Participatory Decision-making Style Research Articles

Principal’s Participatory Leadership Approaches: An Effective Tool for Teacher Effectiveness in Fako Division, Cameroon

Aim: This study intended to investigate the relationship between principal’s participatory leadership approaches and teacher effectiveness in Fako Division, Cameroon.
 Methods: Given a correlational design purpose, data were assembled by drawing a sample of six hundred (600) that is 588 teachers and 22 principals spread across five (5) sub-divisions in Fako Division Cameroon. The first instrument titled “Questionnaire for Principal’s Participatory Leadership Approaches” (QPPLA) comprises three subscales all reflecting a high degree of internal consistency, namely, participatory decision-making (α = 0.843), democratic leadership (α = 0.759), and collective leadership (α = 0.834). The second tool, Questionnaire for Teacher Effectiveness (QTE), also indicates good reliability (α = 0.813). Regarding the verification of the research questions and hypotheses, Pearson's correlation coefficient was subsequently performed at the significance level of p < 0.05.
 Results: The study found that participatory decision-making, democratic leadership and collective leadership styles significantly exerted a strong and positive impact on teacher effectiveness. Ultimately, the findings suggest that the principals should properly use the combinations of participatory decision-making, democratic leadership and collective leadership styles since they are significant in teacher effectiveness in secondary schools in Fako Division, Cameroon.
 Conclusion: The study concluded that there is a strong relationship between principal’s participatory leadership approaches and teacher effectiveness.
 Recommendation: This study recommend principals to enhance and foster teacher effectiveness by adopting participatory leadership approaches in schools.

Provider use of a participatory decision-making style with African American patients with glaucoma

ObjectiveTo examine whether non-adherent African American patients with glaucoma who received a question prompt list and video intervention were more likely to be given treatment options, have their input included into treatment regimens, and rate their providers as using more of a participatory decision-making style. MethodsAfrican American patients with glaucoma taking one or more glaucoma medications and reported being non-adherent were randomized to a pre-visit video and glaucoma question prompt list intervention or usual care. Results189 African American patients with glaucoma participated. Providers gave patients treatment choices during 5.3% of visits and included patient input into treatment regimen decisions during 2.1% of visits. Male patients and patients with more years of education were significantly more likely to rate their providers as using more of a participatory decision-making style. ConclusionAfrican American patients with glaucoma rated their providers high on using a participatory decision-making style. Yet, providers infrequently presented non-adherent patients with medication treatment options, and it was rare for providers to include patient input into treatment decisions. Practice implicationsProviders should provide non-adherent patients with different glaucoma treatment options. Non-adherent African American patients with glaucoma should be encouraged to ask their providers for different medication treatment options.

Experiences With Traditional Chinese Medicine Among Patients With Inflammatory Bowel Disease: A Qualitative Study.

Despite the increasing number of inflammatory bowel disease (IBD) patients using traditional Chinese medicine (TCM), relatively few studies have examined their experiences with TCM in the Chinese healthcare context. The aim of this study was to explore these experiences from the perspective of IBD patients. Adopting a qualitative descriptive method, IBD patients from several comprehensive hospitals in Hangzhou, Zhejiang were recruited through purposive sampling. Data were collected using semistructured interviews and analyzed by a conventional content analysis method. The results are presented thematically. Fourteen IBD patients participated in the study. They often used TCM, such as Chinese herbal medicine, retention enemas of Chinese medicine, and acupuncture, as a complementary therapy instead of as an alternative to conventional therapies. Three themes emerged from the analysis: triggers for initiating TCM, the experienced efficacies of TCM, and disturbances caused by TCM use. The IBD patients initiate TCM treatment due to the unsatisfactory effects of conventional therapies and TCM culture. However, the efficacies of TCM are subjective and slow acting and vary across individuals. There are communication gaps between physicians and patients concerning TCM. Thus, healthcare professionals are encouraged to gain more knowledge on these therapies and employ a participatory decision-making style based on this understanding.

