Elizabeth West

A Time to Grow and a Time to Die: Growth and Mortality of Credit Unions in New York City, 1914–1990

One vision of organizational evolution suggests that old and large organizations become increasingly dominant over their environment. A second suggests that as organizations age they become less able to respond to new challenges. In this article the authors investigate which of these visions best characterizes the evolution of state-chartered credit unions in New York City from 1914 through 1990 by analyzing the effects of organizational age, size, and population density on rates of organizational failure and growth. The authors find evidence that old and small institutions are more likely to fail, while young and small organizations have the highest growth rates.

Hierarchies and cliques in the social networks of health care professionals: implications for the design of dissemination strategies

Interest in how best to influence the behaviour of clinicians in the interests of both clinical and cost effectiveness has rekindled concern with the social networks of health care professionals. Ever since the seminal work of Coleman et al. [Coleman, J.S., Katz, E., Menzel, H., 1966. Medical Innovation: A Diffusion Study. Bobbs-Merrill, Indianapolis.], networks have been seen as important in the process by which clinicians adopt (or fail to adopt) new innovations in clinical practice. Yet very little is actually known about the social networks of clinicians in modern health care settings. This paper describes the professional social networks of two groups of health care professionals, clinical directors of medicine and directors of nursing, in hospitals in England. We focus on network density, centrality and centralisation because these characteristics have been linked to access to information, social influence and social control processes. The results show that directors of nursing are more central to their networks than clinical directors of medicine and that their networks are more hierarchical. Clinical directors of medicine tend to be embedded in much more densely connected networks which we describe as cliques. The hypotheses that the networks of directors of nursing are better adapted to gathering and disseminating information than clinical directors of medicine, but that the latter could be more potent instruments for changing, or resisting changes, in clinical behaviour, follow from a number of sociological theories. We conclude that professional socialisation and structural location are important determinants of social networks and that these factors could usefully be considered in the design of strategies to inform and influence clinicians.

Management matters: the link between hospital organisation and quality of patient care

Some hospital trusts and health authorities consistently outperform others on different dimensions of performance. Why? There is some evidence that “management matters”, as well as the combined efforts of individual clinicians and teams. However, studies that have been conducted on the link between the organisation and management of services and quality of patient care can be criticised both theoretically and methodologically. A larger, and arguably more rigorous, body of work exists on the performance of firms in the private sector, often conducted within the disciplines of organisational behaviour or human resource management. Studies in these traditions have focused on the effects of decentralisation, participation, innovative work practices, and “complementarities” on outcome variables such as job satisfaction and performance. The aim of this paper is to identify a number of reviews and research traditions that might bring new ideas into future work on the determinants of hospital performance. Ideally, future research should be more theoretically informed and should use longitudinal rather than cross sectional research designs. The use of statistical methods such as multilevel modelling, which allow for the inclusion of variables at different levels of analysis, would enable estimation of the separate contribution that structure and process make to hospital outcomes.

School Desegregation, Interracial Exposure, and Antibusing Activity in Contemporary Urban America

Prior research emphasized either resource mobilization or grievance explanations of antibusing activity. This article argues that both explanations imply that racial competition generated collective action against busing. It suggests that increases in interracial exposure in schools and neighborhoods trigger racial and ethnic conflict. This article examines these competition arguments using data on antibusing events, school desegration, and interracial residential exposure in SMSAs from 1968 through 1990. The results suggest that the amount of school desegregation significantly raised rates of protests against busing. Furthermore, there is little evidence that the federal origin of court-ordered busing increased antibusing activity.

