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UBC Theses and Dissertations

Effects on nursing and the nursing profession of the introduction of modern management technologies into… Campbell, Marie Louise 1977

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EFFECTS ON NURSING AND THE NURSING PROFESSION OF THE INTRODUCTION OF MODERN MANAGEMENT TECHNOLOGIES INTO HOSPITALS by MARIE LOUISE CAMPBELL B.A., U n i v e r s i t y of B r i t i s h Columbia, 1976 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF THE FACULTY OF GRADUATE STUDIES (Department of Anthropology and Sociology) We accept t h i s t h e s i s as conforming to the req u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA J u l y , 1977 Marie Louise Campbell, 1977. MASTER OF ARTS In p resent ing t h i s t h e s i s in p a r t i a l f u l f i l m e n t o f the requirements fo r an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e fo r reference and study. I f u r t h e r agree tha t permiss ion fo r e x t e n s i v e copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the Head of my Department or by h i s r e p r e s e n t a t i v e s . It i s understood that copying o r p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l ga in s h a l l not be a l lowed without my w r i t t e n p e r m i s s i o n . Department of Anthropology and Sociology The U n i v e r s i t y of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1WS Date August 27, 1977 ( i i ) ABSTRACT T i t l e : EFFECTS ON NURSING AND THE NURSING PROFESSION OF THE  INTRODUCTION OF MODERN MANAGEMENT TECHNOLOGIES INTO  HOSPITALS A r t i c l e s from Canadian nursing and h o s p i t a l a d m i n i s t r a t i o n j o u r n a l s were used to provide a p i c t u r e of current developments i n the management of h o s p i t a l s , and i n p a r t i c u l a r , of the management of nursing work. Using documentary data (from The Canadian Nurse, Dimensions i n Health S e r v i c e s , and H o s p i t a l A d m i n i s t r a t i o n i n Canada, 1974-1977), the argument i s made that the use of modern management technologies to c o n t r o l h o s p i t a l work i s inappropriate and l i k e l y to reduce the q u a l i t y of care provided. S p e c i f i c a l l y , i t i s argued that as the work of nurses i s subjected to management c o n t r o l and t h e i r d i s c r e t i o n over t h e i r p r a c t i c e i s l o s t , nurses' autonomy to exe r c i s e t h e i r p r o f e s s i o n a l judgment i s destroyed. This d e p r o f e s s i o n a l i z a t i o n of nursing i s consequential not only f o r nurses but f o r the q u a l i t y of care they give p a t i e n t s , as w e l l . Nurses' occupa-t i o n a l p o s i t i o n w i l l be harmed as t h e i r s k i l l s become obsolete, replaced as the r e s u l t of management p r a c t i c e s designed to produce e f f i c i e n t h o s p i t a l operation. These management p r a c t i c e s w i l l segment the nursing labour force i n t o two groups, a mana-g e r i a l e l i t e and a l a r g e r group of i n c r e a s i n g l y l e s s - s k i l l e d , cheaper workers. The two segments w i l l develop divergent i n t e r e s t s and understandings as t h e i r experiences and con d i t i o n s of work are separated. ( i i i ) The argument i s based on the work of Braverman (19 74) who analysed the e f f e c t s of i n d u s t r i a l management on c r a f t s k i l l s i n modern c a p i t a l i s t i n d u s t r y . Braverman i d e n t i f i e d the ob j e c t i v e s of management as monopolization of the knowledge required to make a product, i n order to c o n t r o l that work process and thus to increase p r o d u c t i v i t y , and p r o f i t s . Some a d d i t i o n a l management problems must be confronted i n trans-p l a n t i n g modern management technologies from i n d u s t r y i n t o h o s p i t a l s . These are the r e s u l t of two important d i f f e r e n c e s between organiz a t i o n s run f o r p r o f i t and organizations run to provide s e r v i c e to humans. Management p r a c t i c e s designed f o r the former do not n e c e s s a r i l y , not probably provide adequate d i r e c t i o n f o r the l a t t e r . When the o r g a n i z a t i o n a l goal i s not determinate, as i s the case i n h e a l t h care, i t cannot be deter-minately r e l a t e d to management p r a c t i c e s . S i m i l a r l y , when the work processes are not determinately r e l a t e d to the organiza-t i o n a l goal, as nursing work i s not, they cannot be deter-minately r e l a t e d to management p r a c t i c e s . The use of modern management technologies i n h o s p i t a l s has yet another negative e f f e c t besides those described by Braverman as d e s k i l l i n g the worker and degrading the product: they harness the work process to economic ends which are not those the o r g a n i z a t i o n was set up to provide. In s p i t e of t h i s , an e s t a b l i s h e d trend towards the use of modern management technologies i n h o s p i t a l s i s seen i n Canada i n the 19 70's due to the dominance of admin-i s t r a t o r s i n h o s p i t a l management (Perrow, 1961) . ( i v ) Modern management technologies are a p p l i e d to nursing to increase p r o d u c t i v i t y , that i s , to get more work done at lower cost. They have s i m i l a r e f f e c t s on the nursing labour force to those described by Braverman. In a d d i t i o n , the i n a p p r o p r i -ateness of these methods f o r the c o n t r o l of human s e r v i c e organizations means that the more " s u c c e s s f u l l y " they c o n t r o l h o s p i t a l a c t i v i t y , the more r i s k of m i s a p p l i c a t i o n of h o s p i t a l resources. Examples from the p r o f e s s i o n a l j o u r n a l s of manage-ment p r a c t i c e s described or recommended f o r the c o n t r o l of nursing i n c l u d e : d e c e n t r a l i z e d a d m i n i s t r a t i o n , (Unit Manage-ment); p a t i e n t c l a s s i f i c a t i o n and o b j e c t i v e s t a f f i n g ; work a n a l y s i s and performance e v a l u a t i o n ; nursing a u d i t . Each provides a c o n t r i b u t i o n to management o b j e c t i v e s to c o n t r o l the work process and cheapen nursing labour. This increased management c o n t r o l of nursing work i s a r a d i c a l departure from the t r a d i t i o n a l s i t u a t i o n of nursing i n a h o s p i t a l . In the past, however subordinate t h e i r p o s i t i o n , nurses have been protected from i n t e r f e r e n c e i n t h e i r p r a c t i c e by t h e i r s t r a t e g i c p o s i t i o n at the " f r o n t - l i n e " of the organi-z a t i o n (Smith, 1966). This f u n c t i o n a l autonomy over t h e i r day-to-day i n t e r a c t i o n with p a t i e n t s has been the ground of nurses' p r o f e s s i o n a l p r a c t i c e , which management c o n t r o l destroys. In a h e a l t h care system which r e l i e s on nurses to supply the i n d i v i d u a l i z a t i o n and humanization of i n c r e a s i n g l y impersonal care, the l o s s of autonomy to ex e r c i s e p r o f e s s i o n a l d i s c r e t i o n (v) i s a severe blow to q u a l i t y care. The s u b s t i t u t i o n of care-f u l l y managed nursing, d e t a i l e d accounting procedures f o r p r o v i s i o n of information on which management de c i s i o n s about nursing can be made, and o b j e c t i v e e v a l u a t i o n of nurses who i n c r e a s i n g l y w i l l have n e i t h e r the t r a i n i n g nor the freedom to act w i t h p r o f e s s i o n a l autonomy i s not seen as an adequate tr a d e - o f f f o r c o s t - c u t t i n g . The production of a segmented nursing labour force by the implementation of modern management technologies i n t o h o s p i t a l s i s i d e n t i f i e d , t e n t a t i v e l y , as a c l a s s d i v i s i o n i n n u r s i n g . The i m p l i c a t i o n s f o r the nursing p r o f e s s i o n of t h i s c l a s s d i v i s i o n are as f o l l o w s : the concept of " p r o f e s s i o n a l i s m " among nurses i s c a l l e d i n t o question, and the c o n f l i c t i n g i n t e r e s t s between the classes reduce the p o t e n t i a l of nurses f o r any c o l l e c t i v e a c t i o n . In t h i s way, the e f f e c t of modern management technologies i s to change g r e a t l y the character of what has been known as "the nursing p r o f e s s i o n . " ( v i ) TABLE OF CONTENTS INTRODUCTION 1 The Data 11 CHAPTER ONE: MANAGEMENT 15 I TASKS OF MANAGEMENT . . . 15 Relations Between Worker and Management . . .15 The Problem of Management . . 16 I I HISTORY OF THE DEVELOPMENT OF MANAGERIAL CONTROL 17 D i v i s i o n of Labour 17 S c i e n t i f i c Management 19 I t s Aims 19 P r i n c i p l e s 19 A p p l i c a t i o n to Industry 20 Studies of the Worker Which Contribute to Management Theory and P r a c t i c e s 21 I I I MANAGEMENT AND TECHNOLOGY 23 CHAPTER TWO: MANAGEMENT OF HOSPITALS 25 I RELATIONSHIP OF MANAGEMENT PRACTICES TO ORGANIZATIONAL GOALS 2 5 In Industry 25 In Human Service Organizations 26 II THE DEFINITION OF ORGANIZATIONAL GOALS IN HOSPITALS 26 Competition For Dominance by E l i t e Groups i n the Organization (Perrow) 26 A d m i n i s t r a t i v e Dominance Over O r g a n i z a t i o n a l Goals . . . 29 Operative Goal Choice By A Subordinate Group 32 F r o n t - l i n e Organization (Smith) 33 I I I INADEQUACY OF INDUSTRIAL MANAGEMENT TECHNOLOGIES FOR DIRECTING HOSPITAL WORK . . . . 35 CHAPTER THREE: INDUSTRIAL MANAGEMENT METHODS IN HOSPITALS DATA FROM HOSPITAL ADMINISTRATION JOURNALS, 1974-1976 . . . . 38 I UNCERTAIN CONDITIONS IN HEALTH CARE 38 II HOSPITAL ADMINISTRATION RESPONSES TO UNCERTAIN CONDITIONS 39 I d e o l o g i c a l Underpinnings of Management P o s i t i o n s on Current Health Care Issues . . . 39 Struggle f o r F i s c a l Control 41 Prevention - - A New P r i o r i t y i n Health Care P o l i c y 43 Union A c t i v i s m 45 C r i t i c a l S e l f - A p p r a i s a l by Management of Their Own Methods 46 ( v i i ) I I I APPLICATION OF INDUSTRIAL MANAGEMENT METHODS TO HOSPITAL WORK 48 Decen t r a l i z e d Organization 48 Systems A n a l y s i s i n H o s p i t a l Planning and Operations 49 Work Design 52 CHAPTER FOUR: INDUSTRIAL MANAGEMENT OF NURSING: DATA FROM NURSING AND HOSPITAL ADMINISTRATION JOURNALS, 1974-1977.. . . 55 I THE NURSING POSITION REGARDING THE SCIENTIFIC MANAGEMENT OF HEALTH CARE IN CANADA • 5 5 Science Council Recommends Systems A n a l y s i s to Integrate Health Care 55 CNA Response to the Science Council Report 56 II MANAGEMENT METHODS APPLIED TO NURSING WORK . . . 59 Unit Management 60 Pa t i e n t C l a s s i f i c a t i o n and S t a f f i n g Control . . ' . . 62 Work A n a l y s i s and Performance E v a l u a t i o n 67 Nursing Audit 73 I I I REPERCUSSIONS OF NEW MANAGEMENT METHODS IN NURSING EDUCATION 75 Obsolescence and Continuing Education . . . . 75 Basic Nursing Education 77 IV NURSING ADMINISTRATION/MANAGEMENT ADJUSTMENT TO THE NEW MANAGEMENT METHODS 80 V EFFECTS ON THE NURSING LABOUR FORCE 83 Occupational Changes 83 Unemployment 84 CONCLUSION .' 86 SOCIOLOGICAL REFERENCES CITED 91 HOSPITAL ADMINISTRATION AND NURSING REFERENCES CITED . . .93 ( v i i i ) ACKNOWLEDGEMENT The work represented by t h i s document was l a r g e l y i n s p i r e d and g r e a t l y supported by work being done i n d i v i d u a l l y and c o l l e c t i v e l y by other members of Dorothy Smith's seminar i n Advanced Women's Studies at The U n i v e r s i t y of B r i t i s h Columbia, 1976-1977. In a d d i t i o n , conversations with f e l l o w graduate students, Marguerite Cassin and Nancy Jackson were p a r t i c u l a r l y h e l p f u l . I am also indebted to my s i s t e r , E l l e n Campbell, who volun-teered to type the f i n a l v e r s i o n . INTRODUCTION This t h e s i s i s concerned w i t h the e f f e c t s upon nursing of i n t r o d u c i n g modern management technologies i n t o h o s p i t a l s . P r o j e c t e d changes i n management p r a c t i c e s (as described, discussed and recommended i n the p r o f e s s i o n a l j o u r n a l s of h o s p i t a l a d m i n i s t r a t i o n and nursing) are designed to c o n t r o l the work o r g a n i z a t i o n of nursing i n the i n t e r e s t s of e f f i c i e n c y . I t w i l l be argued here that t h i s c o n t r o l destroys the measure of autonomy over t h e i r work through which nurses i n the past manifested t h e i r p r o f e s s i o n a l commit-ment to the care and needs of the i n d i v i d u a l p a t i e n t . This loss of autonomy s p e l l s the end of the p o s s i b i l i t y of a f u l l y p r o f e s s i o n a l nursing p r a c t i c e . The basis of the argument i s derived from Braverman's a n a l y s i s of the development of management p r a c t i c e s under monopoly c a p i t a l i s m (Braverman, 1974). He shows how modern methods of management have been subjected to t e c h n o l o g i c a l development reducing the work process to one not r e q u i r i n g the s k i l l s and i n i t i a t i v e of the worker, and t r a n s f e r r i n g e f f e c t i v e c o n t r o l of the work process to management. The r e s u l t i s a d i v i s i o n of labour w i t h i n the managerial process i n t o a r e l a t i v e l y s m a l l , h i g h l y t r a i n e d managerial e l i t e and a large group of r e l a t i v e l y low s k i l l e d workers f u n c t i o n i n g i n routine and quasi-mechanical tasks, with minimal d i s c r e t i o n or opportunity f o r i n i t i a t i v e . - 2 -A s i m i l a r segmentation of the work process and d i v i s i o n of labour i s being developed i n another sector of the present-day economy, the p u b l i c s e c t o r . This t h e s i s takes up and examines, i n terms of current developments i n h o s p i t a l manage-ment, the segmentation of the work process i n h o s p i t a l s , focusing on nursing work. H o s p i t a l a d m i n i s t r a t i o n j o u r n a l s are used as a source of information about these new manage-ment methods, and nursing j o u r n a l s provide information about recent developments i n nursing p r a c t i c e . The problems and issues discussed i n the j o u r n a l s can be seen i n d i r e c t r e l a -t i o n to aspects of the o r g a n i z a t i o n a l context i n which these management methods are being employed. This work describes some of these r e l a t i o n s h i p s and draws i m p l i c a t i o n s about nursing from them. In Labour and Monopoly C a p i t a l (19 74), Braverman shows why and how i n c a p i t a l i s t s o c i e t y management p r a c t i c e s have been developed to c o n t r o l i n d u s t r i a l processes. Following Marx, - 3 -Braverman shows that i n c a p i t a l i s m the economic s u r v i v a l of an e n t e r p r i s e depends on inducing workers to work more than i s necessary to produce t h e i r subsistence. The methods developed provide management with c o n t r o l over the work process which changes the nature of the worker's r e l a t i o n s h i p to h i s or her work. What ev e n t u a l l y develops i s a work s i t u a t i o n i n which managerial c o n t r o l seems " n a t u r a l " and i s demonstrably necessary to keep workers at t h e i r jobs. Management theory has i t s o r i g i n s i n the t h i n k i n g of Adam Smith and the c l a s s i c a l economists who saw that the d i v i s i o n of labour was the key to cheaper labour. S c i e n t i f i c manage-ment f u r t h e r developed the d i v i s i o n of labour, u n t i l as Braverman argues, management of business and i n d u s t r y becomes a d i f f e r e n t i a t e d form of work, a technology by which methods of management and methods of work o r g a n i z a t i o n reduce the work process to one i n which the s k i l l s and i n i t i a t i v e of the worker are not re q u i r e d . Instead, the i n i t i a t i v e and c o n t r o l of the work process are t r a n s f e r r e d to management which e x p l o i t s i t s c o n t r o l f o r greater p r o f i t a b i l i t y . The r e s u l t of t h i s d i v i s i o n of labour i n i n d u s t r y i s segmentation of the labour force i n t o two p a r t s : managers who plan and c o n t r o l work, and operatives who f o l l o w i n s t r u c t i o n s , having l o s t t h e i r c r a f t s k i l l s . (Chapter One) In order to s h i f t the a n a l y s i s of management p r a c t i c e s i n - 4 -i n d u s t r y to human s e r v i c e o r g a n i z a t i o n s , s e v e r a l new problems must be considered. F i r s t , the r e l a t i o n s h i p between managerial p r a c t i c e s and o r g a n i z a t i o n a l goals d i f f e r s . In i n d u s t r y , i t i s d i r e c t and determinate, but i n human s e r v i c e o r g a n i z a t i o n s , i t i s indeterminate. In i n d u s t r y , management supplies the c o n t r o l element whereby a s p e c i f i c end r e s u l t i s achieved by c a r e f u l l y ordered work processes, p r e c i s e l y co-ordinated with supplies and markets. The concepts " o r g a n i z a t i o n a l r a t i o n a l i t y " and " o r g a n i z a t i o n a l goals" r e f e r to the c o - o r d i n a t i o n process and the end r e s u l t which managerial c o n t r o l e f f e c t s . They are part of a theory of org a n i z a t i o n s which has been developed by s o c i a l s c i e n t i s t s ( c f . S e l z n i c k , 1948; Simon, 1964; Thompson, 1967) aimed at understanding o r g a n i z a t i o n a l a c t i v i t y so that i t can be c o n t r o l l e d more e f f e c t i v e l y f o r p r o f i t - m a k i n g . Thompson (1967) describes an assembly l i n e p l a n t as approaching "p e r f e c t t e c h n i c a l r a t i o n a l i t y " when knowledge of cause/effect r e l a t i o n s allows c o n t r o l over a l l the r e l e v a n t v a r i a b l e s . In a h o s p i t a l , no such p e r f e c t i o n of o r g a n i z a t i o n a l r a t i o n a l i t y i s p o s s i b l e . Because " h e a l t h " i s an indeterminate concept and i t s r e l a t i o n -ship to s p e c i f i c techniques s u p p l i e d by h o s p i t a l workers i n d e f i n i t e , h o s p i t a l goals may be conceptualized and expressed v a r i o u s l y , and h o s p i t a l technique a p p l i e d v a r i o u s l y . Whereas i n d u s t r i a l management p r a c t i c e s are designed to d i s p l a y economic r e l a t i o n s h i p s because they are the f a c t o r s which inform d e c i -- 5 .