Christine L. Covell PhD, RN
Souraya Sidani, PhD
Due to rising costs of healthcare, determining how registered nurses and knowledge resources influence the quality of patient care is critical. Studies that have investigated the relationship between nursing knowledge and outcomes have been plagued with conceptual and methodological issues. This has resulted in limited empirical evidence of the impact of nursing knowledge on patient or organizational outcomes. The nursing intellectual capital theory was developed to assist with this area of inquiry. Nursing intellectual capital theory conceptualizes the sources of nursing knowledge available within an organization and delineates its relationship to patient and organizational outcomes. In this article, we review the nursing intellectual capital theory and discuss its implications for research and practice. We explain why the theory shows promise for guiding research on quality work environments and how it may assist with administrative decision-making related to nursing human resource management and continuing professional development.
Citation: Covell, C., Sidani, S., (May 31, 2013) "Nursing Intellectual Capital Theory: Implications for Research and Practice" OJIN: The Online Journal of Issues in Nursing Vol. 18, No. 2, Manuscript 2.
Keywords: nursing, knowledge, intellectual capital, human capital, structural capital, quality of care, recruitment, retention, work environment, employer support, nurse staffing, continuing professional development, specialty certification, academic preparation, experience, middle-range theory
Increased demands for healthcare in combination with its rising costs have led to a heightened interest to understand how nursing knowledge influences the quality of care administered to hospitalized patients. The need to better understand the mechanism through which nursing knowledge influences patients and organizations is important as investing in registered nurses and their knowledge development is cost prohibitive for many healthcare organizations and countries. As a result, several initiatives are being implemented including changes in nurse staffing and models of care delivery. These changes are creating challenges in terms of knowing the most appropriate nurse staffing patterns to keep patients safe and levels of support for developing the knowledge registered nurses need to achieve the best patient and system outcomes. To address these questions, researchers have primarily focused on trying to understand the relationship between nurse staffing levels and the occurrence of adverse events, such as patient falls (Blegen & Vaughn, 1998; Blegen, Vaughn, & Goode 2001). Although initially ground-breaking, nurse staffing studies have been plagued with conceptual and methodological issues which have limited the applicability to practice and the validity of their results, respectively (Butler et al., 2012; Clarke & Donaldson, 2008; Spilsbury et al., 2011). Specifically, the majority of the nurse staffing studies are atheoretical (Mark et al., 2004). Therefore, they do not provide a comprehensive conceptualization of nursing knowledge available within healthcare organizations. As such, the evidence falls short in providing a complete understanding of the availability and the contribution of nursing knowledge within an acute care hospital to patient outcomes. The need to better understand the mechanism through which nursing knowledge influences patients and organizations is important as investing in registered nurses and their knowledge development is cost prohibitive for many healthcare organizations and countries (Phillips, Piza, & Ingram, 2012).
Intellectual capital theory provides for such an understanding and is the focus of this discussion. The theory of intellectual capital has been adapted to nursing and is proposed as a guide to research in this area. In this article, we review the parent and nursing theories, summarize empirical evidence, and delineate implications for the use of the theory for research and practice.
Overview of Intellectual Capital
As an intangible organizational asset, intellectual capital includes the knowledge of individual employees or groups of employees who are deemed critical to a company's continued success, and organizational structures that contain information about processes, customers or other information that contributes to improved business performance or profits Intellectual capital is the combination of collective knowledge of individuals and structures in an organization or society (Business Dictionary, 2013). As an intangible organizational asset, intellectual capital includes the knowledge of individual employees or groups of employees who are deemed critical to a company's continued success, and organizational structures that contain information about processes, customers or other information that contributes to improved business performance or profits (Dumay, 2012; Sullivan, 1998). Intellectual capital management is the process of effectively using these knowledge resources to gain a competitive advantage for the organization (Edvinsson & Malone, 1996; Youndt, Subramanian, & Snell, 2004).
Grounded in the fields of economics and accounting, intellectual capital theory delineates the stocks (or sources) and flow of knowledge within organizations (Bontis, 1999). Intellectual capital theory proposes a relationship between knowledge stocks at all levels of the organization. As an increase in individual, group, and organizational knowledge stocks occurs, business performance also improves. An increase in knowledge stocks can happen through organizational investment in learning and hiring or retaining employees. Stocks of knowledge within an organization are diffused through the use of the organization’s social networks (Seibert, Kraimer, & Linden, 2001). Social networks involve personal relationships and social interactions among individuals. It is believed that social networks among employees assist organizations with learning and innovation by increasing the efficiency of information diffusion, encouraging cooperative behavior, and reducing the costs of transactions (Nahapiet & Ghoshal, 1998). Social networks may facilitate the development of intellectual capital by creating the conditions necessary for knowledge exchange. Intellectual capital is composed of three domains: human capital, structural capital and relational capital (Stewart, 1997).
In nursing, intellectual capital is the stocks of nursing knowledge available within a healthcare organization. In nursing, intellectual capital is the stocks of nursing knowledge available within a healthcare organization. It is the combination of nursing knowledge that resides within registered nurses and in organizational structures used by registered nurses to facilitate their clinical decision-making while delivering nursing care. Nursing intellectual capital reflects the knowledge of registered nurses and knowledge resources available on inpatient care units as that is where there is the greatest concentration of registered nurses providing care to hospitalized patients (Covell, 2008; Dumay, 2012; Grantham et al., 2007) within an organizational setting.
