development and validation of scales to measure organisational features of acute hospital wards

Pergamon In!. J. Nurs Stud.. Vol. 32, No. 6, pp. 612421, 1995

Elsevier Science Ltd Prmted in Great Britain

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Development and validation of scales to measure organisational features of acute hospital wards

ANN ADAMS, R.N., B.A., M.Sc. Research Fellow, Department of Nursing and Midwifery, University of Surrey. Guildford GlJ2 5XH, U.K

SENGA BOND,* R.N., Ph.D., F.R.C.N. Professor of Nursing Research, Centre for Health Services Research, University qf Newcastle-upon-Tyne, 21, Claremont Place, Newcastle NE2 4AA, U.K.

SARA ARBER, B.A., M.Sc., Ph.D. Projkssor, Department of Sociology, University of Surrey, Guildford GU2 5XH, U.K.

Abstract-In order to make comparisons between wards and explain variations in outcomes of nursing care, there is a growing need in nursing research for reliable and valid measures of the organisational features of acute hospital wards. This research developed The Ward Organisational Features Scales (WOFS); each set of six scales comprising 14 subscales which measure discrete dimensions of acute hospital wards. A study of a nationally representative sample of 825 nurses working in 119 acute wards in 17 hospitals, drawn from seven Regional Health Authorities in England provides evidence for the structure, reliability and validity of this comprehensive set of measures related to: the physical environment of the ward, professional nursing practice, ward leadership, professional working relationships, nurses’ influence and job satisfaction. Implications for further research are discussed.

0 Crown copyright 1995. *To whom all correspondence should be addressed

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SCALES TO MEASURE ORGANISATIONAL FEATURES OF WARDS 613

Introduction

There is a current need to demonstrate effectiveness in nursing. Nurses are under pressure from NHS management and government to demonstrate value for money, and the nursing profession itself is seeking to demonstrate its distinctive contribution to the care of patients. As a result, the way in which nursing care is organised at ward level has been the focus of both recent government and professional interest: witness the work of the Audit Com- mission (1991) the issuing of the named nurse directive as part of the Patients’ Charter (Department of Health, 1991) and a profusion of studies in the last decade in both the U.S.A. and the U.K. comparing the relative merits of different nursing systems of care delivery, such as primary, team and functional nursing (e.g. Giovanetti, 1981; Shukla, 1982; Shukla and Turner, 1984; Berry and Metcalf, 1986; MacGuire et al., 1994). This is against the background of a growing body of literature which highlights the importance of organisational practice in relation to both organisational and clinical outcomes of care (e.g. Mitchell et al., 1989; Shortell et al., 1991). Such research is not well developed in the U.K., but there is recognition that much previous nursing research has failed to take account of the variety of ways in which nursing systems are operationalised at ward level and the effects on care provision of a sufficient range of organisational features of wards. Hence studies have been unable to explain differences in outcomes of care (Thomas and Bond, 1990; Bond and Thomas, 1991).

In order to compare wards in relation to effective practice, there is a need to develop research tools which permit measurement and numerical description of salient ward organisational features. Tools are needed to facilitate understanding of the relationship between the physical and social aspects of nurses’ work environment and relationships between systems of nursing care provision and nursing effectiveness. They are needed to increase our ability to explain variation in outcomes and provide evidence to make recommendations for good practice. This paper describes the development of a set of scales for this purpose.

Developing usqful measures

In order to be useful, measuring tools must be theory-based, reliable, valid, appropriate to the unit of analysis and relatively easy to administer (Shortell et al., 1991). At present there is little available in the way of tools for measuring the organisational features of nurses’ socio-technical work environment in acute hospital wards. This reflects a lack of organisational theory in nursing. Recent organisational research has addressed technical aspects of care: developing tools to diagnose the system of nursing care provision present in wards (Thomas and Bond, 1990; Bowman et al., 1991; MacGuire, 1989; Mead, 1993). This work has mainly examined primary nursing, and generated many different definitions of the system. The result is that there are still no commonly accepted criteria or scales to describe what nursing system is in place, so that making comparisons between systems and drawing conclusions about their effectiveness is almost impossible. The usefulness of the work is also limited; only a minority of wards in the U.K. are believed to practice some form of primary nursing (Mead, 1993) and few adhere to the organisational criteria of any one system (Thomas and Bond, 1990).

