the work setting of diabetes nursing specialists in the netherlands: a questionnaire survey

The work setting of diabetes nursing specialists in

the Netherlands: A questionnaire survey

Tilja I.J. van den Berg a, Hubertus J.M. Vrijhoef b,c, Gladys Tummers a,Jan A. Landeweerd a, Godefridus G. van Merode a,*

a University of Maastricht, Faculty of Health, Medicine & Life Sciences, Department of Health Organisation,

Policy and Economics, The Netherlandsb University Hospital Maastricht, Department of Integrated Care, The Netherlands

c University of Maastricht, Faculty of Health, Medicine & Life Sciences, Department of Health Care Studies,

Section Nursing Science, The Netherlands

Received 26 April 2007; received in revised form 11 December 2007; accepted 18 December 2007

www.elsevier.com/ijns

Available online at www.sciencedirect.com

International Journal of Nursing Studies 45 (2008) 1422–1432

Abstract

Aim: The aim of this study is to explore whether the work organisation of diabetes specialist nurses (DSNs) differs significantly

from nurses working in hospital and nursing home and if so, does this difference result in positive or negative consequences

regarding work and health.

Background: In traditional health care settings, nurses exhibit a high level of environmental uncertainty and low decision-

making authority, which has a negative effect on psychological reactions towards work. In professional nursing, specialisation,

e.g. diabetic nursing, is a current trend in many countries. Therefore, insight into the determinants of the work situation of

nursing specialists is becoming increasingly relevant.

Methods: Comparisons were made between 3 different samples: 1204 nurses employed by 15 hospitals, 1058 nurses employed

by 14 nursing homes, and 350 diabetes nurses working in other health care settings throughout the Netherlands. Data concerning

organisation, work aspects, and psychological reactions were measured via questionnaires. Variances between the groups were

analysed with ANCOVA, besides hierarchical multiple regression analysis was applied.

Findings: Environmental uncertainty scored lower amongst diabetes nurses when compared to nurses working in the other two

types of health care settings. Social support and role conflict scored low for diabetes nursing specialists who simultaneously

perceived autonomy and role ambiguity highest. Diabetes nursing specialists also scored highest on intrinsic work motivation

and job satisfaction and lowest for psychosomatic health.

Conclusion: Except for social support and role ambiguity, diabetic nurses rate their [work] organisation, [work] aspects and

psychological [work] reactions more positively than nurses employed in other health care settings.

# 2007 Elsevier Ltd. All rights reserved.

Keywords: Diabetes nurse; Work organisation; Work pressure; Emotional exhaustion

* Corresponding author at: University of Maastricht, Department

Hope (Health Organisation, Policy and Economics), Faculty of

Health Sciences, P.O. Box 616, 6200 MD Maastricht, The Nether-

lands. Tel.: +31 43 388 1727; fax: +31 43 367 0960.

E-mail address: [email protected]

(G.G. van Merode).

0020-7489/$ – see front matter # 2007 Elsevier Ltd. All rights reserved

doi:10.1016/j.ijnurstu.2007.12.003

What is already known about the topic?

� T

.

he work organisation of nurses employed in hospitals

differs from nurses employed in nursing homes, more

specifically, environmental uncertainty.

mailto:[email protected]

http://dx.doi.org/10.1016/j.ijnurstu.2007.12.003

T.I.J. van den Berg et al. / International Journal of Nursing Studies 45 (2008) 1422–1432 1423

� R
elations between work organisation, aspects, and psy-
chological attitude are for the most part in line with the

Job Demand Control model regardless of the type of

health care setting.

What this paper adds

� D
iabetes specialist nurses rate their [work] organisation,
[work] aspects and psychological [work] reactions more

positively than nurses employed in other health care

settings.

� T
he transition of work tasks and a high specialisation of
nurses have a positive influence on the psychological

reactions when compared to those nurses employed in

more traditional health care settings.

� I
n the diabetes specialist nurses’ workplace, there was no
significant relation between environmental uncertainty

and psychological reactions.

1. Introduction

Throughout the past 10 years, the diabetes specialist

nurse (DSN) has developed into an indispensable profes-

sional, administering complex care to patients with diabetic.

This nursing specialisation evolved as an answer to staff

shortages in charge of providing care as well as to the

necessity for improvement of the quality of care. Nowadays,

the transfer of tasks between doctors and nurses and sub-

stitution of doctors by nursing specialists are well accepted

in the care for patients with chronic diseases such as diabetes

mellitus (Vrijhoef et al., 2001).

In the Netherlands the work tasks performed by the DSN

can be summarised as follows: direct patient care (medical

history, physical examination, interpretation of laboratory

results, recording findings, and prevention of complica-

tions); co-ordination and organisation of care (identification

of shortcomings, referral to and communicating with other

health care-providers) and the advancement of expertise

(educating patients, other health care-providers and the

nurses themselves). Compared to general nurses, DSNs have

one of the highest qualification levels for nursing care and

are accepted nursing specialists who are focused on diabetes

care and who possess distinctive skills in this area of practice

(Vrijhoef et al., 2002).

