Research

DIMENSION

Staff Nurses’ Experiences

of a Change in the Care
Delivery Model
A Qualitative Analysis
Maryanne Garon, DNSc, RN; Linda Urden, DNSc, RN, CAN-BC, FAAN;
Kathleen M. Stacy, MS, RN, CNS, CCRN, PCCN, CCNS

This qualitative study describes the staff nurses’ perspective of change

in the care delivery model and skill mix in an intermediate care unit.
Data were collected in interviews in focus groups with the registered
nurses affected by the change. Two major themes emerged:
(1) autonomy and control and (2) interdependence. The nurses
emphasized an increased satisfaction (self and patient) with this model.
This study confirmed that autonomy, control, connection with the
patient, and peer and interdisciplinary support and respect are
important for the staff nurse. These findings reinforced the value of
involving the staff members in change and the importance of giving
voice to their perspective through qualitative research.
Keywords: Care models, Content analysis, Skill mix
[DIMENS CRIT CARE NURS. 2009;28(1):30/38]

Change in healthcare organizations is rapid, complex,
and, at times, chaotic.1 Often change has been man-
dated because of new regulations, advances in technol-
ogy, and changes in healthcare reimbursement. Over the
past 20 years, these changes in healthcare have led to
new staffing models and skill mixes in acute care
settings. In particular, in the United States during the
1990s, the onset of managed care and emphasis on
holding down healthcare costs resulted in the increased
use of unlicensed personnel in acute care, including
intermediate care units (IMC) and intensive care units
(ICU).2 Personal anecdotes from staff nurses in that era
often told of doubled number of patients, with one
assistive staff member shared with another registered
nurse (RN). The staff nurses, the ones most affected by
such changes, may perceive organizational change as
imposed from above. As a result, they may feel little
involvement in how it is initiated or how it proceeds.
Most studies on organizational change and impact
of skill mix changes have been quantitative. Few studies
have explored the changes from the perspective of the
staff nurses. This qualitative study was initiated because
the investigators believed in the importance of capturing
the experience of the staff nurses working in a unit that
underwent a change in care delivery model. This article
reports the findings from that study. Although the
results cannot be generalized from a qualitative descrip-
tive study, they reinforce findings on the importance of
involving staff in change and on the powerful impact
that nurses can have in supporting one another.