The need for research which examines the wider organisational context within which hospital nursing takes place and which embraces a more dynamic approach to systems of nursing care provision is increasingly recognised (Madden and Lawrenz, 1990; Bond et al., 1991; Verran and Mark, 1992). This research addresses these issues.

614 A. ADAMS et al.

Examining influences on care

Central to the concept of nursing effectiveness is the delivery of high quality care to

patients (Bond and Thomas, 1991). As a first step in the process of developing new

research tools, existing nursing literature was examined to identify aspects of ward life and organisation known to influence the quality of nursing care. Donabedian’s (1980) frame- work of structure, process and outcome in relation to care, proved helpful. Important aspects of ward structure purported to affect care organisation were characteristics of nurses themselves, particularly the number and clinical grades available (e.g. Carr-Hill et al., ] 992) nurses’ level of competence (e.g. Shukla and Turner, 1984) and their working conditions (e.g. Coffey et al., 1988; Persson et al., 1993; Redfern, 1980; Cavanagh, 1989).

Features of the ward physical environment are also important structural elements. The availability of supplies and support services affect nurses’ ability to provide care (Robinson et al., 1989; Hegyvary, 1979; Bond and Bond, 1989) and have been perceived as possibly having a greater effect on productivity than nursing systems (Shukla, 1982; Shukla and Turner, 1984). Ward layout is also identified as affecting quality of care (Walker, 1981; Noble and Dixon, 1977). In organisational terms, the ward layout affects the number of nurses needed to staff a ward, and the contact time possible between nurses and patients (Canter and Kenny, 1978; Seelye, 1982; Canter et al., 1981).

Process elements of nurses’ work identified in the literature as having a potential impact on care received by patients include working relationships, ward leadership and job control (e.g. Johns, 1992; Whelan, 1988; Persson et al., 1993). The level of job control, latitude in decision-making and autonomy devolved to nurses as a result of the organisation process may directly impact on the care given to patients, as well as having an indirect effect through nurses’ stress and well-being. Difficulty in implementing change, lack of influence or autonomy and instrumental communication have been identified as predictors of nurse turnover (Persson et al., 1993; Cavanagh, 1989), and lack of professional latitude as a predictor of propensity to quit (Dolan, 1992). Participative management and devolved power structures have been recognised as important features of hospital organisation for attracting and maintaining nursing staff (McClure et al., 1982; Murphy and Deback, 1991; O’Grady, 1991) and feature significantly in new nursing practice models.

Nurses do not work in isolation, but in conjunction with other nurses and other professions. The literature suggests that the quality of relationships between staff may have a significant impact upon effectiveness and quality of care (e.g. Nichols et al., 1981; Shortell et al., 1994). While there is little research assessing the effects of cohesiveness amongst ward nurses on organisation and effectiveness, the literature suggests that this may be of particular importance. This is demonstrated in work related to introducing change in the ward organisational mode of care delivery, which emphasises the enduring nature of ward structures, their resistance to and their ability to change only very slowly (e.g. MacGuire et al., 1994; Johns, 1992). This work, along with that of Thomas (1992) who found closer ratings of physical and social aspects of the work environment between qualified and unqualified staff within wards than between wards, supports the idea of distinctive ward cultures. These socially created phenomena transcend different grades. These findings suggest that the effectiveness of any nursing system will therefore be influenced inter alia by the cohesiveness of the ward nursing staff as a necessary, but not sufficient condition for effectiveness.

Nurses work in a multi-disciplinary context, so that aspects of inter-professional working will affect how nurses provide care, as well as its effectiveness. There is a body of literature


describing the socially negotiated nature of care; particularly between nurses and doctors. A major theme in this work is the negative effects of nurses’ subordinate behaviour, which is reflected in low levels of patient autonomy and advocacy (Mackay, 1991, 1992; Elander and Hermeren, 1991; Buckenham and McGrath, 1983; Keddy et al., 1986). There is also a body of literature comparing the role perceptions of nurses and other health care professionals. Investigators identified discrepancies between nurses’ and doctors’ respective conceptualisations of a ‘good’ practitioner (Moran, 1991) and the nature of their respective jobs (Devine, 1978). Research which examines changed boundaries between the respective roles of nurses and doctors, i.e. the extended role of the nurse, reports conflicting findings. Last et al. (1992) report that some nurses’ perceptions of the quality of care and their job satisfaction is enhanced, while others resist what they conceive of as being a doctor’s handmaiden.

