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Health Care Management Review:
doi: 10.1097/HMR.0b013e3181edd992
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Predictors of perceived health care quality for registered nurses during and after health care reform

Gregory, Deborah M.; Way, Christine Y.; Barrett, Brendan J.; Parfrey, Patrick S.

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Author Information

Deborah M. Gregory, PhD, is Clinical Assistant Professor, Clinical Epidemiology Unit, Faculty of Medicine, Memorial University of Newfoundland, Canada. E-mail: dgregory@mun.ca.

Christine Y. Way, PhD, is Professor, Clinical Epidemiology Unit, Faculty of Medicine, and School of Nursing, Memorial University of Newfoundland, Canada.

Brendan J. Barrett, MD, is Professor, Clinical Epidemiology Unit, Faculty of Medicine, Memorial University of Newfoundland, Canada.

Patrick S. Parfrey, MD, is University Research Professor, Clinical Epidemiology Unit, Faculty of Medicine, Memorial University of Newfoundland, Canada.

The Canadian Health Services Research Foundation, Health Care Corporation of St. John's and the Newfoundland and Labrador Department of Health and Community Services funded this research.

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Abstract

Background: Limited research has focused on the predictive nature of organizational culture and trust on registered nurses' perceived health care quality in reformed health care systems.

Purposes: The purpose of this article was to investigate nurses' perceptions of organizational culture factors, trust in employer, and perceived health care quality during and 5 years after major organizational reform in the acute care setting and to test a model linking culture to perceived health care quality.

Methodology: Survey data collected from two samples of nurses (N = 222,343) during and 5 years after major organizational reform in the acute care setting of one Canadian province were analyzed, and an exploratory model linking aspects of culture, trust, and quality was tested.

Findings: For both periods, most variable scores were in the low range and depicted moderately positive intercorrelations with each other. Support for the proposed model was mixed. Select culture variables predicted health care quality at both periods, but trust emerged as a significant predictor in 2000 only. The findings support the negative impact of system transformation on nurses and the link between culture and health care quality.

Practice Implications: The study findings suggest that managers and policy makers must develop and implement supportive and nurturing strategies that will enhance the organizational culture (emotional climate, collaborative relations), which should result in more positive perceptions of health care quality. However, further research is required to gain a better understanding of the relationships among trust, organizational culture, and perceptions of health care quality and what implications this may or may not have for nursing practice.

The Canadian health care system underwent restructuring, downsizing, and reengineering of services throughout the 1990s in response to escalating health care costs and decreasing fiscal resources. Reengineering (changing skill mix, cross-training staff, and client-focused care via multidisciplinary teams) and restructuring (macro-organizational change such as mergers, closings, and enhancement of ambulatory care services) within the acute care sector significantly altered the structure and processes of care. Downsizing initiatives involved reducing the size of the workforce, managerial layers, and number of management personnel. These reform measures were implemented despite the absence of definitive empirical evidence confirming their usefulness (Aiken, Clarke, & Sloane, 2000; Shamian & Lightstone, 1997).

Health system reform in Newfoundland and Labrador (NL), Canada, began with the regionalization of health boards between 1995 and 1997. Acute and long-term care was integrated in all regions except St. John's, the major tertiary care center for the province. Management and support personnel numbers were reduced by 40% to 50%, and a functionally oriented system with multidisciplinary teams replaced the separate administration of facilities in five of the six regions. The St. John's region, the largest employer of registered nurses (herein referred to as nurses), was subjected to the most pervasive reform with the closure and merger of hospitals/facilities, integration of clinical services under program-based management, altered managerial roles and responsibilities, dislocation of about 50% of nursing staff, and use of a professional practice model to facilitate decentralized, collaborative decision making (Twells, Doyle, Gregory, Barrett, & Parfrey, 2005).

The primary objective of reform was to induce greater productivity and efficiency at a reduced cost while maintaining optimal quality of care. Despite extensive literature on the multidimensional impact of reform, less attention has been given to repercussions for the quality of nursing care. Of particular importance is how nurses, the largest group of providers in acute care settings, perceive their ability to deliver quality care in transformed environments. It is also important to identify key aspects of the work environment that shape nurses' perceptions of health care quality.

