Journal of Nursing Management, 2016, 24, 300–308
Resilience and organisational empowerment among long-term care nurses: effects on patient care and absenteeism JAIME WILLIAMS P h D 1, THOMAS HADJISTAVROPOULOS P h D , R D P s y c h , A B P P , F C A H S 2,3, OMEED O. GHANDEHARI M A 4, DAVID C. MALLOY P h D 5, PAULETTE V. HUNTER P h D , R D P s y c h ( P r o v i s i o n a l ) 6 and RONALD R. MARTIN P h D , R D P s y c h 7 1
Research Associate, 3Director, Centre on Aging and Health, University of Regina, Regina, SK, 2Professor, Department of Psychology, University of Regina, Regina, SK, 4Doctoral Candidate, Department of Psychology and Centre on Aging and Health, University of Regina, Regina, SK, 5Professor of Applied Philosophy and Ethics, Faculty of Kinesiology and Health Studies, University of Regina, Regina, SK, 6Assistant Professor, Department of Psychology, St Thomas More College, University of Saskatchewan, Saskatoon, SK and 7Associate Professor, Faculty of Education, University of Regina, Regina, SK, Canada
Correspondence Thomas Hadjistavropoulos Department of Psychology and Centre on Aging and Health University of Regina Regina SK Canada S4S 0A2 E-mail: Thomas. [email protected]
WILLIAMS J., HADJISTAVROPOULOS T., GHANDEHARI O.O., MALLOY D.C., HUNTER P.V. & MARTIN R.R.
(2016) Journal of Nursing Management 24, 300–308. Resilience and organisational empowerment among long-term care nurses: effects on patient care and absenteeism Aim To study resilience among long-term care (LTC) nurses and its relationship to organisational empowerment, self-reported quality of care, perceptions of resident personhood (i.e. viewing another person as a person, implying respect) and absenteeism. Background Although resilience has been examined among nurses, it has not been studied in LTC nurses where resident rates of dementia are high, and nurses may experience stress affecting care and the way residents are perceived. Method A sample of one hundred and thirty LTC nurses from across North America completed a series of questionnaires. Results Resilient nurses were more likely to report higher quality of care and to view residents as having higher personhood status (despite deteriorating cognitive function). Resilience was not predictive of absenteeism. Organisational empowerment did not add to the predictive power of resilience. Conclusions Resilience is of importance in LTC nursing research and future studies could examine this construct in relation to objectively measured resident outcomes. Implications for nursing management Our findings suggest that interventions to improve LTC staff resilience would be important to pursue and that consideration should be given to resilience in optimizing the match between potential staff members and LTC positions. Keywords: absenteeism, hardiness, long-term care, quality of care, resilience
Accepted for publication: 7 April 2015
Background Long-term care (LTC) typically refers to a system of residential facilities that provide medical care and
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assistance with tasks of daily living, mostly for older adults with difficulty caring for themselves due to physical and/or cognitive limitations (Canadian Healthcare Association 2009). Caring for people DOI: 10.1111/jonm.12311 ª 2015 John Wiley & Sons Ltd
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within this environment is an inherently stressful undertaking. It has been estimated that approximately half of residents within LTC have dementia (i.e. cognitive decline from a previous level of functioning to a level that it is concerning to others and/or results in a loss of independence; American Psychiatric Association 2013) associated with conditions such as Alzheimer disease (Moore et al. 2012). These residents, because of the degenerative neurological processes associated with dementia, often behave in ways that are agitated, aggressive or otherwise confused (Ostaszkiewicz et al. 2015). Aggression is problematic and distressing for the resident expressing the behaviour, as well as for other residents and nursing staff. Shields and Wilkins (2009), in a large-scale study of nurses, showed that nurses working in LTC were more likely to be assaulted by patients than nurses working in other facilities. It is known that nurses who are assaulted on the job are the most likely to leave their work setting (Farrell et al. 2006), making the study of resilience in an LTC context especially important. Nonetheless, behaviours characterised by aggression and agitation, can also be communicative signs of distress such as pain or fear, which must be decoded by an observer, especially when residents have limited ability to verbally communicate owing to dementia (Hadjistavropoulos et al. 2009). Furthermore, although central, dementia is but one concern within LTC that complicates care. Other difficulties include various diseases, infections, under-managed pain and injuries resulting from falls (Dever Fitzgerald et al. 2009, Hadjistavropoulos et al. 2009). Taken together these concerns necessitate frequent complex clinical decision-making (Kaasalainen et al. 2007). The special challenges unique to working with populations who have multiple health problems and progressive cognitive impairments contribute to work stress and burden. Given the emphasis on person-centred approaches to LTC—moving away from medical models towards more phenomenological, embodied views of care— caregivers are challenged to work with increasing sensitivity to the lived experiences of residents (Hunter et al. 2013). From an ethical standpoint, LTC residents with dementia are among the most vulnerable citizens in our society. Owing to cognitive impairment, they may be unable to communicate about perceived gaps in care, inappropriate care and about the impact of staff stress on quality of care. As such, it is especially important to study staff attitudes and characteristics to determine how these affect practices. ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 300–308
Further, the full infrastructure support necessary for a person-centred approach is often not provided for various reasons (many of which are financial) resulting in nurses feeling overworked and burdened (Ostaszkiewicz et al. 2015). Staff often rely on psychological, social, and behavioural resources. One personal dimension—resilience—is likely helpful in understanding why some nurses are able to cope better than others with the challenges of the LTC environment. Examination of this construct could have implications for organisational development of LTC employees. Resilience can be described as a positive response to adverse events (Hart et al. 2014). From a theoretical standpoint, Richardson (2002) presented a model that construes resilience from a perspective of homeostasis (i.e. a physical, mental and spiritual balance). The homeostasis can be disrupted in response to stressors that exceed the individual’s personal resources. Various outcomes are then possible, including the ability to re-establish homeostasis (in highly resilient individuals) on one end of the spectrum or to complete dysfunctional reintegration (e.g. substance abuse or other self-defeating behaviours) at the other extreme. This model, which unlike other resilience models, is not limited to particular populations, such as police officers or adolescents, has received support in specific situations such as sports performance (Fletcher & Sarkar 2013) but has not been investigated in the highly stressful environment of LTC (Hart et al. 2014). Resilience among nurses has been associated with reduced burnout and a healthier psychological profile (Mealer et al. 2012). Moreover, Hart et al. (2014) recently completed a scoping review of studies examining resilience among health-care workers, including nurses. Resilience was found to relate to a variety of characteristics, including hopeful attitudes, self-efficacy/adaptability, coping, control, competence, flexibility, skill recognition and non-deficiency focusing (Hart et al. 2014). Among nurses, hardiness which is closely linked to resilience, predicted shift work tolerance (Saksvik-Lehouillier et al. 2013), psychological empowerment (i.e. psychological fortitude, which, in turn predicted job satisfaction and intention to leave) (Larrabee et al. 2003, Hudgins 2015) and lower levels of stress and greater job satisfaction (Judkins 2005), although not always for work-related outcomes (Youssef & Luthans 2007). Theoretically, some challenges exist with the resilience construct. It is difficult to provide an overarching description of resilience because of varying definitions and approaches to measurement but Davydov et al. (2010) note that resilience may be most 301
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appropriately considered a biopsychosocial process. Most researchers consider the biological aspects of resilience to some extent, describing a, ‘trait-like’ aspect, as well as a process-based interaction with the environment (Davydov et al. 2010, Windle et al. 2011). That is, resilience is a response that both reflects the character of the individual, sometimes termed ‘hardiness’ (Jackson et al. 2007, Windle et al. 2011), and is dependent upon specific environmental and social contexts (Levine 2003). We chose a measure of resilience (the Resilience Scale for Adults, RSA; Friborg et al. 2003) that recognises both the biological/trait-based responses comprising resilience as well as environmental support and structural aspects (Windle et al. 2011). In a comprehensive review of resilience instruments, the RSA fared among the best in terms of psychometric properties (Windle et al. 2011). Further, the RSA is organised into six factors; by using factor scores in addition to the total score, we ensure that our study may be considered comparatively with a wider breadth of the current literature. Our primary goal was to better understand the manner in which resilience impacts upon LTC nurses: whether it affects absenteeism, perceived quality of care, attitudes toward patients, and employee empowerment. If our initial findings were to confirm hypothesised relationships among resilience and such variables, further investigation examining the relationship of nursing staff resilience and actual patient outcomes would be warranted.
