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Nurses' perceptions of the impact of a renal nursing professional practice model on nursing outcomes, characteristics of practice environments and empowerment--Part I.



Abstract

A transformational nursing professional practice model (PPM) was developed and implemented in the London Health Sciences Centre's renal renal /re·nal/ (re´n'l) pertaining to the kidney.

re·nal
adj.
Of or in the region of the kidneys.


Renal
Relating to the kidney.
 program. The purpose of this study was to examine the impact of a renal nursing PPM on nurses' perceptions of empowerment em·pow·er  
tr.v. em·pow·ered, em·pow·er·ing, em·pow·ers
1. To invest with power, especially legal power or official authority. See Synonyms at authorize.

2.
, characteristics of practice environments, and nursing outcomes. Quantitative and qualitative methodologies were used in this study. This paper will focus primarily on the quantitative results. The qualitative results are presented in Part II (Harwood, Ridley ridley: see sea turtle. , Lawrence-Murphy, White, Laschinger, Bevan, & O'Brien, in press). A "then-and-now" design was used. There was a significant (p=.005) improvement post-PPM implementation in the nursing foundations for quality of care subscale of the Nursing Worklife Index-Practice Environment Scale (NWI-PES) and organizational relationships (p =.016) measured by the Conditions of Work Effectiveness II (CWEQ-II) Questionnaires. This study provides evidence for PPMs and primary nursing as effective frameworks to positively impact nursing and patient outcomes in a hemodialysis hemodialysis /he·mo·di·al·y·sis/ (-di-al´i-sis) removal of certain elements from the blood by virtue of the difference in rates of their diffusion through a semipermeable membrane while being circulated outside the body; the process  unit.

Key words: professional practice models, empowerment, magnet hospital magnet hospital Hospital care A hospital that features flat organization structure, unit-based decision making, investment in education; MH nurses have less burnout, Pts have better care, ↓ time in hospital and in ICU  traits

Introduction

Nursing professional practice models (PPMs) are care delivery systems based on the assumption that professional nurses should participate in governing gov·ern  
v. gov·erned, gov·ern·ing, gov·erns

v.tr.
1. To make and administer the public policy and affairs of; exercise sovereign authority in.

2.
 their practice environments (Hannah & Shamian, 1992). Practice environments impact nurses' job satisfaction and quality of care. Nursing practice models may be bureaucratic bu·reau·crat  
n.
1. An official of a bureaucracy.

2. An official who is rigidly devoted to the details of administrative procedure.



bu
 or professional. Bureaucratic models of care delivery are hierarchical A structure made up of different levels like a company organization chart. The higher levels have control or precedence over the lower levels. Hierarchical structures are a one-to-many relationship; each item having one or more items below it.  and task-oriented in nature. Professional models, however, take into account the complex and unpredictable aspects of providing patient care (Lake, 2002). PPMs also promote environments that enhance nurses' autonomy and empowerment (Upenieks, 2000).

Nephrology nephrology

Branch of medicine dealing with kidney function and diseases. An understanding of kidney physiology is important not only in treating kidney disease but in knowing the effect of drugs, diet, and hypertension on kidney disease, and vice versa.
, like other areas of health care, is confronting a nursing shortage. This problem is compounded by the rapidly changing technological environment in which nephrology nurses practise prac·tise  
v. & n. Chiefly British
Variant of practice.



practis·er n.
. Dialysis dialysis (dīăl`ĭsĭs), in chemistry, transfer of solute (dissolved solids) across a semipermeable membrane. Strictly speaking, dialysis refers only to the transfer of the solute; transfer of the solvent is called osmosis.  machines offer diagnostic tools (i.e. blood volume monitoring) and programmable treatments. The role of the professional nephrology nurse and the value of her/his knowledge, skill, and judgment in providing care must be clearly articulated ar·tic·u·la·ted
adj.
Characterized by or having articulations; jointed.
. Otherwise, the nurses are at risk of being replaced by non-regulated care providers. Nephrology PPMs help define and articulate articulate /ar·tic·u·late/ (ahr-tik´u-lat)
1. to pronounce clearly and distinctly.

2. to make speech sounds by manipulation of the vocal organs.

3. to express in coherent verbal form.

4.
 the role of the nurse and promote quality nursing care amidst a·midst  
prep.
Variant of amid.



[Middle English amiddes : amidde; see amid + -es, adverbial suffix; see -s3.]
 changing technology and severe financial constraints CONSTRAINTS - A language for solving constraints using value inference.

