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Research suggests that improving hospital work environments and solving the nursing shortage are critical to improving patient care. The Houston–Galveston region created an aggressive approach to this issue by forming an unusual coalition of business, university, and hospital leaders and using a quality improvement approach. Four years later, the project has achieved over 40% participation among hospitals in the 13-county region and includes 50 hospitals employing approximately 15,000 registered nurses. The data that have been collected by this collaborative to date suggests that hospitals are taking action to improve outcomes by modifying their key initiatives to address the attributed causes of poor work environments. From 2004 to 2005, executives of top performing hospitals increasingly attributed successful work environment outcomes to an emphasis on management development and executive-driven initiatives, de-emphasizing specific employee behavior, process, and outcome-based initiatives.

The tradition of medicine has until now been characterized by an aspiration to provide as complete as possible a service of care to the populations to which it owes responsibility. The same holds for nursing and caring practices, but the tradition is loosening. Despite the collective assumption that medical and nursing practice rests on solid grounds of knowledge and is framed by a caring ethos, change in practice not only has typically come about in a complex and diffuse fashion, but has also come along with sacrifices, losses and deficits.

Background – Reliable and valid hospital nurse staffing measures are a major requirement for health services research. As the use of these measures increases, discussion is growing as to whether current nurse staffing measures adequately meet the needs of health services researchers.

Objective – This study assesses whether the measures, sampling frameworks, and data sources meet the needs of health services research in areas such as staffing assessment; patient, nurse, and financial outcomes; and prediction of staffing.

Methods – We performed a systematic review of articles from 1990 through 2007, which use hospital nurse staffing measures in original research, or which address the validity, reliability, and availability of the measures. Taxonomies of measures, sampling frameworks, and sources were developed. Articles were analyzed to assess what measures, sampling strategies, and sources of data were used and to ascertain whether the measures, samples, and sources meet the needs of researchers.

Results – The review identified 107 articles that use hospital nurse staffing measures for original research. Multiple types of measures, some of which are used more often than others and some of which are more valid than others, exist in each of the following categories: staffing counts, staffing/patient load ratios, and skill mix. Sampling frameworks range from hospital units to all hospitals nationally, with all hospitals in a state being the most common. Data sources range from small-scale surveys to national databases. The American Hospital Association Annual Survey is the most frequently used data source, but there are limitations with its nurse staffing measures. Arguably, the multiplicity of measures and differences in sampling and data sources are due, in part, to data availability. The limitations noted by other researchers and by this review indicate that staffing measures need improvements in conceptualization, content, scope, and availability.

Discussion – Recommendations are made for improvements to research and administrative practice and to data.

Hospital nurse managers are in the middle. Their supervisors expect that they will monitor and discipline nurses who commit errors, while also asking them to create a culture that fosters reporting of errors. Their staff nurses expect the managers to support them after errors occur. Drawing on interviews with 20 nurse managers from three tertiary care hospitals, the study identifies key exemplars that illustrate how managers monitor nursing errors. The exemplars examine how nurse managers: (1) sent mixed messages to staff nurses about incident reporting, (2) kept two sets of books for recording errors, and (3) developed routines for classifying potentially harmful errors into non-reportable categories. These exemplars highlight two tensions: the application of bureaucratic rule-based standards to professional tasks, and maintaining accountability for errors while also learning from them. We discuss how these fundamental tensions influence organizational learning and suggest theoretical and practical research questions and a conceptual framework.

This article examines how a profit-centered restructuring of labor relations in an academic medical center undermined team-based care practices in its intensive care unit. The Institute of Medicine has promoted team-based care to improve patient outcomes, and the staff in the intensive care unit researched for this paper had established a set of practices they defined as teamwork. After hospital executives rolled out a public relations campaign to promote its culture of teamwork, they restructured its workforce to enhance numerical and functional flexibility in three key ways: implementing a “service line” managerial structure; cutting a range of staff positions while combining others; and doubling the capacity of its profitable and highly regarded intensive care unit. Hospital executives said the restructuring was necessitated by changes to payment models brought forth by the Affordable Care Act. Based on 300 hours of participant-observation and 35 interviews with hospital staff, findings show that the restructuring lowered staff resources and intensified work, which limited their ability to practice care they defined as teamwork and undermined the unit’s collective identity as a team. Findings also show how staff members used teamwork as a sensitizing concept to make sense of what they did at work. The meanings attached to teamwork were anchored to positions in the hospitals’ organizational hierarchy. This paper advances our understanding of he flexible work arrangements in the health care industry and their effects on workers.

