Is the grass any greener? Canada to United States of America nurse migration.

AIM: Little or no attempt has been made to determine why nurses leave Canada, remain outside of Canada, or under what circumstances might return to Canada. The purpose of this study was to gain an understanding of Canadian-educated registered nurses working in the USA. DATA SOURCES: Data for this study include the 1996, 2000 and 2004 USA National Sample Survey of Registered Nurses and reports from the same time period from the Canadian Institute for Health Information. FINDINGS: This research demonstrates that full-time work opportunities and the potential for ongoing education are key factors that contribute to the migration of Canadian nurses to the USA. In addition, Canada appears to be losing baccalaureate-prepared nurses to the USA. DISCUSSION: These findings underscore how health care policy decisions such as workforce retention strategies can have a direct influence on the nursing workforce. Policy emphasis should be on providing incentives for Canadian-educated nurses to stay in Canada, and obtain full-time work while continuing to develop professionally. CONCLUSION: Findings from this study provide policy leaders with important information regarding employment options of interest to migrating nurses. STUDY LIMITATIONS: This study describes and contrasts nurses in the data set, thus providing information on the context of nurse migration from Canada to the USA. Data utilized in this study are cross-sectional in nature, thus the opportunity to follow individual nurses over time was not possible.

Short-term exercise training improves body composition and hyperlipidaemia in HIV-positive individuals with lipodystrophy.

Exercise/physical activity is increasingly being advocated as a positive addition to the treatment regimen of HIV-positive individuals. We investigated the effects of 10 weeks' aerobic and resistance training on individuals with HIV-related lipodystrophy. These individuals demonstrated an improvement in exercise tolerance, body composition and blood lipid profiles. Potentially, such changes may contribute to an amelioration of some of the adverse metabolic effects associated with highly active antiretroviral therapy.

Carbohydrate and fluid needs of the soccer player.

Soccer is a game that demands a combination of repeated maximal sprinting wit with 10 to 11km of moderate running, sometimes performed under extremely warm conditions. Over the course of a match, there is partial to near complete depletion of glycogen reserves in the leg muscles (depending on the extent of initial reserves and the level of competition), with a resultant decrease in physical performance. Blood glucose levels also fall, sometimes to values likely to cause a deterioration of both tactical thinking and cooperation between players (3.0 to 3.8 mmol/L), while in tropical climates, fluid losses can amount to 4 to 5kg of bodyweight. The effectiveness of glucose solutions in correcting these problems is limited for 2 main reasons: concentrations greater than 2.5% slow the rate of gastric emptying and thus fluid absorption, while provoking a secretion of insulin with a resultant hypoglycaemia. Fructose solutions are less liable to increase insulin secretion, but they have an equal propensity for slowing gastric emptying; moreover, the ingested fructose is largely metabolised in the liver, without boosting blood glucose. However, glucose polymer preparations have a low osmotic pressure per unit content of glucose equivalent, so that substantial amounts of carbohydrate can be administered in this fashion before gastric emptying is inhibited. If polymers are given before and during a soccer game, they sustain blood glucose, sparing muscle glycogen stores and increasing game performance. If the concentration of polymer is too high, one possible complication is a movement of water from the plasma into the gut; nevertheless, with an appropriate choice of concentration (for example, 7% polycose, 360 mOsm/L, plasma volume is increased rather than decreased relative to that seen with administration of water. Probably because the intergame interval for competitive soccer players is short, replenishment of glycogen reserves proceeds quite slowly. Moreover, this process does not seem to be helped by ingestion of either glucose polymers or a high carbohydrate diet.

Criteria for grouping nursing subunits in hospitals.

Data from 135 nursing subunits were used to identify a set of organizational variables that best explained the grouping of activities into nursing subunits in hospitals. Relatively strong support was provided for technology as a basis for grouping nursing subunits; characteristics of the hospital, including its type, size, and location, also were relevant.

Nursing subunit technology: a replication.