["CONSTRAINTS: A Language for Expressing Almost-Hierarchical Descriptions", G.J. Sussman et al, Artif Intell 14(1):1-39 (Aug 1980)].
.

The London Health Sciences Centre The London Health Sciences Centre is a major teaching hospital in London, Ontario, Canada.

It operates three hospital facilities:
  • University Hospital,
  • Victoria Hospital, and
  • South Street Hospital.
 Renal Nursing PPM (see Figure One) took approximately two years to develop and was implemented in 1999. Articles on model development (Lawrence-Murphy, Harwood, Reynolds, Ridley, Ryan, Workentin, & Malek, 2000) and implementation challenges (Harwood, Lawrence-Murphy, Ridley, Malek, Boyle, & White, 2000) have been published. The model has been presented at national and international nursing conferences. This is the only renal nursing PPM published to date.

The model incorporated Benner's (1984) Domains of Nursing Practice. The model consists of four components: professional practice, characteristics of professional nursing practice, model of care delivery (process component), and outcomes (refer to Figure One).

An initial evaluative survey was conducted among the nursing staff and multi-disciplinary team members approximately six months post-implementation. However, a formal evaluation of the model had not been done. The model was embraced to varying degrees among the Health Science Centre's three in-centre dialysis sites. A renewed effort to review and promote model implementation has occurred over the past two years. As significant resources, both human and fiscal, were invested in the PPM, there was a need to evaluate the efficacy of the model using research-based methodology. Evaluating the impact of PPMs on professional practice is a challenging task. Outcomes to be measured must be clearly articulated and theoretically supported (Hoffart & Woods, 1996).

Theoretical framework

Kanter's (1997) theory of empowerment provides the framework for the study. According to according to
prep.
1. As stated or indicated by; on the authority of: according to historians.

2. In keeping with: according to instructions.

3.
 Kanter, employee work behaviours and attitudes are shaped in response to characteristics of the work environment. An empowering work environment is one in which employees have access to support, information, resources and opportunities, both for increasing knowledge and skill, and the potential for advancement within the organization. Without access, employees perceive themselves as powerless and, as such, become rigid and rules-minded, are less committed to the organization, and have less job satisfaction (Kanter, 1977). The study of Kanter's theory and the application and relevance to nursing has been demonstrated over the past decade (Laschinger, Finegan, Shamian, & Wilk, 2001; Wilson & Laschinger, 1994).

[FIGURE 1 OMITTED]

Review of the literature

Empowering work environments result in increased job satisfaction and perceived higher quality of care (Laschinger & Havens, 1997; Laschinger, Finegan, Shamian, & Casier, 2000; Laschinger, Finegan, Shamian, & Wilk, 2001). Aiken, Smith, and Lake (1994) also found that nursing autonomy, control over practice, and relationships with physicians impacted mortality rates.

The nursing shortage of the 1980s led to research examining characteristics of hospitals that successfully attracted and retained nurses. These institutions were designated "magnet hospitals" (Scott, Sochalski, & Aiken, 1999). Numerous researchers have studied nursing practice environments in both magnet and non-magnet institutions. Traits common in magnet hospitals include: autonomy, responsibility, control over the environment, and positive collaborative physician-nurse relationships (Aiken & Patrician patrician (pətrĭsh`ən), member of the privileged class of ancient Rome. Two distinct classes appear to have come into being at the beginning of the republic. Only the patricians held public office, whether civil or religious. , 2000; Lake, 2002; Laschinger, Shamian, & Thomson, 2001; Scott, Sochalski, & Aiken, 1999). Laschinger, Shamian, and Thomson (2001) found that environmental characteristics have an impact on nurses' job satisfaction and perceptions of the care provided. They further noted that work environments that allowed nurses to exercise their judgment and make decisions promoted organizational trust. This trust increased nurses' confidence in their abilities. Organizational trust and leadership are important factors as leadership behaviours have an impact on nurses' perceptions of workplace empowerment (Laschinger, Wong, McMahon, & Kaufmann, 1999).

