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Individual and collective mindfulness attracts growing research attention, yet reports of their impact on health care professionals' work behaviors are scarce, especially in the emergency department. The aim of the current study was to explore whether the association between trait mindfulness and triage accuracy is moderated by the emergency workload environment, and whether this association promotes patient satisfaction subject to levels of collective mindfulness.A prospective consecutive nested design was conducted. Data were collected from ED teams (nurses and physicians, N = 96) on individual characteristics and trait mindfulness. Data were also collected on triage accuracy, triage team characteristics, collective mindfulness, workload, and patient satisfaction (N = 960) at a specific patient-ED team encounter.Findings indicated that ED workload environment (b = 0.24, P0.01), trait mindfulness (b = 1.80, P0.01), and their interaction (b = -0.04, P0.05) were associated with triage accuracy. Triage accuracy (b = 1.81, P0.001), collective mindfulness (b = 1.29, P0.001), and their interaction (b = -0.32, P0.001) were associated with patient satisfaction. The moderated-mediation model was significant under high, but not under extreme, levels of ED workload environment and all levels of collective mindfulness.Trait and collective mindfulness are relevant to ED triage and patient satisfaction, but their effects are bounded by workload. The beneficial gain of nurses' trait mindfulness on triage accuracy and collective mindfulness on patient satisfaction is demonstrated only under high-workload environments but limited under extreme-workload environments.

The objective of this study was to examine the effect of a novel mindfulness-based time-out intervention on state of mindfulness among emergency nurses and, accordingly, on patient satisfaction.A pre-post intervention design among nurses in the emergency department was used with a between-subjects factor of patients who were nested within each nurse. The study was conducted between January 2017 and June 2018 among 48 nurses in the emergency department of a public tertiary academic hospital. For each nurse, a consecutive sample of 20 patients who attended the emergency department was recruited (n = 1920 patients; 960 in each phase). The mindfulness-based time-out intervention was based on theoretical mindfulness principles and carried out every 4 hours with direct communication to the patient at their bedside. Nurses' sociodemographic and professional characteristics and trait mindfulness were collected preintervention. Pre- and postintervention, data was collected on patients' sociodemographic and satisfaction, nurses' state mindfulness, and ED workload.An increase in nurses' state mindfulness and patients' satisfaction was found after the mindfulness-based time-out intervention compared with before the intervention (4.35 [SD = 0.64] vs 4.03 [0.82], P.001 and 4.03 [0.41] vs 3.16 [0.44], P.001, respectively). A positive correlation was found between patients' satisfaction and nurses' state mindfulness (r = 0.29, P.001). The findings also demonstrated that state mindfulness was higher among nurses, characterized by high trait mindfulness, after the mindfulness-based time-out intervention implementation.By adapting mindfulness principles to the dynamic environment of the emergency department, we showed that the mindfulness-based time-out intervention was associated with a significant improvement in state mindfulness and patient satisfaction. The findings elucidate the interrelation among several conceptualizations of mindfulness that are increasingly reported in the literature, namely trait and state mindfulness, and interventions to promote mindfulness.

To develop and test the relationship between nurse champions' personal social networks and innovation success in terms of spread.A cross sectional.Data were collected on 94 nurse champions at three medium-large tertiary medical centres from 2015-2016. Data from champions on their personal network were assessed via a standardized and acceptable three-step network survey. Success in terms of innovation spread was assessed via perceived extent of spread. Network structural and relational characteristics were depicted by level of spread. Multivariate linear regression was used to assess the relationship between network characteristics and innovation spread.Above and beyond various project and network control variables, network density was significantly and positively related to project spread, tie-strength diversity was significantly and negatively related to project spread and difference in ethnic origin between champions and alters was significantly and positively related to project spread. Maximum age of network members was marginally significantly related to project spread.Our findings show that high-density personal social networks; networks where tie strength among network members is similar, thus, creating liking and trust among members; having at least one older network member who might have close access to professional and organizational resources acquired throughout their career; and having ties with network members from different ethnic groups to prevent knowledge stickiness, all promote innovation spread. Champions should be carefully nominated based on their ability to engage network members and to build ties with various network members inside and outside the nursing unit; once selected, champions should be aware of their social networks.The current study explored champions' personal-network structure, composition and variance measures and their implications for innovation project spread. The findings demonstrated that nursing champions' personal social networks matter for innovation spread. This finding has implications for the nominating and the coaching of champions.目的: 发展和测试护士拥护者的个人社交网络与成功创新传播之间的关系。 设计: 横向研究。 方法: 2015年至2016年间,我们共收集三家大中型三级医疗中心的94名护士拥护者的数据。将通过标准化、可接受的三步网络调查对拥护者的个人网络数据进行评估。创新传播的成功将可通过感知的传播程度来评估。网络的结构特征和关系特征均可通过传播水平来描述。此外,可运用多元线性回归分析网络特征与创新传播之间的关系。 发现: 除各类项目和网络控制变量外,网络密度与项目传播呈明显正相关,联系强度多样性与项目传播呈明显负相关,而拥护者和替补人员之间的种族差异与项目传播呈明显正相关。网络成员的最高龄与项目传播显著相关。 结论: 研究结果表明,高密度的个人社交网络,或网络成员之间联系强度相似且可用于创建联系和信任的网络,内部都至少有一名年纪教长的网络成员,且该成员有可能有近距离接触相关专业和组织资源;可与不同民族的网络成员建立联系,降低知识粘性,最终促进创新传播。拥护者的提名应以其吸引网络成员的能力以及与护理单位内外各种网络成员建立联系的能力为基础;如选中,拥护者应了解其社交网络。 影响: 本研究探讨了拥护者的个人网络结构、构成和差异测度及其对创新项目传播的影响。研究结果表明,护理拥护者的个人社交网络对创新传播至关重要。此研究结果对拥护者的提名和执教都有影响。.

