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PubMed2002

Does international nurse recruitment influence practice values in U.S. hospitals?

PURPOSE: To determine if both U.S. and international nurses place high value on organizational attributes that comprises the elements of professional nursing practice and if the absence of these attributes is associated with high levels of burnout in both U.S. and international nurses. DESIGN: A secondary analysis of survey data was conducted with a sample of 799 nurses; 547 were born in the United States (US) and 252 were from 34 other countries. METHODS: Culture of origin was coded according to Hofstede's classification system. Nursing values related to the professional practice environment were measured using the Nursing Work Index, and burnout was measured using the Maslach Burnout Inventory. Analysis of variance and least-squares regression procedures were used to test hypotheses. FINDINGS: No significant differences were found between U.S. and international nurses in the overall degree to which they valued a professional nursing practice environment. A professional practice environment had a significant, inverse effect on job-related burnout on both U.S. and international nurses. CONCLUSIONS: These findings challenge a prevailing sentiment that international nurses hold values inconsistent with professional practice models as defined in the U.S. context. These findings also show that absence of a professional practice environment will produce similar high levels of burnout in both U.S. and foreign-born nurses. To address the nursing shortage, administrators should ensure that organizational attributes are consistent with a professional nursing practice environment.

Emigration and Immigration↗
PubMed2005

Nurse staffing and patient outcomes in Veterans Affairs hospitals.

OBJECTIVE: To assess characteristics and perceptions of nurses working in the Veterans Health Administration (VHA), comparing types of nursing personnel, to benchmark to prior studies across healthcare systems. BACKGROUND: Prior studies have shown relationships between positive registered nurse (RN) perceptions of the practice environment and patient outcomes. To date, no study has reported the comparison of RN perceptions of the practice environment in hospital nursing with those of non-RN nursing personnel. This study is the first to offer a more comprehensive look at perceptions of practice environment from the full range of the nursing work force and may shed light on issues such as the relationship of skill mix to nurse and patient outcomes. METHODS: Cross-sectional observational study with a mailed survey administered to all nursing personnel in 125 VA Medical Centers between February and June 2003. RESULTS: Compared with other types of nursing personnel in the VHA, RNs are generally less positive about their practice environments. However, compared with RNs in other countries and particularly with other RNs in the United States (Pennsylvania), VHA RNs are generally more positive about their practice environment and express more job satisfaction. CONCLUSIONS: The nursing work force of the VHA has some unique characteristics. The practice environment for nurses in the VHA is relatively positive, and may indicate that the VHA, as a system, provides an environment that is more like magnet hospitals. This is significant for a public sector hospital system.

Adult↗
PubMed2004

Nursing practice issues in Jordan: student-suggested causes and solutions.

BACKGROUND: The causes of the worldwide shortage of registered nurses are complex and require a multifaceted approach to the solution. It is imperative that issues of the practice environment are addressed because creating quality practice environments is essential to provide high-quality care and to persuade nurses to remain in practice. AIMS: The aims of this paper are to describe an international collaborative relationship, and to identify, describe and suggest solutions to three nursing practice issues relevant to Jordanian nursing. METHOD: Two faculty members, one from Jordan and one from Canada, collaborated via e-mail to develop a fourth-year course on nursing leadership and management, which was then jointly taught by them. A student assignment required students, working in groups, to identify a nursing practice issue in Jordan and suggest contributing causes and solutions. CONCLUSION: The issues identified by the students were: unclear role expectations, burnout and turnover, all of which were viewed as contributing to problematic practice settings. The students suggested possible solutions to the practice environment issues.

Attitude of Health Personnel↗
PubMedDate not supplied

An essential component of the Magnet journey: fostering an environment for evidence-based practice and nursing research.

Creating, advancing, and sustaining a practice environment grounded in evidence-based practice and nursing research is essential to achieving Magnet status. The purpose of this article is 2-fold. First, to describe a model for the integration of evidence-based practice. Second, to illustrate how a community hospital used this model as a framework for the integration of evidence-based practice and nursing research as part of its journey toward achieving Magnet status.

Benchmarking↗
PubMed2002

Perceptions of the physical environment, stage of change for physical activity, and walking among Australian adults.