It has been suggested that stocks of knowledge within nursing are diffused throughout the nursing unit via the unit’s social network of interpersonal contacts and relationships. Social networks in nursing have been identified as essential for the development of new knowledge, innovation, or creating professional behavior change within the organization (Thomspon, Estabrooks & Degner, 2006). Nursing intellectual capital theory is composed of two interdependent concepts, nursing human capital and nursing structural capital.
Intellectual capital theory defines human capital as the knowledge, talents and experience of employees (Stewart, 2001). Human capital resides within the employee and is loaned to the organization by the employee. It leaves the organization when the employee separates from the organization (Stewart, 1997; Sullivan, 1998).
The attributes of nursing human capital, nurses’ knowledge or experience have been empirically linked to better quality patient care... Human capital within hospitals is extremely important as it reflects the work of highly knowledgeable and skilled people caring for those in need of specialized healthcare (Peng, et al., 2007). Nursing human capital is the knowledge, skills, and experience of registered nurses (McGillis Hall, 2003). It is defined as the theoretical and practical knowledge registered nurses obtain from academic education, participation in continuing professional development activities and specialty training and work experience (Covell, 2008). It is operationalized as the proportion of registered nurses with degrees, proportion of registered nurses with specialty certification, hours of continuing education registered nurses attend per year, years of registered nurse professional experience, years of registered nurse unit tenure or seniority, and years of registered nurse experience in clinical specialty. The attributes of nursing human capital, nurses’ knowledge or experience have been empirically linked to better quality patient care; for example, lower rates of patient falls, patient mortality and failure to rescue (Aiken et al., 2011; Duffield et al., 2011, Tourangeau et al., 2007).
Structural capital is the stock of knowledge that has been converted to the information that exists within an organization’s structures, systems, and databases (Stewart, 1997). Examples of structural capital include software, patents, and trademarks.
Nursing structural capital is operationalized as the availability of practice guidelines for the prevention of adverse events. For nursing, structural capital is the structural resources that contain nursing knowledge and are used to support registered nurses in the application of their knowledge and skills in the delivery of patient care. Examples of nursing structural capital include practice guidelines, care maps, information systems, and information technology such as devices used for diagnostic purposes (e.g. blood glucometers, telemetry) and portable computerized devices (e.g. laptops, iPads, personal digital assistants) used for acquiring evidence-based information when delivering care (Doran & Mylopoulos, 2008). Nursing structural capital is operationalized as the availability of practice guidelines for the prevention of adverse events. The availability of practice guidelines, care maps or protocols have been found to be associated with better quality of patient care and lower adverse events (Duffield et al., 2011; Oman et al., 2012; Tourangeau et al., 2007).
Relational capital represents the knowledge that is contained within the organization’s relationships with internal and external stakeholders and is influenced by the organization’s human and structural capital (Bontis, 2002). A meaningful conceptualization for relational capital has not yet been developed for nursing; it may be reflected in informal or collaborative knowledge translation strategies.
Work Environment and Intellectual Capital
Intellectual capital contains two concepts within the work environment: human capital investment and human capital depletion. Human capital investment and human capital depletion influence the development of human capital (Bontis & Fitz-enz, 2002).
Human Capital Investment: Employer Support for Nurse Continuing Professional Development
Human capital investment represents the organization’s investment in the development of their employees’ human capital through hiring and training initiatives. Organizational investment in training and development, measured as the average dollar amount spent on training for each employee, has been found to positively influence the development of human capital (Bontis & Fitz-enz, 2002).
The presence of nurse educators or specialists to assist registered nurses with clinical decision-making and knowledge and skill development has been found to positively influence the quality of patient care. Healthcare organizations invest in the knowledge and skill development of registered nurses through continuing professional development activities (Covell, 2009). In the nursing intellectual capital theory, human capital investment is redefined as employer support for nurse continuing professional development. It represents a set of behaviors and beliefs demonstrated by the organization that promote and value the education of registered nurses after they enter the profession (Kramer & Schmalenberg, 2004). It is operationalized as the financial support provided to registered nurses by the organization to attend continuing education activities, university courses, and specialty certification; time off to attend continuing education activities; the availability of replacement staff for registered nurses attending continuing education; and clinical educators or consultants (Covell, 2008). Registered nurses have reported they require financial assistance and time off work in order to attend continuing professional development activities (Schweitzer & Krassa, 2010). The presence of nurse educators or specialists to assist registered nurses with clinical decision-making and knowledge and skill development has been found to positively influence the quality of patient care (Butler et al., 2011; Duffield et al., 2011).
Human Capital Depletion: Nurse Staffing
Human capital depletion is the loss of human capital through employee turnover. Developing and retaining employees maintains their human capital which contributes to the organization’s business performance (Bontis & Fitz-enz, 2002).
