Chapter 24. Restructuring and Mergers 

Bonnie M. Jennings 

Background

During the first half of the 20th century, there was a huge increase in the number of freestanding general hospitals in the United States.1

 At that time, registered nurses (RNs) typically 

practiced in hospitals. Consequently, there are strong parallels between the evolution of the 

nursing profession and the growth of hospitals as the central structure in the U.S. health care 

system.2

 By the 1980s, however, a variety of initiatives were implemented for the purpose of 

curtailing the rapid rise in health care costs.3, 4 Based upon the assumption that hospital care was 

very expensive, cutting inpatient care was a central strategy in the attempt to control the cost of 

health care.5

 Moreover, the focus on fiscal challenges shifted the health care industry into a 

business mode that substantially altered the experiences of patients, as well as the roles of health 

care personnel.6

 

Cost-cutting initiatives over the past 20-odd years contributed to tremendous turmoil in 

health care. The initiatives were often introduced concurrently and without empirical evaluations 

to determine their effectiveness. Among the early initiatives was a prospective payment system 

based upon Diagnosis Related Groups (DRGs), which differed from the historical system of 

retrospective payments that covered all services rendered. DRGs established fixed prices for care 

based on set criteria, such as diagnosis, therapy, and discharge status. These fixed prices altered 

hospital reimbursements, which in turn changed their incentives. As a result, for example, 

lengths of stay were shortened. Patients with complex care needs moved through the inpatient 

care setting much more rapidly than in the past, giving rise to the phrase “sicker and quicker” to 

reflect this dramatic change. In addition, preauthorization was implemented to reduce hospital 

use. Together, DRGs and preauthorization provided the impetus to shift care from the hospital to 

the outpatient setting and the home. 

Fewer inpatients required fewer staff. Reductions in hospital personnel helped to reduce 

labor costs; they also raised concerns about the effects of staffing on quality of care and nurses’ 

job satisfaction.7

 By the year 2000, although the hospital remained the primary place of 

employment for RNs, 40 percent of RNs worked in other settings.8

 This represented a significant 

shift over 25 years. 

Also contributing to the turmoil in health care during the 1980s was the rapid growth in 

managed care. All types of managed care programs attempted to control costs by decreasing 

unnecessary use of health care. To support this goal, primary care physicians assumed a more 

dominant role in health care by becoming “gatekeepers,” allocating health care resources such as 

referrals to specialists. 

Managed care also prompted the integration of health services and providers. Through 

horizontal integration, free-standing hospitals merged into multihospital systems owned by 

central organizations (e.g., Humana), and physicians in private practices joined group practices. 

Through vertical integration, a broad array of services covering the care continuum—from 

ambulatory care to long-term care—were pulled together into comprehensive delivery systems.4

Ideally, these mergers helped to streamline functions, reduce administrative redundancy, and 

negotiate reduced rates when purchasing supplies, equipment, and pharmaceutical products. 

1 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

 These often radical changes proceeded, however, with little empirical evidence to guide 

them. Evaluations were uncommon, and those that were conducted could not keep pace with the 

speed of changes resulting from restructuring and mergers. A report from the Institute of 

Medicine9

 concluded that despite enormous organizational turmoil, little progress was made 

toward restructuring health care systems in ways that meaningfully addressed quality and cost 

concerns. Likewise, a critical review of restructuring studies found mixed signals about what was 

accomplished through these organizational changes.3 According to Aiken and colleagues10 (p. 

463), “What we know about changes in organization and structure and the potential for those 

changes to affect patient outcomes pales by comparison to what we do not know.”

Assessments about how restructuring and mergers affected patients and staff are more a look 

through the rearview mirror because they occurred after the fact. Nonetheless, the findings are 

informative, especially when considered in the context of current changes such as recent growth 

in hospital construction.11 Today, ongoing change, not stability, is the order of the day for health 

care. Lessons from the past can be used as a platform for more proactive responses to future 

changes. 

