Work Redesign Research Articles

The 1996 Helene Hudson Memorial Lecture. Work redesign and re-engineering: a challenge for professional nursing practice.

Work redesign and re-engineering have become the buzzwords of the 1990s as all sectors of the health care arena struggle to meet the demands of patient care while coping with increasing fiscal constraint. Redesign and re-engineering are terms that describe a wide range of strategies in health care and radically different models of care delivery. These new approaches to care are shifting the way we view care delivery and how it is structured. This paper describes the principles of redesign and re-engineering, common applications in health care organizations, outcomes and evaluation. Multiskilling and use of genetic health care workers are addressed. The potential impact on the practice of oncology nurses is explored as well as strategies to meet the challenges of today's health care environment.

Work Redesign Making It a Reality

Everyone involved in work redesign must recognize the need to plan for change, thus breaking the myth that new job descriptions primarily affect only the new worker. As part of redesign, specific questions regarding task analysis and job bundling need to be asked. Implementation of a new work design in a medical center applying these principles is described.

Restructuring hospital nursing: reversing the trend toward a professional work force.

Registered nurses are currently threatened by a new managerial strategy to restructure work on hospital wards through the implementation of "Continuous Quality Improvement" and the "downsizing" of the professional work force. The strategy reintroduces nonprofessional and unlicensed nursing personnel in a manner that may displace large numbers of registered nurses (RNs) and affect patient care adversely. Ironically, not only is this change being implemented principally to reduce hospital costs rather than to improve quality, it reverses the cost-containment strategy implemented in the 1980s when hospitals displaced nonprofessional nursing workers and moved toward a professional work force. In this article, the author reviews the prior shift from "team nursing" with a stratified work force that included licensed practical nurses and nurses' aides to "primary nursing" and the trend toward all-RN staffing, and explains how this trend contributed to the present effort to reverse the process. The author then discusses current work redesign methods that have been adapted from traditional industrial applications to destroy work jurisdictions and further rationalize hospital production through the downsizing of the professional work force and the creation of cross-trained workers in a new team-based management approach. The article concludes by discussing nursing's response to corporate-imposed work restructuring and the significance of these changes.

Work redesign and role restructuring in a pharmacy department with pharmacist assistants.

A new staffing model for decentralized pharmacists and support staff at a university hospital is described. A new technical support position--the pharmacist assistant--was created, and activities were reallocated among the pharmacists, pharmacist assistants, and pharmacy technicians according to the recommendations of two total quality management teams. Pharmacist assistants were to perform many of the drug distribution and record-keeping functions previously performed by pharmacists. The activities marked for reallocation accounted for about 50% of pharmacist time in the existing staffing model; they would not be performed by experienced pharmacy technicians who received brief training to be pharmacist assistants. Nine pharmacists and nine technicians tested the new staffing model on four patient care units over a four-week period. The reassignment of pharmacist tasks to pharmacist assistants theoretically gave pilot-unit pharmacists more time for providing and documenting patient-specific clinical activities and an additional 12 hours a week to participate in such global patient care activities as critical-pathway and quality improvement meetings. By the end of the study, the pharmacist assistants demonstrated that they could perform the reassigned activities; however, the pharmacists were not yet confident in the assistants' ability to do so. A pilot study of a new decentralized pharmacy staffing model demonstrated that technical support personnel can perform many distributive and record-keeping activities traditionally performed by decentralized pharmacists.

Streamlining documentation: an opportunity to reduce costs and increase nurse clinicians' time with patients.

Clinical documentation can take up to 25 percent of a nurse's time in an acute care setting, not to mention the time spent by other clinicians and ancillary caregivers on documentation. Institutions can reduce documentation time by systematically determining what information is crucial to the provision of patient care across all disciplines and then using a redesign process that mirrors work redesign. By following a structured process that challenges the philosophy and function of the documentation system, a hospital's multidisciplinary staff members can use their expertise to design alternatives that achieve documentation's original intent-to document diagnoses and treatment accurately-in a more efficient and useful way.

