There have been considerable worldwide concerns about hospital performance in patient safety and quality (Baker & Flintoff, 2004; Committee on Quality of Healthcare in America, 2001; Duckett, 2003; Her Majesty's Stationery Office, 2001; McLean & Walsh, 2003; World Health Organization, 2001), with evidence that hospitals have not been successful in achieving acknowledged best practice in quality health care delivery (Braithwaite & Hindle, 1999; Dwyer & Leggat, 2002; Ibrahim & Majoor, 2002; OECD, 2004). Health care is a labor-intensive industry requiring effective human resource management practices (Bartram, Stanton, Leggat, Casimir, & Fraser, 2007; Stanton, 2008). However, a recent study exploring human resource management practice in Australian hospitals found little evidence of implementation of those aspects of Human Resource Management (HRM) that have been linked to better performance in organizational and patient outcomes (Leggat, Bartram, & Stanton, 2008). These findings suggest that improvements in performance management, training and development, job satisfaction, employee empowerment, and decision making were required for hospitals to improve their performance in patient safety and quality of patient care.
Studies of high-performing organizations in a variety of industries have consistently pointed to a positive relationship between high-performance work systems (HPWS; also referred to as high-performance workplaces, high-commitment workplaces, high-involvement work systems, and high-performance practice) and organizational performance (Barraud-Didier & Guerrero, 2002; Delaney & Huselid, 1996; Guthrie, 2001; Youndt, Snell, Dean, & Lepak, 1996). Although many of these studies have been carried out in manufacturing, which is a very different industry from health care (Preuss, 2003), positive correlations between aspects of HPWS and improved patient outcomes have been found in international health care studies. In the United States, a study of "magnet" hospitals, a designation of quality provided by the American Nurses Association, found that increased autonomy and decision-making latitude, empowerment, and nurse/physician collaboration were associated with lower patient mortality rates (Aiken, Smith, & Lake, 1994). West et al. (2002) and West, Guthrie, Dawson, Borrill, and Carter (2006) also focused on patient mortality in the United Kingdom and found positive correlations between lower patient mortality and appraisal, teamwork, and training.
Although there is mounting evidence of a positive relationship between HPWS and organizational performance, the mechanisms through which high-performance systems shape critical outcomes are unclear and as a result have not been well defined (Becker & Gerhart, 1996; Takeuchi, Chen, & Lepak, 2009; Wright, Dunford, & Snell, 2001). Researchers are asking how human resource management systems actually work (Lepak, Liao, Chung, & Harden, 2006) but theorize that HPWS, such as extensive training, information sharing, teamwork, and decentralized decision making, influence employee attitudes and behaviors that ultimately impact their job performance (Takeuchi et al., 2009). In health care, in particular, there is a limited understanding of how the various components of HPWS are used to impact on the care delivery and ultimately influence patient outcomes (Harris, Cortvriend, & Hyde, 2007). This is particularly important in an environment where there is evidence that decreasing organizational commitment and job satisfaction among nurses are associated with declining quality of patient care (Aiken et al., 2001; Mitchell & Shortell, 1997; Shortell et al., 1994). It is clear from this literature that nurse perceptions of job satisfaction and empowerment may play a crucial role in the quality of patient care.
In this study, we extend previous research by outlining how different aspects of HPWS are enacted among hospital nurses in their roles in providing direct patient care. In particular, we investigate the interactive effects of psychological empowerment and job satisfaction on the relationship between HPWS and nurses' perceptions of the quality of patient care. More specifically, we examine the mediating effects of psychological empowerment on the relationship between HPWS and perceptions of quality of patients and the moderating role of job satisfaction. Given the shortages of nurses in most countries, it is essential that these relationships are well defined to assist in ensuring the most effective human resource management practice to ensure high-quality patient care delivery.
Quality of Care
For this study, quality of care is defined as the "degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge" (Lohr & Schroeder, 1990, p. 707). Quality of care has been measured as patient mortality, reduction in adverse events (most commonly impact on medication errors), and patient satisfaction and as a specific clinical outcome. Recent studies have suggested that patient mortality, as currently used, was not a reliable indicator, largely because there insufficient attention is paid to variations in case mix which limited standardization (Gorton, Jones, & Arke, 2005; Penfold, Dean, Flemons, & Moffatt, 2008). Similarly, hospital medication errors and other adverse events have been used as a measure of quality of care (Preuss, 2003), but studies have identified substantial under reporting of adverse events (Uribe, Schweikhart, Pathak, & Marsh, 2002), suggesting that it may not be a robust measure of quality of care.