In the Netherlands (Vrijhoef et al., 2002), USA (Valen-

tine et al., 2003), the UK (Winocour et al., 2002), and New

Zealand (Kenealy et al., 2004) the role of the DSN increases

while they enhance their position within the diabetes team

(Sigurdardottir, 1999).

According to the DSN job profile, one can expect that the

work setting of the DSN differ significantly, when compared

with nurses working in a hospital or nursing home. Since the

work organisation is of great importance to psychological

attitude, it is relevant to explore what the differences in work

organisation are and whether these differences result in

positive or negative outcomes, directly or mediated through

work aspects on psychological work reactions.

2. Theoretical perspectives on organisations, work,

and psychological work reactions

In this study, two theoretical perspectives are utilized for

the selection of work organisation, work aspects, and psy-

chological reactions, namely, the contingency approach of

organisations (Child, 1977; Galbraith, 1977; Lawrence and

Lorsch, 1967), and the Demand-Control-Support (DCS)

model (Johnson and Hall, 1988; Karasek, 1979; Karasek

and Theorell, 1990).

According to the contingency approach, design decisions

depend on environmental conditions. In addition, organisa-

tional effectiveness is achieved by organisations whose

structural characteristics, i.e. centralisation, formalisation,

and standardisation (Child, 1977; Gutek, 1990; Pennings,

1998) best match the demands of the environment or context,

i.e. environmental uncertainty (Fry and Slocum, 1984; Pen-

nings, 1998; Perrow, 1970; Rundall and Hetherington,

1988).

The DCS model (Johnson and Hall, 1988; Karasek et al.,

1981; Karasek and Theorell, 1990) is an extension of

Karasek’s Job Demand-Control (JD-C) model (Karasek,

1979). Both the JD-C and the DCS models are aimed at

generating a more profound insight into psychosocial risk

factors at work (Karasek, 1979). Following Tummers et al.

(2002), role stressors, i.e. role conflict and role ambiguity,

were added to the framework. Since these stressors may

cause job dissatisfaction and feelings of job-related strain

(Tummers et al., 2002). The relation between these theoretic

perspectives was investigated in previous research (Tum-

mers et al., 2006).

2.1. Organisational characteristics

Both structural (e.g. decision authority) and environmen-

tal characteristics (e.g. complexity and environmental uncer-

tainty) can be used to represent the work organisation in

nursing.

Complexity of care refers to such patient characteristics

as changes in a patient’s health and environmental char-

acteristics. The patient mix on a unit encompasses the

composition with regards to the specialities and patient

diversity. Diversity implies that the differences amongst

patients’ are caused by the type of disease and the level of

health problems. Diabetes management is characterised by

its complex nature and the complex health care needs of

the patients with diabetic (El Fakiri et al., 2003). Aside

from the health status of patients with type 2 diabetes, it is

even more complex with 60% of patients suffering from

co-morbidity (Charman, 2000). Whether or not this com-

plex health status leads to a complex work organisation is

unknown.

T.I.J. van den Berg et al. / International Journal of Nursing Studies 45 (2008) 1422–14321424

Furthermore, nursing units are characterised by high

environmental uncertainty or unpredictable circumstances.

In general, uncertainty indicates that there is a differentiation

between the amount of information required and the amount

of information already held by the organisation (Galbraith,

1973). In this study environmental uncertainty refers to

workflow uncertainty. As we know, nurses working in a

chronic health care setting (nursing home) exhibit signifi-

cantly lower environmental uncertainty than nurses working

in an acute health care setting (hospital) (van den Berg et al.,

2006). In general, diabetes care is not acute, but chronic by

nature. Therefore, the setting wherein diabetes care is admi-

nistered is expected to result in diminished environmental

uncertainty compared to those working in a hospital.

Decision-making authority relates to the way in which

the authority to make such decisions as ‘who is going to do

what and when’ is distributed among members of a ward

(Bodt and Van Tuijl, 1988). The concept of decision-

making authority, as applied in this study, refers to the

performance of various tasks, and the decentralisation of

decision-making. Since DSNs usually work independently,

it is most likely that decision-making authority is highest.

High environmental uncertainty and minimal decision-

making authority has a negative effect on such psycholo-

gical reactions as emotional exhaustion, intrinsic work

motivation, psychosomatic health, and job satisfaction

(Tummers et al., 2002).

The aim of this study is to explore whether the work

organisation of DSNs differs significantly from nurses work-

ing in hospital and nursing home and if so, does this

difference result in positive or negative consequences

regarding work and health. Therefore two research questions

were formulated. The first research question addressed

whether differences in work organisation, work aspects,

and psychological reactions existed between DSNs, hospital

or nursing home care. The second research question relates

to the relationship between work organisation, work aspects,

and the psychological reactions of nurses connected to the

three different settings. This question was divided into three

Fig. 1. Researc

sub-questions, as represented by Lines A, B1, B2 and C in the

research model (Fig. 1):

� L

h m

ine A demonstrates the relationship between character-

istics of the work organisation and work aspects.

