ATTITUDES, BEHAVIOUR, AND PROBLEMS ENCOUNTERED BY NURSING

EMPLOYED AT SAN JOSE OCCIDENTAL MINDORO

Presented to the Faculty of Senior High School

OCCIDENTAL MINDORO STATE COLLEGE
Labangan Campus

In Partial Fulfilments of the Requirements for the Subject

CAPSTONE

MADRIGAL, ANGELO P.
March 2019
 DEDICATION

I sincerely dedicate this thesis to my parents Rowena P. Madrigal and Jun V. Madrigal

whose words of inspiration and momentum for persistence rings in my ears.

I also dedicate this thesis to my friends, siblings, relatives and to all the people who

became part of this study, from the title up to its publication. I will always appreciate all the

things that they have done.

A.P.M
 TABLE OF CONTENTS

Page
CHAPTER
I BACKGROUND OF THE STUDY
Introduction 1
Statement of the Problem 3
Objectives 4
Hypotheses 5
Significance of the Study 5
Scope and Delimitations 6
Definition of terms 7
II REVIEW OF RELATED LITERATURE 8
III RESEARCH METHADOLOGY
Locale of the Study 29
Research Design 30
Respondents of the Study 30
Statistical Tool 30
Research Instrument 30
Data Gathering Procedure 31
REFERENCES 32
 CHAPTER I
BACKGROUND OF THE STUDY

Introduction

Nursing is the one that holds a patient’s health care journey. Across the patient

experience, and wherever there is someone in need of care, nurses work tirelessly to identify and

protect the needs of the individual.

Beyond the time-honoured reputation for compassion and dedication lies a highly

specialized profession, which is constantly evolving to address the needs of society. From

ensuring the most accurate diagnoses to the ongoing education of the public about critical health

issues; nurses are indispensable in safeguarding public health.

Nursing can be described as both an art and a science; a heart and a mind. At its heart,

lies a fundamental respect for human dignity and an intuition for a patient’s needs. This is

supported by the mind, in the form of rigorous core learning. Due to the vast range of specialism

and complex skills in the nursing profession, each nurse will have specific strengths, passions,

and expertise.

However, in assessing a patient, nurses do not just consider test results. Through the

critical thinking exemplified in the nursing process, nurses also use their judgment to integrate

objective data with subjective experience of a patient’s biological, physical and behavioural

needs. This ensures that every patient will receive the best possible care regardless of whom they

are, or where they may be.

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 Nurses have various roles within their work description. The roles of a nurse include to

manage and to treat the patients, to work with families and communities involving health and

health promotion. Furthermore, nurses are expected to contribute to the improvement of the

public health and to promote health of individuals in the society (WHO, 2018). Nurses are also

expected to take on a significant amount of responsibility within their roles. The nurses have four

primary responsibilities containing promoting health and preventing illnesses, restoring health

and to ease suffering (International Council of Nursing, 2012). Nurses are also expected to

support, promote and encourage patients to make lifestyle changes (Swedish Society of Nursing,

2016; Barna, Goodman & Mortimer, 2015).

The fundamentals in nursing are respecting human and cultural rights, the right to life and

self-determination, to honour the patient and to treat the individual with respect (Swedish Society

of Nursing, 2016). Nurses are expected demonstrate professional values such as respectfulness,

responsiveness, compassion, trustworthiness and integrity in his or her work. Nurses also have an

obligation to keep themselves updated regarding evidence-based care and to collect new

knowledge for continuing competence. Nurses are expected to sustain a collaborative and

respectful relationship with co-workers and in other fields. Nurses are expected take appropriate

action to protect the individuals, the families and communities when their health is endangered

by a co-worker or any other individual. Furthermore, nurses are expected to support and guide

co-workers to advance ethical conduct (Swedish Society of Nursing, 2016).

Philippines is the leading country that educates nurses by having 258 nursing schools in

the country (Ranking Web of Universities 2018). The massive emigration of skilled nurses has

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affected the quality and safety of the healthcare in the country (Sjögren, Fochsen, Josephson &

Lagerström, 2005).

Statement of the Problem

This study entitled “Attitudes, Behaviour, and Problems encountered by nursing

employed at San Jose Occidental Mindoro” will seek to answer this following questions:

1. What is the socio-demographic profile of nurses in San Jose in terms of:

a.) Age

b.) Sex

c.) Religion

d.) No. of years in the hospital

e.) Trainings and seminars attended

2. What are the different problems encountered by employed nurses at San Jose Occidental

Mindoro.

3. What are the attitudes and behaviour of nurses when facing problems in:

a. Administration

b. Services

c. Facilities

d. Equipment

3
 e. Patient behaviour

4. Is there any significant relationship between the nursing techniques in dealing with the

problems they encountered?

Objectives

This study will be conducted to determine the nursing techniques in dealing with their

problems in San Jose Occidental Mindoro. Specifically, this study will aim to answer these

following objectives:

1. To describe socio-demographic profile of nurses in San Jose in terms of:

a.) Age

b.) Sex

c.) Religion

d.) No. of years in the hospital

e.) Trainings and seminars attended

2. To determine the problems encountered by employed nurses at San Jose Occidental Mindoro.

3. To determine the behaviour of nurses when facing problems in:

a. Administration

b. Services

c. Facilities

4
 d. Equipment

e. Patient behaviour

4. To determine the significant relationship between the nursing techniques in dealing with the

problems they encountered.

