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The work setting of diabetes nursing specialists in the Netherlands: A questionnaire survey
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International Journal of Nursing Studies 45 (2008) 1422–1432 www.elsevier.com/ijns
The work setting of diabetes nursing specialists in the Netherlands: A questionnaire survey Tilja I.J. van den Berg a, Hubertus J.M. Vrijhoef b,c, Gladys Tummers a, Jan A. Landeweerd a, Godefridus G. van Merode a,* a
University of Maastricht, Faculty of Health, Medicine & Life Sciences, Department of Health Organisation, Policy and Economics, The Netherlands b University Hospital Maastricht, Department of Integrated Care, The Netherlands c University of Maastricht, Faculty of Health, Medicine & Life Sciences, Department of Health Care Studies, Section Nursing Science, The Netherlands Received 26 April 2007; received in revised form 11 December 2007; accepted 18 December 2007
Abstract Aim: The aim of this study is to explore whether the work organisation of diabetes specialist nurses (DSNs) differs significantly from nurses working in hospital and nursing home and if so, does this difference result in positive or negative consequences regarding work and health. Background: In traditional health care settings, nurses exhibit a high level of environmental uncertainty and low decisionmaking authority, which has a negative effect on psychological reactions towards work. In professional nursing, specialisation, e.g. diabetic nursing, is a current trend in many countries. Therefore, insight into the determinants of the work situation of nursing specialists is becoming increasingly relevant. Methods: Comparisons were made between 3 different samples: 1204 nurses employed by 15 hospitals, 1058 nurses employed by 14 nursing homes, and 350 diabetes nurses working in other health care settings throughout the Netherlands. Data concerning organisation, work aspects, and psychological reactions were measured via questionnaires. Variances between the groups were analysed with ANCOVA, besides hierarchical multiple regression analysis was applied. Findings: Environmental uncertainty scored lower amongst diabetes nurses when compared to nurses working in the other two types of health care settings. Social support and role conflict scored low for diabetes nursing specialists who simultaneously perceived autonomy and role ambiguity highest. Diabetes nursing specialists also scored highest on intrinsic work motivation and job satisfaction and lowest for psychosomatic health. Conclusion: Except for social support and role ambiguity, diabetic nurses rate their [work] organisation, [work] aspects and psychological [work] reactions more positively than nurses employed in other health care settings. # 2007 Elsevier Ltd. All rights reserved. Keywords: Diabetes nurse; Work organisation; Work pressure; Emotional exhaustion
* Corresponding author at: University of Maastricht, Department Hope (Health Organisation, Policy and Economics), Faculty of Health Sciences, P.O. Box 616, 6200 MD Maastricht, The Netherlands. Tel.: +31 43 388 1727; fax: +31 43 367 0960. E-mail address: [email protected] (G.G. van Merode).
What is already known about the topic? The work organisation of nurses employed in hospitals differs from nurses employed in nursing homes, more specifically, environmental uncertainty.
0020-7489/$ – see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2007.12.003
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Relations between work organisation, aspects, and psychological attitude are for the most part in line with the Job Demand Control model regardless of the type of health care setting. What this paper adds Diabetes specialist nurses rate their [work] organisation, [work] aspects and psychological [work] reactions more positively than nurses employed in other health care settings. The transition of work tasks and a high specialisation of nurses have a positive influence on the psychological reactions when compared to those nurses employed in more traditional health care settings. In the diabetes specialist nurses’ workplace, there was no significant relation between environmental uncertainty and psychological reactions. 1. Introduction Throughout the past 10 years, the diabetes specialist nurse (DSN) has developed into an indispensable professional, administering complex care to patients with diabetic. This nursing specialisation evolved as an answer to staff shortages in charge of providing care as well as to the necessity for improvement of the quality of care. Nowadays, the transfer of tasks between doctors and nurses and substitution of doctors by nursing specialists are well accepted in the care for patients with chronic diseases such as diabetes mellitus (Vrijhoef et al., 2001). In the Netherlands the work tasks performed by the DSN can be summarised as follows: direct patient care (medical history, physical examination, interpretation of laboratory results, recording findings, and prevention of complications); co-ordination and organisation of care (identification of shortcomings, referral to and communicating with other health care-providers) and the advancement of expertise (educating patients, other health care-providers and the nurses themselves). Compared to general nurses, DSNs have one of the highest qualification levels for nursing care and are accepted nursing specialists who are focused on diabetes care and who possess distinctive skills in this area of practice (Vrijhoef et al., 2002). In the Netherlands (Vrijhoef et al., 2002), USA (Valentine et al., 2003), the UK (Winocour et al., 2002), and New Zealand (Kenealy et al., 2004) the role of the DSN increases while they enhance their position within the diabetes team (Sigurdardo´ttir, 1999). According to the DSN job profile, one can expect that the work setting of the DSN differ significantly, when compared with nurses working in a hospital or nursing home. Since the work organisation is of great importance to psychological attitude, it is relevant to explore what the differences in work organisation are and whether these differences result in
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positive or negative outcomes, directly or mediated through work aspects on psychological work reactions.
2. Theoretical perspectives on organisations, work, and psychological work reactions In this study, two theoretical perspectives are utilized for the selection of work organisation, work aspects, and psychological reactions, namely, the contingency approach of organisations (Child, 1977; Galbraith, 1977; Lawrence and Lorsch, 1967), and the Demand-Control-Support (DCS) model (Johnson and Hall, 1988; Karasek, 1979; Karasek and Theorell, 1990). According to the contingency approach, design decisions depend on environmental conditions. In addition, organisational effectiveness is achieved by organisations whose structural characteristics, i.e. centralisation, formalisation, and standardisation (Child, 1977; Gutek, 1990; Pennings, 1998) best match the demands of the environment or context, i.e. environmental uncertainty (Fry and Slocum, 1984; Pennings, 1998; Perrow, 1970; Rundall and Hetherington, 1988). The DCS model (Johnson and Hall, 1988; Karasek et al., 1981; Karasek and Theorell, 1990) is an extension of Karasek’s Job Demand-Control (JD-C) model (Karasek, 1979). Both the JD-C and the DCS models are aimed at generating a more profound insight into psychosocial risk factors at work (Karasek, 1979). Following Tummers et al. (2002), role stressors, i.e. role conflict and role ambiguity, were added to the framework. Since these stressors may cause job dissatisfaction and feelings of job-related strain (Tummers et al., 2002). The relation between these theoretic perspectives was investigated in previous research (Tummers et al., 2006). 2.1. Organisational characteristics Both structural (e.g. decision authority) and environmental characteristics (e.g. complexity and environmental uncertainty) can be used to represent the work organisation in nursing. Complexity of care refers to such patient characteristics as changes in a patient’s health and environmental characteristics. The patient mix on a unit encompasses the composition with regards to the specialities and patient diversity. Diversity implies that the differences amongst patients’ are caused by the type of disease and the level of health problems. Diabetes management is characterised by its complex nature and the complex health care needs of the patients with diabetic (El Fakiri et al., 2003). Aside from the health status of patients with type 2 diabetes, it is even more complex with 60% of patients suffering from co-morbidity (Charman, 2000). Whether or not this complex health status leads to a complex work organisation is unknown.
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Furthermore, nursing units are characterised by high environmental uncertainty or unpredictable circumstances. In general, uncertainty indicates that there is a differentiation between the amount of information required and the amount of information already held by the organisation (Galbraith, 1973). In this study environmental uncertainty refers to workflow uncertainty. As we know, nurses working in a chronic health care setting (nursing home) exhibit significantly lower environmental uncertainty than nurses working in an acute health care setting (hospital) (van den Berg et al., 2006). In general, diabetes care is not acute, but chronic by nature. Therefore, the setting wherein diabetes care is administered is expected to result in diminished environmental uncertainty compared to those working in a hospital. Decision-making authority relates to the way in which the authority to make such decisions as ‘who is going to do what and when’ is distributed among members of a ward (Bodt and Van Tuijl, 1988). The concept of decisionmaking authority, as applied in this study, refers to the performance of various tasks, and the decentralisation of decision-making. Since DSNs usually work independently, it is most likely that decision-making authority is highest. High environmental uncertainty and minimal decisionmaking authority has a negative effect on such psychological reactions as emotional exhaustion, intrinsic work motivation, psychosomatic health, and job satisfaction (Tummers et al., 2002). The aim of this study is to explore whether the work organisation of DSNs differs significantly from nurses working in hospital and nursing home and if so, does this difference result in positive or negative consequences regarding work and health. Therefore two research questions were formulated. The first research question addressed whether differences in work organisation, work aspects, and psychological reactions existed between DSNs, hospital or nursing home care. The second research question relates to the relationship between work organisation, work aspects, and the psychological reactions of nurses connected to the three different settings. This question was divided into three
sub-questions, as represented by Lines A, B1, B2 and C in the research model (Fig. 1): Line A demonstrates the relationship between characteristics of the work organisation and work aspects. Line B questions whether the relationship between the characteristics of the work organisation and psychological attitude is a direct relationship (B1) or an indirect one, via the work aspects (B2), which means that the work characteristics may be regarded as mediator variables. Line C represents the third sub-question, the relationship between work aspects and psychological reactions. Since the use of contingency theory in nursing is relatively new, there are no validated questionnaires available concerning environmental uncertainty, complexity, and decisionmaking authority. Previous research showed insufficient psychometric properties of the complexity scale in the nursing home sample (Cronbach’s alpha was .32) (van den Berg et al., 2006), the research question of how to improve the conceptualisation of work organisation was addressed as well.
