A hospital-level analysis of the work environment and workforce health indicators for registered nurses in Ontario's acute-care hospitals.

The purpose of this study was to explore the relationship between hospital-level indicators of the work environment and aggregated indicators of health and well-being amongst registered nurses working in acute-care hospitals in Ontario, Canada. This ecological analysis used data from a self-reported survey instrument randomly allocated to nurses using a stratified sampling approach. Multivariable linear regression models were used to examine hospital-level associations for burnout, musculoskeletal pain, self-rated general health, and absence due to illness. The unit of analysis was the hospital (n = 160), with individual nurse responses (n = 6,609) aggregated within hospitals. After controlling for basic differences in nurse workforces, including mean age and education, higher (better) work-environment scores were found to be generally associated with higher health-indicator scores, while a larger proportion of full-time than part-time nurses was found to be associated with lower (poorer) health scores. This study may provide direction for policy-makers in coping with the recruitment and retention of nursing staff in light of the current nursing shortage.

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.

The impact of workplace empowerment, organizational trust on staff nurses' work satisfaction and organizational commitment.

A predictive, nonexperimental design was used to test Kanter's work empowerment theory in a random sample of 412 staff nurses selected from the professional registry list of a central Canadian province. Kanter argues that work environments that provide access to information, support, resources, and opportunity to learn and develop are empowering and influence employee work attitudes, productivity, and organizational effectiveness. Test results suggest that fostering environments that enhance perceptions of empowerment will have positive effects on organizational members and increase organizational effectiveness.

Testing Karasek's Demands-Control Model in restructured healthcare settings: effects of job strain on staff nurses' quality of work life.

BACKGROUND: Job strain among staff nurses has become an increasingly important concern in relationship to employee performance and commitment to the organization in current restructured healthcare settings. OBJECTIVES: The purpose of this study was to test Karasek's Demands-Control Model of job strain by examining the extent to which the degree of job strain in nursing work environments affects staff nurses' perceptions of structural and psychological empowerment, work satisfaction, and organizational commitment. METHOD: A predictive, nonexperimental design was used to test these relationships in a random sample of 404 Canadian staff nurses. Karasek's Job Content Questionnaire, the Conditions of Work Effectiveness Questionnaire-II, Spreitzer's Psychological Empowerment Questionnaire, Meyer and Allen's Organizational Commitment Questionnaire, and the Global Satisfaction Scale were used to measure the major study variables. RESULTS: Nurses with higher level of job strain were found to be significantly more empowered, more committed to the organization, and more satisfied with their work. CONCLUSIONS: Support for Karasek's Demands/Control theory was established in this study.

Impact of structural and psychological empowerment on job strain in nursing work settings: expanding Kanter's model.

OBJECTIVE: In this study, we tested an expanded model of Kanter's structural empowerment, which specified the relationships among structural and psychological empowerment, job strain, and work satisfaction. BACKGROUND: Strategies proposed in Kanter's empowerment theory have the potential to reduce job strain and improve employee work satisfaction and performance in current restructured healthcare settings. The addition to the model of psychological empowerment as an outcome of structural empowerment provides an understanding of the intervening mechanisms between structural work conditions and important organizational outcomes. METHODS: A predictive, nonexperimental design was used to test the model in a random sample of 404 Canadian staff nurses. The Conditions of Work Effectiveness Questionnaire, the Psychological Empowerment Questionnaire, the Job Content Questionnaire, and the Global Satisfaction Scale were used to measure the major study variables. RESULTS: Structural equation modelling analyses revealed a good fit of the hypothesized model to the data based on various fit indices (chi 2 = 1140, df = 545, chi 2/df ratio = 2.09, CFI = 0.986, RMSEA = 0.050). The amount of variance accounted for in the model was 58%. Staff nurses felt that structural empowerment in their workplace resulted in higher levels of psychological empowerment. These heightened feelings of psychological empowerment in turn strongly influenced job strain and work satisfaction. However, job strain did not have a direct effect on work satisfaction. CONCLUSIONS: These results provide initial support for an expanded model of organizational empowerment and offer a broader understanding of the empowerment process.

Voices from the trenches: nurses' experiences of hospital restructuring in Ontario.

