Founded in 1895, Hospital XYZ is a multi-site health care institution which provides a wide range of medical, surgical, obstetric, gynecological, dental, psychiatric, pediatric and other services, including an extensive ambulatory care network. It is a 287 bed facility and has 21 outreach clinics. It houses a new state-of-the-art emergency room and New York City’s first dedicated tuberculosis unit.
Other special services include a 24-hour Psychiatric Emergency Room, the Center for Mental Health, Mobile Crisis Intervention and the Special Treatment Unit for individuals afflicted with AIDS. Hospital XYZ’s emergency room is very active and renders services to more than 52,000 of the residents of the local area. The units are open 24 hours a day, seven days a week with a 911 certification for level two trauma and hospital XYZ is a designated American Heart Association station.
Currently, Hospital XYZ is undergoing the process of restructuring and it involves a change in leadership, downsizing, the exploration of strategic management techniques which hopefully will improve the cost-effectiveness of care delivery and an improvement in the overall business processes. The institution has just closed one of its facilities and this meant the gradual reduction in bed capacity from 650 to 287 beds. This decrease justified management’s position that downsizing was inevitable.
The affected population included nursing staff, doctors, clerks and environmental service workers. In total, there were forty registered nursing positions eliminated, some as a direct result of attrition. This restructuring and downsizing has had severe emotional and psychological effects on both the remaining staff and those who lost their jobs as a result of downsizing. In this paper, I will examine the effects of downsizing from a theoretical standpoint utilizing the organizational theory presented in Robins & Judge (2007) and further clarified in the vast body of literature on the subject of organizational behavior.
Hackman discussed several theoretical approaches that have guided many work redesign initiatives (Scott, 1966; Scott, 1998). The approaches range from a distinctly psychological focus, exemplified by activation theory, to the system-focused perspective of socio-technical theory. Activation theory acknowledges problems within organizations that are related to human behaviors associated with the nature of work assigned to employees (Scott, 1966). The issues involve assigned work that is perceived to be routine and repetitious. The resultant problems included diminished alertness, decreased responsiveness to new inputs and impairment of muscular coordination.
Activation theory proposes that a person’s activation decreases when sensory input is repetitive and that varying patterns of stimuli keeps an individual more alert. Hackman suggested that activation theory is most useful for understanding the consequences of jobs that are significantly under-stimulating. Anecdotally, this is how many hospital pharmacists describe the task of medication cart checking.
An influential theory of work redesign is Herzberg’s two-factor, or motivation-hygiene, theory (Scott, 1998; Hertzberg et. al., 1959). Based on the premise that there are two categories of factors in existence, the two-factor theory proposes that there are intrinsic or motivating factors, as well as extrinsic or hygiene factors. The motivators include factors such as recognition, achievement, responsibility, advancement and personal growth.
The theory suggests that when present, these conditions build motivation. However, in their absence, dissatisfaction does not result. Conversely, hygiene factors are variables such as organizational policies, compensation, working conditions and supervisory practices. In the presence of these factors, a level of no dissatisfaction is maintained. When the conditions are not present, dissatisfaction is a result.
A theme that was discussed in multiple sources was the “socio-technical” systems theory (Scott, 1998; Hackman, 1985). The approach emphasizes the vitality of designing work systems which emphasize the necessity for the social and technical aspects of the work place to be integrated as well as to serve as mutual support for each other. Scott discussed this theory within the context of the open-natural perspective.
The unique, distinguishing feature of an organization, according to the theory, was that it exits as both a social and technical system. A cursory examination of a hospital will likely reveal a highly socio-technical system, with its emphasis on both human-touch care and its utilization of advanced technological equipment. Additional research has indicated that the opportunity to utilize one’s abilities and education is an important motivational factor at the employee level that has implications at the organizational level (Besier & Jang, 1992).
In the late 1950’s, Festinger developed the theory of cognitive dissonance that examined the relationship between attitudes and behavior (Festinger, 1957). Referencing the acknowledged inconsistency between one’s attitudes and behavior, Festinger suggested that a person senses a level of discomfort created by the variance between attitudes and behaviors. Additionally, the greater the variance between the attitudes and behaviors, the higher the discomfort level. Thus, the individual would seek to minimize the disparity.
Weick and Quinn authored an important work in the area of organizational Change (Weick & Quinn, 1999). The article was a review of significant literature in the subject area from 1951-1997. Among the terms utilized, defined, and discussed were continuous and episodic changes. The term continuous, or first-order change, was used to group together organizational changes that tended to be ongoing, evolving, and cumulative.
