Nsg Mgt Pack

8/3/2019 Nsg Mgt Pack

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Prepared by:

RACHEL P. FUENTES, RN

NURSING MANAGEMENT


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COURSE OUTLINE

a. Definition of Nursing Managementb. Levels of Skills Management

1. Conceptual

2. Interpersonal3. Technicalc. Management Functions of the Nurse

1. PLANNINGa. Principlesb. Characteristicsc. Barriersd. Elements/Components (Vision, Mission, Philosophy, Setting

Goals/Objectives, Standards [concerns, functions, sources,elements])

2. ORGANIZINGa. Organizational Concepts & Principlesb. The Organogram Organizational Charts

1. Importance2. Organizational Relationship (line & staff)3. Types of Organization (Hierarchal, Dual, Pyramid,

Centralization vs. Decentralization)4. Staffing (methods, needs, & scheduling)5. Types of Patient Assignment(Case, Primary, Functional, Team, Care Management)

3. DIRECTINGa. Principlesb. Communication of Management (Upward, Downward, Lateral)c. Delegation Concepts, Principles, Processd. Problem-Solving, Decision-Making Methods, Processe. Management Conflict (Causes, Nature/Types, Conflict

Resolution)

4. CONTROLLINGa. Principlesb. Performance-Appraisal-Principles-Processc. Discipline-Principles-Processd. Nursing Audit-Principles-Processe. Management Labor Relations

1. Definition2. Collective Bargaining Agreement, lock out & its implication

to Nursing3. Documentation in Nursing (uses, systems, charting)

f. Computers & Information Management (Implication to Nursing


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Education & Practice)g. Current Issues and Trends in Nursing Management

OVERVIEW OF NURSING MANAGEMENT


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THE NURSING MANAGEMENT PROCESS

Management is a process by which a cooperative group direct actionstowards common goals. It involves techniques by which a distinguished group of

people coordinates the services of the people. Over time, management hasevolved into more than the use of means to accomplish given ends. It nowincludes moral and ethical standards in the selection of right ends toward whichmanagers should strive.

Classic Three-fold ConceptBy Harbizon and Myers

Management is:1. an economic resource,2. a system of authority, and

3. and elite class

As an economic resource, management is one of the factors ofproduction together with land, labor, and capital. As industrialization increases,management is substituted for labor and capital. The management resource of afirm determines to a large extent, its productivity and profitability. Management isused more extensively in industries experiencing innovation.

As a system of authoritymanagement first develops with top individualsdetermining the course of action for the rank and file. Humanitarian conceptshave later developed paternalistic approaches. This is followed by constitutional

management which emphasizes definite and consistent concern for policies andprocedures in dealing with the working group. The trend toward a democratic andparticipative approach follows as employees receive higher education.

From the psychologists point of view, management is a class and statussystem. Managers have become an elite group of brains and education.Entrance to this class is based on education and knowledge. The new managerscontinue to expand their horizons in an effort to attain the ultimate in life.

Modern management theory evolved from the work of Henri Fayol, whoidentified the activities or functions of the administrator as planning, organizing,coordinating and controlling. His work has been called process management.Fayol defined management in these words:

To manage is to forecast and plan, to organize, to command, tocoordinate, and to control. To foresee is to provide means of examiningthe future and drawing up plan of action. To organize means building upthe dual structure, material and human, of the undertaking. To commandmeans binding together, unifying and harmonizing all activity and effort. To


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control means seeing that everything occurs in conformity with establishedrule and expressed demand.

The management process is universal. It is used in business, in thepractice of ones profession, and even in running ones day-to-day personal

affairs. For nurses, knowledge of this process assures them of the smoothfunctioning of their units to attain their goal of quality care through the judicioususe of available human and material resources within specified periods.

ROLE OF MANAGERSBy Mintsberg

These roles describe what managers actually do.

INTERPERSONAL ROLE

The interpersonal role shows the manager:1. As a symbolbecause of the position occupied

consist of duties such as signing of papers/documents2. As a leader

hires, trains, encourages, fires, remunerates, and judges3. As a liaison

between community, suppliers, and organization

INFORMATIONAL ROLEThe informational role presents the manager:

1. As one who monitors information2. Disseminates informationfrom both external and internal sources

3. As spokesperson or representative of the organization- represents subordinates to superiors and the upper managementto the subordinates

DECISIONAL ROLEThe decisional role makes the manager:

1. An entrepreneur or innovator, problem discoverer, a designer toimprove projects that direct and control change in the organization

2. A trouble-shooterhandles unexpected situations such as resignation of subordinates,

firing of subordinates, losses of clients3. As negotiator

when conflicts arise


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DEVELOPING FUTURE MANAGERS

Managerial development programs are very useful means of gettingqualified managers.

LEVELS OF SKILLS MANAGEMENT

By KatzAccording to Katz, the necessary fundamental skills of a manager are:

1. TECHNICAL SKILLS relate to the proficiency in performing an activity inthe correct manner with the right technique.

2. HUMAN RELATIONSHIP SKILLS pertains to dealing with people & howto get along with them

3. CONCEPTUAL SKILLS deal with the ability to see individual matters asthey relate to the total picture and to develop creative ways of identifyingpertinent factors, responding to big problems, & discarding irrelevant facts

By SummerA second approach in developing managers is postulated by Summer in his earlywork which emphasized:

1. KNOWLEDGE FACTORS refer to ideas, concepts or principles that canbe expressed and are accepted because they have logical proofs

2. ATTITUDE FACTORS beliefs, feelings, and values that may be basedon emotions and may not be subjected to conscious verbalization. Interestin ones work, confidence in ones mental competence, desire to acceptresponsibility, respect for the dignity of ones associates, desire forcreative contribution are some attitudes acquired by proper education.

3. ABILITY FACTORS include skill, art, judgment, wisdom. These areabstract factors but they direct ones thinking to factors that can bedeveloped by the individual manager who takes time to consider them.

MAJOR MANAGEMENT FUNCTIONS1. PLANNING2. ORGANIZING3. DIRECTING4. CONTROLLING

Whileplanning is the first function, one must recognize that it permeatesinto the other functions which dependent on it. By forecasting one canestimate the future; by setting objectives the results to be achieved can bedetermined; by developing and scheduling programs, the activities neededwithin a set time frame can be defined; by preparing the budget, tools andresources can be allocated while establishing policies and procedures thatwill define the course of action and standards.


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Organizing establishes formal authority. It sets up the organizationalstructure by identifying groupings, roles, and relationships within theagency. This is depicted in an organizational chart. Job descriptions definethe qualifications and scope of responsibilities, the relationships and

authorities of personnel. Staffing includes determining the staff needed,thus developing and maintaining staffing pattern. The process coversrecruiting, selecting, orienting, and developing personnel to accomplishthe goals of the organization. The selected personnel are then distributedin the various areas of the agency where they are qualified to belong.Staffing schedules are made to meet the needs of clients, personnel, andagency.

Directingor leading actuates efforts to the accomplishment of goals. Thisincludes utilization of various modalities of nursing care through thenursing process; updating policies and procedures; supervising personnel

to harmonize work through adequate guidance and leadership;coordinating personnel and services toward a common goal;communicating via various routes to ensure common understanding;developing people by providing staff development programs; and makingsound decisions.

Controlling leads to the assessment and regulation of performance ofworkers. To ensure the attainment of objectives, certain standards areutilized to measure performance, monitor and evaluate nursing care,including the utilization of resources. Control promptly reveals deviationsfrom set plans and standards necessitating immediate corrective

measures, actions and/or discipline.

THE SETTING

HOSPITAL- an integral part of social and medical org, the function of which is

to provide for the population it serves, complete health care, bothcurative and preventive, & whose out-patient services reach out tothe family in its home environment; it is also a center for the trainingof health workers and for bio-social research. (WHO)

- a place devoted primarily to the maintenance & operation offacilities for the diagnosis, treatment, and care of individualssuffering from illness, disease, or deformity, or in need of obstetricalor other medical or nursing care. (Hospital Licensure Law, RA4226)


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- any institution, building or place where there are beds, cribs orbassinets for use of patients for 24 hours or longer, in the treatmentof diseases, diseased conditions, injuries, deformities, and allinstitutions such as those for convalescence, janitorial care,infirmaries, nurseries, dispensaries, and such other names by

which they may be designated.

