International Journal of Health Care Quality Assurance Influence of leadership on quality nursing care Luis Mendes Maria de Jesus José Gil Fradique
Article information:
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
To cite this document: Luis Mendes Maria de Jesus José Gil Fradique , (2014),"Influence of leadership on quality nursing care", International Journal of Health Care Quality Assurance, Vol. 27 Iss 5 pp. 439 - 450 Permanent link to this document: http://dx.doi.org/10.1108/IJHCQA-06-2013-0069 Downloaded on: 30 January 2016, At: 07:52 (PT) References: this document contains references to 57 other documents. To copy this document: [email protected] The fulltext of this document has been downloaded 2248 times since 2014*
Users who downloaded this article also downloaded: Stephen George Willcocks, (2012),"Exploring leadership effectiveness: nurses as clinical leaders in the NHS", Leadership in Health Services, Vol. 25 Iss 1 pp. 8-19 http://dx.doi.org/10.1108/17511871211198034 Aditi Naidu, (2009),"Factors affecting patient satisfaction and healthcare quality", International Journal of Health Care Quality Assurance, Vol. 22 Iss 4 pp. 366-381 http://dx.doi.org/10.1108/09526860910964834 (2011),"Leadership and Management in Nursing", Leadership in Health Services, Vol. 24 Iss 1 pp. - http:// dx.doi.org/10.1108/lhs.2011.21124aae.001
Access to this document was granted through an Emerald subscription provided by emerald-srm:305060 []
For Authors If you would like to write for this, or any other Emerald publication, then please use our Emerald for Authors service information about how to choose which publication to write for and submission guidelines are available for all. Please visit www.emeraldinsight.com/authors for more information.
About Emerald www.emeraldinsight.com Emerald is a global publisher linking research and practice to the benefit of society. The company manages a portfolio of more than 290 journals and over 2,350 books and book series volumes, as well as providing an extensive range of online products and additional customer resources and services. Emerald is both COUNTER 4 and TRANSFER compliant. The organization is a partner of the Committee on Publication Ethics (COPE) and also works with Portico and the LOCKSS initiative for digital archive preservation. *Related content and download information correct at time of download.
The current issue and full text archive of this journal is available at www.emeraldinsight.com/0952-6862.htm
Influence of leadership on quality nursing care
Quality nursing care
Luis Mendes Management and Economics, University of Beira Interior (CEFAGE-UBI Research Center), Covilha~, Portugal, and
Maria de Jesus Jose´ Gil Fradique Local Health Unit of Castelo Branco, Castelo Branco, Portugal
439 Received 9 November 2012 Revised 3 June 2013 Accepted 6 November 2013
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
Abstract Purpose – The purpose of this paper is to investigate the extent to which nursing leadership, perceived by nursing staff, influences nursing quality. Design/methodology/approach – Data were collected between August and October 2011 in a Portuguese health center via a questionnaire completed by nurses. Our original sample included 283 employees; 184 questionnaires were received (65% response). Findings – The theoretical model presents reasonably satisfactory fit indices (values above literature reference). Path analysis between latent constructs clearly suggests that nursing leadership has a direct ( ß ¼ 0.724) and statistically significant ( p ¼ 0.007) effect on nursing quality. Originality/value – Results reinforce several ideas propagated throughout the literature, which suggests the relationship’s relevance, but lacks empirical support, which this study corrects. Keywords Quality improvement, Leadership, Healthcare quality, Nursing care Paper type Research paper
Introduction Quality remains a central issue for healthcare providers (McLaughlin and Kaluzny, 2004). Calls to continuously improve patient safety and care quality have intensified in the last decade. The literature describes a bureaucratic culture in public sector organizations, rooted in a strong emphasis on rules and regulations (Odom et al., 1990). Since quality improvement requires significant management change, one potential pitfall in the public sector is that accepting initiatives by collaborators may be achieved slowly (McLaughlin and Kaluzny, 2004). In this context, nurses are increasingly challenged to assume a growing responsibility and active participation in quality improvement. Nurses represent the largest professional group in health organizations, being legally and morally responsible for service quality (Estabrooks et al., 2008; Gunther and Alligood, 2002). There is a growing recognition that nurses have a central role in quality health services (Institute of Medicine, 2011; Burke et al., 2009). Nursing quality makes a vital difference in patient outcomes and safety, and nurses, as hands-on caregivers, make major healthcare contributions by: assessing, planning and evaluating patients’ needs; delivering treatments and medications; advocating for patients; and assuring their comfort (Burhans and Alligood, 2010). Quality nursing care from the nurses’ perspective corresponds to meeting human needs through caring, empathetic and respectful interactions (Burhans and Alligood, 2010; Tafreshi et al., 2007). Nursing quality depends on nurses’ response to the patients’ physical, The authors acknowledge partial financial support from FCT (Fundac¸~ao para a Cieˆncia e a Tecnologia).
International Journal of Health Care Quality Assurance Vol. 27 No. 5, 2014 pp. 439-450 r Emerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-06-2013-0069
IJHCQA 27,5
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
440
psychological, emotional, social and spiritual needs; allowing patients to live a normal life and contributing to patient and nurse satisfaction (Kunaviktikul et al., 2001). Positive patient outcomes depend more on nursing quality than on technology (Navuluri, 1999). Although, research supports the link between nursing and patient outcomes, the connection is approached cautiously (Clarke, 2005). There is increasing evidence in the literature that patient outcomes are strongly related to nursing performance and that nurses’ decision making has a significant influence on service quality (Dugdall et al., 2004; Chang et al., 2002; Yen and Lo, 2004; Stone et al., 2007). Therefore, health service leaders should promote a climate that favours nurses’ professional development and aim for enhanced nursing performance. The barriers to improving service quality and patient safety are to do with the need for better communication, collaboration and shared ownership and responsibility for patient care (Buckley et al., 2009). Head nurses may have a key role within a team and can have a decisive influence on nurse staffing, motivation, efficiency and quality. Indeed, nursing patient safety and nursing quality outcomes are significant challenges for nurse leaders everywhere (Kalisch et al., 2012). Head nurses’ capacity to influence depends more on motivation and leadership than the hierarchical level at which they carry out their tasks (Frederico and Castilho, 2006). Therefore, nursing leadership can be considered as the ability to motivate nurses, through ideas, strategies and actions to concentrate efforts and achieve goals and contributing to service effectiveness and success (Bally, 2007). Health services are a rapidly changing environment and subsequently, innovative nursing leadership is required ( Jackson et al., 2009). Nursing leaders should thus develop and implement strategies that help nurses to identify and deliver quality nursing care, caring, empathy, respect and advocacy (Burhans and Alligood, 2010). This means that nurse leaders must invest in the potential that each nurse has, involving him/her in decision making and ensuring that all team members are aware of their role to achieve the organization’s objectives, thus promoting conditions for a creative environment. Therefore, because the leader is the team’s training or service coordination fulcrum, nursing leadership means leading and organizing teamwork, seeking an efficient care service and encouraging staff to develop their full potential (Wong and Cummings, 2009). Unfortunately, nursing leadership can be an independent function, frequently unconnected to the ultimate goal – patient care. Often the leader ends up losing sight of this purpose during the leadership process, which can lead to a working environment that is unfavourable to patients (Barbosa de Sousa and Teixeira Barroso, 2009). In a quality improvement context, leadership is recognized as a key factor playing an important role in excellence models. However, the relationship’s significance is still lacking sufficient empirical evidence, especially in the health sector where research paucity concerning leadership’s influence in improving healthcare quality remains a reality. Our aim, therefore, is to investigate to what extent nursing leadership, perceived by nurses, influences nursing quality. Theoretical framework and research hypothesis Service quality is viewed as a critical aspect in organizational management, especially in the health sector, mostly characterized by a general weak quality culture. In this specific industry, various factors contributed to developing strategies oriented to guaranteeing quality: user dissatisfaction; unequal access to health services; waiting lists; waste owing to ineffectiveness; and absent performance indicators. Indeed, continuously pursuing strategic guidelines, urgently developing and implementing interventions to assess and monitor adequately care quality are key priorities in most
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
organizations. Health professionals, as integral elements, may contribute significantly to such purposes. In this panorama, nurses can play a leading role in defining new standards and developing health quality systems. Quality care requires a clear and deep reflection on how to define effective service objectives, and on how to outline appropriate strategies to achieve these goals; such purposes require that staff generally must provide good working conditions for professionals to plan and implement measures aimed at improving quality, which become part of the nurses’ routine. Kunaviktikul et al. (2001) reported that nursing quality depends on how the patient’s physical, psychosocial, emotional, social and spiritual needs are met by nurses. Likewise, quality care means meeting human needs through caring, empathetic, respectful interactions within which responsibility, intentionality and advocacy form an essential, integral foundation (Burhans and Alligood, 2010; Gunther and Alligood, 2002; Attree, 2001; Glen, 1998). As a result, health service quality needs everyone’s support when implementing systematic management practices oriented towards user satisfaction, with increased attention to continuously improving organizational processes. Thus, leading an organization-wide patient safety effort requires nurse executives to couple exceptional leadership skills with a keen focus on safety, approaching the challenge from a system perspective (Thompson et al., 2005). Changes resulting from various factors, including technological innovation, higher information access and increasingly informed healthcare users, or ongoing constraints in care management, represent strong challenges for nursing leaders (Aiken, 2007). Moreover, operational excellence, service quality and financial performance are increasingly known as key hospital-performance drivers; as a result, key initiatives for nursing leaders include improving and stabilizing nurse staffing, implementing a just and fair culture, reducing variation in clinical practice and providing comprehensive case management (Hines and Yu, 2009). In a nursing context, leaders must invest in the potential that each nurse has and involve them in decision making, ensuring that everyone is aware about his or her key role in achieving the organization’s objectives, thus promoting a creative environment. Indeed, effective leadership should combine task-oriented and relationship centered activity (Rosenbach and Taylor, 1998). Nursing leaders should improve nurse retention and recruiting efforts, encourage interdisciplinary collaboration and, most importantly, demonstrate to their colleagues the value nursing brings to the organization through consistently tracking quality and financial indicators, and linking them to nursing initiatives (Hines and Yu, 2009). Moreover, knowledge about nurses’ needs and expectations is important for service efficiency and effectiveness, although the fundamental skills that allow a leader to be effective are constantly changing (Marquis and Huston, 2011), and that nurses can only exercise their authority as leaders if team members recognize them. Leaders are the team’s fulcrum and nursing leadership means knowing how to conduct and organize teamwork, seeking efficient services, whether regarding education or service coordination and encouraging staff to develop their full potential (Gelbcke et al., 2009). Thus, nursing leaders need to collaborate to integrate and innovate to develop, improve and maintain nursing skills and competent practitioners (Coonan, 2008). As jobs become more knowledge intensive, nursing leaders must find better ways to recognize and develop employees’ valuable knowledge and skills (Wall, 2010). Furthermore, evidence in the literature suggests that certain traits and behaviuors may influence how leadership roles are performed, but do not guarantee its success, hence the critically important relationship based on a permanent dialogue between leaders and followers. When leaders forget such purpose, team members become disappointed, frustrated and may deviate
Quality nursing care
441
IJHCQA 27,5
from organization values (Vesterinen et al., 2009; Balsanelli and Cunha, 2006). The different considerations and arguments lead us to the following hypothesis: H1. Nursing leadership, perceived by nurses, influences nursing quality positively and significantly.
