February 1999 | EPI Study
The Changing Nature of Nursing in Hospitals
by Gil Preuss
This study focuses on a health care industry in the midst of transition. Although we look specifically at hospitals in the Minneapolis/St. Paul area, this study’s findings are pertinent to all health care organizations that seek to provide high-quality, low-cost care in today’s rapidly evolving, competitive environment. This increased competition is forcing hospitals to respond in various ways – some are closing, some are merging, and others are building integrated delivery networks. A companion report to this study, entitled Committing to Care, examines how labor-management relations both shape the work practices adopted by hospitals and affect their financial performance. This study, though, focuses on the development of new staffing and work organization practices that are a central component of recent restructuring aimed at greater cost effectiveness. Although the existing research suggests that changes in hospital work organization can have important consequences for all parties, the hospital administrators making these decisions currently have few theoretical or practical models available to guide them in understanding how different practices affect the quality of patient care.
For some time now, mounting economic pressures have made it more difficult for hospital administrators to balance the seemingly competing priorities of cost and quality. The ease of measuring information about costs relative to the complexity of measuring patient care quality makes the process even more challenging and may result in choices ultimately detrimental to the quality of care. Given these risks and the difficult nature of measuring care quality, this study strives for a better understanding of the role work organization on the nursing unit level plays in shaping costs and care quality.
In light of a recent report by the Institute of Medicine (1996) that found hospitals to be in the process of changing the job responsibilities of registered nurses (RNs) and nursing assistants, this report focuses explicitly on RNs and nursing assistants, although nursing units comprise other workers as well (e.g., licensed practical nurses). The data for this study come primarily from nearly 1,000 surveys of nursing unit employees working at 16 Minneapolis/St. Paul hospitals. This study’s analysis of that data shows that work organization and skill availability on nursing units have important ramifications for the patient care process and the quality of patient care.
One important finding is that the recent trend of broadening nursing assistants’ responsibilities over tasks based on routine knowledge (e.g., taking blood, measuring pulse rates, etc.) has the effect of decreasing the quality of information available for decision making on the unit. The skill level of the person conducting these tasks is critical to the quality of information accumulated and available for decision making. Information is lost as tasks become simple routines rather than opportunities to gather critical information about a patient’s condition. Compared to units where nursing assistants are responsible only for a few tasks (such as transporting, feeding, and bathing patients, etc.), units with more extensive nursing assistant job responsibilities exhibit slightly lower information quality. This small decline in information quality is more than offset, however, when RNs share responsibility for these common nursing assistant tasks. In such cases, the information quality on the unit actually improves. Most of the degradation in information quality occurs when nursing assistant jobs expand to include tasks such as conducting sterile procedures. In turn, lower information quality on nursing units is linked with a higher perceived frequency of medication errors (as reported by RNs) and lower nursing care quality as perceived by patients. There is no direct relationship, however, between a broader job definition for nursing assistants and the perceived frequency of medication errors on the hospital units.
In contrast, maintaining joint responsibility and overlapping the tasks of both registered nurses and nursing assistants for each patient improves the quality of available information and reduces the perceived frequency of medication errors. Moreover, employing care providers with higher formal skills and developing systems to improve informal skills for both RNs and nursing assistants significantly improves outcomes within hospitals.
This report, together with broader research on high-performance work systems, suggests that any successful model of work organization in hospitals must meet three objectives: enable decision makers to cultivate high-quality information, enhance cost effectiveness, and improve patient care by creating an environment that promotes continued learning for nursing staffs. We recommend four practices for meeting these objectives:
- Broaden the definition of RN jobs to include both routine and managerial tasks;
- Overlap job responsibilities across care providers to build communication and information quality;
- Use “clinical pathways” to improve the quality of patient care;
- Create and promote opportunities for continuous learning for all employee groups.