There is little evidence about the quality of inter-disciplinary teamwork in hospitals and its influence on patient outcomes. Studies in Intensive Therapy Units (ITUs) by Shortell et al. (199 1, 1994) assessed organisational features of the units and created an index of ‘care givers interaction’. This was associated with lower mortality as well as lower risk, adjusted length of hospital stay, lower nurse turnover rates and greater perceived technical ability and ability to meet family needs.

The quality of leadership is identified in the nursing literature as being central to the effectiveness of ward nursing. McDaniel and Wolfe (1992) link ward leadership style to nurse turnover, and Whelan (1988) reports that nurses perceive a linkage between the ward sister’s management style and quality of care, and between task orientation, social- emotional leadership and quality of care. Investigators, concerned with evaluating the outcomes of particular organisational modes of care delivery, have identified the potential of ward leadership to have a greater impact upon the quality of care delivered to patients than the organisational mode under scrutiny (Chavigny and Lewis, 1984; Giovanetti, 1981). Shortell et al. (I 991, 1994) also associated nursing leadership with quality of ICU care. The insights gained from literature were tested against the accounts of nurses working in acute hospital wards.

Method

Scale development involved the following stages:

1. Semi-structured interviews with nurses 2. Deciding scale items 3. Pre-pilot scale administration with interviews 4. Pilot survey 5. Main postal survey

Semi-structured interviews

The views of practising nurses about influences on care provision were elicited. Ninety- seven nurses working in acute hospital and surgical wards in fourteen hospitals in both the north and south of England were interviewed, either individually or as part of a small group. For the purposes of the study, acute wards were defined as adult, general wards which admitted acutely ill patients. This includes general medical, general surgical, gynaecological, orthopaedic and some specialist medical and surgical wards. The interviews provided the

616 A. ADAMS et al.

opportunity to obtain a nursing perspective and identify hitherto unreported phenomena. This phase of the study highlighted variety in the ways in which nurses organise care on wards within hospitals, which is related to contextual features specific to the immediate ward environment. The findings from the interviews suggested that nurses regard the following factors operating at ward Ievel as having a major impact on how they organise their work and hence its effectiveness:

l staffing levels related to workload l the quality of relationships between different professional groups l the team building skills of the ward sister or charge nurse l the physical environment of the ward l the amount of influence nurses perceive themselves to have over ward workload and the

resources they need to do their job.

There was a high degree of homogeneity amongst nurses, both within and between ward and hospital settings, about what factors influence the organisation of nursing. Scale items were devised to include these factors operating at ward structural level, organisational processes of care, measures related to nursing practice, to quantify the level of professional practice nurses’ perceive to exist within a ward, and an outcome measure of nurses’ job satisfaction that is specific to the acute ward setting.

Deciding scale items

The next step was to decide items related to the constructs identified in the qualitative study and literature review. Information needed to examine the hypothesised relationships between these organisational features falls into two categories: objective, factual information about ward characteristics, resources and practices; and information about nurses’ perceptions of different phenomena. This led to the development of two separate questionnaires to deal with these two types of data: a ward profile (WP) (not reported in this paper) and a nurses’ opinion questionnaire (NOQ). Scales were developed from the NOQ data only, while data collected using the WP provides important additional organisational information. Items in the NOQ scales were grouped under the headings of:

The Physical Environment of the Ward Professional Nursing Practice Ward Leadership Relationships with Ward Nursing Colleagues Inter-professional Relationships Control and Discretion Issues.

A small amount of personal information was also collected about respondents. The scales were devised as a self-completion questionnaire, with items presented as statements, with which nurses could either agree or disagree. Likert-type response options were offered so that strength of feeling could be indicated. Items were presented as a mix of positive and negative statements, in order to avoid response sets.

Study population

The study population comprised all nurses of grade C and above working in acute hospital wards. Unqualified nursing staff (grades A and B), students and other temporary


members of staff were excluded, although there is some evidence that nursing auxiliaries share similar views of the social and physical environments of wards and quality of care provided with their qualified colleagues (Thomas, 1992; Bond and Bond, 1995).

