PLANNING

is the process of pre- determining a course of action in order to arrive at a desired

result.

a continuous process of assessing, establishing goals and objectives, implementing

and evaluating them, and subjecting these to change as new facts are known.

The Planning Hierarchy

There are many types of planning; in most organizations, these plans form

a hierarchy, with the plans at the top influencing all the plans that follow. As depicted

in the pyramid below, the hierarchy broadens at lower levels, representing an

increase in the number of planning components. In addition, planning components

at the top of the hierarchy are more general and lower components are more

specific.

A. Mission

Is a brief statement identifying the reason that an organization exists.

It is an administrative statement that guides planning and decision making, and it is

not restricted by any time element.

Furthermore, a mission statement identifies the organization’s constituency and

addresses its position regarding ethics, principles, and standards of practice.

Mission of Ospital ng Makati

to ascertain the evolution  of Ospital ng Makati into a world class hospital through

delivery of an efficient, quality and affordable healt care in a human compasionate

manner that ensures client satisfaction

B. Vision

what the group desires to achieve in the future; the prospective reason for

establishing an organization; future-oriented.

Vision of Ospital ng Makati

to make the Ospital ng MAkati into a state of the art hospital, providing ultimate

health case service

C. Philosophy

Flows from the purpose or mission statement and delineates the set of values and

beliefs that guide all actions of the organization.

It is the basic foundation that directs all further planning toward the mission.

Articulates a vision and provides a statement of beliefs and values that direct one’s

practice.

The organizational philosophy provides the basis for developing nursing

philosophies at the unit level and for nursing services as a whole

D. Goals

Defined as the desired result toward which effort is directed; it is the aim of

philosophy.

Are long-term hopes and aspirations.

Should be a broad statement that is not directly measurable but is attainable.

Goals usually have multiple objectives that are each accompanied by a targeted

completion date.

Differs from an objective in lacking deadline, and usually they are long-range rather

than short-term.

Goals, much like philosophies and values, change with time and require periodic

reevaluation and prioritization. Simply stated, goals should clearly delineate the

desired end-product.

Although goals may direct and maintain the behavior of an organization, there are

several dangers in using goal evaluation as the primary means of assessing

organizational effectiveness. The first danger is that goals may be in conflict with

each other, creating confusion for employees and consumers. The second danger

is that publicly stated goals may not truly reflect organizational goals. Organizational

goals can be a mask for individual unit or personal goals. The final danger is that

because goals are global, it is often difficult to determine whether they have been

met.

All in all, goals along with objectives provide direction to both planner and

administrator. Program development goals and objectives describe what the

administration hopes to be able to do on completion of the planning phase of a

project, service, or program.

E. Objectives

Defined as any statement of short-term, measurable, specific activity having a

specific time limit or timeline for completion.

The more specific the objectives for a goal can be, the easier it is for all involved in

goal attainment to understand and carry out specific role behaviors.

Objectives are phases of activities through which one should pass on the way to

accomplishing a goal. Therefore, objectives need to be in line with goals; they

should not be loosely connected to the goal, but should be directly connected to

accomplishing it; and lastly, goals should be in line with and accomplish the mission

statement of the organization. All three factors should assist in fulfilling the strategic

plan of the organization.

Objectives need to be written clearly.

They should be in action oriented, measurable, and detail the specifics of the goal.

Use the KISS (Keep It Short and Simple) method when writing and developing

objectives.

Clearly written goals and objectives must be communicated to all those in the

organization responsible for their attainment. This is a critical leadership role for the

nurse-manager.

Objectives can focus either in the desired process or the desired result.

Process objectives are written in terms of the method to be used; whereas result-

focused objectives specify the desired outcome.

Planning objectives, being very specific, are for the planning, implementation, and

evaluation of new programs and services.

Thus, objectives which are either process or result-focused are most helpful if they

guide the implementation and management process.

F. Policies

Are plans reduced to statements or instructions that direct organizations in their

decision making.

A policy is a statement of expectations that sets boundaries for action taking and

decision making (Paige, 2003).

Explain how goals will be achieved and serve as guides that define the general

course and scope of activities permissible for goal accomplishment.

They serve as a basis for future decisions and actions; help coordinate plans,

control performance, and increase consistency of action by increasing the

probability that different managers will make similar decisions when independently

facing similar situations.

Policies also serve as a means by which authority can be delegated.

Types of Policies:

1. Implied – are policies which are not directly voiced or written but are established by

patterns of decisions. They may have either favorable or unfavorable effects and

represent an interpretation of observed behavior.

2. Expressed – policies which can be oral or written. Oral policies are more flexible

than written ones and can easily adjusted to changing circumstances. However,

they are less desirable than written ones because they may not be known. The

process of writing policies reveals discrepancies and omissions and causes the

manager to think critically about the policy, thus contributing to clarity. However, a

disadvantage of written policies is the reluctance to revise them when they become

outdated.

G. Procedures

Are plans that establish customary or acceptable ways of accomplishing a specific

task and delineate a sequence of steps of required action.

They help achieve a high degree of regularity by enumerating the chronological

sequence of steps.

Procedures are intradepartmental or interdepartmental and consequently do not

affect the entire organization to the extent policy statements do.

H. Rules

Rules and regulations are plans that define specific action or non-action.

Generally included as part of the policy and procedure statements, rules describe

situations that allow only one choice of action. Because rules are the least flexible

type of planning on the planning hierarchy, there should be as few rules as possible

in the organization.

Existing rules, however, should be enforced to keep morale from breaking down

and to allow organizational structure

Planning Process

The planning process is a critical element of management. Nurse administrators

must learn it, because it will not happen by accident. Planning is largely conceptual, but

its results are clearly visible. The statement of the purpose or mission, philosophy, goals,

objectives, policies, procedure, rules, and regulations are all consequences of planning.

Therefore, these elements pave the way for smooth operations or implementation of

various activities.

2 Major Types of Organizational Planning

1. Strategic Planning

extends 3-5 years into the future

begins with in-depth analysis of the internal environment’s strengths and

weaknesses and the external opportunities and threats

determines the direction of the organization, allocates resources, assigns

responsibilities and determines time frames

Goal setting process that is largely carried out by top management

The process of strategic planning is more important than the plan itself. The

process serves to give planners a sense of direction, involves everyone, and

enables unexpected opportunities to be seized and unexpected crises dealt with.

