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PubMed2001

Changes in general health and musculoskeletal outcomes in the workforce of a hospital undergoing rapid change: a longitudinal study.

This article aimed to examine changes in general health and time with back pain and neck pain and to identify predictors of any such changes. Hospital workers were studied longitudinally with surveys in 1995, 1996, and 1997 (N = 712). Back and neck pain were reported only at the 2nd and 3rd surveys. There was a significant decline in general health and significant increases in time with neck pain and back pain. Predictors of changes in these outcomes were mainly work-related variables (initial or change values), such as job interference with family, job influence, work psychological demands, and hours worked.

Adult↗
PubMed1999

Still attractive after all these years? Magnet hospitals in a changing health care environment.

This paper examines the research base for 'magnet hospitals'--hospitals that have a good reputation for recruitment and retention of registered nurses. It also assesses the extent to which the concept of the magnet hospital continues to have relevance to nursing in the United Kingdom (UK). The study reviews previous research, examines recent trends in nursing employment, and reports on case studies conducted as fieldwork research. The early research on magnet hospitals, conducted in the 1980s in the United States of America (USA), is reassessed in the light of subsequent cost containment driven changes in the USA nursing labour market and in the organization of USA hospitals. Many of these changes have impacted on nursing staff, with increases in workload, and with changes in skill mix, particularly as a result of increased use of care assistants. Similar developments have been happening in the UK. The paper examines the extent to which the concept of the magnet hospital can retain validity in this changing health care environment. Case studies in 14 USA magnet hospitals were conducted in 1997. The results highlight that, as a result of hospital reorganization and merger, some of these hospitals no longer exhibit core characteristics of 'magnetism', whilst others have retained these characteristics despite organizational change. The paper concludes by cautioning that the concept of the magnet hospital continues to have a relevance to the management of nursing resources, but that the research base, with some notable exceptions, continues to be weak and that there is a need for monitoring and a process of re- accreditation to maintain a 'live' register of magnet hospitals.

Career Mobility↗
PubMed2002

Nurses' altered conceptions of work in a ward with all-RN staffing.

1. The aim of this study was to investigate how nurses' conceptions of their patients and work changed after reorganization to all RN-staffing and the adoption of a patient-in-focus philosophy on the ward. 2. The study builds on the perspective that the individual's conception of work precedes and forms the basis for the development of knowledge, skills and attributes used in accomplishing work. 3. The findings are based on a secondary analysis of two open interviews with 22 nurses on the ward. These interviews were conducted on two occasions with an interval of 2 years. The third interview was carried out 6 months later, when 10 nurses were asked to talk about a patient's care episode in a narrative form. 4. The nurses' conceptions changed towards a holistic view of the patient, they developed a new approach to work and they used the altered circumstances in their work.

Attitude of Health Personnel↗
PubMed1998

Merger management: a challenge to nursing leadership.

AIM: The article reviews the merger process of two obstetric divisions. BACKGROUND: Mergers of acute care facilities are becoming common due to the need to move towards a market orientation. There is a growing emphasis on corporations, competition, and profit and cost control. Nursing leadership in managing merger processes is crucial. METHODS: Information originated from administrative decisions, feelings expressed by the staff, author observations, and statistical data. Data was analysed by illustrating the merger phases, compared to the literature and research studies. KEY ISSUES: Issues related to planning and preparing the process, the management of human resources, the development of organizational culture, and the physical changes, are vital. CONCLUSIONS: Planning ahead, involving all partners from the early stages, extensive dialogue among colleagues and strong nursing leadership are key elements for a smooth transition.

Decision Making, Organizational↗
PubMed1999

External change and its impact on nurse management: a case study.

