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Healthy Hospital: Toward a Better Tomorrow
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ORIGINAL ARTICLE
ard a Better Torno monstration Project to Pro ure Change through Participa Decision Making n Best, Geoff Walsh, Fred Muzin and Jonathan Berkowitz for the S Hospital Healthy Hospital steering committee
Abstract The three-year “Healthy Hospital” project was designed to increase participatory decision making,
for future research and ications are discussed.
et de trois ans a Healthy
ail. Les mbthodes
S
t. Paul’s Hospital in Vancouver launched a three-year “Healthy Hospital” demonstration project in 1991. The project was designed to increase participatory decision making for all staff groups, thereby decreasingjob stress and increasing job satisfaction. The original impetus was a St. Paul’s Presidential Task Force established to investigate quality of nursing work life issues following a 1989 sQike. However, the health care environment changed rapidly thereafter, so that original concerns with nursing shortages disappeared.2 A second change, before the project was launched, was to broaden the focus to include all staff, rather than just nursing staff. The project built on previous research documenting nurses’ needs for quality of work life and hospitals’ needs for organizational effectiven e ~ s . The ~ - ~specific hypothesis that increased participation in decision making would have the desired effects on job stress and satisfactiondrew on the broad research literature on job stress:-1o job control,11,’2social support13and empowerment.14915 Empirical and popular support for participatory decision making and its relationship to job stress has grown rapidly in the five years since the Healthy Hospital project was conceptualued.16-20
The literature is quite clear on the essential ingredients for increased job satisfaction: participation in decision making quality teamwork peer and supervisor support autonomy and control over how work is organized FALL 1997, VOL. 10, NO. 3
opportunities for challenge and growth open, ongoing communication about changes an organizational culture that supports these aims. The Healthy Hospital project was designed to demonstrate ways to change culture around the participatory decision-making focus, document lessons learned throughout the change process, and measure the effects of these innovations. The work stress literature supports the principle that empowerment is inversely related to strain (the impacts of stress on the worker).21 More particularly, the research question asked was: “Will the collaboration of union and management leaders on an empowered steering committee working with diverse disciplines, departments, and labour and management representatives to promote participatory decision making produce measurable changes in culture, stress and satisfaction?”
Methods Design The Healthy Hospital project was designed as a theory-driven demonstration project. A baseline survey (June 1991) was administered to a stratified random sample of three union groupsz2 (nursing, support staff and allied professions) by two levels of management (supervisors versus non-supervisors), and repeated at one (May 1993) and two years (May 1994). Periodic focus groups, key informant interviews, special surveys and project reports described the determinantsand outcomes
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convergent vers la conclusion que le projet a permis d’obtenir des gains modestes mais importants au sein de I’organisme. On discute dans cet article des legons pour la recherche et les applications ultkrieures.
of the broad culture change process. The Hospital Employees Union chose not to participate in the baseline survey and thus has available data for the one- and two-year follow-ups only.
Program The program was administered by a steering committee of four management representatives, two representatives each from nursing (British Columbia Nurses AssociationBCNU), support staff (Hospital Employees Union/HEU), and allied professions (Health Services Association/HSA), an independent chairperson (a local lawyer), a project evaluator and two project staff. Funding was obtained though a three-year grant of $150,000 a year from the provincial Ministry of Health matched by equal funds from the federal government’s Industrial Adjustment Services program. The project was structured so that it would work within existing collective agreements, and provincial union offices formally agreed to support the demonstration project. The steering committee worked hard for a year, meeting half a day a month plus occasional full-day retreats, to develop the shared understanding, trust, contractual agreements, vision statement and communicationtools necessary to launch the project. They developed the following vision statement to support culture change: Healthy Hospital aims to create a workplace where everyone is empowered to share control over decisions that affect them, where all levels are actively encouraged to work together, without fear of failure, to innovate, problem-solve and experiment in an atmosphere of mutual respect. This governance, funding structure and vision represent the first core program component. Other core components included:
Projects: Grassroots feasibility projects to design, implement, and test solutions to specific problems. A total of 17 projects successfully applied to the steering committee over the two operational years of the project. They ranged from the complex, such as a salary deferral leave plan and an evaluation of needleless intravenous systems, to the somewhat simpler, such as more effective storage of laundry carts. Any project proposal, from any group in the hospital, was eligible for funding if it was aimed at improving quality of work life and collaboration among all staff groups affected by the changes. Communications: A communications and support system included a project coordinator/outreachworker, some 35 trained “ambassadors” from throughout the hospital whose role it was to actively promote the project, a newsletter, public forums, publication of survey and focus groups results, and a speakers program to bring two-person union and management representative teams to the ward or department to discuss the program. An excellent video was produced to introduce the project. Capacity Building: Coaching was available to all project teams to help them develop, implement and evaluate their plans. Some of the specific projects focused on team building. Human Resources developed a widely used “Change Mastery” workshop. FALL 1997, VOL. 10, NO. 3
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In general, it was recognized that staff cannot participate effectively in decision making without necessary skills and support. Evaluation: Not only were there the quantitative and qualitative evaluations described in this paper, but each of the funded projects was required to develop its own evaluation plan. The stated aim was to fund only those demonstration projects that would be supported from operating funds once they had been shown to be effective with funding from Healthy Hospital.
Subjects All hospital employees were eligible to participate in Healthy Hospital-funded projects and activities. The survey drew roughly one in seven subjects randomly from stratified samples of all full-time and part-time staff in the three employee groups described in the design. Procedures The surveys varied between 138 and 186 items across the three employee groups and three survey times, and typically took 30 to 45 minutes to complete. Employees could attend one of many scheduled survey sessions during their work shift, complete the survey on the ward or have it mailed to their home. There were two rounds of focus group studies, the first in early 1992 to identify staff needs, and the second in 1994 to assess program progress. Participants were randomly selected from staff lists. A standard set of questions was discussed. Discussion points were summarized on flip charts and later transcribed, reviewed by the focus group for accuracy, and final content analyzed to identify major themes. Twice the Project Evaluator conducted a structured, confidential interview with each member of the steering committee: first, soon after the program launch in the fall of 1992, and second as the project drew to a close, in the fall of 1994. Taken together, the “Telling Our Story” interview reports were designed to provide a strategic analysis of lessons learned from the project. Interview results were content analyzed, summarized, presented to the steering committee for discussion, and revised to accurately reflect the diverse points of view within the Committee. Measures As mentioned earlier, the evaluation framework was largely theory driven. Quality of work life was conceptualized as the result of interaction between individual and organizational factors. Our conceptual framework was much like that provided by O’Brien-Pallas and BaumannZ3to guide their study of quality of nursing work life. We chose as core constructs those factors that were relatively well established in the research literature and for which there were standardized measures with acceptable psychometric properties. Other variables were explored using the focus groups and interviews described above, but not formally studied in this project. Selected research measures were used for job stress, job satisfaction, work climate, self-esteem and intent to stay at the hospital. Psychometric properties are as follows. Job Stress Karasek and Theorell’sIomeasure of job stress was used as a core measure; items were added to measure particular aspects of the four major dimensions (Psychological Job Demand, Decision AUTOMNE 1997, VOL. 10, NO. 3
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Latitude, Social Support, and Hazardous Exposure) specific to the St. Paul’s environment. Factor analyses reported below pooled the original and new job stress items with related items from job satisfaction, work climate, and self-esteem measures, and new expanded scales developed to provide a 69-item instrument with more sensitive and stable measures of the job stress dimensions. Job Satisfaction The 3 1-item McCloskeyMueller measure of nurses’ job satisfaction (MMSS) was used for all four union groups. Item wording was modified slightly as necessary for non-nurse groups. The measure includes eight subscales of job satisfactionZ4rated on five-point scales: Extrinsic Rewards; Scheduling; WorkRamily Balance; Co-Workers; Interaction Opportunities; Professional Opportunities; Praise/Recognition; and Control/ Responsibility. Four of the subscales have alphas over .70; the global scale has an alpha of .89. Construct validity can be inferred from an alpha = .82 with intent to stay on the job. Work Environment The Work Environment Scale is one of 10 social climate scales developed by Rudy Moos and his colleagues at the Stanford Social Ecology Laborat01-y.~~ The WES includes 10 subscales grouped under three dimensions: Relationships (Involvement, Peer Cohesion and
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are interpreted in a positive direction; that is, “higher” means “more” or “better.” Separate comparisons were made for regular staff, supervisors and for the combined sample. A series of two-sample t-tests was used to compare changes from one year to another. One-way analysis of variance was used to compare unions at each time point. Because of the large number of possible tests of comparison, an ad hoc procedure was used to protect against “over-interpreting” false positives; that is, a difference between two means was not considered “statistically significant” in isolation, but by reference to other related subscales and comparisons. Patterns of significant test results were sought.
