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MODULE ONE





At the end of the module four, you will be able to:
1. Describe the components of effective management
2. Give at least 5 principles of nursing management
3. Define, planning, organizing, leading and controlling
4. State the purpose and benefits of planning
5. Describe the phases of planning
6. Differentiate between strategic and operational planning
7. Describe the steps in strategic planning
8. Apply the WOTs-Up system of analyzing an organization
9. Name the principles of organizing
10. Define leadership
11. Describe leadership styles
12. Name the major elements of directing
13. Name two important criteria in the delegation of responsibilities
14. Name and describe at least three techniques used in controlling










REVIEW OF MAJOR MANAGEMENT
FUNCTIONS

SPECIFIC OBJECTIVES

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Management has been defined as the process of getting work done
through others. According to Fayol (in Swansburg, 1993).
To manage is to forecast and plan, to organize, to command, to coordinate and
to control. To foresee and provide means, examining the future and drawing up
the plan of action. To organize means building up the dual plan of action. To
organize means building up the dual structure, material, and human of the
undertaking. To command means binding, together, unifying and harmonizing
all activity and effort. To control means seeing that everything occurs in
conformity with established rule and expressed demand.
Fayol listed the principles of management as follows:
1. Division of work.
2. Authority
3. Discipline
4. Unity of command
5. Unity of direction
6. Subordination of individual interests to the general interest.
7. Remuneration
8. Centralization
9. Scalar chain

Nursing management is the process by which nurse managers work
through others to achieve nursing organizational goals. The nurse
managers task is to plan, organize, direct, and control available
financial, material and human resources so as to provide the most
effective care possible to groups of patients and their families.
Swansburg (1993) identified thirteen general principles of nursing
management as follows:
Nursing management is planning.
Nursing management is the effective use of time.
Nursing management is decision making.
Meeting patients s nursing care needs is the business of the nurse
manager.
THE MANAGEMENT PROCESS


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Nursing management is the formulation and achievement of social
goals.
Nursing management is organizing.
Nursing management denotes a function, social position or rank, a
discipline, and a field of study.
Nursing management is the active organ of the division of nursing, of
the organization, and of society in which it functions.
Organizational cultures reflect values and beliefs.
Nursing management is directing or leading.
A well-managed division of nursing motivates employees to perform
satisfactorily.
Nursing management is efficient communication.
Nursing management is controlling or evaluating.

Tappen (1996) identified the components of effective management as
follows:
a. Leadership
b. Planning
c. Directing
d. Monitoring
e. Recognition
f. Development
g. Representation
As a process, management has many similarities with the nursing
process. The nursing management process, like the nursing process,
include gathering data, making plans, executing plans, and evaluating
results.

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NURSING PROCESS
MANAGEMENT PROCESS
Figure A. The Nursing Management Process Supports the Nursing
Process
GENERAL OBJECTIVES
At the end of the course, the students will leave acquired advanced
knowledge and understanding of the theories, concepts, principles, and
applications of the administrative processes in nursing organizations.
Specifically, the students will be able to:
1. Define the four major management functions
2. Explain the processes, tasks and applications of planning in nursing
organizations
3. Compare strategic and operational planning in relation to their use in nursing
organizations
ASSESSMENT PLANNING IMPLEMENTATION EVALUATION
DATA
GATHERING
PLANNING ORGANIZING STAFFING LEADING CONTROLLING

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4. Discuss the uses and benefits of management by objectives
5. Compare the advantages and disadvantages of the different kinds of
organizational structures
6. Describe the methods of team building
7. Explain the uses of job analysis
8. Write a job description
9. Give specific examples of the applications of each of the management functions
10. Discuss the dynamics of conflict and conflict resolution
11. Explain the tasks involved in controlling
12. Analyze management situations

REQUIREMENTS:
The following are the requirements to pass the course:
1. Completion of assessment exercises and learning activities at the end of
each unit module.
2. Submission of a 25 page typewritten term paper on the analysis of any of
the aspects of the four management functions.
3. Submission of five annotated bibliography










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COURSE OVERVIEW:
Nursing Administration II provides the student with advanced
knowledge and understanding of theories, concepts, principles and
applications of administrative process in nursing organizations.
Administrative process I is a prerequisite to this course. Major top are
the four major management functions of planning, organizing, directing,
controlling and the general and specific applications in nursing
organizations. Trends, issues, problems can significantly impact on
nursing administration are incorporated in the discussion of each of the
management functions.
This course is organized into six modules:
MODULE I offers a review of the concepts and process of the four
management functions of planning, organizing. Directing and controlling.
MODULE IIdiscusses the administrative processes and tasks involved in
planning. Strategic and operational planning are discussed and
differentiated; tools and planning such as budgeting, development of
standards, formulation of policies, rules, regulations, procedures and
methods, the System Approach are likewise covered.
MODULE III deals with the processes and tasks of organizing.
Organizational structure of tables of organization, organizational charts,
job evaluation, job analysis, job description, team building, group work
are discussed.
MODULE IV centers on organizing patient care and staffing. Topics
covered are different Patient Care Delivery systems, scheduling of staff,
recruitment, selecting orientation of new employees, Staff Development,
the problems of absenteeism.
MODULE V the processes of leading, directing, supervision, coordination,
decision-making, conflict management, communication and delegating
are discussed in this module. The concepts of leadership, power, change
are also covered.
NURSING ADMINISTRATION


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MODULE VI this module covers the processes and tasks of controlling.
This including performance evaluation, standards, quality improvement,
discipline, counseling and terminating of employees.


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Planning is a dynamic and future-oriented process, is the first element of
management and is the first step in the long and oftentimes complicated
process of management. It is complete involving a whole set of
interrelated actions and decisions (Tappen, 1997). Planning has been
defined in several ways as for example making a plan of action for a
foreseeable future (Fayol, 1949, in Swansburg, 1996); or as having a
specific aim or purpose and mapping out a program or method
beforehand for accomplishment of the goal" (Douglas, 1988), a process
beginning with objectives, followed by deciding strategies, policies, then
by detailed steps on how to achieve them (Steiner, 1969). These
definitions indicate it is a process whereby it is decided in advance what
to do, how to do it, when to do ir, who will do it, as well as determining
feedback as bases for new plans. The planning step of the management
process not only consists of determining the care need of different types
of patients, but also includes establishing nurses objectives, determining
budgetary allotments, deciding the size and the type of staff needed,
designing an organizational structure that will maximize staff
effectiveness, and establishing operational policies and
procedures.(Gillies, 1994). Planning is a basic function of all managers.
Why plan? There are many reasons for planning. According to Douglas
(in Swansburg, 1996), benefits and purpose of planning include the
following:
1. Planning leads to success in achieving goals and objectives.
2. It gives meaning to work.
3. It provides for effective use of available personnel and facilities.
4. It helps in coping with crisis situations.
5. It is cost-effective.
6. It is based on past and future, thus helping reduce the element of
change.
7. It can be used to discover the need for change.
8. It is needed for effective control.

Some other benefits of planning include the following:

a. Satisfactory outcomes of decisions;
b. Elements of the planning process;
c. Strategic or long-range planning process
d. The highest of personnel
PLANNING


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Process of Planning. The process of planning is divided into three phases:
A. Developing the plan
B. Presenting the plan
C. Implementing and monitoring the plan

Process of Planning





STEPS
I II III
Develop Plan Present Plan Implement and
Monitor Plan

Establish purpose


Analyze situations:
Problem
analysis
Situational
factors
Response to
change

Formulate
Objectives

Generate
alternative courses
of action

Analyze alternatives
and select course of
action



Plan


Purpose







Objectives


Action



Evaluate

Organize
Implementation

Sequence activities
Set the target date
Responsibilities
Allocation of
resources






Direct Implementation
Monitor Implementation


Evaluate outcomes


Revised and update plan





Figure B. Planning Model






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TYPES OF PLANNING

According to Tomey (1992), planning can either be a long range
strategic planning and short range or operational planning. Tappen (1995),
on the other hand, classified planning according to the purpose it serves. For
example, healthcare planning is a broad, survey approach to determine health
needs of a specified population, a community, or even an entire nation. The
National Health Care Plan is an example. Project Planning is the process
applied to a particular project within an organization or a project carried out in
cooperation with other agencies.

Strategic Planning or long range planning extends to five years into
the future. It begins with in-depth analysis of the organizations internal
environments strengths and weaknesses and the external opportunities and
threats so that realistic goals can be set for the future. Strategic planning goals
are more generic and broader than those of operational planning. Historically,
strategic planning became prevalent in US health care settings and literature in
the 1980s in response to major changes in the health care industry which
began in the 70s. these changes amount to higher cost of healthcare to the
extent that it is almost unaffordable to the general public. Chief executives of
health care organizations are resorting to mergers, joint ventures, networking,
and other ways of cutting costs in order to survive. The main purposes of
strategic planning are to clarify beliefs and values and to give direction to the
organization. It answers questions like what are the organizations strengths
and weaknesses?, what are the potential opportunities and threats?, where
is the organization going?, and how is it going to get there?. Strategic
planning has been proven to improve efficiency, to weed out poor or underused
programs, to eliminate duplication of efforts by concentrating resources on
important services. Strategic planning also improves communications and
coordination of activities, provides a mind-expanding opportunity, allows
adaptation to the changing environment, sets realistic and attainable yet
challenging goals and helps ensure good achievement. Currently in health care
organizations, strategic planning focuses on the future health of an
organization or its component parts. It is often marketing oriented (Tappen,
1997) and may include consideration of political, social, and economic changes
affecting the health care system.

The process of strategic planning cannot be implemented without the
commitment of the administrators themselves. As a first step of the process,
they need to be taught the importance of strategic planning. The second step is
to conduct a situation audit or environmental assessment to analyze the past,
present and future forces that affect the organization. A WOTS-up (weaknesses,
opportunities, threats and strengths) analysis worksheet is also helpful. For
example, internal strengths or weaknesses may include management
development, qualifications of staff, financial situations, cash flow position,
marketing efforts, market share, facilities, location, and quality services.

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Threats may be shortage of nurses, decrease in patient satisfaction, decrease in
insured patients, increase in accounts receivable, decrease in demand for
services, competitions, regulations, litigation, legislative changes, unionization,
and loss of accreditation. Opportunities include nurse and phycisian
recruitment, referral patterns, new programs, new markets, diversification,
population growth, improve technology and new facilities. After the situation
audit is done, the management team writes a purpose or mission statement,
identifies organizational goals and objectives, plans strategies to accomplish
the objectives, identifies required resources, determines priorities, sets time
frames, and determine accountability.

APPROACHES. Planning may be reactive or proactive. Reactive
planning is done in response to an existing problem, for example, an increase
of incidence of post-operative infections, an increase in staff turnover, staff
absenteeism, increase in patients complaints regarding services received.
Proactive planning on the other hand, is done before a problem occurs. It may
be done in anticipation of changing need or to promote growth and excellence.
Bateman (1993) describe proactive planners as people who take it upon
themselves to have an impact of the world around them.


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Organizing is a thinking process that identifies the organizational needs
from mission statements and objectives and from observations of work
performed, and adapting the organizational design and structure to meet these
needs. It is the process of designing the machine (Urwick in Swansburg, 1993).
During the organizing process, activities are grouped, responsibility and
authority are determined and working relationships are established to enable
both the organization and the employees to realize their common objectives.
The basic principles of organizing are, according to Swansburg (1994) are:

1. The Principle of Chain of Command. This principle denotes centralized
authority and corresponding authority. This principle states that to be
satisfying to members, economically effective, and successful in achieving their
goals, organizations are established with hierarchical relationships within
which authority flows from top to bottom. The pure line or hierarchical
structure is a straightforward, direct chain-of-command pattern that
emphasizes superior-subordinate relationship. In the more modem
organizations however, the chain of command is flat.

2. The Principle of Unity of Command. The principle states that employee
has one supervisor/leader and one plan for a group of activities with the same
objective. Although an employee may interact with many different individuals
in the course of his work, he should be responsible to only one supervisor,
whose direction he may regard as final. In nursing, primary nursing and case
management support the principle of unity of command.

3. The Principle of Span of Control.States that a person should be a
supervisor of a group that he or she can effectively supervise in terms of
numbers, functions, and geography. This principle is flexible because the more
trained an employee is the less supervision is needed, while those still under
training need more supervision to prevent mistakes.
4. The Principle of Specialization states that each person; should perform a
single leading function. This concept of division of labor or the differentiation
among kinds of duties, springs from this principle.
ORGANIZING


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Other organizational principles are mentioned by GilliesIn Nursing
Management: A Systems Approach, are:
5. The Principle of Requisite Authority indicates that when responsibility for
a particular task is delegated to a subordinate, that subordinate must be given
authority over the resources needed to accomplish the task.
6. The Principle of Continuing Responsibility refers to the fact that when a
superior delegates responsibility for a particular function to a subordinate, in
no way diminishes his own responsibility for that functions.
7. The Principle of Organizational Centrality refers to the fact that the
greater the number of persons with whom a given worker reacts directly the
more information he receives and the more powerful he becomes in the total
organizational structure.
8. The Principle of Exception refers to a management practice followed in
some organizations, in which subordinates are directed to report only
departures from normal functioning or expected results so that managerial
efforts may be limited to those events and processes that cannot be handled by
routine control mechanisms.

Review of Organizational Concepts.
Role. Role can be defined as the constellation of behaviors and attitudes
expected of an individual by those with whom he/she interacts. A nurse may
occupy several occupational roles at the same time. She may be staff nurse, a
subordinate to her nurse manager, a member of a committee, an officer in a
nursing association, and so forth. A particular head nurse is a subordinate to
her supervisor, a supervisor to her own staff nurses, a peer to other head
nurses, a committee chairperson, and so on. Because each role calls for certain
expectations, these nurses need to adjust and readjust their own behavior and
manner to meet these expectations. Role theory supports the chain of
command and unity of command principles. Role theory indicates that when
employees face inconsistent expectations and lack of information they will
experience role conflict, leading to stress, dissatisfaction and ineffective
performance.
Power. Power is the ability to influence another persons behavior. Power is not
static, it is changing. Most of the time it increase. This is because the person
who has power can generating more power, possibly because of increase in the

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number and quality of communications with others. The reverse seems to
occur. There are different types of power. Reward power is the ability to provide
rewards to another. For example, a supervisor may reward an employee with
additional salary, a preferred shift rotation, an opportunity to attend seminars.
Expert power is the ability to convince another that one possesses a high
degree of knowledge and skill in some area of specialization. Clinical specialists
and educators wield this kind of power over students. Referent power is the
ability to inspire such admiration in others that they identify themselves in
some way with the object of their admiration. For example, a nurse specialist in
the emergency room may wield a high degree of referent power over staff nurses
who wish to emulate her skills in handling emergency situations. Coercive
power is the ability to apply punishment to another. For example, the nurse
manager may punish an employee through demotion, suspension, or firing.

Status. Status may be defined as the rank a group confers on an individual,
organization, a job. The degree of status accorded a particular job is closely
related to its distance from the top of the organizational hierarchy, the amount
of skill called for in performing the job, the degree of special training or
education required for the position, the level of responsibility and autonomy
expected in job performance, and the salary accorded the position. Within an
organization, various personnel have different status, depending upon their
positions in the hierarchy and the salaries they receive. In nursing, the status
of each nurse depends in part on the position of nursing department in the
table of organization. When the nursing directors position is at the same
hierarchical level as that of the medical director, her salary is likely to fall
within the executive range and with that her status goes high. With her
executive position and higher salary, it is easier for her to negotiate higher
salaries for her staff.
Authority. The concept of authority is associated with the concept of
responsibility, higher positions and higher status. Authority is the
organizationally sanctioned power to direct or influence the behavior of
another. An important characteristic of authority is that it is never unlimited or
absolute. For example, a head nurse may have the authority to discipline or
punish a staff, but does not have the authority fire the latter, or she may
recommend hiring nurses, but she may not be authorized to hire them.
Bureaucracy. This term was coined by Max Weber to describe an
organizational make up that is highly structured. The principles of chain of

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command, unity of command, span of control and specialization support
bureaucratic structures. The characteristics of bureaucracy include formality,
low autonomy, division of labor, specialization, standardized procedures,
written specifications, memos and minutes, centralization, controls and
emphasis on a high level of efficiency and production. These characteristics
lead to complaints about red tape, and to procedural delays and general
frustrations. (Swansburg, 1993)
Organizational Climate. Organizational climate refers to work environment. A
work environment that is conducive to worker satisfaction can be promoted by
managers. Some activities identified by Swansburg (1993), as promoting
positive climate are: a) considering personal goals of employees when
developing organizations missions, goals, objectives; b) establishing trust and
openness through communication; c) provide opportunities for growth and
development; d) promote self-esteem, autonomy, and self-fulfillment for
practicing nurses, including feelings that their work experiences are oh high
quality; e) provide job security an environment that enables free expression of
ideas and exchange of opinions without threat of recrimination.















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Directing is a function of leadership. It involves the activite of
commandind, supervising, coordinating, leading, implementing, delegating,
communicating, training, motivating. (Rowland & Rowland, 1994) In nursing,
directing is a physical act of nursing management, the interpersonal process by
which nursing personnel accomplish the objectives of nursing. (Swansburg,
1993). It is the process of applying the management plans to accomplish
nursing objectives. It is also the process by which nursing personnel are
inspired or motivated to accomplish work. In nursing management, twelve
activities related to the directing functon of a nurse manager have been
identified by Douglas (1998). These are:
1. Formulating objectives for care that are realistic for the health
agency, patient, client and nursing personnel.
2. Giving first priority to the needs of patients/ clients assigned to the
nursing staff.
3. Providing for coordination and efficiency among departments that
provides support services.
4. Identifying responsibility for all activities under the purview of the
nursing staff.
5. Providing for safe, continuous care.
6. Considering the need for variety in task assignment and for
development of personnel.
7. Providing for the leaders availability to staff members for
assistance, teaching, counsel and evaluation.
8. Trusting members to follow through with their assignments.
9. Interpreting protocol for responding to incidental requests.
10. Explaining procedure to be followed in emergencies.
11. Giving clear, concise, formal, and informal directions.
12. Using a management control process that assesses the quality of
care given and evaluate individual and group performance given by
nursing personnel.
DIRECTING


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Thirty one task had been identified as tasks of first line nurse
managers/supervisors in a research done by Beaman (in Tappen, 1986). Some
of these are shown in table 1.
Table 1. Tasks of Nurse Managers-Supervisors
1. Assist in service to prepare orientation schedule.
2. Discuss the program of orientation with the new member.
3. Decide when orientation is complete.
4. Write counseling reports and discuss them with staff members
5. Terminate after approval has been obtained.
6. Submit time schedule for three shifts.
7. Assign patients, teams for day shift.
8. Make recommendations about budget to nursing administration.
9. Calculate nursing hour used and justify them.
10. Call in extra help when needed.
11. Prepare reports about budget variances.
12. Make daily patient rounds.
13. Attend and participate in first-line nursing management meetings.
14. Conduct meetings with own staff for problem solving and learning.
15. Set goals for individual units.
16. Participate in setting goals for the nursing department
17. Discuss unit problems with physicians regularly
18. Participate in all levels of quality assurance, including designing studies,
collecting data, and preparing reports.

Three of the major elements of directing are leadership, communication
and motivation. A brief review of the concepts and processes of these three
elements follows.

Leadership. The leaders philosophical beliefs, abilities, leadership style
influence greatly the way he or she directs. Does the leader subscribe to the
trait theories? To the behavioral theories of authoritarian-democratic-laissez
faire style? What is more important to the leader, finishing the task or
maintaining good relationship? Or, is the leader subscribed more to the more
contemporary management and leadership theories such as the motivational
theories of Maslow, McGregors X and Y theories, Taylors Scientific Theory,
Herzberg Hygienic and Motivation theory, or Druckers Management by
Objective (MBO)? Figure C shows the comparison of authotitarian, democratic,
and laissez fair leadership styles.

According to Tappen (1996), leadership attributes of nurse executive include
administrative competence with adequate educational background, business
skills, and clinical expertise combined with a global understanding of
leadership principles. To be effective, she must have the leadership traits

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associated with leadership effectiveness, namely, intelligence, personality,
abilities. The traits related to intelligence inclued judgement, decisiveness,
knowledge, fluency of speech.

Personality inclued adaptability, alertness, creativity, cooperativeness,
personality integrity, self-confidence, emotional balance and control,
independence (non-conformity). Abilitites include ability to enlist cooperation,
popularity and prestige, interpersonal skills, social participation, tact,
diplomacy. Effective nurse managers practice leadership behaviors that
stimulate motivation withing their constituents. These behavior include
promotion of autonomy, decision-making, and participative management by
professional nurses. The componenets of effective leadership include adequate
knowledge self-awareness; effective communication; wise use of energy; clear,
congruent, and meaningful goals; and taking action. The Leadership Effective
Checklist (Figure D), in the next page is a guide to analysis of ones leadership
ability. As a leader/future leader, this should help you identify the strengths
you can build on or to help you identify what changes you nedd to do to
become an effective leader.


Authoritarian | Democratic | Laissez-Faire
Degree of Little freedom Moderate freedom Much freedom
Freedom

Degree of Control High control Moderate control No control
Decision Making By the leader Leader and groupBy the group
together or by no one

Leader Activity High High Minimal
Level

Assumption of Primarily the Shared Abdicated
Responsibility leader


Output of the Group High quantity, Creative, high Variable, may
good quantity quality be poor quality

Efficiency Very efficient less efficient than Inefficient
authoritarian.

Figure C. Comparison of authoritarian, democratic, and laissez faire leadership styles.
(fromTappen (1996).



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Communication.Another major element of directing id communication.
Communication is the sharing of thoughts, feelings, and ideas. It can be more
specifically defined as sending, receiving, and interpreting verbal and nonverbal
messages. It is an exchange of information between at least two people who
coact or affect each other. The communication process, involves the six steps of
Ideation, Encoding, Transmission, Receiving, Decoding and Response or
Feedback. Ideation begins when someone who senses a need to communicate
develops an idea or selects information to share. The purpose of the
communication develops an idea, or selects information to share. The purpose
of the communication may be is to inform, persuade, command, inquire, or
entertain. Encoding involves putting meaning into symbolic forms such as
speaking, writing, or into nonverbal behavior. Transmission of the message is
disseminating it through various media of communication. Oral or face to face
communication is the most common form used by managers. Telephone, e-
mails, fax, bulletin board, memos, and other forms of written materials are also
common. It must be remembered that transmission of the message can be
affected by interference, such as garbled speech, unintelligible use of words,
noise illegible handwriting. In receiving, the receivers senses of seeing and
hearing are activated. In decoding the receiver defines words and interprets
gestures during the transmission of speech. The response or feedback is the
final step. It is important for the sender to know that the message has been
received and accurately interpreted.

Using good communication techniques is one of the hallmarks of effective
leadership and management. (Tappen, 1996). The nurse manager must
understand that cooperational and communication in an organization go hand-
in-hand. He or she should also be aware that there are barriers to effective
communication. These include failure to listen with respect and understanding,
lack of skill in feedback, misinterpreting the meanings of words used by the
speaker. According to Marriner-Tomey (1992), faulty reasoning and poorly
expressed messages are the major barriers to communication. Faulty reasoning
results in poor organization of ideas and lack of coherence. Also, messages are
poorly expressed when there is lack of clarity and precision resulting from
inadequate vocabulary and poorly chosen words. Peoples own biases, values,
attitudes, beliefs and assumption can affect ones perception of the message.

Motivation.The third element of directing is motivation. Motivating
employees achieve high productivity and job satisfaction is a major concern of
the manager. Questions often asked are: what makes people work? Why do
some employees seek perfection in their work while others are content with
mediocrity or less? What causes high turnover rates? What can a manager do
to motivate employees achieve more and to make them feel satisfied? How can
the manager reduce rapid turn-over rates? As many nurse managers know, job
dissatisfaction contributes to high turnover rates among nurses. Frequent
hiring is expensive as it takes considerable time and money to orient new

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nurses. Meantime, employees who stay must assume the job and responsibility
of the resigned employee, in addition to their own work assignments.

Traditional management theory is based on McGregors Theory X, which
is based on the belief that the ordinary person is lazy, unmotivated,
irresponsible, not too intelligent, prefers to be directed, rather than act
independently. The more contemporary theories believe otherwise, having
proven that people can be motivated to complete their work with little or no
supervision, to be creative, trustworthy, enthusiastic, fine work rewarding.
According to Theory Y, the negative traits described in Theory X are due to poor
leadership and management, and that they are symptoms that employees need
for belonging, recognition, self-actualization are not being met. Theory Z even
goes further. Theory Z has a humanistic viewpoint and focuses on developing
better ways to motivate people. These ways include collective decision-making,
long-term employment, slower but more predictable promotions, indirect
supervision, and a holistic concern. Trust, fair treatment, commitment, loyalty,
are all characteristics of Theory Y other motivational theories are Maslows
Hierarchy of Needs and Herzbergs Hygiene and Motivation Factors. A manager
needs to know among others, that employees become dissatisfied if the salary
is inadequate, if supervision is poor, if the working condition is intolerable and
unsafe. She must understand that employees feel satisfied if the work is
meaningful and satisfying, if there are opportunities for advancement, if they
are given appropriate responsibilities and recognition, if interpersonal
relationships among co-employees are good.


Effective Leadership Checklist Very much | Somewhat | Not at all

A. Leadership
1. Have you reviewed the leadership
Checklist?
Are you
Developing self-awareness?
Acquiring adequate knowledge?
Using critical thinking?
Practicing good communication?
Recognizing and reconciling
difference in goals?
Using your energy wisely?
2. Do you give your attention to both the relationship
and takes aspects of your responsibilities?

B. Planning
1. Do you set aside time for planning?
2. Do you manage your time by
Preparing for emergencies and crisis?

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Making the best use of your time?
Helping staff members manage their time well?
3. Do you plan current work and consider
Priorities?
Timing and Sequence?
Deadlines?
Organizational goals?
Skill mix of the staff?
Characteristics of the work?
4. Do you plan for the future of your department?

C. Direction
1. Do you communicate clearly to staff
What is expected of them?
How to do the work?
2. Do you provide direction in a nonthreatening manner?
3. Do you ensure that everyone has a job description?
4. Do you prepare schedules that are
Fair and adequate to meet the needs of the staff?
Developed in consideration of staff suggestions?

D. Monitoring
1. Do you monitor
The care given by your staff?
Individual staff members performance?
The budget?
Operation of the unit as a whole?
2. Do you monitor in a systematic way?
3. Do you use a variety of formal and informal
monitoring methods?

E. Rewards
1. Do you use a variety of both positive and negative
rewards?
2. Do you use rewards to reinforce only the behaviors
that are desired and not other, less desirable behavior?

F. Development
1. Do you encourage staff development by
Rewarding it?
Making opportunities available?
Supporting implementation what is learned?

2. Have you furthered your own professional growth
and development?


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G. Representation
1. In representing staff members and the unit as whole,
do you function as
An advocate?
A coordinator?
A promoter?
2. Do you support Administrations actions and
Represent them fairly to your staff?
3. Do you enforce administrations policy?
4. When administrations action or policy is ineffective
In some way, do you work to change it?
5. When differences between your staff and the
administration occur, do you negotiate an
acceptable settlement?