Participatory Decision-Making Style of the Principals of Vocational High School in Lembah Gumanti District West Sumatra

Abstract: The Participatory Decision-Making Styles of the Principals of Vocational High School in Lembah Gumanti District, West Sumatera. Objective: This study aims to obtain information on teachers’ perceptions of the participatory decision-making styles of the principals of vocational high schools in Lembah Gumanti District, West Sumatera. Method: This was a quantitative descriptive study. The data sources were all teachers at Vocational High Schools in Lembah Gumanti Subdistrict, Solok Regency, with a total of 67 teachers. The research instrument was a Likert scale questionnaire with 5 alternative answers of which the validity and reliability had been assessed. The data were analyzed using the mean formula to get the respondents’ average answers. Findings: The teachers’ perceptions of the four characteristics of the principals’ participatory decision-making styles, namely: (1) low direction and high support, (2) two-way communication, (3) involving subordinates, and (4) power, show a good category with an attainment level of 76.77%. Conclusion: The principals of the vocational high schools in Lembah Gumanti District, West Sumatera has good perceptions of the participatory decision-making styles. Keywords: participatory decision-making styles, principals, vocational high schools. Abstrak: Gaya Pengambilan Keputusan Partisipatif Kepala Sekolah Menengah Kejuruan di Kecamatan Lembah Gumanti, Sumatera Barat . Tujuan : Penelitian ini bertujuan untuk memperoleh informasi mengenai persepsi guru tentang gaya pengambilan keputusan partisipatif Kepala Sekolah Menengah Kejuruan (SMK) Di Kecamatan Lembah Gumanti, Sumatera Barat . Metode : Jenis penelitian ini adalah penelitian kuantitatif deskriptif. Sumber data berasal seluruh guru smk di kecamatan lembah gumanti kabupaten solok yaitu 67 orang guru tersebut. Instrumen penelitian yang digunakan berupa angket dalam bentuk skala Likert dengan 5 alternatif jawaban yang telah diuji validitas dan reliabilitasnya. Data di analisis mengunakan rumus Mean untuk mendapatkan rata-rata jawaban responden . Temuan : P ersepsi guru tentang empat karakteristik gaya pengambilan keputusan partisipatif kepala sekolah yaitu (1) rendah pengarahan dan tinggi dukungan, (2) komunikasi dua arah, (3) melibatkan bawahan dan (4) kekuasaan menunjukkan kategori baik dengan tingkat capaian 76,77% . Kesimpulan : Kepala Sekolah Menengah Kejuruan di Kecamatan Lembah Gumanti, Sumatera Barat memiliki persepsi baik tentang gaya pengambilan keputusan partisipatif. Kata kunci: gaya pengambilan keputusan partisipatif, kepala sekolah, Sekolah Menengah Kejuruan. DOI: http://dx.doi.org/10.23960/jpp.v10.i1.202012

Provider use of a participatory decision-making style with youth and caregivers and satisfaction with pediatric asthma visits.

BackgroundWe conducted a randomized controlled trial to test the effectiveness of an asthma question prompt list with video intervention to engage the youth during clinic visits. We examined whether the intervention was associated with 1) providers including youth and caregiver inputs more into asthma treatment regimens, 2) youth and caregivers rating providers as using more of a participatory decision-making style, and 3) youth and caregivers being more satisfied with visits.MethodsEnglish- or Spanish-speaking youth aged 11–17 years with persistent asthma and their caregivers were recruited from four pediatric clinics and randomized to the intervention or usual care groups. The youth in the intervention group watched the video with their caregivers on an iPad and completed a one-page asthma question prompt list before their clinic visits. All visits were audiotaped. Generalized estimating equations were used to analyze the data.ResultsForty providers and their patients (n=359) participated in this study. Providers included youth input into the asthma management treatment regimens during 2.5% of visits and caregiver input during 3.3% of visits. The youth in the intervention group were significantly more likely to rate their providers as using more of a participatory decision-making style (odds ratio=1.7, 95% confidence interval=1.1, 2.5). White caregivers were significantly more likely to rate the providers as more participatory (odds ratio=2.3, 95% confidence interval=1.2, 4.4). Youth (beta=4.9, 95% confidence interval=3.3, 6.5) and caregivers (beta=7.5, 95% confidence interval=3.1, 12.0) who rated their providers as being more participatory were significantly more satisfied with their visits. Youth (beta=−1.9, 95% confidence interval=−3.4, −0.4) and caregivers (beta=−8.8, 95% confidence interval=−16.2, −1.3) who spoke Spanish at home were less satisfied with visits.ConclusionThe intervention did not increase the inclusion of youth and caregiver inputs into asthma treatment regimens. However, it did increase the youth’s perception of participatory decision-making style of the providers, and this in turn was associated with greater satisfaction.