The distinct quality of continuous change was the idea that small, continuous adjustments, created simultaneously across units, could accumulate and create substantial change. By contrast, episodic change was used to describe organizational changes that tended to be infrequent, discontinuous and intentional. Each of the terms was described in additional detail, with numerous citations provided for specific applications.
The Weick reference was valuable for several reasons. It provided a literature citation to the work of O’Toole, which will be discussed in greater detail later in this chapter (O’Toole, 1995). The reference also contained a citation by Van de Ven and Poole that discussed the situation of failed change interventions (Van de Ven &Poole, 1995). The brief discussion suggested that failed interventions were related to mismatches with prevailing conditions.
The discussion was similar to the Holland-Nimmo practice change model. The model suggests that practice change in pharmacy is dependent on the conditions of learning resources, motivational strategies and practice environment conditions that support the desired practice-change initiative. It is the practice environment component theme that is particularly intriguing. Sevon also addressed a theme referenced in the work by Weick and Quinn (Sevon, 1996).
The theme was summarized by the statement “every theory of organizational change must take into account the fact that leaders or organizations watch one another and adopt what they perceive as successful strategies for growth and organizational structure.” (Weick & Quinn, 1999). Both Gerber and Arndt/Bigelow discuss the “bandwagoning” effect and how hospitals specifically have entered into restructuring programs for the wrong reasons (Gerber, 1983; Arndt & Bigelow, 1996).
Those reasons may have been related to the attempt to reach unattainable objectives. In addition, those objectives may have never been obtained by other organizations through similar restructuring programs. By adopting the structure, organizations are sending a clear message that they intend to adhere, evening light of the fact that the activity does not change the underlying functionality of the organization (Porter-O’Grady, 1996). It might be suggested that there must be a more objective reason to undergo an organizational change than to “fall in line” with other organizations, particularly in an environment of limited and shrinking resources.
Several resources provided discussions regarding valuable definitions and theories concerning organizations and change within their structures. Scott presented three perspectives on the viewing of organizations (Scott, 1998). The first perspective viewed organizations as rational systems that “are collectivities oriented to the pursuit of relatively specific goals and exhibiting relatively highly formalized social structures.” The second way an organization could be viewed was as a natural system.
Scott defined that perspective as “organizations are collectivities whose participants are pursuing multiple interests, both disparate and common, but recognize the value of perpetuating the organization as an important resource. The informal structure of relations that develops among participants provides a more informative and accurate guide to understanding organizational behavior than formal.”
The third perspective was the view as an open system of “interdependent activities linking shifting coalitions of participants: the systems are embedded in – dependent on continuing exchanges with – and constituted by- the environments in which they operate.” While these definitions were helpful in understanding the essential and responsive nature of an organization, they tended to be over simplifications. Scott continued the discussion with examples of combined perspectives, or integrated models, such as layered, closed-rational and closed-natural systems. These discussions were quite useful in that they combined and reconciled the different perspectives. They were also useful in that they more precisely described the dynamic nature of organizations as they exist within their respective environments.
A logical component of a discussion on organizational change is that of resistance-to-change. Several authors have dealt with this subject extensively (Kotter, 1996; O’Toole, 1995; Argyris, 1991). A central theme for these authors deals with resistance-to-change within the organization’s rank-and-file employees related to the behavior of management. Argyris described the term “theory-in-use” as the development of rules to make sense of people’s behavior, particularly when that behavior was inconsistent with their espoused beliefs (Argyris, 1991).
The same idea was echoed by Kotter (1996) when he stated that “perhaps worst of all are bosses who refuse to change and who make demands that are inconsistent with the overall effort.” O’Toole (1995) suggested that “to overcome resistance-to-change, one must be willing, for starters, to change oneself.”
While a great deal of O’Toole’s book dealt with resistance-to-change, an equally important discussion was centered on the differences between contingency theory of leadership and values-based leadership. Contingency leadership theory, according to O’Toole, was the belief that in order to implement change, effective leaders do whatever the circumstances require. However, the author suggested that evidence continues to mount that contingency leadership is ineffective.
A weakness in O’Toole’s argument was that no specific examples were cited. Instead, a generalization consisted of “all around we see signs of failure: the depressing social and organizational indicators that point to the inability of leaders to bring about constructive change.” No direct connection was made between those failures and the utilization of contingency theory of leadership. The possibility exists that the leaders were simply ineffective, regardless of what style of leadership they utilized.
For instance, O’Toole used the example of President Jimmy Carter, who he described as “the most moral of presidents in both private and public life, yet he was not a great president.” While the point the author was attempting to make was understood, there was not compelling evidence that his example supported the case he was attempting to build.
