Article discussion

The contribution of organization theory to nursing health services research Stephen S. Mick, PhD, CHE Barbara A. Mark, PhD, RN, FAAN

We review nursing and health services research on health care organizations over the period 1950 through 2004 to reveal the contribution of nursing to this field. Notwithstanding this rich tradition and the unique perspective of nursing researchers grounded in patient care production processes, the following gaps in nursing research remain: (1) the lack of theo- retical frameworks about organizational factors relating to internal work processes; (2) the need for sophisticated methodologies to guide empirical investigations; (3) the difficulty in understanding how organizations adapt models for patient care delivery in response to market forces; (4) the paucity of attention to the impact of new technologies on the organization of patient care work processes. Given nurses’ deep understanding of the in- ner workings of health care facilities, we hope to see an increasing number of research programs that tackle these deficiencies.

There is little question about the rapid expansion inresearch aimed at better understanding the organi-zation and delivery of nursing services as a mech- anism both to improve quality and patient safety, as well as to enhance working conditions for nurses. This research requires not only deep theoretical knowledge about health care organizations and their functioning, but also knowledge of critical methodologic issues that influence how the research is conducted. This knowl- edge has traditionally resided within the discipline of health services research (HSR). Yet, with more and more nurse scientists involved in such endeavors, there is a need to better understand the intersection of nursing and health services research, and particularly the orga- nizations within which nurses work. This paper pro-

vides a brief historical overview of organizational research within the history of HSR since the beginning of the 1950s, then discusses exemplars of nursing research that have incorporated various organization theories in their studies. Finally, some comments are offered regarding the need for further methodologic development to enhance the quality of nursing health services research.

HISTORICAL OVERVIEW The Internal Focus

Through much of the 1950s and into the early 1960s, social scientists doing HSR studied the hospital as a social system, which yielded richly detailed descrip- tions and analyses of the inner workings of inpatient facilities, including the role of nursing.1 Bureaucratic theory provided much of the conceptual basis for these studies, emphasizing the importance of hierarchy, au- thority, work design, power and control, communica- tion, formalization, and standardization.2 In general, the emphasis of organizational studies in HSR was on the internal operations and management of facilities,3 and nursing was a frequent subject of this focus.

A growing concern that researchers expressed was whether internal organizational forms might show some variety from a “standard” bureaucratic model and whether any of this variation might also be related to performance. This exploration, pursued by such re- searchers as Thompson4 and Woodward,5 among oth- ers, gave birth to the contingency perspective. Contin- gency theory is the focus on what the desirable “fit” might be between the technological tasks an organiza- tion performs and the organization’s structures and designs. Well into the 1980s, works like that of Mintz- berg formulated conceptually distinct organizational forms that were hypothesized to work better, or worse, given the technological tasks the organization faced.6

As promising as the internal focus was— especially for nursing research—it finally ceded the limelight to the concurrent, but ever-growing, interest in organizational environments and their impact on the organization.7

The External Focus The “external focus” had its beginnings in classical

sociological studies of hospitals that depicted them as organizations that both reflected and challenged the

Stephen S. Mick, PhD, CHE, is Arthur Graham Glasgow Professor and Chair, Department of Health Administration, Virginia Commonwealth University, Richmond, VA. Barbara A. Mark, PhD, RN, FAAN, is Sarah Frances Russell Distin- guished Professor, School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC. Reprint requests: Stephen S. Mick, PhD, CHE, Department of Health Administration, Virginia Commonwealth University, Richmond, VA 23298-0203. E-mail: [email protected]

Nurs Outlook 2005;53:317-323. 0029-6554/05/$–see front matter Copyright © 2005 Mosby, Inc. All rights reserved. doi:10.1016/j.outlook.2005.07.002

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social order of the larger society, particularly in the realm of what sociologists call stratification, the study of social differences and social classes and their effect on the provision of patient care.8 The link between the larger society’s social structure and the embedded-ness of hospitals within this matrix produced a natural seedbed for a new generation of organization theorists who, in the late 1960s, “discovered” the field of health care organizations and their environments.9,10 Major theoretical statements about the complex relationship between organizations and their environments were quickly formulated, particularly by scholars such as Lawrence and Lorsch11 and Pfeffer and Salancik.12

In HSR, the emphasis on organizations and their environments led to a burst of conceptualization, theory building, and empirical study that almost completely submerged interest and research in internal organiza- tional issues. We profited enormously from this new research, developing better typologies of organizational environments, defining salient characteristics of health care organizations, and applying increasingly available databases collected on national samples and entire populations of health care organizations. Very little primary data collection or in-depth qualitative analysis was required for this new energy, further contributing to a languishing of study of internal organizational issues in health care organizations.