Higher levels of registered nurse staffing have been associated with better patient outcomes... In healthcare organizations, nursing human capital is reflected in nurse staffing. The recruitment and retention of registered nurses with high knowledge, skills and experience preserves the unit’s nursing human capital to competently care for patients (Capuano, Bokovoy, Hitchings, & Houser, 2005). Nurse staffing is defined for the nursing intellectual capital theory as the supply of registered nurses and mix of registered nurses who possess the knowledge and skills to competently meet the care needs of patients on the unit. It is operationalized as the hours per patient per day, skill mix and registered nurse-to-patient ratio (Covell, 2008). Higher levels of registered nurse staffing have been associated with better patient outcomes (Kane et al., 2007), such as lower rates of pressure ulcers (Twigg, Duffield, Bremner, Rapley, & Finn, 2012), mortality (Sales et al., 2009), patient falls (Duffield et al., 2011) and medication errors (Frith & Anderson, 2012).
Outcomes associated with intellectual capital include improved business performance or the creation of intellectual assets such as innovative technologies or products which create future returns for the company. Intellectual capital assets... have been found to be positively associated with business performance or future outlook for the organization. Performance outcomes are achieved by investing in human capital resources which will produce future returns for the organization by creating intellectual assets or improving performance (Sullivan, 1998). Intellectual capital assets including organizational systems, structures and routines that are developed from the organization’s human capital have been found to be positively associated with business performance or future outlook for the organization (Bontis & Fitz-enz, 2002; Youndt et al., 2004).
Two categories of performance outcomes are associated with nursing intellectual capital. They include outcomes related to the quality of patient care reflected in the rates of adverse events such as hospital-acquired infections, patient falls and medication errors, and cost-related organizational outcomes; for example hours used for nurse orientation, recruitment, and turnover, and vacancy statistics (Covell, 2008).
Propositions of the Nursing Intellectual Capital Theory
The middle-range theory of nursing intellectual capital proposes nursing human capital, operationalized as registered nurses’ knowledge, skills, and experience, is related to patient outcomes associated with quality of patient care and organizational outcomes associated with registered nurse recruitment and retention. Two factors within the work environment, nurse staffing and employer support for nurse continuing professional development, are proposed to influence nursing human capital’s association with quality of patient care and recruitment and retention outcomes. The theory also proposes that nursing structural capital is directly related to quality of patient care outcomes. Table 1 summarizes the propositions of the intellectual capital theory in business and nursing.
Table 1. Concepts and Propositions of Intellectual Capital Theory in Business and Nursing
Intellectual Capital Theory
Nursing Intellectual Capital Theory
Intellectual capital is organizational knowledge that is translated into business performance (Bontis, 1999).
Nursing intellectual capital is nursing knowledge that is translated into nursing and organizational performance.
Business performance leads to organizational profits and retention of key people (Bontis & Fitz-enz, 2002).
Nursing performance leads to improvements in patient outcomes associated with quality of patient care such as reduction in adverse events, such as hospital-acquired infections, patient falls, and medication errors.
Organizational performance leads to improvement in organizational outcomes, such as the cost-related outcomes associated with the recruitment and retention of knowledgeable and experienced registered nurses including (e.g. lower orientation hours, registered nurse turnover, vacancy, higher recruitment and retention statistics).
Human capital is the knowledge, skills, and experience of employees (Edvinsson & Malone, 1997).
Nursing human capital is the knowledge, skills and experience of registered nurses (McGillis Hall, 2003). For registered nurses, this is reflected in:
- Academic preparation
- Specialty certification status
- Hours of continuing education attended
- Professional experience
- Unit tenure
- Clinical specialty experience
Structural capital is organizational knowledge that exists within the organization’s filing cabinets, databases, and routines (Edvinsson & Malone, 1997). Structural capital supports the use of the organization’s human capital (Bontis, 2002).
Nursing structural capital is the structural resources that contain nursing knowledge and are used to support registered nurses in the application of their knowledge and skills in the delivery of patient care. It is operationalized in:
- Availability of practice guidelines, care maps, and protocols
- Information technology for diagnostic purposes (e.g. glucometers, telemetry)
- Portable computerized devices used for acquiring evidence-based information (e.g. laptops, iPads, personal digital assistants)
Human capital investment is the investment by organizations in the development of employees’ knowledge and skills through training and development initiatives (Bontis & Fitz-enz, 2002).
Employer support for nurses' continuing professional development is the investment by the organization in the knowledge and skill development of registered nurses through continuing professional development activities.
It is captured in the following strategies:
- Financial assistance from the organization for registered nurses to attend continuing professional development activities
- Paid and unpaid time off for registered nurses to learn, such as study leaves
- Availability of replacement staff for registered nurses when away from the unit to learn
- Availability of clinical educators or consultants to assist registered nurses with clinical decision-making and knowledge and skill development
Human capital depletion is the loss of employees with knowledge and skills that are of value to the organization (Bontis & Fitz-enz, 2002).
Nurse staffing is the supply and the mix of registered nurses who possess the knowledge, skills and experience to competently meet the care needs of patients on the unit (American Nurses Association, 2002). It is operationalized into:
- Hours per patient per day
- Skill mix
- Registered nurse-to-patient ratio
Adapted from Covell (2008).