Aims To identify the sociodemographic attributes, project characteristics and champion strategies that differentiate formal from informal nursing champions, and to test their success in terms of project spread and novelty. Background Champions spread innovation in healthcare organizations. Empirical research has not explored the differences between formal and informal champions in terms of their antecedents and success. Design A quantitative cross-sectional design. Method Data were collected on 93 nursing champions in three hospitals from 2015 - 2016. Champions were identified according to a validated approach; data on their sociodemographic attributes, project characteristics and strategies were assembled through interviews and validated questionnaires. Their success in terms of novelty and spread was assessed via expert ratings and validated questionnaire. Findings Informal champions had longer tenure and were involved mainly in bottom-up projects aimed mostly at improving human resources and services; formal champions were mostly involved in top-down projects aimed at quality control. Informal champions expressed more enthusiasm and confidence about the innovation; formal champions tended to use more online resources and peer-monitoring strategies. Projects of informal champions were more novel than those of formal champions. Project spread did not differ between the two groups. Conclusion Formal and informal champions differ in their characteristics and implementation strategies. To encourage project's innovation, the organizational climate should encourage the emergence of informal champions; formal and informal champions should be chosen wisely, assuring that they possess enough organizational resources; and coaching programmes for junior champions should be planned to equip them with championing behaviours.

Sleepiness is a common complaint during the night shift and may impair performance. The current study aims to identify bio-psycho-social factors associated with subjective sleepiness during the night shift. Ninety-two female nurses working rotating shifts completed a sociodemographic questionnaire, the Munich ChronoType Questionaire for shift workers, the Pittsburg Sleep Quality Index, and the Pre-sleep Arousal Scale. Subjective sleepiness was measured hourly during two night shifts using the Karolinska Sleepiness Scale, and activity monitors assessed sleep duration 24-h before each shift. Findings showed that increased sleepiness was associated with increased age in nurses with early chronotypes and with more children. High cognitive pre-sleep arousal, but not sleep, was associated with increased sleepiness, especially in late chronotypes. The impact of bio-psycho-social factors on night shift sleepiness is complex, and depends on mutual interactions between these factors. Nurses most prone to increased sleepiness must develop personal strategies for maintaining vigilance on the night shift. Practitioner Summary: This study aims to identify bio-psycho-social factors associated with subjective sleepiness of female nurses during the night shift. Increasing sleepiness was associated with increased age in nurses with early chronotypes and with more children. Increased cognitive pre-sleep arousal, but not sleep, was associated with increased sleepiness, especially in late chronotypes.

Aim To understand how attribution processes (control and stability), which the nurse attributes to parental involvement in maintaining child safety, determine the nurse's response to a safety alert. Background Participation of parents in maintaining their child's safety is shown to reduce the incidence of and risk of clinical errors. Unless nurses respond appropriately to parents’ safety alerts, this potential source of support could diminish. Design A 2 (controllability: high vs. low) × 2 (consistency: high vs. low) factorial design. Methods Data were collected during the period 2013–2014 in pediatric wards. Four variants of scenarios were created corresponding to the different combinations of these variables. A total of 126 nurses read a scenario and completed self-report questionnaires measuring their response to the parent's safety alert. Additional data were collected about the manipulation check, safety norms in the ward and demographic variables. Data were analyzed using analysis of variance. Findings Results showed a main effect of stability and a significant two-way interaction effect of stability and controllability, on a nurse's tendency to help the parent and fix the safety problem. Nurses who attributed lower controllability and lower stability to the parent's behavior tended to help the parent more than in the other three conditions. Further, safety norms were significantly related to nurses’ response. Conclusion These findings contribute to the understanding of antecedents that affect nurses’ responses to parents’ speaking-up initiatives: whether nurses will reject or heed the alert. Theoretical and practical implications for promoting parents’ engagement in their safety are discussed. This article is protected by copyright. All rights reserved.

As part of healthcare organisations’ efforts to improve client satisfaction, special attention is directed to care providers’ expression of authenticity through genuine emotional displays in care encounters. The study’s aim was to test a mediating–moderating model for predicting clients’ satisfaction. The model combined intrapersonal forces (the healthcare provider’s level of caring and emotional load) and interpersonal forces (meeting the client in a team of professionals or alone, and client−provider similarity), as predictors of emotional labour strategies, and subsequent client satisfaction. Clients’ evaluation of whether or not the emotional displays were authentic was intended to moderate the link between emotional labour and client satisfaction. The sample consisted of 103 healthcare providers’ encounters with clients’ family members, randomly selected from five nursing homes. Data were collected by validated questionnaires at three time points. Mixed linear model analyses generally support...

Extensive research has dealt with violence directed at healthcare workers in hospital settings; however, few studies have examined community-based settings. Furthermore, there is also scant literature regarding the perceptions of healthcare providers who were exposed to violence, compared to those who were not. This study aims to narrow these gaps in the literature by examining community-based family physicians' (CBFPs) perceptions in a large national Health Maintenance Organisation (HMO) regarding patient-initiated violence. Using a voluntary online survey, directed at all CBFPs working at the HMO, 412 CBFPs were surveyed on the following issues: exposure to violence initiated by patients or their family members; perceptions of violent occurrences and possible safety measures. The differences between CBFPs who had been exposed to violence and those who had not were compared. The majority of CBFPs reported experiencing verbal attacks (64%), and a small percentage experienced property-related violence (11.7%) or physical violence (3.4%). Comparing CBFPs who were exposed to violence with those who were not, regarding their perceptions of the 'causes of violence', revealed three differentiating factors: 'waiting time', 'failure to meet the patient's expectations' and 'the nature of the physician-patient encounter'. Regarding the desired preventive actions, the four differentiating factors were as follows: 'reduction in the number of patients per physician', 'improved queue management processes', 'longer meetings' and 'violence prevention training'. Conducting separate analyses, according to violence type (verbal abuse, vandalism or physical violence), indicated finer differentiations. In terms of Attribution Theory, one might argue that CBFPs who were directly exposed to patients' aggression attributed internal locus to the attacker, and tended to blame the attacker's personal characteristics and cultural values. Conversely, family CBFPs who were not attacked attributed external locus to situational factors such as waiting time, not receiving service, and the nature of the interaction between the attacker and the CBFP.

The phenomenon of missed nursing care is endemic across all sectors. Nurse leaders have drawn attention to the implications of missed care for patient outcomes, with calls to develop clear political, methodological, and theoretical approaches. As part of this call, we describe three structural theories that inform frameworks of missed care: systems theory, economic theory, and neoliberal politics. The final section provides commentary on the strengths and limitations of these three theories, in the light of structuration theory and calls to balance this research agenda by reinstating nurse agency and examining the interactions between nurses as agents and the health systems as structures. The paper argues that a better understanding of variations in structure–agency interaction across the healthcare system might lead to more effective interventions at strategic leverage points.