Berry (1994) suggests that strategic planning as a management process combines

four basic features:

o A clear statement of the organization’s mission

o The identification of the agency’s external constituencies or stakeholders

and the determination of the assessment of the agency’s purposes and operations

o The delineation of the agency’s strategic goals and objectives, typically in a

3-to-5 year plan

o The development of strategies to achieve the goals

Strategic planning requires managerial expertise in healthcare economics, human

resource management, political and legislative issues affecting healthcare, and

planning theory.

Long-range planning requires the leadership skills of being sensitive to the

environment, being able to appraise accurately the social and political climate, and

being willing to take risks.

2. Operational Planning

Specifies the activities and procedures that will be used.

Sets timetables for the achievement of objectives

Tells who the responsible persons are for each activity and procedure

Are everyday working management plans developed from both long-range

objectives and the strategic planning process and short-range or tactical plans.

Describes ways of preparing personnel for jobs and procedures for evaluating

patient care

Specifies the records that will be kept and policies needed

Gives individual managers freedom to accomplish their objectives and those of the

institution, division, department or unit.

Strategic Planning Process

The strategic planning process includes four specific stages: (1) situational

analysis, which includes both an internal and an external environment

analysis; (2) strategy formulation; (3) strategic implementation; and (4)

strategic control.

1. Situational Analysis

In this initial stage in the strategic planning process, planners seek to identify

and asses the opportunities and threats facing an organization from its external

environment, and to identify and assess the internal strengths and weaknesses of

the organization in the context of its philosophy, culture and objectives.

The Situational Analysis has two components:

A. External Environmental Analysis - the external environment for any organization

includes all the factors outside its boundaries that can influence the organization’s

performance. This analysis includes environmental scanning to identify strategic

issues like trends, developments, opportunities, threats and possible events.

B. Internal Environmental Analysis - a good internal environment analysis includes

two parts: (1) a review of current strategy, and (2) a critical resource analysis in

which both strengths and weaknesses inherent in the organization are identified and

assessed.

2. Strategy Formulation

The second stage in the strategic planning process is Strategy Formulation.

Guided by the results of both the internal and external components of situational

analysis, strategic managers are in the position to establish organizational

objectives, develop and evaluate strategic alternatives, select their strategy, and

develop implementation plans. No matter how carefully the strategies are developed

and formulated for an organization, including how fully they respond to the

opportunities and defend against the threats identified in the situational analysis

stage, these strategies must be effectively implemented if an organization is to be

successful.

3. Strategic Implementation

In the implementation stage of strategic planning, attention is turned to the

challenges involve in carrying out strategies, challenges that can be very significant.

The managers’ abilities to design appropriate organizational structures and to

assemble staffs with the skills and abilities needed to carry out the implementation

of strategies are crucial in successful implementation. Similarly, their ability to

motivate the necessary levels of effort on the part of many different organizational

participants is vital in successful strategic implementation.

4. Strategic Control

Strategic implementation is monitored and the resulting information is used

to control ongoing decisions, actions and behaviors affected by the organization’s

strategies. In this stage, actual results are monitored and compared to previously

established objectives and standards, and deviations are corrected.

Purpose of Strategic Planning

clarifies beliefs and values

gives direction to the organization, improves efficiency, weeds out poor or

underused programs, eliminates duplication of efforts, concentrates resources on

important devices, improves communications and coordination of activities, and

helps ensure goal achievement

Benefits of Strategic Planning

Objective consideration of strategic choices or options that are better matched with

organizational goals and objectives

Outlook becomes futuristic

Resources are allocated systematically

Rapid change is accommodated

Barriers to Planning

1. Fail to establish or understand goal, objective and philosophy within the organization

which are congruent with the goal, objective and philosophy established at higher

levels.

2. Usage of conventional planning which consider status quo as a stable environment,

prefer maintenance of conformity and resistance to change.

3. Establish vague plan discourage rather than motivate employee to reach goal.

4. Inability to include in the planning process the people that could be affected by the

course of action.

5. Over planning and Under planning

6. Lack of evaluation checkpoints that could why plan failed.

Leadership Roles and Management Functions Associated with Planning

Leadership Roles

1. Assesses the organization’s internal and external environment in forecasting and

identifying driving forces and barriers to strategic planning.

2. Demonstrate visionary, innovative and creative in organizational and unit planning,

thus inspiring proactive rather than reactive planning.

3. Influences and inspires group members to be actively involved in long term

planning.

4. Periodically completes value clarification to increase self-awareness.

5. Encourages subordinates toward value clarification by actively listening and

providing feedback.

6. Communicates and clarify organizational goals and values to subordinate.

7. Encourages subordinates to be involved in policy formation, including developing,

implementing, and reviewing unit philosophy, goals, objectives, policies, procedures

and rules.

8. Is receptive to new and varied ideas.

9. Role models proactive planning methods to subordinates

Management Functions

1. Is knowledgeable regarding legal, political, economic and social factors affecting

health care planning.

2. Demonstrate knowledge of and use appropriate techniques in both personal and

organizational planning.

3. Provides opportunity to subordinates, peers, competitors, regulatory agencies, and

the general public to participate in planning.

4. Coordinates unit-level planning to be congruent with organizational goal.

5. Periodically assesses unit constraints and assets to determine the available

resources for planning.

6. Develops and articulates unit philosophy that is congruent with the organization.

7. Develops and articulates unit goals and objectives that reflect unit philosophy.

8. Develops and articulates unit policies and procedure and rules that operationalize

unit objectives.

9. Periodically reviews unit philosophy, goals, policies, procedures and rules and

revises them to meet the unit’s changing needs.

10. Actively participates in organizational strategic planning, defining and

operationalizing, such strategic plans on the unit level

ORGANIZATION PHILOSOPHY:

When nurses work together within a healthcare setting, their professional practice

is guided by that facility's professional philosophy of nursing. The philosophy is derived

from the mission and values of the organization.

Identification

1. At its core, the professional philosophy of nursing reflects the desired approach

to patient care within an organization. At Bloomington (Indiana) Hospital, for

example, nurses follow a holistic approach to lessen the effects of illness and

provide comfort and healing.

