nursing task oriented

Nursing Knowledge Tools and Strategies to Improve Patient Outcomes and the Work Environment

• First Online: 16 July 2023

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• Maria-Eulàlia Juvé-Udina 3 , 4 &
• Jordi Adamuz 4 , 5  

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Task-oriented models of nursing care provision and organization have been employed for years all around the world, despite the evidence published for the last three decades on the benefits of patient-centered models and positive nursing practice environments in patient and organizational outcomes. This chapter presents the experience and results of the implementation of a bundle of leadership-mentorship strategies, along with the use of ATIC knowledge tools and the implementation of bedside clinical projects, to improve nurse-sensitive outcomes in the context of a public hospital system in Catalonia (Spain).

While nursing shortage and nurse understaffing remain pending issues to solve, the main results include generation of evidence, improvements in the nursing work environments, and enhanced selected patient and organizational outcomes, such as mortality, readmissions, or adverse events.

Nursing fundamentals, language systems and applied nursing knowledge, transformational leadership, and peer-to-peer knowledge-based mentoring are key elements contributing to improve nurse-sensitive outcomes.

The secret of change is to focus all of your energy not on fighting the old, but on building the new. —Socrates, 470 B.C.

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Juvé-Udina, ME., Adamuz, J. (2023). Nursing Knowledge Tools and Strategies to Improve Patient Outcomes and the Work Environment. In: Rollins Gantz, N., Hafsteinsdóttir, T.B. (eds) Mentoring in Nursing through Narrative Stories Across the World . Springer, Cham. https://doi.org/10.1007/978-3-031-25204-4_29

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The Value of Critical Thinking in Nursing

• How Nurses Use Critical Thinking
• How to Improve Critical Thinking
• Common Mistakes

Some experts describe a person’s ability to question belief systems, test previously held assumptions, and recognize ambiguity as evidence of critical thinking. Others identify specific skills that demonstrate critical thinking, such as the ability to identify problems and biases, infer and draw conclusions, and determine the relevance of information to a situation.

Nicholas McGowan, BSN, RN, CCRN, has been a critical care nurse for 10 years in neurological trauma nursing and cardiovascular and surgical intensive care. He defines critical thinking as “necessary for problem-solving and decision-making by healthcare providers. It is a process where people use a logical process to gather information and take purposeful action based on their evaluation.”

“This cognitive process is vital for excellent patient outcomes because it requires that nurses make clinical decisions utilizing a variety of different lenses, such as fairness, ethics, and evidence-based practice,” he says.

How Do Nurses Use Critical Thinking?

Successful nurses think beyond their assigned tasks to deliver excellent care for their patients. For example, a nurse might be tasked with changing a wound dressing, delivering medications, and monitoring vital signs during a shift. However, it requires critical thinking skills to understand how a difference in the wound may affect blood pressure and temperature and when those changes may require immediate medical intervention.

Nurses care for many patients during their shifts. Strong critical thinking skills are crucial when juggling various tasks so patient safety and care are not compromised.

Jenna Liphart Rhoads, Ph.D., RN, is a nurse educator with a clinical background in surgical-trauma adult critical care, where critical thinking and action were essential to the safety of her patients. She talks about examples of critical thinking in a healthcare environment, saying:

“Nurses must also critically think to determine which patient to see first, which medications to pass first, and the order in which to organize their day caring for patients. Patient conditions and environments are continually in flux, therefore nurses must constantly be evaluating and re-evaluating information they gather (assess) to keep their patients safe.”

The COVID-19 pandemic created hospital care situations where critical thinking was essential. It was expected of the nurses on the general floor and in intensive care units. Crystal Slaughter is an advanced practice nurse in the intensive care unit (ICU) and a nurse educator. She observed critical thinking throughout the pandemic as she watched intensive care nurses test the boundaries of previously held beliefs and master providing excellent care while preserving resources.

“Nurses are at the patient’s bedside and are often the first ones to detect issues. Then, the nurse needs to gather the appropriate subjective and objective data from the patient in order to frame a concise problem statement or question for the physician or advanced practice provider,” she explains.

Top 5 Ways Nurses Can Improve Critical Thinking Skills

We asked our experts for the top five strategies nurses can use to purposefully improve their critical thinking skills.

Case-Based Approach

Slaughter is a fan of the case-based approach to learning critical thinking skills.

In much the same way a detective would approach a mystery, she mentors her students to ask questions about the situation that help determine the information they have and the information they need. “What is going on? What information am I missing? Can I get that information? What does that information mean for the patient? How quickly do I need to act?”

Consider forming a group and working with a mentor who can guide you through case studies. This provides you with a learner-centered environment in which you can analyze data to reach conclusions and develop communication, analytical, and collaborative skills with your colleagues.

Practice Self-Reflection

Rhoads is an advocate for self-reflection. “Nurses should reflect upon what went well or did not go well in their workday and identify areas of improvement or situations in which they should have reached out for help.” Self-reflection is a form of personal analysis to observe and evaluate situations and how you responded.

This gives you the opportunity to discover mistakes you may have made and to establish new behavior patterns that may help you make better decisions. You likely already do this. For example, after a disagreement or contentious meeting, you may go over the conversation in your head and think about ways you could have responded.

It’s important to go through the decisions you made during your day and determine if you should have gotten more information before acting or if you could have asked better questions.

During self-reflection, you may try thinking about the problem in reverse. This may not give you an immediate answer, but can help you see the situation with fresh eyes and a new perspective. How would the outcome of the day be different if you planned the dressing change in reverse with the assumption you would find a wound infection? How does this information change your plan for the next dressing change?

Develop a Questioning Mind

McGowan has learned that “critical thinking is a self-driven process. It isn’t something that can simply be taught. Rather, it is something that you practice and cultivate with experience. To develop critical thinking skills, you have to be curious and inquisitive.”

To gain critical thinking skills, you must undergo a purposeful process of learning strategies and using them consistently so they become a habit. One of those strategies is developing a questioning mind. Meaningful questions lead to useful answers and are at the core of critical thinking .

However, learning to ask insightful questions is a skill you must develop. Faced with staff and nursing shortages , declining patient conditions, and a rising number of tasks to be completed, it may be difficult to do more than finish the task in front of you. Yet, questions drive active learning and train your brain to see the world differently and take nothing for granted.

It is easier to practice questioning in a non-stressful, quiet environment until it becomes a habit. Then, in the moment when your patient’s care depends on your ability to ask the right questions, you can be ready to rise to the occasion.

Practice Self-Awareness in the Moment

Critical thinking in nursing requires self-awareness and being present in the moment. During a hectic shift, it is easy to lose focus as you struggle to finish every task needed for your patients. Passing medication, changing dressings, and hanging intravenous lines all while trying to assess your patient’s mental and emotional status can affect your focus and how you manage stress as a nurse .

Staying present helps you to be proactive in your thinking and anticipate what might happen, such as bringing extra lubricant for a catheterization or extra gloves for a dressing change.

By staying present, you are also better able to practice active listening. This raises your assessment skills and gives you more information as a basis for your interventions and decisions.

Use a Process

As you are developing critical thinking skills, it can be helpful to use a process. For example:

• Ask questions.
• Gather information.
• Implement a strategy.
• Evaluate the results.
• Consider another point of view.

These are the fundamental steps of the nursing process (assess, diagnose, plan, implement, evaluate). The last step will help you overcome one of the common problems of critical thinking in nursing — personal bias.

Common Critical Thinking Pitfalls in Nursing

Your brain uses a set of processes to make inferences about what’s happening around you. In some cases, your unreliable biases can lead you down the wrong path. McGowan places personal biases at the top of his list of common pitfalls to critical thinking in nursing.

“We all form biases based on our own experiences. However, nurses have to learn to separate their own biases from each patient encounter to avoid making false assumptions that may interfere with their care,” he says. Successful critical thinkers accept they have personal biases and learn to look out for them. Awareness of your biases is the first step to understanding if your personal bias is contributing to the wrong decision.

New nurses may be overwhelmed by the transition from academics to clinical practice, leading to a task-oriented mindset and a common new nurse mistake ; this conflicts with critical thinking skills.

“Consider a patient whose blood pressure is low but who also needs to take a blood pressure medication at a scheduled time. A task-oriented nurse may provide the medication without regard for the patient’s blood pressure because medication administration is a task that must be completed,” Slaughter says. “A nurse employing critical thinking skills would address the low blood pressure, review the patient’s blood pressure history and trends, and potentially call the physician to discuss whether medication should be withheld.”

Fear and pride may also stand in the way of developing critical thinking skills. Your belief system and worldview provide comfort and guidance, but this can impede your judgment when you are faced with an individual whose belief system or cultural practices are not the same as yours. Fear or pride may prevent you from pursuing a line of questioning that would benefit the patient. Nurses with strong critical thinking skills exhibit:

• Learn from their mistakes and the mistakes of other nurses
• Look forward to integrating changes that improve patient care
• Treat each patient interaction as a part of a whole
• Evaluate new events based on past knowledge and adjust decision-making as needed
• Solve problems with their colleagues
• Are self-confident
• Acknowledge biases and seek to ensure these do not impact patient care

An Essential Skill for All Nurses

Critical thinking in nursing protects patient health and contributes to professional development and career advancement. Administrative and clinical nursing leaders are required to have strong critical thinking skills to be successful in their positions.

By using the strategies in this guide during your daily life and in your nursing role, you can intentionally improve your critical thinking abilities and be rewarded with better patient outcomes and potential career advancement.

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

Nursing practice utilizes critical thinking skills to provide the best care for patients. Often, the patient’s cause of pain or health issue is not immediately clear. Nursing professionals need to use their knowledge to determine what might be causing distress, collect vital information, and make quick decisions on how best to handle the situation.

How does nursing school develop critical thinking skills?

Nursing school gives students the knowledge professional nurses use to make important healthcare decisions for their patients. Students learn about diseases, anatomy, and physiology, and how to improve the patient’s overall well-being. Learners also participate in supervised clinical experiences, where they practice using their critical thinking skills to make decisions in professional settings.

Do only nurse managers use critical thinking?

Nurse managers certainly use critical thinking skills in their daily duties. But when working in a health setting, anyone giving care to patients uses their critical thinking skills. Everyone — including licensed practical nurses, registered nurses, and advanced nurse practitioners —needs to flex their critical thinking skills to make potentially life-saving decisions.

Meet Our Contributors

Crystal Slaughter, DNP, APRN, ACNS-BC, CNE

Crystal Slaughter is a core faculty member in Walden University’s RN-to-BSN program. She has worked as an advanced practice registered nurse with an intensivist/pulmonary service to provide care to hospitalized ICU patients and in inpatient palliative care. Slaughter’s clinical interests lie in nursing education and evidence-based practice initiatives to promote improving patient care.