Hypotheses

There is no significant relationship between the nursing techniques in dealing with the

problems they encountered.

Significance of the Study

The significance of the study will depend on its contribution to clarify the nursing

techniques on dealing with the problems they encountered.

Nurses. In this study, nurses will know to deal with the problems they encounter. It will

also help them to understand that nursing techniques will have an effect on dealing with their

problems,

Doctors. Awareness on how nurses’ deal with the problems they encountered is an

essential component of this study. By knowing the significance of this study, the doctors will

know strength and weaknesses of nurses on dealing with the problem and help each individual

on how to deal with the problem they might encounter. In addition, the doctors can create

different techniques and strategies that can help the nurses in terms of dealing with the problem.

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 Community. When the nurses and doctors finally knew the techniques on dealing with

the problem they encounter, the future of the community will be brighter. The hospitals can

produce a productive staffs that can help its patients on a better quality of health care.

Nursing Researchers. This study could provide baseline data for further studies. This

could provide enough information regarding the nursing techniques of the nurses on dealing with

the problem they encountered which could be helpful and useful to support future studies and

other research endeavours.

Scope and Delimitations

This study will revolve around on how nurses deal with the problems they encountered

and its effect on their caring performance. The respondents of the study is only limited to the

employed nurses in San Jose Occidental Mindoro. Since the researchers will be constrained with

specified time table and due to safety purposes, the study will be conducted within the hospitals

in San Jose Occidental Mindoro.

Conceptual Framework
Nursing Practices
Socio-Demographic Profile:
Techniques
a.) Age
Employed
Problems
b.) Sex
Encountered
c.) Religion
Factors Affecting

d.) No. of years in the

Behaviour and
hospital
Attitudes

e.) Trainings and seminars

6
attended
 Figure1. Research Paradigm of the study

Figure 1 shows the research paradigm of the study. It shows the relationship of the different

variables used in the study. Those variables Input box are the independent variable and those

variables in the Process box are the dependent variables. The study will seek if the Socio-

demographic profile and the problems they encountered will have its factors regarding on the

nursing technique and how it can affect the Quality Care of Nurses.

Definition of terms

For a meaningful interpretation of this study, the following terms will be used and define

operationally.

Age. The length of time that a person has lived or a thing has existed.

Religion. The belief in God or in a group of Gods; an organized system of beliefs, ceremonies,

and rules used to worship a God or groups of Gods.

Sex. The anatomy of an individual’s reproductive system, and secondary sex characteristics.

Socio-demographic profile. A description of a particular type of costumer, including their sex,

age, income etc.

Nurses. A person trained to care for the sick or infirm, especially in a hospital.

Techniques. It is the way of carrying out a particular task, especially the execution or

performance of an artistic work or a scientific procedure.

Behaviour. It is a way of how an individual acts or conducts oneself, especially toward others.

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 CHAPTER II

REVIER OF RELATED LITERATURE

This chapter presents the literature review and related studies that will provide background of the

study on attitudes, behaviour, and problems encountered by nursing employed at San Jose

Occidental Mindoro.

Nursing Theories in Clinical Practice

Nursing theory has been employed in a clinical setting; its primary contribution has been

the facilitation of reflecting, questioning, and thinking about what nurses do. For example, a

recent publication described application of Leininger's trans cultural nursing theory for

developing culturally congruent strategies useful to professionals working with suspected child

maltreatment cases (Campbell,2005). Because nurses and nursing practice are often subordinate

to powerful institutional forces and traditions, the introduction of any framework that encourages

nurses to reflect on, question, and think about what they do provides an invaluable service.

Evidence-based practice involves the recognition of which knowledge is appropriate for

application to client care. Practice theories, those that describe the relationships among variables

as applied to specific clinical situations (e.g., theory of postpartum depression), are important

contributors to effective evidence-based practice. An increasing body of theoretical scholarship

in nursing practice has been outside the framework of the formal theories presented. Philosophy

is used to explore both clinical and theoretical issues in the journal Nursing Philosophy.

Family theorists and critical theorists have encouraged the profession to move the focus

from individuals to families and social structures. Debates about the role of theory in nursing

practice provide evidence that nursing is maturing, both as an academic discipline and as a

clinical profession.

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The ‘M’ (manual) Technique as Part of Nursing Care

Nursing practice developed from the care of people’s bodies using touch (Atkinson et al., 2010).

Instrumental or procedural touch is taught in nursing school as part of assessment and

procedures, but expressive or comfort touch is rarely taught as part of nursing care. Not every

patient wants to be touched, but a great many really appreciate the comfort of touch

(O’Lynn&Krautscheid, 2011). Research shows that touch can also emphasize the patient’s belief

in treatment (Guengen&Vion, 2009).