Results Annual Surveys Response Rates by Time Table 1 summarizes the response rates and final sample sizes for analysis, by staff group, for each of the three measurementperiods. Scale Definitions and Group Means over Time The following pairs of tables present definitions of subscales for each of the four major impact measures, and tests of significance for changes within each staff group across the three measurement period^.^' A summary of the results is presented in the next section.
System Change (Clarity, Control, Innovation and Physical Comfort). Cronbach alphas range from .69 to .86, one-month test-retest reliabilities ranged from .69 for Clarity to .83 for involvement. Work Self-Esteem Pierce et a1.26developed a 10-item measure of “organization-based self-esteem.” In brief, OBSE is hypothesized to relate to more global self-esteem and task competence, but to be more specifically determined by managerial respect, job complexity, job stability and job structure. Seven validation studies included some 2,000 individuals and examined a variety of reliability and validity issues. Together, they provide good support for the instrument.
Analytic Methods The measures described in the previous section were thoroughly developed and tested in a variety of settings, primarily in the United States. As a check on whether the same set of dimensions, and the same items within each dimension, were appropriate for Canadian settings, the method of confirmatory factor analysis was used. Scores on all the subscales and dimensions were computed by combining scores from the individual items that made up each scale. Negatively oriented items were reversed so that all scales
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Subscale Title and Definition: Decision Latitude: opportunities to develop skins and freedom to make decisions Psychological Job Demand: excessive workload and time demands Hazardous Exposure: exposure to hazardous conditions or toxic materials Social Support: work environment provides open communication, support, encouragement and recognition
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Modest gains in job satisfaction and self-esteem are also relaBritish Columbia Nurses Association Health Services Association Hospital Employees tively consistent from 1991 to Union 1993. However, comparison of 1991 1993 1994 1991 1993 1994 1993 1994 the 1993 to 1994 data suggests n=137 n=85 n=77 n.64 n=70 n.52 n=91 n=87 either retention of the gains with Decision little further improvement or, in 3.04 3.31* 3.30 2.97 3-25‘ 3.38* 2.81 2.94+ Latitude some cases, a partial loss of the 1991- 1993 gains. Looking at subPsycho2.77 2.84* 2.90 2.78 2.77 2.91+ 2.97 2.72* scales, there are reasonably conlogical Job Demand sistent positive changes in areas like innovation and change, satisHazardous 3.03 3.13 2.19 2.36 2.26 2.09 faction with peer support, autonoExposure my, job integrity,job control, and Social support - the areas theoretically 2.86 3.09* 3.16 2.85 2.93 3.13+ 2.70 2.84+ support expected to be most affected by the participatory decision-making strategies of Healthy Hospital. However, the pattern of the results suggests qualitatively different impacts for the various groups. For example, the HSA shows the greatest changes in organizational climate, the BCNU in job satisfaction measures. HEU climate improved, even Subscale Title and Definition: though stress levels had not improved for the HEU as they had PraiselRecognition: employees’ satisfaction with their supervisor, and amount for the other two unions. of positive feedback FamilyMlork: employees’ satisfaction with weekends off, parental leave time, straight days Co-workers: employees’ satisfaction with their peers Interaction: employees’ satisfaction with the opportunities for social contact with peers and other disciplines at work and outside of work Scheduling: satisfaction with opportunities for part-time work, flexibility in work hours and assigned work hours Professional Opportunities: satisfaction with opportunities for career enhancement through research, interaction with nursing faculty, and institutionalcommittees ControllResponsibility: satisfaction with physicians they work with and child care facilities Overall Job Satisfaction: overall job satisfaction
Results Summary These tables present comparisons of group data for regular staff across the three surveys for the overall stress, satisfaction and work self-esteem scales, and the component subscales. In general, it can be seen that there is a steady increase in job demand, consistent with shrinking provincial budgets and uncertainty surrounding broader health care reforms. However, there are also reasonably consistent gains in decision latitude and social support across all staff groups. Overall stress levels improved for BCNU and HSA staff but not for HEU. It is worth noting that where the item pool was considerably expanded beyond Karasek and Theorell’s,Io the factor structure remained identical.
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Annual History Interviews The project appeared to move through three distinct phases, roughly paralleling the three years of the project. In the first year, steering committee members learned to trust each other and work together; cornerstones for the project were set in place (for example, provincial union support, vision, launch strategy). In year two, the primary focus was on funding and supporting projects. Finally, in year three, the priority turned to strategies and structures focused on the project coming to an end. At the macro level, the concern was with creating necessary structures and staff resources; at the micro level, it was with developing the skills staff needed to continue “the Healthy Hospital way.” The steering committee reached consensus following the second round of interviews on the important lessons learned from the project. Interview data were content analyzed independently and reviewed by the steering committee, but added little additional information. In summary, the steering committee collectively shared and could articulate critical success factors for the project. The following are those seen as the most important: Joint union-management leadership: An empowered, trusting and cohesive union-management steering committee with senior representatives from both sides (for example, vice-presidents from management, union chairs or chief stewards) working within collective agreements. Readiness for collaboration may be an essential prerequisite. For example, a proven track record of strong advocacy by union leadership ensures a greater ability to participate without undermining the membership’s confidence in their leadership.28
a
During the project, there was a convergence of union and management philosophies regarding conflict resolution, shared responsibility for problem solving, etc. These gains spilled
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+ indicates significant difference between 1993 and 1994 (P<.lo) Note: Results arefor regular staff on&; supervisors are omitted
Subscale Title and Description: Innovation: degree to which the organization is responsive to change and new approaches are adopted Work Pressure: amount of pressure, deadlines, work load; expectations that employees feel Clarity: efficiency of planning, and clarity of role's and responsibilities in the organization Physical Comfort: comfort and attractiveness of the physical work environment Control: amount of rules, regulations and supervision imposed on employees Peer Cohesion: degree to which employees work cooperatively with each other and with supervisors Task Orientation: freedom employees feel to behave as they like Supervisor Support efficiency and positivity of employee-supervisor interactions Autonomy: degree to which employees can function independently Involvement: degree to which employees are supported through personal and work-related problems
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over into improved union-management personal relationships outside the project, underscoring the central importance of the steering committee in facilitating culture change, and the critical role of personally committed, highly effective leaders. Vision: An explicit, compelling vision and commitment to shared values. Planning: Explicit goals, objectives and operational plans, which are frequently renewed, to bridge from vision to grassroots action. Bottom-up implementation: Active, extensive involvement of staff in designing, implementing and monitoring innovations. Walk the talk: Public demonstrations of senior management and steering committee commitment to the vision. Early successes: Visible, credible project accomplishments signalling the credibility and potential of the project. Communications: Constant, open, honest, inclusive communications highlighting change and successes. The key role of ambassadors, public forums to discuss major organizational change, and direct involvement of staff in making suggestions for budget planning, were seen as particularly good examples of the potency of communications. Capacity and team development: Concerted effort to develop necessary skills and enabling systems and resources before expecting any group to be effective in participatory decision making (for example, steering committee, senior management team, grassroots, middle managers). Effective links to Human Resources programs and services were seen as critical in this regard. Management support: Consistent middle manager support, otherwise efforts will founder. But managers themselves need skills and support to enable them to play this role. Dedicated, full-time project staff: Staff to coordinate activity and serve as a catalysthesource to grassroots projects. Diversity appreciation: Sensitivity to the diverse needs of staff for projects like this. Tracking and evaluation: Regular monitoring and critical appraisal to document successes, make results tangible and continuously improve strategies. Professional support: Facilitation and evaluation, both seen as key success factors requiring outside expert support. Patience: To bear with progress that is much slower than anyone would imagine, even with a high level of organizational readiness.