Jenna Liphart Rhoads, Ph.D., RN

Jenna Liphart Rhoads is a nurse educator and freelance author and editor. She earned a BSN from Saint Francis Medical Center College of Nursing and an MS in nursing education from Northern Illinois University. Rhoads earned a Ph.D. in education with a concentration in nursing education from Capella University where she researched the moderation effects of emotional intelligence on the relationship of stress and GPA in military veteran nursing students. Her clinical background includes surgical-trauma adult critical care, interventional radiology procedures, and conscious sedation in adult and pediatric populations.

Nicholas McGowan, BSN, RN, CCRN

Nicholas McGowan is a critical care nurse with 10 years of experience in cardiovascular, surgical intensive care, and neurological trauma nursing. McGowan also has a background in education, leadership, and public speaking. He is an online learner who builds on his foundation of critical care nursing, which he uses directly at the bedside where he still practices. In addition, McGowan hosts an online course at Critical Care Academy where he helps nurses achieve critical care (CCRN) certification.

WE TRY HARDER SO YOU LEARN EASIER

Critical Thinking for Your Nursing Career

I remember in the beginning of my professional career.  As a student nurse I was evaluated on tasks that needed to be done and done in a timely manner.  At the end of my shift as a young student nurse I obediently sharpened the used needles, placed them in a glass container, stuffed some cotton at the end and sterilized the needles.  I had all of the thermometers soaking in “green soap” to be rinsed and ready for the next shift.  I had my charting done and ready for shift report.  I gave compassionate nursing care.  I was task-orientated.  I believed I was a valued RN.

Task-orientated nursing refers to the act of a nurse focusing more an activity rather than the surrounding environments. A task-oriented nurse often has a list of things to do and is highly organized. Physician orders were carried out and rules were followed. Task-orientated nursing sometimes does not meet a patient’s spiritual and emotional needs because the nurse is focused on getting her tasks completed.

Today, nurses are skilled and capable professionals whose expertise is essential to patient care and public health initiatives.  It’s been a long road.  And it’s clear that developing our critical thinking skills has helped to bring out this transformation within our industry during the last half century.

Critical Thinking is a multitude of definitions –

Simply stated it is a critical thinking nurse that recognizes a child with rapid respiratory rate and increased work of breathing that begins to decrease in respiratory rate and decrease in work of breathing as a child who is not improving, but getting worse.

A more complex head-scratching definition is the ability to recognize problems and raise questions; gather evidence to support answers and solutions, evaluate alternative solutions and communicate effectively with others to implement solutions for the best possible outcomes.

Critical thinking is definitely a skill that evolves over time and as you gain more experience.  But that doesn’t means it’s absent in young or less experienced nurses.  In fact, critical thinking skills are what make young nurses effective while they are gaining on-the-job experience.  A less experienced nurse with keen critical thinking skills will be able to strategize and manage all sorts of new situations, while dealing effectively with everyone involved – the patient, family members, physicians and other care team members.

If you define critical thinking as multi-dimensional thinking, it becomes clearer when it’s most effectively employed. Multi-dimensional thinking means approaching a situation from more than one point of view. In contrast, one-dimensional thinking tackles the task at hand from a single frame of reference. It definitely has its place in nursing – we use one-dimensional thinking when we chart vital signs or administer a medication.

You’ll need critical thinking skills when you perform a nursing assessment or intervention, or act as a patient advocate. As your patient’s status changes, you’ll have to recognize, interpret, and integrate new information in order to plan a course of action. For example, what would you do if an elderly patient became confused from his medications, was unable to understand your instructions, and put himself at risk for falls? There may be no single “right” answer – you have to weigh all of the variables, prioritize your goals, and temper your next steps with empathy and compassion.

Critical thinking also involves viewing the patient as a whole person – and this means considering his own culture and goals, not just the goals of the health care organization. How would you handle a teenage girl who comes into your clinic asking for information about STDs? What about a seriously hypertensive patient who admits he can afford his medication, but doesn’t believe it is important that he take it every day without fail?

To develop your critical thinking skills, you can:  suspend judgment; demonstrate open-mindedness and a tolerance for other cultures and other views.

• Seek out the truth by actively investigating a problem or situation.
• Ask questions and never be afraid to admit to a lack of knowledge.
• Reflect on your own thinking process and the ways you reach a conclusion.
• Indulge your own intellectual curiosity; be a lifelong learner.
• View your patients with empathy and from a whole-person perspective.
• Look for a mentor with more experience than you have; join professional organizations.
• Advance your nursing education.

The best way to develop your critical thinking skills and empower yourself with knowledge is learning, learning, and more learning.  And remember “learning can be enjoyable.”

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Really thanks for sharing this useful post !! I Want to grow my career in nursing field and this post will definitely help me to achieve my goal.

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• Research article
• Open access
• Published: 28 November 2011

Leadership, staffing and quality of care in nursing homes

• Anders Kvale Havig 1 , 2 ,
• Anders Skogstad 3 ,
• Lars Erik Kjekshus 4 &
• Tor Inge Romøren 2  

BMC Health Services Research volume  11 , Article number:  327 ( 2011 ) Cite this article

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Leadership and staffing are recognised as important factors for quality of care. This study examines the effects of ward leaders' task- and relationship-oriented leadership styles, staffing levels, ratio of registered nurses and ratio of unlicensed staff on three independent measures of quality of care.

A cross-sectional survey of forty nursing home wards throughout Norway was used to collect the data. Five sources of data were utilised: self-report questionnaires to 444 employees, interviews with and questionnaires to 13 nursing home directors and 40 ward managers, telephone interviews with 378 relatives and 900 hours of field observations. Separate multi-level analyses were conducted for quality of care assessed by relatives, staff and field observations respectively.

Task-oriented leadership style had a significant positive relationship with two of the three quality of care indexes. In contrast, relationship-oriented leadership style was not significantly related to any of the indexes. The lack of significant effect for relationship-oriented leadership style was due to a strong correlation between the two leadership styles ( r = 0.78). Staffing levels and ratio of registered nurses were not significantly related to any of the quality of care indexes. The ratio of unlicensed staff, however, showed a significant negative relationship to quality as assessed by relatives and field observations, but not to quality as assessed by staff.

Conclusions

Leaders in nursing homes should focus on active leadership and particularly task-oriented behaviour like structure, coordination, clarifying of staff roles and monitoring of operations to increase quality of care. Furthermore, nursing homes should minimize use of unlicensed staff and address factors related to high ratios of unlicensed staff, like low staff stability. The study indicates, however, that the relationship between staffing levels, ratio of registered nurses and quality of care is complex. Increasing staffing levels or the ratio of registered nurses alone is not likely sufficient for increasing quality of care.

Peer Review reports

The increasing number of older people in Norway combined with the lower ratio of persons of working age raises the quest for more efficient ways to organize and manage nursing homes. Thus, a central goal is - and will be - to identify which factors influence quality of care and how influential the different factors are. Several studies have recognized leadership as a key issue for quality of care in nursing homes [ 1 – 5 ]. There is limited knowledge of what kind of leadership behaviour that is related to quality of care, however [ 3 , 6 – 9 ]. Staffing has further been linked to quality of care in a number of studies [ 10 – 13 ]. In addition, staffing is emphasized in both the media and by the public as one of the most crucial elements for quality in nursing homes [ 14 ]

A weakness with some prior studies of leadership, staffing and quality of care in nursing homes is poor data quality. In particular the reliability of the staffing data [ 11 , 15 – 17 ] and the reliability and validity of the quality of care data [ 18 – 20 ] have been questioned. Furthermore, the majority of the previous studies in nursing homes have used secondary data sources to assess quality of care [ 6 , 9 , 13 ]. While secondary data sources have unquestionably advantages in relation to assess quality of care, there is a need for studies that base the quality assessment on primary data sources [ 13 , 21 , 22 ]. Therefore, in this study we collected rich data in 40 nursing home wards throughout Norway and performed a thorough analysis using both quantitative and qualitative methods. The definition of nursing home quality of care was based on The national regulation for quality in nursing homes and home care [ 23 ] and quality of care was assessed by three independent primary data sources: relatives, staff and field observations.

Quality in nursing homes is a multidimensional and elusive phenomenon and is complicated to define and assess [ 18 , 24 – 26 ]. In his classical work, Donabedian [ 27 ] suggested three approached to quality of care: structure, process and outcome. Structure referred to the general conditions that affect the ability to deliver care like staffing levels, staffing mix and characteristics of the nursing home, process referred to work processes, routines and procedures and outcome referred to the end result for the resident - do they receive good and adequate care? According to Donabedian [ 27 ], outcome measures were the ultimate validation of quality, but also the most complicated and time-consuming to measure. Donabedian's theoretical framework for understanding quality has been widely accepted among researchers [ 13 , 24 , 28 , 29 ].

Quality in nursing homes can also be divided in two dimensions: quality of care and quality of life [ 13 , 29 , 30 ]. Within this definition, quality of care encompasses clinical outcomes like the prevalence of pressure ulcer, falls or use of restrains, and focuses on the quality and safety of care. Contrary, quality of life encompasses residents' well-being and opportunities for choice, autonomy and meaningful social activities. Qualities of life comprise both an objective and a subjective dimension [ 29 ]. The objective dimension can be measured with "objective" indicators, while the subjective dimensions has focus on each individual perception of his or hers well-being.

To assess quality of care primary data sources and/or secondary data sources are used. Primary data sources are self-reported data from residents, relatives, care staff or field observations. Such data is generally time-consuming and expensive to acquire. Secondary data sources are typical national data sets of clinical assessments. The most common secondary data source is the MDS (Minimum Data Set). The indicators are normally calculated according to their presence or absence for an individual and then summed up for all individuals to create a facility level [ 19 , 31 ]. The MDS was not originally designed as a quality measurement instrument; however, researchers have increasingly derived quality indicators from the MDS data. Secondary data sources are the most common data sources of the two, particularly in the US [ 13 ].

In Norway, quality of care is regulated by The national regulation for quality of care in nursing homes and home care [ 23 ]. The regulation has been the starting point for indicators on quality of care in several studies [ 32 – 34 ]. According to the regulation, quality of care is a multidimensional phenomenon, consisting of a variety of aspects like medical care, general care, social activities, autonomy, interaction between staff and residents and privacy. Consequently, the regulation encompasses both a quality of care and a quality of life dimension.

