is fully explored, the needs and goals of the involved parties are understood, and a solution that meets these needs is agreed upon.

Integrative decision making focuses on the means of solving a problem rather than the ends. This strategy is most useful when the needs of the parties are polarized. Integrative deci- sion making is a constructive process in which the parties jointly identify the problem and their needs. They explore a number of alternative solutions and come to consensus on a solution. The

CHAPTER 12 • HANDLING CONFLICT 169

focus of this group activity is to solve the problem, not to force, dominate, suppress, or com- promise. The group works toward a common goal in an atmosphere that encourages the free exchange of ideas and feelings. Using integrative decision-making methods, the parties jointly identify the value needs of each, conduct an exhaustive search for alternatives that could meet the needs of each, and then select the best alternative. Like the consensus methods, integrative decision making focuses on defeating the problem, not each other.

Alternative Dispute Strategies Conflicts that have the potential to lead to legal action are often negotiated using alternative dispute resolution (ADR) (Sander, 2009). Mediation is a form of ADR that involves a third- party mediator to help settle disputes. Mediation agreements can satisfy all parties, cost less and take less time than legal remedies, and lead to improved interprofessional relationships (Gardner, 2010). Mediation has been used successfully in settling disputes in long-term care facilities (Rosenblatt, 2008).

ADR efforts have resulted in the creation of the International Institute of Conflict Prevention and Resolution, expanded state and federal legislation encouraging mediation, a dispute resolu- tion division in the American Bar Association, and development of ADR courses in law schools. The use of ADR in public policy promises to increase in the coming years (Susskind, 2009).

See how one nurse manager handled a conflict between two members of her staff in Case Study 12-1.

CONFLICT MANAGEMENT Mai Tran is the nurse manager of a 20-bed medical- surgical unit in a large university hospital. Her nursing staff is diverse in experience and educational back- ground. Working in a teaching hospital, Mai believes that nurses should be open to new methods and work processes, with an emphasis on evidence-based practice.

Ken Robertson, RN, has worked for two years on the unit and is in his final semester of a master’s program fo- cusing on geriatric care. Eileen Holcomb, RN, has worked on the same unit for the past 28 years and was a gradu- ate of the hospital’s former diploma program. Ken re- cently completed a clinical rotation in dermatology and has worked with the skin care team at the hospital to develop new protocols for preventing skin breakdown. During a recent staff meeting, Ken presents the new protocols to the staff. Eileen makes several comments during the presentation that simply getting patients out of bed and making sure they have adequate nutrition is easier and less time-consuming than the new proto- col. “All these new protocols are just a way to justify all those credentials behind a name,” Eileen says, gathering a chorus of chuckles from some of the older nurses on the staff. Ken frowns at Eileen and responds, “As nurses become educated, we need to reflect a professional practice.” Mai notices that several staff members are un- comfortable as the meeting ends.

Ken and Eileen continue to exchange sarcastic com- ments and glares over the next two shifts they work together. The obvious disagreement is affecting their coworkers, and gossiping is decreasing productivity on

the unit. Mai schedules individual meetings with Ken and Eileen to discuss their perspective. After reviewing the situation and determining that the issue is simply one of personality conflict, Mai brings Ken and Eileen to- gether for a meeting in her office. Mai reviews the facts of the situation with them and shares her opinion that both have acted inappropriately. She states that their actions have affected not only their work, but that of the unit as a whole. She informs Ken and Eileen that they must act in a professional and respectful manner with each other or disciplinary action will be taken. She encourages them to work out any future problems in a cooperative manner and not to bring personal conflicts into the work environment.

Manager’s Checklist The nurse manager is responsible for:

● Understanding how to manage conflict among staff members in a timely manner

● Understanding generational perceptions and how they impact group dynamics

● Understanding when disciplinary action is necessary ● Informing the human resource department of a po-

tential personnel problem and the proposed solution ● Meeting with staff to help them resolve conflict ● Determining whether all staff should be educated on

respect in the workplace ● Documenting interventions and outcomes as

appropriate

CASE STUDY 12-1

170 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

Managing conflict is an essential skill for the manager and, indeed, all nurses. Avoiding unnecessary conflict or allowing conflict to fester and remain unresolved undermines the manag- er’s effectiveness and can result in dissatisfied staff and turnover. Resolving conflict, on the other hand, can lead to better outcomes both with the immediate situation and encourage the manager to resolve conflict in the future.

More strategies for handling conflict can be found in Chapter 10, “Dealing with Difficult People and Situations,” in Becoming Influential: A Guide for Nurses (Sullivan, 2013).

What You Know Now • Conflict is a dynamic process and the consequence of real or perceived differences between individuals

or groups. • Conflict can be positive and the first step in initiating change, or it may be negative and disruptive. • Antecedent conditions that cause conflict include incompatible goals, role conflicts, structural conflict,

competition for scarce resources, and differences in values and beliefs. • A number of strategies exist to handle conflict; choosing the best one to use is based on the situation and

the people involved. • Learning to manage conflict is a requirement for all nurses and managers.

Tools for Handling Conflict 1. Evaluate conflict situations to decide if and when to intervene. 2. Understand the antecedent conditions for the conflict and the positions of those involved. 3. Enlist others to help solve conflicts. 4. Select a conflict management strategy appropriate to the situation. 5. Practice the conflict management strategies discussed in the chapter and evaluate the outcomes.

Questions to Challenge You 1. How are conflicts handled at work or school? Are leaders good conflict managers? Give an example

to explain your answer. 2. Briefly describe a conflict in which you were involved. How did you handle yourself? How did the

others involved? Did it turn out well? Explain. 3. What do you find to be the most difficult part of handling conflicts? Understanding others’ positions?

Devising a successful solution? Enlisting others’ help? Encouraging participants to agree to a solution? 4. Study the chapter for help in improving your areas of weakness. Evaluate your performance.

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

www.nursing.pearsonhighered.com

CHAPTER 12 • HANDLING CONFLICT 171

References Behfar, K. J., Peterson, R. S.,

Mannix, E. A., & Trochim, W. M. K. (2008). The critical role of conflict resolution in teams: A close look at the links between conflict type, conflict man- agement strategies, and team outcomes. Journal of Applied Psychology, 93(1), 170–188.

Cole, M. S., Bedeian, A. G., & Bruch, H. (2011). Linking leader behavior and lead- ership consensus to team performance: Integrating direct consensus and disper- sion models of group com- position. The Leadership Quarterly, 22(2), 383–398.

Filley, A. C. (1975). Inter- personal conflict resolu- tion. Glenview, IL: Scott, Foresman.

Gardner, D. (2010). Expanding scope of practice: Inter- professional collaboration or conflict? Nursing Eco- nomics, 28(4), 264–266.

Goleman, D. (2006). Emotional intelligence: Why it can matter more than IQ. New York: Bantam.

Leever, A. M., Hulst, M. V. D., Berendsen, A. J., Boende- maker, P. M., & Rooden- burg, J. L. N. (2010). Conflicts and conflict management in the collabo- ration between nurses and physicians: A qualitative study. Journal of Inter- professional Care, 24(6), 612–624.

Morrison, J. (2008). The rela- tionship between emotional intelligence competencies and preferred conflict- handling styles. Journal of Nursing Management, 16(8), 974–983.

Pondy, L. R. (1967). Organiza- tional conflict: Concepts and models. Administra- tive Science Quarterly, 12, 296–320.

Rosenblatt, C. L. (2008). Using mediation to manage con- flict in care facilities. Nurs- ing Management, 39(2), 16, 17.

Sander, F. E. A. (2009). Ways of handling conflict: What we have learned, what problems remain. Nego- tiation Journal, 25(4), 533–537.

Sullivan, E. J. (2013). Becom- ing influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall.

Susskind, L. (2009). Twenty-five years ago and twenty-five years from now: The future of public dispute resolution. Negotiation Journal, 25(4), 549–556.

Susskind, L. (2010). Mediating values-based and identity- based disputes. The con- sensus building approach. Retrieved July 12, 2011 from http://theconsensus- buildingapproach.blogspot. com/2010/04/mediating- values-based-and-identity. html

The Joint Commission. (2008, July 9). Behaviors that undermine a culture of safety. Retrieved October 15, 2010 from http://www. jointcommission.org/ SentinelEvents/Sentinel- EventAlert/sea_40.htm

Thomas, K. W. (1976). Conflict and conflict management. In M. D. Dunnette (Ed.), The handbook of industrial and organizational psy- chology. Chicago: Rand McNally.

Thomas, K. W., & Kilmann, R. H. (1974). Thomas- Kilmann Conflict Mode Instrument. Tuxedo, NY: Xicom.

Webb, R. (2010). Healthcare reform and inevitable con- flict: Smaller pie means smaller slices. Healthcare Neutral ADR Blog, Re- trieved July 12, 2011 from http://www.healthcareneu- traladrblog.com/2010/02/ articles/ commercial- healthcare-disputes/ healthcare-reform-and- inevitable-conflict-smaller- pie-means-smaller-slices

Whitworth, B. S. (2008). Is there a relationship between per- sonality type and preferred conflict-handling styles? An exploratory study of registered nurses in south- ern Mississippi. Journal of Nursing Management, 16(8), 921–932.

http://theconsensus-buildingapproach.blogspot.com/2010/04/mediating-values-based-and-identity.html

http://www.jointcommission.org/SentinelEvents/Sentinel-EventAlert/sea_40.htm

http://www.healthcareneu-traladrblog.com/2010/02/articles/commercial-healthcare-disputes/healthcare-reform-and-inevitable-conflict-smaller-pie-means-smaller-slices

http://www.jointcommission.org/SentinelEvents/Sentinel-EventAlert/sea_40.htm

http://www.healthcareneu-traladrblog.com/2010/02/articles/commercial-healthcare-disputes/healthcare-reform-and-inevitable-conflict-smaller-pie-means-smaller-slices

http://theconsensus-buildingapproach.blogspot.com/2010/04/mediating-values-based-and-identity.html

13 Managing Time CHAPTER

Time Wasters TIME ANALYSIS

THE MANAGER’S TIME

Setting Goals DETERMINING PRIORITIES

DAILY PLANNING AND SCHEDULING

GROUPING ACTIVITIES AND MINIMIZING ROUTINE WORK

PERSONAL ORGANIZATION AND SELF-DISCIPLINE

Controlling Interruptions PHONE CALLS, VOICE MAIL, TEXT MESSAGES

E-MAIL

DROP-IN VISITORS

PAPERWORK

Controlling Time in Meetings

Respecting Time

Goal setting Interruption log

Job enlargement Time logs

Time waster To-do list

1. Identify time wasters. 2. Identify goals. 3. Set priorities. 4. Group activities and minimize

routine work.

5. Manage personal organization and self discipline.

6. Minimize time wasters.

Learning Outcomes After completing this chapter, you will be able to:

Key Terms

CHAPTER 13 • MANAGING TIME 173

T ime management is a misnomer. No one manages time: What is managed is how time is used. In today’s downsized health care organization, the pressure to do more in less time has increased. Job enlargement occurs when a flatter organizational structure causes positions to be combined and results in managers having more employees to supervise, a situation common today.

The managerial skills needed today are different from those in the past, according to a study by Gentry and colleagues (Gentry et al., 2008). Changes from the late 1980s until now include flatter organizational structures that result in more responsibilities shared throughout the orga- nization and a greater use of electronic communications. Technology has changed how manag- ers and staff interact. Geographic location is less important, as is time away from work. Being always connected can be both a time-saver and a time-stealer. Nonetheless, instant communica- tion is here to stay.

Teams often do what managers formerly dictated, with the best decisions coming out of the team’s cooperative efforts. Time management is equally important in teamwork as it is for indi- viduals. Teams must plan and organize their work to meet deadlines. Efficiency is paramount.

Time can be used proactively or reactively (Carrick, Carrick, & Yurkow, 2007). If you focus your energy on people and events over which you have some direct or indirect control, you are using a proactive approach. If, on the other hand, you spend most of your time on what concerns you most about other people and events, your efforts are less apt to be effective. For example, you can set and follow your goals and priorities or you can spend your time worrying, blaming, or making excuses about what you do not accomplish. This chapter is designed to help you be proactive in targeting your use of time.

Time Wasters Why do we waste time? It is one of our most valuable resources, and yet everyone admits to wasting it. Box 13-1 answers this question by showing some of the constraints on an individual’s ability to manage time effectively. These patterns of behavior must be understood and dealt with to be effective in managing time.

Why We Fail to Manage Time Effectively

● We do what we like to do before we do what we don’t like to do.

● We do things we know how to do faster than things we do not know how to do.

● We do things that are easiest before things that are difficult.

● We do things that require a little time before things that require a lot of time.

● We do things for which resources are available.

● We do things that are scheduled (for example, meetings) before nonscheduled things.

● We sometimes do things that are planned before things that are unplanned.

● We respond to demands from others before demands from ourselves.

● We do things that are urgent before things that are important.

● We readily respond to crises and emergencies. ● We do interesting things before uninteresting things. ● We do things that advance our personal objectives

or that are politically expedient. ● We wait until a deadline approaches before we

really get moving. ● We do things that provide the most immediate

closure. ● We respond on the basis of who wants it. ● We respond on the basis of the consequences of

our doing or not doing something. ● We tackle small jobs before large jobs. ● We work on things in the order of their arrival. ● We work on the basis of the squeaky-wheel prin-

ciple (the squeaky wheel gets the grease). ● We work on the basis of consequences to the

group.

BOX 13-1

174 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

In addition to these patterns of behavior, certain time wasters prevent us from effectively managing time. A time waster prevents a person from accomplishing the job or achieving the goal. Common time wasters include:

1. Interruptions, such as phone calls, text messages, and drop-in visitors

2. Meetings, both scheduled and unscheduled

3. Lack of clear-cut goals, objectives, and priorities

4. Lack of daily and/or weekly plans

5. Lack of personal organization and self-discipline

6. Lack of knowledge about how one spends one’s time

7. Failure to delegate or working on routine tasks

8. Ineffective communication

9. Waiting for others and thus not using transition time effectively

10. Inability to say no

An experienced manager is often called on to help another new manager who requests help. It is always appropriate to mentor, teach, and guide others, but when you realize you are doing the person’s work and your work is not getting done or is late, your time is wasted.

Time Analysis The first step is to analyze how time is being used. The second is to determine whether time use is appropriate to your role. You may find much of your time is taken up doing “busywork” rather than activities that contribute to a particular outcome. Job redesign places emphasis on ensuring that time is spent wisely and that the right individual is correctly assigned the responsibility for tasks.

Time logs, as shown in Box 13-2, are useful in analyzing the actual time spent on various activities. Select a typical week and keep a log of activities in 15 to 60 minute increments. Keep it simple. List columns for the time period and the activity. Review your log for what activities are essential and what can be delegated or eliminated. Alternatively, you can use a planner or ap- pointment calendar in place of a separate log.

Time Activity Purpose Value

7:00–7:30 Review e-mails received overnight; list work to accomplish during shift

To respond to people who have e-mailed and to plan what work must be done

Sets the plan for the day so as much work can be accom- plished as possible

7:30–8:30 Be available for any night shift staff who need to talk with manager before leaving

Manager is accountable to all staff that work on unit. During this time, manager can have face-to-face interaction with night shift staff and follow up on any issues that present

Provides time for night shift staff to see and talk to manager and develop relationships and strong lines of communication

8:30–10:00 Budget planning meeting Meet with VP of patient care and other managers to work on planning next fiscal year budget

Manager has input into the budget that he/she will work to meet during next fiscal year

BOX 13-2 Time Analysis Log

CHAPTER 13 • MANAGING TIME 175

The Manager’s Time A significant difficulty in moving from a staff nurse position to a leadership position is the need to develop different time-management and organizational skills. In a staff nurse role, the regis- tered nurse has little, if any, free or uncommitted time. No planning is required, because every minute is taken. In contrast, when nurses move to a leadership position, they are responsible for defining how time will be spent. Learning to focus on setting goals, determining priorities, and evaluating time use is an important part of the analysis.

Setting Goals Nurses are accustomed to setting both long- and short-range goals, although typically such goals are stated in terms of what patients will accomplish rather than what the nurse will achieve. A critical component of time management is establishing one’s own goals and time frames.

Goals are specific statements of outcomes that are to be achieved. They provide direc- tion and vision for actions as well as a timeline in which activities will be accomplished. Defining goals and time frames helps reduce stress by preventing the panic people often feel when confronted with multiple demands. Although time frames may not be as fast as the nurse manager would like (the tendency is to expect change yesterday), necessary actions have been identified.

Individual or organizational goals encourage thinking about the future and what might hap- pen, what one wants to happen, and what is likely to happen (Sullivan, 2013). Goal setting helps relate current behavior, activities, or operations to the organization’s or individual’s long-range goals. Without this future orientation, activities may not lead to the outcomes that will help achieve the goals and meet the ideals of the individual or organization. The focus should be to develop measurable, realistic, and achievable goals.

It is useful to think of individual or personal goals in categories, such as:

● Department or unit ● Interpersonal (at work) ● Professional ● Financial ● Family and friends (outside of work) ● Vacation and travel ● Physical ● Lifestyle ● Community ● Spiritual

This partial listing is a guide to stimulate thinking about goals. Think about long-term goals, lifetime goals, and short-term goals. These should be divided into job-related goals and personal goals. Job-related goals may revolve around unit or departmental changes, whereas personal goals may include personal life and community involvement.

Short-term goals should be set for the next 6 to 12 months, but need to be related to long- term goals. To manage time effectively, answer five major questions about these goals:

1. What specific objectives are to be achieved?

2. What specific activities are necessary to achieve these objectives?

3. How much time is required for each activity?

4. Which activities can be planned and scheduled for concurrent action, and which must be planned and scheduled sequentially?

5. Which activities can be delegated to staff?

176 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

Delegating tasks to others can be an efficient time-management tool. Delegation is the pro- cess by which responsibility and authority are transferred to another individual. It involves as- signing tasks, determining expected results, and granting authority to the individual expected to accomplish these tasks. Delegation is perhaps the most difficult leadership skill for a nurse or a manager to acquire. Today, when more assistive personnel are being used to carry out the nurse’s work and when the manager’s span of control has expanded, appropriate delegation skills are essential for success. Chapter 10 discusses delegation in detail.

Determining Priorities To establish priorities, take into consideration both short- and long-term goals. Categorize them as:

● What you must do ● What you should do if possible ● What you could do if you have time to spare (Jones & Loftus, 2009)

Next determine the importance and urgency of each activity as shown in Table 13-1. Activities can be identified as:

● Urgent and important ● Important but not urgent ● Urgent but not important ● Busywork ● Wasted time

Activities that are both urgent and important must be completed. Activities that are impor- tant but not urgent may make the difference between career progression and maintaining the status quo. Urgent but not important activities must be completed immediately but are not con- sidered important or significant. Busywork and wasted time are self-explanatory.

Additionally, others’ emergencies or crisis can intrude on your priorities. Again, determine if these are truly urgent and important or if the person is overreacting to an immediate situation.

Daily Planning and Scheduling Once goals and priorities have been established, you can concentrate on scheduling activities. Prepare a to-do list each day, either after work hours the previous day or early before work on the same day. The list is typically planned by workday or workweek. If you have a combination of many responsibilities, a weekly to-do list may be more effective. Flexibility must be a major consideration in this plan; some time should remain uncommitted to allow you to deal with

TABLE 13-1 Importance–Urgency Chart

Category of Time Use Examples

Important and urgent Replacing two call-offs and ensuring sufficient staffing for the upcoming shift.

Important, not urgent Drafting an educational program for nurses on the changes in Medicare reimbursement.

Urgent, not important Completing and submitting the “beds available” list for a disaster drill.

Busywork Compiling new charts for future patient admissions.

Wasted time Sitting by the phone waiting for return calls.

CHAPTER 13 • MANAGING TIME 177

emergencies and crises that are sure to happen. The focus is not on activities and events, but rather on the outcomes that can be achieved in the time available.

A system to keep track of regularly scheduled meetings (staff meetings), regular events (annual or quarterly report due dates), and appointments is also necessary. This system should be used when establishing the to-do list; it should include both a calendar and files.

The calendar might include information on the purpose of the meeting, who will be attending, and the time and place. Several commercial planning systems are available, including software for computers or smart phones. Any such system includes a daily, weekly, or monthly calendar; a to-do section; a memo or note section; and an address book with phone numbers. Separate files for projects, committees, or reports should be kept arranged by date.

Grouping Activities and Minimizing Routine Work Work items that are similar in nature and require similar environmental surroundings and resources should be grouped within divisions of the work shift. Set aside blocks of uninterrupted time for the really important tasks, such as preparing the budget.

Group routine tasks, especially those that are not important or urgent, during your least pro- ductive time. For example, list what you can do in five minutes, such as scan your e-mail, check text messages, confirm a meeting, or set up an appointment, or in ten minutes, such as return a phone call, scan a Website, or compose an e-mail. This helps you spend the small allotments of time productively.

Much time spent in transition or waiting can be turned into productive use. Commuting time can be used for self-development or planning work activities. We all have to wait sometimes: waiting for a meeting to start or to talk to someone are just two examples. Keep up with message boards on your phone’s mail system or bring along materials to read or work on in case you are kept waiting. View waiting or transition time as an opportunity, especially to think.

If you are having difficulty completing important tasks and are highly stressed, especially as the day winds down, doing routine tasks for a while often helps reduce stress. Pick a task that can be successfully completed and save it for the end of the day. Reaching closure on even a routine task at the end of the day can reduce your sense of overload and stress.

Implementing the daily plan and daily follow-up is essential to managing your time. You should also repeat your time analysis at least semiannually to see how well you are managing your time, whether the job or the environment has changed, and if changes in planning activities are required. This can help prevent reverting to poor time-management habits.

Personal Organization and Self-Discipline Some other time wasters are lack of personal organization and self-discipline, including the inabil- ity to say no, having to wait for others, and excessive or ineffective paperwork. Effective personal organization results from clearly defined priorities based on well-defined, measurable, and achiev- able objectives. Because the nurse manager does not work alone, priorities and objectives are often related to those of many professionals, as well as to objectives of patients and their families.

How time is used is often a matter of resolving conflicts among competing needs. It is easy to become overloaded with responsibilities and with more tasks to do than can be accomplished in the time available. This is typical. There is never enough time for all the activities, situations, and events in which one might like to become involved. (Review the section on priority setting.)

To be effective, nurses and nurse managers must be personally well organized and possess self-discipline. This often includes being able to say no. Taking on too much work can lead to overload and stress. Being realistic about the amount of work to which you commit is an indi- cation of effective time management. If a superior is overloading you, make sure that person understands the consequences of additional assignments. Be assertive in communicating your own needs to others.

An e-mail system without designated folders for automatic storage, a cluttered desk, work- ing on too many tasks at one time, and failing to set aside blocks of uninterrupted time to do

178 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

important tasks indicate a lack of personal self-discipline. Automate e-mails from specified senders, clear your desktop, and get out the materials you need to complete your highest-priority task and start working on it immediately. Focus on one task at a time, making sure to start with a high-priority one.

One manager who felt overwhelmed by all of her responsibilities used the strategies shown in Case Study 13-1 to help her solve her problems.

Controlling Interruptions An interruption occurs any time you must stop in the middle of one activity to give attention to something else. Interruptions can be an essential part of your job, or they can be a time waster. An interruption that is more important and urgent than the activity in which you are involved is a positive interruption: it deserves immediate attention. An emergency or crisis, for instance, may cause you to interrupt daily rounds.

Some interruptions interfere with achieving the job and are less important and urgent than current activities. Because the manager’s role has expanded to a broader span of responsibil- ity, more decision making is placed on teams and the staff. When a manager is interrupted to solve problems within the staff nurse’s scope of accountability, the manager should not become responsible for solving the problem. Gently but firmly directing the individual to search for so- lutions will begin to break old patterns of behavior and help develop individual responsibility. Although it is time-consuming in the beginning, this practice eventually reduces the number of unnecessary interruptions.

TIME MANAGEMENT For the past six years, Jane Schumann has been the manager of staff development for three hospitals in a Catholic health care system. After the health care sys- tem suffered record operating losses last fiscal year, many middle management positions were eliminated. Jane was retained, but had several other departments assigned to her. Now Jane is responsible for staff devel- opment, utilization review staff, in-house float pool, night nursing supervisors, agency staffing, coordination of student nurse clinical rotations, and training of all nursing staff for the new hospital information system at four different hospitals.

Jane has been overwhelmed with her new respon- sibilities. Wanting to establish trust and learn more about her staff, Jane has adopted an “open-door pol- icy” resulting in many drop-in visits each day. She has been working much longer hours and most weekends. She has frequently had to fill in for night supervisors, stretching her workday to 18 hours. Her desk is stacked with paperwork and her voice mailbox is full of mes- sages to be returned. On average, she returns 40 of the 60 e-mails received each day.

When Jane comes across information about a time- management seminar, she quickly signs up. At the seminar, Jane learns a number of strategies that she can use.

Back at work, she makes a plan. First, she makes a list of priorities for each of her departments and a time frame for completing each project. Then she completes daily plans for the next two weeks as well as a three-month plan for the upcoming quarter. Jane also determines who among her new staff members can assume additional responsibilities and notes which tasks can be delegated. She sorts through paperwork and establishes a filing sys- tem for each department. Jane decides that she will train her administrative assistant to file routine paperwork and route other paperwork to Jane or delegated person- nel. Jane also decides that at each departmental meeting, she will establish specific times that she will be available for drop-in visitors. She schedules a meeting with the se- nior nursing executive to discuss the staffing implications for training nurses at the four hospitals to use the new hospital information system. Finally, she takes advantage of an upcoming four-day weekend to catch up on some well-deserved rest.

Manager’s Checklist The nurse manager is responsible for:

● Prioritizing the workload ● Effectively delegating tasks and projects to others ● Respecting one’s own time and the time of others ● Asking for help when appropriate

CASE STUDY 13-1

CHAPTER 13 • MANAGING TIME 179

Keeping an interruption log on an occasional basis may help. The log should show who interrupted, the nature of the interruption, when it occurred, how long it lasted, what topics were discussed, the importance of the topics, and time-saving actions to be taken. An example is shown in Box 13-3.

Analysis of these data may identify patterns for you to plan ways to reduce the frequency and duration of interruptions. They may also indicate that certain staff members are the most frequent interrupters and require individual attention to develop problem-solving skills.

Phone Calls, Voice Mail, Text Messages Phone calls are a major source of interruption, and the interruption log will provide considerable insight for the nurse manager regarding the nature of phone calls received. You will see how some people do not use the phone effectively. A ringing phone or beep from an incoming text is

BOX 13-3 Interruption Log

Name Purpose Time Topics Importance Actions

Joan, RN Stopped in manager’s office to talk

10 minutes Kids’ baseball games, husband’s new job

Not related to work activities, but helps build relationship with staff

Proactively plan time for occasional personal conversa- tions with staff to build relationships; plan to eat lunch in breakroom one day per week with staff to have informal conversations

Bill, janitor Ask manager if he/she has seen any furniture in hallways because a chair was missing from a patient room

5 minutes Patient’s room furniture was missing

Patient rooms need a chair so the pa- tient can get out of bed and have a place to sit. There is an issue with furniture that is sent for repair being misplaced when returned to the unit.

Ask the unit clerk to keep a log of all furniture sent off the unit for repair. When the furniture is returned, rather than putting it in the hall- way until someone says a chair is needed in a room, the unit clerk proactively finds out where the chair belongs and takes it to that location.

Jason, nurse aide

Tells the manager that he has tried four different machines, but no one machine can measure blood pressure, temperature, and oxygen saturation

15 minutes When equipment fails, manager works with employee to call bio med de- partment to get equipment in for repairs; four rental machines are brought to unit while oth- ers are being fixed

Staff need function- ing equipment to do their jobs efficiently

Partner with bio med department to have unit equipment checked once per week to ensure each component of the machines is function- ing properly

180 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

highly compelling; few people can allow it to go unanswered. All of us receive numerous phone calls and texts, and some of them time wasters. Handling them effectively is a must:

● Minimize socializing and small talk. If you answer the phone with, “Hello, what can I do for you?” rather than, “Hello, how are you?” the caller is encouraged to get to business first. Be warm, friendly, and courteous, but do not allow others to waste time with inappro- priate or extensive small talk. Calls placed and returned just prior to lunchtime, at the end of the day, and on Friday afternoons tend to result in more business and less socializing.

● Plan calls. The person who plans phone calls does not waste anyone’s time, including that of the person called. Write down the topics you want to discuss before you make the call. That way, you will not need to call back to give additional information or ask a forgotten question.

● Set a time for calls. You may have a number of calls to return and make. It is best to set aside a time for routine phone calls, especially during your “downtime.” Try not to inter- rupt what is being done at the moment. If an answer is necessary before a project can be continued, phone immediately; if not, phone for the information at a later time.

● State the reason for the call and ask for preferred call times. If a party is not available, explain why you are calling and provide several time frames when you will be available for a return call. Find out when the person you are calling is free. This makes it easier for him or her to be prepared for the call and helps prevent “phone tag.”

Voice mail is an excellent way to send and receive messages when a real-time interaction is not essential. For example, one person or a large group of people can learn about an upcoming meeting in one voice mail message. They can phone their responses at their convenience (with no need to reach each other directly). Like other forms of communication, voice mail must be used appropriately.

Long messages or sensitive information is better conveyed one-on-one. Moreover, another per- son (e.g., unit clerk) may be responsible for taking voice mail messages off the system, so it is im- portant to state the message in a professional manner, omitting personal or confidential information.

Text messages demand attention unless the phone is turned off. Even then, frequently glancing at the phone’s screen alerts you to the message. Few of us can resist checking “just this one” message. Text messages are a combination of voice messages and e-mail, so establish a time to return them.

E-Mail Incoming Messages E-mail can enhance time management or be a further time waster. E-mail minimizes the time you waste trying to contact individuals, enables you to contact many people simultaneously, and allows you to code the urgency of the message. Tone, however, is difficult to convey by e-mail. Therefore, it is better to use more personal forms of communication, such as the phone or in- person contact, for potentially sensitive or troublesome issues.

Checking e-mail too often can waste time. Each time you read a message, you are forced to think about it and you lose your focus on the task at hand. Turn off your e-mail alert and set specific times of day to check your in-box.

Also discourage people who forward you unwanted messages. Set your e-mail filter to di- rect these messages to your spam folder or tell the sender that you cannot receive personal mes- sages at work (Merritt, 2009).

Outgoing Messages Writing clear messages helps increase prompt and useful responses. Here are some tips:

● Direct messages only to the people involved (e.g., committee members) and copy others (e.g., the department chair).

● Title the subject line appropriately. For example, write “Meeting Friday morning” rather than “Information.”

CHAPTER 13 • MANAGING TIME 181

● Avoid salutations, if possible. “Dear” and “Hi” are often not needed on routine messages. ● Craft your message succinctly, but politely: “The division meeting will be held in confer-

ence room C at 9 a.m.”

Drop-In Visitors Although often friendly and seemingly harmless, the typical “got-a-minute?” drop-in visit is rarely as short as that. Take charge of the visit by identifying the issue or question, arranging an alternative meeting, referring the visitor to someone else, or redirecting the visitor’s problem- solving efforts.

If you are fortunate enough to have an office, you will find that open doors are open invita- tions for interruption. Although it is essential that you be available and accessible, you also need time to concentrate. Tell staff that you will be available for a specific block of time (a few hours at most) to address issues.

Of course, some interruptions are important and/or urgent. You must attend to those. For others, however, you can control the duration of the drop-in visitor (Jones & Loftus, 2009). Stand and remain standing. This appears gracious, yet is obvious enough to encourage a short visit. Before the person leaves, politely suggest that he or she visit during your office hours or send an e-mail to make a future appointment.

You can also control interruptions through the way you arrange your office furniture. You are asking for interruptions when you arrange your desk in a way that permits eye contact with passersby or drop-in visitors. A desk turned 90 or even 180 degrees from the door minimizes potential eye contact.

Encouraging people to make appointments to deal with routine matters also reduces inter- ruptions. Regularly scheduled meetings with people who need to see you allow them to hold routine matters for those appointments. Meeting in someone else’s office places you in charge of the time spent: it is easier to leave someone’s office than to ask someone to leave yours.

Paperwork Health care organizations cannot function effectively without good information systems. In addition to phone calls and face-to-face conversations, nurses and managers spend consider- able time writing and reading communications. Increasing government regulations, measures to avoid legal action, stronger privacy requirements, new treatments and medications, data process- ing, work processing, and electronics place pressure on everyone to cope with increasing paper- work (including electronic “paperwork”).

1. Plan and schedule paperwork. Writing and reading reports, forms, e-mail, letters, and memos are essential elements of a job. They will, however, become a major source of frus- tration if their processing is not planned and scheduled as an integral part of daily activi- ties. Learn the organization’s information system and requirements, analyze the paperwork requirements of the position, and make significant progress on that part of the job daily.

2. Sort paperwork for effective processing. A system of file folders either for paper mail or e-mail can be very helpful. Here is a system to handle it:

• Place all paperwork (or e-mail) requiring personal action in a red file or in an “action” folder on your computer’s hard drive. Handle that according to its relative importance and urgency.

• Place work that can be delegated in a separate file, and distribute it appropriately. • Place all work that is informational and related to present work in a yellow file folder or

in an “informational” folder on your hard drive. • Place other reading material, such as professional journals, technical reports, and other

items that do not relate directly to the immediate work, in a blue file folder or a “read” file.

182 PART 2 • LEARNING KEY SKILLS IN NURSING MANAGEMENT

The informational file contains materials that must be read immediately, whereas the reading file materials are not as urgent and can be read later.

Do not be afraid to throw things away or erase them from your computer’s memory. Do not let them become clutter when they no longer have value. Use trash receptacles in the office and on the electronic system.

3. Send every communication electronically. Unless a paper memo, report, or letter is re- quired, send your work electronically.

4. Analyze paperwork frequently. Review filing policies and rules regularly and purge files at least once each year. All standard forms, reports, and memos should be reviewed annu- ally. Each should justify its continued existence and its present format. Do not be afraid to recommend changes and, when possible, initiate those changes.

5. Do not be a paper shuffler. “Handle a piece of paper only once” is a common adage, but impossible to follow if taken literally. Rather, each time you handle a piece of paper or e-mail message, take action to further process it. Paper shufflers are those who continually move things around on their desks or accumulate unread e-mails. They delay action unrea- sonably, and the problem mounts.

Controlling Time in Meetings Meetings consume much of the manager’s time, and much of that time is wasted. To manage meetings follow these rules (Merritt, 2009):

● Do not meet simply because you always meet on Monday morning. If no meeting is needed, cancel it.

● Invite only key people to initial meetings. Others can be sent the minutes or invited to fu- ture meetings.

● Establish the meeting’s goal and outcomes expected at the outset. ● Send information before the meeting so time is not spent reading it. ● Set a time limit for all meetings. Routine meetings should last no more than one hour. If

more time is needed, schedule another meeting. ● Determine the agenda and keep to the topic. ● Follow-up with actions assigned.

Respecting Time The key to using time-management techniques is to respect one’s own time as well as that of others. Using the above suggestions for time management communicates to those who interact with you that you expect them to respect your time. You, however, must reciprocate by respect- ing their time too. If you need to talk to someone, make an appointment, particularly for routine matters.

You should continually ask, “What is the best use of my time right now?” and should an- swer in three ways:

● For myself and my goals ● For my staff and their goals ● For the organization and its goals

Efforts to manage time may seem to take more time, but the reverse is true. Any activity that helps set goals, determine priorities, organize the workday, and minimize interruptions will pay off in increased efficiency and effectiveness.

CHAPTER 13 • MANAGING TIME 183

What You Know Now • The first step in time management is to analyze how you use your time by keeping a time log. • Determine priorities and set goals to establish daily planning and scheduling. • Personal organization strategies help use time productively. • An interruption log helps identify patterns that can be used to reduce unnecessary interruptions. • Control phone calls by minimizing small talk, planning calls, setting aside time for calls, stating preferred

call times, and using voice mail. • To control interruptions by drop-in visitors, stand to meet visitors, encourage appointments, and arrange

furniture to discourage unscheduled visitors. • Written communication can also cause interruptions. These can be minimized by planning and scheduling

paperwork and e-mails and using an effective filing system. • People who respect their own time are likely to find others respecting it also.

Tools for Managing Time 1. Recognize that there will never be enough time to accomplish everything you want. 2. Use a time log to identify and reduce time wasters. 3. Use a planning system to list goals, their priorities, and schedule the workday. 4. Set aside uninterrupted time to complete important tasks. 5. Group routine tasks and use short blocks of time to complete them. 6. Monitor interruptions and decide on ways to minimize them.

Questions to Challenge You 1. What are your major time wasters? Keep a time log for one week. Compare how you thought you

wasted time with what your time log revealed. 2. Write down your goals for the next week. What action steps can you take to realize your goals? At

the end of the week, evaluate your progress. Then write down the next week’s goals. 3. What is keeping you from accomplishing your goals? Think about how you can change the circum-

stances to better reflect your priorities. 4. Do you use a planner or other scheduling device? If not, investigate the choices and select the one

that will work best for you. Then use it! 5. Think about how you handle interruptions. During the next week, try various strategies to minimize

the effect of interruptions.

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

References Carrick, L., Carrick, L., &

Yurkow, J. (2007). A nurse leader’s guide to managing priorities. American Nurse Today, 2(7), 40–41.

Gentry, W. A., Harris, L. S., Baker, B. A., & Leslie, J. B. (2008). Managerial skills: What has changed since the

late 1980s. Leadership & Organization Development Journal, 29(2), 167–181.

Jones, L., & Loftus, P. (2009). Time well spent: Getting things done through effective time management. Philadel- phia, PA: Kogan Page.

Merritt, C. (2009). Too busy for your own good. New York: McGraw Hill.

Sullivan, E. J. (2013). Becom- ing influential: A guide for nurses (2nd ed.). Upper Sad- dle River, NJ: Prentice Hall.

www.nursing.pearsonhighered.com

CHAPTER

14 Budgeting and Managing Fiscal Resources

The Budgeting Process

Approaches to Budgeting INCREMENTAL BUDGET

ZERO-BASED BUDGET

FIXED OR VARIABLE BUDGETS

The Operating Budget THE REVENUE BUDGET

THE EXPENSE BUDGET

Determining the Salary (Personnel) Budget

BENEFITS

SHIFT DIFFERENTIALS

OVERTIME

ON-CALL HOURS

PREMIUMS

SALARY INCREASES

ADDITIONAL CONSIDERATIONS

Managing the Supply and Nonsalary Expense Budget

The Capital Budget

Timetable for the Budgeting Process

Monitoring Budgetary Performance During the Year

VARIANCE ANALYSIS

POSITION CONTROL

Problems Affecting Budgetary Performance

REIMBURSEMENT PROBLEMS

STAFF IMPACT ON BUDGET

1. Describe how the budgeting process works. 2. Differentiate among types of budgets. 3. Demonstrate how to monitor and control

budgetary performance.

4. Explain how to determine budget variance. 5. Describe how staff affect budgetary

performance.

Learning Outcomes After completing this chapter, you will be able to:

Key Terms Benefit time Budget Budgeting Capital budget Cost center Direct costs Efficiency variance Expense budget Fiscal year

Fixed budget Fixed costs Incremental (line-by-line)

budget Indirect costs Nonsalary expenditure

variances Operating budget Position control

Profit Rate variances Revenue budget Salary (personnel) budget Variable budget Variable costs Variance Volume variances Zero-based budget

CHAPTER 14 • BUDGETING AND MANAGING FISCAL RESOURCES 185

B udgeting is the process of planning and controlling future operations by comparingactual results with planned expectations (Finkler & Kovner, 2007). A budget is a detailed plan that communicates these expectations and serves as the basis for compar- ing them to actual results. The budget shows how resources will be acquired and used over some specific time interval; its purpose is to allow management to project activities into the future so that the objectives of the organization are coordinated and met. It also helps ensure that the resources necessary to achieve these objectives are available at the appropriate time. Lastly, a budget helps management control the organization.

Budgeting is performed by business, government, and individuals. In fact, nearly everyone budgets, even though he or she may not identify the process as such. Even if a budget exists only in an individual’s mind, it is nonetheless a budget. Anyone who has planned how to pay a particular bill at some time in the future—say, six months—has a budget. Although it is very simple, that plan accomplishes the essential budget functions. One now knows how much of a resource (money) is needed and when (in six months) it is needed. Note that the “when” is just as important as the “how much.” The money has to be available at the right time.

Demands for patient safety, reimbursement changes with health care reform, technological advances, and the changing roles of health care providers require that budgets be constructed as accurately as possible and variances be as low as possible (Dunham-Taylor & Pinczuk, 2009). This is no small task. Attention to the budgeting process is the first step in understanding how to use resources most effectively.

The Budgeting Process A budget is a quantitative statement, usually in monetary terms, of the plans and expectations of a defined area over a specified period of time. Budgets provide a foundation for managing and evaluating financial performance. Budgets detail how resources (money, time, people) will be acquired and used to support planned services within the defined time period.

The budget process also helps ensure that the resources needed to achieve these objectives are available at the appropriate time and that operations are carried out within the resources available. The budgeting process increases the awareness of costs and also helps employees understand the relationships among goals, expenses, and revenues. As a result, employees are committed to the goals and objectives of the organization, and various departments are able to coordinate activities and collaborate to achieve the organization’s objectives. Budgets also help management control the resources expended through an organizational awareness of costs. Finally, budget per- formance provides management with feedback about resources management and the impact on the budget.

Budgeting is a process of planning and controlling future operations by comparing actual results with planned expectations. Planning first involves reviewing established goals and objectives of both nursing and the organization. Goals and objectives help identify the organiza- tion’s priorities and direct the organization’s efforts. To plan, the organization must know the following:

● Demographics of the population served, community influences, and competitors ● Sources of revenue, especially with changes in reimbursement due to enactment of health

care reform ● Statistical data, including:

• Number of admissions or patient appointments • Average daily census • Average length of stay • Patient acuity • Projected occupancy or volume base for ambulatory or procedure-based units

or home care visits

186 PART 3 • MANAGING RESOURCES

● Wage increases of market adjustments ● Price increases, including inflation rate, for supplies and other costs ● Costs for new equipment or technologies (e.g., wound vacs, sequential compression

devices, monitoring equipment) ● Staff mix (e.g., RNs, LPNs, UAPs) ● Regulatory changes (e.g., legislation mandating nurse-to-patient ratios, state board of

health regulations) for the budgetary period ● Organizational changes (e.g., decentralization of pharmacy or respiratory therapy

services) that result in salary and benefit dollars being charged in portion to the unit

Management normally uses the past as the common starting point for projecting the future, but in today’s volatile payment environment, the past may be a poor predictor of the future. This is one of the major drawbacks of the budgeting process. In a rapidly changing industry, basing budgets on historical data often requires readjustment during the actual budget period.

Controlling is the process of comparing actual results with the results projected in the budget. (See the section on monitoring performance during the year later in the chapter.) Two techniques for controlling budgetary performance are variance analysis and position control. By measuring the differences between the projected and the actual results, management is better able to make modifications and corrections. Therefore, controlling depends on planning.

Approaches to Budgeting Budgets may be developed in various formats depending on how the organization is structured. They may be considered as:

● Cost centers. Managers are responsible for predicting, documenting, and managing the costs (staffing, supplies) of the division.

● Revenue centers. Managers are responsible for generating revenues (previously by increasing patient volume, although health care reform may make the future of revenue-generating centers obsolete).

● Profit centers. Managers are responsible for generating revenues and managing costs so that the department shows a profit (revenues exceed costs).

● Investment centers. Managers are responsible for generating revenues and managing costs and capital equipment (assets).

Nursing units are typically considered to be cost centers, but they may also be viewed as revenue centers, profit centers, or investment centers. How the unit is considered is crucial in determining the manager’s approach to budgeting.

Also, some nursing managers are responsible for service lines, and their staff are from multiple disciplines and departments. Other nurse managers are responsible for a single unit, such as a telemetry unit or the staff in a multiple-physician office.

The organization may choose various approaches, or combinations of approaches, for requesting departmental managers to prepare their budget requests. These approaches are incre- mental (line-by-line), zero-based, fixed, and variable.

Incremental Budget With an incremental, or line-by-line, budget, the finance department distributes a budget worksheet listing each expense item or category on a separate expense line. The expense line is usually divided into salary and nonsalary items. A budget worksheet is commonly used for mathematical calculations to be submitted for the next year. It may include several columns for the amount budgeted for the current year, the amount actually spent year-to-date, the pro- jected total for the year based on the actual amount spent, increases and decreases in the expense amount for the new budget, and the request for the next year with an explanation attached.

CHAPTER 14 • BUDGETING AND MANAGING FISCAL RESOURCES 187

The base or starting point for calculating next year’s budget request may be either the previ- ous year’s actual results or projected expenditures for the current year. For salary expenses, the adjustment might be the average salary increase projected for next year. For nonsalary expenses, the finance department may provide an estimate of the average increase for supplies or opt to use a standard measure of cost increases, perhaps the consumer or medical price index projected for the next year.

To complete budget worksheets accurately, managers must be familiar with expense account categories. What type of expenses, such as instruments and minor equipment, are included under each line item? In addition, the manager has to keep abreast of different factors that have affected the expenditure level for each expense line during the current year. The projected impact of next year’s activities will be translated into increases or decreases in expense levels of the nursing unit’s expenditures for the coming year.

The advantage of the line-by-line budget method is its simplicity of preparation. The dis- advantage of this method is that it discourages cost efficiency. To avoid budget cuts for the next year, an astute manager learns to spend the entire budget amount established for the current year, because this amount becomes the base for the next year.

Zero-Based Budget The zero-based budget approach assumes the base for projecting next year’s budget is zero. Manag- ers are required to justify all activities and programs as if they were being initiated for the first time. Regardless of the level of expenditure in previous years, every proposed expenditure for the new year must be justified under the current environment and its fit with the organization’s objectives.

The advantage of zero-based budgeting is that every expense is justified. The disadvantage is that the process is time-consuming and may not be necessary. For that reason, organizations may not use this process every year. An adaptation of the zero-based budget is to start the budget with a lower base, for example, 80 percent of the current expenses. Managers then have to jus- tify any budgetary expenses requested above the 80 percent base.

Fixed or Variable Budgets Budgets can also be categorized as fixed or variable. In a fixed budget, the budgeted amounts are set without regard to changes that may occur during the year, such as patient volume or program activities, that have an impact on the cost assumptions originally used for the coming year. In contrast, variable budgets are developed with the understanding that adjustments to the budget may be made during the year based on changes in revenues, patient census, utilization of supplies, and other expenses.

The Operating Budget The operating budget, also known as the annual budget, is the organization’s statement of expected revenues and expenses for the coming year. It coincides with the fiscal year of the organization, a specified 12-month period during which the operational and financial perfor- mance of the organization is measured. The fiscal year may correspond with the calendar year— January to December—or another time frame. Many organizations use July 1 to June 30; the federal government begins its fiscal year on October 1. The operating budget may be further broken down into smaller periods of six months or four quarters; each quarter may be further sepa- rated into three one-month periods. The revenues and expenses are organized separately, with a bottom-line net profit or loss calculated.

The Revenue Budget The revenue budget represents the patient care income expected for the budget period. Most commonly, health care payers pay a predetermined rate based on discounts or allowances. In many cases, actual payment generated by a given service or procedure will not equal the charges

188 PART 3 • MANAGING RESOURCES

that appear on the patient bill. Instead, the health care provider will be reimbursed based on a variety of methods. These include:

● Reimbursement of a predetermined amount, such as fixed costs per case (Medicare recipients);

● Negotiated rates, such as per diems (a specified reimbursement amount per patient, per day);

● Negotiated discounts; and ● Capitation (one rate per member, per month, regardless of the service provided).

Revenue projections for the next year are based on the volume and mix of patients, rates, and discounts that will prevail during the budget period. Projections are developed from histori- cal volume data, impact of new or modified clinical programs, shifts from inpatient to outpatient procedures, and other influences. Today, however, these projections may not be viable, especially in the light of health care reform.

With implementation of accountable care organizations and medical homes, Medicare reim- bursement is expected to change (Buerhaus, 2010). Instead of paying for inpatient services at a predetermined specific rate for each Medicare recipient based on the patient’s diagnosis (DRGs), providers will be reimbursed for care of patient groups.

The Expense Budget The expense budget consists of salary and nonsalary items. Expenses should reflect patient care objectives and activity parameters established for the nursing unit. The expense budget should be comprehensive and thorough; it should also take into consideration all available information regarding the next year’s expectations. Described in the next section are several concepts and definitions related to the budgetary process in a health care setting.

Cost Centers In health care organizations, nursing units are typically considered cost centers. A cost center is described as the smallest area of activity within an organization for which costs are accumu- lated. Cost centers may be revenue producing, such as laboratory and radiology, or non–revenue producing, such as environmental services and administration. Nursing managers are com- monly given the responsibility for costs incurred by their department, but they have no revenue responsibilities.

In contrast, if managers are responsible for controlling both costs and revenues and if their financial performance is measured in terms of profit (the difference between revenues and expenses), then the manager is responsible for a profit center. Customarily, nursing is not directly reimbursed for its services. As stated previously, nursing costs today are included in the room charge although that may change as methods to match nurses’ skills to patient needs improve.

Classification of Costs Costs are commonly classified as fixed or variable. Fixed costs are costs that will remain the same for the budget period regardless of the activity level of the organization, such as rental payments and insurance premiums. Variable costs depend on and change in direct proportion to patient volume and patient acuity, such as patient care supply expenses. If more patients are admitted to a nursing unit, more supplies are used, causing higher supply expenses.

Expenditures may also be direct or indirect. Direct costs are expenses that directly affect patient care. For example, salaries for nursing personnel who provide hands-on patient care are considered direct costs. Indirect costs are expenditures that are necessary but don’t affect patient care directly. Salaries for security or maintenance personnel, for example, are classified as indi- rect costs.

CHAPTER 14 • BUDGETING AND MANAGING FISCAL RESOURCES 189

Determining the Salary (Personnel) Budget The salary budget, also known as the personnel budget, projects the salary costs that will be paid and charged to the cost center in the budget period (see Table 14-1). Managing the salary budget is directly related to the manager’s ability to supervise and lead the staff. Better manag- ers tend to have more stable staff with fewer resources spent on supplementary staff, turnover, or absenteeism. In addition to anticipated salary expenses, factors such as benefits, shift differen- tials, overtime, on-call expenses, and bonuses and premiums may affect the salary budget as well.

Benefits After the number of required full-time equivalents (FTEs) is determined (see Chapter 16 on scheduling), it is also necessary to determine how many FTEs are necessary to replace personnel for benefit time (vacations, holidays, personal days, etc). This factor can be calculated by deter- mining the average number of vacation days, paid holidays, personal days, bereavement days, or other days off with pay that the organization provides and the average number of sick days per employee as experienced by the cost center.

To determine FTEs required for replacement:

1. Determine hours of replacement time per individual.

2. Then determine FTE requirement.

Benefit Time Hours/shift Replacement Hours

15 vacation days * 8 hours = 120

8 holidays * 8 hours = 64

4 personal days * 8 hours = 32

5 sick days * 8 hours = 40

Total = 256

TABLE 14-1 Monthly Salary Budget and Year-to-Date Budget Comparison Report Fiscal Year Ending June 30

Position

June Actual Salary

June Budgeted Salary

June Variance

Year-to- Date Actual Salary

Year-to-Date Budgeted Salary

Year-to-Date Variance

Nurse Manager $6,250 $6,250 $0 $68,750 $75,000 $6,250

Registered Nurses

95,722 93,825 (1,897) 1,048,813 1,125,878 77,065

Licensed Practical Nurses

19,025 20,800 1,775 231,426 249,600 18,174

Nursing Assistants

14,886 13,200 (1,686) 159,500 158,400 (1,100)

Unit Clerks 5,483 5,495 12 60,391 65,273 4,882

Float Pool RNs 1,426 1,000 (426) 16,800 12,500 (4,300)

TOTAL SALARY: $142,792 $140,570 ($2,222) $1,585,680 $1,686,651 $100,971

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Divide replacement time by annual FTE base

256

2,080 = 0.12

An FTE budget is calculated from the FTE calculations (Table 14-1). This budget provides the base for the salary budget. However, shift differentials, overtime, and bonuses or premiums may also affect budget performance and need to be considered.

Shift Differentials Some facilities use a set percentage to determine shift differential: 10 percent for evenings, 15 percent for nights, and 20 percent for weekends and holidays, for example. If the hourly rate is $18.00, for instance, then the cost for a nurse working evenings would be $18.00 plus $1.80 for each hour worked. On an eight-hour shift, the total cost would be $158.40, and for the year, $41,184. Other facilities use a set dollar amount per hour as the shift differential. For instance, evenings adds $2.50 per hour to base pay, night shift $4.00, and weekends $2.50 additional pay.

Overtime Fluctuations in workload, patient volume, variability in admission patterns, and temporary replacement of staff due to illness or time off all create overtime in the nursing unit. A projection of overtime for the next year can be calculated by determining by staff classification (RN, LPN, nursing assistant, and other employee classifications) the historical or typical number of hours of overtime worked and multiplying that number by 1.5 times the hourly rate. For example, if the average number of overtime hours paid in a unit for RNs is 35 hours per two-week pay period, and the average hourly rate is $18.00, the projected overtime cost for the year would be $24,570 for the RN category.

To determine overtime costs:

1. Multiply average salary for classification $18.00 by factor * 1.50 to obtain overtime rate $27.00

2. Multiply average overtime hours 35 by overtime rate * $27.00 to obtain expenditure per pay period $945.00

3. Multiply number of pay periods 26 by overtime expenditure * $945.00 to obtain annual overtime costs $24,570.00

Clearly, overtime can rapidly deplete finite budget dollars allocated to a nursing unit. The nurse manager should explore options to overtime, such as using part-time or per diem work- ers in order to keep the cost per hour more in line with the regular hourly rates. A competent manager certainly would also evaluate unit productivity to decrease overtime.

On-Call Hours If the nursing unit uses a paid on-call system, the approximate number of hours that employees are put on call for the year should be estimated and that cost added to the budget. Typically under the on-call system, staff members are requested to be available to be called back to work if patient need arises, and the number of hours on call are paid at a flat rate per hour.

Premiums Some organizations offer premiums for certifications or clinical ladder steps. In this situation, a fixed dollar amount may be added to the base hourly rate of eligible personnel; for example, an

CHAPTER 14 • BUDGETING AND MANAGING FISCAL RESOURCES 191

additional $1.00 per hour paid for professional certifications. This would result in the hourly rate of the employee being adjusted from a base of $18.00 to $19.00. In this case, if the employee is full time and works 2,080 hours a year (40 hours a week multiplied by 52 weeks a year), the annual new salary would be $39,520, or $19.00 multiplied by 2,080.

Salary Increases Merit increases and cost-of-living raises also need to be factored into budget projections. These increases are usually calculated on base pay. For example, if a three percent cost-of-living raise is projected and the base salary for an RN is $40,000, then the new base becomes $41,200.

Additional Considerations Other important factors to consider when developing the salary budget are changes in technology, clinical supports, delivery systems, clinical programs or procedures, and regulatory requirements. Changes in patient care technology or the introduction of new equipment may influence the num- ber, skill, or time that unit personnel may spend in becoming trained to use the new equipment and, later, operating and maintaining it. If significant, the projected number of additional labor hours for the new budgetary period should be incorporated into the request.

The Joint Commission, the organization that accredits health care organizations, evaluates an institution to determine whether it is adhering to the level of staffing required to maintain a safe patient care environment (Joint Commission, 2011). For example, the institution may have established a standard for critical care units and some other specialty units that a minimum of two staff members are required at all times, regardless of patient number or acuity. Additionally, some states have mandated staffing levels.

Departments such as environmental services, dietary, escort, or laboratory may provide the nursing unit with support in performing certain tasks, such as transporting patients or speci- mens. Any change in the level of support they provide should be reviewed, and the effect of such change on the unit’s staffing levels should be quantified for the next year’s budget request. Changes in staffing can place new demands on the unit. Therefore, orientation and additional workload needs should also be considered.

In addition, changes might be made to the way the organization charges costs. For ex- ample, some direct or indirect costs formerly charged under other divisions might now be allocated to the various units. You might find your unit charged its fair share of the heating or security budget. Major changes, of course, are planned ahead of time but some changes occur during the budget year, and the unit might be expected to absorb those additional costs within its original budget.

Managing the Supply and Nonsalary Expense Budget The supply and nonsalary expense budget identifies patient-related supplies needed to operate the nursing unit. In addition to supplies, other operating expenses—such as office supplies, rental fees, maintenance costs, and equipment service contracts—may also be paid out of the nursing unit’s nonsalary budget.

An analysis of the current expense pattern and a determination of its applicability for the next budget period should be performed first. Any projected changes in patient volume, acuity, and patient mix should also be considered because they will affect next year’s supply use and other nonsalary expenses. As an example, if patient days for a particular type of patient are projected to multiply and cause a five percent increase in the use of intravenous solutions, this increase should be addressed in the budget request by requesting an additional five percent for intravenous solu- tion supplies for the next year.

Increases due to an inflation rate index, or at a rate estimated by the finance or purchasing department, are included as part of the budget request. A simple way of calculating the effect of

192 PART 3 • MANAGING RESOURCES

a price increase is to take the estimated total ending expense for the year and multiply it by the inflationary factor.

To determine projected price increases:

Multiply current total line item expense $12,758 by inflation factor plus 1.0 * 1.05

$13,396

Increases in expenses, such as maintenance agreements and rental fees, should also be incorporated as part of the budget request. The introduction of new technology and changes in programs and regulatory requirements may require additional resources for supplies as well as increased salaries.

The Capital Budget The capital budget is an important component of the plan to meet the organization’s long-term goals. This budget identifies physical renovations, new construction, and new or replacement equipment planned within a specified time period. Organizations define capital items based on certain conditions or criteria. Usually, capital items must have an expected performance of one year or more and exceed a certain dollar value, such as $500 or $1,000.

The capital budget is limited to a specified amount, and decisions need to be made how best to allocate available funds. Priority is given to those items needed most. Not all items that fall under capital budget will necessarily get funding in a given year.

Today, few nurse managers are asked to prepare a capital budget because most organiza- tions are buying through consortiums or negotiated agreements with one supplier. Many health care organizations have departments that coordinate bringing in selected vendors and items and limit choices to that equipment. The nurse manager would then be responsible for reporting what needs exist, helping select and determine the amount of equipment needed. The capital pool is expensed out across all units that use the equipment.

The impact of the new equipment on the unit’s expenses, such as the number of staff needed to run the equipment, use of supplies, and maintenance costs, needs to be considered as part of the operating budget, however. Likewise, the need for additional nursing and nonnursing per- sonnel to operate the new equipment, additional workload, and training of personnel should be quantified for the next year’s budget.

Timetable for the Budgeting Process Depending on the size and complexity of the organization, the budgeting process takes between three and six months. The process begins with the first-level manager. The individual at this level of management may or may not have formalized budget responsibilities, but he or she is key to identifying needed resources for the upcoming budget period.

The manager seeks information from staff about areas of needed improvement or change and reviews unit productivity and the need for updated technology or supplies. The manager uses this information to prepare the first draft of the budget proposal.

Depending on the levels of organizational management, this proposal ascends through the managerial hierarchy. Each subsequent manager evaluates the budget proposal, making adjust- ments as needed. By the time the budget is approved by executive management, significant changes to the original proposal usually have been made.

The final step in the process is approval by a governing board, such as a board of direc- tors or designated shareholders. Typically, the budget process timetable is structured so that the budget is approved a few months before the beginning of the new fiscal year.

