THE TRANSITION FROM RRorassIoNALNURsEQ } .. f __
T0 RURSARR MANAGER: A CASE STUDY;
Thesis for the Degree of M. L. LR, A
MICHIGAN STATE umvmsm *
GERALD EDWARD CONNALLY
* 1959

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ABSTRACT

THE TRANSITION FROM PROFESSIONAL NURSE
TO NURSING MANAGER: A CASE STUDY

By
Gerald Edward Connally

The question of assimilation of the professional or
specialist into line management has been a consistent prob-
lem in the Hospital Industry since the advent of systematic
hospital administration. The specific problem has been how
to develop a solid Nursing Management, given the tendency of
persons in such positions to be specialists first and
managers second. This thesis, written on the basis of the
participant-observer technique, is a case study of the
attempt of one hospital to meet this problem.

The hospital under study hypothesized that a success-
ful transition could be made through the use of a well
designed management development program. The population
under examination was comprised of the fifteen middle
management members of the Nursing Management. The adminis-
tration of the hospital treated the strategy of change,
<3hange agents and change techniques to be the independent
‘Lariables,while the nature of nursing management was held
tzo be the dependent variable. They assumed that success
vvould be real to the extent that the desired change was

Seatisfactory in their perception as management.

Gerald Edward Connally

Selected members of upper management of the hospital
pre-tested and post-tested the study population in the
areas of administrative, supervisory, leadership, technical,
and human relations competency against pre-determined
success criteria. Based on a comparison of the two tests,
administration of the hospital concluded that the manage-
ment development program had been successful.

This thesis contains an examination of several aspects
of the planning, development and accomplishment of the

management development program as it occurred.

THE TRANSITION FROM PROFESSIONAL NURSE

TO NURSING MANAGER: A CASE STUDY

By

Gerald Edward Connally

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF LABOR AND INDUSTRIAL RELATIONS

School of Labor and Industrial Relations

1969

' 3

:~\‘\ ~ I.
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\

Copyright by
GERALD EDWARD CONNALLY
1969

To my kin and kindred in

recognition of an unrepayable debt.

iii

TABLE OF

DEDICATION.
LIST OF TABLES
LIST OF FIGURES
INTRODUCTION

Chapter

CONTENTS

I. ENVIRONMENTAL BACKGROUND

The Environment

Character of the New Administraiton.
Administrative Approach. . . . . .

II. THEORETICAL BACKGROUND . . . . . . .

Supervisory Population . . . . . .
Theoretical Framework

Success Criteria

Examination of the Framework

Hypothesis
Variables
Procedure

III. SUCCESS CRITERIA

The Success Criteria. . . . .

IV. THE TRANSITION PROGRAM . . . . .

Change Strategy, Agents, and

Techniques

The Management DevelOpment Program . .
Phase One: Basic Tools Acquisition.
Phase Two: Greater Understanding of

the Labor Force . . .

Phase Three:

Flexibility and Free-

dom of Action for
Supervision.

iv

Page
iii
vi

vii

ONU'IUL) LA)

11

ll
l6
l7
17
28

29
29
3O
3O

37

37
38
1H4

148

Chapter Page

V. MEASUREMENT OF CHANGE . . . . . . . 51
Method of Measurement . . . . . . 51

Data Sources . . . . . . . . . 53

Pre-Test and Post-Test Results . . . 55

VI. SUMMARY AND CONCLUSIONS. . . . . . . 58
Summary . . . . . . . . . . . 58
Conclusions. . . . . . . . . . 58
BIBLIOGRAPHY . . . . . . . . . . . . . 68

LIST OF FIGURES

Figure Page
1. Chart of the structure of upper management. . 7
2. Organization structure of the Nursing

Division prior to the transition program. . l3
3. Organization structure of the Nursing

Division at the onset of the transition

program. . . . . . . . . . . . . 14
A. Mechanism for final evaluation of compliance

with Success Criteria . . . . . . . . 36
5. Demonstration of the elements of basic

management responsibilities in terms of
Administrative, Staff and Department
function . . . . . . . . . AS

vi

LIST OF TABLES

Table
1. Characteristics of trainees. . . . .
2. Data sources utilized in evaluating

performance areas of the success criteria

3. Results of the pre-test and post-test of
compliance with the success criteria

vii

Page
15

54

56

INTRODUCTION

The basic problem under investigation in this thesis

is the integration of personnel traditionally thought of

as professionals into the management structure of a specific

hospital organization. The problem was carefully defined
by the Administration of the hospital, specific procedures
developed and carried out, and an overall evaluation was
made at the end of the process. It, therefore, became a
very interesting and revealing example of what has come to
be recognized as a critical study area in the field of
formal organization. The process of transition should be
of significant interest not only from an academic point

of view, but also from the highly pragmatic point of View
of those concerned not only with management education, but
also with labor force problems within similar types of in-
dustries. The author was priviledged to be present for
the entire duration of this study, and the thesis is
therefore written on the basis of the participant—observer
technique.

In the first chapter, the environmental background
will be explored. In Chapter II, the theoretical back-
ground for the Nursing Management Transition Program will
be examined in detail. The third chapter will set down the

success criteria set up for the transition program, and the

l

fourth chapter will describe the various aspects of that
program. In the fifth chapter the measurements taken to
determine change, and the results of these measurements
will be examined, and in the final chapter the summary

and conclusions will be stated.

CHAPTER I

ENVIRONMENTAL BACKGROUND

The Environment

 

Hospital X (as we shall refer to the hospital under
study) is a short-term, general, acute hospital of some
340 beds, inclusive of a psychiatric unit, servicing ap-
proximately 200,000 people from urban, suburban, and
rural areas in central Michigan. It was established in
the early part of this century by one of several Catholic
orders who specialize in the construction and administra-
tion of hospitals, educational facilities, and other
related institutional charitable activities, and is largely
managed and administered by Nuns.

Over the past two decades, several of these orders
have been experiencing a decline in sheer numbers of
religious personnel, combined with a recognition of the

rapid advancement of managerial technology.1 The order

 

lhnconversations withvarious members of the order
which Operated Hospital X, the author was repeatedly im-
pressed by statements to the effect that although the
order sent religious personnel to institutions of higher
learning for the express purpose of gaining greater
expertise, the sheer shortage of religious personnel was
bringing about a crisis in their order, as well as similar
orders. The crisis was described as a polarization of
opinion between the extremes of performing good works for

which operated Hospital X was of the opinion that the in-
troduction of Lay Administration would provide a solution
to the problem. Hospital X was one of several across the
country singled out by the church for an experiment in
Lay Administration.

At the time of the transition to Lay management which
occurred in 1964, the situation at Hospital X was grave. A
major survey had been performed by a well—known hospital
consultant firm predicting that the facility would become
specialized in extended care activities, thus removing it
from the category of general short-term acute.2 In late
196A, at the point of transition, the new Lay Administra-
tion was presented with a multiplicity of problems. The
financial picture was disastrous. Accounting mechanisms
were sorely lacking. Control of cash flow was non-existent.
Theft was chronic. The facility was badly understaffed,
and the staff was deemed by the Administration to be
sadly unqualified and generally deleterious to the function
of the organization. The labor force was severely underpaid.
Employee benefits were almost non-existent, and there was
no regulation of hours and conditions of work. In short,

the new administration categorized the environment as chaos.

 

individual human beings, on an intimate basis, and, per-
forming an aggregate good through the administration of
public service, removed in large part from individual
contact.

2The survey had been performed at the behest of
national level authorities within the order. Hospital X
'was not unique in the findings.

Medical staff disenchantment with the operation of the
facility and standards of care was well known. The

3

proverbial wolves were at the door.

Character of the New Administration

 

Lay Administration was brought to Hospital X with
the clear understanding that full managerial authority
would rest in the hands of lay personnel. Although a
"religious" was to remain as Administrator of the hospital,
her role was to be one of liaison with higher authorities
only, and a non-interference agreement was established.
From shortly after the administrative transition until the
conclusion of the study herein discussed there was, in
fact, only one working religious in the managerial struc-
ture, and she reported through the organization structure,
accountable for her actions in all respects, except convent
life.Ll Although present at most local advisory board
meetings, the "Administrator" remained fully supportive
of the new concept, expressing on behalf of her religious
superiors, complete recognition of the need for greater

expertise in the form of Lay Administration.

 

3Through various conversations with other hospital
administrative staff throughout the area and at national
levels, the author came to be of the opinion that the
situation of Hospital X was far from uncommon.

“Whereas this does not prove that the Catholic nature
of the institution had no effect, it is offered in illus-
tration of the point that no religious pressure was directly
felt by internal management. This subject will be dealt
with in more detail at a later point in the discussion.

The new administration, from the onset, was charac-
terized by a high degree of sophistication in the field
of administration, well-rounded graduate education, and a
dedication to progressive and innovative management. The
new administration held complete internal authority and
local autonomy. The nature of the terms of its existence
insulated any and all staff members from pressure exerted
by or policy emanating from the religious order.

Two additional points relating to structure must be
made at this Juncture. First, administration of the hos-
pital functioned directly under a regional authority which
was religious. That regional authority sat with a lay
and religious governing body. The local Advisory Board
was advisory in nature, representative of the community,
but without authority. Secondly, Hospital X was associ-
ated with a nursing school owned by the same religious
order, but corporately separate from the hospital. It
was controlled, however, through the mechanism of inter-
locking directorship. The relationship of the school to
this study is incidental. Figure l is a chart of the

structure of upper management.