Leadership has been studied using various approaches - traits, skills, styles and behaviour being the most common [ 35 ]. Regarding styles, a variety of different leadership styles have been identified and studied in the literature: Autocratic, democratic, directive, participative, task-oriented, relationship-oriented, transactional and transformational [ 36 – 40 ]. The present study focuses on two specific styles, namely task-oriented leadership and relationship-oriented leadership. Task-oriented style comprises the behaviours of planning work activities (what to do, how to do it, when to do it and who will do it), clarifying roles and objectives (communication of plans, policies, job responsibilities, role expectations, requirements and goals) and monitoring operations and performance (gathering information about the processes, progress, performance and individual contributions in the organisational unit). In contrast, relationship-oriented style constitutes the behaviours of supporting (consideration, acceptance and concern for the needs and feelings of subordinates), developing (building and developing subordinates' skills) and recognising (praising and showing appreciation toward subordinates for desired performance) [ 40 ]. A range of studies have investigated the effects of the two styles on a variety of outcomes - productivity indicators being among the most studied outcomes.

Studies on relationships between leadership styles and productivity are highly relevant for nursing homes, as quality of care is an essential indicator for the productivity level within the units [ 41 ]. In this research field there is a general agreement that both task-oriented and relationship-oriented leadership styles are systematically related to productivity. The effect of task-oriented leadership style on productivity has in these studies shown to be the strongest predictor of the two [ 35 , 37 , 40 , 42 ]. However, the effects of one style do not exclude the effects of the other. Rather, they complement each other. In line with this Yukl [ 40 ] states that: "The overall pattern of results suggests that effective leaders use a pattern of behaviour that is appropriate for the situation and reflects a high concern for task objectives and a high concern for relationship" (p. 130), while Northouse [ 43 ] states that: "The key to being an effective leader often rests on how the leader balances these two behaviours [task-oriented/relationship-oriented leadership style]. Together they form the core of the leadership process." (p. 44).

While several studies emphasize the importance of leadership for quality of care in nursing homes [ 1 – 5 ], few studies have investigated what kind of leadership influences the quality of care, and to what degree the two are related. In a systematic review of the relationship between nursing leadership and patient outcomes by Wong and Cummings [ 9 ], only seven studies met the inclusion criteria of "measuring leadership of a formal nurse leader" and "reporting a relationship between leadership and patient outcomes". Of these seven studies only one [ 1 ] investigated such relationships in nursing homes. In their literature review of leadership and outcomes in long-term care, Harvath et al. [ 6 ] concluded that "Despite the general consensus that leadership skills are important for nursing home nurses, we found very little evidence to support this claim." (p. 189). Eight studies met their inclusion criteria and linked leadership characteristics and outcome measures; however, only two of these studies included leadership behaviours. Anderson et al. [ 1 ], referred to in the literature study by both Wong and Cummings [ 9 ] and Harvath et al. [ 6 ], studied 164 nursing homes in Texas and found a significant negative relation between relationship-oriented leadership behaviours - as giving constructive feedback, helping staff resolve conflicts, generating trust and being approachable - and the prevalence of fractures and of complications of immobility. However, the studies showed no significant association between relationship-oriented leadership style and the outcome measures such as resident behaviour and restraint use. The task-oriented leadership behaviour of formalization, defined as specifying work procedures and rules and monitoring tasks, showed insignificant relationships with all of the four outcomes. McNeese-Smith [ 44 ], also included in Wong and Cummings' [ 9 ] literature review, interviewed 30 nurses working in a Los Angeles hospital and found that when staff nurses perceived their superiors to employ the typical relationship-oriented behaviours of support and conflict solving, the nurses systematically reported higher levels of productivity.

Three other studies, not included in the two literature reviews above, have shown interesting relationships between leadership behaviours and various quality outcomes. In a study of New York nursing homes, Hasemann [ 45 ] showed that authoritative leadership was systematically related to higher quality of care while nonauthoritative leadership was not. With authoritative leadership Hasemann [ 45 ] meant leaders who were delegating and telling, related to the followers both flexibly and decisively and made firm and impartial decisions. Nonauthoritarian leaders, by contrast, related to employees on a more personal level and were striving to please the employees and make them happy. Albinsson and Stang [ 46 ], in interviewing 32 experienced nursing home employees about how they thought the leader should function to achieve high quality of care, found that task-oriented behaviour characterized by well-defined leadership, goal formulation and care planning was emphasised as decisive in this regard. In a study at a relatively large Swedish hospital, Sellgren et al. [ 47 ] investigated the difference between staff and nurse managers in their preferences of leadership style for achieving high quality of care. They found that subordinates preferred leaders that took an active and clear leadership role and focused on production-orientated aspects of leadership rather than relationship-orientated aspects.

Because studies in nursing homes have been rather few and inconclusive, it is difficult to draw conclusions regarding which leadership style has the strongest effect on quality of care. In general, however, leadership studies has shown task-orientated leadership style to be the most influential of the two in relation to productivity - which in many cases overlap with quality of care. We therefore expected that both leadership styles will be systematically related to quality of care, but that the effect of task-oriented leadership will be the strongest.

The relationship between staffing - in the present study defined as total staffing levels , ratio of registered nurses and ratio of unlicensed staff - and quality of care in nursing homes has been debated by researchers for several years. The vast amount of studies in this field was recently illustrated in three literature reviews, identifying 87, 70 and 50 studies respectively [ 10 , 11 , 13 ]. Castle [ 11 ] identified 302 quality indicators among the 70 studies he examined. One hundred and twenty (40%) of these indicators were found to have a significant positive relationship with staffing levels, while 15 (5%) were found to have a significant negative relationship. Ninety eight out of the 302 quality indicators examined the effect of registered nurses and of these 51 indicators (52%) had a significant positive relationship with quality of care. Bostick et al. [ 10 ] concluded "that there is a proven positive association between higher total staffing levels and improved quality of care" (p. 366). Furthermore, Bostick [ 10 ] found support for an association between higher level of registered nurses and improved quality of care and a higher ratio of unlicensed staff and reduced level of quality of care. There are however, relatively few studies that have examined the effects of the ratio of unlicensed staff compared to studies which have examined the effect of staffing levels and the ratio of registered nurses, and the results of these are inconclusive [ 2 , 48 – 51 ]. In the most recent of the three literature reviews, Spilsbury et al. [ 13 ], found a tentative positive effect of increased total staffing levels and increased ratios of registered nurses on quality of care, however, they concluded that: "The existing evidence base does not enable any firm conclusions to be drawn when considering the relationship between nurse staffing and quality of care for residents in nursing homes." (p. 746). Ninety four percent of the studies examined were conducted in the US and the vast majority used secondary data sources to access quality of care.

Even though the majority of the studies in this research field have found that staffing levels and the proportion of registered nurses are significantly related to quality of care, a significant number of studies have not been able to link the two predictors and the specified criterion. For example, Rantz et al. [ 4 ] investigated 92 nursing homes in Missouri and did not find any effect for either staffing levels or staff mix. The study had reliable staffing data and a robust design, with data collected both quantitatively and qualitatively, the latter by two to four days of participating observations at each nursing home. Likewise, Winsløw & Borg [ 52 ] surveyed 7500 care workers in 36 municipalities in Denmark and found no association between increased staffing levels or level of professional training and quality of care provided by the individual care worker. Furthermore, Arling [ 2 ] and Berlowitz [ 53 ] did not find any significant relationship between staffing levels or staff mix and quality of care in their studies. In a Norwegian setting, three studies have investigated the relationship between total staffing levels and quality of care in nursing homes. Two of the studies found no significant relationship [ 33 , 54 ], while one of the studies found a significant positive effect of increased staffing levels on quality of care [ 32 ]. Harsvik et al. [ 54 ] also studied the effect of increased ratios of registered nurses on quality of care; however, they found no significant effect.

Based on the earlier studies it is still an open question to what degree staffing levels, the ratio of registered nurses and the ratio of unlicensed staff are systematically related to quality of care in nursing homes. The results of the studies are mixed and the reliability and validity of the data, particularly those studies using OSCAR data (Online Survey, Certification and Reporting), may be questioned [ 11 , 15 – 17 ]. Further, the studies are often inaccurate concerning whether they refer to the absolute level or the relative ratio of care staff. However, the majority of the studies indicate a positive effect on quality of care for higher staffing levels and higher ratios of registered nurses and a negative effect on quality of care for higher ratios of unlicensed staff.

The purpose of the present study is twofold: 1) to assess the effect of ward leaders task- and relationship-oriented leadership styles on quality of care in nursing homes and 2) to assess the effect of staffing levels, ratio of registered nurses and ratio of unlicensed staff on quality of care in nursing homes.

Research design

A cross-sectional design was used to collect the data required to test our research questions. Five different sources of data were utilised: self-report questionnaires distributed to 444 employees in nursing homes, interviews with and questionnaires to 13 nursing home directors and 40 ward managers, a telephone survey with 378 relatives and 900 hours of field observations in 40 wards.

One to four wards in 21 nursing homes participated in the study, yielding a total of 40 wards. Nursing home ward was used as measurement unit due to the assumption that both leadership style and quality of care may vary significantly from one ward to another within one nursing home. The facilities were located in towns in eleven medium (6,000 - 20,000) and large-sized (> 20,000) municipalities in seven counties (Finnmark, Nord-Trøndelag, Hordaland, Hedmark, Oslo, Akershus and Aust-Agder) across Norway. The seven counties were selected to achieve geographical spread. Special care units for dementia were excluded, as such wards often have a different structure and relatively more staff than general wards. All nursing homes were public and nonprofit in nature, and owned and run by their local municipalities. The nursing homes ranged in size from 20 to 152 beds, with a mean of 63; the wards ranged in size from 7 to 34 beds, with a mean of 18. The number of staff (full-time equivalents) per ward ranged from 6 to 25, with a mean of 14. Staff was grouped according to number of working hours per week, but respondents were not categorised by the occupational categories of registered nurse, auxiliary nurse and unlicensed staff. Several of the participating wards had only two or three registered nurses, hence anonymity could not have been assured if staff had been categorised by education.

Data collection

The first author distributed the questionnaires to the staff personally. All staff who were working in their ward during the three to four days of field observations were offered a questionnaire. Staff who worked night shifts only were excluded from the study because their work setting differed substantially from those of their colleagues; and staff who had worked less than eight weeks in their ward were excluded for lack of experience. Each staff member was offered a token gift (approximate value = 2 USD) along with the questionnaire. The questionnaires were completed anonymously and returned in sealed envelopes in a box located in the wards' staff room. A total of 444 questionnaires were returned, with a range of 5 to 19 respondents per ward and a mean of 11.4. The response rate from the 40 wards varied from 71% to 100%, with a total response rate of 87%.

Relatives answered a survey by phone interview. This survey was also conducted by the first author. Thirty five relatives were excluded due to limited contact with the resident or a complicated relationship between the relative and the resident. A total of 378 relatives agreed in to answer the questions, giving a response rate on 71%.

