Connecting Organizational Theory With Organizational Reality in EMS, Research Paper Example
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In the book “The Workplace Within: Psychodynamics of Organizational Life,” author Larry Hirschhorn discusses the nature of “social defenses.” Seen through the perspective of social defenses, many of the typical routines and modes of conduct within organizations are predicated not by reason, logic, or efficiency, but by emotional responses to uncomfortable organizational circumstances. Hirschhorn uses as an example the manner in which nurses tend to administer medications to hospital patients: rather than allowing sleeping patients to continue sleeping, patients are awakened according to the nurse’s schedules if they require medication. This schedule affords nurses an opportunity to depersonalize the processes of patient care; by making the administration of medication a mechanical, rather than an emotional process, nurses can put distance between themselves and activities that are distasteful, disgusting, or even frightening. It is no surprise that Hirschhorn points to nursing as one of his book’s first examples of social defense; the health care industry is rife with organizational conduct that does not necessarily put the patient’s needs first. The hospital is, in fact, a near-perfect crucible for testing the strength of various organizational theories. Because the hospital workplace is a constantly-evolving system of processes, different theories are likely applicable at different times. This paper will examine several effective organization theories with an eye towards understanding what threads underpin each construct.
Hospitals have evolved in myriad ways over the last century. In the early 20th Century, hospitals were typically owned by physicians; these same physicians managed the hospitals as well. Over the course of the century, a new breed emerged: the hospital administrator. Several factors fed this phenomenon; advances in medicine gave physicians ever more to do and to learn, while the advances in health insurance fundamentally changed the way hospitals did business. Hospitals now did business not just internally, with patients, but also with the insurance companies that were quickly taking on behemoth status. By 1974 the Health Planning and Development Act was passed, and managers began exerting greater control over hospital resources and decision-making processes. A decade later the Medicare Prospective Payment System was passed, ushering in greater cost-containment incentives for managers and an increased focus on patient care for physicians. Managers and physicians began to see a greater need for co-operation.
In the last few decades, the functions and relationships in hospitals have grown ever more byzantine, as concerns about Medicare reimbursement, health insurance companies, research, and myriad other functions have put pressure on both administrators and physicians to cultivate complex, synergistic working relationships. As these relationships have grown more complex the opportunities to apply different organizational theories has grown in kind. While not all, or even most, applicable theories can be applied to hospitals there are several that deserve at least some consideration.
Returning briefly to Hirschhorn, it is worth noting that at some level, organizational theories are broadly applicable. Hirschhorn describes a scenario in which he consulted for a research facility with some ingrained dysfunctions. Management, eager to appear amenable to (and perhaps intellectually capable to) the staff scientists had developed the habit of soliciting ideas from each of several departments. The scientists in each department, equally eager to appear co-operative (and perhaps eager to appear intellectually capable as well) would put forth ideas regardless of how realistic or useful these ideas were. Management would then simply divide up resources among each department, funding ideas that were never intended to serve the best interests of the organization.
While this scenario is not directly transferrable to a hospital setting, the result is the same: with so many competing forces working incompatibly, and sometimes even at cross-purposes, hospital functions are not necessarily designed to work in the best interest of the organization, or of the patients. Entrenched ideas, patterns, and habits perpetuate themselves by allowing the actors within the hospital to put up psychological defenses that do not just serve to avoid the often-unpleasant tasks associated with patient care, but also the equally unpleasant tasks of dealing with those same entrenched organizational patterns.
Perhaps the most significant development in the health care industry is the advent of Health Maintenance Organizations (HOMs). Seeking to contain costs, insurance companies contract with physicians and other providers to set fee limits for services, treatments, testing and other forms of care. HMOs further seek to establish the very manner in which patients will be seen by physicians, what sorts of tests will and will not be approved, and what sorts of treatments will be applicable for various disorders.
Health care providers are often resistant to what they see as the restrictive nature of the limits and terms set by HMOs. Callister (2001) looks at the conflict between HMOs and health care providers through the perspective of Boundary-spanning theory. This theory examines the ways organizations work –and do not work- together. Callister notes that the source of conflict between these organizations is not necessarily caused by ingrained organizational functions, but by the nature of the actors within these organizations. Primacy in any organization is typically achieved by the most ambitious of actors; these same actors may have found comfortable roles and ways of functioning within their own organization, but may find themselves in conflict with their counterparts from what they often view as the opposition.