Values-based leadership was characterized by leaders who “listen to their followers because they respect them and because they honestly believe that the welfare of followers is the end of leadership (and not that the followers are the means to the leader’s goals).” (O’Toole, 1995). It was not until the following chapter that supportive examples were provided that values-based leadership can be successful. These examples were presented in the case studies of his “Rushmoreans”, Max DePree (Herman-Miller), James Houghton (Corning), Robert Galvin (Motorola), and Jan Carlzon (Scandinavian Airlines).
The individuals in his case studies exhibited characteristics such as integrity, trust, listening, and respect for followers. It was those characteristics, said O’Toole that allowed leaders who used a values-based leadership style to be successful. It was also the lack of those characteristics exhibited by leaders who practiced a contingency style that destroyed the trust essential to win people over to change. It would have been a more convincing argument regarding the dismal failure rate of contingency theory had there been specific modern-day examples provided.
A discussion by Gladwell (2002) concerning change makers was remarkably similar to that of O’Toole’s values-based leadership theory. The analysis centered on characteristics of an individual that makes him/her a “connector”. Gladwell used the example of Paul Revere and William Dawes, who were both involved in the “British are coming” message. While Revere’s ride started a word-of-mouth epidemic, or in other words, Revere’s news “tipped”, Dawes’s message did not. Gladwell defined a tipping point as “the moment when an idea, trend, or social behavior crosses a threshold, tips, and spreads like wild fire.”
Author David Hackett Fischer described Revere as an individual with an “uncanny genius for being at the center of events.” (Gladwell, 2002). Fischer attributed the success of Revere’s ride to his social gifts. Apparently, William Dawes did not possess such a level of social connection. This sounded remarkably similar to O’Toole’s description of successful change makers who possessed the characteristics of integrity and trustworthiness. In Gladwell’s discussion of the “Law of the Few” and the “Stickiness Factor”, he acknowledged that the content of the message was important. However, just as important were the messengers who carried the information. Both O’Toole and Gladwell emphasized the importance of leaders with high quality personal characteristics.
The primary gap in the literature reviewed deals with a phenomenon that has occurred relatively recently within the health care industry. It involves a variation of the merger theme: culture within an alliance or an association. There is an absence of literature involving effective methods for implementing change within a multi-cultural organization. While mergers have occurred within health care, it is just as probable that the “affiliation” will be an integrated health care delivery system (IDS), or as Shortell described it, an organized delivery system (ODS) (Shortell, 1996).
The latter term was chosen because it was believed that at the time, pre-1996, that an IDS was an end point that few, if any, systems had achieved. The mission of an IDS was to provide “womb-to-tomb” or “cradle-to grave” health care services. For example, the system would provide pre-natal, obstetrical, neo-natal, pediatric, adolescent, adult, geriatric and even hospice care, along with all of the specialties for each of the age groups. My experience in health care has been that these services have been provided by organizations that many times, instead of merging, become associated or aligned.
In addition to the work previously described by Hackman, a review of selected change models is appropriate. However, when the change requires movement from a product-oriented practice to a patient-centered one, the models based on those described by Hackman may not be sufficient. Literature suggests that many traditional job incentives are not available in contemporary hospital pharmacy practiced (Holland & Nimmo, 2000).
Pressures to contain departmental budgets make increases in salaries a challenging task. Simultaneously, theories that suggest advancement or recognition as factors that motivate change incur barriers in organizations that flatten structure, thus reducing opportunities for promotion. The Holland Nimmo practice change model (HNPCM) is based on learning theory. Krathwohl’s Taxonomy of Affective Learning forms a platform for the HNPCM in that it focuses on the teaching of values and attitudes (Holland & Nimmo, 2000).
This is related to Festinger’s cognitive dissonance theory in which the relationship between an individual’s values and behavior is of primary focus (Festinger, 1957). Krathwohl’s taxonomy proceeds through an individual’s re-socialization process that begins with receiving information regarding the new practice, responding to the information, valuing the new practice at the organizational level, making priorities for the change in practice, and establishing the change as a person value.
The Transtheoretical, or Prochaska-DiClemente change model encompasses a process that includes the stages of pre-contemplation, contemplation, preparation, action and maintenance (Prochaska & DiClemente, 1982). The initial stage, pre-contemplation, describes the point at which there is no intention on the part of the individual to alter behavior in the foreseeable future due to problem unawareness. Once that recognition occurs and thought about possible change is present, the individual has arrived at the contemplation stage. The preparation phase occurs when the individual begins to commit to making some form of change. The action stage is exemplified by behavior modification. Lastly, during the maintenance phase, the individual works to prevent relapse. This stage may be life-long in duration.
