Rethinking clinical organisational structures: an attitude survey of doctors, nurses and allied health staff in clinical directorates.
ABSTRACT To examine assumptions made by proponents and critics of clinical directorate (CD) structures in hospitals. Proponents argue that CDs are supported by the health professionals who constitute them and confer organisational and clinical benefits compared with traditional structural configurations. Critics deny these benefits and suggest CDs can compromise clinicians by incorporating them into management, to their cost. We investigated the attitudes of health professionals working in CDs to gather and consider evidence for these claims.
A questionnaire survey of 227 health professionals (78 doctors, 89 nurses and 60 allied health) in two large hospitals in Australia that had implemented CDs three years previously.
Respondents were more negative than positive about CDs. Significant attitudinal differences were found between professions. Doctors were the most negative and held their attitudes with the greatest certainty and intensity. Allied health staff were the most positive but their attitudes tended to lack strength or certainty. Nurses' attitudes were polarised and intense but more positive than were doctors'. Increased organisational politics was cited by 58% of respondents as CDs' most frequent effect, followed by improved accountability (48%) and dumping hard decisions on staff (39%). Only 26% thought patient care had improved.
Clinical directorates were designed to promote team approaches and to improve patient care delivery, but the results call for a rethink of what can be expected from structural reforms in organisations.
Article: Differences in doctors' and nurses' assessments of hospital culture and their views about computerised order entry systems.[show abstract] [hide abstract]
ABSTRACT: The organisational culture of a health facility has been identified as a significant factor for successful implementation of clinical information systems. There have been no reported studies exploring the link between sub-cultures and the use of information systems. This study utilises cross sectional surveys to measure doctors' and nurses' perceptions of organisational culture and relate this to their use of a hospital-wide mandatory computerised pathology order entry (CPOE) system. Data were collected by administering an organisational culture survey (Organisational Culture Inventory, OCI) along with a user-satisfaction survey to a population of 103 doctors and nurses from two clinical units in an Australian metropolitan teaching hospital. We identified subcultures based on professional divisions where doctors perceived an aggressive/defensive culture (mean percentile score = 43.8) whereas nurses perceived a constructive culture (mean percentile score = 61.5). There were significant differences between doctors and nurses on three of the attitude variables with nurses expressing more positive views towards CPOE than doctors. The manifestation of subcultures within hospitals and the impact this has on attitudes towards clinical information systems should be recognized and addressed when planning for system implementation.Studies in health technology and informatics 02/2008; 136:15-20.
Article: Promoting safety: longer-term responses of three health professional groups to a safety improvement programme.[show abstract] [hide abstract]
ABSTRACT: Patient safety has been addressed since 2002 in the health system of New South Wales, Australia via a Safety Improvement Programme (SIP), which took a system-wide approach. The programme involved two-day courses to educate healthcare professionals to monitor and report incidents and analyse adverse events by conducting root cause analysis (RCA). This paper aims to predict that all professions would favour SIP but that their work and educational histories would result in doctors holding the least and nurses the most positive attitudes. Alternative hypotheses were that doctors' relative power and other professions' team-working skills would advantage the respective groups when conducting RCAs. Responses to a 2005 follow-up questionnaire survey of doctors (n = 53), nurses (209) and allied health staff (59), who had participated in SIP courses, were analysed to compare: their attitudes toward the course; safety skills acquired and applied; perceived benefits of SIP and RCAs; and their experiences conducting RCAs. Significant differences existed between professions' responses with nurses being the most and doctors the least affirming. Allied health responses resembled those of nurses more than those of doctors. The professions' experiences conducting RCAs (number conducted, leadership, barriers encountered, findings implemented) were similar. Observational studies are needed to determine possible professional differences in the conduct of RCAs and any ensuing culture change that this may be eliciting. There is strong professional support for SIPs but less endorsement from doctors, who tend not to prefer the knowledge content and multidisciplinary teaching environment considered optimal for safety improvement education. This is a dilemma that needs to be addressed. Few longer-term SIPs' assessments have been realised and the differences between professional groups have not been well quantified. As a result of this paper, benefits of and barriers to conducting RCAs are now more clearly understood.International Journal of Health Care Quality Assurance 02/2007; 20(7):555-71.
Article: Trust, communication, theory of mind and the social brain hypothesis: deep explanations for what goes wrong in health care.[show abstract] [hide abstract]
ABSTRACT: The purpose of the paper is to examine the deep conceptual underpinnings of trust and communication breakdowns via selected health inquiries into things that go wrong using evolutionary psychology. This paper explains how this is carried out, and explores some of the adverse consequences for patient care. Evolutionary psychology provides a means of explaining important mental capacities and constructs including theory of mind and the social brain hypothesis. To have a theory of mind is to be able to read others' behaviours, linguistic and non-verbal cues, and analyse their intentions. To have a social (or Machiavellian) brain means being able to assess, compete with and, where necessary, outwit others. In the tough and complex environment of the contemporary health setting, not too different from the Pleistocene, humans display a well-developed theory of mind and social brains and, using mental attributes and behavioural repertoires evolved for the deep past in hunter-gatherer bands, survive and thrive in difficult circumstances. The paper finds that, while such behaviours cannot be justified, armed with an evolutionary approach one can predict survival mechanisms such as turf protection, competitive strategies, sending transgressors and whistleblowers to Coventry, self-interest, and politics and tribal behaviours. The paper shows that few studies examine contemporary health sector behaviours through an evolutionary psychology lens or via such deep accounts of human nature.Journal of Health Organisation and Management 02/2007; 21(4-5):353-67.