Administrative Approach

 

Subsequent to the initial administrative assessment
of the situation, a priority list for program creation
and development was created. The first step was to bring

in a controller for the hospital. The criteria for his

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selection included that he not be heavily grounded in
current hospital industry practices.5 The object was to
introduce new knowledge and broad ability unencumbered by
the traditional hospital approaches to the financial
areas. The second priority item was to tighten up the
cohesiveness of the managerial staff. Thirdly, medical
staff relations were to be solidified, and, fourthly, the
pressing labor force problems were to be resolved. These
:steps were considered preliminary to a broad expansion of
tflne role and activity of the institution. Additionally,
ixt was felt that public relations would best be improved
b3; placing major stress on patient care and patient rela-
tijons. The new administration had inherited a bed census
average of about 80%. This average was subsequently main-
‘teuined throughout the duration of the study. Keeping that
cncczupancy rate was, naturally, a prime concern. Thus,
txaczhnology and facilities were prominent in the list of
c<>ricerns. Central to each of these areas was the problem
of’ the development of a solid Nursing Management within
the organization.
The initial two-year period was occupied by a three-

ft>lxi effort. First, financial problems were of great im-

IMDITtance. Second, master planning for facility maintenance

 

 

5This philosophy remained prevalent throughout recruit-
memrt for staff personnel in all instances where medical or
FNiIVi-medical knowledge was not a mandatory requirement for
.Jot; performance. The intent was to bring in knowledge from
fifields which could directly benefit hospital administration

Wiiihout carrying any traditional bias.

and update was a mandatory undertaking. Thirdly, a weeding
out process was carried out within the hospital labor force
at all levels.

According to the assessment of the new administration,
the nursing staff of Hospital X was a major problem area.
The staff inherited at the point of transition seems best
characterized as "provincial." The hospital at that point
was more of a collection of "private empires" ruled by
senior nurses than a cohesive organization. Boundary main-
tenance seemed to be the strongest single element in the
nature of Nursing Management, although according to the
initial assessment, the term "management" did not apply.

The weeding out process was a semi-violent force-out
of approximately 35% of the nursing staff. It occurred in
conjunction with the two previously stated initial concerns
over a two year period. Thus, at the point in 1966 when
the program for the establishment of Nursing Management
was undertaken, the staff functioned at a skeletal level.6

Nursing at Hospital X in 1966 was best described as
a major crisis area. Nursing moral was low due to the
startling rate of departure of a great many familiar faces.

Present staff felt insecure. Formal structure in Nursing

 

6No personnel statistics were kept at this time
which would enable an exact measurement of the nursing
exodus. However, an examination of past pay records showed
that the nursing staff primarily functioned at about 165
nurses. No Full—time Equivalent conversion is possible based
on the pay records; however, the author would estimate it at
about 146. Pay records also indicate that 57 nurses left
Hospital X during this period while only 13 joined the staff.

10

Management was non-existent. There were virtually no
routinely enforced personnel policies, and no major re-
cruiting activity had been initiated to counter the
shortage of staff. Pay levels were significantly below
industry and area level.7 No written policies existed
either establishing or dis-establishing any concept of
formal seniority. The weed—out process carried the im-
plication that no concept of tenure existed, and no
administrative explanations had been made for any actions
taken.

The time had come, however, in the overall approach
of the new administration, to shore up the nursing division,
to develop new and better organization in nursing manage-
ment, and to train personnel to accomplish a complete re—

vamping of the nursing function at Hospital X.

 

7In 196“ there was no wage administration program.
Records begin in late 19650 In 1966 the wage administra-
tion program was barely in its infancy. Pay records indi-
cate, however, that the average full—time nurse made about
$A900.00 in 1964. The community average at that time ap-
pears to have been about $5200. By 1966 the community
average had risen to $5800. Hospital X paid about $5200.00
at the beginning of that year.

CHAPTER II

THEORETICAL BACKGROUND

Faced with what had been evaluated as a chaotic
situation, upper management created a set of standards for
Nursing Management and designed a Nursing Management Trans-
ition Program to bring about their accomplishment. These
standards were called the Success Criteria. Administration
then set definite behavior objectives for nursing super-
vision which would demonstrate compliance with the Success
Criteria.

Supervisory Population

 

The pOpulation under study was limited to the 15
Assistant Directors of Nursing and Nursing Management.
personnel employed by Hospital X. These personnel were
the immediate subordinates to the Director of Nursing and
they directly supervised the Head Nurses. Whereas the
Head Nurses were also considered to be managerial personnel,
they were primarily first line management.1 The intent of

the program was to train the Assistant Directors in order

 

1Whereas the Head Nurse has 24 hour a day, 7 day a
week responsibility for her unit, she is nonetheless a working
supervisor, required to closely follow the leadership of the
Assistant Directors of Nursing.

11

12

that they might train the Head Nurses, without direct inter-
vention in the training process by upper management.
Figure 2 indicates the organization structure just prior to
the study. Figure 3 indicates the organization at the onset
of the study. Since the structural change comprises part of
the total experimental strategy, it will be discussed at a
later time.2
The 15 Nursing Management Designates (trainees) were
all female and ranged in age from 36 to 53. Their educa-
tional background was predominantly Diploma School.3
Several of the trainees were educated at the nursing school
operated in conjunction with the hospital, and several of
them had practiced nursing only at Hospital X. All
trainees involved had had prior supervisory experience.
Table 1 summarizes these characteristics for each trainee.
At the outset of the Nursing Management Transition
Program, the new administration had based its planning on
several theoretical points. These points provided the

guideposts to the accomplishment of the desired change.

 

2The change strategy is discussed in detail in
Chapter IV.

3The three year or Diploma nursing education program
is one of three types of nursing educational programs. The
others are the two year Associate Certificate Program and the
four year college degree program. The two year program
was initiated long after completion of education by the
youngest of the trainees.

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15

TABLE l.—-Characteristics of trainees.

 

 

Hospital X Years Experience

Education School Supervisory Other than

Trainee Age Program Graduate Experience Hospital X
1 A1 3 year yes yes
2 A0 3 year yes A yes
38 3 year yes 3 no
A A2 3 year yes 6 no
5 51 3 year no 6 yes
6 50 A year no 11 yes
7 56 3 year no 13 yes
8 57 3 year yes 18 no
9 A3 3 year yes 9 no
10 AA 3 year yes 10 yes
11 36 A year no 7 yes
12 37 A year no A yes
13 A9 3 year yes 7 no
1A A2 3 year yes 11 no
15 A7 3 year yes 1A yes

 

16

Theoretical Framework

 

The theoretical position taken by upper management in
the transition program began with the proposition that
patient care was central to the total function of the organ-
ization. All elements, therefore, could be seen in terms
of their contribution to that goal. Furthermore, each
element was interdependent in accomplishing its given task.
The practical significance of this was that the individuals
involved in job performance were in constant contact with
outside individuals necessary for the accomplishment of
their work. By knowing the necessary elements of job per-
formance, and the relationship between and among the
elements of the organization, the behavior of individuals
became highly predictable. The fact that behavior seemed
to be predictable led upper management to believe that the
right of management to prescribe limits on individual
behavior was operationally feasible.

Administration also firmly believed that the tech-
niques and activities of supervision had a direct bearing
on the attitudes and performance of staff personnel.
Therefore, the key to stabilizing the work force and estab-
lishing adherence to performance standards set by upper
management lay in the development of good supervision. The
boundaries of all such activities would be determined by
requirements of patient care.

Additionally, administration believed that setting

up an attractive model of job performance would be a major

17

point in bringing about the identification of Nursing
Management personnel with the overall goals and objectives.
This was designed to be a major part of the achievement of

the desired standards of job performance.

Success Criteria

Administration felt that programs would have to be
conducted at all levels in order to educate Nursing Manage-
ment to its new objectives and bring about acceptance of
new and exacting performance standards. Upper management
felt that it ought to specify behavior changes desired,
analyze exactly what would be required in making the changes,
establish a detailed program for change, and develop a
measurement of the extent to which change actually took

place.

Examination of the Framework
The guideline position taken by upper management can
be expressed for the purpose of examination in a series of
statements.

,1. The elements of an organized activity are
theoretically so arranged to facilitate their
contribution to the overall goal or objective.

2. The nature of the complexity of patient care
renders each element dependent on each of the
others to a greater or lesser degree.

3. Given the work to be performed and the relation-

ship between and among the elements of the

18

organization, behavior of incumbents is to
some degree predictable.

A. Manipulation of the elements and/or the work
to be performed will alter individual behavior.

5. There is a critical relationship between the
nature of supervision and the performance of
workers.

6. The effective mission of supervision at all
levels is to bring about a state of compliance
with the overall objectives of the organization.

7. Managerial development successfully takes place
through a process of specification of objectives,
detailing of behavior change, analysis of suc-
cess indicators through logical task sequence,
and, multi-level managerial program acceptance.

In that these seven statements constitute the theoretical
Imasis of the program to bring about transition from Pro—

fessional Nurse to Nursing Manager, it is appropriate to

examine each.

1. The elements of an organized activity are
theoretically arranged to facilitate their
contribution to the overall goal or objective.