Nurses, the largest occupational group in health care, have been disproportionately affected by health care restructuring initiatives. A survey of registered nurses in Ontario was conducted in the fall of 1998 to examine factors influencing their work life quality in hospital settings. As a part of this survey, respondents were provided with an opportunity to share their concerns about work conditions in an open ended section of the questionnaire. Almost sixty percent of the nurses chose to respond to the open ended question (n = 230), divided equally between males and females. The purpose of the qualitative component of the study was to obtain a more in depth analysis of the effects of hospital restructuring initiatives on staff nurses' working conditions. All geographic areas of the province were represented in the responses. A content analysis of the data was conducted to determine major themes. Similar themes were found across all geographic areas. The four major categories of concerns that emerged from the qualitative analysis were quality of worklife, quality of patient care, relations with management, and cumulative impact of work conditions on feelings and attitudes. Nurses' perceptions of their quality of work life, concern for the quality of patient care and their emotional and attitudinal responses were very similar to those reported in a recent study of hospital staff nurses in the United States. The decade of the 1990's has been characterized as one of constant change bordering on chaos within the health care system in Canada and the United States. In Canada, government fiscal policies have resulted in less money being directed toward health care forcing the system to reorganize in order to meet new financial realities. Many of the organizing efforts have been directed toward the acute care sector of the health care system. Nurses, as the largest occupational group within the health care system, have been disproportionately affected by these efforts. The purpose of this study was to tap nurses concerns about the effects of these changes on their personal and work experiences.

Organizational trust and empowerment in restructured healthcare settings. Effects on staff nurse commitment.

In today's dramatically restructured healthcare work environments, organizational trust is an increasingly important element in determining employee performance and commitment to the organization. The authors used Kanter's model of workplace empowerment to examine the effects of organizational trust and empowerment on two types of organizational commitment. A predictive, nonexperimental design was used to test Kanter's theory in a random sample of 412 Canadian staff nurses. Empowered nurses reported higher levels of organizational trust, which in turn resulted in higher levels of affective commitment. However, empowerment did not predict continuance commitment--that is, commitment to stay in the organization based on perceived lack of other job opportunities. Because past research has linked affective commitment to employee productivity, these results suggest that fostering environments that enhance perceptions of empowerment and organizational trust will have positive effects on organizational members and increase organizational effectiveness.

An evaluation of WHA resolution 45.5: health human resource implications.

The World Health Assembly approved resolution WHA45.5 in 1992. This paper reports the findings of an evaluation of the implementation of this resolution using a survey technique. A total of 150 WHO Member States responded, for a 79% response rate. Findings suggest that the greatest strides worldwide have been made in education. While the data show that progress has been made at the country level, far more action is needed to strengthen nursing and midwifery if these cost-effective resources are to play a decisive role in improving the extent and quality of services, especially as delivered to people in the greatest need.

Quality management: the role of hospital boards.

The changing social, political and economic environment has, for the first time, forced hospitals to account for their financial performance. Hospitals have responded to this demand by restructuring, downsizing and implementing efficiencies. At the same time, professionals and consumers are becoming increasingly concerned about the impact of rapid change on the quality of hospital care. In this context, the challenge for all stakeholders is to explicitly outline who is responsible and accountable for assuring high quality hospital care. The purpose of this paper is to discuss the role of hospital boards in relation to quality improvement. A framework currently used by a metropolitan Canadian teaching hospital, to assure continuous quality improvement despite significant budget cuts, is outlined.

Hospital restructuring initiatives in Canada.

OBJECTIVES: Recent changes in the organization, staffing, and utilization of acute hospitals in Canada are reviewed with regard to the potential implications for quality of care, national nurse workforce requirements, and research. METHODS: Available national and selected provincial data and trends in hospital utilization, capacity, and staffing are synthesized. RESULTS: Health system reform in Canada has resulted in lower utilization of acute inpatient resources, excess hospital capacity, and increased budgetary constraints in the hospital sector. In response, there is widespread hospital restructuring, which includes modifications in nurse staffing ratios and skill mix. Little is known about the potential impact of these changes on patient outcomes. From a workforce perspective, changes in the hospital sector have reduced demand for registered nurses but nursing schools have not modified enrollments. As a result, new graduates are experiencing difficulty obtaining registered nurse positions. CONCLUSIONS: Research should be undertaken to evaluate the impact of changes in the organization and staffing of hospitals on patient outcomes, and on the future requirements for nurses.

Towards quality and cost-effective health care.

Although rich cumulative evidence exists on nursing's effectiveness, few policymakers and healthcare executives apparently are familiar with it. To make such scientific-based knowledge more available so that it can be considered and integrated in healthcare policy and reform, the WHO Collaborating Centre at Mount Sinai Hospital, Toronto, Canada, complied and reviewed research evidence about how nursing services contribute towards cost effectiveness and quality health outcomes. Below, a summary of its findings.