Data for this study were from a population survey of 1,200 adults ages 40-60 years, sampled from the Illawarra region of New South Wales. Questionnaire items on perceptions of the environment were factor analyzed into: Aesthetic Environment and Practical Environment. For both factors, those in the Contemplation stage had more negative views of the environment than those in Maintenance. Those who walked for 0-20 min/week held more negative perceptions of their environment than those who walked for 21-120 min/week and those who walked for > 120 min/week. The health promotion implications of these findings are that environments perceived as attractive and as providing convenient access to services and facilities may influence motivational readiness for physical activity and time spent walking.

Adult↗
PubMed1995

Strategic planning for residency training programs.

Residency training is practice-based learning that is reflective of the practice environment. As practice changes, changes in residency training are needed. Strategic planning is a process that considers internal and external factors that will impact the future. The planning process includes gathering input, focusing on important issues, developing a consensus, and writing clearly defined goals. The strategic planning process was applied to residency training at Hamot Medical Center. A retreat was held, consensus was developed, and a plan was written. The planning process prepared us to make changes in the types of residency programs we offered. This article describes strategic planning for our residency and progress on our goals.

Competency-Based Education↗
PubMed1996

Survey of literacy environments and practices in residences at schools for the deaf.

The purpose of this study was to add to the sparse knowledge about literacy environments and practices in children's residences at schools for the deaf by conducting a nationwide survey. Twenty-six residential schools for the deaf throughout the country responded by mail. Results revealed that all of the responding schools made reading and writing materials available to children in their residences. Counselors read to children individually and supervised homework, and children wrote letters and read independently. However in half of the residences, materials were not regularly rotated and in most residences time was not set aside for group storybook reading. Implications for practice include focusing on providing interesting and stimulating literacy materials for children, rotating materials regularly, and planning group literacy-related events such as storybook reading or storytelling.

Deafness↗
PubMed2004

Traditional and non-traditional collective bargaining: strategies to improve the patient care environment.

Acquiring organizational autonomy and control over nursing practice, through a combination of traditional and non-traditional collective bargaining (CB) strategies, is emerging as an important solution to the nursing shortage crisis. For the past 60 years, nurses have improved their economic and general welfare by organizing through traditional CB, particularly during periods of nursing shortages. During the past decade, however, the downsizing of nursing staffs, systems redesign, and oppressive management practices have created such poor nursing practice environments that improvement in wages no longer is viewed as the primary purpose of CB. Much more essential to nurses is assuring they have a safe practice environment free of mandatory overtime and other work issues, and a voice in the resource allocation decisions that affect their ability to achieve quality health outcomes for patients. The thesis presented in this article is that traditional and non-traditional CB strategies empower nurses to find such a voice and gain control over nursing practice. This article describes the current shortage; discusses how CB can be used to help nurses find a voice to effect change; reviews the American Nurses Association's (ANA's) history of collective action activities; explains differences between traditional and non-traditional CB strategies; and presents a case study in which both strategies were used to improve the present patient care environment.

Collective Bargaining↗
PubMed2001

Understanding practice from the ground up.

BACKGROUND: Our objective was to understand family practices from the ground up through intensive direct observation of the practice environment and patient care. METHODS: Eighteen practices were purposefully drawn from a random sample of Nebraska family practices that had earlier participated in a study of preventive service delivery. Each practice was studied intensely over a 4- to 12-week period using a comparative case study design that included extended direct observation of the practice environment and clinical encounters, formal and informal interviews of clinicians and staff, and medical record review. DESIGN: This multimethod assessment process (MAP) provided insights into a wide range of practice activities ranging from descriptions of the organization and patient care activities to quantitative documentation of physician- and practice-level delivery of a wide range of evidence-based preventive services. Initial insights guided subsequent data collection and analysis and led to the integration of complexity science concepts into the design. In response to the needs and wishes of the participants, practice meetings were initiated to provide feedback, resulting in a more collaborative model of practice-based research. CONCLUSIONS: Our multimethod assessment process provided rich data for describing multiple aspects of primary care practice, testing a priori hypotheses, discovering new insights grounded in the actual experience of practice participants, and fostering collaborative practice change.

Data Collection↗
PubMedDate not supplied

In their own words: the experience of returning to acute care practice.