The approach taken here stems from the logical devel-

opment of an organized activity. Organizations, in a formal

cchtext, are at least minimally goal oriented.3 They

 

3Etzioni defines organizational goals as a state of
affairs which an organization is trying to bring about. He
iruticates in his discussion contained in Complex Organiza-
titnis (p. 72) that a researcher must go further than the

l9

arise out of the simple realization that where a given goal
can not be accomplished by a single individual, greater
resources must be acquired. These resources, then, are
organized and directed toward the achievement of the given
goal.

At first glance, it may be difficult to see the rela-
tionship of a given element to a given goal or objective;
however, a closer look will frequently clarify the situa-
tion.“ An example drawn directly from the hospital industry
lies in the existence of departments of credit and collec-
tions. Whereas it can not be said that a credit department
contributes directly to patient care, it can be said that
a credit department may well be a key enabling factor in
the accomplishment of patient care, by virtue of the nature

of its function.

 

stated goals. He suggests an examination of the work flow
process of the organization. Such an examination in a
hospital setting strongly indicates that the stated goal
of patient care is both realistic and pervasive. We are
not, at this point, concerned with a typology of organi-
zations based goals; however, if we use the Katz and Kahn
approach (The Social Psychology of Organizations), we can
View the hospital setting as an organized system for the
accomplishment of patient care. Thus the rendering of pa-
tient care is the function of the hospital, the rendering
of the best possible patient care becomes the hospital goal.

“Scott Greer discusses this area in Social 0rganiza-
tion (New York: Doubleday, 1955), Chapter I. He points out
that men organize their behavior as the necessary condition
for cooperation. He goes on to point out that the dynamic,
on-going performance of group tasks is the organization's
.reason for being . He goes further to point out that organ-
izations must live within a greater social environment. We
Inust add to this the fact that a hospital, by virtue of its
'very nature, is also an economic organization and, therefore,
Inust exist in an economic as well as a social environment.

2O

2. The nature of the complexity of patient care
renders each element dependent on each of the
others to a greater or lesser degree.

The example of the credit department given above
serves as well to illustrate statement number two. In a
sense, statement 2, is an amplification of the first, but
with a more direct intent. Statements 1 and 2 lead to the
notion of functional interdependence5 at the broadest level
of organization structure. Statement 2 takes us to a more
direct application. In this study, we are directly con-
cerned with the obvious implications of the goal of
patient care, and, in a narrow sense, patient care and
patient contact seem to suggest the same thing.

As our example we will take direct nursing care. The
direct nursing care given to the patient may be performed
by Registered Nurses in the strictest sense, or by the staff
of the nursing division in a slightly broader sense. Either
way, the Nurse or the Nursing staff member (LPN, Aid,
Orderly)6 is bound to come in contact, at some point in
time, with Laboratory personnel, X-Ray personnel, and several

others, either through interpersonal contact, or, dependency

 

SGreer (ibid.) goes on to establish from his discussion
of organizational nature and environment the notion of func-
tional interdependence. He points out that at the inter-
;personal level, dependency is inherent in the nature of an
cirganized activity. At the environmental level he extends
the notion to involve interaction between the organization
and its environment.

6A typical Nursing Unit is likely to be staffed by
Ihegistered Nurses, Licensed Practical Nurses, Nursing Aids
and.possibly Orderlies. The presence of clerical help is
likely; however, they are excluded here by the intent of the
<3ommonality of physical patient care among the unit staff

Inembers.

21

on work performed elsewhere, such as, a large chest X-Ray
or a blood analysis, the results of which may play a key
role in the prescribed regimen for the patient.

We can narrow this down even further. Within a nursing
staff or unit, there is likely to be a sharp division of
labor between the various levels of skill available to

7

render care. The total care regimen, however, is likely to
be comprised of functions performed by a variety of skill
levels within the same nursing unit. To the greater or
lesser extent of this occurrence, the various personnel
at the various skill levels will be dependent if not
precisely on each other, at least on the functions performed
by others. We, therefore, arrive at the notion of inter-
personal functional interdependence,8 and an entry to the
observation of cohesiveness, or the lack of it, in a nursing
unit or staff.
3. Given the factors of work to be performed and

the relationship between and among the elements

of the organization, individual behavior is

predictable.

Two applications of this statement need to be deline-

ated. First, the statement is largely limited to the context

 

7In amplification of footnote 6, these various classi-
fications are normally specifically trained for the accom-
plishment of a variety of tasks. There is an overlapping
of training present which sets up a hierarchy of skills.
For instance, the Nurse is trained in all functions. The
Practical Nurse is trained in less areas than the Nurse, but
more than the Nurse Aid, and so on. The duties of each are
normally clearly allocated.

8Greer, op. cit.

22

set up by statements 1 and 2. That is to say that a knowl-
edge of the design of a given job combined with a knowledge
of the constraints placed upon it by its necessary involve-
ment with other jobs, allows us to make reasonable predic-
tions of task accomplishment.9 For instance, we can say
that in a full staffing situation, a patient will receive

a given treatment, based on our knowledge of the content
and context of that treatment. Perhaps it must come after
a laboratory test, but before a surgical preparation.

There are staff present to perform the treatment, trained
in that performance, and responsible for it. This line

of reasoning allows us to develop tools such as the job
analysis.

Taking the same illustration, we can examine the
second application. Given the situation stated above, we
can introduce factors such as worker satisfaction, the
nature of supervison, the degree of difficulty of the job,
or, the degree of difficulty of the patient, the presence
or absence of which may have a direct bearing on the be-
havior of the individual charged with the treatment in
point. Returning to the previous example, let us say

that the patient is an elderly man who is prone to respond

 

9Greer establishes this line of reasoning (Social
Organizations) when he points out that by defining organi-
zation as behavior which is motivated by and constrained
by the necessities of cooperation, action then becomes
possible only through the structure. He concludes this sec-
tion of his discussion by stating that organizations set
limits on individual behavior and direct it into channels
designed for the functioning of the whole. Therefore, the
individual's behavior is frequently highly predictable.

 

23

violently to the presence of uniforms. From this fact we
may conclude additional personnel will be required to ac-
complish the desired treatment.

A. Manipulation of the elements and/or work to
be performed will alter individual behavior.

Statement A is a logical next step from the previous
statement. The obvious application of this statement is
that slight alteration of the conditions described above
would produce a change in behavior.

In the discussion of the situation at Hospital X, a
general characterization of Nursing Management was given.
We have pointed out that change from those conditions was
considered to be mandatory by the new administration. Per-
haps the single most important tenet upon which the
desired transition was based is contained in statement A,
for it was necessary for the Nursing Management to change
from what was considered to be a traditional role, largely
based on self-interest as perceived by the nurses involved,
to a new and relatively alien role.10 The expectations
which upper management held for these nurses were entirely

different from their entrenched perceptions of their role

as nurses in positions of authority.

 

loGolembiewski, in his book The Small Group (Chicago:
University of Chicago Press, 1962), defines role as a set
of behaviors which are functionally related to some social
unit in which the set of behavioral prescriptions is known
and enforced. Elaborating on this concept, D. W. Olmsted in
Social Groups, Roles and Leadership (East Lansing, Michigan:
Institute for Community Development, Michigan State University,
1961), points out that a role is filled in the context of a
network of expectations on the part of the individual and on

 

2A

The mechanism for producing the desired change was
precisely the manipulation of the pertinent elements of
the organization and of the work to be performed by these
personnel. The major problem lay in having these person-
nel perceive their new roles as providing the same

self-interest, much more positively presented.11

In short,
the new role has to be stated in terms that the Nursing
Manager designates would accept.

5. There is a critical relationship between the
nature of supervision and the performance of
workers.

Statement 5 provides a key to developing a satisfac-

tory Nursing Division. Customarily, supervision cannot

be a cure-all in achieving maximal employee performance.
Factors affecting performance transcend the nature of
supervision. However, it will be demonstrated (Chapter IV)
that the role of the supervisor in this study affected
most, if not all, important elements of job performance.

Given the critical relationship, there are several aspects

of supervisors as a group which must be taken into account.

 

the part of those with whom he interacts. He later sets

up a framework of (l) the role itself; (2) role taking, the
imaginative rehearsal of a role before one actually is
filling the role; and (3) role behavior, or what one
actually overtly does in attempting to fill the role. Thus
we arrive at a process for role change.

llRoland Pellegrin, in his article, "The Achievement
of High Status and Leadership in a Social Group," Social
Forces, XXXII (October, 1953), points out that the unifying
factor in group activity is the concept of norm, which he
defines as all criteria of conduct which define what ought
to be in the group and in accordance with which members guide
their actions, attitudes and beliefs. Given the concept of

25

First, the importance of the work performed has a
direct relationship to peer group solidarity.12 Since the
Nursing Manager Designates were the highest ranking opera-
tional line management, it was felt that strong solidarity
would insure continuity of management.

Secondly, the closeness of supervision tends to be
inversely related to worker satisfaction and performance.13

Since these personnel were to be largely independent, it

 

role and necessity in the transition program for role
change, it becomes apparent that norm change must also take
place, and indeed would be central to the success of the

transition program.

l2Peter Blau and Richard Scott in Formal Organizations
(New York: Chandler Publishing Company, 1962), have pOinted
out that group solidarity encompasses not only the uniting
bonds of group membership but also the collective strength
derived from this solidarity. It is precisely in this col-
lective strength that managerial continuity of the trainees
was to be found. Sayles, in his book Behavior of Industrial
Work Groups (New York: John Wiley and Sons, 1958), found
that the degree of solidarity manifested in common action
and the accomplishment of common goals were at least as im-
portant as the informal ties among members of a work group.
Further, Sayles found that groups engaged in tasks considered
essential to the entire plant possessed a greater degree of
solidarity than groups engaged in less important tasks. In
the case of the trainees under study, the importance of
their positions was considered key to the operation of the

hospital.