CHAPTER 14 • BUDGETING AND MANAGING FISCAL RESOURCES 193

Clearly articulating budgetary needs is essential for the manager to be successful in bud- get negotiations. Senior management must prioritize budget requests for the entire organiza- tion, and they base those decisions on strong supporting documentation. Nurse managers should not expect to receive all of their budget requests, but they need to be prepared to defend their priorities.

Monitoring Budgetary Performance During the Year The difference between the amount that was budgeted for a specific revenue or cost and the actual revenue or cost that resulted during the course of activities is known as the variance. Variance might occur in the actual cost of delivering patient care for a certain expense line item in a speci- fied period of time. Nurse managers are commonly asked to justify the reason for variances and present an action plan to reduce or eliminate these variances.

Managers receive reports summarizing the expenses for the department (see Table 14-1). In the past, monthly reports on paper were sent to managers, but technology makes such a system obsolete today. Reports can be compiled and communicated rapidly, allowing managers to ad- just quicker.

The reports show expense line items with the budgeted amount, actual expenditure, variance from budget, and the percentage from the budgeted amount that such variance represents. These reports often also show the comparison between actual year-to-date results and the year-to-date budget.

To assess variance:

● Identify items that are over or under budgeted amounts ● Find out why the variance occurred (e.g., a one-time event or an ongoing occurrence) ● Keep notes on what you have learned in preparation for next year’s budget ● Examine the payroll and note overtime or use of agency personnel ● Validate the use of overtime or additional personnel and keep a note for your files

Keeping notes throughout the year will help prevent the annual budget process from becom- ing an overwhelming challenge. Trying to reconstruct what happened and why during the past 12 months is unlikely to present a complete and accurate picture of events and makes creating a future budget more difficult.

Variance Analysis In the daily course of events, it is unlikely that projected budget items will be completely on target in all situations. One of the manager’s most important jobs is to manage the financial re- sources for the department and to be able to respond to variances in a timely fashion.

When expenses occur that differ from the budgeted amounts, organizations usually have an established level at which a variance needs to be investigated and explained or justified by the manager of the department. This level may be a certain dollar amount, such as $500, or it may be a percentage, such as a five percent or ten percent increase above the budget.

In determining causes for variance, the nurse manager must review the activity level of the unit for the same period. There may have been increases in census or patient acuity that gener- ated additional expense in salary and supplies.

Also, in many situations, variances might not be independent of one another. Variances may result from expenses that follow a seasonal pattern and occur only at determined times in the year (renewal of a maintenance agreement is one example). Expenses may also follow a ten- dency or trend either to increase or to decrease during the year. Even if the situation is outside the manager’s usual responsibility or control, the manager needs to understand and be able to identify the cause or reason for the variance.

194 PART 3 • MANAGING RESOURCES

To determine when a variance is favorable or unfavorable, it is important to relate the vari- ance to its impact on the organization in terms of revenues and expenses. If more earnings came in than expected, the variance is favorable; if less, the variance is negative. Likewise, if less was spent than expected, the variance is favorable; if more was spent, the variance is negative.

For instance, the nurse manager might receive the following expense report:

Budgeted Expenditures

Actual Expenditures

Variance (in $)

Percent (in %)

$34,560 $36,958 (2,398) (6.9)

This expense variance is considered unfavorable because the actual expense was greater than the budget. In this example, more money was spent on medical/surgical supplies than was projected in the budget.

If the variance percentage of the actual budget amount is not presented in the reports, it can be calculated as follows:

$2,398

$34,560 = 0.069

Divide the dollar variance by the budget amount, then multiply by 100:

0.069 * 100 = 6.9% over budget

Salary Variances With salary expenditures, variances may occur in volume, efficiency, or rate. Typically these factors are related and have an impact on each other. Volume variances result when there is a difference in the budgeted and actual workload requirements, as would occur with increases in patient days. An increase in the actual number of patient days will increase the salary expense, resulting in an unfavorable volume variance. Although the variance is unfavorable, concomi- tant increases in revenues for the organization should be apparent. Thus, the impact to the organization should be welcomed, even though it generated higher salary costs at the nursing unit level.

Efficiency variance, also called quantity or use variance, reflects the difference between budgeted and actual nursing care hours provided. Patient acuity, nursing skill, unit manage- ment, technology, and productivity all affect the number of patient care hours actually pro- vided versus the original number planned or required. At the same time, if the census had been higher than expected, it would be understandable if more hours of nursing care were provided and paid. A favorable efficiency, or fewer nursing care hours paid, could suggest that patient acuity was lower than projected, that staff was more efficient, or that higher- skilled employees were used. An unfavorable efficiency may be due to greater patient acuity than allowed for in the budget, overstaffing of the unit, or the use of less experienced or less efficient employees.

Rate variances, also known as price or spending variance, reflect the difference in budgeted and actual hourly rates paid. A favorable rate variance may reflect the use of new employees who were paid lower salaries. Unfavorable rate variance may reflect unanticipated salary increases or increased use of personnel paid at higher wages, such as agency personnel.

Nonsalary Expenditure Variances A nonsalary expenditure variance may be due to changes in patient volume, patient mix, supply quantities, or prices paid. New, additional, or more expensive supplies used at the nursing unit because of technology changes or new regulations could also influence expenditure totals.

CHAPTER 14 • BUDGETING AND MANAGING FISCAL RESOURCES 195

Position Control Another monitoring tool used by nurse managers is the position control. The position control is used to compare actual numbers of employees to the number of budgeted FTEs for the nursing unit. The position control is a list of approved, budgeted FTE positions for the nursing cost cen- ter. The positions are displayed by category or job classification, such as nurse manager, RNs, LPNs, and so on. The nurse manager updates the position control with employee names and FTE factors for each individual with respect to personnel changes, new hires, and resignations that take place during the year.

Problems Affecting Budgetary Performance Reimbursement Problems The manager may be called upon to help with problems of reimbursement. Here are some examples:

● Insurance company disputes charges for a patient stay and refuses to pay them. The insurance company thinks patient should have been discharged a day sooner and refuses to pay for last day of stay because a good clinical reason to be in the hospital isn’t documented.

Here are three alternative solutions:

1. Ask the physician to elaborate on the clinical reasons why the patient necessitated another day stay in the hospital and submit that documentation to the insurance company.

2. Negotiate the charge with the insurance company and take a settlement on payment that is agreeable to both parties.

3. Have an internal utilization review group go through the patient’s chart and extract lab values, clinical presentation symptoms, testing, etc., that were done on day of stay being disputed and submit to insurance company as an appeal to denial to pay, demonstrating necessity to stay.

● Patient disputes charges during stay and refuses to pay them. The patient gets a PICC line (invasive procedure, longer term intravenous line) placed for IV antibiotics to be infused for one to two weeks. The PICC line is placed because one to two weeks of antibiotics is not something typically a peripheral IV line would be used for because they don’t hold up as well and can’t infiltrate or the patient could get phlebitis. Then, after the PICC line is placed, two days later the doctor decides to discontinue IV antibiotics and remove the PICC line. The patient refuses to pay for the PICC line because it wasn’t used for one to two weeks as the doctor had originally said and feels he should not pay for the doctor’s “change of mind.”

Here are three alternative solutions:

1. Meet with the patient to discuss his case and explain that with his initial clinical presentation, the physician’s decision to place the PICC line was reasonable and the hospital will not waive charges.

2. Agree to negotiate charge with the patient because the PICC line was placed with reasonable and prudent judgment but was not utilized as long as was initially discussed with the patient.

3. Agree to drop charges for PICC line placement.

● Patient is not able to obtain resources needed when discharged. A patient is ready for discharge to home but is on an expensive antibiotic. Even with insurance, she can’t afford the co-pay of $200. So the health care team has to try to find a resource to help the patient pay for the antibiotic or find a replacement drug.

196 PART 3 • MANAGING RESOURCES

Staff Impact on Budget Staff can acutely affect the organization’s finances. Misuse of sick time, excessive overtime or turnover, and wasteful use of resources can result in negative variance. The manager plays a key role in explaining the unit’s goals, the organization’s financial goals, and how each individual is responsible for helping the organization meet those goals.

Improving Performance Organizations have implemented a number of different programs and incentives for increasing employee awareness and minimizing costs. Techniques to decrease absenteeism and turnover may be instituted (see Chapter 20). Displaying equipment costs on supply stickers or requisitions and indicating medication costs on medication sheets increase staff awareness of costs. Participa- tion in quality improvement and action teams also serves to inform staff of cost factors. Bonuses based on net gains have been shared with employees, in addition to cost-of-living raises.

When one staff member wants to take time off, the shift still must be covered. Nurse man- agers must hire enough staff to cover the unit even when people are on vacation without using excessive overtime. Float pool or PRN staff (staff scheduled on an as-needed basis) are often used to cover staff time off. Managers must plan how to cover each employee’s nonproductive time (vacation, sick, education, etc.) in the least expensive way.

BUDGET MANAGEMENT Byron Marshall is a nurse manager for the surgical ser- vices department of a private orthopedic hospital. Byron has received notice from the vice president of clinical services that next year’s budget is due to her for review at the end of the month. Byron has kept careful records during the previous 12 months for use in preparing the surgical services department budget.

Each month, Byron has received and reviewed monthly reports of revenue and expense for his department. He validated each month’s budget targets, carefully noting areas that didn’t meet budget projections. For example, when April pharmacy charges were 15 percent above budget projections, Byron noted that surgery volume was up 30 percent over the previous year, accounting for the increase in preanesthesia drug charges. Nursing salaries were also over budget for the year, but again, increased surgery volume had resulted in the addition of two full-time surgery technicians to the department. When summer vacations resulted in agency staffing in the OR, Byron saved copies of the approval from the vice president and the human resources department and noted the total cost to his department.

Byron will use the budget information for the past 12 months to project the next fiscal year’s budget for his department. Information from the human resources department provides data for cost of living and merit increases in salary, while materials management has pro- jected a 20 percent across-the-board increase in surgi- cal supplies and pharmaceutical charges. Byron will also

request replacement of two OR tables and three gur- neys as part of the capital budget. These items had been requested by staff during the last department meeting when Byron asked for changes and improvements in the budget. Budget discussion is part of each staff meeting and Byron provides copies of actual budget numbers to the staff each month. He has found that showing rev- enue and expense reports to staff increases compliance with overtime expenses and supply usage.

With monthly preparation, good record keeping, and accurate analysis, Byron is confident that his budget pre- sentation will be on time and on target.

Manager’s Checklist The nurse manager is responsible for:

● Learning and understanding the responsibilities of financial planning for the department

● Reviewing monthly revenue and expense reports for accuracy and completeness

● Understanding and tracking the reasons why particular areas did not meet the budget

● Communicating to staff the importance of fiscal responsibility

● Planning for capital items on an ongoing basis ● Identifying and incorporating increasing or

decreasing expenses into the department budget ● Preparing and presenting a complete departmental

budget to administration

CASE STUDY 14-1

CHAPTER 14 • BUDGETING AND MANAGING FISCAL RESOURCES 197

Magnet Hospital Performance In Magnet-certified hospitals, staff are taught about budgeting and how the unit’s money “works.” Bedside staff make excellent, informed decisions about what resources should be used and understand the give and take of budget management. Bedside staff are empowered to make decisions that impact how they work. For example, the charge nurse on the unit takes phone calls about unit staffing. The float pool might have an additional aide coming in to work who is not assigned yet. The charge nurse takes the phone call from the staffing office to ask if the unit needs another aide and makes the decision.

Another example includes flexing staff for needs on the unit. The charge nurse, along with the coworkers, decide whether someone can be sent home on a slow day or if another staff mem- ber should be called in if the unit is excessively busy.

Managing fiscal resources is a challenge for all nurse managers. This is even more true to- day as legislation and regulation of health care reform is implemented. Close attention to costs, balanced by awareness of quality and patient safety, is essential.

Case Study 14-1 illustrates how one nurse manager handled his budget.

What You Know Now • A budget is a quantitative statement, usually written in monetary terms, of plans and expectations over a

specified period of time. • The operating or annual budget is the organization’s statement of expected revenues and expenses for the

coming year. • The revenue budget represents the patient care revenues expected for the budget period based on volume

and mix of patients, rates, and discounts that will prevail during the same period of time. • Nursing units are typically considered cost centers, but may be considered revenue centers, profit centers,

or investment centers. • Nurse managers may be responsible for service lines and staff from multiple disciplines and departments. • Nurse managers have input into capital expenses and are responsible for salary and operating costs related

to new equipment. • A full-time equivalent (FTE) is a full-time position that can be equated to 40 hours of work per week for

52 weeks, or 2,080 hours per year. • The position control is a list of approved, budgeted FTEs that compares the budgeted number of FTEs by

classification (RN, LPN), shift, and status to the actual available employees of the unit. • Variance is the difference between the amount that was budgeted for a specific revenue or cost and the

actual revenue or cost that resulted during the course of activities. • Monitoring the budget throughout the year requires attention to variances and the reasons they occurred.

Tools for Budgeting and Managing Resources 1. Understand the budgeting process in your organization. 2. Determine the number of full-time equivalents necessary to staff the unit. 3. Compute the salary and nonsalary budget, including salary increases and various additional factors. 4. Monitor variances over the budget period and identify negative variances, keeping notes in your

files. 5. Understand that factors out of your control, such as changes in technology or indirect or direct costs

that may be assigned to your budget, affect your budget and its performance. 6. Encourage staff to monitor resource use, including time and supplies.

Questions to Challenge You 1. Do you have a budget for your personal and professional income and expenses? If so, how well

do you manage it? If not, begin next month to track your income and expenses for one month. See if you are surprised at the results.

198 PART 3 • MANAGING RESOURCES

2. How well does your organization manage its resources? Can you make suggestions for improvement?

3. Are there tasks or functions in your work that you believe are redundant, unnecessary, or repetitive or that could be done by a lesser-paid employee? Explain.

4. Does your organization waste salary or nonsalary resources? If not, think of ways that organizations could waste resources. Describe them.

References Buerhaus, P. I. (2010). Health

care payment reform: Impli- cations for nurses. Nursing Economics, 28(1), 49–54.

Dunham-Taylor, J., & Pinczuk, J. Z. (2009). Financial man- agement for nurse manag- ers: Merging the heart with the dollar. Burlington, MA: Jones & Bartlett.

Finkler, S. A., & Kovner, C. T. (2007). Financial manage- ment for nurse managers and executives (3rd ed.). St. Louis, MO: Saunders.

Joint Commission. (2011). Com- prehensive accreditation manual for hospitals: The official handbook. Retrieved July 28, 2011 from

http://www. jcrinc.com/ Accreditation-Manuals/ PCAH11/2130/

Welton, J. M., Zone-Smith, L., & Bandyopadhyay, D. (2009). Estimating nursing intensity and direct cost using the nurse-patient assignment. Journal of Nursing Admin- istration, 39(6), 276–284.

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

http://www.jcrinc.com/Accreditation-Manuals/PCAH11/2130/

www.nursing.pearsonhighered.com

http://www.jcrinc.com/Accreditation-Manuals/PCAH11/2130/

CHAPTER

The Recruitment and Selection Process

Recruiting Applicants WHERE TO LOOK

HOW TO LOOK

WHEN TO LOOK

HOW TO PROMOTE THE ORGANIZATION

CROSS-TRAINING AS A RECRUITMENT STRATEGY

Selecting Candidates

Interviewing Candidates PRINCIPLES FOR EFFECTIVE INTERVIEWING

INVOLVING STAFF IN THE INTERVIEW PROCESS

INTERVIEW RELIABILITY AND VALIDITY

Making a Hire Decision EDUCATION, EXPERIENCE, AND LICENSURE

INTEGRATING THE INFORMATION

MAKING AN OFFER

Legality in Hiring

Recruiting and Selecting Staff 15

Key Terms Four Ps of marketing Age Discrimination Act Americans with Disabilities Act Behavioral interviewing Bona fide occupational

qualification (BFOQ)

Business necessity Interrater reliability Interview guide Intrarater reliability Negligent hiring Personnel decisions

Position description Validity Work sample questions

1. Describe how to recruit applicants. 2. Discuss how to select candidates. 3. Describe how to interview prospective

candidates. 4. Distinguish between appropriate and

inappropriate questions to ask during an interview.

5. Determine how to make a hiring decision.

6. Discuss the legal issues involved in hiring.

Learning Outcomes After completing this chapter, you will be able to:

200 PART 3 • MANAGING RESOURCES

The Recruitment and Selection Process Recruiting and selecting staff who will contribute positively to the organization is crucial in the fast-paced world of health care and in the face of ever-increasing nursing shortages (U.S. Department of Labor, 2011). The direct costs of recruiting, selecting, and training an employee who must later be terminated because of unsatisfactory performance is expensive and unneces- sary. The hidden costs may be even more expensive and include poor quality of work, disruption of morale, and patients’ ill will and dissatisfaction, which may contribute to later liability.

The purpose of the recruitment and selection process is to match people to jobs. Respon- sibility for selecting nursing personnel in health care organizations is usually shared by the hu- man resources (HR) department, which may include a nurse recruiter, and nursing management. First-line nursing managers are the most knowledgeable about job requirements and can best describe the job to applicants. HR performs the initial screening and monitors hiring practices to be sure they adhere to legal stipulations.

Before recruiting or selecting new staff, those responsible for hiring must be familiar with the position description. The position description (see Box 15-1) describes the skills, abilities, and knowledge required to perform the job.

The position description should reflect current practice guidelines and include:

● Principal duties and responsibilities involved in a particular job ● Tasks required to carry out those duties ● Personal qualifications (skills, abilities, knowledge, and traits) needed for the position ● Competency-based behaviors (perhaps)

Recruiting Applicants The purpose of recruitment is to locate and attract enough qualified applicants to provide a pool from which the required number of individuals can be selected. Even though recruiting is pri- marily carried out by HR staff and nurse recruiters, nurse managers and nursing staff play an important role in the process. Recruiting is easier when current employees spread the recruiting message, reducing the need for expensive advertising and reward methods.

The best recruitment strategy is the organization’s reputation among its nurses. Aiken and colleagues (Aiken et al., 2008) found that a positive hospital care environment not only reduced patient mortality but improved nurses’ perception of the work setting. Brady-Schwartz (2005) found that nurses in Magnet hospitals demonstrated higher levels of job satisfaction than those in non-Magnet hospitals. It follows that satisfied nurses are more likely to speak highly of the organization.

Individual nurse managers also affect how well the unit is able to attract and retain staff. A nurse manager who is able to create a positive work environment through leadership style and clinical expertise will have a positive impact on recruitment efforts, because potential staff members will hear about and be attracted to that area (e.g., hospital unit, home health team). In contrast, an autocratic manager is more likely to have a higher turnover rate and less likely to attract sufficient numbers of high-quality nurses.

Any recruiting strategy includes essentially four elements:

1. Where to look

2. How to look

3. When to look

4. How to sell the organization to potential recruits

Each of these elements may be affected by market competition, nursing shortages, reputa- tion, visibility, and location.

CHAPTER 15 • RECRUITING AND SELECTING STAFF 201

BOX 15-1 Position Description: Registered Nurse Adult Medical Intensive Care Unit (MICU)

Job Overview The medical intensive care unit registered nurse is re- sponsible for direct patient care of adults admitted to the MICU for management of complex life-threatening ill- ness. The RN reports directly to the MICU nurse manager.

Qualifications

● Current licensure in good standing in the state of practice.

● Minimum of one year previous adult ICU experi- ence within the past three years or two years telemetry experience within the past three years.

● Current BLS mandatory, ACLS or TNCC preferred. ACLS must be obtained with six months of employment.

Responsibilities

● Performs complete, individualized patient assess- ment within unit time frames and determines patient care priorities based on assessment findings.

● Completes additional patient assessments as re- quired, based on patient status, protocols, and/or physician orders.

● Administers medications and appropriate treat- ments as ordered by the physician accurately and within specified time frames.

● Initiates and maintains an individualized patient plan of care for each patient, using nursing interventions as appropriate.

● Provides ongoing education to the patient and the patient’s family.

● Documents patient assessments, medication and therapy administration, patient response to treat- ments, and interventions in an accurate and timely manner.

● Initiates emergency resuscitation procedures according to ACLS protocols.

● Maintains strict confidentiality of all information related to the patient and the patient’s family.

● Provides nursing care in a manner that is respectful and sensitive to the needs of the patient and the patient’s family and protects their dignity and rights.

● Communicates changes in patient condition to appropriate staff during the shift.

● Maintains (or obtains within six months of initial hire) certification in ACLS.

● Completes unit-based training modules for critical care competency on an annual basis.

Where to Look For most health care organizations, the best place to look is in their own geographic area. Dur- ing nursing shortages, however, many organizations conduct national searches. This effort is frequently futile because most nurses look for jobs in their local area. If the agency is in a ma- jor metropolitan area, a search may be relatively easy; if it is located in a rural area, however, recruitment may need to be conducted in the nearest city. Organizations tend to recruit where past efforts have been the most successful. Most organizations adopt an incremental strategy whereby they recruit locally first and then expand to larger and larger markets until a sufficient applicant pool is obtained.

Because proximity to home is a key factor in choosing a job, recruitment efforts should focus on nurses living nearby. The state board of nursing can provide the names of registered nurses by zip code to allow organizations to target recruitment efforts to surrounding areas. Also, personnel officers in large companies or other organizations in the area can be asked to assist in recruiting nurse spouses of newly hired employees.

Collaborative arrangements with local schools of nursing offer opportunities for recruit- ment. Providing preceptors or mentors for students during their clinical rotation or offering externships or residencies encourages postgraduation students to consider employment in the organization. Nurses who work with students play a key role in recruitment. Students are more likely to be attracted to the organization if they see nurses’ work valued and appreciated and perceive a positive impression of the work group.

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Employing students as aides may provide another recruitment tool because it allows students to learn first hand about the organization and what it has to offer. In turn, the organization can eval- uate the student as a potential employee post-graduation. Some organizations provide assistance with student loan payments if the student continues to work after graduation. Of major importance to new graduates is the orientation program. Graduates look for an orientation that provides suc- cessful transition into professional practice. Other top factors they consider are the reputation of the agency, benefits, promotional opportunities, specialty area, and nurse– patient ratio.

How to Look Posting online on general job search sites (e.g., www.monster.com) or on nurse-specific job referral sites (www.nurse.com) is a common practice. Professional associations such as Sigma Theta Tau International (http://stti.monster.com) and the American Nurses Association (www. nursingworld.org/careercenter) offer job search services. Specialty organizations, such as the American Organization of periOperative Nurses (http://www.aorn.org) could be used for a sur- gical nurse position.

Employee referrals, advertising in professional journals, attendance at professional conven- tions, job fairs, career days, visits to educational institutions, employment agencies (both private and public), and temporary help agencies are all recruiting sources. Advertising in professional journals, Websites, newspapers, or on public access TV can be an effective recruiting tool as well.

During extreme nursing shortages, some organizations offer bonuses to staff members who refer candidates and to the recruits themselves. Direct applications and employee referrals are quick and relatively inexpensive ways of recruiting people, but these methods also tend to perpetuate the current cultural or social mix of the workforce. It is both legally and ethically necessary to recruit individuals without regard to their race, ethnicity, gender, or disability. In addition, organizations can benefit from the diversity of a staff composed of people from a wide variety of social, experiential, cultural, generational, and educational backgrounds.

On the other hand, nurses referred by current employees are likely to have more realistic information about the job and the organization and, therefore, their expectations more closely fit reality. Those who come to the job with unrealistic expectations may experience dissatisfaction. In an open labor market, these individuals may leave the organization, creating high turnover. When nursing jobs are less plentiful or the economy is in a recession, dissatisfied staff members tend to stay in the organization because they need the job, but they are not likely to perform as well as other employees.

When to Look The time lag in recruiting is a concern to nursing because of the shortage. Positions in certain locations (e.g., rural areas) or specialty areas (e.g., critical care) may be especially difficult to fill. Careful planning is necessary to ensure that recruitment begins well in advance of antici- pated needs.

How to Promote the Organization A critical component of any recruiting effort is marketing the organization and available posi- tions to potential employees. The nursing division and/or HR should develop a comprehensive marketing plan. Generally, four strategies are included in marketing plans and are called the four Ps of marketing:

1. Product

2. Place

3. Price

4. Promotion

www.monster.com

www.nurse.com

http://stti.monster.com

www.nursingworld.org/careercenter

http://www.aorn.org

CHAPTER 15 • RECRUITING AND SELECTING STAFF 203

The consumer is the key figure toward which the four concepts are oriented, and in the recruiting process, the consumer is the potential employee.

Product is the available position(s) within the organization. Consider several aspects of the position and organization, such as:

● Professionalism ● Standards of care ● Quality ● Service ● Respect

Place refers to the physical qualities and location, such as:

● Accessibility ● Scheduling ● Parking ● Reputation ● Organizational culture

Price includes:

● Pay and differentials ● Benefits ● Sign-on bonuses ● Insurance ● Retirement plans

Promotion includes:

● Advertising ● Public relations ● Direct word of mouth ● Personal selling (e.g., job fairs, professional meetings)

Developing an effective marketing message is important. Sometimes the tendency is to use a “scatter-gun” approach (recruit everywhere), sugarcoat the message, or make it very slick. A more balanced message, which includes honest communication and personal contact, is prefer- able. Overselling the organization creates unrealistic expectations that may lead to later dissatis- faction and turnover.

Realistically presenting the job requirements and rewards improves job satisfaction, in that the new recruit learns what the job is actually like. Promising a nurse every other weekend off and only a 25 percent rotation to nights on a severely understaffed unit and then scheduling the nurse off only every third weekend with 75 percent night rotations is an example of unrealistic job information. It is important to represent the situation honestly and describe the steps that management is taking to improve situations that the applicant might find undesirable. He or she can then make an informed decision about the job offer.

Cross-Training as a Recruitment Strategy In today’s rapidly changing health care environment, the patient census fluctuates rapidly, and staffing requirements must be adjusted appropriately. These conditions may bring about lay- offs and daily cancellations and contribute to low morale. Offering cross-training to potential employees may increase the applicant pool.

Cross-training has the benefits of increasing morale and job satisfaction, improving effi- ciency, increasing the flexibility of the staff, and providing a means to manage fluctuations in the

204 PART 3 • MANAGING RESOURCES

census. It gives nurses, such as those in obstetrics and neonatal areas, an opportunity to provide more holistic care. On the other hand, some nurses do not want to be cross-trained, and thus requiring cross-training could reduce retention.

If cross-training is used, care should be taken to provide a didactic knowledge base in ad- dition to clinical training. How broadly to cross-train is an important decision, because training in too many areas may overload the nurse and reduce the quality of care. (See Chapter 17 on the use of floating to improve retention.)

Selecting Candidates Once an applicant makes contact with the organization, HR reviews the application and may conduct a preliminary interview (see Table 15-1). If the applicant does not meet the basic needs of the open position or positions, he or she should be so informed. Rejected applicants may be qualified for other positions or may refer friends to the organization and thus should be treated with utmost courtesy.

Reference checks and managerial interviews are next. In most cases, the interview is last, but practices may vary. Even if an applicant receives poor references, it is prudent to carry out the interview so that the applicant is not aware that the reference checking led to the negative decision. In addition, applicants may feel they have a right to “tell their story” and may sponta- neously provide information that explains poor references.

The nurse manager should participate in the interview process because he or she is:

● Best able to assess applicants’ technical competence, potential, and overall suitability ● Able to answer applicants’ technical, work-related questions more realistically.

In some organizations, the candidate’s future coworkers also participate in the interview process to assess compatibility.

The nurse manager must keep others involved in the selection process informed. The man- ager is usually the first to be aware of potential resignations, requests for transfer, and maternity or family medical leaves that require replacement staff. The manager is also aware of changes in the work area that might necessitate a redistribution of staff, such as the need for a night rather than a day nurse. Communicating these needs to HR promptly and accurately helps ensure effec- tive coordination of the selection process.

TABLE 15-1 Selection Process

1. Review application (nurse manager and HR)

2. Conduct screening interview (HR).

3. Contact references (HR).

4. Conduct second interview (nurse manager).

5. Compare applicants (nurse manager/nursing department).

6. Make hire/no hire decision (nurse manager/nursing department).

7. Perform background check (HR).

8. Make phone offer, conditional on clean drug test within 24 hours (nurse manager).

9. With clean drug test, offer is official.

CHAPTER 15 • RECRUITING AND SELECTING STAFF 205

Interviewing Candidates The most common selection method, the interview, is an information-seeking mechanism be- tween an individual applying for a position and a member of an organization doing the hiring. After the applicant’s initial screening with HR, the nurse manager usually conducts an interview.

The interview is used to clarify information gathered from the application form, evaluate the applicant’s responses to questions, and determine the fit of the applicant to the position, unit, and organization. In addition, the interviewer should provide information about the job and the organization. Finally, the interview should create goodwill toward the employing organization through good customer relations.

An effective interviewer must learn to solicit information efficiently and to gather relevant data. Interviews typically last between one and one and a half hours, and include an opening, an information-gathering and information-giving phase, and a closing. The opening is important because it is an attempt to establish rapport with the applicant so she or he will provide relevant information.

Gathering information, however, is the core of the interview. Giving information is also im- portant because it allows the interviewer to create realistic expectations in the applicant and sell the organization, if that is needed. However, this portion of the interview should take place after the information has been gathered so that the applicant’s answers will be as candid as possible. The interviewer should answer any direct questions the candidate poses. Finally, the closing is intended to provide information to the candidate on the mechanics of possible employment.

Principles for Effective Interviewing Developing Structured Interview Guides Unstructured interviews present problems: if interviewers fail to ask the same questions of every candidate, it is often difficult to compare them. The interview is most effective when the infor- mation on the pool of interviewees is as comparable as possible. Comparability is maximized via a structured interview supported by an interview guide. An interview guide is a written document containing questions, interviewer directions, and other pertinent information so that the same process is followed and the same basic information is gathered from each applicant. The guide should be specific to the job, or job category.

Instead of the traditional interview questions, such as “tell me about yourself, what are your strengths and weaknesses, and why do you want to work for us,” specific questions that target job-related behaviors are more common today. Behavioral interviewing, also called competency-based interviewing, uses the candidate’s past performance and behaviors to predict behavior on the job. The questions are based on requirements of the position. Examples of spe- cific behaviors expected of staff nurses and related sample questions are found in Table 15-2.

In addition, you can develop additional questions based on the specific job. For example, you may want to add questions on teamwork and collaboration as they relate to the position. Box 15-2 lists job-related questions for a medical telemetry unit position that candidates could be asked.

Interview guides reduce interviewer bias, provide relevant and effective questions, minimize leading questions, and facilitate comparison among applicants. Space left between the questions on the guide provides room for note taking, and the guide also provides a written record of the interview. An example of an interview script is shown in Box 15-3.

Preparing for the Interview Most managers do not adequately prepare for the interview, which should be planned just like any business undertaking. All needed materials should be on hand, and the interview site should be quiet and pleasant. If others are scheduled to see the applicant, their schedules should be checked to make sure they are available at the proper time. If coffee or other refreshments are to be offered, advance arrangements need to be made. Lack of advance preparation may lead to insufficient interviewing time, interruptions, or failure to gather important information. Other problems include losing focus in the interview because of a desire to be courteous or because

206 PART 3 • MANAGING RESOURCES

TABLE 15-2 Examples of Behavioral Interview Questions

Behavior Sample Question

Decision making What was your most difficult decision in the last month, and why was it difficult?

Communication What do you think is the most important skill in successful communication?

Adaptability Describe a major change that affected you and how you handled it.

Delegation How do you make the decision to delegate? Describe a specific situation.

Initiative What have you done in school or in a job that went beyond what was required?

Motivation What is your most significant professional accomplishment?

Negotiation Give an example of a negotiation situation and your role in it.

Planning and organization

How do you schedule your time? What do you do when unexpected circum- stances interfere with your schedule?

Critical thinking Describe a situation in which you had to make a decision by analyzing informa- tion, considering a range of alternatives, and selecting the best choice for the circumstances.

Conflict resolution Describe a situation in which you had to help settle a conflict.

BOX 15-2 Job Related Questions for Medical Telemetry Unit

Describe your actions in the following situations.

1. You are documenting your patient’s heart rhythms in his medical record for the shift. A peer is sit- ting near you and doing the same. You see that RN document the patient’s heart rhythm as sinus rhythm, when you know the patient has had a trial fibrillation the whole shift.

2. The physician is rounding on your patient. The pa- tient has had an elevated blood pressure of 160/90 despite already having received all of her antihy- pertensive medications for the day. The patient has reported to you that she is also experiencing a head- ache. You tell the doctor about the blood pressure reading and the patient’s headache. You request that the physician order another medication to help lower the patient’s blood pressure. The physician says to you, “Oh, she’ll be fine” and begins to walk away.

3. You are caring for an elderly woman. Her daugh- ter is at her bedside. The patient has been having recurrent flare-ups of congestive heart failure and has been readmitted to the hospital three times in the last month. Each time she returns, the swelling in her extremities and her difficulty breathing is worse than the time before. The physician rounds on the patient and her daughter and shares that the health care team will work to help her, but it appears that her heart is getting weaker again,

and the congestive heart failure is going to con- tinue to get harder to manage. After the doctor leaves, you enter the room. The patient is sleeping and the daughter is quietly crying.

4. You run to the room of a patient where the code blue alarm has been activated. Your team is doing CPR and attaching the code cart to the patient. You put on gloves and step in to help. As you approach the bed of the patient, you look at the patient’s wrist and see a do not resuscitate brace- let on his arm.

5. You are caring for a patient with paranoid schizo- phrenia and a heart dysrhythmia. It is time to ad- minister his 9 A.M. meds. When you enter the room with the medications that the patient takes to prevent ventricular tachycardia, he begins scream- ing, “No, I won’t take those medications, you’re trying to poison me!”

6. You are caring for a patient who is recovering from a myocardial infarction. You have been talk- ing to her about her new cardiac diet and what she can do to be healthy when she leaves the hospital. You discuss eating low amounts of salt, a well-rounded diet rich in fruits and vegetables, and avoiding fried and sugary foods. Later in the day, you pass the patient’s room and see her eat- ing fried chicken and French fries that her family brought.

CHAPTER 15 • RECRUITING AND SELECTING STAFF 207

the interviewee is particularly dominant. This typically keeps the interviewer from obtaining the needed information.

In general, when time is limited, it is better to use part of it for planning rather than spend it all on the interview itself. Before the interview, the interviewer should review job requirements, the application and résumé, and note specific questions to be asked. Planning should be done on the morning of the interview or the evening before for an early morn- ing interview. If you are sure that time will be available, planning is best done immediately before an interview or between interviews. Unfortunately, a busy manager may have to deal with unexpected crises between interviews and may not be able to use the time to plan the next interview.

A cardinal rule is to review the application or résumé before beginning the interview. If the interviewee arrives with the résumé or application in hand, ask him or her to wait for a few min- utes while you review the material. In doing a quick review, look for the following four things:

1. Clear discrepancies between the applicant’s qualifications and the job specifications. If you find them, then only a brief interview may be necessary to explain why the applicant will not be considered. (If a preliminary screening is performed by the HR, such applicants should not be referred to nurse managers.)

2. Specific questions to ask the applicant during the interview.

3. A rapport builder (something you have in common with the applicant) to break the ice at the beginning of the interview.

4. Areas where you need more information. Remember that the résumé is prepared by the applicant and is intended to market an applicant’s assets to the organization. It does not give a balanced view of strengths and weaknesses. So, examine the résumé critically for gaps.

The setting of the interview is important in order to provide a relaxed, informal atmosphere. Both you and the applicant should be in comfortable chairs, as close together as comfortably possible. No table or desk should separate you. If you are using an office, arrange the chairs so that the applicant is at the side of the desk. There should be complete freedom from distracting phone calls and other interruptions. If the view is distracting, do not seat the applicant so that she or he can look out a window.

BOX 15-3 Interview Script for Hiring

1. Why did you choose to become a nurse? 2. Why would you like to work at this hospital? 3. What about this patient specialty interests you? 4. Tell me about your previous work experiences. 5. How do your previous work experiences prepare

you for this job? 6. How would your previous coworkers describe you? 7. What does teamwork mean to you? 8. Tell me about a time when you were successful

because of great teamwork. 9. Tell me about a time you experienced a lack of

teamwork. Describe what happened. 10. Describe a situation in which you had a conflict

with a patient or family member. What happened? 11. Tell me about a time you had a conflict with a

coworker or teacher. Explain what happened.

12. Tell me about a time you were working with someone who wasn’t putting his or her full effort forward, and it was impacting patient care. What did you do?

13. What makes you most nervous about coming to this job?

14. What do you find exciting about coming to this job?

15. What are you most proud of professionally? 16. What is something about you that makes you bet-

ter than any other candidate for this job? 17. What are you looking for from your manager? 18. What do you plan to do in the next five and

ten years of nursing and beyond? What are your goals?

19. What questions do you have about this job?

208 PART 3 • MANAGING RESOURCES

Opening the Interview Begin the interview on time. Give a warm, friendly greeting, introduce yourself, and ask the applicant for her or his preferred name. Try to minimize your status; do not patronize or domi- nate. The objective is to establish an open atmosphere so applicants reveal as much as pos- sible about themselves. Establish and maintain rapport throughout the interview by talking about yourself, discussing mutual interests such as hobbies or similar experiences, and using nonver- bal cues, such as maintaining eye contact. Finally, start the interview by outlining what will be discussed and setting a limit on the meeting time.

Be careful not to form hasty first impressions. Interviewers tend to be influenced by first impressions of a candidate, and such judgments often lead to poor decisions. First impressions may degrade the quality of the interview; interviewers may search for information to justify their first impressions, good or bad. If you have gotten a negative first impression and thus decide not to hire a potentially successful candidate, you have wasted an hour or so and possibly lost a good recruit. If, you hire an unsuccessful candidate based on a positive first impression, problems may continue for months. Conversely, your personal characteristics may influence the applicant’s de- cisions. You create first impressions with your tone of voice, eye contact, personal appearance, grooming, posture, and gestures.

Take notes, using the structured interview guide. Explain that you are doing this in order to remember more about what is discussed in the interview, and tell the candidate that you hope he or she does not mind. There are various ways to ask questions, but ask only one at a time. When possible, ask open-ended questions, such as those listed in Table 15-1. Open-ended questions cannot be answered with a yes, no, or one-word answer and usually elicit more information about the applicant (Parrish, 2006). Closed questions (e.g., what, where, why, when, how many) should only be used to elicit specific information.

Work sample questions are used to determine an applicant’s knowledge about work tasks and his or her ability to perform the job. It is easy to ask a nurse whether she or he knows how to care for a patient who has a central intravenous line in place. A yes answer does not necessarily prove the candidate’s ability, so you might ask some very specific ques- tions about central lines. Avoid leading questions, in which the answer is implied by the question (e.g., “We have lots of overtime. Do you mind overtime?”). You may also want to summarize what has been said, use silence to elicit more information, repeat the applicant’s statements back to him or her to clarify an issue, or indicate acceptance by urging the appli- cant to continue.

Giving Information Before reaching the information-giving part of the interview, consider whether the candidate is promising enough to warrant spending a lot of time on this. Unless the candidate is clearly unac- ceptable, be careful not to communicate a negative impression, because your evaluation of the candidate may change when the entire packet of material is reviewed or if more promising can- didates decline the job offer. You must also know what information you should give, and what is being provided by others. Detailed benefit or compensation questions are usually answered by HR. If you cannot answer a promising candidate’s questions, arrange for someone to contact the candidate later with that information.

Closing the Interview You may want to summarize the applicant’s strengths at the end of the interview. Make sure to ask the applicant whether she or he has anything to add or ask about the job and the or- ganization. You may also want to mention the candidate’s weaknesses, particularly if they are objective and clearly related to the job (such as lack of experience in a particular field). Mentioning a perception of a subjective weakness, such as poor supervisory skills, may lead to legal problems. Wrap up by thanking the applicant and completing any notes that you have been taking.

CHAPTER 15 • RECRUITING AND SELECTING STAFF 209

Involving Staff in the Interview Process Today’s trend toward decentralization of decision making may lead to sharing interview re- sponsibilities with staff. Involving staff in interviews helps strengthen teamwork, improves work-group effectiveness, increases staff involvement in other unit activities, and increases the likelihood of selecting the best candidate for the position.

If staff are involved in interviews, several steps must be taken to protect the integ- rity of the interview process. An organized orientation to interviewing should be given that includes:

● Federal, state, and local laws and regulations governing interviewing, as well as any collective-bargaining agreements that may affect the process

● Tips on handling awkward interviewing situations ● Time for rehearsing interviewing skills; like the manager, staff should follow a structured

interview guide to help standardize the process

Graham Nelson is nurse manager of a dialysis center. Training a new renal dialysis nurse is an expensive process. To reduce turnover among nursing staff, Graham includes peer interviews as part of the overall interview process. Peer interviews can help ensure that potential employees will interact well with existing staff and ensure a cultural fit with the dialysis team. Additionally, an interviewee can gain a better understanding of the day- to-day workflow of the center.

Interview Reliability and Validity Numerous research studies have been performed on the reliability and validity of employment interviews. In general, agreement between two interviews of the same measure by the same in- terviewer (intrarater reliability) is fairly high, agreement between two interviews of the same measure by several interviewers (interrater reliability) is rather low, and the ability to predict job performance (validity) of the typical interview is very low. Research has also shown that:

1. Structured interviews are more reliable and valid.

2. Interviewers who are under pressure to hire in a short time or meet a recruitment quota are less accurate than other interviewers.

3. Interviewers who have detailed information about the job for which they are interviewing exhibit higher interrater reliability and validity.

4. The interviewer’s experience does not seem to be related to reliability and validity.

5. There is a decided tendency for interviewers to make quick decisions and therefore be less accurate.

6. Interviewers develop stereotypes of ideal applicants against which interviewees are evalu- ated. Individual interviewers may hold different stereotypes, which decreases interrater reliability and validity.

7. Race and gender may influence interviewers’ evaluations.

The greatest weakness in the selection interview may be the tendency for the interviewer to try to assess an applicant’s personality characteristics. Although it is difficult to eliminate such subjectivity, evaluations of applicants are often more subjective than they need to be. Informa- tion collected during an interview should answer three fundamental questions:

1. Can the applicant perform the job?

2. Will the applicant perform the job?

3. Will the candidate fit into the culture of the unit and the organization?

210 PART 3 • MANAGING RESOURCES

The best predictor of the applicant’s future behavior in these respects is past performance. Previous work and other experience, past education and training, and current job performance should be considered rather than personality characteristics, which even psychologists cannot measure very accurately.

Making a Hire Decision Education, Experience, and Licensure Education and experience requirements for nurses have long been important screening factors and bear a close relationship to work sample tests. Educational requirements are a type of job knowledge sample because they tend to ensure that applicants have at least a minimal amount of knowledge necessary for the job.

Educational preparation is particularly important for nurses. For example, nurses who are graduates of associate degree and diploma programs are prepared to care for individuals in struc- tured settings and use the nursing process, the decision-making process, and their management skills in the care of those individuals. Baccalaureate graduates can provide nursing care for in- dividuals, families, groups, and communities using the nursing and decision-making processes. Baccalaureate graduates are also prepared for beginning community health positions and pos- sess the leadership and management skills needed for entry-level management positions.

Avoid making assumptions about the type of experience and number of years of experience that an applicant has. Factors such as job requirements, patient acuity, clinic populations, au- tonomy, and degree of specialization vary from organization to organization. Therefore, careful interviewing is needed to determine the applicant’s knowledge and skill level.

References and letters of recommendation are also used to assess the applicant’s past job experience, but there is little evidence that these have any validity. Because few people write unfavorable letters of recommendation, such letters do not really predict job performance. Criti- cisms are likely to be mild and may be reflected by the lack of positive language. Letters with any criticism should be verified with a telephone call, if possible, to avoid overreacting to an unusually honest author.

To avoid legal problems, many organizations only include employment dates, salary, and whether the applicant is eligible for rehire in letters of recommendation. Many organizations do not allow supervisors to write letters of recommendation. Negative references may be viewed as a potential for slander or other legal recourse. Almost every organization will at least verify position title and dates of employment, which helps detect the occasional applicant who falsifies an entire work history. Unfortunately, leaving out a position from a work history is more common than in- cluding a position not actually held. The only way to detect such omissions is to ask that candidates list the year and month of all their educational and work experiences. Caution is necessary when asking about time between jobs; be careful not to inquire about marital or family status.

In almost every selection situation, an applicant fills out an application form that requests information about previous experience, education, and references. As application forms are re- viewed, the critical question to be asked is whether the applicant has distorted responses, either intentionally or unintentionally. Studies indicate that there is usually little distortion, at least not on the easily verifiable information. Applicants may stretch the truth a bit, but rarely are there complete falsehoods. Relative to other predictors, the application form may be one of the more valid predictors in a selection process.

Licensure status can be verified online with the state board of nursing. Because results of the computerized NCLEX-RN® examination are available in 7 to 10 days, most organizations wait for new graduates to obtain a license before starting employment.

Integrating the Information When comparing candidates, first weigh the qualities required for the job in order of importance, placing more emphasis on the most important elements. Second, weigh the qualities desired on the basis of the reliability of the data. The more consistent the observation of behavior from different

CHAPTER 15 • RECRUITING AND SELECTING STAFF 211

elements in the selection system, the more weight that dimension should be given. Third, weigh job dimensions by trainability—consider the amount of education, experience, and additional training the applicant can reasonably be expected to receive, and consider the likelihood that the behavior in that dimension can be improved with training. Dimensions most likely to be learned in training (e.g., using new equipment) should be given the least weight so that more weight is placed on dimensions less likely to be learned in training (e.g., being emotionally able to care for terminally ill children).

Attempt to compare data across individuals in making a decision. It is more accurate to make decisions based on a comparison of several persons than to make a decision for each indi- vidual after each interview. Analysis of the entire applicant pool requires good interview records but lessens the impact of early impressions on the hiring decision because the interviewer must consider each job element across the entire pool.

Making an Offer Before an offer is made, most organizations obtain permission to do criminal background checks. After the interview, if the nurse manager wants to offer a position to a candidate, HR is notified. HR then does a thorough background check on the candidate to confirm reported criminal history, licensure, and employment history. After that clears, the candidate is called and offered the position, with the condition that a drug screen completed within 24 hours of the phone offer is clean. If so, the offer is official.

In addition, organizations are liable for the character and actions of the employees they hire. To satisfy this requirement, the employer must check applicants’ backgrounds before hiring in regard to licensure, credentials, and references. Failure to do so constitutes negligent hiring if that employee harms a patient, visitor, or another employee.

Legality in Hiring As a result of Title VII of the Civil Rights Act of 1964, the Equal Pay Act of 1963, the Age Discrimination Act of 1967, and Title I of the Americans with Disabilities Act of 1990 and its amendments of 2009, recruitment and selection activities are subject to considerable scrutiny regarding discrimination and equal employment opportunity. Title VII of the Civil Rights Act specifically prohibits discrimination in any personnel decision on the basis of race, color, sex, religion, or national origin. “Any personnel decision” includes not only selection but also en- trance into training programs, performance appraisal results, termination, promotions, compen- sation, benefits, and other terms, conditions, and privileges of employment.

The Act applies to most employers with more than 15 employees, although there are several exemptions—among them, a bona fide occupational qualification (BFOQ), a business necessity, and the validity of the procedure used to make the personnel decision. Discrimination is allowed on the basis of national origin (citizenship or immigration status), religion, sex, and age; for in- stance, if that discrimination can be shown to be a “bona fide occupational qualification reasonably necessary for the normal operation of a business.” Examples include a woman playing a female part in a play, a Sunday school teacher of a certain religion, or a female correctional counselor at a women’s prison. Claims of “customer preference” for female flight attendants or gross gender characteristics such as “women cannot lift over 30 pounds” have not been supported as BFOQs.

A BFOQ allows an organization to exclude members of certain groups (such as all men or all women) if the organization can demonstrate that a selection method is a business necessity. A business necessity is likely to withstand a legal challenge only in the unusual instances when a selection method that discriminates against a protected group is necessary to ensure the safety of workers or customers.

The Equal Employment Opportunity Commission (EEOC) is charged with enforcing and interpreting the Civil Rights Act and has issued Uniform Guidelines on Employee Selection Procedures (43 Federal Register, 1978). The guidelines specify the kinds of methods and infor- mation required to justify the job relatedness of selection procedures. These guidelines are not described in detail here; however, the methods of selection discussed in this chapter do follow

212 PART 3 • MANAGING RESOURCES

their specifications. Remember that the law does not say one cannot hire the best person for the job. What it says is that race, color, sex, religion, disability, national origin, or any other pro- tected factor must not be used as selection criteria. As long as the decision is not made on the basis of protected status, one is complying with the Equal Employment Opportunity (EEO) law.

EEO law and successive court decisions have had three major impacts on selection proce- dures. First, organizations are more careful to use predictors and techniques that can be shown not to discriminate against protected classes. Second, organizations are reducing the use of tests, which may be difficult to defend if they screen out a large number of minority applicants. Third, organizations are relying heavily on the interview process as a selection device. Interviews are also subject to EEO and other regulations.

Table 15-3 presents appropriate questions to ask in an interview. The basic rule of thumb for interviewing is when you are in doubt about a question’s legality, ask, How is this question related to job performance? If it can be proved that only job-related questions are asked, EEO law will not be violated.

The Age Discrimination Act prohibits discrimination against applicants and employees over the age of 40. Questions in recruitment and selection that are appropriate with respect to age are also presented in Table 15-3.

TABLE 15-3 Preemployment Questions

Appropriate to Ask Inappropriate to Ask

Name Applicant’s name. Whether applicant has school or work records under a different name.

Questions about any name or title that indicate race, color, religion, sex, national origin, or ancestry.

Questions about father’s surname or mother’s maiden name.

Address Questions concerning place and length of current and previous addresses.

Any specific probes into foreign addresses that would indicate national origin.

Age Requiring proof of age by birth certificate after hiring. Can ask if applicant is over 18.

Requiring birth certificate or baptismal record before hiring.

Birthplace or national origin

Any question about place of birth of applicant or place of birth of parents, grandparents, or spouse.

Any other question (direct or indirect) about applicant’s national origin.

Race or color Can request after employment as affirmative action data.

Any inquiry that would indicate race or color.

Sex Any question on an application blank that would indicate sex.

Religion Any questions to indicate applicant’s religious denomination or beliefs.

A recommendation or reference from the applicant’s religious denomination.

Citizenship Questions about whether the applicant is a U.S. citizen; if not, whether the applicant intends to become one.

Questions of whether the applicant, parents, or spouse are native born or naturalized.

Questions regarding whether applicant’s U.S. residence is legal; requiring proof of citizenship after hiring.

Requiring proof of citizenship before hiring.

CHAPTER 15 • RECRUITING AND SELECTING STAFF 213

TABLE 15-3 Continued

Appropriate to Ask Inappropriate to Ask

Photographs May require after hiring for identification purposes only.

Requesting a photograph before hiring.

Education Questions concerning any academic, professional, or vocational schools attended.

Questions specifically asking the nationality, racial, or religious affiliation of any school attended.

Inquiry into language skills, such as reading and writing of foreign languages.

Inquiries as to the applicant’s mother tongue or how any foreign language ability was acquired (unless it is necessary for the job).

Relatives Name, relationship, and address of a person to be notified in case of an emergency.

Any unlawful inquiry about a relative or residence mate(s) as specified in this list.

Children Questions about the number and ages of the applicant’s children or information on child-care arrangements.

Transportation Inquiries about transportation to or from work (unless a car is necessary for the job).

Organization Questions about organization memberships and any offices that might be held.

Questions about any organization an applicant belongs to that may indicate the race, age, disabilities, color, religion, sex, national origin, or ancestry of its members.

Physical condition/ disabilities

Questions about being able to meet the job requirements, with or without some accommodation.

Questions about general medical condition, state of health, specific diseases, or nature/severity of disability.

Military service Questions about services rendered in armed forces, the rank attained, and which branch of service.

Questions about military service in any armed forces other than the United States.

Requiring military discharge certificate after being hired.

Requesting military service records before hiring.

Work schedule Questions about the applicant’s willingness to work the required work schedule.

Questions about applicant’s willingness to work any particular religious holiday.

References General and work references not relating to race, color, religion, sex, national origin or ancestry, age, or disability.

References specifically from clergy (as specified above) or any other persons who might reflect race, age, disability, color, sex, national origin, or ancestry of applicant.

Financial Questions about banking, credit rating, outstanding loans, bankruptcy, or having wages garnished.

Other qualifications Any question that has direct reflection on the job to be applied for.

Any non-job-related inquiry that may present information permitting unlawful discrimination. Questions about arrests or convictions (unless necessary for job, such as security clearance).

214 PART 3 • MANAGING RESOURCES

The Americans with Disabilities Act that took effect in July 1990 prohibits discrimination based on an individual’s disability. A disability is defined as a physical or mental impairment that substantially limits one or more of the major life activities, or has a record of such impair- ment (e.g., attended a school for the deaf), or is regarded as having such an impairment (e.g., uses a cane to walk). A qualified individual is one who, with or without reasonable accommoda- tion, can perform the essential functions of the position under consideration.

The Act was amended in 2009 (U.S. Department of Justice, 2009). The definition of a dis- ability was broadened in several ways beneficial to employees: The amended Act includes dis- abilities not previously covered (e.g., epilepsy, diabetes, bipolar disorder). The amendments expand the definition of major life activities to include major bodily functions (e.g., immune system, brain functions) and eliminate the ameliorative effects of mitigating measures from con- sideration (e.g., medication, prosthetics).

Employers with 15 or more employees are required to make accommodations to the known disability of a qualified applicant if it will not impose “undue hardship” on the operation of the business. Reasonable accommodations may include making existing facilities used by employ- ees readily accessible to and usable by individuals with disabilities; job restructuring; part-time or modified work schedules; reassignment to a vacant position; acquiring or modifying equip- ment or devices; adjusting or modifying examinations, training materials, or policies; and pro- viding qualified readers and interpreters.

SELECTING STAFF Jack Turner is nurse manager of the emergency depart- ment in a large metropolitan area hospital. He has four full-time RN positions open in his department. There are three nursing programs located in the city: a state uni- versity program, a community college program, and an RN-to-BSN completion program.

Jack recently participated in a nursing job fair hosted by his hospital. The event was well attended by nursing students, and he received several promising résumés of soon-to-be graduate nurses. Jack notes that one of the applicants, Sabrina Ashworth, will graduate next month with a BSN. She has been working for the past year as a nursing assistant in the ER of another local hospital. In addition to her ER work, Sabrina has a high grade point average and indicates a strong interest in trauma and critical care. Jack contacts the human resource depart- ment to set up an interview with Sabrina.

Sabrina agrees to an interview for an RN position in the ER department. Jack schedules a conference room adjacent to the ER for the interview. Prior to Sabrina’s arrival, he reviews her résumé and application, noting her educational background, previous work history, and recent volunteer trip to Mexico to assist with a vaccina- tion program. Jack has assembled a packet for Sabrina, including a job description and materials from human resources that outline the application process.

The interview begins promptly. Jack warmly greets Sabrina and establishes rapport. He follows the interview guide provided by the human resource department. Jack

informs Sabrina that he will be taking notes during the interview process. After reviewing her educational and work history, Jack asks Sabrina several situational ques- tions related to work in the ER. He also allows time for Sabrina to ask questions about the RN position. Jack also has two RN staff members give Sabrina a tour of the ER department. Finally, Jack outlines the next steps in the application process and indicates that he will follow up with Sabrina in 7 to 10 days.

Following the interview, Jack works with the human resource department and asks for transcript and refer- ence checks for Sabrina. After verifying her transcript and receiving positive references, Jack extends an offer to Sabrina, which she accepts.

Manager’s Checklist The nurse manager is responsible for:

● Understanding the organization’s human resource policies and procedures related to selecting staff

● Working closely with the human resource department to facilitate the selection and hiring of qualified staff

● Knowing state and federal regulations related to the application and interview process

● Preparing for the interview process ● Conducting the interview ● Following up with applicants in a timely manner

CASE STUDY 15-1

CHAPTER 15 • RECRUITING AND SELECTING STAFF 215

The 2009 amendments included some employer-friendly provisions as well. Reverse dis- crimination claims by nondisabled individuals are not in violation of the Act. Although the pool of individuals covered in the amendments is expanded, the reasonable accommodation features remain the same, as do existing exclusions for criminal behavior and current drug use.

Recruiting and selecting the most appropriate staff is one of the most important jobs in an organization. Candidates whose qualifications fit the job requirements are more likely to be pro- ductive and to remain on the job. The tendency, especially during times of shortages, is to short- cut the process, but this is ill advised. The effort to attract and select the best candidates pays off over time for the organization.

One nurse manager used the recommendations in this chapter to hire a nurse as shown in Case Study 15-1.

What You Know Now • The selection of staff is a critical function that requires matching people to jobs, and responsibility for

hiring is often shared by HR and nurse managers. • Position description is fundamental to all selection efforts because it defines the job. • Recruitment is the process of locating and attracting enough qualified applicants to provide a pool from

which the required number of new staff members can be chosen. • Selection processes should be job related and most often include screening application forms, résumés,

medical examinations, reference and background checks, and interviews. • Interviewing is a complex skill that is intended to obtain information about the applicant and to give the

applicant information about the organization. • Successful interviews require planning, implementation, and follow-up in order to make the best

decisions. • Developing a structured interview guide is a critical element in interviewing. • Selection decisions are subject to provisions in the Civil Rights Act of 1964, Equal Pay Act of 1963, the

Age Discrimination Act of 1967, and the Americans with Disabilities Act of 1990 as amended in 2009.

Tools for Recruiting and Selecting Staff 1. Conduct or modify a job description as needed. 2. Coordinate recruitment efforts with the human resource department. 3. Ensure that your area of responsibility sends the message you want (see Box 15-1). 4. Prepare adequately for interviews. 5. Conduct interviews following recommendations presented in the chapter. 6. Process the information obtained in interviews and reference and background checks to make a final

decision.

Questions to Challenge You 1. What approach does your organization use to recruit employees? Is it effective? How could the pro-

cess be improved? 2. Imagine that a potential candidate asks you to describe your present workplace. What would you say? 3. Have you ever participated in a staff interview, either as a candidate or as a member of the staff?

Describe your experience. Would you do anything differently now that you’ve read the chapter? 4. Cross-training has been used as a recruitment strategy. What are the pros and cons of using this

strategy? 5. Consider the last interview you had for a job or school. Did the interviewer follow the principles dis-

cussed in this chapter? Explain.

216 PART 3 • MANAGING RESOURCES

References

Web Resources Job search websites:

Monster.com: www.monster.com Nurse.com: www.nurse.com Sigma Theta Tau International Honor Society of Nursing: http://stti.monster.com Nurse’s CareerCenter: www.nursingworld.org/careercenter

Aiken, L. H., Clarke, S. P., Sloane, D. M., Lake, E. T., & Cheney, T. (2008). Effects of hospital care environment on patient mor- tality and nurse outcomes. Journal of Nursing Adminis- tration, 38(5), 223–229.

Brady-Schwartz, D. C. (2005). Further evidence on the Magnet Recognition

Program: Implications for nursing leaders. Journal of Nursing Administration, 35(9), 397–403.

Parrish, F. (2006). How to recruit, interview, and retain employees. Dermatology Nursing, 18(2), 179–180.