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
442
Methods Data collection Data were collected between August and October 2011 in a Portuguese health centre, via questionnaires filled by nurses. Since all investigations should obey strict ethical principles, aiming to protect human rights, a formal authorization to collect data was previously requested from the health centre’s administrative council. To ensure efficiency and effectiveness, the instrument was pre-tested among nurses belonging to other institutions. After confirming there were no doubts regarding its completion, the questionnaire was then applied to our sample. From 283 questionnaires distributed, 197 were received. After a careful screening process, 13 were discarded owing to missing values and outlier data. Therefore, the final sample was 184 – a 65 per cent response. Bias Questionnaires are criticized owing to the potential bias related to non-responses, so reducing non-responses is important; i.e. seeking a significant response rate helps to minimize the risk (Armstrong and Overton, 1977). With a 65 per cent response rate, nonresponse bias was not a significant problem in this research (Rea and Parker, 2005). Operationalization and measuring Nursing leadership, perceived by nurses, was considered a multi-dimensional variable explained by four dimensions, measured through items developed by Frederico and Castilho (2006) and validated in a Portuguese context. Considering the original scale’s dimensions, we decided to use a reduced version. Nursing leadership was therefore measured using 13 items (Appendix), chosen according to their loadings in the original study: staff recognition (four items); communication (three items); team development (four items); and innovation (two items). Nursing quality was measured through six items (Appendix), based on standards emerging from the Portuguese Nursing Association. Table I shows the mean, standard deviation, Cronbach’s a and correlations between various latent variables; each was computed using means. Besides the two central variables (leadership and quality), four others were considered: gender (nominal variable); age (continuous variable); professional category (nominal variable); and tenure (continuous variable).
Table I. Mean, standard deviation, Cronbach’s a and correlations
Recognition (R) Communication (C) Team development (D) Innovation (I) Quality of nursing care (QNC)
Mean (M)
SD
Cronbach’s a
R
C
D
I
QNC
2.89 3.49 3.00 3.05 3.34
0.87 0.95 0.93 0.10 0.79
0.86 0.87 0.91 0.89 0.83
1 0.56** 0.25** 0.59** 0.46**
0.56** 1 0.36** 0.76** 0.61**
0.25** 0.36** 1 0.38** 0.61**
0.59** 0.76** 0.38** 1 0.75**
0.46** 0.61** 0.61** 0.75** 1
Note: **Correlation is significant at 0.01 level (two-tailed)
Analysis For statistical purposes, we computed descriptive statistics (frequencies, means and standard deviation), and performed a structural equation analysis (SEA), using SPSS and AMOS (SPSS Inc., Chicago, IL) software.
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
Results Sample profile More female nurses (78 per cent) responded because nursing is predominantly a female profession. Respondent’s average age was 39 years (range 24-59 years). Only 23 per cent were specialized nurses and average tenure was 16 years (SD ¼ 8), suggesting a large accumulated experience. Validity The proposed model’s viability was investigated through SEA, a statistic that combines factor and linear regression analysis (Maroˆco, 2010), allowing interrelationships between observable and latent variables to be simultaneously analysed (Hair et al., 2009). SEA has two essential steps: measurement model – specifying the relationships between observable variables and their latent variables; and structural model – specifying the relationships between latent variables (Hair et al., 2009). Some assumptions underlie structural equation modelling (Hair et al., 2009). Regarding normality assumptions, results showed that no observable variables were skewed or demonstrated kurtosis – indicating no severe violation (|Sk|o3 and |Ku|o10 – Hair et al., 2009). Linearity assumptions were analysed through Pearson correlations between different variables. Correlations between the different observable variables are expected to be significant (Hair et al., 2009; Kline, 2004). Significant linear relationships (at a 1 per cent level) were found between all variables. To check possible multivariate outliers, we computed and analysed Mahalanobis distance (significance at the 0.01 level). The analysis did not reveal atypical observations. Missing multi-collinearity between observable variables was confirmed by variable inflator factor (VIF) and tolerance statistics. There were no problems regarding multi-collinearity – all VIFs were under three and all tolerance measures under 0.20. For confirmatory factor analysis, we applied the maximum likelihood method, a robust approach most commonly used in SEA, although it can be unsuitable in situations that violate the multivariate normality assumption (Hair et al., 2009; Byrne, 2010). Results show that all variables have high factor loadings (l40.5) and suitable individual reliabilities (R24 ¼ 0.25). Convergent validity was tested through various relative, absolute and parsimony fit measures, commonly used in research based on structural equation modelling (Hair et al., 2009). The model fit indices, which determine the hypothetical model’s fit with the sample data, are summarized in Table II. Except for the goodness of fit index (GFI), all adjustment indices were above those highlighted in the literature (Maroˆco, 2010; Hair et al., 2009). Even though the GFI value is under 0.9, it was considered acceptable since it is close to the limit highlighted in literature. Our results exhibited fit indices exceeding or close to the commonly recommended threshold and indicate that the measurement model exhibit a fairly good fit with the data. The root mean square residual (RMR) indicates that the average residual correlation was 0.073. The root mean square error of approximation (RMSEA) was 0.071. Both estimates provide evidence of model fit as they were below 0.08. The CFI (an incremental fit index) was 0.986, exceeding the level of 0.95, further supporting the model’s acceptance. The normed w2 was 1.915. This falls well within the
Quality nursing care
443
IJHCQA 27,5
Fit measures Absolute measures CMIN/DF Goodness of fit index (GFI) RMSEA
444
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
Table II. Confirmatory factor analysis – model fit measures
Root mean square residual (RMR) Relative measures Comparative fit ´ındex (CFI) Parsimony measures Parsimony comparative fit index (PCFI) Parsimony goodness of fit index (PGFI)
Values
Acceptance level
0.073
o2 (good) 5 (acceptable) (Maroˆco, 2010) 40.9 (good) 0.95 (very good) (Maroˆco, 2010) o0.05 (very good) 0.08 (good) 0.1 ( poor) (Maroˆco, 2010) o 0.10 (Hair et al., 2009)
0.948
40.9 (good) 0.95 (very good) (Maroˆco, 2010)
0.739 0.616
40.6 (reasonable) 0.8 (good) (Maroˆco, 2010) 40.6 (reasonable) 0.8 (good) (Maroˆco, 2010)
1.915 0.889 0.071
recommended range for conditional support to be given for model parsimony. The parsimony comparative fit index (PCFI) and the parsimony goodness of fit index (PGFI) reflect a penalty owing to the model’s complexity by including more free parameters to improve the adjustment; results showed acceptable to good values. Validating the model Having validated the measurement model through confirmatory factor analysis and considering the statistically significant correlations between latent variables, the next step was to validate the structural model. Our hypothesis was that nursing leadership has a positive influence on nursing quality, so we used the maximum likelihood estimation method. The measuring model’s factorial validity is assumed since all observed variables present high factor loadings (l40.5) and a suitable individual reliability (R24 ¼ 0.25). Table III shows that the structural model has a reasonable fit. Except for the GFI, all fit indices are above the literature references (Maroˆco, 2010; Hair et al., 2009). Although the GFI value is under 0.9, it was considered acceptable as it is close to the reference value. Figure 1 summarizes the structural equation modeling analysis’ final output and specifically the standardized regression weight between both constructs and its statistical significance. The path analysis between both latent constructs clearly suggests that nursing leadership has a direct (b ¼ 0.724) and a statistically significant ( p ¼ 0.007) effect on nursing quality. Considering these results, we may accept the original hypothesis, Fit measures Absolute measures CMIN/DF Goodness of fit index (GFI) RMSEA
Table III. Structural model fit indices
Root mean square residual (RMR) Relative measures Comparative fit ´ındex (CFI) Parsimony measures Parsimony comparative fit index (PCFI) Parsimony goodness of fit index (PGFI)
Values
Acceptance level
0.089
o2 (good) 5 (acceptable) (Maroˆco, 2010) 40.9 (good) 0.95 (very good) (Maroˆco, 2010) o0.05 (very good) 0.08 (good) 0.1 ( poor) (Maroˆco, 2010) o 0.10 (Hair et al., 2009)
0.937
40.9 (good) 0.95 (very good) (Maroˆco, 2010)
0.764 0.638
40.6 (reasonable) 0.8 (good) (Maroˆco, 2010) 40.6 (reasonable) 0.8 (good) (Maroˆco, 2010)
2.067 0.879 0.076
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
according to which nursing leadership, perceived by nurses, and considered as a multidimensional variable explained by four dimensions (recognition, communication, team development and innovation) influences directly and significantly, nursing quality. Discussion Our main purpose was to analyse the relationship between two commonly discussed issues in the healthcare management literature: nursing leadership and nursing quality. While many publications have been direct or indirectly stressing a logical association between leadership and nursing quality, empirical results regarding this specific relationship are limited. Our findings represent a valid contribution to expand our knowledge regarding such issues, given the paucity of empirical research in this field. Findings clearly suggest that nursing leadership influences directly and significantly nursing quality, strengthening several ideas conveyed throughout the literature, despite some studies suggesting there is no correlation between quality perceived by healthcare professionals and leadership (DeMarco et al., 2004). Our results corroborate empirically several issues highlighted throughout the literature regarding how nursing quality may be influenced by nursing leadership dimensions, and specifically: (1)
communication (American Association of Critical-Care Nurses, 2005; Clarke and Donaldson, 2008; Heath et al., 2004; Hughes, 2008);
(2)
recognition (Cronin and Bechrerer, 1999; Laschinger and Havens, 1996; Patrick and Lashinger, 2006; Porto, 2004);
(3)
development (Lukas et al., 2007; Normand et al., 2000; Thomas et al., 2008); and
(4)
innovation (Bally, 2007; Dopson and Fitzgerald, 2006; Morjikian et al., 2007; Wang et al., 2006).
