Doctor and nurse perception of inter-professional co-operation in hospitals

Transcription

1 International Journal for Quality in Health Care 2004; Volume 16, Number 6: pp /intqhc/mzh082 Doctor and nurse perception of inter-professional co-operation in hospitals UNNI KROGSTAD 1, DAG HOFOSS 1 AND PER HJORTDAHL 2 1 Norwegian Health Services Research Centre, Quality Evaluations, Oslo, 2 University of Oslo, Department of General Practice and Community Medicine, Norway Abstract Objective. To explore doctor and nurse perception of inter-professional co-operation in hospitals; discuss professional differences as reflections of cultural diversity in the perspective of quality improvement. Design. Cross-sectional survey data from a stratified sample of 15 Norwegian hospitals, September 1998: 551 doctors and 2050 nurses at medical and surgical wards. Measures. Doctor and nurse evaluation of their inter-professional co-operation was mapped. Logistic regression models predicting their satisfaction were compared. Results. Doctors were significantly more often than nurses satisfied with the inter-professional co-operation of the two groups. Satisfaction with inter-professional co-operation was predicted by a number of work situation variables. Some of them contribute differently to doctor and nurse satisfaction. Conclusions. Doctors and nurses not only evaluate their inter-professional co-operation differently, they also appear to define the concept in different ways. Hospital managers should include an understanding of this cultural diversity into the basis of their quality improvement efforts. Keywords: doctor nurse co-operation, hospital care quality, hospital work organization, professional cultures The handling of subcultural diversity is increasingly viewed as an essential part of health care management in connection with quality improvement [1,2]. This article discusses doctor and nurse perception of co-operation in hospitals based on survey data from both professions working together in the same hospital wards. Nursing and medicine are inseparably intertwined in hospital care. Patient outcomes are contingent upon the physicians skills in diagnosis and treatment, as well as upon nurses continuous observations and their skills in communicating the right information to the right professional partner. Good hospital care depends on a system that secures continuity of information and inter-professional collaboration [3 5]. Patient outcome has been shown to depend on interprofessional collaboration in intensive care units [6]. Also, hospitals where nurses report good co-operation with physicians have been described as magnet hospitals with lower nurse turnover and higher job satisfaction [7,8]. However, the relationship between doctors and nurses in hospitals has never been a symmetrical one. The two professions look at co-operation from different perspectives of patient care, different levels in the status hierarchy, and different sides of the gender gap. The field of doctor nurse collaboration has been sociologically attractive as it condenses the classical discourse of profession, power, and gender. Since the origin of the study of professions [9], the interface between health professions, and particularly that between doctors and nurses, has been extensively analysed by sociologists [10 15]. Stein s studies from 1967 [12] and 1990 [13] document a major changes in the nurses attitudes to what he calls the doctor nurse game. From discretely evading their subservient status in the late 1960s by influencing decision-making by observations, experience, and information, but in a way that did not challenge doctors positions, they explicitly claimed a say in clinical decision-making in the 1990s. An important background for this change is the nurses strategy for building their own academic profession [16,17]. Emancipating nursing implicitly changed the nursing perspectives [18] making them more independent of the medical profession. One consequence is an increasing gap between the professions in the daily clinical work. Sociologists have provided major contributions to the understanding of the dynamics of hospital professions, yet this knowledge has remained theoretical and academic. Address reprint requests to U. Krogstad, Norwegian Health Services Research Centre, Quality Evaluations, Box 7004, St Olavs Plass, 0130 Oslo, Norway. unni.krogstad@nhsrc.no International Journal for Quality in Health Care vol. 16 no. 6 International Society for Quality in Health Care and Oxford University Press 2004; all rights reserved 491