Relevance conventions and problem boundaries in work redesign teams

Presents findings from a study undertaken to identify some of the conversational issues in the production of knowledge in cross‐functional work redesign groups. Illustrates what may be key sources of miscommunication based in differing conversational relevance. Postulates that the recognition of relevance and, by extension, the recognition of a valid contribution, is influenced by the manner of discourse or speech style. Feels that the language behaviours as disclosed in the analysis can be inhibiting to the work of cross‐functional teams responsible for a variety of organizational change processes, including IS development and workflow redesign.

The Practice Environment Project

Evaluating the practice environment is essential to determine if the practice environment is conducive to the delivery of quality patient care. The Practice Environment Project (PEP) was created to provide a framework for current and ongoing evaluation of the practice environment. Major changes in the delivery of patient care services have focused attention on the evaluation of the effectiveness of these changes. The extent and type of change may vary throughout an institution. The identification of core variables to assess the effectiveness of these changes sets the framework for ongoing evaluation of new unit-based models for delivery of services. In part 1, quantitative data were collected from nursing staff members (job satisfaction, collaboration with physicians, autonomy), physicians (quality of nursing care, collaboration with nurses), and patients (satisfaction with nursing care). In part 2, focus groups were held with nursing personnel to discuss factors that affected the provision of services. Unit-based action plans were developed to manage barriers to the delivery of services. Patients and physicians reported a high degree of satisfaction with patient care. Physicians reported a higher level of collaboration with nurses than that reported by nurses. Nurses reported a high degree of autonomy in practice, however, in other areas of job satisfaction (development and recognition), they suggested areas for improvement. The PEP created a mechanism to evaluate the current state-of-the-practice environment by identifying core elements for evaluation of work redesign. It also provided a framework for managing barriers that disrupted the delivery of patient care services.

The Work Redesign Team Handbook: A Step by Step Guide To Creating Self Directed Teams

The Work Redesign Team Handbook: A Step by Step Guide To Creating Self Directed Teams

Integration of emerging designs for the practice and management of nursing.

Work redesign and shared governance represent two of the most popular administrative innovations in contemporary nursing. Whereas work redesign creates changes in the content of nurses' jobs, shared governance addresses the organizational context within which nurses are employed. Although the content and context of nurses' work are closely interrelated, many organizations have attended to one of these issues, but failed to give consideration to the other. Building on this background, the state of the art in nursing redesign and restructuring is summarized, and emerging directions in job and organizational design are identified.

Improving patient outcomes through system change

In this article, the authors report on a project that studied the impact of work redesign on the roles of hospital executives. Thirty-six in-depth interviews were conducted with executives from 13 VHA healthcare organizations that were considered excellent practice models in the area of work redesign. This report represents a broad, multidisciplinary perspective reflecting the ideas of various members of the healthcare management team. VHA hired Marie Manthey and Creative Nursing Management, Inc., to conduct the interviews in an objective manner and to assist with results interpretation.

Ethical Issues and the New Staff Mix

The role of the professional nurse is changing due to the effects of work redesign programs, downsizing, and the increasing use of unlicensed assistive personnel (UAP). Nurses recognize that they cannot provide all aspects of the patient's care; however, nurses generally lack the knowledge and skill to delegate effectively. If nurses cannot delegate appropriate tasks to others, mistrust those to whom they are delegating tasks, and show limited respect toward UAP when delegating and supervising their work, there is the distinct possibility that patients will not receive quality care. The authors examine the ethical issues of respect for persons, trust, and promoting patient well-being, as well as the nursing issues related to accountability and responsibility when delegating care. There are several recommendations provided to enable nurses to reduce the threat of compromised patient care created by this new staff mix.

