Professional Documents
Culture Documents
QUANTITATIVE
Correspondence to A. Baethge:
e-mail: baethge@uni-mainz.de
Anja Baethge Dr phil
Psychologist
Work, Organizational and Business
Psychology, Department of Psychology,
Johannes Gutenberg-University, Mainz,
Germany
Andreas M
uller Dr phil
Psychologist
Institute for Occupational Medicine and
Social Medicine, Medical Faculty,
D
usseldorf University, Germany
Thomas Rigotti Dr rer nat
Professor
Work, Organizational and Business
Psychology, Department of Psychology,
Johannes Gutenberg-University, Mainz,
Germany
Abstract
Aims. The aim of this study was to investigate whether selective optimization
with compensation constitutes an individualized action strategy for nurses
wanting to maintain job performance under high workload.
Background. High workload is a major threat to healthcare quality and
performance. Selective optimization with compensation is considered to enhance
the efficient use of intra-individual resources and, therefore, is expected to act as
a buffer against the negative effects of high workload.
Design. The study applied a diary design. Over five consecutive workday shifts,
self-report data on workload was collected at three randomized occasions during
each shift. Self-reported job performance was assessed in the evening. Self-reported
selective optimization with compensation was assessed prior to the diary reporting.
Methods. Data were collected in 2010. Overall, 136 nurses from 10 German
hospitals participated. Selective optimization with compensation was assessed
with a nine-item scale that was specifically developed for nursing. The NASATLX scale indicating the pace of task accomplishment was used to measure
workload. Job performance was assessed with one item each concerning
performance quality and forgetting of intentions.
Results. There was a weaker negative association between workload and both
indicators of job performance in nurses with a high level of selective optimization
with compensation, compared with nurses with a low level. Considering the
separate strategies, selection and compensation turned out to be effective.
Conclusion. The use of selective optimization with compensation is conducive to
nurses job performance under high workload levels. This finding is in line with
calls to empower nurses individual decision-making.
Keywords: forgetting of intentions, nurses, nursing, performance quality, SOC,
workload
A. Baethge et al.
Introduction
Complaints about high levels of workload in the nursing
profession, in terms of the amount of direct and indirect
patient care activity required to carry out the nursing function (Morris et al. 2007, p. 468), have considerably
increased over the last decade (Myny et al. 2011). Nurses
are especially exposed to highly complex demands due to
the unpredictability of events, missing information, unreliable access to resources (Ebright et al. 2003) and a high frequency of interruptions and multitasking demands (Kalisch
& Abersold 2010). High nursing workload, in turn, is considered to be a major threat to performance (and care)
quality (e.g. Carayon & Gurses 2005, Holden et al. 2011,
Van Bogaert et al. 2013). A further typical consequence of
higher levels of workload and frequent interruptions is a
construct known as forgetting of intentions (Einstein et al.
2003, Baethge & Rigotti 2013). Even under optimally
designed work conditions, an increase in nursing workload
2
Background
The purpose of this paper was to investigate whether selective optimization with compensation (SOC; Baltes & Baltes
1990) constitutes an adequate action strategy of nurses both
to maintain quality of performance and to minimize forgetting of intentions under high workload levels. In recent
years, SOC has become a powerful model which has been
used to explain action at work (Baltes & Dickson 2001,
Baltes & Finkelstein 2011, Baltes et al. 2012, Truxillo et al.
2012). From the perspective of action regulation theory
(Frese & Zapf 1994, Hacker 2003) and Conservation of
Resources Theory (COR; Hobfoll 1989, 2001, 2002), SOC
is a psychological construct that is characterized as involving goal-related behaviour that enables a more adaptive
and efficient use of available mental and physiological
resources, such as cognitive capacities, to improve an individuals health and well-being (Baltes 1997, Freund & Baltes 2002). According to Freund and Baltes (2002), the three
action strategies known as selection, optimization and compensation can be defined as follows: With selection, an individual focuses resources on specific goals as opposed to
distributing resources among multiple goals. Thus, selection
determines the direction and scope of resource allocation
(e.g. a nurse prioritizes the most urgent job tasks in periods
of high workload). Optimization involves the individual
obtaining and constantly improving the means of successfully pursuing a selected goal and refers to the quality and
the tenacity of intra-individual resource allocation (e.g. a
nurse persistently attempts to meet the requirements of the
prioritized job task until it is successfully accomplished).