Summary of Research on Intellectual Capital
Positive associations among intellectual capital and business performance have been reported in the literature. Organizations with high intellectual capital have been found to outperform organizations with less intellectual capital as measured by stronger financial returns and financial performance (Bramhandkar et al., 2007; Youndt et al, 2004). Intellectual capital or its related concepts, human capital and structural capital, have been used to frame discussions in the nursing literature related to recruitment and retention of registered nurses (Collins & Collins, 2006; Faulk, 2007); marketability of registered nurses’ knowledge and skills (Hudspeth, 2006; Shirey, 2006); leadership and mentorship of registered nurses
(Davidson, 2007; Reidinger, 2010; Thomka, 2007); use of information technology (Poe, 2011; Simpson, 2007); creation of quality work environments for registered nurses (Weston, Estrada, & Carrington, 2007); and patient safety (Hadaway, 2010). Intellectual capital in nursing has been studied by two groups of Canadian researchers. Rondeau, Williams, and Wagar (2009) investigated the impact of investing in human capital development through staff training on voluntary turnover of registered nurses. Surveying greater than 2000 hospitals across Canada, they found that the perceptions of nursing human capital and the amount of staff training were modestly associated with lower levels of employee turnover. This suggests that healthcare organizations that make greater investments in developing their nursing human capital by providing continuing professional development opportunities for their registered nurses are more likely to retain registered nurses. This finding is consistent with the literature on quality work environments (Weston et al., 2007) and Magnet hospitals (Aiken et al., 2011; Kramer & Schalmenberg, 2004).
Covell and Sidani (2013) tested the newly developed middle-range theory of nursing intellectual capital. Using financial, human resource and risk data from 91 inpatient care units from 6 hospitals, they simultaneously tested two propositions of the theory. First, nurse staffing (measured as registered nurse-to-patient ratio, skill mix, and hours per patient per day) is associated with nursing human capital (measured as academic preparation, specialty certification, hours of continuing education, professional experience, and unit tenure), which in turn, is associated with the quality of patient care (low rates of adverse events of hospital-acquired infections, medication errors, and patient falls) and the recruitment and retention of registered nurses (hours of orientation, vacancy, turnover, and recruitment rates). Second, employer support for nurse continuing professional development (measured as financial assistance, replacement, time off to learn, and availability of clinical educators) is associated with nursing human capital, and in turn, the quality of patient care and recruitment and retention of registered nurses.
The findings supported the first proposition as the nursing human capital variables of academic preparation, unit tenure, professional experience, and specialty certification were associated with lower rates of hospital-acquired infections and lower nurse vacancy rates. This relationship signifies that units with higher levels of nursing human capital (i.e., have highly educated and experienced nursing staff) have better quality of care. They also reported that the association of nurse staffing (represented by three indicators: registered nurse-to-patient ratio, skill-mix, and hours per patient per day) and rates of hospital-acquired infections was partially mediated by the nursing human capital variable of academic preparation. This indicates that the relationship between nurse staffing and hospital-acquired infections was partially reduced by the proportion of registered nurses with university degrees (bachelors or higher). This partially mediated relationship begins to explain the mechanisms underlying the association of nurse staffing with better patient outcomes.
However, the second proposition was not supported. The variables reflecting the employer support for nurse continuing professional development concept were not associated with the nursing human capital variables or with the quality of care or registered nurses recruitment and retention outcomes. This may be due to the type of indicators or data used to measure employer support for the nurse continuing professional development concept in that organizations may apply a subset, but not all, of the strategies to support registered nurses' professional development.
In summary, these findings provide emerging evidence to validate the major proposition of the nursing intellectual capital theory; higher levels of nursing human capital are associated with better quality patient care and registered nurse recruitment and retention. Thus it is the combination of the registered nurses’ knowledge (academic preparation), skills (specialty certification), and experience (unit tenure and professional experience), which are associated with higher quality patient care (low hospital-acquired infections) and better recruitment and recruitment statistics (manifested by less need to recruit and orient new registered nurses).
Potential Utility of the Nursing Intellectual Capital Theory
To date, nursing theories that guide nursing administrative research are limited (Mark et al., 2004), this has resulted in little theoretical explanation of the relationships among nursing knowledge or factors within the work environment (i.e. nurse staffing) and patient and organizational outcomes. Nursing intellectual capital theory was developed to address this theoretical gap. This theory provides a conceptualization of nursing knowledge available within an organization (human and structural) and an explanation of the potential mechanisms responsible for the impact of nursing knowledge on patient and organizational outcomes.
[Nursing intellectual capital theory] proposes meaningful interrelationships among characteristics within the work environment... Nursing intellectual capital theory is a middle-range theory as it is composed of a limited number of concepts and propositions which can be measured and tested in different contexts (Fawcett, 1998). It introduces a framework for understanding the contribution of nursing knowledge within an organization. Innovative in its conceptualization of the work environment as a major influencing factor on the development and use of the collective nursing staff’s human capital, nursing intellectual capital theory is explanatory in nature. It proposes meaningful interrelationships among characteristics within the work environment, such as nurse staffing levels; employer support for nurse continuing professional development; nursing human capital; and the quality of patient care and the recruitment and retention of registered nurses (Covell, 2008).