Features

2. A professional philosophy of nursing reflects how nursing is viewed within the

organization. At the University of Iowa Hospitals and Clinics in Iowa City, nursing is

described as both an art and a science dedicated to improving the well being of

patients.

Functions

3. A shared philosophy of nursing keeps everyone on the same page when

decisions are made about patient care. The philosophy statement for nurses at The

Miriam Hospital in Providence, Rhode Island clearly states nursing is a unique

discipline that delivers care based on the nursing process.

Benefits

4. Ultimately, a professional philosophy of nursing ensures that patients and their

families receive the very best possible care from a cohesive group of professional

nurses.

Significance

5. When the underlying nursing philosophy is clearly-stated, nurses have a valid

framework for making the difficult decisions that are part of everyday professional

practice.

Since the beginning of time, men and women have engaged in the search for reality

and truth. This search is called philosophy. Nursing philosophy examines the

relationship between truth and ideals in nursing. The examination of these truths

and ideals leads to beliefs and ideals that form the framework for nursing practice.

This framework is meant to guide the day-to-day process of nurses.

Nursing philosophy can be individual or it can be global. Individual philosophies

belong specifically to the nurse and reflect the nurse's values, logic, morals, and

ethics.

Global philosophies are usually those that belong to groups or organizations, or to

different bodies of knowledge as a whole, such as colleges, hospitals, or nursing

organizations.

Nursing philosophy is dynamic and changes over time, and with

circumstances. It is influenced by the era and the environment in which it is

practiced. Nursing philosophy and theory are intricately related. Renowned nursing

theorists such as Florence Nightingale and Dorothea Orem are also nursing

philosophers.

If it can be said that nursing philosophy is the search for truth in nursing,

then it can be said that nursing theory is a tentative prediction about the outcome of

that search. Nursing philosophy forms the frame of reference for the scientific view

of the nursing process through the development of a logical body of scientific

evidence. Nursing philosophy gives the practice of nursing credibility and defines it

as a profession.

When nurses discuss the morality of assisted suicide, or verbalize the belief that all

terminally ill patients should be pain free, that is the expression of philosophy.

When nurses make predictions about whether nursing intervention A will work

better than intervention B for pain management, then theories are formed.

When nurses find out through testing that nursing intervention A really does work

better than intervention B, then a logical body of scientific evidence is developed.

So, it becomes easy to see how philosophy, theory, and science flow from

one concept to another with each one being interdependent upon the other.

Individual philosophies can be combined with the philosophies of others to become

global philosophies, and these philosophies can have a tremendous impact upon

the way nursing is practiced through the development of scientific theory.

With that being said, it is important for each individual nurse to examine

their own nursing philosophy, for this is the grassroots core to furthering nursing

scientific logic.

SOCIETAL VALUES:

Societies and organizations have philosophies or set of beliefs that guide

their behaviour. These beliefs that guide behaviour are called values. Values have

an intrinsic worth for a society or an individual. Some strongly held are American

values are individualism, the pursuit of self-interest, and competition. These values

have profoundly health care policy information and implementation. The result is a

health care system that promotes structured inequalities. Despite spending trillions

of dollars on health care annually, millions of American citizens have no health

insurance, and millions of others are underinsured.

Although values seem to be importance for health care policy development

and analysis, public discussion of this crucial variable is often neglected. Instead,

health care policy makers tend to focus on technology, cost-benefit analysis and

cost-effectiveness. Although this type of evaluation is important. It does not address

the underlying values in this country that have led to unequal access to health care.

INDIVIDUAL VALUES:

Values have tremendous impact on the decision that people make. For the

individual, personal beliefs and values are shaped by the person's experiences.

All people should examine their value system and recognize the role that it

plays on how they make decision and resolve conflicts and even how they perceive

things. Therefore, the nurse-leader must be self-aware and provide subordinates

with learning opportunities or experiences that foster increase self-0awareness.

Four Characterisitcs of a True Value:

1. it must be freely chosen from among alternatives only after due reflection

2. it must be prized and cherished

3. it is consciously and consistently repeated

4. it is positively affirmed and enacted

If a value does not meet all four criteria, it is a value indicator. Most people

have many value indicators but few true values. For example, many nurses assert

that they value their national nursing organizaton, yet they do not pay dues or

participate on the organizaton. True values require that the person take action,

where as value indicators do not. Thus, the value ascribed the national nursing

organization is a value indicator for these nurses and not a true value. In addition,

because our values change in time, periodic clarification is necessary to determine

how our values may have changed. Values clarification includes examining values,

assigning priorities for those values, and determining how they influence behaviour

so that one's lifestyle is consistent with the prioritized values. Sometimes, values

change as a result of life experiences or newly acquired knowledge. Most values we

have as children reflect are parent’s values. Later, our values modified by the peers

and role models. Although they are learned, values can not be forced on the person

because they must be internalized. However, restricted exposure to other viewpoints

also limits the number of value choices a person is able to generate. Therefore,

becoming more worldly increases our awareness of alternatives from which we

select our values.

ORGANIZING

Organizational Structure

Organizational structure refers to the way in which an organization’s

activities are divided, grouped, and coordinated into relationships between

managers and employees, managers and managers and employees and

employees.

Components of Organizational Structure

Relationships and Chain of Command

The organization chart defines formal relationships within institution. Formal

relationships, lines of communication, and authority are depicted on a chart by

unbroken solid lines. These line positions can be shown by solid horizontal or

vertical lines. Solid horizontal lines represent communication between people with

similar spheres of responsibility and power but different functions. Solid vertical lines

between positions denote the official chain of command, the formal paths of

communication and authority. Those having the greatest decision-making authority

are located at the top; those with least are the bottom. The level of position on the

chart also signifies status and power.

Dotted or broken lines on the organization chart represent staff positions.

Because these positions are advisory, a staff member provides information and

assistance to the manager but has limited organizational authority.

Advisory positions do not have inherent legitimate authority. Clinical

specialists and in-service directors in staff positions often lack the authority that

accompanies a line relationship. Only line positions have authority for decision

making, staff positions may result in an effective use of support services unless job

descriptions and responsibilities for these positions are clearly spelled out.

