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Biomedical subjects

L H Aiken

Publications and source records attributed to L H Aiken.

At least 19 recordsLinked to original sources
PubMed2001

Are teamwork and professional autonomy compatible, and do they result in improved hospital care?

A postal questionnaire survey of 10 022 staff nurses in 32 hospitals in England was undertaken to explore the relationship between interdisciplinary teamwork and nurse autonomy on patient and nurse outcomes and nurse assessed quality of care. The key variables of nursing autonomy, control over resources, relationship with doctors, emotional exhaustion, and decision making were found to correlate with one another as well as having a relationship with nurse assessed quality of care and nurse satisfaction. Nursing autonomy was positively correlated with better perceptions of the quality of care delivered and higher levels of job satisfaction. Analysis of team working by job characteristics showed a small but significant difference in the level of teamwork between full time and part time nurses. No significant differences were found by type of contract (permanent v short term), speciality of ward/unit, shift length, or job title. Nurses with higher teamwork scores were significantly more likely to be satisfied with their jobs, planned to stay in them, and had lower burnout scores. Higher teamwork scores were associated with higher levels of nurse assessed quality of care, perceived quality improvement over the last year, and confidence that patients could manage their care when discharged. Nurses with higher teamwork scores also exhibited higher levels of autonomy and were more involved in decision making. A strong association was found between teamwork and autonomy; this interaction suggests synergy rather than conflict. Organisations should therefore be encouraged to promote nurse autonomy without fearing that it might undermine teamwork.

Cooperative Behavior↗
PubMed2001

Human inputs: the health care workforce and medical markets.

Arrow wrote his classic article in simpler times, as those who chance upon this article forty years hence will say of today. It was a new era in science and medicine, soon to be fueled by new resources from Medicare and the National Institutes of Health. Fiscal constraint was a stranger, physicians were in short supply, and information asymmetry was pervasive. In the intervening years, Americans have become more comfortable with health care issues. Fatal illness, which was rarely discussed with patients in 1960, is now researched by them on the Internet, and greater attention is paid to patient rights. Nonetheless, concerns about quality have, if anything, increased. Indeed, it is public concern about quality that has invited governmental regulation and induced a defensive posture among medical organizations, which are rushing to establish their own instruments of quality, and it is these same public concerns that have facilitated the ability of managed care to offer itself as the guarantor of quality. However, center stage is now held by another issue: health care costs. As a result, the focus has shifted from resolving information asymmetry by enhancing quality to controlling national health expenditures by changing the size and composition of the health care workforce. Licensure, which was restrictive in 1960, is more relaxed today, thereby reducing the entry barriers for the NPC disciplines, several of which were just beginning when Arrow wrote his article. The entry of NPCs into the realm of physician's services partially counterbalances the constraints that have been placed on physician supply, although the major contributions of NPCs are skewed to the primary care end of the spectrum while the major constraints on physician supply affect specialists. The growing presence of NPCs creates a dynamic market in which practitioners in various disciplines both compete and collaborate. It is, in fact, the perfect market that Arrow reluctantly longed for, in which providers who have different levels of skill offer their services at varying prices. But consumers have little upon which to base their choices. And while many of the services offered by NPCs replace physician services at a lower price, others represent additional services, which add to aggregate spending. Arrow sought to explain how a market replete with uncertainty could function. He saw that licensure, entry rationing, and educational subsidies could work to enhance quality, but they did so at the expense of the market. The market has seen it differently and has usurped these tools for its own purposes, leaving quality to look for other sponsors. Has it done so wisely? We have yet to see how well a multidisciplinary workforce of autonomous providers will function, but both successes and failures abound. What is more apparent is how entry rationing and restrictions on educational subsidies have capped the supply of physicians and limited the production of specialists at a time when there is increasing demand for their services. Arrow identified potent tools for affecting the characteristics of the health care workforce. They now must be redirected to the needs of the future.

Economic Competition↗
PubMed2001

Hospital restructuring: does it adversely affect care and outcomes?

The past decade has witnessed pronounced changes in the organization of U.S. hospitals, many the direct result of restructuring and reengineering initiative intended to decrease costs and increase productivity. Little is known about how these initiatives have affected clinical care and patient outcomes. Using data from a variety of sources, the authors describe initiatives that hospitals undertook over this period, indicate how staffing changed relative to the case-mix of patients receiving care, and examine changes in nursing practice environments over the period from 1996 to 1998. The authors found that apparent increases in nurse-to-patient ratios may be deceiving and that increases in patient acuity and nurses' responsibilities may have increased the workload of nurses in hospitals in ways, when coupled with a deteriorating practice environment, may adversely affect patient outcomes.

