Barriers and carriers: a multicenter survey of nurses’ barriers and facilitators to monitoring of nurse‐sensitive outcomes in intensive care units

Abstract Aim To identify nurses’ barriers and facilitators to monitoring of nurse‐sensitive outcomes in intensive care units (ICUs), and to explore influential nurse characteristics and work environment factors. Design A cross‐sectional survey in three Dutch ICUs between October 2013 ‐ June 2014. Methods A questionnaire with questions regarding facilitators and three types of barriers: knowledge, attitude and behaviour. The Dutch Essentials of Magnetism II was used to examine work environments. Results All 126 responding nurses identified pressure ulcers and patient satisfaction as outcomes that are nurse‐sensitive and nurses’ full responsibility. Lack of time (behaviour) was perceived as the most prominent barrier, followed by unfamiliarity with mandatory indicators (knowledge), and unreliability of indicators as benchmark data (attitude). Education and clear policies were relevant facilitators. Of nurse characteristics, only regularity of shifts was related to perceived attitude related barriers. The work environment factor “clinical autonomy” was potentially associated with behaviour related barriers.

improvements of health care outcomes (Ellis, 2008). Nowadays, nursesensitive outcomes are used as measures to quantify care that is provided and influenced by nurses (Maas, Johnson & Moorehead, 1996).
Nurse-sensitive outcomes (NSOs) are defined as "those outcomes that are relevant, based on nurses' scope and domain of practice, and for which there is empirical evidence linking nursing inputs and interventions to the outcome" (Doran, 2011). Frequently mentioned examples of NSOs are pressure ulcers, patient falls and health care-associated infections (Montalvo, 2007;Needleman, Kurtzman & Kizer, 2007).
In the Netherlands, hospitals are required to report several types of NSOs to the Dutch Health Care Inspectorate, including delirium, malnutrition, pain and pressure ulcers (Inspectie voor de Gezondheidszorg 2012).

| Background
NSOs are referred to as quality indicators and can be used for both external as well as internal purposes; in addition to their use as quality measurement tools for benchmarking hospitals, NSOs are used internally identifying areas in need of and practices for improving nursing professional care (Montalvo, 2007). It is important that nurses themselves recognize the relevance of NSOs and show their commitment to the collection of NSO data, for example by optimizing their screening activities in order to routinely gather data on NSOs. While screening activities should be an integral part of nursing practice, several studies published in the last 20 years indicate that NSO related screening processes are often suboptimal. In their study including all hospitals in the Netherlands, Leistra et al. (2014) reported an average screening percentage of 72% with regard to the screening of malnutrition, one of the mandatory nurse-sensitive indicators. Ely et al. (2004) surveyed nearly one thousand ICU professionals and found that only 40% of nurses were routinely screening for delirium, with a mere 16% of them utilizing a formal assessment tool.
It has been previously suggested that nurses experience various barriers to the collection and completion of NSO data. Lack of time, inadequacy of measurement tools, and workload were demonstrated to be important barriers. These factors have been linked to specific NSOs, such as pressure ulcers (Strand & Lindgren, 2010), malnutrition (Leistra et al., 2014), delirium (El Hussein, Hirst & Salyers, 2014), and pain (Wang & Tsai, 2010). However, there is limited evidence of barriers to the overall use and monitoring of NSOs. The framework of Cabana et al. (1999) proposes that a wide spectrum of barriers, including barriers related to knowledge, attitude and behaviour should be assessed in order to realize the widespread behaviorial change in health care.
This study was designed to assess barriers in nurses' knowledge, attitude and behaviour to a range of NSOs, in order to give a general overview of the perceived barriers to the monitoring of NSOs. This study focused on nurses in the intensive care unit (ICU) setting as complications and adverse outcomes of care, such as NSOs are prominently present in this type of high-risk unit (Singer et al., 2009). Besides barriers, nurse characteristics (e.g., age, educational level) and factors in nurses' work environment (e.g., nurse-physician relationship, staffing) are also potentially relevant in relation to nurses' abilities to provide a high quality of care with regard to NSOs (Kane, Shamliyan, Mueller, Duval & Wilt, 2007;Stalpers, De Brouwer, Kaljouw & Schuurmans, 2015). The research questions addressed are: • What are the barriers and facilitators to monitoring of NSOs as perceived by nurses working in ICU?
• How do nurse characteristics and factors in the work environment of ICU nurses relate to perceived barriers to NSO monitoring?

| Design
A cross-sectional multicenter survey study in intensive care units (ICUs) was performed. Data were collected by means of a questionnaire, aimed at answering the research questions as described above (McLeod, 2014). The questionnaire included predefined statements on three types of barriers: knowledge, attitude and behaviour and facilitators to the monitoring of nurse-sensitive outcomes (NSOs), and close-ended questions regarding nurses' work environment.

