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A SUPPORTIVE NURSING CARE UNIT FOR REGISTERED NURSES

A SUPPORTIVE NURSING CARE UNIT FOR REGISTERED NURSES. Debra S. Hall, RN, PhD candidate University of Kentucky, College of Nursing Advisor: Julie Sebastian, PhD, RN, CS, FAAN. PURPOSE.

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A SUPPORTIVE NURSING CARE UNIT FOR REGISTERED NURSES

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  1. A SUPPORTIVE NURSING CARE UNIT FOR REGISTERED NURSES Debra S. Hall, RN, PhD candidate University of Kentucky, College of Nursing Advisor: Julie Sebastian, PhD, RN, CS, FAAN

  2. PURPOSE investigate the relationship between a specific type of nursing unit governance structure and nurse retention, job satisfaction, job control, self-efficacy, collective efficacy, job stress, co-worker support, supervisor support, somatic complaints, and absenteeism due to illness of Registered Nurses in a hospital recognized for good nursing care

  3. SIGNIFICANCE • In an ANA website survey, 70.5% of nurses cited the acute and chronic effects of stress and overwork among their top three health and safety concerns

  4. SIGNIFICANCE • With a projected shortage of nearly 20% of RNs by 2020, and a cost of $42,000 for the turnover of each general medical-surgical nurse and $64,000 for turnover of a specialty nurse (Advisory Board Company, 2000) determining strategies to recruit and retain nursing personnel is a critical issue (Buerhaus, 2000)

  5. DESIGN • cross-sectional • two phase (quantitative & qualitative) • comparative study of the effects of unit governance structure on RNs working in three different patient care units within the same hospital

  6. DESIGN • Unit 1: traditional nursing unit structure with a non-specialized patient population (n = 28) • Unit 2: a shared governance structural framework (n = 24) • Unit 3: a specialized, homogeneous inpatient population that does not change, in which there are few off-service patients (n = 29)

  7. METHODS – Phase I • Phase I – quantitative survey comprised of nine instruments and single item questions for age, marital status, gender, ethnic/racial background, level of nursing education, length of time working in present unit, and amount of experience as a bedside RN

  8. INSTRUMENTS • The Decision Latitude Scale of the Job Content Questionnaire (JCQ) (Karasek et al., 1998) • Maastricht Autonomy Questionnaire (MAQ) (de Jonge, 1995) • Inventory of Socially Supportive Behaviors (ISSB) (Barrera, Sandler, & Ramsay, 1981) • Personal Efficacy Beliefs tool (10-items) and collective efficacy instrument (Riggs, Warka, Babasa, Betancourt, and Hooker, 1994)

  9. INSTRUMENTS • Nurse Work Stress Scenarios (NWSS) - 24-item instrument designed by the primary investigator • Single-item question on job satisfaction (Warr, Cook, & Wall, 1979) • The Physical Symptoms Inventory (PSI) (Spector & Jex, 1998) • Staff turnover was calculated for each unit

  10. SAMPLE – Phase I • Eighty-one nurses (n = 69) working at least 24 hours per week in a typical staff position in one of three adult nursing units were approached • RNs were at least 18 years old and could not be on orientation, probation, light duty assignment, or other “non-typical” assignments during the study

  11. METHODS – Phase II • Phase II – focus groups with 5 RNs from each of the three units • Nurses were asked open-ended questions related to stressors, coping mechanisms used, types of interventions they used to change stressful situations, and social support they received

  12. SAMPLE – Phase II • Fifteen RNs (n = 13) working in the same units were purposively chosen based on age for Phase II (response rate 87%) • SETTING - a south central teaching hospital serving patients from suburban and rural areas

  13. PROCEDURE • Obtained IRB approval • Contacted Chief Nursing Officer and Unit Managers • Mailed cover letter, questionnaire, postcard, and return SASE to each nurse • Used Dillman’s Total Design Method (Dillman, 2000)

  14. PROCEDURE • Two weeks later, sent reminder postcard • Four weeks later, sent a follow-up letter and replacement questionnaire, postcard, and return envelope to non-respondents • Sent thank you letter to the respondents of the survey

  15. DATA ANALYSIS • Descriptive, univariate statistics (M, SD) • Spearman-S Ranking • Independent t-test • Chi-square test of independence • One-way analysis of variance (ANOVA) • One-way multivariate analysis of variance (MANOVA) • Multiple regression

  16. QUALITATIVE ANALYSIS • Substantive coding of work-related stressors, coping mechanisms, and social support comments • Recoded • Table for each topic • Selective coding • Table of coping mechanisms to compare groups

  17. RESULTS - Sociodemographic • Male RNs scored significantly higher for overall work stress (M =75, SD = 35) than female RNs (M = 40, SD = 19), t(51) = -2.98, p = .04 • Caucasian nurses used a larger number of direct coping mechanisms in the eight scenarios (M = 50.9, SD = 5.8), than did African-American nurses, (M = 42, SD = 6), t(53) = 3.09, p = .03

  18. RESULTS - Sociodemographic • Nurses who were married or had steady partners perceived higher levels of job control, higher collective efficacy, job satisfaction, and used more indirect coping methods, experienced less somatic symptoms, and had less days in which they felt ill but came to work than RNs who were single or divorced