CLASSIFICATION OF HOSPITALS

CLINICAL HOSPITALS1. General Hospitals provide services for all kinds of illnesses, diseases,

injuries and deformitiesEx. Philippine General Hospital, Quirino Memorial Medical Center

2. Special Hospitals services for particular kinds of illnesses or diseasesand offer health and medical care

Ex. National Childrens Hospital, National Orthopedic Center

ACCORDING TO OWNERSHIP AND CONTROL1. Government Hospitals operated and controlled either partially or

wholly by the national, provincial, municipal or city government or otherpolitical subdivision, board or other agency thereof.Ex.

a. National those directly under the Office of the President such asthe Philippine General Hospital and those under the DOH, such asthe National Center for Mental Health and the National orthopedicCenter.

b. Regional Batangas Regional Hospitalc. Provincial Bulacan Integrated Provincial Hospitald. City Ospital ng Maynila, Quezon City General Hospital,

Mandaluyong City Medical Centere. Municipal or Rural Don Formilleza Memorial Hospital

2. Private or Non-Government Hospitals privately-owned, establishedand operated w/ funds, raised capital or other means by privateindividuals. Associations, corporations, religious organizations, firms,companies or joint stock associations.Ex.

a. Missionary Mary Johnston Hospital, Our Lady of LourdesHospital, Iloilo Mission Hospital

b. Civic Organizations Quezon Institute run by PhilippineTuberculosis Society

c. Community Romero Community Hospitald. Private St. Lukes Medical Hospital


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TRAINING & NON-TRAINING1. Training Hospital departmentalized hospital with accredited Residency

Training Program in one or more specified specialty or discipline

Ex. Jose Reyes Memorial Hospital, Tondo Medical Center, QuirinoMemorial Medical Center, and St. Lukes Medical Center2. Non-training Hospital may be departmentalized but without an

accredited Residency Training Program

HOSPITAL CATEGORIES

1. PRIMARY LEVEL HOSPITALS composed of municipal and Medicarehospitals which have facilities and capabilities for first contact emergencycare and hospitalization of simple cases.

2. SECONDARY LEVEL HOSPITALS district hospitals with capabilities

and facilities for medical care of cases requiring hospitalization. It hasexpertise of trained specialist.Ex: hospitals with 50 100 beds

3. TERTIARY LEVEL HOSPITALS specialized centers, regional hospitals,medical centers, provincial or general hospitals.- have capabilities of providing care to cases requiring sophisticateddiagnostic and therapeutic equipment and expertise of trained specialistsand sub-specialists

4. SPECIAL TERTIARY LEVEL HOSPITALS fully equipped withsophisticated diagnostic and therapeutic facilities for specific medicalproblem areas.

Ex: Lung Center of the Philippines, The Philippine Heart Center, thePhilippine Childrens Medical Center, and the National Kidney andTransplant Institute.


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PLANNING FOR THE NURSING SERVICE

PLANNINGPlanning is defined as pre-determining a course of action in order to arrive

at a desired result.

It is the continuous process of assessing, establishing goals andobjectives, implementing and evaluating them, and subjecting these tochange as new facts are known.

Planning, a basic function of management is a principal duty of allmanagers. It is a systematic process and requires knowledgeable activity basedon sound managerial theory. The first element of management defined by Fayolplanning, which he defines as making a plan of action to provide for theforeseeable future. This plan of action must have unity, continuity, flexibility, and

precision.

Rowland and Rowland state that planning is largely a process offorecasting and decision making. It is future oriented, spanning time beginning inthe present.

IMPORTANCE OF PLANNING1. Planning leads to achievement of goals and objectives. Workers relate

what they do to meaningful results since plans are focused on objectives.

2. Planning gives meaning to work. Employees or workers experience

greater satisfaction if what they do becomes meaningful to them.

3. Planning provides for effective use of available resources and facilities.The best use of personnel and material resources prevents wastage.

4. Planning helps in coping with crises. Hospitals should provide for disasterplans. These allow workers to function more clearly and efficiently whenactual emergencies occur such as fire, typhoons, earthquakes, or duringNew Year celebrations and/or other occasions when more people arelikely to get hurt.

5. Planning is cost effective. Costs can be controlled through planning forefficient operation. For example, projecting the number of operations in agiven day, including daily dressings, helps in determining accurately theneeded weekly supplies in the surgical units so as to prevent undersupply,oversupply or pilferages.

6. Planning is based on past and future activities. Evaluation of programs,schedules, and activities whether successful or not, prevents and/or


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reduces the recurrence of problems and provides better ideas in modifyingor avoiding them.

7. Planning leads to the realization of the need for change. Many hospitalshave found out that in-patient hospital days can be greatly reduced by

having the laboratory and diagnostic work-up in the OPD rather than havethese examinations on admission. Minor surgeries are also done at theOPD so that more hospital beds can be allotted to critically-ill patients orfor those needing specialized services.

8. Planning is necessary for effective control. Nurse-managers evaluate theenvironment or setting in which they work or where the patients areconfined and make necessary recommendations to make hospitalconditions more therapeutic not only for the patients but for the workers aswell. Performance of workers and evaluation of services to patients basedon criteria set during the planning stage would indicate whether standards

are met and whether changes are indicated.

WHY MANAGERS FAIL TO PLANMany nurse-managers fail to plan effectively for different reasons.

1. They may lack knowledge of the philosophy, goals and objectives of theagency;

2. They lack understanding of the significance of planning process;3. They may not know how to manage their time devoted for planning;4. They may lack the confidence in formulating plans; or5. They may fear that planning may bring about changes that they are

unwilling to undertake or unable to cope with.

Knowing these factors will help the nurse-managers to overcome theirweaknesses and utilize planning as the key to success in their work.

MAJOR ASPECTS OF PLANNING1. Planning should contribute to objectives. It should seek to achieve a

consistent, coordinated structure of operation focused on desired ends.Actions without plans often result in chaos.

2. Planning precedes all other processes of management. It leads to easyaccomplishment of the agencys objectives which are necessary for groupeffort.

3. Planning pervades all levels. It encompasses both higher and lowerechelons and vice versa and spreads horizontally through peer levelsand/or across services and members of the health team.

4. Planning should be efficient. It should contribute to the attainment ofobjectives not only in terms of peso value, man-hours, units of products


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but should also include individual values and group satisfaction. Fear,resentment and low morale result in low production.

CHARACTERISTICS OF A GOOD PLANA well developed plan should:

1. Have clearly worded objectives, including desired results andmethods of evaluation;2. Be guided by policies and/or procedures affecting the planned

action;3. Indicate priorities;4. Develop actions that are flexible, realistic in terms of available

personnel, equipment, facilities and time;5. Develop a logical sequence of activities; and6. Include the most practical methods in achieving each objective.

ELEMENTS OF PLANNING

Forecasting Setting the Vision/Mission, Philosophy, Goals and Objectives Developing and Scheduling programs Preparing the Budget Establishing the Nursing Standards, Policies and Procedures

FORECASTINGForecasting helps managers look into the future.

It includes:- environment in which the plan will be executed- who the patients will be ---

their customs and beliefs

language/dialect barriers

public attitude and behavior

the severity of condition

kind of care- the number and kind of personnel required

professional & non-professional- necessary resources

equipment facilities

supplies


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SETTING THE VISION/MISSION, PHILOSOPHY, GOALS AND OBJECTIVES

Successful organizations, both for-profit and not-for-profit, have learnedthat they must focus their resources on a limited number of activities. Trying to beall things to all people only results in a dissipation of resources and ineffective

outcomes in many areas. Health care organizations were slow to adopt such afocused approach, but cost constraints have forced them to reexamine theirmission, vision, and goals. Comprehensive strategic planning, often usingoutside consultants, can produce a plan to guide the organization in the nearfuture. (Few organizations today, especially in health care, attempt to plan morethan a few years into the future.)

VISIONA vision statement outlines the organizations future role and action. It

gives the agency something to strive for.

A vision statement describes the goal to which the organization aspires. Avision statement is designed to inspire and motivate employees to achieve adesired state of affairs.

Example: Our vision is regional integrated healthcare delivery system providingpremier healthcare services, professional and community education, andhealthcare research, from the BJC Health System in St. Louis, exemplifies avision statement.

MISSIONThe mission statement outlines the agencys reason for existing, who the

target clients are, and what services will be provided.

The mission of an organization is a broad, general statement of theorganizations reason for existence. Developing the mission is the necessary firststep in designing a strategic plan.

Every organization exists for specific purpose or missions and to fulfillspecific social functions. For health care organizations, this means providinghealth care services to maintain health, cure illness, and allay pain and suffering.

Example: Our mission is to improve the health of the people and communitieswe serve, from BJC Health System in St. Louis, is an example of a missionstatement that guides decision making for the organization.

If, for example, a proposed activity does not promote the organizationsstated mission, it probably would not be pursued.


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ExamplesDepartment of Health

The DOH shall be responsible for the formulation, implementation, andcoordination of policies and programs in the field of health. The primary functionis the promotion, preservation, or restoration of the health of the people through

the provision and delivery of health services and through the regulation andencouragement of providers of health goods and services.