Patient satisfaction has been confirmed as a valid measure of clinical patient outcomes (Kane, Maciejewski, & Finch, 1997) and therefore an appropriate measure of quality of care. The Victorian Patient Satisfaction Monitor is a voluntary patient satisfaction monitoring process that provides discharged hospital patients in the state of Victoria with an opportunity to complete a questionnaire on their views related to their hospital treatment. The Victorian Patient Satisfaction Monitor reports Victorian public hospital patients' assessment of their hospital stay to identify the areas patients are most satisfied with and those they expect to improve. This information is regularly used by hospitals to improve the quality of the services provided.
High-Performance Work Systems
Overall, there is evidence that aspects of HPWS both individually and in "bundles" are positively related to organizational performance (Batt, 1999, 2002; Delaney & Huselid, 1996; MacDuffie, 1995; Snell & Youndt, 1995; Takeuchi et al., 2009; Youndt et al., 1996). The components of HPWS have been described as "a group of separate, but interconnected human resource practises that together recruit, select, develop, motivate and retain employees" (Zacharatos, Barling, & Iverson, 2005, p. 79). HPWS practices are presumed to affect performance by enhancing employees' knowledge/skills/abilities and commitment and by providing them with the information and discretion necessary to capitalize on these skills and commitment in effectively completing their jobs (Guthrie, 2001; Huselid, 1995; Preuss, 2003).
It is not entirely clear what the essential components of the HPWS bundle are because there have been a range of variables included in the HPWS indices in different organizations (Becker & Gerhart, 1996; Godard, 2004). For this study, we considered the following practices confirmed by Zacharatos et al. (2005) as representative of HPWS: security, selective hiring, contingent reward, extensive training, teams and decentralized decision making, reduced status distinctions, information sharing, transformational leadership, and high-quality work (defined as appropriate workload, role clarity, and employee control).
Although some aspects of HPWS and their impact on patient care have been tested in other nursing studies such as extensive training (Tzeng & Yin, 2009), teams (Sjetne, Veenstra, Ellefsen, & Staven, 2009), and leadership (Avolio, Smith, & Lake, 2004), we believed it is valuable to explore links between HPWS and patient care. This is the first study that we are aware of that examines the relationship of HPWS with the perceived quality of patient care.
Hypothesis 1: High-performing work systems are positively associated with perceived quality of patient care.
Empowerment and Job Satisfaction in Nursing
Job satisfaction of nurses has been linked with both structural and psychological empowerment (Larrabee et al., 2003; Laschinger, Finegan, Shamian, & Wilk, 2001; Laschinger & Havens, 1996; Morrison, Jones, & Fuller, 1997). Structural empowerment is related to employees' perceptions of the presence of empowering conditions in the workplace, such as access to information, receiving support, resources necessary to do the job, and opportunity to learn and grow (Kanter, 1993). Conversely, psychological empowerment is defined as a multifaceted construct comprising four cognitions reflecting an individual's orientation to his or her work. The four cognitions are meaning (the value of a work goal), competence (an individual's belief in their capacity to perform job requirements), self-determination (autonomy or control over work behavior/processes), and impact (the extent to which an individual can influence outcomes at work) (Spreitzer, 1995). In sum, empowerment refers to the extent to which an individual can actively shape his or her work role and context (Daniels & Guppy, 1995). Although the research in this area tends to be largely correlational, a 2001 longitudinal study found that changes in nurses' perceptions of access to structural empowerment affected both psychological empowerment and job satisfaction (Laschinger, Finegan, Shamian, & Wilk, 2004).
The delivery of high-quality patient care is an important organizational performance outcome for health care organizations, and there is evidence that psychological empowerment of nurses is positively associated with perceptions of the quality of patient care (Laschinger, Finegan, & Shamian, 2001; Laschinger & Wong, 1999; Scotti, Harmon, & Behson, 2007) and with actual patient satisfaction scores (Donahue, Piazza, Quinn Griffin, Dykes, & Fitzpatrick, 2008).
