Are teamwork and professional autonomy compatible, and do they result in improved hospital care?

A postal questionnaire survey of 10 022 staff nurses in 32 hospitals in England was undertaken to explore the relationship between interdisciplinary teamwork and nurse autonomy on patient and nurse outcomes and nurse assessed quality of care. The key variables of nursing autonomy, control over resources, relationship with doctors, emotional exhaustion, and decision making were found to correlate with one another as well as having a relationship with nurse assessed quality of care and nurse satisfaction. Nursing autonomy was positively correlated with better perceptions of the quality of care delivered and higher levels of job satisfaction. Analysis of team working by job characteristics showed a small but significant difference in the level of teamwork between full time and part time nurses. No significant differences were found by type of contract (permanent v short term), speciality of ward/unit, shift length, or job title. Nurses with higher teamwork scores were significantly more likely to be satisfied with their jobs, planned to stay in them, and had lower burnout scores. Higher teamwork scores were associated with higher levels of nurse assessed quality of care, perceived quality improvement over the last year, and confidence that patients could manage their care when discharged. Nurses with higher teamwork scores also exhibited higher levels of autonomy and were more involved in decision making. A strong association was found between teamwork and autonomy; this interaction suggests synergy rather than conflict. Organisations should therefore be encouraged to promote nurse autonomy without fearing that it might undermine teamwork.

Nurses' reports on hospital care in five countries.

The current nursing shortage, high hospital nurse job dissatisfaction, and reports of uneven quality of hospital care are not uniquely American phenomena. This paper presents reports from 43,000 nurses from more than 700 hospitals in the United States, Canada, England, Scotland, and Germany in 1998-1999. Nurses in countries with distinctly different health care systems report similar shortcomings in their work environments and the quality of hospital care. While the competence of and relation between nurses and physicians appear satisfactory, core problems in work design and workforce management threaten the provision of care. Resolving these issues, which are amenable to managerial intervention, is essential to preserving patient safety and care of consistently high quality.

Human inputs: the health care workforce and medical markets.

Arrow wrote his classic article in simpler times, as those who chance upon this article forty years hence will say of today. It was a new era in science and medicine, soon to be fueled by new resources from Medicare and the National Institutes of Health. Fiscal constraint was a stranger, physicians were in short supply, and information asymmetry was pervasive. In the intervening years, Americans have become more comfortable with health care issues. Fatal illness, which was rarely discussed with patients in 1960, is now researched by them on the Internet, and greater attention is paid to patient rights. Nonetheless, concerns about quality have, if anything, increased. Indeed, it is public concern about quality that has invited governmental regulation and induced a defensive posture among medical organizations, which are rushing to establish their own instruments of quality, and it is these same public concerns that have facilitated the ability of managed care to offer itself as the guarantor of quality. However, center stage is now held by another issue: health care costs. As a result, the focus has shifted from resolving information asymmetry by enhancing quality to controlling national health expenditures by changing the size and composition of the health care workforce. Licensure, which was restrictive in 1960, is more relaxed today, thereby reducing the entry barriers for the NPC disciplines, several of which were just beginning when Arrow wrote his article. The entry of NPCs into the realm of physician's services partially counterbalances the constraints that have been placed on physician supply, although the major contributions of NPCs are skewed to the primary care end of the spectrum while the major constraints on physician supply affect specialists. The growing presence of NPCs creates a dynamic market in which practitioners in various disciplines both compete and collaborate. It is, in fact, the perfect market that Arrow reluctantly longed for, in which providers who have different levels of skill offer their services at varying prices. But consumers have little upon which to base their choices. And while many of the services offered by NPCs replace physician services at a lower price, others represent additional services, which add to aggregate spending. Arrow sought to explain how a market replete with uncertainty could function. He saw that licensure, entry rationing, and educational subsidies could work to enhance quality, but they did so at the expense of the market. The market has seen it differently and has usurped these tools for its own purposes, leaving quality to look for other sponsors. Has it done so wisely? We have yet to see how well a multidisciplinary workforce of autonomous providers will function, but both successes and failures abound. What is more apparent is how entry rationing and restrictions on educational subsidies have capped the supply of physicians and limited the production of specialists at a time when there is increasing demand for their services. Arrow identified potent tools for affecting the characteristics of the health care workforce. They now must be redirected to the needs of the future.

Cause for concern: nurses' reports of hospital care in five countries.

According to most experts, the U.S. faces a growing shortage of registered nurses, threatening the quality of care hospitals can provide. In the setting of nurse shortages and simultaneous concern about patient safety, nurses' job satisfaction and their assessment of quality of care become critical. This Issue Brief highlights a cross-national survey that describes nurses' perceptions of their hospital work environment, and identifies core problems in work design and workforce management in five countries.

Hospital restructuring: does it adversely affect care and outcomes?

The past decade has witnessed pronounced changes in the organization of U.S. hospitals, many the direct result of restructuring and reengineering initiative intended to decrease costs and increase productivity. Little is known about how these initiatives have affected clinical care and patient outcomes. Using data from a variety of sources, the authors describe initiatives that hospitals undertook over this period, indicate how staffing changed relative to the case-mix of patients receiving care, and examine changes in nursing practice environments over the period from 1996 to 1998. The authors found that apparent increases in nurse-to-patient ratios may be deceiving and that increases in patient acuity and nurses' responsibilities may have increased the workload of nurses in hospitals in ways, when coupled with a deteriorating practice environment, may adversely affect patient outcomes.