Characteristics associated with magnet hospitals are similar to those affiliated with PPMs. Hoffart and Woods (1996) examined elements of nursing professional practice models. They identified key elements as being: autonomy, accountability, professional relationships, communication, a comprehensive care delivery system, shared governance Governance makes decisions that define expectations, grant power, or verify performance. It consists either of a separate process or of a specific part of management or leadership processes. Sometimes people set up a government to administer these processes and systems. , and compensations and rewards both tangible and intangible. Professional practice models have been found to enhance autonomy, job satisfaction, accountability and power (Upenieks, 2000). Autonomy and mastery are associated with power (Kanter, 1977). Empowerment is linked with nurses' perceptions of control over their practice environments and autonomy (Laschinger, Almost, & Tuer-Hodes, 2003; Wilson & Laschinger, 1994).

It has been proposed that PPMs may be a vehicle to nurses' perceived autonomy and control (Laschinger, Shamian, & Thomson, 2001). The importance of a work environment that promotes nursing autonomy and professional practice was summarized by Upenieks (2000). She noted that such an environment "enables professional nurses to use their knowledge and to do for patients what they know should be done ..." (p. 565).

There is a paucity pau·ci·ty  
n.
1. Smallness of number; fewness.

2. Scarcity; dearth: a paucity of natural resources.
 of research specific to professional practice in nephrology nursing. To date, our model is the only published renal nursing PPM. There is only one published study on staff nurses' perceptions of the work environment in hemodialysis units (Thomas-Hawkins, Currier, Denno, & Wick, 2003). In this descriptive study the Nursing Worklife Index was used to survey the opinions of 1,000 American Nephrology Nurses' Association (ANNA) members employed in freestanding free·stand·ing  
adj.
Standing or operating independently of anything else: a freestanding bell tower; a freestanding maternity clinic.
 hemodialysis units in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area.  (U.S.). The researchers found that while inter- and intra-disciplinary relationships were viewed positively, there were problems in the area of organizational support. Shared governance was not a reality for many of the nurses and only half of the participants felt they had control over their practice. There was a perceived lack of administrative recognition for their work and inattention in·at·ten·tion  
n.
Lack of attention, notice, or regard.

Noun 1. inattention - lack of attention
basic cognitive process - cognitive processes involved in obtaining and storing knowledge
 toward their professional development.

These studies provide evidence that the nursing work environment can have an impact on professional practice. Factors that promote a positive nursing environment are similar to those germane to nursing PPMs. It is on this premise that our renal nursing PPM was evaluated.

Purpose of the study

The purpose of this study was to examine the impact of the PPM on nurses' perceptions of workplace empowerment, professional practice characteristics in the nephrology nurses' work environment and nursing outcomes.

Methodology

The study setting was the renal program of a university-based teaching hospital. The participants were nurses who had been employed in the renal program prior to model implementation. There was no personal identifying information on the questionnaires. The questionnaires were kept in a locked, secure location during the duration of the study and will be destroyed upon publication of the paper. Only grouped data were reported.

Approval for this study was obtained from the local research ethics Research ethics involves the application of fundamental ethical principles to a variety of topics involving scientific research. These include the design and implementation of research involving human participants (human experimentation); animal experimentation; various aspects of  board.

Design and sample

A pre- and post-design was not possible. A "then-and-now" design was used to capture the impact of the PPM. This involved asking the participants to rate the questionnaire items twice: as they remembered the work environment prior to model implementation and subsequent to model implementation. This type of design has been used in the social sciences (Robinson & Doueck, 1994, pp. 225-226). Quantitative and qualitative research Qualitative research

Traditional analysis of firm-specific prospects for future earnings. It may be based on data collected by the analysts, there is no formal quantitative framework used to generate projections.
 methods were employed in the study.

A convenience sample was employed. Eighty-one surveys were distributed to nurses among the three sites who had been employed in the renal program prior to model implementation. Sample demographics The attributes of people in a particular geographic area. Used for marketing purposes, population, ethnic origins, religion, spoken language, income and age range are examples of demographic data.  are presented in Table One. The sample was largely female (90.3%) with an estimated mean age of 47.2 years. The mean years employed as a nurse was 24.3 with a mean of 15.8 years employed in nephrology nursing. Approximately 29% of the participants were baccalaureate-prepared and 67.8% were diploma-prepared. Three per cent had obtained their post-RN degrees. Approximately seven per cent of the participants had obtained certification in nephrology nursing.

In addition to the quantitative tools, qualitative research methodology was used to enhance the completeness of the data. Ten nurses were randomly chosen to participate in a 30- to 45-minute interview. The interviews were conducted by a graduate nursing student who had no affiliation with the renal program prior to the study. This was done to respect the nurses' anonymity and encourage them to comment openly and honestly. The interviews were semi-structured, audiotaped, and transcribed verbatim ver·ba·tim  
adj.
Using exactly the same words; corresponding word for word: a verbatim report of the conversation.

adv.
.