2 U. Krogstad et al. During the last decade, however, a more practical perspective of collaboration in hospital has been applied. These studies focus on inter-professional co-operation as a condition for effective health care, they are related to patient outcomes, and most importantly, they are published in journals read by health care professionals. One example is the British Medical Journal, which addressed doctor nurse co-operation in a special joint issue with the Nursing Times in April The main message was the need to start from scratch. Zwarenstein and Bryant [19] asked What s so great about collaboration? answering We don t really know. Celia Davies [20] suggested that co-operation does not necessarily mean using each other s resources to reach common ends, it may just be a term used to describe the fact that people of different professions are employed by the same organization. If so, the very concept of co-operation may conceal divergent meanings. One study of two Dutch hospitals reported discrepancies between role concepts and expectations of nurses and doctors [21]. Nurses were more critical towards doctors than vice versa, but neither party lived up to the expectations of the other party. Another study, of four hospitals in the UK and two in Australia [22], concluded that doctors and nurses have somewhat different conceptions of hospital work. Doctors viewed clinical work more as an individualistic venture than did nurses, who considered clinical work more as a collective undertaking. In Norway, three empirical studies have touched upon the issue. Their main message is that inter-professional co-operation is not experienced as a big problem in Norwegian hospitals at least not by male doctors. Yet, the findings indicate, like those of the Dutch and Commonwealth studies mentioned above [21,22], that differences in professional culture may affect inter-professional co-operation. A national survey of Norwegian doctors conducted in 1993 showed hospital doctors reporting favourable impressions of doctor nurse co-operation [23]. Fewer collaboration difficulties were reported by male doctors, older doctors, and psychiatrists. Differences were, however, undramatic and the general impression was friendly co-existence. Based on the same survey of Norwegian doctors, however, Gjerberg and Kjolsrod [24] analysed the more specific question of how female doctors experienced doctor nurse cooperation. They found that 30% of the female doctors, as compared with only 2% of their male counterparts, reported getting less assistance from nurses, than their colleagues of the opposite sex. The authors supplemented the picture by qualitative interview data: It s not that [the nurses] do not have time to help you. They want to tell you that you can t come here and make yourself important. (female medical researcher, 42) In the beginning I got very irritated when the nurses dropped whatever they were doing for me when a male colleague asked for help. Now I ve found that it s best not to ask them for help and try to manage as much as possible myself make myself independent of them. But that triggers reactions, too, because then I m moving into their territory. (female surgeon, 40) An interesting finding, though not discussed in this study, was that co-operation as seen by the doctors is expressed as assistance. Skjorshammer [25] discussed how hospital professionals handle co-operational conflicts. His main finding was that physicians tolerated more stress and disagreement than members of other professions before considering themselves as having a conflict. This may be interpreted as skilfull coping, but it may also indicate that the physician culture is insensitive to a collaborative climate. Most empirical studies of doctor nurse co-operation are either surveys of one profession only or small-scale qualitative studies whose findings may be difficult to generalize from. The present study analyses the experiences of interprofessional co-operation among a large sample of doctors and nurses working at the same time at the same medical and surgical departments in Norwegian hospitals. Methods Identical job experience questionnaires were sent to 932 doctors and 3985 nurses working at 125 surgical or medical wards at 15 hospitals in Norway in September Names and addresses were obtained through the personnel administration systems of the participating hospitals. Non-respondents received a reminder after 2 3 weeks. Personal identification was not included in the data file. Norway has five health regions, each with a 500- to 900-bed university hospital. In 1998 there were 12 county hospitals ( beds) and about 50 local hospitals ( beds). All regions and levels of hospital were represented in the survey. Personnel on long-term leave or having been with the hospital for less than 2 months were not included in the study. The questionnaire The instrument combined standard questions and scales from earlier job satisfaction questionnaires with new questions designed to tap experiences of work organization, leadership, co-operation, and system continuity. New items were generated in a multi-step procedure: participant observation with informal interviews was conducted at surgical and medical wards at three hospitals of different sizes in different parts of the country. A first draft of dimensions and items was discussed with a focus group of five doctors and five nurses. A second draft was distributed to staff at one internal medical and one surgical ward, asking for comments to be written on the questionnaire. The comments were discussed in a team of researchers before the third draft was designed. A third draft was discussed at five wards at three hospitals in other parts of Norway. A pilot study was conducted at two hospitals (N = 141), followed by a principal component analysis. Plenary discussions at the two pilot hospitals resulted in additional items. Demographic and administrative data considered to be neutral and unthreatening commenced the questionnaire. Items were organized thematically in logical sequences. Varying 492

