clinical specialty and organizational features of acute hospital wards

Journal of Advanced Nursing, 1997, 26, 1158–1167

Clinical specialty and organizational features ofacute hospital wards

Ann Adams PhD BA MSc RN

Research Fellow, Postgraduate Research School, European Institute of Health and

Medical Sciences, Stag Hill Campus, University of Surrey, Guildford

and Senga Bond PhD RN FRCN

Professor of Nursing Research, Centre for Health Services Research, School of Health

Sciences, University of Newcastle upon Tyne, Newcastle upon Tyne, England

Accepted for publication 27 November 1996

ADAMS A. & BOND S. (1997) Journal of Advanced Nursing 26, 1158–1167

Clinical specialty and organizational features of acute hospital wards

Ward clinical specialty is a variable which has been largely ignored in studies of

nursing organization and effectiveness. Analysis of data collected from a

nationally representative sample of 83 acute medical, surgical and orthopaedic

hospital wards demonstrates that while wards had similar staffing resources,

differences exist in the likelihood of adopting a nursing organizational system

with devolved authority, in nurses’ views of prevailing hierarchical attitudes,

and their perceived influence over a range of organizational features of the

ward. Medical wards were more likely to have developed organizational

practices associated with increasing nursing autonomy.

Keywords: clinical specialty, ward organization

Competencies Rating Scale (Wandelt & Stewart 1975), andINTRODUCTION

proxy measures, such as clinical grade, have also been

used (e.g. Carr-Hill et al. 1992). Finding ways of determin-Studies of organizational features of hospital wards associ-

ated with nursing effectiveness have three major foci. ing appropriate numbers of nurses according to workload,

chiefly defined by patient dependency and analysis ofThese are: staffing characteristics, nursing organizational

systems, and, to a lesser extent, quality of ward leadership. nurses’ work activity, has been the subject of research over

many years (e.g. Scottish Home and Health Department

1967, Duberley & Norman 1990). Belief that a successfulStaffing characteristics

formula can be found has underpinned the development

of nurse management information systems, which, despiteResearch related to staffing characteristics has examined

staffing levels and the range of clinical competencies increasing evidence of ineffectiveness ( Jenkins-Clarke

1992, Procter 1995), are still widely used in acute NHSamong ward staff. These characteristics have been exten-

sively studied in relation to the effects they have on pro- hospitals.

cesses and, to a lesser extent, outcomes of care (e.g. Auld

1976, Telford 1979, Ball et al. 1984, Melhuish et al. 1993).Organizational systems

Bagust et al. (1992) report that nurses rate care to be of a

higher quality when there are more nursing staff on duty Attempts to study the effectiveness of nursing organiz-

ational systems has yielded a great deal of weak research.and when there is a higher proportion of qualified staff.

While there are no universally accepted methods of meas- While organizational practice is to some extent associated

with staffing characteristics, connections between the twouring nurses’ competence, scales have been developed in

the USA for this purpose, e.g. the Slater Nursing are not well developed. Some links between staffing

1158 © 1997 Blackwell Science Ltd

Organization of acute hospital wards

characteristics, particularly number of staff and levels of marked than differences in the quality of team working

between hospital sites. Carr-Hill et al. (1992), while ignor-competency, and the rigours of operating certain organiz-

ational systems have been made (e.g. Procter 1989). ing clinical specialty in selecting their sample of wards,

found no consistent differences between wards of differentDevolved systems and primary nursing in particular, are

considered to operate most successfully with a consistent clinical specialty when assessing the relationship between

clinical grade mix and quality of care provided forsupply of adequate numbers of permanent ward nurses to

provide continuity of care and personnel (Bond et al. 1990, patients.

There is, however, some sociological evidence whichPearson 1992, Proctor 1995), and where there is a core of

nurses with sufficient clinical expertise to act as primary suggests that clinical specialty is associated with the

nature of nursing. Surgical nursing is said to emphasizenurses (Marram et al. 1974, Hall et al. 1975, Sears &

Williams 1991, Ersser & Tutton 1991). the ‘instrumental’ role of rational problem solving and

technical proficiency, while medical nursing stresses theStudies have attempted to establish which system is

most effective for patients, nurses and the hospital insti- more ‘affective’ compassionate, caring and protective

aspects of nursing (Smith 1976). Clinical specialty is alsotution (e.g. Giovanetti 1981, Chavigny & Lewis 1984, Reed

1988), in particular comparing the relative merits of team associated with the nature of multi-disciplinary working

relationships and nurses’ job satisfaction, both of whichand primary nursing. For a variety of methodological

reasons, the results of this work have been inconclusive are perceived to affect the quality of care provided for

patients within a ward (Mackay 1991, Elander &(Giovanetti 1986, MacGuire 1989, Thomas & Bond 1991).