Today, many nurses struggle with an overload of paperwork and computer work. Compassion

fatigue is a phenomenon commonly experienced by nurses (Romano et al., 2013). The ‘M’

Technique helps nurses to show compassion in an acceptable way. It is also a simple way that

takes not much time, but makes the nurse feel better, as well as the patient.

The practice of touch is a tool that Dr. Jean Watson, a nursing theorist, placed within a

caring–healing model (Watson, 2006; Watson, 2008; Watson, 2009). The very act of touching

can show caring (Gale &Hegerty, 2000) and the very act of touching can empower the caregiver

(Buckle, 2013). As it is accepted as part of holistic nursing, why not use the ‘M’ Technique

(Jackson &Latini, 2013)?

Patient Satisfaction

Generally, patient satisfaction has been defined as the patient’s subjective perception of

care, which is usually an indicator of the “degree of congruency between a patient's expectations

of ideal care and his or her perception of the real care he or she receives” (Ganova-Ioloska, et al.,

9
2008). Most research has tried to correlate these with socio-demographic variables, such as age,

sex, the level of education, employment, income, or marital status.

Patients are consumers, and what they purchase in a medical institution are both products and

services that are rendered primarily to keep them healthy and free of harm.

Determinants of patient satisfaction

In the increasingly competitive market of healthcare industries, healthcare managers should

focus on achieving high or excellent ratings of patient satisfaction to improve the quality of

service delivery; therefore, healthcare managers need to characterize the factors influencing

patient satisfaction which are used as a means to assess the quality of healthcare delivery. In

order to understand various factors affecting patient satisfaction, researchers have explored

various dimensions of the perceived service quality, as meaningful and essential measures of

patient perception of healthcare quality. The measuring satisfaction should "incorporate

dimensions of technical, interpersonal, social, and moral aspects of care" (Kaneet& Marley et al.,

2000) .Research of patient satisfaction in advanced as well as developing countries has many

common and some unique variables and attributes that influence overall patient satisfaction.

Most of the studies in the literature review examined the correlation between

demographic factors such as age, gender, health status and level of education with patient

satisfaction; however, the findings from these studies are conflicting. Two studies, one

conducted in Scotland whereby 650 patients discharged from four acute care general hospitals

during February and March 2002, and the second study was conducted in 32 different large

tertiary hospitals in the USA; both showed that male patients, patients older than 50 years of age,

10
patients who had a shorter length of stay or better health status and those with primary level

education had higher scores related to variable health service-related domains.

On the other hand, a national survey performed in different accredited hospitals of

Taiwan found that patient characteristics such as age, gender and education level only slightly

influenced patient satisfaction but that the health status of patients is an important predictor of a

patient’s overall satisfaction. The two strongest and most consistent determinants of higher

satisfaction are old age and better health status. While two studies reported contrary results

regarding the influential effect of the two controlled variables (age and gender) on overall patient

satisfaction in different aspects of healthcare services. In contrast, a 2006 national survey of 63

hospitals in the five health regions in Norway showed that age, gender, perceived health and

education level were not significant predictors of overall patient satisfaction. (Nguyen and

Jenkinson et al., 2002)

These factors are not modifiable and are impractical for healthcare managers that are

eager to improve patient satisfaction. The patient characteristics should be considered for fair

adjustment of patient satisfaction studies in order to be utilized in benchmarking with other

healthcare institutions. On the other hand, the researchers extensively discussed the

multidimensional attributes of healthcare settings that were shown to be the most potent

determinants for improving the overall patient satisfaction. Healthcare managers need to direct

more efforts towards those highly ranked attributes and initiate some improvement strategies in

other areas of health services that are unsatisfactory from the patient's perspective.

A remarkable outcome of four studies conducted in tertiary hospitals in different

countries revealed that the nurses' courtesy, respect, careful listening and easy access of care was

particularly the strongest driver of overall patient satisfaction. These aspects of nursing care are

11
highly ranked by patients compared to other independent factors such as physician care,

admission process, physical environment and cleanliness. In addition, a study carried out in 430

hospitals in the USA found the nurse work environment and patient-nurse staffing ratio had

statistically significant effects on patient satisfaction and recommendations.

In (2011) Otani et al., surveyed the 32 different large tertiary hospitals in the USA to

identify the relationship of nursing care, physician care and physical environment to the overall

patient satisfaction and the results showed that all attributes were statistically significant and

positively related to overall satisfaction; however, nursing care was the most critical to increase

overall patient satisfaction. The researchers also found that the courtesy and respect of healthcare

providers impact more on patient satisfaction while communication and explanation are the

second most important aspect. In contrast, a survey conducted at 13 acute care hospitals in

Ireland revealed that effective communication and clear explanation had the strongest impact in

improving the overall patient satisfaction among other attributes of care.These findings provide

evidence of the importance of the nursing role as the most significant determinant of overall

patient satisfaction. Ireland revealed that effective communication and clear explanation had the

strongest impact in improving the overall patient satisfaction among other attributes of care.

These findings provide evidence of the importance of the nursing role as the most significant

determinant of overall patient satisfaction.

