As noted in the Learning Resources, systems theory provides a meaningful and beneficial means of examining challenges in health care organizations. To do this effectively, however, it is essential to assess all system components, as some may be relatively healthy while others are problematic.
For this Assignment, you apply systems theory to the examination of a problem in a department or a unit within a health care organization. (Note: You may use the same problem you identified for the Discussion as long as it meets the criteria for this assignment.)
To prepare:
Review the Meyer article, Nursing Services Delivery Theory: An Open System Approach, in this weeks Learning Resources. Focus especially on the information presented in Table 1 (p. 2831) and Figure 2 (p. 2833).
Reflect on your organization or one with which you are familiar. Within a particular department or unit in this organization, identify a problem the staff is encountering.
Using Table 1 in the Meyer article as a guide, analyze the department or unit, identifying inputs, throughput, output, cycles of events, and negative feedback. Consider whether the problem you have selected relates to input, throughput, output, cycles of events, and/or negative feedback.
Think about how you could address the problem: Consider what a desired outcome would be, then formulate related goals and objectives, and translate those goals into policies and procedures.
Research professional standards that are pertinent to your identified problem.
Reflect on the organizations mission statement and values. In addition, consider how addressing this problem would uphold the mission and values, while improving the organizational culture and climate. (Depending on the organization you have selected, you may have explored these in the Week 1 Discussion.)
To complete:
Write a 3- to 5-page paper (page count does not include title and reference page) that addresses the following:
Describe a department or unit within a health care organization using systems theory terminology. Include a description of inputs, throughput, output, cycles of events, and negative feedback.
Describe the problem you identified within the department or unit using an open- systems approach, and state where the problem exists using the systems theory model (input, throughput, output, cycles of events, or negative feedback).
Based on this information, explain how you would address the problem as follows:
Formulate a desired outcome.
Identify goals and objectives that would facilitate that outcome.
Translate those goals and objectives into policies and procedures for the department or unit.
Describe relevant professional standards.
Explain how your proposed resolution to the problem would uphold the organizations mission and values and improve the culture and climate.
References should be less than 5 years oldThe Meyer article:
Nursing Services Delivery Theory: an open system approachAbstract
Aim.? This paper is a discussion of the derivation of the Nursing Services Delivery Theory from the application of open system theory to large-scale organizations.Background.? The underlying mechanisms by which staffing indicators influence outcomes remain under-theorized and unmeasured, resulting in a black box that masks the nature and organization of nursing work. Theory linking nursing work, staffing, work environments, and outcomes in different settings is urgently needed to inform management decisions about the allocation of nurse staffing resources in organizations.Data sources.? A search of CINAHL and Business Source Premier for the years 19802008 was conducted using the following terms: theory, models, organization, organizational structure, management, administration, nursing units, and nursing. Seminal works were included.Discussion.? The healthcare organization is conceptualized as an open system characterized by energy transformation, a dynamic steady state, negative entropy, event cycles, negative feedback, differentiation, integration and coordination, and equifinality. The Nursing Services Delivery Theory proposes that input, throughput, and output factors interact dynamically to influence the global work demands placed on nursing work groups at the point of care in production subsystems.Implications for nursing.? The Nursing Services Delivery Theory can be applied to varied settings, cultures, and countries and supports the study of multi-level phenomena and cross-level effects.Conclusion.? The Nursing Services Delivery Theory gives a relational structure for reconciling disparate streams of research related to nursing work, staffing, and work environments. The theory can guide future research and the management of nursing services in large-scale healthcare organizations.What is already known about this topic
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Because the delivery of nursing services has typically been investigated using hospital-level staffing indicators, the underlying mechanisms by which nursing work influences outcomes remain under-theorized and unmeasured.
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Large-scale organizations can be conceptualized as open systems composed of interacting subsystems that selectively import and transform energic inputs from the external environment to produce services and products.
What this paper adds
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The healthcare organization is conceptualized as an open system characterized by energy transformation, a dynamic steady state, negative entropy, event cycles, negative feedback, differentiation, integration and coordination, and equifinality.
