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Downsizing within a hospital: cutting care or just costs?
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Social Science & Medicine 57 (2003) 1539–1546
Downsizing within a hospital: cutting care or just costs? Claire Browna,b,*, Bengt Arnetzb,c, Ove Peterssond a
Section for Social Medicine, Department of Public Health and Caring Sciences, Uppsala Science Park, SE-751 85 Uppsala, Sweden b Centre for Environmental Illness and Stress Research, Uppsala Academic Hospital, Sweden c Section for Social Medicine, Uppsala University, Uppsala, Sweden d . University Hospital, Orebro, Sweden
Abstract Downsizing of staff is becoming increasingly common in hospitals as a way to meet the demands of shrinking budgets. This study, based in Sweden, used a longitudinal design to study staff views of their work environment, their individual health and the quality of the care they were delivering during a period of hospital downsizing. Although there were no significant changes in perceptions of quality of care, perceptions of workload substantially increased whilst perceptions of mental energy substantially decreased. These two changes could point to future problems with quality of care after a period of hospital downsizing. r 2003 Elsevier Ltd. All rights reserved. Keywords: Quality of care; Work environment; Downsizing; Hospitals; Sweden
Background Health care providers are being asked to cut costs whilst ensuring patient care is not compromised (see e.g. Donabedian, 1989; Leatt, Baker, Halverson, & Aird, 1997; Malloch, 2000). Downsizing is a common response to budgetary cutbacks yet ‘it is astounding to observe how many hospitals have made major investments in organisational restructuring and work redesign in the absence of empirical evidence of the effectiveness of the initiatives, or their safety’ (Aiken & Fagin, 1997, p. OS2). It is important, for managers, practitioners and patients, to evaluate whether the downsizing that is occurring in hospitals around the world is, in any way, compromising the quality of patient care. This paper reports the results of a study in Sweden, that investigated doctor, nurse and patient perceptions of quality of care during a period of hospital downsizing.
*Corresponding author. Department of Public Health and Caring Sciences, Section for Social Medicine, Uppsala Science Park, SE-751 85 Uppsala, Sweden. Tel.: +46-18-611-34-23; fax: +46-18-51-16-57. E-mail address: [email protected] (C. Brown).
The first issue is what is quality, ‘a remarkably difficult notion to define’ (Donabedian, 1966, p. 167). There is no definitive answer to this question as what constitutes quality health care differs according to the perspective of the respondent. In some cases, articles discuss quality in health care without attempting to define the concept (e.g. Campbell, Roland, & Wilkin, 2001). Regardless of definition of this illusive ideal there is little argument that health care institutions differ in their quality of care (e.g. West, 2001). What the issue then becomes is, how is quality measured? One answer to this question is that quality can be measured using clinical outcomes (e.g. Morey, Fine, Loree, Retzlaff-Roberts, & Tsubakitani, 1992; Carey & Burgess, 1999). Using a clinical indicator, the rate of pressure ulcer development, a study in the United States of America showed that quality of care declined during a period of major restructuring (Berlowitz, Young, Brandeis, Kader, & Anderson, 2001). However, the relationship between clinical outcomes and quality of care is not clear (Carey & Burgess, 1999) and some studies have shown quality and clinical outcomes not to be well correlated (e.g. Thomas & Hofer, 1999). Furthermore, the differences between quality and
0277-9536/03/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0277-9536(02)00556-7
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clinical outcomes is often not made clear with some articles on quality reporting clinical outcomes as quality measures with no discussion of the relationship between the two (e.g. Campbell et al., 2001). For the purposes of this paper clinical outcomes were envisaged as a useful, but not sufficient, indicator of quality. An alternate perspective on measuring quality of care is that patients’ perceptions should be used. Studies on patient perceptions of quality of care before and after downsizing have given contradictory results. A study, in Australia, found that patient satisfaction with the quality of care they received in a maternity setting dropped during a period of funding cutbacks (Brown & Lumley, 1998). One Swedish study showed an improvement in patient satisfaction after downsizing had been implemented simultaneously with an intervention designed to improve nursing care (Jakobsson, Hallberg, Lov!en, & Ottosson, 1994). When the measures were repeated in 1993 and 1994 a deterioration in patient satisfaction was noted (Ottosson, Hallberg, Axelsson, & Lov!en, 1997). However, patient views on the quality of care they have received is problematic as a tool from two perspectives: 1. Patients are perceived not to have the technical knowledge to judge the technical quality of their care (see for example comments in Vuori, 1987; Donabedian, 1988; Press, Ganey, & Malone, 1991), and 2. patient satisfaction with the ‘‘caring’’ component of their care is generally high with little variation between health care facilities (see discussion of this point in Rubin, 1990) thus rendering patient satisfaction surveys of disputable use as a discriminating measure of quality. A third view on how quality is measured is that staff directly involved in health work, particularly doctors and nurses, are those who have the most accurate judgements on whether the health care being delivered is of high quality. From a staff perspective, one Swedish study found that, after a period of financial cutbacks, staff perceived the quality of care to have deteriorated (Arnetz, 1999). In the current study, staff were asked directly for their opinions on the quality of the care they were delivering at different times during a period of downsizing. One point that is being increasingly acknowledged is the possible effect of working environment on the quality of care offered by staff, particularly as regards those staff most immediately involved with patient care, that is doctors and nurses. It has been shown that better satisfied staff rate the quality of care they offer more highly (Thomsen, Arnetz, & Arnetz, 2000). Doctors who are under stress, from overwork or