The focus of the current study was on acute care nurses' perceptions of organizational culture (emotional climate, practice issues, and collaborative relations), attitude (trust in employer), and health care quality (safety, standards, and quality) at two points in time (i.e., during and after system reform). Organizational culture is defined as the norms, values, beliefs, and assumptions shared by members of an organization (Gershon, Stone, Bakken, & Larson, 2004). In contrast, organizational climate is viewed as members' shared perceptions of work and practice conditions, many of which are influenced by managers (Scott, Mannion, Davies, & Marshall, 2003). Researchers have sometimes used the terms organizational culture and organizational climate interchangeably. Debate and controversy on how to define and measure these constructs continue (Clarke, 2006). For the purpose of the current study, organizational culture is used to reflect nurses' perceptions of the emotional climate, practice issues, and collaborative relations.

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Conceptual Framework

The primary purpose of the study was to test an exploratory model linking aspects of organizational culture and trust in employer to perceived health care quality. The Conceptual Model of Behavioral Intentions was developed to highlight possible linkages between variables of interest (Figure 1 and its associated Table). The Conceptual Model of Behavioral Intentions hypothesizes that significant positive correlations exist between aspects of organizational culture, trust in employer, and perceived health care quality. Second, organizational culture and trust will be significant independent predictors of perceived health care quality. Third, the predictive power of organizational culture will be mediated by trust.

Figure 1
Figure 1
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Research findings support the predominately negative impact of system reform on nurse ratings of the work environment (Aiken et al., 2000, 2001; Armstrong-Stassen, 2003; Burke, 2001, 2003, 2005; Cummings & Estabrooks, 2003; Laschinger, Shamian, & Thomson, 2001; Laschinger, Finegan, & Shamian, 2001; Way, Gregory, Baker, et al., 2005; Woodward et al., 1999, 2000). Team work, collaborative relations, leadership, quality of work life, and communication/information are common attributes of culture/climate considered important for creating conducive work environments (Gershon et al., 2004; Scott et al., 2003), positive provider outcomes, quality patient care, and optimal health outcomes (Gershon et al., 2004; Lowe & Schellenberg, 2001; Snow, 2002).

Important aspects of the social and psychological dynamics of the work environment are also reflected in trust (psychological contracts formed during social exchanges between employers and employees) (Koehoorn, Lowe, Rondeau, Schellenberg, & Wagar, 2002). Increasing attention is being given to the conduciveness of restructured health care environments for maintaining trustful relations between nursing staff and their employers (Armstrong-Stassen, 2003; Laschinger, Finegan, Shamian, & Casier, 2000; Laschinger, Shamian, et al., 2001; Laschinger, Finegan, et al., 2001; Way, Gregory, Baker, et al., 2005). In a meta-analysis of research on trust in leadership and its antecedents, Dirks and Ferrin (2002) found that more positive perceptions of leadership behaviors and practices, organizational support, participatory style decision-making, justice and fairness, and leadership style were associated with increased trust in leadership. Research evidence highlights the importance of trust in leaders in health organizations, suggesting that supportive leader behavior and trust in management are necessary for staff willingness to voice concerns and offer suggestions for workplace improvements, including patient care (Wong & Cummings, 2009). Health care workers who perceive their work environment as healthy and safe generally are more trustful of management, are engaged with work, and give higher ratings to patient safety and overall quality of unit/team-based services (Lowe, 2006).

