Walker (1950) described a job enlargement scenario in IBM Endicott. This was said to increase production rate and quality (supposedly via increased job satisfaction). This case study was critical to illustrating the interconnectedness of job content (including technological factors), ‘intrinsic’ reward and productivity, within the human resources tradition. It is also important to note that, in this instance, the culture of IBM Endicott was conducive to the job enlargement programme, indicating the need to recognize the role of wider factors in the job content/job satisfaction/output equation (Hollway, 1991: 100).
Case Study 4.2: The Longwall Method of Coal Getting
Trist and Bamforth’s (1951) seminal study of a coal mine as a ‘socio-technical system’ launched the concept of the autonomous workgroup. The study looks at the implications for miners in a Durham colliery of a new method of goal getting (the Longwall method). This new method created many problems, including reduced worker cooperation and trust between workers on different shifts, higher levels of ill-health and productivity deficits. This was attributed to the decease imposed by change in worker and workgroup autonomy, de-skilling, and curtailed opportunities for communication by creating greater temporal and spatial distance between workers and created a new intermediate social structure with high task and remuneration interdependence but no social integration. Trist and Bamforth (1951) called for those involved in organizational restructuring to see how changes to technical systems (machinery, work layout) can have a profound unanticipated effect on the social system. They recommend that companies strive for maximal congruency of task and social work structures (in this case ensuring that task interdependence operates chiefly within rather than across shifts) and preserve or introduce ‘responsible autonomy’, job rotation, flexibility and meaningful whole-tasks to small workgroups. When ‘group production’ was introduced into this system, the problems described earlier were solved. From this and other work, Trist and colleagues went on to formulate socio-technical systems (STS) theory (Emery & Trist, 1969).
Whilst STS theory addressed itself mainly to the problem of introducing new technologies to a social system without addressing the human dimension, its legacy is now more firmly associated with the concept of an autonomous workgroup as a panacea work design solution for the manufacturing sector. Many European companies took up this panacea promise in the 1960s and 1970s as a means of addressing problems of high absenteeism, strikes and sabotage, low product quality and coordination difficulties rife in the manufacturing sector at the time (Den Hertog, 1977).
Case Study 4.3: Leadership in the National Health Service
Recently, various high profile media cases have raised the salience of the leadership issue in the UK National Health Service (NHS) in the public mind. Examples where lack of effective leadership (and the lack of inter-professional collaboration or teamwork) has been an explanation for inadequate (‘fragmented’) health care practice include the public inquiry into cardiac surgery at Bristol Royal Infirmary (www.Bristol-inquiry.org.uk/final_report, HMSO 2001), and the death of Victoria Climbié (Department of Health, 2003). Such cases, coupled with the reality of inter-agency health care, have created an unprecedented increase in organizational complexity, making inter-professional collaboration a contemporary health care imperative. As Griffiths (2003: 144) notes, ‘interface issues are likely to assume increasing strategic importance over the next few years and the boundaries between primary, secondary care, health and social care and treatment and prevention will demand closest attention’.
The issue of leadership is in fact now central to NHS modernization strategy and policy. The Department of Health (Department of Health, 1999, 2000, 2001) has launched a number of major leadership initiatives in recent years, all of which are in one way or another distilled in the NHS Plan (2001). The Modernisation Agency was established to mobilize and implement (among other things) various leadership initiatives, all of which are now coordinated by a designated Leadership Centre (established in May 2001). Such initiatives include clinical governance, citizenship, primary care group leadership, the chief executive programme and clinical leadership development. All initiatives argue that integrated multi-professional care is only possible to the extent that professional and directorate barriers are broken down, and a culture of shared clinical governance is cultivated in which staff are empowered to accept responsibility and accountability at all levels of the hierarchy. In practice this involves clinical audit, risk management, user involvement, evidence-based practice, continuous professional development, management of inadequate performance, reflective practice, team building and team review (Valentine & Smith, 2000). Effective leadership is clearly a key to making this vision an everyday reality.