The first author's interviews with the 40 ward managers and 13 directors were performed in their offices in the course of the week of field observations. The interviews consisted of semi-structured questions. After the interviews, the ward managers answered a questionnaire consisting of specific questions about the ward.

The first author, with six years experience in nursing homes as an unlicensed worker, also conducted the field observations. Each ward was visited and observed for a total of 20 to 30 hours (within three to four days), depending on its size. A uniform was worn during the visits, and the author participated in the daily activities along with the staff. Both day and evening shifts were observed. During the field observations, notes were taken continuously on a PDA (Pocket PC), and the ward was scored according to predefined categories, as described below under the heading "Study variables". To avoid possible bias by a change in staff behaviour during the observations, anonymity was guaranteed to all staff participating in the study. The staff were also informed that the quality of care results would not be made available for the leaders of the nursing homes. A study by Schnelle et al. [ 55 ], indicates that staff behaviour is not influenced significantly by field observations.

Study variables

Quality of care in Norway is regulated by The national regulation for quality of care in nursing homes and home care [ 23 ]. The regulation has been the starting point for indicators on quality of care in several studies [ 32 – 34 ]. According to the regulation, quality of care is a multidimensional phenomenon, consisting of a variety of aspects. Based on the regulation we developed four indicators: medical care, general care, social activities within the ward and social interactions between staff and residents. In addition we included a general indicator assessing the overall perception of the quality level - "all in all, how do you assess the quality of care at this nursing home ward" -, yielding a total of five quality of care indicators (see Table 1 for details). A general indicator has been used in several other composite scales in the health sector, like SF-36 [ 56 ]. The indicators were solely process and outcome measures [ 27 ], with an emphasis on outcome measures. Each indicator was measured by one to five items (see Appendix for details). Staff assessed nine items, relatives eight items and the field observer seven items. All items were measured on a scale ranging from one to seven, with 1 anchored at strongly disagree and 7 anchored at strongly agree .

The responses from relatives, staff and the field observer formed three separate composite indexes (see Table 1 for details). The indexes were created by adding the indicators and calculating the mean value. The indexes based on the responses of relatives and staff contained all five quality indicators, while the index based on field observations did not include medical care , as the field observer has no medical education and since the field observations alone did not the put the field observer in a position to assess the medical care satisfactorily. Internal consistency of the indexes was high with Cronbach's alpha of 0.92 for relatives, 0.85 for staff and 0.92 for field observations, and supported the use of summary indexes. Factor analysis (we rotated the components using the Varimax method) showed that the three sources measured the quality of care significantly different - in accordance with prior studies of proxies and quality of care in nursing homes [ 34 , 57 , 58 ] (see Appendix for details).

Leadership style was measured by a scale based on selected items from Yukl [ 59 ], Northouse [ 43 ] and Bass & Stogdill [ 60 ], and was adapted to a nursing home setting. The instrument measured staffs' perceptions of their leaders' task- and relationship-oriented behaviours. The two leadership styles were each measured by five items on a scale ranging from 1 to 7, with 1 anchored at strongly disagree and 7 anchored at strongly agree (see Table 2 ). The individual data from each employee were aggregated to a ward level, creating a total of 40 different leadership styles. A factor analysis confirmed two leadership dimensions, namely task-oriented leadership style and relationship-oriented leadership style (see Appendix). The factor analysis and a strong support for a distinction between the two leadership styles in prior studies [ 35 , 37 , 40 ], support the use of two separate leadership dimensions. The internal consistency was high for both task-oriented leadership style (Cronbach's alpha 0.89) and relationship-oriented leadership (Cronbach's alpha 0.95).

The ratio of registered nurses was measured by dividing the number of full time equivalents of registered nurses (FTE) in permanent positions in the ward by the total number of care workers (including unfilled posts). Only registered nurses directly involved with patient care were included. Consequently, ward managers and other registered nurses working within the administration were left out.

The ratio of unlicensed staff was measured by registering the actual number of unlicensed staff present at the ward during an average working day. The registering was done through a questionnaire filled in by the ward managers. This method was used due to the high number of vacant positions in nursing homes. Unlicensed staff are overrepresented in vacant positions [ 61 ] and the ratio of unlicensed staff would have been underestimated if we had based the measurement on the ratio of unlicensed staff in permanent positions.

Total staffing levels was measured by dividing the total full-time equivalent of care staff by the number of residents in the ward.

Care level was measured by two factors: the percentage of residents dependent on wheel chair and the percentage of residents dependent on patient lift during care , each of which was allocated a score from 1 to 7 (see Appendix for details). The data were obtained through field observations and interviews with care staff.

Data analysis

We examined the level of collinearity among the independent variables and multicollinearity using the variance inflation factor (VIF) test. The correlations between the independent variables were low to moderate ( r < 0.50), except between task-oriented and relationship-oriented leadership styles ( r = 0.78) (see Table 3 ). We did separate analyses for each of the three quality of care indexes. As the 40 wards were the units of the analyses, all data measured by staff and relatives were aggregated to ward level.

From earlier studies in nursing homes we know that organizational characteristics like ownership status, size and care level have effect on the level of quality of care [ 4 , 32 , 50 , 62 , 63 ]. As all nursing homes included in the present study were nonprofit and both owned and run by the local municipality, the ownership variable was irrelevant. Size and care level are both relevant variables, but due to our limited sample (N = 40) we choose to include only one of them. As size was less correlated with the three quality indexes ( r = 0.28 versus r = 0.40), we included care level as a confounder. We additionally controlled for possible interaction effects among the independent variables [ 50 , 64 ]. The interaction effects were tested separately to limit the degrees of freedom. One significant interaction effect was found between task- and relationship-oriented leadership. The interaction effect was significant in the model with quality of care assessed by relatives only and is therefore not reported.

To account for clustering effects - as the 40 nursing home wards were located in 21 different nursing homes - we performed two-level analyses (random intercept models) [ 65 ]. A random intercept model allows the level of quality of care to vary across nursing homes and is suitable if there is nursing home-level variance that should be considered. The proportional reduction in variance (Pseudo R 2 ) was assessed for ward and nursing home levels separately, as described by Snijders & Bosker [ 65 ].

Data were analyzed using SPSS (Statistical Program for Social Science) version 16 and mixed models were used for the analyses. For all statistical tests a 5% significance level was employed.

Ethical considerations

The study has been approved by the Norwegian Social Science Data Services (NSD), an institution that assists and approves researchers with data gathering, data analysis, privacy issues and research ethics. All data in the study were anonymous, participation was voluntary and no separate data about any residents were collected. Participants were informed that confidentiality was assured and that they had the right to withdraw from the study at any point. Prior to field observations at the nursing homes, the first author made a declaration of nondisclosure of confidential information.

Table 1 presents the quality of care indexes and Table 2 presents descriptive statistics of the predictors used in the analyses. Concerning the assessments of the quality of care, one thing to note is that relatives and staff generally had a tendency to assess the quality to be higher than the field observer. A correlation matrix of the study variables is presented in Table 3 while the multilevel analyses testing the relationships between the quality indexes and the leadership and staffing variables are presented in Table 4 .

The intra-class correlation coefficients (ICC) were 57%, 20% and 64% in the random intercept models with quality assessed by relatives, staff and field observations respectively. This shows that 57%, 20% and 64% of the total variability in quality of care was at the nursing home level and 43%, 80% and 36% at the ward level. These levels of ICCs' are large [ 65 ], and support the appropriateness of multilevel analyses.

The two-level analyses show that task-oriented leadership style was significantly related to quality of care as assessed by relatives ( p = 0.02) and staff ( p = < 0.01), but not significantly related to quality as assessed by field observations ( p = 0.12). The lack of a significant relationship between task-oriented leadership style and the latter quality index is due to the strong correlation between task- and relationship-oriented leadership style ( r = 0.78). In separate analyses of task-oriented leadership style and staffing data - conducted to test the isolated effect of the leadership style - task-orientation was significantly related to all three quality indexes ( p < 0.01). Task-oriented leadership style showed the highest coefficient value in the model with quality assessed by staff and the lowest coefficient value in the model with quality assessed by field observations. Relationship-oriented leadership style was not significantly related to any of the quality indexes ( p = 0.19, p = 0.91, p = 0.37). However, as for task-oriented leadership, separate analyses of relationship-oriented leadership showed a significant effect for relationship-oriented leadership style in all the three models ( p < 0.01) and additionally, the bivariate correlations between relationship-oriented leadership style and the three quality indexes were strong and significant ( r = 0.50, r = 0.50, r = 0.45). Consequently, the effect of relationship-oriented leadership in the multivariate analyses was erased by the strong correlation between the two leadership styles.

Total staffing levels and ratio of registered nurses were not significantly related to any of the quality indexes. Ratio of unlicensed staff was, however, significantly negatively related to quality as assessed by relatives and by field observations ( p < 0.01), but not significantly related to quality as assessed by staff ( p = 0.22). It is noteworthy that the ratio of unlicensed staff was the only predictor that was significantly differently related to the three quality indexes - all other predictors had a similar relationship across the indexes.

Care level showed a strong and significant negative relationship to all quality indexes ( p < 0.01, p < 0.01, p = 0.02). The relationship was particularly strong for quality assessed by relatives.

The explanatory variables contributed to a 64% proportional reduction in variance between wards in the models where quality was assessed by relatives and staff and to 53% proportional reduction in variance between the wards in the model where quality was assessed by field observations.

The consistency of significant predictors in the present study was unexpected. Only one predictor - unlicensed staff - had a significant different effect across the three quality of care indexes. This consistency strengthens the predictors' validity and substantiates that although the factor analysis showed that relatives, staff and the field observer assessed the quality of care differently, these differences were not decisive with regard to their relationships to the predictors. The relatively high explained variance at the ward level (R 1 2 ) was a further surprise, as compared to earlier studies. An explained ward level variance of 64%, 64% and 53% in the models with quality assessed by relatives, staff and field observations respectively, shows that the predictors in the model explained much of the variation in quality of care between the wards and that common method variance was a minor problem in the study.

The strong correlation between task- and relationship-oriented leadership style ( r = 0.78) - leaders who got high scores on task-oriented leadership also got high scores on relationship-oriented leadership and vice versa - showed that the two styles were closely related. This indicates that leadership style in the present study was to a certain extend a general phenomenon and that staff did not strongly differentiate between the two styles. However, factor analysis confirmed two separate leadership styles, showing that there was a significant distinction between the two styles. This distinction between leaders who focus on tasks and relationships, respectively, is in line with prior studies, both in the health sector [ 47 ] and in other organizations [ 35 , 37 , 40 ].