Research Evidence 

 The findings from studies of restructuring can be grouped in numerous ways. A summary of 

the findings is presented in Table 1. These studies represent work conducted internationally, but 

predominantly in the United States and Canada. Most of the evidence came from assessments of 

restructuring in acute care settings.10, 12–48 Although hospital restructuring altered care delivered 

in other settings, little research was found that looked outside acute inpatient care. Exceptions 

were assessments of outpatient care following restructuring in the Department of Veterans 

Affairs (VA), 49, 50 an evaluation of increasing home care needs in Canada,51 and an examination 

of overcrowding in an emergency department following restructuring.52

 Studies typically addressed employee perceptions of restructuring. Overall, the changes that 

occurred through restructuring processes were viewed unfavorably. Most studies considered the 

effect of restructuring on staff nurses.10, 12–21, 23, 25–27, 29–31, 34, 35, 38–44, 47, 48 Other health care 

professions such as physical therapists33 and social workers36 also explored how restructuring 

affected their respective roles. A few investigations considered restructuring from the perspective 

of nurses in administrative positions at the patient unit and executive levels.12, 22, 24, 32, 38, 43 One 

investigation examined the views of top and middle managers from various disciplines at one 

VA hospital, as well as physicians and patients.53 A pair of related investigations considered 

restructuring as viewed by chief executive officers.45, 46 An important finding among these 

studies was that although strong leadership is essential in times of change, staff nurses’ 

assessment of nurse managers’ abilities declined considerably between 1986 and 1998, as did the 

perception of nurse executive power.10 

Few studies explored ways to mitigate the deleterious effects of restructuring. There is 

beginning evidence, however, that empowerment32 and leadership style20 may reduce burnout 

and increase job satisfaction. One study explicitly examined rebuilding after restructuring.24

Staffing changes were central to the rebuilding efforts, especially increases in licensed personnel 

and senior support staff, and decreases in part-time, temporary, agency, and contract nurses. In 

three studies that examined cost, results reflected increased costs at both the unit level13 and the 

hospital level45, 46 suggesting that restructuring did not achieve its intended purpose. 

2
Restructuring & Mergers

The majority of studies examined the relationship between restructuring and job satisfaction. 

Regardless of professional discipline, there was a decline in job satisfaction after 

restructuring.13, 15, 18–21, 23, 30, 32, 33, 36, 45 Aspects of burnout were also frequently explored.19–21, 32, 48

Findings consistently showed burnout was increasing, particularly emotional exhaustion, which 

is viewed as the core feature of burnout. Along with evaluating psychological health, studies 

began to detect a relationship between restructuring and increased musculoskeletal 

injuries.14, 29, 42 

Restructuring can occur within a single institution, while mergers involve integrating two or 

more institutions. A cluster of studies explicitly addressed various aspects of mergers.54–62 

Findings from three studies verified that the success of mergers was enhanced by engaging staff 

from the merging institutions in the process.54, 56, 57 Other investigations evaluated various 

responses of nursing staff to mergers.58–60 In a merger involving three hospitals, for example, 

Jones59 found that uncertainty about job status and feeling unappreciated minimized nurses’ 

organizational commitment. Other studies examined mergers from the standpoint of factors 

effecting financial performance,61 midwifery practice,62 and the integration of two emergency 

departments.55 

A number of investigations relied exclusively on qualitative methods to explore restructuring 

and mergers.16, 17, 25, 27–29, 32, 34, 40, 53, 54, 60, 62 Themes across these studies help to edify potential 

sources of job dissatisfaction and burnout. For example, participants commented that 

restructuring altered work relations in undesirable ways,16, 25, 27, 53, 62 including relations with 

management,32 that contributed to staff distrust of the employing organization.25, 54 Participants 

also identified changes in work life related to increased responsibilities, decreased resources, and 

overall busyness.25, 27, 29, 32, 34, 62 

In two studies, themes emerged indicating that staff viewed restructuring as detrimental to 