Instruments

Two tools were used to obtain the quantitative data. Demographic data were also collected.

The NWI-PES (Lake, 2002) was administered to measure autonomy, control over the practice environment, and MD-RN relationships. Reliability indices for this instrument are high with Cronbach's Alpha Cronbach's (alpha) has an important use as a measure of the reliability of a psychometric instrument. It was first named as alpha by Cronbach (1951), as he had intended to continue with further instruments.  scores ranging from .71 to .84 (Lake, 2002). The NWI-PES measures organizational characteristics that are present in magnet hospitals and captures attributes that characterize professional nursing practice environments. The 31-item tool comprises five subscales of organizational factors including: participation in policy development, nurse foundations for quality care, nurse manager ability, leadership and support for nurses, staffing and resource adequacy, and collegial col·le·gi·al  
adj.
1.
a. Characterized by or having power and authority vested equally among colleagues: "He . . .
 nurse-physician relations (Lake, 2002).

The instrument employs a four-point Likert-type scale ranging from strongly agree (1) to strongly disagree (4) of items present in nurses' current job (with the PPM) and present in the job prior to PPM implementation. For this study, some of the language and questions were changed to reflect the hemodialysis environment. Questions were also asked regarding the relationship between the RNs and the Nurse Practitioner/Clinical Nurse Specialists (NP/CNSs) and job satisfaction.

This instrument has been used with American nurses working in freestanding hemodialysis units (Thomas-Hawkins, Currier, Denno, & Wick, 2003). This tool has been shown to be valid in differentiating nurses who worked within a professional practice environment from those who did not.

The Conditions of Work Effectiveness Questionnaire-II (CWEQ-II) (Laschinger, Finegan, Shamian, & Wilk, 2001) was used to measure staff nurses' perceptions of empowerment. Based on Kanter's (1977) theory, this instrument consists of six subscales: opportunity, information, support, resources, formal power, and informal power. The instrument contains 12 questions. Reliability and validity have been documented with the CWEQ-II (Laschinger, Finegan, Shamian, & Wilk, 2001).

Data analysis

Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS A statistical package from SPSS, Inc., Chicago (www.spss.com) that runs on PCs, most mainframes and minis and is used extensively in marketing research. It provides over 50 statistical processes, including regression analysis, correlation and analysis of variance. ) program. Descriptive and inferential statistics inferential statistics

see inferential statistics.
 were used to analyze remaining data. Paired t-tests were used to examine the then-and-now relationships.

The qualitative data were analyzed an·a·lyze  
tr.v. an·a·lyzed, an·a·lyz·ing, an·a·lyz·es
1. To examine methodically by separating into parts and studying their interrelations.

2. Chemistry To make a chemical analysis of.

3.
 using content analysis to identify common themes. A qualitative data analysis computer program was used to assist with management of the data. As noted, the qualitative data are presented in Part II.

Results

The survey response rate was 38%.

Changes in study variables: Then/now

Scores for the NWI-PES were reverse-coded so that high scores reflected a positive response to each item. Although nurses reported increases in four of the five NWI-PES subscales when comparing pre-PPM implementation to post-PPM implementation, only one was significant. They felt there was a greater emphasis on nursing foundations for quality of care as a result of model implementation (p=.005). Items in this subscale include such things as care being based on a nursing (as opposed to medical) model, a preceptorship program for newly hired nurses, working with clinically competent nurses, and patient assignments that foster continuity of care. Mean scores for the NWI-PES subscales are presented in Table Two. The top-ranking NWI-PES items are listed in Table Three.

Empowerment subscale scores were similar pre-and post-implementation with the exception of informal power, which was significantly increased. The means and standard deviations for empowerment are outlined in Table Four. There was only one statistically significant change (p=.016) in the then-and-now scores on the CWEQ-II. This was in the area of organizational relationships. This refers to formal power: how well people work together and consult one another.

Correlations between empowerment and professional practice characteristics

Nurses' perceptions of empowerment and the professional practice characteristics post-PPM implementation were analyzed to determine the relationship between these two variables (refer to Table Five). Overall, empowerment was strongly and significantly related to overall professional practice characteristics (r=.63; p=.001). Overall empowerment was significantly related to all professional practice subscales (r=.41 to .663). Total professional practice characteristics were significantly related to access to opportunity, information, support, and formal and informal power (r= .43 to .60; p< .05) as well as to global empowerment (r=.69; p=.0001).

