Shaping Nursing Science and Improving Health: The Michigan Legacy

Short Paper: Care Quality, Safety, and Clinical and Organizational Outcomes

During my academic career (1979–2014), I have held a variety of leadership positions, ranging from program director to associate and interim dean. While my responsibilities were primarily administrative, I always strived to maintain a program of research and scholarship. I had the good fortune throughout the years to collaborate with a number of colleagues, conducting my research in interdisciplinary teams. I arrived at Michigan in 1988 and since then have been involved in a variety of projects.

My overall program of research has focused broadly on quality and patient safety in nursing practice environments and their impact on clinical and organizational outcomes. Sometimes I focused on the nursing care team, and at other times I focused on the broader patient care organizational environment. I have been involved in a number of projects within this broad focus, ranging from nurses and patients to organizational outcomes.

In 1990, I began working with a large team to investigate the effects of work redesign on nurses and patients in acute care and ambulatory settings. The team consisted of Professor Shaké Ketefian in the School of Nursing and several directors of nursing in the University of Michigan Health System (UMHS). The directors were Beverly Jones, Carol Spengler, Joan Robinson, Debra Finch, and Sheri Dufek. This project lasted for 5 years, and in addition to several publications, the data from the project were used in 3 dissertations and 12 master’s theses at the University of Michigan School of Nursing.

At that time, UMHS was facing environmental demands common across the U.S. health system: a nursing shortage in the marketplace, financial challenges due to prospective reimbursement and managed care, and increased needs for efficiency. Nursing, along with other health professions, was faced with demands to redesign the care system to improve both the quality and efficiency of its practice. The work redesign project at UMHS was developed to measure the effects of work and role redesign efforts undertaken by the nursing care team. A longitudinal design, with three major data collections over a 4-year period, was implemented using the job characteristics model (Hackman & Oldham, 1980) as the conceptual framework. A variety of standardized instruments were used to assess job characteristics, work roles and responsibilities, job satisfaction, ethical decision making, perceptions of organizational culture and values, and organizational commitment. In addition, institutional data were collected on unit- and organizational-level nursing turnover.

An instrument to measure patient satisfaction with nursing care was developed and tested as part of this project (Ketefian, Redman, Nash, & Bogue, 1997). Conceptual and methodological challenges in conducting this type of research were reported in the literature. The work redesign efforts were shown not to have a detrimental effect on nursing turnover (Redman, Cho, Ketefian, & Hong, 2000). Similar positive results were found on nursing and patient satisfaction (Tzeng, Ketefian, & Redman, 2002). Organizational culture and values were found to be directly related to work redesign outcomes (Tzeng, Redman, & Ketefian, 2000).

As work redesign efforts expanded nationally, many hospitals experimented with new roles on the nursing care team. Often these roles were referred to as patient care technicians or expanded roles for the traditional nursing assistant. I, along with several colleagues, undertook the evaluation of these roles in three private sector hospitals in Michigan. The evaluation was similar to the UMHS project, but the focus was more on the impact of these roles on nurses, managers, and other health disciplines. Qualitative data revealed positive data from the perspectives of managers and other health professionals such as pharmacists and respiratory therapists (Jones, Redman, VandenBosch, Holdwick, & Wolgin, 1999). Overall results of the new multiskilled workers were positive in terms of their contributions to the nursing care team (VandenBosch, Wolgin, Redman, Jones, 1997). Organizational culture was directly related to both positive and negative outcomes, depending on the particular organization. These changes in the nursing care team often resulted in an expansion of the responsibilities of the nurse manager and increased the stress on their roles.

My work with patient satisfaction as an outcome variable resulted in my rethinking about satisfaction from the patient’s perspective. Most patient satisfaction instruments available at that time focused more on hotel-like aspects of the care experience and often did not consider necessarily what was important to the patient. Nationally, there was a renewed interested in patient-centered care, and the patient’s perspective and preferences were being given more emphasis. My interest shifted to patient expectations and examining how these expectations influenced their assessment of the care experience. A discussion of the importance of patient-centered care based on patients’ expectations for that care led me to an examination of the conceptual issues in patient-centered care and the development of an instrument to measure those expectations (Redman & Lynn, 2005). This model of expectations was used in a study to compare Mexican immigrant and second-generation Mexican American mothers’ expectations for the care of their children. Findings supported a shared core of expectations for both immigrant and Mexican American mothers but also differences in health care access and financing, time spent in health care encounters, and cultural and linguistic expectations for care (Clark & Redman, 2007).

In the mid-2000s, colleagues and I conducted two national surveys of staff nurses to assess their perceptions of satisfaction with their career choice and their commitment to nursing as a career. Low-to-moderate levels of work satisfaction were documented along with moderate-to-high levels of career satisfaction, suggesting a number of important implications for employers of nurses in all sectors of the United States (Lynn & Redman, 2006; Lynn, Redman, & Zomorodi, 2006). The article in Western Journal of Nursing (Lynn & Redman, 2006) was among the top-10 downloads from that journal in 2006 and 2007.

In 2010, I became involved in a university-wide health initiative in Ghana. As a result, I became part of large interdisciplinary team comprising physicians and nurses from the University of Michigan and Ghana. This project, funded by the Fogarty International Center at the National Institutes of Health, consisted of a collaborative effort among Kwame Nkrumah University of Science and Technology, Komfo Anokye Teaching Hospital (KATH), and the University of Michigan’s Department of Emergency Medicine and the School of Nursing. Two major goals of this project were to establish a certificate program and nursing baccalaureate specialization in emergency nursing and a residency program in emergency medicine. The nursing education programs have been established, and two cohorts have graduated successfully (Bell et al., 2014). The medical residency has also been successfully implemented, and two cohorts have completed training in emergency medicine. The focus of the project now is on ensuring quality and safe practice in the emergency department at KATH. Interdisciplinary team training of nurses and physicians in the emergency department, or the A & E as it is called in their setting, has been implemented. A longitudinal evaluation is now in process to measure the effects of this team training using the TeamSTEPPS curriculum and methodology developed by the Agency for Healthcare Research and Quality in the United States. The approach has been adapted to fit the Ghanaian culture and practice setting. The project continues as of this writing and will end in 2016.