3 Inter-professional co-operation in hospitals Table 1 Questions and response scales used in this article Scales... In general, how satisfied are you with your job? 1 = not at all 5 = very satisfied Do you experience unrealistic expectations from your own profession? 1 = yes, often 4 = no, never Do you experience unrealistic expectations from other professions? 1 = yes, often 4 = no, never Do you ever feel down or depressed because of criticism from nurses? 1 = yes, daily 5 = no, never Do you ever feel down or depressed because of criticism from doctors? 1 = yes, daily 5 = no, never How often do members of your own profession praise you for good work? 1 = never 4 = often How often do members of other professions praise you for good work? 1 = never 4 = often Co-operation between departments is very good at this hospital 1 = quite wrong 5 = quite right Patient information is always available when needed 1 = quite wrong 5 = quite right At this ward all professional groups have common aims for the patient 1 = quite wrong 5 = quite right Head nurse is well informed of the patients needs on the ward 1 = quite wrong 5 = quite right Co-operation between professions is very good at this ward 1 = quite wrong 5 = quite right At this ward, the other professional groups know the patients well 1 = quite wrong 5 = quite right I discuss patient information with other professions many times a day 1 = quite wrong 5 = quite right Information from other professional groups is very important in my job 1 = quite wrong 5 = quite right Physical workload 1 = intolerable 10 = very easy Emotional workload 1 = intolerable 10 = very easy Competence of nurses at this ward 1 = very lacking 10 = fully adequate Competence of doctors at this ward 1 = very lacking 10 = fully adequate response scales and layout were used to reduce the risk of automatic response. Items fetched from earlier hospital staff surveys had a four-point response scale while the new questions for this study had a five-point Likert format or a 10-grade scale with unique anchorings. The items used in this analysis are listed in Table 1. Measures For the cross-tabulations of work situation variables by profession, summarized in Table 2, item scores were dichotomized so that the two most positive response alternatives on the four and five-point scales were coded as positive, as were the three most positive responses on the 10-grade scales. Differences between professions were tested for significance by Pearson s chi-squared test. To study the possibly differential effects of our set of explanatory variables, we performed a set of regression analyses linking satisfaction with inter-professional co-operation to each of the work environment variables listed in Table 1. As the dependent variable was strongly skewed, it was dichotomized, the value 1 representing the two most satisfied response alternatives on the five-point scale, and analysed by binary logistic regression. Explanatory variables were not dichotomized. To test whether effects were different for doctors and nurses, interaction variables (predictor* profession) were entered and inspected for significance. Where interaction variables were borderline significant, the significance of the difference in the 2LL goodness of fit values for the models with and without the interaction term were checked. Statistical analyses were done by SPSS 11.5 for Windows. Results The overall response rate after one reminder was 65%. A total of 2050 registered nurses (66%) and 551 doctors (61%) returned the completed questionnaire. Hospital response rate varied from 60% to 75%, the lowest rate at the largest hospitals. Responder characteristics are shown in Table 3. Assessment of co-operation As shown in Table 2, the large majority of both nurses (71%) and doctors (79%) considered inter-professional co-operation good at the hospital in which they worked. Doctors, however, were significantly more satisfied. Also, nurses and doctors assessed a number of co-operation relevant items differently. Doctors significantly more often than nurses reported being praised for good work by members of other professions, good co-operation between departments, good inter-professional co-operation, frequently discussing patient care with other professions, considering information from other professions important, and being very satisfied with the doctors competence. Nurses scored more positively than doctors on general job satisfaction, not being victims of unrealistic expectations from members of their own or other groups, being praised for good work by their own profession, finding the other professional group well informed about the patients, acceptable mental workload, and being very satisfied with the nurses competence. The largest differences between the two professions were on satisfaction with interdepartmental co-operation (more common among doctors than nurses), being praised for good work (doctors more often than nurses by members of other professions than by 493