The worldwide nursing shortage requires hospitals to utilize innovative recruitment strategies to attract registered nurses. One of these strategies is the "re-entry" program for registered nurses currently employed outside the hospital. Although there is significant literature on the development of such programs and the personal adjustments made by participants, there is a paucity of literature regarding the experience of returning to practice from a professional practice perspective. This study examines the experience of the registered nurse who returns to acute care, using a descriptive, exploratory qualitative design, and asking: (1) What is the meaning of the nurses' experience when returning to acute care practice? (2) To what extent does the practice environment facilitate the retention of nurses who return to practice? (3) To what extent does the practice environment hinder the transition back to practice? Data indicate that returning registered nurses perceptions could be categorized into 3 themes: (1) motivation prior to entry, (2) coping during the process of returning to practice, and (3) the impact of the role of environment in the facilitation of or hindrance to nurse retention. Implications for staff development specialists are discussed.

Acute Disease↗
PubMed2004

Preanesthetic evaluation in private practice.

The preanesthetic evaluation is an essential element of the anesthetic management of a patient. The type of practice, academic or private, should have no bearing on the quality of the evaluation. The practice environment may play a significant role in the type of patient and procedure but should not diminish the quality of care for any particular patient. However the extent, timing methodologies for the preanesthetic evaluation will vary according to patient medical requirements, surgical procedures, resource availability, patient convenience and,perhaps the key element, staffing availability. Each practice environment needs to develop its own solutions. Private practice, especially in the smaller locations,may need to be more sensitive to staffing and personnel issues and patient satisfaction. Technology, especially in the smaller private practice environments where staffing is more likely to be an issue, may greatly facilitate the process and improve the quality. However, technology may require extensive support (time and money) to implement, but the indirect gains should justify the effort.

Anesthesia↗
PubMed1996

Key influences on the professional socialisation and practice of students undertaking different pre-registration nurse education programmes in the United Kingdom.

A principal aim of pre-registration nurse education programmes is the process of effective socialisation of students into the professional role. Key influences on the professional socialisation and practice of students undertaking such programmes were explored using a semi-structured interview approach (N = 99). This work formed part of a major comparative study of outcomes of pre-registration nurse education programmes in the United Kingdom. Analysis revealed differences between the programmes regarding positive influences of the respective courses; therapeutic influences of the practice environment; modelling performance on exemplars of high quality practice; and the identification of teachers within the educational setting and nurses in practice as key persons. This study has confirmed that the positive influence of the education programmes and the practice environment as well as high quality role models from both education and practice establishments are critical to the professional socialisation of student nurses.

Curriculum↗
PubMedDate not supplied

Effect of training and a structured office practice on physician-delivered nutrition counseling: the Worcester-Area Trial for Counseling in Hyperlipidemia (WATCH).

We examined the effectiveness of a training program for physician-delivered nutrition counseling, alone and in combination with a structured office practice environment for nutrition management, on physicians' counseling practices. Forty-five primary care internists and 1,278 of their patients in the top quarter of the cholesterol distribution at a central Massachusetts health maintenance organization (the Fallon Clinic) were enrolled into a randomized controlled trial. Physicians were randomized by site into three conditions: (1) usual care, (2) physician nutrition counseling training, and (3) physician nutrition counseling training plus a structured office practice environment for nutrition management (prompts and the provision of lipid results and counseling algorithms). A randomly selected 325 patients were given a 10-item patient exit interview (PEI) assessing whether the physician provided advice; assessed past changes, barriers, and resources; negotiated specific plans and goals; provided patient materials; referred the patient to a dietitian; and developed plans for follow-up. Condition 3 physicians demonstrated significantly greater implementation of the nutrition counseling sequence than did physicians in either of the other two conditions (P < .0001). Referrals to nutrition services were markedly reduced in condition 2, despite PEI scores no different than those in condition 1. Higher PEI scores for patients seen by physicians in condition 3 were stable for as long as two years beyond training. Primary care internists, when provided with both training in counseling techniques and a supportive office environment, will carry out patient counseling appropriately. Training alone, however, is not sufficient and may be counterproductive. Medical Subject Headings (MeSH): hypercholesterolemia, diet therapy, coronary disease, health behavior, primary health care, medical education, managed care programs.

Adult↗
PubMedDate not supplied

Measuring organizational traits of hospitals: the Revised Nursing Work Index.

