JONA: The Journal of Nursing Administration Issue: Volume 45(9), September 2015, p 435-442 Copyright: Copyright (C) 2015 Wolters Kluwer Health, Inc. All rightsreserved. Publication Type: [Articles] DOI: 10.1097/NNA.0000000000000229 ISSN: 0002-0443 Accession: 00005110-201509000-00007 [Articles] Linking Unit Collaboration and Nursing Leadership to Nurse Outcomes andQuality of Care Ma, Chenjuan PhD; Shang, Jingjing PhD, RN; Bott, Marjorie J. PhD, RN Author Information Author Affiliations: Assistant Professor (Dr Ma), College of Nursing, New YorkUniversity; Associate Professor (DrBott), School of Nursing, University ofKansas, Kansas City; and Assistant Professor (Dr Shang), School of Nursing,Columbia University, New York. The authors declare no conflicts of interest. Correspondence: Dr Ma, College of Nursing, New York University, 433 First Ave,Office 506, New York, NY 10010 ([email protected]). ———————————————- Outline Abstract Review of the Literature Methods Data and Sample Measures Collaboration Nursing Leadership Nurse Outcomes Nurse-Reported Quality of Care Covariates Statistical Analysis Results Discussion ReferencesAbstractOBJECTIVE: The objective of this study is to identify the effects of unitcollaboration and nursing leadership on nurse outcomes and quality of care.BACKGROUND: Along with the current healthcare reform, collaboration of careproviders and nursing leadership has been underscored; however, empiricalevidence of the impact on outcomes and quality of care has been limited.METHODS: Data from 29742 nurses in 1228 units of 200 acute care hospitals in 41states were analyzed using multilevel linear regressions. Collaboration(nurse-nurse collaboration and nurse-physician collaboration) and nursingleadership were measured at the unit level. Outcomes included nurse jobsatisfaction, intent to leave, and nurse-reported quality of care.RESULTS: Nurses reported lower intent to leave, higher job satisfaction, andbetter quality of care in units with better collaboration and stronger nursingleadership.CONCLUSION: Creating a care environment of strong collaboration among careproviders and nursing leadership can help hospitals maintain a competitivenursing workforce supporting high quality of care.———————————————-Improving the nurse work environments has been recommended as a system-levelintervention to improve quality of care and patient safety.1-3 It also is a keyfactor for retaining a competent nursing workforce.4 The nurse work environmentis multifaceted and consists of a set of organizational characteristics that canfacilitate or constrain professional nursing practice.5 Among these attributes,collaboration among healthcare professionals and nursing leadership are 2essential elements.6,7 In the Institute of Medicine's report of The Future ofNursing: Leading Change, Advancing Health,3 interdisciplinary partnershipbetween nurses and other healthcare professionals and nursing leadership wereunderscored as challenges as well as opportunities to advance nursing andimprove quality of healthcare.Review of the LiteratureA literature review revealed that a body of research has described the statusquo of collaboration (mainly nurse-physician [NP] collaboration) and nursingleadership and emphasized their importance in patient care.8-10 However, only afew studies have empirically linked NP collaboration and nursing leadership tonurse outcomes and quality of care.11,12 In 1 study, the researcher found thatNP communication, an approach to enhancing collaboration, had a direct effect onnurses' job satisfaction and mediated the relationship between structuralfactors (eg, practice environment) and nurse outcomes (eg, nurse job satisfaction).13In another study, Boyle and colleagues reported that unit managers' leadershipstyle was significantly associated with critical care nurses' intent to leave.14While acknowledging the contributions of these studies, it should be noted thatthe majority of them were limited by small samples, and they rarely operationalizedcollaboration and leadership as an organizational factor (eg, unit- orhospital-level factors) in analysis. In addition, teamwork among nurses-thelargest healthcare workforce-was rarely examined.We had a unique opportunity to fill this knowledge gap by using nationwideregistered nurse (RN) survey data from the National Database of Nursing QualityIndicators (NDNQI). NDNQI was founded in 1998 by the American Nursing Associationwith the mission of aiding nurses in efforts of improving care quality andpatient safety.15 NDNQI is the only national nursing quality measurement datarepository in the United States that enables researchers to compare quality ofhospital nursing and nursing-sensitive patient outcomes at the unit level. Thehospital nursing unit is the micro-organization where interactions actuallyhappen between healthcare providers and patients and between healthcareproviders of different disciplines. Units of different types vary in socialmilieu and team relations.16 In the NDNQI data, units from different hospitalswere consistently and systematically classified into a unit type based on thepatient population, type of care