Two primary forces contributed to this development. First, the rise of health economics, which occurred about the same time, reinforced this trend in HSR by emphasizing the role of markets in hospital behavior. Second, the rise of health maintenance organizations (HMOs), particularly as a function of the HMO Act of 1973, helped focus attention on how historically sepa- rate organizations— doctors’ offices and hospitals— could be merged through the conceptual lens of so- called “interorganizational” arrangements.

By the 1980s, this stream of research about organi- zations in health care was dominated by the organiza- tion/environment focus in the social sciences and by the organization/market focus in economics, at least insofar as anyone was concerned with health care organizations qua organizations. The dominant policy issue was how market forces and interorganizational arrangements might be studied and structured to produce cost savings to the entire health care system. Overall, however, for HSR this was a “dry” period in regard to research focusing on the interior of organizations. Attention was riveted on the interplay of organizations and their environments.

A Return to the Internal Focus A major exception came from nursing in a significant

effort to understand internal health care organization processes via the development of the Diagnosis Related Group (DRG) project at Yale. Although its eventual use in Medicare’s Prospective Payment System (PPS) has

obscured the original analytic effort to understand the clinical underpinnings of each separate DRG, which are composed largely of nursing care, it is no less true that the DRG system was an effort to rationalize, standard- ize, and codify the inputs to patient care at the bed- side.13 The key author of this research was John Devereaux Thompson, a nurse trained at Bellevue Hospital in New York. He always credited an earlier nurse, Florence Nightingale, for the inspiration of grouping together patients with similar diagnoses so that a more standardized and rationalized application of care processes could be the basis for improved quality and outcomes.14

The enactment in 1983 of the prospective payment system resulted, over the next 5 to 10 years, in changing patterns of care in acute care organizations that ulti- mately had an impact on HSR. The early 1990s wit- nessed dramatic changes in the operating environment for acute care hospitals as a result of the increasing dominance of managed care. Hospitals responded by implementing a range of strategies aimed at improving the efficiency of their internal operations. First, PPS forced a shift of services from the inpatient side to the ambulatory side, in both the HMO and fee-for-service sectors. Second, with nursing personnel comprising approximately 30% to 40% of overall hospital FTE personnel and approximately 30% of the hospital bud- get, hospitals also responded with re-engineering and redesign strategies that frequently involved changes in nursing staff.15,16 Together, the impact of these changes resulted in increased severity of illness for hospitalized patients who required more intensive nursing care.17 As this phenomenon wore on throughout the 1990s, abetted by the growth of managed care—particularly for-profit plans—and the impact of the Balanced Budget Act of 1997, it translated into new areas of focus for HSR: a refocusing on quality of care as concerns were raised about the effect reimbursement changes were having on hospital care. It is as if there was a “rediscovery” of the central importance of internal elements and processes of organizational life as key to understanding when an organization works well and when it does not, including when it delivers good quality of care. Furthermore, the recent patient safety phenomenon has added to our armamentarium of analytical tools and insights from work design, human factors, and organizational behav- ior and motivation research areas.

The issue of quality caught contemporary organiza- tionally-oriented HSR researchers unprepared because they had few conceptual tools to address the heart of quality concerns: the internal work processes and ar- rangements inside health care organizations. There is, therefore, surprisingly little theoretically-based organi- zational HSR work on quality that addresses the inter- nal organizational issues that contribute to variations in quality. It is our view that nursing research has most

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successfully been filling this gap in the 1990s and into the 2000s.

