Clinical Work Environment Research Articles

Emotional exhaustion and workarounds in acute care: Cross sectional tests of a theoretical framework

BackgroundAs health care organizations strive to improve their work processes, attention is being paid to workarounds in the clinical setting. Some research has found a link between burnout and workarounds. Other research shows that the clinical work environment can influence burnout levels in clinical workers, particularly emotional exhaustion. ObjectiveUnderpinned by Conservation of Resources theory, we examined a conceptual model linking the work environment with workarounds in acute care nurses and other clinicians, and hypothesized that burnout, specifically emotional exhaustion, would mediate these relationships. Study design and settingA cross sectional survey study was conducted in a large tertiary hospital in North America. ParticipantsAll clinical care providers in the hospital's medical units were invited to participate. The response rate was 45%, with nurses comprising 85% of respondents. MethodQuestionnaires were mailed to employee homes using a two-wave methodology. ResultsHypotheses were examined using structural equation modeling. Time pressure was positively related to exhaustion, and autonomy was negatively related. Exhaustion was positively related to workarounds, and mediated the time pressure and autonomy to workarounds relationships. Contrary to expectations, the physical environment was directly and negatively related to workarounds. ConclusionOur findings suggest that the work environment may influence more than individual clinician well-being and exhaustion, it also may influence workaround behaviors that could lead to harm for patients and/or the organization. More attention should be paid to the mechanisms that influence workarounds.

Impact of Healthy Work Environments and Multistage Nurse Residency Programs on Retention of Newly Licensed RNs

The objective of the study was to examine effects of nurse-confirmed healthy unit work environments and multistage nurse residency programs (NRPs) on retention rates of newly licensed RNs (NLRNs). Establishing a culture of retention and healthy clinical nurse practice environments are two major challenges confronting nurse leaders today. Nurse residency programs are a major component of NLRN work environments and have been shown to be effective in abating nurse turnover. Sample for this study consisted of 5,316 new graduates in initial RN roles in 28 Magnet® hospitals. There were no differences in retention rates by education or patient population on clinical unit. NLRN retention rate was higher in community than in academic hospitals. More than half of NLRNs were placed on units with very healthy work environments. Newly licensed RNs on units with work environments needing improvement resigned at a significantly higher rate than did other NLRNs. The quality of clinical unit work environments is the most important factor in NLRN retention.

A novel foot plate to assess 3D range of motion of the hindfoot

Careful diagnosis of ankle joints with suspected ligamentous trauma is necessary to decide on adequate therapy. Accurate 3D stress test techniques can assist in diagnosis. However, the devices used to stress the foot relative to the lower leg are inapt for clinical application as they are not ergonomical. The goal was to present and to evaluate a newly designed 3D foot plate intended to fulfill the requirements of its users. Criteria on functionality included position and fixation of the foot in extreme positions relative to the lower leg; and compatibility with imaging systems. Criteria on usability included the operator having a sense of control, application for 95% of an adult human population, and operation within 100 s with low mental and physical effort. The design was based on a Stewart platform. Preliminary assessment of the 3D foot plate performed with CT-scans of 4 subjects showed that an extreme foot position could be reached repeatedly within 6°. The remainder of evaluation was focused was on ergonomic assessment. The prototype can reach all extreme foot positions for adults with varying anthropometric dimensions. A usability test was performed with 20 radiology technicians who were asked to perform four tasks with the prototype. All radiology technicians surveyed agreed that the device can be operated by one person with minor physical and mental effort (NASA XLT median 3.5–11%). The tasks were executed with a median time of 91 s (20–513 s) and a median error of 0 (0–6). The 3D foot plate fulfills the majority of criteria and is well-received by the intended users. Relevance to industry This study shows how a multidisciplinary approach (engineering, ergonomics, radiology and imaging) can contribute to the design of an industrial product for improved clinical diagnosis and preoperative planning, while taking into account the specific clinical working environment.