Permanent night staff were also excluded on the basis of findings from the qualitative study, because they are still often managed at hospital, rather than ward level, and frequently organise care in different ways and have different opinions to day staff. Ward sisters and charge nurses were included, so that their perceptions of phenomena affecting ward organisation and those of more junior nurses could be compared. In particular, it was expected that there would be a marked difference in the amount of influence the two groups of nurses perceived themselves to have.

Pre-pilot studla

Draft questionnaires were extensively tested with both a subset of the sample of nurses who took part in the qualitative study, and among all nurses in two wards in a hospital which had not previously been involved. In all, nurses working in 29 wards in nine different hospitals participated in this stage of the research. Interviews were conducted after parts of the questionnaires were completed, and reactions were gauged to the wording of items, the appropriateness of terminology, the relevance of items and to assess whether the questions covered the full range of appropriate elements of concepts. In this way the content validity of questionnaires was tested and enhanced. Reactions to different ranges of response options were also assessed as was the grouping of items. A decision was made to use a four point rather than a five point response range, so that nurses would have to either agree or disagree with items, and not have the option of a neutral mid-point. Draft questionnaires were continually refined and field tested. A section of questions relating to nurses’ socio- demographic details relevant to the study was added: asking for clinical grade, length of ward service, length of nursing career, educational background and specialist nursing qualifications.

Pilot survey

Questionnaires were distributed to 324 nurses working on 22 wards in five hospitals: three in the south of England and two in the north. The aim was to generate a sample large enough to replicate many of the important features of the main study sample. Firstly, a good geographical spread of wards throughout the country was sought. Hospitals were drawn from three Regional Health Authorities: two in the south and one in the north. Secondly, it was considered important to include sufficient wards in each hospital to examine the distribution of scores and the prevailing ethos of care within each. This was achieved in three hospitals, where between five and seven wards were sampled. Thirdly, data were collected from the whole ward day nursing staff of grade C and above. Information was collected from sisters and charge nurses using the Ward Leaders’ Questionnaire (WLQ): a modified form of the NOQ which omits the ‘Ward Leadership’ section, but which is otherwise identical. The effectiveness of two methods of questionnaire administration were compared: personal delivery and postal survey. The latter yielded a 3% higher response rate, which led to the adoption of this method for the main study. Overall 68% of questionnaires were returned without a reminder.

A period of questionnaire refinement followed the pilot study. The spread of item scores was assessed by a study of the frequencies of item responses. Items in which less than 5%

618 A. ADAMS et al.

of nurses either agreed or disagreed were removed. Many items in the ‘Ward Leadership’ section in particular fell into this category. It was clear that nurses are very loyal to their ward sisters and charge nurses and loath to commit to paper anything negative about them. Many items with a high ‘social desirability’ factor were identified and removed in this way.

Postal survey

Sample. Nurse Advisers in four Regional Health Authorities were invited to identify four hospitals within their Region, one hospital to represent of each of the four opportunities to achieve NHS Trust status. Three Nurse Advisers responded and 9 of the 12 hospitals agreed to participate. Additional hospitals were recruited to ensure a wide geographical distribution, including two within one NHS Trust in London and one which has a reputation for innovative nursing practice, providing a total of 17 hospitals/NHS Trusts throughout England. Between six and eight acute adult wards were randomly selected from each hospital for inclusion in the study, providing 119 wards and 1499 nurses. An overall response rate of 57% was achieved from 834 nurses. There was however considerable variation in response between hospitals, wards and grades of nurses.

Scale development

First, items were examined for response distribution, and only one was removed, Second, the a priori grouping of items within questionnaire sections and subsections was examined using exploratory factor analysis. Third, multi-item scales based upon significant factors extracted during factor analysis were created. Fourth, inter-item correlations for items within scales were examined. Finally, the psychometric properties of scales were tested, to establish internal consistency and reliability.

Factor analysis

Factor analysis of items within each section of the questionnaires was undertaken using maximum likelihood extraction, to test whether the expected correlations between items existed. Factor analysis was also conducted systematically mixing items from all sections. Both methods produced the same factor structures.