 

l3Blau and Scott (ibid.) produce this conclusion from
a variety of research studies. They feel that the trans-
rnission of pressure, or the lack of it, is primarily respon-
sible for the relationship. They go on to state further
‘that effective leadership is not only refraining from
closely checking on subordinates, but also requires the
Inaking of challenging demands to stimulate the interest
and ability to perform well.

26

was felt that limits should be placed on them through
policy guidelines rather than administrative directives.
Therefore, such impersonnel mechanisms as policy guide-
lines were considered important.lu

6. The effective mission of supervision at all

levels is to bring about a state of com-
pliance with the overall objectives of the
organization.

Control of and responsibility for meeting organiz-
ational objectives rests primarily with upper management,
and it is with the internal environment, or rather within
its context, that this experiment took place. Simply
stated, management sets the terms and conditions for and
of job performance. In a similar sense to statement 5,
supervisory personnel will have terms and conditions pre-
scribed for them by upper management and they in turn
prescribe them for subordinates.

Concurrently, it is the responsibility of management
to bring about compliance with desired norms, goals, objec-

15

tives or patterns of behavior. In a very real sense,

 

l“Blau and Scott (ibid., Chapter VII) point out that
the concept of impersonal authority in formal organizations
is usually interpreted to mean hierarchical relations
free from personal involvement. However, they go on to
point out that impersonal authority may also mean manage-
ment through nonhuman mechanisms of control. It is
possible, therefore, for management to design and install
an impersonal control system in such a manner that it,
rather than the hierarchy, exerts continuous constraints
on the performance of subordinates.

 

15Etzioni (op. cit.) points out that compliance among
higher participants in an organization has as its center
normative power. He goes on further to point out that

27

these norms, goals, objectives or patterns of behavior

can be reinforcing or defeating. Where unity exists between
the perceptions by upper management of the desired state

of being, and the conditions which facilitate that state

of being, the norms, etc., will be reinforcing. Therefore,
it is the responsibility of those who exercise the control
mechanisms within the organization to insure the achiev-
ability of the desired state.

7. Managerial development successfully takes

place through a process of specification

of objectives, detailing of behavior change,
analysis of success indicators through
logical task sequence, and, multi-level
managerial program acceptance.

The essence of statement 7 lies in the degree of
acceptance of the transition program by management, and,
the exactness of the program itself. It must be certain
that the objectives specific to the program are in complete
accord with the perceptions by upper management of the

desired result.16 Additionally, how to achieve the desired

 

normative power can be present not only in individuals,
but also in given positions. He indicates that there are
three major forms for the distribution of Normative Power
(p. 232). First, present at the top only; second, present
in all line positions; third, present in one or more ranks
other than the top.

16Robert J. House in Management Development: Desigp,
Evaluation and Implementation (Ann Arbor, Michigan: Bureau
of Industrial Relations, University of Michigan, 1967),
points out that it is a necessary condition required to
induce change through management development, that the
objectives of development be clearly compatible with organ-
izational objectives. He suggests analysis in the areas
of Change in Knowledge, Change in Attitude, Change in
Ability, Change in Job Performance, and, Change in End
Operational Results.

28

result must be perfectly clear.17 Success must be clearly
recognizable both by upper management and by the trainee.18
Measurement of success is therefore necessary, and that
measurement must be realistic to the situation.19 Finally,
the program must have complete acceptance and approval not
only of top management, but also of the trainee.20 Its

relevancy must be obvious if success is to be achieved.

Hypothesis

 

It was hypothesized that the success criteria could
be met through a definite management education program
(1) basic tools acquisition, (2) greater understanding of
the labor force, and (3) support for flexibility of judg-
ment and freedom of action for supervisors, within

prescribed policy limits.

 

17Chapter 5 of the House book (ibid.), contributed
by Henry L. Tosi, Jr., discusses at length the various
methods of producing management development. He comments
that the clarity and logic of the various steps in each
method must be considered essential to success.

19Chapter 6 of Management Development (ibid.), con-
tributed by John R. Rizzo, stresses the importance of
measuring in reality exactly what you intended to measure
at the outset of a management development program. Rizzo
discusses several different instruments which may be used.

 

2OIn House's discussion of a conceptual framework
for management development (ibid, p.106), he stresses the
importance not only of complete managerial endorsement of
a development program, but also the advisability of
actually having all levels of management senior to the
target level undergo the same training first.

29

Variables

 

The independent variable in this study was the
management strategy of change, inclusive of change agents
and techniques. The dependent variable was the Nursing
Management, its compliance or non-compliance with the pre-
scribed success criteria behavior patterns. The control
variable lay in the assumption that the success criteria
was valid to the extent that it satisfied the standards
set up by upper management and in the assumption that func-
tional interdependence would give rise to sufficient
motivational adjustment to satisfy the psychological demands

of the success criteria.

Procedure

 

The procedure was to examine compliance with the
Administrative, Supervisory, Leadership, Technical Com-
petence and Human Relations areas comprising the Success
Criteria by measuring changes in several specific patterns
of behavior. It is, therefore, appropriate to turn now to
a discussion of the Success Criteria and of the patterns

of behavior to be measured.

CHAPTER III

SUCCESS CRITERIA

Having previously discussed the state of Nursing
Management, and having outlined the frame of reference
for the transition program, this chapter will explain
the Success Criteria for transition accomplishment, and
the various patterns of behavior utilized to demonstrate

successful transition.

The Success Criteria

 

The Success Criteria were divided into five major
areas: Administration, Supervision, Leadership, Tech-
nical Competence, Human Relations. For purposes of exam-
ination, each will be discussed in the order shown above.

Administrative success was comprised of several
elements. First, in order to achieve success in the
administrative area, it was necessary for the supervisor
to know and to utilize proper forms and proper procedures.
The trainees would be required to come in contact with ap-
proximately 300 different forms. Each of these forms was
indicative of a body of procedures relating to the subject
area described. The content of the procedures ranged from
the acquisition of supplies to the proper treatment method
for starting an intravenous feeding on a cardiac patient.

Secondly, the supervisor was expected to meet all deadlines

3O

31

ranging from filing any of several reports to the accom-
plishment of a major space renovation. At face value,
this would seem somewhat out of context for an Assistant
Director of Nursing; however, it will be shown later that
these personnel were actually sufficiently equipped to
give managerial supervision, even in construction work
with which they were concerned. Organizing her personal
workload was considered a major area where satisfactory
performance was necessary.

The job of the Assistant Director included a wide
variety of responsibilities, including assuming the au-
thority of Administration when no line member of upper
management was present. Organizing the work of those
directly supervised by her was a mandatory responsibility
for an Assistant Director, in that she could not possibly
carry out her function without extensive delegation of
authority and responsibility. Communications, up and down,
was a substantial responsibility of the Assistant Director.
From her position of major responsibility, the danger of
supplying or receiving too much or too little information
held the possibility of disastrous results. Proper design
and calendering of responsibilities and events was consid—
ered to be a necessary integral of carrying out the many
and varied activities, as well as insuring proper continu-
ity in management.

Supervisory success was likewise comprised of several
elements. First, in order to insure proper performance,

maintenance of the skill levels of those supervised, and

32

to keep abreast of constantly changing technology, it was
necessary for an Assistant Director to give continuous
orientation and training to those for whom she was respon-
sible, inclusive of insuring that subordinates, in turn,
continue the process to the lowest level of employee
involved in the procedure or work problem area. Secondly,
in order to insure a sense of unity of purpose, i.e., to
encourage all personnel to identify with the goals of
patient care, it was necessary for the supervisor to
explain her orders whenever such action was deemed helpful
to the execution of those orders. Thirdly, the supervisor
had responsibility not only :23 those supervised but also
39 those supervised. This was demonstrated by the neo-
essity to answer questions fully or obtain proper answers
when she was unable to respond personally. In addition,
the supervisor at all times was held responsible for the
administration and support of proper policy. It will be
demonstrated later that she had a voice in policy and
procedure establishment and change. However, she was at
all times held responsible for voicing any criticism
through, and only through, proper organization channels.
In order for her to fulfill her role in communications,
she had to listen to and attempt to correct employee com-
plaints and criticisms, again, however, only through proper
organization channels. As part of this role, she was held

responsible for holding periodic informational and

33

educational meetings with those supervised. The correlary
was that she was also expected to administer proper dis-
cipline when necessary.

The various elements of success in the leadership
area for the Assistant Director began with the necessity
of setting goals and objectives for herself. Her
personal self-appraisal had to be critical and pertinent
to improvement of performance. In conjunction with that
appraisal, and with the appraisal of her immediate super-
ior, she was expected to set definite goals and objectives
in a systematic manner. Similarly, she was expected to
set definite goals and objectives for her subordinates.
These goals and objectives, in both cases, had to be
traceable in terms of time limits on accomplishment and
the development of a logical sequence of events leading
to goal and objective attainment. Naturally, then, she
was expected to meet these goals and objectives within
reason. Further, it was expected that those for whom she
was responsible would meet their respective goals and
objectives through her leadership and supervisory ability.
The Assistant Directors were expected to support their
employees within the limits of proper subordination to
higher authority and compliance with organizational policy
and procedure. Finally, they were expected to be instru-
mental in the development of their employees' potential
for advancement. Thus, the responsibility was both exten—

sively for, and extensively to, subordinates.

