MANG 519-Modules Revised 2009

PRACTICUM IN NURSING ADMINISTRATION
MODULE ONE
REVIEW OF THEORIES AND CONCEPTS
SPECIFIC OBJECTIVES At the end of the session you will: 1. have reviewed the theories, concepts and principles of the four management functions of planning, organizing, directing, and controlling 2. have received an orientation of the course coverage, its objectives and requirements 3. have received an orientation to the hospital/health care facility/nursing schools organizational philosophy, mission, goals, organizational structure, physical set-up 4. have been introduced to the institutions key personnel 5. be able to write a mission statement for a health care facility/nursing school 6. begin to observe the facilitys organization climate, communication patterns, leadership styles 7. examine the organizational chart and determine relationships 8. review the different types of organizational charts/structure 9. submit a description and a diagram of the facilitys table of organization including the names and positions of leaders
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Practicum in Nursing Administration
LESSON 1
REVIEW OF MANAGEMENT CONCEPTS
* Definition of Management Management, sometimes, also referred to as supervision, is a complex process of coordinating, directing and assigning, both physical and human resources in order to accomplish an organizations short-term and long-term objectives, (Carroll, 2007). Management is often synonymous with constant activity and interaction. The most common image of a manager is of a firefighter who responds to problems that emerge randomly, and are addressed in order of emergency. * Managerial Roles One of the most frequently referenced taxonomies of managerial roles is from an in-depth study of Henry Mintzberg. He identified three categories: 1) information-processing role, 2) interpersonal role, and 3) decision-making role, (Mintzberg, 1973 ascited by Kelly, 2008). Specific or distinct roles are part of each of the three categories of managerial roles. The information processing roles are monitor, disseminator, and spokesperson, each of which is used to manage the information needs that people have. The interpersonal roles are figurehead, leader and liaison and each of these is used to manage relationship with people. The decisional roles are the entrepreneur, disturbance handler, allocator of resources, and negotiator roles that managers use to take action when making a decision. * Management Functions They consist of; A. Planning: determining the objectives of an institution or organization and what needs to be done (both in the short term and long term) to achieve those objectives. It consists of four stage process: 1. establish objectives, 2. evaluate the present and predict future trends and events, 3. formulate a planning statement, and 4. convert the plan into an action statement. Nurse Managers are more likely to be involved in the operational planning. It is done in conjunction with budgeting, usually a few months before the new fiscal years. It develops the departmental maintenance and improvement goals for the coming year. B. Staffing: selecting the people who are able to carry out the action plan. This selection is usually based on: a. the knowledge, skills, and experience of the nurse b. the number and type(s) of patients needing care c. number and type of support staff available (Leach, 2003) ___________________________________
C. Organizing: based on the plan as well as knowledge about the structure of the institution or organization, organizing is the process of coordinating human and other resources to meet established goals. Effective organizing consists of: a. knowledge of factors such as institution, environmental, social structure, people, and technology b. ability to assign tasks appropriately to people who can accomplish the tasks successfully (delegation); c. coordinating tasks that have been assigned and changing tasks or staff if goals are not being met; d. using appropriate and accepted types of authority to ensure that required tasks are completed. Depending on the organization and the manager, authority may derive from the managers position in the organization itself, or from the relationship between supervisor and staff member (Sullivan & Decker, 1992, 2001). For example, in a more rigid organizational structure such as a police or fire department, authority comes with rank. D. Directing: motivating and leading personnel to accomplish objectives. How a person directs others depends on that persons authority, power and leadership style. Effective directing is achieved through strategies such as: a. b. c. d. setting specific, clear expectations that are realistic and measurable providing sufficient resources to accomplish the tasks fostering a work environment that balances challenge and success finding ways to recognize and reward work that meets or exceeds objectives in a way that is meaningful to workers (Costello Nickitas, 1997; Sullivan & Decker, 2001).
E. Controlling: establishing standards of performance, comparing results with these benchmarks, and correcting performance that differs from accepted standard. Frequently used means of control include: a. management by objectives (MBO) devices: determining objectives, measuring to see if objectives are being met, and comparing objectives with standards (benchmarks) b. socialization: often a key part of MBO, socialization means that nurses internalize professional values and standard codes of behavior. For nurses, socialization is a process of moving from the early stages of accepting perceived beliefs and values of the profession, through formal and informal education, to the final stage of full membership in the profession and commitment to its norms and values (Sullivan & Decker, 1992). c. Managerial surveillance: the direct observation of staff behavior by the manager as well as indirect observation, for example, through the managers review of records. A key concept of this function is span of control, which refers to the number of individuals for whom a supervisor is directly responsible. A narrow span of control means fewer numbers of directly supervised staff and thus higher degrees of direct observation and control. A wider span of control (more than 10 supervised employees) means less opportunity for direct observation or control d. Continuous quality improvement (CQI): in this formal quality improvement process, staff members participate in and lead the team. All team members are continuously involved in peer review, so that they can identify ways to improve processes or ___________________________________ 3
programs, and constantly enhance and improve the quality of care (Sullivan & Decker, 2001). F. Decision Making: key steps of this function include: a. identifying problems b. establishing criteria that can evaluate potential solutions to the problem(s) c. seeking alternative solutions, including taking no action d. evaluating all the alternatives that have been found e. selecting the best alternative, based on organizational objectives, staff, environment, and other available resources. (Sullivan & Decker, 2001) G. A variety of factors affect management roles and decisions. They include: 1. the institutions structure (for example, size how it handles authority, department size and structure, wide or narrow span of control, amount of centralization or decentralization, how it measures and controls outcomes, and how it selects, recruits, and rewards employees) the organizations objectives: the service(s) it offers (such as a hospital that specializes in cardiology or an outpatient surgical center that specializes in cataract surgery), how productive the organization is or how efficiently it meets objectives, the quality and amount of its human resources and how employees participate is goal setting. environmental factors (for example, the current economics, legal, technological, or social influences that the organization must consider). technology (for example, current state of medical or nursing science, process technology. (computer systems & informatics) tasks that are required or expected (for example, the nature of tasks that need to be completed, how work tasks are designed, and the impact of the organizations physical layout on the nature and design of tasks.) social structure (for example, the organizations internal culture, how it socializes employees, the rituals that it uses to conduct work or deal with conflict.
2.
3. 4. 5. 6.
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LESSON 2
ORIENTATION TO THE ASSIGNED FACILITY (HOSPITAL OR COLLEGE OR NURSING)
Mission and Governance The missions, goals, philosophy and/or objectives of the nursing school and nursing service unit should be consistent with those of the governing organization or differences are justified by the nursing unit goals (NLN) Here are some other organizational concepts that are vital in your observation of the dynamics of, and participation in the management functions: Leadership is commonly defined as a process of influence in which the leader influences others towards goal achievement (Kelly, 2008). Influence is on instrumental part of leadership and means that the leader affects others, often by inspiring, enlivening, and engaging others to participate. The process of leadership involves the leader and the follower in interaction. This implies that ledership is a reciprocal relationship. Leadership can occur between the leader and another individual; between the leader and a group; or between a leader and an organization, a community, or a society. True leadership is not based on traditional views of leadership as having authority, command or power, or power over others. A person in a position of authority is not automatically a leader. Ideally, nurses in positions of authority have highly developed leadership qualities Roles are acts of behaviors expected of a person who occupies a given social position. Positions are location in social systems, such as nurse or teacher. People who occupy a position collectively share common behaviors. Specific behaviors associated with positions constitute roles. Positions and roles have counterparts or counter roles such as nurse client, teacher-student, or leaderfollower (Tomey, 2003)! Behaviors are actions taken by the role enactor. These acts are learned and influenced by norms. They are often voluntary and goal directed. Prescription refers to what should be done by a person in a certain position. Positions often require specific skills, intelligence, or temperament and may be held based on ones age, sex and education. Positions often imply titles such as nurse or teacher. People in positions are exchangeable, but the positions are not. Power is described as the ability to create, get and use resources to achieve ones goals (Kelly, 2008). Goals within an organization vary widely across departments, health care groups, and individuals. Power can be defined at various levels: personal, professional, or organizational. Personal power derives from characteristics in the individual. Professional power is conferred on members of a profession by one another and the larger society to which they belong. This power comes from offering a service that society values. Organizational power comes from ones position in an organizational hierarchy; as well as from understanding the organizational structure and function, and from being authorized to function power fully within an organizational culture.