3. Methods 3.1. Design and procedure In this cross-sectional study nurses working in 15 randomly selected general hospitals, 14 randomly selected nursing homes, and 825 DSNs in the Netherlands were asked whether they were willing to participate, after permission of the institutions director. Questionnaires were distributed in a sealed envelope together with a letter that explained the purpose of the study and anonymity procedures. After completing the questionnaires, subjects were asked to return them in an enclosed return envelope. Participants had been employed for at least 3 months. In the general hospital and nursing home sample all nurses complying with this criteria were included.
Fig. 1. Research model.
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An approval by the Ethics Committee was not necessary. Subjects filled in an informed consent in order to approve the use of data for scientific research. Because all data was retrieved from self-assessed questionnaires and no human body tissues or species were obtained, ethical approval was not necessary.
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women (93%). The mean age was 42.9 years (S.D. = 7.9). The mean job experience was 5.82 years (S.D. = 4.6). 3.3. Questionnaire The following variables were measured by questionnaires as part of a direct mailing. Results of reliability analysis are shown in Table 1.
3.2. Samples and response 3.4. Characteristics of the work organisation Data were collected in three samples, collected at different times over a period of 2 years: Hospital nurses: One thousand eight hundred fifty-five (1855) questionnaires were distributed among nurses from 15 hospitals. In total 1253 questionnaires were returned (a response rate of 68%). The sample size was 1204 (nursing staff employed for a period of less than 3 months were excluded from the sample). The sample consisted of 1019 women (85%). The mean age of the hospital nurses was 35.7 years (S.D. = 8.7). The mean job experience was 15.5 years (S.D. = 8.6), while the working time on the unit was 6.8 years (S.D. = 6.2). Nursing home caregivers: One thousand eight hundred forty-six (1846) questionnaires were distributed among nurses from 14 nursing homes. In total 1139 questionnaires were returned (response rate 62%). The sample size was 1058 (nursing staff employed for a period of less than 3 months were excluded from the sample). The sample consisted of 963 women (94%). The mean age of the nursing home caregivers was 35.8 years (S.D. = 9.7). The mean job experience was 12.6 years (S.D. = 8.4), while the mean working time on the unit was 4.6 years (S.D. = 4.8). DSN: Eight hundred fifty-two (852) questionnaires were distributed to DSNs in the Netherlands, 350 of which were returned (response rate 41%). The sample consisted of 325
Environmental uncertainty contains items referring to workflow and task uncertainty. One example is: ‘‘There are daily emergency admittances on this unit’’. Decision authority was measured in the DSN sample by means of 3 items, ranging from 1 ‘‘totally disagree’’ to 5 ‘‘totally agree’’. In the samples taken from the hospital nurses and nursing home caregivers, the decision-making authority scale consisted of five items. The Cronbach’s alpha was 0.7 in the sample of hospital nurses, and 0.6 in the sample of nursing home caregivers. Using the three-item version – as was the case with the sample conducted of the DSN – Cronbach’s alpha was 0.7 in the sample of hospital nurses and 0.4 in the sample of nursing home caregivers. Since the decision-making authority scale is in the developmental stages, descriptive questions of the work setting were inserted to determine which improvements could be achieved. The Pearson correlations were then calculated between the descriptive and subjective decision-making authority items. It can be concluded that decision-making authority is unrelated to working in a multidisciplinary team, the size of a multidisciplinary team, team supervisor, direct supervisor and method used to record tasks and authorities. Unfortunately reliability analysis on the data of the DSN population was unsatisfactory and yielded a Cronbach’s
Table 1 Results reliability analysis for all three samples Cronbach’s alpha Sample 1 (general hospital)
Sample 2 (nursing home)
Sample 3 (DSN)
Characteristics of the work organisation Environmental uncertainty Decision authority Complexity
0.8 0.7 0.7
0.5 0.4 0.3
0.8 0.1 0.3
Work aspects Autonomy Workload Social support at work Role ambiguity Role conflict
0.8 0.9 0.8 0.7 0.7
0.8 0.9 0.8 0.7 0.7
0.9 0.9 0.7 0.7 0.7
Psychological work reactions Emotional exhaustion Intrinsic work motivation Psychosomatic health Job satisfaction
0.9 0.7 0.8 0.9
0.9 0.7 0.8 0.9
0.9 0.7 0.8 0.9
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alpha of 0.1. Considering the insufficient psychometric properties ‘decision-making authority’ was omitted from the analyses. Complexity was measured by means of eight items. In both the hospital and nursing home samples, complexity was measured by means of ten items on a five-point response scale. Since Cronbach’s alpha emerged as unsatisfactory in the nursing home sample, the ‘‘complexity’’ scale was amended for use in the DSN sample. Descriptive questions were introduced as a means of increasing the psychometric quality, for example, questions concerning the diversity of the patient population and the number of specialisation fields. Then Pearson correlations were calculated between the descriptive and subjective complexity items. This revealed that the descriptive items had an elevated correlation with the mean complexity score and the majority of single complexity items. Furthermore, it was discovered that when nurses are only specialised in diabetes, complexity increases, the result of more complex and specialised tasks being performed, for example, insulin treatment. Unfortunately, Cronbach’s alpha proved inadequate in the DSN population with (0.4) and without descriptive questions (0.3). In order to increase the methodological quality of the scale in the future, a factor analysis was performed for the complexity scale. It was concluded that a two-factor structure is the most suitable. The first factor merely consists of items subjecting nurse specific skills. For example, ‘‘Does the patient need emotional support and psychological help?’’ and ‘‘Do you establish patient insulin treatment instituting?’’ The second factor merely consists of situation dependent complexity. For example, ‘‘What are the expectations in a high risk situation?’’ and ‘‘How many care givers do you have to deal with besides the operational doctor?’’ Considering the insufficient psychometric properties ‘complexity’ was omitted from the analyses. 3.5. Work characteristics Autonomy was measured by means of 10 items on a 5point response scale ranging from 1 ’very little opportunity’ to 5 ’very much opportunity’. This scale was derived from the Maastricht Autonomy Questionnaire, abbreviated MAQ, and was developed by De Jonge et al. (1993). Respondents were asked to rate their work situations as to the opportunities it offers for autonomy. An example of an item is: ‘‘The opportunity that the work offers to leave your workplace whenever you want’’. Workload was measured by means of an 8-item questionnaire, also developed by De Jonge et al. (1993) and ranging from 1 ’never’ to 5 ’always’. The scale consists of both quantitative and qualitative demanding aspects in the working situation, like working under time pressure, working hard, and strenuous work (De Jonge et al., 1993). An example item is: ‘‘In the unit where I work, there is too little time to finish the work’’.
Social support at work ( from colleagues and senior nursing officer) was measured by means of a 10-item scale, derived from a Dutch questionnaire on organisational stress (‘‘Vragenlijst Organisatie Stress-Doetinchem’’—VOS-D; Bergers et al., 1986). An item example is: ‘‘To what extent can you count on your colleagues, when you have difficulties in your work?’’ The items were scored on a 4-point response scale format, ranging from 1 ‘‘never’’ to 4 ‘‘always’’. 3.6. Psychological work reactions Emotional exhaustion was measured by means of the Dutch version of the Maslach Burnout Inventory (MBI (Maslach and Jackson, 1986)): the MBI-NL (Cox et al., 1993; Maslach, 1993; Schaufeli and Van Dierendonck, 1993). The emotional exhaustion scale of the MBI-NL consists of 8 items, ranging from 1 ‘‘never’’ to 7 ‘‘always’’. An item example is: ‘‘I feel emotionally drained from my work’’. Intrinsic work motivation was measured by means of 6 items derived from a scale developed by Warr et al. (1979), ranging form 1 ‘‘totally disagree’’ to 5 ‘‘totally agree’’. An item example is: ‘‘My opinion of myself goes down when I do this job badly’’. 3.7. Statistics Background variables were analysed by using a descriptive analysis. To gain insight into the work organisation, aspects, and psychological reactions of DSNs in relation to nurses employed in hospitals and nursing homes, multivariate analysis (ANCOVA) was carried out. Gender and age were entered as covariates. Post hoc procedure Bonferroni and Scheffe were used. Hierarchical multiple regression analysis was applied in order to investigate the relationships between: (a) characteristics of the work organisation and work aspects, (b) characteristics of the work organisation and psychological work reactions, and (c) work characteristics and psychological work reactions. All the variables included in this study were standardised to reduce problems of multi-colinearity. Two-way interaction effects were tested by computing cross-product terms of the standardised independent variables. Regression analyses were presented separately for DSNs, hospital, and nursing home settings. To investigate which characteristics of work organisation are predictable in terms of emotional exhaustion, intrinsic work motivation, psychosomatic complaints, and job satisfaction, hierarchical multiple regression analyses were performed separately for each criterion variable. Because gender and age were correlated with characteristics of the work organisation, work aspects, and psychological reactions, the analyses were controlled for the background variables gender and age. The order of fit in the hierarchical regression model was: (1) gender and age, (2) workload, (3)
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autonomy, (4) social support, and (5) role ambiguity and role conflict. All analyses were carried out with the Statistical Package for Social Sciences Version 11.0 for Windows (SPSS, 1999).