the quality of care.27, 32 In another two investigations, in which both patients and health care 

professionals were interviewed, findings indicated that patients had fewer complaints about the 

changes than did the hospital staff.34, 53 

 A few studies considered the effects of restructuring on quantifiable patient 

outcomes;10, 13, 18, 30, 37, 42, 49, 50 two of these investigations related to outpatient care.49, 50 The 

paucity of studies exploring patient outcomes related to restructuring illustrates that staff 

response has been the focus of most restructuring and merger studies. Although no causal 

connections have been demonstrated, beliefs and assertions hold that staff characteristics do 

affect patient outcomes. For example, recent findings show emotional exhaustion among nurses 

is associated with higher patient morality.63 

Nevertheless, the staff-focused studies do not help to inform patient care per se. Moreover, 

the concerns addressed a decade ago by Ingersoll26 persist—many studies are reported in 

journals geared to audiences that are more interested in application than scientific rigor. There is 

a continued need for studies with more sophisticated designs to better inform the science of 

patient safety. These needs expose the potential for better informing practice by combining 

health services research techniques with nursing research inquiries. 

3 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

Table: Summary of Research Evidence Related to Restructuring and Mergers 

Care setting • Most studies evaluated restructuring and mergers in acute care settings. 

Effect on costs • Increased unit level costs. 

• Increased hospital level costs. 

Effect on staff nurses • Decreased job satisfaction. 

• Increased burnout, especially emotional exhaustion. 

• Increased musculoskeletal injuries. 

Common sources of 

job dissatisfaction and 

burnout 

• Undesirable changes in work relations, including relations with 

administrators, that fostered organizational mistrust. 

• Increased work responsibilities. 

• Decreased resources. 

Ways to reduce the 

undesirable effects of 

restructuring and 

mergers 

• Empowerment. 

• Empathetic leadership style. 

• Staffing changes—more licensed personnel and senior support staff; 

fewer part-time, temporary, agency, and contract nurses. 

Effect on patient 

outcomes 

• Results are conflicting about patient mortality. 

• Indicator data (e.g., falls, nosocomial infections, medication errors) vary 

over time, making it important to track trends. 

• Indicator data differ when assessed at the hospital level, the unit level, 

and by unit type (e.g., medical or surgical). 

• Overall, the evidence is scattered and inconsistent. 

Evidence-Based Practice Implications 

The 11 studies in Table 2 illustrate findings pertinent to patients as well as staff regarding 

likely connections between restructuring and patient safety. The setting for studies that met 

inclusion criteria was most often acute care,10, 18, 20, 21, 32, 43, 46, 48 with research focused on 

outpatients40, 50 and home care51 also represented. Overall, however, the evidence is scattered 

and, at times, inconsistent. As a consequence, there are few solid implications for practice. 

Patient mortality showed conflicting results. Increases in mortality were found in aggregated 

data from hospitals throughout the United States,10 and decreases were found based on data from 

more than 2,000 patients at a single hospital.18 A study of VA outpatients showed no statistically 

significant differences in mortality between patients who saw a physician for symptoms and 

patients who were not seen.50 

Indicator data for falls, medication errors, nosocomial infections, and intravenous 

complications were examined in an 18-month longitudinal study of four medical-surgical units at 

one hospital.18 The four indicators were assessed for more than 2,500 patients at four points in 

time. Although descriptive data reflected patternless variations in the indicators, all indicators 

were increasing at 18 months. The investigators noted, however, that when indexed by rate of 

occurrence per 100 patients, all four indicators either improved or remained unchanged. 

Sovie43 collected data from 29 university teaching hospitals in eight of the nine U.S. census 

regions. More than findings about the individual patient outcomes, this study illustrated 

important variations depending upon how data were aggregated. That is, data aggregated at the 

hospital level differed from data at the unit level. More striking, findings varied by unit type—

medical or surgical. For falls, pressure ulcers, and urinary tract infections (UTIs), the rates were 

always lower on surgical units than medical units. This may have important implications for 

practice related to staffing considerations. 