Organisational sources of safety and danger: sociological contributions to the study of adverse events

Organisational sociology has long accepted that mistakes of all kinds are a common, even normal, part of work. Medical work may be particularly prone to error because of its complexity and technological sophistication. The results can be tragic for individuals and families. This paper describes four intrinsic characteristics of organisations that are relevant to the level of risk and danger in healthcare settings—namely, the division of labour and “structural secrecy” in complex organisations; the homophily principle and social structural barriers to communication; diffusion of responsibility and the “problem of many hands”; and environmental or other pressures leading to goal displacement when organisations take their “eyes off the ball”. The paper argues that each of these four intrinsic characteristics invokes specific mechanisms that increase danger in healthcare organisations but also offer the possibility of devising strategies and behaviours to increase patient safety. Stated as hypotheses, these ideas could be tested empirically, thus adding to the evidence on which the avoidance of adverse events in healthcare settings is based and contributing to the development of theory in this important area. (Quality in Health Care 2000;9:120–126)

Nurse staffing, medical staffing and mortality in intensive care: an observational study

OBJECTIVES To investigate whether the size of the workforce (nurses, doctors and support staff) has an impact on the survival chances of critically ill patients both in the intensive care unit (ICU) and in the hospital. BACKGROUND Investigations of intensive care outcomes suggest that some of the variation in patient survival rates might be related to staffing levels and workload, but the evidence is still equivocal. DATA Information about patients, including the outcome of care (whether the patient lived or died) came from the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme. An Audit Commission survey of ICUs conducted in 1998 gave information about staffing levels. The merged dataset had information on 65 ICUs and 38,168 patients. This is currently the best available dataset for testing the relationship between staffing and outcomes in UK ICUs. DESIGN A cross-sectional, retrospective, risk adjusted observational study. METHODS Multivariable, multilevel logistic regression. OUTCOME MEASURES ICU and in-hospital mortality. RESULTS After controlling for patient characteristics and workload we found that higher numbers of nurses per bed (odds ratio: 0.90, 95% confidence interval: [0.83, 0.97]) and higher numbers of consultants (0.85, [0.76, 0.95]) were associated with higher survival rates. Further exploration revealed that the number of nurses had the greatest impact on patients at high risk of death (0.98, [0.96, 0.99]) whereas the effect of medical staffing was unchanged across the range of patient acuity (1.00, [0.97, 1.03]). No relationship between patient outcomes and the number of support staff (administrative, clerical, technical and scientific staff) was found. Distinguishing between direct care and supernumerary nurses and restricting the analysis to patients who had been in the unit for more than 8h made little difference to the results. Separate analysis of in-unit and in-hospital survival showed that the clinical workforce in intensive care had a greater impact on ICU mortality than on hospital mortality which gives the study additional credibility. CONCLUSION This study supports claims that the availability of medical and nursing staff is associated with the survival of critically ill patients and suggests that future studies should focus on the resources of the health care team. The results emphasise the urgent need for a prospective study of staffing levels and the organisation of care in ICUs.

Facilitated patient experience feedback can improve nursing care: a pilot study for a phase III cluster randomised controlled trial

BackgroundEngland’s extensive NHS patient survey programme has not fulfilled government promises of widespread improvements in patients’ experiences, and media reports of poor nursing care in NHS hospitals are increasingly common. Impediments to the surveys’ impact on the quality of nursing care may include: the fact that they are not ward-specific, so nurses claim “that doesn’t happen on my ward”; nurses’ scepticism about the relevance of patient feedback to their practice; and lack of prompt communication of results. The surveys’ impact could be increased by: conducting ward-specific surveys; returning results to ward staff more quickly; including patients’ written comments in reports; and offering nurses an opportunity to discuss the feedback. Very few randomised trials have been conducted to test the effectiveness of patient feedback on quality improvement and there have been few, if any, published trials of ward-specific patient surveys.MethodsOver two years, postal surveys of recent inpatients were conducted at four-monthly intervals in 18 wards in two NHS Trusts in England. Wards were randomly allocated to Basic Feedback (ward-specific printed patient survey results including patients’ written comments sent to nurses by letter); Feedback Plus (in addition to printed results, ward meetings to discuss results and plan improvements) or Control (no active feedback of survey results). Patient survey responses to questions about nursing care were used to compute wards’ average Nursing Care Scores at each interval. Nurses’ reactions to the patient feedback were recorded.ResultsConducting ward-level surveys and delivering ward-specific results was feasible. Ward meetings were effective for engaging nurses and challenging scepticism and patients’ written comments stimulated interest. 4,236 (47%) patients returned questionnaires. Nursing Care Scores improved more for Feedback Plus than Basic Feedback or Control (difference between Control and Feedback Plus = 8.28 ± 7.2 (p = 0.02)).ConclusionsThis study provides preliminary evidence that facilitated patient feedback can improve patients’ experiences such that a full trial is justified. These findings suggest that merely informing nurses of patient survey results in writing does not stimulate improvements, even if results are disaggregated by ward, but the addition of ward meetings had an important and significant impact.

