Health Care Restructuring Research Articles

Regional inequalities of hospital morbidity and associations with mortality in Lithuania

Background and objectiveIn Lithuania, hospitalization was planned to be reduced with the approval of the national healthcare restructuring program. The aim of this study was to describe regional inequalities of hospitalization and hospital morbidity in Lithuania and to associate them with mortality in the regions. Materials and methodsRoutine hospital discharge data of Lithuanian hospitals, reimbursed by the Compulsory Health Insurance Fund and registered in database SVEIDRA, was used. Age-adjusted general hospitalization and hospital morbidity rates (per 1000 population) due to cardiovascular diseases (CVD), malignant neoplasms and external causes were calculated. Contribution of diseases, causing major public health problems, to general hospitalization was evaluated by analysis of components. Association of general hospitalization or hospital morbidity and mortality of respective causes was evaluated using non-parametric Spearman correlation. ResultsGeneral hospitalization and hospital morbidity of CVD, malignant neoplasms and external causes had increased from 2005 to 2011. Inequalities of hospitalization and hospital morbidity existed between regions of Lithuania. In Šiauliai, Klaipėda, Utena and Panevėžys regions, general hospitalization remained higher than national level. In Marijampolė, Alytus and Kaunas regions, general hospitalization became lower than Lithuanian average. There was no statistically significant correlation between variation in hospitalization and mortality rates in the regions. ConclusionsDespite national efforts to decrease hospital care, our study detected the failure of hospitalization reduction and revealed an increase of hospitalization with the existing regional inequalities in Lithuania.

Correlates and Consequences of Nursing Staff Job Insecurity

The health care system, and hospitals, underwent considerable restructuring and downsizing in the early to mid-1900s in several countries as governments cut costs to reduce their budget deficits. Studies of the effects of these efforts on nursing staff and hospital functioning in various countries generally reported negative impacts with threats to job security emerging as an important outcome of these changes. Health care restructuring and hospital downsizing is again being implemented as governments struggle to reduce deficits at a time of worldwide economic recession in 2008/2010. This study examines correlates and consequences of job insecurity among Canadian nursing staff, with a focus on nurses’ well-being. Data were collected from 290 nursing staff working in hospitals in Ontario, Canada. Feelings of job insecurity in the sample as a whole were relatively low. Personal demographics and work situation characteristics were generally uncorrelated with feelings of job insecurity. Consistent with previous findings, perceived job insecurity was once again associated with less favorable work and well-being outcomes. Some suggestions for more successful approaches to addressing levels of subjective job insecurity are offered.

Hospital Closures: The Sociospatial Restructuring of Labor and Health Care

Since 2003, more than twenty hospitals in New York City have closed because of debt and a state-driven downsizing program. During this same time period, the labor market for nurses has tightened substantially, shifting from an overall nurse shortage since the 1980s to a job shortage since the mid-2000s. Drawing on an analysis of media and government publications on hospital closures since 2003 and interviews with nurses working in the metropolitan area, I argue that hospital closures and the new job shortage are intertwined. By pushing an austerity agenda in the wake of the 2008 economic crisis, New York City and state government agencies as well as private health care institutions are actively restructuring—or “rightsizing”—the health care sector. Ultimately, this is a downsizing of care provisions by another name. Capitalism's continued devaluation of social reproduction manifests in New York City as a restructuring of the spaces and work of health care. Hospital closures are central to this restructuring that involves the mutually constituted transformations in the built environment, health care provisioning, and the nursing profession. In conclusion, this process risks making good health and good jobs less accessible.