Most interventions to improve clinical outcomes in the emergency department (ED) are based on structural changes. This study embraced a different strategy and examined the impact of a reflective practice intervention (RPI) on ED quality of care.A pre-post-intervention quasi-experimental nested design was conducted between January 2017 and June 2018 in an Israeli public tertiary academic ED. Nighty-six ED teams (triage and staff nurses and a physician) were included pre and post RPI. Data were collected pre and post RPI at patient-triage nurse encounters using triage-accuracy questionnaires. Time to decision, length-of-stay, and hospitalization and mortality rates were retrieved from the medical charts of 1920 patients (20 per team).Accurate triage was significantly higher post than pre intervention (4.84 ± 1.45 vs. 3.87 ± 1.48; range 1-7; p .001), whereas time to decision (253.30 ± 246.75 vs. 304.64 ± 249.14 min), hospitalization rates (n = 291, 30.3% vs. n = 374, 39.0%; p .001), and hospital length-of-stay (5.73 ± 6.72 vs. 6.69 ± 6.20; p = .04) significantly decreased.By adapting organizational reflective practice principles to the ED dynamic environment, the RPI was associated with a significant improvement in ED quality-of-care measures.

Given the effort made in today's birthing rooms to increase women's childbirth satisfaction, special attention is directed to midwives' expressions of authenticity (namely to display emotions that he/she actually experience) in birth encounters.To explore antecedents and consequences of emotional work strategies expressed in a specific birth encounter, to (1) understand the specific factors in a midwife-birthing woman encounter, namely parity (whether or not it is a first birth), use of epidural analgesia, induction of labor, and instrumental birth that stimulate the use of deep or surface acting; (2) test the link between emotional work strategies and birthing experience, and (3) assess whether associations between the midwife's choice of strategy (deep acting or surface acting), and the woman's childbirth experience is moderated by the birthing woman's perception of the midwife's emotional work strategies.A prospective-correlational field study.104 births, selected by a convenience sampling method-including 24 midwives and 104 birthing women, in one birthing room in Israel.Data were collected by validated questionnaires at two time points: immediately after labor and 48h after labor.Linear mixed model analyses revealed that of the antecedents to emotional work strategies, epidural analgesia was negatively associated with surface acting (β=-.301, p.05); primigravida was significantly associated with deep acting (β=611, p.01) and negatively associated with surface acting (β=-.433, p.01); induction of birth was not associated with deep or surface acting (p.05), and instrumental birth was significantly associated with deep acting (β=-.590, p.05) and positively associated with surface acting (β=.444, p.05). Regarding consequences of emotional work strategies, the midwife's engagement with surface acting was negatively related to the woman's birthing experience (β=-.155, p.05), whereas the relationship between midwife's engagement in deep acting and the woman's satisfaction also depended on the latter's perception that the midwife had engaged in deep acting (β=-.096, p.05).The midwife-birthing woman encounter is becoming globally significant for improving childbirth outcomes. Therefore, these findings offer empirical support for the importance of the midwife's expression of authenticity toward the birthing woman in improving her childbirth experience, especially when the woman perceives the midwife's emotional work strategy accurately. Also noteworthy are the aforementioned conditions that shape the midwife's engagement in deep acting or surface acting, with important recommendations to improve women's childbirth experiences.

Background Frontline nurse champions are key innovation-implementation agents. Despite the growing interest in nurse champions’ innovation, whether project novelty is a product of championship behavior (e.g., expressing confidence in the innovation's success and network building), the project's contextual characteristics (project type and initiation level), or their joint effects, remains unsolved. Purpose To develop and test an interactionist model of project novelty in nursing. Methods A cross-sectional design with a multisource approach to data collection. Findings Results demonstrated a direct effect of project type, a two-way interaction effect of level of initiation and project type, a two-way interaction effect of championship and project type, and a three-way interaction effect of project type, initiation level, and championship on project's novelty. Discussion Bottom-up service and administrative projects require champions’ championship behaviors to foster novelty, whereas for bottom-up quality-improvement projects, such behaviors can harm project novelty. For human-resource projects and for top-down projects, championship behaviors do not matter.

Patient safety, as a contemporary health care concern, must remain a priority for nurse educators. This on-line consultation, carried out within the RANCARE COST Action project, determined to establish how patient safety teaching is incorporated into pre-registration education of nurses across 27 countries. How nursing is regulated within countries was examined, along with national guidelines related to nurse education. HEIs were asked to provide details of pre-registration nurse training and how patient safety is taught within programmes. The results confirm that the topic of patient safety is generally not explicitly taught, rather it remains a hidden element within the curriculum, taught across many subjects. Variation in how nursing is regulated exists across the countries also, with the professionalization of nursing remaining a challenge in some states. No guidelines exist at EU level which address how patient safety should be taught to nursing students, and as yet regulatory bodies have not put forward criteria on the subject. As a result individual HEIs determine how patient safety should be taught. The WHO guidelines for teaching patient safety are currently underutilized in nurse education, but could offer a structure and standard which would address the deficits identified in this work.

Video consultations (VCs) provide increased accessibility of primary care to remote areas and overall improved care for chronic patients. They also contribute to higher patient satisfaction and improved resource management. Despite these benefits, VC integration into the health system is complex and slow. Understanding the VC-related preferences of three key stakeholders—patients, primary care physicians (PCPs) and policy makers (PMs)—is crucial for achieving optimal implementation. The aim of this study was to select relevant attributes and levels for a discrete choice experiment (DCE) of stakeholders’ choice—VC or traditional in-clinic consultation (I-CC) in primary care. Ten semi-structured focus group interviews and 24 semi-structured individual interviews were conducted. Data analysis was performed inductively, using a thematic content analysis method. An attribute-ranking exercise was then conducted based on the results gleaned from the interviews. The most important attributes when choosing either VC or I-CC, for both patients and PMs, were: (1) time to next available appointment; (2) time in line before consultation; (3) relationship to PCP; and (4) quality of consultation. For PCPs, the most important attributes were: (1) time in line before consultation; (2) patient’s self-management ability; (3) consultation purpose; (4) quality of consultation. This qualitative study identified attributes and levels for a DCE quantitative stage among three key stakeholder groups. It adds to the literature of examples of developing DCE attributes, and to literature about the stakeholder benefits in the area of telemedicine in healthcare.