� L
ine B questions whether the relationship between the
characteristics of the work organisation and psychological

attitude is a direct relationship (B1) or an indirect one, via

the work aspects (B2), which means that the work char-

acteristics may be regarded as mediator variables.

� L
ine C represents the third sub-question, the relationship
between work aspects and psychological reactions.

Since the use of contingency theory in nursing is relatively

new, there are no validated questionnaires available concern-

ing environmental uncertainty, complexity, and decision-

making authority. Previous research showed insufficient psy-

chometric properties of the complexity scale in the nursing

home sample (Cronbach’s alpha was .32) (van den Berg et al.,

2006), the research question of how to improve the concep-

tualisation of work organisation was addressed as well.

3. Methods

3.1. Design and procedure

In this cross-sectional study nurses working in 15 ran-

domly selected general hospitals, 14 randomly selected

nursing homes, and 825 DSNs in the Netherlands were

asked whether they were willing to participate, after permis-

sion of the institutions director. Questionnaires were dis-

tributed in a sealed envelope together with a letter that

explained the purpose of the study and anonymity proce-

dures. After completing the questionnaires, subjects were

asked to return them in an enclosed return envelope. Parti-

cipants had been employed for at least 3 months. In the

general hospital and nursing home sample all nurses com-

plying with this criteria were included.

odel.


An approval by the Ethics Committee was not necessary.

Subjects filled in an informed consent in order to approve the

use of data for scientific research. Because all data was

retrieved from self-assessed questionnaires and no human

body tissues or species were obtained, ethical approval was

not necessary.

3.2. Samples and response

Data were collected in three samples, collected at dif-

ferent times over a period of 2 years:

Hospital nurses: One thousand eight hundred fifty-five

(1855) questionnaires were distributed among nurses from

15 hospitals. In total 1253 questionnaires were returned (a

response rate of 68%). The sample size was 1204 (nursing

staff employed for a period of less than 3 months were

excluded from the sample). The sample consisted of 1019

women (85%). The mean age of the hospital nurses was 35.7

years (S.D. = 8.7). The mean job experience was 15.5 years

(S.D. = 8.6), while the working time on the unit was 6.8

years (S.D. = 6.2).

Nursing home caregivers: One thousand eight hundred

forty-six (1846) questionnaires were distributed among

nurses from 14 nursing homes. In total 1139 questionnaires

were returned (response rate 62%). The sample size was

1058 (nursing staff employed for a period of less than 3

months were excluded from the sample). The sample con-

sisted of 963 women (94%). The mean age of the nursing

home caregivers was 35.8 years (S.D. = 9.7). The mean job

experience was 12.6 years (S.D. = 8.4), while the mean

working time on the unit was 4.6 years (S.D. = 4.8).

DSN: Eight hundred fifty-two (852) questionnaires were

distributed to DSNs in the Netherlands, 350 of which were

returned (response rate 41%). The sample consisted of 325

Table 1

Results reliability analysis for all three samples

Cronbach’s alpha

Sample 1 (general hospital)

Characteristics of the work organisation

Environmental uncertainty 0.8

Decision authority 0.7

Complexity 0.7

Work aspects

Autonomy 0.8

Workload 0.9

Social support at work 0.8

Role ambiguity 0.7

Role conflict 0.7

Psychological work reactions

Emotional exhaustion 0.9

Intrinsic work motivation 0.7

Psychosomatic health 0.8

Job satisfaction 0.9

women (93%). The mean age was 42.9 years (S.D. = 7.9).

The mean job experience was 5.82 years (S.D. = 4.6).

3.3. Questionnaire

The following variables were measured by question-

naires as part of a direct mailing. Results of reliability

analysis are shown in Table 1.

3.4. Characteristics of the work organisation

Environmental uncertainty contains items referring to

workflow and task uncertainty. One example is: ‘‘There are

daily emergency admittances on this unit’’.

Decision authority was measured in the DSN sample by

means of 3 items, ranging from 1 ‘‘totally disagree’’ to 5

‘‘totally agree’’. In the samples taken from the hospital

nurses and nursing home caregivers, the decision-making

authority scale consisted of five items. The Cronbach’s alpha

was 0.7 in the sample of hospital nurses, and 0.6 in the

sample of nursing home caregivers. Using the three-item

version – as was the case with the sample conducted of the

DSN – Cronbach’s alpha was 0.7 in the sample of hospital

nurses and 0.4 in the sample of nursing home caregivers.

Since the decision-making authority scale is in the devel-

opmental stages, descriptive questions of the work setting

were inserted to determine which improvements could be

achieved. The Pearson correlations were then calculated

between the descriptive and subjective decision-making

authority items. It can be concluded that decision-making

authority is unrelated to working in a multidisciplinary team,

the size of a multidisciplinary team, team supervisor, direct

supervisor and method used to record tasks and authorities.

