First, MoNCD is described as the independent or collaborative work of nurses to provide direct patient care to a group of patients (Havaei, MacPhee, & Dahinten, 2019; Shirey, 2008). A priori power calculation showed a sample size of about 226 individuals would have sufficient power to detect small effect sizes (i.e., R2 = .10) for multiple regression analysis at alpha = .05, and with about 20 predictors. I need a fast track publication journal in nursing child … Skill mix moderated the relationship between patient acuity and emotional exhaustion. Continuing education and professional development educators play a vital role in enhancing quality and safety in the practice setting. In one study examining the relationship between nursing skill mix and MoNCDs, researchers found that skill mix was a determinant of MoNCD (Duffield et al., 2010). Demographic questions included nurse characteristics such as age, gender (0 = male, 1 = female), nursing education (0 = diploma, 1 = BSN or Masters), years of nursing experience, employment status (0 = full-time, 1 = part-time or casual), employment contract (0 = permanent, 1 = temporary), and number of nursing jobs (0 = one job, 1 = more than one job) (Havaei et al., 2019). ,{i:'table1-2377960819869088',type:'table-wrap',g:[{m:'10.1177_2377960819869088-table1.gif',l:'10.1177_2377960819869088-table1.jpeg',size:'305 KB'}]} Integrating the QSEN competencies enables continuing education and professional development educators to emphasize the “why” behind nursing interventions while also highlighting the evidence driving care. British Columbia Ministry of Health. For more information view the SAGE Journals Sharing page. QSEN competencies serve as an appropriate framework for education to address common issues confronting nursing practice, such as medication errors, pressure injuries, and falls. While mode of nursing care delivery was not related to nurse outcomes, work environment factors were the strongest predictors of both nurse outcomes. A single item that asked nurses to endorse the option that best described how care was delivered in their primary unit over the last shift was used to measure MoNCD; response options included (a) patients were assigned to one nurse (e.g., total patient care, labeled as TPC) and (b) patients were assigned to a nursing team (e.g., team nursing, labeled as TN) (Havaei et al., 2019). During this same time, practice saw the introduction of the Hospital Value-Based Purchasing program implemented by the Centers for Medicare & Medicaid Services (2018). Correlations Between Key Study Variables (N = 416). The Journal of Continuing Education in Nursing. CiteScore: 1.9 ℹ CiteScore: 2019: 1.9 CiteScore measures the average citations received per peer-reviewed document published in this title. The Nursing Worklife Model components, particularly “the nursing model of care delivery” and “staffing and resource adequacy” components, were previously linked to improved nurse and patient outcomes (Laschinger, 2008; Laschinger & Leiter, 2006). Unlike RNs and LPNs, care aides are not regulated. To maximize power, only significant interaction terms were retained in the final models. Key methods of data analysis were chi-square analyses, hierarchical multiple regression, and moderated regression. For more information view the SAGE Journals Article Sharing page. This new emphasis is designed to support nurses in practice as they enrich their knowledge, skills, and attitudes in addressing quality and safety issues. Second, skill mix is defined as direct care nurse classifications (Harris & McGillis Hall, 2012). ,{i:'table3-2377960819869088',type:'table-wrap',g:[{m:'10.1177_2377960819869088-table3.gif',l:'10.1177_2377960819869088-table3.jpeg',size:'372 KB'}]} In most acute care settings across British Columbia (BC), there are three key nurse classifications: RNs, licensed practical nurses (LPNs), and nursing care aides (Harris & McGillis Hall, 2012). Third, this study found some LPNs may be caring for high acuity patients independently; this finding raises red flags about LPNs’ adherence to their scopes of practice. If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. ,{i:'table2-2377960819869088',type:'table-wrap',g:[{m:'10.1177_2377960819869088-table2.gif',l:'10.1177_2377960819869088-table2.jpeg',size:'304 KB'}]} Emotional exhaustion was measured with the emotional exhaustion subscale of the Maslach Burnout Inventory-Human Service Scale (Schaufeli, Leiter, & Maslach, 2009). (Eds.). For example, the strongest predictor of both nurse outcomes was the staffing and resource adequacy component of the work environment. CiteScore: 2.7 ℹ CiteScore: 2019: 2.7 CiteScore measures the average citations received per peer-reviewed document published in this title. Share this page ; Nursing focusses on providing medical and personal assistance to the individuals, families, and communities affected physically or psychologically. Does MoNCD moderate the relationship between nurse workload factors and nurse outcomes? Similarly, the “staffing and resource adequacy” component is a proxy for nurses’ perceptions of workload management (Lake, 2002). Many of our Featured Journals include continuing education activities, special features, … None of the interaction terms were significantly related to job satisfaction and hence were dropped from the regression model. ,{i:'fig2-2377960819869088',type:'fig',g:[{m:'10.1177_2377960819869088-fig2.gif',l:'10.1177_2377960819869088-fig2.jpeg',size:'42 KB'}]} The two key components of models of nursing care delivery are mode of nursing care delivery and skill mix. Find out about Lean Library here, If you have access to journal via a society or associations, read the instructions below. ∼ Patricia S. Yoder-Wise, RN, EdD, NEA-BC, ANEF, FANOL, FAAN. QSEN provided resources and partnered with national nursing organizations to support the implementation of the competencies in nursing academia. All significant variables were positively related to job satisfaction. Aligning healthcare safety and quality competencies: Quality and Safety Education for Nurses (QSEN), The Joint Commission, and American Nurses Credentialing Center (ANCC) Magnet. Sherwood, G. (2017). is based on the Incredibly Easy! When comparing team nursing to total patient care, total patient care was associated with a higher proportion of RN hours to all nursing hours and team nursing was associated with a higher proportion of LPN hours to all nursing hours. Some society journals require you to create a personal profile, then activate your society account, You are adding the following journals to your email alerts, Did you struggle to get access to this article? Does skill mix moderate the relationship between nurse workload factors and nurse outcomes? Ultimately, improving nurse outcomes is dependent on several factors. Compared with RNs, LPNs are allowed to care for more stable and less complex patients. (2014). This speculation is consistent with recent research evidence that found some LPNs and a majority of RNs from remote and rural settings performed nursing competencies beyond their legal scope of practice (MacLeod et al., 2019a, 2019b). Sum scores were computed after the intent to leave item was reverse coded. Nursing Journals . If you have access to a journal via a society or association membership, please browse to your society journal, select an article to view, and follow the instructions in this box. Overall, there were four key findings: (a) There were no differences in skill mix between total patient care and team nursing, (b) skill mix moderated the relationship between patient acuity and emotional exhaustion, (c) MoNCD was not related to nurse outcomes, and (d) certain aspects of nurses’ work environments were the most important predictors of both nurse outcomes. Call For Papers: for a Special Issue of Journal of Clinical Nursing with focus on Disaster Nursing. Table 1. Although it sounds like it means thinking about important things, critical thinking really means using reflective, systematic thought processes while weighing alternatives and finding a creative solution. 11873. Nurse workload factors encompassed nurse staffing levels, patient acuity, and dependency. Twice each month, we feature a nursing journal from the more than 60 nursing journals available on our site, enabling you free online access to every article in the latest issue. Nursing Made Incredibly Easy! With the exception of patient dependency, staffing and resource adequacy, participation in hospital factors, and nursing foundation of care delivery, none of the other variables were related to job satisfaction scores (Table 3). With respect to skill mix, over two thirds of nurses reported working with LPNs as opposed to about one third who reported working without LPNs. More than three quarters of nurses identified their MoNCD as TPC compared with one quarter who reported providing care based on TN. Continuing education and professional development educators are often tasked with repeatedly teaching the same required courses containing content that becomes stagnant over time. The descriptive statistics on key study variables are shown in Table 1. Gerry Altmiller, EdD, APRN, ACNS-BC, FAAN; Loraine Hopkins-Pepe, MSN, RN, CCRN-K. The impact of these redesign initiatives on nurse outcomes is unclear. This was an exploratory cross-sectional correlational survey study based on a secondary analysis of data. There were no statistically significant changes in R2 between Models 1, 2, and 3. Main Menu; Journals & Articles; Journals; Books and eBooks; Video Library. & Waxman, K.T. The three key research questions are as follows: What is the relationship between care delivery model components, MoNCD and skill mix, and nurse outcomes after controlling for nurse characteristics, nurse workload factors, and work environment factors? Galante, Christine M. About 30% of patients with … Mean emotional exhaustion scores were high (Mean = 27, SD = 12.9; Silva et al., 2015). ... Journal of Community Health Nursing List of Issues Search