provided, and acuity level. This enablescomparative analysis of units across hospitals.The purpose of this study was 2-fold: to examine the collaboration (both NPcollaboration and nurse-nurse [NN] collaboration) and nursing leadership at theunit level in US acute care hospitals and to identify the extent to whichunit-level collaboration and nursing leadership were associated with nurseoutcomes and nurse-reported quality of care. We hypothesized that units withbetter collaboration (NP collaboration and/or NN collaboration) and strongersupportive nursing leadership would have superior nurse outcomes and quality ofcare.MethodsThis study is a secondary analysis of cross-sectional data from the 2012 NDNQIRN survey, the most recent data available when we initiated the project. Thestudy protocol was approved by the institutional review board at a Midwesternacademic medical center.Data and SampleAiming to better understand the characteristics of the nursing workforce, in2004, NDNQI initiated an annual Web-based RN survey to collect data on nursework conditions, work attitudes, work content, and demographic information fromstaff nurses in NDNQI member hospitals. In this study, we used data fromhospitals with nurses who completed the RN survey with the Job SatisfactionScale in the long form. In 2012, 73 808 RNs in 3,746 units from 237 hospitalscompleted this survey form.To be eligible for the survey, nurses had to meet the following criteria at thetime of survey: (1) spend at least 50% of their time providing direct patientcare, (2) have a minimum of 3-month employment in the current unit, and (3) notagency or contract nurses. To ensure the reliability of the aggregated unitmeasures from individual nurse reports, we excluded units that had less than 5RN respondents and a response rate of less than 50%. A 50% response rate is agenerally accepted criterion for supporting the accuracy of inferences made fromaggregated data.17 We included 5 adult unit types: critical care, step-down,medical, surgical, and medical-surgical combined units. Based on these inclusioncriteria, our analytic sample for this study included 29 742 RNs in 1 228 unitsfrom 200 acute care hospitals in 41 states.MeasuresCollaborationCollaboration was measured by two 6-item scales: NN interaction scale and NPinteraction scale. These 2 scales were adapted from the Index of Work Satisfaction,18a widely used scale for measuring nurses' attitudes toward specific aspects oftheir job. The scales have been tested in pilot studies for feasibility andreliability.19 The NN scale measures nurses' experience of interactions amongnurses on their units. Sample items include the following: "Nursing staff pitchin and help each other when things get in a rush" and "There is a good deal ofteamwork among nursing staff." The NP scale measures nurses' perception ofinteractions between nurses and physicians. Sample items include the following:"In general, physicians cooperate with nursing staff" and "There is a lot ofteamwork between nurses and doctors on our units."Nursing LeadershipNursing leadership was measured by the supportive nursing management scale (5items), a scale adapted from the Practice Environment Scales of Nursing WorkIndex (PES-NWI).5 The PES-NWI is a nursing-sensitive instrument endorsed by theNational Quality Forum.20 This nursing management scale asks nurses about theirperception regarding nurse manager's ability, skills, and styles, for example,"Their nurse manager (NM) is supportive of nurses" and "Their NM consults withstaff on daily problems."We operationalized collaboration and nursing leadership as unit-level organizationalfactors by aggregating individual nurse responses to unit level. For all theitems in the 3 scales (NN scale, NP scale, and NM scale), response options wereprovided on a 6-point Likert-type scale from "strongly disagree" to "stronglyagree." First, each scale score was calculated for each RN respondent as themean of the items comprising the respective scale; the unit-level scale scoresthen were calculated as the mean of scale scores across all the RNs on a unit.Higher scores represent better collaboration and/or more supportive nursingleadership. In the regression models, we categorized scale scores into quartilesfor interpretive purpose. Our preliminary analysis suggested that the aggregatedunit measures were reliable. Each scale's internal consistency reliability amongRN respondents was high (NN scale, [alpha] = .87; NP scale, [alpha] = .91; NMscale, [alpha] = .92). The unit-level reliability, measured by the intraclasscorrelation coefficient (ICC [1,2]) from 1-way analysis of variance (ANOVA),ranged from 0.79 (NP scale) to 0.88 (NM scale). Researchers have suggested thataggregated measures with an ICC of 0.6 or higher are considered sufficientlyreliable.21Nurse OutcomesTwo nurse outcomes were measured: intent to leave and job satisfaction. In theRN survey, nurses were asked to indicate their job plans for the next year. Weconsidered RNs who reported plans of leaving the current position in the nextyear as having the intent to leave. Those RNs who planned to leave their currentposition because