-sions a f f e c t i n g o r g a n i z a t i o n a l goals i n i n d u s t r y , h o s p i t a l goals encompass more than the cost element. What c o n s t i t u t e s acceptable h o s p i t a l goals i s open to d i f f e r e n t i n t e r p r e t a t i o n by d i f f e r e n t people. To e x p l i c a t e " h o s p i t a l o r g a n i z a t i o n a l goals" i n t h i s t h e s i s , the p a r t i c u l a r o r g a n i z a t i o n a l p r a c t i c e s which shape outcomes w i l l be examined. A t t e n t i o n must be paid to the question of who has the power and r i g h t to determine a h o s p i t a l ' s p o l i c y and day-to-day f u n c t i o n i n g since how i t gets organized w i l l determine (and l i m i t ) what w i l l be done. (Perrow, 1961) C u r r e n t l y a d m i n i s t r a t o r s hold t h i s power, due to t h e i r e x p e r t i s e to meet current c o n d i t i o n s of u n c e r t a i n t y ( C r o z i e r , 1964) i n the h e a l t h care f i e l d . They implement i n h o s p i t a l s the methods of management which have been developed i n i n d u s t r y f o r e f f i c i e n t business p r a c t i c e , regardless of the i n a p p r o p r i a t e -ness of applying methods based on cost r e l a t i o n s to an organi-z a t i o n where s e r v i c e to humans, not p r o f i t a b i l i t y i s paramount. Management accounting procedures cannot produce the r i g h t information f o r decisions about o r g a n i z a t i o n a l a c t i v i t y r e l a t e d to the production of " h e a l t h . " On the other hand, i f organiza-t i o n a l goals are determined according to how w e l l management methods can be a r t i c u l a t e d to them, h o s p i t a l a c t i v i t y w i l l be d e f l e c t e d from " s e r v i c e " to " c o s t " ends. - 6 -Related c l o s e l y to t h i s problem of indeterminacy of h o s p i t a l goals, and t h e i r d e f i n i t i o n as the r e s u l t of a competition f o r dominance i n the o r g a n i z a t i o n , i s the added problem i n human se r v i c e organizations of indeterminacy of work processes. How the production of " h e a l t h " or "improved h e a l t h " i s r e l a t e d to what workers do i s not always c l e a r nor p r e d i c t a b l e . This i s determinately r e l a t e d to outcome, and i t s monopolization by management i s accomplished by observation, a n a l y s i s and cate-g o r i z a t i o n of what workers do. In h o s p i t a l s , nursing work i s subjected to various accounting procedures which "capture" aspects of i t . To the extent to which i t can be o b j e c t i f i e d , i t can be managed -- s p l i t o f f from the i n d i v i d u a l s k i l l e d worker and assigned to l e s s s k i l l e d , cheaper workers. The indeterminate character of the work means that the o b j e c t i f i c a t i o n process i s l a r g e l y unsuccessful. What can be p r e c i s e l y described and r o u t i n e l y found i n nursing a c t i v i t i e s tends to be an incomplete d e s c r i p t i o n of the nursing work process. O b j e c t i f i e d task d e s c r i p t i o n s of the work process are deprived of c r u c i a l nursing i n g r e d i e n t s which i n d i v i d u a l i z e p a t i e n t care. When o r g a n i z a t i o n a l a c t i v i t y i s d i r e c t e d by management p r a c t i c e s of t h i s o b j e c t i v e nature, the work process may not respond to i n d i v i d u a l human needs. A t h i r d problem confronting management i n i t s attempts to - 7 -t r a n s f e r i n d u s t r i a l methods to the s p e c i f i c c o n t r o l of nursing work processes i n h o s p i t a l s l i e s i n the " f r o n t - l i n e organiza-t i o n " found i n h o s p i t a l s and other treatment o r g a n i z a t i o n s . (Smith, 1966) Smith describes t h i s feature of mental h o s p i t a l s which s i t u a t e s c o n t r o l of the work process at the periphery of the organiza-t i o n ; i t has allowed nurses to maintain high l e v e l s of i n d i v i d u a l work autonomy even from the p r o f e s s i o n a l l y subordinate p o s i t i o n they occupy i n the h i e r a r c h i c a l s t r u c t u r e of the h o s p i t a l . This s i t u a t i o n i s contrasted to an i n d u s t r i a l e n t e r p r i s e where l i n e workers e x e r c i s e v i r t u a l l y no c o n t r o l over any aspect of t h e i r productive process, t h e i r i n i t i a t i v e being l i m i t e d to resistance.. To the degree which nurses' work escapes p r e c i s e c a t e g o r i z a t i o n , the d i s c r e t i o n nurses exercise by v i r t u e of a h o s p i t a l ' s f r o n t - l i n e o r g a n i z a t i o n must be harnessed by manage-ment i n a l t e r n a t i v e ways. De c e n t r a l i z e d o r g a n i z a t i o n and e x p l o i t a t i o n of nurses' " p r o f e s s i o n a l " ideology are the manage-ment methods u t i l i z e d . (Chapter Two) To support the argument that h o s p i t a l management i s i n c r e a s i n g l y i n f l u e n c e d by i n d u s t r i a l management ideology, and i n c r e a s i n g l y implements i n d u s t r i a l management technologies to c o n t r o l h o s p i t a l work processes, data from h o s p i t a l a d m i n i s t r a t i o n j o u r n a l s are presented. Conditions a f f e c t i n g h e a l t h care s e r v i c e s i n Canada i n the mid-1970's are i d e n t i f i e d and current - 8 -developments i n h o s p i t a l management p r a c t i c e s described. I n d u s t r i a l management methods are seen to provide admini-s t r a t o r s with the t o o l s to handle the u n c e r t a i n t y prevalent i n h e a l t h care at t h i s time. A d m i n i s t r a t i v e dominance i n organizations i s enhanced thereby, and o r g a n i z a t i o n a l p o l i c y i n c r e a s i n g l y i s shaped by a d m i n i s t r a t o r s . Some s p e c i f i c examples of the a p p l i c a t i o n of i n d u s t r i a l management tech-nologies to h o s p i t a l work are presented to show how organiz-a t i o n a l a c t i v i t y i s c o n t r o l l e d by these p r a c t i c e s . (Chapter Three) With increased p r o d u c t i v i t y and e f f i c i e n c y the goals of ad m i n i s t r a t o r s , the o r g a n i z a t i o n of nursing work i s being a l t e r e d by techniques from an armamentarium suppli e d by systems a n a l y s t s , management engineers and human r e l a t i o n s experts. In nursing , as i n other work o r g a n i z a t i o n , modern management procedures attempt to e s t a b l i s h cost r e l a t i o n s h i p s between s e r v i c e s given and r e s u l t s . The aim i s to lower costs and increase the des i r e d outcome. The indeterminacy of the r e l a t i o n s h i p between what nurses do and the "des i r e d outcome" presents a d i f f i c u l t y f o r the r a t i o n a l i z a t i o n of nursing work. To overcome that d i f f i c u l t y , steps are taken at both ends of the work/outcome equation. Work i s c a r e f u l l y analysed and categorized and outcome c r i t e r i a , when u n a v a i l a b l e , are replaced by process c r i t e r i a developed by - 9 -expert p r o f e s s i o n a l judgment. This provides the s i t u a t i o n Braverman describes i n which " d e s k i l l i n g " occurs: s k i l l e d work i s replaced by operations c a r r i e d out by u n s k i l l e d workers f o l l o w i n g i n s t r u c t i o n s , or using a set of s p e c i f i e d r o u t i n e s . Treating nursing care as a determinate work process which can be analysed and s p e c i f i e d i s an undertaking with consequences f o r p a t i e n t s as w e l l as nurses. Health care planning and nursing budgets come to depend upon a r t i f i c i a l r e l a t i o n s h i p s concocted by computers, c o r r e l a t i n g fragments of nursing work with whatever can be documented and q u a n t i f i e d i n p a t i e n t s ' r e a c t i o n s (outcome c r i t e r i a ) or with a program designed by an "expert" who has no contact with the a c t u a l p a t i e n t (process c r i t e r i a ) . Data from nursing and h o s p i t a l a d m i n i s t r a t i o n j o u r n a l s are used to support t h i s argument and to show how the nursing p r o f e s s i o n i s responding to these changes i n nursing p r a c t i c e . The o f f i c i a l nursing p o s i t i o n regarding the s c i e n t i f i c manage-ment of h e a l t h care i s e q u i v o c a l ; reasons f o r t h i s are suggested. Some s p e c i f i c a p p l i c a t i o n s of modern management technologies to nursing work processes are described and i m p l i c a t i o n s of having nursing organized f o r e f f i c i e n c y are pointed out. (Chapter Four) The o v e r a l l i m p l i c a t i o n s f o r nursing of the t r a n s f e r of mana-g e r i a l methods from i n d u s t r y to h o s p i t a l s w i l l be segmentation 1 - 10 -of t h e i r ranks i n t o two groups. One segment w i l l be a s m a l l , highly-educated, t e c h n o l o g i c a l l y - s o p h i s t i c a t e d group a l i g n e d with management, and the other, an i n c r e a s i n g l y c o n t r o l l e d segment of workers who require l i t t l e t r a i n i n g and who w i l l be able to command correspondingly small s a l a r i e s . Evidence of t h i s d e - p r o f e s s i o n a l i z a t i o n of nursing i s already being seen. The i m p l i c a t i o n s f o r the nursing component of he a l t h care -- a s i g n i f i c a n t part of the t o t a l h e a l t h care system, are to be found i n the i n c r e a s i n g l y t e c h n i c a l approach to nursing required by the new accounting procedures. These managerial p r a c t i c e s provide the basis f o r c o n t r o l l i n g the les s s k i l l e d , l e s s motivated and l e s s professional"*' workers to whom the d i r e c t nursing of p a t i e n t s i s being given. P r o f e s s i o n a l i s m , as i t appli e s to nursing, depends upon a p r a c t i t i o n e r ' s autonomy and competence to respond i n a work s i t u a t i o n from an i n t e r n a l i z e d knowledge/skill/judgment base gained i n s p e c i a l i z e d t r a i n i n g and p r a c t i c e . When nurses are deprived of t h i s d i s c r e t i o n a r y power over t h e i r work, they are also deprived of the ground upon which t h e i r p r o f e s s i o n a l i s m r e s t s . Nursing care w i l l be cheaper, but i t w i l l a l s o be degraded. As the lower stratum of the segmented nursing labour force absorbs a l l those middle-range nurses who do not f i t i n t o Throughout t h i s t h e s i s the term " p r o f e s s i o n a l " i s a p p l i e d to r e g i s t e r e d nurses, rather than the more s o c i o l o g i c a l l y c o r r e c t " s e m i - p r o f e s s i o n a l " ( E t z i o n i , 1969). The common usage, as defined above, i s p r e f e r r e d because that i s how nurses i d e n t i f y themselves and how they are ge n e r a l l y regarded by the p u b l i c . - 11 -management p o s i t i o n s , a large competitive pool of workers w i l l be created to f i l l the u n d i f f e r e n t i a t e d nursing jobs f o r which l i t t l e judgment or i n i t i a t i v e i s req u i r e d . The modern e v o l u t i o n of nursing which comes out of the o r g a n i z a t i o n a l changes i n h o s p i t a l s r a i s e s questions about the c l a s s p o s i t i o n of nurses which go beyond the scope of t h i s t h e s i s . They are questions which are fundamental to the understanding of nurses' r e l a t i o n s h i p to t h e i r work, to the organizations i n which they are s i t u a t e d , and to the s o c i e t y of which they are a p a r t . (Conclus ion) The Data Evidence which supports the argument being made i n t h i s t h e s i s i s found i n Canadian nursing and h o s p i t a l a d m i n i s t r a t i o n j o u r n a l s . In a d d i t i o n , the experience of the author as a p r a c t i s i n g nurse and p a r t i c i p a n t i n nursing orga n i z a t i o n s has informed the choice of data presented. The method by which the data was c o l l e c t e d and analysed was as f o l l o w s : F i r s t , a wide reading of the American, B r i t i s h . a n d Canadian p r o f e s s i o n a l l i t e r a t u r e of nursing and h o s p i t a l a d m i n i s t r a t i o n revealed the nature and scope of the debates being undertaken there about the p r o v i s i o n of h e a l t h care i n the 1960's. With t h i s back-ground, the Canadian l i t e r a t u r e was examined f o r evidence of s i m i l a r developments i n Canada i n the 1970's. The framework w i t h i n which these developments were analysed and are under-- 12 -stood has been provided by the w r i t i n g s of Braverman (1974) , Smith (1966), and Perrow (1961). The j o u r n a l s chosen to convey current issues i n h o s p i t a l manage-ment are the two E n g l i s h language jo u r n a l s about h o s p i t a l s and h o s p i t a l a d m i n i s t r a t i o n which are published and d i s t r i b u t e d i n Canada. Each has s t a f f coverage of "news" p e r t i n e n t to the health care f i e l d , and publishes advertisements of vacant p o s i t i o n s , new appointments i n h o s p i t a l a d m i n i s t r a t i o n , and regular features on aspects of management. A rep r e s e n t a t i v e issue of e i t h e r j o u r n a l would include papers from p r o f e s s i o n a l .conferences, and u n s o l i c i t e d a r t i c l e s from a range of c o n t r i -butors i n c l u d i n g a d m i n i s t r a t o r s , academics, business management con s u l t a n t s , nurses, p s y c h o l o g i s t s , pharmacists, etc. Dimensions i n Health Services (Dimensions) i s the o f f i c i a l p u b l i c a t i o n of the Canadian H o s p i t a l A s s o c i a t i o n and i s the only Canadian h o s p i t a l j o u r n a l indexed i n the Index Medicus, the comprehensive index of medical p e r i o d i c a l s . The C.H.A. i s a f e d e r a t i o n of h o s p i t a l a s s o c i a t i o n s i n Canada, The American H o s p i t a l A s s o c i a t i o n , The Canadian Medical A s s o c i a t i o n , i n co-operation with f e d e r a l and p r o v i n c i a l governments and voluntary n o n - p r o f i t organizations i n the he a l t h f i e l d . H o s p i t a l A d m i n i s t r a t i o n i n Canada (HAC) i s a business p u b l i c a -t i o n of the Southam group, whose p o l i c y i t i s to accept s u b s c r i p t i o n s only from q u a l i f i e d members of the he a l t h care - 13 -f i e l d . Frequently, the same w r i t e r s c o n t r i b u t e to both Dimensions and HAC and there i s considerable e d i t o r i a l agree-ment on i s s u e s . A r t i c l e s explore current concerns i n the h e a l t h care f i e l d i n c l u d i n g o r g a n i z a t i o n of h o s p i t a l s e r v i c e s , r o l e s and r e l a t i o n s h i p s among he a l t h p r o f e s s i o n a l s , governments and consumers, t h e o r e t i c a l c o n s i d e r a t i o n s of work mo t i v a t i o n , medical e t h i c s , h o s p i t a l s and the law, e t c . , and reports of research or p r a c t i c a l a p p l i c a t i o n s of new concepts i n manage-ment. Data from nursing and h o s p i t a l a d m i n i s t r a t i o n j o u r n a l s show how these e f f e c t s of modern management of nursing are being f e l t i n Canada i n the 1970's. Most of the data i s taken from The Canadian Nurse (CN), the o f f i c i a l j o u r n a l of the Canadian Nurses' A s s o c i a t i o n . The Canadian Nurse i s p r i n t e d i n both French and E n g l i s h and i s d i s t r i b u t e d monthly to a l l r e g i s t e r e d nurses i n Canada. I t r e g u l a r l y reports news of i n t e r e s t to nurses, p a r t i c u l a r l y concerning p r o f e s s i o n a l a s s o c i a t i o n meetings and po l i c y , s t a t e m e n t s , current a f f a i r s i n the h e a l t h care f i e l d such as research undertaken, employment negotia-t i o n s , government a c t i o n , new educational programs, etc. A r t i c l e s are c o n t r i b u t e d mainly by nurses or "experts" from other f i e l d s w r i t i n g about some aspect of nursing care. The "Nursing" sections of h o s p i t a l a d m i n i s t r a t i o n j o u r n a l s H o s p i t a l A d m i n i s t r a t i o n i n Canada and Dimensions i n Health - 14 -Services provide a r t i c l e s d i r e c t l y concerned with management of nursing, t o p i c s not d e a l t with i n nursing j o u r n a l s . However, what can be found i n the nursing j o u r n a l s are reports of the innovations i n nursing p r a c t i c e which f o l l o w and are an i n t e g r a l p a r t of management p r a c t i c e s . A climate r e c e p t i v e to such innovations i s also being produced; some i n d i c a t i o n s of how that i s done can be derived from a r t i c l e s i n both the a d m i n i s t r a t i o n and nursing j o u r n a l s . In a d d i t i o n , some references are made to American nursing j o u r n a l s -- The American  Journal of Nursing and Nursing Research, both of which are published by The American Journal of Nursing Company and sponsored by " o f f i c i a l " nursing a s s o c i a t i o n s . - 15 -CHAPTER ONE: MANAGEMENT2 I TASKS OF MANAGEMENT Relations Between Worker and Management Braverman (19 74) provides a framework w i t h i n which the r e l a -t i o n s between workers and management can be understood; the tasks of management can be seen to a r i s e from these r e l a t i o n s . In the c a p i t a l i s t o r g a n i z a t i o n of i n d u s t r i a l production, workers are required to s e l l t h e i r labour power to others who own the means of production. Although they are free to work fo r whomever they wish, workers must enter i n t o employment contracts because s o c i a l c o n d i t i o n s leave them l i t t l e or no other means of earning a l i v e l i h o o d . The purpose of the employment of the worker becomes "the expansion of a u n i t of c a p i t a l " (p. 52) or i n other words, the production of value f o r the c a p i t a l i s t . A worker's labour adds value to what the employer already owns by transforming m a t e r i a l s i n t o s aleable commodities by various work processes. What the employer buys and what the workers have to s e l l i s not labour, but labour power, the a b i l i t y to labour over a s p e c i f i e d p e r i o d of time. Therefore, what the employer gets from h i s worker i s a v a r i a b l e q uantity and q u a l i t y of work, with the p o t e n t i a l of producing This chapter i s based on Labor and Monopoly C a p i t a l , Chapters 1-10, by Harry Braverman. Unless otherwise noted, page references are to t h i s work. - 16 -an i n d e f i n i t e amount of surplus ( p r o f i t ) . I t i s i n g e t t i n g more labour out of the worker's labour power, purchased at a determinate p r i c e , that the employer makes h i s p r o f i t . How to accomplish t h i s i s the task of management. The Problem of Management Workers do not need to work hard enough to produce a surplus on which t h e i r employers make p r o f i t s ; i n an equal exchange of work and pay, the worker would stop work having produced enough to exchange f o r the means to s u b s i s t at the l e v e l of hi s or her peers. But the r e l a t i o n s h i p between employer and worker i s "decidedly not a free and voluntary exchange between equals" (Stolzman and Gamberg, 1973-4). If the employer makes a p r o f i t , he must have induced h i s workers to continue working past the time they had earned t h e i r subsistence. This c o n s t i t u t e s an e x p l o i t a t i v e r e l a t i o n -s hip. S i t u a t e d i n an economy which forces workers to s e l l t h e i r labour power, employers then use i t to r e i n f o r c e t h e i r c o n t r o l over workers. Employers take the surplus created by workers' labour power, s e l l i t and r e i n v e s t the p r o f i t to increase t h e i r p r ofit-making p o t e n t i a l . The c a p i t a l they accumulate allows employers to expand t h e i r own e n t e r p r i s e and acquire new ones, gaining a monopoly over the s u p p l i e s , the manufacture, and markets f o r the commodities they produce. Thus t h e i r c o n t r o l over the community i s extended as the p o s s i b i l i t i e s f o r a l t e r -- 17 -n a t i v e employment or f o r independently produced commodities i s o b l i t e r a t e d . Management cannot r e l y on workers' i n t e r e s t i n t h e i r work to keep them attending to i t c o n s i s t e n t l y during t h e i r employment per i o d . Labour, according to Marx, allows people to construct t h e i r world c o l l e c t i v e l y (Stolzman and Gamberg, 1973-4). People who have s o l d t h e i r labour power have l o s t t h e i r a b i l i t y to modify or shape t h e i r world. This i s the a l i e n a t i n g aspect of wage-labour under the c a p i t a l i s t system. I t accounts f o r the worker's apathy or o u t r i g h t h o s t i l i t y toward the production he or she i s i n v o l v e d i n . I t i s the problem of management to organize and implement the e x p l o i t a t i v e r e l a t i o n s h i p i n the c a p i t a l i s t workplace and to maximize the usefulness of the labour power purchased i n the absence of workers' personal involvement i n the process of work. To do t h i s i t i s e s s e n t i a l that the c o n t r o l of the labour process pass from the hands of the worker i n t o the hands of management. II HISTORY OF THE DEVELOPMENT OF MANAGERIAL CONTROL  D i v i s i o n of Labour Braverman describes how the worker's knowledge of h i s or her work (which c o n s t i t u t e s the basis f o r c o n t r o l over that work) - 18 -can pass i n t o the hands of management whose members lack such c r a f t s k i l l s . The key i n t h i s s h i f t i n c o n t r o l i s the s u b d i v i -s i o n