Discussion

The nephrology practice environment

The core of the PPM is the relationship between the patient/family and the nurse. The significant improvement in the foundations of quality care subscale is reflective Refers to light hitting an opaque surface such as a printed page or mirror and bouncing back. See reflective media and reflective LCD.  of this. The significant improvement in organizational relationships subscale indicates that the PPM environment promoted the nurses' empowerment.

No statistically significant differences were noted in the "then" and "now" scores pertaining per·tain  
intr.v. per·tained, per·tain·ing, per·tains
1. To have reference; relate: evidence that pertains to the accident.

2.
 to control over the practice environment. However, it was apparent in the interviews that the nurses felt their voices were now being heard:

I think that as the nurses are given more opportunities to be heard ... they are more empowered.

Items associated with autonomy did not differ significantly "then" and "now". These items included: staff nurses providing leadership, freedom to make patient care and work decisions, support for new and innovative patient care, and nursing controlling its own practice. The nurses interviewed indicated that the PPM promotes autonomy and encourages nurses to take more initiative.

... I have certainly seen nurses ... taking hold of a situation ...

Collaborative nurse-MD and nurse-NP/CNS relationships were highly rated (refer to Table Six). The NP/CNS role does not appear to dilute di·lute
v.
To reduce a solution or mixture in concentration, quality, strength, or purity, as by adding water.

adj.
Thinned or weakened by diluting.
 the nurse-MD relationship--an important factor in empowering environments. It is noteworthy that 77% of the nurses agreed that there was an NP/CNS to provide patient care consultation in the "then" phase. This increased to 97% agreement in the "now" phase (refer to Table Seven). This is of interest as the NP/CNSs' roles and responsibilities did not change with PPM implementation. It is possible that, with the additional responsibility and accountability associated with primary care nursing, the nurses more actively sought out the NP/CNSs for consultation on their primary patients.

Item scores associated with patient care and perceptions of quality of care did not change significantly. Qualitatively, some changes were noted. The nurses interviewed described a sense of ownership. They perceived themselves as being the person who could enact changes and optimize optimize - optimisation  their patients' health.

Low scores were noted in the areas of career laddering and shared governance. The model does not contain career laddering. Shared governance is indirectly implied in the model, but no explicit changes or structures were implemented in these areas.

Comparison with U.S. data

As noted, there has been only one published study examining nurses' perceptions of the hemodialysis work environment (Thomas-Hawkins et al., 2003). The average mean NWI-PES subscore scales pre- and post-PPM implementation in this study are consistent with the mean subscale scores reported by Thomas-Hawkins et al. (2003). The nurse manager ability, leadership and support and nurse-MD relationship subscales scored lower in our study. The other three subscales scored higher. The sample size in the U.S. study was much larger (n=383) and included nurses working in freestanding units across the United States as compared to our sample working in three in-centre units.

A comparison of the U.S. results to this study's is presented in Table Seven. The data are presented as percentage agreement with NWI-PES items. In terms of participation in dialysis provider affairs, the Canadian Canadian (kənā`dēən), river, 906 mi (1,458 km) long, rising in NE New Mexico. and flowing E across N Texas and central Oklahoma into the Arkansas River in E Oklahoma.  nurses indicated that they had more opportunity to serve on committees (90% "then" and "now") and were more involved in the dialysis unit's internal governance both "then" (60%) and "now" (70%) than their U.S. counterparts (34%).

There were a number of similarities between the Canadian and U.S. nurses regarding foundations for quality of care. Both sets of nurses felt that high standards of care were expected by administration and that they were working with clinically competent nurses. The Canadian nurses felt that their care was based more on a nursing than a medical model to a greater extent than did the U.S. nurses ("then" 79%, "now" 86%, U.S. 61%). They also reported greater access to active professional development programs than the U.S. nurses ("then" and "now" 61%, U.S. 40%).

In terms of staffing and resource adequacy, less than 47% of both sets of nurses felt they had enough staff to get the work done. The Canadian nurses, however, felt that there were adequate support services support services Psychology Non-health care-related ancillary services–eg, transportation, financial aid, support groups, homemaker services, respite services, and other services  allowing them to spend time with their patients. Agreement with this item increased from 70% to 81% with PPM implementation. The U.S. nurses' score was 40%.