There is substantial research to demonstrate that employees who experience psychological empowerment and are satisfied with their job often feel committed to their job resulting in higher levels of performance. The delivery of high-quality patient care is an important organizational performance outcome for health care organizations, and there is evidence that psychological empowerment of nurses is positively associated with perceptions of the quality of patient care (Laschinger, Finegan, & Shamian, 2001; Laschinger & Wong, 1999; Scotti et al., 2007) and with actual patient satisfaction scores (Donahue et al., 2008). Moreover, Chang, Ma, Chiu, Lin, and Lee (2009) argue that the key components of HPWS such as effective teamwork are associated with greater job satisfaction and patient satisfaction. On the basis of a sample of over nearly 1,500 clinicians including doctors and nurses, they reported that perceptions of quality of patient care and collaborative relationships were associated with job satisfaction (Chang et al., 2009). Moreover, research and theory consistently show that a work environment that facilities patient-centered care should increase patient safety and nurse satisfaction (Rathert & May, 2007).
On the basis of the relationship found between empowerment and quality of care (Scotti et al., 2007), we hypothesized that psychological empowerment will mediate the relationship between HPWS and quality of patient care.
Hypothesis 2: The relationship between HWPS and quality of patient is mediated by psychological empowerment.
We introduce job satisfaction as a moderator between HPWS and perceptions of quality of care. Job satisfaction in previous studies has been related to components of HPWS and perceptions of the quality of care (Chang et al., 2009).
Hypothesis 3: The relationship between HWPS and quality of patient is moderated by job satisfaction. That is, the relationship between HPWS and quality of patient care will be stronger when nurses perceive higher levels of job satisfaction.
Figure 1 depicts the hypothesized model.
A survey questionnaire was administered in March 2008 to nurses working in a regional hospital in Australia. Appropriate ethics approval was received. There were 455 nurses employed at the hospital, and we received 201 completed responses, a response rate of 44%. Cases that had missing data for more than one item for any of the subscales were deleted. For those cases that had missing data for an item in a subscale, the respondent's average over the other items in the subscale was used as the response to the missing item because each subscale is assumed to consist of reflective indicators. The final sample comprised 182 nurses. Table 1 contains details of the sample by gender and highest level of education. The average age of respondents is 43.1 years (SD = 10.2 years), and their average tenure is 11.0 years (SD = 9.0 years).
The 42-item scale of Zacharatos et al. (2005) was used to measure HPWS. Compensation contingent on performance was omitted from the questionnaire because the working conditions for most of Australian public health care workers are determined by centralized collective bargaining agreements that generally do not include performance-based payment systems. Also, in consultation with hospital management, we omitted the construct of measurement of management practices as most nurses would not be in a position to accurately respond to these statements.
Psychological empowerment was measured using Spreitzer's (1995) 12-item scale that comprises four components: competence, impact, meaning, and self-determination. Sample items included, "The work I do is very important to me" (meaning), "I am confident about my ability to do my job" (competence), "I have a great deal of control over what happens in my job" (autonomy), and "My impact on what happens in my job is large" (impact).
Job satisfaction was measured using the three-item job satisfaction scale of Seashore, Lawler, Mirvis, and Camman (1982). The following three items were used: "all in all, I am satisfied with my job"; "in general, I don't like my job"; and "in general, I like working here."
Perceptions of the quality of patient care delivered were measured using the Victorian Patient Satisfaction questionnaire. The measure consisted of 16 items. Example items are "I treat patients with respect" and "I help to relieve the pain of patients." The following 5-point Likert scale was used for all of the items: 1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, and 5 = strongly agree.