Figure D. Effective Leadership Checklist, (Tappen, page 72-73)

Controlling is the leadership function in which performance is measured
and corrective action is taken to ensure the accomplishment of organizational
goals. According to Rowland & Rowland (1994), it is also the policing operation
in management. It is verifying whether everything occurs in conformity with
the plan adopted, the instructions issued, and principles established
(Swansburg, 1993) and has foor its object to point out weakness and error in
order to rectify them and prevent recurrence. According to Donovan (1975),
controlling includes coordination of numerous activities, decision-making
related to planning and organizing activities, and information from directing
and evaluating of each workers performance. Urwick (in Swansburg, 1993),
controlling is evaluating. He identified three principles of controlling, namely:

The Principle of Uniformity ensures that controls are related to the
organizational structure.
The Principle of Comparison ensures that controls are stated in terms
of the standards of performance required.
The Principle of Exception provides summaries that identify
exceptions to the standards.

The basic control process involves three phases, namely:

Establishing Standards. He controlling process establishes standards
in terms of expected and measurable outcomes. These are the
yardsticks by which achievement of objectives are measured.
Measuring Performance. The standards are applied by collecting data
and measuring the activities of nursing department, comparing
standards with actual care.

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Correcting Deviation. Any improvements deemed necessary from the
feedback are made.

The process can be expressed as a formula:

Ss + Sa + F + C I

Where Ss refers to Standards set and Sa means Standards applied, C is
correction, means Yield, and I is Improvement.

The characteristics of effective control process include ((Rowland &
Rowland, 1996)

a) timeliness
b) economy
c) comprehensiveness
d) specificity and appropriateness
e) objectivity
f) responsibility
g) understandability

Swansburg (1993) described a good control system as one that:

a) reflects the nature of the activity
b) reports error prompty
c) is forward-looking
d) points our exceptions at critical points
e) is flexible
f) is objective
g) reflects organizational pattern
h) is economical
i) is understandable
j) indicates corrective
k) indicates corrective action


In nursing, controlling or evaluating is an ongoing function. Controls
include nursing policies, rules, procedures, discipline, rounds, reports, audits,
evaluation devices, tasks analysis, quality control. Nursing standards are set
and these serve as yardsticks for evaluation of the quality of care and the
performance of the unit and of the individual nurse. Nurse managers, in
collaboration with clinical nurse, develop clinical nursing criteria against which
to measure patient outcomes and the nursing process. Controlling processes in
nursing include planned evaluation, planned nursing rounds, the Standards of

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Nursing Practice as well as the Accreditation Manual, Nursing Policy Manual.
The tools and techniques in controlling are:

a) Standards, which are descriptive statements of the desired levels of
performance against which to evaluate the quality, structure, process
or outcome.
b) Performance Appraisals, where employees behavior is compared to a
set of standards which describe what the employee is expected to
perform.
c) Formal Review by Peers
d) Disciplining of Personnel
e) Budgeting
f) Quality Improvement Techniques


































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Answer the following and submit your typewritten answers/reactions to your
professor.

1. Discuss the similarities between the nursing process and the nursing
management process.

2. Describe at least three components of effective management.

3. Give one example each of a strategic and an operational planning that
you have made or is making in relation to your

a) Professional life
b) Personal life

4. Analyze your organization by using the WOTs-Up technique.
5. Enumerate at least 6 organizational principles.
6. Observe a nurse manager. Of the 18 tasks of nurse
managers/supervisors listed on Table 1, name the ten most often
performed. What are the least or not performed at all? Why are they not
performed?
7. Which of the leadership attributed of nurse executives mentioned by
Tappen do you think is/are lacking in the nurse executives in your
workplace? Explain.
8. Explain the following control process equation:
Ss + Sa + F + C I



LEARNING ACTIVITIES

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MODULE TWO




At the end of the module four, you will be able to:
1. Discuss the philosophy behind Management by Objectives (MBO)
2. State purpose of MBO
3. Name two uses of MBO in planning
4. Discuss the effects of MBO
5. Describe the system approach
6. Discuss how the system approach is used in planning
7. Discuss the importance of budgeting in the planning function
8. Discuss the purposes of nursing care standards







TOOLS IN PLANNING

SPECIFIC OBJECTIVES

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Management by Objectives (MBO) is both a managerial philosophy and a
managerial system. Peter Drucker(1978) introduced the concept of MBO in
industry in the 1950s in an effect to improve worker motivation and
productivity. In its simplest form, MBO is a system whereby employees at
different organizational levels are assisted by their supervisors to set their own
short-term goals, direct their activities toward those goals, and measure their
own achievement with reference to those goals. MBO, when adopted, makes
goal setting routine among worker at different levels in the organizational
hierarchy and enables= them to make risk-taking decision objectively. In MBO,
decisions are made by:
Gathering information to predict the outcomes of various actions
Systematically choosing the most desirable of several possible objectives.
Identifying the most effective of several methods for realizing each
objective
Measuring the actual results of using the chosen methods

MBO is used in nursing to wide participation in day-to-day decisions
that are required for quality control. With MBI, more nurses are made more
aware of their individual responsibility for monitoring and controlling the
quality of their own and their co-workers performance. MBO is also a mean of
focusing the attention of both staff nurses and nurse managers on work
results. MBO is then a tool not only in planning but in controlling.

MBO generates more effective planning at all levels of the organizational
hierarchy. The collaborative goal setting by each superior-subordinate pair
links the effort of each worker more directly to the overall objectives of the
organization. Negotiations between superior and subordinate over work goals
and specification of goals in behavioral terms clarify both the reporting
relationship among staff members and the scope of responsibility and authority
and authority of upper-middle- and lower-level managers. Managers who use
MBO becomes increasingly willing to delegate responsibilities to subordinates,
with the result that subordinates acquire management skills and a sense of
personal responsibility for institutional success. According to Gillies, 1994,
there are several advantages in using MBO. Positive effects mentioned are:

1. Work methods are more effectively tailored to the goals that all levels of
management serve.
2. Work output at each hierarchical level provides more suitable input for
employee in the next higher and lower levels of the organization.
MANAGEMENT BY OBJECTIVES

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3. Institutional progress is facilitated and the welfare and morale of each
individual employee is improved.
4. Since each worker develops her own performance objectives in
collaboration with her supervisor and since adjustments can be made in
her assignment and work situation to ensure maximum self-fulfillment
and occupational advancement, MBO enhances the workers self-esteem
and facilitates self-actualization.
5. MBO eases the assimilation of new employees into a complex
organization and, by encouraging self-direction and skill building,
improves employees chances for promotion. Employees who are
managed by objectives mature more rapidly that employees in more
autocratic organizations because they know exactly what is expected of
them, they receive reliable feedback about the quality of their
performance, and they are continuously backed up with advice and
support from a supervisor-coach who identifies personally with their
success.
6. MBO makes sense from a logistic point of view. With MBO, both action
and control reside in the same individual, because each worker regulates
her own performance through goals of her own choosing.
7. MBO promotes organizational efficiency because it ensures that each
workers assignment is designed by the individual who best understands
that workers interest, abilities, needs, and goals- the employee herself.
The supervisor acts only as a mentor or coach for subordinates, helping
each to correlate her log range career plans with the realities of the work
situation and the needs of the total organization. MBO is particularly
effective in handling knowledge workers such as nurse practitioners,
clinical nurse specialist.
8. MBO is helpful in effecting organizational change.
9. In MBO, the setting of goals for employee performance is a deliberative
and collaborative affair. Before setting short-range goals for herself, the
employee analyzes her own job description, assesses her own job
description, assesses her individual strength and weaknesses, and
reviews her personal plans for long-range career development. The
supervisor acts as consultants or coach in the goal-setting processes,
helping the employee balance her obligations to the institution with her
self-appraisal, her personal goals, and the realities of the work situation.

The Process of Management by objectives. Once the nurse executive decides
to manage the nursing department through the Management by Objectives
system, the following steps are followed (Gillies,1994):

a. The rationale for the decision to shift from the conventional system of
management to the MBO system is discussed to the entire staff;
b. The philosophy, purpose, and the methods by which employees will
establish their own work goals are explained;

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c. The nursing administrator and the supervisors will prepare a brief, clear
statement of the purpose, objectives, and performance standards for the
entire nursing department. This will be discussed and clarified in each
nursing unit, division, departmental meetings to ensure that all
employees thoroughly understand the departments mission, resources,
and constraints;
d. The employee of the whole nursing department agrees on where they are
at a given point in time. They determine at what level of performance and
stage of development the department is functioning at the time of
transition to MBO.
e. Long range goals are set. After long range goals of the nursing
department have been agreed upon the nurse managers make a list of
those issues and activities that require additional emphasis if long-long
goals are to be met. This list of key issues and activities are analyzed by
the nursing management group through exploration of the following
questions concerning each.

1. Does current practice in regard to this issue permit room for
improvement?
2. Does need for improvement in this matter derive principally
from organizational weakness or from employee incompetence?
3. What are the space, materials, and personal resources that
affect nursing performance in this matter?
4. Have there been or are there likely to be changes in client
demand that relate to this issue>
5. How does the current level of nursing performance in this
matter compare with the level of performance of other health
professionals?
6. Are there research findings that indicate desirable directions for
change in this area?
7. Can change be made in the external environment (community,
the healthy industry, the nursing profession) that would
improve performance in this area?

f. Key issues are then analyzed by the nurse managers and the list of
issues and problems are distributed to all staff members, with suggestion
that they address these issues in constructing their annual performance
objectives. Further, the nurse managers analyze the departmental and
divisional functioning to identify the internal and external factors that
affect nursing performance positively and negatively.
g. The nurse managers provide the staff a full set of up-to-date description
of all positions in the department. Since each employee must construct a
set of individual employment objectives that represents an amalgam of
institutional needs, administrative expectations, and personal goals,
should be given a detailed job description that reveals the way in which
that position contributes to the total organization effort.

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Thus, from the organizational goals and from up-dated-job descriptions,
departmental and individual objectives are derived and formulated. These same
objectives will serve as benchmark against which to judge achievement after
the MBO system has been instituted. In preparing her performance objectives,
the employee should discuss here personal statement of job duties with her
supervisor in order to explore and clarify areas of disagreement and
misunderstanding. The employee should select target dates for achievement of
objectives and draw up specific action plans that define the exact steps to be
taken in reaching each goals. The following are guidelines for formulating
objectives:

1. Each objective should address itself to observable behavior and should
be clearly and concisely expressed in written form.
2. Each objective should be sufficiently difficult to challenge the employees
efforts and ingenuity, but fully capable of attainment within the
constraints of institutional reality.
3. Each objective should be measurable and, whenever possible, specifically
quantified.
4. A target date should be set for achievement of each objectives.
5. The final statement of each objective should be accepted without
reservation by both employee and supervisor.
6. Criteria should be established for judging whether or not the objective
has been realized.
7. The objective should support objectives of other agency employees for the
same time period.

Following is a sample of some objectives which might be established for a
staff development nursing instructor:

By December, 1999, I will have:

1. Completed testing fifty staff nurses on the correct use of the new blood
sugar monitor
2. Given two telemetry classes to the nurses assigned in the Medical units.
3. Completed certifying three nurses in each unit on the Basic Life Support.
4. Reviewed 30 nurses notes as to accuracy and form of documentation.
5. Written a pre-discharge patient education tool for each of the following
diagnostic category:
Diabetes mellitus
Leg amputation
Radical mastectomy
Patient who will be discharged with central lines.
6. Plan and present 1 nursing seminar on each of the following topic:
Nursing Care of an HIV-Positive Patient

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Advanced Nursing Assessment Techniques
Trends and Issues in Nursing Education

While an employee is given the responsibility to write her annual
performance objectives, she still needs to meet with her supervisor so they can
review, refine and agree upon the goal statement. During this meeting, the
supervisor assist the employee to draw up an action plan for each objective. In
designing an action plan for each objective, the employee and her supervisor
delineates the activities that must be carried out to meet the objective and
arrange them according to priority. Then, they clarify whose responsibility it is
to perform each action (if it is not the employees sole responsibility) and
assign each task to the appropriate employee. Finally, they calculate the
personnel and material needed to reach each objective. At the time the
employees objectives are approved in final form and the action plans to achieve
each goal are developed, the supervisor sets a date for the two to meet to
assess the employees progress toward the goals. The frequency of meeting
depends upon many factors. A new employee may need more meetings with her
supervisor. If an employee is making little progress, the two can decide whether
the lack of success is a result of misdirection, inadequate effort, or lack of
support. Corrective actions are then taken so the objectives can still be met by
the final target date. In many organizations each employee sets annual goals
for herself at the beginning of the year, and she and her supervisor do not meet
to assess goal achievement until the end of the year. It is recommended
however, that a midyear analysis and assessment be done to enable the
supervisor to applaud a good performance by her subordinate, thereby
reinforcing desirable behavior.


Objective Activities
arranged
according to
importance
Who is
responsible
Resources
financial
materials,
personnel
Target date

Disadvantages of Management by Objectives. While MBO has been found to
have many advantages, there are also certain disadvantages. Among those
mentioned are:

a. There is a possibility that, rather than expanding a managers abilities, it
may actually hamper her development by limiting her attention to those
problems, tasks or projects that can be foreseen weeks or months in
advance.
b. If the technique is applied too rigidly, Management by Objectives can
disrupt the smooth functioning of nursing department. It may also lead
to neglect of the routine and repetitive aspects of management, so that
insufficient attention is paid to monitoring budgetary expenditures,
Figure A. The Process of Designing an Action Plan for each Objective

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updating policies, formulating rules, writing procedures, posting
assignments and other housekeeping tasks
c. Since more attention is given on results rather than on means, little
effort is spent in searching for the least time-consuming, least difficult,
least expensive method of realizing the goals.
d. With this method, the employee is narrowly focused on a few specific
goals to be realized within a specifies time interval that she may be
reluctant to react spontaneously to unforeseen opportunities, to
volunteer for unassigned duties, or to create new structures or methods,
thus may destroy employees individuality.














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The system approach, like the MBO, is an important tool in both
planning and control functions. A system can be simply defined as a set of
objects or elements in interaction to achieve a specific goal (Ryan,1973). It is
not just a logical and orderly arrangement of parts but an ongoing process or
state of change that consist of interconnected and interrelated subsystems,
each of which has its own objective that contributes positively toward the goals
of a larger system. A system can be identified by the fact that it is capable of
maintaining some degree of organization in the face of disturbing influences
from within and without. Its function is to convert or process information,
energy, or materials into a planned outcome or product for use within the
system, outside the system or both. Thus, the nursing process is a system, the
function of which is to convert the knowledge and skills of the nurse, the
patient, the patients family into supportive and therapeutic interventions
against illness, debility, and loss (Gillies,1994.) because a system is also
defined by differences in their constituent parts, the manager must be familiar
with the nature and function of the classic system. The parameters, factors or
elements of any system are goal, input, process or throughput, output,
feedback, control and environment (Figure B).

Feedback Loop

Input Throughput Output

Figure B. CLASSIC SYSTEM ELEMETS

Each system is defined in relation to its environment at the same time
that the systems environment can be defined only in reference to the system
itself. A systems environment is defined as a set of objects, events, or
conditions within certain specific limits that be conceived by the system
boundary, which is established by the system analyst. Input is the operating
material of the system. It may consist of information, money, energy, time,
individual effort, or raw material of some sort. Inputs for health organization
system may be technical, social, financial, or human. Throughput is the process
by which the system converts energy input from the environment into products
and services that are usable either by the system itself or by the environment.
The process of throughput can be modified in response to feedback about
system performance. Output is the outcome or result of system throughput, the
product or service that results from the systems processing of technical, social,
financial, and human input. Feedback is information about some aspect of
SYSTEM APPROACH

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data or energy processing that can be used to monitor and evaluate the system
and guide it to more effective performance.
Historically, the General System Theory was introduced in1963 by
Ludwig Von Bertalanffy, a biologist. Bertalanffy theorized that there are
principles or laws that apply to an systems, regardless of their specific
elements and goals. After more than half a century, the nurse manager finds
the General Systems Theory as still significantly useful in her job as one who
works within, among and upon a variety of systems of all types. The hospital is
a structure system, the nursing department is a functional system, the
management process is a power system, the nursing process is an information
and service system, the work group she leads is a social system, and so on.

The advantages of the System Approach include:
1. The system concept is a particularly useful device for studying
organizational functioning.
2. A systems approach to management information (such as unit census,
patients length of hospital stay, budget allotments, personnel or payroll,
recruitment and turnover statistics, nursing audit results, and quality
assurance findings) will help to ensure unity and direction in the nursing
management process. Through receipt of periodic systematically
organized data about current expenditures and actual nursing
performance, the nurse manager is able to judge progress toward
established targets and can continually redirect the staffs efforts so as to
maximize nursing effectiveness and decrease costs.
3. Systems analysis, which is both a planning and a control, provides the
nurse managers with valuable information for decision making and
problem solving. The systems approach helps in problem solving
because, according to system theory, the analyst is free to define a
system in any way she likes.
4. A systems approach is helpful in increasing the efficiency of work flow.
Following are illustrations of how the Systems Method is used in various
nursing systems (Gillies, 1994):

INPUT PROCESS OUTPUT
DATA PERSONNEL PATIENT CARE



EQUIPMENT






supplies
DATA
GATHERING
Information-
about agency
clients
employees
resources
PLANNING
Objectives
Systems
Standards
Policies
Procedure
Budget

ORGANIZING
Table of
organization
Job
description
Group work
and team
building
STAFFING
Patient
classification
Determining staff
need
Recruitment
Selection
Orientation
Scheduling
Assigning
Minimizing
Absenteeism
Decreasing
turnover
Staff
Development
LEADING
Using power
Problem
solving
Decision
making
Effecting
change
Handling
conflict-
communicati
on and
transactional
analysis
CONTROL
Quality
Assurance
Patient
Audit
Performanc
e appraisal
Discipline
Labor
relations
Computer
information
system

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ELEMENT OF NURSING MANAGEMENT SYSTEM: CLIENT DATA SYSTEM

INPUT THROUGHPUT OUTPUT
From:
Annual reports:
Monthly statistical reports
Periodical staff report
Nursing audit reports
Patient case studies
Patient charts
Patient interviews
Processing employee data by
Reading
Discussing
Computing
Comparing statistics with
national and regional
statistics
Outcomes of processing data:
Daily patient census
Portion of total patient
composed of patients in each
clinical or diagnostic group
Average length of stay
Incidence of various
complications
Treatment compliance rates


ELEMENT OF NURSING MANAGEMENT SYSTEM:GATHERING DATA: NURSING PERSONNEL

INPUT THROUGHPUT OUTPUT
From:
Personnel files
Employee interviews
Performance evaluations
Counseling records
Disciplinary records
Personnel profiles
Attendance and turnover
rates
Occupational records
Interview
Processing employee data by
Reading
Interviewing
Discussions with patients
Observation at work
Consultation with coworkers
Comparison with regional or
national statistics
Outcomes of processing data:
Knowledge of Seniority rates
Educational background
Experiential background
Professional interests
Attendance records
Turnover rates
Skill level
Professional aspirations
Social abilities
Sensitivity to Values, fears,
resentments, strength,
weaknesses
Curiosity regarding
Motivation factors
Group dynamics effects
Educational methods
Work hazards and difficulties.

Table 1. System Framework for Analyzing Environmental Variables

FUNCTION: What is our purpose?
OUTPUT: What is our product?
INPUT: What is needed to produce the purpose?
SEQUENCE: In what order are the inputs needed?
ENVIRONMENT: What is the effect of the context on our functioning?
PHYSICAL CATALYST: What additional things do or would make the work
easier, faster and of higher quality?
HUMAN CATALYSTS: What additional people do or would make the work
easier, faster and of higher quality
INTERRELATIONSHIP: How should the various parts of together to provide an
integrated functional system of operation?


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Budgeting can be defined as the allocation of scarce resources or assets on the
basis of forecasted needs, for proposed programs or activities, over a specified
period of time (Gillies, 1994). It is an essential aspect of financial management
and is a tool for both the planning and control functions of the management
process. Budgeting is a management responsibility of only a small number of
people. In a more decentralized organizations, all managers within the
organization are involved in the preparation and monitoring of the budget. The
managers, on the other hand, seek inputs from their staffs. Decentralization
empowers the nurse manager to plan and make decisions about controlling the
budget. The chief executive officer, however, has the general responsibility for
the over-all budget.

The budget itself is just a document, a collection of pieces of paper with
figure distributed according to a series of decision made by certain people with
the organization. (Tappen, 1997). It is a numerical expression of expected
income and planned expenditures for an organization for a specified period of
time. When completed, the budget frequently has a great deal of power
associated with it (Dillon, in Tappen, 1997). Many times the budget is used as
an excuse for unpopular decisions as for example, when staffing is poor or
when broken and antiquated hospital equipment are not changed.

Types of Budgets. According to Tappen, there are two different
approaches to preparing the budget: a. incremental, and b. zero-base budgeting.
Incremental, or historical is the traditional process in which budgets, are
prepared every year on the basis of what was spent the year before. The two
most basic components of the budget are income (contributions, private
payment, insurance) and expenses (salaries, benefits equipment, supplies,
overhead, staff education, and so forth). Zero-base budgeting on the other
hand, is an approach that is based on the idea that no expense should be
assumed to be absolutely necessary. The result is that every cost must be
analyzed and justified as essential to the function of the organization. The zero-
based budget begins with a blank slate every year, that is, no expense from the
last year can simply be repeated for the next year without giving reasons why it
is necessary.

The use of the decision package is the core of the zero-base budgeting
process. The decision package consist of several basic elements: a. a listing of
all current and proposed objectives or activities of a given time; B. nursing
audit, or department; c. alternative ways of carrying out these activities; d. the
different costs for each alternative; e. the advantages of continuing the activity;
and f. the consequences of discontinuing the activity.

BUDGETING

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Definition of terms use in the process of Budgeting.
Revenue this is the income from sale of products and services. Nursing
revenue is usually included with room charges. Revenue can include accounts
receivable and income-producing endowments

Revenue Budgeting is the process by which a hospital determines revenues
required to cover anticipated costs and to establish prices sufficient to generate
that revenue.

Expenses are the costs of providing services to patients. They are frequently
called overhead and include wages and salaries, benefits, supplies, utilities,
office and medical supplies, equipment and so forth.

Expense Budgeting is the process of forecasting , recording, and monitoring
the manpower, materials, and supply, and monetary needs of an organization
in such a manner that the operation of the various components of the
organization can be controlled. The components of expense budgeting are cost
centers. The purpose of expense budgeting are:

Prediction of the labor hours, material and supplies, and cash flow, flow
needs for future time periods.
establishing procedures for making comparative studies
Providing a mechanism for determining when changes in procedures
need to be made providing gross information on the kinds of changes
needed, and providing evidence that control has been established and
reestablished.

Patient days are statistics used to project revenues. They are commonly used
as units of service to compute staffing. Patient-day statistics are usually
derived from census reports that are done daily and summarized monthly, for
year to date, and annually. Fiscal year is the budgetary on financial year. It
may be the calendar year in some organizations, beginning on January 1 to
December 31. Many organizations use July 1 to June 30.

Year to date (YTD) is the term used to describe that accumulated for a specific
number of days and divided by the number of days.

Average Daily Census (ADC) is the census summarized for a specific number
of days and divided by the number of days.

Unit of Service is a measure for output of hospital service consumed by the
patient. In the operating units and recovery room, it will be minutes or hours;
and in the nursing unit, it will be category of acuity of patients and hours per
day. Measures include procedures, patient days, patient visit and cases.

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Cost/ Benefit Analysis is a planning technique of comparing the costs of
pursuing an objective, a goal, or a program with the benefits they produce.

The Process of Budgeting. The process of budgeting begins with
analyzing the expenses and revenues. According to Tomey (1993), there are
three stages of the development of the nursing budget. These are:

a. The formulation stage,
b. The review and enactment stage,
c. The execution stage.

The formulation stage is usually a set number of months (6-7 months)
before the beginning of the fiscal year in which the budget will be executed.
During this period procedures are used to obtain an estimate of the funds
needed, funds available, expenses, and revenue. These procedures are
communicated by the budget officer to the nursing administrators and
unit/cost center manager who, then analyze the financial reports of expenses
and revenues of their departments. Among the cost center reports that will
assist the nurse administrators and managers are:

Daily staffing reports;
Monthly staffing reports;
Payroll summaries;
Daily list of financial categories of patients;
Reports of occupancy
Monthly financial summaries of revenues and expenses.

Review and Enactment stage are processes of budget development that
put all the pieces together for approval of a final budget. After the cost center
managers presents their budgets to the hospital budget council, the chief nurse
executive consolidates the nursing budget. In preparing the nursing budget she
sees to it that objectives are clearly stated, the cost accurate, the revenues
defensible. In other words, the nurse executive should present a well-prepared
budget. Approval is made by the chief executive officer and the governing board
of the organization. During this entire process of review and enactment there
are conferences at which budget adjustment are made.

Execution Stage. Both the formulation and the review and enactment
stages of the budget are planning activities. Execution of the budget involves
directing and evaluating activities. The budget is executed by the nurse
administrators and managers who planned it. The procedures for monitoring,
evaluating revision of the budget are planned.

Operating or Cash Budgets.The cash budget is the actual operating budget in
detail, excluding the capital budget. It is day-to-day- budget and represents

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money coming in an going out. A cash budget requirement is cash flow that
must be adequate to meet debt obligations, including replacement and
expansion of facilities, unanticipated requirements, the payroll, payment for
supplies and services, and a prudent investment programs. Examples of cash
receipts are those coming from the third party payers, tuition, endowment fund
earnings, gifts and services. A negative cash flow most often result from the
time lag between delivery of services and collection of Operating budget
information supplied to the chief nurse, executive, department head include a
large worksheet and an adjustment explanation worksheet.

The budget worksheet shows information by the cost center account
number and sub code as follows:

Subcode Description Prior
Year
Expense
Original
Budget
Annualized
Expense
Budget
Detail
Budget
Pool

The Budget Worksheet Heading

The worksheet list prior year expense, the original budget, the
annualized expense. The columns for the Budget Details and Budget Pool
are left blank so the cost center manager can fill in the budget expenses for the
projected fiscal year.

An adjustment explanation worksheet is used to justify any increase
from the original budget.

Personnel Budget. In the budgeting process, personnel account for the largest
portion of the nursing budget. The nursing administrator prepares budgets for
personnel assigned in the different nursing department such as the emergency
units, clinics recovery rooms. Operating rooms, delivery rooms and all the
other nursing department. Nursing personnel budgets are prepared using
quantitative workload measurements, which is usually a patient acuity system.
It is usually a computer program that produces staffing requirements by shift
and by day. The system produces an acuity index for each patient, and the
formula indicates needed staff by category (nurses, nursing assistant, midwife)
and by shift. It can also compare actual staffing with that required and can be
summarized month and year. Each day at a given time, a registered nurse
enters each patients acuity rating into a computer terminal. Shows a nursing
budget that is based on a patient acuity rating system. The average daily
census (ADC) is obtained the admission office. It is the result of dividing the
total patient days for a unit for one year by 365 days. Census reports are
prepared according to daily, monthly, and annual basis. Acuity is the result of
the sum of all acuities for one year divided by 365 days. This figure is also
computer generated daily, monthly, and annually. The nursing hours are
generated from an acuity standard. In planning the personnel budget, the

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nurse has quantified information related to staffing and can accurately predict
the number of full time equivalents (FTEs) needed for patient care. Things to
consider in planning personnel budget are like, will there be a pay increase
next year? Will fringe benefits increase? Will a new program require more
personnel?