of retirement were not considered having intent to leave.RN's job satisfaction was measured in an untraditional way. RNs were asked toindicate the extent to which they would recommend their hospital to a friend asa place for employment using a 6-point Likert-type scale from "strongly agree"to "strongly disagree." RNs who reported that they "strongly agreed" or "agreed"were considered as being satisfied with their jobs. This method has been used inmeasuring patient satisfaction with healthcare service from hospitals and hasbeen endorsed as a metric for public report on quality of care.22Nurse-Reported Quality of CareNurse-reported quality of care was measured in 2 ways: overall quality of careand improved quality of care. In the RN survey, nurses were asked to assess theoverall quality of care on their units using a 4-point scale ranging from "poor"to "excellent"; this variable was denoted as nurse-reported overall quality ofcare. Nurses also were asked to indicate whether they perceived that the qualityof care in their units had improved, remained the same, or deteriorated over thepast year; this variable represented nurse-reported improvement in quality ofcare.CovariatesGiven that our data set had a 3-level structure, various variables at thehospital, unit, and individual levels were included as covariates. Hospital-levelcovariates included ownership, bed size, teaching status, Magnet(R) status, andgeographic location. Hospital ownership was categorized as not-profit, profit,or government owned. Hospital size was measured by the number of staffed bedsand grouped into 2 categories (small, =300 beds). Teaching status was classifiedas teaching or nonteaching. Hospitals also were identified whether it was aMagnet-recognized hospital. Using the national standards, hospitals were groupedinto 4 census regions: Northeast, Midwest, South, and West.Unit-level covariates included unit type and unit staffing levels. In thesurvey, nurses were asked to report the number of patients assigned to them ontheir last shift. Unit staffing levels were calculated as the mean number ofpatients per nurse on a unit. This measure has shown to have greater predictivevalidity than administratively reported nurse staffing, which often includesnurses without direct inpatient care assignments.23,24To adjust for differences in nurse mix across units and hospitals, nursedemographics also were controlled in the regression models. These demographicsincluded age, gender, race/ethnicity, education (having BSN or higher degrees ornot), unit tenure (years on the current unit), specialty certification (havingspecialty nursing certification awarded by a national nursing association ornot), and employment status (full time vs not full time).Statistical AnalysisDescriptive statistics were used to characterize nurses, units, and hospitals inour sample. Differences in unit collaboration (NN interaction and NP interaction)and nursing leadership across unit types were tested using 1-way ANOVA withTukey-Kramer (TK) post hoc tests. Three-level hierarchical logistic regressionmodels were conducted to estimate the odds of nurses: (1) expressing intent toleave, (2) being satisfied with their current job, (3) reporting excellentoverall quality of care on their units, and (4) perceiving improved quality ofcare on their units over the past year, when working in units with a workenvironment of different levels of NN collaboration, NP collaboration, ornursing leadership. All the models controlled for nurse and hospital characteristicsand unit type and staffing levels. To account for the clustering of nurseswithin a unit and units within a hospital, we included a unit-level randomintercept and a hospital-level random intercept in all regression models. Allanalyses were conducted using Stata version 12.0 (StataCorp LP, College Station,Texas) with statistical significance set at P ResultsTable 1 summarizes the characteristics of nurse respondents and nurse-reportedoutcomes. Nurses had a mean age of 38 (SD, 11) years. On average, nurses hadworked as an RN for 10 (SD, 9.8) years and been on the current unit for about 6(SD, 6.4) years. The majority of nurses were female (90%), white (68%), and fulltime (84%). Roughly 64% had a bachelor's degree or higher, and 62% had specialtynursing certification(s) awarded by a national association. About 1 in 4 nurseswas in critical care units, which had the lowest percentage of female nurses(86%) and had the highest percentage of white (75%), BSN-prepared (72%) nursesand nurses with specialty certification (96%), compared with units of othertypes (not shown in Table 1). Nurses in critical care units also were mostexperienced with an average RN tenure of 12 (SD, 10.1) years and unit tenure of7 (SD, 7.3) years, not shown in Table 1).Of the 29 742 nurses, 56% of nurses expressed satisfaction with their jobs,approximately 43% of nurses reported excellent quality of care to patient, and39% perceived improvement in quality of care over the past year. There were 28%of nurses reporting intent to leave their current position in the next year.Compared with nurses in other unit types, nurses in critical