VisionHealth as a Right. Health for All Filipino by the Year 2000 and Health in

the hands of the People by the Year 2020.

MissionThe mission of DOH, in partnership with the people to ensure equity,

quality and access to health care by: making services available

arousing community awareness mobilizing resources promoting means to better health

The Quirino Memorial Medical CenterThe Quirino Memorial Medical Center is a government-operated, tertiary

medical center, under the Department of Health, committed to serve the public inpursuit of high quality health care services, through an effective, responsive, andintegrated referral and networking system with other health and welfareagencies, not only Quezon City and its catchments but throughout the country.

VisionThe Medical Center envisions itself to become a Center of Excellence

providing holistic approach to health care services. As a Center of Wellness, theservices provided shall enable the people to improve their health and increasecontrol over it.

MissionThe Medical Center, as a public, tertiary hospital is so maintained as the

peoples partner and improved to provide accessible, quality, cost effective,preventive, promotive, curative, rehabilitative health care services to the generalpublic, especially the destitute. The institution is also committed to medical,nursing, and allied health education, training and research.

PHILOSOPHYA philosophy describes the vision. It is a statement of beliefs and values

that direct ones life or practice. In an organization, the philosophy is the sense ofpurpose of the organization and the reason behind the structure and goals.


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The philosophy of the organization communicates its mission, values, and vision.

GENERAL EMPHASIS IN STATEMENT OF PHILOSOPHY quality, quantity and scope of service decision based on factual information

appropriate delegation of function achievement of organizational goals vertical and horizontal communication flexibility to meet the changing needs of the organization,

individuals, community, and society in general

The philosophy of nursing service dovetails with the philosophy of the agency. Itis an intentionally chosen set of values or purposes that serve as the bases fordetermining the means to accomplish nursing objectives.

Nursing philosophy directs nursing behavior, giving it sense of purpose.

EXAMPLESExcerpts from the statement of the philosophy of the Quirino Memorial HospitalThe Medical Center is guided by the following beliefs:

1. The hospital is committed to assure a vital role in health promotion,disease prevention, curative, rehabilitative, and primary health care inpartnership with public counterparts, the clients, families, andcommunities.

2. The clients are the reason for the hospitals existence. Therefore, allservices are directed toward their care and rehabilitation.

3. The health personnels concern for the quality of their services constitutes

the heart of their responsibility to the public.

Excerpts from the statement of philosophy of the Quirino Memorial Hospital,Nursing divisionThe Nursing Division strongly believes that:

1. Its philosophy and objectives are congruent to the vision, mission,philosophy and objectives of the Quirino Memorial Medical Center.

2. It has the primary responsibility of providing comprehensive, individualizednursing care to patients based on their assessed nursing needs. Nursingcare is coordinated and collaborated with the health team.

3. The most important asset of an institution is its staff. To provide the bestquality of nursing care, nursing personnel should be adequately preparedby education, experience and training to assume the duties andresponsibilities of their position. They are to be treated with dignity andrespect.

4. Nurses are advocates of patients. As such, they should take appropriatesteps to safeguard their patients rights and privileges.


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GOALSGoals are more general and cover a broad area.

Goals are specific statements of what is to be achieved. They follow the

mission and vision of the organization. Goals are measurable and precise.

OBJECTIVESObjectives tend to be more specific and concrete.They are action commitments through which the key elements of the

organizations mission and purpose will be achieved and the philosophy or beliefsustained.

They are stated in terms of results to be achieved and should focus on theproduction of health care services to clients.

Moore states, If objectives are presented in terms of what can beobserved, they can serve as evaluation tools of nursing care and personnelperformance, and as a basis for planning educational programs, staffing,requisition of supplies and equipment, and other functions associated with thenursing department.

Goals apply to the entire organization, whereas objectives are specific toan individual unit.

EXAMPLESGeneral Objectives

To provide the best possible care services to its clients in a high qualitysetting conducive to attaining its vision as a center of wellness and standardmedical center.

Specific ObjectivesThe specific objectives of the Nursing Service of the Quirino Memorial MedicalCenter are:

1. To establish organized governing body so functioning that has overallresponsibility for the conduct of the hospital in a manner consonant with itsphilosophy, mission and objectives.

2. To provide the best quality, accessible and cost effective health servicesto all its clients ensuring preservation of their basic human rights forindependence of expression, decisions, and actions, and concern forpersonal dignity and human relationships.

3. To develop and utilize various evaluation parameters as a means ofproviding information on how well the goals of care are met, at the sametime identifying opportunities for improvement.


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Objectives of a Nursing UnitThe objectives of this unit shall be

1. To provide individualized, total patient care based on physical, emotionaland spiritual needs of the patient, family and SOs;

2. To utilize the nursing process as basis of all care given by the nurses3. To provide quality care in a cost-effective manner to the patient and thehospital.

4. To coordinate services with other hospital divisions, members of thehealth team and the community for optimum patient care whilehospitalized and after discharge.

DEVELOPING AND SCHEDULING PROGRAMS

Programs are determined, developed and targeted within a time frame to

reach the set goals and objectives. Kron has developed a planning formula whichmay be used for daily duties, or for short and long range projects.

THE PLANNING FORMULABy Kron

1. What What has been done? What should be done? Whatequipment and supplies have been used or needed? Whatsteps are necessary in the procedure? What sequence ofactivities was previously used? What other efficient methodsmay be used?

2. When When should the job be done? When was it formerly done?When could it be done?

3. Where Where is the job to be done? Where does an activity occur inrelation to those activities immediately preceding andfollowing it? Where could supplies be stored, cleaned and soforth?

4. How How will the job be done? What are the steps to be followedin doing the procedure? How will the time and energy ofpersonnel be used? How much will it cost? How much timewill it require?

5. Who Who has been doing the job? Who else could do it? Is morethan one person involved?


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6. Why To each of the questions, ask why. Why is this job, thisprocedure, this step necessary? Why is this done in thisway, in this place, at this time, by this person?

7. Can Can some steps or equipment be eliminated? Can this

activity be efficiently combined with other operations? Cansomebody else do it better? Can we get a machine to help?Can we get enough money?

TIME MANAGEMENTTime management is a technique for allocating ones tome through the

setting of goals, assigning priorities identifying and eliminating wasted time, andusing managerial techniques to reach goals efficiently.

Work smarter, not harder.

Ones personality, education and culture influence how he or shemanages time. The way one views time influence the degree of stress he or shewill feel when time is mismanaged.

Symptoms of time mismanagement (Davies, et. al., 1980):1. rushing2. chronic vacillation between unpleasant alternatives3. fatigue and listlessness with hours of non-productive activity4. constantly missed deadlines

5. insufficient time for rest and/or personal relationships6. feeling overwhelmed by details and demands

Principles1. Planning anticipates the problems that will arise from actions without

thought. It anticipates the crises that may occur or the resources neededto solve the problems.

2. Tasks to be accomplished should be done in sequence and should beprioritized according to importance. Failure to prioritize oftentimes resultsin spending more time on unimportant tasks.

3. Setting the deadlines in one's work and adhering to them is an excellentexercise in self discipline. It enables one to have time for himself/herselfbecause of the effective use of time.

4. Deferring, postponing, or putting off decisions, actions, or activities canbecome a habit which oftentimes cause lost opportunities and

productivity, generating personal or interpersonal crises. Learning to


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understand why one procrastinates makes him/her aware that a plan canbe initiated to prevent procrastination.

5. Delegation permits the manager to take authority for decision making andto assign tasks to the lowest level possible consistent with his/her

judgment, facts, and experience. A nurse manager oftentimes doessomething that his/her subordinates would be able to do with support.Delegation frees him/her of some time that can be devoted to other tasks.

TIME-SAVING TECHNIQUES, DEVICES, AND METHODS1. Conduct inventory of activities. Logging your activities for one day would

show how much time is usually spent on each activity. Identify your timeproblems.

2. Set goals and objectives and write them down. Set priorities. Plan on

making things happen rather than reacting to crises.

3. With the use of calendars, executive planners, logs or journals, write whatyou expect to accomplish yearly, monthly, weekly, daily.

4. Break down large projects into smaller parts. Do first things first andconcentrate on one thing at a time. Get all data you need to avoid breaksin your work. Complete each task at the first time.

5. Devote a few minutes at the beginning each day for planning. Prepare alist of what are to be done the following day. At the end of each day,

account for the tasks you have accomplished.

6. Organize your work space so it is functional.

7. Close your door when you need to concentrate. Agree on a period of quietoffice time. Avoid having an open door policy during the entire workday.

8. Learn to delegate. Delegation extends results from what one can do towhat one can control. It also develops subordinates initiative, skill, andconfidence.