Research into violence against health care staff by patients and their families within the health care services shows a rising frequency of incidents. The potentially damaging effects on health care staff are extensive, including diverse negative psychological and physical symptoms. The aim of this qualitative study was to examine how hospital workers from different professions reacted to patients’ and visitors’ violence against them or their colleagues, and how they regulated their emotional reactions during those incidents. The research question was as follows: How do different types of hospital workers regulate the range of their emotional reactions during and after violent events? Participants were 34 hospital workers, representing several professional sectors. Data were collected through in-depth semistructured interviews, which were later transcribed and thematically content analyzed. Five themes were revealed, demonstrating several tactics that hospital workers used to regulate their emotions during incidents of violent outbursts by patients or visitors: (1) Inability to Manage Emotion Regulation, (2) Emotion Regulation by Distancing and Disengagement Tactics, (3) Emotion Regulation Using Rationalization and Splitting Tactics, (4) Emotion Regulation via the Use of Organizational Resources, and (5) Controlling Emotions by Suppression. Hospital workers who experienced dissonance between their professional expectations and their emotional reactions to patients’ violence reported using various emotion regulation tactics, consequently managing to fulfill their duty competently. Workers who did not experience such dissonance felt in full control of their emotions and did not manifest responses of emotion regulation. Others, however, experienced intense emotional flooding and failed to regulate their emotions. We recommend developing health care staff’s awareness of possible emotional implications of violent incidents, for themselves as people and for their intact functioning at work. In addition, we recommend further development of health care staff training programs for coping with violent patients and enhancement of formal and informal organizational support.

This chapter focuses on the phenomenon of organizational citizenship behavior (OCB) in the context of service organizations. Specifically, our aim was to challenge the common approach to OCB by delineating the unique characteristics of service organizations. The chapter begins by capturing the distinctive features of services: their intangibility, inseparability, and heterogeneity. Next, we argue that these characteristics compel service organizations to rely primarily on their employees’ OCBs. Paradoxically, the more committed managers are to service delivery, the less control they have over service quality compared with their counterparts in manufacturing. We then discuss how service characteristics shape the nature of OCB in this unique context and propose an integrated typology for better understanding OCB in service organizations.

Aims To describe the quality and scope of patients' participation in the handover process, in relation to their personal attributes (the big-5 model of personality) and the handover encounter's characteristics (presence of the head nurse, escorts, ward overload-namely nurse-patient ratio). Background The scant research, previously addressing patient participation during a nursing handover, generally indicated that there is stillroom for improvement. Design A quantitative and qualitative cross-sectional design. Method During 2012–2013, we collected data on 100 handovers in five surgical wards. Data on factors of the handover encounter were collected through structured observations of the event and data on personality attributes and demographics were assembled through validated questionnaires; we content-analysed transcriptions of the handover's verbal content for typical content, frequency and quality of the communication. Findings Patient participation proved bi-directional, consisting of patient's initiative and nurse's initiative. Whereas patient's initiative improved when the head nurse and escorts were present and the unit was less loaded, nurse's initiative was facilitated by the presence of escorts and less overload. As for personality attributes, whereas patient's imitative improved with patient's high neuroticism, high agreeableness and low openness to experience, nurse's initiative decreased with patient's high neuroticism, extraversion and conscientiousness. Conclusion Findings illustrated the different communication preferences of patients with different personal attributes, as well as the different approaches by nurses to each of these different personalities. Nurses should be taught about communication and ways to engage patients during handover. Patients' education is also warranted including how and when to approach the different caregivers.

Background: In 2007 an amendment to the law restricting smoking in pubs and bars (P&Bs) was enacted in Israel. However, a year after the ban only slight decreases in airborne smoke in P&Bs in one city have been reported. Purpose: We aimed to assess levels of airborne nicotine in Israeli P&Bs and to measure ifself-reported enforcement of the law by local officials was associated with levels of airborne nicotine in P&Bs. Methods: Airborne nicotine levels were measured in 72 P&Bs in 29 towns in Israel; this consisted of 90% of eligible towns. In addition, 73 local authority officials were interviewed in 25 of these towns. The officials were asked to assess the local authority’s level of enforcement of the law banning smoking in P&Bs. The association of levels of airborne nicotine with the levels of enforcement of the law was calculated. Data were collected during 2009–2010 and analyzed in 2010–2011. Results: Levels of airborne nicotine were comparatively high in P&Bs. No association was detected between levels of nicotine and the P&Bs’ characteristics. In the larger towns, levels of airborne nicotine were higher. In 16% of towns the local authority officials reported high levels of law enforcement. Generally, levels of reported enforcement by local authorities were low and did not predict levels of airborne nicotine in the P&Bs. Conclusions: Self-reported local authorities’ law enforcement was not associated with levels of airborne nicotine in P&Bs in these towns. There is a need to develop ways to increase law enforcement by the local authorities or other agencies.

Background: Despite the importance attributed to accountability in healthcare professionals' education and practice, empirical research lags well behind. Accountability has typically been studied a...

PurposeWith a twofold aim, the purpose of this paper is to focus on the service climate, including its antecedents, consequences, and a moderator. First, it examines whether task‐ and goal‐interdependent configuration facilitates the level of service climate; second, it tests the strength of the moderating role of service climate between service climate levels and service behavior.Design/methodology/approachAmong 54 nursing units at six hospitals, the data were collected using multiple methods (surveys, observations, administrative data).FindingsMixed‐linear model analyses indicated that the joint effects of task and goal interdependence related significantly to service climate level. Service climate strength moderated the relationship of service climate level to quality service behavior.Research limitations/implicationsThe research approach may diminish the generalizability of the research results. Further work should test the propositions in other research contexts.Practical implicationsQuality service behaviors and the service climate could be promoted through well‐designed task‐ and goal‐interdependence structures within units. Assimilating a service climate in units is not enough. To promote high quality service behaviors, managers must direct their efforts toward finding agreement among team members with regard with the importance of service in their unit.Originality/valueThe paper's findings offer empirical support to the persistent social interaction explanation of climate formation and point to the important role of interdependence for creating and maintaining service climate levels and promoting service behaviors in units.