While three other studies found that interpersonal communication skills of physicians in

terms of their attitude, explanation of conditions, level of care, emotional support, respect for

patient preferences and involving patients in decision making were more influential factors than

clinical competence and hospital tangibles on patient satisfaction. However, a survey conducted

in a tertiary care academic hospital in the USA showed that only 33% of physicians were rated as

12
excellent for their communication behaviour which suggests that there is room for improvement

in physician communication behaviour in the hospital to improve quality of care. In addition, the

main outcome of a study using the data of 202 participants from general acute care hospitals in

the USA, concluded that most determinants of patient satisfaction was related to communication,

empathy and caring from hospital personnel.

There are some contrary comments which were disclosed regarding the aspects of

hospital environment and amenities which scored lowest for a patient satisfaction index in a

study carried out in out-patients departments in South Korea. Correspondingly, a study

conducted in a public hospital in France found the most common problems experienced by

patients were related to hospital living arrangements and amenities. A similar result was reported

in a study conducted at five hospitals served under the BJC Healthcare System. It reported that

the major dissatisfaction in an out-patients department was the long waiting time and

overcrowded registration. In contrast, a study carried out in five different hospitals in Scotland

found that physical comfort had the highest satisfaction rate compared to other core dimensions:

information, coordination of care and emotional support. (Arshad et al. 2012)

Nurse communication

Nurse communication refers to patient’s perception regarding nurse communication with

three dimensions of advocacy, therapeutic communication and validation factors that are part of

nurse’s service in outpatient department. The patient can consider the ability and experience of

the nurse, suggestion of how to take care of oneself, clarification of diagnosis and care during

their visit.

13
 Communication is fundamental and vital to all healthcare functions. Communication is a

means of transmitting information and making oneself understand by another or others.

Communication is the creation or exchange of thoughts, ideas, emotions, and understanding

between nurses and patients. It is essential to building and maintaining relationships in the

workplace. Although nurses spend most of their time communicating (e.g., sending or receiving

information), one cannot assume that meaningful communication occurs in all exchanges (Guo&

Sanchez, 2005).

In addition, communication is a strongly dependent on the culture, the social status, and

reciprocal relationships of the patients. The exchange of information with the aim of

understanding is the central characteristic of communication (Usher &Monkley, 2001; Vivian &

Wilcox, 2000).

Furthermore, interpersonal or therapeutic relationships are continuous processes of

communication; consequently communication can be seen as a prerequisite for relations

(Rundell, 1991; Tuckett, 2007). Verbal and nonverbal expressions make up communication, 24

with verbal expressions in the form of language being viewed as basic. In interactional situations

all kinds of behavior are communicative and convey messages between nurse and patients

(Fleischer, Berg, Zimmermann, Wuste, & Behrens, 2009; Daubenmire, Searles, & Ashton,

1978). All behavior can convey messages and all patients’ behaviour has a communicative

meaning and message.

The concepts of nurse communication

Nurses are the frontline caregivers to the patient in the hospital of every country. Nurse

can play an important role to communicate with patients who seeking medical care services.

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Nurse communication is crucial role in all of medical fields during their patient caring in health

care center. Professional nursing practice requires the ability to appropriately and effectively

communicate with patients. The quality of interpersonal communication is related to health

outcomes, including quality of life and patient satisfaction (Klakovich& Cruz, 2006;

Coeling&Cukr, 2000). Patient-centered communication is respectful and responsive to a health

care user’s needs beliefs, values and preferences. Patient-centered communication is important to

ethical, high-quality health care. It is often easy to see the link between effective communication

and high-quality health care.

Patient satisfaction increases when communication is clear, understandable and respectful

(Thanh, 2011). On the other hand, gaps or lapses in communication between health care

professionals and patients, or among health care professionals can lead to medical errors and

unexpected outcomes (American Medical Association [AMA], 2006).

The nurse-patient relationship is primarily mediated by verbal and non verbal

communication. Like communication relationships are unique situations and are mutually

constructed whereby the professional nurse-patient relationship is responsive and inter subjective

(Aranda& Street, 2000). It is this interpersonal relationship that makes the difference between

nursing and caring (Tuckett, 2005). The essential aspect of nursing relationships is dependent on

the skills of the nurse like non-judgmental listening and the ability to convey warmth and

understanding (Gastmans, 2001). The importance of communication and interaction for nursing

has been an often stated point by nurses and nursing scientists since Florence Nightingale in the

19th century and continuing until today. 25 The main intention of communication and interaction

in the health setting is to influence the patient’s health status or state of well-being (Fleischer et

al., 2009).

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 In addition, effective communication is a fundamental element of nursing care that is

integral to the provision of quality patient care (Wilkinson &Tappen, 1999 as cited by

Mackintosh et al., 2001). Social interaction mediated through effective communication is a

critical factor affecting quality of life. For those residing in long-term care (LTC) and complex

continuing care (CCC) facilities, opportunities for socialization occur primarily during

interaction or communication with staff. The effectiveness of a communication is enhancement

intervention, based on a theoretical framework, in enhancing nurse-patient interactions so that

they optimized nurse relationships with patients, and patients’ satisfaction (McGilton, Irwin-

There are seven dimensions of relational communication: comprised of calm,

comfortable, caring, interested, sincere, accepting, and respectful (Finch, 2006). Although not all

seven communication dimensions were viable within the contexts of patient’s perspectives of

communication with nurses, patients did report more satisfaction with nurse patient interactions

when nurses were composed, immediate, receptive, and shared values (Fleischer et al., 2009).