4. Results
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contrary, the social support scores for the DSN were the lowest in relation to the other health care settings. The DSN scored highest for role ambiguity and lowest for role conflict. DSNs scored highest in intrinsic work motivation and job satisfaction, and lowest for psychosomatic ailments. There were no significant differences in psychosomatic ailments between the DSN and hospital nurses ( p = 0.2). 4.2. Relationships between organisational characteristics and work aspects (Line A in Fig. 1)
4.1. Descriptives The majority of DSNs (78%), worked in a multidisciplinary team, mean size 8.9 (S.D. = 6.0) members. Ninety one percent (91%) were employed on a full-time basis. The patient population under care was, in 7% of all cases, ‘‘younger than 18 years’’, in 45% of the cases the population were ‘‘older than 18 years’’, and in 30% of the cases ‘‘the patients were represented by all age groups’’. The majority of DSNs were not specialised in any other field other than diabetes (67%), but for those DSNs who are specialised in other fields, the specialisation often extends to more than one other specialisation. Registration of tasks and authorities took place in 54% of all cases in ‘‘work description’’ or was registered in more than one document (21%). Table 2 demonstrates that nurses working in a general hospital, nursing home or as DSN score significantly different in terms of work organisation, work aspects, and work reactions, as determined by overall F-tests. No significant differences in average score were found for emotional exhaustion. Environmental uncertainty was significantly lower in diabetes care than in both of the other settings. DSNs exhibited the lowest workload in relation to the other health care settings. Post hoc procedure Bonferroni and Scheffe did not reveal any significant global differences in mean score ( p = 0.1) for workload between DSN and hospital nurses. In regard to autonomy, the DSN scored highest in relation to the other health care setting. On the
Table 3 indicates relatively low percentages of the variance (R2) in work aspects that were explained by work organisation. In the DSN setting, environmental uncertainty has a positive relation with role conflict (b = 0.2***) and workload (b = 0.4***). From a work and health point of view, environmental uncertainty is an indicator of negative work characteristics (an increased workload, role conflict, and reduced social support). In the nursing home setting, environmental uncertainty indicates positive work aspects (increased autonomy and less role ambiguity). 4.3. Relationships between organisational characteristics and psychological work reactions (Line B1 in Fig. 1) Table 4 indicates that none of the psychological work reactions were explained by environmental uncertainty in the DSN setting. Emotional exhaustion was not predicted by environmental uncertainty, in any of the settings. From a work and health point of view, environmental uncertainty was an indicator of positive (more intrinsic motivation) as well as negative work reactions (more psychosomatic ailments) in the hospital setting. In a nursing home setting, environmental uncertainty has a positive influence, i.e. higher intrinsic motivation and job satisfaction.
Table 2 Univariate test results Variables [number of items] (x-point Likert scale)
Sample 1 (general hospital) Mean (S.D.)
Sample 2 (nursing home) Mean (S.D.)
Sample 3 (DSN) Mean (S.D.)
Environmental uncertainty [5] (5)
3.9 (.7)
3.8 (.6)
3.7 (.7)
Workload [10] (5) Autonomy [8] (5) Social support at work [10] (4) Social support supervisor [5] (4) Social support colleague [5] (4) Role ambiguity [4] (5) Role conflict [3] (5)
3.3 2.8 3.2 3.2 3.3 2.1 2.7
(.5) (.5) (.3) (.5) (.3) (.5) (.5)
3.4 2.7 3.3 3.3 3.3 2.0 2.5
(.6) (.6) (.3) (.5) (.4) (.6) (.6)
3.3 3.3 2.8 2.7 2.9 2.1 2.4
(.6) (.7) (.4) (.5) (.4) (.6) (.6)
13.8* 178.9* 270.0* 235.9* 143.5* 12.9* 28.5*
Emotional exhaustion [8] (7) Intrinsic work motivation [6] (5) Psychosomatic health [21] (yes/no) Job satisfaction [21] (5)
2.2 4.0 0.2 3.5
(.7) (.5) (.2) (.4)
2.3 4.0 0.2 3.6
(.8) (.5) (.2) (.4)
2.2 4.1 0.1 3.7
(.8) (.5) (.2) (.4)
4.7 11.4* 13.2* 14.3*
*p 0.001.
F (overall)
19.0*
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Table 3 Relation between work organisation and work characteristics Predictor
1. Gender Age
Criterium
Workload
2. Environmental uncertainty 1. Gender Age
Autonomy
2. Environmental uncertainty 1. Gender Age
Diabetes specialist/hospital nurse/nursing home Beta (b)
R2change
R2
.05/.12***/.00 .05/.06*/.06
.00/.01***/.00
.00/.01/.00
.38***/.24***/.09**
.15***/.06***/.01**
.15/.07/.01
.04/.10***/ .05 .12*/.03/ .01
.02/.01**/.00
.02/.01/.00
.05/ .03/.08**
.00/.00/.01**
.02/.01/.01
.01/ .00/.02 .04/ .00/ .03
.00/.00/.00
.00/.00/.00
.08/ .07**/.06
.01/.01**/.00
.01/.01/.00
.02/ .01/ .07* .02/ .05/ .00
.00/.00/.00
.00/.00/.00
.03/.02/ .15***
.00/.00/.02***
.00/.00/.03
.00/ .04/ .03 .12*/ .10***/ .01
.02*/.01***/.00
.02/.01/.00
.24***/.14***/.01
.06***/.02***/.00
.07/.03/.00
Social support
2. Environmental uncertainty 1. Gender Age
Role ambiguity
2. Environmental uncertainty 1. Gender Age
Role conflict
2. Environmental uncertainty *p .05, **p .01, ***p .001.
4.4. Relationship between work characteristics and psychological work reactions (Line C in Fig. 1) Explained variances showed to be higher for emotional exhaustion (R2 = .31) and job satisfaction (R2 = .43) com-
pared to intrinsic motivation (R2 = .05) and psychosomatic complaints (R2 = .10) (Table 5). Emotional exhaustion indicates a positive relation with high workload, role conflict, and role ambiguity across all settings. Job satisfaction was predicted by all measured work
Table 4 Relation between organisational characteristics and psychological work reactions Predictor
1. Gender Age
Criterium
Emotional exhaustion
2. Environmental uncertainty 1. Gender Age
Intrinsic work motivation
2. Environmental uncertainty 1. Gender Age
2. Environmental uncertainty *p .05, **p .01, ***p .001.
Beta (b)
R2change
R2
.00/ .02/ .00 .05/.00/ .01
.00/.00/.00
.00/.00/.00
.09/.05/ .01
.01/.00/.00
.01/.00/.00
.10*/.10***/.02 .05/.08**/.13***
.02/.01***/.02***
.02/.01/.02
.00/.01**/.01***
.02/.02/.03
.02/.04/.05 .06/ .01/.00
.00/.00/.00
.00/.00/.00
.10/.06*/ .03
.01/.04*/.00
.01/.01/.00
.07/.05/.01 .01/.07*/ .01
.01/.01*/.00
.01/.01/.00
.01/.00/.02***
.01/.01/.02
.02/.09**/.12*** Psychosomatic complaints
2. Environmental uncertainty 1. Gender Age
Diabetes specialist/hospital nurse/nursing home
Job satisfaction
.07/ .05/.12***
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Table 5 Relations between work characteristics and psychological work reactions Predictor
1. Gender Age
Criterium
Emotional exhaustion
2. Workload 3. Autonomy 4. Social support 5. Role ambiguity Role conflict 1. Gender Age
Intrinsic Work motivation
2. Workload 3. Autonomy 4. Social support 5. Role ambiguity Role conflict 1. Gender Age
Psychosomatic complaints
2. Workload 3. Autonomy 4. Social support 5. Role ambiguity Role conflict 1. Gender Age
Job satisfaction
2. Workload 3. Autonomy 4. Social support 5. Role ambiguity Role conflict
Diabetes specialist/hospital nurse/nursing home Beta (b)
R2change
R2
.02/ .05/ .04 .06/.01/ .03
.01/.00/.00
.01/.00/.00
.36***/.35***/.34*** .13/.04/ .01 .07/ .14***/ .18*** .24***/.10***/.06* .14*/.18***/.13***
.20***/.20***/.20*** .00/.00/.00* .03***/.05***/.05*** .07***/.04***/.02***
.21/.20/.20 .21/.20/.20 .24/.25/.25 .31/.29/.27
.11/.08**/.01 .02/.07*/.13***
.01/.01***/.02***
.01/.01/.02
.06/ .08*/.08* .12*/ .02/ .01 .08/.12/.07 .04/.04/ .05 .10/ .04/ .09**
.00/.00/.00 .02*/.00/.00 .01/.01***/.01*** .01/.00/.01** .00/.00/.00
.01/.02/.02 .03/.02/.02 .04/.03/.03 .05/.03/.04
.01/.02/.05 .08/ .01/ .01
.01/.00/.00
.01/.00/.00
.24***/.20***/.18*** .00/.02/ .07* .01/ .10**/ .14*** .10/.06/.04 .06/.09**/.08*
.08***/.07***/.07*** .00/.00/.01*** .00/.02***/.03*** .01/.01***/.01** .00/.00/.00
.08/.07/.07 .08/.07/.08 .09/.09/.11 .10/.10/.12 .10/.10/.12
.07/.07**/ .02 .00/.06*/.01
.01/.01*/.00
.01/.01/.00
.07***/.14***/.13*** .07***/.02***/.05*** .19***/.19***/.20*** .10***/.05***/.06*** .00/.00**/.00
.08/.15/.13 .15/.17/.17 .33/.36/.38 .43/.41/.44 .43/.42/.44
.12*/ .21***/ .16*** .15***/.06**/0.11*** .30***/.34***/.36*** .30***/ .19***/ .22*** .13**/ .15***/ .16***
*p .05, **p .01, ***p .001.
