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Social Science & Medicine 57 (2003) 1539–1546
Downsizing within a hospital: cutting care or just costs?
Claire Browna,b,*, Bengt Arnetzb,c, Ove Peterssond
a Section for Social Medicine, Department of Public Health and Caring Sciences, Uppsala Science Park, SE-751 85 Uppsala, Swedenb Centre for Environmental Illness and Stress Research, Uppsala Academic Hospital, Sweden
c Section for Social Medicine, Uppsala University, Uppsala, Swedend University Hospital, .Orebro, Sweden
Abstract
Downsizing of staff is becoming increasingly common in hospitals as a way to meet the demands of shrinking
budgets. This study, based in Sweden, used a longitudinal design to study staff views of their work environment, their
individual health and the quality of the care they were delivering during a period of hospital downsizing. Although there
were no significant changes in perceptions of quality of care, perceptions of workload substantially increased whilst
perceptions of mental energy substantially decreased. These two changes could point to future problems with quality of
care after a period of hospital downsizing.
r 2003 Elsevier Ltd. All rights reserved.
Keywords: Quality of care; Work environment; Downsizing; Hospitals; Sweden
Background
Health care providers are being asked to cut costs
whilst ensuring patient care is not compromised (see e.g.
Donabedian, 1989; Leatt, Baker, Halverson, & Aird,
1997; Malloch, 2000). Downsizing is a common response
to budgetary cutbacks yet ‘it is astounding to observe
how many hospitals have made major investments in
organisational restructuring and work redesign in the
absence of empirical evidence of the effectiveness of the
initiatives, or their safety’ (Aiken & Fagin, 1997, p.
OS2). It is important, for managers, practitioners and
patients, to evaluate whether the downsizing that is
occurring in hospitals around the world is, in any way,
compromising the quality of patient care. This paper
reports the results of a study in Sweden, that investi-
gated doctor, nurse and patient perceptions of quality of
care during a period of hospital downsizing.
The first issue is what is quality, ‘a remark-
ably difficult notion to define’ (Donabedian, 1966,
p. 167). There is no definitive answer to this question
as what constitutes quality health care differs according
to the perspective of the respondent. In some cases,
articles discuss quality in health care without attemp-
ting to define the concept (e.g. Campbell, Roland, &
Wilkin, 2001). Regardless of definition of this illusive
ideal there is little argument that health care insti-
tutions differ in their quality of care (e.g. West, 2001).
What the issue then becomes is, how is quality
measured?
One answer to this question is that quality can be
measured using clinical outcomes (e.g. Morey, Fine,
Loree, Retzlaff-Roberts, & Tsubakitani, 1992; Carey &
Burgess, 1999). Using a clinical indicator, the rate of
pressure ulcer development, a study in the United States
of America showed that quality of care declined during a
period of major restructuring (Berlowitz, Young,
Brandeis, Kader, & Anderson, 2001). However, the
relationship between clinical outcomes and quality of
care is not clear (Carey & Burgess, 1999) and some
studies have shown quality and clinical outcomes not to
be well correlated (e.g. Thomas & Hofer, 1999).
Furthermore, the differences between quality and
ARTICLE IN PRESS
*Corresponding author. Department of Public Health and
Caring Sciences, Section for Social Medicine, Uppsala Science
Park, SE-751 85 Uppsala, Sweden. Tel.: +46-18-611-34-23; fax:
+46-18-51-16-57.
E-mail address: [email protected] (C. Brown).
0277-9536/03/$ - see front matter r 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/S0277-9536(02)00556-7
clinical outcomes is often not made clear with some
articles on quality reporting clinical outcomes as quality
measures with no discussion of the relationship between
the two (e.g. Campbell et al., 2001). For the purposes of
this paper clinical outcomes were envisaged as a useful,
but not sufficient, indicator of quality.
An alternate perspective on measuring quality of care
is that patients’ perceptions should be used. Studies on
patient perceptions of quality of care before and after
downsizing have given contradictory results. A study, in
Australia, found that patient satisfaction with the
quality of care they received in a maternity setting
dropped during a period of funding cutbacks (Brown &
Lumley, 1998). One Swedish study showed an improve-
ment in patient satisfaction after downsizing had been
implemented simultaneously with an intervention de-
signed to improve nursing care (Jakobsson, Hallberg,
Lov!en, & Ottosson, 1994). When the measures were
repeated in 1993 and 1994 a deterioration in patient
satisfaction was noted (Ottosson, Hallberg, Axelsson, &
Lov!en, 1997).