9. In a meeting, define the purpose clearly before starting. Distribute theagenda in advance and control interruptions during the meeting. Conductthe meeting according to time schedule.

10. Take or return phone calls during specified time.

11. Develop effective decision-making skills. Do not be afraid to say no.


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12. Take rest breaks and make good use of your spare time. Reward yourselfperiodically.

PREPARING THE BUDGET

A BUDGETis the annual operating plan, a financial road map and plan which servesas an estimate of future costs and a plan for utilization of manpower,material and other resources to cover capital projects in the operatingprograms.

plan for future activities expressed in operational as well as financial ormonetary terms.

(Webster) a plan or schedule adjusting expenses during a certain periodto the estimated or fixed income for that period.

(Herkimer) an effective budget is the systematic documentation of one ormore carefully developed plans for all individually supervised activities,programs, or sections. The budget is a tool which can aid decision makersin evaluating operating performance and projecting what future operationsmight produce.

A nursing budgetis a plan for allocation of resources based on preconceived needs for aproposed series of programs to deliver patient care during one fiscal year.

A hospital budgetis a financial plan to meet future service expectations.a. REVENUE BUDGET summarizes the income which management

expects to generate during the planning periodb. EXPENSE BUDGET describes the expected activity in operational and

financial terms for a period of timec. CAPITAL BUDGET outlines the programmed acquisitions, disposals

and improvements in an institutions physical capacityd. CASH BUDGET represents the planned cash receipts and

disbursements as well as the cash balances expected during the planningperiod.

BENEFITS DERIVED FROM THE BUDGETARY PROCESS1. Planning2. Coordination3. Comprehensive Control

FACTORS IN BUDGET PLANNING1. The type of patient, length of hospital stay, acuteness of the illness


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2. The size of the hospital and its bed capacity3. The physical layout of the hospital, size and plan of wards and units,

nurses station, treatment rooms, etc4. Personnel policies

a. Salaries

b. Extent of vacation, sick leaves, holidaysc. Provision for staff development programs including instructionalstaff

5. The grouping of patients6. Standards of nursing care7. The method of performing nursing care8. Method of documentation9. The proportion of nursing care provided by professional nurses and those

given by non-professionals10. The amount and quality of supervision available and provided11. The efficiency of job description and job classification

12. The method of patient assignment13. The amount and kind of labor-saving devices and equipment;intercommunication system

14. The amount of centralized service provided15. The nursing service requirements of the ancillary departments: clinics,

admitting office, ER16.Reports required by administration17. Affiliation of nursing students or medical students

COMPONENTS OF BUDGET

CASH BUDGETCash budget forecasts the amount of money received. It consists of the

beginning cash balance, estimates of receipts and disbursement, and theestimated balance for the given period corresponding to that of the operating &capital budgets.

The cash budget is prepared by estimating the amount of money to becollected from patients and allocating it to cash disbursements required to meetobligations promptly as they come.

OPERATING BUDGETOperating budget deals primarily with salaries, supplies, contractual

services, employee benefits, laundry service, drugs and pharmaceuticals, in-service education, travels to professional meetings, books, periodicals,professional magazines, and repairs and maintenance.

The operating budget is composed of revenue and expense budget.


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CAPITAL EXPENDITURE BUDGETThe capital expenditure budget consists of accumulated data for fixed

assets that are expected to be acquired during the budgeted period.

It includes estimated costs and sources of funds for expectedreplacements, improvements and additions to fixed assets.

ESTABLISHING NURSING STANDARDS, POLICIES & PROCEDURES

NURSING STANDARDSprovide professionally desirable norms against which the departments

performance can be measured.

Standards of care are specific, detailed plans of care for individuals withspecific health problem. The purpose of standard of care is to establish the bestpractice and eliminate as much variations as possible. Standards of care ofteninclude aspects of medical care and various therapies as well as nursing care.They identify specific desired outcomes for each day of hospitalization andactions that are to be taken to achieve those outcomes. In some institutions,standards of care may take the form of nursing care plans or may beincorporated into care pathways, critical or clinical pathways. Designed to directthe health care team in daily care, these identify both outcomes and careactivities that are expected to be appropriate for each 24-hour period of

hospitalization. The standards of care become the basis for determining the levelof care delivered and for quality improvement within the organization as well asfor cost analysis.

Standards of nursing practice are authoritative statements that describea common and acceptable level of professional nursing performance. Standardsof practice therefore define professional practice.

EXAMPLEStructure, Criteria, and Standards

Structure: Organization of Nursing ServiceThere is an organized Nursing Service/Department which is directed by a

qualified nurse administrator.

Criterion: Philosophy and GoalsThe nursing service has a written set of philosophy and goals that reflects

the standards prescribed by the nursing profession and provides directiontowards the development of programs to improve the delivery of nursing care. It


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shall consider that such philosophy and goals are congruent with the servicegoals of the institution.

StandardsPhilosophy and Objectives The philosophy shall be based on the belief

that the client is an integral whole and that he is a unique individual with needsthat can be met through nursing interventions.Philosophy shall reflect the collective views of the nursing personnel and

the clientele served.The goals and objectives shall reflect the philosophy of the nursing

service. The primary goal shall be the provision of the prescribed quality andquantity of nursing care.

NURSING SERVICE POLICIESA policy is a designated plan or course of action to be taken in a specific

situation (Ellis & Hartley, 2004).

Policies are broad guidelines for managerial decisions that are necessaryin organizational and departmental planning.

They govern action of workers and supervisors at all levels and areintended to achieve pre-intended goals. They serve as basis for future actionsand decisions; help coordinate plans, control performance and increaseconsistency of action by increasing the probability that different managers willmake similar decisions when independently facing similar situations.

3 general areas in nursing that require policy formulation

1. Areas in which confusion about locus of responsibility might result innegligence or malperformance of an act necessary to a patients welfare2. Areas pertaining to the protection of patients and families rights3. Areas involving personnel management and welfare

CHARACTERISTICS OF GOOD POLICIESPolicies should be:

1. Written and understandable by those who will be affected by them2. Comprehensive in scope, stable, flexible3. Consistent to prevent uncertainty, feelings of bias, preferential treatment

and unfairness4. Realistic and should prescribe limits5. Allow for discretion and interpretation by those responsible for it

EXAMPLES1. Accidents care, reporting, precautions to prevent occurrence2. Admissions receiving, consent, notifying doctor, care of patients3. Autopsies obtaining informed consent4. Breakage classification, responsibility, reporting


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5. BulletinBoards location, posting of information6. Committees types, membership, functions7. Complaints how handled, action taken8. Consent informed consent taken by whom, from whom, shared decision-

making with patient and family and/or SOs together with members of the

health team9. Death notification, care and identification, care of personal belongings,death certificate

10. Discharge time, clearances, discharge planning, accompaniment ofpatient

11. Doctors Orders written, verbal, by telephone12. EquipmentandSupplies list of expendable and non-expendable items,

care, lending, requesting, repairing13. Fireregulations drills, prevention14. NursingCare

a. administration and preparation of oral medications, IV infusions,

BTb. charting forms used, use of various colors of ink, formatconsidering legal implications

c. dailyassignment by whom, where, whend. emergency drug supply contents, responsibility, locatione. kardex use, sample formf. medications card system, responsibility, checking, dosages,

errors: reporting, correctiong. property of patients responsibility and placementh. private duty nurses engaging, obligations to hospital, supervision,

evaluation, remuneration

i. reasonable and due care definition, explanation, legalimplicationsj. referrals within and outside of agencyk. safety devices siderails, restraints

15. Reports forms, responsibility16. Reporting On or Off Duty information given when leaving the unit17. Meetings frequency, purpose, types, membership, minutes

NURSING PROCEDURES

Procedures are specific directions for implementing specific policies.

Procedures spell out how a particular nursing activity is to be completed,often described in a number of steps or processes.Two areas where procedures are needed:

1. those that are related to job situationssuch as reporting complaints or disciplinary instances

2. those involving patient care


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Procedures that involve patient care should consider the safety andcomfort of the patient while undergoing it, use of supplies and equipment, andgood workmanship on the part of the person doing it.

Nursing procedure manuals should be available in each unit to familiarize

nurses with the common nursing procedures utilized in that unit.

EXAMPLES of Contents in a Procedure Manual1. Blood administration2. Catheterization3. Bed Making4. Cleansing enema5. Douche, vaginal6. Dressings, sterile, dry7. AM care8. I & O

9. Thoracentesis10.Lumbar Puncture


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ORGANIZING THE NURSING SERVICE

ORGANIZING

Process of establishing a formal authority. Involves setting up the organizational structure through identification of

groupings, roles and relationships, determining the staff needed bydeveloping and maintaining staffing patterns and distributing them in thevarious areas as needed.

