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We interviewed hospital leaders and unit nurses in twenty-five hospitals between June and October 2008 to explore the effect of performance-based incentives. Interviewees expressed favorable impressions of the impact that incentive policies have on quality and safety. However, they raised concerns about the policies' effects on the nurse workforce. Their concerns included the belief that performance-based incentives would increase both the burden and the blame for nurses without corresponding improvements in staffing levels, work environment, salaries, or turnover. To maximize the intended policy impact without jeopardizing the workforce that holds the key to their adoption, we recommend that policy makers invest in implementation support, redesign hospital incentives to reward teamwork, and involve nursing leaders in the design of future incentive policies.

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Background: A suite of robust instruments are required to investigate the range of contextual and social dimensions in the nursing workforce that contribute to desired outcomes such as resilient work environments, high retention rates, and provision of quality health care. However current instruments do not adequately measure the formal and informal social relationships between nurses and others on the team. This gap is problematic because social relationships can influence how well nurses work together to achieve the desired outcomes. To this end, instruments from other disciplines could be adapted to investigate social dimensions.Purpose: To examine how a social capital framework could measure social relationships in nursing work environments and inform policy and managerial initiatives to reduce turnover and improve quality.Method: Eight contemporary instruments that assess social dimensions and sub-scales in nursing work environments were reviewed. An instrument that measures social dimensions known as social capital (networks, norms, outcomes) was also reviewed for adaptation in nursing. Findings:The eight contemporary instruments do not adequately measure the nature of social relationships (networks, norms, outcomes) between nurses. A social capital instrument developed by social researchers and economists could be adapted to add value and understanding of social relationship issues. Policy Implications and Conclusions:It is timely to develop robust qualitative and quantitative instruments that will permit the examination of social capital in nursing populations globally, and identify mechanisms to achieve desired outcomes, such as job satisfaction, retention, and quality health care.

It is now well accepted that working in research teams that span universities, jurisdictions and countries can be rewarding and economically prudent. To this end, investigators collaborate in the pursuit of knowledge to address human and societal problems and translate results into local and global contexts. This implies that investigators need to develop study instruments that are fit for purpose and strategically manage issues arising from geographical, linguistic and cultural diversity.  A proven method is cognitive interviewing to pre-test the study materials to ensure clarity and relevance in the study population. This paper describes the steps taken to increase the methodological reliability of study instruments through the use of cognitive interviewing and argues this technique should be a standard step in instrument development.