However, patient views on the quality of care they
have received is problematic as a tool from two
perspectives:
1. Patients are perceived not to have the technical
knowledge to judge the technical quality of their care
(see for example comments in Vuori, 1987; Donabe-
dian, 1988; Press, Ganey, & Malone, 1991), and
2. patient satisfaction with the ‘‘caring’’ component of
their care is generally high with little variation
between health care facilities (see discussion of this
point in Rubin, 1990) thus rendering patient satisfac-
tion surveys of disputable use as a discriminating
measure of quality.
A third view on how quality is measured is that staff
directly involved in health work, particularly doctors
and nurses, are those who have the most accurate
judgements on whether the health care being delivered is
of high quality. From a staff perspective, one Swedish
study found that, after a period of financial cutbacks,
staff perceived the quality of care to have deteriorated
(Arnetz, 1999). In the current study, staff were asked
directly for their opinions on the quality of the care they
were delivering at different times during a period of
downsizing.
One point that is being increasingly acknowledged is
the possible effect of working environment on the
quality of care offered by staff, particularly as regards
those staff most immediately involved with patient
care, that is doctors and nurses. It has been shown
that better satisfied staff rate the quality of care they
offer more highly (Thomsen, Arnetz, & Arnetz, 2000).
Doctors who are under stress, from overwork or
lack of sleep for example, report that this contributes
to a lowered standard of care (Firth-Cozens & Green-
halgh, 1997) and studies suggest ‘that sleep deprived
physicians are cognitively impaired’ (Arnetz, 2001,
p. 205).
There is an association between staff who rate
their job satisfaction highly and patients who give a
positive evaluation of their quality of care (Atkins,
Marshall, & Tavalgi, 1996). Perceptions of the staff
working environment are one predictor of patient
quality of care ratings (Arnetz & Arnetz, 1996). A better
working environment for nursing staff, with higher
nurse autonomy and control, is associated with
decreased patient mortality (Aiken, Smith, & Lake,
1994).
Furthermore, quality of care has been shown to be
linked to organisational factors (Arnetz, 1999). It is
acknowledged that ‘the quality of patient care may be
related in an important way to the quality of life
experienced by staff at work’ (West, 2001, p. 41). Job
satisfaction is negatively associated with nurse turnover
(Goodell & Coeling, 1994; Mitchell & Shortell, 1997).
High turnover of nurses negatively affects the pool of
experienced staff (Mitchell & Shortell, 1997) which may
have negative effects on the quality of care offered. Thus
when implementing cost cutting strategies it is important
to measure the impact on work environment as a poor
work environment can increase costs for a hospital by
increasing the need for recruitment and possibly
decreasing the standard of care given.
However, despite the pressures on hospitals to
restructure and the amount of evidence regarding the
effect of work environment on staff, there are few
published studies on the effects of downsizing in
hospitals on work environment and patient care from
a staff perspective (see Arnetz, 1999 for one example).
There are studies which report a negative correlation
between staffing levels and patient mortality (e.g.
Shortell & Hughes, 1988) and a negative correlation
between nurse staffing levels and adverse events (Kovner
& Gergen, 1998; Needleman, Buerhaus, Mattke, Stew-
art, & Zelevinsky, 2002). There are scholarly papers
which suggest that downsizing of professional staff and
their replacement with less trained assistants could be
damaging to patient care (e.g. Robertson & Dowd,
1996). A study in California found that, during a period
of downsizing, nursing provided an acceptable level of
patient care (Lewis, Nitta, Biczi, & Robinson, 1986).
However, it has also been shown that nurses in hospitals
affected by downsizing felt downsizing compromised
the standard of care they could offer (Blythe, Baumann,
& Giovannetti, 2001). There are, however, few
empirical studies that follow the staff of a health care
institution through a period of downsizing, and in
particular, look at their views on the quality of care they
are providing.
