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Person-centered work environments in health care: Preliminary test of a theoretical framework

Article in Academy of Management Annual Meeting Proceedings ? August 2008

DOI: 10.5465/AMBPP.2008.33659871

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October?December 2009

Improving work environments in health care: Test of a theoretical framework

Cheryl Rathert

Ghadir Ishqaidef

Douglas R. May

Background: In light of high levels of staff turnover and variability in the quality of health care, much attention is currently being paid to the health care work environment and how it potentially relates to staff, patient, and organizational outcomes. Although some attention has been paid to staffing variables, more attention must be paid to improving the work environment for patient care. Purposes: The purpose of this study was to empirically explore a theoretical model linking the work environment in the health care setting and how it might relate to work engagement, organizational commitment, and patient safety. This study also explored how the work environment influences staff psychological safety, which has been show to influence several variables important in health care. Methodology: Clinical care providers at a large metropolitan hospital were surveyed using a mail methodology. The overall response rate was 42%. This study analyzed perceptions of staff who provided direct care to patients. Findings: Using structural equation modeling, we found that different dimensions of the work environment were related to different outcome variables. For example, a climate for continuous quality improvement was positively related to organizational commitment and patient safety, and psychological safety partially mediated these relationships. Patient-centered care was positively related to commitment but negatively related to engagement. Practice Implications: Health care managers need to examine how organizational policies and practices are translated into the work environment and how these influence practices on the front lines of care. It appears that care provider perceptions of their work environments may be useful to consider for improvement efforts.

Although hospitals' primary objectives are to provide care for sick or injured patients, they are also workplaces for many individuals. The Institute of Medicine, among others, has argued that the hospital work environment not only influences staff variables such as satisfaction and turnover but also influences the ability to provide high-quality and safe care to patients (Page, 2004). Although management schol-

ars have focused extensively on work contexts in nonhealth care sectors, researchers are only recently turning similar attention to health care workplaces. Some research in health care has explored staffing ratios, use of temporary staff, the number of hours worked, and how these factors relate to patient outcomes (Aiken, Clarke, & Sloane, 2002a; Aiken, Clarke, Sloane, Sochalski, & Silber, 2002b). However, scant attention has been paid to

Key words: health care staff, psychological safety, work environment

Cheryl Rathert, PhD, is Assistant Professor, Health Services Management, Senior Scholar, Center for Health Ethics, School of Medicine, University of Missouri, Columbia. E-mail: RathertC@health.missouri.edu. Ghadir Ishqaidef, BA, is PhD Student, The School of Business, The University of Kansas, Lawrence. E-mail: Ghadir@ku.edu. Douglas R. May, PhD, is Professor and Co-Director, International Center for Ethics in Business, The School of Business, The University of Kansas, Lawrence. E-mail: drmay@ku.edu.

This article awarded Best Paper for the 2008 Annual Meeting of the Academy of Management, Health Care Management Division, August 8?3, 2008, Anaheim, California. This research was funded by a University of Missouri, Columbia, Research Council grant, and the University of Missouri Center for Health Care Quality provided additional support.

Health Care Manage Rev, 2009, 34(4), 334-343 Copyright A 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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the health care work environment and how it may influence important individual and organizational outcomes. This study empirically tested a theoretical framework that proposes linkages between the health care work environment and important staff and patient variables (Rathert & May, 2007a). Identifying such linkages can help provide organizations with specific tools to improve working conditions for staff and in turn improve care for patients.

Three important dimensions have been proposed as being necessary for an optimal health care work environment, and these dimensions are proposed to influence outcomes such as staff psychological safety, positive affect, satisfaction, and organizational commitment (Rathert & May, 2007a). In addition, these dimensions were proposed to influence patient safety and satisfaction. This work environment includes (a) support for patient-centered care, (b) support for continuous quality improvement (CQI), and (c) an ethical climate that is benevolent. The purpose of this study was to empirically explore how these dimensions relate to specific outcome variables. Outcomes of interest in this study included organizational commitment, job engagement, and patient safety. Psychological safety is proposed to mediate relationships between the work environment and outcomes as well. The conceptual model tested in this study is depicted in Figure 1.

Foundations for Care

Work Environments and Caring

Nursing scholars argue that providing top-quality care to patients requires more than simply performing specific care protocols and tasks. For many in care work, caring is a vocation or a calling, as opposed to a job. High-quality care requires development of a somewhat intimate relationship with each patient and involves interpersonal dynamics between the care provider and patient, as well as

intrapersonal dynamics within the care provider (Brechin, 1998). This suggests that personal emotions and relationships must be nurtured. When care providers develop close relationships with patients, they are better able to tailor treatment to each unique patient or avert an impending crisis (Radwin, 1996; Wittemore, 2000). Indeed, such relationships form the basis of patient-centered care, which the Institute of Medicine asserted as one of its six objectives for improving the quality of care (Berwick, 2002). Such care improves patient satisfaction (Cleary, 1998) and clinical outcomes (Fremont et al., 2001).

