The members of the baby boom generation are those that were born after World War II (Adams & Beehr, 2003). This is a significant number of people entering the latter stages of life. As a result many of them will begin to feel the effect of old age and as a consequence, they add pressure into an already worn out U.S. healthcare system. At the same time, the impact of population growth and radical changes in migration patterns is causing a negative impact to a healthcare system that is stretched to the limit. Thus, hospitals and health centers require more qualified health personnel such as nurses. However, the pressure of work as well as rising expectations is just two of the factors that increase the frustration of new graduates. As a consequence, many of them will quit on their first year unless medical centers learn appropriate strategies to significantly reduce turnover rate. An overview of General Systems Theory can help nurse administrators to develop strategies to reduce nurse turnover.
Perioperative nursing refers to “the three phases of surgery: a) preoperative; b) intraoperative; and c) postoperative (Connolly & Komotar, 2010). New graduates that are assigned to work in perioperative care are required to have a higher level of competency than regular nurses. Even if they are hardworking and ready to learn more about the intricacies of perioperative care it is still a fact that perioperative nurses face more daunting challenges than those assigned to less demanding roles. There are two reasons for the added burden. First of all, the novice nurse has not yet acquired the experience needed to become a competent nurse. Secondly, the nature of the job means that even minor mistakes can lead to very serious consequences. This is the reason why many nurses, especially those who work in a high-pressure environment chose to quit on their first year – a staggering 29.5% turnover rate (Halfer, 2007). New graduates are overwhelmed by the pressure of a new job; thus one can easily understand the level of strain that perioperative nurses are experiencing regularly.
It should not be surprising to find out that the turnover rate is also very high in perioperative care. Nurse administrators have to develop effective strategies to ease the transition and policies must be developed to help new nurses cope with the reality of their profession – especially those assigned to the operating room. There are two probable solutions. The first one is to develop a management information system that can significantly improve efficiency by providing necessary information needed by nurses and improving communication to all workers. The second solution is to develop a mentorship program that can help new graduates deal with the challenges of their jobs as well as the special hurdles evident in perioperative care.
General Systems Theory
There are two major concepts related to General Systems Theory that can help nursing administrators deal with nurse turnover. The first one is openness and the other one is integration. With regards to the concept of “openness” in relation to systems theory, “Openness means that the behavior of living (open) systems can be understood only in the context of their environment” (Gharajedaghi, 2000, p.111). With regards to the concept of “integration” the following definition enables readers to understand systems theory much better: “general systems theory can be classified as a management approach that attempts to integrate and unify scientific information across many fields of knowledge” Kerzner, 2009, p.38). It can be clarified even further by stating that it is the attempt to “solve problems by looking at the total picture, rather than through an analysis of the individual components” (Kerzner, 2009, p.38). In the case of perioperative nurses the turnover rate cannot be reduced by simply improving the hiring process or by providing incentives to nurses like increasing pay.
This can be understood from the point of view of developing strategies to combat high nurse turnover rate. For instance, the development of mentorship program requires not only the inputs of the novice nurse and the mentor. Other members of the hospital can provide the needed inputs to develop a better system of training new nurses.
The same thing can be said about the creation of a viable management information system. The top administrator of the hospital must realize that the process is not simply limited to the creation of a storage device or a database system that can be accessed by authorized personnel. There are other factors to consider. The administrator must realize that there is a high level of interaction between physicians, patients, hospitals, clinics and the community in general.
Gharajedaghi asserts that there is “multidimensionality” in systems that leave many perplexed and the reason why many management initiated projects are left in the drawing board and has never seen the light of day. The author pointed out the folly of isolating components and forcing the organization to turn a blind eye on other important aspects of the system and he remarked:
Consider the relationship between security and freedom. One cannot be free if one is not secure; one will not be secure if one is not free. Maybe freedom, justice, and security are three aspects of the same thing and were not meant to be separated in the first place. Certainly, treating them in isolation has been problematic. (Gharajedaghi, 2000, p.112).
Applying Gharajedaghi’s insight into the creation of a management information system will help administrator develop appropriate solutions. It will help administrators create a blueprint that considers every player and every component of the system because it is a mistake to separate some aspects of the system and focus on them in isolation (Hickman et al., 1996). There are separate issues that must be treated as a part of the whole.
The significance of General Systems Theory in solving the problem of nurse turnover can be understood by looking at an organization as if it is a living organism and possessing different levels of complexities as seen in the following breakdown of parts: a) static structure; b) necessary predetermined motions; c) control mechanism; d) open system; e) genetic-societal level; f) animal level; g) human level; h) social organization; and i) transcendental systems (Roussell & Swansburg, 2006, p.9).
There are two ways to understand the static structure of the system, first there is an unchanging framework that means there is a hierarchy of health workers and administrators. In the case of nursing there are many nurses with different levels of education and skills. This framework can cause a dynamic behavior of the organization and at the same time it can cause static or no change in the organization. Thus, the second way to understand static structure is that an organization tends to move towards equilibrium. If there are no significant inputs that can change the system then the problem of high turnover rate continues.
When it comes to necessary predetermined motions, nurses move like clockwork (Roussell & Swansburg, 2006, p.9). Thus, there is continuous movement without realizing that new nurse are overwhelmed by the task as hand and could no longer cope. There is therefore a need for a control mechanism and usually this is the responsibility of the administrator. The administrator must work as a coordinator providing an overview of the operations management of the hospital to quickly determine problem areas.