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Empowerment is the process by which we facilitate the participation of others in decision making and take action within an environment where there is equitable distribution of power. It is demonstrated through: 1. an increased ability to solve problems creatively and affectively; 2. improved communication between nurses and patients, between nurses and management, throughout the organization; 3. increased satisfaction with work; and 4. improvements in peoples level of self-esteem and ability to function with autonomy (Carroll, 2007). Authority or the right to command, accompanies any management position, and is a source of legitimate power, although components of management, authority and power are also necessary to a degree, for successful leadership. The manager knowledgeable about the wise use of authority, power and political strategy is more effective at meetings, personal, unit and organizational goals. Benchmarking. Many organizations have begun using benchmarking as a tool for identifying desired standards of organizational performance. It is a process of measuring products, practices, and services against best-performing organizations (Marquis and Huston, 2006). In doing so, organizations can determine how and why their performance differs from these exemplar organizations and use them as role models for standard development and performance improvement. For example, the wound care regime related to nursing time and product use could be analyzed for quality and cost-effectiveness. How much time does it take for a nurse to complete a dressing? How much do the dressings, tape and other supplies use for the dressing cost? Organizational Structure refers to the way in which a group is formed, its lines of communication, and its means for channeling authority and making decisions (Marquis and Huston, 2006). Each organization has a formal and informal organizational structure. The formal structure is generally highly planned and visible, whereas the informal structure is unplanned and often hidden. Organizational structure are affected by the economic, political, social and technological pressures in society and follow changes in vertical and horizontal integration, geographical dispersion and unit volume. The structure delimits responsibilities, communication channels and the decision-making process environment. Organizational Chart is a drawing that shows how the parts of an organization are linked. It depicts the formal organizational relationships, areas of responsibility, persons to whom one is accountable and channel of communication. The organizational chart may be used for policy making and planning to evaluate strength and weaknesses of the current structure, and for showing relationships with other departments and agencies.
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LEARNING ACTIVITIES 1. Meet with the institutions administrators and be introduced to the key personnel including your precept or/resource persons/facilitators and others who will assist you in achieving the objectives of this course. 2. Have an orientation to the facilitys organizational mission, goals, and philosophy. The institution will assign a staff to give you the orientation. 3. Examine and comment on the institutions mission statements and goals. 4. Make a diagram of the institutions table of organization. administrators and their respective positions. Include the names of
5. If assigned in an educational institution, interview faculty members and discuss with them their own beliefs about nursing and nursing education. 6. If assigned in a nursing service facility, interview staff nurses and/or nurse managers and discuss with them their institutions and nursing service departments philosophy of service. 7. Know the names and qualifications (educational, professional and personal) of the facilitys administrators. 8. Have a tour of the facility and be oriented to the institutions physical facility. 9. Be aware of the institutions organizational climate. 10. Begin to observe channel of communication.
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MODULE TWO
TOOLS FOR PLANNING
SPECIFIC OBJECTIVES At the end of the session in either nursing service or nursing educational system, the student will have observed/participated in: 1. 2. 3. 4. 5. 6. 7. budgeting staffing/faculty assignments and load policy formulation development of standards employee hiring employee orientation staff development
Planning is the first element of management. It is during the planning stage where initially, objectives are formulated, budgetary allotments are determined, decisions are made as the size and type of staff are needed, organizational structure is designed, operational policies and procedures and all the other activities and decision related to the management process are conceived and discussed. Planning makes uses of several tools, including budgeting, setting of criteria and standards.
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LESSON 1
BUDGETTING
A key factor that influences patient care is the cost involved in the delivery of service. Resources - people, equipment, and time - are required to support the services delivered by nurses. These resources cost money. The economic success of a health care organization depends on those who are involved with service delivery. Nurses play an integral role in the preparation, implementation, and evaluation of a unit or department budget. Hospitals use several types of budget to help with future planning and management. These include: 1. Operational budget accounts for the income and expenses associated with day to day activity with a department or organization. 2. Capital budget accounts for the purchase of major new or replacement equipment. Equipment is purchased when new technology becomes available or when older equipment becomes too expensive to maintain because of age related problems. 3. Construction budget is developed when renovation or new structures are planned. The construction costs generally include labor, materials, building permits, inspection, equipment, etc. If it is anticipated that a department will need to close during construction, then projected lost revenue is accounted for in the budget (Kelly, 2008). Budgeting is frequently classified according to how often it is done and the base on which budgeting takes place. Three of the most common budgeting methods are: 1. Incremental budgeting or the flat percentage increase is the simplest method for budgeting. By multiplying current year expenses with a certain figure, usually the inflation rate or consumer price index, this method arrives at the budget for the coming year. Zero based budgeting. This method does not automatically assume that because a program has been funded in the past, it should continue to be funded. This budgeting process is labor intensive for nurse managers. The use of decision package to set funding priorities is a key feature of this method. Key components of decision package are the following: 1. 2. 3. 4. 3. listing of all current and proposed objectives in the department, alternative plans for carrying out these activities, counts for each alternative, and advantages and disadvantages of continuing or discontinuing an activity.
2.
New performance budgeting emphasizes accountability, efficiency, economy by emphasizing outcomes and results instead of activities or outputs. The manager would budget as needed to achieve specific outcomes and would evaluate budgetary success accordingly.
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Managed Care Managed care is a system that attempts to integrate efficiency of care, access, and cost of care. Common denominators of managed health care include panels of contracted providers, some type of limitation on benefits to subscribers who use noncontracted providers (unless authorized to do so), and some type of authorization system (Kongstvedt, 1977 as cited by Marquis and Huston, 2006). Other key principles of managed care include the use of primary care physicians as gatekeepers to the healthcare system, a strong focus on prevention, a decreased emphasis on inpatient hospital care, the use of clinical practice guidelines for providers, selective contracting (whereby providers agree to lower reimbursement levels in exchange for patient population contracts), utilization review, the use of formularies to manage pharmacy care, and continuous quality monitoring and improvement. Another frequent hallmark of managed care is capitation, whereby providers receive a fixed monthly payment regardless of what services are used by that patient during the month. If the cost of caring for a specific person is less than the capitated amount, the provider profits. If the cost is greater than the capitated amount, the provider suffers a loss. The goal, then, for capitated providers is to see that patients receive the essential services to stay healthy or to keep from becoming ill, but to eliminate unnecessary use of healthcare services. One of the most common types of managed care organizations (MCO) is the health maintenance organization (HMO). An HMO was originally defined as a prepaid organization that provided healthcare to voluntarily enrolled members in return for a preset amount of money on a per-person, per-month basis. With the increase in self-insured businesses or financial arrangements that do not include prepayment, this definition now generally includes two possibilities: (1) it is a licensed health plan that places at least some of the providers at risk for medical expenses, and (2) it is a health plan that utilizes designated (usually primary care) physicians as gatekeepers (although some HMOs do not) (Kongstvedt, 1977 as cited by Marquis and Huston, 2006). It is important to remember that there are different types of HMOs as well as different types of plans within HMOs that members may subscribe to. Several types of HMOs include: (1) staff, (2) independent practice association (IPA), (3) group, and (4) network. In staff HMOs, physician providers are salaried by the HMO and under direct control of the HMO. In IPA HMOs, the HMO contracts with a group of physicians through an intermediary to provide services for members of the HMO. In a group HMO, the HMO contracts directly with one independent physician group. In network HMOs, the HMO contracts with multiple independent physician group practices.
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LESSON 2
STANDARDS, POLICIES AND PROCEDURES
A standard of care outlines the level or degree of quality considered adequate by a given profession. These standards represent the skills and learning commonly possessed by members of the profession and generally are the minimal requirements that define an acceptable level of care. Standards of care, which guarantee patients safe nursing care, include organizational policy and procedure statements, job descriptions. In nursing service, the purpose of enunciating, circulating and enforcing standards is threefold: a) b) c) to improve the quality of nursing care to decrease the cost of nursing care to provide a basis for determining nursing negligence.
In nursing education, standards for institutional performance are usually set by the accrediting body, but the institution itself sets its own standards for faculty and student performance, as well as for determining the effectiveness of its educational program and its use of resources. Policies Policies and procedures are means for accomplishing goals and objectives. Policies explain how goals will be achieved and serve as guides that define the general course and scope of activities permissible for goal accomplishment. They serve as a basis for future decisions and actions, help coordinate plans, control performance, and increase consistency of action by increasing probability that different managers will make similar decisions when independently facing similar situations. Policies should be comprehensive in scope, stable, and flexible so they can be applied to different conditions that are not so diverse that they require separate sets of policies. Consistency is important because inconsistency introduced uncertainty and contributes to feelings of bias, preferential treatment, and unfairness. Fairness is an important characteristic that is attributed to the application of the policy. Policies should be written and understandable. Policies can be implied or expressed. Implied policies are not directly voiced or written but are established by patterns of decisions. They may have either favorable or unfavorable effects and represent an interpretation of observed behavior. Courteous treatment of clients may be implied versus expressed. Expressed policies may be written or unwritten. Oral policies are more flexible than written ones and can be easily adjusted to changing circumstances. They are less desirable than written ones because they may not be known.