characteristics, from which high work load, role ambiguity, and role conflict had similar relations across all samples. High workload was positive associated with psychosomatic complaints in all three samples. Interaction terms have been tested but were not additional to the model. 4.5. The mediating role of work aspects (Line B2 in Fig. 1) The possible mediating role of work aspects in the relationship between work organisation and psychological work reactions was not tested in a DSN setting because there were no significant correlations found between psychological work reactions and environmental uncertainty and therefore a mediating role is out of the question (Bennett, 2000). In the hospital and nursing home settings, some results were determined, which indicated that a mediator role is plausible (van den Berg et al., 2006).
5. Discussion The main purpose of this study was to extend knowledge concerning the work situation of DSN in relation to a traditional health care setting. This study demonstrates that 10% of DSN in the Netherlands are working in an integrated care setting, whereas 40% are working in a home care (general practice) setting and 41% in a setting which is available after reference by the GP, for example hospital. The other 10% worked in other settings. This finding corresponds with earlier research conducted by Steuten et al. (2002). The majority of DSN (78%) perform their tasks as part of a multidisciplinary team. This result conforms to the frequent use of multidisciplinary teams in diabetes management and supports Mulcahy’s (1999) opinion, that in diabetes management the use of multidisciplinary teams are logical given the multidimensional nature of diabetes. In addition, indications suggest that almost all DSN are not specialised in any other fields
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other than diabetes (67%). This supports the finding by Vrijhoef et al. (2002), that the DSN is highly specialised and purely focused on diabetic care. Some limitations must be taken into account in this study. First, the cross-sectional design does not permit exploration of causal relationships between work and organisational characteristics and psychological work reactions. Nevertheless, the results are still of interest as they give a first insight in influence of differences in work setting on psychological work reactions. Second, the psychometric quality of the organisational work characteristics was very poor. In the DSN sample reliability analysis showed unsatisfactory Cronbach’s alphas for decision authority and complexity. Both variables were omitted from the analysis. The two scales were not appropriate to measure aspects of the contingency theory in nursing. Third, no non-response analyses could be performed. The response in the DSN sample (41%) was quite lower than in the hospital (68%), and nursing home sample (62%). One explanation could be that nurses working in general hospitals and nursing homes were informed by the managers during the ward meeting about the research topic and purpose, the data collection procedure, and the research report. Whereas DSNs were directly invited to participate in the study without mediation of the manager. In general, differences in work organisation, work characteristics, and psychological work reactions were significant, although the differences were small. In regard to the work organisation, this study revealed that the environmental uncertainty is low amongst DSN in comparison to hospital nurses and nursing home caregivers. Apparently, in the field of diabetes nursing, more knowledge concerning workflow or when ‘‘the inputs’’ will arrive, i.e. patient inflow exists. The findings were as expected. In principle, the patient [visit] schedule is known and care needs are relatively predictable. From a work and health point of view, relatively positive results were found regarding the work aspects of the DSN in relation to nurses working in general hospitals and nursing homes. For example, DSNs scored lowest on workload and role conflict, and highest on autonomy. Despite, again it should be mentioned differences were only minor, except for autonomy. DSNs regard autonomy higher than hospital nurses or nursing home caregivers. The DAWN study (Siminerio et al., 2007) showed, regarding responsibilities, that specialist nurses functioned at a more advanced level and reported taking a more active role in facilitating both selfmanagement and medication management than generalist nurses did. In Brown et al., 2001 it was mentioned that diabetes educators express frustration over the limited authority they have in caring for patients with diabetic . Despite this frustration, the fact that they work on an independent basis is a likely factor in the high score for autonomy, compared with nurses working in other health care settings. Working independently probably attributes to the low scores for social support (from both supervisors and colleagues). Operational tasks are performed rather independently. Personal feedback and support is only obtained during the meetings of the
multidisciplinary team. This finding is in agreement with a study among nurse consultants (Woodward et al., 2005) in which specialised nurse consultants felt less social support from their immediate colleagues than non-specialised nurse consultants felt. This lack of social support could be decreased by focussing on the emotional nature of support from peers and colleagues than that of a physical presence. The knowledge that the nurse can share with a peer or a manager while alone at work under difficult circumstances should be strengthened (Neal-Boylan, 2006). The high scores for role ambiguity may be explained by the fact that the function of a DSN is in the developmental stage where roles increase and are amended. Registration of tasks and responsibilities were available in such documents as task description (54% of all registrations), function profile (10%) or protocol (10%). Apparently, the registration of tasks and responsibilities are in all likelihood, not sufficient enough to compensate this dynamic role development. In regard to work and health, positive results attributed to work aspects are also identified in work reactions. This has resulted in the highest scores being allocated to intrinsic work motivation and work satisfaction, and the lowest scores being allocated to psychosomatic health. The specialised tasks of the DSN could be positive for the experience of stress as the inability to use all of their skills on the job was reported to cause stress in nursing home nurses (Lapane and Hughes, 2007). Yet, equivalent univariate analyses indicated that there were no significant differences of emotional exhaustion between the three health care settings examined in this study. In Charman (2000), it was reported that DSN were at high risk of emotional exhaustion because of their perfectionist character and the psychosocial stressors they regularly deal with. However, these risk factors are not specifically associated to DSN, but rather to the nursing profession in general. With regard to the second aim of the study, it was disclosed that in the DSN setting, environmental uncertainty was positive in relation to workload and role conflict. Work organisation characteristics, decision-making authority, and complexity could not be investigated, as the psychometric quality of these, were not acceptable. No direct relation exists between environmental uncertainty and the psychological work reactions. As a result, any possibility of a mediating role of work characteristics is out of the question. With regard to the relationship between the work characteristics and psychological work reactions, it can be concluded that workload was an important predictor of emotional exhaustion and psychosomatic complaints in all three samples. From the psychological work reactions job satisfaction was best predicted by the work characteristics, which is in line with findings of Rafnsdottir et al. (2004) among nurses in geriatric care. With exceptions to the negative association between autonomy and social support with job satisfaction in the DSN sample, results are in line with the DCS model. Work organisation environmental uncertainty forecast negative work characteristics (more workload and role con-
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flict, less social support) in the DSN and hospital setting. This was not true in the nursing home setting: environmental uncertainty was a forewarning of more autonomy and less role ambiguity. In the nursing home setting environmental uncertainty forecast positive psychological work reactions (more intrinsic motivation and job satisfaction). In the hospital setting relations between environmental uncertainty and psychological work reactions were contradictory. These contradictory findings can probably be attributed to the unsatisfactory psychometric quality of the work organisation variables. Moreover, in all health care settings, explanatory variances were low. In the DSN sample these varied from .01 to .43.
6. Conclusions The work of a DSN can be distinguished by certain characteristics. From an organisational point of view, the work setting is characterised by low environmental uncertainty in comparison with nurses employed in the other two health care settings (hospital and nursing home). Furthermore, the work of the DSN can be characterised by high autonomy and role ambiguity, low workload, social support, and role conflict. Relations between organisational characteristics, work aspects, and psychological work reactions indicated conflicting results due to differing psychometric qualities of the environmental uncertainty variable. DSNs scored most positive in regard to psychological work reactions. It can be concluded that differences in the work organisation through transition of work tasks and high specialisation of nurses has a positive influence on the psychological work reactions in comparison with a more traditional health care setting. Continued improvement of the work situation of DSNs should focus on decreasing role ambiguity and increasing social support. Since the nurse practitioner is the future trend in health care (Reay et al., 2003), e.g. the DSN, it might be expected that transition of work tasks and high specialisation of advanced nurses or nurse practitioners have a positive influence on psychological work reactions in comparison with a more traditional health care setting. Recommendations for additional work suggest a need for the optimal measurement of organisational characteristics. As this study reveals, scales for organisational characteristics require improvement and should even be combined with objective data related to variances in patient flow, patient mix, and role differentiation.