Between nurse-patient communication in the health care setting, may often some barriers in these

situation. Longest, Rakich, &Darr (2000) classify the barriers into two categories including

environmental and personal. Environmental barriers are including competition for attention and

time between nurse and patients. Multiple and simultaneous demands cause messages to be

incorrectly decoded. The patient hears the message, but does not understand it. Due to

inadequate attention paid to the message, the patient is not really “listening.” Listening is a

process that integrates physical, emotional, and intellectual inputs into the quest for meaning and

understanding.

On the other hand, personal barriers arise due to an individual’s frame of reference or

beliefs and values. One may also consciously or unconsciously engage in selective perception or

16
be influenced by fear or jealously. Personal barrier is lack of empathy, in other words,

insensitivity to the emotional states of nurses and patients (Guo& Sanchez, 2005).

National organizations have identified health care communication as an essential element

of public health and a core component of the health care system. For example, Healthy People

2010 has included health communication not only as one of its focus areas, but indicated that it

also affects each of its 10 leading health indicators (Public Health Foundation [PHF], 1999). The

Joint Commission on Accreditation of Health Care 26 Organizations, the National Committee for

Quality Assurance [NCQA] (2004) and others have developed standards that require health care

organizations to recognize individuals’ right to and their need for effective communication.

Lastly, the National Quality Forum [NQF] (2004) is list communication as both a practice for

improving patient safety as well as a national priority for health care quality measurement and

reporting.

There was agreement on the importance of communication is one of the most important

determinants of patient satisfaction. Anderson, Barbara, & Feldman (2007) stated that patient

satisfaction rating was highly influenced by a core communication and follow up care in

outpatient department. The core qualities appear to be the most important, namely

communication, access, interpersonal skills, care coordination follow up care. The quality of

medical care processes, quality of healthcare facilities and quality of other staff followed in order

to importance.

In reaching conclusion, communication is documented as a valuable indicator of quality

of health care service from patient’s perspective. Nurse communication is constitutes patient and

part of the quality health care service and predominantly influence patient satisfaction with

health care service. Nurse communication is patient’s perception regarding with three

17
dimensions of advocacy means clearly conveying diagnostic and other relevant information in a

way that supports patient wish and decisions; therapeutic use of communication by the nurse

means demonstrating interpersonal behaviors that assist patients in achieving healthy emotional

and behavioral outcomes, empathetic, and respectful of the patient; and validation factors means

listening carefully and verifying that intended from nurse’s service in outpatient department. The

patient can think from ability and experience of the nurse, suggestion of how to take care of

oneself, clarification of diagnosis and care. In addition, these three dimensions a profile of

nurse’s strength and weakness can be identified, increasing the specificity of health care services

that build on strengths while improving weakness in this issue.

The Impact of Evidence-Based Practice in Nursing

The EBP Movement

EBP is aimed at hardwiring current knowledge into common care decisions to improve

care processes and patient outcomes.

"Evidence-based medicine is the integration of best research evidence with clinical expertise and

patient values."(Sackett D et al., 2000)

In 2004, ASHA's Executive Board convened a coordinating committee on evidence-

based practice. This committee, charged with assessing the issue of evidence-based practice

18
relative to planning needs and development opportunities for ASHA, used a variation of this

definition:

The goal of EBP is the integration of: (a) clinical expertise/expert opinion, (b) external

scientific evidence, and (c) client/patient/caregiver values to provide high-quality services

reflecting the interests, values, needs, and choices of the individuals we serve. Conceptually, the

trilateral principles forming the bases for EBP can be represented through a simple figure:

Because EBP is client/patient/family centered, a clinician's task is to interpret best current

evidence from systematic research in relation to an individual client/patient, including that

individual's preferences, environment, culture, and values regarding health and well-being.

Ultimately, the goal of EBP is providing optimal clinical service to that client/patient on an

individual basis. Because EBP is a continuing process, it is a dynamic integration of ever-

evolving clinical expertise and external evidence in day-to-day practice.

Following the alarming report that major deficits in healthcare caused significant

preventable harm (IOM, 2000) a blueprint for healthcare redesign was advanced in the

first Quality Chasm report (IOM, 2001). A key recommendation from the nation’s experts was to

employ evidence-based practice. The chasm between what we know to be effective healthcare

and what was practiced was to be crossed by using evidence to inform best practices.

Evidence-based practice holds great promise for moving care to a high level of likelihood

for producing the intended health outcome. The definition of healthcare quality (Box 1) is

foundational to evidence-based practice.

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Box 1. Definition of Quality Healthcare

Definition of Quality Healthcare

Degree to which health services for individuals and populations increase the

likelihood of desired health outcomes and are consistent with current professional

knowledge (IOM 1990; 2013,).