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Procedures are plans that establish customary or acceptable ways of accomplishing a specific task and delineate a sequence of steps of required action. It may have some variation in the steps as long as the same outcome is obtained. Procedures identify the process of steps needed to implement a policy and are generally found in manuals at the unit level of organization. The nurse manager has the responsibility to review and revise policies and procedure statements to ensure currency and applicability. Procedure manuals provide a basis for orientation and staff development and are ready reference for all personnel. They standardize procedures and equipment and can provide a basis for evaluation. Good procedures can result in time and labor savings. Improvement in operating procedures increases productivity and reduces cost. Writing procedures demands a consistent format that considers the definition, purpose, materials needed and how to locate, requisition, and disposition of them, steps in the procedure, expected results, precautions, legal implications, nurse, patient, and doctors responsibilities and appropriate charting.
LEARNING ACTIVITIES Answer the following and submit your answer/reaction to your professor. 1. Observe/interview nurse administrators (dean or director of nursing) to determine what the institutions long range/strategic plans are in connection with physical resources, clientele, and service development. Interview and/or observe nursing service director, supervisors, staff or dean and faculty to determine the following 2.1) 2.2) 2.3) 2.4) 2.5) 2.6) 2.7) 3. Time set aside for planning; How time is managed both by his/her and staff; Time set aside for planning for emergencies and crisis. In planning, how he/she considers priorities, deadlines, organizational goals, characteristics of work. How plans/projects are developed. How plans/projects are approved. How plans are implemented and monitored.
2.
Observe the budgeting process: 3.1) 3.2) 3.3)
Determine the approaches used in planning the budget. Determine staff/faculty participation in planning the budget. Identify the individuals within the organization who have responsibility for budget preparation, approval and monitoring. 3.4) Make a sample budget report for a nursing unit/college of nursing. ___________________________________ 12
3.5) 3.6) 3.7) 4.
Determine the main sources of revenue as well as the major expense; Examine the budget worksheet used and note its components. Determine how the budget is allocated, e.g., how many percent of the budget are allotted for personnel, equipment, supplies physical resources, and so on.
Read the institutions Administrative and Policy Manuals and determine the following: 4.1) 4.2) The role of the nurse administrator in formulating administrative orders/policies, rules and regulations The process and steps involved in writing them. For example, how employees are recruited and selected
5.
With your preceptor, sit in committee meetings as for example, Administrative Committee, Committee on Standards, Nurse Managers Committee, faculty meetings. While attending any of the meetings, observe the following processes and make a brief report of your observation: 6.1) 6.2) 6.3) 6.4) 6.5) Decision-making process: how problems are identified, alternatives explored, choosing most desirable alternatives. Values, attitudes, personality, of participants; Group dynamics, group process; Time Management Leadership styles
6.
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MODULE THREE
ORGANIZING
SPECIFIC OBJECTIVES At the end of the sessions the student will have observed/ examined, and/or participated in the following processes in either a Nursing Service Department or a College of Nursing:
1. 2. 3. 4. 5.
recruitment, selection, hiring and interviewing of new employees; activities related to the retention of old employees; orientation program staff development activities and programs writing and implementing job descriptions of staff/faculty, supervisors, college of nursing dean, nursing service director; 6. determining the qualifications of nursing administrators, faculty and staff; 7. determining the purpose, compositions, functions of committees and 8. determining the other organizing tasks and activities to achieve the agencys goals and mission.
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LESSON 1
STAFFING
The manager is responsible for providing adequate staffing to meet patient care needs. It involves: a) the selection of personnel, b) selection of assignment system, and c) the determination of staffing schedules. Recruitment of qualified personnel is the first step in the selection of personnel. The nurse manager attracts applicants for existing positions. Although at any given time an organization may have an adequate supply of personnel to meet the demand, it should be an ongoing process. The manager maybe greatly or minimally involved with recruiting, interviewing and selecting personnel depending on 1) the size of the institution; 2) the existence of a separate personnel department; 3) the presence of a nurse recruiter within the organization and 4) the use of centralized or decentralized nursing management. Recruitment, however, is not the key to adequate staffing in the long term. Retention is, and it only occurs when the organization is able to create a work environment that makes staff want to stay. Some turnover is normal and desirable. Turnover infuses the organization with fresh ideas. It also reduces the probability of groupthink in which all the people in the organization share similar thought processes, values, and goals. Excessive or unnecessary turnover reduces the ability of the organization to produce its end-product and is expensive. Indocrination as a management function, refers to the planned, guided adjustment of an employee to the organization and the work environment. Induction and orientation are frequently used to describe this function, the indoctrination, process includes three separate phases: 1) induction; 2) orientation, and 3) socialization. Induction takes place after the employee has been selected but before performing the job role. It includes all activities that educate the new employee about the organization and employment and personnel policies and procedures. Orientation activities are more specific for the position. The purpose of the orientation process is to make the employee feel a part of those team. This will reduce burnout and help new employees more quickly become independent in their new roles. Socialization according to Maquiz and Huston (2006) is a sharing of the values and attitudes of the organization by the use of role models, myths and legends. It involves little structured information. Job Description are derived from job analysis and are affected by job evaluation and design. They contain specifications which are the requirements for the job, major duties and responsibilities, and the organizational relationships of a given position. Job description are useful for recruitment, placement, promotion, transfer and evaluation. It helps prevent conflict, frustration and overlapping of duties.
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LESSON 2
ASSIGNMENT SYSTEMS FOR STAFFING
Changes in assignment systems are a response to changing needs. Functional nursing is predominant in response to the shortage of nurses. Team nursing is use to maximize the knowledge and skills of professional nurses and to supervise auxiliary workers. Each system has its own advantage and disadvantages. Pros and Cons of Various Assignment Systems
Assignment System Case method Functional nursing Team nursing Pros Total patient care Efficiency Team effort Frees patient care coordinator to manage the unit Nursing care conferences help problem solve and develop staff Nursing care plan Useful where there are few RNs RNs plan care RNs give total patient care Primary nurse has 24 hour-a-day responsibility Associate nurse works with patient while the primary nurse is off duty Accountability in place Continuity of care is facilitated Reduces number of errors from relay of orders Fewer patient complaints Shorter hospitalization Unit-based Can be used with any nursing care delivery system Standard critical paths Focuses on entire episode of illness Emphasizes achievement of outcomes Incorporates managed care Care is coordinated by a case manager Second-generation primary nursing Critical paths Variation Analysis Intershift reports Health care team meetings Quality assurance Interdisciplinary approach Cons Different nurse, different shifts, different days Nurses do managerial work Nurses aides do patient care Time needed to coordinate delegated work
Modular nursing Primary nursing
Paraprofessionals do technical aspects of care Confines nurses talents to a limited number of patients Associate nurse may change care plan without discussing with primary nurse
Managed care
Questionable continuity of care
Case management
Effort to coordinate
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LESSON 3
STAFFING SCHEDULES
Scheduling of staff is the responsibility of the nurse manager, who must ensure that the schedule places the appropriate staff on each day and shift for safe, effective patient care. There are some considerations in scheduling the staff: 1) the patient type and acuity; 2) the number of patients; 3) the experience of the staff; 4) and supports available to the staff. Advantages and Disadvantages of Various Scheduling Methods
Scheduling Method Self-scheduling Pros Coordinated by staff nurses Saves manager scheduling time Helps develop accountability Increased perception of autonomy Increased job satisfaction Improved team spirit Improved morale Decreased absenteeism Reduced turnover Effective for recruitment and retention Can rotate teams Cons Increases amount of time staff spends on scheduling
Rotating work shifts
Permanent shifts
Can participate in social activities Job satisfaction Commitment to the organization Fewer health problems Less tardiness Less absenteeism Less turnover Same schedule repeatedly Nurses not so exhausted Sick time reduced Personnel know schedule in advance Personnel can schedule social events Decreased time spent on scheduling Staff treated fairly Helps establish stable work groups Decreases floating Promotes team spirit Promotes continuity of care Uses census to determine number and mix of staff Little need to call in unscheduled staff
Block, or cyclical, scheduling
Rotates among shifts Increases stress Affects health Affects quality of work Disrupts development of work groups High turnover Most people want day shift New graduates predominately staff evenings and nights Difficulty evaluating evening and night staff Nurses may not appreciate the work load or problems of other shift Rigidity
Variable staffing
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Pros and Cons of Centralized and Decentralized Staffing