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International Journal of Nursing Studies 45 (2008) 1422–1432 www.elsevier.com/ijns
The work setting of diabetes nursing specialists in the Netherlands: A questionnaire survey Tilja I.J. van den Berg a, Hubertus J.M. Vrijhoef b,c, Gladys Tummers a, Jan A. Landeweerd a, Godefridus G. van Merode a,* a
University of Maastricht, Faculty of Health, Medicine & Life Sciences, Department of Health Organisation, Policy and Economics, The Netherlands b University Hospital Maastricht, Department of Integrated Care, The Netherlands c University of Maastricht, Faculty of Health, Medicine & Life Sciences, Department of Health Care Studies, Section Nursing Science, The Netherlands Received 26 April 2007; received in revised form 11 December 2007; accepted 18 December 2007
Abstract Aim: The aim of this study is to explore whether the work organisation of diabetes specialist nurses (DSNs) differs significantly from nurses working in hospital and nursing home and if so, does this difference result in positive or negative consequences regarding work and health. Background: In traditional health care settings, nurses exhibit a high level of environmental uncertainty and low decisionmaking authority, which has a negative effect on psychological reactions towards work. In professional nursing, specialisation, e.g. diabetic nursing, is a current trend in many countries. Therefore, insight into the determinants of the work situation of nursing specialists is becoming increasingly relevant. Methods: Comparisons were made between 3 different samples: 1204 nurses employed by 15 hospitals, 1058 nurses employed by 14 nursing homes, and 350 diabetes nurses working in other health care settings throughout the Netherlands. Data concerning organisation, work aspects, and psychological reactions were measured via questionnaires. Variances between the groups were analysed with ANCOVA, besides hierarchical multiple regression analysis was applied. Findings: Environmental uncertainty scored lower amongst diabetes nurses when compared to nurses working in the other two types of health care settings. Social support and role conflict scored low for diabetes nursing specialists who simultaneously perceived autonomy and role ambiguity highest. Diabetes nursing specialists also scored highest on intrinsic work motivation and job satisfaction and lowest for psychosomatic health. Conclusion: Except for social support and role ambiguity, diabetic nurses rate their [work] organisation, [work] aspects and psychological [work] reactions more positively than nurses employed in other health care settings. # 2007 Elsevier Ltd. All rights reserved. Keywords: Diabetes nurse; Work organisation; Work pressure; Emotional exhaustion
* Corresponding author at: University of Maastricht, Department Hope (Health Organisation, Policy and Economics), Faculty of Health Sciences, P.O. Box 616, 6200 MD Maastricht, The Netherlands. Tel.: +31 43 388 1727; fax: +31 43 367 0960. E-mail address: [email protected] (G.G. van Merode).
What is already known about the topic? The work organisation of nurses employed in hospitals differs from nurses employed in nursing homes, more specifically, environmental uncertainty.
0020-7489/$ – see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2007.12.003
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Relations between work organisation, aspects, and psychological attitude are for the most part in line with the Job Demand Control model regardless of the type of health care setting. What this paper adds Diabetes specialist nurses rate their [work] organisation, [work] aspects and psychological [work] reactions more positively than nurses employed in other health care settings. The transition of work tasks and a high specialisation of nurses have a positive influence on the psychological reactions when compared to those nurses employed in more traditional health care settings. In the diabetes specialist nurses’ workplace, there was no significant relation between environmental uncertainty and psychological reactions. 1. Introduction Throughout the past 10 years, the diabetes specialist nurse (DSN) has developed into an indispensable professional, administering complex care to patients with diabetic. This nursing specialisation evolved as an answer to staff shortages in charge of providing care as well as to the necessity for improvement of the quality of care. Nowadays, the transfer of tasks between doctors and nurses and substitution of doctors by nursing specialists are well accepted in the care for patients with chronic diseases such as diabetes mellitus (Vrijhoef et al., 2001). In the Netherlands the work tasks performed by the DSN can be summarised as follows: direct patient care (medical history, physical examination, interpretation of laboratory results, recording findings, and prevention of complications); co-ordination and organisation of care (identification of shortcomings, referral to and communicating with other health care-providers) and the advancement of expertise (educating patients, other health care-providers and the nurses themselves). Compared to general nurses, DSNs have one of the highest qualification levels for nursing care and are accepted nursing specialists who are focused on diabetes care and who possess distinctive skills in this area of practice (Vrijhoef et al., 2002). In the Netherlands (Vrijhoef et al., 2002), USA (Valentine et al., 2003), the UK (Winocour et al., 2002), and New Zealand (Kenealy et al., 2004) the role of the DSN increases while they enhance their position within the diabetes team (Sigurdardo´ttir, 1999). According to the DSN job profile, one can expect that the work setting of the DSN differ significantly, when compared with nurses working in a hospital or nursing home. Since the work organisation is of great importance to psychological attitude, it is relevant to explore what the differences in work organisation are and whether these differences result in
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positive or negative outcomes, directly or mediated through work aspects on psychological work reactions.
2. Theoretical perspectives on organisations, work, and psychological work reactions In this study, two theoretical perspectives are utilized for the selection of work organisation, work aspects, and psychological reactions, namely, the contingency approach of organisations (Child, 1977; Galbraith, 1977; Lawrence and Lorsch, 1967), and the Demand-Control-Support (DCS) model (Johnson and Hall, 1988; Karasek, 1979; Karasek and Theorell, 1990). According to the contingency approach, design decisions depend on environmental conditions. In addition, organisational effectiveness is achieved by organisations whose structural characteristics, i.e. centralisation, formalisation, and standardisation (Child, 1977; Gutek, 1990; Pennings, 1998) best match the demands of the environment or context, i.e. environmental uncertainty (Fry and Slocum, 1984; Pennings, 1998; Perrow, 1970; Rundall and Hetherington, 1988). The DCS model (Johnson and Hall, 1988; Karasek et al., 1981; Karasek and Theorell, 1990) is an extension of Karasek’s Job Demand-Control (JD-C) model (Karasek, 1979). Both the JD-C and the DCS models are aimed at generating a more profound insight into psychosocial risk factors at work (Karasek, 1979). Following Tummers et al. (2002), role stressors, i.e. role conflict and role ambiguity, were added to the framework. Since these stressors may cause job dissatisfaction and feelings of job-related strain (Tummers et al., 2002). The relation between these theoretic perspectives was investigated in previous research (Tummers et al., 2006). 2.1. Organisational characteristics Both structural (e.g. decision authority) and environmental characteristics (e.g. complexity and environmental uncertainty) can be used to represent the work organisation in nursing. Complexity of care refers to such patient characteristics as changes in a patient’s health and environmental characteristics. The patient mix on a unit encompasses the composition with regards to the specialities and patient diversity. Diversity implies that the differences amongst patients’ are caused by the type of disease and the level of health problems. Diabetes management is characterised by its complex nature and the complex health care needs of the patients with diabetic (El Fakiri et al., 2003). Aside from the health status of patients with type 2 diabetes, it is even more complex with 60% of patients suffering from co-morbidity (Charman, 2000). Whether or not this complex health status leads to a complex work organisation is unknown.
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Furthermore, nursing units are characterised by high environmental uncertainty or unpredictable circumstances. In general, uncertainty indicates that there is a differentiation between the amount of information required and the amount of information already held by the organisation (Galbraith, 1973). In this study environmental uncertainty refers to workflow uncertainty. As we know, nurses working in a chronic health care setting (nursing home) exhibit significantly lower environmental uncertainty than nurses working in an acute health care setting (hospital) (van den Berg et al., 2006). In general, diabetes care is not acute, but chronic by nature. Therefore, the setting wherein diabetes care is administered is expected to result in diminished environmental uncertainty compared to those working in a hospital. Decision-making authority relates to the way in which the authority to make such decisions as ‘who is going to do what and when’ is distributed among members of a ward (Bodt and Van Tuijl, 1988). The concept of decisionmaking authority, as applied in this study, refers to the performance of various tasks, and the decentralisation of decision-making. Since DSNs usually work independently, it is most likely that decision-making authority is highest. High environmental uncertainty and minimal decisionmaking authority has a negative effect on such psychological reactions as emotional exhaustion, intrinsic work motivation, psychosomatic health, and job satisfaction (Tummers et al., 2002). The aim of this study is to explore whether the work organisation of DSNs differs significantly from nurses working in hospital and nursing home and if so, does this difference result in positive or negative consequences regarding work and health. Therefore two research questions were formulated. The first research question addressed whether differences in work organisation, work aspects, and psychological reactions existed between DSNs, hospital or nursing home care. The second research question relates to the relationship between work organisation, work aspects, and the psychological reactions of nurses connected to the three different settings. This question was divided into three
sub-questions, as represented by Lines A, B1, B2 and C in the research model (Fig. 1): Line A demonstrates the relationship between characteristics of the work organisation and work aspects. Line B questions whether the relationship between the characteristics of the work organisation and psychological attitude is a direct relationship (B1) or an indirect one, via the work aspects (B2), which means that the work characteristics may be regarded as mediator variables. Line C represents the third sub-question, the relationship between work aspects and psychological reactions. Since the use of contingency theory in nursing is relatively new, there are no validated questionnaires available concerning environmental uncertainty, complexity, and decisionmaking authority. Previous research showed insufficient psychometric properties of the complexity scale in the nursing home sample (Cronbach’s alpha was .32) (van den Berg et al., 2006), the research question of how to improve the conceptualisation of work organisation was addressed as well.