ARTICLE IN PRESSC. Brown et al. / Social Science & Medicine 57 (2003) 1539–15461540
The current study seeks to fill this gap and, with data
stretching over six years, asks:
1. Do staff perceptions of quality of care delivered
change during a period of hospital downsizing?
2. Do staff perceptions of their working environment
alter over a period of downsizing?
3. If there are any changes in perceptions of quality or
work environment over a period of downsizing, are
these changes consistent for doctors and nurses?
Method
This study is unique in that it is a longitudinal
correlational study within a health care organisation.
Over a period of years, when budgetary cuts and staff
downsizing were being implemented, an instrument
designed to measure staff opinions of the quality of
care they were delivering and various features of their
work environment was administered. The data provided
maps out the reactions of staff, over the period 1994–
1999, on ten scales (in three main groupings):
1. Work environment
a. Involvement
� Leadership.
� Performance feedback,
� Participatory management
b. Opportunities
� Skills development
� Social work environment
c. Institutional well being
� Organisational efficiency
� Institutional goal quality
2. Individual health
� Mental energy
� Work load
3. Quality of care
The first seven scales examine the ‘‘health’’ of the
work environment from the three perspectives of the
amount of involvement the individual feels they have in
the organisation, the opportunities work offers them
and their view of the organisation’s well being. The two
individual health scales give measures of how well the
individual staff member feels they are coping with the
demands made upon them. Quality of care is a measure
of how highly the individual staff member rates the
quality of care they are delivering to their patients.
Another way of putting this is that what is being
measured is the staff’s assessment of the organisational
well-being of their work environment, their individual
well being and the quality of the care they are delivering.
The current study provides an excellent opportunity
to examine how changes in budget structure affect staff’s
individual well being and their view of organisational
well being. What we have in this study is a report card
on one hospital’s efforts to reign in their budget.
In order to see if any changes found in the various
indices over the four occasions on which the instrument
was administered were consistent across doctors and
nurses, background information was also collected. This
allowed the use of two independent variables—year and
occupation, and one covariate variable—gender. In
order to determine if any significant differences found
in the scores of doctors and nurses on any of the indices
were influenced by the unequal gender make-up of each
occupation.1 Thus, using the data, collected at four
points over 6 years, it is possible to answer the questions
outlined above (Table 1).
The hospital that was the site of the study, is a
regional tertiary care facility in Sweden which had
approximately 4000 employees before downsizing took
place. In 1994, before any budget cuts had been
discussed, the hospital management instituted a quality
improvement programme with staff. The programme
focussed on the seven areas outlined above under work
environment, and quality of care, and aimed at
improving the work environment and improving job
satisfaction (Arnetz & Arnetz, 1996).
The changes in structure over the period in which the
questionnaire was administered were:
* 1994: normal work structures with no indications of
possible financial cut backs,* 1995: staff informed of need to trim budget and staff
by 20% but details not released,* 1997: cut backs in progress,* 1999: cut backs complete.
The questionnaire has been developed over a number
of years. It has been validated in a number of studies
including one which correlated the results on a number
of the scales with biological markers (Arnetz, 1996).
Thus the validity of the instrument has been verified
through both psychosocial assessments and biological
measures. Cronbach’s alpha for each of the scales was
0.7 or higher (Arnetz, 1999).
The questionnaire was sent to all full time employees
of the hospital. Due to the focus of this study on staff
with an immediate patient care role, only the ques-
tionnaires from doctors and nurses were included in
analysis. The questionnaires were completely anon-
ymous and were delivered to employees with an
addressed, postage paid envelope for their return.
Information about the project from the research team,
hospital management and unions was circulated before
the project began. In addition detailed information
ARTICLE IN PRESS
1 Within this sample approximately 67% of doctors and 10%
of nurses were men.
C. Brown et al. / Social Science & Medicine 57 (2003) 1539–1546 1541
about the questionnaire from the research team was
included with the questionnaires. Reminder letters were
sent to all respondents 2 and 4 weeks after the initial
mailing.
The study was a Panel study. Due to the need to
ensure anonymity of responses, no attempts were made
to ensure consistency of respondents over the four
measuring points. However, due to downsizing occur-
ring over the period the numbers of new staff in the
hospital were low. This, combined with the high
response rates (see Results) suggests a reasonable degree
of consistency in terms of respondents over time.