in: Top; Journal Journal of Community Health Nursing Submit an article Journal homepage. the site you are agreeing to our use of cookies. Ethical approval was obtained from the University of British Columbia Human Ethics Approval Review Board (approval number = H14-00789). This finding can be explained by the unexpectedly strong effects of some of the control variables on these study outcomes. I have read and accept the terms and conditions. At higher levels of acuity, nurses who worked with LPNs reported lower levels of emotional exhaustion than their peers who worked without LPNs (see Figure 2). The email address and/or password entered does not match our records, please check and try again. By critically evaluating existing courses and revising them to integrate the QSEN competencies, these educators may begin teaching from a different lens, shifting their focus from teaching tasks to teaching concepts about how to influence and promote high-quality safe care. Lippincott NursingCenter is the premiere destination for professional development for nurses. Cite this article as: Chien, L. Y. CiteScore: 1.2 ℹ CiteScore: 2019: 1.2 CiteScore measures the average citations received per peer-reviewed document published in this title. Browse the list of issues and latest articles from Journal of Community Health Nursing. Among nurses who worked in a TPC MoNCD, 67% identified their skill mix as including LPNs, whereas 72% of nurses who worked in TN MoNCD identified their skill mix as including LPNs. Previous research shows coworker support was related to the three dimensions of burnout (i.e., emotional exhaustion, depersonalization, and personal accomplishment). Accordingly, we strongly recommend future research to investigate LPNs’ scope of practice in light of the workplace MoNCDs. Subscribe. ,{i:'table1-2377960819869088',type:'table-wrap',g:[{m:'10.1177_2377960819869088-table1.gif',l:'10.1177_2377960819869088-table1.jpeg',size:'305 KB'}]} It is unclear how many medical–surgical nurses were invited to participate in the larger study; hence, a response rate could not be computed. A majority of RNs who practiced total patient care reported working in a skill mix including LPNs. There exists little research that investigates both components simultaneously. Three multiple regression models were obtained to examine the relationships between key predictors, MoNCD and skill mix, and each outcome (Research Question 1). Contrary to RNs working without LPNs, RNs working with LPNs reported lower levels of emotional exhaustion when providing care for higher acuity patients. Similar to earlier studies (Laschinger, 2008), nursing work environment factors, particularly staffing and resource adequacy, participation in hospital affairs, and nursing foundation of care delivery, were the most important predictors of nurse outcomes. CriticalCareNurse is a bimonthly publication from the American Association of Critical-Care Nurses … Also, because some of the study measures relied on nurse reports of phenomena that occurred in the past, there is a possibility of measurement error attributed to recall bias. Researchers in a Canadian longitudinal study (Wells, Manuel, & Cunning, 2011) who examined the change in nurse job satisfaction and empowerment after team nursing was replaced with total patient care across three time periods (N = 38, 36, and 21 at Times 1, 2, and 3) reported that no changes were detected across the three time periods. Ideally, nurse self-reports of quality and safety status should be compared with administrative data. Although the QSEN competencies were originally designed for nursing education, this work validates the QSEN competencies as an effective framework to drive excellence and buttress the lifelong learning required by nursing professionals to ensure that the best care is provided to those who access the health care system. Login failed. First, given the importance of work environment factors, we recommend nursing leaders and policy makers to invest in those workplace conditions that improve nurse outcomes. Confirmatory factor analysis of the measure with the study sample confirmed a 5-factor model with a mediocre fit (root mean square error of approximation = .08, standardized root mean square residual = .07, goodness of fit index = .83, comparative fit index = .94, and normed fit index = .92); subscale Cronbach’s alphas ranged from .76 to .82 (Havaei et al., 2019). In total patient care, one registered nurse (RN) is mainly responsible for the complete care of a group of patients throughout a shift, whereas a designated team of nursing staff members with various competencies, skill levels, and scopes of practice provide care to a group of patients in team nursing (Duffield, Roche, Diers, Catling‐Paull, & Blay, 2010). Abstract. Shortly afterward in 2005, the QSEN collaboration, funded by the Robert Wood Johnson Foundation and led by Linda Cronenwett, adopted those five requisites, added safety as a sixth competency, and the newly developed QSEN competencies became