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BACKGROUND: Most health care workers (HCWs) are aware of the rationale for hand hygiene procedures, yet failure to adhere to guidelines is common. Little is known about factors that motivate HCWs to practice hand hygiene. PURPOSE: The purposes of this study were to (1) estimate adherence to hand hygiene recommendations; (2) describe relationships among motivational factors, adherence, and intensity of nursing unit activity; and (3) test an explanatory model for adherence to hand hygiene guidelines based on the theory of planned behavior (TPB). METHOD: A longitudinal, observational design was used to collect data from 120 registered nurses employed in critical care and postcritical care units. Nurses provided information about motivational factors and intentions and a self-report of the proportion of time they followed guidelines. At least 2 weeks later, the nurses' hand hygiene performance was observed while they provided patient care. Structural equation modeling was used to test the TPB-based model. RESULTS: Rate of adherence to recommendations for 1248 hand hygiene indications was 70%. The correlation between self-reported and observed adherence to handwashing recommendations was low (r = 0.21). TPB variables predicted intention to handwash, and intention was related to self-reported hand hygiene. Intensity of activity in the nursing unit, rather than TPB variables, predicted observed adherence to hand hygiene recommendations. CONCLUSIONS: The limited association between self-reported and observed hand hygiene scores remains an enigma to be explained. Actual hand hygiene behavior may be more sensitive to the intensity of work activity in the clinical setting than to internal motivational factors.

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Handwashing is a simple procedure that is critical to prevention and control of infections, yet many health care workers (HCWs) do not practice hand hygiene according to recommended guidelines. The Handwashing Assessment Inventory (HAI) is a self-report instrument that is designed to measure the motivational schema of HCWs for handwashing.

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OBJECTIVE: To compare 2 wound volume measurement techniques, the Kundin device and stereophotogrammetry, on 2 wound shapes. DESIGN: Using 2 wound measurement techniques, the interrater and intrarater reliability and the bias and standard error of measurement of an L-shaped and a pear-shaped plaster of paris wound model were assessed. SETTING: A clinical laboratory of a school of nursing. PARTICIPANTS: Twenty-four raters, all but 2 being registered nurses, measured each of the wounds using both techniques. INTERVENTIONS: Each rater measured each wound twice using each method in a randomly assigned order defined on a card that was drawn from a box. Measurements were recorded on a researcher-designed data collection form, which included some demographic data related to each participant. MAIN OUTCOME MEASURES: The study hypothesis was that there would be no significant difference in accuracy between the 2 wound volume measurement methods. RESULTS: The least biased and most accurate technique was stereophotogrammetry, with the smallest standard of error of measurement. Interrater reliability of average ratings was identical for both methods at 0.98. For single ratings, stereophotogrammetry was slightly higher than the Kundin device. Intrarater reliability was higher on the pear-shaped wound for the Kundin device, which had lower interrater reliability, suggesting that nurses were consistent in the direction and size of personal error. Intrarater reliability for stereophotogrammetry was identical to that of the Kundin device for the L-shaped wound and lower for the pear-shaped wound. CONCLUSIONS: Although both techniques have acceptable accuracy, stereophotogrammetry is more accurate and has more clinical applications.

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Social support interventions that incorporate professionally mediated peer support (PMPS) for improved breastfeeding outcomes were compared with no special breastfeeding support. Fifty-five breastfeeding mothers participated. The breastfeeding outcomes of duration, completeness, satisfaction, and exclusive breastfeeding were compared at 6 weeks postpartum among an experimental group that received PMPS, and among younger community (YC) and older community (OC) groups that received no special breastfeeding support. The PMPS group exclusively breastfed for a significantly longer duration than the YC group. At 6 weeks, mothers in both community groups who had weaned were significantly less satisfied with their breastfeeding experiences than the mothers who were still nursing their babies. Professionally mediated peer support can improve the early breastfeeding outcomes of duration of exclusive breastfeeding and satisfaction with breastfeeding.

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Breast feeding a new baby is a special challenge for college students and university employees. Although success is usually associated with availability of support from the community, little is known about the social context for breast feeding on campus. Personal breast feeding experiences, beliefs about outcomes of breast-feeding and bottle feeding, attitudes toward breast feeding and bottle feeding, and regard for appropriateness of various settings for breast feeding in the campus community were investigated. One hundred seven students, faculty, staff, and administrators at a North Central state university participated in the study. Almost all reported at least one personal breast-feeding experience. Benefits of breast feeding over bottle feeding were acknowledged; however, the university community regarded both feeding methods favorably and saw practical advantages to bottle feeding. Personal spaces, such as infant home or family car, were regarded as more appropriate for breast feeding than public settings. Implications for promotion, support, and protection of breast feeding on campus are discussed.