Quality nursing care
445
According to the American Nurses Association, nurses are directly responsible for: service quality and systematically improving nursing practice. Implementing strategies and developing a working climate conducive to professionals’ greater involvement, higher motivation and creativity are fundamental to continuous improvement processes (Kurcgant et al., 2006). Leaders should develop strategies with nurses to ensure that affection, empathy and respect are present in the service they lead (Burhans and Alligood, 2010). The leader should provide equal opportunities for nurses to grow professionally, to develop and implement measures that can motivate them to develop both knowledge and capacities. Our investigation also strengthens the idea that communication is essential to coordinating group activities, aiming at changing individual behaviours and attitudes to ensure professional satisfaction Recognition
Communication
Nursing Leadership Team Development
Innovation
0.724 (p =0.007)
Quality of Nursing Care
Figure 1. Structural model with standardized coefficients
IJHCQA 27,5
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
446
(Ruthes and Cunha, 2009). The results also suggest that nursing leaders should innovate, encourage and allow collaborating nurses to implement strategies creatively so that care quality is continuously improved. Conclusion Our results suggest that leadership effectively influences nursing quality. Nurses are the agents directly influencing service quality and quality depends significantly on the leader and the way s/he manages the team. Our study calls for head nurses to be conscientious about management processes, considering both staff and physical resources, and how these significantly influence service quality. Our findings show that the following are important for nursing quality: recognition shown by the leader; nurses’ development; communication; and the way leaders inspires and encourages service innovation. Limitations Our study has limitations: the investigation was restricted to a single health unit and so it may not be generalizable to other organizations in the sector. Using nurses’ perceptions to operationalize the variables is another limitation. Items chosen to measure the variables are limited, pointing to the need for studies on a greater scale, allowing the original scale to measure leadership and all standards proposed by the Portuguese Nursing Association in measuring: user satisfaction; health promotion; preventing complications; functional rehabilitation; and organizing nursing care. Suggestions for future research The literature’s paucity concerning leadership’s influence on nursing quality justifies future studies in this area. It would be important to replicate the same study with a much wider population, since the sample study is limited to one health organization, to extend our knowledge about the relationship between leadership and nursing quality. Moreover, the literature enhances that leadership is important to promote employees’ organizational commitment, which in turn is essential in quality improvement programmes. As a result, fruitful research would be to determine to what extent collaborator commitment may act as a moderating variable in the relationship between nursing leadership and quality. Finally, it would also be interesting to develop, in the same organization, a similar study, but from the leader’s perspective before comparing results of both investigations and see if there are significant differences. References Aiken, L. (2007), “Nurse staffing impact on organizational outcomes”, in Mason, D., Leavitt, J. and Chaffee, M. (Eds), Policy and Politics in Nursing and Health Care, 5th ed., Elsevier, St. Louis, MO, pp. 550-559. American Association of Critical-Care Nurses (2005), “AACN standards for establishing and sustaining healthy work environments: a journey to excellence”, American Journal of Critical Care, Vol. 14 No. 3, pp. 187-197. Armstrong, J. and Overton, T. (1977), “Estimating nonresponse bias in mail surveys”, Journal of Marketing Research, Vol. 14 No. 3, pp. 396-402. Attree, M. (2001), “A study of the criteria used by healthcare professionals, managers and patients to represent and evaluate quality care”, Journal of Nursing Management, Vol. 9 No. 2, pp. 67-78. Bally, J.M. (2007), “The role of nursing leadership in creating a mentoring culture in acute care environments”, Nursing Economic$, Vol. 25 No. 3, pp. 143-148.
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
Balsanelli, A.P. and Cunha, I.C. (2006), “Lideranc¸a no contexto da enfermagem (Leadership in the nursing context)”, Revista da Escola de Enfermagem – USP, Vol. 40 No. 1, pp. 117-122. Barbosa de Sousa, L. and Teixeira Barroso, M.G. (2009), “Reflex~ao sobre o cuidado como Esseˆncia da lideranc¸a em Enfermagem”, Escola Anna Nery Revista enfermagem, Vol. 13 No. 1, pp. 181-187. Buckley, M., Laursen, J. and Otarola, V. (2009), “Strengthening physician-nurse partnerships to improve quality and patient safety”, Physician Executive Journal, Vol. 35 No. 6, pp. 24-28. Burhans, L.M. and Alligood, M.R. (2010), “Quality nursing care in the words of nurses”, Journal of Advanced Nursing, Vol. 66 No. 8, pp. 1689-1697. Burke, R.J., Ng, E.S.W. and Fiksenbaum, L. (2009), “Virtues, work satisfactions and psychological wellbeing among nurses”, International Journal of Workplace Health Management, Vol. 2 No. 3, pp. 202-219. Byrne, B. (2010), Structural Equation Modeling with AMOS – Basic Concepts, Applications, and Programming, 1st ed., Routledge, New York, NY. Chang, B., Lee, J., Pearson, M., Kahn, K., Elliott, M. and Rubenstein, L. (2002), “Evaluating quality of nursing care: the gap between theory and practice”, Journal of Nursing Administration, Vol 32 Nos 7/8, pp 405-418. Clarke, S.P. (2005), “The policy implications of staffing-outcomes research”, Journal of Nursing Administration, Vol. 35 No. 1, pp. 17-19. Clarke, S.P. and Donaldson, N.E. (2008), “Nurse staffing and patient care quality and safety”, in Hughes, R.G. (Ed.), Patient Safety and Quality: An Evidence-Based Handbook for Nurses, Chapter 25 Agency for Healthcare Research and Quality (US), Rockville, MD, pp. 646-670. Coonan, P.R. (2008), “Educational innovation: nursing’s leadership challenge”, Nursing Economic$, Vol. 26 No. 2, pp. 117-121. Cronin, S.N. and Bechrerer, D. (1999), “Recognition of staff nurse job performance and achievements”, Journal of Nursing Administration, Vol. 29 No. 1, pp. 26-31. DeMarco, R., Flaherty, L., Glod, C., Merrill, N., Terk, K. and Plasse, M. (2004), “Staff and client perceptions of unit quality: a pilot study”, Journal of Psychosocial Nursing, Vol. 42 No. 5, pp. 36-43. Dopson, S. and Fitzgerald, L. (2006), “The role of the middle manager in the implementation of evidence-based health care”, Journal of Nursing Management, Vol. 14 No. 1, pp. 43-51. Dugdall, H., Lamb, C. and Carlisle, A. (2004), “Improving quality care through a nursing review team”, Clinical Governance: An International Journal, Vol. 9 No. 3, pp. 155-162. Estabrooks, C., Scott, S., Squires, J., Stevens, B., O’Brien-Pallas, l., Watt-Watson, J., Profetto-McGrath, J., Mcgilton, K., Golden-Biddle, K., Lander, J., Donner, G., Boschma, G., Humphrey, C. and Williams, J. (2008), “Patterns of research utilization on patient care units”, Implementation Science, Vol. 3 No. 31, pp. 1-16. Frederico, M. and Castilho, A. (2006), “Percepc¸~ao de lideranc¸a em enfermagem – validac¸~ao de uma escala”, Revista Psycologica, No. 43, pp. 259-270. Gelbcke, F.L., Souza, L.A., Dal Sasso, G.M., Nascimento, E. and Bulb, M.B. (2009), “Leadership in critical care settings: reflections and challenges for the Brazilian nursing”, Revista Brasileira de Enfermagem, Vol. 62 No. 1, pp. 136-139. Glen, S. (1998), “Emotional and motivational tendencies: the key to quality nursing care?”, Nursing Ethics, Vol. 5 No. 1, pp. 36-42. Gunther, M. and Alligood, M.R. (2002), “A discipline-specific determination of high quality nursing care”, Journal of Advanced Nursing, Vol. 38 No. 4, pp. 353-359. Hair, J., Black, W., Babin, B. and Anderson, R. (2009), Multivariate Data Analysis, 7th ed., Pearson Prentice Hall, Upper Saddle River, NJ.