Relationship-oriented leadership style showed no significant effect on quality of care in the simultaneous analyses of the two leadership styles. This could indicate that relationship-oriented leadership style had no effect in the present study. However, this is not correct. Relationship-oriented leadership style had a significant effect on quality of care in separate analyses ( p < 0.01), where the effect of task-oriented leadership was excluded. Consequently, the effect of relationship-oriented leadership style was erased by its strong correlation with task-oriented leadership style. Hence, we can conclude that both styles had a positive effect on quality of care in the present study and that the effect of task-oriented leadership style was the strongest.

The stronger effect of task-oriented leadership style was expected based on prior studies [ 35 , 37 , 40 , 42 ]. There might be unique contingencies in nursing homes though, that particularly facilitate the influence of task-oriented leadership style. In this regard we will propose two factors that are relatively constant for staff in nursing homes: 1) task-oriented leadership style has shown to be favourable for work which is characterized by high task structure and work that requires strong interdependency among staff [ 40 , 66 , 67 ]. Work in nursing homes has a typical task structure with defined and repetitive tasks and strong interdependency among staff is crucial for accomplishing daily tasks [ 8 , 68 ]. 2) Workplaces with shift work and activities 24/7 often have irregular workgroups and additionally the leader is normally present during day shift only. Such work settings may require more structure, planning and clarifying of roles than workplaces without shift work [ 69 ].

Concerning the effect of the two leadership styles on the different quality indexes, the particularly strong effect of task-oriented leadership style on staff assessed quality of care is worth mentioning. The findings are supported by Sellgren et al. [ 70 ], who showed that structure and clarity of roles - typical elements in task-oriented leadership style - were the most important leadership behaviour when staff assessed the quality of care.

The lack of any significant positive effect for staffing levels or ratio of registered nurses on the quality of care indexes stands in contrast to most prior studies [ 10 , 11 ]. An explanation for the present result may be the relatively high staffing levels and the relatively high ratio of registered nurses in Norwegian nursing homes compared with many other countries. There are approximately 0.80 full-time equivalents (FTE) of care workers per resident in Norwegian nursing homes and approximately 26% of them are registered nurses [ 33 , 61 , 71 ]. Studies from US and other Scandinavian countries report a considerably lower level of both staffing levels and ratio of registered nurses [ 52 , 64 , 72 – 74 ]. Thus, one plausible interpretation may be that the effects of increased staffing levels and increased ratio of registered nurses on quality of care are not linear at all staff levels (decreasing marginal productivity). The curve might flatten out, meaning that the positive effect of increased staffing levels and increased ratio of registered nurses on quality of care decreases above a certain level [ 13 , 75 ]. Zhang and Grabowski [ 76 ] and Abt Associates [ 77 ] found support for this assumption in a nursing home setting. Both studies have shown that the positive relationships between staffing and quality of care were significant in the lowest staffed nursing homes only.

Another explanation for the lack of effect could be the choice of quality measures used in the study. Arling et al. [ 2 ] suggested that process measures of quality may be more sensitive to staffing than outcome measures. This is because the outcome measures could be influenced by many other factors besides the defined predictors. In the literature review by Castle [ 11 ] 40% of the process indicators were found to be positively associated with staffing levels, as compared to 38% of the outcome measures. Yet, Castle [ 11 ] underscored that there was an extreme diversity in the quality indicators examined in the studies and that the type of quality measures may influence the effect of staffing. The majority of the quality of care items in the present study were outcome measures (see Appendix).

At last, it should be emphasized that the results concerning the effects of staffing levels and ratio of registered nurses on quality of care is ambiguous. Even if Castle [ 11 ] found a relationship between the two variables in most of the studies he examined in his literature review, 60% of the quality indicators in those studies were not related to increased staffing levels and 48% of the quality indicators were not related to increased level of registered nurses. Furthermore, the literature review by Spilsbury et al. [ 13 ] concluded that: "...research has produced inconsistent and contradictory results about the link between nurse staffing and quality in nursing homes." (p. 748).

In contrast to total staffing levels and ratio of registered nurses, the effect of unlicensed staff was significant; higher ratios of unlicensed staff had a negative effect on quality of care assessed by relatives and field observations. The effect of unlicensed staff on quality assessed by staff was not significant, however. The insignificant relationship ( p = 0.22) may be explained by the assumption that licensed staff assessed the quality of care differently from unlicensed staff, the latter group presumably being less critical of their own work than licensed staff.

We should, however, be hesitant to conclude that unlicensed staff have a direct negative effect on quality of care. High ratios of unlicensed staff tend to be correlated with other factors that are unfavourable for quality of care, such as high staff turnover [ 50 ].

An increased physical care level showed a significant negative effect on all three quality indexes. The relative effect was strongest when quality was assessed by relatives. The strong effect of care level may have two potential explanations: 1) nursing homes provide better care to residents with high physical functional ability than to residents with low physical functional ability and/or 2) the physical functional ability level of the residents influence the assessments of quality of care, and in particular the assessments made by relatives.

The ICCs' of 57%, 20% and 64% showed that there was a substantial clustering of wards within nursing homes (see Table 4 ). Future research is encouraged to use a design that makes it possible to identify both nursing home and ward factors that influence quality of care. A factor of interest is the leadership behaviour of the director of the nursing home, [ 1 ] and a simultaneously assessment of the ward leaders and the director of the nursing homes leadership styles would have been of particular interest.

There are several limitations to our study. First, the number of participating nursing home wards is limited and our sample is not representative of the population of Norwegian nursing homes although regions and communities all over the country were included. Second, the quality of care was assessed by self-reported data only. A potential weakness with primary data sources is the subjective aspect - it depends upon the individuals who carry out the assessment. The inclusion of secondary data sources would have been beneficial for the study. However, Norway has no national data sets like the MDS and other secondary data sources were not available. To compensate for the lack of secondary data sources, we used three independent primary data sources; relatives, staff and field observations. It should be emphasized that these sources are well suited for measuring quality of care in nursing homes [ 13 , 21 , 22 , 34 , 78 – 81 ]. Third, the study had a cross-sectional design which does not take into account the relatively high turnover rate in the sector. Longitudinal design could have strengthened the study; though not possible within the scope of this investigation.

This study indicates that the relationship between staffing levels, ratio of registered nurses and quality of care may be more complex than some prior research suggests. Increasing staffing levels or the ratio of registered nurses above a certain level is not likely to be sufficient for raising quality of care. The study also shows that nursing homes should aim to minimize the use of unlicensed staff where possible by addressing the underlying reasons for the use of such staff, such as high staff turnover. The significant positive effect of leadership styles on quality of care underlines the importance of active leadership in nursing homes. The stronger effect for task-oriented leadership style suggests that leaders in nursing homes should in particular focus on task-oriented conditions like structure, coordination, clarifying of roles and monitoring of operations.

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The authors wish to express their gratitude to the nursing homes and their employees that participated in this study, and to the Research Council of Norway (Reference number: 187986/V50) for financing the study.

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Anders Kvale Havig

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Faculty of Psychology, University of Bergen, Norway

Anders Skogstad

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AKH and TIR designed the study. AKH collected the data, performed the field observations, analysed the data and wrote the first draft of the paper. AS, TIR and LEK participated in the interpretation of the data analysis and critically commented the first draft. All authors approved the final manuscript.

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Havig, A.K., Skogstad, A., Kjekshus, L.E. et al. Leadership, staffing and quality of care in nursing homes. BMC Health Serv Res 11 , 327 (2011). https://doi.org/10.1186/1472-6963-11-327

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• nursing homes
• quality of care

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Leadership, staffing and quality of care in nursing homes

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• PMID: 22123029
• PMCID: PMC3295728
• DOI: 10.1186/1472-6963-11-327

Background: Leadership and staffing are recognised as important factors for quality of care. This study examines the effects of ward leaders' task- and relationship-oriented leadership styles, staffing levels, ratio of registered nurses and ratio of unlicensed staff on three independent measures of quality of care.

Methods: A cross-sectional survey of forty nursing home wards throughout Norway was used to collect the data. Five sources of data were utilised: self-report questionnaires to 444 employees, interviews with and questionnaires to 13 nursing home directors and 40 ward managers, telephone interviews with 378 relatives and 900 hours of field observations. Separate multi-level analyses were conducted for quality of care assessed by relatives, staff and field observations respectively.

Results: Task-oriented leadership style had a significant positive relationship with two of the three quality of care indexes. In contrast, relationship-oriented leadership style was not significantly related to any of the indexes. The lack of significant effect for relationship-oriented leadership style was due to a strong correlation between the two leadership styles (r=0.78). Staffing levels and ratio of registered nurses were not significantly related to any of the quality of care indexes. The ratio of unlicensed staff, however, showed a significant negative relationship to quality as assessed by relatives and field observations, but not to quality as assessed by staff.

Conclusions: Leaders in nursing homes should focus on active leadership and particularly task-oriented behaviour like structure, coordination, clarifying of staff roles and monitoring of operations to increase quality of care. Furthermore, nursing homes should minimize use of unlicensed staff and address factors related to high ratios of unlicensed staff, like low staff stability. The study indicates, however, that the relationship between staffing levels, ratio of registered nurses and quality of care is complex. Increasing staffing levels or the ratio of registered nurses alone is not likely sufficient for increasing quality of care.

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What is task-oriented nursing, and why is it bad?

Nurses General Nursing

Published Apr 13, 2005

I am a 4th semester nursing student at a technical college. I currently work as a nurse intern on a med/surg floor and float to ICU occasionally. I was informed that on graduation there will be no jobs except in ICU. There are two part-time jobs there. Amidst much discussion about taking on a new grad I as placed as an intern in the ICU for the remaining four months until graduation to "try things out." I was given the opportunity to apply for one of the positions, and my interview seemed to go well. I have had nothing but positive reports from my R.N.s, and my manager informed me that my evals look good and have been improving nicely. However, after several "confidential" meetings with my various nurses they have "said that you don't look for enough new experiences. You're too task-oriented." It is now too late to change anything to be able to get a job there. I will continue to work in the ICU until graduation, at which time I will begin 3 months of orientation back on the med/surg floor and then will be offered a float-pool position as that is all that is available there now. "We don't want to lose you, but we think you need to learn to dig deeper before working in ICU." Help! I don't understand what I'm doing wrong. All of my work is done on time every time, the doctors have complimented me several times on good nursing skills, such as noticing new abnormal heart rhythms which necessitated a move to the ICU, and my patients love me. The med/surg nurses that I work with the most have no complaints. I need to know what to change so that I can fix it. I don't want this to be a black cloud hanging over every resume I ever send out! Also, I'm not sure that I want to be there... I have an opportunity to work in a clinic. I know it's not as glamorous, but the hours would be perfect for me as I'm a young-married and hope to have kids. Am I giving up if I take a clinic job and work float-pool?

