J U N E 1990, VOL. 51, N O 6 AORN JOURNAL

Democratic Management Principles INVOLVING THE STAFF IN DECISION MAKING

Robert Goodall

A more democratic management style often leads to improved employee motivation .and performance. Several studies com-

mend the use of participative management techniques and quality circles. But is democratic management always appropriate in the operating room or other hospital departments?

Before explaining how democratic management works, one must know what it is. In this article, I define a democratic management system as one in which staff nurses have frequent opportunities to openly discuss and make decisions about their work through task forces, quality circles, or staff meetings. The supervisor in such a system acts more as a coordinator and facilitator than a decision maker. Democratic management is the opposite of authoritarian management in which nearly all decisions are made unilaterally by the department supervisor.

History has shown that the business arena is moving toward democratic management. Early in the history of industrialism, business owners treated their employees as little more than slaves. Child labor was common, and workers of all ages had little protection. The trade union movement was the result of this situation, and eventually the balance of power shifted. Now many of the most successful companies, unionized or not, have

Robert Goodall, MA, is manager of education services, British Columbia Health Association, Vancouver. He received both his bachelor of arts and master of arts degrees in political science from the Universip 0 f British Columbia, Vancouver.

moved beyond the traditional confrontation of labor versus management to a system whereby all workers have the opportunity to contribute to decision making.

Democratic Management in Health Care

everal hospital studies indicate that increased participation can significantly improve morale and productivity. One study showed

that the introduction of participative management in a hospital laundry considerably decreased absenteeism and increased output.' In another study that focused on work in a hospital laboratory, the researcher said,

The research clearly demonstrated productivity improvements, measured in tests per employee hour, as management style became less authoritarian and more parti- cipative-or as employees were allowed to provide input into management decisions.2 In a study of quality circles in the OR,

researchers showed that quality circles at Mt Sinai Medical Center, Miami Beach, enhanced team building and motivation, increased retention of staff, and improved communication and effective problem-~olving.~

Although some of the research and reports about the success of democratic management are flawed, the sheer volume of those reports is persuasive. The apparent success of democratic management, together with ideological attachment to democratic ideals, tempts supervisors to implement similar practices in their institutions.

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Determining Appropriateness

lthough democratic management often works, it is not always appropriate to use. A Consider the following examples.

Scheduling vacations. For the third time in three months, a junior nurse approaches her head nurse to ask about a change in the vacation schedule. Until now, vacation time has been assigned according to seniority. The senior nurses enjoy having their vacations at the times they request; however, several junior nurses would like to see more flexibility in the system.

The head nurse decides to call a meeting to discuss the issue and to let the nurses themselves contribute to the decision. After a quiet beginning, the meeting deteriorates into an acrimonious debate, and it becomes impossible to resolve the problem. Both senior and junior nurses leave feeling angry and discouraged. The head nurse decides the only alternative is to continue the old system.

Purchasing decisions. Two months before the end of the fiscal year, the hospital administrator decides to purchase a new computerized book- keeping system for the OR. He asks the head nurse to make a recommendation on the type of system to buy. She decides to consult staff members about the decision and invites them to several meetings where company representatives explain various products.

At first, staff members are enthusiastic. But the options are complex, and the decision is difficult. Sometimes the meetings are longer than expected, and nurses stay past the end of their shifts. After the presentations are over, they continue meeting to discuss the choices and make a decision. With one week to go, the group still has not agreed on which system to purchase. In frustration, the head nurse makes the decision herself and announces that fact to the group at their next meeting. The nurses file out silently.

Dilemmas of Participation

learly, democratic management is not always appropriate, and even when it is, C many barriers exist. When considering a

more democratic management style, the first question an OR supervisor should ask is, “What decisions are most appropriate for participative decision making?’

This question reveals one of the first “dilemmas of participation.” Consider the paradox that is presented the employer decides to let employees participate and then determines which issues are appropriate for participation. This paradox is unavoidable and must be recognized, but it is not insurmountable. One author wrote, “The irony of participation by command will eventually fade into historical memory as participation becomes seized and owned by those engaged in it.”4

A supervisor also may have to contend with the following dilemmas of participation.

Extent of staff involvement. Before making any decision regarding democratic management, a nurse manager should ask, “Do my employees want to participate in this particular decision or will participation be seen as a burden?’ In many instances participative decision making is appropriate; however, it is a mistake to think that it should be used in all cases, or indeed, that staff members always want to be involved.