For the most part, the empirical evidence suggests that nurses are dissatisfied with the quality of nursing care in the aftermath of system restructuring (Aiken et al., 2000; Aiken, Clarke, & Sloane, 2002; Arnetz, 1999; Baumann et al., 2001; Burke, 2003, 2005; Cummings Estabrooks, 2003; Gregory, Way, Barrett, & Parfrey, 2005; Laschinger, Shamian, et al., 2001; McGillis Hall, 2003; Shindul-Rothschild, Long-Middleton, & Berry, 1997; Way, Gregory, Baker, et al., 2005; Woodward et al., 1999). Greater clarity is needed concerning the factors responsible for this high level of dissatisfaction. An extensive review of the literature confirmed that the empirical evidence supports a significant association between nurses' perceptions of work environment factors (autonomy, collaborative relations, communication, support, staffing levels, and care delivery models) and health care quality (Aiken et al., 2002; Arnetz, 1999; Burke, 2001, 2003, 2005; Laschinger, Shamian, et al., 2001; O'Brien-Pallas et al., 2004; McGillis Hall, 2003; McGillis Hall & Doran, 2004; McGillis Hall et al. 2001; Sochalski, 2004; Way, Gregory, Baker, et al., 2005). Trust is a key factor of healthy work environments, but very little research exists on the link between trust and health care outcomes (Wong Cummings, 2009), especially trust in employer and health care quality (Laschinger, Shamian, et al., 2001; Way, Gregory, Baker, et al., 2005).

A recent review of the literature revealed only a few predictive studies that used perceived quality of care as the outcome variable. Researchers have used regression modeling (Arnetz, 1999; Aiken et al., 2002; Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Burke, 2005; McGillis Hall & Doran, 2004; Shindul-Rothschild et al., 1997; Sochalski, 2004) or causal modeling (Laschinger, Shamian, et al., 2001) to examine the assumptions of different models that link work environment factors (structure and process) to perceived quality. In their study, Laschinger, Shamian, et al. (2001) depict a multidimensional, linear process incorporating organizational characteristics (autonomy, control, and collaboration), intervening variables (trust and emotional exhaustion), and outcome (work satisfaction, perceived quality of care, and perceived quality of unit). The study's findings support the hypotheses that higher degrees of autonomy, greater control over practice, and more positive nurse-physician collaboration are associated with higher levels of trust in management and lower levels of burnout, which leads to more positive perceptions of the quality of care.

Despite the emerging evidence linking work environment factors to quality outcome, there is limited insight into the factors that mediate this impact. This study is important because it conjectures that a positive link exists between trust in management/employer and perceived health care quality. It is hypothesized that organizational culture factors (emotional climate, practice issues, and collaborative relations) exert independent and interactive effects on intermediate outcome (trust in employer) and outcome (perceived health care quality). The intermediate outcome exerts a direct effect on outcome and mediates the effects of organizational culture factors. Although a link between more positive perceptions of culture, greater trust, and greater perceived health care quality may appear reasonable, exploratory testing of the model is essential.

The following hypotheses were tested in the current study:

1. Significant positive correlations exist between aspects of organizational culture (emotional climate, practice issues, collaborative relations), trust in employer, and perceived nursing care quality.

2. Nurses' perceptions of organizational culture (emotional climate, practice issues and collaborative relations) and trust will be significant independent predictors of perceived nursing care quality.

3. The predictive power of climate, practice-related issues, and collaborative relations for perceived health nursing quality will be mediated by trust.

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Methods

Design

The data were obtained as part of a program of research approved by the Human Investigation Committee of the Faculty of Medicine, Memorial University of Newfoundland. The program of research examined the implications of reform for NL acute care institutions (Parfrey, Barrett, & Gregory, 2005). Descriptive study findings with other samples of nurses have been reported elsewhere (Gregory et al., 2005; Way, Gregory, Baker, et al., 2005; Way, Gregory, Doyle, et al., 2005). The analysis used in the current study moved from the descriptive to the inferential stage and is based on data from a sample selected from the entire accessible population of nurses after major organizational reform (2005) and a randomly selected sample of nurses chosen during the reform process (2000). Predictors of nurses' organizational commitment and intent to stay and model testing was the focus of a recent publication based on the 2005 sample of nurses (Gregory, Way, LeFort, Barrett, & Parfrey, 2007).

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Sample Selection

In 2000, a proportional stratified random sample of 654 was selected from the total accessible population of nurses employed in acute care settings of the six regional health boards in NL, Canada (N = 3,583). The sample did not differ significantly from the total population based on age, education, and employment status (i.e., full-time vs. part-time). In 2005, the NL provincial nursing association generated an updated list of nurses working in acute care settings (N = 3890) by matching region. The accessible population (n = 1,173) was restricted, due to privacy regulations, to those willing to participate in health services research. Although comparable with the provincial nursing population on employment status, the sample was younger and more educated (Gregory et al., 2007). Given normally low response rates, surveys were mailed to the home addresses of the entire accessible population, and reminder letters sent 2 weeks later.