The experiences of undergraduate Assistants in Nursing (AIN)

University academic timelines and a shortage of clinical placements available for students have created challenges for universities to provide maximum clinical exposure and preparation for practise. A State-run health system in Australia developed an incentive whereby students are actively recruited to work as Assistants in Nursing (AINs) whilst completing their undergraduate nursing programme, enabling them to enhance clinical skills learned during university. There have been no previous studies that reflect their experiences. This study aimed to explore and describe experiences of undergraduate AINs in the nursing workforce. Semi-structured interviews were used to obtain in-depth accounts of the undergraduate AIN experience. Six participants who were employed at various healthcare facilities around the Sydney metropolitan area comprised the sample. Interviews were digitally recorded and transcribed verbatim. Data were thematically analysed. Three main themes emerged from the data: becoming part of the team, understanding the scope of the AIN role, and working outside your comfort zone. Findings can add to international discussions in the literature related to the training and education of ancillary nursing staff. Furthermore findings provide insights into some of the challenges faced by tertiary institutions in preparing students for the clinical work environment. Whilst the employment of undergraduate AIN's can be an effective strategy, the lack of formalised guidelines to inform those working with undergraduate AINs may hinder the full potential of their employment.

A confirmatory factor analysis of the Clinical Nursing Practice Environment Scale with hospital registered nurses in Taiwan

The purpose of this study was to develop and evaluate the Clinical Nursing Practice Environment Scale in Taiwan. Many nurses are faced with an unsatisfying clinical nursing work environment in Taiwan. Thus, there is a need for an evaluation instrument that can lead to improvement in the clinical nursing practice workplace strategy index. This is a cross-sectional study. A total of 687 nurses completed the Clinical Nursing Practice Environment Scale. Based on a randomised split of the data, two groups were formed. For the group 1 (n = 344) data, exploratory factor analysis was used to examine the factor structure of the instrument. A second-order confirmatory factor analysis was then used to test the framework of the group 2 (n = 343) data, based on structural equation modelling. The exploratory factor analysis of 29 items yielded a five-factor structure. The five factors explained 62·87% of the total variance. Cronbach's alpha coefficients for the five Clinical Nursing Practice Environment Scale subscales ranged from 0·80-0·93. A second-order confirmatory factor analysis identified a second-order factor termed 'clinical nursing practice environment.' The Clinical Nursing Practice Environment Scale model was judged to fit the data adequately. The Clinical Nursing Practice Environment Scale model provides the hospital manager with information that can be used to evaluate the organisational situation and to develop an intervention to improve the workplace environment in Taiwan.

Nurses report a healthy culture: Results of the Practice Environment Scale (Australia) in an Australian hospital seeking Magnet recognition

The Magnet Recognition Program requires evidence that the nursing practice environment supports staff to provide optimal care, access professional development opportunities and participate in hospital affairs. This research aimed to assess clinical nurses' work environment at a leading private hospital in Sydney, Australia using a version of the Practice Environment Scale of the Nursing Work Index modified for the Australian context. Our results were comparable to Magnet hospitals for two subscales and significantly higher than Magnet results for the remaining three subscales and the composite scale. This was especially pleasing in relation to the hospital's preparation for Magnet recognition. Hospitals across Australasia might find administration of the Practice Environment Scale (modified for use in the Australian context) a useful exercise both as a stimulus to preparation and an indicator of readiness for Magnet recognition.

Patient Safety in the Operating Theatre

The aim of this symposium is to present and discuss recent research on the factors shaping safe and efficient performance in the operating theatre. Ten years ago, it was not generally accepted that a significant number of surgical patients were harmed not as a result of underlying illness or disease but as a result of their treatment. Detailed incident analyses and studies of behavior in the operating theatre revealed that factors such as decision making, situation awareness, coordination and leadership play a contributory role in the multifaceted nature of adverse events. The papers included in this symposium address these issues applying a spectrum of theoretical and methodological approaches. The emergent findings of these studies have important implications for future research as well as training and organizational design. For design recommendations to be useful in clinical practice they require an in-depth understanding of the strengths and vulnerabilities pertaining to the clinical work environment. This is reflected by the fact that this symposium brings together teams of clinicians and human factors experts in discussing their most recent research.