Compensation also refers to the means and processes of
goal attainment. However, it specifically involves the acquisition and application of alternative means of achieving a
selected goal despite intra-individual or external hindrances.
Thus, compensation specifically refers to the flexibility of
intra-individual resource allocation (e.g. a nurse asks
2015 John Wiley & Sons Ltd
The study
Aim
Our diary study investigates the interactive effects of workload and SOC on performance quality and forgetting of
intentions in nurses. We hypothesize that: (1) Workload is
(a) negatively related to performance quality; and (b) positively related to forgetting of intentions in nursing; and (2)
SOC moderates (a) the negative relation between workload
and performance quality; and (b) the positive relation
between workload and forgetting of intentions in nursing,
such that these relations are weaker in nurses with high
SOC use compared with nurses with low SOC use.
Design
This diary study (cf. Ohly et al. 2010) had a non-experimental prospective design. It combined daily self-reports of
workload and performance (repeated measures over five
consecutive workdays for each person) with one overall
measure of SOC strategies. This design allowed us to capture the short-term dynamics between workload and performance on a day level (see Hypothesis 1). Moreover, it
enables the examination of whether the overall personal
level of SOC strategies affects these daily associations (see
Hypothesis 2). We contacted 56 nursing directors in German hospitals and out of these, 10 agreed to take part in
the study. In each hospital, a group of nurses was recruited
who voluntarily participated in the study and could arrange
to have five morning shifts in a row. We decided to sample
only morning shifts because workload can be expected to
3
A. Baethge et al.
Sample/participants
The general survey and the diary survey were completed by
136 nurses (73% males) from 10 German hospitals. Mean
age was 4081 years (SD 1159; range = 2161 years) and
mean organizational tenure was 1833 years (SD 1225;
range = 01043 years. Most of the participants (813%)
were employed full time and in a permanent position
(821%). They worked in inpatient wards in the following
specialties: internal medicine (244%), surgery (179%),
neurology (146%), paediatrics (73%), intensive care
(65%), gynaecology (57%), ENT (33%), dermatology
(16%), geropsychiatry (08%), urology (08%), emergency
ward (08%) and others (81%).
Data collection
We collected the data using the following German-language
instruments.
SOC
To measure selection, optimization and compensation, we
used a German instrument developed for the nursing context by M
uller et al. (2013).
Workload
We used the German version of the NASA-TLX scale (Hart
& Staveland 1988), with seven items. An example item is:
How fast was the pace at which you had to accomplish
your tasks during the last half hour? Answers were given
on a 20-point scroll bar ranging from 1 (very low)-20 (very
high).
Performance quality
To measure subjective satisfaction with ones own performance quality, we adapted one item from Abramis (1994):
Today, I satisfied the personal expectations I have of my
work. Respondents had to indicate the extent to which they
agreed with the statement using a five-point Likert-type
scale, ranging from 1 (strongly disagree)-5 (strongly agree).
Forgetting of intentions
To measure forgetting of intentions in the evening (before
going to bed), we asked our respondents: Today, did you
forget to complete a task you had started or planned to
do? Answers were coded 0 (no) and 1 (yes).
Ethical considerations
According to local regulations, no formal ethical scrutiny
was undertaken. Participation in the study was voluntary
and all participants provided their informed consent to take
part in the study. The collected data were handled in a way
to ensure anonymity of participants. All organizations and
participants in the study received a report on the outcomes
of the study.
Data analyses
We conducted multilevel analyses because the daily assessments were nested within persons and were thus not independent from each other (Ohly et al. 2010). We used the
software package R 3.1.1 (R Core Team, 2014). Centring
the day-level variable workload at the person mean allowed
for the removal of between-person variance from this variable. This eliminated the role of stable differences in
explaining a participants day levels of the perceived stressor workload (Ohly et al. 2010). The moderator variable
SOC, which was assessed on level 2, was centred at the
grand mean. We allowed random slopes and tested them
against simple slope models. As the random slope models
did not have a significantly better fit, we chose the simple
slope model as grounds of Occams razor (Nezlek et al.
2006).
Results
Validity and reliability
SOC
The study by M
uller et al. (2013) demonstrated the validity
of the scale in terms of substantial positive correlations
with the established general SOC-measure by Baltes et al.