Aims To test the moderated-mediation model suggesting that nursing teams’ accountability affects team effectiveness by enhancing team learning when relevant resources are available to the team. Background Disappointing evidence regarding improvement in nurses’ safe and quality care elevate the need in broadening our knowledge regarding the factors that enhance constant learning in nursing teams. Accountability is considered as crucial for team learning and quality of care but empirical findings have shown mixed evidence. Design a cross-sectional design. Methods Forty-four nursing teams participated in the study. Data were collected in 2013-2014: Head nurses completed validated questionnaires, regarding team resources for learning (time availability, team autonomy and team performance feedback), and nursing teams’ effectiveness; and nurses answered questionnaires regarding teams’ accountability and learning (answers were aggregated to the team level). The model was tested using a moderated-mediation analysis with resources as moderating variables, and team learning as the mediator in the team accountability- team effectiveness link. Results The results of a mixed linear regression show that, as expected, nursing teams’ accountability was positively linked to nursing teams’ learning, when time availability, and team autonomy were high rather than low, and team performance feedback was low rather than high. Conclusions Nurturing team accountability is not enough for achieving team learning and subsequent team effectiveness. Rather there is a need to provide nursing teams with adequate time, autonomy, and be cautious with performance feedback, as the latter may motivate nurses to repeat routine work strategies rather than explore improved ones. This article is protected by copyright. All rights reserved.

ABDELHADI N. & DRACH-ZAHAVY A. (2012) Promoting patient care: work engagement as a mediator between ward service climate and patient-centred care. Journal of Advanced Nursing68(6), 1276–1287. Abstract Aims. To test a model that suggests the ward’s climate of service facilitates nurses’ patient-centred care behaviours through its effect on nurses’ work engagement. Background. Organizational efforts to promote patient-centred care focused on interventions aimed to improve nurses’ communication skills, or to improve patient’s participation in the decision-making process. These interventions have been only partially successful, as they do not take the ward context into account; so caring professionals who attend workshops can rarely apply their newly acquired skills due to the daily pressures of the ward. Method. A nested cross-sectional research design (nursing staff within wards) was adopted, with three measures of the care behaviour of nurses. Data were collected in 2009, from 158 nurses working in 40 wards of retirement homes in northern Israel. Nurses’ work engagement, ward’s climate for service and control variables were measured via validated questionnaires. Patient-centred care behaviours were assessed by structured observations. Results. The findings supported our model: service climate proved a link to nurses’ work engagement and patient-centred care behaviours. Nurses’ work engagement mediated the service-climate patient-centred care behaviours. Conclusion. The research is pioneering in demonstrating a close relation between ward service climate and patient-centred care. In practice, to improve patient-centred care managers should invest in facilitating ward service climate, highlighting the importance of service to the organization through appropriate rewards, guidance and administrative practices.

Psychiatric patient assaults on staff are a serious problem, affecting staff, patients, and organizations. To understand the etiology of aggressive events, researchers have documented characteristics of aggressive patients, their victims, and to a lesser degree, the patient–provider interaction. Missing in the literature is how staff’s different perceptions of aggressive incidents might impact their reactions. In this study, we conducted in-depth, semistructured interviews with 11 health care professionals working in a psychiatric ward in one Israeli psychiatric hospital. Through content analysis, we revealed two main themes: patients’ and providers’ controllability over patients’ aggression. From the intersection of these two themes, four prototypes of the aggressive encounter emerged: the power struggle, the therapeutic encounter, inverse power relations, and victim-to-victim encounters, each distinctively characterized by different emotional, cognitive, and behavioral responses. We discuss our findings in light of attribution theory, which carries important theoretical and practical implications for handling aggression.

This study investigated team innovation as a process phenomenon by differentiating the creativity stage from the implementation stage. Based on the interactional approach, the authors argue that team composition (aggregated individual creative personality and functional heterogeneity) affects team creativity, which in turn promotes innovation implementation depending on the team’s climate for innovation. Results from a study of 96 primary care teams confirmed that aggregated individual creative personality, as well as functional heterogeneity, promotes team creativity, which in turn interacts with climate for innovation such that team creativity enhances innovation implementation only when climate for innovation is high.

Interorganizational teams are rapidly becoming more prevalent as a means to improve organizations' responsiveness. To achieve their objective, interorganizational teams must engage in extensive amounts of boundary spanning activity. This study juxtaposed three structural variables, namely team informational diversity, team boundedness, and extrateam links, in an integrated model aimed at promoting our understanding of how to increase interorganizational team boundary spanning activity and its effectiveness. The model was tested with 49 health promotion teams. Our findings indicated that three types of boundary spanning—scouting, ambassadorial, and coordinating—were positively associated with interorganizational team effectiveness. In addition, for team informational diversity, team boundedness, and extrateam links, scouting and ambassadorial activities fully mediated their relationships with team effectiveness; for team boundedness, coordinating activity also fully mediated its relationship with team effe...

Approaches to nurses’ safety in health care organizations, including modifying individual behavior through enforced compliance with safety rules and mandatory participation in safety training, have been of only modest benefit in reducing injuries. Apparently, what matters is not the existence of guidelines, but their implementation. The aim of the present study was to explore nurses’ implicit safety theories concerning when to comply with safety rules. Using a multimethod approach, including semistructured interviews (perceptions), observations (real-time behavior), and documentary evidence from 15 nursing units (90 nurses), we found that nurses developed implicit rules for when and how to protect themselves. These included: (a) continue providing care for the patient even at the price of protecting yourself, (b) do not disturb other nurses’ work, (c) it cannot happen to me!, (d) be aware of recently occurring accidents, and (e) protect yourself when significant others are present. These implicit rules seemed to be reinforced by personal, social, and contextual factors at the unit, limiting the likelihood that the decision makers (nurses) would discover their fallacy.

As the emergency department (ED) faces growing demands, rising acuteness, and longer waiting times, effective, efficient, and accurate triage systems become crucial. Precise triage is even more complex when handling admissions of patients with mental health illnesses. Previous research on that matter ignored the cognitive aspects of a provider-patient encounter in the ED, and the fact that clinicians are not immune to cognitive biases. It is suggested here that implementing mindfulness in the triage can contribute in improving accurate triage and better quality of care for patients with mental illness. The paper introduces the concept of mindful triage and discusses practical interventions to this mean.

In examining whether a leader’s professionalism implies more or fewer helping behaviors for followers, this study designed a model integrating attributional theory explanations with professionalism to predict helping behaviors. Four distinct helping behaviors were conceptualized: supporting, motivating, referral, and rejection. Qualitative methods used in the study consisted of content analysis of interviews with 12 superiors at healthcare organizations concerning their means of helping staff, and the circumstances. Quantitative data were gathered by an experimental design in which four case studies were presented to each of 171 healthcare superiors, who were asked to deal with a distressed staff nurse whose stability and controllability of the distress were rated either high or low. Superiors’ professionalism was assessed. Results indicated that the relationship between professionalism and helping was complex, and critically dependent upon the type of helping behaviors provided, the help provider’s professionalism, and attributions of the help seeker’s controllability and stability. The qualitative and quantitative results favor attribution explanations, and imply that highly professional superiors provide higher levels of supporting, motivating, and rejecting helping behaviors as means to maintain professionalism of staff.