Includes developing job descriptions by defining the qualifications andfunctions of personnel.

Organization

Organization consists of structure and process which allow the agency toenact its philosophy and utilize its conceptual framework to achieve its goals.Itrefers to a body of persons, methods, policies and procedures arranged

in a systematic process through the delegation of functions and responsibilitiesfor the accomplishment of purpose.

An organization is a collection of people working together under adefined structure for the purpose of achieving predetermined outcomes throughthe use of financial, human, and material resources. The justification fordeveloping organizations is both rational and economic. Properly coordinatedefforts capture more information and knowledge, purchase more technology, and

produce more goods, services, opportunities, and securities than individualefforts (Anderson, 1992).

Elements of Organizing Setting up organizational structure Staffing Scheduling Developing job descriptions

The successful setting up of the organizational structure enables anorganization to achieve its purposes:

1. It informs members of their responsibilities so that they may carry themout.

2. It allows the manager & the individual workers to concentrate on his/herspecific roles & responsibilities.

3. It coordinates all organizational activities so there is minimal duplication ofeffort or conflict.

4. It reduces the chances of doubt & confusion concerning assignments.


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TYPES OF ORGANIZATION CLASSIFIED BY NATURE OF AUTHORITY1. LINE ORGANIZATION. the simplest and most direct

- each position has general authority over the lower positions in thehierarchyexample

Clinical & Administration

2. INFORMAL ORGANIZATION. refers to horizontal relationships ratherthan vertical

- composed of small groups of worker with similar interests

3. STAFF ORGANIZATION. purely advisory to the line structure with noauthority to put recommendations into action

exampleTraining & Research

4. FUNCTIONAL ORGANIZATION. each unit is responsible for given partof the organizations workload

- clear delineation of roles and responsibilities which are actuallyinterrelatedexample

All standing & Ad Hoc Committee

ORGANIZING PRINCIPLES1. Unity of Command responsible to only one superior.2. Scalar Principle chain of command; authority and responsibility

should flow in clear unbroken lines from the highest executive to thelowest; proper definition and delegation of authority and responsibilityfacilitate the accomplishment of work.

Must observe the following:a. When responsibility for a particular job is delegated to asubordinate, the latter should have authority over resources needed toaccomplish the task;

Principle of Parity: authority delegation must be equal to theresponsibility assigned

b. When a particular function is delegated to a subordinate, thesuperiors own responsibility is in no way diminished;

Principle of Absoluteness: authority may (and must) bedelegated, but ultimate responsibility is retained.


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c. When a person is bestowed the authority for action, he isaccountable for his actions to the person who bestowed him such.

-the conscientious nurse exhibits accountability toward heremploying hospital, the patient, the government, herprofession, & to God.

3. Homogenous Assignment or Departmentation workers performingsimilar assignments are grouped together for a common purpose.

- promotes specialization of activities, simplifies the administratorswork, & helps maintain effective control.

4. Span of Control the number of workers that a supervisor caneffectively manage should be limited.

- span of managerial responsibility and the number which onesuperior can assist, teach, and help to reach the objectives of their own

jobs.

- Ratio : (Top)Supervisors-workers (1:6)(Base) 1:10

5. Exception Principle recurring decisions should be handled in aroutine manner by lower-level managers whereas problems involvingunusual matters should be referred to the higher level.

- subordinates learn how to make decisions at their own level andfree executives from being bogged down.

6. Decentralization or Proper Delegation of Authority the process ofpushing decision-making to the lower levels of the organization.

- distribution of necessary information about critical issues is vital toany delegation process.

Definition of Terms

1. Authority is the right to act. In legal sense, authority flows downin an organization, e.g., from the Board of Trustees to the HospitalAdministrator then to the various Directors of the hospital

2. Line and Staff Relationshipsa. Line authority is the simplest and most direct type in which

each position has general authority over the lower positionsin the hierarchy in the accomplishment of the mainoperations of the organization.

b. Staff personnelprovides advise, counsel or technical supportthat may be accepted, altered or rejected by the line officer.

3. Accountability means taking full responsibility for the quality ofwork and behavior while engaged in the practice of the profession.


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Organizational ChartAn organizational chart is a line drawing that shows how the parts of an

organization are linked.

It depicts the formal organizational relationships, areas of responsibility,persons to whom one is accountable and channels of communication.

An attempt to depict through a scheme, drawing the formal organizationalrelationships of people and departments.

Can be used for planning, policy-making, instituting organizational change,evaluating strengths and weaknesses of present structures, showingrelationship with other departments and agencies

5 MAJOR CHARACTERISTICS OF AN ORGANIZATIONAL CHART1. DIVISION OF WORK each box represents the individual or sub-unitresponsible for a given task of the organizations workload

2. CHAIN OF COMMAND lines indicate who reports to whom and by whatauthority

3. TYPE OF WORK TO BE PERFORMED indicated by labels ordescriptions for the boxes

4. GROUPING OF WORK SEGMENTS shown by clusters of work groups(departments or single units)

5. LEVELS OF MANAGEMENT indicate individual and entire managementhierarchy

TOP

MIDDLE

FIRST LEVEL

OPERATIONAL LEVEL


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VERTICAL CHART

Solid Line Line Authority-depicts direct relationshipDashed Line Staff Authority advisory & service-oriented shows coordinatedrelationship

Administrator

Vice President

Patient Care Coordinator

RN LPN CNA

S t a f f S t a f f

P a t i e n t C

S t a f S t a f f

P C C

D i r e c t o r

S N S N

P a t i e n t C

S N S N

P C C

D i r e c t o r

V i c e - P r e s

H o s p i t a l

B o a r d o


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Organizational structure of a hospital Nursing Division/Service

S t a f f N u r s

M i d w i v e s

N u r s i n g A t t

I n s t i t u t i o n a l

S e n i o r N u

O P D E R

S u p e r v i s i n gO P D E R

S t a f f N u r s

N u r s i n g A t t

I n s t i t u t i o n a l

S e n i o r N u

S u p e r v i s i n gC l i n i c a l A

S t a f f N u r s

M i d w i v e s

N u r s i n g A t t

I n s t i t u i t o n a l

S e n i o r N u

S u p e r v i s i n gO C D R

T r a i n e e s

N u r s e I n s t

S u p ' g N u r sI n S e r v i c e

A s s t . C h i e f

C h i e f N u r

M e d i c a l C e n

O r g a n i z a t i o n a l C h a r t o f N u r s i n g D i v i s if o r n u r s e t r a i n i n g & r e s e a r c h & f o

( t y p i c a l n s g . o r g a n i z a t i o n a l c h a r t o

N u r s e I n s

S u p e r v iN u r s e I n s

A s s t . C h i

T n g . & R e

S t a f f N u

N u r s i n g A

S e n i o r N

S u p e r v i s iS p l . S e r v

S t a f f N u

N u r s i n g A

S e n i o r N

S u p e r v i s iC l i n i c a l S

A s s t . C h i

C l i n i c a l S

C h i e f N

C h i e f o f H


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Advantages & Limitations of the Organizational Chart:

Advantages:1. Maps lines of decision-making authority.2. Helps people understand their assignments and those of their co-workers.3. Reveals to managers and new personnel how they fit into the

organization.4. Contributes to sound organizational structure.5. Shows formal lines of communication.

Limitations:1. Shows only formal relationships.2. Does not indicate degree of authority.3. May show things as they are supposed to be or used to be rather than as

they are.4. Possibility exists of confusing authority with status.

T r a d i t i o n a l H i e r

N u r s i n g

S t a f f N

S e n i o r

S u p e r v i s

C h i e f N

C h i e f o f


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ORGANIZATIONAL STRUCTURE

The optimal organizational structure integrates organizational goals, size,technology, and environment. When the structure is not aligned withorganizational needs, the organizations response to environmental changediminishes; decisions are delayed; overlooked, or poor; conflict results; andperformance deteriorates (Porter-OGrady, 1994)

Organizational structure is an important tool through which managers canincrease organizational efficiency. Reorganization occurs in response to changesin organizational goals, size, technology, or environment.

FUNCTIONAL STRUCTURE

In functional structures, employees are grouped in departments byspecialty, with similar tasks being performed by the same group, similar groupoperating out of similar department, and similar departments reporting to thesame manager. In a functional structure, all nursing tasks fall under nursingservice; the same is true of other functional areas. Functional structures tend tocentralize decision making because the functions converge at the top of theorganization.

Weaknesses:Functional structures have several weaknesses. Coordination across

function is poor. Decision-making responsibilities can pile up at the top, mayoverload senior managers, who may be less informed of the day-to-dayoperations. Response to external environment that require coordination acrossfunctions are slow.