The roles of managers and health care providers are not seen as balancing act, or equally oppositional forces, by all theorists. More specifically, not all theorists see the roles as equally significant in terms of affecting change or fomenting progress and development with a health care organization. The theory of entrepreneurial management sees managers as integral to the task of pushing health care organizations towards successful outcomes, both for patients and for organizations as a whole. Because the health care industry is a dynamic field, one in a constant state of flux and change, it is imperative that effective management –regardless of whether that management is more “important” than any other role within an organization- take initiative in terms of steering and guiding the organization through the sea of constant change.
Safran et al (2005) view the health care industry as a pattern of interlocking relationships: nurse/patient; physician/patient; nurse/physician; administrator/physician; hospital and external organizations, and so on. Focusing on the physician/patient relationship, Safran et al posit various ways that this relationship can be strengthened in clinical setting such as primary-care facilities and hospitals. Incentives and means of motivating physicians to improve physician/patient relationships are considered; in one scenario, monetary incentives tied to positive patient questionnaires are discussed.
In a hypothetical scenario based on empirical evidence, the rate of improved reporting by patients for the staff physicians of a family-practice office demonstrated that some physicians saw improved scores while some did not. It was not enough to simply suggest that physicians attempt to improve relationships on their own; it was not until concrete, practical steps and plans of action were proffered to each physician that across-the board improvements were seen in patient reporting.
While the relationship between physicians and patients is seen as paramount by some researchers and theorists, others see the relationship between physicians and managers as being the most significant relationship in the health care industry (Guo, 2006). These relationships are no less significant in doctor’s offices than they are in hospitals; the primary difference is one of scale. The social dynamics that inform smaller organizations may still play roles in hospitals, but the sheer size of the various groups in the hospital setting means that the dynamics within and among those groups will
It is difficult to argue with the position that the relationships between managers and physicians are among the most significant in the hospital setting; while there are multiple relationships in hospitals, the complexity of the various functions within hospitals means that effective management is imperative. Where hospitals were once owned and managed by physicians, they are now managed by a tangled web of administrators that must oversee the acquisition of resources, interact with insurance companies, maintain budgets, contain costs, keep staff levels at necessary levels, and ensure that all the other functions of a hospital are properly conducted.
The roles of physicians in hospitals have evolved in response to the forces that have shaped the growth of the health care industry. Where physicians once ruled the proverbial roost in all areas of health care, they are now mere cogs in the larger machine. Physicians used to be revered; medical advice was akin to divine wisdom. The advent of the modern health care industry has seen physicians reduced to participants in a system they used to dominate. Even attempting to define the roles of physicians in the hospital setting can be difficult; are they providers of services, or purchasers of services?
The distinction between provider and purchaser is a significant one, as organizational theories that seek to provide a means of understanding the functions of hospitals rely on defining the roles of actors within that system (Callister, 2001). Defining the roles of physicians in hospitals is a difficult task, as the goalposts seem to move depending on how one views the playing field. Physicians clearly provide services to hospitals; at the simplest level, doctors treat patients. While this distillation of the physician’s role in hospitals is an accurate one, it is not necessarily a complete one. Doctors are not employed by hospitals; they typically operate independently, providing patient care as contractors to and with hospitals.
At the same time as physicians provide their services to patients, it must be understood that they do so through the conduit of hospitals. It is typically not the purview of physicians to acquire resources for hospitals; rather, physicians acquire resources from hospitals. Physicians do not arrive at hospitals bearing bandages, sutures, and medications, nor are they responsible for assuring that such things will be on hand when needed. In that sense, physicians purchase the services of hospitals just as hospitals purchase –or at least pay for- the services of physicians. While this may be an oversimplification of a more complex relationship between physicians and hospitals, it does she light on the constantly-shifting nature of these relationships.
Whether one ascribes relationship theory to their functions, it is clear that the internecine network of relationships is at least in part a defining characteristic of the organizational structure of hospitals. Hospitals are abuzz with all manner of human activity; simply seeking to understand and categorize the activities carried out in and by hospitals is a daunting task. No matter where one looks in a hospital, there is a complex system at work, as physicians, patients, support staff, technicians, vendors, administrators, and visitors go about their business. A seemingly endless list of considerations arises when attempting to define the nature of the hospital-as-organization.
The first question is one of boundaries: on the macro scale, where does the hospital begin and end? In concrete physical terms, hospitals are easily defined. This definition of a hospital as a finite place is quite limited, however; hospitals do not exist in a vacuum. No organization operates entirely independently, of course; businesses rely on vendors and customers, and public-service agencies are beholden to lawmakers. Hospitals are uniquely positioned in the pantheon of organizations, bridging the gap between public and private organizations. Hospitals do not just interact with outside organizations; the edges are far too blurred between and among hospitals, regulators, insurance companies, physician networks, and the entirety of interrelated organizations for simple explanations to suffice.