3A

In the area of technical competence, the Assistant
Director was expected to stay as current as possible on
recent developments in her field. She had to keep abreast
of all changes in procedure, not only hospital procedure,
but also of general nursing procedure which was worth
consideration for adoption by the hospital. Secondly, she
was expected to play a key role in the development of new
procedures in the clinical area, including not only the
testing of proposed new procedures or procedure changes,
but also the direct generalization of proposals for consid-
eration. The Assistant Director was expected to partici-
pate in directly applicable continuing education, not only
as available within the organization, but also be available
outside the organization to the extent of her ability to
do so. She was responsible for finding and correcting
clinical nursing errors which occurred within the areas of
her supervision. She was responsible for noting and
analyzing the various changes which occurred in patient
mix, and for proposing both clinical response and
managerial response to the resultant problems incurred.
She also had to know and understand the functions of the
various auxiliary specialities available to her, and
utilize them to her best advantage.

The final area of the success criteria was in the
area of Human Relations. The elements of this area were as
follows. First, the Assistant Director had a specific

role to play in the determination of the wages, hours,

35

and working conditions of those for whom she was responsible.
This respOnsibility was both individual and aggregate. She
was expected not only to know the wages, Schedules, and job
requirements of all individuals in her charge, but she was
also responsible for safety conditions in her area, knowl-
edge of the general situation on wages for all classifica-
tions she supervised, and be thoroughly familiar with the
scheduling techniques which would produce equity to
employees, while insuring the integrity of patient care.
The Assistant Director had to continually evaluate the
performance of those supervised in a constructive manner, in
order to locate and correct problem areas, and encourage
improvement. She had to demonstrate the ability to solve
problems in a satisfactory manner, upholding the rights and
responsibilities of management, and insuring fair and
equitable treatment of all employees. She had to remain
constantly informed of and aware of the feelings, problems,
and desires of the employee group, and this information had
to be made readily available to those members of upper
management charged with the responsibility of managing the
total labor force.

Figure A is presented as a synopsis of the Success
Criteria. It provides a short listing of the various
elements of the Success Criteria. As will be seen later,
it is also the final evaluation tool for the determination

of compliance with the Success Criteria.

36

ADMINISTRATION
Knows and utilizes proper forms and procedures 7 6 5 A 3 2
Meets deadlines 7 6 5 A 3 2
Organizes personal workload 7 6 5 A 3 2
Organizes work of those supervised 7 6 5 A 3 2
Appraises immediate superior of all current developments 7 6 5 A 3 2
Work from well designed calendar of responsibilities
and projects 7 6 5 A 3 2
SUPERVISION
Gives continuous orientation and on the job training 7 6 5 A 3 2
to employees supervised
Explains orders whenever possible 7 6 5 A 3 2
Answers questions fully or obtains answers for
employees supervised 7 6 5 A 3
Administers and supports proper policy 7 6 5 A
Listens to and attempts to correct employee complaints 7 6 5 A 3 2
Holds periodic meetings with employees to pass on
information 7 6 5 A 3
Administers discipline when necessary 7 6 5 A 3 2
LEADERSHIP
Sets goals and objectives of self 7 6 5 A 3 2
Sets goals and objectives for employees supervised 7 6 5 A 3 2
Meets goals and objectives for self 7 6 5 A 3 2
Helps employees meet goals and objectives 7 6 5 A 3 2
Supports employees supervised within the limits
of proper subordination 7 6 5 u
Supports hospital policies and procedures 7 6 5 A
Helps develop employee potential for advancement 7 6 5 A 3 2
TECHNICAL COMPETENCE
Keeps up with changing procedures 7 6 5 A 3 2
Generates new procedures 7 6 5 A 3 2
Participates in outside in-service training 7 6 5 A 3 2
Finds and corrects clinical nursing errors 7 6 5 A 3 2
Notes and analyzes changes in patient mix 7 6 5 A 3 2
Utilizes ancilary assistance when required 7 6 5 A 3 2
HUMAN RELATIONS
Participates in analysis of wages, hours, and working
conditions of those supervised 7 6 5 A 3 2
Continually evaluates performance of those supervisors
in a constructive manner 7 6 5 A 3 2
Demonstrates ability to solve problems in a
satisfactory manner 7 6 5 A 3 2

Stays aware of general tone and tenor of employee group 7 6 5 A 3 2

Passes on positive and negative feedback to
administration 7 6 5 A 3 2

Figure A.--Mechanism for final evaluation of compliance with Success Criteria.

rd H #JFH H

+4 H +4 H

H

H

H para F‘FJ H

CHAPTER IV
THE TRANSITION PROGRAM

Having examined the tenets of the Success Criteria,
it is now appropriate to examine the change mechanism.
This will be done in two sections: first, the change
strategy, change agents, and change techniques will be
discussed. Then, the development program will be reviewed

in detail.

Change Strategy, Agents, and Techniques

The intent of the development program was to bring
about a change in the behavior of Nursing Management
trainees which would lead them away from their traditional
role of Nurse first, to a new role characterized as Nursing
lWanager. In order to do this, upper management realized
that it would be necessary to deal with the problem in
terms of the role perception of the trainees. The intent
'was to create a different role perception by the trainees,
:reinforced by group norms, which would coincide with the
eexpectations of upper management.

The technique was to conduct an educational program
fill all aspects of the new role desired, inclusive of a
conmarison of the new and old roles. In order to insure

ea conceptual acceptance of the new role by all trainees,

37

38

the program was designed to be as realistic as possible.
The approach was highly pragmatic, dealing with real and
on-going problems, including work assignments which were
designed not only to reinforce the program subject matter,
but also to produce a notable accomplishment for the
trainees at each stage of the program. Whereas Adminis—
tration insisted that the reports and procedures be
adopted, Administration made an overt demand that total
behavior change was to take place, nor was the total intent
of the program clearly revealed until after final evalua-
tion had been accomplished. The pragmatic approach was
deemed to be sufficient to allow the trainees to perceive
self-interest in making the transition, without lengthy
rationalizations.

The program was conducted by a staff specialist,
with the Director of Nursing present in an observer role.
Administration did not directly participate in program
presentation; however, at various points, well known
experts in various fields under study were invited to par-

ticipate. Attendance was mandatory.

The Management Development Program

 

Phase One: Basic Tools Acquisition

The basic tools material was presented over a ten week
period, one topic each week, in two-hour sessions. At the
end of each session, a work assignment was made designed to

stimulate both learning and establishment of needed programs

39

and documentation. In all cases, the meetings were held
during the working day, and the work assignments were to
be done during working hours. The following is a brief
discussion of each of the ten topics covered during this

phase.

'Job description andpjob analysis.--First, the uses
of the job description were discussed as they pertained
to the Department Head level, Administrative level, and
in the Personnel function. The format of a Job Descrip-
tion was established and its specific relationship to
recruitment and wage administration was explored. Next,
the technique and rationale for weighting a job descrip-
tion were examined. The weighting process and its appli-
cations were examined in detail. Following the subject
of job description, the discussion turned to job analysis.
A function by function format, according to time ordering,
was established. The relationship of the job analysis to
the job description was explored, and examples were taken.
At the conclusion of the session, the trainees were
assigned to develop Job Descriptions and Job Analysis for

personnel under their supervision.

Orientation and in-service training.-—This discussion
dealt first with the purpose of orientation and then with
the functional importance of orientation. The orientation
;process was broken down into three levels. The first level

‘was Hospital; second, Departmental; third, Job Orientation

AC

was examined. The interrelationship of the orientation
function to in-service education was established and ad-
ministrative procedures were introduced. Format and
technique for the establishment and conduct of orienta-
tion was developed. Next, the function and purpose of
in—service education was discussed. The concept of a
multi-track educational system within the organization
was discussed, and program development was explored. At
the close of the meeting the trainees were assigned to
develop orientation programs for personnel supervised

and submit areas for in—service program development.

Policy and_procedure.--In this section the subjects

 

of Policy and Procedure were examined. The format, pur-
pose and intent were discussed. Policy generation as a
supervisory responsibility was explored, definitions of
policy levels and policy subjects were established. A
structure for review and revision was established, and a
linkage to both Medical Staff and Advisory Board was
examined. Similarly, the same areas for procedure genera-
tion and usage were examined. The role of policy and
procedure in both administration and job performance was
discussed, and the effect of policy and procedure on
orientation was clarified. The assignment was to prepare
statements of policy and proposed procedures as they

related to the work performed by the trainees.

A1

Position control and recruitment.-—The scope and im-
portance of a position control system was discussed in
detail. The information generated from such a system in
terms of work performance, lost time, employee utilization
and manpower planning was discussed. The legal require-
ments were related to the availability of training and
orientation records, for the purpose of establishing
employee accountability. Budgeting and other financial
aspects were covered. The recruitment process was reviewed
and systematically related to the position control tech-
nique. The role of the supervisor both in recruitment and
in screening was examined, and the trainees were directed
to institute the applicable particulars of the position

control system.