Efficiency, Organizational↗
PubMed2001

Cause for concern: nurses' reports of hospital care in five countries.

According to most experts, the U.S. faces a growing shortage of registered nurses, threatening the quality of care hospitals can provide. In the setting of nurse shortages and simultaneous concern about patient safety, nurses' job satisfaction and their assessment of quality of care become critical. This Issue Brief highlights a cross-national survey that describes nurses' perceptions of their hospital work environment, and identifies core problems in work design and workforce management in five countries.

Canada↗
PubMed2000

Hospital restructuring: does it adversely affect care and outcomes?

The past decade has witnessed pronounced changes in the organization of United States hospitals, many the direct result of restructuring and re-engineering initiatives intended to decrease costs and increase productivity. Little is known about how these initiatives have affected clinical care and patient outcomes. Using data from a variety of sources, the authors describe initiatives that hospitals undertook during this period, discuss how nurse staffing changed relative to the case mix of patients receiving care, and examine changes in nursing practice environments from 1986 to 1998.

Diagnosis-Related Groups↗
PubMed1999

Shaping systems to promote desired outcomes. The magnet hospital model.

The organization of nurses' work is a major determinant of patient and staff welfare. Magnet hospitals have demonstrated organizational attributes that enable nurses to fully use their knowledge and expertise to provide high-quality patient care. The empirical evidence that this type of organization produces better patient and staff outcomes is compelling. Therefore when reconfiguring the delivery of care, the organizational form found in the magnet hospitals should shape systems to promote desired outcomes.

Benchmarking↗
PubMed1999

Organization and outcomes of inpatient AIDS care.

OBJECTIVE: To compare differences in AIDS patients' 30-day mortality and satisfaction with care in dedicated AIDS units, scattered-bed units in hospitals with and without dedicated AIDS units, and in magnet hospitals known to provide good nursing care. METHODS: Data were obtained on 1,205 consecutively admitted patients in 40 units in 20 hospitals and on 820 of their nurses. RESULTS: Mortality was lower and satisfaction was higher for AIDS patients in dedicated AIDS units and in nursing magnet hospitals. Primary nursing, end-of-life care counseling, and discharge planning were also more common. Higher nurse to patient ratios and AIDS physician specialty services were strongly associated with lower mortality. Patient satisfaction was strongly associated with organizational control of care by bedside nurses. Homosexuals were more likely to be admitted to dedicated AIDS units, which largely explains the under-representation of minorities and women. CONCLUSIONS: Dedicated AIDS units and magnet hospitals offer important benefits to AIDS patients, including lower odds on dying within 30 days of admission, higher patient satisfaction, and care meeting professional standards. Better nurse staffing, AIDS physician specialty services, and more organizational control by bedside nurses improve patient outcomes.

Acquired Immunodeficiency Syndrome↗
PubMed1999

Organization and outcomes of inpatient AIDS care.

The establishment of AIDS hospitals and AIDS units within hospitals has been controversial. Unlike other specialty care, AIDS care arrangements were initially developed as much to segregate AIDS patients from other patients and staff as to provide the best possible care. Ten years after many of these units opened, little evidence was available about whether the benefits of aggregating AIDS patients outweighed the potential hazards of segregating people from the mainstream of hospital care. This Issue Brief describes a national study to determine how different organizational settings affect the outcomes of inpatient AIDS care.

Acquired Immunodeficiency Syndrome↗
PubMed1997

Satisfaction with inpatient acquired immunodeficiency syndrome care. A national comparison of dedicated and scattered-bed units.

OBJECTIVES: This study sought to determine whether there were differences in acquired immunodeficiency syndrome (AIDS) patients' satisfaction with inpatient nursing care on dedicated AIDS units compared with conventional, multidiagnosis medical units. METHODS: Interview data were collected from more than 600 consecutive AIDS admissions in 40 patient care units in 20 hospitals in 11 high AIDS incidence cities. Ten hospitals with dedicated AIDS units were matched with comparable hospitals treating AIDS patients on multidiagnosis medical units. AIDS patients' satisfaction with nursing care on dedicated AIDS units was compared with AIDS patients' satisfaction with care on scattered-bed units in the same hospital and with AIDS patients' satisfaction on scattered-bed units in different, matched hospitals without dedicated units. Interhospital differences that were not controlled by design were controlled statistically, as were differences in patient characteristics and illness severity. RESULTS: Acquired immunodeficiency syndrome patients receiving care on dedicated AIDS units were significantly more satisfied with their nursing care. In hospitals with units of both types, dedicated AIDS units had a higher proportion of white patients, men, and homosexuals, whereas scattered-bed units had more minority patients and intravenous drug users. Controlling for these factors as well as for differences in illness severity and interhospital differences in patient satisfaction did not diminish the positive AIDS unit effect on patient satisfaction. CONCLUSIONS: Dedicated AIDS units achieve higher levels of satisfaction among patients with AIDS than general medical units. There is no evidence that patients feel isolated or stigmatized on dedicated AIDS units compared with patients on general units, and many patients have a clear preference for dedicated units.

