ORIGINAL RESEARCH

A longitudinal study of aspects of a hospital’s family-centred nursing: changing practice through data translation Chris White & Valerie Wilson Accepted for publication 14 June 2014

Correspondence to C. White: e-mail: [email protected] Chris White MA RN Practice Development Education Nurse Manager Nursing Research and Practice Development Unit, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia and Honorary Lecturer University of Technology Sydney, New South Wales, Australia Valerie Wilson PhD RN RSCN Director and Professor of Nursing Research and Practice Development Nursing Research and Practice Development Unit, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia and Professor of Nursing Research & Practice Development The University of Technology Sydney, New South Wales, Australia

W H I T E C . & W I L S O N V . ( 2 0 1 5 ) A longitudinal study of aspects of a hospital’s family-centred nursing: changing practice through data translation. Journal of Advanced Nursing 71(1), 100–114. doi: 10.1111/jan.12478

Abstract Aims. To examine how results and data from multiple Family Centred Nursing Index surveys help the development of family-centred nursing at organizational and ward levels. Design. A critical analysis of survey data. Background. The Family Centred Nursing Index provides a valid and reliable assessment of aspects of nursing, through a comprehensive survey of traditional indicators of practice development and a broader range of aspects of practice. Methods. A survey with 113 questions, each to be answered on 7-point Likert scale conducted six times in the last 7 years. Surveys have been in 2006, 2008, 2009, 2010, 2011/2012 and 2012/2013. All nurses employed by the organization can participate. Results. These are reported as means across 19 constructs linked to five key domains and their significance is examined by year and (in the clinical settings) and compared against the organizational (whole population) averages. Ongoing survey and analysis of nurses’ views of their work is providing a valuable source of developmental data. The results show unexpected associations between constructs e.g. – a high level of work stress does not correlate with a lower level of job satisfaction (and vice versa). A clear historical picture of many elements of developing family-centred care is emerging at both the organizational and individual-ward levels. Conclusion. This study provides insights into aspects of organizational and wards working environment for nurses and how these aspects of nurses’ work interact in unexpected ways. It is appropriate for providing information to organizations and ward teams in relation to their development towards familycentred cultures. Keywords: family-centred, longitudinal surveys, mixed methodologies, nursing satisfaction, nursing stress, organizational culture

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Why is this research or review needed? ● Surveys of this type administered longitudinally afford organizations greater insight into their evolving culture and enhance the potential for positive change. ● Practice is underpinned by Family-Centred philosophy and the survey examines one aspect of this relating to nurses perceptions about the way they care; it then means that nurses’ perceptions are about the degree to which they deliver this. ● The survey is multifactorial and instruments such as these provide a better understanding of the influences on ‘family-centredness’ in an organizational culture.

What are the key findings? ● This survey method produces a clear picture of aspects of the nursing workplace culture in this organization; it also further critically analyses traditional linkages in nurses’ views of their work. ● Longitudinal surveys such as this provide useful data which leaders can respond to as a means of transforming practice and then monitor the impact of this in subsequent surveys. ● These surveys showed that increases in perceptions of ‘workload stress’ are not reflected in nurses’ perceptions of their satisfaction in an organization.

How should the findings be used to influence policy/ practice/research/education? ● It is useful to demonstrate that nurses’ perceptions of their workload are not directly connected to their perceptions of their satisfaction relating to their work.

Person centred nursing index

increased awareness of the organizational (or ward) culture, which is seen as a positive developmental step for a hospital (Manley 2004). This article examines nurses’ attitudes towards working in a metropolitan children’s hospital, through the use of the Person Centred Nursing Index (PCNI). In particular, exploring which aspects changed over time and how they interrelate. The organization has as its guiding principles continually working towards family-centred care, with the challenges that that entails (Mikkelsen & Frederiksen 2011); a fundamental issue in this (according to the organization’s vision statement) is ‘utilising evidence to inform practice’ – this survey provides evidence to the organization (and clinical areas) about how nurses feel about their work and the care they give. This is intended to assist in the identification and recognition of developments in practice(s) across the organization with regard to family-centredness. The PCNI has run six times to date and has provided interesting insights that inform the organization’s view of its nursing culture. In the context of Schein’s (1990) work, the PCNI is aimed at improving insight into the second and third levels of cultural awareness, where respondents are asked to rate their practice according to their values and beliefs (and underlying assumptions) they have about their individual or ward practice. Carrol and Quijada (2004), in the adaptation of Schein’s work, opens this and other spaces for our examination, in recognizing that an institution has numerous cultures (for example, along professional/disciplinary lines). This is one basis of the rationale for conducting the PCNI – it acknowledges Schein’s assertion:

● Undertaking longitudinal surveys of this type are valuable

We cannot start with ‘cultural phenomena’ and then use their exis-

and a means of tracking results over time for organizations

tence as evidence for the existence of a group. We must first specify

and nurses.

that a given set of people has enough stability and common history

● Engaging in the Family Centred Nursing Index process

to have allowed a culture to form. (Schein 1990, p. 111)

enables specific change to be targeted at both the macro and micro levels in an organization by nurse executives and nurse managers.