Quality nursing care
447
IJHCQA 27,5
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
448
Heath, J., Johanson, W. and Blake, N. (2004), “Healthy work environments: a validation of the literature”, Journal of Nursing Administration, Vol. 34 No. 11, pp. 524-530. Hines, P.A. and Yu, K.M. (2009), “The changing reimbursement landscape: nurses’ role in quality and operational excellence”, Nursing Economic$, Vol. 27 No. 1, pp. 7-13. Hughes, R.G. (2008), “Nurses at the ‘Sharp End’ of patient care”, in Hughes, R.G. (Ed.), Patient Safety and Quality: An Evidence-Based Handbook for Nurses, Chapter 2 Agency for Healthcare Research and Quality (US), Rockville, MD, pp. 25-54. Institute of Medicine (2011), The Future of Nursing: Leading Change, Advancing Health, The National Academies Press, Washington, DC. Jackson, J.R., Clements, P.T., Averill, J.B. and Zimbro, K. (2009), “Patterns of knowing: proposing a theory for nursing leadership”, Nursing Economic$, Vol. 27 No. 3, pp. 149-159. Kalisch, B.J., Terzioglu, F. and Duygulu, S. (2012), “The MISSCARE Survey-Turkish: psychometric properties and findings”, Nursing Economic$, Vol. 30 No. 1, pp. 29-37. Kline, R. (2004), Principles and Practice of Structural Equation Modeling, 2nd ed., The Guilford Press, New York, NY. Kunaviktikul, W., Anders, R.L. and Srisuphan, W. (2001), “Development of quality nursing care in Thailand”, Journal of Advanced Nursing, Vol. 36 No. 6, pp. 776-784. Kurcgant, P., Tronchin, D. and Melleiro, M. (2006), “A construc¸~ao de indicadores de qualidade para a avaliac¸~ao de recursos humanos nos servic¸os de enfermagem: pressupostos teoricos”, Acta Paulista de Enfermagem, Vol. 19 No. 1, pp. 88-91. Laschinger, H.K. and Havens, D.S. (1996), “Staff nurse work empowerment and perceived control over nursing practice: conditions for work effectiveness”, Journal of Nursing Administration, Vol. 26 No. 9, pp. 27-35. Lukas, C.V., Holmes, S.K., Cohen, A.B., Restuccia, J., Cramer, I.E., Shwartz, M. and Charns, M.P. (2007), “Transformational change in health care systems: an organizational model”, Health Care Management Review, Vol. 32 No. 4, pp. 309-320. McLaughlin, C.P. and Kaluzny, A.D. (2004), “Defining quality improvement: past, present and future”, in McLaughlin, C.P. and Kaluzny, A.D. (Eds), Continuous Quality Improvement in Healthcare, 2nd ed., Aspen Publishers, Gaithersburg, MD, pp. 3-33. Maroˆco, J. (2010), “Analise de Equac¸o˜es Estruturais: Fundamentos Teoricos, Software e Aplicac¸o˜es”, report number Peˆro pinheiro. Marquis, B.L. and Huston, C.J. (2011), Leadership Roles and Management Functions in Nursing: Theory and Application, Wolters Kluwer Health/Lippincott Williams & Wilkins, Philadelphia, PA. Morjikian, R.L., Kimball, B. and Joynt, J. (2007), “Leading change: the nurse executive’s role in implementing new care delivery models”, Journal of Nursing Administration, Vol. 37 No. 9, pp. 399-404. Navuluri, R.B. (1999), “Integrated quality improvement program in patient care”, Nursing & Health Sciences, Vol. 1 No. 4, pp. 249-254. Normand, C., Doagllas, H. and Castelnuovo, E. (2000), “Quality in nursing care: context, complexity and the role of professions”, Journal of Research in Nursing, Vol. 5 No. 6, pp. 407-415. Odom, R.Y., Boxx, R.W. and Dunn, M.G. (1990), “Organizational cultures, commitment, satisfaction, and cohesion”, Public Productivity & Management Review, Vol. 14 No. 2, pp. 157-169. Patrick, A. and Lashinger, H.K. (2006), “The effect of structural empowerment and perceived organizational support on middle level nurse managers’ role satisfaction”, Journal of Nursing Management, Vol. 14 No. 1, pp. 13-22.
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
Porto, G. (2004), “The role of the risk manager in creating patient safety”, in Youngberg, B.J. and Hatlie, M.J. (Eds), The Patient Safety Handbook, Jones & Bartlett, Sudbury, MA, pp. 305-426. Rea, L. and Parker, R. (2005), Designing and Conducting Survey Research: A Comprehensive Guide, 3rd ed., John Wiley & Sons, San Francisco, CA. Rosenbach, W.E. and Taylor, R.L. (1998), Contemporary Issues in Leadership, 4th ed., Westview Press, Oxford. Ruthes, R. and Cunha, I. (2009), “Competeˆncias do enfermeiro na gest~ao do conhecimento e capital intelectual”, Revista Brasileira de Enfermagem, Vol. 62 No. 6, pp. 901-905. Stone, P.W., Mooney-Kane, C., Larson, E.L., Horan, T., Glance, L.G., Zwanziger, J. and Dick, A.W. (2007), “Nurse working conditions and patient safety outcomes”, Medical Care, Vol. 45 No. 6, pp. 571-578. Tafreshi, M., Pazargadi, M. and Saeedi, Z. (2007), “Nurses’ perspectives on quality of nursing care: a qualitative study in Iran”, International Journal of Health Care Quality Assurance, Vol. 20 No. 4, pp. 320-328. Thomas, J., Collins, A., Collins, D., Herrin, D., Dafferner, D. and Gabriel, J. (2008), “The language of business: a key nurse executive competency”, Nursing Economic$, Vol. 26 No. 2, pp. 122-127. Thompson, P.A., Navarra, M.B. and Antonson, N. (2005), “Patient safety: the four domains of nursing leadership”, Nursing Economic$, Vol. 23 No. 6, pp. 331-333. Vesterinen, S., Isola, A. and Paasivaara, L. (2009), “Leadership styles of Finnish nurse managers and factors influencing it”, Journal of Nursing Management, Vol. 17 No. 4, pp. 503-509. Wall, S. (2010), “Critical perspectives in the study of nursing work”, Journal of Health Organization and Management, Vol. 24 No. 2, pp. 145-166. Wang, M.C., Hyun, J.K. and Harrison, M. (2006), “Redesigning health systems for quality: lessons from emerging practices”, Joint Commission Journal on Quality and Patient Safety, Vol. 32 No. 11, pp. 599-611. Wong, C. and Cummings, G. (2009), “Authentic leadership: a new theory for nursing or back to basics?”, Journal of Health Organization and Management, Vol. 23 No. 5, pp. 522-538. Yen, M. and Lo, L. (2004), “A model for testing the relationship of nursing care and patient outcomes”, Nursing Economic$, Vol. 22 No. 2, pp. 75-80. Appendix. Operationalizing the variables Nursing Leadership Regarding your hierarchical superior, indicate your opinion, on a scale from 1 (Not at all) to 5 (Always) Recognition: .
R1. He/she recognizes and supports nurses’ decisions when these are challenged by others (superiors, doctors, etc.)
.
R2. He/she rewards team members’ actions and behaviour driven to improving nursing care
.
R3. He/she shows special recognition when someone does a good work
Communication: .
C1. He/she does not listen to all team members impartially and attentively (R)
.
C2. He/she does not have the perspicacity to identify team’s needs (R)
.
C3. He/she is not sufficiently sensitive to grasp what is really being said (R)
Quality nursing care
449
IJHCQA 27,5
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
450
Development: .
D1. He/she identifies the key components of a strategic plan
.
D2. He/she identifies the most important projects and activities and defines priorities
.
D3. He/she identifies and approves the necessary resources for carrying out nursing projects and activities
Innovation: .
I1. He/she challenges nurses to think about new ways to solve existing problems
.
I2. He/she does not encourage innovative ideas to achieve quality in nursing care (R)
Nursing quality Regarding quality nursing care, please indicate your perception in relation to the following items, on a scale from 1 (Completely disagree) to 5 (Completely agree): .
Q1. Nurses are encouraged to come up with suggestions for nursing care improvements
.
Q2. Nurses are encouraged to have in-service training
.
Q3. Teamwork is encouraged
.
Q4. There are standardized procedures facilitating quality improvement in nursing care practices
.
Q5. To improve the quality of nursing records, audits are regularly performed
.
