Educational levels of hospital nurses and conflict resolution outcomes

Nursing Research

The objective of this research is to answer the question of whether educational levels of hospital nurses make a difference in conflict resolution and if this affects the quality of patient care and the resulting outcomes for patients.

The method employed in this research is of a qualitative nature and will be conducted through an extensive review of relevant literature in this area of study that is of a peer-reviewed and academic or professional nature.

The Board of Nursing in the state of Texas reports the passage of House Bill 456 which mandates that the Texas Board of Nursing "appoint a task force to review and make recommendations regarding provision of health maintenance tasks to persons with functional disabilities in independent living environments, including the analysis of: "...procedures for resolving disagreements between clients and registered nurses or home and community support service agencies about the appropriateness and safety of delegating or assigning tasks." (Texas Board of Nursing, nd) This work concerning the conflict resolution model is nursing relates that the practice of a professional nurse requires "substantial specialized judgment and skills, the proper performance of which is based on knowledge and application of the principles of biological, physical and social sciences as acquired in an approved school of nursing." (Texas Board of Nursing, nd) Education must necessarily include areas of 'personal competence' which is defined as "how we manage ourselves." This may fall within several specific self-management areas, which includes:

Self-awareness - Knowing one's internal states, preferences, resources, and intuitions;

Self-regulation - Managing one's internal states, impulses and resources;

Motivation - Emotional tendencies that guide or facilitate reaching goals; a passion to achieve for other than external rewards.

Social Competence - How we handle relationship

Empathy - Awareness of others' feelings, needs and concerns; and Social Skills - adeptness at inducing desirable responses in others. (Texas Board of Nursing, nd)

The work entitled: "What Factors Influence Job Satisfaction and Staff Morale in Nursing Homes?" published in the Home and Community Care Digest (2006) relates that nursing staff availability "is an increasingly important issue in the long-term care sector, and staffing issues such as morale and turnover are thought to have a direct bearing on the quality of the resident experience. This study examines the relationship between individual characteristics, work demands, work resources, and conflict resolution styles on the one hand, and nursing staff outcomes such as morale, burnout, and job satisfaction on the other. Morale and job satisfaction were found to depend more on variables that can be controlled by managers - such as shift scheduling and allocation, conflict resolution training, and ensuring adequate resources - than on individual characteristics that are beyond managers' control. The results indicate potential for improving the workplace experience of nursing home staff, and thus improving the human resources issues that confront the sector." (2006)

The work of Joanne Lavin (1990) reports a study conducted for the purpose of determining the relationship between assertiveness and self-esteem, conflict management style and other selected variables in female registered nurses. Lavin relates: "A review of the literature indicated that assertiveness is beneficial in the practice of professional nursing." (1990) This study reports the use of four instruments: (1) the Coopersmith Self-Esteem Inventory; (2) the Tennessee Self-Concept Scale; (3) the assertion inventory; and (4) the Thomas Kilmann Conflict Mode Instrument. These instruments were "...administered at one time to the participants...' which included ninety-eight participants with a response rate of 79% which yielded a sample of 77. Findings of the study state that "A significant negative relationship was found between assertiveness and an accommodating conflict resolution style." (Lavin, 1990)

The work of Oermann and Heinrich, an "Annual Review of Nursing Education 2003" relates that critical thinking skills are extremely necessary in the nursing profession as "A person who can think critically demonstrates a willingness to test opinions and consider all perspectives." (Oermann and Heinrich, 2003) Additionally stated is: "Critical thinking or 'thinking about thinking' is one mechanism" that can be used in nursing education to "effectively bridge the gap between the classroom and clinical experience." (Oermann and Heinrich, 2003) the work of Bandura (1997) is highlighted and stated is that Bandura 'defined perceived self-efficacy as 'beliefs in one capabilities to organize and execute the courses of action required to produce given attainments." (Oermann and Heinrich, 2003) Oermann and Heinrich state that the use of clinical scenarios may be effectively used in nursing education to promote self-efficacy and conflict resolution skills.

