Monday, August 31, 2009

The Staff Nursing Paradox

By: Gary J. Salton, Ph.D.
Chief: Research & Development

Professional Communications, Inc.


INTRODUCTION

This evidence-based research traces nursing from entry through nurse training and into maturity as a staff nurse in a hospital setting. The research finds that the average staff nurse holds a consistent worldview as defined by the “I Opt” Logical Processor strategic style. This homogeneity means that initiatives are likely to have a profound effect. Everyone will be affected the same way. The dampening effects of style variation will likely be low.


STAFF NURSES
Staff nurses favor the Logical Processor (LP) strategic style as their short-term decision making strategy. Their level commitment is shown in Graphic 1. The LP strategic style is characterized by a disciplined, methodical approach to issues. It is often accompanied by high level of loyalty, commitment, integrity, consistency and dependability. People holding this style put high value on precision, certainty of outcome and stability.

There is also paradoxical side of the LP coin. Consistency is supported by an attitude of skepticism. A cautious posture toward change braces stability. A slow pace of adaptability insures that precision is maintained. A need for full specification buttresses certainty of outcome. These qualities are the corollaries that allow the more favorable qualities to exist.

Graphic 1
STAFF NURSE “I Opt” STRATEGIC STYLE COMMITMENT
(Sample Size = 344)


The question of whether the LP style is optimal for nursing can be answered by looking the system that generates the strategic style distribution. Different system elements all pointing in the LP direction would indicate that there is consensus that the LP approach is optimal for the task. This approach uses behavior rather than opinion as its validation tool and starts with the student nurse.


FIRST YEAR STUDENT NURSES
Why are students’ attracted to nursing? As part of the survey process, students were given an opportunity to assess nursing using their own words. Table 1 shows a content analysis of these responses.

Table 1
PRINCIPAL WORD CONTENT ANALYSIS
FREQUENCY OF CITATION


The “job” dominates the responses. This is confirmed by a contextual review. Responses like “job guarantee”, “job security” and “I’ll always have a job” reoccur. Students are seeing nursing as a low risk career choice. It would be expected that the Logical Processor (LP) style would be attracted to this situation. The style is inherently risk averse because of value it places on consistency and predictability. Graphic 2 shows that this is exactly what occurs.

Graphic 2
1st YEAR STUDENT NURSE vs. STAFF NURSES

INFORMATION PROCESSING STRATEGIC STYLE COMMITMENT



First year students appear to be cut from the same cloth as staff nurses. There are statistically significant differences. But not in the dominant LP approach. Both groups tend to interpret the world in the same manner.

There is an immediate implication to this finding. If you want to change the mix of strategic styles in nursing, lessen job security. A different kind of student will be attracted and existing staff nurses will exit at first opportunity. Initiatives that trade-off job security for incentive pay will likely have this kind of effect. This kind of diagnostic prediction shows one of the benefits of knowing how people use information processing to interpret the world. It can effect policy decisions.


FOURTH YEAR STUDENT NURSES
Fourth-year students continue to focus on the “job” (see Table 1). We would expect that the risk adverse LP style will persist as the student matures. Graphic 3 shows that this is exactly the case.

Graphic 3
4th YEAR vs. 1st YEAR STUDENT NURSES

INFORMATION PROCESSING STRATEGIC STYLE COMMITMENT


Statistical tests (both Mann-Whitney and t-Test) confirm the obvious. There is no difference in the style profiles of the 1st and 4th year students. This means that the nursing school experience had no affect on their basic mindset. They came in as strong LPs and left as strong LPs. The school taught them what to think about. It did not change how they go about thinking about it.


DIFFERENT SCHOOLS
It could be argued that the results are particular to the school surveyed. To answer this potential concern the results from two very different universities were contrasted. One group of students is from a major research university. The other is from a large, regionally anchored university. The results are shown on Graphic 4.

Graphic 4
RESEARCH vs. REGIONAL UNIVERSITY STUDENT NURSES

INFORMATION PROCESSING STRATEGIC STYLE COMMITMENT



There is one statistically significant difference between the schools. The regional students are more inclined to use the HA style (Hypothetical Analyzer) to think through issues and options (p< .01). However, their commitment is only 16% higher. Further, both groups of students fall in the middle of the moderate range. In other words, the difference is statistically significant but of little practical consequence. This finding means that it is reasonable to treat nursing students as a single population. Initiatives that work in one school will probably work in all of them.