3. Methods 3.1. Design and procedure In this cross-sectional study nurses working in 15 randomly selected general hospitals, 14 randomly selected nursing homes, and 825 DSNs in the Netherlands were asked whether they were willing to participate, after permission of the institutions director. Questionnaires were distributed in a sealed envelope together with a letter that explained the purpose of the study and anonymity procedures. After completing the questionnaires, subjects were asked to return them in an enclosed return envelope. Participants had been employed for at least 3 months. In the general hospital and nursing home sample all nurses complying with this criteria were included.
Fig. 1. Research model.
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An approval by the Ethics Committee was not necessary. Subjects filled in an informed consent in order to approve the use of data for scientific research. Because all data was retrieved from self-assessed questionnaires and no human body tissues or species were obtained, ethical approval was not necessary.
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women (93%). The mean age was 42.9 years (S.D. = 7.9). The mean job experience was 5.82 years (S.D. = 4.6). 3.3. Questionnaire The following variables were measured by questionnaires as part of a direct mailing. Results of reliability analysis are shown in Table 1.
3.2. Samples and response 3.4. Characteristics of the work organisation Data were collected in three samples, collected at different times over a period of 2 years: Hospital nurses: One thousand eight hundred fifty-five (1855) questionnaires were distributed among nurses from 15 hospitals. In total 1253 questionnaires were returned (a response rate of 68%). The sample size was 1204 (nursing staff employed for a period of less than 3 months were excluded from the sample). The sample consisted of 1019 women (85%). The mean age of the hospital nurses was 35.7 years (S.D. = 8.7). The mean job experience was 15.5 years (S.D. = 8.6), while the working time on the unit was 6.8 years (S.D. = 6.2). Nursing home caregivers: One thousand eight hundred forty-six (1846) questionnaires were distributed among nurses from 14 nursing homes. In total 1139 questionnaires were returned (response rate 62%). The sample size was 1058 (nursing staff employed for a period of less than 3 months were excluded from the sample). The sample consisted of 963 women (94%). The mean age of the nursing home caregivers was 35.8 years (S.D. = 9.7). The mean job experience was 12.6 years (S.D. = 8.4), while the mean working time on the unit was 4.6 years (S.D. = 4.8). DSN: Eight hundred fifty-two (852) questionnaires were distributed to DSNs in the Netherlands, 350 of which were returned (response rate 41%). The sample consisted of 325
Environmental uncertainty contains items referring to workflow and task uncertainty. One example is: ‘‘There are daily emergency admittances on this unit’’. Decision authority was measured in the DSN sample by means of 3 items, ranging from 1 ‘‘totally disagree’’ to 5 ‘‘totally agree’’. In the samples taken from the hospital nurses and nursing home caregivers, the decision-making authority scale consisted of five items. The Cronbach’s alpha was 0.7 in the sample of hospital nurses, and 0.6 in the sample of nursing home caregivers. Using the three-item version – as was the case with the sample conducted of the DSN – Cronbach’s alpha was 0.7 in the sample of hospital nurses and 0.4 in the sample of nursing home caregivers. Since the decision-making authority scale is in the developmental stages, descriptive questions of the work setting were inserted to determine which improvements could be achieved. The Pearson correlations were then calculated between the descriptive and subjective decision-making authority items. It can be concluded that decision-making authority is unrelated to working in a multidisciplinary team, the size of a multidisciplinary team, team supervisor, direct supervisor and method used to record tasks and authorities. Unfortunately reliability analysis on the data of the DSN population was unsatisfactory and yielded a Cronbach’s
Table 1 Results reliability analysis for all three samples Cronbach’s alpha Sample 1 (general hospital)
Sample 2 (nursing home)
Sample 3 (DSN)
Characteristics of the work organisation Environmental uncertainty Decision authority Complexity
0.8 0.7 0.7
0.5 0.4 0.3
0.8 0.1 0.3
Work aspects Autonomy Workload Social support at work Role ambiguity Role conflict
0.8 0.9 0.8 0.7 0.7
0.8 0.9 0.8 0.7 0.7
0.9 0.9 0.7 0.7 0.7
Psychological work reactions Emotional exhaustion Intrinsic work motivation Psychosomatic health Job satisfaction
0.9 0.7 0.8 0.9
0.9 0.7 0.8 0.9
0.9 0.7 0.8 0.9
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alpha of 0.1. Considering the insufficient psychometric properties ‘decision-making authority’ was omitted from the analyses. Complexity was measured by means of eight items. In both the hospital and nursing home samples, complexity was measured by means of ten items on a five-point response scale. Since Cronbach’s alpha emerged as unsatisfactory in the nursing home sample, the ‘‘complexity’’ scale was amended for use in the DSN sample. Descriptive questions were introduced as a means of increasing the psychometric quality, for example, questions concerning the diversity of the patient population and the number of specialisation fields. Then Pearson correlations were calculated between the descriptive and subjective complexity items. This revealed that the descriptive items had an elevated correlation with the mean complexity score and the majority of single complexity items. Furthermore, it was discovered that when nurses are only specialised in diabetes, complexity increases, the result of more complex and specialised tasks being performed, for example, insulin treatment. Unfortunately, Cronbach’s alpha proved inadequate in the DSN population with (0.4) and without descriptive questions (0.3). In order to increase the methodological quality of the scale in the future, a factor analysis was performed for the complexity scale. It was concluded that a two-factor structure is the most suitable. The first factor merely consists of items subjecting nurse specific skills. For example, ‘‘Does the patient need emotional support and psychological help?’’ and ‘‘Do you establish patient insulin treatment instituting?’’ The second factor merely consists of situation dependent complexity. For example, ‘‘What are the expectations in a high risk situation?’’ and ‘‘How many care givers do you have to deal with besides the operational doctor?’’ Considering the insufficient psychometric properties ‘complexity’ was omitted from the analyses. 3.5. Work characteristics Autonomy was measured by means of 10 items on a 5point response scale ranging from 1 ’very little opportunity’ to 5 ’very much opportunity’. This scale was derived from the Maastricht Autonomy Questionnaire, abbreviated MAQ, and was developed by De Jonge et al. (1993). Respondents were asked to rate their work situations as to the opportunities it offers for autonomy. An example of an item is: ‘‘The opportunity that the work offers to leave your workplace whenever you want’’. Workload was measured by means of an 8-item questionnaire, also developed by De Jonge et al. (1993) and ranging from 1 ’never’ to 5 ’always’. The scale consists of both quantitative and qualitative demanding aspects in the working situation, like working under time pressure, working hard, and strenuous work (De Jonge et al., 1993). An example item is: ‘‘In the unit where I work, there is too little time to finish the work’’.
Social support at work ( from colleagues and senior nursing officer) was measured by means of a 10-item scale, derived from a Dutch questionnaire on organisational stress (‘‘Vragenlijst Organisatie Stress-Doetinchem’’—VOS-D; Bergers et al., 1986). An item example is: ‘‘To what extent can you count on your colleagues, when you have difficulties in your work?’’ The items were scored on a 4-point response scale format, ranging from 1 ‘‘never’’ to 4 ‘‘always’’. 3.6. Psychological work reactions Emotional exhaustion was measured by means of the Dutch version of the Maslach Burnout Inventory (MBI (Maslach and Jackson, 1986)): the MBI-NL (Cox et al., 1993; Maslach, 1993; Schaufeli and Van Dierendonck, 1993). The emotional exhaustion scale of the MBI-NL consists of 8 items, ranging from 1 ‘‘never’’ to 7 ‘‘always’’. An item example is: ‘‘I feel emotionally drained from my work’’. Intrinsic work motivation was measured by means of 6 items derived from a scale developed by Warr et al. (1979), ranging form 1 ‘‘totally disagree’’ to 5 ‘‘totally agree’’. An item example is: ‘‘My opinion of myself goes down when I do this job badly’’. 3.7. Statistics Background variables were analysed by using a descriptive analysis. To gain insight into the work organisation, aspects, and psychological reactions of DSNs in relation to nurses employed in hospitals and nursing homes, multivariate analysis (ANCOVA) was carried out. Gender and age were entered as covariates. Post hoc procedure Bonferroni and Scheffe were used. Hierarchical multiple regression analysis was applied in order to investigate the relationships between: (a) characteristics of the work organisation and work aspects, (b) characteristics of the work organisation and psychological work reactions, and (c) work characteristics and psychological work reactions. All the variables included in this study were standardised to reduce problems of multi-colinearity. Two-way interaction effects were tested by computing cross-product terms of the standardised independent variables. Regression analyses were presented separately for DSNs, hospital, and nursing home settings. To investigate which characteristics of work organisation are predictable in terms of emotional exhaustion, intrinsic work motivation, psychosomatic complaints, and job satisfaction, hierarchical multiple regression analyses were performed separately for each criterion variable. Because gender and age were correlated with characteristics of the work organisation, work aspects, and psychological reactions, the analyses were controlled for the background variables gender and age. The order of fit in the hierarchical regression model was: (1) gender and age, (2) workload, (3)
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autonomy, (4) social support, and (5) role ambiguity and role conflict. All analyses were carried out with the Statistical Package for Social Sciences Version 11.0 for Windows (SPSS, 1999).
