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
Organization of acute hospital wards
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
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A. Adams and S. Bond
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.
1162 © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 1158–1167
Organization of acute hospital wards
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
1163© 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 1158–1167
A. Adams and S. Bond
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
1164 © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 26, 1158–1167
Organization of acute hospital wards
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-
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