One reason is that examples of nursing systems exhibiting Hermeren 1991, Cavanagh 1992). Coser (1963) found that

nurses working in an acute ward experienced less alien-all of the criteria described in the literature, and con-

trolling for other variables, do not exist in practice, ren- ation than nurses working in the rehabilitation ward in

the same hospital. She attributed this to greater com-dering comparison well nigh impossible. Nurses develop

organizational systems which approximate to ideal types, plexity in the work role sets of nurses in the acute ward,

which provided opportunities for greater multi-but which are moulded to suit local circumstances and

which operate flexibly in order to cope with variations in disciplinary contact of a more stimulating nature. Reed &

Bond (1991) found differences in how nurses approachedward workload and staffing levels (Anderson & Choi

1980, Thomas & Bond 1990, Mead 1993). Such findings their work in acute and long-term care of elderly people

wards. In the latter, with an inappropriate ideal of cure,have led to a growing recognition of the need for descrip-

tions of nursing in hospital wards which take account of nurses found difficulty in obtaining satisfaction from

their work which was perceived as having low status.staffing characteristics and organizational systems, along

with other aspects of ward structure and care processes. These findings reflect different social milieu associated

with clinical purpose.

More recently, sociological analysis of the powerWard clinical specialty and nursing

relationships existing in the multi-disciplinary health care

team in the acute sector, has suggested that different powerWard clinical specialty remains one aspect of structure

which has been largely ignored in studies of staff relation- balances operate within different clinical specialties.

Mackay (1989, 1993) considers that where the need forships (McMahan et al. 1994) and nursing effectiveness. For

example, it does not appear as a parameter in any of the medical intervention is less and the need for nursing is

both frequent and skilled, as in acute care of the elderlynursing management information systems, which aim to

supply ward specific staffing and workload information and general medical wards, nurses develop greater self-

confidence and autonomy in their practice, and nurses andbased on tasks and/or patient dependency levels. In stud-

ies comparing nursing organizational systems, study doctors are more likely to collaborate as equals. Work car-

ried out in Oxford provides clinical evidence to supportwards tend to be matched according to clinical specialty

(e.g. Martin & Stewart 1983), thereby removing or con- this argument, where nurses operating the devolved pri-

mary nursing system demonstrated their ability to functiontrolling out any effects of clinical specialty, so that the

contribution of this variable to processes and outcomes of more autonomously and to develop professional work

practices in both medical and care of elderly people wardscare remains unknown.

Studies which have examined the overt effects of ward (Pearson et al. 1992, Titchen & Binnie 1995).

On the other hand, in surgical wards, where there is lessclinical specialty on care processes and outcomes show

conflicting findings. Recent research suggests that ward clinical uncertainty to tolerate and less opportunity for

nurses and surgeons to work together, nurses’ skills areclinical specialty explains less variation in process fea-

tures of nursing than the prevailing hospital ethos of care. more likely to be overlooked and devalued. Parkes (1982)

found more stress among nursing students in medical com-Walby et al. (1994) found differences between the quality

of team working between doctors and nurses in different pared with surgical wards. Job satisfaction and job dis-

cretion scores were higher in surgical wards when bothclinical specialties within the same hospital to be less

1159© 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 1158–1167

A. Adams and S. Bond

types of ward had the same work pressure, and a moreMETHOD

favourable social climate was perceived to prevail in the

surgical wards. These findings suggest that nursing stud-Sample

ents may hold different views about nursing and social

climate than their qualified seniors. Current research The sample comprised a nationally representative sample

of 119 wards in 17 acute hospitals in seven Englishwhich examines how nurses make decisions, also under-

lines the importance of the clinical specialty within which regional health authorities. Wards were drawn from the

range of clinical specialties and represent a good balancenurses work. Significant differences were found in the

sources and types of information nurses used in clinical between broadly medical and surgical wards. Highly

specialized and critical care units were excluded. Nursesdecision-making in surgical and medical wards (Lamond

et al. 1996). Collectively, this research highlights the of grades C and above appearing on the day time off-duty

rota were included.varied nature of nursing work in different clinical special-

ties, and the different skills which nurses need to acquire

to function effectively within them. They highlight theResearch tools

importance of attending to how nurses regard their work,

which varies in different clinical specialties, and how they Data were collected about ward characteristics and nursing

practice using a self-completion ward profile (WP).are regarded by others with whom they work.

Questions in the WP related to: ward management, teach-

ing programmes, quality assurance and audit programmes,Aims of the study

multi-disciplinary working, staffing resources and the

accomplishment of a range of nursing activities. The WPAs part of a wider study of organizational aspects of nurs-

ing in acute hospital wards, exploration of relationships was distributed by post and completed by either the ward

sister or charge nurse or a deputy, providing one profilebetween clinical specialty and organizational practice, and

a range of structural and process features of nursing care per ward. Pre-coded response options to a set of closed

questions as well as open-ended questions were included.provision were included. In particular, the study investi-

gates differences in objective ward features between Data about nurses’ perceptions of ward organizational

features were collected using the Ward Organizationalspecialties: in staff resources, systems of nursing organiz-

ation and multi-disciplinary working practice. Differences Features Scales (WOFS) (Adams & Bond 1995, Adams et al.