Dimension Title and Description: Relationship: combinationof the subscales of Involvement, Peer Cohesion and Supervisor Support Personal Growth: combinationof the subscales of Autonomy, Task Orientation and Work Pressure System Maintenance and Change: combinationof the subscales of Organizational Efficiency, Control, Innovationand Physical Comfort
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The steering committee believes these are lessons that can be generalized and will hold true for health care managers seeking to promote positive culture change in their organizations.
Focus Groups Overall, the focus groups were also reasonably consistent with the critical success factors identified by the steering committee. The first round at the beginning of the project identified AUTOMNE 1 9 9 7 , VOL. 10, NO. 3
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n=137 Innovation
n.85
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Health Services Association
n7.7
n=64
5.17"
n=70
G E S T ~ O ND E s S O I N S D E S A N T E
Hospital Employees Union
n=52
n=91
n-87
4.66"
Work Pressure
5.95
5.46
5.66
6.20
5.24"
5.79
5.69
4.97
Clarity
5.56
5.77
5.08+
4.67
5.61"
5.71
4.76
4.63
Physical Comfort
3.93
5.22"
4.56
3.13
3.94"
4.36
4.89
5.22
Control
5.37
4.61'
4.40
4.89
4.27"
4.40
4.31
2.69t
Peer Cohesion
6.27
6.45
6.42
6.28
5.79
6.65
5.07
5.41
Task Orientation
6.93
6.93
6.87
6.38
6.69"
6.50
7.80
7.76
Supervisor Support
4.97
5.15
5.44
4.76
5.35"
6.01
5.07
4.78
Autonomy
4.93
5.97
5.71
4.94
5.46"
5.92
Involvement
6.60
6.66
6.51
5.34
6.46'
6.73
Relationship
5.95
6-09"
6.12
5.46
5.87"
6.47+
Personal Growth
5.93
6.12
6.08
5.84
5.80
6.07
System Maintenance and Change
4.76
5.19"
4.65+
4.03
4.62"
4.91
* indicates significant difference between 1991 and 1993 (P
+ indicates significant difference between 1993 and 1994 (P< SO) Note: Results arefor regular staff only; supervisors are omitted
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Work Self-Esteem: the degree to which the employee feels valued by the organization.
British Columbia Nurses Union 1991 1993 n=137 n=85 WorkSelf-Esteem 5.26
5.70"
Health Services Association
1994 n=77
1991 n6.4
1993 n=70
1994 n5.2
5.28+
5.30
5.38
5.23
-+-
Hospital Employees Union
1993 n=91
1994 n8.7
4.92
5.09
* indicates significant difference between 1991 and 1993 (P<.lo) + indicates significant difference between 1993 and 1994 (P
needs in four areas: improved communications, more participatory decision making, increased staffing, and improved facilities. The Healthy Hospital program was designed to address the first two areas; concerns in the other two areas were referred to the appropriate body in the hospital. During the second round after the project had been functioning for about a year and a half postlaunch, improved communications FALL 1997, VOL. 10, NO. 3
and decision making continued to be priorities, but there was also recognition of and appreciation for the positive accomplishments of Healthy Hospital. Balancing the survey results showing Healthy Hospital impacts, the focus groups suggested moderate progress. While there was awareness of the program and its aims, and broad agreement that progress had been made, a common perception remained that the development of a culture of participatory decision making still had a good ways to go. Of particular significance is the general perception that the highest levels of management had not visibly bought in enough to the participatory decision-making culture.
Discussion
The Healthy Hospital program provides the first Canadian data demonstrating the feasibility of producing a planning culture change toward 5.54 5.81 greater participatory decision making. The data confirm that such culture changes tend to 5.37 5.33 decrease job stress while increasing job satis5.17 5.18 faction and work self-esteem. This demonstration is remarkable, given the organic nature of 6.34 6.18 the culture change methodology: by seeding culture change with a strong union-manage4.52 4.28 ment steering committee, a clear vision and a limited number of staff-driven pilot projects, pervasive shifts were seen across representative samples of employees, despite the fact that the vast majority had not been directly involved in any of the more intensive committee and project work of Healthy Hospital. Reflection on the degree of change across the battery of measures suggests an interesting corollary: there seems to be a dose-response relationship. BCNU showed the greatest amount of change, and excluded staff the least, with HEU and HSA intermediate. This corresponds to the degree to which the different staff groups overall took advantage of the opportunity for Healthy Hospital-funded projects. This tendency was probably influenced by concurrent changes in the hospital: a new Vice-President Nursing was moving her staff toward participatory governanceat the same time that Healthy Hospital was developing. Additional data support the inference that it was Healthy Hospital and not other factors that produced change. For example, on average, 50 to 80 percent of staff across the four groups reported on the 1994 survey that they believed Healthy Hospital was making St. Paul's a better place to work (the 80 percent represented BCNU members). Respondents consistently reported increases in control over decision making, and there was a trend toward perceptions of better change management throughout the hospital. Steering committee members were under no illusions that they had achieved substantial and lasting culture change. Both quantitative and qualitative data suggest modest gains, and the limited beginnings of the culture change that can realistically be
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expected in the relatively short time frame of two years. Indeed, the qualitative data suggested disquieting trends toward relapse as the demonstration project drew to a close. For example, interviewees noted turnover in steering committee membership and a renewed tendency to let managers take the initiative on plans for transition to the postproject period. They were well aware that some positive initiatives were bogging down because of the lack of support from increasingly beleaguered middle managers. The final year of the project was greatly strained by the provincial government’s announcement of significant budget cuts - it was difficult to commit funds to the continuation and institutionalization of project work, although a full-time coordinator position was funded. The steering committee members themselves who surprisingly were generally not among the change leaders in the hospital - were experiencing palpable burnout with their program involvement, and there was a growing need for membership renewal. Large-scale organizational change has become common place in recent years, and the basic “how to’s” are becoming clear, whatever the challenge: total quality management, re-engineering, right sizing or culture change. KotteS9 recently listed the following eight key steps: establishing a sense of urgency; forming a powerful guiding coalition; creating a vision; communicatingthe vision; empowering others to act on the vision; planning for and creating short-term wins; consolidating improvements and producing still more change; and institutionalizingnew approaches. With the benefit of hindsight, it seems that Healthy Hospital followed the first six steps in almost classic fashion, and succeeded accordingly. As the project moved into its final year, it started to sputter, and there was too little time, energy and sustained leadership to succeed in the final two steps. Looking back over the three-year project, we conclude that the Healthy Hospital project did not achieve enduring culture change. The project did not have the wherewithal to “go the distance” and build on early gains. As rewarding as they were, improved relationships within the steering committee itself did not produce large enough ripple effects in everyday supervisor-staff relationships. The project initially produced widespread hope throughout the hospital, but without systemic changes in the way power is shared throughout the organization, the initial promise of participatory decision making eventually withered on the vine. The challenges of sustainability for demonstration projects are well known. But being forewarned was not sufficient. Specific objectives to build for sustainability could have been built in from the beginning, to avoid difficulties encountered with Kotter’s steps seven and eight. With the benefit of hindsight, it is clear that a deeper, more consistent understanding and application of participatory decision making - by both union and management leadership was needed to bridge from demonstration project to healthy organization.20Healthy Hospital could serve as a catalyst, but could not continue to nurture culture change by itself. A better
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understanding of this reality from the beginning, and closer integration between the Healthy Hospital project and overall hospital operations, might have ensured consolidation and institutionalization of new appro ache^.^' In summary, this demonstration project represents a modest beginning in the search for innovative management strategies that will assist hospitals to cope with the revolutionary changes of the 1990s. The data suggest moderate but consistent changes during the first two years of the project. Qualitative data provide a number of critical success factors to incorporate into future programs designed to produce changes in decision-making culture. It is painfully clear that even higher levels of commitment and effort were needed to translate early wins into enduring culture change.
