Improving the Health Care Work Environment: Implications for Research, Practice, and Policy

Organizational Strategies for Providing Cancer Palliative Care to Many

PURPOSE

Hospitals and healthcare organizations are today operating in an extremely competitive environment, with increasing pressure to improve quality while reducing costs. In responding to this dynamic situation, transformation of any organization requires the will to organize delivery around the needs of patients.

RECENT FINDINGS

Providing palliative care to the many who require it needs the value agenda to be formulated based on mutually reinforcing components. Here we present an overview of the framework for a palliative care department in a comprehensive cancer center, which includes different levels that are embedded within a comprehensive system. Detailed information on each level is presented, followed by a discussion of quality of care, as an integrating theme for the framework. The chapter concludes by detailing the benefits that a comprehensive cancer palliative care center provides to a country's healthcare efforts through service, education, research, and advocacy.

Hispanic nurses' experiences of bias in the workplace

PURPOSE

The continuing issue of health inequity for Hispanics highlights the importance of retaining Hispanic nurses in the workplace. This article describes the use of short answers such as "Describe the bias you experienced" and "If a patient refused care, what was the reason given?" to increase understandings about bias through the descriptions of Hispanic nurses. In this study, bias was defined as those implicit negative stereotypes and attitudes that negatively affect judgments about, evaluations of, and actions toward others.

DESIGN/METHOD

For this qualitative component of a descriptive study employing both qualitative and quantitative methods, 111 Hispanic nurses responded to open-ended questions about experiences of bias that were included with a survey tool and demographic questionnaire.

FINDINGS

Three themes emerged: being overlooked and undervalued, having to prove competency, and living with "only-ness." Respect was an overarching concept.

DISCUSSION/CONCLUSIONS

The written descriptions of bias provided depth and understanding to the quantitative findings. Nurse leaders are well positioned to develop and implement strategies to more effectively support Hispanic nurses and to promote nonbiased interactions in the workplace.

IMPLICATIONS

Retaining Hispanic nurses is a vital component to address issues of health inequity for Hispanic patients.

Methods and metrics challenges of delivery-system research

Background

Many delivery-system interventions are fundamentally about change in social systems (both planned and unplanned). This systems perspective raises a number of methodological challenges for studying the effects of delivery-system change--particularly for answering questions related to whether the change will work under different conditions and how the change is integrated (or not) into the operating context of the delivery system.

Methods

The purpose of this paper is to describe the methodological and measurement challenges posed by five key issues in delivery-system research: (1) modeling intervention context; (2) measuring readiness for change; (3) assessing intervention fidelity and sustainability; (4) assessing complex, multicomponent interventions; and (5) incorporating time in delivery-system models to discuss recommendations for addressing these issues. For each issue, we provide recommendations for how research may be designed and implemented to overcome these challenges.

Results and conclusions

We suggest that a more refined understanding of the mechanisms underlying delivery-system interventions (treatment theory) and the ways in which outcomes for different classes of individuals change over time are fundamental starting points for capturing the heterogeneity in samples of individuals exposed to delivery-system interventions. To support the research recommendations outlined in this paper and to advance understanding of the "why" and "how" questions of delivery-system change and their effects, funding agencies should consider supporting studies with larger organizational sample sizes; longer duration; and nontraditional, mixed-methods designs.

A version of this paper was prepared under contract with the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services for presentation and discussion at a meeting on "The Challenge and Promise of Delivery System Research," held in Sterling, VA, on February 16-17, 2011. The opinions in the paper are those of the author and do not represent the views or recommendations of AHRQ or the US Department of Health and Human Services.¹

Improving the health care work environment: a sociotechnical systems approach

This issue examines findings on key elements of the hospital environment, identifies risks to safety and quality, and proposes operational and policy solutions.