Unfortunately reliability analysis on the data of the DSN

population was unsatisfactory and yielded a Cronbach’s

Sample 2 (nursing home) Sample 3 (DSN)

0.5 0.8

0.4 0.1

0.3 0.3

0.8 0.9

0.9 0.9

0.8 0.7

0.7 0.7

0.7 0.7

0.9 0.9

0.7 0.7

0.8 0.8

0.9 0.9


alpha of 0.1. Considering the insufficient psychometric

properties ‘decision-making authority’ was omitted from

the analyses.

Complexity was measured by means of eight items. In

both the hospital and nursing home samples, complexity was

measured by means of ten items on a five-point response

scale. Since Cronbach’s alpha emerged as unsatisfactory in

the nursing home sample, the ‘‘complexity’’ scale was

amended for use in the DSN sample. Descriptive questions

were introduced as a means of increasing the psychometric

quality, for example, questions concerning the diversity of

the patient population and the number of specialisation

fields. Then Pearson correlations were calculated between

the descriptive and subjective complexity items. This

revealed that the descriptive items had an elevated correla-

tion with the mean complexity score and the majority of

single complexity items. Furthermore, it was discovered that

when nurses are only specialised in diabetes, complexity

increases, the result of more complex and specialised tasks

being performed, for example, insulin treatment. Unfortu-

nately, Cronbach’s alpha proved inadequate in the DSN

population with (0.4) and without descriptive questions

(0.3).

In order to increase the methodological quality of the

scale in the future, a factor analysis was performed for the

complexity scale. It was concluded that a two-factor struc-

ture is the most suitable. The first factor merely consists of

items subjecting nurse specific skills. For example, ‘‘Does

the patient need emotional support and psychological help?’’

and ‘‘Do you establish patient insulin treatment instituting?’’

The second factor merely consists of situation dependent

complexity. For example, ‘‘What are the expectations in a

high risk situation?’’ and ‘‘How many care givers do you

have to deal with besides the operational doctor?’’ Con-

sidering the insufficient psychometric properties ‘complex-

ity’ was omitted from the analyses.

3.5. Work characteristics

Autonomy was measured by means of 10 items on a 5-

point response scale ranging from 1 ’very little opportunity’

to 5 ’very much opportunity’. This scale was derived from

the Maastricht Autonomy Questionnaire, abbreviated MAQ,

and was developed by De Jonge et al. (1993). Respondents

were asked to rate their work situations as to the opportu-

nities it offers for autonomy. An example of an item is: ‘‘The

opportunity that the work offers to leave your workplace

whenever you want’’.

Workload was measured by means of an 8-item ques-

tionnaire, also developed by De Jonge et al. (1993) and

ranging from 1 ’never’ to 5 ’always’. The scale consists of

both quantitative and qualitative demanding aspects in the

working situation, like working under time pressure, work-

ing hard, and strenuous work (De Jonge et al., 1993). An

example item is: ‘‘In the unit where I work, there is too little

time to finish the work’’.

Social support at work ( from colleagues and senior

nursing officer) was measured by means of a 10-item scale,

derived from a Dutch questionnaire on organisational stress

(‘‘Vragenlijst Organisatie Stress-Doetinchem’’—VOS-D;

Bergers et al., 1986). An item example is: ‘‘To what extent

can you count on your colleagues, when you have difficulties

in your work?’’ The items were scored on a 4-point response

scale format, ranging from 1 ‘‘never’’ to 4 ‘‘always’’.

3.6. Psychological work reactions

Emotional exhaustion was measured by means of the

Dutch version of the Maslach Burnout Inventory (MBI

(Maslach and Jackson, 1986)): the MBI-NL (Cox et al.,

1993; Maslach, 1993; Schaufeli and Van Dierendonck,

1993). The emotional exhaustion scale of the MBI-NL

consists of 8 items, ranging from 1 ‘‘never’’ to 7 ‘‘always’’.

An item example is: ‘‘I feel emotionally drained from my

work’’.

Intrinsic work motivation was measured by means of 6

items derived from a scale developed by Warr et al. (1979),

ranging form 1 ‘‘totally disagree’’ to 5 ‘‘totally agree’’. An

item example is: ‘‘My opinion of myself goes down when I

do this job badly’’.

3.7. Statistics

Background variables were analysed by using a descrip-

tive analysis. To gain insight into the work organisation,

aspects, and psychological reactions of DSNs in relation to

nurses employed in hospitals and nursing homes, multi-

variate analysis (ANCOVA) was carried out. Gender and age

were entered as covariates. Post hoc procedure Bonferroni

and Scheffe were used.

Hierarchical multiple regression analysis was applied in

order to investigate the relationships between: (a) character-

istics of the work organisation and work aspects, (b) char-

acteristics of the work organisation and psychological work

reactions, and (c) work characteristics and psychological

work reactions.