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Data Collection Instruments

The Employee Attitude Survey was used to collect standardized demographic/work-related data (years of work experience, current position tenure, education, employment status, geographic region, gender, and age in years). In addition, data were collected on select organizational culture factors (emotional climate, practice-related issues and collaborative relations), health care quality (i.e., quality of care, safety issues, and standards of care), and provider attitudes (trust in employer).

Two subscales of the Revised Impact of Health Care Reform Scale (RIHCRS) consisted of 11 items examining emotional climate (e.g., management and peer support, open communication, and constructive organizational climate) and practice-related issues (e.g., control/empowerment and input into decision making). Items on the RIHCRS are rated from 1 to 6, with higher scores indicating more positive perceptions of the emotional climate and practice issues. The RIHCRS is a modified version of the Impact of Health Care Reform Scale used in a survey of nurses (Way, 1995). Both versions had good construct validity (factor analysis) and fairly high internal consistency. The psychometric properties of the instrument were tested in a diverse sample of health care providers (allied health professionals, licensed practical nurses, nurses working in acute care settings, management personnel from three institutional boards, and all doctors employed in the province) who responded to surveys sent in 2000. Cronbach's α coefficients were reported for the climate (.71) and practice issues (.75; Way, Gregory, Doyle, Twells, Barrett & Parfrey, 2005). With regard to the two samples of nurses used in the current study in 2000 and 2005, Cronbach α values were .80 and .82 for the emotional climate and .75 and .76 for practice issues, respectively (Table 2).

Table 2
Table 2
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The total health care quality scale consisted of 13 items from three subscales of the RIHCRS. The total scale examined perceptions of quality of care, standards of care, and safety concerns. The items are rated from 1 to 6, with higher scores indicating more positive perceptions of health care quality. Cronbach's α coefficients were also reported for the quality of care (.71), standards of care (.75), and safety concerns (.88) scales (Gregory et al., 2005). In the current study, factor analysis confirmed the feasibility of combining the quality of care, standards of care, and safety issues scales to generate the perceived health care quality scale. With regard to the two samples of nurses used in the current study, Cronbach α values were .85 in 2000 and .84 in 2005 (Table 2).

The 5-item Collaborative Relations scale assessed satisfaction with managerial and interdisciplinary relations after restructuring. The Collaborative Relations scale developed by the researchers had good construct validity (i.e., a one-factor solution and strong internal consistency). Cronbach's α coefficients were reported for the collaborative relations (.88) scale in a sample of health care providers (Way, Gregory, Doyle, et al., 2005). In the current study, Cronbach α values in 2000 and 2005 were .89 and .86, respectively (Table 2).

The four-item Psychological Contract Violation scale assessed trust in employers (Turnley & Feldman, 1999). Items are rated from 1 to 5, with higher scores indicative of less perceived violations (higher levels of trust). Cronbach's α has been reported to be .75 (Way, Gregory, Doyle, et al., 2005). In the current study, Cronbach α values for this scale in 2000 and 2005 were .78 and .70, respectively (Table 2).

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Data Analysis

Data analyses were performed with the Statistical Package for the Social Sciences, version 11.5, and the Analysis of Moment Structures statistical package, version 5.0. Descriptive statistics examined personal characteristics and distribution of subscale scores. Chi-square and t tests were used to compare groups. Independent-samples t tests were used to determine differences in organizational culture, work-related attitudes, and outcome between 2000 and 2005. Analysis of variance tests were used to determine the impact of personal characteristics on scale scores at each period, and the post hoc Scheffe test was used to investigate pair-wise differences. Evaluation of internal consistency and intercorrelations was based on Cronbach's α and bivariate correlations, respectively. Hierarchical regression analysis was used to identify the best predictors (determinants and intermediate outcome) of outcome (health care quality). Only independent variables significantly correlated with health care quality were entered into the regression equation. Multicollinearity among independent variables was examined, but none of the variables was very strongly associated with others. Theoretical models were tested using path analysis. Preliminary analysis indicated that the problem with missing data was random and not severe, resulting in the elimination of 18 cases (8.1%) in 2000 and 30 cases (8%) in 2005. As recommended by Kline (1998), a minimum of four criteria was employed to evaluate model fit: chi-square (χ2), Comparative Fit Index (CFI), Incremental Fit Index(IFI), Tucker-Lewis Index (TLI), and the root mean square error of approximation (RMSEA).

