Media, Technology and Society

Contradictions of Control: New Managerial Practices and Canadian Healthcare

According to workplace technologist Robert Howard, managers employ new workplace technologies not to increase productivity and phase out repetitive and menial aspects of workers jobs, but rather to replace or deskill the workers themselves. For Howard, the contradiction here is that reducing or eliminating any dependency on workers’ skills not only reduces their job satisfaction, it also compromises the supposed goals of increased efficiency, productivity and product/service quality. Healthcare researcher Pat Armstrong describes a similar contradiction in her study of government health care reformers and managers’ attempts to transform point of care wards into efficient, cost effective facilities. But what notion of efficiency is being upheld here – efficient in terms of control and cost effectiveness, or efficient in terms of quality care?

Armstrong’s critique of the supposed benefits of rationalizing patient care is supported by Howard’s analysis in key areas. In both circumstances, practices or technological “improvements” are said to assist workers in doing their job, while in actuality undermining their ability to do so. In Howard’s analysis, the agent of reform is not new standards and practices, although these are key, but rather the use of technology as an instrument for labour savings. Howard quotes a memo from AT&T vice president to Bell Systems Managers in which a new telecommunications technology is described as ultimately “[getting] people off the payroll” (Howard, 47).

In Armstrong’s research however, workers are not replaced by any technology, but like other examples in Howard’s analysis, their labour is fragmented where possible and substituted with less-skilled and cheaper labour.(i) This might seem to be a less detrimental alternative to replacing nurses with technology, but according to the nurses involved, the managerial reasons behind it, and the consequent threat to quality service is similar:

“[the practical nurse] didn’t know [of the patients dehydration, previous dosages and bowel conditions and] just went in and removed…a patient’s IV” (Armstrong, 100).

The nurses describe the practical nurses as “just following orders” unable to draw upon the nurses’ extensive training and experience to act as safeguards for patient care - in some cases
despite what doctors orders, or procedure require:

“if a registered nurse thinks you need an IV, you get an IV…if she thinks you need more narcotics she’s going to be on the phone for that” (Armstrong, 100).

In both analyses then, quality suffers as a result of these managerial strategies, regardless of whether workers are replaced with another department of less skilled workers or a new technological system.

In his study, Howard draws upon the illuminating experience of machinist Dave Boggs who was deskilled despite his ability to outperform the programming department and his ambition to use the new technological system to gain more “complex skills” (Howard, 41). While Howard description of technology as a tool for reducing labour overhead while also compromising quality is reflected in Armstrong’s study(ii), his suggestion that workers have the complexity of their work reduced doesn’t seem as immediately apparent with the nurses. For example, the nurses are required to self manage and coordinate themselves in the absence of the (downsized) head nurse position.

However, a closer examination reveals that many of the features of managerial control and ‘contradictions’ outlined in Howard’s work are still seen in Armstrong’s example. Although an increase in responsibilities for individual nurses amounts to more complexity and difficulty, it certainly doesn’t ensure increased job pride or fulfillment.(iii) Quite the opposite, the immense pressure upon nurses to both self manage, and coordinate themselves 24 hours a day while delivering patient care according to a rigid quota of tasks is still a threat to autonomy, job satisfaction and morale (Armstrong, 120).(iv) That said, the nurses in Armstrong’s example didn’t see their work decrease in complexity as did the workers described in Howard’s analysis, but rather they were concerned that “critical skills – registered nursing skills [that are] essential to patient care [were] disappearing in the process of task definition and task transfer” (Armstrong, 103). Some aspects of their job became more complex (coordination, communication), while others became more routine and task oriented, when nurses would rather that they weren’t (bathing, etc).(v)

The most consistent and damning conclusion that can be drawn from these critiques of Taylorist management practices and technology in the workplace is that both threaten the autonomy of workers and their ability to perform the job according to their own standards of quality.(vi) The reduction of work to tasks threatens all work that is not countable or quantifiable, and thus pressures workers to either ignore or rush through aspects of their job that they are not explicitly required to undertake(vii) Although management and health care reformers may say they have patient care in mind, they have ultimately established a system of measurement and standardized benchmarks which rewards nursing practices that are incompatible with quality patient care.
Bibliography

Armstrong, Pat et al. (2000) Heal Thyself: Managing Health Care Reform Ontario, Garmond Press., Canada.

Howard, Robert (1985) “Contradictions of Control” in Brave New Workplace, New York: Penguin Books., US.

