Factors influencing turnover and retention of midwives and consultants: a literature review.

This study is a review of literature on the factors affecting the retention and turnover of hospital consultants and midwives. While there is widespread concern and acknowledgement of staff retention problems for professional occupations within the NHS, far less research has analysed the causes of the staff retention problems for the occupations in question. This study shows that there is a dearth of literature in this area and that systematic comparative analysis of retention and turnover factors through both primary and secondary research is urgently required in order that policy-making can take place on the basis of informed choice. Tentative initial findings were that lack of appreciation or perceptions of not being valued are key factors influencing turnover for both occupations. Working hours, workload and work schedules are also common concerns to both groups. In addition, career development, promotion and appreciation of contribution were important retention factors for midwives, while a supportive professional environment, reduction in workload and working hours and more flexible work patterns were important to consultants.     

Hospitals' marketing challenge: influencing physician behavior

Physicians' referring and admitting behavior as well as their clinical management practices are major determinants of hospitals' profitability under prospective payment. Four techniques are available to hospitals that seek to increase market share: Recruitment and retention strategies. In planning the mix of specialties represented on staff, hospitals should consider the effects of a physician's practice on the hospital's case mix. Peer pressure. Peer review programs in hospitals as well as through medical or specialty societies may help persuade physicians to alter their use of services. Education and information programs. Hospitals can assist physicians in patient management by conducting economic grand rounds, developing committees to study and communicate cost data to physicians, and providing information on alternatives to hospitalization. Incentives. Putting physicians at risk by linking planned expenditures to hospital financial performance can influence practice patterns. Other techniques include offering limited partnerships to medical staff members and merging the hospital and medical staff into one corporation. Hospitals may also need to influence physicians away from ventures that compete directly with the institution, such as ambulatory surgery centers.     

Hospital management contracts: institutional and community perspectives.

Previous studies have shown that external management by contract can improve the performance of managed hospitals. This article presents a conceptual framework which develops specific hypotheses concerning improved hospital operating efficiency, increased ability to meet hospital objectives, and increased ability to meet community objectives. Next, changes in the process and structure of management under contractual arrangements, based on observations from two not-for-profit hospital systems, are described. Finally, the effects of these management changes over time on hospital and community objectives are presented. These effects suggest progressive stages in the development of management contracts. The first stage focuses on stabilizing hospital financial performance. Stage two involves recruitment and retention efforts to secure necessary personnel. In the third stage, attention shifts to strategic planning and marketing.     

Barriers to the nurse practitioner movement: problems of women in a woman's field.

Barriers to the nurse practitioner movement are explored in this article. Historically, the subordination of women and the sex segregation of nursing and medicine have helped to establish interaction patterns between the two professions which included a subordination of nurses as well as informal doctor-nurse games. These patterns were reinforced by hospital training schools and state laws which restricted the roles of nurses. Recent changes in state movement, but the stereotyped communication patterns between nurses and physicians remain as a barrier to the full use of the talents of nurses in practitioner roles.     

The cyclical behavior of hospital utilization and staffing.

Aggregate monthly data on hospital utilization and staffing are examined to assess the hospital industry's ability to adjust staffing levels to regular monthly cycles in demand. Graphical analysis and linear regression are used to assess the relationship between monthly trends in utilization and full-time-equivalent hospital personnel. We show that although regular seasonal patterns exist in both utilization and staffing levels, these series are largely independent of each other. The staffing level response to cycles in admissions and patient-days is, in fact, small relative to those observed for other industries that face predictable and regular fluctuations in product demand. Staffing levels appear to be more closely related to bed levels than to actual utilization levels. For a typical hospital which does not face effective incentives to control costs, smoother patterns of seasonal utilization probably will not result in lower staffing levels and reduced costs unless accompanied by a slowdown in the rate of increase in hospital bed size.     

Interactions between hospital and nursing home use.

National estimates are provided, for the first time, of the number of hospitalizations in a year for elderly persons who also experience some nursing home use, and patterns for this interaction are described. In 1987, 816,000 persons were transferred from nursing homes to hospitals, constituting 8.5 percent of all Medicare hospital admissions for persons ages 65 and older. Another 347,000 hospital stays involved people admitted from the community and discharged to a nursing home. The reporting of discharge destination on Medicare hospital bill data in 1987 also is analyzed. It was found that these data may have underreported a nursing home as the destination by between 15 and 20 percent. The magnitude of hospitalizations of nursing home residents suggests that programs aimed at improving nursing home care might have an important impact on total days of hospital care, and that it is important to learn more about the optimal use of expensive hospital care.     