Method In this research involving LTC nurses [registered nurses (RNs) and licensed practical nurses (LPNs)], we examined whether resilience and organisational empowerment along with nurse demographics predicted (via regression analyses) absenteeism, self-reported quality of patient care, and personhood perception of residents with dementia. We expected that higher levels of resilience and organisational empowerment would predict more positive outcomes.
Measures Demographics questionnaire Basic demographic information was collected using a questionnaire developed for this study. Information included age, gender, job, years of education, years of experience in LTC and within their current LTC facility, funding their LTC facility receives (i.e. private, 302
public), facility religious affiliation, and the facility location (i.e. urban, rural). Absenteeism We included an index of self-reported absenteeism; this was measured as indicated by Gaudine and Gregory (2010): the sum of number of days missed during the past year due to physical illness, stress and mental illness, and personal or family reasons. Resilience scale for adults Friborg et al.’ (2003) RSA is a 33-item measure that assesses beliefs in the presence of protective resources. We used the total score on the RSA to increase statistical sensitivity, as per Friborg et al. (2003). The original 5-point Likert type scale used in this study has shown satisfactory psychometrics with internal consistencies of the scale constructs ranging from 0.67–0.79 (Friborg et al. 2003). The RSA assesses six dimensions of resilience: personal strength/perception of self, personal strength/perception of future, structured style, social competence, family cohesion, and social resources. The total scale demonstrated strong internal consistency (a = 0.93), while the subscales demonstrated moderate to strong internal consistencies (a = 0.60–0.91), consistent with Friborg et al.’ (2003) original research. It is important to note that a recent psychometric review of resilience assessment scales identified the RSA as the strongest tool of its kind (Windle et al. 2011). We used both the total score and the subscale scores for the RSA. Personhood in dementia questionnaire Hunter et al.’ (2013) personhood in dementia questionnaire (PDQ) is a 20-item measure designed to assess health-care respondents’ beliefs about resident personhood while living with dementia. The PDQ has demonstrated good psychometric properties and has been shown to predict clinical care intentions (Hunter et al. 2013). For the present study the total scale score was interpreted and the strong psychometric properties were maintained (a = 0.91). Modified organisational empowerment scale Matthews et al.’ (2003) organisational empowerment scale (OES) is a 19-item measure designed to distinguish and measure three environmental factors (dynamic structural framework, control of workplace decisions and fluidity in information sharing) that are related to an employee’s perception of empowerment in the workplace. The three subscales, that is, dynamic structural framework (a = 0.91), control of workplace ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 300–308
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decisions (a = 0.90) and fluidity in information sharing (a = 0.81) of the original 19-item version had moderate to strong psychometric properties. Because the internal consistencies of the three subscales of the modified OES were moderate in strength and were 0.73, 0.72 and 0.58, respectively, we chose to interpret the total scale (a = 0.87). Quality of care questionnaire To the best of our knowledge no suitable self-report measure currently exists to assess nurses’ perception of the quality of care they are delivering with respect to their LTC patients. One measure, the Karen Instrument for Measuring Quality of Nursing Care – Provider version (Lindgren & Andersson 2011) was potentially applicable, but emphasised organisational factors rather than the staff member’s perception of the care he or she personally provides. Therefore, for the purposes of this investigation, we developed a much briefer, 13-item quality of care questionnaire (QCQ). In accordance with procedures outlined by Lindgren and Andersson (2011), we based our measure on Donabedian’s (1988) highly cited and influential quality of health-care model, which emphasis provider/patient processes. In this model, both technical proficiency and interpersonal prowess are considered integral to quality of care and our face-valid questionnaire assesses both. Example items from this measure are as follows: ‘I am aware of best practice guidelines for managing the most common conditions which affect the patients I work with (e.g. pain, urinary tract infections, depression); I work to improve my sensitivity and empathy when communicating with the patient’ (the full Quality of Care Questionnaire is available on request from the authors). Participants are asked to rate their degree of agreement with each statement on a seven-point Likert type scale (1 = never/ not at all and 7 = always/very much). A higher score on this measure indicates a greater positive selfperception with respect to the quality of care being delivered by the respondent. The total scale provided satisfactory internal consistency for the purposes of this investigation (a = 0.78).
Participants and procedures All methods were approved by the Research Ethics Board of our institution (University of Regina Research Ethics Board #2014-104). Informed consent was obtained. Participants were required to read and agree with an electronic consent form, which they ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 300–308
were able to download and/or print a copy for their records. Participants were recruited through Qualtrics (http:// www.Qualtrics.com) opt-in research panels (i.e. Qualtrics participants who meet study criteria are invited to participate and can choose to opt in). Qualtrics is a large research company that offers participant recruitment services for researchers. Individuals can join Qualtrics panels and indicate their interest in participating in research by signing up with their online vendors. All the participants are profiled on many details of their life, including occupation. This information is checked against a database to ensure participants are not entering misinformation or inconsistencies in their profiles. This is especially rigorous when potential participants indicate they work in health care. The North America-wide sampling strategies avoids biases inherent to sampling individuals from a single facility or a small number of facilities. Qualtrics panels have been used widely in health care and university research (Fortney et al. 2013). Compensation of respondents was handled by Qualtrics. We recruited 130 participants, which was the number determined through power analyses (see the Results section), who were employed as RNs (n = 65) and LPNs (n = 65) within USA or Canadian LTC facilities. These two groups, based on our experience, are the nurses who are primarily employed in LTC settings. There were no other inclusion or exclusion criteria. Both RNs and LPNs were the focus of our investigation rather than other front-line care providers (e.g. ‘special care aides’, ‘personal care assistants’), as the latter can be unregulated in terms of training and education, which would introduce unnecessary variance into our design. Approximately 83% of participants were female. Average age was 48.82 years (SD = 10.76). Participants reported an average of 15.20 years (SD = 2.37) of education. Participants reported working 15.81 years in LTC (SD = 9.60) with 9.87 years (SD = 7.36) taking place at their current LTC facility. A majority of participants were employed in an urban setting (70.8%) and their LTC facility had no religious affiliation (80.8%). The average number of beds was 132.37 (SD = 130.70) with substantial numbers of the residents having moderate to severe dementia (mean = 51.44%, SD = 25.34). On average, participants reported taking 7.95 days (SD = 9.71) off for illness (mean = 3.10, SD = 4.31), mental health concerns, including stress and burnout (mean= 0.96, SD = 2.68), and for personal and family reasons (mean = 3.89, SD = 7.11). 303
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Variable Predictor variables Age Experience in LTC (years) Position (RN or LPN) RSA F1 RSA F2‡ RSA F3 RSA F4 RSA F5‡ RSA F6‡ OES total score Criterion variables PDQ total score QCQ total score Absenteeism†
Mean (SD), n = 130
Correlations PDQ total, r(128)
Correlations QCQ total, r(128)
Correlations absenteeism†,a, r(128)
48.82 16.04 65 25.20 16.89 16.49 23.65 24.35 30.63 76.25
(10.76) (9.78) each (3.29) (3.09) (2.71) (4.38) (5.35) (4.71) (18.29)
0.43 0.16 0.18 0.23** 0.35** 0.19* 0.06 0.16 0.29** 0.11
0.18 0.13 –0.02 0.46** 0.50** 0.33** 0.48** 0.34** 0.46** 0.27**
0.06 0.10 0.02 0.13 0.17 0.02 –0.06 0.02 0.05 0.04
116.60 (15.94) 82.05 (8.01) 7.95 (9.71)
1.00 0.43** 0.001
0.43** 1.00 –0.01
–0.001 0.01 1.00
Table 1 Means and standard deviations (SD) for variables used in regressions
Absenteeism, total days off = sick + mental health + personal; LPN, licensed practical nurses; LTC, longterm care; OES, Organizational Empowerment Scale; PDQ, Personhood in Dementia Questionnaire; QCQ, Quality of Care Questionnaire; RN, registered nurse; RSA, Resilience Scale for Adults; F1, Personal strength: Perception of self; F2, Personal strength: Perception of future; F3, Structured style; F4, Social competence; F5, Family cohesion; F6, Social resources. *P < 0.05; **P < 0.01. † Distributions were transformed using square root. ‡ Distributions were transformed using reverse and square root. Because correlations involved reversed variables, signage was reversed in the output. It is presented here as it should be interpreted.
