Groups controlling the operation of an organization are the ones that establish, maintain and supervise its regulatory system and effective functioning and employ its workers. Ac-cording to the definition in scientific literature the approach of the factual control has to be started from the owner and/or the financer. (Amstrong 1995)
The owners of the health care system (hospitals, surgeries) are the local authorities that have provisional commitments, they are responsible for assuring health care services for the population. At the same time it raises a lot of questions about what kind of financial sources the local authorities have to use to cover the costs of this need. Does it solely have enough income to finance all the expenses (including development) that are not covered by health care insurance or by the pa-tients’ contributions? Answering these questions causes a lot of problems to the local authorities, so from their part, in a simplified manner, the only task to be solved is organizing the assurance of care in a way that the operation is preferably problem-free. In these processes representing the patients’ in-terest is only important for political reasons, for political con-siderations, effective representation of interest does not take place.
The other organization that has a significant impact on health care organizations is the financer of their services, OEP - the Country-wise Health Insurance Pay-Office. Through fi-nancing, it controls the operation in order to make health care cost effective and economical. (Jávor, 2005)
However, coming up to this expectation often clashes with the interests of both care providers and the provided ones and so far it has not been able to create a properly function-ing, plannable financing system.
We can rank numerous market participants, business en-terprises among the organizations that practise environmen-tal control in the functioning of health care organizations.
They have taken a significant part and an emphasized role by their products and services in health care provision since the 90s. One of them is pharmaceutical companies that have an outstanding influence; they intervene with the health care processes a great deal, although ’just’ indirectly, by, for exam-ple, having introduced and sustained doctors’ visits.
Now in this process where is the doctor, the nurse or main-ly the patient, in the interest of whom the organization oper-ates? Nowadays unfortunately we must say that they are the ones who are capable of controlling the functioning of the organization only partially (doctors, maybe nurses) or hardly at all (patients). Chart 4 demonstrates well that in the many-participant system of health care patients stand, in their own client-centred organization, at the very bottom of the hierar-chy and they are very far from decision making levels. They are far in a physical sense too but they are also far from service providers’ level of knowledge. This situation could be resolved by a well-functioning system representating patients’ rights, organized by patients but at present these are just opportu-nities ensured by legal regulations and in reality they do not mean an efficiently functioning representation of enforcing patients’ interests.
Participants in the functioning of health care organizations
In favour of the recovery and care of patients the function-ing of health care organizations is basically assured by doctors and paramedic professionals, like nurses, physical therapists, nutritionists, midwives and emts.
Out of the above mentioned groups now we are highlight-ing two groups, doctors and nurses, in this chapter, takhighlight-ing into consideration their ratio of presence within the health care system. At the same time we confirm the importance of the other paramedical professionals in health care but their role and presence are not analyzed here due to the remit of this book. However we recommend further readings on this topic within scientific literature which are listed at the end of this chapter.
Doctors’ and nurses’ roles together form an occupational role system that is labelled as a ’profession’ in scientific lit-erature. As a matter of fact, society labels only a very few
oc-cupational activities as true professions. The practitioners of this profession are qualified experts with a special knowledge, who serve the interests of the patients. The job of practitio-ners of a profession is connected to people, those who do this work are characterized by altruism not only during their work hours but outside of that as well; they immediately act according to the expectations of their profession if necessary.
A profession related job is extremely useful not just by itself for the benefit of the client but also for his/her environment and the whole of society. Due to this, communities acknowledge this type of qualified work, it is held on high societal esteem.
At the same time, their special knowledge creates a monopo-listic situation for the representatives of this profession since they are the only ones who possess it.
The practitioners of this profession are not only in a mo-nopolistic situation but they also have an especially significant degree of autonomy upon their work related activities since they can largely make themselves independent of the current political and economic environment. They themselves define their tasks, the social norms connected to doing their jobs, the circle of people performing their work and they are able to prevent outsiders from evaluating their work.
Due to a high degree of monopoly and autonomy, the professional organization brings forth the ethical code for the practitioners of the profession, which regulates their work. At the same time this professional-ethical code ensures super-vision over the given professional area, it represents mutual interests, it maintains the monopoly of knowledge, it deter-mines the criteria for members to be admitted, it provides protection against rivals and besides it supervises the profes-sional knowledge and ethical attitude of the members. (Hel-man, 2003)
Strict inside regulatedness and a strong hierarchy char-acterizes the circle of the practitioners of the profession. The position taken within the hierarchy depends partly on profes-sional knowledge and on power position. (Sági, 2006)
After the general conceptual review, let us survey how the question of this profession works out in today’s health care or-ganizations and how it contributes to the assurance of client-centred care. Starting from the fact that the tasks are done by practitioners of a high prestige and autonomous profes-sion, it can logically be concluded that the purposes of the organization offer great opportunities. In our case it means that according to its designation, besides a high level of pro-fessional knowledge, the health care system does its curing, caring activity in a client-centred way, primarily in the interest of the patients.
d
ocTorSAlthough the contextual meaning of this profession has not changed, the system of conditions for the practitioners of this profession and along with this their relationship to the patients underwent several changes in the last two decades.