Acknowledgments This project was supported by the British Columbia Ministry of Health’s Advisory Committee on Nursing, with matching fimds from Human Resource Development Canada’s Industrial Adjustment Service program. Their financial contributions and steadfast interest are gratefully acknowledged. Projects like this provide a stage for so many heroines and heroes that they cannot all be recognized by name. We particularly thank the steering committee members and ambassadors who gave unstintingly of their time, passion, patience and creativity, in a sincere commitment to finding better ways for labour and management to collaborate. Both union and management leaders provided ongoing support through the project: the partnership of the Local executives of the BCNU, HEU and HSA is sincerely appreciated. Finally, we want to thank the scores of staff who enthusiastically involved themselves in the specific Healthy Hospital projects that breathed life into the Healthy Hospital vision. @
References and Notes 1. Best JA., Burke BE, Walsh RG, Mulchey RD.Healthy Hospital: a demonstration project to improve nursing worklife. Dimensions in Health Services 1991;68(4):27-29.
2. Villeneuve M et al. Research in progress: Worklife concerns of Ontario nurses. Review: Quarterly Newsletter of the Quality of Nursing Work life Unit 1993;3(4):1-2. 3. Canadian Nurses AssociationKanadian Healthcare Association. Nurse retention and quality of life: a national perspective. Ottawa: The Associations; 1990. 4.Frisina A, Murray MA, Aird C. What do nurses want?: a review of job satisfaction and job turnover literature. Toronto: Hospital Council of Metropolitan Toronto; 1998.
5. Kramer M. The magnet hospitals: excellence revisited. Journal of Nursing Administration 1990;20(9):35-44. 6. Kramer M, Schmalenberg C. Magnet hospitals: part I - institutions of excellence. Journal of Nursing Administration 1988a;18(1):13-24. 7. Kramer M, Schmalenberg C. Magnet hospitals: part I1 - institutions of excellence. Journal of Nursing Administration 1988c;18(2):13-19. 8. Murray MA, Smith SD. Nursing morale in Toronto: an analysis of career, job, and hospital satisfaction among hospital staff nurses. Toronto: Hospital Council of Metropolitan Toronto; 1988. 9. Antonovsky A. Health, stress, and coping. San Francisco: Jossey-Bass; 1979.
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10. Karasek R,'Theorell T. Healthy work stress, productivity, and the reconstruction of working life. New York Basic Books; 1990. 11. Israel B. Social networks and social support: implications for natural helper and community level interventions. Health Education Quarterly 1985;12:66-80. 12. Peters TJ, Waterman RH Jr. In search of excellence. New York: Harper & Row; 1982. 13. Cohen S, Syme S, editors. Social support and health. Orlando (FL): Academic; 1985. 14. Minkler M. Improving health through community organization. In: Glantz K, Lewis FM, Rimer BK, editors. Health behavior and health education: theory, research, and practice. San Francisco: Jossey-Bass; 1990. 15. Wallerstein N, Bernstein E. Empowerment education: Freire's ideas adapted to health education. Health Education Quarterly 1988;15:379394. 16. Glass Ceiling Commission. Good for business: making full use of the nation's human capital. Washington (DC): U.S. Government Printing Office; 1995. 17. Hemingway MA, Smith CS. Organizational climate, occupational stressors, and withdrawal behavior in nurses. Paper presented at Work, Stress, and Health '95: Creating Healthier Workplaces Conference; September 14-16; Washington, D.C. 18. Landy F, Quick JC, Kasl S. Work, stress, and well-being. International Journal of Stress Management 1994; 1:33-73. 19. MacLennan BW. Stressor reduction: an organizational alternative to individual stress management. In: Quick JC, Murphy LR, Hun-ell JJ, editors. Stress and well-being at work. Washington (DC): American Psychological Association; 1992. 20. Rosen R, Flower J. The leaner, healthier company. Healthcare Forum Journal 1992 May-June. 2 1. Michela JL, Lukaszewski MP, Allegrante JP. Organizational climate and work stress: a general framework applied to inner-city schools. In: Sauter SL, Murphy LR, editors. Organizational risk factors for job stress. Washington (DC): American Psychological Association; 1995. 22. Hospital Employees Union members include housekeeping, licensed practical nurses, biomedical electronics technicians, dietary and clerical workers, open heart perfusionists, etc. Health Services Association members include social work, physio and occupational therapy, dietitians, X-ray and medical laboratory technologists, etc.
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27. Note that the scales have various ranges, so means of scales and subscales are not all directly comparable. Some are based on four-point scale items, some on five-point scales and some on seven-point scales. The Job Stress subscale scores range from 1 (Strongly Disagree) to 4 (Strongly Agree), with higher scores meaning greater job control and personal support, but also greater job demand and hazard; the midpoint is 3. The Job Satisfaction subscale scores range from 1 (Very Dissatisfied) to 5 (Very Satisfied), with higher scores meaning greater satisfaction; the midpoint is 3. The Organizational Climate subscale scores range from a minimum of 1 (Poor) to a maximum of 9 (Excellent), with higher scores being positive; the midpoint is 5 . The Organization-Based Self-Esteem (OBSE) scores range from 1 (Strongly Disagree) to 7 (Strongly Agree), with higher scores meaning greater self-esteem; the midpoint is 4. The midpoints can be used as an indicator of positive or negative attitudes about job stress, job satisfaction, organizational climate, and work self-esteem. Means above the midpoints are positive, means below the midpoints are negative. 28. Centre for Labour and Management Studies. Organizational practices and the changing employment relationship. Proceedings of the Canadian Workplace Research NetworkKentre for Labour and Management Studies Inaugural Conference; 1996 Oct 18-19; Vancouver. In press. 29. Kotter JP.Leading change: why transformation efforts fail. Harvard Business Review 1995 March-April; 59-67. J. Allan Best, PhD, is Principal, the Organization Development Group. He is also Clinical Professor, Department of Health Care and Epidemiology, and Associate, Institute of Health Promotion Research, University of British Columbia. George Walsh, MBA, was Vice President, St. Paul's Hospital, at the time of this project and is now retired. Fred Muzin, BSc, was Chairperson, St. Paul's Local Hospital Employees' Union during this project and is now President, B. C. Hospital Employees' Union. Jonathan Berkowitz, PhD, is Principal, Berkowik & Associates Consulting Inc.; and Adjunct Professor, Faculty of Commerce and Business Administration, Clinical Assistant Professor, Department of Family Practice, University of British Columbia as well as Associate, Institute of Health Promotion Research.
23. O'Brien-Pallas L, Baumann A. Quality of nursing work life issues - a unifying framework. Canadian Journal of Nursing Administration
1992;5:12-16. 24. Mueller CW, McCloskey JC. Nurses' job satisfaction: a proposed measure. Nursing Research 1990;39:113-117. 25. Moos RH. Work environment scale manual. 2nd ed. Palo Alto: Consulting Psychology Press; 1981. 26. Pierce JL, Gardner DG, Cummings LL, Dunham RB. Organization-based self-esteem: construct definition, measurement, and validation. Academy of Management Journal 1989;32(3):622-648.