30 Dimensions of Critical Care Nursing Vol. 28 / No. 1

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BACKGROUND
Recent economic pressures in the healthcare delivery
system have impacted nurse staffing. In the United States
in the mid-1990s, the movement to managed care, cost
containment, downsizing, and hospital restructuring
and redesign focused on saving money in nursing
services. This was often manifested by replacing RNs
with unlicensed personnel.3 Unfortunately, the changes
were often made without research as to appropriate RN
staffing levels, impact on the nurses’ morale, or patient
safety. Because staff nurses were seldom involved in
decision-making processes in staffing and work design
changes during this time, management was viewed with
increasing distrust and suspicion.3,4 Nurse dissatisfac-
tion led to increased unionization and even caused the
nurses to enter the political arena when they pushed for
passage of staffing ratios in California.3
With the approach of the year 2000, the impact of
the nursing shortage in the United States became
apparent. Hospital administrators shifted their focus to
retaining current nurses and ensuring their satisfaction.
Once again, a flurry of studies on RN job satisfaction
appeared. They confirmed that job satisfiers for RNs
include the importance of workload, work environment,
and professional recognition, among others.5 There was
also an increased interest in professional practice
environments and the American Nurses Credentialing
Center Magnet Recognition Program. Studies linked
both of these with higher job satisfaction for RNs,
increased quality of care, and greater retention of
nurses. In addition, there was evidence that RN involve-
ment in decision making was linked with increased job
satisfaction.6 Hospital administrators wanted to retain
experienced nurses, so they needed to listen to the nurses
and involve them in the decision-making process.
Hospital administrators shifted their
focus to retaining current nurses and
ensuring their satisfaction.
In addition, a body of literature demonstrating the
impact of RN staffing and nursing work environments
on patient safety was emerging.7-9 There was recogni-
tion of an ongoing need for research about the rela-
tionship of RN staffing to a variety of outcomes, from
quality of care to job satisfaction. The pilot initiated by
the unit in this study was in response to a number of
these factors: concern about RN satisfaction, improving
a high turnover rate, the need to meet California staffing
ratios for an IMC, and an interest in conducting re-
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Staff Nurses’ Experiences of Change
search that would increase knowledge related to nurse
staffing and patient outcomes.
A Pilot of the New Care Delivery Model
The setting for the study was an IMC in a large non-
profit community hospital in the western United States
(California). The IMC is a 32-bed progressive care unit
whose patient population consists of adolescents and
adults (914 years old) with complex medical, surgical,
and trauma conditions, including patients receiving long-
term mechanical ventilation. The original care delivery
model was that of modified team nursing with a skill mix
of RNs and certified nursing assistants (CNAs) working
12-hour shifts. The RN-to-patient ratio was 1:4, and the
CNA-to-patient ratio was 1:8 for both day and night
shifts. In addition, there was a charge nurse, a unit
secretary, and a monitor technician. After much discus-
sion, the staff and unit practice council, along with the
unit manager, advocated for a change to an all-RN staff
with an RN-to-patient ratio of 1:3, using a total patient
model, wherein each patient had an assigned nurse re-
sponsible for all his/her care. This would move the IMC
toward meeting the California state requirement for 1:3
staffing before the mandated requirement deadline.
With input from the staff, the unit practice council
undertook the task of establishing pilot guidelines and
implementing the change. An action plan was then
developed and implemented to facilitate the transition to
the new model and skill mix. The CNAs, who had little
input about the change, were given positions in other
areas of the hospital. Information about the pilot was
communicated throughout the organization in the
month preceding its implementation. The new model
was implemented with minimal difficulty. The role of
the charge nurse, unit secretary, and monitor technician
remained the same. A resource RN to assist with break
coverage and a variety of clinical issues and tasks was
introduced to the staffing pattern.
Year 1: The Quantitative Study
After the decision was made to implement the changes,
the unit manager, clinical nurse specialist, and hospital
researcher decided that it was important to also initiate
2 research studies, a quantitative study and this qual-
itative one, to evaluate the outcomes of the pilot changes.
First, a year-long quantitative study was initiated at the
same time that the care delivery model was being piloted,
with data collection points before implementation, at
6 months, and after 1 year. Briefly, the quantitative
study’s findings showed positive changes in several key
areas related to nurse-sensitive indicators and patient out-
comes, including autonomy, professional relationships,
overtime hours, and medication errors (see Table 1). It is
January/February 2009 31
 Staff Nurses’ Experiences of Change