4 U. Krogstad et al. Table 2 Percentage of doctors and nurses ticking at positive end of scale 1 Denominators vary for nurses from 1974 to 2037 and for doctors from 529 to 545 depending on missing data. Valid per cent (N ) 1... Nurses Doctors P value... In general, how satisfied are you with your job? (very much/quite) Do you experience unrealistic expectations from your own profession? (never/rarely) <0.001 Do you experience unrealistic expectations from other professions? (never/rarely) <0.001 Do you ever feel down or depressed because of criticism from nurses? (never/couple of times a year) Do you ever feel down or depressed because of criticism from doctors? (never/couple of times a year) How often do members of your own profession praise you for good work? < (often/sometimes) How often do members of other professions praise you for good work? < (often/sometimes) Co-operation between departments are very good at this hospital (quite right/partly right) < Patient information is always available when needed (quite right/partly right) At this ward all occupational groups have common aims for the patient (quite right/partly right) The ward s head nurse is well informed of the patients needs (quite right/partly right) Co-operation between professions is very good at this ward (quite right/partly right) <0.001 At this ward the other professional groups know the patients well (quite right/partly right) <0.001 I discuss patient information with other professions many times a day <0.001 (quite right/partly right) Information from other professional groups is crucial in my job (quite right/partly right) Physical workload [10 (= very light)/9/8] Emotional workload [10 (= very light)/9/8] Competence of nurses at this ward [10 (= fully adequate)/9/8] <0.001 Competence of doctors at this ward [10 (= fully adequate)/9/8] <0.001 their colleagues, nurses more often than doctors by other nurses than by members of other professions), and considering nurses competent (nurses more positive than doctors). Predictors of satisfaction with doctor nurse co-operation As shown in Table 4, practically all the predictors influenced nurse and doctor satisfaction with their mutual co-operation in the expected direction. Most of the predictors did not affect one group s satisfaction with inter-professional co-operation significantly more strongly than the other s. Yet, the sets of significant predictors for satisfaction with doctor nurse cooperation were not identical for the two groups. Nurse satisfaction was affected significantly more than doctor satisfaction by their general satisfaction with their job, and significantly less by seeing that all professions had the same aim(s) for the patients, finding the head nurse and members of other professions well acquainted with the patients problems and seeing information from other professions as vital to their job. Discussion Collaboration presupposes agreement upon a joint mission. In the hospital setting, the common project of nursing and medicine is the patient. Nurses and doctors share a wide field of knowledge, observations, and objectives. But they also have different perspectives and different tasks related to the patient, and their professional culture and pride are often rooted in perceived and/or formalized competence monopolies. Therefore, inter-professional co-operation takes place at a junction of crossing interests and expectations. We interpret our data as showing three potential mismatches: of goals, of competencies, and of co-operation concepts. Nurses and doctors were equally likely to consider all professions as working towards the same goal(s) for the patient. But doctor satisfaction with inter-professional collaboration depended more strongly on their feeling that this was so. When in doubt about common aims doctors co-operation satisfaction suffered significantly more than that of the nurses. Nurse satisfaction with inter-professional co-operation was significantly less affected by not seeing all as having the 494

5 Inter-professional co-operation in hospitals Table 3 Description of respondents Doctor... 1 Registered nurses only, analysis did not include auxiliary nurses. same goal(s). On the background that nursing has liberated itself from medicine this finding is not unexpected. To be an attractive co-operational partner one must also possess the professional qualifications considered necessary by the other party to reach the common goal. Doctors were considered highly competent by both nurses and doctors, but many doctors were uncertain about the nurses competence. While doctors and nurses assessments of inter-professional co-operation were not differentially affected by their general impression of doctor and nurse competence, seeing other professions and the ward head nurse as well informed about the patients currently in the ward was significantly less important for the nurses satisfaction with inter-professional co-operation than for the doctors. Our data indicate that nurses feel less dependent than doctors on what other professions know about the patients, and consider members of other professions less important sources of relevant information. This interpretation fits with the differential effect in Table 4 of the feeling that information from other professions is vital to one s work. More satisfaction with inter-professional co-operation is reported by both doctors and nurses who feel that updating from other professions is crucial. But