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The goal of the Nursing Center at the University of North Dakota is to prepare professional nurses to meet priority health needs of the next century through service to people currently in need. Health needs in the state, educational needs related to preparation for primary health care roles, and an explicit nursing paradigm for primary health care framed the development of the Nursing Center. As an integral part of the College of Nursing, the Nursing Center serves as a primary site for undergraduate clinical experiences. Family-centered, community-based programs were designed to simultaneously meet health needs of underserved rural populations and educational needs of undergraduates for preparation in primary health care roles. Implementation proved feasible from both service and educational perspectives. Initial evaluation data demonstrated a high level of effective clinical activity and role development for students beyond that experienced in more traditional settings.

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Covariance structures analysis is often used in nursing research to appraise statistical models reflecting complex human health processes. The model selection approach in covariance structures analysis is designed to select the "best" model from a specified set of theoretically defensible, competing alternatives, all of which are viewed as approximations. Model selection criteria explicitly incorporate both model misfit in the population and sampling error to evaluate the set of models. The result is that interpretability of model parameters and goodness-of-fit are enhanced simultaneously. Relative merits of the model selection approach are identified in light of technical concerns, parsimony, and use of scientific theory in nursing.

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OBJECTIVES: The major objective of this study was to identify predictor variables that accurately differentiated breastfeeding women who weaned during the first 4 weeks, those who weaned between 5 and 26 weeks, and those who weaned after 26 weeks. Predictors were demographic variables, Theory of Planned Behavior (TPB) variables, breastfeeding knowledge, and difficulties experienced during the first month. METHODS: Primiparas who delivered healthy infants in an urban midwestern hospital provided initial data prior to discharge. Follow-up occurred at 1, 3, 6, 9, and 12 months. Following appropriate bivariate analyses, polychotomous logistic regression was used to determine predictors of weaning group. Linear multiple regression was used to predict intended duration. RESULTS: Most of the 84 women who weaned very early had intended to breastfeed considerably longer. According to the multivariate analysis, women who weaned earlier were younger, had completed fewer years of education, had a more positive bottle-feeding attitude and a less positive breastfeeding attitude, intended to breastfeed less time, had lower knowledge scores, had higher perceived insufficient milk scores, and planned to work outside the home. Variables postulated by the TPB to be direct predictors of intention explained 36% of the variance in intended duration. CONCLUSIONS: Women at risk for early weaning can be identified with reasonable accuracy using a TPB-based conceptual framework expanded to include breastfeeding specific variables. Casefinding using empirically derived screening methods and careful postpartum follow-up, along with professional intervention, should be used to avert unintended early weaning.

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Two- and three-dimensional wound measurement techniques are documented in the literature and used clinically, as well as in research. The purpose of this study was to compare 4 two-dimensional wound measurement techniques: linear length and width using a ruler, planimetry, computerized stereophotogrammetry (SPG) length and width, and computerized SPG area. Three plaster of Paris wound models were developed and baseline measurements of outer wound perimeters obtained via a Coordinate Measuring Machine. The convenience sample of raters included 66 upper-division baccalaureate nursing students, graduate nursing students, nursing staff, and wound care nurses. Each rater measured each wound twice in a randomly assigned order of methods written on a card drawn from an envelope. The least biased technique was the computer area, followed in order by the computer length and width, planimetry, and ruler length and width. The most accurate technique, given multiple raters, was determined by the standard error of measurement. The smallest standard error of measurement, thus the most accurate, was the computer area technique, followed in order by the ruler length and width, computer length and width, and planimetry. Interrater reliability of average ratings was high; only the SPG area measurements for single ratings were reliable enough for clinical or research purposes. Intrarater reliability was high for methods with low interrater reliability, suggesting that nurses are consistent in the direction of personal error.

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The Clinical Assessment of Confusion-A (CAC-A) is an observational checklist developed for practicing nurses to measure the presence and level of confusion in hospitalized adults. In a previous study, the following dimensions were found using principal factor analysis: cognition, general behavior, motor activity, orientation, psychotic/neurotic behavior, and two uninterpretable factors. A replication study was conducted to evaluate the validity of a statistically derived model for confusion suggested by the CAC-A. Data from a sample of 566 nurses were analyzed. Three theoretically justified statistical models for the structure of confusion were estimated and compared using a model selection approach to covariance structures analysis: a single-factor unidimensional model, an orthogonal six-factor model, and an oblique six-factor model similar to the structure suggested in the development study. The oblique six-factor model provided the best fit in the predictive sense and was the most satisfactory from a theoretical perspective.