U. S. Department of Justice. (2009). Americans with disabilities act of 1990, as

amended. Retrieved July 25, 2011 from http://www. ada.gov/pubs/ada.htm

U. S. Department of Labor, Bureau of Labor Statistics. (2011). Statistics on regis- tered nurses. Retrieved July 25, 2011 from http://www. dol.gov/wb/factsheets/ Qf-nursing-05.htm

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

www.monster.com

www.nurse.com

http://stti.monster.com

www.nursingworld.org/careercenter

http://www.ada.gov/pubs/ada.htm

http://www.dol.gov/wb/factsheets/Qf-nursing-05.htm

www.nursing.pearsonhighered.com

CHAPTER

Staffing PATIENT CLASSIFICATION SYSTEMS

DETERMINING NURSING CARE HOURS

DETERMINING FTEs

DETERMINING STAFFING MIX

DETERMINING DISTRIBUTION OF STAFF

Scheduling CREATIVE AND FLEXIBLE STAFFING

AUTOMATED SCHEDULING

SUPPLEMENTING STAFF

Staffing and Scheduling 16

1. Determine staffing needs. 2. Demonstrate how to use patient classifica-

tion systems to calculate nursing care hours necessary.

3. Calculate FTEs.

4. Determine the appropriate staffing mix and distribution of staff.

5. Describe the various ways to schedule staff. 6. Explain how to supplement staff when

needed.

Learning Outcomes After completing this chapter, you will be able to:

Baylor plan Block staffing Demand management Full-time equivalent (FTE)

Key Terms Nursing care hours (NCHs) Patient classification systems (PCSs) Pools Self-scheduling

Staffing Staffing mix

218 PART 3 • MANAGING RESOURCES

S taffing and scheduling is an important responsibility of the nurse manager and a critical aspect of providing nursing care. Higher nurse staffing levels reduce mortality in hospi-talized patients (Schilling et al., 2010; Needleman et al., 2011). Furthermore, failing to match patient needs to nurses’ skills also increases patient mortality (Needleman et al., 2011).

The impact of California’s mandated nurse staffing supports these findings. Not only did higher nurse staffing levels translate into lower mortality, but hospitals reported better nurse retention rates as a result (Aiken et al., 2010). In addition, Magnet hospitals report higher nurse staffing levels (Hickey et al., 2010) and improved teamwork (Kalisch & Lee, 2011).

Staffing The goal of staffing is to provide the appropriate numbers and mix of nursing staff (nursing care hours) to match actual or projected patient care needs (patient care hours) to provide effective and efficient nursing care. There is no single or perfect method to achieve this. In addition, vari- ability in patient census requires continuous fine-tuning.

A hospital unit may experience a steady census during the seven days of the week or a higher census from Monday to Friday. Its patient days may be distributed evenly during the year, or it may consistently experience peaks in occupancy in certain months (seasonality pattern) such as during an outbreak of influenza. Outpatient clinics may be busier on days when special- ists are available or vaccines are offered. Staffing is a challenge in all health care settings.

To determine the number of staff needed, managers must examine workload patterns for the designated unit, department, or clinic. For a hospital, this means determining the level of care, average daily census, and hours of care provided 24 hours a day, seven days a week.

Both the Joint Commission, hospitals’ accrediting body, and the American Nurses Association identify staffing requirements. The Joint Commission (2011) requires that the right number of competent staff be provided to meet patients’ needs based on organization-selected criteria. The American Nurses Association (ANA) (Manojlovich, 2009) specifies requirements for staffing systems as shown in Box 16-1.

Patient Classification Systems Patient classification systems (PCSs), sometimes referred to as patient acuity systems, use patient needs to objectively determine workload requirements and staffing needs. To be most effective, patient classification data are collected midpoint for every shift by the unit nursing staff and analyzed before the next shift to ensure appropriate numbers and mix of nursing staff.

Ideally, this system would accurately predict the number and skill level of nurses needed for the next shift. But much can go amiss. Some nurses may call in sick; the nurses scheduled may not have the skill set necessary for a new admission, for example; or, most important, the patient’s condition may change.

BOX 16-1 Requirements for Staffing Systems

A reliable and valid staffing plan must:

● Be created with input from direct-care registered nurses

● Be based on the number of patients and patient-acuity level with consideration of patient admissions, discharges, and transfers on each shift

● Reflect the level of preparation and experience of those providing care

● Reflect staffing levels recommended by specialty organizations

● Provide that an RN not be forced to work in a unit without having established that he or she is able to provide professional care on such a unit

Adapted from Manojlovich, M. (2009). Seeking staffing solutions. American Nurse Today, 4(3), 26.

CHAPTER 16 • STAFFING AND SCHEDULING 219

Picard and Warner (2007) suggest fine-tuning PCS systems to predict the demand for nursing expertise several days in advance. They complain that basing staffing on immediate patient needs is short-sighted and often results in failure as mentioned above. Their system, called demand man- agement, uses best-practices staffing protocols to predict and control the demand for nurses based on patient outcomes. Based on historical data, a patient progress pattern typifies expected patient outcomes throughout a stay. Deviations are tracked and staffing adjusted accordingly. This system allows the manager to staff into the next few days with more assurance than predicting from one shift to the next. Whatever system is used, the next step is to determine the necessary nursing care hours.

Determining Nursing Care Hours Patient workload trends are analyzed for each day of the week (each hour in critical care) or for a specific patient diagnosis to determine staffing needs, known as nursing care hours (NCHs). For example, if 26 patients with the following acuities required 161 nursing care hours, then an average of 6.19 nursing hours per patient per day (NHPPD) are required. NHPPD are calculated by divid- ing the total nursing care hours by the total census (number of patients).

There are no specific standards for NCHs for any type of patient or patient care unit. NCHs may vary on the average from five to seven hours of care for patients on medical and/or surgi- cal units, to 10 to 24 hours of care for patients in critical care units, to 24 to 48 hours of care for selected patients, such as new, severely burned patients.

Number of Patients

Acuity Level

Associated Hours of Care

Total Hours of Care

3 I 2 6

10 II 6 60

11 III 7 77

2 IV 9 18

Total 26 161

Determining FTEs Positions are defined in terms of a full-time equivalent (FTE). One FTE equals 40 hours of work per week for 52 weeks, or 2,080 hours per year. In a two-week pay period, one FTE would equal 80 hours. For computational purposes, one FTE can be filled by one person or a combination of staff with comparable expertise. For example, one nurse may work 24 hours per week, and two other nurses may each work 8 hours per week. Together, the three nurses fill one FTE (24 + 8 + 8 = 40).

Several methods are available for determining the number of FTEs required to staff a unit 24 hours a day, seven days a week. One technique incorporates information regarding the hours of work for the staff for two weeks, average daily census, and hours of care. The average daily census can be determined by dividing the total patient days (obtained from daily census counts for the year) by the number of days in the year.

■ EXAMPLE

Total patient days = 9490

365 = 26 patients per day

Data Number of hours worked per FTE in two weeks = 80 Number of days of coverage in two weeks = 14 Average daily census = 26 Average nursing care hours (from PCS) = 6.15

220 PART 3 • MANAGING RESOURCES

Formula

x = average nursing care hours * days in staffing period * average patient census

hours of work per FTE in two weeks

x = 6.15 * 14 * 26

80 =

2238.6

80 = 27.98, or 28 FTFEs

A second technique uses nursing care hours and annual hours of work provided by one FTE:

Data Number of hours worked per FTE in one year = 2080 Total nursing care hours (from PCS) = 161

Formula

x = Total nursing care hours * days in a year

Total annual hours per one FTE

x = 161 * 365

2080 =

58,765

2080 = 28.25, or 28 FTEs

One person working full-time usually works 80 hours (10 eight-hour shifts) in a two-week period. However, to staff an eight-hour shift takes 1.4 FTEs, one person working 10 eight-hour shifts (1.0 FTE) and another person working four eight-hour shifts (0.4 FTE) in order to provide for the full-time person’s two days off every week. For 12-hour shifts, it takes 2.1 FTEs to staff one 12-hour shift each day, each week; two people each working three 12-hour shifts and one person working one 12-hour shift each week (0.9 FTE = 0.9 FTE = 0.3 FTE = 2.1 FTEs). Therefore, the same number of FTEs is required to staff a unit for 24 hours a day for two weeks, regardless of whether the staff are all on 8-hour shifts (1.4 FTEs × 33 shifts = 4.2 FTEs) or 12-hour shifts (2.1 FTEs × 32 shifts = 4.2 FTEs).

Determining Staffing Mix The same data used to determine FTEs are used to identify staffing mix. For example, for patient care needs involving general hygiene care, feeding, transferring, or turning patients, licensed practical nurses (LPNs) or unlicensed assistive personnel (UAPs) can be used. For patient care needs involving frequent assessments, patient education, or discharge planning, RNs will be needed because of the skills required. A high RN-skill mix allows for greater staffing flexibility. Again, information on typical or usual patient needs is obtained by using trends from the patient classification system.

Determining Distribution of Staff For many patient care units, the distribution of staff varies from shift to shift and by days of the week. Patient census on a surgical unit will probably fluctuate throughout the week, with a higher census Monday through Thursday and a lower census over the weekend. In addition, some surgical units may have more complex cases earlier in the week and short-stay surgical cases later in the week. Surgical patients may have a shorter length of stay (LOS) than many medical patients. The patient census on a medical unit rarely fluctuates Monday through Friday, but may be less on weekends, when diagnostic tests are not done.

The workload on many units also varies within the 24-hour period. The care demands on a surgical unit will be heaviest early in the morning hours prior to the start of the surgical schedule; mid-morning, when the unit receives patients from critical care units; late in the afternoon, when patients return from the postanesthesia recovery unit; and in the evening hours, when same-day surgical patients are discharged.

Critical care units may have greater care needs in the mornings when transferring patients to medical or surgical units and in the early afternoon hours when admitting new surgical cases.

CHAPTER 16 • STAFFING AND SCHEDULING 221

Medical units usually have the heaviest care needs in the morning hours, when patients’ daily care needs are being met and physicians are making rounds. On skilled nursing and rehabilitation units, care needs are greatest before and immediately after mealtimes and in the evening hours; during other times of the day, patients are often away from the unit and involved in various therapeutic activities.

In contrast with the medical, surgical, critical care, and rehabilitation units that have definite patterns of patient care needs, labor-and-delivery and emergency department areas cannot predict when patient care needs will be most intense. Thus, labor-and-delivery and emergency department areas must rely on block staffing to ensure that adequate nursing staff are available at all times.

Here’s what a nurse manager told a new nurse candidate when asked about the nurse to staff ratio:

“On the surgical step-down floor, we most typically staff at a one-RN-to-four-patient ratio. We also plan to have a charge nurse who is not taking patients to assist staff with extra tasks and needs. On occasion, a nurse may have three patients or five patients. We always work to be flexible, looking at the acuity of the patients and the competencies of the staff who are working. During each shift, we reassess every four hours and as needed to ensure assignments are still appropriate and patient needs haven’t significantly changed, necessitating a reassignment of patients. We also have nurse aides on this floor. They help with vital signs, bed changes, baths, and ambulation. There is most typically one aide for every 8 to 12 patients. Also, a unit clerk answers the phones and greets guests. This team dynamic creates for great patient care.”

Block staffing involves scheduling a set staff mix for every shift. However, there may be trends in peak workload hours in emergency departments, when additional staff (RN, UAP, or secretary) beyond the block staff are necessary. Examples of peak workload hours within the emergency department may be from 6:00 p.m. to 10:00 p.m. to accommodate patient needs after physicians’ offices close, or from 12:00 a.m. to 3:00 a.m. to accommodate alcohol-related injuries. All these needs in patterns of care must be known when staffing requirements and work schedules are established. Data reflecting peak workload times must be continuously monitored to maintain the appropriate levels and mix of staff.

Scheduling Creative and Flexible Staffing Nurse shortages and current restrictions in salary budgets have made creative and flexible staffing patterns necessary and probably everlasting. Combinations of 4-, 6-, 8-, 10-, and 12-hour shifts and schedules that have nurses working six consecutive days of 12-hour shifts with 13 days off, and staffing strategies, such as weekend programs and split shifts, are common.

Flexible staffing patterns can be a major challenge and, in some cases, a mathematical challenge. However, once a schedule is established and agreed to by the nurse manager and the staff, it can become a cyclic schedule for an extended period of time, such as 6 to 12 months. This allows staff members to know their work schedule many months ahead of time.

The use of 8-hour and 12-hour shifts is fairly straightforward. Problems with combined staffing patterns may include:

● The perception that nurses don’t work full-time when they work several days in a row and then are off for several days in a row

● Disruption in continuity of care if split shifts are used (7:00 to 11:00 a.m.; 11:00 a.m. to 3:00 p.m.; 3:00 p.m. to 7:00 p.m.; 7:00 p.m. to 1:00 a.m.; 1:00 a.m. to 7:00 a.m. shifts)

● Immense challenges for nurse managers to communicate with all staff in a timely manner

222 PART 3 • MANAGING RESOURCES

Advantages of using combined staffing patterns are that it:

● Better meets patient care needs during peak workload times ● Improves staff satisfaction ● Maximizes the availability of nurses

Ten-hour shifts provide greater overlap between shifts to permit extra time for nurses to complete their work; for this reason, they may increase salary expenditures. There are a few specialty units in which 10-hour shifts would be cost-efficient: postanesthesia recovery areas, operating departments, and emergency departments are examples.

Self-staffing and Scheduling Some hospitals have instituted self-staffing. This is an empowerment strategy that allows unit staff the authority to use their backup staffing options if the patient workload increases or if unscheduled staff absences occur. Likewise, staff can and must go home early if the patient workload decreases.

Self-scheduling allows the staff to create and manage the schedule. Self-scheduling can be positive for the staff and for the manager, but attention must be paid to balancing unit needs with individual requests (Bailyn, Collins, & Song, 2007). Whether the schedule is determined by the manager or by staff, the schedule can be transparent for all staff by posting it online (also see section on automated scheduling). In this way, the organization can demonstrate fairness in scheduling and leverage staff expertise in an equitable manner.

Shared Schedule A new tool currently in use is a shared schedule. Two people share one full-time schedule by splitting the day of 12 hours into half days of 6.5 hours each, alternating morning and afternoon shift. This allows nurses who might not be able to work the full 12 hours to share the shift.

Open Shift Management Open shift management is an innovative technique to allow an organization’s staff to self- schedule additional shifts (Bantle, 2007). With the schedule posted online, as described above, staff members can select assignments and shifts that fit their expertise and accommodate their personal schedules. This strategy is especially valuable to health care systems with several hos- pitals in which nurses from one hospital can select assignments at any of the others. The organi- zation itself could establish an internal staffing pool (see next section).

Case Study 16-1 shows how one hospital used open scheduling to decrease its use of agency staff and improve staff morale.

Weekend Staffing Plan Hospitals can no longer arbitrarily staff patient care units on weekends or at nights with mar- ginal numbers or levels of qualified staff. The acuity of patients in hospitals, including medical and surgical patients, mandates staffing units on the weekends by the same principles used for weekdays. Thorough trend analysis of patient data can provide the justification necessary to appropriately decrease the number of RNs, at least for some levels, because of differences in patient care needs throughout the day.

A creative method for weekend staffing is the Baylor plan. Developed at Baylor University Medical Center, nurses agree to work only 12-hour shifts on the weekend and are paid for a standard work week. Numerous hospitals have adopted this model for weekend staffing (Cedar Community Hospital, 2011; St. Vincent’s Hospital, 2011).

Automated Scheduling Technology today makes automated scheduling feasible (Douglas, 2010). Matching patient demand to nurse staffing is better done by automated systems than by individuals. To aid in scheduling decisions, data should include patient information, nurse characteristics, and hospital

CHAPTER 16 • STAFFING AND SCHEDULING 223

data (Frith, Anderson, & Sewell, 2010). Automated systems improve patient care outcomes because nurses spend more time with the patients who need the most nursing care. In addition, using nurses’ time appropriately improves financial outcomes as well (Barton, 2011).

Data are often displayed on a dashboard. A dashboard is a computer display of real-time data collected from various sources and categorized for use in decision making.

Supplementing Staff When there is a need for additional staff because of scheduled or unscheduled absences, increased workload demands, or existing staff vacancies, the nurse manager or staffing person must find additional staff. Options include using PRN staff (staff scheduled on an as-needed basis), part-time staff, internal float pools, or outside agency nurses.

Supplemental staff are needed when workload increases beyond that which the existing staff can manage, staff absences and resignations occur, and staff vacancies exist. Chronic staffing problems need to be addressed in a proactive manner involving the nurse manager, the chief nurse executive, and the nursing personnel on the unit with the problem. Strategies for dealing with turnover and for managing absenteeism are discussed in Chapter 20.

Internal Pools Acute staffing problems can be addressed by establishing internal float pools using nurs- ing staff and unlicensed assistive personnel (UAPs). Internal float pools of nurses can provide

SCHEDULING Tori Abraham and Jillian Moore are both nurse manag- ers of general med/surg units at separate hospitals that are part of a large metropolitan health care system. Staffing among the med/surg units has been problem- atic due to increased patient volume and cost control measures enacted by the health care corporation. Staff members have complained numerous times that extra shifts are only offered to part-time employees and that premium pay shifts are given to those with more senior- ity. As the holidays approach, staff tension increases as a lottery system has traditionally been used to assign shifts for major holidays. Additionally, since employees are free to transfer within any of the eight metropoli- tan hospitals, there has been significant turnover on the med/surg units as employees decide to transfer to ambu- latory care and same day surgery facilities.

Tori and Jillian have volunteered to be part of a new scheduling system for their health care system. Nurses and nursing assistants will be able to view open shifts on each unit and e-mail Tori or Jillian with requests to staff shifts for which they are qualified. By allowing staff to have greater control over which additional shifts and at which facility they prefer to work, the nurse managers hope to decrease agency staffing and increase employee satisfaction. Additional units are expected to come on- line, which will also allow staff to have experience on oncology, skilled nursing, and orthopedic patients. The education department will provide a database of employee certifications to managers to ensure that staff

wishing to work away from their home units are quali- fied for the job.

After 90 days of using the new open shift schedul- ing system, Tori and Jillian are pleased with the results. Agency staff use has decreased by 60 percent, and staff members report they are happier with the ability to schedule their own additional shifts as well as work at a different facility without having to transfer. Holiday staffing has been easier, as those employees who pre- fer to work premium pay for holidays are able to self- schedule. Tori and Jillian present their findings to the chief nursing officer and will be part of the team imple- menting systemwide use of open shift scheduling.

Manager’s Checklist The nurse manager is responsible for:

● Understanding the scheduling and staffing needs for his or her areas of responsibility

● Analyzing the economic impact of using agency staffing for open shifts and the financial impact on budget

● Ensuring adequate staffing for safe and appropriate patient care

● Communicating with staff members regarding con- cerns or frustrations over scheduling and staffing

● Using creative problem solving to address scheduling and staffing issues

● Improving employee job satisfaction and patient care skills

CASE STUDY 16-1

224 PART 3 • MANAGING RESOURCES

supplemental staffing at a substantially lower cost than external agency nurses. In addition, in- ternal staff are familiar with the organization. All staff participating in the internal float pool must be adequately trained for the type of patient care they will be giving.

Internal float pools can be centralized or decentralized. A centralized pool is the most efficient. A pool of RNs, LPNs, UAPs, and unit clerks are available for placement anywhere in the institution. However, it may be difficult to place the person with the correct skills for a particular unit at the needed time.

In decentralized pools, a staff member usually works only for one nurse manager or on only one unit. The advantages of decentralized pools include better accountability, improved staffing response, and improved continuity of care. Critical care units, operating rooms, maternal–child units, and other highly specialized or technical areas tend to use a decentralized system.

In addition, staff can receive cross-training in preparation for assignment to another unit. A critical-care nurse might be cross-trained for the step-down unit, for example. Dual-unit positions could be established in the recruiting phase to give the organization the maximum flexibility in scheduling and the employee an opportunity to acquire additional skills.

External Pools For some institutions, agency nurses become part of the regular staff contracted to fill vacancies for a specified period of time (e.g., a nurse on maternity leave). However, most agency nurses are used as supplemental staff. All agency nurses require orientation to the facility and unit, and they must work under the supervision of an experienced in-house nurse. Management must verify valid licen- sure, ensure that either the agency or agency nurse has current malpractice insurance, and develop a mechanism to evaluate the agency nurse’s performance. Although an agency nurse may meet an urgent staffing need, continuity of care may be compromised and there may be some staff resent- ment because these nurses may earn two to three times the salary of in-house nurses.

Concern about the quality of agency nurses appears to be unfounded, according to a study analyzing adverse events in Pennsylvania hospitals (Aiken, Xue, Clarke, & Sloane, 2007). Rather, adverse outcomes resulted from deficits in the hospital environments, not from the quality of the agency nurse assigned there.

Ensuring that sufficient staff are available and that they are scheduled appropriately is a demanding task and one that is constantly in flux. Nevertheless, such activities are critical to achieving positive patient outcomes and providing safe, effective, and cost-conscious staffing.

What You Know Now • The goal of staffing and scheduling is to provide an adequate mix of nursing staff to match patient care

needs. • The Joint Commission requires that organizations determine criteria for nurse staffing and provide

adequate numbers of competent staff to meet that criteria. • Patient classification systems use patient needs to determine workload requirements and staffing needs. • Scheduling involves assigning available staff in a way that patient care needs are met. • Flexible and creative staffing and scheduling techniques are increasingly necessary. • Self-staffing and scheduling, including open shift management, is an option in which nursing staff partici-

pate in designing the schedule and accept responsibility for ensuring attendance. • Automated scheduling improves patient outcomes and uses fiscal resources appropriately.

Tools for Handling Staffing and Scheduling 1. Familiarize yourself with the current patient classification, acuity system, or automated system in

use. 2. Determine the nursing care hours needed.

CHAPTER 16 • STAFFING AND SCHEDULING 225

3. Determine FTEs needed. 4. Create or modify a schedule that best meets your patients’ needs. 5. Supplement staff as needed. 6. Consider self-staffing if appropriate.

Questions to Challenge You 1. What has been your experience with staffing? Use any work setting where you are or have been an

employee. How well did it work? Was there adequate coverage to meet the needs of the organiza- tion? Explain.

2. Using the formulas for calculating FTEs in the chapter, create your own examples and work the problems from them. Were you able to compute needed FTEs? Now calculate the hours needed when nursing staff work 8-hour or 12-hour shifts.

3. On occasion, there are more staff available than are needed. As a nurse manager, how would you handle this? How might the staff respond?

4. No one is ever completely satisfied with the schedule. How would you handle a staff member who repeatedly asks to have his schedule changed?

Aiken, L. H., Xue, Y., Clarke, S., & Sloane, D. M. (2007). Supplemental nurse staffing in hospitals and quality of care. Journal of Nursing Administration, 37(7/8), 335–342.

Aiken, L. H., Sloane, D. M., Cimiotti, J. P., Clarke, S. P., Flynn, L., Seago, J. A., Spetz, J., & Smith, H. L. (2010). Implications of the California nurse staffing mandate for other states. Health Services Research, 45(3), 904–921.

Bailyn, L., Collins, R., & Song, Y. (2007). Self-scheduling for hospital nurses: An attempt and its difficulties. Journal of Nursing Management, 15(1), 72–77.

Bantle, A. (2007). Automated workforce tracking keeps

you flexible. Nursing Management, 38(9), 29.

Barton, N. S. (2011). Matching nurse staffing to demand. Nursing Management, 42(2), 37–39.

Cedar Community Hospital. (2011). Baylor weekend staffing program. Retrieved July 29, 2011 from http:// www.cedarcommunity. org/opportunities_92_ 2341037709.pdf

Douglas, K. (2010). Digital dashboards and staffing: A perfect match. American Nurse Today, 5(5), 52–53.

Frith, K. H., Anderson, F., & Sewell, J. P. (2010). Assessing and selecting date for a nursing services dashboard. Journal of Nursing Administration, 40(1), 10–16.

Hickey, P., Gauvreau, K., Connor, J., Sporing, E., & Jenkins, K. (2010). The relationship of nurse staffing, skill mix, and Magnet recognition to in- stitutional volume and mor- tality for congenital heart surgery. Journal of Nurs- ing Administration, 40(5), 226–232.

Joint Commission. (2011) Comprehensive ac- creditation manual for hospitals: The official handbook. Retrieved July 28, 2011 from http://www.jcrinc.com/ Accreditation-Manuals/ PCAH11/2130/

Kalisch, B. J., & Lee, K. H. (2011). Nurse staffing levels and teamwork: A cross-sectional study of

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

References

http://www.cedarcommunity.org/opportunities_92_2341037709.pdf

http://www.jcrinc.com/Accreditation-Manuals/PCAH11/2130/

www.nursing.pearsonhighered.com

http://www.cedarcommunity.org/opportunities_92_2341037709.pdf

http://www.jcrinc.com/Accreditation-Manuals/PCAH11/2130/

226 PART 3 • MANAGING RESOURCES

patient care units in acute care hospitals. Journal of Nursing Scholarship, 43(1), 82–88.

Manojlovich, M. (2009). Seeking staffing solutions. American Nurse Today, 4(3), 25–27.

Needleman, J., Buerhaus, P., Pankratz, S., Leibson, C. L., Stevens, S. R., & Harris, M. (2011). Nurse staffing and inpatient hospital mortal- ity. New England Journal of Medicine, 364(11), 1037–1045.

Picard, B., & Warner, M. (2007). Demand management: A methodology for outcomes-driven staffing and patient flow manage- ment. Nurse Leader, 5(2), 30–34.

Schilling, P. L., Campbell, D. A., Englesbe, M. J., & Davis, M. M. (2010). A comparison of in-hospital mortality risk conferred by high hospital occupancy, differences in nurse staffing levels, weekend admission, and seasonal influenza.

Medical Care, 48(3), 224–232.

St. Vincent’s Hospital. (2011). Baylor staffing plan agreement. Retrieved July 28, 2011 from http:// intranet.stv.org/documents/ docmanager/nursingservices/ display/formnumber8720_/ 87200350baylors/8720- 0350BaylorStaffing- PlanAgreement.pdf

http://intranet.stv.org/documents/docmanager/nursingservices/display/formnumber8720_/87200350baylors/8720-0350BaylorStaffing-PlanAgreement.pdf

CHAPTER

A Model of Job Performance EMPLOYEE MOTIVATION

MOTIVATIONAL THEORIES

Manager as Leader

Staff Development ORIENTATION

ON-THE-JOB INSTRUCTION

PRECEPTORS

MENTORING

COACHING

NURSE RESIDENCY PROGRAMS

CAREER ADVANCEMENT

LEADERSHIP DEVELOPMENT

Succession Planning

Motivating and Developing Staff 17

Key Terms Content theories Equity theory Expectancy theory Extinction Goal-setting theory Horizontal promotion

1. Describe how motivation and ability affect job performance.

2. Discuss how different theories explain motivation.

3. Explain how orientation, preceptors, and on-the-job instruction can help motivate staff.

4. Describe the benefits of nurse residency programs, career advancement strate- gies, and leadership development on motivation.

5. Discuss why succession planning is essential to the future.

Learning Outcomes After completing this chapter, you will be able to:

Motivation On-the-job instruction Operant conditioning Orientation Preceptor Process theories

Punishment Reinforcement theory

(behavior modification) Shaping

228 PART 3 • MANAGING RESOURCES

A continual and troublesome question facing managers today is why some employees perform better than others. Making decisions about who performs what tasks in a particular manner without first considering individual behavior can lead to irreversible, long-term problems.

Each employee is different in many respects. A manager needs to ask how such differences influence the behavior and performance of the job requirements. Ideally, the manager performs this assessment when the new employee is hired. In reality, however, many employees are placed in positions without the manager having adequate knowledge of their abilities and/or interests. This often results in problems with employee performance, as well as conflict between employ- ees and managers. Employee performance literature ultimately reveals two major dimensions as determinants of job performance: motivation and ability (Hersey, Blanchard, & Johnson, 2007).

A Model of Job Performance Nurse managers spend considerable time making judgments about the fit among individuals, job tasks, and effectiveness. Such judgments are typically influenced by both the manager’s and the employee’s characteristics. For example, ability, instinct, and aspiration levels—as well as age, education, and family background—account for why some employees perform well and others poorly. Based on these factors, a model that considers motivation and ability as determinants of job performance is presented in Table 17-1.

This performance model identifies six categories likely to be viewed as important:

1. Daily job performance

2. Attendance

3. Punctuality

4. Adherence to policies and procedures

5. Absence of incidents, errors, and accidents

6. Honesty and trustworthiness

Although there is conceptual overlap in these categories, separate designation of each helps emphasize their importance.

When using this model, carefully consider several factors. First, the health care organiza- tion should establish and communicate clear descriptions of daily job performance so that de- viations from expected behaviors can be easily identified and documented. Second, behaviors

TABLE 17-1 A Simplified Model of Job Performance

Motivation And Ability = Employee Performance

Compensation Responsibilities Daily job performance

Benefits Education—basic/advanced Attendance

Job design Continuing education Punctuality

Leadership style Skills/abilities Adherence to policies and procedures

Recruitment and selection Absence of incidents/errors/accidents

Employee needs/goals/abilities Honesty and trustworthiness

CHAPTER 17 • MOTIVATING AND DEVELOPING STAFF 229

considered troublesome in one department may be acceptable in another department. Finally, some behaviors are viewed as serious only when repeated (e.g., being late to work), whereas others are classified as troublesome following only one incident (e.g., a medication error with severe consequences).

Employee Motivation Motivation describes the factors that initiate and direct behavior. Because individuals bring to the workplace different needs and goals, the type and intensity of motivators vary among employees. Nurse managers prefer motivated employees because they strive to find the best way to perform their jobs. Motivated employees are more likely to be productive than are nonmotivated workers. This is one reason that motivation is an important aspect of enhancing employee performance.

Motivational Theories Historically, motivational theories were concerned with three things:

1. What mobilizes or energizes human behavior

2. What directs behavior toward the accomplishment of some objective

3. How such behavior is sustained over time

The usefulness of motivational theories depends on their ability to explain motivation adequately, to predict with some degree of accuracy what people will actually do, and, finally, to suggest practical ways of influencing employees to accomplish organizational objectives. Motivational theories can be classified into at least two distinct groups: content theories and process theories.

Content Theories Content theories emphasize individual needs or the rewards that may satisfy those needs. There are two types of content theories: instinct and need. Instinct theorists characterized instincts as inherited or innate tendencies that predisposed individuals to behave in certain ways. These theo- ries were attacked for their difficulty in pinpointing the specific motivating behaviors and the acute awareness of the variability in the strengths of instincts across individuals. In addition, the development of need theories supported the concept that motives were learned behaviors.

Process Theories Whereas content theories attempt to explain why a person behaves in a particular manner, process theories emphasize how the motivation process works to direct an individual’s effort into performance. These theories add another dimension to the manager’s understanding of mo- tivation and help predict employee behavior in certain circumstances. Examples of process theo- ries are reinforcement theory, expectancy theory, equity theory, and goal-setting theory.

Reinforcement theory, also known as behavior modification, views motivation as learn- ing (Skinner, 1953). According to this theory, behavior is learned through a process called oper- ant conditioning, in which a behavior becomes associated with a particular consequence. In operant conditioning, the response–consequence connection is strengthened over time—that is, it is learned.

Consequences may be positive, as with praise or recognition, or negative. Positive reinforc- ers are used for the express purpose of increasing a desired behavior.

Kyle, a staff nurse, offered a creative idea to redesign work flow on the unit. His manager supported the idea and helped Kyle implement the new process. In addition, the man- ager praised Kyle for the extra effort and publicly recognized him for the idea. Kyle was encouraged by the outcome and sought other solutions to work-flow problems.

230 PART 3 • MANAGING RESOURCES

Negative reinforcers are used to inhibit an undesired behavior. Punishment is a common technique.

To get Rose to chart adequately, the manager required her to come to his office daily with her patient charts, and they reviewed her charting together. She was required to do this until she achieved an acceptable level of charting. Rose found the task laborious and humiliating. As a result, Rose was soon charting appropriately.

Because punishment is negative in character, an employee may fail to improve and also may avoid the manager and the job, as well. The effects of punishment are generally temporary. Undesirable behavior will be suppressed only as long as the manager monitors the situation and the threat of punishment is present. Conversely, positive reinforcement is the best way to change behavior.

Extinction is another technique used to eliminate negative behavior. By removing a positive reinforcer, undesired behavior is extinguished.

Consider the case of Jasmine, a chronic complainer. To curb this behavior, her man- ager chose to ignore her many complaints and not try to resolve them. Initially, Jasmine complained more, but eventually she realized her behavior was not getting the desired response and stopped complaining.

A problem with operant conditioning (behavior modification) is that there is no sure way to elicit the desired behavior so that it can be reinforced. In addition, staff and the manager may view consequences differently.

Take Thad, for example. As a new employee, Thad conscientiously completed critical paths for his assigned patients. When the manager recognized Thad for his good work, his peers began to exclude him from the group. Although the manager was attempting positive reinforcement, Thad quit completing critical paths because he felt the manager had aliena- ted him from his coworkers.

Another procedure is shaping. Shaping involves selectively reinforcing behaviors that are successively closer approximations to the desired behavior. When people become clearly aware that desirable rewards are contingent on a specific behavior, their behavior will eventually change.

Behavior modification works quite well, provided that rewards can be found that, in fact, employees see as positive reinforcers, and provided that supervisory personnel can control such rewards or make them contingent on performance. This does not mean that all rewards work equally well or that the same rewards will continue to function effectively over a long time. If someone is praised four or five times a day every day, the praise would soon begin to wear thin: it would cease to be a positive reinforcer. Care must be taken not to over do a good thing.

Like reinforcement theory, expectancy theory (Vroom, 1964) emphasizes the role of re- wards and their relationship to the performance of desired behaviors. Expectancy theory regards people as reacting deliberately and actively to their environment.

In an effort to improve the amount of delegation by the nurses on her unit, Andrea ap- proached the situation from an expectancy theory perspective. She identified that the nurses wanted to assign more duties to assistive personnel but were reluctant because of concerns about liability. Once Andrea was able to clarify liability issues, the nurses were eager to delegate tasks that could be performed by nonlicensed staff in order to devote more time to their professional responsibilities.

Expectancy theory also considers multiple outcomes. Consider the possibility of a promo- tion to nurse manager. Even though a staff nurse believes such a promotion is positive and is a

CHAPTER 17 • MOTIVATING AND DEVELOPING STAFF 231

desirable reward for competent performance in patient care, the nurse also realizes that there are possibly some negative outcomes (e.g., working longer hours, losing the close camaraderie en- joyed with other staff members). These outcomes may influence the staff nurse’s decision.

Similarly, equity theory suggests that a person perceives that one’s contribution to the job is rewarded in the same proportion that another person’s contribution is rewarded. Job contribu- tions include such things as ability, education, experience, and effort, whereas rewards include job satisfaction, pay, prestige, and any other outcomes an employee regards as valuable (Adams, 1963, 1965).

Unlike expectancy theory and equity theory, goal-setting theory suggests that it is not the rewards or outcomes of task performance per se that cause a person to expend effort, but rather the goal itself (Locke, 1968).

Timothy was new to a home care hospice program. An important skill in care with the termi- nally ill is therapeutic communication. Timothy and his manager recognized that he needed help to improve his skills in communicating with these patients and their families. His man- ager asked him to write two goals related to communication. Timothy expressed a desire to attend a communications workshop and also indicated he would try at least one new com- munication technique each week. Within a month, Timothy’s therapeutic communication skills had already improved. As a result, Timothy was more satisfied with his position, his patients received more compassionate care, and Timothy found his work more rewarding.

Each theory of work motivation contributes something to our understanding of, and ulti- mately our ability to influence, employee motivation.

Manager as Leader The manager serves as a role model, exemplifying leadership qualities that reflect the organiza- tion’s values, mission, and vision and plays a key role in staff members’ job satisfaction and retention (Failla & Stichler, 2008). Additionally, the manager can create conditions that enhance employee motivation (Doucette, 2009) and provide opportunities and encouragement for staff development (Urquhart, 2009).

Staff Development Orientation Getting an employee started in the right way is essential. A well-planned orientation reduces the anxiety that new employees feel when beginning the job. In addition, socializing the employee into the workplace contributes to unit effectiveness by reducing dissatisfaction, absenteeism, and turnover (see Chapter 20).

Orientation is a joint responsibility of both the organization’s staff development personnel and the nursing manager. In most organizations, the new staff nurse completes the orientation program, whereupon the nurse manager (or someone appointed to do this) provides an on-site orientation. Staff development personnel and unit staff should have a clear understanding of their respective, specific responsibilities so that nothing is left to chance. The development staff should provide information involving matters that are organization-wide in nature and relevant to all new employees, such as benefits, mission, governance, general policies and procedures, safety, quality improvement, infection control, and common equipment. The nurse manager should concentrate on those items unique to the employee’s specific job.

New employees often have unrealistically high expectations about the amount of challenge and responsibility they will find in their first job. If they are assigned fairly undemanding, entry- level tasks, they feel discouraged and disillusioned. The result is job dissatisfaction, turnover, and low productivity.

232 PART 3 • MANAGING RESOURCES

So, one function of orientation is to correct any unrealistic expectations. The nurse manager needs to outline specifically what is expected of new employees. Such realistic job previews help prevent early departures from the organization and, possibly, the nursing profession.

Socializing new employees can sometimes be difficult because of the anxiety people feel when they first come on the job. They simply do not hear all of the information they are given. They spend a lot of energy attempting to integrate and interpret the information presented, and consequently they miss some of it. So repetition may be necessary the first few days or weeks on the job. Ongoing follow-up is important.

Trina Prescott, RN, joined the pediatric oncology unit of a large university teaching hospital. Her nurse manager, Lily Yuen, scheduled a lunch with Trina 30 days after she started. Lily had a relaxed conversation with Trina about the first 30 days of her employ- ment. Trina expressed how much she enjoyed her new job, but that she still felt uncomfort- able accessing implanted vascular ports without assistance. Lily makes a note to schedule one-on-one teaching for Trina with a nurse from the IV team. Scheduling a lunch with new employees approximately 30 to 60 days into their employment has improved new employee retention and increased open communication between Lily and her staff.

On-the-Job Instruction The most widely used educational method is on-the-job instruction. This often involves assign- ing new employees to experienced nurse peers, preceptors, or the nurse manager. The learner is expected to learn the job by observing the experienced employee and by performing the actual tasks under supervision.

On-the-job instruction has several positive features, one of which is its cost-effectiveness. New nurses learn effectively at the same time they are providing care. Moreover, this method re- duces the need for outside instructional facilities and reliance on professional educators. Trans- fer of learning is not an issue because the learning occurs on the actual job. However, on-the-job instruction often fails because there is no assurance that accurate and complete information is presented, and the instructor may not know learning principles. As a result, presentation, prac- tice, or feedback may be inadequate or omitted.

On-the-job instruction fulfills an important function; however, staff members involved may not view it as having equal value to more standardized and formal classroom instruction.

To implement effective on-the-job instruction, the following are suggested:

1. Employees who function as educators must be convinced that educating new employees in no way jeopardizes their own job security, pay level, seniority, or status.

2. Individuals serving as educators should realize that this added responsibility will be instrumental in attaining other rewards for them.

3. Pair teachers and learners to minimize any differences in background, language, personal- ity, attitudes, or age that may inhibit communication and understanding.

4. Select teachers on the basis of their ability to teach and their desire to take on this added responsibility.

5. Staff nurses chosen as teachers should be carefully educated in the proper methods of instruction.

6. Formalize assignments so that nurses do not view on-the-job instruction as happenstance or second-class instruction.

7. Rotate learners to expose each one to the specific know-how of various staff nurses or education department teachers.

CHAPTER 17 • MOTIVATING AND DEVELOPING STAFF 233

8. Employees serving as teachers should understand that their new assignment is by no means a chance to get away from their own jobs but that they must build instructional time into their workload.

9. The efficiency of the unit may be reduced when on-the-job instruction occurs.

10. The learner must be closely supervised to prevent him or her from making any major mistakes and carrying out procedures incorrectly.

Preceptors One method of orientation is the preceptor model, which can be used to assist new employees and to reward experienced staff nurses. The preceptor model provides a means for orienting and socializing the new nurse as well as providing a mechanism to recognize exceptionally compe- tent staff nurses. Staff nurses who serve as preceptors are selected based on their clinical com- petence, organizational skills, ability to guide and direct others, and concern for the effective orientation of new nurses.

The primary function of the preceptor is to orient the new nurse to the unit. This includes proper socialization of the new nurse within the group as well as familiarizing her or him with unit functions. The preceptor teaches any unfamiliar procedures and helps the new nurse develop any necessary skills. The preceptor acts as a resource person on matters of unit func- tions as well as policies and procedures. The preceptorship is for approximately three weeks, although the time may vary depending to the nurse’s individual learning needs or the organi- zation’s policies.

New nurses may need to use their preceptors as counselors as they make their transition to the unit. If new nurses experience discrepancy between their educational preparation or their expectations and the realities of working in the unit, the preceptor’s role as counselor can prove invaluable in helping them cope with “reality shock.”

The preceptor also serves as a staff nurse role model demonstrating work-related tasks, how to set priorities, solve problems and make decisions, manage time, delegate tasks, and interact with others. In addition, the preceptor evaluates the new nurse’s performance and provides both verbal and written feedback to encourage development.

The staff development department’s function is to teach the experienced nurse the role of a preceptor, principles of adult education applicable to learning needs, how to teach necessary skills, how to plan teaching, how to evaluate teaching and learning objectives, and how to pro- vide both formal and informal feedback.

Mentoring Mentoring is another strategy to improve retention. Mentors take a greater role than preceptors in developing staff. Precepting usually is associated with orientation of staff, whereas mentoring occurs over a much longer period and involves a bigger investment of personal energy. Mentor- ing is suggested as a strategy to retain new graduates (Butler & Felts, 2006).

A mentor is a wiser and more experienced person who guides, supports, and nurtures a less experienced person. Mentors are usually the same sex as the protégé, eight to fifteen years older, highly placed in the organization, powerful, and willing to share their experiences. They are not threatened by the mentee’s potential for equaling or exceeding them. Mentees are selected by mentors for several reasons: good performance, loyalty to people and the organization, a similar social background or a social acquaintance with each other, appropriate appearance, an opportu- nity to demonstrate the extraordinary, and high visibility.

Mentor–mentee relationships seem to advance through several stages. The initiation stage usually lasts six months to a year, during which the relationship gets started. The mentee stage is that in which the mentee’s work is not yet recognized for its own merit, but rather as a byproduct

234 PART 3 • MANAGING RESOURCES

of the mentor’s instruction, support, and encouragement. The mentor thus buffers the mentee from criticism.

A breakup stage may occur from six months to two years after a significant change in the relationship, usually resulting from the mentee taking a job in another department or organiza- tion so that there is a physical separation of the two individuals. It also can occur if the mentor refuses to accept the mentee as a peer or when the relationship becomes dysfunctional for some reason. The lasting friendship stage is the final phase and will occur if the mentor accepts the mentee as a peer or if the relationship is reestablished after a significant separation. The com- plete mentoring process usually includes the last stage.

Coaching Coaching is a strategy suggested to address nurses’ job dissatisfaction (Stedman & Nolan, 2007). A coach helps the staff member focus on solving a specific problem or conflict that in- terferes with the employee’s satisfaction at work. Coaches are often nurses or human resources staff within the organization prepared to help resolve conflicts. Conflicts could be between two nurses, between a nurse and a patient, or between a nurse and a physician. In a confidential en- vironment, the coach helps the staff member explore the exact nature of the problem, consider various alternatives (e.g., transfer, quit, do nothing), delve into embedded issues (e.g., values conflict with organization, unmatched expectations), discover links (e.g., working with friends), and the disadvantages of leaving (e.g., start over with vacation time, benefits, leave friends). The goal is to reduce turnover from issues that can be resolved.

Nurse Residency Programs Residency programs, 12 or 18 months in length, are designed to acclimate new graduates to the work environment. One example is the Versant RN Residency Program™, an 18-month resi- dency that includes both educational and emotional components. Novice nurses receive lectures and online access to best practices as well as a nurse partner who maintains an ongoing relation- ship and teaches professional accountability and critical thinking. In addition, residents partici- pate in emotional support groups to share experiences and feelings. New-graduate turnover rates have gone from 35 percent to less than 6 percent, according to surveys of hospitals using the program (Mcpeck, 2006).

One-year residency programs for new graduates implemented at 12 sites have been shown to be effective in reducing turnover (Williams et al., 2007). Each residency involved a partner- ship between a school of nursing and a hospital. The program included a core curriculum, clini- cal guidance by a nurse preceptor, and a resident facilitator for professional role development assistance in addition to the usual orientation at the institution. The results showed that turnover of new graduates averaged 12 percent, more than half the national average.

Later reports of the residency program, implemented in 26 sites, found turnover rates de- clined to a low 5.7 percent (Lynn, 2008). The program continues to be refined with recent offer- ings including peer, preceptor, and manager participation and employee recognition components (Goode et al., 2009). It follows that programs that reduce turnover have been successful in mo- tivating employees.

Career Advancement One example of a career advancement development strategy is the clinical ladder program. It uses a system of performance indicators to advance an employee within the organization. The three key components are:

1. Horizontal promotion

2. Clinical ladder

3. Clinical mentee

CHAPTER 17 • MOTIVATING AND DEVELOPING STAFF 235

Horizontal promotion rewards the excellent clinical nurse without promoting the nurse to management. A clinical ladder, based on Benner’s (2000) novice-to-expert concepts, includes:

1. Clinical apprentice—new nurse or nurse new to the area

2. Clinical colleague—a full partner in care

3. Clinical mentee—demonstrates preceptor ability

4. Clinical leader—demonstrates leadership in practice

5. Clinical expert—combines teaching and research with practice

The strength of the system is that superb, clinical nurses can remain at the bedside, clinical excellence can be rewarded, and nurses can move back and forth among the levels based on their personal and professional goals and needs.

Another example of clinical advancement program was used at a Magnet-certified insti- tution, Cincinnati Children’s Hospital Medical Center (Allen, Fiorini, & Dickey, 2010). The program’s goal was to improve the quality of patient care, provide career opportunities for par- ticipating nurses, and to enhance job satisfaction and nurse retention. Evaluation of the program illustrated that goals were met. An additional finding revealed that the program had a substantial positive fiscal impact on the organization as well.

Leadership Development Developing internal staff is a cost-effective way to build leaders within the organization. The advantages include knowledge of the skills and strengths of the candidates, the cost saving in retaining high-performing staff, and the ability to design a program that fits the organization’s specific needs. In fact, many nurse leaders fail not because they don’t want to do the job, but because they don’t have the leadership tools required.

Built around Benner’s novice to expert concepts (Benner, 2000), one hospital designed a leadership curriculum that targeted the learning needs of staff at different developmental levels, e.g., 200 level for charge nurses, 300 level for assistant nurse managers, 400 level for nurse managers (Swearingen, 2009). As a result, the organization developed a pool of candidates available for promotion to higher-level positions. In addition, they found nurse retention rates improved.

Succession Planning Due to an aging nursing workforce, as well as the overall shortage of nurses, succession plan- ning at all levels of nursing management is essential to ensure a smooth transition after a man- ager leaves or retires (Ponti, 2009). Succession planning is a strategic process that is a natural outgrowth of leadership development. It involves identifying core competencies required at each level of management, recognizing potential recruits, and providing opportunities for develop- ment and growth.

One institution developed a nurse management internship program to prepare first-line man- agers from an internal pool of interested nurses (Wendler, Olson-Sitki, & Prater, 2009). The one- year program successfully prepared several nurses for management positions in its first year. Those costs were recouped when a long term management opening was filled by one of the nurses who completed the internship.

There is no one single way to motivate people. The organization and the manager must use various tools to offer incentives and rewards that satisfy their staff. Increased productivity, pa- tient care quality, job satisfaction, and retention are all outcomes that can result in appropriate motivational activities.

Case Study 17-1 illustrates how one nurse manager used her ingenuity to motivate staff.

236 PART 3 • MANAGING RESOURCES

What You Know Now • Job performance is determined by motivation and ability. • Motivational theories (e.g., reinforcement, expectancy, equity, and goal-setting theories) describe the fac-

tors that initiate and direct behavior. • The manager serves as a role model for staff. • Staff development methods include orientation, preceptors, and on-the-job instruction.

MOTIVATING STAFF Jamie Edgar is nurse manager of the mental health out- patient clinic for a large county health department. Her staff includes nurses, licensed clinical social workers, li- censed mental health technicians, and clerical support staff. State funding for mental health services has been drastically cut. Jamie had a difficult decision to make re- garding who on the staff would receive pay increases and who would not. Compounding her problem is the shortage of qualified psychiatric nurses and two vacant nursing positions that she has been unable to fill due to the low starting salary.

Jamie decides that the nursing staff will receive a four percent raise and the licensed clinical social work- ers will receive a three percent raise. The mental health technicians and clerical staff will not receive a wage in- crease this year. The mental health technicians and cleri- cal staff members are upset when Jamie tells them there will not be any pay increases this year. Kevin Adams, a licensed mental health technician, and Charlotte Du- Bois, an administrative assistant, have both expressed frustration about the disparity in pay increases. Over the past two workweeks, Kevin has been clocking in 10 minutes late each work day and taking longer lunch periods than scheduled. The quality of Charlotte’s work has decreased, and she is using more business time for personal telephone calls and personal business.

Jamie is concerned that Kevin’s and Charlotte’s nega- tive attitudes will continue to affect their work as well as the morale of the staff. Initially, she tried more fre- quent praise of Kevin’s and Charlotte’s work, but after three weeks, noted no improvement in their attitude or performance. She counseled each employee individu- ally about performance expectations; however, neither employee made an effort to improve his or her behav- ior. After receiving a final budget for her clinic, Jamie allocated $800 for training of clerical staff and mental health technicians. She met with Kevin, Charlotte, and two other staff members. Jamie asked the group to assist her in determining how to best spend the $800 training budget. The group agreed that time-management skills could be improved among many of the staff. After review- ing the cost associated with several time- management

training programs, the group was surprised at the ex- pense. Jamie challenged her group to think of alterna- tive ideas other than sending staff members to a semi- nar and offered a restaurant gift certificate for the most creative ideas.

At their next meeting, Kevin produced reviews of several interactive CD-ROM training programs. Kevin had searched the Internet for the best price for the programs and brought in several demonstration CDs of the top two time-management programs. Charlotte proposed purchasing planners for those staff members who didn’t already have a planner or electronic calen- dar. Charlotte had spoken to the supplier who had the contract for county office supplies. They had agreed to a price of $12 per planner for a complete year of time- planning supplies. The group agreed that both Kevin and Charlotte’s ideas were excellent, as well as coming in under the $800 limit.

Kevin and Charlotte were responsible for implement- ing their ideas with staff who requested training in time management. Although neither employee received a raise in base salary, Jamie was able to secure approval for both to work extra hours to complete training for the clinic staff. Jamie continued to praise both employees for their commitment to the clinic and their coworkers. Kevin began to arrive promptly for each work shift and kept his lunch periods to 30 minutes. Charlotte was ea- ger to demonstrate to coworkers how her new planner helped her prioritize work and personal tasks. Her use of work time for personal business greatly decreased.

Manager’s Checklist The nurse manager is responsible for:

● Understanding motivating factors for employees and how motivation affects job performance

● Using motivational techniques to enhance employee performance

● Utilizing creative techniques to motivate staff when traditional rewards such as pay or benefit increases are unavailable

● Empowering staff to use creativity to enhance job performance

CASE STUDY 17-1

CHAPTER 17 • MOTIVATING AND DEVELOPING STAFF 237

• Nurse residencies, career advancement opportunities, and leadership development programs can help motivate staff members.

• Succession planning is a strategic process to develop future nurse leaders.

Tools for Motivating and Developing Staff 1. Recognize that an employee’s job performance includes both ability to do the job and motivation. 2. Become familiar with various theories of motivation and use the information to help you motivate

others. 3. Be aware that you may be a role model to other staff regardless of your formal position. 4. Identify core competencies involved in specific positions and high performers with the potential

to fill those positions. 5. Encourage staff development at all levels, including your own.

Questions to Challenge You 1. What motivational theory appeals to your sense of how you learn? Why? 2. You are a new nurse manager: a. How would you discover what motivates the individuals on your staff? b. How could you utilize the organization’s resources to motivate your staff? c. What staff development programs are available in your organization or community? d. How could you make those resources available to your staff? 3. What recommendations would you make to a new nurse manager regarding motivating staff? Have

you seen any of these work? Explain.

Adams, J. S. (1963). Toward an understanding of inequity. Journal of Abnormal and Social Psychology, 67, 422.

Adams, J. S. (1965). Injustice in social exchange. In L. Berkowitz (Ed.), Advances in experimental social psy- chology (Vol. 2). New York: Academic Press.

Allen, S. R., Fiorini, P., & Dickey, M. (2010). A streamlined clinical ad- vancement program im- proves RN participation and retention. Journal of Nurs- ing Administration, 40(7/8), 316–322.

Benner, P. (2000). From novice to expert: Excellence and

power in clinical nursing practice. Upper Saddle River, NJ: Prentice Hall.

Butler, M. R. & Felts, J. (2007). Tool kit for the staff men- tor: Strategies for improv- ing retention. Journal of Continuing Education in Nursing, 37(5), 210–213.

References

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

www.nursing.pearsonhighered.com

238 PART 3 • MANAGING RESOURCES

Doucette, J. N. (2009). Create a great work culture. Ameri- can Nurse Today, 4(6), 13–14.

Failla, K. R., & Stichler, J. F. (2008). Manager and staff perceptions of the man- ager’s leadership style. Journal of Nursing Admin- istration, 38(11), 480–487.

Goode, C. J., Lynn, M. R., Krsek, C., & Bednash, G. D. (2009). Nurse residency programs: An essential requirement for nursing. Nursing Econom- ics, 27(3), 142–159.

Hersey, P., Blanchard, K. H., & Johnson, D. E. (2007). Management of organiza- tional behavior (9th ed.). Upper Saddle River, NJ: Prentice Hall.

Locke, E. A. (1968). Toward a theory of task motives and incentives. Organizational Behavior and Human Performance, 3, 157.

Lynn, M. R. (2008). UHC/AACN nurse residency programs. Paper presented at the University Health-System Consortium Performance Excellence Forum, Dallas, TX.

McPeck, P. (2006). Residencies ease new grads into practice. NurseWeek, September 11, 2006. Retrieved January 2008 from http://www.ver- sant.org/item.asp?id=70

Ponti, M. D. (2009). Transi- tion from leadership de- velopment to succession management. Nursing Administration Quarterly, 33(2), 125–141.

Skinner, B. F. (1953). Science and human behavior. New York: Free Press.

Stedman, M. E., & Nolan, T. L. (2007). Coaching: A differ- ent approach to the nursing dilemma. Nursing Admin- istration Quarterly, 31(1), 43–49.

Swearingen, S. (2009). A jour- ney to leadership: Design- ing a nursing leadership development program. Journal of Continuing Edu- cation in Nursing, 40(3), 107–112.

Urquhart, C. (2009). How to mo- tivate your staff. American Nurse Today, 4(7), 27–28.

Vroom, V. H. (1964). Work and motivation. New York: Wiley.

Wendler, M. C., Olson-Sitki, K., & Prater, M. (2009). Suc- cession planning for RNs. Journal of Nursing Admin- istration, 39(7/8), 326–333.

Williams, C. A., Goode, C. J., Krsek, C., Bednash, G. D., & Lynn, M. R. (2007). Postbaccalaureate nurse residency 1-year option. Journal of Nursing Admin- istration, 37(7/8), 357–365.

http://www.ver-sant.org/item.asp?id=70

CHAPTER

The Performance Appraisal EVALUATION SYSTEMS

EVIDENCE OF PERFORMANCE

EVALUATING SKILL COMPETENCY

DIAGNOSING PERFORMANCE PROBLEMS

THE PERFORMANCE APPRAISAL INTERVIEW

Potential Appraisal Problems LENIENCY ERROR

RECENCY ERROR

HALO ERROR

AMBIGUOUS EVALUATION STANDARDS

WRITTEN COMMENTS PROBLEM

Improving Appraisal Accuracy APPRAISER ABILITY

APPRAISER MOTIVATION

Rules of Thumb

Evaluating Staff Performance 18

Key Terms Ambiguous evaluation

standards problem Behavior-oriented rating

scales

Critical incidents Group evaluation Halo error Leniency error

Performance appraisal Recency error Written comments problem

1. Describe criteria that can be used to evaluate staff performance.

2. Discuss different methods used to evaluate performance.

3. Describe problems to expect when evaluating performance.

4. Explain how to use critical incidents to improve annual evaluations.

5. Explain how to conduct a performance appraisal interview.

Learning Outcomes After completing this chapter, you will be able to:

240 PART 3 • MANAGING RESOURCES

T he goal of a performance evaluation is to support nursing practice development (Schoessler et al., 2008). Evaluating past performance, compared to specified stan-dards, enables the employee and the manager to identify developmental needs. Performance-related behaviors are directly associated with job tasks and need to be accom- plished to achieve a job’s objectives (Topjian, Buck, & Kozlowski, 2009).

The Performance Appraisal The primary purpose of performance evaluations is to give constructive feedback. A good appraisal system ensures that staff know what is expected and how well they meet those expecta- tions. Performance appraisals serve as developmental tools as well as providing information for salary increases and promotions.

The performance appraisal process includes:

● Day-to-day manager–employee interactions (coaching, counseling, dealing with policy violations, and disciplining are discussed in Chapter 19)

● Making notes about an employee’s behavior ● Encouraging the employee to complete a self evaluation ● Directing peer evaluation, if used ● Conducting the appraisal interview ● Following up with coaching and/or discipline when needed

In addition, performance appraisals and the decisions based on those appraisals, such as lay- offs, are covered by several federal and state laws. In the past, employees have successfully sued their organizations over discriminatory employment decisions that were based on questionable performance appraisal results.

There are several steps to help ensure that an appraisal system is nondiscriminatory.

1. The appraisal is in writing and carried out at least once a year.

2. The performance appraisal information is shared with the employee.

3. The employee has the opportunity to respond in writing to the appraisal.

4. Employees have a mechanism to appeal the results of the performance appraisal.

5. The evaluator has adequate opportunity to observe the employee’s job performance during the course of the evaluation period. If adequate contact is lacking (e.g., the appraiser and the apprai- see work different shifts), then appraisal information should be gathered from other sources.

6. Anecdotal notes on the employee’s performance are kept during the entire evaluation period (e.g., three months, one year). These notes, called critical incidents, and discussed later, are shared with the employee during the course of the evaluation period.

7. Evaluators are trained to carry out the performance appraisal process, including

a. What is reasonable job performance; b. How to complete the form; and c. How to carry out the feedback interview.

8. The performance appraisal focuses on employee behavior and results rather than on per- sonal traits or characteristics, such as initiative, attitude, or personality.

Regardless of how an organization uses performance appraisals, they must accurately reflect the employee’s actual job performance. If performance ratings are inaccurate, an inferior em- ployee may be promoted, another employee may not receive needed training, or there may not be a tie between performance and rewards (thus lessening employee motivation). For appraisals to be successful, the needs of the staff and requirements of the organization must be bridged.

CHAPTER 18 • EVALUATING STAFF PERFORMANCE 241

Evaluation Systems Nurses engage in a variety of job-related activities. To reflect the multidimensional nature of the job, the performance appraisal form should cover different performance dimensions, such as pain management. In addition, the form should state specific criteria to be evaluated, such as “Evaluates pain levels and administers appropriate medications.” Finally, the form should in- clude the individual’s goals for the year based on the previous year’s evaluation.

Results-Oriented System All organizations need to be concerned with the bottom line. If a hospital has a 35 percent occupancy rate or a 20 percent employee absenteeism rate, its future is in jeopardy. In recent years, therefore, top management has turned to appraising some employees at least partly on results. With a results-oriented appraisal system, employees know in advance what is expected. Results are quantifiable, objective, and easily measured.

A focus on results requires setting objectives for what the employee is to accomplish. Although this technique has many variations, basically it involves two steps.

First, a set of work objectives is established at the start of the evaluation period for the employee to accomplish during some future time frame. These objectives can be developed by the employee’s supervisor and given to the employee; however, it is better if the manager and employee work together to develop a set of objectives for the employee.