the blueprint for nurse educators working to re-channel the focus of formal nursing education programs (Cronenwett et al., 2007). Similarly, Huang et al. A shared care model vs. a patient allocation model of nursing care delivery: Comparing nursing staff satisfaction and stress outcomes, Global use of the practice environment scale of the nursing work index, Changing the model of care delivery: Nurses’ perceptions of job satisfaction and care effectiveness, An introduction to hierarchical linear modeling, SAGE Publications Inc., unless otherwise noted. The final model, Model 4, explained 38% of the variance in emotional exhaustion scores, F(19, 295) = 9.41, p < .001. (2016). About three quarters of participants were bachelors prepared with permanent contracts. However, there are differences in their level of education, competencies, and, subsequently, in their scopes of practice. Fast turnaround: - Time from submission to First Decision: 21 days - Time from submission to Final Decision: 29 days - Time from submission to Reject Decision: 20 days - Time to Publication: 7 days to Accepted Article publication, and 30 days to Early View (final version) publication 2018 Cite Score: 1.91 - ranked 8th in the listing for mental health journals! Nursing school enrollment is not growing fast enough to meet the projected demand for RN and APRN services. When MoNCD or skill mix decisions are only efficiency driven, RNs may experience significant stress because of the mismatch between nurse competencies and patient needs that may result from these decisions. Hierarchical Regression Analysis Results for Variables Predicting Nurse Outcomes (N = 416). … The two strongest predictors were staffing and resource adequacy (β = .25, p < .001) and participation in hospital affairs (β = .19, p < .01). This product could help you, Accessing resources off campus can be a challenge. Google Scholar The Practice Environment Scale-Nursing Work Index (PES-NWI) was used to measure the quality of nurses’ work environments (Lake, 2002). Nurses are the linchpin in achieving quality and safety outcomes, and they are frequently viewed as the last defense between the patient and potential errors (Sherwood & Zomorodi, 2014). Many of our nursing articles are a part of leading journals, including AJN, American Journal of Nursing, Nursing2020, Nursing Management, The Nurse Practitioner, and Nursing2020 Critical Care. Questions are raised, therefore, about LPNs’ working beyond their scope of practice. Subscribe today! Havaei, F., MacPhee, M., & Dahinten, S. (2019). What followed was 13 years of transformation as the QSEN competencies were integrated into curriculum plans and accreditation standards for schools of nursing. Journal of the American Medical Directors Association. Overall, there were no statistically significant changes in R2 between Models 1, 2, and 3, but the R2 increased by 1.1% from Model 3 to Model 4 after the addition of Acuity × Skill Mix. (2011) examined the change in satisfaction of only 38 RNs in a cross-sectional study after total patient care was replaced with team nursing and found no significant changes in RNs’ satisfaction scores. In Sherwood, G. & Barnsteiner, J. The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. List of Nursing & Health Care Conferences; November 30-01, 2020 10th International conference on Palliative Care, Barcelona, Spain: December 01-02, 2020 7th Global Summit on Midwifery and Womens Health, Rome, Italy: December 04-05, 2020 Sherwood, G. & Zomorodi, M. (2014). Mode was operationalized as total patient care versus other (i.e., team nursing and primary nursing). Only one Canadian secondary analysis was found in which researchers examined the effect of both MoNCD and skill mix on nurse outcomes (i.e., RN job stress and role tension; McGillis Hall & Doran, 2007). (2010) and confirmed by subject matter experts (i.e., professional practice officers of BC health authorities, senior nurse leaders from the provincial nurses’ union; 0 = TPC and 1 = TN). Using crosswalk methodology, they aligned the six QSEN competencies, the Magnet® standards, and the Joint Commission Accreditation Standards. Most articles are offered as part of a free nursing journal or at a consistent low price. Second, as a skill mix with LPNs was found to buffer against the negative effects of high workload on RN emotional exhaustion, we believe nurse leaders can use skill mix considerations as a strategy to enhance nurse outcomes. This finding may suggest that transition from total patient care to team nursing in BC medical–surgical settings has been slower than anticipated because of inadequate sustained organizational supports and resources that facilitate this transition. Among primary effects, staffing and resource adequacy (β = −.40, p < .001) and skill mix (β = .27, p < .05) were the strongest predictors of emotional exhaustion. But the study findings should be interpreted with considerations of its limitations. In both studies, a small sample was used (N ≤ 38). RNs and LPNs are both self-regulated, which means that their registration or licensure and maintenance of their professional standards of practice are overseen by a regulatory body (Havaei et al., 2019; MacPhee, 2014). Hayes, L. J., O’Brien-Pallas, L., Duffield, C., Shamian, J., Buchan, J., Hughes, F., North, N. (, Hessels, A. J., Flynn, L., Cimiotti, J. P., Cadmus, E., Gershon, R. R. (, Huang, L.