Introduction Nursing literature addressing ‘culture’ strongly indicates that discovering more about its facets and workings is a useful exercise. Analysts think that information on culture is always valuable in professional or organizational studies (Westrum 2004) and undertaking surveys is a useful method of obtaining this information (Elwyn et al. 2004). Surveys are important in the development of ‘emotionally smart’ (Gooch 2006) organizations that open themselves to the learning on offer (Nutley & Davies 2001) through

© 2014 Commonwealth of Australia. Journal of Advanced Nursing © 2014 John Wiley & Sons Ltd

Background The PCNI process contributes to a cultural analysis of nursing with its genesis as a survey tool in nursing. The range of issue areas it addresses can be seen in (Supporting Information File S1). In conducting the PCNI, the intentions are to provide the organization with a series of assessments as to how the nurses working in the institution feel about the care they give. The survey is a valid, reliable (Slater et al. 2009, 2010) and comprehensive assessment of aspects of nursing including: nursing and work stress, job satisfaction, organizational characteristics and attributes of caring (see Table 1 for the detail and their research bases included in

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Table 1 Summary of PCNI domains, constructs and their theoretical origins. Source

Domain

Constructs

Nursing stress scale (Gray-Toft & Anderson 1981)

Nursing stress scale

Work stress scale (Rout 2000)

Work stress scale

Measure of job satisfaction (Traynor & Wade 1993)

Nursing satisfaction

Nurse work index – revised (Slater et al. 2010)

Organizational traits

Quality of work life scale (Gifford et al. 2002)

Organizational outcomes

Workload Inadequate preparation Lack of staff support Conflict with other nurses Uncertainty over treatment Work/home interface and social life Work environment Lack of communication and social support Career development Pay and prospects Training Familial satisfaction Professional satisfaction Adequate staffing and resources Doctor nurse relationships Nursing management Empowerment Organizational commitment Intent to leave

the PCNI). In addition to the usual constructs of these types of surveys, it also elicits feelings (about care and care issues) from the respondents and therefore builds on some of its contemporary alternatives – for example, the Alberta Context Tool (Estabrooks et al. 2009). Conducting the PCNI helps to avoid the ontological trap between the ‘espoused culture’ and the ‘culture–in–practice’ discussed by Manley (2000). It generates a space between the espoused vision of the organization and parts of the reality of its culture, where there may be some elements identified for change. Nutley and Davies (2001) support this, in their view that organizational knowledge can be less than the individuals who comprise it. The PCNI also makes a significant contribution in reducing this space. There is a growing interest in understanding and shaping local environments in health care though this is not yet matched by widespread use of available instruments (Mannion et al. 2009). While there are extant tools that cover ‘many of the most important cultural attributes identified by clinical governance managers, the over-riding focus of tools in use is on safety rather than a holistic assessment of the dimensions of healthcare quality and performance’ (Mannion et al. 2009, p. 153). These latter aspects are a major focus for the PCNI and a founding rationale for its use as a ward based and organizational survey. Correlations are consistently been between patient safety outcomes and the quality of the nursing practice work environment (Laschinger & Leiter 2006, Kramer et al. 2010). The inability to influence patient care and an unmet need 102

to feel valued and appreciated, contribute to nursing workforce attrition (Chiarella & McInnes 2008). The PCNI was developed to provide a comprehensive measure of identified factors contributing to organizational culture. Sources of stress – workload, leadership/management issues and emotional demands of caring have been consistently identified as contributing to nursing and work stress (McVicar 2003). Measures for tackling stress prevention, it was noted, should focus on both individual and organizational levels – another central feature of the PCNI. Lim et al. (2010) conducted a review of research reporting identified stress in Australian nurses between 1996– 2008 and found stressors included work overload, role conflicts and experiences of aggression. A review of factors contributing to job satisfaction for nurses in acute hospitals found that there are a range of influential factors including coping strategies, autonomy, co-worker interaction, direct patient care, resource adequacy and educational opportunities (Hayes et al. 2010). The review concluded that collaboration between individual nurses, their managers and others is crucial to increase nurses’ job satisfaction. Work–family conflict has also been found to have an impact on job satisfaction, in a study designed to investigate the link Cortese et al. (2010) showed the importance of some predictors, such as supportive management, emotional charge and job demand, not only for their connections with work-family conflict but also for their direct associations with job satisfaction. It is with these in mind that we believe the PCNI provides a comprehensive review © 2014 Commonwealth of Australia. Journal of Advanced Nursing © 2014 John Wiley & Sons Ltd

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of many aspects of organizational culture and data for informing ongoing changes in practice.

and has resulted in an increase in participation rates. The survey is accessed online or in hard copy.