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Results

Response Rates and Sample Description

Of the total surveys mailed out in 2000, 223 were returned (34.1% response rate). Eighteen (8.1%) cases with incomplete data were eliminated, leaving a final sample of 205. In 2005, although 458 surveys were returned (39%response rate), 85 managers/nursing faculty and 30 incomplete surveys were excluded, leaving a final sample of 343.

Table 1 summarizes the demographic characteristics of nurses employed in the acute care setting for both survey years. Most respondents were diploma prepared, had been in their current position for five or more years, had 10 or more years of nursing experience, and worked full-time. The average age in 2000 and 2005 was 38.3 and 37.4 years, respectively. Although most respondents worked in acute care facilities in regions outside St. John's in 2000, the sample was equally divided between St. John's and other regions in 2005. The percentage increase in the proportion of degree-prepared nurses in the workforce from 14% in 2000 to 41.4% in 2005 was expected due to the provincial nursing association's requirement of a bachelor of nursing degree for entry to practice. The sample of respondents after restructuring was composed of a greater number of nurses with ≤4 years of total work experience. This was most likely attributable to the government addressing nurses' workload issues by investing $44 million over 5 years to create 325 new permanent nursing positions ("Workload Issues for Nurses,"1999). There were no significant differences between the samples based on years in current position, employment status, or age.

Table 1
Table 1
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Descriptive Statistics

Descriptive data on predictor and outcome variables for 2000 and 2005 are presented in Table 2. For both study periods, nurses believed that restructuring negatively impacted the organizational culture, were distrustful of employers' intentions to fulfill commitments made to them upon hiring, and viewed health care quality in a negative light. Improvement in scores was observed over time for all scales, including organizational culture, trust in current employer, and perceived health care quality (p < .001).

The first step in hypotheses testing was to determine the intercorrelations among major variables and the effects of personal characteristics. The correlation matrix is presented in Table 3. The low to moderate correlations of organizational culture variables with intermediate and outcome variables at both periods suggest that more positive perceptions of the emotional climate, practice issues, and collaborative relations are related to greater trust and more positive perceptions of health care quality. As well, moderate to strong intercorrelations were observed between higher levels of trust and greater satisfaction with health care quality. However, the magnitude of the observed association between trust in employer and perceived health care quality was weaker in 2005 (r = .39, p < .001) than 2000 (r = .52, p < .001). The rationale for the observed change in the strength of the relationship between the two variables could potentially be due to the fact that almost one quarter of the sample had less than 4 years of nursing experience and, thus, would not have experienced the same sense of trust violation from employers. Most personal characteristics exerted little or no influence on intermediate and outcome variables (data not shown). The decision was therefore made to exclude them from further analysis.

Table 3
Table 3
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Prediction of Perceived Health Care Quality

During regression analysis, variables were entered according to their position in the model (organizational culture variables first, intermediate outcome second). The hypothesized model for perceived health care quality was partially supported. For 2000, at the first step of the analysis, emotional climate and collaborative relations entered the model. At the second step, the mediating effects of trust were minimal. Emotional climate, collaborative relations, and trust combined to explain 50% of the variance. Slightly different results were obtained in 2005. At the first step, climate, practice issues, and collaborative issues entered the model. At the second step, the mediating effects of trust were minimal and failed to enter the equation. Climate, practice issues, and collaborative issues combined to explain 42% of the variance (data not shown).

