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Voice, silence, perceived impact, psychological safety, and burnout among nurses: A structural equation modeling analysis

Lee, Seung Eun; Seo, Ja kyung; Squires, Allison
Background: The organizational studies' literature suggests that employees' expressions of voice and silence may be distinct concepts with different predictors. Organizational researchers also argue that both employees' voice and silence are related to burnout; however, these relationships have not been adequately examined in the healthcare context. Objective: This study aimed to investigate the relationships among nurses' perceived impact, psychological safety, voice behaviors, and burnout using a theoretical model. Voice behaviors were conceptualized as voice and silence. Design: A cross-sectional, correlational study design was employed. Settings: Study data were collected in 34 general hospitals in South Korea. Participants: A total of 1255 registered nurses providing direct care to patients were included in this study. Methods: Using a convenience sampling method, a web-based survey was conducted to obtain data. All variables were measured using standardized instruments. A structural equation modeling analysis was employed to test a hypothesized model positing that perceived impact and psychological safety have both direct and indirect effects on nurse burnout through voice and silence. The response rate was 72.8 %. Results: The findings supported the hypothesized model. Both perceived impact and psychological safety were positively related to expressions of voice, but both were negatively associated with silence. We also found that perceived impact was more strongly associated with voice than with silence, while psychological safety had a stronger impact on silence than on voice. Furthermore, voice reduced burnout, while silence increased it. Finally, perceived impact reduced burnout through voice (β = − 0.10, 95 % confidence interval [− 0.143, − 0.059]) and silence (β = − 0.04, 95 % confidence interval [− 0.058, − 0.014]), and psychological safety also decreased burnout through voice (β = − 0.04, 95 % confidence interval [− 0.057, − 0.016]) and silence (β = − 0.07, 95 % confidence interval [− 0.101, − 0.033]). Additional analyses revealed that prohibitive voice and silence significantly mediated the associations between psychological safety and burnout and perceived impact and burnout, but the mediating role of promotive voice was not statistically significant. Conclusions: It is important to recognize that voice and silence are distinct concepts. Moreover, to reduce nurse burnout, nurse managers and hospital administrators should develop separate strategies for promoting nurses' perceived impact and psychological safety, as their influences on voice and silence differ. Registration: Not applicable. Tweetable abstract: Voice and silence both influence nurse burnout. Separate strategies should be applied to voice and silence, as they are different concepts.
SCOPUS:85181116805
ISSN: 0020-7489
CID: 5629052

Voice, silence, perceived impact, psychological safety, and burnout among nurses: A structural equation modeling analysis

Lee, Seung Eun; Seo, Ja-Kyung; Squires, Allison
BACKGROUND:The organizational studies' literature suggests that employees' expressions of voice and silence may be distinct concepts with different predictors. Organizational researchers also argue that both employees' voice and silence are related to burnout; however, these relationships have not been adequately examined in the healthcare context. OBJECTIVE:This study aimed to investigate the relationships among nurses' perceived impact, psychological safety, voice behaviors, and burnout using a theoretical model. Voice behaviors were conceptualized as voice and silence. DESIGN/METHODS:A cross-sectional, correlational study design was employed. SETTINGS/METHODS:Study data were collected in 34 general hospitals in South Korea. PARTICIPANTS/METHODS:A total of 1255 registered nurses providing direct care to patients were included in this study. METHODS:Using a convenience sampling method, a web-based survey was conducted to obtain data. All variables were measured using standardized instruments. A structural equation modeling analysis was employed to test a hypothesized model positing that perceived impact and psychological safety have both direct and indirect effects on nurse burnout through voice and silence. The response rate was 72.8 %. RESULTS:The findings supported the hypothesized model. Both perceived impact and psychological safety were positively related to expressions of voice, but both were negatively associated with silence. We also found that perceived impact was more strongly associated with voice than with silence, while psychological safety had a stronger impact on silence than on voice. Furthermore, voice reduced burnout, while silence increased it. Finally, perceived impact reduced burnout through voice (β = -0.10, 95 % confidence interval [-0.143, -0.059]) and silence (β = -0.04, 95 % confidence interval [-0.058, -0.014]), and psychological safety also decreased burnout through voice (β = -0.04, 95 % confidence interval [-0.057, -0.016]) and silence (β = -0.07, 95 % confidence interval [-0.101, -0.033]). Additional analyses revealed that prohibitive voice and silence significantly mediated the associations between psychological safety and burnout and perceived impact and burnout, but the mediating role of promotive voice was not statistically significant. CONCLUSIONS:It is important to recognize that voice and silence are distinct concepts. Moreover, to reduce nurse burnout, nurse managers and hospital administrators should develop separate strategies for promoting nurses' perceived impact and psychological safety, as their influences on voice and silence differ. REGISTRATION/BACKGROUND:Not applicable. TWEETABLE ABSTRACT/CONCLUSIONS:Voice and silence both influence nurse burnout. Separate strategies should be applied to voice and silence, as they are different concepts.
PMID: 38160639
ISSN: 1873-491x
CID: 5635082