Though the theory conceptualized the collective human capital of registered nurses working on inpatient care units, it also shows promise for guiding studies designed to investigate the human capital of registered nurses that occupy other types of nursing roles such as public health registered nurses, academics, and advanced practice registered nurses. This type of investigation would require careful consideration of the desired outcomes and factors that may be associated with the registered nurses’ use of their human capital (Covell, 2008). However, further theoretical work is required to refine some measures of the concepts, specifically those associated with the employer support for nurse continuing professional development and nursing structural capital concepts (Covell & Sidani, 2012). The propositions should also be retested with data from different contexts and countries to confirm the study’s findings.
Promoting Quality Work Environments
Findings from the two studies focusing on intellectual capital in nursing are consistent with the Magnet hospital literature that suggests quality work environments positively influence the quality of patient care and retains and reduces voluntary nurse turnover within hospitals (Aiken et al., 2011; Kramer & Schalmenberg, 2004). Both studies investigated the relationship between investment in nursing human capital and registered nurse recruitment and retention. Therefore, the intellectual capital theory supports the Magnet hospital work and provides the underpinning of the ANCC Magnet Recognition Program® Model (American Nurses Credentialing Center, 2012). Specifically the concepts and mechanisms of nursing intellectual capital theory are similar to many of the Forces of Magnetism such as Force 6: Quality of Care; Force 8: Consultation and Resources; and Force 14: Professional Development (Messmer & Turkel, 2011). As such, nursing intellectual theory may also assist with explaining how the Forces of Magnetism contribute to better outcomes for patients and organizations. For example, using nursing intellectual capital theory to frame research may help explain how factors within quality work environments, such as nurse manager support or nurse–physician relationships, facilitate registered nurses’ use of their human capital, and in turn, quality patient care and the recruitment and retention of a highly competent registered nurse staff. Creating such evidence may assist healthcare administrators with allocating or obtaining funding to implement the recommendations outlined in the Magnet hospital literature.
Implications for Research
Because nursing knowledge is an intangible organizational asset, conducting research to determine its contribution to the quality of patient care is challenging. Because nursing knowledge is an intangible organizational asset, conducting research to determine its contribution to the quality of patient care is challenging. Most of the intellectual capital research, conducted in the field of business such as Fortune 500 companies, report on the perceptions of intellectual capital and does not directly measure knowledge within organizations. This approach was used by Rondeau et al. (2009), who used existing intellectual capital questionnaires to survey employees’ perceptions of the influence of organizational investment in human capital on voluntary nurse turnover in hospitals. However, studies that investigate individuals’ perceptions are predisposed to reporting biases, potentially yielding an overestimate of the relationships among concepts.
While the study conducted by Covell and Sidani (2013) attempted to measure the actual intellectual capital available within hospitals by using data from hospital departmental databases, researchers were limited by the type of data available within the participating hospitals. This further highlights the difficulty in measuring knowledge stocks within organizations, especially since Covell and Sidani (2013) found that some of the measures did not reflect the related concept well. Thus consideration may be given to modifying existing intellectual capital questionnaires to reflect the nursing intellectual capital theory. The revised questionnaire could be used to conduct studies to compare and contrast the validity of the two types of data (i.e. responses to questionnaires versus relevant indicators selected from hospital databases) in order to identify the most accurate and feasible method for measuring intellectual capital within nursing organizations. Further research should also explore the contribution of nursing intellectual capital to nursing sensitive outcomes such as patient falls and symptom management.
Implications for Practice
Since it is the combination of human capital indicators that influence better quality patient care and retain registered nurses, nurse managers may consider retaining a nursing staff that is composed of registered nurses with university degrees, specialty certification and experience. Nurse managers can accomplish these objectives in several ways. First, to increase the academic preparation of their staff, nurse managers can adjust their hiring practices to include a greater proportion of baccalaureate prepared registered nurses, reimburse registered nurses for the expenses associated with advancing their academic education, and make efforts to retain registered nurses with university degrees when possible. Findings from the study that tested selected propositions of the nursing intellectual capital theory suggests that units with higher human capital have better quality of patient care or less adverse events.
The findings from the study that tested selected propositions of the nursing intellectual capital theory suggests that units with higher human capital have better quality of patient care or less adverse events (Covell & Sidani, 2013). Findings from the study that tested selected propositions of the nursing intellectual capital theory suggested that units with higher human capital have better quality of patient care or less adverse events. Thus, in order to ensure safer patient care, nurse managers may consider employing a high number of registered nurses with specialty certification (Kendall-Gallagher & Blegen, 2009; Newhouse, Johantgen, & Pronovost, 2005). To accomplish this, organizations may assist registered nurses to obtain specialty certification by offering to subsidize the associated expenses such as the examination and recertification fees and providing paid time off to prepare for and write the exam.
