Changes in the Geriatric Care Environment Associated with NICHE (Nurses Improving Care for HealthSystem Elders)

Changes in the Geriatric Care Environment Associated with NICHE (Nurses Improving Care for HealthSystem Elders) Marie Boltz, PhD, RN, GNP, BC, Elizabeth Capezuti, PhD, RN, FAAN, Susan Bowar-Ferres, PhD, RN, CNAA-BC, Robert Norman, PhD, Michelle Secic, MS, Hongsoo Kim, PhD, MPH, RN, Susan Fairchild, MPH, Mathy Mezey, EdD, RN, FAAN, Terry Fulmer, PhD, RN, FAAN The aging of the U.S. population has profound implications for acute care nursing practice. NICHE (Nurses Improving Care for HealthSystem Elders) is the only national nursing program that addresses the needs of the hospitalized older adult. This secondary analysis examines the influence of the NICHE program on nurse perceptions of the geriatric nursing practice environment and quality of geriatric care, as well as geriatric nursing knowledge in a sample comprising 8 acute care hospitals in the United States that administered the Geriatric Institutional Assessment Profile before and after NICHE implementation. Results were compared in a sample of 821 and 942 direct care nurses, respectively. Controlling for hospital and nurse characteristics, both nurse perceptions of the geriatric nursing practice environment (P ⬍ .0001) and quality of geriatric care (P ⫽.0004) increased, but not geriatric nursing knowledge (P ⫽.1462), following NICHE implementation. NICHE tools and principles can exert an important influence over the care provided to older adult patients by increasing the organizational support for geriatric nursing. (Geriatr Nurs 2008;29:176-185) dults age 65 and older utilize 48% of the nation’s total health care resources and comprise approximately 60% of all adult non-obstetric acute care admissions.1 This aging trend is expected to continue, as the U.S. Administration on Aging projects that more than 20% of the population will be aged over 65 years by the year 2030, with the fastest growing segment being those aged 85 and above.2 Compared with other age cohorts, older hospitalized pa-

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tients demonstrate higher acuity, use more health care resources, experience more complications, and have longer lengths of stay.3 The ever-increasing number of older adults and the health care needs of an aging population make it inevitable that most nursing care in the hospital will continue to be delivered to older adults4 and require specialized knowledge of geriatric and aging-sensitive care delivery.5 Experts in the field agree that quality geriatric care, similar to patient-centered care in general, is evidence based; is individualized to the patient’s needs, situations, and preferences; and promotes patient decision making.6-8 It is specialized to the older adult patient in that the evidence base is aging-specific and interdisciplinary in nature and supports continuity across settings.5,9-11 Essential components of the nurse practice environment necessary to provide quality geriatric care include: 1) institutional values that align the rights of older adults to receive specialized care and the professional autonomy of the direct care nurse; 2) nurse access to geriatric-specific resources (material and human); and 3) institutional practices and protocols that support interdisciplinary collaboration.12 The development of elder-friendly care environments is hindered by the fact that the majority of nurses have received no formal education regarding the specialized nursing needs of older patients13,14 despite evidence that lack of geriatric education negatively affects quality of care.15 Further complicating the problem is the fact that few of the nation’s approximately 6000 hospitals have institutional practice guidelines, educational resources, and administrative practices that support best practices care of older adults.16 NICHE (Nurses Improving Care for HealthSystem Elders), a program of the Hart-

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Figure 1. Components of the NICHE Tool Kit. ford Institute for Geriatric Nursing at New York University College of Nursing, addresses these shortfalls and is the only national nursing program designed to strengthen the geriatric nurse practice environment.17 NICHE provides guiding principles and operational tools to develop

and utilize geriatric-specific resources, evidence-based clinical protocols and nursing organizational models.18 Figure 1 provides an overview of the NICHE tool kit. In single-site studies, NICHE hospitals demonstrate improved clinical outcomes,19-23 rates

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of compliance with institutional protocols,20,21 cost-related outcomes,21,23 and nurse knowledge.20,24,25 NICHE coordinators report that an institutional commitment to geriatric care is integral to the successful implementation and stabilization of the NICHE program,16 consistent with studies demonstrating that the nurse practice environment (organizational factors that constrain or support nursing practice26) has particular implications for nurse effectiveness and patient outcomes.26,27 The purpose of this study was to examine the influence of NICHE in a national sample of member hospitals on select geriatric outcomes. We hypothesized that, controlling for nurse and hospital characteristics, NICHE implementation would increase nurse perceptions of the geriatric nursing practice environment and the quality of geriatric care provided to older adult patients, as well as increase geriatric nursing knowledge.