Q6. Patients are duly accompanied to ensure a better adaptation outside the hospital environment
Note: (R) Reversed items Corresponding author Assistant professor Luis Mendes can be contacted at: [email protected]
To purchase reprints of this article please e-mail: [email protected] Or visit our web site for further details: www.emeraldinsight.com/reprints
Article information:
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
To cite this document: Luis Mendes Maria de Jesus José Gil Fradique , (2014),"Influence of leadership on quality nursing care", International Journal of Health Care Quality Assurance, Vol. 27 Iss 5 pp. 439 - 450 Permanent link to this document: http://dx.doi.org/10.1108/IJHCQA-06-2013-0069 Downloaded on: 30 January 2016, At: 07:52 (PT) References: this document contains references to 57 other documents. To copy this document: [email protected] The fulltext of this document has been downloaded 2248 times since 2014*
Users who downloaded this article also downloaded: Stephen George Willcocks, (2012),"Exploring leadership effectiveness: nurses as clinical leaders in the NHS", Leadership in Health Services, Vol. 25 Iss 1 pp. 8-19 http://dx.doi.org/10.1108/17511871211198034 Aditi Naidu, (2009),"Factors affecting patient satisfaction and healthcare quality", International Journal of Health Care Quality Assurance, Vol. 22 Iss 4 pp. 366-381 http://dx.doi.org/10.1108/09526860910964834 (2011),"Leadership and Management in Nursing", Leadership in Health Services, Vol. 24 Iss 1 pp. - http:// dx.doi.org/10.1108/lhs.2011.21124aae.001
Access to this document was granted through an Emerald subscription provided by emerald-srm:305060 []
For Authors If you would like to write for this, or any other Emerald publication, then please use our Emerald for Authors service information about how to choose which publication to write for and submission guidelines are available for all. Please visit www.emeraldinsight.com/authors for more information.
About Emerald www.emeraldinsight.com Emerald is a global publisher linking research and practice to the benefit of society. The company manages a portfolio of more than 290 journals and over 2,350 books and book series volumes, as well as providing an extensive range of online products and additional customer resources and services. Emerald is both COUNTER 4 and TRANSFER compliant. The organization is a partner of the Committee on Publication Ethics (COPE) and also works with Portico and the LOCKSS initiative for digital archive preservation. *Related content and download information correct at time of download.
The current issue and full text archive of this journal is available at www.emeraldinsight.com/0952-6862.htm
Influence of leadership on quality nursing care
Quality nursing care
Luis Mendes Management and Economics, University of Beira Interior (CEFAGE-UBI Research Center), Covilha~, Portugal, and
Maria de Jesus Jose´ Gil Fradique Local Health Unit of Castelo Branco, Castelo Branco, Portugal
439 Received 9 November 2012 Revised 3 June 2013 Accepted 6 November 2013
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
Abstract Purpose – The purpose of this paper is to investigate the extent to which nursing leadership, perceived by nursing staff, influences nursing quality. Design/methodology/approach – Data were collected between August and October 2011 in a Portuguese health center via a questionnaire completed by nurses. Our original sample included 283 employees; 184 questionnaires were received (65% response). Findings – The theoretical model presents reasonably satisfactory fit indices (values above literature reference). Path analysis between latent constructs clearly suggests that nursing leadership has a direct ( ß ¼ 0.724) and statistically significant ( p ¼ 0.007) effect on nursing quality. Originality/value – Results reinforce several ideas propagated throughout the literature, which suggests the relationship’s relevance, but lacks empirical support, which this study corrects. Keywords Quality improvement, Leadership, Healthcare quality, Nursing care Paper type Research paper
Introduction Quality remains a central issue for healthcare providers (McLaughlin and Kaluzny, 2004). Calls to continuously improve patient safety and care quality have intensified in the last decade. The literature describes a bureaucratic culture in public sector organizations, rooted in a strong emphasis on rules and regulations (Odom et al., 1990). Since quality improvement requires significant management change, one potential pitfall in the public sector is that accepting initiatives by collaborators may be achieved slowly (McLaughlin and Kaluzny, 2004). In this context, nurses are increasingly challenged to assume a growing responsibility and active participation in quality improvement. Nurses represent the largest professional group in health organizations, being legally and morally responsible for service quality (Estabrooks et al., 2008; Gunther and Alligood, 2002). There is a growing recognition that nurses have a central role in quality health services (Institute of Medicine, 2011; Burke et al., 2009). Nursing quality makes a vital difference in patient outcomes and safety, and nurses, as hands-on caregivers, make major healthcare contributions by: assessing, planning and evaluating patients’ needs; delivering treatments and medications; advocating for patients; and assuring their comfort (Burhans and Alligood, 2010). Quality nursing care from the nurses’ perspective corresponds to meeting human needs through caring, empathetic and respectful interactions (Burhans and Alligood, 2010; Tafreshi et al., 2007). Nursing quality depends on nurses’ response to the patients’ physical, The authors acknowledge partial financial support from FCT (Fundac¸~ao para a Cieˆncia e a Tecnologia).
International Journal of Health Care Quality Assurance Vol. 27 No. 5, 2014 pp. 439-450 r Emerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-06-2013-0069
IJHCQA 27,5
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
440
psychological, emotional, social and spiritual needs; allowing patients to live a normal life and contributing to patient and nurse satisfaction (Kunaviktikul et al., 2001). Positive patient outcomes depend more on nursing quality than on technology (Navuluri, 1999). Although, research supports the link between nursing and patient outcomes, the connection is approached cautiously (Clarke, 2005). There is increasing evidence in the literature that patient outcomes are strongly related to nursing performance and that nurses’ decision making has a significant influence on service quality (Dugdall et al., 2004; Chang et al., 2002; Yen and Lo, 2004; Stone et al., 2007). Therefore, health service leaders should promote a climate that favours nurses’ professional development and aim for enhanced nursing performance. The barriers to improving service quality and patient safety are to do with the need for better communication, collaboration and shared ownership and responsibility for patient care (Buckley et al., 2009). Head nurses may have a key role within a team and can have a decisive influence on nurse staffing, motivation, efficiency and quality. Indeed, nursing patient safety and nursing quality outcomes are significant challenges for nurse leaders everywhere (Kalisch et al., 2012). Head nurses’ capacity to influence depends more on motivation and leadership than the hierarchical level at which they carry out their tasks (Frederico and Castilho, 2006). Therefore, nursing leadership can be considered as the ability to motivate nurses, through ideas, strategies and actions to concentrate efforts and achieve goals and contributing to service effectiveness and success (Bally, 2007). Health services are a rapidly changing environment and subsequently, innovative nursing leadership is required ( Jackson et al., 2009). Nursing leaders should thus develop and implement strategies that help nurses to identify and deliver quality nursing care, caring, empathy, respect and advocacy (Burhans and Alligood, 2010). This means that nurse leaders must invest in the potential that each nurse has, involving him/her in decision making and ensuring that all team members are aware of their role to achieve the organization’s objectives, thus promoting conditions for a creative environment. Therefore, because the leader is the team’s training or service coordination fulcrum, nursing leadership means leading and organizing teamwork, seeking an efficient care service and encouraging staff to develop their full potential (Wong and Cummings, 2009). Unfortunately, nursing leadership can be an independent function, frequently unconnected to the ultimate goal – patient care. Often the leader ends up losing sight of this purpose during the leadership process, which can lead to a working environment that is unfavourable to patients (Barbosa de Sousa and Teixeira Barroso, 2009). In a quality improvement context, leadership is recognized as a key factor playing an important role in excellence models. However, the relationship’s significance is still lacking sufficient empirical evidence, especially in the health sector where research paucity concerning leadership’s influence in improving healthcare quality remains a reality. Our aim, therefore, is to investigate to what extent nursing leadership, perceived by nurses, influences nursing quality. Theoretical framework and research hypothesis Service quality is viewed as a critical aspect in organizational management, especially in the health sector, mostly characterized by a general weak quality culture. In this specific industry, various factors contributed to developing strategies oriented to guaranteeing quality: user dissatisfaction; unequal access to health services; waiting lists; waste owing to ineffectiveness; and absent performance indicators. Indeed, continuously pursuing strategic guidelines, urgently developing and implementing interventions to assess and monitor adequately care quality are key priorities in most
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
organizations. Health professionals, as integral elements, may contribute significantly to such purposes. In this panorama, nurses can play a leading role in defining new standards and developing health quality systems. Quality care requires a clear and deep reflection on how to define effective service objectives, and on how to outline appropriate strategies to achieve these goals; such purposes require that staff generally must provide good working conditions for professionals to plan and implement measures aimed at improving quality, which become part of the nurses’ routine. Kunaviktikul et al. (2001) reported that nursing quality depends on how the patient’s physical, psychosocial, emotional, social and spiritual needs are met by nurses. Likewise, quality care means meeting human needs through caring, empathetic, respectful interactions within which responsibility, intentionality and advocacy form an essential, integral foundation (Burhans and Alligood, 2010; Gunther and Alligood, 2002; Attree, 2001; Glen, 1998). As a result, health service quality needs everyone’s support when implementing systematic management practices oriented towards user satisfaction, with increased attention to continuously improving organizational processes. Thus, leading an organization-wide patient safety effort requires nurse executives to couple exceptional leadership skills with a keen focus on safety, approaching the challenge from a system perspective (Thompson et al., 2005). Changes resulting from various factors, including technological innovation, higher information access and increasingly informed healthcare users, or ongoing constraints in care management, represent strong challenges for nursing leaders (Aiken, 2007). Moreover, operational excellence, service quality and financial performance are increasingly known as key hospital-performance drivers; as a result, key initiatives for nursing leaders include improving and stabilizing nurse staffing, implementing a just and fair culture, reducing variation in clinical practice and providing comprehensive case management (Hines and Yu, 2009). In a nursing context, leaders must invest in the potential that each nurse has and involve them in decision making, ensuring that everyone is aware about his or her key role in achieving the organization’s objectives, thus promoting a creative environment. Indeed, effective leadership should combine task-oriented and relationship centered activity (Rosenbach and Taylor, 1998). Nursing leaders should improve nurse retention and recruiting efforts, encourage interdisciplinary collaboration and, most importantly, demonstrate to their colleagues the value nursing brings to the organization through consistently tracking quality and financial indicators, and linking them to nursing initiatives (Hines and Yu, 2009). Moreover, knowledge about nurses’ needs and expectations is important for service efficiency and effectiveness, although the fundamental skills that allow a leader to be effective are constantly changing (Marquis and Huston, 2011), and that nurses can only exercise their authority as leaders if team members recognize them. Leaders are the team’s fulcrum and nursing leadership means knowing how to conduct and organize teamwork, seeking efficient services, whether regarding education or service coordination and encouraging staff to develop their full potential (Gelbcke et al., 2009). Thus, nursing leaders need to collaborate to integrate and innovate to develop, improve and maintain nursing skills and competent practitioners (Coonan, 2008). As jobs become more knowledge intensive, nursing leaders must find better ways to recognize and develop employees’ valuable knowledge and skills (Wall, 2010). Furthermore, evidence in the literature suggests that certain traits and behaviuors may influence how leadership roles are performed, but do not guarantee its success, hence the critically important relationship based on a permanent dialogue between leaders and followers. When leaders forget such purpose, team members become disappointed, frustrated and may deviate
Quality nursing care
441
IJHCQA 27,5
from organization values (Vesterinen et al., 2009; Balsanelli and Cunha, 2006). The different considerations and arguments lead us to the following hypothesis: H1. Nursing leadership, perceived by nurses, influences nursing quality positively and significantly.