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ORIGINAL ARTICLE
ard a Better Torno monstration Project to Pro ure Change through Participa Decision Making n Best, Geoff Walsh, Fred Muzin and Jonathan Berkowitz for the S Hospital Healthy Hospital steering committee
Abstract The three-year “Healthy Hospital” project was designed to increase participatory decision making,
for future research and ications are discussed.
et de trois ans a Healthy
ail. Les mbthodes
S
t. Paul’s Hospital in Vancouver launched a three-year “Healthy Hospital” demonstration project in 1991. The project was designed to increase participatory decision making for all staff groups, thereby decreasingjob stress and increasing job satisfaction. The original impetus was a St. Paul’s Presidential Task Force established to investigate quality of nursing work life issues following a 1989 sQike. However, the health care environment changed rapidly thereafter, so that original concerns with nursing shortages disappeared.2 A second change, before the project was launched, was to broaden the focus to include all staff, rather than just nursing staff. The project built on previous research documenting nurses’ needs for quality of work life and hospitals’ needs for organizational effectiven e ~ s . The ~ - ~specific hypothesis that increased participation in decision making would have the desired effects on job stress and satisfactiondrew on the broad research literature on job stress:-1o job control,11,’2social support13and empowerment.14915 Empirical and popular support for participatory decision making and its relationship to job stress has grown rapidly in the five years since the Healthy Hospital project was conceptualued.16-20
The literature is quite clear on the essential ingredients for increased job satisfaction: participation in decision making quality teamwork peer and supervisor support autonomy and control over how work is organized FALL 1997, VOL. 10, NO. 3
opportunities for challenge and growth open, ongoing communication about changes an organizational culture that supports these aims. The Healthy Hospital project was designed to demonstrate ways to change culture around the participatory decision-making focus, document lessons learned throughout the change process, and measure the effects of these innovations. The work stress literature supports the principle that empowerment is inversely related to strain (the impacts of stress on the worker).21 More particularly, the research question asked was: “Will the collaboration of union and management leaders on an empowered steering committee working with diverse disciplines, departments, and labour and management representatives to promote participatory decision making produce measurable changes in culture, stress and satisfaction?”
Methods Design The Healthy Hospital project was designed as a theory-driven demonstration project. A baseline survey (June 1991) was administered to a stratified random sample of three union groupsz2 (nursing, support staff and allied professions) by two levels of management (supervisors versus non-supervisors), and repeated at one (May 1993) and two years (May 1994). Periodic focus groups, key informant interviews, special surveys and project reports described the determinantsand outcomes
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convergent vers la conclusion que le projet a permis d’obtenir des gains modestes mais importants au sein de I’organisme. On discute dans cet article des legons pour la recherche et les applications ultkrieures.
of the broad culture change process. The Hospital Employees Union chose not to participate in the baseline survey and thus has available data for the one- and two-year follow-ups only.
Program The program was administered by a steering committee of four management representatives, two representatives each from nursing (British Columbia Nurses AssociationBCNU), support staff (Hospital Employees Union/HEU), and allied professions (Health Services Association/HSA), an independent chairperson (a local lawyer), a project evaluator and two project staff. Funding was obtained though a three-year grant of $150,000 a year from the provincial Ministry of Health matched by equal funds from the federal government’s Industrial Adjustment Services program. The project was structured so that it would work within existing collective agreements, and provincial union offices formally agreed to support the demonstration project. The steering committee worked hard for a year, meeting half a day a month plus occasional full-day retreats, to develop the shared understanding, trust, contractual agreements, vision statement and communicationtools necessary to launch the project. They developed the following vision statement to support culture change: Healthy Hospital aims to create a workplace where everyone is empowered to share control over decisions that affect them, where all levels are actively encouraged to work together, without fear of failure, to innovate, problem-solve and experiment in an atmosphere of mutual respect. This governance, funding structure and vision represent the first core program component. Other core components included:
Projects: Grassroots feasibility projects to design, implement, and test solutions to specific problems. A total of 17 projects successfully applied to the steering committee over the two operational years of the project. They ranged from the complex, such as a salary deferral leave plan and an evaluation of needleless intravenous systems, to the somewhat simpler, such as more effective storage of laundry carts. Any project proposal, from any group in the hospital, was eligible for funding if it was aimed at improving quality of work life and collaboration among all staff groups affected by the changes. Communications: A communications and support system included a project coordinator/outreachworker, some 35 trained “ambassadors” from throughout the hospital whose role it was to actively promote the project, a newsletter, public forums, publication of survey and focus groups results, and a speakers program to bring two-person union and management representative teams to the ward or department to discuss the program. An excellent video was produced to introduce the project. Capacity Building: Coaching was available to all project teams to help them develop, implement and evaluate their plans. Some of the specific projects focused on team building. Human Resources developed a widely used “Change Mastery” workshop. FALL 1997, VOL. 10, NO. 3
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In general, it was recognized that staff cannot participate effectively in decision making without necessary skills and support. Evaluation: Not only were there the quantitative and qualitative evaluations described in this paper, but each of the funded projects was required to develop its own evaluation plan. The stated aim was to fund only those demonstration projects that would be supported from operating funds once they had been shown to be effective with funding from Healthy Hospital.
Subjects All hospital employees were eligible to participate in Healthy Hospital-funded projects and activities. The survey drew roughly one in seven subjects randomly from stratified samples of all full-time and part-time staff in the three employee groups described in the design. Procedures The surveys varied between 138 and 186 items across the three employee groups and three survey times, and typically took 30 to 45 minutes to complete. Employees could attend one of many scheduled survey sessions during their work shift, complete the survey on the ward or have it mailed to their home. There were two rounds of focus group studies, the first in early 1992 to identify staff needs, and the second in 1994 to assess program progress. Participants were randomly selected from staff lists. A standard set of questions was discussed. Discussion points were summarized on flip charts and later transcribed, reviewed by the focus group for accuracy, and final content analyzed to identify major themes. Twice the Project Evaluator conducted a structured, confidential interview with each member of the steering committee: first, soon after the program launch in the fall of 1992, and second as the project drew to a close, in the fall of 1994. Taken together, the “Telling Our Story” interview reports were designed to provide a strategic analysis of lessons learned from the project. Interview results were content analyzed, summarized, presented to the steering committee for discussion, and revised to accurately reflect the diverse points of view within the Committee. Measures As mentioned earlier, the evaluation framework was largely theory driven. Quality of work life was conceptualized as the result of interaction between individual and organizational factors. Our conceptual framework was much like that provided by O’Brien-Pallas and BaumannZ3to guide their study of quality of nursing work life. We chose as core constructs those factors that were relatively well established in the research literature and for which there were standardized measures with acceptable psychometric properties. Other variables were explored using the focus groups and interviews described above, but not formally studied in this project. Selected research measures were used for job stress, job satisfaction, work climate, self-esteem and intent to stay at the hospital. Psychometric properties are as follows. Job Stress Karasek and Theorell’sIomeasure of job stress was used as a core measure; items were added to measure particular aspects of the four major dimensions (Psychological Job Demand, Decision AUTOMNE 1997, VOL. 10, NO. 3
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Latitude, Social Support, and Hazardous Exposure) specific to the St. Paul’s environment. Factor analyses reported below pooled the original and new job stress items with related items from job satisfaction, work climate, and self-esteem measures, and new expanded scales developed to provide a 69-item instrument with more sensitive and stable measures of the job stress dimensions. Job Satisfaction The 3 1-item McCloskeyMueller measure of nurses’ job satisfaction (MMSS) was used for all four union groups. Item wording was modified slightly as necessary for non-nurse groups. The measure includes eight subscales of job satisfactionZ4rated on five-point scales: Extrinsic Rewards; Scheduling; WorkRamily Balance; Co-Workers; Interaction Opportunities; Professional Opportunities; Praise/Recognition; and Control/ Responsibility. Four of the subscales have alphas over .70; the global scale has an alpha of .89. Construct validity can be inferred from an alpha = .82 with intent to stay on the job. Work Environment The Work Environment Scale is one of 10 social climate scales developed by Rudy Moos and his colleagues at the Stanford Social Ecology Laborat01-y.~~ The WES includes 10 subscales grouped under three dimensions: Relationships (Involvement, Peer Cohesion and
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are interpreted in a positive direction; that is, “higher” means “more” or “better.” Separate comparisons were made for regular staff, supervisors and for the combined sample. A series of two-sample t-tests was used to compare changes from one year to another. One-way analysis of variance was used to compare unions at each time point. Because of the large number of possible tests of comparison, an ad hoc procedure was used to protect against “over-interpreting” false positives; that is, a difference between two means was not considered “statistically significant” in isolation, but by reference to other related subscales and comparisons. Patterns of significant test results were sought.