Unity of command is indicated by the vertical solid line between positions on

the organizational chart. This concept is best described as one person/one boss:

employees have one manager to whom they report and to whom they are

responsible.

Span of Control

Span of control also can be determined from the organization chart. The

number of people directly reporting to any one manager represents that manager’s

span of control and determines the number of interactions expected of him or her.

Theorists are divided regarding the optimal span of control for any one manager.

Quantitative formulas for determining the optimal span of control have been

attempted; suggested ranges are from 3 to 50 employees. When determining an

optimal span of control of control in an organization, the manager’s abilities, the

employees’ maturity, task complexity, geographic location, and level in the

organization at which the work occurs must be all considered. The number of people

reporting to any supervisor must be the number that maximizes productivity and

worker satisfaction. Too many people reporting to a single manager delays decision

making, whereas too few results in an inefficient, top-heavy organization.

Managerial Levels

In large organizations, several levels of managers often exist. Top-level

managers look at the organization as a whole, coordinating internal and external

influences, and generally make decisions with few guidelines or structures.

Examples of top level managers include CEO and the highest level nursing

administrator.

Responsibilities common to top-level managers include determining the

organizational philosophy, setting policy, and creating goals and priorities for

resource allocation. Top-level managers have a greater need for leadership skills

and are not as involved in routine daily operations as are lower-level managers.

Middle-level managers coordinate the efforts of lower levels of the hierarchy

and are the conduit between lower and top-level managers. Middle-level managers

carry out day-to-day operations but are still involved in some long-term planning and

in establishing unit policies. Examples of middle-level managers include nursing

supervisors, nurse-managers, head nurses, and unit managers.

First-level managers are concerned with their specific unit’s work flow. They

deal with immediate problems in the unit’s daily operations, with organizational

needs, and with personal needs of employees. The effectiveness of first-level

managers tremendously affects the organization. First-level managers need good

management skills. Because they work so closely with patients and healthcare

teams, first-level managers also have an excellent opportunity to practice leadership

roles that will greatly influence productivity and subordinates’ satisfaction. Examples

of first level managers include primary care nurses, team leaders, case managers,

and charge nurses.

Centrality

Centrality refers to the location of a position on an organization chart where

frequent and various types of communication.

Centrality is determined by organizational distance. Employees with

relatively small organizational distance can receive more information than those who

are view of the organization than other levels of management. A middle manager

has a large degree of centrality because this manager receives information upward,

downward, and horizontally.

Types of Organizational Structure

Formal and Informal Organizational Structure

Each organization has a formal and an informal organizational structure.

The formal structure is generally highly planned and visible, whereas the informal

structure is unplanned and often hidden. Formal structure, through

departmentalization and work division, provides a framework for defining managerial

authority, responsibility, and accountability. In a well-defined formal structure, roles

and functions are defined and systematically arranged, different people have

differing roles, and rank and hierarchy are evident.

Informal structure is generally social, with blurred or shifting lines of

authority and accountability. People need to be aware that informal authority and

lines of communication exist in every group, even when they are never formally

acknowledged.

Tall/ Centralized/ Bureaucratic (Hierarchal) Structure

A hierarchal structure is commonly called a line structure. It is the oldest

and simplest form of management and is associated with the principle of chain of

command, bureaucracy and a multi-tiered hierarchy, vertical control and

coordination, levels differentiated by function and authority, and downward

communications.

In a simple centralized organizational structure, power, decision making

authority and responsibility for goal setting are vested in one person at the top. This

structure is usually found in small and single-person-owned organizations. The basic

requirement of a simple centralized structure is that it has only one or two functions,

and a few people who are specialists in critical functions. The manager is generally

an expert in all related areas of functions and is responsible for coordination. Thus,

the organization has only two hierarchical levels. However, this structure has to

become more complex for growth, diversification or other reasons.

Line, Staff, and Line-and-Staff Structures

Bureaucratic organizational designs are commonly called line structures of

line organizations. Those with staff authority may be referred to as staff

organizations. Both of these types of organizational structures are found frequently

in large healthcare facilities and usually resemble Weber’s original design for

effective organizations.

Because of most people’s familiarity with these structures, there is little

stress associated with orienting people to these organizations. In these structures,

authority and responsibility are clearly defined, which leads to efficiency and

simplicity of relationships.

A line-and-staff organization develops when a simple line structure is

altered to provide support to line authorities. The line functions are command and

control. The staff functions are separate from the chain of command, involve

specialization, and are supportive to line authorities. Staff does what the executives

are too busy to do. It is the function of staff to serve the line organization and to

submerge personal interests to champion the executive’s long range of objectives.

Staff can manage policies and procedures, in-service and continuing education, or

quality improvement.

Advantages of line and staff structures are that the executive can delegate

tasks that the executive does not have the skill or time to do to functional experts.

Disadvantages are that they often produce monotony, alienate workers, and make

adjusting rapidly to altered circumstances difficult. Another problem with line and

line-and-staff structures is their adherence to chain of command communication,

which restricts upward communication. Good leaders encourage upward

communication to compensate for this disadvantage. However, when line positions

are clearly defined, going outside the chain of command for upward communication

is usually inappropriate. Another is that executives may get the credit for staff

recommendations. Staff may increase their influence by usurping the authority of

the executive by making decisions without consulting the executive. The executive

may ignore the staff’s recommendations.

Ad Hoc Design

The Ad hoc design is a modification of the bureaucratic structure and is

sometimes used on a temporary basis to facilitate completion of a project within a

formal line organization. They are also called 'free form' or organic organization

structures. They stress managerial styles which do not depend upon formal

structures. An adhocratic structure is flexible, adaptive and organized around special

problems to be solved by a group consisting of experts with diverse professional

skills (Robbins, 1989). These experts have decision making authority and other

powers. The adhocratic Structure is usually small, with an ill-defined hierarchy. Such

a design is suitable for high technology and high growth organizations where an

arranged and inflexible structure may be a handicap. Ad hoc structures are usually

disbanded after a project is completed. This structure’s disadvantages are

decreased strength in the formal chain of command and decreased employee

loyalty to the parent organization.

Matrix structure

A Matrix organization structure is designed to focus on both product and

function. Function is described as all the tasks required to produce the product, and

the product is the end result of the function. For example, good patient outcomes

are the product and staff education and adequate staffing may be the functions

necessary to produce the outcome.