Collegial nurse-MD relations were rated highly by both sets of nurses. Despite (74% "then" and 84% "now") agreement with this statement, the Canadian nurses did not agree that there was much teamwork (product, software, tool) Teamwork - A SASD tool from Sterling Software, formerly CADRE Technologies, which supports the Shlaer/Mellor Object-Oriented method and the Yourdon-DeMarco, Hatley-Pirbhai, Constantine and Buhr notations.  between nurses and physicians. These apparently contradictory findings could be associated with the NP/CNS role. The NP/CNS is often an intermediary Intermediary

See: Financial intermediary


intermediary

See financial intermediary.
. Perhaps the nurses feel that the physicians interact more with the NP/CNSs than themselves. This score increased somewhat between the "then" and "now" periods (48% to 56%). Only 26% of the U.S. nurses worked with an NP/CNS who provided patient care consultation. The Canadian score increased from 77% to 97% with the implementation of the PPM.

A number of other practice environment items were also compared. Both sets of nurses strongly agreed that they had good relationships with other professional services (job) professional services - A department of a supplier providing consultancy and programming manpower for the supplier's products.  (> 93% agreement) and that they worked with experienced nurses who knew their facilities (83% to 100% agreement).

The U.S. nurses (66%) felt they had more freedom to make important patient care and work decisions than the Canadians (56% "then" and 59% "now"). The Canadian nurses also reported feeling less supported in pursuing specialty certification and degrees than their American counterparts.

Neither group of nurses felt that their contribution to patient care was publicly acknowledged. The Canadian score increased slightly from 47% "then" to 50% "now", while only 36% of our U.S. counterparts agreed with this item.

In summary

Research has demonstrated that the professional practice environment has a positive impact on nurses' autonomy, power, and job satisfaction, as well as the perceived calibre calibre

see caliber.
 of care they provide. While not all of this study's results are statistically significant, they indicate that the renal nursing PPM promotes a positive and empowering environment for hemodialysis nurses.

Implications for nursing practice and research

The study results are of importance to our renal leadership team. Nurses are vital members of the health care team. Their perceptions of the dialysis environment have an impact on their image as team members and the care they provide. Their input is critical when evaluating the renal program and planning future goals and directions. This is an important area of study given the upcoming nursing shortage and the need to generate strategies for recruitment and retention of dialysis nurses. This study focused on one regional program. It would be important to conduct a provincial or national study with a much larger sample size. Research specific to nephrology nurses' practice environments is very limited. More research in this area is critical as strategies to ameliorate a·mel·io·rate  
tr. & intr.v. a·me·lio·rat·ed, a·me·lio·rat·ing, a·me·lio·rates
To make or become better; improve. See Synonyms at improve.



[Alteration of meliorate.
 the nursing shortage and provide adequate patient care should be based on evidence.

Limitations

Several factors limit the generalizability of the study findings. These include: the use of a convenience sampling technique in a single nephrology program, the relatively small sample size, and the lack of a control group.

Conclusions

The results of this study provide initial evidence of the value of PPMs. The data provide encouragement that the PPM is fostering an environment to promote quality nursing practice. It has also allowed us to identify areas that must be improved upon if we are to promote an environment conducive con·du·cive  
adj.
Tending to cause or bring about; contributive: working conditions not conducive to productivity. See Synonyms at favorable.
 to professional practice and enhance the quality of care provided.

Acknowledgement

This study was funded by the London Health Sciences Centre Baxter Research Awards. The authors wish to extend their thanks to Paul Heidenheim for his assistance with data analysis and Joanne Clark for her assistance with the manuscript manuscript, a handwritten work as distinguished from printing. The oldest manuscripts, those found in Egyptian tombs, were written on papyrus; the earliest dates from c.3500 B.C. .

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Depletion of a tax shelter's benefits. In the context of mortgage backed securities it refers to the percentage of the pool that has prepaid their mortgage.
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By Lori Harwood, RN, MSc, CNeph(C), NP/CNS, Jane Ridley, RN, MScN, CNeph(C), NP/CNS, Julie Ann ANN, Scotch law. Half a year's stipend over and above what is owing for the incumbency due to a minister's relict, or child, or next of kin, after his decease. Wishaw. Also, an abbreviation of annus, year; also of annates. In the old law French writers, ann or rather an, signifies a year.  Lawrence-Murphy, RN(EC), MScN, CNeph(C), NP/CNS, Heather K. Spence-Laschinger, RN, PhD, Sharon White, RN, MBA, Joy Bevan, RN, BScN, and Karen O'Brien, RN, MScN, CNeph(C)

Lori Harwood, RN, MSc, CNeph(C), is NP/CNS, Adam Linton Hemodialysis Unit, Victoria Hospital, London Health Sciences Centre, London, Ontario.