Organizations such as businesses usually have one overarching task: providing a product or series of products to customers while competing against other organizations that provide similar products. Public-service organizations are not beholden to the bottom line in the same manner as private organizations; rather, they are granted revenue by external organizations –typically governments, charities, or other bodies- and do not compete against other public organizations. Hospitals must meet the demands of both types of organizations, while not necessarily reaping the benefits associated with either.
While patients are the ultimate “customers” of hospitals, they do not necessarily function in the same way as do customers of typical private organizations. Although patients may have some flexibility and freedom of choice regarding which hospitals they choose to go to for medical care, it is still the purview of medical professionals to make most decisions about treatment choices. A customer interested in a new car does not go to the dealership expecting the salesman to select a car for purchase; a patient, on the other hand, does expect that his or her physician will determine which medications, surgeries, or other treatments are appropriate.
The advent of for-profit hospitals has made the already-complex functions of such facilities even more dense and complicated. Just as hospitals can be seen as a network of relationships, so to can they be seen as a network of competing pressures. Owners, stakeholders, and boards of directors pressure hospitals to generate profits. Regulatory agencies pressure hospitals to conform to the appropriate legislation regarding the practice of medical care. Insurance agencies pressure hospitals to administer the least effective tests and treatments as often as possible. Administrators pressure physicians to conform to the pressures placed on them by regulators and insurance agencies. Patients pressure physicians to give them the best medical care possible, leaving concerns about cost to the insurance companies.
This increasingly complex system of functions, relationships, pressures, and inter-and intra-relationships between and among hospitals and their concomitant organizations is not static; hospitals are very different places now than they were a generation ago, and that evolution is not likely to cease anytime soon. Understanding how hospitals got where they are is likely an important consideration for those interested not just in how hospitals function today, but how they will function, and continue to change, in the future. Aldrich (1999) examines organizations not as static systems meant to be understood or made more efficient, but as dynamic systems that have changed and will continue to change.
Nowhere is such a consideration more important than hospitals. Returning to the car analogy for a moment: the greatest shift in automotive technology in recent decades has involved the application of so-called hybrid engines to the task of providing motion to vehicles that still has four tires and a steering wheel. Advances in medical technology and health care in the last century have been on a much grander scale; the widespread use of prescription medicines, a mainstay of health care, really only emerged after WWII, when medicines such as penicillin were manufactured in large quantities. Prior to the middle of the 20th century, physicians and pharmacists typically created their own compounds, many of which were medically useless. Today, prescription medications are a multi-billion dollar business. Similar advances in all areas of medicine have been seen, and this evolution will likely continue into the foreseeable future.
Aldrich notes the “social network context” for organizations. The personal networks to which actors are linked determine the amount of support –emotional and material- they will receive. Larger social networks within and among organizations will also determine what resources and support are available to individuals and organizations as whole. Diversity within these networks is fundamental to their success and longevity, as it is diversity that assures that new resources will always be available to a dynamic organization.
Traylor and Van Avery (2000) echo this idea of social networks, suggesting that these networks can be viewed as a series of conversations. Finite, mechanical explanations for organizational functions may serve some purposes, but they leave out the human factor. In this perspective, conversations are the basic form of human communication; viewing organizations as a large “conversation” among different nodes form within the system may serve to assure that the human factor is appropriately considered. Abstractions about the functions of organizations, properly applied, are useful in helping to understand how the organizations function, but many theoretical constructs may see these functions as relatively static. Viewed as conversation, while still an abstraction, allows for the possibility that the actions of one “speaker” in the conversation may trigger an unanticipated idea or response in another speaker; the dynamism of conversations, applied to organizations, may be useful in accounting for the unpredictable nature of at least some organizational functions.
Once identified, this human factor can be seen as a thread running through the works of nearly all organizational theorists. Pfeffer (1997) discusses the “social model of behavior” as applied to organizations. The earliest forms of organizational theory took a largely mechanistic view; in short, functions were broken down to their components, and the primary motivational force for actors within the organization was determined to be the wages paid for the position held. This view failed to account for the human factor, or the psychological forces at work within and among the actors in an organization.
In the social model of behavior, organizational behavior is inextricable from social behavior. Human interaction is metaphor for organizational functions, largely because human interaction is at the core of organizational functions. Actors in an organization are affected by their social contexts as much as they are by embedded organizational forces. The public perception of a particular task or role helps to determine whether an actor will be satisfied with that role; this is of particular note when considering the organizational functions of hospitals, and examining how such functions have evolved. As noted the public perception of physicians has changed quite drastically in recent decades. The formerly oracular status held by physicians for centuries has all but disappeared in the contemporary health care system. Where physicians were once revered, they are now seen as providers of services, differentiated from other hospital vendors only by the nature of the services they provide.