Results We employed a multiple regression analytical approach (Cohen et al. 2003) because we were interested in determining whether nurse-reported quality of care, perceived personhood and absenteeism could be predicted from self-reported resilience and organisational empowerment. Moreover, although our data were ordinal from Likert scales, parametric statistics based on a regression or correlation models are commonly used and recommended for such data because they are robust to violations of normality (Norman 2010). We further tested all distributions for violations of normality and transformed non-normal distributions as appropriate (see below). For our regression analyses, we employed a conservative approach wherein the full model was initially tested. If significant, the unique contributions of each variable were examined after all other variables had been controlled for. Power analysis indicated that 130 participants would be more than sufficient to detect a medium effect size in a multiple regression analysis with 10 predictors, assuming a small to moderate standardized effect size (e.g. 0.25), a = 0.05 and power = 0.80. We conducted three multiple regression analyses to determine whether resilience along with organisational empowerment predicted: (1) self-reported quality of care provided; (2) staff-perceived personhood of 304
patients diagnosed with dementia; and (3) absenteeism. In each of these analyses, the predictor variables were age, years of experience, position (RN vs. LPN), RSA factors 1–6 and OES total score. Before analysis, distributions were checked for outliers according to procedures outlined by Tabachnick and Fidell (2013). Eight outliers (0.47% of the data) were replaced. Before conducting analyses, all distributions were checked for normalcy using skewness and kurtosis statistics and, when necessary, transformed according to procedures outlined by Tabachnick and Fidell (2013). When applicable, transformed variables were used in analyses, although descriptive information references the untransformed distributions (Table 1). Descriptive statistics and correlations for the variables used in our analyses can be found in Table 1. Results for the overall model of the first regression analysis predicting the PDQ total score from the demographics, RSA factors (1–6) and OES total score were significant [F(10, 118) = 3.37, P < 0.01, R2 = 0.22]. Results from the follow-up regression analyses of the effects of individual predictor variables are presented in Table 2. Overall, RSA (resilience) factors 2 and 6 (i.e. Personal Strength: Perception of Future, Social Resources), and Factor 4 to a lesser extent (i.e. Social Competence) were important for the prediction of PDQ (personhood perception). ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 300–308
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Table 2 Results of follow-up regression analysis for the outcome of personhood in dementia questionnaire total scores
Variable
Beta (standard error)
Age Years of experience Position (RN or LPN) RSA Factor 1 RSA Factor 2† RSA Factor 3 RSA Factor 4 RSA Factor 5† RSA Factor 6† OES Total score
0.073 0.10 4.77 –0.01 –5.45 0.20 –0.72 2.22 –4.03 0.00
(0.14) (0.16) (2.79) (0.56) (1.80) (0.55) (.39) (1.53) (1.62) (0.08)
t(127)
F(10, 128)
0.51 0.64 1.71 0.02 –3.02** 0.36 –1.86 (P = 0.06) 1.45 –2.49 0.005
0.26 0.40 2.92 0.00 9.14** 0.13 3.46 (P = 0.06) 2.10 6.21* 0.00
R2 change 0.00 0.00 0.02 0.00 0.06 0.00 0.02 0.01 0.04 0.00
Factor 1, Personal strength: Perception of self; Factor 2, Personal strength: Perception of future; Factor 3, Structured style; Factor 4, Social competence; Factor 5, Family cohesion; Factor 6, Social resources; LPN, Licensed Practical Nurse; OES, Organizational Empowerment Scale; RN, Registered Nurse; RSA, Resilience Scale for Adults. *P < 0.05; **P < 0.01. † Distributions were transformed using reverse square root, results presented here are as they appear in the output.
Results for the overall model of the second regression analysis predicting the QCQ total score from the demographics, RSA factors (1–6) and OES total score were significant [F(10, 118) = 7.92, P < 0.01, R2 = 0.40]. Results from the follow-up regression analyses of the effects of individual predictor variables are presented in Table 3. Overall, RSA (resilience) factors 2, 4, and 6 (i.e., Personal Strength: Perception of Future; Social Competence; Social Resources) were important for the prediction of QCQ (nurse-reported quality of care). The omnibus test for the criterion variable, Absenteeism, was not significant and therefore, we did not
Table 3 Results of follow-up regression analysis for the outcome of selfassessed quality of care questionnaire total scores Variable Age Years experience Position (RN or LPN) RSA Factor 1 RSA Factor 2† RSA Factor 3 RSA Factor 4 RSA Factor 5† RSA Factor 6† OES total score
Beta (standard error) 0.11 0.03 0.50 0.15 1.59 0.20 0.42 0.62 1.84 0.01
(0.06) (0.07) (1.24) (0.25) (.80) (0.24) (0.17) (0.68) (.72) (0.04)
t(127) 1.76 0.41 0.40 0.59 2.00* 0.85 2.46* 0.91 2.56* 0.26
F(10, 128)
R2 change
3.11 0.17 0.16 0.34 3.96* 0.72 6.07* 0.82 6.57* 0.07
0.02 0.00 0.00 0.00 0.02 0.00 0.03 0.00 0.03 0.00
Factor 1, Personal strength: Perception of self; Factor 2, Personal strength: Perception of future; Factor 3, Structured style; Factor 4, Social competence; Factor 5, Family cohesion; Factor 6, Social resources; LPN, Licensed Practical Nurse; OES, Organizational Empowerment Scale; RN, Registered Nurse; RSA, Resilience Scale for Adults. *P < 0.05; **P < 0.01. † Distributions were transformed using reverse square root, results presented here are as they appear in the output. ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 300–308
conduct follow-up analyses to test the contributions of individual predictors.
Discussion Our findings point to the potential importance of resilience for self-perceived quality of care and attitudes and beliefs towards residents with dementia (i.e. perceived personhood) among nurses employed in LTC. Specifically, resilience factors (i.e. Personal Strength: Perception of the Future; Social Competence; and Social Resources) were significant predictors of these outcomes. These findings are consistent with predictions that would be made based on theoretical models of resilience (Richardson 2002). Resilient nurses were more likely to report increased respect for persons with dementia, which previous research suggests relates to better care decisions (Hunter et al. 2013). Our results support the potential importance of resilience in LTC. With further study, these findings could have implications for staffing interventions aimed at improving quality of care and attitudes towards residents with dementia. In this study, we sought to provide clear and specific information regarding resilience as a concept. By employing the RSA as the resilience measure, we were able to tease apart the construct’s subcomponents, focusing especially on differentiating biological, traitbased factors from social/environmental factors. We thought it important to provide as specific information as possible about resilience, utilising six separate factor scores as opposed to a unified measure of resilience, which is more typical (Hart et al. 2014). The three factors of the RSA that were significantly implicated in predicting staff-reported quality of care and 305
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personhood perception were: Personal Strength— Perception of the Future (able to plan, have goals), Social Competence (sociability, enjoy socializing) and Social Resources (has others to rely on). Moreover, although the two criterion variables (staff-perceived quality of care and perceived personhood) significantly correlated with one another, the size of the effect and examination of individual scale items indicate that they are not synonymous with each other. Contrary to expectations, organisational empowerment was not predictive of any of the variables under investigation. It is uncertain why this occurred, given that some studies (Caspar & O’Rourke 2008) have emphasised the role of organisational empowerment on person-centred care and culture change, which theoretically overlaps with quality of care. Further attention may be given to the OES. Although this measure displayed satisfactory psychometric properties in the literature (Matthews et al. 2003) and our sample, there may be more appropriate measures for nurses. The QCQ, our quality of care questionnaire, was constructed for this study but showed good internal consistency. Similar assessments of quality of care have been developed by other researchers (Lindgren & Andersson 2011) in a manner that is consistent with our approach. Moreover, the total score approximated a normal distribution. The distribution’s standard deviation indicated variability in score dispersion. However, the range was restricted to the upper end of the scale (scores ranged from 32 out of 78 points at the upper end of the scale), with most questions not utilising the full range of responses (i.e. for all but two questions no-one used the value 1). Although we maintain that the total score of this newly-constructed face valid measure demonstrated enough psychometric rigour to warrant interpretation, future research could include an additional, more distal measure of quality of care, such as job performance evaluations.
Limitations A few limitations warrant mention with regard to these interpretations. First, this research is based upon psychometric questionnaires and nurse self-report. While anonymity of responses is known to minimize social desirability biases (Grimm 2010), we acknowledge the possibility of discrepancies between questionnaire responses and actual nurse behaviour. We attempted to mitigate this somewhat by design, relying upon Qualtrics, which is independent of any LTC employers. Furthermore, our data were normally distributed or easily transformed, indicating a range of 306
responses with adequate dispersion, and our constructs demonstrated theoretically valid relationships with each other, which argues against an overly skewed responding bias. Nonetheless, we also recognize that while nurses’ resilience can affect their views of patients, there may also be a reciprocal relationship wherein such views have an impact on resilience. Our findings on the relationship between resilience perceived quality of care and attitudes toward patients underscore the importance of future research utilising actual patient outcomes, patient perspectives and direct observation of behaviour. Such follow-up research would be critical in both confirming, in actual practice, our findings that were based in psychometric tools.