The study

Data reports

Aim/s The aim is to examine how results and data from multiple Family Centred Nursing Index (PCNI) surveys help the development of a family-centred nursing culture at organizational and ward levels.

Design This is a longitudinal study of the outcomes of a survey of nurses which has run six times over 7 years. The survey is divided into five principal domains, with each domain having several different constructs (Table 1); each construct then has several key statements (questions) associated with it. Each question is individually scored (range 1–7), all answers in the construct are combined and an overall mean score is obtained for that construct i.e. ‘conflict with other nurses’. The means of each construct are then grouped in the specific domains and graphs are created to represent the findings i.e. Job Satisfaction (Domain) had four constructs pay and prospects; training; personal and professional satisfaction which are drawn from 18 individual questions. The combination of these aspects means the PCNI provides a comprehensive measure of some aspects of nurses’ work that contribute to the delivery of family-centred care and enables the measurement of nurses’ views of changes in ward, team and organizational ‘family-centeredness’ over time.

Sample/participants The PCNI was conducted in 2006, 2008, 2009, 2010, 2011 and 2012 and distributed to all nursing staff regardless of age, gender, grade or length of service (approximately 800 eligible respondents per year). It included all nursing staff contracted to work across all areas in the hospital; it excluded casual/agency staff, due to the ongoing nature of collecting the data.

Data collection Initially, the survey period was in the Australian winter months (June, July); this was changed to November, December and January in subsequent years, following discussions with ward managers. Summer was perceived to be a quieter time of year, enabling greater access to the survey © 2014 Commonwealth of Australia. Journal of Advanced Nursing © 2014 John Wiley & Sons Ltd

The organizational results are provided to staff (via presentation to all nurses at the ‘Nursing Forum’ with written reports to the Nursing Executive Team) and individual reports are provided to each ward – of their results compared with the overall organizational results. Wards that do not have a minimum return rate of 25%, do not receive a written report. The researchers took the view that this was the minimum level at which the information in the reports could be seen as illustrative of shared experiences of working in the wards. Initially, the findings of the report, were discussed with the ward manager (with other staff at his/ her invitation), however, they were encouraged to show the report and discuss its contents, with the rest of the ward nursing team and with their direct line managers. The value of disseminating the results across the wider team is emphasized as an expected part of the process.

Ethical considerations Full ethical approval was obtained from the hospital’s Ethical Review Board before the PCNI was instituted in the organization. All participants in the survey were considered to have given their consent for their responses to be anonymously included in the findings and reports produced. The identity of those completing (and not completing) the survey is confidential and known only to the research team who are not directly connected with the wards. Similarly, the contents of each ward report are shared only with the staff of that ward, though wards were encouraged to share their findings (and particularly any innovations that came from the results) with their managers and more broadly in the organization.

Data analysis Results are processed by SPSS v.15 (IBM Corporation, New York, NY, USA) for each of the constructs, based on the responses to the questions from all participants, to arrive at the organizational mean results. This same process is undertaken for each ward (there is an identifying question at the end of the survey). The results for each ward are then compared with the organizational results. In addition to the constructs, there are two single item questions: ‘How stressed do you feel in your job?’ and ‘How satisfied are you in your job?’ which give an overall stress and overall satisfaction mean score (see Figure 6).

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Table 2 Ward & organizational response rates 2006–2012. Year

2006

2008

2009

2010/11

2011/12

2012/13

Timing Response rate Number of wards receiving a report/number of wards in survey

Jul–Aug 47% 24/29 (83%)

June/July 38% 23/25 (92%)

Nov/Dec 45% 18/23 (78%)

Dec/Jan 54% 21/21 (100%)

Dec/Jan 57% 24/24 (100%)

Dec/Jan 59% 24/24 (100%)

@Ward numbers varied across the years due to on-going restructuring in the organization.