Since the aim of factor analysis was to identify significant factors existing within the data, factors were therefore scrutinised at several stages of extraction. Firstly, the unrotated solutions were examined. Only factors identified with two or more items correlated at the 0.3 level or above in the unrotated solution were retained for further analysis (Comrey’s common factor rule, Comrey, 1973). Factor rotations were then used to clarify factor analyses. For each section of the questionnaire, common factor solutions were achieved with both orthogonal and oblique rotations, confirming the robustness of solutions. The best factor solutions were deemed to be those achieved by the rotation offering the most distinctive and easily interpretable item groupings. Where a chosen solution is based upon oblique factor rotation, all inter-factor correlations are below 0.6.

The significance of rotated factors was further assessed by the size of the eigenvalues. Where identified factors failed to achieve an eigenvalue of 1 or above (Guttman’s weakest lower bound, Guttman, 1953), reduced criteria were specified until all factor solutions comprised factors with an eigenvalue 2 1.

In order to determine the most appropriate sample from which factors should be extracted, the analysis was conducted both including and excluding the ward leaders’ data.


Very similar factor structures emerged, with the exception of those derived from the section of the questionnaire related to nurses’ influence. This suggests that many of the phenomena which affect the organisation of care delivery at ward level are perceived in a similar way by all grades of nurses, including ward leaders, but, as hypothesised, ward leaders systematically perceive themselves to have more influence over people, resources and events. This confirms the expectations of earlier conceptual work.

A decision was made to base the extraction of all factors and subsequent scale development upon data related to ward nurses of grades C to F (N=715), excluding ward leaders. Figure 1 presents as an example, details of factor structures and loadings of individual items on the factor with which they are most strongly associated for the physical environment scales. Table 1 summarises the analysis, giving the names apportioned to

Items Factor 1 Factor 2 Factor 3 Factor 4

Availability of equipment Facilities for patients Facilities for relatives Quality of equipment Facilities for staff Quality of ward maintenance services Patient privacy Quality of laundry services Our nurse/patient allocation system works well for the nursing skill mix we currently have on the ward Our nurse/patient allocation system works well for the type of patients we have on this ward Tie skill mix on this ward is about right TIere are enough permanent nurses on this ward to give a good standard of care to all our patients T’he ward off duty roster works well Mistakes are sometimes made because our workload is too great Patient safety Patients being able to attract the nurses’ attention Observation of all patients Good usage of nurses’ time Good communication between nurses working on the ward The ward’s chosen way of organising nursing care delivery (i.e.: functional, team or primary nursing) Availability of portering services Quality of portering services Quality of sterile supply services Quality of pharmacy services

Fig. 1. Factor loadings of items related to the ward physical environment

620 A. ADAMS et al.

Table 1. Summary of factor analysis of items related to the ward physical environment

Name of factor Eigenvalue % Variance explained

Ward Facilities (Factor 1) 6.31 23.4 Staff Organisation (Factor 2) 1.52 5.1 Ward Layout (Factor 3) 1.68 6.2 Quality of Ward Services (Factor 4) 1.14 4.2

factors, eigenvalues and percentage of variance explained within the factor model. Factor analysis of the six different sets of items in the NOQ produced two or more factors with an eigenvalue 2 1 in most cases; the exceptions being within items related to ward leadership and job satisfaction, where only single factors emerged. (For full details of factor analysis see Adams and Bond (1995).) There was a strong resemblance between extracted factors and a priori item groupings, further underlining the inherent construct validity of earlier conceptual work.

The robustness of factor structures was further assessed using split half tests. This involved randomly splitting the sample of 715 nurses in half, and treating the two halves as independent samples. Factor analysis was conducted using each of the two samples separately, following the procedure outlined above. The resulting factor structures from both halves of the sample were almost identical, and all groups of items identified as scales, were present together within the factor structures of both samples.

Scale testing

Items grouped together by factor analysis were tested as scales for internal consistency and reliability using Cronbach’s alpha. The aim of scale testing was to produce a par- simonious set of scales with an optimal trade-off between scale brevity and a high Cron- bath’s alpha score.

