Background
The Alberta Context Tool (ACT)
Concept | Definition | Sample item |
---|---|---|
Leadership1
| The actions of formal leaders in an organization (unit) to influence change and excellence in practice, items generally reflect emotionally intelligent leadership | The leader calmly handles stressful situations |
Culture1
| The way that "we do things" in our organizations and work units; items generally reflect a supportive work culture | My organization effectively balances best practice and productivity |
Evaluation1
| The process of using data to assess group/team performance and to achieve outcomes in organizations or units (i.e., evaluation) | Our team routinely monitors our performance with respect to the action plans |
Social Capital1
| The stock of active connections among people. These connections are of three types: bonding, bridging, and linking | People in the group share information with others in the group |
Informal Interactions2
| Informal exchanges that occur between individuals working within an organization (unit) that can promote the transfer of knowledge | How often do you interact with people in the following roles or positions?; - Someone who champions research and its use in practice |
Formal Interactions2
| Formal exchanges that occur between individuals working within an organization (unit) through scheduled activities that can promote the transfer of knowledge | How often do these activities occur?; - Team meetings |
Structural/Electronic Resources3
| The structural and electronic elements of an organization (unit) that facilitate the ability to assess and use knowledge | How often do you use/attend the following?; - A library |
Organizational Slack | The cushion of actual or potential resources which allows an organization (unit) to adapt successfully to internal pressures for adjustments or to external pressures for changes | |
Staffing1
| Enough staff to deliver quality care | |
Time1
| Time to do something extra for patients | |
Space1
| Use of designated space |
Patient Care Units as Microsystems
Methods
Design, Sample, and Data Collection
Measures
Study Variables
Dependent variables
Independent variables
Variables | Overall | Surgical | Medical | Critical Care | P-value1
|
---|---|---|---|---|---|
Individual level variables, N
| 844 | 199 | 329 | 316 | |
Employment Status (N, %) | |||||
Full-time | 517 (61.8%) | 120 (60.3%) | 199 (60.5%) | 198 (62.7%) | 0.977 |
Part-time | 295 (35.0%) | 71 (35.7%) | 117 (35.6%) | 107 (33.9%) | |
Casual | 32 (3.8%) | 8 (4.0%) | 13 (4.0%) | 11 (3.5%) | |
Education (N, %) | |||||
Diploma | 305 (36.3%) | 79 (39.9%) | 102 (31.0%) | 124 (39.6%) | 0.029 |
Bachelor | 522 (62.1%) | 118 (59.6%) | 218 (66.3%) | 186 (59.4%) | |