the effect is significantly stronger among doctors. That may reflect the simple fact that doctors are fewer in number, and therefore have to rely more Registered nurses 1... Total N Valid % N Valid %... Gender Male Female Did not answer Age < Did not answer Type of hospital Regional County Local Type of department Surgical Internal medicine Did not answer Years at this hospital <1 year years >5 years Did not answer Total on observations by others not least the head nurse, who may be a more important source of information and collaborative partner to doctors than to nurses. But it may also be read as an indication that nurses regard skills in patient communication and emotional care as their core competence and special professional mission. The fact that only about half of the nurses say that they discuss patients with other professional groups in the course of a normal day supports the interpretation that nurses may attach less weight to their traditional role as the doctors front-line observers of the medical condition of the patients. A re-orientation like that is likely to affect interprofessional co-operation negatively, and the doctors lower rating of nurses competence and patient knowledge may signal a degree of dissatisfaction with the amount and/or quality of the clinical medical information they get from the nurses. Our findings that the traditionally dominant group, the physicians, are more satisfied with co-operation than the nurses may support the suspicions that co-operation may look less problematic to the controlling partner and that the very concept of co-operation does not mean the same to the two professions. This may explain the interesting paradox that doctors rated nurses knowledge about the patients as well as nurse competence lower than they rated their own; still they were more satisfied with inter-professional co-operation. Nurses, more positive about doctors competence and 495

6 U. Krogstad et al. Table 4 Effects of predictors of nurse and doctor satisfaction with inter-professional co-operation [odds ratio (95% CI)], significance of interaction predictor occupation group Predictor OR (95% CI)... Nurses Doctors P values for differences in odds ratios in doctors and nurses... General job satisfaction (per point on 1 5 scale) 1.9 ( ) 1.5 ( ) <.001 Experiencing unrealistic expectations from own profession 1.3 ( ) 1.3 ( ) 0.84 (per point on 1 4 scale) Experiencing unrealistic expectations from other professions 1.5 ( ) 1.3 ( ) 0.24 (per point on 1 4 scale) Down/depressed by criticism from nurses (per point on 1 5 scale) 1.4 ( ) 1.8 ( ) 0.10 Down/depressed by criticism from doctors (per point on 1.6 ( ) 1.7 ( ) scale) Being praised for good work by members of own profession 1.3 ( ) 1.4 ( ) 0.79 (per point on 1 4 scale) Being praised for good work by members of other professions 1.4 ( ) 1.6 ( ) 0.48 (per point on 1 4 scale) Interdepartmental co-operation is good (per point on 1 5 scale) 1.9 ( ) 1.8 ( ) 0.66 Patient information always available when needed 2.1 ( ) 1.6 ( ) 0.07 (per point on 1 5 scale) All professions same goal(s) for patients (per point on 1 5 scale) 2.6 ( ) 3.6 ( ) 0.04 Head nurse well informed about the ward s patients (per point on 1.8 ( ) 3.6 ( ) < scale) Other professions well informed about the patients (per point on 3.6 ( ) 5.1 ( ) scale) I discuss patients with other professions many times a day 1.5 ( ) 1.5 ( ) 0.77 (per point on 1 5 scale) In my job, information from other professions is very important 1.2 ( ) 1.6 ( ) 0.04 (per point on 1 5 scale) Workload heavy physical (per point on 1 10 scale) 1.1 ( ) 1.1 ( ) 0.50 Workload heavy emotional (per point on 1 10 scale) 1.1 ( ) 1.1 ( ) 0.65 Competence of nurses (per point on 1 10 scale) 1.3 ( ) 1.4 ( ) 0.13 Competence of doctors (per point on 1 10 scale) 1.2 ( ) 1.2 ( ) 0.94 patient knowledge, reported to a lesser extent the need to have it communicated, and were less satisfied with the interprofessional co-operation. We interpret the nurse position as a growing underdog dissatisfaction, to be solved through distancing their work from that of doctors. Doctors professionally and self-confidently maintain their traditional focus on diagnosis and medical treatment, which still, to a degree that they can accept, dominates hospital work. To them, good co-operation means having their therapeutic decisions effectively implemented and being kept informed about their effect. Nurses are in the business of reforming inter-professional relationships. To them, co-operation does not only mean communicating medical observations or administering medication, but also being appreciated for their independent contributions to the healing process, e.g. by mapping and understanding the patients complete situation and set of needs and mobilizing his/her coping strength. To nurses, the word co-operation not only refers to work situations and tasks, it is also a question of re-shaping work-place relationships that is why their satisfaction with inter-professional co-operation depends more strongly than that of the doctors on their general job satisfaction. Implications Implementing quality improvement strategies at any organizational level in hospitals will depend on the core professions of medicine and nursing to co-operate. We believe that an understanding of the conceptual asymmetry is important for change management as well as for the professions themselves if the rhetoric of collaboration is to go beyond mere words. Several recent articles have focused on the cultural aspects of quality improvement in health care [1,2,22,26,27]. Furthermore, attention has turned towards the sharp end of hospital care; the micro-systems [28 32]. Clinical micro-systems, defined as small groups of professionals who work together on a regular basis to provide care to discrete subpopulations 496