lack of sleep for example, report that this contributes to a lowered standard of care (Firth-Cozens & Greenhalgh, 1997) and studies suggest ‘that sleep deprived physicians are cognitively impaired’ (Arnetz, 2001, p. 205). There is an association between staff who rate their job satisfaction highly and patients who give a positive evaluation of their quality of care (Atkins, Marshall, & Tavalgi, 1996). Perceptions of the staff working environment are one predictor of patient quality of care ratings (Arnetz & Arnetz, 1996). A better working environment for nursing staff, with higher nurse autonomy and control, is associated with decreased patient mortality (Aiken, Smith, & Lake, 1994). Furthermore, quality of care has been shown to be linked to organisational factors (Arnetz, 1999). It is acknowledged that ‘the quality of patient care may be related in an important way to the quality of life experienced by staff at work’ (West, 2001, p. 41). Job satisfaction is negatively associated with nurse turnover (Goodell & Coeling, 1994; Mitchell & Shortell, 1997). High turnover of nurses negatively affects the pool of experienced staff (Mitchell & Shortell, 1997) which may have negative effects on the quality of care offered. Thus when implementing cost cutting strategies it is important to measure the impact on work environment as a poor work environment can increase costs for a hospital by increasing the need for recruitment and possibly decreasing the standard of care given. However, despite the pressures on hospitals to restructure and the amount of evidence regarding the effect of work environment on staff, there are few published studies on the effects of downsizing in hospitals on work environment and patient care from a staff perspective (see Arnetz, 1999 for one example). There are studies which report a negative correlation between staffing levels and patient mortality (e.g. Shortell & Hughes, 1988) and a negative correlation between nurse staffing levels and adverse events (Kovner & Gergen, 1998; Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002). There are scholarly papers which suggest that downsizing of professional staff and their replacement with less trained assistants could be damaging to patient care (e.g. Robertson & Dowd, 1996). A study in California found that, during a period of downsizing, nursing provided an acceptable level of patient care (Lewis, Nitta, Biczi, & Robinson, 1986). However, it has also been shown that nurses in hospitals affected by downsizing felt downsizing compromised the standard of care they could offer (Blythe, Baumann, & Giovannetti, 2001). There are, however, few empirical studies that follow the staff of a health care institution through a period of downsizing, and in particular, look at their views on the quality of care they are providing.
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The current study seeks to fill this gap and, with data stretching over six years, asks: 1. Do staff perceptions of quality of care delivered change during a period of hospital downsizing? 2. Do staff perceptions of their working environment alter over a period of downsizing? 3. If there are any changes in perceptions of quality or work environment over a period of downsizing, are these changes consistent for doctors and nurses?
Method This study is unique in that it is a longitudinal correlational study within a health care organisation. Over a period of years, when budgetary cuts and staff downsizing were being implemented, an instrument designed to measure staff opinions of the quality of care they were delivering and various features of their work environment was administered. The data provided maps out the reactions of staff, over the period 1994– 1999, on ten scales (in three main groupings): 1. Work environment a. Involvement Leadership. Performance feedback, Participatory management b. Opportunities Skills development Social work environment c. Institutional well being Organisational efficiency Institutional goal quality 2. Individual health Mental energy Work load 3. Quality of care The first seven scales examine the ‘‘health’’ of the work environment from the three perspectives of the amount of involvement the individual feels they have in the organisation, the opportunities work offers them and their view of the organisation’s well being. The two individual health scales give measures of how well the individual staff member feels they are coping with the demands made upon them. Quality of care is a measure of how highly the individual staff member rates the quality of care they are delivering to their patients. Another way of putting this is that what is being measured is the staff’s assessment of the organisational well-being of their work environment, their individual well being and the quality of the care they are delivering. The current study provides an excellent opportunity to examine how changes in budget structure affect staff’s
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individual well being and their view of organisational well being. What we have in this study is a report card on one hospital’s efforts to reign in their budget. In order to see if any changes found in the various indices over the four occasions on which the instrument was administered were consistent across doctors and nurses, background information was also collected. This allowed the use of two independent variables—year and occupation, and one covariate variable—gender. In order to determine if any significant differences found in the scores of doctors and nurses on any of the indices were influenced by the unequal gender make-up of each occupation.1 Thus, using the data, collected at four points over 6 years, it is possible to answer the questions outlined above (Table 1). The hospital that was the site of the study, is a regional tertiary care facility in Sweden which had approximately 4000 employees before downsizing took place. In 1994, before any budget cuts had been discussed, the hospital management instituted a quality improvement programme with staff. The programme focussed on the seven areas outlined above under work environment, and quality of care, and aimed at improving the work environment and improving job satisfaction (Arnetz & Arnetz, 1996). The changes in structure over the period in which the questionnaire was administered were: *
*
* *
1994: normal work structures with no indications of possible financial cut backs, 1995: staff informed of need to trim budget and staff by 20% but details not released, 1997: cut backs in progress, 1999: cut backs complete.
The questionnaire has been developed over a number of years. It has been validated in a number of studies including one which correlated the results on a number of the scales with biological markers (Arnetz, 1996). Thus the validity of the instrument has been verified through both psychosocial assessments and biological measures. Cronbach’s alpha for each of the scales was 0.7 or higher (Arnetz, 1999). The questionnaire was sent to all full time employees of the hospital. Due to the focus of this study on staff with an immediate patient care role, only the questionnaires from doctors and nurses were included in analysis. The questionnaires were completely anonymous and were delivered to employees with an addressed, postage paid envelope for their return. Information about the project from the research team, hospital management and unions was circulated before the project began. In addition detailed information 1 Within this sample approximately 67% of doctors and 10% of nurses were men.