(1999). Moreover, previous studies showed positive associations with the work ability of nurses (M
uller et al. 2012)
and predictive effects on the well-being of nurses in a 6month time span (M
uller et al. 2013). Each subscale consists of three items (e.g. I concentrate on the most important tasks to do my job well for selection; I do exercises
to accomplish the physical demands in nursing for optimization; I ask for help to accomplish heavy physical tasks
for compensation). Answers were given on a five-point
scale, ranging from 1 (no, not all)-5 (yes, exactly). Cronbachs alpha was 077 for the whole scale and 058 (S),
063 (O) and 077 (C) for the subscales.
Workload
Cronbachs alpha in our sample ranged from 078-086 in
the three shift occasions of the 5 days (shift 1: 078-085;
shift 2: 082-086; shift 3: 084-086). The NASA-TLX scale
(Hart & Staveland 1988) has been shown to have good
concurrent validity with other instruments measuring workload (Rubio et al. 2004). Furthermore, it has been used in
other nursing studies (Lopez et al. 2010) establishing, for
instance, a positive relationship with sleepiness (Geiger
Brown et al. 2014).
As performance quality and forgetting of intentions were
one-item measures, no Cronbachs alphas for these scales
can be calculated. Nonetheless, we tested the convergent
2015 John Wiley & Sons Ltd
A. Baethge et al.
Table 1 Means, standard deviations and zero-order correlations of all study variables.
1
2
3
4
5
6
7
8
Variable
SD
SD
Age
SOC (total)
Selection
Optimization
Compensation
Workload
Performance
Quality
Forgetting
4098
384
413
361
377
782
389
1155
055
054
073
084
242
067
783
392
284
088
012
016
004
010
022*
014
013
022
013
033
011
066***
080***
085***
012
035***
032***
037***
017
038***
029***
023**
049***
008
025**
007
023**
027**
021*
034***
039***
027**
022***
024***
037***
Correlations below the diagonal are person-level correlations (N = 129-136). Correlations above the diagonal are day-level correlations
(n = 593-631). Day-level correlations can only be estimated with variables assessed at the day level.
*P 005; **P 001; ***P 0001.
Parameter
Intercept
Level 1
Workload
Level 2
Age
SOC
Interaction
Workload 9 SOC
2 * log
Diff-2 * log
d.f.
Model 1
B (SE)
390 (006)***
001 (000)+
51531
Model 2
B (SE)
Model 3
B (SE)
Model 4
B (SE)
389 (006)***
389 (005)***
389 (005)***
008 (002)***
008 (002)***
008 (002)***
001 (000)+
001 (000)
044 (010)***
001 (000)
044 (010)***
40587
943**
1
39310
1277***
1
008 (003)*
38781
529*
1
Level 2: N = 129-131. Level 1: n = 566-571. The scores of the Level 1 variables were centred at the individuals means to eliminate
between-individual variance. The scores of the Level 2 variables were grand-mean centred.
+
P 01; *P 005; **P 001; ***P 0001.
5
Performance quality
45
4
35
3
25
2
Low SOC (1 SD)
High SOC (+1 SD)
15
1
Low workload (1 SD)
1
09
Probability of forgetting
137386
3461***
1
140846
Level 2: N = 131-133. Level 1: n = 571-587. The scores of the Level 1 variables were centred at the individuals means to eliminate between-individual variance. The scores of the
Level 2 variables were grand-mean centred.
+
P 01; *P 005; **P 001; ***P 0001.
Coef., unstandardized regression coefficient; OR, odds ratio; CI, confidence interval.
050-097
132909
647*
1
069
036 (017)*
133555
3830***
1
099-107
016-069
103
033
099-107
015-062
102
102
002 (002)
099-106
002 (002)
099-106
003 (002)
118 (036)**
103
031
003 (002)
111 (037)**
099-107
122
105-154
127
024 (010)*
105-154
024 (010)*
128
020 (010)+
005-011
007
267 (021)***
005-011
007
264 (021)***
004-010
007
273 (022)***
005-010
007
268 (021)***
OR
Parameter
Intercept
Level 1
Workload
Level 2
Age
SOC
Interaction
W 9 SOC
2 * log
Diff-2 * log
d.f.