Each performance objective should be defined in concrete, quantifiable terms and have a specific time frame. For example, one objective may need to be accomplished in one month (e.g., “Revise the unit orientation manual to reflect the new Joint Commission standards”); another objective may not have to be met for 12 months (e.g., “Take and pass the CCRN examination within the next year”). In setting objectives, it is important that the employee perceive them as challenging yet attainable.

Sylvia is an experienced critical care nurse. Her goals for the year include:

● Complete advanced cardiac life support (ACLS) recertification. ● Obtain CCRN credentialing. ● Precept one new graduate nurse. ● Serve on hospital shared governance committee.

The second step involves the actual evaluation of the employee’s performance. At this time, the supervisor and employee meet and focus on how well the employee has accomplished his or her objectives.

At Sylvia’s annual performance review, her manager noted that she had:

● Become ACLS recertified. ● Obtained CCRN credentialing. ● Precepted a new graduate nurse who was functioning above expectations. ● Chaired subcommittee of hospital shared governance committee.

Behavior-Oriented System Behavior-oriented systems focus on what the employee actually does, as exemplified in Table 18-1.

Focusing on specific behaviors in appraising performance gives new employees specific in- formation on how they are expected to behave and facilitates development of current staff mem- bers. Although there are several varieties of behavior-oriented rating scales, they all have a number of things in common:

1. Groups of workers who are very familiar with the target job (generally, individuals doing the job and their immediate supervisors) provide written examples (critical incidents) of superior and inferior job behaviors.

242 PART 3 • MANAGING RESOURCES

Employee Performance Evaluation Form

Employee Name: ______________________

Position: Registered Nurse

Department: ______________________

Hire Date: ______________________

Evaluation Review Period: ______________________

Manager Reviewer: ______________________

This appraisal contains a five-point scale that each performance expectation is rated on. The description of each number ranking on the five point scale is:

5 Significantly Exceeds Expectations—Staff member consistently goes above and beyond ordinary expectations. Staff member is the pillar role model of excellence 100% of the time.

4 Exceeds Expectations—Staff member frequently does things that are beyond their ordinary expectations. Peers and patients comment that staff member goes beyond others and routine expectations.

3 Meets Expectations—Staff member always meets expectation as expected.

2 Usually Meets Expectations—Staff member is able to demonstrate meeting performance expectations at times.

1 Does Not Consistently Meet Expectations—In this category, remediation work is necessary.

Performance Expectations

5–Significantly Exceeds Expectations

4–Exceeds Expectations

3–Meets Expectations

2–Usually Meets Expectations

1–Does Not Consistently Meet Expectation

1. Models critical thinking and expert judgment in patient care.

2. Completes assessments, plans of care, and documentation as expected.

3. Has developed technical skills and seeks opportunity to enhance skills as appropriate.

4. Develops trusting, collaborative relationships with patients and peers.

5. Maintains confidentiality of information.

6. Demonstrates accountability for actions

7. Follows policies and protocols appropriately.

8. Completes annual education competencies and all education on new policies and procedures as expected.

9. Demonstrates care, respect, and compassion in all interactions.

TABLE 18-1 Hill Top Healthcare System

CHAPTER 18 • EVALUATING STAFF PERFORMANCE 243

TABLE 18-1 Continued

10. Ensures patients are safe and implements all safety protocols for patients that are appropriate.

11. Brainstorms ideas of needed improvement on the unit and offers ideas to the group along with solutions.

12. Is flexible with staffing and works with peers to meet the needs of patients when planning schedule.

13. Shows commitment to learning and expanding knowledge.

14. Serves as a preceptor and charge nurse as requested.

15. Demonstrates cost awareness and uses supplies and equipment appropriately.

16. Embraces personal responsibility to the organization, patient care, and unit team.

17. Works well with multidisciplinary team, recognizing many people must work together to make great patient care.

18. Participates in a hospital or unit committee.

19. Models direct, purposeful communication.

20. Works in harmony with coworkers, being a team player and settling conflicts professionally.

Employee’s Goals for Next Year

What is the goal the employee will complete in the next 12 months? How can the manager support this goal? _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

Signatures

This verifies that this review was completed and does not necessarily signify agreement or disagreement with the contents of the review.

_________________________________________________________________________________________________________

Employee’s Signature

Date __________

Manager’s Signature __________ Date __________ Human Resource’s Signature __________ Date __________

244 PART 3 • MANAGING RESOURCES

2. These critical incidents are stated as measurable/quantifiable behaviors. (Examples are given in Box 18-1.)

3. Critical incidents that are similar in theme are grouped together. These behavioral group- ings (performance dimensions) are labeled, for example, patient safety.

Such behavior-oriented appraisal measures can be used only for one job or a cluster of similar jobs, so these scales are time-consuming and therefore expensive to develop. For these reasons, behavior-oriented systems are generally developed when a large number of individuals are doing the same job, such as critical care nurses.

Evidence of Performance Evidence of an individual’s performance is collected in several ways, including peer review, self- evaluations, group evaluations, and the manager’s notes and evaluation.

Peer Review This is a process by which nurses assess and judge the performance of professional peers against predetermined standards (Davis, Capozzoli, & Parks, 2009). Peer review is designed to make performance appraisal more objective because multiple ratings give a more diverse appraisal. It is used frequently in clinical ladder programs, self-governance models, and evaluation of ad- vanced practice nurses.

The steps for peer review are as follows:

1. The manager and/or employee select peers to conduct the evaluation. Usually, two to four peers are identified through a predetermined process.

2. The employee submits a self-evaluation portfolio. The portfolio might describe how he or she met objectives and/or predetermined standards during the past evaluation cycle. Sup- porting materials are included.

3. The peers evaluate the employee. This may be done individually or in a group. The indi- viduals or group then submit a written evaluation to the manager.

BOX 18-1 Example of a Critical Incident

1. Name of employee: Cindy Siegler 2. Date and Time of incident: March 22, 23, 24,

at 0915 3. Description: Ms Siegler, patient care assistant, for

the third time this week had nurses complain to manager that 0800 vital signs and finger sticks were not completed at 0900. Nurses use the vital signs and finger stick results as supporting facts in safely administering their medications that are scheduled for 0900.When the nurses go to find Ms. Siegler, each time she has been in the break room on her cell phone and eating. The nurses asked Ms. Siegler why she is in the break room for long periods of time. Ms. Siegler reported to them that she’s not going to “push herself early in the day” and she likes to “ease into her shift.” The nurses also asked Ms. Siegler why she must take a break when her work isn’t done and it is a critical assessment and medication pass time for the unit. The nurses shared with Ms. Siegler that

they depend on her for vital sign and finger stick results. Ms. Siegler has told the nurses on three occasions now “I’ll get there in a bit.”

4. Comments: Ms. Siegler was counseled by man- ager. Manager told Ms. Siegler her one priority at work has to be meeting the needs of patients. Ms. Siegler was told that her role on the team is im- portant and vital sign data and finger stick results must be completed and entered into the com- puter system for nurses before 0900. Ms. Siegler was instructed to not be in the breakroom unless the charge nurse had approved the break. She was also educated on proper break length being 15 minutes. Ms. Siegler was told that failing to meet any of the expectations discussed would result in written warning counseling. Ms. Siegler acknowl- edged understanding. She said, “I’ll try harder.” Manager stated she would talk with Ms. Siegler to touch base in two weeks.

CHAPTER 18 • EVALUATING STAFF PERFORMANCE 245

4. The manager and employee meet to discuss the evaluation. The manager’s evaluation is included, and objectives for the coming evaluation cycle are finalized.

Implementing a peer review involves several considerations. First, it is best to avoid selecting personal best friends for the review. Friends can provide poor ratings as well as in- flated ratings, resulting in a negative experience. Second, consider how often to evaluate expert practitioners—for example, those nurses who have reached the top of a clinical ladder. Third, monitor the time needed for portfolio preparation. The object is to improve professionalism and quality of patient care, not to create more paperwork.

Self-Evaluation Self-evaluations help the employee examine performance over the year and consider improve- ments to be made. It is difficult for anyone to accurately rate one’s own performance, so self- evaluations tend to be overly positive or, in some cases, excessively negative. Nonetheless, it is a valuable exercise to require employees to focus attention on how well they have met the requirements of the job regardless of whether the appraisal is behavioral-oriented (“Completes patient care plan within 24 hours of admission”) or results-oriented (“Presented one in-service on the unit”).

Group Evaluation Another technique is group evaluation. Here, several managers are asked to rank employee performance based on job descriptions and performance standards. Usually, one manager facili- tates the process. In addition to evaluating individual performance, the performance of groups of nurses can also be evaluated in this way, and group variances can be benchmarked and evalu- ated. Using group evaluation reduces personal bias, is timely, and can be effective.

Manager’s Evaluation Appraising an employee’s performance can be a difficult job. A nurse manager is required to reflect on a staff member’s performance over an extended period of time (usually 12 months) and then accurately evaluate it. Given that nurse managers have several employees to evaluate, it is not surprising that they frequently forget what an individual did several months ago or may actually confuse what one employee did with what another did.

A useful mechanism for fighting such memory problems is the use of critical incidents, which are reports of employee behaviors that are out of the ordinary, in either a positive or a negative direction. Critical incidents include four items: name of employee, date and time of incident, a brief description of what occurred, and the nurse manager’s comments on what trans- pired (Box 18-1). Electronic devices, index cards, or a small notebook are best to use because they allow notes to be taken immediately. In addition, lag time increases the likelihood of errors and the possibility that the manager will neglect to share the incident with the employee (see next section).

Recording critical incidents as they occur is bound to increase the accuracy of year-end performance appraisal ratings. Although this type of note taking may sound simple and straight- forward, a manager can still run into problems. For instance, some managers are uncomfortable about recording behaviors; they see themselves as spies lurking around the work area attempting to catch someone. What they need to remember is that this note taking will enable them to evalu- ate the employee more accurately and makes recency error (described later) much less likely.

The best time to write critical incidents is just after the behavior has occurred. The note should focus specifically on what took place, not on an interpretation of what happened. For example, instead of writing, “Ms. Hudson was rude,” write, “Ms. Hudson referred to the patient as a slob.”

Once a critical incident has been recorded, the manager should share it with the employee in private. If the behavior is positive, it is a good opportunity for the nurse manager to praise

246 PART 3 • MANAGING RESOURCES

the employee; if the behavior is considered in some way undesirable, the manager may need to coach the employee (see Chapter 19).

Because most managers are extremely busy, they sometimes question whether note taking is a good use of their time. In fact, keeping notes is not a time-consuming process. The average note takes less than two minutes to write. If one writes notes during the gaps in the day (e.g., while waiting for a meeting to start), little, if any, productive time is used. In the long run, such note taking saves time. In addition, keeping and sharing notes forces a manager to deal with problems when they are small and thus are more quickly addressed. Then completing the ap- praisal form at the end of the evaluation period takes less time with notes for reference.

A key factor in effectively using this note-taking approach is how nurse managers introduce the technique to their staff. To get maximum value out of note taking, managers need to keep in mind two important facts:

1. The primary reason for taking notes is to improve the accuracy of the performance review.

2. When something new is introduced, people tend to react negatively to it.

Managers should be open and candid about the first fact, admitting that they cannot remem- ber every event associated with every employee and telling employees that these notes will make more accurate evaluations possible. Even then, employees will still be suspicious about this pro- cedure. One way to get the procedure off to a good start is for managers to make the first note they record on an employee a positive one, even if they have to stretch a bit to find one. By doing this, each employee’s first contact with critical incidents is positive.

Three types of mistakes common with using notes are:

1. Some managers fail to make them specific and behavior oriented; rather, they record that a nurse was “careless” or “difficult to supervise.”

2. Some managers record only undesirable behavior.

3. Some managers fail to give performance feedback to the employee at the time that a note was written.

Each of these errors can undermine the effectiveness of the note-taking process. If the notes are vague, the employee may not know specifically what he or she did wrong and therefore does not know how to improve. If only poor performance is documented, employees will resent the system and the manager. If the manager does not share notes as they are written, the employee will often react defensively when confronted with them at the end of the evaluation period. In sum, any manager who is considering using this powerful note-taking procedure needs to take the process seriously and to use it as it is designed.

By increasing the accuracy of the performance review, written notes also diminish the legal liability of lawsuits. If a lawsuit is brought, written notes are very persuasive evidence in court. Sharing the notes with employees throughout the evaluation period also improves the communi- cation flow between the manager and the employee. Having written notes also gives the manager considerable confidence when it comes time to complete the evaluation form and to carry out the appraisal interview.

The manager will feel confident that the appraisal ratings are accurate. Not only does the manager feel professional, but the staff nurse also shares that perception. In fact, it is typically found that with the use of notes, the performance appraisal interview focuses mainly on how the employee can improve next year and what developmental activities are needed rather than on how he or she was rated last year. Thus, the tone of the interview is constructive rather than argumentative.

One final issue needs to be addressed. Different employees react differently to the use of notes. Good employees react positively. Although the manager records both what is done well and what is done poorly, good employees will have many more positive than negative notes and

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therefore will benefit from notes being taken. In contrast, poorer employees do not react well to notes being taken.

Whereas once they could rely on the poor memory of the nurse manager to produce inflated ratings, note taking is likely to result in more accurate (i.e., lower) ratings for poor employees. The negative reaction of poor employees, however, tends not to be a lasting one. Generally, the poor performers either leave the organization, or when they discover that they no longer can get away with mediocre performance, their performance actually improves.

In most organizations, an employee’s immediate manager is in charge of evaluating her or his performance. If the immediate supervisor does not have enough information to evaluate an employee’s performance accurately, alternatives are necessary. The manager can informally seek out performance-related information from other sources, such as the employee’s cowork- ers, patients, or other managers who are familiar with the person being evaluated. The manager weighs this additional information, integrates it with his or her own judgment, and completes the evaluation.

Evaluating Skill Competency Health care organizations are required to assess their employees’ abilities to perform the skills and tasks required for their positions (Joint Commission, 2011). Validation of competency is an ongoing process, initiated in orientation, followed up by development, and assessed on an annual basis and, possibly, remediation. Skill evaluation most commonly takes place in a skills lab, with simulation models, or by direct observation at the point of care. The manager plays a key role in determining the competences required on the job, especially for unit or department- specific competencies.

Diagnosing Performance Problems If the manager notes poor or inconsistent performance during the appraisal process, the manager must investigate and remedy the situation. Certain questions should be asked:

“Is the performance deficiency a problem?” “Will it go away if ignored?” “Is the deficiency due to a lack of skill or motivation? How do I know?”

The first step is to begin with accepted standards of performance and an accurate assessment of the current performance of the staff member. This means job descriptions must be current and performance appraisal tools must be written in behavioral terms. It also implies that employee evaluations are regularly carried out and implemented according to recognized guidelines. Also, the employee must know what behavior is expected.

Next decide whether the problem demands immediate attention and whether it is a skill- related or motivation-related problem. Skill-related problems can be solved through informal training, such as demonstration and coaching, whereas complex skills require formal training (e.g., in-service sessions or workshops). If there is a limit to the time an employee has to reach the desired level of skill, the manager must determine whether the job could be simplified or whether the better decision would be to terminate or transfer the employee.

If the performance problem is due to motivation rather than ability, the manager must ad- dress a different set of questions. Specifically, the manager must determine whether the em- ployee believes that there are obstacles to the expected behavior or that the behavior leads to punishment, reward, or inaction. For example, if the reward for conscientiously coming to work on holidays (rather than calling in sick) leads to always being scheduled for holiday work, then good performance is associated with punishment.

Only when the employee sees a strong link between valued outcomes and meeting perfor- mance expectations will motivation strategies succeed. The manager plays a role in tailoring motivational efforts to meet the individual needs of the employee (see Chapter 17). Unfortu- nately, creating a performance–reward climate does not eliminate all problem behaviors. When

248 PART 3 • MANAGING RESOURCES

the use of rewards proves ineffective, other strategies, such as coaching and discipline, are war- ranted (see Chapter 19).

To differentiate between lack of ability and lack of motivation, the manager can analyze past performance. If past performance has been acceptable and little change in standards of per- formance has taken place, then the problem results from a lack of motivation. In contrast, if the nurse has never performed at an acceptable level, then the problem may be primarily skill re- lated. Different intervention strategies should be used, depending on the source of the problem. The objective should be to enhance performance rather than to punish the employee. Figure 18-1 summarizes the steps to take.

The Performance Appraisal Interview Once the manager completes an accurate evaluation of performance, an appraisal interview can be scheduled. The appraisal interview is the first step in employee development.

Preparing for the Interview Keep in mind what needs to be accomplished during the interview. If the appraisal ratings are accurate, they are more likely to be perceived as such by the employee. This perception should, in turn, make the employee more likely to accept them as a basis for both rewards as well as developmental activities. More specifically, to motivate employees, rewards need to be seen as linked to performance.

The performance appraisal interview is the key to this linkage. In the interview, establish that performance has been carefully assessed and that, when merited, rewards will be forthcom- ing. Developmental activities also need to be derived from an accurate evaluation. If an em- ployee is rated as “needs immediate improvement” on delegation skills, for example, any effort to remedy this deficiency must stem from the employee’s acceptance of the need for improve- ment in delegation.

Even though managers try to fill out the appraisal form accurately, they should still antici- pate disagreement with their ratings. Most employees tend to see themselves as above-average performers. This tendency to exaggerate our own performance results from the fact that we tend to forget our mistakes and recall our accomplishments; we often rationalize away those instances where our performance was substandard (e.g., “I forgot, but with this heavy workload, what do you expect?”). Given this tendency to over evaluate one’s own performance and the fact that most staff previously have had poor experiences with the evaluation process, expect that staff will lack confidence in the whole appraisal process.

Assess performance

Is there a problem?

If the problem is

Provide education.

Coach.

Simplify task.

Reassign.

Replace if time does not warrant other techniques.

Clarify expectations.

Determine obstacles and remove them.

Determine if desired performance is being punished; remove punishment.

Determine employee values regarding rewards; ensure equitable treatment.

Give feedback as appropriate.No

Yes

Motivation relatedSkill related

Figure 18-1 • Decision tree for evaluating performance.

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A key step for making the appraisal interview go well is to set up the performance appraisal interview in advance, preferably giving at least two days’ notice. Schedule enough time: most interviews last 20 to 30 minutes, although the time needed will vary considerably depending on the degree to which the nurse manager and the staff nurse have talked regularly during the year.

In preparing for the appraisal interview, have specific examples of behavior to support the ratings. Such documentation is particularly important for performance areas in which an em- ployee receives low ratings. In addition, try to anticipate how the staff member will react to the appraisal. For example, will the individual challenge the manager’s ratings as being too low? Anticipating such a reaction, one can respond by saying, “Before I made my ratings, I talked with two other unit managers to make sure my standards were reasonable.”

The setting should also be considered in planning the meeting. It is critical that the inter- view take place in a setting that is private and relatively free from interruptions. This allows a frank, in-depth conversation with the employee. Although it is difficult to limit interruptions in a health care setting, choosing the meeting time carefully will help. You may be able to schedule the meeting when another manager can cover, or at a time when interruptions are least likely to occur. The most important point to remember is that a poor setting limits the usefulness of the interview. No one wants weaknesses discussed in public. Similarly, interruptions destroy the flow of the feedback session.

The Interview The appraisal interview is most likely to go well if the nurse manager has written and shared critical incidents throughout the evaluation period. If such feedback has occurred, staff members go into the interview with a good idea of how they are likely to be rated, as well as what behav- iors led to the rating. If the nurse manager has not kept notes throughout the year, it is important to recall numerous, specific examples of behavior, both positive and negative, to support the rat- ings given.

The major focus of the feedback interview should be on how the nurse manager and the staff member can work together to improve performance in the coming year. However, establish- ing such an improvement-oriented climate is easier said than done. In giving feedback, be aware that every employee has a tolerance level for criticism beyond which defensiveness sets in. Thus, in reviewing an employee’s performance, emphasize only a few areas—preferably, no more than two—that need immediate improvement.

Unfortunately, evaluators often exceed an employee’s tolerance level, particularly if perfor- mance has been mediocre. Typically, the manager will come up with an extensive list of areas needing improvement. Confronted with such a list, the staff member gradually moves from a constructive frame of mind (“I need to work on that”) after one or two criticisms are raised to a destructive perspective (“She doesn’t like me,” “He’s nitpicking,” “How can I get even?”) as the list of criticisms continues.

Following are recommendations for conducting an appraisal interview:

1. Put the employee at ease. Most individuals are nervous at the start of the appraisal inter- view, especially new employees who are facing their first evaluation or those who have not received frequent performance feedback from their manager over the course of the evaluation period. Begin the interview by giving an overview of the type of information that was used in making the performance ratings, such as, “In preparing for this review, I relied on the notes I have taken and shared with you throughout the year.” Rather than trying to reduce the tension an employee may have at the start of the interview, it is bet- ter to ignore it.

2. Clearly state the purpose of the appraisal interview. An improvement-oriented theme should be conveyed at the beginning of the interview, can lead to identifying development activities, and will help the employee do the best possible job in the coming year.

250 PART 3 • MANAGING RESOURCES

3. Go through the ratings one by one with the employee. Provide a number of specific examples of behavior that led to each rating. Be careful not to rush. By systematically going through the ratings and providing behavioral examples, nurse managers project an image of being prepared and of being a professional. This is important for getting the staff nurse to accept the ratings and act on them.

4. Draw out the employee’s reactions to the ratings. Ask for the employee’s reaction to the ratings and then listen, accept, and respond to them. Of the seven key behaviors for do- ing performance reviews, nurse managers have the most difficulty with this one. To carry out this phase of the interview effectively, you must have confidence in the accuracy of the ratings.

When asked to express their reactions, individuals who have received low ratings will frequently question the rater’s judgment (“Don’t you think your standards are a little high?”). Not surprisingly, the manager whose judgment has been questioned tends to get defensive, cutting off the employee’s remarks and arguing for the rating in question. Being cut off sends a contradictory message to the employee. The individual was asked for reactions, but when given, the supervisor did not want to hear them. You should an- ticipate that the ratings will be challenged and must truly want to hear the staff nurse’s reaction to them.

After having listened to the employee’s reactions, accept and respond to them in a man- ner that conveys that you have heard what the employee said (e.g., paraphrase some of the comments) and accept the individual’s opinion (“I understand your view”). In addition, you may want to clarify what has been said (“I do not understand why you feel your initiative rating is too low. Could you cite specific behavior to justify a higher rating?”). Strive for a candid, two-way conversation to find out exactly how the employee feels.

5. Decide on specific ways in which performance areas can be strengthened. The focus of the interview should now shift to the future. If a thorough review of an employee’s perfor- mance reveals deficiencies, you and the employee may jointly develop action plans to help the individual improve. An action plan describes mutually agreed-on activities for improv- ing performance. Such developmental activities may include formal training, academic course work, or on-the-job coaching. Together, you and the staff nurse should write down the resulting plans.

Because of the possibility of defensiveness, address only one or two performance areas needing improvement. Choose only the areas that are most troublesome and focus attention on these. In arriving at plans for improving performance, begin by asking the staff member for ideas on how to enhance personal performance. After the individual has offered sugges- tions, you can offer additional suggestions.

It is critical that such performance plans refer to specific behavior. In some cases, not only will the staff member be expected to do things in a different manner (“I will refer to a patient as Mr., Mrs., or Ms. unless specifically told otherwise”), but you may also be expected to change your behavior (“I will post changes in hospital policy before enforcing them”).

6. Set a follow-up date. After having agreed on specific ways to strengthen performance in problem areas, schedule a subsequent meeting, usually four to six weeks after the ap- praisal interview. At this later meeting, provide specific feedback on the nurse’s recent performance.

This meeting also gives you and the nurse an opportunity to discuss any problems they have encountered in attempting to carry out their agreed-on performance/improvement plans. In most cases, this follow-up session is quite positive. With only one or two areas to work on and a specific date on which feedback will be given, the nurse’s performance usually improves dramatically. Thus, the follow-up meeting is one in which you have the opportunity to praise the employee.

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7. Express confidence in the employee. The final key behavior is simple but often over- looked. It is nevertheless important that a manager indicate confidence that improvement will be forthcoming.

Since no more than two problem areas should be addressed in the appraisal interview, other problem areas may be considered later in the year. If the targeted performance areas continue to improve significantly, then meet again with the staff member one or two weeks after this follow- up session to raise another area that needs attention. As before, develop and write down specific ways to improve the performance deficiency and schedule another follow-up meeting. In short, performance deficiencies are not ignored, they are merely temporarily overlooked.

Potential Appraisal Problems No matter what type of appraisal system is used, problems that lessen the accuracy of the performance rating can arise, such as leniency, recency, and halo errors; ambiguous evalu- ation standards; and written comments problems. These, in turn, limit the usefulness of the performance review.

Leniency Error Managers tend to overrate their staff’s performance. This is called leniency error. For example, a manager may rate everyone on her or his staff as “above average.” Although numerous reasons are given for inflated ratings (e.g., “I want my nurses to like me,” “It’s difficult to justify giving someone a low rating”), these reasons do not lessen the problems that leniency error can create for both the manager and the organization. If you give a mediocre nurse lenient ratings, it is dif- ficult to turn around and take corrective action, such as discipline.

Leniency error can also be demoralizing to the best performers, because they would have received high ratings without leniency. However, with leniency error, these outstanding nurses look less superior compared to their coworkers. Thus, leniency error tends to be welcomed by poorer performers and disliked by better ones.

Recency Error Another difficulty with most appraisal systems is the length of time over which behavior is eval- uated. In most organizations, employees are formally evaluated every 12 months. Evaluating employee performance over such an extended period of time, particularly if one supervises more than two or three individuals, is a difficult task. Typically, the evaluator recalls recent perfor- mance and tends to forget more distant events. Thus, the performance rating reflects what the employee has contributed lately rather than over the entire evaluation period. This tendency is called recency error; it too can create both legal and motivational problems.

Shelby Miller, RN, transferred from a medical unit to the telemetry unit nine months ago. Overall, her performance has been good and she is an excellent team member. On two occasions, other nursing staff told the nurse manager, Lucinda Amos, about Shelby’s quick and accurate assessment of critical changes in patient status. Last week, Shelby mis- read a physician’s order and didn’t administer pre-procedure medications as directed. The procedure had to be rescheduled, resulting in surgical delays as well. The physician was angry and complained to both Lucinda and the cardiology nursing director. On her annual performance appraisal, Lucinda rated Shelby “below average” on patient care delivery.

Legally, if a disgruntled employee can demonstrate that an evaluation that supposedly re- flects 12 months actually reflects performance over the last 2 or 3 months, an organization will have difficulty defending the validity of its appraisal system. In terms of motivation, recency error demonstrates to all employees that they only need to perform at a high level near the time

252 PART 3 • MANAGING RESOURCES

of their performance review. In such situations, an employee is highly motivated (e.g., asking the supervisor for more work) just prior to appraisal but considerably less motivated as soon as it is completed.

As with leniency error, recency error benefits the poorly performing individual. Nurses who perform well year-round may receive ratings similar to those mediocre nurses who noticeably improve as their evaluation time approaches. Fortunately, recording critical incidents during the year lessens the impact of recency error.

Halo Error Sometimes an appraiser fails to differentiate among the various performance dimensions (e.g., nursing process, communication skills) when evaluating an employee and assigns ratings on the basis of an overall impression, positive or negative, of the employee. Thus, some employees are rated above average across dimensions, others are rated average, and a few are rated below aver- age on all dimensions. This is referred to as halo error.

If a nurse is excellent, average, or poor on all performance dimensions, she or he deserves to be rated accordingly, but in most instances, employees have uneven strengths and weaknesses. Thus, it should be relatively uncommon for an employee to receive the same rating on all per- formance dimensions. Although halo error is less common and troublesome than leniency and recency error, it still is not an accurate assessment of performance.

Ambiguous Evaluation Standards Most appraisal forms use rating scales that include words such as “outstanding,” “above average,” “satisfactory,” or “needs improvement.” However, different managers attach different meanings to these words, giving rise to what has been labeled the ambiguous evaluation standards problem.

One organization dealt with the problem by identifying core competencies and skill level descriptors and tagging them with evaluation criteria, such as “exceeds expectation,” “meets ex- pectation,” or “requires improvement” (Schoessler et al., 2008). Senior leadership validated that competency statements met accepted standards. Another approach is to develop rating forms that have each gradation along the performance continuum (e.g., excellent, satisfactory) anchored by examples of behavior that is representative of that level of performance.

Written Comments Problem Almost all performance appraisal forms provide space for written comments by the appraiser. The wise manager uses this space to justify in detail the basis for the ratings, to discuss develop- mental activities for the employee in the coming year, to put the ratings in context (e.g., although the evaluation period is 12 months, the appraiser notes on the form that he or she has only been the nurse’s manager for the past 3 months), or to discuss the employee’s promotion potential. Unfortunately, few nurse managers use this valuable space appropriately; in fact, the spaces for written comments are often left blank. When there are comments, they tend to be few and gen- eral (e.g., “Joan is conscientious”), focus totally on what the individual did wrong, or reflect only recent performance.

Dawn Stanley, RN, is director of nursing for an assisted living center. Two certified nurse aides transferred to her center from other facilities in the health care system. Both CNAs have struggled to meet performance expectations in the first 90 days of their new posi- tions. In preparing performance appraisals for both employees, Dawn reviewed previous appraisals to see if other managers had indicated areas for improvement or performance trends. Both employees were rated as “marginal performers” but no written comments were provided, making the appraisal process more difficult for Dawn.

The existence of the written comments problem should not be surprising. Most managers wait until the end of the evaluation period to make written comments; thus, the manager is faced

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with a difficult, time-consuming task. Small wonder, then, that the few comments tend to be vague, negative in tone, and reflect recent events. Fortunately, regular note taking can lessen the problems associated with written comments.

Improving Appraisal Accuracy For the manager and employee to get maximum benefit from an appraisal, it needs to encom- pass all facets of job performance and be free from rater error. Although attempting to get com- pletely accurate evaluations is often impossible, there are ways to greatly improve the accuracy of appraisals.

Appraiser Ability Accurately evaluating an employee’s performance involves using the job description, skill level descriptors, or core competency statements to identify behaviors required, then observing the employee’s performance over the course of the evaluation period and recalling it, and knowing how to use the appraisal form accurately. To the extent that any of these things are lacking, a manager’s ability to rate accurately is limited.

Fortunately, a manager’s ability to rate employees can be improved. An organization can de- velop detailed job descriptions, skill level descriptors, and competency statements. The rater can be given more opportunities to directly or indirectly observe an employee’s behavior. For example, other supervisors can provide information on an employee’s performance when the immediate su- pervisor is not present. Managers can be taught to take notes on an employee’s behavior to facili- tate recall. In addition, managers can learn to use the appraisal form better through formal training.

Formal training programs help to increase appraiser ability by making raters aware of the various types of rating errors (the assumption being that awareness may reduce the error ten- dency), by improving raters’ observational skills, and by improving raters’ skill in carrying out the performance appraisal interview.

Simone Hurtado is team manager for the pediatric home services team. In previous years, Simone has struggled to adequately evaluate her employees. Since all of the patient care is delivered in client’s homes, Simone relied on sporadic client feedback and review of patient care documentation to complete employee appraisals. Recently Simone attended an appraisal workshop. Using some of the suggested strategies, Simone and the other team managers have set up an observation schedule for their employees. Each employee will be randomly observed by a team manager in a client’s home every six to eight weeks. Additionally, employees will be asked to complete self-evaluations as well as evaluations of other team members they work with on a regular basis. Simone has also established a system for compiling ongoing employee performance documentation.

Appraiser Motivation Managers have a multitude of tasks to perform, often immediately. Not surprisingly, then, they often view performance appraisals as a task that can be done later. Furthermore, many managers do not see doing appraisals as particularly important, and some question the need for doing them at all. This is especially true if all employees receive the same percentage salary increase. Thus, if nurse managers are to be motivated to do appraisals well, they need to be rewarded for their efforts.

A nurse manager may spend little time on appraisals for several reasons:

● The organization does not reward the person for doing a good job. ● The manager’s supervisor spends little time on the manager’s own appraisal (thus sending

the message that doing appraisals is not important). ● If a manager gives low ratings to a poor employee, a superior may overrule and raise the

ratings.

254 PART 3 • MANAGING RESOURCES

In short, in many health care organizations, the environment may actually dampen appraiser motivation rather than stimulate it. Given these reasons for not spending time on appraisals, it is fairly obvious how an organization can enhance appraiser motivation:

● The manager needs to be rewarded for conscientiously doing performance reviews. ● The manager’s supervisor needs to present a good model of how an appraisal should be

carried out. ● As far as possible, the manager should be able to reward the highly rated staff.

This becomes more likely as outcomes are used as the basis for reimbursement to the orga- nization and, subsequently, the organization bases rewards on productivity. For the organization and its employees to benefit from the performance appraisal system, pay increases should not be across the board, layoffs should not be based on seniority, and promotions should be tied to superior performance.

Learn how one manager used a performance evaluation to help a staff member and benefit the organization at the same time (see Case Study 18-1).

EVALUATING STAFF Brenda Tice has been nurse manager for the medical in- tensive care unit (MICU) in a large urban hospital for six months. The MICU rarely has staff openings and the average nurse has 12 years of experience on the unit. Brenda herself was a nurse on the unit for 10 years prior to her promotion to nurse manager.

Lori Cook has been an RN on the MICU day shift for the past 18 months. Lori is pleasant and tries hard to please her patients and coworkers. However, she consis- tently stays late to complete her charting, relies heavily on coworkers to help her throughout the shift, and has little confidence in her own ability to handle complex patients. Often Lori will break down and cry during a patient code and is seemingly overwhelmed by the code process. Although the other nurses are supportive of Lori, they are aware of her limitations. Several nurses have complained when they have been assigned two high acuity patients and Lori is assigned one lower acu- ity patient.

Brenda discussed the issues with Lori. Brenda told Lori that she would help her attempt remediation as part of an action plan for performance improvement in order to meet minimum expectations for her position. Brenda arranged for Lori to attend several training programs designed specifically for ICU nurses, provided opportu- nities for experienced nurses to mentor Lori on more complex patients, and provided her with reference ma- terials to reinforce Lori’s skill set. Brenda also reviewed Lori’s personnel records for the past 18 months. While Lori is rated high for attendance and her interpersonal skills, her clinical skills are rated as fair. Brenda notices three separate performance counseling documents dat- ed within the past 12 months, with little improvement noted in her clinical performance.

Following another code incident in which Lori started crying and was asked to leave by a physician, Brenda determines that while Lori has many positive qualities, she does not have the clinical skills necessary to func- tion independently in the MICU. Brenda had provided Lori with an action plan and fair warning and conversa- tion about her not meeting expectation in the ICU and shared that Lori may not be a fit in the ICU environment. After contacting the human resources department to discuss the transfer process because of Lori’s continued lack of ability to meet ICU performance expectations, she schedules a meeting with Lori to discuss her perfor- mance issues. Brenda reviews the performance concerns with Lori and informs her that due to her continued lack of ability to meet expectations she has 30 days to accept reassignment within the hospital to a unit that more closely matches her clinical abilities. Lori decides to in- terview for positions in the geriatric psychiatric unit and the psychiatric day treatment program.

Manager’s Checklist The nurse manager is responsible for:

● Understanding the performance appraisal process and appraisal tools used by the organization

● Providing honest and timely feedback to all employees

● Communicating as needed with the human resources department when performance issues arise

● Accurately and thoroughly documenting all performance-related issues

● Identifying the impact of poor performers on the morale and productivity of staff

● Making staffing decisions in a timely manner

CASE STUDY 18-1

CHAPTER 18 • EVALUATING STAFF PERFORMANCE 255

Rules of Thumb For approximately five percent of employees, the prescriptions given in this chapter will not work, for reasons yet unknown. Additional suggestions or “rules of thumb” derived from practi- cal experience include the following:

● Go beyond the form. Too often, people doing evaluations cite an inadequate form as an excuse for doing a poor job of evaluating their employees. No matter how inadequate an appraisal form is, managers can go beyond it. They can focus on behavior even if the form does not require it. They can set goals even if other supervisors do not. They can use criti- cal incidents. In short, managers should do the best job of managing they can and not let the form handicap them.

● Postpone the appraisal interview if necessary. Once the appraisal interview begins, there is often the belief that the session must be completed in the time allotted, whether the ses- sion is going well or not. Managers forget the goal of the appraisal interview is not merely to get an employee’s signature on the form but also to get the employee to improve perfor- mance in the coming year. Therefore, if the interview is not going well, a manager should discontinue it until a later time. Such a postponement allows both the manager and the em- ployee some time to reflect on what has transpired as well as some time to calm down.

In postponing the meeting, the manager should not assign blame (“If you’re going to act like a child, let’s postpone the meeting”), but should adopt a more positive approach (“This meeting isn’t going as I hoped it would; I’d like to postpone it to give us some time to collect our thoughts”). Most managers who have used this technique find that the sec- ond session, which generally takes place one to two days later, goes much better.

● Don’t be afraid to change an inaccurate rating. New managers often ask whether they should change a rating if an employee challenges it. They fear that by changing a rating, they will be admitting an error. They also fear that changing a rating will lead to other ratings be- ing challenged. A practical rule of thumb for this situation is if the rating is inaccurate, change it, but never change it during the appraisal interview. Rather, if an employee challenges a rat- ing and the manager believes the employee has a case, the manager should tell the person that some time is needed to think about the rating before getting back to the employee.

The logic behind this rule of thumb is as follows: If a manager does a careful job of evaluating performance, few inaccurate ratings will be made. But no one is perfect, and on occasion, managers will err. When such an error occurs, the manager should correct it. Most employees respect a manager who admits a mistake and corrects it. By allowing for time to reflect on the ratings, a manager eliminates the pressure to make a snap judgment.

An effective performance evaluation contributes to the employee’s development, improves job satisfaction, and enhances employee morale. Learning how to evaluate employees is one of the nurse manager’s useful activities.

What You Know Now • Doing performance appraisals is one of the most difficult and most important management activities. • Accurate appraisals provide a sound basis for both administrative decisions (e.g., salary increases, promo-

tions) and employee development. • The evaluations system may be results oriented or based on behavioral criteria. • Evaluation standards must be based on identified criteria, such as job descriptions, skill level descriptors,

or core competencies, and based on performance as evaluated over the course of a year. • To enhance the accuracy of the performance appraisal, the manager should record critical incidents

throughout the evaluation period. • Self-evaluation, peer review, group evaluations, and the manager’s evaluation are examples of ways to col-

lect evidence of performance.

256 PART 3 • MANAGING RESOURCES

• To improve the value of the appraisal interview, the manager should follow the key behaviors for conduct- ing an appraisal interview.

• Problems with employee appraisal include leniency error, recency error, halo error, ambiguous standards, and the inadequate use of written comments.

• The manager’s ability to accurately evaluate staff can be improved through formal training and a posi- tive example from the manager’s supervisor.

Tools for Evaluating Staff Performance 1. Become familiar with the evaluation process adopted by your organization. 2. Familiarize yourself with the appraisal instrument used for staff evaluation. 3. Learn to use critical incidents and include positive behaviors as well as those needing improvement. 4. Be alert to the chances for error in the appraisal process. 5. Prepare for an appraisal interview using the strategies suggested in the chapter. 6. Follow the key behaviors for conducting an appraisal interview.

Questions to Challenge You 1. What evaluation method is used at your workplace or clinical site? If you do not know, find out and

share it with a colleague or class. 2. If you have been evaluated in the skills lab, on a simulator, or at the point of care, which assessment

best evaluated your skills? 3. What components of your job (or clinical placement) are evaluated? Are they the appropriate ones? 4. What types of assessment methods have been used to evaluate you? Were they the best ones to eval-

uate your performance? What would you suggest? 5. If you have been evaluated as an employee, did your evaluator follow the key behaviors in this chap-

ter? What improvements would you suggest? 6. Have you ever evaluated someone else’s performance at work? How closely did your actions follow

the suggestions in the chapter?

References Davis, K. K., Capozzoli, J., &

Parks, J. (2009). Imple- menting peer review: Guidelines for managers and staff. Nursing Admin- istration Quarterly, 33(3), 251–257.

Joint Commission. (2011). Com- prehensive accreditation manual for hospitals: The

official handbook. Retrieved July 28, 2011 from http://www.jcrinc.com/ Accreditation-Manuals/ PCAH11/2130/

Schoessler, M. T., Aneshansley, P., Baffaro, C., Castellan, T., Goins, L., Largaespada, E., Payne, R., & Stinson, D. (2008). The performance

appraisal as a developmen- tal tool. Journal for Nurses in Staff Development, 24(3), E12–E18.

Topjian, D. F., Buck, T., & Kozlowski, R. (2009). Em- ployee performance? For the good of all. Nursing Management, 40(4), 24–29.

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

http://www.jcrinc.com/Accreditation-Manuals/PCAH11/2130/

www.nursing.pearsonhighered.com

http://www.jcrinc.com/Accreditation-Manuals/PCAH11/2130/

CHAPTER

Day-to-Day Coaching

Positive Coaching

Dealing with a Policy Violation

Disciplining Staff

Terminating Employees

Coaching, Disciplining, and Terminating Staff 19

Key Terms Coaching Discipline

Progressive discipline Terminate

1. Describe how to coach an employee. 2. Discuss positive coaching. 3. Explain how to confront an employee

about a policy violation.

4. Discuss how to discipline an employee. 5. Describe how to terminate an employee.

Learning Outcomes After completing this chapter, you will be able to:

258 PART 3 • MANAGING RESOURCES

O ne of the most challenging problems for managers is knowing what to do when employees fail to perform to expectations. Managers often want to ignore the prob-lems, hoping they’ll disappear, but that seldom happens. Instead, the manager can learn how to handle these problems.

Day-to-Day Coaching Coaching, the day-to-day process of helping employees improve their performance, is an impor- tant tool for effective nurse managers. Yet coaching is probably the most difficult task in man- agement and is often neglected. In one short interaction, it encompasses needs analysis, staff development, interviewing, decision making, problem solving, analytical thinking, active listening, motivation, mentoring, and communication skills. Intervening immediately in performance prob- lems on a day-to-day basis usually eliminates small problems before they become larger ones and the subject of discussion in performance appraisal interviews or disciplinary actions. Coaching should also be used when performance meets the standard but improvement can still be obtained.

The goal of coaching is to eliminate or improve performance problems, but few nurses are prepared to coach and are often hesitant to confront employee problems. Coaching employees when the problem initially surfaces can potentially save time, prevent poor morale from occur- ring, and avoid more difficult action later, such as discipline or termination (Palermo, 2007). Additionally, appropriate and timely coaching can help retain employees and reduce turnover (Stedman & Nolan, 2007). (See Chapter 20 for more on reducing turnover and retaining staff.)

Examples of problems that coaching can improve or eliminate are incorrect flow sheet doc- umentation, excessive absenteeism, or frequent personal phone calls or excessive texting. Before entering into a coaching session, the nurse manager (coach) should prepare for the interaction and try to anticipate how the employee will react (“Everybody gets personal phone calls”) in or- der to formulate an appropriate response (“I am here to talk about the number of personal phone calls you receive”). In general, coaching sessions should last no more than 5 to 10 minutes. The steps in successful coaching are:

1. State the targeted performance in behavioral terms. “For the past two days, the physical assessment portions of your flow sheets have not been filled out.”

2. Tie the problem to consequences for patient care, the functioning of the organization, or the person’s self-interest. “It’s difficult for other nurses and physicians to know whether the patient’s status is changing, and therefore it’s hard to know how to treat the patient. Physical assessments are a standard of practice in our unit. Failure to document assessments could lead to legal problems should the patient’s record go before a court of law.” This is an important but often overlooked step because it cannot be taken for granted that the employee knows why the behavior is a problem. If employees are expected to act in a certain way, they need to under- stand why the behavior is important and be rewarded when it has improved. Avoid threatening language, such as “If you want to stay in this unit, you had better complete your documenta- tion.” This puts the employee on the defensive and makes the person less receptive to change.

3. Having stated the problem behavior, avoid jumping to conclusions but instead explore reasons for the problem with the employee. Listen openly as the employee describes the problem and the reasons for it. If the problem was caused by ignorance—for instance, lack of familiarity with the standard of care on performing and documenting assessments—sim- ply inform the nurse of the appropriate behavior and end the coaching session.

4. Ask the employee for his or her suggestions and discuss ideas for how to solve the problem. In many cases, the employee knows best how to solve the problem and is more likely to be committed to the solution if it is his or her own. It is better to encourage employees to solve their own problems; however, this does not mean that managers cannot add suggestions for improvement. It is essential to listen openly to understand the employee’s perspectives.

CHAPTER 19 • COACHING, DISCIPLINING, AND TERMINATING STAFF 259

5. How formal should the coaching session be? If the problem is minor and a first-time oc- currence, you may simply state what actions will be taken to solve the problem and end the meeting. In most cases, however, you and the employee should agree on specific behavioral steps each will take to solve the problem; write down these steps for later reference.

6. Arrange for a follow-up meeting, at which time the employee will receive performance feedback. It is possible that an employee may bring up personal problems as a cause for the work problems. The coaching session then verges on becoming a counseling session. When the employee brings up personal problems, nurse managers should convey their concern and willingness to work with the employee to get help for the problems. In most cases, nurse managers will not be the direct source of the help but rather will help the employee seek out other, more appropriate, sources, such as the organization’s employee assistance program. Do not delve into potential personal problems (“Are there problems at home that I should know about?”) unless staff raise them. The employee’s personal life is not the manager’s business.

Positive Coaching Coaching as a strategy to improve problem performance has been discussed, but coaching can also be used as tool to reinforce positive behaviors (Karsten et al., 2010). In fact, negativity is a far more common experience than a positive experience (Huseman, 2009). Coaching can be a leadership development tool as well.

Coaching has been shown to help leaders become more confident and competent and to improve their team’s functioning as well (McDermott & Levenson, 2007; McNally & Lukens, 2007). Coaching leaders is especially useful during times of transition, but historically, asking a leader to use a coach has been seen as punitive (Karsten et al., 2010). Often a senior executive uses a coach to model the importance to administrative staff. Coaching administrators is also a strategy for succession planning (McNally & Lukens, 2006).

Leadership coaching can be undertaken as one-on-one interactions with a coach, a group with similar needs participating in coaching sessions together, or individual and group sessions. Such coaching is results oriented, and its purpose is to help the participant become more self- aware, ensure accountability, and attain professional goals (McNally & Lukens, 2006).

Dealing with a Policy Violation As with day-to-day coaching, the manager must prepare to confront an employee about a policy violation. The leadership style of the manager is important in determining whether the employee perceives that he or she is being told what to do versus being sold on the idea that she or he is an important contributor to the staff. The steps involved in confrontation are similar to coaching. These steps are outlined in Box 19-1.

The first key behavior is to determine whether the employee is aware of the policy. The employee should have received policy information at orientation, and an updated policy manual should be readily accessible to all employees. It is also important to know whether the policy has been enforced consistently. If policies regarding tardiness are not applied to everyone on a daily basis, efforts to change this behavior in one individual predictably will be unsuccessful. It is bet- ter to identify policies and procedures that the majority of staff accept and to determine which employees need direction in compliance.

Second, describe the behavior that violated the policy in a manner that conveys concern to the employee regarding the outcome. By focusing on the employee’s behavior, you avoid mak- ing the interaction a personal issue.

After stating that the policy has been violated, obtain a document that states the policy so that in- terpretation issues can be clarified. For example, if the policy being violated is the requirement that nurses report to a peer about their patients when leaving the unit, have a copy of the policy in hand.

260 PART 3 • MANAGING RESOURCES

The next step is to solicit the employee’s reason for the behavior (e.g., what is preventing the person from informing a peer about patients when leaving the unit). Allow sufficient time for the employee to respond while at the same time guarding against the pursuit of extraneous, unrelated issues. In the latter event, redirect the employee’s attention to the policy violation and suggest dealing with other issues at another time.

Convey to the employee that she or he cannot continue breaking an established policy. In the previous example, you could discuss the effects of the behavior, such as medications not given, IVs running dry, and patients being left unattended, as reasons for having the policy.

Next, explore alternative solutions so that negative outcomes will be avoided. Ask the em- ployee for suggestions for solving the problem, and discuss each of the suggestions. Offer help if it is appropriate. Decide and agree on a course of action. The last step in the process is to set up a reasonable date to follow up with the employee on adherence to the established policy.

Although dealing with policy violations in a distinct step-by-step sequence is not always possible, proceed in an orderly manner. Many policy violations require early and decisive inter- ventions, and these must be handled in an immediate, forthright manner.

Disciplining Staff Most managers dread having to discipline an employee. Nevertheless, there will be occasions where discipline is necessary (e.g., when a regulation has been violated that jeopardizes patient safety). Managers may hesitate to discipline for many reasons, including:

● Lack of management support or training ● Letting past inappropriate behavior go by without mention ● Rationalizing to avoid disciplining ● Previous poor experience with attempting to discipline employees ● Fear that the employee will respond negatively (White, 2006)

Learning how to discipline effectively can reduce your concerns and improve morale for all em- ployees. Keep in mind, though, that the primary function of discipline is not to punish the guilty party, but to teach new skills and encourage that person and others to behave appropriately in the future.

BOX 19-1 Steps in Confrontation

1. Prepare before the meeting.

2. Without attacking the person, describe the un- desired behavior. Tie that behavior to its con- sequences for the patients, organization, or employee.

3. Solicit and openly listen with empathy to the em- ployee’s reasons for the behavior.

4. Explain why the behavior cannot continue, and ask for suggestions in solving the problem. If none are offered, suggest solutions. Agree on steps each will take to solve the problem.

5. Set and record a specific follow-up date.

Is the employee aware of the policy and procedure? Desired behavior?

Has the policy/procedure been consistently enforced?

How will the employee react?

Jane, were you aware that it is clinic policy to notify both the clinic manager and the hospital supervisor when you will be absent from work? Not only were we worried about you, but we had to reschedule patient procedures because we did not have the staff to attend to both clinic appointments and special procedures.

Why didn’t you notify someone about your absence?

In the future, you will need to notify both the clinic manager and the hospital supervisor if you cannot come in. How do you suppose you might do this, since you do not have a phone?

Can we meet again in one month to review this plan?

CHAPTER 19 • COACHING, DISCIPLINING, AND TERMINATING STAFF 261

BOX 19-2 Guidelines for Effective Discipline

1. Get the facts before acting. 2. Do not act while you are angry. 3. Do not suddenly tighten your enforcement of rules. 4. Do not apply penalties inconsistently. 5. Discipline in private. 6. Make the offense clear. Specify what is appropri-

ate behavior.

7. Get the other side of the story. 8. Do not let the disciplining become personal. 9. Do not back down when you are right. 10. Inform the human resources department and

administration of the outcome and other pertinent details.

BOX 19-3 Verbal Warning Form

Employee’s name: Date of verbal warning: Specific offense or rule violation: Specific statement of the expected performance:

Any explanation given by the employee or other significant information:

_____________________

Supervisor Date _____________________

When faced with a disciplinary situation, maintain close contact with the organization’s human resources department and administration. Before taking any disciplinary action, discuss the action you intend to take and seek approval for it. This close coordination with administration is essential to guarantee that any disciplinary action is administered in a fair and legally defensible manner.

To further ensure fairness, rules and regulations must be clearly communicated, a system of progressive penalties must be established, and an appeals process must be available. To enforce rules or regulations, managers must inform employees of them ahead of time, preferably in writ- ing. Guidelines for effective discipline can be found in Box 19-2.

Penalties should be progressive. Progressive discipline is the process of increasingly severe warnings for repeated violations that can result in termination. Questions to ask include:

● How many different offenses are involved? ● What is the seriousness of the offense? ● What were the time interval and employee responses to prior disciplinary action? ● What is the previous work history of the employee?

Penalties are also progressive, beginning with a verbal warning (Box 19-3), and followed by a written warning (Box 19-4), suspension, and discharge.

For minor violations (e.g., smoking outside in an unauthorized area), penalties may progress from an oral warning, to a written warning placed in the employee’s person- nel folder, to a suspension, and ultimately to discharge. For major rule violations (e.g., theft of property), however, initial penalties should be more severe (e.g., immediate suspension).

262 PART 3 • MANAGING RESOURCES

At each stage of the disciplinary process, documentation is essential. In addition, an appeals process should be built into an organization’s disciplinary procedures to ensure that discipline is carried out in a fair, consistent manner.

Case Study 19-1 shows how one nurse manager handled a disciplinary problem.

Terminating Employees Unfortunately, some employees do not respond to either coaching or discipline, and nurse man- agers will face the day when they must terminate, or fire, an employee (Bing, 2007). The steps in terminating an employee are similar to those for disciplining, except there are no plans to cor- rect the behavior and no follow-up. As with a disciplinary action, nurse managers must maintain close contact with the organization’s human resource department and nursing administration. They must discuss the termination and seek approval for it.

Preparation before terminating an employee is essential (Cohen, 2006). To prepare, answer the following questions:

1. Did you set your expectations clearly from the beginning? Did you review the job descrip- tion, performance appraisal criteria, and pertinent policies and procedures with the em- ployee? These expectations should have been in writing.

2. Did you document the employee’s performance on a continuing basis, using the critical in- cident or a similar method?

BOX 19-4 Written Warning Form

Employee’s name: Date of conversation: Specific rule violation or performance problem:

Previous conversations about the rule violation or performance problem:

Specific change in the employee’s performance or behavior expected:

Employee’s comments:

Supervisor’s comments:

Employee’s signature: -or- Employee was asked to sign this written warning on _____________ but declined to sign.

_____________________ Supervisor Date _____________________

CHAPTER 19 • COACHING, DISCIPLINING, AND TERMINATING STAFF 263

PROGRESSIVE DISCIPLINE Katie Connors is nurse manager of the birthing center in a metropolitan hospital. The hospital has several different nursing programs that utilize various patient care units for clinical instruction. A student nurse, Amber Schroeder, was assigned to work with Natalie Cole, RN, for the day shift. Natalie and Amber’s patient arrives at the birth- ing center for induction of labor. During the admission process, the patient confides to Natalie and Amber that she is terrified that she might need a caesarean section. Amber tells the patient that a young woman and her baby recently died at the hospital during an emergency C-section. The patient begins to hyperventilate, refuses to let Natalie continue with the admission, and threatens to leave the birthing center. Natalie is so angry at Amber for scaring the patient that she grabs her by the arm and pulls her out of the room. Natalie loudly berates Amber in the hallway to the point that Amber is crying.

Katie hears the commotion in the hallway and in- structs Amber to sit in the staff lounge until her instruc- tor can return to the unit. Katie and Natalie reassure the patient, who allows Natalie to complete the admission process. Throughout the shift, Natalie tells every staff member and physician about Amber’s “stupid com- ment.” Katie speaks with the nursing instructor and Amber about the incident. She also checks back with the patient and gently gathers facts about the incident.

Katie is concerned about Natalie’s response to the situation. While Natalie has excellent nursing skills, she has often been abrupt or rude to other staff members. Katie has coached Natalie on her communication skills in three other specific incidents and verbally warned Nata- lie about her lack of professional communication. After discussing the incident with the human resources man- ager, Katie agrees that a written warning will be placed in Natalie’s personnel file.

At the end of the shift, Katie requests that Natalie come to her office to discuss what happened with the

student nurse. Katie informs Natalie she is disappointed in how she reacted to the inappropriate comment made by the student nurse. Specifically, physically grabbing the student and verbally attacking her in front of patients and staff was unacceptable and violates hospital policy. Further, Natalie continued to disparage the student to other staff and physicians, which is also unacceptable. Natalie expresses her frustration at the thoughtlessness of Amber’s comment. Katie tells Natalie that while Am- ber’s comment was inappropriate, Natalie’s response was also inappropriate. Katie reinforces to Natalie the im- portance of professional communication at all times and reviews the communication points she had provided to Natalie in the past. She also informs Natalie that she will have a written warning placed in her personnel file. Nat- alie apologizes for her actions and assures Katie she will work on her communication skills. Katie documents the incident and follow-up action in Natalie’s personnel file.

Manager’s Checklist The nurse manager is responsible for:

● Collecting all necessary facts related to the disciplin- ary situation

● Communicating with the human resources depart- ment and nursing administration about the offense and appropriate penalty

● Disciplining the employee in a timely manner ● Providing strategies to the disciplined employee to

improve his or her behavior ● Clearly and firmly communicating expectations for

appropriate behavior ● Documenting the outcome of the discipline as

appropriate ● Following up with the human resources department

and nursing administration regarding the outcome of the discipline

CASE STUDY 19-1

3. Did you keep the employee informed about his or her performance on a regular basis?

4. Did you conduct coaching sessions or deal with policy or procedure violations in a timely manner? Were the sessions and the agreed-on actions in these meetings documented?

5. Were you honest with the employee about the poor performance or the policy that was vio- lated? Were you specific about behaviors that failed to meet expected standards? Was the expected performance stated in behavioral terms?

6. Were you consistent among employees in how you dealt with performance issues and policy or procedure violations?

7. Did you follow up? Did you deliver the actions you agreed to in the coaching sessions?

8. Did you document everything in writing? The importance of this cannot be overstated.

9. Have you notified security so that the terminated employee may be escorted out?

264 PART 3 • MANAGING RESOURCES

This checklist applies to almost every instance of termination. The few exceptions might be theft or physical abuse of a patient or assault on others. Even in the latter instances, observation and documentation are crucial to avoid legal challenges.

A sample script for a termination conversation is shown in Box 19-5. See how one manager handled terminating an employee in Case Study 19-2. Terminating an employee affects the morale of the entire unit. Coworkers may take sides,

and the manager may need to share pertinent facts if they relate to patient safety or acceptable behavioral standards. Not terminating poor performing staff, conversely, can hurt the manager’s credibility and decrease performance on the unit (Hader, 2006).

Employees cannot be fired simply for being a member of a protected class, including their race, sex, national origin, or religion, or their disability as long as their disability does not pre- vent them from doing their job. In addition, a nurse, for example, cannot be fired for refusing to follow medical orders that he or she believes might harm a patient.

Even with careful documentation and the most conscientious adherence to organizational poli- cies regarding termination, firing an employee may be followed by legal action, grievance proce- dures, and stressful and time-consuming hearings. A preferable alternative is that the employee voluntarily resign. Careful documentation may allow the manager to suggest that the employee vol- untarily leave the organization. This allows the employee to leave without a record of termination.

Being a nurse manager is a challenging, ever-changing job and seldom more difficult than when employees must be disciplined or terminated. Even coaching employees can be a stressful experience. Developing the skills to intervene early with employee problems and follow-up as necessary should the problem continue or escalate will help reduce incidents and improve per- formance and morale.

BOX 19-5 Script for a Termination Conversation

Manager: Lucy, we are here today to have the conversation I told you we would be having about your attendance. On March 13, you received a written warn- ing counseling for your attendance. Since then, you have accumulated the following unscheduled absences:

On March 17, you missed work because of car problems. Then on May 2, you didn’t report to work be- cause you said you forgot you were working, and then refused to come in. You have now accumulated eight incidents of unscheduled absence this year. Our hospi- tal attendance policy states that the hospital relies on employees being dependable to take excellent care of patients and that when employee attendance interrupts the ability to provide excellent care, we must advance the corrective action process. At our hospital, eight ab- sences in a 12-month period is considered an unaccept- able, very serious violation of our hospital’s policy.

Prior to today, you received a verbal counseling and a written warning for your attendance. At the time of your verbal counseling, you had accumulated the following unscheduled absences:

August 23, last year, you missed your shift at work, stating you had a family issue.

September 8, you missed work, stating you were ill. September 24, you called in reporting GI illness

and did not come to work.

November 20, you called in to work reporting you had overslept and wouldn’t be reporting to work.

