- Email: [email protected]
The Challenge of Change
THE CHALLENGE OF CHANGE George
T. Maloney
Change has become a way of life, affecting virtually all aspects of modern society. Since the end of World War 11, we have lived through many drastic changes not only in the hospital field, but in almost every other area of life. To set the stage for the dramatic changes in health care, let us first review some of the more general changes of the last 20-odd years. Shopping habits have changed markedly. We’ve gone from small “Mom and Popyy neighborhood stores to sprawling supermarkets featuring upwards of 10,000 items per store. In aviation the propeller airplane has been largely superseded by mammoth jets flying at speeds approximating or exceeding the speed of sound. The once-mighty B-29 is obsolete. Now we have airplanes three times its size that fly three times as fast, with bigger and faster ones on the drawing boards. In music, we have gone from the sweet melodic sounds of Glenn Miller to the electronically amplified beat of rock and roll. In the movies, subject matter has undergone tremendous change-from “National Velvet” and “The Wizard of Oz” to “Who’s Afraid of Virginia Woolf?” and “The Graduate.” Television has come of age, going from the bC giant” 12-inch screen to the 25-inch color set, with 1%-inchportables for the younger set. In fashion, dress lengths have gone full circle from the post-war “new look,” 5 inches ~
George Maloney is a graduate of St. Bernadine of Siena College in Loudonville, New York where he received a B.S. A former labor relations representative for General Motors, Mr. Maloney later joined C. R. Bard, Inc. in New Jersey and has since been a salesman, division manager and merchandise manager. He is currently Vice President of Merchandising. Mr. Maloney’s article, “Standardization-Will It Ever Come,” appeared in the June, 1967 issue of the Journal.
38
below the knee, to the “miniskirt,y’ 5 inches above, and now back down again to “maxis.” Agriculture has progressed from the family farm to gigantic agri-business combines. Soil fertility, the basic life cycle, insect control, selective breeding, mechanization and automation are some of the aspects of challenge. We look forward to the agriculture of the future when one man, sitting in a control tower (like the nurse in her control station), will direct a variety of automated equipment functioning over a considerable area.
WHERE IS CHANGE GOING TO END? Man’s passion €or urban communities began only in his recent past, but already urban sprawl is everywhere, enormous, swarming, attractive, repulsive. Within a mere score of years over half of the people on earth will live in city communities of at least 100,000 population. In this world, good health is the element above all others that makes it possible for man to work and to play with zest and enjoyment. Traditionally, it has been said that only two things in this world are certain: death and taxes. Now we must add a third-change -and at an ever-accelerating pace. As human beings we are inclined to resist change because it requires us to abandon much that is familiar; it poses ever new problems-as if we didn’t have enough already. But today in the health field, unless we make the most of change, we sacrifice time and human life, our most valuable assets. Advances in medical science and technology demand adaptability and continuing education to keep abreast of change. Scientific knowledge is said to be doubling itself every ten years or less at the present
AORN Journal
time. Research within medicine itself has had a major impact, but research in other fields has also had a profound effect on health care. Developments in electronics, physics and now in computer technology can be expected to revolutionize the practice of medicine-to make the tasks of doctors and nurses as we know them today substantially unfamiliar to the coming generation. Consider the general changes we have seen in the past 20 years in the medical field. 1) Advances in drugs and medical techniques. The introduction of new products has been so dynamic that seven out of ten now on the market were unavailable a decade ago. 2 ) Increasing public interest in and knowledge of health matters with aspirations for health, for protection against disease and for longer life becoming goals desired by all. 3) Medicare and Medicaid for the elderly and pre-paid insurance plans that place adequate medical care within the means of virtually all citizens. 4) A vast post-war hospital construction program, spurred by the Hill-Burton aid bill. 5) High birth rate: More babies have been born, many with congenital anomalies, and more have been salvaged.