OWS Nursing stress 2012/2013

7 Frequency of events in last 7 days Mean score: 1 = Never; 7 = Always

6·5 6 5·5 5 4·5 4 3·5 3 2·5 2 1·5 1

2006

2008

2009 2010 Survey years

2011/12

Workload Inadequate preparation Lack of staff support Conflict with other nurses Uncertainty over treatment

Validity and reliability/rigour The PCNI research-based and in its piloted versions is valid and reliable. It is comprehensive in both its range and depth and this has been refined during its construction phases. Its philosophical basis is demonstrated in the range of issues the survey addresses and that it is designed to be a private space for each respondent to offer their views. It is a comprehensive assessment of aspects of nursing and nurses’ feelings across themes including: nursing and work stress, job satisfaction, organizational characteristics and attributes of caring.

Results Ward and organizational response rates varied across the six surveys (Table 2); of note is the fact that all wards received a report from 2010 onwards. Concentrating on the organizational response rates reveals some interesting facets; the greatest negative difference in response rates is 104

CHW 2012/13

Figure 1 Organizational nursing stress results 2006–2012.

between surveys one (2006) and two (2008). In the organizational results, there are some expected reflections of this: the stressor constructs show their highest levels across all surveys, in eight of the nine stressor constructs in 2008 (Figures 1 and 2, Tables 3 and 4). Scores in all eight of the satisfaction/agreement constructs are at their lowest at this point also (Figures 3 and 4, Tables 5 and 6). Anecdotally, managers fed back to the administrators of the survey (and the nursing executive of the organization) that this was a bad time of year to conduct it (at the height of the ‘winter pressures’ period) in terms of staff access, staff having time to complete the survey and feeling under workload pressure. They were not surprised by the results (although the survey asks respondents to take a longer-term view) and indicate that this was a reflection of the pressure nurses were under and how they felt at the time. It was also felt that the lead-up to the survey had not been as fully advertised as it could have been. Subsequently, the survey period was moved to a period later in the year, which afforded more opportunity for nurses to participate and a © 2014 Commonwealth of Australia. Journal of Advanced Nursing © 2014 John Wiley & Sons Ltd

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OWS work stress 2012/2013 Level of stress experienced Mean score: 1 = No stress; 7 = Extreme stress

7 6·5 6 5·5 5 4·5 4 3·5 3 2·5 2 1·5 1

Figure 2 Organizational

work

2006

2008

2009 2010 Survey years

168

CHW 2012/13

Work/Home Interface & social life Working environment Lack of communication and social support Career development

stress

results 2006–2012.

Table 3 Organizational nursing stress results 2006–2012 (Numerical). Nursing stress

2006 2008 2009 2010 2011/2012 2012/2013

Workload

Inadequate preparation

Lack of staff support

Conflict with other nurses

Uncertainty over treatment

3
85 4
24* 4
1 4
03 3
77 3
67†

2
81 3
15* 3
1 2
96 2
88 2
66†

2
88 3
16* 3
1 2
94 3
03 2
74†

2
01 2
1 2
1 1
99† 2
17* 2
05

2
24 2
42* 2
26 2
28 2
32 2
12†

*Highest numerical level. † Lowest numerical level.

more structured communication strategy (about the survey) was employed by its administrators. Yearly results also generated other initiatives, both at the ward (see vignettes below) and organizational levels. The results shown in Figure 1 indicate that ‘workload and stress’ is the highest scoring stressor in all surveys, with means ranging from 4
24 at its height (2008 survey) to 3
67 (2012) (Table 3). The point of interest here is that other organizational data shows an increase in both overall and seasonal activity in the organization year on year (e.g. increased presentations at hospital, higher patient acuity) indicating the respondents’ perceptions of their workload has eased over these 5 years, even in the face of working in a busier organization. No single expla© 2014 Commonwealth of Australia. Journal of Advanced Nursing © 2014 John Wiley & Sons Ltd

nation for this apparent anomaly is possible; some organizational and ward-level actions addressed this. From 2008 onwards, sharing the results across the organization (via a ‘nursing forum’) was a more active feature of the survey process – this was recognized and facilitated by the nursing executive. At the ward level, as nurses became more familiar with the survey and the process of individual wards receiving results and how it worked, it was increasingly seen as the avenue of expression for nurses and certainty about the survey (especially its anonymity) increased. In relation to the satisfaction/agreement constructs (Figures 3–5) the narrative is not as linear as the stress results. From Survey two (the nadir for most constructs results)

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Table 4 Organizational work stress results 2006–2012 (Numerical).

