Hospital Hierarchy Research Articles

Interest in Working as an Infection Prevention and Control Nurse and Perception of This Position by Nursing Students-Results of a Pilot Study.

Background: The results of several studies in the area of infection control in Poland are disturbing. The situation may be shaped by many factors. However, the key factor for effective infection prevention and control is dedicated personnel, especially infection prevention and control nurses (IPCN). Nevertheless, based on the available published data and the authors’ experience, in many Polish hospitals infection control is not sufficiently appreciated by managers, it is consequently underfunded, and treated by medical staff as a nuisance. This may influence the nurses willingness to work as IPCN. The aim of the study was to assess the nursing students’ perception of the work of IPCN and their interest in employment in this position, as well as the potential reasons for choosing this particular specialization. Materials and methods: The study was conducted using the authors’ anonymous questionnaire conducted among nursing students of three Polish universities. The questionnaire was prepared by a panel of experts working in the field of infection control, including nurses working both as academic teachers and infection control nurses in hospitals. The design of the questionnaire was based on the authors’ own experience, knowledge, and exchanging information with the practitioners in infection control in Poland. The reliability of the questionnaire was confirmed by the Cronbach alpha test. The raw alpha values and 95% CI for two main questions concerning opinion were: 0.76 (0.72–0.81) and 0.69 (0.63–0.75). Results: The study was conducted among 253 students, mostly women (98%) of full-time (31.4%) and extramural (68.6%) studies. The age range of the respondents was 20–58 years, median = 26 years, IQR = 19 years. To the key item in the questionnaire, i.e., “Would you like to work as an IPCN?”, 84.6% (214 respondents; first group) of the respondents answered “no” and 15.4% (39 respondents, second group) answered “yes”. The results revealed no significant differences between the two groups concerning the position responsibilities and appreciation by other medical staff. Additionally, for respondents willing to work as ICPN the most important issues were the influence on patient safety, expected salary, and possibility of professional development; for the respondents from the other group the most important issue was lack of contact with patients. The results concerning the students’ opinion on the perception of IPCN by medical personnel proved to be peculiar. About 80% of the respondents confirmed the IPCNs’ key role in ensuring patient and personnel safety, while only 31.6% declared their high standing in the hospital hierarchy. Conclusions: The obtained results indicate the necessity of thorough studies on the organization and structure of infection control in Polish hospitals, with a particular emphasis on building a positive perception of IPCNs by medical staff, as well as implementing an education campaign on infection control in the hospital environment.

54 Patient Safety Culture at a Teaching Hospital in Kuala Lumpur

Abstract Introduction Patient safety, such as inpatient falls, is a global problem, accounting for increasing compensation costs from our healthcare facilities. The aim of this study was to evaluate the patient safety culture among healthcare providers. Method An online survey was developed within the hospital staff portal at the University of Malaya Medical Centre, with a dialogue box appearing on the launching of the portal website inviting the members of staff to participate in the survey. The survey contained a safety assessment questionnaire (SAQ) which measures the patient safety culture. The SAQ consists of 36 items measuring the six domains: teamwork climate, job satisfaction, safety climate, stress recognition, working conditions, and perception of management. Each domain is assigned a percentage score, and comparisons of scores according to healthcare disciplines were then made. Results 5275 (80%) responded to the online SAQ which was sent out to all 6562 healthcare professionals employed, by the hospital. The teamwork and safety climate was poor among supporting staff, with scores of 56.7 and 59.8 respectively. Job satisfaction (62.9), perception of ward management (56.8), and hospital management (53.2), and working conditions (44.7) were less among the clinicians. Stress recognition (36.5) was in alarmingly low among the nurses. Conclusion A comprehensive unit-based safety programme will be conducted in response to the SAQ findings, and should incorporate objective falls the outcome in order to convince the hospital hierarchy of the need for urgent solutions to lower the rates of inpatient falls.

Chinese Minority Perceives the Doctor-Patient Relationship Differently: A Cultural and Economic Interpretation.