A matrix management structure superimposes a horizontal program

management over the traditional vertical hierarchy. Personnel from various

functional departments are assigned to a specific program or project and become

responsible to two bosses – a program manager and their functional department

head. Thus an interdisciplinary team is created with core and extended team

members.

The matrix organization design enables timely response to external

competition and facilitates efficiency and effectiveness internally through

cooperation among disciplines. The figure below depicts a matrix organizational

structure and shows that the director of maternal childcare could report both to a

vice president for maternal and women’s services (product manager) and a vice

president for nursing services (functional manager). Although there are less formal

rules and fewer levels of the hierarchy, a matrix structure is not without

disadvantages. For example, in this structure, decision making can be slow

because of the necessity of information sharing, and it can produce confusion and

frustration for workers because of its dual-authority hierarchal design. The primary

advantage of centralizing expertise is frequently outweighed by the complexity of the

design.

Flat/Decentralization (horizontal, participatory) Structure

Flat organizational structures are effort to remove hierarchal layers by

flattening the scalar chain and decentralizing the organization. Decentralization

refers to the degree to which authority is shifted downward within an organization to

its divisions, services, and units. Decentralization is delegating decision-making

responsibilities to the ones doing the work – participatory management.

Implementation of a philosophy of decentralized decision-making by top

management sets the stage for involving more people – perhaps even the entire

staff – in making decisions at the level at which an action occurs. Both

decentralized management and participatory management delegate authority from

top managers downward to the people who report to them. In doing so, objectives

or duties are assigned, authority is granted, and an obligation or responsibility is

created by acceptance.

THE PATIENT CLASSIFICATION SYSTEM

The PCS is a scheme that group patients according to the amount and

complexity of their nursing care requirements. It serves as a tool to measure patient

needs, caregiver interventions, and the skill levels required to meet those needs.

The Purpose Of The Patient Classification System is To:

Determine the required nursing hours needed to provide safe and efficient patient

care based on standards of care and practice.

Determine the number and category of staff (skill mix) needed for providing quality

patient care.

Monitor changes in patient demographics and care needs.

Provide data on each patient care unit that directs and supports staffing decision-

making.

Ensure that quality nursing care is provided in a safe environment.

Assess the level and support services required.

Enhance staff satisfaction through a stress free work environment

This process will determine the actual workload needed and  predict the nursing

load required. Once the care needs are determined, the hours can be broken down into

time requirements for each category of nursing personnel. Thus, the PCS software

determines the number of nurses needed for a group of patients, together with the skill

mix within that number.

Categories or levels of care of patients. Nursing care hours needed per patient

per day and ratio of professionals to non-professionals.

Levels of Care NCH Needed Per Pt. Per

Day

Ratio of Prof. to Non-

Prof.

Level I

Self Care or Minimal Care

Level II

Moderate or Intermediate Care

Level III

Total or Intensive Care

Level IV

Highly Specialized or

Critical Care

1.50

3.0

4.5

6.0

7 or higher

5:45

60:40

65:35

70:30

80:20

Level I – Self Care or Minimal Care

Patient can take a bath on his own, feed himself, feed and perform his activities of

daily living. Falling under this category are patients about to discharged those in non-

emergency, those newly admitted, do not exhibit unusual symptoms, and requires little

treatment/observation and/or instruction.

Level II – Moderate Care or Intermediate Care

Patients under this level need some assistance in bathing, feeding, or ambulating

for short period of time. Extreme symptoms of their illness must have subdivided or have

not yet appeared. Patients may have slight emotional needs, with vital signs ordered up to

three times per shift, intravenous fluid or blood transfusion; are semi conscious and

exhibiting some psychosocial or social problems; periodic treatments, and / or

observations and / or instructions.

Level III – Total, Complete or Intensive Care

Patients under this category are completely dependent upon the nursing

personnel. They are provided complete bath, are fed, may or may not be unconscious,

with marked emotional needs, with vital signs more than three times per shift, maybe on

continuous oxygen therapy, and with chest or abdominal tubes. They require close

observation at least 30 minutes for impending hemorrhage, with hypo or hypertension and

/ or cardiac arrhythmia.

Level IV – Highly Specialized Critical Care

Patients under this level need maximum nursing care with a ratio of 80

professionals to 20 non-professionals. Patients need continuous treatment and

observation; with many medications, IV piggy backs; vital signs every 15-30 minutes;

hourly output. There are significant changes in doctor’s order and care hours per patient

per day may range from 6-9 or more, and the ratio of professionals to non-professionals

also range from 70:30 to 80:20.

Percentage of patients at various levels of care per type of hospital.

Type of Hospital Minimal

Care

Moderate

Care

Intensive

Care

Highly

Special Care

Primary Hospital

Secondary Hospital

Tertiary Hospital

SpecialTertiary

Hospital

70

65

30

10

25

30

45

25

5

5

15

45

-

-

10

20

Major types of nursing care modalities:

1. Functional Method

2. Team Nursing

3. Primary Nursing

4. Case Method

1. Functional Method

This method is commonly called as “Task Based Nursing” in which a particular

nursing function is assigned to each staff member. Example: One RN is responsible

for administering medication, one for treatment, one for managing intravenous

administration, and so on. No nurse is responsible for the total care of any patient. It

is efficient and best system when confronted with a large patient load and a

shortage of professional nurses.

Advantage: It accomplishes the most work in the shortest amount of time.

Disadvantages:

a) It fragments nursing care

b) It decreases nurse’s accountability and responsibility

c) It makes the nurse-patient relationship difficult to establish

d) It gives professional nursing low status in terms of responsibility for patient care.

2. Team Nursing

Teams within a group are formed and a nurse acts either as a team leader or a

member. The team leader assumes responsibilities from the nurse manager insofar

as his members and task assigned are concerned. In effect, not all powers of

supervision are exercised by the nurse manager, as it is delegated to each team

leader and to all members of the health care team.

Advantages:

a) It involves all team members in planning patient’s nursing care, through the use of

team conferences and writing nursing care plans.

b) It provides the best of care at the lowest, according to some advocates

Disadvantages:

a) It can lead to fragmentation of care if the concept is not implemented totally

b) It can be difficult to find time for team conferences and care plans

c) It allows the RN who is the team leader to have the only significant responsibility

and authority

** The disadvantages of team nursing can be overcome by educating competent

leaders in the principles of nursing management.