Pros Centralized Decentralized Fairness Cost containment Managers have authority Staff get personalized attention Staffing is easier Staffing is less complicated Cons Lack of individualized treatment Unfair treatment Schedule used to punish and reward Time-consuming for managers Less efficient use of resources Cost containment is more difficult
Pros and Cons of Variable Staffing

Pros 8 hours 10 hours Traditional Time to complete work Long weekends Extra days off Decreased overtime Cover peak workloads Decrease costs Lower staffing requirements Lowers cost per patient day Increased knowledge of patients Get new admissions settled Not so rushed Better continuity of care Team development is possible Less daily reporting Less time to do staffing Reduced travel time Less personal expenses for gas, meals, babysitting Fewer people need to work weekends Weekends off more frequently Work fewer hours for greater pay Staffing improved Morale improved Cons Longer workday Fatigue Overlap Difficult to find substitute
12 hours
Overtime Exhaustion increases at end of workweek Tension increases at end of workweek Increases in minor accidents Increases medication errors Home and social life suffers the week worked
Baylor plan/weekend option
Illness increased Absences increased
Patient Care Delivery System and Assignment System Used in Community Health Services are: Managed care, case management, and collaborative practice. Managed care, according to Marriner-Tomey (2003) is a unit-based care system that can be used in any nursing delivery system. Activities, consultations, diet, discharge planning, medications, teaching, tests, treatment are noted. Case management focuses on the entire episode of illness, including all settings in which the client receives care. It emphasizes achievement of outcomes in designated time frames with limited resources. Typically, it incorporates managed care. Care is coordinated by case manager, usually a registered nurse. Case management is sometimes called second-generation primary nursing. Collaborative practice can include interdisciplinary teams, nurse-physician interaction in joint practice, or nurse-physician collaboration in care giving.
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LESSON 4
FACULTY ASSIGNMENT
In Article III (Administration) Section I. of CHED Memo No. 30 Series of 2001, which is called the Updated Policies and Standards for Nursing Education, the college of nursing should be administered by a full-time dean who: a. b. c. d. is a Filipino citizen; is a current Registered Nurse in the Philippines; is a holder of Masters degree in Nursing; has at least five (5) years of competent teaching and supervisory experience in colleges or institutes of Nursing; e. is an active member of good standing of the Association of Deans and Philippine Colleges of Nursing (ADPCN) and the accredited national nurses association Section 2. The general functions and responsibilities of the Dean of Nursing are to:
a. assist the administrators to attain institutional goals, e.g. instruction, research, community extension services and all related matters; b. initiate curriculum development programs; c. implement faculty development programs; d. recommend faculty for appointment, promotion and tenure including leave and nonreappointment; e. approve faculty teaching load; f. oversee facultys academic advisement of the student; g. collaborate with student services, admission policies and referrals based on established criteria; h. ensure adherence to established standards of instruction; i. ascertain that requirements for graduation are complied with; j. represent the school in professional and community civic affairs; k. attend to physical and budgetary resources; l. collaborate with the health services and other academic units in the implementation of instructional programs.
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ARTICLE IV FACULTY Section 1. The faculty shall have academic preparation appropriate to teaching assignment. In addition, she/he must: a. b. c. d. e. be a Filipino citizen; be a current Registered Nurse in the Philippines; be a holder of Masters degree in their major field and / or allied subjects; have at least three (3) years of clinical practice in the field of specification; be a member of good standing of the accredited national nursing association
Section 2. When vacancies occur in the teaching force of the college during the school year, substitute or replacement with similar or higher qualifications shall be employed. Section 3. a. b. The following conditions of employment must be observed:
The salary of faculty shall be commensurate with their rank. Full time faculty member who shall be responsible for both classroom and Related Learning Experience (RLE) must teach nursing courses.
Section 4. The faculty shall be assigned academic ranks in accordance with their academic training and clinical expertise. The recognized ranks are: instructor, assistant professor, associate professor, and professor. Section 5. The faculty development program plays a role in the effective operation of the college. It consists of activities and programs towards the development of the faculty for intellectual, personal, and professional as well as moral and spiritual growth. The program may be in the form of: a. b. c. d. scholarship grant graduate studies in-service and continuing training programs clinical skills enhancement for at least two weeks a year
Section 6. The teaching load of college faculty members should be as follows: a. Dean not to exceed a total of six (6) units of lecture in a semester. b. Full-time faculty members may carry a regular teaching load of 15-24 units per semester. One hour of related learning experience supervision is equivalent to one (1) unit credit. c. Government employees who serve as part time faculty for non-nursing course must secure permit from the employer and may be given a maximum teaching load of nine (9) units. d. Part-time faculty employed full-time elsewhere may carry a teaching load of not more than 9 units in all the schools in which he teaches.
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Selection of Faculty Members. Colleges of nursing may vary in their requirements for hiring faculty members. However, there are guidelines/standards that have to be followed and these are related to educational, professional and teaching experience and license requirements. The Masters Degree is the minimum credential required for teaching in colleges of nursing. The selection of faculty members must take into consideration the criteria and requirements of the regulating bodies such as the Board of Nursing and the Commission on Higher Education. Nursing School Administrator. A college of nursing is administered by the dean. The dean must be experientially and academically qualified to assume the authority and responsibility for the development and administration of the BSN program. The dean may also have instructional load, an ex-officio member of all standing committees, an active member or leader of professional and community service organizations. She prepares an annual report and may report either to the vice-president for academic affairs or to the Board of Trustees. Committees. In all democratic organizations, committees are formed to assist the administrators in their functions of planning, organizing, directing and controlling. In schools and colleges of nursing, the usual standing committees are Admissions and Promotions, Curriculum, Faculty Development, Evaluation, Recruitment and Publicity, Library, Physical Resources. The duties of the chairperson of standing committees include preparation of agency for meetings, presiding, channeling recommendations between the Committee and administration, presenting an annual report to the Administrator (dean). The duties of the secretary are to record attendance and minutes of all meetings, and to submit them to the chairman.
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ARTICLE VI INSTRUCTIONAL STANDARDS Section 1. The institution must maintain a high standard of instruction, utilizing appropriate and updated syllabi and instructional methods/strategies that contribute to sound nursing education. a. The professional nursing subjects must be offered observing strictly pre-requisite requirements and sequence. b. Credit for the completion of the course is based on the fulfillment of curricular requirements. c. The ratio of faculty to student in science laboratory class is 1:25; in regular classroom is 1:50. d. The institution shall provide for a systematic and continuing plan of evaluation of the students progress through a marking system that is consistent and congruent to set objectives. e. A system of supervision should be instituted and implemented for the purpose of evaluating teaching performance. f. There should be a regular academic audit of instructional resources such as syllabi, textbooks and others. g. Record management must be maintained. Section 2. The Related Learning Experience (RLE) are highly selected to develop competencies utilizing the nursing process in varying health situations. The following conditions must be observed. a. There should be close correlation of theoretical knowledge to related learning experience. Classroom and RLE activities must be congruent b. Classroom and RLE is a continuous process. Faculty teaching in the classroom must continue to teach the students in their RLE. c. Related learning experiences are organized around the objectives and competencies set for the course and all students must be able to achieve such. d. Faculty compensation is based on the computation of one (1) hour RLE equivalent to one (1) lecture hour. e. Effectiveness and efficiency of the related learning experience, must consider the following factors: 1. Background knowledge and capacity of the learner. 2. Size and nature of the learning resources both in institutions and communities. 3. Adequate number and variety of clientele. 4. Adequate number of qualified nursing and other personnel. 5. Evidence of quality nursing care services. 6. Compliance with the required equivalence of fifty one (51) hours to (one) 1 unit RLE 7. Ratio of student to clientele depends upon the objectives and the capacity of the student. The ratio of student to clientele is:
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Level III IV
1st Sem 1:1 1:2-3
2nd Sem 1:2 1:3-5
8. A faculty-student ratio of: Level III IV 1st Sem 1:8-10 1:12-15 2nd Sem 1:8-12 1:12-15
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LEARNING ACTIVITIES Answer the following and submit your answer/reaction to your professor. 1. Read and study the Administrative Employee manuals. Determine the following: a) activities related to recruitment; b) activities related to retention; c) policies related to selection and hiring of employees; 2. Get a copy of application form and note the information needed. 3. Get a copy of a job description of staff nurse/faculty, nurse manager/dean. Write one long range plan and one short plan objectives for each position. 4. Attend an orientation program for new employees 5. What are the components of the orientation program? 6. Attend a staff development class. Determine what continuing education programs are available to staff/faculty. 7. Interview staff. Ask them about their professional and educational needs. 8. Attend committee meetings/obtain copies of committee minutes. What are the standing committees? What are their compositions and functions? In the college of nursing, for example, how does the curriculum committee organize learning activities of students in order to achieve the goals and mission of the school? 9. Submit a weekly report and evaluation of your learning activities including suggestions and recommendations for the institution and for the course. Specifics of Nursing Service: 1. Interview the supervisor/nurse manager who is in charge of staffing. following: Determine the
a) patient care delivery modes or assignment system b) policies regarding staffing c) staffing system to determine the number of full-time staff needed for vacation, holiday, absentee coverage per year. 2. Study staffing schedules 3. Determine the patient classification system used 4. Determine an assignment system to be used in one of the units. Calculate the number and level of staff needed on an 8 hour shift.
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Specifics for Nursing Education: 1. Read the Faculty Manual. Interview a faculty, school officer and determine the following: a) Faculty load b) Basis of faculty assignment c) Faculty-Student ratio: 1) in the classroom 2) in the clinical area. 2. Observe how the process of organization works: a) in the clinical teaching setting b) in the classroom teaching. 3. Attend: Curriculum Development Committee and faculty meetings. meeting is organized. Observe how the
4. Study the Curriculum. Write a brief comment on how the curriculum is organized. 5. Study the Student Manual. 6. Take note of the learning resources.
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MODULE FOUR
CONTROLLING AND EVALUATION
SPECIFIC OBJECTIVES At the end of the session the student will have observed/participated in the controlling and evaluation function of the nurse administrator in the assigned facility, either in nursing education or nursing service. Specifically, the student will have observed/participated in: 1. establishing standards; 2. measuring performance; and 3. correcting deviation.
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LESSON 1
CONTROL MEASURES