In China, doctor-patient relationships (D-P relationships) are cited frequently and attracted international attention. This study assesses whether the D-P relationship experienced by the Chinese is associated with ethnicity, hospital hierarchies, and socioeconomic factors. In a national cross-sectional survey, multi-stage random sampling was adopted to assess regional and socio-economic differences between year 2016 and year 2017. Each area surveyed consisted of about 250 randomly chosen households, and valid results were obtained from 4,173 adults aged 16–99. When provided a choice of eight types of D-P relationship, for doctors in primary care institutions, 63.8% of ethnic minorities indicated having a friend-type relationship with their physicians, with 23.3% having a trading/reciprocal relationship. Han Chinese, however, predicts the opposite relationship between doctors from different hierarchy and the types of D-P relationship. For physicians working in hospitals, this difference in relationship was more pronounced, where 52.9% of ethnic minorities indicated having a friend-type relationship with their physicians, and 30.1% indicated the presence of a trading/reciprocal relationship. For Han Chinese, however, 53.3% indicated having a reciprocal relationship with their doctor. Overall, the prevalence of friendly D-P relationships was correlated with ethnic minorities, lower levels of education, and lower incomes. Ethnic minorities are most likely to perceive their physicians as friends, while Han Chinese are more likely to perceive a trading relationship with their physicians. The primary contribution of this research is the finding that D-P relationships differ for Han Chinese and other ethnic minorities.

Nurses' perception of empowerment and its relationship with organizational commitment and trust in teaching hospitals in Iran.

The aim of the present study was to clarify the relationship between perception of job empowerment and organizational commitment and trust among nurses in teaching hospitals of Khorramabad (Iran). Lack of power has been widespread among nurses in their workplaces due to uneven distribution of power among hospital staffs. Giving power to only a few individuals at the top of hospital hierarchy may often make nurses feel weak in their workplaces and causes reduction in the patients' quality care. This is a descriptive cross-sectional study which included 160 officially employed nurses in four teaching hospitals of Khorramabad (west Iran) selected by stratified random sampling. The instruments used were: The Conditions of Work Effectiveness Questionnaire-II (C.W.E.Q-II), which measures nurses' empowerment, the Pressure Management Indicator, which measures organizational commitment and the Trust in Management Scale, which measuresorganizational trust. The data were analysed by the SPSS software using the descriptive and analytic statistical tests employing chi-square, Fisher's test and the Spearman-Brown correlation coefficient. The results showed that the nurses had a below moderate score in their perception of job empowerment ( =2.38±0.70), with the highest score in their perception of access to "opportunity" subscale ( =3.11±0.95), and the lowest score in their perception of access to "formal power" ( =2.43±0.95). Additionally, moderate "organizational commitment" and "organizational trust" were reported with =4.5±0.90 and =4.01±1.11, respectively. The highest and the lowest perception scores were found for "continuous commitment" and "affective commitment" with =4.94±0.97 and =4.26±1.21, respectively. There were positive significant relationships between the three major variables of the study (p<0.001). The results showed that there was a positive and significant relationship between nurses' perception of job empowerment, organizational commitment and trust. Nursing managers can increase the motivating factors among their nurses through evaluating organizational variables like empowerment and organizational trust. In fact, through recognition of the relationship between empowerment and organizational trust, one can design the interventions of structural empowering for the improvement of professional nursing practice, nurses' workplace well-being and safe quality care.

How nurse manager’s position in the hospital hierarchy influences evidence-based practice implementation in nursing: A qualitative case study of the Nigerian acute care setting

Background and objective: Evidence-based practice (EBP) is widely acknowledged as an essential aspect of healthcare delivery. Nurse managers are expected to contribute to the development of organisational cultures promoting EBP. However, there are indications that nurse managers are not necessarily empowered to drive implementation due to hierarchical constraints. This study explores how nurse manager’s position in the hospital hierarchy influences EBP implementation in nursing, in the Nigerian acute care settings.Methods: A qualitative case study methodology is utilised to gather data from two large acute care settings in Nigeria. Drawing on semi-structured interview, twenty-one ward managers and two nurse managers were interviewed. Data were transcribed and inductively analysed to generate four overarching themes.Results: Nurse managers were hugely constrained by lack of autonomy to mobilise resources for EBP related activities. The hierarchical structure of the settings promoted top-down decision-making processes which in turn, limited nurse manager’s visibility in the boardroom. Consequently, nurse managers were excluded from key strategic planning within the organisation and could not drive EBP implementation.Conclusions: Findings highlight need for nurse managers to have greater visibility and managerial influence to enable them create opportunities for implementation of EBP in nursing. Implications for nursing management: Administratively, there is need for nurses to have greater involvement in management. Adequate authority and leadership visibility as well as managerial influence would enable nurse managers create opportunities for successful implementation.

Using gallery walks to navigate hospital hierarchy.