Jane Ridley, RN, MScN, CNeph(C), is NP/CNS, University Hospital, Hemodialysis Unit, London Health Sciences Centre, London, Ontario.

Julie Ann Lawrence-Murphy, RN(EC), MScN, CNeph(C), is NP/CNS, University Hospital, Hemodialysis Unit, London Health Sciences Centre, London, Ontario.

Heather K. Spence-Laschinger, RN, PhD, is Professor and Associate Director, Nursing Research, University of Western Ontario Western is one of Canada's leading universities, ranked #1 in the Globe and Mail University Report Card 2005 for overall quality of education.[2] It ranked #3 among medical-doctoral level universities according to Maclean's Magazine 2005 University Rankings. , School of Nursing, Faculty of Health Sciences, London, Ontario.

Sharon White, RN, MBA, is Program Director, Renal Care Program, London Health Sciences Centre, London, Ontario.

Joy Bevan, RN, BScN, is Manager, Renal Care Program, London Health Sciences Centre, London, Ontario.

Karen O'Brien, RN, MScN, CNeph(C), is Professor, Fanshawe College The London campus was founded in 1962 as the Ontario Vocational Centre (OVC). In 1967 it became Fanshawe College, one of a province-wide system of colleges of applied arts and technology, also referred to as community colleges. Area campuses were subsequently established in Woodstock, St. , London, Ontario.

Address correspondence to Jane Ridley at: Jane.Ridley@lhsc.on.ca

Submitted for publication: July 28, 2006.

Accepted for publication in revised form: November 20, 2006.
Table One. Demographics

                                    PPM (Then & Now) (n = 31)

Gender (%)
Female                              90.3
Male                                 3.2
N/A                                  6.5

Age (yrs)
Mean                                47.2
Range                               25 to 58

Years Employed as an RN
Mean                                24.3
Range                                3 to 37

Years Worked in Nephrology
Mean                                15.8
Range                                2 to 33

Education (%)
Diploma                             67.8
Baccalaureate                       29
N/A                                  3.2

CNeph(C) (%)
Yes                                  7
No                                  90
N/A                                  3

Plan to Leave Job in Next Year (%)
Yes                                  9.7
No                                  83.8
N/A                                  6.5

Table Two. Mean scores for NWI--PES subscales

                           Mean Score    Thomas-Hawkins
Subscale                   Then   Now    et al., 2003

Nurse participation in     2.19   2.25   2.25
dialysis provider affairs
Nursing foundations        2.77*  2.93*  2.73
for quality of care
Nurse manager ability,     2.31   2.26   2.62
leadership and support
Staffing and               2.6    2.63   2.28
resource adequacy
Nurse-MD (collegial)       2.61   2.68   2.90
relationship

*(p = < 0.005)

Table Three (a). NWI-PES mean scores (top ten)--PPM then

Item                                        Score  Rank

Regular, permanently assigned staff
nurses never have to float to another unit  3.69   1
Working with experienced nurses
who know the hospital                       3.37   2
Working with nurses who
are clinically competent                    3.23   3
Staff nurses can serve on hospital
and nursing committees                      3.23   3
NP/CNSs and nurses have
good working relationships                  3.23   3
A preceptor program for newly hired RNs     3.20   4
Opportunity to work on a
highly specialized unit                     3.17   5
NP/CNSs who provide
patient care consultation                   3.16   6
Good relationships with
other departments                           3.13   7
Collaboration between
nurses and NP/CNSs                          3.13   7

Table Three (b). NWI-PES mean scores (top ten)--PPM now

Item                                        Score  Rank

Regular, permanently assigned staff
nurses never have to float to another unit  3.83   1
NP/CNSs who provide
patient care consultation                   3.61   2
NP/CNSs and nurses have
good working relationships                  3.48   3
Staff nurses can serve on hospital
and nursing committees                      3.35   4
Collaboration between nurses
and NP/CNSs                                 3.35   4
A preceptor program for newly hired RNs     3.33   5
Standardized policies, procedures
and ways of doing things                    3.27   6
Working with experienced nurses
who know the hospital                       3.26   7
Working with nurses who
are clinically competent                    3.23   8
Opportunity to work on
a highly specialized unit                   3.23   8
A lot of teamwork between
NP/CNSs and nurses                          3.23   8