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This theory situates the work of nursing in the production subsystems of the organization and explicates the division and coordination of nursing work.
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The theory gives a relational structure that reconciles how nursing work, staffing, and work environment variables contribute to the global work demands placed on nurses at the point of care.
Implications for practice and/or policy
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Future research can be guided by this theory to examine how variations in inputs, throughputs, and organizational characteristics result in optimal outputs related to nursing services delivery.
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Managers can use this theory as an overarching framework to manage the key components conceptualized to influence the delivery of nursing services at the point of care in organizations.Introduction
In many countries, the sustainability and quality of nursing services are threatened by global shortages of healthcare professionals (International Council of Nurses 2006). As one component of a multifaceted response to this crisis, policy and decision-makers have prioritized the nursing practice environment and organizational performance as key areas for intervention (International Council of Nurses 2006). Nursing services are generally contracted through an employment relationship. To recruit, retain, and deploy scarce nursing human resources effectively and to produce quality and cost-effective care, the associations between organizational structures, human resource management policies and the goals, resources, context, and outcomes of nurses work need to be understood. A challenge in nursing health services research has been the need for a unifying theory to conceptualize and examine the delivery of nursing services (Edwardson 2007).In the conceptual model for nursing and health policy, Russell and Fawcett (2005) identified four levels of focus: (i) nursing practice processes; (ii) administrative practices for nursing service (or healthcare) delivery subsystems; (iii) healthcare system administrative practices; and (iv) world health administrative practices. The Nursing Services Delivery Theory (NSDT) addresses the second level of phenomena in this model by examining the effectiveness and efficiency of administrative practices for nursing service delivery subsystems. Using the strategy of theory derivation, the NSDT gives a theoretical understanding of the nature of an organization, situates the work of nurses in the organizational context, and integrates the design and organization of nursing work. In this study, we present a description of the derivation of the NSDT from the application of Open System Theory to large-scale organizations and the structural and conceptual elements of the NSDT. Examples from the empirical literature are used to illustrate the relational structure the NSDT describes among nursing work, work environment, and staffing variables. Further implications of the theory are discussed.
Background
Nursing health services research is characterized by a growing need for a coherent theoretical framework that combines clinical, organizational, financial, and outcome variables from a nursing perspective (Edwardson 2007). Nurse staffing studies often apply traditional nurse staffing indicators to give crude estimates of the amount of nursing resources available for care. However, by virtue of their simplicity, nurse staffing indicators also de-contextualize care. Conceptually, hours per patient day (HPPD) assume a standard time per occupied bed, whereas nursepatient ratios are based on average nurse capacity (OBrien-Pallas et al. 2005). Workload measurement systems quantify patients requirements for nursing care as the sum of the times of the tasks required or as the amount of time required relative to standard patients (Thibault et al. 1990). In the community, numbers of visits reflect standard times allotted per home visit. These types of nurse staffing indicators inadequately consider factors known to influence variability in nursing work, namely the characteristics of care recipients and nursing teams, and factors related to the care delivery environment (OBrien-Pallas et al. 1997).Although staffing research examining large administrative data sets in the United States of America (USA), Canada, and the United Kingdom has identified associations between key nurse staffing indicators and patient outcomes at the organizational level (Lankshear et al. 2005), these types of secondary analyses do not measure the actual work performed by nurses (Clarke 2006). Thus, the underlying mechanisms by which staffing indicators influence outcomes remain under-theorized and unmeasured, resulting in a black box that masks the nature and organization of nursing work. Although large database studies allow for comparisons across organizations, evidence on which to re-organize and improve nursing services to varied clinical populations at the point of care is lacking (Clarke 