A separate principal components analysis was conducted for each of the eight constructs in the HPWS scale of Zacharatos et al. (2005) because of the size of the sample. A cutoff value of .50 was used to indicate a satisfactory loading. The number of items that met the loading criterion and the Cronbach's alphas for the eight subscales are as follows: employment security (both items included, α = .734), selective hiring (all eight items included, α = .86), extensive training (all eight items included, α = .93), self-managed teams and decentralized decision making (all four items included, α = .856), information sharing (six of seven items included, α = .863), transformational leadership (all six items included, α = .94), and high-quality work (three of four items included, α = .72). Although two of the three items that were used to measure status distinctions loaded satisfactorily on a single component, the Cronbach's alpha was unsatisfactory (i.e., α = .35). The two items are as follows: (a) employees at different levels within this unit are encouraged to interact, and (b) some members of this unit have privileges that are unavailable to other members (e.g., reserved parking and dining facilities). It was decided to use the first of these items to represent status distinctions because this item partly encompasses the second item in that the ability of high-status employees to interact with other employees will be reduced if special privileges are provided to high-status employees. Thirty-eight items were therefore used to measure HPWS. Responses to these 38 items were averaged to create an overall score for HPWS.
A four-component varimax solution revealed that all of the 12 empowerment items loaded satisfactorily on their respective components. Cronbach's alphas for the four three-item scales are as follows: competence (α = .90), impact (α = .91), meaning (α = .90), and self-determination (α = .91). Responses to the 12 items were averaged to create an overall score for empowerment.
Perceptions of patient care were measured using 16 items, and the Cronbach's alpha for this scale was .96. One of the items was removed from the scale on the basis of the findings of a principal components analysis. The Cronbach's alpha for the 15-item scale is .95. Responses to the 15 items were averaged to create an overall score for patient care quality.
A principal components analysis found that all three items that were used to measure job satisfaction loaded satisfactorily on a single component, with a Cronbach's alpha of .87. Responses to these three items were averaged to create an overall score for job satisfaction.
All of the data were self-reported from a single source and obtained from the same method (i.e., a 5-point Likert scale). A principal components analysis was conducted on the items used to measure HPWS, empowerment, job satisfaction, and quality of patient care to check for the effects of common method variance. This analysis revealed that the first component explained 29.6% of the total variance in the items, thereby indicating that common method variance does not account for most the variance in the items. Furthermore, the discriminant validity between two constructs is demonstrated if the correlation coefficient is less than 1 minus two times the standard error of the correlation coefficient (Bagozzi & Warshaw, 1990). According to this criterion, all four of the scales used to measure the variables mentioned in the hypotheses have satisfactory discriminant validity.
Table 2 contains the mean and standard deviation values and the correlations for the variables. HWPS had a significant positive correlation with empowerment and nonsignificant correlations with job satisfaction and quality of patient care. Empowerment had significant positive correlations with job satisfaction and quality of patient care. Finally, job satisfaction had significant positive correlation with quality of patient care. Hypothesis 1 is not supported; that is, there was no significant correlation between HPWS and quality of patient care.
Age and tenure were measured as continuous variables, gender was measured as a dichotomous variable, and education was measured as a polychotomous variable. Age has a nonsignificant correlation with patient care (r = .04, p>.05, n = 149), and tenure has a nonsignificant correlation with patient care (r = .04, p > .05, n = 168). An independent samples t test revealed a nonsignificant difference between men and women in terms of perceptions of the quality of patient care (t = 0.56, df = 174, p > .05); the assumption of homogeneity of variance was supported (f = 0.81, p > .05). A one-way analysis of variance revealed a nonsignificant difference between the four education groups in terms of perceptions of the quality of patient care, F(3, 167) = 1.62, p > .05; the assumption of homogeneity of variance was supported, F(3, 167) = 1.27, p > .05.
Table 2 contains the mean and standard deviation values and the correlations for the key variables. HWPS has significant positive correlations with empowerment and job satisfaction and a nonsignificant correlation with quality of patient care. Hypothesis 1 is therefore not supported because there is a nonsignificant correlation between HPWS and quality of patient care. Empowerment has significant positive correlations with job satisfaction and quality of patient care. Finally, job satisfaction has a significant positive correlation with quality of patient care.
Table 3 provides the results of the analyses that were used to test the hypothesized model. The average variance accounted for by the model is .17 (i.e., the R2 for empowerment is .22 and for quality of patient care is .11). This level of R2 is acceptable as it exceeds the minimum requirement of .10 proposed for statistical modeling (Falk & Miller, 1992).