Implications for nursing management This research establishes a relationship between nurse self-reported resilience and self-reported quality of care as well as increased perceptions of patient personhood, which have been linked to better care decisions in previous research (Hunter et al. 2013). Our results suggest that some consideration of the resilience dimension is potentially warranted when considering persons for employment in LTC. Nonetheless, recognising that decisions about hiring health-care staff are highly complex, there are important ethical issues/guidelines (e.g. privacy concerns, the need for extensive validation of relevant assessment tools/interviews in the context of a job application, the potential for bias in the process) that should be taken into account each time a personality characteristic is evaluated/considered in hiring (Stabile 2013). That said, a primary applied implication of our findings relates to the potential for developing preventative interventions for improving resilience among the LTC workforce. Employers often aim to support the psychological well-being of their employees through continued education and wellness initiatives (Blake & Lloyd 2008, Lalonde et al. 2013). The subcomponents of resilience that were found to be important in this study (i.e. positive future outlook, ability to engage in and enjoy social pursuits, and adequate social support) could be incorporated into existing programming aimed at supporting staff. Many of these initiatives are preventative and potentially many types of employees in the LTC facility (e.g. nurses, nursing assistants, physical therapists) could benefit from skill-based training in sociability, goal setting and seeking support when required. Moreover, at the organisational level, LTC culture change initiatives may include aspects dedicated to the creation ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 300–308
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of support systems for staff, opportunities to interact socially with other staff, residents and their families, and brainstorming with management on ways to incorporate social support and social opportunities into already hectic work days. Finally, organisations should seek more opportunities to provide employee incentives for attendance at conferences, courses and other events that may facilitate employee personal goal setting and positive future planning.
Source of funding This research was funded by a Saskatchewan Health Research Foundation Team Grant to T.H. and colleagues.
Ethics approval This research was approved by the University of Regina Research Ethics Board #2014-104.
References American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders: DSM-5. American Psychiatric Association, Washington, DC. Blake H. & Lloyd S. (2008) Influencing organisational change in the NHS: lessons learned from workplace wellness initiatives in practice. Qualitative Primary Care 16 (6), 449–455. Canadian Healthcare Association (2009) New Directions for Facility-Based Long Term Care. Canadian Healthcare Association, Ottawa, ON. Caspar S. & O’Rourke B. (2008) The influence of care provider access to structural empowerment on individualized care in long-term-care facilities. Journal of Gerontology: Social Sciences 63B (4), S255–S265. Cohen J., Cohen P., West S.G. & Aiken L.S. (2003). Applied Multiple Regression/Correlation Analysis for the Behavioral Sciences. Routledge, New York, NY. Davydov D.M., Stewart R., Ritchie K. & Chadieu I. (2010) Resilience and mental health. Clinical Psychology Review 30 (5), 479–495. Donabedian A. (1988) The quality of care: how can it be assessed? JAMA 260 (12), 1743–1748. Dever Fitzgerald T., Hadjistavropoulos T. & MacNab Y.C. (2009) Caregiver fear of falling and functional ability among seniors residing in long-term care facilities. Gerontology 55, 460–467. Farrell G.A., Bobrowski C. & Bobrowski P. (2006) Scoping workplace aggression in nursing: findings from an Australian study. Journal of Advanced Nursing 55 (6), 778–787. Fletcher D. & Sarkar M. (2013) Psychological resilience: a review and critique of definitions, concepts, and theory. European Psychologist 18 (1), 12–23. Fortney L., Luchterhand C., Zakletskaia L., Zgierska A. & Rakel D. (2013) Abbreviated mindfulness intervention for job ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 300–308
satisfaction, quality of life, and compassion in primary care physicians: a pilot study. Annals of Family Medicine 11 (5), 412–420. Friborg O., Hjemdal O., Rosenvinge J.H. & Martinussen M. (2003) A new rating scale for adult resilience: what are the central protective resources behind healthy adjustment? International Journal of Methods in Psychiatric Research 12 (2), 65–76. Grimm P. (2010) Social Desirability Bias. Wiley International Encyclopedia of Marketing. 2. doi: 10.1002/9781444316568. wiem0257. Gaudine A. & Gregory C. (2010) The accuracy of nurses’ estimates of their absenteeism. Journal of Nursing Management 18 (5), 599–605. Hadjistavropoulos T., Hunter P. & Dever Fitzgerald T. (2009) Pain assessment and management in older adults: conceptual issues and clinical challenges. Canadian Psychology 50, 241– 254. Hart P.L., Brannan J.D. & De Chesnay M. (2014) Resilience in nurses: an integrative review. Journal of Nursing Management 22 (6), 720–734. Hudgins T.A. (2015) Resilience, job satisfaction and anticipated turnover in nurse leaders. Journal of Nursing Management Advance online publication. Doi: 10.1111/jonm.12289. Hunter P.V., Hadjistavropoulos T., Smythe W.E., Malloy D.C., Kaasalainen S. & Williams J. (2013) The personhood in dementia questionnaire (PDQ): establishing an association between beliefs about personhood and health providers’ approaches to person-centred care. Journal of Aging Studies 27 (3), 276–287. Jackson D., Firtko A. & Edenborough M. (2007) Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review. Journal of Advanced Nursing 60 (1), 1–9. Judkins S. (2005) Hardiness, job satisfaction, and stress among home health nurses. Home Health Care Management 17 (2), 113–118. Kaasalainen S., Coker E., Dolovich L. et al. (2007) Pain management decision-making among long-term care physicians and nurses. Western Journal of Nursing Research 29 (5), 561–580. Lalonde M., McGillis Hall L., Price S., Andrews G., Harris A. & MacDonald-Rencz S. (2013) Support and access for nursing continuing education in Canadian work environments. Nurse Leadership, 26 (Spec. Iss.), 51–60. Larrabee J.H., Janney M.A., Ostrow C.L., Withrow M.L., Hobbs G.R.J. & Burant C. (2003) Predicting registered nurse job satisfaction and intent to leave. Journal of Nursing Administration 33 (5), 271–283. Levine S. (2003) Psychological and social aspects of resilience: A synthesis of risks and resources 5 (3), 273–280. Lindgren M. & Andersson I.S. (2011) The Karen instruments for measuring quality of nursing care: construct validity and internal consistency. International Journal for Quality in Health Care 23 (3), 292–301. Matthews R.A., Diaz M.W. & Cole S.G. (2003) The organizational empowerment scale. Personnel Review 32 (3), 297– 318. Mealer M., Jones J., Newman J., McFann K.K., Rothbaum B. & Moss M. (2012) The presence of resilience is associated with a healthier psychological profile in intensive care unity
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(ICU) nurses: results of a national survey. International Journal of Nursing Studies 49 (3), 292–299. Moore K.L., Boscardin W.J., Steinman M.A. & Schwartz J.B. (2012) Age and sex variation in prevalence of chronic medical conditions in older residents of U.S. nursing homes. Journal of the American Geriatric Society 60 (4), 756–764. Norman G. (2010) Likert scales, levels of measurement and the ‘laws’ of statistics. Advances in Health Sciences Education 15 (5), 625–632. Ostaszkiewicz J., Lakhan P., O’Connell B. & Hawkins M. (2015) Ongoing challenges responding to behavioural and psychological symptoms of dementia. International Nursing Review Advance online publication. doi:10.1111/inr.12180. Richardson G.E. (2002) The metatheory of resilience and resiliency. Journal of Clinical Psychology 58 (3), 307–321. Saksvik-Lehouillier I., Bjorvatn B., Hetland H. et al. (2013) Individual, situational and lifestyle factors related to shift
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work tolerance among nurses who are new to and experienced in night work. Journal of Advanced Nursing 69 (5), 1136–1146. Shields M. & Wilkins K. (2009) Factors related to on-the-job abuse of nurses by patients. Health Reports 20 (2), 7–19. Stabile S.J. (2013) The use of personality tests as a hiring tool: is the benefit worth the cost? University of Pennsylvania Journal of Business Law 4 (2), 279–313. Tabachnick B.G. & Fidell L.S. (2013) Using Multivariate Statistics, 6th edn. Pearson, Boston, MA. Windle G., Bennett K.M. & Noyes J. (2011) A methodological review of resilience measurement scales. Health and Quality of Life Outcomes 9 (1), 8. doi: 10.1186/1477-7525-9-8. Youssef C.M. & Luthans F. (2007) Positive organizational behavior in the workplace: the impact of hope, optimism, and resilience. Journal of Management 33 (5), 774–800.