SUMMARY This study addressed the question of how to structure coalitions in order to increase their engagement in multiple strategies for health promotion and consequently to improve their effectiveness. Three structural variables were chosen: (i) coalition’s heterogeneity, captured by the professional diversity of its members; (ii) coalition’s configuration, defined as the way members were involved in the coalition: full- or part-cycle membership, full- or part-time assignment, and core or peripheral membership; and (iii) coalition’s contractual collaborations with external professionals. A large non-profit network of community centers served as the setting for this study. The sample consisted of 37 coordinators of local coalitions for health promotion in Israel. The study’s design was a crosssectional survey. Data were collected by a multimethod (semistructured interviews, self reported questionnaires and administrative data) approach. Effectiveness was assessed by a self-report questionnaire administrated to coalition coordinators. Engagements in multistrategies as well as structural variables were measured by semistructured interviews with coalition coordinators. Results demonstrated that while a homogeneous, bounded structure seemed to promote the implementation of health education programs, a more flexible coalition configuration with frequent use of professionals contributed more to working by multiple strategies and improved coalition’s effectiveness. In addition, the use of external professionals promoted action for a healthier environment, but did not add to empowering the community. The results contribute to shifting the conception of a coalition as a tightly bounded, well-defined, stable entity to that of a more fluid and permeable structure interacting with an external environment. These findings highlight the importance of incorporating structural considerations into the management of coalitions and are discussed in light of the potential costs and benefits of alternative modes of structuring such coalitions.

The present study explored the issue of organizational citizenship behaviour (OCB) as a context-related phenomenon, from a multidimensional perspective. More specifically, it was hypothesized that organizational learning (structures and learning values) would be positively related to (a) OCB that benefited the organization as a whole (OCBO) and (b) OCB that immediately benefited particular individuals (OCBI). The hypotheses identified the school as the unit of analysis; so all variables were aggregates of individual responses to the organizational level of analysis. Justification for aggregation was provided by a within-group similarity index (r wg ) and a within- and between-entities analysis (WABA). Results from a sample of 31 schools confirmed the main hypotheses, and generally supported the notion that OCB could be treated as a context-related phenomenon. These results should encourage researchers and practitioners to focus more attention on the organizational context and its characteristics as related to OCB.

Background. Most studies examining primary nursing focus on outcome variables such as enhanced patient and staff satisfaction with care, perceived autonomy and quality of care, whereas only limited research has examined processes of implementing and maintaining primary nursing. In addition, the few studies that have explored process variables discuss only direct relationships between the design of the primary nursing care-delivery system, process and nurse outcomes, and disregard how such variables interact. Aim. This study sought to address previous inconsistent findings about the impact of primary nursing care-delivery models on the performance of nurses by incorporating the moderating role of supportive management practices. Method. Three hundred and sixty-eight nurses from a variety of wards completed questionnaires that assessed the degree of primary nursing on their unit, the support practices of their direct supervisor and their perceptions of the cost of seeking support from their supervisor. In addition, the direct supervisor evaluated the nurse's performance in the unit. Results. Primary nursing did not exert a direct impact on nurses’ performance. Rather, the interaction of primary nursing with supervisor support was more predictive of performance: if supervisor support was high, performance was substantially higher than if supervisor support was low. In addition, nurses’ perceptions of the costs of seeking support had a detrimental impact on their performance. Conclusions and limitations. The study was cross-sectional and relied on self-report data only. Nevertheless, the findings show that supportive management practices are crucial to the success of implementing primary nursing.

The present study seeks to enlighten our understanding of ways to promote the performance of teams of professionals. Considering that job enrichment practices might block support for a team, and hence its performance, the study examined the moderating effects of cultural factors, namely individualism–collectivism and power distance, and the team leader's practices as a source of support in the job enrichment–team support relationship. Further, the study examined the mediating role of team support in improving the performance of professional teams. Results from 56 healthcare teams from different hospitals indicated that attempts to promote professionals' performance should consider at a minimum how to balance job enrichment practices and the team's need for support. The findings suggest that this balance could be achieved by emphasizing the support provided by the leader, and by strengthening the cultural values of low power distance and collectivism in the team. Copyright © 2004 John Wiley & Sons, Ltd.

SUMMARY Multisectoral cooperation is an important strategy in working for health promotion. Fifty-two health professionals completed a questionnaire measuring factors motivating, enhancing and inhibiting partnerships. The respondents also reported the type or structure of the partnerships. The results indicated that partnerships were formed primarily in order to promote the project; however, previous positive experience with partnerships was also very important as a motivating force for joining partnerships. The three most important facilitating factors were related to project management: effective leadership, aims of the project, and sharing a vision and goals. The two most frequent items mentioned as very important barriers to partnerships were related to dysfunction of the steering committee. Two types or structures of partnerships were identified. The first was fragmental, where partnerships existed only at specific stages of the project; most respondents reported working within this structure. The second type was continuous, where partnerships existed through all the project’s stages. Using multiple regression analysis we found that health staff (mainly nurses) worked more frequently in fragmental partnership structures than did health promotion and welfare workers. In addition, the more experienced the respondents, the less they worked in fragmental partnership structures. These results highlight the importance of acquiring skills for working in partnerships and indicate a need for guidelines to be agreed by the partners at the beginning of the working process.

From caring to managing and beyond: an examination of the head nurse's role Aim. The aim of this study was to depict the essence of what head nurses do, and how they perform their managerial role. Methods. To achieve this, the work behaviour of 48 head nurses was examined by a semi-structured observation technique for 6 hours each. Results. Results demonstrated that head nurses spent a large proportion of their time in clinical practice, followed by co-ordinating care, operating the unit's functions, and leading staff. Personnel management and quality improvement occupied only a marginal share of head nurses' time. Conclusions. These results implied that head nurses exhibited a management style orientated to maintenance rather than to re-creation, focusing more on the `doing' and the `here and now' aspects of the job than on leading, planning, and proactive problem solving.