A process of backwards elimination was used, removing items one by one which had the least impact on Cronbach’s alpha. All inter-item correlations within scales were scrutinised, as high inter-item correlations suggest that items are measuring almost the same thing, and therefore artificially inflate Cronbach’s alpha. The results of testing revealed that all inter- item correlations within scales achieved a significance level of P<O.OOl, but where a correlation of 0.65 or above existed between two items, one was discarded. The choice of item to discard was based upon the impact on Cronbach’s alpha for the scale when the item was removed. The item having the least impact was discarded.

Table 2 presents a summary of the scales: the number of items within each, Cronbach’s alpha, and the correlation coefficient for test-retest reliability. The scale items are presented in Appendix I. Some of the broad conceptual areas are measured by several subscales, as in the case of the physical environment of the ward, while others are measured by a single scale, such as ward leadership. This reflects the results of factor analysis. Of the 14 subscales developed, only two failed to achieve a Cronbach’s alpha score of 20.7, generally considered the acceptable rule of thumb indicating that a scale is reliable (De Vaus, 1991). These subscales were retained however on the grounds that the factors from which they were derived achieved eigenvalues of 2 1, and because they were considered conceptually important. They must be used with caution in future work however.


Reliability and aalidity

Test-retest reliability. Test-retest reliability of scales was examined by a sample of respondents completing a second questionnaire, NOQ or WLQ at an interval of 24 weeks after the first administration. Second questionnaires were sent to the first 90 nurses to return the original questionnaires, to capitalise on their high motivation. A 73% response rate was achieved without a reminder.

The Pearson correlation coefficient of the two sets of scale scores was computed, with a correlation coefficient of at least 0.7 taken as the criterion value (De Vaus, 1991). The results are presented in Table 2. Each scale has achieved a correlation coefficient of 0.7 or above, indicative of high retest reliability.

Validation

Validation relates to the amount of confidence we can place on inferences made about nurses, and in this case their work environment, based on their scale scores. Criterion validity of the scales was assessed by comparing scale scores obtained from staff working in six wards which had taken part in the survey and a ‘blind’ observational assessment of ward characteristics. The assessments were made by two pairs of independent assessors who carried out a series of observations and interviews on each ward, designed to reflect scale constructs. Ward observation data was summarised by means of a rating schedule, which comprised dimensions closely corresponding to the sections of the NOQ. Each

Table 2. Summary of scales and their statistical properties

Name of scale No. of items Cronbach’s alpha

I Physical Environment of the Ward (a) Ward Facilities (b) Staff Organisation (c) Ward Layout (d) Quality of Ward Services

0.79 0.80 0.80 0.71 0.81 0.75 0.68 0.71

II Professional Nursing Practice (a) Professional Practice (b) Hierarchical Practice

13 0.83 0.77 6 0.66 0.74

III Ward Leadership (a) Team-building

Skills of Ward Leader 9 0.92 0.90

IV Professional Working Relationships (a) Collaboration with Medical Staff (b) Collaboration with Other

9 0.86

Health Care Professionals (c) Cohesion Amongst Nurses

V Nurses’ Influence over (a) Ward Management (b) Timing of Ward and Patient Events (c) Financial and Human Resources

7 0.84 0.70 10 0.9 1 0.84

10 9 5

0.90 0.85 0.81

VI Job Satisfaction (a) Job Satisfaction I 0.77

Test-retest Pearson correlation coefficient

0.83

0.80 0.71 0.78

0.77

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component part was rated independently along a five point scale, and then an overall rating decided for each dimension which reflected the scores of the component parts.

Analysis of the two sources of ward data led us to conclude that the criterion validity of the scales was good. Similar trends were evident in nurses’ scale scores and the observers’ ratings. Of 48 paired ratings, 33 were either identical or differed only by one point of magnitude (Adams and Bond, 1995).

Future use of ward organisational features scales ( WOFS)

WOFS will enable researchers and managers to measure a range of organisational features of wards likely to affect quality of care. These include the effects on care of aspects of the ward physical environment, ward leadership, working relationships and the amount of control or influence nurses have over ward life. In addition, WOFS will enable researchers and managers to measure the level of professional practice nurses perceive to exist within wards, and nurses’ job satisfaction. Comparisons between wards on each of the six scales can be made, and also comparisons within wards over time. Our fieldwork suggests that WOFS will be particularly useful for assessing the impact of new practices on the organisational environment within wards.

