Page 396 - Encyclopedia of Nursing Research

ORGANIzATIONAL DeSIGN n 363

the Scientific Management School proposed In health care, organizational design
that because workers were reliable, predict- research has mainly focused on the relation-
able, and economically motivated, technical ships between structures and outcomes at O
solutions such as time-and-motion studies the organizational level, with less emphasis
and monetary incentives could be used to on processes and on work unit level analy-
plan, to control, and to evaluate work flow ses (Hearld, Alexander, Fraser, & Jiang, 2008).
and outputs (e.g., Principles of Scientific For example, hospital level analyses of nurse
Management by Taylor, 2003). Classic manage- staffing over the past two decades have typ-
ment theorists, who were typically company ically linked structural indicators (e.g.,
executives, applied administrative principles nurse-to-patient ratios) to outcomes without
using a top–down approach to divide and identifying the care processes at the individ-
coordinate work activities among workers ual and work unit levels that explain differ-
who were viewed as skilled and specialized ences in care quality. The result is a black box
technicians (e.g., Theory of Organization by that reflects “an unknown and often unknow-
Gulick, 1937). However, post–World War I able mechanism, process, or system which is
labor markets were characterized by increas- judged solely by observing its inputs and out-
ing activism and unionism (O’Connor, puts” (Park, 2007) and that offers little guid-
1999). This gave rise to the Human Relations ance for reorganizing the delivery of nursing
School, which emphasized the behavioral services to varied clinical populations at the
aspects and informal structures of organiza- point of care. These large-scale staffing stud-
tions. Workers were perceived to be socially ies, which allowed for comparisons between
and psychologically motivated, thus neces- organizations, used mainly cross-sectional
sitating democratic leadership practices to research designs and were prevalent, in part,
empower workers and gain their cooperation because of the availability and accessibility
to improve performance (e.g., Participative of secondary administrative data sets.
Decision Making by Likert, 1961). After During the 1980s, the concept of “mag-
World War II, the processes (rather than net” hospitals emerged in the United States,
structures) of organizations gained attention, and research found positive associations
and the organization was viewed as an open between patient and nurse outcomes and
system that adapted to its external environ- visible and responsive nursing leadership
ment (e.g., Contingency Theory by Lawrence at all levels in the organizational chart (i.e.,
& Lorsch, 1967). Workers were viewed as hierarchy) as well as strong nursing profes-
semiautonomous agents acting within and sional identity characterized by primary
across system boundaries to integrate inter- nursing (i.e., division of work), nurse–physi-
dependent system functions. In response to cian collaboration (i.e., mutual adjustment),
globalization and knowledge-based econo- autonomous clinical decision making, and
mies, management theory has increasingly participative decision making about unit
focused on interorganizational phenomena and organizational processes (i.e., decen-
and the dissolution of traditional organiza- tralization; Scott, Sochalski, & Aiken, 1999).
tional boundaries (e.g., international strategic In response to economic downturns during
alliances, virtual networks). The “boundary- the 1990s, health systems in North America
less” organization, which emerged from and elsewhere underwent restructuring
postbureaucratic theory, is characterized and reengineering of structures, roles, and
by nonhierarchical, flexible, temporary, and coordination mechanisms to contain costs,
continuously changing organizational mem- to improve quality, service, and speed, and
bership, structures, and processes centered to address increasing patient acuity and
on projects rather than roles (Shamir, 1999). demand for health care services. Professional