As shown in Table 3, empowerment has a significant effect on quality of patient care over and above the main and interaction effects of HWPS and job satisfaction. This finding and the significant positive correlation between HPWS and empowerment provide support for Hypothesis 2.
Table 3 shows that over and above the effect of empowerment on quality of patient care, the direct effect of HWPS on quality of patient care is moderated by job satisfaction. To more closely examine this moderation effect, job satisfaction was divided into two groups using a median split (i.e., low and high groups for job satisfaction), and the relationship between HPWS and quality of patient care was examined separately for these two groups using correlation analyses. These analyses revealed that the correlation between HPWS and quality of patient care is nonsignificant for the low job satisfaction group (r = −.10, p > .05, n = 137) but is significant for the high job satisfaction group (r = .32, p < .05, n = 45). These findings indicate that the relationship between HPWS and perceptions of the quality of patient care depends on nurses' job satisfaction. Specifically, HPWS has a significant positive relationship with perceptions of the quality of patient care only among nurses with higher levels of job satisfaction. Hypothesis 3 is thus supported.
This is the first study that we are aware of that captures the mechanisms by which HPWS influence the quality of care provided by hospital nurses. Our results suggest that HPWS, specifically, selective hiring, extensive training, teams and decentralized decision making, information sharing, transformational leadership, and quality of work, are related to enhanced empowerment, which is then related to perceptions of higher quality care delivery. Moreover, the relationship between HPWS and perceived quality of care is moderated by job satisfaction.
The findings also revealed a positive correlation between empowerment and job satisfaction. This finding is consistent with the argument that feeling empowered results in job satisfaction because feeling empowered means that not only does an individual find his or her work meaningful, but they also find their work to be a source of intrinsic satisfaction because of feelings of competency and freedom and the belief that they have a positive impact on the organization. This finding is also important because of the negative link between job satisfaction and intent to leave demonstrated among nurses (Laschinger, Finegan, & Shamian, 2001). Identifying mechanisms to increase job satisfaction may assist in reducing the substantial turnover in nursing staff. Human resource management practices that enhance empowerment are likely to influence both job satisfaction and nursing turnover.
These results are consistent with other studies. Nurses who reported that they were empowered also perceived that they were better at their jobs (Laschinger & Wong, 1999), with others findings a significant positive relationship between nurses' perceptions of empowerment and patient satisfaction scores (Donahue et al., 2008). A study of Italian and Irish hospitals found that employee empowerment was essential for health care quality programs (Adinolfi, 2003), and a study comparing high- and low-performing hospitals in the UK National Health Service found that the middle managers in the lower performing hospitals in comparison with the middle managers of the higher performing hospitals were powerless and lacking empowerment (Mannion, Davies, & Marshall, 2005). More specifically, psychological empowerment has been found to have a mediating effect between a number of organizational and outcome variables. For example, psychological empowerment mediated the relationship between structural empowerment and innovative behavior of nurses (Knol & van Linge, 2009) and between workplace environment and nurse burnout (Hochwalder, 2007). Our results confirm that even in the presence of organizational factors found to be related to performance, without the presence of psychological empowerment, high-performing work systems have limited impact on the quality of patient care.
The confirmation of Hypothesis 3, that job satisfaction moderates the relationship between HPWS and perceived quality of patient care, is also consistent with previous research. The findings revealed that HPWS has a positive correlation with the quality of patient care only among nurses with higher levels of job satisfaction. Exploration of the nurse quality patient care chain has consistently confirmed a relationship between nurse satisfaction, quality of patient care provided, and patient satisfaction (Newman & Maylor, 2002; Newman, Maylor, & Chansarkar, 2001), and we have known for a while that nursing job satisfaction is the strongest predictor of patient satisfaction in a clinic setting (Weisman & Nathanson, 1985).
Implications for Management Practitioners
The clear implication of these findings is that managers at all levels in health care organizations should focus on ensuring HRM systems, structures, and processes are aimed at promoting high-performing work systems rather than acting as traditional personnel functions. Consistent with other research, managers at all levels need to recognize that there is growing evidence that strategic management of human resources in health care is an important tool for improving employee well-being and delivering high-quality patient care (Khatri, Brown, & Hicks, 2009; Khatri, Wells, McKune, & Brewer, 2006; Leggat & Dwyer, 2005; Singer, Falwell, Gaba, Meterko, et al. 2009).
