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The aim of this study was to examine nurses’ attitudes about the importance of family in nursing care from an international perspective. We used a cross-sectional design. Data were collected online using the Families’ Importance in Nursing Care—Nurses’ Attitudes (FINC-NA) questionnaire from a convenience sample of 740 registered nurses across health care sectors from Sweden, Ontario, Canada, and Hong Kong, China. Mean levels of attitudes were compared across countries using analysis of variance (ANOVA). Multiple regression was used to identify factors associated with nurses’ attitudes and to test for interactions by country. Factors associated with nurse attitudes included country, age, gender, and several practice areas. On average, nurses working in Hong Kong had less positive attitudes compared with Canada and Sweden. The effects of predictors on nurses’ attitudes did not vary by country. Knowledge of nurses’ attitudes could lead to the development of tailored interventions that facilitate nurse-family partnerships in care.

The objective of this scoping review is to identify and map the evidence reporting the knowledge, skills, attitudes, beliefs, and implementation of evidence-based practice among nurses in low- and middle-income countries.Evidence-based practice aims to improve health care quality, safety, and health system efficiency. Numerous research studies have explored nurses' engagement in evidence-based practice in high-income countries. Developing nations have recently joined the evidence-based practice movement, and primary research about nurses' engagement with it are emerging.The scoping review will include primary studies (quantitative, qualitative, and mixed methods) and gray literature addressing knowledge, skills, attitudes, beliefs, and implementation of evidence-based practice among nurses. Participants will include registered nurses working in low- and middle-income countries. Studies conducted in all health care settings, including acute and community settings, in low- and middle-income countries will be included.We will search MEDLINE, Embase, CINAHL, Scopus, ERIC, JBI Evidence-based Practice Database, Cochrane Library, LILACS, and AIM. Gray literature will be sourced from ProQuest Dissertations and Theses Global and Google Scholar for primary studies. Studies published in the English language will be included, with no limit on publication date. Titles, abstracts, and full-text articles will be assessed against the inclusion criteria by 2 independent reviewers. The extracted data will be analyzed quantitatively using frequencies and counts. Textual data from qualitative studies will be analyzed using descriptive content analysis. Results of the data analysis will be presented using graphs, tables, and a narrative format.Open Science Framework ( https://osf.io/hau5y ).

Background: Understanding nursing students’ knowledge about and attitudes towards older adults’ using a context-specific survey instrument may help to identify, and design effective learning and teaching materials to improve the care for older adults. The study aimed to evaluate the items on the Knowledge about Older Patients Quiz and the Kogan's Attitudes towards Old People Scale suitable for the African context. Methods: A cross-sectional study was conducted using second- and third-year nursing students from two public Nursing Training Institutions in Ghana. Data were collected from December 2019 - March 2020 using the Knowledge about Older Patients Quiz and the Kogan’s Attitudes Towards Old People Scale. Item response theory was employed to evaluate the difficulty level and discrimination indices of the Knowledge about Older Patients Quiz. Corrected item-to-total correlation analysis was conducted for the Kogan's Attitudes towards Old People scale. The internal consistency for both scales was examined.Results: Of the 170 participants, 169 returned completed surveys. The mean age of participants was 21years (SD = 3.7), and (54%) were female. Of the 30-items of the Knowledge about Older Patients Quiz, seven items were very difficult for most of the students to choose the correct response, and one was easy, as most of the students chose the correct response. Although, 22 items demonstrated appropriate difficulty level, discrimination indices, were used to select the final 15- items that discriminated moderately between upper and lower 25% performing students. The Kuder-Richardson-20 reliability was 0.30. Considering the Kogan's Attitudes towards Old People scale, 10-items were removed following negative and low corrected item-to-total correlation and a high Alpha coefficient if items were deleted. The final 22-items had a Cronbach alpha coefficient of 0.65.Conclusion: Evaluation of the scales demonstrated essential content validity and moderate internal consistency for the context of our study. Further research should focus on ongoing context specific refinement of the survey instruments to measure nursing students’ knowledge about and attitudes towards the care of older adults in the African context.

Background: Family members and healthcare providers play an integral role in a person’s assisted dying journey. Their own needs during the assisted dying journey are often, however, unrecognized and underrepresented in policies and guidelines. Circumstances under which people choose assisted dying, and relational contexts such as the sociopolitical environment, may influence the experiences of family members and healthcare providers. Ethical considerations: Ethics approval was not required to conduct this review. Aim: This scoping review aims to identify the relational influences on the experiences of family members and healthcare providers of adults who underwent assisted dying and of those unable to access assisted dying due to the loss of capacity to consent. Methods: A literature search was conducted in four databases, including MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. The search retrieved 12,074 articles, a number narrowed down to 172 articles for full-text screening. Thirty-six articles met the established inclusion criteria. A feminist relational framework guided the data analysis. Results: Five key themes on the influences of family members’ and healthcare providers’ experiences throughout the assisted dying process were synthesized from the data. They include (1) relationships as central to beginning the process, (2) social and political influences on decision making, (3) complex roles and responsibilities of family members and healthcare providers, (4) a unique experience of death, and (5) varying experiences following death. Conclusion: The feminist relational lens, used to guide analysis, shed light on the effect of the sociopolitical influences and the relationships among patients, families, and healthcare providers on each other’s experiences. Addressing the needs of the family members and healthcare providers is vital to improving the assisted dying process. Including families’ and healthcare providers’ needs within institutional policies and enhancing collaboration and communication among those involved could improve the overall experience.

Quality improvement (QI) projects are common in healthcare settings and often involve interdisciplinary teams working together towards a common goal. Many interventions and programmes have been introduced through research to convey QI skills and knowledge to healthcare workers, however, a few studies have attempted to differentiate between what individuals ‘learn’ or ‘know’ versus their capacity to apply their learnings in complex healthcare settings. Understanding and differentiating between delivery, receipt, and enactment of QI skills and knowledge is important because while enactment alone does not guarantee desired QI outcomes, it might be reasonably assumed that ‘better enactment’ is likely to lead to better outcomes. This paper describes the development, application and validation of a tool to measure enactment of core QI skills and knowledge of a complex QI intervention in a healthcare setting. Based on the Institute for Healthcare Improvement’s Model for Improvement, existing QI assessment tools, literature on enactment fidelity and our research protocols, 10 indicators related to core QI skills and knowledge were determined. Definitions and assessment criteria were tested and refined in five iterative cycles. Qualitative data from four QI teams in long-term care homes were used to test and validate the tool. The final measurement tool contains 10 QI indicators and a five-point scale. Inter-rater reliability ranged from good to excellent. Usability and acceptability among raters were considered high. This measurement tool assists in identifying strengths and weaknesses of a QI team and allows for targeted feedback on core QI components. The indicators developed in our tool and the approach to tool development may be useful in other health related contexts where similar data are collected.