Conceptual Framework Bandura’s concept of collective efficacy guided the measures and analysis for this study. Collective efficacy is defined as “the conjoint capabilities to organize and execute the courses of action required to produce given levels of attainment”28 (p. 477). According to Bandura, there are 3 ways to measure collective self-efficacy: the aggregate of each individual’s self-evaluation of his or her personal skills; the aggregate of each member’s appraisal of the group’s capabilities, and a measure of performance as a whole. Accordingly, this study evaluated the effectiveness of the NICHE program by measuring the change in the following components of the geriatric care environment: 1) nurse knowledge of geriatric care (a measure of individual efficacy); 2) the perception of the geriatric nurse practice environment (a measure of group capability); and 3) the perception of quality of geriatric care (a measure of organizational performance). Social and structural factors can influence organizational efficacy,28 including the characteristics of the setting and the group composition (in this study, nurse and hospital characteristics). Thus, this study examined the influence of the NICHE program on 3 measures of geriatric-specific efficacy while considering the potentially additive effects of nurse and hospital characteristics.

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Methods Design This study was a secondary analysis of data collected by the NICHE program, used to assess a hospital’s readiness to implement geriatric initiatives. Data from the Geriatric Institutional Assessment Profile (GIAP) database, a proxy measure for the overall quality of care provided to older adult patients, was used. The GIAP serves as a benchmarking tool to assist hospitals in identifying gaps in knowledge, specific practice issues and concerns, and organizational attributes of the hospital relevant to geriatric care.29 A pre-post, cross-sectional design was used, examining data before and after NICHE implementation. Sites and Participants The GIAP responses of 8 urban, not-for-profit, acute-care hospitals were examined. The hospitals were located in the following geographic areas: the Northeast (1), the Southeast (1), the Midwest (1), the Northwest (2), the Southwest (1), South Central (1), and non-mainland United States (1). Four hospitals were members of the Council of Teaching Hospitals. The hospitals differed in size, 1 with 100-199 beds, 2 with 200-299 beds, 2 with 300-399 beds, and 3 with more than 400 beds. Payer mix also varied, with the mean annual percentage of Medicare and Medicaid discharges ranging from 8% to 50% and 3% to 25%, respectively. The sample was restricted to acute-care, staffregistered nurses in direct care positions who work with older adults. There were 896 registered nurses in the pre-NICHE implementation group (pre-NICHE) and 1028 nurses in the postNICHE implementation group (post-NICHE). The difference in the number of respondents is related to the availability of respondents between the 2 groups and reflects personnel changes that typically occur on a hospital unit. Nurses from the following units were included: general medical, general surgical, medical/surgical, emergency department, critical care, noncritical care specialty unit (e.g., orthopedic, pulmonary unit), geriatric, and psychiatric. Excluded were nurses who worked on nonacute (rehabilitation, ambulatory care, and home care), obstetric/gynecologic, and “rotating” units (preNICHE, n ⫽ 75; post-NICHE, n ⫽ 86), yielding a

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Table 1. Geriatric Institutional Assessment Profile Study Scales and Subscales Construct

Conceptual Definitions

The Geriatric Nurse Practice Environment (GNPE) scale

A composite measure of the 3 variables associated with the concept of the geriatric nursing practice environment: 1) institutional values regarding older adults and staff, 2) capacity for collaboration, and 3) resource availability Nurse perceptions of respect for the rights of older adults, involvement of older adults and families in decision making, support of nurse autonomy and personal growth Nurse perceptions of other disciplines’ knowledge of geriatric care, use of geriatric protocols, and degree of conflict Nurse perceptions of access to human and material resources specific to care of older adults and management support of communication with patients and families Knowledge of the assessment and nursing management of 4 common geriatric syndromes: pressure ulcers, incontinence, restraint use, and sleep disturbance Geriatric-specific, evidence-based, individualized care that promotes informed decision making and is continuous across settings