Leadership and nurses’ satisfaction with supervision

Objective: The main objectives of this study were to evaluate the performance of leadership roles and the nurses’ satisfaction with supervision and to examine the relationship between the performance of leadership roles and nurse satisfaction.Methods: A quantitative, descriptive, correlational and transversal study was conducted, with a sample made up of 79 nurses practicing in two public health institutions in the district of Coimbra in Portugal. Data collected included demographic characteristics, eight leadership roles and five levels of supervision satisfaction. The Munson’s Supervision Satisfaction Scale and the Quinn’s Leadership Scale were used. The instruments adaptation and validation study revealed adequate psychometric properties being considered as valid instruments for the quantitative study pursuance.Results: The results indicate an acknowledgement of all roles of leadership, having a tendency towards the roles of producer (4.73) and director (4.64) indicating leadership centered on the rational goals model, revealing a greater concern with efficiency and productivity. The role of innovator was the one least perceived (4.16). Most nurses (83.50%) were satisfied with the supervision. The relationships between all the leadership roles and nurse satisfaction were positive, with the roles of facilitator (r = .842; p < .001) and mentor (r = .871; p < .001) with the strongest correlation.Conclusions: The investigation revealed that the leader who plays all roles of leadership raises the level of supervision satisfaction of the nurses he/she leads. A poor performance of the facilitator role suggests the need for head nurses to acquire leadership skills which help them manage interpersonal conflicts and promote cohesion and teamwork within the current context of health care restructuring and decreased nurse staffing levels.

Valdymo sprendimų įtaka infekcinių ligų ir tuberkuliozės ligoninės raidai

Straipsnyje nagrinėjama valdymo sprendimų įtaka naujo tipo specializuotosios ligoninės, sujungimo būdu įsteigtos orientuojantis į sveikatos priežiūros įstaigų restruktūrizavimo modelį, raidai. Ligoninės raida siejama su veiklos analize, veiksmingumo vertinimu, naujų vadybos priemonių taikymu. Atsižvelgiama į pagrindinių veiklos rodiklių (pacientų skaičius, lovų skaičius, lovos užimtumas, lovos apyvarta, vidutinė gydymo trukmė) atitiktį restruktūrizavimo strategijos siekinius nuo ligoninės įsteigimo 2003 m. iki integracijos į Vilniaus universiteto ligoninę Santariškių klinikas (toliau – VUL SK) ir VUL SK sudėtyje. Siūlomos į procesus orientuotos veiklos veiksmingumo ir vadovavimo kokybės vertinimo priemonės.

Productive restructuring in the area of health and obstetric nursing

This reflection aimed to show the productive restructuring dimensions achieved in Brazilian healthcare, discussing the nexuses between this phenomenon and the work in obstetrical nursing. Its construction was based on articles about productive restructuring and health available in the Virtual Health Library, reflecting the consequences on this speciality's caregiving process. We observed that the productive restructuring in health care may be seen under the health system management and work organization viewpoints. Despite the negative impacts in the field of work, there has been an appreciation of living labor in obstetrics in a context favorable to changes in labor care, through the introduction of obstetrical nursing and implementation of health care technologies. We conclude that, besides the focus on living labor and soft technologies, such concepts comprise technological innovation, as they have changed and resignified the way of providing care, thus beginning the process of the inversion of the technological core in obstetrics.

Economic austerity and healthcare restructuring: correlates and consequences of nursing job insecurity

The healthcare system underwent considerable restructuring and downsizing in the early to mid-1990s in several countries as governments cut costs to reduce their budget deficits. Studies of the effects of these efforts on nursing staff and hospital functioning in various countries generally reported negative impacts. Healthcare restructuring and hospital downsizing is again being implemented in North America in 2009/2010 as governments struggle to reduce their deficits at a time of worldwide economic recession. The present study examines the relationship of hospital restructuring initiatives in and their link with increased threats to job security with a variety of individual and hospital outcomes in a sample of nursing staff working in hospitals undergoing significant restructuring and downsizing. Data were collected from 289 nursing staff working in California hospitals. Nurses reported a relatively large number of restructuring and downsizing initiatives. Restructuring initiatives and threats to job security accounted for a greater increment in explained variance on every outcome measure than did personal demographic factors and work situation characteristics. Threats to job security were generally associated with negative work attitudes and satisfactions, levels of psychological well-being and perceptions of hospital functioning. Some suggestions for more successful approaches to cost reductions are offered.