The phrases in this definition bring into focus three aspects of quality: services

(interventions), targeted health outcomes, and consistency with current knowledge (research

evidence). It expresses an underlying belief that research produces the most reliable knowledge

about the likelihood that a given strategy will change a patient's current health status into desired

outcomes. Alignment of services with current professional knowledge (evidence) is a key goal in

quality. The definition also calls into play the aim of reducing illogical variation in care by

standardizing all care to scientific best evidence.

The EBP movement began with the characterization of the problem—the unacceptable

gap between what we know and what we do in the care of patients (IOM, 2001). In the

report, Crossing the Quality Chasm (IOM, 2001), IOM experts issued the statement that still

drives today’s quality improvement initiatives: “Between the health care we have and the care

we could have lies not just a gap but a chasm” (IOM, 2001, p. 1) and urged all health professions

to join efforts for healthcare transformation.

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 Development of evidence-based practice is fuelled by the increasing public and professional

demand for accountability in safety and quality improvement in health care.

A major part of the proposed solution to cross this chasm was “evidence-based practice.”

Experts continue to generate direction-setting IOM Chasm reports (IOM, 2003; IOM,

2008a; IOM, 2008b; IOM, 2011a); each report consistently identifies evidence-based practice

(EBP) as crucial in closing the quality chasm. The intended effect of EBP is to standardize

healthcare practices to science and best evidence and to reduce illogical variation in care, which

is known to produce unpredictable health outcomes. Development of evidence-based practice is

fueled by the increasing public and professional demand for accountability in safety and quality

improvement in health care.

Leaders in the field have defined EBP as “Integration of best research evidence with

clinical expertise and patient values” (Sackett et al, 2000, p. ii). Therefore, EBP unifies research

evidence with clinical expertise and encourages individualization of care through inclusion of

patient preferences. While this early definition of EBP has been paraphrased and sometimes

distorted, the original version remains most useful and is easily applied in nursing, successfully

aligning nursing with the broader field of EBP. The elements in the definition emphasize

knowledge produced through rigorous and systematic inquiry; the experience of the clinician;

and the values of the patient, providing an enduring and encompassing definition of EBP.

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 The entry of EBP onto the healthcare improvement scene constituted a major paradigm shift.

The EBP process has been highly applied, going beyond any applied research efforts

previously made in healthcare and nursing. This characteristic of EBP brought with it other shifts

in the research-to-practice effort, including new evidence forms (systematic reviews), new roles

(knowledge brokers and transformers), new teams (interprofessional, frontline, mid- and upper-

management), new practice cultures (just culture, healthcare learning organizations), and new

fields of science to build the “evidence on evidence-based practice” (Shojania&Grimshaw,

2005). The entry of EBP onto the healthcare improvement scene constituted a major paradigm

shift. This shift was apparent in the way nurses began to think about research results, the way

nurses framed the context for improvement, and the way nurses employed change to transform

healthcare.

Impact on Nursing Practice

In this wide-ranging effort, another significant player was added…the policymaker. For

EBP to be successfully adopted and sustained, nurses and other healthcare professionals

recognized that it must be adopted by individual care providers, micro system and system

leaders, as well as policy makers. Federal, state, local, and other regulatory and recognition

actions are necessary for EBP adoption. For example, through the Magnet Recognition

Program® the profession of nursing has been a leader in catalyzing adoption of EBP and using it

as a marker of excellence.

22
 A recent survey of the state of EBP in nurses indicated that, while nurses had positive

attitudes toward EBP and wished to gain more knowledge and skills, they still faced

significant barriers in employing it in practice.

In spite of many significant advances, nurses still have more to do to achieve EBP across

the board. (Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012). The evidence-based

program, Team Strategies and Tools to Enhance Performance and Patient Safety (Teams

EPPS®) (AHRQ, 2008) carries with it proven effectiveness of reducing patient safety issues and

the program is available with highly-developed training and learning materials.

Nursing encountered problems

Burnout and job dissatisfaction are perennial problems resulting in costly employee

turnover (Larrabee et al., 2003) and poor patient outcomes (McHugh, Kutney-Lee, Cimiotti,

Sloane, & Aiken, 2011; Vahey, Aiken, Sloane, Clarke, & Vargas, 2004). Nurses working in

hospitals with excessive patient workloads and poor work environments are more likely to be

burned out and dissatisfied with their job (Aiken, Clarke, Sloane, Lake, & Cheney, 2008; Aiken,

Clarke, Sloane, Sochalski, & Silber, 2002; Maslach, Schaufeli, &Leiter, 2001). These

conditions—the level of nurse staffng and the quality of nurses’ work environment—can be

changed through good management and organizational practices that value professional nursing.