Table 5 Organizational work satisfaction results 2006–2012 (Numerical). Work satisfaction

Work stress

2006 2008 2009 2010 2011/2012 2012/2013

Work/home interface & social life 2
78 3
03* 2
98 3
03* 2
81 2
67†

Working environment

Lack of communication and social support

Career development

2
78 3
11* 2
92 2
88 2
69 2
56†

2
99 3
37* 3
2 3
10 2
87 2
79†

2
48 2
83* 2
71 2
65 2
41 2
39†

2006 2008 2009 2010 2011/2012 2012/2013

Pay and prospects

Training

Familyal satisfaction

Professional satisfaction

4
27 4
12† 4
26 4
20 4
34 4
43*

4
16 4
21* 3
71 3
65† 3
94 4
21*

5
4 5
2† 5
39 5
27 5
44* 5
28

4
9 4
68† 4
93 4
87 5
00* 4
95

*Highest numerical level. † Lowest numerical level.

*Highest numerical level. † Lowest numerical level.

satisfaction results do trend positively year on year – though there are some notable exceptions. In surveys three and four, satisfaction with training is in a noticeable trough – as a result of a perceived freeze on training for nurses in the organization. While there had been a slow down on training for a short period (a few months), the temporary nature of this did not filter down to the wards. This trend in surveys three and four was a catalyst for the nursing leader to ensure that all nurses were made aware that funding for training was available and this in turn has resulted in

satisfaction rating improving incrementally over the last two surveys. The ‘organizational outcome’ patterns (Figure 5) vary only slightly in the face of the stress and satisfaction pictures described above. The smallest gap between the two constructs (‘organizational commitment’ and ‘intention to leave’) was in survey two and since then there has been a very gradual widening of the gap. This s that while levels of satisfaction and stress have been volatile, respondents’ views of the organization as being responsive to their needs and messages are a more even characteristic of the results.

Levels of satisfaction Mean score: 1 = Very dissatisfied; 7 = Very satisfactied

OWS work satisfaction 2012/2013 7 6·5 6 5·5 5 4·5 4 3·5 3 2·5 2 1·5 1 2006

2008

2009

2010

2011/2012 CHW 2012/13

Survey years Pay and prospects Training

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Personal satisfaction

Figure 3 Organizational work satisfac-

Professional satisfaction

tion results 2006–2012. © 2014 Commonwealth of Australia. Journal of Advanced Nursing © 2014 John Wiley & Sons Ltd

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Table 6 Organizational ‘organizational trait’ results 2006–2012 (Numerical). Organizational traits

2006 2008 2009 2010 2011/2012 2012/2013

Adequate staffing and resources

Doctor/nurse relationship

Nursing management

Empowerment

3
88 3
43† 3
96 4
05 4
26 4
46*

4
86 4
74† 5
07 5
01 5
29 5
3*

4
78 4
54† 4
76 4
78 4
78 4
92*

4
33 4
29† 4
36 4
40 4
45 4
58*

most recent survey. These results are also reflected in each of the domains where stress levels are at their lowest across all constructs and satisfaction levels are at their highest or close to highest in all constructs (Figures 1–6).

Reporting results in individual wards To offer a greater insight into the ward-level experience of how the PCNI has helped in guiding practice changes, two vignettes are discussed below. This provides an illustration of the worth of the PCNI as a resource for historical data for clinical nurses.

*Highest numerical level. † Lowest numerical level.

Creating vignettes Overall stress and satisfaction These results (Figure 6) show the negative trending of survey two (2008) seen in other domains, but also show the effect of a seminal event in survey four (2010). In 2010, the mean for ‘overall stress’ is at its highest and ‘overall satisfaction’ at its lowest’. At this time a major re-structuring of the service (Child Health) was announced with two paediatric standalone hospitals coming together to form a unified organization, the tension/anxiety that this produced is visible in the narrowing of these results. This alerted the nursing executive to the need for greater dissemination of information to nurses about the structure and effects of the reforms. In the wake of improvements in these processes, we have seen the gap between ‘stress’ and ‘satisfaction’ at its widest in the

Interviews were undertaken with ward managers to provide more texture and detail of the ward’s journey, how the current results were achieved and a comparison to previous (ward or organizational) outcomes. The overall stress and satisfaction mean scores have been used to support the vignette. The interviewees consented to the process and subsequently verified that the interview data used remained faithful to the spirit and letter of what they had said.