7 Inter-professional co-operation in hospitals of patients [28], may be seen as the essential building blocks of the health care system. As quality improvement implies cultural change there is a need for hospital research to include local cultural studies applying a variety of methods. Invocations of co-operation by doctors and nurses may lead us to believe that the concept is equally appreciated and understood by both professions. Asking both groups about their experiences of inter-professional co-operation we may erroneously believe that they answer the same question. As we have shown, it is not necessarily so. Acknowledgements This study was supported by grants from the Research Council of Norway and from the Foundation for Health Services Research. References 1. Scott T, Mannion R, Davies H, Marshall M. Healthcare Performance and Organisational Culture. Abingdon, Oxon: Radcliffe Medical Press, Scott T, Mannion R., Davies H, Marshall M. Implementing culture change in health care: theory and practice. Int J Qual Health Care 2003; 15: Firth-Cozens J. Celebrating teamwork. Qual Health Care 1998; 7 (Suppl): Cook RI., Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. Br Med J 2000; 320: Krogstad U, Hofoss D, Hjortdahl P. Continuity of hospital care: beyond the question of personal contact. Br Med J 2002; 324: Baggs JG, Schmitt MH, Mushlin AI et al. Association between nurse physician collaboration and patient outcomes in three intensive care units. Crit Care Med 1999; 27: Aiken LH, Smith HL, Lake ET. Lower Medicare mortality among a set of hospitals known for good nursing care. Med Care 1994; 32: Aiken LH, Sloane DM, Sochalski J. Hospital organisation and outcomes. Qual Health Care 1998; 7: Carr-Saunders AM, Wilson PA. The Professions. Oxford: Clarendon Press, Allen D. The nursing medical boundary: a negotiated order? Sociol Health Illn 1997; 19: Davies C. The sociology of professions and the sociology of gender. Sociology 1996; 30: Stein LI. The doctor nurse game. Arch Gen Psychiatry 1967; 16: Stein LI, Watts DT, Howell T. The doctor nurse game revisited. N Engl J Med 1990; 322: Svensson R. The interplay between doctors and nurses a negotiated order perspective. Sociol Health Illn 1996; 18: Weller D, Johnson D, McDonald E et al. Functional teams lead to Joint Commission success. J Nurs Care Qual 1997; 12: Roy C. Adaptation: A conceptual framework for nursing. Nurs Outlook 1970; 18 (3): Travelbee J. Interpersonal Aspects of Nursing. Philadelphia, PA: F.A. Davies, Meleis A. Theoretical Nursing. Philadelphia, PA: J.B. Lipincott Company, Zwarenstein M, Bryant W. Interventions to promote collaboration between nurses and doctors. Cochrane Database Syst Rev 2000; 19: CD Davies C. How well do doctors and nurses work together? [editorial]. Nurs Times 1999; 95 (33): Verschuren PJ, Masselink H. Role concepts and expectations of physicians and nurses in hospitals. Soc Sci Med 1997; 45: Degeling P, Kennedy J, Hill M. Mediating the cultural boundaries between medicine, nursing and management the central challenge in hospital reform. Health Serv Manage Res 2001; 14: Hoftvedt BO, Falkum E, Akre V. [Perception among Norwegian hospital physicians of physician nurse cooperation]. Tidsskr Nor Laegeforen 1998; 118: Gjerberg E, Kjolsrod L. The doctor nurse relationship: how easy is it to be a female doctor co-operating with a female nurse? Soc Sci Med 2001; 52: Skjorshammer M. Co-operation and conflict in a hospital: interprofessional differences in perception and management of conflicts. J Interprof Care 2001; 15: Davies H, Nutley SM, Mannion R. Organisational culture and quality of health care. Qual Health Care 2000; 9: Degeling P, Sage D, Kennedy J, Perkins R, Zhang K. A comparison of the impact of hospital reform on medical subcultures in some Australian and New Zealand hospitals. Aust Health Rev 1999; 22: Batalden PB, Nelson EC, Edwards WH, Godfrey MM, Mohr JJ. Microsystems in health care: Part 9. Developing small clinical units to attain peak performance. Jt Comm J Qual Saf 2003; 29: Mohr JJ, Barach P, Cravero JP et al. Microsystems in health care: Part 6. Designing patient safety into the microsystem. Jt Comm J Qual Saf 2003; 29: Wasson JH, Godfrey MM, Nelson EC, Mohr JJ, Batalden PB. Microsystems in health care: Part 4. Planning patient-centered care. Jt Comm J Qual Saf 2003; 29: Nelson EC, Batalden PB, Homa K et al. Microsystems in health care: Part 2. Creating a rich information environment. Jt Comm J Qual Saf 2003; 29: Nelson EC, Batalden PB, Huber TP et al. Microsystems in health care: Part 1. Learning from high-performing front-line clinical units. Jt Comm J Qual Improv 2002; 28: Accepted for publication 13 August

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