4
Restructuring & Mergers

Berlowitz49 led a study of pressure ulcers among residents of long-term care units at 150 VA 

medical centers nationwide. This study illustrated that, as care shifted from a focus on hospitalbased specialty care to outpatient primary care, pressure ulcers increased, even after risk 

adjustment. Conversely, in a study from a single VA facility in California, Rubenstein and 

colleagues50 demonstrated that the shift to outpatient care yielded improvements in continuity of 

care and preventive care related to smoking, exercise, detection of depression, and the number of 

individuals with hypertension receiving treatment. 

The final study involving a patient focus examined home care needs for patients after 

hospitals closed beds.51 Not only did more patients need care after discharge, but service 

intensity also increased. The intensity diminished in the second week after discharge. Although 

findings from single studies do not warrant practice changes, the effects of restructuring on home 

care needs remains an important consideration for patient safety. 

The studies that evaluated various staff response to restructuring displayed a much clearer 

pattern to their findings—restructuring was associated with negative effects on staff.21, 32, 48

Interested in mitigating these effects, Cummings and colleagues20 tested a model that examined 

leadership style. Empathy was a critical leadership competency that served to offset the negative 

effects of restructuring. It was characterized by individuals who listened and responded to 

employee concerns. 

Finally, Walston and colleagues46 evaluated changes in hospital costs during restructuring 

efforts. They found that restructuring altered work processes by changing the workflow and job 

responsibilities. This exerted a negative influence by increasing hospital costs relative to 

competitors. 

Research Implications 

Given the current evidence, we know that reducing inpatient care as the central strategy for 

controlling the cost of health care has not succeeded. We know that staff report being dissatisfied 

with their job conditions. We also know there is no consistent pattern in the few studies that have 

examined the effect of organizational change on patient outcomes. Furthermore, we know that 

change in health care organizations is likely to continue. 

Consequently, there are large gaps in knowledge about restructuring and mergers. It is not 

feasible to provide a comprehensive list of areas for future study. However some general notions 

can be outlined. A fundamental premise is that health care leaders must seriously consider which 

changes to implement and the best processes for introducing changes into their organizations. In 

addition, they need to evaluate changes—not just implement them. The evaluations need to be 

sufficiently comprehensive so that organizational goals (e.g., costs) do not overshadow 

examination of the effects of change on staff and patients. These studies also need to be 

longitudinal, to track the effects of restructuring over time. This strategy will help to fill the void 

about the effects of restructuring on patient safety. 

Moreover, if existing care delivery structures are not effective, then a central question 

concerns how best to organize care. For example, if the Institute of Medicine’s aims for the 21stcentury health care system are still appropriate,9

 then what structures will lead to care that is safe, 

effective, patient-centered, timely, efficient, and equitable? Continuity of care before and after 

restructuring and mergers is an aspect of care that could benefit from in-depth exploration 

because it could contribute to improvements in each of the desired aims. Acute care, outpatient 

5 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

care, and home care have all been affected by restructuring. What mechanisms could be 

introduced to enhance continuity from unit to unit and across the care continuum? 

Many studies of restructuring follow a sociological view of organizations; a psychological 

framework has been used less often. Human relations—among both staff and patients—are 

central to caregiving organizations. Kahn64 asserts that interpersonal transactions are at the core 

of caregiving organizations. He believes that resilient organizations have members who are able 

to learn and grow, even in difficult environments. Resilient organizations are better able to 

absorb stress and maintain the capacity to function effectively. Therefore, regardless of the 

structure, health care organizations would benefit from investigations that examine interpersonal 

conditions at work. Interventions could then be developed to help staff improve relationships 

with one another and work together more effectively. To date, studies have not examined the 

effects of restructuring on the dynamics among caregivers and between caregivers and patients. 