The work of several nurse researchers has clearly demonstrated how organization theory can advance a better understanding of internal organizational issues and how they contribute to quality of care. For example, using contingency theory, Alexander and Randolph found that nursing subunit performance was better predicted by the “fit” between technology (ie, work) and structure, than by either technology or structure alone.18 Mark and Hagenmueller also used contingency theory and found significant technological and environ- mental differences among intensive care units, suggest- ing the importance of different management structures and processes for these units.19 Mitchell and her col- leagues also found contingency theory to be useful in their study of critical care outcomes.20

As for studies that more directly assess the organi- zational features surrounding patient care, nursing re- searchers have made remarkable inroads. More re- cently, the work of Mark, Salyer, and Wan, which found that professional nursing practice (eg, decentral- ization of clinical decision making, enhanced auton- omy, collaborative relationships with physicians), al- though having strong positive effects on nurse satisfaction, actually had only limited impact on other outcomes such as medication errors.21 Aiken’s work on “magnet status” also suggests important organizational features to support patient care. For example, Vahey, Aiken, and associates confirmed the hypothesis that nurse-reported adequate staffing levels, positive admin- istrative support, and good relations with physicians led to higher patient satisfaction and lower nurse burnout.22

Similar results were found in English-speaking cross- national studies.23 In nursing homes, organizational characteristics like for-profit status, large size, and high occupancy rates are correlated with low staffing levels and more quality problems.24,25 Poor hospital climates, or work environments, have been found to be correlated with poor quality and lower patient safety levels.26,27

Restructuring and re-engineering of hospital services have also come under scrutiny.28 These are examples of the kind of research by nurses that attempt to better understand the internal characteristics of health care organizations and how they contribute to quality of patient care.

Another aspect of this work builds on time-motion and “human engineering” studies that have been part of the nursing research realm for some time. Potter and colleagues’ application of graphic techniques to study nursing work is an exciting example of micro-level research that seeks to explain the complexity of nursing work,29 work that involves much feedback and interac- tion and that is not easily captured through traditional industrial engineering and industrial quality control theorizing. By examining so-called “cognitive path- ways,” the complex decision-making nature of nursing

is revealed. Without acknowledging it explicitly, these nursing researchers are joining with a few other health care organizational analysts in the application of net- work theory to health care work.30,31 The difference is that the nursing researchers are applying it to the internal organization, whereas the non-nursing re- searchers are using it in the interorganizational realm.

There is obviously much more to be done as both the theoretical frameworks and the methodologies become increasingly complex. But the point is that it is the exploration of work structures and processes at the nursing unit level that is contributing to the lion’s share of advancing knowledge about what does and does not have an impact on patient and organizational outcomes.

IMPROVING METHODOLOGICAL RIGOR As stated earlier in this paper, not only is there a need for understanding the roots of health services research and how it intersects with contemporary nursing re- search, there is also a compelling need to improve the methodological sophistication of the research. We iden- tify 4 gaps that need to be addressed if nursing health services research is to succeed in reaching its potential for improving health care quality. The first gap relates to the lack of cogent theoretical frameworks that fully and accurately reflect the complexity of both nursing work and patient outcomes and quality of care. This relates to identification of the second gap—the need for increasingly sophisticated research methodologies. The third gap is tackling the difficult topic of studying the processes of research translation and adaptation, partic- ularly in so far as understanding how health care organizations adapt models for the delivery of patient care in response to market forces that demand higher levels of effectiveness and efficiency. The final gap is the relative lack of attention paid to the impact of new technologies, including electronic communications, on the organization of work processes of patient care.

Need for Theoretical Development Notwithstanding the great strides made, there remain

gaps in our understanding of how organizational fea- tures of health care organizations of all types relate to nursing work and patient care. The current research emphasis on the relationship between nurse staffing and quality and patient safety serves as an example of critically important research that could be substantially improved by strong theoretical frameworks. Nurse staffing has been linked to numerous patient outcomes, both at the unit level and at the hospital level. For example, Blegen, Goode, and Reed found RN hours of care inversely related to unit level rates of medication errors, decubitus ulcers, and patient complaints.32 At the hospital level, several studies relying on the analysis of large secondary databases have examined the rela-

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tionship between nurse staffing and a variety of out- comes.33-36