Retaining registered nurses, thus reducing turnover, is essential to control human resource costs (O’Brien-Pallas et al., 2006). The results of the studies by Rondeau et al. (2009) and Covell & Sidani (2013) provided evidence that hospitals may be able to reduce turnover by investing in the continuing professional development of registered nurses. This is particularly important for specialty areas where it has been estimated that replacing an experienced specialty registered nurse can exceed the nurse’s salary for one year (Bland-Jones, 2008). Nurse managers may find that facilitating registered nurses’ participation in ongoing learning activities enhances their knowledge and skills, which may lead to the retention of experienced and knowledgeable registered nurses, better quality patient care, and lower orientation costs.
Continuing professional development of registered nurses within hospitals should be guided by theories not only related to how learning occurs but also those explaining the conditions under which the uptake and use of the knowledge in practice is optimal. Continuing professional development of registered nurses within hospitals through the provision of in-service education, workshops, and conferences should be guided by theories not only related to how learning occurs but also those explaining the conditions under which the uptake and use of the knowledge in practice is optimal (Committee on Planning a Continuing Health Professional Education Institute, 2010). Nursing intellectual capital theory conceptualizes the nursing human capital of the collective nursing staff. Thus to ensure that a continuing education activity has the greatest impact on patient care and costs, it is recommended that the assessment, planning, and evaluation of continuing education activities and their impact occur at the nursing unit level. Nurse managers are encouraged to consider conditions of the work environment (e.g. nurse staffing levels) and their potential influence on the registered nurses’ ability to attend educational activities (Covell, 2009).
Since investing in the development of nursing human capital seems to result is lower nurse voluntary turnover and the retention of a highly competent nursing staff, keeping records of the types and hours of internal and external continuing professional development activities attended by registered nurses is suggested. Since registered nurses are the most knowledgeable about the type and amount of continuing professional development in which they take part, the development of a nursing human capital database where registered nurses can independently update their knowledge, skills, and experience profile would give nurse managers a clearer idea of the amount of nursing human capital available on their unit. Nurse managers may be able to use this information to make decisions regarding the type of continuing professional development to provide to the nursing staff, identify mentors for new graduates or newly hired staff, and complete patient assignments and performance appraisals.
New and innovative, the nursing intellectual capital theory may help researchers generate specific and nursing-relevant research questions... The aim of this article was to present the intellectual capital theory in the context of its application to and impact on nursing research and practice. New and innovative, the nursing intellectual capital theory may help researchers generate specific and nursing-relevant research questions and understand how the knowledge that registered nurses acquire after they enter the profession and from advanced education influences outcomes. It may also help researchers begin to address the gap in the literature related to the cost benefits of developing a highly educated and skilled nursing workforce. However, refinement and testing of the middle-range theory of nursing intellectual capital in different geographical settings and types of hospitals is required prior to further determining its suitability to guide future research.
Christine L. Covell, PhD, RN
Christine L. Covell, PhD, RN, is a Canadian Institutes of Health Research-Institute of Gender and Health Postdoctoral Fellow at the Faculty of Health Science at the University of Ottawa, Ottawa, Ontario, Canada. Her areas of expertise are theory development and testing, empirical indicator development and measurement, and structural equation modeling. Her program of research focuses on determining the contribution of nursing knowledge to patient and organizations and on nursing human resources, including internationally educated nurses and models of care.
Souraya Sidani, PhD
Souraya Sidani is a Professor and Canada Research Chair at the School of Nursing at Ryerson University in Toronto, Ontario, Canada. Her areas of expertise are in quantitative research methods, intervention design and evaluation, and measurement. Her program of research focuses on evaluating interventions and advanced practice roles, examining patient preferences for treatments, and refining research methods and measures for determining the clinical effectiveness of interventions.
Aiken, L.M., Cimiotti, J. P., Sloane, D.M., Smith, H. L., Flynn, L., & Neff, D. F. (2011). Effects of nurse staffing and nurse education on patient deaths in hospital with different nurse work environments. Medical Care, 49, 1047-1053.
American Nurses Association (2012). Principles of nurse staffing (2nd ed.) Retrieved from www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/NursingStandards/ANAPrinciples/ANAsPrinciplesofNurseStaffing.pdf.aspx
American Nurses Credentialing Center. (2012). Magnet recognition® program model. Retrieved from www.nursecredentialing.org/Magnet/ProgramOverview/New-Magnet-Model
Bland-Jones, C. (2008). Revisiting nurse turnover costs. Adjusting for inflation. Journal of Nursing Administration, 38(1), 11-18.
Blegen, M.A., & Vaughn, T. (1998). A multisite study of nurse staffing and patient outcomes. Nursing Economics, 16(4), 196-202.
Blegen, M.A., Vaughn, T. E., & Goode, C. J. (2001). Nurse experience and education: Effect on quality of care. Journal of Advanced Nursing, 31(1), 33-39.
Bontis, N. (1999). Managing an organizational learning system by aligning stocks and flows of knowledge: An empirical examination of intellectual capital, knowledge management, and business performance. (Doctoral Dissertation). Dissertation Abstracts International. (AAT NQ40244).
Bontis, N. (2002). Managing organizational knowledge by diagnosing intellectual capital: Framing and advancing the state of the field. In N. Bontis (Ed.), World Congress on Intellectual Capital Readings (pp. 13-56). Boston: Butterworth Heinemann.