Background Effective communication between residents (older adults), families, and the healthcare team supports person-centred care. However, communication breakdowns can occur that can impact care and outcomes. The aim of this paper is to describe a feedback approach to developing a communication tool for residents and families to guide information sharing during care discussions with the healthcare team in long-term care. Methods Development of the communication tool included consultation with key stakeholders for their feedback and input. Following initial development of the tool template by our research team, we invited feedback from our study collaborators. Next, individual interviews and a focus group were conducted with family members, followed by individual interviews with selected residents from two long-term care homes in Ontario, Canada. Participants were asked to provide input and feedback on the tool's content and usability and to share ideas for improving the tool. Content analysis was used to analyse the interview data. Results Feedback from residents and family included suggestions to enhance the tool's content and use of plain language, and suggestions for potential application of the tool. Conclusion Feedback highlighted the value of engaging residents and family members in the development of a communication tool. The communication tool offers a structured format to support participation of residents and families in information sharing for care discussions with the healthcare team.

Background The aim of this review was to examine the extent and nature of published literature on nurses' and nursing students' preparedness to care for older adults in lower and middle-income countries. Method A scoping review with 27 articles, guided by the Arksey and O’Malley (2005) framework was conducted. The following electronic databases were searched: MEDLINE, CINAHL, ERIC and SCOPUS. Grey literature using Google Scholar and ProQuest were also searched. Key search terms and subject headings such as “nursing students”, “nurses”, “stakeholders”, “ministry of health”, “readiness”, “knowledge”, “attitudes”, “elder care”, “seniors care” and “older adults” were used to identify relevant articles. Studies that reported on gerontological nursing, nursing students’ and nurses’ knowledge and attitudes towards older adults, and stakeholders/employers’ views about nursing students’ knowledge and attitudes towards older adults were included. Results Nurses reported having moderate to insufficient knowledge in the care of older adults in the majority of the studies. Nursing students reported insufficient knowledge in the care of older adults. However, both nurses and nursing students reported positive attitudes towards the care of older adults but held misconceptions about caring for older adults. Nursing students also reported a low preference for working with older adults. Discussion and implications The inadequate preparation of nurses and nursing students in the care of older adults means there are opportunities to enhance knowledge about health and nursing care in lower and middle-income countries and build on the positive attitudes towards older adults.

Background Long-term care facilities offer shelter and care for Canadian seniors; however, there are great variances in the quality of care that is provided to older adults across facilities. One factor that could contribute to this variation in quality is the diffusion and implementation of advice and innovations within this sector. This study sought to understand the motivations of identified opinion leaders within the Canadian long-term care sector to disseminate advice within their social networks. Research questions addressed specific drivers of motivation and the potential outcomes of having motivated opinion leaders present within interpersonal advice-seeking networks with respect to diffusion and implementation of innovations in the Canadian long-term care sector. Methods This secondary analysis study analyzed semi-structured qualitative interviews with opinion leaders (n = 13) and advice seekers of opinion leaders (n = 13) from a national, social network study, Advice Seeking Networks in Long Term Care (Cranley et al. 2019; Dearing et al. 2017). Constant comparison analysis was used and supported by a theoretical framework developed from diffusion of innovation theory and the COM-B framework. Results The motivations of opinion leaders in the Canadian long-term care sector were represented across seven themes: obligations of the position, value of education, systemness, relationships, supportiveness, passion, and caring nature. Conclusions This research provides further evidence that opinion leaders in the long-term care sector are motivated individuals and that they are using this motivation as a driver to create change and improve care practices. As residents of the long-term care sector continue to increase in number and complexity, the presence of motivated opinion leaders represents a promising outlook for the future through achieving specific outcomes such as the diffusion and implementation of innovations, an increased sense of community within the network, and increased readiness for the future.

Background Effective communication among interdisciplinary healthcare teams is essential for quality healthcare, especially in nursing homes (NHs). Care aides provide most direct care in NHs, yet are rarely included in formal communications about resident care (e.g., change of shift reports, family conferences). Audit and feedback is a potentially effective improvement intervention. This study compares the effect of simple and two higher intensity levels of feedback based on goal-setting theory on improving formal staff communication in NHs. Methods This pragmatic three-arm parallel cluster-randomized controlled trial included NHs participating in TREC (translating research in elder care) across the Canadian provinces of Alberta and British Columbia. Facilities with at least one care unit with 10 or more care aide responses on the TREC baseline survey were eligible. At baseline, 4641 care aides and 1693 nurses cared for 8766 residents in 67 eligible NHs. NHs were randomly allocated to a simple (control) group (22 homes, 60 care units) or one of two higher intensity feedback intervention groups (based on goal-setting theory): basic assisted feedback (22 homes, 69 care units) and enhanced assisted feedback 2 (23 homes, 72 care units). Our primary outcome was the amount of formal communication about resident care that involved care aides, measured by the Alberta Context Tool and presented as adjusted mean differences [95% confidence interval] between study arms at 12-month follow-up. Results Baseline and follow-up data were available for 20 homes (57 care units, 751 care aides, 2428 residents) in the control group, 19 homes (61 care units, 836 care aides, 2387 residents) in the basic group, and 14 homes (45 care units, 615 care aides, 1584 residents) in the enhanced group. Compared to simple feedback, care aide involvement in formal communications at follow-up was 0.17 points higher in both the basic ([0.03; 0.32], p = 0.021) and enhanced groups ([0.01; 0.33], p = 0.035). We found no difference in this outcome between the two higher intensity groups. Conclusions Theoretically informed feedback was superior to simple feedback in improving care aides’ involvement in formal communications about resident care. This underlines that prior estimates for efficacy of audit and feedback may be constrained by the type of feedback intervention tested. Trial registration ClinicalTrials.gov (NCT02695836), registered on March 1, 2016

Background Fidelity in complex behavioural interventions is underexplored. This study examines fidelity of the INFORM trial and explores the relationship between fidelity, study arm and the trial’s primary outcome – care aide involvement in formal team communications about resident care. We examined fidelity of intervention delivery, receipt, and enactment. The primary outcome in the INFORM study (care aide involvement in formal team communications about resident care) was also included as an outcome in this fidelity study.Methods A concurrent process evaluation of implementation fidelity was conducted in 33 nursing homes in Western Canada (Alberta and British Columbia). Study participants are from 106 clinical care units clustered in 33 nursing homes randomized to the Basic and Enhanced Assisted Feedback arms of the INFORM trial.Results Fidelity of the INFORM intervention was moderate to high, with fidelity delivery and receipt higher than fidelity enactment for both study arms. Higher enactment teams experienced a significantly larger improvement in formal team communications between baseline and follow-up than lower enactment teams ( F (1, 70) = 4.27, p = .042).Conclusions Overall fidelity enactment was associated with improvements in formal team communications, but study arm was not. This suggests that the intensity with which an intervention is offered and delivered may be less important than the intensity with which intervention participants enact the core components of an intervention. Greater attention to fidelity assessment and publication of fidelity results through studies such as this one is critical to improving the utility of published trials.