On November 25, you were given verbal counsel- ing concerning your attendance. A copy of the policy was given to you at that time, your absences were reviewed, and you acknowledged that you understood you should not miss more work unplanned.

You continued to accumulate unscheduled absences and were given a written warning on February 1. These absences included the following:

On December, 16 you called in to work reporting a scheduling conflict.

On January 27, you called in and said you had a cold and weren’t coming to work.

In addition to your verbal and written warnings, I, as your manager, spoke with you on other occasions as well to remind you about the attendance policy and the seriousness of your current attendance situation. You have continued to accumulate absences and have seri- ously violated the attendance policy despite multiple attempts at coaching. Therefore today, May 3, your employment is terminated. Human Resources is here with us to provide you all information on your benefits, retirement fund, and to answer any questions you have.

CHAPTER 19 • COACHING, DISCIPLINING, AND TERMINATING STAFF 265

What You Know Now • Coaching is the day-to-day process of helping employees improve their performance or eliminate a per-

formance problem. • Coaching can reinforce positive behaviors, serve as a leadership development tool, and assist with succes-

sion planning. • To confront an employee, make the employee aware of the policy violation and its consequences, elicit

reasons for the behavior, and agree on steps to prevent future recurrence. • When rule violations occur, disciplinary action is needed. Penalties should be progressive. • When staff members do not respond to discipline, managers must terminate their employment. • If an employee must be terminated, the manager must stay in close contact with the human resources

department and administration when planning and carrying out the termination.

TERMINATING STAFF Carrie Lyle is nurse manager of a 20-bed medical–surgi- cal unit in a suburban hospital. Six months ago, Mar- garet Johnson, LPN, transferred to the unit from the skilled nursing unit. Carrie noted that although Marga- ret had been an employee of the hospital for 12 years, her personnel record included several entries regarding substandard performance. Carrie also found gaps in her performance appraisals from other units. Carrie dis- cussed these issues with Margaret prior to her transfer and clearly indicated performance expectations. Howev- er, Margaret often arrives late to work and leaves before report is finished for the day shift.

Claire Kindred, RN and night shift charge nurse, has worked with Margaret for the past six months. Claire requested a meeting with Carrie to discuss patient care concerns. Claire indicated that during most shifts, Mar- garet takes extended meal and break times. She has been found sleeping during her shift in empty patient rooms. Recently, Claire helped one of Margaret’s pa- tients to the bathroom. When recording the patient’s output, she noted that Margaret had charted the pa- tient’s IV intake for the entire shift even though it was only three hours into the night shift. When confronted, Margaret laughed and told Claire she was “just saving time.” Claire had documented the dates of the incidents and provided them to Carrie.

Carrie met that evening with Margaret to discuss her performance and informed her that she will be on pro- bation for the next 30 days. During the probation time, Margaret’s performance would be reviewed each shift to ensure she is completely meeting all expectations for patient care and performance. The next morning, Rob- ert Adams, RN, brought one of his patient’s charts to Carrie’s office. The patient had been assigned to Mar- garet on the night shift. In addition to diabetes, the patient has bilateral below-the-knee amputations. On the patient’s physical assessment, Margaret had charted

positive pedal pulses. She also charted she had changed the patient’s IV tubing and IV dressing. On closer in- spection, Robert found that the date stickers had been covered over by new stickers and no IV tubing changes were noted on the patient’s chart. Carrie immediately contacted the human resources department. She tells them that Margaret has falsified patient documentation in direct violation of her probation and hospital policy. The human resources department reviews Margaret’s file and concurs that immediate termination is appropri- ate. Exit paperwork is initiated by the human resources department and forwarded to Carrie.

Carrie meets Margaret as she arrives for her sched- uled shift. She asks Margaret to come into her office to discuss her immediate termination of employment. Margaret is visibly shaken and says “I’ll do better,” then “You can’t do this to me.” Carrie calmly outlines the per- formance problems and compliance issues that support Margaret’s termination. She has a security officer escort Margaret to her locker to gather her personal items. Carrie documents the meeting outcome in Margaret’s personnel file.

Manager’s Checklist

The nurse manager is responsible for: ● Understanding the organization’s discipline and

termination policies and procedures ● Reviewing personnel files and identifying past per-

formance problems that may affect current or future performance

● Addressing employee performance issues in a timely manner

● Verifying performance problems rather than person- ality problems

● Working with the human resources department when employee termination is indicated

CASE STUDY 19-2

266 PART 3 • MANAGING RESOURCES

Tools for Coaching, Disciplining, and Terminating Staff 1. To prepare and conduct a coaching session a. Note the behavior and why it is unacceptable b. Explore reasons for the behavior with the employee c. Ask the employee for suggestions to solve the problem d. Arrange for follow-up 2. To conduct a discipline session a. Be certain you are calm before beginning b. Assure privacy before beginning c. Apply rules consistently d. Get both sides of a story e. Keep the focus on the problem, not the person f. Arrange for follow-up g. Inform the human resources department and administration 3. To prepare to terminate a staff member a. Inform the human resources department and administration beforehand b. State the offending behavior and the reason for termination c. Explain the termination process d. Remain calm e. Arrange for employee to be escorted out f. Report back to the human resources department and administration

Questions to Challenge You 1. Have you ever been coached, confronted, or disciplined in your workplace or clinical site? How well

did the intervenor handle the situation? How well did you handle it? Did you learn from it? 2. Have you ever had to coach, confront, or discipline someone? How did the person respond? How

well did you do? What did you learn? 3. Do you think you could terminate a staff member? If not, how would you prepare yourself? 4. Select a colleague or classmate and role-play four situations: a. A coaching session b. A confrontation c. A discipline session d. A termination After you have completed these sessions, reverse positions and play the opposite role. 5. Critique each other’s performance.

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

www.nursing.pearsonhighered.com

CHAPTER 19 • COACHING, DISCIPLINING, AND TERMINATING STAFF 267

References Bing, S. (2007). A tale of three

firings. Fortune, 156(2), 210. Cohen, S. (2006). How to termi-

nate a staff nurse. Nursing Management, 37(10), 16.

Hader, R. (2006). Put employee termination etiquette to practice. Nursing Manage- ment, 37(12), 6.

Huseman, R. C. (2009). The importance of positive cul- ture in hospitals. Journal of Nursing Administration, 39(2), 60–63.

Karsten, M., Baggon, D., Brown, A., & Cahill, M.

(2010). Professional coach- ing as an effective strategy to retaining frontline managers. Journal of Nursing Adminis- tration, 40(3), 140–144.

McDermott, M., & Levenson, A. (2007). What coaching can and cannot do for your orga- nization. Human Resources Planning, 30(2), 30–37.

McNally, K., & Lukens, R. (2006). Leadership develop- ment: An external-internal coaching partnership. Jour- nal of Nursing Administra- tion, 36(3), 155–161.

Palermo, J. C. (2007). Well-crafted worker discipline program diminishes risk. Business Insurance, 41(8), 9.

Stedman, M. E., & Nolan, T. L. (2007). Coaching: A dif- ferent approach to the nursing dilemma. Nursing Administration Quarterly, 31(1), 43–49.

White, K. M. (2006). Better manage your human capi- tal. Nursing Management, 37(1), 16–19.

20 CHAPTER Managing Absenteeism,

Reducing Turnover, Retaining Staff

Absenteeism A MODEL OF EMPLOYEE ATTENDANCE

MANAGING EMPLOYEE ABSENTEEISM

ABSENTEEISM POLICIES

SELECTING EMPLOYEES AND MONITORING ABSENTEEISM

FAMILY AND MEDICAL LEAVE

Reducing Turnover COST OF NURSING TURNOVER

CAUSES OF TURNOVER

UNDERSTANDING VOLUNTARY TURNOVER

Retaining Staff EMPLOYEE ENGAGEMENT

HEALTHY WORK ENVIRONMENT

IMPROVING SALARIES

RECOGNIZING STAFF PERFORMANCE

ADDITIONAL RETENTION STRATEGIES

Key Terms Absence culture Absence frequency Attendance barriers Engagement Family and Medical Leave Act

1. Explain absenteeism. 2. Discuss ways to manage absenteeism. 3. Describe how nursing turnover affects the

organization. 4. Explain voluntary turnover.

5. Discuss what organizations can do to improve retention of nurses.

6. Discuss what managers can do to help retain nurses.

Learning Outcomes After completing this chapter, you will be able to:

Involuntary absenteeism Involuntary turnover Presenteeism Salary compression Total time lost

Turnover Voluntary

absenteeism Voluntary turnover

CHAPTER 20 • MANAGING ABSENTEEISM, REDUCING TURNOVER, RETAINING STAFF 269

K eeping higher-performing nurses is a priority in health care. Appropriate hiring deci-sions begin the process, but once employment begins organizations can do much to ensure that they retain their best performers. It is appropriate to mention several sug- gestions here from Chapter 17, Motivating and Developing Staff. Mentoring, coaching, nurse residency programs, and clinical ladder advancement programs all help retain nurses. In order to understand why nurses are absent or leave the organization and develop ways to retain them, it is necessary to consider absenteeism, turnover, and retention.

Absenteeism Although the extent or the cost of nurse absenteeism is difficult to determine, it is well estab- lished that absenteeism in health care organizations is both pervasive and expensive. The costs of absenteeism, however, can also have a detrimental effect on the work lives of the other staff. Working shorthanded, especially for an extended period of time, can create both physical and mental strain. Even if temporary replacements are called in, the work flow of the unit will still be disrupted as hurried staff must take time to explain standard organizational procedures to replacement nurses.

A Model of Employee Attendance To understand employee absenteeism, it is important to distinguish voluntary from involuntary absenteeism. For example, not coming to work in order to finish one’s income taxes would be seen as voluntary absenteeism (i.e., absenteeism under the employee’s control). In contrast, taking a sick day because of food poisoning would be considered involuntary absenteeism (i.e., largely outside of the employee’s control). Although this distinction seems reasonable in theory, in practice it is often difficult to distinguish these two categories because of a lack of accurate information (few employees will admit to abusing sick leave). In fact, 65 percent of employees call in sick for reasons other than illness (CCH Survey, 2007).

Some organizations try to distinguish voluntary from involuntary absenteeism by the way they measure absenteeism. Traditionally, health care organizations have measured absenteeism in terms of total time lost (i.e., the number of scheduled days an employee misses). Given that one long illness can drastically affect this absenteeism index, total time lost is clearly not a perfect measure of voluntary absenteeism. In contrast, absence frequency (i.e., the total number of distinct absence periods, regardless of their duration) is somewhat insensitive to one long illness.

This distinction between absence frequency and total time lost should make sense to man- agers. For example, an employee who missed nine Mondays in a row would have nine absence frequency periods as well as nine total days absent. In contrast, a person who missed nine con- secutive days of work would have nine total days lost but only one absence frequency period. Intuitively, it seems likely that the first individual was much more prone to being absent volun- tarily than the second.

An employee’s attendance at work is largely a function of two variables: the individual’s ability to attend and motivation to attend as shown in Figure 20-1.

As seen in Figure 20-1, an employee’s ability to attend can be affected by such attendance barriers as:

● Personal illness or injury ● Family responsibilities (e.g., a sick child) ● Transportation problems (e.g., an unreliable automobile)

Although it is natural to view such barriers as resulting in involuntary absenteeism, some- times this is too simplistic a judgment. For example, an employee whose car was not running may consciously have not made alternative arrangements to get to work the next day because he or she was not motivated to attend. This example illustrates that some of the distinctions

270 PART 3 • MANAGING RESOURCES

portrayed in Figure 20-1 are not always clear-cut. In trying to understand employee absenteeism, a manager will have to make assumptions about why the behavior is occurring (e.g., a manager cannot be certain that a person was actually ill).

According to the attendance model, an employee’s motivation to attend is affected by several factors: the job itself, organizational practices, the absence culture, generational differ- ences, management, the labor market, and the employee’s personal characteristics.

The Job Itself In assessing the job itself, employees holding more enriched jobs are less likely to be absent than those with more mundane jobs. Enriched jobs may increase attendance motivation because employees believe that what they are doing is important and because they know that other em- ployees are depending on the job holder (i.e., if the job holder doesn’t do his or her job, other employees can’t do theirs).

The nature of a job influences attendance through its effect on attendance motivation as well as on illness and injuries (i.e., attendance barriers). For example, a job that requires heavy lifting (e.g., moving patients from beds to stretchers) may increase the likelihood that a staff nurse will be injured. Similarly, a job that exposes a nurse to patients with highly contagious conditions, such as in an outpatient clinic, may increase the likelihood of illness.

Organizational Practices As portrayed in Figure 20-1, organizational practices can also influence attendance motiva- tion. Some health care organizations have absence control policies that reward employees for good attendance and/or punish them for excessive absenteeism. An organization may also be able to increase attendance motivation by carefully recruiting and selecting employees (see Chapter 15). In addition to affecting attendance motivation, organizational practices may influ- ence an employee’s ability to attend. Organizational activities, such as offering wellness pro- grams, employee assistance programs, van pools, on-site child care, or coordinating car pools could influence an employee’s ability to attend work.

Absence Culture The absence culture of a work unit (or an organization) can also influence employee attendance motivation. Some work units have an absence culture that reflects a tolerance for absenteeism. Other units have a culture in which being absent is frowned upon. Although an organization’s

Attendance barriers lllness and injuries Family responsibilities Transportation problems Past experiences

Job itself

Organizational practices

Supervision

Labor market

Absence culture Employee attitudes, values, and goals

Attendance Attendance motivation

Perceived ability to attend

Figure 20-1 • A diagnostic model of employee attendance.

CHAPTER 20 • MANAGING ABSENTEEISM, REDUCING TURNOVER, RETAINING STAFF 271

absence culture can be affected by organizational practices (e.g., attendance policies) and the nature of the jobs involved (e.g., people in higher-level jobs tend to be less accepting of cowork- ers calling in sick), it is also affected by informal norms that develop among work-group mem- bers. For example, people in a cohesive work group may develop an understanding that missing work, except for an emergency or a serious illness, is unacceptable. Such an attendance culture is likely to emerge if the employees work in jobs that they see as important (e.g., providing di- rect patient care) and if an employee being absent causes a hardship for coworkers (e.g., forced overtime, being called in on a day off).

Generational Differences Today’s workforce includes nurses from four generations, and each cohort (traditionals, baby boomers, Generation X, and Generation Y) has different expectations in the workplace (Dols, Landrum, & Wieck, 2010). Younger nurses expect to have flexible scheduling and may use absenteeism to achieve it.

Older nurses may resent the younger ones, especially their technology skills and their lower need for social interaction. Here is an example:

Kirsten McNamara is 24 years old. She spends her lunch break relaxing and returning text and e-mail messages on her phone while she eats; she uses the quiet time to rejuve- nate. Her coworkers, traditionals and baby boomers, are offended, and complain that she was “on her phone and rude” the whole lunch hour.

Generational differences affect retention as well. Generation X and Y nurses want challeng- ing careers that offer opportunities for growth and advancement as well as time for lives outside of work. Flexible schedules and time off are valued by these cohorts, and organizations can ex- pect high turnover if these expectations are not met.

Expectations of the younger generational cohorts affect supervision as well. They expect independence and to be involved in decision making (Farag, Tullai-McGuinness, & Anthony, 2009). Thus, shared governance is an appropriate structure, and consultation is an effective man- agement strategy.

Management Management influences attendance motivation of all staff as well. A nurse manager can influ- ence the nature of a staff nurse’s job (e.g., the degree of responsibility given and participation in decision making), decisions about personnel, the consistency with which organizational prac- tices are applied (e.g., whether sanctions are enforced for abuse of sick leave), and a work unit’s absence culture by stressing the importance of good attendance.

A shared governance organizational model encourages attendance because of the emphasis on cooperative decision making. The manager who consults frequently with staff supports this model. Knowing that their input is valuable to the unit’s functioning promotes participation and, thus, attendance.

Cost-cutting is here to stay (Ferenc, 2009), and managers must be flexible in the work environment. Recognize staff performance, make any enhancement or flexibility necessary in order to keep staff. Evaluate work flow and consider creative ways to use staff to get all the work done. Be open to potentially having to work in a different way or change a work flow.

Labor Market Another factor that influences attendance is the labor market. If the nurse believes that plenty of equivalent jobs are available locally, he or she might be less motivated to attend than if fewer jobs were available.

272 PART 3 • MANAGING RESOURCES

To the extent that the local employment market for nurses leads an employee to perceive it would be easy to find an equivalent job if she or he lost or disliked the current one, one would expect a lower level of attendance motivation than if market conditions were less favorable. This might happen during a nursing shortage.

Personal Characteristics Although features of the job itself, organizational practices, absence culture, generational dif- ferences, supervision, and the labor market can all have a direct effect on employee attendance motivation, these factors can also interact with an employee’s attitudes (e.g., job satisfaction), values (e.g., personal work ethic), or goals (e.g., desire to get promoted). If a person who seeks variety works in a job that does not provide it, the employee may become dissatisfied and thus more likely to abuse sick leave.

The reverse is also true. Employees’ attitudes, values, and goals can also have a direct effect on attendance motivation. For example, a staff nurse with a high personal work ethic or a goal of getting promoted should be more highly motivated to attend work than a nurse who lacks such a work ethic.

An employee’s attendance behavior is also influenced by past experiences. For example, if an employee’s perfect attendance in the previous year was not recognized, we might expect the employee’s attendance motivation to decrease in the coming year. Conversely, if a coworker with an outstanding attendance record received a promotion, peers who value a promotion and who witnessed this link between performance and reward would be more motivated to attend work in the upcoming year.

Managing Employee Absenteeism The attendance model in Figure 20-1 is useful not only for understanding why absenteeism occurs, but also for developing strategies to control it. Some causes of absenteeism, such as transportation difficulties or child care problems, may be beyond the direct control of nurse managers. A manager, however, should try to do what is possible, either in interactions with staff or by attempting to influence the organization to change policies that may be interfering with a nurse’s ability or motivation to attend work. On the other hand, the manager must be careful that the steps taken do not go so far as to discourage the legitimate use of sick leave. Clearly, one does not want sick nurses coming to work and exposing patients and coworkers to their illnesses.

To diagnose the key factors leading to absenteeism, the manager needs information from several sources, including staff, the human resources department, other nurse managers, and administration. Absence patterns can answer such questions as:

● Is absenteeism equally distributed across all nurses? ● In comparison to other units, does your area of responsibility have a high

absenteeism rate? ● Are most absences of short or long duration? ● Does the absenteeism have a consistent pattern (e.g., occur predominantly on weekends or

shortly before a person quits)?

Although a manager may not be able to do much to affect the staff’s ability to attend, the organization can take several actions. For example, to lessen child care problems, the organiza- tion could set up or sponsor a child care center. To reduce transportation problems, an orga- nization could provide shuttle buses or coordinate car pools. Health fairs, exercise programs, and stress-reduction classes could be offered to promote health. Given that alcoholism and drug abuse are widely recognized as important causes of absenteeism, an employee assistance pro- gram may be cost-effective. In addition to these organizational actions, a nurse manager, through coaching, may be able to influence a staff nurse’s attendance. (See Chapter 19 for information on how to coach staff.)

CHAPTER 20 • MANAGING ABSENTEEISM, REDUCING TURNOVER, RETAINING STAFF 273

Clearly, the best way for nurse managers to control absenteeism is by encouraging their staff’s motivation to attend. Other absenteeism management strategies that a nurse manager might consider include:

● Enriching the staff nurse’s job by increasing its responsibility, variety, or challenge ● Reducing job stress (e.g., by providing timely and more concrete information) ● Creating a norm of excellent attendance (e.g., by emphasizing the negative impact of a

nurse not coming to work) ● Enhancing advancement opportunities (e.g., by providing developmental experiences so

that the best employees are promotable) ● Improving coworker relations (e.g., by considering coworker compatibility when schedul-

ing work and/or creating work teams) ● Trying to select employees who will be satisfied with and committed to their jobs ● Being a good role model by rarely taking sick days ● Discussing the employee’s attendance during the performance appraisal interview ● Rewarding good attendance with salary increases and other rewards ● Enforcing absenteeism control policies (e.g., carrying through on employee discipline

when there is an attendance problem)

Absenteeism Policies Most organizational policies allow employees to accrue paid sick days—typically, one sick day for every month employed. Unused sick days accrue across time to some maximum number (e.g., 60 days). Typically, if an employee leaves the organization with accumulated sick leave or days above the maximum, the person simply loses it.

Although such a policy may seem reasonable, it may actually encourage unwanted behav- ior. For example, once a nurse has reached the maximum limit for accrued sick days, the person may see no reason for not using sick days that would otherwise be lost. Such a policy also en- courages employees who know they will be leaving the organization (e.g., those about to retire or change jobs) to use accumulated sick leave.

An innovative approach for managing absenteeism is substituting personal days for unused sick days. Two problems arise if personal days are not given: Employees are forced to lie (i.e., say they are sick when they are not) to carry out what they see as legitimate activities (e.g., at- tending a conference with their child’s teacher), and their manager has no warning and therefore may have difficulty covering for the absent employee.

By substituting personal days for sick days, the employee no longer has to lie, and the nurse manager may have time to plan for a replacement. In moving to a policy that incorporates the use of personal days, an organization typically allocates fewer paid sick days but adds personal days. For example, instead of 12 sick days, an employee may annually receive nine sick days and three personal days. With the availability of personal days, a staff nurse can inform the man- ager in advance of the need for a personal day off. In many cases, the two of them can arrive at a day off that is optimal for both of them.

Realizing that they have not been motivating good attendance, some progressive organiza- tions have allowed sick days to accumulate without an upper limit. Then, when an employee leaves the organization, she or he is paid for unused sick days (e.g., one-half day’s pay for each unused sick day). Other organizations allow retiring employees to add unused sick days to days worked. Still other organizations have paid employees for their sick days, or allowed the conver- sion of sick days to vacation days or additional pay.

Obviously, changing an organization’s paid sick leave policy is beyond the control of the nurse manager. However, a concerted effort by an organized group of managers may be effec- tive in encouraging the human resources department and administration to initiate such changes. Considering the high costs of absenteeism, these changes can be quite cost-effective.

Most health care organizations have formal policies concerning how much absentee- ism is allowed. Once this limit is reached, disciplinary steps are prescribed. In disciplining an

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employee, the manager must follow the discipline policy carefully. The effectiveness of disci- pline as a strategy for reducing absenteeism is limited. Most discipline policies only take effect after excessive absenteeism. Not surprisingly, most employees know what this is and are careful not to exceed it. In effect, the nurse manager is left with an absenteeism problem but not one that she or he is able to address through the use of discipline.

Selecting Employees and Monitoring Absenteeism Many of the managerial actions addressed in other chapters of this book are relevant to the control of absenteeism. For example, in recruiting employees, the use of a realistic job preview should increase the congruence between job characteristics and employee values and expecta- tions. Similarly, basing merit pay and advancement opportunities on an employee’s overall per- formance appraisal rating (which is partly based on attendance) will motivate better attendance. Also, leadership skills are important in getting the organization to change policy to lessen absen- teeism (e.g., providing payment for unused sick days).

Strategies for dealing with employees with excessive absences include:

● Set expectations with each new employee. Give her or him the attendance policy in writ- ing, and clarify any questions.

● Monitor each individual’s attendance, and document it. ● Intervene early and consistently, coaching and dealing with policy or procedure violations

as appropriate. ● If discipline is called for, use the key behaviors for disciplining in Chapter 19. ● Be sure to reward staff who have good attendance. Ensure that any organizational rewards

are delivered, and give your personal reward through feedback in performance appraisals. ● Be a role model for good attendance yourself.

These steps will set a tone of intolerance for poor attendance. The opposite of absenteeism is presenteeism when the employee is at work although disabled by physical or mental illness. Those employees who were sick more often, who had heavier workloads, were highly skilled, enjoyed positive relationships with coworkers, or whose job status was precarious were more likely to be present at work even though ill (Biron, Brun, Ivers, & Cooper, 2006). Additionally, high psychological distress and psychosomatic illness were predictors of presenteeism.

Family and Medical Leave The federal Family and Medical Leave Act (FMLA) took effect in 1993 and has been amended by federal statute as well as court decisions (U.S. Department of Labor, 2011). Under this act, all public employers (federal, state, and local) and all private employers employing 50 or more indi- viduals must provide their eligible employees with leave of up to 12 weeks during any 12-month period for the employee’s own serious illness, the birth or adoption of a child, the placement of a foster child into the household, or the care of a seriously ill child, spouse, or parent.

The FMLA also allows eligible employees to maintain health insurance coverage while on leave and allows them to return to the same or equivalent position at the end of the leave period. The leave may be taken all at once, intermittently, or by working a reduced work schedule, if available. The employee must be allowed to take leave for qualified purposes without pressure or discour- agement by the employer or manager. More generous collective bargaining agreements or state laws supersede the FMLA, but the FMLA supersedes any inconsistent or less generous provisions. FMLA may run concurrently with other leaves, including state workers’ compensation leave.

Employees are eligible to take leave if they:

● Have worked for the employer for at least 12 months ● Have worked at least 1,250 hours during the previous 12 months ● Are at a work site with 50 or more employees, or at a site where 50 workers are employed

within 75 miles of the work site (50 employees/75 miles rule)

CHAPTER 20 • MANAGING ABSENTEEISM, REDUCING TURNOVER, RETAINING STAFF 275

The FMLA is quite complex. (See U.S. Department of Labor Web site for updated informa- tion at http://www.dol.gov/compliance/laws/comp-fmla.htm.)

State law and collective bargaining agreements may make the organization’s leave policy unique. Furthermore, the overlap and interaction between the Americans with Disabilities Act and the FMLA is complicated. The organization is responsible for assuring that the employee can perform the job while at the same time ensuring that the employee’s legal rights are not vio- lated (Lester, 2011). The human resources department at each organization is the best source of information about FMLA and ADA requirements.

Reducing Turnover Closely related to absenteeism is employee turnover, the number of staff members who vacate a position. Reducing turnover begins with recruitment and selection (see Chapter 15) and con- tinues with motivation and development of staff. Retaining both experienced nurses and new graduates is essential (Hill et al., 2010; Hirschkorn et al., 2010; Salt, Cummings, & Profetto- McGrath, 2008).

Cost of Nursing Turnover Two interrelated factors affect the nurse turnover rate: market opportunities and the economy. When the economy is robust, health care organizations tend to hire more staff; during a reces- sion, the hospital may cut staff or leave positions vacant. At the same time, nurses are more apt to stay in a position if the economy is poor or if there are few other opportunities (Healthcare Association of New York State, 2010).

Data from a national survey in 2009 found that turnover rates that year (7.1 percent) had declined from the 10.1 percent of the previous year (Healthcare Association of New York State, 2010). The surveyors attributed the change to the poor economy and the lack of opportunities.

Given the expense in hiring a new nurse (e.g., recruiting, selection, orientation, on-the-job training) and temporarily replacing a nurse who quits or is fired (e.g., paying other nurses to work overtime or filling the vacancy with a temporary replacement), the costs are certainly siz- able. Thus, nursing turnover needs to be understood better and controlled more effectively.

Turnover has been thought of in simplistic terms and seen as universally negative. Such a primitive view of turnover is not helpful to managers as they attempt to deal with this costly problem. Rather, varieties of turnover need to be differentiated:

● Did the employee leave of her or his own accord, or was the person asked to leave? ● Was the departed individual’s performance exceptional or mediocre? ● Did the employee leave for career development (e.g., return to school) or because of dis-

satisfaction with the organization? ● Will the departed nurse be easy or difficult to replace?

Turnover has consequences that go far beyond direct dollar costs. Turnover can have a num- ber of repercussions among other nurses who worked with the departed nurse (Jones, 2008). They may have to work longer hours (overtime) or simply work harder to cover for a departed nurse; this can cause both physical and mental strain and may result in additional departures. Thus, departed nurses may begin a cycle of nurses leaving, resulting in a turnover spiral. If tem- porary replacements are used, problems still can result as the work flow of the unit is disturbed and communication patterns within the unit are disrupted.

Turnover is not always undesirable. Anyone with work experience can remember some individual (e.g., coworker, administrator) whose departure would have improved the organiza- tion’s functioning significantly. Furthermore, what may be seen as a desirable departure by some (e.g., the nurse manager) may be viewed as a loss by others (e.g., a subset of coworkers). If the departed nurse was a poor performer, performance may improve. Recently hired staff may be more enthusiastic, long-running conflicts between people may be reduced or eliminated, or

http://www.dol.gov/compliance/laws/comp-fmla.htm

276 PART 3 • MANAGING RESOURCES

administration may be challenged to improve the work environment (see the Healthy Work En- vironment section later in the chapter).

Causes of Turnover Before turnover can be managed, its causes must be understood. Traditionally, organizations have attempted to determine the reasons for voluntary turnover through two sources: the exiting employee’s supervisor is asked why the employee is leaving, and an exit interview with the de- parting employee is conducted by someone in the human resources department.

Such an approach for determining the cause of voluntary turnover is certainly straightfor- ward, but departing employees may not give honest answers in their exit interviews because they know that future employers will ask for references. Thus, exiting employees may provide safe responses (e.g., “a better opportunity came along”) during an exit interview.

Although this tendency for departing employees to make safe responses is understand- able, it makes it difficult to determine why turnover is occurring. Surveys sent to former employees several weeks after they have resigned may be more useful. Former employees need to be assured that their responses will not influence any future reference information furnished about them, but rather will be used only to help the organization identify the rea- sons why nurses are leaving. Another way to attempt to discover the cause of nurse turnover is to conduct interviews with the former employee’s coworkers, who often know why an employee left.

Understanding Voluntary Turnover The discussion in this chapter focuses on voluntary turnover (i.e., employees choose to leave). If an organization finds a significant amount of involuntary turnover (i.e., employees being ter- minated), then it needs to carefully examine the way it recruits, selects, motivates, and develops employees. (See Chapters 15 and 17.)

The goal should be to reduce voluntary turnover. The manager’s first opportunity to reduce turnover is when the decision to hire is made. An individual’s length of stay at past employers is an indication of how long the person could be expected to stay on a new job.

Turnover is a direct function of a nurse’s perceptions of both the ease and the desirability of leaving the organization. Perceived ease of movement depends on the nurse’s personal charac- teristics, such as:

● Education ● Area of specialization ● Age ● Geographic mobility ● Contacts at other hospitals ● Transportation

As well as external forces, such as:

● Job openings at other organizations ● Non–health care organizations hiring nurses for nursing or nonnursing positions ● Economy

As with ease of movement, perceptions of the desirability of movement can be affected by several factors. One is the opportunity for movement within the organization. If other positions exist within the organization, the less turnover there should be; that is, a nurse may be able to leave the current position by means of a lateral transfer, promotion, or demotion. For example, a nurse who is having problems with a coworker may be able to transfer to a new unit rather than leave the organization.

Turnover and employee absenteeism have been referred to as withdrawal behaviors be- cause they allow an employee to leave the workplace, in one case temporarily and, in the other,

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permanently. In many cases, these withdrawal behaviors share a common cause: job dissatisfac- tion discussed next.

Retaining Staff Job satisfaction is a key component to retaining staff (Wisotzkey, 2011). Job satisfaction is af- fected by various facets of the work environment, including:

● Relationships with the nurse manager, other staff nurses and unit employees, patients, and physicians

● Shift worked (e.g., day versus evening, rotating versus fixed) ● Fit between nurse values and institutional culture ● Expectations of practice setting ● Compensation level ● Equal and fair distribution of rewards and punishments

Employee Engagement Employee engagement is tied to employee retention as well as customer satisfaction, but em- ployees engaged in their workplace are in the minority across industries (Advisory Board Com- pany, 2007). Additionally, in a survey of more than 4,000 nurses, researchers found uneven levels of engagement among them (Advisory Board Company, 2007). Engagement is defined as being inspired by the organization, willing to invest effort, likely to recommend the organiza- tion, and planning to remain in the organization.

Rivers, Fitzpatrick, and Boyle (2011) studied factors that affect employee engagement. Key factors of engagement were control over practice, professional development and growth, teamwork, and nurse–physician collaboration. The least important factors related to engagement were salary and benefits. The implications for managers and administration suggest that an orga- nizational structure that encourages staff input, frequent communication and attention to prob- lems as soon as they occur, and development opportunities are some of the ways to encourage employee engagement.

Healthy Work Environment A healthy work environment increases nurse job satisfaction, a necessary condition for retaining nurses (Paris & Terhaar, 2011; Weston, 2010). Environmental factors can improve job satisfac- tion and reduce the intention to leave, according to Applebaum, Fowler, and Fiedler (2010). Miracle (2008) posits that both nurse satisfaction and excellent nursing care is the product of a healthy work environment.

The American Association of Critical Care Nurses (AACN, 2005) established six criteria for a healthy work environment to “foster excellence in patient care” (p. 1). These criteria are:

● Skilled communication—as important as clinical skills ● True collaboration—between and among nurses and other health care professionals ● Effective decision making—involved as partners in making policy and leading

organizations ● Appropriate staffing—effective match between patient needs and nurse competencies ● Meaningful recognition—for value of work ● Authentic leadership—leaders embrace, live, and engage others in it

Improving Salaries As the largest group of health care professionals, nurses’ wages account for the majority of an organization’s salary budget. It is reasonable (although not cost-effective) that organizations imagine they can reduce expenses by constraining nurses’ salaries or allowing open positions to

278 PART 3 • MANAGING RESOURCES

go unfilled. Thus, nurses employed for many years find their salaries only slightly greater than (or even less than) nurses with only a few years of experience. This effect is known as salary compression. Paying new nurses a higher starting salary or rewarding those with fewer years of experience with higher increases results in the salaries of long-term employees being at or below those of less-experienced nurses.

Sign-on bonuses and loan-forgiveness programs, for example, are strategies used to attract new graduates. They are, however, only quick fixes that serve to disadvantage already-employed nurses whose salary ceilings remain fixed. Pay scales, however, can be reconfigured to reflect achievement and accomplishment.

Recognizing Staff Performance Recognizing the contributions of staff is not necessarily expensive or time-consuming. The man- ager can integrate some strategies into the everyday managing of staff. Here are some examples:

● Provide personalized immediate feedback of a job well done. ● Write a personal note acknowledging an employee’s good performance. Leave in the em-

ployee’s mailbox or mail to a home address. ● Publicly recognize an employee’s good performance—at staff meeting, in an e-mail to all,

with kudos on the unit bulletin board. ● Encourage staff to post notes on the bulletin board to thank a coworker for a great job or

recognize a peer for impressive observed work with a patient. ● Design a bulletin board to highlight one employee. Change it every two weeks or once per

month. The employee can bring in personal and family photos as well as post facts about them. This facilitates employee recognition and a sense of camaraderie as employees get to know each other better.

Examples of low-cost and formal rewards for staff are shown in Box 20-1.

BOX 20-1 Rewarding Employees

Low-Cost Rewards for Employees

● Allow staff to have a half day, whole day, or Friday off for excellent performance by flexing hours and completing hours for week in fewer days. For ex- ample, allow an employee to choose four 10-hour shifts one week as a treat instead of five 8-hour days.

● Give magazine subscriptions. ● Have a monthly birthday celebration potluck

to recognize all employees with a birthday that month—rotate the theme for different kinds of food/activities.

● Initiate an employee of the month program— reward the employee with a gift card, certificate of recognition, or some other small gift.

● Start a newsletter and devote a section to describ- ing excellent employee performance and including staff kudos to one another.

Formal Rewards for Employees ● Give awards for perfect attendance, patient ad-

vocate, clinical leader, expert nurse, most cost– effective, etc. Present the awards at a hosted annual awards banquet, with food and formal recognition.

● Start a reward points system in which employees earn points for great customer service/teamwork. Make a “treat box” that has small gift items such as snacks, pens, notepads, etc. Assign a point value to each gift item and let staff accumulate points. Staff can then “buy” items with their points.

● Provide continuing education opportunities pre- sented by physician sponsors or nurses from the community. Start a program that gives staff the opportunity to take time off to attend an educa- tional offering once per year or a set number of times as determined by the group.

● Help with tuition reimbursement for continuing education.

● Give customer service awards based on years of service.

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Additional Retention Strategies In addition to the work environment, salary adjustments, and staff recognition, managers can use several other strategies to help retain a valued employee in the organization. These include:

● Providing a realistic job preview to new hires ● Facilitating movement within the organization ● Coordinating with other managers to influence organizational policy ● Adapting to turnover rate

Provide Realistic Job Preview and Follow-up Retaining nurses begins with the interview when the manager has an opportunity to present the job realistically. Retention continues with orientation and socialization of the new nurse to the unit (Hatler et al., 2011). Both clinical advancement programs and preceptorships, discussed in Chapter 17, have been found to improve retention (Allen, Fiorini, & Dickey, 2010; Salt, Cummings, & Profetto-McGrath, 2008).

Facilitate Intraorganizational Movement If a staff nurse is “burned out” from working on an oncology floor, one option is to allow a trans- fer to another service area in the organization (e.g., home care). Unfortunately, some managers hinder or even prohibit such a transfer (particularly if the potential transferee is an excellent performer), not wanting to lose a good nurse. However, this perspective is shortsighted. If the staff nurse cannot transfer to another area (intraorganizational mobility), she or he may leave the organization entirely (interorganizational mobility).

One nurse manager decreased voluntary turnover on her unit without incurring additional costs (see Case Study 20-1).

RETENTION Mona Karnes is nurse manager of labor and delivery at a suburban hospital. Over the past 12 months, the voluntary turnover rate among full-time RNs has been 15 percent for her unit and 25 percent for the hospital as a whole. Despite increasing starting salary rates and offering signing bonuses, turnover rates have remained high. Administration is in the process of conducting an annual salary review as well as a benefits review.

Mona has collected information from exit interviews conducted by the human resources department. From these data, Mona has developed three strategies to aid in retention for her unit:

1. Rotate leadership responsibilities on the unit to offer all nurses the opportunity to develop leader- ship and management skills. These responsibilities currently include a weekly charge nurse role for each shift, education committee chair, physician relations liaison, women’s health service line representative, and information technology repre- sentative. Other leadership roles will be added as appropriate.

2. Survey staff to determine interests and strengths and connect staff members with a mentor. For example, Debbie Edwards, RN, enjoys developing patient education modules. Debbie will work with

Heather Adams, new nurse graduate, to develop Heather’s patient education skills.

3. Schedule free monthly CEU offerings during staff meetings that are presented by staff members, physicians, or pharmaceutical company representa- tives. By attending monthly staff meetings, most RNs will complete 90 percent of state-required CEUs for license renewal.

All three strategies are at no cost to the unit or hos- pital. After six months, the voluntary turnover rate on Mona’s unit has decreased to 8 percent.

Manager’s Checklist The nurse manager is responsible for:

● Understanding the financial impact of voluntary turnover on the unit and the organization

● Gathering and analyzing data that provide insight into the reasons for voluntary turnover

● Utilizing creative solutions to increase staff retention ● Establishing open and effective communication with

staff members ● Evaluating retention strategies in a timely manner

and adjusting processes as appropriate ● Communicating successful strategies to colleagues

and administration

CASE STUDY 20-1

280 PART 3 • MANAGING RESOURCES

Adapt to Turnover Rate Sometimes the organization may simply need to adapt to a high turnover rate. Even if this is the case, the manager may be able to lessen potential problems by doing two things:

1. Manage beliefs about why a nurse left. Sometimes, the reason is unclear, and the grapevine will often provide an inaccurate and less attractive reason from the organization’s perspec- tive (e.g., “He left for $1.05 more an hour at a competitor institution”).

2. Provide human resources with a preferred list of replacement workers. Some organizations keep an up-to-date list of former nurses who will fill in on an occasional basis. Such for- mer employees are familiar with organizational procedures and can handle the work more efficiently.

The strategies outlined in this chapter have been shown to be effective in addressing ab- senteeism and reducing turnover. However, not all are equally applicable to all situations. Situ- ational factors determine what is appropriate. For example, flexible work hours may be suitable for a clinic but not for an around-the-clock operation. By being creative, nurse managers not only can reduce absenteeism and turnover, but can also have an influence on nurses’ attendance and on which nurses leave by providing incentives for the exceptional nurse to stay and by doing less to retain mediocre nurses.

What You Know Now • Employee attendance is affected by the job, organizational practices, absence culture, generational dif-

ferences, labor market, management, and the employee’s characteristics. • An organization can improve employee attendance by addressing specific barriers, such as adding a child

care center, coordinating car pools, or offering health promotion and employee assistance programs. • Innovative solutions to absenteeism problems include substituting personal days for sick days, allowing

sick days to accrue and unused days to be paid to the employee, or converting unused sick days to paid days at retirement.

• Turnover may be voluntary or involuntary, but it is always costly to the organization. • Many factors cause voluntary turnover, including job dissatisfaction, undesirable work environment, and

ease of movement. • Organizations can help retain nurses by providing healthy work environments, improving salaries, and rec-

ognizing performance. • Managers can help reduce turnover by providing realistic job previews and follow-up, facilitating intra-

organizational movement, but may have to adapt to turnover rate.

Tools for Reducing Turnover, Retaining Staff 1. Become familiar with your organization’s policies on employee attendance. 2. Identify attendance problems and monitor them, if necessary. 3. Monitor turnover and evaluate the causes. 4. Provide realistic job previews to new hires, especially new graduates. 5. Monitor new graduates’ performance and offer additional support and training as needed. 6. Consider ways to improve the work environment.

Questions to Challenge You 1. As a nurse manager, what would you do to reduce absenteeism? 2. Can you recall instances where an employee’s leaving has benefited the organization? Describe what

happened. 3. Have you voluntarily left a job? a. What was the reason? Was there more than one reason? b. What reason did you give your supervisor? c. Was it the same rationale that you answered in part a of this question?

CHAPTER 20 • MANAGING ABSENTEEISM, REDUCING TURNOVER, RETAINING STAFF 281

4. In addition to ideas presented in the chapter, can you think of other ways to reduce voluntary turnover?

5. Have you seen managers be effective in retaining staff? What did they do that worked especially well?

6. If you were a manager, what specific actions would you take to retain staff?

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

Advisory Board Company (2007). Engaging the nurse workforce: Best practices for promoting excep- tional staff performance. Washington, DC: Advisory Board Company.

American Association of Critical Care Nurses. (2005). AACN’s healthy work environments initia- tive. Retrieved August 22, 2011 from http://www. aacn.org/wd/hwe/ content/hwehome. pcms?menu=practice

Allen, S. R., Fiorini, P., & Dickey, M. (2010). A streamlined clinical ad- vancement program im- proves RN participation and retention. Journal of Nurs- ing Administration, 40(7/8), 316–322.

Applebaum, D., Fowler, S., & Fiedler, N. (2010). The im- pact of environmental fac- tors on nursing stress, job satisfaction and turnover intention. Journal of Nurs- ing Administration, 40(7/8), 323–328.

Biron, C., Brun, J., Ivers, H., & Cooper, C. L. (2006). At work but ill: Psychosocial work environment and well-being determinants of presenteeism propensity.

Journal of Public Mental Health, 5(4), 26–37.

CCH survey finds most em- ployees call in “sick” for reasons other than illness. (2007). Wolters Kluwer Press Release (October 10, 2007). Retrieved August 22, 2011 from http://www. wolterskluwer.com/Press/ Latest-News/2007/Pages/ pr_11oct07_2.aspx

Dols, J., Landrum, P., & Wieck, K. L. (2010). Leading and managing an intergenera- tional workforce. Creative Nursing, 16(2), 68–74.

Farag, A. A., Tullai-McGuinnes, S., & Anthony, M. K. (2009). Nurses’ perception of their manager’s leader- ship style and unit climate: Are there generational dif- ferences? Journal of Nurs- ing Management, 17(1), 26–34.

Ferenc, J. (2009). Cost cuts to stay. Material Management in Health Care, 18(12), 4–12.

Hatler, C., Stoffers, P., Kelly, L., Redding, K., & Carr, L. L. (2011). Work unit trans- formation to welcome new graduate nurses. Nursing Economics, 29(2), 88–93.

Healthcare Association of New York State (2010). Nurses

needed: Short-term re- lief, ongoing shortage. Results from the 2010 nursing workforce sur- vey. Retrieved August 22, 2011 from http://www. hanys.org/ workforce/ reports/2010-06-07_nurse_ survey_results_2010.pdf

Hill, K. S., Cleary, B. L., Hewlett, P. O., Bleich, M. R., Davis, K., & Hatcher, B. J. (2010). Commentary: Experienced RN retention strategies. Journal of Nurs- ing Administration, 40(11), 468–470.

Hirschkorn, C. A., West, T. B., Hill, K. S., Cleary, B. L., & Hewlett, P. O. (2010). Experienced nurse retention strategies. Journal of Nurs- ing Administration, 40(11), 463–467.

Jones, C. B. (2008). Revisiting nurse turnover costs. Jour- nal of Nursing Administra- tion, 38(1), 11–18.

Lester, R. L. (2011). Ensuring the health care worker can perform the essential func- tions of their position in the increasingly restricted legal environment governing hiring and disability accom- modation. Kentucky Bar Association Bench & Bar, 75(3), 10–16.

References

www.nursing.pearsonhighered.com

http://www.aacn.org/wd/hwe/content/hwehome.pcms?menu=practice

http://www.wolterskluwer.com/Press/Latest-News/2007/Pages/pr_11oct07_2.aspx

http://www.hanys.org/workforce/reports/2010-06-07_nurse_survey_results_2010.pdf

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282 PART 3 • MANAGING RESOURCES

Miracle, V. A. (2008). A healthy work environment. (Edito- rial). Dimensions of Critical Care Nursing, 27(1), 41–42.

Paris, L. G., & Terhaar, M. (2011). Using Maslow’s pyramid and the national database of nursing qual- ity indicators to attain a healthier work environ- ment. The Online Journal of Issues in Nursing, 16(1). Retrieved August 22, 2011 from http://www.nursing- world.org/MainMenuCat- egories/ANAMarketplace/ ANAPeriodicals/OJIN/ TableofContents/Vol- 16-2011/No1-Jan-2011/ Articles-Previous-Topics/ Maslow-and-NDNQI-to- Assess-and-Improve-Work- Environment.aspx

Rivera, R. R., Fitzpatrick, J. J., & Boyle, S. M. (2011). Closing the RN engage- ment gap: Which drivers of engagement matter. Journal of Nursing Administration, 41(6), 265–272.

Salt, J., Cummings, G. G, & Profetto-McGrath, J. (2008). Increasing retention of new graduate nurses. Journal of Nursing Admin- istration, 38(6), 287–296.

U. S. Department of Labor. (2011). The Family and Medical Leave Act (FMLA). Retrieved August 22, 2011 from http://www.dol.gov/ compliance/laws/comp- fmla.htm

Weston, M. J. (2010). Strategies for enhancing autonomy and control over nursing

practice. The Online Jour- nal of Issues in Nursing, 15(1). Retrieved August 22, 2011 from http://www. nursingworld.org/MainMe- nuCategories/ANAMar- ketplace/ANAPeriodicals/ OJIN/TableofContents/ Vol152010/No1Jan2010/ Enhancing-Autonomy-and- Control-and-Practice.aspx

Wisotzkey, S. (2011). Will they stay or will they go? Insight into nursing turnover. Nurs- ing Management, 42(2), 15–17.

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http://www.dol.gov/compliance/laws/comp-fmla.htm

http://www.nursingworld.org/MainMe-nuCategories/ANAMar-ketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No1Jan2010/Enhancing-Autonomy-and-Control-and-Practice.aspx

CHAPTER

Harassing Behaviors BULLYING

LACK OF CIVILITY

LATERAL VIOLENCE

How to Handle Problem Behaviors MARGINAL EMPLOYEES

DISGRUNTLED EMPLOYEES

The Employee with a Substance Abuse Problem

STATE BOARD OF NURSING

STRATEGIES FOR INTERVENTION

REENTRY

THE AMERICANS WITH DISABILITIES ACT AND SUBSTANCE ABUSE

Dealing with Disruptive Staff Problems 21

Key Terms Lateral violence Marginal employees

1. Identify harassing behaviors, including bullying, incivility, and lateral violence.

2. Describe strategies to deal with bullying behaviors.

3. Explain how to manage staff with problem behaviors.

4. Discuss how to handle marginal and disgruntled employees.

5. Explain how to handle staff with a substance abuse problem.

Learning Outcomes After completing this chapter, you will be able to:

284 PART 3 • MANAGING RESOURCES

A major challenge confronting managers today is not only improving individual perfor-mance and productivity, but also enhancing the efforts of the entire work group. Some of the general techniques for enhancing performance described in Chapter 17 are inef- fective because individual problems affect group functioning.

Harassing behaviors—including bullying, incivility, and lateral violence—marginal staff, dis- gruntled employees, and employees abusing alcohol or drugs are addressed in this chapter. There are no proven methods for managing these problems; the strategies presented here are a starting point. Assistance from administration and the human resources department often is needed.

Harassing Behaviors Bullying Bullying in the workplace increases staff dissatisfaction, turnover, and litigation, and can dam- age the organization’s reputation as well (Dempster, 2006). In a health care setting, bullying threatens not only the victim (the “target”), but poses a danger to patients too (Stokowski, 2010). Called incivility, verbal abuse, or vertical or horizontal violence, all such behaviors are examples of bullying (Broome, 2008). Nurses report verbal abuse as the most frequent form of bully- ing (Christmas, 2007) with senior nurses, managers, and physicians the most likely perpetrators (Vessey, DeMarco, Gaffney, & Budin, 2009).

Bullying can occur online, via text messages, or in person. Bullies use words, nonverbal behaviors, or involve other people, such as with gossiping. Bullying behaviors can range from mildly irritating to dangerously violent (Stowoski, 2010). Examples include:

● Being ignored or given the “silent treatment” ● Treated in a condescending or patronizing manner ● Derogatory remarks made within hearing ● Dismissive body language, such as eye rolling ● Ridicule, sarcasm ● Verbal abuse ● Scapegoating ● Isolating ● Failure to assist ● Sexual harassment ● Physical attack

Policy efforts to combat bullying in health care settings have been launched by the Joint Com- mission and the American Nurses Association. Joint Commission recommends zero tolerance of disruptive or abusive behavior (Joint Commission, 2008). The American Nurses Association rec- ommends strategies to combat hostility, abuse, and bullying in the workplace (ANA, 2010).

Several states are considering healthy workplace bills that would allow workers to sue for harm from abusive treatment (Stowoski, 2010). As widespread reports of abuse surface, it is hoped that swift legal action will offer redress for victims (Sullivan, 2013).

Lack of Civility At times, an instance of bullying is not so obvious. Lack of civility is an example. Uncivil behav- ior creates an environment that also endangers patients (Covell, 2010). Lack of civility includes any behavior that is:

● Rude ● Disrespectful ● Impolite ● Ill-mannered

CHAPTER 21 • DEALING WITH DISRUPTIVE STAFF PROBLEMS 285

Examples are aggressive behaviors, such as:

● Yelling ● Swearing ● Spreading rumors ● Destroying or taking another’s property

Here’s an example:

Reid Martin, nurse manger, has encouraged new graduate nurse Joy Gabriel, to de- velop an informational presentation for a staff meeting as a strategy to improve her self-confidence. At the next monthly staff meeting, Joy presents information about a new occlusive dressing. Joy is shy, and public speaking is difficult for her. Her voice shakes, and she drops the box of new dressings she brought to demonstrate. Kristi Sanderson, RN, has been rolling her eyes and sighing loudly throughout Joy’s presentation. At the end of the meeting, Kristi makes a point of telling several other staff members that it was “pain- ful” to sit through Joy’s presentation. Joy overhears Kristi’s comments.

This example is a situation that does not quite rise to the level of bullying. Nonetheless, the manager must confront Kristi and explain why nonverbal signals are inappropriate. (Remember you learned in Chapter 9 that nonverbal communication is more powerful than verbal commu- nication.) Kristi must be also told that sotto voce criticisms will not be tolerated. Following the suggestions on coaching and progressive discipline, the manager must explain the consequences for repeated instances of discourtesy to her fellow staff members and insist that Kristi conduct herself in a civil manner. The manager also followed up with Joy and shared that her presenta- tion was excellent and apologized for the inappropriate comments. The manager told Joy that the issue was being handled so that another staff member would not face such uncivil behavior in the future.

Lateral Violence Another example of the complexity of bullying is lateral violence, harassment between employ- ees of equal rank. See the following example:

Jeana Rossi, RN, is a staff nurse on a medical unit. At 0700, she took over care for five patients from Greg Robeson, RN, an agency nurse who had worked the 7p–7a shift. During her review of patient medication administration records, Jeana noted that an IV antibiotic scheduled to be administered at 2300 had not been charted. Checking the IV bin, Jeana found the 2300 dose. Greg had already left the unit. Per hospital policy, Jeana completed a missing dose report and turned it in to her manager. Two days later, Greg corners Jeana in the staff lounge and loudly berates her in front of other staff members for completing a missing dose report. “You’re so stupid!” Greg shouts. “You just wanted to make me look bad, didn’t you?”

This example shows how difficult some staff problems can be to manage. If you were the manager on this unit, how would you handle the situation? Here are some alternatives. The manager could report Greg to the agency and request that he no longer be assigned to the unit, but then a replacement must be found and the manager may have concerns about the com- petency of other nurses this agency might send. Remember, Greg was the only nurse on the night shift. The manager could also discuss the event with Greg and counsel him on violating hospital policy. In the end, the manager reported the situation to her supervisor and called the director of the agency, who assured the manager that the agency would provide a competent nurse for the next shift.

The manager has a special duty to protect staff from bullying by others, to each other, or to students. Take every report of verbal aggression seriously, document events, and use the

286 PART 3 • MANAGING RESOURCES

appropriate conflict strategy to resolve it. Left on its own, bullying is likely to continue and escalate.

One caveat regarding bullying: if the situation becomes threatening, seek help immedi- ately, preferably from security. Also see the section in the next chapter, Preventing Workplace Violence, for specific strategies.

How to Handle Problem Behaviors Here is another example of a complex staff problem.

The staff at the outpatient imaging center all share a common break room. Over the past several months, several staff members have complained to their nurse manager, Julie Fredrickson, that their lunches are missing from the break room refrigerator or particular items such as desserts or cans of soda are missing. One afternoon, Julie enters the break room to get a cup a coffee and sees one of the radiologists, Dr. Gibson, eating a brownie and looking through several lunch bags. “I never get a chance to get out for lunch,” Dr. Gibson said. “I’m sure your staff doesn’t mind sharing with a hungry physician.”

If you were the nurse manager at this outpatient center, how would you handle this situation? Dr. Gibson was committing theft, even if the items he stole were inexpensive. Nonetheless, his behavior caused nurses to go without some of their own food, and, more importantly, it was dis- respectful to them. It implied that he thought his needs were more important than any of theirs. When informed, the manager alerted his supervisor and then confronted Dr. Gibson who, after threatening to report the manager to administration, calmed down, said he would donate pizza for the staff the next day, and agreed to stop stealing (yes, the manager used the word “stealing”).

Managers and nurses are faced with any number of other problems presented by employ- ees, including staff who are marginally competent, perpetually complaining, verbally abusive, or who lack civility in the workplace. Still others may have a substance-abuse problem.

Marginal Employees Some staff, no matter how many times they are coached or disciplined, never seem to reach the level of competence expected of an experienced nurse (Arnold, Pulich, & Wang, 2008). These are marginal employees. Work habits may be sloppy, communication skills poor, or deci- sion making inadequate. Discipline does not help either in spite of the employee’s attempts to improve.

Marginal employees present the manager with a unique challenge. The manager can ig- nore the problem and hope that the employee will improve, a largely ineffective strategy. This also leaves the unit vulnerable to complaints from other staff who must cover for the marginal employee, and affects the unit’s morale.

The manager could, in contrast, follow the organization’s procedures for progressive disci- pline and termination (see Chapter 19), which may leave the unit understaffed. Furthermore, the nurse may move on to another institution, perpetuating the poor performance.

In some organizations (e.g., government institutions and those with union contracts), the manager must follow strict guidelines for discipline and, especially, for dismissal. Because of the time and effort involved, managers in these organizations may allow the behavior to persist (Abbassi, Hollman, & Hayes, 2008).

It is crucial, then, for the manager to address the poor performance of a marginal employee. By not having crucial conversations with a marginal employee, action planning to improve per- formance, and following through with formal corrective action if behavior does not improve after coaching, the manager is failing the high-performing employees (Weston, 2009). If the manager is persistent, fair, and consistent, employees are more likely to perceive the policies are just (Henle, Kohut, & Booth, 2009).

CHAPTER 21 • DEALING WITH DISRUPTIVE STAFF PROBLEMS 287

Disgruntled Employees Disgruntled employees are those who are always complaining; their behavior affects morale on the unit. They complain about anything and everything, but they direct most of their complaints against the organization. They may air them in public, which can affect how others view the organization. Although the temptation is to label this as an attitude problem, complaining is a behavior and as such can be addressed by the following:

● Remember to set standards of performance and communicate them to the employee. ● Keep notes about incidents of complaining in behavioral terms. ● Take action early, and be consistent among employees. ● Use key behaviors for coaching found in Chapter 19. ● Follow up as scheduled.

Case Study 21-1 describes one manager’s experience with an employee with another prob- lematic behavior.

PROBLEM STAFF Gene Marshall is the nurse manager for a general medical–surgical unit in a veteran’s hospital. His busy unit primarily serves elderly male patients. Felicia Ralston, RN, has worked on the medical–surgical unit for three years. Since her hiring, Felicia has obtained several body pierc- ings, including her nose, eyebrow, and tongue. She usu- ally wears large hoops or bars in her facial piercings. Not long ago, Felicia added a visible tattoo to the back of her neck and upper shoulder. The tattoo on her lower back can often be seen despite her uniform. Recently, she came to work after adding purple highlights to her hair.

As the number and prominence of Felicia’s pierc- ings and body art have increased, several patients and their family members have told Gene that they were “uncomfortable” having Felicia as their nurse. Some pa- tients feel intimidated by her unusual appearance. Gene speaks with Felicia about the patient and family mem- ber concerns and reviews the hospital’s dress code with her. Felicia becomes angry and tells Gene that hair color, body piercings, and tattoos are a form of individual ex- pression and have nothing to do with her performance as a nurse.

Later, Felicia tells everyone on the unit about her discussion with Gene, speaking loudly and inappropri- ately in patient care areas. She asks the unit clerk if she knows which patients or family members complained to Gene about her appearance. The following day, Felicia asks each of her assigned patients if they “have a prob- lem” with her. Felicia reports back to Gene that none of her patients said they had any problems with her or her appearance. After discussing the situation with the hu- man resources department, Gene meets with Felicia and provides her with a written warning regarding her body piercings, tattoos, and hair color as well as her unpro- fessional behavior following their initial meeting. Gene

tells Felicia that she must remove jewelry from her nose and eyebrows prior to reporting for work and that her hair color must be a natural color. He also tells her that her tongue jewelry must be small and unnoticeable. Fe- licia’s uniforms are to cover her tattoos completely.

Gene also provides Felicia with a copy of the federal court ruling in which the court ruled that body piercings and tattoos are not considered protected as free speech and that employers have the right to set standards of dress and appearance for their employees. Gene tells Felicia that not only has her behavior been inappropri- ate and unprofessional but, because it made staff and patients uncomfortable, it could be considered harass- ment or workplace violence. Finally, Gene emphasizes to Felicia that she should directly speak with him regard- ing any performance issues or problems and not involve staff or patients in the situation. If Felicia does not com- ply with these standards within 10 working days, she will be terminated from her position.

Manager’s Checklist The nurse manager is responsible for:

● Understanding the human resources policies for their organization

● Consistently applying policies to all employees ● Providing timely and appropriate feedback when an

employee is in violation of policies ● Remaining professional at all times when dealing

with an irate or angry employee ● Maintaining accurate and thorough documentation

of performance issues ● Following up with the human resources department

as necessary

CASE STUDY 21-1

288 PART 3 • MANAGING RESOURCES

The Employee with a Substance Abuse Problem As substance abuse has become increasingly prevalent in society, nursing has not remained im- mune. Substance abuse not only is detrimental to the impaired nurse, but also jeopardizes pa- tients’ care, thereby also exposing the employing agency to greater liability.