Bontis, N. & Fitz-enz, J. (2002). Intellectual capital ROI: A causal map of human capital antecedents and consequents. Journal of Intellectual Capital, 3(3), 223-247.
Bramhandkar, A., Erickson, S., & Applebee, I. (2007). Intellectual capital and organizational performance: An empirical study of the pharmaceutical industry. The Electronic Journal of Knowledge Management, 5(4): 357-362. Retrieved from: www.ejkm.com/volume5/issue4.
Business Dictionary. (2013). Intellectual capital. Retrieved from www.businessdictionary.com/definition/intellectual-capital.html.
Butler, M., Collins, R., Drennan, J., Halligan, P., O’Mathúna, D.P., Schultz, T.J.,… Vilis, E. (2011). Hospital nurse staffing models and patient and staff-related outcomes. Cochrane Database of Systematic Reviews, Issue 7. Art. No.: CD007019. DOI: 10.1002/14651858.CD007019.pub2.
Capuano, T., Bokovoy, J., Hitchings, K., & Houser, J. (2005). Use of validated model to evaluate the impact of work environment on outcomes at a Magnet hospital. Health Care Management Review, 30(3), 229-236.
Clarke, S.P., & Donaldson, N.E. (2008) Nurse staffing and patient care quality and safety. In Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043). Agency for Healthcare Research and Quality, Rockville, MD. Retrieved from www.ahrq.gov/qual/nurseshdbk.
Collins, S.K. & Collins, K.S. (2006). Valuable human capital: The aging health care worker. The Health Care Manager, 25(3), 213-220.
Committee on Planning a Continuing Health Professional Education Institute (2010). Redesigning continuing education in the health professions. Institute of Medicine Report. Washington, D.C: The National Academies Press.
Covell, C. L. (2008). The middle-range theory of nursing intellectual capital. Journal of Advanced Nursing, 63(1): 94-103.
Covell, C. L. (2009). Outcomes achieved from organizational investment in nursing continuing professional development. Journal of Nursing Administration, 39(10), 438-443.
Covell C.L., & Sidani, S. (2012). Nursing intellectual capital theory: Operationalization and empirical validation of the concepts. Journal of Advanced Nursing. 16 Nov 2012. Retrieved from: doi: 10.1111/jan.12040
Covell C.L., & Sidani S. (2013). Nursing intellectual capital theory: Testing selected propositions. Journal of Advanced Nursing. 5 March 2012. doi: 10.1111/jan.12118.
Davidson, D. (2007). Strength in nursing leadership: The key to the evolution of intellectual capital. Nursing Administration Quarterly, 31(1), 36-42.
Doran, D. & Mylopoulos, J. (2008). Outcomes in the palm of your hand. Improving the quality and continuity of patient care. Canadian Health Services Research Foundation. Retrieved from www.cfhi-fcass.ca/Migrated/PDF/ResearchReports/OGC/DoranReport1_3_25_FINAL.pdf
Duffield, C., Diers, D., O’Brien-Pallas, L., Aisbett, C, Roche, M., King, M., & Aisbett, K (2011) Nursing staffing, nursing workload, the work environment and patient outcomes. Applied Nursing Research 24, 244-255.
Dumay, J.C. (2012). Grand theories as barriers to using IC concepts. Journal of Intellectual Capital, 13(1), 4-15.
Edvinsson, L., & Malone, M.S. (1997). Intellectual capital: Realizing your company's true value by finding its hidden brainpower. New York: Harper Business.
Faulk, N.L. (2007). Strategies to enhance retention and effective utilization of aging nursing faculty. Journal of Nursing Education, 46(4), 165-169.
Fawcett, J. (1998). The relationship of theory and research (3rd ed). Philadelphia: F. A. Davis Company.
Frith, K.H., Anderson, E.F., Tseng, F., & Fong, E.A. (2012). Nurse staffing is an important strategy to prevent medication errors in community hospitals. Nursing Economic$, 30(5), 283-294.
Grantham, C.E., Nichols, L.D., & Schonberner, M. (1997). A framework for the management of intellectual capital in the health care industry. Journal of Health Care Finance, 23(3), 1-19.
Hadaway, L. (2010). Development of an infusion alliance. Journal of Infusion Nursing, 33(5): 278-90.
Hudspeth, R. (2006). Securing intellectual capital by using scope of practice. Nursing Administration Quarterly, 3(1), 89-90.
Kane, R.L., Shamliyan, T.A., Mueller, C., Duval, S., & Wilt, T.J. (2007). The association of registered nurse staffing and patient outcomes. Systematic review and meta-analysis. Medical Care, 45(12): 119-1204.
Kendall-Gallagher, D., & Blegen, M.A. (2009). Competence and certification of registered nurses and safety of patients in intensive care units. American Journal of Critical Care, 18(2), 106-113.
Kramer, M., & Schmalenberg, C. (2004). Essentials of a magnetic work environment. Part 1. Nursing 2004, 34(6), 50-54.
Mark, B. A., Hughes L. C., & Bland Jones, C. (2004). The role of theory in improving patient safety and quality health care. Nursing Outlook, 52, 11-16.