Although the results of this research have general- ly—although not entirely consistently—found a bene- ficial effect of nurse staffing on relevant outcomes, the lack of a unifying theory that explains how nurse staffing affects outcomes limits the use of these findings in practice. For example, given hospital financial con- straints and the widespread nursing shortage, “simply” hiring more nurses is not a feasible strategy for most nurses. Further, despite mandated minimum nurse staff- ing ratios in California, there is no theoretically-based research that is informative on the issue of “optimal” nurse staffing levels. Such findings await the develop- ment of clear theoretical developments that can better inform the development, conduct, and interpretation of this research.

Recent work has also applied theoretical frameworks to illuminate the work that occurs in health care organizations. Scott, for example, presented a useful contrast among so-called “mindless systems” (or a mechanistic view of organizations), “uniminded sys- tems” (a biological view) and “multiminded systems” (a view that is sociocultural).37 The mindless system is a different way of depicting the classical mechanistic form of organizations in which they become and stay the instruments of their controllers, with an emphasis on efficiency and usually, but not always, profit maximi- zation. The uniminded system emphasizes that the principal goal of an organization is simply to survive. Organizational responses to environmental changes are generally those that attempt to improve chances that the organization does not die, much like a Darwinian survival of the fittest perspective. The multiminded system emphasizes the organization of free-willed peo- ple who come together to enact explicit choices about goals, reflective of the sociocultural values of the larger environment. This multiminded approach third view offers boundless possibilities for the deliberate alter- ation of organizational action that surpasses more prim- itive organizational impulse, eg, simply to survive.

Beyond specific examples like that of Scott above, we note that two overarching schools of thought have emerged: the “rationalizing” school and the “critical” school. The first borrows unwittingly from bureaucratic theory and stresses standardization and rationality in the delivery of patient care. It provides a basis for deep empirical investigation of nursing care, seeking “oper- ant mechanisms” that link organizational attributes to patient outcomes. An essay by Aiken, Sochalski, and Lake is an example of this kind of theorizing.38 The second relies on critical theory, including post-modern deconstructionist perspectives, to warn about deperson- alization and deprofessionalization of patient care as a function of bureaucratic intrusion in the name of patient safety and improved quality.39 The application of a critical theory approach seems to have expanded into

many nursing domains, promising advances that foster a breaking away from patterns of dominance and asymmetries of power through transformation and dia- logue.40,41

The debate between these two schools of thought is an inevitable consequence of the inherent conflict in tightening, structuring, coordinating, standardizing, and rationalizing patient care processes (heightening bu- reaucracy) and in maintaining and enhancing auton- omy, decentralization, freedom in decision making, and flexible responses in cases of uncertainty (heightening professionalism). A possible middle ground in this debate is the formalization of a “professional bureau- cracy,” as contrasted to a “machine bureaucracy,” among other organizational forms. But, as Kimberly and Minvielle have argued,42 the pressure to improve quality of care often pushes health care organizations toward traditional bureaucratic solutions, which contain inherently contradictory and counterproductive forces that can undo the intent of organizational actors. At its worst, bureaucratic forces lead to an organization that is unable to adapt its behavior by learning from its errors,43 which seems an apt description of many contemporary American health care organizations.44,45

A healthy debate appears to be underway among nursing researchers on this issue.

Need for Increasingly Sophisticated Methodologies

The first issue pertaining to this gap is that there is an over-reliance on cross-sectional studies and not enough longitudinal work. Cross-sectional studies are vulnera- ble not only to a confusion of what is cause and what is effect—endogeneity— but also to selection effects that arise from samples that may contain bias and response/ nonresponse differences. Second, more studies should be based on objective data and not on self-reports of nurses. Although self-reports are extremely valuable in tapping attitudes, opinions, and even intentions, they need to be verified by observations of disinterested parties. Nursing research needs to avoid the trap of relying too heavily on self-reported data. Third, more work needs to be conducted in sites other than hospitals and nursing homes. Much care is delivered in diffuse networks of private offices, linked together through managed care contacts; this domain appears to be understudied in nursing and health services research. Fourth, given the publication of an ever increasing number of empirical studies by nursing researchers on issues of nurse staffing, performance, and outcomes, it is probably time for the execution of meta-analyses to distill more precisely what we know and how reliable that knowledge is. Fifth, there is need for improvement in critical measures of what nursing staffing means and of appropriate outcome measures that can be linked to nurse staffing. Finally, more attention must be given to the multilevel nature of patient care and the application