of the work each s p e c i a l l y t r a i n e d worker does. Braverman makes a d i s t i n c t i o n between the d i v i s i o n of labour i n s o c i e t y whereby d i f f e r e n t occupations are formed "each adequate to a branch of p r o d u c t i o n " (p. 72) and the breakdown of occupations "which renders the worker inadequate to c a r r y through any complete production process" (p. 73). The advantage of the l a t t e r , seen already by p o l i t i c a l economists of the pe r i o d of the I n d u s t r i a l Revolution as c r u c i a l to advancements i n c a p i t a l i s t production, i s expressed by Charles Babbage, w r i t i n g i n 1832: The master manufacturer, by d i v i d i n g the work to be executed i n t o d i f f e r e n t processes, each r e q u i r i n g d i f f e r e n t degrees of s k i l l or of f o r c e , can purchase e x a c t l y the p r e c i s e q u a n t i t y of both which i s necessary f o r each process; whereas, i f the whole work were executed by one workman, that person must possess s u f f i c i e n t s k i l l to perform the most d i f f i c u l t , and s u f f i c i e n t strength to execute the most laborious of the operations i n t o which the a r t i s d i v i d e d . (pp. 79-81) Braverman adds that " t r a n s l a t e d i n t o market terms, t h i s means that the labour power capable of performing the process may be purchased more cheaply as d i s s o c i a t e d elements than as a capacity i n t e g r a t e d i n a s i n g l e worker" (p. 81). The work of F rederick Winslow Taylor, c a l l e d S c i e n t i f i c Management, - 19 -o p e r a t i o n a l i z e s t h i s philosophy. S c i e n t i f i c Management It s Aims -- Taylor's work, which formed the basis f o r the s c i e n t i f i c management movement, was d i r e c t e d toward e s t a b l i s h i n g management c o n t r o l over every aspect of the labour process. Taylor's c l a i m to being s c i e n t i f i c r e s t s on h i s d e t a i l e d examin-a t i o n of work; he studied what workers d i d "with an eye to systematizing and c l a s s i f y i n g i t " (p. 110). On the basis of t h i s knowledge he devised methods f o r d i c t a t i n g to the worker the p r e c i s e manner i n which each aspect of the work was to be performed. This allowed u n s k i l l e d workers to be shown how to carry out segments of a c r a f t , the t o t a l i t y of which had formed the e x p e r t i s e of the s k i l l e d worker. A f t e r h i s study, the manager knew the p r e c i s e method of performing the work segments, as w e l l as the p a t t e r n of execution (the process). When u n s k i l l e d workers were h i r e d to replace s k i l l e d , the managers became the only ones who knew how the segments f i t t e d together. The craftsman no longer c o n t r o l l e d an e s s e n t i a l piece of knowledge nor possessed unique s k i l l s ; such s k i l l s had become obsolete. P r i n c i p l e s -- Braverman c i t e s three p r i n c i p l e s of s c i e n t i f i c management which Taylor a r t i c u l a t e d : 1. C o l l e c t i n the hands of management at l e a s t as much i n f o r -mation about the work process as the worker has; s p e c i f i -- 20 -c a l l y , how to do i t , and how much time i t takes; 2. Remove a l l p o s s i b l e brainwork from the workplace. "Conception and execution must be rendered separate spheres of work, and f o r t h i s purpose the study of the work processes must be reserved to management, and kept from the workers" (p. 118). Workers must f o l l o w simple i n s t r u c t i o n s " u n t h i n k i n g l y and without comprehension of the underlying t e c h n i c a l reasoning or data" (p. 118); 3. Control each step i n the labour process and i t s mode of execution by gaining a monopoly over the knowledge of the work. This allows each worker's d a i l y tasks to be preplanned by a s p e c i a l management s t a f f . A p p l i c a t i o n to Industry -- Taylor h i m s e l f t i e d h i s management methods to economic i n c e n t i v e s , convinced that what workers want i s more money. He saw h i s methods as a way of ensuring c o n s i s t e n t worker e f f o r t to reach and maintain increased p r o d u c t i v i t y . He thought that d i f f e r e n c e s between workers and c a p i t a l i s t s could be erased by r e l a t i n g wages to managerial estimates of a " f a i r day's work" c a l c u l a t e d by time studies ( l a t e r time and motion, and more s o p h i s t i c a t e d p h y s i o l o g i c a l s t u d i e s ) . Increases i n wages would be earned by d i r e c t l y observable p r o d u c t i v i t y increases. Workers and t h e i r unions understandably protested the implemen-t a t i o n of s c i e n t i f i c management methods and many managers and - 21 -academics were c r i t i c a l of some aspects of Taylor's e f f i c i e n c y methods. However, none of the c r i t i c s f a i l e d to see the advan-tages to management these methods could achieve. The p r i n c i p l e s became embedded i n the developing d i s c i p l i n e of business admini-s t r a t i o n and have become, Braverman says, "the bedrock of a l l work design" (p. 87). This a s s e r t i o n i s supported by Peter Drucker whose w r i t i n g s on business a d m i n i s t r a t i o n are a u t h o r i -t a t i v e i n that f i e l d : Personnel A d m i n i s t r a t i o n and Human Relat i o n s are the things t a l k e d about and w r i t t e n about whenever the management of worker and work i s being discussed... But they are not the concepts that u n d e r l i e the a c t u a l management of worker and work i n American i n d u s t r y . This concept i s S c i e n t i f i c Management...Altogether i t may w e l l be the most powerful as w e l l as the most l a s t i n g c o n t r i b u t i o n America has made to Western thought since the F e d e r a l i s t Papers. (p. 88; quoted from Drucker, 1954) Studies of the Worker Which Contribute to Management Theory and  P r a c t i c e s During the time that i n d u s t r y was implementing the e f f i c i e n c y methods of Taylor and h i s successors i n the S c i e n t i f i c Manage-ment movement, a separate l i n e of research about work was developing. I t s focus was the problem of worker r e s i s t a n c e to management c o n t r o l . I t began with p s y c h o l o g i c a l studies --aptitude t e s t s (how to choose the r i g h t man f o r the r i g h t j o b ) , and progressed to s o c i o l o g i c a l studies of group behaviour (how to p r e d i c t and modify i t ) . I m p l i c i t i n both the s c i e n t i f i c management studies and the i n v e s t i g a t i o n of the "human element" - 22 -i n work was the c a p i t a l i s t assumption that the optimal condi-tions of work are those which produce the greatest p r o f i t . The c o n t r a d i c t i o n which arose was that the p r a c t i c e s i n s t i t u t e d to increase p r o d u c t i v i t y a l s o increased a l i e n a t i o n of the workers. The schools of I n d u s t r i a l Psychology and Sociology which developed to study workers' s u b j e c t i v e responses to these taken f o r granted ( a l i e n a t i n g ) c o n d i t i o n s were not able to develop e f f e c t i v e means for e l i m i n a t i n g worker r e s i s t a n c e . Their f i n d i n g s have been i n t e g r a t e d i n t o management courses i n Human Relations and Personnel A d m i n i s t r a t i o n , and corporations have added departments with experts i n these f i e l d to advise on c e r t a i n problems with t h e i r workers. The a c t u a l i n f l u e n c e of the ideas generated by the "human element" researchers i n shaping c o n d i t i o n s i n an i n d u s t r y i s somewhat l i m i t e d . Braverman suggests that t h e i r c o n t r i b u t i o n may be l a r g e l y that of p r o v i d i n g a smokescreen of propaganda about a l i e n a t i n g company p r a c t i c e s . He r e f e r s to a study which shows that the job design i n some companies s y s t e m a t i c a l l y deprives workers of the opportunity to make i n d i v i d u a l c o n t r i b u t i o n s , while Personnel rep r e s e n t a t i v e s emphasize the importance of the i n d i v i d u a l to the o r g a n i z a t i o n : Job design represents r e a l i t y while personnel a d m i n i s t r a t i o n represents only mythology...the l a t t e r represents a manipulation to habituate the worker to the former. (pp. 145-6) - 23 -I I I MANAGEMENT AND TECHNOLOGY A d i s t i n c t i o n which Braverman makes and which i s important to the development of t h i s present work i s between the r o l e of management and the r o l e of s c i e n t i f i c / t e c h n o l o g i c a l innovation i n i n d u s t r y . Management's r o l e as "organizer of labour" i s to supply a p a r t i c u l a r formal s t r u c t u r e f o r the production process; the content of the labour process i s su p p l i e d by the technique used to modify the m a t e r i a l s . Techniques used i n i n d u s t r y have been "assuming an i n c r e a s i n g l y s c i e n t i f i c character as knowledge of n a t u r a l laws grows and d i s p l a c e s the scrappy knowledge and f i x e d t r a d i t i o n of craftsmanship" (p. 155). The labour process changes as i t s components change; i t s content or technique i s being i n f l u e n c e d by s c i e n t i f i c and engineering advances. I t s form i s being d i c t a t e d by imperatives of c a p i t a l i s t management. The importance of c l a r i f y i n g the d i s t i n c t i o n between what science and technology c o n t r i b u t e to the labour process and what management methods c o n t r i b u t e i s to be able to see how they are harnessed together i n c a p i t a l i s t i c endeavour. I t i s not the case that machines c o n t r o l workers of t h e i r own free w i l l ; s p e c i f i c choices are made by people to use machines i n p a r t i c u l a r ways. Management p r a c t i c e s harness workers to machines i n the manner which i s conducive to the greatest p r o d u c t i v i t y . Science i s deployed by in d u s t r y to serve c a p i t a l i s t ends; the use of s c i e n t i f i c knowledge to serve - 24 -humanity i s an a l t e r n a t i v e which i s overlooked because i t would not be p r o f i t a b l e . Management p r a c t i c e s t r a n s f e r r e d from i n d u s t r y to human s e r v i c e o r g a n i z a t i o n s c a r r y w i t h them t h e i r f e a l t y to " p r o d u c t i v i t y " over " s e r v i c e to humanity." In the next chapter, the r o l e of management i n p r o v i d i n g d i r e c t i o n f o r an org a n i z a t i o n ' s a c t i v i t y i s discussed. I t i s pointed out that a h o s p i t a l ' s s e r v i c e goals can be d e f l e c t e d by the form i n which i t s work processes are cast by i n d u s t r i a l management methods. - 25 -CHAPTER TWO: MANAGEMENT OF HOSPITALS I RELATIONSHIP OF MANAGEMENT PRACTICES TO ORGANIZATIONAL GOALS  In Industry How w e l l an o r g a n i z a t i o n can achieve i t s goals depends, as Thompson (1967) says, on how w e l l the cause/effect r e l a t i o n s h i p between the o r g a n i z a t i o n a l technology and goals i s understood, and the re l e v a n t v a r i a b l e s c o n t r o l l e d f o r . In i n d u s t r y , where the r e l a t i o n s h i p between the work processes and the product i s c l e a r l y discernable and q u a n t i f i a b l e , and supply and demand f a c t o r s c a l c u l a b l e , the o r g a n i z a t i o n a l goal of maximum re t u r n on investment i s determinately r e l a t e d to i t s "cause" i n organ-i z a t i o n a l a c t i v i t y . Management p r a c t i c e s provide monitoring and feedback of the re l e v a n t v a r i a b l e s upon which d e c i s i o n s a f f e c t i n g the success of the o r g a n i z a t i o n depend. The deter-m i n i s t i c r e l a t i o n s h i p between goals and work processes and supply and demand f a c t o r s of the o r g a n i z a t i o n a l technology means that management accounting p r a c t i c e s can provide information to f a c i l i t a t e achievement of o r g a n i z a t i o n a l goals. This i s po s s i b l e because o r g a n i z a t i o n a l goals i n business and in d u s t r y are conceptualized and c a l c u l a b l e i n economic terms, the same dimension of o r g a n i z a t i o n a l a c t i v i t y as the accounting proce-dures are r e p o r t i n g . The success of management p r a c t i c e s i n in d u s t r y can be seen to depend upon t h e i r d e t e r m i n i s t i c r e l a t i o n s h i p to o r g a n i z a t i o n a l goals. - 26 -In Human Service Organizations In n o n - p r o f i t s e r v i c e o r g a n i z a t i o n s such as a h o s p i t a l , o r g a n i z a t i o n a l goals n e i t h e r have the u n i f y i n g c h a r a c t e r i s t i c of necessary c a p i t a l accumulation nor are they l i k e l y to be d e t e r m i n i s t i c a l l y r e l a t e d to management methods based on accounting procedures. I f the o r g a n i z a t i o n a l goal cannot, be defined i n such a way as to s p e c i f y p r e c i s e l y and i n quanti-t a t i v e terms, how the work process i s r e l a t e d to i t , the f i g u r e s produced by management accounting procedures are l i k e -wise not determinately r e l a t e d to the o r g a n i z a t i o n a l goal. I t foll o w s that such f i g u r e s are not an adequate basis f o r informing o r g a n i z a t i o n a l p o l i c y . A more d e t a i l e d a n a l y s i s of how o r g a n i z a t i o n a l p o l i c y i s formulated and h o s p i t a l a c t i v i t y i s d i r e c t e d must be undertaken to provide an understanding of how management p r a c t i c e s are r e l a t e d to o r g a n i z a t i o n a l goals i n h o s p i t a l s . Perrow's (1961) work on the a n a l y s i s of goals i n complex organizations i s i n s t r u c t i v e . II THE DEFINITION OF ORGANIZATIONAL GOALS IN HOSPITALS Competition For Dominance by E l i t e Groups i n the Organization  (Perr.ow) The process of goals determination i n h o s p i t a l s i s a dynamic one with o r g a n i z a t i o n a l goals r e f l e c t i n g changes i n funding arrangements, the state of the h e a l i n g a r t s , p u b l i c demands f o r s e r v i c e s , e t c . The i d e n t i f i c a t i o n of what a c t u a l goals u n d e r l i e - 27 -managerial decisions requires c a r e f u l a n a l y s i s since the statement of o f f i c i a l goals i n the o r g a n i z a t i o n ' s c h a r t e r or annual report may not c o r r e c t l y i n d i c a t e what ends are a c t i v e l y being pursued by the o r g a n i z a t i o n . Operative goals, those which i n f l u e n c e p o l i c y , may be a p o r t i o n of the o f f i c i a l l y s t a t e d goals although l e s s prominance i s given to them i n p u b l i c r e l a t i o n s e f f o r t s , or they may be q u i t e u n r e l a t e d to o f f i c i a l goals. The l a t t e r may begin as u n o f f i c i a l goals ( s p e c i a l i n t e r e s t s of a p a r t i c u l a r member or group) and gain such prominance i n the o r g a n i z a t i o n that they i n f l u e n c e p o l i c y . For example, a h o s p i t a l whose o f f i c i a l goals are "to promote the he a l t h of the community through c u r i n g the i l l , teaching and conducting research" may a c t u a l l y be operating on p o l i c y which neglects aspects of the o f f i c i a l goals or contravenes them e n t i r e l y . Expenditure on teaching, r e q u i r i n g r e d u c t i o n of nursing s t a f f , may create c o n d i t i o n s r e s u l t i n g i n lower q u a l i t y of p a t i e n t care; funding may be d i v e r t e d from the operating budget to a research program, the primary purpose of which i s to advance i n d i v i d u a l careers of powerful members, etc. In the absence of a c l e a r cut and unquestionable goal d e f i n i -t i o n f o r a h o s p i t a l , how the o r g a n i z a t i o n ' s a c t i v i t i e s are d i r e c t e d and resources a l l o c a t e d i s a matter of who commands the most powerful p o s i t i o n i n the o r g a n i z a t i o n . Perrow sees t h i s as a competition f o r dominance among the e l i t e s k i l l groups - 28 -i n the o r g a n i z a t i o n . Operative goal choice w i l l be made by the e l i t e group which achieves the dominant p o s i t i o n because of being able to s u c c e s s f u l l y accomplish the most problematic tasks of the o r g a n i z a t i o n . The major tasks of a v i a b l e organi-z a t i o n o u t l i n e d by Perrow are: 1. to secure inputs of c a p i t a l s u f f i c i e n t to e s t a b l i s h , operate and expand as the need a r i s e s ; 2. to secure acceptance i n the form of b a s i c l e g i t i m a t i o n of a c t i v i t y ; 3. to marshall necessary s k i l l s ; and 4. to co-ordinate the a c t i v i t i e s of i t s members and the r e l a t i o n s of the o r g a n i z a t i o n w i t h other o r g a n i z a t i o n s and "consumers. (Perrow, 1961) About these tasks he says: A l l four are not l i k e l y to be e q u a l l y important at any one time. Each of these task areas provides a presumptive b a s i s f o r c o n t r o l or domination by the group equipped to meet the problem involved...The operative goals w i l l be shaped by the dominant group, r e f l e c t i n g the imperatives of the p a r t i c u l a r area that i s most c r i t i c a l , t h e i r own back-ground c h a r a c t e r i s t i c s ( d i s t i n c t i v e perspec-t i v e s based on t h e i r t r a i n i n g , career l i n e s , and areas of competence) and the u n o f f i c i a l uses to which they put the o r g a n i z a t i o n f o r t h e i r own ends. (Perrow, 1961) In the h i s t o r i c a l p e r i o d before the prevalence of s c i e n t i f i c medicine, trustees dominated the policy-making i n v o l u n t a r y h o s p i t a l s , g i v i n g way to doctors when that group's e x p e r t i s e was i n c r e a s i n g l y r e q u i r e d to make de c i s i o n s about t e c h n o l o g i c a l - 29 -and s c i e n t i f i c advances. The current phase, Perrow says, i s c h a r a c t e r i z e d by a d m i n i s t r a t i v e dominance. As C r o z i e r (1964) has shown, the group with the e x p e r t i s e to handle s i t u a t i o n s of u n c e r t a i n t y i n an o r g a n i z a t i o n w i l l w i e l d considerable i n f l u e n c e . The u n c e r t a i n t i e s produced f o r h e a l t h care organi-zations i n the 1970's by government alarm over costs of p u b l i c -financed medical and h o s p i t a l s e r v i c e s , and by the down-turn of the economy provide a context f o r management, as e f f i c i e n c y -experts, to expand t h e i r c o n t r o l . A d m i n i s t r a t i v e Dominance Over O r g a n i z a t i o n a l Goals The i n c r e a s i n g complexity of h e a l t h care requires more s k i l l and a t t e n t i o n towards c o - o r d i n a t i o n of e f f o r t s of d i f f e r e n t workers than doctors are able to handle. In a d d i t i o n , the new f i n a n c i n g arrangements -- government sponsored h o s p i t a l i z a t i o n and medical s e r v i c e s insurance -- make p u b l i c a c c o u n t a b i l i t y mandatory and put new emphasis and new s t r a i n on e f f i c i e n t use of resources. The required s k i l l s are taught i n Schools of Business A d m i n i s t r a t i o n , and t h e i r mastery allows t h i s group to achieve new prominance i n h o s p i t a l o r g a n i z a t i o n . Admini-s t r a t o r s can consolidate t h e i r strength by i n t e r f e r i n g with doctors' t r a d i t i o n a l r e l a t i o n s h i p s with other workers by which doctors' demands f o r deference and time-saving conveniences were met. "By maintaining close s u p e r v i s i o n over employees or promoting t h e i r own independent bas i s f o r competence, and by supporting them i n c o n f l i c t s with doctors, the a d m i n i s t r a t o r - 30 -can, to some degree, overcome the high f u n c t i o n a l a u t h o r i t y that doctors command" (Perrow, 1961). A d m i n i s t r a t o r s ' c o n t r o l of communication i n the o r g a n i z a t i o n enhances t h e i r s t r a t e g i c p o s i t i o n . Access to info r m a t i o n , p a r t i c u l a r l y about c r u c i a l f i n a n c i a l and l e g a l matters a f f o r d s a d m i n i s t r a t o r s power over other groups. Perrow describes two tendencies i n a d m i n i s t r a t i v e dominance: to support operative goals concerned w i t h f i n a n c i a l solvency, or operative goals r e f l e c t i n g i n c r e a s i n g " p r o f e s s i o n a l i z a t i o n " of h o s p i t a l a d m i n i s t r a t o r s . In the f i r s t , there i s a t t e n t i o n to c a r e f u l accounting procedures and e f f i c i e n c y and i n the second, concern about "broader m e d i c a l - s o c i a l r o l e of h o s p i t a l s i n v o l v i n g o r g a n i z a t i o n a l and f i n a n c i a l innovations i n the form of care" (Perrow, 1961). These two tendencies would seem to have been r e i n t e g r a t e d by the p r o l i f e r a t i o n of use of systems a n a l y s i s and computer technology i n h o s p i t a l a d m i n i s t r a t i o n . I t s methods o f f e r the most advanced means of r a t i o n a l i z e d decision-making and give the h o s p i t a l a d m i n i s t r a t o r new pr e s t i g e as both an e f f i c i e n c y - e x p e r t w i t h i n the h o s p i t a l and a planner of h e a l t h care i n the wider f i e l d of s o c i a l s e r v i c e s -- both on the basis of computerized data-processing and e f f i c i e n t business p r a c t i c e . This i s the point at which the danger of goal displacement (Scott , 1967) appears. Scott describes a s i t u a t i o n i n which s t a f f of a s o c i a l s e r v i c e agency a c t u a l l y changed t h e i r b e l i e f s about the c l i e n t s t h e i r agency - 31 -had been set up to a i d , when the c l i e n t s became a burden on i t s s u c c e s s f u l business operation. As the p r a c t i c e s which c o n s t i t u t e " o r g a n i z a t i o n a l goals" change from s o c i a l r e l a t i o n s to f i n a n c i a l r e l a t i o n s , human concerns can be overlooked. This i s the concern Hoos (1972) expresses regarding systems a n a l y s i s i n h e a l t h care. She f i n d s unconvincing the now widely held b e l i e f that systems a n a l y s i s a p p l i e d to s o c i a l problems can produce b e t t e r s o l u -t i o n s . Her research corroborates a t e c h n o l o g i c a l conception of a problem l i m i t s the focus to those aspects which can be expressed q u a n t i t a t i v e l y and which f i t c e r t a i n models. The t e c h n o l o g i c a l s o l u t i o n which r e s u l t s may be s a t i s f a c t o r y from an engineering p o i n t of view but, because i t has encompassed only s e l e c t e d f a c e t s , v i t a l dimensions may have been neglected. Such v i o l a t i o n of the essence of problems may, i n the long run, exacerbate r a t h e r than ameliorate the troublesome c o n d i t i o n . (Hoos, 1972) Hoos documents the progression i n the U.S.A. of the use of systems theory and technology from the Space Program to the Defense Department and thence throughout government o f f i c e s and agencies to i t s now unquestioned a p p l i c a t i o n to management decision-making i n any o r g a n i z a t i o n . The success of the Space Program encouraged optimism i n the u n l i m i t e d c a p a b i l i t i e s of automatic data-processing to allow computerized s e l e c t i o n of the best option f o r any undertaking. The management p r a c t i c e s - 32 -b u i l t on t h i s basis are those of s c i e n t i f i c management-separation of conception and execution, c a r r i e d to t h e i r t e c h n i c a l extreme. Planning-Programming-Budgeting, and Cost-B e n e f i t A n a l y s i s are o r g a n i z a t i o n a l forms i n which the d e c i -sions are made on the basis of information from work-areas c o r r e l a t e d to c r i t e r i a which management has formulated out of a " t e c h n o l o g i c a l conception" of the o r g a n i z a t i o n a l goals. In Canada, f o l l o w i n g i n s t i t u t i o n of tax-supported h o s p i t a l insurance and pre-paid s u b s i d i z e d medical p l a n s , r i s i n g costs have induced government funders to support economy-minded methods. Modern management methods using systems a n a l y s i s and e l e c t r o n i c data-processing are advanced here, as i n the U.S.A., f o r e f f i c i e n c y i n a h e a l t h care system which i s c o s t i n g too much to operate. While the problem of authentic i n d i c a t o r s of he a l t h has continued to b a f f l e researchers, conversion of h o s p i t a l record systems, c l i n i c a l as w e l l as those concerned wi t h o r g a n i z a t i o n a l process, has gone on. The i n d i c a t o r s by which d e c i s i o n s are made continue to r e f l e c t , as i n i n d u s t r y , economic c o n s i d e r a t i o n s , skewing an orga n i z a t i o n ' s p o l i c y away from human con s i d e r a t i o n s which cannot be q u a n t i t a t i v e l y expressed or assigned a monetary value. Operative Goal Choice By A Subordinate Group While Perrow's argument that a dominant e l i t e group determines o r g a n i z a t i o n a l goals i n a h o s p i t a l has considerable e m p i r i c a l - 33 -v a l i d i t y in l i g h t of the present s i t u a t i o n in Canadian hospitals, i t does not account for important modifications to hospital policy and a c t i v i t y made by members of a subordinate group. The potential for independent goal choice by nurses can be estimated by recent and increasing attention by management to tightening control of nursing work. Implications of this new control over what nurses do may rebound on patients whose nursing care has always been the product of considerable nursing discretion due to the hospital's " f r o n t - l i n e organization" (Smith, 1966). Front-line Organization (Smith) When the work structure creates a s i t u a t i o n in which the task is c a r r i e d out r e l a t i v e l y independently at the locus of work, the members of such i s o l a t e d work groups are i n a position to influence each others' behaviour -- to r i v a l the influence of organizational goals set elsewhere. Control over behaviour of nurses tends to be exercised by peer pressure due to the closed work groups whose locus is the ward. Working i n d i v i d u a l l y with patients or i n small work groups, they have l i t t l e contact i n the course of a day's work with nurses from other wards. Their contact with other technical and service workers i s mediated by t r a d i t i o n a l understandings about occupational role behaviour which reduce the influence of such persons over the observed behaviour of nurses in their professional relationships with patients. For example, - 34 -c l e a n i n g and food-service s t a f f are l a r g e l y c o n s t i t u t e d by nurses as "non-persons" (Goffman, 1959), and contact w i t h t e c h n i c a l workers as f l e e t i n g tradesperson r e l a t i o n s h i p s (Davis, 1959). So although general h o s p i t a l wards are not "closed" i n the sense that mental h o s p i t a l wards may be, the " p r o f e s s i o n a l " atmosphere which p r e v a i l s i n s u l a t e s the ward s t a f f from o u t s i d e r s to the extent that the " i n s i d e r s ' " v e r s i o n of operative goals may dominate. B a r r i e r s to d i r e c t s u p e r v i s i o n of nurses on the ward allows nurses some leeway to e x e r c i s e i n d i v i d u a l c o n t r o l over opera-t i v e goals. To c o n t r o l nurses' behaviour, supervisors need info r m a t i o n , e i t h e r gathered d i r e c t l y by observation or i n d i r e c t l y i n r e p o r t s . The process of r e p o r t i n g allows the person on the scene d i s c r e t i o n over "the f a c t s " reported; these " f a c t s " are the basis on which o r g a n i z a t i o n a l a c t i o n i s taken. A nurse's judgment must be r e l i e d on by people i n management who t r a n s l a t e reports i n t o c e n t r a l i z e d organiza-t i o n a l a c t i o n . In these ways nurses, although not an e l i t e group o v e r t l y competing f o r dominance i n the o r g a n i z a t i o n , are t a k i n g organ-i z a t i o n a l i n i t i a t i v e s , i n f l u e n c i n g t h e i r peers to act according to group standards rather than o r g a n i z a t i o n a l ones, and are e x e r c i z i n g t h e i r own i n f l u e n c e over operative goals by p r o v i d i n g or w i t h o l d i n g key information. Nursing work processes - 35 -have l a r g e l y escaped d i r e c t o r g a n i z a t i o n a l c o n t r o l up u n t i l the present time. The "doctor-nurse game" has served as an adequate method f o r preventing i n t e r f e r e n c e by doctors i n nursing o b j e c t i v e s ( S t e i n , 1968). F r o n t - l i n e o r g a n i z a t i o n of h o s p i t a l s has prevented s u c c e s s f u l managerial c o n t r o l . I l l INADEQUACY OF INDUSTRIAL MANAGEMENT TECHNOLOGIES FOR DIRECTING HOSPITAL WORK El u s i v e i n d e f i n i t i o n , changeable over time and with ascendancy of d i f f e r e n t e l i t e groups i n h o s p i t a l s or with pressure from i n t e r e s t e d groups w i t h i n or outside the o r g a n i z a t i o n , goals d i r e c t e d towards " h e a l t h , " once defined, e x h i b i t a character-i s t i c which d e f i e s s u c c e s s f u l a p p l i c a t i o n of i n d u s t r i a l manage-ment methods. How the goal of "production of b e t t e r h e a l t h " or " p r o v i s i o n of adequate h e a l t h s e r v i c e s to an i n d i v i d u a l or community" i s to be r e l a t e d to a determinate set of work processes which can then be monitored and r e l a t e d to s p e c i f i c costs i s an i n s o l u b l e problem. This l i n k between work processes and goals i s necessary f o r managerial p r a c t i c e s based on accounting procedures which b u i l d i n the assumption that f i n a n c i a l c o n s i d e r a t i o n s have a p r i o r i t y i n decision-making. Health care, however, depends upon a co-operative e f f o r t between the i n d i v i d u a l and the h e a l t h care worker. What the worker does may vary from person to person, w i t h s i m i l a r r e s u l t s , depending upon such i n t a n g i b l e i n g r e d i e n t s as the p a t i e n t ' s m o t i v a t i o n to get w e l l , and a multitude of other i n t r a p e r s o n a l - 36 -f a c t o r s . H e a l i n g and growth are m y s t e r i o u s p r o c e s s e s , s t i l l n ot under complete c o n t r o l o f s c i e n c e and t e c h n o l o g y . I n d u s t r i a l management methods are c u r r e n t l y b e i n g f o c u s e d on n u r s i n g work. A d m i n i s t r a t o r s see nurses as the work group to be managed more e f f i c i e n t l y i n an e f f o r t t o reduce h e a l t h c a r e c o s t s . "Management" means c o n t r o l of the work p r o c e s s and i t s c l o s e r a r t i c u l a t i o n to g o a l s which management p r e s c r i b e s --g o a l s which are t e c h n o l o g i c a l l y c o n c e i v e d and q u a n t i t a t i v e l y e x p r e s s e d f o r a c c o u n t i n g p u r p o s e s . As work p r o c e s s e s are s t r e a m - l i n e d and c o s t - a n a l y s e d f o r e f f i c i e n c y , n u r s i n g a c t i v -i t i e s which are now taken f o r g r a n t e d may be e x c l u d e d as too c o s t l y from p r e p l a n n e d , timed s c h e d u l e s . The s i g n i f i c a n c e of n u r s e s ' d i s c r e t i o n over t h e i r work, o v e r l o o k e d by a n a l y s t s l i k e Perrow, has been to p r o v i d e e s s e n t i a l human elements t o h o s p i t a l c a r e ; a t a time when t e c h n o l o g i c a l f e a t u r e s o f h e a l t h c a r e are r e p l a c i n g human c o n t a c t , modern management methods i n h o s p i t a l s are b e g i n n i n g t o o r g a n i z e n u r s e s ' work t o r e s t r i c t t h e i r t r a d i t i o n a l d i s c r e t i o n . T h i s i s a dangerous t r e n d f o r h e a l t h c a r e as w e l l as f o r n u r s e s and n u r s i n g . The use of i n d u s t r i a l management methods i n h o s p i t a l s i s s u s p e c t i n terms of adequacy of c a r e . I t must be k e p t i n mind t h a t i f management a c c o u n t i n g p r o c e d u r e s are " s u c c e s s f u l l y " p r o v i d i n g a b a s i s f o r o r g a n i z a t i o n a l d e c i s i o n - m a k i n g , they are not n e c e s s a r i l y i n f o r m i n g the b e s t d e c i s i o n s about h e a l t h or - 37 -he a l t h care. Goals f o r human s e r v i c e o r g a n i z a t i o n s are of a d i f f e r e n t order than those determined by " r e t u r n on investment" a n a l y s i s . Decision-making about what i s good f o r people i s u n l i k e l y to s e r e n d i p i t o u s l y accompany e f f i c i e n t business p r a c t i c e . Braverman's work s p e c i f i c a l l y describes the opposite e f f e c t . In Chapter Three, management responses to current issues i n the p r o v i s i o n of h e a l t h care i n Canada are examined. What i s being pointed to i s the reinforcement of a d m i n i s t r a t i v e dominance i n h o s p i t a l s by current economic d i f f i c u l t i e s . In t u r n , t h i s dominance allows implementation of managerial technologies which, d i r e c t e d towards handling the economic problems, skew hea l t h goals. - 38 -CHAPTER THREE: INDUSTRIAL MANAGEMENT METHODS IN HOSPITALS DATA FROM HOSPITAL ADMINISTRATION JOURNALS, 1974-1976 I UNCERTAIN CONDITIONS IN HEALTH CARE During 1974-1976, the important issues f o r h e a l t h care admini-s t r a t o r s a r i s i n g from e x t e r n a l c o n d i t i o n s were, f i r s t : pending or a c t u a l budget cuts by governments responsible f o r h e a l t h care funding; second: government i n i t i a t i v e s towards new he a l t h care p o l i c y , i n d i c a t e d by p u b l i c a t i o n of New Perspectives on the  Health of Canadians ( M i n i s t r y of Health and Welfare, Canada, 1974) which o u t l i n e d need f o r a change i n emphasis from i l l n e s s care to preventive h e a l t h care; and t h i r d : general r i s i n g costs were ac c e l e r a t e d by new wage demands backed by increased c o l l e c -t i v e a c t i o n by h o s p i t a l workers. This created a climate of u n c e r t a i n t y i n which h o s p i t a l admini-s t r a t o r s attempted to regain the upper hand by advancing s o l u -t i o n s based on the e f f i c i e n c y methods of modern management. Their responses to the i n i t i a t i v e s of government and workers had the e f f e c t of more c l e a r l y d e f i n i n g h e a l t h care as a business e n t e r p r i s e , and i t s a d m i n i s t r a t i o n p r o p e r l y r e q u i r i n g management methods borrowed from business and in d u s t r y . - 39 -II HOSPITAL ADMINISTRATION RESPONSES TO UNCERTAIN CONDITIONS The responses of a d m i n i s t r a t o r s to the new c o n d i t i o n s i n d i c a t e how they react to threats to t h e i r hegemony i n the h e a l t h care management e n t e r p r i s e . They see government eroding t h e i r a u t h o r i t y (HAC 18:9,4) and suggest that h o s p i t a l a d m i n i s t r a t o r s and trustees must prevent f u r t h e r government i n t r u s i o n i n t o what i s r i g h t f u l l y t h e i r own concern -- de c i s i o n s about how healt h care money w i l l be spent. Examples from the j o u r n a l s are presented to suggest how h o s p i t a l management incorporates i n d u s t r i a l ideology and how i t takes form i n response to new issues of f i s c a l c o n t r o l , preventive h e a l t h p o l i c y and union a c t i v i s m . I d e o l o g i c a l Underpinnings of Management P o s i t i o n s on Current  Health Care Issues The speaker chosen to give the 1976 Canadian H o s p i t a l Associa-t i o n keynote address a r t i c u l a t e d h o s p i t a l management's concern about too much government c o n t r o l i n h o s p i t a l a f f a i r s . Maxwell Henderson, former audit o r - g e n e r a l of Canada, c a l l e d f o r a r e t u r n to h o s p i t a l boards and managements of the r i g h t to conduct t h e i r own a f f a i r s i n order to "keep a l i v e the competition, i n i t i a -t i v e , and s e l f - r e l i a n c e that are among our best Canadian c h a r a c t e r i s t i c s " (HAC 18:8,6). This speech was given promin-ance i n both HAC and Dimensions; both c a r r i e d p i c t u r e s of Henderson, one on the cover. - 40 -In c o n t r a s t was the response to T.C. Douglas, p a r l i a m e n t a r i a n , speaker at the Canadian College of Health Service Executives meeting the evening p r i o r to the CHA convention, and i n the same c i t y . Douglas 1 t a l k c a l l e d f o r governments to respond to t h e i r "inescapable r e s p o n s i b i l i t y to ensure that those who are s i c k and c r i p p l e d receive a l l the treatment and care which modern science has made p o s s i b l e without money and without p r i c e " (HAC 18:8,6). The HAC e d i t o r i a l commenting on the two speeches noted the c o n t r a s t , c a l l i n g i t "Two Opposing Tenden-c i e s . " An unnamed ad m i n i s t r a t o r i s quoted i n the e d i t o r i a l , expressing a perspective apparently supported by HAC: "Should we look at needs and humanity or costs and r e a l i t y ? " (HAC 18: 8,6). The management p o s i t i o n i n labour disputes was the subject of an address by Charles P e r r a u l t , President of the Quebec Employers C o u n c i l , to the j o i n t meeting of the Canadian College of Health Service Executives and the American H o s p i t a l Admini-s t r a t o r s , November, 1975. This t a l k by a business leader put the question of government expenditures on s o c i a l s e r v i c e s i n t o c a p i t a l i s t p e r s p e c t i v e : to have money to meet people's demands f o r s o c i a l s e r v i c e s , the government must support i n d u s t r y i n making p r o f i t s ; to make p r o f i t s , i n d u s t r y requires a low p a i d labour f o r c e . P e r r a u l t pointed out that i n d u s t r y has made c e r t a i n concessions to keep workers s a t i s f i e d , such as job enlargement, and c e r t a i n personnel techniques, but i t - 41 -won't pay higher wages. Instead, i n d u s t r y w i l l move i t s produc-t i o n to more rec e p t i v e c o u n t r i e s r a t h e r than pay b i g wages. Unions which won't co-operate w i t h t h i s philosophy should not be allowed to operate, P e r r a u l t suggested. In h i s t a l k , he represented government as misguided, naive, pandering to p o l i -t i c a l a c t i v i s t s and workers, without the strength to make appropriate d e c i s i o n s to b e n e f i t management. Industry's p o s i -t i o n i s c h a r a c t e r i z e d as representing "the common good" against which organized groups of workers defend t h e i r s e l f i s h wishes (Dimensions 53:3,44-46). This speech was given the highest r a t i n g of approval by admini-s t r a t o r s attending the conference, suggestive of agreement with the views being expressed. The b e l i e f s manifest i n these speeches, i n the r i g h t of management to c o n t r o l h e a l t h care i n a b u s i n e s s - l i k e f a s h i o n , p u t t i n g money matters before human need can be seen the i d e o l o g i c a l underpinnings of modern manage-ment i n h o s p i t a l s . I t i n f l u e n c e s management p o s i t i o n s i n three p a r t i c u l a r areas of current concern which are discussed below. Struggle f o r F i s c a l Control H o s p i t a l a d m i n i s t r a t o r s see themselves i n a s t r u g g l e with govern-ment over the f i s c a l c o n t r o l of h e a l t h care, and f e e l that they can b e n e f i t from the p a r t i c i p a t i o n of other h e a l t h p r o f e s s i o n a l s i n the contest. In an e d i t o r i a l (HAC 18:12,6) e d i t o r John Boyd suggests i t i s time f o r more " p l a i n speaking" by p r o f e s s i o