Using gallery walks to navigate hospital hierarchy.

Barriers and facilitators to implementing a process to enable parent escalation of care for the deteriorating child in hospital.

ObjectiveTo identify barriers and facilitators to implementing a parent escalation of care process: Calling for Help (C4H).DesignAudits, semi‐structured interviews and focus groups guided by the Theoretical Domains Framework.SettingAustralian paediatric hospital where a parent escalation of care process was introduced in the previous 6 months.ParticipantsFour children, 13 parents, 91 nurses and doctors including Medical Emergency Team (MET) members.Main outcome measuresParent awareness and involvement in escalating care and factors impacting implementation of C4H.ResultsTwo audits identified low level of parent awareness (16/88, 19% and 5/85, 6%). Parent involvement in escalation of care was documented in 11/62 (18%) events. The main facilitators included uniformly positive views that C4H was in the child's best interest, acknowledgement that parents had skills to recognize deterioration and would take action. C4H was considered to add to patient safety and being reviewed by the MET was a patient benefit. Key barriers were the low level of awareness, doubt about parent capabilities, concern about parents’ information overload, anticipated overuse of resources, staff unease about possible repercussions and anticipated difficulty for parents to question staff with potential negative effects on parent‐staff relationships. Overall C4H presents a challenge to traditional hospital hierarchy and culture.ConclusionsAlthough there was a low level of awareness about C4H in practice, there was in‐principle support for the concept. Initial strategies had primarily targeted policy change without taking into account the need for practice and organizational behaviour changes. Using a theoretical approach to identify key factors will enable a targeted approach to implementation.

Eventide by Therese Bohman

Therese Bohman Eventide Trans. Marlaine Delargy. New York. Other Press. 2018. 240 pages. Amid a midlife crisis, Karolina Andersson knows her “pathetic” life must change so she can face the end of the day—eventide. A tenured art history professor at the University of Stockholm, she lives in “a noisy two-room apartment full of books and loneliness,” having recently left her partner of eleven years, Karl Johan. Childless, she mulls over love versus career. Karolina no longer derives pleasure from her addictions to alcohol and sex, working to hold onto her area of scholarly research: women depicted in turn-of-thecentury art. Up pops Anton Strömberg, a young male doctoral student who tells her he’s discovered groundbreaking letters from an overlooked female artist smackdab in the center of Karolina’s bailiwick. From this scenario, Swedish author Therese Bohman produces an absorbing feminist novel of psychological suspense as she explores her protagonist’s inner life. Bohman gives us the whole woman. Karolina contemplates mannerism, Swedish art, and German symbolism. It bugs her when students treat theories as truths. She reflects on Finland’s nuclear waste, hedgehogs, Svalbard’s seed bank, refugees, Ilya Ivanovich Ivanov’s human-ape hybrid, and architectural columns. She watches pornography in her office, has an affair with a married Anders, considers one with childhood friend Robban , suggests one to colleague Peter, is repulsed by the thought of one with fellow professor Lennart, but hmmmm . . . what about Anton? She realizes: Must. Stop. Falling. For. Everyone. Doubting herself as she wonders how to recognize happiness , she’s vulnerable. Bohman’s previous two novels, also translated by Marlaine Delargy, placed other female protagonists against different male-dominated backdrops, illustrating the societal issues women face. Each central character has had greater self-esteem than her predecessor, with a larger supporting cast. Drowned (2012) perambulated literary life, and The Other Woman (2016) trekked hospital hierarchy, exploring emotional and sexual abuse, class differences, power, male ego, and professional success. Now, in Eventide, Bohman expands these themes in a new setting—the university : “a place where learning is generated .” Her details about ivory-tower life are spot-on; she nails turf wars in academia with subtle wit. Karolina Andersson is the strongest of Bohman’s three protagonists, and Eventide the most ambitious of her books. In many ways, it’s the most winning —a wild-woman archetype tale à la Pauls Bankovskis 18 Trans. Ieva Lešinska Vagabond Voices This novel, translated from Latvian and set against an important moment in Latvian history, sees a family trying to unravel the mystery of a digital camera buried in their grandfather’s coat as well as a Latvian soldier’s desertion and travels a century earlier. The stories examine questions of time, growth, and freedom, and the writing is approachable and vivid. Évelyne Bloch-Dano Paper Gardens: A Stroll through French Literature Trans. Teresa Lavender Fagan University of Virginia Press The author of several award-winning French-language biographies, Évelyne Bloch-Dano now turns her talents to an overview and analysis of the roles of the garden in French literature. This charmingly detailed account includes a history of types and styles of gardens, both literary and literal, before examining the various places gardens appear in French literary history, “from Proust to Duras.” Nota Bene WORLDLIT.ORG 69 Women Who Run with the Wolves by Clarissa Pinkola Estés. The novel ends in an elegant twist awash in schadenfreude. Eventide is ink well spent. Lanie Tankard Austin, Texas Dolores Redondo All This I Will Give to You Trans. Michael Meigs. Seattle. Amazon Crossing. 2018. 478 pages. One expects a thick novel to be expansive in theme or epically cover a great deal of time and territory, but lately several mysteries, especially in translation, have been showing up with all the heft of One Hundred Years of Solitude or The Brothers Karamazov. At 478 pages, All This I Will Give to You is by Spanish novelist Dolores Redondo, whose Baztán Trilogy (set in the Basque country) has sold a million and a half copies in Spanish and been translated into thirty-five languages. Her books have been nominated for several major awards, including the Crime...