Hospital restructuring: does it adversely affect care and outcomes?

The past decade has witnessed pronounced changes in the organization of United States hospitals, many the direct result of restructuring and re-engineering initiatives intended to decrease costs and increase productivity. Little is known about how these initiatives have affected clinical care and patient outcomes. Using data from a variety of sources, the authors describe initiatives that hospitals undertook during this period, discuss how nurse staffing changed relative to the case mix of patients receiving care, and examine changes in nursing practice environments from 1986 to 1998.

Measuring organizational traits of hospitals: the Revised Nursing Work Index.

BACKGROUND: The organizational context in which nurses practice is important in explaining variation in patient outcomes, but research has been hampered by the absence of instruments to measure organizational attributes empirically. OBJECTIVES: To report on the development and utility of the Revised Nursing Work Index (NWI-R) in measuring characteristics of professional nursing practice environments. METHODS: The NWI-R was used in a national acquired immunodeficiency syndrome (AIDS) care study. The sample consisted of 40 units in 20 hospitals. Of these 20 hospitals, 10 provided AIDS care in both dedicated AIDS units and general medical units, thus introducing to the design an element of internal control. The remaining 10 hospitals were selected through a matching procedure. Three of the matched control hospitals were magnet hospitals. Nurses were recruited into the study if they worked at least 16 hours per week on the study unit. The nurses completed the NWI-R in addition to other measures. RESULTS: A response rate of 86% was attained. Response rates per unit ranged from 73% to 100%. Cronbach's alpha was 0.96 for the entire NWI-R, with aggregated subscale alphas of 0.84 to 0.91. Validity of the NWI-R was demonstrated by the origin of the instrument, its ability to differentiate nurses who worked within a professional practice environment from those who did not, and its ability to explain differences in nurse burnout. CONCLUSION: The NWI-R has been found to capture organizational attributes that characterize professional nursing practice environments.

Organization and outcomes of inpatient AIDS care.

OBJECTIVE: To compare differences in AIDS patients' 30-day mortality and satisfaction with care in dedicated AIDS units, scattered-bed units in hospitals with and without dedicated AIDS units, and in magnet hospitals known to provide good nursing care. METHODS: Data were obtained on 1,205 consecutively admitted patients in 40 units in 20 hospitals and on 820 of their nurses. RESULTS: Mortality was lower and satisfaction was higher for AIDS patients in dedicated AIDS units and in nursing magnet hospitals. Primary nursing, end-of-life care counseling, and discharge planning were also more common. Higher nurse to patient ratios and AIDS physician specialty services were strongly associated with lower mortality. Patient satisfaction was strongly associated with organizational control of care by bedside nurses. Homosexuals were more likely to be admitted to dedicated AIDS units, which largely explains the under-representation of minorities and women. CONCLUSIONS: Dedicated AIDS units and magnet hospitals offer important benefits to AIDS patients, including lower odds on dying within 30 days of admission, higher patient satisfaction, and care meeting professional standards. Better nurse staffing, AIDS physician specialty services, and more organizational control by bedside nurses improve patient outcomes.

Shaping systems to promote desired outcomes. The magnet hospital model.

The organization of nurses' work is a major determinant of patient and staff welfare. Magnet hospitals have demonstrated organizational attributes that enable nurses to fully use their knowledge and expertise to provide high-quality patient care. The empirical evidence that this type of organization produces better patient and staff outcomes is compelling. Therefore when reconfiguring the delivery of care, the organizational form found in the magnet hospitals should shape systems to promote desired outcomes.

Organization and outcomes of inpatient AIDS care.

The establishment of AIDS hospitals and AIDS units within hospitals has been controversial. Unlike other specialty care, AIDS care arrangements were initially developed as much to segregate AIDS patients from other patients and staff as to provide the best possible care. Ten years after many of these units opened, little evidence was available about whether the benefits of aggregating AIDS patients outweighed the potential hazards of segregating people from the mainstream of hospital care. This Issue Brief describes a national study to determine how different organizational settings affect the outcomes of inpatient AIDS care.

Studying outcomes of organizational change in health services.

OBJECTIVES: The rapidly changing organizational context within which health care is delivered is altering provider-patient relations and processes of clinical decision-making, with significant implications for patient outcomes. Yet definitive research on such effects is lacking. The authors seek to underscore the contribution of organizational research to studies of clinical outcomes and demonstrates several approaches to further such efforts. METHODS: The authors present a theoretical framework of the operant mechanisms linking organizational attributes and patient outcomes. They use case examples from their ongoing research on hospitals to illustrate strategies for measuring these mechanisms and for overcoming some of the feasibility issues inherent in organizational research. RESULTS: Several methodological issues are explored: (1) exploiting "targets of opportunity" and "natural experiments" is a promising strategy for studying patient outcomes related to organizational reform; (2) indices of organizational traits, constructed from individual survey responses, can illuminate the operant mechanisms by which structure affects outcomes; and (3) secondary data sources and innovative statistical matching procedures provide a feasible strategy for constructing study comparison groups. Extending the organizational outcomes research strategy to new areas of inquiry offers an opportunity to enhance our understanding of how nursing organization affects outcomes. CONCLUSIONS: Improving the effectiveness of medical care in a health-care system undergoing fundamental restructuring requires greater understanding of how organizational context affects clinical outcomes. A higher priority should be placed on organizational outcomes research by researchers and funding agencies.