patient complexity factors and their influence on nurses' perception of staffing adequacy

161 Pages·2017·2.29 MB·English

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Theses & Dissertations
4-22-2016
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Margaret Mary Duffy
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Adequacy" (2016). Theses & Dissertations. 6.
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Molloy College
The Division of Nursing
PhD in Nursing Program

PATIENT COMPLEXITY FACTORS AND THEIR INFLUENCE ON NURSES’
PERCEPTION OF STAFFING ADEQUACY

a dissertation

by
MARGARET MARY DUFFY

submitted in partial fulfillment of the requirements
for the degree of
Doctor of Philosophy

April 22, 2016
© Copyright by MARGARET MARY DUFFY
All Rights Reserved
2016

Abstract
PATIENT COMPLEXITY FACTORS AND THEIR INFLUENCE ON NURSES’
PERCEPTION OF STAFFING ADEQUACY
By
MARGARET MARY DUFFY
Nurse leaders must consider the influence of nurse-specific and patient-specific factors
on nursing workload and nurses’ perception of staffing adequacy when developing nurse staffing
plans. All of the factors that influence individual nurses’ perception of staffing adequacy are not
known. Using a synthesis of the Roy Adaptation Model (RAM) and economic theory as a
guiding model, the purpose of the current study was to determine if selected patient complexity
factors that are not consistently captured in the measurement of patient acuity by an automated
workforce management system influence nurses’ perception of staffing adequacy.
The current study employed a complex predictive correlational research design, which
included repeated measures of patient data and nurses’ perception of staffing adequacy at the
shift-level. A selection of repeated measures data from 26 Registered Nurses (RNs) and 1,605
patients over 328 shifts was entered into the initial analysis. The number of shifts with complete
data used for final analysis was N = 294. Disruptive behavior (r= -.274) and family demands
(r=-.186), were negatively correlated with nurses’ perception of staffing adequacy and explained
10% of the variance in a regression model. There was a negative correlation between total shift
factor score (r=-.418), derived from the presence of patient complexity factors, and nurses’
perception of staffing adequacy. No correlation was found between perception of staffing
adequacy and nurse staffing variables.
A theoretical proposition of RAM was tested to describe the interaction between the
group subsystems and the RAM modes in relationship to the goals of an organizational system.
Study findings supported the RAM proposition and contribute to the middle range theory of
adaptation, production decision-making process, and nurses’ perception of staffing adequacy.
The findings inform the science of nurse staffing, but indicate further opportunities for research
since other factors might exist that contribute to the perception of staffing adequacy.
Dedication

In loving memory of my parents, John and Joan Connelly.
To my dad, who taught me the value of reading and education.
And to my mom, who taught me how to persevere in the face of hardship.

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Acknowledgements
I extend my deepest gratitude to the members of my dissertation committee: Dr. Debra
R. Hanna, chair, Dr. Ann Marie Paraszczuk, and Dr. Lawrence A. DiFiore. I greatly appreciate
your generosity of time, and your care and consideration throughout this process. You pushed
me to a level of thinking I did not believe was possible. I would like to thank Dr. Veronica Feeg
for her unending support of the inaugural cohort of PhD students, the “pioneers.” Your vision
and guidance kept us motivated at every phase of the doctoral journey.
I am very grateful to the nurses who took the time to participate in this study. Thank you
for your contribution to research.
My sincere thanks to my friend and mentor, Dr. Lee Anne Xippolitos. You always see in
me what I do not see in myself. I would not have reached this milestone without your direction
and coaching.
The friendships forged among the colleagues of our cohort are something I will treasure
for years to come. Each of us contributed uniquely to an amazing experience. A special “thank
you” to the members of the Sunday PhD club: Dr. Nikki Fiore-Lopez, Anna tenNapel, and
Valerie Terzano. Your support every week made all the difference. We were small in numbers
but mighty in spirit!
To my close friends and family, many thanks for your encouragement and understanding
during this journey. My children, Tom and Jack, provided endless amounts of laughter and love,
and kept me going. I am fortunate to have such inspiring young men to call my sons. And to the
love of my life, my husband Tom, who endured the most during this journey. I could never have
achieved what I have done professionally without your love, support, and your ability to make
me see the humor in every situation. This accomplishment is yours as much as mine.
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TABLE OF CONTENTS
LIST OF TABLES ......................................................................................................................... vi
LIST OF FIGURES ...................................................................................................................... vii
CHAPTER 1: STATEMENT OF THE PROBLEM .......................................................................1
Introduction ..........................................................................................................................1
Background ..........................................................................................................................3
Purpose .................................................................................................................................6
Theoretical Framework ........................................................................................................6
Study Aims...........................................................................................................................7
Significance..........................................................................................................................8
Conclusion ...........................................................................................................................9
Definitions..........................................................................................................................10
CHAPTER 2: LITERATURE REVIEW ......................................................................................11
Overview ............................................................................................................................11
Conceptual Framework ......................................................................................................12
Roy Adaptation Model .......................................................................................... 12
Economic Theory .................................................................................................. 18
Explication of the Linkages ................................................................................... 22
Testing the Roy Adaptation Model Proposition .................................................... 24
Development of Knowledge about Nurse Staffing ............................................................24
Florence Nightingale ............................................................................................ 24
Defining Nursing Workload .................................................................................. 26
Workload Measurements ...................................................................................... 28
Nursing Shortages ................................................................................................. 30
Establishing Staffing Ratios .................................................................................. 34
Significance of Nurse Staffing ...........................................................................................38
Nurses’ Perception of Staffing Adequacy ............................................................. 38
Nurse Staffing and Patient Safety ......................................................................... 42
Nursing Work Environment .................................................................................. 46
Nurses’ Education and Quality Care .................................................................... 49
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Missed Nursing Care ............................................................................................ 50
Patient Complexity Factors ................................................................................................51
Obesity as a Patient Complexity Factor ............................................................... 53
Limited English Proficiency .................................................................................. 55
Disruptive Behavior .............................................................................................. 57
Restraint Use ......................................................................................................... 58
Continuous Observation ....................................................................................... 59
Family Demands ................................................................................................... 60
Conclusion .........................................................................................................................61
CHAPTER 3: METHODS ............................................................................................................63
Study Design ......................................................................................................................63
Study Question ...................................................................................................................64
Procedures ..........................................................................................................................65
Independent Variables .......................................................................................... 68
Instruments .........................................................................................................................70
Practice Environment of the Nursing Work Index (PES-NWI) ............................. 70
Staffing Adequacy Perception - VAS..................................................................... 72
Dependent Variable .............................................................................................. 73
Data Collection ..................................................................................................................74
Data Cleaning ....................................................................................................... 76
Data Analysis .....................................................................................................................77
Human Subjects Protection ................................................................................................78
Chapter 4: FINDINGS ...................................................................................................................80
Quality of Data Collected ..................................................................................................80
Descriptive Statistics ..........................................................................................................84
Sample of Nurse Participants ............................................................................... 84
Psychometric Analyses ......................................................................................................85
Exploratory Factor Analysis ................................................................................. 86
Convergent Validity .............................................................................................. 88
Research Question .............................................................................................................89
Study Aim #1 .....................................................................................................................90
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