This article examines provincial policy influence on long-term care (LTC) professionals’ advice-seeking networks in Canada’s Maritime provinces. The effects of facility ownership, geography, and region-specific political landscapes on LTC best-practice dissemination are examined. We used sociometric statistics and network sociograms, calculated from surveys with 169 senior leaders in LTC facilities, to identify advice-seeking network structures and to select 11 follow-up interview participants. Network structures were distinguished by density, sub-group number, opinion leader, and boundary spanner distribution. Network structure was affected by ownership model in Nova Scotia and Prince Edward Island, and by regional geography in New Brunswick. Political instability within each province’s LTC system negatively affected network actors’ capabilities to enact innovation. Moreover, provincial policy variations influence advice-seeking network structures, facilitating and constraining relationship development and networking. Consequently, local policy context is essential to informing dissemination strategy design or implementation.

Background The context of care provided in long-term care homes is changing, as an increasing number of older adults are entering long-term care with advance stages of illness and higher care needs. Long-term care homes are quickly becoming the place of death for an increasing number of older adults, despite recent literature identifying inadequate and suboptimal levels of end-of-life care. Within long-term care, healthcare assistants represent 60%-70% of the unregulated workforce and provide 70%-90% of the direct care to residents. Research indicates that a high level of uncertainty exists surrounding the role of healthcare assistants in end-of-life care, with numerous studies reporting the role of healthcare assistants to be 'unclear' with varying levels of responsibilities and autonomy. Objective The purpose of this scoping review was to explore healthcare assistants' experiences and perspectives of their role in end-of-life care in long-term care. Methods We applied Arksey and O'Malley's methodological framework, with recommendations from Levac and colleagues' guiding principles. Electronic databases and the grey literature were searched for relevant articles. Search concepts included end-of-life care and healthcare assistants. Articles were included in this review if they explored healthcare assistants' experiences or perspectives of providing end-of-life care in long-term care. The peaceful end of life theory by Ruland and Moore (1998) was used to organise data extraction and analysis. Results A total of n = 15 articles met the inclusion criteria. The most predominant role-required behaviours reported by healthcare assistants were as follows: psychosocial support to significant others, knows the resident's care wishes and physical care with respect and dignity. The most predominant extra-role behaviours reported by healthcare assistants were as follows: becoming emotionally involved, acting as extended family and ensuring residents do not die alone. Conclusions Findings from this review expanded the concept of end-of-life care by illustrating the role-required and extra-role behaviours healthcare assistants perform when providing end-of-life care in long-term care. Implications for practice Findings from this scoping review highlight the numerous behaviours healthcare assistants perform outside their role description in order to provide end-of-life care to dying residents in long-term care. These findings could inform policymakers and managers of long-term care homes.

Background Implementation scientists and practitioners, alike, recognize the importance of sustaining practice change, however post-implementation studies of interventions are rare. This is a protocol for the Sustainment, Sustainability and Spread Study (SSaSSy). The purpose of this study is to contribute to knowledge on the sustainment (sustained use), sustainability (sustained benefits), and spread of evidence-based practice innovations in health care. Specifically, this is a post-implementation study of an evidence-informed, Care Aide-led, facilitation-based quality-improvement intervention called SCOPE (Safer Care for Older Persons (in long-term care) Environments). SCOPE has been implemented in nursing homes in the Canadian Provinces of Manitoba (MB), Alberta (AB) and British Columbia (BC). Our study has three aims: (i) to determine the role that adaptation/contextualization plays in sustainment, sustainability and spread of the SCOPE intervention; (ii) to study the relative effects on sustainment, sustainability and intra-organizational spread of high-intensity and low-intensity post-implementation “boosters”, and a “no booster” condition, and (iii) to compare the relative costs and impacts of each booster condition. Methods/design SSaSSy is a two-phase mixed methods study. The overarching design is convergent, with qualitative and quantitative data collected over a similar timeframe in each of the two phases, analyzed independently, then merged for analysis and interpretation. Phase 1 is a pilot involving up to 7 units in 7 MB nursing homes in which SCOPE was piloted in 2016 to 2017, in preparation for phase 2. Phase 2 will comprise a quasi-experiment with two treatment groups of low- and high-intensity post-implementation “boosters”, and an untreated control group (no booster), using pretests and post-tests of the dependent variables relating to sustained care and management practices, and resident outcomes. Phase 2 will involve 31 trial sites in BC (17 units) and AB (14 units) nursing homes, where the SCOPE trial concluded in May 2019. Discussion This project stands to advance understanding of the factors that influence the sustainment of practice changes introduced through evidence-informed practice change interventions, and their associated sustainability. Findings will inform our understanding of the nature of the relationship of fidelity and adaptation to sustainment and sustainability, and afford insights into factors that influence the intra-organizational spread of practice changes introduced through complex interventions.