by 11 RNs. One of the 4 scheduled groups was

TABLE 1 Initial Quantitative StudyVAreas
of Change cancelled, as there were no attendees. Several reasons
were proposed for the relatively low number of attend-
Baseline 12 Mo P ees. First, although the charge nurses worked to arrange
Autonomy a
25.13 27.24 .029a coverage, the unit did have seriously ill patients and
only a few could be freed from patient care. A few did
Professional relationshipsa 36.59 38.88 .048a
stay after their shift ended, but, of course, not all nurses
Overtime hours (for 3-mo period) 750 450 G.01 chose to do so. In addition, there had been a large
Medication errors (6-mo period before 11 3 Vb number of new staff hired when the change was made,
each data collection point) and the newer RNs had not lived through the change
and were not as eager to talk about it.
a
Scores from subscales of the Work Quality Index. The participants were all females with experience
b
Not statistically significant, but downward trend noted.
ranging from less than 1 year to more than 40 years.
Most participants worked on the day shift. Educational
important to note that medication errors decreased from preparation was predominately associate degree level
11 to 3 during the pilot study period. (2-year community college) (9 of 11). All participants
In addition to the quantitative data, the perspectives reported some experience with team nursing and work-
of the RNs needed to be known. By documenting the ing with nursing assistants (Table 2).
expressed views of the staff nurses, it was believed that
this would further support the quantitative data. The Procedure
researchers wanted to know what the experience of this Upon approval by the institutional review board, the
year-long pilot had been like from the perspective of the unit manager/clinical nurse specialist informed the
staff nurses. From this, the qualitative study was launched nurses about the study and the scheduled focus groups.
after the completion of the quantitative study, 1 year into The focus group time and place were posted, and charge
the implementation of the practice model change. nurses arranged for patient care assignments to be
covered. The focus groups were held at times that
QUALITATIVE STUDY would best accommodate nursing work schedules. The
principal investigator, an experienced qualitative re-
Methodology searcher not affiliated with the medical center, con-
This study was a descriptive qualitative design using ducted the focus groups.
content analysis. The purpose of the study was to An interview guide was used for the audiotaped
describe the experience of change in the care delivery interviews (Figure 1). The interview questions came
model and skill mix from the nurses’ perspective.
Interviews were conducted using focus groups recruited
TABLE 2 Demographic Data
from the nurses who had experienced this change on the
IMC. Content analysis was found to be the most Data Collected n
appropriate method because of its focus on description Educational level
of a phenomenon in an area with limited existing
Associate degree in nursing 9
literature.10
Diploma in nursing 1
Participants Bachelor of science in nursing 1
All 60 of the RNs on the unit were invited to participate Usual shift worked
in 1 of 4 focus groups. As is typical of qualitative
7 AM to 7 PM 8
research, the goal was to interview participants who
were able to verbally describe their experiences. Since all 7 PM to 7 AM 2
RNs on the unit had some experience with the change, Just wrote in ‘‘7-7’’ 1
all were invited. Participation was entirely voluntary. Past experiences with other practice models
The focus groups were scheduled at the convenience
‘‘All registered nurses’’ 9
of the staff, 2 at the beginning of the day shift and 2 at
the beginning of the night shift. It was decided to have Team nursing 11
separate focus groups for the RNs who had been on the Primary nursing 9
unit before the change and to have 2 for those who had Modular model with licensed practical nurses 1
been there after the change. Focus groups were attended

