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To investigate whether the size of the workforce (nurses, doctors and support staff) has an impact on the survival chances of critically ill patients both in the intensive care unit (ICU) and in the hospital.
Investigations of intensive care outcomes suggest that some of the variation in patient survival rates might be related to staffing levels and workload, but the evidence is still equivocal.
Information about patients, including the outcome of care (whether the patient lived or died) came from the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme. An Audit Commission survey of ICUs conducted in 1998 gave information about staffing levels. The merged dataset had information on 65 ICUs and 38,168 patients. This is currently the best available dataset for testing the relationship between staffing and outcomes in UK ICUs.
A cross-sectional, retrospective, risk adjusted observational study.
Multivariable, multilevel logistic regression.
ICU and in-hospital mortality.
After controlling for patient characteristics and workload we found that higher numbers of nurses per bed (odds ratio: 0.90, 95% confidence interval: [0.83, 0.97]) and higher numbers of consultants (0.85, [0.76, 0.95]) were associated with higher survival rates. Further exploration revealed that the number of nurses had the greatest impact on patients at high risk of death (0.98, [0.96, 0.99]) whereas the effect of medical staffing was unchanged across the range of patient acuity (1.00, [0.97, 1.03]). No relationship between patient outcomes and the number of support staff (administrative, clerical, technical and scientific staff) was found. Distinguishing between direct care and supernumerary nurses and restricting the analysis to patients who had been in the unit for more than 8 h made little difference to the results. Separate analysis of in-unit and in-hospital survival showed that the clinical workforce in intensive care had a greater impact on ICU mortality than on hospital mortality which gives the study additional credibility.
This study supports claims that the availability of medical and nursing staff is associated with the survival of critically ill patients and suggests that future studies should focus on the resources of the health care team. The results emphasise the urgent need for a prospective study of staffing levels and the organisation of care in ICUs.
Patient experience surveys are increasingly used to gain information about the quality of healthcare. This paper investigates whether patients who respond before and after reminders to a large national survey of inpatient experience differ in systematic ways in how they evaluate the care they received.
The English national inpatient survey of 2009 obtained data from just under 70,000 patients. We used ordinal logistic regression to analyse their evaluations of the quality of their care in relation to whether or not they had received a reminder before they responded.
33% of patients responded after the first questionnaire, a further 9% after the first reminder, and a further 10% after the second reminder. Evaluations were less positive among people who responded only after a reminder and lower still among those who needed a second reminder.
Quality improvement efforts depend on having accurate data and negative evaluations of care received in healthcare settings are particularly valuable. This study shows that there is a relationship between the time taken to respond and patients’ evaluations of the care they received, with early responders being more likely to give positive evaluations. This suggests that bias towards positive evaluations could be introduced if the time allowed for patients to respond is truncated or if reminders are omitted.
Recent evidence from the USA suggests that people engaged in occupations involving providing care for others, such as childcare and teaching, suffer a wage penalty. After taking into account job and individual characteristics such as level of education and work experience, people in these occupations in the American study earned about 6 per cent less than their peers in other types of occupation. However, we do not yet know if people working in similar occupations in other countries also suffer the same degree of disadvantage. The issue is important because, despite the perception that people in caring jobs place a relatively low weight on the level of remuneration when making career decisions, a number of studies have shown clear evidence of an association between pay and the propensity to give up working in a caring occupation. There are implications too for social inequality as many caring jobs are done by women and associated wage penalties could contribute to the persistent gender gap in pay. This study compares and contrasts the predictions of neoclassical economics, cultural feminist theory and social closure theory.
Data are taken from 17 waves of the British Household Panel Survey and include a total of 23,773 individuals, giving 110,677 person-year observations. These data are analysed using multi-level linear regression. The results show clear evidence of a statistically significant wage penalty associated with working in some caring occupations. Those occupations requiring lower levels of educational qualification, such as nursing assistants and auxiliaries, are particularly hard-hit by the wage penalty. On the other hand, some occupations, such as medicine and teaching, have fared better than comparable non-caring occupations over the same period. We discuss the implications of these results for the gender gap in pay, poverty, social inequality and the future supply of caring workers.