Scheduling and staffing.--In this session techniques
of scheduling were discussed. The legal requirements for
hours worked were reviewed, and methods for encouraging
greater full-time employment, equity to employees, and the
integrity of patient care, were reviewed. Development and
determination of proper staffing levels was explored,
evaluation of staffing problems undertaken, and staffing
documentation techniques were established. The trainees
were then assigned to develop manning tables and master

schedules for the areas supervised.

Departmental documentation and facilities.--This

section covered the development of a central department

A2

manual for each area, to include all pertinent reports and
statistics related to the function and performance of the
area. Proper information gathering techniques were dis-
cussed, and pertinent categories of necessary management
information were established. Facilities planning was
explained. The relationship of the trainees to the various
staff departments responsible for facilities was reviewed,
and the areas of assistance available to the trainees from
these departments was clarified. Management by objectives
was introduced, and the trainees were assigned to develOp
plans for any necessary facility alteration in their respec-
tive areas in conjunction with the various staff departments

available to assist.

Wage and salary administration.--In this section,

 

the system of wage and salary administration was explained.
The dependency of wage administration upon concepts
developed in earlier sessions was examined. The role

of the supervisor in wage administration and wage level
establishment was covered at great length. Staff depart-
ments available to coordinate and assist in matters per-
taining to wages were examined, and factors leading to the
determination of a wage level were brought out, in terms of
the labor market, job performance, and organizational
financial limits. The trainees were assigned to trouble-
shoot any and all wage problems pertinent to personnel

under their supervision.

A3

Emplpyee and supervisory,evaluation.--The role and

 

importance of on-going performance evaluation was dis—
cussed in this section. The nature and technique of
supervisory evaluation was reviewed at length, and the
intent and usage of employee evaluation was explored.
The role of the supervisor in the evaluation process was
examined, and the impact of evaluation upon wage deter-
mination was established. The positive application of
the evaluation process toward performance improvement
was explored, and the trainees were assigned to review
and update the evaluations of all personnel functioning

under their supervision.

Formal communications.—-The discussion of formal

 

communications encompassed both written and oral communi-
cations. The maze of procedures involved in running the
organization was reviewed, and a central mechanism for
forms review and disestablishment was created. Types and
kinds of information which should or should not be
restricted to various levels were discussed, and the
impact and potentialities of informal communication were
examined at length, both from the point of view of the

employee, as well as from a managerial position.

Facilities management.—-In the final section, the
subjects of purchasing, inventory control and establish-
ment, major equipment acquisition and maintenance, and

budgetary aspects, were covered. The trainees were

AA

assigned to develop supplies and equipment inventories,
and to institute shelf level supply systems.

The trainees wera,at this point,given a two week
break prior to beginning the next phase of training.

Figure 5 demonstrates the various key elements of
the management tools subject matter in terms of Adminis-
trative responsibility, Staff responsibility, and Depart-
mental responsibility, graphically illustrating the over—

lapping nature of managerial function.

Phase Two: Greater Understanding of the Labor Force

The labor force education program was presented over
a seven week period utilizing two-hour meetings held
during the early evening. There were no specific work
assignments resulting from the meetings. Outside experts
participated in some of the sessions. The following is a

brief discussion of each of the seven topics.

Formal organizations.--This topic was divided in

 

three general areas. First, the subject of power was
discussed. The meaning of structure and function was ex-
amined, the concept of hierarchy was explored, mechanisms
of control were examined, and the concept of organizational
sanctions was reviewed. Secondly, the basis of authority
was brought out. The discussion centered on the question
of why people work, the legitimacy of power and authority,
the relationship between the two, and the notion of

delegation of authority. Thirdly, role theory was

A5

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A6

examined in terms of its applicability to understanding
why people behave as they do. Expectation theory, social-
ization, group dynamics, frustration, the role of leader-
ship, peer relations, and the use of discipline in this

context, were discussed in detail.

The nature of communications.--This topic was a
direct outgrowth of the Basic Tools phase. In this session
patterns of communication, types of communication and the
effects of control of information were examined in both a
formal and informal context. Utilizing the same contexts,
the nature of group activity, self-concept, self-
expectations, motivation, satisfaction and group equili-
brium were examined. Resistance to change, development of
change, participation and non-participation in change
activity, andthe groupediects and consequences of change,

were explored at length.

Labor history.—-In this session the film "The

 

Inheritance," produced for the Amalgamated Clothing Workers,
was shown. Following the film, a noted authority on labor
history spoke on the birth of unionism in Registered Nursing

and the subsequent California experience.

Labor 1aw.—-In session four, the development of

 

labor law was outlined, and pertinent concepts of applic-
able legislation at the national and state levels were

explained. The discussion covered Norris-LaGuardia,

A7

Wagner, Taft—Hartly, Landrum—Griffin, Railway Labor, and

state strike control legislation.

Professional unionism.--For session five, the

 

trainees were joined by another distinguished expert on
the American Labor Movement who spoke from both knowledge

and experience about unionism at the professional level.

Collective bargaining.--For this session the group

 

was joined by yet another well-known expert in the field
of organized labor who presented the subject of collective

bargaining.

Tactical problems in labor relations.--This was a

 

general recap and critique of the previous six programs,
followed by a discussion of the practical problems caused
by being involved in an organizing campaign, the effects
of union presence upon supervision, the experience by
some of the members of the group with professional union-
ism, and the desirability or non-desirability of the
presence of a union.

The seven programs in phase two of the management
development program were characterized by informal dis-
cussion rather than formal presentation of materials as
in phase one. The trainees explored, as a group, such
questions as: How do we make a system work? What do
employees expect of a supervisor? What are the conse—

quences of saying too much or too little? And, several

A8

others of this general nature. At the conclusion of
these seven programs, the trainees were given a two week
break in preparation for the third and final phase of
the program.
Phase Three: Flexibility and Freedom of
Action for Supervision

The third phase of the develOpment program was com-
prised of both discussion sessions and direct action by
and for the trainees. The content of each of the sessions
will be discussed as above, and the activity involved will
be briefly outlined. This phase was made up basically of
four sections; however, the fourth session was in reality

the launching point for full scale performance.

Critique and evaluation.--This session involved first
a general critique and evaluation of all programs given up
to that time. Secondly, a general review of all accumu-
lated documentation was undertaken for the purpose of
ascertaining completeness and accuracy. Thirdly, a
general discussion ensued regarding the various patient
and staffing mixes for the nature and type of care
provided by the institution. Findings were presented
with regard to utilization of facilities, and specialty
areas, over the duration of the program. The trainees
were then recessed for two weeks, during which they were
to locate problem areas in Nursing Management, and com-

plete any documentation left outstanding.

A9

Session on nursing practices.--The trainees returned
at the end of the two week period to discuss problem
areas. Several questions were raised that fell under the
general heading of wage and salary administration, and a
third meeting was scheduled to follow in one week. The
discussion then turned to the subject of revamping the
nursing units to launch the concept of Team Nursing.

The trainees felt this would provide a substantial
countermeasure to the major problems within the division.
The trainees were asked to assess the role of the Head

Nurse within the institution and the session adjourned.

The role of the Head Nurse.--The first item in the
session related to the questions raised by the trainees
in the previous session. In response to those questions,
the first half of the meeting was devoted to the discus-
sion and establishment of a new compensation system for
Registered Nurses. The reclassification of several
categories of unskilled personnel was discussed, and the
establishment of wage recommendations for the division
was undertaken. The second half of the meeting was
devoted to deciding upon the particulars of the role
the Head Nurse was to play in Nursing Management. The
trainees were then dismissed with instructions to return
in one week prepared to discuss a training program for

Head Nurses.

50

Development of the Head Nurse_program.-—The fourth

 

session was opened with the announcement that the wage
recommendations of the previous meeting had been installed.
Secondly, the trainees were informed that for all prac-
tical purposes the training program had come to its con-
clusion, and that they were now to assume full function
and responsibility as Assistant Directors of Nursing.
Thirdly, they were presented with a wage scale for their
classification which had been substantially revised
upwards. The program coordinator then left the session.
The Nursing Management proceeded to conduct its first
full scale staff meeting. Their purpose was to design a
management development program for Head Nurses.

The training program to accomplish the transition
of the fifteen Nursing Management designates from
Professional Nurse to Nursing Managers was now complete.
The Assistant Directors were left essentially on their
own, reporting directly to the Director of Nurses. For
the following ninety days there was virtually no inter-
ference or policy guidance from Administration, other
than routine directives and Operational demands. At
the conclusion of that ninety days, the final measurement
for compliance with the Success Criteria was taken.

Chapter V deals with that measurement and its results.

CHAPTER V

MEASUREMENT OF CHANGE

Thus far, the environment for the study has been
described, the theoretical framework has been discussed,
the success criteria have been outlined, and the manage-
ment development program has been reviewed. In this
chapter the measurement of change will be presented in
three sections. First, the method of measurement will
be explained. Secondly, the sources of data for each
behavior pattern will be examined. Finally, the meas-

urement data will be reviewed.

Method of Measurement

 

At the onset of the study, evaluations were com-
pleted on each of the trainees. The evaluations were
arrived at by having three members of upper management
complete an evaluation form similar to Figure A of
Chapter III. The three forms were then averaged, and a
general discussion took place among the evaluators for
the purpose of establishing the averages as a pretest
measure. The three upper management personnel involved
were first, a member of Administration; second, the
managment development specialist; and third, the Director

of Nursing. The evaluating committee met with the

51

52

authority to modify the averages obtained from the three
evaluation forms; however, it was the decision of that
committee in each case to let the averages stand without
judgmental modification. These averages then became the
base line for unacceptability of performance.