DIFFERENT HOSPITALS
The staff nurse sample was drawn from two hospitals, one private and the other a government facility. It could be argued these different environments attract different kinds of staff nurses. Graphic 5 shows that this is not the case.

Graphic 5
PRIVATE vs. GOVERNMENTAL HOSPITAL NURSES

INFORMATION PROCESSING STRATEGIC STYLE COMMITMENT


The similarity of the two groups is obvious. There is a statistically significant difference in the Relations Innovator (RI) style (p<.05). But it is a difference without consequence. The nurses at government hospital are 15% higher in RI but groups still fall in the “low” category. As was the case with nursing schools, the staff nurses from different hospitals can be treated as a single population. Managerial strategies that work in one hospital are likely to work equally well in another.


STAFF vs. STUDENT NURSES

Graphic 6 combines the students from the two schools and the nurses from the two hospitals. The result can be seen as a reasonable sample of staff and student nurses as a whole.


Graphic 6
STAFF vs. STUDENT NURSES

INFORMATION PROCESSING STRATEGIC STYLE COMMITMENT


The Logical Processor strategic style dominates both groups. There is no statistically significant difference between the groups on the LP dimension. This LP approach will be both familiar and comfortable to the student as they transition from school to work.

The three remaining strategic styles do show significant differences. Staff nurses are about 13% more committed to the analytical HA style than are the students (p<.001). This is probably due to the supervised nature of schools. Students are expected to make errors and they are usually corrected without consequence. The need to consider carefully before acting is diminished. Staff nurses do not have a comparable safety net. They have more choice and their choice carries greater consequence. It is reasonable for them to develop a more thoughtful, analytical posture. Students will probably evolve into the same posture as they mature in line positions. Staff nurses also differ from students in both the spontaneous action RS style (p<.001) and the idea generating RI styles (p<.001). However, the level of commitment is “low” for both groups. The differences may be noticed but are not notable.


THE STORY PAINTED BY THE NUMBERS

First year students enter with an LP orientation. This suggests that people see the nursing profession as favoring their way of interpreting the world. They evidence this judgment by choosing nursing.

The education component of the nursing system also appears to see nursing as an LP profession. Universities have the time, reward structure and control necessary to alter the strategic style of students if they chose to. They do not do it. This behavior evidences the fact that schools recognize and support the value of the LP approach.

Hospital behavior appears to agree that the LP approach as the right one for their staff nurses. They populate their staff nurse positions with people who favor the LP style. They have a choice. Graphic 7 shows that nurses come with a range of LP commitments. Hospitals could elect to hire and retain those at the lower end of the range. They don’t.

Graphic 7
STAFF and STUDENT NURSE LOGICAL PROCESSOR (LP)
STRATEGIC STYLE COMMITMENT


The actual behaviors of all involved suggest consensus judgment. The Logical Processor style is the one best suited to the staff nurse position as it is currently defined.

What this means is that it is useless to lament any undesirable qualities commonly cited as characteristic of staff nurses (e.g., resistance to change, rigidity, poor stress management, participation reluctance, etc.). Many of these are behavioral corollaries of those qualities that are ideal for the main mission. These corollary behaviors are to be managed, not corrected.


NURSING SCHOOL IMPLICATIONS
Nursing schools appear to be doing their job. They are attracting students whose “I Opt” profile matches the profiles of people in the positions that the students are likely to fill. They are graduating students without having altered that original match. This is not a bad outcome.

But there is a missing element in nurse education. That element is teaching students to manage both themselves and the mix of other strategic styles that populate the institution they will soon join. This does not refer to a psychological “understanding.” It pertains to actual behavior that will improve the student’s career outcomes and the personal satisfaction that they experience in navigating that career.

On a personal level, every “I Opt” strategic style necessarily carries with it strengths and vulnerabilities. A course that assesses each student’s personal approach to managing life’s information flows can alert them to their exposures and competencies. The program could then proceed to show the student how their strengths can be magnified and vulnerabilities offset. The individual students addressed by this kind of program will be different but “I Opt” is well-tested paradigm that will fit all of them.

The career component shifts focus on managing others. For example, nurse managers and executives markedly differ in their strategic style from the typical staff nurse (Kalisch and Begeny, 2007). What is logical to one group can appear irrational to the other. If this happens, it is a natural formula for conflict, dissatisfaction and poor organizational performance.