When it was initiated in 2001, England's national patient survey programme was one of the first in the world and has now been widely emulated in other healthcare systems. The aim of the survey programme was to make the National Health Service (NHS) more "patient centred" and more responsive to patient feedback. The national inpatient survey has now been running in England annually since 2002 gathering data from over 600,000 patients. The aim of this study is to investigate how the data have been used and to summarise what has been learned about patients' evaluation of care as a result.
Two independent researchers systematically gathered all research that included analyses of the English national adult inpatient survey data. Journals, databases and relevant websites were searched. Publications prior to 2002 were excluded. Articles were also identified following consultation with experts. All documents were then critically appraised by two co-authors both of whom have a background in statistical analysis.
We found that the majority of the studies identified were reports produced by organisations contracted to gather the data or co-ordinate the data collection and used mainly descriptive statistics. A few articles used the survey data for evidence based reporting or linked the survey to other healthcare data. The patient's socio-demographic characteristics appeared to influence their evaluation of their care but characteristics of the workforce and the. At a national level, the results of the survey have been remarkably stable over time. Only in those areas where there have been co-ordinated government-led campaigns, targets and incentives, have improvements been shown. The main findings of the review are that while the survey data have been used for different purposes they seem to have incited little academic interest.
The national inpatient survey has been a useful resource for many authors and organisations but the full potential inherent in this large, longitudinal publicly available dataset about patients' experiences has not as yet been fully exploited.
This review suggests that the presence of survey results alone is not enough to improve patients' experiences and further research is required to understand whether and how the survey can be best used to improve standards of care in the NHS.
This study investigates whether men and women in caring occupations experience more negative job-related feelings at the end of the day compared to the rest of the working population. The data are from Wave Nine of the British Household Panel Survey (1999) where respondents were asked whether, at the end of the working day, they tended to keep worrying or have trouble unwinding, and the extent to which work left them feeling exhausted or “used up.” Their responses to these questions were used to develop ordinal dependent variables. Control variables in the models include: number of children, age, hours worked per week, managerial responsibilities and job satisfaction, all of which have been shown in previous research to be significantly related to “job burnout.” The results are that those in caring occupations are more likely to feel worried, tense, drained and exhausted at the end of the working day. Women in particular appear to pay a high emotional cost for working in caring occupations. Men do not emerge unscathed, but report significantly lower levels of worry and exhaustion at the end of the day than do women.
Objective: To investigate whether affective and relational components of nurses' experience of work have a significant impact on their intentions to leave either the job or the nursing profession in models that control for other factors (sociodemographic, work conditions, perceptions of quality of care) that are known to affect career decisions.
Method: An exploratory, cross-sectional postal survey of 2880 nurses in grades A–I in 20 National Health Service (NHS) Hospital Trusts, 11 in inner London and nine in outer London, was carried out between January and July 2002, looking at nurses' intention to leave their current job or the nursing profession. The data were analysed using logistic regression with robust standard errors.
Results: In models that controlled for known sources of job dissatisfaction, relationships with supervisors and managers were found to have a significant effect on respondents' career intentions. Feeling valued by the Trust and by society was very important. Nurses seemed to distinguish between local problems that are the responsibility of the Trust and those, such as levels of pay, that could only be solved at the national level.
Conclusion: Nurses' career intentions are complex and multifactorial. Feelings of being valued and listened to play a role, as well as the individual and job-related characteristics. The study highlights the role of supervisors and managers in retaining staff and suggests that investment in robust systems of communication, conflict resolution and security could slow nurse turnover. The NHS as an employer may be most interested in the role of pay in nurse retention, and the general public in how societal attitudes and verbal abuse shape nurses' career decisions.
Objectives: Previous research on nurse retention has focused mainly on its relationship with employment conditions. This study aimed to include an examination of the impact of nurses' perceived barriers to delivering high-quality patient-centred care on their intentions to leave their current employers.