In addition, leadership as a linchpin of relationships between staff and administrators begs to be 

better understood. 

From the perspective of patient outcomes, however, we know very little. There is no 

discernible pattern in existing findings; there is no meaningful statement that can be made. The 

impact of restructuring on patient safety remains unknown. Measurement and methods questions 

are important considerations to enhance that understanding—which indicators to use, how they 

are defined, how they are measured, what the unit of analysis is. Decreased resources, including 

sufficient staff, surfaced as a concern in studies of restructuring. It would be beneficial to assess 

different care structures, determine the work that needs to be done, determine who needs to do it, 

provide the proper type and number of staff to do the work, and then assess which organizational 

structures yield the best opportunity for providing safe care to patients. 

 It would also be extremely useful to pursue a series of qualitative studies to better depict the 

current state of health care organizations. Data could be collected from staff at all levels of 

individual organizations as well as vertically and horizontally integrated systems of care. Data 

could also be collected from patients getting care in different venues, including the home. Family 

member perspectives would be valuable, too. Such studies would be very complex and difficult, 

but they could elucidate key issues and concerns. These could then be used to construct 

interventions or guide future restructuring efforts. 

This is just the beginning of an almost endless list of ideas that could be studied to advance 

the understanding of restructuring and mergers. Future endeavors need to be more proactive in 

assessing organizational change early in the change process. They also need to approach 

questions over time, using a comprehensive set of variables, as well as sophisticated 

methodological and statistical techniques, to truly advance the understanding of restructuring on 

the staff as well as patient safety. 

Conclusion 

As reflected in the Table (see above), most studies of restructuring and mergers have been 

conducted in acute care settings. Many of these studies have examined the effects of 

restructuring and mergers on cost, staff nurses, and patient outcomes. In the aggregate, 

restructuring and mergers did not achieve the desired reductions in cost. However the upheaval 

accompanying restructuring efforts and mergers can be related to lower job satisfaction among 

nurses and increased burnout. The effects of restructuring and mergers on patient care, however, 

6
Restructuring & Mergers

are more difficult to understand because the evidence varies over time, by hospital or unit, and 

by unit type. 

 There is convergence in findings about sources of job dissatisfaction and burnout related to 

restructuring and mergers. Organizational and unit leaders would be wise to carefully assess 

work relations, work responsibilities, and the availability of resources, all of which may be 

sources of dissatisfaction and burnout. It would also behoove the leaders to consider the evidence 

that illustrates ways to minimize the undesirable effects of restructuring and mergers. These 

include empowerment, empathetic leadership, and staffing changes that increase the number of 

licensed nurses who are employed by the institution. 

Search Strategy 

A reference librarian assisted in running database searches in both MEDLINE® and 

CINAHL® to identify literature for this review. Both databases were searched from 1995 to 

2005, using the same two MESH headings: hospital restructuring and health facility mergers. 

The searches were limited to research reports published in the English language. A total of 149 

potential publications were identified, 56 in MEDLINE® and 93 in CINAHL®. Based upon an 

assessment of the abstracts, 67 of the publications were regarded as being suitable for inclusion 

in this review. The 82 papers that were omitted were a combination of brief reports or abstracts, 

topics not suitable to this review (i.e., mental health triage tools), and doctoral dissertations. 

 After reading the 67 publications in their entirety, 14 were omitted from further 

consideration. Some of these papers, for example, were only tangentially related to restructuring 

and mergers, a few were redundant publications, and others were about instrument development. 

This review is therefore based on 53 research reports. 

Acknowledgment 

Tremendous gratitude is expressed to the staff of the Armed Forces Medical Library, Falls 

Church, VA, for their considerable support of this work. They conducted the database searches 

and assisted in acquiring numerous papers considered in this review. 

Author Affiliations 

Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N.; Colonel, U.S. Army (Retired); and health care 

consultant. E-mail: bmjennings@cox.net. 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

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importance of self-efficacy and emotional reactivity. 

