Date of Award

2013

Degree Type

Thesis

Degree Name

Doctor of Philosophy

School

School of Business

Faculty

Business and Law

First Advisor

Professor Alan Brown

Second Advisor

Associate Professor Peter Standen

Abstract

This study broadly pertained to the issue of public health sector governance. The field of healthcare governance had been characterised as having challenges of greater intricacy and sensitivity than those found in any other sector (Philippon & Braithwaite, 2008). While increasingly regarded as important to health system performance, governance had, however, been evaluated as poorly understood in conceptual and practical terms and subject to competing ideas regarding its role and challenges (Brinkerhoff & Bossert, 2013). Specifically, the thesis elucidated frontline regional and rural hospital nurses’ cognitive schema of strategic aspects of governance practice of managers in the Western Australian Country Health Service (WACHS). It also explored the question of whether compatibility between nurses’ schema and their perceptions of governance practice increased their propensity to form the intention to leave their jobs in WACHS hospitals. Because of its heavy reliance on its nursing workforce, the Australian regional and rural health system had been described as an essentially ‘nurse-led’ healthcare context dominated by public hospitals (Bish et al., 2012). Regional and rural health reforms had also deeply affected the practice and work environments of many nurses in these areas over a long period and more change was proposed by State and Commonwealth levels of government (Department of Health and Ageing, 2010; Mahnken, 2001; WACHS, 2007, 2009). The Department of Health and Ageing had suggested an outcome of this had been that many clinicians in regional and rural areas were unhappy with strategic aspects of healthcare governance, which had led to less responsive services and the loss of opportunities to improve clinical safety and quality. Given this context, the strategic governance perspectives of frontline hospital nurses’ employed by WACHS appeared an important area of study. A core purpose of the study was to anchor the assessment of regional and rural nurses’ perspectives of strategic aspects of governance within the theoretical frames of Stewardship Governance (Travis et al., 2003) and Trust in Management (Clark & Payne, 1997, 2003, 2006). These frames had been postulated as consistent with the underpinning motives of caring professions such as nursing (Brown & Calnan, 2010, 2011; Calnan, Rowe, & Entwistle, 2006; Saltman & Ferroussier-Davis, 2000) suggesting they were likely to be apparent within the profession’s broader architecture of ‘shared mental models’ or schema of appropriate governance practice (Epitropaki & Martin, 2004; Mohammed et al., 2010). Methods suited to elucidating schema were employed in the study (Floyd & Widaman, 1995). The validity of the schema measures identified was subsequently tested with respect to their relevance and importance to the study population. This validation process was theoretically grounded in the empirically-supported cognitive process of schema ‘compatibility testing’ (Beach, 1993; Miner, 2007) and entailed the use of a turnover intention scale developed by Roodt (Jacobs & Roodt, 2007) as an outcome measure. The design features of this scale suggested it was suited to the assessment of nurse ‘compatibility testing’ of governance schema (Morrell et al., 2008). The issue of nursing turnover had also been established as a widespread and important problem for healthcare systems (Coomber & Barriball, 2007; Holtom et al., 2008; Hwang & Chang, 2008; McCarthy, Tyrrell, & Lehane, 2007; West, 2005) and had been linked with issues of management style and governance (Attree, 2005; Hayes et al., 2006; Kleinman, 2004). The stages of the research undertaken included initial interviews with 16 highly experienced clinician-managers, in which the boundaries, principles and practices of managerial governance were explored with a view to ascertaining the preferences of hospital nurses. Data from these interviews was used along with information derived from literature on the elements of Stewardship Governance (Travis et al., 2003) and Trust in Management (Clark & Payne, 1997, 2003, 2006) to construct an inventory of strategic governance practices. This inventory was then used to develop a governance questionnaire, which was further developed and evaluated in two subsequent mail surveys. Data from an initial small-scale mail survey (n=199, response rate 44%) were analysed using Exploratory Factor Analysis to check item reliability and validity, thereby guiding item deletion. The subsequent main-study survey of 1682 nurses working in WACHS regional and rural hospitals resulted in the return of 697 completed questionnaires, representing a response rate of 45%. Main-study data were interpreted using Principal Components Analysis to elucidate governance scales reflecting WACHS frontline hospital nurses’ underlying schema of strategic aspects of governance in their organisation. Scale validation was undertaken using multiple regression analyses with scores on Roodt’s Turnover Intention Scale as the dependent variable. The results supported the study hypothesis that compatibility between the governance schema of frontline regional and rural public hospital nurses employed by WACHS and their perceptions of WACHS managers’ governance practices would predict their turnover intentions. Overall, the thesis lent weight to the World Health Organization’s (WHO, 2000) claim that the concept of Stewardship Governance had relevance to health systems. Further, it supported the contentions of those like Brown, Calnan, Rowe and colleagues in relation to the relevance of trust to manager-clinician governance relationships (Brown & Calnan, 2010, 2011; Calnan & Rowe, 2008a; Calnan, Rowe, 2008b; Calnan et al., 2006). The research findings have relevance to issues of effective healthcare reform; models of nurse management and the development and support of nurse managers; and the prevention of nurse turnover in regional and rural public hospitals. The scales developed in the study may be useful in similar investigations in other regional and rural jurisdictions and to nursing research in other contexts. The scales might also have value in evaluating the impact of changes to governance in regional and rural public hospitals on frontline nurses.

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