Aim The aim of this study was to explore shared decision-making among residents, their families and staff to determine relevant strategies to support shared decision-making in long-term care (LTC). Background Meaningful engagement of long-term care home (LTCH) residents and their families in care decisions is key in the provision of quality of care. Shared decision-making is an interprofessional approach to increasing resident and family engagement in care decisions which can lead to higher quality decisions, more relevant care interventions and greater resident, family, and staff satisfaction. Despite these advantages, shared decision-making has not been widely implemented in practice in LTC. Methods The study took place in one LTCH in Toronto, Ontario, Canada. A qualitative descriptive design was used to explore how residents, family members and staff described how they collaborate when making decisions concerning resident care, and their perceptions of facilitators and challenges to a collaborative approach to decision-making. Individual interviews were conducted with nine participants: residents, families and staff. Data were analysed using content and thematic analysis. Findings Four main themes that described resident, family and staff perspectives of shared decision-making were as follows: (a) oral communication pathways for information sharing; (b) supporting resident decision-making autonomy; (c) relational aspects of care facilitate shared decision-making; and (d) lack of effective communication creates barriers to shared decision-making. Conclusion As the demand for LTC continues to increase, it is crucial that healthcare providers engage in collaborative, relational practices that foster high-quality resident care. While a relational approach to care can facilitate shared decision-making, there are opportunities to further cultivate shared decision-making in LTCHs through more effective communication and collaboration. Implications for practice Understanding how information is shared and decisions are made can facilitate shared decision-making in LTCHs. The strategies identified from this study could be further co-developed and implemented in LTCHs.

Tailoring feedback data to engage end-user stakeholders when sharing organizational context data is a central component of quality improvement and integrated knowledge translation. For over a decade, our research team has collected survey data (using the validated Alberta Context Tool) on modifiable aspects of organizational context from long-term care (LTC) staff (e.g., nurses, unregulated providers) across a representative cohort of 94 LTC facilities in Western Canada. We have fed back data at the facility and care unit level with the goal of making research findings more useful for decision-making and aiding improvement efforts. We have used a binary method (more favourable / less favourable organizational context) to report multidimensional data. While useful to our stakeholders (e.g., administrators) we are continually seeking ways to increase the detail in our reporting, while maintaining usability for stakeholders. We have now developed a more detailed method – the context rank summary, which displays rankings of care units within and across LTC facilities. In this study, we used a qualitative descriptive design to explore perspectives of administrators and managers (leaders) from LTC facilities on the two different methods for reporting survey data. We conducted a total of three focus groups with 16 leaders in the Maritimes and Ontario, Canada. Transcripts were analysed using content analysis. Leaders preferred a feedback report that combines a binary method with the greater detail of the context rank summary. Providing organizational context data that is more meaningful, relevant and actionable could offer an additional path to identifying areas for improvement.

Background: Interpersonal relationships among professionals drive both the adoption and rejection of consequential innovations. Through relationships, decision-makers learn which colleagues are choosing to adopt innovations, and why. The purpose of our study was to understand how and why long-term care (LTC) leaders in a pan-Canadian interpersonal network provide and seek advice about care improvement innovations, for the eventual dissemination and implementation of these innovations. Methods: We used a mixed methods approach. An online survey was sent to senior leaders in 958 LTC facilities in 11 Canadian provinces and territories. Participants were asked to name up to three individuals whose advice they most value when considering care improvement and practice innovations. Sociometric analysis revealed the structure of provincial-level advice networks and how those networks were linked. Using sociometric indicators, we purposively selected 39 key network actors to interview to explore the nature of advice relationships. Data were analyzed thematically. Results: In this paper, we report our qualitative findings. We identified four themes from the data. One theme related to characteristics of particular network roles: opinion leaders, advice seekers, and boundary spanners. Opinion leaders and boundary spanners have long tenures in LTC, a broad knowledge of the network, and share an interest in advancing the sector. Advice seekers were similarly committed to LTC; they initially seek and then, over time, exchange advice with opinion leaders and become an important source of information for them. A second theme related to characterizing advice seeking relationships as formal, peer-to-peer, mentoring, or reciprocal. The third and fourth themes described motivations for providing and seeking advice, and the nature of advice given and sought. Advice seekers initially sought information to resolve clinical care problems; however, over time, the nature of advice sought expanded to include operational and strategic queries. Opinion leaders sought to expand their networks and to solicit information from their more established advice seekers that might benefit the network and advance LTC. Conclusions: New knowledge about the distinct roles that different network actors play vis-a-vis one another offers healthcare professionals, researchers, and decision- and policy-makers insights that are useful when formulating best practice dissemination strategies.

Background Our overarching study objective is to further our understanding of the work psychology of Health Support Workers (HSWs) in long-term care and home and community care settings in Ontario, Canada. Specifically, we seek novel insights about the relationships among aspects of these workers’ work environments, their work attitudes, and work outcomes in the interests of informing the development of human resource programs to enhance elder care. Methods We conducted a path analysis of data collected via a survey administered to a convenience sample of Ontario HSWs engaged in the delivery of elder care over July–August 2015. Results HSWs’ work outcomes, including intent to stay, organizational citizenship behaviors, and performance, are directly and significantly related to their work attitudes, including job satisfaction, work engagement, and affective organizational commitment. These in turn are related to how HSWs perceive their work environments including their quality of work life (QWL), their perceptions of supervisor support, and their perceptions of workplace safety. Conclusions HSWs’ work environments are within the power of managers to modify. Our analysis suggests that QWL, perceptions of supervisor support, and perceptions of workplace safety present particularly promising means by which to influence HSWs’ work attitudes and work outcomes. Furthermore, even modest changes to some aspects of the work environment stand to precipitate a cascade of positive effects on work outcomes through work attitudes.

Background Interventions to improve quality of care for residents of long-term care facilities, and to examine the sustainability and spread of such initiatives, remain a top research priority. The purpose of this exploratory study was to assess the extent to which activities initiated in a quality improvement (QI) collaborative study using care aide led teams were sustained or spread following cessation of the initial project and to identify factors that led to its success. Methods This study used an exploratory mixed methods study design and was conducted in seven residential long-term care facilities in two Canadian provinces. Sustainability and spread of QI activities were assessed by a questionnaire over five time points for 18 months following the collaborative study with staff from both intervention with non-intervention units. Semi-structured interviews were conducted with care managers at six and 12 months. QI team success in applying the QI model was ranked as high, medium, or low using criteria developed by the research team. Descriptive statistics, bivariate analyses, and General Estimating Equations were used to analyze the data. Interview data were analyzed using thematic analysis. Results In total, 683 surveys were received over the five time periods from 476 unique individuals on a facility unit. Seven managers were interviewed. A total of 533 surveys were analyzed. While both intervention and non-intervention units experienced a decline over time in all outcome measures, this decline was significantly less pronounced on intervention units. Facilities with medium and high success ranking had significantly higher scores in all four outcomes than facilities with a low success ranking. Care aides reported significantly less involvement of others in QI activities, less empowerment and less satisfaction with the quality of their work life than regulated care providers. Manager interviews provided evidence of sustainability of QI activities on the intervention units in four of the seven facilities up to 18 months following the intervention and demonstrated the need for continued staff and leadership engagement. Conclusion Sustainability of a QI project which empowers and engages care aides is possible and achievable, but requires ongoing staff and leadership engagement. Electronic supplementary material The online version of this article (10.1186/s12913-018-2978-0) contains supplementary material, which is available to authorized users.