Coef. (SE)
Coef. (SE)
95% CI
OR
Coef. (SE)
Coef. (SE)
95% CI
Model 2
Model 1
Forgetting of intentions
Table 3 Estimates for multilevel logistic regression models predicting forgetting of intentions.
Model 3
OR
95% CI
Model 4
OR
95% CI
08
07
06
05
04
03
02
01
0
Low workload (1 SD)
Low SOC
(1 SD)
High SOC
(+1 SD)
High workload (+1 SD)
Discussion
Our study demonstrates that SOC is an adequate, individualized action strategy for nurses who want to optimize their
job performance under high workload levels. The use of
SOC emphasizes the efficient use of intra-individual
resources at hand for the most important work goals and
the optimized pursuit of these goals, while considering possible compensatory means. As such, SOC should not be
mistaken with a downward adjustment of task goals under
excessive workload (such as reducing the accuracy, paying
less attention to subsidiary tasks, e.g. Hockey 1997). Nevertheless, SOC is in contrast to the mere increase in overall
effort to keep up performance during high workload levels.
Putting more energy and (compensatory) effort into a task
could increase performance outcomes in the short run, but
it would also deplete resources, leading to fatigue and, in
turn, higher levels of strain (cf., Zijlstra et al. 1999, Mark
et al. 2008, Baethge et al. 2015). Instead of working
7
A. Baethge et al.
Table 4 Additional (post-hoc) analyses of the three subscales of SOC (Performance Quality).
Outcome
Moderator
Parameter
Intercept
Level 1
Workload
Level 2
Age
Moderator
Interaction
Workload 9 Moderator
Performance quality
Selection
B (SE)
Optimization
B (SE)
Compensation
B (SE)
388 (005)***
388 (006)***
389 (005)***
007 (002)***
007 (002)**
008 (002)***
000 (000)
050 (010)***
001 (000)
022 (008)*
001 (000)
019 (007)*
008 (003)*
003 (003)
006 (002)*
Level 2: N = 129-131. Level 1: n = 566-571. The scores of the Level 1 variables were centred at the individuals means to eliminate
between-individual variance. The scores of the Level 2 variables were grand-mean centred.
The alpha levels were Bonferoni-corrected (divided by 3).
*P 0017; **P 0003; ***P 00003.
harder, SOC is a way of working smarter. Our study corroborates previous findings of the benefits of SOC for job
performance (Abraham & Hansson 1995, Bajor & Baltes
2003, Yeung & Fung 2009, Demerouti et al. 2014) and
contributes to the growing body of research showing that
the use of SOC buffers detrimental effects of stressful or
difficult work conditions (Yeung & Fung 2009, Zacher &
Frese 2011, Schmitt et al. 2012). Furthermore, the reported
results extend the validity of these findings to the nursing
profession.
Like other studies, we observed differential effects of the
three SOC sub-dimensions on performance. In line with
previous research (Abraham & Hansson 1995, Bajor &
Baltes 2003, Yeung & Fung 2009), our findings indicate
that selection strategies are particularly conducive to performance. This finding highlights the benefits of the prioritization of goals in stressful work situations (Hockey
1997). Especially in the nursing profession, it is important
to quickly decide which are the most urgent of the tasks at
hand (Lake et al. 2009). Otherwise, a special characteristic
or difficulty of the nursing profession is that most of the
tasks have to be done during one shift. That is, they cannot
be postponed to the next day. Thus, selection does not necessarily mean that non-relevant tasks are skipped. On the
contrary, selection could mean that tasks are (re-)scheduled
and that the amount of resources (e.g. time, effort) is allocated to different tasks. It is possible to spend more time
on tasks that are done first rather than on tasks that have
to be done shortly before the shift ends. Another characteristic of the nursing profession is the definite end of the
workday, or the handover. Tasks have to be performed up
to this deadline. It is unusual for nurses to finish tasks after
8
Table 5 Additional (post-hoc) analyses of the three subscales of SOC (Forgetting of Intentions).