Institutional Values Regarding Older Adults and Staff (GNPE subscale)

Capacity for Collaboration (GNPE subscale)

Resource Availability (GNPE subscale)

Geriatric Nursing Knowledge scale

Quality of Geriatric Nursing Care/Aging-Sensitive Care Delivery scale

No. Items

Possible Range

␣

␣‡

18

0-72

.93*

.89

7

0-28

.84*

.84

3

0-12§

.83*

.83

8

0-32§

.90*

.89

22

0-10

.60†

.66

10

0-40

.94*

.93

*Data from Kim et al., 2007.30

Data from Abraham et al., 1999.29 Study database. § Reverse scored. † ‡

study sample of 821 nurses in the pre-NICHE group and 942 nurses in the post-NICHE group. The study was approved by the New York University Committee on Activities Involving Human Subjects (UCAIHS). Measurement The GIAP, which contains 68 major questions and a total of 152 items, surveys geriatric practice knowledge, care attitudes, and perception of the geriatric care environment in the acutecare setting, as well as respondent demographic and professional characteristics.17,29 Two scales of the GIAP, the geriatric care environment

scale and the knowledge scale, were used for this study. Psychometric testing of these scales yielded good internal consistency (␣ ⫽ .60 –.94)30 and good interrater reliability (r ⫽ .71–.85).31 In the study data set, internal consistency ranged from ␣ ⫽ .66 to ␣ ⫽ .93. Table 1 summarizes the constructs, conceptual definitions, number of items in each construct, possible ranges, published Cronbach’s alphas, and then the sample Cronbach’s alphas. Nurse and Hospital Characteristics. Nurse demographic (age, sex, and race/ethnicity) and professional data (nurse educational level, years of experience in the profession, the years of

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experience at the institution, and the primary type of unit worked on) were extracted from the GIAP. Nurse educational level was defined as the nurse’s highest nursing degree (diploma, associate, baccalaureate, master’s, or doctorate). The GIAP and the American Hospital Association Survey32 provided information on the following hospital characteristics: teaching status (based on hospital membership in the Council of Teaching Hospitals), bed size, and payer mix (defined by 2 variables: the percentage of Medicare discharges and the percentage of Medicaid discharges). Nurse and hospital structural characteristics were used for descriptive purposes, were examined for possible associations with the outcomes, and were included as covariates in the model, as indicated. Nurse Perception of the Geriatric Nurse Practice Environment. The nurse practice environment, a term synonymous with organizational support, encompasses the hospital organizational characteristics that facilitate or constrain nursing practice.26 Three constructs are associated with the concept of the geriatric nursing practice environment: 1) institutional values regarding older adults and staff, 2) capacity for collaboration, and 3) resource availability. Each of these constructs serves as a dimension or subscale of the geriatric care environment scale and are more fully described in Table 1. The composite measure of the 18-item geriatric nursing practice environment as well as each dimension—resource availability (8 items), institutional values (7 items), and capacity for collaboration (3 items)—were outcome variables, evaluated as the mean value of the items composing each of the constructs. Nurse Perception of Quality of Geriatric Care. Nurse perception of quality of geriatric care, another outcome variable, is defined as evidence-based care that is specialized to the care of older adults and individualized to the patient’s needs, situations, and preferences.29 It is operationalized by the 10-item aging-sensitive care delivery subscale of the GIAP geriatric care environment scale30 and evaluated as the mean of the values for each item measured for this construct. Geriatric Nursing Knowledge. Geriatric nursing knowledge, also an outcome variable and a GIAP subscale, was evaluated as the mean of the values for each item measured for this construct. It is defined as knowledge of the assess-