CEO

nursing

dietary pharmacy

storeroom


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SERVICE-INTEGRATED STRUCTURE(Product-line or Self-contained unit Structures) In service-integrated

structure, all functions needed to produce a product or service are groupedtogether in self-contained units. A large health care institution that acquires asmaller clinic may operate it as a self-contained unit. The service-integratedstructure is decentralized; units are based on product, service, geographicallocation, or type of costumer.

Strengths:One of the strengths of the integrated service structure is its potential for

rapid change in unstable environment. Because each division is specialized andits outputs can be tailored to the situation, client satisfaction is high. Coordinationacross function occurs easily; work partners identify with their own service and

can compromise or collaborate with other service functions to meet service goalsand reduce conflict. Service goals receive priority under this organizationalstructure because employees see the service outcomes as the primary purposeof their organization.

CEO

Oncology

nsg dietary pharmacy storeroom

Cardiology

Burn Unitnsg dietary pharmacy storeroom

nsg dietary pharmacy storeroom


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Weaknesses:The major weaknesses of service-integrated structures include possible

duplication of resources (such as ads for new positions) and lack of in-depthtraining and specialization. Coordination across service categories (oncology,cardiology, and the burn unit, for example) is difficult; services operateindependently and often compete. Each service category, which is independentand autonomous, has separate and often duplicate staff and competes with otherservice areas for resources.

HYBRID STRUCTUREWhen an organization grows, it typically organizes both self-contained

units and functional units; the result is a hybrid organization.

Strengths:The strengths of the hybrid structure are it (a) provides simultaneous

coordination w/in product divisions while maintaining quality of each function, (b)improves alignment between corporate and service or product goal, and (c)fosters better adaptation to the environment while still maintaining efficiency.

Chief executive officer

nursing Storeroom &maintenance

dietary admitting pharmacy billing

Rural clinicExecutive officer

nursing admitting


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Weaknesses:The weakness of hybrid structures is conflict between top administration

and managers. Managers often resent administrators intrusion into what theysee as their own area of responsibility. Overtime, organizations tend toaccumulate large corporate staff to oversee divisions in an attempt to providefunctional coordination across service or product structures.

MATRIX STRUCTUREThe matrix structure is unique and complex. When organizations find that

functional, product-line, or hybrid structures do not work, they often organize intoa matrix. The unique defining characteristic of a matrix is that it integrates bothproduct and functional structure into one overlapping structure. In a matrix

structure, different managers are responsible for function and product. Forexample, the nurse manager for the oncology clinic may report to the vicepresident for the nursing as well as the vice president for outpatient services.

Strength:Matrix tends to develop where there are strong outside pressures for dual

organizational focus on product and function. The matrix is appropriate in ahighly uncertain environment that changes frequently but also requiresorganizational expertise.

Vice President outpatient services

Oncology Pediatrics Family medicine

Vice PresidentNursingServices

Nurse manager

Nurse managerNurse manager


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Weaknesses:The major weakness of the matrix structure is its dual authority, which can

be frustrating and confusing for departmental managers and employees.Excellent interpersonal skills are required from the managers involved. A matrixorganization is time-consuming because frequent meetings are required toresolve problems and conflicts; the structure will not work unless participants cansee beyond their own functional area to the big organizational picture. Finally, ifone side of the matrix is more closely aligned with organizational objectives, thatside may become dominant.

PARALLEL STRUCTUREParallel structure is a structure unique to health care. It is the result of

complex relationships between the formal authority of health care organizationand the authority of its medical staff. In a parallel structure, the medical staff isseparate and autonomous from the organization. The result is as organizationaldilemma: two lines of authority. One line extends from governing body to CEO tomanagerial structure; the other line extends from governing body to medical staff.These two intersect in departments such as nursing, in which decision makinginvolves both managerial and clinical elements.

Parallel structures are found in health care institutions with functionalstructure and separate medical governance structure. Parallel structures arebecoming less successful as health care organizations integrate into newer

models that incorporate physician practice under organizational umbrella.Purchased, allied, incorporated, and partnered physician practice arrangementsare making parallel structures more untenable and difficult to maintain.


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legend:CNS Clinical Nurse Specialist LPN Licensed Practical NursesNM Nurse Manager UAP Unlicensed Assistive PersonnelRN Registered Nurse (Staff Nurse)

UAP individuals who are trained to function in an assistive role toregistered professional nurse in provision of patient/client care activities asdelegated by and under the supervision of the registered professionalnurse (ANA, 1994).

SELF-ORGANIZING STRUCTUREWheatly (1992) describes a new adaptive organization that evolves from

organizational tasks. This self-organizing (self-renewing) structure is flexible andable to respond to both internal and external change. The only requirement ofthis structure is self-reference; that is, future structures are consistent withpreviously established identity and its past. Rigid, permanent structures areavoided; the organizational structure changes when need arises.

Roles and structures are created out of need and interest; relationships,exchanges, and connections among employees are nurtured as the primarysource of organizational creativity and success.

Chief executiveofficer

Chief nurse

executive

Chief finance

executive

Chief officer of

Support acivitiesMedicaldirector

Chief ofservice

Internalmedicine

Surgery

Pediatrics

Ob-Gyn

budget

housekeeping maintenance

finance

budget finance

CNS NM NM NM

RN UAP

LPN

RN

LPN

UAP

RN UAP

LPN


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Staffing

Process of determining and providing the acceptable number and mix ofnursing personnel to produce a desired level of care to meet the patientsdemand.

Purpose: to provide each nursing unit with an appropriate and acceptablenumber of workers in each category to perform the nursing tasks required.

Staffing is one of the major problems in a nay nursing organization,whether that organization is a hospital, nursing home, home health care agency,ambulatory care agency, or another type of facility. Aydelotte has stated that

Nurse staffing methodology should be an orderly, systematic process,based upon sound rationale, applied to determine the number and kind ofnursing personnel required to provide nursing care of predeterminedstandard to a group of patients in a particular setting. The end result isprediction of the kind and number of staff required to give care to patients.

Factors Affecting Staffing:1. Type, philosophy, and objectives of the hospital and the nursing service;2. Population served or the kind of patients served whether pay or charity;3. 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 the various nursing units and resources available within thedepartment such as adequate equipment, supplies and materials;

Patient Care Classification Categories

Level I Self Care or Minimal Care - can perform ADL, for discharge, non-emergency, newly-admitted,requires little treatment/observation and/or instruction.- Nursing Care = 1.5 hrs/pt/day- Professional to non-professional nursing personnel = 55:45.

Level II Moderate Care or Intermediate Care -need some assistance- extreme symptoms must have subsided or have not yet appeared.- slight emotional needs-V/S 3x/shift- IVFs or BT- semi-conscious and exhibiting some psychosocial or social problems


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- periodic treatment, observations and/or instructions- Nursing Care = 3 hrs/pt/day- Professional to non-professional nursing personnel = 60:40.

Level III Total, Complete or Intensive Care

- completely dependent- marked emotional needs- V/S > 3x/shift- may be on continuous O2 therapy, with chest or abdominal tubes.- require close observation- Nursing Care = 6 hrs/pt/day- Professional to non-professional nursing personnel = 65:35.

Level IV Highly Specialized Critical Care - maximum nursing care- Professional to non-professional nursing personnel = 80:20.

- continuous treatment and observation- many meds, IV piggy backs- V/S q 15-30 minutes; hourly output- Nursing Care = 6-9 hrs or more/pt/day

Levels of CareNCH needed per Pt/day

Ratio of Prof toNon-Prof

Level I

Self Care orMinimal Care

1.50 55:45

Level IIModerate orIntermediate Care

3.0 60:40

Level IIITotal orIntensive Care

4.5 65:35

Level IVHighly Specialized or

Critical Care

7.07 or up

70:3080:20

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


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Type of Hospital Minimal Care ModerateCare

IntensiveCare

HighlySpecializedCare

Primary

Secondary

Tertiary

Special Tertiary

70%

65%

30%

10%

25%

30%

45%

25%

5%

5%

15%

45%

-

-

10%

20%

Computing for the # of Personnel Needed

Republic Act 5901 The 40-Hour Week Law- >100 bed capacity = 40 hrs. a week.- agencies w/ 1M population = 40 hrs. a week.- agencies


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Relievers NeededConsider the Following:1. Average # of leaves taken each year 15

a. Vacation Leave 10b. Sick Leave 5

2. Holidays 12

3. Special Privileges as per CSC MC#6 s.1996 34. Continuing Education Program for Professionals 3

Total Average Leaves = 33

Divide 33 (the average # of days an employee is absent per year) by the #of working days per year that each employee serves (whether 213 or 265).