6) Increased longevity: more geriatric patients have required specialized care and rehabilitation. 7) A trend toward use of expendable products. 8) Computerization. 9) Increased urbanization. 10) Greater use of hospital facilities as diagnostic and treatment centers. SPECIFIC ACHIEVEMENTS Because some have accepted the challenge of change, we have witnessed a number of medical advances in the past 20 years. Among them are:
1) control of Rh hemolytic disease of the newborn (intramuscular injections of Rh im-
December 1968
munoglobulin, 72 hours before delivery, now successfully prevent this formerly fatal disease of the newborn); 2 ) successful treatment of kidney disease (persons who otherwise would have died or suffered severe disablement visit the hospital for dialysis-or have home units to do the job-permitting them to live a fairly normal life) ; 3) development of new surgical techniques: open heart surgery, vascular surgery, microsurgery, cryosurgery, organ transplants, use of homografts and heterografts; 4) development of the laser; 5 ) production of artificial limbs; 6) remarkable success in reducing the tremor and rigidity of Parkinson’s disease, achieved by coagulation of the globus pallidus or ventrolateral thalamus through insertion of a needle-like instrument; and 7) control of infectious diseases. The space program has been responsible for another area of change. More than a quarter of a million patients in the United States have already benefitted directly from this program. One big contribution came from the techniques of radio-telemetry, developed for the biomedical monitoring of astronauts during space flight. The same techniques have been adopted for monitoring blood pressure, respiration and temperature in the critically ill, postoperative and heart disease patients. Once patients are “hooked up” to a unit, a nurse down the hall is alerted when the triggering of electronic warning devices indicates need for prompt medical intervention. Such devices have saved many lives, and it is a safe prediction that soon practically every hospital in the country will have this equipment, at least in their concentrated care areas. Another important area of change is in treatment of diseases with a previously unfavorable prognosis. One such field is that of vital organ transplants and implantation of prosthetic devices, such as aortic valves. Biological sciences are probing every possible avenue to solve the problem of rejection
39
mechanisms. Once solutions are found, this achievement can lead only to development of new, highly technical products-and increased utilization of hospitals. DEMANDS OF PROGRESS The foregoing examples could be extended indefinitely. Changes have brought about improvements which everyone can enjoy, directly or indirectly; they can be measured in real dividends of reduced morbidity and mortality and of more years of useful life. Paradoxically, such heartening changes have created demands for even greater progress. The demand for health professionals is and will continue to be insatiable. In other segments of the economy, demand creates supply. In health services, supply creates demand. No sooner is a new treatment discovered than people want it. Yesterday there was no shortage because it didn’t exist; today there is a shortage because there’s not enough to go around. No wonder many doctors and nurses already feel they are running up the down escalator. Under our voluntary system, with an unregimented medical profession and over 7,000 hospitals, operating essentially as individual units, we have by no means attained perfection. In spite of our optimism, the health field is constantly under public attack for rising costs. And recent reports indicate that private health care costs of this country are going to continue to rise.
HOSPITALS’ HIGH COSTS There are three major reasons why hospital costs can be expected to continue their upward spiral. First, inflation shows no signs of stopping. Second, hospital employees’ salaries must increase. They were unbelievably low until the past five to ten years. They have been improved somewhat but truly professional levels have by no means been attained. Third, and most important, “a day of hos-
40
pital care” is not the same as it was back in 1946. More professional and technically trained personnel plus complicated scientific equipment account for the higher costs. Although the average patient cost per day is up to $4&$100 in some New York hospitals, it is still a good bargain. Contrast the expense to the price of a room in a first-class hotel costing from $15 to $22 a day. For that sum you receive a room and housekeeping services. In the hospital, the patient also receives nursing care around the clock and a room with three (sometimes five) meals a day; his physical wants are attended and lifesaving trealments and necessary supplies are available when needed. It is no fairer to compare a 1946 hospital bill with one in 1968 than it is to compare the cost of a DC-3 airplane with that of a modern jet-liner. Who wants to go back to hospital care as it was in 1946? The trend of rising operating expenses and salaries has brought about a number of changes in the principles and practices of hospital management. One important change has been the substitution of disposables for reusable products. The introduction of disposables in medicine can be traced to the early 1920’s. The military services were the first to use one of these products (syringe with needle) on a wide basis, but it wasn’t until after World War I1 that this item was widely adopted for hospital use. Until a few years ago it was almost unheard of for a hospital to change to the use of a disposable product until studies had demonstrated that the cost would be more than offset by savings in time and money. What happened? A number of things. For one, the operating room supervisor played a key role in stimulating acceptance and widespread use of disposables. Because of her dedication to total patient care and recognition that prepackaged, sterile disposables could contribute to a cleaner environment,
AORN Journal
she often took the lead in bringing together various sectors of the hospital organization to examine, consider and adopt the newer products.