Although many employees are capable of and interested in a more active decision-making role, their interest may be limited. Most have competing demands for their attention (ie, families, hobbies, community work). If employees feel they are treated fairly and they have an opportunity to voice concerns when they have them, they do not always want complete democracy in the workplace. A supervisor should take some time initially to determine whether or not employees would like to have a greater opportunity to influence decisions within the department.

Urgency of the decision. Participative decision making, particularly when it is new, takes time, and time is a precious commodity. If time constraints exist, participative decision making may not be appropriate. It is important, however, not to let time limitations become an excuse for autocratic leadership. Too often in hospitals, employees make decisions only under pressure of time. When time is available, it seems that both supervisors and employees are reluctant to use it for planning, consultation,

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People who grow up in democratic countries assume that they know how

to make democratic decisions.

and more democratic styles of decision making. Efject of the decision. Will the questions under

consideration result in shared understanding and agreement or increased tension and disagreement. Do some members of the team have a vested interest in maintaining the status quo? If so, consensus will be more difficult to achieve. Another question is how to deal with disagreement if it occurs. If the supervisor cannot help the group resolve conflicts successfully, what began as a team building activity quickly becomes a team demolition activity.

Decision-making skills. People who grow up in democratic countries assume that they know how to make democratic decisions. There is a considerable difference, however, between voting in an election and working toward consensus with a group of peers. How many of them have training in group leadership, group decision making, or group dynamics?

Internal or external control. When working with a group, the secret of managerial success for a supervisor is to understand the “loose-tight” requirements of employees. That is, the supervisor needs to figure out when to encourage partici- pation and when he or she should make the decision. Employees are willing to allow leaders to make many decisions for them; however, employees will perform best if they feel that they have some control over decisions that affect them. Managing this “loose-tight” dimension means discovering how much control employees really want and then managing accordingly.

In the book, In Search ofExcellence, the authors describe an interesting experiment that demon- strates this principle.

Adult subjects were given some complex puzzles to solve and a proofreading chore. In the background was a loud, randomly occurring distracting noise; to be specijic, it was a combination of two people speaking Spanish, one speaking Armenian, a mimeo-

graph machine running, a desk calculator, and a typewriter, and street noise- producing a composite, nondistinguishable roar.

The subjects were split into two groups. Individuals in one set were told to work at the task. Individuals in the other group were provided with a button to push to turn off the noise, a modern analog of control-the off switch. The group with the off switch solved five times the number of puzzles as their cohorts and made but a tiny fraction of the number of proofreading errors.

Now for the kicker. None of the subjects in the off switch group ever used the switch. The mere knowledge that one can exert control made the difference.5 One area in which control is becoming an

important issue is the assignment of shifts. There is a growing body of evidence that one of the chief sources of dissatisfaction is the lack of control over the shifts worked, as well as the unceasing demands to put in extra time. Many believe that the current nursing shortage is due largely to the concerns over shift work.

Assignment of shift work is a promising area in which supervisors can introduce a more democratic management style of self-scheduling or another participatory method of assigning shifts. To do so, supervisors should ensure that they lay the groundwork by lobbying those employees who may resist a more democratic approach or by discovering ways that allow more control without threatening the privileges of those who benefit from the current system. In addition, supervisors should ensure that they have the support of the nursing department before implementing changes that may reach beyond their immediate area.

More specifically, a democratic approach can be used effectively when

the group has the clear authority to make a decision,

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A manager should remember that involving a staff in the decision making

can be a learning process itself.

a consensus or some agreement seems

there is no urgency in decision making, group members have relevant knowledge to contribute and are willing to participate, and the group leader has confidence in parti- cipative techniques and is skilled in their use.

Conversely, the participative approach should not be used when one person clearly has the expertise to make the decision, and those that are affected by the decision acknowledge and accept the person’s expertise.6 When a manager already knows what he or she wants, or if making the decision is part of the job, a team approach should not be used. Also, if staff members do not care about the outcome and nothing would be gained by their involvement, participative management should not be used. Supervisors should recognize that some people work more happily and productively when alone.

possible,

Guidelines for Success

hen considering the use of participative decision-making sessions, a manager W should remember that involving staff

in the decision making can be a learning process itself. It is not necessary to succeed perfectly the first time a manager tries democratic management methods. The more frequently staff members are consulted and encouraged to contribute, the more expert they will become at helping to make decisions, and the more confident the manager will become about facilitating group discussion. Treating group meetings as learning experiences as well as problem-solving sessions can only enhance their effectiveness.