Acquired Immunodeficiency Syndrome↗
PubMed1997

Hospital restructuring in the United States, Canada, and Western Europe: an outcomes research agenda.

OBJECTIVES: This article describes the extent and nature of hospital restructuring across the United States, Canada, and Western Europe, countries with differently organized and financed health-care systems, and assesses the feasibility of international research on the outcomes of hospital restructuring. METHODS: The conceptual background, context, and focus for the Bellagio conference on Hospital Restructuring in North America and Western Europe held in November 1996 is provided, illustrating key issues on hospital and workforce trends using the US data with international comparisons. RESULTS: Hospital systems internationally are undertaking very similar restructuring interventions, particularly ones aimed at reducing labor expenses through work redesign. Nursing has been a prime target for work redesign, resulting in changes in numbers and skill mix of nursing staff as well as fundamental reorganizing of clinical care at the inpatient unit level. Yet little is known about the outcomes of such organizational interventions and there are few efforts in place to critically evaluate these actions. CONCLUSIONS: Restructuring of the hospital workforce and redesign of work in inpatient settings is widespread and markedly similar across North American and Europe, and warrants systematic study. Cross-national studies of the impact of restructuring inpatient care on patient outcomes would yield valuable lessons about the cost-quality tradeoffs in hospital redesign and re-engineering, as well as inform national planning about the numbers and types of nurses needed in the coming decades.

Canada↗
PubMed1997

Studying outcomes of organizational change in health services.

OBJECTIVES: The rapidly changing organizational context within which health care is delivered is altering provider-patient relations and processes of clinical decision-making, with significant implications for patient outcomes. Yet definitive research on such effects is lacking. The authors seek to underscore the contribution of organizational research to studies of clinical outcomes and demonstrates several approaches to further such efforts. METHODS: The authors present a theoretical framework of the operant mechanisms linking organizational attributes and patient outcomes. They use case examples from their ongoing research on hospitals to illustrate strategies for measuring these mechanisms and for overcoming some of the feasibility issues inherent in organizational research. RESULTS: Several methodological issues are explored: (1) exploiting "targets of opportunity" and "natural experiments" is a promising strategy for studying patient outcomes related to organizational reform; (2) indices of organizational traits, constructed from individual survey responses, can illuminate the operant mechanisms by which structure affects outcomes; and (3) secondary data sources and innovative statistical matching procedures provide a feasible strategy for constructing study comparison groups. Extending the organizational outcomes research strategy to new areas of inquiry offers an opportunity to enhance our understanding of how nursing organization affects outcomes. CONCLUSIONS: Improving the effectiveness of medical care in a health-care system undergoing fundamental restructuring requires greater understanding of how organizational context affects clinical outcomes. A higher priority should be placed on organizational outcomes research by researchers and funding agencies.

Acquired Immunodeficiency Syndrome↗
PubMed1997

Hospital nurses' occupational exposure to blood: prospective, retrospective, and institutional reports.

OBJECTIVES: This study examined nurses risk of exposure to blood resulting from injuries with needles and sharps, the methods of estimating those risks, and the factors affecting risks. METHODS: Nurses on 40 medical units in 20 hospitals in cities with a high incidence of AIDS were studied. Percutaneous injuries were documented for every shift during a 30-day period. These prospective reports were compared with retrospective and institutional reports. Factors affecting the likelihood of injuries were explored. RESULTS: Based on the prospective reports, the rate of injuries to staff nurses was 0.8 per nurse-year. Prospective and retrospective rates were similar, while institutional rates were significantly lower. Factors associated with increased injuries included recapping needles and temporary work assignments. Working in hospitals characterized by professional nurse practice models and taking precautions to avoid blood contact were associated with fewer injuries. CONCLUSIONS: Injuries from needlesticks are more common than institutional reports suggest and do not occur at random. Diminishing the frequency with which nurses recap needles, increasing precautions they take, reducing use of temporary nursing personnel, and implementing organizational changes may lower the odds of nurses being injured.

Acquired Immunodeficiency Syndrome↗