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of appropriate statistical techniques to identify the simultaneous influences of different organizational lev- els on patient care processes and outcomes. For exam- ple, there is very little understanding of how nursing units are influenced by the larger structure of a health care organization or of administrative and support processes. Although several recent studies have used multilevel modeling in studies of staffing and patient safety,46 there is much additional work to be done related to the question of how organizational infrastruc- tures impede or enhance clinical performance, particu- larly nursing care.

Adapation and Translation The third gap is the ongoing difficulty in understand-

ing how health care organizations adapt models for the delivery of patient care in response to market forces that demand higher levels of effectiveness and efficiency. Research is needed to gain a better understanding of what these macro-level policy forces mean for nursing care in hospitals, health plans, and office-based prac- tices. A major current debate is whether, after 30 years of increasingly pro-market rhetoric and policy actions, there has been a fulfillment of the predictions and promises that reliance on “market discipline” is sup- posed to bring to health care.47,48

As the introductory section of this paper argues, there is now an enormous volume of literature on organizations and their environments and interorgani- zational arrangements and exchanges. It is now time for nursing research to apply aspects of this vast empirical and theoretical experience to questions about nursing work. We do know that these external market, policy, and environmental forces have an impact on features of nursing care. At the overall organizational level, new research is suggesting that the larger organizational context produces variation in nursing practices and patient outcomes. Some nursing researchers are casting their theoretical nets into the realm of organizational culture to find a rationale for why there is a connection between these organizational contexts and unit nursing behavior and outcomes. The next step will be to link market characteristics and interorganizational connec- tions to this research. For instance, as hospitals continue to consolidate into horizontally integrated health sys- tems that dominate local and regional markets, there will be system-wide characteristics and policies that will have to enter into our analyses.

New Technologies The fourth gap is the relative lack of attention paid to

the impact of new technologies, including electronic communications, on the organization of work processes of patient care. An example is the spread of so-called “eICUs,” intensive care units that have electronic con- nections to centralized stations where physician and nurse intensivists oversee patients. It is clear that a

whole new field dubbed “nursing informatics” is rising quickly.49 There is concern about how the Internet, computers, and electronic communications are influ- encing nursing practice. Whether it be in the area of education or of nurse practice in critical care, or in advanced practice, the impact of informatics will need aggressive study. This is true not only because of the ways that technology may alter nursing style, relations with other providers, and relations with patients and families, but also because of the ways that nursing may be affected in terms of power and control relationships with physicians and administrators. The forces of ratio- nalized communication and information flow and their relationship to work processes will be increasingly intertwined.

This latter relationship will be an extension of concerns from some nursing quarters about “pathways,” “guidelines,” and standardization generally as a form of depersonalization and near deprofessionalization. Any- one well versed in bureaucratic theory will see the immediate applicability of changed (improved?) infor- mation flow through technology as a way to assert organizational control on the patient care production process. Standardization and uniformity, including de- tailed documentation, are keystones of effective bureau- cracy.50 Thus, as technology assumes a greater role in patient care and insinuates itself ever more intrusively into the provider-patient relationship, hard attention must be given over to the gains and losses this phenom- enon produces.

CONCLUSION Nurses have made substantial advances in contributing to health services research, particularly in improving our understanding of internal structures as they relate to the organization and delivery of care, nurse staffing, and patient safety and quality outcomes. However, we have identified certain limitations of this work that need to be overcome if the knowledge gained is to be useful across the spectrum of health delivery systems. Given nurses’ deep understanding of the inner workings of health care facilities, we would hope to see an increas- ing number of research programs that focus on organi- zational responses to market forces and the application of ever more sophisticated information technology on these inner workings. Issues that are deeply embedded in the interiors of health care organizations probably have intimate but indirect connections with these mac- ro-level forces that impinge on them. Nursing health services researchers are uniquely positioned to illumi- nate these connections.