• + Add a Comment

VivaLasViejas, ASN, RN

22 Articles; 9,987 Posts

Sounds like the clinic job would be your best choice........the money isn't as good as it would be in the ICU, but peace of mind and good hours are worth a lot more than high wages. (Believe me, I know.)

That said, I'm wondering just what your preceptors' expectations for a student nurse are.......seems to me they're a little high. New nurses are, by nature, task-oriented; they don't have the knowledge or the critical-thinking skills necessary to 'dig deeper'---those come only with time and experience!

It takes at least a year, and usually more, even to become comfortable with the job; by then you've seen a lot of things over and over and learned how to respond. Being proactive comes even later.......I've been a med/surg nurse now for about 5 years total, and it's been only in the last year or so that I feel I've really come into my own, that I'm competent and know my 'stuff'. So, even without really knowing the specifics of the situation, I feel the criticism given you was a little unfair, and I think they're expecting too much for someone who's still very much a beginner.

Good luck to you. :)

Thank you, that makes me feel a little better. I have interned for two years, and apparently the criticism comes from the fact that I have been compared with two other interns (one of whom is competing for the same job and has been working as a CNA/EMT for 15 years) and a couple of students who have also worked in ICU at one time or another. My husband agrees that if I think I would like clinic nursing I should try it. Thanks again!

SharonH, RN

2,144 Posts

New nurses are, by nature, task-oriented; they don't have the knowledge or the critical-thinking skills necessary to 'dig deeper'---those come only with time and experience!

That's true. I really don't have a lot to add what Marla wrote; she pretty much covered the bases. As a new nurse, you are trying to learn a lot of new skills as well as where all the pieces of the puzzle fit. I wouldn't feel too bad about performing "task-oriented" nursing at this point in your career. Now when I work with nurses of 5, 10, and 15 years of experience who do nothing but what is in the physician order set and nothing else, then I get frustrated.

Okay, all of this is comforting. However, it still doesn't explain what "task-oriented" means, and how I can change it. This is my problem. Nobody will tell me what to do differently. They say nurses eat their young. Unfortunately I'm starting to agree. The nurses I work with are great, at least on the evening shift. However our day-shift nurses have been there so long that they expect everyone to meet their level of nursing. Soooo, they don't answer questions. They just expect me to figure it out on my own, like if I don't I'm not good enough to be a nurse with them. Someone please help. I want to change, so that I can be a better nurse.

geekgolightly, BSN, RN

I think what they mean by task oriented nursing, is focusing on completing task X (such as inserting a foley) rather than WHY we are performing task X and even if we should be performing it. (does pt have hx of fx UTI etc. etc.). It's tough to think that way all the time when just performing the task is such a new experience. I don't know how long their preceptor program is, or what they have to offer, but I guess they feel they don't have the ability to take a new grad from task oriented nursing (which is what we all do as new grads, so don't fret) to the level of critical thinking it takes in ICU. it reflects on them, not on you. You are exactly where you should be.

good luck in whatever you choose :)

Well, thank you all very much for your help. Now, it gets better. I was turned down for this job because I was too task-oriented, and becuase I "need to have a medical-surgical foundation first." Sooo, my manager has gone on to hire a girl who graduates with me who has never worked on a med/surg floor except 5 years or so ago when she was a CNA there. I'm a little offended, I have to say. I have worked on the Med/Surg floor as an intern for two years, and have floated to the ICU at least two or three times a month almost every month. How is it that I need a better foundation, but she's okay when she has NO foundation? I'm a little confused. I wish her the best, but I'm having a hard time understanding my manager's thinking process. Especially since the general thought in the unit was that she didn't do well on her interview, couldn't time manage and fluffed her way through the answers. I guess on the one hand it makes me realize again that it truly is not what you know but who you know.

4,177 Posts

float nurses usually should be a more experienced nurse because they are confronted to many different parts of the hospital but if you feel like you can handle this assignment you will certainly learn more than you could possibly do in a clinic setting

I actually will not be working in that type of float position. It's more of an occasional position. Also, I have since been offered a regular part-time position. It's kind of crappy hours, and nobody wants me there because we don't really need another nurse on our floor right now. Yeah, there MIGHT be another nurse quitting soon and then I'll get more hours. However, when I told my manager that I had some other places I had applied, she got all huffy and said she wasn't sure if she could guarantee me that job either! I really need the med/surg experience, because without it I don't have a chance of getting a job in my dream spot-E.R. I'm doing my preceptorship in our E.R. right now. I love it. We had a 2-car MVC with 2 injured patients that came to our E.R. One of them ended up in my area and my nurse and I were on the trauma team. It was an amazing adrenaline rush. Also, we probably saved the girls life. Very cool. The team-work was amazing, and I recieved some nice compliments for how well I handled the situation. I think that is what nursing is all about.

ButterflyRN04

That Manager sounds like she has something against you. You don't need that kind of treatment, especially if you have worked there for 2 years. If I were you I would apply elsewhere and gain that medsurge experience. OR what about applying in the ER? they take new grads sometimes.

3,836 Posts

Task oriented means you are focused more on getting specific things done, rather than paying attention to the whole global picture surrounding the patient and the situation around you. Which is totally okay, at this stage of your career, just like everyone has said.

If you are curious about where this idea came from, it is described very well in Patricia Benner's nursing theory, From Novice to Expert. She described 5 stages: novice, advanced beginner, competent, proficient and expert. (Gee, can you tell I just wrote a paper for my nursing theory class :rotfl: ). You are somewhere in the advanced beginner area, moving along (its a continuum, not set stages) quite well especially if you can notice rhythm changes, and keep it together in a trauma scene in ED.

Keep asking questions whether some others like it or not, its the way to learn. Sometimes the key is in the way you ask, as in "check me on this, we are doing this because ....., is there anything else about it I'm missing?" That lets people know you aren't totally unaware of stuff, just wanting to know more. Find one person you really respect and ask if she will be your unofficial mentor for a while, someone you can come to without being made to feel stupid.

Most nurses in the proficient and expert stages also get all the tasks done efficiently, but can see many more things around the patient, implications of things, etc., so can do more than just tasks but also meet multiple needs of patients (not just the stuff that physical tasks take care of). Google some articles by Benner, she's really good.

Again, you don't have to "change", just grow. And that takes time and experience, and you sound like someone I would love to work with. Wanna move to New Mexico?

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Nurses Coping with Stressful Situations—A Cross-Sectional Study

Grażyna iwanowicz-palus.

1 Chair of Obstetrics Development, Faculty of Health Sciences, Medical University of Lublin, 4-6 Staszica St., 20-081 Lublin, Poland

Mariola Mróz

Krystyna kowalczuk.

2 Department of Integrated Medical Care, Faculty of Health Sciences, Medical University of Bialystok, 15-096 Bialystok, Poland

Beata Szlendak

3 Center of Postgraduate Education for Nurses and Midwives, 02-106 Warsaw, Poland

Agnieszka Bień

Mateusz cybulski, associated data.

Data are available upon reasonable request.

Nursing belongs to the group of professions particularly exposed to stress. Since the ability to cope with stress is an important aspect of mental health, the aim of this study was to identify the types of nurses’ behaviours in terms of different coping styles used when dealing with work-related and psychosocial stress. The study was conducted among 1223 Polish nurses by means of a diagnostic survey, using the Coping in Stressful Situations Questionnaire (CISS), the Generalised Self-Efficacy Scale (GSES) and a questionnaire of the author’s own design. Three types of nurses were distinguished: Type 1 (non-harmonious/organised)—nurses with lower professional education, longer work experience, at least average severity of stress related to working conditions, the lowest GSES scores, and worse psychophysical condition, who focused on their own emotional state when faced with stressful situations. Type 2 (harmonious)—nurses with higher education, the lowest intensity of work-related stresses, the highest GSES scores, positive self-reported psycho-physical condition, most often using the task-oriented coping style in stressful situations. Type 3 (non-harmonious/disorganised)—nurses with shorter length of service in the profession, the highest intensity of work-related stress, average GSES scores, and poorer self-reported psycho-physical condition. The presented results may provide a basis for preventive measures to minimise stress and increase competence in coping strategies, thus contributing to improved psychological and physical well-being of nurses.

1. Introduction

In the 21st century, stress has become a natural, unavoidable part of our daily lives [ 1 , 2 ]. Stressors are varied and can be seen as negative events that inhibit the undertaking of new tasks or the continuation of ongoing tasks, but they can also be a kind of motivator to continue actions in the chosen direction [ 2 , 3 ]. Professional work is one of the most important human activities, as it satisfies needs, provides a sense of self-worth and is the basic source of income for employees and their families. It can be a source of life satisfaction, but also of dissatisfaction and stress [ 4 , 5 , 6 , 7 ].

Nurses are a vital link in the health care system. However, nursing is one of more demanding professions involving exposure to a number of stressors associated with the responsibility for the health and life of another human being [ 8 , 9 , 10 , 11 ]. Nursing requires constant focusing of attention, rapid responses, decision-making and the ability to perform many activities simultaneously, often under time pressure [ 4 , 12 , 13 ]. This is accompanied by the lack of promotion prospects, shift work and work overload, as well as an inadequate organisational structure, including staff shortages and low pay [ 6 , 14 , 15 , 16 ]. Other sources of stress include contact with patients’ families, working in a multidisciplinary team and within one’s own age-diverse professional group, as well as insufficient social support at work. [ 4 , 6 , 17 , 18 ]. The role of stressors also increases with the ever-increasing demands made by employers and recipients of medical services [ 4 ].

Stress coping is a constantly changing behavioural and cognitive effort directed at specific internal and/or external demands appraised as taxing or beyond one’s resources [ 19 ]. Endler and Parker (1990) distinguished three styles of coping with stress: task-oriented style (TOS—after the initial assessment, there is a tendency to make an effort to solve the problem); emotion-oriented style (EOS—undertaking action to reduce the emotional tension accompanying a stressful situation through wishful thinking, fantasising); avoidance-oriented style (AOS—rejecting thoughts about the fundamental problem, not allowing oneself to experience it and engage in solving the stressful situation: this style is expressed in two subscales, i.e., ESA—engaging in substitute activities—and SSC—searching for social contacts) [ 20 , 21 , 22 , 23 ].