All the variables included in this study were standardised

to reduce problems of multi-colinearity. Two-way interac-

tion effects were tested by computing cross-product terms of

the standardised independent variables. Regression analyses

were presented separately for DSNs, hospital, and nursing

home settings.

To investigate which characteristics of work organisation

are predictable in terms of emotional exhaustion, intrinsic

work motivation, psychosomatic complaints, and job satis-

faction, hierarchical multiple regression analyses were per-

formed separately for each criterion variable. Because

gender and age were correlated with characteristics of the

work organisation, work aspects, and psychological reac-

tions, the analyses were controlled for the background

variables gender and age. The order of fit in the hierarchical

regression model was: (1) gender and age, (2) workload, (3)


autonomy, (4) social support, and (5) role ambiguity and role

conflict.

All analyses were carried out with the Statistical Package

for Social Sciences Version 11.0 for Windows (SPSS, 1999).

4. Results

4.1. Descriptives

The majority of DSNs (78%), worked in a multidisci-

plinary team, mean size 8.9 (S.D. = 6.0) members. Ninety

one percent (91%) were employed on a full-time basis. The

patient population under care was, in 7% of all cases,

‘‘younger than 18 years’’, in 45% of the cases the population

were ‘‘older than 18 years’’, and in 30% of the cases ‘‘the

patients were represented by all age groups’’. The majority

of DSNs were not specialised in any other field other than

diabetes (67%), but for those DSNs who are specialised in

other fields, the specialisation often extends to more than one

other specialisation. Registration of tasks and authorities

took place in 54% of all cases in ‘‘work description’’ or was

registered in more than one document (21%).

Table 2 demonstrates that nurses working in a general

hospital, nursing home or as DSN score significantly dif-

ferent in terms of work organisation, work aspects, and work

reactions, as determined by overall F-tests. No significant

differences in average score were found for emotional

exhaustion. Environmental uncertainty was significantly

lower in diabetes care than in both of the other settings.

DSNs exhibited the lowest workload in relation to the other

health care settings. Post hoc procedure Bonferroni and

Scheffe did not reveal any significant global differences

in mean score ( p = 0.1) for workload between DSN and

hospital nurses. In regard to autonomy, the DSN scored

highest in relation to the other health care setting. On the

Table 2

Univariate test results

Variables [number of items]

(x-point Likert scale)

Sample 1

(general hospital)

Mean (S.D.)

Environmental uncertainty [5] (5) 3.9 (.7)

Workload [10] (5) 3.3 (.5)

Autonomy [8] (5) 2.8 (.5)

Social support at work [10] (4) 3.2 (.3)

Social support supervisor [5] (4) 3.2 (.5)

Social support colleague [5] (4) 3.3 (.3)

Role ambiguity [4] (5) 2.1 (.5)

Role conflict [3] (5) 2.7 (.5)

Emotional exhaustion [8] (7) 2.2 (.7)

Intrinsic work motivation [6] (5) 4.0 (.5)

Psychosomatic health [21] (yes/no) 0.2 (.2)

Job satisfaction [21] (5) 3.5 (.4)

*p � 0.001.

contrary, the social support scores for the DSN were the

lowest in relation to the other health care settings. The DSN

scored highest for role ambiguity and lowest for role conflict.

DSNs scored highest in intrinsic work motivation and job

satisfaction, and lowest for psychosomatic ailments. There

were no significant differences in psychosomatic ailments

between the DSN and hospital nurses ( p = 0.2).

4.2. Relationships between organisational

characteristics and work aspects (Line A in Fig. 1)

Table 3 indicates relatively low percentages of the var-

iance (R2) in work aspects that were explained by work

organisation. In the DSN setting, environmental uncertainty

has a positive relation with role conflict (b = 0.2***) and

workload (b = 0.4***). From a work and health point of

view, environmental uncertainty is an indicator of negative

work characteristics (an increased workload, role conflict,

and reduced social support). In the nursing home setting,

environmental uncertainty indicates positive work aspects

(increased autonomy and less role ambiguity).

4.3. Relationships between organisational

characteristics and psychological work reactions (Line

B1 in Fig. 1)

Table 4 indicates that none of the psychological work

reactions were explained by environmental uncertainty in

the DSN setting. Emotional exhaustion was not predicted by

environmental uncertainty, in any of the settings. From a

work and health point of view, environmental uncertainty

was an indicator of positive (more intrinsic motivation) as

well as negative work reactions (more psychosomatic ail-

ments) in the hospital setting. In a nursing home setting,

environmental uncertainty has a positive influence, i.e.

higher intrinsic motivation and job satisfaction.

Sample 2

(nursing home)

Sample 3

(DSN)

F (overall)

Mean (S.D.) Mean (S.D.)