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Table 1 Questions in indices (adapted from Arnetz, 1999) Index
Questions
Leadership
Immediate supervisor: communicates clearly, acts consequently, describes how to achieve the departmental goals, provides opportunities to develop professional skills, open to changes in how the workplace is organised and work habits. Clear directives from immediate supervisor, feedback from supervisor when task has been done well or badly. Opportunity to influence workplace decisions, influence over workplace decisions in relationship to how much influence is desired, ability to decide how work should be done and what tasks should be done, sufficient influence in relationship to responsibilities, access to adequate information to carry out work duties efficiently, information from immediate supervisor sufficiently concrete to be useful in employees work. Professional skills development in employee’s work, immediate supervisor provides opportunities for skills development, opportunities for a more advanced position within health care, employee’s skills are utilised in current position, current job tasks offer professional development. Positive atmosphere at work, feeling of cohesion amongst co-workers, supportive atmosphere among colleagues. Work is planned within the workplace, employees work toward a common goal, the decision-making process works well, the resources in the workplace are optimally utilised. Workplace goals are: well-defined, realistic, able to be influenced and assessable Feelings of restlessness, irritability, worry, feeling low, moodiness and difficulty concentrating during the last month. One task can be completed before turning to the next, do you work very hard? Information given to patients about their illness, tests and treatment and hospital routines; accessibility of staff and professional resources; staff attitude; patient involvement in decision-making; quality of medical care and treatment; quality of nursing care.
Performance feedback Participatory management
Skills development
Social work environment Organisational efficiency Institutional goal quality Mental energy Workload Quality of care
about the questionnaire from the research team was included with the questionnaires. Reminder letters were sent to all respondents 2 and 4 weeks after the initial mailing. The study was a Panel study. Due to the need to ensure anonymity of responses, no attempts were made to ensure consistency of respondents over the four measuring points. However, due to downsizing occurring over the period the numbers of new staff in the hospital were low. This, combined with the high response rates (see Results) suggests a reasonable degree of consistency in terms of respondents over time. Initial analysis, to determine whether scores on the ten scales varied significantly over time or between doctors and nurses, was by use of a general linear model (GLM) using SPSS version 10.0. GLM is in essence a MANOVA technique allowing the use of categorical independent variables (in this case the four category Year and the dichotomous Occupation) and a continuous dependent variable (in this instance the ten indices). At all stages of analysis statistical significance was set at pp0:05: If Occupation was shown to be significant for any of the indices a GLM was re-run including Year, Occupation and Gender as independent variables. This enabled a more detailed picture of any significant differences in perception between doctors and nurses to be gained.
If year was significant for any of the indices in the initial analysis, a one-way ANOVA for the relevant index, with Year as the independent variable was run. This enabled the use of post hoc tests (either Bonferroni or Dunnett T3 depending on homogeneity of variance) to determine if differences between any pair of years was statistically significant allowing for multiple comparisons. Finally, for those indices where Occupation was significant a one-way ANOVA was run for Year for that index with this analysis being run separately for doctors and nurses. The analyses outlined above develop a full picture of the effect of downsizing of a hospital on those staff most directly in frontline patient care and the effect this has on their perceptions of the quality of care they are offering.
Results The response rate for each year was: * *
1994 Nurses (N ¼ 1006); Doctors 78% (N ¼ 357). 1995 Nurses 56% (N ¼ 795); Doctors 71% (N ¼ 285).
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Table 2 Means for each index for each year for each occupation Scale
1994
Leadership Performance feedback Participatory management Skills development Social work environment Organisational efficiency Institutional goal quality Mental energy Workload Quality of care
*
*
1997 Nurses (N ¼ 272). 1999 Nurses (N ¼ 254).
1995
1997
1999
Nurses
Doctors
Nurses
Doctors
Nurses
Doctors
Nurses
Doctors
75.2 61.6 62.2 49.9 66.5 61.1 64.5 81.7 62.1 N/A
73.2 56.5 62.2 55.2 62.9 57.6 66.3 80.1 68.4 N/A
74.2 60.5 56.3 59.4 62.7 60.2 63.6 77.6 63.1 72.4
73.3 58.0 66.4 68.7 60.1 58.1 65.1 74.3 68.8 71.2
67.5 48.3 68.7 60.4 66.8 54.9 63.8 75.5 72.2 72.3
65.4 49.7 70.7 62.7 61.1 51.7 64.2 73.5 79.2 70.6
86.0 53.2 66.7 64.9 69.3 58.4 63.2 70.0 75.1 70.0
84.1 51.8 66.6 65.1 64.9 53.2 62.2 66.0 83.7 70.9
63%
(N ¼ 839);
Doctors
73%
55%
(N ¼ 748);
Doctors
66%
In a study on the influence of non-response in a health care worker survey there was no difference found between responders and non-responders (Thomsen, 2000) thus it has been assumed that the samples are representative of health care workers in the hospital. There were only two indices for which Year was not significant in the initial GLM with year and occupation as independent variables. These were perceptions of institutional goal quality and perceptions of quality of care delivered. Nor was Occupation a significant independent variable for either of these indices but it was significant in all other cases. Both whether an employee is a doctor or a nurse and downsizing (year is a proxy measure for stage of downsizing) affected all indices except quality of care and institutional goal quality. The views of staff of the quality of care they were delivering did not change significantly during the period of downsizing. Their perceptions of various measures of their work environment did change. When the GLMs for the eight indices for which Occupation was significant were expanded to include Gender as an independent variable, only in two cases, perceptions of participatory management and mental energy, did gender significantly affect the results. When Gender was included with Year and Occupation as independent variables with perceptions of participatory management as the dependent variable, Occupation became non-significant. Gender was a significant independent variable and the interaction variable between Gender and Occupation was significant for both of these indices. The significance of the interaction variable indicates that the effect of occupation on either of these indices was not consistent across the genders. For mental energy, Gender was a significant
independent variable and the interaction variable between Gender and Occupation was significant. As Occupation was significant for all indices in which Year was significant a one-way ANOVA was run for all eight of these indices, separately for doctors and nurses. The means for these eight indices, and also institutional goal quality and quality of care,2 are given in Table 2. As can be seen, in Table 3, the significant differences in means on the indices do not fit an overall pattern. In general it seems that for both doctors and nurses leadership was perceived to be lowest in 1997 and highest in 1999. Performance feedback was generally seen to be low in 1997 and participatory management and opportunities for skills development were low in 1994. The social work environment was higher in 1999 than in 1995 for both doctors and nurses. Organisational efficiency was low in 1997 for both doctors and nurses and high in 1994 for both groups. For both occupations their mental energy was highest in 1994 and lowest in 1999. Workload for doctors and nurses seems to have increased as downsizing progressed with the highest level reached in 1999.