Methods: An American employee questionnaire was adapted for use with British nurses. The questionnaire was mailed to 6160 nurses directly employed by 20 London hospitals. Up to two reminders were sent to non-responders. The questionnaire asked nurses to report on experiences in their working lives and to state their intentions to leave or stay with their current employer. Demographic and employment history information was also elicited.
Results: Responses were received from 2880 (47%). Nurses report that the care they are able to provide often falls short of recognised standards. Factor analysis combined 82 questions on nurses' experiences into four patient-centred and four nurse-centred dimensions. Nurses who report more problems in both nurse-centred and patient-centred dimensions are more likely to intend to leave their current employers. Satisfaction with pay and the cleanliness of work areas are also important factors.
Conclusions: Standards of care are often perceived by nurses to be unacceptably poor. Furthermore, their experience of barriers to care has a demonstrable impact on their decision to leave or stay with their current employer. Nurse managers need to address the perceived barriers to providing high-quality care when considering nurse retention strategies.
Objectives: The current shortage of nurses is a major problem for health care systems around the world and has revitalized interest in the dynamics of nurses' careers. This paper investigates the factors associated with qualified nurses in Britain moving to different employment statuses, including jobs outside nursing, unemployment, maternity leave and family care over time.
Methods: British Household Panel Survey (BHPS) data collected between 1991 and 2001 were used to estimate the effects of covariates on transition rates between different employment statuses.
Results: Individual characteristics associated with shorter tenure in the profession include being male, being younger, having a degree, and having been born in the UK. Many nurses leave to care for their families, which suggests the possibility of returning to the profession at a later date. A number of job characteristics are also related to leaving, including low pay, managerial responsibility, full-time work and lack of opportunities to use initiative. Nurses seem to be particularly vulnerable to leaving early in their careers, but those who survive the first few years are likely to remain in the profession for the rest of their working lives.
Conclusions: It is particularly important in policy terms that ability to use initiative is related to leaving nursing for another form of full-time employment and, in particular, to leaving for a better job. This finding is consistent with results from studies of the Magnet hospitals in the US. Taken together, these results suggest that strategies to improve nurse retention must attend to nurses' status, authority and position in the hierarchy if they are to be successful. The results also provide strong support for those who argue that better rates of pay are necessary in order to improve nurse retention.
Aims and objectives. To investigate whether nurses experience barriers to delivering high quality care in areas that are of particular concern to patients and to describe which aspects of care are most affected when nurses lack the required resources, such as time, tools and training to do their job.
Background. Patient surveys conducted in the National Health Service of the United Kingdom tend to show there is variation in the extent to which they are satisfied with care in a number of important areas, such as physical comfort, emotional support and the coordination of care.
Design. A sample of nurses working in 20 acute London hospitals was asked to complete a postal questionnaire based on a prototype employee survey developed in the United States and adapted by the authors for use in the United Kingdom.
Method. Staff in the human resources departments of participating hospitals mailed the questionnaires to nurses’ home addresses. After two reminders, 2880 (out of 6160) useable responses were returned, giving a response rate of 47%.
Results. Nurses are aware that there are deficits in standards of care in areas that are particularly important to patients. The majority feel overworked (64%) and report that they do not have enough time to perform essential nursing tasks, such as addressing patients’ anxieties, fears and concerns and giving patients and relatives information. Their work is often made more difficult by the lack of staff, space, equipment and cleanliness. They are often unable to control noise and temperature in clinical areas. Nurses in acute London hospitals are subject to high levels of aggressive behaviour, mainly from patients and their relatives, but also from other members of staff. More positively, high proportions of the nurses in our survey expressed the desire for further training, particularly in social and interpersonal aspects of care.
Relevance to clinical practice. This paper goes beyond reporting problems with the quality and safety of care to try to understand why patients do not always receive optimum care in areas that are important to them. In many cases nurses lack the time, tools and training to deliver high quality care in acute London hospitals. We suggest a number of low-cost interventions that might remove some of the barriers to patient-centred care. The questionnaire we have developed could be a useful tool for improving quality locally.