| Data collection
The study was conducted in the ICUs of three teaching hospitals lo- including scholars working more than 6 months in the ICU. Nurses with temporary contracts and staff nurses not participating in direct patient care (e.g., team leaders) were excluded. All 283 staff nurses received a paper-based questionnaire which was anonymous and voluntarily. The questionnaires could be returned in a sealed box which was placed in each of the three ICUs. The study contact person in each of the three units (ICU nurses with an additional research education) motivated nurses to fill in the questionnaire. The primary researcher was present in the ICUs during the data collection period and sent several email reminders to the nurses.

| Questionnaire
The first part of the questionnaire referred to the demographic features of nurses; including age, gender, years of nursing experience, years of experience as an ICU nurse, highest level of education (Associate Degree in Nursing versus Bachelor Degree in Nursing or higher), full-time versus part-time employment status (32 or more hr/ week versus less than 32 hr/week) and regularity of shift schedules (exclusively working day shifts, evening shifts or night shifts versus rotating shifts).
The second part addressed nurses' opinion on barriers and facilitators to monitoring of NSOs. For this purpose, the statements from a previous study on quality indicators in Dutch ICUs were used . These statements on barriers were based on the validated framework of Cabana et al. (1999) regarding behaviour change in health care, and included the following domains: (i) knowledge (awareness or familiarity); (ii) attitude (motivation); and (iii) behaviour (external factors, time and organizational issues).
The facilitators were based on a literature review by Davies, Powell and Rushmer (2007) regarding health care professionals' views on enablers for quality improvements. For the current study, an independent expert group (n = 3), consisting of a team leader with a background in ICU nursing, a person with a PhD with a background in ICU nursing, and a staff nurse with a scientific background, evaluated the face validity and content validity of these statements, as well as their relevance for nurses. Based on this expert feedback and on relevant literature (Cummings et al., 2010;McFadden, Stock & Gowen, 2015;Weston, 2010), the barrier statement "monitoring of quality indicators can be done without huge investments" was replaced with "nurse-sensitive indicators offer opportunities to increase nursing autonomy" and the facilitator "pay-for-performance" was replaced with "support manager", resulting in a questionnaire including 11 statements on barriers and 13 facilitators to the monitoring of NSOs. These items were scored on a 5 point Likert-scale, ranging from "strongly disagree" (*1) -"strongly agree" (*5). In addition, we added a self-developed item to the questionnaire to assess which NSOs are considered by ICU nurses to be nurse-sensitive. Results on the 4 point Likert-scale, ranging from "strongly disagree" (*1) to "strongly agree" (*4) were used to extract proportions on the impor- While one subscale showed a low Cronbach's alpha, the authors claimed that the correlations between the items of this subscale were high, and therefore they did not alter the subscale (De Brouwer et al., 2014). The D-EoM II contains 58 statements and the EoM II was designed to assess the eight domains which are essential for a magnetic and healthy work environment: (i) working with clinically competent peers; (ii) support for education; (iii) collaborative nurse-physician relationships; (iv) practice of clinical autonomy; (v) control of nursing practice; (vi) leadership and nurse manager support; (vii) patient-centered cultural values; and (viii) adequacy of staffing (Kramer & Schmalenberg, 2004). These statements were scored on a 4 point Likert-scale, ranging from "strongly disagree" (*1) -"strongly agree" (*4).

| Data analysis
First, descriptive statistics were used to characterize the study sample of responding ICU nurses. Second, nurses' perception of barriers and facilitators were analysed using proportions on the 24 items. To calculate an overall mean score (MS) of the barrier domains of knowledge, attitude and behaviour, we used negative, neutral and positive formulated statements, including reverse-order questions. A score less than 3 was considered as a negative overall result, indicating a need for improvement. Responses that were missing a value for one or more statements in a barrier domain resulted in the data for that domain being excluded from the data analysis. In addition, to explain differences in scores among subgroups, we used analysis of variance (ANOVA) with the overall mean scores on the domains as response variables and nurse characteristics as explanatory variables. Then, nurse characteristics were accounted for by involving all variables simultaneously in a multiple linear regression analysis. Dummy variables were created for the three units (Unit A, B and C). Multi-collinearity was tested by means of the variance inflation factor (VIF) and tolerance value. Variables with a VIF >10 or a tolerance of <0.10 were suspected for multi-collinearity and were excluded from further analysis (Stevens, 1992). Lastly, for each individual ICU the overall mean scores of the eight domains which considered as essential for a mag-

| Ethical consideration
Ethics approval for this study was granted by the hospitals' Medical Ethical Review Commission (W13.030). The board of directors of each hospital involved in this study gave formal permission to conduct the study.