Discussion Year is significantly associated with the scores on eight of the ten indices measured in this project but not with quality of care. The previous study which found that staff perceived quality of care to have deteriorated during a period of financial cutbacks (Arnetz, 1999) was a cross-sectional study, using retrospective recall of the personnel’s view of changes in quality. The current study showed no significant changes in perceptions of quality 2 Despite Occupation not being significant for either of these indices, it was felt that reporting the means separately for doctors and nurses gave a fuller picture than reporting overall means.
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Table 3 Significant (pp0:05) differences in post hoc analysis between years for indices Index
Doctors
Nurses
Leadership
1997oall other years 1999>all other years 1994>1997 1995>1997 1995>1999 1994o1997
1997oall other years 1999>all other years 1997oall other years 1999o1994 & 1995
Performance feedback
Participatory management Skills development Social work environment Organisational efficiency Mental energy Work load
1994oall other years 1995>1997 1995o1999 1994>1997 & 1999 1995>1997 & 1999 1994>all other years 1999oall other years 1997>1994, 1995 1999>all other years
of care using repeat analysis of how staff rated quality at four definite points during downsizing. That no evidence was found suggests that downsizing may not affect quality of care from the perspective of doctors and nurses. However, the perceptions of staff of their work environment did change over the time of downsizing. In terms of staff members’ perceptions of leadership, 1999 was a good year whereas in 1997 both doctors and nurses had low scores on this index. Similarly for performance feedback, 1997 was very low for nurses and fairly low for doctors. The third index measuring involvement in the work place, is participatory management. It was low in 1994 and 1995 (lowest in 1995 for nurses) for both groups. Overall it would seem that downsizing had its most severe affect on staff perceptions of involvement in the work place while the downsizing was actually taking place. In terms of opportunities staff perceived as available to them, the scale measuring the opportunities for skills development was lowest for both groups in 1994, before there was any suggestion of downsizing. The perceptions of the social work environment, as measured by perceptions of the general atmosphere at work (see Table 1 for details), was lowest in 1995 for nurses and lower in 1995 than 1999 for doctors. This suggests that the announcement, without details, of general cutbacks, damaged the work atmosphere far more than the actual imposition of the cuts. In terms of institutional well-being the two indices returned inconsistent results. Perceptions of institutional goal quality showed no significant changes over the period. Perceptions of organisational efficiency generally declined. The staff may have felt a part of the process,
1995oall other years 1994o1997 & 1999 1994oall other years 1999>all other years 1994o1999 1995oall other years 1994>1999 1997oall other years 1994>all other years 1999oall other years 1997>1994, 1995 1999>all other years
but in general they seemed to have declining views of the efficiency of the organisation. In general the scores on the indices measuring work environment seem to give some support to the notion that downsizing resulted in a better working environment for both doctors and nurses. However, looking at the two indices measuring individual health, it would seem this may not be the case. Mental energy was at its lowest in 1999 while workload was at its highest. That these two indices should demonstrate an inverse association is to be expected, what is not expected is that indices measuring institutional well-being should associate so poorly with those measuring individual health. There are three possible explanations for this: 1. The indices are not particularly valid, or 2. staff are aware of their own health problems (and workload increases) but, due perhaps to loyalty to colleagues, do not translate this to organisational ill health, or 3. the quality improvement programme mentioned above was effective in improving the work environment but did not spill over to improving the individual health of employees. As the scales have been used over many years, in three countries and with a very large cumulative sample, and the scales have been rigorous tested, it is conjectured that the first of these explanations is not sustainable. There is no evidence to support the second explanation. The third explanation seems the most likely as the programme was specifically aimed at the areas studied under work environment whilst the cutbacks
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presumably increased workloads which would lead to a decrease in mental energy. There are implications for health care managers of this study. Firstly, in general, the perceptions of doctors and nurses of their working environments do differ and this difference is not mediated by gender. Except in the two cases noted, mental energy and participatory management, differences found in the various indices between doctors and nurses, are not an artefact of the differential proportions of both genders in those occupations. Doctors and nurses do have different experiences of hospital work regardless of gender. Management, in general, needs to be aware that the two groups of staff most immediately involved in patient care have substantially different views of their work environment. In particular, looking at Aiken’s work on ‘‘magnet’’ hospitals (e.g. Aiken et al., 1994), the working environment of nursing staff is negatively associated with patient mortality. The second major implication of this study is that, although perceptions of quality of care did not alter over the period, perceptions of workload did. As has been shown in previous research doctors who are working hard can feel that overworking diminishes their standard of care (Firth-Cozens & Greenhalgh, 1997). Although management was taking steps to improve the working environment during the period of downsizing and this is shown in the results, there is still the possibility of overwork and a decline in mental energy among staff leading to the possibility of future problems with the quality of care. The current study does not provide any evidence that quality of care is affected, either positively or negatively, by the implementation of downsizing. It does, however, suggest that downsizing does affect staff views of their workloads and mental energy which has potential problems with quality of care. It is these potential trouble spots in particular that should be borne in mind by managers responsible for downsizing.
Acknowledgements . Sincere thanks to all the staff at Orebro University Hospital for their dedication to filling out questionnaires throughout the years of the study. Thanks are given to AFA Insurance, Sweden, the Working Life Fund of . Orebro, Sweden and to the two anonymous reviewers for their helpful comments.