Controlling is the last stage in the management process. Measuring performance and taking corrective actions are leadership functions which ensure the accomplishments of organizational goals. Control measures include; 1) discipline; 2) rounds, reports, audits; 3) evaluation devices; and 4) quality control and improvement. Discipline Disciplining Problem Employee. Problem employees include the substance abusers, those with excessive tardiness or absenteeism, those whose performance is below par and those who are withdrawn, angry, quarrelsome. When an employee reports to work in apparently intoxicated state, the manager should note the signs objectively and should ask a second person to validate her observation. The intoxicated employee should be removed from the area, confronted briefly and firmly about the behavior, and sent home. The incident is recorded. Each time a performance problem occurs, it should be documented. The date and time, who was observed by whom and description of the incident should be noted. At a pre-arranged conference, the employee is confronted with the observations. The employee is given the opportunity to explain, alternatives are explored, and a course of action is planned. The supervisor/manager may refer the employee for remedial measures, treatment or counseling. For example, an alcoholic may be referred to a treatment facility, or a nurse whose clinical performance is below par, may be referred to the staff development instructor for further practice. Audits Auditing in healthcare organization provides managers with a means of applying the control process to determine the quality of service rendered. It can occur retrospectively, concurrently, or prospectively. The audits frequently used in quality control include outcome, process and structure audits. Outcome audits determine what results, if any, occurred as a result of specific nursing interventions for clients. It assumes that the outcome accurately demonstrate the quality of care that was provided. Process audits are use to measure the process of care or how the care was carried out. It is task oriented and focus on whether practice standards are being fulfilled. It assumes that a relationship exists between the quality of the nurse and the quality of care provided. It can be documented in patient care plans, procedure manuals, or nursing protocol announcements. Structure audits assume that a relationship exists between quality care and appropriate structure. It ensures a safe and effective environment but does not address the actual care provided. ___________________________________
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Performance Measurement The only way to know whether the staff are meeting their goals is to measure performance. 1. Purpose of performance measurement is to: a. provide feedback b. justify merit increase and other compensation adjustments c. identify candidate for promotion d. confirm hiring decisions e. counsel and terminate 2. To effectively assess employee performance, the nurse manager must know the principles of performance management a. know the job description and performance standards for the person being evaluated b. remain objective and evaluate performance over time, not just the month before the formal performance appraisal is due c. encourage employee to set attainable short-term and long term goals and to include professional development activities d. allow the person being evaluated to respond to the evaluation and discuss any performance successes or difficulties e. identify specific ways for employee to improve job performance and specific ways to motivate employee f. write down goals and objectives in a contract that specifies expectations and encourages growth 3. The Key Elements of Performance Measurement a. Quality and Volume of Work. Does the person perform the amount of work expected and do it according to standards set by the department? b. Work Knowledge. Does the employee understand department policies and procedures, regulations, resources, and trends that are applicable to his or her daily responsibilities? c. Work Judgment. Does the person show reliable and consistent decision making and predictable, appropriate behavior? d. Organization. Does the person effectively plan and organize work, and meet set deadlines and use time wisely? e. Responsibility and Flexibility. Does the employee accept responsibility for his or her work and avoid blaming others for failures? Does he or she accept instruction or direction appropriately? Can the employee readily adapt to changing conditions such as admissions, changes in patient condition, and other modifications to do the assignment during a given shift? f. Interpersonal Skills. Does the employee communicate effectively with other staff members, families etc.?
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The Importance of Job Descriptions as Part of Performance Measurement 1. Job description help nurse managers produce results such as customer satisfaction, an efficient and effective work environment, meeting patient care objectives, and costeffective care 2. Effective Job Descriptions a. b. c. d. e. f. g. h. help employees understand their duties improve work flow evaluate job performance clarify relationships among jobs identify potential training needs help determine employee hiring and placement needs establish a structure for promotion and salaries (Costello Nickitas, 1997) consistent with licensure laws and do not assign duties to noncredentialed staff that can only be performed by licensed nurses
Quality Improvements Health care organizations need to continually monitor their services to improve quality of care. The concepts of quality assurance and quality improvement (QI) began in the manufacturing industry, but it is applicable to health care as well. A. Difference between Quality Assurance and Quality Improvement 1. focus on quality assurance (also called doing it right) a. assess or measure performance b. determine whether performance meets standards (goal in manufacturing, for example, is zero defects) c. improve performance when it does not meet standards 2. a. b. c. d. e. focus on quality improvement (also called doing the right thing) meet the customers needs build quality performance into the work process assess the work process to identify opportunities for improved performance employ a scientific approach to assessment and problem solving improve performance continuously as an on going management strategy, not just when standards are not met (McLaughlin & Houston, 2003) f. performance integrates processes and outcomes and continually seeks a better way to accomplish desired outcomes
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B. General principles of quality improvement A. Priority is to benefit patients and other internal and external customers 1. customer is anyone who receives 2. internal customer works within the organization (for example, nurses in the intensive care unit are customers of radiologic technologists using portable equipment in the unit for radiographs) 3. external customer is anyone outside the organization who receives the output of the organization (for example, patients, insurance companies, regulators, and the community; surgeons who bring patients to a hospital for surgery are also customers of the hospital) B. Organizations achieve quality through the participation of everyone in that organization; this promotes ownership so that employees 1. take responsibility for an organizations success or failure 2. take an active role in developing new ways of doing business and bringing in new customers 3. know that their efforts are valued 4. for example, a nurse organizes her day so that she can spend a few moments with a critically ill patients family; or a respiratory therapist checks with the nurse so as to coordinate treatment times for patients with chronic obstructive pulmonary disease to reduce patient fatigue C. Focusing on work process provides opportunities for improvement 1. processes are causes or conditions that repeatedly come together in a series of steps to transfer inputs into outcomes 2. steps in a process can be studied, based on evidence-based practice, eliminated, changed, or standardized to improve the overall work process 3. for example, all the steps required to take a patients blood sample can be observed, analyzed, compared with best practices, and changed to eliminate repetition of steps or otherwise improve speed and accuracy of results D. Decisions to change or improve a system are based on data 1. a system is an interdependent group of items, people, or processes with a common purpose 2. outcomes can be observed and improved on, by analyzing their systemic roots 3. for example, to improve the time required to take a patients blood sample and receive diagnostic results, you would need not only to improve the response time of the phlebotomist, but also examine the processes at work in the lab
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E. Houston, 2003) 1.
Improvement of service quality is a continuous process (McLaughlin & products or services are designed and made based on the knowledge about the customer 2. the customer judges the product or service and how well it does or does not meet his / her needs 3. based on this information, the product or service is improved (Sullivan & Decker, 2001; McLaughlin & Houston, 2003)
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LESSON 2
EVIDENCE BASED PRACTICE
Evidence based practice (EBP) is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. It uses outcomes research and other current research findings to guide the development of appropriate strategies to deliver quality, cost-effective care. Outcomes research can also identify potentially effective strategies that can be implemented to improve the quality and value of care, (Kelly, 2008). EBP is a total process that begins with knowing what clinical questions to ask, how to find the best practice, and how to critically appraise the evidence for validity and applicability to the particular care situation. The best evidence is then applied by a clinician with expertise based on the patients unique values and needs. Ingersoll has defined evidence-based nursing practice (EBNP) as the conscientious, explicit, and judicious use of theory derived, research-based information in making decisions about nursing care delivery to individuals or groups of individuals and in consideration of individual needs and preferences (Tomey, 2000). Evidence-based practice has a medical focus, whereas evidencebased nursing practice considers the individuals needs and preferences based on nursing theory and research. The role of the nurse is to participate in developing a comprehensive, interdisciplinary evidence-based plan of care in conjunction with the patient and members of the health care team. Why is evidence-based care important? 1. patients, health care providers, and payers recognize the significance of collecting data and analyzing outcomes to achieve optimum care. 2. outcome strategies developed in evidence-based practice are based on science, not tradition, and used to create clinical protocols, guidelines, pathways, and algorithms, which are the key tools for health care interventions 3. evidence-based practice is most successful when the entire organization is invested in the process and participates in and supports it 4. evidence-based practice has become the key to identifying and developing better strategies to monitor and improve quality of care.
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LEARNING ACTIVITIES Read the following: 1. 2. 3. Accreditation Manual; The employee/Faculty/Student manuals; Administrative and Policy Manuals and study the institutions general policies, rules and procedure relating to personnel, resources, programs/standards and criteria for desired levels of performance. 4. Observe/interview a nurse administrator and staff to determine the following: a) How employees /students performance are monitored b) Performance appraisal/grading techniques used: Examine and study the different methods used, such as anecdotal notes, rating scales, peer evaluation and interview. Study the grading system of the school. c) How the manager/dean deal with problem employees, including substance abuser, those who are habitually .late or absent, those whose performance are below par, those who are quarrelsome. In the same manner, how does the school administrator deal with problem students? d) Disciplinary measures used: Do employees/students have the right to appeal? e) Measures resorted to before suspending and/or terminating an employee/student f) How the use of resources are monitored g) Cost saving measures: How is the budget used as a control measure? 2. Study the Quality/Assurance/Improvement Program of the institution. How was it developed? 3. Study the institutions Planned Evaluation Program, if there is any. What is the institutions status in terms of being accredited? Other Suggested Activities Specific for Nursing Education: Interview faculty members and ask them about their views regarding education, nursing, and the schools responsibility to the student. Analyze minutes of meetings of the standing committees and faculty organizations if important issues are being addressed properly; Examine school organizational charts for relationships. Confer with members of the Evaluation Committee to determine their evaluation system. Review the Committees annual report. Speak to one or two faculty members to determine their professional and educational needs. Speak to faculty members to determine how they evaluate current forms and process used in evaluating them. Read the student manual and interview students if necessary to determine how policies are implemented. Examine the counseling program, health program, and financial assistance program. Interview the dean and faculty members and ask about students performance in the Board Examination and in the job market. ___________________________________ 33
