Nursing Efficiency as the Link Between Service and Science

1. Nursing Efficiency as the Link Between Service and Science Presented by: Stephanie Luman, MSN, RN

2. Rejection of Nursing as a Profession Continued into the Early Twentieth Century

3. Old Barriers Blocked the Way Toward Nursing Advancement • Students were the best and cheapest nursing personnel. • Physicians fought for nurses to remain subordinate. • No public understanding of the difference between trained and untrained nurses.

4. Nursing Leaders Forged Ahead • Sought out a new language and set of practices to transform nursing into the 20th century. • Adopted the Progressive Era’s drive for efficiency to redefine nursing. • Sought to change the traditional emphasis from “one right way” to a more scientific approach of the “one best way.”

5. Efficiency Expectations in the 20th Century • Hardworking, disciplined, unemotional, and willing to become an effective expert. • Systematic breakdown, analysis, and timing of steps. • Separation of mental labor from manual, in search for the “best way.” • Incorporated managerial control. • Link between service and science • Helped forge nursing’s way into a profession.

6. Redefining the Purpose of the Hospital • By the early 1910s, hospitals had grown in number, size, and complexity. • The hospital’s purpose changed from a charitable enterprise to an institution that sold care as a commodity. • Nursing leaders used the ideas and methods for efficiency and scientific management to push to legitimize, upgrade, and standardize nursing.

7. Borrowing a Volume from Industry • Just as industry began to boom, so did hospitals. • Hospitals began to view their patients as sources of income, rather than charity. • “Should a hospital be run like a business?”

8. Time for Compromise • By the 1910s hospitals were administered as public trusts. • The moral duty was to become a business, with the understanding of charity and the promise of science. • Hospitals were called upon to provide efficient care, yet no true way to measure adherence to efficiency in practice existed. • Whereas economics set the measurement for efficiency in industry, efficiency alone, could not be used to measure a hospital’s worth.

9. Physician Pushback • Not all physicians were pleased with the idea of outsiders managing the hospitals as businesses. • A small group of elite surgeons formulated set standards for physicians within the hospital setting. • When the standards were first put to the test in 1919, only 89 of 678, 100 bed hospitals received a passing rate. • Over time, the standards were raised and became the measures against which other hospitals were judged.

10. The Appeal of Efficiency for Nursing • Hospital efficiency truly depended on the nurses. • Scientifically-based efficiency could be had by increasing nursing education and hiring more aides. • Upgrading nursing would be the best path toward economic and scientific efficiency. • Efficiency schemes would stand to improve patient care and relieve nursing from the drudgery. • Efficient and scientific management stood to improve cooperation, eliminate waste and drudgery, raise the standards, increase morale within the hospitals, and provide freedom from physician control.

11. A Call for Systemization of Nursing Education • While efficiency within the hospital had it’s many benefits, it also raised a great question…. ”How can the nurses be pupils for greater nursing education and at the same time do actual work in the hospitals?”

12. Forms of Rationalization from the Nurse’s Point of View • Nurses should be intimately involved in hospital construction and modernizations. • Nurses’ greatest concerns for change with modernization were wasted energy, enforced drudgery, and subsequent fatigue. • Nursing superintendents pushed for a focus on proper structure, as opposed to ornate appearances.

13. Forms of Rationalization from the Architect’s, the Physician’s, and Administrator’s points of view • Focused on design that economized, reorganized, and managed nursing services. • A few influential planners began to recognize that more inexpensive nurses’ aids could be hired if centralized areas were built. • Nurses’ comfort and right to design the workplace were not always important when evaluating hospital efficiency.

14. Nursing Efficiency Studies • In 1913, nursing leaders began working to develop an ideal nurse: patient ratio. • In 1921, the first of several true time studies was performed. • These studies documented long-running disparities. • These studies were also used to determine a rational nursing load. • Work overload and understaffing of finally coming to the forefront.

15. Task Analysis • Concern with proper division of nursing loads led to the “functional” or “efficiency” method of nursing. • No longer was the patient the center of thought, but rather the work to be done. • Preference for the scientific management concept of finding and utilizing the “one best way.” • Servants or aids should perform menial tasks, so that nurses would not waste their time and miss out on “real training.” • Menial tasks could hardly be justified by analysis of nursing’s professional requirements. • The introduction of standardized methods and more theory in nursing would restore dignity rekindle ideals, and upgrade nursing as a profession.

16. An Uncertain Promise • Physicians felt nurses were learning too much medicine and not enough nursing practice. • Activity analysis of nursing duties had to be based on more qualitative understandings of what constituted “good nursing.” • Nursing superintendents, continued to measure hospital success by how smoothly and economically nursing services were run, without consideration of nursing theory. • The public’s image of nursing training must be improved in order to attract future students to a career in nursing. • New nursing living quarters were built, yet the workload became heavier and more complex. • Administrators remained reluctant to commit hospital funding to the nursing educational programs.

17. The Reality of Efficiency • By the early 20th century, hospitals were becoming more essential to the public • Rather than a theoretical focus on the “right way,” hospital administrators focused on how quickly nursing students could perform certain tasks. • Nursing leaders were hopeful that efficiency in nursing would allow nurses to redefine its ethic of order and caring. • Nursing leaders simply wished to link science with sentiment. • The link between nursing services and the nursing school’s education programs continued to impede progress. • Nursing leaders pushed to raise the schools’ entry standards, sever nursing education from hospital nursing services, and differentiate trained from untrained nurses. • In addition, they continued to pursue other tactics to bring about nursing as a profession and the other changes they desired.

18. Reference • Reverby, S. (1987). Ordered to care: the dilemma of American nursing.1850 to 1945. (Chapter 8: Nursing Efficiency as the Link between Service and Science). Cambridge, UK: Cambridge University Press.