HPWS require organization level human resource management policies, procedures, and practices. Existing studies on magnet hospitals, which are organized to provide many aspects of HPWS, support the need for an organization response that ensures effective human resource management (Kramer & Schmalenberg, 2004; Laschinger, Shamian, & Thomson, 2001; Upenieks, 2003). The HR department has a critical role to play in ensuring that the clinical managers understand and appreciate the link between HR and patient care. However, our findings make it clear that an organizational response is necessary but not sufficient. This requires nurse unit managers who display transformational leadership, with skills in information sharing, and the ability to encourage teams and decentralized decision making to enhance the empowerment and the job satisfaction of their staff. For human resource management policies and practices to impact employee attitudes and subsequently perceptions of quality of patient care, they need to be clearly understood, valued, and articulated by the nurse unit manager (Leggat et al., 2008). Without reinforcement at the nursing unit level, the goals of HPWS cannot be achieved, but without sufficient support, nurse managers themselves become frustrated and dissatisfied (Patrick & Laschinger, 2006). Our findings suggest that there is much to be gained at the unit level by making sure nurse managers have the knowledge, skills, and abilities to translate HR policies and practices to empower and to support their staff in the key objective of providing excellence in patient care (Bartram et al., 2007). More broadly, Kharti, Wells, McKune, and Brewer (2006) argue that the HR department can function as a learning organization and enable clinical units to effectively use the key components of HPWS (e.g., selective hiring, employee involvement in decision making, extensive training, and transformational leadership) to transform their work cultures and better manage subcultures through articulating a set of shared patient-centered values among all clinical groups. HR managers have a critical role to play in ensuring that clinical unit managers have the necessary support and direction.
Our findings demonstrate that both psychological empowerment and job satisfaction are associated with nurse perceptions of quality of care. Nurse unit managers can draw some important guidance from these findings. Research has demonstrated that for nurses to become empowered, they have to have influence and decision-making authority over their work environment and work roles (Kuokkanen, Leino-Kilpi, & Katjisto, 2003). Upenieks (2003) argues that some of the success of magnet hospitals may be related to the model that encourages decision making decentralized to the unit level, using a shared governance model that offers nurses as much discretion as possible to use their expert skills in contributing to patient care. Nurse unit managers are in a position to enhance empowerment and job satisfaction of nurses by using transformational leadership strategies to effectively communicate and implement the key components of HPWS (e.g., selective hiring, extensive training, decentralized decision making, reduced status distinctions, information sharing, high-quality work-workload, role clarity, and employee control) to ensure that nurses are able to practice the full scope of their professional role (Ning, Zhong, Libo, & Qiujie, 2009).
There are limitations in the study. First, the study only measured the perceptions of the nursing staff of the quality of care provided in one regional hospital. Although nurses' views of the quality of care they deliver correspond closely to patients' views (Newman et al., 2001), there is a need in future studies to measure the actual care delivered.
Second, our HPWS measure may not be comprehensive. For example, we did not include measures of performance appraisal/management or suggestions received/implemented-measures that have been included in other HPWS studies. In other health care settings and in other countries, these may be vital elements, and therefore researchers should review prior research to identify the appropriate HPWS package for their context. Finally, although we tested for nonresponse bias and found none, there is the potential that nonresponse bias has influenced the results.
The clear implication of these findings is that leaders in health care organizations should focus on ensuring human resource management systems, structures, and processes that support HPWS. At the organizational level, these practices comprise selective hiring, extensive training, and fostering appropriate security. The findings of this study suggest a strong need to orient organizational human resource management policies and procedures toward high-performing work systems.
In addition, the organizational level practices need to be supported at the nursing unit level by nurse unit managers who display transformational leadership, with skills in information sharing, and the ability to encourage teams and decentralized decision making to enhance the empowerment and the job satisfaction of their staff. Our findings suggest that there is much to be gained at the unit level by making sure nurse managers have the knowledge, skills, and abilities to translate HR policies and practices to empower and to support their staff in the key objective of providing excellent patient care.
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