agement practices to establish the organization as a “learning organization.” Evidence shows that these practices are not employed in many nursing work environments.

In particular, many hospital restructuring and redesign initiatives1 that have been widely adopted over the last two decades have changed the ways in which licensed nurses and nurse assistants are organized to provide patient care. Many of these changes have been focused largely on increasing efficiency and have been undertaken in ways that have damaged trust between nursing staff and management. Changes often have been poorly managed so that intended results have not been achieved, infrequently have involved nurses in decision making pertaining to the redesign of their work, and have not employed practices that encourage the uptake and dissemination of knowledge throughout the organization. The committee found, for example, that:

  • Loss of trust in hospital administration is widespread among nursing staff (Decker et al., 2001; Ingersoll et al., 2001; Kramer and Schmalenberg, 1993). This loss of trust stems in part from a perception that initiatives in patient care and nursing work redesign have emphasized efficiency over patient safety. Poor communication practices have also led to mistrust (Walston and Kimberly, 1997). This loss of trust has serious implications for the ability of hospitals and other HCOs to make the fundamental changes essential to providing safer patient care.

  • Clinical nursing leadership has been reduced at multiple levels, and the voice of nurses in patient care has diminished. Hospital reengineering initiatives often have resulted in the loss of a separate department of nursing (Gelinas and Manthey, 1997). At the same time, nursing staff have perceived a decline in chief nursing executives with power and authority equal to that of other top hospital officials, as well as in directors of nursing who are highly visible and accessible to staff (Aiken et al., 2000). These changes—along with losses of chief nursing officers without replacement; decreases in the numbers of nurse managers; and increased responsibilities of remaining nurse managers for more than one patient care unit, as well as for supervising personnel other than nursing staff (e.g., housekeepers, transportation staff, dietary aides) (Aiken et al., 2001; Sovie and Jawad, 2001)—have had the cumulative effect of reducing direct management support available to patient care staff. This situation hampers nurses’ ability to fix problems in their work environments that threaten patient safety (Tucker and Edmondson, 2002).


The terms “restructuring,” “reengineering,” and “redesigning” are used interchangeably in the literature.

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