Aim To examine the relation between the strategies the nurses employ during handover and the number and types of treatment errors in patient care in the following shift. Background Patient handover has repeatedly been declared an area of considerable vulnerability to patient safety. This study examined factors that affect treatment errors in patient care, including the use of handover strategies from high reliability organizations. Design Prospective study. Method Data were collected in 2012–2013 from 200 randomly selected handovers in five internal wards. Handover strategies previously adopted from High Reliability Organizations were assessed via observations; treatment errors – dosage discrepancy, order postponed, no documentation – captured from the patient's files and demographical data were collected via questionnaires. Findings On average, in nearly one-fifth of the patient's files, medication dosage given was inaccurate; in nearly one-third a care order was fulfilled late; and in nearly half, documentation was partially missing. Rate of use of handover strategies previously adopted from high reliability organizations varied substantially. Results of negative binomial regression analysis revealed that face-to-face verbal update with interactive questioning, update from practitioners other than the outgoing, topics initiated by incoming and outgoing team, including the latter's stance on care plans and writing a summary prior to handover, were significantly and negatively linked to number of treatment errors (P

Aims and objectives In this study, we aimed to understand how nurses manage handovers at shift change and to identify the working strategies they employ to maintain patients' safety. Background Nursing handovers at shift change are potentially hazardous for patients' quality of care. The nurses on the outgoing and incoming shifts need accurate understanding of the patient's current state, under circumstances that are frequently turbulent and time constrained. Design Qualitative study. Method Eighteen nurses working in a central Israeli hospital participated in the study. Data were collected through in-depth semi-structured interviews, conducted over a 10-month period in 2011–2012. The interviews were tape-recorded and transcribed verbatim. Content analysis method was used. Results We revealed three interrelated themes: (1) Adaptation of declared handover goals to goals, which better fit the day-to-day routine of the ward; (2) Contextual turbulent circumstances, and (3) Strategies to optimise care for patients. Nurses on the outgoing shift developed organising strategies, ensuring efficient transmission of all important information; nurses on the incoming shift used cross-checking strategies to verify the accuracy of the received information. Conclusion A nursing handover is both vulnerable and resilient, given its imposed constraints. The handover should be restructured, assuring resilience in patients' care while also limiting the risk for vulnerability. Relevance to clinical practice Handover should be restructured so that it creates opportunities to cross-check the information against as many sources of information as possible. During handover, special time should be devoted to reading written reports and notes, preferably when the outgoing nurses are still on the ward or are accessible via e-mail or telephone. Team discussions should focus on achieving agreement about the order and manner of delivering concise information and facilitating shared understanding and trust among nurses.

This paper focuses on the working strategies nurses develop and employ in their day-to-day routine in an attempt to identify "red alerts" which enable them to maintain patient safety despite the load and interruptions characterizing their work environment. Based on insights gained from three studies (focusing on nurses’ medication administration, use of protective measures and transferring information during handover) we develop a theoretical model that describes how understanding aspects of the day-to-day life in healthcare organizations, and the system of meaning that guides everyday life, can inform our understanding of workplace safety. The model illustrates how the chaotic, turbulent, and complex environment characterizing the nurses' workplace prevents them from fully complying with the declared safety goals practices and procedures. Yet even under these near-impossible circumstances, the nurses’ main mission is to maintain patients' safety. Embracing a resilience strategy allows nurses to actively prevent something bad from happening or becoming worse, and to repair something bad once it has occurred, which of course contribute to patient’s safety. Otherwise, nurses might rely on an implicit theories strategy, limiting the likelihood that they will discover their misperceptions, thereby putting patients' safety at risk. The model further describes how each of these two strategies is reinforced by positive feedback loops on the individual, ward, and organizational levels. Practical implications for managers include work practices that can encourage nurses’ resilience by creating a work environment of professionalism, mindfulness and awareness of errors.

The present study focused on innovation of teams, examining the contributions of team interaction processes (exchanging information, learning, motivating, and negotiating) and structures (functional heterogeneity and frequency of meetings) to innovation. Specifically, it was hypothesized that (a) team structures will be positively related to team innovation, (b) team heterogeneity will be positively related to team interaction processes, (c) team interaction processes will be positively related to team innovation, and (d) team interaction processes will mediate the relationship between team heterogeneity and team innovation. Results from a sample of 48 intact teams in elementary and secondary schools supported the main hypotheses. These results imply that the development of mutual interaction processes is a crucial mechanism for translating team heterogeneity into innovation.

Attention in the ward should shift from preventing medication administration errors to managing them. Nevertheless, little is known in regard with the practices nursing wards apply to learn from medication administration errors as a means of limiting them.To test the effectiveness of four types of learning practices, namely, non-integrated, integrated, supervisory and patchy learning practices in limiting medication administration errors.Data were collected from a convenient sample of 4 hospitals in Israel by multiple methods (observations and self-report questionnaires) at two time points. The sample included 76 wards (360 nurses). Medication administration error was defined as any deviation from prescribed medication processes and measured by a validated structured observation sheet. Wards' use of medication administration technologies, location of the medication station, and workload were observed; learning practices and demographics were measured by validated questionnaires.Results of the mixed linear model analysis indicated that the use of technology and quiet location of the medication cabinet were significantly associated with reduced medication administration errors (estimate=.03, p.05 and estimate=-.17, p.01 correspondingly), while workload was significantly linked to inflated medication administration errors (estimate=.04, p.05). Of the learning practices, supervisory learning was the only practice significantly linked to reduced medication administration errors (estimate=-.04, p.05). Integrated and patchy learning were significantly linked to higher levels of medication administration errors (estimate=-.03, p.05 and estimate=-.04, p.01 correspondingly). Non-integrated learning was not associated with it (p.05).How wards manage errors might have implications for medication administration errors beyond the effects of typical individual, organizational and technology risk factors. Head nurse can facilitate learning from errors by "management by walking around" and monitoring nurses' medication administration behaviors.

drach-zahavy a. & pud d. (2010) Learning mechanisms to limit medication administration errors. Journal of Advanced Nursing66(4), 794–805. Abstract Title. Learning mechanisms to limit medication administration errors. Aim. This paper is a report of a study conducted to identify and test the effectiveness of learning mechanisms applied by the nursing staff of hospital wards as a means of limiting medication administration errors. Background. Since the influential report `To Err Is Human', research has emphasized the role of team learning in reducing medication administration errors. Nevertheless, little is known about the mechanisms underlying team learning. Method. Thirty-two hospital wards were randomly recruited. Data were collected during 2006 in Israel by a multi-method (observations, interviews and administrative data), multi-source (head nurses, bedside nurses) approach. Medication administration error was defined as any deviation from procedures, policies and/or best practices for medication administration, and was identified using semi-structured observations of nurses administering medication. Organizational learning was measured using semi-structured interviews with head nurses, and the previous year’s reported medication administration errors were assessed using administrative data. Results. The interview data revealed four learning mechanism patterns employed in an attempt to learn from medication administration errors: integrated, non-integrated, supervisory and patchy learning. Regression analysis results demonstrated that whereas the integrated pattern of learning mechanisms was associated with decreased errors, the non-integrated pattern was associated with increased errors. Supervisory and patchy learning mechanisms were not associated with errors. Conclusion. Superior learning mechanisms are those that represent the whole cycle of team learning, are enacted by nurses who administer medications to patients, and emphasize a system approach to data analysis instead of analysis of individual cases.