Forgetting of intentions
Outcome
Selection
Moderator
Parameter
Optimization
Coef. (SE)
Intercept
Level 1
Workload
Level 2
Age
Moderator
Interaction
W 9 Moderator
OR
95% CI
276 (023)***
006
004-010
018 (011)
119
003 (002)
105 (042)*
054 (019)*
Compensation
Coef. (SE)
OR
95% CI
269 (022)***
007
004-010
097-147
021 (002)
123
103
035
099-107
015-079
002 (002)
074 (029)*
058
040-085
020 (012)
Coef. (SE)
OR
95% CI
267 (021)***
007
005-011
101-151
023 (010)+
125
103-153
102
047
099-106
027-085
003 (002)
050 (025)
103
060
099-106
037-098
082
064-104
015 (011)
086
069-107
Level 2: N = 129-131. Level 1: n = 566-571. The scores of the Level 1 variables were centred at the individuals means to eliminate
between-individual variance. The scores of the Level 2 variables were grand-mean centred.
The alpha levels were Bonferoni-corrected (divided by 3).
+
P 003; *P 0017; ***P 00003.
Coef., unstandardized regression coefficient; OR, odds ratio; CI, confidence interval.
1
09
Performance
4
35
3
25
2
Low selection (1 SD)
High selection (+1 SD)
15
1
Low workload (1 SD)
Probability of forgetting
5
45
08
07
06
05
04
03
02
01
0
Low workload (1 SD)
Low
selection
(1 SD)
High
selection
(+1 SD)
High workload (+1 SD)
performance quality.
forgetting of intentions.
5
4.5
Performance
4
3.5
3
2.5
2
1.5
1
Low workload (1 SD)
A. Baethge et al.
method variance might lead to an inflation of observed associations (Podsakoff et al. 2012). By using a within-person
design and a multilevel framework (centring focal variables
by the person mean), we were able to rule out between-person differences as having influenced the results. Still, future
studies may opt to assess both workload and performance
outcomes by means other than self-report, such as workplace
observations, supervisor ratings or objective performance
indicators. Third, the assessment of workload during the shift
might be perceived as an additional stressor. The time to
respond to the questions during the shift averaged less than
three minutes. Given the high complexity of demands in nursing, we believe it is unlikely that it was our questionnaire that
substantially increased the level of workload. Fourth, the outcomes were assessed using 1-item scales and although more
item scales would have a higher reliability, it is the common
practice in diary designs to use such (short) scales to keep
intrusive effects of the study low and the compliance of participants high (Ohly et al. 2010). Fifth, the Cronbachs alpha
of the SOC subscales selection and optimization is quite low.
Similar findings were reported in several other studies on the
SOC model (e.g. Freund & Baltes 2002, Riedel et al. 2015).
This might reflect the fact that SOC captures a multifaceted
phenomenon that usually is accompanied by decreased internal consistencies. The results of the SOC subscales, therefore,
have to be interpreted with caution. A replication with a
more reliable assessment of the subscales is needed. In the
case of selection, we have already begun a discussion on the
presumably diverse nature of this construct. What is still
needed is an assessment of the different facets of selection in
different occupations. Nevertheless, as the Cronbachs alpha
of the total SOC scale is acceptable, our overall finding that
SOC is conducive to the job performance of nurses under
high workload levels is reliable. Finally, even with a diary
study conducted over five consecutive workdays, we cannot
make any causal statement about the relationship of studied
variables.
Funding
This research was supported by the Bundesanstalt f
ur
Arbeitsschutz und Arbeitsmedizin.
Conflict of interest
No conflict of interest has been declared by the authors.
Author contributions
All authors have agreed on the final version and meet at
least one of the following criteria [recommended by the
ICMJE (http://www.icmje.org/recommendations/)]:
Conclusion
Our findings are in line with calls for empowering nurses
individual decision-making due to the fact that they are the
experts in how care should be delivered (Kalisch & Abersold 2006). In that vein, nurses might already be acquainted
with the SOC model and its potential benefits to managing
high workload levels. Nevertheless, individual strategies,
such as SOC, have to be safeguarded by a supportive work
environment: Research has indicated that job control in
terms of autonomy and discretion to schedule work and
make decisions (Morgeson & Humphrey 2006) facilitates
10
References
Abraham J.D. & Hansson R.O. (1995) Successful aging at work:
an applied study of selection, optimization and compensation
through impression management. Journal of Gerontology:
Psychological Sciences 50(2), P94P103. doi:10.1093/geronb/
50B.2.P94.
Abramis D.J. (1994) Relationship of job stressors to job
performance: linear or an inverted-U? Psychological Reports 75
(1), 547558. doi:10.2466/pr0.1994.75.1.547.