1995). These scales were rigorously tested and found to bein the perceptions of nurses working in medicine, surgery

and orthopaedic wards are explored in relation to: reliable and valid measures of nurses perceptions of

aspects of the ward organizational environment. Theyperceived standards of professional nursing practice

achieved, the quality of multi-disciplinary working include measures of nurses’ perceptions of: the ward

physical environment; standards of professional practice;relationships, nurses’ influence and job satisfaction. It is

expected that significant differences will be found to exist ward leadership; professional working relationships;

nurses’ influence; and nurses’ job satisfaction.between the specialties because of the varied nature of the

care work carried out within them.

In order to focus the investigation, three hypotheses aris-RESULTS

ing out of existing theory were tested. They relate to the

notion that there is a degree of ‘fit’ between certain systemsResponse rates

of nursing organization and the nature of nursing work

undertaken within particular clinical specialties. WP responses were received from 107 wards, a 90%

response rate. However, due to missing data only 83 of the

107 (78%) are included in this analysis.1 Nurses in surgical and orthopaedic wards have more

hierarchical organizational structures than those in Table 1 profiles the study sample according to clinical

specialty, indicating that roughly equal numbers of medi-medical wards.

2 Nurses in medical wards perceive a higher degree of cal and surgical wards were represented in the analysis.

Five acute care of elderly people wards are included ascollaboration with other disciplines than those in surgi-

cal and orthopaedic wards. ‘medical’ wards, and seven gynaecological wards are

included as ‘surgical’ wards. Given the generally longer3 Nurses in medical wards engage in more autonomous

practice than nurses in surgical and orthopaedic wards. in-patient stays of orthopaedic compared with other surgi-

cal wards, as well as differences in resource variables, they

were sufficient to form a separate category in the analysis.Analysis of these relationships will indicate whether clini-

cal specialty is a variable which should be taken into con- Usable responses were received from 825 of the 1499

nurses sampled, a 55% response rate; 592 nurses workedsideration when examining organizational practice in

nursing in acute hospital wards. in the 83 wards, representing 72% of all the responding

1160 © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 1158–1167


Table 1 Ward types included

in each category Medical (n) Surgical (n) Orthopaedic (n)

Acute elderly 5 Gynaecology 7 Trauma 2

Chest medicine 1 Vascular 3 Elective and trauma 11

Haematology 2 Neurosurgery 1

Renal 1 Urology 4

General medicine 24 ENT 3

Ophthalmology 2

General surgery 17

Total 33 37 13

nurses. The number of nurses responding are of a similar no statistically significant differences between wards of

different clinical specialty either in the number of perma-proportion to the wards in the analysis (Table 2).

nent nurses or the qualified/unqualified staff grade mix.

Noteworthy, however, is that for both of these analyses itWard clinical specialty and staffing resources

is orthopaedic wards which fare worst.

Analysis of the qualified nurse:bed ratio within wards in

the study sample revealed a range of scores from 0·4 to 1·4Ward clinical specialty and system of nursing

permanent ward nurses per ward bed, with a mean ratioorganization

of 0·7. Analysis of variance of the ratio of permanent ward

nurses:beds revealed no significant differences between The organizational system in use was defined according

to an empirically derived classification system for wardsclinical specialties (Table 3). The mean values for ratio of

permanent qualified nurses:beds are: medical wards 0·79; based on hierarchical cluster analysis of features of ward

nursing practice collected in the WP, and is fully describedsurgical wards 0·71, and orthopaedic wards 0·64.

There are more qualified nursing staff (grades C and in Adams et al. (in press). The analysis identified three

major clusters named ‘devolved’, ‘two-tier’, and ‘cen-above), as a percentage of all permanent nursing staff,

working in surgical wards (87%) compared with both tralized’ nursing, to include all wards.

medical (80%) and orthopaedic (79%) wards. These differ-

ences approached statistical significance when using the Devolved nursingKruskal-Wallis test (H=5·56, P<0·06). There are therefore While nurses in most of the wards practising ‘devolved

nursing’ work in groups or teams, the focus of responsi-Table 2 Profile of the study sample in designated ward clinical bility for care is more firmly vested in individual nurses;specialty hence the label ‘devolved nursing’. Updating and responsi-

bility for care plans and contacting other health care pro-Wards Nurses

fessionals and relatives is most usually done by any RN

within this system, and those who most usuallyClinical specialty n % n %

accompany doctors on their ward rounds are nurses caring

for particular patients seen on the round. Compared withMedicine 33 40 257 43

the other two, this system has the highest incidence ofSurgery 37 45 252 43nurses in charge of the shift or nurse coordinators alsoOrthopaedics 13 15 83 14

accompanying ward rounds, but ward sisters or chargeTotal 83 100 592 100

nurses do not fulfil this role. This system has the lowest

incidence of sisters or charge nurses contacting other

health care professionals or relatives.Table 3 Analysis of variance of ratio of permanent ward