2006). Specific theory and evidence linking staffing practices and outcomes in different settings are urgently needed to inform management decisions about the allocation of nurse staffing resources in organizations.A review of funded nursing health services research in the USA identified that conceptual frameworks were often used in isolation by researchers (Edwardson 2007). Donabedians (1980) Healthcare Organization and Delivery Model is one of the most frequently used frameworks to examine nursing performance (Hall 2004, Edwardson 2007). Conceptual frameworks of nursing care based on Donabedians (1980) formulation for the assessment of care quality typically organize patient, nurse, work, work environment, and outcome variables according to structure, process, and outcome (e.g. Irvine et al. 1998, Cho 2001). However, because Donabedian (1980) was focused on an approach for assessing the quality of medical care, rather than on system design and organization, the fundamental questions of What is an organization? and What is nursing work? remain unanswered. Rationales for including variables in a structureprocessoutcome framework have tended to rely on empirical findings, rather than a theoretical understanding of the nature of an organization or the delivery of nursing services. In addition, because linear relationships are frequently assumed between structure, process, and outcome variables, the dynamic interactions between variables are often neglected (Mitchell et al. 1998).Building on a rich tradition of systems thinking in clinical (Holden 2005) and nursing management, the NSDT addresses many of these challenges to nurse staffing and nursing work research. In particular, Jelinek (1967) described a Patient Care System Model composed of personnel types and physical facilities as inputs; organizational and environmental factors as throughput; and patient care, patient satisfaction, and personnel satisfaction as outputs. Subsequently, the interrelationships among nursing complexity, medical complexity, nurse characteristics, environmental complexity, and outcomes were tested in a systems model in community and hospital settings to investigate the factors that cause patients or clients with very similar medical conditions to have different nurse resource requirements (OBrien-Pallas et al. 1997, 2001, 2002, 2004, Meyer et al. 2009). In these models, inputs consisted of the characteristics of patients or clients, nurses, and the system and system behaviours; throughput involved the nursing care delivery subsystem, where nursing interventions are performed and its environmental complexity; and outputs involved outcomes for patients or clients, nurses, and the system. Mark et al. (1996) also applied structural contingency theory, a subset of Open System Theory, to the evaluation of nursing system outcomes. Key variables included environment (e.g. organizational size, skill mix), technology (e.g. stability of patient acuity, diversity of patient conditions), structure (e.g. degree of centralization), and effectiveness (e.g. patient and administrative outcomes). The basic premise was that to perform effectively and to produce quality outcomes, an organization must structure its nursing units to complement the environment and technology.The NSDT complements and extends the scope of previous systems models in nursing by theorizing the nature of an organization, locating the work of nursing at the work group level in an organizational suprasystem, and explicating the division and coordination of nursing work. By viewing the healthcare organization through the lens of objectivism, the work of nurses is assumed to exist as an objective, external reality with identifiable and measurable characteristics.The theory derivation was guided by these questions: What is the nature of an organization? How do healthcare organizations produce nursing services? How do management structures contribute to the delivery of nursing services? According to Walker and Avant (2005), theory derivation is an iterative and creative process that involves: (i) becoming very familiar with the level of theory development in the field and evaluating existing theories; (ii) reading widely both in and outside the field of study to make creative associations between distinct fields of study; (iii) choosing a parent theory for the derivation; (iv) identifying which content and structural elements of the parent theory will be used; and (v) recasting these elements for the phenomenon of interest.
Data sources
Building on our pre-existing knowledge, literature from the nursing, healthcare, and management fields was examined. A search of CINAHL and Business Source Premier was conducted using combinations of the following terms: theory, models, organization, organizational structure, management, administration, nursing units, and nursing. The search was limited to English language, peer-reviewed publications or books published between 1980 and 2008. Seminal works were also included. Documents with a major focus on theory related to work performance and management in organizations were reviewed.