Despite hospitals’ efforts to reduce health care-associated infections (HAIs), success rates vary. We studied how leadership practices might impact these efforts.

We conducted eight case studies at hospitals pursuing central line-associated blood stream infection (CLABSI)-prevention initiatives. At each hospital, we interviewed senior leaders, clinical leaders, and line clinicians (n=194) using a semi-structured interview protocol. All interviews were transcribed and iteratively analyzed.

We found that the presence of local clinical champions was perceived across organizations and interviewees as a key factor contributing to HAI-prevention efforts, with champions playing important roles as coordinators, cheerleaders, and advocates for the initiatives. Top-level support was also critical, with elements such as visibility, commitment, and clear expectations valued across interviewees.

Results suggest that leadership plays an important role in the successful implementation of HAI-prevention interventions. Improving our understanding of nonclinical differences across health systems may contribute to efforts to eliminate HAIs.

The purpose of the study was to explore in literature what different leadership styles and behaviors of head nurses have a positive influence on the outcomes of patient safety or quality of care.

We reviewed the literature from January 2000 until September 2011. We searched Pubmed, Embase, Cinahl, Psychlit, and Econlit.

We found 10 studies addressing the relationship between head nurse leadership and safety and quality. A wide array of styles and practices were associated with different patient outcomes. Transformational leadership was the most used concept in the studies. A trend can be observed over these studies suggesting that a trustful relationship between the head nurse and subordinates is an important driving force for the achievement of positive patient outcomes. Furthermore, the effects of these trustful relationships seem to be amplified by supporting mechanisms, often objective conditions like clinical pathways and, especially, staffing level.

This study offers an up-to-date review of the limited number of studies on the relationship between nurse leadership and patient outcomes. Although mostly transformational leadership was found to be responsible for positive associations with outcomes, also contingent reward had positive influence on outcomes. We formulated some comments on the predominance of the transformational leadership concept and suggested the application of complexity theory and political leadership for the current context of care. We formulated some implications for practice and further research, mainly the need for more systematic empirical and cross cultural studies and the urgent need for the development of a validated set of nurse-sensitive patient outcome indicators.

Although it is widely acknowledged that health care delivery systems are complex adaptive systems, there are gaps in understanding the application of systems engineering approaches to systems analysis and redesign in the health care domain. Commonly employed methods, such as statistical analysis of risk factors and outcomes, are simply not adequate to robustly characterize all system requirements and facilitate reliable design of complex care delivery systems. This is especially apparent in institutional-level systems, such as patient safety programs that must mitigate the risk of infections and other complications that can occur in virtually any setting providing direct and indirect patient care. The case example presented here illustrates the application of various system engineering methods to identify requirements and intervention candidates for a critical patient safety problem known as failure to rescue. Detailed descriptions of the analysis methods and their application are presented along with specific analysis artifacts related to the failure to rescue case study. Given the prevalence of complex systems in health care, this practical and effective approach provides an important example of how systems engineering methods can effectively address the shortcomings in current health care analysis and design, where complex systems are increasingly prevalent.

This research examines effects on emotional burnout among “maternity support workers” (MSWs) that support women in labor (labor and delivery (L&D) nurses and doulas). The emotional intensity of maternity support work is likely to contribute to emotional distress, compassion fatigue, and burnout.

This study uses data from the Maternity Support Survey (MSS) to analyze emotional burnout among 807 L&D nurses and 1,226 doulas in the United States and Canada. Multivariate OLS regression models examine the effects of work–family conflict, overwork, emotional intelligence, witnessing unethical mistreatment of women in labor, and practice characteristics on emotional burnout among these MSWs. We measure emotional burnout using the Professional Quality of Life (PROQOL) Emotional Burnout subscale.

Work–family conflict, feelings of overwork, witnessing a higher frequency of unethical mistreatment, and working in a hospital with a larger percentage of cesarean deliveries are associated with higher levels of burnout among MSWs. Higher emotional intelligence is associated with lower levels of burnout, and the availability of hospital wellness programs is associated with less burnout among L&D nurses.

While the MSS obtained a large number of responses, its recruitment methods produced a nonrandom sample and made it impossible to calculate a response rate. As a result, responses may not be generalizable to all L&D nurses and doulas in the United States and Canada.

This research reveals that MSWs attitudes about medical procedures such as cesarean sections and induction are tied to their experiences of emotional burnout. It also demonstrates a link between witnessing mistreatment of laboring women and burnout, so that traumatic incidents have negative emotional consequences for MSWs. The findings have implications for secondary trauma and compassion fatigue, and for the quality of maternity care.