Along with the need to provide better patient care, intrapersonal dynamics must be considered for the sake of care providers. When care providers are involved in processes that lead to poor outcomes or medical errors, they tend to experience emotional distress. Increased stress or distress impacts job and career perceptions, can lead to physical health problems, and can impact the care of subsequent patients (Firth-Cozens & Greenhalgh, 1997; Waterman et al., 2007; Wu, 2000). Physicians have acknowledged that job-related stress results in medical errors that cause harm and even death to patients (FirthCozens, 2003). Thus, it is imperative to begin identifying specific work environment attributes that influence the ability of providers to deliver the best care to patients. In this study, the work environment is conceptualized as the social atmosphere that gives rise to management practices and interactions among staff, as opposed to the physical and structural context.

Important Outcomes in Health Care

Staff Engagement and Organizational Commitment

Given that staffing and turnover are and will continue to be a challenge for hospitals (Aiken et al., 2002a,

Figure 1

Conceptual framework linking the work environment to outcomes CQI = continuous quality improvement

Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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2002b; Page, 2004), we argue that organizations should focus on engaging staff in their work and on characteristics that should facilitate organizational commitment. Organizational commitment has been shown to be a better predictor of turnover than is job satisfaction (Gees, Manojlovich, & Warner, 2008). Commitment is a dynamic, iterative process and develops when individuals accept the organization's goals and values and are motivated to contribute to and maintain a good relationship with the organization (Shwu-Ru, 2008). Accordingly, commitment may facilitate high-quality care even in the face of staffing shortages.

Work engagement should be a desired outcome for health care organizations given that many care providers seek caring as a vocation. Engagement relates to enthusiasm for and immersion in one's work and the extent to which that work meets the worker's needs (May, Gilson, & Harter, 2004; Vinje & Mittlemark, 2007). Importantly, engagement appears to be related to burnout in that as engagement decreases, burnout tends to increase (Maslach & Leiter, 2008; Saks, 2006). Thus, engagement seems to be a particularly important variable to cultivate among health care providers.

Psychological Safety

The model of Rathert and May (2007a) proposes that psychological safety is an important outcome of the work environment and an antecedent to care provider and patient variables. Psychological safety means that providers are not afraid to speak up to improve work processes or call attention to a potentially dangerous situation. Individuals who experience psychological safety in their work roles tend to be more engaged (Kahn, 1990; May et al., 2004). Care providers who are engaged in their work are likely to be more cognitively vigilant, empathically connected to their patients, and observant of processes that can be improved. We suggest that psychological safety is an important variable that links the work environment with care provider job engagement and organizational commitment. When staff are more engaged and committed, there should be improved patient safety as well.

Antecedent Work Environment Dimensions

tered. Although most hospitals claim their missions and values include patient-centered care, when policies and practices are examined, patients are often far from central. When the work environment is more patient centered, care providers should be supported in developing relationships with patients and thus be more engaged in their work. Similarly, when they develop closer relationships with patients, care providers are more likely to avert errors (Rathert & May, 2007b; Wittemore, 2000). When care providers are supported in these value-consistent ways, we also might expect them to develop stronger bonds with the organization overall (i.e., commitment).

Hypothesis 1: Patient-centered work environments will be positively related to care providers' organizational commitment, job engagement, and patient safety.

Continuous Quality Improvement

Continuous quality improvement means that small innovative improvements are continually made to processes and that these processes have a customer-driven focus. In a study of organizational culture, Baker, Murray, and Tasa (2002) found that successful hospitals had staff who felt that they had influence over their work and processes, were encouraged to focus primarily on patients, and had managers with specific styles conducive to CQI. CQI environments emphasize participation, teamwork, and staff empowerment. Empowerment in the workplace is associated with meaning and satisfaction (Spreitzer, 1995, 1996). Because CQI enables care providers to study their work processes and empowers them to improve their work, we should expect staff to be more fully engaged. Positive emotional energy derived from resulting high-quality collegial relationships likely facilitates strong emotional bonds with the organization, thus increasing commitment. Similarly, engaged staff should focus their full cognitive attention on patients, so patient safety is likely to increase as well.

Hypothesis 2: CQI will be positively related to care providers' organizational commitment, job engagement, and patient safety.