Initial analysis, to determine whether scores on the ten
scales varied significantly over time or between doctors
and nurses, was by use of a general linear model (GLM)
using SPSS version 10.0. GLM is in essence a
MANOVA technique allowing the use of categorical
independent variables (in this case the four category
Year and the dichotomous Occupation) and a contin-
uous dependent variable (in this instance the ten
indices). At all stages of analysis statistical significance
was set at pp0:05:If Occupation was shown to be significant for any of
the indices a GLM was re-run including Year, Occupa-
tion and Gender as independent variables. This enabled
a more detailed picture of any significant differences in
perception between doctors and nurses to be gained.
If year was significant for any of the indices in the
initial analysis, a one-way ANOVA for the relevant
index, with Year as the independent variable was run.
This enabled the use of post hoc tests (either Bonferroni
or Dunnett T3 depending on homogeneity of variance)
to determine if differences between any pair of years was
statistically significant allowing for multiple compari-
sons.
Finally, for those indices where Occupation was
significant a one-way ANOVA was run for Year for
that index with this analysis being run separately for
doctors and nurses.
The analyses outlined above develop a full picture of
the effect of downsizing of a hospital on those staff most
directly in frontline patient care and the effect this has
on their perceptions of the quality of care they are
offering.
Results
The response rate for each year was:
* 1994 Nurses (N ¼ 1006); Doctors 78% (N ¼ 357).* 1995 Nurses 56% (N ¼ 795); Doctors 71%
(N ¼ 285).
ARTICLE IN PRESS
Table 1
Questions in indices (adapted from Arnetz, 1999)
Index Questions
Leadership Immediate supervisor: communicates clearly, acts consequently, describes how to achieve the
departmental goals, provides opportunities to develop professional skills, open to changes in how the
workplace is organised and work habits.
Performance feedback Clear directives from immediate supervisor, feedback from supervisor when task has been done well or
badly.
Participatory
management
Opportunity to influence workplace decisions, influence over workplace decisions in relationship to
how much influence is desired, ability to decide how work should be done and what tasks should be
done, sufficient influence in relationship to responsibilities, access to adequate information to carry out
work duties efficiently, information from immediate supervisor sufficiently concrete to be useful in
employees work.
Skills development Professional skills development in employee’s work, immediate supervisor provides opportunities for
skills development, opportunities for a more advanced position within health care, employee’s skills
are utilised in current position, current job tasks offer professional development.
Social work environment Positive atmosphere at work, feeling of cohesion amongst co-workers, supportive atmosphere among
colleagues.
Organisational efficiency Work is planned within the workplace, employees work toward a common goal, the decision-making
process works well, the resources in the workplace are optimally utilised.
Institutional goal quality Workplace goals are: well-defined, realistic, able to be influenced and assessable
Mental energy Feelings of restlessness, irritability, worry, feeling low, moodiness and difficulty concentrating during
the last month.
Workload One task can be completed before turning to the next, do you work very hard?
Quality of care Information given to patients about their illness, tests and treatment and hospital routines; accessibility
of staff and professional resources; staff attitude; patient involvement in decision-making; quality of
medical care and treatment; quality of nursing care.
C. Brown et al. / Social Science & Medicine 57 (2003) 1539–15461542
* 1997 Nurses 63% (N ¼ 839); Doctors 73%
(N ¼ 272).* 1999 Nurses 55% (N ¼ 748); Doctors 66%
(N ¼ 254).
In a study on the influence of non-response in a health
care worker survey there was no difference found
between responders and non-responders (Thomsen,
2000) thus it has been assumed that the samples are
representative of health care workers in the hospital.
There were only two indices for which Year was not
significant in the initial GLM with year and occupation
as independent variables. These were perceptions of
institutional goal quality and perceptions of quality of
care delivered. Nor was Occupation a significant
independent variable for either of these indices but it
was significant in all other cases. Both whether an
employee is a doctor or a nurse and downsizing (year is a
proxy measure for stage of downsizing) affected all
indices except quality of care and institutional goal
quality. The views of staff of the quality of care they
were delivering did not change significantly during the
period of downsizing. Their perceptions of various
measures of their work environment did change.