Overton, Schneck, and Hazlett's (1977) measurement of nursing subunit technology was replicated using 157 subunits of 9 types located in 24 hospitals in Alberta. A 21-item questionnaire was given to nurses, and the answers were subjected to factor analyses. Results indicated three dimensions of technology: instability, uncertainty, and variability. Because of the similarity of these variables to those in the Overton, Schneck, and Hazlett study, the results suggested a high degree of construct validity for the measure. The technological dimensions also differentiated among the types of subunits in the same pattern as in the original study. A relatively quick method of obtaining measures of instability, uncertainty, and variability by using composite scores was tested and found reliable.

Corporatization and deprivatization of health services in Canada.

Canada's system of health services has been shaped by the forces and values in the Canadian political, cultural, social, and economic environment; these forces continue to place constraints on future changes. We distinguish between "corporatization" and "privatization", and the implications of each for improved efficiency of the system. Although the organization of health services is, in certain provinces, undergoing significant structural changes, there is evidence that rather than privatizing, the system may actually be continuing to experience what we have termed deprivatization, as the scope of government involvement expands to include a more comprehensive definition of health care. Trends in Canada differ considerably from those in the United States; universal health insurance has curbed the ability and desire of institutions to exclude members of some socioeconomic groups from receiving care. U.S.-based models, if applied to Canada, could lead to both higher costs and lower quality of care. Considerable efficiencies can be realized within Canada's current system.

Downsizing, reengineering, and restructuring: long-term implications for healthcare organizations.

This article provides a framework for analyzing how downsizing and reengineering have affected healthcare organizations. These approaches are reviewed, and key tools that have been used, such as across-the-board cuts, reorganizing, and redesigning, are described. Examples are drawn from healthcare as well as other business sectors. The consequences of cost reduction strategies for an organizations's performance in terms of costs, quality of services, and satisfaction of consumers and employees are explored. The case is made that an organization's context--that is, its culture, level of trust, and leadership--is an important factor that influences the effect of cost-cutting strategies. Characteristics of organizations where downsizing has a better chance of succeeding also are described.

Hospital-physician integration: case studies of community hospitals.

Hospitals are attempting more meaningfully to involve physicians in management as one approach to increasing the efficiency and effectiveness of their operations. The purpose of this research was to explore the relationship between the structure of the medical staff organization, the extent to which physicians are integrated into hospital decision making and the hospital's financial performance. A measure of hospital-physician integration was developed based on Alexander et al's (1986) dimensions of hospital-physician integration which were based on Scott's (1982) organizational models, ie, autonomous, heteronomous and conjoint. A multiple case study design, which comprised eight community non-teaching hospitals over 200 beds located in the Province of Ontario, Canada, was used to examine the relationship between variables. Study results suggest that there is variation among community hospitals on both contextual and organization factors. Hospitals with high levels of hospital-physician integration were located in highly populated areas, had formulated and implemented a strategic plan, had highly structured medical staff organizations, and had no budgetary deficit. In contrast, hospitals with moderate or low levels of integration were more likely to be located in lowly populated areas, had little planning activity, had a moderately structured medical staff organization, and had deficit budgeting. Suggested areas for future research include examining the role of the Board of Trustees in determining physicians' organizational roles and identifying differences in commitments, characteristics, and motivations of physicians working in rural versus urban hospitals and their impact on integrative strategies.

Prediction of the financial performance of Ontario hospitals: a test of environmental determinist and adaptationist perspectives.

While other industries for many years have been concerned with the problem of financial distress, it is only recently that this issue has become a matter of interest to hospital managers, policy makers, and the general public. However, the determinants of hospital financial performance are neither well studied nor understood. The objectives of this study were to identify factors that affect the financial performance of Ontario hospitals and to construct a model that could be used to predict financial performance in the future. A number of organization and environmental factors that could influence financial performance were postulated and then tested for their statistical impact and predictive ability. Cross-sectional data over the 3-year-period 1986-1988 for 223 Ontario public hospitals were used. The first 2 years of data served as a derivation sample for hypothesis testing and development of a predictive model. The third year of data was used as a holdout sample for cross validation. Information on the variables investigated came from secondary sources, in particular Statistics Canada's Annual Hospital Returns. Univariate analyses revealed distressed hospitals were more likely to earn more revenues from non-government sources, to be non-teaching institutions and have longer chronic lengths of stay, and to be found in areas with higher per capita incomes, number of females in the population, physician supply, and area wage rates. A five variable prediction model was developed which accounted for 25% of the variance in financial performance in the derivation sample and on cross validation dropped to 21%. The model identified greater hospital size, older plants, higher technological complexity, more intensive care services, and location in areas with more females to be significant predictors of financial distress. Overall, environmental factors (community and structural characteristics) were more important in influencing financial performance. The implication for hospital managers is to underscore that an important dimension of successful leadership requires they remain outwardly focused and involved in managing the external environment. For policy makers the need is to develop funding formulae which encourage efficiency and are also responsive to differences in community and structural characteristics across hospitals.