  19. RESULTS - Occupational Stress • Hypothesis - the level of job stress for RNs in a clinical role would vary by type of nurse unit governance • Not supported by findings • Most commonly occurring stressor organizational barriers such as a lack of supplies and equipment • The scenario eliciting the most stress involved a lack of skilled labor

  20. RESULTS - Occupational Stress • Supervisor support predicted 7% of the variance in frequency of encountering stressful situations at work, F (1,65) = 5.10, p < ,05, adjusted R2 =.06 • Supervisor support and type of unit predicted 18% of the variance in experiencing work stress, F (1, 49) = 5.39, p < .05, adjusted R2 =.15

  21. RESULTS - Job control • Hypothesis - levels of job control would vary by type of nurse unit governance • Not supported by findings as there wereno significant differences among units on amount of job control; overall average scores were low • MAQ (M = 2.6, SD = .66) between little control and some control • Decision Latitude Scale had higher scores for skill discretion (learning new things, requiring high level of skill) than for decision authority (say about what happens on job) (M = 67.3, SD = 9.2)

  22. RESULTS • Supervisor support predicted 18% of the variance in job control as measured by the MAQ, F (1,64) =13.62, p < .005, adjusted R2 = .16 • Supervisor support predicted 12.3% of the variance in job control based on the decision latitude scale, F (1,65) = 9.09, p < .005, adjusted R2 = .11

  23. RESULTS – Coworker Support • Hypothesis - level of support from co-workers for RNs in a clinical role will vary by type of nurse unit governance; not supported • Co-worker support was uniformly high among all three units (M = 4.0, SD = 1.1)

  24. RESULTS – Coworker Support • Positive correlation between amount of co-worker support and supervisor support, unit efficacy, and job satisfaction • Regression equation combining number of years in current unit with supervisor support and number of years as an RN predicts 25% of the variance in co-worker support, F (3,62) = 6.93, p < .001, adjusted R2 = .22

  25. RESULTS – Self-efficacy • Hypothesis – RNs working in shared governance or specialty unit will have higher self-efficacy levels; not supported by findings • Nurses ranked themselves high on work related self-efficacy in all three units with a mean score of 4.8 (SD = .7)

  26. RESULTS – Self-efficacy • Positive correlation between job self-efficacy and age, years of experience as an RN, and years working in the current unit • Regression equation with age and type of unit predicts 15.6% of the variance in job self-efficacy, F (2,65) = 6.01, p < .005, adjusted R2 = .13

  27. RESULTS – Collective efficacy • Hypothesis - level of collective efficacy for RNs in a clinical role will vary by type of unit governance • Not supported by findings as the overall rating of unit efficacy was similarly high among all three units (M = 4.4, SD = .8)

  28. RESULTS – Collective efficacy • Positive correlation between unit efficacy and job control, co-worker and supervisor support, job satisfaction, and indirect coping mechanisms • Regression equation with supervisor support predicted 10.6% of the variance in unit efficacy, F (1, 65) = 7.7, p < .05, adjusted R2 = .09

  29. RESULTS – Coping with Stress • Hypothesis - RNs working in the clinical role in a shared governance unit would have more proactive or direct coping methods and use an increased number of coping methods than RNs working in traditional or specialized units • Results did not support this hypothesis

  30. RESULTS – Coping with Stress • Positive correlation between number of proactive coping mechanisms used and number of somatic complaints and number of days the RN felt ill but came to work

  31. RESULTS – Coping with Stress • Positive correlation between the number of indirect coping mechanisms used and job control (using the MAQ), unit efficacy and job satisfaction • Negative correlation between with the frequency of encountering stress and overall stress and number of indirect coping mechanisms used

  32. RESULTS – Days Ill • Hypothesis - RNs working in shared governance will have less absenteeism related to illness than RNs working in a unit with traditional governance • Hypothesis supported: one-way ANOVA, between-groups design revealed a significant effect for type of unit governance, F(2, 64) = 3.37; p < .04

  33. RESULTS – Days Ill • Tukey’s HSD test showed that nurses in the shared governance unit (M = .7, SD = .9)used significantly less sick days than nurses in the traditional unit (M = 3.4, SD = 5.4) (p < .05)

  34. RESULTS – Days Ill • Negative correlation between amount of supervisor support and number of days the RN felt ill but came to work • Positive correlation between the number of days absent due to sickness, number of symptoms experienced and number of direct coping mechanisms used

  35. RESULTS – Days Ill • Number of years in current unit with type of unit predicted 15.7% of the variance in days absent from work due to illness, F (2,63) = 5.93, p < .005, adjusted R2 = .13 • Age and supervisor support predicted 13% of the variance in number of sick days used with each illness, F (5, 52) = 5.9, p < .05, adjusted R2 = .13 • Supervisor support predicted 7.4% of the variance in number of days the nurse felt ill, F (1,65) = 5.2, p < .05

  36. RESULTS – Somatic Complaints • Hypothesis - RNs working in shared governance or specialty units will have a lower number of somatic complaints than RNs working in a unit with traditional governance • Hypothesis not supported by findings • Most of the somatic complaints listed had been experienced by the nurses (M = 26.1, SD = 4.5).