Student curriculum. Compare the curriculum objectives to the philosophy and goals of the school. Analyze course content in relation to the course objectives: Attend a class/clinical laboratory. Note adequacy of facilities and resources. Study the faculty and student evaluation tools. Visit the school library. Note adequacy of current materials. Visit the administrative office to determine the recording system as to: a) faculty records, b) student records c) graduate records.
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MODULE FIVE
COLLECTIVE BARGAINING
SPECIFIC OBJECTIVES At the end of the session the student should be able to: 1. 2. relate the process of managing in a union environment. analyze the pros and cons of collective bargaining in the workplace.
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LESSON 1
COLLECTIVE ACTION
Historically, nurses have often been perceived as hard-working, submissive staff who do what they are told. The scope of nursing has changed so drastically that today nurses cannot afford to have a submissive image and do what they are told. Nurses are educated to advocate for their patients and themselves. Clinical situations arise in which nurses must voice their opinions and stand up for what is best for patients. One of the main purposes of collective action for nurses is to advance the profession of nursing. Two types of collective action are; 1) workplace advocacy; and 2) collective bargaining. Workplace advocacy refers to activities nurses undertake to address problems in their everyday workplace setting. This is the most common in nursing. An activity that falls under workplace advocacy is forming a committee to address problems, devising alternative to achieve optimal care, and conducting new inventory ways to implement change. An example of an issue that would be addressed by this is patient advocacy. Patients rely on nurses to do this. In collective bargaining the group is bargaining with management for what the group desire. If the group cannot achieve its desires through informal collective bargaining with management, the group may decide to use a collective bargaining agent to form a union. Factors Influencing Nurses to Unionize In general, nurses who are content in their workplace do not unionize. It is when nurses feel powerless that they initiate attempts to unionize. Other motivation to unionize include job stress, physical demands, need to communicate concerns and complaints to management without fear of losing their jobs. Issues that are commonly the subject of collective bargaining include poor wages, unsafe staffing, health and safety issues, mandatory overtime, poor quality of care and job security. Many nurses are morally opposed to unions because they believe if they are members of a union, they may be forced to strike. In reality, a collective agent cannot make the decision to strike. The decision to strike is made only if the majority of union members decide to do so. Most nursing collective bargaining agents insert in the contract a no strike clause, stating that striking is not an option for its members. Whistle blowing is the act in which an individual discloses information regarding a violation of a law, or regulation, or a substantial and specific danger to public health or safety. As a patient advocate, nurses have an ethical and moral duty to protect their patients.
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LEARNING ACTIVITIES 1. You are the nurse in a medical unit. The nurse manager explains to you that the unit uses workplace advocacy. How will it affect your functioning as the nurse in the medical unit? Explain the workplace advocacy in the place where you are working, e.g. hospital, community health center, college of nursing.
2. You are hired in a hospital that is a union shop. How does unionization differ from a workplace advocacy? Give 3 examples of how unionization differs from workplace advocacy.
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MODULE SIX
OBSERVATION IN COMMUNITY HEALTH CARE AGENCIES
SPECIFIC OBJECTIVE At the end of the session the student will be able to observe the processes and function of management in the assigned community health care agencies.
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LESSON 1
GLOBAL AND COUNTRY HEALTH IMPERATIVES
HEALTH GLOBAL AND COUNTRY IMPERATIVES Public health systems are operating within a context of ongoing changes, which exert a number of pressures on the public health system. These changes include: 1. Shifts in demographic and epidemiological trends in diseases, including the emergence and re-emergence of new diseases and in the prevalence of risk and protective factors: 2. New technologies for health care, communication and information; 3. Existing and emerging environmental hazards some associated with globalization; 4. Health reforms. In response to above trends, the global community, represented by the United Nations General Assembly, decided to adopt a common vision of poverty reduction and sustainable development in September 2000. This vision is exemplified by the Millennium Development Goals (MDGs) which are based on the fundamental values of freedom, equality, solidarity, tolerance, health, respect for nature, and shared responsibility. The eight Millenium Development Goals are as follows: 1. 2. 3. 4. 5. 6. 7. 8. Eradicate extreme poverty and hunger Achieve universal primary education Promote gender equality and empower women Reduce child mortality Improve maternal health Combat HIV/AIDS, malaria and other diseases Ensure environmental sustainability Develop a global partnership for development
Except for goals 2 and 3, all the MDGs are health or health-related. Health is essential to the achievement of these goals and is a major contributor to the overarching goal of poverty reduction. In order to achieve these goals, the participation of all members of the society from both developing and developed countries is required. Achievement of these goals by 2015 is now a priority of the global community and dictates the priority public health programs that should be implemented. At the country level, the Philippines has experienced considerable improvements in its health status for the past 50 years, yet it has also in recent year experienced decline as shown in its poor performance in reducing infant and maternal mortality rates. The Philippines is also experiencing an epidemiologic shift, which means that while it is still contending with the burden of communicable ___________________________________ 39
diseases, it is also at same time contending with the devastation brought about by noncommunicable, chronic lifestyle-related diseases. Currently, the country is being threatened with the devastating of a triple whammy which will be brought about not only by this epidemiologic shift but also by the emergence of plague-like infectious diseases such as Severe Acure Respiratory Syndrome (SARS) and Avian Flu. With this scenario, the need to strengthen the capability of the public health infrastructure including the public health nurse to adequately respond is imperative. Currently there are various country initiatives to implement a more cost-effective health care services. The Health Sector Reform Agenda (HSRA) implemented through FOURmula ONE and operationalized in the National Objectives for Health 2005 to 2010 spells out the program imperatives of the health sector. All these are in line with Millenium Development Goals and the Medium-Term Development Plan of the country.
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LESSON 2 Vision
DEPARTMENT OF HEALTH (DOH)
The DOH is the leader, staunch advocate and model in promoting Health for All in the Philippines. Mission Guarantee equitable, sustainable and quality health for all Filipinos, especially the poor and shall lead the quest for excellence in health. The DOH shall do this by seeking all ways to establish performance standards for health human resources; health facilities and institutions; health products and health services that will produce the best health systems for the country. This, in pursuit of its constitutional mandate to safeguard and promote health for all Filipinos regardless of creed, status or gender with special consideration for the poor and the vulnerable who will require more assistance. Goal: Health Sector Reform Agenda (HSRA) Health Sector reform is the overriding goal of the DOH. Support mechanisms will be through sound organizational development, strong policies, systems and procedures, capable human resources and adequate financial resources. Rationale for Health Sector Reform Although there has been a significant improvement in the health status of Filipinos for the last 50 years, the following conditions are still seen among the population: Slowing down in the reduction in the Infant Mortality Rate (IMR) and the Maternal Mortality Rate (MMR). Persistence of large variations in health status across population groups and geographic areas. High burden from infectious diseases. Rising burden from chronic and degenerative diseases. Unattended emerging health risks from environmental and work related factors. Burden of disease is heaviest on the poor.
The reasons why the above conditions are still seen among the population can be explained by the following factors: Inappropriate health delivery system as shown by an inefficient and poorly targeted hospital system, ineffective mechanism for providing public health programs on top of health human resources maldistribution.
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Inadequate regulatory mechanisms for health services resulting to poor quality of health care, high cost of privately provided health services, high cost of drugs and presence of low quality of drugs in the market. Poor health care financing and inefficient sourcing or generation of funds for healthcare. The following are the implications of the above situation: There is poor coverage of public health and primary care services. There is inequitable access (physical and financial) to personal health care services. There is low quality and high cost of both public and personal health care.
In order to address the problem in the way the Philippines health care system delivers and pays for health services, interrelated reforms in five areas have been identified as critical in transforming the health system into one that ensures the delivery of cost effective services, universal access to essential services and adequate and efficient financing. Areas that needed to be reformed are on health financing, health regulation, local health systems, public health programs and hospital systems. Framework for Implementation of HSRA: FOURmula ONE for Health This is adopted as the implementation framework for health sector reforms under the current administration. It intends to implement critical interventions as a single package backed by effective management infrastructure and financing arrangement following a sectorwide approach. Goals of FOURmula ONE for Health 1. Better health outcomes 2. More responsive health systems 3. Equitable health care financing The four elements of the strategy are: 1. Health financing the goal of this health reform area is to foster greater, better and sustained investments in health. The Philippine Health Insurance Corporation, through the National Health Insurance Program and the Department of Health through sectorwide policy support will lead this component jointly. 2. Health regulation the goal is to ensure the quality and affordability of health goods and services. 3. Health service delivery the goal is to improve and ensure the accessibility and availability of basic and essential health care in both public and private facilities and services. 4. Good governance the goal is to enhance health system performance at the national and local levels. A key feature of the FOURmula ONE for Health implementation strategy is the engagement of the National Health Insurance Program (NHIP) as the main lever to effect desired changes and outcomes in each of the four implementation components. The NHIP supports each of the elements in terms of: ___________________________________
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financing, as it reduces the financial burden placed on Filipinos by health care costs; governance, as it is a prudent purchaser of health care thereby influencing the health care market and related institutions; regulation, as the NHIPs role in accreditation and payments based on quality acts as a driver for improved performance in the health sector; and, service delivery, as the NHIP demands fair compensation for the costs of care directed at providing essential goods and services in health.
Roadmap for All Stakeholders in Health: National Objectives for Health 2005 to 2010 The NOH 2005-2010 provides the road map for stakeholders in health and health-related sectors to intensity and harmonize their efforts to attain its time-honored vision of health for all Filipinos and continue its avowed mission to ensure accessibility and quality of health care to improve the quality of life of all Filipinos, especially the poor. The NOH sets the targets and the critical indicators, current strategies based on field experiences, and laying down new avenues for improved interventions. It provides concrete handle that would guide policy makers, program managers, local government executives, development partners, civil society and the communities in making crucial decisions for health. Building on the initiatives under Health Sector Reform Agenda and as set forth in the NOH 1999-2004, an implementation is defined through FOURmula ONE for health which strategically focuses on interventions that create the most impact and generates buy-in from all partners. FOURmula ONE for Health is an overarching philosophy to achieve the end goals of better health outcomes, a responsive health system and equitable health care financing. It is directed towards ensuring accessible, affordable quality health. Building on the initiatives under Health Sector Reform Agenda and as set forth in the NOH 19992004, as implementation is defined through FOURmula ONE for Health which strategically focuses on interventions that create the most impact and generates buy-in from all partners. FOURmula ONE for Health is an overarching philosophy to achieve the end goals of better health outcomes, a responsive health system and equitable health care financing. It is directed towards ensuring accessible, affordable quality health care especially for the more disadvantaged and vulnerable sectors of the population.