Decentralization of decision-making in Canada's health system: the Sunnybrook experience.

Though there is a significant literature which notes that physicians are fast becoming organizational members, there has been little research evidence to suggest that the adoption of new management models have actually facilitated their involvement. This study sought to examine whether a conscious effort at decentralizing decisions at the clinical unit level would actually result in increased involvement of physicians and other clinicians in decision-making at that level. Two major surveys examining individual roles and responsibilities and unit relationships with other units were conducted, at two points in time, in a large Canadian tertiary care centre. Results suggest that physicians had experienced an increase in administrative discretion. There was an overall increase of many groups in influencing clinical unit decisions with a perceived decrease in senior management influence in budget administration at the unit level. Lessons learned in conducting this type of research are described.

The behavioural outcomes of quality improvement teams: the role of team success and team identification.

This study investigates the relationship between hospital quality improvement (QI) team success and changes in empowerment, 'organizational commitment, organizational citizenship behaviour' (OCB) and job behaviour related to QI. Data were collected from administrative staff, healthcare professionals and support staff from four community hospitals. The study involved a field investigation with two data collection points. Structured questionnaires and interviews with hospital management were used to collect data on the study variables. High scores were observed for organizational commitment, OCB and job behaviour related to QI when individuals identified with teams that were successful. Low scores were observed when individuals identified with teams that were unsuccessful. Empowerment was positively related to job behaviour associated with QI. It is concluded that participation on QI teams can lead to organizational learning, resulting in the inculcation of positive 'extra-role' and 'in-role' job behaviour.

Regulatory intensity, hospital size and the formalization of medical staff organization in hospitals.

Using a theory of organizational response to regulation, this study examined the effects of regulatory intensity and hospital size on the formalization of medical staff organization in Canadian hospitals. The general hypothesis was that, in provinces with greater regulatory intensity, hospitals would exhibit greater formalization of medical staff, and greater involvement of physicians in hospital governance and management; larger hospitals would have greater formalization of medical staff than smaller hospitals. Data from 574 hospitals indicated that both hospital size and provincial regulatory intensity were important factors predictive of the overall formalization of medical staff organization. Depending upon the provincial location, hospitals have developed different patterns of formalizing their medical staff structures.

The nature and extent of hospital competition in a government-funded health system.

A national study of Canadian hospitals assessed the perceived level and types of competition and the strategies pursued by these hospitals. Questionnaire data were obtained from chief executive officers in 715 hospitals, yielding a national response rate of 68%. Respondents indicated the perceived level of competition in the environment, the content of competition, and stated hospital strategies. Additional data were obtained on market share and hospital type. Close to half of the respondents indicated little or no competition in their environment, while 30% indicated substantial levels of competition. This represents a significant deviation from conventional wisdom about the Canadian health services environment. Respondents in hospitals with more than 75% of the market share were less likely to perceive competition than those with a smaller market share. CEOs in teaching hospitals and in hospitals located in larger communities reported higher levels of competition. Hospitals competed mostly for capital, programs, and staff; about a third of hospitals competed for patients and no differences were found by type of institution. Those hospitals in more competitive environments were more likely to indicate the use of diversification and horizontal integration as organizational strategies.

Measurement of staff empowerment within health service organizations.