Factors influencing the occupational injuries of physical therapists in Taiwan: A hierarchical linear model approach.

The evidence literature suggests that physical therapy practitioners are subjected to a high probability of acquiring work-related injuries, but only a few studies have specifically investigated Taiwanese physical therapy practitioners. This study was conducted to determine the relationships among individual and group hospital-level factors that contribute to the medical expenses for the occupational injuries of physical therapy practitioners in Taiwan. Physical therapy practitioners in Taiwan with occupational injuries were selected from the 2013 National Health Insurance Research Databases (NHIRD). The age, gender, job title, hospitals attributes, and outpatient data of physical therapy practitioners who sustained an occupational injury in 2013 were obtained with SAS 9.3. SPSS 20.0 and HLM 7.01 were used to conduct descriptive and hierarchical linear model analyses, respectively. The job title of physical therapy practitioners at the individual level and the hospital type at the group level exert positive effects on per person medical expenses. Hospital hierarchy moderates the individual-level relationships of age and job title with the per person medical expenses. Considering that age, job title, and hospital hierarchy affect medical expenses for the occupational injuries of physical therapy practitioners, we suggest strengthening related safety education and training and elevating the self-awareness of the risk of occupational injuries of physical therapy practitioners to reduce and prevent the occurrence of such injuries.

\u201cA steep learning curve\u201d: junior doctor perspectives on the transition from medical student to the health-care workplace

BackgroundThe transition from medical student to hospital-based first year junior doctor (termed “intern” in Australia) is known to be challenging, and recent changes in clinical learning environments may reduce graduate preparedness for the intern workplace. Although manageable challenges and transitions are a stimulus to learning, levels of burnout in junior medical colleagues are concerning. In order to prepare and support medical graduates, educators need to understand contemporary junior doctor perspectives on this transition.MethodsFinal-year University of Queensland medical students recruited junior doctors working in diverse hospital settings, and videorecorded individual semi-structured interviews about their transition from medical student to working as a junior doctor. Two clinical academics (NS and JT) and an intern (ZT) independently conducted a descriptive analysis of interview transcripts, and identified preliminary emerging concepts and themes, before reaching agreement by consensus on the major overarching themes.ResultsThree key themes emerged from the analysis of 15 interviews: internship as a “steep learning curve”; relationships and team; and seeking help. Participants described the intern transition as physically, mentally and emotionally exhausting. They learned to manage long days, administrative and clinical tasks, frequent interruptions and time pressures; identify priorities; deal with criticism without compromising key relationships; communicate succinctly; understand team roles (including their own status within hospital hierarchies); and negotiate conflict. Participants reported a drop in self-confidence, and difficulty maintaining self-care and social relationships. Although participants emphasised the importance of escalating concerns and seeking help to manage patients, they appeared more reluctant to seek help for personal issues and reported a number of barriers to doing so.ConclusionFindings may assist educators in refining their intern preparation and intern training curricula, and ensuring that medical school and intern preparation priorities are not seen as competing. Insights from non-medical disciplines into the organisational and relational challenges facing junior doctors and their health-care teams may enhance inter-professional learning opportunities. Workplace support and teaching, especially from junior colleagues, is highly valued during the demanding intern transition.