The focus on individual nurse responsibility for care isnurses:beds in three clinical specialtiesreflected in the way in which oral medications are admin-

istered and reports are made on patients’ progress. TheSum of Mean

most common mode of oral medication administrationSource d.f. squares squares F ratio Probability

for this system is individual nurses distributing medi-

Between groups 2 2023·44 1011·72 2·29 0·11 cines to their individual patients, and the large formal

Within groups 62 28388·70 441·75 daily ward report where information is shared about all

patients is not a feature in these wards. It is also notice-Total 64 29412·15able that student nurses, nursing auxiliaries and health



Table 4 Relationship between ward clinical specialty and systemcare assistants do not contact patients’ families, a taskof nursing organizationreserved for nurses.

This system appears to be close to the ‘ideal type’ ofWard clinical specialtyprimary nursing organization, although it is noticeable that

not all wards are described as having nurses working inNursing Medicine Surgery Orthopaedics

groups, and that sisters and charge nurses maintain a rela-organizational

tively high degree of contact with other health care pro-system n % n % n %

fessionals and relatives. These responsibilities are

described in the literature as being devolved from the sisterDevolved 3 11 3 11 0 0

or charge nurse to the domain of the primary nurse (e.g. Two-tier 23 86 19 63 12 100Ersser & Tutton 1991). Centralized 1 3 8 26 0 0

Total 27 100 30 100 12 100Two-tier nursing

‘Two-tier’ represents the most common method of organiz-P<0·05.

ing nursing at acute ward level. It is characterized by

nurses working in groups or teams, and where a group

leader has responsibility for coordinating certain aspects by one round for all patients and a daily formal report on

the progress of all patients is given between the morningof nursing work. The dominant mode of oral medication

administration is by group or team drug round. While team and afternoon staff, where again most staff on both shifts

attend. Some wards within the cluster also have nursesor group responsibility for patient care is central, vestiges

of a more hierarchical structure remain; hence the epithet working in groups or teams.

There was a statistically significant association between‘two-tier nursing’. Compared with the other two systems

identified, wards which practice in this way have the high- ward clinical specialty and nursing organizational system

(Table 4).est incidence of sisters or charge nurses accompanying

doctors on their ward rounds, and a high incidence of Surgical wards adopt more varied systems of nursing

organization compared with medical and orthopaedicthese same nurses being responsible for contacting both

other health care professionals and relatives. All the wards wards. The dominant system in all three specialties is

‘two-tier’ nursing, but amongst surgical wards there is alsopractising ‘two-tier’ nursing were found to have one large

formal daily ward report on all patients, which is well a higher prevalence of ‘centralized’ nursing, indicating that

a more traditional approach to work organization remainsattended by both morning and afternoon staff. Ward report

practice was found to be another useful discriminator in more wards. In medical wards only one ward used the

‘centralized’, more traditional system. In orthopaedicsbetween nursing organizational systems. While in many

ways this system is like team nursing, these latter charac- there is no variety of system: all wards have adopted the

two-tier system. The findings suggest an association be-teristics are contrary to the ‘ideal type’ described in litera-

ture (e.g. Boekholdt & Kanters 1978, Waters 1985), and tween ward clinical specialty and the system of nursing or-

ganization, indicative of a greater adherence to hierarchicalsuggest that in reality most ward sisters retain a higher

degree of control and authority within wards than the working and task orientation within surgical wards.

‘ideal’ model suggests.

Quality assurance, audit and aspects of multi-Centralized nursing

disciplinary workingIn ‘centralized nursing’, power and control remains firmly

in the hands of the ward sister or charge nurse. Compared In addition to examining the relationship between ward

clinical specialty and systems of nursing organization,to the other two, this system has the lowest degree of group

or team working and the formal group leader role does not relationships between clinical specialty and approaches to

quality assurance, ward audit and aspects of multi-exist. Instead, nursing responsibilities are most usually

shared jointly by any RN, the nurse in charge of the shift disciplinary working practice were also explored. This

provided a more thorough analysis of the nature and distri-and the ward sister or charge nurse. The nurse in charge

of the shift or the co-ordinator most usually accompanies bution of work environments existing in the three types

of ward.doctors on their rounds, and compared to the other two,

this system has the highest incidence of sisters or charge

nurses contacting other health care professionals andWard nursing audit

relatives.

