West et al



This article will evaluate and critique the research article conducted by West et al (2002). First it clarifies the author's aim of the research undertaken. Then it provides a brief of the research methods used by the authors and explores their appropriateness for the context. The article seeks to find out the benefits as well any limitations/ drawbacks of the research methods used. A wide range of research method literature is used to evaluate the effectiveness of the methodology. The article also looks at other similar researches. In conclusion, the article suggests alternative research strategies/methodologies which could be advantageous in this kind of research.
Research design and Approach

The authors felt that a little research had been done on HRM practices affecting performance in hospitals, which is a highly complex organization (Lyon and Ivancevich, 1978). Through this research the authors examined the link between the management of employees in acute hospitals (UK NHS Trusts) and quality of health care. The research aimed to find not only a link between human resource management practises and quality of care, but also to know which practices affected those outcomes.

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The detailed literature review of ‘Taylorist' (Walby, 1994) and Progressive Human Resource Management practices (Bratton and Gold, 2003) provided an adequate foundation, on which further analysis of hospital's human resource management practices could be built upon. This knowledge served to provide a perspective on how the subject developed (Hart, 1998) and how the further research should follow. Critical review of previous researches in the same field like the one of ‘magnet' hospitals in US (Aiken et al., 1994), opened several key issues and questions that the authors addressed within their research. They kept note of the problems with the results of the previous researches; which relied less on objective data and were largely speculative. The authors reviewed a lot of literature supporting their hypothesis however they missed the studies that gave considerable contradictory evidence in relationships between specific work conditions and patient mortality (Kazanjian et al., 2005). Looking more into such contradictory evidences should have given more depth to the research.

The authors in this research determined links between human resource management practices and hospital performance by measuring patient mortality rates. Author's literature review showed that the key practices of appraisal, training, and team-working were positively related to levels of performance (Fletcher and Williams(1985), d'Arcimoles((1997)). They used these results to predict the same in hospitals also. Based on such predictions authors tried to find association between these HRM practices and patient mortality rates.

Research Methodology

For finding conclusive evidence the authors followed a very systematic, well planned mix-method approach. The full research process was divided into two parts. In the first part, Chief executives and HRM directors of 137 acute hospitals in England were invited to complete questionnaire surveys detailing HR strategies, policies and procedures in the hospital. Of these 81 responded to participate, which was a high response rate for such kind of organizations. In second part, a separate research team collected quantitative performance data for each of the hospital. Deliberately the two teams were kept separate to disallow any contamination of data. The authors aimed to find associations between the HR management techniques followed in hospitals as evident by the surveys and the performance of the hospitals as deciphered from performance data collection.

The use of structured questionnaire in the first phase offered scope to the respondents reply (Bryman and Bell, 2007, p447). The authors gave the respondents flexibility to reply by post or telephonic interview. Some respondents choose to reply to the questionnaire by post (mail). Traditional mails have advantages of less ‘sampling bias' and generally have high response rate (Jackson, 2009). In this research also authors noted that the respondents who replied by post gave answers to more questions. A few others chose to give telephonic interviews. However, as Silverman(1989) points out, there are many uncontrollable sources which affect outcomes of interviews and pose a fundamental drawback to interview technique. Seltzer and Bass (1990) highlight that there is strong inclination to provide positive answers, whereby social norms influence behaviour and individuals are responsive to how language is used, even if individuals tend feel that there is more freedom with regards to questionnaires than interviews. Alvesson and Deetz(2000) suggest that interview is instead better as a scene for conversation rather than a data collection tool. These issues also exist within the questionnaires, used by the authors to collect UK acute hospital data in this research. The respondents who answered by telephone may have been inclined to give positive answers regarding the HR techniques followed in their hospitals. However use of fixed questionnaire kept the responses focussed.

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Nevertheless, other researchers within this field like Aiken et al. (1994) also had similar findings as the authors, which suggest that the choice of research strategy/methodology was appropriate for achieving the aims of the research. All findings conclude that there are positive fundamental links between Human resource management techniques and the mortality rates in hospitals.