In examination of the success criteria, the eval-
uating committee decided that in order for performance
to be satisfactory, a minimum of fifty per cent improve-
ment would have to be demonstrated. That is to say
that taking the post-test of a per cent of the pre—test,
the result would have to exceed 150 per cent. Further,
it was decided that the success criteria would be con-
sidered met only where seventy-five per cent improvement
was demonstrated. That is to say that the post-test
would have to be equal to or greater than 175 per cent.
It was the decision of the evaluation committee to
scrutinize the ninety day period immediately following
completion of the development program, and at the end
of that period, to reevaluate the trainees with the
same instrument used to pre—test. Any demonstrable
changes in the results of the final evaluation would
then be measured against the pre-test to determine the
degree of change and the direction it had taken. The
final evaluation, or post-test, was to be conducted in
the same manner as the pre—test, i.e., by each member of

the committee and averaged.

53

Data Sources

 

In this section,the sources of data which provided
the basis for evaluation of each behavior pattern will
be reviewed. For the sake of simplification the phrases
from Figure A, Chapter III, will receive an alphabetical
designator comprised of the first letter of the Success
Criteria area (A = Administration), and a numerical
designator indicating the order of appearance in Figure 3
under each major heading (Al-A6). These designators will
be used for ease of presentation. Each data source will
be given an alphabetical code beginning with "A", in the
order of presentation. We will now list the sources of
data used in the study. Table 2 relates the data sources

to the phrases from Figure A, Chapter III.

Source A: Major Project Records*

Source B: Written Policies and Procedures*

Source C: Personnel Files

Source D: Business Office Records and Charge Slips
Source E: Departmental Records and Diaries*

Source F: Incident Reports

Source G: Disciplinary Reports

Source H: Supervisor's Limited Access Personal Files
Source 1: Travel Reports

Source J: Patient Charts

Source X: Subjective Judgment

In each case where data could be expressed in numerical
terms, for instance error rates on reports, a correlation
coefficient was developed to express these terms on the

one to seven Success Criteria scale.

 

*It is a condition of these data that the records
and documentation systems were much improved as a result
of the transition program; however, the performance areas
were not altered from the pre-test. Numerical scores were,
however, secondary to the individual judgments of the
evaluators.

5A

TABLE 2.--Data sources utilized in evaluating performance
areas of the success criteria.

 

[1']

 

Al
A2
A3
AA
A5
A6

81
S2
S3
SA
S5
S6
S7

L1
L2
L3
LA
L5
L6
L7

T1
T2
T3
TA
T5
T6

H1
H2
H3
HA
H5

><

><><><><

:4

>4

>4

><><><><

>4><><>4>< N >4><><><>< ><><><><

>4><

><><><><><

 

55

Pre-Test and Post-Test Results

 

As has been previously indicated, the evaluation
format for the pre- and post-tests were similar to
Figure A, in Chapter III. In the preceding section, each
factor was listed and coded. In this section, the code
will be used to present a comparison of the pre—test and
post-test data. It should be borne in mind that the
population tested was comprised of fifteen trainees.

Table 3 displays the results of the pre-test and the
results of the post-test. Due to the small size of the
population tested (N = 15), only the mean and percentage
increase were taken. No other manipulations of the data
were conducted.

In an examination of Table 3, the categories listed
are pre-test mean, range of pre—test score achieved, post-
test mean, range of post-test score achieved, and the
post-test mean as a per cent of the pre-test mean. Note
that only factors T3, TA, T6, and H3 fail to meet the
minimum satisfactory level of 150 per cent. Additionally,
S3, 68, L3, L7, fail to meet the 175 per cent test for
Success Criteria compliance. Thus, we see that of the
thirty-one areas of behavior change, eight failed to fully
meet the compliance standard and four fell into the unsat-
isfactory area. Taken as a whole, the group achieved a
mean level of 2A2 per cent, considerably above the Success

Criteria compliance level.

56

TABLE 3.-—Results of the pre-test and post-test of
compliance with the success criteria.

 

 

 

 

Pre-Test Post-Test Post-Test Mean
Factor Mean Low-High Mean Low-High as a Per Cent
Range Range of Pre-Test Mean

Al 2.00 1-3 5.33 5-7 266
A2 2.00 1-3 6.66 5—7 333
A3 2.5 1-3 5.66 A-6 226
AA 2.66 2-A 5.33 5-7 200
A5 2.00 1-3 6.33 5-7 316
A6 1.33 1-2 6.66 5-7 500
81 3.00 l—A 5.33 3—6 178
S2 2.66 1-3 5.00 3-6 188
S3 3.00 1-A 5.0 A—7 166
SA 2.33 1-3 6.66 5—7 286
S5 2.00 1—3 5.33 A—6 266
S6 3.00 2—A 5.00 5-6 166
S7 1.33 1-2 6.00 5—7 A51
L1 1.66 1-2 6.66 5-7 A00
L2 1.33 1-2 5.00 A-6 376
L3 3.00 1-3 A.66 A-5 158
LA 1.00 1-1 A.33 A-5 A33
L5 1.66 1—2 6.00 A-7 361
L6 1.33 1-2 6.66 5-7 500
L7 2.66 1-3 A.33 3-5 156
T1 3.00 l-A 6.33 5-7 210
T2 1.33 1-2 5.00 A-6 376
T3 3.33 2-A A.00 3-5 120
TA A.66 A-6 6.33 5-7 136
T5 1.66 1-2 A.66 3-5 281
T6 A.33 3—5 A.66 3-5 110
H1 1.00 1-1 5.00 A—7 500
H2 2.00 1-3 5.0 A-5 250
H3 A.33 3-5 5.33 A—7 123
HA 3.33 2-A 6.33 A-7 190
H5 2.33 1-3 6.66 5-7 286

Group 1.3- A.1-

Average 2'26 3.0 5.A6 6.3 2A2

 

57

In examination of the factors which did not reach
the success level, the evaluators felt that four satis-
factory areas (S3, S6, L3, L7) would improve in time, and
that the four areas where change did not meet the satis-
factory level (T3, TA, T6, H3) were well performed at
the time of the pre-test.

Administration, therefore, arrived at the following
conclusions:

1. Change did occur.

2. The change was in the direction of achieving

the objectives.

3. The change was generally sufficient to meet

the Success Criteria.
Therefore, on the grounds of these results, the hypothesis
that the success criteria could be met through a definite
management education program consisting of (1) basic tools
acquisition, (2) greater understanding of the labor force,
and (3) support for flexibility of judgment and freedom
of action for supervisors, within perscribed policy limits,

was supported.

CHAPTER VI

SUMMARY AND CONCLUSIONS

Summary
In 196A Hospital X underwent a change in adminis-

tration which effectively removed the Catholic Church

from line administration of the organization and substi-
tuted highly trained lay personnel for religious personnel.
Without interference, the lay administration set about to
change the organization in several areas. One of the major
targets for change was the Nursing Division. Administration
elected to bring about change in the Nursing Division by
instituting a Management Development program. A specialist
was brought in to perform the function.

In conjunction with the Director of Nursing and
Administration, the Specialist began, in 1966, to build a
program which would bring about the desired change. The
goals and objectives were specified, the program was
planned and designed and a method to measure accomplish-
ment was adopted. The fifteen Nursing personnel who had,
at that time, been in supervisory positions at Hospital X
from one to eighteen years were given a promotion in title
and were regarded as Nursing Management designates. The

period of ninety days immediately preceding the program

58

59

was utilized to establish a pre-test of performance in
terms of specific Success Criteria. Thirty-one different
areas of behavior were observed and measured based on the
best evidence obtainable at the time. A twenty—eight

week three-phase program was then initiated, consisting
of acquisition of basic managerial skills, development of
greater understanding of the labor force and support for
the new role of Nursing Management. At the conclusion of
the program, the fifteen trainees assumed full and complete
responsibility for their function. During the following
ninety day period, the trainees were evaluated in the same
thirty-one areas of behavior which were examined prior to
the development program. Based on a comparison of the

two evaluations, Administration arrived at the conclusion

the program had been a success.

Conclusions

 

In concluding this presentation, several points
require comment. First, from a scientific point of view,
the structure of the study was far from elegant. Given
the nature of the change to be produced, the possible
effects of varying age, education, attitudes, experience,
and motivation on the part of the trainees were never
fully examined. Secondly, it is not possible to tell
what exactly caused the change; the program was a complex
one. There were several outside sources of pressure,

such as Medical Staff, staffing levels for patient care,

60

employee group reaction, etc., which were not accounted
for. The extent to which those factors would or would
not have an effect were not measurable within the design
of the study. Thirdly, there was no control group
present. Therefore, it cannot be said without the possi-
bility of error that the development program, and that

in particular, caused the change to take place. True, it
is safe to say that change occurred; however, it must be
noted that at the immediate conclusion of the development
program a substantial wage increase was given to the
trainees. Additionally, promotions, although in title
only, were given to the trainees at the outset of the
study. It, therefore, seems likely that both the economic
incentive and status differentials may well have had a
strong hand in producing change.