Masters or Higher | 13 (1.5%) | 1 (0.5%) | 9 (2.7%) | 3 (1.0%) | |
Age (N, %) | |||||
20-24 YEARS | 84 (10.0%) | 25 (12.6%) | 40 (12.2%) | 19 (6.0%) | 0.000 |
25-29 YEARS | 239 (28.3%) | 60 (30.2%) | 115 (35.0%) | 64 (20.3%) | |
30-34 YEARS | 143 (16.9%) | 28 (14.1%) | 56 (17.0%) | 59 (18.7%) | |
35-39 YEARS | 89 (10.5%) | 22 (11.1%) | 36 (10.9%) | 31 (9.8%) | |
40-44 YEARS | 82 (9.7%) | 15 (7.5%) | 31 (9.4%) | 36 (11.4%) | |
45-49 YEARS | 83 (9.8%) | 12 (6.0%) | 25 (7.6%) | 46 (14.6%) | |
50-54 YEARS | 75 (8.9%) | 22 (11.1%) | 16 (4.9%) | 37 (11.6%) | |
55-59 YEARS | 42 (5.0%) | 14 (7.0%) | 6 (1.8%) | 22 (7.0%) | |
60-64 YEARS | 6 (0.7%) | 1 (0.5%) | 4 (1.2%) | 1 (0.3%) | |
MBI-Exhaustion (Mean, STD) | 2.287 (1.249) | 2.401 (1.308) | 3.859 (0.853) | 3.839 (0.813) | 0.332 |
Adequate Orientation (Mean, STD) | 3.953 (0.756) | 2.240 (1.208) | 3.961 (0.734) | 3.939 (0.734) | 0.107 |
Job Satisfaction (Mean, STD) | 3.910 (0.774) | 2.287 (1.249) | 3.953 (0.756) | 3.924 (0.789) | 0.327 |
Unit level variables, N
|
32
|
8
|
14
|
10
| |
MBI-Cynicism (Mean, STD) | 2.230 (0.687) | 2.292 (0.718) | 2.095 (0.712) | 2.371 (0.664) | 0.612 |
MBI-Efficacy (Mean, STD) | 3.825 (0.711) | 3.820 (0.693) | 3.845 (0.824) | 3.802 (0.618) | 0.990 |
Years on Unit (Mean, STD) | 7.734 (2.900) | 7.108 (2.734) | 6.425 (2.183) | 10.068 (2.683) | 0.004 |
French/Anglophone (N, %) | |||||
French | 4 (12.5%) | 1 (12.5%) | 2 (14.3%) | 1 (10.0%) | 0.952 |
English | 28 (87.5%) | 7 (87.5%) | 12 (85.7%) | 9 (90.0%) | |
# of occupied unit beds (Mean, STD) | 20.043 (10.069) | 21.675 (4.862) | 20.756 (10.037) | 17.741 (13.279) | 0.684 |
Support for innovative ideas (Mean, STD) | 3.290 (0.288) | 3.290 (0.281) | 3.389 (0.197) | 3.152 (0.363) | 0.138 |
Proportion of baccalaureate or higher (Mean, STD) | 71.666 (14.324) | 68.913 (14.075) | 77.282 (15.345) | 66.007 (11.007) | 0.134 |
Analytic Approach
Reliability and validity of aggregated data at the unit level
Multi-level analysis
Individual-level variables
Unit-level variables
Variable | WMS | F | BMS | ICC(1) | ICC(2) | η2 | ω2
| PROB |
---|---|---|---|---|---|---|---|---|
MBI Cynicism | 1.4412 | 7.6249 | 10.9893 | 0.2013 | 0.8688 | 0.2274 | 0.1974 | 0.0000 |
MBI Efficacy | 0.9902 | 12.0921 | 11.9737 | 0.2968 | 0.9173 | 0.3174 | 0.2909 | 0.0000 |
Support for Innovative ideas | 0.6401 | 3.6563 | 2.3405 | 0.0918 | 0.7265 | 0.1226 | 0.0890 | 0.0000 |
Modeling process
Results
Sample Characteristics
Specialty | Unit | N | Leadership | Culture | Eval. | Formal Interact | Informal Interact | Social Capital | OS-Staff | OS-Space | OS-Time | Resources |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Surgical
| AA | 32 | 3.39 (.85) | 3.72 (.51) | 2.80 (.70) | 1.09 (.78) | 5.07 (1.03) | 3.85 (.36) | 2.84 (1.10) | 2.47 (.88) | 2.80 (.60) | 4.92 (1.67) |