A comparison of the training needs of maternity and sexual health professionals in a London teaching hospital with regards to routine enquiry for domestic abuse

To identify maternity and sexual healthcare professionals' training needs regarding routine enquiry for domestic abuse. A cross-sectional survey, part of a theory-based evaluation of a routine enquiry for domestic abuse intervention in a South London teaching hospital. Two hundred and twenty-eight maternity professionals (68% of staff) and 46 sexual health practitioners (45% of staff) attended a 1-day domestic abuse training session. Pre-training questionnaires were completed by 208 respondents (80% response rate). The questionnaire elicited information about previous training experiences, dealing with cases of abuse, general knowledge, attitudes towards victims of abuse and views on routine enquiry. Bivariate and multivariate analyses were conducted to identify differences according to healthcare setting, prior training, and practitioners' demographic and experiential traits. Maternity and sexual health professionals reported positive attitudes towards women affected by abuse, but had limited domestic abuse training. Previously trained health professionals had good general knowledge, but failed to question attendees about abuse. Sexual health professionals were more likely to enquire about domestic abuse, and were more confident about implementing routine enquiry than maternity staff. Views on routine enquiry were influenced by health setting, demographic, attitudinal and experiential factors. Domestic abuse training is necessary in maternity and sexual health services. Educational interventions for routine enquiry should include practice-enabling components in addition to awareness modules and pre-training assessment of individuals' training needs to provide content that is tailored to their clinical practice and working environments. Institutional guidelines are recommended to enhance and sustain the positive effects of training.

Current Challenges and Opportunities for Better Integration of Human Factors Research with Development of Clinical Information Systems

Clinical information system (CIS) developers and implementers have begun to look to other scientific disciplines for new methods, tools, and techniques to help them better understand clinicians and their organizational structures, clinical work environments, capabilities of clinical information and communications technology, and the way these structures and processes interact. The goal of this article is to help CIS researchers, developers, implementers, and evaluators better understand the methods, tools, techniques, and literature of the field of human factors. We developed a framework that explains how six key human factors topics relate to the design, implementation, and evaluation of CISs. Using this framework we discuss the following six topics: 1) informatics and patient safety; 2) user interface design and evaluation; 3) workflow and task analysis; 4) clinical decision making and decision support; 5) distributed cognition; and 6) mental workload and situation awareness. Integrating the methods, tools, and lessons learned from each of these six areas of human factors research early in CIS design and incorporating them iteratively during development can improve user performance, user satisfaction, and integration into clinical workflow. Ultimately, this approach will improve clinical information systems and healthcare delivery.

Research on the care environment: Celebrating signs of success, posing questions to advance future investigations

Research on the care environment: Celebrating signs of success, posing questions to advance future investigations

Pediatric hospitalists: Training, current practice, and career goals

To determine the range and frequency of experiences, clinical and nonclinical roles, training, work expectations, and career plans of practicing pediatric hospitalists. Mail survey study of a national sample of 530 pediatric hospitalists of whom 67% (N = 338) were from teaching hospitals, 71% (N = 374) were from children's hospitals, 43% (N = 230) were from freestanding children's hospitals, and 69% (N = 354) were from hospitals with >or=250 beds. The response rate was 84%. The majority (54%; N = 211) had been practicing as hospitalists for at least 3 years. Most reported that the pediatric inpatient unit (94%) and inpatient consultation service (51%) were a part of their regular clinical assignment. Most did not provide service in the normal newborn nursery (58%), subspecialty inpatient service (52%), transports (85%), outpatient clinics (66%), or as part of an emergency response team (53%). Many participated in quality improvement (QI) initiatives (84%) and practice guideline development (81%). This study provides the most comprehensive information available regarding the clinical and nonclinical roles, training, work expectations, and career plans of pediatric hospitalists. However, the field is currently a moving target; there is significant flux in the hospitalist workforce and variation in the roles of these professionals in their clinical and nonclinical work environment.

Accurate assessment of clinical nurses' work environments: Response rate needed

Improvement of hospital unit work environments is key to quality patient care, productivity, nurse retention, and job satisfaction. Accurate measurement of such environments is necessary prior to introduction and evaluation of improvement structures and strategies. Characteristics and attributes of work environments are group level phenomena. Accurate assessment of these phenomena requires survey response rates of sufficient size to ensure sample representativeness and data that can reliably be aggregated to group level. What is the sufficient response rate? This question was answered through psychometric testing of five random samples from the population of 23 M.D. Anderson Cancer Center clinical units that had 100% response rates on an environmental survey. Response rates of 40% or more had acceptable psychometric properties for unit-specific scales.