Death is a common occurrence in intensive care units (IC Us) and the complexity of care makes it difficult for nurses to find a balance between the patient's physical needs and the family's emotional needs, especially in circumstances of unexpected death. Cumulative or unresolved grief for families can have lasting negative repercussions. Nurses, therefore, need access to bereavement education in order to provide optimal- bereavement support.The purpose of this review is to identify challenges and facilitators that nurses experience in delivering bereavement support during and after sudden or unexpected death in ICUs.A narrative overview was conducted based on a literature search using GINA HL, Medline, Psyclnfo, Scopus, and Pro quest databases, as well as grey literature, revealing 241 articles, 15 of which met inclusion criteria.Four themes surrounding bereavement support in the ICUs emerged: influence of hospital policies and organizational constraints; sign ~tl cance of time and trust; level of knowledge and support of staff and nurses' inner conflict, moral distress, and personal ways of coping.The availability of up-to-date literature in this area is limited. Further research could inform organizational poli- cies, nursing education, and nursing staff development to address existing barriers. With adequate resources, practical strate- gies could be implemented to provide bereavement support that ensures optimal bereavement outcomes for families experiencing sudden or unexpected death in ICUs.

BackgroundImplementing research findings into practice is a complex process that is not well understood. Facilitation has been described as a key component of getting research findings into practice. The literature on facilitation as a practice innovation is growing. This review aimed to identify facilitator roles and to describe characteristics of facilitation that may be associated with successful research use by healthcare professionals.MethodsWe searched 10 electronic databases up to December 2016 and used predefined criteria to select articles. We included conceptual papers and empirical studies that described facilitator roles, facilitation processes or interventions, and that focused on healthcare professionals and research use. We used content and thematic analysis to summarise data. Rogers’ five main attributes of an innovation guided our synthesis of facilitation characteristics.ResultsOf the 38 488 articles identified from our online and manual search, we included 195 predominantly research studies. We identified nine facilitator roles: opinion leaders, coaches, champions, research facilitators, clinical/practice facilitators, outreach facilitators, linking agents, knowledge brokers and external-internal facilitators. Fifteen facilitation characteristics were associated with research use, which we grouped into five categories using Rogers’ innovation attributes: relative advantage, compatibility, complexity, trialability and observability.ConclusionsWe found a diverse and broad literature on the concept of facilitation that can expand our current thinking about facilitation as an innovation and its potential to support an integrated, collaborative approach to improving healthcare delivery.

The Advice Seeking Networks in Long Term Care Study used social network analysis to understand the informal advice networks of senior leaders in Canadian long term care (LTC), with the goal of using this knowledge to inform future efforts to more effectively disseminate quality improvement innovations. In this abstract we describe one main component of the study, a qualitative analysis of interviews conducted with 39 opinion leaders, boundary spanners, and advice seekers identified in interpersonal advice networks in the sector. At each of the 958 LTC facilities spanning 11 of Canada’s 13 provinces and territories, we asked one senior leader to complete a survey identifying individuals who were informal sources of advice about quality improvement. The survey data from 482 respondents was then used to identify and interview network advice seekers by their out-degree scores, opinion leaders by their in-degree scores, and boundary spanners by their betweenness centrality scores. Results from thematic analysis of the interviews indicated that advice seekers tend to seek advice from those with whom they deem trustworthy and knowledgeable and with whom they share similar professional backgrounds and care philosophies. Opinion leaders possess an appetite for change and a strong sense of responsibility for improving care throughout the LTC system. They often have career trajectories that move them from clinical to administrative or oversight roles. Advice seeking relationships often endure over many years, transcending roles and even care sectors, and can evolve into reciprocal relationships.

Aim This is a report on generation-specific incentives and disincentives selected by acute care nurses that promote and discourage them to remain employed in hospitals. Background Recent literature indicates that nurse preferences for strategies to promote their retention may differ across generational cohorts. However, current literature is primarily anecdotal with few studies focused on evidence-based generation-specific nurse retention-promoting strategies. Methods Data were gathered from a cross-sectional survey administered to a random sample of 9904 registered nurses working in Alberta and Ontario, Canada. Two survey items asking nurses to identify preferences for incentives to remain employed and disincentives that encourage them to leave employment were included. Survey items were based on information gathered from previous focus groups exploring determinants of nurse retention. Results There were statistically significant differences in the rates of selection across generations of nurses for eight of 10 incentives to remain employed and for eight of 15 disincentives. All generational cohorts selected the same two incentives most frequently: reasonable workloads and manageable nurse–patient ratios. Two of the three most frequently selected disincentives were the same across generations: inadequate staffing and unmanageable workloads. Implications for nursing management Leaders should implement and evaluate strategies that ensure workloads are reasonable and nurse–patient ratios are manageable to promote retention among all generations of nurses in the acute care hospital workforce.

tourangeau a., cranley l., laschinger h. & pachis j. (2010) Journal of Nursing Management 18, 1060–1072 Relationships among leadership practices, work environments, staff communication and outcomes in long-term care Aim To examine the role that work relationships have on two long-term care outcomes: job satisfaction and turnover intention. Background It is easy to overlook the impact that human relations have in shaping work environments that are conducive to organizational effectiveness. Employee job satisfaction and retention are important organizational outcomes. Methods Six hundred and seventy-five nursing and other staff from 26 long-term care facilities were surveyed about their work environments, work group relationships, observed leadership practices, organizational support, job satisfaction and turnover intention. Results Higher job satisfaction was associated with lower emotional exhaustion burnout, higher global empowerment, higher organizational support, higher psychological empowerment, stronger work group cohesion and higher personal accomplishment. Higher turnover intention was associated with lower job satisfaction, higher emotional exhaustion burnout, more outside job opportunities, weaker work group cohesion, lower personal accomplishment and higher depersonalization. Conclusions No relationship was found between leadership practices and job satisfaction or turnover intention. Stronger work group relationships, stronger sense of personal accomplishment and lower emotional exhaustion have direct effects on increasing job satisfaction and lowering turnover intention. Implications To retain long-term care staff, attention should be paid to fostering positive work group cohesion, supporting and acknowledging staff accomplishments and minimizing staff burnout.