When the GLMs for the eight indices for which
Occupation was significant were expanded to include
Gender as an independent variable, only in two cases,
perceptions of participatory management and mental
energy, did gender significantly affect the results.
When Gender was included with Year and Occupa-
tion as independent variables with perceptions of
participatory management as the dependent variable,
Occupation became non-significant. Gender was a
significant independent variable and the interaction
variable between Gender and Occupation was significant
for both of these indices. The significance of the
interaction variable indicates that the effect of occupa-
tion on either of these indices was not consistent across
the genders. For mental energy, Gender was a significant
independent variable and the interaction variable
between Gender and Occupation was significant.
As Occupation was significant for all indices in which
Year was significant a one-way ANOVA was run for all
eight of these indices, separately for doctors and nurses.
The means for these eight indices, and also institutional
goal quality and quality of care,2 are given in Table 2.
As can be seen, in Table 3, the significant differences
in means on the indices do not fit an overall pattern. In
general it seems that for both doctors and nurses
leadership was perceived to be lowest in 1997 and
highest in 1999. Performance feedback was generally
seen to be low in 1997 and participatory management
and opportunities for skills development were low in
1994. The social work environment was higher in 1999
than in 1995 for both doctors and nurses. Organisational
efficiency was low in 1997 for both doctors and nurses
and high in 1994 for both groups. For both occupations
their mental energy was highest in 1994 and lowest in
1999. Workload for doctors and nurses seems to have
increased as downsizing progressed with the highest level
reached in 1999.
Discussion
Year is significantly associated with the scores on
eight of the ten indices measured in this project but not
with quality of care. The previous study which found
that staff perceived quality of care to have deteriorated
during a period of financial cutbacks (Arnetz, 1999) was
a cross-sectional study, using retrospective recall of the
personnel’s view of changes in quality. The current study
showed no significant changes in perceptions of quality
ARTICLE IN PRESS
Table 2
Means for each index for each year for each occupation
Scale 1994 1995 1997 1999
Nurses Doctors Nurses Doctors Nurses Doctors Nurses Doctors
Leadership 75.2 73.2 74.2 73.3 67.5 65.4 86.0 84.1
Performance feedback 61.6 56.5 60.5 58.0 48.3 49.7 53.2 51.8
Participatory management 62.2 62.2 56.3 66.4 68.7 70.7 66.7 66.6
Skills development 49.9 55.2 59.4 68.7 60.4 62.7 64.9 65.1
Social work environment 66.5 62.9 62.7 60.1 66.8 61.1 69.3 64.9
Organisational efficiency 61.1 57.6 60.2 58.1 54.9 51.7 58.4 53.2
Institutional goal quality 64.5 66.3 63.6 65.1 63.8 64.2 63.2 62.2
Mental energy 81.7 80.1 77.6 74.3 75.5 73.5 70.0 66.0
Workload 62.1 68.4 63.1 68.8 72.2 79.2 75.1 83.7
Quality of care N/A N/A 72.4 71.2 72.3 70.6 70.0 70.9
2 Despite Occupation not being significant for either of these
indices, it was felt that reporting the means separately for
doctors and nurses gave a fuller picture than reporting overall
means.
C. Brown et al. / Social Science & Medicine 57 (2003) 1539–1546 1543
of care using repeat analysis of how staff rated quality at
four definite points during downsizing. That no evidence
was found suggests that downsizing may not affect
quality of care from the perspective of doctors and
nurses.
However, the perceptions of staff of their work
environment did change over the time of downsizing.
In terms of staff members’ perceptions of leadership,
1999 was a good year whereas in 1997 both doctors and
nurses had low scores on this index. Similarly for
performance feedback, 1997 was very low for nurses and
fairly low for doctors. The third index measuring
involvement in the work place, is participatory manage-
ment. It was low in 1994 and 1995 (lowest in 1995 for
nurses) for both groups. Overall it would seem that
downsizing had its most severe affect on staff percep-
tions of involvement in the work place while the
downsizing was actually taking place.
In terms of opportunities staff perceived as available
to them, the scale measuring the opportunities for skills
development was lowest for both groups in 1994, before
there was any suggestion of downsizing. The perceptions
of the social work environment, as measured by
perceptions of the general atmosphere at work (see
Table 1 for details), was lowest in 1995 for nurses and
lower in 1995 than 1999 for doctors. This suggests that
the announcement, without details, of general cutbacks,
damaged the work atmosphere far more than the actual
imposition of the cuts.