Using linked records to improve National estimates of hospital admissions for coronary heart disease (CHD)

ABSTRACTObjectivesNational statistics for hospital admissions for acute CHD based on unlinked administrative data are inflated because of inter/intra-hospital transfers or related readmissions for further investigations or procedures. Our objective was to estimate the inflation of CHD inpatient counts using multiple approaches based initially on Western Australian data that can be applied to future National studies.&#x0D; ApproachWe used a linked hospital morbidity dataset from the Western Australian Data Linkage System to determine hospitalisations for each CHD subcategory from 1990-2010. Transfers were defined as contiguous admissions separated by ≤1 day. Episodes-of-care (EOC) were defined as admissions (with/without transfers) that were within 28 days of the initial CHD admission. As the principal diagnosis may vary between hospitals involved in transfers or admissions within an EOC, we explored four approaches for allocating a diagnosis:i. Hierarchical diagnosis: selection of diagnosis based on clinical severity (ST-elevation myocardial infarction (STEMI)&gt;non-STEMI&gt;unstable angina&gt;stable angina&gt;other CHD&gt;chest pain); ii. Hospital hierarchy: diagnosis based on highest hospital level (tertiary&gt;private&gt;other metropolitan non-tertiary&gt;rural);iii/iv. Temporal order of diagnosis: diagnosis based on first or last record in transfer/EOC.&#x0D; ResultsThe proportion of cases that were transferred varied according to disease severity and time: 13% (1990) to 27% (2010) for STEMI; 5% to 7% for stable angina and unchanged at 4% for chest pain. Compared to transfer-level data using the first approach, unlinked data overestimated STEMI counts by 3% (1990) to 11% (2010), stable angina by 3% to 5% and chest pain by 6% to 6%. Similarly for EOC-level data, the overestimates were 5% (1990) to 12% (2010) for STEMI, 13% to 19% for stable angina and 20% to 14% for chest pain. The four approaches for allocating a diagnosis produced differing counts with the difference being larger for more clinically severe diagnoses than for less clinically severe diagnoses. For example, using transfer-level data, the differences between approaches i and iv in 2010 were 12%, 2% and 1% for STEMI, stable angina and chest pain respectively.&#x0D; ConclusionThere is a potential to overestimate counts of CHD in inpatient data if transfers and readmissions are not taken into account, and this inaccuracy can differ across disease subcategories and approach used. This has important implications where higher disease severity, such as myocardial infarction, is an indicator of population health. Transfer- or EOC-level data are more likely to reflect true CHD hospitalisation counts than unlinked-level data, and are more appropriate for epidemiological studies of CHD rates.

Clinical and social barriers to antimicrobial stewardship in pulmonary medicine: A qualitative study

The treatment of pulmonary infections is one of the largest indications for antibiotics in human health care, offering significant potential for antibiotic optimization internationally. This study explores the perspectives of pulmonary clinicians on antibiotic use in hospital pulmonary infections. Twenty-eight pulmonary doctors and nurses from 2 hospitals participated in semi-structured interviews focusing on their experiences of antibiotic use. Barriers to antibiotic optimization in pulmonary infections were identified. Clinical barriers are as follows. The first is differentiating pneumonia vs chronic obstructive pulmonary disease: differentiating pulmonary diagnoses was reported as challenging, leading to overtreatment. The second is differentiating viral vs bacterial: diagnostic differentiation was perceived to contribute to excess antibiotic use. The third is differentiating colonization vs pathogen: the interpretation of ambiguous results was reported to lead to under- or overprescribing depending on the perspective of the treating team. Social barriers are as follows. The first is the perception of resistance: antibiotic resistance was not perceived as an immediate threat. The second is the perceived value of antibiotic clinical guidelines: there was mistrust in antibiotic guidelines. The third is hospital hierarchies: hierarchical structures had a significant influence on prescribing. Substantial barriers to antibiotic optimization in pulmonary infections were identified. To facilitate change in antibiotic use there must be a systematic understanding and interventions to address specific clinical issues. In the case of pulmonary medicine, significant identified issues, such as mistrust in clinical guidelines and diagnostic challenges, need to be addressed.