Recovering disrupted social capital: insights from Lao DPR rural villagers' perceptions of local leadership.

BackgroundSocial capital is often believed to be one of the key prerequisites for successful implementation of community-based health programs. In less-developed countries, local leaders are positioned as major players in broad community health strategies and interventions, and their capacities and roles are expected to increase in prominence in future community-health-care promotions. In this study, we examined how local leaders’ capacities could be related to social capital in rural villages in Lao PDR, and thus to villagers’ willingness to participate in community-based health efforts.MethodsWe adopted a qualitative approach, conducting semi-structured interviews for both individuals and focus groups. In 2012, 103 people from six villages in the Khoun and Phoukoud districts participated in the interviews. For the individual interviews, we interviewed 22 mothers who had given birth in the past 5 years. For the focus groups, we interviewed 30 women (six groups), 30 men (six groups), and 21 senior villagers (five groups).ResultsFirst, we noted large variations in the levels of community social capital across villages: four out of six study villages showed a high level of social capital, while two villages suffered greatly from a low level of social capital. In search of the reasons for the disrupted social capital in the latter two villages, interviews revealed that failed leadership, especially in regard to local resource allocations—lack of transparency and corrupt practices—were commonly cited reasons for disrupted social capital. The data also showed that the villagers’ mistrust of these failed local leaders critically reduced their willingness to participate in community-based health efforts, and especially in those that involved resource mobilization and risk-sharing for healthcare. Finally, we found that good communication skills and participatory decision-making styles were attributes that rural villagers in Lao PDR expected of their local leaders.ConclusionThis study suggests that failed local leadership is detrimental to community participation, resource mobilization, and building communities’ social capital. To achieve intended health care goals through community-based interventions, there is a need to first support local leadership at all levels through capacity-building and improved communication within communities.

How Physicians, Patients, and Observers Compare on the Use of Qualitative and Quantitative Measures of Physician-Patient Communication.

The purpose of this study was to compare several different measures of physician-patient communication. We compared data derived from different measures of three communication behaviors, patient participation, physician information giving, and physician participatory decision-making (PDM) style, from 83 outpatient visits to oncology or thoracic surgery clinics for pulmonary nodules or lung cancer. Communication was measured with rating scales completed by patients and physicians after the consultation and by two different groups of external observers who used rating scales or coded the frequency of communication behaviors, respectively, after listening to an audio recording of the consultation. Measures were compared using Pearson's correlations. Correlations of patients' and physicians' ratings of patient participation (r = .04) and physician PDM style (r = .03) were low and not significant (p > .0083, Bonferroni-adjusted). Correlations of observers' ratings with patients' or physicians' ratings for patient participation and physician PDM style were moderate or low (r = .15, .27, .07, and .01, respectively) but were not statistically significant (p > .0083, Bonferroni-adjusted). Correlations between observers' ratings and frequency measures were .31, .52, and .63 and were statistically significant with p values .005, <.0001, and <.0001, respectively, for PDM style, information giving, and patient participation. Our findings highlight the potential for using observers' ratings as an alternate measure of communication to more labor intensive frequency measures.

Exploring the relationships between participatory decision-making, visit duration, and general practitioners’ provision of argumentation to support their medical advice: Results from a content analysis

ObjectiveGeneral practitioners’ medical recommendations are not always accepted by their patients. As patients bring their own beliefs, knowledge, and preferences to the medical encounter, their opinions concerning diagnosis and treatment may deviate from their doctors’. Aiming to convince their patients of the acceptability of their advice, doctors can advance arguments.Few quantitative studies have been conducted focusing on general practitioners’ provision of argumentation and little is known about the relationship between the use of argumentation and characteristics of the medical visit, such as (participatory) decision-making and visit duration. This study seeks to explore these relationships. MethodsAn observational study of seventy, randomly drawn videos of general practice consultations was conducted. A theory-based codebook was developed. Two independent coders analyzed doctors’ provision of argumentation, their decision-making style, and the duration of each visit. ResultsGeneral practitioners’ provision of argumentation was found to be associated with lengthier visits and a more participatory decision-making style. In addition, visit duration and participatory decision-making appeared associated. ConclusionThese results suggest that the use of argumentation may contribute toward achieving patient-centered care through communication. Practice implicationsAs a result, the findings underscore the potential relevance of developing courses focusing on doctors’ argumentation skills.