-C., Lee, J.-L., Liang, Y.-W., Hsu, M.-Y., Cheng, J.-F., Mei, T.-T. (, MacLeod, M. L. P., Stewart, N. J., Kosteniuk, J. G., Penz, K. L., Olynick, J., Karunanayake, C. P., Moffitt, P. (, MacLeod, M. L. P., Stewart, N. J., Kosteniuk, J. G., Penz, K. L., Olynick, J., Karunanayake, C. P., Zimmer, L. V. (, MacPhee, M., Dahinten, V. S., Havaei, F. (, Schaufeli, W. B., Leiter, M. P., Maslach, C. (, Sermeus, W., Aiken, L. H., Van den Heede, K., Rafferty, A. M., Griffiths, P., Moreno-Casbas, M. T., Bruyneel, L. (, Silva, J. L. L. D., Soares, R. D. S., Costa, F. D. S., Ramos, D. D. S., Lima, F. B., Teixeira, L. R. (, Sundin, L., Bildt, C., Lisspers, J., Hochwälder, J., Setterlind, S. (, Tran, D. T., Johnson, M., Fernandez, R., Jones, S. (, Woltman, H., Feldstain, A., MacKay, J. C., Rocchi, M. (. Please read and accept the terms and conditions and check the box to generate a sharing link. Nurses were asked to rate their patients’ overall levels of acuity (0 = not acute at all, 3 = very acute) and dependency (0 = completely independent, 3 = completely dependent) over the last month; acuity and dependency were recoded into binary variables (Havaei et al., 2019). Home Oxygen Therapy. Descriptive Statistics of the Study Key Variables (N = 416). A detailed description of the larger study design can be found in MacPhee, Dahinten, & Havaei (2017). ]}. (2019). Journal of Advanced Nursing. The work of Lyle-Edrosolo and Waxman (2016) has been significant in bridging academia and practice. Evidence-based practice and nursing research. Cancer Nursing Practice; Emergency Nurse; Evidence-Based Nursing; Learning Disability Practice; Mental Health Practice; Nurse Researcher; Nursing Children and Young People; Nursing Management; Nursing Older People; Nursing Standard; Primary Health Care; Learning Portfolio Havaei, F., MacPhee, M., & Dahinten, S. (2019). The e-mail addresses that you supply to use this service will not be used for any other purpose without your consent. This program reimbursed hospitals based on quality of care rather than quantity, thus driving efforts to improve quality and safety within health care systems. That call to action identified five competencies required by all health care providers to transform the health care system, shifting the emphasis to include patient-centered care, teamwork and collaboration, use of evidence-based practice, quality improvement skills, and the integrated use of informatics in the care provided for patients (Institute of Medicine, 2003). (2007). Skill mix type was measured with an item that inquired about the number of each nurse type providing direct care in respondent’s primary unit (Havaei et al., 2019). More than 85% of participants identified their patients as somewhat or very dependent. The study design was specifically chosen to address the limitations noted in previous studies by examining the effect of both MoNCD and skill mix on nurse outcomes; differentiating between the two most common MoNCDs (i.e., total patient care and team nursing); including an adequate sample size; and controlling for the effect of known predictors of nurse outcomes such as nurse characteristics, workload factors, and work environment factors. The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work is supported by BC Nurses’ Union and Collaborative Alliances of Nursing Outcome. Evidence-Based Nursing systematically searches a wide range of international healthcare journals applying strict criteria for the validity of research and relevance to best nursing practice. Mean job satisfaction scores were about 8 (SD = 2.1). Working to Full Scope: The Reorganization of Nursing Work in Two Canadian Community Hospitals, Hospital Demand for Licensed Practical Nurses. In 2009, graduate-level QSEN competencies that demonstrated enhanced leadership KSAs were developed, but through all this, practice was slow to embrace the QSEN competencies. Our collection of nursing journals is updated and reviewed by our physician readers every day to ensure they are still vital sources of the latest information for healthcare professionals and physicians alike. [Review], Psychosocial factors and prevalence of burnout syndrome among nursing workers in intensive care units, Quality of care, nurse staffing, and patient outcomes. The negative beta associated with staffing and resource adequacy suggests that one standard deviation increase in staffing and resource adequacy would result in a .40 standard deviation decrease in emotional exhaustion. We would like to show you a description here but the site won’t allow us. Nursing research deals with evidence supporting nursing practices. While mode of nursing