Staffing Formula:

The staffing formula is: Average Census x Nursing Hours x 1.4 x 1.14
7.5

Example: Medical Floor
Average daily census= 31.8
Nursing hours= 4 (per 24 hours)
1.4 is a constant representing 7 days in a week with full time worker 5 days in
a week
7-5=1.4
1.14 is a constant representing an allowance of 0.14 FTE for vacation, illness,
etc. for each 1.0 FTE
7.5 represents 1 work day

31.8x4x1.4 x 1.14 = 27 FTEs
7.5

Supplies and Equipment Budget. This is part of the operating budget. It
includes all supplies and equipment used in provision of services. Examples of
supplies to be budgeted includes office supplies, medical/surgical supplies,
pharmacy supplies, and others. Capital Budget, is separated from the
operating budget. Each item in the budget is defined in terms of dollar value. If
it is an equipment, it is usually used and reused over a period of time. The
budget provides for depreciation for each capital budget items.

Within the frame of the standards written by authorized groups, institutions
modify and develop locally applicable nursing standards. The locally developed
set of standards includes:

a. Statement of institutional philosophy and objectives to assist
establishing priorities.
b. Adoption of a nursing theory to facilitate decision making and
c. Identification of basic issues and problem for which standards should be
developed. In organizing the staff to construct practice standards, the
director of nursing appoints a task force to spearhead the project. The
task force includes a nursing administrator who is thoroughly familiar
with the institutions purpose, philosophy, long range goals, financial
constraints, and personnel resources; a clinical nurse specialist, a
nursing supervisor, who is well-versed in staffing strategies, a head

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nurse, and a staff nurse with working experience in more than one
clinical specialty. After the task force members have developed the first
draft of a set of process or outcome standard, it is submitted to a sample
of nurses for review, analysis, and evaluation. Each standards is
reviewed as to applicability, suitability, clarity, measurability, as to
whether they are achievable. An example of nursing standards written for
prevention and management of skin breakdown and decubiti follows
(Gillies, 1994 page 105).

NURSING STANDARDS FOR PREVENTION AND MANAGEMENT OF SKIN BREAKDOWN

Disease and/or Related
Conditions
Critical Preventive and Response Management
1. Immobility
2. Dehydration
3. Poor nutritional
status
4. Chronic illness
with multiple
system disease
Prevention
1. Note patients tolerance of caloric intake daily by mouth,
feeding tube, or intravenous fluids
2. Summarize intake and output q8h
3. Notify MD if intake less than 1000cc/24hr unless on fluid
restriction
4. Turn q2h while bedridden
5. Provide daily back care
6. Note condition of the skin daily
7. if extremity paralyzed, provide full range of motion exercise
q8h (once per shift)

Responsive Management
8. notify MD of any break in skin integrity
9. continue turning patient q2h while on bedrest
10. cleanse open area 3x/day, dry carefully, and keep open to
air.
11. Apply tincture of benzoin around the area of breakdown
12. Apply further local therapy per MD order.


Nursing Service Policies. Policies, procedure, rules, and regulations are
the standing plans of nursing organizations. (Swansburg,1993). They are
conceptual plans that are translated into physical entities, usually called
manuals.
A policy is a mechanism that establishes constraints or boundaries for
administrative action and sets a course to be followed. Policies are formal or
informal, covert or written. Formal policies are those that apply to:
a. Organizations as a whole
b. A functional entity such as a division or department
c. A basic unit such as a ward, floor, special care unit, clinic

Implementation of nursing standards implies that policies will be
developed for carrying them out. Generally policies fall into three main
categories:
a) Those that apply to patient

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b) Those that apply ton personnel
c) Those that apply to the environment
A fourth category could be that f relationship with other disciplines or
department.

Policies are usually developed by a policy committee. At the nursing
division level the committee is made up of representatives from different
nursing specialist and nursing top nursing management. The policy
development process includes the following steps. (Swansburg, p168) :

1. Determination that a policy is needed.
2. Assignment of the development of each policy to a committee member or
members
3. Development of policy from appropriate sources of information by using
published sources, computer search, and other sources.
4. Review of the draft policy by committee
5. Circulation of the draft to appropriate clinical committee of physicians
who will write orders and nurses who will carry them out. A no code
policy, for example would go to these groups, other policies would go to
other appropriate groups
6. Review of returned comments
7. Referral to the organizations attorney for approval when indicated (such
as no code policy)
8. Final approval by committee and signature of the organizations chief
executive officer
9. Distribute with appropriate communication. In the case of no code
policy all personnel who would respond to a cardiac arrest need to be a
informed.

Nursing Service Procedure.in addition to policies, a written and current
procedure manual should be available to all nursing personnel. The manual
contains detailed plans for nursing skills (procedures) that include steps in
proper sequence. Procedures outline a standard technique or method for
performing duties and serve as guide for action.

Advantages of procedure include:
Procedures conserves management effort
Procedures facilitate delegation of authority
Procedures lead to more efficient methods of operation
Procedures permit significant economy in personnel
Procedures facilitate control
Procedures aid in coordination of activities.




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The following are the steps in developing a new procedure.
1. A task or title is stated
2. A need is identified and a purpose is stated
3. A draft of steps and sub steps is made
4. References and experts, including manufacturers, are consulted
5. The committee member responsible for development of the specific
procedure drafts it in standard format, including related policies,
equipment needed, line drawings, location of equipment, and ordering
procedure. the draft provides step-by-step instructions in performances,
brief theory statements and supporting documents.
6. The draft is edited
7. An index code number is assigned
8. The procedure is typed and distributed as draft to reviewers with a
deadline for feedback
9. Returned drafts used to revise the procedure
10. The revised manuscript is submitted to approval authorities
11. When approved, the procedure is printed and distributed
12. In-serve training on the procedure is given to the appropriate personnel.





























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Answer the following and submit your typewritten answers/reactions to your
professor.

1. You as a nurse executive, decide to manage the nursing department by
MBO. Explain how you go about it.
2. What will you do to prevent or overcome resistance to the use of MBO?
3. Explain how the systems approach can facilitate planning.
4. Illustrate how the systems method is used in nursing management.
5. If you are not responsible for preparing a budget, interview someone who
is in your place of work. From the interview/s explain the step by step
procedure of how the Department of Nursing prepared budget. Who
is/are responsible for preparing the budget?
6. Using the nursing staffing formula, calculate the number of FTEs for
medical floor with a daily census of 33 patients
7. Discuss the process of policy and procedure development in your
organization
8. Using the steps of procedure development, prepare a draft of steps and
sub steps to follow in performing a nursing procedure of your choice, as
example, Blood transfusion administration, intravenous administration,
taking vital signs and so forth.
9. Describe how nursing standards are developed.


LEARNING ACTIVITIES

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MODULE THREE




At the end of the module four, you will be able to:
1. Differentiate between hierarchical and matrix organizational structures.
2. Make a table of organization.
3. Make a job description.
4. Describe the processes involved in job evaluation.
5. Explain each of the four (4) methods of job evaluation.
6. Describe the techniques for team building.
7. Discuss Bales method for analyzing group members interactions
8. Describe how the principles of group dynamics are used in designing
work groups.

ORGANIZATIONAL STRUCTURE,
JOB DESCRIPTION, AND JOB
EVALUATION

SPECIFIC OBJECTIVES

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Forms of Organizational Structure

There are two common forms of organizational structures, hierarchical, and
free-form. A mixture of both is needed in nursing. The hierarchical structure is
commonly called a line structure. This is the traditional structure and is
associated with the principle of chain of command, bureaucracy, vertical
control and coordination, level differentiated by functions and authority, and
downward communication. The line structure is still used in many nursing
organizations because of its advantages such as:

It is easy to orient new employees to a line organization because of the
simplicity of interpersonal relations;
It is easy to function in a line organization because responsibility and
accountability for each function are clearly defined;
It is relatively easy to manage a line organization because of the speed
with which orders can be transmitted and, generally, the acquiescence of
workers to authoritative commands;
It is well suited to execution of tasks that require large numbers of
moderately-educated workers to perform routine operations;
The emphasis in line organization on clear-cut work specialization and
role separation makes line structure more effective in relatively stable
organizations in which the pace of change is slow.


There are also disadvantages especially to the staff. These are:

The small, repetitive, cyclical performance of tasks produces monotony
and worker alienation;
Over-emphasis on specialization leads to communication difficulties
among specialists;
Structures inability to adjust rapidly to altered circumstances;
There is a tendency of bureaucratic structure to engender passivity and
dependency in staff members and to encourage autocratic behavior in
managers;
There is lack of coordination and integration between divisions or
sections of the organization;
There is the tendency for limited use of available knowledge in a
bureaucratic setting due to the relative isolation of employees from other
departments.

A modification of the line structure is the line and staff organization. This
pattern minimizes the disadvantages of the line organization. Here, a simple
line organization is altered by providing management specialists to support and
strengthen the top executives.
ORGANIZATIONAL STRUCTURE


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The free-form organizational structures are called matrix organizations.
When project team or task force organization is superimposed upon and built
into a fully-functionalized hierarchical organization, the result is a matrix
organization. In a matrix organization, the efforts of numerous specialists are
coordinated both vertically and horizontally (Gillies, 1994). Vertical
coordination occurs through the hierarchical chain of command, in that the
efforts of several specialized department are integrated by the executive who
supervises them. Horizontal coordination takes place through direct
interactions among diverse members of the patient care team, who represent
different departments and occupational groups. The matrix structure is
different from hierarchical and the line and staff structures in that there are
fewer levels of hierarchy, greater decentralization of decision making, and less
rigid adherence to formal rules and procedures. The advantages of matrix
nursing organization structure include (Swansburg, 1993):

1. Improved communication through vertical and horizontal control and
coordination of interdisciplinary patient care teams.
2. Increased organizational adaptability and fluidity to respond to
environmental changes.
3. Increased efficiency or resource use with fewer organizational levels and
decision making closer to primary care operations.
4. Improved human resource management because of increased job
satisfaction with achievement and fulfillment, improved communication,
improved communication, improved interpersonal skills, and improved
collegial relationships.
There are also disadvantages because in matrix organization, there may be:

1. Potential conflict because of dual or multiple lines of authority,
responsibility, and accountability relationships.
2. Role ambiguity.
3. Loss of control over functional discipline due to multidisciplinary team
approach.


According to Swanburg (1993), the characteristics of a matrix organization
include the following:

1. Maintenance of old-line authority structures
2. Specialists resources obtained from functional areas.
3. Promotion of formation of new organizational units.
4. Occurrence of decision-making at the organizational level of group
consensus, the middle management level.
5. The matrix manager exercising authority over the functional manager.
6. Cooperative planning of program development and allocation of resources
to accomplish program objectives.

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Organizational Charts

Organizational charts, also called schemas, are graphic representations
of the organizing process in an institution. These charts show reporting
relationships and communication channels as well as distribution of
responsibilities. Line charts show supervisor and supervised relationships from
top to bottom of the nursing organization. Staff charts show the advisory
relationship of specialists or experts who are extensions of the nurse
supervisors.

Decentralization

Decentralization refers to the degree to which authority within an
organization is delegated downward to its divisions, branches, services, and
units. Decentralization of authority includes delegation of all the management
components of planning, organizaing, leading, and controlling. Flat
organizational structures are characteristic of decentralized management.
Because of the participatory management characteristic of decentralization,
many management titles and positions are either eliminated or decreased.

The Informal Organization

Every formal organization has an informal one. The informal organization
can pose a problem in an institution as it can create conflicting loyalties
restricted productivity, resistance to change, and management plans. On the
positive side, the informal organization, meets the employees needs for
relationships, friendships, for sharing interests, hobbies, experiences, and
feelings. It meets their need to belong. The informal organization can also help
serve the goals of the formal organization. It should not be controlled but
instead, the wise manager should exercise tolerance and understanding.

Informal organization should be encouraged and nurtured especially if they:

1. Provide a sense of belonging, security, and recognition to employees.
2. Provide methods for friendly and open discussions of concerns.
3. Maintain feelings of personal integrity, self-respect, and independent
choice.
4. Provide an informal and accurate communication link.
5. Provide opportunities for social interaction.
6. Provide a source of practical information for managerial decision making,
7. Are sources of future leaders.





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Steps in Analyzing Organizational Structure

There are six steps in analyzing the organizational structure of a division of
nursing. Analyzing organizational structures are used when there is a major
organizational problem, such as friction among departments heads over
authority, staffing problems, and so forth.

1. Compile a list of the key activities determined by the mission and
objectives of patient care. It must be remembered that when there are
changes in the institutions mission, philosophy, objectives, the
organizational structure should be reviewed and analyzed. Once the list
is completed, it is analyzed and grouped according to similarities or
kinds of contribution they make, such as:

Results-producing activities related to direct patient care, such as
the nursing process.
Support activities, which may include audit, advice, and teaching
Hygiene and housekeeping activities.
Top management activities, including managing people, marketing,
innovation, audits.
2. Based on the work functions to be performed, decide on the units of the
organization. Decide which kinds of decisions will be required and who
will make them. All decisions should be placed at the lowest kevel and as
close to the operational scene as possible.
3. Decide which units or components will be joined and which will be
separated. Join activities that make the same kind of contribution.
4. Decide on the size and shape of the units or components.
5. Decide on appropriate placement and relationships of different units or
components .this will require relations analysis.
6. Draw or diagram the design and put it in operation. This will result in an
organizational chart or schema.



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MATRIX ORGANIZATION











HOSPITAL
NURSING
SERVICE
ADMINISTRATOR

UNIT
COORDINATOR
DIRECTOR,
MEDICAL
NURSING
DIRECTOR,
SURGICAL
NURSING
DIRECTOR,
CRITICAL CARE
NURSING
DIRECTOR,
MATERNAL
CHILD NURSING
DIRECTOR,
STAFF
EDUCATION

HEAD
NURSE

HEAD
NURSE
UNIT
MANAGER
UNIT
MANAGER
UNIT
MANAGER
UNIT
MANAGER

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MATRIX ORGANIZATION
CHAIRPERSON,
DEPARTMENT
OF EDUCATION
DIRECTOR,
STAFF
DEVELOPMENT
MEDICAL
SERVICES
DIRECTOR,
STAFF
DEVELOPMENT
SURGICAL
SERVICES
DIRECTOR,
MEDICAL
SERVICES
DIRECTOR,
GENERAL
SURGERY/
GYNECOLOGY
DIRECTOR,
HEAD & NECK/
MEDICAL
ONCOLOGY
DIRECTOR,
THORACIC/
UROLOGY
DIRECTOR,
MEDICAL
NURSING
CHAIRPERSON,
DEPARTMENT
OF QUALITY
ASSURANCE
AND RESEARCH
DIRECTOR,
RESEARCH
DIRECTOR,
QUALITY
ASSURANCE
DIRECTOR,
OPERATING
ROOM SPECIAL
CARE UNITS
DIRECTOR,
PROJECT
DEVELOPMENT
DIRECTOR,
SPECIAL CARE
UNITS
DIRECTOR,
SPECIALTY
TEAMS
DIRECTOR,
OPERATING
ROOM
DIRECTOR,
PEDIATRICS/
ADOLESCENT

PRESIDENT
VICE-PRESIDENT
FOR PATIENT
CARE

ADMINISTRATIVE
ASSISTANT II

HEAD, DIVISION
OF NURSING

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FUNCTIONS OF A HOSPITAL NURSING SERVICE
PATTERNS OF
CARE
PERSONNEL
MANAGEMENT
PHYSICAL
ENVIRONMENT
RELATIONSHIPS ADMINISTRATIVE
PRACTICE

1. Determine
kind and
amount of
nursing
care
needed for
individualiz
ed nursing
care.
2. Provide for
day-to-day
fluctuation
of nursing
care needs.
3. Provide for
special
nursing
care of
critically-ill
patients.
4. Provide for
continuity
in nursing
care on the
ward and
in the
community
.

1. Determine
categories
and
number of
positions
needed.
2. Determine
qualificatio
ns and
provide job
description
s.
3. Make and
maintain a
staffing
pattern.
4. Maintain a
recruitmen
t program
and
appoint
personnel.
5. Evaluate
performanc
e of
personnel.
6. Provide
opportuniti

1. Plan for
allocation
and
utilization
of space for
all nursing
functions
and
motivations
2. Determine
needs and
provide for
necessary
equipment
and
supplies.
3. Evaluate
effectivenes
s of
existing
physical
environme
nt and
recommen
d changes,
improveme
nts and
adjustment

1. Develop plans to
interpret nursing
and to coordinate
activities with
hospital groups.
a. Administrative
Officers
b. Professional
Personnel
c. Hospital
Departments
d. Within Nursing
Service
2. Provide for
association with
community groups.
a. Educational
Institutions
(Colleges &
Universities)
b. Professional
Organizations
(Physicians,
Dietitians,
Pharmacists)
c. Service
Organizations
(Philanthropic

1. Develop
organizational
structure.
2. Plan, organize,
direct, and
coordinate
administrative
activities.
a. Set
standards
for patient
care, and
other
nursing
functions.
b. Assign
responsibility
and delegate
authority.
c. Provide for
directed
group
participation
d. Establish
nursing
programs of
conference
for direction

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5. Simplify
and
standardize
nursing
procedures
and
techniques.
6. Instruct
patients in
their own
care.

es for
growth and
developme
nt of
personnel
through
programs
of
education.
7. Provide
working
conditions
and
recommen
d economic
considerati
on which
provide for
job
satisfaction
8. Establish
and
maintain
complete
personnel
record.

Societies) of
supervisory
personnel.
e. Establish
systems for
reporting
and
recording of
all functions.
f. Interpret
nursing
needs and
problems to
administrati
ve officers
and other
hospital
personnel.
g. Provide
channels for
methods of
communicati
on within
nursing
services, the
hospital and
the
community.
h. Identify
areas
needing
study and
plan for

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research.
i. Prepare and
administer
the nursing
budget.



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Job Descriptions. A job description provides a definition of the
responsibility and authority involved with each position. It is also a contract
that includes the jobs function obligations and tells the person to whom the
worker is responsible ( Swanburg, 1993) It is written report normally prepared
by a job analyst outlining duties, responsibilities, and condition of the
assignment.
A job description is a description of a job and not of a person who
happens to hold the job. Job descriptions are based on the functional needs of
the agency. ( Tomey, 1992)
The purpose of writing a job description, in addition to recording data for
a job evaluating are too:
a) Facilitate wage and salary administration
b) Provide a basis for manpower planning
c) And assist with recruitment, selection , placement, orientation, and
evaluation of employees
d) Clarify relationships between jobs to avoid overlaps and gaps in
responsibility
e) Help employees analyze their duties so that they will have a better
understanding their jobs
f) Establish lines of promotion within the department ( Swanburg,1993)

Format. Each job description should include the following
information: job title, job code, summary statement of job purpose,
function, and span of responsibility, listing of principles and
subsidiary duties, and personal requirement or specifications for
employees.

Job description should be written in a standardized outline. To
eliminate confusion among workers and managers, each job should
be referred to only one title. For example, if the nurse educator, the
education specialist and staff development instructor titles refer to the
same position in an institution, only one of these titles should be
consistently used. The ideal title brief and descriptive of a job. For
example, head nurse, ICU.

The summary statement in the job description should be written in such
a way as differentiate the job from all others in the department. It should be
written in such a way as differentiate the job from all others in the
JOB ANALYSIS, JOB EVALUATION, JOB
DESCRIPTIONS


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department. It should indicate reporting relationship to other jobs. The
summary statement of a nurse educator position in the surgical units might
required plans, executes and evaluates educational programs for the staff
nurses in the three surgical units. Serves as educational and clinical resource
person to the head nurse

Job specification are the enumeration of necessary and desirable
personal qualities that an applicant should posses in order to execute the job
satisfactory. They include needed knowledge, skills, attitudes, temperament
and experience. According to Gillies( 1994), a good rule thumb to follow in
writing a job description is to explain the jobs duties, responsibilities and
conditions in enough detail, with such specificity that an uninformed outsider
would have no difficulty in visualizing the job tasks or understanding the
purpose and significance of the job activities.

Job Evaluation. Job evaluation is needed in creating a sound wage
salary and career ladder systems. In order to ensure fair salary structure for
the department of nursing, the nurse manager must be able to evaluate and
cost out various nursing jobs according to the methods used by the
personnel and financial experts. Jobs evaluation requires job analysis and job
description.

Job evaluation can be defined as systematical method of appraising
the work of each job in relation to all other jobs in organization ( Belcher, in
Gillies, 1994). The purpose of job evaluation is to determine the relative worth
of each job as a basis for equitable pay differentials. The objective of job
evaluation is to identify those job factors or conditions that place one job
higher than another in a value hierarchy and to measure the number and
degree of these factors present in these job.

The first step in job evaluation is job analysis. Job analysis is the
process of investigating each job from two standpoints a). the duties and
responsibilities associated with each job and b). the skills and personal
attributes required to perform the job satisfactorily. Thought job analysis, the
manager can determine what the worker does in a particular job, how does it,
why he does it a he does, and how much skill is required to do it Following is
an illustration of a bipartite approach to job analysis (Gillies, 1994 page 138):




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JOB CHARACTERISTICS PERSONAL CHARACTERISTICS
Job Duties Knowledge
Job Responsibilities Skill
Job Contact Personal attributes








Figure 4 Bipartite Approach to Job Analysis.

The following aspect are studied in analyzing any job: a) procedure to be
executed, b) equipment to be used, c) subject matter to be dealt with, d)
problems to be handled, e) scope and responsibility associated with the job, f)
amount of discretions allowed in making decisions, standards of job
performance, g) magnitude of workload, h) number and type of supervisory
and reporting relationship, i) length of training period required, j) working
condition and hazards, k) and promotional opportunities associated with
successful job performance.

Methods of Job Evaluation: There are four methods by which job evaluation
is carried out. These are:
a) Ranking
b) Job Classification
c) Factor Comparison, and
d) Point System
Job ranking is the simplest and the least precise. Ranking consists of
arranging jobs in hierarchy of complexity from highest to lowest. It does not
reveal the degree of difference in value of between jobs at various points in the
hierarchy. The advantage of the ranking method is its ease and speed of use. In
job classification, the number of job grades and decided, each job grade is
defined, and appropriate pay range is assigned for each job grade. The
description of each job grade should indicate the general type of work and the
level of responsibility involved. Grade descriptions should be sufficiently
detailed and precise to ensure that similar jobs will be grouped together and
that groups of job will be differentiated according to the number and level of
compensable factors present A bench mark job should be identified to typify
each job grade. To qualify as bench mark job, a position must be: numerically
important as far as the total work force is concerned; must be fairly stable in
job content over a long period of time; must be well known to the managers,
line workers, personnel experts, and job analyst who constitute the Job

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Evaluation Committee, must be possible to describe clearly and concisely,
must be representative of wide range of jobs. An appropriate monetary value is
assigned for each benchmark job on the basis of prevailing market rate. Job
classification method is favored by many managers because it differentiates
between jobs and because it is easy for both employees and managers to
comprehend.
A grade classification system for hospital personnel might group nursing
jobs in the following manner: (Gillies, 1994 p145)
Grade 16: High level administrative activities, with a large measure of
discretionary power in planning, budgeting, directing, and controlling the
activities of a large work force of diverse levels and types of workers several
geographical locations (Masters level preparation: Director of Nursing)
Grade 15: Experienced practitioner and midlevel manager, with
responsibility for planning, organizing, staffing, supervising, coordinating, and
monitoring the work force of an entire nursing specialty division. (Master level
of preparation: Divisional Director)
Grade 14: Highly skilled subject specialist with department-wide
responsibility for care planning, problem solving, research, and patient and
staff teaching, with advisory rather than command responsibilities towards
other staff members. (Masters level of preparation: Clinical Specialist)
Grade 13: Skilled practitioner and first level manager with total
responsibility for day-to-day planning, direction, evaluation of the efforts of a
primary work group on a single patient unit with direct supervisor
responsibility for a staff of 25 to 30 employees. (Bachelors degree: Head nurse)
Grade 12: Professional care giver with considerable responsibility for
independent decision making relative to the adaptation of hospital routines and
procedures to the care of specific patients, but little responsibility for the
direction of other health workers. (Bachelors degree: Staff nurse)
Grade 11: Highly skilled technical care giver with some responsibility for
programmed decision making with the limits of well-defined protocols. No
responsibility for the direction of other workers. (Diploma state: Nurse)
Grade 10: Low level technical specialist with narrowly defined
responsibility for caregiving under direct supervision of a professional worker.
(Practical Nurse)
Grade 9: Ancillary worker with responsibility for carrying out orders for
the unskilled specs of nursing care. (Nursing Aide)





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Groups. A group can be defined as an entity consisting of several
individuals having collective perception of their unity and a tendency to act in a
united manner toward the environment. All group objectives are two types: 1)
achievement of some specific group goal and 2) maintenance of strengthening
of the group itself. (Cartwright in Gilles, 1994 p150)
Group Communication. In all work groups such as committees, project
team conference groups, workshop and seminar groups, the work of the group
is accomplished through communication of ideas and opinions among
members. However, communication within a group is different from a simple
one-to-one interchange because of the greater number of person involved. As
the size of discussion group increases as for example, from six to twelve, the
degree of consensus achieved through discussion decreases markedly
especially when time is limited. Furthermore, the larger the group, the more
skill is required from the leader to assist the group to achieve consensus.
Aside from the number of persons involved, there are other factors that
influence communication within a group. According to McDougall (I GIllies,
1994 p152), group syntality or togetherness is another factor that makes
group communication different from individual communications. Group
syntality develops from the strong pressures exerted toward uniformity of
behavior and attitude among group members. These pressures for togetherness
are of such magnitude as to cause some members to discredit their own
perceptions and judgment in order to move toward majority opinion when faced
with a conflict situation.
Reasons for joining the group is another factor that influence
communication within group. An individual may join a group because she
admires certain people in the group and wants to be with them, or an
individual may join a group because she sees membership in the group as
means toward a desired end. Not only are some members attracted to a group
because of liking for certain group members, but once assimilated into group,
new member also tend to act a (agree with) those group members whom they
especially admire. Social power of group members also influences
communication within a group. Social power can be defined as the ability to
impel others to act in a certain manner. Differences in social powerange status
among group members affect both the number and type of communications
initiated by each.
Leadership styles influence communication within group.
Communication within a group with a democratic leader will be different from a
group with either an autocratic leader or odd whose leadership is laissez faire.
GROUP WORK AND TEAM BUILDING

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Another factor that controls communication among group member
is the configuration of the communication network. A communication network
is the system of communication channels within a group that determines the
direction of message flow among members. The table of organization creates a
formal communication network. An informal communication network can also
be created within a group as when one habitually takes the same seating
position relative to each other, in a circular arrangement.
Group Interaction. Bales and Slater developed a method for analyzing
the interaction of group member by which communication act may be classified
into one of 12 categories:
1. Shows solidarity, raises anothers status, gives help or reward;
2. Shows tension release, jokes, laughs, shows satisfaction;
3. Agrees, shows passive acceptance, understands, concurs,
complies
4. Gives suggestions, directions, implying autonomy of other
5. Gives opinions, evaluations, analysis, expresses feeling or wish;
6. Gives orientation, information, repetition, confirmation;
7. Asks for orientation, information, repetition, confirmation;
8. Asks for opinion, evaluation, analysis, expression of feeling;
9. Asks for suggestions, direction, possible ways of action;
10. Disagrees, shows passive rejection. Formality, withholds
help;
11. Shows tension, asks for help, withdraws from field;
12. Shows antagonism, deflates others status, defends or
asserts self.
Behavior in categories 4,5 and 6 are considered problem-solving behavior
accounts for about half of all communication acts. Categories 1,2 and 3 are
positive reactions, while categories 10,11 and 12 are negative reactions.