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Resilience and organisational empowerment among long-term care nurses: effects on patient care and absenteeism JAIME WILLIAMS P h D 1, THOMAS HADJISTAVROPOULOS P h D , R D P s y c h , A B P P , F C A H S 2,3, OMEED O. GHANDEHARI M A 4, DAVID C. MALLOY P h D 5, PAULETTE V. HUNTER P h D , R D P s y c h ( P r o v i s i o n a l ) 6 and RONALD R. MARTIN P h D , R D P s y c h 7 1
Research Associate, 3Director, Centre on Aging and Health, University of Regina, Regina, SK, 2Professor, Department of Psychology, University of Regina, Regina, SK, 4Doctoral Candidate, Department of Psychology and Centre on Aging and Health, University of Regina, Regina, SK, 5Professor of Applied Philosophy and Ethics, Faculty of Kinesiology and Health Studies, University of Regina, Regina, SK, 6Assistant Professor, Department of Psychology, St Thomas More College, University of Saskatchewan, Saskatoon, SK and 7Associate Professor, Faculty of Education, University of Regina, Regina, SK, Canada
Correspondence Thomas Hadjistavropoulos Department of Psychology and Centre on Aging and Health University of Regina Regina SK Canada S4S 0A2 E-mail: Thomas. [email protected]
WILLIAMS J., HADJISTAVROPOULOS T., GHANDEHARI O.O., MALLOY D.C., HUNTER P.V. & MARTIN R.R.
(2016) Journal of Nursing Management 24, 300–308. Resilience and organisational empowerment among long-term care nurses: effects on patient care and absenteeism Aim To study resilience among long-term care (LTC) nurses and its relationship to organisational empowerment, self-reported quality of care, perceptions of resident personhood (i.e. viewing another person as a person, implying respect) and absenteeism. Background Although resilience has been examined among nurses, it has not been studied in LTC nurses where resident rates of dementia are high, and nurses may experience stress affecting care and the way residents are perceived. Method A sample of one hundred and thirty LTC nurses from across North America completed a series of questionnaires. Results Resilient nurses were more likely to report higher quality of care and to view residents as having higher personhood status (despite deteriorating cognitive function). Resilience was not predictive of absenteeism. Organisational empowerment did not add to the predictive power of resilience. Conclusions Resilience is of importance in LTC nursing research and future studies could examine this construct in relation to objectively measured resident outcomes. Implications for nursing management Our findings suggest that interventions to improve LTC staff resilience would be important to pursue and that consideration should be given to resilience in optimizing the match between potential staff members and LTC positions. Keywords: absenteeism, hardiness, long-term care, quality of care, resilience
Accepted for publication: 7 April 2015
Background Long-term care (LTC) typically refers to a system of residential facilities that provide medical care and
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assistance with tasks of daily living, mostly for older adults with difficulty caring for themselves due to physical and/or cognitive limitations (Canadian Healthcare Association 2009). Caring for people DOI: 10.1111/jonm.12311 ª 2015 John Wiley & Sons Ltd
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within this environment is an inherently stressful undertaking. It has been estimated that approximately half of residents within LTC have dementia (i.e. cognitive decline from a previous level of functioning to a level that it is concerning to others and/or results in a loss of independence; American Psychiatric Association 2013) associated with conditions such as Alzheimer disease (Moore et al. 2012). These residents, because of the degenerative neurological processes associated with dementia, often behave in ways that are agitated, aggressive or otherwise confused (Ostaszkiewicz et al. 2015). Aggression is problematic and distressing for the resident expressing the behaviour, as well as for other residents and nursing staff. Shields and Wilkins (2009), in a large-scale study of nurses, showed that nurses working in LTC were more likely to be assaulted by patients than nurses working in other facilities. It is known that nurses who are assaulted on the job are the most likely to leave their work setting (Farrell et al. 2006), making the study of resilience in an LTC context especially important. Nonetheless, behaviours characterised by aggression and agitation, can also be communicative signs of distress such as pain or fear, which must be decoded by an observer, especially when residents have limited ability to verbally communicate owing to dementia (Hadjistavropoulos et al. 2009). Furthermore, although central, dementia is but one concern within LTC that complicates care. Other difficulties include various diseases, infections, under-managed pain and injuries resulting from falls (Dever Fitzgerald et al. 2009, Hadjistavropoulos et al. 2009). Taken together these concerns necessitate frequent complex clinical decision-making (Kaasalainen et al. 2007). The special challenges unique to working with populations who have multiple health problems and progressive cognitive impairments contribute to work stress and burden. Given the emphasis on person-centred approaches to LTC—moving away from medical models towards more phenomenological, embodied views of care— caregivers are challenged to work with increasing sensitivity to the lived experiences of residents (Hunter et al. 2013). From an ethical standpoint, LTC residents with dementia are among the most vulnerable citizens in our society. Owing to cognitive impairment, they may be unable to communicate about perceived gaps in care, inappropriate care and about the impact of staff stress on quality of care. As such, it is especially important to study staff attitudes and characteristics to determine how these affect practices. ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 300–308
Further, the full infrastructure support necessary for a person-centred approach is often not provided for various reasons (many of which are financial) resulting in nurses feeling overworked and burdened (Ostaszkiewicz et al. 2015). Staff often rely on psychological, social, and behavioural resources. One personal dimension—resilience—is likely helpful in understanding why some nurses are able to cope better than others with the challenges of the LTC environment. Examination of this construct could have implications for organisational development of LTC employees. Resilience can be described as a positive response to adverse events (Hart et al. 2014). From a theoretical standpoint, Richardson (2002) presented a model that construes resilience from a perspective of homeostasis (i.e. a physical, mental and spiritual balance). The homeostasis can be disrupted in response to stressors that exceed the individual’s personal resources. Various outcomes are then possible, including the ability to re-establish homeostasis (in highly resilient individuals) on one end of the spectrum or to complete dysfunctional reintegration (e.g. substance abuse or other self-defeating behaviours) at the other extreme. This model, which unlike other resilience models, is not limited to particular populations, such as police officers or adolescents, has received support in specific situations such as sports performance (Fletcher & Sarkar 2013) but has not been investigated in the highly stressful environment of LTC (Hart et al. 2014). Resilience among nurses has been associated with reduced burnout and a healthier psychological profile (Mealer et al. 2012). Moreover, Hart et al. (2014) recently completed a scoping review of studies examining resilience among health-care workers, including nurses. Resilience was found to relate to a variety of characteristics, including hopeful attitudes, self-efficacy/adaptability, coping, control, competence, flexibility, skill recognition and non-deficiency focusing (Hart et al. 2014). Among nurses, hardiness which is closely linked to resilience, predicted shift work tolerance (Saksvik-Lehouillier et al. 2013), psychological empowerment (i.e. psychological fortitude, which, in turn predicted job satisfaction and intention to leave) (Larrabee et al. 2003, Hudgins 2015) and lower levels of stress and greater job satisfaction (Judkins 2005), although not always for work-related outcomes (Youssef & Luthans 2007). Theoretically, some challenges exist with the resilience construct. It is difficult to provide an overarching description of resilience because of varying definitions and approaches to measurement but Davydov et al. (2010) note that resilience may be most 301
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appropriately considered a biopsychosocial process. Most researchers consider the biological aspects of resilience to some extent, describing a, ‘trait-like’ aspect, as well as a process-based interaction with the environment (Davydov et al. 2010, Windle et al. 2011). That is, resilience is a response that both reflects the character of the individual, sometimes termed ‘hardiness’ (Jackson et al. 2007, Windle et al. 2011), and is dependent upon specific environmental and social contexts (Levine 2003). We chose a measure of resilience (the Resilience Scale for Adults, RSA; Friborg et al. 2003) that recognises both the biological/trait-based responses comprising resilience as well as environmental support and structural aspects (Windle et al. 2011). In a comprehensive review of resilience instruments, the RSA fared among the best in terms of psychometric properties (Windle et al. 2011). Further, the RSA is organised into six factors; by using factor scores in addition to the total score, we ensure that our study may be considered comparatively with a wider breadth of the current literature. Our primary goal was to better understand the manner in which resilience impacts upon LTC nurses: whether it affects absenteeism, perceived quality of care, attitudes toward patients, and employee empowerment. If our initial findings were to confirm hypothesised relationships among resilience and such variables, further investigation examining the relationship of nursing staff resilience and actual patient outcomes would be warranted.
Method In this research involving LTC nurses [registered nurses (RNs) and licensed practical nurses (LPNs)], we examined whether resilience and organisational empowerment along with nurse demographics predicted (via regression analyses) absenteeism, self-reported quality of patient care, and personhood perception of residents with dementia. We expected that higher levels of resilience and organisational empowerment would predict more positive outcomes.