Table Four. Means and standard deviation for empowerment

                                          Laschinger,     Laschinger,
                                          Finegan,        Almost
                    PPM                   Shamian & Wilk  & Tuer-Hodes
                    Then       Now        (2001) (n=263)  (2003) (n=263)
                    Mean  SD   Mean  SD   Mean  SD        Mean  SD

CWEQII Opportunity  3.55  .86  3.5   .85  3.78   .79      3.83  .71
Information         2.38  .78  2.52  .78  2.7    .88      2.72  .75
Support             2.51  .95  2.64  .97  2.62   .84      2.79  .82
Resources           3.07  .53  2.98  .67  2.81   .78      3.0   .69
Job Activities      2.37  .86  2.30  .81  2.43   .85      2.57  .76
Organizational      2.96  .72  3.22  .77  3.38   .76      3.47  .73
  Relationships
Global Empowerment  2.98  .86  2.81  .86  2.83  1.01      3.09  .9

Table Five. Relationships between NWI-PES and CWEQII subscales (PPM now)

                Nurse                              Nurse
                Participation     Nurse            Manager Ability,
                in Dialysis       Foundations for  Leadership and
CWEQII          Provider Affairs  Quality Care     Support for Nurses

Opportunity     .382*             .371*            .333
Information     .535*             .513*            .420*
Support         .526*             .473*            .656 (^)
Resources       .117              .013             .114
Job Activities  .494*             .434*            .489*
Organizational  .199              .245             .166
Relationships
Global          .661 (^)          .550*            .582*
Empowerment
Total           .576*             .526*            .564 (^)
Empowerment

                Staffing and  Collegial      Total
                Resource      Relationships  NWI-PES
CWEQII          Adequacy      RN-MD          Score

Opportunity     .003          .599 (^)       .427*
Information     .321          .403*          .545*
Support         .106          .370*          .556 (^)
Resources       .652 (^)      .044           .188
Job Activities  .457*         .526*          .596 (^)
Organizational  .200          .551*          .301
Relationships
Global          .406*         .514*          .694 (^)
Empowerment
Total           .406*         .630 (^)       .663 (^)
Empowerment

2 tailed t-test: *p=<.05
(^) p=<.001

Table Six. RN collegial relationships--mean scores RN-MD, RN-NP/CNS

                            Mean Scores
Items                       Then  Now

NP/CNS and nurses have      3.23  3.48
good working relationships
Physicians and nurses have  2.90  2.97
good working relationships
Collaboration between       3.13  3.35
nurses and NP/CNSs
Collaboration between       2.50  2.57
nurses and physicians
A lot of teamwork between   3.03  3.23
nurses and NP/CNSs
A lot of teamwork between   2.41  2.50
nurses and physicians

Table Seven--Selected NWI-PES items percentage agreeing that item is
present in work environment

                                           % Agreeing
                                                      Thomas-Hawkins,
                                                      Denno, Currier
Items                                      Then  Now  & Wick (2003)

Opportunity to serve on committees.         90   90   50
Involved in internal governance of the      60   70   34
   dialysis unit.
High standards of nursing care expected     80   83   87
  by administrators.
Nursing care is based on a nursing rather   79   86   61
  than a medical model.
Active professional development programs    61   61   40
  for nurses.
Enough staff to get the work done.          47   47   45
Adequate support services allow me to       70   81   40
  spend time with my patients.
MD and nurses have good working             74   86   86
  relationships.
Much teamwork between nurses and MD.        48   56   68
Advanced practice nurses who provide        77   97   26
  patient care consultation.
Good relationships with other               93   97   95
   professional services.
Working with experienced nurses who know   100   96   83
  the facility.
Freedom to make important patient care      56   59   66
  and work decisions.
Nursing staff is supported in pursuing      27   27   57
  specialty certification.
The contribution that nurses make to        47   50   36
  patient care is publicly acknowledged.
COPYRIGHT 2007 Canadian Association of Nephrology Nurses & Technologists
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2007 Gale, Cengage Learning. All rights reserved.

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Author:Harwood, Lori; Ridley, Jane; Lawrence-Murphy, Julie Ann; Spence-Laschinger, Heather K.; White, Sharo
Publication:CANNT Journal
Article Type:Report
Geographic Code:4EUUK
Date:Jan 1, 2007
Words:5235
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