This will be 0.15/person who works 40 hrs/wk, & 0.12/person working 48hrs/wk.

Multiply the computed reliever/person by the computed # of nursingpersonnel = the total # of relievers needed.

Distribution by Shifts

Morning/day shift needs the most nursing personnel @ 45-51%. Afternoon shift 34-37%. Night shift 15-18%.

Philippines:

Rights & Privileges Given Working Hours Per Week

Each Personnel Per Year 40 hours 48 hours

1. Vacation Leave 15 15

2. Sick Leave 15 153. Legal Holidays 10 10

4. Special Holidays 2 2

5. Special Privileges 3 3

6. Off-Duties as per R.A. 5901 104 52

7. Continuing Education Program 3 3

Total Non-Working Days Per Year 152 100

Total Working Days Per Year 213 265

Total Working Hours Per Year 1,704 2,120


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Morning 45% Afternoon 37% Night 18%

Staffing Formula:

1. Categorize the number of patients according to the levels of care needed.Multiply the total number of patients by the percentage (%) of patients ateach level of care (whether minimal, intermediate, intensive or highlyspecialized).

2. Find the total number of nursing care hours needed by the patients ateach category level.a. Find the number of patients at each level by the average number ofnursing care hours needed/day.b. Get the sum of the nursing care hours needed at the various levels.

3. Find the actual number of nursing care hours needed by the given numberof patients. Multiply the total nursing care hours needed/day by the totalnumber of days in a year.

4. Find the actual number of working hours rendered by each nursingpersonnel per year. Multiply the number of hours on duty/day by the actualworking days/year.

5. Find the total number of nursing personnel needed.a. Divide the total number of nursing care needed/year by the actualnumber of working hrs rendered by an employee per year.b. Find the number of relievers. Multiply the number of nursing personnelneeded by 0.15 (for those working 40 hours/week) or 0.12 (for those

working 48 hours/week).c. Add the number of relievers to the number of nursing personnel needed

6. Categorize the nursing personnel into professional and non-professional.Multiply the number of nursing personnel according to the ratio ofprofessionals to non-professional.

7. Distribute by shifts.

To illustrate:Find the number of nursing personnel needed for 250 pts in a tertiary hospital.

1. Categorize the patients according to levels of care needed.250 pts x .30 = 75 pts needing minimal care

250 pts x .45 = 112.5 pts needing moderate care250 pts x .15 = 37.5 pts need intensive care250 pts x .1 = 25 pts need highly specialized nursing care 250

2. Find the # of NCH needed by patients at each level of care/day.


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75 pts x 1.5 (NCH needed @ Level I) = 112.5 NCH/day112.5 pts x 3 (NCH needed @ Level II) = 337.5 NCH/day37.5 pts x 4.5 (NCH needed @ Level III)= 168.75 NCH/day25 pts x 6 (NCH needed @ Level IV) = 150 NCH/day

Total 768.75 NCH/day

3. Find the total NCH needed by 250 patients per year.768.75 x 365(days/yr) = 280,593.75 NCH/year

4. Find the actual working hrs rendered by each nursing personnel per year.8(hrs/day) x 213(working days/yr) = 1,704 (working hrs/year)

5. Find the total # of nursing personnel needed.a. Total NCH per year = 280,593.75 = 165

Working hrs / year 1,704b. Relief x Total Nursing Personnel = 0.15 x 165 = 25

c. Total Nursing Personnel needed 165 + 25 = 190

6. Categorize to professional and non-professional personnel. Ratio ofprofessionals to non-professionals in a tertiary hospital is 65:35.

190 x .65 = 124 professional nurses190 x .35 = 66 nursing attendants

7. Distribute by shifts.124 nurses x .45 = 56 nurses on AM shift124 nurses x .37 = 46 nurses on PM shift124 nurses x .18 = 22 nurses on NIGHT shift

Total = 124 nurses66 Nsg attendats x .45 = 30 NA on AM shift66 Nsg attendats x .37 = 24 NA on PM shift66 Nsg attendats x .18 = 12 NA on NIGHT shift

Total = 66 Nursing Attendants

* Above personnel are only for in-patients, therefore additional personnel shouldbe hired for those in supervisory and administrative position and for those inspecial units such as the O.R., D.R., E.R., & Out-Patient Department.

SCHEDULING


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Schedule a timetable showing planned work days and shifts for nursingpersonnel.

Objectives:

- assign working days and days-off to the nursing personnel so that adequatepatient care is assured.- a desirable distribution of off-duty days can be achieved treated fairly.- know their schedule in advance.

Factors Considered:a. Different levels of the nursing staffb. Adequate coverage for 24 hours, 7 days a week.c. Staggered vacations and holidays.d. Weekends.e. Long stretch of consecutive working days.

f. Evening and night shifts.g. Floating.

Assessing a Scheduling System:1. Ability to cover the needs of the unit. minimum required number of staff

must meet the nursing needs of the patients in the units and all shifts.2. Quality to enhance the nursing personnels knowledge, training and

experience. prefer to experience before settling down to a particular unit.3. Fairness to the staff. fair share: difficult, light, undesirable4. Stability. know in advance5. Flexibility. the ability to handle changes brought about by emergency

leaves, scheduled or unscheduled leaves of absence

Types of Scheduling:1. Centralized one person (Chief Nurse or her designate), assigns the

nursing personnel to the various units of the hospital. Includes the shiftson duty and off-duty.

2. Decentralized shift and off-duties are arranged by the Supervising Nurseor Head or Senior Nurse of the particular unit.

3. Cyclical covers a designated number of weeks called the cycle lengthand is repeated thereon. It assigns the required number of nursingpersonnel to each nursing unit consistent with the units patient carerequirements, the staffs preference, their education, training, andexperience.Advantages: Fair to all, Saves time, Enables employee to plan ahead for

their personal needs, scheduled leave coverage, productivity is improved.

Other types of scheduling


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a. Self-scheduling personnel are scheduled to work theirpreferred shifts as much as possible, as long as theirpreferred shifts meet the needs of the unit and balance withthe needs of coworkers. Self-scheduling is an activity thatmay make the staff happier, more cohesive, and more

committed. It should be planned carefully on a unit (costcenter) basis with a written policy in place as guideline.b. Modified Work Week use of 10- and 12-hour shifts.

Scheduling Variables:a. Length of scheduling period whether 2 or 4 wks;b. Shift rotation;c. Week-ends off;d. Holiday offs;

e. Vacation leaves;f. Special days;g. Scheduled events in the hospital, training programs or meetings;h. Jog categories; continuing professional education (CPE) programs.

A FOUR-WEEK CYCLICAL SCHEDULE

P E R S O N N E LS M T W T H F S S M T W T H F S S M T W T H F S S M T W T H F

7 - 3 H e a d / S r . N u r s eX X X X X X X

S t a f f N u r s e X X X X X X X X X

N s g . A t t . 1X X X X X X X X

N s g . A t t . 2 X X X X X X X X

3 - 1 1 S t a f f N u r s eX X X X X X X

N s . A t t . X X X X X X X X

1 1 - 7 S t a f f N u r s eX X X X X X X X

N s g . A t t . X X X X X X X X

G e n . R e l. 3 - 1 1 ; 1 1 - 7

S t a f f N u r s e3 - 1 13 - 1 11 1 - 7X X 3 - 1 11 1 - 71 1 - 7X 7 - 33 - 1 13 - 1 11 1 - 7X X 7 - 33 - 1 13 - 1 11 1 - 71 1 - 7X X 3 - 1 11 1 - 71 1 - 7X 7 - 33

N s g . A t t .3 - 1 11 1 - 7X 7 - 33 - 1 11 1 - 7X 7 - 33 - 1 1X 1 1 - 71 1 - 7X 3 - 1 1X 7 - 31 1 - 7X 3 - 1 13 - 1 11 1 - 71 1 - 7X 7 - 33 - 1 13 - 1 11 1 -

Job Description a statement that sets the duties and responsibilities of aspecific job.


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- includes the needed characteristics or qualities of the individual toperform such duties successfully.

- an important management tool to make certain that responsibilities arewisely delegated, that work is efficiently distributed, that talents are fully used,and morale is maintained.

Uses:1. For recruitment and selection of qualified personnel;2. To orient new employees to their jobs;3. For job placement, transfer or dismissal;4. As an aid in evaluating the performance of an employee;5. For budgetary purposes;6. For determining departmental functions and relationships to help define

the organizational structure;7. For classifying levels of nursing functions according to skill levels required;8. To identify training needs;

9. As basis for staffing;10.To serve as a channel of communication.

DIRECTING THE NURSING SERVICES


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Directing is the issuance of orders, assignments, and instructions thatenable the nursing personnel to understand what are expected of them. Itincludes supervision and guidance so that in doing their job well, nurses canmaximally contribute to the organizations goals in general and to the nursingservice objectives in particular.