The NHS Plan: nurse satisfaction, commitment and retention strategies.

The NHS Plan envisages a paradigm shift from a centralized, producer-led National Health Service (NHS) to a devolved, patient-centred health care service, fuelled by a substantial investment in human resources, beds, hospitals and infrastructure. The planned net increase of 20,000 nurses by 2004 is examined in the light of findings from a qualitative study of nurse satisfaction, commitment or intention to leave their hospital, nursing or the NHS, involving 124 nurses in four London hospitals. This paper presents nurses' perceptions and rankings of retention strategies and we compare these with the Plan's proposals. Lastly we propose an integrated approach to examining and dealing with the complex issue of nurse recruitment, retention and quality of patient care, based on a conceptual framework, the Nurse Satisfaction, Service Quality and Nurse Retention Chain, which highlights the scope of the challenges confronting the Plan, in both design and implementation of proposals designed to improve working conditions as a foundation for nurse recruitment and retention. Our principal findings are that just 57% of our interviewees may be viewed as 'core loyals' to the profession, 12% are serious in their intention to leave and the remainder may be sensitive to further deterioration in working conditions or a failure to meet expectations on pay. Such findings if realized clearly threaten the Plan's success.     

Factors affecting physician loyalty and exit: a longitudinal analysis of physician-hospital relationships.

This article examines forces that influence physicians to change the percentage of their admissions to a hospital (loyalty) and to cease admitting patients to a hospital altogether (exit). Because physicians are both members of a hospital and consumers of its services, their admitting patterns can be described using models of employee commitment and consumer buying behavior. We test several hypotheses drawn from these literatures using data on physician admissions at hospitals over a two-year period. Results indicate that admitting patterns are explained primarily by convenience and inertia processes characteristic of consumer behavior. On the other hand, factors believed to influence organizational commitment (e.g., decision-making involvement, conflict, economic investments) have little effect on loyalty and exit. The findings question the utility of hospital strategies to improve the climate of physician-hospital relations, and suggest several qualifications for research on the commitment of professionals.     

Stainless steel manual metal arc welding fumes in rats.

Forty two male Wistar rats were exposed to manual metal arc (MMA) stainless steel (SS) welding fumes generated by an automatic welding device for "nose-only" exposure. The exposure simulated an actual MMA/SS welding environment as closely as possible. For the retention study, the duration of exposure was one hour per workday for one, two, three, of four weeks and for the clearance study four weeks. The retention and clearance of the chromium, nickel, and iron found in MMA/SS welding fumes in the rats' lungs were studied as was the distribution of the metals to other organs. Instrumental neutron activation analysis (INAA) was used for the multi-element chemical activation analyses. The concentrations of chromium and nickel in the blood and the urine were determined by atomic absorption method (AAS). The retention of exogenous iron was determined by a magnetic measuring method. The results indicated that the lungs were the target organs of soluble hexavalent chromates. The half times of lung clearance for Cr, Ni, and Fe were 40 +/- 4 d, 20 +/- d, and 50 +/- 10 d. When the lung clearance curves are compared, the half times of Cr and Fe lung clearance are similar but nickel disappears faster. The distribution and clearance patterns of chromium to other organs differ from those obtained after single intravenous or intratracheal injections of alkaline chromates.     

Birth order in small multihospital systems.

The strategic behaviors of small multihospital systems have received little attention in the literature despite the fact that small systems are the predominant scale among multihospital systems. This study examines one important aspect of small-system strategic behaviors: the birth-order or evolutionary patterns of hospital acquisition. The evolutionary patterns of acquisition are compared across three strategic model types studied elsewhere: local market, investment, and historical. Using data obtained from a variety of sources, local market model systems are found, in the sequence of acquisition, to be significantly different from the other two model types in terms of relative distances of acquisitions from the initiating or parent hospital, the sizes of acquisition hospitals, the complexity of those hospitals, and the likelihood that the acquisitions are located in rural areas. Differences between parents and acquisitions are also significant, as hypothesized, for the market model system types, although they are not generally significant for the other two model types. The findings suggest that the market model represents an important strategic form that may have important implications for the restructuring of hospital markets.     

Utilization patterns of cohorts of elderly clients: a structural equation model.