References 1. Freidson E, ed. The hospital in modern society: eleven

studies of the hospital today. New York: The Free Press; 1963.

Nursing health services research Mick and Mark

321N O V E M B E R / D E C E M B E R N U R S I N G O U T L O O K

2. Merton RK, Gray AP, Hockey B, Selvin HC, eds. Reader in bureaucracy. New York: The Free Press; 1952.

3. Revans RW. Research into hospital management and orga- nization. In: Organizational issues in the delivery of health services, Zola IK, McKinlay JB, eds. New York: Milbank Memorial Fund/PRODIST; 1974, p. 271-309.

4. Thompson JD. Organizations in action. New York: McGraw-Hill; 1967.

5. Woodward J. Industrial organization: theory and practice. London: Oxford University Press; 1965.

6. Mintzberg H. Structure in fives: designing effective organi- zations. Englewood Cliffs (NJ): Prentice-Hall; 1983.

7. Perrow C. Complex organizations: a critical essay. 2nd ed. Glenview (IL): Scott, Foresman and Company; 1979.

8. Duff RS, Hollingshead AB. Sickness and society. New York: Harper & Row; 1968.

9. Emery FE, Trist EL. The causal texture of organizational environments. Hum Relat 1965;18:21-31.

10. Terreberry S. The evolution of organizational environments. Administrative Sciences Quarterly 1967;12:590-613.

11. Lawrence PR, Lorsch JW. Organization and environment. Boston: Harvard University Press; 1967.

12. Pfeffer J, Salancik GR. The external control of organizations: a resource dependence perspective. New York: Harper & Row; 1978.

13. Thompson JD. The history of the development of DRGs. In: White WD, editor. Compelled by data: John D. Thompson. New Haven (CT): Yale University School of Medicine; 2003. p. 71-84.

14. Thompson JD. Epidemiology and health services administration: future relationships in practice and educa- tion. Milbank Mem Fund Q 1978;56:253-73.

15. Witt Associates. Today’s nurse executive: data analysis, 1990 survey. Survey cosponsored by the American Organi- zation of Nurse Executives. Oak Brook Terrace (IL).: Witt/Kieffer, Ford, Hadelman & Lloyd; 1990.

16. American Nurses Association. Survey finds loss of RNs jeopardizes patient safety. Am Nurse 1995.

17. Shamian J, Hagen B, Hu T, Fogarty TE. The relationship between length of stay and required nursing hours of care. J Nurs Adm 1994;24:52-8.

18. Alexander JA, Randolph W. The fit between technology and structure as a predictor of performance in nursing subunits. Acad Manag J 1985;28:844-59.

19. Mark B, Hagenmueller A. Technological and environmental characteristics of intensive care units. J Nurs Adm 1994; 24(4S):65-71.

20. Mitchell P, Shannon S, Cain K, Hegyvary S. Critical care outcomes: linking structures, processes and organizational and clinical outcomes. Am J Crit C 1996;5:353-63.

21. Mark BA, Salyer J, Wan TTH. Professional nursing practice: impact on organizational and patient outcomes. J Nurs Adm 2003;33:224-34.

22. Vahey DC, Aiken LH, Sloane DM, Clarke SP, Vargas D. Nurse burnout and patient satisfaction. Med Care 2004;42(2 suppl):1157-66.

23. Aiken LH, Clarke SP, Sloane DM. Hospital staffing, orga- nization, and quality of care: cross-national findings. Nurs Outlook 2002;50:187-94.

24. Harrington C, Woolhandler S, Mullan F, Carrillo H, Himmel- stein D. Does investor-ownership of nursing homes compro- mise quality of care? Am J Public Health 2001;91;1452-5.

25. Harrington C, Swan JH. Nursing home staffing, turnover, and casemix. Med Care Res Rev 2003;60:366-92.

26. Clarke SP, Sloane DM, Aiken LH. Effects of hospital staffing and organizational climate on needlestick injuries to nurses. Am J Public Health 2002;92:1115-9.