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
442
Methods Data collection Data were collected between August and October 2011 in a Portuguese health centre, via questionnaires filled by nurses. Since all investigations should obey strict ethical principles, aiming to protect human rights, a formal authorization to collect data was previously requested from the health centre’s administrative council. To ensure efficiency and effectiveness, the instrument was pre-tested among nurses belonging to other institutions. After confirming there were no doubts regarding its completion, the questionnaire was then applied to our sample. From 283 questionnaires distributed, 197 were received. After a careful screening process, 13 were discarded owing to missing values and outlier data. Therefore, the final sample was 184 – a 65 per cent response. Bias Questionnaires are criticized owing to the potential bias related to non-responses, so reducing non-responses is important; i.e. seeking a significant response rate helps to minimize the risk (Armstrong and Overton, 1977). With a 65 per cent response rate, nonresponse bias was not a significant problem in this research (Rea and Parker, 2005). Operationalization and measuring Nursing leadership, perceived by nurses, was considered a multi-dimensional variable explained by four dimensions, measured through items developed by Frederico and Castilho (2006) and validated in a Portuguese context. Considering the original scale’s dimensions, we decided to use a reduced version. Nursing leadership was therefore measured using 13 items (Appendix), chosen according to their loadings in the original study: staff recognition (four items); communication (three items); team development (four items); and innovation (two items). Nursing quality was measured through six items (Appendix), based on standards emerging from the Portuguese Nursing Association. Table I shows the mean, standard deviation, Cronbach’s a and correlations between various latent variables; each was computed using means. Besides the two central variables (leadership and quality), four others were considered: gender (nominal variable); age (continuous variable); professional category (nominal variable); and tenure (continuous variable).
Table I. Mean, standard deviation, Cronbach’s a and correlations
Recognition (R) Communication (C) Team development (D) Innovation (I) Quality of nursing care (QNC)
Mean (M)
SD
Cronbach’s a
R
C
D
I
QNC
2.89 3.49 3.00 3.05 3.34
0.87 0.95 0.93 0.10 0.79
0.86 0.87 0.91 0.89 0.83
1 0.56** 0.25** 0.59** 0.46**
0.56** 1 0.36** 0.76** 0.61**
0.25** 0.36** 1 0.38** 0.61**
0.59** 0.76** 0.38** 1 0.75**
0.46** 0.61** 0.61** 0.75** 1
Note: **Correlation is significant at 0.01 level (two-tailed)
Analysis For statistical purposes, we computed descriptive statistics (frequencies, means and standard deviation), and performed a structural equation analysis (SEA), using SPSS and AMOS (SPSS Inc., Chicago, IL) software.
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
Results Sample profile More female nurses (78 per cent) responded because nursing is predominantly a female profession. Respondent’s average age was 39 years (range 24-59 years). Only 23 per cent were specialized nurses and average tenure was 16 years (SD ¼ 8), suggesting a large accumulated experience. Validity The proposed model’s viability was investigated through SEA, a statistic that combines factor and linear regression analysis (Maroˆco, 2010), allowing interrelationships between observable and latent variables to be simultaneously analysed (Hair et al., 2009). SEA has two essential steps: measurement model – specifying the relationships between observable variables and their latent variables; and structural model – specifying the relationships between latent variables (Hair et al., 2009). Some assumptions underlie structural equation modelling (Hair et al., 2009). Regarding normality assumptions, results showed that no observable variables were skewed or demonstrated kurtosis – indicating no severe violation (|Sk|o3 and |Ku|o10 – Hair et al., 2009). Linearity assumptions were analysed through Pearson correlations between different variables. Correlations between the different observable variables are expected to be significant (Hair et al., 2009; Kline, 2004). Significant linear relationships (at a 1 per cent level) were found between all variables. To check possible multivariate outliers, we computed and analysed Mahalanobis distance (significance at the 0.01 level). The analysis did not reveal atypical observations. Missing multi-collinearity between observable variables was confirmed by variable inflator factor (VIF) and tolerance statistics. There were no problems regarding multi-collinearity – all VIFs were under three and all tolerance measures under 0.20. For confirmatory factor analysis, we applied the maximum likelihood method, a robust approach most commonly used in SEA, although it can be unsuitable in situations that violate the multivariate normality assumption (Hair et al., 2009; Byrne, 2010). Results show that all variables have high factor loadings (l40.5) and suitable individual reliabilities (R24 ¼ 0.25). Convergent validity was tested through various relative, absolute and parsimony fit measures, commonly used in research based on structural equation modelling (Hair et al., 2009). The model fit indices, which determine the hypothetical model’s fit with the sample data, are summarized in Table II. Except for the goodness of fit index (GFI), all adjustment indices were above those highlighted in the literature (Maroˆco, 2010; Hair et al., 2009). Even though the GFI value is under 0.9, it was considered acceptable since it is close to the limit highlighted in literature. Our results exhibited fit indices exceeding or close to the commonly recommended threshold and indicate that the measurement model exhibit a fairly good fit with the data. The root mean square residual (RMR) indicates that the average residual correlation was 0.073. The root mean square error of approximation (RMSEA) was 0.071. Both estimates provide evidence of model fit as they were below 0.08. The CFI (an incremental fit index) was 0.986, exceeding the level of 0.95, further supporting the model’s acceptance. The normed w2 was 1.915. This falls well within the
Quality nursing care
443
IJHCQA 27,5
Fit measures Absolute measures CMIN/DF Goodness of fit index (GFI) RMSEA
444
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
Table II. Confirmatory factor analysis – model fit measures
Root mean square residual (RMR) Relative measures Comparative fit ´ındex (CFI) Parsimony measures Parsimony comparative fit index (PCFI) Parsimony goodness of fit index (PGFI)
Values
Acceptance level
0.073
o2 (good) 5 (acceptable) (Maroˆco, 2010) 40.9 (good) 0.95 (very good) (Maroˆco, 2010) o0.05 (very good) 0.08 (good) 0.1 ( poor) (Maroˆco, 2010) o 0.10 (Hair et al., 2009)
0.948
40.9 (good) 0.95 (very good) (Maroˆco, 2010)
0.739 0.616
40.6 (reasonable) 0.8 (good) (Maroˆco, 2010) 40.6 (reasonable) 0.8 (good) (Maroˆco, 2010)
1.915 0.889 0.071
recommended range for conditional support to be given for model parsimony. The parsimony comparative fit index (PCFI) and the parsimony goodness of fit index (PGFI) reflect a penalty owing to the model’s complexity by including more free parameters to improve the adjustment; results showed acceptable to good values. Validating the model Having validated the measurement model through confirmatory factor analysis and considering the statistically significant correlations between latent variables, the next step was to validate the structural model. Our hypothesis was that nursing leadership has a positive influence on nursing quality, so we used the maximum likelihood estimation method. The measuring model’s factorial validity is assumed since all observed variables present high factor loadings (l40.5) and a suitable individual reliability (R24 ¼ 0.25). Table III shows that the structural model has a reasonable fit. Except for the GFI, all fit indices are above the literature references (Maroˆco, 2010; Hair et al., 2009). Although the GFI value is under 0.9, it was considered acceptable as it is close to the reference value. Figure 1 summarizes the structural equation modeling analysis’ final output and specifically the standardized regression weight between both constructs and its statistical significance. The path analysis between both latent constructs clearly suggests that nursing leadership has a direct (b ¼ 0.724) and a statistically significant ( p ¼ 0.007) effect on nursing quality. Considering these results, we may accept the original hypothesis, Fit measures Absolute measures CMIN/DF Goodness of fit index (GFI) RMSEA
Table III. Structural model fit indices
Root mean square residual (RMR) Relative measures Comparative fit ´ındex (CFI) Parsimony measures Parsimony comparative fit index (PCFI) Parsimony goodness of fit index (PGFI)
Values
Acceptance level
0.089
o2 (good) 5 (acceptable) (Maroˆco, 2010) 40.9 (good) 0.95 (very good) (Maroˆco, 2010) o0.05 (very good) 0.08 (good) 0.1 ( poor) (Maroˆco, 2010) o 0.10 (Hair et al., 2009)
0.937
40.9 (good) 0.95 (very good) (Maroˆco, 2010)
0.764 0.638
40.6 (reasonable) 0.8 (good) (Maroˆco, 2010) 40.6 (reasonable) 0.8 (good) (Maroˆco, 2010)
2.067 0.879 0.076
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
according to which nursing leadership, perceived by nurses, and considered as a multidimensional variable explained by four dimensions (recognition, communication, team development and innovation) influences directly and significantly, nursing quality. Discussion Our main purpose was to analyse the relationship between two commonly discussed issues in the healthcare management literature: nursing leadership and nursing quality. While many publications have been direct or indirectly stressing a logical association between leadership and nursing quality, empirical results regarding this specific relationship are limited. Our findings represent a valid contribution to expand our knowledge regarding such issues, given the paucity of empirical research in this field. Findings clearly suggest that nursing leadership influences directly and significantly nursing quality, strengthening several ideas conveyed throughout the literature, despite some studies suggesting there is no correlation between quality perceived by healthcare professionals and leadership (DeMarco et al., 2004). Our results corroborate empirically several issues highlighted throughout the literature regarding how nursing quality may be influenced by nursing leadership dimensions, and specifically: (1)
communication (American Association of Critical-Care Nurses, 2005; Clarke and Donaldson, 2008; Heath et al., 2004; Hughes, 2008);
(2)
recognition (Cronin and Bechrerer, 1999; Laschinger and Havens, 1996; Patrick and Lashinger, 2006; Porto, 2004);
(3)
development (Lukas et al., 2007; Normand et al., 2000; Thomas et al., 2008); and
(4)
innovation (Bally, 2007; Dopson and Fitzgerald, 2006; Morjikian et al., 2007; Wang et al., 2006).