Measures Demographics questionnaire Basic demographic information was collected using a questionnaire developed for this study. Information included age, gender, job, years of education, years of experience in LTC and within their current LTC facility, funding their LTC facility receives (i.e. private, 302
public), facility religious affiliation, and the facility location (i.e. urban, rural). Absenteeism We included an index of self-reported absenteeism; this was measured as indicated by Gaudine and Gregory (2010): the sum of number of days missed during the past year due to physical illness, stress and mental illness, and personal or family reasons. Resilience scale for adults Friborg et al.’ (2003) RSA is a 33-item measure that assesses beliefs in the presence of protective resources. We used the total score on the RSA to increase statistical sensitivity, as per Friborg et al. (2003). The original 5-point Likert type scale used in this study has shown satisfactory psychometrics with internal consistencies of the scale constructs ranging from 0.67–0.79 (Friborg et al. 2003). The RSA assesses six dimensions of resilience: personal strength/perception of self, personal strength/perception of future, structured style, social competence, family cohesion, and social resources. The total scale demonstrated strong internal consistency (a = 0.93), while the subscales demonstrated moderate to strong internal consistencies (a = 0.60–0.91), consistent with Friborg et al.’ (2003) original research. It is important to note that a recent psychometric review of resilience assessment scales identified the RSA as the strongest tool of its kind (Windle et al. 2011). We used both the total score and the subscale scores for the RSA. Personhood in dementia questionnaire Hunter et al.’ (2013) personhood in dementia questionnaire (PDQ) is a 20-item measure designed to assess health-care respondents’ beliefs about resident personhood while living with dementia. The PDQ has demonstrated good psychometric properties and has been shown to predict clinical care intentions (Hunter et al. 2013). For the present study the total scale score was interpreted and the strong psychometric properties were maintained (a = 0.91). Modified organisational empowerment scale Matthews et al.’ (2003) organisational empowerment scale (OES) is a 19-item measure designed to distinguish and measure three environmental factors (dynamic structural framework, control of workplace decisions and fluidity in information sharing) that are related to an employee’s perception of empowerment in the workplace. The three subscales, that is, dynamic structural framework (a = 0.91), control of workplace ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 300–308
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decisions (a = 0.90) and fluidity in information sharing (a = 0.81) of the original 19-item version had moderate to strong psychometric properties. Because the internal consistencies of the three subscales of the modified OES were moderate in strength and were 0.73, 0.72 and 0.58, respectively, we chose to interpret the total scale (a = 0.87). Quality of care questionnaire To the best of our knowledge no suitable self-report measure currently exists to assess nurses’ perception of the quality of care they are delivering with respect to their LTC patients. One measure, the Karen Instrument for Measuring Quality of Nursing Care – Provider version (Lindgren & Andersson 2011) was potentially applicable, but emphasised organisational factors rather than the staff member’s perception of the care he or she personally provides. Therefore, for the purposes of this investigation, we developed a much briefer, 13-item quality of care questionnaire (QCQ). In accordance with procedures outlined by Lindgren and Andersson (2011), we based our measure on Donabedian’s (1988) highly cited and influential quality of health-care model, which emphasis provider/patient processes. In this model, both technical proficiency and interpersonal prowess are considered integral to quality of care and our face-valid questionnaire assesses both. Example items from this measure are as follows: ‘I am aware of best practice guidelines for managing the most common conditions which affect the patients I work with (e.g. pain, urinary tract infections, depression); I work to improve my sensitivity and empathy when communicating with the patient’ (the full Quality of Care Questionnaire is available on request from the authors). Participants are asked to rate their degree of agreement with each statement on a seven-point Likert type scale (1 = never/ not at all and 7 = always/very much). A higher score on this measure indicates a greater positive selfperception with respect to the quality of care being delivered by the respondent. The total scale provided satisfactory internal consistency for the purposes of this investigation (a = 0.78).
Participants and procedures All methods were approved by the Research Ethics Board of our institution (University of Regina Research Ethics Board #2014-104). Informed consent was obtained. Participants were required to read and agree with an electronic consent form, which they ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 300–308
were able to download and/or print a copy for their records. Participants were recruited through Qualtrics (http:// www.Qualtrics.com) opt-in research panels (i.e. Qualtrics participants who meet study criteria are invited to participate and can choose to opt in). Qualtrics is a large research company that offers participant recruitment services for researchers. Individuals can join Qualtrics panels and indicate their interest in participating in research by signing up with their online vendors. All the participants are profiled on many details of their life, including occupation. This information is checked against a database to ensure participants are not entering misinformation or inconsistencies in their profiles. This is especially rigorous when potential participants indicate they work in health care. The North America-wide sampling strategies avoids biases inherent to sampling individuals from a single facility or a small number of facilities. Qualtrics panels have been used widely in health care and university research (Fortney et al. 2013). Compensation of respondents was handled by Qualtrics. We recruited 130 participants, which was the number determined through power analyses (see the Results section), who were employed as RNs (n = 65) and LPNs (n = 65) within USA or Canadian LTC facilities. These two groups, based on our experience, are the nurses who are primarily employed in LTC settings. There were no other inclusion or exclusion criteria. Both RNs and LPNs were the focus of our investigation rather than other front-line care providers (e.g. ‘special care aides’, ‘personal care assistants’), as the latter can be unregulated in terms of training and education, which would introduce unnecessary variance into our design. Approximately 83% of participants were female. Average age was 48.82 years (SD = 10.76). Participants reported an average of 15.20 years (SD = 2.37) of education. Participants reported working 15.81 years in LTC (SD = 9.60) with 9.87 years (SD = 7.36) taking place at their current LTC facility. A majority of participants were employed in an urban setting (70.8%) and their LTC facility had no religious affiliation (80.8%). The average number of beds was 132.37 (SD = 130.70) with substantial numbers of the residents having moderate to severe dementia (mean = 51.44%, SD = 25.34). On average, participants reported taking 7.95 days (SD = 9.71) off for illness (mean = 3.10, SD = 4.31), mental health concerns, including stress and burnout (mean= 0.96, SD = 2.68), and for personal and family reasons (mean = 3.89, SD = 7.11). 303
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Variable Predictor variables Age Experience in LTC (years) Position (RN or LPN) RSA F1 RSA F2‡ RSA F3 RSA F4 RSA F5‡ RSA F6‡ OES total score Criterion variables PDQ total score QCQ total score Absenteeism†
Mean (SD), n = 130
Correlations PDQ total, r(128)
Correlations QCQ total, r(128)
Correlations absenteeism†,a, r(128)
48.82 16.04 65 25.20 16.89 16.49 23.65 24.35 30.63 76.25
(10.76) (9.78) each (3.29) (3.09) (2.71) (4.38) (5.35) (4.71) (18.29)
0.43 0.16 0.18 0.23** 0.35** 0.19* 0.06 0.16 0.29** 0.11
0.18 0.13 –0.02 0.46** 0.50** 0.33** 0.48** 0.34** 0.46** 0.27**
0.06 0.10 0.02 0.13 0.17 0.02 –0.06 0.02 0.05 0.04
116.60 (15.94) 82.05 (8.01) 7.95 (9.71)
1.00 0.43** 0.001
0.43** 1.00 –0.01
–0.001 0.01 1.00
Table 1 Means and standard deviations (SD) for variables used in regressions
Absenteeism, total days off = sick + mental health + personal; LPN, licensed practical nurses; LTC, longterm care; OES, Organizational Empowerment Scale; PDQ, Personhood in Dementia Questionnaire; QCQ, Quality of Care Questionnaire; RN, registered nurse; RSA, Resilience Scale for Adults; F1, Personal strength: Perception of self; F2, Personal strength: Perception of future; F3, Structured style; F4, Social competence; F5, Family cohesion; F6, Social resources. *P < 0.05; **P < 0.01. † Distributions were transformed using square root. ‡ Distributions were transformed using reverse and square root. Because correlations involved reversed variables, signage was reversed in the output. It is presented here as it should be interpreted.