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An important element of quality assessment/quality improvement efforts in health care organizations is the evaluation of patient satisfaction. This element is also important in academic nursing centers, where students provide home visiting services to improve access to care for vulnerable populations in the community. Using a modified version of an existing patient satisfaction instrument, faculty and staff of the University of North Dakota Nursing Center surveyed clients at the end of each semester of service. Results indicated overwhelming satisfaction with all aspects of care provided by the students. Other effects of the program on clients are discussed.

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Insufficient milk is a poorly understood problem that is often identified as a major reason for early discontinuation of breastfeeding. This study explored the relationship between anemia and insufficient milk in 630 first-time mothers. The frequency of anemia (postpartum hemoglobin < 10 g/dL) was 22 percent. Anemic mothers reported a higher level of symptomatology associated with insufficient milk and were more frequently classified as having insufficient milk syndrome. Mothers with the syndrome reported a shorter period of full breastfeeding, and weaned at an earlier age. They identified not having enough milk, baby nursing too often, and baby not gaining enough weight as the main reasons for discontinuing breastfeeding, compared with baby's disinterest and conflicts with school or work as main reasons among mothers not reporting symptoms related to insufficient milk syndrome. The study results suggest that anemia is associated with the development of insufficient milk, which in turn, is related to duration of full breastfeeding and to age at weaning.

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A sampling experiment was designed to evaluate the robustness of some estimators used in the analysis of covariance structures to misspecification of the discrepancy function in finite samples. The estimators were studied under four distribution (a multivariate normal, an elliptical, a non-elliptically symmetric, and an asymmetric multivariate distribution, and eight sample size (75, 150, 300, 600, 1200, 2400, 4800, 9600) conditions. Parameters of the composite direct product model for a 6-variable MTMM matrix were estimated using the Maximum Wishart Likelihood (MWL), generalized least squares (GLS), asymptotically distribution free (ADF), and approximate ADF (DADF) estimators. Browne's elliptical correction (CMWL) to the test statistic and standard errors for scale-invariant models was also made for each sample. Each of the 32 distribution-sample size conditions was replicated 300 times. The accuracy of the parameter estimates and estimated standard errors and the distribution of the test statistic were studied. The theoretically predicted importance of information contained in higher-order moments of arbitrary distributions was confirmed. Robustness of the MWL and normal theory GLS estimators cannot be taken for granted. Elliptical corrections may be a practical solution to some data analytic problems.

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Complex models for covariance matrices are structures that specify many parameters, whereas simple models require only a few. When a set of models of differing complexity is evaluated by means of some goodness of fit indices, structures with many parameters are more likely to be selected when the number of observations is large, regardless of other utility considerations. This is known as the sample size problem in model selection decisions. This article argues that this influence of sample size is not necessarily undesirable. The rationale behind this point of view is described in terms of the relationships among the population covariance matrix and 2 model-based estimates of it. The implications of these relationships for practical use are discussed.

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Leadership style has been defined as a two-factor construct composed of "consideration" and "initiating structure." Research has suggested that these factors affect the behavior and attitude of subordinates. This study's purpose was to quantify the relationships of head nurse leadership style with self-reported staff nurse burnout and job satisfaction in Neonatal Intensive Care Units (NICUs). Three instruments--the Minnesota Satisfaction Questionnaire, the Tedium Scale, and the Leadership Opinion Questionnaire--were voluntarily completed by 283 registered nurses employed by 14 level-III NICUs in the United States. The leadership dimensions of consideration and structure were distinct (r = -.10). Staff nurse satisfaction and burnout were related (r = -.41). Head nurse consideration was clearly related to staff nurse satisfaction (r = -.55) and to a lesser extent to burnout (r = -.29). Initiating structure alone was not related to satisfaction or burnout. Aggregate perceptions of head nurse leadership were ranked across NICUs in order to classify the head nurses on consideration and structure. The 14 head nurses were separated into four groups: high consideration-high structure, high consideration-low structure, low consideration-high structure, and low consideration-low structure. Satisfaction and burnout of staff nurses in each of the leadership-style groups were then compared. Analysis of variance for satisfaction (F(3,279) = 3.10, p = .03) and burnout (F(3,279) = 3.90, p = .01) were both significant. For both satisfaction and burnout, the head nurse leadership classification of low consideration-high structure was most deviant.(ABSTRACT TRUNCATED AT 250 WORDS)

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