Group Dynamics. In designing work groups, the manager should:
1. Apply the principles of group dynamics appointing individuals
to group membership, chairing work groups, and serving as
group members in an appointed or a voluntary capacity.
2. Weigh the effect of group size against the need for
representation of certain groups, since consensus is difficult to
achieve in group with more than 10 to 12 members.
3. Consider the probable effect of each candidates position in the
formal communication network on the number and type of her
communications within the group.

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4. Consider the possible effect of various seating arrangement on
establishment of chance related communication networks and
should alter positions when necessary to improve message flow
through the group.
5. Classify communications according to the method of Bales and
Slater into task-oriented or group-oriented behaviors when
serving as group leader.
6. Practice those task-oriented and group-oriented messages with
which she is still at ease.
Team Building. Team building activities involves identifying work
group problems, identifying solutions and developing action plans,
implementing the plans, and evaluating and monitoring the outcomes.
Teams are working groups. To be considered a team, a group must have
some stability of membership and common purpose. The members work
interdependently; they function as interrelated parts of the whole team. A
group whose member work independently of each other with little
communications, coordination, or shared responsibility, are not working as a
team.
Teams can be classified according to composition, purpose, leadership,
and function. (Tappen, 1996)
As for comparison, some teams are made up of people in only profession,
as for example, the medical team. Others are made up of people at different
levels within a particular profession, such as the nursing team which consists
of registered nurses, midwives, nursing, and assistants. The interdisciplinary
team is made up of people from different professions, such as the physicians,
nurses, social workers, physical therapists, nutritionists, a psychologist, and
patient educator.
The purpose of the team is often reflected in its name. For example there
are surgeon teams, intravenous teams, primary care teams, cardiac care
teams, and code team.
A team can have a leader who is designated, emergent, or situational.
One or more leaders can exist at any one time in a team. The designated leader
is one who has been deliberately chosen either by the team or by an
administrator who has some authority over the team. The emergent leader is
one who evolves from the group by acting as the leader consistently enough to
become an actual leader of the team. Emergent leaders often arise when the
designated leader is weak or when the team has no designated leader. The
situational leader emerges from group in response to a particular situation or
need.

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Teams can also be categorized according to the way in which they
function. Teams can be classified according to their stage of development
(forming, storming, morning, performing or adjourning), or degree of maturity.
Another classification of function closely related to the style of leadership
concerns the way members of the team relate to each other. This may be
collegial or hierarchical. When the relationships are collegial, every member is
accorded equal worth as an individual and recognition is based n their
contribution to the team. In contrast, hierarchical relationships are based on
each team members status and position.
Steps in Team Building. Effective teas do not just happen. Team
building requires specific knowledge and skill. The following are the steps in
the team building as suggested by Tappen (1996):
1. Select team members. In selecting team members, the following
are to be considered: (a) ability to contribute to both the task
and the relationship aspects of team functioning; (b) there
should be an appropriate mix of people and skills in a team; (c)
stability of membership to maintain the team.
2. Set goals, There is a need to clearly define the purpose of the
team.
3. Define roles. Role clarification is essential to smooth team
function. If roles are vague and ambiguous, conflict may arise,
especially if the team is interdisciplinary the roles should be
consistent with the defined goals and roles.
4. Develop team identity and cohesiveness. Cohesion is needed to
develop commitment to the goals of the team and the
willingness of team members to engage in the sharing and
support function of the team. Identity and cohesiveness can be
done by: (a) defining to the members the purpose and functions
of the team (b) the new team needs to stake out its territory,
which established team holds and often expands its territory,
which is not only geographic but also functional and
psychological; (c) cohesiveness is also develop by increasing the
number of links among team members. Holding regular
meetings increases theses connections. (d) Esprit de Corps is a
shared spirit, a feeling of enthusiasm that characterizes the
team as a whole. This has something to do with the leaders
own enthusiasm and energy, it is also developed when
members need are met.
5. Guide decision making. The different ways in which decisions
are made by a group include default, authority, minority vote,

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consensus and unanimous consent. Decision by default is the
result of a groups failure to reach a decision. Silence or lack of
response from the team is taken to mean consent. Decision
made by a minority are those made by a small number of people
on the team, usually a dominant subgroup. When decisions are
railroaded this way, it is often presented by the rest of the
group. Majority made by talking a poll of the entire team are
acceptable to most people. Decisions made by consensus are
those in which the team are acceptable to most people. It seeks
to gain every members agreement on the issue. Unanimous
consent is a decision that reflects genuine agreement of every
team member on an issue.
6. Influence group norms. Norms are those unwritten rules that
prescribe acceptable behavior in the group. Once a norm is
established within a group, it can be difficult to change. Norms
that support creativity and flexibility and resistance would
affect the team responds to a new assignment. Norms
supporting open communication over suppression of feelings
and disagreements affect the way conflicts are handled.
7. Encourage open communication. Open communication is
essential to the development effective working relationships
within the team and with outside groups.
8. Manage conflicts. As a general rule, conflict is neither to be
avoided nor stimulated. Too much conflict or unresolved conflict
reduce the teams effectiveness and eventually immobilize the
team. On the other hand, suppressed conflict continues to grow
underground and is more difficult to resolve when it eventually
surfaces.

Motivating the Individual Employee. The five basic needs that can be
used by the manager as motivators are the following according to Kafka
(Tappen, p309)
(a) Economic security
(b) Control or the ability of the employee to influence the situation
(c) Recognition or attention or visibility
(d) Personal self-worth
(e) Belonging
A different approach to motivation is based on an analysis of the goals
that are set and responses to the degree to which they are met. (Evans,
Tappen, p305). In the first stage, employee faces a new task and accepts a goal

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that has been set by the manager, by the employee or by both. Accepting the
goal has several effects. It directs attention to the task, mobilizes and sustains
efforts and stimulates thinking about ways to meet the goal. A difficult goal is
generally thought to increase motivation unless it is considered unrealistic or
impossible to achieve. The effort to reach the goal occurs in the second
performance stage of the cycle. At the third stage both employee and the
manager evaluate the degree to which the original goal was met measuring it in
terms of degrees of success or failure. In fourth stage, the reasons for success
or failure are analyzed. These include the amount of effort put into meeting the
goal, the difficulty level of the task, the employees skill level and how much
luck was involved in achieving success. In the fifth stage, the employees
satisfaction and feelings of effectiveness comes as a result of effort, ability and
luck. At this point the cycle is complete and the employee faces new goal, the
cycle begins all over again but this time it may be with increased satisfaction,
self-confidence and motivation or with the same or less motivation depending
on the results of the previous experience.

QUALIFICATION POINT SYSTEM FOR JOB GRADING

Numerical values are assigned to qualifications to establish consistent
compensation bases for all levels of positions in the nursing department. Once
point values have been assigned to various job factors, they can be added to
determine a grade. The grades for various job can be ranked, and job-to-job
comparisons can provide a basis for determining pay.
Qualifications
Education
Less than a high school diploma
10
High school diploma
20
High school diploma plus a special training course
30
Associate degree or three years in work-study program and
40
passage of accrediting examinations
Baccalaureate degree and passage of accrediting examinations
50
Masters degree in area of specially needed for the position
60

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Doctorate in area of specially appropriate for the position
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Mental Skills
Work is simple and repetitive and is performed according to
instructions 10
Work involves a variety of duties that are performed according to
procedures 20
but requires alertness to identify needed changes
Work involves a variety of complicated duties and some
independent 30
actions in adapting procedures to specific situations
Work involves planning, organizing, implementing, and evaluating
40
actions related to patient care
Work involves development of policies and procedures,
organization of functions, 50
development of staffing patterns, and budget preparations.
Manual Skills
Work involves the normal manual skills, such as lifting, pushing,
folding, writing, filing 10
Work involves above normal manual skills, such as accurate
measurements, 40
administration of medications and treatments, manipulation
of instruments, typing, bookkeeping
Work involves considerable manual skill, such as administering
complex treatments 50
and manipulation of complex equipment


Responsibility for resources
Personnel
Supervises no one
10
Supervises fewer than 10 people
20
Directs up to 25 people
30
Directs up to 50 people

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40
Directs up to 100 people
50
Directs more than 100 people
60
Finances
No responsibility for the budget
10
Responsible for budget up to $10,000
20
Responsible for budget up to $25,000
30
Responsible for budget up to $100,000
40
Responsible for budget over $100,000
50
Effort
Mental
Requires little thinking or judgment
10
Requires some alertness while performing repetitions tasks
according to directions 20
Requires mental effort for problem solving
30
Requires considerable mental effort for decision making and
problem solving 40
Requires continuous mental effort for dealing with the most
difficult situations 50

Physical
Light work requiring little physical effort; usually needed
10
Light physical work, use of light materials; frequently seated
20
Sustained physical activity; seldom seated
30
Considerable physical effort, continuous activity, lifting
40


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Working conditions
Good working conditions: light, ventilation, freedom from
10
disagreeable elements such as dirt, heat, wetness, ordors, noise

Average working conditions with occasional exposure to
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disagreeable elements and danger
Fair working conditions with frequent exposure to disagreeable
elements and danger 30
Poor working conditions with continuous exposure to
40
disagreeable elements and danger

Figure 6: Sample Job Descriptions

Clinical Nurse (CN1)
The clinical nurse I supports the philosophy of primary nursing by
planning and coordinating nursing care for a group of patients within his/her
district. It is the CN Is responsibility to direct auxiliary personnel for full
implementation of the plan of care. The CN I supports the management of the
unit and uses resources persons and or materials when the need arises.
He/She has the satisfactorily mastered the basic skills requires to work on the
assigned unit. The CN Is scope of nursing practice is focused on his/her
assigned group of patients and does not extend into administrative aspects of
the unit at large.

CLINICAL NURSE IV (CN IV) INIT CLINICIAN
The CN IV is an advance clinical nurse who supports the practice of
primary nursing on the unit, as well as hospital-wide. He/She is recognized
within the specific area, as well as throughout the hospital, as being proficient
in the delivery of complicated nursing care. The CN IV has mastered the many
facets of nursing care required at the CN II and CN III levels. This qualification
is validated through the acquisition of national certification in the appropriate
specialty area.
The CN IV coordinates and directs emergency situations, seeks out
learning opportunities for the unit staff and serves as a resource for all aspects
of nursing care delivery.

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The CN IV collaborates closely with physicians on the unit for the
implementation of the plan of care.
This may be facilitated through assessing special equipment needs, as
well as planning multidisciplinary programs.
The CN IV works closely with the nurse manager in planning unit goals
and objectives and unit specific orientation programs, as well as assisting with
the staff performance evaluations.
The CN IV acts a liaison between his/her unit and the Department of
Nursing Education and Patient Education.

Figure 7: STRATEGIES FOR MAXIMIZING ACCOUNTABILITY

The success of a strategy to maximize accountability is dependent on the intent
and the roughness with which it is used as well as the involvement of people at
all levels.
Some approaches are suggested below:
Hold an open presentation and discussion of the nurse managers
requirements for successful goal accomplishment at any given point in
time including a review of external forces and internal problems shown
by past performance.
Discuss a broad analysis of changes in performance required to meet the
demands of reality.
Conduct an analysis of how everyone in the department can contribute
best to the organization effort-carried out face-to-face at all levels.
Request statements from each patient unit of the goals and standards to
which it commits itself. This includes an analysis of the help the unit
feels is needed to accomplish its goals, such as information feedback,
staff resources, policy or procedure changes, and equipment and staffing
needs.


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Answer the following and submit your typewritten answers/reactions to your
professor
1. Observe a health care organization. Make an analysis of it in terms of
a) Structure
b) Organizational schema
c) Strengths and weaknesses
d) Presence/absence of informal organizations
2. Write your own job description based on your present responsibilities
and tasks. Compare it with the official job description for the position
you are now occupying. If there is no development one, based on what
you think it should be for the position. Use the suggested format.
3. Describe the processes involved in job evaluation. Compare these with
how job evaluation is done in you institution.
4. Describe the steps in team building. Compare with how team building is
fostered in your place of work.

LEARNING ACTIVITIES

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MODULE FOUR




At the end of the module four, you will be able to:
1. Name and describe the six basic nursing models for providing patient
care
2. Discuss the advantages of case method over the functional method of
assignment
3. Differentiate between modular and district nursing
4. Described four staffing patterns
5. Calculate staffing needs, taking into consideration vacation, holiday, and
absentee coverage per year
6. Name four factors that determine staffing and scheduling decisions
7. Identify activities related to recruitment and selection of personnel
8. Make an orientation schedule
9. Discuss some strategies to minimize absenteeism
10. Describe the functions of the staff development department








ORGANIZING PATIENT CARE
SPECIFIC OBJECTIVES

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Models for Organizing the Delivery of nursing care. According to Tappen
(1996) there are six models for delivering nursing care: these are:
a) Case method
b) Functional method
c) Team
d) Primary
e) Care management, and
f) Patient focused care

The case method is the assignment of one nurse to the total care of one
or more patient clients. The assigned nurse is responsible for providing all the
nursing care that is needed. Private duty nurse uses the case method. The
advantages of using the case method are:

a) The care given is comprehensive, continuous and usually holistic,
b) It is simple and direct in comparison with other methods,
c) It does not require the complex assignment planning that some other
methods do
d) And it has clear lines of responsibility.
The one big advantage is that it is much more costly because it uses
highly skilled higher paid professionals (the registered nurses) to do work that
can be done by less skilled lower paid employee (nursing assistant).
The functional method of delivering nursing care is based on a division of
labor similar an assembly line. Each individual nurse and nursing assistant is
assigned to do specific task rather than being assigned to certain patients or
clients. Tasks are given to the lowest-skilled and lowest-paid worker who is
able to do work. One nurse is assigned to be in charge, another administers all
medications, a nursing assistant takes vital signs. The major advantage of the
functional method is its efficiency. Other advantages are:
a) The method makes it possible to use lesser skilled personnel to get
the work done;
b) Because care givers do the same task on a regular basis, they get
used to it and can get the work done better and faster;
c) It is easy to give clearly defined assignments;
PATIENT CARE DELIVERY SYSTEMS

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d) There is very little overlap of assignments and confusing about job
assignments;
e) It is more economical because it minimizes time for coordinating staff
members.
Among its disadvantages are:
a) Although it is considered efficient, it may not be effective from the point
of view of establishing a trusting relationship between the nurse and the
patient. When three or four different people enter a patients room (one to
give medications, another to take vital signs, another to give a bed bath,
still another to check a dressing, and so on), the patient may not even
remember everyones name, much more know who his nurse really is.
b) There is fragmentation of care. The functional method is impersonal and
emphasizes the more technical aspects as of nursing care. The nurse
may not have the satisfaction of having accomplished something.
c) For the staff, the work may be repetitious and boring. Doing the same
disconnected tasks prevents them from the feeling of having completed
something.
d) When communication between staff members is minimal it may happen
that no one is really aware of everything that is happening to the patient.
Team Nursing is the delivery of nursing care by a designated group of staff
members including both professional nurses and ancillary staff. In team
nursing these guidelines are followed:
The team leader has the authority to make assignments for team
members and she guides the work of the team. The team leader
should be a registered nurse and not an ancillary worker.
The leader is expected to use a democratic or participative style in
interactions with team members.
The team is responsible for the total care given to an assigned group
of patients.
Communication among team members is basic to its success. Written
patient care assignments, nursing care plans, reports to and from the
team leader, team conferences in which patient care problems and
team concerns are discussed, and frequent informal feedback among
team members are important ways of communicating.



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The advantages of team nursing are:
a) This method of assignment is less fragmented than the functional
method because of increased communication among its members.
b) It allows comprehensive and holistic nursing care.
c) It helps solve staffing problem at the same that it delivers quality care,
by using a large proportion of ancillary worker.
d) In comparison with the functional method, it is far more satisfying to
both the patients and the staff.
e) The abilities of each staff are more likely to be recognized and fully
used.
f) The increase amount of communication and cooperation among team
members can raise morale, improve functioning of the staff as a
whole, and give team members are greater sense of having
contributed to the outcomes of the care given.
g) Nurses working on teams find that they know their patients and
fellow staff workers better than when using the functional method.

The disadvantages of team nursing are:
a) It requires a great deal of cooperation and communication from all
staff members. It demands a lot more from the team leader who
spends most of her time coordinating and supervising team members.
b) The leader must be skilled both as a leader and as a practitioner. Not
every nurse is prepared to assume the role.
c) Some efficiency is lost because of the demands for increased
interaction among staff members.
Primary nursing. Under primary nursing, every patient has a designated
primary nurse who is responsible for planning the care and ensuring that the
plan is implemented around the clock, seven days a week. When the primary
nurse is not at work, the implementation of care planis designated to an
associate nurse. The primary nurse is still responsible and in some institutions
may be called on when a problem arises. When primary nursing is
implemented, the impatient unit is usually divided into districts or small
modular units with the primary nurse assigned to each district. Nursing
assistants are assigned to provide personal care for patients, assist the primary
nurse with patients with complex care needs, keep water pitchers filled, answer
call lights, and convey messages to the primary nurse about patient needs. The
primary nurse does all initial assessments and then develops care plans for

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assigned patients. They provide complex treatment, coordinate the nursing
care plan with other disciplines, administer medications, plan for patients
discharge, provide patient education, and evaluate interventions.
Advantages of primary nursing:
a) Nurses have more autonomy than in the functional or team
approaches and are challenged to work to their full capacity.
b) They spend less time in coordinating and supervising activities
and more time in direct care.
c) The primary nurse is more accountable because responsibility
is focused rather than diffused.
d) Nurses gain more satisfaction from being involved in the entire
care of a patient and from being able to give more holistic care.
e) Patients appreciate the more personalized and holistic care they
receive. They are especially please to say, This is mu Nurse
f) People from other disciplines also appreciate that they can
consult with one particular identifiable nurse who knows all
about the patient.
Disadvantages of primary nursing:
a) Primary nursing demands more independence, accountability
and the ability to make thorough assessments and plan nursing
care accordingly. Note every nurse is prepared for this.
b) Primary nursing does not clearly define the roles of the ancillary
personnel as compared to team nursing which specifies who
does what.
Nursing care management. First of all, nursing care management should
not be confused with the teams manage care and case management.
managed care is an approach to providing a range of services in such a way
that use of services and resulting cost are carefully controlled, that is, well
managed. Health maintenance organizations and preferred provider
organizations are examples of manage care system. Therefore, managed care is
not a method for organizing patient care. Case management, on the other
hand, is a process most often used in community nursing that include
engaging the client, setting goals, accessing services, coordinating these
services and finally disengaging. This is a process whose focus is coordination
of services for the individual and his/her family. This is used by both nurses
and social workers. Nursing care managementused in the hospitals is a
combination of primary nursing and case management. In nursing care

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management, the primary care nurse assumes responsibility for both the
clinical and economic outcomes of a patients stay in the hospital. Thus, nurses
provide both direct care and case management services to assigned patients
and their families. A key feature of nursing care management is that care is
organized around the patient, not around the geographic unit on which the
patient has been placed or the particular medical team serving that patient.
Another important feature is improved continuity and coordination of nursing
care cross traditional discipline. Patients progress toward recovery and
discharge is carefully monitored through the use of mechanisms such as
critical pathways. The critical pathway identities the intermediate goals that
must be achieved within a certain length of time in order to continue progress
toward the ultimate goal of recovery and discharge within the time allotted by
the diagnostic-related group (DRG) or other reimbursement system. For
example, a patient admitted with diabetic ketoacidosis may be expected to
achieve control of blood glucose levels by second day, learn self-care techniques
by the third day, and be discharged by the fifth day (Tappen, 1996)
The advantages of nursing care management can be summarized as
follows: the holistic orientation of nursing care management yields an
enormous amount of satisfaction for both nurse and the patient. Not only can
the nurse follows patient progress from admission to discharge and even
beyond, but the nurse can also influence overall course of treatment far more
than in the other models. The patient can identify with a particular nurse as in
primary care and has someone to turn to who understands all facets of his/her
care. There is also better coordination and better access to needed services in
nursing care management. With administrative support, cooperation from
other disciplines, the nursing care management model has been found to be
highly successful both in terms of staff and patient satisfaction and in cost
effectiveness. Although nursing care management makes greater demands on
the individual nurse, it offers the opportunity for greater professional rewards
as well.
With all its advantages, the use of nursing care management may be
difficult for some nurse. This is an innovation that calls for an extended role for
the nurse. Some nurses may not be prepared to assume the responsibilities
that accompany the new role. They may be uncomfortable with the autonomy
and direct decision making responsibility in the nursing care management
model. There also have been some setbacks in its implementation as when
decisions recent being called for consultation by nurses rather than fellow

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physicians. Resistance also comes from financial officers who anticipated that
the implementation of nursing care management requires added cost.
Patient-focused care brings as many services as possible to the patient
rather than bringing the patient to the services. Most direct care pair is
provided by a care, usually a nurse and a technician, who shares responsibility
for a given group of patients. Members of the care pair are cross-trained to
provide basic respiratory therapy, physical therapy, phlebotomy, and
electrocardiography (EGG) as well as the usual bedside nursing care. Strictly
speaking, patient-focused care is not a model for organizing nursing care
because it involves non-nursing staff.


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The major factors in determining staffing and scheduling decisions are:
a) the model of nursing care used; b) patient census c) the complexity of their
care c) patient acuity; d) staff mix; e) budget.
Patient Census. The number of patients on a unit is a major factor
affecting staffing decisions. A unit with 30 patients obviously needs more staff
than a unit with 15 patients. The fluctuation of patient census also affects
staffing as, for example, a surgical unit have more admissions and discharges
than an oncology unit. The census of any unit also varies from day to day and
from shift to shift. These variations may mean adequate staffing in one shift
and inadequate staffing in another shift, as when staffing is decided during the
morning shift when the census w and no staffing adjustment is made for the
evening shift when the census rises because of admissions.
Methods of determining staffing. Aside from the census, acuity and
complexity of patients needs affect staffing. Acuity and complexity of patients
needs are classified according to the number of hours of nursing care needed.
A basic question before staff can be appropriately assigned to care for a
particular group of patients is, what kind of care do they need? How many
require complete care because they cannot care for themselves? how many
need to be fed through a naso-gastric tube?, How many have a colostomy
bag? how many needs specific patient teaching, as teaching a diabetic patient
self-injection? are just a few of the specific questions to be answered to make a
decision about the number and mix of staff to be assigned. The diagnostic-
Related Groups (DRGs) system is another factor that is considered in staffing.
The system tells the hospital the number of days that will be reimbursed for a
particular medical diagnosis. It does not take into account what the patients
actual self-care deficits or nursing needs are. It does not consider patients
other problems and nursing needs. Some of the conditions descriptive of
patients nursing care needs and status that are considered in staffing are:
Feeds self with little or no assistance versus requires total
assistance.
Is emotionally stable versus subject to panic attacks;
Is ambulatory versus bedbound;
Is receiving oral medication versus intravenous medication;
Require special wound care or isolation;
STAFFING AND SCHEDULING

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Needs teaching of specific self-care functions;
It confused and disoriented;
Needs vital signs measured every 15 minute versus every 4
hours.
Patient Classification System. Different patients require different
amounts of patient care. Patient classification systems were developed
approximately 20 years ago to help the nurse manager determine what
appropriate staff levels were. Also, a valid and reliable patient acuity
classification instrument is a tool for determining the cost of nursing care.
The patient classification instruments being used today are generally
categorized into two: the prototype evaluation method and the factor evaluation
method. (Behner, 1990)
The prototype evaluation method determines nursing resource
requirements by assigning patients predetermined categories based on a
description of patient care needs. For examples, one patient could be described
as ambulatory and able to do all the activities of daily living independently. At
the other end is the patient who requires almost constant monitoring and total
assistance with the activities of daily living. The prototype method is simple
and the most commonly used system. A disadvantage of this method is the
probable variability between rates. Some rates may rate the patient level of
needs higher to make the units workload seem higher than it actually is.
The factor evaluation method identities pertinent patient care attributes
and assigns predetermined weighs or relative value units (RVUs) to them.
These weights are then summed to classify the patient into one of several
homogenous groups. Typically, the RVU has an arbitrarily set value of 6 or 10
minutes. This means that a patient who needs 60 RVUs would need 360
minutes of nursing care in a 24-hour period, depending on the given value of
RVU.
Staff Mix. Once the patients level of needs and the time required for
meeting these needs are known, a second factor that is considered is the mix of
staff members assigned to care to the patients: how many RNs, midwives (if
there are), nursing attendants have been assigned to work on that unit? Who is
the best prepared to take care of the particular needs of each patient? The rule
is that the unit with high acuity or complexity index, such as the critical units
should have a high proportion of RNs needed to plan and manage care.

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Staffing Systems. Better utilization of time, increasing efficiency,
flexibility of time are just some of the factors being considered in developing a
system for staffing patients units. Flex time, self-scheduling, specialization,
use of temporary personnel are systems used for staffing.
Flextime. This system assigns staff in a flexible manner. This may take
the form of 4-day weeks of 10-hour shifts or 3-day weeks of 12-hour shifts.
Many nurses are happy about this scheduling mechanism as it allows them to
have more consecutive days off. It is also advantageous for the hospital
because longer shifts make it possible to have more staff on duty during the
heavy-need hours of the day, early in the morning or at supper time. In health
care agencies, nurses adjust their hours of the day, early in the morning or at
super time. In health care agencies, nurses adjust their hours to suit the needs
of their patients, making it possible to provide a broader range of services.
Self-scheduling. This system offers the staff scheduling flexibility and
control over ones time. In some institution in the United States, the staff works
out their own schedules. Self-scheduling is as one factor that might help retain
experience staff members.
Specialization. Another way to increase efficiency of staff assignments is
to group patients with the same diagnosis or unique needs on the same unit.
When nurses are assigned to an especially unit, they develop a high level of
expertise in caring for patients with a particular problem. Neonatal intensive
care, burns unit, spinal cord injury unit, oncology unit, alcohol abuse
treatment units, are examples of these types of specialization. Because the staff
is taking care of patients with similar needs so consistently, they also become
more efficient in identifying the common needs those patients are likely to have
and in providing specific interventions to meet these needs. Many aspects of
care become routine and can be accomplished in less time than it would take
the nurse who is not accustomed to caring of these patients. This system is
seen as a good way to provide cost-efficient, quality care.
Temporary Personnel. Temporary staff may be hired for periods of
unexpectedly high demand for services. The temporary staff may be hired from
the hospitals temporary pool or obtained from a registry agency. The use of
temporary personnel is wide spread. The advantage of using staff is that it
allow a facility to respond efficiently to changing staffing needs resulting from
census fluctuations, increased acuity, or staff vacancies. The main advantage
is that there is no continuity of care for the patients. It is also though the
temporary employees lack the commitment to the organization.