3. Primary Nursing

Direct planning of patients’ care is formulated by a primary nurse to certain patients

from the moment of admission till discharge. The management of care of patient is

assumed by the primary nurse is practically 24 hours continuous care. Increase in

the accountability, responsibility, cost planning, communication and coordination are

always the basic characteristics of this method of nursing care delivery.

Advantages:

a) It provide increase autonomy on the part of the nurse, thus increasing motivation,

responsibility and accountability

b) It assures more continuity of care, as the primary nurse gives or direct care

throughout hospitalization.

c) It makes available increase knowledge of the patient’s psychosocial and physical

needs because the primary nurse does the history and physical assessment,

develops the care plan, and acts as a liaison between the patient and other health

workers.

d) It leads to increase rapport and trust between nurse and patient that will allow

formation of a therapeutic relationship.

e) It improves communication of information to physicians

f) It eliminates nurse aides from the administration of direct patient care.

Disadvantage:

The main disadvantage is that, it is said to require that the entire staff be RNs,

which increases staffing cost.

4. Case Method

The case method of nursing provides for a 1:1 RN-to-client ratio and the provision of

constant care for a specified period of time. Examples are private duty, intensive

care and community health nurses. This method is similar to that of primary nursing,

except that relief nurses on other shifts are not associate RNs.

STAFFING

Staffing is the process of determining and providing the acceptable number and

mix of nursing personnel to produce a desired level of care to meet the patients’ demand.

Purpose of Staffing

The purpose of all staffing activities is to provide each nursing unit with an

appropriate and acceptable number of workers in each category to perform the nursing

tasks required. Too few or an improper mixture of nursing personnel will adversely affect

the quality and quantity of work performed. Such situation can lead to high rates of

absenteeism and staffs turn-over resulting in low morale and dissatisfaction.

Staffing Philosophy

Staffing is certainly one of the major problems of any nursing organization, whether

it be a hospital, nursing home, home health care agency, ambulatory care agency, or

other type of facility. Nurse staffing methodology should be an orderly, systematic

process, based upon sound rationale, applied to determine the number and kind of

nursing personnel required to provide nursing care of a predetermined standard to a

group of patients in a particular setting. The end result is prediction of the kind and

number of staff required to give care to patient.

The staffing process is complex. Components of the staffing process as a control

system include a staffing study, a master staffing plan, a scheduling plan, and a nursing

management information system (NMIS).

The nurse administrator develops a staffing philosophy as a basis for a staffing

methodology. Community expectations will be related to economic status, local value and

belief systems, and local standards of culture. Nurses’ expectations will be related to the

same community standards, their own perceptions of the practice of nursing, and its

components, desired results, and tolerated workload.

Nurse managers can discern various values related to staffing from the nursing

division’s existing statement of purpose, philosophy, and objectives. A staffing philosophy

may encompass beliefs about using a patient classification system (PCS) for identifying

patient care needs. A successful nursing leader’s personal philosophy should include

allowing nursing staff some degree of control within their work environment. Nurses who

believe their work environment offers them a higher level of control are more likely to work

for improvements rather than leave the organization.

Objectives of nurse staffing are excellent care, positive patient outcomes, and high

productivity. Professional nurses can develop a statement of purpose that is

comprehensive in stating the quality and quantity of performance it is intended to

motivate. Purpose statement should be quantified.

Components of a Staffing Process

Staffing Study

A staffing study should gather data about environment factors within and outside

the organization that affect staffing requirements.

There are four techniques drawn from engineering to measure the work of nurses.

All involved the concept of time required for performance.

These techniques are:

1. Time study and task frequency

1.1 Tasks and task elements (procedures)

1.2 Point and time started

1.3 Point and time ended

1.4 Sample size

1.5 Average time

1.6 Allowance for fatigue, personal variation, and unavoidable standby

1.7 Standard time = step 1.1(1.5) + 1.1(1.6)

1.8 Frequency of task x standard time = volume of nursing work

2. Work sampling (variation of task frequency and time). Procedure is as follows:

Master Staffing Plan

Scheduling Plan

Position Control Plan

Budgeting Plan

Nursing Management Information System

Staffing Study

2.1 Identify major and minor categories of nursing activities.

2.2 Determine number of observations to be made.

2.3 Observe random sample of nursing personnel performing activities.

2.4 Analyze observations. Frequency occurring in a specific

category = percent of total time spent in that activity. Most work sampling studies sample

direct and indirect care to determine ratio.

3. Continuous sampling (variation of task frequency and time). Technique is the same as

for work sampling except that:

3.1 Observer follows one individual in the performance of a task.

3.2 Observer may observe work performed for one or more patients if they can be

observed concurrently.

4. Self-reporting (variation of task frequency and time).

4.1 The individual records the work sampling or continuous sampling on himself or herself.

4.2 Tasks are logged using time intervals or time tasks start and end.

4.3 Logs are analyzed.

There are three cardinal rules for forecasting staffing requirements. The first is to

base staffing projections upon past staffing history. The data can be collected from the

patient classification system reports and census reports. Such data is readily available in

most hospitals. Other data needed are sick time, overtime, holidays, and vacation time.

The attrition rate is also important.

The second cardinal rule for staffing is to review current staffing levels. Review of

future plans for the institution is the third cardinal rule. When clinical nurses are involved

in staffing plans, they will have confidence in them. These staffing studies can be made

with electronic spreadsheets.

Staffing requires much planning on the part of the nurse administrator. Data must

be collected and analyzed. The data include facts about the product – patient care. They

include diagnostic and therapeutic procedures performed both by physicians and by

nurses. They include the knowledge elements of professional nursing translated into

professional nursing skills of history-taking and assessment, nursing diagnosis and

prescription, application of care, evaluation, record keeping, and all other actions related

to primary health care of patients.

Basic to planning for staffing of a division of nursing is the fact that qualified

nursing personnel must be provided in sufficient numbers to ensure adequate, safe

nursing care for all patient 24 hours a day, 7 days a week, 52 weeks a year. Each stuffing

plan must be tailored to the needs of the hospital and cannot be arrived at by a simple

worker/patient ratio or formula.