Capsule Commentary on Kaplan et al., Reducing Racial/Ethnic Disparities in Diabetes: The Coached Care (R2D2C2) Project

One of the most troubling aspects of US medicine is the level of disparities in health and healthcare outcomes,1–3 While previous work has generally focused on one or two potential contributors, the paper by Kaplan et al. examines a myriad of patient, provider and system characteristics to explore the source of disparities in diabetes control among Mexican-Americans.4 The differences in glycosylated hemoglobin seen between Vietnamese-Americans, non-Hispanic whites and Mexican-Americans were explained by differences in gender, age, duration of diabetes, education and income level and insurance status. While statistically significant, communication markers such as communication quality, trust, language barriers and participatory decision-making style explained no additional variance in outcomes. Targeting disparities reduction will require understanding the source of these differences. Determining how much improvement is amenable to modification by healthcare systems is also useful; it may prove less than we hope. In this study, most of the factors contributing to the difference, such as age, gender, diabetes duration, education attainment and income level are outside the influence of healthcare systems. It is also discouraging that communication had no impact. While improved patient–provider communication is a healthcare goal, lapses in communication quality having been frequently observed, demonstrating that other than trust or satisfaction, better communication improves patient health outcomes, yet has proven elusive.

Caregiver rating of provider participatory decision-making style and caregiver and child satisfaction with pediatric asthma visits

Caregiver rating of provider participatory decision-making style and caregiver and child satisfaction with pediatric asthma visits

Caregiver rating of provider participatory decision-making style and caregiver and child satisfaction with pediatric asthma visits

ObjectiveThe purpose of this study was to examine the relationship between caregiver ratings of provider use of a participatory decision-making style and caregiver and child satisfaction with their pediatric asthma visits. MethodsChildren ages 8 through 16 with persistent asthma and their caregivers were recruited at five pediatric practices. Children were interviewed and caregivers completed questionnaires after their child's medical visits. Generalized estimating equations were used to analyze the data. ResultsThree hundred and twenty children were recruited. Caregivers were significantly more satisfied with providers who they perceived as using more of a participatory decision-making style (beta=17.80, p<0.001). Children (beta=−0.10, p<0.05) and caregivers (beta=−0.21, p<0.01) were significantly more satisfied with younger providers. Children were significantly more satisfied with providers who knew them better as a person (beta=2.87, p<0.001). ConclusionsCaregivers were more satisfied with providers who they perceived as involving them more during treatment decisions made during pediatric asthma visits. Practice implicationsProviders should attempt to use a more participatory decision-making style with families during pediatric asthma visits.

Participatory decision making, patient activation, medication adherence, and intermediate clinical outcomes in type 2 diabetes: a STARNet study.

Participatory decision making (PDM) is associated with improved diabetes control. We examine a causal model linking PDM to improved clinical outcomes that included patient activation and medication adherence. This observational study was conducted in 5 family physician offices. Diabetic patients were recruited by mail and by completing a study interest card at the conclusion of their office visit. Two survey questionnaires, administered 12 months apart, elicited patients' ratings of their physician's PDM style at baseline and their level of activation and medication adherence both at baseline and at follow-up. Measures of glycated hemoglobin (hemoglobin A(1c)), systolic blood pressure, and low-density lipoprotein (LDL) cholesterol were abstracted from the medical record starting 12 months before the baseline survey to 12 months after the follow-up survey. A path analysis using a structural equation model was used to test hypotheses. We mailed questionnaires to 236 participants; 166 (70%) returned the baseline questionnaire, and 141 (80%) returned the follow-up questionnaire. Hemoglobin A(1c) levels, systolic blood pressure, and LDL cholesterol values all declined significantly, and patient activation and medication adherence improved. PDM at baseline was associated with patient activation at follow-up. Patient activation at follow-up was associated with medication adherence at follow-up, and medication adherence at follow-up was associated with change in hemoglobin A(1c) levels and LDL cholesterol values but not with systolic blood pressure. Participatory decision making during primary care encounters by patients with type 2 diabetes resulted in improvements in hemoglobin A(1c) levels and LDL cholesterol values by improving patient activation, which in turn improved medication adherence.