Early recognition of alcohol or drug dependency and prompt referral for treatment is essen- tial. Some general signs and symptoms may become evident as a nurse’s dependency progresses (Boxes 21-1 and 21-2).

In addition to the signs and symptoms listed in Boxes 21-1 and 21-2, the nurse manager should be alert for workplace indications of drug abuse as shown in Box 21-3.

If the manager discovers signs or symptoms in an employee or becomes aware of the unit changes described, further investigation is warranted, and administration should be informed.

Signs of Alcohol or Drug Dependency

● Family history of alcoholism or drug abuse ● Frequent change of work site (same or other

institution) ● Prior medical history requiring pain control ● Conscientious worker with recent decrease in

performance ● Decreased attention to personal appearance ● Frequent complaints of marital and family

problems ● Reports of illness, minor accidents, and

emergencies

● Complaints from coworkers ● Mood swings/depression/suicide attempts ● Strong interest in patients’ pain control ● Frequent trips to the bathroom ● Increasing isolation (night shift request; eating

alone) ● Elaborate excuses for tardiness ● Difficulty in meeting schedules/deadlines ● Inadequate explanation for missing work

BOX 21-1

BOX 21-2 Physical Symptoms of Alcohol or Drug Dependency

● Shakiness, tremors of hands, jitteriness ● Slurred speech ● Watery eyes, dilated or constricted pupils ● Diaphoresis ● Unsteady gait

● Runny nose ● Nausea, vomiting, diarrhea ● Weight loss or gain ● Blackouts (memory losses while conscious) ● Wears long-sleeved clothing continuously

BOX 21-3 Workplace Indications of Drug Abuse

● Incorrect narcotics counts ● Alterations of narcotics containers ● Discrepancies on medication records or frequent

corrections on them ● High wastage of narcotics

● Marked shift variations in the quantity of narcotics required on the unit

● Excessive patient reports that their pain medication was ineffective

CHAPTER 21 • DEALING WITH DISRUPTIVE STAFF PROBLEMS 289

State Board of Nursing State boards of nursing are charged with protecting the public, including the practice by nurses impaired by substance abuse. Reporting laws vary from state to state, as do consequences, but most state boards require the nurse manager to report an impaired colleague (Collins & Mikos, 2008).

Diversion programs offering referral, assistance, and monitoring may be offered in lieu of disciplinary action in some states. For example, the Kansas Nurse Assistance Program (KNAP) is offered to nurses whose practice is impaired by substance abuse (Sidlinger & Hornberger, 2008). Nurses who successfully complete the program are not reported to the Kansas State Board of Nursing (Kansas State Board of Nursing, 2008).

Strategies for Intervention Once the manager has identified a nurse with a substance abuse problem, intervention with that nurse must be planned. With the assistance of the human resources department and administra- tion, the manager should examine the organization’s policies and procedures and licensure laws as well as determine if a diversion program exists (see above).

Before intervening, the manager should collect all documentation or information about the nurse’s behavior that would suggest an abuse problem. Documentation includes records of ab- senteeism and tardiness (especially recent changes), records of patient complaints about inef- fective medications or poor care, staff complaints about job performance, records of controlled substances, and physical signs and symptoms noticed at different times. Dates, times, and be- haviors should be carefully noted. Any one behavior means very little; it is the composite pattern that identifies the problem.

Next, the manager should identify appropriate resources to help the nurse. Internal resources in- clude an employee assistance program (EAP) counselor, if the organization has one, or other nurses recovering from alcohol or drug dependency who have offered to help. External resources include the names and phone numbers of treatment center staff, other recovering nurses (if known), and Alcoholics Anonymous or Narcotics Anonymous. It is absolutely essential that several sources be provided so that the nurse knows that help from someone who knows how he or she feels is avail- able, and also knows how to get it. This support cannot be emphasized enough. Failing to offer this assistance is like telling a diabetic he has diabetes and failing to tell him where he can get insulin.

In addition to assistance for the nurse, the manager should check on health insurance provi- sions for substance abuse treatment. Many insurance carriers have recognized that successful treatment reduces the use of other health care services and, thus, reduces the cost of health care. Accordingly, they offer coverage for treatment to encourage participants to enter recovery pro- grams. Others, unfortunately, do not. Because many of an organization’s employees may be cov- ered under the same health care plan, the manager should be able to check these provisions. Few policies cover anything but brief inpatient care, usually only for detoxification, but they may cover outpatient treatment, which is considerably less expensive. Even when there is little or no insurance coverage, the nurse may be able to afford outpatient care. Alcoholics Anonymous and Narcotics Anonymous are effective alternatives, and both are free.

The goal of the intervention is to get the nurse to an appropriate place for an evaluation of the possible problem. Treatment centers or therapists who specialize in substance abuse are rec- ommended to conduct the evaluation. They have the necessary experience for diagnosing and, if indicated, treating the disease.

The manager, human resources, and administration must also decide beforehand what ac- tion on the part of the nurse will be acceptable. If the nurse refuses to go for an evaluation, what will the consequences be? The organization’s policies and the state board of nursing regulations must be met, and the manager must be clear about the consequences (e.g., discipline, termina- tion) and willing to carry them out. Most experts in treating addictions in nurses recommend that the nurse be offered the option of substance abuse evaluation and, if needed, treatment. If she or he does not agree to that, then the manager should follow the usual disciplinary process and make a report to the state board of nursing, if indicated.

290 PART 3 • MANAGING RESOURCES

Once preparations have been made, the intervention should be scheduled as soon as pos- sible. Others may be asked to join the manager, but the group should be small and restricted to only those involved in past problems, a substance abuse or human resource staff person, or the manager’s supervisor. In some organizations, the top nursing administrator conducts all sub- stance abuse interventions and, in that case, the nurse manager must fully inform the administra- tor of all circumstances leading to the intervention and provide all the documentation needed. Also, the manager should participate in the intervention so that all relevant information is pre- sented and denial is kept to a minimum.

The intervention should be scheduled at a time and place when and where interruptions can be avoided. It is best to surprise the nurse with a request to come to the office. Denial can build, rationalizations can be developed, and defensiveness can increase if the nurse is given time to consider the problem.

The manager should present the nurse with the collected evidence showing a pattern of behaviors that suggests an abuse problem might be occurring and that an evaluation must be undertaken to know for sure. It is important to focus on the problem behaviors, not on the inad- equacy of the person. The individual has already experienced shame and guilt about the use. The manager has an opportunity to help the nurse recognize that substance abuse is an illness that needs treatment; then the nurse will be better able to accept that a problem exists.

In the best-case scenario, the nurse admits the problem, is grateful to be getting help, and goes willingly to treatment. It is best to go directly to treatment from the work site if this can be arranged beforehand. It is important to move quickly before denial resurfaces.

Some nurses, of course, will continue to deny the obvious, in which case the manager must continue to confront the nurse with the reality of the circumstances. If the nurse refuses to go for an evaluation, the manager must follow the organization’s disciplinary process. If the nurse is using alcohol or drugs at the time, immediate removal from patient care is necessary. The man- ager should arrange to have someone (either a family member or another staff member) drive the nurse home, whether the nurse is going to treatment or not. Not only do alcohol or drugs make the nurse an unsafe driver, but the stress of the intervention may distract the nurse even more.

If the nurse agrees to go for an evaluation and/or treatment, specific plans must be made. It should be clear to all parties when the nurse will contact the treatment center (the sooner the better, even if mood-altering chemicals are not being used at the time) and when the nurse will report back to the manager with the recommended course of action. It is possible to arrange with a treatment facility for reports to be made directly to the manager, but federal regulations regard- ing confidentiality prohibit treatment staff from reporting a patient’s status to anyone without that person’s written consent. Because the goal of treatment is recovery, which includes return- ing to work, most facilities request that the nurse give this consent.

The decision to allow an employee to return to work or even to require the employee to avoid returning for any period of time will be based on the recommended treatment. Withdrawal from narcotics very likely will require inpatient detoxification; partial hospitalization also may be recommended. If the employee needs time off for these treatments, sick leave can be used, or the employee may be given an unpaid leave of absence (see the section on the Americans with Disabilities Act and substance abuse).

Reentry Reentry to the workplace must be carefully planned, whether the employee has been absent for any length of time or not. It is especially important for the manager and administration to recognize the threat that access to the category of drugs the nurse was addicted to (e.g., narcot- ics) poses to recovery. Return to work is usually recommended, but not all treatment staff are familiar enough with nursing to be aware of the danger of putting the nurse in constant, daily contact with the drugs that may have been abused in the past. However, it is vitally important to the nurse’s recovery that he or she return to work, preferably in the same setting.

This dilemma has often been dealt with in two ways. One method is to reassign the nurse for a period of time (possibly as long as two years) to a job or a unit where few mood-altering

CHAPTER 21 • DEALING WITH DISRUPTIVE STAFF PROBLEMS 291

drugs are given, such as the nursery, department of education, rehabilitation, home care, dialysis, or patient care audits. Although reassignment presents a problem for the organization and may be disappointing to the nurse, it is far better to make this accommodation than to jeopardize the nurse’s recovery by providing access to drugs too soon. This is less a concern with nurses who abused only alcohol.

Another method is to retain the nurse on the unit but not allow administration of mood- altering medications. In fact, state law or organizational policy may require that recovering nurses in the early posttreatment period be restricted from handling controlled substances, car- rying narcotic keys, being in charge, or working overtime. This method requires that other staff not only know about the nurse’s problem but also be willing to give pain and sleep medications to that nurse’s patients. Because this involves disclosing the nurse’s addiction, management and staff must decide whether this is reasonable, and the nurse must agree.

Recovering nurses may be discouraged from working evening or night shifts. A reentry contract may be used to specify these restrictions. The contract also may require documentation of participation in recovery groups and random urine drug tests. Ideally, the reentering nurse should have an identified support person available at work.

These restrictions are usually necessary only for the nurse who was addicted to narcotics, but each case should be individually decided based on the amount of stress in the job, the need for rotating shifts, and other factors that may inhibit recovery.

The Americans with Disabilities Act and Substance Abuse The Americans with Disabilities Act (ADA) went into effect in 1990 and was amended in 2009 (U.S. Department of Justice). The Act applies to employers of 15 or more people. This law prohibits discrimination in personnel policies (such as hiring and firing) and other employment- related issues if an individual has a qualifying disability. Because alcohol or drug dependency limits one or more of a nurse’s activities, it is considered a disability under the ADA. Only those who have been identified with substance abuse disorders, either diagnosed or self-reported, are protected under the law. A person using drugs or who is under the influence of alcohol in the workplace is not protected from the job-related consequences of that use.

The same consideration must be given to the nurse addict as to a nurse with a hearing im- pairment. This means providing sick leave and treatment opportunity, as well as making rea- sonable job accommodations. Several reasonable job accommodations have been mentioned previously: assignment to a unit where narcotics and sedatives are not given or are given infre- quently, exemption from shift rotation, exemption from charge duties, and the like. Furthermore, the employee’s drug abuse history must be kept private. The ADA confidentiality provisions require the employer to keep records on employee substance abuse (i.e., disability) in separate, locked files with access limited to a need-to-know basis.

As with other chronic diseases, alcohol and drug dependency is a disorder prone to relapse. How relapses will be treated under this law is not clear. As with many other personnel issues, it is wise for the nurse manager to consult with human resources and administration about ADA requirements.

Health care today requires that every employee function at peak efficiency and effective- ness. Health care organizations cannot afford to protect an employee whose professional func- tioning is impaired by substance abuse. Discharging the employee and allowing the person to go to another institution to continue practicing and endangering patients, as well as himself or herself, cannot be allowed. The nurse manager is the frontline contact with staff and can be alert to the signs and symptoms of substance abuse problems, learn intervention techniques and skills, and help recovering nurses return to the workplace. Concern for patients’ safety requires intervention, and humane concern for nurse colleagues mandates that such assistance be made available.

Dealing with employee problems present ongoing challenges for the nurse manager, but the steps are similar to those described in Chapter 19. That is, identify the problem, intervene appropriately, and follow up as necessary. In addition, the manager must be persistent, fair, and consistent when intervening with problem employees.

292 PART 3 • MANAGING RESOURCES

What You Know Now • Bullying increases staff dissatisfaction and turnover and can pose a danger to patients as well. • Incivility and lateral violence are examples of bullying. • The behaviors of employees who harass others, are marginal performers, are disgruntled, or abuse

substances affect coworkers as well as patient care. • Nurse managers need to identify staff problems early and intervene if necessary. • Identifying, intervening, and returning nurses with substance abuse problems to the workplace help the

organization, the manager, and the affected nurse. • Substance abuse not only is detrimental to the impaired nurse but also jeopardizes patient care and places

the organization at increased liability. • The manager must be persistent, fair, and consistent when intervening with problem employees.

Tools for Managing Staff Problems 1. Identify bullying behavior promptly and intervene as appropriate. 2. Document all instances of problem behavior. 3. Try to resolve conflicts and deal with problems as they appear. 4. Consult administration and human resources before intervening in serious problems, such as

substance abuse. 5. Follow up problem behaviors with coaching, disciplining, or terminating if needed, using the guide

in Chapter 19.

Questions to Challenge You 1. Have you ever worked or shared a class with a person who caused problems? (Most of us have.)

How did the problem manifest itself? How was it handled? How do you wish the problem had been handled?

2. Have you ever experienced bullying or seen others bullied? How did you or they handle it? 3. Are you familiar with the signs and symptoms of substance abuse? Have you seen someone exhibit

these characteristics? What signs or symptoms did they exhibit? What happened? 4. Using the examples in the chapter, consider how you would respond to the problem behaviors.

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

References Abbassi, S. M., Hollman, K. W., &

Hayes, R. D. (2008). Bad bosses and how not to be one. The Information Man- agement Journal, 42(1), 52–56.

American Nurses Association. (2010). House of Delegates Resolution. Hostility, abuse and bullying in the

workplace. The Kansas Nurse, 85(6), 17.

Arnold, E., Pulich, M., & Wang, H. (2008). Managing immature, irresponsible, or irritating employees. The Health Care Manager, 27(4), 350–356.

Baird, C. (2010). Spotting alco- hol and substance abuse.

American Nurse Today, 4(7), 29–31.

Broome, B. A. (2008, Winter). Dealing with sharks and bullies in the workplace. ABNF Journal, 28–30.

Christmas, K. (2007). Workplace abuse: Finding solutions. Nursing Economics, 25(6), 365–367.

www.nursing.pearsonhighered.com

CHAPTER 21 • DEALING WITH DISRUPTIVE STAFF PROBLEMS 293

Collins, S. E., & Mikos, C. A. (2008). Evolving taxonomy of nurse practice act viola- tions. Journal of Nursing Law, 12(2), 85–91.

Covell, C. L. (2010). Can civility in nursing work environ- ments improve medication safety? Journal of Nursing Administration, 40(7/8), 300–301.

Dempster, M. (2006). Turning blind eye to bullies hurts business. Business Edge. Retrieved December 2007 from http://www. businessedge.ca/article.cfm/ newsID/9505.cfm

Henle, C. A., Kohut, G., & Booth, R. (2009). Design- ing electronic use policies to enhance employee per- ceptions of fairness and to reduce cyberloafing: An empirical test of justice the- ory. Computers in Human Behavior, 25(4), 902–910.

Joint Commission. (2008, July 9). Behaviors that undermine a culture of safety. Retrieved October 15, 2010 from http://www.jointcommission. org/SentinelEvents/ SentinelEventAlert/ sea_40.htm

Kansas State Board of Nurs- ing. (2008). The Kansas nurses assistance program. Retrieved August 23, 2011 from http://www.ksbn.org/ knap.htm

Sidlinger, L., & Hornberger, C. (2008). Current characteris- tics of the investigated im- paired nurse in Kansas. The Kansas Nurse, 83(1), 3–5.

Stokowski, L. A. (2010). A mat- ter of respect and dignity: Bullying in the nursing profession. Retrieved October 15, 2010 from http://www.medscape.com/ viewarticle/729474

Sullivan, E. J. (2013). Becom- ing influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall.

U. S. Department of Justice. (2009). Americans with disabilities act of 1990, as amended. Retrieved July 25, 2011 from http://www. ada.gov/pubs/ada.htm

Vessey, J. A., DeMarco, R. F., Gaffney, D. A., & Budin, W. C. (2009). Bullying of staff registered nurses in the workplace. Journal of Pro- fessional Nursing, 25(5), 299–306.

Weston, M. J. (2009). Managing and facilitating innova- tion and nurse satisfaction. Nursing Administration Quarterly, 33(4), 329–334.

http://www.businessedge.ca/article.cfm/newsID/9505.cfm

http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm

http://www.ksbn.org/knap.htm

http://www.medscape.com/viewarticle/729474

http://www.ada.gov/pubs/ada.htm

http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm

CHAPTER

Preparing for Emergencies

Types of Emergencies NATURAL DISASTERS

MAN-MADE DISASTERS

LEVELS OF DISASTERS

National Responses to Emergency Preparedness

Hospital Preparedness for Emergencies EMERGENCY OPERATIONS PLAN

DISASTER TRIAGE

CORE COMPETENCIES FOR NURSES

CONTINUATION OF SERVICES

IMPACT ON EMPLOYEES

Preparing for Emergencies22

Key Terms Emergency operations plan (EOP)

1. Identify examples of disasters that require preparation.

2. Describe potential emergency situations. 3. Explain triage in disaster situations. 4. Discuss the core competencies nurses must

have to be prepared for emergencies.

5. Discuss how services can be continued during an emergency.

6. Identify the impact disasters may have on employees

Learning Outcomes After completing this chapter, you will be able to:

CHAPTER 22 • PREPARING FOR EMERGENCIES 295

Preparing for Emergencies In the decade since September 2001, emergency preparedness has been the focus of national and local efforts. Emergencies can be natural disasters (e.g., tornadoes, hurricanes, earthquakes, or floods), or they may be man-made accidents (e.g., hazardous material spill) or intentionally cre- ated (e.g., acts of terrorism). Regardless of the cause, health care organizations must be prepared to deal with the mass casualties that may occur due to any type of emergency (see Box 22-1).

Types of Emergencies

Natural Disasters Natural disasters include any disaster that is not man-made. Floods, hurricanes, tornadoes, vol- canos, heat waves, and blizzards are examples of natural disasters. Location is a key element in preparing for natural disasters. Coastal areas must prepare for hurricanes, Mississippi River towns should prepare for flooding, and plains areas should plan for tornado disasters.

Health disasters are also natural disasters. Epidemics of diseases that spread rapidly through the population and pandemics that spread disease around the globe are health disasters. Severe acute respiratory syndrome (SARS), AIDS, antibiotic resistant bacteria, the Ebola virus, and the H1N1 influenza virus are examples of epidemics and pandemics.

Man-Made Disasters Sadly, man-made disasters are much more common today than just a few decades ago, when even a bomb threat would be unlikely and possibly thought a hoax. Now, any such threat would be deemed critical, and personnel would respond accordingly.

Man-made disasters can be accidental or intentional. Industrial hazards, structural collapses of buildings or bridges, and power outages are examples of accidental hazards. Subways, sports stadiums, and airplanes may be attacked. Chemical, physical, biological, radiological, or nuclear toxins may spread to the population causing illness and death. Anthrax, a bacterial toxin, and asbestos, a physical toxin, are examples of poisonous substances that can cause environmental disasters.

Levels of Disasters Disasters are further categorized by level as follows:

● Level I: Local level response and containment suffices ● Level II: Regional level response is necessary ● Level III: Statewide or national assistance is needed (Smeltzer et al., 2010)

BOX 22-1 Examples of Disasters

Natural Disasters

Floods Hurricanes Earthquakes Landslides and mudslides Wildfires Epidemics and pandemics (influenza, SARS, H1N1)

Man-Made Disasters

Accidental Structural collapse of buildings or bridges Industrial spills Power outages Intentional Explosive or incendiary devices Sniper or mass casualty shootings Release of toxins (chemical, physical, biological, radiological, nuclear) Arson fires

296 PART 3 • MANAGING RESOURCES

Every health care organization must prepare for both natural and man-made disasters and the resulting mass casualty incidents (MCI). Unfortunately, efforts sometimes fall short of the goal.

The National Center for Health Statistics (NCHS) (Niska & Shimizu, 2011) found that only half of U.S. hospitals had plans for alternate care areas with beds, staffing, and equipment. Only half had arranged for advanced registration of health care professionals. More than half, how- ever, had staged practice drills. NCHS has concluded that emergency response preparedness nationwide has not met the goal of full preparedness. Thus, national efforts are being directed toward improving disaster management.

National Responses to Emergency Preparedness At the national level, the Joint Commission and the federal government have created initiatives to help prepare first responders and health care organizations to handle emergencies (Sauer et al., 2009). The Joint Commission expanded its emergency management standards to include mitigation, preparedness, response, and recovery (The Joint Commission, 2009). The executive branch of the U.S. government issued executive orders establishing, among other initiatives, the Office of Homeland Security. The U.S. Congress passed legislation addressing bioterrorism and pandemics. Congress also directed the Federal Emergency Management Agency (FEMA) to coordinate disaster relief efforts.

Hospital Preparedness for Emergencies Plans for emergency management are required of all hospitals (The Joint Commission, 2009). Key to successful emergency management is a hospital emergency operations plan (EOP). The EOP includes preparation, education and training, and implementation of the hospital’s re- sponse to emergency situations.

Emergency Operations Plan The hospital’s EOP includes the following components:

● Activation response ● Communication plan ● Patient care coordination plan ● Security plan ● Traffic flow plan ● Data management strategy ● Resources availability (Smeltzer et al., 2010)

Finally, the EOP must include plans to deactivate the response, follow-up with post-incident review, and a schedule for practice drills.

Implementation of the EOP includes three components: planning, preparing, and practicing (Smeltzer et al., 2010).

Planning Planning involves determining the hospitals’ top three to five vulnerabilities based on its geo- graphic location. For example, if the hospital is near a factory, the EOP would include plans for possible industrial accidents. If the hospital is located in a city near the Atlantic Ocean, they would prepare for hurricane victims. On the other hand, if the hospital sits on the Kansas plains, tornadoes are more likely. Once vulnerabilities have been determined, planning can proceed based on the possible patient injuries.

CHAPTER 22 • PREPARING FOR EMERGENCIES 297

Preparing Preparation includes staff education and training. Both knowledge and skills training are needed, and lectures and computer simulations may be used. Participants’ knowledge and skills must be evaluated and, if deficient, retraining conducted.

Practicing Hospitals are required to test their EOP twice a year (The Joint Commission, 2009). One prac- tice can be a tabletop event, but one must involve realistic situations and simulated patients (Sauer, 2011). The timing of exercises should include occasions when the hospital is at low capacity to test its readiness in the most adverse situations. Evaluation of the hospital’s EOP and performance should be evaluated annually.

Disaster Triage Similar to the triage system used by the military in war situations, hospitals must reverse their usual triage method of treating the most-seriously injured person first. Instead, they must priori- tize scarce resources to those who can benefit the most (Kirwan, 2011). The Simple Triage and Rapid Treatment (START) system is an example (www.start-triage.com). The goal is to treat as many injured people as possible in the shortest time possible. Inundated with mass casual- ties, precious time must be directed to the least seriously injured first, then the more seriously injured, and so on.

Core Competencies for Nurses The National Emergency Preparedness Education Coalition (2003) established core competen- cies for nurses to prepare for mass casualties. These include:

● Critical thinking. Critical thinking in disasters is different than in normal health care situ- ations. Mass casualties may inundate the facility, the triage system is reversed, and the nurse may be concerned about family at home. Nurses’ abilities to prioritize, demonstrate clinical judgment, and make decisions are key to successful emergency responses (Coyle, Sapnas, & Ward-Presson, 2007).

● Assessment. Assessment includes self-assessment and situational assessment (Coyle, Sap- nas, & Ward-Presson, 2007). Patient assessment includes physical injuries, as expected, but also emotional injuries and family assessments. During a disaster such as SARS, the hospital may be inundated with “psychological” casualties—people who think they have the symptoms. Triage must address how to treat these casualties as well.

● Technical skills. In addition to therapeutic interventions skills, nurses must be able to implement appropriate therapies, arrange transport, and maintain patient safety during an incident. The nurse must also be aware of hazardous substances, the isolation techniques necessary and use personal protective equipment as needed.

● Communication. When dealing with mass casualties, communication within the hospital and with local officials is essential. A system to track patients throughout their stay is nec- essary for staff follow-up so that families can be kept informed (Kirwan, 2011).

Continuation of Services Complicating emergency preparedness is the need to provide for continuation of services in the event of an emergency. Routine services may be disrupted. Loss of electrical power may be countered by the backup generators, but if computer capabilities close down, how will the electronic medical record and the medication system work? How will documentation continue? Resupply of medications, food, water, and supplies may be interrupted. What if resupply lines are impacted by a disaster (e.g., trucks delivering meds cannot get through due to flooded or washed out roads)? Furthermore, how will the facility handle a large influx of patients and/or

www.start-triage.com

298 PART 3 • MANAGING RESOURCES

casualties? If needed, how will the evacuation of the facility be handled? The EOP must address all of these issues.

Risk assessment is necessary to identify the hospital’s vulnerability (Edwards et al., 2007). Hospitals are often the frontline responders to mass casualty events, but maintaining services in the face of overwhelming numbers of casualties can be challenging. Capabilities, resources, and education and training needs must be assessed.

Surge capacity describes an institution’s ability to mobilize when suddenly confronted with a vast increase in patient demand (Hick et al., 2008). By planning ahead of time for an influx of patients, strategies can be put in place to mobilize emergency procedures. A surge system includes:

● Supplies ● Personnel ● Physical space ● Management infrastructure

These components are known as “stuff, staff, and structure” (Barbisch & Koenig, 2006). At the onset of a disaster and the impending arrival of mass casualties, a hospital incident command structure can be implemented, a rapid needs assessment conducted, and appropriate activities mobilized. Preparation and drills ensure that all components are in place. Post-incident follow- up is essential to continually evaluate performance and initiate improvements.

Impact on Employees Depending upon the nature of the emergency, staff will be affected. They may become ill them- selves, their homes may be flooded, or they may have children left at home that they have to go to, for example. With the loss of staff, how will the agency continue to accept and care for new patients?

Employee fatigue and exhaustion, including mental fatigue, must be addressed. Personal protective equipment must be available and staff must be trained to use the equipment and know how to access it in an emergency. Protective equipment includes respiratory protection, eye and face protection, and hand, arm, and body protection, if needed.

Education, training, and practice drills help staff prepare for sudden MCI (Williams, Nocera, & Casteel, 2008). Key to maintaining operational readiness is the staff’s willingness to come to work during a disaster (Davidson et al., 2009). The hospital’s surge capacity includes a callback system to request that staff return to work during an emergency but doesn’t address the staff member’s willingness to come to work (Cone & Cummings, 2006).

Several factors determine staff members’ decisions to come to work, including vulnerability of family, personal safety concerns, professional accountability, past experience with disasters, caring connection with the organization, and the desire to help (Davidson et al., 2009).

These factors suggest appropriate management responses. Developing a caring relationship with staff members and a compassionate response during and after a disaster may slightly help mitigate staff concerns about family vulnerability and personal safety. Worry about pets, chil- dren, dependent adults, and their own security will, of course, still affect employees’ decisions to return to work (Davidson et al., 2009).

In addition to the complications of preparing for emergencies, the hospital also may not be reimbursed for care provided, standards of care may not be established or able to be maintained, and the hospital may incur liability for volunteers’ safety or their performance (Hodge et al., 2009). Emergency preparedness, however, has improved in the past decade and promises to im- prove in the future.

See how one hospital prepared for an impending emergency in Case Study 22-1.

CHAPTER 22 • PREPARING FOR EMERGENCIES 299

PREPARING FOR AN IMPENDING EMERGENCY Weather forecasters were predicting 15 inches of snow to fall in the next 24 hours. It was likely to be the biggest snow storm the town had seen in as many years as any- one could remember. Everyone was in an uproar over the impending severe storm that threatened to shut the city down. Mt. Bethel Hospital administration wanted to make sure they were prepared for this blizzard ahead of time and had an effective emergency plan in place to get the patients good, uninterrupted care.

The snow was expected to start at four o’clock in the afternoon. Hospital managers and administrators met early that morning at seven o’clock to get a plan in place. It was decided that a message would go out to all staff who were scheduled to work that night, advising them to come into the hospital for their night shift early. The hos- pital would serve dinner in the cafeteria to those waiting for their shift to start. Getting night staff to the hospital before the blizzard was projected to be at its worst would allow the hospital to run in routine fashion overnight. The hospital also encouraged night shifters to bring a bag to stay over the next day at the hospital and asked them to consider working the following night shift too.

The administration team increased its linen and gro- cery orders with vendors so the hospital would be well stocked in case deliveries couldn’t be made for a few days. The grocery order was delivered and included all items requested. The linen order was delivered that day;

it was only double the routine delivery, because many other facilities had also requested excess linens to be delivered. The administration made a note in its plan to notify staff to conserve linen resources if a normal linen delivery couldn’t occur the next day.

The administration announced to the day-time staff that all staff had been invited to spend the night at the hospital after their shift and asked to work the next day as well. Each staff member was provided with a cot to sleep on, blankets, meals, and scrubs. In addition, the hos- pital made shower facilities within the building available for staff, and even put up sign-up sheets for each shower so staff could schedule their time. Most day staff agreed to stay at the hospital to avoid driving home and so they would be available the next day when people at home were likely not going to be able to drive in for their shift.

Mt. Bethel was well prepared for the impending bliz- zard. With proper advance preparation, the hospital was able to operate under normal patient care standards. The staff had been so gracious to stay at the hospital and meet the staffing needs for patient care. Within 36 hours, the streets were cleared and the city was back to its usual operations. Staff was able to commute to work, deliveries of groceries and linens were back on schedule, and the hospital was operating under normal conditions again. Mt. Bethel administration was pleased it had been able to successfully plan and work through the weather emergency.

CASE STUDY 22-1

What You Know Now • Emergencies include natural disasters, man-made accidents, and acts of terrorism. • Emergency preparedness is the focus of national efforts and promises to increase in the coming decade. • Every hospital is required to have an emergency operations plan (EOP). • Triage in a mass casualty incident is the reverse of normal standards: the goal is to treat the most people in

the shortest time with the resources available. • Planning, preparing, and practicing are the steps necessary to manage potential emergencies. • Core competencies for nurses include critical thinking, assessment, technical skills, and communication. • Surge capacity describes an institution’s ability to mobilize when confronted with an influx of patients. • Education, training, and practice drills help staff prepare for sudden MCI. • Employees’ caring connection with the institution may help mitigate their concerns about family

vulnerabilities and personal safety.

Tools for Preparing for Emergencies and Preventing Violence 1. Become familiar with your organization’s emergency operations plan (EOP).

2. Participate in education and training sessions to prepare for emergencies. 3. Refresh your training regarding reverse triage. 4. Recognize that an actual disaster will challenge your ability to handle family situations, concerns

about your personal safety, and effect your decision to come to work. 5. When an emergency occurs (practice or actual), recall your training and participate as required.

300 PART 3 • MANAGING RESOURCES

Questions to Challenge You 1. Do you know what to do in an emergency? List the steps you would take. Then locate a copy of your

organization’s policies and procedures for emergencies and evaluate yourself. 2. Create a fictitious emergency situation with a classmate or colleague. Challenge each other on how

each of you would handle the situation. Share your experience with others. 3. Have you participated in disaster drills? How well did you follow your training? How well did the

organization handle the drill? Did you see areas for improvement? 4. Have you been involved in an actual disaster experience? If so, share your experience with class-

mates or colleagues. Nothing makes a situation real better than a factual account.

Barbisch, D., & Koenig, K. L. (2006). Understanding surge capacity: Essen- tial elements. Academic Emergency Medicine, 13(11), 1098–1102.

Cone, D. C., & Cummings, B. A. (2006). Hospital disaster staffing: If you call, will they come? American Journal of Disaster Medi- cine, 1(1), 28–36.

Coyle, G. A., Sapnas, K. G., & Ward-Presson, K. (2007). Dealing with disaster. Nursing Management, 38(7), 24–29.

Davidson, J. E., Sekayan, A., Agan, D., Good, L., Shaw, D., & Smilde, R. (2009). Disaster dilemma: Factors affecting decision to come to work during a natural disaster. Advanced Emergency Nursing Journal, 31(3), 248–257.

Edwards, D., Williams, L. H., Scott, M. A., & Beatty, J. (2007). When disaster strikes: Maintaining operational readiness. Nursing Management, 38(9), 64–66.

Hick, J. L., Koenig, K. L., Barbisch, D., & Bey, T. A. (2008). Surge capacity concepts for health care facilities: The CO-S-TR model for initial incident assessment. Disaster Medicine and Public Health Preparedness, 2(Supple- ment 1), 551–557.

Hodge, J. G., Garcia, A. M., Anderson, E. D., & Kaufman, T. (2009). Emer- gency legal preparedness for hospitals and health care personnel. Disaster Medicine and Public Health Preparedness, 3(Supple- ment 1), S37–S44.

Howard, P. K., & Gilboy, N. (2009). Workplace violence. Advanced Emergency Nurs- ing Journal, 31(2), 94–100.

Kirwan, M. M. (2011). Disaster planning: Are you ready? Nursing Made Incredibly Easy, 9(3), 18–24.

Niska, R. W., & Shimizu, I. M. (2011, March 24). Hospital preparedness for emergency response: United States, 2008. National Health Statistics Reports, 37, 1–15.

Nursing Emergency Prepared- ness Education Coalition. (2003). Educational compe- tencies for registered nurses responding to mass casualty incidents. Retrieved August 23, 2011 from http://www. nursing.vanderbilt.edu/ incmce/competencies.html

Sauer, L. M., McCarthy, M. L., Knebel, A., & Brewster, P.

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

Web Resource START Triage: http://www.start-triage.com

References

http://www.nursing.vanderbilt.edu/incmce/competencies.html

www.nursing.pearsonhighered.com

http://www.start-triage.com

CHAPTER 22 • PREPARING FOR EMERGENCIES 301

(2009). Major influences on hospital emergency management and disaster preparedness. Disaster Medicine and Public Health Preparedness, 3(Supple- ment 1), S68–S73.

Smeltzer, S., Bare, B., Hinkel, J., & Cheever, K. (2010). Brunner and Suddarth’s

textbook of medical– surgical nursing (12th ed.). Philadelphia, PA: Lippin- cott Williams & Wilkins.

The Joint Commission. (2009). Emergency management in The Joint Commission Hospital Accreditation Pro- gram. Oakbook Terrace, IL: The Joint Commission.

Williams, J., Nocera, M., & Casteel, C. (2008). The effectiveness of disaster training for health care workers: A systematic review. Annals of Emergency Medicine, 52(3), 211–222.

Workplace violence

Key Term

1. Discuss what health care organizations can do to prevent violence.

2. Identify threats and threatening behaviors. 3. Describe how to recognize escalating

violence.

4. Discuss how to respond to a violent incident.

5. Describe how to handle the follow-up to a violent incident.

Learning Outcomes After completing this chapter, you will be able to:

Violence in Heath Care INCIDENCE OF WORKPLACE VIOLENCE

CONSEQUENCES OF WORKPLACE VIOLENCE

FACTORS CONTRIBUTING TO VIOLENCE IN HEALTH CARE

Preventing Violence ZERO-TOLERANCE POLICIES

REPORTING AND EDUCATION

ENVIRONMENTAL CONTROLS

Dealing with Violence VERBAL INTERVENTION

A VIOLENT INCIDENT

OTHER DANGEROUS INCIDENTS

POST-INCIDENT FOLLOW-UP

Preventing Workplace Violence23

CHAPTER

CHAPTER 23 • PREVENTING WORKPLACE VIOLENCE 303

Violence in Health Care Workplace violence is any violent act, including physical assaults and threats of assault, di- rected toward persons at work or on duty. Those working in health care are among the most vulnerable to attack (Howard & Gilboy, 2009). Most assaults in health care are by patients, but attacks are also made by disgruntled family members, coworkers, vendors, employers, or even colleagues (Gates, Gillespie, & Succop, 2011). Some assaults are episodes of domestic violence that occur at work (Pollack et al., 2010).

Violence includes:

● Threatening actions, such as waving fists, throwing objects, or threatening body language ● Verbal or written threats ● Physical attacks, including slapping, hitting, biting, shoving, kicking, pushing, beating ● Violent assaults, including rape, homicide, and attacks with weapons, such as knives,

firearms, or bombs

Incidence of Workplace Violence Violence in health care occurs more often than in other workplace settings (U.S. Department of Health and Human Services, 2008). Public focus, however, has been on other occupational set- tings with violence in health care receiving little attention (Gates, Gillespie, & Succop, 2011). This is in spite of an increase in assaults in health care (U.S. Department of Labor, Bureau of Labor Statistics, 2009).

Consequences of Workplace Violence Violence can range in intensity and cause physical injuries, temporary or permanent disability, psychological trauma, or death (Howard & Gilboy, 2009). In health care, violence is more likely to occur in psychiatric settings, emergency rooms, waiting rooms, and geriatric units, while clin- ics are reported to be less likely sites of violence (Nachreiner et al., 2007).

In addition to harming employees, violence in the workplace can affect worker morale, in- crease staff stress, cause a mistrust of administration, and exacerbate a hostile work environment (Gates et al., 2011). Furthermore, absenteeism and turnover are expensive, and the organization may incur additional health costs for care of injured workers.

Factors Contributing to Violence in Health Care Working with the public carries with it inherent risks, and the added stress by staff, patients, and families in health care settings increases that risk (Gates et al., 2011). Furthermore, hospitals have an “open door” policy for visitors. Visiting hours are not restricted, and visitors are often not required to check in when they enter.

Patients with head trauma, seizure disorders, dementia, alcohol or drug withdrawal, or who are homeless may lash out in violence. Crime victims and the perpetrators might be admitted to the same hospital, and gang violence could spill over into the hospital. In addition, family members’ stress and fear as well as long waits can contribute to the possibility of violent actions. Finally, the absence of visible, armed, and adequately trained security personnel may make the setting less secure.

Although no workplace can be certain to be free from violence, especially random violence, some additional risk factors for potential violence in health care organizations include:

● Working understaffed, especially at meal times and visiting hours ● Long waiting times ● Overcrowded waiting rooms ● Working alone

304 PART 3 • MANAGING RESOURCES

● Inadequate security ● Unlimited public access ● Poorly lit corridors, rooms, and parking lots

Injuries to nurses from violence are likely underreported for several reasons (Gacki-Smith et al., 2009). The definition of workplace violence may not be clear, reporting policies may not be in place, and employees may simply believe that assaults are part of the job (Ray, 2007). Staff also may fear that reporting an assault will be construed as poor job performance (Gacki-Smith, 2009).

Preventing Violence Zero-Tolerance Policies The health care organization should cultivate a culture of intolerance to violence and set its vio- lence prevention policies to reflect that position (Gates, Gillespie, & Succop, 2011). Appropri- ate personnel policies must state clearly what will happen if violence or the threat of violence occurs. Policies regarding patients and visitors must do the same. Specifically, anyone who be- comes violent or who exhibits threatening behavior must be removed from the setting and the authorities contacted.

Questions to ask when developing policies regarding violence prevention are shown in Box 23-1.

Reporting and Education Employees must be educated to recognize the warning signs of violence and potential assailants or agitators, and be taught conflict resolution skills and de-escalation tactics. They should also be alerted to use care when storing health instruments (stethoscopes, hemostats, scissors) that could be used as weapons.

Once adequate policies are in place, employees must be informed about them so that they are prepared in case of an event or crisis. In addition, they need to know how to report and to whom to report as well as how to document problem situations. Employees should be reassured that reporting threatening behavior will not result in reprisals.

Environmental Controls The organization should institute environmental controls to ensure patient, visitor, and employee safety. These include:

● Adequate lighting ● Security devices ● Bullet-resistant barriers in the emergency department ● Curved mirrors in hallways

BOX 23-1 Preventing Violence: Questions to Ask

● Does your facility have a clear reporting procedure in the event that there’s a workplace aggression incident?

● Whom does the staff inform of its concerns? ● What are the repercussions should individuals

report an incident that makes them uneasy?

● Does your facility offer a mental health support program for staff? Is it effective in helping to reduce employee stress?

● When someone voices a concern to supervisory staff, is action taken to address the problem quickly?

From: DelBel, J. C. (2003). De-escalating workplace aggression. Nursing Management, 34(9), 30–34.

CHAPTER 23 • PREVENTING WORKPLACE VIOLENCE 305

In addition, safe work practices should be implemented, such as:

● Escort services ● Adequate staffing ● Judicious use of restraints or seclusion ● Alerting staff about patients with histories of violent behavior, dementia, or intoxication

Dealing with Violence Verbal Intervention Verbal threats often precede a physically violent event; thus, all employees need to know tech- niques for reducing aggression in people who are making verbal threats. (See Box 23-2.)

When faced with a potentially violent situation, try to keep calm even when another person is screaming threats or abuse. Try to get the person away from others. A crowd might encourage the abuser, or the person might be afraid to “lose face” in the presence of others.

As you learned in Chapter 9, nonverbal communication is more powerful than your words, so watch your body language and keep a distance from the person. Use clear and direct words; anxiety could make it difficult for the person to comprehend. Reflect the person’s words back; this lets the person know that you hear him or her. Silence is often effective because it forces the person to think about what is being said and may be calming in itself. Finally, keep your tone of voice calm, keep your volume normal, and slow your rate of speech. Together, these strategies may reduce the person’s anxiety and aggression (Gates, Gillespie, & Succop, 2011).

A Violent Incident In spite of all that an organization and individuals do to try to prevent violence, the person’s ag- gression may escalate. In the event that such a situation occurs, the organization should make certain that all employees are prepared. Each employee should:

● Recognize the signs of escalating violence ● Know the organization’s violence policies ● Be prepared to protect their patients, their visitors, and themselves

Every employee should learn how to watch for threatening behaviors to evaluate when a person is likely to become violent. Law enforcement personnel recommend watching for these behaviors:

● Clenched fists ● Blank stare ● Fighting stance (one foot back with arm pulled back ready to strike) ● Arms raised in a fighting position ● Standing too close or advancing toward you ● Holding anything that might be used as a weapon, such as a pen, letter opener, heavy

object, or an actual weapon—a gun or knife ● Overt intent (saying that they intend to “kick your —,” or similar statements) ● Movement toward the exit to prevent you from leaving (Sullivan, 2013)

BOX 23-2 Verbal Intervention Strategies

1. Remain calm. 2. Isolate the individual. 3. Watch your body language. 4. Keep it simple.

5. Use reflective questioning. 6. Embrace silence. 7. Maintain moderation in speech.

From: DelBel, J. C. (2003). De-escalating workplace aggression. Nursing Management, 34(9), 30–34.

306 PART 3 • MANAGING RESOURCES

When these threatening behaviors are present, or if the person becomes physically violent, you must protect your patients, visitors, other staff, and yourself. Contact security immediately and follow the steps in Box 23-3.

Other Dangerous Incidents An infant abduction, a bomb threat, or a gun on the unit are some examples of other dangerous incidents that could occur. Most organizations now have a specific code to alert staff to a po- tential or real infant abduction, such as Code Pink, and many hospitals now also place security bands on babies and parents to prevent a baby being abducted from the nursing unit.

Policies are in place in most hospitals to address bomb threats or a gun on the unit and the procedures to follow, and the staff are trained to call the hospital’s 911 number. Other threats also use specific codes for alerting security and obtaining assistance. In addition, drills for infant abductions, bomb threats, and firearms on the unit are practiced on a routine basis and included in yearly competency testing for employees. Keeping patients safe is always the focus.

Post-Incident Follow-Up After a violent incident, everyone involved will suffer some degree of emotional, if not physical, trauma. Gates, Gillespie, and Succop (2011) found that 94 percent of emergency department nurses experienced at least one symptom of posttraumatic stress disorder (PTSD) following an incident of violence, with 17 percent diagnosed with probable PTSD.

Post-incident follow-up is essential for the well-being of patients, visitors, and staff mem- bers. The steps to take are shown in Box 23-4.

A nurse manager used the steps in handling a violent incident and its follow-up in Case Study 23-1.

Violence in the workplace is a reality of life today, but organizations and individuals can take steps to reduce potential threats. Because the nursing shortage is continuing, and because nurses and women are more likely to be attacked, organizations must take all the necessary steps to ensure that their nurses are kept safe from harm. Additionally, nurses themselves must be in- formed about how to recognize potential threats and how to prevent violence from escalating. In this way violence may be prevented or, at the least, reduced.

BOX 23-3 How to Handle a Violent Incident

1. Notify security immediately. 2. Never try to disarm someone with a weapon.

3. If not armed, enlist staff help in restraining a violent person.

4. Put a barrier between you and the violent person.

BOX 23-4 How to Handle Post-Incident Follow-Up

1. Be certain that everyone is safe following a violent event.

2. Arrange immediate treatment for the injured. 3. Complete injury and incident reports. 4. Follow up with human resources regarding the

worker’s compensation process for the injured employees.

5. Contact security to determine if a police report should be filed.

6. Contact the injured employee at home to express concern for the person’s well-being and follow up with any questions the person may have.

CHAPTER 23 • PREVENTING WORKPLACE VIOLENCE 307

WORKPLACE VIOLENCE Melanie Sanchez is nurse manager of a 30-bed skilled nursing unit (SNU) in an urban hospital. Patient confu- sion and aggression are not uncommon occurrences for her staff. Nursing and assistive staff have been trained on conflict resolution and methods for dealing with ag- gressive patients.

Sandra Porter, RN, has worked in the SNU for the past six years. Today, while administering medication to pa- tients before lunch in the common dining room, Sandra noticed a newly admitted patient, Mr. B, yelling obsceni- ties at another staff member. Sandra secured her medi- cation cart and came to the aid of the nursing assistant. Sandra attempted to verbally de-escalate the situation, but Mr. B became increasingly aggressive. When Sandra turned to instruct the nursing assistant to clear patients from the dining room, Mr. B. picked up a chair and struck Sandra in the arm and shoulder. The nursing assis- tant alerted Melanie and several nurses to the problem. Melanie immediately called the hospital operator to request that security respond to a violent patient on the SNU. Upon entering the dining room, nursing staff were able to restrain Mr. B while Melanie accompanied Sandra to the emergency department for treatment of her injuries. Sandra sustained a broken arm, a laceration to her shoulder, and several contusions.

As soon as Sandra’s injuries were treated and she was released from the emergency department, Melanie contacted the medical/surgical nursing division director and the human resources department about the assault and filled out an incident report. She also completed an injury report for Sandra’s worker’s compensation claim. Melanie contacted the security department and requested

a meeting with the security director to determine if a police report should be filed regarding Mr. B’s assault of Sandra. The next day, Melanie contacted Sandra at home and informed her that a case manager from hu- man resources would call her within the week regarding her worker’s compensation claim. Melanie also checked to see how Sandra was doing and encouraged her to call Melanie directly if she had questions or concerns.

Manager’s Checklist The nurse manager is responsible for:

● Ensuring that appropriate action is taken to secure the safety and well-being of the injured employee, patients, and other staff immediately following a workplace violence incident

● Securing immediate and appropriate treatment for the injured employee

● Informing administration and human resources departments of the incident

● Completing required injury and incident reports in a timely manner

● Following up with human resources regarding the worker’s compensation process for the injured employee

● Contacting security to determine if a police report should be filed regarding the incident.

● Contacting the injured employee at home to express concern for their well-being and follow up with any questions they may have

● Ensuring any scheduling problems due to the injured employee’s absence are resolved

CASE STUDY 23-1

What You Know Now • Health care organizations are vulnerable to violence in the workplace, but incidents of violence may be

underreported. • Risk factors for violence in health care organizations include understaffing, patient conditions, family

members’ anxiety, unlimited public access, inadequate security, and an unsafe physical environment. • The organization should establish a zero-tolerance for violence policy and make certain that all employees

know it. • All employees should be able to recognize potential threats and the warning signs of violence. • All employees should know how to report threats and threatening behavior, to whom to report such

episodes, and how to document the incidents. • Employees should be assured that reporting potential threats will not result in reprisals. • All employees should know the steps to take if a violent incident occurs.

308 PART 3 • MANAGING RESOURCES

Tools for Preparing for Emergencies and Preventing Violence 1. Recognize potential threats and threatening behavior and how to report them. 2. Alert staff and administration to these threats. 3. Know how to respond to a person who becomes violent. 4. Know what to do following a violent incident. 5. Monitor the environment for dangerous areas and report your observations to administration. 6. Remain alert for potential violence and instruct staff to stay vigilant.

Questions to Challenge You 1. Evaluate your current workplace or clinical site. See if you can find potential opportunities that

would allow violence to occur. Describe them. 2. Ask to see the workplace violence policies at your school, clinical site, and/or workplace. Evaluate

them. Are they adequate? Can you suggest changes? 3. Have you ever been the victim of violence or threats of violence? How did you handle the event and

its aftermath? Would you do something differently now? How did the authorities respond? Could you suggest changes for them?

4. Are you aware of specific action that your school, workplace, or clinical site has done to protect people from violence? What more could you suggest?

References

DelBel, J. C. (2003). De- escalating workplace aggression. Nursing Management, 34(9), 30–34.

Gacki-Smith, Juarez, A. M., Boyett, L., Homeyer, C., Robinson, L., & MacLean, S. L. (2009). Violence against nurses working in U.S. emergency departments. Journal of Nursing Administration, 39(7/8), 340–349.

Gates, D., Gillespie, G., Smith, C., Rode, J., Kowalenko, T., & Smith, B. (2011). Using action research to plan a vi- olence prevention program for emergency departments.

Journal of Emergency Nurs- ing, 37(1), 32–39.

Gates, D. M., Gillespie, G. L., & Succop, P. (2011). Violence against nurses and its im- pact on stress and produc- tivity. Nursing Economics, 29(2), 59–66.

Howard, P. K., & Gilboy, N. (2009). Workplace violence. Advanced Emergency Nurs- ing Journal, 31(2), 94–100.

Nachreiner, N. M., Hansen, H. E., Okano, A., Gerberich, S. G., Ryan, A. D., McGovern, P. M., Church, T. R., & Watt, G. D. (2007). Difference in work-related violence by nurse license type. Journal

of Professional Nursing, 23(5), 290–300.

Pollack, K. M., McKay, T., Cumminskey, C., Clinton- Sherrod, A. M., Lindquist, C. H., Lasater, B. M., Hardison Walters, J. L., Krotki, K., & Grisso, J. A. (2010). Employee assis- tance program services of intimate partner violence and client satisfaction with these services. Journal of Occupational and Environ- mental Medicine, 52(8), 819–826.

Ray, M. M. (2007). The dark side of the job: Violence in the emergency department.

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

www.nursing.pearsonhighered.com

CHAPTER 23 • PREVENTING WORKPLACE VIOLENCE 309

Journal of Emergency Nurs- ing, 33(3), 257–261.

Sullivan, E. J. (2013). Becom- ing influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall.

U.S. Department of Labor, Bu- reau of Labor Statistics.

(2009). Nonfatal occupa- tional injuries and illnesses requiring days away from work, 2009. Retrieved Au- gust 24, 2011 from http:// www.bls.gov/news.release/ osh2.nr0.htm

U.S. Department of Health and Human Services.

(2008). Understanding and responding to workplace violence. Washington, DC: U.S. Department of Health and Human Services.

http://www.bls.gov/news.release/osh2.nr0.htm

Collective bargaining

Key Terms

1. Discuss the laws that govern collective bargaining.

2. Describe the nurse manager’s role in collective bargaining.

3. Explain what is involved in the grievance process.

4. Describe the legal issues involved for nurses.

5. Discuss the future of nursing unions.

Learning Outcomes After completing this chapter, you will be able to:

Laws Governing Unions

Process of Unionization THE GRIEVANCE PROCESS

THE NURSE MANAGER’S ROLE

Status of Collective Bargaining for Nurses LEGAL STATUS OF NURSING UNIONS

THE FUTURE OF COLLECTIVE BARGAINING FOR NURSES

Handling Collective Bargaining Issues24

CHAPTER

Grievances Strike

CHAPTER 24 • HANDLING COLLECTIVE BARGAINING ISSUES 311

Laws Governing Unions Before federal laws governing labor relations in this country were enacted, disputes between the owners or managers of a company and the company’s labor force were settled by the judiciary branch of government. During this period of American history, the courts often ruled that collective bargaining, collective action taken by workers to secure better wages or working conditions, was illegal. Today, however, labor laws enacted by Congress, decisions by the U.S. Supreme Court, and the National Labor Relations Board (NLRB) guide labor relations between employers and employees.

Since enactment of the National Labor Relations Act in 1935, nurses and other employees of private, for-profit health care institutions have been protected in their right to organize for col- lective bargaining purposes. Under the provisions of the act, as amended in 1974, employees of voluntary, not-for-profit health care institutions also were granted the same rights and protections.

In the United States, a closed shop is a business in which union membership (often of a spe- cific union and no other) is a precondition to employment. An open shop is a business in which union membership is not a component in hiring decisions and union members don’t receive any preference in hiring.

A right-to-work state is a state in which no person can be denied the right to work because of membership or nonmembership in a labor union. Trade unions and employers cannot make membership in a union or payment of union dues or “fees” a condition of employment, either before or after hiring.

Collective bargaining laws differ depending on if the nurses are employed in the private sector in either nonprofit or for-profit organizations or if they are employed in the public sector as city, county, state, or federal employees. Negotiations may be classified as mandatory, prohib- ited, or permissive. Parties are obligated to negotiate on mandatory subjects of bargaining.

In the private sector, wages, hours, and other terms and conditions of work are considered mandatory subjects for negotiation. In the public sector, the scope of mandatory subjects of bar- gaining is often far narrower.

The Civil Service Reform Act of 1978 gave certain federal employees the right to organize, bargain collectively, and participate through labor organizations of their choice in decisions af- fecting their work environment, although it depends on what federal agency is their employer. Wages—a mandatory item in the private sector—is a prohibited subject.

State or local employees, however, fall under state regulations, which vary greatly from state to state. Nurses in state hospitals, for example, would be governed by their state laws. Some states don’t allow employees to strike or form collective bargaining units; other states don’t allow wages or overtime pay to be part of a union contract.

Process of Unionization The process of establishing a union in any setting begins when at least 30 percent of eligible employ- ees sign a card to indicate interest in a union. Then the union petitions the National Labor Relations Board (NLRB) to conduct an election. The NLRB meets with both the union and the employer. At the conclusion of this meeting, the NLRB will determine who is eligible to participate in the union, establish that the signers are employees of the organization, and set a date for the union election.

The process of selecting a bargaining agent produces a tense, emotional climate that af- fects everyone in the organization. Both nurse managers and staff nurses need to remember that during this period, the rules of unfair labor practice apply. Managers must refrain from any ac- tion that could be seen as interfering with the employees’ right to determine their collective bargaining representative. Such actions include individually questioning staff nurses about their knowledge of collective bargaining activities and making promises or threats to individual staff members based on the outcome of the election.

Staff nurses also must be careful that their discussions regarding collective bargaining take place away from the work site and not on work time. Nor may employees use their employer’s e-mail system to communicate about unionizing activities.

312 PART 3 • MANAGING RESOURCES

Certification by the NLRB of a union to be the bargaining agent does not automatically mean employees have a contract. The contract is considered to be in effect when both manage- ment of the organization and employees agree on its content. The final agreement is subject to a ratification vote by a simple majority of eligible members who vote.

The role of administering the contract then falls to an individual designated as the union representative. This individual may be an employee of the union or a member of the nursing staff.

The Grievance Process The grievance procedure will be specified in the agreement and will contain a series of progres- sive steps and time limits for submission/resolution of grievances. Grievances are formal com- plaints that may be caused by misunderstandings, a lack of familiarity with the contract, or an inadequate labor agreement.

To ensure that there is a balance between the rights of employees and the rights of the public to health care, Congress passed a special set of dispute-settling procedures to be applied in the health care industry:

1. Before changing or terminating a contract, one party must notify the other of its intent to do so 90 days prior to the contract expiration date. This is 30 days more than specified for other industries.

2. If after 30 days of this notification both sides cannot agree, then the Federal Mediation and Conciliation Service (FMCS) must be notified.

3. The FMCS will appoint either a mediator or an inquiry board within 30 days.

4. The mediator or board must make recommendations within 15 days.

5. If after 15 more days both sides cannot agree, then a strike vote can be conducted and a strike, the organized stoppage of work by employees, can be scheduled.

If a strike vote is affirmed, then a 10-day written notice must be given to management indi- cating the date, time, and place of the strike. This is to ensure that a hospital has adequate time to provide for continuity of patient care in the event of a strike.

The Nurse Manager’s Role The nurse manager in a health care organization where nurses are organized into a collective bargaining unit needs to be aware of the five categories of unfair labor practices described by labor law (National Labor Relations Act [NLRA], Sec. 9[e]2).

1. Interference with the right to organize

2. Domination

3. Encouraging or discouraging union membership

4. Discharging an employee for giving testimony or filing a charge with the NLRB

5. Refusal to bargain collectively

Another responsibility of the manager is to participate in resolving grievances, using the agreed-upon grievance procedure. Grievances can usually be classified as:

1. Contract violations

2. Violations of federal or state law

3. Failure of management to meet its responsibilities

4. Violation of agency rules

CHAPTER 24 • HANDLING COLLECTIVE BARGAINING ISSUES 313

See how one nurse manager handled discipline in a hospital with a collective bargaining agreement in Case Study 24-1.

Status of Collective Bargaining for Nurses The majority of American nurses do not work under a collective bargaining agreement, but those that do have higher salaries (Albro, 2008) and are more often satisfied with their wages (Pittman, 2007). Conversely, nurses who do not work in unionized hospitals are more satisfied with their jobs but less satisfied with their pay (Pittman, 2007). Seago and colleagues (2011) posit, how- ever, that union nurses may simply be more willing to voice their dissatisfaction.

The challenge then in a collective bargaining environment is to retain high-performing nurses and help them become more satisfied with their jobs (Lawson et al., 2011). Partnering nursing staff with management personnel is one strategy to improve nurse retention. For exam- ple, After a partnership between nursing and management was established at a Magnet-certified institution, turnover decreased and satisfaction improved (Porter, 2010; Porter et al., 2010). Such partnerships are supported by the trend toward labor-management partnerships in other occupa- tional sectors (Hayter, Fashoyin, & Kochan, 2011).

Legal Status of Nursing Unions Three areas of supervision over subordinates have been under debate for a number of years. These are:

1. The responsibility to assign

2. The responsibility to direct

3. Independent judgment

DISCIPLINE PROCEDURE IN A HOSPITAL WITH COLLECTIVE BARGAINING UNIT Maria Sanchez is the nurse manager for 4 south pedi- atrics in a university medical center hospital, where the nurses established a collective bargaining agreement with the hospital several years ago. Maria has a disci- plinary problem with Tia, a staff nurse, about not com- pleting intake and output documentation or vital sign documentation on her patients during her last shift. Maria notes that Tia had a friendly reminder about fail- ing to complete documentation last month. Per hospital policy, Susan, as Tia’s manager, must complete verbal counseling with Tia.

During recent union negotiations between the hos- pital and the nursing union, it was agreed that when a verbal counseling is needed, the manager must for- mally say to the staff member, “I am providing you with verbal counseling today about your performance. This is official, will be documented in your file, and if you fail to meet the expectation, the next step in this pro- cess is a written notice of warning about failure to meet your job expectations. Do you have any questions about

the verbal counseling process before we proceed?” The manager then continues with the verbal counseling about the unmet specific performance issue and policies.