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Model Testing

The proposed conceptual model was tested with the 2000 and 2005 samples using AMOS 5. The proposed model was saturated (emotional climate, practice-related issues, and collaborative relations had paths to trust and perceived health care quality; trust had a path to health care quality) but could be used to test the critical ratios for each path. In both samples of nurses, most critical ratios were significant, except the path from practice to trust and practice to perceived health care quality in 2000 and the paths from practice to trust and trust to perceived health care quality in 2005. The paths were constrained to zero in the revised model for each respective sample and were reevaluated.

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Model Fit

When the nonsignificant paths from practice to trust and practice to perceived health care quality were constrained to zero in the 2000 sample, the final model fit the data (χ2 = 2.03, df = 2, CFI = 1.00, IFI = 1.00, TLI = 1.00, RMSEA = .008), with all paths highly significant. Emotional climate (β = .45) and collaborative relations (β = .24) had a direct effect on trust. Emotional climate had a direct effect on perceived health care quality (β = .46) and an indirect effect through trust (β = .06). The findings also supported the direct effects of collaborative relations (β = .24) on perceived health care quality and its indirect effect through trust (β = .03). As well, trust had a direct effect (β = .14) on perceived health care quality. Positive perceptions of the emotional climate and collaborative relations were associated with greater levels of trust in the employer and higher levels of perceived health care quality. Based on the magnitude of their total effects, the determinants of health care quality may be ranked as follows: emotional climate (.53), collaborative relations (.28), and trust (.14) (Table 4). The standardized path coefficients for the final model are presented in Figure 1. The amount of explained variance in trust and perceived health care quality was 38% and 52%, respectively.

Table 4
Table 4
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In 2005, the nonsignificant paths from practice to trust and trust to perceived health care quality were constrained to zero, with the revised model fitting the data (χ2 = 2.67, df = 2, CFI = .999, IFI = .999, TLI = .999, RMSEA = .031) and all paths highly significant. Emotional climate (β = .32) and collaborative relations (β = .24) had a direct effect on trust. In addition, climate (β = .46), practice-related issues (β = .13), and collaborative relations (β = .14) had direct effects on perceived health care quality. However, trust was not found to exert a direct effect. Positive perceptions of the emotional climate, practice-related issues, and collaborative relations were associated with greater levels of trust in employer and higher levels of perceived health care quality. Based on the magnitude of their total effects, the determinants of health care quality may be ranked as follows: emotional climate (.46), collaborative relations (.14), and practice-related issues (.13) (Table 4). The standardized path coefficients for the final model are presented in Figure 1. The amount of explained variance in trust and perceived health care quality was 31% and 42%, respectively.

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Discussion

The restructuring of acute care hospitals in one Canadian province provided the opportunity to investigate the impact on nurses' (RNs) perceptions of organizational culture factors (emotional climate, practice-related issues, and collaborative relations), trust in employer, and perceived health care quality during and 10 years after initiation of extensive system transformation in the acute care hospital sector. Another aim of the study was to test a theoretical model linking aspects of organizational culture and work-related attitudes to perceived health care quality. Registered nurses employed in acute care settings continue to experience negative effects after the transformation, despite significant improvements in all study variable scores over time. It is anticipated that the revitalization of the nursing workforce in NL will be a major challenge given that further system changes involving retraction to four regional integrated authorities from 14 regional health boards were implemented in April 2006. The government departments that invoke extensive transformation, as well as regional integrated health authorities responsible for carrying out government directives, must become more cognizant of the potential for the long-term negative impact on nurses and have concomitant policies to buffer that impact.

The results of the correlation analysis provide partial support for the hypothesized relationships. All aspects of organizational culture (emotional climate, practice-related issues, and collaborative relations) were positively associated with trust in current employer and perceived health care quality. The findings corroborate the positive associations observed between comparable and different culture variables and trust in other studies of nurses (Laschinger & Finegan, 2005; Laschinger, Finegan, et al., 2001; Laschinger et al., 2000; Laschinger, Shamian, et al., 2001). Study findings also support the positive associations observed between similar and disparate culture variables and perceived health care quality in other studies (Aiken et al., 2002; Arnetz, 1999; Burke, 2001, Burke, 2003; Burke, 2005; Laschinger, Shamian, et al., 2001; McGillis Hall, 2003, McGillis Hall & Doran, 2004; McGillis Hall et al., 2001; O'Brien-Pallas et al., 2004; Sochalski, 2004; Way, Gregory, Baker, et al., 2005).