Discussion
Katz and Kahns (1978)The Social Psychology of Organizations, based on Open System Theory, was selected as the parent theory because it addressed the questions guiding the derivation in a comprehensive manner and facilitated new insights and connections about research in the areas of nursing work, staffing, and work environments. Selected structural and conceptual elements of the parent theory were redefined. Specifically, the open system characteristics of organizations and the five functional subsystem types, which are the fundamental defining characteristic of social systems (Katz & Kahn 1978), were recast in the NSDT with an emphasis on the dynamics and mechanisms of production subsystems.Open System Theory
The theoretical foundation of the NSDT is Open System Theory as applied to large-scale organizations by Katz and Kahn (1978). In their view, an organization constitutes an energic inputoutput system. An organization depends on its supporting environment for continued inputs to ensure its sustainability and processes these inputs through the recurring and patterned activities and interactions of individuals to yield outputs. An organization is therefore essentially a social system. As such, an organization and its subsystems strive to achieve a dynamic steady state whereby regularities in energy flow preserve the character of the system and disturbances prompt system adaptation (Katz & Kahn 1978). To survive, an organization needs to counteract entropy, which is an inevitable process of disorder and dissolution caused by loss of inputs or by inability to transform energies. An open system must acquire negentropy (i.e. negative entropy), usually through some form of storage capacity, to ensure its continued existence (Katz & Kahn 1978). For organizations, negentropy can involve renewing inputs, storing energy, creating slack resources, or maximizing imported energy relative to exported energy (Galbraith 1974, Katz & Kahn 1978). Organizations can also counteract entropy by adapting system functioning in response to informational signals and feedback from the environment. Characteristics of open systems and their application to large-scale organizations and to the NSDT are presented in Table 1.Table 1. ?Open system concepts and their corollary in the Nursing Services Delivery Theory
Concept Definition (Katz & Kahn 1978) Application to large-scale organization (Katz & Kahn 1978) Application to the Nursing Services Delivery Theory
Inputs The inflow of energy and information from the external environment renews the system Energic inputs may include people, materials, or resources from other organizations. Informational inputs include negative feedback or signals about the external environment People e.g. staff, care recipients Materials e.g. supplies Resources e.g. funding Information e.g. labour market conditions
Throughput Energies inside the system are transformed by reorganizing the inputs Reorganization may entail processing of materials, generation of products, or provision of services Services e.g. nursing interventions
Output Product must be exported to the external environment Outputs may consist of materials, products, or services Service outputs e.g. patient volumes
Systems as cycles of events The process of exchanging and transforming energy must renew the system thus creating a repeated series of activities Renewal may be generated by system output or by its own activities Outputs e. g., revenues Activities e.g. accreditation criteria achieved
Negative feedback Internal information about system functioning is a corrective device used to adjust energy intake and expenditure Subsystem feedback about operational functioning is used to keep the organization on target Negative feedback e.g. organizational performance indicators
Open System Theory recognizes the hierarchical nature of entities, whereby each level of the organization comprises a subsystem of interrelated parts. In large-scale organizations, the transformation of energy (i.e. throughput) occurs in production subsystems that divide the labour to accomplish tasks (Katz & Kahn 1978). The function of the production subsystem is to transform energy to meet task requirements and to optimize task accomplishment via technical proficiency (Katz & Kahn 1978). The underpinning mechanism is the division of labour that determines the structure and work flow in the production subsystem. Subdividing the work creates breaks in work flow. Organizations address this challenge by integrating work processes across roles and subunits using coordination devices (Katz & Kahn 1978). As an organization differentiates, additional integration and coordination are required to unify system functioning (Katz & Kahn 1978). Thus, the size, complexity, and coordination demands of an organization increase as its subsystems multiply and specialize in function.The production subsystems interact dynamically with the supportive, maintenance, and adaptive subsystems of the broader organization (Figure 1). These subsystems import people, materials, and energies through transactions at the organizational boundaries; balance internal work structures relative to human inputs by formalizing activities and socializing and rewarding members; and deal with problems of adjustment to external forces by recommending and incorporating change (Katz & Kahn 1978). Overall organizational functioning and adjustment to external demands are coordinated and integrated by the management subsystem, which crosscuts and directs all subsystems and negotiates conflict across hierarchical levels (Katz & Kahn 1978). In terms of functioning, the production, supportive, maintenance, adaptive, and management subsystems do not operate in isolation, but rather are interdependent and interact dynamically as part of a greater, complex whole.image