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Downsizing within a hospital: cutting care or just costs? Claire Browna,b,*, Bengt Arnetzb,c, Ove Peterssond a
Section for Social Medicine, Department of Public Health and Caring Sciences, Uppsala Science Park, SE-751 85 Uppsala, Sweden b Centre for Environmental Illness and Stress Research, Uppsala Academic Hospital, Sweden c Section for Social Medicine, Uppsala University, Uppsala, Sweden d . University Hospital, Orebro, Sweden
Abstract Downsizing of staff is becoming increasingly common in hospitals as a way to meet the demands of shrinking budgets. This study, based in Sweden, used a longitudinal design to study staff views of their work environment, their individual health and the quality of the care they were delivering during a period of hospital downsizing. Although there were no significant changes in perceptions of quality of care, perceptions of workload substantially increased whilst perceptions of mental energy substantially decreased. These two changes could point to future problems with quality of care after a period of hospital downsizing. r 2003 Elsevier Ltd. All rights reserved. Keywords: Quality of care; Work environment; Downsizing; Hospitals; Sweden
Background Health care providers are being asked to cut costs whilst ensuring patient care is not compromised (see e.g. Donabedian, 1989; Leatt, Baker, Halverson, & Aird, 1997; Malloch, 2000). Downsizing is a common response to budgetary cutbacks yet ‘it is astounding to observe how many hospitals have made major investments in organisational restructuring and work redesign in the absence of empirical evidence of the effectiveness of the initiatives, or their safety’ (Aiken & Fagin, 1997, p. OS2). It is important, for managers, practitioners and patients, to evaluate whether the downsizing that is occurring in hospitals around the world is, in any way, compromising the quality of patient care. This paper reports the results of a study in Sweden, that investigated doctor, nurse and patient perceptions of quality of care during a period of hospital downsizing.
*Corresponding author. Department of Public Health and Caring Sciences, Section for Social Medicine, Uppsala Science Park, SE-751 85 Uppsala, Sweden. Tel.: +46-18-611-34-23; fax: +46-18-51-16-57. E-mail address: [email protected] (C. Brown).
The first issue is what is quality, ‘a remarkably difficult notion to define’ (Donabedian, 1966, p. 167). There is no definitive answer to this question as what constitutes quality health care differs according to the perspective of the respondent. In some cases, articles discuss quality in health care without attempting to define the concept (e.g. Campbell, Roland, & Wilkin, 2001). Regardless of definition of this illusive ideal there is little argument that health care institutions differ in their quality of care (e.g. West, 2001). What the issue then becomes is, how is quality measured? One answer to this question is that quality can be measured using clinical outcomes (e.g. Morey, Fine, Loree, Retzlaff-Roberts, & Tsubakitani, 1992; Carey & Burgess, 1999). Using a clinical indicator, the rate of pressure ulcer development, a study in the United States of America showed that quality of care declined during a period of major restructuring (Berlowitz, Young, Brandeis, Kader, & Anderson, 2001). However, the relationship between clinical outcomes and quality of care is not clear (Carey & Burgess, 1999) and some studies have shown quality and clinical outcomes not to be well correlated (e.g. Thomas & Hofer, 1999). Furthermore, the differences between quality and
0277-9536/03/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0277-9536(02)00556-7
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clinical outcomes is often not made clear with some articles on quality reporting clinical outcomes as quality measures with no discussion of the relationship between the two (e.g. Campbell et al., 2001). For the purposes of this paper clinical outcomes were envisaged as a useful, but not sufficient, indicator of quality. An alternate perspective on measuring quality of care is that patients’ perceptions should be used. Studies on patient perceptions of quality of care before and after downsizing have given contradictory results. A study, in Australia, found that patient satisfaction with the quality of care they received in a maternity setting dropped during a period of funding cutbacks (Brown & Lumley, 1998). One Swedish study showed an improvement in patient satisfaction after downsizing had been implemented simultaneously with an intervention designed to improve nursing care (Jakobsson, Hallberg, Lov!en, & Ottosson, 1994). When the measures were repeated in 1993 and 1994 a deterioration in patient satisfaction was noted (Ottosson, Hallberg, Axelsson, & Lov!en, 1997). However, patient views on the quality of care they have received is problematic as a tool from two perspectives: 1. Patients are perceived not to have the technical knowledge to judge the technical quality of their care (see for example comments in Vuori, 1987; Donabedian, 1988; Press, Ganey, & Malone, 1991), and 2. patient satisfaction with the ‘‘caring’’ component of their care is generally high with little variation between health care facilities (see discussion of this point in Rubin, 1990) thus rendering patient satisfaction surveys of disputable use as a discriminating measure of quality. A third view on how quality is measured is that staff directly involved in health work, particularly doctors and nurses, are those who have the most accurate judgements on whether the health care being delivered is of high quality. From a staff perspective, one Swedish study found that, after a period of financial cutbacks, staff perceived the quality of care to have deteriorated (Arnetz, 1999). In the current study, staff were asked directly for their opinions on the quality of the care they were delivering at different times during a period of downsizing. One point that is being increasingly acknowledged is the possible effect of working environment on the quality of care offered by staff, particularly as regards those staff most immediately involved with patient care, that is doctors and nurses. It has been shown that better satisfied staff rate the quality of care they offer more highly (Thomsen, Arnetz, & Arnetz, 2000). Doctors who are under stress, from overwork or