OBJECTIVE. To identify a model that takes into account the interrelationship of health services utilization variables, and that allows examination of the utilization patterns of health services for a cohort of elderly clients. DATA SOURCES AND STUDY SETTING. The data of each client in the study were taken from three computer databases maintained for administrative purposes by the Ministry of Health in British Columbia. Time frame for the utilization variables is one year before and one year after admission to the long-term care program in BC which occurred in 1981-1982. STUDY DESIGN. A basic model was fitted to the utilization data for the year before admission and patterns of utilization were assessed for each gender-age group for the year before admission and for the two periods, using LISREL. Fifteen utilization variables were included: number of GP and specialist visits in different settings (office, home, etc.) and number of other services such as lab tests, hospital stay, etc. DATA COLLECTION. The three files were linked to produce one record per client. PRINCIPAL FINDINGS. A model was identified that fits the data well. The total effect of GP emergency room visits on hospital stay is 0.30 compared to 0.19 direct effect. The additional impact is produced via the effect of specialist consultations on hospital stay. This and similar findings by age, gender, and period are consistent with the joint dependency of utilization variables. CONCLUSIONS. The analysis shows that males and females have different utilization patterns, while age has no effect on utilization of health services by male clients and only a small effect on utilization patterns by female clients. Admission to LTC causes more specialist contacts resulting from contact with a GP and generally a more intensive use of diagnostic and surgical procedures. However, there is significantly less acute care hospital services utilization.     

精神专科医院医务人员职业认同与留职意愿研究

目的 调查精神专科医院医务人员职业认同与留职意愿现状以及二者之间关系,为稳定精神卫生人才队伍提供建议.方法 采用职业认同量表、留职意愿量表对四川省某二级精神专科医院和某三级精神专科医院的医务人员进行问卷调查.结果 调查对象总体职业认同水平处于中等偏上,在医院级别、职称上差异有统计学意义;留职意愿总体处于中等偏上水平,在...     

Medical education and the retention of rural physicians.

OBJECTIVE. This study inquires whether retention in rural practice settings is longer for graduates of public medical schools and community hospital-based residencies, and for those who participated in rural rotations as medical students and residents. These questions are addressed separately for "mainstream" rural physicians and physicians serving in the National Health Service Corps (NHSC). DESIGN. Design is a prospective cohort study. PARTICIPANTS. Study subjects were 202 primary care physicians who graduated from U.S. allopathic medical schools from 1970-1980, and who in 1981 were working in a nationally representative sample of externally subsidized rural practices. Nearly half were serving in the NHSC. Physicians were first identified in 1981 as part of an earlier study. INTERVENTION. In 1990, study subjects were re-located and sent a follow-up mail survey inquiring about their medical training backgrounds and their careers from the time of graduation until 1990. We examined associations between four features of physicians' medical training and their subsequent retention in rural practice settings. RESULTS. Among those not in the NHSC, rural retention duration did not differ for those from public versus private medical schools, those who trained in community hospitals versus university hospital-based residencies, or for those who completed versus did not complete rural rotations as students or residents. Among NHSC physicians, no retention duration differences were noted for those with rural experiences as students or residents, or for those trained in community hospital residencies. Contrary to common wisdom, public school graduates in the NHSC remained in rural areas for shorter periods than private school graduates. CONCLUSIONS. These findings call into question whether current rural-focused medical education initiatives prepare rural physicians in ways able to influence their retention in rural settings. For purposes of enhancing the rural practice retention of its alumni, the NHSC should not selectively award scholarships to students from public medical schools.     

Diffusion of surgical technology. An exploratory study.

The study presents an empirical analysis of the diffusion patterns of five surgical procedures. Roles of payer mix, regulatory policies, physician diffusion, competition among hospitals, and various hospital characteristics such as size and the spread of technologies are examined. The principal data base is a time series cross-section of 521 hospitals based on discharge abstracts sent to the Commission on Professional and Hospital Activities. Results on the whole are consistent with a framework used to study innovations in other contexts in which the decisions of whether to innovate and timing depend on anticipated streams of returns and cost. Innovation tends to be more likely to occur in markets in which the more generous payers predominate. But the marginal effects of payer mix are small compared to effects of location and hospital characteristics, such as size and teaching status. Hospital rate-setting sometimes retarded diffusion. Certificate of need programs did not.     

Measuring casemix specialization and the concentration of diagnoses in hospitals using information theory.