| Barriers and facilitators to NSO monitoring
Additionally, urinary tract infections (UTI), delirium, sepsis and multidrug-resistant (MDR) infections were not perceived to be nursesensitive by approximately 20% of respondents.
As shown in Fig. 2, 42% (n = 51) agreed that the monitoring of NSOs takes too much time (behaviour domain), nearly 20% (n = 24) was not familiar with the mandatory set of NSOs as determined by the Dutch Health Care Inspectorate (knowledge domain), and 15% (n = 19) did not agree that monitoring leads to reliable benchmark data (attitude domain).

| Relationship with nurse characteristics and work environment
Collinearity statistics showed that age was interfering too much with other nurse characteristics (VIF = 13, tolerance = 0.08), and there-  Table 2, confirms that after adjusting for nurse characteristics, nurses in unit B gave a significant lower behaviour-related score as compared to nurses in the other units (R 2 = 0.15, F(8, 120) = 2.42, p = 0.02).

| DISCUSSION
This study aimed to investigate potential barriers and facilitators to monitoring of nurse-sensitive outcomes (NSOs) from the perspective of nurses in Dutch intensive care units (ICUs), and to explore influential nurse characteristics and work environment factors. A major strength of this study is that we determined barriers and facilitators with regard to a wide range of NSOs, in contrast to previous studies focusing on one single NSO (El Hussein et al., 2014;Leistra et al., 2014;Strand & Lindgren, 2010;Wang & Tsai, 2010). As a result, we were able to draw more comprehensive conclusions about NSO monitoring by ICU nurses.
We found that all nurses agreed that pressure ulcers and patient satisfaction were clearly nurse-sensitive indicators. Fewer nurses agreed regarding presumed NSOs, such as mortality, urinary tract infections, and sepsis. These findings contradicted those of Needleman et al. (2007) who referred to urinary tract infection and sepsis to be highly nurse-sensitive. It is important to know how ICU nurses view NSOs, as those nurses who not perceive them as reliable and valid outcome measures of their work will be less likely to be motivated to adequately monitor these NSOs.
Another important finding was that lack of time was perceived as a major behaviour related issue in the monitoring of NSOs in ICUs.
Besides the usual care practices, the administrative burden on nurses is increasingly present in the contemporary health care setting (De Vos et al., 2009). NSOs can be important indicators for the quality of care; however, in order to persuade nurses to behave accordingly, health care organizations need to place an emphasis on how monitoring NSOs relates to nurses' regular duties and responsibilities, and that monitoring is not an unnecessary time-consuming activity. One way in which this can be achieved is by determining the usefulness of NSOs in various types of units (Burston, Chaboyer & Gillespie, 2014). For example, specific NSOs, such as pressure ulcers and delirium frequently occur in patients admitted to critical care units, but are not as common in step-down units involving patients with lower levels of complexity.
As a result, nurses in critical care units should dedicate more time to monitoring these specific NSOs than non-critical care units.
One reason for not screening NSOs is an ignorance on the part of nurses that screening for NSOs is part of their job requirement.  (Beckel, Wolf, Wilson & Hoolahan, 2013).
These knowledge related barriers are relatively easy to counter, and the most commonly described facilitators in this study, more education and clear policies, could stimulate NSO knowledge in ICUs and ideally improve the screening levels. The relevance of continuing education has been mentioned in previous studies investigating screening processes by health care professionals (Leistra et al., 2014).
In addition to barriers related to behaviour and knowledge, other factors identified as potentially contributing to suboptimal monitoring of NSOs were related to nurses' attitudes. For example, 15% of nurses in our sample did not understand that NSO data could be utilized for benchmark purposes. This implies that simply informing nurses of the requirement to monitor NSOs may not be enough; in order to make a change, nurses need to understand how data related to NSOs is used by the local and national health care organizations. The abstract nature of attitude related barriers make them more difficult to overcome than knowledge related barriers, and changing a nurse's attitude often takes much longer than changing a nurse's level of education on NSOs.
While attitude related barriers may prove more challenging than other barriers, they have a large impact on clinical outcomes, such as ventilation associated pneumonia, pressure ulcers and central line infections (Beeckman et al., 2007;Soh, Davidson, Leslie, DiGiacomo & Soh, 2013

| Limitations
Several study limitations occurred during the course of this study.  (Baruch & Holtom, 2008), bias from non-responders was another limitation in this study. This response rate is comparable to that of other survey studies focusing on critical care nurses (Cahill, Murch, Cook & Heyland, 2012) and the demographic characteristics of our sample resemble that of the full population of Dutch ICUs (Hansen, Van Velden & Hingstman, 2008). T A B L E 2 Multiple linear regression results for the barrier domains of knowledge, attitude and behaviour knowledge, behaviour and attitude towards the necessity of NSO monitoring is one way to increase nurses' understanding of NSOs and NSO monitoring. Further research on work environment factors that potentially affect nursing processes in ICUs is needed in order to permanently improve and optimize nursing quality in these high-intensity units.