3.8 (.6) 3.7 (.7) 19.0*

3.4 (.6) 3.3 (.6) 13.8*

2.7 (.6) 3.3 (.7) 178.9*

3.3 (.3) 2.8 (.4) 270.0*

3.3 (.5) 2.7 (.5) 235.9*

3.3 (.4) 2.9 (.4) 143.5*

2.0 (.6) 2.1 (.6) 12.9*

2.5 (.6) 2.4 (.6) 28.5*

2.3 (.8) 2.2 (.8) 4.7

4.0 (.5) 4.1 (.5) 11.4*

0.2 (.2) 0.1 (.2) 13.2*

3.6 (.4) 3.7 (.4) 14.3*


Table 3

Relation between work organisation and work characteristics

Predictor Criterium Diabetes specialist/hospital nurse/nursing home

Beta (b) R2change

R2

1. Gender Workload .05/.12***/.00 .00/.01***/.00 .00/.01/.00

Age .05/.06*/.06

2. Environmental uncertainty .38***/.24***/.09** .15***/.06***/.01** .15/.07/.01

1. Gender Autonomy �.04/.10***/�.05 .02/.01**/.00 .02/.01/.00

Age .12*/.03/�.01

2. Environmental uncertainty .05/�.03/.08** .00/.00/.01** .02/.01/.01

1. Gender Social support �.01/�.00/.02 .00/.00/.00 .00/.00/.00

Age �.04/�.00/�.03

2. Environmental uncertainty �.08/�.07**/.06 .01/.01**/.00 .01/.01/.00

1. Gender Role ambiguity �.02/�.01/�.07* .00/.00/.00 .00/.00/.00

Age .02/�.05/�.00

2. Environmental uncertainty .03/.02/�.15*** .00/.00/.02*** .00/.00/.03

1. Gender Role conflict .00/�.04/�.03 .02*/.01***/.00 .02/.01/.00

Age �.12*/�.10***/�.01

2. Environmental uncertainty .24***/.14***/.01 .06***/.02***/.00 .07/.03/.00

*p � .05, **p � .01, ***p � .001.

4.4. Relationship between work characteristics and

psychological work reactions (Line C in Fig. 1)

Explained variances showed to be higher for emotional

exhaustion (R2 = .31) and job satisfaction (R2 = .43) com-

Table 4

Relation between organisational characteristics and psychological work r

Predictor Criterium

1. Gender Emotional exhaustion

Age

2. Environmental uncertainty

1. Gender Intrinsic work motivation

Age


1. Gender Psychosomatic complaints

Age


1. Gender Job satisfaction

Age


*p � .05, **p � .01, ***p � .001.

pared to intrinsic motivation (R2 = .05) and psychosomatic

complaints (R2 = .10) (Table 5).