J Nurs Manage 2003;11:59-63. 

64. Kahn WA. Holding fast. The struggle to create 

resilient caregiving organizations. New York: 

Brunner-Routledge; 2005. 

59. Jones JM. Dual or dueling culture and commitment. 

The impact of a tri-hospital merger. J Nurs Adm 

2003;33(4):235-42. 

 

10
Evidence Table: Restructuring and Mergers 

Source 

Safety Issue Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention K

Aiken 200010 Staffing Cross-sectional Design: Level 4; 

Patient outcomes: mortality (Level 1) 

Hospitals throughout the United States, 646 CEOs, 2,000 nurses, patient data from American Hospital Association and Health Care Financing Administration databases 

Restructuring: personnel reductions via attrition (69%), crosstraining (84%), skill mix reductions (60%), reassignment of support services (60%), redistribution of patients on nursing units (42%); reduction of management positions (54% by layoffs, 70% by attrition) 

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Berlowitz 200149 Outpatient care Retrospective cohort Design: Level 4, Patient outcomes: 

risk-adjusted development of stage 3 or 4 pressure ulcers (Level 1) 

Department of Veterans Affairs (VA) long-term care units at about 150 VA medical centers nationwide between 1990 and 1997; 274,919 observations of 103,499 VA residents who were without a pressure ulcer (PU) at an index assessment: 97% were men, average age was 71 years 

Reorganization beginning in 1995 to shift from a hospital-based, specialtyfocused system to one based on primary care delivered in outpatient settings 

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11
12

Source Safety Issue Related to Clinical Practice Design Type Study Design, Study Outcome Measure(s) Study Setting & Study Population Study Intervention KBryan 199818 Patient- centered care Cross-sectional, Same variables measured at 4 points in time using different patients (preimplement- ation, 6, 12, and 18 months after) Design: Level 3, Patient outcomes: mortality, falls, medication errors, nosocomial infections, IV- related complications (Level 1), patient satisfaction Four medical-surgical units in one Pennsylvania hospital: patients at baseline = 2,700 6 months = 2,500 12 months = 2,756 18 months = 2,672 Hospital redesign using patient-centered concepts—facility changes (e.g., alter location and number of work stations and supply areas), enhanced information systems (e.g., redesigned patient call system), total redesign of work processes (e.g., redesigned staff roles to use multiskilled personnel) M

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Cummings 200520 Leadership Cross-sectional Design: Level 3, 15 nursing outcomes: e.g., emotional health; physician- nurse teamwork; nurse workgroup collaboration; satisfaction with 

time to spend with patients, supervision, financial rewards, one’s job; perceived quality of care as measured by unmet patient needs (Level 3) 

Acute care hospitals in Alberta, Canada; 6,526 registered nurses (53% response rate) 

Leadership styles: resonant (visionary, coaching, affiliative, democratic), dissonant (pace setting, commanding), mixed. 

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13

Source 

Safety Issue Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention K

Cummings 200321

Effects on nurses who remained employed while others lost their jobs 

Systematic literature review 

Design: Level 1, effects of restructuring on nurses remaining employed in hospitals (Level 3) 

Published research—84 papers were screened for inclusion criteria: 22 papers were included in the review (18 of 24 quantitative papers and 4 of 9 qualitative papers) 

Hospital restructuring effects on nurses (RNs and LPNs) 

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Keller 200451 Hospital bed 

closures 

Cross-sectional Design: Level 4; 

outcomes: rate of home care, service intensity 

Kingston, Ontario, Canada; closure of 134 acute care beds in 2 tertiary teaching hospitals in 1997; hospital patients ages 45 and older, discharged to a home setting between 1996 and 2000, covered by the provincial health insurance plan and admitted to the local Community Care Access Center within 5 days before or after hospital discharge (

n = 

1,651) 

Delivery of home care by registered nurses (RNs) and registered practical nurses (RPNs) 