It would be appropriate to use the individual scales within WOFS in isolation or in conjunction with other research tools. WOFS has in-built process of care measures and an outcome measure of nurses’ job satisfaction, but there are many others in existence with which it could be successfully combined. WOFS offers researchers the opportunity to assess the impact of and control for the effects of ward organisational features, using for example quality of care measures and also a wide range of clinical and organisational outcome measures.

Conclusion

This set of scales has been constructed with great care and attention at all stages of the process of scale development. The thorough qualitative interviews from which scales were derived provide a secure grounding for the content of the scales and demonstrate the value of combining qualitative and quantitative research methods to develop practical tools for research and management purposes. While we cannot claim to have covered all organisational features of wards, we have capitalised on what nurses themselves feel are important influences on how they provide care in acute hospital wards.

The sound basis of the scales is reflected in the factorial structure derived, and its resemblance to the concepts identified in the interviews. While we had initially expected some finer factorial structures within scales to measure different dimensions of, for example, interprofessional working, ward leadership and job satisfaction, these scales proved to be confined to single factors. The inter-item correlations between items retained in the scales were of a moderate range so that individual items are tapping different aspects of the concept being measured. This leads us to conclude that the scales are sufficiently encompassing to provide a good representation of the concepts as they are perceived by nurses in hospital wards. In some of the other scales more than one factor has emerged-aspects of the physical environment of the wards, the influence nurses have and professional practice. Again these strongly relate to nurses accounts and the items within factors show good face validity.

SCALES TO MEASURE ORCANISATIONAL FEATURES OF WARDS 623

The test-retest reliability was calculated on the basis of selecting the items retained in the scales from the total number of items included in the questionnaires. This means that questionnaires were long and that there was a lot of ‘noise’ in the scales completed. This should have had the effect of reducing the obtained correlations. The correlations obtained were of a very high order for every scale. It is noteworthy that those scales assessing inter- professional relationships showed the highest correlations, suggesting that these features are not influenced by day to day fluctuations but are relatively enduring features of ward life, at least over the short term. That such good re-test reliability was obtained over the short term at a time of immense turbulence in the NHS hospital sector is encouraging of the value of the scales in describing ward characteristics. Equally the good response rate to a very long questionnaire, in so many of the hospitals at a time of stress, indicates that rank and file nurses found the questions pertinent.

There were no similar scales available which had been validated in the U.K. against which to assess the properties of many of the new scales. Of course the absence of scales was the reason for having developed them in the first place. While there are scales by which to assess job satisfaction among nurses, these are sometimes very long (Traynor and Wade, 1993) or have not been subjected to appropriate psychometric analysis to offer confidence in using them as a comparison. Our validation procedure, like the derivation of the scales, was based on obtaining data at first hand. By carrying out observations and interviews without knowledge of the factor structure or scale scores obtained in a sample of wards, this offered a rigorous test. The results obtained, albeit by relatively crude ratings of the relationship between observations of indicators of scale concepts and scale scores leads us to have confidence in the construct validity of the scales.

The process of scale construction has been described without reference to other aspects of ward organisation which will be the topic of subsequent papers and which further add to scale validity in terms of sensitivity and discriminating power.

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(Received 20 March 1995; accepted,@ publication 16 May 1995)

Appendix

Scale Items

Physical environment of the ward

Ward Facilities. Influence on work: Very Good Influence-Very Bad Influence Facilities for relatives Facilities for patients Facilities for staff Availability of equipment Quality of ward maintenance services

Staff Organisation. Strongly Agree-Strongly Disagree Our nurse/patient allocation system works well for the nursing skill mix we currently have on the ward Our nurse/patient allocation system works well for the type of patients we have on this ward The skill mix on this ward is about right There are enough permanent nurses on this ward to give a good standard of care to all our patients The ward off duty roster works well

Ward Layout. How easy is it to achieve each of the following: Very Easy-Very Difficult Patients being able to attract the nurses’ attention Patient safety Good usage of nurses’ time Observation of all patients Good communication between nurses working on the ward The ward’s chosen way of organising nursing care delivery (i.e. functional, team or primary nursing)

Quality of Ward Services. Influence on work: Very Good InfluenceVery Bad Influence Availability of portering services Quality of portering services Quality of pharmacy services Quality of sterile supply services

