Clinical and organizational impact of multiple changes in critical care: a case study
Mitchell, Pamela Holsclaw, 1940-
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This research evaluated the impact of a natural cluster of change in one community hospital division on clinical and organizational performance of the hospital's critical care units. The divisional changes were comprised of multiple changes in physical facilities of the critical care units, technology and divisional leadership. Their combined impact was evaluated by comparing post change data to an existing database of nurse and physician perceptions of the critical care units and of patient care outcomes. Variables of interest included selected indices of critical care unit clinical performance (mortality and patient satisfaction with nursing care) and critical care unit organizational performance (nursing retention, nurse and physician ratings of unit effectiveness, patient length of stay, and nurse perceptions of the work environment and beliefs about role in patient welfare). These effects were interpreted from differing theoretical points of view: the system-structural viewpoint that emphasizes the value of formal structure in stabilizing organizations during change, and the strategic choice perspective that emphasizes the social creation of meaning surrounding organizational events. Data were obtained through paper and pencil surveys, interviews, participant observation, and medical records, with data collected in 1986-87 compared to those obtained in 1990.Because the first line nursing managers remained constant, the system-structural perspective predicted that the multiple divisional changes would have no effect on clinical and organizational performance. These hypotheses were supported in that patient mortality ratio remained below 60 percent of predicted; patient satisfaction with nursing care remained high; nursing retention did not drop significantly; nursing satisfaction did not change significantly. Patient length of stay did decrease significantly, which is consistent with improved efficiency of unit functioning.There was also support for the hypotheses derived from the strategic choice perspective. This view, as expressed in the concept of constructed organizational meaning, posits that unit-level attributes, such as beliefs and values will change to the extent that environmental changes induce differences in the meaning that staff assign to these changes. Unit nurses' aggregate ratings of beliefs about the meaning and importance of their work did not change over time, despite the influx of a large number of new staff nurses. Interviews suggested that staff devoted considerable energy to maintaining the values of high standards of patient care, hard work and of being part of a professional team. The data affirm the importance of individual actors in mediating change, but within a context of stable organizational structures.