32 Dimensions of Critical Care Nursing Vol. 28 / No. 1

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Figure 1. Focus group interview guide. RN indicates registered nurse.
from areas from the initial quantitative study that
seemed to need additional exploration. The research
team members used their background knowledge and
diverse experience to finalize the interview questions. As
is common in qualitative studies, the interviewer used
the questions as a guide, seeking elaboration from the
participants when needed.
The interviewer used the questions as
a guide, seeking elaboration from the
participants when needed.
At each focus group, participants were given study
information and asked to sign the consent form and
complete the demographic questionnaire. Refreshments
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Staff Nurses’ Experiences of Change
were provided at each session. Participants received no
other remuneration. Extra care was taken to ensure
confidentiality because of the small number of partici-
pants and the potential for sensitive answers. During
the audiotaping, members were asked to use initials to
identify themselves and others. They were reminded that
the discussion in the groups was confidential. In
addition, the audiotapes were transcribed by a person
not associated with the medical center. No names were
used on the transcriptions. Finally, the 2 members of the
research team affiliated with the medical center did not
know which staff members attended the focus groups.
Data Analysis
After receiving the printed transcriptions of the focus
groups, the 3 research team members met to review the
analysis method and begin the analysis process. Each
January/February 2009 33
 Staff Nurses’ Experiences of Change
researcher individually read through the transcripts to
get a feel of the whole, circling words and phrases that
seemed to capture key concepts. However, since 2 team
members were not experienced with qualitative re-
search, they found it difficult to know how to proceed
and thought that it would be most productive to jointly
analyze the data. They discussed their first-level con-
cepts and the words and phrases identified in the first
reading. Then an affinity diagram method was used to
sort the concepts into like categories or themes.11 Each
researcher wrote the words identified onto self adhesive
notes. Next, the researchers affixed the self adhesive
notes to the walls of the conference room, grouping the
concepts into like content areas.
A conceptual scheme emerged from the transcripts
as the team members discussed how they saw the
seemingly unrelated concepts linked together as themes.
They quickly reached consensus on the themes. As they
reflected on the themes, the team members further asked
one another: how were these related? What is it that the
nurses were describing? What does it mean? Using this
information, a model was created to represent the
findings as the team had conceptualized them (Figure
2). As the team members reviewed the conceptual
model, they discussed and refined further to ensure that
the model remained faithful to the data. In the next
section, the findings as conceptualized in the scheme are
presented.
KNOWLEDGE GAINED FROM THE STUDY
After reviewing and analyzing the qualitative data, the
researchers found that most of them were organized into
2 major themes: autonomy/control and interdepen-
dence. There were 5 subthemes for each of those, with
a substantial amount of supportive data in each.
Autonomy/Control
The first major theme was the RN’s feeling of increased
autonomy and control. Within this theme, there were 5
subthemes: (1) knowledge of patient; (2) respect from
physicians, patients, and families; (3) patient satisfac-
tion; (4) nurse satisfaction; and (5) one labeled ‘‘running
the show.’’ There was minimal overlap among these
subthemes, and each was well supported by the quali-
tative data.
Nearly every nurse mentioned knowledge of the
patient as one of the major advantages to the change.
The nurses noted that they were able to better assess the
patients, get to know them better, and be more focused
and attuned to their needs. One respondent noted, ‘‘I
know skin care issues, I know what theirI patterns are
34 Dimensions of Critical Care Nursing Vol. 28 / No. 1
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like, how they’re voiding, how they walk, if dizzyI
when you have CNAs, you let those Ftrivial_ things go,
but they’re very important to the overall care of the
patient.’’ Others noted how much more knowledgeable
they felt when talking with the physicians and how
much more attuned they were to the patients’ needs.
Along with increased knowledge of their patients,
the RNs noted more respect from physicians, staff, and
patients. The nurses in the focus groups believed that
they could participate more knowledgeably in rounds
with the physicians, as they were better able to report on
their patients’ status. As a result, most of the nurses felt
as if their relationships with the physicians were more
collegial. They also noted that the unit now seemed
more professional with an atmosphere more ‘‘like a
critical care unit.’’ From the nurses’ perspective, the
patients and families also had more respect for the
nurse’s role and knew who their nurse was. The nurses
reported that there had been an improvement in patient
satisfaction, there were fewer patient complaints, and
the patients seemed to like the change.
Next, the nurses were nearly unanimous in their
satisfaction with the new skill mix and care delivery
model, emphasizing its benefits. The nurses believed that
the new skill mix and the new care delivery model
worked better than that of the previous system, and they
attributed that to a more professional environment.
They liked that they were now doing primary nursing
and really enjoying their role as nurses. Some of their
statements were as follows: ‘‘I can’t even say how much
I love it,’’ ‘‘I wouldn’t go back,’’ and ‘‘I’m very
satisfied.’’ A few commented that this was all they had
ever known, but they also emphasized their satisfaction.
In all, the focus groups described a positive, professional
atmosphere on the unit.
The final subtheme in the area of autonomy and
control was labeled running the show by the research
team. This was a direct quote from one of the nurses,
who stated with pride that she was now running the
show. The nurses described feelings of increased pro-
fessional autonomy, accountability, and a sense of being
the one in charge of everything. They reported being the
‘‘hub’’ of the team. Most expressed a preference for this:
‘‘The way I work is: I’d rather get it done myself,’’ ‘‘I
like to be there for my patients and give 100%,’’ ‘‘I
don’t like to depend on others,’’ ‘‘I’d rather do it myself
and make sure it gets done right.’’ The participants
reported that, when they had worked with CNAs, they
sometimes felt as if they did not have all the informa-
tion. In addition, it sometimes seemed to them that it
took more work to make sure the CNAs were following
through. There was also a downside to the increased
autonomy. Some of the nurses described how they
 Staff Nurses’ Experiences of Change

Figure 2. Conceptual scheme: intermediate care qualitative study.