AIMS: This paper sets out to identify major changes in the tasks and responsibilities of the nurse manager at a small postgraduate unit in central London as it and its parent hospital group became subject to major changes in the policy and financial environment. What happened to the nurse manager's function could well make transparent some of the important changes still affecting nurse management more generally today. BACKGROUND: The article adds to the somewhat meagre academic literature which considers the middle management role in nursing. METHODS: The paper is based on a single yet detailed case study and the data were gathered by one of the authors over the period of change. The pros and cons of the dual researcher/participant role need to be considered along with the possibly wider significance of the case study. FINDINGS: The overriding conclusion is that nurse management in the specialist unit is evolving from a classic bureaucratic mode in which managerial authority, information and decision making were highly centralized to a much more devolved set of arrangements. Clearly a host of factors--e.g. the culture and history of the organization, and the personality types of the key players--could affect such change. However, this article concentrates on showing how the earlier, more centralized style was increasingly problematic in the rapidly changing circumstances faced by the unit. CONCLUSIONS: In understanding the wider significance of this particular case study, it seems important to understand the strengths and weaknesses of the methodology. If such changes in nurse management are widespread, they represent a new era for nursing in action and one perhaps more consonant with a profession whose status is being enhanced by developments such as diploma and graduate education and the development of specialist roles.

Hospital Restructuring↗
PubMed2003

Redesigning mental health services: lessons on user involvement from the Mental Health Collaborative.

OBJECTIVES: To explore the involvement of mental health service users in the redesign of in-patient mental health services in six Trusts participating in a multi-regional NHS modernization programme. DESIGN: Semi-structured interviews and observation of team meetings undertaken as part of an action research study. PARTICIPANTS AND SETTING: Users, clinical, medical and managerial staff from six mental health trusts which participated in the Northern & Yorkshire and Trent regions' Mental Health Collaborative (MHC). RESULTS AND CONCLUSIONS: Whilst there were some problems, user involvement was undoubtedly a strength of the MHC in comparison to other modernization programmes within the NHS we have studied. However, the particular challenges posed by the specific context of acute mental health services should not be overlooked. The initial approach taken in each of the sites was to simply invite a user or user representative to join the local project team. In the course of events, various changes were made to this initial mechanism for involving users in the ongoing work of the teams. These changes--and setbacks in some sites--make drawing firm conclusions as to the effectiveness of the various strategies employed problematic. However, our qualitative data suggest a number of broad lessons that will assist both those leading and participating in other redesign initiatives to maximize the benefits to be gained from service user involvement.

Community Participation↗
PubMed2001

Use of a modified Postanesthesia Recovery Score in phase II perianesthesia period of ambulatory surgery patients.

Use of discharge criteria in the ambulatory surgery setting has been the topic of many research studies and reviews. This article provides a discussion of a research utilization project regarding the use of a modified Postanesthesia Recovery Score for Ambulatory Patients (PARSAP) in Phase II recovery of a perianesthesia unit. The impetus for this project was the closure of a hospital's only inpatient ward, resulting in all surgery performed on an outpatient basis. Based on community standards and a review of literature, this project evaluated the use of the modified PARSAP on ambulatory surgery patients. The intent of the project was to improve the flow of patients through the recovery process in an effort to contain or reduce costs while still maintaining high-quality patient care standards. Results of the project showed a decreased inpatient length of stay without any increase in reports of postoperative complications. The favorable outcomes of the use of this scoring system have led to its implementation on a permanent basis. This is a U.S. government work. There are no restrictions on its use.

Ambulatory Surgical Procedures↗
PubMed2002

A critical ethnographic approach to facilitating cultural shift in midwifery.

OBJECTIVE: to improve understanding of local midwifery morale, inform development and reorganisation of a maternity unit, and enhance midwifery involvement in strategic planning. PARTICIPANTS: a randomised stratified sample of 20 midwives working in a UK National Health Service (NHS) hospital and its surrounding community area. METHOD: within a critical ethnographic framework, focus groups were tape-recorded and transcribed, and analysed using a thematic content analysis approach. FINDINGS: key areas affecting midwifery morale were identified, in particular staffing levels, working relationships and organisational issues. One year later, despite many changes having taken place, midwifery morale was still low but participants were more politically analytical of, and actively involved in changing their situation. The findings of the study indicate that there are complex and long-standing cultural inhibitions to the effective development of midwifery care but, if these are made explicit through a planned collaborative process, such as in this study, a process of cultural shift can be seen to begin. IMPLICATIONS FOR PRACTICE: focus groups can be a useful tool in moving midwifery culture forward within a local context.

