The contribution of organization theory

The contribution of organization theory to nursing
health services research
Stephen S. Mick, PhD, CHE
Barbara A. Mark, PhD, RN, FAAN
We review nursing and health services research on
health care organizations over the period 1950
through 2004 to reveal the contribution of nursing to
this field. Notwithstanding this rich tradition and the
unique perspective of nursing researchers grounded
in patient care production processes, the following
gaps in nursing research remain: (1) the lack of theoretical
frameworks about organizational factors relating
to internal work processes; (2) the need for sophisticated
methodologies to guide empirical investigations; (3) the
difficulty in understanding how organizations adapt
models for patient care delivery in response to market
forces; (4) the paucity of attention to the impact of new
technologies on the organization of patient care work
processes. Given nurses’ deep understanding of the inner
workings of health care facilities, we hope to see an
increasing number of research programs that tackle
these deficiencies.
There is little question about the rapid expansion in
research aimed at better understanding the organization
and delivery of nursing services as a mechanism
both to improve quality and patient safety, as
well as to enhance working conditions for nurses. This
research requires not only deep theoretical knowledge
about health care organizations and their functioning,
but also knowledge of critical methodologic issues that
influence how the research is conducted. This knowledge
has traditionally resided within the discipline of
health services research (HSR). Yet, with more and
more nurse scientists involved in such endeavors, there
is a need to better understand the intersection of nursing
and health services research, and particularly the organizations
within which nurses work. This paper provides
a brief historical overview of organizational
research within the history of HSR since the beginning
of the 1950s, then discusses exemplars of nursing
research that have incorporated various organization
theories in their studies. Finally, some comments are
offered regarding the need for further methodologic
development to enhance the quality of nursing health
services research.
The Internal Focus
Through much of the 1950s and into the early 1960s,
social scientists doing HSR studied the hospital as a
social system, which yielded richly detailed descriptions
and analyses of the inner workings of inpatient
facilities, including the role of nursing.1 Bureaucratic
theory provided much of the conceptual basis for these
studies, emphasizing the importance of hierarchy, authority,
work design, power and control, communication,
formalization, and standardization.2 In general, the
emphasis of organizational studies in HSR was on the
internal operations and management of facilities,3 and
nursing was a frequent subject of this focus.
A growing concern that researchers expressed was
whether internal organizational forms might show some
variety from a “standard” bureaucratic model and
whether any of this variation might also be related to
performance. This exploration, pursued by such researchers
as Thompson4 and Woodward,5 among others,
gave birth to the contingency perspective. Contingency
theory is the focus on what the desirable “fit”
might be between the technological tasks an organization
performs and the organization’s structures and
designs. Well into the 1980s, works like that of Mintzberg
formulated conceptually distinct organizational
forms that were hypothesized to work better, or worse,
given the technological tasks the organization faced.6
As promising as the internal focus was—especially for
nursing research—it finally ceded the limelight to the
concurrent, but ever-growing, interest in organizational
environments and their impact on the organization.7
The External Focus
The “external focus” had its beginnings in classical
sociological studies of hospitals that depicted them as
organizations that both reflected and challenged the
Stephen S. Mick, PhD, CHE, is Arthur Graham Glasgow Professor and
Chair, Department of Health Administration, Virginia Commonwealth
University, Richmond, VA.
Barbara A. Mark, PhD, RN, FAAN, is Sarah Frances Russell Distinguished
Professor, School of Nursing, The University of North Carolina
at Chapel Hill, Chapel Hill, NC.
Reprint requests: Stephen S. Mick, PhD, CHE, Department of Health
Administration, Virginia Commonwealth University, Richmond, VA
Nurs Outlook 2005;53:317-323.
0029-6554/05/$–see front matter
Copyright © 2005 Mosby, Inc. All rights reserved.
N O V E M B E R / D E C E M B E R N U R S I N G O U T L O O K 317
social order of the larger society, particularly in the
realm of what sociologists call stratification, the study
of social differences and social classes and their effect
on the provision of patient care.8 The link between the
larger society’s social structure and the embedded-ness
of hospitals within this matrix produced a natural
seedbed for a new generation of organization theorists
who, in the late 1960s, “discovered” the field of health
care organizations and their environments.9,10 Major
theoretical statements about the complex relationship
between organizations and their environments were
quickly formulated, particularly by scholars such as
Lawrence and Lorsch11 and Pfeffer and Salancik.12
In HSR, the emphasis on organizations and their
environments led to a burst of conceptualization, theory
building, and empirical study that almost completely
submerged interest and research in internal organizational
issues. We profited enormously from this new
research, developing better typologies of organizational
environments, defining salient characteristics of health
care organizations, and applying increasingly available
databases collected on national samples and entire
populations of health care organizations. Very little
primary data collection or in-depth qualitative analysis
was required for this new energy, further contributing to
a languishing of study of internal organizational issues
in health care organizations.
Two primary forces contributed to this development.
First, the rise of health economics, which occurred
about the same time, reinforced this trend in HSR by
emphasizing the role of markets in hospital behavior.
Second, the rise of health maintenance organizations
(HMOs), particularly as a function of the HMO Act of
1973, helped focus attention on how historically separate
organizations— doctors’ offices and hospitals—
could be merged through the conceptual lens of socalled
“interorganizational” arrangements.
By the 1980s, this stream of research about organizations
in health care was dominated by the organization/
environment focus in the social sciences and by the
organization/market focus in economics, at least insofar
as anyone was concerned with health care organizations
qua organizations. The dominant policy issue was how
market forces and interorganizational arrangements
might be studied and structured to produce cost savings
to the entire health care system. Overall, however, for
HSR this was a “dry” period in regard to research
focusing on the interior of organizations. Attention was
riveted on the interplay of organizations and their