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Recruitment and Selection. Having qualified employees is vital to the
establishment and maintenance of any organization. Therefore, it is important
to select the right persons for the job. The attraction of qualified applicants is
the first step in the selection of personnel. To attract qualified applicants
Human Resource department resorts to active recruitment. This includes
employee recommendations and word of mouth, advertisement in newspapers,
nursing organizations, bulletins, nursing journals; flyers and newsletters,
posters, career days, job fairs, contracts, placement services, nursing
conventions. Word of mouth can be very effective, but it can also lead to the
hiring of friends and relatives of the current work force, thus leading to
nepotism. The use of advertisements in professional journals, newspapers and
radio, employment agencies, and contracts with schools graduating classes
can offer a broader choice of qualified applicants. It is recommended that the
institution should have a nurse recruiter who know nursing qualifications well
as well as the need of the institution.
When applying the person should submit a biographical data. She fills
up an application form which should include personal history educational
background, work experience, and other pertinent information. The application
form is used to:
Determine whether the applicant meets minimum hiring requirements
such as minimum educational requirement
Furnish background data useful in the selection interview;
Obtain names of references who may be contacted for further
information;
Collect information for personnel administration, such as social security
number.
A letter of recommendation is often requested from references listed on the
application form, from previous employers or both. A pre-employment interview
to predict job success should be conducted with the most qualified applicants.
Information obtained from the application form and letters of reference should
be taken into consideration. The purposes of the interview are: a) to obtain
information b) to give information c) to determine if the applicant meets the
requirements for the position. The interviewer judges the applicants
dependability, willingness to assume responsibility for the job adaptability,
consistency of goals with available opportunities, willingness and ability to
SELECTION OF PERSONNEL

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work with others, interest in the job, and conformance of manners and
appearance to job requirements. The interviewer answers questions, explains
policies and procedures, and helps acquaint the applicant with the position.
The interviewer must be able to predict whether the applicants over-all
performance will be satisfactory. The value of the interview depends upon the
ability of the interviewer to evaluate the applicant and to predict her success.
The interviewer should be a good listener, should try to avoid premature
judgment, should avoid judgment based on appearance. She must have the
ability to answer applicants questions and to provide necessary information. It
is helpful to devise an interview form to more or less standardize the interview.
The use of the job description to define and specify job dimension increase
interviewers reliability.


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Orientation. After the applicants have been selected to fill in required
positions, they undergo orientation. The purpose of orientation is to prepare
the employee to function effectively in the position for which she is hired. The
goals of orientation are two-fold:
1) To enable the newly hired individual to be rapidly assimilated into the
nursing care system and
2) To ensure that the newcomer is a safe practitioner before allowing her
a measure of self-direction in carrying out her assigned role.
There is considerable variation between nursing organizations with
regard to length, form, and content of the orientation program. Content for
each employees orientation should be determined by her job description and
by a personal skills inventory that she is asked to complete. Usually it is four
weeks for nurses assigned to the general wards, while three to four months
may be needed for the operating room and the intensive care units. Orientation
may be centralized to be done by in-service instructors and decentralized to be
done by unit instructor or nurse clinician; it may be individualized, or
standardized for all personnel regardless of preparation and experience. The
new employee should be given an orientation manual which contains
information about personnel policies, time scheduling policies, schedule of pay
days, vacation, holiday, sick time allowances, disciplinary and grievance
procedures; food service, infirmary hours, counseling opportunities,
educational benefits, committee functions, pension plan, insurance coverage,
social activities, information about the existence of labor contracts (if
applicable) and the name and telephone number of labor representative (if
applicable).
The planned program of orientation typically starts with orientation to
the institutions physical and social environment. This includes:
a) Tour of the facilities
b) A description of the organizational structure
c) A discussion of different departmental functions
d) A presentation of the philosophy, goals, and standards
e) An interpretation of administrative policies and procedures and
possibly an explanation of hospital relationships with the community
(Tomey, 1992)
ORIENTATION AND STAFF
DEVELOPMENT

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This first aspect of the orientation is what Gillies (1994) term the
induction or general indoctrination. During the orientation to the physical
facilities, fire extinguishers and fire escapes should be shown, and hospital
policies and procedures regarding Fire and Safety, Disaster Plan, Infection
Control, Occupation Hazards, Risk Management should be explained.
Next, the newly hired nurse is oriented to the nursing service, including
interdepartmental relationships, departmental organization, administrative
controls, philosophy, goals, policies, procedures, and job descriptions.
The new nurse will need a tour of the unit of assignment to know the
location of supplies, equipment, policy and procedure books. Information about
how the unit is run, specific practices, communication systems are important.
Introductions to other personnel help the new employee feel welcome.
The next step, which is the job orientation phase, is to orient the new
nurses to their specific jobs. Usually, they are assigned to other nurses. In
some institutions, a buddy system is used to orient the new employee to her
job. That is, the newly hired nurse is paired with an experienced nurse in the
same unit. The content of the orientation program may be planned in each
nursing unit, section, or division by nurses already practicing in that specially.














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Exhibit 1
ORIENTEES EVALUATION OF ORIENTATION PROGRAM

(To be completed after four weeks on permanent unit)
Instructions: Please answer the following questions. If you mark sometimes please explain on the back of this page.

Yes No Sometimes
I found that my questions were readily
answered by personnel.
I found the orientation time moving too slowly.
The inservice coordinator assisted me in my
adjustment to the unit
I was give enough time and explanations to
learn routines before starting evenings or
nights.
The head nurse participated in my
orientation.
I feel that I am part of the team.
My introduction and supervision of the
medication system were satisfactory.
I found the progression of team member, team
leader, and introduction to charge
responsibilities helpful to my growth on the
unit.
I feel comfortable with most of the nursing
procedures performed on my unit.
I was made to fell welcome at the hospital.
My team leading experience here at the
hospital was beneficial.
More follow up by the inservice coordinator
should have been carried out.
I feel that I needed additional time for the
head nurse to explain and demonstrate
problem-solving techniques.
I found it difficult to move from the orientation
unit to my permanently assigned patient care
area.


__________
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__________


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__________
Who appeared to be your best source for the questions you had?
______________________________________________________________________________
Discuss briefly any suggestions or comments you may have regarding your
orientation time.
______________________________________________________________________________
______________________________________________________________________________


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Topics
Instructor
Date/Initial
Clinician
Date/Initial
Employee
Date/Initial
POLICIES/PROCEDURES
Admissions
Transfer
Discharges
Surgery (preoperative and
postoperative care)

Death
Intake/output
Isolation/infection control
Transcribing physician orders
Blood transfusions
IV therapy
Medication administration
Narcotic control
Fire procedure
Evacuation/disasters
Code blue procedures
Nursing care plans
Suctioning
Oxygen administration
Operative site/stomadhesive
Feeding tubes
Electrical safety

Progress Notes:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________


Instructor: ______________ Clinician: _____________ Employee: ________________




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Exhibit 2
ORIENTEES INSERVICE/CONFERENCE EVALUATION FORM


Name of Session ___________________________________ Date _________________
Instructor _______________________________Name (optional)__________________
Rate the effectiveness of this presentation (place a check in the appropriate
box):

Excellent
1

2

3

4
Poor
5
Comments
Instructors organization of
subject material

Instructors knowledge of
subject

Presentation of material
Teaching methods
Instructors responsiveness to
group




What parts of the class were especially helpful to you?
____________________________________________________________________________
__________________________________________________________________________

What information provided can you apply to your role/job?
___________________________________________________________________________

What suggestions do you have for improvement?
____________________________________________________________________________
__________________________________________________________________________

I actively participated in the class (i.e, listened, asked questions, participated in discussions)
(Please put a check on the appropriate line).


______________Agree _____________Neutral _____________Disagree

Courtesy of Rochester Methodist, Rochester, Minnesota.



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Exhibit 3
DOCUMENTATION FORM C-UNIT ORIENTATION EVALUATION

Name ______________________________________________ Unit ___________________

RN ______________ LPN _____________ Other __________ Key: AA -Above Average
A-Average
BA-Below Average

Has competed ________________________ weeks of orientation and skill training.

Objectives AA A BA Comments
Understanding and Utilization of Concepts of Patient
Care

Provide comfort measure to patients.
Recognizes and assesses condition of patient through
vital signs, observation, and patient communication

Communicates significant data to head nurse.
Initiates and revises nursing care plan from admission
to discharge.

Understands and practices priorities of patient care.
Understands and explain to patients significance of
therapeutics, diets, medications, therapy, tests,
treatments, etc.

Takes initiative in patient teaching-including the family.
Provides emotional support to patient and family.
Charts concisely and effectively.
Understands physicians orders.
Effective Leadership and Unit Management
Is understanding and considerate of coworkers.
Uses judgment and diplomacy in interpersonal
relations.

Is able to assess significant changes in patient
condition and communicate to the oncoming shift.

Is able to delegate responsibility to various levels of
personnel so as to meet the total needs of the unit.

Functions effectively as primary nurse.
Demonstrate judgment in everyday nursing situations
and decision making.

Functions in Stress Situations
Functions effectively during emergency situation.
Effectively provides leadership and direction during
emergency situation.

Is able to cope with and provide support in the distress
of a patient or family.

Uses good judgment in calling for help when necessary.
Keeps supervisory personnel aware of changes in
condition and pertinent problems.



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Item Date Done Initial
Location of medication rooms ____________ ____________
Time sheet location ____________ ____________
Patients room ____________ ____________
Use of call bells ____________ ____________
Operation of bed ____________ ____________
Operation of TV ____________ ____________
Location and use of oxygen outlets, suction ____________ ____________
Operation of side rails ____________ ____________
Routines ____________ ____________
Listen to taped reports ____________ ____________
Tape reports ____________ ____________
A.M. care ____________ ____________
P.M. care ____________ ____________
Vital signs, T, P, R, BP, charting vital signs ____________ ____________
Intake and output, charting ____________ ____________
Meal hours for patients ____________ ____________
Visiting hours ____________ ____________
Lunch assignment, breaks ____________ ____________
Admission of patient ____________ ____________
Discharge of patient ____________ ____________
Patient transfer ____________ ____________
Unit conferences ____________ ____________
Staff development calendar ____________ ____________
Inservice classes ____________ ____________
Nursing Care Plans ____________ ____________
Complete a nursing history ____________ ____________
Initiate a nursing care plan ____________ ____________
Revise nursing care plan ____________ ____________
Initiate a patient teaching plan ____________ ____________
Assist with discharge planning ____________ ____________
Medications ____________ ____________
Check medications against Kardex ____________ ____________
Administer regular medications ____________ ____________
Administer PRN medications ____________ ____________
Chart medications ____________ ____________
Order STAT medications ____________ ____________
Order charge floor stock ____________ ____________
Order noncharge floor stock ____________ ____________
Count controlled drugs ____________ ____________
IVs ____________ ____________
Check Ivs ____________ ____________
Maintain KVO ____________ ____________
Regulate ordered drop rate ____________ ____________
Change IV tubing ____________ ____________
Change IV dressing ____________ ____________
Administer drip IV medications ____________ ____________
Charting IVs ____________ ____________
Transcription ____________ ____________
Transcribe physician orders ____________ ____________

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Exhibit 4
CHECKLIST-DOCUMENTATION OF NONCLINICAL TOPICS COVERED
DURING RN ORIENTATION

Employee ___________________________ Orientation Start Date _______________

Topics Instructor
Date/Initials
Clinician
Date/Initials
Employee
Date/Initials
GENERAL INFORMATION
Hospital philosophy

Organization structure
Benefits
Job description
Badge in/badge out
Exception reports
Sick calls
Employee policies
Professional liability
NURSING UNIT
Physical layout

Location of
equipment/supplies

Methods of assignment
Time schedules
Special requests
Shift change reporting
system

Charting guidelines
Kardex
Discharge planning
Pneumatic tube system
Evaluations
PATIENT CARE REPORTS
Patient charts

Notification forms
Medication error reports
Responsibility releases
Patient census/condition
reports

Discharge sheet
Decubitus care form
Code blue report forms
Surgery consent forms
Preoperative checklists

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Exhibit 5
ORIENTATION DOCUMENTATION PACKET

DOCUMENTATION FORM A-SELF-ASSESSMENT FOR ORIENTING NURSES

Name ___________________________________________________ Unit _______________

Circle one of the following responses for each item below:

1 Have never done have no knowledge 3 Little experience- need review
2 Have never done understand theory 4 Competent can function independently
PREORIENTATION POSTORIENTATION
Admission
1 2 3 4 Complete a patient assessment 1 2 3 4
1 2 3 4 Initiate the nursing care plan 1 2 3 4
1 2 3 4 Orient the patient to use of call bell, TV,
operation of bed, bathroom
1 2 3 4
Bed Scales
1 2 3 4 Operation 1 2 3 4
Blood and Blood Components
1 2 3 4 Use of blood tubing 1 2 3 4
1 2 3 4 Procedure for obtaining blood 1 2 3 4
1 2 3 4 Proper administration of blood 1 2 3 4
Catheter Care
1 2 3 4 Insertion of indwelling catheter 1 2 3 4
1 2 3 4 Straight catheterization 1 2 3 4
1 2 3 4 Continuous irrigation 1 2 3 4
1 2 3 4 Meatal care 1 2 3 4
Cardiopulmonary Resuscitation
1 2 3 4 Able to diagnose and initiate CPR 1 2 3 4
1 2 3 4 Certified on BLS Category C 1 2 3 4
1 2 3 4 Know location of emergency drugs 1 2 3 4
1 2 3 4 Use of prefilled jet syringes 1 2 3 4
1 2 3 4 Knowledge of emergency drugs 1 2 3 4
1 2 3 4 Preparation of arterial blood gas set 1 2 3 4
1 2 3 4 Use of defibrillator 1 2 3 4
1 2 3 4 Use of external pacemaker 1 2 3 4
Central Service
1 2 3 4 How to obtain equipment 1 2 3 4
1 2 3 4 How to charge correctly 1 2 3 4
1 2 3 4 How to return supplies 1 2 3 4
1 2 3 4 How to credit supplies 1 2 3 4
Colostomy
1 2 3 4 Care if appliance 1 2 3 4
1 2 3 4 Irrigation 1 2 3 4
1 2 3 4 Dressings 1 2 3 4
1 2 3 4 Role of enterostomal RN 1 2 3 4
Discharge/Transfer
1 2 3 4 Understand discharge procedure 1 2 3 4
1 2 3 4 Initiate a discharge plan for patient 1 2 3 4
1 2 3 4 Transfer a patient to another unit 1 2 3 4
1 2 3 4 Admit a transferred patient 1 2 3 4
Diagnostic Procedures

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1 2 3 4 Prepare patient for chest x-ray 1 2 3 4
1 2 3 4 Prepare patient for IVP 1 2 3 4
1 2 3 4 Prepare patient for barium enema 1 2 3 4
1 2 3 4 Prepare patient for GI series 1 2 3 4
1 2 3 4 Prepare patient for scans, liver, bone, lung 1 2 3 4
1 2 3 4 Prepare patient for brain, CT scan 1 2 3 4
1 2 3 4 Prepare patient for cardiac catheterization 1 2 3 4
Death
1 2 3 4 Care of body after death 1 2 3 4
Elimination
1 2 3 4 Enemas-SS/Fleet/oil 1 2 3 4
1 2 3 4 Gastric Intubation 1 2 3 4
1 2 3 4 Insertion of NG tube (Salem sump, enteral
feeding)
1 2 3 4
1 2 3 4 Knowledge of tube feedings 1 2 3 4
1 2 3 4 Constant suction 1 2 3 4
1 2 3 4 Intermittent suction 1 2 3 4
1 2 3 4 Irrigation of tube 1 2 3 4
Surgical Drains
1 2 3 4 Knowledge of general care (Jackson-Pratt,
Hemovac)
1 2 3 4
Intravenous Therapy
1 2 3 4 Insertion of IV 1 2 3 4
1 2 3 4 Knowledge in use of IV bag 1 2 3 4
1 2 3 4 Care of IV site 1 2 3 4
1 2 3 4 Policy for changing IV tubing 1 2 3 4
1 2 3 4 Labeling IV tubing 1 2 3 4
1 2 3 4 Regulation of flow, including KVO 1 2 3 4
1 2 3 4 Discontinue IV infusion 1 2 3 4
1 2 3 4 Use of heparin lock 1 2 3 4
1 2 3 4 Use of multiple lumen subclavian catheters 1 2 3 4
1 2 3 4 Use of mediport 1 2 3 4
1 2 3 4 Use of Hickman and Groshong catheters 1 2 3 4
Intake and Output
1 2 3 4 Accurate recording 1 2 3 4
Isolation
1 2 3 4 Obtain equipment for isolation room 1 2 3 4
1 2 3 4 Care of patient 1 2 3 4
1 2 3 4 Discontinue isolation precautions 1 2 3 4
K Pad
1 2 3 4 Use of 1 2 3 4
Medications
1 2 3 4 Understand unit dose system 1 2 3 4
1 2 3 4 Understand safe and effective preparation and
administration of the following medications:
1 2 3 4
1 2 3 4 Oral 1 2 3 4
1 2 3 4 IM 1 2 3 4
1 2 3 4 Subcutaneous 1 2 3 4
1 2 3 4 Rectal 1 2 3 4
1 2 3 4 IV push 1 2 3 4
1 2 3 4 IV continuous 1 2 3 4
1 2 3 4 Understand importance of accurate charting of
the following:
1 2 3 4
1 2 3 4 Continuous medications 1 2 3 4
1 2 3 4 PRN 1 2 3 4

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1 2 3 4 Single dose 1 2 3 4
1 2 3 4 Preoperative 1 2 3 4
Nursing Care Plan
1 2 3 4 Keep an up-to-date nursing care plan on each
patient
1 2 3 4
1 2 3 4 Write problems, expected outcomes,
deadlines, and nursing orders
1 2 3 4
1 2 3 4 Indicate patient problems on care plan 1 2 3 4
1 2 3 4 Understand use of standard care plans 1 2 3 4
Preoperative Care
1 2 3 4 Preoperative teaching 1 2 3 4
1 2 3 4 Prepare patient for operating room 1 2 3 4
Postoperative Care
1 2 3 4 Evaluate patient 1 2 3 4
1 2 3 4 Chart requirements 1 2 3 4
1 2 3 4 Care of surgical dressings 1 2 3 4
1 2 3 4 Care of surgical tubes 1 2 3 4
Primary Nursing
1 2 3 4 Understand 8-hour concept 1 2 3 4
1 2 3 4 Understand responsibility and accountability
of primary nurse
1 2 3 4
1 2 3 4 Function as primary nurse 1 2 3 4
Care of Patient with Respiratory Problems
1 2 3 4 Oxygen administration 1 2 3 4
1 2 3 4 Set up oxygen wall/portable 1 2 3 4
1 2 3 4 Use nasal cannula 1 2 3 4
1 2 3 4 Use chest tube drainage system 1 2 3 4
1 2 3 4 Use oxygen mask 1 2 3 4
1 2 3 4 Artificial airway 1 2 3 4
1 2 3 4 Oral airway 1 2 3 4
1 2 3 4 Tracheostomy 1 2 3 4
1 2 3 4 Suctioning 1 2 3 4
1 2 3 4 Oral-pharyngeal 1 2 3 4
1 2 3 4 Nasotracheal 1 2 3 4
Restraints
1 2 3 4 Use side rail 1 2 3 4
1 2 3 4 Use jacket 1 2 3 4
1 2 3 4 Use arm 1 2 3 4
1 2 3 4 Use leg 1 2 3 4
Skin Care
1 2 3 4 Recognize high-risk patient 1 2 3 4
1 2 3 4 Initiate treatment for the stages 1 2 3 4
1 2 3 4 Initiate reporting system 1 2 3 4
Specimens
1 2 3 4 Understand procedures for specimen
collection
1 2 3 4
1 2 3 4 Admission urine 1 2 3 4
1 2 3 4 Clean-catch urine 1 2 3 4
1 2 3 4 Catheterized urine 1 2 3 4
1 2 3 4 24-hour urine 1 2 3 4
1 2 3 4 Fractional urine 1 2 3 4
1 2 3 4 Stool specimen 1 2 3 4
1 2 3 4 Cultures 1 2 3 4
1 2 3 4 Use of blood glucose monitoring device 1 2 3 4
Suctions

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1 2 3 4 Suctioning technique 1 2 3 4
1 2 3 4 Nasopharyngeal suctioning 1 2 3 4
1 2 3 4 Tracheostomy suctioning 1 2 3 4
1 2 3 4 Care of tracheostomy 1 2 3 4
Transcription of Physicians Order
1 2 3 4 Understand responsibility of unit secretary 1 2 3 4
1 2 3 4 Accurately check orders 1 2 3 4
1 2 3 4 Verbal orders 1 2 3 4
1 2 3 4 Telephone orders 1 2 3 4
1 2 3 4 Accurately transcribe via computer 1 2 3 4
Vital Signs
1 2 3 4 Use of electronic thermometer 1 2 3 4
1 2 3 4 BP monitoring 1 2 3 4
1 2 3 4 Apical pulse 1 2 3 4

Please review this skills checklist with your proctor and head nurse before
completing your orientation. It will be placed in your personnel life.

Exhibit 6
DOCUMENTATION FORM B- UNIT ORIENTATION CHECKLIST

Name ________________________________________ Date ________________________

Supervised by: _____________________________________________________________

Item Date Done Initial
Time Clock-Time Cards (Location) _____________ _____________
Introduce to Staff Members _____________ _____________
Unit Floor Layout _____________ _____________
Patient room numbers _____________ _____________
Patient bed numbers _____________ _____________
Location of waiting rooms _____________ _____________
Location of conference rooms _____________ _____________
Location of fire alarm and extinguisher _____________ _____________
Medication carts _____________ _____________
Linen closets-time and distribution _____________ _____________
Utility rooms-use of trayveyor _____________ _____________
Examining rooms _____________ _____________
Exchange carts-charge system _____________ _____________
Location of crash carts _____________ _____________
Location of defibrillator _____________ _____________
Desk area _____________ _____________
Physicians charting area _____________ _____________
Telephones _____________ _____________
Intercom system _____________ _____________
Addressograph _____________ _____________
Computer _____________ _____________
Charts _____________ _____________
Charting supplies _____________ _____________
IV trays _____________ _____________
Manuals _____________ _____________

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Towards the end of probationary period, there should be a systematic
evaluation usually by the head nurse and the head manager.

Providing a thorough, comprehensive as well as pleasant orientation
experience for new employees cannot be over-emphasized.

Staff Development. Staff development includes all training and
education undertaken by an employer to improve the occupational and
personal knowledge, skills, and attitude of employees (Tomey, 1992). The types
of staff development programs are:
a) Induction training
b) Orientation program
c) In service education
d) Continuing education
e) Management training
f) Organization development Education

Staff development is closely related to retention, pay raises, advancement
to other positions, and even disciplinary actions as when a staff member does
not comply with the attendance to mandate the courses such as Basic Life
Support and Advanced Life Support for ICU nurses, or when a staff nurse
shows no sign of improvement in performing certain nursing procedure in spite
of staff development efforts to train her.

Usually the Staff Development Department is headed by a nurse
executive who is a member of upper management. Under her are staff
development instructors. The staff development instructor is a nurse who holds
a Masters degree in Nursing and who has achieved a high level of nursing
knowledge skills as well as ability to use both direct and indirect methods of
teaching. Her personal attributes qualify her as a role model for staff.

The staff development department has for its main functions:

a) Planning of educational program and resources
b) Induction and orientation training
c) In-service education, and
d) Continuing education
Educational supplies, equipment, expertise, financial report are
administered by this department. This department also makes available to the

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staff opportunities for professional growth through the continuing education
programs offered by in-house educators and specialists, professional nursing
organization, pooled resources from consortia of hospitals, affiliated
educational.

A body of educational concepts and principles underlies successful staff
development programs. Gillies (1994) stated these as follows:
1. The ultimate responsibility of professional growth rests on the
individual nurse herself. Therefore, inputs from individual employees
to the content of any staff development program should be solicited
and encouraged.
2. Employees learned best when cast into situation that encouraged self-
discovery of significant truths. This is because learning is a
combination experience and conceptualization
3. Since learning is an internal, personal, and an emotional process,
methods and techniques that involve the individual on a deeply
personal level produce the most significant learning
4. Old ideas, inclinations, habits must be changed before new thoughts,
pastimes, actions, and attitudes can be wholeheartedly undertaken.
5. Generally speaking, teaching is an authoritarian manner to adult
learners may not be effective because adult learners demand
considerable autonomy is seeking, regulating, and utilizing learning
experiences.
6. Adults learn best when what they are learning is needed for
immediate application. Therefore, a problem solving format is
especially well suited for nursing staff development.
7. Behavior that is positively rewarded has greater likelihood of being
repeated, therefore, learners need positive reinforcements when they
display the target behavior for which the training is undertaken.
8. Each aspect of a learning situation should be designed to complement
and supplement every other aspect, so that all education elements fit
together smoothly in supporting desired outcome objectives. This is
because human psychology is such that an individual always tends to
organize an entire learning situation into an integrated, simple ang
stable phenomenon.
9. Transfer of learning is maximized when training occurs in life
situations that closely resemble those in which the learned behavior is
later to be applied. Therefore, illustrative examples, descriptive case
studies, and educational projects should all be representative of the
work problems that the employee will be expected to resolve after
training.
10. Transfer of learning can be maximized by conditioning the
organization to support changes in the workers behavior that have
been affected by staff development activities. When performance
changes are sought, several employees should be educated

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simultaneously in the desired knowledge, skills and attitudes and
supervisors, peers, and subordinates, of these trainees should be
taught to accept and reward target behavior in the work situation.
11. Learning is an active process, therefore, assigning a trainee to
carry out a particular function according to prescribed guideline
under supervision results in more learning than simply enabling her
to observe performance of the task by a skilled individual.
12. Adults are self-directed and have a huge reservation of life
experiences upon which to draw in applying new knowledge and skill.
In order to design problem solving situations to enable the adult
learner to satisfy highly learning needs, the educator must have
considerable familiarity with the learners life circumstances and
previous occupational and educational experiences.
13. Adult learners are heterogeneous group, differing widely in life
experiences motivational level, cognitive style, learning speed,
therefore, staff development activities should employ a variety of
source materials, teaching methods, and audiovisual aides so as to
satisfy the individual learning needs of as many students as possible.

The head nurse plays a vital role in supporting staff development
programs. She has responsibility to determine the staff development needs of
her personnel. She should review the goals of staff development programs and
provides a budget for the activities entailed (Tomey, 1992). She should also
plan employee coverage to allow her staff to attend seminars, conferences, and
to renew BLS certification and other certifications. Positive reinforcement
through recognition, such as oral praise in the unit, acknowledge od
accomplishments through the institutions newsletter, encouraging staff to
echo information and knowledge learned in staff meetings useful in
encouraging attendance to staff development activities.

Teaching Methods.The teaching methods used in staff development
sessions should stimulate the student to want to learn the course content or to
participate actively with the experiential learning. The methods used should
suit the objectives of the particular course. The lecture method is effective
when acquisition of new knowledge is desired. The discussion method is
preferred when problem-solving skills and attitudinal changes are sought. The
use of films method is effective in ensuring transfer of new learning to the
students clinical environment. Case studies are useful in developing critical
thinking and problem solving techniques. Role playing and simulation enable
the learner to experiment with various approaches to a problem without
incurring the risk of failure.

A method that is showing successful result is the trainer-coach approach
(Gillies, 1994). The coaching approach starts with an individual who has
already demonstrated potential for successful performance and who desires to

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become a more expert practitioner. In a coaching relationship, the trainees
abilities and her potential for improvement are given more focus and
importance, unlike in a traditional method of teaching where the teacher plays
the dominant role.