Vignette A Ward A is one of the smaller wards in the hospital, with a total of 12 nurses. The response rate pattern shows a grad-

Level of agreement Mean score: 1 = Strongly disagree; 7 = Strongly agree

OWS Organisational traits 2012/2013

Figure 4 Organizational

trait

results

2006–2012. © 2014 Commonwealth of Australia. Journal of Advanced Nursing © 2014 John Wiley & Sons Ltd

7 6·5 6 5·5 5 4·5 4 3·5 3 2·5 2 1·5 1 2006

2008

2009 2010 2011/2012 2012/13 Survey years

Adequate staffing and resources Doctor/Nurse relationship Nursing Management Empowerment

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Levels of agreement Mean score: 1 = Strongly disagree; 7 = strongly agree

OWS Organisational outcomes 2012/2013 7 6·5 6 5·5 5 4·5

4·7

4·64

3·33

3·43

4·83

4·85

4·97

4·96

3·29

3·26

3·37

3·25

4 3·5 3 2·5 2 1·5 1 2006

2008

2009 2010 Survey years Organisational commitment

2011/12 CHW 2012/13

Figure 5 Organizational

Mean score STRESS: 1 = No strees; 7 = High stress SATISFACTION: 1 = Very dissatisfied; 7 = Very satisfied

Intention to leave

outcome

results 2006–2012.

OWS overall stress & satisfaction 2012/2013 7 6·5 6 5·5 5

5·13

4·92

4·98

4·01

3·92

4·96

4·93

5·19

4·5 4 3·5

4·19

3·67 3·39

3·43

3 2·5 2 1·5 1 2006

2008

2009

2010

2011/12

CHW 2012/13

Survey years Stress - overall

Figure 6 Organizational overall stress

Satisfaction - overall

and satisfaction results 2006–2012.

ual increase across the surveys, being sustained at the maximum 100% over the last three (Table 7). Ward A started with a relatively high ‘overall stress’ level (4
83) in the 2006 survey (Figure 7) compared with the organization as a whole (3
67). Their overall satisfaction rate was at the exact same level (4
83) which was lower than the organizational satisfaction rate (5
13). These unusual results are set against the background of a low response rate to date 108

(38%) well below the organizational response rate (47%). By survey two, the return rate had increased (55%) and there is a noticeable increase in ‘overall satisfaction’ (6
00) and a reduction in the level of ‘overall stress’ (3
67). These positive trends were attributed to a new manager being appointed and indicated that nurses felt a greater sense of unity than previously. Several longer-term staff left, a new educator was appointed and the ward held their first ‘staff © 2014 Commonwealth of Australia. Journal of Advanced Nursing © 2014 John Wiley & Sons Ltd

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Table 7 Participation rates for Ward A. Year

2006

2008

2009

2010/2011

2011/2012

2012/2013

Timing Response rate

July–Aug 38%

June/July 55%

Nov/Dec 83%

Dec/Jan 100%

Dec/Jan 100%

Dec/Jan 100%

Mean score STRESS: 1 = No strees; 7 = High stress SATISFACTION: 1 = Very dissatisfied; 7 = Very satisfied

Ward A - Overalls 2012/13 7 6·5 6

6·00

5·5

5·36

5

4·83

5·00

4·91

3·89

3·83

4·5 4·30

4 3·67

3·5

3·40

3·27

3 2·5 2 1·5 1 2006

2008

2009 2010 Survey years

2011/2012 2012/2013

Stress - overall

Figure 7 Overall stress & satisfaction

Satisfaction - overall

results for Ward A 2006–2012.

Table 8 Participation rates for Ward B. Year

2006

2008

2009

2010/2011

2011/2012

2012/2013

Timing Response rate

July–Aug 50%

June/July 52%

Nov/Dec 46%

Dec/Jan 63%

Dec/Jan 96%

Dec/Jan 94%

development day’. In survey three (2009) however, the ‘overall satisfaction’ result goes to its lowest so far (4
30), however, ‘stress’ continued to fall (3
4), the manager was absent from the unit for long periods and other staff positions had newly recruited staff (e.g. the Clinical Nurse Educator role) and staff were therefore uncertain about the workplace and the level of support for them in their roles. Sometimes new energies and directions appear to have emerged from new appointments in the ward. In 2010 there is a positive trend in ‘overall satisfaction’ (5
0) while overall stress also rose (3
89). This coincided with a new manager being appointed and may indicate that while staff were happy with the clarity they were unsure of what the new manager would bring to the ward. Just © 2014 Commonwealth of Australia. Journal of Advanced Nursing © 2014 John Wiley & Sons Ltd

before the latest survey (2012/2013) the ward commenced a Practice Development (PD) initiative, an essential feature of this is that all the nurses openly share their views and experiences of working together. The timing of this is against a background of the survey results (100% return) indicating an increase in satisfaction (5
36) and a decrease in stress level (3
27), the lowest stress level to date. Many of those participating commented positively on the PD process for providing a new forum for expression, as a means of developing collective action. Connected to this, the development of the participation rates also seems to illustrate greater stability and security amongst these nurses and a desire to understand more about the way they work together.