Planning for staffing requires judgment, experience, and thorough knowledge of

the requirements of the organization in which the individual nurse administrator is

employed. It requires support of hospital administration, physicians in charge of clinical

services, and the nursing staff.

The basic requirement is unchanging, regardless of the type or size of the

institution: plan for the kinds and numbers of nursing personnel that will give safe,

adequate care to all patients and will ensure that the work of nursing is productive and

satisfying.

Changing and expanding knowledge and technology in the physical and social

sciences, in the medical field, and in economics influence planning for staffing. Health

care institutions are treating more clients on an outpatient basis. New drugs, improved

diagnostic and therapeutic procedures, and reimbursement changes have decreased the

length of hospital stays.

Planning for staffing is influenced by changing concepts of nursing roles for clinical

nursing practitioners and specialists. Decision-making is being delegated to the lowest

practical level. Ward clerks and unit managers have assumed duties formerly done by

nursing personnel.

Staffing plans are influenced by institutional missions and objectives related to

research, training, and many specialties. They are influenced by personnel policies and

practices related to vacations, time off, overtime, holidays, temporary workers, and other

factors. They are influenced by policies and practices related to admission and discharge

times of patients, assignment of patients to units, and intensive and progressive care

practices.

The amount and kind of nursing staff required will be influenced by the degree to

which other departments carry out their supporting services. This is particularly true during

weekends, evenings, night, and holidays. Staffing requirements should plan for nursing

personnel to perform non-nursing duties, such as dietary functions, clerical work,

messenger and escort activities, and housekeeping. Whether these services should or

should not be carried out by nursing personnel is not the point here; the point is that the

degree to which situation exists has to be considered in any planning. Nurse managers

should avoid assuming responsibility for non-nursing services and encourage the

appropriate departments to perform such services. Whether they do not, nurse managers

should have system of charging the provided services to the appropriate other cost center.

They will then become revenue to the nursing cost center.

Staffing plans will be influenced by the number and composition of the medical

staff and the medical services offered. Nursing requirements will be affected by

characteristics of patient populations determined by the size and capability of the medical

staff. Special requirements of the individual physicians; the time and length of their

rounds; the time required. And the complexity and number of tests, medications, and

treatment ordered; and kind and amount of surgery will all affect the quality and quantity of

nursing personnel required and influence their placement.

Arrangement of the physical plant has a large impact on staffing requirements.

Fewer personnel are needed for a modern, compact facility equipped with labor-saving

devices and efficient working arrangements than for one that is spread out and has few or

no labor-saving devices. Different staffing is required for facility that is arranged

functionally than for one that is not.

Staffing is further affected by the organization of the division of nursing. Plans

should be reviewed and revised to organize the department to operate efficiently and

economically with written statements of mission, philosophy, and objectives; sound

organizational structure; clearly defined functions and responsibilities; written policies and

procedures; effective staff development programs; and planned periodic system

evaluation. Staffing plans for such a department will be different from those for one that is

loosely organized with overlapping functions and responsibilities, vague or conflicting

policies, and poorly defined standards or nursing practice.

Staffing Function

Staffing function should probably be centralized, as this removes a clerical burden

from first line nurse managers and provides more time for them to attend to direct patient

care and nursing practice activities. All the activities related to staffing should be

developed into policies and procedures that reflect the thinking of nursing administration

and can be performed by non-nurse employees. Obviously, nurse managers will remain

involved in hiring, firing, and promotions, in consultation with top nurse managers and

human resources specialists.

A sign of maladministration in nursing is too many levels of supervision. There is

often a professional nurse employed at the department or division level to perform the

function of scheduling. Scheduling is time consuming and can be done by non-nurse

personnel. The staffing employee should be very competent person – “ a good

businessperson, mature, effective in interpersonal relations, objective in dealing with

personnel, fair and firm; one who can communicate effectively orally, by phone, and in

writing, and finally, one who has above average mathematical ability”

Staffing Responsibilities

The following are the sequential steps of staffing responsibilities, although each

step has some interdependence with all staffing activities:

1. Determine the number and types of personnel needed to fulfill the philosophy,

meet fiscal planning responsibilities, and carry out the chosen patient care delivery system

selected by the organization.

2. Recruit, interview, select, and assign personnel based on established job

description performance standards.

3. Use organizational resources for induction and orientation.

4. Ascertain that each employee is adequately socialized to organization values and

unit norms.

5. Develop a program of staff education that will assist employees with meeting the

goals of the organization.

6. Use creative and flexible scheduling based on patient care needs to increase

productivity and retention.

Factors Affecting Staffing

1. The type, philosophy, objectives of the hospital and the nursing service.

2. The population served or kind of patients served whether pay or charity.

3. The number of patients and severity of their illness-knowledge and ability of nursing

personnel are matched with the actual care needs of patients

4. Availability and characteristics of the nursing staff, including education, level of

preparation, mix of personnel, number and position.

5. Administrative policies such as rotation, weekends, and holiday off- duties.

6. Standards of care desired which should be available and clearly spelled out.

7. Layout of various nursing units and resources available within the department such as

adequate equipment, supplies, and materials

8. Budget including the amount allotted to salaries, fringe benefits, supplies, materials and

equipment

9. Professional activities and priorities in nonpatient activities like involvement i

professional organizations, formal educational development, participation in research and

staff development.

10. Teaching program or the extent of staff involvement in teaching activities.

11. Expected hours of work per annum of each employee. This is influenced by 40 hour

week law.

12. Patterns of work schedule-traditional 5 days per week, 8 hours per day; 4 days a

week, ten hours per day and three days off; or 3 ½ days of 12 hours per day and 3 ½ days

off per week.

Staffing Policies

Must be readily available in the following areas:

1. vacation

2. holidays

3. sick leaves

4. weekends off

5. conservative days off

6. rotation to different shifts

7. overtime

8. part time personnel

9. uses of float personnel

10. exchangeability of staff

11. uses of special abilities of individual staff members

12. exchanging hours

13. request of personnel

14. request of management

15. the work week

SCHEDULING

Is a timetable showing planned work days and shifts for nursing personnel.

Objective

1. To assign working days and days off to the nursing personnel so that adequate

patient care is assured.