The current study's findings also support the significant correlations among trust and its relationship to perceptions of health care quality. Laschinger, Shamian, et al. (2001) reported that nurses who had higher levels of trust in management were also more likely to have more positive perceptions of health care quality. Similar findings were reported by Way, Gregory, Baker, et al. (2005).

The current study's findings also partially supported the theoretical model linking organizational culture and work-related attitudes to perceived health care quality. More positive perceptions of the emotional climate and collaborative relations were directly linked with more positive perceptions of health care quality during and after extensive transformation of the health care system. These findings highlight the importance of creating more positive work climates (challenging, motivating, and supportive) and collaborative relations with managers and other professional groups. Similar to the current study, the study of Arnetz (1999) reported that autonomy, influence over daily decisions, participatory management, and skill development had a direct positive impact on perceived quality of care. The findings of the study of Arnetz and of the current study highlight the importance of targeting these areas with management strategies and interventions aimed at improving perceptions of quality of care.

With regard to the proposed mediating role of trust between organizational culture factors and perceived health care quality, the current study provides minimal and inconsistent support for trust. The lack of predictive power for trust in 2005 may be related to the significant decline in the magnitude of the relationship between trust and perceived health care quality and the slight increase in the strength of the association between practice issues and quality. The switch between trust and practice-related issues in 2005 may also be explained by the fact that major system reforms had already taken place 5 years previously. It may also be due to inadequate sensitivity and specificity of the scales used to measure perceived health care quality, changes in the relevancy of the practice-related issues scale between the 2000 and 2005 samples, or the sample sizes. Despite the inconsistent role of trust as a predictor of perceived health care quality, it is an important factor to consider in a system that is undergoing continuous transformation. Only one study was identified in the literature directly linking trust to perceived health care quality (Laschinger, Shamian, et al., 2001). Laschinger, Shamian, et al. (2001) found that trust was a significant mediator between organizational characteristics (autonomy, control, and collaboration) and nurse assessments of quality care. In contrast to the study of Laschinger, Shamian, et al., the current study used two cross-sectional samples of nurses at two intervals of the restructuring process (before and after).

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Limitations

The study findings must be viewed with caution given the cross-sectional nature of the study design, which does not permit inference of causality among the constructs. Generalization of the findings may be limited due to (1) the study population consisting of nurses who indicated a willingness to participate in research, (2) the relatively low response rate, and (3) the use of self-reported data. In addition, there is a possibility of clustering of effects within hospitals and units, which could impact on the validity of the conclusions. Although it is possible to test for the clustering effect using causal modeling techniques, we did not collect unit/hospital-level data.

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Practice Implications

This study was designed to examine acute care nurses' perceptions of organizational culture (emotional climate, practice issues, and collaborative relations), health care quality (safety, standards and quality), and attitude (trust in employer) at two points in time (i.e., during and following system reform). A second study aim was to test a model linking aspects of culture to trust in employer and perceived health care quality, and trust to perceived health care quality. Study findings provide partial support for the hypothesized relations specified in the conceptual model. This study makes a theoretical contribution in that it confirms that nurses' perceptions of the work environment have a strong impact on how they perceive trust and health care quality. Study findings suggest that it is necessary for managers and policy makers to develop and implement supportive and nurturing strategies that will enhance the organizational culture (emotional climate, collaborative relations), which could result in more positive perceptions of health care quality. However, further research is required to gain a better understanding of the relationships among trust, organizational culture, and perceptions of health care quality and what implications this may or may not have for nursing practice.

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Acknowledgments

The authors thank the Association of Registered Nurses of Newfoundland and Labrador and the respondents, without whom this study would not have been possible. The authors thank the following research staff for their contributions to this project: Angie Batstone, Charlene Dodd, Gloria Kent, Carol Negrijn, and Jacquelin McDonald.

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Keywords:

model testing; nurses; perceived health care quality

© 2010 Lippincott Williams & Wilkins, Inc.

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