For purposes of study, however, it must be remembered
that Administration held the change strategy, change agents,
and change techniques, to be the independent variable, the
Nursing Management to be the dependent variable. In terms
of the measurements utilized, change did take place.
Academically, the entire experiment is open to a wide
range of criticisms, and must be accepted with the afore-
mentioned reservations. However, it must be borne in mind
that this process took place in a working environment.
Upper management wanted to produce positive change. The

definition of positive change was theirs to make, and

61

they got what they wanted. For whatever the reasons, the
program worked and must be accepted as successful to the
extent that it was perceived to be successful by the
management which conceived it and constructed it. It is,
therefore, an interesting account of a process of gaining
compliance by Registered Nurses who must play the part of
management with managerial norms. In addition, the study
provided a fairly detailed examination of an exercise in
management development in general.

Perhaps the essence of the development program can
be stated as the application of the fundamentals of per-
sonnel administration and employee relations to management
training. Certainly it stands to reason that a solid
system of documentation makes supervision an easier task.
The introduction of a job description program, combined
with exacting standards for job content evaluation in the
job evaluation process goes a long way to insure that the
supervisor knows exactly what he is supervising at any
given point in time. This alone should tend to increase
the acceptability of the supervisor's performance. Against
this framework, which can be compared to a road map of the
organized unit for which the supervisor is responsible,
the introduction of policies and procedures goes even
further, not only in helping the supervisor know what he is
supervising, but also in setting standards by which to
judge the performance of those supervised. Now, if an

organization goes even further and introduces uniform

62

communications channels and mechanisms, it becomes in-
creasingly easier to coordinate the activities of the
various units of an organization, and thus the supervisor
will have still more clearly defined perimeters of Opera-
tion. Finally, if in addition to the areas indicated
above, management takes steps to educate a supervisor in
the nature of his or her work force, why people act as
they do in a given setting, and how they are likely to

act when the circumstances are changed, the general perfor—
mance of the supervisor is bound to make a marked improve—
ment.

Dr. Theo Haimann, in the book Sppervisory Management
1

 

for Hospitals and Related Health Facilities makes a strong

 

effort to place supervisory training in the context of
Planning, Organizing, Staffing, Directing and Controlling.
Dr. Haimann stresses the importance of the supervisors
knowing their roles in each of these areas, and cites
examples of methods and techiques of achieving results in
these areas. The case study herein described goes with
depth into each of these areas, with a systematic and
pragmatic program for acquisition and application of these
principles. Even beyond this, however, the management
development program herein discussed delved into what it

is like to be a supervisor, and how a supervisor is

 

lTheo Haimann, Supervisory Management for Hospitals
and Related Health Facilities (Washington, D. C.: The
Catholic Hospital Association, 1965).

63
regarded by an employee. Such knowledge may well tend to
counter the often discussed pressures which a line manager
up from the ranks is subjected to. It can offset the
feeling of anxiety toward former employee level associ-
ates, as well as the tendency to be suspect of senior
managers who presumably do not understand what it is really
like to be a line supervisor, especially in an environment
such as a hospital where administration is not likely to
be comprised of experienced Nurses, and Nursing Management
must be.

It must be continually born in mind that the Profes-
sional Nurse is educated into an environment of not only
medical but also social problems as they exist in a broad
community.2 She is likely to be confronted with a variety
of people ranging from children to older people suffering
from a huge variety of diseases, disorders and mental prob-
lems. In the treatment of these people, she must of
necessity come in contact with not only the paramedical
and professional medical people at every conceivable skill
level, but also with social agencies, legal agencies, and
members of patients' families both close and distant. She
is the on-site juggler of every possible resource that will
contribute to patient care. And the patient, to the Nurse,
is a human being, not a member. When we ask a person

trained and educated to existence in such a complex

 

2Sr. Mary Isodore Lennon, RSM, Sociology apd780cial
Problems in Nursing (New York: The C. V. Mosby Co., 1959),
Section VI, p. 3A8.

6A

environment to transfer her function to a managerial
function, the only thing she may find in common with her
former role is that both are problem-solving in nature.
Beyond that, She may initially perceive a conflict between
the goals of management and of patient care. The key to
success in making the transition is the knowledge that
the role of management is to coordinate and facilitate the
process of patient care in the hospital environment.3
This, more than anything else, had to be the philosophical
goal of the Management Development Program at Hospital X.
The hospital administrator has much less power and
authority than his counterparts in other industries because
of the pressure of such a wide variety and stratification
of skills which he does not possess. He must, therefore,
rely on a system of delegation of authority based upon a
structure wherein the functions of each unit of organiza-
tion are clearly related and definable. Programmed co-
ordination, planned and controlled through patterned
activities such as the patient care regime associated
with a given illness can act as strong channels; however,
the administrator must rely on line supervision educated
and trained to understand the intricacies far better than
he. It becomes obvious that in Nursing, as well as in
every other medical or paramedical activity in the hospital,

he must have supervision which possess the skills he does not.

 

3Basil s. Georgopoulos and Floyd 0. Mann, The Community
General Hospital (New York: The MacMillian Company, 1962),
Chapter 6.

65

Basil S. Georgopoulos and Floyd C. Mann, in their
book, The Communipy General Hospital,4 perceive coordina-
tion to be one of the keys to successful hospital manage-
ment. They call for a style of supervison which lies
somewhere between Autocratic and Human Relations oriented.
The skills and techniques imparted to supervision at
Hospital X make a significant contribution to fulfilling
these requirements.

Before closing our discussion of the transition from
Professional Nurse to Nursing Manager at Hospital X, one
final set of implications must be examined; the impact of
this program upon collective bargaining. According to
the Taft-Hartley Act, Sec. 2 (11):

The term "supervisor" means any individual having
authority in the interest of the employer to hire,
transfer, suspend, lay off, recall, promote, discharge,
assign, reward, or discipline other employees, or
responsibly direct them, or to adjust their grievances,
or effectively recommend such action if in connection
with the foregoing the exercise of such authority is
not of a merely routine or clerical nature, but
requires the use of independent judgment.

Even a brief inspection of the success criteria
utilized in this study clearly reveals that the requirements
of the Taft-Hartly Act are fully met. The case for exclusion
from a Professional Nursing bargaining unit is strong and
complete. However, this writer would like to strongly urge
that in the consideration of collective bargaining in
hospital nursing, participants go well beyond the deter-

mination of the bargaining unit.

 

ulbid., Chapter 9.

66

The reader will remember that one of the main points
in the development program was the introduction of policy
and procedure such that the environment for patient care
could be continually and systematically modified toward
keeping up with changing technology. Remember also that
one of the key areas in the success criteria was technical
professional development. The supervisors in this study
were charged with the direction, control and coordination
of the process of patient care in such a way that the goal
of the best possible patient care would always be served.
This writer submits that no matter what the nature of the
health care environment, the goal of the best possible
patient care must always be served. Further, the fluidity
of change in patient care, its complexity and speed of
advancement dictate the greatest of care be given to
avoidance of impeding this process. I would argue not
only for the clear exclusion of nursing management from
the bargaining unit, but also that matters other than
those directly affecting wages, hours and working condi—
tions exclusive of the procedures of patient care be kept
strictly out of the realm of collective negotiation.

This thesis in and of itself gives rise to several
additional questions. First, to what extent does role
perception actually change when the specialist in Nursing
care must transfer to the role of manager of the process

of Nursing care? Secondly, is it in fact desirable to

67

have the professional Nurse fill a managerial role?
Thirdly, what are the effects on management development
in Nursing when a professional or union organization
enters the environment? It is hoped that this thesis
will provide an introduction to the study of Nursing

Management.

BIBLIOGRAPHY

Bailey, Norman D. Hospital Personnel Administration.
New York: Physicians Record Company, 1959.

 

Beal, George M., et a1. Leadership and Dynamic Group
Action. Ames, Iowa: Iowa State University Press,
1962.

Blau, Peter M. and W. Richard Scott. Formal Organiza-
tions. Chicago: Chandler Publishing Company, 1962.

 

Blueprint for Progress in Hospital Nursing. Proceedings
of the 1962 Conferences of the State Leagues of
Nursing. Washington, D. C.: National League for
Nursing, 1963.

Brown, J. A. C. The Social Psychology of Industpy.
New York: Pelican Books, 195A.

Etzioni, Amitai. A Comparative Analysis of Complex
Organizations. New York: The Free Press, 1961.

 

Falcone, Nicholas S. Labor Law. New York: John Wiley
and Sons, 1962.

 

Greer, Scott A. Social Organization. New York:
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Georgopoulos, Basil S. and Floyd C. Mann. The Community
General Hospital. New York: MacMillian Company,
1962.

 

 

Golembiewski, Robert T. The Small Group. Chicago: The
University of Chicago Press, 1962.

 

Haimann, Theo. Supervisory Management: for Hospitals and
Related Health Facilities. Washington, D. C.: The
Catholic Hospital Association, 1965.

 

Hawley, K. S. Economics of Collective Bargaining by
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Iowa State University Press, 1967.

House, Robert J., et a1. Management Development: Design,
Evaluation and Implementation. Ann Arbor: Bureau
of Industrial Relations, University of Michigan, 1967.

 

68

69

Katz, Daniel and Robert L. Kahn. The Social Psychology
of Organizations. New York: John Wiley and Sons,
1966.

 

 

Kruger, Daniel H. "The Appropriate Bargaining Unit for
Prggessional Nurses," Labor Law Journal, January,
19 .

 

Lambert, William and Wallace Lambert. Social Psychology.
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