It is reported in the work entitled: "Nurse Staffing and Quality of Patient Care" that a study was conducted for the purposes of making an assessment of: "...how nurse to patient ratios and nurse work hours were associated with patient outcomes in acute care hospitals, factors that influence nurse staffing policies, and nurse staffing strategies that improved patient outcomes."

This study reports a method of review through observational studies being reviewed in which the relationship between nurse staffing and outcomes." (nd) a meta-analysis conducted tested the consistency of the association between the nurse staffing and patient outcomes, classes of patient and hospital characteristics were analyzed separately." (Ibid) the study results state that higher registered nurse staffing were associated with less hospital-related mortality, failure to rescue, cardiac arrest, hospital acquired pneumonia, and other adverse events. The effects of increased registered nurse staffing on patients safety was strong and consistent in intensive care units and in surgical patients. Greater registered nurse hours spent on direct patient care were associated with decreased risk of hospital-related death and shorter lengths of stay. Limited evidence suggests that the higher proportion of registered nurses with BSN degrees was associated with lower mortality and failure to rescue. More overtime hours were associated with an increase in hospital related mortality, nosocomial infections, shock, and bloodstream infections. No studies directly examined the factors that influence nurse-staffing policy. Few studies addressed the role of agency staff. No studies evaluated the role of internationally educated nurse staffing policies." (Ibid) This study stated conclusions that: Increased nursing staffing in hospitals was associated with lower hospital-related mortality, failure to rescue, and other patient outcomes, but the association is not necessarily causal. The effect size varied with the nurse staffing measure, the reduction in relative risk was greater and more consistent across the studies, corresponding to an increased registered nurse to patient ratio but not hours and skill mix. Estimates of the size of the nursing effect must be tempered by provider characteristics including hospital commitment to high quality care not considered in most of the studies. Greater nurse staffing was associated with better outcomes in intensive care units and in surgical patients." (Ibid)

The work of Hodge, et al. (2002) entitled: "Developing Indicators of Nursing Quality to Evaluate Nurse Staffing Ratios" states the fact that nursing "...is a critical factor in determining the quality of patient care in hospitals, and ultimately patient outcomes." (Hodge, et al., 2002) it is related that policy remedies are under consideration, which includes legislation that would require the "development of formulae to ensure safe patient care, requirements that licensed nurses provide at least 65% of direct care hours and the introduction by state mandatory minimum nurse to patient staffing ratios." The principal findings of this study relate: "In the course of its deliberations, the panelists focused on three key issues: definitions of indicators, sensitivity to changes in nursing ratios, and feasibility of data collection. Panelists felt that, definitions of indicators should be constructed using nationally recognized criteria, identifying outcomes in which nursing care plays a pivotal role and for which nurses have primary control is critically important and finally, recognizing that although time consuming and expensive, evaluating patient outcomes with clinical data from the medical record or other sources may provide the most accurate and valid information." (Hodge, et al., 2002) Conclusion of the study relate: "Based on this process, the following indicators were considered valid, feasible, and suitable for evaluating specific staffing ratios; risk adjusted mortality, length of stay in medical patients, failure to rescue, patient satisfaction, patient teaching, quality of care, and work-related injuries. Fourteen other indicators were rated highly on important dimensions and considered useful in the evaluation process. The results of this project demonstrate that this is a useful method for identifying indicators appropriate for use in outcomes research with a focus on structural predictors of quality in health care." (Hodge, et al., 2002)