McGillis Hall, L. (2003). Nursing intellectual capital: A theoretical approach for analyzing nursing productivity. Nursing Economics, 2, 14-19.
Messmer, P.R., & Turkel, M.C. (2011). Magnetism and the Nursing Workforce. In A.T. Debisette & J. A. Vessey (Eds.), Annual review of nursing research volume 29, 2010: Nursing workforce issues, (pp. 233-252) Springer Publishing Company.
Nahapiet, J., & Ghoshal, S. (1998). Social capital, intellectual capital, and the organizational advantage. The Academy of Management Review, 23(2), 242-266.
Newhouse, R.P., Johantgen, M., & Pronovost, P.J. (2005). Perioperative nurses and patient outcomes-mortality, complications and length of stay. AORN Journal, 81(3), 508-528.
O'Brien-Pallas, L., Griffin, P., Shamian, J., Bunhan, J., Duffield, C., Hughes, F., Laschinger, H.S, & Stone, P. W. (2006). The impact of nurse turnover on patient, nurse, and system outcomes: A pilot study and focus for a multicenter international study. Policy, Politics, & Nursing Practice, 7(3), 169-179.
Oman, K.S., Flynn Makic, M.B., Fink, R., Schraeder, N., Hulett, T., Keech, T., & Wald, H. (2012). Nurse-directed interventions to reduce catheter-associated urinary tract infections. American Journal of Infection Control, 40: 548-553.
Peng, T.A. (2007). Intellectual capital and performance indicators: Taiwanese healthcare sector. Journal of Intellectual Capital, 8(3): 538-556.
Phillips, J.L., Piza, M., & Ingram, J. (2012). Continuing professional development programmes for rural nurses involved in palliative care delivery: An integrative review. Nursing Education Today, 32, 385-392.
Poe, S.S. (2011). Building nursing intellectual capital for safe use of information technology: A before-after study to test an evidence-based peer coaching intervention. Journal of Nursing Care Quality, 26(2), 110-119.
Reidinger, G. (2010). The preservation of intellectual capital of nurses working in the community hospital. (Doctoral dissertation,Olivet Nazarene University).Retrieved from http://digitalcommons.olivet.edu/edd_diss/11
Rondeau, K.V., Williams, E. S. & Wagar, T.H. (2009) Developing human capital: What is the impact on nurse turnover? Journal of Nursing Management, 17, 739-748.
Sales, A., Sharp , N., Li, Y., Lowy, E., Greiner, G., Liu, C.,... Needleman, J. (2008). The association between nursing factor and patient mortality in the Veterans Health Administration. Medical Care, 46(9): 938-945.
Schweitzer, D.J., & Krassa, T.J. (2010). Deterrents to nurses’ participation in continuing professional development: An integrative literature review. Journal of Continuing Education in Nursing, 41(10):441-447.
Seibert, S.E., Kraimer, M. L. & Linden, R.C. (2001). A social capital theory of career success. The Academy of Management Review, 44(2), 219-237.
Shirey, M.R. (2006). Entrepreneurship. Turning your intellectual capital into tangible results. Clinical Nurse Specialist, 20(4), 179-182.
Simpson, R. L. (2007). Information technology. Building nursing intellectual capital for the information age. Nursing Administration Quarterly, 3(1), 84-88.
Spilsbury, K., Hewitt, C., Stirk, L., & Bowman, C. (2011). The relationship between nurse staffing and quality of care in nursing homes: a systematic review. International Journal of Nursing Studies, 48(6), 732-750.
Stewart, T. (1997). Intellectual capital: The new wealth of organizations. New York, U.S.A: Currency Doubleday.
Stewart, T. A. (2001). The wealth of knowledge: Intellectual capital and the twenty-first-century organizations. New York, U.S.A.: Currency Doubleday.
Sullivan, P. H. (1998). Profiting from intellectual capital: Extracting value from innovation. New York: John Wiley & Sons.
Thomka, L. A. (2007). Mentoring and its impact on intellectual capital. Through the eyes of the mentee. Nursing Administration Quarterly, 31(1), 22-26.
Thompson, G. N., Estabrooks, C. A., & Degner, L. F. (2006). Clarifying the concepts in knowledge transfer: a literature review. Journal of Advanced Nursing, 5(6), 691-701.
Tourangeau, A., Doran, D., McGillis Hall, L., O'Brien-Pallas, L., Pringle, D., Tu, J.V., & Cranley, L.A. (2007). Impact of hospital nursing care on 30-day mortality for acute medical patients. Journal of Advanced Nursing, 57(1), 32-44.
Twigg, S., Duffield, C., Bremner, A., Rapley, P., & Finn, J. (2012). Impact of skill mix variations on patient outcomes following implementation of nursing hours per patient day staffing: A retrospective study. Journal of Advanced Nursing, 68(12), 2710-2719.
Weston, M.J., Estrada, N.A., & Carrington, J. (2007). Reaping the benefits from intellectual capital. Nursing Administration Quarterly, 31(1), 6-12.
Youndt, M., Subramanian, M., & Snell, S.A. (2004). Intellectual capital profiles: An examination of investments and returns. Journal of Management Studies, 41(2), 335-361.
© 2013 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2013
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