CC | 21 | 3.24 (.56) | 3.68 (.70) | 2.37 (.50) | 1.79 (1.16) | 4.21 (2.02) | 3.59 (.48) | 2.26 (.93) | 2.37 (.87) | 2.42 (.40) | 4.19 (1.85) | |
Z | 26 | 2.92 (.81) | 3.56 (.57) | 2.08 (.79) | 0.84 (.73) | 4.40 (1.39) | 3.62 (.53) | 2.08 (1.06) | 2.59 (1.01) | 2.62 (.44) | 3.12 (1.51) | |
Q | 20 | 3.06 (.91) | 3.83 (.59) | 2.96 (.83) | 2.05 (.90) | 5.50 (.79) | 3.88 (.36) | 2.95 (.90) | 3.03 (.71) | 3.05 (.29) | 5.00 (1.79) | |
D | 15 | 3.39 (.69) | 3.82 (.43) | 2.67 (.99) | 2.07 (.94) | 5.29 (.83) | 4.01 (.42) | 2.40 (.87) | 3.73 (.52) | 2.63 (.54) | 4.53 (1.33) | |
BB | 23 | 3.99 (.62) | 4.19 (.58) | 3.07 (.82) | 1.93 (1.15) | 5.50 (1.60) | 4.03 (.44) | 3.00 (1.17) | 2.49 (1.11) | 3.05 (.72) | 5.27 (1.56) | |
F | 25 | 3.42 (.78) | 3.75 (.53) | 2.49 (.74) | 0.92 (.77) | 5.90 (1.26) | 3.96 (.45) | 2.70 (1.06) | 2.79 (.88) | 2.71 (.53) | 4.00 (2.30) | |
FF | 37 | 3.70 (.76) | 3.84 (.43) | 2.95 (.76) | 1.72 (.99) | 5.46 (1.49) | 3.88 (.38) | 3.23 (.80) | 3.48 (.57) | 3.02 (.52) | 5.77 (1.47) | |
Mean (SD)
|
3.41 (.82)
|
3.79 (.56)
|
2.69 (.81)
|
1.50 (1.03)
|
5.18 (1.45)
|
3.85 (.45)
|
2.73 (1.05)
|
2.86 (.94)
|
2.81 (.56)
|
4.67 (1.87)
| ||
Medical
| V | 24 | 3.53 (.75) | 3.69 (.60) | 2.61 (.58) | 0.98 (.97) | 4.07 (1.47) | 3.93 (.63) | 3.15 (.98) | 2.89 (.85) | 2.76 (.61) | 4.17 (1.92) |
J | 19 | 3.66 (.64) | 3.94 (.73) | 2.76 (.89) | 2.40 (.64) | 5.21 (1.11) | 4.05 (.38) | 2.76 (.73) | 3.37 (.67) | 3.09 (.37) | 5.22 (1.86) | |
I | 24 | 3.97 (.53) | 3.71 (.35) | 2.76 (.71) | 1.30 (1.17) | 3.52 (1.36) | 3.83 (.41) | 2.42 (.65) | 1.87 (.80) | 2.58 (.65) | 3.72 (1.80) | |
Y | 17 | 3.54 (.75) | 3.83 (.54) | 2.98 (.52) | 1.94 (1.03) | 4.32 (1.85) | 4.05 (.49) | 2.38 (.86) | 2.98 (.85) | 2.68 (.54) | 4.44 (2.02) | |
T | 32 | 3.78 (.39) | 3.97 (.37) | 3.29 (.72) | 1.57 (.94) | 5.23 (1.50) | 3.94 (.48) | 3.18 (.73) | 2.85 (.77) | 2.83 (.39) | 4.69 (1.36) | |
M | 26 | 3.64 (.52) | 4.04 (.36) | 2.77 (.82) | 1.77 (.95) | 5.65 (1.42) | 4.03 (.35) | 3.35 (.96) | 3.65 (.61) | 2.97 (.59) | 5.24 (1.95) | |
C | 35 | 3.89 (.62) | 4.03 (.42) | 3.34 (.58) | 2.26 (1.00) | 5.19 (1.39) | 3.81 (.49) | 2.84 (1.00) | 3.29 (.85) | 3.04 (.58) | 5.37 (1.88) | |
H | 28 | 3.79 (.70) | 3.96 (.35) | 3.14 (.76) | 1.91 (.88) | 5.46 (1.15) | 3.78 (.56) | 2.95 (.93) | 3.02 (.75) | 2.80 (.47) | 5.05 (1.66) | |
S | 20 | 3.51 (.57) | 3.83 (.57) | 2.86 (.69) | 1.60 (.88) | 4.98 (1.15) | 3.88 (.28) | 3.48 (.77) | 2.65 (.91) | 3.01 (.40) | 4.37 (1.87) | |
EE | 19 | 3.85 (.99) | 3.97 (.36) | 2.73 (.75) | 2.50 (1.07) | 5.66 (1.53) | 3.90 (.42) | 4.40 (.49) | 3.95 (.50) | 3.59 (.61) | 5.16 (1.62) | |
W | 20 | 4.19 (.44) | 4.20 (.45) | 3.18 (.86) | 2.35 (1.30) | 5.13 (1.69) | 4.12 (.47) | 2.85 (.92) | 3.05 (.91) | 3.05 (.50) | 4.83 (2.01) | |