(Balázs, Sztrilich, 2003; Firth-Cozen, 2003)
As it was previously introduced, the profession of doc-tors is an activity tied to autonomy and to the series of in-dependent, free professional decisions and it considers itself sovereign of the rules of economy and accepting economic arguments. Nevertheless, the requirements for an economi-cally efficient operation concerning health care organiza-tions have been verbalized to a stronger or weaker degree since the democratic transformation. These requirements obviously restrict the freedom of doctors’ medical pursuit, whereas they assure the economical sustenance of health care organizations.
Therefore doctors’ scope for action has significantly nar-rowed down in this frame system. The essence of a doctors’
profession, is that they wish to serve the recovery of patients.
The more a doctor identifies with the interests of patients, the more probable it is that they dedicate more time to the treat-ment of the patient and spends money that burdens the bud-get of the hospital. It is especially so if the patient rewards the extra time, the costier diagnostics, treatments and the more recent medication in the form of providing a gratuity.
Other than the service of the patient, doctors can be moti-vated by professionalism, by professional ambition. If, as a re-sult of this, they would like to keep up with the development of technology and science and that is why they are ready to resort to the freshest, promisingly more effective and at the same time more expensive medications, diagnostic methods and equipments, supplementary medical means etc. than the earlier ones, then they are very likely to oppose to the rules of cost-efficient functioning.
Doctors’ ’sensitivity’ about taking into consideration eco-nomic aspects can be achieved in two ways. Common sense may prevail by accepting the limitations of the resources at hand but it is more frequent that doctors take the adminis-trative limitations, the strict control of costs, maybe the fi-nancial motivation against increased expenses as pressure.
Day by day doctors are in the grip of motivations which contradict one another, like the urge to spend money in the interest of the patient on one hand and the financial and moral stimulation to restrict expenses on the other hand and this often distracts their attention from the client-cen-tred patients’ care.
We assume all of these result in the following issues that have been pointed out in a research done by Mária Kopp (Győrffy, Ádám, Kopp, 2005; Győrffy, Ádám, 2006) and her co-workers concerning doctors’ society:
• the degree of chronic stress at work has increased to an extraordinary extent;
• besides the expectations for growing efforts and taking jobs excessively, the ratio of bonuses has decreased considerably – it primarily boiled down to the psycho-logical feeling of satisfaction –, the feeling of being in control, trust and the option for practising medicine with devotion have also diminished;
• being burnt-out, leaving the profession and the country have been characteristic of doctors’ society.
n
urSeSWe have been able to speak about the nurse’s profession since the work of Florence Nightingale (1820–1910) who was the creator of nurses’ worldly work as a profession in a modern sense. In the society of her time Florence Nightingale recog-nized the ever growing demand for a large number of quali-fied nurses. Nightingale established a nurse training school in London where students were educated both theoretically and practically and qualified nurses could take jobs as hospital nurses or private patient’s nurses. In nurse training institutions an almost military discipline was required from the trainees.
Nurses had to dedicate their way of life fully to the interest of patients’ recovery and for this they had to execute the doc-tors’ instructions precisely. (Abel-Smith, 1964) The relationship between doctors and nurses were based on authoritarian principles and was characterized by the constant presence of soldierly order and discipline. Although the prestige of nurses’
work built on professional knowledge was recognized even at that time, it has kept its traditional prestige hierarchy in its relationship to doctors even today. This is supported by a sur-vey on prestige which was done in 1988, according to which out of 156 jobs society ranks nurses’ work as the 11th most useful one. In spite of this, from the point of view of income this profession was listed in 100th place. Researchers found the biggest difference between usefulness and the degree of income in case of this occupation. The necessary knowledge for doing this job was placed as 38th according to the people questioned. (Blasszauer, Jakab, 1994)
Despite the above mentioned issues we can keep on con-sidering nurses’ work as a profession based on several criteria and the following reasons:
• The high degree of societal necessity which is increa-sing due to the peculiar demographic trends.
• The altruistic inclination and the service done for com-munities connected to nurses’ activities.
• The requirement for more and more specialized profes-sional knowledge which is supported by scientific re-sults.
• Nurses’ early choice of career and their dedication to work. (Feith, Kovácsné, Hajagos, Balázs, 2007)
Nurses’ work in health care organizations, similarly to that of doctors’, is done in the interest of the patients; their tasks can be connected to the most diversified areas of nursing among numerous work conditions resulting in stressful situations.