Role modeling. Role modeling enables a student to learn a whole complex
of skills in a real life situation by vicariously experiencing the payoff for
effective nursing interventions. For role modeling to work the student must be
a novice in the activity under study and the teacher must be able to
demonstrate a superior level of knowledge and skills. (Gillies, 1994).direct role
modeling occurs when a clinical specialist or nurse clinician allows a staff
nurse to observe her carrying out a highly skilled or complex nursing activity
and to ask question about the purpose, method, and result of that
intervention. Indirect role modeling is often preferred when patient privacy
must be protected or when the instructors presence in the case situation
would jeopardize the patients relationship with her primary care giver, who
also happens to be the trainee.

Preceptorship is a teaching method used by some institutions to help
recruit, orient, retain, and develop staff. To recruit new graduates, the
institution may offer a preceptorship program for senior students to orient
them to the institution. The preceptorship program also gives the institutopm
the opportunity to evaluate and determine if a student is someone they would
like to hire.

Preceptorship is often used by staff development department after
graduates has been hired. The staff development faculty may present the
formal content in orientation is someone they would like to hire.

Mentoring is another method used in staff development. Mentors give
their time, energy and material support to teach, guide, assist, counsel, and
inspire a younger nurse. The mentor is a role model, a resource person who
supports the development of the young person through influence and
promotion. The mentor acquaints the mentee, usually a younger person, with
the values, customs, resource, of the profession.
The phases of the monitoring process are:

At first during the invitational stage, a mentor must be willing to
use her time and energy to nurture someone who is goal-directed,
willing to learn, and respectfully trusting of the mentor. The
younger professional has a career goal, a vision and is willing to
share the secrets of her success.
The period of questioning comes next. This is when the younger
professional has self-doubt and fears of being unable to meet the
goals.

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The mentor shares information about power and politics, tells how
she became successful, and serves as sounding board.
The transitional phase is the final phase, when the mentor helps
the mentee personalize learning and become aware of her own
strength and uniqueness.
Mentorship has been shown to provide an opportunity to share
information, review work, provide feedback, explore tissues, plan strategies,
and solve problems. It helps socialize novices into professional norms, values,
and standards. Career advancement successes are promoted, thus increasing
self-confidence, self-esteem, and greater personal satisfaction.

Topics for Staff Development Programs. Continuing education offering
should be relevant to the occupational interest of employees. Employee
preference as well as the opinions of managers should be the major sources of
topics for staff development. Using interview and questionnaires the desired
class topics can be identified. Other sources include results of the studies on
these particular subjects. Some of these studies are cited by Gillies (1994). A
study done at Rutgers University in New Jersey among ten health agencies.,
found that hospital nurses preferred classes to be scheduled on Wednesday
rather than at the beginning or end pf the work week. A survey in the Chicago
area showed that obstetrical nurses preferred instruction about new
equipment; outpatient nurses desired instruction in making referrals to
community agencies, psychiatric nurses desired instruction on communication
techniques, and medical-surgical nurses desired instruction in team nursing
organization. In the same survey, head nurses expressed their preference for
budget making while supervisors wanted instruction in communication
technique. As a rule, topics in nursing staff development must include those
that enhance both clinical and personal development of the employee. Topics
related to clinical improvement may include: coronary care, cardiac
arrhythmias, intravenous therapy, pharmacology, interpersonal relations,
communication, narcotic, withdrawal, cardiopulmonary resuscitation, and
inhalation therapy. Topics related to personal development may include:
writing skills, grooming, financial planning, safety, drug abuse, telephone
usage, human relations.

Management Development. One form of staff development that has
emerged during the past decade is management development. This is given to
nurse managers to enhance interpersonal skills and to develop a more
democratic approach to leadership. An approach that has been found to be
effective management development is the system approach. Systems approach
allows designing the program into an integrated whole which relates the
management function of planning, organizing, staffing, and controlling. Each
management program should begin by establishing agreement among top
executives and middle managers at every level to the organizational hierarchy.
Once this is done the top executive should evaluate the effectiveness of each

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levels of management by analyzing personnel, production, and quality control
reports. Ineffective performance by a particular supervisor or section chief
might be revealed by a review of incidents reports, liability suits, or turn-over
rates. A review of personnel and supply cost per patient per day supervisor or
director. A review of patient audits or quality control surveys might identity
ineffective leadership by a head nurse or supervisor.

The usual topics for management development programs include:
political systems, economic principles, legal constraints, cultural and emotional
determinants of behavior, trade unionism, employment practices, types of
leadership, decision making, communication methods, statistical analysis,
interviewing techniques, performance appraisal, implementing change, conflict
management, report writing, establishing performance goals, administering
labor contracts, arbitration of labor agreements, assertiveness, and negotiated
order relations (Gillies, p 275). Leadership development topic include study of
group dynamic and refinement of interpersonal skills in group setting. Practical
exercises can help the manager gain insight into those behavioral
consequences of her own and others action, and can lead her to discover more
effective responses to hostility, criticism, dependency, affection, and
manipulation. Practical exercises and laboratory techniques can also be used
to effect attitudinal change, such as improving tolerance for individual
differences, increasing willingness to cooperate with other managers,
facilitating flexibility and adaptability in thought, and increasing interest in
innovative methods of problem solving.

Absenteeism.A serious problem to any organization, absenteeism can be
defined broadly as any time away from scheduled work (Gillies, 1994). A
method to calculate the quantify absenteeism is by using time lost percentage
and the absence frequency rate:

Number of days lost x 100 = Percentage of time lost
Number of potential work days


Total episodes of absence per year X = year absence
Average number of employees during the year frequence rate

A high rate of absenteeism is extremely costly from the standpoint of
economics and from the standpoint of morale. First the absent worker must be
replaced by an overtime worker. Second the replacement worker is often
unfamiliar with the tasks to be performed, so inefficiencies and errors result,
other workers are demoralized, and absenteeism rates increase among them as
well.

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There have been many industrial studies about causes of absenteeism.
Gillies (1994) cited some of these studies:

a) Studies show no correlation between a workers illness-absence and the
amount of overtime worked,
b) But a correlation has been found between unexcused absence and
double-jobbing.
c) Those workers with high illness-absence rates usually demonstrate
excessive tardiness as well.
d) Some studies indicate that employees who live a long distance from
workplace tend toward higher rates of absenteeism.
e) Absenteeism also tends to occur on Monday, lowest rates on Friday.
f) Absenteeism is lower in small work groups than in large work groups.
g) According to researches, the most common causes for illness-absence
are respiratory disease, digestive disorders, circulatory disorders,
gynecological disorders and psychoneurosis.
h) Employees with high absenteeism rates tend also toward high accident
rates.
i) A study also revealed that nursing personnel had more accident-absence
than other categories of health workers. The most common injuries were
back and leg injuries associated with lifting and pulling.

Methods of Reducing Absenteeism.Many methods have been tried to
reduce
Absenteeism with varying degrees of success. According to Gillies, (1994) the
first step is to keep accurate records of employee attendance and to calculate
absenteeism rates at frequent intervals in order to identify each employees
pattern of attendance, particularly during the early period of employment. Any
employee with excessive absenteeism should be counseled by the supervisor
and to identify causes so that action can be taken. Some measures to reduce
absenteeism due to illness includes:

1. Providing free health care to employees. An on-site employee clinic is
preferable.
2. Calling or visiting an employee who is sick. In one institution, a visiting
nurse was assigned to contact and give nursing service to each employee
who missed work because of illness.
3. Providing a strong safety and accident prevention program to decrease
work-related injuries.

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Aside from illness, there are other causes of excessive absenteeism. Among
these are: boredom and lack of challenge, low employee morale, unpleasant
working condition and environment, poor interpersonal relationship with other
employees, dissatisfaction with material rewards.

It is the responsibility of the manager to improve those aspects of work
environment that influence motivation to come to work. She should know the
causes of absenteeism in her department and apply measures to remedy the
problem. An incentive plan that rewards good attendance has been found to be
helpful in decreasing short term absences. A perfect attendance reward in
terms of recognition or monetary incentive has also been found to decrease
absenteeism. If nothing else works, disciplinary measures may be used among
problem employees. Effective disciplinary control requires that absences and
tardiness be accurately documented. Memos, counseling and other measures
prior to the disciplinary action should be recorded.


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Answer the following and submit your typewritten answers/reactions to your
professor.

1. Define the six basic nursing models for providing patient care.
2. Describe the advantages and disadvantages of the case and functional methods
of staff assignment.
3. Describe the four staffing patterns.

If you are not a nurse manager, interview one who is and find out the answers to
the following pertaining to a health institution/hospital:

4. How are staffing needs determined in the institution? What factors are
considered when making scheduling decisions?
5. How are nurses recruited and hired?
6. Describe the orientation program.
7. How are problems (if any) of tardiness and absenteeism resolved?
8. What strategies are used to reduced absenteeism?
9. Studying the staff development programs offered, what suggestions can you
offer to make them more meaningful and beneficial to both staff and their
managers?
10. Describe your reaction/s as to the appropriateness of the nursing model or
models used for providing patient care? If you think another model is more
advantageous, justify your answer.


LEARNING ACTIVITIES

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MODULE FIVE


Webster dictionary defines to lead as to go before or with to show the
way and to influence or induce (1997). Leading is guiding, to lead toward a
definite result, to direct. These actions are needed in nursing leadership. The
nurse managers lead their staff by clarifying the path toward institutional goals
and by coordinating and rewarding workers efforts toward goal achievement.
According to Gillies (1994), leadership is a social relationship in which one
party has greater ability to direct and motivate the behaviour of another than
to be influenced by him. Thus the function of leadership is based on a power
differential between involved parties.
Leadership Activities. Leadership consists of three major activities:
a) Directing orpointing the way;
b) Supervising or overseeing the action;
c) Coordinating, or synthesizing the efforts of several individuals.
Directing is the most complicated and most difficult among these activities,
because in directing, the leader is often cast in a parenteral or authoritarian
role. Coordination is considered to be the most critical activity because it keeps
those concerned on track by frequent realignment of methods and goals as well
as by continual integration of individual efforts.
Leadership Styles: research has identified the following four styles of
leadership from various fields:
a) Autocratic
b) Democratic
c) Participative
d) Laissez faire
The autocratic style of leadership is one in which a predominantly task
oriented. Leader uses her position and positional power in an authoritarian
manner, retaining responsibility for all goal setting and decision making, and
motivating subordinates by manipulation of praise, blame and reward. The
clarity of power and authority relationships that characterizes autocratic
leadership facilitates rapid decision making and efficient work organization.
LEADERSHIP

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Therefore, the authoritarian style is effective in crisis situations, when rapid
mobilization of effort is essential. On the other hand, the authoritarian
leadership may provoke negative feelings and actions among employees.
Furthermore, authoritarian leadership has the tendency to encourage
dependency among subordinates. The democratic style of leadership is one in
which the leader values the individual characteristics and abilities of each
subordinate. The democratic leader uses personal and positional power to draw
out ideas from employees and motivates members of the work group to set
their own goals, develop their own plans, and control their own practice. The
participative style of leadership is a compromise between authoritarian and
democratic styles of leadership. In participative leadership, the manager
presents her own analyses of problems and plan of action to members of the
work group, inviting their criticism and comments. Having the subordinates
responses to her proposals, the manager then makes final decisions for the
whole group. The laissez fairestyle of leadership is one in which the official
appointed abdicates leadership responsibility, leaving the workers without
direction, supervision, coordination, and forcing them to plan, execute, and
evaluate their work in any way they see it.
More recent researches in leadership tend to show that each leadership
style is effective in different types of situations but ineffective in others. The
factors that determine the best leadership in a given situation include: a)
difficulty or complexity of assigned tasks; b) amount of time for task
completion; c) size of the work group; d) communication patterns, within the
group; d) educational and experiential background of the employees; e)
workers needs for information and achievement; f) leaders personality and
training.
There are more recent theory of leadership that is replacing the trait and
style of theory. One good example is the situation theory of leadership. The
situation theory holds that since the total culture, the work group are in
constant flux, the most effective leader for a particular situation one whose
personality and style best satisfy needs of the work group for structure as they
attack the task at hand. According to the situation theory, the leader must
adjust from one person to another or from one style to another as changes
occur within the work. To lead others effectively the leader must be a member
of the work group to be led, viewed by the group members as superior to
themselves in some significant attribute, he occupy a position of high potential
with the groups force field (Gillies, 1994). She possesses recognized skill in
nursing, management, communication, institutional politics. She represent a

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specialization or she must be a holder of skill certification, such as psychiatric,
geriatric nursing or ICU. In order to adapt leadership to workers specific
methods for directing, supervising, and coordinating should be used on the
basis of: a) the tasks are clear or unclear, b) workers desire for autonomy or
structure, c) the autocrat or is a skilled group worker.
Direction. The first of the major activities of the leader-manager is direction.
To direct activities of the employees, the leader manager may use assignments,
orders, specifications, procedures, rules, regulations, standards, opinions,
suggestions, or questions. Some actions and guidelines when giving directions
and orders are:
The more authoritarian forms of direction are usually preferred by the more
dependent workers. On the other hand, employees with a need for
independence prefer to be led by democratic leaders who are skilled in group
dynamics.
Directions should be written especially if the employee requires a high
degree of structure or when trust is lacking between the leader and the
employee. In emergencies, orders may be given verbally, but it is necessary to
repeat such orders at intervals to prevent misunderstanding and confusion
that may ensue. When leader and subordinates are well known to each other
and trust each other or when the employee is self directed, directions may be
given orally to ensure comfortable give-and-take between them.

Orders may be given orally or in written form. Either way, the order should
be worded specifically to misunderstanding and to save time. When the task is
ambiguous, or the leader cannot foresee all possible circumstances related to
task completion, either an oral or written order should be general in nature so
employees can adjust their actions to accommodate unforeseen difficulties.
The leader must be aware that some workers rely heavily on visual sources
of information while others are more reliant on aural perceptions, and still
others learn and understand more information and directions are both shown
explained.
All orders should be issued in direct and simple language to avoid
misinterpretation of orders. Orders are most effective when issued directly from
leader to the employee rather than indirectly through someone else.

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To minimize friction between the leader and the subordinate and to
emphasize the tasks to be accomplished, the giving of orders should be
depersonalized as much as possible. The leader must also remember that the
giving and receiving of orders can often result in employee resentment.
Therefore, orders are to be given only when necessary. Rather, when there is a
situation problem, the leader should unify her staff to work on the problem
with her.
Delegating is an element of directing. Delegation to ancillary workers is
being resorted to more frequently these days as one way of containing
manpower cost. Tasks used to be done by registered nurses are now delegated
to nursing assistants and technicians. Some hospitals hire operating room
technicians to assist surgeons, some train and hire neonatal care technicians
and still other hospitals hire psychiatric technicians and other nurse
extenders. But aside from cutting personnel costs, there are other reasons for
delegating. According to Swansburg (1993), delegating can be done for routine
task, for tasks which the nurse manager does not have time to do, and to build
the capabilities of other personnel. In delegating, the nurse executive should
see to it that the personnel to whom a task or responsibility is delegated has
the ability to carry out the task. She has to know the knowledge skills, legal
definitions, job descriptions of her personnel. She should be able to
differentiate between the different levels of caregivers within each discipline in
order to appropriately delegate tasks and responsibilities. She must remember
that in addition to being accountable for her own work, she is also accountable
for work delegated to others. Also, in delegating, the person doing the
delegation must be fair. Fairness means evenly distributing the workload so
that no one has substantially more work than the others.
Supervision (Overseeing). The second major leadership activity of the
manager is supervising her subordinates work. Supervising consists of
inspecting the work of another, evaluating the adequacy of performance, and
either approving or correcting it. Most employees are anxious about being
closely supervised because they fear that their supervisors dissatisfaction with
their performance can jeopardize job security. Supervision is needed for quality
control but it does not necessarily mean that it should be restrictive. Rather,
supervision is a facilitating process that ensures correct performance of tasks
through the inspection of the work in progress. The process of inspecting is
done to solve rather than to punish poor performance.
The degree of supervision should be suited to a) the work institution b)
needs of the employee c) skills of the leader

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Supervision is best when its purpose is to inspect, evaluate and improve
worker performance. The official job description and association performance
standards can be used as criteria against which to appraise the quality of the
workers behaviour.
The following elements of performance should be appraised:
a) Quantity of production
b) Quality of production
c) Utilization of time
d) Utilization of resources
Supervision as coaching is based on the philosophy and techniques of sports
coaching. The supervisor-coach considers group goals as superseding the
needs and desires of individual team members and that any member who
excels in tea play may be singled out for recognition, so as long as he attributes
his success to, in part, to support from other team members. Like a sports
coach, the supervisor-coach develops strategies and tactics by which she
mobilizes her group effort to move against adversity towards the group goal.
She is aware that technical skills wither when not in use and flourishes with
practice so she provides supervised practice to solve faulty techniques. She
continues to upgrade her subordinates performances. Like a game coach, she
uses persuasion, exhortation, and a judicious mixture of reward and
punishment to motivate her subordinates toward higher levels of performance.
She also disciplines any player who disregard policies and who fails to perform
adequately. The coaching approach to supervision is effective because it meets
subordinates needs for structure and support.
Aside from a leadership activity, supervision is also a control technique.
For quality control purposes, supervision takes place in the patient care
environment. By observing nursing personnel care for their patients, reliable
feedback are obtained about the efficacy of organizational design, job
descriptions, performance standards, hiring efforts, placement decisions,
assignment methods, and training techniques (Gillies, 1994).
To supervise, the leader-supervisor uses a variety of techniques. In one
approach to clinical supervision, the supervisor may ask a subordinate to work
with her for a day or two. She can then observe or even assist the nurse as se
cares for one group of patients. She may demonstrate certain procedures or
techniques or may offer suggestions for resolution of unusual patient problems.
If the nurse being supervised requires correction it should be done in private to
preserve patients confidence to her nurse and to avoid humiliating the nurse.

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Another method of supervising subordinates is to spot-check certain
activities at regular intervals. The supervisor may check a nurse technique of
performing nursing procedures, for example, medication administration. She
may spot-check content and accuracy of documentation by examining patients
charts and incident reports.
Since knowledge and thinking cannot be discerned by observation alone,
the supervisor uses questioning to determine subordinates knowledge about
what the information and data she has about her patient, her nursing
assessment, plans, evaluation about the patients progress and the result of
her care. By questioning, the supervisor is able to determine the subordinates
ability to analyze, to think critically and to make decisions.
Coordination. The third type of leadership activity is coordination.
Coordination consists of activities by the supervisor that integrate
subordinates work activities and efforts and allows them to work
harmoniously. According to Gillies, coordination is becoming more and more
important in ensuring effective patient care because, as technology advances,
workers become more specialized and less able to communicate with each
other, although at the same time each specialist is required to build upon the
efforts of others and integrate his activities with others. The methods used by
the manager to coordinate activities vary according to a) difficulty and urgency
of the tasks b) communication style of the manager c) the size and
sophistication of the work force. To coordinate dissimilar workers, the manager
may need to control their activities, so that some tasks may be speeded up or
delayed to keep them in pace with some other tasks. The scope of some tasks
may have to be narrowed to prevent disputes among workers. Diplomacy and
persuasion, rather than autocratic direction, should be used when
coordinating the activities on nursing experts. Coordination requires frequent
information exchange between leader and subordinate. The usual methods for
transmitting information within the work group are face-to-face conversations,
memoranda, posters, and position papers. A memorandum is a brief, informal,
written communication that spells that transmits essential information in a
timely fashion and conversational language. Memoranda are useful when
speed, precision, and clarity of the message are of critical importance. Posters
are useful in communicating brief, factual, operational such as notification of
group meetings and educational offerings, reminder or reinforcement of rules of
governing clinical practice and detailed personnel data.


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Power is defined as the ability and willingness on the part of the manager
to influence the behaviour of others to produce certain intended effects. To be a
successful manager one has to understand the concept and use of power.
When utilizing power, the nurse manager controls the behaviour of
subordinates by manipulating rewards and punishments that are important to
those subordinates. The nurse manager needs power to move others in desired
directions. She also needs others to compete with other organizational leaders
for scarce resources such as funds, personnel, space. She needs power for the
sake of her patients and of her subordinates. A very important characteristic of
power is that it is dynamic, and therefore, it can decrease or increase
depending on circumstances.
Sources of Power. To understand and use power effectively, the nurse
manager must be aware of how one achieves it. For example, there are three
actual or potential sources of managerial power: personal, positional, and
social. A managers personal power is proportional to the strength of her self
concept and her level of self esteem. This means that a person who values
herself and believes in her ability feels capable of controlling and influencing
others. On the other hand, occupying a certain position confers on the person
a certain degree of power and authority that goes with the position. Because
positional power is unrelated to the personality and ability of the incumbent,
the positional power for a particular position remains constant as different
person occupy the position. Thus, although different nurse managers may have
varying personal power, their positional power stays, as long as they are
occupying the position. Social power is derived from the frequency and the
quality of the managers interactions with her peers, subordinates and
superiors.
Levels of Power Potentials. To acquire power and use it well, the manager
must know the manifestation of power. According to May (in Gillies, 1994 pg
305), there are five levels of power potentials in each individual which can be
arranged in increasing intensity:
1. The Power to Be. The maintenance of a purely vegetative existence
requires minimum force and ability.
2. The Power of Self-affirmation. The drive to define oneself and establish
ones significance within the world represents a degree of force greater
than that required simply to exist.
POWER IN THE WORKPLACE

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3. The Power of Self-assertion. Compelling the world to reckon with ones
individuality and ones right requires greater force than that involved in
self-affirmation.
4. The Power of Aggression. Moving into anothers territory and taking
possession of it requires force beyond that needed to define ones identity
and rights.
5. The Power of Violence. The application of harmful force against ones own
or anothers person or property constitutes a disturbance in definition of
self, other or property.

Power-oriented individuals, or those, with high power needs are more
concerned with their impact on others that with the quality of their
performance. They take pains to ensure that their official actions are highly
visible and audible to peers, subordinates and superiors. The power-motivated
or the highly competitive individuals on the other hand, prefer to participate in
competitive and status oriented situations. They often engage in arguments to
prove their point.
Power Principles. There are principles that the manager can follow to
increase her power.
1. Since power is dynamic and elusive, one should assume that anyone who
fails to increase his power automatically decreases it and that power is
obtained only through active means, e.g., it must be asserted against
resistance or wrested from an opponent against his will.
2. The power-oriented manager learns to use any means of control that can
effectively manipulate circumstances in her favour.
3. Winning in organizational politics requires total commitment to ones
goals. The manager should identify the purpose and goals for each action
and to take full responsibility for his behaviour.
4. Restraint is needed to ensure the most effective use of power. One should
use only as much force as needed to achieve ones desired objective.
When making an onslaught into a competitors territory, one should
always maintain a fall-back position to which retreat is possible in case
the fight goes badly.

Power Acquisition Skills. There are six types of basic skills for exerting power
over others. These are:

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a) Peer Skills are those communication and interactional skills by which
one builds and maintains a strong network of contacts among equals
who can be called upon for support in a crisis.
b) Leadership Skills include those communication and relational skills with
which one resolves problems that arise from power, authority, and
dependency issues.
c) Information Processing Skills include the skills of receiving, encoding,
grouping, storing, retrieving, translating, sending information, by which
one makes sense of the world and communicate data, ideas, opinions,
feelings and intention to others.
d) Conflict Resolution Skills are those skills by which one finds a common
ground of agreement between contenders and persuades each to join
forces with his opponent in order to realize a mutual gain.
e) Skill in unstructured decision making includes abilities to identify and
analyze problems as to cause and effect relations, generate alternative
solutions, select and the most effective and least expensive course of
action, and assign appropriate individuals the responsibility for
executing each aspect of the chosen solution.
f) Entrepreneurial skills include the ability to single-handedly select
targets, make plans take risks, and effect innovations so as to
accomplish unrealized goals.












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The ability to solve problems is an important management tool. The
nurse manager in doing her daily work confronts several types of problems.
Some of these problems are serious, some minor, some new and some old,
many relating to her job and responsibilities, still many others relating to
interpersonal relations with subordinates, peers, supervisors.
Problem-Solving Methods. Several methods are suggested for solving
nursing problems. Among the more common are: trial and error, scientific
experimentation, multistage situation critique, and metaphor-based creative
approaches.
Trial and Error consists of employing one intervention after another in
succession until other relief of the problem manifestations. This is the simplest
method but it is also the most time consuming. This is often used by managers
who are untrained in the more sophisticated techniques.
Scientific experimentation is a process by which selected elements of a
problem situation are studied under highly controlled conditions. An
experimental approach is useful when additional data are needed to
understand a problem situation, adequate time is available to institute rigorous
controls and the controls required will not interfere with realization of primary
institutional goals. This is not advised when conditions do not permit
separation of patients into controlled and experimental groups.
Critique of a problem situation consists of evaluating ones action in a
thoughtful way before, during and after the event in question. For purposes of
critique, information about a problem situation can be obtained by inspection,
simulation, or participation observation.
Metaphor-based techniques for developing creative problem solutions are
concerned with breaking conventional thinking patterns and suspending
judgement so as to evoke a volume of highly original ideas within a short time
through the process of forces association.
The use of all these methods requires that the manager has a high
degree of cognitive skill, analytical and creative thinking, previous experience
on problem solving.

PROBLEM-SOLVING IN NURSING

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Principles of Problem-Solving.
1. To ensure prompt attention to those problems having maximum effect on
organizational efficiency, the manager must separate big from little
problems, use policy to resolve smaller problems, and conserve expensive
managerial time for handling major problems confronting the work force.
2. The manager should delegate smaller problems to subordinates, who
should be encouraged to resolve such problems by applying institutional
rules and regulations, thereby, strengthening their identification with
institutional goals at the same time that they increase their autonomy
and self-sufficiency.
3. In attempting to resolve the more difficult problems confronting her work
group, the manager should consult as necessary with experts inside and
outside the institution so as to operate on a solid basis of facts while
searching for a problem solution.
4. The quality of problem solutions will be enhanced if the manager is
relaxed in her approach to problems, refuses to solve problems under
stress, and avoids making crisis decisions in response to undue pressure
from others.
5. In solving big problems, the manager should realize that because it is
impossible to anticipate all eventualities, she cannot be 100 percent
correct in diagnosing and solving all nursing problems. Since perfection
is impossible, she should not hesitate in selecting each problem solution,
and once that decision has been made she should accept the solution as
the best that could be made under prevailing circumstances and turn
her attention to other matters.

In order to conserve her own and subordinates time in problem-solving
activities, the nurse manager should ensure that all job descriptions and
personnel evaluations specify individual responsibilities for problem solving.
She should be explicit in assigning deliberating responsibilities to specific staff
members, should prepare specific agendas and detailed minutes for all
problem-solving, should display sympathetic tolerance for unacceptable ideas
generated during the presentation of problem-solving proposals.
Steps in Problem Solving. When using the Critique Method, the steps are
similar to the steps of the scientific method. The steps are:
a) Problem definition
b) Data collection

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c) Generation of possible solutions
d) Selection of one solution from several alternatives
e) Implementation of the preferred solution
f) And evaluation of the solution used
The primary purpose of problem definition is to identify the root or core
cause of the problem. Ways to determine the root cause of problem are by:
Identifying the differences in the work situation when the desired goal is
achieved and when it is not.
Searching for evidence to refute the hypothetical cause.
Observing the workplace, reviewing institutional records, conversing with
patients, nurses and other health workers. When interviewing the
patients and personnel to obtain information for problem definition, the
manager should keep in mind the following guidelines:
a) Ask questions that do not commit the respondent to a particular position
relative to the problem solution.
b) Invite respondents to describe rather than to evaluate situations, events
and actions.
c) Stimulate respondents to answer questions from a subjective standpoint,
so as to reveal feelings and attitudes that may have a bearing on problem
generation or solution.
d) Show attention to and respect for the respondents reactions to questions
through active listening, nonjudgmental rephrasing, and accurate
summarization.
During the problem identification phase, the manager should assess and
analyze which the problem developed, as well as diagnose the nature and
severity of the problem.
Generating Solutions. The objective of this step is to develop several possible
solutions, maximizing the probability that the best possible solution is among
those being considered. Two or more solutions are needed, the more solution
alternative are generated, the larger tool of intervention from which to design a
multidirectional approach to solution. To realize the quality of solution
alternatives, the manager may use idea checklists, psychodrama, and other
problem-solving approaches that stimulate creativity among the problem.
Selecting a Solution. In selecting a solution from among alternatives, the
manager can established criteria for acceptability, measuring each alternative
against all the choices and determine an over all acceptability rating for each

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solution. The manager is also responsible of what she thinks as to what
solution is most promising of success and best suited to the performance. It
may be helpful to develop a guide sheet for evaluating alternatives solutions to
each criteria is given proper consideration in evaluation of alternatives.