literally ran the entire shift. Their feelings of increased Interdependence

responsibility and heavy workload are discussed further In contrast to the feelings of autonomy and control that
under the theme of interdependence. Overall, the nurses the nurses reported, there was also a theme identified of
were proud of being the professional in charge of the continued interdependence, when support was needed,
care of their assigned patients. on managers, one another, other professionals, and

January/February 2009 35

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 Staff Nurses’ Experiences of Change
physicians. For the most part, this interdependence was
viewed positively. However, lack of support also fell
into this theme.
The focus group nurses identified multiple supports.
They praised the manager and the unit pharmacist. Day
shift nurses noted that there are many adjunct depart-
ments and always ‘‘tons of people around to support’’
them. Newer nurses pointed to the preceptors and other
staff as being especially helpful to them. Nurses
appreciated their colleagues. The focus group attendees
painted glowing pictures of the guidance and support
that the all-RN staff gave one another. Colleagues were
praised for their knowledge and experience and their
desire to help. Some of the comments were as follows: ‘‘I
yell, Fplease help me_ and they’ll be there.’’ ‘‘There’s an
RN who can help you and who is more skilled than
you.’’ ‘‘The nurses around here are so incredibly smart
and I love that.’’ In addition to the positive relationships
with other nurses, the participants also noted more
rapport and respect from the physicians.
However, the other side of the interdependence was
both the increased need for help and perceived lack of
some forms of support. Patients in this unit have a variety
of diagnoses and healthcare problems. As in other acute
care settings, patients are sicker and they need more care.
One nurse stated, ‘‘It’s a very difficult time for patients
and families.’’ As a result, the work seemed more hectic
and more chaotic for the nurses. When the ‘‘resource
nurse’’ and lift team were available, they felt the work-
load was manageable. However, since the completion of
the year-long pilot, the nurses reported that at times,
these were more a luxury than an expectation. In
addition, there was no lift team in the hospital after
3:30 PM. Often there were as many as 5 patients weighing
more than 400 pounds on the unit, leaving only the
nurses to do all the turning and transferring at night.
Finally, some dissatisfaction seemed to be emerging.
During the pilot study, the skill mix and the new model
were ‘‘protected.’’ However, recently, the participants
reported that RNs were being floated from the IMC and
replaced by CNAs. The nurses lamented this lack of
resources, ‘‘We need a lift team at nights,’’ ‘‘We can’t get
the baths done,’’ and ‘‘Like, we’re not Fsuper nurses._’’
Some recognized that this may be due to the overall
nursing shortage, but others thought that it might be a
lack of understanding of the acuity of the patients on the
IMC. Although this was just a minor part of the findings,
the lack of resources was probably the biggest cause of
dissatisfaction expressed by the IMC focus group nurses.
Other Findings
Some of the focus group’s comments did not fit into the
2 major themes. A few felt that their status was
36 Dimensions of Critical Care Nursing Vol. 28 / No. 1
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somehow diminished because they now had to do
CNA work. For example, one nurse told how a patient
commented, ‘‘you do great work down in the kitchen,’’
as she delivered the food tray. Another nurse com-
plained, ‘‘I feel like I have so many tasks. You know, we
get here and clock inI we’re on a treadmill: vital signs,
get going. I’m doing so many tasks that I’m not doing
the critical things like I used toI that’s how I feel.’’ One
participant noted that when CNAs were on the unit,
they (the CNAs) would be monitoring the patients and
answering call lights, freeing the RNs to make rounds
with the doctors. There were also concerns about
interactions with the CNAs themselves, ‘‘I thought it
[the change to primary nursing] was smooth, but
somehow it created a lot of animosity from CNAs in
the whole hospital, because they all talk together.’’
However, despite these reports, when the focus groups
were asked directly, ‘‘do you want to go back?’’ The
RNs responded with an emphatic ‘‘No!’’
DISCUSSION
This study added to quantitative data on one unit’s
change in the care delivery model by including the views
and experiences of the actual staff nurses who lived it.
The findings are consistent with others in the literature
about factors that influence nurses’ job satisfaction.4,5
Multiple studies have reported autonomy, control over
work, and involvement in decision making as key
satisfiers for nurses.12-15 Conversely, when nurses are
unhappy with staffing levels and patient-to-nurse ratios,
there is an increase in turnover and decrease in satisfac-
tion.6,16,17 This group of nurses was vocal in expressing
satisfaction and feelings of reward about their experi-
ences with the current care delivery model and skill mix.
This group of nurses was vocal in
expressing satisfaction and feelings of
reward about their experiences with
the current care delivery model and
skill mix.
Relationships with managers and relationships with
physicians have also been related to nursing job sat-
isfaction.4,5 In this study, collegial (RN-RN) interactions
were highly positive and an additional satisfier for RNs.
This may give increased support to the importance of
mentor programs and new graduate programs.
The nurses’ involvement in this unit change may
have played a strong role in how positively it was