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Mean score STRESS: 1 = No strees; 7 = High stress SATISFACTION: 1 = Very dissatisfied; 7 = Very satisfied

Ward B - Overalls 2012/2013 7 6·5 6 5·70

5·5 5

5·24 5·00

5·00

4·88

4·5

4·50 4·13

4·31

4 3·75

3·65

3·5

3·52 3·23

3 2·5 2 1·5 1 2006

2008

2009

2010

2011/2012 2012/2013

Survey years Stress - overall

Figure 8 Overall stress & satisfaction

Satisfaction - overall

results for Ward B 2006–2012.

Vignette B Ward B is a medical ward with approximately 35 nurses. Response rates have been relatively consistent, however, they show marked increases since 2009 (Table 8). The overall stress and satisfaction levels for the ward have varied between each survey, with the increasing of the response rate in the last three surveys, generally the trending has been positive (Figure 8). In 2009, there is a marked increase in their overall stress (4
88) well above the organizational mean (3
29) with a corresponding decrease in their satisfaction (4
31) against a higher organizational mean (4
83) resulting in their stress score being higher than their satisfaction score – this is attributed to the confluence of several factors. The ward underwent a change in its patient profile late in that year, resulting in pressure for staff to rapidly gain a new set of skills, knowledge and understanding about this new patient cohort. It was particularly busy for the time of year with an increase in complex patient care cases which had a direct bearing on the atmosphere in the ward and perceptions of stress for the nurses. There were fewer staff on the ward at the time and the nurse educator was on long-term sick leave. There was also a lack of stability and continuity at senior nursing levels on the ward. Overall, the nurses at the time reported feeling that they worked in a ward that lacked structure, planning and goals for its care. With action taken (or resolution) of many of these factors, after the 2009 result, the overall stress

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declines noticeably and satisfaction improves markedly. These actions included: • increased staffing following a ward review; • the nurse educator returning from sick leave; • greater clarification for the nurses working in team leader roles at weekends Staff reported that as a result of participating in a care review process, they not only had the opportunity to share their feelings with each other in an open forum, this enabled them to feel more like a team. In the latest survey (94% return) overall satisfaction is at its highest to date (5
7) well above the organizational result (4
96) with stress close to its lowest (3
52) producing a widening of the gap between the satisfaction and stress. This vignette and the one above (Ward A) show that the PCNI results provide individual wards with data which enables them to consider what may be required if they embark on a consultative and collaborative process of change. We now return to considering the wider issues in administering the survey and this organization’s record in relation to this.

Discussion Our experience is that response rates are closely linked to the relevance and accuracy of the results produced. Scott et al. (2003) highlights that our latest response rate of 59% © 2014 Commonwealth of Australia. Journal of Advanced Nursing © 2014 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH

would rate as ‘one of the best’ given that these areas of investigation are plagued with low response rates arising from the view that examining features like these is often seen to have a hidden managerial agenda. The evidence presented in this paper suggests that this appears to lessen over time, as the potential of undertaking the survey becomes clearer through experience. The results are presented to each individual ward, ensuring that the data reaches the ‘front line staff’, which addresses this important aspect raised by Manley (2000). The ‘nursing stress’ experiences of the respondents across the surveys has varied though there are consistencies and to some extent they could be seen as expected from a review of the literature (Applebaum et al. 2010). However, there are also discrepancies according to associations made between stress factors in the literature (Aiken et al. 2012). There is a rise across all the stressors (taken as a whole) between the 2006–2008 surveys. Contributing factors could include global nurse shortages and increasing healthcare demands (Boyle 2006) and local health service restructures at a state level. In relation to the individual constructs in Figure 2, that ‘Workload’ shows as the highest stressor across all the surveys is in keeping with the ways nurses’ prioritise stress factors in the literature (Kowalski 2010, Lim et al. 2010). ‘Workload’ in these surveys appears as a barometer of stress taken across all the constructs in the organizational results. In other words, when it is at its highest, the picture across all the stressors is one of raised levels; when it is lower, stress in all the facets is seen to be lower. This indicates that many of the assumed connections between attitudes and experiences in nurses’ clinical work (for example, a supposed connection between busyness and satisfaction) are questioned by the findings here. There is a need for further refinement in thinking and research on the complexity of cultural factors and their relationship to care given. Figure 5 shows that the ‘intention to leave’ is relatively low across all surveys and has remained in a relatively narrow range across all the surveys (high of 3
43, low of 3
25 (2012/13); while ‘organizational commitment’ remains relatively high throughout. Since the 2008 results, the gap between the two levels has gradually increased – a positive trend in itself. Against the background of variations in other domains and constructs, this aspect supports Utriainen and Kyng€as (2009) findings showing the relatively higher morale amongst nurses in paediatric settings; they also support visions of organizational culture as a series of attributes, as opposed to a uniform/unified concept. In at least one respect the findings for this organization deviate from literature findings. When having relatively high levels of workload stress, it could also be expected © 2014 Commonwealth of Australia. Journal of Advanced Nursing © 2014 John Wiley & Sons Ltd