Cross-Sectional Evaluation of Parental Decision Making Factors for Vesicoureteral Reflux Management in Children

Parental decision making in children with vesicoureteral reflux has potentially become more complex with the evolution of ethnic diversity in the United States, the Internet, the publication of contradictory clinical data and the emergence of minimally invasive surgery. We performed a cross-sectional study of parental management for pediatric vesicoureteral reflux. We administered a 26-item questionnaire to parents of children with vesicoureteral reflux seen at Texas Children's Hospital urology offices or undergoing antireflux surgery at that institution. Univariate and multivariate analysis was done on patient disease characteristics, demographics, predicted reflux duration, surgery success rate, antibiotic cessation, complication risk, financial considerations, urologist recommendations, Internet information, friend recommendations, and postoperative voiding cystourethrography, renal ultrasound and recovery. Enrolled in the study were 15 boys and 49 girls with a mean age of 3.5 years and a mean reflux grade of 2.8. Of the cases 37 were bilateral. Parents chose endoscopic treatment in 38 children, open ureteroneocystostomy in 9, antibiotic prophylaxis in 14 and observation without antibiotics in 3. Univariate analysis suggested that Hispanic parents rated ultrasound and financial considerations as more important than white parents (p <0.05). Multivariate analysis revealed that differences seen on univariate analysis may have been due to an association between race and income. Finally, 93.6% of parents rated urologist opinion as very or extremely important. Data indicate that the parents of our patients highly value the opinion of the pediatric urologist when choosing treatment for their children with vesicoureteral reflux. Despite social changes the physician-parental relationship remains critical. Differences in parental decision making may be linked to associations between race and income.

Physicians’ decision-making style and psychosocial outcomes among cancer survivors

Objective We evaluated pathways linking physicians’ decision-making style with cancer survivors’ health-related quality of life (HRQOL). Methods We analyzed survey data from 623 survivors diagnosed with leukemia, colorectal, or bladder cancer in Northern California, 2–5 years prior to the study. Of these, 395 reported making a medical decision in the past 12 months and were asked about their physician's decision-making style. We evaluated the association of physician style with proximal communication outcomes (trust and participation self-efficacy), intermediate cognitive outcomes (perceived control and uncertainty), and distal health outcomes (physical and mental HRQOL). Results Overall, 54% of survivors reported a sub-optimal decision-making style for their physician. With the exception of physical health, physician style was associated with all proximal, intermediate, and distal outcomes ( p ≤ 0.01). We identified two significant pathways by which a participatory physician style may be associated with survivors’ mental health: (1) by increasing survivors’ participation self-efficacy and thereby enhancing their perceptions of personal control ( p < 0.01); (2) by enhancing survivors’ level of trust and thereby reducing their perceptions of uncertainty ( p < 0.05). Conclusion A participatory physician style may improve survivors’ mental health by a complex two-step mechanism of improving survivors’ proximal communication and intermediate cognitive outcomes. Practice implications Physicians who adopt a participatory decision-making style are likely to facilitate patient empowerment and enhance patients’ HRQOL.

Psychiatrists' Use of Shared Decision Making in the Treatment of Schizophrenia: Patient Characteristics and Decision Topics

Psychiatrists' Use of Shared Decision Making in the Treatment of Schizophrenia: Patient Characteristics and Decision Topics

Incorporating Disparity Reduction into Pay-for-Performance

Incorporating Disparity Reduction into Pay-for-Performance

Arthritis patients' perceptions of rheumatologists' participatory decision‐making style and communication about complementary and alternative medicine

To examine if patients with arthritis who reported using complementary and alternative medicine (CAM) were more likely to tell their physicians about their CAM use if they rated their rheumatologist as using a more participatory decision-making style and what reasons patients gave for telling or not telling their rheumatologist about their CAM use. A survey that asked about CAM use, health status, demographics, physician use of a participatory decision-making style, and medical skepticism was sent to individuals with arthritis who saw 23 rheumatologists at universities and private practice clinics in North Carolina. Generalized estimating equations were used to analyze the data. A total of 92% of patients reported using CAM for their arthritis and 54% of these patients discussed their CAM use with their rheumatologist. Women, patients who used more types of CAM, and patients who rated their rheumatologist as using a more participatory decision-making style were significantly more likely to tell their physicians about their CAM use. Our findings suggest that if rheumatologists use more participatory styles of decision making with patients and involve them when making treatment decisions, patients are more likely to tell them about their CAM use.