Figure 1. ?Simplified representation of the organization as an open system based on Katz & Kahn (Meyer 2010, reproduced with permission).As an open system, the organization adapts its functioning in response to negative feedback and external informational signals through a series of iterative adjustments that allow the system to evolve while maintaining its character (Katz & Kahn 1978). Although Figure 1 is a simplified representation of the organization as an open system, the phenomenon is neither uni-dimensional nor static. Large-scale organizations typically consist of multiple interacting subsystems (e.g. multiple production subsystems by specialty, hierarchically layered management subsystems). The principle of equifinality states that an open system can achieve its end state from various initial conditions and through differing trajectories (Katz & Kahn 1978). This suggests that there is no single way for an organization to be structured or to achieve positive outcomes.Nursing Services Delivery Theory
The NSDT applies Open System Theory to nursing work in large-scale healthcare organizations (Figure 2). With respect to system structure, the NSDT identifies that care is delivered by nurses clustered in work groups that are nested in a department or programme in the larger organization. Inpatient units in a hospital or nursing teams in home healthcare are examples of production subsystems. These work groups transform energic inputs to deliver nursing services and to yield outputs. Imported inputs consist of care recipients, staff, material and fiscal resources and information, which are subsequently transformed in a nursing production subsystem through the work performed, its structure, and its internal work conditions.image
Figure 2. ?The Nursing Services Delivery Theory.Distal outputs include clinical, human resource, and organizational outcomes. These energic outputs give feedback and reactivate the system in a cyclical manner because positive outcomes in each of these domains ensure that members of the community continue to use the organizations services, staff are retained to give the services, and the organizations accreditation and funding are sustained. With respect to nurse staffing, entropy may be counteracted in several ways. Examples of negentropy include: (i) renewal of inputs by retaining or hiring nurses; (ii) storing energy by using buffer inventories of nursing capacity (e.g. float pools, agency nursing); (iii) creation of slack resources by loosening performance targets to reduce the number of exceptions (e.g. longer lengths of stay), by increasing fiscal resources (e.g. greater nursing HPPD), or by extending lead times (e.g. richer staffing ratios); and (iv) more efficient use of imported energy relative to exported energy by intensifying nursing workload to increase volumes (e.g. lower staffing ratios).In Open System Theory, each system and its subsystems adapt to internal and external demands and feedback. Demands external to the healthcare organization encompass environmental factors (e.g. labour market, legislation, population characteristics). Healthcare organizations continuously adapt system functioning in response to feedback and informational signals to counteract entropy. For example, aligning organizational policies to meet performance targets set by external agencies exemplifies the dynamic interaction between the organization and its external environment.At the point of care, each nursing production subsystem also adapts to and interacts reciprocally with the other organizational subsystems. The management, supportive, maintenance, and adaptive subsystems coordinate and allocate the inflow of energic inputs and establish the structures necessary for the completion, evaluation, and renewal of nursing work in production subsystems. Internal demands of nursing production subsystems relate to the nature of the work performed, structures arising from the division of nursing labour, and the work conditions at the point of care. Negative feedback includes organizational performance indicators (e.g. longer than expected length of stay or time on programme).The dynamic interdependence among subsystems, the organization, and the external environment is illustrated using the example of emergency department overcrowding and one of its proposed solutions, the introduction of nurse practitioners. In response to pressures to reduce crowding (i.e. external demand), subsystems would recommend and implement the proposed solution (i.e. adaptive function); hire the nurse practitioners (i.e. supportive function); formalize policies to enable the work of nurse practitioners (i.e. maintenance function); and integrate these changes across subsystem, role, and hierarchical boundaries to ensure stakeholder buy-in and to monitor performance (i.e. management function). The emergency department (i.e. nursing production subsystem) would re-divide the labour to accommodate the new role and the work performed (i.e. internal demands). By altering the staffing mix (i.e. inputs), service capacity (i.e. throughput) is increased, leading to reduced overcrowding and increased consumer satisfaction (i.e. organizational and clinical outcomes; e.g. Carter & Chochinov 2007). In turn, because nurse practitioners typically engage in primary care and health promotion, unnecessary readmissions to the emergency department could be offset in the future (i.e. feedback cycle).By considering the various inputs and throughputs that influence nursing service delivery and outputs, the NSDT proposes that nursing work in a given production subsystem is not performed in isolation; rather, nursing work in production subsystems is dynamically interdependent with the other subsystems and the organization suprasystem that interact with the external environment. There is no single way for an organization, or for nursing production subsystems, to deliver nursing services effectively. The NSDT emphasizes that a confluence of factors determines the global work demands in the nursing production subsystem.Components of the Nursing Services Delivery Theory