Patient-related decisional regret: An evolutionary concept analysis

Chehade, Mireille; Mccarthy, Margaret M.; Squires, Allison
Background: Health-related decision-making is a complex process given the variability of treatment options, conflicting treatment plans, time constraints and variable outcomes. This complexity may result in patients experiencing decisional regret following decision-making. Nonetheless, literature on decisional regret in the healthcare context indicates inconsistent characterization and operationalization of this concept. Aim(s): To conceptually define the phenomenon of decisional regret and synthesize the state of science on patients' experiences with decisional regret. Design: A concept analysis. Methods: Rodgers' evolutionary method guided the conceptualization of this review. An interdisciplinary literature search was conducted from 2003 until 2023 using five databases, PubMed, CINAHL, Embase, PsycINFO and Web of Science. The search informed how the concept manifested across health-related literature. We used PRISMA-ScR checklist to guide the reporting of this review. Results: Based on the analysis of 25 included articles, a conceptual definition of decisional regret was proposed. Three defining attributes underscored the negative cognitive-emotional nature of this concept, post-decisional experience relating to the decision-making process, treatment option and/or treatment outcome and an immediate or delayed occurrence. Antecedents preceding decisional regret comprised initial psychological or emotional status, sociodemographic determinants, impaired decision-making process, role regret, conflicting treatment plans and adverse treatment outcomes. Consequences of this concept included positive and negative outcomes influencing quality of life, health expectations, patient-provider relationship and healthcare experience appraisal. A conceptual model was developed to summarize the concept's characteristics. Conclusion: The current knowledge on decisional regret is expected to evolve with further exploration of this concept, particularly for the temporal dimension of regret experience. This review identified research, clinical and policy gaps informing our nursing recommendations for the concept's evolution. No Patient or Public Contribution: This concept analysis examines existing literature and does not require patient-related data collection. The methodological approach does not necessitate collaboration with the public.
SCOPUS:85193571933
ISSN: 0962-1067
CID: 5660832

A multi-language qualitative study of limited English proficiency patient experiences in the United States

Squires, Allison; Gerchow, Lauren; Ma, Chenjuan; Liang, Eva; Trachtenberg, Melissa; Miner, Sarah
Objective: The purpose of this study was to understand the limited English proficiency patient experience with health care services in an urban setting in the United States. Methods: Through a narrative analysis approach, 71 individuals who spoke either Spanish, Russian, Cantonese, Mandarin, or Korean shared their experiences through semi-structured interviews between 2016 and 2018. Analyses used monolingual and multilingual open coding approaches to generate themes. Results: Six themes illustrated patient experiences and identified sources of structural inequities perpetuating language barriers at the point of care. An important thread throughout all interviews was the sense that the language barrier with clinicians posed a threat to their safety when receiving healthcare, citing an acute awareness of additional risk for harm they might experience. Participants also consistently identified factors they felt would improve their sense of security that were specific to clinician interactions. Differences in experiences were specific to culture and heritage. Conclusions: The findings highlight the ongoing challenges spoken language barriers pose across multiple points of care in the United States' health care system. Innovation: The multi-language nature of this study and its methodological insights are innovative as most studies have focused on clinicians or patient experiences in a single language.
SCOPUS:85163774732
ISSN: 2772-6282
CID: 5548152

Making the invisible visible: The importance of applying a lens of Intersectionality for researching Internationally Educated Nurses

Thompson, Roy A; Lewis, Kaleea R; Curtis, Cedonnie A; Olanrewaju, Sherif A; Squires, Allison
PMID: 37984020
ISSN: 1528-3968
CID: 5608262

Language Access for Families With Limited English Proficiency: Why Does It Matter?