satisfied another appears in its place. At the lowest level are the physiological needs-need for food is an example. Man will steal and even kill to get food, but once Since this evolution, the operating room this need is filled it no longer motivates. An supervisor is becoming more aware that she important principle to remember is this: a must consider her performance as a planner, satisfied need is not one that motivates behavorganizer, coordinator, manager, budget- ior. maker, and communicator if she is to meet When physiological needs, i. e., food and the new challenges of her expanding re- shelter, are reasonably satisfied, needs at the sponsibilities. next higher level begin to dominate man’s behavior and to motivate him. These are called safety needs, needs for protection against COMPLEX STRUCTURE The hospital with its organizational struc- danger, threat, deprivation. ture is among the most complex of organizaWhen physiological and safety needs are tions. It has two competing systems of au- satisfied, man’s social needs become importhority: the medical and paramedical, who tant motivators of behavior-for belonging, consider service to the patient the most im- for association, for acceptance by his felportant, overriding factor; and the admin- lows, for giving and receiving friendships istrative, which is caught up in the economics and for love. and maintenance problems that encroach on Next in the hierarchy of needs are the the quality and quantity of service. egoistic needs. These are the needs relating Also, the typical hospital is inhabited by to one’s self-esteem: needs for self-confiemployees with a variety of skills, back- dence, for independence, for achievement, grounds, duties and points of view. It doesn’t for competence, for knowledge, for status, for take much to have a breakdown in com- recognition, for appreciation, for the deserved munications which results in little or no ac- respect of one’s fellows. tion. This is truly the challenge of tomorrow Finally, a capstone as it were, are the -enlightened management to enable any of needs for self-fulfillment. These are the needs us to handle change. for realizing one’s own potentialities, for It is well known that greater changes can continued self-development, for being crebe effected through groups than through in- ative in the broadest sense. dividuals. But, to be successful in group proThe fact that management has provided ductivity, much depends on the ability of the for the physiological and safety needs has medical team to exchange ideas freely and changed motivational emphasis to the social clearly, to interact and to feel involved in and egoistic needs. Unless there are oppordecision making. tunities to satisfy these higher-level needs, people will feel deprived and dissatisfied and their behavior will reflect this deprivation. LEVELS OF CHANGE This need for teamwork has given strong The importance of attitude and motivation in impetus to a branch of theory known as “hu- job performance cannot be overeetimated. man relations in management,” which start“Direction and control” are essentially useed some 20 years ago. An interesting concept less in motivating people whose important is Maslow’s Triangle, illustrating the levels needs are social and egoistic-remember of change man goes through. Man is a want- your challenge is better leadership. Leadering animal: as soon as one of his needs is ship consists of getting things done through
December 1968
41
other people. The best method to accomplish this is to arrange working conditions and procedures so your people can achieve their own goals by directing their efforts toward organizational objectives. This is best done by creating opportunities, removing obstacles, encouraging growth and providing guidance. That is what Peter Drucker has called “Management by Objectives” in contrast to “Management by Control.” Simply, it is really the difference between treating people as children and treating them as mature adults. By allowing people to direct their creative energies toward organizational objectives, giving them some voice in decisions that affect them, opportunities will be provided for satisfying social and egoistic needs. Thus leadership creates change, and change creates the need for better leadership. With the steady flow of new products coming out in the hospital industry, the job of the operating room supervisor will become even more complex. The march of medical technology requires ever more sophisticated and expensive equipment and ever-increasing numbers of highly skilled people. To utilize to the maximum the skills of employees, registered nurses must develop their communication and leadership roles and institute educationally sound programs to prepare available manpower to perform at optimal levels. Recently, a professor of industrial administration at Carnegie-Mellon University predicted that the life cycles of products will become shorter and that as superior technology displaces products from traditional markets, firms will have to fight back by looking for new “pastures.” The resulting growth of internationalized markets will add to the competitive “turbulence.” The new environment will call for more managerial skills in human relations, Increasing importance will be placed on the supervisor so that her ability to communicate rapidly and intelligibly will gain acceptance