4. Results
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contrary, the social support scores for the DSN were the lowest in relation to the other health care settings. The DSN scored highest for role ambiguity and lowest for role conflict. DSNs scored highest in intrinsic work motivation and job satisfaction, and lowest for psychosomatic ailments. There were no significant differences in psychosomatic ailments between the DSN and hospital nurses ( p = 0.2). 4.2. Relationships between organisational characteristics and work aspects (Line A in Fig. 1)
4.1. Descriptives The majority of DSNs (78%), worked in a multidisciplinary team, mean size 8.9 (S.D. = 6.0) members. Ninety one percent (91%) were employed on a full-time basis. The patient population under care was, in 7% of all cases, ‘‘younger than 18 years’’, in 45% of the cases the population were ‘‘older than 18 years’’, and in 30% of the cases ‘‘the patients were represented by all age groups’’. The majority of DSNs were not specialised in any other field other than diabetes (67%), but for those DSNs who are specialised in other fields, the specialisation often extends to more than one other specialisation. Registration of tasks and authorities took place in 54% of all cases in ‘‘work description’’ or was registered in more than one document (21%). Table 2 demonstrates that nurses working in a general hospital, nursing home or as DSN score significantly different in terms of work organisation, work aspects, and work reactions, as determined by overall F-tests. No significant differences in average score were found for emotional exhaustion. Environmental uncertainty was significantly lower in diabetes care than in both of the other settings. DSNs exhibited the lowest workload in relation to the other health care settings. Post hoc procedure Bonferroni and Scheffe did not reveal any significant global differences in mean score ( p = 0.1) for workload between DSN and hospital nurses. In regard to autonomy, the DSN scored highest in relation to the other health care setting. On the
Table 3 indicates relatively low percentages of the variance (R2) in work aspects that were explained by work organisation. In the DSN setting, environmental uncertainty has a positive relation with role conflict (b = 0.2***) and workload (b = 0.4***). From a work and health point of view, environmental uncertainty is an indicator of negative work characteristics (an increased workload, role conflict, and reduced social support). In the nursing home setting, environmental uncertainty indicates positive work aspects (increased autonomy and less role ambiguity). 4.3. Relationships between organisational characteristics and psychological work reactions (Line B1 in Fig. 1) Table 4 indicates that none of the psychological work reactions were explained by environmental uncertainty in the DSN setting. Emotional exhaustion was not predicted by environmental uncertainty, in any of the settings. From a work and health point of view, environmental uncertainty was an indicator of positive (more intrinsic motivation) as well as negative work reactions (more psychosomatic ailments) in the hospital setting. In a nursing home setting, environmental uncertainty has a positive influence, i.e. higher intrinsic motivation and job satisfaction.
Table 2 Univariate test results Variables [number of items] (x-point Likert scale)
Sample 1 (general hospital) Mean (S.D.)
Sample 2 (nursing home) Mean (S.D.)
Sample 3 (DSN) Mean (S.D.)
Environmental uncertainty [5] (5)
3.9 (.7)
3.8 (.6)
3.7 (.7)
Workload [10] (5) Autonomy [8] (5) Social support at work [10] (4) Social support supervisor [5] (4) Social support colleague [5] (4) Role ambiguity [4] (5) Role conflict [3] (5)
3.3 2.8 3.2 3.2 3.3 2.1 2.7
(.5) (.5) (.3) (.5) (.3) (.5) (.5)
3.4 2.7 3.3 3.3 3.3 2.0 2.5
(.6) (.6) (.3) (.5) (.4) (.6) (.6)
3.3 3.3 2.8 2.7 2.9 2.1 2.4
(.6) (.7) (.4) (.5) (.4) (.6) (.6)
13.8* 178.9* 270.0* 235.9* 143.5* 12.9* 28.5*
Emotional exhaustion [8] (7) Intrinsic work motivation [6] (5) Psychosomatic health [21] (yes/no) Job satisfaction [21] (5)
2.2 4.0 0.2 3.5
(.7) (.5) (.2) (.4)
2.3 4.0 0.2 3.6
(.8) (.5) (.2) (.4)
2.2 4.1 0.1 3.7
(.8) (.5) (.2) (.4)
4.7 11.4* 13.2* 14.3*
*p 0.001.
F (overall)
19.0*
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Table 3 Relation between work organisation and work characteristics Predictor
1. Gender Age
Criterium
Workload
2. Environmental uncertainty 1. Gender Age
Autonomy
2. Environmental uncertainty 1. Gender Age
Diabetes specialist/hospital nurse/nursing home Beta (b)
R2change
R2
.05/.12***/.00 .05/.06*/.06
.00/.01***/.00
.00/.01/.00
.38***/.24***/.09**
.15***/.06***/.01**
.15/.07/.01
.04/.10***/ .05 .12*/.03/ .01
.02/.01**/.00
.02/.01/.00
.05/ .03/.08**
.00/.00/.01**
.02/.01/.01
.01/ .00/.02 .04/ .00/ .03
.00/.00/.00
.00/.00/.00
.08/ .07**/.06
.01/.01**/.00
.01/.01/.00
.02/ .01/ .07* .02/ .05/ .00
.00/.00/.00
.00/.00/.00
.03/.02/ .15***
.00/.00/.02***
.00/.00/.03
.00/ .04/ .03 .12*/ .10***/ .01
.02*/.01***/.00
.02/.01/.00
.24***/.14***/.01
.06***/.02***/.00
.07/.03/.00
Social support
2. Environmental uncertainty 1. Gender Age
Role ambiguity
2. Environmental uncertainty 1. Gender Age
Role conflict
2. Environmental uncertainty *p .05, **p .01, ***p .001.
4.4. Relationship between work characteristics and psychological work reactions (Line C in Fig. 1) Explained variances showed to be higher for emotional exhaustion (R2 = .31) and job satisfaction (R2 = .43) com-
pared to intrinsic motivation (R2 = .05) and psychosomatic complaints (R2 = .10) (Table 5). Emotional exhaustion indicates a positive relation with high workload, role conflict, and role ambiguity across all settings. Job satisfaction was predicted by all measured work
Table 4 Relation between organisational characteristics and psychological work reactions Predictor
1. Gender Age
Criterium
Emotional exhaustion
2. Environmental uncertainty 1. Gender Age
Intrinsic work motivation
2. Environmental uncertainty 1. Gender Age
2. Environmental uncertainty *p .05, **p .01, ***p .001.
Beta (b)
R2change
R2
.00/ .02/ .00 .05/.00/ .01
.00/.00/.00
.00/.00/.00
.09/.05/ .01
.01/.00/.00
.01/.00/.00
.10*/.10***/.02 .05/.08**/.13***
.02/.01***/.02***
.02/.01/.02
.00/.01**/.01***
.02/.02/.03
.02/.04/.05 .06/ .01/.00
.00/.00/.00
.00/.00/.00
.10/.06*/ .03
.01/.04*/.00
.01/.01/.00
.07/.05/.01 .01/.07*/ .01
.01/.01*/.00
.01/.01/.00
.01/.00/.02***
.01/.01/.02
.02/.09**/.12*** Psychosomatic complaints
2. Environmental uncertainty 1. Gender Age
Diabetes specialist/hospital nurse/nursing home
Job satisfaction
.07/ .05/.12***
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Table 5 Relations between work characteristics and psychological work reactions Predictor
1. Gender Age
Criterium
Emotional exhaustion
2. Workload 3. Autonomy 4. Social support 5. Role ambiguity Role conflict 1. Gender Age
Intrinsic Work motivation
2. Workload 3. Autonomy 4. Social support 5. Role ambiguity Role conflict 1. Gender Age
Psychosomatic complaints
2. Workload 3. Autonomy 4. Social support 5. Role ambiguity Role conflict 1. Gender Age
Job satisfaction
2. Workload 3. Autonomy 4. Social support 5. Role ambiguity Role conflict
Diabetes specialist/hospital nurse/nursing home Beta (b)
R2change
R2
.02/ .05/ .04 .06/.01/ .03
.01/.00/.00
.01/.00/.00
.36***/.35***/.34*** .13/.04/ .01 .07/ .14***/ .18*** .24***/.10***/.06* .14*/.18***/.13***
.20***/.20***/.20*** .00/.00/.00* .03***/.05***/.05*** .07***/.04***/.02***
.21/.20/.20 .21/.20/.20 .24/.25/.25 .31/.29/.27
.11/.08**/.01 .02/.07*/.13***
.01/.01***/.02***
.01/.01/.02
.06/ .08*/.08* .12*/ .02/ .01 .08/.12/.07 .04/.04/ .05 .10/ .04/ .09**
.00/.00/.00 .02*/.00/.00 .01/.01***/.01*** .01/.00/.01** .00/.00/.00
.01/.02/.02 .03/.02/.02 .04/.03/.03 .05/.03/.04
.01/.02/.05 .08/ .01/ .01
.01/.00/.00
.01/.00/.00
.24***/.20***/.18*** .00/.02/ .07* .01/ .10**/ .14*** .10/.06/.04 .06/.09**/.08*
.08***/.07***/.07*** .00/.00/.01*** .00/.02***/.03*** .01/.01***/.01** .00/.00/.00
.08/.07/.07 .08/.07/.08 .09/.09/.11 .10/.10/.12 .10/.10/.12
.07/.07**/ .02 .00/.06*/.01
.01/.01*/.00
.01/.01/.00
.07***/.14***/.13*** .07***/.02***/.05*** .19***/.19***/.20*** .10***/.05***/.06*** .00/.00**/.00
.08/.15/.13 .15/.17/.17 .33/.36/.38 .43/.41/.44 .43/.42/.44
.12*/ .21***/ .16*** .15***/.06**/0.11*** .30***/.34***/.36*** .30***/ .19***/ .22*** .13**/ .15***/ .16***
*p .05, **p .01, ***p .001.