lack of sleep for example, report that this contributes to a lowered standard of care (Firth-Cozens & Greenhalgh, 1997) and studies suggest ‘that sleep deprived physicians are cognitively impaired’ (Arnetz, 2001, p. 205). There is an association between staff who rate their job satisfaction highly and patients who give a positive evaluation of their quality of care (Atkins, Marshall, & Tavalgi, 1996). Perceptions of the staff working environment are one predictor of patient quality of care ratings (Arnetz & Arnetz, 1996). A better working environment for nursing staff, with higher nurse autonomy and control, is associated with decreased patient mortality (Aiken, Smith, & Lake, 1994). Furthermore, quality of care has been shown to be linked to organisational factors (Arnetz, 1999). It is acknowledged that ‘the quality of patient care may be related in an important way to the quality of life experienced by staff at work’ (West, 2001, p. 41). Job satisfaction is negatively associated with nurse turnover (Goodell & Coeling, 1994; Mitchell & Shortell, 1997). High turnover of nurses negatively affects the pool of experienced staff (Mitchell & Shortell, 1997) which may have negative effects on the quality of care offered. Thus when implementing cost cutting strategies it is important to measure the impact on work environment as a poor work environment can increase costs for a hospital by increasing the need for recruitment and possibly decreasing the standard of care given. However, despite the pressures on hospitals to restructure and the amount of evidence regarding the effect of work environment on staff, there are few published studies on the effects of downsizing in hospitals on work environment and patient care from a staff perspective (see Arnetz, 1999 for one example). There are studies which report a negative correlation between staffing levels and patient mortality (e.g. Shortell & Hughes, 1988) and a negative correlation between nurse staffing levels and adverse events (Kovner & Gergen, 1998; Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002). There are scholarly papers which suggest that downsizing of professional staff and their replacement with less trained assistants could be damaging to patient care (e.g. Robertson & Dowd, 1996). A study in California found that, during a period of downsizing, nursing provided an acceptable level of patient care (Lewis, Nitta, Biczi, & Robinson, 1986). However, it has also been shown that nurses in hospitals affected by downsizing felt downsizing compromised the standard of care they could offer (Blythe, Baumann, & Giovannetti, 2001). There are, however, few empirical studies that follow the staff of a health care institution through a period of downsizing, and in particular, look at their views on the quality of care they are providing.
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The current study seeks to fill this gap and, with data stretching over six years, asks: 1. Do staff perceptions of quality of care delivered change during a period of hospital downsizing? 2. Do staff perceptions of their working environment alter over a period of downsizing? 3. If there are any changes in perceptions of quality or work environment over a period of downsizing, are these changes consistent for doctors and nurses?
Method This study is unique in that it is a longitudinal correlational study within a health care organisation. Over a period of years, when budgetary cuts and staff downsizing were being implemented, an instrument designed to measure staff opinions of the quality of care they were delivering and various features of their work environment was administered. The data provided maps out the reactions of staff, over the period 1994– 1999, on ten scales (in three main groupings): 1. Work environment a. Involvement Leadership. Performance feedback, Participatory management b. Opportunities Skills development Social work environment c. Institutional well being Organisational efficiency Institutional goal quality 2. Individual health Mental energy Work load 3. Quality of care The first seven scales examine the ‘‘health’’ of the work environment from the three perspectives of the amount of involvement the individual feels they have in the organisation, the opportunities work offers them and their view of the organisation’s well being. The two individual health scales give measures of how well the individual staff member feels they are coping with the demands made upon them. Quality of care is a measure of how highly the individual staff member rates the quality of care they are delivering to their patients. Another way of putting this is that what is being measured is the staff’s assessment of the organisational well-being of their work environment, their individual well being and the quality of the care they are delivering. The current study provides an excellent opportunity to examine how changes in budget structure affect staff’s
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individual well being and their view of organisational well being. What we have in this study is a report card on one hospital’s efforts to reign in their budget. In order to see if any changes found in the various indices over the four occasions on which the instrument was administered were consistent across doctors and nurses, background information was also collected. This allowed the use of two independent variables—year and occupation, and one covariate variable—gender. In order to determine if any significant differences found in the scores of doctors and nurses on any of the indices were influenced by the unequal gender make-up of each occupation.1 Thus, using the data, collected at four points over 6 years, it is possible to answer the questions outlined above (Table 1). The hospital that was the site of the study, is a regional tertiary care facility in Sweden which had approximately 4000 employees before downsizing took place. In 1994, before any budget cuts had been discussed, the hospital management instituted a quality improvement programme with staff. The programme focussed on the seven areas outlined above under work environment, and quality of care, and aimed at improving the work environment and improving job satisfaction (Arnetz & Arnetz, 1996). The changes in structure over the period in which the questionnaire was administered were: *
*
* *
1994: normal work structures with no indications of possible financial cut backs, 1995: staff informed of need to trim budget and staff by 20% but details not released, 1997: cut backs in progress, 1999: cut backs complete.
The questionnaire has been developed over a number of years. It has been validated in a number of studies including one which correlated the results on a number of the scales with biological markers (Arnetz, 1996). Thus the validity of the instrument has been verified through both psychosocial assessments and biological measures. Cronbach’s alpha for each of the scales was 0.7 or higher (Arnetz, 1999). The questionnaire was sent to all full time employees of the hospital. Due to the focus of this study on staff with an immediate patient care role, only the questionnaires from doctors and nurses were included in analysis. The questionnaires were completely anonymous and were delivered to employees with an addressed, postage paid envelope for their return. Information about the project from the research team, hospital management and unions was circulated before the project began. In addition detailed information 1 Within this sample approximately 67% of doctors and 10% of nurses were men.