Looking good or doing better? Patterns of decoupling in the implementation of clinical directorates

The interest toward hospital restructuring has risen significantly in recent years. In spite of its potential benefits, often organizational restructuring in health care produces unexpected consequences. Extant research suggests that institutional theory provides a powerful theoretical lens through which hospital restructuring can be described and explained. According to this perspective, the effectiveness of change is strongly related to the extent to which innovative arrangements, tools, or practices are adopted and implemented within hospitals. Whenever these new arrangements require a substantial modification of internal processes and practices, resistance to implementation emerges and organizational change is likely to become neutralized. This study analyzes how hospital organizations engage in decoupling by adopting but not implementing a new organizational model named clinical directorate. We collected primary data on the diffusion of the clinical directorate model, which was mandated by law in the Italian National Health Service to improve hospital services. We surveyed the adoption and implementation of the clinical directorate model by monitoring the presence of clinical governance tools (measures for the quality improvement of hospital services) within single directorates. In particular, we compared hospitals that adopted the model before (early adopters) or after (later adopters) the mandate was introduced. Hospitals were engaged in decoupling by adopting the new arrangement but not implementing internal practices and tools for quality improvement. The introduction of the law significantly affected the decoupling, with late-adopter hospitals being less likely to implement the adopted model. The present research shows that changes in quality improvement processes may vary in relation to policy makers' interventions aimed at boosting the adoption of new hospital arrangements. Hospital administrators need to be aware and identify the institutional changes that might be driven by law to be able to react consistently with expectations of policymakers.

Politics of Organizational Restructuring in Health Care and Work Ability of Nurses’

Nurses are the largest employee group in health care but continue to lack presence in organizational restructuring processes. This study examines whether nurses’ opportunities to be involved in organizational restructuring are associated with their work ability. Respondents of a survey were asked to identify the organizational changes that had transpired at their workplaces in the previous two years, and to evaluate their opportunities to be involved in these changes. They were also asked to evaluate their work ability and to assess certain statements related to their individual resources and the characteristics of their work at the time of the survey. The study shows that exclusion of nurses from health care restructuring processes may cause feelings of injustice and lower commitment to work and thus decrease work ability. Nurses who evaluated their opportunities to be involved in the restructuring as poor were at a two-fold risk of decreased work ability in comparison to nurses who stated that their opportunities to be involved were good. We conclude that the nursing profession should collectively aim to enhance individual nurse's opportunities to take part in the planning and implementation of organizational restructuring in health care. Poor opportunities to be involved in restructuring processes may result in costs not only to individual nurses but also to society at large as successful public health outcomes of health care restructuring are dependent on nurses’ work ability and performance.

Effective Leadership: Competing Values Framework

Abstract Introduction The importance of leadership in the performance of the organization has been demonstrated in various studies (1,2,3) . Given that an effective leadership relies on the performance of leadership roles, it becomes essential to identify the led nurses’ perceptions of the performance of leadership roles by the head nurse. Material and methods A descriptive and correlational study was developed using Quinn's Model of Leadership, which is composed of 32 questions assessing leadership skills in 8 roles (mentor, facilitator, broker, innovator, monitor, coordinator, director and producer). The sample was composed of 690 nurses, mostly female (76.7%), with a mean age of 34.56 years and 12 years of professional experience. This instrument showed satisfactory psychometric properties. Results The subordinate nurses’ leadership perceptions showed mean scores above the midpoint of the scale in all leadership roles, with a mean and standard deviation of 5.00±1.15, respectively. Conclusions The subordinate nurses’ perceptions of a high level of performance of leadership roles indicate that these leaders are competent. A poor performance of the facilitator role suggests the need for head nurses to acquire leadership skills which help them manage interpersonal conflicts and promote cohesion and teamwork within the current context of health care restructuring and decreased nurse staffing levels.