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Decision making is a deliberative, cognitive process consisting of
sequential steps that can be analyzed, refined, and integrated to yield greater
precision and accuracy in solving problems and initiating action. It is the last
step in the process by which an individual chooses one alternative from several
in an effort to achieve a desired goal. The selection of alternative requires
analytical, deductive and inductive reasoning by the decision maker.
Decision making is considered as the most important tasks of leading
and the core of management process, since a decision is necessary to instigate
any significant action by the manager or the subordinate. (Gillies, 1994 page
328).
Decision making used to be easier and simpler. But with knowledge and
information explosion as well as the democratic way of managing, decision
making has become more complex. When making decisions, the modern
manager is expected to make use of research findings about nursing practice,
nursing practitioners, management of personnel, finance, facilities and other
resources. She is expected to have a know how to negotiate with a wide variety
of employee in order to ensure broad participation in problem organization and
resolution. According to Gillies (1994) a nurse manager may approach her
decision making responsibility in either of the two viewpoints: the idealized
view of the Economic man or the pragmatic view of the Administrative man.
According the idealized view the manager, when faced with the situation which
requires decision making, carefully and deliberately weighs the economic
aspects of all alternative courses of action and chooses that which can be
expected to yield the greatest net gain or the least loss. The pragmatic view, on
the other hand, postulates that real-life management decisions are never
carried out under conditions of clarity and certainly, because the manager is
never fully aware of the causes and effects of a complex phenomenon and
seldom envisions all possible solutions to a problem or the full range of
immediate and long-range effects of such solutions. Therefore, according to
Simon (in Gillies, 1994 p329) managers tend to based work-related decisions
on a simplified notion of the real world.
The quality of each management decision is dependent upon the quantity
and quality of work-related information that is available to the decision maker
during the decision process. Lawyler and Rhode (in Gillies, 1994 page 329)
DECISION MAKING

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point out that much of information used in making managerial decisions is
obtained in the form of feedback from various institutional control systems.
Types of Decisions. Management decisions can be classified as:
a) Strategic
b) Administrative
c) Operational

Strategic decisions are those made by top executives in the agency that commit
valuable resources to pursuit a major, long term goals that are crucial to the
agencys welfare. Administrative management decisions are those made by
middle management when resolving unusual problems and developing
innovative techniques to improve institutional functioning. Operational
Decisions are those routine decisions governing day-to-day events that are
made in accordance with institutional rules, regulations, instructions,
precedents and strategies.
Decision strategy. A strategy is defined in Gillies (1994 p334) as an artful or
clever overall plan of applying methods and techniques in pursuit of the goal.
The following strategies have been suggested by management experts for
managerial decision making.
1. Optimizing strategy
2. Satisficing strategy
3. Opportunistic strategy
4. Do-nothing strategy
5. Strategy of solving for the critical limiting factor
6. The maximax strategy
7. The maximim strategy
8. The strategy of mini-regret
9. The precautionary strategy
10. Evolutionary strategy
11. The chameleon strategy
The optimizing strategy is one in the decision maker determines the varying
states of nature that can exist, the available courses of action. The possible
outcomes of each action, and the probability of each outcome. The manager
selects from a matrix that reveal the expected payoff probability of each stature
of nature the course of action which yields the highest number of desired
outcomes.

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Satisficing strategy consists of seeking not the best of all possible solutions
to a problem, but one that is good enough under prevailing circumstances to
meet minimum standards of acceptance.
An opportunistic strategy is based on realization that the employee that
identifies an organizational problem has a better-than-average opportunity to
shape both the manner in which the problem is formulated and the method
used for handling it.
The do-nothing strategy is used when the manager refrains from decision or
action. The existing crisis or conflict is resolved and present condition has
stabilized.
The strategy of identifying and removing the critical limiting factor is aimed
at eliminating the most serious, most immediate, or most lasting obstacle to
success in the belief that such restructuring of the problem may motivate the
staff to a more effective attack on remaining obstacles.
The maximax strategy is an optimistic decision-making approach based on
the assumption that for every interaction between a state a state of nature and
a particular alternative, the highest possible payoff will result. The decision
maker constructs a two-dimensional grid reflecting all possible states of nature
and all available alternatives, and calculates the maximum possible payoff for
each situation outcome. The then chooses the approach that will yield the
largest of these maximum payoffs.
The maximim strategy is a pessimistic approach that is used by the
manager who expects the worst possible results from any action she may take
because she believes that the most undesirable state of nature will exist at the
time the action must be taken. A two-dimensional grid is constructed to
present all possible states of nature and available alternatives, with
probabilities and expected payoffs for each combination. The decision maker
then selects that action which will yield the best result under the most
unfavorable circumstances or that action whose worst outcome is better than
the worst outcome of all other possible actions.
The strategy of mini-regret is one designed to minimize the surprise that can
result from any decision by choosing that action which yields an outcome that
departs as little as possible from either the most desired or the least desired
outcome. Again, the decision maker constructs a two-dimensional grids that
includes all possible states of nature and all available course of action, with
probabilities and expected payoffs, the manager chooses a course of action that

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in combination with the most common state of nature will yield a payoff that in
combination with the most common state of nature will yield a payoff that is
midway between highest and lowest possible payoffs.
A Precautionary strategy is useful when the manager is engaged in a zero-
sum conflict with another, that is, each party can gain or lose at the expense of
the other. The precautionary strategy consist of forecasting all possible action
by ones adversary together with the effects on oneself of each of those actions,
and then determining a course of action that will maximize gain and minimize
loss regardless of the opponents action. The purpose of precautionary strategy
is to forewarn and accommodate oneself to the worst effect that an opponent
can have on ones goal-directed behavior in a zero-sum conflict.
The evolutionary strategy for decision making is based on the assumption
that subordinates can more easily adjust to a sequential series of small
changes than to quantum leap when moving from a present undesirable state
to an improved future situation. In using an evolutionary rather than a
revolutionary strategy toward decision making, the manager contents herself
with small inroads into a large problem when her total improvement program is
too threatening to be fully acceptable to subordinates. The manager who opts
for slow, steady progress toward goals may have to forgo personal credit for
innovative ideas and progressive ideas among informal and factional leader so
that they can unobtrusively transmit these ideas among informal and factional
leaders so that they can unobtrusively transmit these ideas to the rank and file
who are responsible for implementing proposed changes.
The chameleon strategy for decision making consists of framing basic
management decisions in such general terms that they can be interpreted
differently at differently at different times in the future. In that way, a basic
policy decision established for long-term effect can be used to guide employee
behavior through a succession of differing circumstances and in the face of
changing pressures from the environment.
Steps in Decision making
The first step in making management decisions is the determination of
institutional goals and priorities. This is very important because setting of
organizational goals and priorities results from the fact that each managers
decisions are rooted in her philosophy and values, and these are determined in
large part by her knowledge and acceptance of institutional purpose (Gillies,
1994 page337)

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The second step is perception of a challenge or problem that creates the
need for a decision defining the problem and the question for which a decision
is needed is crucial to effective decision making (Drucker, in Gillies, 1994
p337).
The third step consists of identifying criteria for a successful method of
meeting the challenge or solving the problem. This is needed to guide the
managers thinking as she envisions possible means of moving the situation
from the present condition of threat to a more secure future condition.
The fourth step is a search for acceptable alternative courses of action.
The more the alternatives to choose, the greater are the chances for the
manager to make high quality decisions.
The fifth step is weighing of alternatives to determine which best meets
the criteria for successful handling of the issue. Here both pros and cons of the
available choices are studied and weighed. If none of the alternatives is
acceptable, the decision maker should return to step four.
The sixth step is selection of one alternative from the many that were
examined. The selection is made after some moments of indecisions and
discomfort as well as considerable vacillation from one alternative to another
until the choice is made.
The seventh step consists of deliberation regarding commitment to the
selected actions. At this point the manager may have some anxieties about
changes that have to make as a result of the decision. She may also be anxious
about informing others about the changes.
The eighth step is implementation of the decision by translating it into
action personally or by assigning it to specific staff members.
The ninth step is confirmation of the decisions or adherence to the
selected course of action despite negative feedback.
They are number of creative and cognitive devises that can assist the
decision maker, among which is using models which are symbolic abstraction
or verbal, mathematical, statistical or structural representation of a system
that is used to make the situation easier to understand and to predict. Another
aid is the use of games and simulations. A decision. Three is a mathematical
tool and depicts related decision points and outcome probabilities as an
interconnecting no network of branches and nodes.

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Methods of Decision making
According to Vroom and Yetton (in Gillies, 1994 p341), a manager
usually selects one of five methods for decision making depending on her
personal characteristics, her perception of the problem, and her assessment of
her own and her subordinates capabilities. The five methods are:

1. Autocratic I. The manager makes the decision herself using whatever
information she has on her hand.
2. Autocratic II. The manager obtains necessary information from her
subordinate anduses them to make the decision herself. She may not
tell her staff what the problem is, but she makes it clear that what
she needs are information, rather than opinion.
3. Consultive I. The manager discusses the problem individually with
her staff, obtaining information and suggestions from them without
bringing them together. She then makes the decision that may or may
not represent the opinions and references of her staff.
4. Consultive II. The manager discusses the problem with her staff and
obtains suggestions from them she then makes the decision which
may or may not reflect her subordinates suggestions.
5. Group II. The manager, acting as the discussion leader, discusses the
problem with subordinates as a group. The group decides what action
to take, and the manager accepts the solution that is supported by
the whole group.










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Figure 1
COMMITTEE STRUCTURE FOR DECISION MAKING



































Key: AHRN = Assistant head registered nurse
CNS/DON = Clinical Nurse Specialist/Director of Nursing
HRN = Head Registered Nurse
NPC = Nursing Practice Council
SNCG = Staff Nurse Conference Group

Source: dough Haley and Susan Matyas Black. committee and
communications structure,. In commitment to excellence developing a professional
nursing Staff. Sue Ellen Pinkecon and Patricia Schroeder, eds. Aspea Publishers, Inc.
@ 1998
NURSING SERVICE DEPARTMENT
Ad Hoc Committees
(theory, Socialpolicy)
Standing committees
(policy, procedures,
forms, objectives, O.A
research, etc.)
NPC
SNCG
AHRN HRN CNS/DO
N
Staff Nurses

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Based from their study on decision making model, Vroom and Yetton
produced the following decision in rule:
1. If quality of the decision is important to institutional success and the
subordinate lacks the necessary information or skill to make the needed
decision, dont use the Autocratic I method.
2. If quality of the decision is important to institutional success and
subordinates lack commitment to organization goals, dont use the
group II method, as managerial control of the final decision will be
needed to ensure decision quality.
3. If quality of the decision is important to institutional success, the
manager lacks necessary information or skill, and the problem is
unstructured, there needs to be interaction among all subordinates,
dont use the Autocratic I, Autocratic II, or Consultive I methods of
decision making.
4. If subordinates acceptable of the final decision is necessary to its
effective implementation and it is not certain that an autocratic decision
by the manager would be accepted by subordinates, dont use Autocratic
I or Autocratic II method of decision making.
5. If acceptance of the decision by the subordinates is critical to successful
implementation of the decision, if subordinates are not likely to accept an
autocratic decision by the manager, and if subordinate are apt to be in
conflict over the final solution, dont use the Autocratic I, Autocratic II, or
Consultive I method, since face-to-face interchange among the
subordinates will be needed to resolve their conflicts.
6. If quality of the decision is unimportant to institutional success but
acceptance is critical to implementation of the decision, and
subordinates are not apt to accept an autocratic decision by the
manager, dont use either the autocratic, or the consultive method of
decision making, since only the group II method will maximize
acceptance of the decision, which is the only relevant consideration.










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To continue to survive and to grow one has to change. Change is
inevitable and the only thing in this life that does not change. The change may
be subtle, obvious, slow or rapid. It may be simple or complicated.
Knowledge explosion and the rapidly advancing technology produce
accelerated and complicated changes to modern organizations. The modern day
manager, faced with an enormous amount of information and repertoire of
tools and devices, is pressured to make frequent personal and organizational
changes in order to be effective.
Changes in health care organizations often take place because workers
and consumers are more increasingly aware of their right to participate in
making decision about issues that concern them. For example, the community
may demand that a hospital offer a service not previously available, or hospital
workers who are now more assertive may decide to unionize, or they may
demand increases in salary and fringe benefits. Another factor that calls for
institutional changes, are the stringent control and standards set not only by
the Board of Health or by other control groups.
The rich supply of pertinent, up to date management information, often
times computerized, that nurse managers receive regularly makes management
changes a part of her daily life. Among this information are reports of daily
census, patient diagnoses and conditions, patient admissions, transfers, and
discharges; weekly reports of financial account expenditures, equipment and
supply availability; monthly reports of absenteeism rates, overtime
expenditures. This information about patient, financial resources, and work
force assist the manager solve problem, shape policies, making plans to keep
the institution on target amidst constantly changing circumstances. (Gillies,
1994 p345).
What is change? Change is both content and process. It applies both to
an altered future state or significant departure from the status quo and as
process of moving from one system to another (Gilllies, 1994 p. 348).
Change may be accidental or planned. An accidental change is referred
to as homeostatic or reactive because it occurs in response to an outside
stimulus of some kind and is directed toward reestablishing balance between
the system and its environment. (Lippitt, in Gillies, 1994 p 347). In crisis
situations, change of this sort occurs. For example, when there is an
CHANGE

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institutional power outage the system of delivering meal services to the patients
has to be modified. Instead of delivering meal trays by elevator, the dietary staff
will have to use the stairs to reach the upper floors. Planned change on the
other hand, is the result of a conscious, deliberate, collaborative effort that is
intended to improve the operation of a system and to facilitate acceptance of
that improvement by involved parties. An example is shifting from the
traditional to multidisciplinary charting requires collaborative effort and
acceptance of doctors, nurses, social, workers, dietitians, respiratory therapies
and others who document in patients charts.
Any planned change proceeds through the three stages of:
a) Unfreezing the forces the status quo,
b) Implementing the change process by which the present system is
converted to future system, and
c) Refreezing the forces that will stabilize the new system by integrating
it into organizational routines.
Change can also be differentiated into first, second or third level change.
First level change is change in the agent of change herself. For example, a
manager may change her management style if she senses that her autocratic
leadership style does not work. The second level change is one in which the
altered behavior of the change agent results in behavioral changes in others.
For example, the subordinates may improve their performance and change
their behavior to negative to positive towards the manager whose autocratic
leadership has been changed to a more democratic style. Third level change
consists of more complicated alternations that affect the whole organization or
department. Examples are innovative changes in policies as well as in
organizational set-up, computerization of documentation, innovations in
communication the systems and so forth.
Effects of change. The ripple effect of an organizational change may
produce significant changes in any area of the organization.
These changes may have disruptive effects not only on the organization
but on its members.
The nurse manager should consider that:
1. Even small department or organization change can be upsetting to her
staff.

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The effective manager can prevent disruptive effects by, whenever
possible, involving her staff in the planning and execution stages of
changes . She can also help them by permitting them to express their
opinions and wishes during these stages.
2. Taking risks is an aspect of planned change. Risks that associated
with organizational change include the risk of making mistakes and
losing efficiency, the risk failure and loss of face, the risk of excessive
personnel or supply costs, the risk of physical or mental exhaustion,
the risk of lowered morale and increased employee turnover, and the
risk of union opposition to the project (Gillies, 1994 p350).
3. The effect of organizational change on individual workers is related to
the individuals beliefs and values.
4. The manager should strive to control change so that it occurs at the
right time, at the right speed and in the right direction so that change
can take place with as little disruptions possible.
5. Many times, resistance arises not from individuals but from cliques
within the work force. The sense of togetherness of a clique causes
members to conform to group norms and to adopt common beliefs
and values to which they adhere. It is helpful for the manager to
remember that in any attempt for innovation, there are always people
who will oppose the changes.
6. In general, the amount of resistance encountered in instituting
organizational change is related to the scope and depths of change
attempted. Thus, a sweeping policy change affecting the whole
organization will likely generate more resistance than a minor
procedural change that affects only a few workers.
Strategies for change. There are strategies that a nurse manager can use to
effect proposed change:
1. Work through the line organization to change organizational
structure. A structural change is characterized by a change in the
table of organization and alteration of task-authority relationships
among the employees. A change in job descriptions and a change in
line-staff relationships are likely to follow.
2. Work through a staff officer or outside consultant to alter employees
attitudes and behavior, by using a therapeutic approach.
3. Decide the amount of authority for change that is to be retained by
the change agent and the amount of authority to be given to the
change target. The authority may be unilateral, in which case the

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change is affected by issuance of edict by top management. It may
also be delegated authority where the manager relinquishes her
authority on the change process giving complete authority on the
change process giving complete authority to a group of subordinates
to make whatever change they deem necessary. A strategy that lies
between this two is shared authority. Here the change agent directs,
motivates, coordinates the actions of the subordinates who help her
define the problem and select satisfactory solutions.
4. Another strategy is the systems approach to the change process. A
systems approach is useful because the subsystems of a modern
health organization are highly interdependent. The cyclical or loop
strategy for organizational change is based on the systems concept.
5. The authoritative approach is another strategy that is used to effect
change especially where the institution is under pressure to accelerate
change, as for example, when accrediting bodies exert pressure on the
institution to improve its service and to correct major faults. Top
management then uses its authority to command and enforce
implementation of prescribed change.
6. In contrast to the authoritative approach is the persuasive mode
strategy. Here the change agent sell the proposed change by
emphasizing that the new method is better than the old method. She
tells the change target that the new method is better than the old
easier and she asks them to give it a try on an experimental basis. If
the employees report dissatisfaction with the new method, she
suggests minor adjustments then ask them again to try the method
on an experimental basis.
The camels head in the tent strategy I useful in instituting any complex
change that is apt to confuse employees and that will take weeks or months so
complete. Here the objective is to work out a flow chat of the change process
with an accompanying time line. The change agent explains only a segment of
the total plan at a time, waiting until thee segment is understood, accepted and
implemented before the next segment is explained.
Lewins change theory and strategy is the most common. It is a three-stage
approach:
a) The forces maintaining the status quo are unfrozen or weakened; b)
forces are applied to hasten, increase and reward employee behavior that
moves the situation from its present state to the desired future state; c)
power and sanctions are applied to refreeze or stabilize the system at its

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level of performance, so as to prevent reversion to the previous status
quo.
Another strategy is the redistribution of power within the organization.
This can be accomplished by identifying new sources of power or innovative
leadership and then straightening them while weakening or decreasing the
power of older, more traditional leaders. For example, it may be necessary to
replace the traditional supervisor by a clinical specialist in order to improve
the quality of nursing care in the Medical-surgical units.
Aside from the broader strategies, the change agent can resort to some
specific tactics in effort change. Some these tactics are:
A common tactic is to stir up disagreements by deliberately creating
differences in opinion and dialogue between opponents so as to loosen those
forces that maintain the status quo.
Discover the discrepancy between the real nature of the situation and
how it is perceived by member of the work force. From the degree of
disparity the change agent will be able to diagnose and discover
communication difficulties, biases, lack of appropriate feedback between
and among the subsystems.
To introduce complex organizational change, start by talking about major
ideas, such as changes in organizational goals, slowly in informal, one-on-
one contacts with employees during lunch or coffee breaks. By using a
personalized approach to informal leaders within the work force, the change
agent can identify the type of opposition the change is apt to provoke and
can adjust early on either the performance plan or logistical plan for
change.
Linking the objectives of the proposed change to the personal goals of key
employees and groups is a tactic often used by the psychologically oriented
change agent. For example, if the employees have expressed a desire to
improve their interpersonal relationships, the change agent may take the
emphasized that one of



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Relationships, the change agent may take the opportunity to emphasize that
one the goals of the desired change is to upgrade the staffs ability to
communicate and relate well with others, if that really is the case.
5. another tactic is to start the change process with those individuals
most receptive the proposal. It is preferable to have the support of top
management before initiating any organizational change that has
system wide implications. If administration is resisting any
innovation, the change agent should turn her efforts to winning over
key subordinates, who can later assist her in convicting the
administration.
6. To reduce opposition and resistance to change agent should
analyze the present situation, look at it from the point of view of those
resisting her proposal and try to identify the reason/s for opposition.
This way the change agent may empathize with and discover some
means of winnings over the adversary.
7. The proposed change should be presented in an assertive way, by
persistently and repeatedly enunciating in clear simple language what
change is desired. To be assertive is very different from being
aggressive, as the latter can invite opposition.
8. A tactic for speeding the change process is by using positive
reinforcement. The use of praise for performing desired behavior can
hasten refreezing.
9. The use of compromise is another tactic in change strategies. When
the change agent is unable to persuade the change target to adopt the
proposal, she may have approach her objective more slowly, making
progress through a succession of small gains won through a series of
political trade-offs with the opposition.
10. Regular meetings should be scheduled between change agent and
involved worked to facilitate sharing of ideas, ventilation of feelings,
timely solution of process problems.
Change process. The change process follows steps similar to those of the
nursing process. It starts with assessment of system problems and identifying
what needs to be changed. When planning, the agent determines the objectives
for the change process and develops or helps other develop criteria for the
employees to judge the efficacy of the change. She should choose or help others
to choose, the most undesirable of these courses and should design a flow
chart showing the sequence of actions needed to move the system from its
present state to the desired state. Implementation consists of assigning tasks

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to individuals, coaching and providing support to ensure that the required
actions are performed effectively, coordinating efforts of all workers involved to
ensure timely performance of each task.
Principles of organizational change: the principles of organizational
change according to (Gillies, 1994 page 360) are;
Change of any type represents a loses to participants. As a result of
organizational change, workers may suffer a loss of social support a social
acceptance, an economic loss or a loss of status or prerequisites. Even when a
workers situation is improved as when an employee gets a more roomy office,
he suffers from loss of previous stability and familiar companions and
surroundings.
The more consistent the change objective with the individuals personal
beliefs and values, the more accepting he will be of the proposed innovation.
The employee who helps to develop the activity or performance plan for a
proposed future reality feels some responsibility for the outcome of a change
process.
When an individual is required to demonstrate a specific behavior
consistently, his attitude toward the behavior in question will shift from
negative to positive in order to decrease cognitive dissonance.
The more difficult, troublesome, or agonizing an individuals period of
socialization into a new system, the greater the individuals attraction to that
system as time goes by.
With each successive move from one system to another, the individuals
psychological adjustment to changed circumstances lags farther and farther
behind his physical adjustment. Therefore, a series of major organizational
changes in rapid succession tends to disorganize and demoralize staff
members.
The diagnostic orientation of a change agent may become a self-fulfilling
phenomenon. Thus, a change agent with a background in systems analysis is
apt to diagnose organizational problems as resulting from inappropriate inputs,
faulty throughput, inadequate feedback.
The greater the distance that a change proposal must travel from
initiator to decision maker, the greater the likelihood that resistance will
develop. Therefore, the change agent should communicate her performance

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and logistical plans for change to top administration, middle managers, and
the workers directly rather than through an intermediary.
The roles of the change agent and change targets in the change process
should be blurred rather than sharp in order to encourage reciprocal action
and decision making throughout all stages of change.
Each innovative project should be designed not only to produce the
desired, organizational change, also to arm the staff with new insights, skills,
and methods that can be used in later change efforts.
While change is inevitable, there and instances where innovative efforts
seem to be useless. When there are serious deterrents to change it is not
advisable to initiate change effort. Here are some examples:
The organization has as a long history of unresponsiveness to change.
When there re administrators, managers or employees who wish to make
use of the change agent as a pawn in a game of power politics.
When personnel have already decided upon and are committed to a
certain position.
When the change targets are powerless within the organizational
influence network.
When the client system displays numerous symptoms of social-
psychological pathology, such as lying, manipulation, scapegoating,
rigidly, or obsession.

Evaluation. When the change process has run its course, the innovative
efforts should be evaluated. Both the change process and the altered state
should be evaluated. The criteria for evaluating change should include
effectiveness of the new state in supporting organizational goals, efficiency of
the change plan and change process in achieving to desired change;
satisfaction of administrators, managers, change agents, and change targets
with the interactions required to effect the change.





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Note: to evaluate change, asses both the change process and the change
product.

INPUT OUTPUT
PROCESS (Change process)
(altered state of reality)








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Conflict is defined as a clash between hostile or opposing parties or ideas.
Conflict was looked at as unhealthy to an organization, but today, conflict was
recognized as a natural that strengthens an organization by reconciling
divergent opinions and resolving. From this point of view, conflict is seen as
unifying rather than divisive.
Conflicts between employees grow out of differing perceptions about what is
occurring work situation. The differing perceptions of two parties to conflict
may result because possess the same facts or they see the problem from
different viewpoints, or because about their own roles and powers. Role
ambiguity or confusion concerning tasks with ones positions as well as role
conflict or the assignment of contradictory behaviors on position predispose to
conflicts among employees. Role ambiguity, which can results aerial disputes
between co-workers, are usually cause by unclear job descriptions. Role or
disagreement between the worker and others concerning the jobs
responsibilities also causes the employees to behave with hostility towards one
another. The greater the number of employees within a workforce, the more
common are disagreements about expected role behavior. Given organization,
either an increase in the number of hierarchical levels or an increase number
of health occupational groups causes a proportionate increase in interpersonal
or up conflict.
Effects of conflict. Under certain conditions, conflict can be advantageous to a
work because it can clear the air of irritations that if, unexpressed, would
impair group unity and communication. The nurse manager therefore, should
develop skills in recognition and management of conflict.
On the positive side, aside from what has been mentioned in the preceding
paragraph of interpersonal conflict within an organization has been found to
increase worker, stimulate innovative problem solving, and afford a clearer
understanding of one anothers point of view.
On the negative side, an individual who craves for recognition and has an
excessive need simulation may engage in conflict as a way of getting attention.
In general, engaging in genders a sense of crisis in an individual becomes
increasingly defensive, keeps mostly and is disinclined to exchange needed
information and opinion.
MANAGING CONFLICT

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In order to control conflict between employees, a manager must be familiar
with conflict and the course of conflict development. Normally, conflict is
cyclical and is of the following four stages.
The conflict is latent and there is no overt manifestation of the conflict
although the employees concerned are already developing hostile and
suspicious feelings toward one another.
In the second stage, there is an outbreak of open hostility in the form of
verbal or physical behavior between those involved.
In the third stage each participant of the conflict situation reacts to the
behavior of the other by temporarily withdrawing from the conflict.
Finally, the cycle is complete and the hostilities are less manifested for a
while though each party may harbor antagonistic feelings that make
provoke even more severe hostilities with further provocation.
A conflict that runs full course from interception to satisfactory
resolution must proceed through two phases: a) the phrase of
differentiation, and b) the phrase of integration. During the phrase of
differentiation the protagonists enumerate and elucidate the issues that
divide them and ventilate their feelings about these differences. During the
phrase of integration the protagonists explore similarities, acknowledge
agreement on certain matters, and identify elements of positive feeling
toward one another and situation. The mediating role of the nurse manager
is to determine whether the phase of differentiation has just begun, is well
along, or has nearly terminated. This is important to know because any
attempt to initiate integration before differentiation is completed may result
in a short-conflict resolution.
Analysis of conflict. Through observation and investigation of the conflict,
the nurse manger must be able to analyze and diagnose conflict accurately
in order to effectively intervene in conflict situations. She must accurately
identify the participants, issues involved, type of conflict, stage of conflict,
conflict related behaviors, possible consequences to participants and co-
worker.
There are usually three or more persons involved in a conflict
situation. It is most cases there is an aggressor a victim and an instigator. It
is important for a nurse manager to determine which of those involved is
playing each role to be able to intervene effectively. As much as possible,
she should equalize the power of the victim and the aggressor and she
should try to eliminate trigger behaviors of the instigator.