Results Annual Surveys Response Rates by Time Table 1 summarizes the response rates and final sample sizes for analysis, by staff group, for each of the three measurementperiods. Scale Definitions and Group Means over Time The following pairs of tables present definitions of subscales for each of the four major impact measures, and tests of significance for changes within each staff group across the three measurement period^.^' A summary of the results is presented in the next section.
System Change (Clarity, Control, Innovation and Physical Comfort). Cronbach alphas range from .69 to .86, one-month test-retest reliabilities ranged from .69 for Clarity to .83 for involvement. Work Self-Esteem Pierce et a1.26developed a 10-item measure of “organization-based self-esteem.” In brief, OBSE is hypothesized to relate to more global self-esteem and task competence, but to be more specifically determined by managerial respect, job complexity, job stability and job structure. Seven validation studies included some 2,000 individuals and examined a variety of reliability and validity issues. Together, they provide good support for the instrument.
Analytic Methods The measures described in the previous section were thoroughly developed and tested in a variety of settings, primarily in the United States. As a check on whether the same set of dimensions, and the same items within each dimension, were appropriate for Canadian settings, the method of confirmatory factor analysis was used. Scores on all the subscales and dimensions were computed by combining scores from the individual items that made up each scale. Negatively oriented items were reversed so that all scales
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Subscale Title and Definition: Decision Latitude: opportunities to develop skins and freedom to make decisions Psychological Job Demand: excessive workload and time demands Hazardous Exposure: exposure to hazardous conditions or toxic materials Social Support: work environment provides open communication, support, encouragement and recognition
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Modest gains in job satisfaction and self-esteem are also relaBritish Columbia Nurses Association Health Services Association Hospital Employees tively consistent from 1991 to Union 1993. However, comparison of 1991 1993 1994 1991 1993 1994 1993 1994 the 1993 to 1994 data suggests n=137 n=85 n=77 n.64 n=70 n.52 n=91 n=87 either retention of the gains with Decision little further improvement or, in 3.04 3.31* 3.30 2.97 3-25‘ 3.38* 2.81 2.94+ Latitude some cases, a partial loss of the 1991- 1993 gains. Looking at subPsycho2.77 2.84* 2.90 2.78 2.77 2.91+ 2.97 2.72* scales, there are reasonably conlogical Job Demand sistent positive changes in areas like innovation and change, satisHazardous 3.03 3.13 2.19 2.36 2.26 2.09 faction with peer support, autonoExposure my, job integrity,job control, and Social support - the areas theoretically 2.86 3.09* 3.16 2.85 2.93 3.13+ 2.70 2.84+ support expected to be most affected by the participatory decision-making strategies of Healthy Hospital. However, the pattern of the results suggests qualitatively different impacts for the various groups. For example, the HSA shows the greatest changes in organizational climate, the BCNU in job satisfaction measures. HEU climate improved, even Subscale Title and Definition: though stress levels had not improved for the HEU as they had PraiselRecognition: employees’ satisfaction with their supervisor, and amount for the other two unions. of positive feedback FamilyMlork: employees’ satisfaction with weekends off, parental leave time, straight days Co-workers: employees’ satisfaction with their peers Interaction: employees’ satisfaction with the opportunities for social contact with peers and other disciplines at work and outside of work Scheduling: satisfaction with opportunities for part-time work, flexibility in work hours and assigned work hours Professional Opportunities: satisfaction with opportunities for career enhancement through research, interaction with nursing faculty, and institutionalcommittees ControllResponsibility: satisfaction with physicians they work with and child care facilities Overall Job Satisfaction: overall job satisfaction
Results Summary These tables present comparisons of group data for regular staff across the three surveys for the overall stress, satisfaction and work self-esteem scales, and the component subscales. In general, it can be seen that there is a steady increase in job demand, consistent with shrinking provincial budgets and uncertainty surrounding broader health care reforms. However, there are also reasonably consistent gains in decision latitude and social support across all staff groups. Overall stress levels improved for BCNU and HSA staff but not for HEU. It is worth noting that where the item pool was considerably expanded beyond Karasek and Theorell’s,Io the factor structure remained identical.
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Annual History Interviews The project appeared to move through three distinct phases, roughly paralleling the three years of the project. In the first year, steering committee members learned to trust each other and work together; cornerstones for the project were set in place (for example, provincial union support, vision, launch strategy). In year two, the primary focus was on funding and supporting projects. Finally, in year three, the priority turned to strategies and structures focused on the project coming to an end. At the macro level, the concern was with creating necessary structures and staff resources; at the micro level, it was with developing the skills staff needed to continue “the Healthy Hospital way.” The steering committee reached consensus following the second round of interviews on the important lessons learned from the project. Interview data were content analyzed independently and reviewed by the steering committee, but added little additional information. In summary, the steering committee collectively shared and could articulate critical success factors for the project. The following are those seen as the most important: Joint union-management leadership: An empowered, trusting and cohesive union-management steering committee with senior representatives from both sides (for example, vice-presidents from management, union chairs or chief stewards) working within collective agreements. Readiness for collaboration may be an essential prerequisite. For example, a proven track record of strong advocacy by union leadership ensures a greater ability to participate without undermining the membership’s confidence in their leadership.28
a
During the project, there was a convergence of union and management philosophies regarding conflict resolution, shared responsibility for problem solving, etc. These gains spilled
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+ indicates significant difference between 1993 and 1994 (P<.lo) Note: Results arefor regular staff on&; supervisors are omitted
Subscale Title and Description: Innovation: degree to which the organization is responsive to change and new approaches are adopted Work Pressure: amount of pressure, deadlines, work load; expectations that employees feel Clarity: efficiency of planning, and clarity of role's and responsibilities in the organization Physical Comfort: comfort and attractiveness of the physical work environment Control: amount of rules, regulations and supervision imposed on employees Peer Cohesion: degree to which employees work cooperatively with each other and with supervisors Task Orientation: freedom employees feel to behave as they like Supervisor Support efficiency and positivity of employee-supervisor interactions Autonomy: degree to which employees can function independently Involvement: degree to which employees are supported through personal and work-related problems
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over into improved union-management personal relationships outside the project, underscoring the central importance of the steering committee in facilitating culture change, and the critical role of personally committed, highly effective leaders. Vision: An explicit, compelling vision and commitment to shared values. Planning: Explicit goals, objectives and operational plans, which are frequently renewed, to bridge from vision to grassroots action. Bottom-up implementation: Active, extensive involvement of staff in designing, implementing and monitoring innovations. Walk the talk: Public demonstrations of senior management and steering committee commitment to the vision. Early successes: Visible, credible project accomplishments signalling the credibility and potential of the project. Communications: Constant, open, honest, inclusive communications highlighting change and successes. The key role of ambassadors, public forums to discuss major organizational change, and direct involvement of staff in making suggestions for budget planning, were seen as particularly good examples of the potency of communications. Capacity and team development: Concerted effort to develop necessary skills and enabling systems and resources before expecting any group to be effective in participatory decision making (for example, steering committee, senior management team, grassroots, middle managers). Effective links to Human Resources programs and services were seen as critical in this regard. Management support: Consistent middle manager support, otherwise efforts will founder. But managers themselves need skills and support to enable them to play this role. Dedicated, full-time project staff: Staff to coordinate activity and serve as a catalysthesource to grassroots projects. Diversity appreciation: Sensitivity to the diverse needs of staff for projects like this. Tracking and evaluation: Regular monitoring and critical appraisal to document successes, make results tangible and continuously improve strategies. Professional support: Facilitation and evaluation, both seen as key success factors requiring outside expert support. Patience: To bear with progress that is much slower than anyone would imagine, even with a high level of organizational readiness.