42
for change and innovation and will determine how effectively she can motivate and lead the operating room personnel in new directions. The way she “manages,” and the way she shapes her departments, affects and reflects how successful she is going to be. PREDICTIONS FOR MEDICINE IN THE YEAR 2,000 According to Dr. Oscar Creech, Jr., professor of surgery and chairman of the department of Tulane University School of Medicine, private practice in 1990 will no longer exist as it is known in the United States in 1968. He predicts: << -Medicine will be practiced on an assembly-line basis. -Physicians will be full time employees of geographical medical complexes, providing total care for residents of a community. -Physicians will be employed either on an annual fee basis or as salaried employees of the Federal Government. -Diagnosis, with few exceptions, will be performed automatically and interpreted by computer systems. -Patients’ entire medical records from birth will be instantly available from computerized medical information centers. -Intensive-care patients will be constantly observed by monitoring devices that will detect abnormalities and correct them automatically. -Physicians will no longer concern themselves with the routine practice of medicine, which will be done by others whose training is more vocationally oriented. -A new category of medical personnel, the “Clinical Associate,” will evolve. After high school these persons will have four more years of formal education, then a year of internship, which would allow the clinical associate to assume the functions performed by most practicing physicians today.” Neither patients nor physicians are ready now for such changes. “But if the past re-
AORN Journal
flects the future, radical changes in the practice of medicine are inevitable,” said Dr. Creech. Nursing can be expected to undergo equally dramatic changes. Already, nurses are being required to assume more of the practice of medicine. In the future, shortages in medical personnel will force the doctor to delegate even more of his duties to the profeesional nurse. What her role will be in year 2,000 is probably the biggest challenge faced by the profession today. Let us look ahead to the year 2,000 to see how medical care will be provided: A patient visits his community hospital, presenting himself first to the computer keyboard in the admitting office. He punches buttons correlating with symptoms and general complaints, then inserts his universal credit card. He next goes down the hall to the preparation room while the computer clicks out his complete medical history, retrieved from central files in Washington. He is greeted by a hypnotist, the first (and last) human being he sees, seated in a wheel chair and put into deep sleep. A nurse attaches devices to measure pulse, respiration, temperature, evaporation, skin color, brain waves, heart activity and many
other parameters recognized as important diagnostic inputs. The patient is hooked up to intravenous tubes for feeding and medication as needed. By remote control, from a master board, a nurse monitors his welfare. A cubicle, perhaps 3 x 4 ~ 5feet is the patient’s “home away from home.” A wheel chair rocks gently, pneumatic pads on its arms; seat and legs inflate periodically to help respiration and circulation. Nutrients and water are exactly controlled to balance bodily requirements and eliminate accumulation of wastes. No clothes are needed. Relieved of its physical and mental stresses, the body is free to recover, aided by drugs, radiation, special atmospheres, even vibration and sound. Some days later the patient is awakened, reclothed and given his electronically prepared bill. The incredible part of this fantasy is that a great deal of this regimen is already in existence today. The professional nurse can’t afford the luxury of apathy or complacency. Accept the challenge-the leadership and management of people by helping them to achieve their own goals. Only then will you and your profession find fulfillment.
BIBLIOGRAPHY “Eupsychian Management,” Abraham Maslow. “The Cost of Medical Care” Vol. 111, American Medical Association. “Disposables Study,’’ Romaine Pierson Publishers, Inc.
“Tomorrow’s Hospital,” Donald Carner, Executive Vice President, Memorial Hospital of Long Beach, California. Freda, V. J., Gorman, J. G., and Pollack, W. New England Jourllcll of Medicine 277:1022 (Nov. 9) 1967.