It is reported that the Massachusetts General Hospital Patient Care Services' Professional Practice Model (PPM) is the guiding framework for Nursing practice and the practices of other health disciplines. This report state that relationship and collaboration between the nurse, patients, families and other providers, enhances problem-solving and promotes dialogue and reflection." (Massachusetts General Hospital Patient Care Services, 2002) it is related that each "individual plan of care is continuously revised to respond to the changing needs of the patient and families. Desired outcomes for patients are achieved in mutual partnership, with the nurse and patient leading to the implementation of a plan that best to each individual situation." (Massachusetts General Hospital Patient Care Services, 2002) Reported as methods used in professional development are those of: (1) Clinical narratives; (2) professional conferences; and (3) Formal education. Clinical narratives are used for the articulation and sharing of knowledge and experience which has been acquired over time and through experiential learning and is a way of enabling nurses to "tap into the thought processes and best practices of expert clinicians" through sharing of stories based on experience. Professional conferences involve the attending of conferences, which expose nurses to ideas that are new and best practices of other institutions than the one in which they work. Finally, formal education addressed "technical excellence and an over-arching understanding of the art and science of professional practice..." (Massachusetts General Hospital Patient Care Services, 2002) a very important aspect of the program is "collaborative decision-making" which involves: (1) Quality committees; (2) Ethics in Clinical Practice Committee; (3) Nursing Research Committees; (4) staff nurse advisory committees; and (5) professional development committees. Quality Committees. It is related that the 'Ethics in Clinical Practice Committee' has the responsibilities of: (1) Design and implement programs to support the education of all staff in the area of healthcare ethics; (2) Identify strategies to improve quality; (3) provide increased communication and awareness of systems-improvements; (4) provide an arena to evaluate and promote quality initiatives not specifically initiated by this committee; and (5) review findings and recommend departmental actions. (Massachusetts General Hospital Patient Care Services, 2002)

The work entitled: "Common Denominators in Shared Governance and Workplace Advocacy" published in the Online Journal of Issues in Nursing (2004) relates that the work of Porter-O'Grady (IOM, 2004) relates that "Principles embedded in conflict resolution (collaborative) strategies can enhance nursing empowerment, however, conflict resolution is an area in which nurses typically have limited skills. In the ideal world, health care organizations would embrace conflict resolution strategies as the standard way of doing business. In reality, nursing may have to take the lead by adopting the principles of conflict resolution." (Journal of Issues in Nursing, 2004) WPA groups are reported to responsible in the healthcare industry for the development and modification of the effective use of conflict resolution strategies. Specifically stated is that 'use of these strategies moves health care from a hierarchical model of communication or a model where conflict is resolved at the lowest level, the level at which conflict occurs. For nurses this is often at the bedside level. The effective use of conflict resolution reduces costs, provides more empowered and satisfied workers, and results in higher quality outcomes. This strategies can also reduce the use of costly litigation can serve nurses, other professionals, patients and the organization." (Journal of Issues in Nursing, 2004) This work states that it is essential for the organization to effectively utilize conflict resolution strategies as: "...nurses need to develop skills in conflict analysis, collaboration, and mediation." (Journal of Issues in Nursing, 2004) the use of outside coaching to assist the conflict resolution process is stated to be encouraged which involves calling a hotline or certified nurse ombudsman.

The work of Lassen, et al. (1997) entitled: "Nurse/Physician Collaborative Practice: Improving Health Care Quality While Decreasing Cost" published in the Journal of Nursing Economics relates a study using a collaborative approach that served to enhance "nurse-physician relationships, resulting in cost savings as well as diminished anxiety and confusion among the patients of neonates diagnosed with R/O sepsis." (Lassen et al., 1997) Additionally relate is the fact that medical journals have failed to focus only but very little attention to: "...possible benefits resulting from nurse/physician collaboration. One possible explanation is found in the historical nature of that relationship." (Lassen et al., 1997) Lassen et al. relates that collaboration may be defined as: "...a flexible process of ongoing interaction, assertiveness, and creativity between individuals from two or more disciplines which influences the direction of patient care." (1997) Required in this process is communication and "interdependent decision making regarding patient care." (Lassen et al., 2007) Outcomes measurements are stated to include: (1) patient mortality/morbidity rates; (2) hospital costs; and (3) hospital readmissions in the work of Baggs, et al. (1992), Knaus et al., (1986) and Mitchell et al. (1989) who reported "significant reductions in patient mortality and readmissions in adult ICU units with implementation of collaborative practice. (Lassen, et al., 1997; p.1)