Because organizations cannot just assume that actors will automatically perform in a manner that best suits the organization’s needs, reward systems must be put into place. Where such systems once consisted largely of concrete and specific quantities primarily in the form of wages, less quantifiable rewards are now recognized as being important considerations as well. Whether or not an actor is satisfied in a particular role is not determined solely by how much that actor is paid, but also by social and psychological factors. Just as public perception of roles can influence actors, perceptions within the organization are significant determinants of how happy and successful an actor will be. Positions that command respect, by their nature, lend to the actor a sense of self-importance. Though the wage paid for such a respected position may be in part the reason why the position commands respect, such respect is a separate component that influences the actor’s perceptions of his or her role.
The dynamic nature of the hospital organization lends itself to an organic form of understanding (Burns and Stalker; 1961). Strictly hierarchical systems, such as manufacturing plants, can be seen at least in part from a mechanistic viewpoint; such a viewpoint is, in fact, helpful to understanding how such organizations function. This does not mean that hierarchical systems do not change; any organization that seeks to maintain its own existence must adapt to survive. Such adaptation in a hierarchical system, however, may also be done as methodically and mechanistically as any other function of the organization.
Just as is the case in so many other ways, hospitals diverge from the typical in terms of the mechanistic/organic dichotomy. There are clear hierarchies within hospitals, though these hierarchies are different based on who is observing or interacting with them. In a for-profit hospital, for example, the board of directors sits atop the hierarchical structure, at least as seen from within the organization. Physicians are certainly influential within the organization, but the ultimate decisions about costs, the acquisition of resources, and future growth are determined by the representatives of the hospital’s shareholders. This construct, while obviously influenced by social and psychological forces, can be seen as mechanistic system of functions.
From a patient’s perspective, physicians sit at the peak of the hospital hierarchy. Patient’s first interactions in a hospital are usually with nurses; the nurse position obviously commands a measure of respect both from patients and from other actors in the organization. At best, however, nurses are seen as adjuncts to physicians; it is the physicians that command the most respect from patients. At the bottom of the heap, at least from the patient perspective, are the hospital administrators. These positions may be seen by some as little more than a necessary evil, functionaries needed to facilitate the financial transactions among hospital, insurance company, and patient. This perspective on the hospital hierarchy is influenced almost entirely by social and psychological factors; this is at least as much an organic viewpoint as a mechanist one.
The moment a physician leaves a patient’s room, he or she is thrust immediately back into the more mechanistic construct of the organization’s perspective. This ever-shifting pattern of hierarchical relationships would seem to be unique to hospitals. While it may be an oversimplification, the roles of actors within, say, a manufacturing facility are seen quite similarly whether viewed from within or outside the organization. From CEO to shopworker, the hierarchical structures do not typically shift depending on the perspective of the viewer. Such shifts within the organization of the hospital are simply a fact of life for those involved, but they are no less significant for their ubiquity.
It is impossible to separate the psychological and social components of an organization from the mechanistic, non-organic components. Because patient care is at the heart of a hospital’s function, the safety of patients overarches all other considerations. The majority of accidents and other negative outcomes in hospitals arise from poor communication (Safran et al, 2005). All manner of things can and do go wrong in hospitals; patients might not receive the proper tests or medications, treatments may be inappropriate, and surgeries may turn out badly. It is the rare occurrence when such negative outcomes are the result of a breakdown in mechanistic functions; most are predicated of failures in the human, organic aspects of the organizational functions.
Failures of communication can manifest in entirely different ways; some may simply be isolated incidents, while others may stem from ingrained components within the organizational structure. Those failures engrained in the organization are often rooted in the psychology of the actors within the organization. This phenomenon has been described as a “psychic prison” (Morgan, 2006); in this context, deep-seated patterns of behavior emerge that are predicated not to benefit the organization, but to protect the actors within the organization from fear or anxiety. The idea of the psychic prison dates back to Plato’s Allegory of the Cave but is no less applicable today for having survived the intervening centuries. Actors within an organization often become trapped in ways of thinking that can lead to problems for the organization.
Morgan (2006) discusses this phenomenon in the context of the automobile industry. The American automobile manufacturers held sway with American buyers from the time the automobile was invented all the way until the 1970s. In that decade a paradigm shift occurred, a shift to which the American car companies were slow to respond. The OPEC oil embargo caused a spike in gasoline prices on the world market, and the Asian manufacturers were well-positioned to respond to this spike. Though car makers from Japan and other Asian nations had been producing small, fuel-efficient cars for several decades, these cars had failed to capture a significant sector of the American car market. As prices went up, however, American buyers were quick to adopt these smaller vehicles.