Quality nursing care
445
According to the American Nurses Association, nurses are directly responsible for: service quality and systematically improving nursing practice. Implementing strategies and developing a working climate conducive to professionals’ greater involvement, higher motivation and creativity are fundamental to continuous improvement processes (Kurcgant et al., 2006). Leaders should develop strategies with nurses to ensure that affection, empathy and respect are present in the service they lead (Burhans and Alligood, 2010). The leader should provide equal opportunities for nurses to grow professionally, to develop and implement measures that can motivate them to develop both knowledge and capacities. Our investigation also strengthens the idea that communication is essential to coordinating group activities, aiming at changing individual behaviours and attitudes to ensure professional satisfaction Recognition
Communication
Nursing Leadership Team Development
Innovation
0.724 (p =0.007)
Quality of Nursing Care
Figure 1. Structural model with standardized coefficients
IJHCQA 27,5
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
446
(Ruthes and Cunha, 2009). The results also suggest that nursing leaders should innovate, encourage and allow collaborating nurses to implement strategies creatively so that care quality is continuously improved. Conclusion Our results suggest that leadership effectively influences nursing quality. Nurses are the agents directly influencing service quality and quality depends significantly on the leader and the way s/he manages the team. Our study calls for head nurses to be conscientious about management processes, considering both staff and physical resources, and how these significantly influence service quality. Our findings show that the following are important for nursing quality: recognition shown by the leader; nurses’ development; communication; and the way leaders inspires and encourages service innovation. Limitations Our study has limitations: the investigation was restricted to a single health unit and so it may not be generalizable to other organizations in the sector. Using nurses’ perceptions to operationalize the variables is another limitation. Items chosen to measure the variables are limited, pointing to the need for studies on a greater scale, allowing the original scale to measure leadership and all standards proposed by the Portuguese Nursing Association in measuring: user satisfaction; health promotion; preventing complications; functional rehabilitation; and organizing nursing care. Suggestions for future research The literature’s paucity concerning leadership’s influence on nursing quality justifies future studies in this area. It would be important to replicate the same study with a much wider population, since the sample study is limited to one health organization, to extend our knowledge about the relationship between leadership and nursing quality. Moreover, the literature enhances that leadership is important to promote employees’ organizational commitment, which in turn is essential in quality improvement programmes. As a result, fruitful research would be to determine to what extent collaborator commitment may act as a moderating variable in the relationship between nursing leadership and quality. Finally, it would also be interesting to develop, in the same organization, a similar study, but from the leader’s perspective before comparing results of both investigations and see if there are significant differences. References Aiken, L. (2007), “Nurse staffing impact on organizational outcomes”, in Mason, D., Leavitt, J. and Chaffee, M. (Eds), Policy and Politics in Nursing and Health Care, 5th ed., Elsevier, St. Louis, MO, pp. 550-559. American Association of Critical-Care Nurses (2005), “AACN standards for establishing and sustaining healthy work environments: a journey to excellence”, American Journal of Critical Care, Vol. 14 No. 3, pp. 187-197. Armstrong, J. and Overton, T. (1977), “Estimating nonresponse bias in mail surveys”, Journal of Marketing Research, Vol. 14 No. 3, pp. 396-402. Attree, M. (2001), “A study of the criteria used by healthcare professionals, managers and patients to represent and evaluate quality care”, Journal of Nursing Management, Vol. 9 No. 2, pp. 67-78. Bally, J.M. (2007), “The role of nursing leadership in creating a mentoring culture in acute care environments”, Nursing Economic$, Vol. 25 No. 3, pp. 143-148.
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
Balsanelli, A.P. and Cunha, I.C. (2006), “Lideranc¸a no contexto da enfermagem (Leadership in the nursing context)”, Revista da Escola de Enfermagem – USP, Vol. 40 No. 1, pp. 117-122. Barbosa de Sousa, L. and Teixeira Barroso, M.G. (2009), “Reflex~ao sobre o cuidado como Esseˆncia da lideranc¸a em Enfermagem”, Escola Anna Nery Revista enfermagem, Vol. 13 No. 1, pp. 181-187. Buckley, M., Laursen, J. and Otarola, V. (2009), “Strengthening physician-nurse partnerships to improve quality and patient safety”, Physician Executive Journal, Vol. 35 No. 6, pp. 24-28. Burhans, L.M. and Alligood, M.R. (2010), “Quality nursing care in the words of nurses”, Journal of Advanced Nursing, Vol. 66 No. 8, pp. 1689-1697. Burke, R.J., Ng, E.S.W. and Fiksenbaum, L. (2009), “Virtues, work satisfactions and psychological wellbeing among nurses”, International Journal of Workplace Health Management, Vol. 2 No. 3, pp. 202-219. Byrne, B. (2010), Structural Equation Modeling with AMOS – Basic Concepts, Applications, and Programming, 1st ed., Routledge, New York, NY. Chang, B., Lee, J., Pearson, M., Kahn, K., Elliott, M. and Rubenstein, L. (2002), “Evaluating quality of nursing care: the gap between theory and practice”, Journal of Nursing Administration, Vol 32 Nos 7/8, pp 405-418. Clarke, S.P. (2005), “The policy implications of staffing-outcomes research”, Journal of Nursing Administration, Vol. 35 No. 1, pp. 17-19. Clarke, S.P. and Donaldson, N.E. (2008), “Nurse staffing and patient care quality and safety”, in Hughes, R.G. (Ed.), Patient Safety and Quality: An Evidence-Based Handbook for Nurses, Chapter 25 Agency for Healthcare Research and Quality (US), Rockville, MD, pp. 646-670. Coonan, P.R. (2008), “Educational innovation: nursing’s leadership challenge”, Nursing Economic$, Vol. 26 No. 2, pp. 117-121. Cronin, S.N. and Bechrerer, D. (1999), “Recognition of staff nurse job performance and achievements”, Journal of Nursing Administration, Vol. 29 No. 1, pp. 26-31. DeMarco, R., Flaherty, L., Glod, C., Merrill, N., Terk, K. and Plasse, M. (2004), “Staff and client perceptions of unit quality: a pilot study”, Journal of Psychosocial Nursing, Vol. 42 No. 5, pp. 36-43. Dopson, S. and Fitzgerald, L. (2006), “The role of the middle manager in the implementation of evidence-based health care”, Journal of Nursing Management, Vol. 14 No. 1, pp. 43-51. Dugdall, H., Lamb, C. and Carlisle, A. (2004), “Improving quality care through a nursing review team”, Clinical Governance: An International Journal, Vol. 9 No. 3, pp. 155-162. Estabrooks, C., Scott, S., Squires, J., Stevens, B., O’Brien-Pallas, l., Watt-Watson, J., Profetto-McGrath, J., Mcgilton, K., Golden-Biddle, K., Lander, J., Donner, G., Boschma, G., Humphrey, C. and Williams, J. (2008), “Patterns of research utilization on patient care units”, Implementation Science, Vol. 3 No. 31, pp. 1-16. Frederico, M. and Castilho, A. (2006), “Percepc¸~ao de lideranc¸a em enfermagem – validac¸~ao de uma escala”, Revista Psycologica, No. 43, pp. 259-270. Gelbcke, F.L., Souza, L.A., Dal Sasso, G.M., Nascimento, E. and Bulb, M.B. (2009), “Leadership in critical care settings: reflections and challenges for the Brazilian nursing”, Revista Brasileira de Enfermagem, Vol. 62 No. 1, pp. 136-139. Glen, S. (1998), “Emotional and motivational tendencies: the key to quality nursing care?”, Nursing Ethics, Vol. 5 No. 1, pp. 36-42. Gunther, M. and Alligood, M.R. (2002), “A discipline-specific determination of high quality nursing care”, Journal of Advanced Nursing, Vol. 38 No. 4, pp. 353-359. Hair, J., Black, W., Babin, B. and Anderson, R. (2009), Multivariate Data Analysis, 7th ed., Pearson Prentice Hall, Upper Saddle River, NJ.