Bennett, Sheryl; Squires, Allison P; McCabe, Ellen
This manuscript guides school nurses in addressing the unique needs of U.S. school-aged students and families with limited English proficiency (LEP). Owing to the increasing ethnic and racial diversity in U.S. K-12 schools, school nurses will likely encounter children and families with LEP. Students with LEP may be part of a family which immigrated to this country as permanent residents, are refugees, or asylum seekers. Some may be from migrant families who move throughout the region or country for work. School health services, including nursing services, may be the first and only health resource to which these children have consistent access. The availability and importance of language access services are highlighted, as well as tips for school nurses to advocate for language access resources, training for effective communication, understanding the legal landscape, and addressing cultural beliefs that influence health behaviors. Advocacy toward identifying the distinctive needs of families with LEP aims to help school nurses target equitable health outcomes.
PMID: 37515454
ISSN: 1942-6038
CID: 5617822

Continuity of Care Versus Language Concordance as an Intervention to Reduce Hospital Readmissions From Home Health Care

Squires, Allison; Engel, Patrick; Ma, Chenjuan; Miner, Sarah M; Feldman, Penny H; McDonald, Margaret V; Jones, Simon A
BACKGROUND:Language concordance between health care practitioners and patients have recently been shown to lower the risk of adverse health events. Continuity of care also been shown to have the same impact. OBJECTIVE:The purpose of this paper is to examine the relative effectiveness of both continuity of care and language concordance as alternative or complementary interventions to improve health outcomes of people with limited English proficiency. DESIGN:A multivariable logistic regression model using rehospitalization as the dependent variable was built. The variable of interest was created to compare language concordance and continuity of care. PARTICIPANTS:The final sample included 22,103 patients from the New York City area between 2010 and 2015 who were non-English-speaking and admitted to their home health site following hospital discharge. MEASURES:The odds ratio (OR) average marginal effect (AME) of each included variable was calculated for model analysis. RESULTS:When compared with low continuity of care and high language concordance, high continuity of care and high language concordance significantly decreased readmissions (OR=0.71, 95% CI: 0.62-0.80, P<0.001, AME=-4.95%), along with high continuity of care and low language concordance (OR=0.80, 95% CI: 0.74-0.86, P<0.001, AME=-3.26%). Low continuity of care and high language concordance did not significantly impact readmissions (OR=1.04, 95% CI: 0.86-1.26, P=0.672, AME=0.64%). CONCLUSION:In the US home health system, enhancing continuity of care for those with language barriers may be helpful to address disparities and reduce hospital readmission rates.
PMCID:10421624
PMID: 37561604
ISSN: 1537-1948
CID: 5595402

Improving care for older people: A special issue [Editorial]

Zisberg, Anna; Lickiewicz, Jakub; Squires, Allison
PMID: 36931177
ISSN: 1873-491x
CID: 5495552

How nurses' job characteristics affect their self-assessed work environment in hospitals- Slovenian use of the practice environment scale of the nursing work index

Skela-Savič, Brigita; Sermeus, Walter; Dello, Simon; Squires, Allison; Bahun, Mateja; Lobe, Bojana
BACKGROUND:Nurses' work environment influences nursing practice. Inappropriate working conditions are the result of underdeveloped workplace infrastructure, poor work organisation, inadequate education, and inappropriate staffing norms. The aim of this study was to describe and examine the predictors that affect nurses' work environment using the Practice Environment Scale of the Nursing Work Index (PES-NWI). METHODS:The validation of the PES-NWI was made. Nurse-reported job characteristics were used as independent variables. The sample included 1,010 nurses from adult surgical and medical units at 10 Slovenian hospitals. The Nurse Forecasting (RN4CAST) protocol was used. Permission to conduct the study was obtained from the National Medical Ethics Committee. RESULTS:The PES-NWI mean (2.64) was low, as were job and career satisfaction at 2.96 and 2.89, respectively. The PES-NWI can be explained in 48% with 'Opportunities for advancement', 'Educational opportunities', 'Satisfaction with current job', 'Professional status', 'Study leave', and 'Level of education'. A three-factor solution of PES-NWI yielded eight distinct variables. CONCLUSIONS:The obtained average on the Nursing Work Index was one of the lowest among previously conducted surveys. Nurses should be recognized as equals in the healthcare workforce who need to be empowered to develop the profession and have career development opportunities. Inter-professional relations and equal involvement of nurses in hospital affairs are also very important. TRIAL REGISTRATION/BACKGROUND:This is a non-intervention study - retrospectively registered.
PMCID:10077322
PMID: 37024874
ISSN: 1472-6955
CID: 5496392

Freedom is not free: Examining health equity for racial and ethnic minoritized veterans [Editorial]

Riser, Tiffany J; Thompson, Roy A; Curtis, Cedonnie; Squires, Allison; Mowinski-Jennings, Bonnie; Szanton, Sarah L
PMID: 36929135
ISSN: 1098-240x
CID: 5449022