Baethge A. & Rigotti T. (2013) Interruptions to workflow: their
relationship with irritation and satisfaction with performance and
2015 John Wiley & Sons Ltd
11
A. Baethge et al.
Kalisch B.J. & Abersold M. (2010) Interruptions and multitasking
in nursing care. The Joint Commission Journal on Quality and
Patient Safety 36(3), 126132.
Lake S., Moss C. & Duke J. (2009) Nursing prioritization of the
patient need for care: a tacit knowledge embedded in the clinical
decision-making literature. International Journal of Nursing
Practice 15(5), 376388. doi:10.1111/j.1440-172X.2009.01778.x.
Lopez K.D., Gerling G.J., Cary M.P. & Kanak M.F. (2010)
Cognitive work analysis to evaluate the problem of patient falls
in an inpatient setting. Journal of the American Medical
Informatics
Association
17(3),
313321.
doi:10.1136/
jamia.2009.000422.
Mark G., Gudith D. & Klocke U. (2008) The cost of interrupted
work: more speed, more stress. In Proceedings of the 2008 ACM
Conference on Human Factors in Computing Systems (CHI
2008) (Burnett M., Costabile M.F., Catarci T., deRuyter B., Tan
D., Czerwinski M. & Lund A., eds), ACM Press, New York,
NY, pp. 107110.
Morgeson F.P. & Humphrey S.E. (2006) The Work Design
Questionnaire
(WDQ):
developing
and
validating
a
comprehensive measure for assessing job design and the nature
of work. Journal of Applied Psychology 91(6), 13211339.
doi:10.1037/0021-9010.91.6.1321.
Morris R., MacNeela P., Scott A., Treacy P. & Hyde A. (2007)
Reconsidering the conceptualization of nursing workload:
literature review. Journal of Advanced Nursing 57(5), 463471.
doi:10.1111/j.1365-2648.2006.04134.x.
M
uller A., Weigl M., Heiden B., Glaser J. & Angerer P. (2012)
Promoting work ability and well-being in hospital nursing:
the interplay of age, job control and successful ageing strategies.
Work 44(1), 51375144. doi:10.3233/WOR-2012-0083-513.
M
uller A., Weigl M., Heiden B., Herbig B., Glaser J. & Angerer P.
(2013) Selection, optimization and compensation in nursing:
exploration of job-specific strategies, scale development and agespecific associations to work ability. Journal of Advanced
Nursing 69(7), 16301642. doi:10.1111/jan.12026.
Myny D., Van Goubergen D., Gobert M., Vanderwee K., Van
Hecke A. & Defloor T. (2011) Non-direct patient care factors
influencing nursing workload: a review of the literature. Journal
of Advanced Nursing 67(10), 21092129. doi:10.1111/j.13652648.2011.05689.x.
Nezlek J.B., Schr
oder-Abe M. & Sch
utz A. (2006)
Mehrebenenanalysen in der psychologischen Forschung - Vorteile
und
M
oglichkeiten
der
Mehrebenenmodellierung
mit
Zufallskoeffizienten [Multilevel analyses in psychological
research. Advantages and potential of multilevel random
coefficient modeling]. Psychologische Rundschau 57(4), 213223.
doi:10.1026/0033-3042.57.4.213.
Ohly S., Sonnentag S., Niessen C. & Zapf D. (2010) Diary studies
in organizational research: an introduction and some practical
recommendations. Journal of Personnel Psychology 9(2), 7993.
doi:10.1027/1866-5888/a000009.
Podsakoff P.M., MacKenzie S.B. & Podsakoff N.P. (2012) Sources
of method bias in social science research and recommendations
on how to control it. Annual Review of Psychology 65, 539
569. doi:10.1146/annurev-psych-120710-100452.
12
The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of
evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance
and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original
research reports and methodological and theoretical papers.
For further information, please visit JAN on the Wiley Online Library website: www.wileyonlinelibrary.com/journal/jan
Reasons to publish your work in JAN:
High-impact forum: the worlds most cited nursing journal, with an Impact Factor of 1527 ranked 14/101 in the 2012 ISI Journal Citation Reports (Nursing (Social Science)).
Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries
worldwide (including over 3,500 in developing countries with free or low cost access).
All in-text references underlined in blue are linked to publications on ResearchGate, letting you access and read them immediately.
13