Dimension Title and Description: Relationship: combinationof the subscales of Involvement, Peer Cohesion and Supervisor Support Personal Growth: combinationof the subscales of Autonomy, Task Orientation and Work Pressure System Maintenance and Change: combinationof the subscales of Organizational Efficiency, Control, Innovationand Physical Comfort
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The steering committee believes these are lessons that can be generalized and will hold true for health care managers seeking to promote positive culture change in their organizations.
Focus Groups Overall, the focus groups were also reasonably consistent with the critical success factors identified by the steering committee. The first round at the beginning of the project identified AUTOMNE 1 9 9 7 , VOL. 10, NO. 3
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n=137 Innovation
n.85
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n7.7
n=64
5.17"
n=70
G E S T ~ O ND E s S O I N S D E S A N T E
Hospital Employees Union
n=52
n=91
n-87
4.66"
Work Pressure
5.95
5.46
5.66
6.20
5.24"
5.79
5.69
4.97
Clarity
5.56
5.77
5.08+
4.67
5.61"
5.71
4.76
4.63
Physical Comfort
3.93
5.22"
4.56
3.13
3.94"
4.36
4.89
5.22
Control
5.37
4.61'
4.40
4.89
4.27"
4.40
4.31
2.69t
Peer Cohesion
6.27
6.45
6.42
6.28
5.79
6.65
5.07
5.41
Task Orientation
6.93
6.93
6.87
6.38
6.69"
6.50
7.80
7.76
Supervisor Support
4.97
5.15
5.44
4.76
5.35"
6.01
5.07
4.78
Autonomy
4.93
5.97
5.71
4.94
5.46"
5.92
Involvement
6.60
6.66
6.51
5.34
6.46'
6.73
Relationship
5.95
6-09"
6.12
5.46
5.87"
6.47+
Personal Growth
5.93
6.12
6.08
5.84
5.80
6.07
System Maintenance and Change
4.76
5.19"
4.65+
4.03
4.62"
4.91
* indicates significant difference between 1991 and 1993 (P
+ indicates significant difference between 1993 and 1994 (P< SO) Note: Results arefor regular staff only; supervisors are omitted
I
Work Self-Esteem: the degree to which the employee feels valued by the organization.
British Columbia Nurses Union 1991 1993 n=137 n=85 WorkSelf-Esteem 5.26
5.70"
Health Services Association
1994 n=77
1991 n6.4
1993 n=70
1994 n5.2
5.28+
5.30
5.38
5.23
-+-
Hospital Employees Union
1993 n=91
1994 n8.7
4.92
5.09
* indicates significant difference between 1991 and 1993 (P<.lo) + indicates significant difference between 1993 and 1994 (P
needs in four areas: improved communications, more participatory decision making, increased staffing, and improved facilities. The Healthy Hospital program was designed to address the first two areas; concerns in the other two areas were referred to the appropriate body in the hospital. During the second round after the project had been functioning for about a year and a half postlaunch, improved communications FALL 1997, VOL. 10, NO. 3
and decision making continued to be priorities, but there was also recognition of and appreciation for the positive accomplishments of Healthy Hospital. Balancing the survey results showing Healthy Hospital impacts, the focus groups suggested moderate progress. While there was awareness of the program and its aims, and broad agreement that progress had been made, a common perception remained that the development of a culture of participatory decision making still had a good ways to go. Of particular significance is the general perception that the highest levels of management had not visibly bought in enough to the participatory decision-making culture.
Discussion
The Healthy Hospital program provides the first Canadian data demonstrating the feasibility of producing a planning culture change toward 5.54 5.81 greater participatory decision making. The data confirm that such culture changes tend to 5.37 5.33 decrease job stress while increasing job satis5.17 5.18 faction and work self-esteem. This demonstration is remarkable, given the organic nature of 6.34 6.18 the culture change methodology: by seeding culture change with a strong union-manage4.52 4.28 ment steering committee, a clear vision and a limited number of staff-driven pilot projects, pervasive shifts were seen across representative samples of employees, despite the fact that the vast majority had not been directly involved in any of the more intensive committee and project work of Healthy Hospital. Reflection on the degree of change across the battery of measures suggests an interesting corollary: there seems to be a dose-response relationship. BCNU showed the greatest amount of change, and excluded staff the least, with HEU and HSA intermediate. This corresponds to the degree to which the different staff groups overall took advantage of the opportunity for Healthy Hospital-funded projects. This tendency was probably influenced by concurrent changes in the hospital: a new Vice-President Nursing was moving her staff toward participatory governanceat the same time that Healthy Hospital was developing. Additional data support the inference that it was Healthy Hospital and not other factors that produced change. For example, on average, 50 to 80 percent of staff across the four groups reported on the 1994 survey that they believed Healthy Hospital was making St. Paul's a better place to work (the 80 percent represented BCNU members). Respondents consistently reported increases in control over decision making, and there was a trend toward perceptions of better change management throughout the hospital. Steering committee members were under no illusions that they had achieved substantial and lasting culture change. Both quantitative and qualitative data suggest modest gains, and the limited beginnings of the culture change that can realistically be
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expected in the relatively short time frame of two years. Indeed, the qualitative data suggested disquieting trends toward relapse as the demonstration project drew to a close. For example, interviewees noted turnover in steering committee membership and a renewed tendency to let managers take the initiative on plans for transition to the postproject period. They were well aware that some positive initiatives were bogging down because of the lack of support from increasingly beleaguered middle managers. The final year of the project was greatly strained by the provincial government’s announcement of significant budget cuts - it was difficult to commit funds to the continuation and institutionalization of project work, although a full-time coordinator position was funded. The steering committee members themselves who surprisingly were generally not among the change leaders in the hospital - were experiencing palpable burnout with their program involvement, and there was a growing need for membership renewal. Large-scale organizational change has become common place in recent years, and the basic “how to’s” are becoming clear, whatever the challenge: total quality management, re-engineering, right sizing or culture change. KotteS9 recently listed the following eight key steps: establishing a sense of urgency; forming a powerful guiding coalition; creating a vision; communicatingthe vision; empowering others to act on the vision; planning for and creating short-term wins; consolidating improvements and producing still more change; and institutionalizingnew approaches. With the benefit of hindsight, it seems that Healthy Hospital followed the first six steps in almost classic fashion, and succeeded accordingly. As the project moved into its final year, it started to sputter, and there was too little time, energy and sustained leadership to succeed in the final two steps. Looking back over the three-year project, we conclude that the Healthy Hospital project did not achieve enduring culture change. The project did not have the wherewithal to “go the distance” and build on early gains. As rewarding as they were, improved relationships within the steering committee itself did not produce large enough ripple effects in everyday supervisor-staff relationships. The project initially produced widespread hope throughout the hospital, but without systemic changes in the way power is shared throughout the organization, the initial promise of participatory decision making eventually withered on the vine. The challenges of sustainability for demonstration projects are well known. But being forewarned was not sufficient. Specific objectives to build for sustainability could have been built in from the beginning, to avoid difficulties encountered with Kotter’s steps seven and eight. With the benefit of hindsight, it is clear that a deeper, more consistent understanding and application of participatory decision making - by both union and management leadership was needed to bridge from demonstration project to healthy organization.20Healthy Hospital could serve as a catalyst, but could not continue to nurture culture change by itself. A better
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understanding of this reality from the beginning, and closer integration between the Healthy Hospital project and overall hospital operations, might have ensured consolidation and institutionalization of new appro ache^.^' In summary, this demonstration project represents a modest beginning in the search for innovative management strategies that will assist hospitals to cope with the revolutionary changes of the 1990s. The data suggest moderate but consistent changes during the first two years of the project. Qualitative data provide a number of critical success factors to incorporate into future programs designed to produce changes in decision-making culture. It is painfully clear that even higher levels of commitment and effort were needed to translate early wins into enduring culture change.