  37. RESULTS – Somatic Complaints • Significant positive correlation between the number of somatic complaints reported and amount of job stress, frequency of stressful job situations, number of days feeling ill, number of days using sick time, and number of proactive coping mechanisms used • Somatic complaints correlated negatively with amount of supervisor support, amount of job control, level of job satisfaction, and number of indirect coping mechanisms

  38. RESULTS – Somatic Complaints • Supervisor support predicted 8% of the variance in reported somatic complaints, F (1, 65) = 5.5, p < .05, adjusted R2 = .06 • It accounted for 18% of the variance in the amount of upset stomach/nausea experienced by nurses, F (1, 65) = 14.25, p = .001, adjusted R2 = .167 and for 12% of the variance in the amount of diarrhea experienced by nurses, F (1, 65) = 8.55, p = .005, adjusted R2 = .10 • Supervisor support predicted 9% of the variance in reported loss of appetite, F (1, 65) = 6.6, p < .05, adjusted R2 = .08

  39. RESULTS – Job satisfaction • Results supported the hypothesis that RNs working in shared governance or specialty units will have more job satisfaction that RNs working in a unit with traditional governance • Job satisfaction was highest on the specialty unit (M = 5.08, SD = 1.32) and lowest on the traditional unit (M = 4.48, SD = 1.60); however, the traditional unit had the highest level of supervisor support

  40. RESULTS – Job satisfaction • Supervisor support and type of unit accounted for 27% of the variance in job satisfaction of nurses, F (2, 64) = 12.1, p < .0001, adjusted R2 = .25 • Significant positive correlation between job satisfaction and job control, co-worker support, supervisor support, and number of indirect coping mechanisms • Significant negative correlation between job satisfaction and work stress, frequency of encountering stressful situations, and number of somatic complaints

  41. RESULTS – RN Turnover • Hypothesis - specialty units will have less RN turnover than traditional governance units • A one-way ANOVA, between-groups design revealed a significant effect for staff turnover, F(2, 66) = Infinity; p < .0001

  42. RESULTS - • Tukey’s HSD test showed that nurses in the specialty unit had a significantly lower rate of turnover (7.2%) than nurses in the traditional unit (9.5%) who had a significantly lower rate of turnover than nurses in the shared governance unit (18%) • Supervisor support and type of unit governance predicted 17% of the variance in staff turnover, F (2,64) = 6.51, p < .005, adjusted R2 = .14

  43. RESULTS – Supervisor Support • A one-way ANOVA, between-groups design revealed a significant effect for supervisor support, F(2, 65) = 7.26; p < .0014 • Tukey’s HSD test showed that nurses in the traditional governance unit (M = 2.7, SD = 1.3)had significantly more supervisor support (once or twice a week) than nurses in the other two units

  44. RESULTS – Supervisor Support • Nurses in the specialty unit had significantly more supervisor support (M = 2.0, SD = .9) (p < .05) than nurses in the shared governance unit (M = 1.6, SD = .4) • A one-way MANOVA, between-groups design, revealed a significant multivariate effect for supervisor support, Wilks’ lambda = .19, F(2, 39) = 3.69; p < .05 between the shared governance unit and the traditional governance unit

  45. RESULTS – Supervisor Support • positive correlations between supervisor support and job control, co-worker support, unit efficacy, and job satisfaction • Negative correlations between supervisor support and work stress, frequency of encountering stressful situations, number of somatic complaints, and number of days the nurse felt ill but was not absent

  46. RESULTS – Type of Unit Governance • Results supported the hypothesis that specialty units with homogeneous patient populations will have less RN turnover than traditional governance units; however, there was no support for decreased RN turnover in a shared governance unit as this unit had a higher rate of turnover than either of the other two units and a lower amount of perceived supervisor support

  47. RESULTS – Type of Unit Governance • Results supported the hypothesis that RNs working in a shared governance unit will have less absenteeism related to illness than RNs working in a unit with traditional governance • Results supported the hypothesis that RNs working in shared governance or specialty units will have more job satisfaction that RNs working in a traditional governance unit

  48. RESULTS – Type of Unit Governance • Although most of the hypotheses for the study were not supported, the significant difference in amount of supervisor support between the units had a greater effect on the dependent variables than any other independent variable

  49. CONCLUSIONS • Findings support the effect of shared governance unit structure on job satisfaction and absenteeism; however, they do not support positive outcomes on physical symptoms and turnover rate • Although structural environment was not significantly related to outcomes, social environment in the form of supervisor support was related to outcomes • It is the affirmative contact with the first-line supervisor, rather than a shared governance model, that relates to physical and psychological outcomes

  50. CONCLUSIONS • Male nurses may perceive more work stress related to their role as a minority in the work environment of nurses • Direct (proactive) mechanisms of coping may cause more perceived work stress and physical symptoms • The positive correlation between using more proactive coping mechanisms and having more somatic complaints and days the RN felt ill may demonstrate the strain that direct action in response to stress causes, even if the action is successful

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