Maria follows the guidelines established in the cur- rent agreement in her meeting with Tia, and Tia agrees that she has not been consistent in completing docu- mentation. Tia agrees that Maria should monitor her performance for a week, when they will meet again to determine if Tia has been completing documentation appropriately and consistently.

Manager’s Checklist The nurse manager is responsible for:

● Preparing notes about the verbal counseling session ● Meeting with employee for verbal counseling session ● Discussing expectations that were not met ● Reviewing policies and guidelines relating to unmet

expectations ● Answering employee questions ● Providing coaching as needed

CASE STUDY 24-1

314 PART 3 • MANAGING RESOURCES

The NLRB issued several landmark decisions regarding the supervisory status of nurses (NLRB, 2006). Three cases were considered together and have become known as the Kentucky River trilogy. They are Oakwood Healthcare, Inc., Golden Crest Healthcare Center, and Croft Metal, Inc. These rulings are important to nurses because those employees deemed as supervi- sors are prohibited from joining a union.

The NLRB clearly defined the supervisory status of nurses in its ruling in 2006, and that ruling stands today (NLRB, 2006). It ruled that:

1. The responsibility to assign includes nurses’ responsibility to assign other nurses and assistants to patients.

2. The responsibility to direct includes the responsibility for the actions of those to whom tasks have been assigned.

3. Independent judgment includes the nurse’s decision to match staff skills to patient needs.

This ruling has an impact on the eligibility of many nurses who heretofore were not con- sidered supervisors and were thus eligible to be members of a collective bargaining unit. Nurses who are charge nurses either permanently or part-time on a regular basis and who meet the above criteria for assigning, directing, and using independent judgment are considered supervi- sors and therefore are not eligible to join a union (NLRB, 2006).

Complicating the collective bargaining issue today are numerous other efforts to organize nurses. National Nurses United has affiliate organizations in 12 states plus the District of Colum- bia, the Virgin Islands, and Veterans Affairs. United American Nurses is an AFL/CIO affiliate. In addition, employees of individual health care organizations often form their own collective bar- gaining organization and include nurses. Nurses at some health care organizations have formed their own union. So, collective bargaining in nursing runs the gamut from national collaboration of state organizations, to coordination with other employees in health care, to individual units of nurses.

The Future of Collective Bargaining for Nurses The use of collective bargaining as a way for nurses to influence the practice environment and to ensure their economic security presents both concerns and promises, especially with the radical changes occurring in health care today. The concerns are that the very processes of collective bargaining separate rather than unite nurses, notably between staff nurses and those in manage- ment. What the future holds for collective bargaining in nursing is uncertain and unknown.

What You Know Now • Laws governing unions are administered by the National Labor Relations Board. • Subjects for union negotiations may be mandatory, prohibited, or permissive. • Private sector subjects differ from public ones, which are generally more restrictive. • The process of unionization involves selecting a bargaining agent, developing a contract and administering

the contract. • The nurse manager may not interfere in union organizing, but may be involved in resolving grievances. • Most nurses do not work under collective bargaining agreements. • The future of collective bargaining for nurses is uncertain and unknown.

Tools for Handling Collective Bargaining Issues 1. Determine if your organization has a collective bargaining arrangement with its registered nurse

employees. 2. If so, become familiar with provisions of the policy and grievance procedure. 3. Contact administration for any questions you may have with contract policies.

CHAPTER 24 • HANDLING COLLECTIVE BARGAINING ISSUES 315

4. If your organization does not have a union contract, be aware of the possibility that efforts to estab- lish a collective bargaining unit may be initiated.

5. If attempts are made to unionize your workplace, obtain information on the legal obligations you have as an employee and/or manager.

6. Remember, collective bargaining is an agreement between an employer and its employees; it does not need to be adversarial.

Questions to Challenge You 1. Are you a member of a collective bargaining unit? Do you know anyone who is? 2. Have you been involved in union organizing? What happened during and after the process? 3. If you have not been involved in union organizing, find someone who has been and ask what

happened. 4. What is your opinion of unions for nurses? Name the pros and cons. 5. You are negotiating a union contract on behalf of the nurses. List your demands in priority order. 6. You are negotiating a union contract on behalf of administration. Respond to the demands on your

list generated in question 5.

References

Albro, A. (2008). “Rubbing salt in the wound”: As nurses battle with a nationwide staffing shortage, an NLRB decision threaten to limit the ability of nurses to unionize. Northwestern Journal of Law and Social Policy, 3(1), 103–130.

Hayter, S., Fashoyin, T., & Kochan, T. A. (2011). Col- lective bargaining for the 21st century. Journal of Industrial Relations, 53(2), 225–247.

Lawson, L. D., Miles, K. S., Vallish, R. O., & Jenkins, S. A. (2011). Recognizing nursing professional growth and

development in a collective bargaining environment. Journal of Nursing Admin- istration, 41(5), 197–200.

National Labor Relations Board (NLRB). (2006). Annual report of the National Labor Relations Board. Retrieved August 29, 2011 from http://www.nlrb.gov/sites/ default/files/ documents/119/ nlrb2006.pdf

Pittman, J. (2007). Registered nurse job satisfaction and collective bargaining unit membership status. Journal of Nursing Administration, 37(10), 471–476.

Porter, C. (2010). A nurs- ing labor management

partnership model. Journal of Nursing Administration, 40(6), 272–276.

Porter, C. A., Kolcaba, K., McNulty, S. R., & Fitzpatrick, J. J. (2010). The effect of a nursing labor management partnership on nurse turnover and sat- isfaction. Journal of Nurs- ing Administration, 40(5), 205–210.

Seago, J. A., Spetz, J., Ash, M., Herrara, C. N., & Keane, D. (2011). Hospital RN job satisfaction and nurse unions. Journal of Nurs- ing Administration, 41(3), 109–114.

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

http://www.nlrb.gov/sites/default/files/documents/119/nlrb2006.pdf

www.nursing.pearsonhighered.com

Burnout Compassion fatigue Reality shock

Key Terms

1. Explain why stress is necessary. 2. Describe the organizational, interpersonal,

and individual factors that cause stress. 3. Explain the consequences that result from

stress, including burnout and compassion fatigue.

4. Discuss how individuals can manage stress. 5. Discuss how managers can help themselves

and their staff manage stress. 6. Explain how organizations can help reduce

stress in the workplace.

Learning Outcomes After completing this chapter, you will be able to:

The Nature of Stress

Causes of Stress ORGANIZATIONAL FACTORS

INTERPERSONAL FACTORS

INDIVIDUAL FACTORS

Consequences of Stress

Managing Stress PERSONAL METHODS

ORGANIZATIONAL METHODS

Managing Stress25 CHAPTER

Role ambiguity Role conflict

Role redefinition Stress

CHAPTER 25 • MANAGING STRESS 317

Consider the following scenario: Keandra is a medical nurse with 10 years’ experience. She is married and has two

children under the age of 6 who attend preschool while she is at work. As a nurse manager, Keandra has 24-hour responsibility for supervision of two 30-bed medical units. She fre- quently receives calls from the unit nurses during the evenings and nights, and approxi- mately once a week she has to return to the unit to intervene in a situation or replace nurses who are absent. Keandra is responsible for scheduling all the nurses on her unit and has no approval to use agency nurses, in spite of a 20 percent vacancy rate. In ad- dition, Keandra serves on four departmental committees and the hospital task force on consumer relations. She consistently takes work home, including performance appraisals, quality assessment reports, and professional journals. Although Keandra has an office, she has little opportunity to use it because of constant interruptions from nurses, physicians, other departmental leaders, and her clinical director. Recently, Keandra saw her family physician, complaining of persistent headaches, weight loss, and a feeling of constant fa- tigue. After a complete diagnostic workup, she was found to have a slightly elevated blood pressure, with a resting pulse of 100. Her physician prescribed an exercise program, and she was advised to lighten her workload, take a vacation, and reduce her stress level.

Stress is the nonspecific reaction that people have to demands from the environment that pose a threat. Stress results when two or more incompatible demands on the body cause a con- flict. Recognized as the pioneer of stress research, Selye (1978) suggests that the body’s wear and tear results from its response to normal stressors. The rate and intensity of damage increase when an organism experiences greater stress than it is capable of accommodating.

Selye maintains that the physiological response to stress is the same whether the stressor is positive, eustress, or negative, distress. It is easy to see how negative events, such as job loss, can cause stress. However, positive events also may cause stress.

Anthony was the director of nursing for critical care in a 400-bed hospital. He was of- fered the opportunity to develop a hyperbaric unit. In assuming the additional responsibil- ity, Anthony began putting in long hours and working weekends. As the project progressed, Anthony became unable to sleep and gained 10 pounds. After the unit opened, Anthony’s sleep pattern and weight returned to normal. Clearly, Anthony displayed emotional and physical signs of stress although he was experiencing a “positive” promotion and career opportunity.

A certain amount of stress is essential to sustain life, and moderate amounts serve as stimuli to performance; however, overpowering stress can cause a person to respond in a maladaptive physiological or psychological manner.

The Nature of Stress A balance must exist between stress and the capability to handle it. When the degree of stress is equal to the degree of ability to accommodate it, the organism is in a state of equilibrium. Normal wear and tear occur, but sustained damage does not. When the degree of stress is greater than the available coping mechanism, the individual experiences negative aspects of stress. The situation is often described metaphorically through such statements as “carrying a load on one’s shoulders” or “bearing a heavy burden.” This often leads to physiological and psychological problems for the person and poor performance for the organization. When the degree of stress is not stimulating enough, lack of interest, apathy, boredom, low motivation, and even poor perfor- mance can result.

318 PART 4 • TAKING CARE OF YOURSELF

The experience of stress is subjective and individualized. One person’s stressful event is another’s challenge. One individual can experience an event, positive or negative, that would prove overwhelming for someone else. Even a minor change in organizational policy may cause some individuals to experience stress, whereas others welcome it. Some nurses seem to thrive on the demands of work, family, school, and community involvement, whereas others find even minimal changes in their expectations a source of great discomfort.

For nurses, stress in the workplace can develop from several sources and may be due to or- ganizational, interpersonal, or individual (intrapersonal) factors.

Causes of Stress Organizational Factors Stress can result from job-related factors, such as task overload, conflicting tasks, inability to do the tasks assigned because of lack of preparation or experience, and unclear or insufficient in- formation regarding the assignment. Nurses’ jobs are often performed in life-or-death situations; emergencies may cause periods of extreme overload.

The physical environment may also be stressful. Consider the intensive care unit with its constant alarms, beeps, and other noises. Studying the effect of environmental factors (e.g., odor, noise, light, and color) on nurses’ stress, Applebaum and colleagues found that noise, in particular, correlated with stress, job dissatisfaction, and intent to leave (Applebaum et al., 2010). Besides noise levels, lighting and other comfort factors may increase stress within the environment. Tight quarters, poorly organized work environments, and lack of equipment also augment stress levels.

Nurse managers’ stress was studied by Shirey and associates (Shirey et al., 2010). They found that experienced nurse managers used a combination of emotion-focused and problem- centered coping strategies to handle stress and had fewer negative outcomes from stress than novice managers. Furthermore, novice managers reported experiencing more physical exhaus- tion, sleep problems, and hypertension than their more experienced colleagues.

Other organizational factors that can lead to stress include organizational norms and ex- pectations that conflict with an individual’s needs. Managers trying to do more with less, over- worked staff, and more acutely ill patients can lead to an organizational environment that by its very nature is stressful. New technology, increased expectations from patients and their families, liability concerns, and increased pressures for efficiency, in addition to the dramatic changes in health care proposed by health care reform legislation, promise to increase stress in nursing and make the role of nurses and nurse managers more difficult, conflicting, and stressful.

Interpersonal Factors To add to the pressures created by organizational changes, nurses must contend with strained interpersonal relationships with other health care professionals and administrators. Interprofes- sional difficulties may precipitate tension. As resources in health care continue to shrink, nurses are being asked or told to assume responsibility for tasks that had been performed by other departments (e.g., phlebotomy, electrocardiography, respiratory therapy).

In a rehabilitation setting, therapists expect the patients to be bathed, to have eaten breakfast, and to be dressed and ready to start therapy by 8:30 A.M. This expectation places undue stress on rehabilitation nurses, who must motivate patients who complain that they have had far too little sleep. Here is another example of stress due to interpro- fessional conflict: a radiology technician responds to a 9:00 P.M. page for a chest X-ray examination and informs the registered nurse that the patient will have to be brought back down because the radiology department is understaffed.

CHAPTER 25 • MANAGING STRESS 319

Interactions between physicians and nurses are often strained. Most nurses have experi- enced an irate response from a physician who is awakened during the night for something the physician thinks should have been handled earlier or might have waited until morning.

An internist in a small community hospital was well known for his outbursts during middle-of-the-night calls. One experienced nurse dealt with necessary calls to him by di- rectly stating when he answered the phone, “This is Jane Jones from St. Matthew’s. I have two important things to tell you about Mrs. Smith. . . .” This helped the internist focus on the problem at hand and eliminated his outbursts.

The need to fulfill multiple roles is another source of stress. A role is a set of expectations about behavior ascribed to a specific position in society (e.g., nurse, spouse, parent). Conflict between family and professional roles results in stress. Adding to stress is the shift and weekend work required in nursing jobs in hospitals that must be staffed 24 hours a day, seven days a week.

Nurses who work on evening or night shifts may experience family problems if their spouse and children are on different schedules, especially if the nurse rotates shifts. It takes several weeks to adjust physiologically to a change in shifts; however, rotation patterns often require nurses to change shifts several times a month. Managers can reduce the physiological pressure by ensur- ing that nurses receive adequate rest and work breaks, rotating staff only between two shifts, and never scheduling “double backs” (working eight hours, off eight hours, working eight hours).

Individual Factors Stress can result from personal factors as well. One of these factors is the rate of life change. Changes throughout life, such as marriage, pregnancy, or purchasing a new home, generate stress. Each individual responds to stress differently, but the cumulative effects of stress often lead to the onset of disease or illness. The ways people interpret events ultimately determine whether the person sees the event as stressful or as a positive challenge.

New graduates, for example, often do not recognize that they have demonstrated a definitive set of skills and knowledge in having passed all the requirements to become a registered nurse. The stress they experience when changing from the student role to the professional practitioner role has been explained by Kramer (1974) as reality shock. When students move from a familiar school culture to a work culture—where values, rewards, and sanctions are different and often seem illogical—they experience surprise and disequilibrium.

Moving from a staff nurse position to management also creates surprise and disequilibrium. New managers often experience a sense of isolation from the peer group of staff nurses who previously provided support. Doing a job and directing others to do a job are different. Directing others is stressful, and a person may be tempted to believe that it will be faster to complete a task by doing it herself or himself.

Role ambiguity results from unclear expectations for one’s performance. Individuals with high tolerances for ambiguity can deal better with the strains that come from uncertainties and, therefore, are likely to be able to cope with role ambiguity. Role underload and underutilization can also occur. Being underutilized or not having much responsibility may be seen as stressful by a person who is a high achiever or who has high self-esteem.

Role conflict is the result of incompatibility between the individual’s perception of the role and its actual requirements. Novice nurse managers experience this type of conflict when they find that administration expects primary loyalty to the organization and its goals, whereas the staff expects the nurse manager’s first loyalty to be to their needs.

Role conflicts also occur when an individual has two competing roles, such as when a nurse manager both assumes a patient care assignment and needs to attend a leadership meeting. An- other example is the conflict between nurses’ personal roles as parents or spouses versus their roles as professional nurses.

320 PART 4 • TAKING CARE OF YOURSELF

Consequences of Stress What happens to a person when he or she experiences stress overload? Both physiological and psychological responses can cause structural or functional changes, or both. The warning signs of too much stress include:

● Undue, prolonged anxiety; phobias; or a persistent state of fear or free-floating anxiety that seems to have many alternating causes

● Depression, which causes people to withdraw from family and friends; an inability to experience emotions; a feeling of helplessness to change the situation

● Abrupt changes in mood and behavior, which may be exhibited as erratic behavior ● Perfectionism, which is the setting of unreasonably high standards for oneself and leads to

a feeling of constant stress ● Physical illnesses, such as an ulcer, arthritis, colitis, hypertension, myocardial infarction,

and migraine headaches

Ineffective coping methods for reducing stress include excessive use of alcohol and other mood-altering substances, which can result in substance abuse or dependence (Epstein, 2010). Some people become workaholics in an attempt to cope with real or imagined demands.

The term burnout refers to the perception that an individual has used up all of his or her avail- able energy to perform the job and feels that he or she doesn’t have enough energy to complete the task (Epstein, 2010). Burnout is a combination of physical fatigue, emotional exhaustion, and cogni- tive weariness. As a result, the individual may reduce hours worked or change to another profession.

Compassion fatigue is secondary traumatic stress experienced by caregivers (Newsom, 2010). Similar to posttraumatic stress disorder, the term includes those involved in caring for others who are suffering from physical or emotional pain (Yoder, 2010). Symptoms are similar to those of burnout, but may be more severe if the caregiver is providing care to those traumatized by crime, war, and war-related traumatic stress or are emergency workers or first responders.

Additionally, nurses themselves may experience posttraumatic stress disorders (PTSD). Gates, Gillespie, and Succop (2011) found that 17 percent of emergency room nurses who had been involved in a violent incidence were symptomatic for PTSD.

Job performance suffers during times of high stress; so much energy and attention are needed to manage the stress that little energy is available for performance. In addition, increased absenteeism and turnover may result. Although there are various causes of absenteeism and turn- over (see Chapter 20), both may occur when the individual attempts to withdraw from a stressful situation. Such a situation is financially costly in industry but even more costly in human health and well-being.

A director of nursing at a 120-bed nursing home stated that she could no longer handle the overwhelming needs of the patients; the ever-present shortage of qualified, caring nurses; and the consistently dwindling resources. When a for-profit chain purchased the home and further reduced economic resources, the director of nursing left to become a real estate agent.

Managing Stress We will always have factors in our lives that create stress. To manage those factors effectively and keep stress at levels that enhance one’s performance rather than deplete energy, the key is to develop some resiliency. To accomplish this requires a comprehensive approach to managing stress, which involves planning, time, and energy.

Personal Methods One of the first steps in managing stress is to recognize stressors in the environment. Nurses tend to think they can be “all things to all people.” Therefore, it is important to improve one’s self- awareness regarding stressors.

CHAPTER 25 • MANAGING STRESS 321

Keeping your life in balance is difficult, but it can be done (Sullivan, 2013). Effective habits include role redefinition, time management, and self-care. Development of interpersonal skills and identifying and nurturing social supports can also facilitate stress management.

Role redefinition involves clarifying roles and attempting to integrate or tie together the various roles that individuals play. If there is role conflict or ambiguity, it is important to con- front others by pointing out conflicting messages. Role redefinition may also involve renegotia- tion of roles in an attempt to lessen overload.

Much of the stress that nurses and nurse managers experience results from the perception that staff, patient, and work-group needs must be met immediately and simultaneously. A no- table method of coping with and reducing this stress of time is through time management. We determine how, where, and when our time is used. Time is the essence of living, and it is the scarc- est resource. One lost hour a day every day for a year results in 260 hours of waste, or 6.5 weeks of missed opportunity, annually. (Strategies for time management are included in Chapter 13.)

Caring for yourself physically (e.g., eating a well-balanced diet, exercising regularly, get- ting adequate sleep) and developing effective mental habits are important self-care strategies for coping with stress. To be able to care for others, nurses need to replenish themselves and practice relaxation techniques. This is not easy, especially for an individual with a high-stress job. Some relaxation methods are listening to music, reading, and socializing with friends. Developing out- side interests, such as hobbies and recreational activities, can provide diversion and enjoyment and can also be a source of relaxation. Taking regular vacations, regardless of job pressures, is important for renewal and revitalization.

More personal strategies for keeping a balance in your life can be found in Chapter 14, “Balancing Your Life,” in Eleanor Sullivan’s book Becoming Influential: A Guide for Nurses, 2nd ed. (Prentice Hall, 2013).

Organizational Methods Nurse managers are often in the position of helping others identify their level of stress and stress- ors. If staff appear to be under a great deal of stress, the manager must help identify the source and decide how these can be reduced or eliminated. In addition to suggesting the techniques previously delineated, the manager should explore work-related sources of stress.

The manager must ask these questions:

● Is role ambiguity or conflict creating the stress? ● Can the manager help clarify individual staff members’ roles, thereby reducing the con-

flict or ambiguity? ● Is the manager using an appropriate leadership style? (See Chapter 4.) ● Does the manager need to clarify a staff member’s goals and eliminate barriers that are

interfering with goal attainment? Involving staff in decision making is one way to identify and reduce such stress.

● Is the stress due to feelings of low self-worth? ● Would additional training or education help reduce the stress? ● Would recognizing and reinforcing positive behaviors and accomplishments reduce stress? ● Can other sources of support, such as the work group, help the individual deal with stress? ● Is an employee assistance program with counseling services available in the organization?

When stress is job related, several strategies can be used. First, proper matching of the job with the applicant during the selection and hiring process is an important step in reducing stress (see Chapter 15). Adequate orientation about what to expect on the job and using more expe- rienced nurses as preceptors can reduce stress in novice nurses (Epstein, 2010). Skills training also reduces stress and promotes better performance and less turnover (see Chapter 17).

In addition, the organization can provide employee assistance programs (EAPs). Organizations that not only provide EAPs but promote their use in the organization report greater use of the service than organizations that promoted wellness and prevention instead of EAPs (Azzone et al., 2009).

322 PART 4 • TAKING CARE OF YOURSELF

Nurse managers can learn to recognize symptoms of stress-related problems among their staff and initiate referrals to EAPs. It is essential, however, to help remove the stigma about using such ser- vices (Epstein, 2010).

Communication and social support are additional factors in reducing stress. Both upward and downward communication channels should be open. Keeping personnel informed about what is going on in an organization helps reduce suspicion and rumor. Team building encourages staff to build a network of support with each other (see Chapter 11).

Policies that reduce the stress of shift work are also important. The number of hours in the night shift, weekend, and holiday work assignments also affects the level of stress. Providing adequate opportunities for breaks and meals is an important function of the organization.

Nurse managers are also vulnerable to stress. Shirey and colleagues found lower stress among nurse managers with more experience, those with a greater span of control, and those empowered by their chief nurse (Shirey et al., 2010). Thus, in addition to individual coping strategies, organizations can provide support for nurse managers and make them more likely to remain in their positions.

See Case Study 25-1 for an example of how one nurse managed her own stress and helped her staff manage theirs.

MANAGING STRESS Madeline Mears, RN, is nurse manager of emergency ser- vices and critical care units at two corporately owned sub- urban hospitals. The corporation recently purchased three not-for-profit hospitals located in the urban center of the metropolitan area. Madeline and several other nurse managers at the suburban hospitals have been informed by the vice president for patient care services that they will now be responsible for managing the same service lines at the newly acquired hospitals. Managers at the urban hospitals will move into charge nurse roles on their respective units.

Madeline has the challenge of effectively and effi- ciently managing emergency services and critical care units at five separate facilities, all located within a 60-mile metropolitan radius. Her past experience in merg- ing the management responsibilities at the two suburban hospitals will be extremely useful as she works to transi- tion the new hospitals into the health care system.

Madeline anticipates that staff at the hospitals will be concerned over the changes in ownership and man- agement. Some staff may be fearful of the unknown and worried about their jobs, while others may be ex- cited at the opportunity for increased pay and job mo- bility in the health care system. Former managers at the hospitals may be angry about their demotion. Human resources representatives have indicated that they will offer former managers the opportunity to apply for open management positions in the health care system.

Myriad reactions among the staff members are ex- pected as well as the potential for increased stress. Mad- eline and the other nurse managers meet and develop a transition plan. The transition plan defines the tasks, time frames, and expectations for merging the patient care units. Additionally, the plan helps decrease the

stress Madeline and her fellow managers experience by organizing and delineating roles and responsibilities. Consistency in implementing change will help decrease stress among the staff at the urban hospitals. Each man- ager is committed to meeting with staff on each unit to address questions, concerns, and morale issues. Made- line plans to schedule a lunch meeting with each former manager to discuss the unit’s strengths and weaknesses as well as her goals for the unit.

Three months into the transition, Madeline’s units have had low turnover, and staff members report they are satisfied with the new management structure. In particular, staff nurses enthusiastically have accepted the clinical ladder promotion program and evidence- based practice implementation. Two of the former man- agers have moved into management roles in the health care system. The transition has been stressful, but Mad- eline has enjoyed the opportunity to stretch her leader- ship skills.

Manager’s Checklist The nurse manager is responsible for:

● Recognizing the impact of stress, both positive and negative, on themselves and their staff

● Utilizing personal and professional strategies to identify stressors and develop a plan to manage stress

● Communicating openly and honestly with employees who are stressed in their work environment

● Using creative solutions to address stress so employ- ees are able to effectively perform their jobs

● Assessing the effectiveness of solutions and adjust as necessary

CASE STUDY 25-1

CHAPTER 25 • MANAGING STRESS 323

Regardless of the work or life situation, everyone experiences stress, both positive and negative. It is how stress is handled that makes life interesting or excessively difficult. Stress- management strategies enable nurses to improve job performance and professional satisfaction.

What You Know Now • Stress is a person’s reaction to demands from the environment. • Stress can be both positive and negative; regardless, the physiological response is the same. • Causes of stress come from organizational, interpersonal, and individual factors. • Stress can cause physical and psychological problems, including burnout and compassion fatigue. • Individuals can help manage stress by recognizing stressors, redefining roles, time management, and

self-care. • Managers can help their staff and themselves manage stress. • Organizations can support employees to manage work-related stress by matching applicants to appropriate

jobs, providing adequate orientation and skills training, and using experienced nurses to preceptor novice nurses.

• Organizations can provide employee assistance programs and promote their use to staff.

Tools for Managing Stress 1. Recognize that stress is necessary for life. 2. Acknowledge the impact of stress, both positive and negative, on your professional and personal life. 3. Review your stress-management strategies and evaluate them for effectiveness. 4. Pay attention to your stress levels and try to create opportunities to help deal with stress. 5. If you are experiencing an exceptional amount of stress, consider various ways to care of yourself.

Questions to Challenge You 1. What causes you the most stress? 2. What methods do you use to cope with stress? 3. Have you seen others respond negatively to stress? Explain what happened. 4. Have you experienced any of the consequences of stress described in the chapter? How did you

handle it? Explain. 5. Have you experienced role ambiguity or role conflict? Describe the situation. How did you

handle it? 6. What ways do you care for yourself? What other ways might you add to your repertoire of self-care

skills?

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

www.nursing.pearsonhighered.com

324 PART 4 • TAKING CARE OF YOURSELF

References Applebaum, D., Fowler, S.,

Fiedler, N., Osinubi, O., & Robson, M. (2010). The im- pact of environmental fac- tors on nursing stress, job satisfaction, and turnover intention. Journal of Nurs- ing Administration, 40(7/8), 323–328.

Azzone, V., Hiatt, D., Hodgkin, D., & Horgan, C. (2009). Workplace stress, organizational factors and EAP utilization. Journal of Workplace Behavioral Health, 24(3), 344–356.

Epstein, D. G. (2010). Extin- guish workplace stress.

Nursing Management, 41(10), 34–37.

Gates, D. M., Gillespie, G. L., & Succop, P. (2011). Violence against nurses and its im- pact on stress and produc- tivity. Nursing Economics, 29(2), 59–66.

Kramer, M. (1974). Reality shock. St. Louis, MO: Mosby.

Newsom, R. (2010). Compas- sion fatigue: Nothing left to give. Nursing Management, 41(4), 42–45.

Selye, H. (1978). The stress of life (2nd ed.). New York: McGraw-Hill.

Shirey, M. R., McDaniel, A. M., Ebright, P. R., Fisher, M. L., & Doebbeling, B. N. (2010). Understanding nurse manager stress and work complexity. Journal of Nursing Administration, 40(2), 82–91.

Sullivan, E. J. (2013). Becom- ing influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall.

Yoder, E. A. (2010) Compassion fatigue in nurses. Applied Nursing Research, 23(4), 191–197.

CHAPTER

Envisioning Your Future

Managing Your Career

Acquiring Your First Position APPLYING FOR THE POSITION

THE INTERVIEW

ACCEPTING THE POSITION

DECLINING THE POSITION

Building a Résumé TRACKING YOUR PROGRESS

IDENTIFYING YOUR LEARNING NEEDS

Finding and Using Mentors

Considering Your Next Position FINDING YOUR NEXT POSITION

LEAVING YOUR PRESENT POSITION

When Your Plans Fail TAKING THE WRONG JOB

ADAPTING TO CHANGE

Advancing Your Career 26

Key Terms Activity log Certification

1. Describe how to envision your future. 2. Explain why your career requires planning. 3. Discuss how to obtain your first job. 4. Build a résumé.

5. Explain how to find and use mentors. 6. Explain how to find your next job. 7. Discuss what to do when your plans fail.

Learning Outcomes After completing this chapter, you will be able to:

Mentor Résumé

326 PART 4 • TAKING CARE OF YOURSELF

Envisioning Your Future The future is always uncertain, which leads many to believe they cannot do anything about it. The future, however, is shaped by human decisions and actions, including our own, made daily. What any one person cannot do is control the future. Nonetheless, we are affecting the future by what we do today or what we fail to do.

The future seems like something over which we have so little control that it isn’t realistic to plan for it. Wait to see what happens, try to handle the circumstances, and hope for the best, are as much planning as most people do.

Instead, imagine yourself in one year, creating in your mind the life you most desire. What are you doing? What have you done over the course of the past year?

Now imagine what you are doing in five years. How about what you are doing in 10 years? Finally, what will you be doing right before you retire? Will you be satisfied with what you’ve done? What will you wish you had done?

A nurse met with the advisor in a baccalaureate program designed for RNs. After talking about the requirements of the program, the classes she needed, and her own schedule, they concluded that by taking one course a semester, it would take the nurse five years to com- plete the program. The RN looked discouraged. The advisor asked her what was wrong.

“If I enroll in this program I’ll be 35 in five years,” she said.

The advisor smiled. “Yes, and you’ll be 35 in five years if you don’t.”

Managing Your Career Finishing school and searching for your first job is a priority. Worrying about your career can wait. Or so you think. Shirey (2009) advises otherwise. She divides a nursing career into three stages:

● Phase 1: Promise (first 10 years). Initial experiences in the promise phase are essential building blocks for a long-term, successful career.

● Phase 2: Momentum (11 to 29 years). Continuing to learn and grow, choosing multiple ex- periences, and becoming visible in the profession are all important for continued success.

● Phase 3: Harvest (last years of career). While continuing to grow and learn, nurses also share their experiences and expertise with younger nurses and leave a legacy for the next genera- tion. Shirey (2009) further posits that a career doesn’t just happen: it is planned and cultivated.

Acquiring Your First Position The first step, after you’ve completed your basic nursing education, is to select your first job. The purpose of this job is to learn as much as you can and to perfect your clinical skills. Addi- tionally, you will make contacts among your colleagues and supervisors.

Here are some criteria for choosing your first job.

● You will have opportunities to hone your skills in a clinical area of interest. ● You will learn from more experienced clinicians who are willing to teach you. ● The culture of the organization and, especially, the administration are supportive of nursing. ● The organization’s mission fits your values (e.g., a teaching hospital that serves the poor). ● There are opportunities for advancement.

No job is perfect, just as no relationship, home, career, or family is perfect. Use the above criteria to assess the position and the organization. If the position and the organization fit most of them, especially the criteria most important to you, consider the following additional criteria.

● The schedule fits your lifestyle. ● The institution is near your home.

The least important criteria for selecting your first job is the salary. A small amount more in your hourly pay is worth much less than opportunities to help meet your future goals. Remember,

CHAPTER 26 • ADVANCING YOUR CAREER 327

you have a long time to be in your career; don’t sacrifice opportunities in the future for a slight difference in salary now.

Applying for the Position Some organizations ask you to fill out an application, either online, by mail, or in person; oth- ers request a résumé. A résumé is a written record of your educational achievements, employ- ment, and accomplishments. (See Box 26-1 for a sample.) Your résumé might also include your

BOX 26-1 Sample Résumé

Chloe R. Stevenson, RN, BSN 5625 Summit Lane

Overland Park, KS 66222 913.555.2222

chloestevenson@anyprovider.net

Objective To obtain a position as a professional registered nurse in a dynamic intensive care unit that will utilize my strong clinical skills, work ethic, problem-solving ability, and passion for providing superior patient care.

Work Experience

Registered Nurse May 2009–Present

Telemetry Unit, Memorial Hospital, Overland Park, KS ● Currently provide direct patient care to a variety of cardiac and postoperative cardiac patients on a 30-bed

telemetry unit. ● Clinical duties include assessment, medication administration (as well as titration of cardiac IV medications),

cardiac monitoring, and all other aspects of nursing care. ● Actively develop, implement, and monitor individualized patient plans of care as well as document patient

response and outcomes. ● Became ACLS-certified and serves as leader of unit’s critical response team. ● Participates as a member of an evidence-based practice committee for cardiology services.

Patient Care Technician January 2008–May 2009

Telemetry Unit, Memorial Hospital, Overland Park, KS ● Worked under the supervision of an RN to provide direct patient care, including taking vital signs, dressing

changes, bathing, ambulation of patients, and assisting with the admission and discharge process. ● Was responsible for appropriate clinical documentation. ● Was trained to perform 12-lead EKGs as well as cardiac monitoring. ● Served on unit’s quality improvement team.

Education ● Bachelor of science in nursing, May 2009, University of Kansas, GPA: 3.7/4.0 ● Registered nurse, state of Kansas, June 2009 ● Advanced Cardiac Life Support (ACLS) certified, August 2009

Awards ● Jane Smith Award for Excellence in Clinical Nursing, May 2009; awarded by faculty to the senior nursing

student who demonstrates excellence in clinical skills and academic coursework.

References available upon request.

328 PART 4 • TAKING CARE OF YOURSELF

immediate professional goal, such as “gain clinical experience” and/or your long-term goal, such as “become a manager.”

Education includes:

● Degrees, institutions, years attended, graduation date (actual or expected) ● Specialty training ● Continuing education

Employment includes:

● Positions held ● Names of employers ● Dates of employment

Accomplishments might include:

● Volunteer service, such as helping in a homeless shelter ● Organizational service, such as serving as student body president ● Awards won, such as Outstanding Junior Student

Once you have applied for a position and the organization contacts you to say a representa- tive is interested in meeting you, you will agree on a time and place for an interview. The inter- view is your chance (sometimes your only chance) to sell yourself to a potential employer. Make no mistake: if you can’t sell yourself, no one can. You need to prepare for your interview just as you would for any other important meeting. That includes knowing who you are meeting, learn- ing as much as you can about the organization, and anticipating questions you might be asked.

The Interview Preparing for the Interview The purpose of an interview is twofold: for a potential employer to learn about you and for you to learn about the organization (Krischke, 2010). Ideally, the two of you will discover if there is a role for you in the organization, what is known as a good “fit.”

To prepare, identify:

● What you want to know about the position and the organization ● What questions you might be asked about your education or past experiences. Be prepared

to describe briefly your achievements. ● What you think your strengths and weaknesses are and how those fit with your potential

employer’s needs ● What you want to know about the organization and the job

Find out who will be interviewing you and ask for the person’s position and role in the or- ganization. You may interview with someone in the human resources office as well as the person who would be your supervisor.

Be especially courteous to office staff; they have the power to smooth your way or report your behavior to their boss. Try to schedule your interview for a time when you can be rested and unhurried, not right after a long day at work or when you must be somewhere else immedi- ately afterward.

You will probably be sent some information about the organization (or you can request it). A position description is essential—you can compare it with your qualifications. The materials you receive may include the organization’s mission statement, its vision for the future, and its goals. (See Chapter 2 for examples.)

An organizational chart also is helpful, but not always available. The important information for you is where this position fits in the organizational structure. That will tell you to whom you would report and also explain that person’s reporting relationship. The most direct line to top administration is the most powerful.

CHAPTER 26 • ADVANCING YOUR CAREER 329

What to Wear to the Interview Most people anguish over what to wear to an interview. With good reason. The way you dress creates your first impression and can enhance or detract from your words. Keep it simple and conservative. You want the interviewer to focus on your qualifications, not your clothing.

Clean, pressed slacks, and a tie and jacket for men is appropriate. Women can wear pants or a skirt with a jacket in neutral colors, low-heeled shoes, simple jewelry, and carry a handbag or briefcase. Wear something you feel comfortable in. Resist the urge to buy a new outfit unless you don’t have anything suitable in your wardrobe.

At the Interview Take along a copy of your résumé even if you filled out an application. (You can refer to it if you are asked to explain an item.) Ask for explicit directions to the building and office where you will go, and plan to arrive a few minutes early. Prepare mentally by reminding yourself of the qualifications you bring to the position, noting items on the position description that fit you. Enter the office with confidence, smile, and shake hands firmly.

To consider what questions you might be asked in an interview, see examples of general questions in Table 26-1 and review Table 15-1 for examples of behavioral interview ques- tions. In addition, you will be asked questions about your education and work history. An- swer questions honestly, but don’t feel you must explain anything you are not asked. You will have an opportunity to ask your questions about the position and the organization. Be sure you are prepared to do so. A candidate who has no questions suggests a lack of interest or expertise.

Most interviewers today understand what questions are legal to ask and what are not. You are not required to answer questions about how many children you have, their ages, or your marital status, for example. (See Table 15-2 for a list of illegal questions.) Simply being asked

TABLE 26-1 Examples of Interview Questions

YOUR CURRENT JOB

What do you do in your present job? What do you like best about your present job? What do you like least? Why do you want to leave your present job?

YOUR ACHIEVEMENTS AND GOALS

What are you most proud of accomplishing? What do you think you do especially well? What are your areas of weakness? What are your long-term goals? What do you plan to do to meet your goals?

YOUR INTEREST IN THE POSITION

Why are you interested in this position? What do you see yourself doing next? Why do you think you are right for this position? Is there anything you would like to add about your qualifications that we haven’t already discussed?

From Sullivan, E. J. (2013). Becoming influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall Health. Used with permission.

330 PART 4 • TAKING CARE OF YOURSELF

such questions indicates an organizational bias, and if you are asked such questions, you might want to reconsider your interest in the organization. Chapter 15 also includes information about interviewing from the employer’s position.

To practice for an interview, role-play using the interview script in Box 26-2.

After the Interview Send a thank-you letter within 24 hours of the interview to everyone who interviewed you. Your letter can be handwritten on nice quality notepaper or typed on letter-sized stationery. It should be brief, thanking the interviewer for interest in you and saying that you enjoyed the meeting. Include a few words summing up your qualifications that fit the position. Close the letter by say- ing that you are looking forward to hearing from her or him soon.

BOX 26-2 Interview Script

MANAGER: Hi, I’m Paula Green. I’m the nurse manager for the surgical care unit. Thank you for coming in today! I’d like to start by telling you a little about the surgical care unit and then we’ll talk about you and why you would like to work here.

The unit is a 32-bed patient care unit that is open 24 hours a day, seven days a week. We provide care to patients who have most typically had abdominal surgeries or orthopedic surgeries. The average length of stay for a patient here is three days. All rooms are private, with one patient to a room. We encourage a family member to stay overnight in the sleeper chair if desired. We work hard to create a good experience for every patient.

Now, tell me about you and why you’ve chosen to consider working with us.

INTERVIEWEE: I’m Samuel Jones. I’ve been a nurse for three years. I went to school at Upstate University. I worked in the community hospital surgical unit after I graduated from nursing school; I had clinicals there during my studies.

Now, I would like to move on to a larger facility that has a greater variety of patients. I’ve read a lot about your hospital and was very excited to see the job posting. I think this organization would be an excellent place for me to work.

MANAGER: Tell me more about why you think our hospital is a good fit for you.

INTERVIEWEE: Well, I know you keep adding more floors and services, and I want to be part of a growing place. I also know your Web site says you have just re- ceived Magnet designation. I want to be at a hospital where nursing is valued and growth is encouraged. A member of my family came here for care and loved it. He said everybody was very warm and professional.

MANAGER: That is very good to hear! So, let’s talk about your work experience at the community hospital. Tell me about your role there.

INTERVIEWEE: Well, I’m a staff nurse in the surgical unit. I work the night shift. After working there about a year and a half, I took a preceptor class and began helping train new nurses. I am also the charge nurse there. I lead the shift, help my coworkers with their patients, get patients placed in a room when they’re admitted, and talk to patients who have concerns about their care.

MANAGER: It sounds like you’ve done well in the last three years. Tell me about being the charge nurse leader. That’s a large responsibility. Why do you like that responsibility, and how you think your peers would describe you in that role?

INTERVIEWEE: I like working hard and being a role model to encourage the other staff members to work hard. I also think that most issues can be fixed with good communication, so I try to always get people to talk and to share information. I think my coworkers would say I’m always asking them if they need help with their patients. I want them to know I’m there for them.

MANAGER: Tell me about your strengths as a nurse.

INTERVIEWEE: I try to keep myself and everybody focused on the patient. I’m also very dependable. This is the third year in a row that I’ve had a perfect record of attendance at work.

MANAGER: Tell me about your weaknesses.

INTERVIEWEE: I think sometimes I don’t ask for help and then I get overwhelmed with my work. I always try to help others but get embarrassed when I need to ask for help. I need to learn to give and take better.

MANAGER: We all have strengths and weaknesses. We can build on your strengths and help you learn to deal with your weaknesses. Would you like to tour the unit now?

CHAPTER 26 • ADVANCING YOUR CAREER 331

A Second Interview It is not unusual to have a second interview if you have passed initial scrutiny and appear to be an appropriate candidate for the position. The second interview usually includes colleagues and managers with whom you would work. You will probably tour the unit and meet potential co- workers, giving you an opportunity to assess the environment.

Situational questions are often asked at this time. For example, you are given a scenario and asked how you would handle the situation. Take your time to think through an answer. Obvi- ously they think you can handle such situations because you have been asked back. Keep your answer short and to the point. Your goal is to show you are a competent, confident professional.

Interviewing with potential coworkers is also your opportunity to find out what you want to know about the specific responsibilities and challenges of the position. You might ask, “What are the most pressing problems facing the unit?” or “What do you need most from a nurse practitio- ner in this clinic?”

You will probably be asked if you are still interested in the position. If you are, ask when a hiring decision will be made. Following this interview, again send thank-you letters, but only to the new people who have interviewed you.

Accepting the Position When you are offered the position, you have an opportunity to negotiate. Don’t ignore this op- portunity in your excitement of getting the job.

Salary is usually the main topic for negotiation. Most employers have some flexibility with salary if they have a justifiable reason for it, but they will seldom tell you that. It is much more common for an organization to offer the lowest salary in its range and see if the candidate asks for more. Ask for a number higher than your lowest acceptable figure, but don’t get carried away. Asking for a salary that is a great deal higher than the offer is not only unprofessional, but it makes you appear to be more interested in the money than the job.

Follow up your verbal agreement with a formal letter of acceptance to the administrator who hired you. Thank the individual for having confidence in you and your potential, and state again how pleased you are to be joining the organization.

Declining the Position Sometimes you will decide not to accept a position offered to you. It might not be the right job, at the right time, or in the right organization. Be sure to let the appropriate person know your intention as soon as possible. Thank him or her for the offer and the confidence the organization has in you. Explain briefly why you cannot accept the job at this time and state that you hope the organization will keep you in mind in the future. Follow up with a letter as well. Even if you are not interested in this position or this organization, someone there might prove valuable in referring another organization to you in the future, for example. Your career will be long; never alienate potential connections.

Building a Résumé Once you have accepted your first position, it is time to think about what you will need to ad- vance in your career.

The first step is to assess yourself. Identify:

● Your personality, values, beliefs, likes, and dislikes ● Your lifestyle ● Your family ● Your friends and social life ● Your hobbies and personal activities ● Your vision of your future

332 PART 4 • TAKING CARE OF YOURSELF

● Your skills ● Your knowledge ● Your nursing preferences

The last item refers to the areas of nursing that suit you best. This may take some time and experience in practice. Then ask yourself:

● Do you like a fast-paced environment, such as an ER, OR, or trauma care? ● Do you prefer to have time with your patients? Rehabilitation nursing, a medical floor, or

long-term care might suit you better. ● Which patient conditions and treatments do you prefer? ● Which patient conditions intrigue you the most? Cardiac problems, psychiatric conditions,

or diagnostics (e.g., GI lab)? ● Would you like to work in a clinic, medical office, in home care, or in public health? ● Would you enjoy school nursing or occupational health?

This assessment is not done quickly; it involves a period of time in practice, introspection, asking friends and family members for their thoughts about you, and learning from reading or attending programs. It is also flexible and responsive to ways in which you grow and change. Your family and social life change also, sometimes making adjustments in your plan necessary.

The next step is to assess the environment. Consider what might change in the health care system (today, changes occur rapidly). How

will changes proposed in health care reform legislation affect your future? Are any new medica- tions or vaccines pending that might eliminate current jobs or create new opportunities for you? Are any new educational programs being proposed?

The clinical nurse leader, as explained in Chapter 4, is an example. As advances in trans- plant technology proliferate, new specialties of nurses and physicians are created. Today’s non- invasive technology for monitoring and treating patients for a variety of ills and from a distance suggests that many changes in clinical care may be on the horizon.

There are many ways to learn about the environment. Certainly, paying attention to popu- lar media reports on scientific breakthroughs and advances in technology is one way. Reading your professional literature, checking certain professional Web sites for updates, or attending programs in your interest area is another. Joining a professional or specialty organization and receiving its newsletters and journals is especially useful because those target your interests.

Observing others may prove worthwhile. Many people chose their career path after watch- ing more experienced members of the profession. Nurses who pursue teaching and administra- tion often do so after working with an especially competent role model.

Talking with experts, colleagues, and administrators is also valuable. Keep alert to what you hear, evaluate its credibility, and assess its usefulness to you. Gathering information is an ongo- ing process. Your plan will not be fixed; it will change in response to changes in your life, your goals, and the environment.

Once you have assessed yourself and the environment, determine what your options are. Include legal constraints or possibilities (e.g., is the nurse practice law in your state going to be changed to allow more privileges for nurse practitioners?), new programs proposed (e.g., a local university is starting an acute care nurse practitioner program), your own desires (e.g., doctoral education to become a nurse researcher), and how willing you are or might become to relocate, go into debt, or sacrifice the time to reach your goal. The latter issues are likely to change over time as your family life or lifestyle changes.

Evaluate what experiences you need and where you might get those from a continuing edu- cation program, on-the-job training, a certificate offered by your institution’s education depart- ment, or a graduate degree. Is there a license or certification you need? What organizations, such as working at a trauma center or accepting a leadership position in your chapter of Sigma Theta Tau International, could help you achieve your goals? Are there publications or online resources that would help?

CHAPTER 26 • ADVANCING YOUR CAREER 333

Nursing offers an incredible array of opportunities in clinical areas as diverse as cardiac surgery and trauma care to home health and rehabilitation nursing. You can be a clinician or a specialist, a teacher, administrator, or researcher. You can become an entrepreneur, an informa- tion systems specialist, you can branch into pharmaceutical sales, or, for that matter, you can write books about nursing—all the while being a nurse. See how one nurse advanced his career in Case Study 26-1.

Create a plan that is long term and flexible. No one knows what will happen in his or her own life or in the environment over time, or what opportunities may emerge. Keep an open mind; talk to other professionals; explore your interests. What we do know is that we are con- tributing to our own future by what we do or fail to do today.

Tracking Your Progress Keep an activity log to track everything you are doing so that when the time comes to apply for a new position, you are not frantically trying to remember your accomplishments, what continu- ing education programs you took, or when you completed a course at your hospital. Note the name of the program, activity, certification, or accomplishments, add the dates, who sponsored it and where, and note anything special you received or learned. Include a list of accomplishments on your job, such as teaching a class or preceptoring students, or skills you’ve acquired. Include any cross-training as well. Table 26-2 shows an example of a format you could use.

Every item on your activity log will not go on every résumé. A résumé must be crafted to meet the purpose you have for submitting it. For example, the résumé you submit to an

ADVANCING YOUR CAREER Trevor Briggs, RN, BSN, has worked as the operating room supervisor for the past four years. The department has used a stand-alone clinical information system for the past two years, and Trevor has been an integral part of the successful implementation of technology in the OR. In addition to training staff to use the system, Trevor has worked with the IT vendor to enhance the system’s capabilities. Recently, Trevor was appointed by his nurse manager to serve on a hospital-wide clinical information system selection committee. Administration has initiated the process of selecting an integrated clinical informa- tion system and is seeking input from each service line.

Trevor enjoys working with the committee and learn- ing about the implementation processes. The chief infor- mation officer met with the committee and announced the creation of a new role: clinical systems team leader. Team leaders will be nurses who are specially trained to work with the IT department in implementing the new clinical information system. Trevor’s background with the OR system makes him an excellent candidate for the team leader position. After interviewing with the IT department manager, Trevor is selected as a clinical sys- tems team leader. Trevor also learns that the hospital is willing to pay for specialized training, including tuition reimbursement for graduate classes.

To increase his knowledge of information systems, Trevor enrolls in a master of information management

systems program at the city university. After completing the initial 12 hours of the master’s program, Trevor must decide whether to pursue a specialty track in software development or project management. Trevor reviews market trends to determine the best option and also considers his personal preferences. He also takes the time to meet with an instructor in the masters program, who is an informatics nurse specialist and has worked in the IT field for 10 years. Trevor decides to pursue a track in project management, which will allow him to utilize his strong leadership and people management skills. Af- ter completing his master’s degree, Trevor is promoted to clinical systems nurse manager and is now pursuing certification in nursing informatics.

Manager’s Checklist The nurse manager is responsible for:

● Determining what career track best suits individual skills, talents, and interests.

● Looking for opportunities to enhance skills and knowledge outside of your current career.

● Analyzing market trends for emerging roles. ● Networking with experts and mentors in the field

that may present opportunities.

CASE STUDY 26-1

334 PART 4 • TAKING CARE OF YOURSELF

TABLE 26-2 Activity Log for Career Progress

Activity Content

Education earned Include names of schools, location, dates attended, degrees

Employment Include all positions, including summer jobs and part-time or full-time work while in school

Licenses Include license number and state

Certificates/Credentials Include name, date earned, sponsoring organization

Professional Organizations Include name, date joined, any committees or offices held with dates

Publications Include title, name of publication, date

Volunteer Activities Include name of organization and your participation

Accomplishments Include accomplishments from your job, professional activities, volunteer experiences

From Sullivan, E. J. (2003). Becoming influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall Health. Used with permission.

organization to be considered for membership differs from one you would use to apply to gradu- ate school. Having a comprehensive list of all your activities and accomplishments helps ensure that when you put together an application or submit your résumé, you will be less likely to forget some of your achievements.

Keep track of your expenses as well. Note them in your activity log or in a separate file organized by year; this information comes in handy at tax time. You can use a document on your computer or in a notebook. It is helpful to keep continuing education (CE) certificates and receipts in a file as well.

Identifying Your Learning Needs Pursuing a career involves lifelong learning. You can learn in many ways. Online courses, spe- cialty certification, graduate school, books, journals, Web sites, and professional meetings are just a few of the ways you can acquire the knowledge you need. To develop skills, however, you need experience. Several options are possible.

Baccalaureate Education for RNs Today, many RNs have added a baccalaureate degree in nursing to their basic education from a hospital diploma program or an associate degree from a community college. In addition, the Institute of Medicine (2010) recommends that 80 percent of nurses be prepared at the baccalu- areate or higher level by 2020. Most baccalaureate programs in nursing have an option for RNs to complete their degrees without repeating content from their basic program, and many offer programs online.

Certification Certification is growing in nursing as clinical care becomes more specialized. Certification is a formal recognition that a nurse has acquired specialized knowledge, skills, and experience that meet identified standards (Miller & Boyle, 2008). Nursing certification programs are accredited by either the National Commission for Certifying Agencies (NCCA) or the American Board of Nursing Specialties (ABNS). Nursing certifications are available in a wide range of clinical

CHAPTER 26 • ADVANCING YOUR CAREER 335

specialties, including nurse practitioner, clinical nurse specialist, and clinical specialties, such as cardiac rehabilitation, gerontological nursing, informatics, and primary care.

Nurses may be reluctant to pursue certification for several reasons (Watts, 2010), including the costs of the examination and study guides, lack of employer support, or absence of on-the-job rewards. However, the benefits to your long-term career may offset the immediate disadvantages.

Graduate Education Graduate school, in either a master’s or doctoral program, offers both didactic content and ex- perience, which might be clinical for a practitioner program or research in a doctoral program, depending on your goals. If you want to be a nurse practitioner, teach nursing, become a nurse researcher, or advance as an administrator, you need graduate preparation.

Choosing a graduate program is a difficult and time-consuming endeavor. You must learn as much as you can about the program, its requirements, and its graduates’ success to determine if the program will meet your needs. Gather literature, meet with admissions staff and faculty, and talk to students and colleagues. Compare national rankings of the schools that interest you. Request the names of recent graduates to contact for references and interview them. Ask your teachers, supervisors, and preceptors for advice.

This is one of the most important decisions you will make in your career. It can also be the most valuable. Take your time, consider your options, and be fully committed before you enroll.

Many options are available to pay for graduate school education. As with the decision to select a school and a program, finding sources of funding takes perseverance. The school’s financial aid office can help you locate loans and scholarships. Service clubs, such as Rotary International, support nursing scholarships.

It is helpful to know your long-term goal, especially if you are interested in an area of need. For example, a nursing faculty shortage is increasing as retirements thin the ranks of today’s teachers. Nurse practitioners are needed to work in disadvantaged areas; some scholarships exist for nurses who agree to provide care in these areas for a period of time after graduation. In addi- tion, the military offers scholarships in return for a service commitment.

Continuing Education Finding continuing education to further your career is not difficult; determining the quality of the program is not as easy. If you receive information about a program that interests you and fits with your career goals, evaluate the information using the following:

● Is the program sponsored by a known organization, such as a college or professional association?

● Who are the speakers? Are their credentials appropriate to their presentations? ● Is the content appropriate to you at this stage in your development—neither too advanced

nor too elementary? ● Can you obtain financial assistance to attend? If you do, what will you owe the organiza-

tion? Bringing back a report of a program you’ve attended is an excellent way to reinforce your own learning. This will give you an opportunity to speak in public as well.

● Consider attending, even if you must pay your own way. You may be able to deduct the expense on your taxes and, after all, you and your career are the beneficiary.

● Can you arrange to be off work, if necessary, and afford the time and expense?

Professional Associations Membership in professional associations offers many opportunities for learning. Journals, news- letters, Web sites, blogs, listservs, meetings, conventions, and programs are just the beginning. The opportunity to meet and network with your colleagues and senior people in the profession and to learn by serving on committees, task forces, and boards is immense. Many successful nurses began their career by participating in a professional association.

336 PART 4 • TAKING CARE OF YOURSELF

Nursing associations cover every specialty and interest. Membership in the American Nurses Association is open to all registered nurses through its constituent member associations. Sigma Theta Tau International has more than 400 chapters affiliated with schools of nursing around the world. Specialty organizations exist for nurses who work in many clinical areas, such as the American Association of Critical Care Nurses or the American Psychiatric Nurses Asso- ciation. Each of these organizations has divisions, committees, and boards where your time and talents are welcomed.

Finding and Using Mentors One of the most important tasks in your career is to identify and cultivate mentor relationships. A mentor is a person who has more experience than you and is willing to help you progress in your career. A mentor introduces you to key people and tells you what you need to know and do to move ahead. A mentor provides opportunities for learning, counsels you on mistakes, and takes pride in your successes.

A mentor may be a senior nurse or someone in another closely aligned profession, mostly because the mentor must have contacts that can be useful to your career. Often you work for the same organization, but that is not a requirement. You can have more than one mentor, but usually not at one time.

You might identify someone you would like to be your mentor, or the mentor might select you. The arrangement of mentor and mentee, however, is rarely named as such. Usually, you find yourself relying more and more on one or two people for advice, or a mentor singles you out for special opportunities or assignments. If any of those do not work out especially well, or if the two of you don’t seem to be compatible, nothing is lost. You both go on your way without any bad feelings. A person becomes a mentor when positive experiences accumulate, bringing satisfaction to you both.

A number of benefits accrue for both you and your mentor. You gain a sense of accomplish- ment by working with a mentor, and the mentor acquires fulfillment from contributing to you, and by extension, to your profession. People who are senior in the field have a responsibility to pass along what they’ve learned and to prepare those who come after them. These are the satis- factions of a career done well.

The time will come, however, when you move away from your mentor. You take a new job or your mentor does. Your relationship changes as a result. You may then become colleagues and friends, and you may acquire a new mentor in the new organization. Sometimes you will move ahead of the mentor, a situation that requires tact and commitment from both of you. Accomplished professionals know that they will always owe a debt to their mentor, and they will continue to show their appreciation in large and small ways.

Considering Your Next Position The time to think about your next job is when you accept the first one. Begin to assess how much you can learn in this job and think about your next step. Take every opportunity you can to learn.

One new grad had already determined that she wanted to teach nursing and knew that she needed clinical experience before she went on to graduate school. She used each clini- cal experience as a learning opportunity. She made notes on the patients she cared for and looked up their conditions, treatments, and meds on her time off from work. In less than a year, she had compiled a study guide of her own notes. She began graduate school full- time and continued to work part-time, continuing to add notes throughout her graduate school experience. By the time she graduated, she was an experienced clinician, although the actual hours she spent in clinical work were fewer than most of the other new nurse faculty.

CHAPTER 26 • ADVANCING YOUR CAREER 337

Finding Your Next Position When jobs are plentiful, you have many opportunities for finding the next job in your career. This move must not be taken lightly, however, no matter how many jobs are available. This is where self-assessment is essential. You want to be certain you are ready to leave your current job, that you have learned and accomplished what you came there to do, that you will not be leaving at a crucial time (e.g., an imminent Joint Commission visit), and that you have selected the job that fits your needs now.

When you are ready, there are many ways to find potential positions. Online sources abound; Nurse.com is one example (www.nurse.com/jobs). Professional associations offer job search services. These include Sigma Theta Tau International at http://stti.monster.com, and the American Nurses Association at www.nursecareercenter.com. (See the Web Resources at the end of this chapter.)

Career fairs, ads in newspapers and nursing publications, and faculty from the school where you graduated are additional ways to inquire about opportunities and to let others know you are interested in considering future options.

Leaving Your Present Position Just as there is a way to find a job, there is also a way to leave a job. First, check to see how much notice your employer requires. Tell your supervisor as soon as you have accepted the new position, and follow up with a formal letter of resignation. Add some friendly comments, regard- less of how you feel about the organization, your coworkers, or the supervisor. Your goal is to leave on good terms.

Resist the urge to just walk out, regardless of the situation. The only reason for doing this would be that you are in physical danger, and the organization is not providing adequately for your safety. This is a rare, though not unknown, situation.

Always be polite in your interactions with your coworkers and your supervisor. Resist, also, the urge to belittle the organization or the administration. Negative comments about others re- flect mostly on you. Of course, don’t say anything that is untrue. If the situation is difficult, the other employees know it as well. You needn’t say anything at all, even if you’re asked. You never know what the future will bring, and ending relationships politely is best for your future.

When Your Plans Fail Be assured that the future you envision will not work exactly as you hope (it might work out better), and you will make mistakes. All successful people take risks, and all have failed at some point in their careers. What makes their career progress significant, however, is that they learn from their mistakes and are willing to go on when external events affect their plans.

Taking the Wrong Job Sometimes you will take a job that is not the right one for you. Maybe you thought you were ready for a management job, but are now overwhelmed by the responsibility. No job turns out exactly the way we thought it would, but sometimes the disconnect between our expectations and what actually happens is so far apart that we cannot continue.