Directing actuates efforts to accomplish goals. It is the connecting linkbetween organizing for work and getting the job done.

- Must be complete, understandable and given in logical order.- Giving them in a courteous manner encourages cooperation, interest, and

better performance in their jobs.

Directing includes delegation of work to be performed, utilization of policiesand procedures, supervision of personnel, coordination of services,communication, staff development, and making decisions.

Fayol states that a manager must know how to handle people and mustbe able to defend his or her point of view with confidence and enthusiasm. Themanager learns continuously and educates people at all levels for access in theirassigned task.

Fayol stated that command occurs when the manager gets the optimumreturn from all employees of his unit in the interest of the whole concern. To dothis, the manager must know the personnel, eliminate the incompetent;understand binding agreements with employees; set a good example; conductperiodic audits; confer with chief assistants to focus on unity of direction; not

become mired in detail; and have as a goal unity, energy, initiative, and loyaltyamong employees. Fayol defines coordination as creating harmony among allactivities to facilitate the work and success of the unit. In modern management,command and coordination are often labeled directingorleading.

According to Urwick, it is the purpose of command and the function ofdirecting to see that the individual interests do not interfere with the generalinterest. Directing protects the general interest and ensures that each unit has acompetent and energetic head. Command functions to promote esprit de corpsand to carefully select a staff that can be of most service.

Rowland and Rowland state that directing initiates and maintains actiontoward desired objectives and is closely related to leadership. These authorssuggest that a managers choice of leadership style will be the major factor indirecting. Among the activities of directing are delegation, communication,training, and motivation.

Elements of Directing


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DelegationDelegating is the process by which a manager assigns specific

tasks/duties to workers with commensurate authority to perform the job. Theworker in return assumes responsibility for its satisfactory performance and isheld accountable for its results.

By delegating well defined tasks and responsibilities, nurse manager canbe freed of valuable time that can be well spent on planning and evaluatingnursing programs and activities. Delegation also trains and develops staffmembers who desire greater opportunities and challenges in their work makingthem more committed and satisfied in their jobs.

Two Criteria:1. the ability of the worker to carry out the task2. fairness not only to the employee but to the team as a whole

Concepts from clinical delegation can also be applied as an overall model fordelegation. Hansten and Jackson outline the following principles of delegation:

know your world (practice, organization)

know your organization (communication channels,collaboration, resolution)

know your practice (professional, technical, amenity, basedon outcomes)

know yourself (barriers, benefits)

know your delegate (competency, motivation)

Reasons for Delegating

The following are five reasons for delegating:1. Assigning routine tasks.2. Assigning tasks for which the nurse manager does not have time.3. Problem solving.4. Changes in the nurse managers own job emphasis.5. Capability building.

The nurse manager must be careful not to misuse the clinical nurse bydelegating tasks that can be done by the nonnurses or nonlicensed personnel.

Principles of Delegation:1. Select the right person to whom the job is to be delegated. Make sure

that the employee is capable of doing the job. Give the employee theaccountability and authority to do the job.

2. Delegate both interesting and uninteresting tasks. uninteresting jobs canbe used to challenge, motivate & increase a persons performance andcommitment. Interesting jobs draw out the best among employees andinspire them to a higher achievement.

3. Provide subordinates with enough time to learn. Expertise can beachieved through training and experience.


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4. Delegate gradually. new employees may not be able to assume fullresponsibilities as employees who have stayed longer on the job.

5. Delegate in advance. Specify goals and objectives to be met within a settime frame. Describe the specific results expected out of the activities tobe performed.

6. Consult before delegating. Clarification minimizes problems andpromote teamwork.7. Avoid gaps and overlaps. occurs when a job is left out with no one

taking responsibility; an overlap happens when two or more people haveresponsibility for the same job, causing confusion and low morale.

The following list suggests ways for nurse managers to successfully delegate:1. Train and develop subordinates..2. Plan ahead.3. Control and coordinate the work of subordinates but do not peer over their

shoulders.

4. Follow up by visiting subordinates frequently.5. Coordinate to prevent duplication of effort.6. Solve problem and think about new ideas.7. Accept delegation as desirable.8. Specify goals and objectives9. Know subordinates capabilities, and match the task or duty to the

employee.10.Agree on performance standards.11.Take an interest in employees.12.Assess the results.13.Give the appropriate rewards.

14.Do not take back delegated tasks.

THE DELEGATION PROCESSThere are five steps to the delegation process:

1. Defining the task,2. Determining to whom to delegate,3. Providing clear communication about expectations regarding the

task,4. Reaching mutual agreement about the task at hand, and5. Monitoring and evaluating the results and providing feedback to the

individual regarding his or her performance.

Delegation Scheme


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Define the taskWhat can you delegate?What are the complexities of the task?What areas of authority must the person control?What resources are needed?Are there any limitations to the amount of authority

or resources?What level of delegation should be used?

Determining whoWhat skills or abilities are necessary?Are there any limitations imposed by scope ofpractice laws?Who is available?Who is willing?

Describe expectationsWhat is to be accomplished?Why is the task necessary?

What incentives are there for accepting this task?When, how, and by what standards will the task beevaluated?Is a written report required?What constraints or risks apply?

Seek agreement

Monitor performance andprovide feedback

Identifying and Defining the Task and Level of Delegation

The first step in delegation is determining what can be delegated. You candelegate only an aspect of yourown work for which you have responsibility andauthority. These include: (a) routine tasks, (b) tasks for which you do not havetime, (c) tasks that have moved down in priority, (d) problem solving, and (e) staffbuilding. In addition, Morrison (1993) suggests you should delegate only whatyou know best. She contends this is important in providing guidance and

feedback. Clearly, lack of expertise in the task hinders delegators ability todefine the task and associated requirements. Therefore, know well the task to bedelegated.

What Cannot Be Delegated


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1. Overall responsibility, authority and accountability for satisfactorycompletion of all activities in the unit. Nurse Managers cannot beabsolved of poor performance of subordinates by blaming them.

2. Authority to sign ones name is never delegated. The worker whoperformed the task should be the one to sign it.

3. Evaluating the staff and/or taking necessary corrective or disciplinaryaction.4. Responsibility for maintaining morale or the opportunity to say a few words

of encouragement to the staff especially the new ones. showingconfidence in the workers boost their morale and build up their self-confidence.

5. Jobs that are too technical and those that involve trust and confidence.

Why Nurse Managers Do Not Delegate- Due to lack of confidence in their staff, feeling that only they could do the

task better and faster.

- May fear loss of control if some of their duties are delegated.- Preference for operating by oneself.- Insecurity, fear of being disliked- Refusal to allow mistakes

Apprehensions in Accepting Delegated Tasks:In return, subordinates may be apprehensive in accepting delegated tasks for

- fear of criticism,- lack of experience, ineptitude, or incompetence- avoidance of responsibility- disorganization, overload of work

- immersion in trivia

*Can be avoided if there is an open communication among the staff.*There should be warm and cordial relationships where every one is freeto ask questions or seek clarifications regarding a delegated task which tothem may be too difficult to understand.

Nursing Care Assignment: (Modalities of Nursing Care, Systems of NursingCare, Patterns of Nursing Care)


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4 Methods:1. Functional Nursing

This kind of modality is task-oriented in w/c a particular nursing function isassigned to each worker.

- one RN may be responsible for giving medications, another foradmission and discharge, while nursing attendants change linen, providehygienic care or do simple nursing procedures.

- this method divides the work to be done with each person beingresponsible to the Head or Senior Nurse.

- the best system that can be used when there are many patients &professional nurses are few.

Functional nursing, also called task nursing, began in hospitals in the mid-1940s in response to national shortage. In functional nursing, the needs of agroup of patients are broken down into tasks. Tasks are assigned to RNs, LPNs,

and UAPs so that skill and licensure of each caregiver is used to the bestadvantage. An RN gives medications while others give baths, make beds, takevital signs, administer treatments, and so forth.

The advantage of this system is that all employees, even UAPs, becomevery efficient and effective at performing their regular assigned tasks. However,these personnel are likely to be effective and efficient if assigned to another task.Other disadvantages of functional nursing include (a) uneven continuity of care,(b) absence of holistic view of patient, (c) time-consuming communications, and(d) problems with follow-up. Today, functional nursing is used infrequently inacute care facilities and only occasionally in long-term care facilities.

Advantages:

Charge Nurse

Medication

nurse

Treatment

nurse

UAP with

bath duty

UAP responsible

for vital signs

UAP

responsible fortransportation

Patients


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1. Allows most work to be accomplished in the shortest time possibl

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