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 A satisfactory wage is a significant factor in job-seeking behavior and is especially

important in keeping workers in their current positions. Increasing wage to solve institutional

workforce recruitment and retention problems is an easy-to-implement intervention in the short

run (May, Bazzoli, &Gerland, 2006). Wage, however, is not the only factor; many nonwage job

characteristics are important considerations for workers in selecting and staying at a workplace

(Antonazzo, Scott, Skatun, & Elliott, 2003; Blau, 1991; Chiha& Link, 2003; García& Molina,

1999; Kovner, Brewer, Wu, Cheng, & Suzuki, 2006; Shields, 2004; Woodbury, 1983). Work

takes place within a larger context of hierarchies, relationships, management environments,

ethical climates, operating rules, resources, and space distribution (Maslach et al., 2001). Work

environments that are more favourable to workers are associated with lower burnout, job

dissatisfaction, and intent to leave across a number of sectors, including health care and nursing

(Aiken et al., 2008; Kovner et al., 2006; Kovner, Brewer, Greene, & Fairchild, 2009; Maslach&

Jackson, 1982; Shields, 2004; Shields & Ward, 2001; Ulrich et al., 2007). To nurses, the

organizational climate may be as or even more important than wages as a reason for staying in

their job (Hayes et al., 2006; Stone et al., 2007).

Wage increases may need to be combined with non-pecuniary factors, especially

modifiable hospital factors such as work environment and workload, to recruit adequate numbers

of nurses and prevent them from leaving the hospital setting to work in other jobs (Buerhaus,

1991; Ehrenberg & Smith, 2008; McHugh et al., 2011; Spetz& Given, 2003).

Gone are the days when nurses slept in the hospital wards to be close to their patients.

However, it wasn’t until after World War II that nursing adopted the standard 8-hour day.

Hospitals began using the 12-hour shift in the 1970s during a national nursing shortage as a way

to retain nurses. Today, 75% of hospital nurses work12-hour shifts (Townsend, 2013).Nursing

24
shifts of 12 hours or longer are more common in teaching and high-technology hospitals

(Stimpfel,Sloane, & Aiken, 2012).

Nurses can work less hours anddays, and potentially have an improved work/life balance.

For hospitals,the longer shifts mean less overtime and use of agency nurses, and greater ease in

developing schedules, with only two shifts to cover each day and two daily handoffs.

Stone and colleagues (2006) found that nurses who worked 12-hourshifts were generally

more satisfied with their jobs, reported less emotional exhaustion, and were about 10times more

satisfied with their work schedules, compared with those working 8-hour shifts. Units that

offered 12-hour shifts had lower vacancy rates, and vacant positions were filled more quickly.

Patients tend to like having fewer names and faces to remember. Dr.Joan Rich, vice

president of theSchool of Nursing at Rasmussen College, says she feels more connected to her

patients when she can seethem and their families over a longer day (as cited in Knoll, 2013). Dr.

Rich cites better continuity of care; communication is better when patient information and

assessments are being passed between two people instead of three in a day (as cited in Knoll,

2013).

Despite these positives outcomes, a recent comprehensive scoping review of evidence of

the impact and effectiveness of 12-hour shifts found inconclusive evidence in areas of risksto

patients, patient experience, and risks to staff, staff experience, and impact on the hospital

(Harris, Sims, Parr, &Davies, 2015). Some studies demonstrated positive impacts, and others

negative or no impacts.

One area of concern is how 12-hour shifts can affect nurses and what that might mean,

not only for the nurse, but also for the hospital. A study of over 22,000 nurses in the United

25
States reported that more than 80% of nurses was satisfied with scheduling practices at their

hospital (Stimpfel et al., 2012). However, percentages of nurses reporting burnout and an

intention to leave the job increased incrementally as shift length increased, up to two and a half

times higher for nurses who worked longer shifts than for nurses who worked shifts of 8 to 9

hours.

Drury, Francis, and Chapman (2009) suggest that many older nurses are leaving acute

care settings due to required 12-hour shifts. Older nurses have identified difficulties associated

with shift work: excessive tiredness, aches and pains, sleep deprivation, and physical and

emotional exhaustion, with night shift nurses reportina more difficult time in transitioning

between night shifts and days off (Gabrielle, Jackson, & Mannix, 2009).In fact, a study by

Poisson net and Vernon (2000) confirmed that fatigue in nurses (especially on night

shifts)increased with age.

With older nurses significantly adoring shorter shifts (Hoffman &Scott, 2003), some have

referred to mandatory 12-hour shifts as “a way of getting rid of older nurses” (SharonNess,vice

president for United Food& Commercial Workers Local 141, as cited in Pritchett, 2011, para

2).Nurses feeling forced out could lead to age discrimination lawsuits. But equally important, the

exodus of seasoned nurses with invaluable skills that improve the quality of care may pose a

threat to patient safety (Hill, 2010). In its action report on 12-hourshifts and fatigue, the Georgia

Nurses Association (2011) points out that the added expense of recruiting and training new

employees and the risk of errors may outweigh the initial cost benefits of 12-hour shifts.

Fatigue and insufficient/poor-quality sleep for nurses are troublesome factors in 12-hour

shifts for nurses of all ages (Geiger-Brown et al., 2012). In December 2011, in response to

ongoing concerns about the risks for fatigue in relation to patient care, The Joint Commission

26
issued a Sentinel Event Alert. Such an event indicates the risk for, or an actual unexpected

occurrence of, death or serious injury in the health care setting. The alert urges health care

organizations to increase their efforts to reduce the risks for medical errors related to fatigue

among workers enduring extended shifts, including assessing policies for shift work, developing

strategies to prevent fatigue, bolstering teamwork and collaboration in providing support for

those on longer shifts, and ensuring a safe, smooth transition at hand off at the end of a shift (The

Joint Commission, 2011).The Joint Commission offered nine evidence-based actions, which

could eventually become part of accrediting standards.