K | 22 | 3.21 (.81) | 3.83 (.58) | 2.58 (.72) | 1.46 (1.14) | 4.91 (1.45) | 3.89 (.37) | 3.25 (.75) | 3.17 (.69) | 2.85 (.42) | 4.33 (1.86) | |
B | 23 | 3.96 (.50) | 3.96 (.52) | 2.91 (1.01) | 1.91 (.96) | 5.85 (1.67) | 4.13 (.40) | 3.57 (.79) | 3.28 (.73) | 3.04 (.41) | 6.20 (1.51) | |
E | 20 | 4.03 (.79) | 3.54 (.53) | 2.61 (.61) | 1.58 (1.09) | 5.15 (1.66) | 3.67 (.49) | 1.93 (.75) | 2.47 (.76) | 2.66 (.69) | 4.93 (1.82) | |
Mean (SD)
|
3.76 (.68)
|
3.90 (.50)
|
2.93 (.77)
|
1.81 (1.07)
|
5.04 (1.56)
|
3.92 (.47)
|
3.04 (.98)
|
3.04 (.89)
|
2.92 (.56)
|
4.86 (1.85)
| ||
Critical
Care
| L | 31 | 2.81 (.81) | 3.61 (.59) | 2.87 (.79) | 2.02 (.85) | 5.39 (1.18) | 4.00 (.42) | 3.44 (.90) | 2.62 (.69) | 3.23 (.59) | 4.89 (1.88) |
X | 30 | 3.67 (.66) | 3.81 (.52) | 2.45 (.65) | 1.45 (.98) | 4.10 (1.86) | 4.01 (.44) | 2.52 (.78) | 2.79 (.85) | 2.82 (.51) | 3.98 (1.92) | |
P | 35 | 2.87 (.76) | 3.52 (.57) | 3.09 (.69) | 1.84 (.88) | 4.47 (1.63) | 3.74 (.50) | 2.30 (.91) | 1.88 (.67) | 2.71 (.62) | 4.07 (1.68) | |
N | 30 | 3.91 (.60) | 3.97 (.35) | 3.47 (.75) | 2.35 (.90) | 5.82 (1.41) | 4.01 (.44) | 3.07 (.97) | 3.06 (.69) | 3.08 (.43) | 5.90 (1.66) | |
R | 33 | 2.89 (.83) | 3.71 (.52) | 3.25 (.67) | 1.73 (.98) | 5.71 (1.92) | 3.66 (.34) | 3.41 (.99) | 2.90 (.80) | 2.96 (.58) | 4.76 (1.77) | |
U | 30 | 4.08 (.65) | 4.17 (.41) | 2.88 (.71) | 2.18 (.94) | 5.35 (1.45) | 4.19 (.59) | 3.00 (.91) | 2.44 (.76) | 2.97 (.49) | 3.75 (1.96) | |
O | 32 | 3.79 (.78) | 3.91 (.50) | 3.99 (.66) | 2.38 (.79) | 6.14 (1.56) | 4.18 (.51) | 1.89 (.69) | 3.64 (.42) | 2.92 (.49) | 4.55 (1.57) | |
DD | 25 | 3.36 (.75) | 3.57 (.42) | 3.40 (.63) | 2.42 (.75) | 5.42 (1.54) | 3.82 (.49) | 2.40 (.102) | 3.07 (.75) | 3.15 (.61) | 5.30 (1.80) | |
A | 59 | 3.28 (.81) | 3.63 (.49) | 2.92 (.77) | 1.89 (.89) | 5.09 (1.57) | 3.75 (.41) | 2.91 (.95) | 2.70 (.81) | 2.84 (.49) | 4.99 (2.04) | |
G | 11 | 3.86 (.45) | 3.73 (.51) | 2.91 (.94) | 2.36 (1.14) | 5.50 (1.28) | 3.82 (.39) | 2.23 (.85) | 2.70 (.78) | 2.91 (.57) | 3.77 (2.30) | |
Mean (SD)
|
3.40 (.86)
|
3.75 (.52)
|
3.12 (.81)
|
2.02 (.93)
|
5.27 (1.66)
|
3.91 (.49)
|
2.76 (1.02)
|
2.76 (.85)
|
2.95 (.55)
|
4.67 (1.93)
| ||
Overall mean (SD)
|
3.54 (.80)
|
3.82 (.53)
|
2.94 (.81)
|
1.81 (1.03)
|
5.16 (1.58)
|
3.90 (.47)
|
2.86 (1.02)
|
2.89 (.89)
|
2.90 (.56)
|
4.74 (1.89)
| ||
P-value1
| 0.000 | 0.000 | 0.000 | 0.000 | 0.000 | 0.000 | 0.000 | 0.000 | 0.000 | 0.000 | ||
P-value2
| 0.000 | 0.001 | 0.000 | 0.000 | 0.199 | 0.191 | 0.000 | 0.000 | 0.018 | 0.368 |
Dependent Variable | Variance | Null | Model11
| Model22
| Model33
|
---|---|---|---|---|---|
Leadership
| Variance component | 0.1298**4
| 0.1205** | 0.1036** | 0.0797** |