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ment and management of the following common geriatric syndromes: pressure ulcers, incontinence, restraint use, and sleep disturbance.30 Data Analysis Before data analysis, imputation methods were employed. Although multiple imputation33 methods are attractive, they assume all variables to be imputed are multivariately normally distributed. Although this method is widely used to impute categorical data, there is a natural concern about the consequences of violating these assumptions,34 and this introduces biased estimates of proportions in the database.35 In addition, the analyses developed for multiple imputed data sets do not allow categorical variables to be defined in the models because they assume all imputed variables are normally distributed. Again, the assumption would have to be made that the categorical variables were continuous in the modeling stage, thus introducing another layer of bias. Because the database has many categorical covariates, single-sample imputation methods were used. The first step of the multiple imputation methods to impute multiple data sets was used and then only a randomly selected single sample was used for analysis. This therefore removed the need for use of the multiple imputation process and allowed for use of standard statistical modeling procedures after single-sample imputation. It is also important to point out that imputation was conducted on the item level, not the construct level. To ensure reliability of the data, imputation was not conducted for cases in which more than half of the items in a certain construct were missing (approximately 5% of total cases). Descriptive data of the nurses in the 8 hospitals that implemented NICHE were examined, comparing preintervention to postimplementation. Changes pre- to post-NICHE implementation in the perception of the geriatric nurse practice environment, perception of quality of geriatric care, and geriatric nursing knowledge were examined using a linear mixed effects (LME) model using these variables as the outcomes to be modeled, testing for a relationship with the administration time (pre- and postNICHE implementation). The relationship of potential nurse or hospital characteristics (or both) with the outcomes were explored and added as covariates to the model when indi-

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Table 2. Comparison of Nurse Characteristics: Pre- and Post-NICHE

Female* Race/Ethnicity* White Black/African American Hispanic/Latino Asian Other Education* Diploma Associate Baccalaureate Master or doctorate Age† Unit worked* Medical Surgical Medical-surgical Critical care Non–critical care specialty unit Emergency department Geriatric Psychiatric Missing

Pre-NICHE (n ⴝ 821)

Post-NICHE (n ⴝ 942)

National Profile

90 (739)

92 (867)

94.2

80 2 1 13 3

(659) (17) (11) (108) (26)

78 3 1 15 3

(739) (28) (9) (138) (28)

81.8 4.2 1.7 3.1 7.8

8 45 45 2 9.7

(68) (370) (365) (18) (40)

7 45 47 1 40

(66) (424) (443) (9) (10.5)

25.2 33.7 34.2 13 46.8

10 9 27 21 13 7 5 2 6

(83) (75) (222) (169) (110) (55) (40) (19) (48)

11 9 26 19 14 7 5 3 6

(104) (84) (245) (179) (132) (66) (47) (29) (56)

Data from: Health Resources and Services Administration. (2006). 2004 National Sample Survey of Registered Nurses.36 *Percentage (n) values.

Mean (SD).NICHE ⫽ Nurses Improving Care for HealthSystem Elders.

†

cated. The nurse characteristic variables include age, gender, race/ethnicity, education level, years of professional experience, years of experience at the institution, and type of unit worked. The hospital characteristics included type of hospital ownership, hospital bed size, and hospital teaching status. Within the statistical model, the hospital characteristics and nursing staff levels were considered random effects because the levels of the factors within the sample do not exhaust all possible levels for every hospital/staff. Therefore, they could not be considered fixed, like gender, for example; they were more appropriately defined as random effects in the model. Analyses were conducted using SPSS for Windows version 15.0 (Chicago, IL) and SAS software. A P value of ⬍.05 was considered significant for all tests. Findings The study hospitals are all not-for-profit, urban sites with diverse payer mixes and geo-

graphic locations that conducted the GIAP before and after NICHE implementation. There were 821 nurses in the pre-NICHE implementation sample and 942 in the post-NICHE implementation sample. The nurses’ demographic and professional characteristics are similar in the pre-NICHE and post-NICHE implementers. Table 2 compares the key characteristics of the study nurses at both time points to the national profile of nurses. The sample has less diploma nurses and master’s or doctorally prepared nurses compared with national figures of registered nurses, which is not surprising given that the nurses were in direct care positions. The majority of nurses in each group was white and female and had either an associate or baccalaureate degree as the highest level of academic nursing preparation. Comparatively, the average age of 40.0 for both pre- and post- samples is somewhat younger than the national average age of 46.8, which is not surprising given that the sample was re-

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Table 3. Linear Mixed Effects Model: Pre- and Post-NICHE Comparisons of the Geriatric Nurse Practice Environment (Composite and Dimensions), Quality of Geriatric Care, and Geriatric Nursing Knowledge n GNPE