A measure of empowerment was developed and its psychometric properties evaluated. Employees (n = 52) of two hospitals participated in semistructured interviews and a pilot test of the research instrument. A second study was undertaken with professional, support, and administrative staff (n = 405) of four community hospitals. Psychometric evaluation included factor analysis, reliability estimation, and validity assessment. Subjects responded to questionnaires measuring empowerment, leadership behavior, organizational citizenship behavior and job behaviors related to quality improvement. Factor analysis indicated three dimensions of empowerment: behavioral, verbal, and outcome empowerment. Coefficient alphas ranged from .83 to .87. The three dimensions were positively related to leadership behavior that encouraged self-leadership and negatively related to directive leadership. The three dimensions discriminated between the empowerment level of managers compared to that of nonmanagement staff. Empowerment predicted organizational citizenship behavior and job behaviors related to quality improvement.

Management partnerships: a reaction.

Although there are important differences that will affect future changes in the Canadian system, health care in Canada often parallels that in the United States. The concept of the hospital is changing from sickness care to health care. There is a growth of multi-institutional arrangements, bureaucracy is on the rise, and the number of nursing and other allied health professionals is growing. These trends are having an impact on the physician-nurse-administrator partnerships of program management.

A framework for assessing the performance of integrated health delivery systems.

Competing demands for resources within the health care system require health care providers to ensure the most effective and efficient use of resources. The evidence from the United States, the United Kingdom and other jurisdictions suggests that integrated health delivery systems (IDS) may be a cost-effective way to meet the health care needs of a population. This article introduces a framework for use in monitoring and evaluating the performance of an integrated delivery system. The establishment of a consistently used evaluation framework for integrated delivery systems will provide the government, governing bodies and other evaluators with an effective assessment tool that will enable greater understanding of the impact of the IDS on the health care system. It will also provide information to enable ongoing performance improvements within the system.

Governing integrated health delivery systems: meeting accountability requirements.

Many Canadian provincial governments are exploring methods to increase the integration of health services in an effort to improve the care provided, while maintaining or reducing the costs. Integrated health delivery systems are being implemented in the United States, Britain and other European countries. Such systems aim to provide a full continuum of care to a defined target population under a financing system of capitation. This article explores the issues associated with the governance accountabilities of an IDS. A review of potential governance models is completed, and the factors that influence the choice of a governance model for an integrated delivery system are presented. In 1987. Ewell identified governing boards as the weakest link in the integrated health care systems of the United States. It is suggested that early attention to governance in the development of IDS models in Canada may improve the effectiveness of these systems.

Technology acquisition in Canadian hospitals: how is it done, and where is the information coming from?

A 1990 nation-wide survey on technology acquisition in Canadian hospitals, based on 509 Anglophone and 55 Francophone hospital questionnaires and 193 hospital equipment request forms, revealed that 53% of capital funds were used to replace existing equipment, with the remainder spent on new purchases. However, very little regional planning was taking place. Most of the institutional acquisition decisions were made by committees, 17% of which were classified as medical staff, 25.1% as administrative, 32.4% as board committees and 22.5% as mixed. Although administration was heavily represented, medical staff were frequently present and nursing was just as likely to have at least minimal representation. However, technical experts usually played a minimal role. This omission, combined with the limited information asked for on equipment request forms and the limited availability and use of technology assessment information, suggests that acquisition decisions in many Canadian hospitals are likely to be based on inadequate information.

Technology acquisition in Canadian hospitals: how are we doing?

We surveyed attitudes of decision makers involved in making decisions about technology acquisition in hospitals, receiving replies from 989 (72%) anglophone respondents and 201 (68%) from francophone respondents. Respondents split on whether to try unverified procedures, strongly agreed that medical technology should be evaluated, and expressed a desire for technology assessment data. The quality of health care, need, and compatibility with the institution's role and mission were seen as the most important factors affecting acquisitions. Our study suggests that half the battle has been won; decision makers appear convinced that technologies must be evaluated. Organizational mechanisms, however, may still be required to ensure implementation.

Multidisciplinary teams in health care: lessons from oncology and renal teams.

An indepth study conducted on units treating renal disease and cancer clinics determined that multidisciplinary teams are relatively commonplace in these areas. Developing four team organizational structures--sequential, primary, nucleus and dynamic--the authors hypothesize that each varies on a continuum in terms of how highly structured they are. The framework suggests that the ideology of equal participation on the team is the most difficult to sustain, and that difficulties typically arise as organization requirements become more complex. More research seems to be indicated to develop a comprehensive organizational framework, and the probable effect of organizational form on team performance. One of the key issues addressed is team leadership.