Title: Investigating and Measuring Certified Registered Nurse Anesthetist Organizational Climate
Description: Approximately 40,000 certified registered nurse anesthetists (CRNAs) are included in the anesthesia workforce in the United States. They provide a critical portion of anesthesia care throughout the country often practicing in rural and underserved areas of America. CRNAs are educated and trained to provide high-quality, cost-effective care for patients. Policy makers and health care organizations consistently call for policies to enable these providers to deliver care to the full extent of their education and training. The National Academy of Medicine (former Institute of Medicine) recommends in their seminal report, The Future of Nursing: Leading Change, Advancing Health, that CRNAs practice to their full potential as full partners with physicians. In order to promote CRNA ability to practice to the full extent of their training and education and assure that patients have access to safe anesthesia services, both policy and organizational influences on their care provision and should be taken into account.

Whereas focus has been paid to policy restrictions and their influence on CRNA care, little is known about organizational influences on CRNA care or organizational structures that are present in the employment settings of CRNAs. Organizational climate, which is employees’ perceptions of and experience with organizational structures within their employment settings, has been studied in healthcare settings. Studying organizational climate in healthcare settings is important because research concludes that organizational climate of healthcare settings impacts providers and patients. Registered nurse (RN) organizational climate has been well studied, and researchers identified that important aspects of RN organizational climate include autonomy, control over practice, teamwork, and collaborative relationships with physicians and staff. When RN organizational climate is favorable, job satisfaction and nurse retention improve, and patients receive high-quality care. Researchers have also studied nurse practitioner (NP) organizational climate and have identified climate characteristics that enable NPs to function to their full capacity, while promoting job retention, decreasing costs, and improving access to care.

Whereas evidence is clear that organizational climate is an important concept to study within healthcare organizations, little is known about CRNA organizational climate or how it impacts CRNA outcomes or patient outcomes, nor do we know how to measure organizational climate and further asses it. Therefore, this dissertation investigates CRNA organizational climate and adapts a tool to measure CRNA organizational climate. In Chapter 1, a background on CRNA contributions to anesthesia care in the United States is presented. In addition, challenges and restrictions affecting CRNA practice are discussed, and studying the concept of CRNA organizational climate is introduced. The theoretical and empirical underpinnings guiding the dissertation are presented, and the three aims of the dissertation are stated. In Chapter 2, aim one of the dissertation is addressed. Aim one of the dissertation is achieved by systematically reviewing and synthesizing evidence regarding CRNA working conditions and outcomes.

This evidence lays the foundation for studying CRNA organizational climate. In Chapter 3, aim two of the dissertation is addressed. This aim is achieved by selecting an instrument to adapt to measure CRNA organizational climate. In this chapter, the processes of content validity testing and reliability testing of the Certified Registered Nurse Anesthetist Organizational Climate Questionnaire (CRNA-OCQ), the adapted instrument to measure CRNA organizational climate, are presented. In Chapter 4, aim three of the dissertation is addressed. This aim is achieved by the further psychometric testing of the CRNA-OCQ, which is presented in this chapter. In this chapter, the CRNA-OCQ is refined and finalized through conducting exploratory factor analysis. In addition, the internal consistency reliability of CRNA-OCQ subscales is assessed. In Chapter 5, results from the three included studies are discussed and synthesized. In addition, practice, policy, and research recommendations are presented. Lastly, the strengths and limitations of the dissertation are discussed before the conclusion.