Academic journal article Research and Theory for Nursing Practice

Nurse Dose: Validation and Refinement of a Concept

Academic journal article Research and Theory for Nursing Practice

Nurse Dose: Validation and Refinement of a Concept

Article excerpt

In this article, we report the results of two studies aimed at validating the concept of nurse dose. The first study examined the relevance of the critical attributes and empirical indicators in accurately reflecting the concept of nurse dose. Ten experts in staffing research rated the relevance of the attributes and indicators. The second study explored the factorial structure of the nurse dose concept. Data on the nurse dose indicators were obtained from 26 inpatient units. The operationalization of nurse dose was refined based on the two studies' results. Nurse dose is posited as a structural variable capturing nurses' capacity to deliver high quality care in acute care hospitals. It is defined as the level (i.e., number and type) of nursing staff required to provide care that produces intended patient outcomes. Nurse dose is reflected in two attributes: (1) active ingredients representing the essential elements that distinguish nurses from other health care professionals and operationalized in nurses' theoretical and practical knowledge, and skill mix; and (2) intensity representing the potential for nurse-patient interactions and operationalized in terms of amount (indicated by full-time equivalent) and frequency (indicated by nurse-patient ratio and hours per patient day). The concept of nurse dose has the potential for guiding future staffing research.

Keywords: concept validation; factorial structure; nurse dose; nurse staffing; theory building

Considerable research has been generated to understand how nurses and nursing care contribute to patient outcomes within the acute care context. The focus of most studies has been on linking nurse staffing variables such as skill mix and hours per patient day (HPPD) to patient outcomes, where staffing variables were considered proxies for actual nursing care ( Burnes Bolton, Donaldson, Rutledge, Bennett, & Brown, 2007 ). The atheoretical nature of most staffing research ( Mark, Hughes, & Jones, 2004 ) makes it difficult to find consistent results across studies ( Jiang, Stocks, & Wong, 2006 ) and develop knowledge to inform staffing-related decisions. Empirical evidence, which consistently links nurse staffing to patient outcomes, is critical because the wrong number and/or type of nurses assigned to a unit may jeopardize the quality of nursing care and contribute to harmful consequences for patients ( Aiken, Clarke, Sloane, Sochalski, & Silber, 2002 ; Mark & Harless, 2007 ) as well as higher health care costs ( Cho, Ketefian, Barkauskas, & Smith, 2003 ).

Manojlovich and Sidani (2008) began to fill this theoretical void by building on a concept initially identified by Brooten and colleagues as "nurse dose" ( Brooten & Naylor, 1995 ; Brooten & Youngblut, 2006 ). Through concept analysis and derivation, Manojlovich and Sidani clarified the conceptual and operational definitions of nurse dose within acute care contexts. They viewed nurse dose as a coherent concept that underpins staffing patterns, which are required to provide high quality nursing care. They defined nurse dose as the level of nursing staff needed to produce intended patient outcomes; it is characterized by four critical attributes that are operationalized by relevant staffing variables.

As a concept derived from relevant scientific literature ( Hupcey & Penrod, 2005 ), nurse dose has to be validated if it is to guide research and decision-making related to nurse staffing in acute care settings. Thus, the next step in this theory-building endeavor, after the concept analysis and derivation exercise, was to empirically validate the concept ( Schwartz-Barcott, Patterson, Lusardi, & Farmer, 2002 ). The goal of the initial steps in the process of empirical validation is to determine the extent to which the critical attributes and their respective indicators accurately reflect the concept of nurse dose. We undertook two complementary strategies to address this goal. …

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