Acknowledgments This project was supported by the British Columbia Ministry of Health’s Advisory Committee on Nursing, with matching fimds from Human Resource Development Canada’s Industrial Adjustment Service program. Their financial contributions and steadfast interest are gratefully acknowledged. Projects like this provide a stage for so many heroines and heroes that they cannot all be recognized by name. We particularly thank the steering committee members and ambassadors who gave unstintingly of their time, passion, patience and creativity, in a sincere commitment to finding better ways for labour and management to collaborate. Both union and management leaders provided ongoing support through the project: the partnership of the Local executives of the BCNU, HEU and HSA is sincerely appreciated. Finally, we want to thank the scores of staff who enthusiastically involved themselves in the specific Healthy Hospital projects that breathed life into the Healthy Hospital vision. @
References and Notes 1. Best JA., Burke BE, Walsh RG, Mulchey RD.Healthy Hospital: a demonstration project to improve nursing worklife. Dimensions in Health Services 1991;68(4):27-29.
2. Villeneuve M et al. Research in progress: Worklife concerns of Ontario nurses. Review: Quarterly Newsletter of the Quality of Nursing Work life Unit 1993;3(4):1-2. 3. Canadian Nurses AssociationKanadian Healthcare Association. Nurse retention and quality of life: a national perspective. Ottawa: The Associations; 1990. 4.Frisina A, Murray MA, Aird C. What do nurses want?: a review of job satisfaction and job turnover literature. Toronto: Hospital Council of Metropolitan Toronto; 1998.
5. Kramer M. The magnet hospitals: excellence revisited. Journal of Nursing Administration 1990;20(9):35-44. 6. Kramer M, Schmalenberg C. Magnet hospitals: part I - institutions of excellence. Journal of Nursing Administration 1988a;18(1):13-24. 7. Kramer M, Schmalenberg C. Magnet hospitals: part I1 - institutions of excellence. Journal of Nursing Administration 1988c;18(2):13-19. 8. Murray MA, Smith SD. Nursing morale in Toronto: an analysis of career, job, and hospital satisfaction among hospital staff nurses. Toronto: Hospital Council of Metropolitan Toronto; 1988. 9. Antonovsky A. Health, stress, and coping. San Francisco: Jossey-Bass; 1979.
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10. Karasek R,'Theorell T. Healthy work stress, productivity, and the reconstruction of working life. New York Basic Books; 1990. 11. Israel B. Social networks and social support: implications for natural helper and community level interventions. Health Education Quarterly 1985;12:66-80. 12. Peters TJ, Waterman RH Jr. In search of excellence. New York: Harper & Row; 1982. 13. Cohen S, Syme S, editors. Social support and health. Orlando (FL): Academic; 1985. 14. Minkler M. Improving health through community organization. In: Glantz K, Lewis FM, Rimer BK, editors. Health behavior and health education: theory, research, and practice. San Francisco: Jossey-Bass; 1990. 15. Wallerstein N, Bernstein E. Empowerment education: Freire's ideas adapted to health education. Health Education Quarterly 1988;15:379394. 16. Glass Ceiling Commission. Good for business: making full use of the nation's human capital. Washington (DC): U.S. Government Printing Office; 1995. 17. Hemingway MA, Smith CS. Organizational climate, occupational stressors, and withdrawal behavior in nurses. Paper presented at Work, Stress, and Health '95: Creating Healthier Workplaces Conference; September 14-16; Washington, D.C. 18. Landy F, Quick JC, Kasl S. Work, stress, and well-being. International Journal of Stress Management 1994; 1:33-73. 19. MacLennan BW. Stressor reduction: an organizational alternative to individual stress management. In: Quick JC, Murphy LR, Hun-ell JJ, editors. Stress and well-being at work. Washington (DC): American Psychological Association; 1992. 20. Rosen R, Flower J. The leaner, healthier company. Healthcare Forum Journal 1992 May-June. 2 1. Michela JL, Lukaszewski MP, Allegrante JP. Organizational climate and work stress: a general framework applied to inner-city schools. In: Sauter SL, Murphy LR, editors. Organizational risk factors for job stress. Washington (DC): American Psychological Association; 1995. 22. Hospital Employees Union members include housekeeping, licensed practical nurses, biomedical electronics technicians, dietary and clerical workers, open heart perfusionists, etc. Health Services Association members include social work, physio and occupational therapy, dietitians, X-ray and medical laboratory technologists, etc.
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27. Note that the scales have various ranges, so means of scales and subscales are not all directly comparable. Some are based on four-point scale items, some on five-point scales and some on seven-point scales. The Job Stress subscale scores range from 1 (Strongly Disagree) to 4 (Strongly Agree), with higher scores meaning greater job control and personal support, but also greater job demand and hazard; the midpoint is 3. The Job Satisfaction subscale scores range from 1 (Very Dissatisfied) to 5 (Very Satisfied), with higher scores meaning greater satisfaction; the midpoint is 3. The Organizational Climate subscale scores range from a minimum of 1 (Poor) to a maximum of 9 (Excellent), with higher scores being positive; the midpoint is 5 . The Organization-Based Self-Esteem (OBSE) scores range from 1 (Strongly Disagree) to 7 (Strongly Agree), with higher scores meaning greater self-esteem; the midpoint is 4. The midpoints can be used as an indicator of positive or negative attitudes about job stress, job satisfaction, organizational climate, and work self-esteem. Means above the midpoints are positive, means below the midpoints are negative. 28. Centre for Labour and Management Studies. Organizational practices and the changing employment relationship. Proceedings of the Canadian Workplace Research NetworkKentre for Labour and Management Studies Inaugural Conference; 1996 Oct 18-19; Vancouver. In press. 29. Kotter JP.Leading change: why transformation efforts fail. Harvard Business Review 1995 March-April; 59-67. J. Allan Best, PhD, is Principal, the Organization Development Group. He is also Clinical Professor, Department of Health Care and Epidemiology, and Associate, Institute of Health Promotion Research, University of British Columbia. George Walsh, MBA, was Vice President, St. Paul's Hospital, at the time of this project and is now retired. Fred Muzin, BSc, was Chairperson, St. Paul's Local Hospital Employees' Union during this project and is now President, B. C. Hospital Employees' Union. Jonathan Berkowitz, PhD, is Principal, Berkowik & Associates Consulting Inc.; and Adjunct Professor, Faculty of Commerce and Business Administration, Clinical Assistant Professor, Department of Family Practice, University of British Columbia as well as Associate, Institute of Health Promotion Research.
23. O'Brien-Pallas L, Baumann A. Quality of nursing work life issues - a unifying framework. Canadian Journal of Nursing Administration
1992;5:12-16. 24. Mueller CW, McCloskey JC. Nurses' job satisfaction: a proposed measure. Nursing Research 1990;39:113-117. 25. Moos RH. Work environment scale manual. 2nd ed. Palo Alto: Consulting Psychology Press; 1981. 26. Pierce JL, Gardner DG, Cummings LL, Dunham RB. Organization-based self-esteem: construct definition, measurement, and validation. Academy of Management Journal 1989;32(3):622-648.
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