1540

Values

1634

RA

1663

CC

1701

ASCD

1655

GNK

1370

Administration* Time Time Time Time Time Time Time Time Time Time Time Time

1 2 1 2 1 2 1 2 1 2 1 2

t

P

19.7

⬍.0001

3.9

⬍.0001

45.8

.1100

3.8

.1300

11.3

.0004

1.4

.1462

Estimated Mean

Standard Error

39.0 41.9 15.4 17.4 15.5 16.1 7.5 7.7 22.7 24.3 4.8 4.9

0.47 0.44 0.27 0.25 0.21 0.20 0.10 0.93 0.30 0.30 0.30 0.28

ASCD ⫽ Aging-sensitive Care Delivery; CC ⫽ Capacity for Collaboration; GNK ⫽ Geriatric Nursing Knowledge; GNPE ⫽ Geriatric Nursing Practice Environment (Composite); IV ⫽ Institutional Values regarding Older Adults and Staff; NICHE ⫽ Nurses Improving Care for HealthSystem Elders; RA ⫽ Resource Availability. *Admin Time 1: Pre-NICHE implementation; Time 2: Post-NICHE implementation.

stricted to direct care nurses who tend to be younger than nurses in administrative and other positions.36 Additionally, there is more representation of Asian nurses and fewer nurses who describe their race ethnicity as “other” in the study sample. These differences are most probably reflective of geographic differences between the study sample and the national sample. Most participants worked in a medical or surgical unit (or both), and the mean years of experience in the nursing profession were 13.1 years (SD 9.9) in the pre-NICHE group, and 13.2 years (SD 10.4) in NICHE implementers. The mean years worked at the institution was 8.6 (SD 7.6) in the pre-NICHE group and 8.1 (SD 8.0) in NICHE implementers. Neither nurse characteristics nor hospital characteristics demonstrated a significant association with the nurses’ perception of the geriatric nurse practice environment, perception of aging-sensitive care delivery, or geriatric nursing knowledge. Table 3 compares perceptions of the geriatric nursing practice environment, perceptions of quality of geriatric care, and geriatric nursing knowledge, pre- and post-NICHE implementation. The mean estimated geriatric nurse practice environment scores increased significantly with NICHE implementation from 39.0 to 41.9 (P ⬍.0001). The mean score for institutional values

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around care of older adults and staff increased from 15.4 to 17.4 (P ⬍.0001). No statistically significant change in capacity for collaboration or resource availability was found. The mean aging-sensitive care delivery scores (measuring perceptions of quality of geriatric care) significantly increased from 22.7 to 24.3 after NICHE implementation (P ⫽.0004). The time of administration (pre- vs. post-NICHE implementation) of the GIAP does not show a statistically significant relationship with geriatric nursing knowledge scores (P ⫽ .1462).

Discussion NICHE implementers demonstrated a significant improvement in the scores measuring nurse perceptions of both the geriatric nursing practice environment and quality of geriatric care. Thus, the findings suggest that these sites demonstrated a trend toward improvements associated with the stated goal of NICHE, which is to provide organizational tools to modify the nurse practice environment to make it more geriatric-responsive. This finding is consistent with the initial pilot testing of the NICHE implementers, which demonstrated an increase in nurses’ perceptions of improved practice environment related to the care of older adult pa-

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tients.17 Study results further demonstrate an increase in the nurse perception of the institutional values related to the care of older adult patients and staff, a dimension of the geriatric nurse practice environment. This finding is similar to those of other studies demonstrating that leadership commitment to the values of both patient and nurse self-direction are associated with nurse perceptions of an institutional values of patient centered care,37,38 promotion of nurse autonomy, and improved patient care delivery.39,40 Among the 3 subscales of the geriatric nursing practice environment, 2—nurse perception of resource availability and capacity for collaboration— did not significantly increase with NICHE implementation. The level of implementation (for example, unit vs. institutional-wide dissemination) was unknown and most likely varied between settings, a limitation of the study. Future investigation is warranted to examine the effects of “NICHE doses,” using uniform process and structure measures that quantify NICHE implementation. Nurses perceived an increase in the quality of geriatric care with NICHE implementation. This finding suggests that NICHE can be effective in addressing the issues deemed important by older adults: competence in nursing staff, support of patient autonomy, and skill in facilitating positive discharge planning.6,41-44 The increase in nurse perception of the geriatric nurse practice environment, in combination with an increase in aging-sensitivity scores associated with NICHE implementation, supports the main findings of a previous study that significantly linked the geriatric nursing practice environment to quality of geriatric care.12 Thus study results suggest that NICHE tools and principles can exert important influence over the care provided to older adult patients by increasing the organizational support for geriatric nursing. NICHE implementers did not demonstrate an increase in geriatric nursing knowledge. Again, it is not known how many of the nurses completing the GIAP were exposed to NICHE training or the extent of that training. Also, the length of time between NICHE training/implementation and postevaluation may not have been sufficient to effect substantial change in nurse geriatric nursing knowledge. This is an area for future investigation because the required training and time frame to effect sustained improve-