n a l s , - 42 -and notes that f e l l o w e d i t o r , Brousseau, of Dimensions has made a beginning by c r i t i c i z i n g the government i n the October, 1976 issue of h i s j o u r n a l . Two e f f e c t s might be f e l t : while medical and nursing support f o r the a d m i n i s t r a t i o n p o s i t i o n against government cutbacks would strengthen o p p o s i t i o n to such funding cuts, opposing claims by doctors and nurses f o r l a r g e r shares of h o s p i t a l budgets could be used by a d m i n i s t r a t i o n to t h e i r own advantage. A d m i n i s t r a t i v e techniques f o r o b j e c t i v e l y measuring e f f e c t i v e n e s s of medical and nursing performance are being o f f e r e d as the answer to c o n f l i c t i n g a l l o c a t i o n claims (HAC 18: 1,4). As i n i n d u s t r y , managers using economic c r i t e r i a c l a i m preeminence i n planning and decision-making as repre s e n t a t i v e s of the common good. F i s c a l problems, then, strengthen the a d m i n i s t r a t i o n c l a i m to c o n t r o l h e a l t h care resource a l l o c a t i o n ; a d m i n i s t r a t o r s can point to t h e i r e x p e r t i s e i n business management when e f f i c i e n c y methods are c a l l e d f o r . John Boyd, i n an e d i t o r i a l i n HAC (Vol. 17:8,4) says we ought to take a long-range view and...develop, slowly and d e l i b e r a t e l y , step by step, a system that w i l l e v e n t u a l l y be more cost e f f i c i e n t . Research on such systems i s reported i n Dimensions 51:1,34-36 and a p p l i c a t i o n s of management methods focusing on work a n a l y s i s , and accounting procedures f o r o b j e c t i v e l y e s t a b l i s h i n g - 43 -remuneration r a t e s , or otherwise g e t t i n g "more work per hour of employee labour" are f r e q u e n t l y discussed i n a r t i c l e s (HAC 16:6,6). The approach to management which poses problems i n economic terms alone i s now being a p p l i e d to a l l aspects of he a l t h care decision-making; examples of i t s use i n h o s p i t a l management, con t r a c t disputes, government a l l o c a t i o n of funds, medical and nursing p r a c t i c e w i l l be discussed i n more d e t a i l i n l a t e r s e c t i o n s of the paper. Prevention - - A New P r i o r i t y i n Health Care P o l i c y The newest threat to H o s p i t a l A d m i n i s t r a t o r s ' dominance i s the p o l i c y announced by the f e d e r a l Health Department i n d i c a t i n g i t s i n t e n t i o n to emphasize prevention (1974), and to do so by taking money out of h o s p i t a l a l l o c a t i o n (Dimensions, Aug. 76, 42-43). These i n i t i a t i v e s were followed by statements i n a d m i n i s t r a t i o n j o u r n a l s of the p r i o r i t y of h o s p i t a l s and the h o s p i t a l ' s r o l e i n the community. John Boyd, i n an e d i t o r i a l "Broadening Health Care Horizons" (HAC, Aug. 75,4) responds to the f e d e r a l p o l i c y statement about prevention: H o s p i t a l s are here to stay and w i l l continue to be the core of our h e a l t h care system f o r a long time to come. and goes on to recommend that more economic ways of operating them be found. - 44 -When i t became apparent that the government intended to provide f o r any new preventive programs out of money already budgeted to h o s p i t a l s , h o s p i t a l a d m i n i s t r a t o r s began to emphasize the c e n t r a l p o s i t i o n h o s p i t a l s play i n the community and to suggest that h o s p i t a l s are the l o g i c a l place f o r preventive programs to be l o c a t e d (Dimensions 52:10,8). In a guest e d i t o r i a l i n HAC, an a d m i n i s t r a t o r of a Toronto h o s p i t a l suggests that H o s p i t a l A d m i n i s t r a t o r s and Trustees should c o n t r o l the " i n t e r n a l and e x t e r n a l " h e a l t h care budgets, p o i n t i n g out that a d m i n i s t r a t o r s have the necessary e x p e r t i s e (HAC 18:9,4). Community Health Care Centres represent a new development not under the c o n t r o l of h o s p i t a l budgets and they are c r i t i c i z e d i n a Dimensions e d i t o r i a l . The c o n c l u s i o n reached i s that these experimental h e a l t h centres were fundamentally not accept-able to the h e a l t h workers, i n p a r t i c u l a r , the medical profes-s i o n , and that h o s p i t a l s could b e t t e r take on the r o l e of community h e a l t h centres (Dimensions 51:6,4). Other groups i n t e r e s t e d i n maintenance of h o s p i t a l f u n c t i o n i n g at i t s present s t a t e are heard from as w e l l . For example, a h o s p i t a l t r u s t e e , and a U n i v e r s i t y of Toronto researcher from the I n s t i t u t e of P o l i c y A n a l y s i s employed on a "Physician's Survey," co-authored an a r t i c l e i n HAC (Vol. 18:10,9). I t examined the h o s p i t a l ' s need to take more " s o c i a l r e s p o n s i b i l i t y " or s u f f e r a l i e n a t i o n from the p u b l i c . This i s a theme which administra-t i o n j o u r n a l s echo (Dimensions 52:10,8) representing a p o s i -t i o n taken by the new breed of " p r o f e s s i o n a l " a d m i n i s t r a t o r s , - 45 -according to Perrow (1961). Union A c t i v i s m H o s p i t a l a d m i n i s t r a t i o n supports government e f f o r t s to a r r i v e at " o b j e c t i v e standards" by which s a l a r y l e v e l s can be c a l c u -l a t e d r a t h e r than being l e f t to "the exercise of raw power" -- as c o l l e c t i v e a c t i o n by nurses and other h o s p i t a l employees i n Ontario has been described (Dimensions 51:3,14). This a r t i c l e r e f e r s to a H o s p i t a l Inquiry Commission e s t a b l i s h e d by the Ontario government to review and report on comparable categories of work to which h o s p i t a l workers' demands can be r e l a t e d . The Commission, made up of a p o l i t i c a l economist and two s t e e l company executives i s weighted i n favour of the business ideology p r e v i o u s l y discussed which views "the common good" a r i s i n g from paying workers the lowest wages p o s s i b l e . In t h e i r own o r g a n i z a t i o n s , h o s p i t a l a d m i n i s t r a t o r s are i n t r o -ducing o b j e c t i v e standards f o r performance e v a l u a t i o n which can be used as the basis f o r comparison to e x t e r n a l standards from indus t r y when these are a r r i v e d at. Methods f o r measuring the p r o d u c t i v i t y of h o s p i t a l personnel "with a view to improving s t a f f u t i l i z a t i o n and c o n t r o l l i n g c o s t s " have been the focus of studies undertaken i n Saskatoon since 1974 by the H o s p i t a l Systems Study Group, funded by the W.K. Kellogg Foundation. This p r o j e c t undertook implementation and ev a l u a t i o n of manage-ment to o l s f o r gauging and monitoring s t a f f performance. I t s - 46 -f i n d i n g s have been made a v a i l a b l e to h o s p i t a l s throughout Canada (Dimensions 51:1,34-36) and references to t h i s work are now appearing i n reports of modern management implementa-t i o n i n other h o s p i t a l s (HAC 18:2,22-25). In the past, h o s p i t a l s have r e l i e d on job s e c u r i t y and workers' i d e a l i s m to make work there a t t r a c t i v e . Now that h o s p i t a l workers are using c o l l e c t i v e a c t i o n to support demands f o r higher wages, governments are co-operating with i n d u s t r y to keep the l i d on r i s i n g labour c o s t s . C r i t i c a l S e l f - A p p r a i s a l by Management of Their Own Methods Another response noted i n h o s p i t a l a d m i n i s t r a t i o n j o u r n a l s i s the d i s c u s s i o n of management's preparedness to cope success-f u l l y w i t h the new c o n d i t i o n s i n the climate of h e a l t h care. S i g n i f i c a n t l y , a r t i c l e s comparing h o s p i t a l management to i n d u s t r i a l management appear i n t h i s time p e r i o d (HAC 17:2, 31-34; Dimensions 51:8,57-61). Obsolescence i n both organiza-t i o n a l s t r u c t u r e s and of managers themselves i s noted (HAC 17: 11,20-25; HAC 17:9,17-20). What i s being suggested i n these a r t i c l e s i s that new c o n d i t i o n s require new methods; the methods of choice are those based on systems a n a l y s i s --program budgeting, c o s t - b e n e f i t a n a l y s i s and new o r g a n i z a t i o n a l forms and personal management behaviours to c a p a c i t a t e these methods. - 47 -The need to accentuate the d i v i s i o n between management and labour i n an o r g a n i z a t i o n i n the i n t e r e s t of increased c o n t r o l i s the focus of s e v e r a l a r t i c l e s . Department heads should not be unionized (Dimensions 52:10,46-47), and nurses i n management p o s i t i o n s should be educated to the proper p e r s p e c t i v e regarding t h e i r f u n c t i o n (HAC 18:12,26-28; HAC 17:6,49-53). The emphasis on re-education of nurses f o r management p o s i t i o n s i s a t t r i b -utable to the importance of middle management p o s i t i o n s i n e s t a b l i s h i n g managerial c o n t r o l over work processes s t i l l c o n t r o l l e d by s k i l l e d workers. Re-education includes winning management nurses over to the view that o r g a n i z a t i o n a l goals of p r o d u c t i v i t y and e f f i c i e n c y are p r i o r to humanitarian concerns. Symbolic of the new r e l a t i o n s h i p of these nurses to the organi-z a t i o n they w i l l have learned to see as superordinate, nurse graduates of the management course at Hamilton C i v i c H o s p i t a l s are given a desk set pen holder; management i s to be seen as an o f f i c e job, and these nurses are to i d e n t i f y w ith administra-t i o n , not with other nurses who do t e c h n i c a l work. Methods f o r maintaining managerial c o n t r o l are discussed at Health Service Executives meetings, and a r t i c l e s e x t o l l i n g the value of new methods appear f r e q u e n t l y i n the j o u r n a l s . Such techniques as "consensus management" i n t o which " s k i l l s of co - o r d i n a t i o n and persuasion are b u i l t " extend managerial power t h e i r proponents say, because of the tendency of other h o s p i t a l groups to turn to management f o r help using the t o o l - 48 -(HAC 18:6,4). "Management by o b j e c t i v e s " i s seen as the p r e f e r e n t i a l management method because of i t s b u i l t - i n focus on q u a n t i f i a b l e r e s u l t s (Dimensions 51:6,17-18). I l l APPLICATION OF INDUSTRIAL MANAGEMENT METHODS TO HOSPITAL  WORK Decentr a l i z e d Organization Reference has already been made to some of the s p e c i f i c methods trans p l a n t e d from business and ind u s t r y to the h o s p i t a l . One innovation i n h o s p i t a l management i s r e - o r g a n i z a t i o n of the formal s t r u c t u r e of a d m i n i s t r a t i o n i n t o the form developed i n large corporations (Sloan, 1972). This method d e c e n t r a l i z e s the operations of the o r g a n i z a t i o n and combines t i g h t c o n t r o l by the c e n t r a l a d m i n i s t r a t i o n over p o l i c y and finance while a l l o w i n g maximum d i s c r e t i o n i n the d e c e n t r a l i z e d u n i t s . P o l i c y d e c i s i o n s a r i s e i n the a d m i n i s t r a t i v e centre and are implemented by u n i t heads who are accountable to the centre f o r the func-t i o n i n g of t h e i r u n i t s . What d i s c r e t i o n a c t u a l l y occurs i n the un i t s i s w i t h i n the parameters of the p o l i c y d e c i s i o n s and budget a l l o c a t i o n s made i n the a d m i n i s t r a t i v e centre. This system of management and i t s v a r i a n t s which have been described by Stevenson and Paterson (Dimensions 53:3,11-13) and Carruthers (Dimensions 51:8,57-61) uses f o r e c a s t i n g of resource needs, monitoring of a c t u a l use, and a c c o u n t a b i l i t y by desig-nated personnel to c o n t r o l c o s t s . Carruthers p o i n t s out that - 49 -s t r a t e g i c planning allows " u n p r o f i t a b l e products" to be trimmed o f f . Systems A n a l y s i s i n H o s p i t a l Planning and Operations The techniques f o r planning and decision-making are based on system a n a l y s i s , as are monitoring and accounting procedures. Planning, Programming, Budgeting Systems (PPBS) r e q u i r e s the t r a n s l a t i o n i n t o q u a n t i t a t i v e terms of information about problems to be solved, a f t e r which i t can be processed auto-m a t i c a l l y and a l t e r n a t i v e courses of a c t i o n suggested by the computer. Confidence i n the computer s e l e c t i o n of the best course of a c t i o n using i t s a b i l i t y to scan a l l the combinations of a l t e r n a t i v e s presented to i t i s very high due to the perva-s i v e r e s i d u a l e f f e c t s of the American space program (Hoos, 1972). These a l t e r n a t i v e s are " c o s t " a l t e r n a t i v e s , and depend upon the v a l i d i t y and completeness of information about the "problem" f o r t h e i r r e l i a b i l i t y or appropriateness. Cost-Benefit A n a l y s i s i s a planning technique which attempts to assess how e f f e c t i v e a p a r t i c u l a r program or treatment has been. I t r e l a t e s the amount of h e a l t h care i n t e r v e n t i o n to the outcome i n an e f f o r t to a s c e r t a i n f o r future programs what treatments, e t c . , provide maximum r e t u r n i n improved heal t h on c a p i t a l invested i n personnel, equipment and other resources. The problems i n attempting to conceptualize these r e l a t i o n s h i p s and to gather r e l i a b l e information to describe - 50 -the phenomena which are being cost-compared, remain monumental. However, great amounts of money are being expended to develop information systems i n Canadian h o s p i t a l s by which a l l kinds of h e a l t h care d e c i s i o n s can be made. Information about treatment outcomes and other data about c l i n i c a l problems are gathered from p a t i e n t records. To be used i n data-processing equipment, standard nomenclature has to be agreed upon and records kept i n a standard form. Such a system has been i n operation i n Ontario h o s p i t a l s since 1974, p r o v i d i n g information on p a t i e n t i d e n t i f i c a t i o n , admissions, discharges, d i a g n o s i s , doctors and s e r v i c e s i n v o l v e d , procedures and treatments c a r r i e d out, medical and lab o r a t o r y f i n d i n g s , e t c . The q u a l i t y of t h i s information depends, according to a s t a t i s t i c i a n who works with the i n f o r -mation system, upon scrupulous care i n the c o l l e c t i o n , programming and a n a l y s i s of data...Only h i g h l y q u a l i f i e d and pr o p e r l y t r a i n e d personnel can use the medical informa-t i o n from the medical sheets and record i t on the ab s t r a c t sheets f o r computer input. (Dimensions 51:7,59) Even i f the data from records are r e l i a b l e , and many p o s s i b i l -i t i e s f o r ina c c u r a c i e s and omissions occur along the informa-t i o n production l i n e , what i s done with t h i s information must - 51 -be questioned. Physicians express concern about c o n f i d e n t i -a l i t y and medical e t h i c s ; the s t a t i s t i c i a n p r e v i o u s l y quoted worries about the cost of gathering and processing vast amounts of data which w i l l never be used. Attempts to f i n d " i n d i c a t o r s , " by which planning d e c i s i o n s can be made, i n what can be q u a n t i f i e d f o r automatic processing equipment, i s r i s k y . Only c e r t a i n aspects of e i t h e r the costs or b e n e f i t s of h e a l t h s e r v i c e s can ever be t r a n s l a t e d i n t o q u a n t i f i a b l e terms. Basing h e a l t h care d e c i s i o n s on numbers of p a t i e n t s discharged with "improved" w r i t t e n on t h e i r medical record, or some other such fragment of the whole i n t e r a c t i o n , i s not an improvement i n planning even i f neat graphs and c o r r e l a t i o n s can be made. At present only o r g a n i z a t i o n a l processes can be r e l i a b l y converted to computerized decision-making. C l i n i c a l d e c i s i o n -making by computer i s s t i l l i n the experimental or demonstration-p r o j e c t phase. An example of o r g a n i z a t i o n a l process which has been " r a t i o n a l i z e d " by systems a n a l y s i s and computer processing of data i s s t a f f i n g of h o s p i t a l wards. P a t i e n t c l a s s i f i c a t i o n systems c o d i f y the nursing needs of s p e c i f i c p a t i e n t s and these codes are matched by computer to predetermined s t a f f comple-ments. This " o b j e c t i v e " demonstration of s t a f f requirements fo r h o s p i t a l wards i s examined c r i t i c a l l y i n the next chapter when e f f e c t s of modern management techniques on nurses i s discussed. 52 -Work Design A separate undertaking which i s v i t a l to the use of automatic data-processing i n h o s p i t a l s i s management c o n t r o l of the or g a n i z a t i o n of work. The f o l l o w i n g advertisement i n HAC i l l u s t r a t e s the focus of a t t e n t i o n of a "management engineer" i n a general h o s p i t a l . Management Engineer re q u i r e d f o r a general h o s p i t a l . Must be capable of accepting r e s p o n s i b i l i t y f o r the a n a l y s i s , design and implementation of improved procedures i n any h o s p i t a l department. Accomplishment of t h i s u l t i m a t e aim would req u i r e the su c c e s s f u l a p p l i c a n t to be knowledge-able i n communication s k i l l s , methods study, work s i m p l i f i c a t i o n , work measurement, forms design and c o n t r o l , s t a f f i n g patterns and c r e a t i n g the proper environment f o r s u c c e s s f u l implementation... (HAC 18:12,39) Two c r u c i a l aspects of work design are: 1. (The Braverman P r i n c i p l e ) Work i s . broken i n t o the smallest p o s s i b l e segments; the mental work i s relegated to manage-ment c o n t r o l and the segments are performed by r e l a t i v e l y u n s k i l l e d workers. 