tourangeau a.e., cummings g., cranley l.a., ferron e.m. & harvey s. (2010) Determinants of hospital nurse intention to remain employed: broadening our understanding. Journal of Advanced Nursing66(1), 22–32. Abstract Title. Determinants of hospital nurse intention to remain employed: broadening ourunderstanding. Aim. This paper is a report of a study to identify nurse reported determinants of intention to remain employed and to develop a model explaining determinants of hospital nurse intention to remain employed. Background. A worsening shortage of nurses globally suggests that efforts must be made to promote retention of nurses. However, effective retention promotion strategies depend on understanding the factors influencing nurse retention. Methods. A descriptive study using focus group methodology was implemented. Thirteen focus groups including 78 nurses were carried out in two Canadian provinces in 2007. Thematic analysis strategies were incorporated to analyse the data. Findings. Eight thematic categories reflecting factors nurses described as influencing their intentions to remain employed emerged from focus groups: (1) relationships with co-workers, (2) condition of the work environment, (3) relationship with and support from one’s manager, (4) work rewards, (5) organizational support and practices, (6) physical and psychological responses to work, (7) patient relationships and other job content, and (8) external factors. A model of determinants of hospital nurse intention to remain employed is hypothesized. Conclusion. Findings were both similar to and different from previous research. The overriding concept of job satisfaction was not found. Rather, nurse assessments of satisfaction within eight thematic categories were found to influence intentions to remain employed. Further testing of the hypothesized model is required to determine its global utility. Understanding determinants of intention to remain employed can lead to development of strategies that strengthen nurse retention. Incorporation of this knowledge in nurse education programmes is essential.

BACKGROUND Structures and processes of care such as work environments and care provider responses to work environments have been shown to influence organizational outcomes. To improve health care quality, structures, processes, and outcomes of care should be considered. There is almost no literature reporting on the structural characteristics of work environments and care provider responses to work environments in institutional long-term (chronic) care settings. PURPOSE The purpose of this article was to report how a convenience sample of multidisciplinary care providers working in institutional long-term (chronic) care settings in Ontario, Canada, evaluated their work environments and their responses to these environments. METHODOLOGY A sample of multidisciplinary care providers working within six institutional long-term care settings completed a survey rating their work environments (e.g., supervisor support and effectiveness and work empowerment) and responses to work environments (e.g., job satisfaction, burnout, and intention to remain employed). The survey included three well-established instruments: Supervisory Support Scale; Learn, Empower, Achieve, and Produce instrument; and the Maslach Burnout Inventory. Descriptive statistics were used to summarize survey data. To determine whether there were differences in staff characteristics, ratings of work environments, and responses to work environments across the four participant job categories, tests of differences were completed using analyses of variance with Tukey post hoc (continuous variables) and chi-square (categorical variables) tests. FINDINGS Ratings of the work environment were similar across job categories and indicated opportunities for improvement. Overall job satisfaction was rated between "neutral" and "satisfied." On average, the staff reported moderate levels of emotional exhaustion (burnout). More than one third of all staff members reported planning to leave their employment, including two thirds of allied health professionals. PRACTICE IMPLICATIONS Strategies are suggested to strengthen institutional long-term care work environments to promote more positive staff responses to work environments, including higher job satisfaction and intention to remain employed.

Aim: This paper is a report of the results of a review of the literature conducted with the goal of determining how nurses' clinical uncertainty has been conceptualized in the nursing literature. Background: Although existing research has advanced the body of knowledge regarding the concept of uncertainty in decision-making, this has been largely from physicians' viewpoints and from patients' perspectives (patients' uncertainty). Understanding how nurses' experience and act on uncertainty remains relatively unreported. Method: A search of Medline, CINAHL, and PubMed databases was conducted to retrieve literature published from 1990 to 2007. The question guiding the literature review was: How has nurses' clinical uncertainty been conceptualized in nursing literature? Findings: Little exploration has been done of nurses' experience of uncertainty in practice. Many investigators have not theorized about the uncertainty in their studies, but have described nurses' uncertainty in the context of clinical decision-making. The findings from these studies indicated that unfamiliarity with the aspects of patient care is a source of uncertainty, and nurses tended to rely on heuristics or on the expertise of colleagues as sources of information for practice decisions. Expressing uncertainties as information needs might help guide information seeking and reduce uncertainty. However, studies indicated that nurses have difficulty recognizing or expressing uncertainties, and as a result, information needs are not recognized and information seeking is not initiated. Conclusions: A more comprehensive understanding of nurses' uncertainty could lead to the development and implementation of strategies to support nurses in their clinical decision-making and practice. Descriptions are needed about how nurses experience and respond to uncertainty in their practice, and the influence of uncertainty on their information needs and information seeking.

Aim To explore generational differences in job satisfaction. Background Effective retention strategies are required to mitigate the international nursing shortage. Job satisfaction, a strong and consistent predictor of retention, may differ across generations. Understanding job satisfaction generational differences may lead to increasing clarity about generation-specific retention approaches. Method The Ontario Nurse Survey collected data from 6541 Registered Nurses. Participants were categorized as Baby Boomer, Generation X or Generation Y based on birth year. Multivariate analysis of variance explored generational differences for overall and specific satisfaction components. Results In overall job satisfaction and five specific satisfaction components, Baby Boomers were significantly more satisfied than Generations X and Y. Conclusion It is imperative to improve job satisfaction for younger generations of nurses. Implications for Nursing Management Strategies to improve job satisfaction for younger generations of nurses may include creating a shared governance framework where nurses are empowered to make decisions. Implementing shared governance, through nurse-led unit-based councils, may lead to greater job satisfaction, particularly for younger nurses. Opportunities to self schedule or job share may be other potential approaches to increase job satisfaction, especially for younger generations of nurses. Another potential strategy would be to aggressively provide and support education and career-development opportunities.

Aim: The aim of the project was to develop an electronic information gathering and dissemination system to support both nursing-sensitive outcomes data collection and evidence-based decision-making at the point-of-patient care. Background: With the current explosion of health-related knowledge, it is a challenge for nurses to regularly access information that is most current. The Internet provides timely access to health information, however, nurses do not readily use the Internet to access practice information because of being task-driven and coping with heavy workloads. Mobile computing technology addresses this reality by providing the opportunity for nurses to access relevant information at the time of nurse–patient contact. Method: A cross-sectional, mixed-method design was used to describe nurses' requirements for point-of-care information collection and utilization. The sample consisted of 51 nurses from hospital and home care settings. Data collection involved work sampling and focus group interviews. Findings: In the hospital sector, 40% of written information was recorded onto “personal papers” at point-of-care and later transcribed into the clinical record. Nurses often sought information away from the point-of-care; for example, centrally located health records, or policy and procedure manuals. In home care, documentation took place in clients' homes. The most frequent source of information was “nurse colleagues.” Nurses' top priorities for information were vital signs data, information on intravenous (IV) drug compatibility, drug references, and manuals of policies and procedures. Implications: A prototype software system was designed that enables nurses to use handheld computers to simultaneously document patients' responses to treatment, obtain real-time feedback about patient outcomes, and access electronic resources to support clinical decision-making. Conclusion: The prototype software system has the potential to increase nurses' access to patient outcomes information and evidence for point-of-care decision-making.