perceived by the nurses in these focus groups. The
management clearly valued their opinion and participa-
tion and was, in turn, respected by the staff. Most focus
group members were highly enthusiastic and positive
about their unit and the change.
An emerging area of concern is the nurses’ percep-
tion of ‘‘deficits of support’’ at times. Although
autonomy and control over practice were cited by the
nurses in this study as highly rewarding, these were
balanced by the interdependence they reported with
other team members, including supportive management.
An appropriate RN-to-patient ratio is only one part of
the picture. If the RN does not have adequate assistive
support, both patient care and job satisfaction may
suffer. The care delivery model and staffing mix may
continue to be an important issue, as some of the study
participants pointed to the continued need for assistive
personnel. The study findings and these concerns are
being reviewed by the unit-based practice council for
recommendations and actions.
Finally, the study confirmed that it is hard to quantify
many aspects of nursing care. The nurses’ expressions of
workload and their experiences give additional informa-
tion that was not captured by any tool or measurement.
It reinforces the importance of qualitative studies of
nurses’ views and the value of triangulating qualitative
findings with quantitative studies to give additional
perspectives and rich descriptive data.
STUDY LIMITATIONS
This was a small qualitative study using content analysis
conducted in one unit in a hospital. It was initiated to add
richness to quantitative data. As in any qualitative study,
the findings are not generalizable. However, the value of
qualitative research is in its ability to richly describe an
experience from the perspective of the participants. Next,
the use of focus groups, although a more time-efficient
method, may have inherent problems, as some members
may feel hesitant to speak up if they disagree with their
peers. Group members may also influence one another in
reporting their experiences. Additional research is needed
into how change is experienced in the view of the staff
nurse. Future studies on organizational change, such as
the one described, could be undertaken with larger
groups of nurses and in multiple systems. It might be
advantageous to use individual interviews and to focus
on a variety of organizational changes. The experiences
and findings from this study could be used to help guide
additional research questions and interviews.
CONCLUSION
The voice of the staff nurse can be easily lost when
organizational changes are made. Yet the value of
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Staff Nurses’ Experiences of Change
involving staff in change, from the perspective of
both nurse retention and satisfaction, and the pos-
itive impact on multiple aspects of care are clear. In
addition, research on organizational change needs to
also focus on those most affected by change (RNs,
CNAs, physicians, administrators, and other health-
care providers). Qualitative studies that give voice to
their concerns continue to have value in augmenting
other data. Staff nurses too often perceive those in
management and academia as being so far removed
from the bedside, as having lost understanding or
perspective of the struggles of providing direct pa-
tient care. These nurses remind us that although
there are many rewards, nursing is hard work, at
times, it is hard physical work. By listening to their
concerns and supporting the work of those at the
front lines, nursing leaders can better support and
seek changes that will impact the nurses’ satisfaction
and patient outcomes.
References
1. Porter O’Grady T, Malloch K. Quantum Leadership: A
Resource for Health Care Innovation. 2nd ed. Sudbury, MA:
Jones and Bartlett; 2007.
2. Brannon RL. Restructuring hospital nursing: reversing the
trend toward a professional work force. Int J Health Serv.
1996;26(4):643-654.
3. Huber D. Leadership and Nursing Care Management. 3rd ed.
Philadelphia, PA: Saunders; 2006.
4. Page A, ed. Keeping Patients Safe: Transforming the Work
Environment of Nurses: An Institute of Medicine Report.
Washington, DC: National Academies Press; 2004. http://
www.nap.edu/books/0309090679/html/index.html. Accessed
September 10, 2007.
5. Garon M, Ringl K. Job satisfaction for hospital based
registered nurses. Online J Clin Innov. 2004;7:1-45.
6. Upenieks V. Assessing differences in job satisfaction of nurses
in magnet and nonmagnet hospitals. J Nurs Adm. 2002;32:
564-576.
7. Aiken L, Clarke S, Sloane D, Sochalski J, Silber J. Hospital
nurse staffing and patient mortality, nurse burnout, and job
dissatisfaction. JAMA. 2002;288:1987-1993.
8. Jackson M, Chiarello L, Gaynes R, Gerberding J. Nurse
staffing and healthcare associated infections: proceedings from
a working group meeting. J Nurs Adm. 2002;32:314-322.
9. Laschinger H, Leiter M. The impact of nursing work environ-
ments on patient safety outcomes: the mediating role of
burnout/engagement. J Nurs Adm. 2006;36:259-267.
10. Hsieh H, Shannon S. Three approaches to qualitative content
analysis. Qual Health Res. 2005;2005:1277-1288.
11. Plain C. Build an affinity for K-J method. Qual Prog. 2007;
40(3):88.
12. Tonges M, Rothstein H, Carter H. Sources of satisfaction in
hospital nursing practice: a guide to effective job design. J Nurs
Adm. 1998;28:47-61.
13. Anderson E. Empowerment, Job Satisfaction, and Professional
Governance of Nurses in Hospitals With and Without Shared
Governance: A Descriptive Correlational and Comparative
Study [dissertation]. Louisiana State University Medical Center
in New Orleans, School of Nursing; 2000.
14. Manojlovich M, Laschinger H. The relationship of empower-
ment and selected personality characteristics to nursing job
satisfaction. J Nurs Adm. 2002;32:586-595.
January/February 2009 37
 Staff Nurses’ Experiences of Change