Results We employed a multiple regression analytical approach (Cohen et al. 2003) because we were interested in determining whether nurse-reported quality of care, perceived personhood and absenteeism could be predicted from self-reported resilience and organisational empowerment. Moreover, although our data were ordinal from Likert scales, parametric statistics based on a regression or correlation models are commonly used and recommended for such data because they are robust to violations of normality (Norman 2010). We further tested all distributions for violations of normality and transformed non-normal distributions as appropriate (see below). For our regression analyses, we employed a conservative approach wherein the full model was initially tested. If significant, the unique contributions of each variable were examined after all other variables had been controlled for. Power analysis indicated that 130 participants would be more than sufficient to detect a medium effect size in a multiple regression analysis with 10 predictors, assuming a small to moderate standardized effect size (e.g. 0.25), a = 0.05 and power = 0.80. We conducted three multiple regression analyses to determine whether resilience along with organisational empowerment predicted: (1) self-reported quality of care provided; (2) staff-perceived personhood of 304
patients diagnosed with dementia; and (3) absenteeism. In each of these analyses, the predictor variables were age, years of experience, position (RN vs. LPN), RSA factors 1–6 and OES total score. Before analysis, distributions were checked for outliers according to procedures outlined by Tabachnick and Fidell (2013). Eight outliers (0.47% of the data) were replaced. Before conducting analyses, all distributions were checked for normalcy using skewness and kurtosis statistics and, when necessary, transformed according to procedures outlined by Tabachnick and Fidell (2013). When applicable, transformed variables were used in analyses, although descriptive information references the untransformed distributions (Table 1). Descriptive statistics and correlations for the variables used in our analyses can be found in Table 1. Results for the overall model of the first regression analysis predicting the PDQ total score from the demographics, RSA factors (1–6) and OES total score were significant [F(10, 118) = 3.37, P < 0.01, R2 = 0.22]. Results from the follow-up regression analyses of the effects of individual predictor variables are presented in Table 2. Overall, RSA (resilience) factors 2 and 6 (i.e. Personal Strength: Perception of Future, Social Resources), and Factor 4 to a lesser extent (i.e. Social Competence) were important for the prediction of PDQ (personhood perception). ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 300–308
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Table 2 Results of follow-up regression analysis for the outcome of personhood in dementia questionnaire total scores
Variable
Beta (standard error)
Age Years of experience Position (RN or LPN) RSA Factor 1 RSA Factor 2† RSA Factor 3 RSA Factor 4 RSA Factor 5† RSA Factor 6† OES Total score
0.073 0.10 4.77 –0.01 –5.45 0.20 –0.72 2.22 –4.03 0.00
(0.14) (0.16) (2.79) (0.56) (1.80) (0.55) (.39) (1.53) (1.62) (0.08)
t(127)
F(10, 128)
0.51 0.64 1.71 0.02 –3.02** 0.36 –1.86 (P = 0.06) 1.45 –2.49 0.005
0.26 0.40 2.92 0.00 9.14** 0.13 3.46 (P = 0.06) 2.10 6.21* 0.00
R2 change 0.00 0.00 0.02 0.00 0.06 0.00 0.02 0.01 0.04 0.00
Factor 1, Personal strength: Perception of self; Factor 2, Personal strength: Perception of future; Factor 3, Structured style; Factor 4, Social competence; Factor 5, Family cohesion; Factor 6, Social resources; LPN, Licensed Practical Nurse; OES, Organizational Empowerment Scale; RN, Registered Nurse; RSA, Resilience Scale for Adults. *P < 0.05; **P < 0.01. † Distributions were transformed using reverse square root, results presented here are as they appear in the output.
Results for the overall model of the second regression analysis predicting the QCQ total score from the demographics, RSA factors (1–6) and OES total score were significant [F(10, 118) = 7.92, P < 0.01, R2 = 0.40]. Results from the follow-up regression analyses of the effects of individual predictor variables are presented in Table 3. Overall, RSA (resilience) factors 2, 4, and 6 (i.e., Personal Strength: Perception of Future; Social Competence; Social Resources) were important for the prediction of QCQ (nurse-reported quality of care). The omnibus test for the criterion variable, Absenteeism, was not significant and therefore, we did not
Table 3 Results of follow-up regression analysis for the outcome of selfassessed quality of care questionnaire total scores Variable Age Years experience Position (RN or LPN) RSA Factor 1 RSA Factor 2† RSA Factor 3 RSA Factor 4 RSA Factor 5† RSA Factor 6† OES total score
Beta (standard error) 0.11 0.03 0.50 0.15 1.59 0.20 0.42 0.62 1.84 0.01
(0.06) (0.07) (1.24) (0.25) (.80) (0.24) (0.17) (0.68) (.72) (0.04)
t(127) 1.76 0.41 0.40 0.59 2.00* 0.85 2.46* 0.91 2.56* 0.26
F(10, 128)
R2 change
3.11 0.17 0.16 0.34 3.96* 0.72 6.07* 0.82 6.57* 0.07
0.02 0.00 0.00 0.00 0.02 0.00 0.03 0.00 0.03 0.00
Factor 1, Personal strength: Perception of self; Factor 2, Personal strength: Perception of future; Factor 3, Structured style; Factor 4, Social competence; Factor 5, Family cohesion; Factor 6, Social resources; LPN, Licensed Practical Nurse; OES, Organizational Empowerment Scale; RN, Registered Nurse; RSA, Resilience Scale for Adults. *P < 0.05; **P < 0.01. † Distributions were transformed using reverse square root, results presented here are as they appear in the output. ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 300–308
conduct follow-up analyses to test the contributions of individual predictors.
Discussion Our findings point to the potential importance of resilience for self-perceived quality of care and attitudes and beliefs towards residents with dementia (i.e. perceived personhood) among nurses employed in LTC. Specifically, resilience factors (i.e. Personal Strength: Perception of the Future; Social Competence; and Social Resources) were significant predictors of these outcomes. These findings are consistent with predictions that would be made based on theoretical models of resilience (Richardson 2002). Resilient nurses were more likely to report increased respect for persons with dementia, which previous research suggests relates to better care decisions (Hunter et al. 2013). Our results support the potential importance of resilience in LTC. With further study, these findings could have implications for staffing interventions aimed at improving quality of care and attitudes towards residents with dementia. In this study, we sought to provide clear and specific information regarding resilience as a concept. By employing the RSA as the resilience measure, we were able to tease apart the construct’s subcomponents, focusing especially on differentiating biological, traitbased factors from social/environmental factors. We thought it important to provide as specific information as possible about resilience, utilising six separate factor scores as opposed to a unified measure of resilience, which is more typical (Hart et al. 2014). The three factors of the RSA that were significantly implicated in predicting staff-reported quality of care and 305
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personhood perception were: Personal Strength— Perception of the Future (able to plan, have goals), Social Competence (sociability, enjoy socializing) and Social Resources (has others to rely on). Moreover, although the two criterion variables (staff-perceived quality of care and perceived personhood) significantly correlated with one another, the size of the effect and examination of individual scale items indicate that they are not synonymous with each other. Contrary to expectations, organisational empowerment was not predictive of any of the variables under investigation. It is uncertain why this occurred, given that some studies (Caspar & O’Rourke 2008) have emphasised the role of organisational empowerment on person-centred care and culture change, which theoretically overlaps with quality of care. Further attention may be given to the OES. Although this measure displayed satisfactory psychometric properties in the literature (Matthews et al. 2003) and our sample, there may be more appropriate measures for nurses. The QCQ, our quality of care questionnaire, was constructed for this study but showed good internal consistency. Similar assessments of quality of care have been developed by other researchers (Lindgren & Andersson 2011) in a manner that is consistent with our approach. Moreover, the total score approximated a normal distribution. The distribution’s standard deviation indicated variability in score dispersion. However, the range was restricted to the upper end of the scale (scores ranged from 32 out of 78 points at the upper end of the scale), with most questions not utilising the full range of responses (i.e. for all but two questions no-one used the value 1). Although we maintain that the total score of this newly-constructed face valid measure demonstrated enough psychometric rigour to warrant interpretation, future research could include an additional, more distal measure of quality of care, such as job performance evaluations.
Limitations A few limitations warrant mention with regard to these interpretations. First, this research is based upon psychometric questionnaires and nurse self-report. While anonymity of responses is known to minimize social desirability biases (Grimm 2010), we acknowledge the possibility of discrepancies between questionnaire responses and actual nurse behaviour. We attempted to mitigate this somewhat by design, relying upon Qualtrics, which is independent of any LTC employers. Furthermore, our data were normally distributed or easily transformed, indicating a range of 306
responses with adequate dispersion, and our constructs demonstrated theoretically valid relationships with each other, which argues against an overly skewed responding bias. Nonetheless, we also recognize that while nurses’ resilience can affect their views of patients, there may also be a reciprocal relationship wherein such views have an impact on resilience. Our findings on the relationship between resilience perceived quality of care and attitudes toward patients underscore the importance of future research utilising actual patient outcomes, patient perspectives and direct observation of behaviour. Such follow-up research would be critical in both confirming, in actual practice, our findings that were based in psychometric tools.