characteristics, from which high work load, role ambiguity, and role conflict had similar relations across all samples. High workload was positive associated with psychosomatic complaints in all three samples. Interaction terms have been tested but were not additional to the model. 4.5. The mediating role of work aspects (Line B2 in Fig. 1) The possible mediating role of work aspects in the relationship between work organisation and psychological work reactions was not tested in a DSN setting because there were no significant correlations found between psychological work reactions and environmental uncertainty and therefore a mediating role is out of the question (Bennett, 2000). In the hospital and nursing home settings, some results were determined, which indicated that a mediator role is plausible (van den Berg et al., 2006).
5. Discussion The main purpose of this study was to extend knowledge concerning the work situation of DSN in relation to a traditional health care setting. This study demonstrates that 10% of DSN in the Netherlands are working in an integrated care setting, whereas 40% are working in a home care (general practice) setting and 41% in a setting which is available after reference by the GP, for example hospital. The other 10% worked in other settings. This finding corresponds with earlier research conducted by Steuten et al. (2002). The majority of DSN (78%) perform their tasks as part of a multidisciplinary team. This result conforms to the frequent use of multidisciplinary teams in diabetes management and supports Mulcahy’s (1999) opinion, that in diabetes management the use of multidisciplinary teams are logical given the multidimensional nature of diabetes. In addition, indications suggest that almost all DSN are not specialised in any other fields
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other than diabetes (67%). This supports the finding by Vrijhoef et al. (2002), that the DSN is highly specialised and purely focused on diabetic care. Some limitations must be taken into account in this study. First, the cross-sectional design does not permit exploration of causal relationships between work and organisational characteristics and psychological work reactions. Nevertheless, the results are still of interest as they give a first insight in influence of differences in work setting on psychological work reactions. Second, the psychometric quality of the organisational work characteristics was very poor. In the DSN sample reliability analysis showed unsatisfactory Cronbach’s alphas for decision authority and complexity. Both variables were omitted from the analysis. The two scales were not appropriate to measure aspects of the contingency theory in nursing. Third, no non-response analyses could be performed. The response in the DSN sample (41%) was quite lower than in the hospital (68%), and nursing home sample (62%). One explanation could be that nurses working in general hospitals and nursing homes were informed by the managers during the ward meeting about the research topic and purpose, the data collection procedure, and the research report. Whereas DSNs were directly invited to participate in the study without mediation of the manager. In general, differences in work organisation, work characteristics, and psychological work reactions were significant, although the differences were small. In regard to the work organisation, this study revealed that the environmental uncertainty is low amongst DSN in comparison to hospital nurses and nursing home caregivers. Apparently, in the field of diabetes nursing, more knowledge concerning workflow or when ‘‘the inputs’’ will arrive, i.e. patient inflow exists. The findings were as expected. In principle, the patient [visit] schedule is known and care needs are relatively predictable. From a work and health point of view, relatively positive results were found regarding the work aspects of the DSN in relation to nurses working in general hospitals and nursing homes. For example, DSNs scored lowest on workload and role conflict, and highest on autonomy. Despite, again it should be mentioned differences were only minor, except for autonomy. DSNs regard autonomy higher than hospital nurses or nursing home caregivers. The DAWN study (Siminerio et al., 2007) showed, regarding responsibilities, that specialist nurses functioned at a more advanced level and reported taking a more active role in facilitating both selfmanagement and medication management than generalist nurses did. In Brown et al., 2001 it was mentioned that diabetes educators express frustration over the limited authority they have in caring for patients with diabetic . Despite this frustration, the fact that they work on an independent basis is a likely factor in the high score for autonomy, compared with nurses working in other health care settings. Working independently probably attributes to the low scores for social support (from both supervisors and colleagues). Operational tasks are performed rather independently. Personal feedback and support is only obtained during the meetings of the
multidisciplinary team. This finding is in agreement with a study among nurse consultants (Woodward et al., 2005) in which specialised nurse consultants felt less social support from their immediate colleagues than non-specialised nurse consultants felt. This lack of social support could be decreased by focussing on the emotional nature of support from peers and colleagues than that of a physical presence. The knowledge that the nurse can share with a peer or a manager while alone at work under difficult circumstances should be strengthened (Neal-Boylan, 2006). The high scores for role ambiguity may be explained by the fact that the function of a DSN is in the developmental stage where roles increase and are amended. Registration of tasks and responsibilities were available in such documents as task description (54% of all registrations), function profile (10%) or protocol (10%). Apparently, the registration of tasks and responsibilities are in all likelihood, not sufficient enough to compensate this dynamic role development. In regard to work and health, positive results attributed to work aspects are also identified in work reactions. This has resulted in the highest scores being allocated to intrinsic work motivation and work satisfaction, and the lowest scores being allocated to psychosomatic health. The specialised tasks of the DSN could be positive for the experience of stress as the inability to use all of their skills on the job was reported to cause stress in nursing home nurses (Lapane and Hughes, 2007). Yet, equivalent univariate analyses indicated that there were no significant differences of emotional exhaustion between the three health care settings examined in this study. In Charman (2000), it was reported that DSN were at high risk of emotional exhaustion because of their perfectionist character and the psychosocial stressors they regularly deal with. However, these risk factors are not specifically associated to DSN, but rather to the nursing profession in general. With regard to the second aim of the study, it was disclosed that in the DSN setting, environmental uncertainty was positive in relation to workload and role conflict. Work organisation characteristics, decision-making authority, and complexity could not be investigated, as the psychometric quality of these, were not acceptable. No direct relation exists between environmental uncertainty and the psychological work reactions. As a result, any possibility of a mediating role of work characteristics is out of the question. With regard to the relationship between the work characteristics and psychological work reactions, it can be concluded that workload was an important predictor of emotional exhaustion and psychosomatic complaints in all three samples. From the psychological work reactions job satisfaction was best predicted by the work characteristics, which is in line with findings of Rafnsdottir et al. (2004) among nurses in geriatric care. With exceptions to the negative association between autonomy and social support with job satisfaction in the DSN sample, results are in line with the DCS model. Work organisation environmental uncertainty forecast negative work characteristics (more workload and role con-
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flict, less social support) in the DSN and hospital setting. This was not true in the nursing home setting: environmental uncertainty was a forewarning of more autonomy and less role ambiguity. In the nursing home setting environmental uncertainty forecast positive psychological work reactions (more intrinsic motivation and job satisfaction). In the hospital setting relations between environmental uncertainty and psychological work reactions were contradictory. These contradictory findings can probably be attributed to the unsatisfactory psychometric quality of the work organisation variables. Moreover, in all health care settings, explanatory variances were low. In the DSN sample these varied from .01 to .43.
6. Conclusions The work of a DSN can be distinguished by certain characteristics. From an organisational point of view, the work setting is characterised by low environmental uncertainty in comparison with nurses employed in the other two health care settings (hospital and nursing home). Furthermore, the work of the DSN can be characterised by high autonomy and role ambiguity, low workload, social support, and role conflict. Relations between organisational characteristics, work aspects, and psychological work reactions indicated conflicting results due to differing psychometric qualities of the environmental uncertainty variable. DSNs scored most positive in regard to psychological work reactions. It can be concluded that differences in the work organisation through transition of work tasks and high specialisation of nurses has a positive influence on the psychological work reactions in comparison with a more traditional health care setting. Continued improvement of the work situation of DSNs should focus on decreasing role ambiguity and increasing social support. Since the nurse practitioner is the future trend in health care (Reay et al., 2003), e.g. the DSN, it might be expected that transition of work tasks and high specialisation of advanced nurses or nurse practitioners have a positive influence on psychological work reactions in comparison with a more traditional health care setting. Recommendations for additional work suggest a need for the optimal measurement of organisational characteristics. As this study reveals, scales for organisational characteristics require improvement and should even be combined with objective data related to variances in patient flow, patient mix, and role differentiation.
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