2. To distribute a fair schedule of off duty days.

Functions of Assessing a Scheduling System

1. Ability to cover the needs of the unit

2. Quality to enhance the nursing personnel’s knowledge, training and

experience.

3. Fairness to the staff.

4. Stability

5. Flexibility

Types of Scheduling

Centralized Schedule – One person usually the Chief nurse or he designate,

assigns the nursing personnel to the various units of the hospital.

Decentralized Schedule – The shift and off duties are arranged by the

supervising nurse of particular unit.

Cyclical Schedule – It covers a designated number of weeks called the cycle

length

Advantages of Cyclical Schedule

It is fair to all.

It saves time as the schedule does not have to be redone every week or two.

It enables to employees to plan ahead for their personal needs preventing

frequent changes in schedule.

Scheduled leave coverage such as vacation, holidays and sick leaves are

more stable.

Productivity is improved

Rotating Workshifts

Is common in most hospitals.

It is desirable that there be equal share of morning afternoon and night shifts as

prolonged night shifts may affect the health of the personnel.

Morning shift duty most frequently given to senior nurses.

CONCEPT OF EMPOWERMENT

the hallmark of transformational leadership

means to enable, develop or allow

decentralization of power (Kreitner and Kinicki, 1998)

Leaders communicate their vision, provide employees with opportunities to use

and improve their talents, and encourage learning, creativity and exploration within the

work area.

Empowerment in Nursing

nursing knowledge and research

encourage critical thinking, problem solving and application of knowledge to

practice

frees staff from mechanistic thinking

Three Components of Empowerment:

1. Professional traits

2. Supportive working environment

3. Effective leadership

Barriers to Empowerment:

1. Authoritarianism

When authority and power are viewed as the key motivational forces in the

achievement of an organization’s mission and strategic planning, empowerment is

blocked.

2. Rigid control

Emphasis of managers on rules, regulations, mandated policies, and procedures,

employee participation and empowerment is neglected.

Queen bee syndrome

shows unwillingness to teach others

does not want to see others succeed

wants to be the main attraction

desires subordinates to remain powerless

disinterest in improving or changing the profession

3. Organizational inertia

Lack of an organizational commitment, of time, energy, and resources does not

create an environment for empowerment as it does not happen naturally.

4. Internal competition

Personal and interdepartmental rivalries will result in internal competition for

resources and less organizational emphasis on empowerment process.

5. Employee mix

A large and diverse organization pose a greater challenge in creating a focused

and yet flexible strategy to empower the workforce attributed to gender, age, and cultural

differences.

6. Lack of staff accountability

A lack of ability and unwillingness of staff to assume responsibilities and

accountability for their attitudes and behaviors will hinder staff empowerment. Clarity of job

roles or job expectations, wherein staff can understand what is expected of them and their

areas for improvement will encourage empowerment.

7. Managerial incompetence

Managerial skills are vital components in establishing empowerment among

subordinates.

PRODUCTIVITY

- a measurement of the efficiency of production

- Labor productivity takes account of inputs of employee hours worked

- Output divided by input (Swansburg)

Hanson’s productivity illustration

Required staff hours / Provided staff hours X 100 = productivity percentage

Nursing productivity

- related both to how clinical nurses deliver nursing care and to how effective that

care is relative to its quality and appropriateness

- the volume and quality of products divided by the costs of producing and delivering

them (Davis)

- related to “what the nurses do and how they do it”

Haas defines efficiency as the relationship of the personnel assigned and time

spent, to materials expanded, as well as to capital and management employed, for the

greatest economy in use. Productive nurses must balance their personal energies and

their institutional resources with their effectiveness.

Professional Productivity Measures (Curtin)

1. Objective measures of efficacy: years of formal education, levels of educational

achievement, evidence of continuing education, skill development, and years of

experience.

2. Objective measures of effectiveness: demonstrated ability to execute job-related

procedures, correctly prioritized procedures, performance according to professional and

legal standards, appropriate information clearly and concisely reported, and cooperative

working with others.

3. Objective measures of efficiency: promptitude, attendance, reliability, precision,

adaptability, and economical disposition of resources.

Nursing Productivity Index - a system proposed by Curtin and Zurlage for measuring

nursing productivity that includes a nursing productivity ratio, relating nursing productivity

to hospital revenue and a nursing productivity index.

- developed and tested in all departments of John Hopkins Hospital

RECRUITMENT

A process of actively seeking out or attracting applicants for existing positions.

Interview

Defined as a verbal interaction between individuals for a particular purpose, it is also a

foundation for selecting people for positions.

Purposes or goals of the selection interview:

1. The interviewer seeks to obtain enough information to determine the applicant’s

suitability for the position.

2. The applicant obtains adequate information to make an intelligent decision about

accepting the job, should it be offered.

3. The interviewer seeks to conduct the interview in such a manner that, regardless

of the interview’s results, the applicant will continue to have respect for and goodwill

towards the organization.

Types of interview:

1. Unstructured interview: Requires little planning because the goals for hiring maybe

unclear, questions are not prepared in advanced, and often the interviewer does more

talking than the applicant.

2. Structured interview: Requires greater planning time because questions must be

developed in advanced that address the specific job requirements, information must be

offered about the skills and qualities being sought.

Developing a Job Description

Job Description – a statement that sets the duties and responsibilities of a specific

job. It includes the needed characteristics of qualifications of the individual to perform such

duties successfully.

Contents of a Job Description

1. Identifying data

Position Title: Staff Nurse

Department: Nursing

Supervisor’s Title: Head/Senior Nurse

2. Job Summary – includes the essential features of the job that distinguish it

from the others.

3. Qualification Requirements – educational preparation, training and

experience necessary to fill the position.

4. Job Relationships – source of workers.

5. Specific and Actual Functions and Activities.

Use of Job Description

1. Recruitment and selection of qualified personnel;

2. Orient new employees to their jobs;

3. Job placement, transfer or dismissal;

4. An aid in evaluating the performance of an employee.

5. Budgetary purposes.

6. Determining departmental functions and relationships to help define the

organizational structure.

7. Classifying levels of nursing functions according to skill levels required.

8. Identify training needs;

9. Basis for staffing

10. Serve as channel of communication.