Burnout in hospital nurses: a comparison of internal, surgery, psychiatry and burns wards

Burnout is a phenomenon in which the cumulative effects of a stressful work environment gradually overwhelm the defenses of staff members, forcing them to withdraw psychologically. This study compared the levels of burnout among nurses in different nursing specialties. The sample of the study consisted of all the nurses working in all public hospitals in Shiraz, Iran who were graduates of either technological educational institutions or universities and had experienced clinical nursing practice for at least 1 year. Using Maslach Burnout Inventory and General Health Questionnaire (28-item version), we identified the psychiatric morbidity and burnout among nurses. Study results indicated that nurses of psychiatry wards showed significantly higher levels of emotional exhaustion and depersonalization in comparison with nurses working in other wards, and burn wards nurses showed significantly higher levels of personal accomplishment. Also, nurses who were single were more emotionally exhausted. Different clinical working environments appear to have an impact on the development of nurses' burnout.

Passive resistance: Early experiences of midwifery students/graduates and the Baby Friendly Health Initiative 10 steps to successful breastfeeding

PASSIVE RESISTANCE: Early experiences of midwifery students/graduates and the Baby Friendly Health Initiative (BFHI) 10 steps to successful breastfeeding. What factors, in relation to the BFHI 10 steps to successful breastfeeding, influence the development of breastfeeding support practice for beginning practitioner midwives? Newly graduated midwives about to commence a Graduate Midwifery Program (GMP) were recruited from two South Australian universities and one Western Australian hospital to participate in the study. This qualitative longitudinal study used critical incident technique for a series of three semi-structured interviews with each participant. The theoretical framework of the project was Bandura's Social Learning Theory with Boyatzis' Data driven approach used to thematically analyze the data. Participants highlighted experiences such as time pressure and the established clinical practices of experienced midwives that undermined their commitment to the BFHI 10 steps. Outdated practices by senior midwives and passive resistance to the BFHI 10 steps were commonplace even in participating hospitals which are BFHI accredited. The clinical working environment has a major impact on the way newly graduated midwives integrate the BFHI 10 steps into their breastfeeding support practice. Commitment to the BFHI 10 steps should not be taken for granted just because a hospital achieves BFHI accreditation. Many experienced midwives are continuing with outdated practices that confuse breastfeeding mothers and newly graduated midwives alike.

Bone health: the effect of androgen deprivation therapy in prostate cancer patients

AbstractAndrogen deprivation therapy (ADT) in the management of prostate cancer poses a considerable risk to bone health in prostate cancer patients, throughout their continuum of care. Associated decreases in bone mineral density and an increased risk of fracture can lead to major quality‐of‐life concerns and an adverse impact on morbidity and mortality, in an often already overburdened patient. Urology nurses in their administration and monitoring of the effects of ADT are essential for identifying at‐risk patients and ensure timely and effective assessment and treatment. As health educators, they are ideally situated to promote and influence patients to adopt essential lifestyle changes in a multidisciplinary arena, to reduce risk factors. Supportive treatments are available to significantly reduce both bone loss and fracture risk that can easily be adopted by urology nurses in their existing clinical working environments to further strengthen positive management strategies for bone health.

Factors influencing recent dental graduates' location and sector of employment in Victoria

Recruitment and retention of dentists in the public sector and rural areas in Victoria has become increasingly difficult in recent years. There are little available data on the factors that influence the sector and location of practice of new dental graduates. The objective of this study was to investigate the factors considered by new graduates in determining the location and sector of employment after graduation, and influencing any early changes in career path. Questionnaires were sent to dentists who Mgraduated from The Univrersity of Melbourne from graduated from The University of Melbourne from 2000-2003 who were currently practising in Victoria. There were 154 subjects to whom questionnaires were sent and 109 useable questionnaires were returned, a response rate of 74 per cent. Upon graduation, 53 per cent of the new graduates chose to work in the private sector only, compared to 15 per cent in public sector only and 33 per cent in both. At present, 71 per cent work in the private sector only, 17 per cent in the public sector only and 12 per cent in both. The most important factors for choosing to work in the private sector were receiving broad range of clinical experience, opportunities to familiarize with practice management and providing a continuity of care. The principal factors for practising in the public sector were clinical mentoring and advice, consolidating clinical skills and work environment. Initially, 48 per cent of the sample chose to work in metropolitan areas only, 39 per cent in rural areas only and 13 per cent in both. Factors that influenced the decision to work in rural areas were the broad range of clinical experience and remuneration, while the main factors for choosing to work in metropolitan areas were lifestyle and proximity to family and friends. This study found that a large proportion of new dental graduates initially chose to work in the public sector and rural areas on graduation primarily as a means of consolidating their clinical skills. However, retention of dentists in both these areas appears to be a problem, with less than 10 per cent of 2000-2001 graduates still than 10 per cent of 2000-2001 graduates still working in the public sector and only 20 per cent of 2000-2001 graduates still working in rural areas.