Much of the previously reviewed literature relates to the activity of motivating individuals to change attitudes and values within the pharmacy work environment. The discussion that follows involves the development of a pharmacy practice change model by Ross Holland and Christine Nimmo—the Holland-Nimmo practice change model. According to this model, the responsibility of practice change lies with the individual pharmacist because the decision to change ultimately rests with the individual practitioner, not the organization. However, the facilitator of the change is the manager with whom leadership responsibility is entrusted by the organization (Holland & Nimmo, 1999b).
Such is the theme developed by Holland and Nimmo in a series of five articles in which they examined the evolution of pharmacy practice in the United States and elsewhere (Holland & Nimmo, 1999a; Holland & Nimmo, 1999b; Holland & Nimmo, 1999c; Holland & Nimmo, 1999d; & Hammer & Champy, 1993). The discussion of the current state of pharmacy practice models-distributive, drug information, clinical pharmacy, self care and pharmaceutical care provides background for the effective use of the Holland-Nimmo practice change model (HNPCM).
For the purposes of this study, the pharmacy distributive practice model will be composed of the following activities: ensuring the completeness of a medication order before preparing or permitting distribution of the first dose, interpreting the appropriateness of a medication order before preparing or permitting distribution of the first dose, following established policies and procedures to maintain the accuracy of the patient profile, preparing medication products by using appropriate techniques and following established policies and procedures, dispensing medication by following established policies and procedures, providing basic medication-use information to patients, and following accepted policies and procedures to document medication distribution activities.
The HNPCM proposes that there are three sets of conditions that must be simultaneously satisfied before the change is likely to be implemented. If any of the conditions is not met or is not met simultaneously with the others, it is predicted that the process of achieving change will be less than anticipated (Holland & Nimmo, 1999b).
As discussed previously, one of the major themes derived from the reviewed literature is that organizations have not historically achieved the degree of success expected from work redesign. It is possible that the operations aspect, or the processing of new job task activities, have received the majority of attention at the expense of preparing employees to successfully implement and sustain those changes. The examination of this practice change model is of value within the profession of pharmacy because it stresses the importance of preparing employees to adopt changes that the organization has identified as being necessary to obtain its stated objectives.
The HNPCM consists of three components: practice environment, learning resources, and motivational strategies. The element of practice environment suggests that there must be an environment in place that supports the opportunity for the practitioner to engage in activities of the new practice model. Inherent in the creation of this environment are managerial responsibilities, since such environments do not generally occur on their own.
Such responsibilities include, but are not limited to, planning, implementing, and nurturing. Activities within this process may be the acquisition of necessary resources, rewriting of job descriptions and redesigning job activities and tasks. An additional requirement of this component is an investment in training of staff in order to achieve the necessary skills and knowledge needed to affect the desired change and outcome. The influence of environmental impact is important whether the setting is social, educational or organizational (Lindquist, 1978; Havelock, 1971; Dunphy, 1981). An important criterion to be met in this category deals with the necessity to re-engineer jobs, if necessary, to provide pharmacists time to undertake new professional activities (Holland & Nimmo, 1999c).
The second component of the model is the acquisition of learning resources that enable the practitioner to become knowledgeable and skilled in the new practice environment. There are several issues that must be addressed within this component. These issues include materials/programs, awareness, access/affordability and time. Stated another way, practitioners involved in a practice change must have an awareness of accessible and affordable materials and programs that educate them on the specifics of the practice change. They must also be provided the time necessary to take advantage of those educational resources. Krathwohl’s Taxonomy of Affective Learning is of particular importance to the component of learning. Elements of receiving and responding are crucial to the functioning of this activity (Holland & Nimmo, 2000).
The third component of the HNPCM is motivation. Even with the first two components in place, with no motivation to change, there usually is none. Significant consideration by management to issues of incentives and reward systems must occur. Managers, wishing to influence their staff, must account for the mindset of each practitioner and apply a systematic motivational process that will maximize the possibility of a decision to implement the desired change (Holland & Nimmo, 1999b). The previously discussed work in the area of motivational theory as described by Hackman, Herzberg, and Scott are important to this component (Scott, 1998; Herzberg, 1959; Hackman, 1985).
The practice change model suggests that in order to achieve maximum potential for individual pharmacists to change their practice, managers must simultaneously fulfill three responsibilities: creation of an environment conducive to the new form of practice, identification of learning resources to enable necessary knowledge and skills to be acquired, and motivation of individual practitioners to change (Holland & Nimmo, 1999b). The relationship of the practice change model components to organizational behavior theory is illustrated in the grid that follows.