This paper examines the application of Information Theory to hospital discharge data. Information Theory offers a general methodology to compare sets of casemix proportions as a measure of (1) the concentration of admissions across hospitals for specific medical conditions and (2) specialization across diagnostic categories for individual hospitals. Unfortunately, Information Theory indices are difficult to interpret and subject to a potentially serious statistical bias when computed from discrete frequency counts, such as those obtained from discharge abstract data. The analysis presented here first clarifies the interpretation of Information Theory indices by relating them to formal statistical tests of hypotheses about hospital and diagnosis-specific patterns of admissions. It then documents the magnitude of the bias due to calculating indices from discrete frequency counts and proposes analytical strategies for dealing with this bias. Finally, the paper examines the empirical importance of the bias and the proposed adjustment, using data that are typical of those available for research on hospital casemix.     

Estimating hospital service areas using mortality statistics.

This article reports research testing an alternative methodology for patient origin studies that uses hospital deaths as a proxy measure for all discharges from a selected group of urban tertiary hospitals. Results indicated that mortality data from vital statistics records provide a reasonable approximation of patient travel patterns to acute care hospitals. Hospital service area indexes constructed from mortality statistics accurately predicted, on an aggregate regional basis, the results of a conventional patient origin study based on all hospital discharges. Hospital service areas, an important element of locational analysis in health planning, can be identified with the suggested methodology for states and areas lacking statewide uniform hospital discharge systems. A number of caveats are suggested for applying this methodology and interpreting its results.     

Cost effectiveness of home health care as an alternative to inpatient care.

This study of a sample of patients discharged from the Visiting Nurse Association of Greater St. Louis (VNA) focused on the extent to which VNA services were used as an alternative to institutional care. Based on physician estimates, patients averaged 18 fewer days in the hospital due to home care, saving more than $3,300 per patient. Utilization patterns are discussed for patients grouped by age, diagnosis, payment source and disposition upon discharge. Variations observed suggest valuable avenues for additional investigation into the types of patients for whom home care is most likely to be an appropriate alternative to hospital care.     

Outbreak of nosocomial infections with two different MRSA-strains involved: significance of genomic DNA fragment patterns in strains otherwise difficult to type.

Methicillin-resistant Staphylococcus aureus isolates from an outbreak of 17 cases of wound infection in a municipal hospital were typed by conventional methods, phage typing by three sets of phages, reverse phage typing and plasmid profiles, as well as by genomic DNA fragment patterns obtained after Sma-I digestion and pulsed-field electrophoresis. These isolates were non-typable by phages, only some were typable by reverse phage typing and were not uniform in plasmid profile. Only the genomic DNA fragment patterns resulted in a clear discrimination of 2 strains (12 isolates for the first and 7 isolates for the second). Both strains were disseminated in different wards of the same hospital and one strain had obviously spread to another clinic in the same city.     

Planning, budgeting, and controlling--one look at the future: case-mix cost accounting.

This paper outlines the system for cost accounting and managerial control which is an extension of the usually accepted departmental costing systems and takes as its units the 383 Diagnosis Related Groups (DRGs) considered to be the hospital's products. It is held that such an approach offers hospital managers a more powerful, analytic, budgeting, and cost-finding tool and offers the opportunity to involve the medical staff in the issues of how their practice patterns are affecting hospital costs.     

Hospital Choice of Medicare Beneficiaries in a Rural Market: Why Not the Closest?

As part of a larger study of hospital choice, the travel patterns of more than 12,000 Medicare beneficiaries residing in three overlapping rural areas were examined. During 1986 these Medicare beneficiaries were admitted to one of 53 hospitals in an area that encompassed parts of Minnesota, North Dakota, and South Dakota. Information on ZIP code of residence, closest hospital, and hospital of admission were used to analyze hospital choices of the Medicare rural elderly residing in this area. To summarize their travel patterns, the admitting hospital was categorized based on whether it was urban or rural, its size and whether or not it was the closest facility. Findings indicated that 60 percent of these rural Medicare beneficiaries used hospital services at their closest rural hospital, regardless of its size. However, 79 percent of those whose closest hospital was larger than 75 beds used it, while only 54 percent of those whose closest rural hospital was fewer than 75 beds obtained services there. Overall, 30 percent of those residing in this rural market area went to an urban hospital. These patterns appeared to reflect an evaluation by the physician and/or individual of the relative attractiveness of the local hospital versus alternatives available, as well as the individual's characteristics. Travel patterns varied by the beneficiary's age as well as his or her relative complexity of illness, as measured by a Disease Staging methodology. Findings have implications for the provision and financing of hospital services in rural areas.