ICC | 0.2032 | 0.2073 | 0.1835 | 0.1473 | |
Explained variance (R
2
) | N/A | 0.0716 | 0.2018 | 0.3863 | |
Culture
| Variance component | 0.0257** | 0.0165** | 0.0154** | 0.0003 |
ICC | 0.0928 | 0.0745 | 0.0697 | 0.0016 | |
Explained variance (R
2
) | N/A | 0.3581 | 0.4021 | 0.9875 | |
Evaluation
| Variance component | 0.1169** | 0.1156** | 0.0964** | 0.0258* |
ICC | 0.1770 | 0.1774 | 0.1524 | 0.0459 | |
Explained variance (R
2
) | N/A | 0.0111 | 0.1754 | 0.7795 | |
Social Capital
| Variance component | 0.0171** | 0.0147** | 0.0158** | 0.0018 |
ICC | 0.0777 | 0.0716 | 0.0766 | 0.0095 | |
Explained variance (R
2
) | N/A | 0.1437 | 0.0789 | 0.8940 | |
OS-Staffing
| Variance component | 0.2555** | 0.2042** | 0.2004** | 0.1698** |
ICC | 0.2395 | 0.2199 | 0.2168 | 0.1900 | |
Explained variance (R
2
) | N/A | 0.2008 | 0.2157 | 0.3354 | |
OS-Space
| Variance component | 0.2136** | 0.2078** | 0.2105** | 0.1104** |
ICC | 0.2634 | 0.2709 | 0.2734 | 0.1648 | |
Explained variance (R
2
) | N/A | 0.0272 | 0.0145 | 0.4831 | |
OS-Time
| Variance component | 0.0371** | 0.0304** | 0.0300** | 0.0169* |
ICC | 0.1168 | 0.1050 | 0.1039 | 0.0615 | |
Explained variance (R
2
) | N/A | 0.1807 | 0.1905 | 0.5430 | |
Formal
Interactions
| Variance component | 0.1730** | 0.1375** | 0.1145** | 0.0963** |
ICC | 0.161 | 0.1386 | 0.1181 | 0.1012 | |
Explained variance (R
2
) | N/A | 0.2052 | 0.3382 | 0.4435 | |
Informal
Interactions
| Variance component | 0.2886** | 0.2180** | 0.2287** | 0.0710 |
ICC | 0.1155 | 0.0938 | 0.0979 | 0.0326 | |
Explained variance (R
2
) | N/A | 0.2446 | 0.2076 | 0.7541 | |
Structural and electronic
resources
| Variance component | 0.3490** | 0.2840** | 0.3059** | 0.1655* |
ICC | 0.0979 | 0.0831 | 0.0890 | 0.0502 | |
Explained variance (R
2
) | N/A | 0.9169 | 0.9110 | 0.9498 |
Dependent Variable | Explained variance (R
2) | |||
---|---|---|---|---|
Null vs. Model 11
| Model 1 vs. Model 22
| Model 1 vs. Model 33
| Model 2 vs. Model 34
| |
Leadership
| 7.16% | 14.02% | 33.89% | 23.11% |
Culture
| 35.81% | 6.85% | 98.05% | 97.90% |
Evaluation
| 1.11% | 16.62% | 77.70% | 73.25% |
Social Capital
| 14.37% | -7.57% | 87.62% | 88.49% |
OS-Staffing
| 20.08% | 1.86% | 16.85% | 15.27% |
OS-Space
| 2.72% | -1.30% | 46.87% | 47.55% |
OS-Time
| 18.07% | 1.19% | 44.22% | 43.55% |
Formal interactions
| 20.52% | 16.73% | 29.98% | 15.91% |
Informal
interactions
| 24.46% | -4.91% | 67.44% | 68.96% |
Structural and
electronic resources
| 91.69% | -7.71% | 41.73% | 45.90% |
Dependent Variable | Level | Model 3 (individual, specialty and unit variables) | Coefficients | SE | P-value |
---|---|---|---|---|---|
Leadership
|
Individual Unit
| Exhaustion | -0.6610 | 0.0217 | 0.0024 |
Job satisfaction | 0.1925 | 0.0362 | < 0.0001 | ||