Emotional exhaustion indicates a positive relation with

high workload, role conflict, and role ambiguity across all

settings. Job satisfaction was predicted by all measured work

eactions

Diabetes specialist/hospital nurse/nursing home

Beta (b) R2change

R2

�.00/�.02/�.00 .00/.00/.00 .00/.00/.00

.05/.00/�.01

.09/.05/�.01 .01/.00/.00 .01/.00/.00

.10*/.10***/.02 .02/.01***/.02*** .02/.01/.02

.05/.08**/.13***

�.02/.09**/.12*** .00/.01**/.01*** .02/.02/.03

.02/.04/.05 .00/.00/.00 .00/.00/.00

.06/�.01/.00

.10/.06*/�.03 .01/.04*/.00 .01/.01/.00

.07/.05/.01 .01/.01*/.00 .01/.01/.00

.01/.07*/�.01

�.07/�.05/.12*** .01/.00/.02*** .01/.01/.02


Table 5

Relations between work characteristics and psychological work reactions

Predictor Criterium Diabetes specialist/hospital nurse/nursing home

Beta (b) R2change

R2

1. Gender Emotional exhaustion .02/�.05/�.04 .01/.00/.00 .01/.00/.00

Age .06/.01/�.03

2. Workload .36***/.35***/.34*** .20***/.20***/.20*** .21/.20/.20

3. Autonomy .13/.04/�.01 .00/.00/.00* .21/.20/.20

4. Social support �.07/�.14***/�.18*** .03***/.05***/.05*** .24/.25/.25

5. Role ambiguity .24***/.10***/.06* .07***/.04***/.02*** .31/.29/.27

Role conflict .14*/.18***/.13***

1. Gender Intrinsic .11/.08**/.01 .01/.01***/.02*** .01/.01/.02

Age Work motivation .02/.07*/.13***

2. Workload .06/�.08*/.08* .00/.00/.00 .01/.02/.02

3. Autonomy .12*/�.02/�.01 .02*/.00/.00 .03/.02/.02

4. Social support .08/.12/.07 .01/.01***/.01*** .04/.03/.03

5. Role ambiguity .04/.04/�.05 .01/.00/.01** .05/.03/.04

Role conflict �.10/�.04/�.09** .00/.00/.00

1. Gender Psychosomatic complaints .01/.02/.05 .01/.00/.00 .01/.00/.00

Age .08/�.01/�.01

2. Workload .24***/.20***/.18*** .08***/.07***/.07*** .08/.07/.07

3. Autonomy �.00/.02/�.07* .00/.00/.01*** .08/.07/.08

4. Social support �.01/�.10**/�.14*** .00/.02***/.03*** .09/.09/.11

5. Role ambiguity .10/.06/.04 .01/.01***/.01** .10/.10/.12

Role conflict .06/.09**/.08* .00/.00/.00 .10/.10/.12

1. Gender Job satisfaction .07/.07**/�.02 .01/.01*/.00 .01/.01/.00

Age .00/.06*/.01

2. Workload �.12*/�.21***/�.16*** .07***/.14***/.13*** .08/.15/.13

3. Autonomy �.15***/.06**/0.11*** .07***/.02***/.05*** .15/.17/.17

4. Social support �.30***/.34***/.36*** .19***/.19***/.20*** .33/.36/.38

5. Role ambiguity �.30***/�.19***/�.22*** .10***/.05***/.06*** .43/.41/.44

Role conflict �.13**/�.15***/�.16*** .00/.00**/.00 .43/.42/.44

*p � .05, **p � .01, ***p � .001.

characteristics, from which high work load, role ambiguity,

and role conflict had similar relations across all samples.

High workload was positive associated with psychosomatic

complaints in all three samples. Interaction terms have been

tested but were not additional to the model.

4.5. The mediating role of work aspects (Line B2 in

Fig. 1)

The possible mediating role of work aspects in the

relationship between work organisation and psychological

work reactions was not tested in a DSN setting because there

were no significant correlations found between psychologi-

cal work reactions and environmental uncertainty and there-

fore a mediating role is out of the question (Bennett, 2000).

In the hospital and nursing home settings, some results were

determined, which indicated that a mediator role is plausible

(van den Berg et al., 2006).

5. Discussion

The main purpose of this study was to extend knowledge

concerning the work situation of DSN in relation to a tradi-

tional health care setting. This study demonstrates that 10% of

DSN in the Netherlands are working in an integrated care

setting, whereas 40% are working in a home care (general

practice) setting and 41% in a setting which is available after

reference by the GP, for example hospital. The other 10%

worked in other settings. This finding corresponds with earlier

research conducted by Steuten et al. (2002). The majority of

DSN (78%) perform their tasks as part of a multidisciplinary

team. This result conforms to the frequent use of multidisci-

plinary teams in diabetes management and supports

Mulcahy’s (1999) opinion, that in diabetes management the

use of multidisciplinary teams are logical given the multi-

dimensional nature of diabetes. In addition, indications sug-

gest that almost all DSN are not specialised in any other fields


other than diabetes (67%). This supports the finding by

Vrijhoef et al. (2002), that the DSN is highly specialised

and purely focused on diabetic care.

Some limitations must be taken into account in this study.

First, the cross-sectional design does not permit exploration

of causal relationships between work and organisational

characteristics and psychological work reactions. Neverthe-

less, the results are still of interest as they give a first insight

in influence of differences in work setting on psychological

work reactions. Second, the psychometric quality of the

organisational work characteristics was very poor. In the

DSN sample reliability analysis showed unsatisfactory

Cronbach’s alphas for decision authority and complexity.

Both variables were omitted from the analysis. The two

scales were not appropriate to measure aspects of the con-

tingency theory in nursing. Third, no non-response analyses

could be performed. The response in the DSN sample (41%)

was quite lower than in the hospital (68%), and nursing home

sample (62%). One explanation could be that nurses working

in general hospitals and nursing homes were informed by the

managers during the ward meeting about the research topic

and purpose, the data collection procedure, and the research

report. Whereas DSNs were directly invited to participate in

the study without mediation of the manager.

In general, differences in work organisation, work char-

acteristics, and psychological work reactions were significant,

although the differences were small. In regard to the work

organisation, this study revealed that the environmental uncer-

tainty is low amongst DSN in comparison to hospital nurses

and nursing home caregivers. Apparently, in the field of

diabetes nursing, more knowledge concerning workflow or

when ‘‘the inputs’’ will arrive, i.e. patient inflow exists. The

findings were as expected. In principle, the patient [visit]

schedule is known and care needs are relatively predictable.