The Holland-Nimmo practice change model (HNPCM) within the framework of Organizational Behavior
Adapted from: Robbins, Stephen P., Organizational Behavior: Concepts, Controversies, Applications
After having examined organizational behavior utilizing a hospital currently in the process of restructuring it is prudent to restate the fact that organizational behavior is a complex entity. It is one that involves a multidisciplinary approach in other to assure the goals of the organization are met and the needs of its employees are managed utilizing the constructs of psychology as well as all of the other pertinent disciplines. In order to clarify this virtual maze, it is prudent that we examine these notions from a theoretical standpoint and then practically applying the theoretical constructs. A true understanding of organizational behavior can only be attained through a meeting of theory and practice. When the two meet, it makes for an interesting view of the integral elements of organizational behavior.
References
Argyris, C, Teaching Smart People How to Learn. Harvard Business Review, 1991. p. 99-109.
Arndt, M., Bigelow, B., Benefits and Disadvantages of Corporate Restructuring: The Hospital View. Hospital Topics, 1996. 74(1): p. 21-25.
Besier, J.L., Jang, R., Factors affecting practice-area choices by pharmacy students in the Midwest. American Journal of Hospital Pharmacy, 1992. 49(3): p. 598-602.
Dunphy, D.C, Organizational change by choice. 1981, Sydney: McGraw-Hill.
Festinger, L., Theory of Cognitive Dissonance. 1957, Stanford: Stanford University Press.
Gerber, L., Hospital Restructuring: Why, When & How. 1983, Chicago: Pluribus Press Inc.
Gladwell, M., The Tipping Point: How Little Things Make a Big Difference. 2002, Boston: Little Brown and Company.
Hackman, J.R., Work Redesign for Organizational Development, in Readings in Human Resource Management, M. Beer, Spector, B., Editor. 1985, The Free Press: New York. p. 528-544.
Hammer, M., Champy, J., Reengineering the Corporation: A Manifesto for Business Revolution. 1993, New York: Harper Business.
Havelock, R.G., The change agent’s guide to innovation in education. 1971, Englewood Cliffs: Educational Technology.
Herzberg, F., et al., The Motivation to Work. Second ed. 1959, New York: Wiley.
Holland, R. W., Nimmo, CM., Transitions in pharmacy practice, part 2: Who does what and why? American Journal of Health-System Pharmacy, 1999b. 56(19): p. 1981-1987.
Holland, R.W., Nimmo, CM., Transitions in pharmacy practice, part 3: Effecting change-the three ring circus. American Journal of Health-System Pharmacy, 1999c. 56(21): p. 2235-2241.
Holland, R.W., Nimmo, CM., Transitions in pharmacy practice, part 4: Can a leopard change its spots? American Journal of Health-System Pharmacy, 1999d. 56(23): p. 2358-2462.
Holland, R.W., Nimmo, CM., Transitions in pharmacy practice, part 5: Walking the tightrope of change. American Journal of Health-System Pharmacy, 2000. 57(1): p. 64-72.
Holland, R.W., Nimmo, CM., Transitions, part I: Beyond Pharmaceutical Care. American Journal of Health-System Pharmacy, 1999a. 56(17): p. 1758-1764.
Kotter, J., Leading Change. 1996, Boston: Harvard Business School Press.
Lindquist, J., Strategies for Change. 1978, Berkeley: Pacific Soundings.
O’Toole, J., Leading Change: Overcoming the Ideology of Comfort and the Tyranny of Custom. 1995, San Francisco: Jossey-Bass.
Porter-O’Grady, T., The Seven Basic Rules for Successful Redesign. Journal of Nursing Administration, 1996. 26(1): p. 46-53.
Prochaska, J.O., DiClemente, C.C., Transtheoretical therapy toward a more integrative model of change. Psychotherapy: Theory, Research, and Practice, 1982.1(3): p. 276-287.
Scott, W.E., Activation Theory and Task Design. Organizational Behavior and Human Performance, 1966. 1: p. 3-30.
Scott, W.R., Organizations: Rational, Natural, and Open Systems. 1998, Upper Saddle River: Prentice Hall.
Sevon, G., Organizational Imitation in Identity Transformation. Translating Organizational Change, 1996: p. 60-61.
Shortell, S.M., et al., Remaking Health Care in America: Building Organized Delivery Systems.1996, San Francisco: Jossey-Bass.
Van de Ven, A.H., Poole, A.S., Explaining Development and Change in Organizations. Academy Management Review, 1995. 20(3): p. 510-540.
Weick, K.E., Quinn, R.E., Organizational Change and Development. Annual Review of Psychology, 1999. 50: p. 361-386.