Abstract
Demographic and educational characteristics of nurses and their role in relation to medicine leads to the classification of nursing as a semi-profession. Nursing of the acutely ill is basically hospital based. Hospitals are complex organisations with multiple goals of patient care, diagnostic and treatment services, and in many, education and training of doctors, nurses and other personnel. They are also professional organisations in which the primary goals are pursued by the health professionals rather than the line management. Semi-professionals are traditionally hierarchichally organised and heavily bureaucratised. The major professions, of which medicine is typical, are characterised by egalitarianism in the interests of professional autonomy. They are thus traditionally resistant to most forms of bureaucratic organisation. Because of these characteristics of hospitals and their personnel there is potential for conflict. This is exacerbated by the speed of change which has overtaken the health services along with society as a whole. The mechanistic systems of organisation, designed to meet the stable conditions prevailing at the time of the industrial revolution, are ineffective for management of modern complex organisations. There are now typically multiple vertical lines, and heads of departments. Effectiveness is dependent on an organismic structure capable of developing horizontal and vertical co-ordination essential for success. Nursing needs are accorded only secondary importance to the now major objective of maximum medical output to meet continually increasing demands and nursing is relatively powerless to correct the imbalance in a traditionally organised service. A study was carried out in a Provincial Teaching Hospital to attempt to identify organisational factors which may adversely affect the performance of nursing staff both within and above ward level. Questionnaires were completed by U2 Day Sisters concerning organisational problems and relationships. Analysis showed that the sisters were largely homogeneous in outlook despite certain differences. Excessive pressure owing, principally to the work load was widespread, and severity of pressure was significantly associated with age. Questionnaire's completed by 10 Night Sisters and 8 Nurse Administrators showed that the Night Sisters ranking of wards was closer to the Student Nurses than that of the Nurse Administrators. Night Sisters' perception of problems was specifically clinically orientated and Nursing Administrations' management orientated. Interviews with 9 Senior Nurse Administrators and 21 Medical Consultants revealed an almost total failure of co-ordination between the two on- management problems intrinsic to the effectiveness of nursing services and a corresponding failure of the Nursing Administrative function. There was evidence of medical complacency and non-involvement and of inadequate preparation of nurses for senior positions, within and above ward level. 240 Senior, Student and Pupil Nurses completed questionnaires from which wards were ranked according to evaluations on care, discipline and preference for working in them. Regression analysis produced highly significant correlations between the three variables. Reasons for preferences, interpreted in relation to Hertzberg's Motivation-Hygiene theory, suggested that motivators were poorly developed and dissatisfiers exaggerated, especially on least preferred wards. Analysis of a patient satisfaction survey of 4,000 discharged, patients contained significant differences between patients on male wards, female wards, and mixed wards, and between general medicine and surgery, specialties and accident wards. Highest and lowest student nurse rankings were within the patients' highest and lowest satisfaction rankings. Factor analysis of the patient data revealed three predominant discriminators of patient satisfaction. The UOH Management Structure was seen to be deliberately biased towards medical predominance and to lack the total organismic structure necessary for the development of co-ordination, constructive management and increased commitment at all levels. An alternative structure is proposed and further research recommended.