Anecdotes as Topic↗
PubMed2001

The impact of managed care and current governmental policies on an urban academic health care center.

BACKGROUND: Managed care and governmental policies have restructured hospital reimbursement. We examined reimbursement trends in trauma care to assess the impact of this market driven change on an urban academic health center. METHODS: Patients injured between January 1997 and December 1999 were analyzed for Injury Severity Score (ISS), length of hospital stay, hospital cost, payer, and reimbursement. RESULTS: Between 1997 and 1999, the volume of patients with an ISS less than 9 increased and length of stay decreased. In addition, overall cost, payment, and profit margin increased. Commercially insured patients accounted for this margin increase, because the margins of managed care and government insured patients experienced double-digit decreases. Patients with ISS of 9 or greater also experienced a volume increase and a reduction in length of stay; however, costs within this group increased greater than payments, thereby reducing profit margin. Whereas commercially insured patients maintained their margin, managed care and government insured patients did not (double- and triple-digit decreases). CONCLUSIONS: Managed care and current governmental policies have a negative impact on urban academic health center reimbursement. Commercial insurers subsidize not only the uninsured but also the government insured and managed care patients as well. National awareness of this issue and policy action are paramount to urban academic health centers and may also benefit commercial insurers.

Academic Medical Centers↗
PubMed2000

Hospital board structure: changing form and changing issues.

Economic and social pressures are compelling many hospitals to consider their current board structure in an effort to position their hospital to meet changing demands. A national profile of the structures of hospital boards has been compiled from a questionnaire completed by hospital board representatives from both government and non-government sectors. Results show that hospital board structures are a hybrid of both philanthropic and corporate models. New structures may be required to meet future challenges. In developing new structures, consideration should be given to identifying the skills and processes required to undertake board business.

Australia↗
PubMed2000

Employment relationships in Victorian public hospitals: the Kennett years.

From 1992 to 1999, the Kennett government in Victoria moved to competitive market models of service delivery and the measurement of service provision through casemix funding. Public hospital managers were given greater accountability for the costs and provision of service delivery and a new range of service providers, many from the private sector, entered the public health market. The decentralisation of the industrial relations system led to new developments in bargaining that brought both opportunities and problems. In the Victorian public health system there was an increasing emphasis on decentralisation in both service provision and employment relations. In this paper I suggest that there were contradictions in these developments for government, and new challenges and difficulties for employers, employees and trade unions.

Contract Services↗
PubMed1999

Improved trauma care after reorganisation: a retrospective analysis.

OBJECTIVE: To shorten the time to make a diagnosis and to begin definitive treatment of severely injured patients, thereby improving their medical care. DESIGN: Retrospective analysis. SETTING: Teaching hospital, Sweden. SUBJECTS: 61 patients who had sustained high-energy injuries, including head injury which required surgical intervention, and fracture of the femoral shaft before (1987-1988 n = 23) and after (1991-1993 n = 38) the reorganisation. INTERVENTION: Trauma care was reorganised during the year 1989-1990 and the concept of early multidisiplinary treatment with the general surgeon as trauma-leader was adopted. MAIN OUTCOME MEASURES: The time required to make a diagnosis and begin definitive treatment as well as the assessment of medical care taking account of the patient's general condition and other injuries. RESULT: The immediate medical care was classified as delayed or inappropriate in 9 of 23 patients before, and in 2 of 38 patients after, the reorganisation (p = 0.001). The time needed to make a diagnosis was less than 4 hours in all cases. The time needed to start definitive treatment of head injuries was less than four hours in 9 of 12 patients before, and in 18 of 21 patients after the reorganisation. The internal fixation of femoral fractures was started within four hours in 2 of 11 femoral fractures before, compared with 12 of 17, after the reorganisation. CONCLUSION: The time to beginning definitive treatment of severe injuries was shorter after the reorganisation, as a result of early participation of members of the trauma team.

Accidental Falls↗
PubMed1995

Re-engineering the hospital: a house without rooms.