This centralization of control and authority over care is The conduct of audits of ward nursing practice was con-

sidered to be an indicator of more innovative nursing atreflected in drug round and report practice. The dominant

mode of oral medication administration in these wards is ward level, likely to be associated with ‘devolved’ practice.



Table 6 Relationship between ward meetings to discuss specificTable 5 Relationship between ward nursing audit and clinical

specialty patients and ward clinical specialty

Ward clinical specialtyWard clinical specialty

Medicine Surgery OrthopaedicsMedicine Surgery Orthopaedics

Ward nursingWard nursing

audit n % n % n %audit n % n % n %

Yes 13 54 19 60 7 64 Yes 22 79 19 54 7 58

No 6 21 16 46 5 42No 12 46 11 40 4 36

Total 28 100 35 100 12 100Total 25 100 30 100 11 100

P=0·07.P=0·66.

The existence of audits of nursing was found to be more of higher participation of senior medical staff in medical

wards was also evident in multi-disciplinary meetings toprevalent in orthopaedics, where 64% of wards reported

that audit of ward nursing practices is taking place, com- discuss ward policy, although again there were no statisti-

cally significant differences between clinical specialties.pared to 60% and 54% of surgical and medical wards

respectively (Table 5). However, these differences do not

reach statistical significance.Clinical specialty and features of the ward

While orthopaedic wards reported the highest levels oforganizational environment

audit activity, in most cases the development had not been

initiated at ward level. Fifty-seven per cent of orthopaedic In order to develop the analysis further, to embrace nurses’

perceptions of the wards in which they provide care, thewards reported that audit of ward nursing practice was

introduced through senior management, compared with relationship between pertinent WOFS scales and clinical

specialty was examined. Scales included in the analysis50% of surgical wards and 35% of medical wards. Ward-

led developments, by sisters and charge nurses, were more were considered relevant to testing the stated hypotheses

regarding autonomous and hierarchical practice andprevalent in medicine, where 41% of wards reported this

being the case, compared with 36% surgical and 29% of collaboration between nurses and with other disciplines.

Multivariate analysis of variance between nurses’ scoresorthopaedic wards. These findings provide support for the

hypothesis that medical wards are more likely to be on selected WOFS scales and subscales and ward clinical

specialty indicated differences (P<0·001) in the organiz-characterized by a higher degree of ward-based nursing

innovation compared with the other two specialties. ational environment of medical, surgical and orthopaedic

wards. In order to examine whether these differences are

consistent with the hypotheses, analysis of variance wasMulti-disciplinary working

conducted between individual scale scores and clinical

specialty (Table 7).Differences between specialties were evident in the pattern

of multi-disciplinary ward meetings. Seventy-nine per Differences between clinical specialty were not evident

where perceived quality of nursing practice is assessed bycent of medical wards reported having meetings to discuss

individual patients, compared with 58% of orthopaedic the WOFS subscale ‘professional practice’. However, there

are differences (P<0·05) in the WOFS subscale ‘hierarchi-and 54% of surgical wards (Table 6). These results are per-

haps not surprising given the nature of care provided in cal practice’ which measures a style of nursing charac-

terized by lack of innovation and staff development, wheremedical wards, which tends to be more conservative and

of longer duration compared with surgical care in particu- nurses feel that their work is devalued both by nurse man-

agers and medical staff. Comparison of mean scores withinlar, where increasingly patients are discharged home very

soon after surgery. However, the differences do not reach each specialty revealed higher scores in orthopaedic wards

(15·3), with the lowest scores occurring in medical wardsstatistical significance, given the similarity of findings in

the surgical and orthopaedic wards. (14·4). This finding supports the first hypothesis, that hier-

archical attitudes to care will be more prevalent in ortho-The attendance of senior medical staff at ward meetings

was considered to be indicative of multi-disciplinary col- paedic and surgical wards; but does not provide evidence

to support the contention that nursing practice in medicallaboration. The highest incidence of senior medical staff

participation in meetings to discuss specific patients wards is regarded by nurses themselves as more

innovative.occurred in medical wards (65%), compared with 58% of

surgical wards and 43% of orthopaedic wards. This trend Turning to inter-professional relationships, we found no



Table 7 Comparison of nurses’

