Quality Of Care a study

Alexander, JW and Bauerschmidt, AD (1987). Implications for nurse administrators of the relationship of technology and structure to quality of care. Nursing Administration Quarterly, 11, (4), 1-10.

Summary

The purpose of this study was to investigate the fit between technology and structure of nursing units and the quality of nursing care delivered on the units. Three propositions were tested:

1. Nursing units with non-routine technology produce higher quality nursing care if the structure for the delivery of care is organic.
2. Nursing units with routine technology produce higher quality nursing care if the structure for the delivery of care is mechanistic.
3. Nursing units with intermediate technology produce the same quality of care irrespective of the structure for delivery of care.

The researchers found no support for these propositions. They concluded that perhaps technology and structure interact differently on nursing units than they do in other organizations.

Data was collected on 34 nursing units in 3 general hospitals. Hospital and unit sample selection techniques were not discussed. Nursing personnel were selected randomly on a proportionate basis to represent unit staff. Patients were randomly selected from each unit.

Technology and structure were measured by Likert scales. Quality of care was measured by gathering data from patient records, patient interviews, staff interviews, and observation on the unit.

Data analysis was done by calculating variables that were the absolute values of the differences between technology and structural scores. The technique assumes that for each of the three hypothesized dimensions of technology there is a “best” match with a structural type. Regression analysis using the three most significant differences explained 52% of the variability in the model.

Strengths and Weaknesses Regarding Scientific Merit

The relationship between technology, structure, and quality of nursing care is an important and interesting question for the practice of nursing. There are several problems with this study, however, that stem from the conceptual model and study design.

On a conceptual level, the authors chose a model that uses a mechanistic-organic continuum to describe unit organizations. The mechanistic model was originally developed in highly standardized work situations such as factory production lines and fast food outlets. It is a fallacy to equate even the most “routine” of nursing units to a production line. The work accomplished on any of the nursing units that were studied requires tremendous amounts of priority setting, independent judgement, and varied skills, none of which fits a “mechanistic” model of work.

Secondly, the mechanistic and organic models are rather older models of organization that have received a great deal of criticism in sociological literature for ignoring the influence of environmental factors (Morgan, 1986; Scott, 1987). It is highly probable that environmental factors such as the nature of the work setting and the patients themselves could be intervening variables in this model.

Instruments are also problematic in this study. The instrument that measured structure had low reliability scores on both the original reliability studies and in this study, which calls validity into question.

Several possible sources of bias were evident in the sampling techniques and not addressed in this article. It is difficult to know what bias may have been present in the original selection of units since this is not addressed, but selection of patients was through permission of head nurses could introduce some bias into the findings. Some units had only one staff nurse as a respondent. All units had the head nurse as an informant, so some units would have had a 50% administrative response to the questionnaire.

Finally, the data analysis was able to explain only 52% of the variability, despite dropping some of the variables to achieve a better fit to the model.

Strengths and Weaknesses for Clinical Applicability

The researchers suggest that nurse administrators develop nursing units around these technical and structural parameters without having much support from their research, and the recommendations are in general too strong for the findings of this study.

Nursing is a complex activity requiring many decisions and actions on the part of the nurse. The authors state that units with more technological uncertainty (defined as the degree to which patients are understood by the staff) should employ “more rules and regulations”. As rules and procedures cannot encompass all of the possible situations, it seems more sensible to place an emphasis on problem-solving techniques.

Implementation of findings should be done only after research with reliable and valid instruments has shown that manipulation of these parameters genuinely results in better quality of care for patients.

Key Words

Hospital Unit Structure, Technology, Structure, Nursing Activities, Quality of Care, Research.