Self-efficacy is also an important element in dealing with stress [ 24 , 25 , 26 ]. This factor enables proper assessment of the situation and the search for an effective coping strategy to deal with the encountered difficulties and obstacles. Self-efficacy can contribute to motivation to act and help achieve the individual’s intended goals [ 27 ]. High self-efficacy may reduce the tendency to show symptoms of work-related stress and increase competence to constructively deal with stress [ 28 ]. In addition, self-efficacy is positively correlated with organisation, commitment and job satisfaction, as well as better coping with difficulties [ 24 , 29 ].

Research on stress coping styles may be found in the literature. It shows, among other things, that nurses using the task-oriented style better deal with stressful situations. However, studies that would distinguish different types of nurses, depending not only on their stress-coping strategies, but also on the frequency of psychosocial and occupational stressors and personal resources, including self-efficacy, are missing [ 18 , 30 , 31 ].

The present study was designed considering the aforementioned stressors and potential difficult situations nurses are exposed to in their workplace, as well as the lack of scientific reports identifying types of nurses’ behaviours when faced with stress. In order to minimise stress, it has become essential to understand and categorise nurses’ behaviours in difficult situations, thereby providing a wider perspective for designing preventive measures.

The aim of this study was to distinguish the types of nurses’ behaviours in terms of their varied coping styles, work-related variables and their socio-demographic characteristics, as well as organisational, occupational and psychosocial stressors.

2. Materials and Methods

2.1. study design and participants.

This cross-sectional study was conducted in accordance with the guidelines for The strengthening the Reporting of Observational Studies in Epidemiology (STROBE). It was conducted in 2018 among 1223 nurses employed in medical institutions in Poland. Probability sampling was used. Research data was collected in randomly selected institutions offering postgraduate training for nurses across the country. The respondents were informed of the anonymity and voluntary nature of their participation in the diagnostic survey and that the results obtained would be used for research purposes only.

The respondents were informed about the course and purpose of the survey and instructed on how to complete the questionnaire. Those who agreed to participate in the study were given the survey questionnaire together with an informed consent form. The consent forms and survey questionnaires were left in special boxes which were opened after the survey was completed.

The inclusion criteria were as follows: a valid nursing licence and active professional practice. The exclusion criteria included lack of active nursing practice and incorrectly filled or incomplete questionnaire.

The group attending postgraduate training in the year of the study included 9845 nurses [ 32 ]. The minimum number of respondents was estimated at 370 (with a maximum error of 5% and a confidence level of 95%). A total of 1270 forms were distributed among the participants. A total of 1223 correctly completed survey questionnaires qualified for further statistical analysis (47 questionnaires were incompletely or incorrectly completed). The success rate of the data obtained was 96.29% ( Figure 1 ).

Flowchart of the recruitment process.

2.2. Assessments

The study was conducted by diagnostic survey method. The research tool was a questionnaire consisting of two sections:

The Coping in Stressful Situations Questionnaire (CISS) consisting of 48 statements relating to various behaviours in difficult and stressful situations, divided into three scales representing stress-coping styles used by the respondents:

Task-oriented style (TOS) scale—identifies a coping style that involves planning and undertaking tasks to bring about a solution to a difficult situation.

Emotion-oriented style (EOS) scale—focusing on one’s own experiences, emotions.

Avoidance-oriented style (AOS)—identifies coping with stress that involves avoidance of thinking, experiencing emotions and difficult, stressful situations. This style can take two forms: engaging in substitute activities (ESA) or searching for social contacts (SSC).

Each scale consists of 16 questionnaire items and respondents can score between 16 and 80 points in each scale. The respondents answer the questions on a 5-point scale (1—never, 5—very often). Scores are converted to sten norms and are interpreted as follows: stens 1–4—low scores, stens 5–6—medium scores, stens 7–10—high scores. Reliability as measured by the α-Cronbach coefficient for the tool is 0.74–0.88. The α-Cronbach coefficient for the study group for individual scales was as follows: TOS—0.90; EOS—0.87; AOS—0.89; ESA subscale—0.86; SSC subscale—0.87 [ 23 ].

Generalised Self-Efficacy Scale (GSES)—a questionnaire comprising 10 questions with the possibility to choose one of four answers (1—no, 2—rather no, 3—rather yes, 4—yes). The scale measures the level of an individual’s overall belief in their effectiveness in coping with obstacles and difficult situations. The sum of all scores yields an overall self-efficacy index. Scores are interpreted based on sten norms: a sten score of 1–4 is defined as low and a sten score of 7–10 as high. The Cronbach’s α coefficient was 0.85 for GSES and 0.89 for the study group [ 33 ].

The author’s original questionnaire ( Supplementary File ) included questions to characterise the respondents and to assess their working conditions and work-related burdens. The respondents gave their opinion on a five-point Likert scale as to the frequency of certain work-related situations (1 for never and 5 for very often). The questions were grouped into 3 sections.

Stress related to the organisation of work: excessive responsibilities; rush; lack of time; lack of breaks; monotony of work; poor conditions; working extra hours; large number of patients under care; having to comply with inconsistent orders; poor conditions and insufficient organisation in the workplace; limited career opportunities; autonomy and independence in decision-making; safety in the workplace; stability of employment. Score range: min. 13, max. 65.

Psychosocial stress: providing the highest level of care to patients; receiving work instructions that are not in line with professional qualifications; lack of kindness, support and trust within the team; interpersonal conflicts; conflicts with supervisors, patients and their families; aggression from patients; respect from patients; recognition from supervisors. Score range: min. 12, max. 60.

Stress related to individual’s characteristics: high responsibility for health and life; frequent exposure to suffering/death; fear of losing work; lack of motivation to work; need to improve professional qualifications. Score range: min. 5, max. 25.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (the Bioethics Committee of the Medical University of Lublin: KE-0254/128/2017) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

2.3. Statistical Analysis

Statistical analyses were performed using Statistica version 13.3 and IBM SPSS Statistics (StatSoft Polska Sp. z o.o., Cracow, Poland). Characteristics of the study group was based on descriptive statistics of the analysed variables, including: mean (M), standard deviation (SD), numbers (n) and percentage (%). The significance of differences between the means was determined by one-way analysis of variance (F—Fisher statistics) and Student’s parametric t-test. The Pearson’s chi-square test (X 2 ) was also used, which made it possible to estimate whether the distribution observed in a given group depended on another variable. Agglomerative cluster analysis and k-means cluster analysis were performed to distinguish subtypes in the study group of nurses and midwives. The level of statistical significance was set at p < 0.05.

3.1. Characteristics of the Surveyed Nurses

Table 1 shows the characteristics of study participants. The respondents were predominantly nurses in the age range of 41–50 years (42.19%) living in a provincial city (39.33%), married or in an informal relationship (76.70%), with a master’s degree (40.31%), with work experience in the profession of 21 to 25 years (20.44%), ( Table 1 ).

Participants’ baseline characteristics.

(n)—number, %—percentage.

3.2. Assessment of Occupational Stressors and Nurses’ Stress-Coping Styles

In the study group of nurses, the highest scores in stress-coping styles were obtained for TOS (M = 55.49 ± 7.84), while the lowest for SSC (M = 17.08 ± 3.09). The mean score of general self-efficacy in the study group was 29.84 ± 3.69. As for the nurses’ self-reported occurrence of specific stressors, the highest severity was reported for the organisational dimension of professional work (42.81 ± 5.84), while the lowest severity was reported for the dimension related to individual’s characteristics (18.60 ± 2.76)— Table 2 .

Mean scores of nurses’ stress-coping styles and their organisational, individual and psychosocial working conditions.

M—mean, SD—standard deviation.

3.3. Types of Nurses in Terms of Stress-Coping Strategies and Perceived Psychosocial and Occupational Stressors

We used an agglomerative analysis followed by cluster analysis to classify the respondents. The clusters identified in the group of nurses express three types of stress coping strategies.

Type 1 ( n = 383; 31.32%) was characterised by:

• - Average intensity of stress associated with the organisation of work;
• - The highest intensity of stress associated with psychosocial working conditions;
• - Average intensity of stress associated with an individual’s characteristics.
• - In terms of stress coping styles:
• - The task-oriented, avoidance-oriented coping styles and engaging in substitute activities and searching for social contacts were used least frequently when facing stress;
• - The emotion-oriented coping style was used relatively frequently.

Since nurses functioning according to this type perceived their work as very mentally taxing and focused on their own emotional state when in a stressful situation, this type of coping with stress was termed the non-harmonious/organised type ( Table 3 ).

Comparative analysis between nurses functioning according to the three types of stress-coping strategies in terms of coping styles and specific types of stress.

(Type 1)—non-harmonious-organised, (Type 2)—harmonious, (Type 3)—non-harmonious-disorganised; (TOS)—task-oriented style, (EOS)—emotion-oriented style, (AOS)—avoidance-oriented style, (ESA)—engaging in substitute activities, (SSC)—searching for social contacts; (M)—mean, (SD)—standard deviation, (Me)—median; (F)—coefficient of variance analysis, ( p )—statistical significance, (η2)—measure of effect strength.

Type 2 ( n = 385; 31.48%) was characterised by:

• - The lowest intensity of stress related to work organisation and psychosocial working conditions, and work-related stress;
• - The lowest intensity of stress related to the individual’s characteristics;
• - The task-oriented coping style was used most frequently;
• - The emotion-oriented style was used least frequently;
• - Coping style focused on avoidance and engaging in substitute activities and seeking social contacts was used relatively frequently.

Since nurses functioning according to this type rated organisational and psychosocial factors low and used a task-oriented style in stressful situations, this type was defined as the harmonious type ( Table 3 ).

Type 3 ( n = 454, 37.12%) was characterised by:

• - The highest intensity of stress related to work organisation;
• - Average severity of stress related to psychosocial working conditions;
• - The highest intensity of stress related to the individual’s characteristics.
• - The task-oriented stress coping style was used relatively frequently;
• - The most commonly used coping styles were emotion-oriented, avoidance-oriented; engaging in substitute activities and searching for social contacts.

Since nurses in this category reported the highest intensity of stressors (organisational, psychosocial and individual) and used the emotion-oriented style, avoided problem solving, engaged in substitute activities or searched for social contacts, this type was termed non-harmonious/disorganised ( Table 3 ).

The analysis of variance presented in Table 3 confirmed that the nurses constituting the three distinct clusters differed in their preferred stress-coping style and in their perception of stress related to work organisation, psychosocial working conditions and stress related to individual characteristics. The reported effect strengths are high with the exception of the differences in stress related to individual characteristics.

3.4. Analysis of Sociodemographic Variables among Nurses with Different Stress-Coping Styles

Table 4 presents the results of a comparative analysis between nurses using three types of stress-coping strategies in terms of socio-demographic characteristics and work-related variables.

Comparative analysis between nurses functioning according to the three types of stress-coping strategies in terms of selected socio-demographic characteristics, condition and GSES.