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Intervention in conflict. After the manager has assessed and diagnosed the
nature, type, cause, duration, severity and extent of the conflict she can
decide to either ignore or to appropriately intervene.
If the conflict is minor, involved only two persons, is not affecting
patient care and the those involved have the capacity to resolve the conflict,
it is advisable for the manager to ignore it and let the conflict run its normal
course. On the other hand, if the conflict concerns patient issues, is
escalating to a point where are and more people are getting involved, and is
affecting work performance, the manager should intervene immediately.
Having decided that intervention is needed, the manager should ask
herself whether she is the right person to intervene or it may be that
another mediator, perhaps in the person of a senior nurse, may be needed.
However, conflict resolution is one of the responsibilities and tasks that go
with being a manager.
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When not to intervene? According to Gillies (1994 p327), one should not
intervene in a conflict situation at a time when there is little hope of
conciliation, that is, if the protagonists believes that they are right and neither
is willing to listen to each others and to an outsides view. The mediator should
postpone intervention until such time when either or both participants show
signs of being more receptive.
Guidelines in Mediating.
The mediator should determine each partys motivation for conflict for
negotiation, since there is little point in negotiating unless at least one
participant is motivated to seek a mutuality satisfactory solution to a common
problem.
The mediator should maneuver events, in choosing a place and time for
meeting and in refereeing discussion, so as to equalize situational power
between participants during negotiation. If one occupies a higher position,
there is a tendency that she will speak more frequently than the one who has
the lesser positional status. The mediator should interrupt at intervals to give
the latter a chance to speak. The responsibility of the mediator to synchronize
the positive and negative moods and moves of the participants. Communication
between them the participants is more effective if they are in the same
wavelength, that is, when both are expressing negative feelings during the
phrase of differentiation and expressing positive feelings during the integration

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phase. The mediator should moderate, direct, conversations to keep them
focused on the same topics and themes.
The mediator is responsible for showing and clarifying the arguments of the
participants to each other. Since anxiety narrows perception, the other
participant listens actively, understands, and perceiving correctly the
arguments of the other. To maximize understanding between participants, the
mediator should encourage frequent feedback by which each party can reveal
his reaction to the others opinions, intentions, and proposals.
To facilitate fee and full expression of feeling during negotiation, the mediator
must respect the self-respect of both participants. It is suggested that the
mediator take each of the participant aside before the negotiation and train
then to avoid generalizations, to listen to another without asking questions,
without giving opinions, without making interpretations, without judging, and
to respond with empathy.
Confrontation. Confrontation is a tactic where issues dividing the participants
are directly. In confrontation, each individual expresses his experiences,
observations, and intentions in a direct manner, at the same time avoiding
anger and blame. Confrontation is most successful in managing conflict when
the participants focus on one issue confrontation method consists of two
stages. In stage one, the participants make a direct the basic problematic
issues, stating their positions in simple and concrete terms. Participant argues
the importance and validity of her own the conflict issues. In stage two,
participants search for points of agreement and similar intentions so as to
mend difference.



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MODULE SIX




At the end of the module four, you will be able to:
1. Discuss at least two purposes of controlling
2. Describe the characteristics of a good control measure
3. Discuss the importance of Nursing Standards in improving the quality of
nursing care
4. Discuss the purposes and the processes of continuous quality
improvement
5. List at least five purposes of personnel evaluation
6. Describe three methods of personnel evaluation
7. Explain how the budget is used as a control measure
8. Describe the methods for dealing with problem employees
9. Identify at least three types of employee counseling

PROCESS AND METHODS
OF CONTROLLING

SPECIFIC OBJECTIVES

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Controlling is the last step in the management process. It is a leadership
function in which performance is measured and corrective action is taken to
ensure the accomplishment of organizational goals. According to Rowland &
Rowland (1994), it is the policing operation in management, although the
manager seeks to create a positive climate so that the process of control is
accepted as a part of routine activity. The characteristics of effective control
process are (Rowland):

1. Timeliness. The control device should reflect deviations from the
standard promptly and early, so there is only a small lag between
detection and the beginning of the corrective action.
2. Economy. The control device must be the worth its cost.
3. Comprehensiveness. The control process should be directed at the basic
phases of the work rather than later levels. For example, a detective part
is best inspected and eliminated before it has been assembled with other
parts.
4. Specificity and appropriateness. The control process should reflect the
nature of the activity.
5. Objectivity. The control process should be grounded in facts. Standards
should be known and verifiable.
6. Responsibility. The control process should reflect the authority-
responsibility pattern. As far as possible the worker and the immediate
supervisor should be involved in the monitoring and correction process.
7. Understandability. Control devices charts, graphs, and reports should
not be complicated and cumbersome.

Swansburg (1993) describe a good control system as one that a) reflects
the nature of the activity; b) reports error promptly; c) is forward looking; d)
points out exceptions at critical points; e) is flexible; f) is objective; g) reflects
the organizational pattern; h) is economical; i) is understandable; j) indicates
corrective action.

Each nurse manager should have a master plan of control that
incorporates all standards related to these actions. Controls used include:

a) Nursing policies, rules, procedures
b) Discipline
c) Rounds, reports, audits
d) Evaluation devices
e) Task analysis
f) Quality control

NATURE AND PURPOSE OF
CONTROLLING

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Nursing policies, rules, procedures are found in Nursing Policy and Procedure
manuals. Regular nursing rounds cover such issues as patient care, nursing
practice, unit improvement.

Nursing standards are set during the planning stage and they serve as the
basis for evaluation of the quality of care and the performance of the unit and
the individual nurse executive/managers, in collaboration with the clinical
nurses, develop clinical nursing against which to measure patient outcomes
and the nursing process. These standards are patient outcomes and as nursing
care processes.

What are standards? According to Tappen (1996), a standard is a desired
quantity, or level of performance with reference to a criterion that is considered
proper for a given and against which actual performance is to be measured. It
is a descriptive statement of the level of performance against which to evaluate
the quality of structure and process.

Why is there a need for standards? The major reason for setting standards is to
increase quality by defining as clearly as possible what is acceptable and what
is not acceptable. A reason is for everyone involved with the organization as
well the consumers know what service is expected in that organization. A third
reason is to avoid biased evaluations. The standards, the judgments that are
made in the evaluation process can be variable and subjective.
























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Performance appraisal is a periodic formal evaluation of how well the
nurse has performed her duties on a specific period. (Marriner-Tomey, 1992).
The performance appraisal is accomplished by the manager or supervisor, and
more recently by the employees peers. In performance appraisals, the
employees performance is compared to a set of standards which describe what
the employee is expected to perform. Initially, employees need to know what are
expected of them.

The purposes of the evaluation according to Marriner-Tomey are:

1. To determine job competence;
2. To enhance staff development;
3. To discover the employees aspirations and to recognize her
accomplishments;
4. To improve communication between managers and staff associates and
to reach an understanding about the objectives of the job and agency.
5. To improve performance by examining and encouraging better
relationships among nurses;
6. To aid managers coaching and counseling;
7. To determine training and developmental needs of nurses;
8. To make inventories of talent within the organization and re assesses
assignments.
9. To select qualified nurses for advancement and salary increases, and;
10. To identify unsatisfactory employees.

Because evaluations are made by raters who tend to have their own
built-in sets of standards or sets of references in addition to their own biases
and prejudices, human errors in evaluation can easily occur. The manager
should be aware of these errors. For example Halo error can happen when
rating is done on the basis of general impressions. A logical error is rating a
nurse high on one characteristic because she possesses another characteristic
that is logically related. A manager is likely to rate personnel who are
compatible with her higher than they deserve. A person who does not complain
is also likely to have higher ratings than the person who does. The horns
error occurs with a manager who is perfectionist and hypercritical. These
usually rate personnel lower than they should. This is because they may
compare how to the job with how the employees do it now. The contrast error
is produced by a manager to rate the employee opposite from the way the
employee perceives.



PERSONNEL EVALUATION

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Methods of Evaluation.In Nursing, the methods of evaluation most often used
are:

Anecdotal Notes. These are objectives descriptions of behavior recorded on
plain paper or form. The notation includes who was observed, by whom, when,
and where. It describes the setting or background and the incident, as well as
the interpretation and recommendations.

Checklists. The checklists assess the presence or absence of desired
characteristics or behavior. Checklists are very useful for evaluating nursing
skills.

Rating Scales. The rating scale locates the behavior at a point on a continuum
notes quantitative and qualitative abilities. The numerical rating scale usually
includes numbers against which a list of behaviors are evaluated.
The scale can also be in the form of graphic (outstanding, above average, below
average, unsatisfactory) or descriptive graphic (usually on time, sometimes late,
usually late). BARS is an acronym for behaviorally anchored rating scales,
sometimes known as BES or behavior expectation scales. BOS is an acronym
for behavioral expectation scales (almost and always to almost and never).

Ranking. In ranking forces the manager rank staff in describing order from
highest to lowest, even if she does not feel there is a difference. In paired
comparison forces the manager compare each nurse with each other. If the
manager is ranking four nurses (A,B,C,D), she must deal with six possible
pairs:
A vs B Bvs C
A vs C B vs D
A vs D Dvs C

Tally marks can be placed in a matrix to help visualize the ranking.

Management by Objectives. Aside from being a tool for planning, MBO is also
an appraisal tool. In MBO the nurse has input and some control over her
future; she knows the standard by which she will be judged. She knows this
because she helped identify and determine her major job responsibilities and
expected levels of accomplishment.

Peer Review. This is a process whereby a group of practicing registered nurses
evaluates the quality of another registered nurses professional performance.
The peers should have similar education, experience and occupational status.
Its purpose is to provide the individual with the feedback from those who are
the best acquainted with the requirements and demands of that particular
position. Peer review includes both process and outcomes of practice.
Observations are made by one or more peers, compared with previously set
standards, and then shared with the person being reviewed. The reviewer is

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expected to look for those items indicated by the standards and to avoid
making judgments based on a personal standard of feelings. All feedback must
be documented in the review materials.

Appraisal Interview. According to Marriner-Tomey (1993), there are several
kinds of appraisal interview.

1. Tell-and-sell technique The manager does the most of the talking while
the employee listens. This assumes that the manager is qualified to
evaluate the employee and that she will want to correct her weaknesses if
she knows them. In other words, the manager assumes the role of a
judge. In using this technique, the manager risks losing the loyalty of the
employee, who usually becomes defensive.
2. Tell-and-listen. The manager speaks for about half of the time and lets
the employee speak for the remainder. The manager outlines the strong
and weak points of the employees job performance and then listens to
the employees response. She listens to disagreements and allows
defensive behavior without attempting to refute any response. This tends
to remove defensive behavior and the employee feels accepted. Resistance
to change is reduced with this technique.
3. Problem-solving. With this method, the interviewer assumes the role of
helper to stimulate growth and development in the employee. It assumes
that discussing problems can lead to improvements. The employee deos
most of the talking while the interviewer listens, reflects ideas and
feelings, asks exploratory questions, and summarizes. With this
technique, intrinsic motivation is stimulated.
4. Goal setting is a future oriented technique. It focuses attention on the
employees achievement. This is the same as MBO.

Evaluating Marginal Staff. It is easy to evaluate a highly motivated and
competent employee, but having to evaluate a marginal employee is altogether
a different story. It is not easy for any manager to sit down with the employee
and confront her with her shortcomings. But there is no excuse either for
inaction. Sometimes a manager can rationalize her inaction by saying that the
poor performance is just a temporary lapse, or that is due to a personal
problem at home. Sometimes, the poor performance is being excused because
the employee is a very nice person.

Sometimes though, the poor performance may not be entirely due to
the employee. These are factors in the work environment that leads to an
employees marginal performance. It may have started from the time of
selection, hiring and orientation. The employee may not have been carefully
screened or the orientation process may not have been thoroughly enough.
Poor communication, vagueness as to job expectations, unrealistic
expectations, as when assigning an inexperienced new graduate to take charge
of a unit, are factors contributing to poor performance.

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According to Tappen (1996), the first step in resolving poor performance is to
observe and actively document the problem. Once the problem behavior is
carefully documented, it is the counseling session with the employee. Both
positive and negative feedback should be the employee, so that a plan for
resolution of the problem can be developed. It is very important that employees
point of view be heard and that the employee is treated with respect. While
supporting the employee, it must made clear to her the consequences of poor
performance such as no raise, no promotions, a demotion or termination of
contract.

Every employee should be given at least a second perhaps a third opportunity.
An improvement plan should be clearly spelled out. The plan should include
specific problems which improvement is needed. It is important to warn the
employee of the consequences to improve. Several counseling sessions may be
needed to help employee improve. If plans to resolve the problem and improve
performance have failed, then the demotion or termination of the employee may
be resorted to.






























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Problem employees include the substance abusers, those who are withdrawn,
angry, those with excessive tardiness or absenteeism, those who are
quarrelsome and those whose performance are below par, in spite of remedial
measures. Disciplining and terminating these employees present a big
challenge to management. In each case with the problem, and evaluate the
results.

The Substance Abusers. Perhaps substance abuse is not so much a
problem in this country as in the western countries. But it is helpful for a
nurse manager to be aware of signs manifested by an employee with an alcohol
or drug addictions. Among alcoholic nurses studied in the United States, most
had been in the top third in their class, held advanced degrees, help
responsible and demanding jobs, and had an excellent work history (Marriner-
Tomey, 1992).

Employees with alcohol or drug problems often exhibit psychosocial
problems. She or he may become more irritable, withdrawn, moody, and
exhibits other signs of personality changes. He/she exhibits social changes
such as losing interest in socializing with others, avoiding social gatherings,
eating alone. There are also changes in personal appearance such as changes
in dressing, an unkempt appearance, flushed complexion, red eyes, swollen
face, hand tremors. Mental status changes include forgetfulness, confusion,
and decreased alertness. The impaired employees general behavior may also
change. She becomes intolerant and suspicious of others. Work efficiency
drops, there is a decline in the quality and quantity of work and the work pace
becomes uneven. Some assigned tasks are forgotten. Arriving late and leaving
early and extended lunch hours and break times becomes patters of behavior.
Accidents increase.

When an employee reports to work in an apparently intoxicated state,
the manager notes the signs objectively and asks a second person to validate
the observations. Signs of intoxicated include odor of alcohol, slurred speech,
unsteady gait, and errors in judgment. The intoxicated employee is removed
from the situation, confronted briefly and firmly about the behavior, and sent
home. The incident is recorded.

Among substance abusers, chronic performance problems are common.
Each time a performance problem occurs it should be documented. The date,
time, who was observed by whom, and a description of the incident are noted.
At a pre-arranged conference, the employee is confronted with the observations
and how they affect job performance and patient care. The employee is given
the opportunity to explain, alternatives are explored, and a course of action is
DEALING WITH PROBLEM EMPLOYEES

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planned. The manager may refer the employee to a treatment facility and meets
with her periodically to monitor progress. When alcoholics or drug abusers
refuse counseling or fail to follow the plan of care, they are told that treatments
are mandatory for continued employment. If they still refuse mandatory
participation in the treatment, they are terminated in accordance with the
organizations policies.

Angry or Withdrawn Employees. Managers may sometimes have to deal
with the angry and withdrawn employees who use such behaviors as response
to anxiety. The angry are likely to be considered trouble-maker. The withdrawn
are often viewed as nice. However, both need displaced anger, hostility,
aggressive behaviors such as using critical, sarcastic, and obscene with other
employees and patients have no place in the work setting. These behaviors
cause interpersonal relationships to suffer and impairment to productive work.
Managers recognize aggressive and passive behavior among employees, teach
and display assertive behavior among employees, and encourage problem
solving.

Other problems needing counseling and disciplinary actions are
excessive absenteeism and decreased productivity.

One of the difficult tasks that a manager will have to do at one time or
another is terminating an employee. The manager must help the employee deal
with related feelings at the same time the employee must deal too, with her
own mixed feelings and discomfort. She must understand that the employee
experiences a sense of loss and grief. Like any form of grief, it starts with a
period of denial followed by anger and loneliness. The manager can help the
terminated employee by providing an opportunity to talk about her feelings.
She should be allowed to air herself about leaving, her interest self-image, her
interest about filling another position, and other things to help relieve anxiety.
Rituals such as best wishes cards and giving away parties serve to pledge the
termination and provides a rite of separation that facilities the termination.

Employee Counseling. Counseling helps improve employees mental
health by enhancing self control and self confidence, ability to work effectively.
Communication both upward and downward is improved through counseling.
The directive, non-directive cooperative counseling, outplacement counseling (
Marriner-Tomey, 1992).

Directive Counseling happens when the counselor listens to the
employees problems to solve the problems, and tells he employee what to do.
The counselor gives advice. This type if counseling can give some emotional
release and fosters communication.

Non-directive counseling is client oriented. The counselor listens and
encourages the employee to explain her problems, identify alternatives, explore

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the ramifications of each option and determine the most appropriate solution.
This is a more costly and time consuming way of directing.

Cooperative Counseling is a compromise between directive and non-
directive. It is a creative effort by the counselor and the employee through an
exchange of ideas to help solve the problem. The cooperative counselor starts
by listening to the problem and as the flow progresses, she offers information
and insight and is likely to discuss the problems with broad knowledge of the
organizations point of view. This may help change the employees attitude.

Outplacement Counseling can be used to minimize the emotional and
professional pain of being terminated from a job. As discussed earlier, poor
performance, tardiness, absenteeism, substance abuse, inappropriate behavior,
and staff reduction are the most common reasons for discharging employees.
Some behavior may warrant immediate dismissal as for example, abuse of
patients and visitors, insubordination, intoxication, possession of drugs, theft,
gambling, disorderly conduct, willful destruction of property, sleeping on duty,
or falsification of records.

Termination usually involves several steps, beginning with an oral
warning, followed by a written warning with corrective interviews if the
employee has not improved. The written warnings used with corrective
interviews should state the expected level of performance and the consequence
if that standard is not met. Suspension is usually used before termination. The
counseling note is signed by both employee and manager. If the employee
refuses to sign a witness cant validate that the employee has read the
counseling notes and refuses to sign them.




















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Three different aspects of health care can be evaluated in a Quality
Improvement (QI) or Total Quality Management (TQM) program: the structure
within which, the care is given, the process of giving that care, and the
outcome of that care. To be comprehensive, an evaluation program must
include all three aspects of health care (Donnabedian, 1987).

Structure refers to the setting in which the care is given and the
resources that are available. The following are some of the aspects of health
care organization that can be included in a formal evaluation (Tappen, 1995):

a) Facilities: comfort, convenience of layout, accessibility of support
services, safety.
b) Equipment: adequate supplies, state-of-the-art equipment, staff ability to
use it.
c) Staff: credentials, experience, absenteeism, turn-over-rate, staff-patient
ratios.
d) Finances: salaries, adequacy, and sources.

Process refers to the actual activities carried out by the health care
providers. It includes psychosocial interventions, such as teaching and
counseling, as well as physical care measures. It can include leadership
activities such as interdisciplinary team conferences. The most direct way of
collecting process data is by observation of care giving activities. Other ways
are self-report of the care giver and the chart or record that is kept, called
audit.

Outcome refers to the results of the activities in which the healthcare
provider have been involved. Outcome measures evaluate the effectiveness of
these nursing activities by answering such questions as: Did the patient
recover? Is the family more independent now? Has team functioning
improved?

Quality Improvement.Tappen (1995) summarized the concept and
process of quality improvement as follows: Quality Improvement otherwise
known as QI is defined as conformance to currently accepted standards of
nursing practice and achievement of expected outcomes. The process of quality
improvement follows the process of problem solving. It may be retrospective,
concurrent, or prospective and may focus on structure, process and outcome
or all three. Data collection procedures include record audits, observation,
interviews, questionnaires.

EVALUATION OF FACTORS INVOLVED
IN HEALTH CARE

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The goal of quality improvement is to achieve optimal patient outcomes while
keeping costs to a minimum. At the unit level, a quality improvement project
begins with assignment of responsibility and identification of an area for study.
Once the scope of care is defined, the problem is further analyzed in terms of
its important aspects, generally accepted standards of care, indicators that the
standards have been met.

In 1991, the Joint Commission on Accreditation of Health Care
Organization put out guidelines on how to use Continuous Quality
Improvement to monitor, evaluate and improve nursing care on an ongoing
basis. The process is described in the following ten steps:

1. Assign responsibility. The organization leaders are responsible for
overseeing the design of, and fostering an approach to
continuously improving quality, establishing quality improvement
responsibilities in the organization and setting strategic priorities
for quality assessment and improvement.
2. Delineate scope of care and service. The first move is to identify key
functions. Key functions are those functions that have the greatest
effect on the quality of care the patient ultimately receives.
3. Identify important aspects of care and service that will be
monitored, and establish priorities among them.
4. Indentify indicators. Indicators are measures that can be used to
monitor care and services; the measures can be related the process
or outcome of care. Indicators are the measures of specific,
objective events, occurrences, facets of treatment and so forth that
provide information about the quality of a particular aspect of care
of service. To ensure that the most accurate and productive
indicators are used, those staff who are knowledgeable about the
particular aspects of care of service should work together.
5. Establish thresholds for evaluation. In this step organization
establishes, for each indicator, a mechanism to determine when
further evaluation must be triggered.
6. Reports, incident reports, medication sheets, department logs,
autopsy reports, infection control reports, direct observation and
measurement, utilization review findings.
7. Initiate evaluation. A decision is made about whether the data,
both from ongoing monitoring and other quality-related feedback,
warrant further evaluation the aspect of care and service.
8. Take actions to improve care. If evaluation identifies an
opportunity for improvement, actions should be recommended and
taken.
9. Assess the Effectiveness of Action and Maintain the Gain. The staff
review subsequent findings and recommend further action if
necessary. Ongoing monitoring should continue for selected
important aspects of care.

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10. Communicate Results to Relevant Individuals and Groups.
To close the loop of monitoring and evaluation, the conclusions,
recommendations, actions and follow-up should be disseminated
throughout the organization.










































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Budget as a Control Measure. A budget is a plan used for both
allocating of resources and to control costs. Usually budget periods coincide
with other control devices such as managerial reports, balance sheets, and
profit and loss statements. The budget establishes financial standards for the
division of nursing and through its cost center for each nursing unit. Feedback
on daily, weekly, monthly and quarterly basis supplies information needed to
compare managerial performance with the established standards. The budget
tells the manager a) whether or not they are exceeding the budget b) what
adjustments are needed c) whether their goals are being met d) whether
supplies and equipment are purchased and installed as scheduled e) whether
employees are recruited and used effectively to provide quality care f) whether
there are problem areas, and who are responsible for them.

The budget is a plan based on the best estimates and therefore, it
should be flexible to allow fluctuations in the volume of business and should
consider other factors and constraints that affect the organization. External
constraints facing the nurse managers are the rising costs of health care and
the ensuring cost cutting measures instituted by the organizations. The nurse
managers should not be penalized when the budgetary objectives are not met
due to events beyond their control. However, it should not hide waste and
inefficiency.

To effectively monitor the budget, it is necessary that all budget
objectives should contain procedures for quality review (Swansburg, 1993).
These techniques include identification of a budget monitor team to perform
such a review. This team together with the nurse administrators develops
financial instructions of guidelines and policies. The nurse manager brings to
its meetings standards of service that are defensible, such as data on workload
including numbers and types of procedures, patients, surgical operations and
visits. On-going programs and projects are reviewed by this team and if
programs are not meeting objectives are costly and unprofitable they are
cancelled.

Cost Containment. Because of the rising cost of health care, cost
containment is resorted to by health care organizations in order to stay solvent
and in competition with other organizations. The goal of cost containment is to
keep costs within acceptable limits. It involves cost awareness, monitoring,
management, and incentives to prevent, reduce, and control costs.

Cost Awareness makes the employee pay attention on the cost of supplies,
equipment and other resources involved in providing care. It increases
BUDGET AND COST CONTROL

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organizational awareness for containing costs, how they can be managed, and
by whom. Managers understand the budgeting process of the organization.

Cost Monitoringindentifies, reports, and monitor costs. The costs of staffing,
recruitment, turnover, absenteeism, sick time are analyzed, and inventories are
controlled.

Cost Management focuses on what can be done to contain costs. Program,
plans, objectives, and strategies are utilized. Responsibility and accountability
are established. Examples of strategies used on nursing units include: forming
a staff pool to maximize flexibility in staffing, cross-training of personnel,
encouraging employee vacation when census is low, tape recording shift
reports, controlling central supplies, allowing volunteers to discharge and
transport patients, and so forth.

Cost Incentive motivates cost containment and reward desirable behavior.
Contests for the best money saving ideas, perfect attendance are examples.

Cost Avoidance means not buying supplies, technology or services. It means
also carefully analyzing supply and equipment costs before making the
decision to purchase. Cost and effectiveness of disposable versus reusable
items are compared. The receipt, storage, and delivery of disposables and
processing costs of reusable items are part of the analysis. The least expensive
and most expensive items are identified.
Cost Reduction means spending less for goods and services. Safety programs
that reduce the costs of workers compensation and absenteeism programs that
reduce sick time, and absenteeism, and turnover reduce costs.

Cost Control is effective use of available resources through careful forecasting,
planning, budget preparation, reporting and monitoring. Cost Effectiveness
compares costs and identifying goals, analyzing alternatives, comparing costs
per program unit of service and amount of services needed, assessing effect of
the outcome, and determining cost outcome and cost effectiveness.


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It is now time for you to complete your term paper. It is suggested that
you write an analysis (complete with recommendations based on the findings of
the analysis) of any of the aspects of four management functions. The term
paper should be typewritten and at 25 pages long. The analysis has to be done
on a healthcare organization (hospital, basic healthcare setting, college of
nursing). If you have not yet chosen your topic, here are some suggestions:
Your analysis and recommendation for:
1. The Quality Assurance Program of your organization and your
recommendations for Improvement
2. Orientation Program
3. Control Measures such as cost containment, performance appraisal
4. Disciplining, Counseling, Terminating Employees
5. Dealing with Problem Employees
6. Budget
7. Staff Development Programs
8. Organizational structure and climate
9. The Process of Change
10. Power Play

LEARNING ACTIVITIES