DIAGNOSIS Are things just not going right? Nerves shattered, tensions tight? Others at fault? That may be true; But could it be, at least partly, you? Examine yourself, and then look about, Discover the cause and put it to rout. Perhaps when self has been rearranged, You’ll discover all has happily changed. -Harry
December 1968
and Joan Mier
43
T. Maloney
Change has become a way of life, affecting virtually all aspects of modern society. Since the end of World War 11, we have lived through many drastic changes not only in the hospital field, but in almost every other area of life. To set the stage for the dramatic changes in health care, let us first review some of the more general changes of the last 20-odd years. Shopping habits have changed markedly. We’ve gone from small “Mom and Popyy neighborhood stores to sprawling supermarkets featuring upwards of 10,000 items per store. In aviation the propeller airplane has been largely superseded by mammoth jets flying at speeds approximating or exceeding the speed of sound. The once-mighty B-29 is obsolete. Now we have airplanes three times its size that fly three times as fast, with bigger and faster ones on the drawing boards. In music, we have gone from the sweet melodic sounds of Glenn Miller to the electronically amplified beat of rock and roll. In the movies, subject matter has undergone tremendous change-from “National Velvet” and “The Wizard of Oz” to “Who’s Afraid of Virginia Woolf?” and “The Graduate.” Television has come of age, going from the bC giant” 12-inch screen to the 25-inch color set, with 1%-inchportables for the younger set. In fashion, dress lengths have gone full circle from the post-war “new look,” 5 inches ~
George Maloney is a graduate of St. Bernadine of Siena College in Loudonville, New York where he received a B.S. A former labor relations representative for General Motors, Mr. Maloney later joined C. R. Bard, Inc. in New Jersey and has since been a salesman, division manager and merchandise manager. He is currently Vice President of Merchandising. Mr. Maloney’s article, “Standardization-Will It Ever Come,” appeared in the June, 1967 issue of the Journal.
38
below the knee, to the “miniskirt,y’ 5 inches above, and now back down again to “maxis.” Agriculture has progressed from the family farm to gigantic agri-business combines. Soil fertility, the basic life cycle, insect control, selective breeding, mechanization and automation are some of the aspects of challenge. We look forward to the agriculture of the future when one man, sitting in a control tower (like the nurse in her control station), will direct a variety of automated equipment functioning over a considerable area.
WHERE IS CHANGE GOING TO END? Man’s passion €or urban communities began only in his recent past, but already urban sprawl is everywhere, enormous, swarming, attractive, repulsive. Within a mere score of years over half of the people on earth will live in city communities of at least 100,000 population. In this world, good health is the element above all others that makes it possible for man to work and to play with zest and enjoyment. Traditionally, it has been said that only two things in this world are certain: death and taxes. Now we must add a third-change -and at an ever-accelerating pace. As human beings we are inclined to resist change because it requires us to abandon much that is familiar; it poses ever new problems-as if we didn’t have enough already. But today in the health field, unless we make the most of change, we sacrifice time and human life, our most valuable assets. Advances in medical science and technology demand adaptability and continuing education to keep abreast of change. Scientific knowledge is said to be doubling itself every ten years or less at the present
AORN Journal
time. Research within medicine itself has had a major impact, but research in other fields has also had a profound effect on health care. Developments in electronics, physics and now in computer technology can be expected to revolutionize the practice of medicine-to make the tasks of doctors and nurses as we know them today substantially unfamiliar to the coming generation. Consider the general changes we have seen in the past 20 years in the medical field. 1) Advances in drugs and medical techniques. The introduction of new products has been so dynamic that seven out of ten now on the market were unavailable a decade ago. 2 ) Increasing public interest in and knowledge of health matters with aspirations for health, for protection against disease and for longer life becoming goals desired by all. 3) Medicare and Medicaid for the elderly and pre-paid insurance plans that place adequate medical care within the means of virtually all citizens. 4) A vast post-war hospital construction program, spurred by the Hill-Burton aid bill. 5) High birth rate: More babies have been born, many with congenital anomalies, and more have been salvaged.