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Table 1 Questions in indices (adapted from Arnetz, 1999) Index
Questions
Leadership
Immediate supervisor: communicates clearly, acts consequently, describes how to achieve the departmental goals, provides opportunities to develop professional skills, open to changes in how the workplace is organised and work habits. Clear directives from immediate supervisor, feedback from supervisor when task has been done well or badly. Opportunity to influence workplace decisions, influence over workplace decisions in relationship to how much influence is desired, ability to decide how work should be done and what tasks should be done, sufficient influence in relationship to responsibilities, access to adequate information to carry out work duties efficiently, information from immediate supervisor sufficiently concrete to be useful in employees work. Professional skills development in employee’s work, immediate supervisor provides opportunities for skills development, opportunities for a more advanced position within health care, employee’s skills are utilised in current position, current job tasks offer professional development. Positive atmosphere at work, feeling of cohesion amongst co-workers, supportive atmosphere among colleagues. Work is planned within the workplace, employees work toward a common goal, the decision-making process works well, the resources in the workplace are optimally utilised. Workplace goals are: well-defined, realistic, able to be influenced and assessable Feelings of restlessness, irritability, worry, feeling low, moodiness and difficulty concentrating during the last month. One task can be completed before turning to the next, do you work very hard? Information given to patients about their illness, tests and treatment and hospital routines; accessibility of staff and professional resources; staff attitude; patient involvement in decision-making; quality of medical care and treatment; quality of nursing care.
Performance feedback Participatory management
Skills development
Social work environment Organisational efficiency Institutional goal quality Mental energy Workload Quality of care
about the questionnaire from the research team was included with the questionnaires. Reminder letters were sent to all respondents 2 and 4 weeks after the initial mailing. The study was a Panel study. Due to the need to ensure anonymity of responses, no attempts were made to ensure consistency of respondents over the four measuring points. However, due to downsizing occurring over the period the numbers of new staff in the hospital were low. This, combined with the high response rates (see Results) suggests a reasonable degree of consistency in terms of respondents over time. Initial analysis, to determine whether scores on the ten scales varied significantly over time or between doctors and nurses, was by use of a general linear model (GLM) using SPSS version 10.0. GLM is in essence a MANOVA technique allowing the use of categorical independent variables (in this case the four category Year and the dichotomous Occupation) and a continuous dependent variable (in this instance the ten indices). At all stages of analysis statistical significance was set at pp0:05: If Occupation was shown to be significant for any of the indices a GLM was re-run including Year, Occupation and Gender as independent variables. This enabled a more detailed picture of any significant differences in perception between doctors and nurses to be gained.
If year was significant for any of the indices in the initial analysis, a one-way ANOVA for the relevant index, with Year as the independent variable was run. This enabled the use of post hoc tests (either Bonferroni or Dunnett T3 depending on homogeneity of variance) to determine if differences between any pair of years was statistically significant allowing for multiple comparisons. Finally, for those indices where Occupation was significant a one-way ANOVA was run for Year for that index with this analysis being run separately for doctors and nurses. The analyses outlined above develop a full picture of the effect of downsizing of a hospital on those staff most directly in frontline patient care and the effect this has on their perceptions of the quality of care they are offering.
Results The response rate for each year was: * *
1994 Nurses (N ¼ 1006); Doctors 78% (N ¼ 357). 1995 Nurses 56% (N ¼ 795); Doctors 71% (N ¼ 285).
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Table 2 Means for each index for each year for each occupation Scale
1994
Leadership Performance feedback Participatory management Skills development Social work environment Organisational efficiency Institutional goal quality Mental energy Workload Quality of care
*
*
1997 Nurses (N ¼ 272). 1999 Nurses (N ¼ 254).
1995
1997
1999
Nurses
Doctors
Nurses
Doctors
Nurses
Doctors
Nurses
Doctors
75.2 61.6 62.2 49.9 66.5 61.1 64.5 81.7 62.1 N/A
73.2 56.5 62.2 55.2 62.9 57.6 66.3 80.1 68.4 N/A
74.2 60.5 56.3 59.4 62.7 60.2 63.6 77.6 63.1 72.4
73.3 58.0 66.4 68.7 60.1 58.1 65.1 74.3 68.8 71.2
67.5 48.3 68.7 60.4 66.8 54.9 63.8 75.5 72.2 72.3
65.4 49.7 70.7 62.7 61.1 51.7 64.2 73.5 79.2 70.6
86.0 53.2 66.7 64.9 69.3 58.4 63.2 70.0 75.1 70.0
84.1 51.8 66.6 65.1 64.9 53.2 62.2 66.0 83.7 70.9
63%
(N ¼ 839);
Doctors
73%
55%
(N ¼ 748);
Doctors
66%
In a study on the influence of non-response in a health care worker survey there was no difference found between responders and non-responders (Thomsen, 2000) thus it has been assumed that the samples are representative of health care workers in the hospital. There were only two indices for which Year was not significant in the initial GLM with year and occupation as independent variables. These were perceptions of institutional goal quality and perceptions of quality of care delivered. Nor was Occupation a significant independent variable for either of these indices but it was significant in all other cases. Both whether an employee is a doctor or a nurse and downsizing (year is a proxy measure for stage of downsizing) affected all indices except quality of care and institutional goal quality. The views of staff of the quality of care they were delivering did not change significantly during the period of downsizing. Their perceptions of various measures of their work environment did change. When the GLMs for the eight indices for which Occupation was significant were expanded to include Gender as an independent variable, only in two cases, perceptions of participatory management and mental energy, did gender significantly affect the results. When Gender was included with Year and Occupation as independent variables with perceptions of participatory management as the dependent variable, Occupation became non-significant. Gender was a significant independent variable and the interaction variable between Gender and Occupation was significant for both of these indices. The significance of the interaction variable indicates that the effect of occupation on either of these indices was not consistent across the genders. For mental energy, Gender was a significant
independent variable and the interaction variable between Gender and Occupation was significant. As Occupation was significant for all indices in which Year was significant a one-way ANOVA was run for all eight of these indices, separately for doctors and nurses. The means for these eight indices, and also institutional goal quality and quality of care,2 are given in Table 2. As can be seen, in Table 3, the significant differences in means on the indices do not fit an overall pattern. In general it seems that for both doctors and nurses leadership was perceived to be lowest in 1997 and highest in 1999. Performance feedback was generally seen to be low in 1997 and participatory management and opportunities for skills development were low in 1994. The social work environment was higher in 1999 than in 1995 for both doctors and nurses. Organisational efficiency was low in 1997 for both doctors and nurses and high in 1994 for both groups. For both occupations their mental energy was highest in 1994 and lowest in 1999. Workload for doctors and nurses seems to have increased as downsizing progressed with the highest level reached in 1999.