In terms of institutional well-being the two indices
returned inconsistent results. Perceptions of institutional
goal quality showed no significant changes over the
period. Perceptions of organisational efficiency generally
declined. The staff may have felt a part of the process,
but in general they seemed to have declining views of the
efficiency of the organisation.
In general the scores on the indices measuring work
environment seem to give some support to the notion
that downsizing resulted in a better working environ-
ment for both doctors and nurses. However, looking at
the two indices measuring individual health, it would
seem this may not be the case. Mental energy was at its
lowest in 1999 while workload was at its highest. That
these two indices should demonstrate an inverse
association is to be expected, what is not expected is
that indices measuring institutional well-being should
associate so poorly with those measuring individual
health. There are three possible explanations for this:
1. The indices are not particularly valid, or
2. staff are aware of their own health problems (and
workload increases) but, due perhaps to loyalty to
colleagues, do not translate this to organisational ill
health, or
3. the quality improvement programme mentioned
above was effective in improving the work environ-
ment but did not spill over to improving the
individual health of employees.
As the scales have been used over many years, in three
countries and with a very large cumulative sample, and
the scales have been rigorous tested, it is conjectured
that the first of these explanations is not sustainable.
There is no evidence to support the second explanation.
The third explanation seems the most likely as
the programme was specifically aimed at the areas
studied under work environment whilst the cutbacks
ARTICLE IN PRESS
Table 3
Significant (pp0:05) differences in post hoc analysis between years for indices
Index Doctors Nurses
Leadership 1997oall other years 1997oall other years
1999>all other years 1999>all other years
Performance feedback 1994>1997 1997oall other years
1995>1997 1999o1994 & 1995
1995>1999
Participatory management 1994o1997 1995oall other years
1994o1997 & 1999
Skills development 1994oall other years 1994oall other years
1995>1997 1999>all other years
Social work environment 1995o1999 1994o1999
1995oall other years
Organisational efficiency 1994>1997 & 1999 1994>1999
1995>1997 & 1999 1997oall other years
Mental energy 1994>all other years 1994>all other years
1999oall other years 1999oall other years
Work load 1997>1994, 1995 1997>1994, 1995
1999>all other years 1999>all other years
C. Brown et al. / Social Science & Medicine 57 (2003) 1539–15461544
presumably increased workloads which would lead to a
decrease in mental energy.
There are implications for health care managers of
this study. Firstly, in general, the perceptions of doctors
and nurses of their working environments do differ and
this difference is not mediated by gender. Except in the
two cases noted, mental energy and participatory
management, differences found in the various indices
between doctors and nurses, are not an artefact of the
differential proportions of both genders in those
occupations. Doctors and nurses do have different
experiences of hospital work regardless of gender.
Management, in general, needs to be aware that the
two groups of staff most immediately involved in patient
care have substantially different views of their work
environment. In particular, looking at Aiken’s work on
‘‘magnet’’ hospitals (e.g. Aiken et al., 1994), the working
environment of nursing staff is negatively associated
with patient mortality.
The second major implication of this study is that,
although perceptions of quality of care did not alter over
the period, perceptions of workload did. As has been
shown in previous research doctors who are working
hard can feel that overworking diminishes their standard
of care (Firth-Cozens & Greenhalgh, 1997). Although
management was taking steps to improve the working
environment during the period of downsizing and this is
shown in the results, there is still the possibility of
overwork and a decline in mental energy among staff
leading to the possibility of future problems with the
quality of care.
The current study does not provide any evidence that
quality of care is affected, either positively or negatively,
by the implementation of downsizing. It does, however,
suggest that downsizing does affect staff views of their
workloads and mental energy which has potential
problems with quality of care. It is these potential
trouble spots in particular that should be borne in mind
by managers responsible for downsizing.
Acknowledgements
Sincere thanks to all the staff at .Orebro University
Hospital for their dedication to filling out questionnaires
throughout the years of the study. Thanks are given to
AFA Insurance, Sweden, the Working Life Fund of.Orebro, Sweden and to the two anonymous reviewers
for their helpful comments.
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