Í nóvember árið 2005 var birt doktorsritgerð sem byggði á viðamikilli rannsókn á starfsumhverfi Landspítala. Rannsóknin náði til spurningalistakönnunar með þátttöku 695 hjúkrunarfræðinga og ljósmæðra og til viðbótar voru tekin rýnihópaviðtöl til að kafa nánar ofan í niðurstöður könnunarinnar.
Rannsóknarniðurstöðurnar voru bornar saman við niðurstöður sambærilegra rannsókna í fimm löndum, þ.e. Bandaríkjunum, Kanada, Þýskalandi, Skotlandi og Englandi þar sem alls staðar var byggt á sama mælitækinu sem kennt er við ,,Magnet hospital”.
Þrátt fyrir að niðurstöður hér á landi væru að mörgu leyti hagstæðar þegar þær voru bornar saman við erlendu niðurstöðurnar komu þar sem mjög greinileg viðvörunarmerki um neikvæða þróun í starfsmannamálum á Landspítala á þeim árum.
Miðað við stöðu mála hér á landi, nú tíu árum síðar, er áhugavert að líta til niðurstaðna rannsóknarinnar frá 2005. Þessar niðurstöður voru kynntar starfsfólki og stjórnendum Landspítala á sínum tíma með margsvíslegum hætti. Ritgerðin var gefin út af Rannsóknarstofnun í hjúkrunarfræði vorið 2006 (Sigrún Gunnarsdóttir, 2006) og prentuð í 200 eintökum sem dreift var m.a. til stjórnenda og starfsfólks Landspítala. Auk þess voru niðurstöður kynntar á alls konar kynningum, erindum, fyrirlestrum og með greinaskrifum.
Í lokakafla ritgerðarinnar segir m.a. (bls. 200-205):
Despite the positive results generated for working environment, job satisfaction and burnout there is some evidence of certain weaknesses in the organisation of nursing at LSH. Firstly, increasing demands on and shortage in staff with a consequent increase in nurse workload. Secondly, a widening gap between senior management and staff. Thirdly, low levels of nurse-reported excellent quality of care compared with other countries, notwithstanding the cultural and linguistic reasons for the observed difference.
These three groups of potentially weak factors contradict other findings of this study, and the proposed similarities between LSH nurses’ working environment characteristics and the traits of magnet hospitals and organisational empowerment are partial rather than
5.1 Implications for leadership practice and future research
The present research has built on the work of similar studies, but there is a growing need for further research to understand the processes involved, to assess outcomes and to illustrate the linkage between them. This is necessary in order to enhance the evidence and guide decision-making in hospital nurse management, to contribute to the growing and ever more sophisticated analysis of problems within nurse working environments, to unpick and understand the complexities of the infrastructure, and draw attention to the existing
strengths of hospitals. Similarly, it is vital to emphasize the potential for hospital nurse management to devise human resource interventions, and demonstrate that these can be delivered in the practice of successful hospital management.
The study findings are specific to Iceland, but they have relevance for the wider, international nursing community. The findings may contribute to the understanding of the changing nature of nurses’ working environment and thereby help to resolve recruitment and retention
problems. Based on the study findings, a set of proposals and key tasks to improve the management of hospital nursing are presented. Some of these proposals have already been presented to staff and management at LSH, and to the Icelandic health authorities. The feedback has been positive and some projects have been launched as a response to
challenges that have been identified in this study.
5.1.1 Adequate staffing
The findings of this study on the importance of adequate staffing levels contributes to the body of evidence on the crucial role of staffing and work demands for nurse job attitudes and nurse retention. It is reasonable to assume that if current trends in cost-containment and lower staffing levels at LSH continue, they could produce negative effects, not only for patient care, but also for nurses and thus their retention and recruitment. If leaders at LSH can secure adequate levels of staffing they can enable nurses to achieve quality care based on human relationships that inevitably take time and emotional space. This goal is vital both for nurse and patient outcomes. In light of this research and previous studies this is a priority action for health care leadership more widely. The use of multiple methods would be a useful step towards developing sophisticated measures.
5.1.2 Supportive management
It is crucial that senior management at LSH support its unit managers to enable professional and independent nurse practice. Frontline managers should encourage nurses in their perception that nursing is a job worth doing. This will help to foster job satisfaction and nurses’ ability to provide good patient care. Previous research has shown that transformational and empowering leadership behaviours are useful in this matter (Bass, 1998), and will help nurses to feel valued, to use their skills for high-quality patient care as well as encouraging them to remain in health care. In line with the present findings and the literature on magnet hospitals and organisational empowerment, there are reasons to suppose that supportive management
is of equal importance for hospitals in other countries. More evidence must however be assembled on the role of nurse management, in particular at the unit level (Andrews and Dziegielewski, 2005). The need for more research on the influence of support from nurse managers on nurse and patient outcomes is supported by a recent review of the literature (Shirey, 2004). An intervention study might be useful in this matter.
5.1.3 Intrinsic job motivation
This study indicates that nurses’ intrinsic job satisfaction is an important aspect of successful management of hospital nursing, and successful recruitment and retention strategies. Consequently, leaders in health care should balance their cost-containment interventions so
that they retain sufficient numbers of nurses who are able to enjoy intrinsic nursing values and to provide care based on human relationships. Such relationships inevitably need time and emotional space to ensure success. According to the present study it is reasonable to
recommend that nurse managers and the leadership at LSH acknowledge intrinsic nurse job satisfaction as advantageous in relation to nurse and patient outcomes. This might contribute to the solution to the current problem of nurse recruitment and retention. A further possible approach to investigate this is a qualitative study with the potential to develop a sophisticated measure of intrinsic job satisfaction. Nursing values, age and educational background are important variables for consideration in this regard (see e.g. McNeese-Smith, 2003).