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LESSON 3
PRIMARY HEALTH CARE (PHC)
WHO defines PHC as essential health care made universally accessible to individuals and families in the community by means acceptable to them through their full participation and at a cost that the community and country can afford at every stage of development. Primary Health Care was declared during the First International Conference on Primary Health Care held in Alma Ata, USSR on September 6-12, 1978 by WHO. The goal was Health for All by the year 2000. This was adopted in the Philippines through Letter of Instruction 949 signed by President Marcos on October 19, 1979 and has an underlying theme of Health in the Hands of the People by 2020. The concept of PHC is characterized by partnership and empowerment of the people that shall permeate as the core strategy in the effective provision of essential health services that are community based, accessible, acceptable and sustainable at a cost which the community and the government can afford. It is a strategy, which focuses responsibility for health on the individual, his family and the community. It includes the full participation and active involvement of the community towards the development of self-reliant people, capable of achieving an acceptable level of health and well being. It also recognizes the interrelationship between health and the overall political, socio-cultural and economic development of society. Although the goal of PHC of Health for All in the Year 2000 may have already been challenged as unrealizable in the given time frame, the concept and processes has already taken root all over the world and has shown progress in the lives of peoples in communities it has empowered. The recent PHC Summit held on February 23-24, 2006 has showcased the various community managed health activities that has successfully placed health in the hands of the people in this country, and is a testimony that indeed the concepts of Primary Health Care as an approach to health works and has virtually changed the landscape for health services in the country. Elements/Components of Primary Health Care 1. Environmental Sanitation (adequate supply of safe water and good waste disposal) 2. Control of Communicable Diseases 3. Immunization 4. Health Education 5. Maternal and Child Health and Family Planning 6. Adequate Food and Proper Nutrition 7. Provision of Medical Care and Emergency Treatment 8. Treatment of Locally Endemic Diseases 9. Provision of Essential Drugs ___________________________________ 44
Strategies 1. Reorientation and reorganization of the national health care system with the establishment of functional support mechanism in support of the mandate of devolution under the Local Government Code of 1991. 2. Effective preparation and enabling process for health action at all levels. 3. Mobilization of the people to know their communities and identifying their basic health needs with the end in view of providing appropriate solutions (including legal measures) leading to self-reliance and self determination. 4. Development and utilization of appropriate technology focusing on local indigenous resources available in and acceptable to the community. 5. Organization of communities arising from their expressed needs which they have decided to address and that this is continually evolving in pursuit of their own development. 6. Increase opportunities for community participation in local level planning, management, monitoring and evaluation within the context of regional and national objectives. 7. Development of intra-sectoral linkages with other government and private agencies so that programs of the health sector, intermediate and community levels. 8. Emphasizing partnership so that the health workers and the community leaders/members view each other as partners than merely providers and receiver of health care respectively. The framework for meeting the goal of primary health care is organizational strategy, which calls for active and continuing partnership among the communities, private and government agencies in health development. Four Cornerstones/Pillars in Primary Health Care 1. 2. 3. 4. Active community participation Intra and inter-sectoral linkages Use of appropriate technology Support mechanism made available
TYPES OF PRIMARY HEALTH CARE WORKERS Various categories of health workers make up the primary health care team. The types vary in different communities depending upon: Available health manpower resources Local health needs and problems Political and financial feasibility
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In general, the PHC team may consist of physician, nurses, midwives, nurse auxiliaries, locally trained community health workers, traditional birth attendants and healers. The preparation of a new kind of health worker is not often required. What is needed may only be a redefinition of roles and functions of existing personnel. For instance, in the Philippines under the restructured health care delivery system, a physician, a public health nurse and midwives compose the basic primary health care team. Each is trained and oriented to assume his/her redefined roles and functions. Two levels of primary health care workers have been identified 1. 2. Village or Barangay Health Workers (V/BHWs). This refers to trained community health workers or health auxiliary volunteer or a traditional birth attendant or healer. Intermediate level health workers. General medical practitioners or their assistants. Public Health Nurse, Rural Sanitary Inspectors and Midwives may compose these groups.
LEVELS OF HEALTH CARE AND REFERRAL SYSTEM 1. Primary Level of Care Primary care is devolved to the cities and the municipalities. It is health care provided by center physicians, public health nurses, rural health midwives, barangay health workers, traditional healers and others at the barangay health stations and rural health units. The primary health facility is usually the first contact between the community members and the other levels of health facility. 2. Secondary Level of Care Secondary care is given by physicians with basic health training. This is usually given in health facilities either privately owned or government operated such as infirmaries, municipal and district hospitals and out-patient departments of provincial hospitals. This serves as a referral center for the primary health facilities. Secondary facilities are capable of performing minor surgeries and perform some simple laboratory examinations. 3. Tertiary Level of Care Tertiary care is rendered by specialists in health facilities including medical centers as well as regional and provincial hospitals, and specialized hospitals.
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LESSON 4
HEALTH PROMOTION AND EDUCATION
HEALTH PROMOTION AND EDUCATION The prominence of health promotion came about as a result of the changing patterns of health and the corresponding emphasis on life style as a factor. Life style is a composite expression of the social and cultural circumstances that condition and constrain behavior. Although health education had been successful to change single-directed acts, many policy makers and health officials were not confident that health education could bring about changes in life styles. Public health education could have an impact on public health only if it joined other sectors and brought multiple social forces to bear. The behavioral change that health education is able to effect can only be maintained if supportive environment were provided through the effort of other sectors-political, economic, social, bio-medical etc. (Green) The first use of the term health promotion occurred in 1945 when Henry E. Sigerist, the great medical historian defined the four major tasks of medicine as 1) the promotion of health; 2) the prevention of illness; 3) the restoration of the sick and 4) rehabilitation. According to him, health is promoted by providing a decent standard of living, good labor conditions, education, physical culture, means of rest and recreation. These concepts are found in the Ottawa Charter for Health Promotion which occurred 40 years later. The Ottawa Charter for a Health Promotion The Ottawa charter defines health promotion broadly, as the process of enabling people to increase control over and to improve their health. To reach as state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspiration; to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being. Prerequisite for Health The fundamental conditions and resources for health are listed below. Improvement in health requires a secure foundation in these basic prerequisites. Peace, Shelter, Education, Food, Income, ___________________________________ 47
A stable eco-system, Sustainable resources, Social justice and, Equity.
In order to operationalize the concept of health promotion the Charter recommended the following action areas: 1. Build Healthy Public Policy Health Promotion policy combines diverse but complementary approaches including legislation, fiscal measure, taxation, and organizational change. It is a coordinated action that leads to health, income and social policies that foster greater equity. Joint action contributes to ensuring safer and healthier goods and services, healthier public services, and clear, more enjoyable environments. Health promotion policy requires the identification of obstacles to the adoption of healthy public policies in non-health sectors, and ways of removing them. The aim must be to make healthier and easier choice for policy makers as well. 2. Create Supportive Environments Our societies are complex and interrelated. Health cannot be separated from other goals. The inextricable links between people and their environment constitutes the basis for a socioecological approach to health. The overall guiding principle for the world, nations, regions, and communities alike, is the need to encourage reciprocal maintenance to take care of each other, our communities and our natural environment. The conservation of natural resources throughout the world should be emphasized as a global responsibility. Systematic assessment of health impact of a rapidly changing environment particularly in areas of technology, works, energy production and urbanization is essential and must be followed by actions to ensure positive benefit to health of the public. The protection of the natural and built environments and the conservation of natural resources must be addressed in any health promotion strategy.
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LEARNING ACTIVITIES Answer the following and submit your answer/reaction to your professor. 1. Oriented to: a) b) c) the community health care concepts, philosophy and objectives, programs, resources; organizational structure, communication network, community it serves; administrators and personnel
2. In the clinical area/health centers the student should: a) observe the administrators/managers while the latter are performing the tasks and functions of planning, organizing, directing, coordinating, controlling. b) Work with administrators/managers/personnel in the delivery of health care services; c) Interact with clients d) Observe and ask how the agency is adapting to the change brought about by the present Health Reform Agenda. 3. Submit a written report of the learning experience.
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BIBLIOGRAPHY
Bennis W. (2003). Leadership: Strategies For Taking Charge; New York, Harper Collins Business School Press. Benzon, Lydia M. (2003). Professional Nursing in the Philippines. C & E Publishing Co., Ellis, Janice Rider and Hartley, Celia Lore (2001). Nursing in Todays World. Lippincot. Heidenthal, Patricia Kelly (2003). Learning. Nursing Leadership and Management, Thomson, Delmar
Heneman, Herbert G. III and Timothy A. Judge (2003). Staffing Organizations, McGraw-Hill Kelly-Heidenthal, Patricia (2003). Nursing Leadership and Management. Thomson Delmar. Marquis, Bessie and Huston, Carol J; (2003). Leadership Roles and Management Functions in Nursing Theory and Application. Philadelphia: Lippincott Williams and Wilkin, Paton, Robert A. and James McColunan (2000). Publications Change Management 2nd Edition, SAGE
Roussel, L. (2006). Nursing Management ad Leadership. Sudbury, Massachusetts; Jones and Bartlett Publisher. Stredwick, John (2005). An Introduction to Human Resources Management. Sullivan, Eleanor J. and Philip J. Decker (2005). Effective Leadership and Management in Nursing, Pearson Prentice Hall Stredwick, John (2005). An Introduction to Human Resources Management. Tappen, Ruth M. et. al. (2004). Essentials of Nursing Leadership and Management 3rd Edition, F.A. Davis Company Tomey, Am.; (2000). Guide to Nursing Management and Leadership. 6th Edition Missouri; Mosby.
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Whetten, David A and Kim S. Cameron (2002). Developig Management Skills 5th Edition, Pearson Education Inc. Yoder Patricia S. (2003). Leading and Managing in Nursing 3rd ed., Mosby, Inc. USA
Periodical Health Services For All Filipinos Via the Health Sector Reform Agenda, The Manila Bulletin 2000. Other References The Holy Name School of Nursing Accreditation Report. New Jersey, 1998.
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MANG 519-Modules Revised 2009