長崎県上五島地域における医療供給体制の再編成とそのメカニズム

長崎県上五島地域における医療供給体制の再編成とそのメカニズム

Essential Paths to Life after Residency

Essential Paths to Life after Residency

Value-based neurosurgery: the example of microvascular decompression surgery

Value of care is emerging as a promising framework to restructure health care, emphasizing the importance of reporting multiple outcomes that encompass the entire care episode instead of isolated outcomes specific to care points during a patient's care. The authors assessed the impact of coordinated implementation of processes across the episode of surgical care on value of neurosurgical care, using microvascular decompression (MVD) as an example. This study is a retrospective review of consecutive cases involving patients with either trigeminal neuralgia or hemifacial spasm undergoing first-time MVD. Patients were divided into 2 groups: Group 1 included patients who underwent surgery between February 2008 and November 2009 and Group 2 included those who underwent surgery between January 2011 and October 2012. The authors collected data on outcome measures spanning the entire surgical episode of care according to the Outcome Measures Hierarchy. Forty-nine patients were included: 20 patients in Group 1 and 29 patients in Group 2. Thirty-one patients underwent MVD for trigeminal neuralgia and 18 for hemifacial spasm. A zero mortality rate and high degree of symptom resolution were achieved in both groups. Group 2 benefited from a reduction in the average total operating room time, a decrease in the mean and median postoperative length of hospital stay, a decrease in the mean length of stay on the floor, and a reduction in the rates of complications and readmissions. Comprehensive implementation of improvement processes throughout the continuum of care resulted in improved global outcome and greater value of delivered care. Enhanced-recovery perioperative protocols and diagnosis-specific clinical pathways are two avenues built around global care delivery that can help achieve an "optimal episode of surgical care" in every case.

In need of outside help

Canadian nursing shortages after health care restructuring and hospital downsizing offer opportunities for qualified British staff. MJ Deschamps reports

The effects of perceived organisational support and span of control on the organisational commitment of novice leaders

The purpose of this study was to examine the main and interaction effects of perceived organisational support, span of control and leadership rank on novice nurse leaders' organisational commitment. As nurse leaders' organisational commitment is eroded at times of healthcare restructuring, it is important to study factors associated with organisational commitment. Cross-sectional data from 69 novice nurse leaders, collected via mailed surveys at two time points, were analysed using hierarchical regression. The findings supported our hypotheses about the positive effect of perceived organisational support, the positive effect of leadership rank and the negative effect of span of control on novice nurse leaders' organisational commitment. In addition, perceived organisational support was shown to moderate the negative effect of span of control on novice nurse leaders' organisational commitment at time 2. Organisational strategies aimed at supporting nurse leaders, and attention to span of control, are required to enhance the organisational commitment of novice nurse leaders. Nurse leaders with a wide span of control, in particular those with little leadership experience, need to adopt leadership strategies that maximise their effectiveness, such as organising smaller work groups or teams within their wide span of control.

Nursing Entrepreneurship: Motivators, Strategies and Possibilities for Professional Advancement and Health System Change

In Canada, as well as internationally, efficiency-focused organizational restructuring in healthcare has resulted in stressful job change for nurses, although nurses continue to work in a system that values technology-based, physician-provided services. Employed nurses have had to participate in organizational activities that undermine their professional values and goals. Nursing entrepreneurship presents an opportunity to explore nursing's professional potential in nursing practice that is uniquely independent. In this study, a focused ethnographic approach was used to explore the experiences of self-employed nurses, who see themselves as leaders in advancing the profession of nursing and its contribution to healthcare. Key themes in the findings include the responses of self-employed nurses to health system change, expanded roles for nurses, the consequences of this non-traditional approach to nursing work and the possibilities for change that arise from nursing entrepreneurship. This research has implications for healthcare policy, professional advocacy and nursing education.

Protests against Welfare Retrenchment: Healthcare Restructuring inSweden

The ‘new politics’ perspective in welfare state research holds that class‐based parties and unions have lost some of their influence and that they have been replaced by client organizations that are capable of resisting retrenchment pressures. However, scholars within the ‘power resource tradition’ contend that class is still fundamental and that client interests are weak in corporatist countries with a strong labour movement. It is argued in this article that scholars within the power resource approach have focused too much on social insurance programmes and traditional forms of political participation, and that this has made them blind to client protests. An empirical study of political efforts to close down nighttime emergency surgery in Swedish hospitals is presented. The Swedish counties planned to close down emergency surgery in 17 hospitals in the period 2003–04. The political proposals to close down emergency departments were met with strong protests from client groups, and politicians often withdrew their proposals of closures. In this case study, politicians claim that it was client protests that made them withdraw a decision to close the emergency surgery. This result suggests that client protests are politically important and diverges from the expectations deduced from the power‐resource approach but lends credibility to the theory of the new politics of the welfare state.