Background Health care is shifting out of hospitals into community settings. In Ontario, Canada, home care organizations continue to experience challenges recruiting and retaining nurses. However, factors influencing home care nurse retention that can be modified remain largely unexplored. Several groups of factors have been identified as influencing home care nurse intent to remain employed including job characteristics, work structures, relationships and communication, work environment, responses to work, and conditions of employment. Purpose The aim of this study was to test and refine a model that identifies which factors are related to home care nurse intentions to remain employed for the next 5 years with their current home care employer organization. Methodology/approach A cross-sectional survey design was implemented to test and refine a hypothesized model of home care nurse intent to remain employed. Logistic regression was used to determine which factors influence home care nurse intent to remain employed. Findings Home care nurse intent to remain employed for the next 5 years was associated with increasing age, higher nurse-evaluated quality of care, having greater variety of patients, experiencing greater meaningfulness of work, having greater income stability, having greater continuity of client care, experiencing more positive relationships with supervisors, experiencing higher work-life balance, and being more satisfied with salary and benefits. Practice implications Home care organizations can promote home care nurse intent to remain employed by (a) ensuring nurses have adequate training and resources to provide quality client care, (b) improving employment conditions to increase income stability and satisfaction with pay and benefits

Background Facilitation is a guided interactional process that has been popularized in health care. Its popularity arises from its potential to support uptake and application of scientific knowledge that stands to improve clinical and managerial decision-making, practice, and ultimately patient outcomes and organizational performance. While this popular concept has garnered attention in health services research, we know that both the content of facilitation and its impact on knowledge implementation vary. The basis of this variation is poorly understood, and understanding is hampered by a lack of conceptual clarity. Discussion In this paper, we argue that our understanding of facilitation and its effects is limited in part by a lack of clear theoretical grounding. We propose a theoretical home for facilitation in organizational learning theory. Referring to extant literature on facilitation and drawing on theoretical literature, we discuss the features of facilitation that suggest its role in contributing to learning capacity. We describe how facilitation may contribute to generating knowledge about the application of new scientific knowledge in health-care organizations. Summary Facilitation’s promise, we suggest, lies in its potential to stimulate higher-order learning in organizations through experimenting with, generating learning about, and sustaining small-scale adaptations to organizational processes and work routines. The varied effectiveness of facilitation observed in the literature is associated with the presence or absence of factors known to influence organizational learning, since facilitation itself appears to act as a learning mechanism. We offer propositions regarding the relationships between facilitation processes and key organizational learning concepts that have the potential to guide future work to further our understanding of the role that facilitation plays in learning and knowledge generation. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0323-0) contains supplementary material, which is available to authorized users.

The extent to which nursing interventions provided during hospitalization are associated with patients' therapeutic self-care and functional health outcomes was explored with a voluntary sample of 574 patients. Nurses collected data on patient outcomes at admission and discharge using the minimum data set (MDS) and the therapeutic self-care scale (TSCS). Research assistants audited charts for documentation of nursing interventions. The results indicated that nursing interventions aimed at exercise promotion, positioning, and self-care assistance predicted functional status outcome. Higher functional status outcome predicted therapeutic self-care ability at hospital discharge. The results demonstrate that nurses can use MDS and TSCS data on patient outcomes to gain insight into the effectiveness of their interventions.

Aim To identify factors affecting Canadian home care nurse intention to remain employed (ITR). Background In developed nations, healthcare continues to shift into community settings. Although considerable research exists on examining nurse ITR in hospitals, similar research related to nurses employed in home care is limited. In the face of a global nursing shortage, it is important to understand the factors influencing nurse ITR across healthcare sectors. Methods A qualitative exploratory descriptive design was used. Focus groups were conducted with home care nurses. Data were analysed using qualitative content analysis. Results Six categories of influencing factors were identified by home care nurses as affecting ITR: job characteristics; work structures; relationships/communication; work environment; nurse responses to work; and employment conditions. Conclusion Findings suggest the following factors influence home care nurse ITR: having autonomy; flexible scheduling; reasonable and varied workloads; supportive work relationships; and receiving adequate pay and benefits. Home care nurses did not identify job satisfaction as a single concept influencing ITR. Implications for nursing management Home care nursing management should support nurse autonomy, allow flexible scheduling, promote reasonable workloads and create opportunities for team building that strengthen supportive relationships among home care nurses and other health team members.

Background and Purpose. In this paper, we present a protocol for advanced psychometric assessments of surveys based on the Standards for Educational and Psychological Testing. We use the Alberta Context Tool (ACT) as an exemplar survey to which this protocol can be applied.Methods. Data mapping, acceptability, reliability, and validity are addressed. Acceptability is assessed with missing data frequencies and the time required to complete the survey. Reliability is assessed with internal consistency coefficients and information functions. A unitary approach to validity consisting of accumulating evidence based on instrument content, response processes, internal structure, and relations to other variables is taken. We also address assessing performance of survey data when aggregated to higher levels (e.g., nursing unit).Discussion. In this paper we present a protocol for advanced psychometric assessment of survey data using the Alberta Context Tool (ACT) as an exemplar survey; application of the protocol to the ACT survey is underway. Psychometric assessment of any survey is essential to obtaining reliable and valid research findings. This protocol can be adapted for use with any nursing survey.