Indicators for competent nursing practice.

This paper identifies and classifies indicators for competent nursing practice and validates these indicators in a variety of settings. Descriptive data to address competent practice in a variety of settings were collected from staff nurses, head nurses and nursing directors in an acute 1000-bed university hospital in Finland. The data obtained from 25 expert groups were analysed to identify a clinical set of indicators for competent nursing practice from the data. The relevance of this set of indicators in a variety of clinical settings was further validated with a second sample of expert nurses (n = 26). Thereafter, data were analysed to identify generic competencies that were applicable to all clinical working environments. Twenty-three generic indicators of competent nursing practice were identified in a variety of settings. The findings suggest that these competence indicators are meaningful to nurses with various backgrounds and practice settings. Collaboration and coordination, as well as the holistic management of the situation, are highly recognized as meaningful characteristics of competent nursing practice.

Job satisfaction amongst nurses in an interim secure forensic unit in Wales

All grades of nursing staff in a recently established interim secure forensic unit completed the Index of Work Satisfaction (IWS; n = 40). High levels of job satisfaction were achieved on four of the IWS subscales: (i) professional status; (ii) interaction; (iii) doctor-nurse relationship; and (iv) autonomy. Moderate levels of satisfaction were found on two of the subscales, task requirements and administration, while the salary subscale was the major area of dissatisfaction across the group. The high level of overall satisfaction in this area of psychiatric nursing may be regarded as a significant achievement in the development of new clinical services in what is regarded as a stressful area of nursing. Measures of job satisfaction may be useful benchmarks for evaluating future changes and developments in the service and for monitoring and improving the clinical work environment.

96/05713 Restructuring the East German energy system

University academic timelines and a shortage of clinical placements available for students have created challenges for universities to provide maximum clinical exposure and preparation for practise. A State-run health system in Australia developed an incentive whereby students are actively recruited to work as Assistants in Nursing (AINs) whilst completing their undergraduate nursing programme, enabling them to enhance clinical skills learned during university. There have been no previous studies that reflect their experiences.This study aimed to explore and describe experiences of undergraduate AINs in the nursing workforce.Semi-structured interviews were used to obtain in-depth accounts of the undergraduate AIN experience. Six participants who were employed at various healthcare facilities around the Sydney metropolitan area comprised the sample. Interviews were digitally recorded and transcribed verbatim. Data were thematically analysed.Three main themes emerged from the data: becoming part of the team, understanding the scope of the AIN role, and working outside your comfort zone.Findings can add to international discussions in the literature related to the training and education of ancillary nursing staff. Furthermore findings provide insights into some of the challenges faced by tertiary institutions in preparing students for the clinical work environment. Whilst the employment of undergraduate AIN's can be an effective strategy, the lack of formalised guidelines to inform those working with undergraduate AINs may hinder the full potential of their employment.

96/05709 The millennium and beyond

University academic timelines and a shortage of clinical placements available for students have created challenges for universities to provide maximum clinical exposure and preparation for practise. A State-run health system in Australia developed an incentive whereby students are actively recruited to work as Assistants in Nursing (AINs) whilst completing their undergraduate nursing programme, enabling them to enhance clinical skills learned during university. There have been no previous studies that reflect their experiences.This study aimed to explore and describe experiences of undergraduate AINs in the nursing workforce.Semi-structured interviews were used to obtain in-depth accounts of the undergraduate AIN experience. Six participants who were employed at various healthcare facilities around the Sydney metropolitan area comprised the sample. Interviews were digitally recorded and transcribed verbatim. Data were thematically analysed.Three main themes emerged from the data: becoming part of the team, understanding the scope of the AIN role, and working outside your comfort zone.Findings can add to international discussions in the literature related to the training and education of ancillary nursing staff. Furthermore findings provide insights into some of the challenges faced by tertiary institutions in preparing students for the clinical work environment. Whilst the employment of undergraduate AIN's can be an effective strategy, the lack of formalised guidelines to inform those working with undergraduate AINs may hinder the full potential of their employment.