Molloy College DigitalCommons@Molloy Theses & Dissertations 4-22-2016 Patient Complexity Factors and their Influence on Nurses' Perception of Staffing Adequacy Margaret Mary Duffy This research was completed as part of the degree requirements for the Nursing Department at Molloy College. Follow this and additional works at: https://digitalcommons.molloy.edu/etd Part of the Nursing Administration Commons This Dissertation has All Rights Reserved. DigitalCommons@Molloy Feedback Recommended Citation Duffy, Margaret Mary, "Patient Complexity Factors and their Influence on Nurses' Perception of Staffing Adequacy" (2016). Theses & Dissertations. 6. https://digitalcommons.molloy.edu/etd/6 This Dissertation is brought to you for free and open access by DigitalCommons@Molloy. It has been accepted for inclusion in Theses & Dissertations by an authorized administrator of DigitalCommons@Molloy. For more information, please contact [email protected],[email protected]. Molloy College The Division of Nursing PhD in Nursing Program PATIENT COMPLEXITY FACTORS AND THEIR INFLUENCE ON NURSES’ PERCEPTION OF STAFFING ADEQUACY a dissertation by MARGARET MARY DUFFY submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy April 22, 2016 © Copyright by MARGARET MARY DUFFY All Rights Reserved 2016 Abstract PATIENT COMPLEXITY FACTORS AND THEIR INFLUENCE ON NURSES’ PERCEPTION OF STAFFING ADEQUACY By MARGARET MARY DUFFY Nurse leaders must consider the influence of nurse-specific and patient-specific factors on nursing workload and nurses’ perception of staffing adequacy when developing nurse staffing plans. All of the factors that influence individual nurses’ perception of staffing adequacy are not known. Using a synthesis of the Roy Adaptation Model (RAM) and economic theory as a guiding model, the purpose of the current study was to determine if selected patient complexity factors that are not consistently captured in the measurement of patient acuity by an automated workforce management system influence nurses’ perception of staffing adequacy. The current study employed a complex predictive correlational research design, which included repeated measures of patient data and nurses’ perception of staffing adequacy at the shift-level. A selection of repeated measures data from 26 Registered Nurses (RNs) and 1,605 patients over 328 shifts was entered into the initial analysis. The number of shifts with complete data used for final analysis was N = 294. Disruptive behavior (r= -.274) and family demands (r=-.186), were negatively correlated with nurses’ perception of staffing adequacy and explained 10% of the variance in a regression model. There was a negative correlation between total shift factor score (r=-.418), derived from the presence of patient complexity factors, and nurses’ perception of staffing adequacy. No correlation was found between perception of staffing adequacy and nurse staffing variables. A theoretical proposition of RAM was tested to describe the interaction between the group subsystems and the RAM modes in relationship to the goals of an organizational system. Study findings supported the RAM proposition and contribute to the middle range theory of adaptation, production decision-making process, and nurses’ perception of staffing adequacy. The findings inform the science of nurse staffing, but indicate further opportunities for research since other factors might exist that contribute to the perception of staffing adequacy. Dedication In loving memory of my parents, John and Joan Connelly. To my dad, who taught me the value of reading and education. And to my mom, who taught me how to persevere in the face of hardship. i Acknowledgements I extend my deepest gratitude to the members of my dissertation committee: Dr. Debra R. Hanna, chair, Dr. Ann Marie Paraszczuk, and Dr. Lawrence A. DiFiore. I greatly appreciate your generosity of time, and your care and consideration throughout this process. You pushed me to a level of thinking I did not believe was possible. I would like to thank Dr. Veronica Feeg for her unending support of the inaugural cohort of PhD students, the “pioneers.” Your vision and guidance kept us motivated at every phase of the doctoral journey. I am very grateful to the nurses who took the time to participate in this study. Thank you for your contribution to research. My sincere thanks to my friend and mentor, Dr. Lee Anne Xippolitos. You always see in me what I do not see in myself. I would not have reached this milestone without your direction and coaching. The friendships forged among the colleagues of our cohort are something I will treasure for years to come. Each of us contributed uniquely to an amazing experience. A special “thank you” to the members of the Sunday PhD club: Dr. Nikki Fiore-Lopez, Anna tenNapel, and Valerie Terzano. Your support every week made all the difference. We were small in numbers but mighty in spirit! To my close friends and family, many thanks for your encouragement and understanding during this journey. My children, Tom and Jack, provided endless amounts of laughter and love, and kept me going. I am fortunate to have such inspiring young men to call my sons. And to the love of my life, my husband Tom, who endured the most during this journey. I could never have achieved what I have done professionally without your love, support, and your ability to make me see the humor in every situation. This accomplishment is yours as much as mine. ii TABLE OF CONTENTS LIST OF TABLES ......................................................................................................................... vi LIST OF FIGURES ...................................................................................................................... vii CHAPTER 1: STATEMENT OF THE PROBLEM .......................................................................1 Introduction ..........................................................................................................................1 Background ..........................................................................................................................3 Purpose .................................................................................................................................6 Theoretical Framework ........................................................................................................6 Study Aims...........................................................................................................................7 Significance..........................................................................................................................8 Conclusion ...........................................................................................................................9 Definitions..........................................................................................................................10 CHAPTER 2: LITERATURE REVIEW ......................................................................................11 Overview ............................................................................................................................11 Conceptual Framework ......................................................................................................12 Roy Adaptation Model .......................................................................................... 12 Economic Theory .................................................................................................. 18 Explication of the Linkages ................................................................................... 22 Testing the Roy Adaptation Model Proposition .................................................... 24 Development of Knowledge about Nurse Staffing ............................................................24 Florence Nightingale ............................................................................................ 24 Defining Nursing Workload .................................................................................. 26 Workload Measurements ...................................................................................... 28 Nursing Shortages ................................................................................................. 30 Establishing Staffing Ratios .................................................................................. 34 Significance of Nurse Staffing ...........................................................................................38 Nurses’ Perception of Staffing Adequacy ............................................................. 38 Nurse Staffing and Patient Safety ......................................................................... 42 Nursing Work Environment .................................................................................. 46 Nurses’ Education and Quality Care .................................................................... 49 iii Missed Nursing Care ............................................................................................ 50 Patient Complexity Factors ................................................................................................51 Obesity as a Patient Complexity Factor ............................................................... 53 Limited English Proficiency .................................................................................. 55 Disruptive Behavior .............................................................................................