Person centred nursing index

that high levels of ‘conflict with other nurses’ would be evident (Almost et al. 2010). This is not shown in the PCNI results; with this construct the lowest stressor across each survey. In considering the outcomes for ‘work stress’ (Figure 2), there are some agreements with the literature, where ‘Lack of communication and social support’ feature prominently as a stressor. Hsu et al. (2011) makes this link between social interactions as a major feature of (or mitigation against) a feeling of being stressed about workload. The results for work/home interface show variation from the expectations in the literature – at times of increased workload stress, nurses also report deterioration in the stress generated for them at the work/home interface (Cortese et al. 2010). This is not the case in these PCNI results, the work/home interface scores are relatively stable, even in the face of variance in workload stress levels. Contextual issues contribute to understanding the results in organizational satisfaction. At the time of the 2008–2009 surveys there was a belief in the organization of reduced provision for nurses to attend training. There is a significant difference in the results for the construct ‘training’ which contributes to the work satisfaction domain in these years (4
21 and 3
71 respectively – Figure 3), this confirms the view that access to and satisfaction with ‘training’ do form a significant part of the satisfaction picture for nurses (Utriainen & Kyng€ as 2009). After a great effort at clarification of this situation by the nursing executive across the organization, we see the ‘training satisfaction’ levels increase in the subsequent years (3
94 in 2011/2012 and 4
21 in 2012/13). The PCNI provides a clear picture of many of the variables associated with ‘workplace culture’ that are recognized and addressed in the organization where it is applied (White & Wilson 2013). To continue this process will only reap greater rewards, both in mapping where the organization is against where it wants to get to and providing a snapshot in time of its current situation. This will be maximised if they are considered against local, national and international contextual influences and are in keeping with Beil-Hildebrand’s (2002) views on the value of ‘extended labour process analyses’.

Limitations The survey data is focussed on nursing perception and does not include recipients of care (children) or their families as data sources. While recognizing this limitation to the PCNI, data is collected in the organization about the experiences of patients and their families (see e.g. Lewis et al. 2007, Hooke et al. 2008, Redshaw et al. 2011) and this adds to

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the PCNI data and provides the organization and individual units with a more comprehensive picture of their culture.

Conflict of interest The authors declare no conflict of interest.

Conclusion

Author contributions

The PCNI is intended to illustrate how people feel about working in the organization and about the care they provide. This article shows the challenges to thinking that can arise from a continuing survey of this type. It also challenges the strategists and who wrestle with the situations demonstrated by the results at both an organizational and individual-ward level. This is a continuing journey, however and further sets of results will serve to maintain the push towards increasing satisfaction amongst nurses in the organization and as a model for other organizations to continue to refine the process. The survey also asks a lot of respondents, requiring they take a long-term view of issues/experiences when this may not always be possible for all respondents. The survey presents a longer-tem illustration (in its results) of what may be a more-immediate experience for the respondents- and this is acknowledged as a limitation of surveys of this type. The vignettes show the value of keeping a record of history and that the insight the PCNI provides, can be used to form part of/reinforce ward teams’ developmental agenda. This development can be seen primarily in two domains: the ways they work together and in the refining of practice processes in which they participate. It shows a willingness and commitment towards developing familycentredness amongst the nurses in a graduated, coordinated way. The results trace a picture of increasing workload for nurses across the organization; however, this situation is not accompanied by decreases in commitment or rises in ‘intention to leave’. The results reinforce the value of identifying those aspects of the PCNI that form part of the ‘organizational culture’ as actionable and lend weight to seeing the space between these as valuable.

All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/ethical_1author.html)]:

Acknowledgements The authors acknowledge the assistance of Kelly Kornman in the editing and reviewing of this article. They also thank the staff of Children’s Hospital Westmead for their ongoing support and assistance.

Funding There was no funding required for this undertaking. 112

• •

substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content.

Supporting Information Additional supporting information may be found in the online version of this article at the publisher’s web-site.

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