As shown in Figure 2, the delivery of nursing services in production subsystems occurs inside the environment structured by the organization suprasystem, and is dependent on the inflow of inputs, which include care recipients, nurses, materials, and other energies.Characteristics of the organizational suprasystem include organizational type, size, location, structure, and ideology. Type of organization can vary by healthcare sector (e.g. acute, community or long-term care), academic affiliation, or by funding source. Location may refer to geography (e.g. rural, urban) or dispersion (e.g. multi-site organization, catchment areas). Depending on the purpose of the inquiry, organizational size can be measured as the quantity of personnel, physical capacity, volume of inputs or outputs, or discretionary resources of an organization (Kimberly 1976). Organizational structure results from trade-offs between the differentiation of work by function (e.g. nursing, pharmacy) and the integration of work processes by programme (e.g. cardiology, trauma; Charnes & Tewksbury 1993). This gives rise to a continuum of functional, matrix, and programme organizational forms (Charnes & Tewksbury 1993). Ideology refers to the common norms and values held by the majority of organizational members about expected member behaviours and the appropriateness of organizational activities and functions (Katz & Kahn 1978).Care recipient characteristics include demographics, health status, resources, medical condition, and nursing condition. Examples of demographic variables are age, gender, language, and ethnicity. Health status includes the physiological and psychosocial health states of the person. Resources available to care recipients can be considered in terms of material support (e.g. healthcare coverage) and social support (e.g. informal caregivers). Medical condition encompasses the number and types of medical diagnoses and co-morbidities and severity. Nursing condition refers to the healthcare needs of recipients that generate the demand for nursing services in terms of complexity (e.g. number and types of nursing diagnoses) or intensity (e.g. workload). Self-care management involves the pre-existing knowledge, health behaviours, and symptom management of care recipients and their informal caregivers about the underlying health conditions.Nurse characteristics consist of demographic, professional, and health factors. Demographics include age and gender. Profession reflects occupational factors such as licensure, education, clinical expertise, experience, and employment status. Health entails the physiological and psychosocial health states of the nurse.Other energic sources include materials, fiscal resources, and information. Materials consist of equipment and supplies. Fiscal resources refer to the budget allocated to a production subsystem. Information can include, but is not limited to, organizational trends and policies, new technologies, and feedback that the production subsystem imports from other organizational subsystems.Throughput consists of several factors. Nursing work is performed in the production subsystem. Key factors influencing the delivery of nursing services in the production subsystem entail the nature of the work, its structure, and its environment. Technology refers to the work performed by nurses. Nursing work may be conceptualized as independent and collaborative interventions that encompass any treatment, based upon clinical judgment and knowledge, which a nurse performs to enhance patient/client outcomes (McCloskey & Bulechek 2000, p. 3). In terms of the nursing work performed, technology refers to task uncertainty (i.e. degree to which cause and effect are analysable), instability (i.e. the degree to which moment to moment changes in care recipient status occur), and variability (i.e. diversity of number of different components; Overton et al. 1977). The extent to which tasks are interdependent (Thompson 1967) and time-constrained (Adler 1995) is an additional dimension of work performance. Temporal dimensions of nurses work (e.g. duration, temporality, timing, tempo) may also be considered (Jones 2001). Uncertainty, instability, variability, interdependence, and timing of nursing work and interventions are amenable to measurement. Quantity and uncertainty of inputs also influence nursing work in the production subsystem. Input quantity may be reflected by volumes of care recipient admissions, visits, procedures, or patients; by number of staff or nursing HPPD; or by fiscal resources. Input uncertainty is determined by the number and probability of choices or alternatives in a given situation (Argote 1982). With respect to care recipients, uncertainty is reflected by diversity in the health conditions and care needs of the population served and the number of