care units weremost likely to report excellent quality of care (50%), but least likely toreport intent to leave (25%), job satisfaction (55%), and improved quality of(33%) (not presented in Table 1).Table 2 describes the characteristics of hospitals and units. Of the 200hospitals, the majority were nonprofit (80%) and non-Magnet hospitals (70%) andhad less than 300 beds (70%). Roughly half of the hospitals were teachinghospitals (49%). About 34% of the hospitals were located in the Northeast, 32%in the Midwest, 34% in the South, and 9% in the West. Of the 1228 units,approximately 1 in 4 (24%) were medical-surgical combined units, followed bymedical units (23%), critical care units (21%), surgical units (17%), andstep-down units (15%). Units had an average nurse staffing level of 5 patientsper nurse, with the critical care units having the lowest patient-to-nurse ratio(2.52) and the medical-surgical combined units having the highest (6.02)patient-to-nurse ratio.Table 3 depicts unit-level descriptive statistics for collaboration (NN and NP)and nursing leadership. The overall mean scores on NN scale (measuringcollaboration among nurses), NP scale (measuring collaboration between nursesand physicians), and NM scale (measuring nursing leadership) were 4.53 (SD,0.37), 4.12 (SD, 0.38), and 4.28 (SD, 0.65), respectively. Although there wereslight unit-type differences in scores of each scale, ANOVAs with TK post hoctests indicated that none of these observed unit-type differences werestatistically significant.Our estimates (Table 4) from multilevel regressions showed that unit-levelcollaboration and nursing leadership were significantly associated with nursejob satisfaction, intent to leave, and nurse-reported quality of care topatients (overall quality and quality improvement), and these associations wereindependent of nurse staffing. Compared with those in units with the worstcollaboration among nurses (1st quartile of the NN scale score), nurses in unitswith the best NN collaboration (4th quartile of the NN scale score) were about 2times more likely (odds ratio [OR], 3.06; 95% confidence interval [CI],2.70-3.47) to recommend their hospitals for employment (denoted as jobsatisfaction), 3 times more likely (OR, 4.07; 95% CI, 3.57-4.63) to reportexcellent overall quality of care, 1 time more likely (OR, 2.42; 95% CI,2.10-2.79) to report improved quality of care, and approximately 57% less likely(OR, 0.43; 95% CI, 0.38-0.49) to express intent to leave. Compared with those inunits with the worst collaboration between nurses and physicians (1st quartileof the NP scale score), nurses in units with the best NP collaboration (4thquartile of the NP scale score) were approximately 2 times more likely torecommend their hospitals (OR, 2.64, 95% CI, 2.31-3.01) or report excellentquality of care (OR, 2.95; 95% CI, 2.56-3.40), 1 time more likely (OR, 1.88; 95%CI, 1.62-2.18) to report improved quality of care, and 49% less likely (OR,0.51; 95% CI, 0.45-0.58) to express intent to leave. Compared with those inunits with the worst nursing leadership (1st quartile of the NM scale score),nurses in units with the best nursing leadership (4th quartile of the NM scalescore) were about 2 times more likely to recommend their hospitals (OR, 2.61;95% CI, 2.32-2.93) or report improved quality of care (OR, 2.60; 95% CI,2.29-2.96), 1 time more likely (OR, 2.47; 95% CI, 2.16-2.82) to report excellentquality of care, and 57% less likely (OR, 0.43; 95% CI, 0.39-0.49) to expressintent to leave.DiscussionOur study provides empirical evidence that better collaboration (both NPcollaboration and NN collaboration) and nursing leadership as unit-levelorganizational factors were associated with lower intent to leave, higher nursejob satisfaction, and better quality of care as reported by nurses. Thesefindings suggest that hospital administrators can improve nurse outcomes andquality of care with 2 approaches: (1) improving collaboration among nurses andbetween nurses and other healthcare professionals and (2) strengthening nursingleadership.Under the ongoing healthcare reform (eg, adopting a value-based purchase modeland enhancing integrated and coordinated care delivery across the carecontinuum), interprofessional collaboration (particularly the collaborationbetween nurses and physicians) is drawing growing attention from varioushealthcare stakeholders as a potential strategy to achieve the goals ofhealthcare reform.25 Findings from our study provided evidence that better NPcollaboration led to not only positive nurse outcomes but also superior qualityof patient care, which is consistent with previous studies.26 In addition tointerprofessional collaboration, our study suggests that NN collaboration alsodeserves close attention because the quality of teamwork among nurses caninfluence nurse outcomes and quality of care too, where empirical evidence hasbeen rare. Improving collegial relations among healthcare providers requiresstrong commitment from the hospital administrators, but may be achieved atlittle cost.27 Previous research has demonstrated that hospitals could improveteam collaborations via well-designed