2. The tasks i n each segment are s p e c i f i e d so that the job may be p r e c i s e l y described, evaluated o b j e c t i v e l y , pay grades determined and c o r r e l a t i o n s made with s i m i l a r cate-gories of work i n other f i e l d s ( i n i n d u s t r y , f o r example) to o b j e c t i v e l y determine comparable scales f o r c o l l e c t i v e - 53 -bargaining settlement. D e t a i l e d knowledge of p r e c i s e work tasks affords management c o n t r o l which can be used to increase pressure on workers i n various ways. A step-by-step report of t h i s procedure, a p p l i e d i n a h o s p i t a l o f f i c e , i s reported i n an a r t i c l e c a l l e d "Get More Out Of Your T y p i s t , " w r i t t e n by a systems analyst at a Toronto h o s p i t a l (Dimensions 52:11,11-12). Work measure-ment and s i m p l i c a t i o n procedures i n t h i s department increased i t s output of typing by 661.while u n i t costs of the work decreased by 131. Changes included monitoring i n d i v i d u a l t y p i s t s ' d a i l y p r o d u c t i v i t y , r e o r g a n i z i n g the work process to remove any s o r t i n g or planning of work by the t y p i s t s , and reduce the time spent i n s e t t i n g up d i f f e r e n t reports and c o r r e c t i n g e r r o r s . The work area was renovated to remove the p o s s i b i l i t y of d i s t r a c t i o n from outside s t i m u l i . Management, i n gaining c o n t r o l of the work process had been able to reorganize and r o u t i n i z e i t so that the a c t i v i t y of fewer s t a f f could be t i g h t l y c o n t r o l l e d and t h e i r output v a s t l y increased. This same ki n d of procedure i s a p p l i e d to a l l categories of h o s p i t a l work, to the extent to which work processes can be made determinate. A News item i n The Canadian Nurse (72:7,11) reports research on optimum s t a f f i n g being done by a study team at the U n i v e r s i t y of Saskatoon. One of the ways nursing - 54 -work i s being streamlined i s by having pharmacists prepackage s i n g l e doses of medications f o r h o s p i t a l i n p a t i e n t s , to reduce time spent by nurses i n t h i s a c t i v i t y . Studies of pharmacists' work reveals that t h i s increase i n t h e i r duties would increase the t o t a l cost of t h i s aspect of h e a l t h care unless a corres-ponding reduction i n nursing time occurred. The next chapter discusses a p p l i c a t i o n s of modern management technologies to nursing work processes. - 55 -CHAPTER FOUR: INDUSTRIAL MANAGEMENT OF NURSING: DATA FROM  NURSING AND HOSPITAL ADMINISTRATION JOURNALS, 1974-1977 I THE NURSING POSITION REGARDING THE SCIENTIFIC MANAGEMENT  OF HEALTH CARE IN CANADA Science Council Recommends Systems A n a l y s i s to Integrate  Health Care On October 16, 1974, the Science Council of Canada presented i t s Report No. 22: "Science f o r Health S e r v i c e s " i n which new s c i e n t i f i c d i r e c t i o n s i n h e a l t h care p o l i c y and management were recommended to the f e d e r a l government. The Canadian Nurses' A s s o c i a t i o n was one of the groups asked to respond to the re p o r t . Besides the o f f i c i a l p o s i t i o n of nurses to the s o l u t i o n s being proposed f o r h e a l t h care problems, the nursing statement provides some i n d i c a t i o n s of underlying conditions which a f f e c t nurses* t h i n k i n g about t h e i r involvement i n h e a l t h care. The f i r s t recommendation of the Science Council's report i s that Canada's h e a l t h care be "reorganized i n t o an i n t e g r a t e d system... using a systems approach" (CN 70:12,9). I t recognizes the need f o r " s a t i s f a c t o r y h e a l t h i n d i c a t o r s " and c a l l s f o r work on them to be i n t e n s i f i e d ; i t c a l l s f o r development of a computer-based health information system which would allow "monitoring the e f f e c t i v e n e s s of the h e a l t h care system i n greater d e t a i l . " - 56 -Another recommendation i s f o r " f u r t h e r r e d e f i n i t i o n of the r o l e s of h e a l t h personnel...which would reduce the formal r e s t r i c t i o n s of the s e r v i c e s that can be performed by various personnel." CNA Response to the Science Council Report The CNA response supported the general p r i n c i p l e s i n the Science Council Report but added that i t s s o l u t i o n s "do not address the fundamental problems," which nursing sees as "the problems of a c c e s s i b i l i t y and use of resources, which are treated only at the l e v e l of general p r i n c i p l e s ; mental h e a l t h , which receives only prefunctory a t t e n t i o n ; and the c l i e n t s ' p o i n t of view, which i s l a c k i n g " (CN 70:12,9). But a f t e r s p e c i f i c a l l y r e j e c t i n g the Science Council's proposed s o l u t i o n s f o r h e a l t h care, the Nurses' A s s o c i a t i o n r a t i f i e s the method o u t l i n e d i n the Report: The A s s o c i a t i o n recognizes the usefulness of the a p p l i c a t i o n of science and technology to the h e a l t h care system, along the l i n e s suggested by the Report. I t q u a l i f i e s i t s endorsement of the approach by adding: However, CNA h e s i t a t e s to endorse the use of a s i n g l e approach to solve a l l the problems of the h e a l t h care system. This equivocal response must be seen i n the context of the - 57 -r e l a t i o n s h i p between nurses and the s c i e n t i f i c and i n t e l l e c t u a l community represented at t h i s conference. Two features stand out: the v u l n e r a b i l i t y of the nurses as a member of that group, and the s t r a t e g i c usefulness to nurses of supporting the systems approach. In an era when science and technology are preeminent, to be unsupportive of the systems approach suggested by Report No. 22 of the p r e s t i g i o u s Science Council of Canada would be seen as a n t i - i n t e l l e c t u a l and r e g r e s s i v e . Nursing i s c u r r e n t l y strug-g l i n g to be recognized as a p r o f e s s i o n . I t bases i t s c l a i m on e s t a b l i s h i n g i t s own s c i e n t i f i c knowledge foundation, and wants to be seen as r i g h t f u l l y a member of the i n t e l l e c t u a l community (U.B.C. School of Nursing "Model f o r Nursing," unpublished manuscript). On the other hand, nurses are s c e p t i c a l of mechan-i s t i c approaches to s o l v i n g human problems. Discussion of humanitarian concerns which have motivated nurses h i s t o r i c a l l y , i s not easy i n s c i e n t i f i c c i r c l e s , nor i s nurses' t r a d i t i o n a l way of knowing l i k e l y to be,seen as a u t h o r i t a t i v e (Campbell, 1976). In the f i n a l outcome, as nurses are beginning to r e a l i z e and resent, what they say or do makes l i t t l e impact on p o l i c y decisions anyway (CN 72:4,8). For the shorter term goals, both o f f i c i a l and u n o f f i c i a l i n nature, nurses are l i k e l y to see the new methods being introduced by h o s p i t a l management as a p o s i t i v e step. For example, systems approaches which require new admini-s t r a t i v e methods such as d e c e n t r a l i z a t i o n ( u n i t management) seem - 58 -to o f f e r nurses more autonomy (Morgan. Dimensions 51:8,55-61). Perrow observed that a d m i n i s t r a t o r s w i l l support nurses' claims fo r more autonomy over t h e i r p r a c t i c e i n order to break doctors' t r a d i t i o n a l t i e s with nurses, and to r e i n f o r c e t h e i r own (adm i n i s t r a t o r s ' ) power (Perrow, 1961). The new approach to health care o f f e r s nurses i n management op p o r t u n i t i e s f o r advancement i n t h e i r careers. I t i s the stat e d aim of management t r a i n i n g programs such as the Hamilton C i v i c H o s p i t a l s one (HAC 17:6,49-53) to provide management nurses with the experiences and p r i v i l e g e s of belonging to an e l i t e group. As the use of these management methods p r o l i f -e r a t e , more nurses are being r e q u i r e d to f i l l these r o l e s . These nurses are r e c r u i t e d from nursing supervisory or admini-s t r a t i v e ranks whose members, along with nurse educators, form the policy-making committees of nursing a s s o c i a t i o n s . Products of the same educational processes as other u n i v e r s i t y - e d u c a t e d p r o f e s s i o n a l s , nurses are i n c r e a s i n g l y being taught to approach t h e i r work with the t o o l s s u p p l i e d by systems a n a l y s i s . The f i r s t work on nursing t r a n s l a t i o n s of systems theory was done by an engineer and published i n the e a r l y 1960's (Nursing  Research 12:3,172-4; NR 12:4,232-6; NR 13:1,4-7). Since that time, many nursing t h e o r i e s and "models"/of nursing (e.g. CN 71:9,40-1) have been developed, based r a t h e r l o o s e l y on general systems theory. However e p i s t e m o l o g i c a l l y unsound (see Hoos, 1972:26-7 on t h i s point) t h i s work has provided an i d e o l o g i c a l - 59 -connection f o r nurses with the e l i t e whose " r u l i n g " i s based on these concepts (Smith, 1973) . In p r a c t i c e , however, modern management methods, which have incorporated the systems approach, s p l i t n ursing i n t o two pa r t s : those who manage and those whose work i s managed, and they also focus a t t e n t i o n on the cost r e l a t i o n s i n nursing care at the expense of the s o c i a l r e l a t i o n s . The next s e c t i o n provide some d e t a i l s of how t h i s happens. II MANAGEMENT METHODS APPLIED TO NURSING WORK The methods which management imposes on nursing work are adapted from i n d u s t r y and have the same aims. There i s an attempt to monopolize the knowledge of the work process, to s p e c i f y (preplanned) ta s k s , and to c o n t r o l the performance of those tasks. These procedures supply " o b j e c t i v e " information about nursing s k i l l l e v e l s and nursing time needed which forms the basis f o r " o b j e c t i v e " work assignment; they reduce the need f o r nurses to exercise d i s c r e t i o n i n the performance of t h e i r work, thereby lowering s k i l l requirements; and they provide, through d e t a i l e d performance e v a l u a t i o n and r e t r o s p e c t i v e document checks, f o r worker compliance to task s p e c i f i c a t i o n s . This c o n t r o l over the work process at the locus of a c t i v i t y i n nurse/ p a t i e n t contact reduces the need f o r c e n t r a l a d m i n i s t r a t i v e c o n t r o l -- which was never e f f e c t i v e i n c o n t r o l l i n g nursing - 60 -i n i t i a t i v e s anyway. The economies e f f e c t e d by o b j e c t i v e s t a f f i n g : fewer t o t a l s t a f f , more t e c h n i c a l (vs p r o f e s s i o n a l ) workers, and fewer nursing supervisors are augmented by p o l i c i e s informed by cost data r e l a t e d to s p e c i f i c nursing tasks. I t i s here that the indeterminate r e l a t i o n s h i p between h e a l t h care goals and managerial p r a c t i c e s becomes problematic. What i s economical may not be good enough when i t i s human beings, not inanimate m a t e r i a l , being worked on. The s p e c i f i c tasks described as a "process" towards improved h e a l t h may be inadequate, d e s c r i b i n g a p a r t i c u l a r job, rather than what i s i n a p a t i e n t ' s best i n t e r e s t s . The f o l l o w i n g examples discovered i n accounts of nursing from nursing or a d m i n i s t r a t i o n p e r i o d i c a l s i l l u s t r a t e how nursing work i s organized by management p r a c t i c e s to accomplish these ends. Unit Management Dece n t r a l i z e d o r g a n i z a t i o n of a d m i n i s t r a t i o n i n h o s p i t a l u n i t s has already been described i n the s e c t i o n on i n d u s t r i a l manage-ment methods being used i n h o s p i t a l s (Chapter Three). This method o r i g i n a t e d i n the General Motors Corporation during the 1920's; i t s prime purpose and what i t achieved f o r that organi-z a t i o n was t i g h t e r a d m i n i s t r a t i v e c o n t r o l . O r g a n i z a t i o n a l d e c i s i o n s were made on the basis of s t a t i s t i c s worked up i n the u n i t s and fed i n t o the c e n t r a l decision-making core. Choices - 61 -among a l t e r n a t i v e s were based on economic considerations since profit-making was the goal of t h i s o r g a n i z a t i o n . In the i n t e r e s t s of e f f i c i e n t management, t h i s i n d u s t r i a l method i s being implemented i n h o s p i t a l s i n s p i t e of d i f f i c u l t i e s , already described, with decision-making about h e a l t h matters due to lack of authentic i n d i c a t o r s of healthy outcomes of health care s e r v i c e s . Nurses see the new management methods as o f f e r i n g them more independence of a c t i o n . Monaghan suggests that greater programming and s p e c i a l i z a t i o n w i l l make i t p o s s i b l e f o r h o s p i t a l s to dispense with nurses at the super-v i s o r y l e v e l , and the c l u s t e r i n g of several u n i t s w i l l e l i m i n a t e many head nurses; t h i s w i l l s a t i s f y the "healthy d r i v e f o r greater r e s p o n s i b i l i t y by general s t a f f nurses" (CN 71:9,22). Another nurse, w r i t i n g i n Dimens ions describes the e f f e c t s of management methods which remove d i r e c t s u p e r v i s i o n from nursing u n i t s as a way to "arrange the release of as much nurse power as p o s s i b l e (Dimensions 52:8,14), and reminds her readers that i n the north (of Canada) nurses have more r e s p o n s i b i l i t y than they are allowed i n southern h o s p i t a l s . What these nurses are not attending to i s the increase of c o n t r o l which w i l l be based on information systems, the production and processing of which w i l l r e quire nursing time and change nursing a c t i v i t i e s . In General Motors, d i s c r e t i o n over any matters of major concern was removed from the u n i t s . Carruthers, w r i t i n g about the changing r o l e of the c h i e f - 62 -executive o f f i c e r of the h o s p i t a l (HAC 16:8,57-61) says that the best way t o i a l l o w the management more freedom to manage i s to change the s t r u c t u r e of the o r g a n i z a t i o n . He points out that o v e r - c e n t r a l i z a t i o n prevents the development of the concept of h o l d i n g l i n e - e x e c u t i v e s responsible f o r i n d i v i d u a l opera-t i o n s . This s t r a t e g y i s one which tightens c o n t r o l over work-groups by making t h e i r immediate superior accountable f o r a c t i v -i t i e s i n that area. I t also provides the b a s i s f o r a demand by supervisory s t a f f f o r performance e v a l u a t i o n t o o l s . I f they are being r e q u i r e d to produce o b j e c t i v e evidence of t h e i r area's performance, they w i l l need to evaluate t h e i r s t a f f i n a manner which produces t h i s k i n d of data. P a t i e n t C l a s s i f i c a t i o n and S t a f f i n g Control The r a i s o n d'etre of p a t i e n t c l a s s i f i c a t i o n i s to lower s t a f f i n g c o s t s , by reducing the number of nurses doing the work (Dimensions 52:8,13). The d i r e c t o r of nursing s e r v i c e s at a h o s p i t a l which r e c e n t l y i n s t i t u t e d the method puts i t t h i s way: The nursing a d m i n i s t r a t o r who i s armed wit h f a c t s and f i g u r e s to support demands fo r s t a f f w i l l be i n a more favorable p o s i t i o n to achieve goals than the colleague who i s s t i l l r e l y i n g on experience and good judgment however r e a l needs may be. Although experience and judgment f o r the most part are r e l i a b l e , demands must nevertheless be supported by s t a t i s t i c a l proof. The question could always be asked "How do - 63 -you know you need more s t a f f ? Prove i t . " . . . I t was decided that s c i e n t i f i c proof was needed to s u b s t a n t i a t e demands f o r more nursing s t a f f . I t was also agreed that one of the answers might be more e f f i c i e n t u t i l i z a t i o n of a v a i l a b l e s t a f f . (Dimensions 53:5 ,36) An " o b j e c t i v e " method of c a t e g o r i z i n g p a t i e n t s according to t h e i r "nursing needs," which have been predetermined according to categories of acuteness, replaces nurses' judgment. Since the o b j e c t i v e method r e s u l t s i n fewer nurses being a l l o c a t e d to nursing u n i t s than nurses' judgment c a l l e d f o r -- a nurse's judgment i s biased not only by concern f o r p a t i e n t s , but by not wanting to work too hard h e r s e l f -- fewer nurses can be h i r e d , and savings e f f e c t e d . The system implemented i n one Ontario h o s p i t a l i s described i n d e t a i l i n Dimensions (53:3,39-44). I t s o r i g i n was i n research conducted by the U.S. Department of Health, Education and Welfare. S i m i l a r work c a r r i e d out by Canadian researchers i n Saskatoon provided the basis f o r implementation of systems of p a t i e n t c l a s s i f i c a t i o n i n other Canadian h o s p i t a l s . This i s how the Ontario system mentioned above works. Each day the head nurse on a ward checks an itemized l i s t of s p e c i f i c nursing needs f o r a l l p a t i e n t s on her ward. A pre - formulated accounting procedure provides a " p a t i e n t c l a s s i f i c a t i o n " f i g u r e from t h i s data. The f i g u r e i n d i c a t e s the a c u i t y of the p a t i e n t ' s - 64 -c o n d i t i o n and ranges from 1 to 4 (ambulatory to i n t e n s i v e c a r e ) . Each p a t i e n t c l a s s i f i c a t i o n f i g u r e c a r r i e s a "work load c o e f f i c i e n t " by which the ward's t o t a l work load i s determined; t h i s i s done by m u l t i p l y i n g the numbers of p a t i e n t s i n that c l a s s i f i c a t i o n by the work load c o e f f i c i e n t and adding the r e s u l t s . Another mathematical computation provides the "work load index" -- wi t h Type 2 being the standard p a t i e n t , the t o t a l work load f i g u r e i s transformed i n t o a s t a t i s t i c representing the equivalent number of Type 2 p a t i e n t s on the ward. The work load index i s then d i v i d e d by the ward census to generate a f i g u r e d e s c r i b i n g the average d i f f i c u l t y of a group of p a t i e n t s -- the "mix index," which i s used to determine recommended number of s t a f f and the p r o f e s s i o n a l to a u x i l i a r y s t a f f r a t i o . I t i s pointed out by the manager who described t h i s procedure that the recommended s t a f f i s not always a v a i l a b l e f o r reasons of shortage of personnel or funds. The advantage of the c l a s s i -f i c a t i o n and a l l o c a t i o n system i s i n r i d d i n g the s t a f f i n g o f f i c e of emotion and rancor when shortages are f e l t on the wards. He stre s s e d that a l l wards are tr e a t e d a l i k e and that documented evidence i s provided by the system to demonstrate that an i n d i v i d u a l head nurse seeking a d d i t i o n a l s t a f f cannot i n f l u e n c e the a l l o c a t i o n of s t a f f by being persuasive. Another advantage i s seen i n using p r o f e s s i o n a l s t a f f " a p p r o p r i a t e l y , " i . e . the s t a f f mix a l l o c a t e s p r o f e s s i o n a l workers to the s i c k e s t - 65 -p a t i e n t s . Most advantageous i s the reduction of permanent s t a f f made p o s s i b l e by maintaining minimum s t a f f coverage of the wards and supplementing an over-burdened s t a f f with nurses p u l l e d from other l e s s busy wards, or w i t h part-time workers. These new management methods are accompanied by p r o p a g a n d i s t s explanations of how i t w i l l c o r r e c t some problem of long-standing concern to nurses. P a t i e n t c l a s s i f i c a t i o n , although c l e a r l y a method f o r i n c r e a s i n g a nurse's workload, i s no exception. The nursing s e r v i c e s d i r e c t o r quoted above describes t h i s process at her h o s p i t a l : P r e p a r a t i o n of the nursing s t a f f was the v i t a l l i n k to success. Long before (the system was implemented) the s t a f f was made aware...that they would have an opportunity to p a r t i c i p a t e i n deciding s t a f f i n g needs through c l a s s i f i c a t i o n of p a t i e n t s , as w e l l as having an opportunity to provide input f o r s t a f f scheduling i n an e f f o r t to accommodate t h e i r i n d i v i d u a l l i f e s t y l e s . (page 37) This account glosses over the devaluing of nursing judgment inv o l v e d and misrepresents the a c t u a l intended outcome. When " p r e f e r e n t i a l scheduling" i n t h i s h o s p i t a l was u n s a t i s f a c t o r y to twenty percent of the s t a f f , the explanation i s given that negotiated changes i n the employment c o n t r a c t created problems - 66 -to which the system could not adapt. The a c t u a l changes i n s t a f f i n g which accounted f o r nurses having"more preference i n s h i f t s and days o f f must be seen i n yet another (negative.) l i g h t : the new s t a f f i n g system r e l i e s on a supplementary work force of part-time nurses who are presumably f o r f e i t i n g f u l l -time employee b e n e f i t s . This s t a f f i n g system depends upon the a v a i l a b i l i t y of a competitive pool of under-employed nurses. Reduction's i n s t a f f mean l e s s time a v a i l a b l e per p a t i e n t f o r nursing care. Reductions i n p r o f e s s i o n a l s t a f f mean that these nurses w i l l be spending t h e i r time with p a t i e n t s i n t h e i r most acute phase of i l l n e s s and t h e i r contact