Maybe you took the right job, but for the wrong reason. You wanted a faster-paced environ- ment and accepted a position in a busy surgical ICU, working nights. You soon discover that the pressure, loss of sleep, and the acuity of your patients is more than you can handle.

When you think you may have made a mistake, try to get some advice from someone you trust. An advisor, teacher, or a mentor may be able to help you sort out what’s wrong. It may not be the job. Maybe you need a brief period of counseling or to learn better ways to handle stress. (See Chapter 25, “Managing Stress.”)

If you decide you must leave this job, do so with as much care as you can. You will undoubt- edly be leaving your employer in a difficult position, so you want to do everything you can to

www.nurse.com/jobs

http://stti.monster.com

www.nursecareercenter.com

338 PART 4 • TAKING CARE OF YOURSELF

help. Also, having a short-term employment on your résumé is generally seen as negative, so you want to be able to explain this experience in the future and ensure that your employer will report that you did all you could to help the organization once you realized you did not fit the job.

Adapting to Change Change occurs every day in health care, and the pace of change seems to come faster and faster. In order to pursue the career you want and to find satisfaction in that career, you must be able to adjust and respond to change. The most important attribute you can bring to this effort is to remain flexible. The courage to change direction is essential for nurses, according to Shaffer (2006).

Marika, experienced in psychiatric nursing and home care, entered a master’s program, intending to work as a mental health clinical specialist for a home health care agency. While she was in graduate school, she learned that the agency would no longer be reim- bused by insurers for the services of a mental health specialist, and they had eliminated the position.

Fortunately, Marika had a backup plan. She changed course, continued on in graduate school, and obtained her doctorate. She became a nursing faculty member and now re- searches mental health problems in patients with home care needs.

Other events can change your future. Your spouse is offered a job in another part of the country. You find you’re going to become a parent. Your parents need more care than you have been providing. When events intrude on your plan, you may need to adjust your time schedule, taking graduate classes more slowly, for example.

Life is a work in progress. We never know what our future will bring. Allow for unplanned events, such as illness, pregnancy, or the closing of your hospital. Plan for contingencies, but keep your eye on your vision. Remain flexible. You might discover that new opportunities await you, bringing a better future than one you had imagined.

Note: This chapter was adapted from content in Sullivan, E. J. (2013). Becoming influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall.

What You Know Now • You have learned how to envision your future. • You recognize that your career consists of three phases: promise, momentum, and harvest phase. • You have learned how to select your first position, and how to apply, interview, and accept or decline the

position. • You have learned how to create and build a résumé. • You have learned how to track your progress and identify your learning needs. • You have learned how to find and use mentors. • You have learned how to find your next position and leave your current one. • You have learned that flexibility is needed to adapt to change.

Tools for Advancing Your Career 1. Select positions and professional activities that further your short- and long-term goals. 2. Keep a log of your activities and accomplishments. 3. Keep abreast of the health care and policy environment, noting possibilities for your future. 4. Evaluate educational opportunities for their appropriateness for your learning needs and career

advancement. 5. Identify and cultivate mentor relationships. 6. Evaluate your progress periodically and update with new information or interests.

CHAPTER 26 • ADVANCING YOUR CAREER 339

Questions to Challenge You 1. Answer the questions posed in the chapter about how you envision your future. Is the study or work

you are currently doing helping you progress toward that future? If not, what do you need to do to help yourself?

2. Role-play the interview with a colleague in Box 26-2 and then reverse roles. How is the experience different if you are the interviewer versus the candidate being interviewed?

3. Create or review your résumé. Is it up to date? If not, add all the missing information. Take a few moments to ponder your accomplishments.

4. Begin an activity log. Periodically review your accomplishments. 5. Do you have a mentor? Evaluate that relationship. What more might you want from your interac-

tions with your mentor? How might that occur? 6. What educational needs do you have? Investigate potential opportunities to acquire the necessary

education or certification. 7. Have you ever had your professional plans fail? What, if anything, would you do differently in the

future?

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

Web Resources Nurse.com: www.nurse.com/jobs Sigma Theta Tau International: http://stti.monster.com American Nurses Association: www.nursecareercenter.com

References Institute of Medicine (2010).

The future of nursing: Leading change, advanc- ing health. Retrieved April 26, 2011 from http://www. thefutureofnursing.org/ IOM-Report

Krischke, M. M. (2010). Nurs- ing interview guide, Part II: Asking the right questions at the right time. Retrieved December 16, 2010 at www.NurseConnect.com

Miller, P. A. & Boyle, D. K. (2008). Nursing specialty certification: A measure of expertise. Nursing Management, 39(10), 10–16.

Shaffer, J. (2006). Cultivating personal courage. American Nurse Today, 1(10), 52–53.

Shirey, M. R. (2009). Building an extraordinary career in nursing: Promise, mo- mentum, and harvest. The

Journal of Continuing Edu- cation, 40(9), 394–400.

Sullivan, E. J. (2013). Becom- ing influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall.

Watts, M. D. (2010). Certifica- tion and clinical ladder as the impetus for professional development. Critical Care Nursing Quarterly, 33(1), 52–59.

www.nursing.pearsonhighered.com

www.nurse.com/jobs

http://stti.monster.com

www.nursecareercenter.com

http://www.thefutureofnursing.org/IOM-Report

www.NurseConnect.com

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4 Ps of marketing Four strategies in- cluded in marketing plans: product, place, price, and promotion.

A Absence culture The informal norms

within a work unit that determine how employees of that unit view absenteeism.

Absence frequency The total number of distinct absence periods, regardless of their duration.

Accommodating An unassertive, co- operative tactic used in conflict man- agement when individuals neglect their own concerns in favor of others’ concerns.

Accountable care organization A group of health care providers that provide care to a specified group of patients.

Accountability The act of accepting ownership for the results or lack thereof.

Activity log An ongoing record of professional progress, including edu- cational programs, training, certifica- tions, and accomplishments.

Adaptive decisions The type of deci- sions made when problems and alter- native solutions are somewhat unusual and only partially understood.

Additive task A task in which group performance depends on the sum of individual performance.

Adjourning The final stage of group development, in which a group dis- solves after achieving its objectives.

Age Discrimination Act A law prohib- iting discrimination against applicants and employees over the age of 40.

Ambiguous evaluation standards prob- lem The tendency of evaluators to place differing connotations on rating scale words.

Americans with Disabilities Act A law prohibiting discrimination against qualified individuals who have physi- cal or mental impairments that sub- stantially limit one or more of the ma- jor life activities.

Artificial intelligence Computer tech- nology that can diagnose problems and make limited decisions.

Assignment Allocating tasks appro priate to the individual’s job description.

Attendance barriers The events that affect an employee’s ability to attend (e.g., illness, family responsibilities).

Authority The right to act or empower. Avoiding A conflict management tech-

nique in which the participants deny that conflict exists.

B Baylor plan A staffing plan developed

at Baylor University Medical Center whereby nurses work 12-hour shifts on the weekend and are paid for a standard work week.

Behavioral interviewing Interview questions that use the candidates’ past performance and behaviors to predict behavior on the job.

Behavior-oriented rating scales A type of scale, used in evaluations, that focuses on specific behaviors and uses critical incidents grouped into perfor- mance dimensions.

Benchmarking A method of compar- ing performance using identified qual- ity indicators across institutions or disciplines.

Benefit time Paid time, such as vaca- tion, holidays, and sick days, for which there is no work output.

Block staffing Scheduling a set staff mix for every shift so that adequate staff is available at all times.

Bona fide occupational qualification (BFOQ) A characteristic that ex- cludes certain groups from consider- ation for employment.

Brainstorming A decision-making method in which group members meet and generate diverse ideas about the nature, cause, definition, or solution to a problem.

Budget A quantitative statement, usu- ally in monetary terms, of the ex- pectations of a defined area of an organization over a specified period of

time in order to manage its financial performance.

Budgeting The process of planning and controlling future operations by comparing actual results with planned expectations.

Bureaucracy A term proposed by Max Weber to define the ideal, intention- ally rational, most efficient form of organization.

Burnout The perception that an indi- vidual has used up all available energy to perform the job and feels that he or she doesn’t have enough energy to complete the task.

Business necessity Discrimination or exclusion that is allowed if it is neces- sary to ensure the safety of workers or customers.

C Capital budget A component of the

budget plan that includes equipment and renovations needed by an orga- nization in order to meet long-term goals.

Capitation A fixed monthly fee for providing services to enrollees.

Certification Formal recognition that the nurse has acquired specialized knowledge, skills, and experience that meet identified standards.

Chain of command The hierarchy of authority and responsibility within an organization.

Change The process of making some- thing different from what it was.

Change agent One who works to bring about change.

Charge nurse An expanded staff nurse role with increased responsibility and the function of liaison to the nurse manager.

Chronic care model A system-wide, proactive model designed to provide daily care to patients by clinical teams.

Clinical ladder A system of using per- formance indicators to advance an employee within an organization.

Clinical microsystems A small unit of care that maintains itself over time.

GLOSSARY

GLOSSARY 341

Clinical nurse leader A lateral integra- tor of care responsible for a specified group of clients within a microsystem of the health care setting.

Coaching The day-to-day process of helping employees improve their performance.

Cohesiveness The degree to which the members are attracted to the group and wish to retain membership in it.

Collaboration All parties working to- gether to solve a problem.

Collective bargaining Collective ac- tion taken by workers to secure better wages or working conditions.

Committees or task forces Groups that deal with specific issues involving several service areas.

Communication A complex, ongoing, dynamic process in which the par- ticipants simultaneously create shared meaning in an interaction.

Compassion fatigue Secondary trau- matic stress experienced by caregivers.

Competing An all-out effort to win, re- gardless of the cost.

Competing groups Groups in which members compete for resources or recognition.

Competitive conflict A type of conflict that is resolved through competition, in which victory for one side and loss for the other side is determined by a set of rules.

Compromise A conflict management technique in which the rewards are divided between both parties.

Conflict The consequence of real or perceived differences in mutually ex- clusive goals, values, ideas, attitudes, beliefs, feelings, or actions.

Confrontation The most effective means of resolving conflict, in which the conflict is brought out in the open and attempts are made to resolve it through knowledge and reason.

Conjunctive task A task in which the group succeeds only if all members succeed.

Connection power Power based on an individual’s formal and informal links to influential or prestigious persons within and outside an organization.

Consensus A conflict strategy in which a solution that meets everyone’s needs is agreed upon.

Content theories Motivational theories that emphasize individual needs or the rewards that may satisfy those needs.

C o n t i n u o u s q u a l i t y i m p r o v e m e n t (CQI) The process used to improve quality and performance.

Controlling The process of comparing actual results with projected results.

Cost center The smallest area of activ- ity within an organization for which costs are accumulated.

Creativity The ability to develop and implement new and better solutions.

Critical incidents Reports of employee behaviors that are out of the ordinary, either positive or negative.

Critical pathways Tools or guidelines that direct care by identifying ex- pected outcomes.

Critical thinking A process of exam- ining underlying assumptions, inter- preting and evaluating arguments, imagining and exploring alternatives, and developing reflective criticism for the purpose of reaching a reasoned, justifiable conclusion.

D Dashboards Electronic tools that can

provide real-time data or retrospective data, known as a scorecard.

Decision making A process whereby appropriate alternatives are weighed and one is ultimately selected.

Delegation The process by which re- sponsibility and authority are trans- ferred to another individual.

Demand management A system that uses best-practices protocols to pre- dict the demand for nursing expertise several days in advance.

Democratic leadership A leadership style that assumes individuals are mo- tivated by internal forces; leader uses participation and majority rule to get work done.

Descriptive rationality model A decision-making process that empha- sizes the limitations of the rationality of the decision maker and the situation.

Diagonal communication Communi- cation involving individuals at differ- ent hierarchical levels.

Direct costs Expenses that directly af- fect patient care.

Directing The process of getting the work within an organization done.

Discipline The action taken when a regulation has been violated.

Disjunctive task A task in which the group succeeds if one member succeeds.

Disruptive conflict A type of conflict in which winning is not emphasized and there is no mutually acceptable set of rules; parties involved are en- gaged in activities to reduce, defeat, or eliminate the opponent.

Diversification The expansion of an or- ganization into new arenas of service.

Divisible task Tasks that can be broken down into subtasks with division of labor.

Downward communication Commu- nication, generally directive, given from an authority figure or manager to staff.

DMAIC A Six-Sigma process im- provement method.

Driving forces Behaviors that facilitate change by pushing participants in the desired direction.

E Efficiency variance The difference

between budgeted and actual nursing care hours provided.

Electronic health records (EHRs) Integrated records that include infor- mation from all medical sources and can be accessed from multiple loca- tions by sanctioned providers.

Emergency operations plan (EOP) The EOP includes preparation, educa- tion and training, and implementation of the hospital’s response to emer- gency situations.

E m o t i o n a l i n t e l l i g e n c e P e r s o n a l competence (self-awareness a nd self-management) and social compe- tence (social awareness and relation- ship management) that begin with authenticity.

Empirical-rational model A change agent strategy based on the assump- tion that people are rational and fol- low self-interest if that self-interest is made clear.

Engagement When an employee is in- spired by an organization, willing to

342 GLOSSARY

invest effort, likely to recommend the organization, and planning to remain in the organization.

Equity theory The motivational theory that suggests effort and job satisfac- tion depend on the degree of equity or perceived fairness in the work situation.

Evidence-based practice Applying the best scientific evidence to a patient’s unique diagnosis, condition, and situ- ation to make clinical decisions.

Expectancy theory The motivational theory that emphasizes the role of rewards and their relationship to the performance of desired behaviors.

Expense budget A comprehensive budget that lists salary and nonsalary items that reflect patient care objec- tives and activity parameters for the nursing unit.

Experimentation A type of problem solving in which a theory is tested to enhance knowledge, understanding, or prediction.

Expert power Power based on the manager’s possession of unique skills, knowledge, and competence.

Expert systems Computer programs that provide complex data processing, reasoning, and decision making.

Extinction The technique used to elim- inate negative behavior, in which a positive reinforcer is removed and the undesired behavior is extinguished.

F Family and Medical Leave Act (FMLA)

A federal law stating that employers must provide employees with leave when serious illness or family issues arise, while maintaining insurance and an equal position within an organization.

Felt conflict The negative feelings be- tween two or more parties.

First-level manager The manager responsible for supervising non- managerial personnel and day-to-day activities of specific work units.

Fiscal year A specified 12-month pe- riod during which operational and fi- nancial performance is measured.

F ixe d budget A budget in which amounts are set regardless of changes that occur during the year.

Fixed costs Expenses that remain the same for the budget period regardless of the activity level of the organization.

Fogging A communication technique in which one agrees with part of what was said.

Followership An interactive and com- plementary relationship to leadership.

Fo r c i n g A c o n f l i c t m a n a g e m e n t technique that forces an immediate end to conflict but leaves the cause unresolved.

Formal committees Committees in an organization with authority and a spe- cific role.

Formal groups Clusters of individuals designated by an organization to per- form specified organizational tasks.

Formal leadership Leadership that is exercised by an individual with legiti- mate authority conferred by position within an organization.

Forming The initial stage of group de- velopment, in which individuals as- semble into a well-defined cluster.

Full-time equivalent (FTE) The per- centage of time an employee works that is based on a 40-hour workweek.

G Goal setting The relating of current

behavior, activities, or operations to an organization’s or individual’s long- range goals.

Goals Specific statements of outcomes that are to be achieved.

Goal-setting theory The motivational theory that suggests that the goal itself is the motivating force.

Grievances Formal expressions of com- plaints, generally classified as misun- derstandings, contract violations, or an inadequate labor agreement.

Group An aggregate of individuals who interact and mutually influence each other.

Group evaluation An evaluation pro- cess whereby managers compare in- dividual and group performance to organizational standards.

Groupthink A negative phenomenon occurring in highly cohesive, isolated groups in which group members come to think alike, which interferes with critical thinking.

H Halo error The failure to differentiate

among the various performance di- mensions when evaluating.

Hawthorne effect The tendency for people to perform as expected because of special attention.

Hidden agendas A group member’s in- dividual, unspoken objectives that inter- fere with commitment or enthusiasm.

Horizontal integration Arrangements between or among organizations that provide the same or similar services.

Horizontal promotion A program to reward a high-performing employee without promoting the employee to a management position.

I Incident reports Accurate and com-

prehensive reports on unplanned or unexpected occurrences that could po- tentially affect a patient, family mem- ber, or staff.

Incremental (line-by-line) budget A budget worksheet listing expense items on separate lines that is usu- ally divided into salary and nonsalary expenses.

Indicator A tool used to measure the performance of structure, process, and outcome standards.

Indirect costs Necessary expenditures that do not affect patient care directly.

Informal committees Committees with no delegated authority that are organized for discussion.

Informal groups Groups that evolve from social interactions that are not defined by an organizational structure.

Informal leadership Leadership that is exercised by an individual who does not have a specified management role.

Information power Power based on an individual’s access to valued data.

Innovation A strategy to bridge the gap between an existing state and a de- sired state

Innovative decisions The type of de- cisions made when problems are unusual and unclear and creative solu- tions are necessary.

Integrated health care networks Or- ganizational health care structures that deliver a continuum of care, provide

GLOSSARY 343

coverage for a group of individuals, and accept fixed payments for that group.

Integrative decision making A con- flict strategy that focuses on the means of solving a problem rather than the ends.

Interrater reliability An agreement between two measures by several interviewers.

Interruption log A journal of specific information regarding interruptions, analysis of which may help identify ways to reduce interruptions.

Intersender conflict Difficulty in interpreting the intended meaning of a message due to two conflicting messages received from differing sources.

Interview guide A written document containing questions, interviewer directions, and other pertinent infor- mation so that the same process is fol- lowed and the same basic information is gathered from each applicant.

Intrarater reliability An agreement between two measures by the same interviewer.

Intrasender conflict Difficulty in i n t e r p r e t i n g t h e i n t e n d e d m e a n – ing of a message due to incongru- ity between verbal and nonverbal communication.

Involuntary absenteeism Absentee- ism that is not under the employee’s control.

Involuntary turnover When an em- ployee is terminated by his or her employers.

J Job enlargement A flatter organiza-

tional structure that causes positions to be combined and results in managers having more employees to supervise.

Just culture An environment for re- porting of errors without fear of undue retribution.

L Lateral communication Communica-

tion that occurs between individuals at the same hierarchical level.

Lateral violence Harassment between employees of equal rank.

Leader Someone who uses interper- sonal skills to influence others to ac- complish specific goals.

Lean Six Sigma A quality program that focuses on improving process flow and eliminating waste.

Leapfrog Group A coalition of pub- lic and private employers organized to bring attention to consumers about quality indicators in health care and mo- bilize employers to reward health care organizations that demonstrate quality outcome measures.

Legitimate power A manager’s right to make requests because of authority within an organizational hierarchy.

Leniency error The tendency of a man- ager to overrate staff performance.

Line authority The linear hierarchy of supervisory responsibility and authority.

Logic model A practice-based research network (PBRN) that provides a framework for planning and evalua- tion of primary care

Lose-lose strategy A conflict strategy in which neither side wins; the settle- ment reached is unsatisfactory to both sides.

M Magnet® recognition program Rec-

ognition by the American Nurses Cre- dentialing Center that an organization provides quality nursing care.

Manager An individual employed by an organization who is responsible for efficiently accomplishing its goals.

Marginal employees Employees who never reach the expected level of competence.

Medical home A patient-centered model where all services are pro- vided by a group of health care professionals.

Mediation Use of a third-party media- tor to help settle disputes.

Mentor A more experienced person who guides, supports, and nurtures a less experienced person.

Metacommunications Nonverbal mes- sages in communication, including body language and environmental factors.

Mission A general statement of the purpose of an organization.

Motivation The factors that initiate and direct behavior.

N Negative assertion A communication

technique in which one accepts some blame for what was said.

Negative inquiry A communication technique used to clarify objections and feelings (e.g., I don’t understand . . .).

Negligent hiring Failure of an organi- zation, responsible for the character and actions of all employees, to ascer- tain the background of an employee.

Negotiation A conflict management technique in which the conflicting parties give and take on various issues.

N o n s a l a r y e x p e n d i t u re va r i a n c e s Deviation from the budget as a result of changes in patient volume, supply quantities, or prices paid.

Normative-reeducative strategy A change agent strategy based on the assumption that people act in accor- dance with social norms and values.

Norming The third stage of group de- velopment, in which group members define goals and rules of behavior.

Norms Informal rules of behavior shared and enforced by group members.

Nursing care hours (NCHs) The num- ber of hours of patient care provided per unit of time.

O Objective probability The likelihood

that an event will or will not occur based on facts and reliable information.

Objectives Statements of specific outcomes within a component of an organization.

On-the-job instruction An educational method using observation and practice by which employees learn new skills after being employed.

Operant conditioning A process by which a behavior becomes associated with a particular consequence.

Operating budget An organization’s statement of expected revenues and expenses for the upcoming year.

Ordinary interacting groups Com- mon types of groups; generally have a formal leader and are run accord- ing to an informal structure with the

344 GLOSSARY

purpose of solving a problem or mak- ing a decision.

Organization A collection of people working together under a defined structure to achieve predetermined outcomes.

Organizational culture The basic as- sumptions and values held by mem- bers of an organization.

Organizational environment The system-wide conditions that contribute to a positive or negative work setting.

Organizing The process of coordinat- ing the work to be done within an organization.

Orientation A process by which staff development personnel and man- agers ease a new employee into an organization by providing relevant information.

Outcome standards Standards that re- flect the desired result or outcome of care.

Overdelegation A common form of in- effective delegation that occurs when the delegator loses control over a situ- ation by giving too much authority or responsibility to the delegate.

P Patient classification systems (PCSs)

Systems developed to objectively determine workload requirements and staffing needs.

Patient-centered care A nursing care delivery system that is unit based and consists of patient care coordinators, patient care associates, unit support assistants, administrative support per- sonnel, and a nurse manager.

Patient Protection and Affordable Care Act (PPACA) The health care reform bill signed into law in 2010 de- signed to expand American’s access to health care that awaits court decisions for implementation

Peer review A process by which other employees assess and judge the per- formance of professional peers against predetermined standards.

Perceived conflict One’s perception of another’s position in a conflict.

Performance appraisal The process of interaction, written documentation, for- mal interview, and follow-up that occurs

between managers and their employees to give feedback, make decisions, and cover fair employment practice law.

Performing The fourth stage of group development, in which group mem- bers agree on basic purposes and ac- tivities and carry out the work.

Personal power Power based on an in- dividual’s credibility, reputation, exper- tise, experience, control of resources or information, and ability to build trust.

Personnel decision A decision that af- fect the terms, conditions, and privi- leges of employment.

Philosophy The mission, values, and vision of an organization.

Planning A four-stage process to es- tablish goals, evaluate the present situation and predict future trends and events, formulate a planning state- ment, and convert the plan into an ac- tion statement.

Policy Decisions that govern action and determine an organization’s relation- ships, activities, and goals.

Political decision-making model A decision-making process in which the particular interests and objectives of powerful stakeholders influence how problems and objectives are defined.

Politics A means of influencing the al- location of scarce resources, events, and the decisions of others.

Pooled interdependence A type of in- terdependence in which each individ- ual contributes to the group but no one contribution is dependent on any other.

Pools Internal or external groups of workers that are used as supplemental staff by an organization.

Position control A monitoring tool used to compare actual numbers of employees to the number of budgeted FTEs for the nursing unit.

Position description Describes the skills, abilities, and knowledge re- quired to perform the job.

Position power Power of an individual that is determined by the job description, assigned responsibilities, recognition, advancement, authority, the ability to withhold money, and decision making.

Power The potential ability to influ- ence in order to achieve goals.

Power-coercive strategies Change agent strategies based on the application

of power by legitimate authority, eco- nomic sanctions, or political clout.

Power plays Attempts by others to di- minish or demolish their opponents.

Practice partnership A nursing care delivery system in which senior and junior staff members share patient care responsibilities.

Preceptor An experienced individual who assists new employees in ac- quiring the necessary knowledge and skills to function effectively in a new environment.

Presenteeism When an employee is at work but disabled by physical or men- tal illness.

Probability The likelihood that an event will or will not occur.

Probability analysis A calculation of the expected risk made to accurately determine the probabilities of each alternative.

Problem solving A process whereby a dilemma is identified and corrected.

Process standards Standards con- nected with the actual delivery of care.

Process theories Motivational theories that emphasize how the motivation process works to direct an individual’s effort into performance.

Productivity A measure of how well the work group or team uses the re- sources available to achieve its goals and produce its services.

Profit The difference between revenues and expenses.

Progressive discipline The process of in- creasingly severe warnings for repeated violations that can result in termination.

Punishment A process used to inhibit an undesired behavior by applying a negative reinforcer.

Punishment (coercive) power Power based on penalties that a manager might impose if the individual or group does not comply with authority.

Q Quality initiatives Various initiatives

designed to reduce medical errors. Quality management A preventive

approach designed to address prob- lems efficiently and quickly.

Quantum leadership A leadership style based on the concepts of chaos theory.

GLOSSARY 345

R Rate variances The difference between

budgeted and actual hourly rates paid. R a t i o n a l d e c i s i o n – m a k i n g m o d e l

A decision-making process based on logical, well-grounded, rational choices that maximize the achieve- ment of objectives.

Real (command) groups Groups that accomplish tasks in an organization and are recognized as legitimate orga- nizational entities.

Reality shock The stress, surprise, and disequilibrium experienced when shifting from a familiar culture into one whose values, rewards, and sanc- tions are different (e.g., from a school culture to a work culture).

Recency error The tendency of a man- ager to rate an employee based on re- cent events, rather than over the entire evaluation period.

Reciprocal interdependence A type of interdependence in which members must coordinate their activities with every other individual in the group.

Redesign A technique that examines the tasks within each job with the goal of combining appropriate tasks to im- prove efficiency.

Referent power Power based on admi- ration and respect for an individual.

Re-forming A stage of group develop- ment in which the group reassembles after a major change in the environ- ment or in the goals of the group that requires the group to refocus its activities.

Reinforcement theory (behavior modi- fication) The motivational theory that views motivation as learning and proposes that behavior is learned through a process called operant conditioning.

Reportable incident Any unexpected or unplanned occurrence that affects or could potentially affect a patient, family member, or staff.

Resistance A behavior that can be posi- tive or negative and may mean a re- sistance to change or disobedience, or at times an effective approach to han- dling power differences.

Resolution The stage of conflict that occurs when a mutually agreed-upon

solution is arrived at and both parties commit themselves to carrying out the agreement.

Responsibility An obligation to ac- complish a task.

Restraining forces Behaviors that im- pede change by discouraging partici- pants from making specified changes.

Retail medicine Walk-in clinics that provide convenient services for low- acuity illnesses without scheduled appointments.

Résumé A written record of an indi- vidual’s educational achievements, employment, and accomplishments.

Revenue budget A projection of ex- pected income for a budget period based on volume and mix of patients, rates, and discounts.

Reverse delegation A common form of ineffective delegation that occurs when someone with a lower rank delegates to someone with more authority.

Reward power Power based on in- ducements offered by the manager in exchange for contributions that ad- vance the manager’s objectives.

Risk management A program directed toward identifying, evaluating, and taking corrective action against poten- tial risks that could lead to injury.

Robotics Using robots to deliver sup- plies and remote care.

Role A set of expectations about behav- ior ascribed to a specific position.

Role ambiguity The frustrations that result from unclear expectations for one’s performance.

Role conflict The incompatibility be- tween an individual’s perception of the role and its actual requirements.

Role redefinition The clarification of roles and an attempt to integrate or tie together the various roles that indi- viduals play.

Root cause analysis A method to work backwards through an event to exam- ine every action that led to the error or event that occurred.

Routine decisions The type of de- cisions made when problems are relatively well defined and common and when established rules, policies, and procedures can be used to solve them.

S Salary (personnel) budget A budget

that projects salary costs to be paid and charged to the cost center during the budget period.

Salary compression The effect of a higher starting pay for new nurses or rewarding those with fewer years of experience with higher increases that results in the salaries of long-term employees being at or below those of less-experienced nurses.

Satisficing A decision-making strategy whereby the individual chooses a less- than-ideal alternative that meets mini- mum standards of acceptance.

Self-scheduling A staffing model in which managers and their staff com- pletely manage staffing and schedules.

Sequential interdependence A type of interdependence in which members must coordinate their activities with others in some designated order.

Servant leadership The premise that leadership originates from a desire to serve; a leader emerges when others’ needs take priority.

Service-line structures Organizational structures in which clinical services are organized around patients with specific conditions.

Shaping The selective reinforcement of behaviors that are successively closer approximations to the desired behavior.

Shared governance An organizational paradigm based on the values of in- terdependence and accountability that allows nurses to make decisions in a decentralized environment.

Shared leadership An organizational structure in which several individuals share the responsibility for achieving an organization’s goals.

Shared visioning An interactive pro- cess in which both leaders and follow- ers commit to an organization’s goals.

Six Sigma A quality management pro- gram that uses measures, goals, and management involvement to monitor performance and ensure progress.

Smoothing Managing conflict by com- plimenting one’s opponent, down- playing differences, and focusing on minor areas of agreement.

346 GLOSSARY

Social media Connects diverse popu- lations and encourages collaboration and the exchange of images, ideas, opinions, and preferences through various interactive online methods.

Span of control The number of em- ployees that can be effectively super- vised by a single manager.

Staff authority The advisory relation- ship in which responsibility for actual work is assigned to others.

Staffing The process of balancing the quantity of staff available with the quantity and mix of staff needed by an organization.

Staffing mix The type of staff nec- essary to perform the work of an organization.

Stakeholders People or groups with a direct interest in the work of an organization.

Standards Written statements that de- fine a level of performance or a set of conditions determined to be accept- able by some authority.

Status The social ranking of individu- als relative to others in a group based on the position they occupy.

Status incongruence The disruptive impact that occurs when factors as- sociated with group status are not congruent.

Storming The second stage of group development, in which group mem- bers develop roles and relationships; competition and conflict generally occur.

Strategic planning A process of con- tinual assessment, planning, and eval- uation to guide the future.

Strategies Actions by which objectives are to be achieved.

Stress The nonspecific reaction that people have to threatening demands from the environment.

Strike The organized stoppage of work by employees within the union.

Structure standards Standards that relate to the physical environment, organization, and management of an organization.

Subjective probability The likelihood that an event will or will not occur based on a manager’s personal judg- ment and beliefs.

Suppression The stage of conflict that occurs when one person or group de- feats the other.

Synergy model of care An organiza- tional model that matches patients’ needs to nurses’ competencies.

T Task forces Ad hoc committees ap-

pointed for a specific purpose and a limited time.

Task group Several individuals who work together to accomplish specific time-limited assignments.

Team building A group development technique that focuses on the task and relationship aspects of a group’s functioning in order to build team cohesiveness.

Teams Real groups in which people work cooperatively with each other in order to achieve some goal.

Terminate To fire an employee. Throughput A performance measure

related to moving patients into and out of the health care system.

Time logs Journals of activities that are useful in analyzing actual time spent on specific activities.

Time waster Something that prevents a person from accomplishing a job or achieving a goal.

To-do list A list of responsibilities to be accomplished within a specific time frame.

Total quality management (TQM) A management philosophy that empha- sizes a commitment to excellence throughout an organization.

Total time lost The number of sched- uled days an employee misses.

Transactional leadership A leadership style based on principles of social ex- change theory in which social interac- tion between leaders and followers is essentially economic, and success is achieved when needs are met, loyalty is enhanced, and work performance is enhanced.

Tr a n s fo r m a t i o n a l l e a d e r s h i p A leadership style focused on effect- ing revolutionary change in an orga- nization through a commitment its vision.

Transitions The periods of time be- tween the current situation and when change is implemented.

Trial-and-error method A method whereby one solution after another is tried until the problem is solved or ap- pears to be improving.

Turnover The number of staff mem- bers who vacate a position.

U Underdelegation A common form of

ineffective delegation that occurs when full authority is not transferred, re- sponsibility is taken back, or there is a failure to equip and direct the delegate.

Upward communication Commu- nication that occurs from staff to management.

V Validity The ability to predict out-

comes with some accuracy. Values The beliefs or attitudes one has

about people, ideas, objects, or actions that form a basis for behavior.

Variable budget A budget developed with the understanding that adjust- ments to the budget may be made dur- ing the year.

Variable costs Expenses that depend on and change in direct proportion to patient volume and acuity.

Variance The difference between the amount that was budgeted for a spe- cific cost and the actual cost.

Vertical integration An arrangement between or among dissimilar but re- lated organizations to provide a con- tinuum of services.

Virtual care Technologies used to as- sess, intervene, and monitor patients from remote locations.

Vision A mental model of a possible future.

Vision statement A description of the goal to which an organization aspires.

Volume variances Differences in the budget as a result of increases or de- creases in patient volume.

Voluntary absenteeism Absenteeism that is under the employee’s control.

Voluntary turnover When an employee chooses to leave an organization.

GLOSSARY 347

W Win–lose strategy A strategy used dur-

ing conflict in which one party exerts dominance and the other submits and loses.

Win–win strategy A conflict strategy that focuses on goals and attempts to meet the needs of both parties.

Withdrawal The removal of at least one party from the conflict, making it impossible to resolve the situation.

Work sample questions Questions that are asked to determine an appli- cant’s knowledge about work tasks and the ability to perform a job.

Workplace violence Any violent act, including physical assaults and threats of assault, directed toward persons at work or on duty.

Written comments problem The ten- dency of evaluators not to include written comments on appraisal forms.

Z Zero-based budget A budgetary ap-

proach that assumes the base for projecting next year’s budg e t is zero; managers are required to jus- tify all activities and every proposed expenditure.

348

A Absence culture, 270. See also Employee

attendance model Absence frequency, 269 Absenteeism:

effects, 269 employee attendance model, 269–72, 270f involuntary, 269 managing, 272–73 monitoring, 274 policies, 273–74 stress and, 320 voluntary, 269

Accommodating, in conflict management, 167 Accountability, 132 Accountable care organizations, 23 Activity log, 333–34, 334t Acute care hospitals, 20 Adaptive decisions, 104 Additive task, 151 Adult education theory, 233 Age Discrimination Act, 212 Agency for Healthcare Research and Quality

(AHRQ), 3, 150 Agendas, hidden, 156 Aging population, 7 AIDS, 101 Alternative Dispute Strategies (ADS), 169 Ambiguous evaluation standards problem, 252.

See also Appraisal problems American Academy of Nursing, 115 American Association of Critical Care Nurses

(AACN), 25, 37, 96, 277 American Bar Association, 169 American Board of Nursing Specialties (ABNS),

334. See also Nursing certification American Medical Association, 20 American Nurses Association (ANA), 72, 96, 218,

284, 336 American Organization of Nurse Executives

(AONE), 47 Americans with Disabilities Act (ADA), 214, 291 Annual budget, 187–88 Appraisal problems, 251–53. See also Performance

appraisal ambiguous evaluation standards problem, 252 halo error, 252 leniency error, 251 recency error, 251–52 written comments problem, 252–53

Appraiser. See also Performance appraisal ability, 253 motivation, 253–54

Artificial intelligence, 107 Assignment, 132 Attendance barriers, 269 AT&T’s language line service, 126 Authority, 132 Average daily census, 219 Avoiding, in conflict management, 167

B Baby boomers, 6, 121, 122, 271 Baccalaureate degree for RNs, 334 Bargaining agent, 311, 312 Baylor plan, 222 Behavior modification (reinforcement theory),

229–31 shaping in, 230

Behavioral interviewing, 205, 206t, 329 Behavior-oriented evaluations, 241–44, 242t–243t Behavior-oriented rating scales, 241, 244 Benchmarking, 3 Benefit time, 189 Block staffing, 221 Bona Fide Occupational Qualification (BFOQ), 211 Brainstorming, 108–9, 108f Budget(s), 185–86

capital, 192 expense, 188 fixed, 187 improvement, 196 incremental. See Line-by-line monitoring, 193–95 operating. See Annual budget problems of, 195–97 revenue, 188–89 salary. See Personnel budget staff impact on, 196 supply and nonsalary expense, 191–92 variable, 187 worksheet, 186–87 zero-based, 187

Budgeting: approaches to, 185 Case Study, 196t future trends, 193–95 overview, 185–86 process, 185–86. See also Controlling; Planning timetable, 192–93

Bullying: examples of, 284 in health care, 284

Bureaucracy, 12 Burnout, 320. See also Stress Business necessity, 211

C California Critical Thinking Disposition Inventory,

100 Capital budget, 192 Capitation, 23 Care maps. See Critical pathways Career advancement, 234–35 Career development and advancement:

adapting to change and, 338 Case Study, 333 envisioning the future, 326 first position, 326–27

accepting, 331 applying for, 327 criteria for, 326 declining, 331 interviewing for, 328 post-interview letter, 331 second interview for, 331

identifying learning needs, 334–36 leaving present position, 337 mentors for, 336 next position, 336–37 self-assessment, 337 taking wrong job, 337–38 tracking progress, 333–34t

Carnegie Foundation, 7, 101 Case management, 34–35, 34f Case method, 32, 32f Case Studies:

budget management, 196t collective bargaining, 313t

communication, 128t conflict management, 169t creative problem solving, 104t critical thinking and problem solving, 113t delegation, 137t emergency preparedness, 299t encouraging change, 66t evaluating staff, 254t motivation, 236 problem staff, 287t progressive discipline, 263t risk management, 82t scheduling, 223t staff retention, 279t staff selection, 214 stress management, 322t team building, 154t terminating staff, 265t time management, 178t using organizational politics for personal advantage, 95t

workplace violence, 307t Centers for Medicare and Medicaid Services, 2 Centralized pool, 224 Certification, 334. See also Nursing certification Certification to contract, 312. See also Unionization Change, 56

constant, 66–67 implementing, 65–66 initiating, 64–65, 66t nurse’s role in, 64–66, 66t resistance to, 62–64

Change agent, nurse as, 56–57 Change process:

assessment, 58–60 Case Study, 66t evaluation, 61 implementation, 60–61 planning, 60 steps in, 59t

Change strategies: empirical–rational model, 62 normative-reeducative, 62 power-coercive, 61–62

Change theories, 57–58, 57f, 58t Chaos theory, 15, 42 Charge nurse, 49 Chronic care model, 37–38. See also Nursing care

delivery Civil Service Reform Act of 1978, 311 Classical theory, 12–14, 13f

chain of command, 12–13, 13f division and specialization of labor, 12 elements of, 12–14, 13f organizational structure, 12 span of control, 13–14, 13f

Clinical advancement program, 235 Clinical information systems, 70 Clinical ladder, 145, 234–35 Clinical mentee, 234–35 Clinical microsystems, 37 Clinical nurse leader, 50–51 Closed shop, 311 Coach, 234 Coaching, 234, 258–59

leaders, 259 leadership, 259 positive behavior reinforcement, 259 steps of, 258–59

Cohesiveness, 151–52

INDEX

Page numbers followed by f indicate figures and those followed by t indicate tables or boxes.

348

INDEX 349

obstacles to, 114–15. See also Stumbling blocks vs. problem solving, 103–4 process, 106–7, 107t steps in, 107t stumbling blocks, 114–15 techniques, 107–8, 108f types of decisions, 104 under uncertainty and risk, 105–6, 105t

Delegation, 132, 176 accepting, 137 accountability in, 132 vs. assignment, 132 authority in, 132 benefits of, 132–33 Case Study, 137t decision tree, 134f five rights of, 133–34, 133t, 134f ineffective, 138–41 liability and, 133, 139–40 obstacles to, 138–41 process, 134–36, 135t, 136t responsibility in, 132

Demand management, 219 Deming, W. Edwards, 3, 70 Democratic leadership, 110 Depression, 320. See also Stress Descriptive rationality model, 106 Diagnosis-related groups (DRGs), 34, 188 Diagnostic procedure incident, 79 Diagonal communication, 120. See also

Communication Differentiated practice, 36 Difficult people, communication

with, 125 Direct cost, 188 Directing, 47 Disasters, 295–96. See also Emergencies

examples of, 295t levels of, 295

Discipline, 260–62, 261t, 262t problems faced by managers, 260

Disgruntled employees, 287. See also Staff Disjunctive task, 151 Disruptive conflict, 161 Distorted communication, 118–20, 119t.

See also Communication causes of, 119–20 intersender conflict, 119 intrasender conflict, 119 metacommunications, 118–19

Diversification, 22 Divisible task, 151 DMAIC method, 74, 74f Downward communication, 120.

See also Communication Drexel University’s College of Nursing, 115 Driving forces, 57 Drop-in visitors, 181 Dynamic Network Analysis Decision Support

(DyNADS) project, 108

E Effective listening, 120–21

barriers, 120–21 defensiveness, 121 flagging energy, 120 habit, 121 lack of self-confidence, 120 preconceived beliefs, 120

Efficiency variance. See Quantity variance Electronic health records (EHRs), 5.

See also Health care Electronic medical records (EMRs), 75 Electronic medication administration record

(eMAR), 76 E-mail, 118, 120, 122, 124, 129

managing, 180–81

Conflict management, 165–70 accommodating in, 167 avoiding in, 167 Case Study, 169t collaboration in, 167 competing in, 167 compromise in, 167 confrontation in, 166–67 forcing in, 167–68 negotiation in, 167 resistance in, 168 smoothing in, 167

Confrontation: about policy violation, 259–60, 260t in conflict management, 166–67 steps in, 259–60, 260t

Conglomerate diversification, 22 Conjunctive task, 151 Connection power, 88 Consensus, in conflict management, 168 Contemporary theories, 42–44

emotional leadership, 44. See also Emotional intelligence

quantum leadership, 42 and chaos theory, 42

servant leadership, 44 shared leadership, 43–44

in nursing, 43–44 transactional leadership, 42–43. See also Social exchange theory

transformational leadership, 43 Content theories, motivation, 229 Contingency planning, 46 Contingency theory, 14–15 Continuing education, 335 Continuous quality improvement (CQI), 34, 47,

71–72 Controlling, 47, 186 Core competencies, 297 Corporate health care network, 22f Cost:

direct, 188 fixed, 188 indirect, 188 variable, 188

Cost centers, 186 Cost consciousness, 186 Covey, Stephen, 87 Creativity, 101–3, 102t, 103f

employees and, 101 incubation, 103, 103f insight, 103, 103f preparation, 103, 103f stages in, 103 verification, 103, 103f

Critical incidents, 244t, 245 Critical pathways, 35–36 Critical thinking, 100

Case Study, 104t, 113t characteristics, 102t creativity in, 101–3, 102t, 103f model, 100f in nursing process, 100–101, 102t using, 101

Critical-thinking skills, 100, 101 Crossing the Quality Chasm, 23 Cross-training, 203–4 Cultural differences, in communication, 121–22

D Dashboards, 76 Decentralized pool, 224 Decision making, 103

under certainty, 104–5 conditions surrounding, 104–6, 105t group techniques, 108–9 integrative, 168

Co-leadership, 44 Collaboration, in conflict management, 167 Collaborative communication, 126–28. See also

Communication Collective activity, politics as, 93 Collective bargaining. See also Unionization

Case Study, 313t laws governing, 311 legal issues for nurses in, 313–14 nurses, future of, 314 private vs. public sector, 311

Combined staffing, 221–22 Command group, 144 Committees, 144. See also Task forces

formal, 154 informal, 154 leading, 154–56

Communication, 118 with administrators and superiors, 123–25, 124t Case Study, 128t with coworkers, 125 with difficult people, 125 directions of, 120 distorted. See Distorted communication effective listening, 120–21 with employees, 123 gender differences in, 121, 121t, 122t generational and cultural differences in, 121–22 goal of, 118 in group, 153 improving, 127–28, 127t leadership and, 123 with medical staff, 125–26 modes of, 118 organizational culture and, 122 with other health care personnel, 126 with patients and families, 126 with subordinates, 123–24

Communication skills, enhancement of, 129 Communication technology, 5–6

smartphones, 5 social media, 5–6

Compassion fatigue, 320. See also Stress Competency-based interviewing. See Behavioral

interviewing Competing, in conflict management, 167 Competing group, 145 Competition, for scarce resources, 164 Competitive conflict, 161 Complaint handling, 80–81 Complexity theory, 15 Comprehensive quality management plan, 72 Compromise, in conflict management, 167 Computerized prescriber order entry (CPOE), 76 Concentric diversification, 22 Conflict, 161, 319

behavior, 165 competitive, 161 disruptive, 161 felt, 164 intergroup, 161 interpersonal, 161 interprofessional, 161–62 intragroup, 161 intrapersonal, 161 management, 165–70, 169t mediation, 166 outcomes, 165 perceived, 164 process model, 162–65, 162f resolution, 165 responses, 166–68 role, 163 structural, 163 suppression, 165 types, 161–62 withdrawal from, 167

350 INDEX

robotics and remote care, 5 terrorism and disaster preparedness, 6 violence in, 6, 303–4

Health care environment, 44 Health care organizations, 3, 30, 41, 43, 144

diversification, 22 interorganizational relationships, 21, 22f ownership types, 18–19, 19f redesigning, 23–24 strategic planning, 24–25 types of, 19–21

Health Information Technology for Economic and Clinical Health Act (HITECH), 76

Health Resources and Services Administration (HRSA), 6–7

Hidden agendas, 156 Hire decision, 210–11

education and experience requirement, 210

information integration, 210–11 making an offer, 211

Homans, G., 146 Home health care, 20 Home health care agencies, 20 Horizontal integration, 21, 22f Horizontal promotion, 234–35 Hospitals

acute care, 20 emergency preparedness, 296–98 magnet, 4

Humanistic theory, 14 Hybrid structure, 16

I Image:

politics and, 93 as power, 89–91

Implementation, in staff development process, 232

Incident reports, 78 Incoming messages, 180 Incremental (line-by-line) budget, 187 Indicator, 72 Indirect cost, 188 Industrial Revolution, 12 Ineffective delegation, 138–41

overdelegation, 140–41 reasons for, 138–41 reverse delegation, 140 underdelegation, 140

Inflation rate index, 191 Informal committees, 154 Informal groups, 144 Informal leadership, 41. See also Leadership Information power, 88 Innovation, 115 Innovative decisions, 104 Institute of Healthcare Improvement (IHI),

36, 74–75 Institute of Medicine (IOM), 2, 7, 23, 56, 70 Integrated health care networks, 21 Integrative decision making, 168 Interdependence:

pooled, 151 reciprocal, 151 sequential, 151

Intergroup conflict, 161 Internal float pools, 223–24 International Institute of Conflict Prevention and

Resolution, 169 Interpersonal conflict, 161 Interpersonal endeavor, politics as, 93 Interprofessional conflict, 161–62 Interrater reliability, 209 Interruption log, 179, 179t Interruptions, controlling, 178–82 Intersender conflict, 119

4 Ps of marketing, 202–3 place, 203 price, 203 product, 203 promotion, 203

Full-time equivalents (FTEs), 189–90, 219–20 example of, 219–20 and position control, 195

Functional nursing. See Task nursing Functional structure, 16

G Gender differences, in communication,

121, 121t, 122t Gender-neutral communication, 121, 122t.

See also Communication Generation X, 6, 122, 271 Generational differences:

in absenteeism, 271 in communication, 121–22

Goal setting, 175–76 Goals, 25, 163, 175

incompatible, 163 Goal-setting theory, 231 Graduate education, 335 Grapevine communication, 120.

See also Communication Grievances, 312 Group(s):

cohesiveness, 151–52 communication in, 153 competing, 145 composition, 151 decision making in, 108–9 formal, 144, 146 informal, 144, 146 manager, 144

leadership style, 146 meetings, 155–56, 156t members, 144, 146 norms in, 147–48 ordinary interacting, 145–46 problem solving in. See Group problem solving

process, 147–49, 147f productivity, 151 real. See Command roles in, 148–49 size, 151 status, 149 task, 144, 151. See also Task forces types, 144–46 value, 149

Group evaluation, 245 Group problem solving, 112–14, 113f

advantages of, 112–13 disadvantages of, 113–14, 113f groupthink, 114

Groupthink, 114

H Halo error, 252. See also Appraisal problems Havelock, change theory, 57, 58t Hawthorne effect, 14 Health care, 30

changes in, 2 cost consciousness in, 186 cultural, gender and generational differences, 6 delivery of, 35 electronic health records (EHRs), 5 error reduction efforts, 2–3 evidence-based practice, 3–4 health care networks, 21 pay for performance, 2 paying for, 2, 188 quality improvement, 74–76 quality improvement, 2–4

Emergencies, 295 employees, impact on, 298 man-made disasters, 295 natural disasters, 295 types of, 295

Emergency operations plan (EOP), 296–97 planning, 296 practicing, 297 preparing, 297

Emergency preparedness: Case Study, 299t hospitals response to, 296–99, 299t

emergency services, continuation of, 297–98 national responses to, 296 triage system, 297

Simple Triage and Rapid Treatment (START), 297

Emotional intelligence, 44, 162 and leadership, 44

Employee assistance programs (EAPs), 321–22 See also Stress

Employee attendance model, 269–72, 270f. See also Absenteeism

absence culture, 270–71 generational differences, 271 job, nature of, 270 labor market, 271–72 management, 271 organizational practices, 270 personal characteristics, 272

Engagement, 277 Equal Employment Opportunity Commission

(EEOC), 211 Equity, 231 Equity theory, 231 Erwin, change theory, 58 Evidence-based practice (EBP), 3–4, 75. See also

Health care Expectancy, 230–31 Expectancy theory, 230–31 Expense budget, 188 Experimentation, 109 Expert power, 88 Expert systems, 107 External pools, 224 Extinction, 230

F Family:

communication with, 126 dissatisfaction with care, 79

Family and Medical Leave Act (FMLA), 274–75

Fayol, Henry (French industrialist), 46 Federal Emergency Management Agency

(FEMA), 296 Federal Mediation and Conciliation Service

(FMCS), 312 Felt conflict, 164 Filley’s strategy, 168

lose-lose, 168 win–lose, 168 win–win, 168

Fiscal year, 187 Fixed budget, 187 Fixed cost, 188 Fogging, 124 Followers, 51

characteristics of, 51 nurse, 51

Followership, 51. See also Leadership Forcing, in conflict management,

167–68 Formal committees, 154 Formal groups, 144 Formal leadership, 41. See also Leadership Forming, 146

INDEX 351

Motivational theories: content, 229 equity, 231 expectancy, 230–31 goal-setting, 231 process, 229–31 reinforcement, 229–31

N National Center for Health Statistics

(NCHS), 296 National Center for Nursing Research, 93 National Commission for Certifying Agencies

(NCCA), 334. See also Nursing certification National Council of State Boards of Nursing

(NCSBN), 133–34 National Emergency Preparedness Education

Coalition, 297 National Institute of Nursing Research, 93 National Institutes of Health (NIH), 93 National Labor Relations Act (NLRA), 311–12 National Labor Relations Board

(NLRB), 311–12 National Nurses United, 314 National Quality Forum, 74 Negative assertion, 124 Negative inquiry, 124 Negligent hiring, 211 Negotiation, 167 Nightingale, Florence, 93 Nonsalary expenses, 187

variance, 194 Nonverbal communication, 119, 123. See also

Communication Normative-reeducative strategy, 62 Norms, 147–48 Nurse managers, 2, 24, 42–43

challenges facing, 7–8 as change agents, 56, 65, 66t. See also Change charge nurse, 49 clinical nurse leader, 50–51 communication of, 153 competencies of, 47, 48t first-level management, 48–49

and health care, 48 staff nurse, 48 stress factors for, 318–21 stress management strategies of, 318 sucess of, 51 as team leader, 153–54, 154t

Nurse staffing, 76 Nursing:

career in, 326 certification, 334. See also Nursing certification

cost consciousness in, 188 cultural and gender differences in, 6 cultural diversity in, 6 education, 7 future of, 7 gender mix in, 6 management training, 7–8 opportunities in clinical areas, 333 political history, 93 shortage, 7 training, 6

Nursing care delivery: evolving models, 36–38

chronic care model, 37–38 clinical microsystems, 37 patient-centered care, 36–37 synergy model of care, 37

integrated models, 34–38 case management, 34–35, 34f critical pathways, 35–36 differentiated practice, 36 practice partnership, 34, 34f

Leadership coaching, 259 Leadership development, 235 Lean Six Sigma, 73–74 Leapfrog Group, 3 LegacyMd, 126 Legitimate power, 88 Length of stay (LOS), 220 Leniency error, 251. See also Appraisal problems Lewin, force-field model of change, 57–58, 57f, 58t Liability, delegation and, 133, 139–40 Licensed Practical Nurses (LPN), 30–32 Licensure requirements, 210 Line authority, 12–13, 13f Line-by-line budget, 186–87

advantage of, 187 Lippitt, change theory, 57, 58t Long-term care facilities, 20–21 Lose-lose strategy, in conflict

management, 168

M Machiavelli, Niccolò, 12 Magnet hospitals, 4 Magnet Recognition Program, 4 Magnet-certified hospitals, 197 Managed health care organizations:

health maintenance organizations (HMOs), 23 point-of-service plans (POS), 23 preferred provider organizations (PPOs), 23 types of, 23

Managers, 41 first-level, 48 as leader, 231 time of, 175

Managing teams, 150–53 development and growth, 152 group size and composition, 151 productivity and cohesiveness, 151–52 shared governance, 152–53 task, 151

additive, 151 conjunctive, 151 disjunctive, 151 divisible, 151

Manthey, Marie, 33–34 Marginal employees, 286. See also Staff Marketing, 4 Ps of, 202–3 Matrix structure, 16 Mediation, 169 Medical home, 23–24 Medical technologies:

changes in, 5 communication technology, 5–6 electronic health records (EHRs), 5 hospital information systems (HIS), 5 point-of-care data entry (POC), 5 robotics and remote care, 5. See also Robotics virtual care, 5

Medical-legal incident, 79 Medication errors, 76, 78–79 Meeting:

mambers of, 155–56 participation of, 155 patient care conferences, 157–58

conducting, 155–56, 156t task forces, 156–57

place and time of, 155 preparation of, 155

Meeting management, 182 Mentor, 233–34, 336 Mentoring, 233–34 Metacommunications, 118–19 Mission, 24 Modular nursing, 31f Mortality rate, 30 Motivation, 228f, 229

Case Study, 236t

Interview, 204–5, 328–31 closing, 208, 330 giving information in, 208 job-related questions, 329t job-related questions in, 205, 206t legal considerations, 211–12, 212t, 213t, 329 opening, 208 preparation for, 205–7, 328–29 principles for effective, 205–8 reliability and validity, 209–10 role-play in, 330 salary negotiation, 331 staff involvement in, 209, 328 structured guides for, 205

Interview guide, 205, 328–29 Intragroup conflict, 161 Intrapersonal conflict, 161 Intrarater reliability, 209 Intrasender conflict, 119 Investment centers, 186 Involuntary absenteeism, 269. See also Absenteeism Involuntary turnover, 276. See also Turnover

J Job contributions, 231 Job enlargement, 173 Job performance, 320. See also Performance

appraisal consequence of stress on, 320 documenting, 244–48 employee ability in, 232–33 model, 228–29, 228t motivation in, 229–31 problem diagnosis, 247–48, 248f skill competency evaluation, 247

Job satisfaction, 231 Joint Commission on Accreditation of Healthcare

Organizations, 70, 74–75 staffing requirements, 218

Joint venture, 22 Just culture, 82

K Kentucky River trilogy, 314

L Lack of civility, 284–85. See also Staff

aggressive behaviors, 285 Lateral communication, 120.

See also Communication Lateral violence, 285–86. See also Staff Leaders, 41

administrative, 44 clinical, 44 clinical nurse, 50 and managers, 41 nurse, 51–52

sucess of, 51–52 servant, 44

characteristics of, 44 transformational, 43

Leadership: behaviors, 42 communication and, 123. See also Communication

competencies of, 49f emotional, 44 formal, 41 informal, 41 power and, 87 quantum, 42 sevant, 44 shared, 43–44 skills, 45 style, 42 transactional, 42–43 transformational, 43

352 INDEX

electronic medical records (EMR) and, 75 evidence-based practice (EBP) and, 75 medication errors and, 76 national initiatives for, 74–75 nurse staffing and, 76 peer review and, 76

Quality management, 2–3, 70–74 components of, 72–73 continuous quality improvement (CQI), 71–72 DMAIC method, 74, 74f Lean Six Sigma, 73–74 Six Sigma, 73 total quality management, 3 total quality management (TQM), 70–71, 71f

Quantity variance, 194

R Rate variance, 194 Rational decision-making model, 106 Reagan, Ronald, 93 Real (command) groups, 144 Reality shock, 319 Recency error, 251. See also Appraisal problems Reciprocal interdependence, 151 Recruiting applicants, 200 Recruitment. See Staff, recruitment and selection Redesign, 23 Referent power, 88 Re-forming, 147 Registered Nurses (RN), 30–32 Reimbursement, 195 Reinforcement theory (behavior modification),

229–31 Reportable incident, 78 Residency programs, nurse, 234 Residential care facilities, 21 Resistance, in conflict management, 168 Resistance, to change, 62–64

management of, 63–64 reasons for, 62–63

Resolution, 165 Responsibility, 132 Restraining forces, 57 Results-oriented evaluations, 241 Resume, 327–28, 327t, 331

writing, 331 accomplishments, 327 educational achievements, 327 employment, 327

Retail medicine, 20 Retention rate, 218 Revenue budget, 188–89 Revenue centers, 186 Reverse delegation, 140. See also Ineffective

delegation Reward power, 87 Right-to-work state, 311 Risk management, 77–82

blame-free environment and, 81–82 Case Study, 82t incident examples, 78–79 nurse manager’s role, 80–81 nursing’s role in, 77–78 root cause analysis, 80

Robert Wood Johnson Foundation, 36 Robotics, 5

laser-guided robots, 5 mobile robots, 5

Rogers, change theory, 57–58, 58t, 63 Role, 148–49, 163

nurturing, 149 task, 148

Role ambiguity, 319 role underload, 319 underutilization, 319

Role conflict, 163, 319. See also Conflict Role redefinition, 321. See also Stress

documenting performance for, 244–48 evaluation methods, 241–44, 242–43t interview, 248–51 potential problems, 251–53 process of, 240 purpose of, 240 rules of thumb, 255

Performance evaluation, 47, 49, 153, 154t Performing, 147 Personal power, 88 Personnel budget, 189–91, 189t

managing, 189 Personnel decision, 211 Philosophy, organizational, 24 Phone calls, managing, 179–80 Physical examinations, in recruitment process, 210 Planning, 46, 185, 235 Policy, 93

violation of, 259–60, 260t Political decision-making model, 107 Political savvy, 94 Politics, 92–93 Pooled interdependence, 151 Pools, 223–24

external, 224 internal float, 223–24

centralized, 224 decentralized, 224

Position control, 195 Position description, 200, 201t Position power, 88 Post-anesthesia recovery areas, 34 Posttraumatic stress disorder (PTSD), 320.

Familial Health Traditions

April 10, 2022/in Nursing /by admin

Instructions:

Read and follow the directions on pages 160 and 161.
Conduct an interview with an older family member.
Summarize your findings regarding familial and social changes, and your ethnocultural and religiousheritage. (Include one example)
Your paper should be:
- One (1) page
- Typed according to APA style for margins, formating and spacing standards
  - See NUR3045 – Library (located on left-side on menu) for tutorial Using APA Style
- Typed into a Microsoft Word document, save the file, and then upload the file.
- I ATTACHED THE PDF OF THE BOOK SO YOU CAN LOOK AT PAGE 160 AND 161 WHCIH IS PART OF CHAPTER 7

Nursing Research Methods and Critical Appraisal for Evidence-Based Practice

Models of Health Throughout history

Obesity In Adults

Formulate a PICOT statement using the PICOT format provided in the assigned reading

Personal Philosophy of Nursing Paper:

The Evidence-Based Practice Movement

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