Professional Practice. How often does each happen: Almost Always-Never Professional Practice

Nurses actively support one another when trying out new ideas Nurses are encouraged to build up the ward’s teaching resources Nurses try out new approaches to care Decisions are made democratically by nurses on this ward Nurses are encouraged to reach their full potential Nurses actively seek out learning opportunities Nurses give one another feedback on their practice All individual patient needs are met Nurses keep up to date by reading professional journals Nurses set time aside to reflect on their practice

626 A. ADAMS et al.

Relatives participate in making decisions about care Nurses base their practice on research Patients participate in making decisions about their care

Hierarchical Practice Nurses allow themselves to be at the beck and call of doctors Nurses live in fear of making mistakes Nurses stick to a strict ward routine Nurse managers get VIP treatment on this ward Nurses get thrown in at the deep end Auxiliaries and Health Care Assistants give most of the ‘hands on’ patient care

Ward Leadership. Strongly Agree-Strongly Disagree Creates a good atmosphere on the ward Is always fair in dealings with staff Always gives praise when it is due Deals sensitively with inter-personal frictions Inspires commitment from staff Does not inspire confidence Is good at nipping problems in the bud Likes to see staff doing well in their careers Knows the strengths and weaknesses of ward staff

Professional Relationships. Strongly Agree-Strongly Disagree Between Nurses and Medical Staff

We have a good understanding with the doctors about our respective responsibilities Doctors are usually willing to take into account the convenience of the nursing staff when planning their

work I feel that patient treatment and care are not adequately discussed Nurses and medical staff share similar ideas about how to treat patients Doctors are willing to discuss nursing issues Medical staff co-operate with the way we organise nursing Medical staff would be willing to co-operate with new nursing practices The medical staff on this ward do not usually ask for nurses’ opinions Medical staff anticipate when we will need their help

Between Nurses and other Health Care Professionals Other health care professionals do not co-operate with the way we organise nursing Disagreements with other health care professionals often remain unresolved Other health care professionals would not be willing to discuss their new practices with nurses We have a good understanding with the other health care professionals about our respective responsibilities Other health care professionals ignore the convenience of the nursing staff when planning their work Treatment carried out by other health care professionals often gives me cause for concern The other health care professionals on this ward think they are a cut above the nurses

Amongst Nurses Nurses on this ward show a lot of respect for each other Staff can be really bitchy towards each other Nurses are always willing to help each other get through their work on this ward There is a lot of unrest simmering under the surface Nursing staff on this ward work well together All the nurses on this ward pull their weight I feel nurses do not communicate with each other as well as they should Nurses here are cliquey Important information is always passed on We share similar ideas about priorities on this ward

Influence. A great deal of Influence-It never happens Timing of Ward and Patient Events

Other health care professionals’ visits to your ward Other types of therapy that are carried out on your ward (e.g. physiotherapy) Other procedures carried out on your ward (e.g. taking x-rays, lumbar punctures, etc.) Ward maintenance (e.g. plumbing, and electrical repairs) Deliveries of sterile equipment to the ward Ward cleaning by domestic staff


Porters’ arrival on the ward Patient investigations in other hospital departments Ward rounds

Ward Management Convening meetings with your ward nursing colleagues Making changes in ward management and administrative procedures Making changes in ward clinical nursing practice Changing routine shift times (e.g. to suit ward workload/nurses’ personal commitments) Changing the design of nursing documentation Controlling the amount of paperwork nurses on the ward have to complete Controlling the quality of ward support services (e.g. domestics, portering, catering) Deciding who is ‘in charge’ of the ward Getting additional temporary nurses for the ward on a daily basis (i.e. bank, agency or borrowed!) Ward visiting times

Human and Financial Resources Recruiting permanent staff for the ward Deciding the skill mix for the ward establishment Setting the ward budget Identifying priorities for spending the ward budget

Job Satisfaction. Strongly Agree-Strongly Disagree This job does not live up to my expectations Knowing what I do now, I would apply for this job again I often feel like resigning 1 know that 1 am doing a really worthwhile job I am satisfied with the relationship I have with my ward nursing colleagues I worry that this job is undermining my health On the whole, I am satisfied with my working relationships with doctors

development and validation of scales to measure organisational features of acute hospital wards

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