with convalescing p a t i e n t s or those l e s s acutely i l l w i l l be replaced by care provided by nurses' aids or p r a c t i c a l nurses. The care given by l e s s h i g h l y t r a i n e d workers w i l l r e f l e c t t h e i r t r a i n i n g and t h i s poses a problem of q u a l i t y c o n t r o l . H o s p i t a l and nursing l i t e r a t u r e i s f i l l e d with examples of " o b j e c t i v e " q u a l i t y c o n t r o l measures and d i s c u s s i o n of t h e i r a p p l i c a t i o n to nursing p r a c t i c e . This i s a r e l a t i v e l y new concern f o r nurses who have p r e v i o u s l y r e l i e d on i n d i v i d u a l l y i n t e r n a l i z e d p r o f e s s i o n a l standards. .There are two threads of o b j e c t i v e q u a l i t y c o n t r o l , both derived from i n d u s t r i a l s c i e n t i f i c management: Work An a l y s i s and Performance E v a l u a t i o n . Work A n a l y s i s attempts to t r a n s f e r to management the c o n t r o l over the knowledge of the work process. Performance E v a l u a t i o n uses that knowledge to c o n t r o l workers. - 67 -Work A n a l y s i s and Performance E v a l u a t i o n The a n a l y s i s of nursing work i s deterred by the indeterminacy of technique employed by p r o f e s s i o n a l nurses. References to nursing job d e s c r i p t i o n s do appear i n both the h o s p i t a l admin-i s t r a t i o n and nursing j o u r n a l s , however. I t i s important i n assessing the e f f e c t s of i n d u s t r i a l management technologies on nursing to note how they are adapted to work areas f o r which they seem so unsuited, and what claims are made f o r t h e i r use. An a r t i c l e p ublished i n HAC (18:12,26-28) describes a manage-ment development program i n an Ontario h o s p i t a l i n which job d e s c r i p t i o n s and performance evaluations were p a r t of the performance a p p r a i s a l which s u p p l i e d supervisors with informa-t i o n on which to take i n i t i a t i v e s towards p r o d u c t i v i t y , e f f i c i e n c y and cost-containment. The o b j e c t i v e of the program was to educate supervisors regarding these management methods and to e l i c i t t h e i r a c t i v e p a r t i c i p a t i o n i n implementing them. F i r s t , the h o s p i t a l sponsored a ten week management course f o r i t s supervisors at a l o c a l community c o l l e g e ; t h i s course included human r e l a t i o n s , behavioural sciences, management by o b j e c t i v e s , and performance e v a l u a t i o n t o p i c s . Then workshops were held at the h o s p i t a l on the use of job d e s c r i p t i o n s , a f t e r which the supervisors were i n s t r u c t e d how to work wi t h t h e i r s t a f f to c o l l e c t d e t a i l e d d e s c r i p t i o n s of t h e i r work a c t i v i -t i e s . In Phase I I of the h o s p i t a l program, workshops were arranged f o r supervisors to study performance e v a l u a t i o n and - 68 -p r o d u c t i v i t y , and be t r a i n e d i n the use of the performance ev a l u a t i o n t o o l which had been worked up by management. Super-v i s o r s were then expected to have reg u l a r interviews with t h e i r s t a f f about t h e i r job, i t s content and management's expecta-tions of the worker. When problems were i d e n t i f i e d with i n d i v i d u a l workers, interviews would be more frequent. To keep the worker's a t t e n t i o n on the performance expectations f o r her job, her personnel f i l e w ith job d e s c r i p t i o n and current p e r f o r -mance a p p r a i s a l was made a v a i l a b l e to both her and her super-v i s o r at a l l times. This use of work a n a l y s i s to produce information by which a nurse's a c t u a l performance i s "appraised" i s a method f o r applying p s y c h o l o g i c a l pressure to step up a c t i v i t y rates or to encourage conformity to procedures. This i s s t i l l r a t her loose c o n t r o l , r e l y i n g as i t does on observations made sporadi-c a l l y or even on s e l f - r e p o r t s of employees. The human r e l a t i o n s techniques, c o u n s e l l i n g i n t e r v i e w s , e t c . , can be used to r e i n -force the " p r o f e s s i o n a l ideology" which nurses f r e q u e n t l y have i n t e r n a l i z e d -- that they should manage somehow to take care of a l l the p a t i e n t s ' needs, whatever the p r a c t i c a l c o n d i t i o n s i n which they work. These management techniques l a r g e l y r e l y on persuasion buttressed by the a u t h o r i t y of the o r g a n i z a t i o n . More s o p h i s t i c a t e d use of work a n a l y s i s f o r designing work processes which themselves d i r e c t and c o n t r o l nursing a c t i v i t y - 69 -have been widely discussed i n American and Canadian h o s p i t a l and nursing l i t e r a t u r e . These range from attempts to measure output with time s t u d i e s , to s t r e a m l i n i n g nursing a c t i v i t i e s by the use of disposable equipment, to r e s e r v i n g nurses f o r s p e c i f i c a l l y nursing tasks, e.g. new job categories have been created to do c l e r i c a l aspects of nursing work; pre-prepared medication dosages reduce nursing time spent i n g i v i n g medica-t i o n s . Many p r e v i o u s l y time-consuming and e s s e n t i a l nursing functions have been incorporated i n t o machine c a p a b i l i t y . These machines f o r treatment, measurement and monitoring p a t i e n t s ' p h y s i o l o g i c a l f u n c t i o n i n g require tending, which s t r u c t u r e s nursing time and a c t i v i t i e s . Computer programs to " a s s i s t the nursing process" by prompting nurses to gather the c o r r e c t data (NR 24:4,299-305) are being researched. An approach to nursing care c a l l e d "problem-o r i e n t e d " i s a r t i c u l a t e d to a s t r u c t u r e d method of data-c o l l e c t i o n and recording. The method, ; designed by a doctor, f a c i l i t a t e s monitoring the care provided and i s seen as a way of overcoming " r e l i a n c e on spoken communication and memory" of h e a l t h care workers (AJN 73:1169'). A l l workers involved with the p a t i e n t do so on the basis of the information compiled i n a composite "data-base;" the p a t i e n t ' s chart i s organized on the basis of the p a t i e n t ' s problems rather than the source of. data about them, such as the r a d i o l o g i s t ' s , p a t h o l o g i s t ' s or nurse's comments. This system has been c r i t i c i z e d by nurses - 70 -who fear that "important areas of p a t i e n t care w i l l be neglected unless nursing maintains i t s own c o n t r i b u t i o n i n the form of h e a l t h o b j e c t i v e s developed with the person and his f a m i l y and based on nursing assessment and p r i o r i t i e s " (AJN 76:585). The "problem-oriented" approach to medical and nursing p r a c t i c e has many concealed drawbacks f o r nurses. Not the l e a s t of these i s that any method which attempts to l o g i c a l l y s t r u c t u r e and systematize the c o n c e p t u a l i z a t i o n of how nursing care should be done f a l l s i n t o the trap of t r e a t i n g as determinate work processes which are not. Ca r e f u l performance e v a l u a t i o n and accounting procedures based on documentation of these predetermined a c t i v i t i e s do not therefore provide information about q u a l i t y of care, as i s claimed f o r the problem-oriented record system. A l l c o n t r o l technologies implemented i n nursing work process depend f o r t h e i r success upon management c o n t r o l of the know-ledge of what c o n s t i t u t e s s u c c e s s f u l nursing care. Much of the research on nursing care which i s d i r e c t e d towards " q u a l i t y of care" c o n s i s t s of observation and attempts at c a t e g o r i z a t i o n of su c c e s s f u l nursing care. One such study i s b r i e f l y o u t l i n e d i n a News item i n The Canadian Nurse which reports a " b r i g h t future f o r nursing research" (CN 72:1,6). V i v i e n Jenkinsen, a nursing systems a n a l y s t , developed a twenty-two item, s i n g l e page e v a l -u a t ion sheet by which the nursing.care given by one nurse to - 71 -one p a t i e n t could be evaluated by an observer. What i s being evaluated i s the q u a n t i t y of s p e c i f i c behaviours which are observed. What i s taken f o r granted i n t h i s k i n d of behaviourally-anchored r a t i n g procedures i s that what cannot be seen cannot be evaluated, and therefore i s not important (HAC 17:2,28). To the extent i t can be p r e c i s e l y defined, b e h a v i o u r a l l y , the nursing work process can be c o n t r o l l e d , and (given a d m i n i s t r a t i v e dominance i n h o s p i t a l s ) i s i n danger of being degraded. This k i n d of nursing research i s p r o v i d i n g management with the kind of information needed f o r e s t a b l i s h i n g nursing work designs where work i s broken down i n t o components which can be performed by the cheapest labour and monitored by management. Non-professional nurses are not prepared, t e c h n i -c a l l y or s o c i a l l y , to c r i t i c i z e and modify programs of nursing a c t i v i t i e s which they are given as guides to t h e i r p r a c t i c e ; t h i s i s how nursing care to p a t i e n t s can s u f f e r . The r e l a t i o n -ship between e v a l u a t i o n procedures and e f f i c i e n c y measures i s more c l e a r l y drawn i n an a r t i c l e by Barbara Redman i n The  Canadian Nurse (71:2,19-21). In order to c o n t r o l p o l i c y d e c i s i o n s , nursing work i s subjected to c o s t - b e n e f i t a n a l y s i s . Nursing p r a c t i c e must adapt to f a c i l i t a t e these management p r a c t i c e s . C o st-benefit a n a l y s i s requires documentation of q u a n t i t i e s of nursing i n t e r v e n t i o n s made and they must be able to be added up to a f i n a l goal representing improvement. The problem of healthy outcomes of nursing care presents great d i f f i c u l t i e s f o r measurement, so Redman has defined "process - 72 -c r i t e r i a " f o r a s p e c i f i c area of nursing p r a c t i c e -- p a t i e n t education, to be used as i n d i c a t o r s of good nursing care. These are the s p e c i f i c nursing tasks she o u t l i n e d : 1. document the need f o r teaching, 2. develop p r i o r i t y system f o r meeting needs, 3. teach the p a t i e n t or r e l a t i v e s about medications or treatment; give enough information to ensure s a f e t y , 4. teach s e l f - c a r e procedures s u f f i c i e n t to ensure s a f e t y , 5. demonstrate teaching s k i l l s , knowledge of teaching methods, e v a l u a t i o n techniques. Using t h i s model, nurses would l e a r n p r e c i s e steps l a i d out by nursing planners, and how to apply them i n s p e c i f i c s i t u a t i o n s . , Eva l u a t i o n of t h e i r i n d i v i d u a l performance and of the program of which they were part would be on the basis of documentation -- how w e l l i t r e l a t e d to the optimal c r i t e r i a ; i . e . how many such tasks done, and how much expenditure made. The question s t i l l remains: are the technologies implemented to show cost r e l a t i o n s h i p s a l s o going to demonstrate " q u a l i t y of care?" Frequently, the d i s t i n c t i o n between e v a l u a t i o n of good care and e v a l u a t i o n of economical care i s not made. The f o l l o w i n g excerpt from a News item (CN 72:7,9) shows the b l u r - , r i n g which occurs i n c o n c e p t u a l i z i n g what i s being measured. The item i s e n t i t l e d , " Q u a l i t y Assurance Program to Get Underway i n B.C.": - 73 -a system intended to evaluate nursing perform-ance (process), r e s u l t s of care (outcome), and agency resources ( s t r u c t u r e ) simultaneously uses w r i t t e n , r a t i f i e d standards (of c a r e ) , [and] i t also i n i t i a t e s a c t i o n to maintain or improve d e s i r a b l e standards of c a r e . . . I t w i l l o f f e r numerous advantages i n c l u d i n g : c l a r i f i -c a t i o n of job d e s c r i p t i o n s , d i r e c t i o n of nursing p r a c t i c e , increased job s a t i s f a c t i o n . . . This kind of o b j e c t i v e e v a l u a t i o n of nursing care r e l i e s on a new category of nurse expert to provide an e s s e n t i a l c o n sulta t i v e f u n c t i o n -- q u a l i t y c o n t r o l agent i n the task s p e c i f i c a -t i o n f u n c t i o n and trouble-shooter i n c l i n i c a l p r a c t i c e . These nurse experts add the p r o f e s s i o n a l judgment i n g r e d i e n t which i s being excluded from the work process by i n d u s t r i a l management technologies. I f work i s s p e c i f i e d , "standards r a t i f i e d " by experts, and t i g h t performance evaluations c a r r i out, nursing care can be purchased much more cheaply from workers who have l e s s t r a i n i n g . Nursing Audit As long as p r o f e s s i o n a l judgment remains s u b j e c t i v e and the e x c l u s i v e property of s p e c i a l groups of workers, the h e a l t h care system i s dependent upon these people f o r the knowledge they c o n t r o l . Doctors are the group who most c l e a r l y belong i n t h i s powerful p o s i t i o n . Nurses' knowledge i s l e s s s p e c i a l i z e d and therefore nurses are more vulnerable to managerial c o n t r o l , as has been shown. Both doctors and nurses c l a i m the c a p a b i l i t y and the r i g h t to determine what i s adequate - 74 -se r v i c e f o r them to provide. Administrators must in v o l v e them-selves i n that determination i f they are to s u c c e s s f u l l y r a t i o n a l i z e and c e n t r a l i z e the c o n t r o l of decision-making i n h o s p i t a l s . Both medical and nursing p r a c t i c e i s being s c r u t i n -i z e d by management accounting procedures aimed at greater a d m i n i s t r a t i v e c o n t r o l (HAC 17:2,36-38). H o s p i t a l record-keeping i s being converted to a standardized format, and a standardized medical nomenclature has been developed. The "problem-oriented" record system (AJN 73: 1168-1171) o f f e r s a method f o r c o n c e p t u a l i z i n g the p a t i e n t / nurse contact as a s e r i e s of problems to be i d e n t i f i e d , attended to and charted i n a p r e c i s e and standardized way. The method f a c i l i t a t e s computer-processing of data from medical records. Nursing audit i s a management p r a c t i c e by which r e t r o s p e c t i v e s c r u t i n y of nursing care i s c a r r i e d out. Using predetermined " i n d i c a t o r s , " p a t i e n t s ' records are searched f o r evidence of the c o r r e c t nursing i n t e r v e n t i o n s which have been documented i n the normal course of nursing p r a c t i c e . Just as Redman (previous s e c t i o n , t h i s chapter) o u t l i n e d "process c r i t e r i a " f o r p a t i e n t education, o b j e c t i v e c r i t e r i a can be s p e c i f i e d f o r any category of p a t i e n t care. The same c r i t i c i s m s apply: i t i s evident that a convincing nursing regimen could be worked up and implemented which would have l i t t l e to do w i t h the p a t i e n t ' s s u b j e c t i v e c o n d i t i o n , understandings, or expecta-- 75 -t i o n s . A system which emphasizes documentation would there-fore r e i n f o r c e a tendency toward goal displacement i n nursing care. Objective c r i t e r i a are at present determined by "experts" who i d e n t i f y by various means what i s proper and re q u i r e d t r e a t -ment f o r a p a r t i c u l a r h e a l t h problem. Then manually or by computer, the records are searched to see how c l o s e l y the care provided (or at l e a s t , documented) adheres to the c r i t e r i a f o r that category of problem. As the t r a n s l a t i o n of nursing p r a c t i c e s i n t o task l i s t s based on o b j e c t i v e c r i t e r i a i s completed, h e a l t h p r o f e s s i o n a l s w i l l not be needed i n the jobs which mediate between management and nurses. New ad d i t i o n s or mod i f i c a t i o n s to the e x i s t i n g programs w i l l be able to be made i n one c e n t r a l l o c a t i o n and fed out to u n i t s a u t o m a t i c a l l y . This p r o j e c t i o n i n t o the future assumes that the S c i e n t i f i c Management concept -- monopoly over the knowledge of the work, a f f o r d i n g management c o n t r o l over the work process, can be used on the indeterminate technique of he a l t h care. This i s the assumption upon which the a p p l i c a t i o n of systems theory to h e a l t h care r e s t s . I l l REPERCUSSIONS OF NEW MANAGEMENT METHODS IN NURSING EDUCATION  Obsolescence and Continuing Education Concern about obsolescence of nursing p r a c t i t i o n e r s i s l i n k e d - 76 -w i t h i n t e n s i f i e d d i s c u s s i o n and planning of programs of conti n u i n g nursing education. What educators do not attend to i n t h e i r d i s c u s s i o n s of the need f o r c o n t i n u i n g education f o r nurses i s the o r i g i n of that need i n the o r g a n i z a t i o n of work which i s being imposed on nurses. Monaghan, a nurse with t r a i n i n g i n H o s p i t a l A d m i n i s t r a t i o n , makes t h i s connection e x p l i c i t . The h e a l t h s e r v i c e i s . . . r a p i d l y changing i n the content of jobs and i n the working methods that i t demands. This r a i s e s f o r nursing personnel the spectre of t e c h n o l o g i c a l obso-lescence, formerly a concern of i n d u s t r i a l workers only. (CN 71:9,21) Educators are being c a l l e d on to prepare nurses to perform new r o l e s and to support nurses while they make moves which require major p s y c h o l o g i c a l wrenches. P r e v i o u s l y discussed was the move of nurses to managerial r o l e s where they need to develop new "mental" s k i l l s , and replace t r a d i t i o n a l b e l i e f s with new management ideology (Hamilton C i v i c H o s p i t a l s program). A l a r g e r group of nurses have to adopt work methods and a t t i t u d e s j u s t as f o r e i g n to t r a d i t i o n a l l y t r a i n e d nurses -- and not so m a t e r i a l l y rewarding. These nurses are being moved from a p r o f e s s i o n a l l e v e l of f u n c t i o n i n g to a t e c h n i c a l employee l e v e l . F l a h e r t y addresses t h i s issue but does not c l a r i f y i t . She r e l a t e s obsolescence i n nursing r o l e s to nurses' poor prepara-t i o n f o r and lack of commitment to " p r o f e s s i o n a l i s m . " She - 77 -suggests c o n t i n u i n g education as a way of g e t t i n g more c o n t r o l over t h e i r own p r a c t i c e : As long as nurses remain unprepared to use t h e i r own p r o f e s s i o n a l e x p e r t i s e i n the ev a l u a t i o n of nursing p r a c t i c e through peer review they w i l l not be masters of t h e i r own d e s t i n i e s , and nursing w i l l not be a profes-s i o n . (CN 71:7,21) What F l a h e r t y does not recognize i s that e v a l u a t i o n of nursing performance by nurses using the management methods described here does not c o n s t i t u t e " p r o f e s s i o n a l peer review," and i s s p e c i f i c a l l y r e l a t e d to reducing nursing autonomy. The new l e v e l s of t e c h n i c a l f u n c t i o n i n g r e q u i r e nurses to f o l l o w p r e s c r i b e d work methods ra t h e r than make independent choices from t h e i r a p p r a i s a l of p a t i e n t s and s i t u a t i o n s . H arrison has observed that these new requirements create d i f f i c u l t i e s f o r nurses who do not understand or appreciate a new system which w i l l make them work harder as s t a f f s are reduced (CN 71:7,15). Basic Nursing Education The v u l n e r a b i l i t y of nurses to changes i n management p r a c t i c e s and p o l i c y has been demonstrated r e c e n t l y by the l o s s of jobs f o r nurses which r e s u l t e d from economic r e s t r