training programs that helped nurses andphysicians understand their respective practice and expertise, responsibilities,and values.28,29 A valid source for improving teamwork is the TeamSTEPPSprogram, which was developed by the Agency for Healthcare Research and Qualityand the Department of Defense to improve communication and teamwork amonghealthcare providers.30 Another suggested approach of improving collaborationacross disciplines is providing interprofessional education to students ofdifferent healthcare disciplines. Lack of formal training in collaborativepractice and team-based care has been considered a big barrier for effectivecollaboration among healthcare providers. A recent report from Robert WoodJohnson Foundation indicated that there is a trend of growth in the number ofschools requiring interprofessional education; however, the number of schoolsthat are able to provide interprofessional education is limited, and nocomprehensive data are available to quantify interprofessional activities andcourses offered nationwide.31 Academic institutions and hospitals need to investmore in providing courses and training on interprofessional collaboration, andpolicymakers can help promote interprofessional education by establishinggovernment funding.Our study suggests that improving supportive nursing leadership is anotherstrategy to improve nurse outcomes and quality of care. Supportive leadershipcan enhance nurses' abilities to perform up to their competency in meetingorganizational goals.9 In a work environment with strong support from NMs andother leaders, nurses feel safe to speak out issues regarding patient safetysuch as medication errors.12 Magnet hospitals are the best exemplars offavorable nursing leadership. Emerging research demonstrates that hospitalsimplementing American Nurses Credentialing Center's blueprint for Magnetrecognition achieved significant improvements in their practice environmentsincluding nursing leadership.32,33 To build the skills and competency of nurseleaders, it requires commitment of hospitals and nursing association toinvestment in leadership development programs.34 For instance, in addition tofinancial sources, hospitals should offer NMs protected time to participate inleadership training. It has documented that 1 of the biggest barriers for nurseleaders to enroll in leadership development programs is the lack of time awayfrom the clinical settings.35 Another approach of strengthening nursingleadership is to create opportunities for nurses to take leadership positions atall levels, for example, unit, hospital, state, or national level, so nurses canhave voices in health policy making and be a full partner with other healthcareprofessionals.3Our study is not without limitations. First, our findings are based oncross-sectional data, and therefore, we cannot establish causality. Second, weused unit-level data of a large and national sample of hospitals from the NDNQIdatabase, and it still should be cautious when generalizing the results fromthis study to nonmember hospitals of NDNQI. Hospitals voluntarily chose toparticipate in NDNQI; therefore, certain hospital characteristics (eg, largerand Magnet hospitals) may be overpresented in the NDNQI data.36,37 Third, weused nurse reports to measure quality of care instead of objective qualityindicators such as mortality, hospital readmission, and falls. It is desirableto include objective outcomes measures; however, researchers have suggestedthat, in addition to objective data, perceptions of nurses who provide directpatient care at the bedside and round-the-clock are an importance source ofinformation when judging the quality of patient care.38 McHugh and Stimpfel 39compared nurse-reported quality of care to objective indicators of quality,including mortality and failure to rescue, and concluded that quality of carereported by nurses is a valuable indicator of hospital quality.In conclusion, this is the 1st study using unit level data from hospitalsnationwide to examine the role of collaboration (both between nurse andphysician and among nurses) and nursing leadership in nurse outcomes and qualityof care. Our findings of the significant influence of collaboration betweenhealthcare providers and administrative support on nurse job satisfaction,intent to leave, and quality of care provide hospital executives and nurseadministrators empirical evidence and specific directions in creating a healthywork environment for retaining a competent nursing workforce and obtainingsuperior quality of care.References1. Institute of Medicine. Crossing the Quality Chasm: A New Health System forthe 21st Century. Washington, DC: National Academies Press; 2001. 2. IOM. Keeping Patients Safe: Transforming the Work Environment of Nurses.Washington, DC: National Academies Press; 2004. 3. IOM. The Future of Nursing: Leading Change, Advancing Health. Washington, DC:National Academies Press; 2010. 4. Disch J. Creating healthy work environments for nursing practice. In: ChaskaN, ed. The Nursing Profession: Tomorrow and Beyond. Thousand Oaks, CA: Sage;2001. 5. Lake ET. 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