ment in nurse knowledge of care of older adult patients is not known. Additionally, further evaluation of the knowledge scale of the GIAP is warranted to ensure that questions continue to be clinically relevant and reflect current evidence. The role of the nurse leader is critical in shaping the nurse practice environment. Nurse leaders who promote effective collaboration, facilitate access to resources, and support nurse autonomy are more likely to engender increased nurse work satisfaction45-47 and improved care delivery.37,48 Accordingly, additional investigation of the practice environment and associated leadership characteristics of various types of nursing units (e.g., critical care, emergency room, orthopedic unit) is indicated to help build flexible, adaptable versions of both the Acute Care of the Elderly (ACE) unit model and the Geriatric Resource (GRN) model20,22,23,25 and inform the development of specialty-specific protocols and education programs. An added value of examining programs at the unit level is the potential to develop and test efficiently pilot models of funding and evaluation. Limitations A threat to internal validity is the time span (9 years) of data collection, posing the possibility that the demands imposed by external forces (regulatory and reimbursement) may have exerted varying influences on the organization of acute care geriatric nursing at different time periods. The reliance on nurse perceptions as the source of GIAP data and the potential for other unknown factors influencing nurse perceptions poses an additional threat to internal validity. Examples of other factors that were not measured in this study (because of data limitations) that could influence nurse perceptions include patient acuity and staffing. Also, the study did not include nurses from for-profit hospitals and rural areas, limiting the generalizability of results to those groups. As stated previously, because of data limitations, the study did not address the intensity, consistency, and duration of NICHE implementation. Future research should address issues of treatment fidelity by standardizing NICHE interventions across study sites and establishing mechanisms of ensuring fidelity. Essential components of the treatment fidelity program

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should include measures that quantify interventions, study controls, and treatment adherence, training of NICHE providers, and validation of skill acquisition in implementing interventions.49 The GIAP is used to assess a hospital’s readiness for geriatric nursing initiatives by focusing on the institutional milieu supporting geriatric care. These study findings suggest that NICHE hospitals improve the hospital’s capacity to provide quality geriatric care. However, the GIAP is not intended to measure clinical effectiveness and thus is limited in its capacity to evaluate an organization’s geriatric care in a comprehensive manner. NICHE researchers are currently developing structural, process, clinical outcome, and organizational outcome measures to be used for both national benchmarking and evaluation of NICHE program effectiveness. In conclusion, despite the fact that the majority of hospital patients are older adults and the primary practice location of the nation’s 2.7 million registered nurses is the hospital setting,26 limited attention has been paid to the delivery of geriatric nursing care by RNs.16 This study demonstrates that hospitals that have adapted the NICHE model can modify the nurse practice environment to promote an institutional milieu that improves the quality of geriatric care. Additionally, NICHE can be implemented in both teaching and nonteaching hospitals regardless of size and payer mix and by nurses with diverse demographic and professional characteristics.

