ILR Review

The authors estimate the impact of nurse unions on health care quality using patient-discharge data and the universe of hospital unionization in California between 1996 and 2005. They find that hospitals with a successful union election outperform hospitals with a failed election in 12 of 13 potentially nurse-sensitive patient outcomes. Hospitals were more likely to have a unionization attempt if they were of declining quality, as measured by patient outcomes. When such differential trends are accounted for, unionized hospitals also outperform hospitals without any union election in the same 12 of 13 outcome measures. Consistent with a causal impact, the largest changes occur precisely in the year of unionization. The biggest improvements are found in the incidence of metabolic derangement, pulmonary failure, and central nervous system disorders such as depression and delusion, in which the estimated changes are between 15% and 60% of the mean incidence for those measures.

The authors investigate whether electronic medical record (EMR) systems are associated with higher levels of nursing home performance. Their difference-in-differences analysis is based on a survey of health care information technology (HIT) use in approximately 304 New York State nursing homes, combined with regulatory data from the Center for Medicaid and Medicare Studies (CMS) Nursing Home Compare database and the New York State RHCF-4 financial reports. For nursing home owners, the authors find a positive effect of EMR-system implementation, on the order of 1% higher productivity, 3% greater efficiency, but approximately 2.7% higher cost. They also find that EMR systems amplify the returns to modern workplace organization. Facilities that are one standard deviation higher on a work-organization scale—composed of practices that encourage employee collaboration, decision making, suggestions, and problem solving—have no adverse cost impact of adoption of HIT, and adoption of HIT is associated with a productivity increase of 1.5% or more. They find no evidence of an impact on health care quality.

The authors use a mixed-methods approach to investigate how the integration of electronic health records between ambulatory and hospital practices affected physician productivity and birth outcomes at a large health network. Physicians and staff were interviewed during a five-year staged integration of electronic health records, and a direct measure of physician productivity, relative value units, was analyzed concurrently with several measures of birth outcomes. The regression analyses show an 11% reduction in total productivity following the installation of the new system at primary-care sites. The qualitative findings indicate the reduction is attributable to the additional time physicians and staff needed to learn new processes, adopt work practice changes, and develop coordination. Nevertheless, users value the additional integration, especially as information flows back to the ambulatory practices from the hospital. This is supported by increases in treatment intensity over time and a 37% reduction in the severity of adverse birth events.

In this article, the authors evaluate the role of the nurse staffing mix on hospital patient satisfaction. Using three years (2009 to 2011) of hospital patient satisfaction data linked to data on the productive staffing hours of registered nurses (RNs), licensed vocational nurses, nurse’s aides, and contract nurses for 311 California hospitals, the authors analyze how nurse staffing levels affect 10 dimensions of patient satisfaction. The findings indicate that a higher level of RNs per bed appears to increase overall patient satisfaction. Conversely, hospitals with a higher proportion of nursing hours provided by contract nurses have significantly lower levels of patient satisfaction on scores related to overall patient satisfaction and nurses’ communication with the patient. The results have implications for RN staffing strategies and inform the broader literature on worker-skill mix and employment arrangements.

Hospitals are increasingly looking to new work practices and processes to reduce the epidemic of medical errors. The authors examine one such innovative approach emulating high-reliability organizations (e.g., nuclear power plants) that use a combination of specific work practices and behavioral processes to detect and adapt to unexpected events to operate in a nearly error-free manner. They explore whether and how reliability-enhancing work practices (REWPs) help enable such processes and improve performance (i.e., reduce errors). Using survey and archival data from 1,685 registered nurses and 95 nurse managers in 95 hospital nursing units, the authors examine how REWPs affect a set of attitudinal (affective commitment and organizational citizenship behavior) and discursive (respectful interaction and mindful organizing) processes and, in turn, patient safety. They find the greater use of REWPs are directly and indirectly (through respectful interaction and mindful organizing) associated with fewer medication errors and patient falls. In contrast, organizational citizenship behavior was associated with more medication errors and patient falls.

Health care workers are employed in a complex, stressful, and sometimes hazardous work environment. Studies of the health of health care workers tend to focus on estimating the effects of short-term health outcomes on employee attitudes and performance, which are easier to observe than long-term health outcomes. Research has paid only scant attention to work characteristics that are controlled by the employer and its employees, and their relationship to employees’ long-term physical health and organizational outcomes. The authors use data from the National Longitudinal Survey of Youth (NLSY) from 1992 to 2010 to estimate the relationships among working time, long-term physical health, job satisfaction, and turnover among health care employees. Using a between- and within-person design, they estimate how within-person changes in work characteristics affect the within-person growth trajectory of body mass index (BMI) over time and the relationship between working-time changes and physical health, and occupational turnover. The study finds that health care employees who work more hours suffer from a higher level of BMI and are more likely to leave their occupation.

Although work schedulers serve an organizational role influencing decisions about balancing conflicting stakeholder interests over schedules and staffing, scheduling has primarily been described as an objective activity or individual job characteristic. The authors use the lens of job crafting to examine how schedulers in 26 health care facilities enact their roles as they “fill holes” to schedule workers. Qualitative analysis of interview data suggests that schedulers expand their formal scope and influence to meet their interpretations of how to manage stakeholders (employers, workers, and patients). The authors analyze variations in the extent of job crafting (cognitive, physical, relational) to broaden role repertoires. They find evidence that some schedulers engage in rule-bound interpretation to avoid role expansion. They also identify four types of schedulers: enforcers, patient-focused schedulers, employee-focused schedulers, and balancers. The article adds to the job-crafting literature by showing that job crafting is conducted not only to create meaningful work but also to manage conflicting demands and to mediate among the competing labor interests of workers, clients, and employers.

Based on case studies in 12 nursing homes in the United Kingdom, the authors illustrate how financial cutbacks affect job quality and the quality of care. The dimensions of job quality that suffered most were those directly related to the ability of workers to provide care: reductions in staffing, longer working hours, and work intensification. Cuts to labor costs eroded the quality of workers’ jobs in all 12 homes but with two differential outcomes: in seven homes, care quality was maintained, and in five homes, it deteriorated. Care quality was maintained in homes where a patient-centered care approach and remaining job quality allowed workers to develop work-arounds to protect residents from spillover effects. Care quality declined in homes where custodial approaches to care and low job quality did not provide workers the time or resources to protect residents or to maintain prior levels of care. A tipping point was reached, leading to a spillover into impoverished care.