Endnotes

i. For example this entails separating “practical” nurse work from registered nurse (RN) work.
ii. Although cheaper, less skilled labour is used in lieu of technology.
iii. For example, there is the example in Armstrong’s case of nurses who were immensely pressured between providing the quality care they felt professionally responsible to provide, and the manager’s unwillingness to pay them for the overtime required to provide this care (Armstrong, 119-120).
iv. As described previously in the context of quality care loss, the efforts of managers to designate some nursing duties as “practical” or only requiring a set amount of time to complete is a threat to nurses autonomy and ability to take pride in their work.
v. Other important but stymied duties include communicating with patients and being able to their own exercise experience and judgment.
vi. For example, most nurses in Armstrong’s study view patient care as more than a set of distinct tasks to be performed and then forgotten about.
vii. For example, Howards example of how industrial machinist Dave Boggs learned how to program the new machine cutting technologies on his own time, but was not rewarded for his enthusiasm to teach himself evidences a disincentive for this positive behaviour. Similarly, Armstrong provides examples of how nurses rushed through their interactions with patients in order to complete tasks to the detriment of establishing valuable patient relationships.

Kraft and Greenbaum: Perspectives on the Routinization of Computer Programming Work

In his paper on the Industrialization of Computer Programming, Philip Kraft describes early programmers working from 1946 to the early 1960s as “programmer artists”, possessing the unwieldy and broad knowledge and skills necessary to design and implement computer programs single-handedly. Kraft recalls the joy and sense of freedom that many programmers felt in being able to manage their own duties and get the job done according to the general rubric of ‘programming’, after all “every programmer did more or less the same thing as any other programmer” (Kraft, 5). But this kind of freedom and unstructured job design was contrary to managerial and industrial desires to reduce labour costs and exert control over workers’ labour.

Kraft traces this desire for “control” to managers and computer manufacturers belief that making computers easier to use and more reliable was a hardware problem, and that software and the user were the bottleneck: this was where “human error” and “inefficiency” cropped up (Kraft, 5). In order to turn the complex work of programmers into “shop” labour, the kind that clearly evidenced a separation of the “head” and “hands”, managers needed to subdivide programming tasks into discrete manageable fragments.

According to Kraft, the answer came during the Korean-war era SAGE project, with the separation of “conceptual” computer-program design work from the “mechanical” labour of inputting code. With the conceptual work undertaken by the sub-occupation of “systems analyst”, Kraft argues that a distinct class of intellectual, creative design was conceived. The skills of the “head” had been identified and isolated, meaning that the second phase of managerial control could begin: routinizing and subdividing the rest of work required to bring finished concepts and software designs into completed products.
This process was assisted by many factors, including the development of higher-level languages and structured programming. The first of these, higher level languages, involved a degree of separation from the assembler level languages and allowed more abstract, logical programming to take place. A programmer could learn to use these higher-level languages without understanding assembly-line code and thus, required less skill and education in order to be productive.

Secondly, structured programming continued the trend set in place by the creation of the systems analyst position. Structured programming was a rejuvenated Taylorist approach to programming, involving the minute separation of tasks, a strict hierarchy of labour and a rigid set of standard procedures and protocols governing work practices (Kraft, 10). With this system, a few elite professionals could (in theory) perform all the intellectual, creative work, and pass all the rest of the construction of the software down to discrete ‘modules’ of workers, who would specialize in writing a single piece of the code. For these workers, almost no skills and experience were required to assemble discrete fragments of programs, and thus, they could be paid far less than the elite systems analysts and engineers.
Ultimately, Kraft concludes that two ‘tiers’ of workers were produced out of this systematic and formal separation of programming work. The elite and well paid electrical engineers and analysts who were educated in elite schools such as MIT, Harvard and so forth, and the low-paid coders and applications programmers [who were] trained in junior and community college programs designed to prepare them for [lower paying] and [routine] technician jobs” (Kraft, 13).

Kraft explains the managerial impetus for the deskilling and routinization as being motivated by a managerial desire to cut labour costs. Kraft’s work and his concluding statement, that technology has not necessarily led to “more jobs” is well supported by his own set of statistics and additionally by Joan Greenbaum’s work in Windows on the Workplace.

In particular, Greenbaum expands on the implications of the creation of tiered labour forces and the “professional ethic” as an ideology which white collar workers ‘buy into’ . This ideology, Greenbaum contends, resulted in the design of programs that supported the division of labour and ultimately furthered what Kraft and Braverman describe as the basic social function of skilled professional workers – “to design machines, technologies and work processes to deskill other workings” (Kraft, 2). Greenbaum argues that the purpose of deskilling, the professional ethic and job hierarchies is to get workers to view themselves not as collectives fighting for a fair working environment and wage rate, but rather as individuals who are rewarded or punished based on their own education or merits (Greenbaum, 142). By dividing workers according to skills and tasks, inefficiencies and mistakes can be blamed on different tiers or workers, instead of on the bureaucracy itself.

References:

(1) Greenbaum, Joan (1995) Windows on the Workplace, Monthly Review Press: New York

(2) Kraft, Phillip (1979) The Industrialization of Computer Programming: From Programming to “Software Production” in Andrew Zimbalist, ed., Case Studies on the Labor Process, New York: Monthly Review, 1-17