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27. Aiken L, Sochalski J, Lake E. Studying outcomes of organizational change in health services. Med Care 1997;35:NS6-NS18. 28. Bandura, A. Collective efficacy. In: Self-efficacy: the exercise of control. New York: WH Freeman; 1997, p. 477-525. 29. Abraham IL, Bottrell MM, Dash KR, et al. Profiling care and benchmarking best practice in care of hospitalized elderly: the Geriatric Institutional Assessment Profile. Nurs Clin North Am 1999;34:23755. 30. Kim H, Capezuti E, Boltz M, et al. Factor structure of the Geriatric Care Environment Scale. Nurs Res 2007; 56:339-47. 31. Capezuti E, Boltz M, Kim H, et al. Nurse perceptions of hospital restraint, 1997-2006 [abstract]. Gerontologist 2007;47(special issue):117. 32. Hospital statistics. Chicago: American Hospital Association; 2006. 33. Yuan YC. Multiple imputation for missing data: concepts and new developments (Institute Technical Report P267-25). Chicago: SAS; 2000. 34. Allison P. Imputation of categorical variables with PROC MI. SAS Users’ Group International 30 Proceedings, April 2005. 35. Horton NJ, Lipsitz SR, Parzen M. A potential for bias when rounding in multiple imputation. Am Statist 2003;57:229-32. 36. Health Resources and Services Administration, U.S. Department of Health and Human Services; 2006. The registered nurse population, national sample survey of registered nurses 2004. Available at http://bphr.hrsa.gov/healthworkforce/rnsurvey04/2.htm. Cited August 26, 2007. 37. Kramer M, Schmalenberg C, Maguire P. Essentials of a magnetic work environment. Nurs 2004;34(9):44-8. 38. Wright J, McCormack B. Practice development: Individualized care. Nurs Stand 2001;15:37-42. 39. Aiken LH, Clarke SP, Sloane, DM. Hospital staffing, organization, and quality of care: cross-national findings. Int J Qual Health Care 2002;14:5-13. 40. Houser J. A model for evaluating the context of nursing care delivery. J Nurs Adm 2003;33:39-47. 41. Chang E, Chenoweth L, Hancock K. Nursing needs of hospitalized older adults. J Gerontol Nurs 2003(September):32-41. 42. Fagerstrom L, Ericsson K, Engberg I (1998). The patient’s perceived caring needs as a message of suffering. J Adv Nurs 1998;28:978-87.

43. Hancock K, Chang E, Chenoweth L, et al. Nursing needs of acutely ill older people. J Adv Nurs 2003;44: 507-16. 44. Santo-Novak D. Older adults’ description of their role expectations of nursing. J Gerontol Nurs 1997;23:32-40. 45. Amos MA, Hu J, Herrick CA. The impact of team building on communication and job satisfaction of nursing staff. J Nurs Staff Dev 2005;21:10-16. 46. Manojlovic M. The effect of nursing leadership on hospital nurses’ professional practice behaviors. J Nurs Adm 2005;35:366-74. 47. Shermont H, Krepico D. The impact of culture change on nurse retention. J Nurs Adm 2006;36:407-15. 48. Page A. Editor. Keeping patients safe: transforming the work environment of nurses. Washington, DC: National Academies Press; 2004. 49. Resnick B, Bellg AJ, Borelli B, et al. Examples of implementation and evaluation of treatment fidelity in the BCC studies: where we are and where we need to go [Abstract]. Ann Behav Med 2005;29:46-54. MARIE BOLTZ, PhD, RN, GNP, BC, is an assistant professor at New York University College of Nursing, New York, New York. ELIZABETH CAPEZUTI, PhD, RN, FAAN, is an associate professor and codirector of the Hartford Institute for Geriatric Nursing, New York University College of Nursing, New York, New York. SUSAN BOWAR-FERRES, PhD, RN, CNAA-BC, is a professor of nursing and nursing administration, and senior vice president and chief nursing officer at New York University Medical Center, New York, New York. ROBERT NORMAN, PhD, is a research associate professor and director of biostatistics at New York University College of Dentistry, New York, New York. MICHELLE SECIC, MS, is president and independent consultant, Secic Statistical Consulting, Inc., Chardon, Ohio. HONGSOO KIM, PhD, MPH, RN, is an assistant professor at New York University College of Nursing, New York, New York. SUSAN FAIRCHILD, MPH, is a NICHE program evaluator, John A. Hartford Foundation Institute for Geriatric Nursing New York University College of Nursing, New York, New York. MATHY MEZEY, EdD, RN, FAAN, is a professor and director of the John A. Hartford Foundation Institute for Geriatric Nursing, New York University College of Nursing, New York, New York. TERRY FULMER, PhD, RN, FAAN, is dean and the Erline Perkins McGriff Professor at New York University College of Nursing, New York, New York. 0197-4572/08/$ - see front matter © 2008 Mosby, Inc. All rights reserved. doi:10.1016/j.gerinurse.2008.02.002

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