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Effects on nursing and the nursing profession of the introduction of modern management technologies into hospitals

University of British Columbia

Articles from Canadian nursing and hospital administration journals were used to provide a picture of current developments in the management of hospitals, and in particular, of the management of nursing work. Using documentary data (from The Canadian Nurse, Dimensions in Health Services, and Hospital Administration in Canada, 1974-1977), the argument is made that the use of modern management technologies to control hospital work is inappropriate and likely to reduce the quality of care provided. Specifically, it is argued that as the work of nurses is subjected to management control and their discretion over their practice is lost, nurses' autonomy to exercise their professional judgment is destroyed. This deprofessionalization of nursing is consequential not only for nurses but for the quality of care they give patients, as well. Nurses' occupational position will be harmed as their skills become obsolete, replaced as the result of management practices designed to produce efficient hospital operation. These management practices will segment the nursing labour force into two groups, a managerial elite and a larger group of increasingly less-skilled, cheaper workers. The two segments will develop divergent interests and understandings as their experiences and conditions of work are separated. The argument is based on the work of Braverman (1974) who analysed the effects of industrial management on craft skills in modern capitalist industry. Braverman identified the objectives of management as monopolization of the knowledge required to make a product, in order to control that work process and thus to increase productivity, and profits. Some additional management problems must be confronted in transplanting modern management technologies from industry into hospitals. These are the result of two important differences between organizations run for profit and organizations run to provide service to humans. Management practices designed for the former do not necessarily, not probably provide adequate direction for the latter. When the organizational goal is not determinate, as is the case in health care, it cannot be determinately related to management practices. Similarly, when the work processes are not determinately related to the organizational goal, as nursing work is not, they cannot be determinately related to management practices. The use of modern management technologies in hospitals has yet another negative effect besides those described by Braverman as deskilling the worker and degrading the product: they harness the work process to economic ends which are not those the organization was set up to provide. In spite of this, an established trend towards the use of modern management technologies in hospitals is seen in Canada in the 1970's due to the dominance of administrators in hospital management (Perrow, 1961) . Modern management technologies are applied to nursing to increase productivity, that is, to get more work done at lower cost. They have similar effects on the nursing labour force to those described by Braverman. In addition, the inappropriateness of these methods for the control of human service organizations means that the more "successfully" they control hospital activity, the more risk of misapplication of hospital resources. Examples from the professional journals of management practices described or recommended for the control of nursing include: decentralized administration, (Unit Management); patient classification and objective staffing; work analysis and performance evaluation; nursing audit. Each provides a contribution to management objectives to control the work process and cheapen nursing labour. This increased management control of nursing work is a radical departure from the traditional situation of nursing in a hospital. In the past, however subordinate their position, nurses have been protected from interference in their practice by their strategic position at the "front-line" of the organization (Smith, 1966). This functional autonomy over their day-to-day interaction with patients has been the ground of nurses' professional practice, which management control destroys. In a health care system which relies on nurses to supply the individualization and humanization of increasingly impersonal care, the loss of autonomy to exercise professional discretion is a severe blow to quality care. The substitution of carefully managed nursing, detailed accounting procedures for provision of information on which management decisions about nursing can be made, and objective evaluation of nurses who increasingly will have neither the training nor the freedom to act with professional autonomy is not seen as an adequate trade-off for cost-cutting. The production of a segmented nursing labour force by the implementation of modern management technologies into hospitals is identified, tentatively, as a class division in nursing. The implications for the nursing profession of this class division are as follows: the concept of "professionalism" among nurses is called into question, and the conflicting interests between the classes reduce the potential of nurses for any collective action. In this way, the effect of modern management technologies is to change greatly the character of what has been known as "the nursing profession."

Text

2010-02-19

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http://hdl.handle.net/2429/20502

Sociology

University of British Columbia

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