The American manufacturers more or less ignored this phenomenon, continuing to churn out the same types of cars they had always made. Evolution in American cars was basically confined to advances and changes in style, as well as incremental mechanical changes. Asian manufacturers were able to capitalize on the myopia of the American car companies and gain a foothold in the American market, leading to fundamental and permanent changes to the automobile industry.
The same phenomenon was seen in the aerospace sector, though with far more visceral and tragic consequences. Building on a string of successes that culminated with several moon landings, engineers at NASA began to develop a sense of infallibility. This infallibility was not, of course, predicated on realistic measures of success and safety; quite the opposite, in fact. Failure to address, or even consider, potential failure of catastrophic proportions arose as a psychological defense against fear and anxiety. Turning a blind eye to the possibility of failure, NASA engineers plowed forward with the Space Shuttle program; this blindness eventually caught up with them when the Challenger shuttle exploded over Florida.
Such defense mechanisms do not always result in such tragic consequences, but it does seem clear that they rarely align with the best interests of an organization. If defenses are predicated on fear or anxiety, they must arise in most cases to allow actors to avoid consideration of real concerns about what might go wrong. Hirschhorn’s example of nurses mechanistically administering medications is predicated on legitimate concerns about patient care. Patients do sometimes die while in the care of nurses; while such deaths may be less unexpected than, say, the Challenger disaster, they are still emotionally evocative for nurses. If such a significant set of functions can arise largely because of emotional and psychological pressures, it is clear that such pressures must be considered in any effort to improve –or to simply understand- the functions of an organization.
The best organizational theories do not just seek to shed light on how organizations function; they also seek to offer suggestions about how organizations can improve. While no organizational theory is applicable in all circumstances, there are some perspectives that are uniquely suited to understanding how hospitals function, as well as how they can improve such functions. At the risk of placing too much emphasis on Hirschhorn, the ideas presented in The Workplace Within are at least as applicable to the functions of hospitals as are any others. The unique functions of such organizations require the application of theoretical constructs that address the human factor that pervades hospitals.
Even the most mechanistic functions of the hospital-as-organization are predicated largely on human factors. As described, the shifting patterns of relationships within the organization are at least as psychologically-influenced as they are objectively different when seen from various perspectives. Mechanistically speaking, a physician is a physician, a nurse is a nurse, and a manager is a manager. The roles and duties of each position are well-defined and do not change much fro one actor to the next, or from one hospital to the next. The swirling mass of pressures and forces that influence each actor, however, do change, sometimes from minute to minute. No effort to improve such an organization can afford to ignore the psychological and social forces at play.
Hirschhorn posits the notion of change through the perspective of organizational culture. The effective Reparative Culture takes both a mechanistic and an organic view of organizational processes; actors within the organization are encouraged to understand not just their own roles in the organization, but the overarching concerns and successes of the organization. By recognizing the need for actors to understand the mechanistic functions of the organization, the psychological needs of those actors are also addressed. The Reparative Culture, properly established, can evolve into the Developmental Culture. Hirschhorn places great emphasis on the value of work, asserting that actors within an organization who understand the value of their individual contributions to the organization, as well as the organization’s contributions to those it services, are more likely to function effectively.
The most effective organizational theories must take into consideration the psychological and social forces that influence organizational outcomes. Actors within an organization who see little value in their work, or who do not understand their own roles and functions in the organization, will be inclined to put up psychological defenses to protect themselves against fear and anxiety. These defenses do not arise consciously, but they must be addressed consciously if they are to be alleviated.
There is, perhaps, an overarching lesson behind all effective organizational theories; while not visible solely in the context of the hospital organization, such a setting does provide an effective perspective from which to view such a lesson. It is clear that the roles of the actors in the hospital organization are sometimes difficult to pin down, and that what constitutes a positive outcome for such an organization may be defined differently depending on who does the defining. By understanding that even the most mechanistic processes have psychological and social components, and that even the most human of processes can also be seen through a mechanistic lens, the value in the work for all actors may become easier to define and understand.
When the actors within the hospital setting are willing and able to see their functions for what they are and what they provide to the organization, the “medication schedule” may finally be replaced with a routine that serves the needs of the patient. This would be a significant first step towards effectively humanizing an organization that all too often fails to recognize that the human factor is at the heart of every success the organization will ever achieve.
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