WOFS scores between clinical

specialtiesDegrees

Source of of Sum of Mean P

Name of scale variance freedom squares squares F ratio value

Professional practice Between groups 2 106·77 53·39 2·39 0·09

Within groups 519 11614·23 22·38

Total 521 11721·00

Hierarchical practice Between groups 2 112·63 56·32 6·05 0·003

Within groups 589 5482·80 9·31

Total 591 5595·43

Collaboration with Between groups 2 44·16 22·08 1·35 0·26

doctors Within groups 519 8519·45 16·42

Total 521 8563·66

Collaboration with Between groups 2 16·88 8·44 1·23 0·29

other health care Within groups 519 3572·52 6·88

professionals Total 521 3589·40

Cohesion amongst Between groups 2 175·92 87·96 3·38 0·03

nurses Within groups 589 15338·89 26·04

Total 591 15514·81

Influence over ward Between groups 2 478·80 239·40 3·89 0·02

management Within groups 519 31976·58 61·61

Total 521 32455·38

Influence over the Between groups 2 88·51 44·25 1·50 0·22

timing of ward and Within groups 519 15283·14 29·45

patient events Total 521 15371·64

Influence over ward Between groups 2 51·88 25·94 2·06 0·13

human and financial Within groups 519 6544·27 12·61

resources Total 521 6596·15

Staff organization Between groups 2 24·01 12·01 1·63 0·20

Within groups 519 3818·55 7·36

Total 521 3842·57

Job satisfaction Between groups 2 9·98 4·99 0·47 0·63

Within groups 519 5552·31 10·70

Total 521 5562·29

differences between clinical specialties in perceived col- There were no differences between specialties in the

extent to which nurses perceived the appropriateness oflaboration between nurses and medical staff or with other

health care professionals. A statistically significant finding staffing and work organization to workload (the staff

organization WOFS sub-scale) or in job satisfaction.(P<0·05) which was contrary to expectations, was that

nurses working in orthopaedic wards perceived them-

selves to be most cohesive, while nurses in medical wardsDISCUSSION

perceived least cohesion with nursing colleagues. We

hypothesized that nurses in medical wards would regard This comparison of some of the organizational features of

three different types of acute hospital ward, classified bythemselves as having a greater degree of autonomous prac-

tice. While the WOFS influence scales tend to yield uni- medical treatment criteria, indicate that some similarities

and differences exist between them. There were no sig-formly low scores, we found no differences between the

clinical specialties in relation to perceived influence over nificant differences in the permanent nurse:bed ratios or

the qualified:unqualified nursing staff ratios, although forward resources or the timing of ward and patient-related

events. We did, however, find that there was a difference both of these staffing indices, orthopaedic wards, which

typically have a large proportion of heavy and elderlyin influence over ward management — a sub-scale which

assesses perceived influence over a range of administrative patients with multiple pathology, fared worst.

Differences were found between specialties in the likeli-tasks associated with nursing and staffing issues. Nurses

in medical wards felt that they had greater influence (mean hood of adopting more devolved nursing systems or retain-

ing more traditional hierarchical systems. More medicalscore 22·4) and nurses in orthopaedic wards least (mean

score 20·7). wards adopted a devolved nursing system and more



surgical wards retained a more hierarchical system. While there are more likely to be differences between acute wards

and wards characterized as rehabilitation or continuingour first hypothesis is accepted, it is evident that only a

minority of medical wards show more than a limited care, where the clinical ethos and the pace of work are

different. Within the acute sector, the degree of devolutiondegree of devolved practice. The large majority of wards

organize nursing on the basis of some degree of responsi- of nursing, attitudes to practice and the nature of inter-

professional working also may be more different whenbility devolved from the ward sister to other staff, but only

to a limited extent, and not to the extent that would charac- comparisons are drawn with high dependency or critical

care units, than differences between lower dependencyterize primary nursing organization, where named staff

have continuous responsibility for the management and adult medical and surgical wards. Also, hospital-wide dif-

ferences exist. Staffing matters, like the ratio of registereddelivery of care to individual patients.

In line with nurses in medical wards being more likely nurses to other personnel and nurse:patient ratios, as well

as organizational features such as the degree of autonomyto adopt more devolved systems, we found them to be less

likely to perceive that hierarchical attitudes to practice and control afforded nurses (Aiken et al. 1994) are associ-

ated with differences in patient mortality. Organizationalprevailed, to be more likely to hold multi-disciplinary

meetings to discuss individual patients, and to have and staff relationship differences between different units

within clinical specialties, such as intensive care (Shortellgreater involvement of senior medical staff in these meet-

ings. However, this did not translate into feelings among et al. 1994), have been shown also to be associated with

patient outcomes, as well as with nurse’s job satisfactionmedical nurses that nursing was more professionally

advanced, or that more collaborative relationships existed (Baggs & Ryan 1990).