Quality nursing care
447
IJHCQA 27,5
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
448
Heath, J., Johanson, W. and Blake, N. (2004), “Healthy work environments: a validation of the literature”, Journal of Nursing Administration, Vol. 34 No. 11, pp. 524-530. Hines, P.A. and Yu, K.M. (2009), “The changing reimbursement landscape: nurses’ role in quality and operational excellence”, Nursing Economic$, Vol. 27 No. 1, pp. 7-13. Hughes, R.G. (2008), “Nurses at the ‘Sharp End’ of patient care”, in Hughes, R.G. (Ed.), Patient Safety and Quality: An Evidence-Based Handbook for Nurses, Chapter 2 Agency for Healthcare Research and Quality (US), Rockville, MD, pp. 25-54. Institute of Medicine (2011), The Future of Nursing: Leading Change, Advancing Health, The National Academies Press, Washington, DC. Jackson, J.R., Clements, P.T., Averill, J.B. and Zimbro, K. (2009), “Patterns of knowing: proposing a theory for nursing leadership”, Nursing Economic$, Vol. 27 No. 3, pp. 149-159. Kalisch, B.J., Terzioglu, F. and Duygulu, S. (2012), “The MISSCARE Survey-Turkish: psychometric properties and findings”, Nursing Economic$, Vol. 30 No. 1, pp. 29-37. Kline, R. (2004), Principles and Practice of Structural Equation Modeling, 2nd ed., The Guilford Press, New York, NY. Kunaviktikul, W., Anders, R.L. and Srisuphan, W. (2001), “Development of quality nursing care in Thailand”, Journal of Advanced Nursing, Vol. 36 No. 6, pp. 776-784. Kurcgant, P., Tronchin, D. and Melleiro, M. (2006), “A construc¸~ao de indicadores de qualidade para a avaliac¸~ao de recursos humanos nos servic¸os de enfermagem: pressupostos teoricos”, Acta Paulista de Enfermagem, Vol. 19 No. 1, pp. 88-91. Laschinger, H.K. and Havens, D.S. (1996), “Staff nurse work empowerment and perceived control over nursing practice: conditions for work effectiveness”, Journal of Nursing Administration, Vol. 26 No. 9, pp. 27-35. Lukas, C.V., Holmes, S.K., Cohen, A.B., Restuccia, J., Cramer, I.E., Shwartz, M. and Charns, M.P. (2007), “Transformational change in health care systems: an organizational model”, Health Care Management Review, Vol. 32 No. 4, pp. 309-320. McLaughlin, C.P. and Kaluzny, A.D. (2004), “Defining quality improvement: past, present and future”, in McLaughlin, C.P. and Kaluzny, A.D. (Eds), Continuous Quality Improvement in Healthcare, 2nd ed., Aspen Publishers, Gaithersburg, MD, pp. 3-33. Maroˆco, J. (2010), “Analise de Equac¸o˜es Estruturais: Fundamentos Teoricos, Software e Aplicac¸o˜es”, report number Peˆro pinheiro. Marquis, B.L. and Huston, C.J. (2011), Leadership Roles and Management Functions in Nursing: Theory and Application, Wolters Kluwer Health/Lippincott Williams & Wilkins, Philadelphia, PA. Morjikian, R.L., Kimball, B. and Joynt, J. (2007), “Leading change: the nurse executive’s role in implementing new care delivery models”, Journal of Nursing Administration, Vol. 37 No. 9, pp. 399-404. Navuluri, R.B. (1999), “Integrated quality improvement program in patient care”, Nursing & Health Sciences, Vol. 1 No. 4, pp. 249-254. Normand, C., Doagllas, H. and Castelnuovo, E. (2000), “Quality in nursing care: context, complexity and the role of professions”, Journal of Research in Nursing, Vol. 5 No. 6, pp. 407-415. Odom, R.Y., Boxx, R.W. and Dunn, M.G. (1990), “Organizational cultures, commitment, satisfaction, and cohesion”, Public Productivity & Management Review, Vol. 14 No. 2, pp. 157-169. Patrick, A. and Lashinger, H.K. (2006), “The effect of structural empowerment and perceived organizational support on middle level nurse managers’ role satisfaction”, Journal of Nursing Management, Vol. 14 No. 1, pp. 13-22.
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
Porto, G. (2004), “The role of the risk manager in creating patient safety”, in Youngberg, B.J. and Hatlie, M.J. (Eds), The Patient Safety Handbook, Jones & Bartlett, Sudbury, MA, pp. 305-426. Rea, L. and Parker, R. (2005), Designing and Conducting Survey Research: A Comprehensive Guide, 3rd ed., John Wiley & Sons, San Francisco, CA. Rosenbach, W.E. and Taylor, R.L. (1998), Contemporary Issues in Leadership, 4th ed., Westview Press, Oxford. Ruthes, R. and Cunha, I. (2009), “Competeˆncias do enfermeiro na gest~ao do conhecimento e capital intelectual”, Revista Brasileira de Enfermagem, Vol. 62 No. 6, pp. 901-905. Stone, P.W., Mooney-Kane, C., Larson, E.L., Horan, T., Glance, L.G., Zwanziger, J. and Dick, A.W. (2007), “Nurse working conditions and patient safety outcomes”, Medical Care, Vol. 45 No. 6, pp. 571-578. Tafreshi, M., Pazargadi, M. and Saeedi, Z. (2007), “Nurses’ perspectives on quality of nursing care: a qualitative study in Iran”, International Journal of Health Care Quality Assurance, Vol. 20 No. 4, pp. 320-328. Thomas, J., Collins, A., Collins, D., Herrin, D., Dafferner, D. and Gabriel, J. (2008), “The language of business: a key nurse executive competency”, Nursing Economic$, Vol. 26 No. 2, pp. 122-127. Thompson, P.A., Navarra, M.B. and Antonson, N. (2005), “Patient safety: the four domains of nursing leadership”, Nursing Economic$, Vol. 23 No. 6, pp. 331-333. Vesterinen, S., Isola, A. and Paasivaara, L. (2009), “Leadership styles of Finnish nurse managers and factors influencing it”, Journal of Nursing Management, Vol. 17 No. 4, pp. 503-509. Wall, S. (2010), “Critical perspectives in the study of nursing work”, Journal of Health Organization and Management, Vol. 24 No. 2, pp. 145-166. Wang, M.C., Hyun, J.K. and Harrison, M. (2006), “Redesigning health systems for quality: lessons from emerging practices”, Joint Commission Journal on Quality and Patient Safety, Vol. 32 No. 11, pp. 599-611. Wong, C. and Cummings, G. (2009), “Authentic leadership: a new theory for nursing or back to basics?”, Journal of Health Organization and Management, Vol. 23 No. 5, pp. 522-538. Yen, M. and Lo, L. (2004), “A model for testing the relationship of nursing care and patient outcomes”, Nursing Economic$, Vol. 22 No. 2, pp. 75-80. Appendix. Operationalizing the variables Nursing Leadership Regarding your hierarchical superior, indicate your opinion, on a scale from 1 (Not at all) to 5 (Always) Recognition: .
R1. He/she recognizes and supports nurses’ decisions when these are challenged by others (superiors, doctors, etc.)
.
R2. He/she rewards team members’ actions and behaviour driven to improving nursing care
.
R3. He/she shows special recognition when someone does a good work
Communication: .
C1. He/she does not listen to all team members impartially and attentively (R)
.
C2. He/she does not have the perspicacity to identify team’s needs (R)
.
C3. He/she is not sufficiently sensitive to grasp what is really being said (R)
Quality nursing care
449
IJHCQA 27,5
Downloaded by University of Florida At 07:52 30 January 2016 (PT)
450
Development: .
D1. He/she identifies the key components of a strategic plan
.
D2. He/she identifies the most important projects and activities and defines priorities
.
D3. He/she identifies and approves the necessary resources for carrying out nursing projects and activities
Innovation: .
I1. He/she challenges nurses to think about new ways to solve existing problems
.
I2. He/she does not encourage innovative ideas to achieve quality in nursing care (R)
Nursing quality Regarding quality nursing care, please indicate your perception in relation to the following items, on a scale from 1 (Completely disagree) to 5 (Completely agree): .
Q1. Nurses are encouraged to come up with suggestions for nursing care improvements
.
Q2. Nurses are encouraged to have in-service training
.
Q3. Teamwork is encouraged
.
Q4. There are standardized procedures facilitating quality improvement in nursing care practices
.
Q5. To improve the quality of nursing records, audits are regularly performed
.
Q6. Patients are duly accompanied to ensure a better adaptation outside the hospital environment
Note: (R) Reversed items Corresponding author Assistant professor Luis Mendes can be contacted at: [email protected]
To purchase reprints of this article please e-mail: [email protected] Or visit our web site for further details: www.emeraldinsight.com/reprints