Development and implementation of an operating room scheduling tool: an action research study

In this study, we report the results of an action research project whose aim was to develop and implement an operating room scheduler at the Meyer University Children’s Hospital. The study offers insights into the features that make an MSS optimisation model and scheduler effective and easy to implement, and shed light on those actions facilitating their introduction and use. Specifically, it suggests that creating an effective operating room scheduler requires clustering patients in homogeneous surgery groups and developing a flexible tool that allows: scheduling surgery groups instead of actual patients, easily adding/removing constraints, changing the objective function(s) and adjusting the planning horizon. In addition, it posits that gaining the commitment of top management by showing credible preliminary results, inferring stakeholder preferences by letting them comment on tentative schedules, introducing changes gradually and involving staff at lower levels of the hospital hierarchy can significantly facilitate the scheduler development and implementation.

Levels of job dissatisfaction and work-related stressors experienced by medical doctors in Greek hospitals

Although a considerable number of studies have been conducted with regard to work well-being of medical personnel, few of these have focused on smaller countries with a cultural setting such as Greece. In specific, much attention has been given to the mental health of medical doctors who appear to be at high risk and prone to a number of job stressors. Many of these factors can significantly reduce their general ability to respond effectively to their demanding duties. The present study investigates the extent to which specific occupational stressors may predict various aspects of job satisfaction amongst 514 Greek hospital doctors. The main sample consisted of 277 male and 237 female doctors covering the spectrum of the typical hospital hierarchy, who completed the author Hospital Doctors Stress Questionnaire, the Occupational Stress Indicator (OSI) and a Job Satisfaction scale. Analyses of the data demonstrated that, overall, hospital doctors presented low levels of job satisfaction in relation to salary, working hours, opportunities for promotion and general working conditions. The highest levels of satisfaction were indicated with regard to relationships with colleagues and superiors, responsibilities, and appreciation for their work. The results of this study identify that certain occupational stress factors influence the overall job satisfaction of Greek hospital doctors. Finally, as regards to demographic variables as potential predictors of job satisfaction, presence of physical symptoms, specialism and age were significantly associated to the overall job satisfaction.

The role of patient-provider interactions: Using an accounts framework to explain hospital discharges against medical advice

The phenomenon of leaving the hospital against medical advice (AMA) despite being quite common and associated with significant deleterious health outcomes remains inadequately understood and addressed. Researchers have identified certain patient characteristics as predictors of AMA discharges, but the patients' reasons for these events have not been comprehensively explored. Moreover, because the medical authority model dominates this research area, providers' experiences of AMA discharges remain unstudied. We examined the AMA discharge from a patient-centered perspective by analyzing the content of notes providers generate to record such events. We analyzed providers' notes for all inpatients with a primary HIV diagnosis (N = 33) that, in 2012, left an urban hospital AMA. Applying the Scott and Lyman accounts framework, we identified that the notes constituted records of providers' and patients' excuses and justifications for failing to meet the expectations of a provider offering patient-centered care and a compliant patient receiving care. Alongside the patients' reasons for leaving AMA, the notes also revealed the providers' reasons for honoring or discrediting the patients' accounts. The style of the accounts and the professional status of the notes' authors enabled us to contextualize the production and sharing of AMA notes in the hospital hierarchy. Conceptualizing AMA notes as dyadic accounts elicited specific factors that challenge the patient-provider relationship, and generated insights on how to strengthen it, and thus decrease the rates of AMA discharges and their associated health effects.

Variation in worker responses to subcontracted employment: A qualitative case study

This article shows that professional skill level of employees is a key factor in the formation of employee responses to subcontracted forms of employment. In addition, the proportion of employees hired through temporary staffing arrangements compared to the core workers determines the employees’ capacity for collective action. This article uses observational and interview data from a public university hospital, where both skilled health care professionals and janitorial workers are hired through temporary staffing arrangements. The findings reveal that skilled health care professionals develop more individualistic responses to cope with the subcontracting practices, and the co-employment of subcontracted and permanent workers undermines solidarity among them. Lacking the professional skills and positioned at the bottom of the hospital hierarchy, janitorial workers opt for collective action against the hospital administration. Finally, the analysis of counter-responses of the hospital administration points to the dynamic nature of workplace relations, and the capacity of employers to reshape the responses of workers.

Healthcare management challenges in two university hospitals

The economic downturn in developed countries has had implications in the field of healthcare. In Finland, public hospitals have been forced to improve their production efficiency while coping with limited resources. In this study, 14 interviewees from two Finnish University hospitals were interviewed. The aim of the study was to shed light on today's work process, change, information, medical technology, and lean management challenges. Both hospitals had recently undergone rigorous renovation and relocation projects. The employees and patients were happy with the hospital management. However, there were several improvements needed regarding hospital hierarchy, bureaucracy, communication, ICT technology, logistics, safety, teamwork, personnel structure and outsourcing. The managements at both hospitals desired to improve their work processes, employee well-being and patient care, and also develop the lean work processes. Several functions were praiseworthy, and those in need of improvement were transparently discussed by the hospital management.