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14

Source Safety Issue Related to Clinical Practice Design Type Study Design, Study Outcome Measure(s) Study Setting & Study Population Study Intervention KLaschinger 200432 Nurse managers’ health Cross-sectional Design: Level 3, outcomes: empowerment, burnout (emotional exhaustion [EE]), job satisfaction, mental and physical health (Level 3) Acute care hospitals in Ontario, Canada; random sample of 500 nurse managers; 286 usable surveys were returned (62%); first-line managers (

n = 202), 

95% female, average age 48, average years nursing experience 25, average years managerial experience 10, 42%, were baccalaureate prepared; middle managers (

n = 84), 96% 

female, average age 49, average years nursing experience 27, average years managerial experience 14, 43%, were master’s prepared 

Restructuring F

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15

Source 

Safety Issue Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention K

Rubenstein 199650 Outpatient care Cross-sectional with data 

collected at 3 points in time—1989, before implementation; 1992, early in implementation; and 1993 after implementation 

Design: Level 3, outcomes: mortality (Level 1), continuity, preventive care, access, workload (Level 3) 

A VA medical center in California; data for practice-based comparisons came from 1,262 veterans in 1992 and 1,373 in 1993 (697 were from a new crosssectional sample and 676 were from the original cohort); data for visit-based comparisons came from 1,407 veterans in 1992 and 643 in 1993 (92.3% of the new clinic crosssection). Patient survey responses were linked to computerized utilization and mortality data. 

Implementation of the Primary Ambulatory Care and Education (PACE) program, a medicalcenter-wide interdisciplinary matrix management system and training program; put in place in 1990–1991. 

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Source Safety Issue Related to Clinical Practice Design Type Study Design, Study Outcome Measure(s) Study Setting & Study Population Study Intervention KSovie 200143 Nursing structure and processes Cross-sectional Design: Level 3, outcomes: structure (full-time equivalents for each type of nursing staff; skill mix, hours worked per patient day [HPPD] for all staff); process (management practices and organizational processes, e.g., autonomy, decisionmaking); outcomes (annual rates for nosocomial pressure ulcers [NPUs], urinary tract infections [UTIs], falls, (Level 1); patient satisfaction with pain management, 

education, attention to needs, nursing and the hospital, preparation for discharge (Level 3) 

29 university teaching hospitals with > 300 acute operating beds in 8 of 9 U.S. census regions; chief nurse executives (CNEs) at each hospital (all were women with graduate degrees, 15 had doctorates), patients and nursing staff (registered nurses [RNs], licensed practical nurses [LPNs], unlicensed assistive personnel [UAP]) from a medical unit and a surgical unit at each hospital (RN participants: 

n = 1,687 

in 1997, 1,256 in 1998; 92–93% female, 57–58% married, 53% BSN degrees, mean age 37, mean years in nursing 11) 

Restructuring had been in progress in 50% of the hospitals for over 4 years prior to data collection. The goal of restructuring was to achieve reductions in operating costs. 

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Walston 200046 Changed work processes and 

design 

Cross-sectional Design: Level 3, 

outcomes: changes in hospital cost per adjusted patient day relative to the hospital’s market area (controlling for bed size and other factors) (Level 3) 

All U.S. general medical/ surgical hospitals in urban areas with > 100 beds (

N = 2,306); CEOs 

surveyed November 1996 through July 1997 

Reengineering (60% rate of adoption in sample) 

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17

Source 

Safety Issue Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention K

Woodward 199948

Cross-sectional 

at 3 points in time over 2 years 

Design: Level 3, outcomes: work environment, emotional distress, personal resources, perceptions of patient care and the hospital as an employer (Level 3) 

One large teaching hospital in Ontario; 900 randomly sampled employees, 881 of whom were eligible, 730 of whom were employed 2 years later, 47% responded in all time periods. Respondents to all 3 surveys included 220 health care professionals, 40 service/technical staff, 66 secretarial personnel, 20 business staff. 

Re-engineering S

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