Adverse events among Ontario home care clients associated with emergency room visit or hospitalization: a retrospective cohort study.

BackgroundHome care (HC) is a critical component of the ongoing restructuring of healthcare in Canada. It impacts three dimensions of healthcare delivery: primary healthcare, chronic disease management, and aging at home strategies. The purpose of our study is to investigate a significant safety dimension of HC, the occurrence of adverse events and their related outcomes. The study reports on the incidence of HC adverse events, the magnitude of the events, the types of events that occur, and the consequences experienced by HC clients in the province of Ontario.MethodsA retrospective cohort design was used, utilizing comprehensive secondary databases available for Ontario HC clients from the years 2008 and 2009. The data were derived from the Canadian Home Care Reporting System, the Hospital Discharge Database, the National Ambulatory Care Reporting System, the Ontario Mental Health Reporting System, and the Continuing Care Reporting System. Descriptive analysis was used to identify the type and frequency of the adverse events recorded and the consequences of the events. Logistic regression analysis was used to examine the association between the events and their consequences.ResultsThe study found that the incident rate for adverse events for the HC clients included in the cohort was 13%. The most frequent adverse events identified in the databases were injurious falls, injuries from other than a fall, and medication-related incidents. With respect to outcomes, we determined that an injurious fall was associated with a significant increase in the odds of a client requiring long-term-care facility admission and of client death. We further determined that three types of events, delirium, sepsis, and medication-related incidents were associated directly with an increase in the odds of client death.ConclusionsOur study concludes that 13% of clients in homecare experience an adverse event annually. We also determined that an injurious fall was the most frequent of the adverse events and was associated with increased admission to long-term care or death. We recommend the use of tools that are presently available in Canada, such as the Resident Assessment Instrument and its Clinical Assessment Protocols, for assessing and mitigating the risk of an adverse event occurring.

Psychiatric readmission: an integrative review of the literature

In the global context of contemporary psychiatric deinstitutionalization, the phenomenon of psychiatric readmission imposes important challenges, as it exposes the fragility of the network of mental health services. To gather, synthesize and analyse the national and international scientific literature regarding the phenomenon of psychiatric readmission in the context of deinstitutionalization. Through the combination of descriptors, an integrative review was performed of publications from the period 1997 to 2010 included in the MedLine, PubMed, LILACS, SciELO and PsycINFO databases. Selection of the articles was based on pre-established inclusion and exclusion criteria. Three authors independently evaluated the eligibility of the articles. The level of inter-judge concordance was calculated, using the formula: agreement = Σ possible concordance subtracted from real discordance divided by the number of articles. Information about the selected studies was systematized and analysed. Sixteen articles met the inclusion criteria. Studies conducted and published in international journals, mainly in the USA, with a quantitative approach predominated. In general, the studies addressed the phenomenon of psychiatric readmission after the restructuring of mental health care. The variables investigated were clinical and sociodemographic factors and the characteristics of the mental health service associated with readmission, as well as the programs developed specifically for patients vulnerable to hospital readmissions. It was noted that the perspective of the patient regarding their readmissions, as well as the interface with the social and familial context in which they maintain their social relationships and care for their health, was largely unexplored by the literature.

The workplace perspective on supporting family caregivers at end of life: evaluating a new Canadian social program

There is a growing realization that employers need to accommodate the issue of work-life balance for employees who are also providing care for family members or friends in palliative or end-of-life situations, as this phenomenon is only expected to increase within developed nations in the future given demographic trends and health care restructuring. This research aims to uncover the expectations that Canadian employers/human resources (HR) professionals have of the Compassionate Care Benefit (CCB), in addition to their experienced realities of having staff utilize this social program. The CCB provides employed family/informal caregivers with a job-secured work leave and six weeks of employment insurance benefits while they take time off to provide care to a dying family member or close other, often at home (in the community). Five focused discussions were implemented with employers/HR across Canada. Using thematic analysis, the data reveal how well (or not) the CCB meets caregivers' needs, as well as the informational and procedural needs of workplaces. In light of these findings, suggestions for program improvement, with respect to the CCB, are made in order to advocate for continued support of family/informal caregivers whose voices are rarely heard.