Discussion Year is significantly associated with the scores on eight of the ten indices measured in this project but not with quality of care. The previous study which found that staff perceived quality of care to have deteriorated during a period of financial cutbacks (Arnetz, 1999) was a cross-sectional study, using retrospective recall of the personnel’s view of changes in quality. The current study showed no significant changes in perceptions of quality 2 Despite Occupation not being significant for either of these indices, it was felt that reporting the means separately for doctors and nurses gave a fuller picture than reporting overall means.
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Table 3 Significant (pp0:05) differences in post hoc analysis between years for indices Index
Doctors
Nurses
Leadership
1997oall other years 1999>all other years 1994>1997 1995>1997 1995>1999 1994o1997
1997oall other years 1999>all other years 1997oall other years 1999o1994 & 1995
Performance feedback
Participatory management Skills development Social work environment Organisational efficiency Mental energy Work load
1994oall other years 1995>1997 1995o1999 1994>1997 & 1999 1995>1997 & 1999 1994>all other years 1999oall other years 1997>1994, 1995 1999>all other years
of care using repeat analysis of how staff rated quality at four definite points during downsizing. That no evidence was found suggests that downsizing may not affect quality of care from the perspective of doctors and nurses. However, the perceptions of staff of their work environment did change over the time of downsizing. In terms of staff members’ perceptions of leadership, 1999 was a good year whereas in 1997 both doctors and nurses had low scores on this index. Similarly for performance feedback, 1997 was very low for nurses and fairly low for doctors. The third index measuring involvement in the work place, is participatory management. It was low in 1994 and 1995 (lowest in 1995 for nurses) for both groups. Overall it would seem that downsizing had its most severe affect on staff perceptions of involvement in the work place while the downsizing was actually taking place. In terms of opportunities staff perceived as available to them, the scale measuring the opportunities for skills development was lowest for both groups in 1994, before there was any suggestion of downsizing. The perceptions of the social work environment, as measured by perceptions of the general atmosphere at work (see Table 1 for details), was lowest in 1995 for nurses and lower in 1995 than 1999 for doctors. This suggests that the announcement, without details, of general cutbacks, damaged the work atmosphere far more than the actual imposition of the cuts. In terms of institutional well-being the two indices returned inconsistent results. Perceptions of institutional goal quality showed no significant changes over the period. Perceptions of organisational efficiency generally declined. The staff may have felt a part of the process,
1995oall other years 1994o1997 & 1999 1994oall other years 1999>all other years 1994o1999 1995oall other years 1994>1999 1997oall other years 1994>all other years 1999oall other years 1997>1994, 1995 1999>all other years
but in general they seemed to have declining views of the efficiency of the organisation. In general the scores on the indices measuring work environment seem to give some support to the notion that downsizing resulted in a better working environment for both doctors and nurses. However, looking at the two indices measuring individual health, it would seem this may not be the case. Mental energy was at its lowest in 1999 while workload was at its highest. That these two indices should demonstrate an inverse association is to be expected, what is not expected is that indices measuring institutional well-being should associate so poorly with those measuring individual health. There are three possible explanations for this: 1. The indices are not particularly valid, or 2. staff are aware of their own health problems (and workload increases) but, due perhaps to loyalty to colleagues, do not translate this to organisational ill health, or 3. the quality improvement programme mentioned above was effective in improving the work environment but did not spill over to improving the individual health of employees. As the scales have been used over many years, in three countries and with a very large cumulative sample, and the scales have been rigorous tested, it is conjectured that the first of these explanations is not sustainable. There is no evidence to support the second explanation. The third explanation seems the most likely as the programme was specifically aimed at the areas studied under work environment whilst the cutbacks
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presumably increased workloads which would lead to a decrease in mental energy. There are implications for health care managers of this study. Firstly, in general, the perceptions of doctors and nurses of their working environments do differ and this difference is not mediated by gender. Except in the two cases noted, mental energy and participatory management, differences found in the various indices between doctors and nurses, are not an artefact of the differential proportions of both genders in those occupations. Doctors and nurses do have different experiences of hospital work regardless of gender. Management, in general, needs to be aware that the two groups of staff most immediately involved in patient care have substantially different views of their work environment. In particular, looking at Aiken’s work on ‘‘magnet’’ hospitals (e.g. Aiken et al., 1994), the working environment of nursing staff is negatively associated with patient mortality. The second major implication of this study is that, although perceptions of quality of care did not alter over the period, perceptions of workload did. As has been shown in previous research doctors who are working hard can feel that overworking diminishes their standard of care (Firth-Cozens & Greenhalgh, 1997). Although management was taking steps to improve the working environment during the period of downsizing and this is shown in the results, there is still the possibility of overwork and a decline in mental energy among staff leading to the possibility of future problems with the quality of care. The current study does not provide any evidence that quality of care is affected, either positively or negatively, by the implementation of downsizing. It does, however, suggest that downsizing does affect staff views of their workloads and mental energy which has potential problems with quality of care. It is these potential trouble spots in particular that should be borne in mind by managers responsible for downsizing.
Acknowledgements . Sincere thanks to all the staff at Orebro University Hospital for their dedication to filling out questionnaires throughout the years of the study. Thanks are given to AFA Insurance, Sweden, the Working Life Fund of . Orebro, Sweden and to the two anonymous reviewers for their helpful comments.
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