Background In Canada, healthcare aides (also referred to as nurse aides, personal support workers, nursing assistants) are unregulated personnel who provide 70-80% of direct care to residents living in nursing homes. Although they are an integral part of the care team their contributions to the resident care planning process are not always acknowledged in the organization. The purpose of the Safer Care for Older Persons [in residential] Environments (SCOPE) project was to evaluate the feasibility of engaging front line staff (primarily healthcare aides) to use quality improvement methods to integrate best practices into resident care. This paper describes the process used by teams participating in the SCOPE project to select clinical improvement areas. Methods The study employed a collaborative approach to identify clinical areas and through consensus, teams selected one of three areas. To select the clinical areas we recruited two nursing homes not involved in the SCOPE project and sampled healthcare providers and decision-makers within them. A vote counting method was used to determine the top five ranked clinical areas for improvement. Results Responses received from stakeholder groups included gerontology experts, decision-makers, registered nurses, managers, and healthcare aides. The top ranked areas from highest to lowest were pain/discomfort management, behaviour management, depression, skin integrity, and assistance with eating. Conclusions Involving staff in selecting areas that they perceive as needing improvement may facilitate staff engagement in the quality improvement process.

Background This project is part of the Translating Research in Elder Care (TREC) program of research, a multi-level and longitudinal research program being conducted in 36 nursing homes in three Canadian Prairie Provinces. The overall goal of TREC is to improve the quality of care for older persons living in nursing homes and the quality of work life for care providers. The purpose of this paper is to report on development and evaluation of facility annual reports (FARs) from facility administrators’ perspectives on the usefulness, meaningfulness, and understandability of selected data from the TREC survey. Methods A cross sectional survey design was used in this study. The feedback reports were developed in collaboration with participating facility administrators. FARs presented results in four contextual areas: workplace culture, feedback processes, job satisfaction, and staff burnout. Six weeks after FARs were mailed to each administrator, we conducted structured telephone interviews with administrators to elicit their evaluation of the FARs. Administrators were also asked if they had taken any actions as a result of the FAR. Descriptive and inferential statistics, as well as content analysis for open-ended questions, were used to summarize findings. Results Thirty-one facility administrators (representing thirty-two facilities) participated in the interviews. Six administrators had taken action and 18 were planning on taking action as a result of FARs. The majority found the four contextual areas addressed in FAR to be useful, meaningful, and understandable. They liked the comparisons made between data from years one and two and between their facility and other TREC study sites in their province. Twenty-two indicated that they would like to receive information on additional areas such as aggressive behaviours of residents and information sharing. Twenty-four administrators indicated that FARs contained enough information, while eight found FARs ‘too short’. Administrators who reported that the FAR contained enough information were more likely to take action within their facilities than administrators who reported that they needed more information. Conclusions Although the FAR was brief, the presentation of the four contextual areas was relevant to the majority of administrators and prompted them to plan or to take action within their facility.

Background Engaging end-users of research in the process of disseminating findings may increase the relevance of findings and their impact for users. We report findings from a case study that explored how involvement with the Translating Research in Elder Care (TREC) study influenced management and staff at one of 36 TREC facilities. We conducted the study at ‘Restwood’ (pseudonym) nursing home because the Director of Care engaged actively in the study and TREC data showed that this site differed on some areas from other nursing homes in the province. The aims of the case study were two-fold: to gain a better understanding of how frontline staff engage with the research process, and to gain a better understanding of how to share more detailed research results with management. Methods We developed an Expanded Feedback Report for use during this study. In it, we presented survey results that compared Restwood to the best performing site on all variables and participating sites in the province. Data were collected regarding the Expanded Feedback Report through interviews with management. Data from staff were collected through interviews and observation. We used content analysis to derive themes to describe key aspects related to the study aims. Results We observed the importance of understanding organizational routines and the impact of key events in the facility’s environment. We gleaned additional information that validated findings from prior feedback mechanisms within TREC. Another predominant theme was the sense that the opportunity to engage in a research process was reaffirming for staff (particularly healthcare aides)—what they did and said mattered, and TREC provided a means of having one’s voice heard. We gained valuable insight from the Director of Care about how to structure and format more detailed findings to assist with interpretation and use of results. Conclusions Four themes emerged regarding staff engagement with the research process: sharing feedback reports from the TREC study; the meaning of TREC to staff; understanding organizational context; and using the study feedback for improvement at Restwood. This study has lessons for researchers on how to share research results with study participants, including management.

Background This project occurred during the course of the Translating Research in Elder Care (TREC) program of research. TREC is a multilevel and longitudinal research program being conducted in the three Canadian Prairie Provinces of Alberta, Saskatchewan, and Manitoba. The main purpose of TREC is to increase understanding about the role of organizational context in influencing knowledge use in residential long-term care settings. The purpose of this study was to evaluate healthcare aides’ (HCAs) perceptions of a one-page poster designed to feed back aggregated data (including demographic information and perceptions about influences on best practice) from the TREC survey they had recently completed. Methods A convenience sample of 7 of the 15 nursing homes participating in the TREC research program in Alberta were invited to participate. Specific facility-level summary data were provided to each facility in the form of a one-page poster report. Two weeks following delivery of the report, a convenience sample of HCAs was surveyed using one-to-one structured interviews. Results One hundred twenty-three HCAs responded to the evaluation survey. Overall, HCAs’ opinions about presentation of the feedback report and the understandability, usability, and usefulness of the content were positive. For each report, analysis of data and production and inspection of the report took up to one hour. Information sessions to introduce and explain the reports averaged 18 minutes. Two feedback reports (minimum) were supplied to each facility at a cost of CAN$2.39 per report, for printing and laminating. Conclusions This study highlights not only the feasibility of producing understandable, usable, and useful feedback reports of survey data but also the value and importance of providing feedback to survey respondents. More broadly, the findings suggest that modest strategies may have a positive and desirable effect in participating sites.

To examine the role that work relationships have on two long-term care outcomes: job satisfaction and turnover intention.It is easy to overlook the impact that human relations have in shaping work environments that are conducive to organizational effectiveness. Employee job satisfaction and retention are important organizational outcomes.Six hundred and seventy-five nursing and other staff from 26 long-term care facilities were surveyed about their work environments, work group relationships, observed leadership practices, organizational support, job satisfaction and turnover intention.Higher job satisfaction was associated with lower emotional exhaustion burnout, higher global empowerment, higher organizational support, higher psychological empowerment, stronger work group cohesion and higher personal accomplishment. Higher turnover intention was associated with lower job satisfaction, higher emotional exhaustion burnout, more outside job opportunities, weaker work group cohesion, lower personal accomplishment and higher depersonalization.No relationship was found between leadership practices and job satisfaction or turnover intention. Stronger work group relationships, stronger sense of personal accomplishment and lower emotional exhaustion have direct effects on increasing job satisfaction and lowering turnover intention.To retain long-term care staff, attention should be paid to fostering positive work group cohesion, supporting and acknowledging staff accomplishments and minimizing staff burnout.