The effect of hospital organisational structure on patient and nurse outcomes

A great body of international research has been undertaken to examine the impact of the organisational structure and process on outcomes. However, the effect of hospital organisational structure on patient and nurse outcomes in Saudi Arabia has never been investigated. In general, organisational structure is the most important means of protecting and promoting the quality of patient care. Structure for health services includes the characteristics of resources in the work environment, including for example, the number and skill mix of nursing staff, equipment, and other administrative components, such as policies. Process is the actual care, and includes the technical and interpersonal aspects of care. Outcomes include the changes in patients’ status that can be attributed to the health care and staff outcomes such as workplace satisfaction. Leiter and Laschinger’s Nursing Worklife Model (2006) and Donabedian’s Structure-Process-Outcome (SPO) Model (1966) are theoretical frameworks underpinning nurses’ work and the quality phenomenon, the two principles of focus for the study. The purpose of this thesis was to understand the relationship between hospital structures in seven public hospitals in the Kingdom of Saudi Arabia (KSA) and their key outputs and make recommendations to the Ministry of Health. The researcher is an employee of the Ministry. The aims of this study were: 1. To identify if there is a relationship between hospital organisational structure and job satisfaction; 2. To examine the relationship between hospital organisational structure and nurses’ perception about their practice environment; and 3. To determine the relationship between patient outcomes and nurse staffing levels in ICU. To address these aims, a quantitative-dominant mixed-method research project was designed. In order to achieve a representative sample, the required percentage of intensive care beds in the sample was almost 20 per cent of the total intensive care beds in Ministry of Health (MOH) hospitals. A cross-sectional design was employed to examine the effects of nurse staffing levels on patient mortality, medication errors, and infection rates. A self-reported questionnaire survey was used to describe and compare nurse workplace satisfaction and perceived work environment. The sample was a purposive sample that included 400 intensive care nurses with one year or more experience at their current workplace. The qualitative data were collected through open-ended questions included in the survey to explore nurses’ perceptions of the quality of care and to gain better understanding of the type of organisational structures that support nursing control of practice and nursing leadership. In this study, three research hypotheses are tested; (1) the more decentralised hospital organisational structure, the higher level of workplace satisfaction, (2) the more decentralised hospital organisational structure, the more positive the perception of the practice environment, and (3) the higher the RN skill mix, the lower the mortality and the incidence of adverse events in ICU. The first hypothesis was partially supported. The analysis revealed no differences in the level of satisfaction for nurses in both centralised and semi-autonomous hospital structures; however, the level of satisfaction for nurses working in autonomous was higher than nurses working centralised and semi-autonomous hospitals. The third hypothesis was partially supported. The analysis of data revealed no relationship between nurse staffing levels and patient mortality. However, there was a relationship between nurse staffing levels and medication errors and infection rates. The second hypothesis, which addressed the practice environment, was fully supported. In any health care setting, there is a fundamental requirement to provide high quality patient care that promotes a professional nursing practice environment with clinical guidelines that reflect evolving evidence. Organisational structure, for hospitals in this study, has impacted on the outcomes for patient and nurses. Hospitals with decentralised structure facilitate accomplishment of the organisation goals, in terms of enhanced patient outcomes, greater staff workplace satisfaction and have a more favourable nursing practice environment. This study is the first of its kind in KSA to investigate the impact of hospital organisational factors on patient and nurse outcomes. Further research is recommended in other clinical areas such as medical surgical wards where the majority of patients are cared for, in general hospitals. This will inform the evidence for practice for intensive care patients transferred to or from the wards and for general admissions. The study findings are likely to inform policy makers within the Ministry and elsewhere who are designing effective, quality, health care delivery systems and staff recruitment and retention strategies.