Thesis advisor: Dorothy A. Jones / Thesis advisor: Pamela J. Grace / The purpose of the study was to explore the relationship between multiple variables within a model of critical thinking and moral reasoning that support and refine the elements that significantly correlate with accuracy and clinical decision-making. <bold>Background:</bold> Research to date has identified multiple factors that are integral to clinical decision-making. The interplay among suggested elements within the decision making process particular to the nurse, the patient, and the environment remain unknown. Determining the clinical usefulness and predictive capacity of an integrated ethically driven environmental model of decision making (IEDEM-CD) in emergency settings in facilitating accuracy in problem identification is critical to initial interventions and safe, cost effective, quality patient care outcomes. Extending the literature of accuracy and clinical decision making can inform utilization, determination of staffing ratios, and the development of evidence driven care models. <bold>Methodology:</bold> The study used a quantitative descriptive correlational design to examine the relationships between multiple variables within the IEDEM-CD model. A purposive sample of emergency nurses was recruited to participate in the study resulting in a sample size of 200, calculated to yield a power of 0.80, significance of .05, and a moderate effect size. The dependent variable, accuracy in clinical decision-making, was measured by scores on clinical vignettes. The independent variables of moral reasoning, perceived environment of care, age, gender, certification in emergency nursing, educational level, and years of experience in emergency nursing, were measures by the Defining Issues Test, version 2, the Revised Professional Practice Environment scale, and a demographic survey. These instruments were identified to test and refine the elements within the IEDEM-CD model. Data collection occurred via internet survey over a one month period. Rest's Defining Issues Test, version 2 (DIT-2), the Revised Professional Practice Environment tool (RPPE), clinical vignettes as well as a demographic survey were made available as an internet survey package using Qualtrics TM. Data from each participant was scored and entered into a PASW database. The analysis plan included bivariate correlation analysis using Pearson's product-moment correlation coefficients followed by chi square and multiple linear regression analysis. <bold>Findings: </bold>The elements as identified in the IEDEM-CD model supported moral reasoning and environment of care as factors significantly affecting accuracy in decision-making. Findings reported that in complex clinical situations, higher levels of moral reasoning significantly affected accuracy in problem identification. Attributes of the environment of care including teamwork, communication about patients, and control over practice also significantly affected nurses' critical cue recognition and selection of appropriate interventions. Study results supported the conceptualization of the IEDEM-CD model and its usefulness as a framework for predicting clinical decision making accuracy for emergency nurses in practice, with further implications in education, research and policy / Thesis (PhD) — Boston College, 2011. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Thesis advisor: Dorothy A. Jones / In Taiwan, the ability to measure the changing of health care reform and the improvement in nursing practice environment is hindered by the lack of a valid, reliable, and culture-sensitive instrument for measuring nursing practice environment. The purposes of this two-phase study were to translate and psychometrically validate the Chinese versions of the PPE Scale (CPPE). Phase I focused on translating and adapting the 38-item PPE into CPPE and evaluating the semantic and content equivalency. Semantic equivalence of the CPPE was secured using Translation Validity Indices as judged by American and bilingual experts. The content equivalence of the CPPE was supported by the satisfactory Content validity Indices. To increase the cultural sensitivity and comprehensiveness of the CPPE, 27 items were added at the suggestion of Taiwanese experts following content validation. A 66-item CPPE including 38 PPE items, 1 adapted item and 27 new items was produced for psychometric evaluation. Phase II focused on establishing the psychometric properties of the CPPE. A cross-sectional survey was conducted to test the 66-item CPPE on 977 Taiwanese nurses working in acute care settings. PCA with Varimax rotation on the 38 PPE items produced an eight-component solution for the 36-item CPPE after deleting two items. Cronbach's alpha was .90 for the total 36-item CPPE and .68 - .87 for the eight subscales. PCA with Varimax rotation on 66 items of the CPPE produced an eleven-component solution for the 58-item CPPE after deleting 8 items. Cronbach's alpha was .95 for the total 58-item CPPE and .71 - .87 for the eleven subscales. Both the 36-item CPPE and the 58-item CPPE demonstrated satisfactory test-retest reliability and concurrent validity. The psychometric structures of the 36-item CPPE and the 58-item CPPE were different from the original PPE. Both the 36-item CPPE and the 58-item CPPE were reliable and valid, but the 58-item CPPE is culturally sensitive to the Taiwanese nurses. The 58-item CPPE is useful for measuring Taiwanese nursing practice environment. / Thesis (PhD) — Boston College, 2009. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Control over nursing practice (CONP) is a participatory process through which nurses have input and engage in decision making about the context of practice and unit operations related to nursing practice. CONP has been associated with a number of positive outcomes related to nurse satisfaction, nurse status, effectiveness of patient care, and quality of patient outcomes. However, no comprehensive model has been created nor comprehensive analysis been conducted related to approaches for increasing CONP. This study tested a hypothesized model of antecedents to CONP developed from a review of the literature in nursing, psychology, and organizational management using a complexity theory perspective.The study used a nonexperimental, comparative design. The sample for data analysis consisted of 28 nurse managers and 583 staff nurses from 32 units in 10 hospitals. Existing instruments were used in a paper and pencil format to collect demographic and perceptual data on CONP and the hypothesized antecedent variables. Data were aggregated to provide an analysis of organizational and unit level contextual and variable effects related to CONP.Contextual regression indicated a greater influence of unit-level variables than organizational-level variables on nurses' perceptions of CONP. Regression analyses and revised model testing demonstrated that nurse manager supportiveness, implementation of a formal structure for CONP, and information flow consisting of open and accurate communication were positively related to CONP. Hierarchy of authority was negatively related to CONP. The relationship between CONP and job codification and autonomy varied based upon the measurement of the dependent variable. Manager's perception that participative decision making enhances organizational effectiveness; manager's perception that participative decision making does not reduce their power; nurses' experience, expertise, and educational preparation; and nurses' desire for control did not significantly relate to CONP as hypothesized.This study contributes to nursing research and clarifies strategies for improving the work environment for nurses by delineating antecedents to CONP in the acute care hospital setting. These data will be useful to nurses, nurse managers, and hospital administrators who want to improve patient safety, reduce patient mortality, increase nurse satisfaction, and increase nurse retention.

Unintended consequences of electronic health records represent undesired effects on individuals or systems, which may contradict initial goals and impact patient care. The purpose of this study was to determine the extent to which a new quantitative measure called the Carrington-Gephart Unintended Consequences of Electronic Health Record Questionnaire (CG-UCE-Q) was valid and reliable. Then, it was used to describe acute care nurses' experience with unintended consequences of electronic health records and relate them to the professional practice environment. Acceptable content validity was achieved for two rounds of surveys with nursing informatics experts (n = 5). Then, acute care nurses (n = 144) were recruited locally and nationally to complete the survey and describe the frequency with which they encounter unintended consequences in daily work. Principal component analysis with oblique rotation was applied to evaluate construct validity. Correlational analysis with measures of the professional practice environment and workarounds was used to evaluate convergent validity. Test-retest reliability was measured in the local sample (N = 68). Explanation for 63% of the variance across six subscales (patient safety, system design, workload issues, workarounds, technology barriers, and sociotechnical impact) supported construct validity. Relationships were significant between subscales for electronic health record-related threats to patient safety and low autonomy/leadership (P < .01), poor communication about patients (P < .01), and low control over practice (P < .01). The most frequent sources of unintended consequences were increased workload, interruptions that shifted tasks from the computer, altered workflow, and the need to duplicate data entry. Convergent validity of the CG-UCE-Q was moderately supported with both the context and processes of workarounds with strong relationships identified for when nurses perceived a block and altered process to work around it to subscales in the CG-UCE-Q for electronic health record system design (P < .01) and technological barriers (P < .01).