Making a Performance Improvement Plan Work

A carefully crafted organizational performance improvement (PI) plan can guide implementation and demonstrate that the organization is serious about continuously improving its processes and patient care outcomes. A good plan provides an overview of both the processes that are used to achieve PI and the expected outcomes. This article describes the process by which St John's Regional Medical Center (Joplin, Mo) developed and implemented its P1 plan. The first task is to define the desired PI program elements, such as use of teams and teamwork, measurement and monitoring systems, resource management tools, work redesign and reengineering, and customer-focused care. Then cultural changes to support the PI system need to be identified; the plan should include specific strategies to avoid or overcome any possible stumbling blocks. As an example of customer-focused improvement, intensive care unit nurses formed a team to address customer complaints about waiting room policies and physical facilities. An open visiting policy was initiated, pagers for family members of patients were provided, and the waiting room was made more comfortable. Use of resource management tools is illustrated by the development of algorithms and pathways to address variation in care provided to patients with complicated and uncomplicated acute myocardial infarction. Expectations for involvement from the top should be set, holding managers and employees accountable for participating appropriately; hospital departments and the medical staff should be integrated as soon as possible; and bureaucratic requirements should be kept to a minimum.

Home Health Care Reengineered

This article applies the corporate strategies of reengineering to the home care setting. Examples are given of meaningful ways to apply these principles and strategies to the home care organization. Leadership involvement and development are discussed as key components to the successful restructuring/reengineering project. Key strategies include work redesign, task breakdown analysis and reintegration, clinical pathways, information technology enhancement, and patient-focused care teams. Receptiveness to change and establishment of a new organizational culture in which learning is valued are integral components of home care reengineering. The myriad of credentialling standards is taken into consideration in the article's discussion of implemented changes.

Work and Role Redesign: Tools and Techniques for the Health

Work and Role Redesign: Tools and Techniques for the Health

Stress in the offshore oil and gas exploration and production industries: An organizational approach to stress control

Many researchers have pointed out the limitations of stress management strategies which aim solely to help the individual employee cope with stress in the work environment. In this study a stress audit approach to stress control was used to identify sources of stress which might be either reduced or eliminated by organizational change strategies. Three hundred and ten males (92 per cent British) on 97 installations working in the UK offshore oil and gas exploration and production industries took part in a stress audit. By using interview (N = 50) and questionnaire techniques, personnel were monitored over an 18-month period. Factor analysis and multiple regression analyses were used to identify sources of negative stress in the offshore environment. In this article, some of the stressors associated with job dissatisfaction are discussed and a variety of methods, including work redesign, are recommended as stress control strategies.

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.

Managed care and the nurse's ethical obligations to patients.

The goal of managed care is to control health care costs by such means as keeping people healthy and decreasing the length of hospital stays. This change in health care delivery has resulted in work redesign programs, lay-offs, cross-training, and the use of an increasing number of nonprofessional care providers. The challenge for nursing, as a result of these changes, is how to fulfill its obligations of fidelity and due care. The authors discuss these ethical responsibilities and the impact that managed care is having on the fiduciary relationship between nurse and patient. Four strategies that nurses can use to fulfill their obligations include engaging in personal reflection, communicating and collaborating, protecting patient's rights, and evaluating patient outcomes.

Expert Panel Method for Nurse Staffing and Resource Management

The Expert Panel Nurse Staffing and Resource Management Method is a bold new approach for the identification of nurse staffing requirements and the management of resources. Expert panels comprised of those most knowledgeable of the patient population and the uniqueness of specific patient care areas identify staff needed to meet clinical, administrative, education, continuous quality improvement, and research needs. In addition, the expert panels explore opportunities for systems improvements, work redesign, and administrative restructuring within the context of budgetary realities.

Work Redesign and the Balance of Control Within a Nursing Context

Within the nursing organization of four hospital wards, a new work design was introduced, which was primarily characterized by the delegation of responsibilities from head nurses to nurses and by the participation of patients. First, it was hypothesized that the participation of patients in health care would enhance their perception of both their own and the nurses' control over their stay in the hospital. Second, it was hypothesized that, in the perceptions of head nurses, nurses, and doctors, the new work design would enhance the perceived control of nurses and reduce the perceived control of head nurses over nursing care. Over 1000 patients, nurses, head nurses, and doctors completed questionnaires. The data support the hypotheses and the results are discussed in terms of participation and decentralization effects of work design changes. It was further observed that doctors evaluated some practical aspects of the new work design negatively, but measures have been taken to overcome these problems. Some organizational and management implications are briefly discussed.

Comptency based orientation: A tool for work redesign

Comptency based orientation: A tool for work redesign