6) Increased longevity: more geriatric patients have required specialized care and rehabilitation. 7) A trend toward use of expendable products. 8) Computerization. 9) Increased urbanization. 10) Greater use of hospital facilities as diagnostic and treatment centers. SPECIFIC ACHIEVEMENTS Because some have accepted the challenge of change, we have witnessed a number of medical advances in the past 20 years. Among them are:
1) control of Rh hemolytic disease of the newborn (intramuscular injections of Rh im-
December 1968
munoglobulin, 72 hours before delivery, now successfully prevent this formerly fatal disease of the newborn); 2 ) successful treatment of kidney disease (persons who otherwise would have died or suffered severe disablement visit the hospital for dialysis-or have home units to do the job-permitting them to live a fairly normal life) ; 3) development of new surgical techniques: open heart surgery, vascular surgery, microsurgery, cryosurgery, organ transplants, use of homografts and heterografts; 4) development of the laser; 5 ) production of artificial limbs; 6) remarkable success in reducing the tremor and rigidity of Parkinson’s disease, achieved by coagulation of the globus pallidus or ventrolateral thalamus through insertion of a needle-like instrument; and 7) control of infectious diseases. The space program has been responsible for another area of change. More than a quarter of a million patients in the United States have already benefitted directly from this program. One big contribution came from the techniques of radio-telemetry, developed for the biomedical monitoring of astronauts during space flight. The same techniques have been adopted for monitoring blood pressure, respiration and temperature in the critically ill, postoperative and heart disease patients. Once patients are “hooked up” to a unit, a nurse down the hall is alerted when the triggering of electronic warning devices indicates need for prompt medical intervention. Such devices have saved many lives, and it is a safe prediction that soon practically every hospital in the country will have this equipment, at least in their concentrated care areas. Another important area of change is in treatment of diseases with a previously unfavorable prognosis. One such field is that of vital organ transplants and implantation of prosthetic devices, such as aortic valves. Biological sciences are probing every possible avenue to solve the problem of rejection
39
mechanisms. Once solutions are found, this achievement can lead only to development of new, highly technical products-and increased utilization of hospitals. DEMANDS OF PROGRESS The foregoing examples could be extended indefinitely. Changes have brought about improvements which everyone can enjoy, directly or indirectly; they can be measured in real dividends of reduced morbidity and mortality and of more years of useful life. Paradoxically, such heartening changes have created demands for even greater progress. The demand for health professionals is and will continue to be insatiable. In other segments of the economy, demand creates supply. In health services, supply creates demand. No sooner is a new treatment discovered than people want it. Yesterday there was no shortage because it didn’t exist; today there is a shortage because there’s not enough to go around. No wonder many doctors and nurses already feel they are running up the down escalator. Under our voluntary system, with an unregimented medical profession and over 7,000 hospitals, operating essentially as individual units, we have by no means attained perfection. In spite of our optimism, the health field is constantly under public attack for rising costs. And recent reports indicate that private health care costs of this country are going to continue to rise.
HOSPITALS’ HIGH COSTS There are three major reasons why hospital costs can be expected to continue their upward spiral. First, inflation shows no signs of stopping. Second, hospital employees’ salaries must increase. They were unbelievably low until the past five to ten years. They have been improved somewhat but truly professional levels have by no means been attained. Third, and most important, “a day of hos-
40
pital care” is not the same as it was back in 1946. More professional and technically trained personnel plus complicated scientific equipment account for the higher costs. Although the average patient cost per day is up to $4&$100 in some New York hospitals, it is still a good bargain. Contrast the expense to the price of a room in a first-class hotel costing from $15 to $22 a day. For that sum you receive a room and housekeeping services. In the hospital, the patient also receives nursing care around the clock and a room with three (sometimes five) meals a day; his physical wants are attended and lifesaving trealments and necessary supplies are available when needed. It is no fairer to compare a 1946 hospital bill with one in 1968 than it is to compare the cost of a DC-3 airplane with that of a modern jet-liner. Who wants to go back to hospital care as it was in 1946? The trend of rising operating expenses and salaries has brought about a number of changes in the principles and practices of hospital management. One important change has been the substitution of disposables for reusable products. The introduction of disposables in medicine can be traced to the early 1920’s. The military services were the first to use one of these products (syringe with needle) on a wide basis, but it wasn’t until after World War I1 that this item was widely adopted for hospital use. Until a few years ago it was almost unheard of for a hospital to change to the use of a disposable product until studies had demonstrated that the cost would be more than offset by savings in time and money. What happened? A number of things. For one, the operating room supervisor played a key role in stimulating acceptance and widespread use of disposables. Because of her dedication to total patient care and recognition that prepackaged, sterile disposables could contribute to a cleaner environment,
AORN Journal
she often took the lead in bringing together various sectors of the hospital organization to examine, consider and adopt the newer products.