Teaching the student why this divergence exists and why it is functional is a first step. Teaching behaviors that facilitate the integration and optimization of the divergent strategic styles is the second step. Complete both steps and the success of the student as well as the reputation of the teaching institution will be positively magnified.

The investment needed to implement this initiative is small. A teacher can learn the basics of “I Opt” technology in 5 hours through an e-learning program. The student can acquire the knowledge applicable to their particular information processing approach in an afternoon. The cost is minimal. Non-profit charities currently buy the needed materials on an ongoing basis to support their own efforts. If they can afford it, the institutions training our future nurses can probably finance the effort out of petty cash. This is a doable and worthwhile initiative.


HOSPITAL MANAGEMENT IMPLICATIONS
The core issue for hospitals is managing the staff nurse component of their delivery system. This means maintaining the favorable elements of the LP style and mitigating its negative corollaries. The homogeneity of styles means that any management actions are likely to be magnified, for good or ill. Nurses talk to each other. When they do they are likely to reinforce each others view as the correct one. Positions can solidify quickly and can easily harden to the point of rigidity.

An obvious corollary to the above observation is that hospitals should make every effort to do things right the first time. The consequences of mistakes are magnified since all of the staff nurses are likely to be affected the same way at the same time. Of course the reverse is also true. Do things right and the benefits can be magnified just as quickly. It will pay hospitals to invest before acting.

One strategy that can give the hospital fast returns at a low cost is to invest in staff nurse knowledge. The first step might be to show how the process works. The way people process information affects how they behave. For example, if you don’t pay attention to detail you will not be precise. It does not matter how you “feel.” You simply will not have the information needed. This kind of reasoning moves the discussion to objective, non-personal dimension. It is easily accepted.

The next step is converting the new knowledge into practical behavioral options. As with the students, this could apply to both personal management and the management of relationships. The same methods as outlined for the students can be applied to the staff nurse

Hospitals need to take a third step. Staff nurses work in groups. It is important that they understand how the interplay of “I Opt” profiles affect the outcomes the group will enjoy or suffer. “I Opt” has the proven technology of TeamAnalysis™ and LeaderAnalysis™. These tools can calculate the effects of everyone on the team interacting simultaneously. The concept is easily grasped. The actual calculations require a computer and access to proprietary formulas. There are no substitutes.

These three steps—self-management, the management of interactions and team behavior—equip staff nurses with the tools needed to accommodate any management initiative. They will be better able to manage their own responses, gauge the suitability of the initiative and influence the outcome using a “win-win” perspective. “I Opt” can be seen as a universal facilitator for management actions.

The cost in terms of learning the new technology is small. The same e-learning program suggested for universities would apply to hospitals. Existing staff in the Training or HR functions can probably be enlisted to conduct the program.

The material needed to conduct the program will be a bit different than that used in universities. Universities need only focus on individuals. Hospitals need to encompass groups. The materials needed for groups are a bit more costly but easily within the reach. For example, small firms and even churches regularly use “I Opt” group reports to smooth organizational transitions as they grow or change. This suggests that even the smallest charity hospital will find the cost easily manageable.

The materials provided by “I Opt” technology will contribute immediate benefit. But the larger and more durable return will be enjoyed as “I Opt” is used as a lens to understand and support all of the complex processes and interactions that make a hospital work. Hospitals differ in their needs and their initiatives will be unique. However, regardless of content any initiative will involve information transfer. The information-processing framework of “I Opt” will always apply and will always affect the outcome. If managed properly, that effect will always be positive.


SUMMARY
This research has shown that staff nurses are a homogeneous group. The research traces the system that produces staff nurses. There appears to be a consensus among those entering the profession, the universities that train them and the hospitals that hire them. This consensus is that the Logical Processor strategy is best able to meet the responsibilities of the staff nurse position.

The favorable behaviors of the LP style have corollaries. These corollaries are what permit the strengths of the LP style to exist. They are also the source of challenge for management. Strategies for both universities and hospitals to help manage these challenges center on providing the staff nurse with the tools they need to manage themselves, their interactions and the environment in which they participate.

Readers who want to explore the Staff Nursing Paradox on a practical, "how to" level can link to the Staff Nursing Paradox Addendum on the "I Opt" Engineering research blog. That site offers specific recommendations in a "10 things you can do" format. While the format restricts depth, it does provide an opportunity for fast results. It also demonstrates the character (but not range) of the kind of initiatives that might be undertaken using "I Opt" technology. It is worth a look.

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