From a work and health point of view, relatively positive

results were found regarding the work aspects of the DSN in

relation to nurses working in general hospitals and nursing

homes. For example, DSNs scored lowest on workload and

role conflict, and highest on autonomy. Despite, again it

should be mentioned differences were only minor, except

for autonomy. DSNs regard autonomy higher than hospital

nurses or nursing home caregivers. The DAWN study (Simi-

nerio et al., 2007) showed, regarding responsibilities, that

specialist nurses functioned at a more advanced level and

reported taking a more active role in facilitating both self-

management and medication management than generalist

nurses did. In Brown et al., 2001 it was mentioned that

diabetes educators express frustration over the limited author-

ity they have in caring for patients with diabetic . Despite this

frustration, the fact that they work on an independent basis is a

likely factor in the high score for autonomy, compared with

nurses working in other health care settings. Working inde-

pendently probably attributes to the low scores for social

support (from both supervisors and colleagues). Operational

tasks are performed rather independently. Personal feedback

and support is only obtained during the meetings of the

multidisciplinary team. This finding is in agreement with a

study among nurse consultants (Woodward et al., 2005) in

which specialised nurse consultants felt less social support

from their immediate colleagues than non-specialised nurse

consultants felt. This lack of social support could be decreased

by focussing on the emotional nature of support from peers

and colleagues than that of a physical presence. The knowl-

edge that the nurse can share with a peer or a manager while

alone at work under difficult circumstances should be

strengthened (Neal-Boylan, 2006). The high scores for role

ambiguity may be explained by the fact that the function of a

DSN is in the developmental stage where roles increase and

are amended. Registration of tasks and responsibilities were

available in such documents as task description (54% of all

registrations), function profile (10%) or protocol (10%).

Apparently, the registration of tasks and responsibilities are

in all likelihood, not sufficient enough to compensate this

dynamic role development.

In regard to work and health, positive results attributed to

work aspects are also identified in work reactions. This has

resulted in the highest scores being allocated to intrinsic

work motivation and work satisfaction, and the lowest scores

being allocated to psychosomatic health.

The specialised tasks of the DSN could be positive for the

experience of stress as the inability to use all of their skills on

the job was reported to cause stress in nursing home nurses

(Lapane and Hughes, 2007). Yet, equivalent univariate

analyses indicated that there were no significant differences

of emotional exhaustion between the three health care

settings examined in this study. In Charman (2000), it

was reported that DSN were at high risk of emotional

exhaustion because of their perfectionist character and the

psychosocial stressors they regularly deal with. However,

these risk factors are not specifically associated to DSN, but

rather to the nursing profession in general.

With regard to the second aim of the study, it was

disclosed that in the DSN setting, environmental uncertainty

was positive in relation to workload and role conflict. Work

organisation characteristics, decision-making authority, and

complexity could not be investigated, as the psychometric

quality of these, were not acceptable. No direct relation

exists between environmental uncertainty and the psycho-

logical work reactions. As a result, any possibility of a

mediating role of work characteristics is out of the question.

With regard to the relationship between the work character-

istics and psychological work reactions, it can be concluded

that workload was an important predictor of emotional

exhaustion and psychosomatic complaints in all three sam-

ples. From the psychological work reactions job satisfaction

was best predicted by the work characteristics, which is in

line with findings of Rafnsdottir et al. (2004) among nurses

in geriatric care. With exceptions to the negative association

between autonomy and social support with job satisfaction

in the DSN sample, results are in line with the DCS model.

Work organisation environmental uncertainty forecast

negative work characteristics (more workload and role con-


flict, less social support) in the DSN and hospital setting.

This was not true in the nursing home setting: environmental

uncertainty was a forewarning of more autonomy and less

role ambiguity. In the nursing home setting environmental

uncertainty forecast positive psychological work reactions

(more intrinsic motivation and job satisfaction). In the

hospital setting relations between environmental uncertainty

and psychological work reactions were contradictory.

These contradictory findings can probably be attributed

to the unsatisfactory psychometric quality of the work

organisation variables. Moreover, in all health care settings,

explanatory variances were low. In the DSN sample these

varied from .01 to .43.

6. Conclusions

The work of a DSN can be distinguished by certain

characteristics. From an organisational point of view, the

work setting is characterised by low environmental uncer-

tainty in comparison with nurses employed in the other two

health care settings (hospital and nursing home). Further-

more, the work of the DSN can be characterised by high

autonomy and role ambiguity, low workload, social support,

and role conflict. Relations between organisational charac-

teristics, work aspects, and psychological work reactions

indicated conflicting results due to differing psychometric

qualities of the environmental uncertainty variable. DSNs

scored most positive in regard to psychological work reac-

tions. It can be concluded that differences in the work

organisation through transition of work tasks and high

specialisation of nurses has a positive influence on the

psychological work reactions in comparison with a more

traditional health care setting.

Continued improvement of the work situation of DSNs

should focus on decreasing role ambiguity and increasing

social support. Since the nurse practitioner is the future trend

in health care (Reay et al., 2003), e.g. the DSN, it might be

expected that transition of work tasks and high specialisation

of advanced nurses or nurse practitioners have a positive

influence on psychological work reactions in comparison

with a more traditional health care setting.

Recommendations for additional work suggest a need for

the optimal measurement of organisational characteristics.

As this study reveals, scales for organisational characteris-

tics require improvement and should even be combined with

objective data related to variances in patient flow, patient

mix, and role differentiation.

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