satisfied another appears in its place. At the lowest level are the physiological needs-need for food is an example. Man will steal and even kill to get food, but once Since this evolution, the operating room this need is filled it no longer motivates. An supervisor is becoming more aware that she important principle to remember is this: a must consider her performance as a planner, satisfied need is not one that motivates behavorganizer, coordinator, manager, budget- ior. maker, and communicator if she is to meet When physiological needs, i. e., food and the new challenges of her expanding re- shelter, are reasonably satisfied, needs at the sponsibilities. next higher level begin to dominate man’s behavior and to motivate him. These are called safety needs, needs for protection against COMPLEX STRUCTURE The hospital with its organizational struc- danger, threat, deprivation. ture is among the most complex of organizaWhen physiological and safety needs are tions. It has two competing systems of au- satisfied, man’s social needs become importhority: the medical and paramedical, who tant motivators of behavior-for belonging, consider service to the patient the most im- for association, for acceptance by his felportant, overriding factor; and the admin- lows, for giving and receiving friendships istrative, which is caught up in the economics and for love. and maintenance problems that encroach on Next in the hierarchy of needs are the the quality and quantity of service. egoistic needs. These are the needs relating Also, the typical hospital is inhabited by to one’s self-esteem: needs for self-confiemployees with a variety of skills, back- dence, for independence, for achievement, grounds, duties and points of view. It doesn’t for competence, for knowledge, for status, for take much to have a breakdown in com- recognition, for appreciation, for the deserved munications which results in little or no ac- respect of one’s fellows. tion. This is truly the challenge of tomorrow Finally, a capstone as it were, are the -enlightened management to enable any of needs for self-fulfillment. These are the needs us to handle change. for realizing one’s own potentialities, for It is well known that greater changes can continued self-development, for being crebe effected through groups than through in- ative in the broadest sense. dividuals. But, to be successful in group proThe fact that management has provided ductivity, much depends on the ability of the for the physiological and safety needs has medical team to exchange ideas freely and changed motivational emphasis to the social clearly, to interact and to feel involved in and egoistic needs. Unless there are oppordecision making. tunities to satisfy these higher-level needs, people will feel deprived and dissatisfied and their behavior will reflect this deprivation. LEVELS OF CHANGE This need for teamwork has given strong The importance of attitude and motivation in impetus to a branch of theory known as “hu- job performance cannot be overeetimated. man relations in management,” which start“Direction and control” are essentially useed some 20 years ago. An interesting concept less in motivating people whose important is Maslow’s Triangle, illustrating the levels needs are social and egoistic-remember of change man goes through. Man is a want- your challenge is better leadership. Leadering animal: as soon as one of his needs is ship consists of getting things done through
December 1968
41
other people. The best method to accomplish this is to arrange working conditions and procedures so your people can achieve their own goals by directing their efforts toward organizational objectives. This is best done by creating opportunities, removing obstacles, encouraging growth and providing guidance. That is what Peter Drucker has called “Management by Objectives” in contrast to “Management by Control.” Simply, it is really the difference between treating people as children and treating them as mature adults. By allowing people to direct their creative energies toward organizational objectives, giving them some voice in decisions that affect them, opportunities will be provided for satisfying social and egoistic needs. Thus leadership creates change, and change creates the need for better leadership. With the steady flow of new products coming out in the hospital industry, the job of the operating room supervisor will become even more complex. The march of medical technology requires ever more sophisticated and expensive equipment and ever-increasing numbers of highly skilled people. To utilize to the maximum the skills of employees, registered nurses must develop their communication and leadership roles and institute educationally sound programs to prepare available manpower to perform at optimal levels. Recently, a professor of industrial administration at Carnegie-Mellon University predicted that the life cycles of products will become shorter and that as superior technology displaces products from traditional markets, firms will have to fight back by looking for new “pastures.” The resulting growth of internationalized markets will add to the competitive “turbulence.” The new environment will call for more managerial skills in human relations, Increasing importance will be placed on the supervisor so that her ability to communicate rapidly and intelligibly will gain acceptance
