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Organization and Information at the Bedside (dissertation)


A dissertation submitted to the faculty of the Division of Social Sciences of the University of Chicago in candidacy for the degree of Doctor of Philosophy in Sociology

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The practice of medicine is undergoing an industrial revolution akin to the one that occurred in manufacturing in the 19th century. Cost-containment, nursing professionalization and new information technologies combine with growing administrative dominance in health care organizations to challenge the traditional role of the physician. Hospitals and insurance firms threaten to reduce physician autonomy and incomes, and substitute nurses and other allied health professionals into roles traditionally controlled by physicians. In this study, I test for evidence of, and predictors of, nurse substitution for physicians in patient counseling, education and case-management.

Chapter One reviews the literatures related to the doctor-nurse division of labor, including those on the doctor-patient relationship, doctor-hospital relationship, and the doctor-nurse relationship.  I then place these dynamics in the context of academic medical centers (AMCs) strategically adapting to the growth of managed health care. I propose that the division of labor between doctors and nurses will develop curvilinearly with managed care growth and hospital administrative rationalization, moving from:

(a) an initial phase, in which the university hospital is the academic physicians’ workshop, and physicians devote themselves to research and delegate patient care to nurses and housestaff, to
(b) an intermediate phase where physicians and administrators begin to respond to competitive markets by substituting licensed practical nurses (LPNs) for registered nurses (RNs), and by encouraging physicians to return to patient case-management and direct patient care, and then to
(c) a later phase of full administrative rationalization, where administrators begin to substitute nurses for physicians in patient care.

In Chapter Two, I describe the quantitative and qualitative data used in this study. Three years of patient surveys (N=50,000) in 45 university hospitals provide parallel measures of reported amounts of patient care performed by nurses and doctors, and the percent of patients reporting they had a physician case-manager.  These measures reveal some hospitals to be more “physician-centered,” where attending physicians perform more of the patient counseling, education and case-management tasks than nurses and housestaff. Conversely, patients at other hospitals report care being more “nurse-centered,” with less physician case-management, and nurses and housestaff providing as much patient counseling and education as attending physicians.

To complement this quantitative analysis, I conducted three case studies in academic medical centers with widely varying characteristics. I interviewed administrators, physicians and nurses in these AMCs about the key concepts and dynamics of this study. 

In Chapter Three, I examine intra-hospital and patient-level characteristics related to the dependent labor measures. While age, gender, payor status, illness, and medical-surgical status are related to reports of doctor and nurse work, these patient-level variables explain little of the variance, largely obviating the need for case-mix adjustments at the aggregate level. The exception is physician case-management, which is strongly predicted by indigency and medical-surgical status.

In Chapter Four, I demonstrate that managed care growth in local markets is related to variations in the inpatient experience of doctors and nurses. I also demonstrate that staffing ratios appear to be a key intermediate variable between managed care growth and the reported division of labor. The more nurses per bed, the more patients perceive that nurses do, and the less they say doctors do; the more housestaff per bed, the less nurses and doctors are perceived to do.

In Chapter Five, I explore whether “institutional resources” are related to the dependent labor measures, and mediate the managed care-division of labor relationship. In particular, I demonstrate the direct effects of state-ownership, university-ownership, prestige, payor case-mix and hospital size, and the degree to which these characteristics appear to insulate AMCs from the market pressures of managed care. Both direct and mediating effects are found, but not in patterns that support an “institutional resources” model.

In Chapter Six, I explore Total Quality Management (TQM), hospital automation, case-management nursing, and the internal segregation of the indigent as adaptations to managed care market growth, which may in turn effect patients’ experience of the division of labor. The data do not support the hypotheses that these organizational innovations are either direct responses to market evolution, or affect the division of labor.

In Chapter Seven, I discuss the role of nursing culture in inhibiting or encouraging nursing role expansion and labor substitution for physicians. I demonstrate that nursing schools are related to reports of expanded nursing roles, while nursing unions are related to more limited nursing roles.

In the concluding chapter I explore summary regression models, and the implications of this study for the ongoing changes in health care organization.


Chapter 1 : The Division of Labor in the Hospital 1

Chapter 2 : Data Collection and Methods 114

Chapter 3 : Variation Across Patient Groups and Within Hospitals 135

Chapter 4 : Managed Care and Market Evolution 149

Chapter 5 : Hospital Characteristics and Market Sensitivity 171

Chapter 6 : Responses to the Market 202

Chapter 7 : Nursing Culture 228

Chapter 8 : Summary and Conclusions 243

Appendix : Survey Instruments 263

Bibliography 292

James Hughes Ph.D., the Executive Director of the Institute for Ethics and Emerging Technologies, is a bioethicist and sociologist who serves as the Associate Provost for Institutional Research, Assessment and Planning for the University of Massachusetts Boston. He is author of Citizen Cyborg and is working on a second book tentatively titled Cyborg Buddha. From 1999-2011 he produced the syndicated weekly radio program, Changesurfer Radio. (Subscribe to the J. Hughes RSS feed)


good post, serious stuff

Yes, agree - good post

Very insightful.

In this study, I test for evidence of, and predictors of, nurse substitution for physicians in patient counseling, education and case-management.

Nurse Practitioner Jobs

Mr. James Hughes, you always write such insightful and powerful social commentary. I’ve been following your work since I encountered a copy of your book Citizen Cyborg by chance. As a nurse myself, I could really relate to your thesis this time. Good work!

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