Implications for nursing management This research establishes a relationship between nurse self-reported resilience and self-reported quality of care as well as increased perceptions of patient personhood, which have been linked to better care decisions in previous research (Hunter et al. 2013). Our results suggest that some consideration of the resilience dimension is potentially warranted when considering persons for employment in LTC. Nonetheless, recognising that decisions about hiring health-care staff are highly complex, there are important ethical issues/guidelines (e.g. privacy concerns, the need for extensive validation of relevant assessment tools/interviews in the context of a job application, the potential for bias in the process) that should be taken into account each time a personality characteristic is evaluated/considered in hiring (Stabile 2013). That said, a primary applied implication of our findings relates to the potential for developing preventative interventions for improving resilience among the LTC workforce. Employers often aim to support the psychological well-being of their employees through continued education and wellness initiatives (Blake & Lloyd 2008, Lalonde et al. 2013). The subcomponents of resilience that were found to be important in this study (i.e. positive future outlook, ability to engage in and enjoy social pursuits, and adequate social support) could be incorporated into existing programming aimed at supporting staff. Many of these initiatives are preventative and potentially many types of employees in the LTC facility (e.g. nurses, nursing assistants, physical therapists) could benefit from skill-based training in sociability, goal setting and seeking support when required. Moreover, at the organisational level, LTC culture change initiatives may include aspects dedicated to the creation ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 300–308
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of support systems for staff, opportunities to interact socially with other staff, residents and their families, and brainstorming with management on ways to incorporate social support and social opportunities into already hectic work days. Finally, organisations should seek more opportunities to provide employee incentives for attendance at conferences, courses and other events that may facilitate employee personal goal setting and positive future planning.
Source of funding This research was funded by a Saskatchewan Health Research Foundation Team Grant to T.H. and colleagues.
Ethics approval This research was approved by the University of Regina Research Ethics Board #2014-104.
References American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders: DSM-5. American Psychiatric Association, Washington, DC. Blake H. & Lloyd S. (2008) Influencing organisational change in the NHS: lessons learned from workplace wellness initiatives in practice. Qualitative Primary Care 16 (6), 449–455. Canadian Healthcare Association (2009) New Directions for Facility-Based Long Term Care. Canadian Healthcare Association, Ottawa, ON. Caspar S. & O’Rourke B. (2008) The influence of care provider access to structural empowerment on individualized care in long-term-care facilities. Journal of Gerontology: Social Sciences 63B (4), S255–S265. Cohen J., Cohen P., West S.G. & Aiken L.S. (2003). Applied Multiple Regression/Correlation Analysis for the Behavioral Sciences. Routledge, New York, NY. Davydov D.M., Stewart R., Ritchie K. & Chadieu I. (2010) Resilience and mental health. Clinical Psychology Review 30 (5), 479–495. Donabedian A. (1988) The quality of care: how can it be assessed? JAMA 260 (12), 1743–1748. Dever Fitzgerald T., Hadjistavropoulos T. & MacNab Y.C. (2009) Caregiver fear of falling and functional ability among seniors residing in long-term care facilities. Gerontology 55, 460–467. Farrell G.A., Bobrowski C. & Bobrowski P. (2006) Scoping workplace aggression in nursing: findings from an Australian study. Journal of Advanced Nursing 55 (6), 778–787. Fletcher D. & Sarkar M. (2013) Psychological resilience: a review and critique of definitions, concepts, and theory. European Psychologist 18 (1), 12–23. Fortney L., Luchterhand C., Zakletskaia L., Zgierska A. & Rakel D. (2013) Abbreviated mindfulness intervention for job ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 300–308
satisfaction, quality of life, and compassion in primary care physicians: a pilot study. Annals of Family Medicine 11 (5), 412–420. Friborg O., Hjemdal O., Rosenvinge J.H. & Martinussen M. (2003) A new rating scale for adult resilience: what are the central protective resources behind healthy adjustment? International Journal of Methods in Psychiatric Research 12 (2), 65–76. Grimm P. (2010) Social Desirability Bias. Wiley International Encyclopedia of Marketing. 2. doi: 10.1002/9781444316568. wiem0257. Gaudine A. & Gregory C. (2010) The accuracy of nurses’ estimates of their absenteeism. Journal of Nursing Management 18 (5), 599–605. Hadjistavropoulos T., Hunter P. & Dever Fitzgerald T. (2009) Pain assessment and management in older adults: conceptual issues and clinical challenges. Canadian Psychology 50, 241– 254. Hart P.L., Brannan J.D. & De Chesnay M. (2014) Resilience in nurses: an integrative review. Journal of Nursing Management 22 (6), 720–734. Hudgins T.A. (2015) Resilience, job satisfaction and anticipated turnover in nurse leaders. Journal of Nursing Management Advance online publication. Doi: 10.1111/jonm.12289. Hunter P.V., Hadjistavropoulos T., Smythe W.E., Malloy D.C., Kaasalainen S. & Williams J. (2013) The personhood in dementia questionnaire (PDQ): establishing an association between beliefs about personhood and health providers’ approaches to person-centred care. Journal of Aging Studies 27 (3), 276–287. Jackson D., Firtko A. & Edenborough M. (2007) Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review. Journal of Advanced Nursing 60 (1), 1–9. Judkins S. (2005) Hardiness, job satisfaction, and stress among home health nurses. Home Health Care Management 17 (2), 113–118. Kaasalainen S., Coker E., Dolovich L. et al. (2007) Pain management decision-making among long-term care physicians and nurses. Western Journal of Nursing Research 29 (5), 561–580. Lalonde M., McGillis Hall L., Price S., Andrews G., Harris A. & MacDonald-Rencz S. (2013) Support and access for nursing continuing education in Canadian work environments. Nurse Leadership, 26 (Spec. Iss.), 51–60. Larrabee J.H., Janney M.A., Ostrow C.L., Withrow M.L., Hobbs G.R.J. & Burant C. (2003) Predicting registered nurse job satisfaction and intent to leave. Journal of Nursing Administration 33 (5), 271–283. Levine S. (2003) Psychological and social aspects of resilience: A synthesis of risks and resources 5 (3), 273–280. Lindgren M. & Andersson I.S. (2011) The Karen instruments for measuring quality of nursing care: construct validity and internal consistency. International Journal for Quality in Health Care 23 (3), 292–301. Matthews R.A., Diaz M.W. & Cole S.G. (2003) The organizational empowerment scale. Personnel Review 32 (3), 297– 318. Mealer M., Jones J., Newman J., McFann K.K., Rothbaum B. & Moss M. (2012) The presence of resilience is associated with a healthier psychological profile in intensive care unity
307
J. Williams et al.
(ICU) nurses: results of a national survey. International Journal of Nursing Studies 49 (3), 292–299. Moore K.L., Boscardin W.J., Steinman M.A. & Schwartz J.B. (2012) Age and sex variation in prevalence of chronic medical conditions in older residents of U.S. nursing homes. Journal of the American Geriatric Society 60 (4), 756–764. Norman G. (2010) Likert scales, levels of measurement and the ‘laws’ of statistics. Advances in Health Sciences Education 15 (5), 625–632. Ostaszkiewicz J., Lakhan P., O’Connell B. & Hawkins M. (2015) Ongoing challenges responding to behavioural and psychological symptoms of dementia. International Nursing Review Advance online publication. doi:10.1111/inr.12180. Richardson G.E. (2002) The metatheory of resilience and resiliency. Journal of Clinical Psychology 58 (3), 307–321. Saksvik-Lehouillier I., Bjorvatn B., Hetland H. et al. (2013) Individual, situational and lifestyle factors related to shift
308
work tolerance among nurses who are new to and experienced in night work. Journal of Advanced Nursing 69 (5), 1136–1146. Shields M. & Wilkins K. (2009) Factors related to on-the-job abuse of nurses by patients. Health Reports 20 (2), 7–19. Stabile S.J. (2013) The use of personality tests as a hiring tool: is the benefit worth the cost? University of Pennsylvania Journal of Business Law 4 (2), 279–313. Tabachnick B.G. & Fidell L.S. (2013) Using Multivariate Statistics, 6th edn. Pearson, Boston, MA. Windle G., Bennett K.M. & Noyes J. (2011) A methodological review of resilience measurement scales. Health and Quality of Life Outcomes 9 (1), 8. doi: 10.1186/1477-7525-9-8. Youssef C.M. & Luthans F. (2007) Positive organizational behavior in the workplace: the impact of hope, optimism, and resilience. Journal of Management 33 (5), 774–800.
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