The experience of learning to speak up: a narrative inquiry on newly graduated registered nurses.

To explore the process of learning to speak up in practice among newly graduated registered nurses. Speaking up is an important aspect of communication to ensure patient safety within a healthcare team. However, nurses have reported being hesitant about speaking up or being unable to be heard, despite adopting various safety tools. A power differential could be a factor in their hesitation to speak up. While a large number of new graduates are employed in the lower rungs of the hospital hierarchy to resolve local and global nursing shortages, the process of their learning to speak up remains under-explored. The narrative concept of experience is addressed through the three-dimensional space of a narrative inquiry. Eighteen new graduates were recruited. Stories of experiences of speaking up emerged naturally during repeated unstructured interviews and ongoing email conversations with three participants. The complex process of learning to speak up is schematically represented. Three interrelated narrative threads were identified: (1) learning to speak up requires more than one-off training and safety tools, (2) mentoring speaking up in the midst of educative and miseducative experiences and (3) making public spaces safe for telling secret stories. Speaking up requires ongoing mentoring to see new possibilities for sustaining professional identities in the midst of miseducative experiences under the potential shaping of the Chinese culture and generational differences. Appreciative inquiry might be a new approach that can be used to promote positive cultural changes to encourage newly graduated registered nurses to learn to speak up to ensure patient safety. Cultivating a safe and open culture of communication and mentoring new graduates to speak up will benefit patient safety now and in the future by helping to retain committed patient advocates who could mentor future generations.

Survey of the nursing ethics cognition status after carrying out the "High quality nursing service demonstration project" in Guangxi Zhuang Autonomous Region

Objective We aimed to investigate the nurses' ethics cognition status and its influencing factors after carrying out the High quality nursing service demonstration project in Guangxi Zhuang Autonomous Region. Methods From May to June 2014, 379 clinical nurses from 59 hospitals of different grades in Guangxi Zhuang Autonomous Region were investigated with the self-designed questionnaire. Results After carrying out the High quality nursing service demonstration project , the total score of the nurses' ethics cognition were (51.29±3.46), which was higher than those in 2010. There was no statistical difference in cognition of medical confidentiality between 2014 and 2010, but it showed significant statistical differences in dimensions of medical optimization, informed consent, the value of life, t value was 11.389, 7.448 and 2.126, P<0.05. The multiple linear regression analysis showed that nurse-job seniority and hospital hierarchy of clinical nurses were influencing factors of nurses' ethics cognition; educational levels, professional title and nurse-job seniority of clinical nurses were influencing factors of medical optimization; nurses' professional title was influencing factor of informed consent; nurse-job seniority, department and hospital hierarchy of clinical nurses were influencing factors of medical confidentiality; nurses' educational level was influencing factor of life value. Conclusions The High quality nursing service demonstration project contributes to improve the level of nurses' ethics cognition. We should strengthen the nursing ethics continuing education system, in order to improve the nurses' comprehensive ethics cognition. Key words: High quality nursing care; Clinical nurse; Ethics; Cognition

Workaholism: are physicians at risk?

Work addiction (WA), often called 'workaholism', is a relatively recent concept that has not yet been clearly defined. Ongoing studies have found prevalence rates that are highly variable due to the diversity of the models used and the populations studied. To assess the characteristics of WA among hospital medical staff. All physicians practising at a French university hospital were invited to participate in a survey based on two questionnaires: the Work Addiction Risk Test (WART) for WA and the Job Contents Questionnaire (JCQ) to assess psychosocial constraints at work. There were 444 responding physicians. The response rate was 45%. Thirteen per cent of respondents were considered to be highly work addicted and a further 35% were considered mildly work addicted. Professors had the highest average WART score, but neither age nor sex was associated with WA. Furthermore, all 3D scores obtained using the JCQ correlated with the WART score; the highest correlation coefficient being obtained between the WART score and the job demands score, indicating that workaholics experienced high job demands. WA especially affects professors, who have the highest status amongst doctors in the hospital hierarchy. This study highlights the importance of constraints and workload, which are consistent with individual vulnerability factors. These factors may help identify ways of preventing and managing this type of addiction, through improvement of working conditions and organizational structures.