The purpose of this study was to describe the social and geographical boundaries around the networks of senior nurse executives and physician leaders and managers in acute-care hospitals in the United Kingdom. A telephone survey was conducted using standard social network methods. A random sample was drawn from a national list and repeatedly sampled until 100 respondents were interviewed. The response rate was 49.5%. Both groups tended to discuss "important professional matters" with others who were similar to themselves in terms of profession, gender, age, and seniority, with physicians being more extreme in this regard. The implication is that gaps in the network of informal ties will impede the dissemination of information and the spread of social influence between these 2 important groups. Managers (non-clinically qualified) appear to occupy a powerful "brokerage" role. Informal networks are mainly composed of local ties. The authors argue that dissemination and influence strategies that take features of the social structure into account are more likely to be successful.
Geroski's discussion of organizational ecology from the point of view of an industrial economist is useful and illuminating. However, I believe that there are a few areas in which someone not familiar with the ecological literature might be misled. I therefore provide a slightly more detailed discussion of work done by ecologists in three key areas: the relationship between density, legitimacy, competition and the rates at which organizations enter and exit a population; the ways in which ecologists conceptualize and model legitimacy; and the theory of structural inertia.
Interest in how best to influence the behaviour of clinicians in the interests of both clinical and cost effectiveness has rekindled concern with the social networks of health care professionals. Ever since the seminal work of Coleman et al. [Coleman, J.S., Katz, E., Menzel, H., 1966. Medical Innovation: A Diffusion Study. Bobbs-Merrill, Indianapolis.], networks have been seen as important in the process by which clinicians adopt (or fail to adopt) new innovations in clinical practice. Yet very little is actually known about the social networks of clinicians in modern health care settings. This paper describes the professional social networks of two groups of health care professionals, clinical directors of medicine and directors of nursing, in hospitals in England. We focus on network density, centrality and centralisation because these characteristics have been linked to access to information, social influence and social control processes. The results show that directors of nursing are more central to their networks than clinical directors of medicine and that their networks are more hierarchical. Clinical directors of medicine tend to be embedded in much more densely connected networks which we describe as cliques. The hypotheses that the networks of directors of nursing are better adapted to gathering and disseminating information than clinical directors of medicine, but that the latter could be more potent instruments for changing, or resisting changes, in clinical behaviour, follow from a number of sociological theories. We conclude that professional socialisation and structural location are important determinants of social networks and that these factors could usefully be considered in the design of strategies to inform and influence clinicians.
I construct theoretical models of the founding, failure, and growth of organizations that, when combined, constitute an explanation of the process by which the number of organizations in an population (the population density) declines from a peak, while at the same time the population mass (the aggregate size of the organizations in the population) continues to increase.
Deregulation has stimulated much economic and political interest. This paper develops a framework for understanding the effects of deregulation from an ecological perspective and reports empirical studies of financial institutions (banks, thrifts and mutual funds) at two levels of analysis: the system and the population. These both show that deregulation bad a dramatic impact on the level of competitive intensity within the financial industry. The main contributions of this paper are the application of a general sociological theory of organizational dynamics to understanding deregulation and the development of a general approach to modelling which could lead to new ways to evaluate the organizational consequences of major environmental changes.
In this paper, I study the early development of two organizational forms: credit unions and Morris Plan banks which, in the early twentieth century became socially acceptable money-lenders. Three forms of legitimacycognitive, moral, and pragmaticare important in understanding their evolution and social integration. Cognitive legitimacy corresponds to what is usually considered by organizational ecologists to be legitimacy as 'taken-for-grantedness'. Organizations have moral legitimacy in so far as they have the moral approval of most members of society. Pragmatic legitimacy 'rests on the self-interested calculations of an organization's most immediate audiences' (Suchman 1995). The analysis goes beyond previous work in two ways. First, new mechanisms of legitimation are introduced into models of organizational founding and growth. Second, organizations are assumed to be able to deliberately influence their legitimacy by their actions. Empirical tests combine quantitative analyses of founding and growth rates with a qualitative analysis of historical material. In addition to density-dependent processes of legitimation, the organizations are found to act in a social-movement-like manner, thereby enhancing their moral legitimacy. This increases their founding and growth rates, and gives them a competitive advantage over earlier forms of money-lending that lacked moral legitimacy. I also find evidence that pragmatic legitimacy is spread via social networks.