Nursing in the public sphere: breaching the boundary between research and policy.

Nursing in the public sphere: breaching the boundary between research and policy Nurses and nursing are associated traditionally with activities in a private sphere. This paper argues that, if clinical care is to be improved, nurses need to take a more active public role in making and implementing health policy at both local and national levels. In the current climate, empirical evidence is one of the most important tools for influencing health policy. This paper discusses contemporary models of the policy-making process before outlining a number of strategies that could be used to increase the policy impact of nursing research. Finally, while the current climate in the United Kingdom health-care arena presents opportunities for researchers to have an impact on policy, the growth of health policy research as a distinct field of scholarship also poses a number of challenges and dangers.

Is there a relationship between pain and psychological concerns related to falling in community dwelling older adults? A systematic review

Abstract Purpose: To systematically review and synthesise the research evidence linking pain to psychological concerns about falling in community dwelling older adults. Methods: A systematic review was conducted in accordance with the preferred reporting items of systematic reviews and meta-analysis statement (PRISMA). Major electronic databases were searched from inception until June 2013. Two authors independently conducted the searches, extracted data and completed methodological quality assessments. Articles were included if they measured one of the psychological concerns related to falling in a sample of community dwelling older adults with pain, or explored the association between the two. Results: Of a potential 892 articles, 12 met the eligibility criteria (n = 3398). The methodological quality of the included studies was variable and none of the included studies primary aim was to investigate the relationship between pain and psychological concerns related to falls. Two studies found significant differences in psychological concerns related to falls in older adults with pain and a control group. Nine out of 10 studies reported a significant correlation between pain and psychological concerns related to falls in their sample. Conclusion: This review provides provisional evidence that pain is associated with fear of falling (FOF), avoidance of activities due to FOF and falls efficacy in community dwelling older adults. Implications for Rehabilitation Pain is a common and pervasive problem in community dwelling older adults and can affect an individual’s mobility, levels of physical activity and increase their falls risk. Psychological concerns related to falls, such as fear of falling (FOF), falls efficacy and balance confidence are also common and troublesome issues in older adults, yet the association with pain has not been investigated with a systematic review. This review provides provisional evidence that pain may increase older adult’s risk of developing FOF, avoiding activities due to a FOF and impact their falls efficacy. In recognition of the findings of this review, clinicians working with older adults with pain should consider assessing psychological concerns related to falls and if necessary intervene if they identify an individual at risk.

Tied to the job: affective and relational components of nurse retention.

Objective To investigate whether affective and relational components of nurses’ experience of work have a significant impact on their intentions to leave either the job or the nursing profession in models that control forother factors (sociodemographic, work conditions, perceptions of quality of care) that are known to affect career decisions. Method An exploratory, cross-sectional postal survey of 2880 nurses in grades A-I in 20 National Health Service (NHS) Hospital Trusts, 11 in inner London and nine in outer London, was carried out between January and July 2002, looking at nurses’ intention to leave their current job or the nursing profession. The data were analysed using logistic regression with robust standard errors. Results In models that controlled for known sources of job dissatisfaction, relationships with supervisors and managers were found to have a significant effect on respondents’ career intentions. Feeling valued by the Trust and by society was very important. Nurses seemed to distinguish between local problems that are the responsibility of the Trust and those, such as levels of pay, that could only be solved at the national level. Conclusion Nurses’ career intentions are complex and multifactorial. Feelings of being valued and listened to play a role, as well as the individual and job-related characteristics. The study highlights the role of supervisors and managers in retaining staff and suggests that investment in robust systems of communication, conflict resolution and security could slow nurse turnover. The NHS as an employer may be most interested in the role of pay in nurse retention, and the general public in how societal attitudes and verbal abuse shape nurses’ career decisions.