42
for change and innovation and will determine how effectively she can motivate and lead the operating room personnel in new directions. The way she “manages,” and the way she shapes her departments, affects and reflects how successful she is going to be. PREDICTIONS FOR MEDICINE IN THE YEAR 2,000 According to Dr. Oscar Creech, Jr., professor of surgery and chairman of the department of Tulane University School of Medicine, private practice in 1990 will no longer exist as it is known in the United States in 1968. He predicts: << -Medicine will be practiced on an assembly-line basis. -Physicians will be full time employees of geographical medical complexes, providing total care for residents of a community. -Physicians will be employed either on an annual fee basis or as salaried employees of the Federal Government. -Diagnosis, with few exceptions, will be performed automatically and interpreted by computer systems. -Patients’ entire medical records from birth will be instantly available from computerized medical information centers. -Intensive-care patients will be constantly observed by monitoring devices that will detect abnormalities and correct them automatically. -Physicians will no longer concern themselves with the routine practice of medicine, which will be done by others whose training is more vocationally oriented. -A new category of medical personnel, the “Clinical Associate,” will evolve. After high school these persons will have four more years of formal education, then a year of internship, which would allow the clinical associate to assume the functions performed by most practicing physicians today.” Neither patients nor physicians are ready now for such changes. “But if the past re-
AORN Journal
flects the future, radical changes in the practice of medicine are inevitable,” said Dr. Creech. Nursing can be expected to undergo equally dramatic changes. Already, nurses are being required to assume more of the practice of medicine. In the future, shortages in medical personnel will force the doctor to delegate even more of his duties to the profeesional nurse. What her role will be in year 2,000 is probably the biggest challenge faced by the profession today. Let us look ahead to the year 2,000 to see how medical care will be provided: A patient visits his community hospital, presenting himself first to the computer keyboard in the admitting office. He punches buttons correlating with symptoms and general complaints, then inserts his universal credit card. He next goes down the hall to the preparation room while the computer clicks out his complete medical history, retrieved from central files in Washington. He is greeted by a hypnotist, the first (and last) human being he sees, seated in a wheel chair and put into deep sleep. A nurse attaches devices to measure pulse, respiration, temperature, evaporation, skin color, brain waves, heart activity and many
other parameters recognized as important diagnostic inputs. The patient is hooked up to intravenous tubes for feeding and medication as needed. By remote control, from a master board, a nurse monitors his welfare. A cubicle, perhaps 3 x 4 ~ 5feet is the patient’s “home away from home.” A wheel chair rocks gently, pneumatic pads on its arms; seat and legs inflate periodically to help respiration and circulation. Nutrients and water are exactly controlled to balance bodily requirements and eliminate accumulation of wastes. No clothes are needed. Relieved of its physical and mental stresses, the body is free to recover, aided by drugs, radiation, special atmospheres, even vibration and sound. Some days later the patient is awakened, reclothed and given his electronically prepared bill. The incredible part of this fantasy is that a great deal of this regimen is already in existence today. The professional nurse can’t afford the luxury of apathy or complacency. Accept the challenge-the leadership and management of people by helping them to achieve their own goals. Only then will you and your profession find fulfillment.
BIBLIOGRAPHY “Eupsychian Management,” Abraham Maslow. “The Cost of Medical Care” Vol. 111, American Medical Association. “Disposables Study,’’ Romaine Pierson Publishers, Inc.
“Tomorrow’s Hospital,” Donald Carner, Executive Vice President, Memorial Hospital of Long Beach, California. Freda, V. J., Gorman, J. G., and Pollack, W. New England Jourllcll of Medicine 277:1022 (Nov. 9) 1967.
DIAGNOSIS Are things just not going right? Nerves shattered, tensions tight? Others at fault? That may be true; But could it be, at least partly, you? Examine yourself, and then look about, Discover the cause and put it to rout. Perhaps when self has been rearranged, You’ll discover all has happily changed. -Harry
December 1968
and Joan Mier
43