Support for innovative ideas | 0.6610 | 0.2394 | 0.0114 | ||
Culture
|
Individual Unit
| Education (Diploma)1
| 0.3123 | 0.1313 | 0.0224 |
Education (Bachelor) | 0.2797 | 0.1288 | 0.0360 | ||
Age | -0.0337 | 0.0092 | 0.0003 | ||
Exhaustion | -0.0432 | 0.0144 | 0.0028 | ||
Adequate orientation | 0.0639 | 0.0222 | 0.0042 | ||
Job satisfaction | 0.2169 | 0.0236 | < 0.0001 | ||
Cynicism | 0.1794 | 0.0681 | 0.0151 | ||
Years on unit | 0.0196 | 0.0089 | 0.0392 | ||
Support for innovative ideas | 0.4343 | 0.0675 | < 0.0001 | ||
Evaluation
|
Individual Unit
| Employment status (part time)2
| -0.2879 | 0.1404 | 0.0458 |
Specialty (surgical)3
| -0.6672 | 0.1181 | < 0.0001 | ||
Specialty (medical) | -0.4444 | 0.1223 | 0.0015 | ||
Unit size (no. beds) | 0.0128 | 0.0035 | 0.0014 | ||
Support for innovative ideas | 0.9394 | 0.1644 | < 0.0001 | ||
Proportion of baccalaureate or higher | -0.0095 | 0.0043 | 0.0393 | ||
Social capital
|
Individual Unit
| Adequate orientation | 0.0708 | 0.0214 | 0.0010 |
Job satisfaction | 0.1029 | 0.0229 | < 0.0001 | ||
Unit size (no. of beds) | -0.0044 | 0.0015 | 0.0102 | ||
Support for innovative ideas | 0.3763 | 0.0719 | < 0.0001 | ||
OS - Staffing
|
Individual Unit
| ExhaustionJob satisfactionN/A | -0.15170.2027N/A | 0.02730.0454N/A | < 0.0001 < 0.0001N/A |
OS - Space
|
Individual Unit
| Exhaustion | -0.0819 | 0.0240 | 0.0007 |
Job satisfaction | 0.1126 | 0.0400 | 0.0050 | ||
Years on unit | 0.0737 | 0.0343 | 0.0436 | ||
Support for innovative ideas | 0.7787 | 0.2788 | 0.0106 | ||
OS - Time
|
Individual Unit
| Exhaustion | -0.0809 | 0.0162 | < 0.0001 |
Job satisfaction | 0.1241 | 0.0269 | < 0.0001 | ||
N/A | N/A | N/A | N/A | ||
Formal interactions
|
Individual Unit
| Exhaustion | -0.1074 | 0.0297 | 0.0003 |
Specialty (surgical) | -0.5417 | 0.1975 | 0.0119 | ||
Support for innovative ideas | -0.3962 | 0.2759 | 0.0226 | ||
Informal interactions
|
Individual Unit
| Exhaustion | -0.1290 | 0.0464 | 0.0056 |
Support for innovative ideas | 0.8710 | 0.2970 | 0.0077 | ||
Structural and electronic resources
|
Individual Unit
| Exhaustion | -0.1500 | 0.0568 | 0.0084 |
Support for innovative ideas | 0.9376 | 0.4087 | 0.0317 |
Reliability of Aggregated Unit-Level Variables
Variability in the Dependent Variables
Results of the Multi-Level (HLM) Analysis
Null model
Analysis of individual predictors (Model 1)
Analysis of individual and specialty predictors (Model 2)
Analysis of individual and specialty and other unit predictors (Model 3)
-
burnout-cynicism (with culture)
-
years on the unit (experience) (with culture and organizational slack-space)
-
unit size (with evaluation and social capital)
-
percentage of baccalaureate or higher prepared nurses (with evaluation)