Patient-Centered Care

Benevolent Ethical Climates

Patients have defined quality as patient-centered care (Cleary, 1998; Gerteis et al., 1993). Patient-centeredness means that care is delivered in an individualized manner, with consideration of the patients' needs and preferences at center, as opposed to being disease or physician cen-

In contrast to other types of work, care work has been said to be ``morally defined'' because the work involves attending to sick and injured individuals (Austin, Lemermyer, Goldberg, Bergum, & Johnson, 2005). Accordingly, there is a need to understand how organizational

Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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policies and procedures manifest in the work environment in terms of ethics. At the organization level, leaders face the conflicting goals of maximizing the quality of patient care while at the same time minimizing costs (Mills & Spencer, 2005). Such dilemmas may result in unintended or mixed messages about decision-making priorities for frontline staff and may lead to moral conflict at the bedside (Rathert & Fleming, 2006). Thus, the ethical environment likely plays a key role in important outcomes.

Much of the research on organizational ethics has stemmed from the seminal work of Victor and Cullen (1988) that found that the social context and group norms in organizations impact moral behavior above and beyond individual ethics. They argued that the social context is composed of different ethical climates. Ethical climates are shared employee perceptions about the types of behaviors expected in the organization or work group (Cullen, Parboteeah, & Victor, 2003). Nine ethical climate types have been proposed and empirically supported based on a theoretical matrix derived from three types of ethical theory and three types of referent groups for decision making (Martin & Cullen, 2006). Of interest in this study was the climate type known as the caring or benevolent type. Benevolent climates promote consideration for the concerns of others, such as the work unit as a group. In contrast, other climate types focus on individuals themselves, instrumental concerns of the organization, or even strict adherence to prescribed moral codes. Given that care providers feel called upon to focus beyond their immediate needs in the care of others (Vinje & Mittlemark, 2007), the type of ethical climate in their work environment should impact their engagement and organizational commitment.

In benevolent climates, individuals would be expected to make decisions that benefit the patient's wellbeing, the care team, the work unit, or the community, as opposed to themselves as individuals or the organization's bottom line. Thus, care providers would likely be encouraged and committed to the patient care goals of the unit overall and be more likely to engage themselves more fully in their daily roles. Importantly, a benevolent ethical environment in health care would be less likely to be punitive as it suggests a more systemsoriented approach as opposed to an individualistic one. For example, as opposed to reprimanding staff when a medical error occurs, unit leaders would offer support and examine the systems and processes that led to the error because the emphasis would be on the greater good as opposed to punishing individuals. Nonpunitive work environments are said to be essential for improving care quality and patient safety (Kohn, Corrigan, & Donaldson, 2000). In such a benevolent work environment, staff should feel more supported and thus more committed to the organization overall.

Hypothesis 3: Benevolent ethical environments will be positively related to care providers' organizational commitment, job engagement, and patient safety.

The Mediating Role of Psychological Safety

Optimal working environments in health care should benefit both patients and care providers because of positive psychological states experienced by care providers in such an environment (Rathert & May, 2007a). Of interest in this study was the mediating role of psychological safety. Identifying antecedents to psychological safety is important because health care providers who are more psychologically safe have been shown to make more medical error interceptions (Edmondson, 1996) and learn new techniques more efficiently (Edmondson, Bohmer, & Pisano, 2001), and employees who are more psychologically safe also tend to be more engaged in their work (May et al., 2004). Furthermore, psychologically safe staff tend to engage in more quality improvement efforts (Nembhard & Edmondson, 2006) and less in workarounds (Halebesleben & Rathert, 2008). Thus, we expected care providers who feel more psychologically safe to be more engaged in their work and more committed overall to the organization because of the support they feel. Because staff should be more comfortable speaking up or correcting flawed care processes, patient safety should be improved.

The theoretical framework tested in this study proposes that the work environment can elicit psychological safety in care providers (Rathert & May, 2007a). An environment that supports patient-centered care should help providers feel safe because they are supported in engaging themselves fully in the work for which they feel a calling. An environment that supports CQI practices should elicit psychological safety because providers are empowered to study their work processes and are expected to initiate improvements in patient care practices. A caring and benevolent ethical environment also should support psychological safety because of its emphasis on decisions that support patients, the unit, and the community, as opposed to encouraging defensive behaviors. Thus, given that psychological safety should result from the work environment and should be antecedent to positive outcomes, we hypothesized that psychological safety would mediate relationships between the work environment and outcomes. Still, we acknowledge that work environments may operate through additional mechanisms not explored here. Thus, we proposed the following:

Hypothesis 4: Psychological safety will partially mediate the relationship between the work environment and care providers' organizational commitment and job engagement and patient safety.

Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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