with medical or other health professionals than were

found in the other two types of ward. In fact medicalCONCLUSION

nurses reported less positive attitudes towards their nurs-

ing colleagues than did other nurses. Our second hypoth- The findings of the present study show that there are differ-

ences between wards and nurses in acute hospital clinicalesis, that medical nurses would perceive a higher degree

of collaboration with other disciplines is rejected. It was specialties. On the whole, nurses in medical

wards are more likely to have greater autonomy, whichnurses in orthopaedic wards, which had least involvement

of medical staff, who felt warmest towards their nursing has implications for patient welfare, than nurses in surgi-

cal or orthopaedic wards. The clinical designation of thecolleagues. They also perceived that more hierarchical atti-

tudes towards nursing prevailed in their wards than did ward in which care is provided is therefore one potentially

influential variable associated with nursing organizationalsurgical nurses. Surgical wards and nurses’ attitudes

within them appear to be a less homogeneous group, with features. The evidence is such that there may be subtle

differences associated with the nature of the medical treat-some surgical wards retaining centralized work

organization. ment and associated nursing work, which are related to,

or influence organizational variables associated withWith regard to the extent of autonomous practice, it was

nurses in medical wards who themselves were more likely increasing nursing staff autonomy, and are distinct

from hospital-wide or individual staff considerations.to have introduced ward audits and to have a greater sense

of contributing to decision making over a range of ward Discovering what these differences are requires a different

form of research.administrative and organizational issues, compared with

their surgical or orthopaedic counterparts. Our third

hypothesis is therefore partially upheld, that nurses inAcknowledgements

medical wards are more likely to engage in more

autonomous practice. We would like to thank all of the nurses and managers

who so generously gave their time to assisting us in thisThat there were no differences in job satisfaction

between nurses working in the three types of ward study, to Gillian Carey, Claire Hale, Claire Hawkes and

Helen Quinn who assisted in devising the scales and col-reinforces that factors other than the medical treatment

provided, and associated characteristics of staff and lecting data, Sara Arber for her constructive advice and

support and to Mike Procter for statistical advice. Thepatients, are more influential in determining how nurses

feel about their work. study was supported by a grant from the Department of

Health. The views expressed are those of the authors andTaken together, we find that comparison between three

acute clinical specialties shows some indications that not the funding body.

nurses in these medical wards are somewhat more pro-

gressive in adopting nursing systems that rely on increasedReferences

delegation and autonomy, while having more involvement

with medical colleagues. Earlier studies of different nurs- Adams A. & Bond S. (1995) Nursing Organisation in Acute Care:

The Development of Scales. Report No. 71. Centre for Healthing orientations to work and relationships suggest that



Services Research, University of Newcastle upon Tyne, Jenkins-Clarke S. (1992) Measuring Nursing Workload: A

Cautionary Tale. Centre for Health Economics, University ofNewcastle upon Tyne.

Adams A., Bond S. & Arber S. (1995) Development and validation York, York.

Lamond D., Crow R., Chase J., Doggen K. & Swinkels M. (1996)of scales to measure organisational features of acute hospital

wards. International Journal of Nursing Studies 32(6), 612–627. Information sources used in decision-making: considerations

for simulation development. International Journal of NursingAdams A., Bond S. & Hale C.A. (1998) Nursing systems revisited:

identifying a classification system for ward organisational prac- Studies 33(1), 47–57.

MacGuire J. (1989) An approach to evaluating the introduction oftice. Journal of Advanced Nursing, in press.

Aiken L.H., Smith H.L. & Lake E.T. (1994) Lower medicare mor- primary nursing in an acute medical unit for the elderly— II.

Operationalizing the principles. International Journal oftality among a set of hospitals known for good nursing care.

Medical Care 32(8), 771–787. Nursing Studies 26(3), 253–260.

Mackay L. (1989) Nursing a Problem. Open University Press,Anderson M. & Choi T. (1980) Primary nursing in an organis-

ational context. Journal of Nursing Administration 10(3), 26–30. Milton Keynes.

Mackay L. (1991) Inter-professional relations: doctors and nursesAuld M. (1976) How Many Nurses? RCN, London.

Baggs J.C. & Ryan S.A. (1990) ICU nurse-physician collaboration in hospitals. Paper presented at the BSA Medical Sociology

Conference, September. University of York, York.and nursing satisfaction. Nursing Economics 8(6), 386–392.

Bagust A., Slack R. & Oakley J. (1992) Ward Nursing Quality and Mackay L. (1993) Conflicts in Care: Medicine and Nursing.

Chapman and Hall, London.Grade Mix: Report of Paired Ward Experiments in the North

Western Region. York Health Economics Consortium, Marram G., Schlegel M. & Bevis E. (1974) Primary Nursing: A

Model for Individualised Care. Mosby, Saint Louis.University of York, York.

Ball J.A., Goldstone L.A. & Collier M.M. (1984) Criteria for Care. Martin P.J. & Stewart A.J. (1983) Primary and non-primary nurs-

ing-evaluation by process criteria. The Australian Journal ofThe manual for the Northwest Nurse Staffing Levels Project,

Polytechnic Products Ltd, Newcastle upon Tyne. Advanced Nursing 1(1), 31–37.

McMahan E.M., Hoffman K. & McGee G.W. (1994) Physical-nurseBoekholdt M.G. & Kanters H.W. (1978) Team nursing in a general

hospital: theory, results and limitations. Journal of relationships in clinical settings: a review and critique of the

literature 1966–1992. Medical Care Review 51(1), 83–112.Occupational Psychology 51, 315–325.