Re-engineering of health care systems is defined, and the experience with re-engineering at a medical center is discussed. Re-engineering is a business concept that involves totally redesigning work processes to achieve much higher efficiencies and quality; it should not be confused with cost cutting, downsizing, and continuous improvement. Re-engineering seeks to combine multiple jobs into one, empower workers and make them more accountable, sequence the elements of work more naturally, create greater flexibility, and blur or remove organizational boundaries. Re-engineering at The Ohio State University Medical Center began with the formation of an operations improvement team consisting of department heads. Work processes were selected for re-engineering and prioritized, and teams were created to identify activities calling for radical change, such as activities that wasted time, could be done on an outpatient basis, or were duplicative. It was concluded that the redesign had to focus on the entire medical center, not the individual departments. A list of the characteristics of a better organization was prepared and distributed to the staff, along with other documents to help them understand the need for change. The operations improvement team specified expected outcomes of the re-engineering, and each re-engineering team developed measures of these outcomes. Many of the recommendations submitted have been implemented. One innovation has been the consolidation of the duties of utilization-review nurses, continuity-of-care nurses, social workers, and patient-education nurses into a single job category. When the medication-use re-engineering team meets, it will not be re-engineering the pharmacy department, it will be addressing the drug-use process. A medical center is re-engineering itself so that it will be able to continue to meet the health care needs of the community it serves.

Efficiency, Organizational↗
PubMed1995

Collaborating with re-engineering consultants: maintaining resources for the future.

The negotiations of a pharmacy department with a consulting firm hired to help cut the institution's staff are described. In July 1994 Duke University Medical Center announced its intention to reduce the number of full-time equivalents (FTEs) from 6500 to 5000 and hired a consulting firm. The pharmacy department was scheduled to be studied for 16 weeks. The entire pharmacy staff was educated about the initiative and about what management expected of the staff during the process. Each assistant director of pharmacy was asked to lead the "operations improvement process," as the re-engineering plan was called, in his or her area of responsibility. The assistant directors were to describe key work activities and their time requirements and develop instruments for measuring work activities. Data were collected on supplemental resource requirements for paid time off and educational and meeting time. Resource requirements for clinical pharmacy specialists and other selected staff members were determined separately. The data were collected for one fiscal month, and the assistant directors then began negotiating human-resource requirements with the consultants. The director finalized the negotiations and presented the results to the hospital's leaders and the consulting firm's executives. It was proposed to reduce total pharmacy FTEs by only 5%, and the department actually gained 1 pharmacist FTE. Far greater reductions were proposed for most other departments (the entire medical center lost more than 800 FTEs). The pharmacy department at Duke dealt successfully with a re-engineering initiative. Strategies that contributed to the success included teamwork, active participation by the entire staff, empowering a core group to help lead in the process, and substantiating the value of the pharmacy's services to the medical center and its patients.

Consultants↗
PubMed1995

Re-engineering for dramatic improvement in the medication-use process.

Planning for re-engineering the medication-use process at a university hospital is described. In summer 1992 the University of Cincinnati Hospital hired a consultant on quality to help with work-process improvement and re-engineering. By early 1993, re-engineering for patient-focused care was under way. Within a year of the implementation of patient-focused care in a pilot unit, it was realized that all departments that provided direct and indirect care would also have to undergo re-engineering. In August 1994 a retreat was held to begin the re-engineering effort in the pharmacy department. The retreat participants set as goals of the re-engineering (1) support of the hospital's strategic initiatives, (2) getting the right drug to the right patient at the right time, (3) improved patient outcomes, and (4) reducing the pharmacy labor and drug budget. Pharmacy activities for re-engineering were identified, and two planning teams were created, a pharmacy production team and a pharmacy knowledge-transfer team. The production team was made responsible for re-engineering dispensing, inspecting, producing, storing, and transporting, and the knowledge-transfer team was assigned teaching, recording, treating, and monitoring. A detailed plan was prepared for each team to follow using a framework provided by the consultant and consisting of strategy, technology, process, and personnel. Careful planning and a consultant helped a university hospital prepare for organizationwide re-engineering.

Focus Groups↗