15. Larrabee J, Janney M, Ostrow C, Withrow M, Hobbs G,
Burant C. Predicting registered nurse job satisfaction and
intent to leave. J Nurs Adm. 2003;33:271-283.
16. Shaver K, Lacey L. Job and career satisfaction among staff
nurses. J Nurs Adm. 2003;33:166-172.
17. Strachota E, Normandin P, O’Brien N, Clary M, Krukow B.
Reasons registered nurses leave or change employment status.
J Nurs Adm. 2003;33:111-117.
ABOUT THE AUTHORS
Maryanne Garon, DNSc, RN, is the coordinator of the Graduate
Programs and an associate professor at the Department of Nursing,
California State University, Fullerton in Fullerton.
Linda Urden, DNSc, RN, CAN-BC, FAAN, works as the executive
director of Nursing Quality, Education, and Research, Palomar
Pomerado Health, Escondido, California, and is clinical professor and
coordinator of the Executive Nurse Leader Graduate Program at the
University of San Diego in California.
Kathleen M. Stacy, MS, RN, CNS, CCRN, PCCN, CCNS, is currently
the Clinical Nurse Specialist in the Intermediate Care Unit, Palomar
Medical Center in Escondido, California.
Address correspondence and reprint request to: Maryanne Garon,
DNSc, RN, California State University, Fullerton, P O Box 6868,
Fullerton, California 92834 (mgaron@fullerton.edu).

Coming in the
March/April 2009 Issue
& Recognizing and Preventing Refeeding Syndrome
& A Brief Report: Evaluating the Effects of Ketamine on Memory
in Posttraumatic Stress Disorder
& Student Abstract: Protocol Versus Nursing Practice: Sedation
Vacation in a Surgical Intensive Care Unit
& Compassionate Use in Research
& Pediatric Research Abstracts
& News Bits: Information for Critical Care Nurses
& Medical Futility: A Paradigm as Old as Hippocrates

38 Dimensions of Critical Care Nursing Vol. 28 / No. 1

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