Does Participatory Decision Making Improve Hypertension Self‐Care Behaviors and Outcomes?

This study examined patients' perceptions of their providers' participatory decision making (PDM) style and hypertension self-care behaviors and outcomes. Five hundred fifty-four veterans with hypertension enrolled in the Veterans' Study to Improve the Control of Hypertension rated providers' PDM styles using a validated 3-item instrument. Behaviors assessed included presence of a home blood pressure monitor, monitoring frequency, and self-reported antihypertensive medication adherence. Overall, veterans with hypertension rated providers as highly participatory. In adjusted analyses, a lower PDM score was associated with decreased odds of having a home monitor (odds ratio, 0.90 per 10-point decrement in PDM score; 95% confidence interval, 0.83-0.98) but not with monitoring frequency, adherence, or blood pressure control. Providers' involvement of patients in decision making, reflected in ratings of PDM style, may be important to securing patients' participation in their own care, but alone this factor seems insufficient. No relationship between PDM score and blood pressure control was observed.

Trust in physicians and elements of the medical interaction in patients with rheumatoid arthritis and systemic lupus erythematosus

To identify components of the patient-doctor relationship associated with trust in physicians. We assessed 102 patients with systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA) seen at publicly funded hospitals in Houston, Texas. Patients completed a self-response survey examining patient perceptions of the medical encounter and trust in their physicians. Evaluated components of physicians' behaviors included: informativeness, sensitivity to concerns, reassurance and support, patient-centeredness, and participatory decision-making style. Scales were scored 0 to 10, with higher numbers indicating more positive perceptions of communication. Seventy patients had RA and 32 SLE; 25% were white, 43% Latino, 31% African American, and 75% were female. Mean scores for the medical interaction and trust scales ranged from 6.2-7.1, indicating moderate degrees of positive perceptions. All components were highly and positively correlated with each other, and with trust, suggesting that these traits are all elements of a positive style of doctor-patient communication. In multivariate analysis, ethnicity, physicians' informativeness, physicians' sensitivity to concerns, patient-centeredness, disease activity, and patient trust in the US health care system were independent predictors of trust in physicians. A separate model examined the predictors of patient disclosure of information. Patient perceptions of physicians' patient-centeredness and severity of disease activity were independently predictive of patient disclosure of information. In patients with SLE and RA, trust in physicians is significantly associated with patients' ethnicity and their perceptions about specific components of physicians' communication style. Trust in physicians can be improved by using a patient-centered approach, being sensitive to patient concerns, and providing adequate clinical information. Furthermore, patients appear to be more willing to disclose concerns when physicians use a patient-centered communication style.

Nurse and resident satisfaction in magnet long-term care organizations: do high involvement approaches matter?

This study examines the association of high involvement nursing work practices with employer-of-choice (magnet) status in a sample of Canadian nursing homes. In response to a severe shortage of registered nursing personnel, it is imperative for health care organizations to more effectively recruit and retain nursing personnel. Some long-term care organizations are developing employee-centred cultures that allow them to effectively enhance nurse and resident satisfaction. At the same time, many nursing homes have adopted progressive nursing workplace practices (high involvement work practices) that emphasize greater employee empowerment, participation and commitment. A mail survey was sent to the director of nursing in 300 nursing homes in western Canada. In total, 125 useable questionnaires were returned and constituted the data set for this study. Separate ordinary least squares regressions are performed with magnet strength, nurse satisfaction and resident satisfaction used as dependent variables. Nursing homes that demonstrate strong magnet (employer-of-choice) characteristics are more likely to have higher levels of nurse and patient satisfaction, even after controlling for a number of significant factors at the establishment level. Magnet nursing homes are more likely to have progressive participatory decision-making cultures and much more likely to spend considerable resources on job-related training for their nursing staff. The presence of high involvement work practices is not found to be a significant predictor in magnet strength, nurse or resident satisfaction. Merely adopting more high involvement nursing work practices may be insufficient for nursing homes, which desire to become 'employers-of-choice' in their marketplaces, especially if these practices are adopted without a concomitant investment in nurse training or an enhanced commitment to establishing a more democratic and participatory decision-making style involving all nursing staff.