BACKGROUND: The organizational context in which nurses practice is important in explaining variation in patient outcomes, but research has been hampered by the absence of instruments to measure organizational attributes empirically. OBJECTIVES: To report on the development and utility of the Revised Nursing Work Index (NWI-R) in measuring characteristics of professional nursing practice environments. METHODS: The NWI-R was used in a national acquired immunodeficiency syndrome (AIDS) care study. The sample consisted of 40 units in 20 hospitals. Of these 20 hospitals, 10 provided AIDS care in both dedicated AIDS units and general medical units, thus introducing to the design an element of internal control. The remaining 10 hospitals were selected through a matching procedure. Three of the matched control hospitals were magnet hospitals. Nurses were recruited into the study if they worked at least 16 hours per week on the study unit. The nurses completed the NWI-R in addition to other measures. RESULTS: A response rate of 86% was attained. Response rates per unit ranged from 73% to 100%. Cronbach's alpha was 0.96 for the entire NWI-R, with aggregated subscale alphas of 0.84 to 0.91. Validity of the NWI-R was demonstrated by the origin of the instrument, its ability to differentiate nurses who worked within a professional practice environment from those who did not, and its ability to explain differences in nurse burnout. CONCLUSION: The NWI-R has been found to capture organizational attributes that characterize professional nursing practice environments.

Acquired Immunodeficiency Syndrome↗
PubMed2004

The changing professional practice of physician assistants: 1992 to 2000.

BACKGROUND: Substantial changes in professional practice for physician assistants (PAs) occurred between 1992 and 2000. This paper describes a new professional practice index for the PA profession for 2000 that reflects current practice environments more accurately than did an index developed to reflect practice environments in 1992. In addition, the paper examines the relationships among the profession, its professional environment, and physicians, as well as the relationship between the PA profession and access to care for underserved populations. RESULTS: Comparisons of the 1992 professional practice index for the PA profession and indices for 2000 indicate that, collectively, the scope of practice of PAs increased significantly across the United States over the 8-year period. Variation of the index scores narrowed over the same period, suggesting that the 1990s were a period of convergence of professional practice across the 50 states. During this period the numbers of practicing PAs nearly doubled between 1992 and 2000, and in 2000 there were 5.8 practicing PAs per 100 physicians in active patient care in the United States. The professional practice index for the profession is positively correlated with the numbers of PAs per capita across the 50 states for both 1992 and 2000. CONCLUSION: Enabling legislation for PAs has been enacted in all 50 states and the District of Columbia over a 3-decade period. A period of consolidation and convergence of statutes and policies over the 1990s suggests that American medicine has endorsed the role of PAs. In spite of these findings, almost one third of states continue to have limited or restricted statutes for PA practice, mostly in the area of reimbursement.

Health Services Accessibility↗
PubMed1993

A comparison of physician-patient interaction at fee-for-service and HMO sites.

Research has begun to identify elements in the practice environment that influence practice styles and health outcomes. One key element known to influence physician-patient interaction is the type of treatment environment: fee-for-service or health maintenance organization. Observers using the Davis Observation Code coded 82 physician-patient encounters in private practice settings and 72 encounters in a health maintenance organization. Populations were similar on all demographic measures except age, with health maintenance organization patients being older. Fee-for-service visits were shorter but included more coded behaviors per observation interval, resulting in equivalent total numbers of coded behaviors in each type of visit. Health maintenance organization visits included significantly more patient questions, preventive services, disease prevention, treatment planning, and discussion of substance use. Results may have reflected physician gender differences across sites or patient self-selection to sites rather than site differences. These results have implications for developing further research to explore treatment environment, process, and outcome.

Adult↗
PubMed1994

Scorecard cardiovascular medicine. Its impact and future directions.

Public release of operator-specific data for cardiovascular procedures has set a new precedent, introducing the "scorecard" era. Justification exists for public disclosure, but the mechanics of appropriate data release are complex from a clinical, statistical, and logistic standpoint. Scorecard medicine may appropriately promote regionalization of medical centers and consolidation of services, but unless the process is directed effectively, it may impair the development of new treatments because of a more restrictive clinical practice environment. We propose revamping our current system to facilitate rapid and accurate access to outcome data in the local practice environment so that improvement in practice occurs on a voluntary basis rather than in response to punitive restrictions. A rational plan needs to be developed for dealing with high-risk patients, perhaps through compensation in regression models used to calculate expected outcomes, and for the start-up of novice physicians. Special provisions are needed to promote clinical research. Before procedures are done, it would be ideal to provide a full disclosure informed consent, whereby the physician reports operator-specific data and the patient's decision-making process is facilitated. Overall, appropriate implementation of scorecards could ultimately lead to a substantial improvement in the quality of U.S. cardiovascular medicine.

Cardiology↗