(Type 1)—non-harmonious-organised, (Type 2)—harmonious, (Type 3)—non-harmonious-disorganised; (M)—mean, (SD)—standard deviation, (Me)—median; (F)—coefficient of variance analysis, ( p )—statistical significance, (η2)—measure of effect strength.

Type 1—nurses functioning according to the non-harmonious/organised type of coping had lower professional education, longer work experience in the profession, the lowest general self-efficacy and rated their overall health and psychophysical condition as lower ( Table 4 ).

Type 2—nurses functioning according to the harmonious type of coping had higher professional education, the highest general sense of self-efficacy and rated their health, physical and mental condition highest ( Table 4 ).

Type 3—nurses functioning according to the non-harmonious/disorganised type had shorter professional experience, average general sense of self-efficacy and rated their general health and psycho-physical condition as lower ( Table 4 ).

4. Discussion

The present study assessed and distinguished specific types of nurses in terms of coping with stress, taking into account the severity of work-related stress, psychosocial working conditions and factors related to individual’s characteristics, including self-efficacy.

Our analysis revealed differences in sociodemographic variables in the identified types that characterise nurses. Education and length of service of the respondents were associated with their use of specific styles of coping with stress. Nurses belonging to the harmonious type had a higher level of education. The higher the educational level of nurses, the more often they used the task-oriented stress coping style. Kotarba and Borowiak (2018) also confirmed this relationship, indicating that nurses with higher educational levels cope better with occupational stress by using the task-oriented style [ 18 ].

According to Żuralska et al. (2015), unmarried nurses were more likely to choose confrontation-based strategies rather than avoidance. In our study, marital status did not significantly differentiate between respondents regardless of whether they represented the non-harmonious/organised, harmonious or non-harmonious/disorganised type [ 34 ].

Work experience was a differentiating variable in the identified types of nurses, in terms of work-related stressors and stress-coping styles. Nurses belonging to the non-harmonious/disorganised type had shorter work experience in the profession, and most often used the emotion-oriented and avoidance-oriented styles of coping. Our findings are in line with the data obtained by Perek et al. (2007), showing that the shorter the seniority of nurses, the more often they used the emotion-oriented style [ 35 ]. On the other hand, a study conducted among doctors by Basińska and Dziewiątkowska (2012) showed an inverse relationship. Namely, those with longer seniority were more likely to use avoidance and resignation strategies in stressful situations at workplace [ 36 ].

Kotarba and Borowiak (2018) showed that the value of task-oriented style among the nurses surveyed varied depending on age. The data obtained in the present study did not correspond with these results [ 18 ].

The levels of stress related to work organisation and psychosocial working conditions, as well as individual characteristics were also differentiating factors for the nurses surveyed. Nurses who reported the highest intensity of stress related to work organisation, an average intensity of stress related to psychosocial working conditions, the highest intensity of stress related to individual characteristics in a stressful situation used the emotion-oriented style, avoided solving their problems and engaged in substitute activities or sought social contacts. Medium intensity of work organisation-related stress, the highest intensity of stress related to psychosocial working conditions and average intensity of stress related to individual characteristics led nurses to focus on their own emotional state. Nurses who showed the lowest intensity of work organisation-related stress, the lowest intensity of stress related to psychosocial working conditions and the lowest intensity of stress related to individual characteristics used the task-oriented stress coping style. The results obtained correlate with the findings of C. Jenaro, N. Flores and B. Arias (2007), who conducted their study among Spanish social workers, indicating that the task-oriented coping style is associated with high job satisfaction [ 30 ]. The main goal of an individual using the emotion-oriented style is the need to reduce the psychological tension accompanying a stressful situation through wishful thinking, which has little effect and often results in a further increase in negative emotions and depressed mood [ 23 ]. In contrast, the task-oriented style allows difficulties to be overcome and triggers a positive attitude. Individuals who score high on this scale are above all able to plan and implement a solution to a problem. The task-oriented style is therefore considered to be the most optimal form of functioning in difficult situations [ 31 ].

In terms of stress related to cooperation with a supervisor, nurses who reported the most frequent occurrence of situations such as conflicts and receiving work instructions incompatible with qualifications were relatively more likely to use the emotion-oriented style than the task-oriented strategy. The results of the study did not correspond with the data obtained by Kaźmierczak et al. (2019), who found no difference between the lack of support from superiors and the choice of stress-coping strategies [ 37 ].

The non-harmonious/organised type was characterised by the highest intensity of stress related to psychosocial working conditions, which included lack of kindness, support and trust within the team. Nurses representing this type were least likely to use the task-oriented style in contrast to respondents in Kaźmierczak et al. (2019), who chose active stress coping strategies [ 37 ].

The nurses in our research who were found to have the highest levels of stress in terms of collaboration within the therapeutic team were the least likely to use the avoidance-oriented style and to engage in substitute activities, which was also reflected in the research data obtained by Kaźmierczak et al. (2019), according to which the lack of collaboration between members of a therapeutic team was significantly more likely to lead nurses to attend to something else [ 37 ].

The process of coping with stress depends on several factors, including social support and self-efficacy. In our study, we found that nurses belonging to the non-harmonious/organised type were least likely to seek social contacts despite being characterised by the highest intensity of psychosocial stress and the use of EOS. Similar results were obtained by Kaźmierczak et al. (2019), who found that nursing staff did not seek support from others when faced with team conflicts [ 37 ].

Available research shows that more coping skills in stressful situations and more adaptive behaviour in relation to professional work are reported among nurses characterised by higher levels of general self-efficacy. Nurses with high levels of self-efficacy show a better ability to cope with specific situations and are more likely to perform their tasks [ 38 , 39 ]. Those with high self-efficacy are also more satisfied with their work organisation. In addition, Andruszkiewicz, A. et al. (2011) proved that self-efficacy protects this professional group from experiencing too much work-related stress [ 24 ].

Our study showed that the more often the nurses used the task-oriented and avoidance-oriented style, the higher their sense of self-efficacy was. In contrast, the more often they used the emotion-oriented coping style, engaged in substitute activities and sought social contacts, the lower their general sense of self-efficacy was. Konaszewski et al. (2021) also indicated a positive correlation between self-efficacy and TOS [ 40 ]. The use of the task-oriented style by the professional group of nurses may indicate that they make an effort to solve a problem when facing stress.

Stress is a factor that interferes with the body’s equilibrium, indirectly affecting human health; therefore, while distinguishing the types of nurses in terms of stressors, sociodemographic variables and stress coping styles, attention was also paid to the important factor of the psychophysical condition of the representatives of this professional group. Based on our study, it was found that nurses using the emotion-oriented stress coping style and reporting more frequent stress rated their general health and psychophysical condition lower. In contrast, nurses functioning according to the harmonious type, using the task-oriented style, and who rated organisational and psychosocial stress as low, had better self-reported mental and physical condition and health status. Kaźmierczak et al. (2019) showed that somatic symptoms experienced by nursing staff and psychological factors were also significantly related to the choice of stress coping strategies [ 37 ]. Additionally, Kowalczuk et al. (2021) indicated that nurses using active stress coping styles were more likely to seek rational and positive solutions to difficult situations, which predisposes to maintaining good health [ 21 ].

Workplace stressors and coping styles are key factors influencing the mental and physical health of nurses (including anxiety and depression) and other negative emotions. Low self-reported psychophysical health condition leads to an increased absenteeism at work, staff fluctuation, and thus increased operating costs of healthcare facilities.

Since the available studies on coping styles presented by many authors do not distinguish between the modes of nurses’ functioning upon exposure to stress, the results presented here may provide a basis for preventive measures to minimise stress and increase coping competence, thus contributing to improved psychophysical well-being and the healthcare system.

The results may become a predictor for creating and introducing training sessions to develop task-oriented coping styles and improve self-efficacy. Furthermore, the introduction of measures to counteract unfavourable workplace phenomena, as well as the implementation of interpersonal training aimed at developing the ability to deal with stress, may increase the employee’s effectiveness and job satisfaction, and thus improve the self-reported health among the nursing personnel. Our findings may be a key element in the choice of methods and tools to ensure rational protection of nurses, thus providing them with a sense of security in their work environment.

Strengths and Limitations of the Study

The strength of our study is that it collected data from across the country on coping styles used by nurses to deal with stress. The results obtained, using cluster analysis, allowed us to identify different types of nurses’ behaviours upon exposure to stress and factors predisposing to the use of the task-oriented style, which is the most desirable strategy.

As for the limitations, it should be pointed out that this was a cross-sectional study, therefore causal relationships could not. Furthermore, as the nursing profession is mainly practised by women, men did not participate in the study [ 41 ]. However, it would be relevant and interesting to conduct a study also in the group of active male nurses.

5. Conclusions

Nurses use varied coping styles when faced with stress, and they also show different degrees of stress related to work organisation, psychosocial working conditions and individual characteristics. Three types of coping with stress by the nurses surveyed were identified:

The harmonious type was the most acceptable type in nurses’ work, bringing together individuals who had low ratings of organisational and psychosocial stress and were most likely to use the task-oriented stress-coping style. These individuals also had the highest level of education and the highest levels of self-efficacy and a sense of being successful at work.

The type of behaviour described as non-harmonious organised was used by nurses with lower education, longer work experience and low self-efficacy. They perceived the work as highly mentally taxing and used the emotion-oriented coping style in difficult, stressful situations.

The non-harmonious disorganised type brought together nurses who had the shortest length of service, the highest sense of work overload and work-related stress, and a medium level of self-efficacy. In a stressful situation, they used the emotion-oriented style, avoided solving the problem by engaging in substitute activities or focusing on seeking social contacts.

Determining the types of nurses’ behaviours upon exposure to stress can provide a basis for interventions aimed at improving coping with stress, thus minimising the negative consequences of occupational stress. In order to counteract the perception of work as stressful, competence development should be promoted through continuing professional education and participation in coaching, aimed at developing the ability to apply the task-oriented style of coping with stress and building self-efficacy.

Acknowledgments

The authors are deeply grateful to all patients participating in this study.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/ijerph191710924/s1 .

Funding Statement

This research received no external funding.

Author Contributions

Conceptualization, G.I.-P. and B.S.; methodology, M.M. and A.B.; formal analysis, M.M. and B.S.; investigation, G.I.-P. and B.S.; resources, B.S.; data curation, B.S.; writing—original draft preparation, G.I.-P., B.S., M.M., K.K. and M.C.; writing—review and editing, M.M., B.S., A.B., K.K. and M.C.; supervision, G.I.-P., B.S. and M.M.; project administration, G.I.-P. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

We declare that all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (the Bioethics Committee of the Medical University of Lublin: KE-0254/128/2017) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

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