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 theo- retical 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 in- ner 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 inresearch aimed at better understanding the organi-zation and delivery of nursing services as a mech- anism 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 knowl- edge 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 orga- nizations within which nurses work. This paper pro-

vides 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.

HISTORICAL OVERVIEW 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 descrip- tions 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, au- thority, work design, power and control, communica- tion, 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 re- searchers as Thompson4 and Woodward,5 among oth- ers, gave birth to the contingency perspective. Contin- gency theory is the focus on what the desirable “fit” might be between the technological tasks an organiza- tion performs and the organization’s structures and designs. Well into the 1980s, works like that of Mintz- berg 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.