5.1.4 Nurse-doctor working relationships
The current study suggests that there is a need to improve working relationships between nurses and doctors. A potential strategy is to develop further an effective collaboration between nurses and doctors and emphasise mutual respect for the professional responsibilities
of each discipline (Institute of Medicine, 2004; Rice, 2000). The content of the nurse-doctor working relationship needs further exploration to identify successful communication strategies and models of collaboration between these professions and to facilitate the development and training of professional skills. Qualitative studies using the “participant observation” technique might be appropriate. Further research is also needed to examine the importance of good
nurse-doctor working relationships for nurse job attitudes.
5.1.5 The role of senior management
The gap between staff and senior management may be a sign of some organisational weaknesses at LSH. Given this, the hospital would benefit from enhancement of trust within the organisation (Gunnarsdóttir, 2004). According to the levels of social capital in the country this would be an appropriate and appreciated goal, and consistent with local societal norms (Halman et al., 2001). Increased trust between staff and senior management would help to create effective communication channels, strengthen professional collaboration and be favourable for staff and patients (Berwick, 2003). Despite the available literature to the contrary, the influence of senior management on nurse and patient outcomes was not indicated in the present findings. Further investigation of these relationships is needed to help health care leaders organise health care services and human resources in the most productive way.
5.1.6 Nurse philosophy and professional practice
Surprisingly, the survey findings do not show that measures of philosophy of nursing practice significantly predict nurse and patient outcomes. However, the focus group findings show that for nurses it is important to build their care on professional nursing philosophy and standards. There appears to be a limited set of measures and available evidence on how to evaluate this aspect of nursing and how this is related to health care outcomes. A concept analysis in this
relation is an important research topic.
5.1.7 Future research related to the NWI-R
In light of the findings presented here and recent literature there is a need to further develop the NWI-R measure. In particular, to investigate further the validity of the NWI-R instrument and its different sub-scales in measuring the different aspects of nurses’ working environment, e.g. nurse autonomy, nurse and doctor working relationships, staffing, the underlying philosophy of nursing and the role of senior nurse management.
5.2 Summary of contributions
The findings of the present study show the relationship between nurses’ working environment and nurse and patient outcomes, and the importance of intrinsic motivation for these outcomes. This study’s major contribution to knowledge is, firstly, to re-emphasize the important role of supportive nurse managerial and leadership behaviour and opportunities at the unit level. Secondly, the findings show the importance of adequate staffing levels for good nurse outcomes, thereby maximising nurses’ opportunities to foster intrinsic job satisfaction
through their relations with patients. Thirdly, the results re-confirm the importance of structured and mutually respectful nurse-doctor working relationships for patient outcomes. Fourthly, highlighting the importance of the cultural and linguistic adaptation of the IHOS measurement when applying the instrument in a different context. Fifthly, the results largely support a framework that confirms the working environment in a distinct and in many respects unique culture and health care system. Sixthly, careful analysis of the NWI-R data generated
five empirically and conceptually acceptable sub-scales, which can be of use in further research. Seventhly, presentation of international comparison of nurse burnout levels helped to contextualise the Icelandic case. Finally, the findings of this study are noteworthy because
the observed relationships between study variables are consistent with theory and other empirical findings, and that there are fundamental differences between LSH findings and those from other countries.
5.3 The way forward
Potential solutions to the challenges of nurse recruitment and retention are undoubtedly dependent on cultural and organisational aspects as well as nurse education and the status of the profession. The overall aim remains to solve these problems with knowledge that is based on a diverse range of data utilising different methodologies across cultures and systems. Improving nurses’ working environment contributes to the well being of nurses as well as their patients and is among the most important public health interventions. Despite the crucial role of extrinsic values in hospital nursing, intrinsic nursing values and intrinsic motivation are fundamental to nurses’ quality of working life and to the quality of the care they give to their patients. The views of the nurses in the present study provide important messages that can benefit the success of hospital administration and leadership. These views correspond to these of Layard in his recent publications about happiness (Layard, 2005a; 2005b): “If we want a happier society, we should focus most on the experiences which people value for their intrinsic worth and not because other people have them – above all, on relationships in the family, at work and in the community,” (Layard, 2005b, p. 24). Health authorities and hospital administrators need to make better use of available evidence to meet major challenges in recruiting and retaining high quality staff and providing high-quality patient care. This thesis can be of use in raising health care leaders’ awareness of problems and potentials within nurses’ working environment and engage them in deciding priorities when investing in healthy nurses’ working life with the ultimate goal of health advancement for staff and patients. Communicating the evidence by reporting on the determinants of better nurse and patient outcomes is all the more important in the face of pressure to manage costs and to maintain
access to successful health services. The main conclusion of this thesis is that to ensure high-quality patient care, it is essential to support nurses to gain recognition of their work, to expand their range of responsibilities, and to enjoy healing relationships with patients and empowering collaboration with other health care team members and their superiors.
Doktorsritgerð Sigrúnar Gunnarsdóttur um starfsumhverfi Landspítala (pdf). Ritgerðin var varin við London School of Hygiene & Tropical Medicine í nóvember 2005 og gefin út af Rannsóknarstofnun í hjúkrunarfræði árið 2006.