Looking at the impact of the 12-hour shift on patient care and patient satisfaction, Ball,

Dall’Ora, and Griffiths (2015) reported that both longer shifts and working overtime were

significantly associated with lower quality of care, worse patient safety reports, and more care

left undone. These findings are aligned with Stimpfel and colleagues’ (2012) study results

comparing nurses’ shift length and patient satisfaction as measured by the Hospital Consumer

Assessment of HealthCare Providers and Systems (HCAHPS) survey. HCAHPS provides a

standardized survey instrument and data collection methodology for measuring patients’

perspectives on hospital care. Patients rate items covering nine key topics: 1) communication

with doctors, 2) communication with nurses, 3) responsiveness of hospital staff, 4)pain

management, 5) communication about medicines, 6) discharge information, 7) cleanliness of the

hospital environment, 8) quietness of the hospital environment, and 9) transition of

care(HCAHPS, 2015). Stimpfel et al. (2012)found that 7 of the 10 outcomes were significantly

and adversely affected by the proportion of nurses in the hospital working shifts of more than 13

hours, including both of the global assessment of care – patients’ rating of the hospital overall –

and whether patients would recommend the hospital. In other words, increases in the proportion

27
of nurses working shifts of more than 13 hours were associated with increases in patient

dissatisfaction. Further, having higher proportions of nurses working shorter shifts – 8 to 9hours

or 10 to 11 hours – resulted in decreases in patient dissatisfaction.

These HCAHPS findings are important to hospitals for at least two reasons. Most nurses

would agree that 12-hourshifts are not going away, and perhaps with appropriate regulations in

place, they don’t need to. Organizations such as the Institute of Medicine and the American

Nurses Association have made or supported recommendation to minimize fatigue and improve

patient safety. Some states, such as California, have passed legislation that protects workers’

breaks and rest periods (Stimpfel& Aiken, 2013). The Joint Commission’s recommended

strategies might serve as the basis for standards, and it might capture hospitals’ attention.

On the other hand, there are other avenues to explore. For example, research indicates

that how nurses spend their time between shifts maybe more important than the actual shift. For

example, many nurses like the 12-hour shift because it allows them more flexibility with their

family life, and for some, the opportunity to hold a second job. Both of these circumstances can

be exhausting and result in not getting enough sleep (Knoll, 2013). Other research shows that

certain nurses appear more vulnerable to sleep loss than others (Geiger-Brown et al., 2012).

The implications of fatigue on job performance are well documented. Ball et al. (2015)

suggest that future research needs to start from a different viewpoint: “not ‘Are 12-hourshifts

good or bad?’ but ‘In what conditions can a 12-hour shift system be operated without risk to

patient safety or nurse well-being’”

28
 Chapter III

Methodology

Locale of the Study

This study will be conducted in selected Barangays in San Jose such as: Murtha,

Barangay 1, Pag-asa, Barangay 3, Barangay 7. The locations mentioned are the major barangays

were the major hospital in San Jose were located.

San Jose is one of the rural areas in Occidental Mindoro headed by Mayor Romulo

Muloy Festin. The study will be conducted at the hospitals of San Jose Occidental Mindoro. The

study will be focusing on the nurses of different hospitals of San Jose which has a total of 40

respondents.

The researcher chose the area because the researchers are currently living in the said town

and it will be convenient to both the researchers and the respondents to conduct the study in the

hospital where they are working. Furthermore, any significant findings may be observed in

choosing the locale.

29
Research Design

This study will be using the qualitative method that will aim to determine the Attitudes,

Behaviour, and Problems Encountered by Nursing Employed at San Jose Occidental Mindoro.

Qualitative research deals with the techniques in collecting, organizing, describing and

analyzing data. The researcher will use this method in attempt to examine and interpret the

meaning of the perspective of the respondents in this research.

Respondents of the Study

The researcher will conduct a survey among forty (40) nurses within the different

hospitals in San Jose Occidental Mindoro.

The researcher chose the area because the researchers are currently living in the said

town. Furthermore, it will be very convenient to both the researchers and the respondents to

conduct the study in the hospital where they are working.

Statistical Tools

The data gathered will be organized analysed statistically using the mean, frequency

percentage distribution, and Chi-square test for determining the degree of relationship between

variables

Research Instrument

The researcher will be using the quota sampling technique for the nurses because all of

the nurses in different hospitals in San Jose Occidental Mindoro will be the respondents of this

30
study. Furthermore, the researchers chose the respondents because they are suitable and capable

for the study.

Data Gathering Procedure

Gathering of data will be done as soon as the questionnaires are already checked by the

panellist. Protocol in the conduct of the study will be followed such as seeking permit from the

Barangay Captains of the selected barangay. Upon arrival, the researcher will conduct data

gathering using the validated instrument. Adequate copies of questionnaire will be produced, and

will be distributed to the target respondents.

31
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