It has been discussed earlier that the application of this theory is in the realization that the hospital can be compared to an open system or a cell-like organism that can only function if it can access outside resources. A hospital can never be a self-sustaining unit and so it must be open to ideas coming from the outside world. This is crucial when it comes to developing a management information system and a mentorship program especially if the administrator has no expertise with regards to Information technology and how mentoring should work.
The genetic-societal level informs administrators that there must be a clear division of labor. New graduates must work hard and they must learn to absorb as much information as possible. They must be exposed to different facets of the job. However, there must be a proper delineation of responsibilities to minimize work-related stress and to prevent confusion.
The animal and human level pertain to a higher level of awareness when it comes to the outside world and how nurses and nurse administrators can use insights gleaned from studying the business and industrial world for instance to improve healthcare service (Chinn & Kramer, 2004). This is similar to the open system described earlier but this time around nurses have a more proactive role in getting information from the outside world.
The two highest levels are “social organization” and “transcendental systems” (Roussell & Swansburg, 2006, p.10). In these two levels nurse managers and their subordinates are aware that there is a need to increase the ability to communicate effectively and to develop relationships and other interpersonal processes (Roussell & Swansburg, 2006, p.10). This is the reason why aside from developing an IT-based management information system, nurse administrators must also initiate a mentoring program. These two strategies enhance communication while at the same time improving the working relationships of the nurses thereby reducing turnover rate.
It has become increasingly clear that information technology is an indispensable part of any organization. Thus, a hospital cannot exist outside of the real world – there must be continuous learning process necessary to absorb useful information that can in turn be utilized to improve healthcare services. The application of General Systems Theory enables nurse managers and administrators to look for outside help.
Another application of this theory is the realization that the creation of an IT-based management information system requires the assistance and inputs of all stakeholders and this includes not only the physicians and the administrative staff but also the nurses and other users of the said information system. Thus, from the conceptual stage up to the delivery stage every stakeholder’s input is considered in the overall design of the system. This approach increases the level of acceptance of the system and helps develop a tool with fewer errors.
Many are in agreement that one of the best ways to deal with high turnover rate is the development of a mentoring program (Halfer, 2007). This is made possible by pairing of a novice with an expert or by creating small groups, mixing new graduates and veterans so that they can learn from each other. The veterans gain an understanding of the difficulties that new graduate face in perioperative care and they can offer insights as well as provide inputs that can be used by administrators to improve the system.
Parsley comments on the difficulty of constant need for professional development and the obligations to maintain knowledge and proficiency and he remarked, “This is a particular challenge to professionals where new knowledge is growing at a rapid rate […] This problem is compounded for other clinical professionals […] who need to keep abreast not only of advances in the diagnosis treatment but also of the associated changes in their professional knowledge” (1999, p.12). Administrators may feel that they already know everything and falls into a trap that prevents them from improving their ability to manage and at the same time create an environment conducive for learning.
The first step is to evaluate the different levels of competency (Benner, 2011):
- Stage 1 – Novice
- Stage 2 – Advanced Beginner
- Stage 3 – Competent
- Stage 4 – Proficient
- Stage 5 – The Expert
It can be argued that new nurses are sustained by rules (Benner, 2011). In other words aside from what they learned in school there is practically nothing that they know about the specific requirements of a particular hospital or specialized care like perioperative nursing. They may have technical knowledge but the proper application of that knowledge requires the steady guidance of an expert. Rules are easy to read but difficult to understand in the context of a specific setting. Thus, a new nurse can interpret the rules differently and commit errors. The unwanted accumulation of stress-related work can be avoided if there is a more proficient veteran nurse that can show them the ropes so to speak.
New nurse had no prior experience regarding a specific task and they cannot look back on a particular incident that they can use to solve a particular problem. New nurses have not yet developed the necessary wisdom gained through experience that they use to help them solve a critical dilemma in the workplace/ According to Benner their situation is made more difficult by rules that are context-free and independent of specific cases (2011). Thus, if the situation that they are in has not been described in their manual then they can be paralyzed by indecision and unable to contribute.
The creation of an IT-based management information system and the development of a mentoring program are well-grounded on theory. The idea of providing a helping hand and creating a mentoring program is supported by insights gleaned from the study of General Systems Theory. It is important to apply the principles of “open system” as well as the principle of “integration” to deal with the problem with an eye towards the big picture. In application the mentoring program is the realization that rulebooks and manuals cannot reduce the turnover rate because new nurses can only acquire necessary knowledge through hands-on learning and by observing an expert at work.
The input-output scheme outlined in Fig. 1indicates the importance of the interaction between two types of environment the internal and external environment. The administrator must realize that a boundary exists that prevents the movement of information from the outside world into the closed system of the hospital. The administrator must adopt a position that would enable the hospital to become an open system. In this way there is less resistance to change.
There is also the realization that the hospital may not have the resources to implement change such as the development of a management information system and mentoring program. The requirements may have to come from outside the system. It may come in the form of consultants that are brought in to develop new tools and applications. The inputs can come in the form of books and seminars that key leaders of the hospital must access to affect change. But every time a strategy is developed the administrator must be mindful of a feedback mechanism to collate information from all the stakeholders such as a administrative support staff, new nurses, senior-level nurses, physicians, patients etc.
The use of General Systems Theory enables hospital administrators to develop strategies that require inputs from both the internal and external environment. There is also a heightened realization that all the personnel working in the hospital including the patients that are under their care constitutes a part of the whole. The administrators cannot afford to treat the problem in isolation. Solutions must be developed with an eye towards the big picture and an overall assessment of the whole system with interconnected parts.
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