care delivery refers to the independent or collaborative work of nurses to provide care to a group of patients, skill mix is defined as direct care nurse classifications. In healthy work environments, skill mix decisions are motivated by creating a match between patient needs and nursing competencies. As The Journal of Continuing Education in Nursing celebrates our next half-century of editorial excellence, we welcome manuscripts that describe the ways continuing education/professional development educators prepare nurses with competencies for ensuring quality and safety in nursing care and demonstrate the link to improved patient outcomes. The topic is intentionally broad and welcomes papers, which relate to a wide variety of issues including (but not limited to) intimate partner violence, gender based violence, sexual violence, elder abuse and workplace violence in the context of healthcare To our knowledge, this is the first study to examine the effect of both MoNC and skill mix on Canadian medical–surgical RN outcomes. Please check you selected the correct society from the list and entered the user name and password you use to log in to your society website. A cross-sectional survey study of 210 Spanish nurses found higher collegial support was associated with lower emotional exhaustion scores (Albar Marín & Garcia-Ramirez, 2005). The inclusion criteria for the current study included direct care RNs with a practicing status and working in medical or surgical specialties. Research, policy, and best practices must ensure that nurses with the right competencies adopt the most appropriate approach to care (MoNCD) to address patients’ needs. Reframing continuing education programs in the QSEN competencies supports the work of continuing education and professional development educators as they work to better highlight the critical impact of the nursing profession on quality care and patient outcomes. In particular, sufficient staffing and resources and opportunities for nurse participation in organizational affairs were found to be important to nurses. This work demonstrates the relationship among these three driving forces and how nursing education framed in quality and safety aligns with expectations for excellence in nursing practice. Registered nurses in a skill mix with licensed practical nurses reported lower emotional exhaustion when caring for more acute patients compared with those in a skill mix without licensed practical nurses. Nurse types included RNs (or registered psychiatric nurses), LPNs, and unlicensed personnel (e.g., care aides). In this study, the “nursing model of care delivery” component is operationalized as the MoNCD and skill mix. Additionally, framing educational offerings in the QSEN competencies allows all educators to promote the universal language of quality and safety. Manuscript content on this site is licensed under Creative Commons Licenses, Effect of Nursing Care Delivery Models on Registered Nurse Outcomes,,, Fernandez, Johnson, Tran, & Miranda, 2012, British Columbia Ministry of Health, 2014, Sundin, Bildt, Lisspers, Hochwalder, & Setterlind, 2006, Hessels, Flynn, Cimiotti, Cadmus, & Gershon, 2015, Woltman, Feldstain, MacKay, & Rocchi, 2012, Canadian Institute for Health Information, 2010,, APNA Position Statement: Staffing Inpatient Psychiatric Units. Two key components of models of nursing care delivery are mode of nursing care delivery (MoNCD) and skill mix (Huber, 2013). The larger study used a proportionate stratified sampling strategy based on health authorities and employment status. You can be signed in via any or all of the methods shown below at the same time. Editor's Note: This special guest editorial is presented as a beginning to a series in the Teaching Tips column that focuses on QSEN (Quality and Safety Education for Nurses). To increase response rate, several strategies were implemented in the larger study: advertisements through union media, e-mail reminders to nonrespondents, incentives, and hard copy send-outs to a random sample of nurses. A principal component analysis with varimax rotation among the study sample confirmed a unidimensional factor structure with factor loadings of .61 to .87 explaining 50% of the variance; Cronbach’s alpha was .64 which is an acceptable internal consistency for scales with few items (Paul, 2000). Over half of the sample were full time compared with 24% with part time and 20% with casual employment status. In sum, there were four key findings in this study: (a) Work environment factors were the strongest predictors of nurse outcomes, highlighting the need to attend to nurses’ working conditions; (b) a skill mix including LPNs was found to buffer against the negative effects of high workload on RN emotional exhaustion; (c) some BC medical–surgical LPNs provided total patient care to high acuity patients; and (d) there has been a slow transition from total patient care to team nursing in most medical–surgical settings.

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