To increase the chances that participative decision-making sessions will be successful, nurse managers should use some of the following hints.

Do’s. First, it is important to clearly outline

the nature of the decision, limits of the group’s authority for decision making, and the approx- imate time available for discussion. This infor- mation should be posted where everybody can see it. The supervisor also should describe what will happen if the group is unable to reach consensus within a reasonable amount of time.

Group members should use group decision- making techniques such as brainstorming, cause- and-effect diagrams, and histograms. During the sessions, the supervisor should allow enough time for all group members to express their ideas. He or she also should summarize the group’s progress frequently and listen carefully to all contributions to ensure that group members understand one another.

The leader is responsible for monitoring and controlling the amount and type of participation. He or she needs to balance participation from each group member (ie, encourage the reluctant, restrain the overenthusiastic). It is important to balance task-oriented and group maintenance- oriented contributions. If problems erupt, the leader should focus on facts and data rather than on personality conflicts.

During the meeting itself, contributions should be recorded on a blackboard or flip chart. Afterward, any decisions made by the group should be circulated in written form to group members. If more than one meeting is required, written agendas and minutes should be used to keep everyone informed. The group leader is responsible for carrying out and following up on group decisions.

Don’ts. The group leader should not rush people through the “surface” agenda. One must not ignore potential conflicts and unexpressed opinions. The leader should never unilaterally revoke a promise of participation and consensus decision-making. A group should not be used to make preconceived decisions or solutions of the supervisor legitimate. When the group leader has

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ideas or opinions, however, he or she should not withhold them. Rather, he or she should express them openly and encourage frank discussion. The group leader also needs to control the participation of group members and not let one or a few members dominate the discussion.

Finally, the supervisor should not expect all discussion and decision making to take place within the formal meetings of a group. Useful information often is exchanged in less formal circumstances such as coffee breaks.

Summary

articipative management is consistent with our history and culture, and it can often P improve morale and productivity among

hospital staff. Participative management, however,

is not a panacea, nor is it necessary for managerial success. It should be used with discretion, following some of the guidelines outlined in this article. 0

Notes 1. J E Bragg, I R Andrews, “Participative decision

making: An experimental study in a hospital,” Journal of Applied Behavioral Science 9 (November 1973) 727- 733.

2. J K Taylor, “Participative management lifts lab productivity,” Medical Laboratoly Observer 18 (April

3. D R Faulconer, E Rendall, “Quality circles: Effective problem solving in the operating room,” Perioperative Nursing Quarter& 1 (March 1985) 6- 15.

4. R M Kanter, The Change Masters (New York City: Simon & Shuster, Inc, 1983) 243-245.

5. T J Peters, R H Waterman, Jr, In Search of Excellence (New York City: Warner Books, 1984) 21- 22.

1986) 46-50.

6. Kanter, The Change Masters, 243.

Occupational Diseases Should be Reported The US Bureau of Labor Statistics reported eight cases of occupational injury or illness and 63.4 lost work days per 100 full-time employees in 1984. Mandatory reporting of such illness is criti- cal in preventing work-related injuries and illnesses, according to a report in the Dec 1, 1989, issue of the Journal of the American Medi- cal Association.

Researchers found that state reporting require- ments for occupational diseases are less uniform than those for infectious diseases. Response rates vary. According to the article, as of 1985 only 32 states had enacted laws for voluntary or manda- tory reporting of occupational diseases. Not one had evaluated its program to determine the fre- quency of reporting.

The researchers state that awareness of occu- pational hazards and their consequences can influence control measures. Physicians can help identify work sites with potentially hazardous exposures by reporting work-related illness and injury. Once reported, the information would be included in a system to monitor trends and iden- tify emerging problems.

Ten states are working with the National Insti- tute for Occupational Safety and Health (NIOSH) in its Sentinel Event Notification Sys- tem for Occupational Risks (SENSOR). The SENSOR program is designed to establish reporting mechanisms for a list of occupational conditions determined by NIOSH to be amena- ble to reporting. These include carpal tunnel syn- drome, lead poisoning, noise-induced hearing loss, occupational asthma, pesticide poisoning, and silicosis. The researchers state that manda- tory reporting requirements would be helpful. Without it, concerns about confidentiality may inhibit health care workers’ willingness to pro- vide information.

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