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PRACTICUM IN NURSING ADMINISTRATION

REVIEW OF MANAGEMENT CONCEPTS

ORIENTATION TO THE ASSIGNED FACILITY (HOSPITAL OR COLLEGE OR NURSING)

PRACTICUM IN NURSING ADMINISTRATION

STANDARDS, POLICIES AND PROCEDURES

Observe the budgeting process: 3.1) 3.2) 3.3)

3.5) 3.6) 3.7) 4.

PRACTICUM IN NURSING ADMINISTRATION

ASSIGNMENT SYSTEMS FOR STAFFING

Modular nursing Primary nursing

Questionable continuity of care

Rotating work shifts

Block, or cyclical, scheduling

Pros and Cons of Centralized and Decentralized Staffing

Pros and Cons of Variable Staffing

Baylor plan/weekend option

Illness increased Absences increased

1st Sem 1:1 1:2-3

2nd Sem 1:2 1:3-5

PRACTICUM IN NURSING ADMINISTRATION

EVIDENCE BASED PRACTICE

PRACTICUM IN NURSING ADMINISTRATION

PRACTICUM IN NURSING ADMINISTRATION

GLOBAL AND COUNTRY HEALTH IMPERATIVES

DEPARTMENT OF HEALTH (DOH)

PRIMARY HEALTH CARE (PHC)

HEALTH PROMOTION AND EDUCATION

A stable eco-system, Sustainable resources, Social justice and, Equity.

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