Bond S., Fall M., Thomas L., Fowler P. & Bond J. (1990) Primary Mead D.M. (1993) The development of primary nursing in NHS

care giving institutions in Wales. Unpublished PhD thesis,Nursing and Primary Medical Care: A Comparative Study in

Community Hospitals. Health Care Research Unit Report University of Wales, Cardiff.

Melhuish E., Maguire B., Nolan M. & Grant G. (1993) The pro-No. 39, University of Newcastle upon Tyne, Newcastle upon

Tyne. fessional role of the nurse. British Journal of Nursing 2(6),

330–335.Carr-Hill R., Dixon P., Griffiths M., Higgins M., McCaughan D. &

Wright K. (1992) Skill Mix and the Effectiveness of Nursing Parkes K.R. (1982) Occupational stress among student nurses: a

natural experiment. Journal of Applied Psychology 67(6),Care. Centre for Health Economics, University of York, York.

Cavanagh S.J. (1992) Job satisfaction of nursing staff working in 784–796.

Pearson A. (1992) Nursing at Burford: A Story of Change. Scutarihospitals. Journal of Advanced Nursing 17, 704–711.

Chavigny K. & Lewis A. (1984) Team or primary nursing care? Press, Harrow.

Pearson A., Punton S. & Durant T. (1992) Nursing Beds: AnNursing Outlook 32(6).

Coser R.L. (1963) Alienation and the social structure: case analysis Evaluation of the Effects of Therapeutic Nursing. Scutari

Press, Harrow.of a hospital. In The Hospital in Modern Society (Freidson E.

ed.), Collier-Macmillan, London. Procter S. (1989) The function of nursing routines in the manage-

ment of transient workforce. Journal of Advanced Nursing 14,Duberley J. & Norman S. (1990) Nursing Workload Measurement

and Nursing Data for Resource Management. Financial 180–189.

Procter S. (1995) Planning for continuity of carer in nursing.Management Directorate, Resource Management Unit, NHS

Management Executive, London. Journal of Nursing Management 3, 169–175.

Reed J. & Bond S. (1991) Nurses’ assessment of elderly patientsElander G. & Hermeren G. (1991) The autonomy of nurses in high

dependency care: conflicts of loyalties and their consequences in hospital. International Journal of Nursing Studies 28(1),

55–64.for patient care. Scandinavian Journal of Caring Science 5(3),

149–156. Reed S.E. (1988) A comparison of nurse-related behaviour, philos-

ophy of care and job satisfaction in team and primary nursing.Ersser S. & Tutton E. (1991) Primary Nursing in Perspective.

Scutari Press, London. Journal of Advanced Nursing 13, 383–395.

Scottish Home and Health Department (1967) Nurses’ Work inGiovanetti P. (1981) Primary Nursing — Is it the Answer?

Research — A Base for the Future? Edinburgh University Hospitals in the North-Eastern Region. Scottish Home and

Health Department, Edinburgh.Nursing Research Unit, Edinburgh.

Giovanetti P. (1986) Evaluation of primary nursing. In Annual Sears H.J. & Williams S. (1991) Managerial implications of pri-

mary nursing. In Primary Nursing in Perspective. (Ersser S. &Review of Nursing Research (Werley H.H. & Fitzpatrick J.J. eds),

Springer, New York. Tutton E. eds), Scutari, London.

Shortell S.M., Zimmerman J.E., Rousseau D.M. et al. (1994) TheHall L.E., Alfano G.J., Rifkin E. & Levine H.S. (1975) Longitudinal

Effects of an Experimental Nursing Process. Loeb Centre for performance of intensive-care units — does good management

make a difference? Medical Care 32(5), 508–525.Nursing, New York.



Smith J.P. (1976) Sociology and Nursing. Churchill Livingstone, practice: the cultural journey. Unpublished paper presented at

the Royal College of Nursing Research Advisory GroupLondon.

Telford W.A. (1979) Determining nursing establishments. Health Conference, April, Belfast.

Walby S., Greenwell J., Mackay L. & Soothill K. (1994) MedicineService Manpower Review 5(4).

Thomas L.H. & Bond S. (1990) Towards defining the organization and Nursing: Professions in a Changing Health Service. Sage,

London.of nursing care in hospital wards: an empirical study. Journal

of Advanced Nursing 15, 1106–1112. Wandelt M. & Stewart D. (1975) Slater Nursing Competencies

Rating Scale. Appleton-Century-Crofts, New York.Thomas L.H. & Bond S. (1991) Outcomes and nursing care.

International Journal of Nursing Studies 28(4), 291–314. Waters K. (1985) Team nursing. Nursing Practice 1, 7–15.

Titchen A. & Binnie A. (1995) Putting patient-centred nursing into


clinical specialty and organizational features of acute hospital wards

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