27. Clarke SP, Rockett JL, Sloane DM, Aiken LH. Organiza- tional climate, staffing, and safety equipment as predictors of needlestick injuries and near-misses in hospital nurses. Am J Infect Control 2002;30:207-16.

28. Aiken LH, Clarke SP, Sloane DM. Hospital restructuring: does it adversely affect care and outcomes? J Nurs Adm 2000;30:457-65.

29. Potter P, Boxerman S, Wolf L, Marshall J, Grayson D, Sledge J, et al. Mapping the nursing process: a new approach for understanding the work of nursing. J Nurs Adm 2004;34:101-9.

30. Shortell SM, Rundall TG. Physician-organization relationships: social networks and strategic intent. In: Mick SS, Wyttenbach ME, eds. Advances in health care organization theory. San Francisco (CA): Jossey-Bass; 2003. p. 141-73.

31. Wholey DR, Burns LR. Understanding health care markets: actors, products, and relations. In: Mick SS, Wyttenbach ME, eds. Advances in health care organization theory. San Francisco (CA): Jossey-Bass; 2003. p. 99-139.

32. Blegen M, Goode C, Reed L. Nurse staffing and patient outcomes. Nurs Res 1998;47:43-50.

33. Mark B, Harless D, McCue M, Xu Y. A longitudinal examination of hospital registered nurse staffing and quality of care. Health Serv Res 2004;39:279-300.

34. Kovner C, Gergen P. Nurse staffing levels and adverse events following surgery in US acute care hospitals. Image 1998;30:315-21.

35. Kovner C, Jones C, Zhan C, Gergen P, Basu J. Nurse staffing and post-surgical adverse events: an analysis of administra- tive data from a sample of US hospitals, 1990 —1996. Health Serv Res 2002;37:611-29.

36. Needleman J, Buerhaus P, Mattke S, Steward M, Zelevinsky K. Nurse staffing levels and the quality of care in hospitals. N Engl J Med 2002;346:1715-22.

37. Scott KA. Creating highly reliable hospitals through strengthening nursing. J Nurs Adm 2004;34:170-2.

38. Aiken LH, Sochalski J, Lake ET. Studying outcomes of organizational change in health services. Med Care 1997; 35(Suppl):NS6-18.

39. Georges JM, McGuire S. Deconstructing clinical pathways: map- ping the landscape of health care. Adv Nurs Sci 2004;27:2-11.

40. Berman H. Getting critical with children: empowering approaches with a disempowered group. Adv Nurs Sci 2003;26:102-13.

41. Fraser KD, Strang V. Decision-making and nurse case management: a philosophical perspective. Adv Nurs Sci 2004;27:32-43.

42. Kimberly JR, Minvielle E. Quality as an organizational problem. In: Mick SS, Wyttenbach ME, eds. Advances in health care organization theory. San Francisco (CA): Jossey- Bass; 2003. p. 205-32.

43. Crozier M. The bureaucratic phenomenon. Chicago (IL): University of Chicago Press; 1964.

44. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academy Press; 2001.

45. Wachter RM, Shojania KG. Internal bleeding: the truth behind America’s terrifying epidemic of medical mistakes. New York: Rugged Land; 2004.

Nursing health services research Mick and Mark

322 V O L U M E 5 3 ● N U M B E R 6 N U R S I N G O U T L O O K

46. McGillis Hall L, Doran D, Baker G, Pink G, Sidani S, O-Brien-Pallas L, et al. Nurse staffing models as predictors of patient outcomes. Med Care 2003;41:1096-109.

47. Rice T. The economics of health reconsidered. 2nd ed. Chicago (IL): Health Administration Press; 2002.

48. Nichols LM, Ginsburg PG, Berenson RA, Christianson J, Hurley RE. Are market forces strong enough to deliver

efficient health care systems? Confidence is waning. Health Aff 2004;23:8-21.

49. Zytkowski M. Nursing informatics: the key to unlocking contemporary nursing practice. AACN Clin Iss 2003;14: 271-81.

50. Gerth HH, Mills CW, eds. From Max Weber: essays in sociology. Oxford University Press; 1946.

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323N O V E M B E R / D E C E M B E R N U R S I N G O U T L O O K