Working in two or more shifts, considerable responsibility and adaptive skills, the lack of autonomy, physical and psychologi-cal strain etc. can be such examples. (Artazcoz, Artieda, Bor-rell, Cortes, Benach, Garcia, 2004; Knudsen, Ducharme, Roman, 2007)
Since nurses spend their work hours almost completely among patients, the client-centred provision of service is more obvious. This is amplified by the fact that other than the verbal form, patient-nurse contact also involves touching the body
and ordinary and extraordinary situations may take turns in their work. The relationship between the patient and the nurse is direct, nurses often have much more information about patients than the doctors who treat them. The nurse’s posi-tion between the doctor and the patient bears the nature of a mediator. However, this middle position is subordinate and authoritarian at the same time, the offences caused by doctors, the head nurse, subordination, the pressure due to the nature of their job and conflicts can often ’poison’ the relationship with patients. (László, Susánszky, 2006; McGrath, Reid, Boore, 2003)
p
aTienTSHealing jobs bear a special significance in every society. The effectiveness of the process typically goes with considerable uncertainty since it is questionable in every case whether the given person recovers or not. The doctor, the nurse achieve or can achieve cooperation via their relationship with the patient, but considering the contents and the nature of the relationship between the parties we can speak of manifold options. We cannot undertake the detailed introduction of these here but knowledge about them can be obtained and widened from the reference studies. (Buda, 1989/a; Buda, 1989/b; Crutchfield, Morgan, 2010; László, 2006; Parsons, 1951;
Williams, 1997)
According to the client-centred concept of health care or-ganizations every activity is performed in the interest of the patient. The patient obviously expects the people who work in the organization to cure them as soon as possible and as fully as possible and in the meantime to suffer as little as pos-sible and endure as little inconveniences and subordination as possible. Other than this, most patients require the doc-tor to listen to their complaints patiently and to provide them with the necessary information about their disease and the diagnostic and treatment alternatives. The patients’ demand is similar in relation to the nurses as well i.e. patients’ will claim to want more attention, patience and an appropriate amount of time for being nursed. However, the patient would welcome the improvement of not only the personnel but the financial conditions of curing just as the more comfort-able hospital care. These are completely understandcomfort-able, ra-tional expectations. The majority of these wishes though are accompanied by extra costs, the coverage of which is not at the health care organizations’ command. So what is left from the patients’ wishes? What kind of grievances can the patients who get health care services have?
Based on the research done among the users of health care organizations the above problems can be summarized as listed below:
• in health care organizations patients consider the ac-cess time to services unjustifiably long and the period of time for being dealt with and cared for too short.
• asymmetric information flow in the doctor-nurse-pa-tient relationship is typical i.e. padoctor-nurse-pa-tients are not informed about the indispensably necessary issues for making
their decisions, consequently they participate in the or-ganizational processes passively and helplessly.
• patients are not aware of the possible circle and quality of available services, or the process of curing and the course and risks of the treatments and interventions.
• patients have to struggle with the difficulty that they can find out about the essential characteristics of the received services only subsequently or after having utilized them for longer. The case is more serious when the consumer is either not capable of judging the quality of the service even after the service or they can judge only its fragments.
• patients do not understand the language of curing neit-her from the verbal communication or from the docu-mentation in relation to their status.
• the received medical interventions are almost exclusi-vely determined by the therapeutic doctor, the patient is very rarely given a role in the decision making process.
• practically there is no one to turn to with the complaints that have risen during patients’ care. The conflicts ha-ving developed this way cannot be undertaken by the majority of patients because they do not have a proper amount of information with appropriate contents and there is no adequate forum for discussing these prob-lems either. (Tahin, Jeges, Lampek, 2000)
According to the research results the interests of patients can be seriously offended and we do not wish to blame the doctors or nurses about this. But it is important to admit that the realization of services of client-centred health care organi-zations is considerably questionable.
Summary
In this chapter we have given a brief summary about the func-tioning of societal organizations, health care organizations among them, and the problems occurring during their op-eration. We have also reviewed the relations system of health care organizations. From all of this we can draw the conclusion that the influence of doctors, nurses and patients upon health care organizations varies a great deal. A relatively narrow circle of doctors, namely the ones who are are in power positions, can have a significant effect on shaping the organizational processes, though the circle of people who hardly have any effect, or just partial effects on the organizational operation processes is much wider. Interestingly enough they are the doctors who invest the most energy in satisfying patients’
needs and thus provide a client-centred service. Almost the full range of nurses resemble them, they are mostly capable of realizing a client-centred care via their developed direct con-tact with the patients. However, all of these do not affect the factual transformation of the organization to become client-centred because these two groups possess the least informa-tion in relainforma-tion to strategic developments and they stand the furthest from power positions. The worthwhile transformation of health care services though, is not possible without them.
B
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