The purpose of this article is to identify and test the effectiveness of work strategies employed by regional implementation teams to attain high quality care for diabetes patients.The study was conducted in a major health maintenance organization (HMO) that provides care for 70 per cent of Israel's diabetes patients. A sequential mixed model design, combining qualitative and quantitative methods was employed. In-depth interviews were conducted with members of six regional implementation teams, each responsible for the care of 25,000-34,000 diabetic patients. Content analysis of the interviews revealed that teams employed four key strategies: task-interdependence, goal-interdependence, reliance on top-down standardised processes and team-learning. These strategies were used to predict the mean percentage performance of eight evidence-based indicators of diabetes care: percentage of patients with HbA1c7 per cent, blood pressureor = 130/80 and cholesterolor = 100; and performance of: HbA1c tests, LDL cholesterol tests, blood pressure measurements, urine protein tests, and ophthalmic examinations.Teams were found to vary in their use of the four strategies. Mixed linear models analysis indicated that type of indicator (simple process, compound process, and outcome) and goal interdependence were significantly linked to team effectiveness. For simple-process indicators, reliance on top-down standardised processes led to team effectiveness, but for outcome measures this strategy was ineffective, and even counter-effective. For outcome measures, team-learning was more beneficial.The findings have implications for the management of chronic diseases.The advantage of allowing team members flexibility in the choice of the best work strategy to attain high quality diabetes care is attested.

Title. Patient-centred care and nurses’ health: the role of nurses’ caring orientation. Aim. This paper is a report of a study of the moderating effect of caring orientation on the relationship of patient-centred care to nurses’ physical and mental health. Background. Providing effective patient-centred care is well-accepted as an important contributor to a host of patients’ health outcomes. Based on two theoretical perspectives – person–environment fit and emotional labour – I suggest that providing patient-centred care per se does not potentially harm nurses’ health; the cause is the fit (or non-fit) of a nurse’s caring orientation and the displayed patient-centred care behaviours. Method. Data were collected in 2007 with a random sample of 325 registered nurses working in the Israeli public healthcare sector in in-patient units. Caring orientation, health and control variables were measured via validated questionnaires. Patient-centred care behaviours were assessed by structured observations. Results. The mental health of nurses who exhibited high caring orientation combined with high patient-centred care, or that of nurses who exhibited low caring orientation combined with low patient-centred care, was statistically significantly higher in comparison with the mental health of nurses who exhibited incongruent (low/high or high/low) caring orientation and patient-centred care behaviours. For nurses’ physical health, the findings revealed that providing patient-centred care was associated with worsened health, and possessing a caring orientation was associated with better health. Conclusions. The findings support the hypotheses that were derived from person–environment fit and emotional labour only with regard to mental health. Separate theory needs to be developed on how to maintain nurses’ physical health.

Two separate studies conceptualized the health friendliness of a workplace, the first qualitatively through content analysis of interviews with 69 nursing superiors about the means employed by their workplace to promote staff health. Findings supported the conceptualization of workplace health friendliness, which was further validated against the staff’s health indicators. The second study tested a model explaining the cross-level effects of workplace health-friendliness initiatives on workers’ health. The model depicted workers as rational human beings calculating costs/ benefits in deciding whether to commit to those initiatives. Benefits represent workers’ potential gains through compliance; costs represent their potential losses. Perceived social costs were noted as a possible cost; a worker’s perceived stress signaled that he or she might benefit from joining health-friendly initiatives. Analysis of data from 45 nursing units supported the cross-level model: workplace health friendliness was positively associated with workers’ health and perceived social costs and stress moderated that link. Accordingly, workplace health friendliness should be regarded as the joint responsibility of the workers and the organization, and attention should be paid to the processes whereby these initiatives become enhancers or inhibitors of workers’ health.

Publisher Summary This chapter adopts a comprehensive perspective on coping with work–family conflict (WFC) and undertakes three complementary goals: to delineate the range of coping strategies for dealing with WFC among employed parents and to test their effectiveness; to identify organizational practices aimed at redesigning work and work roles for handling WFC and to probe their effectiveness; and to propose models for depicting the joint effects of individual and organizational coping strategies in easing work–family conflict. It starts by describing the changing social context affecting the burgeoning interest in coping with WFC and reviews the three main perspectives for examining this issue. It reviews the literature on coping with work–family conflict and then it discusses a number of typologies pertaining to the strategies that individuals use to cope with work–family conflict. Next, it describes how workplace family-friendly policies relate to coping with work–family conflict. Following this, it proposes three models that depict different ways of integrating the individual and organizational perspectives: the compensatory model, the complementary model, and the spiral model. The chapter concludes with a discussion of recurring themes in the literature, and the identification of problems with the current perspective on coping with WFC. Specific suggestions for developing an integrative model combining the individual and organizational perspectives for coping, future research, and managerial implications are also made.

Teamwork in community clinics was examined to propose and test a model that views the different kinds of commitment (job involvement and organizational commitment) and the potential conflict between them, as mediators between personal and organizational factors (mechanistic structuring and organic structuring) and the effectiveness of interprofessional teamwork. Differences among the professional groups became evident with regard to their views of the goals of teamwork and the ways to achieve them. As for mechanistic structuring, although the clinic members saw their mechanistic structuring in a more bureaucratic sense, the combination of mechanistic structuring and organic structuring led to effective teamwork. In terms of commitment, while staff members were committed primarily to their job and not the organization, commitment to the organization produced effective teamwork in the clinics.

Audit and feedback is widely used as a part of a multimodal strategy to improve hand hygiene (HH) compliance. Few studies have investigated the effect of different feedback strategies.