In second phase, authors collected performance data of the hospitals. They ensured independence of data in the two stages to avoid any contamination due to ‘experimenter effects'. As Rosenthal (1966) points out, researchers expectations for their subject's behaviour actually affect that behaviour. But the authors in this case took care of this aspect. In the research hospital size and ‘local health needs' were used as control variables to remove their effect on results (Punch, 1998). Jarman et al (1999) proved that there was a strong correlation between doctors per bed and patient mortality rate. So the author's using it also as control variable was quite a commendable task. However, a serious design limitation was that West et al.(2002) did not control for the previous healthcare performance records of the hospitals (West et al., 2006).

The mixed method research approach however had few limitations. The research design depended heavily on questionnaire response which was quite low and non-uniform as many HR directors didn't answered all questions. Fixed questionnaires sometimes become constraining on the interviewee (Alvesson and Deetz, 2000). The authors noted that they faced difficulties of sample size as only 21 hospitals have given all information; rest had given only partial information which was not enough for every analysis. To rectify this, they included all hospital data for every analysis.

The major drawback of the research was the performance and the data on mortality rate. As the authors confess, the variables making up the mortality variable were from different timescales. Also performance data for NHS was unreliable and incomplete. This reflected on the outcomes which was a lot of approximation of data (Harrison, 2009). In such scenario, the use of more than one method or source of data (Bryman and Bell, 2007) is often better as it increases the ability to interpret the findings (Thurmond, 2001,p253). The authors admit that HRM data was collected in 1999-2000, while collection of performance data for the subsequent period was not possible. This was a major drawback to the research, because to compare data of similar timescales was the most basic to get any conclusive results. Also authors were not able to draw any conclusive causal inferences from the analysis. The researchers did not come across any ethical issues during the course of the research.


In conclusion, from taking a brief look at other studies and given the exploratory nature of the research, the adoption of a mixed method approach appears to be a suitable methodology. The combination of methods arguably allows for a better understanding of the phenomenon, as opposed to if just one of the methods had been used. Yin (1984) highlights that collection of both quantitative and qualitative data is a beneficial for this research which is adopting a mixed method strategy.

However, the strength of the research questions in particular is in its ability to allow the exploration of issues to emerge within the interviews, without being restricted by them, allowing for important insights into the phenomena under study to be generated. The use of quantitative structured interviews only with HR managers was not enough as HR policy issues are complex and messy involving a range of opinions, concerns and perceptions, from senior managers to doctors, nurses and other hospital staff. Skinner et al (2000) suggests that within such circumstances, a richness and depth of understanding can be achieved through detailed qualitative research. Also as noted by Tufte (1970), sometimes a questionnaire would not be flexible to capture more information.

Further methodological factors that could be improved include a clearer specification of the methodology implemented. Including issues such as how the hospitals were chosen. The research would also arguably benefit from a more flexible approach. Furthermore, the validity and reliability of the research could be enhanced through the use of researcher triangulation. I would also argue that in order to truly establish a link between HR practices and hospital performance, the actual staff of the hospital could also be taken into consideration. Instead of talking to only HR directors and managers, staff should also have been asked to take a better assessment of the HR practices prevalent in the hospital. Employment security is also an element of HRM which is likely to enhance job satisfaction. In turn, studies by Hinshaw & Atwood (1984) have linked healthcare workers' satisfaction levels to patient satisfaction and quality of healthcare. A clear inference could have been drawn from the research by exploring this area also.

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This research design also suffers limitations of simultaneity and reverse causality. HR practice related data in the study were contemporaneous (i.e., spanned the same time period) with patient mortality data. The human resource practice data were also somewhat limited. In the research they gathered data on mortality rates for the period subsequent but very near to the period to which the HRM practices data applied. Also while testing the influence of HRM on mortality rates West et al.(2002) did not control for the previous performance records of the hospitals. This design limitation increases concerns upon the interpretation of causality. In this scenario it was very hard to determine whether lower mortality rates were actually the result of only better HRM practices or some other factors were also involved.

A much better approach would have been to gather data on mortality rates in hospitals for an extensive period prior to the point at which they collected data on HR practices. This would have enabled them to clearly determine whether the likely direction of causality is from HRM practices to mortality rather than the opposite. This approach would have strengthened the primary hypothesis.

The authors admit that the survey had mixed response and low response rates from many hospitals. The data was also not consistent enough. Due to research design limitations no causal inferences could be drawn conclusively.

However, strong positive relationship was found between HR practises of appraisal, team work and training and lower patient mortality rates. This result is consistent with other researches in the field which suggest that HR systems are related to the quality of healthcare and specifically patient mortality in hospitals (West et al., 2006).