One vision of organizational evolution suggests that old and large organizations become increasingly dominant over their environment. A second suggests that as organizations age they become less able to respond to new challenges. In this article the authors investigate which of these visions best characterizes the evolution of state-chartered credit unions in New York City from 1914 through 1990 by analyzing the effects of organizational age, size, and population density on rates of organizational failure and growth. The authors find evidence that old and small institutions are more likely to fail, while young and small organizations have the highest growth rates.
I begin this paper by describing several methods that can be used to analyze count data. Starting with relatively familiar maximum likelihood methods-Poisson and negative binomial regression-I then introduce the less well known (and less well understood) quasi-likelihood approach. This method (like negative binomial regression) allows one to model overdispersion, but it can also be generalized to deal with autocorrelation. I then investigate the small-sample properties of these estimators in the presence of overdispersion and autocorrelation by means of Monte Carlo simulations. Finally, I apply these methods to the analysis of data on the foundings of labor unions in the U.S. Quasi-likelihood methods are found to have some advantages over Poisson and negative binomial regression, especially in the presence of autocorrelation.
This article assesses the robustness of recent estimates of the effect of density on the founding rates in organizational populations. It reports reanalyses of data on founding rates of six populations of organizations using a generalization of quasi-likelihood estimation that allows specification of autocorrelation processes. Autocorrelation is indeed present in five of the six data sets. However, the main substantive finding of earlier research proves to be robust-a nonmonotonic relationship between density and founding rate-continues to hold in most cases even when autocorrelation is taken into account. In other words, the predicted pattern of nonmonotonic density dependence is robust with respect to the form of autocorrelation investigated.
This paper presents the authors' opinion on claims of Petersen and Koput (PK) regarding a problem in the usual interpretation of tests of the theory of density-dependent legitimation and competition as applied to rates of organizational mortality. PK argue that the negative first-order effect of organizational density on mortality rates is compatible with a simpler and thus preferable alternative explanation that relies on the operation of unobserved heterogeneity instead of legitimation. Their strongly stated assertions of generality fail to acknowledge that the artifactual effect of density occurred in only half of their simulations. Even substantively trivial effects are likely to be statistically significant when so many observations are generated by the simulation. Age of population and density are so highly correlated in the data sets produced by the simulation structure of PK that we could not estimate models including these two variables because we could not invert the Hessian. The most unrealistic feature of the simulation of PK concerns its treatment of founding processes. For unexplained reasons, they chose a deterministic founding process: The same fixed number of foundings occur each year in each frailty class.
Hannan, West, and Barron investigate the development of credit unions over time, focusing on organizational processes that shaped and continue to determine the evolution of credit unions. They clarify how the potential for future development of the credit union movement is shaped by the past dynamics of American credit union development, the growth of competing forms of deposit institutions, and government regulation. They use the theoretical and methodological perspective of organizational ecology. This approach to organizational analysis seeks to understand how social conditions affect the rates at which new organizations and new organizational forms arise, the rates at which organizations change their fundamental features, and the rates at which organizations and organizational forms die out.
Hannan, West, and Barron posed hypotheses that apply to many kinds of organizational populations and collected credit union data appropriate for testing these hypotheses. Their research reveals a number of informative patterns in the proliferation and growth of credit unions. These patterns suggest strong parallels with the dynamics of other kinds of organizational populations. Consequently, they conclude that their research indicates that organizational ecology theory can help us better understand the evolution of credit unions.