Several have noted the critical importance of front-line leadership in the development of integrated teamwork, one part of which will involve making the team process visible and something to reflect upon, and actively manage, particularly if there are blocks to the effective formation of collaborative partnerships arising from professional differences (for example, Department of Health, 2001c).
Integral to the modernization programme is the need for professionals to become more involved in leadership. In the words of Crisp (2001):
Leadership must be exercised at all levels in all settings in the clinical team and in support services, in the ward and in the community and in the boardroom. Leadership is about setting direction, opening up possibilities, helping people to achieve, communicating and delivery. It is also about behaviour. (NHS Modernisation Agency, 2001)
Given that nurses (and midwives) deliver 80 percent of all health care, the birth of the concept of clinical leadership, and in particular the idea that nurses should play a critical role in implementing the new NHS (‘Shifting the balance of power: the next steps’, DOH, 2002) is thus not a surprising development in the NHS vision (Jasper, 2002: 63). The Royal College of Nursing (RCN) response to this is embodied in the National Nursing Leadership Programme as a vehicle for ‘leading the process of change’ (
www.nursingleadership.co.uk), involving the introduction of ‘bigger nursing roles’ (‘Liberating the talents: helping nurses and PCTs to deliver the NHS plan’,
www.doh.gov/cno/liberating talents).
One of the problems, however, with implementing these initiatives (and making the vision a reality) is the possibility (suggested by many nurse commentators) that clinical leadership will become yet another management fad, translated into a preoccupation with local planning and control, rather than making a real difference to the care delivery process through effective relationship management. The task of leadership is made even more difficult by the absence of a uniting framework for leadership theory.
Case Study 4.4: Groupthink in Practice
Griffiths and Luker (1994) provide a case study illustrating groupthink at work. Sixteen District Nurses (DNs) working in two primary health-care centres were operating as caseload managers, authorized to carry out patient assessment and make decisions about treatment. Griffiths and Luker found that DN practice was underpinned by ‘unspoken’ group rules that preserved team harmony and cohesion at the expense of client needs and interests. The main ‘rule’ they uncovered declared that it was unacceptable to commit a colleague to anything when carrying out a first assessment visit on their behalf. They could cover for absence but were unable to interfere by offering opinions, question their nursing decisions or provide nursing input.
The culture in which these invisible rules had become entrenched was one of ‘collegiality‘, that is, intra-professional respect and mutual support. This resulted in the evolution of a protective norm making it unacceptable to either appraise or criticize one’s peers. This in turn inhibited the possibility of patient involvement and choice in care decisions.
Appendix 7 Socio-technical Systems Theory
· The work system is an open system, which means, for example, that environmental factors have knock-on consequences for working practices – for example, heightened competition. STS theory proposes that the consequences of turbulence should be dealt with by the affected groups to allow them the freedom and flexibility to respond as they see fit (rather than the problem being addressed at the top, and dictated down). This principle emphasizes that organizational design, involving the simultaneous consideration of social/behavioural and technical systems, is an ongoing process. Evaluation and review must continue indefinitely (incompletion).
· People should be allowed to use their own ingenuity at the front line of production so long as they are appropriately trained and supported, rather than be required to operate only through procedures. This entails management by objectives or goals (what is to be achieved) rather than procedures (how work is done) (minimal critical specification).
· Problems in production and its quality should be addressed at source, by those responsible (socio-technical criterion).
· The workgroup should be provided with all necessary information to furnish its self-regulatory ability including information about customer feedback (information flow).
· Boundaries between groups should be sufficiently permeable to allow information and knowledge exchange and not tied to technological functions. For instance, planning, implementing, and quality inspection should be undertaken within the same group rather than being separated into distinct functions, to facilitate communication (Boundary Location).
· Groups within the same organization are in a dynamic interrelationship so optimizing one cannot be undertaken without optimizing the other. There should be consistency across all human support systems and the organizations’ design and general philosophy. For example, an incentive system based on individual output would be counter-productive in a team-based structure (support congruency).
· There is no one best way to complete a task successfully. Jobs should be designed so that they are reasonably demanding and provide opportunities for learning, decision making, and recognition (design and human values).
· One should look at the long-term impact of change, as there may be some unintended consequences.
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