a i n t s i n he a l t h care spending, e s p e c i a l l y i n Ontario i n 1976. R e t r o s p e c t i v e l y , i t i s seen as poor planning, w i t h too many nurses being produced. An e d i t o r i a l i n The Canadian Nurse points out the complexity of the problem of attempting to match supply and - 78 -demand of p r o f e s s i o n a l and s k i l l e d manpower (CN 73:1,2). C e r t a i n l y nurses have concerns about t h e i r educational programs which c o n f l i c t w i t h i n t e r e s t s of other members of the h e a l t h care d e l i v e r y system, and programs which are developed to prepare nurses w i l l r e f l e c t the dominant ideas. Presented below i s one example of a nursing education program which would seem to be responding to requirements f o r a l e s s h i g h l y s k i l l e d and cheaper labour force to replace t r a d i t i o n a l l y t r a i n e d r e g i s t e r e d nurses. Nursing educators have been concerned about the "dead-end" character of n u r s i n g jobs and education f o r those jobs. A t t e n t i o n has been pai d to developing new programs which permit v e r t i c a l m o b i l i t y by al l o w i n g a worker to b u i l d on her i n i t i a l education. This i s the "ladder concept" i n nursing education. A program at Humber College of A p p l i e d Arts and Technology i n Toronto has i n t e g r a t e d core courses f o r nursing a s s i s t a n t s and diploma nursing students (CN 71:1,20-22). The f i r s t semester i s taken together; then separation i n t o the two streams i s made. I t was recognized that most of the students i n both the programs wanted to become R.N.'s although only the diploma stream would be q u a l i f i e d f o r t h i s s t a t u s . The diploma program's entrance requirements were i n i t i a l l y r e s t r i c t i v e , but students i n the nursing a s s i s t a n t program had a s p i r a t i o n s to move up the ladder on the bas i s of good work. However, more diploma students were t r a n s f e r r e d down than nursing - 79 -a s s i s t a n t students moved up. Another i n t e r e s t i n g aspect of t h i s program i s seen i n the production of ideas about the r e s p e c t i v e r o l e s appropriate f o r graduates of the courses. I t i s noted that by the end of the second semester, most students perceived the r e g i s t e r e d nurse as the person responsible f o r the administra-t i v e side of nursing and f o r medications... and as the team-leader (who)... supervises the R.N.A.'s. Most (of the students) perceived the nursing a s s i s t a n t as the bedside nurse (p. 21). What i s being seen i s the adjustment of educational programs to f i t the requirements of the mental/manual s p l i t i n worker f u n c t i o n s . Just where that s p l i t w i l l occur i n the nursing h i e r a r c h y i s not r e a d i l y apparent i n Canada, although p o l i c i e s about t h i s issue are being defined now i n the U.S.A. By 1885, a l l r e g i s t e r e d nurses ( p r o f e s s i o n a l l e v e l ) i n New York State are r e q u i r e d to have baccalaureate p r e p a r a t i o n (American  Journal of Nursing 75:12,2141). Alb e r t a ' s p r o f e s s i o n a l a s s o c i a t i o n has followed t h i s lead by announcing support f o r a p o l i c y to be e f f e c t i v e i n 1990, r e q u i r i n g u n i v e r s i t y education of a l l A l b e r t a nursing students seeking r e g i s t r a t i o n (CN 72: 80 -9,11). A l e t t e r to the e d i t o r of The Canadian Nurse suggests that the o f f i c i a l voice of the Canadian Nurses' A s s o c i a t i o n i s already i d e n t i f y i n g the concerns of the upper echelon group as i t s concerns. "More and more your magazine i s f i l l e d w ith a r t i c l e s that cater to B.N.'s and i n s t r u c t o r s i n every l e v e l of education i n nursing. You are missing most of your readers. What about h o s p i t a l - t r a i n e d nurses who are slogging away i n miserable r o u t i n e s ? " (CN 71:3, 7) . IV NURSING ADMINISTRATION/MANAGEMENT ADJUSTMENT TO THE NEW MANAGEMENT METHODS The s h i f t i n philosophy at the highest l e v e l s i n h e a l t h care, and the o p e r a t i o n a l d e c i s i o n s a r i s i n g from the new p o l i c y create r e a l problems f o r nurse-administrators who are account-able f o r the operation of a ward or department. Fernande H a r r i s o n , a Canadian Nurses' A s s o c i a t i o n member-at-large f o r nursing a d m i n i s t r a t i o n a r t i c u l a t e d the problem: The nursing s e r v i c e a d m i n i s t r a t o r i s conscious of the immediate need f o r the h o s p i t a l to become part of an i n t e g r a t e d , r a t i o n a l , r e g i o n a l system of h e a l t h care...This system w i l l r e q u i r e more e f f e c t i v e use of h o s p i t a l s t a f f , e s p e c i a l l y nurses. (CN 71:7,15) 81 She sets the problem w i t h i n the context of current nursing p r a c t i c e and points out the c o n t r a d i c t i o n between the nursing a d m i n i s t r a t o r ' s p o s i t i o n and a generation of nurses who have come to • understand the s c i e n t i f i c and p h i l o s o p h i c a l basis f o r nursing act ion...(and) have been taught to recognize t h e i r worth as i n d i v i d u a l s and p r o f e s s i o n a l s , and (who) want to use t h i s knowledge to f i l l the gap they see i n the e x i s t i n g h e a l t h care system. (CN 71:7,15) Harrison discusses the problem she sees as i f i t were one of mutually e x c l u s i v e aims: of nurses -- to provide b e t t e r i n d i v i d u a l care, and of the nursing a d m i n i s t r a t o r who must uphold the "more e f f e c t i v e " use of nurses i n the r a t i o n a l system. A few months l a t e r , H arrison provides a s o l u t i o n to the "challenge" of g e t t i n g nurses to r e t h i n k the philosophy and ob j e c t i v e s of resource a l l o c a t i o n which i s threatening t h e i r jobs. By now she i s convinced that using a systems approach i s the only way f o r h o s p i t a l s to survive and that the r a t i o n -a l i t y of the approach i s s e l f - e v i d e n t and convincing. She says : Given that f a i r d e c i s i o n s can only be made on the basis of up-to-date and r e l i a b l e data, a c t i v i t i e s w i l l be geared to upgrade the information base...The i n t r o d u c t i o n of - 82 -improved information systems to achieve superior management de c i s i o n s might be termed...a very s i m p l i s t i c ... approach... (but) s u r v i v a l depends upon j u s t t h i s type of n a t u r a l a c t i o n . (CN 72:3,19) An a r t i c l e c a l l e d "A P s y c h o l o g i c a l Contract of S e r v i c e " by John Runyan, a systems analyst and management analyst (CN 70: 9,19-23) addresses the problem of the middle manager, caught between executive d e c i s i o n s and worker r e a c t i o n s . The e d i t o r of The Canadian Nurse draws the p a r a l l e l between head-nurses and middle-managers i n her e d i t o r i a l i n t r o d u c t i o n to the a r t i c l e . Runyan acknowledges that being i n the middle i s d i f f i c u l t ; the aim of the a r t i c l e i s to help middle managers cope "and not r e b e l . " His suggestions are of the type Braverman c a l l e d myths -- used to habituate workers to bad work condi-t i o n s . Runyan c a l l s f o r "openness" from management about t h e i r aims, and f o r the c r e a t i o n of an environment i n which workers can be c r e a t i v e . At the same time he i s acknowledging the dilemma f o r workers of t e c h n o l o g i c a l change. His p l a t i t u d e s about freedom from fear and managing change and coping with s t r e s s are i n d i r e c t o p p o s i t i o n to h i s frank a p p r a i s a l of executive i n d i f f e r e n c e to what happens to workers as a r e s u l t of t h e i r p o l i c i e s . Harrison's dilemma of p a c i f y i n g u n d e r l i n g nurses who do not understand management de c i s i o n s must be seen i n t h i s context. The " p s y c h o l o g i c a l " approach which Runyan recommends to "stave - 83 -o f f r e v o l u t i o n " (p. 23) i s one to which nurses are e s p e c i a l l y v u l n e r a b l e . Their commitment of s e r v i c e to others has been used to j u s t i f y t h e i r e x p l o i t a t i o n f r e q u e n t l y , i n the past. Now the segmentation of nursing work i s c r e a t i n g new condi-tions of e x p l o i t a t i o n to which one group of nurses must l e a r n to habituate the other group. V EFFECTS ON THE NURSING LABOUR FORCE Occupational Changes Occupational changes are s p e c i f i c a l l y described by Monaghan, and a l l u d e d to f r e q u e n t l y by other w r i t e r s i n l e s s e x p l i c i t ways. Stinson suggests that the " k n o w l e d g e - s k i l l base of n u r s i n g " has changed (CN 71:8,17). Others r e f e r vaguely to the need f o r continuing education, as discussed i n a previous s e c t i o n . The i m p l i c a t i o n i s that the nurse's b a s i c prepara-t i o n was somehow fundamentally inadequate to prepare her f o r the complexities of modern-day nursing p r a c t i c e . What seems more accurate i s that nurses with t r a d i t i o n a l s k i l l s are no longer r e q u i r e d because l e s s h i g h l y t r a i n e d , cheaper workers are taking over t r a d i t i o n a l nursing jobs. Monaghan (CN 72: 12,40-1) shows that the number of R.N.A.'s r e g i s t e r e d i n Ontario has increased from 8,103 i n 1963 to 30,544 i n 1975, and suggests that a l l jobs not r e q u i r e d by law to be f i l l e d by R.N.'s are being f i l l e d by R.N.A.'s. 84 -An e d i t o r i a l i n CN shows the d i r e c t i o n of the change i n nurses' work. As budgets become t i g h t e r i t seems i n e v i t a b l e that the status nurses have worked so hard to achieve w i l l be i n c r e a s i n g l y threatened by inadequate s t a f f i n g patterns and that pressure w i l l be exerted on R.N.'s to delegate some of the r e s p o n s i b i l i t i e s t h e i r experience and education have prepared them to accept...The no t i o n that R.N.'s no longer have the time to provide the d i r e c t p a t i e n t care i n v o l v e d i n "bedside n u r s i n g " has become i n c r e a s i n g l y common among members of the general p u b l i c . (CN 72:5,4) I t seems c l e a r that the budgetary cutbacks i n the 1970's accel e r a t e d a trend already i n progress by then. F i s c a l problems are now used as j u s t i f i c a t i o n f o r i n t e n s i f y i n g e f f i c i e n c y methods. Unemployment Concern about nursing unemployment mounted i n 1976 and surveys of employment prospects i n d i f f e r e n t regions were reported i n The Canadian Nurse (72:5,10-11 and 73:1,10-11). Ontario was hardest h i t w i t h an estimated 10,000 nurses unemployed according to Ontario College of Nursing (CN 72:12,39). An employment se r v i c e set up by the Registered Nurses' A s s o c i a t i o n of Ontario counselled nurses to seek employment i n the U.S.A. Other s o l u t i o n s f o r unemployed and unemployable r e g i s t e r e d nurses have been suggested by d i f f e r e n t w r i t e r s i n CN. - 85 -Monaghan f e e l s that nurses must move to other occupations, and s p e c i f i c a l l y mentions that "capable and i n t e r e s t e d " nurses can b e t t e r t h e i r p o s i t i o n s by t r a i n i n g f o r new jobs i n data-processing and planning of h e a l t h care (CN 72:12,41). I t i s apparent that such t r a i n i n g i s not a v a i l a b l e to many, nor i s t h i s sector of h e a l t h care l i k e l y to absorb many nurses. Rather, what can be a n t i c i p a t e d f o r superfluous r e g i s t e r e d nurses i s continued narrowing of the s k i l l e d job market which w i l l force them i n t o l e s s s k i l l e d c a t e g o r i e s where they w i l l have to compete wi t h a l a r g e r group of workers. This w i l l have a depressing e f f e c t on wages and ev e n t u a l l y on q u a l i f i -c a tions f o r such work. 86 -CONCLUSION The development of modern management i n c a p i t a l i s t i n d u s t r y has been described i n p r e p a r a t i o n f o r c o n s i d e r a t i o n of the problems p e c u l i a r to managing h o s p i t a l s . The outcomes of i n d u s t r i a l management are i n d i c a t i v e of what can be expected when these methods are a p p l i e d elsewhere, as w e l l . Modern management methods are being a p p l i e d i n h o s p i t a l s to increase p r o d u c t i v i t y of workers. In a d d i t i o n , these methods increase the power of the a d m i n i s t r a t i o n to run h o s p i t a l s according to managerial philosophy, f u r t h e r c o n s o l i d a t i n g a d m i n i s t r a t i v e dominance. Braverman has shown that increased p r o d u c t i v i t y i n i n d u s t r y has occurred at the expense of workers and the product; the i m p l i c a t i o n s of such expenses i n the h e a l t h care i n d u s t r y are l e s s t o l e r a b l e due to the nature of the "product" of a human se r v i c e o r g a n i z a t i o n . Evidence of d i f f i c u l t i e s pending i n a ^ r a t i o n a l i z e d h e a l t h care system are already a v a i l a b l e and have been presented i n t h i s paper. The s k i l l s and knowledge of h e a l t h care workers must be d i v e r t e d to management c o n t r o l i n order t o ' r a t i o n a l i z e the work processes f o r e f f i c i e n c y . Management methods f o r accomplishing t h i s t r a n s f e r are i n d u s t r i a l technologies based on accounting - 87 -procedures which r e l a t e production outcomes to costs. Quanti-t a t i v e information c o l l e c t e d about p a t i e n t s and treatment i s not an adequate base f o r decision-making about h e a l t h care because i t does not adequately describe the phenomena invo l v e d . Nor does a pre-programmed work design, based on e x p l i c i t c r i t e r i a r e l a t e d to o b j e c t i v e e v a l u a t i o n and computation of c o s t s , represent adequate (nursing) care. M i s s i n g are the elements, not r e l a t e d to cost a n a l y s i s , which cannot be q u a n t i f i e d , and which d i f f e r e n t i a t e a human r e l a t i o n s h i p from a r e l a t i o n s h i p between things. Nursing i s f o l l o w i n g a p a t t e r n described by Braverman i n which work i s s p l i t i n t o mental and manual components; a small managerial e l i t e i s being created to c o n t r o l the knowledge v. which a l l nurses once shared. The work of management -- gaining c o n t r o l of the knowledge of the work processes, planning c o - o r d i n a t i o n of the work segments, monitoring the execution of preplanned tasks, motivating workers to co-operate i n a work process which has been removed from t h e i r c o n t r o l -- requires a labour force of s p e c i a l l y t r a i n e d workers. C u r r e n t l y , female nurses are being t r a i n e d f o r these jobs i n management. One wonders i f nursing w i l l f o l l o w the trend toward managerial p o s i t i o n s being reserved f o r men, with women being relegated to the lower s t a t u s , lower paid, lower r e s p o n s i b i l i t y human contact jobs, f o r which t h e i r sex makes them seem appropriate. - 88 -In i n d u s t r y , shoddy workmanship of d e s k i l l e d , a l i e n a t e d workers can be concealed by programs of planned obsolescence of the product, and a c t u a l l y c a p i t a l i z e d on f o r increased market revenue. This a l t e r n a t i v e i s not open i n the h e a l t h care industry.. The p u b l i c w i l l continue to demand and expect high q u a l i t y care which p r o f e s s i o n a l workers now have the e x p e r t i s e and commitment to provide. Management p r a c t i c e s have been described which t r a n s f e r that knowledge, however inadequately, i n t o " o b j e c t i v e forms" which can be c o n t r o l l e d by management. The pay o f f i s i n economies produced by replacement of profes-s i o n a l nurses by cheaper workers. Braverman argues i n Labor and Monopoly C a p i t a l "that the 'mode of production'..., the manner i n which labor processes are organized and c a r r i e d out, i s the product of the s o c i a l r e l a -tions we know as c a p i t a l i s m " (Braverman, p. 21); i t i s always i n f l u x , changing the r e l a t i o n s h i p of workers to t h e i r work and to each other, and a l t e r i n g s o c i e t y as i t has been known p r e v i o u s l y . This t h e s i s has examined the o r g a n i z a t i o n of nursing work i n h o s p i t a l s as i t i s being transformed by modern c a p i t a l i s t forms, and i t points to how these transformations are consequential. Nurses are seen to be standing i n d i f f e r i n g r e l a t i o n s h i p s to the means of t h e i r production. The question which i s r a i s e d , i n concluding, but not able to be d e a l t with i n the scope of t h i s work, concerns the i m p l i c a t i o n s of the segregation of the nursing labour force by modern management i n h o s p i t a l s . - 89 -The p r a c t i c e s which segregate the nursing labour force can be seen as c r e a t i n g a c l a s s d i v i s i o n i n nursing. Braverman points out that the complexity of the c l a s s s t r u c t u r e of modern monopoly c a p i t a l i s m a r i s e s from occupational s h i f t s by which almost a l l the population has been transformed i n t o employees of c a p i t a l (Braverman, p. 404). He recommends that evidence of a worker's c l a s s p o s i t i o n -- i n i n d u s t r y or i n n o n - p r o f i t o r g a n i z a t i o n s , i s now more c o r r e c t l y sought i n c a r e f u l examina-t i o n of the s o c i a l o r g a n i z a t i o n of h i s or her work which w i l l r e v e a l the worker's "true place i n the r e l a t i o n s of production" (Braverman, p. 407). Braverman suggests that mass occupations such as nursing are changing i n t h e i r c l a s s p o s i t i o n , t a k i n g on c h a r a c t e r i s t i c s of both the c a p i t a l i s t and the working c l a s s . The research on which t h i s t h e s i s i s based begins to accumulate evidence of what these changes are. I t has been shown that the s o c i a l o r g a n i z a t i o n of the h o s p i t a l r e s u l t s i n two segments i n the nursing labour force who work i n e n t i r e l y d i f f e r e n t ways. They are educated d i f f e r e n t l y and develop d i f f e r e n t r e l a t i o n s with other members of the o r g a n i z a t i o n . They begin to under-stand the p r i o r i t i e s of the h o s p i t a l d i f f e r e n t l y and develop d i f f e r e n t i n t e r e s t s which must be protected. What must be asked i s "what does p r o f e s s i o n a l i s m among nurses mean when the nurses who c o n s t i t u t e the p r o f e s s i o n are d i v i d e d i n t h i s way?" Such a d i v i s i o n d i s s i p a t e s nurses' p o t e n t i a l f o r c o l l e c t i v e a c t i o n both f o r making improvements i n t h e i r working c o n d i t i o n s and f o r agreeing on and pursuing p r o f e s s i o n a l goals. The d i r e c t r e l a t i o n s h i p between modern management p r a c t i c e s and the segre-- 90 -gation of the nursing labour force shows how the i n t r o d u c t i o n of modern management technologies i n t o h o s p i t a l s has changed the character of what has been known as the nursing p r o f e s s i o n . An i n c r e m e n t i a l l y negative e f f e c t on i n d i v i d u a l nurses, nursing p r a c t i c e and i n e v i t a b l y on p a t i e n t s i s foreseen. 91 -SOCIOLOGICAL REFERENCES CITED Braverman, Harry. Labor and Monopoly C a p i t a l . New York: Monthly Review Press, 1974. Campbell, Marie L. "A Proposal f o r S o c i o l o g i c a l E x p l i c a t i o n of the Nurse's Place: Towards Members' Understanding of Oppression i n t h e i r Work." Unpublished paper, given at "The Working Sexes Symposium," U n i v e r s i t y of B r i t i s h Columbia, 1976. C r o z i e r , Michael. The Bureaucratic Phenomenon. 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